We sought to determine whether patterns of ictal hyperfusion demonstrated using [99mTC]HMPAO (hexamethylpropylene amine oxime) single photon emission computed tomography (SPECT) predict outcome of temporal lobectomy; in particular, whether the more extensive patterns of ictal hyperperfusion are associated with poor outcome. We studied 63 patients who had ictal SPECT studies prior to temporal lobectomy. Hyperperfusion on ictal SPECT scans was lateralized, and classified into: (i) 'typical', (ii) 'typical with posterior extension', (iii) 'bilateral' and (iv) 'atypical' patterns. Outcome (minimum of 2 years follow-up) was classified as either seizure free, or not seizure free. Actuarial analysis was used to test the relationship of SPECT patterns with outcome. There were 35 cases with the typical ictal SPECT pattern, 13 posterior, nine bilateral and six atypical cases. The atypical pattern was associated with lack of pathology in the surgical specimen. Outcome was similar for the typical, posterior and bilateral with 60%, 69% and 67% seizure free, respectively. In contrast, the atypical group had a worse outcome with only 33% seizure free. Actuarial analysis showed a significant difference in outcome between patients with the typical pattern, and patients with the atypical pattern (P = 0.04). We conclude that extended patterns of ictal perfusion in temporal lobe epilepsy do not predict poor outcome, indicating that extended hyperperfusion probably represents seizure propagation pathways rather than intrinsically epileptogenic tissue. Atypical patterns of hyperperfusion are associated with poor outcome and may indicate diffuse or extra-temporal epileptogenicity.
Twenty-six cases of chronic intrathecal morphine administration are described: 19 cases utilizing the Spinalgesic injectable subcutaneous reservoir and 7 cases utilizing the Infusaid implanted infusion pump. In 25 cases, the morphine was delivered into the spinal subarachnoid space, and in 1 case of thalamic pain it was delivered into the temporal horn of the ipsilateral cerebral ventricle. The average duration of usage of the system was 132 days. The efficacy of the method was excellent: 23 of 26 patients used no other analgesics or only minor ones such as aspirin, paracetamol, or dextropropoxyphene. The complication rate was low, with no infections under the author's care, and only 4 catheter blockages (1 by tumor). There have been no complications in the 7 patients with implanted pumps. From this experience, the author concludes that the implanted pump is now the method of choice in all patients who can afford it and for whom the life expectancy outside an institution is in excess of 60 days. A special and relatively absolute indication for the pump is the situation of pain in the arm, head, or neck areas, in which case the constant morphine levels likely to be achieved with the pump may prevent failure of the method due to intractable nausea or emesis. The subcutaneous reservoir is otherwise to be preferred if the patient's disease is progressing rapidly, if the patient is already institutionalized and likely to remain so, or where the cost of the implanted pump would cause hardship. Either method of delivery of morphine to the subarachnoid space can provide incomparable analgesia without clouding of consciousness, with a very low complication rate.
A titanium rod and buttress prosthesis may be a faster and easier alternative to conventional iliac crest/fibula autograft after multisegmental cervical vertebral corpectomy.
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