Richard C. Schneider

Vascular insufficiency of brain stem and spinal cord in spinal trauma

IN THE STUDY of the relationship of spinal trauma to the resultant acute and chronic damage to the brain stem and spinal cord, some clinical and pathologic features cannot be explained readily on the basis of the initial traumatic lesion. A remote or secondary clinical or pathologic effect often is present which requires further explanation. Evidence accumulating in the literature suggests that these facts may be related to the peculiarities of the vascular supply to the brain stem and spinal cord. The task of describing briefly the normal circulation of these areas is almost impossible when one reviews the immense volume of literature on the subject. A group of references will be cited without too great amplification of the subject matter, so that the reader does not become so lost in anatomic details that correlation with the clinical aspects of the problem is forgotten. Adamkiewicz,l Kadyk20 and Ross31 contributed the outstanding fundamental work on the vascular supply of the spinal cord during the last twenty years of the nineteenth century. With the exception of the paper written by Stopford42 and a few other scattered articles, more than thirty-five years elapsed before interest in the subject was rekindled by Alexander and Suh,2 Bolton,7 Herren and Alexander,16 Klaue,22 Sahs,33 Suh and Alexander,43 Tureen,46 Y o s s , ~ ~ and Zulch.49 The culmination and condensation of much of their extensive investigations are ably presented in two texts, Mettle97 and Bing.6

Chronic Neurological Sequelae of Acute Trauma to the Spine and Spinal Cord: The Significance of the Acute-flexion or "tear-drop" Fracture-dislocation of the Cervical Spine

The acute-flexion or tear-drop fracture-dislocation associated with injuries of the cervical spinal cord warrants special attention. It is characterized by the separation and downward and forward displacement of the anterior inferior margin of the involved vertebral body. The posterior inferior margin of this same vertebral body is displaced posteriorly into the spinal canal. Acute injuries of this type may be associated with the syndrome of damage to the anterior aspect of the cervical cord. This syndrome may be due to either destruction of this portion of the cord or to compression by displaced bone or disc material. If due to compression, this may be relieved by a surgical procedure. In these cases surgical exploration with the patient in traction and section of the dentate ligaments are indicated, if neurological signs are present. Spine fusion should then be performed at the primary operation, or at a secondary procedure. This will prevent See Images in the PDF file instability of the spine, and the fractured cervical vertebrae will heal in good alignment without the formation of a bony bulge posteriorly. Such bulging may cause chronic compresion of the anterior portion of the cervical spinal cord with neurological sequelae. If the tear-drop fracture is present without neurological signs, spine fusion without laminectomy should be performed after spinal re-alignment by cervical traction.

Considerations on the surgical treatment of slipped epiphysis with special reference to nail fixation.

Conservative treatment of slipped epiphysis has now been superseded by surgical procedures. If the slipping is slight or moderate, bone-pegging or fixation in situ with a nail is indicated. In our series of 185 nailed hips, the complications which occurred in the patients operated upon were: driving away of the epiphysis, bending of the guide wire, perforation of the cortex of the femoral head, gliding of the nail, femoral fracture, and necrosis of the femoral head. Only in one patient had complicating necrosis of the femoral head any permanent effect on the hip. The frequency of complications was lower following the use of blunt three-flanged nails. Wedge osteotomy of the femoral neck performed on patients in the series of eighty-four hips was followed by necrosis in 27 per cent and it is questionable whether this method is justified.

Evidence for some of the Trends in the Phylogenetic Development of the Vertebrate Telencephalon

In this brief account of the shifts in position and changes in size and in differentiation of certain structures in the medial and lateral walls of the vertebrate telencephalon, it is understood that one is not dealing with a direct line of evolution of these structures. The brains considered are those of representative forms which occupy positions on side branches and in some cases on almost terminal branchlets of the phylogenetic tree. Of these forms, the lungnsh is probably the nearest and the higher teleosts and higher birds the farthest away from the main trunk. Nuclear patterns and relations and fiber tracts appearing in many divergent forms are supposed to be common characteristics of the brains of animals no longer known to exist, which held positions along the main trunk of this phylogenetic tree.

Temporal or occipital lobe hallucinations triggered from frontal lobe lesions

DIAGKOSIS of a temporal lobe lesion is usually made when the patient has a single or several of the following symptoms: auditory, olfactory, or visual hallucinations, experiential illusions, macropsia, micropsia, dbjd uu phenomena, or automatic movements. T h e question a t once arises i i s to whether this group of symptoms occurs only with temporal lobe involvement or whether it may be obtained from lesions in m y other portion of the cerebral hemisphere and, if so, what the relationship of this second area may be to the temporal lobe. T h e patients whose case histories are reported below, although exhibiting the symptoms risrially regarded as diagnostic of a temporal lobe syndrome, were found a t operation to have frontal lobe involvements.

Vertigo and rotational movement in cortical and subcortical lesions.

Abstract The case histories of 7 patients with brain tumors, who experienced vertigo or rotational movements, have been presented as a basis for a discussion of the central origin of these symptoms. Six of the neoplasms were in the frontotemporal region and 1 in the parietal area. The value of activation of the EEG focus, and of electrocorticography and depth electrode studies in determining the location and extent of the lesions has been demonstrated. A discussion of the anatomical basis for the development of these symptoms and their relationship to neoplasms and traumatic lesions is included.

Stimulation of “Second” Motor Areas in the Macaque Temporal Lobe

CONTRACTION F THE MUSCLES of the face on the side of stimulation and ipsilateral or bilateral movements of the upper and, occasionally, of the lower extremities have been elicited repeatedly on stimulation of the tip of the temporal lobe, the anterior portion of the superior temporal gyrus, and the lateral and basal portions of the inferior temporal gyrus. This is a preliminary report of the movements elicited. The interesting responses which were demonstrated suggest that considerably more attention must be devoted to discovering the pathways involved in the reactions. The results obtained from ablation studies in these animals and further stimulation experiments will be reported at a later date. Ipsilateral movements on stimulation of regions of the cerebral cortex other than area 4 have been reported in various animals by numerous observers, including Wertheimer and Lepage,13 Hering,’ Rothmann,” Vogt,12 Bucy,l Bucy and Fulton,2 Wyss,“ Lemmer~,~ and Lauer.s The ipsilateral representation of the extremities has also been demonstrated or suggested in human subjects by F ~ e r s t e r , ~ Gardner? Dandy: and Penfield.lo Penfield and his associates regarded the regions from which these movements are obtained as “additional” motor areas. None of these reported ipsilateral responses upon stimulation of the temporal cortex of animals or man. For an excellent discussion of ipsilateral movements, the reader is referred to the paper by Bucy and Fulton.2 They were able to produce ipsilateral movements in monkeys by stimulating a restricted region about the superior precentral sulcus, predominately in area 6 but also including the anterior portion of area 4. They found that the responses were independent of the contralateral movements with which they were frequently associated and seemed to be carried by an ipsilateral tract through the central nervous system, although a double decussation within the brainstem could not be excluded.

The Effects of Chronic Recurrent Spinal Trauma in High-diving: A Study of Acapulco's Divers

The high divers at Acapulco provide a unique opportunity to study the effects of chronic recurrent cervical-spine trauma. The histories and neurological findings of these six divers were normal, thereby excluding lesions referable to the cervical spinal canal. Roentgenograms of the cervical spine showed some chronic bone changes in the spines of four of the divers; there was minimum bone encroachment on the cervical spinal canal by spurs or ridges posteriorly in only one of these. The three cervical spines which showed the greatest bone changes were in those divers who had slightly longer, less heavily muscled necks and who struck the water with their hands outstretched, absorbing the shock of impact directly upon their heads. A control group of ten persons of similar age but from other walks of Mexican life had normal cervical spines and neurological examinations. The data suggest that cervical spondylosis may not be caused by recurrent trauma but by degenerative disease. This is a preliminary study. An investigation of high-platform divers in the United States is contemplated for the future. Although results as dramatic as those presented here are not to be expected because of the decreased frequency and lesser height of the dives, there may be sufficient evidence to indicate need for standardization of diving techniques.

Certain Afferent Cortical Connections of the Rhinencephalon

Publisher Summary Afferent connections from various cortical areas to the hippocampal gyrus and the hippocampus are traced in Marchi preparations following suitable lesions. The projection of the cingulate gyrus to the inferior temporal gyrus and the hippocampal gyrus and, in less amount, directly to the hippocampus and the amygdala are demonstrated. The connections of the orbital surface of the frontal lobe with the hippocampal gyrus and the hippocampus, as well as with the inferior temporal cortex, are described from a clinical case in which there was a lesion in the orbital cortex. The results exhibit that the anterior temporal lobe syndrome (involving the rostral end of the temporal lobe, the rostral end of the hippocampus, and the hippocampal gyrus and the amygdala of the anatomists) may be equally well obtained from irritating lesions in frontal cortex or cingulate cortex without any direct inclusion of the rostral temporal or rhinencephalic fields in the lesion. The typical anterior temporal lobe syndrome includes deja vu phenomena, olfactory aura, micropsia and macropsia, and sometimes auditory hallucinations.

Transposition of the Compressed Spinal Cord in Kyphoscoliotic Patients with Neurological Deficit: With Special Reference to the Vascular Supply of the Cord

There is a definite place for transposition of the spinal cord in selected cases of kyphoscoliosis with neurological deficit due to spinal-cord compression. In the three cases presented, there was recovery ranging from a considerable degree to complete restoration of normal function after operation. The normal vascular supply of the spinal cord is discussed, and the two zones of poor collateral blood supply at the fourth thoracic and first lumbar cord levels are pointed out. Anterior transposition of the spinal cord without rhizotomy may be more desirable in these areas of critical blood supply. Lateral transposition of the cord achieved by removal of bone and section of the nerve roots may be without danger between the fifth and ninth thoracic vertebral segments. The three case reports are discussed with relation to the dangers of rhizotomy with associated vascular insufficiency to the spinal cord.