Experimentally (atoxyl) induced ampullar degeneration and damage to the maculae utriculi

Atoxyl administration to guinea pigs may cause vesicular degeneration of both the secretory and the sensory regions of the cristae ampullares and macula utriculi. Some of the severely damaged secretory cells were even expelled from the surface into the endolymphatic space. The nerve chalices of type I hair cells disintegrated. The degeneration of the secretory region will thus block the endolymph circulation and the electrolyte balance is likely to collapse. Whether hair cell degeneration can best be explained on this basis (indirect atoxyl effect) or by a direct action of atoxyl on the hair cells and the nerve chalices of type I hair cells is discussed.     

A prospective and consecutive study of surgically treated lumbar spinal stenosis. Part I: Clinical features related to radiographic findings

STUDY DESIGN: A prospective and consecutive study of surgical results obtained during serial follow-up investigations in patients who underwent surgery for central lumbar spinal stenosis. OBJECTIVES: To evaluate the result after surgical decompression for lumbar spinal stenosis, at regular intervals after surgery, and to correlate these results with values for preoperative parameters; special interest was focused on the results in relation to the degree of constriction of the spinal canal. SUMMARY OF BACKGROUND DATA: The outcome after surgery for spinal stenosis is debatable; long-term follow-up investigations have indicated deterioration with passing time. Results of studies in nonsurgical patients have demonstrated that the symptoms do not progress with time. Results of a meta-analysis of the literature on surgical results have demonstrated a wide variation of outcomes. MATERIAL AND METHODS: In a prospective study, 105 consecutive patients who underwent surgical decompression (laminectomy with facet-preserving technique, but no fusion) were evaluated at follow-up examinations 4 months and 1, 2, and 5 years after surgery. At the follow-up examinations, the patient's opinion on the surgical result was registered, using a four-grade scale. The occurrence of pain at rest and at night was registered, as well as the patient's walking ability. Statistical analysis was performed, relating the surgical results to patient age, gender, preoperative duration of symptoms and radiographically observed constriction as described in Part I of this study. The radiologist was blinded to patient outcome. Logistic regression analysis was performed. RESULTS: During the follow-up period, 19 patients underwent reoperation, consisting of fusion to treat lumbar pain (n = 4), repeat decompression because of progressive stenosis (n = 13), and repairs in response to surgical complications (n = 2). Follow-up results: The result, related to the recurrence of leg symptoms, deteriorated with passing time. Excellent results were reported by 63% to 67% at 4-month and 2-year follow-ups compared with 52% at the 5-year follow-up. There was a correlation between the constriction of the spinal canal and the outcome at all intervals. Patients with an anteroposterior diameter of 6 mm or less at the narrowest site had significantly better results. The logistic regression analysis demonstrated a significant correlation between a severe reduction of the anteroposterior diameter and excellent results and a tendency toward better results in patients with a shorter preoperative duration of symptoms. Improvement of walking ability was also associated with a pronounced constriction of the spinal canal. CONCLUSION: The results after surgical decompression in patients with central spinal stenosis deteriorated with time. There was a significant correlation between good result and pronounced constriction of the spinal canal. Patients with a preoperative duration of symptoms of less than 4 years and patients with no preoperative back pain tended to have better surgical outcomes. The reoperation rate was 18% within 5 years. When surgery for spinal stenosis is contemplated, these prognostic factors should be taken into consideration: The "ideal patient" has a pronounced constriction of the spinal canal, insignificant lower back pain, no concomitant disease affecting walking ability, and a symptom duration of less than 4 years.     

Hypoglossal nerve injury caused by halo-suspension traction. A case report

STUDY DESIGN: A case report of injury to the hypoglossal nerve (CN XII) resulting from the use of halogravity traction in a child with severe cervicothoracic kyphosis after an anterior and posterior spinal release. OBJECTIVE: To describe one of the potential dangers of halo-suspension (gravity) traction, which has not been reported previously in the orthopedic literature. SUMMARY OF BACKGROUND DATA: Cranial nerve injuries resulting from halo-skeletal traction are a recognized complication of such treatment, especially in patients with myelomeningocele. Halo-suspension traction using the patient's body weight as counter-traction has been recommended to provide a less rigid force and to reduce complications. METHODS: The authors report on the mechanism of injury and clinical course in a 12-year-old boy with myelomeningocele and a bilateral CN XII injury caused by halo-suspension traction from onset to resolution. RESULTS: This patient had dysphagia and difficulty swallowing 5 days after surgery. His wheelchair traction at this point was approximately 40% of his body weight. The traction was reduced, and a corticosteroid was administered. The patient's symptoms began to abate 5 days later. At 6 weeks after injury, his cranial nerve function was normal. CONCLUSIONS: Although halo-suspension traction or halo-wheelchair traction may be less rigid, injury to the hypoglossal nerve can be produced with traction exceeding 40% of body weight. In the patient in the current report, resolution of this injury was complete within 5 weeks, an outcome that is consistent with those of other reported cases of CN XII injury.     

Suppression of sympathetic nervous system during fasting

We describe 3 patients within whom ocular torsion could be induced by application of positive air pressure to one external ear canal. In all cases, the superior pole of the eye rotated away from the stimulated ear when positive pressure was applied. The amplitude of torsion ranged from 3 degrees to 16 degrees. Exploratory tympanotomy was performed in all 3 patients. In 2 patients, round-window fistulas were found and repaired. In the third patient, no fistula was noted but the oval- and round-window areas were patched. There was no resolution of symptoms after surgery in any patient. Based on these cases, patients presenting with pressure-induced ocular torsion are unlikely to have resolution of their symptoms, even when a perilymphatic fistula is confirmed and repaired. We hypothesize that pressure-induced ocular torsion is caused by an irreversible juxtaposition of the utricle and stapes footplate.     

Occlusion of the semicircular canal using argon laser

The effects of argon laser on the bony semicircular canals were studied in the guinea pig. After intraperitoneal administration of Nembutal, the bulla was opened in order to approach the lateral and posterior canals. The anterior canal was approached through the posterior fossa. The argon laser was applied through a probe which was connected to a device from HGM Medical Laser Systems. One of the three semicircular canals was irradiated one to several times by argon laser (1.0-1.5 W x 0.5 sec). Histopathologic examination of the temporal bones revealed that the semicircular duct shrank immediately after irradiation. The laser produced a charred area in the bony canal wall. The semicircular canals gradually became fibrotic and ossified and completely occluded within several weeks. Heat produced in the bony canal may be responsible for the morphologic changes. On delayed observation, the cochlea of the canal-irradiated animals showed no morphologic changes. Auditory brain stem responses were normal. Caloric stimulation using 5 ml/5 sec of ice water revealed no response in the lateral canal-irradiated animals.     

Appendiceal ultrasonography performed by nonradiologists: does it help in the diagnostic process?

OBJECTIVE: In this study, the effects of pulsed Nd:YAG laser irradiation during root canal treatment of infected teeth were investigated histopathologically in dogs. SUMMARY BACKGROUND DATA: Effects of Nd:YAG laser on infected root canal treatment have not been reported in vivo. METHODS: One hundred thirty-five teeth with a single root, including incisors and premolars, in 15 healthy adult beagle-strain dogs were used in this study. After inducing infection in the teeth, each root canal was shaped with at least a # 40 K-file, then the canal was irradiated using the following parameters: 1 W, 30 pps for 1 and 2 sec; 2 W, 30 pps for 1 and 2 sec. Efficacy of debris removal and evaporation on the root canal walls at 2 weeks, and the degree of inflammation of the periapical region at 2, 4, and 8 weeks after laser irradiation were examined histopathologically by light microscopy. RESULTS: Effective debris removal was observed in all cases of the laser-treated groups. No evaporation was observed except at the conditions of 2 W for 2 sec. Inflammation of periapical region in the laser-treated groups was similar in the control group at 2 weeks, but was significantly less than that in the control group at 8 weeks (p < 0.05). CONCLUSION: These results suggest that pulsed Nd:YAG laser is useful for one-visit root canal treatment of infected teeth in dogs, if appropriate parameters are selected, and this is a potential therapy for human apical lesions of teeth.     

High-output heart failure due to a renal arteriovenous fistula in a pregnant woman with suspected preeclampsia

A 29-year-old nulliparous woman had development of hypertension, proteinuria, and congestive heart failure during the third trimester of her pregnancy. Her symptoms and cardiovascular changes were consistent with congestive heart failure and severe preeclampsia. The underlying pathophysiology was believed to be caused by the high-output state of pregnancy and by the increased peripheral vascular resistance of preeclampsia. The patient underwent an elective cesarean section, but her cardiovascular symptoms did not resolve. Soon after delivery, the patient was found to have an arteriovenous fistula of the right renal artery that caused the high-output cardiac state. Embolization and surgical removal of the arteriovenous fistula resulted in complete resolution of the patient's high-output heart failure. All previously reported cases of renal arteriovenous fistulas and malformations that have occurred during pregnancy are reviewed.     

Fournier''s gangrene

OBJECTIVE: To evaluate the therapeutic efficacy of decompression of optic nerve canal in the eye with indirect nerve injury in the optic nerve canal. METHODS: 121 patients with indirect injury of optic nerve in the canal were selected and decompression of optic nerve canal was performed on them. Then the outcomes were reviewed and analyzed. RESULTS: Visual acuities of 76 patients (62.81%) were improved. CONCLUSION: It is obvious that decompression of optic nerve canal is associated with significant improvement in cases with good preoperative vision. In cases without light perception, treatment of steroids and dehydrant should be firstly applied, afterwards according to the patient's individual situation, selectively the case is to perform the operation. Thus the therapeutic effectiveness can be greatly elevated. Decompression of optic nerve canal is safe and reliable.     

Pharyngeal reconstruction after laryngectomy

A method of pharyngeal reconstruction following laryngectomy is described. In 44 successive laryngectomies using this technique, no postoperative pharyngocutaneous fistulas occurred. Ten of the patients had received full courses of radiation therapy prior to the surgical procedure and had recurrent carcinomas. Other reports have noted that laryngectomy following full courses of "unplanned preoperative" radiation therapy is usually associated with a high incidence of postoperative pharyngeal fistula. The pharyngeal fistula problem, and the pharyngeal repair that was used in our series, are discussed. The pharynx was closed carefully in three layers with fine, absorbable sutures, and a submucosal inverting technique was used for the important mucous membrane closure. Tube feedings were used for two weeks after surgery. A high incidence of pharyngocutaneous fistula after laryngectomy in the irradiated patient can be prevented.     

Compression of the ulnar nerve at the wrist (author's transl)

Compressions of the ulnar nerve at the wrist in or beyond the canal de Guyon are comparative rare. Those originating from compression in the sulcus ulnaris at the elbow are much more common. The clinical symptoms are typical: Weakness of the small muscles of the hand, loss of sensibility and pain. The diagnosis can be made on the clinical picture. It has to be confirmed by electromyography. Surgery should be performed as early as possible to avoid permanent damage to the nerve. Any delay can cause irreversible loss of function of the ulnar nerve. As causes of the compression of the ulnar nerve tumours, inflammation of the sourrounding tissue or trauma have been described. In this paper we report about compression of the ulnar nerve in the canal de Guyon due to a thrombosed aneurysme of the ulnar artery. This condition is quite rare. It is characterized through sudden onset of pain in the hand. Immediate surgery with decompression of the nerve, as we did in our case, will result in complete recovery.     

Transconjunctival application of mitomycin C in combination with laser sclerostomy ab interno: a long-term morphological study of the postoperative healing process

The precise mechanism whereby mitomycin C enhances IOP reduction in glaucoma filtering surgery still eludes us. Ten rabbits received full-thickness Nd:YAG laser sclerostomy ab interno and adjunctive intraoperative treatment with mitomycin C (MMC) applied topically over the intact conjunctiva (0.5 mg ml-1 for 5 min). A systematic ultrastructural analysis of the fistulas and surrounding tissue was then conducted in conjunction with clinical observations, over the ensuing 10 weeks. In order to investigate also the extent to which MMC impedes fistula occlusion in the absence of percolating aqueous humour, we created non-perforating ('half-thickness') sclerostomies ab interno in three additional rabbits, one with and two without MMC therapy. Transconjunctival MMC application resulted in no serious complications. Eight of the ten full-thickness fistulas remained patent throughout the study, maintaining significant IOP reduction; the other two sclerostomies were compromised by iris incarceration. The MMC-treated, half-thickness canal remained as a tissue-free cul de sac; the two non-treated ones became completely occluded within one week without having recourse to extraocular cell populations. MMC suppressed the migration and proliferation of fibroblasts, macrophages and clump cells from the episclera, sclera, ciliary body and iris root. Repolymerization of heat-damaged collagen was abortive; neosynthesis was not observed. Myofibroblasts were encountered in the vicinity of the sclerostomy canals, and, after the fifth week, these cells were also found to be deployed as a canal-lining layer, delimiting the lumen from the surrounding stroma along most of the fistula length. Towards the external ostium, this layer of myofibroblasts was incomplete or absent. Near the internal ostium, lining cells were derived from the corneal endothelium. The transconjunctival mode of applying MMC appears to be efficient. This antifibrotic drug exerts its inhibitory influence by suppressing not only cell migration and proliferation, but also phagocytic and synthetic activities. However, exposed tissues are not acellular, and amongst the populations present, myofibroblasts are found to dominate the scene. The canal-delimiting cellular lining may play a role in maintaining fistula patency in MMC-treated eyes.     

Prospects in video-assisted spinal surgery

Advances in spinal surgery for both posterior procedures on herniated discs and anterior procedures involving the vertebral body have been greatly affected by developments in video-assisted techniques. Many of the procedures mentioned here are still in the development stage, others have proven their efficacy. Discoscopy, achieved by introducing the endoscope via a posterolateral route into the intervertebral disc, can be used for diagnosis and treatment of the disc and the end plates. Other techniques exploring the spinal canal are also being developed. With miniaturization, these techniques will undoubtedly be predominant in the near future. The anterior route is facilitated at the thoracic level by the pleural cavity. Current indications for anterior endoscopic spinal surgery are limited to cord compression syndromes, but perspectives for trauma or tumor surgery as well as reconstruction surgery for malformations in children are quite promising. On the lumbar level, surgery involving the lombo-sacral disc is the main indication for transperitoneal endoscopy. The risks (sepsis, occlusion, gas emboli) cannot be overlooked, but few complications have been observed to date. The retroperitoneal route can be used to approach the anterolateral aspect of the spine, particularly useful for the upper lumbar bodies. A third possibility is the extraperitoneal anterior route for video-assisted procedures from L2-L3 to L5-S1. Although video-assisted procedures have not yet been shown to improve long-term outcome after spinal surgery, the immediate post-operative period is greatly simplified, a point which may be of particular importance depending on the patient's general status.     

A case of persistent manic depressive illness induced by interferon-alfa in the treatment of chronic hepatitis C

Hemodialysis-associated subclavian venous stenosis should be suspected when upper extremity edema occurs after a graft or fistula has been placed there. Alternatively, venous thoracic outlet syndrome could also produce venous congestion, simulating subclavian stenosis. The latter diagnosis was unsuspected until central subclavian vein obstruction on venography became complete, with the arm passively hyperabducted. The patient's symptoms resolved after surgical decompression. Causes of thoracic outlet obstruction are reviewed.     

Primary lymphoma of the liver with bile duct invasion and tumoral occlusion of the portal vein: report of a case

Vertebral artery tortuosity and loop formation are rare causes of cervical radiculopathy. The authors present the case of a 70-year-old man with 9 years of progressive right-sided cervical and scapular pain but no history of trauma. Computerized tomography myelography and magnetic resonance imaging revealed an ovoid mass in the right C3-4 intervertebral foramen. The patient underwent a right C-3 and C-4 hemilaminectomy and a complete C3-4 facetectomy. A pulsatile vascular structure was found compressing the right C-4 nerve root. The bone overlying the vascular structure was removed, producing decompression of the nerve root. Immediate postoperative angiography showed that this lesion was a focal vertebral artery loop. The patient's symptoms resolved after surgery, supporting the use of vascular decompression of a cervical nerve root compressed by a vertebral artery loop for the relief of radicular symptoms.     

Deglutition in patients treated with reconstructive laryngectomy]

BACKGROUND: Chronic papilledema may lead to irreversible damage of optic nerve fibers. To preserve visual functions, a decompression of the optic nerve is recommended by means of a fenestration of the optic nerve sheath. In this study long-term results after optic nerve sheath fenestration in patients with idiopathic pseudotumor cerebri are reported. PATIENTS AND METHODS: 14 patients were re-examined 15 to 145 months (mean 62 months) after a fenestration of the retrobulbar optic nerve sheath on 23 eyes by a transconjunctival approach. Surgery was done to treat progressive visual loss or in severe obscurations. The patient's symptoms, visual acuity, visual fields, and ophthalmoscopic findings of the optic nerve head and the central fundus were compared to the preoperative status. RESULTS: Re-examination revealed improvement or stabilisation of objective and subjective findings in 17 eyes, one of them was operated on the more involved contralateral side only. Six eyes showed a recurrence of the papilledema without a functional change for the worse after an interval of 7 to 121 months. Three eyes of two patients ended up with optic atrophy and extensive visual loss. Preoperatively, these eyes had shown cotton wool spots in the optic nerve head and a rapid deterioration of vision. CONCLUSIONS: Fenestration of the retrobulbar optic nerve sheath can prevent further visual loss in most patients with pseudotumor cerebri, unless the eye has already become nearly blind. Postoperatively, ophthalmological controls are necessary at regular intervals because relapses after successful surgery can occur after months or years.     

Cat-scratch disease presenting as an epitrochlear arm mass

Delayed sciatic neuropathy due to pelvic reconstruction plate loosening following complex acetabular reconstruction in total hip arthroplasty seems not be have been previously reported. We identified a 79-year-old woman who developed progressive neurologic signs of entrapment 6 months following reconstruction of a pelvic discontinuity due to fracture nonunion caused by radiation necrosis. Magnetic resonance imaging of the lumbar spine was unrevealing and electromyography demonstrated a peripheral neurogenic process involving the sciatic nerve. Sciatic nerve exploration was done at 12 months after surgery finding a loose screw in the pelvic plate impinging the nerve. Substantial improvement in clinical symptoms resulted from removal and nerve release.     

Is transglutaminase the mediator between antimalarial drugs and psoriasis?

The object of this experimental study was to investigate the influence of low-energy He-Ne laser on the motor nerve cells of the spinal cord. The experimental study included as follws: (1) Four rabbits were used in this experiment. The L5-6 spinal cord segment was irradiated by He-Ne laser percutaneously, the nerve velocity of the comon peroneal nerve was measured in order to determine the function of the spinal motor nerve cells when the peripheral nerve was intact. (2) The common peroneal nerve was transected on one side wothout repair, two weeks after laser irradiation, the grey mater of the spinal cord of L5-6 segment was procured for electronic microscopic examination. (3) The common peroneal nerve on the contralateral side was transected and followed by end-to-end anastomosis, and laser irradiation was done on the same spinal cord segment. Two weeks after irradiation, the nerve velocity of the common peroneal nerve and the toe expanding test were investigated. The results were: (1) the He-Ne laser can influence the spinal motor nerve cells function as expressed by latent rate when the peripherial nerve is intact. i.e. the nerve velocity is slower than mormal, and the amplitude is markedly decreared. (2) the change of the microstructure of the spinal motor nerve cells is comparatively slight in the 10 and 15 minutes groups. (3) the recovery of the nerve velocity and the toe expansion are more earlier in the 15 min. group. In short, the low-energy He-Ne laser can influence the function of the spinal motor nerve cells.     

Clinical analysis of two-level compression of the cauda equina and the nerve roots in lumbar spinal canal stenosis

STUDY DESIGN: This study is a prospective, clinical study assessing the efficacy of selective decompression of the responsible level in two-level stenosis in accordance with neurologic findings defined by the gait load test, and functional diagnosis based on selective nerve root block. OBJECTIVE: To clarify the clinical features of two-level stenosis regarding the neurologic level responsible for the symptoms, neurogenic intermittent claudication, and the outcome of selective decompression. SUMMARY OF BACKGROUND DATA: Experimental studies have indicated that double-level compression of the cauda equina induces a more severe impairment of nerve function than does single-level compression. However, few studies have focused on the clinical importance of two-level stenosis. The clinical effects of two-level stenosis on the cauda equina and nerve roots are unknown. METHODS: A total of 81 patients with lumbar spinal canal stenosis due to spondylosis and degenerative spondylolisthesis were divided into two groups, two-level stenosis at L3-L4 and L4-L5, and one-level stenosis at L4-L5, based on myelography. The types of neurogenic intermittent claudication, the level responsible for neurologic findings, and the postsurgical outcome were compared between both groups. The level responsible for the symptoms in two-level stenosis was determined in accordance with neurologic findings on the gait load test and functional diagnosis based on a selective nerve root block. All patients underwent a prospective, selective decompression at the neurologically responsible level only. The average follow-up period was 4.6 years (range, 1-8 years). RESULTS: The patients with two-level stenosis more frequently had cauda equina symptoms than those with one-level stenosis, except patients with degenerative spondylolisthesis. It was therefore assumed that two-level stenosis was associated with cauda equina impairment, Changes in neurologic condition before and after the gait test were observed in four patients with two-level stenosis. Finally, for 28 patients with two-level stenosis, the levels responsible for the neurologic symptoms were the caudal level (L4-L5) in 22 patients, the cranial level (L3-L4) in 1 patient, and both cranial and caudal levels (L3-L4 and L4-L5) in 5 patients. All stenotic levels on the myelogram were not always symptomatic in two-level stenosis. However, in one-level stenosis, all of the responsible levels completely corresponded to the myelogram. Selective decompression only at the neurologically responsible level improved neurogenic intermittent claudication in all patients. The asymptomatic levels at which the stenotic condition was left unchanged at surgery did not become symptomatic at follow-up; in addition, there was no significant difference in the postoperative outcome between two-level stenosis and one-level stenosis. CONCLUSIONS: Two-level stenosis in patients with lumbar spondylosis is associated with production of cauda equina lesions. The gait load test provides information regarding changes in symptoms and neurologic condition during exercise. The responsible levels should be determined based on neurologic findings after the gait load test and a selective nerve root block. It is uncommon for both stenotic levels to be symptomatic in patients with two-level stenosis. Less invasive surgery such as selective decompression for the responsible level in patients with two-level stenosis is a useful technique with a good potential for long-term success.     

Transfixion of cervical cord by a glass fragment--report of a case (author's transl)

Stab wound of the spinal cord caused by accident occurred in the home life is rare absolutely. One case of stab wound of the cervical spinal cord caused by penetrated and retained glass fragment within the spinal canal was reported. A 30-year-old woman was hospitarized on August 16, 1971. with complaint of left hemiparesis, gait disturbance and sensory impairment on the right side. A glass door fell down on the patient's neck on April 14, 1971. and one glass fragment was removed from the patient's left neck by one of the patient's family and no immediate spinal cord symptom appeared and no physician was consulted at that time. One and a half month after the injury the patient rod a motor bicycle and pain and severe stiffness in the shoulder and neck, and headache. These subjective symptom disappeared by rest and same subjective symptom repeated in following five days. Three and a half months after the injury the patient found sensation loss in the right foot and gait distrubance appeared. After the sensory impairment extended to the cervical level which was accompanied by left hemiparesis. On examination, the patient was found to have merked weakness of left limbs, spastic gait and severe impairment of touchpain- and thermosensation below the fifth cervical level but deep sensation was preserved. All tendon reflexes showed marked exaggeration and pathological reflexes were proved. Roentgenograms of the cervical spine revealed a long triangular glass fragment which had been retained in the spinal canal between the first and second cervical vertebrae. The air myelogram suggested the glass fragment had transfixed the cervical spinal cord. Laminectomy was performed and the glass fragment which had a shape of a sharp pointed surgical knife was removed by gentle move in the opposite direction of invation. Following removal of the foreign body, the patient's left hemiparesis recovered to normal state at four months after the operation and right sensory impairment also improved. The cervical spinal cord may be injured in the following way: the right lateral spinothalamic tract may be injured by the skewer injury due to glass fragment but injury of the left same tract may be avoided because of oblique direction of penetration of the glass fragment in the spinal cord. On the other hand, the left pyramidal tract may be compressed by glass fragment and not injured, because left hemiparesis recovered very well postoperatively.     

Compression of the common digital nerve in the palm of the hand: a case report

A case in which the common digital nerve to the radial side of the ring finger was compressed by a fascial band in the palm of the hand is reported. The patient's symptoms disappeared after transection of the band.