Faculty Bibliography

A massive hemispheric "high"-grade astrocytoma, diagnosed in a 6-week-old infant, was totally excised by means of two craniotomies. The child is still alive and well with minimal neurological dysfunction 1.5 years after operation. This case report illustrates the benefit of aggressive surgical excision (without radiation or chemotherapy) of massive malignant neonatal astrocytomas. While surgical deficits may be minimized by the plasticity of the developing nervous system, extensive excision may yield occasional long-term palliation.

Unilateral S-1 nerve root compression after an S-1 sacral fracture was found in an 18-year-old man after a motor vehicle accident. The positive myelogram, myelogram-computed tomogram, and magnetic resonance studies led to surgical intervention. Marked bony callous formation contiguous with the S-1 alar fracture protruded into the canal and was responsible for tethering the S-1 nerve root. A right L-5 hemilaminectomy, an L-4, L-5 and L-5, S-1 medial facetectomy, and foraminotomy facilitated nerve root decompression. Postoperatively, the patient was markedly improved. The authors suggest a more aggressive attitude in the diagnostic, radiographic, and surgical management of sacral fractures now that more specific technical facilities are available to define the precise character of the lesions involved

An attempt has been made to identify and manage patients symptomatic from both cervical and lumbar spinal stenosis. The order of operative intervention was related to the degree of myelopathy and radiculopathy. Patients requiring cervical surgery first had absolute stenosis with a spinal canal equal to or less than 10 mm in anteroposterior diameter. Those requiring lumbar surgery first presented with stenosis and a canal between 11 and 13 mm in depth. In the latter group, patients presented with radiculopathy in their upper and lower extremities. A significant portion (50%) had intermittent neurogenic claudication (INC). Motor and sensory changes were severe in those with absolute as compared to relative stenosis. After cervical laminectomy, myelopathy improved or stabilized, and the subsequent lumbar decompression could be completed with less risk. Cervical cord decompression often resulted in improvement in lumbar symptoms with resolution of pain, spasticity, and sensory deficits of myelopathic origin. However, latent symptoms of INC caused by lumbar stenosis were not affected by cervial decompression and increased in severity. Electrodiagnostic studies were helpful in that somatosensory evoked potentials showed conduction delays in the cervical cord in patients with significant disease. The identification of motor neuron disease and peripheral neuropathies was essential. The surgical management included extensive, multiple level laminectomy, unroofing of the lateral recesses, and foraminotomy. Neurolysis and untethering of the spinal cord was essential. Significant improvement was shown by 90% of these patients

The treatment over the past 12 years of 60 patients with degenerative spondylolisthesis with an intact neural arch is reviewed. The patients averaged 65 years of age, with women outnumbering men by a ratio of 2:1. Symptoms in the lower extremities had been present for 3 months to 10 years, although varying back pain had existed for longer periods. Two-thirds showed signs of motor dysfunction. Sensory alterations and a positive Las egue's sign could be demonstrated in only one-half of the patients studied. Four of 5 patients developed intermittent neurogenic claudication, with varying evidence of painful radiculopathy. The marked disability caused by claudication contrasted sharply with the lesser neurological changes, and these patients required early surgical decompression. Diagnostic studies included electromyography, plain x-ray films, tomography, computed tomographic scanning, and myelography. The latter outlined a relative stenosis caused by olisthesis as well as arthrotic and spondylotic changes that determined the extent of decompressive operation required. The L-4, L-5 interspace was involved in 56 patients, L-3, L-4 was involved in 2, and L-5, S-1 was involved in 2. The ideal operation with L-4, L-5 olisthesis included complete laminectomy of L-4 and L-5 with unroofing of the lateral recesses and foraminotomy. This more extensive procedure was justified because of the failures encountered in previous patients in whom inadequate decompression had been performed. Among failures, obesity, diabetes, hyperlordosis, and extensive long-standing dysfunction were prominent. The relief of symptoms of intermittent neurogenic claudication was the most gratifying response observed. There was no unusual morbidity

Sutural stripping, morcellation, subtotal craniectomy, and even subtemporal decompression, have been employed in the treatment of sagittal synostosis. This report describes a further modification of past techniques, the total vertex craniectomy. This procedure, employed in 9 patients, has achieved uniformly excellent cosmetic results.

A 6-year-old child with a brain stem tumor presented with the unusual complaint of intractable facial pain resembling trigeminal neuralgia in the absence of other symptoms or signs referable to the 5th cranial nerve. The radiological evaluation included a computed tomographic scan with intravenous contrast administration, which demonstrated an enhancing intramedullary lesion extending from the obex to C-4. After radiation and chemotherapy had failed to achieve symptomatic relief, the tumor, later proven to be a ganglioglioma, was radically removed with the ultrasonic aspirator. Postoperatively the patient experienced full pain relief.

Spinal stenosis is a well defined clinical entity that is occasionally encountered in patients with acromegaly. Persistent elevation of growth hormone promotes hypertrophy of the bones and ligaments, resulting in widening of the thoracolumbar vertebral bodies, and developmental narrowing of the spinal canal. This report describes the case of a 54-year-old acromegalic man with a 30-year history of low-back pain. Who developed symptoms of spinal stenosis. This case and two similar cases from the literature are discussed, and the appropriate therapeutic approaches reviewed