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David G. Kline

It has been said of Silas Weir Mitchell (1829–1914) that as a young man he was first among the physiologists of his day, in middle age first among physicians, and as an older man, one of the most noted novelists of his country. Mitchell's novels were written in his later life as a means to avoid boredom during lengthy summer vacations that were the norm for that time among the affluent members of Philadelphia society. These novels were criticized by some because of poor plots, which in some instances failed to move along, or for text that offered a stereotyped depiction of genteel society and the effects that war or personal disaster had on the characters' behavior The criticism came despite the fact that all critics agreed that Mitchell's portrayals of psychopathology in his fictional characters was unique and accurate. However, in his 30s, Mitchell had written and by chance had published a fictional short story that not only transcended such criticisms but became immensely popular.

“The Strange Case of George Dedlow” portrays a union officer who was not a physician but who had some medical background and who sustained a series of war wounds leading to severe nerve pain, the author's first description of causalgia, multiple amputations, and the psychological as well as physical symptoms of phantom limb syndrome. The protagonist tells of his torments in the first person in a very engaging fashion. Thus, long before he began writing his, at that time, acclaimed novels in the 1880s, Mitchell wrote a piece of fiction that combines accurate and very important medical observations with fiction of great historical interest. The following rendering of this now classic short story includes selected quotes and some interpretation and is perhaps appropriate for this year, 2 years after the centenary year of his death in 1914.

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David G. Kline

✓ Many gunshot wounds (GSW's) to the brachial plexus do not improve spontaneously with time and are therefore candidates for surgery. Over an 18-year period, 141 patients with GSW's were evaluated, 90 of whom were operated on; 75 of the surgical cases were followed for 2 years or more. Thirty operative patients had initial vascular repair, while eight required thoracotomies. Total plexus palsy was present in 19 of those selected for operation. The average interval between injury and operation was 17 weeks. Six patients required early operation for an expanding aneurysm with progressive neural loss. Persistent complete loss of function in the distribution of one or more elements and/or noncausalgic pain not managed by medications provided the major operative indications. Four patients required sympathectomies for causalgia.

Of 166 lesions in continuity believed to be complete, based on clinical examination and electromyography, 48 with preserved intraoperative nerve action potentials (NAP's) were spared resection or were treated with a split repair with excellent eventual results on a weighted grading system. By comparison, only seven of 55 elements believed to have incomplete loss or to be recovering did not have NAP's and required repair. Fifty-three of 98 lesions repaired by grafts and 18 of 26 wounds with suture repair recovered to a Grade 3 level or better. Most elements were in continuity but 14 were found “blown apart” and required repair, usually by grafting.

The best outcome was achieved with upper trunk and lateral and posterior cord lesions, but recovery occurred with some C-7 to middle trunk and medial cord to median repairs. Results with lower trunk and most medial cord lesions were poor unless early regeneration was proved by operative NAP's, in which case either neurolysis or split repair could be performed. Surgery is warranted for selected GSW's to the plexus.

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David G. Kline

✓On August 29, 2005, a hurricane named Katrina struck the Gulf Coast. Many feared the consequences of such a storm, but very few believed that it could ever happen. This article is a narrative written shortly after the evacuation of patients and personnel from the flooded Charity Hospital.

The days at Charity hospital were hot and humid following Katrina, and as time passed the air was permeated by a stench that was inescapable. Rendering care to patients without electricity, and thus light and air conditioning, with a temperature in the 90°s and no running water was a challenge. Trying to cool patients with central fever and providing adequate ventilation for unconscious patients was extremely difficult. Without elevators, climbs up to and down from the 14th floor—where the author and his colleagues had their sleeping rooms—and the 12th (surgical intensive care unit [ICU]), seventh (neuro ICU and step-down units), and sixth (medical ICU) floors were tedious. The descent to check the emergency department and obtain a closer look at flooding in the streets around the hospital, which maintained a 4- to 5-foot water level, became prohibitive because of the contemplation of the necessary return ascent.

There were 21 patients, mostly neurosurgical, in the neuro ICU and step-down units and wards. This is their story.

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Joseph Nadell and David G. Kline

✓ Instead of discarding bone as in past practice with depressed skull fractures, fragments were soaked in Betadine, trimmed, reinserted into the skull defect, and covered with flaps of pericranium, muscle, or fascia. Of the 110 patients who had bone replaced, 65 had frontal fractures, which in 33 involved the frontal sinus, cribriform plate, or orbital rim. Fractures involving sinuses were treated by exenterating the sinus and packing it with muscle. The frontal and orbital rim region were reconstructed whenever possible with a mosaic of replaced bone. There were no deaths due to the minimal complications from the procedure. Despite severely macerated, contaminated, and in several instances, infected scalp wounds, most bone fragments have survived, and cranial defects have gradually filled with new bone. The authors believe that immediate bone replacement for depressed frontal fractures with or without orbital, sinus, or cribriform plate involvement is both practical and safe.

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David G. Kline and Stephen Mahaley Jr.

✓ In recent years, one-half of the 23 recognized specialty boards in medicine have begun formally to recognize subspecialization with some type of certification process. One such board, the American Board of Internal Medicine, examines and certifies in 11 subspecialty areas while the American Board of Pathology does so in nine, the American Board of Pediatrics in eight, the American Board of Obstetrics and Gynecology in four, and the American Board of General Surgery in three. Arguments for and against similar recognition of subspecialization within neurosurgery are reviewed. The present position of other specialties and their boards regarding this sensitive issue is summarized, as well as their certification structure. The various pathways available to certifying boards for recognition of subspecialization are also presented.

The American Board of Neurological Surgery (ABNS) has approved a subspecialty certificate called a “certificate of Special Qualification in Critical Care Medicine.” This is a subspecialty that is longitudinally oriented, touching on a number of other specialties in addition to neurosurgery, and thus differs from a vertical subspecialty such as Pediatric Neurosurgery or Cerebrovascular Neurosurgery. The background for development of such a certificate and the current requirements for obtaining it are reviewed. At the present time, the ABNS opposes the possible fragmentation of neurosurgery by offering certification in multiple subspecialty areas. Nonetheless, the current trend in medicine as a whole is in the direction of such subspecialization and its formal recognition. Increasing numbers of neurosurgeons tend to concentrate all or a good deal of their professional efforts in a specific area. Thus, organized neurosurgery must continue to consider methods for subspecialty recognition.

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Daniel H. Kim and David G. Kline

✓ Seventy-eight traumatic neuropathies were seen in 94 patients with femoral nerve lesions; 54 of these were operated on because of persistent complete functional loss and/or pain. The most common mechanism of injury to the femoral nerve was iatrogenic due to inguinal herniorrhaphy, total hip replacement, intraabdominal vascular or gynecological operation, and, less commonly, appendectomy, lumbar sympathectomy, and laparoscopic procedures. Femoral nerve injuries also resulted from penetrating gunshot and stab wounds, laceration by glass, and stretch/contusive injuries associated with pelvic fractures. There were no signs of clinical or electrical recovery in 45 of 78 patients with traumatic nerve injuries. These and other partial injuries associated with pain were explored and evaluated by intraoperative nerve stimulation and recording of nerve action potentials (NAPs).

Despite complete loss of nerve function preoperatively, 13 patients had recordable NAPs and underwent neurolysis; each recovered function to at least a Grade 3 level. Twenty-seven patients had sural graft repairs performed with graft lengths varying from 2.5 to 14 cm. Most patients had some nerve regeneration and regained function to Grade 3 to 4 levels by 2 years postoperatively. Four of five patients with suture repairs recovered to Grade 3 or better within 2 years postoperatively. Despite a proximal pelvic level for most of these injuries and, as a result, lengthy graft repairs, recovery of some useful function was the rule rather than the exception. Tumors involved the femoral nerve in 16 patients and included eight neurofibromas, four schwannomas, one neurogenic sarcoma, two ganglion cysts, and one leiomyosarcoma. All tumors were treated surgically and most were removed successfully.

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David G. Kline and Donald J. Judice

✓ A 12-year operative experience with 171 consecutive patients with severe brachial plexus lesions who had at least 1½ years of follow-up review is analyzed. Selection for and timing of operation was helped by categorization of each individual plexus element as “completely” or “incompletely” injured and as “in continuity” or “not in continuity.” Results for each element could be given a single grade by a system which defined that element's proximal and distal input.

For most lesions in continuity, an operative delay of several months is advocated so that intraoperative electrical evaluation can be used. Thus, in 282 gunshot wounded and stretch-injured elements of which 210 were thought to be clinically complete, 63 were spared resection because of nerve action potentials (NAP's) found at intraoperative testing, and 57 recovered function with only neurolysis. Elements resected (120) were confirmed as neurotmetic both by intraoperative electrical and subsequent histological studies. Acceptable results were achieved in 16 of 24 sutures, in 43 of 89 grafts, and in each of seven split repairs. Upper trunk and lateral and posterior cord elements fared better than lower trunk and medial cord lesions unless the latter were shown, with evidence of NAP's, to be regenerating and could be spared resection. Some stretched elements could, however, not be repaired, even though an attempt was made to exclude such cases from operation.

Lacerations to the brachial plexus where continuity is lost are best repaired primarily if the injury is sharp; in this series, 14 of 18 elements having such repair recovered, whereas in 37 elements with secondary repair, grafts were often necessary and only 50% recovered function. Although associated with skin lacerations, 17 elements with complete loss were in continuity, and six of these were shown to be regenerating and were not resected. Despite intraneural location, large size, and prior operation, many benign tumors (including neurofibromas) can be removed without significant loss by use of the surgical loupes or microscope and repetitive NAP recording. Surgery for selected brachial plexus lesions is worthwhile.

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David G. Kline and Hector J. Leblanc

✓ The successful treatment of a civilian gunshot wound of the vermis and pons is described. A large missile fragment was removed from a depth of 2 cm within the pons at the level of the facial colliculus. Despite initial coma and subsequent irregular respiration with sleep apnea, the patient survived. Neurological, radiographic, and operative findings are correlated with the anatomy of the pons.

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Progression of partial experimental injury to peripheral nerve

Part 2: Light and electron microscopic studies

Alan R. Hudson and David G. Kline

✓ Biopsies from partially lacerated nerves were taken at the sites of proximal stimulus, laceration, and distal recording, and from stimuli and recording sites of control nerves. Electron microscopic examination of the partially lacerated major fasciculus revealed three zones of injury. The laceration zone showed neurotemetic changes, the adjacent or intermediate zone, partial degeneration, and the zone most peripheral to the laceration, changes in ground substance. Progression of the original injury is apparently due to ongoing changes in the intermediate and peripheral zones while much of the relative early recovery is due to reversal of changes in these zones. Regeneration through the laceration or neurotemetic zone is limited but does account for a small amount of late recovery of function.