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John A. Jane, Charles S. Haworth, William C. Broaddus, Joung H. Lee and Jacek Malik

✓ A technique for exposing far-lateral intervertebral disc herniations without disrupting the facet is described. This technique is a simple modification of the standard neurosurgical approach.

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Jacek M. Malik, G. Rees Cosgrove and Scott R. VandenBerg

✓ The case is reported of a 28-year-old man with “ectopic” craniopharyngioma recurring in the epidural space 21 years after the original tumor was resected. Previously described cases of similar remote recurrences as well as some features of the biological behavior of craniopharyngioma are discussed. The rarity of this postoperative complication is addressed.

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Paul C. Francel, Bruce A. Long, Jacek M. Malik, Curtis Tribble, John A. Jane and Irving L. Kron

✓ Traumatic spinal cord injury occurs in two phases: biomechanical injury, followed by ischemia and reperfusion injury. Biomechanical injury to the spinal cord, preceded or followed by various pharmaceutical manipulations or interventions, has been studied, but the ischemia/reperfusion aspect of spinal cord injury isolated from the biomechanical injury has not been previously evaluated. In the current study, ischemia to the lumbar spinal cord was induced in albino rabbits via infrarenal aortic occlusion, and two interventions were analyzed: the use of U74006F (Tirilazad mesylate), a 21-aminosteroid, and cerebrospinal fluid (CSF) drainage. These treatment modalities were tested alone or in combination.

In Phase 1 of this study, the rabbits received 1.0 mg/kg of Tirilazad or an equal volume of vehicle (controls) prior to the actual occlusion, three doses of Tirilazad (1 mg/kg each) during the occlusion, then several doses after the occlusion. Of the Tirilazad-treated animals, 30% became paraplegic while 70% of the control animals became paraplegic. Phase 2 involved the same doses of Tirilazad as in Phase 1 and, in addition, CSF pressure monitoring and drainage were performed. The paraplegia rate was 79% in the control animals, 36% in the group receiving Tirilazad alone, 25% in the group with CSF drainage alone, and 20% in the Tirilazad plus CSF drainage group. This rate also correlated with changes noted in CSF pressure; both Tirilazad administration alone and CSF drainage alone induced a decrease in CSF pressure and the two combined produced a further decrease. There was marked improvement in the perfusion pressure when using Tirilazad alone, CSF drainage alone, and Tirilazad therapy in combination with CSF drainage, with the last group producing the largest increase. This change in CSF pressure and perfusion pressure correlated with improved functional neurological outcome. Pathological examination revealed that Tirilazad therapy reduced the extensive and diffuse neuronal, glial, and endothelial damage to (in its most severe form) a more patchy focal region of damage in the gray matter. Cerebrospinal fluid drainage resulted in pyknosis of some motor neurons, and some eosinophilia. The combination of CSF drainage and Tirilazad administration resulted in the least abnormality, with either normal or near-normal spinal cords.

It is concluded that Tirilazad administration decreased CSF pressure during spinal cord ischemia and reperfusion and, like CSF drainage, increased and improved the perfusion pressure to the spinal cord, decreased spinal cord damage, and improved functional outcome. These effects may be related to the role that Tirilazad has on free radical scavenging during ischemia and reperfusion, and it is possible that Tirilazad therapy alone or in combination with CSF drainage is an effective adjunct to other neural protective measures in spinal cord injury.

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Charles G. diPierro, Gregory A. Helm, Christopher I. Shaffrey, James B. Chadduck, Scott L. Henson, Jacek M. Malik, Thomas A. Szabo, Nathan E. Simmons and John A. Jane

✓ A new surgical technique for the treatment of lumbar spinal stenosis features extensive unilateral decompression with undercutting of the spinous process and, to preserve stability, uses contralateral autologous bone fusion of the spinous processes, laminae, and facets. The operation was performed in 29 patients over a 19-month period ending in December of 1991. All individuals had been unresponsive to conservative treatment and presented with low-back pain in addition to signs and symptoms consistent with neurogenic claudication or radiculopathy. Nine had undergone previous lumbar decompressive surgery. The minimum and mean postoperative follow-up times were 2 and 2 1/2 years, respectively. The mean patient age was 64 years; only two patients were younger than 50 years of age.

Of the patients with neurogenic claudication, 69% reported complete pain relief at follow-up review. Of those with radicular symptoms, 41% had complete relief and 23% had mild residual pain that was rated 3 or less on a pain—functionality scale of 0 to 10. For the entire sample, this surgery decreased pain from 9.2 to 3.3 (p < 0.0001) on the scale. Sixty-nine percent of patients were satisfied with surgery. Low-back pain was significantly relieved in 62% of all patients (p < 0.0001). Low-back pain relief correlated negatively with number of levels decompressed (p < 0.05). To assess fusion, follow-up flexion/extension radiographs were obtained, and no motion was detected at the surgically treated levels in any patient.

The results suggest that this decompression procedure safely and successfully treats not only the radicular symptoms caused by lateral stenosis but also the neurogenic claudication symptoms associated with central stenosis. In addition, the procedure, by using contralateral autologous bone fusion along the laminae and spinous processes, can preserve stability without instrumentation.

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Bizhan Aarabi, Babak Tofighi, Joseph A. Kufera, Jeffrey Hadley, Edward S. Ahn, Carnell Cooper, Jacek M. Malik, Neal J. Naff, Louis Chang, Michael Radley, Ashker Kheder and Ronald H. Uscinski

Object

Civilian gunshot wounds to the head (GSWH) are often deadly, but some patients with open cranial wounds need medical and surgical management and are potentially good candidates for acceptable functional recovery. The authors analyzed predictors of favorable clinical outcome (Glasgow Outcome Scale scores of 4 and 5) after GSWH over a 24-month period.

Methods

The authors posited 2 questions: First, what percentage of civilians with GSWH died in the state of Maryland in a given period of time? Second, what were the predictors of favorable outcome after GSWH? The authors examined demographic, clinical, imaging, and acute care data for 786 civilians who sustained GSWH. Univariate and logistic regression analyses were used to analyze the data.

Results

Of the 786 patients in this series, 712 (91%) died and 74 (9%) completed acute care in 9 trauma centers. Of the 69 patients admitted to one Maryland center, 46 (67%) eventually died. In 48 patients who were resuscitated, the Injury Severity Score was 26.2, Glasgow Coma Scale (GCS) score was 7.8, and an abnormal pupillary response (APR) to light was present in 41% of patients. Computed tomography indicated midline shift in 17%, obliteration of basal cisterns in 41.3%, intracranial hematomas in 34.8%, and intraventricular hemorrhage in 49% of cases. When analyzed for trajectory, 57.5% of bullet slugs crossed midcoronal, midsagittal, or both planes. Two subsets of admissions were studied: 27 patients (65%) who had poor outcome (25 patients who died and 2 who had severe disability) and 15 patients (35%) who had a favorable outcome when followed for a mean period of 40.6 months. Six patients were lost to follow-up.

Univariate analysis indicated that admission GCS score (p < 0.001), missile trajectory (p < 0.001), surgery (p < 0.001), APR to light (p = 0.002), patency of basal cisterns (p = 0.01), age (p = 0.01), and intraventricular bleed (p = 0.03) had a significant relationship to outcome. Multivariable logistic regression analysis indicated that GCS score and patency of the basal cistern were significant determinants of outcome. Exclusion of GCS score from the regression models indicated missile trajectory and APR to light were significant in determining outcome.

Conclusions

Admission GCS score, trajectory of the missile track, APR to light, and patency of basal cisterns were significant determinants of outcome in civilian GSWH.