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Joseph A. Epstein and Bernard S. Epstein

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Joseph A. Epstein, Bernard S. Epstein and Leroy S. Lavine

✓ Effective relief of radicular pain and recovery of function is reported in four elderly patients with lumbar scoliosis following surgical decompression of the lateral recesses of the spinal canal. The operation includes laminectomy or hemilaminectomy with unroofing of the lateral recesses and foramina by medial facetectomy or facetectomy. The patients tolerated surgery without morbidity, were walking within 2 or 3 days, and recovered without incident. The pathological anatomy and operative criteria are discussed.

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Joseph A. Epstein, Bernard S. Epstein, Laura Molho and Harry M. Zimmerman

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Joseph A. Epstein, Robert Carras, Leroy S. Lavine and Bernard S. Epstein

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Joseph A. Epstein, Robert Carras, Bernard S. Epstein and Leroy S. Levine

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Joseph A. Epstein, Bernard S. Epstein, Leroy S. Lavine, Robert Carras and Alan D. Rosenthal

✓ Five patients with typical cervical myeloradiculopathy caused by focal cervical spinal stenosis are presented. Dorsal intrusions into the spinal canal by hypertrophied apophyseal joints and thickened laminae resulted in cord and nerve root compression. Minor spondylotic changes were present in the floor of the spinal canal. Laminar decompression with foraminotomy and facetectomy relieved the patients of their symptoms. An anterior approach should not be considered in the management of this disorder. Our findings of severe apophyseal arthrosis with lesser degrees of associated spondylosis are similar to those described in anatomical studies by other authors. While uncommon, myelopathy caused by dorsal compression of the spinal cord and nerve roots deserves specific mention so that therapy can be directed to the proper quadrants of the spinal canal wherein the significant pathology is located.

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Joseph A. Epstein, Bernard S. Epstein, Leroy S. Lavine, Robert Carras and Alan D. Rosenthal

✓ Twenty patients treated for degenerative spondylolisthesis with an intact neural arch principally at the L4–5 interspace had neural compression caused by dislocation of the vertebral bodies and intrusions of lamina and enlarged, arthrotic facets into a stenotic spinal canal. The resulting “pincer” effect caused complete or partial block demonstrable on myelography, with nerve root and cauda equina compression. Most of the patients were women aged 45 to 84 years. Seven had neurogenic claudication. The majority had unrestricted straight-leg raising, and no signs of acute neural entrapment were seen as in patients with a herniated disc. Absent ankle reflexes, and weakness and atrophy of the anterior tibial muscle group were common, while sensation was relatively undisturbed. Treatment consisted of liberal laminar decompression including foraminotomy and medial or total facetectomy. Good-to-excellent results were obtained, and no patient was made worse by the procedure.

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Joseph A. Epstein, Bernard S. Epstein, Alan D. Rosenthal, Robert Carras and Leroy S. Lavine

✓ Fifteen patients with intense sciatic pain in whom surgical exploration disclosed no evidence of a herniated disc were found to have an entrapped L-5 or S-1 nerve root in a stenotic lateral recess beneath the superior articular facet of the inferior vertebra. Neurological abnormalities were infrequent. A conspicuously positive Lasègue sign was the most definite and consistent finding. Roentgenograms of the spine were not helpful, and myelography was negative or showed minimal changes because of the normal ventrodorsal diameter of the spinal canal and the lack of filling of the narrow lateral recesses. Electromyography was positive in the five patients studied. Surgical unroofing of the lateral recess with removal of the overhanging horizontal portion of the superior facet decompressed the incarcerated nerve root and relieved symptoms.

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Joseph A. Epstein, Bernard S. Epstein, Leroy S. Lavine, Robert Carras, Alan D. Rosenthal and Philip Sumner

✓ The authors report their experience with 12 cases in which the roots of the sciatic nerve were compressed at the intervertebral foramina by degenerative arthritis (arthrosis) of the posterior facets, and in which foraminotomy and facetectomy brought relief of pain. Patients with disc narrowing, spondylolisthesis, and transitional vertebrae place unusual stress on the posterior facets. This may lead to hypertrophy and the development of marginal osteophytes that project downward with eventual constriction of the intervertebral foramen and entrapment of the nerve root. Such alterations are common in patients over 40, and when found in the presence of unremitting sciatic pain without evidence of a herniated disc or other etiology, a causal relationship must be considered.

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Joseph A. Epstein, Bernard S. Epstein, Leroy S. Lavine, Alan D. Rosenthal, Robert E. Decker and Robert Carras

✓ The authors report five patients with spinal stenosis who had a total myelographic block at the level of the obliterated subarachnoid space. Arachnoiditis had not been considered as a primary diagnosis until laminectomy revealed a non-pulsating, thickened dural sac that conformed to the internal configuration of the involved spinal canal. Two patients had stenosis complicated by spondyloarthrosis over multiple lumbar levels, one had a previous spinal fusion, another had degenerative spondylolisthesis, and the fifth had a large midline extruded disc at L2–3 that completely blocked the spinal canal. The dura was opened in two patients, confirming the lesion. Despite obliteration of the subarachnoid space, significant relief for approximately 1 year followed decompressive laminectomy, foraminotomy, and discectomy, with disappearance of neurogenic claudication in three patients. Postoperative erect films showed no caudad passage of contrast. While further observations are required, an awareness of this complication of spinal stenosis is important in the diagnosis and management of such patients and in evaluating their ultimate prognosis.