Setti S. Rengachary

Safety and feasibility of craniectomy with duraplasty as the initial surgical intervention for severe traumatic brain injury.

BACKGROUNDnDecompressive craniectomy has historically served as a salvage procedure to control intracranial pressure after severe traumatic brain injury. We assessed the safety and feasibility of performing craniectomy as the initial surgical intervention.nnnMETHODSnOf 29 consecutive patients undergoing emergent decompression for severe traumatic brain injury with horizontal midline shift greater than explained by a removable hematoma, 17 had traditional craniotomy with or without brain resection and 12 underwent craniectomy.nnnRESULTSnThe craniectomy group had lower Glasgow Coma Scale scores at surgery (median, 4 vs. 7; p = 0.04) and more severe radiographic injuries (using specific measures). Mortality, Glasgow Outcome Scale scores, Functional Independence Measures, and length of stay in both the acute care setting and the rehabilitation phase were similar between the surgical groups.nnnCONCLUSIONnDespite more severe injury severity, patients undergoing initial craniectomy had outcomes similar to those undergoing traditional surgery. A randomized evaluation of the effect of early craniectomy on outcome is warranted.

Biomechanical comparison of two stabilization techniques of the atlantoaxial joints: transarticular screw fixation versus screw and rod fixation.

OBJECTIVE: To compare the biomechanical stability imparted to the C1 and C2 vertebrae by either transarticular screw fixation (TSF) or screw and rod fixation (SRF) techniques in a cadaver model. METHODS: Ten fresh ligamentous human cervical spine specimens were harvested from cadavers. The specimens were tested sequentially in the intact state, after injury and stabilization (unilateral left side and bilateral), and after fatiguing to 5000 cycles (0.5 Hz) at ±1.0 N·m of flexion and extension. The specimens were stabilized by use of TSF in 5 spines or SRF in the other 5 spines. The data were converted to angular displacements, and the stabilized cases were compared with intact states for evaluating the efficacies of the two techniques in stabilizing the C1–C2 segments. RESULTS: In the TSF group, the unilateral fixation using one screw imparted a significant stability in only the axial rotation mode. The unilateral procedure in the SRF group was effective in stabilization in all modes except in extension. The bilateral procedure in both of the groups was effective across the C1–C2 segment. However, the SRF group afforded higher stability than the corresponding TSF group in the flexion and extension modes. The degree of stability did not change after fatigue compared with the prefatigue data. CONCLUSION: In general, a surgeon should undertake a bilateral fixation to achieve sufficient stability across the atlantoaxial complex, and either technique will provide satisfactory results, although the SRF technique may be better in the flexion and extension modes. One should use the SRF procedure while trying to achieve stability with a unilateral system.

Complications of head injury.

Abstract Management of head injury is based on two concepts, proper treatment of the acute insult and the prevention and treatment of secondary insults. The head injured patient is subject to both intracranial and extracranial secondary insults. This paper will review complications related to the central nervous system as well as the pulmonary, infectious, gastrointestinal, and psychiatric complications frequently seen following traumatic brain injury. Complications following head trauma lead to significant acute and chronic morbidity and mortality. It is essential that clinicians be able to recognize and treat these complications in order to more effectively manage head trauma, improve outcome, and care for patients. [Neurol Res 2001; 23: 227-236]

Safety of instrumentation in patients with spinal infection: Clinical article

OBJECTnTreatment of spine infection remains a challenge for spine surgeons, with the most effective method still being a matter of debate. Most surgeons agree that in early stages of infection, antibiotic treatment should be pursued; under certain circumstances, however, surgery is recommended. The goals of surgery include radical debridement of the infective focus. In some cases, when surgery causes mechanical spinal instability, the question arises whether the risk of recurrent infection outweighs the benefits of spinal instrumentation and stabilization. The authors report their series of cases in which instrumentation was placed in actively infected sites and review the relevant literature.nnnMETHODSnThe authors performed a retrospective analysis of all cases of spinal infection that were surgically treated with debridement and placement of instrumentation at their institution between 2000 and 2006. Patient presentation, risk factor, infective organism, surgical indication, level of involvement, type of procedure, and ultimate outcome were reviewed. Improved outcome was based on improvement of initial American Spinal Injury Association Impairment Score.nnnRESULTSnForty-seven patients (32 men, 15 women) were treated with instrumented surgery for spinal infection. Their average age at presentation was 54 years (range 37-78 years). Indications for placement of instrumentation included instability, pain after failure of conservative therapy, or both. Patients underwent surgery within an average of 12 days (range 1 day to 5 months) after their presentation to the authors institution. The average length of hospital stay was 25 days (range 9-78 days). Follow-up averaged 22 months (range 1-80 months). Eight patients died; causes of death included sepsis (4 patients), cardiac arrest (2), and malignancy (2). Only 3 patients were lost to follow-up. Using American Spinal Injury Association scoring as the criterion, the patients conditions improved in 34 cases and remained the same in 5. Complications included hematoma (2 cases), the need for hardware revision (1), and recurrent infection (2). Hardware replacement was required in 1 of the 2 patients with recurrent infection.nnnCONCLUSIONSnInstrumentation of the spine is safe and has an important role in stabilization of the infected spine. Despite the presence of active infection, we believe that instrumentation after radical debridement will not increase the risk of recurrent infection. In fact, greater benefit can be achieved through spinal stabilization, which can even promote accelerated healing.

The spontaneous resorption of herniated cervical discs

The spontaneous resolution of herniated cervical discs has not been previously well documented. The authors analysed four cases who underwent spontaneous resolution of herniated cervical discs, and all other cases reported in the literature. A complex physiopathologic mechanism that includes the release of basic fibroblast grow factors, endothelial cell proliferation, chemotaxis of inflammatory cells into the disc fragment, foreign body inflammatory reaction, neovascularization and phagocytosis and accounts for the resorption of herniated discs is reviewed.

Modern psychosurgery before Egas Moniz: a tribute to Gottlieb Burckhardt

The history of modern psychosurgery has been written in several ways, weaving around many pioneers in the field during the 19th century. Often neglected in this history is Gottlieb Burckhardt (1836-1907), who performed the first psychosurgical procedures as early as 1888, several decades before the work of Egas Moniz (1874-1955). The unconventional and original case series of Burckhardt, who claimed success in 50% of patients (3 of 6), had met with overt criticism from his contemporary medical colleagues. The authors describe 2 illustrative cases of cortical extirpation performed by Burckhardt and review his pioneering case series for surgical outcome, despite the ambiguity in postoperative evaluation criteria. Although Burckhardt discontinued the project after publication of his surgical results in 1891, neurosurgeons around the world continued to investigate psychosurgery and revitalized his ideas in 1910; psychosurgery subsequently developed into a full-fledged neurosurgical specialty.

Hangman's fracture: a historical and biomechanical perspective

The execution technique of hanging, introduced by the Angle, Saxon, and Jute Germanic tribes during their invasions of the Roman Empire and Britain in the 5th century, has remained largely unchanged over time. The earliest form of a gallows was a tree on which prisoners were hanged. Despite the introduction of several modifications such as a trap door, the main mechanism of death remained asphyxiation. This created the opportunity for attempted revival after the execution, and indeed several well-known cases of survival following judicial hanging have been reported. It was not until the introduction of the standard drop by Dr. Samuel Haughton in 1866, and the so-called long drop by William Marwood in 1872 that hanging became a standard, humane means to achieve instantaneous death. Hangmen, however, fearing knot slippage, started substituting the subaural knot for the traditional submental knot. Subaural knots were not as effective, and cases of decapitation were recorded. Standardization of the long drop was further propagated by John Berry, an executioner who used mathematical calculations to estimate the correct drop length for each individual to be hanged. A British committee on capital sentences, led by Lord Aberdare, studied the execution method, and advocated for the submental knot. However, it was not until Frederic Wood-Jones published his seminal work in 1913 that cervical fractures were identified as the main mechanism of death following hanging in which the long drop and a submental knot were used. Schneider introduced the term hangmans fracture in 1965, and reported on the biomechanics and other similarities of the cervical fractures seen following judicial hangings and those caused by motor vehicle accidents.

The legendary contributions of Thomas Willis (1621–1675): the arterial circle and beyond

Thomas Willis established neurology as a distinct discipline and made significant original contributions to many related fields including anatomy, pathology, cardiology, endocrinology, and gastroenterology. He is most remembered for his work in elucidating the function and anatomy of the circle of Willis. Willis accomplishments and research methods can be credited in large part to his unconventional medical education which did not include traditional teachings, but rather emphasized learning through clinical practice. Although Willis was not the first to describe the arterial circle, he was the first to describe its function and provide a complete, undisputed illustration through his own innovative use of dye studies. The Willis classification of cranial nerves was still in use over 100 years after its original description. He has also described several disease entities and named many brain structures. Willis accomplishments in comparative anatomy and understanding the pathophysiology of various diseases through original multidisciplinary experimental work in a clinical setting reveal that he was a true pioneer in translational research.

DEVELOPMENT OF ANATOMIC SCIENCE IN THE LATE MIDDLE AGES: THE ROLES PLAYED BY MONDINO DE LIUZZI AND GUIDO DA VIGEVANO

MEDICAL HISTORIANS GENERALLY consider anatomic science, as we know it today, to have been established through the pioneering work of Vesalius during the Renaissance. Although this is largely true, detailed assessment of the scientific advances made in the late Middle Ages, though not as spectacular as those made during the Renaissance period, did pave the way and form a foundation for subsequent progress. During the two centuries of AD 1300 to 1500, several worthwhile advances occurred. Many universities, centers of learning excellence, were established throughout Europe, most notably in Italy. King Frederick II, the Holy Roman Emperor, established guidelines for medical education and practice that seem to parallel current regulations. Human cadaveric dissection was performed, after a hiatus of over 1700 years, as the foundation for the study of anatomy. Observation of human dissection became a requirement for medical students. A manual for anatomic dissection was written, printed, and published for the first time in history by Mondino de Liuzzi. His student, Guido da Vigevano, who also had an engineering background, established two “firsts” of his own: providing illustrations of anatomy and designing the first automobile in history. The authors believe that the contributions of these two key anatomists in the late Middle Ages should not be forgotten.

Charles-Edouard Brown-Séquard: an eccentric genius.

BROWN-SÉQUARD IS known eponymously for the syndrome of hemisection of the spinal cord, but most clinicians are not familiar with his colorful, quixotic, and eccentric life history. His contributions to medicine and neuroscience reached much further than his discovery of the spinal hemisection syndrome. He lived in five countries on three continents and crossed the Atlantic 60 times, spending a total of almost 6 years on the sea. He contributed more than 500 papers in his lifetime, was even the editor of many prestigious journals, and spent his last years as Professeur au Collége de France, a most coveted position for a French neuroscientist. Many are not aware of his contributions to endocrinology and hormone replacement therapy, even those who consider him the father of modern endocrinology. Brown-Séquard was a skillful experimentalist. He pioneered the concept of the advancement of neuroscience through experimental physiological observation. He was devoted to science. He was not interested in monetary gains through his inventions or patient care. Although he may be criticized for arriving at some incorrect conclusions from his experiments, his visionary ideas and prescient statements have stood the test of time; he truly was an eccentric genius. This article highlights Brown-Séquards life history, specifically his time in France and North America, and his contributions to neuroscience and endocrinology.