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Surgical treatment of bone metastases from kidney cancer is often complicated by profuse blood loss. The authors report the results of a retrospective review of 30 consecutive patients who underwent surgery for spinal metastases from kidney cancer. Seventeen patients (57%) were operated on after failing radiation therapy. Prior to operation, selective spinal angiography and embolization were performed in 17 patients with no permanent neurological deficits resulting. Gross total resection of the tumor and stabilization of the spine were then accomplished with acceptable blood loss. Twenty-seven (90%) of the 30 patients improved neurologically following surgery. There was a median survival time of 16 months, a 2-year survival rate of 33%, and a 5-year survival rate of 15%. Major surgical complications in this series were related to excessive blood loss in patients without embolization. These data suggest that patients with spinal metastases from kidney cancer should undergo spinal angiography and embolization prior to resection of the tumor. To improve upon current results, such treatment should be carried out prior to external radiation therapy.

Seventeen patients were treated for 28 documented cerebral mycotic aneurysms. Initial neurological symptoms were attributable to aneurysm rupture in only 7 patients, and in 3 of them symptoms did not suggest subarachnoid hemorrhage. Six patients presented with embolic infarction and 1 with meningitis; in 3 patients it was uncertain if aneurysm rupture occurred. Four patients had rupture of at least one aneurysm while receiving appropriate antibiotic treatment and another had rupture at the conclusion of therapy. Of 20 aneurysms followed angiographically or with computed tomography during medical treatment, 10 became smaller or disappeared and 10 remained unchanged or enlarged, 1 with fatal rupture. Eight ruptured aneurysms were surgically excised; 2 of the patients with ruptured aneurysms died and 2 had residual aphasia or cognitive impairment. All 4 patients whose only surgery was for an unruptured aneurysm made uneventful recoveries. Recognizing the retrospective and anecdotal nature of our data and the differing views of previous investigators, we recommend: (1) that careful neurological examination, computed tomography, and (unless contraindicated) lumbar puncture be performed on any patient with endocarditis; (2) that those with neurological abnormalities not attributable to systemic toxicity, including pleocytosis in the cerebrospinal fluid or apparent infarction on computed tomographic scans, undergo four-vessel cerebral angiography; (3) that single accessible mycotic aneurysms in medically stable patients be promptly excised, with individualization of multiple or proximal aneurysms; and (4) that repeat angiography be performed at the conclusion of antibiotic therapy in patients requiring long-term anticoagulation.(ABSTRACT TRUNCATED AT 250 WORDS)

Spondylectomy is the complete surgical removal of all parts of one or more vertebrae above the sacrum. We report our initial experience with spondylectomy in eight patients with malignant tumors of the spine operated on over a 7-year period (1980 to 1986). Four patients had primary neoplasms of the spine, and four others had solitary metastases to the vertebrae. Following surgery, five patients underwent radiation therapy (RT) and chemotherapy depending on histology of the tumor. Radiographic confirmation of tumor resection was obtained on all patients. Pain relief was noted in all patients, and six patients with preoperative neurological deficits improved. There was no surgical mortality, and one patient developed wound dehiscence following surgery. Six of the eight patients are alive with a median follow-up of 36 months, and local control was achieved in six of the eight patients. These preliminary data suggest that malignant tumors of the spine can be completely resected using a staged approach. In potentially responsive tumors, systemic chemotherapy is recommended between the two operations to reduce the risk of systemic dissemination.

Endothelial toxicity occurs at the right time and with the appropriate pathophysiology to contribute to MGK. Based on these findings, we propose a model that explains the relationships among SM dose, the biphasic progression, and the various clinical trajectories of corneal SM injury and that provides a mechanism for temporal variations in MGK onset. Finally, we discuss the implications for the management of SM casualties.

Currently, external radiation and steroid therapy are used in most patients with neoplastic spinal cord compression. Surgery is generally used to treat those who do not respond to radiation therapy. To determine the role of de novo surgery in patients with spinal metastases, a prospective study was undertaken. Over a 4 1/2-year period, the cases of 54 patients with radiologically documented spinal metastases were studied. The sites of tumor origin included soft tissue sarcoma (8 patients), kidney (6 patients), lung (5 patients), breast (5 patients), spine (6 patients), unknown primary site (6 patients), and others (18 patients). Sites of compression included the cervical spine segments in 15 patients, thoracic segments in 23, lumbar in 14, and sacral in 2. Before surgery, 24 patients (44%) were nonambulatory. Three surgical approaches were used: anterior vertebral body resection in 45 patients, laminectomy in 7, and lateral osteotomy in 2. After surgery, 37 patients received external radiation therapy. All patients improved (became ambulatory) after surgery, with 23 of 25 patients surviving at 2 years continuing to be ambulatory. The 30-day mortality rate was 6% (three patients); eight patients (15%) sustained various surgical complications. These results are superior to those reported after external radiation therapy and steroids alone, and they support the concept that de novo surgery be considered in selected patients with spinal metastases.

A patient with cerebral trauma recovered considerably from the resulting anterograde but not retrograde amnesia. The persistence of retrograde amnesia is attributed to a lesion in the ventral tegmental region, which suggests a role for mesencephalic reticular activation in long-term retrieval.