Neurosurgery
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A retrospective review of 373 adult patients admitted to Harbor General Hospital between 1980 and 1984 for minor closed head injury (Glasgow coma scale 13-15) was performed to determine the benefits of skull radiography, computed tomographic (CT) scanning of the head, and admission for observation. Variables reviewed were mental status, neurological examination, presence or absence of loss of consciousness, clinical evidence of basilar skull fracture, and fracture on skull radiography. The neurological examination (including mental status and Glasgow coma scale) in the emergency room was the best predictor of subsequent deterioration or the presence of an operative hematoma. ⋯ If no operative lesion is found on the CT scan, the patient should be admitted for observation because there is still a risk of deterioration. Those with a Glasgow coma scale score of 15, a normal mental status, and no hemispheric neurological deficit may be discharged to be observed at home by a competent observer despite basilar or calvarial skull fracture, loss of consciousness, or cranial nerve deficit. No benefit was gained from skull radiography in any group.
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Advances in microsurgical techniques combined with a widening interest in same-day surgery led us to investigate ambulatory lumbar discectomy. We could find no precedent in the literature. Ten patients with classic ruptured lumbar discs confirmed by computed tomography chose to participate. ⋯ All returned to their usual occupation between 3 and 14 days postoperatively. All were satisfied and would choose the outpatient program again. Our experience indicates that ambulatory lumbar microdiscectomy can be a safe, effective option for selected patients.
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Thirteen patients harboring large petroclival meningiomas are reported. The evolution of the petrosal approach is discussed, and modifications for improvement in surgical technique are described. There was no mortality in this series, and total removal was achieved in all but two patients. Morbidity included cranial nerve deficit, pulmonary embolism, and hemiparesis.
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Randomized Controlled Trial Clinical Trial
Use of perioperative steroids with microvascular decompression operations.
Complications associated with the use of perioperative steroids in elective craniotomies were evaluated in a single-blind prospective study of 222 consecutive microvascular decompression operations. Patients were randomized into one of three groups: Group A received steroids preoperatively and for 4 days postoperatively, Group B received steroids pre- and postoperatively for 1 day, and Group C received no steroids. There were 17 complications in Group A; 12 of these were wound-related. ⋯ The use of perioperative steroids did not reduce the length of postoperative hospitalization. Duration of the operation had no significant effect on the incidence of postoperative complications or the length of postoperative hospitalization. We conclude that there is no indication for the routine perioperative use of steroids with microvascular decompression operations of the posterior fossa cranial nerves and that such use leads to a higher incidence of postoperative complications.
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Dorsal root entry zone (DREZ) lesions have been shown to yield short term relief from the pain associated with a brachial plexus avulsion injury. Because of the propensity of pain to recur after neuroablative procedures, 39 patients with pain after a brachial plexus avulsion injury were observed for 14 months to 10 years after DREZ lesions were made. Fifty-four per cent of these patients were afforded good pain relief. Of 21 patients who had multiple small lesions made within the DREZ, 15 (72%) were afforded good pain relief.