Neurosurg Focus
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Patients with symptomatic herniated thoracic discs may require operation for intractable radiculopathy or functionally disabling myelopathy. In the past, laminectomy was the procedure of choice for the treatment of thoracic herniations, but it was found that the approach was associated with an unacceptably high rate of neurological morbidity. Several strategies have been developed to excise the disc without manipulating the spinal cord. The focus of this paper is the transpedicular approach. ⋯ As experience accumulates in the use of multiple approaches for the treatment of thoracic disc herniations, the role of each is becoming more clearly defined. The transpedicular approach is most applicable to lateral or centrolateral calcified or soft discs. The more anterior (transthoracic or thoracoscopic) and lateral (costotransversectomy or lateral extracavitary) approaches may be more useful for excision of central calcified discs.
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The practice of modern neurointensive care is based on the use of multimodality monitoring to respond rapidly to physiological, biochemical, or morphological changes and avoid secondary brain injury. Until recently, one important monitoring method, computerized tomography (CT), has not been available for bedside use. ⋯ In this report, they describe three illustrative cases in which the mobile CT scanner was of great value in the management of difficult neurosurgical intensive care problems. It is concluded that the availability of bedside morphological monitoring in the neurosurgery intensive care unit is of great help in management and clinical decision making.
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The indications for cranioplasty after decompressive craniectomy are cosmetic repair and, mainly, restoration of cerebral protection. Although neurological improvement after cranioplasty is repeatedly noted, the reasons for this still remain unclear. Few observations concerning the impact of CSF hydrodynamic and/or atmospheric pressure were published during the last decades. ⋯ Metabolic deficits, which were observed in the injured as compared with the noninjured hemisphere, were found to improve after reimplantation of the skull bone flap. Cranioplasty appears to affect postural blood flow regulation, CVR capacity, and cerebral glucose metabolism markedly. Thus, early cranioplasty is warranted to facilitate rehabilitation in patients after decompressive craniectomy.
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The authors report their experience with 42 patients in whom anterior lumbar fusion was performed using titanium cages as a versatile adjunct to treat a wide variety of spinal deformity and pathological conditions. These conditions included congenital, degenerative, iatrogenic, infectious, traumatic, and malignant disorders of the thoracolumbar spine. Fusion rates and complications are compared with data previously reported in the literature. ⋯ The complication rate mirrors the low morbidity rate associated with the anterior approach. A detailed study of clinical outcomes is in progress. Patient selection and strategies for avoiding complication are discussed.
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This study was conducted to document the extent to which flow depends on valve position in relation to head-pressure reference. Medtronic PS Medical Delta valves (contour model, performance levels 0.5, 1.0, 1.5, and 2.0) were studied in a bench test designed to evaluate flow rates with respect to valve position in relation to the head-pressure reference postion. The valves were connected to an "infinite" reservoir by the standard inlet catheter. ⋯ Movement of the valve above this level results in a net decrease in effective head pressure, and movement below this position results in a net increase in effective head pressure. Thus, the positioning of shunt valves in locations different from this pressure reference position should be performed only with the knowledge that significant increases in outflow rate may occur when the valve body is positioned lower than the inlet catheter tip. This increase in outflow rate is not the result of siphoning or a defect in the antisiphon device but instead the result of a net increase in effective head pressure.