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Richard D. Bucholz and K. Charles Cheung

✓ The indications for surgical fusion, as opposed to halo fixation, in the management of cervical spine injury are still unclear. At St. Louis University Medical Center a conservative protocol has been adopted to treat almost all cervical spine fractures with halo fixation. To determine what factors have contributed to failure of halo fixation, the records and radiographs of all patients with cervical spine injuries who were treated at that institution between 1984 and 1986 were reviewed. During this interval, 124 patients were treated, consisting of 93 men and 31 women between 6 and 94 years old. Of these, 15 (12%) had cervical fusion without preoperative halo device application. This group included eight patients with old injuries and delayed diagnosis, three with nonreducible locked facets, and four with miscellaneous indications. The remaining 109 patients were treated with halo vests. Four died before completing the 3-month standard treatment. Of those completing the treatment, 48 had C1–2 level injuries and 57 had C3–T1 level injuries. Sixteen patients (15%) failed their halo treatments and required surgical fusion: eight while still in halo fixation and eight after they had completed treatment with a halo device. Failure of halo treatment was indicated by recurrent dislocation in 13 patients and increased neurological deficit in three. Thirteen of the patients who failed treatment had C3–T1 injuries and three had C1–2 injuries. Of 27 patients with odontoid fractures, only two (7.4%) failed halo fixation. There were no failures in 11 patients with hangman's fractures. Of the 57 patients with C3–T1 injuries, 13 (23%) failed treatment, nine of whom had locked or “perched” facets. The factors causing failure of halo fixation were analyzed. The overall success rate was 85%, suggesting that the halo vest can be used to treat most patients with cervical spine injuries. Under certain circumstances (in the presence of old injuries, difficult reduction, or locked or “perched” facets), surgery may be indicated to avoid unnecessary delay in definitive management.

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Gary E. Kraus, Richard D. Bucholz, and Thomas R. Weber

✓ Spinal cord arteriovenous malformations (AVM's), like other vascular anomalies of the central nervous system, can be associated with similar vascular lesions of the skin and viscera. A 7-year-old girl, who presented with rapidly progressing paraplegia, was found to have a spinal cord AVM, cutaneous angioma, and a chylous malformation of the lymphatic system. She had previously undergone treatment for a posterior thoracic cutaneous angioma. At surgery, upon incision of the paravertebral muscle fascia, viscous pale fluid was encountered emanating from a foramen in the thoracic lamina. The spinal AVM was resected in spite of concern that the abnormality represented spinal osteomyelitis. Postoperatively, there was full return of function in the lower extremities, along with recurrent episodes of chylothorax, which slowly came under control with dietary manipulation. A review of the anatomy of the thoracic duct and nontraumatic causes of chylothorax is presented, and the association of cutaneous and central angiomas is discussed. Finally, the treatment of chylothorax is delineated.

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Temporoparietal craniopagus

Case report and review of the literature

Richard D. Bucholz, Kong-Woo Yoon, and Raymond E. Shively

✓ A case of craniopagus twins joined in the temporoparietal area is presented, along with a review of the literature on craniopagus. A large area of brain was shared between the neurologically normal infants, with defects in the scalp, skull, and dura. The twins were separated in a three-step procedure. First, areas of shared brain were divided and separated with silicone sheets. The second procedure consisted of the insertion of scalp expanders to allow primary skin closure. In the third procedure complete separation was performed which was complicated by severe hypotension in one infant that was due to dural sinus hemorrhage. Cerebrospinal fluid leak was the most difficult problem encountered in the postoperative period; this was treated with lumboperitoneal and ventriculoperitoneal shunts. After 2 years, one twin is neurologically normal; the other is severely developmentally delayed, possibly related to the severe hypotension experienced during the third procedure. A review of the literature on craniopagus is presented. Analysis of data in the literature suggests that the area involved in the craniopagus as well as the venous connections are closely related to survival following separation of craniopagus twins.

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Richard D. Bucholz, Hector W. Ho, and Jason P. Rubin

✓ Stereotactic localization using computerized tomography (CT) is increasingly employed to guide neurosurgical procedures in crucial areas of the brain such as the brain stem. This technique allows the surgeon to resect a lesion in its entirety while sparing critical areas of the brain. Thus, the parameters used for scanning should be selected for maximum accuracy. While the small pixel size of CT scanners suggests a high degree of precision in localization, there have been few systematic studies of this accuracy. The authors have studied the amount of error in localization created by variables such as CT scan thickness, interscan spacing, size of lesion, and method of computation when using the Brown-Roberts-Wells (BRW) stereotactic system.

Over 1000 CT scans were made of a phantom composed of spheres of differing diameter and location. The CT slice thickness was varied from 1.5 to 5.0 mm, and interscan spacing was varied from 0.5 to 3.0 mm. The coordinates of the center of the spheres were calculated independently using the laptop computer supplied with the unit and also by a stereotactic computer which automatically calculates the center of the fiducials. The actual BRW coordinates of the sphere center were obtained using the phantom base and were then compared to the computer-calculated coordinates to determine error in localization.

Variables with a significant effect on error included the scan thickness, interscan spacing, and sphere size. The mean error decreased 23% as the scan thickness decreased from 5.0 to 1.5 mm and 45% as the interscan spacing decreased from 3.0 to 0.5 mm. Mean error was greatest for the smallest sphere sizes. The two computational methods did not differ in error. This study suggests that, for critical areas of the brain or for small lesions, a scan thickness of 1.5 mm and interscan spacing of 0.5 mm should be employed.

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Bahram Chehrazi, Jacqualyn Parkinson, and Richard Bucholz

✓ This study was undertaken to identify the normal somatosensory evoked potential pattern from stimulation of the common peroneal nerve in order to provide basic data for clinical use in diagnosis and management of patients with spinal cord lesions. Thirty-four adult volunteers, free of neurological disease, and 12 patients were tested. The recording technique is described and is similar to that reported by Perot. The primary evoked response (P1) was easily visualized in 88% of the recordings from normal subjects. The peak latency of the primary response was 38.9 msec, and the deflection was positive. A vertex potential (P4) was a relatively consistent peak that appeared at approximately 240 msec in 78% of the subjects. Additional components of the waveform are also described and are compared to previous studies. Clinically, the presence of primary response seems to correlate with a favorable neurological outcome, and recovery of the primary response may precede major clinical improvement. The literature is reviewed and results compared to the current study.

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Guy L. Clifton, Christopher S. Coffey, Sierra Fourwinds, David Zygun, Alex Valadka, Kenneth R. Smith Jr., Melisa L. Frisby, Richard D. Bucholz, Elisabeth A. Wilde, Harvey S. Levin, and David O. Okonkwo


The authors hypothesized that cooling before evacuation of traumatic intracranial hematomas protects the brain from reperfusion injury and, if so, further hypothesized that hypothermia induction before or soon after craniotomy should be associated with improved outcomes.


The National Acute Brain Injury Study: Hypothermia I (NABIS:H I) was a randomized multicenter clinical trial of 392 patients with severe brain injury treated using normothermia or hypothermia for 48 hours with patients reaching 33°C at 8.4 ± 3 hours after injury. The National Acute Brain Injury Study: Hypothermia II (NABIS:H II) was a randomized, multicenter clinical trial of 97 patients with severe brain injury treated with normothermia or hypothermia for 48 hours with patients reaching 35°C within 2.6 ± 1.2 hours and 33°C within 4.4 ± 1.5 hours of injury. Entry and exclusion criteria, management, and outcome measures in the 2 trials were similar.


In NABIS:H II among the patients with evacuated intracranial hematomas, outcome was poor (severe disability, vegetative state, or death) in 5 of 15 patients in the hypothermia group and in 9 of 13 patients in the normothermia group (relative risk 0.44, 95% CI 0.22–0.88; p = 0.02). All patients randomized to hypothermia reached 35°C within 1.5 hours after surgery start and 33°C within 5.55 hours. Applying these criteria to NABIS:H I, 31 of 54 hypothermia-treated patients reached a temperature of 35°C or lower within 1.5 hours after surgery start time, and the remaining 23 patients reached 35°C at later time points. Outcome was poor in 14 (45%) of 31 patients reaching 35°C within 1.5 hours of surgery, in 14 (61%) of 23 patients reaching 35°C more than 1.5 hours of surgery, and in 35 (60%) of 58 patients in the normothermia group (relative risk 0.74, 95%, CI 0.49–1.13; p = 0.16). A meta-analysis of 46 patients with hematomas in both trials who reached 35°C within 1.5 hours of surgery start showed a significantly reduced rate of poor outcomes (41%) compared with 94 patients treated with hypothermia who did not reach 35°C within that time and patients treated at normothermia (62%, p = 0.009).


Induction of hypothermia to 35°C before or soon after craniotomy with maintenance at 33°C for 48 hours thereafter may improve outcome of patients with hematomas and severe traumatic brain injury. Clinical trial registration no.: NCT00178711.

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Christopher C. Gallen, Barry J. Schwartz, Richard D. Bucholz, Ghaus Malik, Gregory L. Barkley, Joseph Smith, Howard Tung, Brian Copeland, Leonard Bruno, Sam Assam, Eugene Hirschkoff, and Floyd Bloom

✓ The boundaries of somatosensory cortex were localized noninvasively by means of a large-array biomagnetometer in six patients with mass lesions in or near eloquent cortex. The results were used by neurosurgeons and neurologists in preoperative planning and for reference in the operating room. The magnetic source imaging (MSI) localizations from somatosensory evoked potentials were used to predict the pattern of phase reversals measurable intraoperatively on the cortical surface, providing a quantitative comparison between the two measures. The magnetic localizations were found to be predictive in all six cases, with the two sets of localizations falling within an 8-mm distance on average. Somatosensory localizations using MSI offer accuracy in localizing somatosensory cortex stereotactically and in depicting its relationship to lesions. Such data are valuable preoperatively in assessing the risks associated with a proposed surgical procedure and for optimizing subsequent minimum-risk surgical strategy.

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Georgios Alexopoulos, Nabiha Quadri, Maheen Khan, Henna Bazai, Carla Formoso Pico, Connor Fraser, Neha Kulkarni, Joanna Kemp, Jeroen Coppens, Richard Bucholz, and Philippe Mercier


Penetrating brain injury (PBI) is the most lethal of all firearm injuries, with reported survival rates of less than 20%. The projectile trajectory (PT) has been shown to impact mortality, but the significant lobar tracks have not been defined. The aim of this retrospective case-control study was to test for associations between distinct ballistic trajectories, missile types, and patient outcomes.


A total of 243 patients who presented with a PBI to the Saint Louis University emergency department from 2008 through 2019 were identified from the hospital registry. Conventional CT scans combined with 3D CT reconstructions and medical records were reviewed for each patient to identify distinct PTs.


A total of 65 ballistic lobar trajectories were identified. Multivariable regression models were used, and the results were compared with those in the literature. Penetrating and perforating types of PBI associated with bitemporal (t-statistic = −2.283, p = 0.023) or frontal-to-contralateral parietal (t-statistic = −2.311, p = 0.025) projectile paths were universally found to be fatal. In the group in which the Glasgow Coma Scale (GCS) score at presentation was lower than 8, a favorable penetrating missile trajectory was one that involved a single frontal lobe (adjusted OR 0.02 [95% CI 0.00–0.38], p = 0.022) or parietal lobe (adjusted OR 0.15 [95% CI 0.02–0.97], p = 0.048). Expanding or fragmenting types of projectiles carry higher mortality rates (OR 2.53 [95% CI 1.32–4.83], p < 0.001) than do nondeformable missiles. Patient age was not associated with worse outcomes when controlled by other significant predictive factors.


Patients with penetrating or perforating types of PBI associated with bitemporal or frontal-to-contralateral parietal PTs should be considered as potential donor candidates. Trauma patients with penetrating missile trajectories involving a single frontal or parietal lobe should be considered for early neurosurgical intervention, especially in the circumstances of a low GCS score (< 8). Surgeons should not base their decision-making solely on advanced patient age to defer further treatment. Patients with PBIs caused by nondeformable types of projectiles can survive multiple simultaneous intracranial missile trajectories.