RESUMEN
The association of congenital hydrocephalus and heart disease in children is infrequent, but may present considerable dilemmas in management. This report describes the treatment and prognosis of 11 children with both clinical problems. There were 5 males and 6 females. Hydrocephalus occurred following aqueductal stenosis in 5 children and the Dandy-Walker malformation in 3. Three children were diagnosed with idiopathic hydrocephalus. Ten children underwent cerebrospinal fluid diversion procedures for control of hydrocephalus. Five children received pharmacological therapy for cardiac disease; 4 children required surgical correction. Two children died from medical conditions; 2 families declined treatment. Follow-up from 2 to 7 years in the remaining 7 children demonstrated moderate or severe neurodevelopmental disability in 5. One child at 2 years of age showed borderline developmental disability while 1 child is developing normally at 10 years of age. Overall the occurrence of symptomatic hydrocephalus and heart disease in the perinatal period resulted in mortality or neurodevelopmental disability in 9/11 children.
Asunto(s)
Cardiopatías Congénitas/complicaciones , Hidrocefalia/complicaciones , Niño , Preescolar , Progresión de la Enfermedad , Femenino , Estudios de Seguimiento , Humanos , Hidrocefalia/cirugía , Masculino , Pronóstico , Estudios Retrospectivos , Resultado del Tratamiento , Derivación Ventriculoperitoneal/métodosRESUMEN
The variety of perinatal neurologic injuries described in this article suggests that any region of the central or peripheral nervous system may be affected by the birth process. Fortunately, these injuries are infrequent and, in many instances, resolve without any intervention.
Asunto(s)
Traumatismos del Nacimiento , Plexo Braquial/lesiones , Traumatismos Craneocerebrales/etiología , Traumatismos de la Médula Espinal/etiología , Humanos , Recién Nacido , Traumatismos de la Médula Espinal/diagnósticoRESUMEN
Therapeutic transfusion was not a common procedure at the turn of the century. Although its safety was enhanced by the discovery of blood groups and preinfusion testing in the decade prior to World War I, techniques and indications remained cumbersome and clinically naive. By 1916, a stable Western Front, an efficient line of transport, and the operative requirements of a large number of wounded demonstrated the futility of pharmacotherapy or saline infusion for traumatic shock. In the same year, Rous and Turner at the Rockefeller Institute developed a preservative solution for whole blood. Rous' student, Dr. O.H. Robertson, arrived in France with Base Hospital 5 in June 1917 during a period of growing recognition by military surgeons that transfused blood was an effective therapy, although a practical delivery system was not available. Over the next 8 months, Robertson clinically tested a transfusion technique using preserved blood in glass jars carried to the front in specially designed cases. The method was accepted immediately, and by the Armistice transfusion was used frequently on the front line or during the perioperative period. The accessibility of preserved blood with an efficient transfusion system reinforced the introduction of "resuscitation teams" attached to Casualty Clearing Hospitals for the specialized management of traumatic shock. Robertson's success at technical innovation during World War I associated with a large clinical population resulted in the development of the indications and procedures for modern transfusion therapy.
Asunto(s)
Transfusión Sanguínea , Medicina Militar , Guerra , Transfusión Sanguínea/métodos , Historia del Siglo XX , Humanos , Estados UnidosRESUMEN
Over the past 4 years, 7.4% of deaths caused by strangulation in Peoria County, Ill., involved children under 18 years of age. Clinical review of a consecutive series of 13 children treated from 1985 through 1994 revealed an incidence of 32 of 10,000 intensive care unit admissions with a 5.5:1 male bias. Accidental causes were seen in six children, with suicide or autoerotic causes prevalent in older children and adolescents. Five children had behavioral disorders before injury. The initial Glasgow Coma Scale score was 8 or below in seven children. Cervical roentgenograms in all patients and computed tomographic examinations performed in seven children were interpreted as normal. Seven children required ventilatory assistance, and four had pneumonia or acute lung injury. Intracranial pressure monitoring in three children failed to reveal sustained elevations of pressure. Serial changes in electroencephalograms in five patients paralleled improvements in their clinical examinations. Ten children were normal on follow-up; one adolescent reported mild neurologic sequelae and one adolescent showed severe disability. One adolescent died 2 days after injury. Comparison of this series with previous reports of 26 children indicated that the extent of the initial injury and effectiveness of resuscitation were major determinates for outcome. Pulmonary complications were common, whereas the development of elevated intracranial pressure indicated a poor prognosis and suggested the use of telemetry in children, with clinical evidence of severe injury. Continued awareness of preventative measures for accidental strangulation in infants and intentional hanging in children with behavioral disorders may reduce the incidence of these injuries.
Asunto(s)
Accidentes , Homicidio , Traumatismos del Cuello , Suicidio , Accidentes/estadística & datos numéricos , Adolescente , Causas de Muerte , Niño , Preescolar , Femenino , Homicidio/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Humanos , Illinois/epidemiología , Incidencia , Masculino , Pronóstico , Estudios Retrospectivos , Distribución por Sexo , Suicidio/estadística & datos numéricos , Heridas y Lesiones/complicaciones , Heridas y Lesiones/epidemiología , Heridas y Lesiones/terapiaRESUMEN
The cerebrovascular hemodynamics were recorded in two children with comparable hypoxic-ischemic injuries after strangulation. Monitoring was initiated within 13 hours of injury and continued for at least 38 hours. The profile included continuous measurements of cortical regional cerebral blood flow (rCBF) with a subdural thermal diffusion probe, intracranial pressure, mean arterial pressure, and expired CO2 tension. Data sets were obtained every 15 minutes or every 5 minutes during epochs of hyperventilation and inotropic support. Arterial CO2 and oxygen content and pH and, in the second patient, cardiac output (and cardiac index) were determined every 3 to 6 hours. Both children showed cortical hyperemia with a gradual rise of rCBF during the study; neither child showed elevated intracranial pressure. Mean CO2 reactivities were 1.8 and 2.1 mL/100 g/minute/mm Hg, with gradual elevations during the study. Mean cerebrovascular resistances were 0.7 and 0.9 mL/100 g/minute/mm Hg, respectively. Dissociative vasoparalysis with loss of autoregulation and preservation of CO2 reactivity was observed in both children. In the second child, during two periods of hyperventilation, an inverse steal occurred with rCBF indirectly related to expired CO2 tension; the rCBF was not related to changes in cardiac output or cardiac index. Neurologic outcome was not related to mean levels of rCBF, CPP, and CO2 reactivity, or clinical dissociative vasoparalysis. Lower initial and mean values of rCBF and an inverse steal after hyperventilation were associated with a poor outcome in the second patient.
Asunto(s)
Isquemia Encefálica/fisiopatología , Circulación Cerebrovascular , Traumatismos del Cuello , Adolescente , Química Encefálica , Isquemia Encefálica/etiología , Dióxido de Carbono/análisis , Niño , Estudios de Seguimiento , Humanos , Presión Intracraneal , Masculino , Monitoreo Fisiológico , Oxígeno/análisis , Pronóstico , Heridas y Lesiones/complicacionesRESUMEN
A retrospective analysis was undertaken in a consecutive series of 33 full-term infants (birth weight > 2500 g and a minimum of 37 weeks gestational age) with symptomatic intracranial hemorrhage (ICH) admitted to a regional neonatal intensive care unit from January 1986 to December 1992. Eleven infants were born in our institution; 17 were male. The estimated local incidence of symptomatic ICH for the inborn population was 4.9/10000 live births, with a regional incidence of 2.7/10000 live births. Twenty-four (72.3%) infants presented with seizures, apnea, or respiratory distress. Five (15.1%) children developed ICH associated with extracorporeal membrane oxygenation, ventriculoperitoneal shunting, and cardiac surgery. There were two deaths (6.1%) associated with a grade IV periventricular hemorrhage (PVH) and cardiac surgery. Nine infants (27.3%) showed PVH, while an additional nine children developed multifocal cortical hemorrhages. Eight infants (24.2%) showed extra-axial ICH, four children (12.1%) sustained lobar hemorrhages, and three children (9.1%) showed ICH associated with prenatal CNS abnormalities. Excluding five children with iatrogenic ICH, coagulopathies occurred in 9 of 28 infants (32.1%) and constituted a major determinant of the development of ICH. Neurosurgical intervention was limited to one infant with massive ICH and one child with hydrocephalus as a late sequela of ICH. Developmental follow-up was complete in 32 children with a mean and median duration of 3.4 years. Full-term infants with ICH associated with risk factors for hypoxic-ischemic injury showed a significantly greater risk of developmental delay compared to infants with uncomplicated ICH.
Asunto(s)
Hemorragia Cerebral/diagnóstico , Femenino , Edad Gestacional , Humanos , Recién Nacido , Imagen por Resonancia Magnética , Masculino , Estudios RetrospectivosRESUMEN
BACKGROUND: The rates of seizure activity associated with surgical treatment of chronic subdural hematoma (CSH) reported in the literature has varied greatly. The efficacy of prophylactic anticonvulsive medication (ACM) has been debated and its use been erratic. With improved diagnosis, reduction of associated morbidity impacts greatly on the mortality rate, and so the use of ACM may be important to the patient with CSH. METHODS: We conducted a retrospective analysis of the records of patients treated surgically for CSH and examined the prevalence of seizure activity, morbidity, and mortality and the effects of anticonvulsant medication. RESULTS: Ninety-eight patients (65 = male) were identified with a mean age of 72 years and a range of 4 to 97 years. Six patients had a preexisting seizure disorder; despite therapeutic serum levels of ACM, 3 of these 6 patients experienced seizures without mortality. Seizures occurred in 20/98 (20.4%) patients during hospitalization or follow-up. Of the 92 patients without a preexisting seizure disorder, 42 (46%) received prophylactic phenytoin with therapeutic serum levels. One patient among the 42 (2.4%) who received prophylactic ACM experienced seizure activity in comparison to 16 of 50 (32%) patients who did not receive adequate prophylactic ACM (P = < 0.001). Six of 11 deaths within one month of discharge occurred in patients with a new onset of seizures (P = < 0.005). Age, sex, history of trauma, Markwalder scores on admission, location of hematoma, or type of surgery were unrelated to the occurrence of seizures or mortality. Following hospital discharge, patients were continued on ACM for a mean duration of 8 months without seizures. CONCLUSIONS: The onset of new seizures was found in 17 (18.5%) of 92 patients and was associated with increases in morbidity and mortality. Patients who received prophylactic ACM demonstrated a significant decrease in the occurrence of seizures, and we therefore recommend the use of phenytoin prophylaxis in patients treated surgically for chronic subdural hematoma.
Asunto(s)
Anticonvulsivantes/uso terapéutico , Hematoma Subdural/complicaciones , Complicaciones Posoperatorias/prevención & control , Convulsiones/prevención & control , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Enfermedad Crónica , Femenino , Hematoma Subdural/cirugía , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Convulsiones/etiologíaRESUMEN
A chart analysis for a 5-year period through December 1992 identified four full-term neonates with lobar hemorrhage. Prenatal and obstetrical histories were uncomplicated; all infants presented with seizures within 48 h following birth. Perinatal asphyxia and isoimmune thrombocytopenia were associated with lobar hemorrhage in two children. Although computed tomography was sufficient for diagnosis, magnetic resonance evaluation provided assessment of specific cortical injury and the age of the hemorrhage. No infant underwent surgical intervention; three children reached developmental milestones at a mean follow-up of 3.3 years.
Asunto(s)
Encéfalo/fisiopatología , Hemorragia Cerebral/fisiopatología , Recién Nacido , Hemorragia Cerebral/diagnóstico , Hemorragia Cerebral/etiología , Femenino , Estudios de Seguimiento , Lateralidad Funcional , Edad Gestacional , Humanos , Imagen por Resonancia Magnética , Masculino , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND AND PURPOSE: This report examines the occurrence of subcortical infarction in 5 children, reviews the English literature, and discusses evaluation of this uncommon childhood illness. METHODS: Clinical characteristics and neurological follow-up were examined in children who presented with subcortical infarction within the past 7 years. The English literature over the previous 20 years was reviewed to identify similar patients with radiological documentation of subcortical infarction. RESULTS: Mean age of the patients in this series was 4.8 years (range, 4 months to 12 years); 3 children were female. Three patients presented with the sudden onset of hemiparesis, 1 with dystonia, and 1 with fever and focal seizures. Protein C deficiencies were demonstrated in 2 children; a cardiomyopathy was seen in 1 patient. Mean follow-up was 1.5 years. Two patients were neurologically normal, mild residual symptoms persisted in 2, and 1 patient showed severe dystonia. The literature analysis indicated that specific risk factors were described in 79 patients; complete clinical analysis was available for 51 patients. In the latter group, the mean age was 5.7 years; 26 children were female. Forty-six presented with hemiplegia, 4 with dystonia, and 1 with focal seizures. Follow-up greater than 5 months in 29 patients showed complete or good resolution of deficits in 23. Specific risk factors such as infection, trauma, hematologic disorders, or cardiac or vascular abnormalities were identified in 62 of 79 children. CONCLUSIONS: This analysis indicates that children with subcortical infarction usually presented with acute hemiparesis. Risk factors were identified in the majority of children, and follow-up demonstrated good or complete resolution of neurological deficits in 80% of the patients.
Asunto(s)
Infarto Cerebral/diagnóstico , Infarto Cerebral/fisiopatología , Arterias Cerebrales/patología , Niño , Preescolar , Evaluación de la Discapacidad , Femenino , Humanos , Lactante , Imagen por Resonancia Magnética , Masculino , Sistema Nervioso/fisiopatología , Tomografía Computarizada por Rayos XRESUMEN
A leading proponent of neurological surgery at the onset of World War I, Victor Horsley's uncompromising liberalism was unpopular among the medical hierarchy. Assigned to the Mediterranean Expeditionary Force (MEF) his political activism proved more valuable than his surgical talent. This report will outline his military career and death in 1916. As a member of the local Territorial Force at the outbreak of the war, Horsley requested active duty on the Western Front. He was eventually posted as Director of Surgery of the 21st General Hospital and sent to Egypt for the Dardanelles Campaign in May 1915. Several months later he was promoted to colonel and appointed surgical consultant of the Army Medical Service. Although he operated electively and lectured to medical officers on Gallipoli, the chaotic medical conditions promoted him (and others) to push for re-organization of the medical services; public outcry succeeded in effecting a change. At the end of this campaign, Horsley volunteered for duty in Mesopotamia. The appalling medical conditions prevented adequate surgery and for the next 4 months he devoted his attention to transport, equipment and ancillary care for the diseased troops. His death was sudden and controversial. A vehement opponent of alcohol and the 'rum ration', he publicly testified to his own good health in the tropics as an example of the benefit of abstinence. In mid-July, 1916, he developed severe hyperpyrexia and died within 36 h. Detractors pointed to the uselessness of abstinence while proponents described his death as the unavoidable result of epidemic paratyphoid. In summary, Horsley's political activism was partially successful in medical reorganization, but his surgical abilities could not be used appropriately in a theatre of operations where infectious disease played a major role. His early death mirrored the waste and tragedy of the Great War.
Asunto(s)
Medicina Militar/historia , Historia del Siglo XIX , Historia del Siglo XX , Neurocirugia/historia , Reino UnidoRESUMEN
A 2-month-old infant demonstrated clinical brain death 48 hours after suffering a closed head injury accompanied by cardiac arrest. Two nuclear cerebral blood flow (CBF) studies demonstrated normal perfusion. On the 11th day following injury, cerebral electrical activity ceased and a normal glucose metabolic gradient between gray and white matter was documented on positron emission tomography. Autopsy revealed widespread necrosis with mononuclear cell infiltrates throughout all cerebral cortical layers. Nine children have previously been described with clinical brain death, electrocerebral silence, and evidence of CBF by radionuclide scan. The dissociation between cerebral electrical activity and blood flow may be explained by an increase in cranial volume allowed by the expansile neonatal skull, preventing both intracranial hypertension and a reduction in perfusion pressure. The persistence of glucose metabolism may be associated with the presence of inflammatory microglial cells in the ischemic cortex. The authors conclude that persistence of CBF and glucose metabolism in brain-dead children may not indicate neuronal survival. If repeated neurological examinations with or without electroencephalography support the diagnosis of brain death, the presence of CBF and glucose metabolism should not alter this conclusion.
Asunto(s)
Muerte Encefálica/metabolismo , Muerte Encefálica/fisiopatología , Encéfalo/metabolismo , Encéfalo/fisiopatología , Circulación Cerebrovascular , Glucosa/metabolismo , Encéfalo/diagnóstico por imagen , Electroencefalografía , Electrofisiología , Humanos , Lactante , Masculino , CintigrafíaRESUMEN
Approximately 12 million Americans undergo spinal manipulation therapy (SMT) every year. Renewed interest in this method requires an analysis of its reported risks and possible benefits. This review describes two patients with spinal cord injuries associated with SMT and establishes the risk/benefit ratios for patients with lumbar or cervical pain. The first case is a man who underwent SMT for recurrent sciatica 4 years after chemonucleolysis. During therapy, he developed bilateral sciatica with urinary hesitancy. After self-referral, myelography demonstrated a total block; he underwent urgent discectomy with an excellent result 3 months after surgery. The second patient with an indwelling Broviac catheter and a history of lumbar osteomyelitis underwent SMT for neck pain. Therapy continued for 3 weeks despite the development of severe quadriparesis. After self-referral, he underwent an urgent anterior cervical decompression and removal of necrotic bone and an epidural abscess with partial neurological recovery. An analysis of these cases and 138 cases reported in the literature demonstrates six risk factors associated with complications of SMT. These include misdiagnosis, failure to recognize the onset or progression of neurological signs or symptoms, improper technique, SMT performed in the presence of a coagulation disorder or herniated nucleus pulposus, and manipulation of the cervical spine. Clinical trials of SMT have been summarized in several recent articles.(ABSTRACT TRUNCATED AT 250 WORDS)
Asunto(s)
Dolor de Espalda/terapia , Quiropráctica , Discitis/terapia , Desplazamiento del Disco Intervertebral/terapia , Manipulación Ortopédica , Paraplejía/etiología , Trastornos Urinarios/etiología , Adulto , Arterias/lesiones , Trastornos Cerebrovasculares/etiología , Vértebras Cervicales/lesiones , Quiropráctica/historia , Ensayos Clínicos como Asunto/métodos , Ensayos Clínicos como Asunto/normas , Terapia Combinada , Contraindicaciones , Discitis/complicaciones , Discitis/cirugía , Estudios de Evaluación como Asunto , Historia del Siglo XVIII , Historia del Siglo XIX , Historia del Siglo XX , Historia Antigua , Humanos , Incidencia , Desplazamiento del Disco Intervertebral/complicaciones , Desplazamiento del Disco Intervertebral/cirugía , Dolor de la Región Lumbar/terapia , Vértebras Lumbares , Masculino , Manipulación Ortopédica/efectos adversos , Manipulación Ortopédica/historia , Metaanálisis como Asunto , Persona de Mediana Edad , Riesgo , Factores de Riesgo , Ciática/etiología , Ciática/terapia , Método Simple Ciego , Traumatismos Vertebrales/epidemiología , Traumatismos Vertebrales/etiologíaRESUMEN
A 16-year-old boy presented with acute midline thoracic pain followed by rapidly progressive paraplegia. The initial neurological examination demonstrated a complete sensory and motor paraplegia, which significantly improved spontaneously over the following 2 days. Magnetic resonance imaging revealed a posterior epidural hematoma extending from the T-4 to T-6 vertebrae, and spinal angiography demonstrated an arteriovenous malformation (AVM) with a nidus of abnormal epidural vessels at the level of the T-5 vertebra, which was confirmed surgically. This case represents one of the first reports of a spinal epidural AVM confirmed by angiography.
Asunto(s)
Malformaciones Arteriovenosas/diagnóstico por imagen , Espacio Epidural/irrigación sanguínea , Médula Espinal/irrigación sanguínea , Enfermedad Aguda , Adolescente , Angiografía , Malformaciones Arteriovenosas/complicaciones , Malformaciones Arteriovenosas/cirugía , Espacio Epidural/diagnóstico por imagen , Humanos , Laminectomía , Imagen por Resonancia Magnética , Masculino , Dolor/etiología , Paraplejía/etiología , Periodo Posoperatorio , Rotura Espontánea , Médula Espinal/diagnóstico por imagen , TóraxRESUMEN
This retrospective analysis describes the clinical characteristics, treatment, and outcome of 19 patients aged 80 years or older with odontoid fractures. The fractures were due to falls in 15 patients (78.9%) and were associated with motor-vehicle accidents in four. Type III fractures were seen in three patients and type II fractures in 16. No patient suffered a neurological injury associated with the fracture. Five patients (26.3%) died during hospitalization; factors contributing to their death included prolonged bed rest, associated injuries, and concomitant medical illnesses. The mean follow-up period in the remaining 14 patients was 28.8 months (range 5 to 72 months). Eight patients with a posterior displacement of 5 mm or less were treated with cervical immobilization, three of whom showed a stable non-union of the fracture site at follow-up review. One patient with 10-mm displacement refused operative treatment. Three of the patients without surgical treatment subsequently died from unrelated causes; all remaining patients resumed their routine activity. Five patients with displacement of 5 mm or greater and instability at the fracture site were treated with posterior cervical fusion of C1-2 using wire and autologous iliac bone grafts. In this group, no operative morbidity or mortality occurred and stable constructs developed in all patients; one patient died from an unrelated cause during the follow-up period and the other patients resumed their normal activity. Prolonged bed rest caused respiratory complications in two of six patients who survived initial hospitalization; two of three patients treated with rigid immobilization developed complications that required alternative treatments.
Asunto(s)
Apófisis Odontoides/lesiones , Fracturas de la Columna Vertebral/terapia , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Apófisis Odontoides/cirugía , Estudios Retrospectivos , Fracturas de la Columna Vertebral/clasificación , Fracturas de la Columna Vertebral/cirugía , Resultado del TratamientoRESUMEN
From 1985 to 1991, 13 children were diagnosed at the University of Illinois College of Medicine at Peoria, Saint Francis Medical Center, with cerebral venous thrombosis (CVT) by magnetic resonance imaging scan. Ages ranged from newborn to 5 years. Six children were premature neonates, five were term neonates and two were 5 years old. In the premature neonates, thrombosis was usually associated with other problems. All the term neonates had seizures. In all neonates, thrombosis resolved without any specific treatment. In the two older children, one presented with pseudotumor cerebri and one with coma. These children required neurosurgical intervention. Follow-up magnetic resonance imaging scans were obtained in 9 of 13 children and showed thrombus resolution in each case. Three children were studied in the acute and convalescent stages by magnetic resonance angiography using time-of-flight techniques. Each follow-up magnetic resonance angiogram showed improvement in venous flow consistent with their clinical course and other imaging studies. We conclude that 1) CVT in children encompasses a range of clinical conditions which may or may not require neurosurgical intervention; 2) magnetic resonance imaging is superior to other modalities for the diagnosis of CVT; and 3) magnetic resonance angiography is an alternative means to monitor the evolution of CVT and efficacy of therapeutic intervention.
Asunto(s)
Angiografía Cerebral , Enfermedades del Prematuro/diagnóstico , Imagen por Resonancia Magnética/métodos , Trombosis de los Senos Intracraneales/diagnóstico , Preescolar , Femenino , Estudios de Seguimiento , Traumatismos Cerrados de la Cabeza/diagnóstico , Traumatismos Cerrados de la Cabeza/cirugía , Humanos , Recién Nacido , Enfermedades del Prematuro/cirugía , Masculino , Examen Neurológico , Complicaciones Posoperatorias/diagnóstico , Trombosis de los Senos Intracraneales/cirugíaRESUMEN
OBJECTIVE: To describe the long-term outcome and complications of spinal surgery in a population of elderly patients. DESIGN: Retrospective chart review and clinical follow-up. SETTING: A 700-bed tertiary care midwestern hospital. PATIENTS: Patients 70 years of age or older who underwent elective surgical procedures for the treatment of benign lesions of the spinal canal. MAIN OUTCOME MEASURES: Data obtained from chart review included age, sex, nature and duration of neurological symptoms, activities of daily living (ADL), associated illnesses, length of hospitalization, type of surgery, and complications attributable to surgery. Outcome measurements included changes in neurological symptoms and ADL and a standardized scale obtained from consecutive outpatient visits, telephone interviews, or written responses. RESULTS: Seventy-eight patients with lumbar canal stenosis or soft disc herniations underwent laminectomies, foraminotomies or discectomies. Eleven patients underwent cervical laminectomies for multilevel spondylitic myelopathy. Limb and spine pain were the most common neurological symptoms in patients with lumbar lesions; diminished ADLs were present in eight patients with cervical myelopathies. Six patients died of unrelated causes, and 78 were followed for an average of 27.1 months. Twenty-three (85.2%) of 27 patients with lumbar disc herniations reported improvements or resolution of limb pain while 35 (81.4%) of 43 patients with lumbar canal stenosis reported fair or good results. Five of eight patients with multilevel cervical spondylosis reported improvements of myelopathic symptoms. Twenty-six (28.6%) complications were attributable to 91 surgical procedures including five severe complications and one fatality. Patients with three or more associated illnesses demonstrated a significantly higher incidence of postoperative complications. CONCLUSIONS: Elderly patients with benign lesions of the spinal canal may achieve significant reduction in limb pain and increases in ADL following appropriate surgery, with a tolerable rate of severe complications. The preoperative physical condition of the elderly patient served as an indicator for operative morbidity.
Asunto(s)
Actividades Cotidianas , Complicaciones Posoperatorias/rehabilitación , Canal Medular/cirugía , Enfermedades de la Columna Vertebral/cirugía , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Desplazamiento del Disco Intervertebral/rehabilitación , Desplazamiento del Disco Intervertebral/cirugía , Laminectomía , Masculino , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos , Ciática/rehabilitación , Ciática/cirugía , Enfermedades de la Columna Vertebral/rehabilitación , Osteofitosis Vertebral/rehabilitación , Osteofitosis Vertebral/cirugía , Estenosis Espinal/rehabilitación , Estenosis Espinal/cirugíaRESUMEN
Born in Latvia in 1836, Ernst von Bergmann received his medical education and first academic position at the University of Dorpat in Russia. In 1866, he served as a military surgeon in the Prusso-Austrian War, followed by duty in the Franco-Prussian War of 1870. He was appointed to the faculty of the University of Würzburg in 1878 and 4 years later moved to the University Clinic in Berlin. As a professor and chairman of surgery, he taught until his death in 1907. Von Bergmann practiced general surgery but devoted a large part of his career to the treatment of neurological diseases. Known for his development of aseptic technique, his early military experiences directed his attention to cranial trauma and, ultimately, neurosurgery. In 1880, he authored his first textbook, which described missile ballistics and animal experiments first demonstrating the physiological response later known as "the Cushing reflex" and advocated meticulous intracranial debridement with thorough closure after trauma. Twenty years later, as senior editor of the massive System of Practical Surgery, his contributions included pediatric neurosurgery, successful treatment of abscesses and tumors, diagnostic radiography, and cerebral localization using external landmarks and the neurological examination. Revered by his students and honored by his colleagues, von Bergmann became a proponent for aggressive neurosurgical treatment. His skilled techniques, developed in parallel with accurate experimental physiology, advanced 19th century surgical progression and formed a solid framework for the advances of neurosurgical specialists.
Asunto(s)
Neurocirugia/historia , Alemania , Historia del Siglo XIX , Historia del Siglo XX , Medicina Militar/historiaRESUMEN
Release of results of a clinical study to the public press prior to dissemination in a professional journal is a substantive issue which must undergo continued scrutiny. This report analyzes the second National Acute Spinal Cord Injury Study (NASCIS-2) and its subsequent reportage. NASCIS-2 was an elaborate protocol consisting of the randomized blinded use of methylprednisolone (MP), naloxone or placebo in 487 patients within 12 hours of spinal cord injury. Analysis of the entire population failed to show a significant clinical difference among treatments although data stratification revealed a significant change in patients with a complete loss of function who received MP within 8 hours of injury. The administration of MP was associated with a 7.1% incidence of wound infection. While these results suggested clinical benefit, incomplete data and statistical descriptions reduced assertions. Discrepancies in the report included lack of radiological data or descriptions of time-dependent surgical manipulations and extent of rehabilitative therapy. Justification for the broad 8-hour stratum and multiple hypothesis testing was unclear; incomplete design details included level of statistical significance, study power, stopping rules, trial duration and odds ratio data. The hypothesis that press release prior to publication in a professional journal would result in rapid therapy remained unproven. Reasons for pre-release, including limited peer review, physician familiarity with drug and dosage, and lack of alternative treatment or treatment complications were either unjustified or problematic. Early disclosure to the press resulted in da ta misinterpretation and oversimplification, failure to recognize exclusion or appropriate legal ramifications,and lack of communication to appropriate physicians.