Scott Shapiro

Medical realities of cauda equina syndrome secondary to lumbar disc herniation.

Study Design. An analysis of 44 cauda equina syndrome cases. Objectives. To determine the neurologic outcome of cauda equina syndrome cases, in light of the significant medical implications of this disorder. Summary of Background Data. Cauda equina syndrome from lumbar disc herniation accounts for up to 1% of all disc herniations. Most of the literature supports surgery within 24 hours as a means of improving the outcome. Methods. A retrospective &khgr;2 analysis was performed of 44 patients surgically treated for lumbar disc herniation who initially sought treatment for cauda equina syndrome. Results. In 20 patients, diagnosis was made and surgery performed within 48 hours of the cauda equina syndrome onset, including 18 patients (90%) who underwent surgery within 24 hours. In 24 patients, surgery was performed more than 48 hours after the onset of cauda equina syndrome, with a mean delay of 9 days, including 17 patients (71%) with a mean delay of 3.7 days. Causes for delay were patient-related in 4 cases (17%) and physician-related in 20 cases (83%). According to &khgr;2 analysis, a greater chance of persistent bladder/sphincter problem (P = 0.008), persistent severe motor deficit (P = 0.006), persistent pain (P = 0.025), and sexual dysfunction (P = 0.006) existed with delayed surgery. Conclusion. The data strongly support the management of cauda equina syndrome from lumbar disc herniation as a diagnostic and surgical emergency.

Cauda Equina Syndrome Secondary to Lumbar Disc Herniation

ABSTRACTBETWEEN 1986 AND 1991, 14 patients (nine men and five women), ranging in age from 22 to 67 years (mean, 43 yr), presented with acute cauda equina syndrome from a herniated lumbar disc. All presented with bilateral sciatica and leg weakness; 13 (93%) had urine or stool incontinence, or both.

Closed continuous drainage of cerebrospinal fluid via lumbar subarachnoid catheter for treatment or prevention of cranial/spinal cerebrospinal fluid fistula

One hundred and seven patients who had a lumbar subarachnoid catheter (teflon or silicone) placed for closed continuous cerebrospinal fluid (CSF) drainage between 1983-1991 are presented. Overall, the drain was successful in achieving the desired goal in 101 of 107 (94%) cases. There were no deaths. Five of 107 (5%) patients developed infections including two cases (2%) of meningitis. There were three cases (3%) of overdrainage with temporary neurologic decline, but all recovered. Five of fifteen (33%) teflon catheters required replacement because of occlusion, but only 5 of 92 (5%) silicone catheters required replacement. Transient lumbar nerve root irritation was seen in 15 of 107 (14%) patients treated for a CSF fistula, and all symptoms resolved after drain removal. CSF fistula/pseudomeningocele after spine surgery was cured by CSF drainage in 36 of 39 (92%) cases; there was a 10% incidence of infection (1 wound, 2 discitis, 1 meningitis). CSF fistula after cranial surgery was cured in 22 of 25 (87%) cases; there was 1 case of (4%) infection and 1 case (4%) of overdrainage. A drain was used to augment a tenuous dural closure in 38 patients with 100% success; no infection occurred and there were 2 cases (5%) of overdrainage. Five patients were successfully treated for traumatic CSF rhinorrhea/otorrhea without complications. The silicone catheter appears superior to the teflon catheter; however, both are simple, safe, and efficacious for the treatment or prevention of CSF fistulas.

Origin of Organisms Infecting Ventricular Shunts

&NA; Results of skin cultures obtained before 413 of 505 operations for cerebrospinal fluid‐diverting ventricular shunt placement or revision in a pediatric population from April 1980 to May 1983 are analyzed and compared to results of cultures from 20 subsequent shunt infections. Sensitivities to 11 different antibiotics were determined for each isolate cultured. The total operative infection rate was 20 of 505 (4%). Gram‐negative bacilli alone accounted for 3 of 20 (15%) shunt infections. One gram‐negative bacillus/Staphylococcus aureus infection occurred. Factors predisposing for gramnegative bacillus shunt infection were found in all 4 cases. The majority of shunt infections were caused by typical resident skin organisms: Staphylococcus epidermidis alone, 9/20 (45%); Staphylococcus aureus alone, 4/20 (20%); Corynebacterium sp., 1/20 (5%); &agr;‐Streptococcus with S. epidermidis, 1/20 (5%); and Micrococcus with S. epidermidis, 1/20 (5%). Only 4 (20%) of the 20 shunt infections were due to organisms identical to those originally grown from the skin. Another 4 (20%) seemed to be infected with a strain of organism different from that initially recovered from the skin. The remaining skin organism shunt infections may or may not have come from the patients skin. The data suggest that not all skin organism shunt infections arise from contamination by resident skin bacteria at the incision sites at the time of operation. Alternate sources for the infecting organisms are discussed. The antibiotic sensitivity data on skin isolates and shunt isolates suggest that vancomycin is the antibiotic best suited for prophylaxis against shunt infection at our institution.

Neurotransmission by neurons that use serotonin, noradrenaline, glutamate, glycine, and γ-aminobutyric acid in the normal and injured spinal cord

OBJECTIVE The science of neurotransmission in the normal and injured spinal cord has grown. This is a review of neurotransmission using serotonin, noradrenaline, glutamate, glycine, and gamma-aminobutyric acid. METHODS The literature on spinal cord neurotransmission and changes that occur with trauma are reviewed. CONCLUSION Serotonergic and noradrenergic bulbospinal tracts influence interneurons and motor neurons via postsynaptic inhibition. Colocalization of serotonin and thyrotropin-releasing hormone occur in bulbospinal tracts, and reduction in uptake and thyrotropin-releasing hormone immunoreactivity quantitates the degree of injury in chronic spinal cord injury (SCI). Glutamate functions as an excitatory transmitter of some dorsal root afferent neurons and interneurons modulating nociceptive and motor neurons via at least five different receptors. Reactive synaptogenesis occurs after SCI, leading to an increase in the number of excitatory glutamatergic synapses below the level of SCI. gamma-Aminobutyric acid is an inhibitory transmitter of spinal interneurons that functions both pre- and postsynaptically. After SCI, a reduction occurs in the number of inhibitory synapses related to gamma-aminobutyric acid. Glycine is an inhibitory neurotransmitter that functions postsynaptically and also modulates the N-methyl-D-aspartate receptor. After SCI, a reduction in glycine adds to the loss of local inhibition below the SCI.

The fiberoptic intraparenchymal cerebral pressure monitor in 244 patients

BACKGROUND The fiberoptic intraparenchymal pressure monitor has been shown to provide reliable data in patients monitored for a short period of time. An analysis of a large population, including patients monitored for a prolonged period such as weeks, has never been performed. METHODS We conducted a retrospective study in which we evaluated the fiberoptic intraparenchymal cerebral pressure monitor for complications and accuracy. RESULTS The fiberoptic intraparenchymal cerebral pressure (ICP) monitor was used in 244 patients since 1988. Pathology included trauma in 180, intracerebral hemorrhage (ICH) in 19, aneurysmal subarachnoid hemorrhage in 16, arteriovenous malformations in 10, cerebral edema in 12, and tumor in 7. The mean length of monitoring was 7 days with 49 patients (20%) monitored 1-2 days, 105 (43%) monitored 3-6 days, 48 monitored for 7-10 days (20%), and 42 (17%) monitored from 10-24 days. Seventy-four patients also had ventriculostomies and there was strong correlation with the ICP monitor (p < 0.001). Complications from insertion were 2 patients (0.8%) with ICH, both with hepatic dysfunction. In the group monitored greater than 6 days, 34 patients (38%) required at least one catheter change due to upward drift of the ICP. Fiberoptic breakage requiring replacement was documented in 41 patients (16%). An insertion-site infection occurred in one case monitored for 23 days. Two infected bone flaps occurred that had a monitor placed in the flap. There were no cases of bacterial meningitis or cerebral abscess. CONCLUSIONS The monitor is easy, safe, and reliable to use with a very low rate of infection. Coagulopathic patients may best be monitored by an alternative method.

Management of unilateral locked facet of the cervical spine

Twenty-four patients with unilateral cervical locked facets were treated between 1986 and 1990. The primary mechanisms of injury were vehicular accidents (58%) and altercations (38%). The level of unilateral facet dislocation was C5-C6 (41%), C6-C7 (25%), C3-C4 (17%), and C4-C5 (17%). Seventeen (70%) came to the hospital with radiculopathy, five (20%) were normal, and two (10%) had spinal cord injuries. Plain films showed subluxation but no fracture. All patients had a cervical computed tomographic scan. Fracture in addition to facet locking was seen in 12 (50%) of 24 scans: 5 with facet fracture, 4 with facet/laminar fractures, 2 with facet/laminar/body fractures, and 1 foramen transversarium fracture. On the basis of CT findings, closed reduction was thought to be contraindicated in two cases. Five patients (22%) underwent successful closed reductions. Two of the patients with closed reductions were placed in a halo but again had subluxation. Thus, 24 patients underwent surgery for open reduction, posterior spinous process wire fixation, and facet wiring to struts of the iliac crest for bony fusion. The initial surgery was successful in 23 (96%) of 24 patients. One patient experienced subluxation and underwent further surgery for anterior cervical fusion/plating. Two wound infections were treated, and there were no deaths or neurological worsening. At 1 year, all deficits had improved. Of 16 radiculopathies, 3 (19%) had persistent 4/5 weakness, and the rest were normal, including 2 delayed-diagnosis patients who both showed improvement from 2/5 to 5/5 strength within 1 week of surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Microsurgical carpal tunnel release

Carpal tunnel release has been performed in our institution on 378 patients (a total of 461 hands) since 1987. Of these operations, 175 were right-sided, 120 were left-sided, and 83 were bilateral. The technique used for the operations was outpatient microsurgery (with most patients under local anesthesia). During this surgery, a longitudinal incision of 3 cm was made; the incision never crossed the wrist flexion crease. Five patients had the recurrent thenar branch exit through the middle or ulnar part of the ligament, and in all these patients, the branch was preserved. Perioperative complications included four stitch abscesses managed on an outpatient basis and three wound infections for which the patients were admitted to the hospital for wound care and for intravenous administration of antibiotics. One wound dehisced after a steroid-dependent patient had fallen; this was primarily repaired; in another patient, a trigger finger developed 6 months after surgery. The mean time before the patients returned to work was 6 weeks (range, 2 d-16 wk). The mean follow-up for these patients was 37 months (range, 6-72 mo). In 332 patients, all painful dysethesias completely disappeared. In another 30 patients, marked improvement was seen in dysethesias, so that the overall improvement rate was 96%. Motor improvement occurred in 349 (97%) of 360 patients who had experienced motor weakness before surgery. In seven patients with bilateral symptoms, the symptoms in the contralateral side resolved after unilateral surgery. Eight patients had persistent incisional wound pain that required persistent medication and that delayed or prevented return to work; six of these patients were receiving workmens compensation.(ABSTRACT TRUNCATED AT 250 WORDS)

Cranioplasty, Vertebral Body Replacement, and Spinal Fusion with Tobramycin-impregnated Methylmethacrylate

A prospective analysis of cranioplasty, vertebral body replacement, and spinal fusion using tobramycin-impregnated methylmethacrylate in 65 patients is presented. Cranioplastic methacrylate (1 packet) was mixed with 1.2 g of powdered tobramycin and placed into the desired location. The polymer was irrigated with bacitracin until it became solid. All patients received prophylactic medication with intravenously administered nafcillin and cephalosporin perioperatively and for 48 hours postoperatively. The follow-up time ranged from 7 to 57 months (mean, 32.2 months). Serum tobramycin levels remained below 0.5 microgram/ml in all patients tested, regardless of the time interval. Blood urea nitrogen and creatinine levels remained within normal limits in all patients, and there has been no nephrotoxicity or ototoxicity. There has been 1 infection among the 65 patients (1%) to date. It occurred in a patient who had a previously treated local infection. Cranioplasty, vertebral body replacement, or spinal fusion with tobramycin-impregnated methylmethacrylate is safe and may reduce the incidence of infection.

Management of Subarachnoid Hemorrhage Patients Who Presented With Respiratory Arrest Resuscitated With Bystander CPR

BACKGROUND AND PURPOSE The sudden death rate from aneurysmal subarachnoid hemorrhage (SAH) is 10%. Since 1989, 26 SAH patients who were witnessed to collapse into coma with respiratory arrest and required cardiopulmonary resuscitation (CPR) at the scene survived to reach the hospital and be diagnosed. Although reports on hospital management of grade V SAH suggest improved outcome, no report has previously addressed the issue of respiratory arrest after acute SAH. We analyze our experience with this unique subgroup of aneurysmal SAH patients. METHODS This is a retrospective analysis of 26 consecutive SAH patients who collapsed at the scene and required CPR for respiratory arrest and survived to reach the hospital and be diagnosed. Statistical analysis was performed using the t test and Mann-Whitney rank-sum test. RESULTS All patients were grade V on arrival at the emergency department. Twenty-one patients received mouth-to-mouth resuscitation only, and 5 received chest compressions as well. The mean duration of bystander CPR was 12 to 15 minutes. CT scan showed diffuse, thick SAH in all patients, an associated subdural hemorrhage in 2, and an intraparenchymal hemorrhage in 4. After CT scan, an intracranial pressure (ICP) monitor was placed in 24, and 2 were taken to emergency surgery for subdural and intracerebral hemorrhage. ICP was elevated in 24 patients (mean, 54 mm Hg), and a ventriculostomy was placed in all 24. ICP was unresponsive in 12, and all suffered brain death. ICP lessened to < 25 mm Hg in 12, and all underwent angiography. All 12 had an aneurysm and underwent emergency surgical clipping. Time to surgery from SAH was < or = 11 hours in all 12 patients. All were managed with calcium channel blockers and hyperdynamic therapy in addition to aggressive control of ICP. The outcome at 12 months in the 14 surgical cases was normal in 3 patients (21%), good in 2 (14%), vegetative in 1 (7%), and death in 8 (57%). CONCLUSIONS Aneurysmal SAH patients that present with respiratory arrest present as grade V patients with elevated ICP. Bystander CPR coupled with early retrieval, diagnosis, and therapy can lead to 20% functional survival in what used to be sudden death from aneurysmal SAH.