Browse

You are looking at 1 - 10 of 15 items for

  • Refine by Access: all x
  • By Author: Winn, H. Richard x
  • By Author: Grady, M. Sean x
Clear All
Restricted access

James M. Schuster, Anthony M. Avellino, Frederick A. Mann, Allain A. Girouard, M. Sean Grady, David W. Newell, H. Richard Winn, Jens R. Chapman, and Sohail K. Mirza

Object. The use of structural allografts in spinal osteomyelitis remains controversial because of the perceived risk of persistent infection related to a devitalized graft and spinal hardware. The authors have identified 47 patients over the last 3.5 years who underwent a surgical decompression and stabilization procedure in which fresh-frozen allografts were used after aggressive removal of infected and devitalized tissue. The patients subsequently underwent 6 weeks of postoperative antibiotic therapy (12 months for those with tuberculosis [TB]).

Methods. Follow-up data included results of serial clinical examinations, radiography, laboratory analysis (erythrocyte sedimentation rate and white blood cell count), and clinical outcome questionnaires. Of the original 47 patients (14 women and 33 men, aged 14–83 years), 39 were available for follow up. The average follow-up period at the time this article was submitted was 17 ± 9 months (median 14 months, range 6–45 months). In the majority of cases (57%), a Staphylococcus species was the infectious organism. Predisposing risk factors included intravenous drug abuse (IVDA), previous surgery, diabetes, TB, and concurrent infections. During the follow-up period only two patients suffered recurrent infection at a contiguous level; both had a history of IVDA and one also had a chronic excoriating skin condition. No other recurrent infections have been identified, and no patient has required reoperation for persistent infection or allograft/hardware failure.

Conclusions. It is the authors' opinion that the use of structural allografts in combination with aggressive tissue debridement and adjuvant antibiotic therapy provide a safe and effective therapy in cases of spinal osteomyelitis requiring surgery.

Restricted access

Joseph M. Eskridge, Joon K. Song, J. Paul Elliott, David W. Newell, M. Sean Grady, and H. Richard Winn

✓ The authors describe a new endovascular technique that improves catheterization and balloon angioplasty of the A1 segment of the anterior cerebral artery after it has been narrowed by vasospasm. The technical results of using this method in seven patients are presented.

Restricted access

Gerald A. Grant, Sohail K. Mirza, Jens R. Chapman, H. Richard Winn, David W. Newell, Dolors T. Jones, and M. Sean Grady

Object. The authors retrospectively reviewed 121 patients with traumatic cervical spine injuries to determine the risk of neurological deterioration following early closed reduction.

Methods. After excluding minor fractures and injuries without subluxation, the medical records and imaging studies (computerized tomography and magnetic resonance [MR] images) of 82 patients with bilateral and unilateral locked facet dislocations, burst fractures, extension injuries, or miscellaneous cervical fractures with subluxation were reviewed. Disc injury was defined on MR imaging as the presence of herniation or disruption: a herniation was described as deforming the thecal sac or nerve roots, and a disruption was defined as a disc with high T2-weighted signal characteristics in a widened disc space. Fifty-eight percent of patients presented with complete or incomplete spinal cord injuries. Thirteen percent of patients presented with a cervical radiculopathy, 22% were intact, and 9% had only transient neurological deficits in the field.

Early, rapid closed reduction, using serial plain radiographs or fluoroscopy and Gardner—Wells craniocervical traction, was achieved in 97.6% of patients. In two patients (2.4%) closed reduction failed and they underwent emergency open surgical reduction. The average time to achieve closed reduction was 2.1 ± 0.24 hours (standard error of the mean).

The incidence of disc herniation and disruption in the 80 patients who underwent postreduction MR imaging was 22% and 24%, respectively. However, the presence of disc herniation or disruption did not affect the degree of neurological recovery, as measured by American Spinal Injury Association motor score and the Frankel scale following early closed reduction. Only one (1.3%) of 80 patients deteriorated, but that occurred more than 6 hours following closed reduction.

Conclusions. Although disc herniation and disruption can occur following all types of traumatic cervical fracture subluxations, the incidence of neurological deterioration following closed reduction in these patients is rare. The authors recommend early closed reduction in patients presenting with significant motor deficits without prior MR imaging.

Restricted access

J. Paul Elliott, David W. Newell, Derek J. Lam, Joseph M. Eskridge, Colleen M. Douville, Peter D. Le Roux, David H. Lewis, Marc R. Mayberg, M. Sean Grady, and H. Richard Winn

Object. The purpose of this study was to test the hypothesis that balloon angioplasty is superior to papaverine infusion for the treatment of proximal anterior circulation arterial vasospasm following subarachnoid hemorrhage (SAH). Between 1989 and 1995, 125 vasospastic distal internal carotid artery or proximal middle cerebral artery vessel segments were treated in 52 patients.

Methods. Blood flow velocities of the involved vessels were assessed by using transcranial Doppler (TCD) monitoring in relation to the day of treatment with balloon angioplasty or papaverine infusion. Balloon angioplasty and papaverine infusion cohorts were compared based on mean pre- and posttreatment velocity at 24 and 48 hours using the one-tailed, paired-samples t-test. Balloon angioplasty alone was performed in 101 vessel segments (81%) in 39 patients (75%), whereas papaverine infusion alone was used in 24 vessel segments (19%) in 13 patients (25%). Although repeated treatment after balloon angioplasty was needed in only one vessel segment, repeated treatment following papaverine infusion was required in 10 vessel segments (42%) in six patients because of recurrent vasospasm (p < 0.001). Seven vessel segments (29%) with recurrent spasm following papaverine infusion were treated with balloon angioplasty. Although vessel segments treated with papaverine demonstrated a 20% mean decrease in blood flow velocity (p < 0.009) on posttreatment Day 1, velocities were not significantly lower than pretreatment levels by posttreatment Day 2 (p = 0.133). Balloon angioplasty resulted in a 45% mean decrease in velocity to a normal level following treatment (p < 0.001), a decrease that was sustained.

Conclusions. Balloon angioplasty is superior to papaverine infusion for the permanent treatment of proximal anterior circulation vasospasm following aneurysmal SAH.

Full access

J. Paul Elliott, David W. Newell, Derek J. Lam, Joseph M. Eskridge, Colleen M. Douville, Peter D. LeRoux, David H. Lewis, Marc R. Mayberg, M. Sean Grady, and H. Richard Winn

The authors used daily transcranial Doppler (TCD) evaluation to test the hypothesis that balloon angioplasty is superior to papaverine infusion for the treatment of proximal anterior circulation arterial vasospasm following subarachnoid hemorrhage (SAH). Between 1989 and 1995, 125 vasospastic distal internal carotid artery or proximal middle cerebral artery vessel segments were treated in 52 patients. Blood flow velocities of the involved vessels were assessed using TCD monitoring in relation to the day of treatment with balloon angioplasty or papaverine infusion. Balloon angioplasty and papavarine infusion cohorts were compared based on mean pretreatment velocity and mean posttreatment velocity at 24 and 48 hours using the one-tailed, paired-samples t-test. Balloon angioplasty alone was performed in 101 vessel segments (81%) in 39 patients (75%), whereas papaverine infusion alone was used in 24 vessel segments (19%) in 13 patients (25%). Although repeated treatment following balloon angioplasty was needed in only one vessel segment, repeated treatment following papaverine infusion was required in 10 vessel segments (42%) in six patients because of recurrent vasospasm (p < 0.001). Seven vessel segments (29%) with recurrent spasm following papaverine infusion were treated with balloon angioplasty. Although vessel segments treated with papaverine demonstrated a 20% mean decrease in blood flow velocity (p < 0.009) on posttreatment Day 1, velocities were not significantly lower than pretreatment levels by posttreatment Day 2 (p = 0.133). Balloon angioplasty resulted in a 45% mean decrease in velocity to a normal level following treatment (p < 0.001), which was sustained. The authors conclude that balloon angioplasty is superior to papaverine infusion for the permanent treatment of proximal anterior circulation vasospasm following aneurysmal SAH.

Restricted access

Peter D. Le Roux, David W. Newell, Arthur M. Lam, M. Sean Grady, and H. Richard Winn

✓ Jugular bulb oxygen monitoring can be used to estimate the adequacy of cerebral blood flow to support cerebral metabolism after severe head injury. In the present study, the authors studied the cerebral arteriovenous oxygen difference (AVDO2) before and after treatment in 32 head-injured patients (Glasgow Coma Scale scores ≤ 8) to examine the relationships among AVDO2 and cerebral perfusion pressure (CPP), delayed cerebral infarction, and outcome. Fifteen patients (Group A) underwent craniotomy for hematoma evacuation and 17 (Group B) received mannitol for sustained intracranial hypertension (intracranial pressure > 20 mm Hg, > 10 minutes). Radiographic evidence of delayed cerebral infarction was observed in 14 patients. Overall, 17 patients died or were severely disabled. Cerebral AVDO2 was elevated before craniotomy or mannitol administration; the mean AVDO2 for all patients before treatment was 8.6 ± 1.8 vol%. Following craniotomy or mannitol administration, the AVDO2 decreased in 27 patients and increased in five patients (mean AVDO2 6.2 ± 2.1 vol% in all patients; 6 ± 1.9 vol% in Group A; and 6.4 ± 2.4 vol% in Group B). The mean CPP was 75 ± 9.8 mm Hg and no relationship with AVDO2 was demonstrated. Before treatment, the AVDO2 was not associated with delayed cerebral infarction or outcome. By contrast, a limited improvement in elevated AVDO2 after craniotomy or mannitol administration was significantly associated with delayed cerebral infarction (Group A: p < 0.001; Group B: p < 0.01). Similarly, a limited improvement in elevated AVDO2 after treatment was significantly associated with an unfavorable outcome (Group A: p < 0.01; Group B: p < 0.001). In conclusion, these findings strongly indicate that, despite adequate cerebral perfusion, limited improvement in elevated cerebral AVDO2 after treatment consisting of either craniotomy or mannitol administration may be used to help predict delayed cerebral infarction and poor outcome after traumatic brain injury.

Full access

Peter D. Le Roux, David W. Newell, Arthur M. Lam, M. Sean Grady, and H. Richard Winn

Jugular bulb oxygen monitoring can be used to estimate the adequacy of cerebral blood flow to support cerebral metabolism after severe head injury. In the present study, the authors studied the cerebral arteriovenous oxygen difference (AVDO2) before and after treatment in 32 head-injured patients (Glasgow Coma Scale scores ¾ 8) to examine the relationships among AVDO2 and cerebral perfusion pressure (CPP), delayed cerebral infarction, and outcome. Fifteen patients (Group A) underwent craniotomy for hematoma evacuation and 17 (Group B) received mannitol for sustained intracranial hypertension (intracranial pressure > 20 mm Hg, > 10 minutes). Radiographic evidence of delayed cerebral infarction was observed in 14 patients. Overall, 17 patients died or were severely disabled. Cerebral AVDO2 was elevated before craniotomy or mannitol administration; the mean AVDO2 for all patients before treatment was 8.6 ± 1.8 vol%. Following craniotomy or mannitol administration, the AVDO2 decreased in 27 patients and increased in five patients (mean AVDO2 6.2 ± 2.1 vol% in all patients; 6 ± 1.9 vol% in Group A; and 6.4 ± 2.4 vol% in Group B). The mean CPP was 75 ± 9.8 mm Hg and no relationship with AVDO2 was demonstrated. Before treatment, the AVDO2 was not associated with delayed cerebral infarction or outcome. By contrast, a limited improvement in elevated AVDO2 after craniotomy or mannitol administration was significantly associated with delayed cerebral infarction (Group A: p < 0.001; Group B: p < 0.01). Similarly, a limited improvement in elevated AVDO2 after treatment was significantly associated with an unfavorable outcome (Group A: p < 0.01; Group B: p < 0.001). In conclusion, these findings strongly indicate that, despite adequate cerebral perfusion, limited improvement in elevated cerebral AVDO2 after treatment consisting of either craniotomy or mannitol administration may be used to help predict delayed cerebral infarction and poor outcome after traumatic brain injury.

Restricted access

J. Paul Elliott, Peter D. Le Roux, Galen Ransom, David W. Newell, M. Sean Grady, and H. Richard Winn

✓ To determine the relationship between clinical grade on admission and treatment cost after aneurysm rupture, the authors retrospectively examined the length of hospital stay (LOS) and total hospitalization costs (excluding professional fees) for 543 patients admitted for aneurysm surgery between 1983 and 1993. The overall median LOS was 18 days, with a range of 1 to 165 days. Increased median LOS correlated with Hunt and Hess Grades 0 to IV on admission (p< 0.001). Median LOS for Grade V patients was reduced, in part, because of early mortality. Increased treatment cost also correlated with worse admission clinical grade (p < 0.001). A significant proportion of total expenditures occurred early in the hospitalization for patients in all clinical grades. Identification of additional factors affecting the cost of aneurysm treatment is indicated to complement treatment outcome studies.

Restricted access

Peter D. Le Roux, J. Paul Elliott, David W. Newell, M. Sean Grady, and H. Richard Winn

✓ To determine what factors predict outcome, the authors retrospectively reviewed the management of all 159 poor-grade patients admitted to Harborview Medical Center at the University of Washington who suffered aneurysmal subarachnoid hemorrhage between 1983 and 1993. Favorable outcome (assessed by the Glasgow Outcome Scale) occurred in 53.9% of Hunt and Hess Grade IV, and 24.1% of Grade V patients. Outcome was largely determined by the initial hemorrhage and subsequent development of intractable intracranial hypertension or cerebral infarction. Using multivariate analysis, the authors developed three models to predict outcome. It was found that predicting outcome based only on clinical and diagnostic criteria present at admission may have resulted in withholding treatment from 30% of the patients who subsequently experienced favorable outcomes. It is concluded that aggressive management including surgical aneurysm obliteration can benefit patients with poor neurological grades and should not be denied solely on the basis of the neurological condition on admission.

Restricted access

Peter D. Le Roux, J. Paul Elliott, Lois Downey, David W. Newell, M. Sean Grady, Marc R. Mayberg, Joseph M. Eskridge, and H. Richard Winn

✓ Several significant diagnostic and therapeutic advances in the management of subarachnoid hemorrhage have emerged during the last 10 years. The present study was undertaken to determine whether these advances have improved overall outcome in patients of low surgical risk and what factors predict outcome. The authors retrospectively reviewed the management of good-grade patients seen at the Harborview Medical Center at the University of Washington, who suffered ruptured anterior circulation aneurysms between 1983 and 1993. The results in this series demonstrate that favorable outcomes occurred in 96.8% of patients designated Hunt and Hess Grade I, 88.3% of those assigned Grade II, and 81.3% of those deemed Grade III after rupture of anterior circulation aneurysms. On the basis of clinical and radiographic factors present at admission, correct prediction can be made about all favorable, but only 17% of unfavorable outcomes. During the decade under investigation, the authors observed a significant (p = 0.002) increase in the number of favorable outcomes: 74.5% of patients treated during the first management period (1983–1987); 87% of patients treated during the second period (1987–1990); and 93.5% of patients treated during the third management period (1990–1993) experienced favorable outcomes. Improvements in critical-care techniques and the management of vasospasm may be associated with the improved outcome observed during this series.