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.
Part I: The significance of intracranial pressure monitoring
Lawrence F. Marshall, Randall W. Smith and Harvey M. Shapiro
✓ The authors have analyzed the hospital course and outcome in 100 consecutive patients with severe head injuries who either on admission or within 24 to 48 hours of their hospitalization were not verbally responsive, and not able to follow commands. All were treated in a uniform manner. Operative intervention was performed immediately in patients with significant extracerebral hematomas or large superficial intracerebral hematomas. Intracranial pressure (ICP) was monitored in all, and in 55 patients treatment with a combination of dexamethasone, hyperventilation (PaCO2 of 25 to 28 mm Hg), mannitol, normothermia, and controlled systemic arterial pressure was required for intracranial hypertension (ICP > 15 mm Hg). In 25 patients whose ICP remained significantly elevated (ICP > 40 mm Hg for 15 minutes or more), high-dose pentobarbital therapy was used to lower the ICP. Forty-five patients recovered with no or minimal neurological deficit, and returned to their pre-injury occupation (good recovery). Fifteen patients are moderately disabled, four are severely disabled, and eight remain in a persistent vegetative state. The mortality rate was 28%. The favorable outcome in this series suggests that early aggressive surgical treatment, successful control of intracranial hypertension, and careful attention to medical complications can improve the outcome in patients with severe head injuries.
A longitudinal prospective study of adult and pediatric head injury
Thomas G. Luerssen, Melville R. Klauber and Lawrence F. Marshall
✓ A series of 8814 head-injured patients admitted to 41 hospitals in three separate metropolitan areas were prospectively studied. Of these, 1906 patients (21.6%) were 14 years of age or less. This “pediatric population” was compared to the remaining “adult population” for mechanism of injury, admission Glasgow Coma Scale score, motor score, blood pressure, pupillary reactivity, the presence of associated injuries, and the presence of subdural or epidural hematoma. The relationship of each of these factors was then correlated with posttraumatic mortality. Except for patients found to have subdural hematoma and those who were profoundly hypotensive, the pediatric patients exhibited a significantly lower mortality rate compared to the adults, thus confirming this generally held view. This study indicates that age itself, even within the pediatric age range, is a major independent factor affecting the mortality rate in head-injured patients.
Melville R. Klauber, Steven M. Toutant and Lawrence F. Marshall
✓ A graph is presented for predicting delayed intracranial hypertension (intracranial pressure (ICP) greater than 30 mm Hg) for severely head-injured patients, based on a logistic regression model. Data gathered during the first 24 hours of patient observation are used to predict patient status during the subsequent 48 hours. The best predictor out of 10 factors analyzed was the peak ICP level during the first 24 hours (p < 0.0001). Other predictors used in the final model were the presence of hypotension (p = 0.045) and abnormal ventricles — defined as ventricles which were either absent, small, or enlarged (p = 0.086). Error rates of 24% and 20% were obtained initially and by means of a separate cross-validation group, respectively. Use of a conservative cut point (25% estimated chance of developing excess ICP) for designating high-risk patients provided a procedure with sensitivity of 86% to 89% for the two groups.