Biomedical subjects
N E Epstein
Publications and source records attributed to N E Epstein.
Simultaneous occurrence of herniated disc and mesothelial cyst in a 16-year-old male.
The unusual, simultaneous occurrence of both a herniated disc and an intraspinal mesothelial cyst in an adolescent is reported. The patient was a 16-year-old white male who presented with sciatic pain in his left lower extremity. Myelography revealed evidence of a left L4-5 discal herniation, and a L5-S3 midline sacral lesion that proved to be a mesothelial cyst.
Unilateral S-1 root compression syndrome caused by fracture of the sacrum.
Unilateral S-1 nerve root compression after an S-1 sacral fracture was found in an 18-year-old man after a motor vehicle accident. The positive myelogram, myelogram-computed tomogram, and magnetic resonance studies led to surgical intervention. Marked bony callous formation contiguous with the S-1 alar fracture protruded into the canal and was responsible for tethering the S-1 nerve root. A right L-5 hemilaminectomy, an L-4, L-5 and L-5, S-1 medial facetectomy, and foraminotomy facilitated nerve root decompression. Postoperatively, the patient was markedly improved. The authors suggest a more aggressive attitude in the diagnostic, radiographic, and surgical management of sacral fractures now that more specific technical facilities are available to define the precise character of the lesions involved.
Shunt placement and myelomeningocele repair: simultaneous vs sequential shunting. Review of 12 cases.
The optimal management of patients with myelomeningocele and hydrocephalus is facilitated by a constant review of the patients with the aid of the sonogram and CT scan. Six infants treated with simultaneous shunt placement and myelomeningocele repair were compared with six other neonates treated with conventional sequential myelomeningocele repairs requiring a second separate procedure for shunt placement. Infants operated upon simultaneously experienced no increase in morbidity or mortality and appeared to benefit substantially.
S1-S2 sacral fracture involving neural elements of the cauda equina. A case report and review of the literature.
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Coexisting cervical and lumbar spinal stenosis: diagnosis and management.
An attempt has been made to identify and manage patients symptomatic from both cervical and lumbar spinal stenosis. The order of operative intervention was related to the degree of myelopathy and radiculopathy. Patients requiring cervical surgery first had absolute stenosis with a spinal canal equal to or less than 10 mm in anteroposterior diameter. Those requiring lumbar surgery first presented with stenosis and a canal between 11 and 13 mm in depth. In the latter group, patients presented with radiculopathy in their upper and lower extremities. A significant portion (50%) had intermittent neurogenic claudication (INC). Motor and sensory changes were severe in those with absolute as compared to relative stenosis. After cervical laminectomy, myelopathy improved or stabilized, and the subsequent lumbar decompression could be completed with less risk. Cervical cord decompression often resulted in improvement in lumbar symptoms with resolution of pain, spasticity, and sensory deficits of myelopathic origin. However, latent symptoms of INC caused by lumbar stenosis were not affected by cervial decompression and increased in severity. Electrodiagnostic studies were helpful in that somatosensory evoked potentials showed conduction delays in the cervical cord in patients with significant disease. The identification of motor neuron disease and peripheral neuropathies was essential. The surgical management included extensive, multiple level laminectomy, unroofing of the lateral recesses, and foraminotomy. Neurolysis and untethering of the spinal cord was essential. Significant improvement was shown by 90% of these patients.
Conservative management of Citrobacter diversus meningitis with brain abscess.
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Degenerative spondylolisthesis with an intact neural arch: a review of 60 cases with an analysis of clinical findings and the development of surgical management.
The treatment over the past 12 years of 60 patients with degenerative spondylolisthesis with an intact neural arch is reviewed. The patients averaged 65 years of age, with women outnumbering men by a ratio of 2:1. Symptoms in the lower extremities had been present for 3 months to 10 years, although varying back pain had existed for longer periods. Two-thirds showed signs of motor dysfunction. Sensory alterations and a positive Las ègue's sign could be demonstrated in only one-half of the patients studied. Four of 5 patients developed intermittent neurogenic claudication, with varying evidence of painful radiculopathy. The marked disability caused by claudication contrasted sharply with the lesser neurological changes, and these patients required early surgical decompression. Diagnostic studies included electromyography, plain x-ray films, tomography, computed tomographic scanning, and myelography. The latter outlined a relative stenosis caused by olisthesis as well as arthrotic and spondylotic changes that determined the extent of decompressive operation required. The L-4, L-5 interspace was involved in 56 patients, L-3, L-4 was involved in 2, and L-5, S-1 was involved in 2. The ideal operation with L-4, L-5 olisthesis included complete laminectomy of L-4 and L-5 with unroofing of the lateral recesses and foraminotomy. This more extensive procedure was justified because of the failures encountered in previous patients in whom inadequate decompression had been performed. Among failures, obesity, diabetes, hyperlordosis, and extensive long-standing dysfunction were prominent. The relief of symptoms of intermittent neurogenic claudication was the most gratifying response observed. There was no unusual morbidity.
Moderate grade astrocytoma presenting in a 4-month-old child with a family history of von Recklinghausen's neurofibromatosis spanning four generations: a case report.
Intracranial gliomas are found in association with von Recklinghausen's neurofibromatosis. However, few truly neonatal lesions have been identified and studied. This case report concerns a 4-month-old child who was found to have a massive thalamic glioma of moderate grade. Four paternal generations had suffered from different manifestations of this transmissible autosomal-dominant (Ad) phakomatosis.
Pseudocoarctation of the aorta.
A case of pseudocoarctation of the thoracic aorta manifested by a mediastinal mass on a roentgenogram of the chest and subsequently evaluated with computed tomography (CT) is presented. The following combination of CT findings is thought to be diagnostic of this rare congenital anomaly: (a) demonstration that the mass is part of the aorta, (b) the depiction of the unusual aortic arch high in the mediastinum, (c) visualization of the isthmus portion of the descending aorta not adjacent to the spine but rather located ventral to it and surrounding by aerated lung, and (d) more caudal origin of the subclavian artery resulting in a vascular shadow posterior to the kinked aortic arch.
From postsurgical imaging... Marked superior and inferior migration of a dynamic plate after multilevel anterior corpectomy and fusion with posterior wiring.
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Traumatic myelopathy in a seventeen-year-old child with cervical spinal stenosis (without fracture or dislocation) and a C2-C3 Klippel-Feil fusion. A case report.
A 17-year-old white male patient sustained a cervical hyperextension injury while body surfing. Plain cervical radiographs, tomography, and CAT scan showed neither fracture nor subluxation, but congenital narrowing of the spinal canal and fusion of C2-C3 (Klippel-Feil). Clinically, he had a central cord syndrome, characterized by a motor dominant myelopathy. The conservative management of this patient with a central cord injury in the presence of spinal stenosis and a Klippel-Feil syndrome resulted in almost full recovery although he was quadriplegic initially. This constellation of findings rarely has been reported in adolescence.
Lumbar intervertebral disk herniation in teenage children: recognition and management of associated anomalies.
Herniated disks in children and adolescents can be extremely disabling and difficult to diagnose because of the paucity of neurologic abnormalities and the consequent suspicions of hysteria. The Laségue sign is often the only consistent positive finding, and when persisting without remission, justifies early diagnostic studies such as CT scanning, and electromyography. Myelography may be avoided if these studies are definitively diagnostic. The almost uniformly good results that follow diskectomy do not justify prolonged conservative care. Management is facilitated by awareness of often unrecognized structural abnormalities found in these patients. These include spinal stenosis, lateral recess narrowing, and transitional vertebra. Spinal fusion, while rarely indicated, should be considered where motion segment instability contributes to persistent backache. The management of 25 patients is recorded. Twenty-one of these presented with an anomaly worthy of record requiring modifications in surgical technique to provide proper decompression and lasting relief of symptoms.
Advantages of topical marcaine during spinal surgery. Technical note.
Marcaine applied to irritated nerve roots during extradural spinal surgery may attenuate sympathetically mediated and somatosensory (pain)-related hypertensive and tachycardic crises.