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Ruptured Intervertebral Disc

Report of a Case with a Defect in the Anterior Annulus Fibrosus

Milam E. Leavens and F. Keith Bradford

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Carlos Gorbitz and Milam E. Leavens

✓ A modified technique for alcohol block of the celiac plexus in cases of upper abdominal visceral pain is described. The hazards and complications of the procedure are discussed. The results in 11 patients are reported.

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J. Martin Barrash and Milam E. Leavens

✓ Experience with dorsal rhizotomy in 71 patients with intractable pain is presented. The authors believe this treatment is indicated for cancer patients who are in good enough physical condition to tolerate a laminectomy, have a moderate life expectancy, and whose pain involves structures innervated by one or several roots. An extremity should be denervated only if it is already without functional value. The advantage of sensory rhizotomy is that it produces a lasting anesthesia that is tolerable to the patient. The results Were good to excellent in 50 of the 71 patients. There were five operative deaths.

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Alvin Thaggard, Stanley Handel, Milam E. Leavens and George Isaacs

✓ A patient with cerebellar hemangioblastoma underwent two successive cerebral arteriograms within a 48-hour period. The first arteriogram suggested an arteriovenous malformation. The second angiogram showed a dramatic change with nearly total absence of the earlier dilated draining veins. This change was found on examination of the surgical specimen to be caused by venous thrombosis.

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Cully A. Cobb III, Milam E. Leavens and Nylene Eckles

✓ A retrospective series of 12,478 patients with breast cancer included 2467 patients with spinal metastases. Local treatment was not necessary in 688 patients. Neurological deficit did not develop in 1735 patients who underwent radiotherapy. Forty-four patients developed myelopathy due to spinal cord compression as demonstrated by neurological examination and myelography. Twenty-six of these patients were initially treated by laminectomy and 18 were initially treated with radiotherapy. The two groups did not significantly differ in their outcome with respect to motor power, pain relief, or ability to walk. Six patients who underwent radiotherapy deteriorated during 2 months of treatment. Four of these patients were not operative candidates because of poor general condition (three patients) or long duration of paraplegia (one patient). Of two patients who underwent emergency laminectomy, one became paraplegic; however, the other patient was significantly improved. For this reason it is essential that patients undergoing radiotherapy for spinal cord compression be followed closely by a neurosurgeon. The authors believe that in appropriate cases radiotherapy alone can yield results as good as laminectomy combined with radiotherapy.

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Milam E. Leavens, Naguib A. Samaan, Richard H. Jesse Jr. and Robert M. Byers

✓ Sixteen patients with acromegaly treated with transsphenoidal pituitary surgery were evaluated with the measurement of serum human growth hormone (HGH) before and after intravenous stimulation with thyrotropin-releasing hormone (TRH). Fourteen of these patients showed a significant rise of serum HGH after TRH stimulation before surgery. After surgery, 12 patients with Grade 2 noninvasive adenomas had normal fasting serum HGH levels which did not stimulate with TRH. Two of these patients showed high serum HGH levels both at fasting and after TRH stimulation and required a second operation to remove residual adenoma within the sella before adequate lowering of HGH was achieved. Evidence of recurrent adenoma has not occurred clinically or biochemically in this group of 12 patients followed for an average of 24 months (2 to 60 months).

The results were unsatisfactory in four of these 16 patients. One patient who has a postoperative HGH of 9 ng/ml which still stimulates with TRH has made clinical improvement, but must have residual adenoma in the sella or invasive adenoma in the dura and tumor capsule. Additional treatment with irradiation has been given. Failure to achieve satisfactory results in the other three patients was attributed to the presence of locally invasive adenoma; one in the sphenoid sinus, and the other two possibly as a consequence of previous operative procedures.

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Joel M. Steinberg, John J. Gillespie, Bruce MacKay, Robert S. Benjamin and Milam E. Leavens

✓ A case is presented of meningeal melanocytoma that invaded the thoracic spinal cord of a 71-year-old woman. The light and electron microscopic features of the lesion indicate that it derives from melanocytes normally found in the leptomeninges. This tumor closely resembles the dermal cellular blue nevus and does not have the ultrastructure of a meningioma. “Melanotic meningioma” is consequently a misnomer and the name “meningeal melanocytoma” is more appropriate. These tumors may appear to be benign histologically, but they are locally aggressive. Total surgical excision offers the best chance for cure.

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Milam E. Leavens, C. Stratton Hill Jr., David A. Cech, Jane B. Weyland and Jaye S. Weston

✓ Intractable pain in six cancer patients was treated with lumbar intrathecal morphine (two patients) and intraventricular morphine (four patients). Daily percutaneous injections of morphine through Ommaya reservoirs were made. Initially, 1 mg of lumbar intrathecal morphine resulted in pain relief for 10 to 14 hours, and 2.5 to 4.0 mg of intraventricular morphine gave relief for 12 to 24 hours. This treatment was continued for 3 to 7 months in three of the adults. Morphine requirements gradually increased. Side effects were minimal, and there were no complications.

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Rajesh K. Bindal, Raymond Sawaya, Milam E. Leavens and J. Jack Lee

✓ The authors conducted a retrospective review of the charts of 56 patients who underwent resection for multiple brain metastases. Of these, 30 had one or more lesions left unresected (Group A) and 26 underwent resection of all lesions (Group B). Twenty-six other patients with a single metastasis who underwent resection (Group C) were selected to match Group B by type of primary tumor, time from first diagnosis of cancer to diagnosis of brain metastases, and presence or absence of systemic cancer at the time of surgery. Statistical analysis indicated that Groups A and B were also homogeneous for these prognostic indicators. Median survival duration was 6 months for Group A, 14 months for Group B, and 14 months for Group C. There was a statistically significant difference in survival time between Groups A and B (p = 0.003) and Groups A and C (p = 0.012) but not between Groups B and C (p > 0.5). Brain metastasis recurred in 31% of patients in Group B and in 35% of those in Group C; this difference was not significant (p > 0.5). Symptoms improved after surgery in 65% of patients in Group A, 83% in Group B, and 84% in Group C. Symptoms worsened in 13% of patients in Group A, 6% in Group B, and 0% in Group C. Groups A, B, and C had complication rates per craniotomy of 8%, 9%, and 8%, and 30-day mortality rates of 3%, 4%, and 0%, respectively. Guidelines for management of patients with multiple brain metastases are discussed. The authors conclude that surgical removal of all lesions in selected patients with multiple brain metastases results in significantly increased survival time and gives a prognosis similar to that of patients undergoing surgery for a single metastasis.

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Rajesh K. Bindal, Raymond Sawaya, Milam E. Leavens, Kenneth R. Hess and Sarah H. Taylor

✓ Results of reoperation in 48 patients who developed recurrent brain metastases between January 1984 and April 1993 are presented. Median time from first craniotomy to diagnosis of recurrence (time to recurrence) was 6.7 months. Median Karnofsky performance scale (KPS) score prior to reoperation was 80. Recurrence was local in 30 patients, distant in 16 patients, and both local and distant in two patients. Median survival time after reoperation was 11.5 months. There were no operative mortalities. Multivariate analysis revealed that presence of systemic disease (p = 0.008), KPS scores less than or equal to 70 (p = 0.008), time to recurrence of less than 4 months (p = 0.008), age greater than or equal to 40 years (p = 0.51), and primary tumor type of breast or melanoma (p = 0.028) negatively affected patient survival time. These five factors were used to develop a grading system (Grades I–IV). Patients categorized in Grade I had a 5-year survival rate of 57%, whereas the median survival time of patients in Grades II, III, and IV was 13.4, 6.8, and 3.4 months, respectively (p < 0.0001).

Overall, 26 patients developed a second recurrence after reoperation. Seventeen patients underwent a second reoperation, whereas nine did not. Patients undergoing a second reoperation survived a median of 8.6 additional months versus 2.8 months for those who did not (p < 0.0001).

This study concludes that reoperation for recurrent brain metastasis can prolong survival and improve quality of life. A second reoperation can also increase survival. Five factors influence survival: status of systemic disease, KPS score, time to recurrence, age, and type of primary tumor. The grading system using these five factors correlates with survival time. Reoperation should be approached with caution in Grade IV patients because of their poor prognosis.