Permanent Neurological Deterioration Research Articles

Neurological complications and symptom resolution following Gamma Knife surgery for brain metastases 2 cm or smaller in relation to eloquent cortices

Object Reports on resection of tumors in or near eloquent cortices have noted neurological complications in up to 30% of patients. This paper contains an analysis of symptom resolution and neurological morbidity following 20-Gy Gamma Knife surgery (GKS) for supratentorial brain metastases ≤ 2 cm in greatest diameter. Methods The authors performed a retrospective analysis of 98 consecutively treated adults (33 men and 65 women with a median age of 61.4 years at the time of GKS) with Karnofsky Performance Scale score ≥ 60, who underwent GKS for supratentorial brain metastases ≤ 2 cm in diameter. Lesion location was classified as noneloquent (Grade I), near eloquent (Grade II), or eloquent (Grade III), in accordance with the grading system developed by the group at M. D. Anderson Cancer Center. Following treatment, the patients underwent MR imaging and clinical examinations at 6 weeks and every 3 months thereafter. Results Ninety-eight patients underwent 20-Gy GKS for 131 metastases at initial presentation and 31 patients underwent salvage 20-Gy GKS for 76 new lesions, for a total of 207 lesions (mean lesion volume 0.44 cm3). Lesions were classified as follows: Grade I, 96 (46.4%); Grade II, 51 (24.6%); and Grade III, 60 (29%). Fifteen patients (2 with Grade II and 13 with Grade III lesions) presented with deficits referable to their lesions, yielding pre-GKS deficit rates of 7.2% per lesion and 15.3% per patient. The pre-GKS deficits improved or resolved in 10 patients (66.7%) at a median time of 2.8 months and remained stable in 3 patients (20%). Two patients (13.3%) experienced worsened neurological deficits. One patient who was neurologically intact prior to treatment developed a new hemiparesis (1 of 83 patients [1.2%]). The rates of permanent neurological deterioration following GKS for Grades I, II, and III lesions were 0% (0 of 96 tumors), 2% (1 of 51), and 3.3% (2 of 60), respectively. The pre-GKS neurological deficits and larger lesions were the most significant risk factors for post-GKS neurological deterioration. Conclusions Gamma Knife surgery performed using a 20-Gy dose provides amelioration of neurological deficits from brain metastases that are ≤ 2 cm in diameter and located in or near eloquent cortices in nearly two-thirds of patients with a low incidence of morbidity. Consistent with the surgical literature, higher rates of neurological complications were observed as proximity to eloquent regions and lesion size increased. There was no neurological deterioration in patients harboring metastases in noneloquent areas.

Role of radiosurgery in the management of cavernous sinus meningiomas.

To provide our early experience and philosophy in the utility of radiosurgery in the management of cavernous sinus meningiomas. Twenty-five consecutive cases with cavernous sinus meningiomas treated between 1990 and 1995 were reviewed. Three cases were treated with gamma-knife radiosurgery, 15 with preceding surgery and gamma knife, 7 with surgery. Mean follow-up following radiosurgery and surgery were 34.8 and 25.4 months, respectively. The 5-year actuarial tumor control rate following radiosurgery was 85.7% and tumor remission rate was 61.4%. Permanent neurological deterioration after radiosurgery was seen in 1 case (5.9%), whereas newly developed or worsened neurological deficits permanently persisted in 59.1% of patients after surgery. There was a clear correlation between surgical radicality and postoperative morbidity rate. Gamma-knife radiosurgery is a valuable addition to surgical removal in the treatment of cavernous sinus meningiomas. Combination of non-radical resection and subsequent radiosurgery is recommended to improve treatment-associated morbidity.

THE CURRENT ROLE OF MICROSURGERY FOR POSTERIOR CIRCULATION ANEURYSMS

During the past decade, management of posterior circulation aneurysms has shifted away from microsurgery. Currently, microsurgical clipping is considered a primary, competitive alternative to endovascular coiling, or more commonly, a secondary alternative when endovascular therapy is unfavorable. We present a large, multidisciplinary team experience with posterior circulation aneurysms in an institution that continues to use microsurgery as a primary treatment modality for selected aneurysms. During a 9-year period, 217 patients with 228 posterior circulation aneurysms were treated microsurgically; they included 106 basilar bifurcation, 27 posterior cerebral artery, 23 superior cerebellar artery, eight anteroinferior cerebellar artery, five basilar trunk, 47 posteroinferior cerebellar artery, and 12 vertebral artery aneurysms. Overall, 81% of patients presented with hemorrhage, and 33% of the aneurysms were large or giant in size. Direct clipping was performed in 75% of cases, and the overall rate of angiographic aneurysm obliteration was 98.1%. Sixteen patients (7.4%) died after surgery, 25 patients (11.5%) experienced transient neurological deterioration, and 17 patients (7.8%) experienced permanent neurological deterioration. At late follow-up (mean duration, 13.6 mo), 144 patients had good outcomes (Glasgow Outcome Scale scores of 5 or 4, 66%), and 184 patients (85%) either improved or were unchanged relative to their preoperative baseline. Overall, mean Glasgow Outcome Scale scores improved from 3.60 to 3.97. Despite increasing reliance on endovascular therapy with posterior circulation aneurysms, there is a role for microsurgical therapy. Microsurgery remains a competitive, primary therapy for superior cerebellar artery, P1 posterior cerebral artery, distal anteroinferior cerebellar artery, and posteroinferior cerebellar artery aneurysms. Microsurgery has become a secondary therapy for P2 posterior cerebral artery, basilar trunk, proximal anteroinferior cerebellar artery, vertebrobasilar junction, and vertebral artery aneurysms when endovascular therapy is unfavorable. The preferred therapy for basilar bifurcation aneurysms remains unclear. Collaborative, multidisciplinary teams are strengthened and results are improved by offering competitive treatment alternatives for patients to consider and select. Rather than abandoning the posterior circulation prematurely, aneurysm surgeons should maintain technical proficiency with these lesions.

Efficacy of superficial temporal artery–middle cerebral artery anastomosis with routine postoperative cerebral blood flow measurement during the acute stage in childhood moyamoya disease

Surgical revascularization for moyamoya disease prevents cerebral ischemic attacks by improving cerebral blood flow (CBF). It is undetermined, however, how rapid increase in CBF affects chronic ischemic brain during the acute stage in childhood moyamoya disease. The present study includes nine consecutive cases of patients with childhood moyamoya disease (2 to approximately 8 years old, 6.2 in average), who underwent superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis on 17 hemispheres. We prospectively performed single-photon emission computed tomography 1 and 7 days after 17 surgeries. The follow-up period ranged from 12 to 37 months (24.9 in average). The outcome of 17 surgeries was excellent (disappearance of transient ischemic attack) in 14 hemispheres (82.4%) and good (reduction of transient ischemic attack) in three hemispheres (17.6%). No patient suffered peri-operative infarction, except for one (5.9%) manifesting as pseudolaminar necrosis in a part of the cerebral cortex supplied by STA-MCA bypass at the subacute stage, which did not affect his long-term neurological status. One patient (5.9%) presented with transient facial palsy due to hyperperfusion, which resolved within several days. No patient manifested permanent neurological deterioration during the follow-up period. The STA-MCA anastomosis is a safe and effective treatment for childhood moyamoya disease. We recommend routine CBF measurement for avoiding surgical complications including both cerebral ischemia and hyperperfusion.

Safety and efficacy of stereotactic radiosurgery for tumors of the spine

Object. The extension of stereotactic radiosurgery treatment of tumors of the spine has the potential to benefit many patients. As in the early days of cranial stereotactic radiosurgery, however, dose-related efficacy and toxicity are not well understood. The authors report their initial experience with stereotactic radiosurgery of the spine with attention to dose, efficacy, and toxicity. Methods. All patients who underwent stereotactic radiosurgery of the spine were treated using the Novalis unit at Westchester Medical Center between December 2001 and January 2004 are included in a database consisting of demographics on disease, dose, outcome, and complications. A total of 31 patients (12 men, 19 women; mean age 61 years, median age 63 years) received treatment for 35 tumors. Tumor types included 26 metastases (12 lung, nine breast, five other) and nine primary tumors (four intradural, five extradural). Thoracic tumors were most common (17 metastases and four primary) followed by lumbar tumors (four metastases and four primary). Lesions were treated to the 85 to 90% isodose line with spinal cord doses being less than 50%. The dose per fraction and total dose were selected on the basis of previous treatment (particularly radiation exposure), size of lesion, and proximity to critical structures. Conclusions. Rapid and significant pain relief was achieved after stereotactic radiosurgery in 32 of 34 treated tumors. In patients treated for metastases, pain was relieved within 72 hours and remained reduced 3 months later. Pain relief was achieved with a single dose as low as 500 cGy. Spinal cord isodoses were less than 50% in all patients except those with intradural tumors (mean single dose to spinal cord 268 cGy and mean total dose to spinal cord 689 cGy). Two patients experienced transient radiculitis (both with a biological equivalent dose (BED) > 60 Gy). One patient who suffered multiple recurrences of a conus ependymoma had permanent neurological deterioration after initial improvement. Pathological evaluation of this lesion at surgery revealed radiation necrosis with some residual/recurrent tumor. No patient experienced other organ toxicity. Stereotactic radiosurgery of the spine is safe at the doses used and provides effective pain relief. In this study, BEDs greater than 60 Gy were associated with an increased risk of radiculitis.

Safety and efficacy of stereotactic radiosurgery for tumors of the spine

Object. The extension of stereotactic radiosurgery treatment of tumors of the spine has the potential to benefit many patients. As in the early days of cranial stereotactic radiosurgery, however, dose-related efficacy and toxicity are not well understood. The authors report their initial experience with stereotactic radiosurgery of the spine with attention to dose, efficacy, and toxicity. Methods. All patients who underwent stereotactic radiosurgery of the spine were treated using the Novalis unit at Westchester Medical Center between December 2001 and January 2004 are included in a database consisting of demographics on disease, dose, outcome, and complications. A total of 31 patients (12 men, 19 women; mean age 61 years, median age 63 years) received treatment for 35 tumors. Tumor types included 26 metastases (12 lung, nine breast, five other) and nine primary tumors (four intradural, five extradural). Thoracic tumors were most common (17 metastases and four primary) followed by lumbar tumors (four metastases and four primary). Lesions were treated to the 85 to 90% isodose line with spinal cord doses being less than 50%. The dose per fraction and total dose were selected on the basis of previous treatment (particularly radiation exposure), size of lesion, and proximity to critical structures. Conclusions. Rapid and significant pain relief was achieved after stereotactic radiosurgery in 32 of 34 treated tumors. In patients treated for metastases, pain was relieved within 72 hours and remained reduced 3 months later. Pain relief was achieved with a single dose as low as 500 cGy. Spinal cord isodoses were less than 50% in all patients except those with intradural tumors (mean single dose to spinal cord 268 cGy and mean total dose to spinal cord 689 cGy). Two patients experienced transient radiculitis (both with a biological equivalent dose (BED) > 60 Gy). One patient who suffered multiple recurrences of a conus ependymoma had permanent neurological deterioration after initial improvement. Pathological evaluation of this lesion at surgery revealed radiation necrosis with some residual/recurrent tumor. No patient experienced other organ toxicity. Stereotactic radiosurgery of the spine is safe at the doses used and provides effective pain relief. In this study, BEDs greater than 60 Gy were associated with an increased risk of radiculitis.

Stroke after cardiac surgery: a risk factor analysis of 16,184 consecutive adult patients

Background Stroke remains a devastating complication after cardiac surgical procedures despite advances in perioperative monitoring and management. The purpose of this study was to determine the predictors of stroke in a large, contemporary cardiac surgery population. Methods Prospective data on 16,184 consecutive patients undergoing cardiac surgery (coronary artery bypass grafting [CABG], n = 8,917; beating heart CABG, n = 1,842; aortic valve surgery, n = 1,830; mitral valve surgery, n = 708; double or triple valve surgery, n = 381; CABG and valve surgery, n = 2,506) between April 1996 and August 2001 were subjected to univariate and multivariate analysis. Stroke was defined as any new permanent (manifest stroke) or temporary neurologic deficit or deterioration (transient ischemic attack or prolonged reversible ischemic neurologic deficit) and was confirmed by computed tomography or magnetic resonance imaging whenever possible. Results Overall incidence of stroke was 4.6% and varied between surgical procedures (CABG 3.8%; beating-heart CABG 1.9%; aortic valve surgery 4.8%; mitral valve surgery 8.8%; double or triple valve surgery 9.7%; CABG and valve surgery 7.4%). Of 63 patient-specific and treatment variables, 54 were found to have a significant univariate association with postoperative stroke. Multivariable analysis revealed 10 variables that were independent predictors of stroke: history of cerebrovascular disease, peripheral vascular disease, diabetes, hypertension, previous cardiac surgery, preoperative infection, urgent operation, CPB time more than 2 hours, need for intraoperative hemofiltration, and high transfusion requirement. Beating heart CABG was associated with a lower incidence of stroke in this multivariable analysis. Conclusions Identification of predictors for stroke is important for understanding the pathogenesis of this devastating complication as well as for developing preventative strategies. Although retrospective analyses can be subject to selection bias we believe beating heart CABG is associated with a lower incidence of stroke and may therefore improve patient outcomes.

Friday, November 1, 2001 4:29–5:12 pm Concurrent Session 4A: Tumors: 4:29 Comparison of giant and non giant symptomatic herniated thoracic discs: an analysis of 104 consecutive surgical cases

Purpose of study: Giant herniated thoracic discs (HTDs), occupying more than 40% of the spinal canal, present formidable technical difficulties for surgical removal. The distinguishing clinical features of giant HTDs have not been elucidated.Methods used: Of 104 consecutive patients treated for HTDs by the author between 1992 and 2001, 14 (14%) had giant HTDs. The clinical and operative findings were compared with the 90 patients with nongiant HTDs. Long term follow-up (longer than 1 year) was achieved in 95% of patients.of findings: Giant HTDs compared with nongiant HTDs were more likely to present with myelopathy (93% vs. 63%), have ossified discs (86% vs. 4%), have transdural erosion (43% vs. 0%), to require multiple surgeries to completely resect the discs (64% vs. 1%), to experience operative related neurological deterioration (43% vs. 1%) and to require spinal instrumentation and fusion (36% vs. 1%). The giant HTDs were approached anteriorly (n=10) more often than posterolaterally (n=4). The nongiant HTDs were approached anteriorly (n=60) more often than posterolaterally (n=20). Giant HTDs presented with more severe spinal cord deficits than nongiant HTDs and were more prone to temporary (n=3) or permanent (n=3) worsening of their myelopathy perioperatively. At follow-up, 11 of 14 patients (79%) with giant HTDs had successful neurological outcomes. Seven patients (50%) recovered significantly more neurological function compared with their baseline neurological status. The neurological deficits were stabilized in four patients (29%).Relationship between findings and existing knowledge: Giant HTDs are extremely challenging surgical management problems. They are usually associated with severe spinal cord deficits at presentation, are often ossified, erode through the dura and are at high risk for transient or permanent neurological deterioration perioperatively. Successful long-term surgical results are possible with targeted surgical approaches that allow adequate room to work (ie, corpectomy for midline disc herniations, or a costotransversectomy for lateral disc herniations) yet minimize manipulation or retraction of the spinal cord.Overall significance of findings: Giant HTDs are distinctly different from small HTDs. They produce more severe presenting neurological deficits, are usually ossified and transdural, have higher surgical neurological morbidity and a worse prognosis.Disclosures: No disclosures.Conflict of interest: No conflicts.

Anesthetic management of deep hypothermic circulatory arrest for cerebral aneurysm clipping.

This article will briefly review the rationale for DHCA in the setting of cerebral aneurysm treatment. We will then use the main aspects of the protocol practiced by the senior author (WLY), as a point of departure to review the issues regarding anesthetic and perioperative management. Rationale The ability to temporarily eliminate or reduce blood flow into an aneurysm gives the surgeon an important advantage—without flow, an aneurysm is converted from a hard, pulsating mass into a soft, collapsed sac, allowing more aggressive manipulation of the aneurysm to complete its dissection. With most aneurysms, temporary occlusion of the proximal parent artery or arteries will effectively control blood flow into the lesion. With large or complex aneurysms, the aneurysm mass may prevent optimal visualization and clip application to the neck. Collapse of the aneurysm mass creates more working space for dissection and precise clip application. Deep hypothermic circulatory arrest is used for aneurysms that cannot be adequately controlled by conventional surgical or endovascular techniques. Aneurysms in the anterior circulation are, in general, accessible enough to be managed with temporary clipping. Aneurysms that defy conventional treatment are typically in the posterior circulation and large (10 –25 mm in diameter) or giant (25 mm in diameter) in size. 11 Often these aneurysms cannot be collapsed easily because of the breadth of the neck, the complexity of the arterial branches at the base, the presence of thrombus or endovascular coils in the lumen, artheroma or calcium in the walls, and fusiform configuration. These anatomic features make direct clipping more difficult and lower the efficacy of conventional techniques. The surgeon’s ability to manage these anatomic factors is directly related to operative exposure. When proximal and distal arteries are inaccessible with these complex aneurysms, DHCA may provide the only safe and effective means of vascular control. Deep hypothermic circulatory arrest should be considered an option of last resort for these unusual aneurysms, when all conventional techniques have failed or have been carefully considered. Rarely, DHCA has also been proposed or described for other central nervous system lesions, such as tumors 8 or arteriovenous malformations, 12 but this discussion is not

Preservation of cranial nerve function following Gamma Knife radiosurgery for benign skull base meningiomas: experience in 121 patients with follow-up of 5 to 9.8 years.

Microsurgical excision with preservation of juxtaposed neurovascular structures is considered the treatment of choice for skull base meningiomas, but there exists a great controversy regarding surgical resectability, potential risk for subsequent postoperative Cranial Nerve Deficit (CND) and the role of adjuvant or adjunctive treatment options. In this study we evaluated the effect of Gamma Knife Radiosurgery (GKRS) in 121 patients with benign basal meningiomas after a follow-up of 5 to 9.8 years. Sixty patients had undergone open resections prior to radiosurgical treatment and 61 patients were treated by GKRS alone. Tumour volumes of 0.5 to 89.9 ccm (median 6.8 ccm) received a median marginal dose of 13 Gy (range 7-25 Gy) at the covering 25% to 80% isodose volume curves (median 45%). Neuroradiological controls demonstrated decreased tumour size in 73 patients (60.3%), stable meningioma volume in 47 cases (38.9%) and tumour enlargement in one patient (0.8%). Clinically, 54 patients (44.6%) improved and 61 cases (50.4%) remained unchanged. Four patients (3.3%) showed temporary and two patients (1.7%) permanent neurological deterioration (unrelated to tumour or treatment in one patient). Two patients (1.7%) developed radiation induced new or aggravated pre-existent CND (1 transient, 1 permanent) and two patients (1.7%) required further surgical resection. In our long-term experience, GKRS proved to be an attractive additional and save alternative primary treatment option in selected patients with basal meningiomas. The tumour control rate of 98.3% associated with excellent clinical outcome and low incidence for treatment related CND (1.7%) compares favourably with the reported microsurgical series.

Discectomía cervical y artrodesis intersomática mediante técnica de Cloward: Análisis retrospectivo de las complicaciones y los resultados radiológicos en 167 casos

Patients and methodsWe performed a retrospective analysis of complications and radiological results in 167 patients surgically treated, for discal or spondylotic disease of the cervical spine, with Cloward procedure. Using uni and multivariate analysis, we tried to identify risk factors that might be correlated with surgical complications or radiological results. ResultsSurgical treatment was indicated for cervical radiculopathy in 68% of the patients and for myelopathy or radiculomielopathy in the remaining 32%. The pathologic disease responsible of the symptomatology was soft disk herniation in 59% of the cases and spondylotic changes in 41%. The patients that underwent surgery because of myelopathy were one decade older, had a longer symptomatic period and presented multisegmentary spondylotic disease with higher frequency than patients afected of radiculopathy. The most common segments operated were CS–C6 (44.3%) and C6–C7 (30.5%). Surgical mortality was 0.6% and morbidity 29.3%. Most of the complications were transient, although 4.8% of the patients developed permanent neurological deterioration. ConclusionsComplications were most commonly seen in the group of the patients undergoing surgery because of long-lasting myelopathy with multisegmentary spondylotic disease, in those with vascular risk factors and in those operated of more than one segment. Surgeon anatomic knowledge and experience are critical for diminishing such complications. Non-union rate was 9.6%, and another 9.6% of the patients developed post-surgical kyphosis. Both factors correlated with the need of re-operation.

Assessing motor and sensory function — A focused survey

The giant calcified herniated thoracic disc (HTD), a rare disease, is a challenge for surgeons because of its complications. This review aimed to confirm the surgical treatment, including surgical approach, results, and complications of HTDs.This systematic review of the literature complies with the PRISMA guidelines and involves a search of PubMed, Embase, and the Cochrane Library for all papers describing surgical treatment of giant calcified HTDs in ≥3 patients. Data on the surgical approach, change in neurologic impairment, and complications were extracted from the search results.A total of 11 studies, including 164 patients with giant calcified HTDs that met the inclusion criteria, were included in this systematic review. Of the 164 patients, 145 had myelopathy in giant calcified HTDs, and 8 surgical approaches were included. After the surgical treatment, the neurologic grades were improved in 69% of patients, remained unchanged in 22% of patients, and worsened further in 3% of patients at the final follow-up. Also, of the total patients analyzed, 3% had permanent neurologic deterioration, 4% patients had subarachnoid–pleural cerebrospinal fluid fistula complications, 30% had other complications, 4% had reoperation via transthoracic approach, 13% had permanent neurologic deterioration via the posterolateral approach, and 25% had permanent neurologic deterioration via the thoracoscopy approach.Surgical treatment can improve or stabilize neurologic impairment for most patients with giant calcified HTDs. We thus recommend the anterior thoracotomy approach for giant calcified HTDs because of the theoretical advantages over other approaches and the low rate of neurologic deterioration, subarachnoid–pleural cerebrospinal fluid fistula, and reoperation.

Cervical corpectomy: report of 185 cases and review of the literature.

This study was conducted to determine the indications, safety, efficacy, and complication rate associated with performing corpectomy to achieve anterior decompression of neural elements or for removing anterior lesions. Between 1987 and 1998, 185 patients underwent cervical corpectomy for the treatment of degenerative spondylitic disease (81 cases), ossification of posterior longitudinal ligament (16 cases), correction of postoperative kyphosis (31 cases), trauma (39 cases), tumor (10 cases), and infection (eight cases). Ninety-nine patients presented with myelopathy, 48 with radiculomyelopathy, 24 with radicular pain, and 14 with neck muscle pain. Eighty-seven patients underwent a one-level corpectomy; 45 of these patients underwent a discectomy at a different level. Seventy patients underwent a two-level corpectomy; 27 of these patients underwent a discectomy at a different level. Twenty-eight patients underwent a three-level corpectomy. Autograft (iliac crest) was used in 141 cases and allograft (fibula) in 44 cases. All but six patients underwent fixation with an anterior plate-screw system. There were no operative deaths. During the procedure the vertebral artery was injured in four patients and preserved in two of them. No neurological sequelae were encountered. Postoperative hoarseness, transient dysphagia, and pain at the graft site were transitory and successfully managed. The fusion rate was 98.8%. Six patients experienced transient deterioration after surgery but they improved. No patient experienced permanent neurological deterioration and 160 (86.5%) improved. Corpectomy has an important role in the management of various degenerative, traumatic, neoplastic, or infectious disorders of cervical spine. Following treatment in this series, radiculopathy always improved and myelopathy was reversed in most patients.

The role of image-directed biopsy in the diagnosis and management of brainstem lesions.

The appreciation that brainstem tumours do not comprise a homogeneous pathological group and that up to 20% of the preoperative radiological diagnoses of brainstem lesions prove at operation to be wrong, has established the need for a firm histological diagnosis prior to treatment. Current neuro-imaging modalities may have increased the diagnostic accuracy and the detection rate of intrinsic brainstem lesions, but open exploration in cases without an exophytic component is still associated with a low diagnostic yield and considerable morbidity. A series of 72 brainstem lesions approached stereotactically with CT or MRI guidance is presented. A transcortical frontal precoronal trajectory was used in 58 and a suboccipital transcerebellar route in 14. Haematoma was diagnosed preoperatively in 16 cases and therapeutic aspiration was planned. In 56 cases the diagnosis was uncertain, although intrinsic tumour was suspected. A histological diagnosis was established in 52 cases, although in the remaining four cases a tumour was excluded. Unexpected findings occurred in over 15% of the cases. There were no operative deaths and the morbidity was low. In no case was there a permanent neurological deterioration directly related to the procedure, although there was a transient deterioration in two patients and another patient required early re-aspiration of a haematoma.

Bracing of thoracic and lumbar spine fractures.

A prospective study of the non-operative management of 33 thoracic and lumbar fractures and dislocations was undertaken examining factors such as duration of bed rest and brace prescription. Outcome was assessed using Frankel's grading system and serial radiological examination. Bed rest for 6 to 8 weeks followed by 16 weeks of immobilisation in a thoraco-lumbar orthosis (either a moulded plastazote lined polythene brace or a Taylor brace) resulted in less than 15 degrees kyphus in 85% of patients and less than 20% kyphus in 94%. One patient with a T12/L1 dislocation who had an early decompressive laminectomy showed persistent instability and required internal fixation. One patient with an L1 fracture who initially wore a Hexalite brace developed late instability (at 12 months after injury) and required spinal osteotomy and fusion. Neurological improvement was observed in 50% of patients, and no permanent neurological deterioration occurred. A non-operative regimen of treatment of fractured thoracic and lumbar vertebrae as described is an alternative to prolonged immobilisation in bed, or early operative fusion.

Needle biopsy of tumors in the region of the third ventricle.

Twenty-six patients underwent needle biopsy of tumors in the area of the third ventricle. Operative mortality was zero, and the diagnosis was established in 23 of the 26 patients. There was no permanent neurological deterioration in any of the patients. Needle biopsy yields diagnostic information with small risk, and is particularly helpful in the posterior portion of the third ventricle where tumors are likely to be quite radiosensitive.