Kenneth E. Livingston
Kenneth E. Livingston and Richard G. Perrin
✓ In acute experiments with adult cats, a 5 mg/kg bolus of procaine hydrochloride blocked the reflex vagal slowing elicited by stimulation of the carotid sinus nerve. That this blockade does not represent a generalized depression of central nervous system function is indicated by the fact that the superficial reflexes appeared undiminished when the cardiac response was completely abolished. In unanesthetized, freely-moving cats with chronically-implanted cortical and depth electrodes, the electroencephalogram and behavior were not altered at doses well in excess of those required to abolish the baroreceptor reflex. This central reflex blockade was not altered in animals immobilized with succinylcholine. Procaine hydrochloride was several times more effective than lidocaine in blocking the central reflex response, suggesting a mechanism not directly dependent on anesthetic potency. Interruption of the reflex and its continuing blockade were dose-related.
Kenneth E. Livingston and Richard G. Perrin
✓ The authors report a series of 100 consecutive patients with spinal metastases causing cord or cauda equina compression, who were treated with surgical decompression. Of these, 30% (all women) had breast cancer. The most common primary neoplasm in man was prostatic carcinoma. Pain was the earliest and most prominent symptom, followed by weakness. Bladder dysfunction was recorded in 40 patients. The thoracic region was the most common site of cord compression (76 patients). Surgical treatment involved urgent and extensive laminectomy decompression. Concomitant spinal stabilization was required in 10 cases, involving posterior rib graft fusion in seven and Harrington rod instrumentation in three. At last follow-up review, 29 of these patients were living with an average postoperative survival of 2.3 years; 71 patients had died with an average survival of 8.8 months. Surgical decompression produced effective pain relief in 70% of the patients. Postoperatively, 58 patients could walk; of these, 40 were walking and continent of urine 6 months following surgery (including five patients who were totally paraplegic on admission). Positive approach and aggressive management in this problem can achieve results superior to those generally reflected in the literature.
Henry G. Decker and Kenneth E. Livingston
Richard G. Perrin and Kenneth E. Livingston
✓ The treatment of 20 patients with symptomatic pathological fracture-dislocation of the spine is reviewed. The single most common primary disease was carcinoma of the breast (12 cases). Pain was the presenting symptom in 19 patients. At the time of surgery, six patients were weak but ambulatory, seven were bedridden, and three were paraplegic. The cervical spine (10 cases) was most frequently involved, followed by the thoracic region in six, and the lumbar segments in four. Treatment aimed at improving or preserving neurological function involved decompression of the cord (or cauda) with reduction of bone deformity and stabilization of the spine. Laminectomy decompression was performed in 18 cases. Posterior rib graft fusion was used to stabilize the spine in all patients with cervical, and in three with upper thoracic, pathological fracture-dislocation; Harrington rod instrumentation was used for lower thoracic and lumbar levels. All patients were considered for radiotherapy and/or chemotherapy. Ten patients are living, an average of 20 months following surgery. Among the remainder, the average survival was 5 months. Fourteen patients were ambulatory after surgery, four were improved, and two were unchanged. Twelve patients have achieved a “satisfactory” result (walking and continent 6 months after treatment), including the three who were paraplegic at the time of surgery.
Spinal metastases presenting as pathological fracture-dislocation of the spine may produce potentially devastating cord compression. Critical neurological sequelae can be avoided, and a satisfactory result can be achieved by urgent decompression of the cord and stabilization of the spine.
A report of 10 cases
Richard G. Perrin, Kenneth E. Livingston, and Bizhan Aarabi
✓ The management of 10 patients with symptomatic localized intradural extramedullary spinal metastasis is reviewed. The single most common primary source was carcinoma of the breast (four cases). The initial symptom in nine patients was pain, with five patients reporting a characteristically severe cramping discomfort with radicular distribution. All patients underwent laminectomy decompression. At the time of surgery, six of the patients were weak but ambulatory and four were bedridden. Following surgery, four patients enjoyed some measure of pain relief, seven patients became ambulatory, and three remained bedridden. Two patients achieved a “satisfactory” result, and were walking and continent 6 months after surgery. Secondary brain tumors were demonstrated or implicated in nine patients, supporting the concept that the spinal metastases represented tertiary deposits following dissemination via the cerebrospinal fluid.
Symptomatic intradural extramedullary spinal metastasis causes a virulent clinical syndrome with poor prognosis and disappointing outcome after treatment. Given the high incidence of associated cerebral metastatic involvement, total neuraxis radiation and/or chemotherapy should be considered when symptomatic spinal metastasis is discovered to be intradural and extramedullary.