Journal of neurosurgery
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The authors conducted a retrospective study to evaluate the treatment of complex C1-2 fractures. ⋯ The goals in treating these complex fractures are to achieve early maximum stability and minimum reduction in range of motion. These are often competing phenomena. Frequently in cases of atlas-axis fracture, odontoid screw fixation combined with hard collar immobilization is the best therapy, provided the transverse atlantal ligament is competent. If not, C1-2 stabilization with placement of transarticular screws is required for best results.
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Despite 50 years of neurosurgical experience, occipitocervical fusion continues to present a technical challenge to the surgeon. Traditional nonrigid techniques applied in the occiput and cervical spine often fail secondary to postsurgical cranial settling or rotational deformity. Unlike widely used nonrigid and semirigid techniques, rigid fixation of the craniocervical junction should allow correction of deformity in any plane, provide immediate stability without need for external orthosis, and prevent cranial settling. ⋯ Although it is still evolving, the current technique for obtaining rigid occipitocervical fixation allows for immediate rigidity and stability of the spine without the use of an external orthosis (that is, in the absence of osteoporosis), may be extended to any level of the spine, may be used in the absence of posterior elements, prevents postsurgical cranial settling and restenosis, facilitates reduction of the spinal deformity in any plane, and sometimes eliminates the need for an anterior (transoral) decompressive procedure.
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Journal of neurosurgery · Oct 1999
Prognostic value of early computerized tomography scanning following craniotomy for traumatic hematoma.
Patients with head injuries traditionally were categorized on the basis of whether their lesions appeared to be diffuse, focal, or mass lesions on admission computerized tomography (CT) scanning. In the classification of Marshall, et al., the presence of a hematoma (evacuated or not evacuated) is more significant than any diffuse injury (DI). The CT scan appearance after evacuation of a mass lesion has not been analyzed previously in relation to outcome. The authors have investigated the importance of: 1) neurological assessment at hospital admission; 2) the status of the basal cisterns and associated intracranial lesions on the admission CT scan; and 3) the degree of DI on the early CT scan obtained after craniotomy to identify patients at risk for development of raised intracranial pressure (ICP) and lowered cerebral perfusion pressure (CPP) and to discover the influence of the postoperative CT appearance of the lesion on patient outcome. ⋯ Features on CT scans obtained shortly after craniotomy constitute an independent predictor of outcome in patients with traumatic hematoma. Patients in whom DI III or IV appears on postoperative CT scanning, who often present with an mGCS score of 3 or less and nonreactive pupils, are at high risk for the development of raised ICP and lowered CPP.
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Journal of neurosurgery · Oct 1999
Randomized Controlled Trial Comparative Study Clinical TrialValproate therapy for prevention of posttraumatic seizures: a randomized trial.
Seizures frequently accompany moderate to severe traumatic brain injury. Phenytoin and carbamazepine are effective in preventing early, but not late, posttraumatic seizures. In this study the authors compare the safety and effectiveness of valproate with those of short-term phenytoin for prevention of seizures following traumatic brain injury. ⋯ Valproate therapy shows no benefit over short-term phenytoin therapy for prevention of early seizures and neither treatment prevents late seizures. There was a trend toward a higher mortality rate among valproate-treated patients. The lack of additional benefit and the potentially higher mortality rate suggest that valproate should not be routinely used for the prevention of posttraumatic seizures.
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Syringomyelia causes progressive myelopathy. Most patients with syringomyelia have a Chiari I malformation of the cerebellar tonsils. Determination of the pathophysiological mechanisms underlying the progression of syringomyelia associated with the Chiari I malformation should improve strategies to halt progression of myelopathy. ⋯ The progression of syringomyelia associated with Chiari I malformation is produced by the action of the cerebellar tonsils, which partially occlude the subarachnoid space at the foramen magnum and act as a piston on the partially enclosed spinal subarachnoid space. This creates enlarged cervical subarachnoid pressure waves that compress the spinal cord from without, not from within, and propagate syrinx fluid caudally with each heartbeat, which leads to syrinx progression. The disappearance of the abnormal shape and position of the tonsils after simple decompressive extraarachnoidal surgery suggests that the Chiari I malformation of the cerebellar tonsils is acquired, not congenital. Surgery limited to suboccipital craniectomy, C-I laminectomy, and duraplasty eliminates this mechanism and eliminates syringomyelia and its progression without the risk of more invasive procedures.