Russell W. Hardy

Cervical myelopathy: a comparison of magnetic resonance and myelography

Fifty-seven patients with a strong clinical suspicion of cervical myelopathy were studied with body coil magnetic resonance (MR) and conventional myelography or CT myelography. Eight patients were believed to have normal studies with both modalities. There were six patients with syringomyelia; four with an intramedullary tumor; one with an arteriovenous malformation; 19 with cervical spondylosis at multiple levels; eight with cervical spondylosis at a single level; four with extensive rheumatoid arthritis; four with extradural neoplasm; two with trauma; and one patient with an epidural abscess. In this study, body coil MR was the superior examination for the evaluation of an intramedullary process. It was as diagnostic as myelography in one case of an extramedullary intradural lesion. In patients with extradural disease, body coil MR was the superior study in 45%, equivalent to myelography in 37%, and, although still diagnostic, inferior to myelography in 17%. In 8% of the cases, body coil MR was at best equivocal, whereas myelography was diagnostic. It appears that in technically adequate studies, MR is at least equivalent to myelography in its ability to delineate disease. A superior MR study provides a better appraisal of the size and character of the spinal cord as well as the degree of both anterior and posterior defects on the subarachnoid space and neural structures. In addition, MR is as good as conventional myelography for the identification of extrinsic cervical cord lesions producing cervical myelopathy. Finally, an additional small group of 30 patients were studied with a prototype surface coil to determine its advantages relative to body coil imaging. Each patient had correlative myelography. As with body coil MR, imaging with the surface coil was believed to be more informative than conventional myelography in four patients with intramedullary lesions. The remaining 26 patients suffered from cervical spondylosis. Surface coil MR was believed to be more informative than myelography in six cases (23%), equivalent to myelography in 19 (73%), and less diagnostic than myelography in one (4%). The improved spatial resolution with the use of the surface coil was believed to increase the accuracy of MR.

Long Term Results in the Management of Craniopharyngiomas

The results of surgical treatment, with and without radiotherapy, in 50 patients with craniopharyngioma treated over a 26-year period at the Cleveland Clinic are presented. Thirty-five patients were operated upon before the introduction of the operating microscope, and 30 of these survived operation. In this group of 30 patients, long term survival (5 to 24 years) occurred in 8 of 10 (80%) nonradiated patients who were considered to have had total excision. Nine of 11 patients (82%) who had aggressive subtotal excision and radiation therapy have survived from 3 to 17 years. Seven of nine patients (78%) died 1 to 14 years after subtotal excision without radiation therapy. Since the introduction of the operating microscope in 1972, 15 patients have had surgical treatment, and 12 of these have survived.

Nuclear Magnetic Resonance of the Spine: Clinical Potential and Limitation

&NA; Magnetic resonance can visualize the vertebral bodies, discs, neural structures, cerebrospinal fluid (CSF), neural foramina, and extradural structures in the sagittal, axial, and coronal planes. The normal nucleus pulposus can be differentiated from the anulus and changes associated with degeneration. Infection, trauma, and neoplastic conditions can be identified. The signal intensity of the CSF relative to extradural and neural structures can be increased to provide evaluation of the size and configuration of the contents of the thecal sac without the use of an intrathecal contrast medium. Impingement by disc, tumors, fracture segments, and expansile masses can then be accurately evaluted, It is the most accurate modality for the evaluation of the foramen magnum, Chiari malformation, syringomyelia, infection, and degeneration of intervertebral discs. It can identify paravertebral soft tissue and bony changes when plain films and computed tomographic (CT) studies are negative or equivocal. Not only can lesions be localized, but significant information regarding the nature of the process can be obtained. Using variations of the spin‐echo technique with appropriate T1 and T2‐weighted images, magnetic resonance can produce tissue contrast distinctions not possible with CT scans or conventional angiography. (Neurosurgery 15:583‐592, 1984)

Surgical treatment of compressive cervical band.

Compression of the lower portion of the brachial plexus by a cervical band continuous with the scalenus medius is a rare but well-defined cause of arm pain. The syndrome should be suspected in a patient who presents with chronic arm pain and thenar atrophy. Cervical ribs or prominent C-7 transverse processes will be present on an anteroposterior roentgenogram of the cervical spine, and the diagnosis is confirmed by characteristic electromyographic findings. The syndrome should be differentiated from other causes of chronic arm pain, such as herniated cervical disc, syringomyelia, spinal cord tumor, or carpal tunnel syndrome. The condition is readily treated by surgical division of the compressive band, approached through a supraclavicular incision.

Ewing's tumor metastatic to the clivus, simulating meningitis: case report.

Ewings sarcoma, which is regarded as one of the most lethal primary bone tumors, lies in the domain of the orthopedic surgeon because it occurs most commonly in the shaft of the long bones, especially in the lower extremities. Pain, leukocytosis, fever, anemia, and an elevated erythrocyte sedimentation rate are commonly seen. We are presenting a case of Ewings sarcoma of the left greater trochanter with metastasis to the clivus producing a bilateral 6th nerve palsy. The presence of fever, nuchal rigidity, and photophobia simulated meningitis. The rapid evolution of radiological signs will be discussed.

Dural arterio-venous malformations involving the cavernous sinus: a case report.

A case of dural arteriovenous malformation involving the cavernous sinus is reported. The patient was successfully treated with selective embolisation of the fistula. These patients constitute a distinct neuro-ophthalmological syndrome which may be very difficult to diagnose clinically because of the subtle signs and symptoms they present with. Angiography is necessary to make diagnosis and to differentiate these patients from those with the more common carotidcavernous fistulae.

Computed tomographic, myelographic, and operative findings in patients with suspected herniated lumbar discs.

Fifty patients presenting with a suspected herniated lumbar intervertebral disc were evaluated with sector computed tomography (CT). Excluded from this series were patients with prior lumbar laminectomy or a clinical diagnosis of lumbar canal stenosis. Forty-six of the patients also underwent preoperative lumbar myelography. All patients subsequently underwent laminectomy. In 40 patients (80%), CT was positive. In the remaining 10 patients (20%), it was negative; in this group the myelogram correctly predicted the lesion in 8 (80%). Sector CT correctly predicted the nature of the lesion in 24 patients (48%), was incorrect in 14 (28%), and gave incomplete findings in 12 (24%). CT was most accurate when it demonstrated a disc protrusion as the only finding. In this group, sector CT correctly predicted the operative findings in 24 of 25 patients (96%). CT was less accurate when spondylitic compression was diagnosed. This study suggests that sector CT is a useful test in the evaluation of patients with sciatica and that, when a soft herniated disc is demonstrated on CT, myelography may be omitted.