Abstract: 4 In the 1 970s there were two outstanding changes which influenced the management of spinal disorders. First, significant advances occurred in investigative methods: safer water-soluble contrast agents became available, leading to improved myelography; computerised tomography heralded a revolution in non-invasive imaging of the spinal canal; ultrasonic measuring techniques were applied to the spine; and epidural venography attained some popularity. Secondly, there was a growing interest in the clinical problems attributed to spinal stenosis, with an emerging awareness of differences in symptoms and signs produced by stenosis of the central canal and of the so-called lateral canal. In this area of spinal disorders the use of terminology has remained vague, lacking in precision particularly when applied to descriptions of operative techniques. The purpose of this paper is to describe the anatomy of the nerve root canals of the lumbar spine, to outline a number of common pathological conditions which may lead to deformity of these canals and of the related intervertebral foramina, and to describe the essential surgical manoeuvres required to decompress them. A series of line drawings, constructed from anatomical specimens and from observations made at operation, illustrate the normal and pathological anatomy and demonstrate the extent of operations to decompress the spinal nerve root canals and intervertebral foramina.

Abstract: There are many difficulties associated with the localisation of the symptomatic segment in patients presenting with cervicobrachial pain with no evidence of impaired conduction in the nerve root. Ancillary radiological investigations such as myelography, epidural phlebography, and epidural myelograms are of unreliable diagnostic value. However, discography can be of value if the technique described here is used. Infiltration of the cervical nerve root with local anaesthetic has also proved useful in the localisation of the symptomatic segment. The techniques used in cervical discography and infiltration of the nerve root are described and their reliability is assessed.

Abstract: Current Status of Moderi Vol 8. Disorders of Moveme by Andre Barbeau (pp 21 Lancaster: MTP Press, 1981. In the past two decades therc many intriguing and at timer contradictory contributions t of movement disorders-at common and compelling both neurologists and psy and there has been a press need for an authoritative This is the purpose of t; volume. The historical scen4 set by Andre Barbeau whos survey embraces the mediaeval epidemics, the en classical terminology and th assessment of controversial, r entities. Only he who is conf the diagnostic criteria ol electric chorea, Jumping of Maine, Latah of Ma Myriachit of Siberia can neglect this chapter. Throughout the contribu cerning the pathophysiology ment of the dyskinesias, wh reference is made to the sal

Abstract: A patient wirh c1inical and radiological evidence of disc protru sion may get complete relief of pain, stiffness, limitation of straighr-leg-raising SLR, and paresthesia on conservative treat menr. This was shown by Falconer er al. (9) to occur wirbout change in the size of the protrusion in their medically rreated group of cases. On the other hand, these symptoms may persist afrer ca mpiere disc evacuation and constitute a problem in furrher management although the neurological signs may improve. Back pain and sciatica also exisr in cases of lumbar disc degeneration in spite of the absence of any d inical, radiog raphic, or electromyographic abnormalities. Ir may be concluded that the signs and symptoms of such conditions can fall into two separate groups. The first indudes back pain, sciatica, paraesthesia, limitation of spinal rnove ments and SLR. This may be called the irritative or protective group. The second indudes motor or sensory deficits as weil an inhibition or absence of tendon jerks. Th is may be called rhe compressive or destructive group. These two groups may or may not coexisr, meaning thar they have different und erlying pathology. The irrirative group alone is also commonly seen in non-discogerne problems such as spondylolisthesis, ankylosing spondylitis, hyperlordotic spines as weil as in some cases of simple trau ma without fractures or disc protrusion

Abstract: In lumbar disc herniations, musculoskeletal findings usually predominate at the outset. There is often an acute list or impaired lateral mobility to one side or the other. This finding represents a protective mechanism to splint the affected disc space in the position where the disc prolapse exerts the least possible pressure on the affected nerve root. An attempt was therefore made to determine whether the relationship of the disc herniation to the nerve root could be delineated by having the patient bend maximally to each side. Three hundred patients who would normally be candidates for routine (static) x-ray study of the lumbar spine had lateral bending (dynamic) films instead. These were then correlated with myelograms and/or surgery, when performed. Lateral bending roentgenograms can often pinpoint the level of lumbar disc herniation.

Abstract: 1. The intracranial and intraorbital course of the optic nerve is described concisely, the intracanicular one in full details. Apart from the wide and small sections of the optic canal, its axis opposite to the cranial planes, the coating of the canal and the adjacency to the paranasal sinuses and arteries are exactly described. 2. At the trigeminal nerve the trigeminal ganglion, its roots and also the mandibular nerve have great importance in the practical medicine considering thermo-coagulation or surgery of the trigeminal nerve. This segments and also the adjacency of the fifth nerve to the internal carotid artery and subarachnoideal brain vessels are exactly, the nuclei areas and central tracts are briefly explained. 3. The nuclei of the facial nerve the intracerebral and intracisternal course and its development, the facial canal and its narrow passes are described. Also the position of the internal acoustic pore in the skull, the dimensions of the internal acoustic meatus and the relations between nerves and vessels are explained. In addition to the geniculate ganglion and the chorda tympani the communications of the facial nerve inside the temporal bone, the tympanic intumescentia (ganglion) and the nervus intermedius, also the petrosal nerves are included in the description. The sheaths of the segments of the seventh cranial nerve and also the fasculation are exactly, the somatotopic organization is briefly described. 4. The extracranial course of the glossopharyngeal nerve is briefly, its intracranial sections are included exactly in the investigation. 5. The nuclei of the vagus nerve and the intra- und extracranial course are described. 6. The accessory nerve, its nucleus and the intra- and extracranial course are concisely explained. 7. The hypoglossal nerve, its nucleus, the emergence of the fibres and also the relations of nerves and vessels in the posterior cranial fossa are described. The hypoglossal canal and also the extracranial course are explained as briefly as possible.

Abstract: The H-index was studied in 42 healthy subjects and in 20 patients showing unilateral S1 root compression. When compared to the normal subjects, all patients showed a decreased H-index, or an increased difference in H-index between the sides or both. These results indicate that both parameters are valuable in the diagnosis of S1 root impairment due to intervertebral disc protrusion.

Abstract: Reflex sympathetic dystrophy can be associated with lumbar disc herniations. Both central and peripheral neuroanatomic pathways can be implicated in the development of this syndrome. Clinical findings of vasomotor instability in the leg supported by plain roentgenograms showing osteopenia, bone scan showing increased uptake, and a favorable response with sympathetic blocks suggest the diagnosis. Symptoms should be relieved with appropriate nerve root decompression but may require, in addition, a therapeutic lumbar sympathetic blockade.

Abstract: The spinal nerve roots and dorsal ganglia of 104- to 135-week-old rats with spontaneous radiculoneuropathy were examined by light and electron microscopy. Demyelination was common in myelinated fibers of various diameters of both ventral and dorsal roots. The most striking alteration was wide distention of myelin sheaths, which extended throughout the entire internode. The spaces formed between separated lamellae frequently were invaded by macrophages. Subsequent vesicular degeneration of myelin seemed to be mediated by invading macrophages. These processes caused complete myelin destruction, but most axons showed no degenerative changes except for obvious reduction in diameter. Occasionally, there were clumping and partial degradation of neurofilaments and ruptured axolemma in the severely demyelinated axons. A few fibers also were undergoing wallerian-type degeneration, perhaps secondary to the severe demyelinative changes. Remyelinating fibers in various phases of repair were coexistent with markedly demyelinated ones. Demyelinative changes described above also developed within some of these remyelinated internodes. There were no remarkable changes in neurons of the dorsal root ganglia, though accumulation of lipofuscin was common. Our findings suggest that the changes in the nerve roots are essentially a primary segmental demyelination in aging rats with radiculoneuropathy.

Abstract: A series of 100 patients with pain in the leg was studied and the accuracy of electrical studies in the diagnosis of nerve root lesions was investigated before operation. The electrical studies which were performed on all the patients, included recordings of fibrillation potentials, H-reflex and ankle reflex latencies. This diagnosis technique was found to be more accurate than radiculography or clinical examination and did not give false evidence. Seventy patients were classed as having a lesion of the nerve root. Fifty of these patients were treated surgically. The operation revealed compression of the nerve root by osteophytes arising from degenerative and incompletely dislocated posterior facet joints in 43 patients.

Abstract: Any discussion on the pathophysiology of cranial nerve injury would be incomplete if it failed to direct attention to certain differences in the structure of the extra- and intracranial parts of a cranial nerve and to the manner in which these differences influence the damaging effects of stretch and compression on nerve fibres. This Chapter is devoted to this aspect of the subject.

Abstract: Low lumbar pain with radiation into the leg is a common symptom pattern caused by a number of pathological processes. Isolated disc resorption is one such entity which can be readily identified and is amenable to surgical treatment. This study consisted of two groups of patients. Group I were 50 patients suffering from isolated disc resorption at L5--S1 with ill-defined low backache extending into the buttocks and down one or both legs, but not into the feet. Clinical signs of nerve root dysfunction were found in 16 per cent of patients. Radiographic changes with loss of disc height, facet over-riding and intrusion into the nerve root canal and intervertebral foramen were common and frequently associated with sclerosis of the vertebral end-plate. Group II were a series of 45 patients with isolated disc resorption independently reviewed an average of 45 months after surgical decompression of the S1 (98 per cent) or lower lumbar nerve roots. Based on objective grading by the clinician and subjective assessment by the patient complete success was achieved in 62 per cent of the patients and partial success in 24 per cent. Provided there is full appreciation of the pathological anatomy, strict diagnostic criteria and meticulous surgery, decompression of the nerve root canal is a useful surgical procedure in severely disabled patients suffering from isolated disc resorption.

Abstract: A medullary cone metastasis from an adenocarcmoma of oesophagus, and a solitary lumbar spinal nerve root metastasis from a breast carcinoma, gave rise to two cases of cauda equina syndrome.

Abstract: Spinal cords from 20 patients (13–78 years of age) were studied for the occurrence of peripheral nerve fibers within the cord. Peripheral nerve fibers were observed in all but two younger patients, 13 and 24 years old, respectively, but all the spinal cords were otherwise normal. The nerve fibers were thin and predominantly myelinated. They were seen in two forms, small parallel bundles resembling normal nerve fascicles and larger interlacing bundles or whorled masses indistinguishable from traumatic neuromas. They almost always occurred in the perivascular spaces of the major parenchymal branches of the anterior sulcal artery and/or in the anterior median sulcus. The neuromas in the otherwise normal cords were identical with those occurring in the cord with old traumatic injury in three patients studied, but they were few in the former, while numerous and widespread in the injured segments of the latter. Accumulating evidence suggests 1. that most, if not all, of the parallel nerve bundles about the anterior sulcal artery in otherwise normal spinal cords represent aberrant, regenerated nerve fibers originating from ventral spinal nerve roots which are severed by clinically occult injuries in adult life, and 2. that the regenerated nerve fibers continue to grow into the anterior median sulcus and perivascular spaces and may become entangled or return upon themselves, forming neuromas as their way is blocked by the pia-glial barrier.

Abstract: Evoked potentials were recorded from the skin over the lumbar and cervical portions of the spinal cord, and the scalp over the sensory cortex of the brain, using averaging techniques. Responses could be identified over the cauda equina and root entry zone in the lumbar spine to stimulation of the tibial nerve at the popliteal fossa. These responses had characteristics of nerve root and spinal cord events in their thresholds, timing, duration, and refractoriness. Stimulation of the median nerve at the wrist likewise resulted in recognizable responses over root entry portions of the cervical spinal cord. These later waves had a morphology suggestive of components arising from nerve plexus, nerve roots, and spinal cord. Responses recorded over the spinal cord were in the 1-10 ?V amplitude range. Tibial, peroneal and median nerve stimulation were used to elicit 1-20 ?V responses recorded over the cortex, which were found to be sensitive to the site, amplitude, and rate of stimulation.

Abstract: Serpentine filling defects caused by redundant nerve roots were demonstrated myelographically in three patients with a nonionic, water-soluble contrast material. All patients had either total obstruction or severe stenosis of the subarachnoid space secondary to extradural lesions.

Abstract: This paper describes the technique of anastomosis of intercostal nerves to spinal nerve roots together with Harrington Rod fusion in traumatic paraplegia, with the help of a case history in which this combined procedure has been performed for the first time.

Abstract: Autopsy examination of a 3 1/4-year-old child with a severe congenital hypomyelination neuropathy showed the anterior spinal nerve roots and motor cranial nerves to be almost devoid of myelin in their subarachnoid course. The posterior spinal nerve roots and peripheral nerves were less severely affected. Onion bulb formation was minimal and was present only in the sural nerve. There was extensive glial overgrowth in cranial nerves and spinal nerve roots adjacent to the brainstem and spinal cord. The extent and severity of glial overgrowth were similar to that described in Werdnig-Hoffmann disease and morphologically appeared as glial bundles. These glial bundles are most likely secondary to chronic myelin and axonal damage.

Abstract: Onset and completeness of anesthesia were compared in 15 patients with back pain or sciatica and in 10 patients without back pain given lumbar epidural anesthesia with 20 to 25 ml of 1.5% mepivacaine, 80 mg of methylprednisolone, and 1:200,000 epinephrine. Sensory block was complete within 30 minutes in patients without back pain. Eleven of 15 (73%) patients with back pain had delayed onset of anesthesia ranging from 35 to 95 minutes. The difference between the two groups was statistically significant (p less than 0.001). When there was a delay, the affected nerve roots were blocked 10 to 70 minutes after the contralateral unaffected roots. Differences in time of onset between affected nerves and contralateral nerves were also significant (p less than 0.01). The nerve roots involved, as determined from the myelogram or the electromyogram, or those adjacent to them, were the roots with delayed onset of block. Any effect of the steroid on nerve blockade was ruled out as there was solid anesthesia in patients without back pain.

Abstract: ✓ The transport of protein molecules by axoplasmic flow has been used to trace axonal projections in the trigeminal system of the cat. Autoradiography with tritiated amino acid labeling of synthesized proteins and the transport of the enzyme horseradish peroxidase have been employed. The latter method has enabled demonstration of afferent axons within the portio minor, some of which are of cutaneous origin. The trigeminal “motor root” thus appears to be homologous with spinal ventral roots in possessing a potentially significant sensory function. The presence of such afferent fibers in nerve roots thought previously to have an exclusively motor function may explain instances of preserved sensation or failure to relieve pain following rhizotomy of the trigeminal portio major.

Abstract: A thermographic study on admission of 174 hospital patients with sciatica revealed a significant correlation between decreased temperature of the distal part of the affected limb and the probability of spinal nerve root compression The highest order of preponderance for "coldness" was related to the group of patients whose symptoms were confirmed surgically as those of a herniated disc The follow-up thermograms of 30 patients, on the average 29,4 months postoperatively showed correlation between normalization of the temperature and the relief of symptoms Opinions regarding the neurophysiological mechanism of peripheral vasomotor control are controversial and the findings give rise to discussion of its complex pattern Hypothetically derangement of anterograde axoplasmic transport of vasodilatory peptide macromolecules to the skin vessels may be involved

Abstract: Current nerve repair techniques are based on long history of animal experimentation and clinical experience. The complex anatomy of the peripheral nervous system is closely correlated with function and plays an important role in the nerve repair. Traumatic nerve injuries are classified according to experimental mechanism, anatomical injury, and clinicopathological response. The treatment of surgical disorders is based upon morphological and clinical criteria. The phases of recovery are correlated with useful function. The role that clinical factors other than nerve repair play in determining recovery is presented. The problems with clinical studies and the current expectation for successful recovery are discussed.

Abstract: Sciatic nerve damage by intragluteal injections tends to injure the peroneal nerve trunk more severely than the other components of the sciatic nerve. 2 patients with predominant or sole damage to the posterior tibial nerve trunk were observed. This distribution was documented electrophysiologically. Our cases are unusual and point to a wider spectrum of such injuries. It is also suggested that internal fibrosis of the nerve is of greatest importance as a pathogenetic mechanism in these injuries.