Object. This study was undertaken to evaluate the long-term benefit in 202 patients who were surgically treated via a microsurgical far-lateral approach for foraminal or extraforaminal lumbar disc herniations.Methods. All patients underwent surgery at the authors' institute since 1987 and represented 6.5% of all lumbar spinal disc surgeries. There were 67 women and 135 men who ranged in age from 19 to 78 years (mean age 58 years). All patients had unilateral leg pain due to lumbar disc herniations into or lateral to the lateral interpedicular compartment. One patient underwent surgery at the L1–2 level, nine at L2–3, 48 at L3–4, 86 at L4–5, and 58 at the L5—S1 level. The mean follow-up period was 50 months (range 12–120 months). Outcome was defined as excellent (no pain), good (some back pain), fair (moderate radiculopathy), and poor (unchanged or worse) based on Macnab classification. Overall, excellent and good results were achieved in 62 (31%) and 85 (42%) patients, respectively, and fair and poor results in 40 (20%) and 15 (7%) patients, respectively. Of 11 recurrent disc herniations, four presented in an extreme-lateral position, five in a paramedian location, and two on the contralateral side. There were three minor complications related to surgery, seven general complications, and no case of spinal instability.Conclusions. The far-lateral approach is a safe, effective procedure that avoids the risk of secondary spinal instability.
The anatomy of the lateral aspect of the lumbar spine and our lateral microsurgical technique for extreme lateral lumbar disc herniations (ELLDH) is described. This study was based on the microdissection of 4 cadavers, on the morphometric evaluation of these as well as 6 dried cadaver spines and 8 lumbar CT scans, and on the use of this technique on over 200 cases. Level dependent changes in the posterior arch cause a shift of the disc space distally relative to the facet joint, an increasing amount of bone to overlie the intervertebral foramen, and a decreasing amount of working space within the exposure in the caudal direction. Therefore, more bone removal from the lateral aspect of the pars interarticularis and supero-lateral aspect of the facet joint is required in the lower lumbar spine. When the exposed ligamentum flavum is resected, the dorsal root ganglion is seen and access to the herniation and disc space is achieved. Level dependent changes in the pedicles and transverse processes lead to an alteration in the course and relationships of the nerves, thereby influencing the pathophysiology of and surgical technique for the ELLDH. The operative target is the lateral aspect of the pars interarticularis and not the intertransverse space as has been previously described. Our techniques allows for the early identification of the nerve with minimal risks of injury to it, to the adjacent vessels and to the structural integrity of the facet joint and pars interarticularis.
This prospective study is based on 256 patients with severe brain injury. Six patients (2.3%) developed the clinical picture of inappropriate secretion of antidiuretic hormone (SIADH): 3 in the first 3 days following the injury, 3 after more than a week. Their ADH plasmatic level were measured by radio-immunoassay. In the former, many factors, largely iatrogenic, can explain the increased secretion of ADH we found and which is then definitely "appropriate". It should be prevented by fluid restriction. In the latter, we found adequately low ADH levels, when the hypo-osmolarity is taken into account. Here, the aetiology seems to be a renal salt loss, eventually in relation to a natriuric factor (e.g. atrial natriuretic factor), justifying the term: "Cerebral salt wasting syndrome". With the resistance to fluid restriction, the treatment still remains a problem.
Cavernous hemangiomas can grow extra-axially within dural sinuses, particularly the cavernous sinus and present like tumours. Five cases of cavernous hemangiomas arising within or from the wall of the cavernous sinus are reported. Three of them had an "endophytic" growth within the cavernous sinus with a lateral extension into the middle cranial fossa, a medial extension into the sella and an anterior extension into the superior orbital fissure. Two cases presented with an "exophytic" extension from the sinus wall at the point of entry of the third and fourth cranial nerves respectively. These patterns of growths are best appreciated by MRI. Keeping in mind that these lesions are contained within a pseudocapsule will help in planing surgical strategy. Characteristic MRI findings of cavernous hemangiomas in this location include hypo-intensity on T 1-weighted images, marked hyperintensity on T2-weighted images and Gadolinium enhancement.
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