Neurosurgery
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The author present a patient who developed an acute intracranial subdural hematoma approximately 35 hours after an uncomplicated delivery under saddle block analgesia. The proposed mechanism is that of cerebrospinal fluid efflux through the lumbar puncture site during uterine contractions and straining; shift of the intracranial structures, especially veins; venous hypertension; venous rupture; and subdural hematoma formation.
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Any pain experience results from the interaction of biological and functional (namely, psychological and environmental) factors. In some cases functional factors may be primarily responsible for exacerbating and maintaining pain, therefore, the physician should be attentive to a variety of signs that may indicate a significant nonorganic component to the patient's pain. Problems in case management commonly arise when the organic signature is blurred, for pain patients are notoriously resistant to any suggestion that their pain is not purely organic in origin. Clinical experience has shown that the diagnosis and treatment of pain patients can be greatly facilitated by educating the patient about the complex nature of pain and by integrating the assessment of functional factors into the overall diagnostic work-up.
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A clinical entity called roof disc is described. It is a centrally located disc extruction found posterior to the posterior borders of the vertebrae that is enclosed by the intact posterior longitudinal ligament; the roof disc exerts pressure against the dorsally lying thecal sac and its enclosed cauda equina roots, causing symptoms and signs incident to this pressure. ⋯ Three varieties are described and examples are presented. Its concealed location makes the conventional surgical approaches ineffective, including foraminotomy and laminotomy or laminectomy with standard discectomy.
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Radiation therapy provides the most effective adjuvant treatment for patients with malignant brain tumors, but brain intolerance to potentially curative doses of radiation is limiting. Solid tumors are thought to contain a substantial population of cells that are hypoxic; because much of the cell kill caused by ionizing radiation is the result of an oxygen-dependent, free radical-mediated attack on deoxyribonucleic acid, hypoxic tumor cells are known to be radioresistant and are therefore a barrier to cure. With the hope of improving the therapeutic ratio of brain tumor radiation therapy, hypoxic cell radiosensitizers are being evaluated. ⋯ Clinical trials ae providing considerable information about the pharmacokinetics and toxicities of these agents. The preliminary results obtained in clinical trials with brain tumor patients are somewhat discouraging; drug toxicity limits the number of radiation treatments with which a sensitizer may be given. The results of ongoing clinical trials with metronidazole and misonidazole and the identificiation of new, less toxic hypoxic cells sensitizers may improve the potential for this modality of therapy.