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Burak M. Ozgur and Lawrence F. Marshall

Object. The authors retrospectively reviewed the presenting symptomatology and 6-month outcome in 241 consecutive patients who underwent C6–7 anterior cervical discectomy (ACD) from an overall series of 1008 patients in whom the senior author performed one-level procedures.

Methods. In 28 (12%) of the 241 patients, the sole complaint was subscapular pain on the side ipsilateral to nerve root compression. In 11 patients (5%), the primary complaint was unilateral deep breast or chest pain. No patient experienced any of the traditional radicular signs involving C-7 such as numbness of the second or third digits, pain in the triceps, and/or atrophy or weakness of the triceps or pronator muscles. Of the 28 patients presenting with subscapular pain 238 (93%) of 241 experienced complete symptom relief within 6 months, and of the 11 who presented with chest pain complete relief or relief to the point of requiring nonnarcotic analgesic agents occurred in nine cases.

Conclusions. Approximately 15% of patients with a C-7 radiculopathy are likely to present with atypical symptoms that, if persisting after nonsurgical therapy, will often resolve after ACD and fusion.

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The outcome with aggressive treatment in severe head injuries

Part II: Acute and chronic barbiturate administration in the management of head injury

Lawrence F. Marshall, Randall W. Smith and Harvey M. Shapiro

✓ In a series of 100 consecutive patients with severe head injuries, uncontrolled intracranial hypertension, which was defined as occurring when intracranial pressure (ICP) exceeded 40 mm Hg for 15 minutes or more, occurred in 25 patients. This was despite high-dose dexamethasone, hyperventilation, mannitol, normothermia, appropriate surgical evacuation, and cerebrospinal fluid drainage when possible. Persistently elevated ICP occurred in 19 patients with diffuse brain injury, and in six patients uncontrolled intracranial hypertension followed evacuation of a surgical mass. All of these patients received intravenous barbiturates to control the ICP. At the time of initial barbiturate administration, 11 of the 25 had bilaterally unreactive pupils and 12 were decerebrate. The initial pentobarbital loading dose (3 to 5 mg/kg) effectively reduced the ICP in 76% of the patients. Prolonged pentobarbital treatment with blood barbiturate levels from 2.5 to 3.5 mg% was associated with normalization of the ICP (ICP less than 15 mm Hg) in 13 patients. In those patients responding to barbiturates, the daily mannitol requirement was reduced from 4.5 to 0.5 gm/kg/day (p < 0.01). In six nonresponders to barbiturates, mannitol requirements increased to 5.9 gm/kg/day; five of these died and one remains vegetative.

Ten of the 19 barbiturate responders have returned to a productive life, two remain moderately disabled, two are severely disabled, one is vegetative, and four are dead. The high rate of good quality survival in this series of severely brain-injured patients indicates that barbiturates are useful in the treatment of uncontrolled intracranial hypertension and that a broader investigation of the clinical application of barbiturates is indicated.