Neurosurgery
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We report 43 consecutive surgically treated patients with pyogenic (37 patients) and tuberculous (6 patients) osteomyelitis of the thoracic and lumbar spine encountered within an 8-year period, including 1 with late recurrence after 15 months. There were 24 men and 18 women, ranging in age from 21 to 83 years. Twenty-six patients were in poor general condition because of associated illnesses, especially diabetes mellitus. ⋯ Two patients required further surgery because of postoperative epidural hematoma and pedicle screw malpositioning. In conclusion, most patients with thoracic and lumbar osteomyelitis can be successfully treated by combined débridement and internal fixation using only a posterior approach. Autogenous interbody bone grafting can be simultaneously performed and allows early mobilization of the patient.
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We report two patients who had symptomatic cerebral vasospasm and cardiac failure after aneurysmal subarachnoid hemorrhage and who were treated successfully with intra-aortic balloon pump counterpulsation therapy. Both patients developed congestive heart failure and pulmonary edema while receiving postoperative hypertensive, hypervolemic, hemodilutional (Triple-H) therapy for symptomatic cerebral vasospasm. Both cases of cardiac failure were refractory to maximum pressor and inotropic infusions. ⋯ Both patients have had good long-term outcomes. These two cases illustrate the potential usefulness of the intra-aortic balloon pump as an adjunct to Triple-H therapy in patients with symptomatic cerebral vasospasm and cardiac failure. To our knowledge, this report documents the first clinical application of this adjunctive therapy for vasospasm after aneurysmal subarachnoid hemorrhage.
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Comparative Study
Comparison of surgical treatments for trigeminal neuralgia: reevaluation of radiofrequency rhizotomy.
In this study, we reevaluate the results of radiofrequency rhizotomy and review the effectiveness of other surgical procedures for the treatment of trigeminal neuralgia. Five hundred patients with trigeminal neuralgia underwent radiofrequency rhizotomy at the University of Cincinnati Medical Center, Cincinnati, OH, between 1981 and 1986. Their results are compared with those of patients reported in the literature who underwent radiofrequency rhizotomy (6205 patients), glycerol rhizotomy (1217 patients), balloon compression (759 patients), microvascular decompression (MVD) (1417 patients), and partial trigeminal rhizotomy (250 patients). ⋯ All percutaneous procedures had similar rates of dysesthesia. Posterior fossa exploration had the highest rates of permanent cranial nerve deficit, intracranial hemorrhage or infarction, and perioperative morbidity and mortality. On the basis of our experience and a review of the literature, we conclude the following: 1) percutaneous techniques and posterior fossa exploration offer advantages and disadvantages, 2) radiofrequency rhizotomy is the procedure of choice for most patients undergoing first surgical treatments, and 3) MVD is recommended for healthy patients who have isolated pain in the first ophthalmic trigeminal division or in all three trigeminal divisions and patients who desire no sensory deficit.
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Transcranial doppler (TCD) ultrasonography is often used to guide the management of patients with subarachnoid hemorrhage (SAH). However, the correlation between increased blood velocity as measured by TCD ultrasonography and angiographic vasospasm was established before the routine use of hypervolemia/hemodilution and administration of nimodipine and did not address blood flow. The relationship of blood velocity as measured by TCD ultrasonography and local cerebral blood flow (LCBF) in SAH managed with these modalities is unknown. ⋯ Furthermore, although focal neurological deficits corresponded with decreased contralateral LCBF in the MCA, increased velocity did not correlate with neurological findings. Therapeutic decisions based solely on blood velocity revealed by TCD ultrasonography might be inappropriate and potentially harmful. Xe/CT studies of LCBF are useful in guiding the management of SAH.
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Comment Letter Comparative Study
Simple risk predictions for arteriovenous malformation hemorrhage.