Responding to change: the challenge of the 1990s

In 1995, neurosurgery in the United States is facing challenges and threats never before imagined. In its attempts to respond as a relatively small specialty, the neurosurgical community can no longer afford to remain a house divided. Neurosurgical unit has now become a critical matter. In particular, our neurosurgical leadership must minimize duplication of efforts and efficiently allocate its resources. Most importantly, it must unify its energies in directing the numerous joint American Association of Neurological Surgeons/Congress of Neurological Surgeons activities, as well as serving as a direct liaison with the emerging representative assembly under the Joint Council of State Neurosurgical Societies. The unification of the neurosurgical leadership will clearly enhance our ability to deal with all of our present challenges and future changes, but more importantly it will permit our specialty to truly speak with one voice.

Spinal tuberculosis: a diagnostic and management challenge

The authors reviewed 29 cases of spinal tuberculosis treated from 1973 to 1993 with an average follow-up time of 7.4 years. Clinical findings included back pain, paraparesis, kyphosis, fever, sensory disturbance, and bowel and bladder dysfunction. Twenty-two patients (76%) presented with neurological deficit; 12 (41%) were initially misdiagnosed. Sixteen patients (55%) had predominant vertebral body involvement; nine had marked bone collapse with neurological compromise. Eleven individuals (39%) had intraspinal granulomatous tissue causing neurological dysfunction in the absence of bone destruction, and two (7%) had intramedullary tuberculomas. All patients received antituberculous medications: 13 were initially treated with bracing alone, eight underwent laminectomy and debridement of extra- or intradural granulomatous tissue, and eight underwent anterior, posterior, or combined fusion procedures. No patient with neurological deficit recovered or stabilized with nonoperative management. Thirteen patients were readmitted with progression of inadequately treated osteomyelitis; 12 (92%) of these required new or more radical fusion procedures. Anterior fusion failure was associated with marked preoperative kyphosis and multilevel disease requiring a graft that spanned more than two disc spaces. Courses of antibiotic medications shorter than 6 months were invariably associated with disease recurrence. It was concluded that 1) patients should receive at least 12 months of appropriate antituberculous therapy; 2) individuals with neurological deficit should undergo surgical decompression; 3) laminectomy and debridement are adequate for intraspinal granulomatous tissue in the absence of significant bone destruction; 4) when vertebral body involvement has produced wedging and kyphosis, aggressive debridement and fusion are indicated to prevent delayed instability and progression of disease.

Targeted brain biopsy: a comparison of freehand computed tomography-guided and stereotactic techniques

With computed tomography (CT) and magnetic resonance imaging stereotactic systems, biopsies of intracranial lesions can be made with safety and ease. Before the development of this technique, neurosurgeons often performed freehand brain biopsies under CT guidance. While stereotactic biopsy is the procedure of choice for small, deep lesions, few studies have compared the morbidity, mortality, and efficacy in obtaining a diagnosis associated with these two techniques for superficial lesions. A total of 167 consecutive CT-guided or stereotactic brain biopsies were performed in 154 patients. Fourteen of the stereotactic and 12 of the CT-guided biopsies were of deep lesions and were excluded from analysis. The results of 75 freehand CT-guided biopsies of superficial lesions in 69 patients were compared with those of 66 stereotactic biopsies (34 CT-guided and 32 MRI-guided) performed with the Brown-Roberts-Wells stereotactic system in 60 patients. Twenty-five of the lesions in the stereotactic biopsy group measured < or = 2 cm, as compared with 13 of those in the freehand CT-guided biopsy group. There were no biopsy-related deaths among the patients who underwent freehand CT-guided biopsy and one death among those who underwent stereotactic biopsy (1.5%). Freehand CT-guided biopsy was associated with 5% morbidity, compared with 6% morbidity for stereotactic biopsy. Seven CT-guided needle biopsies (9%) and 12 stereotactic biopsies (18%) were nondiagnostic. Statistical analysis showed no significant difference between morbidity and mortality in the two groups, but the rate of diagnostic failure was significant (P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Continual intracavitary administration of amphotericin B as an adjunct in the treatment of aspergillus brain abscess: case report and review of the literature

Aspergillus brain abscess is often a fatal disease, regardless of the mode of therapy. Most often seen in the compromised host, it is notoriously refractory to systemic antifungal agents and intrathecal antimycotics. Even with radical surgical debridement, only 13 patients, including the present case, have survived longer than 3 months after being treated for aspergillus brain abscess or granuloma. Studies have shown poor penetration of amphotericin B into the brain and cerebrospinal fluid. One way to achieve therapeutic levels of the agent near the abscess is through the direct introduction of the agent into the abscess site via an indwelling catheter. In the present case, a woman with an aspergillus abscess of the left temporal lobe was treated by a combination of systemic agents, radical debridement, and local therapy, resulting in a cure with a follow-up of 6 years. This is the first reported instance of the use of long-term, local antifungal therapy delivered to the area of the abscess cavity, using a closed reservoir system, and this patient is only the second renal transplant patient reported to have survived aspergillus brain abscess. This form of treatment produced no untoward long-term side effects or neurological sequelae. Local irrigation with antifungal agents should be considered in conjunction with systemic antifungal drugs and drainage and/or debridement in cases of fungal intracerebral aspergilloma. This technique may also prove useful with other fungal brain lesions.

Microsurgical management of craniopharyngiomas

A retrospective analysis of 34 patients who underwent microsurgical therapy for craniopharyngioma from 1975 to 1989, a period when CT imaging was routinely used, is presented. Mean follow-up was 6.4 years with no patients lost to follow-up. Those who underwent subtotal resection with adjuvant radiation had a significantly better recurrence-free interval compared with those who either underwent total or subtotal surgical resection only (p < 0.05 and p < 0.025). Among patients treated with surgery alone, the total resection group had a recurrence rate of 20% and those with a subtotal resection 60%. Those with subtotal resection and radiation had a 12% rate of recurrence. Endocrine and visual deficits were common after surgery. Based on this review, our results suggest that with a policy of attempted total resection where possible, subtotal removal along with adjuvant radiation, in cases where total resection was deemed unsafe, may be more effective than aggressive total resection alone as the initial management of craniopharyngioma.

Diastematomyelia of the cervical spinal cord with tethering in an adult

A case of cervical diastematomyelia associated with spinal cord tethering in an adult is presented. The differences between cervicodorsal and lumbar region spinal dysraphic states are emphasized with a review of the embryological factors involved. Possible causes and subsequent treatment are outlined.

Pituitary adenomas in patients under 20 years old. A clinicopathological study of 12 cases

The clinical manifestations, pathological features and follow-up data on 12 cases of pituitary adenoma in patient less than 20 years old were evaluated. This group represented 8.5% of our 142 cases of pituitary adenoma from all age groups during the period of study. There were five males and seven females whose ages ranged from 13 to 19 years at diagnosis. Immunocytochemical staining demonstrated the presence of prolactin in 10 tumors, ACTH in one tumor and the remaining neoplasm was negative for the five major pituitary hormones (prolactin, hGH, ACTH, TSH, gonadotrophin). The results of the immunocytochemistry correlated appropriately with the clinical manifestations. Extension beyond the sella turcica at presentation was a common feature as evidenced by the high incidence of visual defects (75%). A complete excision was accomplished in only two patients. The aggressive behavior of these tumors was demonstrated by a recurrence rate of 50% and only a single long-term cure. Early detection and therapy, if possible, are essential for the successful management of pituitary adenomas in younger patients as implied by our study and other reports in the literature.

Experience in the management of odontoid process injuries: an analysis of 128 cases

The authors present a retrospective analysis of 128 cases of odontoid process injury treated at the University of Minnesota and affiliated hospitals between the years 1967 and 1983. Of these 128 cases, 110 were acute fractures, while 18 patients suffered from old, unstable odontoid injuries. Motor vehicle accident was the leading cause of injury, and the largest group of patients was in their second decade. Type II fractures were the most commonly encountered type of injury, and anterior subluxation was the most common displacement. Posterior subluxation, however, had the highest incidence of associated neurological deficit. Regarding treatment, the 110 acute fracture patients fell into the following groups: 16 patients died during the acute phase, 14 patients underwent early posterior cervical fusion, and 80 patients underwent a course of external skeletal fixation. The remaining 18 patients with old unstable injuries underwent posterior cervical fusion. An analysis of the results in these groups led to the elucidation of certain factors that likely are important in determining the treatment of each individual patient. These factors include age of the patient, type of odontoid fracture, direction and degree of fracture displacement, and diagnostic delay. Fracture reduction and halo immobilization are the treatments preferred for patients who are diagnosed within 1 week of injury, who are less than 65 years of age and who have anteriorly, nondisplaced, or minimally posteriorly subluxed (less than 2 mm) Type II fractures, or who have any Type III injury.(ABSTRACT TRUNCATED AT 250 WORDS)

Use of the dexamethasone-adrenocorticotropin test to assess the requirement for continued glucocorticoid replacement therapy after pituitary surgery

We assessed the need for continued glucocorticoid replacement therapy in postsurgical pituitary tumor patients using a dexamethasone-ACTH test. The patients received 1 mg dexamethasone, orally, at 2300 h and 250 micrograms synthetic ACTH (Cosyntropin), iv, at 0800 h the next morning. The mean +/- SD integrated cortisol response for a 2-h period of the 31 pituitary tumor patients [1264 +/- 924 micrograms X min/dl (34.87 +/- 25.49 mumol X min/liter)] was significantly less (P less than 0.005) than that of 25 normal subjects [3331 +/- 544 micrograms X min/dl (91.90 +/- 17.04 mumol X min/liter)]. Replacement glucocorticoids were abruptly discontinued in 11 patients with responses above 1450 micrograms X min/dl (40.01 mumol X min/liter). No clinical or laboratory evidence of adrenal insufficiency occurred as long as 15 months after discontinuation. Metyrapone tests, however, in the 11 glucocorticoid-withdrawn patients revealed a reduced mean +/- SD serum 11-deoxycortisol level compared with that of 10 normal subjects [8.9 +/- 4.7 vs. 15.6 +/- 5.0 micrograms/dl (0.26 +/- 0.13 vs. 0.45 +/- 0.16 mumol/liter); P less than 0.005]. Our results indicate that the dexamethasone-ACTH test is useful in identifying patients in whom replacement glucocorticoid therapy can be safely withdrawn under nonstressed conditions. The test can be simplified to one plasma cortisol level determined 30 min after ACTH administration.

Extreme lateral disc herniation: diagnosis by computed tomographic scanning

Extreme lateral disc herniation with compression of the nerve root as it exits through the foramen has been a recognized entity for a number of years. Until recently, this diagnosis was made infrequently except at the time of operation. Reported here are 12 cases of root compression from disc herniation at the level of the pedicle or farther laterally in the foramen (extreme lateral disc herniation). Diagnosis and localization of the root compression were determined preoperatively in 11 of 12 cases based on the computed tomographic (CT) scan appearance of the lesion. Myelography was performed in 9 cases and was interpreted as normal in 6 and abnormal in 3 instances. In each of the 3 abnormal studies, the actual abnormality was at a different level than that predicted by the myelogram. The clinical presentations in these patients were not distinct except that a positive straight leg raising test was present in only 7 of 12. Preoperative knowledge of the site of nerve root compression as delineated by CT scanning was essential in planning the operative procedure. It prevented unnecessary exploration of uninvolved levels and directed the surgeon to the far lateral site of the herniation. Illustrative examples are presented.

Pyridine nucleotide synthesis in normal and neoplastic human pituitary cells in culture

14C-Nicotinic acid (NA) incorporation into nicotinamide adenine dinucleotide (NAD) was studied in cultures from 7 normal human pituitaries and 13 chromophobe adenomas. 14C-NA (7.2 microM) was incubated with both normal and tumor cell cultures for periods up to 48 hours. Cells and culture media were examined separately for metabolites at 24 and 48 hours. NAD was the major labeled metabolite found in both normal and tumor cells, accounting for 65.4% for normal cells and 56.8% for tumor cells of the total cellular label at 48 hours. Nicotinamide (NAm), a product arising from NAD, was the only labeled metabolite found in the culture medium, aside from the 14C-NA added initially. Total incorporation of 14C-NA into NAD was estimated by adding the cellular 14C-NAD and labeled products of NAD (NMN, NAm and NADP) to the 14C-NAm found in the medium for each culture. Cultures derived from adenomas demonstrated greater than twice the rate of incorporation of 14C-NA into NAD as did normal cell cultures (P less than 0.01 at 24 hours and less than 0.001 at 48 hours). This difference did not appear to be related to the secretory status of the tumor, since both secreting and nonsecreting tumors demonstrated increased rates when compared to normal cells. This difference also persisted in two different culture media and with cells that had been maintained in culture for different lengths of time (6-day dispersed cell cultures and 6- to 16-week fragment cultures).

Aspergillus infections of the lumbar disc spaces. Report of three cases

Three cases of lumbar vertebral interspace infection due to the Aspergillus fungus are presented. Two patients responded to vigorous surgical therapy in combination with prolonged administration of antifungal agents. The third patient died of complications related to the antibiotic therapy. Possible etiologies of this unusual problem are reviewed in light of the changing spectrum of nosocomial and spontaneously acquired infectious processes. Combined aggressive medical and surgical therapy is discussed with respect to the known difficulties in eradicating deep-seated osseous mycotic infections.

Thoracolumbar injuries

Thoracolumbar injuries represent an unique neurologic injury. In light of the potential for recovery in the roots of the cauda equina, an aggressive plan of management should be undertaken, to absolutely ensure an adequate decompression of the spinal canal and neural elements, but in addition to accomplish a simultaneous bony reduction and fusion of the injury site. Traditional laminectomy alone has minimal benefit in most of these cases, since compression is usually anterior and decompression is best achieved through a posterolateral or anterior transthoracic approach. The best avenue of decompression is dictated by a careful and complete preoperative radiographic evaluation, including polytomography and CT scanning. Utilization of this aggressive plan of management can then offer an optimum milieu for neurologic recovery and at the same time produce solid, pain-free bony healing with a minimum of spinal deformity.

Neurocutaneous Masson's vegetant intravascular hemangioendothelioma

Since first described, Masson's vegetant intravascular hemangioendothelioma (VIH) has been recognized in various locations. The neurocutaneous dissemination of the lesions in our case represent a unique characteristic. The histopathological and radiological similarities between VIH and malignant lesions are stressed.

Central nervous system involvement in the nevoid basal cell carcinoma syndrome: case report and review of the literature

The characteristic features of central nervous system involvement in the nevoid basal cell carcinoma syndrome are reviewed. Emphasis is given to the frequent association of medulloblastoma with the syndrome.

Unilateral hydranencephaly: case report

Unilateral hydranencephaly has been known to occur, yet may be confused with other pathological processes. We describe a case that seems to meet the criteria of hydranencephaly limited to one hemisphere. Its significance is discussed in terms of both pathogenesis and prognosis.

Redundant nerve roots of the cauda equina

Two cases of the syndrome of redundant nerve roots of the cauda equina are reported. Both cases were treated surgically, A review of the clinical picture, management. and etiology is presented. In each case, preoperative and postoperative myelography was performed: in one patient myelography demonstrated a complete resolution of the characteristic serpentine filling defects.

Acromegaly: reassessment of the long-term therapeutic effectiveness of transsphenoidal pituitary surgery

Of 11 patients with active acromegaly treated with transsphenoidal selective pituitary adenomectomy, four failed to show evidence of clinical improvement. An additional four patients showed clinical and biochemical improvement after the surgical procedure but, with more prolonged follow-up, showed a recurrence of acromegaly. Only three patients had prolonged clinical and biochemical evidence of improvement; they had glucose suppressed growth hormone concentrations of 1.0, 2.7, and 2.8 ng/mL 22, 40, and 24 months, respectively, after the surgical procedure. Two of these three patients, however, showed an increase in growth hormone concentration after thyrotropin-releasing hormone injection, a finding that suggests the possibility of eventual relapse. Our data also clearly indicated a need for more rigorous criteria for biochemical cure of acromegaly than those used previously. Study of 20 healthy volunteers showed that growth hormone concentration should normally be suppressible to less than 2.0 ng/mL after 100 g oral glucose.

Neurofibromatosis with congenital glaucoma and buphthalmos in a newborn

A newborn infant with unilateral eyelid swelling, proptosis, and glaucoma is described. The diagnosis of congenital neurofibromatosis was made on the basis of a positive family history and by inspection of the patient. It is suggested that this clinical problem is more common at birth than generally recognized. Clinicians should be aware that congenital glaucoma secondary to neurofibromatosis is a distinct entity that can manifest itself in the newborn period.

Prolactin suppression of leukocyte chemotaxis in vitro

Leukocyte chemotaxis in vitro was studied for cells from patients with pituitary adenomas. Leukocytes obtained preoperatively from two of three patients with elevated serum prolactin levels demonstrated chemotaxic alterations described in other malignant disease. Statistically significant suppression of chemotaxis occurred in the leukocytes of four of 12 specimens from normal donors at concentrations of 1000 ng/ml, and in four of eight specimens at 2000 ng/ml of prolactin in preincubation media. Thus prolactin concentration may influence the motility of leukocytes. The variable neoplastic behavior of morphologically similar pituitary adenomas may, in part, reflect a neurohormonally altered host response to the presence of these lesions.

Transnasal excision of a neurohypophyseal tumor

Neurohypophyseal tumors are rare. A case of a glioma of the neurohypophysis is presented. The tumor closely resembled pituicytomas or infundibulomas. Management of these lesions poses special problems as their natural history is unclear. This tumor was excised via the transnasal, transphenoidal route and there has been no recurrence during the subsequent thirty months. The transnasal approach for posterior lobe tumors appears to be acceptable for those confined to the sella turcica or displaying minimal suprasellar extension. The literature is reviewed.

Surface topography of normal and neoplastic human anterior pituitary cells maintained in vitro

Pituitary tissues were obtained from 25 patients who underwent surgery for excision of pituitary macroadenomas, selective excision of microadenomas, or removal of a normal gland for palliation of metastatic cancer. Cells thus obtained were maintained in vitro for varying intervals, fixed, and examined by light (phase contrast), microscopy, transmission electron microscopy (TEM), and scanning electron microscopy (SEM). Previous SEM reports indicate that surface topography of in vitro neoplastic cells displays features that may correlate with neoplastic behavior. Cultured normal and pituitary tumor cells did not display these surface differences, with one exception, a prolactin-secreting microadenoma. Characteristic patterns for the cell populations were identified. Certain cell types appeared in all the cultures: 1) large and small granule-containing cells; 2) flat and irregular cells; 31 spindle-shaped cells; and 4) spherical, irregularly surfaced cells. In one case of an endocrine-inactive juvenile pituitary chromophobe adenoma, unique cells were observed. Surface topography did not appear to be of predictive value in determining the neoplastic character of pituitary tumors.

Non-operative management of acute upper cervical injuries

The results of a closed, non-operative type of treatment in acute upper cervical injury have been reviewed, especially as they relate to the use of the halo cast or vest. The morbidity with the use of this device has been minimal and there has been no mortality. Early patient mobilization has been readily achieved and in the case of the Hangman's, Jefferson's, and odontoid fractures, stable solid bony healing has been achieved in nearly all cases. Similar results have been noted in the C-1 arch fracture, as well as the acute post-infectious subluxations of C-1/C-2. In a small number of cases involving traumatic C-1/C-2 and occipital/atlas subluxation, there has occurred a significant incidence of instability, despite adequate closed treatment. This has been likely to be due to the serious ligamentous disruption in these cases and it would appear that surgical fusion may be the preferential form of initial treatment in this group of injuries.

Transnasal transsphenoidal approach to the sella

The transnasal transsphenoidal approach to the sella turcica has been refined and perfected through advances in medicine and technology. Originally performed for excision of pituitary adenomas, its present primary use is pituitary ablation is hormonally dependent diseases. Our study of 55 patients who have undergone this procedure during the years 1970-1975 demonstrates that this microscopic technique gives excellent exposure and visualization of intrasellar contents. Our method gives excellent exposure and visualization of intrasellar contents. Our method with several instrument modifications is discussed. It is technically an easy procedure with a minimum of morbidigy and mortality.

Spectrum of the hangman's fracture

The authors review their experience in managing 26 cases of "hangman's fracture." The basic mechanism of injury was hyperextension of the upper cervical spine. Radiographic studies revealed a spectrum of injury beginning with the classical hangman's fracture and progressing to the simple C-2 laminar-pedicle fracture. Appreciation of the fracture instability will dictate the method and duration of fracture treatment. Management by a closed, nonoperative means resulted in solid union of the bone in all fully treated cases, with a minimum of morbidity.

Suction-irrigation treatment of craniotomy infections. Technical note

✓ A simple method of early debridement and institution of suction-irrigation has been used on eight consecutive craniotomy infections. The principles of treatment are identification of the infecting organism, open debridement of the wound, and closed irrigation of the subgaleal area with an antibiotic solution for 5 days. The treatment has been, thus far, uniformly successful in resolving these craniotomy infections, thereby avoiding bone flap removal.

Giant arteriovenous malformations of infancy and childhood

✓ Twelve patients are presented with giant arteriovenous malformations of the brain requiring therapy in the neonatal or infant period. Eight patients were operated on, and six survived with no neurological deficit. Four patients were not operated on and all died. The diagnostic clinical triad of enlarged head, cranial bruit, and cardiac failure or enlargement is described, and angiographic characteristics and surgical therapy discussed.