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Biomedical subjects

N E Epstein

Publications and source records attributed to N E Epstein.

At least 19 recordsLinked to original sources
PubMed1998

Evaluation and treatment of clinical instability associated with pseudoarthrosis after anterior cervical surgery for ossification of the posterior longitudinal ligament.

BACKGROUND: Between 1989 to 1993, clinical instability associated with pseudarthrosis was evaluated in 76 patients with cervical ossification of the posterior longitudinal ligament (OPLL). Average 2.5 level extended anterior diskectomy and fusion and average 3.0 level anterior corpectomy and fusion were performed without anterior plate instrumentation using iliac crest or fibular strut autografts. METHODS: Fusion versus pseudarthrosis resulting in clinical instability, as defined by White and Panjabi, was assessed using flexion and extension X-rays 3 and 6 months post-operatively. Radiographic instability was defined by > 3.5 mm. of sagittal plane translation (or 20%) and > 20 degrees of sagittal plane rotation on dynamic X-rays. Two and 3 dimensional (D) computed tomography (CT) scans, also obtained 3 months postoperatively, either confirmed fusion or indicated failed bony union. The average clinical follow up period was 3 years (range, 25-52 months). RESULTS: Three months postoperatively, dynamic X-rays in 20 patients demonstrated radiographic instability consistent with pseudarthrosis, whereas 2 and 3D CT studies indicated a lack of fusion. At 6 months, flexion and extension X-rays revealed that 10 patients were fused and that another 7 were clinically stable despite persistent, irregular, linear lucencies at graft/body interfaces. Three (4%) patients with clinical instability associated with pseudarthrosis required secondary posterior wiring and fusion. CONCLUSION: Only 4% of patients undergoing average 2.75 level anterior OPLL surgery without anterior plate instrumentation required secondary posterior wiring and fusion for clinical instability associated with pseudarthrosis.

Aged↗
PubMed1998

Decompression in the surgical management of degenerative spondylolisthesis: advantages of a conservative approach in 290 patients.

The management of degenerative spondylolisthesis with laminectomy alone or laminectomy with fusion remains controversial. From the early 1970s to 1996, 290 patients with degenerative spondylolisthesis were treated with 249 laminectomies and 41 fenestration procedures over an average of 3.2 levels. One level olisthesis was encountered in 250 patients, and two levels of slip in 40. Patients averaged 67 years of age, and were followed an average of 10 years. Using Prolo's outcome scale, 69% of patients exhibited excellent, 13% good, 12% fair, and 6% poor outcomes. Secondary decompressions with fusions for increased olisthy/instability (five patients) and recurrent stenosis/disc disease/instability (three patients) required one posterolateral "in situ" fusion and seven Texas Scottish Rite Hospital instrumented procedures. Decompression alone successfully managed degenerative spondylolisthesis in 290 patients treated over 3 decades, because only 8 (2.7%) required secondary fusion.

Adult↗
PubMed1997

A comparison of surgeon's assessment to patient's self analysis (short form 36) after far lateral lumbar disc surgery. An outcome study.

STUDY DESIGN: Between 1984 and 1994, 170 patients had surgery for far lateral discs. Patients were assessed by the surgeon as having poor (no improvement, increased deficit), fair (mild improvement, moderate residual deficit), good (moderate improvement, mild residual deficit) or excellent (marked improvement, no deficit) physical outcomes. The Medical Outcome Trust's SF-36 survey was completed by 76 (45%) patients, using one interviewer. OBJECTIVES: Patient-based outcome studies are becoming increasingly important. A surgeon's assessment of outcome was compared with the patients' self assessment (Short Form 36) after far lateral lumbar disc surgery. SUMMARY OF BACKGROUND DATA: The SF-36 survey provides measures on eight dimensions: physical function, role physical, bodily pain, general health, vitality, social function, role-emotional, and mental health. METHODS: Patients averaged 60.1 years of age, and included 43 men and 33 women. Patients were last examined an average of 9.1 months after their surgery, and were interviewed by telephone an average of 2.8 years later. RESULTS: Patients completing the survey were evaluated on their last visit to the surgeon as having excellent (32 patients), good (24), fair (12), and poor (8) outcomes. Overall correlations between the surgeon's assessment and all 76 patients' SF-36 scores were modest. However, for those patients examined within 4.5 years of the surgeon's assessment (n = 56), correlations were statistically significant for 6 of the SF-36 measures. Only general health and social function showed correlations less than 0.25. CONCLUSIONS: The surgeon's assessment was a particularly good predictor of SF-36 measures if the surgeon assessed the patient within the past 4.5 years. The SF-36 should be useful for large-scale outcome studies.

Aged↗
PubMed1996

Advanced cervical spondylosis with ossification into the posterior longitudinal ligament and resultant neurologic sequelae.

Advanced cervical spondylosis (ACS) with ossification of the posterior longitudinal ligament (OPLL) may be distinguished from classical OPLL on magnetic resonance- and computed tomography-based studies by the presence within the hypertrophied posterior longitudinal ligament (PLL) of segments of punctate calcification-ossification. Between 1989 and 1993, 50 patients with an early form of classical OPLL, variably associated with ACS, had cervical surgery. Averaging in their mid-40s in age, and exhibiting signs of radiculopathy or myeloradiculopathy, patients were uniformly managed with anterior surgical decompression and fusion. The average follow-up interval was 38 months (range 18-66 months). In select patients, early OPLL coexisted with classic OPLL. ACS with OPLL may represent an early form of the generation of classic OPLL in younger symptomatic individuals, which may be successfully addressed with an anterior surgical approach.

Adult↗
PubMed1995

Magnetic resonance angiographic diagnosis of ectatic vertebral artery.

In the cervical spine, routine and contrast magnetic resonance (MR)- and computed tomography (CT)-based studies may fail to differentiate between an ectatic vertebral artery and a solid foraminal mass. A complete cervical and lumbar Myelo-CT scan in a 67-year-old female with lumbar stenosis revealed an incidental, left-sided C3-C4 foraminal mass. A vascular lesion was suspected when the MR study revealed the lesion to be a signal void. MR angiography confirmed an ectatic C3-C4 vertebral artery loop. The possibility of a vertebral artery anomaly should be considered in patients with asymptomatic lateral and foraminal cervical lesions on CT studies. In these patients, routine MR and MR angiography are necessary to demonstrate the status of the vertebral artery in the foramen.

Aged↗
PubMed1995

Evaluation of varied surgical approaches used in the management of 170 far-lateral lumbar disc herniations: indications and results.

This study was undertaken to determine and compare indications and relative benefits of various surgical approaches in 170 patients (average age 55 years) with far-lateral herniated lumbar discs, identified by magnetic resonance (MR) imaging and computerized tomography (CT) and operated on between 1984 and 1994. Essentially three surgical procedures were performed: complete facetectomy in 73 patients, laminotomy with medial facetectomy in 39 patients, and intertransverse discectomy (also known as ITT) in 58 patients. Follow-up periods averaged 5 years (range 0.5-10 years). Outcomes were scored as excellent (no deficit), good (mild radiculopathy), fair (moderate radiculopathy), and poor (unchanged or worse). Overall, excellent and good results were achieved in 73 and 51 patients, respectively, and fair and poor results in 26 and 20, respectively. There was little difference among the results encountered for the three major surgical groups: 79% of the intertransverse (ITT) group had good-to-excellent outcomes, as compared with 70% of the facetectomy group, and 68% of the group who underwent at minimum laminotomy, and additional hemilaminectomy or laminectomy with medial facetectomy. Results were the same for the 121 patients followed for more than 2 years and for the 49 patients studied for under 2 years. In the management of far-lateral discs, total facetectomy provides the best exposure, but increases the risk of instability. Laminotomy and medial facetectomy uncover the lateral and subarticular recess and preserve stability, but visualization of the far-lateral compartment is often inadequate. The intertransverse approach offers extensive far-lateral but not medial intraforaminal exposure, while also preserving stability. Full facetectomy, laminotomy with medial facetectomy, and the intertransverse approaches yielded nearly comparable outcomes in far-lateral disc surgery. Only the full facetectomy exposes the entire course of the nerve root both medially and laterally, whereas the intertransverse procedure provides direct exposure of the fat-lateral compartment alone. It is important to select the correct approach or combination of approaches to address attendant complicating factors such as spinal stenosis, spondyloarthrosis, and degenerative spondylolisthesis identified on CT and MR studies.

Adult↗
PubMed1995

Different surgical approaches to far lateral lumbar disc herniations.

In far lateral disk surgery, although total facetectomy provides the best exposure and allows for removal of medial and far lateral extruded disk fragments, the risk of instability is increased as a result of excision of the pars interarticularis, Medial facetectomy uncovers the lateral and subarticular recess and preserves stability but does not allow for proper visualization of the far lateral compartment. The isolated extraforaminal approach provides access only to far lateral sequestrated fragments and does not allow access for more medial diskectomy or decompression of associated stenosis. Combining the extraforaminal exposure with a laminotomy, hemilaminectomy, or laminectomy complements the intertransverse (ITT) approach and affords access both to lateral and to medial disk lesions and stenotic abnormalities. The advantages and disadvantages of the less popular extraforaminal, transpars, percutaneous, and anterior decompressive techniques are also assessed. No one technique of far lateral disk excision is applicable for the management of all lesions. It is more appropriate to choose the right operation for the right patient.

Humans↗
PubMed1994

The surgical management of ossification of the posterior longitudinal ligament in 43 north americans.

From 1989 to 1992, 43 of 174 (25%) consecutive North Americans had cervical ossification of the posterior longitudinal ligament (OPLL). After the non-random selection of anterior corpectomies and fusions, anterior discectomies and fusions, or five-level laminectomies, the preoperative and postoperative outcomes of the OPLL patients were compared using Ranawat's neurological classes and grades. Patients who had anterior OPLL surgery exhibited superior outcomes compared with those who had laminectomies. Specifically, the 20 patients who underwent corpectomies and had the most severe preoperative deficits, had the best postoperative results; the 13 discectomy patients, with the least severe preoperative deficits, had intermediate recoveries, whereas the ten laminectomy patients, with intermediate preoperative neurologic dysfunction, had biased future surgical choices to favor more anterior approaches.

Adult↗
PubMed1994

Ossification of the posterior longitudinal ligament in evolution in 12 patients.

Ossification of the posterior longitudinal ligament (OPLL) in evolution (OEV), an early form of OPLL, was newly discovered in 12 of 43 (28%) patients who had OPLL and underwent operations from 1989-1992. Magnetic resonance imaging and CT studies of OEV patients who were younger, in their mid-forties, and had less severe spastic myeloradiculopathy, showed hypertrophied posterior longitudinal ligaments containing punctate ossification at disc spaces and contiguous endplates, with occasional extension behind vertebral bodies. However, both location and neuroradiologic appearance allowed OEV to be confused readily with disc or spondylotic disease. Only heightened awareness of the clinical and radiographic findings of OEV allowed the correct diagnosis. The appropriately extended anterior discectomies or corpectomies with fusions contributed to better outcomes.

Adult↗
PubMed1994

Thoracic spinal stenosis: diagnostic and treatment challenges.

Thoracic stenosis may be defined by a narrowing of the anteroposterior (AP) diameter of the thoracic spinal canal to < 10 mm. Primary thoracic stenosis, documented when myelography is carried beyond the thoracolumbar junction into the upper thoracic canal, is most frequently associated with lumbar stenosis, whereas secondary stenosis, attributed to endocrinopathies and systemic diseases, more typically involves the entire spinal canal. Recognition of the presence of primary or secondary thoracic stenosis and the entire extent of attendant disease in the adjacent cervical or lumbar regions is essential to proper surgical management. Nine cases of primary and one instance of secondary thoracic spinal stenosis were reviewed. Seven of nine patients with primary thoracic stenosis had accompanying lumbar involvement, whereas one patient with secondary stenosis attributed to acromegaly had cervical, thoracic, and lumbar stenosis.

Acromegaly↗
PubMed1994

Nerve root complications of percutaneous laser-assisted diskectomy performed at outside institutions: a technical note.

Two patients, treated with percutaneous laser-assisted diskectomy, developed postoperative nerve root complications. The first patient, whose diskectomy had been performed by a gastroenterologist, suffered an acute foot drop that resolved following delayed surgical diskectomy, whereas the second patient's L4 and L5 root deficits remained permanent. Percutaneous laser-assisted diskectomy, by reducing intradiscal volume, is considered an alternative to open surgery in the management of contained lumbar disc herniations. After an L4-L5 diskectomy and a fenestration procedure performed 2 months later for a sequestrated disc herniation and segmental stenosis, the first patient's foot drop resolved. Unfortunately, the second patient's L4 and L5 root injuries, without MRI and myelo-CT surgical pathology, were complete. The laser-assisted diskectomy may produce reversible and irreversible nerve root injuries.

Adult↗
PubMed1993

Evaluation of intraoperative somatosensory-evoked potential monitoring during 100 cervical operations.

Continuous intraoperative somatosensory-evoked potential monitoring during scoliosis surgery, along with improved instrumentation techniques, has contributed to the reduction of neurologic injury from 4-6.9% to 0-0.7%. To assess whether somatosensory-evoked potential monitoring might play a similar role in cervical surgery, the authors compared the morbidity and mortality rates associated with 218 patients who were not monitored and were operated on between 1985-1989 with those found in 100 consecutive somatosensory-evoked potential monitored procedures done from 1989-1991. The cervical procedures were conducted for disc disease, stenosis, spondylosis, and ossification of the posterior longitudinal ligament. Eight of 218 unmonitored patients became quadriplegic (3.7%) and 1 died (0.5%); no instances of quadriplegia and no deaths were encountered among the 100 monitored patients. The reduction of neurologic deficit was attributed in part to early somatosensory-evoked potential detection of vascular or mechanical compromise of the spinal cord or nerve roots and to the immediate alteration of anesthetic or surgical technique in response to somatosensory-evoked potential changes, i.e., reversal of systemic or "relative" hypotension, adjustment of operative position, release of distraction, and cessation of manipulation. Continuous intraoperative somatosensory-evoked potential monitoring also was a practical tool in monitoring cervical surgery.

Cervical Vertebrae↗
PubMed1993

Synovial cyst of the cervical spine.

Synovial cyst herniations, typically observed in the lumbar region in conjunction with degenerative changes of the facet joints, only rarely present as space occupying lesions in the cervical spine. The case of a 47-year-old white man with a C7-T1 synovial cyst impinging on the spinal cord and right C8 nerve root is presented.

Cervical Vertebrae↗
PubMed1992

Lumbar surgery for 56 limbus fractures emphasizing noncalcified type III lesions.

The clinical, radiologic, and surgical procedures performed for 56 out of 59 patients with Type I-IV fractures of the vertebral limbus were reviewed, stressing the diagnostic and operative management of noncalcified Type III (NC III) lesions. Forty-four calcified Type I-IV (CA I-IV) limbus fractures, interpreted as routine disc herniations on magnetic resonance imaging scans, were correctly identified as limbus fragments on computed tomographic and myelographic/computed tomographic studies, whereas 15 NC III lesions were mistaken for disc herniations alone on all three radiographic examinations. The preoperative recognition of the CA I-IV and NC III fracture types proved essential to the successful resection of five Type I, five Type II, 36 Type III, and ten Type IV fragments through extended laminotomies, hemilaminectomies, and laminectomies with the down biting curette, tamp, and mallet technique. In the absence of routine disc herniations, expanded standard dissectomies to the superior or inferior pedicular levels allowed for the identification and removal of NC III fractures.

Adult↗
PubMed1991

Fungal brain abscesses (aspergillosis/mucormycosis) in two immunosuppressed patients.

Although the mortality rate for fungal brain abscesses in immunosuppressed patients remains unacceptably high, this figure may be reduced if computed tomography or magnetic resonance imaging scans are performed more promptly in susceptible individuals with seemingly mild intracranial complaints. Earlier presumptive amphotericin B treatment and more timely surgical debridement may minimize neurological injury and enhance survival. These assumptions were only tentatively supported by the clinical courses of two patients, one an alert patient with promyelocytic leukemia and an aspergillosis brain abscess who survived, and the other, a comatose intravenous drug abuser with mucormycosis who died.

Adult↗
PubMed1991

Limbus lumbar vertebral fractures in 27 adolescents and adults.

Fractures of the lumbar vertebral limbus involve varying degrees of fragmentation of the peripheral ring apophysis, located at the posterior superior or posterior inferior margins of the mid to lower lumbar vertebrae. Four types, uniquely found in adolescents and young adults, have been described. Type I lesions consist of avulsions of the posterior cortical vertebral rim. Type II fractures are composed of central cortical and cancellous bone fractures. Type III lesions are more lateralized chip fractures. Type IV fractures span the entire length and breadth of the posterior vertebral margin between the end plates. The clinical, neuroradiologic, and surgical management of 27 patients with these four types of lumbar limbus vertebral fractures are reviewed. The data regarding location and type of fracture were critical for planning piecemeal surgical resection with a downbiting curette, tamp, and mallet technique.

Adolescent↗