Neurosurgery
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Clinical Trial
Administration of intraspinal morphine sulfate for the treatment of intractable cancer pain.
A total of 24 patients with intractable cancer pain were evaluated as candidates for spinal morphine therapy. Temporary trials were carried out with bolus injections of preservative-free morphine sulfate via percutaneously inserted epidural catheters. Fourteen patients felt that pain relief was sufficient to warrant long term morphine application, and permanent drug delivery systems were implanted. ⋯ A persistent cerebrospinal fluid fistula developed in 1 patient; this required wound revision. No other serious complications or episodes of respiratory depression occurred. We conclude that intraspinal morphine sulfate is a beneficial treatment option for cancer patients in whom pain has become debilitating and unresponsive to oral or parenteral narcotic regimes.
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Craniocerebral gunshot wounds are a significant cause of injury and death in the United States. However, despite reports of occasional unexpectedly favorable outcome in surgically treated patients, these injuries have been viewed pessimistically and indeed have generally been excluded from modern studies of head injuries, which have concentrated on closed head injuries. ⋯ A detailed analysis of these patients, including demographic details, general and neurological condition, anatomic injuries, laboratory findings, surgical care, neurological course, and neurological and functional outcome follows. The helpfulness of early resuscitation and appropriate criteria for surgery need to be studied using historic or randomized controls.
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The extent of treatment for the victims of gunshot wounds to the brain remains quite controversial, particularly when these patients present with extensive neurological dysfunction. We propose guidelines regarding the degree and aggressiveness of therapy. The factors that seem to have a significant impact on the patient's final outcome are the neurological examination at the time of admission, the radiological findings, and the motivation for the shooting. Thus, the authors propose a nonsurgical line of therapy for comatose patients with unilateral or bilateral cerebral gunshot wounds where bone or metal fragments are visualized away from the bullet path on computed tomography scan, particularly when these individuals are suicide victims.
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The authors report a series of 16 hemiplegic patients suffering from harmful spasticity in the upper limb and treated with selective posterior rhizotomy (SPR) in the dorsal root entry zone (DREZ). This severe spasticity was associated with irreducible abnormal postures in flexion in 11 cases and painful manifestations in 12. The method was introduced in 1972 on the basis of anatomical studies of the DREZ in humans, in which a topographical segregation of the root afferents, according to their anatomicofunctional destinations, has been shown. ⋯ In 1 case only, a marked tendency for spasticity to return was observed. Of the 12 patients with painful manifestations, 9 were completely relieved and 3 improved. These beneficial effects on both spasticity and pain led to a gain in functional status in 93% of cases.(ABSTRACT TRUNCATED AT 250 WORDS)
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Complete gross and microscopic neuropathological examinations of 25 children who died with meningomyelocele, the Arnold-Chiari malformation, and hydrocephalus revealed a wide range and frequency of associated central nervous system malformations. The most remarkable of these anomalies were hypoplasia or aplasia of cranial nerve nuclei (20%), demonstrable obstruction of cerebrospinal fluid flow within the ventricular system (92%), cerebellar dysplasia (72%), a disorder of migration of cortical neurons (92%), fusion of the thalami (16%), agenesis of the corpus callosum (12%), and complete or partial agenesis of the olfactory tract and bulb (8%). The anomalies associated with posterior neural tube closure defects can no longer be considered secondary, but rather must be considered part of a spectrum of malformations caused by an unidentified primary insult to the central nervous system. The frequency and pattern of brain malformations associated with neural tube defects of some children with meningomyelocele suggest that such malformations may seriously affect intellectual outcome.