Study Design. A meta-analysis of surgical outcomes of cauda equina syndrome secondary to lumbar disc herniation. Objectives. To determine the relationship between time to decompression after onset of cauda equina syndrome and clinical outcome, and to identify preoperative variables that were associated with outcomes. Summary of Background Data. The timing of surgical decompression for cauda equina syndrome is controversial. Although most surgeons recommend emergent decompression, results in certain studies show that delayed surgery may provide a satisfactory outcome. Methods. A meta-analysis was performed to determine the correlation between timing of decompression and clinical outcome. One hundred four citations were reviewed, and 42 met the inclusion criteria. Preoperative and postoperative data were recorded. Length of time to surgery was broken down into five groups: less than 24 hours, 24-48 hours, 2-10 days, 11 days to 1 month, and more than 1 month. Logistic regression was used to determine the association between preoperative variables and postoperative outcomes. Results. Outcomes were analyzed in 322 patients. Preoperative chronic back pain was associated with poorer outcomes in urinary and rectal function, and preoperative rectal dysfunction was associated with worsened outcome in urinary continence. In addition, increasing age was associated with poorer postoperative sexual function. No significant improvement in surgical outcome was identified with intervention less than 24 hours from the onset of cauda equina syndrome compared with patients treated within 24-48 hours. Similarly, no difference in outcome occurred in patients treated more than 48 hours after the onset of symptoms. Significant differences, however, were found in resolution of sensory and motor deficits as well as urinary and rectal function in patients treated within 48 hours compared with those treated more than 48 hours after onset of symptoms. Conclusions. There was a significant advantage to treating patients within 48 hours versus more than 48 hours after the onset of cauda equina syndrome. A significant improvement in sensory and motor deficits as well as urinary and rectal function occurred in patientswho underwent decompression within 48 hours versus after 48 hours.

Cauda equina syndrome secondary to lumbar disc herniation: a meta-analysis of surgical outcomes.

Cognitive impairment and decline are associated with asymptomatic high-grade stenosis of the left internal carotid artery but not the right carotid artery. The lack of association with right-sided ...

Cognitive Impairment and Decline Are Associated with Carotid Artery Disease in Patients without Clinically Evident Cerebrovascular Disease

• The Nocturnal Oxygen Therapy Trial (NOTT) showed previously that patients with hypoxemic chronic obstructive pulmonary disease (COPD) frequently suffered from neuropsychologic deficit and experienced disturbed mood, personality, and life quality. The present study has followed up 150 NOTT patients six months after they were randomized to continuous oxygen treatment (COT) or nocturnal oxygen treatment (NOT). Tested off oxygen, 42% showed modest neuropsychologic improvement after six months of therapy, and the rates for COT and NOT were comparable. A subsample (n = 37) was examined a third time, after 12 months of treatment. At this point patients receiving COT registered better neuropsychologic performance than those receiving NOT. Concurrently, the COT group began showing improved survival. Despite mild neuropsychologic improvement, patients reported little change in emotional status or life quality. It is concluded that prolonged oxygen treatment is associated with small but definite improvement in brain functioning among patients with hypoxemic COPD, and that COT might have some advantage over NOT in enhancing neuropsychologic functioning as well as survival. (Arch Intern Med1983;143:1941-1947)

Psychologic Effects of Continuous and Nocturnal Oxygen Therapy in Hypoxemic Chronic Obstructive Pulmonary Disease

Increasingly, psychological assessment is conducted with clients and patients involved in child custody and personal injury litigation. Clinical neuropsychologists are being asked sophisticated questions by attorneys regarding the validity of practitioners' most highly respected tests. Research reviewed here bears on the validity of test-buttressed clinical opinions, including research related to the following psychometric properties of individual test scores: standard errors of measurement, test-retest stability and subtest-to-subtest intercorrelations. The highest and the lowest subtest scores used as indices, respectively, of an individual's premorbid level of cognitive functioning and the degree of current impairment from that presumed earlier level is not justified when used in isolation from the life history and current medical findings. Although many practitioners use information from the wider research, courtroom experience suggests that a number do not; contrariwise, the attempt of Faust and Ziskin (1988a) to undermine the courtroom testimony of every psychologist who serves as an expert witness is also criticized.

Psychological assessment versus psychological testing. Validation from Binet to the school, clinic, and courtroom

The configuration of the intracranial pressure (ICP) pulse wave represents a complex sum of various components. Amplitude variations of an isolated component might reflect changes in a specific intracranial structure. Fifteen awake patients suffering from hydrocephalus, benign intracranial hypertension, or head injury underwent ICP monitoring through a ventricular catheter and were subjected to three standardized maneuvers to alter the intracranial dynamics: head elevation, voluntary hyperventilation, and cerebrospinal fluid (CSF) withdrawal. A 12 degrees head elevation and fractionated CSF withdrawal caused a mild ICP drop and a proportionate amplitude reduction of all the wave components. Voluntary hyperventilation caused a comparable fall in ICP, and a disproportionate reduction in the amplitude of the wave components, especially the P2 component. It is postulated that the decrease in amplitude of the P2 component reflects the reduction of the cerebral bulk caused by hyperventilation. Head elevation and CSF withdrawal caused a decrease of global ICP but no specific changes in any intracranial structure, and consequently the configuration of the pulse wave remained unchanged. The establishment of relationships between anatomical substrate and particular wave components is promising since potentially it could be useful for monitoring conditions such as vasoparalysis, impaired cerebrovascular reactivity, and cerebral edema.

Analysis of the cerebrospinal fluid pulse wave in intracranial pressure

Recently published studies have reported clinically significant increases in cognitive functioning in humans following surgical removal of obstructive atheromatous placque from the carotid artery leading from the heart to the brain. Detailed study by us of test-retest changes in group means in our own setting as well as scrutiny of similar test-retest scores for each individual patient comprizing our group of 17 carotid endarterectomy patients, and comparing them to similar detailed analyses in our one normal sample and two additional patient samples which served as reference groups, failed to confirm these earlier reported findings. Rather, our test-retest results with the full WAIS and 11 measures from the Halstead-Reitan Battery were little different from the test-retest changes found in these three reference groups which underwent no surgery. We concluded that the clinically unremarkable changes found in our endarterectomy and three reference samples are little different from the test-retest ...

IQ and neuropsychological changes following carotid endarterectomy

Nasal dermoid cysts with intracranial extension have been thought to be a rare entity. Seven new cases of nasal dermoid cyst with intracranial involvement were treated from 1975 through 1982 by combined otolaryngological-neurosurgical management. Preoperative radiological studies were helpful in predicting intracranial extension in only three cases. The extracranial lesion was resected by the otolaryngologist using surgical hemoclips to tag the dermoid remnant entering the cranium. These hemoclips were a helpful landmark for the neurosurgeon when resecting the intracranial extension through a bifrontal craniotomy approach. In four cases, the dermoid cyst entered the cranium through a persistent foramen cecum and lay within the falx in association with a bifid crista galli. We think that this entity is more common than was previously appreciated. Patients with a diagnosis of nasal dermoid should undergo polytomography or computed tomography of the glabellar area. Even when all x-ray studies are negative, neurosurgical preoperative evaluation and operative standby should be obtained before the otolaryngologist attempts the resection of a nasal dermoid cyst.

Intracranial extension of nasal dermoids

Giant occipital encephaloceles rarely contain large amounts of neural tissue that cannot be replaced in the abnormally small calvarium. Resection of neural elements is therefore often necessary in order to accomplish a closure. A technique is described wherein an extracranial compartment is prepared utilizing fine tantalum mesh to enclose the neural contents. The mesh is attached to the periphery of the skull defect providing a rigid extracranial compartment for the encephalocele. As intracranial pressure increases, the calvarium is forced to expand. The tantalum mesh is gradually imbricated into the calvarium by daily digital compression. If ventriculomegaly occurs, an interval ventriculoperitoneal shunt is placed. The encephalocele repair is reopened and the tantalum is surgically imbricated at that time. This allows for a satisfactory cosmetic result with preservation of all neural elements.

Repair of giant occipital encephaloceles with microcephaly secondary to massive brain herniation.

✓ A case of neurogenic hamartoma involving the middle cranial fossa, nasopharynx, and left anterior cervical region and presenting at birth as an obstructive oropharyngeal mass is described. Special management included Gelfoam embolization of the vascular supply, control of airway and feeding, assessment of biological activity of the mass, and appropriate staging of the procedure with neurosurgical, head and neck surgical, and radiological support.

Intracranial and extracranial neurogenic hamartoma

✓ One hundred patients with the provisional diagnosis of nerve root compression in the lumbar spine were subjected to routine bladder evaluation by cystometry in addition to the standard somatic neurological examination. Eighty-three were found to have cystometrograms characteristic of bladder hypofunction. Residual urine was found in 20% of the 100 patients. By contrast, the examination of the somatic nervous system disclosed sensory deficits in 36%, weakness in 59%, reflex alterations in 66%, and positive sciatic-stretch tests in 69%. Almost all cystometric studies (96%) became normal after successful surgical or conservative therapy. It is concluded that occult bladder dysfunction is a major manifestation of lumbar nerve root compression. The neurophysiological mechanisms involved are discussed in detail.

Anthony E. Gallo

Papers

IQ and neuropsychological changes following carotid endarterectomy

Intracranial extension of nasal dermoids

Repair of giant occipital encephaloceles with microcephaly secondary to massive brain herniation.

Intracranial and extracranial neurogenic hamartoma

Cystometry as an adjunct in the evaluation of lumbar disc syndromes