Neurosurgery
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Case Reports Randomized Controlled Trial Clinical Trial
Intrathecal octreotide for relief of intractable nonmalignant pain: 5-year experience with two cases.
Somatostatin is distributed in the substantia gelatinosa in the dorsal horn of the spinal cord, and its application has been found to produce an inhibitory effect on nociceptive neurons. Although intraspinal administration of somatostatin-14 produces pain relief in patients with cancer and in postoperative patients, its short half-life limits its clinical usefulness. ⋯ This article describes the 5-year clinical course of two patients receiving intrathecal octreotide for severe, intractable nonmalignant pain. Included in this description are the results of blinded, randomized "N of 1" trials conducted in each of these patients.
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Hyponatremia is frequently seen in neurosurgical patients and is often attributed to inappropriate secretion of antidiuretic hormone. A number of studies in recent years have shown that hyponatremia in many patients with intracranial disease may actually be caused by cerebral salt wasting, in which a renal loss of sodium leads to hyponatremia and a decrease in extracellular fluid volume. The appropriate treatment of cerebral salt wasting fluid and salt replacement, is opposite from the usual treatment of hyponatremia caused by inappropriate secretion of antidiuretic hormone. This review summarizes the evidence in favor of cerebral salt wasting in patients with intracranial disease, examines the possible mechanisms responsible for this phenomenon, and discusses methods for diagnosis and treatment.
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Comprehensive anatomic and clinical analyses of 39 patients with injuries involving the transverse atlantal ligament or its osseous insertions were performed to assess the morphology of the injured ligaments and the patients' capacity to heal. Injuries of the upper cervical spine were screened with plain radiographs, thin-section computed tomography, and magnetic resonance imaging studies. The injuries were classified as disruptions of the substance of the ligament (Type I injuries, n = 16) or as fractures and avulsions involving the tubercle for insertion of the transverse ligament on the C1 lateral mass (Type II injuries, n = 23). ⋯ Type II injuries, which rendered the transverse ligament physiologically incompetent even though the ligament substance was not torn, should be treated initially with a rigid cervical orthosis, because they had a 74% success rate nonoperatively. Surgery should be reserved for patients with Type II injuries that have nonunion with persistent instability after 3 to 4 months of immobilization. Type II injuries had a 26% rate of failure of immobilization; therefore, close monitoring is needed to detect patients who will require delayed operative intervention.
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Revascularization is an important component of treatment for complex aneurysms that cannot be directly clipped and instead require parent vessel occlusion. A consecutive series of 61 patients with 63 aneurysms requiring cerebral revascularization is presented. Aneurysms were located along the petrous internal carotid artery (ICA) (n = 5), the cavernous ICA (n = 16), the supraclinoid ICA (n = 12), the middle cerebral artery (n = 17), the anterior cerebral artery (n = 4), the vertebral artery/posterior inferior cerebellar artery (n = 5), and the midbasilar artery (n = 4). ⋯ This experience demonstrates that revascularization can be performed with low morbidity and mortality. We think that the cumulative risks of not performing revascularization in patients who tolerate ICA balloon occlusion exceed the surgical risk of revascularization. We therefore favor revascularization in patients with complex aneurysms treated by surgical arterial occlusion.
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Organized neurosurgery at Yale began in 1918 with Dr. Sam Harvey. In 1928, Dr. ⋯ This tradition has continued under the guidance of Dr. Dennis Spencer since 1987. This article provides a brief overview of the history of neurosurgery at Yale, its current practice, and plans for the future.