Stabilization and manipulation of instruments in endoscopic neurosurgery has traditionally been a manual task. Conventional self-retaining retractors have failed to provide reliable fixation for endoscopic procedures. Most surgeons rely on a team approach to endoscopy with one individual controlling the endoscope while the other manipulates instruments within the field of view. This two-surgeon approach is manpower intensive and not an option at many facilities. Recently developed technology provides the independent practitioner with another option. Several nitrogen-powered stabilizing arms have been introduced which decrease or eliminate problems with post-positioning drift. To facilitate fine maneuvering of the endoscope, a new positioning arm is available with an incorporated microdriver capable of sub-millimeter adjustments. We present an illustrative case of the utility of this device in selected endoscopic procedures.

INTRODUCTION: Operation Iraqi Freedom (OIF) started on March 20, 2003. Major offensive campaigns ended May 1, 2003. Since that time, troops have remained in Iraq serving in a wide variety of roles. The purpose of this paper is to present the experience at Walter Reed Army Medical Center (WRAMC) and National Naval Medical Center-Bethesda (NNMC) with patients who were medically evacuated from the theater for neurosurgical issues over the first year of combat. METHODS: A retrospective chart review was performed on all medical evacuations from OIF to WRAMC and NNMC from March 20, 2003, through March 20, 2004. Patients who were medically evacuated for neurosurgical evaluation or consultation were included. RESULTS: There were 2594 patients evacuated to WRAMC/ NNMC during this time period. Two thousand twenty-three (78%) were from OIF. Neurosurgery was either the primary or consulting service for 281 (14%) of these patients. There were 102 cranial injuries (36%) and 150 (53%) spine or spinal cord disorders. The remaining evacuations were composed of a variety of disorders such as peripheral nerve injuries and newly discovered tumors. One hundred four (37%) were battle injuries and 177 (63%) were nonbattle injuries or disease. Of the cranial cases, 54 (53%) were penetrating head injuries, and 48 (47%) were closed-head injuries. Of the spine cases, 134 (89%) were low back pain, neck pain, or radiculopathies. Sixteen of these cases (11%) were penetrating spine/spinal cord injuries or fractures. CONCLUSION: OIF and continued operations in Iraq represent the longest continuous large-scale active military conflict since Vietnam. By reviewing the medical evacuations from the theater, it is possible to determine the role for a military neurosurgeon in times of war. It also provides evidence for further research into body armor and helmets that eliminate vulnerable areas, such as the neck and face, and are practical for use in austere environments.

OBJECTIVE: This prospective study presents repair results after missile-caused ulnar nerve ruptures as well as factors influencing the outcomes. METHODS: Between 1991 and 1994, 128 casualties with missile-caused complete ulnar nerve injury were managed surgically in the Neurosurgical Department of the Belgrade Military Medical Academy. At least 4 years after surgery, we scored sensorimotor recovery, neurophysiological recovery, and patient judgment of the outcome. On the basis of the total score, we defined the final outcome as poor, insufficient, good, or excellent. The last two outcomes were considered to be successful. RESULTS: A successful outcome was obtained in 0% of high-level, 33.8% of intermediate-level, and 77.3% of low-level repairs (P< 0.001). On average, the nerve defect, preoperative interval, and patient age were lower for patients with a successful outcome than for those with an unsuccessful outcome (P= 0.004, P= 0.032, and P= 0.003, respectively). Worsening of the outcome was related to nerve defect longer than 4.5 cm, preoperative interval longer than 5.5 months, and age older than 23 years (P= 0.002, P= 0.034, and P= 0.023, respectively). A successful outcome occurred in 48.8% of patients repaired with direct suture and in 41.2% of patients repaired with a nerve graft (P> 0.05). A successful outcome also occurred 22.2% of combined ulnar-median nerve repairs and in 49.5% of isolated ulnar nerve repairs (P= 0.011). Repair level (P< 0.001), preoperative interval (P= 0.001), length of the nerve defect (P< 0.001), and associated median nerve rupture (P= 0.028) were independent predictors of a successful outcome. CONCLUSION: The outcome of ulnar nerve repair depends significantly on the repair level, preoperative interval, associated median nerve injury, length of the nerve defect, and age of the patient. High-level ulnar nerve repair is probably useless if performed in the classic manner.

A novel method for identifying compartment syndrome is presented. This method is based on a novel device that uses electromagnetic waves in the microwave radio frequency (RF) region and a modified algorithm previously used for the estimation of the angle of arrival of radar signals. In this study, we employ this radio frequency triage tool (RAFT) to the clinical condition of compartment syndrome, which is a clinical condition where blood or edema in the muscle compartment of the leg leads to critical sichemia of that exptremity. In anesthetized pigs, RAFT can detect changes in the R F signature from a leg is due to 2cc or greater of either blood or slaine (a surrogate of edema). These results are compared to clinical examination. RAFT is superior to clinical examination in its ability to detect compartment syundrome in pigs.

A novel method for identifying pneumothorax is presented. This method is based on a novel device that uses electromagnetic waves in the microwave radio frequency (RF) region and a modified algorithm previously used for the estimation of the angle of arrival of radar signals. In this study, we employ this radio frequency triage tool (RAFT) to the clinical condition of pneumothorax, which is a collapsed lung. In anesthetized pigs, RAFT can detect changes in the RF signature from a lung that is 20% or greater collapsed. These results are compared to chest x-ray. Both studies are equivalent in their ability to detect pneumothorax in pigs.

A baseline computerized cognitive assessment was completed by 483 military cadets before their initial school year. Fourteen cadets concussed during physical education boxing were retested <1 hour after injury and again on return to full activity 4 days later. Compared with baseline testing, postinjury performance on simple reaction time and continuous performance tests was significantly slowed, even after cadets experienced resolution of physical symptoms and were cleared to resume full activity. These findings may be relevant to current concussion management guidelines.

A novel method for identifying and localizing brain hemorrhage is presented. The method uses electromagnetic waves in the microwave and RF region and a modified algorithm previously used for the estimation of the angle of arrival of radar signals. Results are presented applying this device for detecting subdural and intraparenchymal hemorrhages in anesthetized pig.

CONTEXT:Traumatic brain injury (TBI) is a principal cause of death and disability in young adults. Rehabilitation for TBI has not received the same level of scientific scrutiny for efficacy and cost-efficiency that is expected in other medical fields.OBJECTIVE:To evaluate the efficacy of inpatient cognitive rehabilitation for patients with TBI.DESIGN AND SETTING:Single-center, parallel-group, randomized trial conducted from January 1992 through February 1997 at a US military medical referral center.PATIENTS:One hundred twenty active-duty military personnel who had sustained a moderate-to-severe closed head injury, manifested by a Glasgow Coma Scale score of 13 or less, or posttraumatic amnesia lasting at least 24 hours, or focal cerebral contusion or hemorrhage on computed tomography or magnetic resonance imaging.INTERVENTIONS:Patients were randomly assigned to an intensive, standardized, 8-week, in-hospital cognitive rehabilitation program (n=67) or a limited home rehabilitation program with weekly telephone support from a psychiatric nurse (n=53).MAIN OUTCOME MEASURES:Return to gainful employment and fitness for military duty at 1-year follow-up, compared by intervention group.RESULTS:At 1-year follow-up, there was no significant difference between patients who had received the intensive in-hospital cognitive rehabilitation program vs the limited home rehabilitation program in return to employment (90% vs 94%, respectively; P=.51; difference, 4% [95% confidence interval ¿CI¿, -5% to 14%]) or fitness for duty (73% vs 66%, respectively; P=. 43; difference, 7% [95% CI, -10% to 24%]). There also were no significant differences in cognitive, behavioral, or quality-of-life measures. In a post-hoc subset analysis of patients who were unconscious for more than 1 hour (n = 75) following TBI, the in-hospital group had a greater return-to-duty rate (80% vs 58%; P=. 05).CONCLUSIONS:In this study, the overall benefit of in-hospital cognitive rehabilitation for patients with moderate-to-severe TBI was similar to that of home rehabilitation. These findings emphasize the importance of conducting randomized trials to evaluate TBI rehabilitation interventions. JAMA. 2000;283:3075-3081

Context Traumatic brain injury (TBI) is a principal cause of death and disability in young adults. Rehabilitation for TBI has not received the same level of scientific scrutiny for efficacy and cost-efficiency that is expected in other medical fields.Objective To evaluate the efficacy of inpatient cognitive rehabilitation for patients with TBI.Design and Setting Single-center, parallel-group, randomized trial conducted from January 1992 through February 1997 at a US military medical referral center.Patients One hundred twenty active-duty military personnel who had sustained a moderate-to-severe closed head injury, manifested by a Glasgow Coma Scale score of 13 or less, or posttraumatic amnesia lasting at least 24 hours, or focal cerebral contusion or hemorrhage on computed tomography or magnetic resonance imaging.Interventions Patients were randomly assigned to an intensive, standardized, 8-week, in-hospital cognitive rehabilitation program (n=67) or a limited home rehabilitation program with weekly telephone support from a psychiatric nurse (n=53).Main Outcome Measures Return to gainful employment and fitness for military duty at 1-year follow-up, compared by intervention group.Results At 1-year follow-up, there was no significant difference between patients who had received the intensive in-hospital cognitive rehabilitation program vs the limited home rehabilitation program in return to employment (90% vs 94%, respectively; P=.51; difference, 4% [95% confidence interval {CI}, -5% to 14%]) or fitness for duty (73% vs 66%,respectively; P=.43; difference, 7% [95% CI, -10% to 24%]). There also were no significant differences in cognitive, behavioral, or quality-of-life measures. In a post-hoc subset analysis of patients who were unconscious for more than 1 hour (n=75) following TBI, the in-hospital group had a greater return-to-duty rate (80% vs 58%; P=.05).Conclusions In this study, the overall benefit of in-hospital cognitive rehabilitation for patients with moderate-to-severe TBI was similar to that of home rehabilitation. These findings emphasize the importance of conducting randomized trials to evaluate TBI rehabilitation interventions.

Primary CNS neoplasms can rarely be associated with abnormal vascularity which is more striking than usual hypervascularity or neovascularization. These lesions are sometimes reported as angiogliomas, angiomatous astrocytomas, or descriptively as two distinct pathological entities. This vascular pattern has been reported with astrocytomas, oligodendrogliomas, neurilemmomas, meningiomas, pituitary adenomas, gangliogliomas, hemangioblastomas, mixed gliomas, gliosarcomas, and craniopharyngiomas. These lesions are classically found to be extremely vascular, both radiographically and at surgery. The true nature of these lesions is a point of controversy with some interpreting them merely as intensely vascularized tumors. Most agree, however, that unlike neovascularity in astrocytomas, the vascularity in these lesions does not carry any significant prognostic importance. In this report we present six such cases from The Children's Hospital of Philadelphia seen in the pediatric population. Four patients had vascular malformations associated with diffuse astrocytomas, and in 2 patients they were associated with subependymal giant cell astrocytomas. Five of the lesions were supratentorial, and 1 was located in the posterior fossa. The history and theories surrounding these lesions are explored.

Cervical instability secondary to fracture/dislocation or traumatic subluxation involving the posterior elements may be treated by a variety of fusion techniques. The rigidity of the stainless steel wires used in posterior cervical fusions often leads to difficulty with insertion, adequate tension, and conformation of the graft construct. This report describes a technique of posterior cervical fusion employing a wire system using flexible stainless steel cables. The wire consists of a flexible, 49-strand, stainless steel cable connected on one end to a short, malleable, blunt leader with the opposite end connected to a small islet. The cable may be used in occipitocervical, atlantoaxial, facet-to-spinous process, and interspinous fusion techniques. The cable loop is secured by using a tension/crimper device that sets the desired tension in the cable. In addition to superior biomechanical strength, the flexibility of the cable allows greater ease of insertion and tension adjustment. In terms of direct operative instrumentation in posterior cervical arthrodesis, involving both the upper and lower cervical spine, the cable system appears to be a safe and efficient alternative to monofilament wires.

Cervical spondylotic myelopathy appears to result from a combination of factors. The two major components are 1) compressive forces resulting from narrowing of the spinal canal, and 2) dynamic forces owing to mobility of the cervical spine. There is substantial evidence to suggest that the repetitive trauma to the spinal cord that is sustained with movement in a spondylotic canal may be a major cause of progressive myelopathy. Utilization of extensive anterior procedures that remove the diseased ventral features as well as eliminate the dynamic forces owing to the accompanying fusion have grown in popularity. Cervical laminectomy enlarges the spinal canal, but does not reduce the dynamic forces affecting the spinal cord, and may actually increase cervical mobility, leading to a perpetuation of the myelopathy. The authors propose the combination of posterior decompression and Luque rectangle bone fusion to deal with both the compressive and the dynamic factors that lead to cervical spondylotic myelopathy. Ten patients who had advanced myelopathy underwent the combined procedures. Nine of the 10 experienced significant neurological improvement, and the 10th has had no progression. The combination of posterior decompression and Luque rectangle bone fusion may offer a simple, safe, and effective alternative treatment for cervical spondylotic myelopathy.

Cervical instability secondary to fracture/dislocation or traumatic subluxation involving the posterior elements may be treated by a variety of fusion techniques. The rigidity of the stainless steel wires used in posterior cervical fusions often leads to difficulty with insertion, adequate tension, and conformation of the graft construct. This report describes a technique of posterior cervical fusion employing a wire system using flexible stainless steel cables. The wire consists of a flexible, 49-strand, stainless steel cable connected on one end to a short, malleable, blunt leader with the opposite end connected to a small islet. The cable may be used in occipitocervical, atlantoaxial, facet-to-spinous process, and interspinous fusion techniques. The cable loop is secured by using a tension/crimper device that sets the desired tension in the cable. In addition to superior biomechanical strength, the flexibility of the cable allows greater ease of insertion and tension adjustment. In terms of direct operative instrumentation in posterior cervical arthrodesis, involving both the upper and lower cervical spine, the cable system appears to be a safe and efficient alternative to monofilament wires.

Pineal cysts are being described with increasing frequency since the advent of magnetic resonance imaging. Although pineal cysts are incidental findings in as many as 4% of magnetic resonance imaging studies, symptomatic pineal cysts are quite rare. We present a case of pineal cyst causing aqueductal obstruction with symptomatic hydrocephalus and resultant headache and syncope, which was treated by surgical resection. A review of the relevant literature and discussion follow.