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Journal of Neurology, Neurosurgery, and Psychiatry, 1972, 35, 137-144

Proceedings of theSociety of British Neurological Surgeons

The 82nd Meeting of the Society of British Neurological Surgeons was held in Newcastle uponTyne on 23-25 September 1971 as a joint meeting with the Sociedad de NeurocirugiaLuso-Espaniola.

INFLUENCE OF IMMEDIATE CLOSURE AND INTENSIVETREATMENT IN SPINA BIFIDA CYSTICA

L. P. LASSMAN (Newcastle upon Tyne) reported thatfrom October 1964 to March 1970 a study had beenmade of 240 cases of spina bifida cystica treated byclosure within 48 hours of birth with a follow-up ofthree to six years of 150 consecutive cases. Thespecial care of these patients had lowered themortality rate but had preserved a large number ofchildren whose severe disability was incompatiblewith an independent existence or a satisfactoryquality of survival. It had been found that very few,if any, improved neurologically after treatment butthat a noticeable deterioration occurred betweenbirth and operation due to drying of the sac, super-ficial sepsis, and fibrosis which damaged underlyingnervous tissue. Due to the stretching of an expandingmyelomeningocele, nerve roots might be furtherdamaged and it was, therefore, considered importantthat, where indicated, surgical treatment should beundertaken as soon as possible after birth.An analysis of the results obtained in this series of

cases suggested that babies with myelomeningoceleshould be selected for surgical treatment. It had beenfound that children with no power to flex the hipswould require elaborate splintage to enable them towalk. They would have total sensory loss below the12th thoracic dermatome at least and sphincterparalysis. These children and those with a grosskyphosis or other major congenital defects shouldnot be treated surgically.

CAROTID-CAVERNOUS FISTULA WITH CONTRALATERALEXOPHTHALMOS

A. ROCHA MELO and P. MENDO (Oporto) describedthe signs, symptoms, and angiographic findings in apatient suffering from a carotid-cavernous fistulawith contralateral exophthalmos. They comparedthis case with 14 similar ones from the literature.

ANGIOGRAPHIC DIAGNOSIS AND MICROSURGICAL RE-MOVAL OF ARTERIOVENOUS MALFORMATIONS OF THE

SPINAL CORDA. LEY, F. BACCI, M. ROVIRA, and J. M. RIUS (Barcelona)referred to the work of Djindjian, Di Chiro, and

others on the angiographic visualization, by selec-tive injection of the radicular arteries, of arterio-venous malformations of the spinal cord and stressedthe importance of such detailed studies for adequatediagnosis and the proper planning of surgical treat-ment. They regarded the development of micro-surgical techniques and the use of bipolar coagula-tion as the most significant recent advances in thesurgical handling of these lesions. Since September1969, spinal angiographic studies had been carriedout in 29 patients suspected of having an arterio-venous malformation and in seven the diagnosis wasconfirmed by this means. Three cases were regardedas unsuitable for surgery and the four patients whowere operated upon were presented in detail.The patients were males aged between 28 and 59

years with symptoms extending for two to six years.Three complained of radicular pain and two hadbilateral sciatica attributed to lumbar disc pro-trusions, both of whom had been unsuccessfullyoperated upon elsewhere. Three of the patients alsosuffered transient episodes of claudication of thespinal cord and all had severe motor, sensory, andsphincter disturbances. Myelography had shownpartial blockage with features suggestive of anarteriovenous malformation. Bilateral selectiveangiography was performed at different thoraco-lumbar levels and in each case the lesion was filled bya single radicular artery. All four lesions were situa-ted within the range of the 8th thoracic to the firstlumbar segments, three being dorsally situated andone on the ventrolateral aspect of the cord being atfirst concealed by dentate ligaments. The feedingvessel, which had been demonstrated angiographic-ally, was identified and occluded in three casesfollowed by bipolar coagulation of the abnormalvessels constituting the bulk of the lesion. Totalremoval was achieved in only one case. The firstthree operations produced satisfactory results as,after a transient postoperative aggravation ofsymptoms, which in two cases was very marked, theyshowed progressive improvement beyond their pre-operative state which continued eight to 20 monthsafter operation. The fourth case, who immediatelyafter operation showed hardly any aggravation ofhis neurological condition, died on the fifth post-

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Proceedings of the Society of British Neurological Surgeons

operative day as a result of a pseudomonas infection.In two of the three survivors postoperative spinalangiography was done and showed no filling of thearteriovenous malformation.

CAROTID-OPHTHALMIC ANEURYSMSB. H. DAWSON (Salford) reviewed 20 cases ofcarotid-ophthalmic aneurysms. Fifteen of the cases werefemale and in a quarter of the cases other aneurysmswere present. Sixteen of the patients presented withsubarachnoid haemorrhage and the other four withvisual disturbances. The author emphasized theimportance of oblique angiographic views to pro-vide adequate information of the site, size, anddirection of these aneurysms. Three types of carotid-ophthalmic aneurysm were described: (1) a sub-chiasmal type in which the aneurysm passedhorizontally and medially at right angles to thecarotid and compressed the undersurface of theoptic nerve: (2) in the supra-chiasmal type theaneurysm passed upwards and medially towards theanterior communicating complex and rested uponthe superior surface of the optic nerve and chiasma:(3) the para-chiasmal type of aneurysm passedforwards from the anterior wall of the carotid andover the anterior clinoid process into the anteriorfossa. The three types varied in their clinical pre-sentation and in management. Thus, the authorstated that type 1 aneurysms rarely caused haemor-rhage but, by adhering to the undersurface of theoptic nerve and chiasm, they produced visualdisturbances and might be difficult to dissect fromthe optic nerve in an attempt to define the neck forclipping. Types 2 and 3 commonly presented withsubarachnoid haemorrhage and the surgical accessto type 3 was more straightforward than with theother two.

Four of the 20 patients had received no surgicaltreatment and had had no further bleeding for 10,six, and seven years. The fourth case died from asubarachnoid haemorrhage from another aneurysm.Surgical treatment had been undertaken in 16 cases,10 by craniotomy and six by common carotid liga-tion. Six of the cases subjected to craniotomy didwell, two died after operation, and in two the post-operative condition was poor with no improvementin vision. There had been no morbidity or mortalityin the six patients subjected to common carotidligation and they had remained well for periods ofone to seven years and, in two cases with visualimpairment, significant improvement occurred. Theauthor felt that there was much to be said in favourof common carotid ligation in the surgical manage-ment of these difficult aneurysms and suggested thatasymptomatic ophthalmic aneurysms were bestignored, even when exposed at craniotomy performedfor another bleeding aneurysm.

CAROTID-OPHTHALMIC ANEURYSMSR. P. SENGUPTA (Newcastle upon Tyne) defined,described their incidence, and gave a number ofillustrative case histories of 25 patients with carotid-ophthalmic aneurysms treated by different surgeonsin the Regional Neurological Centre. Nearly alloccurred in females and in a quarter of the casesmultiple aneurysms were present. Management wasconsidered in detail because of the differences ofopinion in regard to the best form of treatment ofthis particular aneurysm. Five cases were not treatedsurgically, three because of further haemorrhagebefore surgery could be undertaken and two whowere not considered fit for operation. One of thelatter patients died at home one year later and theother was alive after a year and was well apart froma hemiplegia. Eight patients were subjected to com-mon carotid ligation. Six of these were alive and wellfrom one to 13 years later, although one patient wasblind in the left eye and another had a mild lefthemiparesis four years after treatment. Of the othertwo patients, one had a further haemorrhage fol-lowed by a right hemiplegia and dysphasia five yearsafter ligation and the second died at home ofunknown cause eight years after treatment. Twelvecases had intracranial operation; eight did well andwere alive with little neurological deficit from 11years to three months after operation; two withsevere visual impairment showed significant improve-ment. Four patients died after operation, one afterhaemorrhage from an unsuspected basilar aneurysm.Three other patients suffered postoperative complica-tions; in one case a right hemiparesis and transientdysphasia followed entrapment and excision of theaneurysm, a transient dysphasia occurred in another,and in the third there was a mild dysphasia andsensory disturbance which were still present afterfour years.When the aneurysm could not be clipped, it was

entrapped. In one case with poor cross-circulationthe aneurysm was wrapped in muslin and in anothera very small aneurysm was so covered by the opticnerve that the operation was abandoned and com-mon carotid ligation employed. Some technicalproblems of surgery and anaesthesia were describedand it was pointed out that, although in this seriescarotid ligation had been successful, there had beena tendency for cases with satisfactory cross-flow tobe submitted to carotid ligation rather than todirect surgery. The situation was also considered inwhich visual impairment caused by the aneurysmwas the principal indication for treatment.

POST-TRAUMATIC ARTERIOVENOUS FISTULAS OF THEBASE OF THE SKULL OTHER THAN CAROTID-CAVERNOUS

SINUS FISTULAF. ISAMAT, F. BARTUMEUS, M. SUBIRANA, and A. M.MIRANDA (Barcelona) stated that in spite of theincrease in the incidence of severe head injuries,

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fistulas between the carotid artery and its branchesand associated veins were still a rare sequela oftrauma, the most common being carotid-cavernousfistula. The traumatic consequences of this occur-rence rapidly led patients to seek medical attentionbut even so in a review of the literature the authorscould find only 545 surgically treated cases. A cranialbruit as the only symptom after a head injury wasvery rare. Two cases in the literature had describeda fistula between the middle meningeal artery and avenous sinus and more recently two cases had beendescribed of fistulas between the internal carotidartery and the venous plexus on the clivus.The authors reported three patients with post-

traumatic 'basal arteriovenous fistulas' who com-plained only of cranial bruit. The angiographicappearances of these cases were demonstrated; thefirst had a fistula between the internal carotid arteryand the basilar venous plexus with striking evidenceof drainage through the vertebral venous plexus andthe occipital vein. In the second case the fistula haddeveloped between the ascending pharyngeal arteryand the basilar venous plexus with drainage throughthe internal vertebral venous plexus and with asecond fistulous communication between the middlemeningeal artery and the superior petrosal sinus.The third case also showed two arteriovenousfistulas, the first between the meningeal branches ofthe occipital artery and the transverse sinus and thesecond again involving the ascending pharyngealartery and the basilar plexus. The difficulties oftreatment were considered.

RADIOCIRCULOGRAPHY IN THE MANAGEMENT OF THEACUTE NEUROSURGICAL SITUATION

H. A. CROCKARD and A. R. TAYLOR (Belfast) hadfound radiocirculography (RCG) to have manyadvantages over any one other method in the acutesituation and a useful adjunct to clinical assessment.Into an antecubital vein 250-500 ,uc Tc99m is in-jected behind an inflated cuff which is rapidlyreleased and the passage of the radioactive bolus ismonitored over the praecordium and then the head.Two collimators are used for each hemisphere. Theradiation detected is counted by ratemeters and theresults expressed graphically. As the isotope passesthrough the head a basic or primary curve isobtained. The rate of change of the primary curve isalso noted. The primary curves provide a TransitTime (TT) for the radioactive bolus and the derivedcurves a Mean Circulation Time (MCT). Slowing ofthe circulation will result in a prolonged TT andMCT. The change may be unilateral or bilateral andit is these changes which the authors had found soinformative. It was emphasized that RCG was notinterpreted with cerebral blood flow in digital terms.Nevertheless, rapid and dramatic changes in theprimary curves were observed pari passu with

clinical alterations and, though in scientific termsthe exact meaning of these changes was unclear, theauthors had found them useful as a guide in theacute situation. The wide variations obtained withfew control studies had been quoted as evidence ofunreliability but in this series more than 150 normalshad been obtained over the years and when groupedaccording to age comprised a very acceptablebiological range. The problem of absolute values didnot arise when the same patient was the subject ofrepeated investigations, for he was his own controland with a lesion in one hemisphere, the other hemi-sphere RCG curve was the control.A series of slides illustrated the use of this tech-

nique in cases of cerebral compression due to anumber of different causes, in cases of arterialspasm and haematoma due to subarachnoidhaemorrhage, and in the monitoring of severe headinjuries.

Hyperventilation had proved valuable in selectedcases in causing clinical improvement, reducing theintracranial pressure, and decreasing transit time.Hyperventilation, however, was not likely to suceedif the transit time did not decrease in the first fewhours along with intracranial pressure.The authors regarded RCG as a simple, repeatable,

atraumatic test which was valuable in monitoringthe acute situation. Changes were noted in RCGcurves hours before clinical alterations in patientswith space occupying lesions. Head injuries might bemonitored, their treatment assessed, and prognosisoffered as a result of serial testing but it was empha-sized that, while the test was simple, reproducibleresults were obtained only by meticulous attention todetails of technique.

CEREBRAL BIOPSYH. H. GOSSMAN (Plymouth) had studied a personal,prospective series during the past six and a half yearsof 98 cases of burr hole biopsy ofcerebral tumours inorder to discover the accuracy of this method ofdiagnosis. The author had performed the burr holebiopsy himself in every case except one and in thefirst three years had performed angiography also.The histological reports had been made by threegeneral pathologists. The reasons for preferring burrhole biopsy were as follows:

1. Anatomical-when a more radical approachmight have inflicted serious neurological damage.

2. Pathological-when the angiogram or latterlythe isotope scan revealed multiple lesions or stronglysuggested malignancy.There was a distribution of two males to one

female. A positive histological diagnosis wasobtained in two-thirds of the cases-that is, 64 werepositive and 34 were negative-but no histologicalreport was regarded as positive unless the pathologisthad named the nature of the tumour. Two cases

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proved to have infarctions and were considered asnegative, three were intracerebral haematomaswhich were removed and these were regarded aspositive. The sixth case was one of herpes simplexencephalitis presenting as a right temporal tumourand this was regarded as a negative biopsy. Thirty-two of the patients were known to have died but thefate of the others was not known. There had beenfive surgical deaths, one from pulmonary embolus,two soon after burr hole biopsy, and two aftersubsequent lobectomy.

EMPTY SELLA HEADACHESS. OBRADOR (Madrid) described the detailed ana-tomical study of Busch of variations of the dia-phragma sellae and recalled that Busch, in his studyof nearly 1,000 patients not suffering from pituitarydisease, had found 40 examples of the most extremedegree of attenuation of the diaphragm, of which 34occurred in females. Significant percentages ofpatients studied radiologically and from necropsymaterial had shown extensions of the subarachnoidspace lying within the sella turcica. The author thenconsidered the development of this syndrome inrelation to the surgical treatment and radiotherapyof pituitary adenomas which, in some cases, wasthought to be the cause of late progressive visualdeterioration. Following the recommendation ofGuiot and others, he had attempted to avoid thedownward displacement of the optic nerves by fillingthe empty sella with small plastic balls. He alsodescribed the occurrence of benign intrasellar cystswhich, after surgical removal, had developed anempty sella as demonstrated by air studies afteroperation. As a final stage an empty and erodedsella was thought sometimes to be the cause ofspontaneous cerebrospinal fluid rhinorrhoea.

After this description of the pathological con-ditions thought to be responsible for the empty sella,the author described 28 female patients presentingwith headaches as their main or only symptom. Inseven of these patients varying degrees of abnormalfilling of the sella turcica by air were demonstratedby lumbar air encephalography. The physicalcharacteristics and nature of the headaches com-plained of were described in relation to the radio-logical abnormality and in three cases in a youngerage group (between 34 and 37 years old) two pre-sented some degree of papilloedema and one withdiplopia.

CEREBROSPINAL FLUID RHINORRHOEA ASSOCIATEDWITH THE EMPTY SELLA SYNDROME

E. LEY PALOMEQUE and F. SALAZAR (Madrid) re-viewed the literature referring to cerebrospinal fluidrhinorrhoea from a defect in the sella turcicaassociated with the radiological picture of an 'empty

sella' in the absence of any apparent neoplastic,inflammatory, or traumatic cause. Ten such patientshad been described in four different papers. Theauthors added a further case history of a patientwho had been under their care and in whom thefistula from the sella had been successfully occludedat the second attempt by removing the tuberculumsellae, entering the sphenoidal sinus, and displacingits mucosa antero-inferiorly. Thus a good view intothe sella was obtained, although no obvious defectin its anterior wall could be demonstrated. It waspossible, however, by this approach to fill theanterior part of the pituitary fossa with muscle aswell as the posterior part of the sphenoidal sinus. Apiece of fascia was left in place over the muscle andthere has been no recurrence of rhinorrhoea in theintervening 15 months.

In considering the characteristics of the 11 casesthe authors noted that there was a high incidence inobese women between the ages of 45 and 57 withoutdetectable hypopituitarism. Usually, except in theirown case, there were no visual disturbances butradiographs of the skull almost always showed asomewhat enlarged sella and sometimes by tomo-graphy it was possible to demonstrate the fistula. Inthese cases air studies or surgical exploration hadalways shown an 'empty sella'. Speculation on thepathogenesis of this syndrome was discussed and itappeared that the surgical treatment of this specialtype of cerebrospinal fluid rhinorrhoea had givengood results in most cases.

EMPTY SELLA SYNDROMEG. BRAVO, B. BARCELO, and R. CARRILLO (Madrid)presented accounts of six patients with pituitary dys-function and visual field defects associated withradiological changes in the sella turcica. Althoughthe initial diagnosis in these cases had been pituitaryadenoma, exploration in some patients and lumbarair encephalography in others had not confirmed theclinical diagnosis. They had demonstrated a sellafilled with CSF and were considered as examples ofthe empty sella syndrome.Some cases had been diagnosed years previously

as pituitary adenomas and had been treated byradiotherapy or by surgery followed by radio-therapy. Two patients had been neither operatedupon nor irradiated.The empty sella syndrome described by Lee and

Adams in 1968 was discussed, as well as the conceptof intrasellar arachnoid diverticulae and intrasellarcyst. The world literature was reviewed and aetiologyand treatment were discussed.

MULTIPLE INTRACRANIAL ANEURYSMSA. PATERSON and M. BOND (Glasgow) first describedthe difference of opinion expressed in the literature

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on the problems of the surgical treatment of multipleaneurysms as regards the limitation of surgery to theaneurysm known to have caused the haemorrhage orthe attempt to obliterate all the aneurysms known tobe present. The authors presented a retrospectivestudy of the results of three forms of treatment formultiple aneurysms-namely, conservative manage-ment, subtotal surgery, and total surgery-empha-sizing a comparison between the two forms ofsurgical treatment. One hundred and sixty-threepatients admitted to Killearn Hospital between 1958and 1969 had been shown on angiography to havemore than one aneurysm. Of these patients 49 weremale and 114 were female. In general, patientstreated surgically were significantly younger thanthose treated conservatively and it was pointed outthat comparison between the groups assigned to thethree different forms of treatment must be inter-preted with reservations, since the method ofselection placed the fittest patients in the group whohad total surgery and the poorest category in theconservatively treated group. However, the differ-ence shown appeared to be of significance for,although those who had all their aneurysms operatedupon were in the fittest group, their mortalityequalled or was higher than those who underwentsubtotal surgery. Surgical complications were theprime factor causing mortality in those who diedafter operation whereas virtually all those patientswho died, having been treated conservatively, did sofrom the effects of subarachnoid haemorrhage. Asmall number of patients who had subtotal surgerydied from a further haemorrhage, indicating thatthe aneurysm that had ruptured was not the one thathad been treated, that the operation was inadequate,or that another aneurysms had bled for the firsttime. Although the number of cases was not great, itwas impressive that of those patients who died aftertotal surgery all but one had had other aneurysmsoperated upon at the same time, whereas the sur-vivors had had more than one operation, havingrecovered from the effects of earlier surgery beforea further operation was undertaken to complete thetreatment. It was suggested that this was theexplanation of the higher mortality in thosetreated by total as opposed to subtotal surgery.Data were still being collected concerning the longterm survival at 3 to 11 years in these cases butwith 7500 of the information now available thereappeared to be no significant difference in thelate mortality between the two surgically treatedgroups.The authors concluded that, in the light of this

analysis, it would be prudent to operate only uponthe aneurysm that could be identified as the sourceof haemorrhage in patients who presented withmultiple aneurysms. If, however, it was decided tooperate upon more than one aneurysm this shouldbe carried out as a staged procedure.

POSITIVE CONTRAST VENTRICULOGRAPHY IN THEDIAGNOSIS OF HYDROMYELIC CAVITIES

P. PERAITA, L. SANJUANBENITO, A. ZAFRA, andS. GIMENEZ ROLDAN (Madrid) described the demon-stration, using the technique of iodoventriculo-graphy, of hydromyelic cavities which communicatedwith the 4th ventricle. Two illustrative cases werepresented: the first was that of a 12 year old boyborn after a difficult labour. At the age of 7 years hehad presented with scoliosis, truncal ataxia, and lossof fine movements of the hands. His disabilities hadprogressed until eventually there were gross dis-turbances of gait and coordination of the upperlimbs, bilateral papilloedema, and glossopharyngealpalsies. By iodoventriculography the communicationwas demonstrated between the floor of the 4thventricle and the widely dilated central canal of thespinal cord. Ventriculoatrial shunt produced re-markable improvement and two years after opera-tion he was able to walk and was living a normal life.The second patient, aged 33 years, had suffered a

cerebral illness of unknown nature in infancy and hissubsequent development had been slightly retarded.At the age of 20 he was first known to have a spasticparaparesis and truncal ataxia with loss of the bicepsreflexes and disturbance of temperature sensation inboth arms. His condition had been a progressive oneand was thought on clinical grounds to be due tohydrocephalus with probable hydromyelia. Atlumbar pneumoencephalography air was introducedinto the central canal of the cord and was seen topass up to the 3rd cervical segment. lodoventriculo-graphy showed a communication between the dilatedcanal, which extended throughout the cord, and theventricular system. At operation the 4th ventriclewas decompressed and the orifice of the centralcanal was occluded. Unfortunately, the patient didnot survive due to respiratory failure.The authors recommended the use of positive

contrast ventriculography in the diagnosis of hydro-myelic cavities in conditions which combined intra-cranial and syringomyelic symptoms and signs andthey also discussed the value of ventriculoatrialshunt in the treatment of such patients.

POST-TRAUMATIC DIZZINESS AND THE ELECTRONYSTAG-MOGRAPH

R. M. KALBAG and N. E. F. CARTLIDGE (Newcastle uponTyne) recalled the long-continued controversy onthe organic nature of symptoms in the 'post-concussional syndrome'. They had studied 400patients who had suffered a head injury during aperiod of two years and reported on their findings asregards the complaint of dizziness. Of the 400 patientsseen during their hospital admission 260 werefollowed up for six months and 140 for one year. Ondischarge 20%V of the patients were still complainingof dizziness and at six months the figure had reduced

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to 1500. This latter group were still complaining ofdizziness at the end of one year and subsequentfollow-up will be reported.The organic origin of this complaint seemed to be

confirmed by the high proportion of cases showingnystagmus induced by change in position andrecords had been obtained using the technique ofelectronystagmography. Examples of such recordswere shown, some taken with the eyes closed. Thecommonest symptom of rotational vertigo wasassociated with clinically visible positional nystagmusin 7500 of patients but even patients with minordegrees of dizziness, often only a feeling of faintnesson arising in the morning, showed positionalnystagmus in about 20%.The authors concluded that the patients' history

alone was inadequate in evaluating dizziness afterhead injury and on the basis of their detailed studiesby electronystagmography they suggested a peri-pheral labyrinthine origin for nystagmus in thesecases.

LATE RESULTS IN THE SURGICAL TREATMENT OFCERVICAL SPONDYLOSIS WITH NEUROLOGICAL INVOLVE-

MENTE. LAMAS (Granada) presented 70 cases of cervicalspondylosis surgically treated with a follow-up ofone to five years which were classified as follows:(1) radiculopathy-39 cases; (2) radiculo-myelo-pathy-18 cases; (3) myelopathy-13 cases.The cases with root compression had been treated

by anterolateral discectomy and interbody fusion byCloward's technique in 14 cases and by Robinson-Smith's technique in 23 cases. Only in two instanceswere laminectomy and foraminotomy performed.Cloward's anterior interbody fusion had beensatisfactory within three to six months in 13 out of14 patients. With the Robinson-Smith technique agood bone fusion had been obtained in 14 out of 23patients, a fibrous arthrodesis in seven, and anegative result in two. However, in the author'sopinion, the degree of fusion was not directly relatedto the clinical result. Thus, pain disappeared in 85%/of the cases and the motor deficit recovered com-pletely in 550/o and partially in 42%. Completerecovery of sensory deficit was seen in only 3500 ofthe affected patients. Laminectomy-foraminotomywas used on only two occasions with an excellentresult in one and a moderate result in the other.The 31 cases of spondylotic myelopathy under-

went a total of 33 operations-in two the anteriorapproach was combined with a posterior decompres-sion. Disc removal at one or more levels with antero-lateral interbody fusion was performed in 19 patients(nine by Cloward's technique and 10 by Robinson-Smith's). In a third of the cases a good bony fusionwas obtained. Cloward's operation seemed moresatisfactory and allowed better visualization. Its

disadvantage was the anterior angulation seen in aquarter of the cases in this group, probably due toprevious alterations of the cervical spine. Improve-ment of the motor deficit and of gait was seen inapproximately 5000 of the cases and sensory im-provement to a lesser degree (350%). Two years afteroperation improvement reduced to 3000. In sevenout of 12 patients submitted to laminectomy-foraminotomy (approximately 60%) an improvementof gait and motor deficit was observed. Two yearsafterwards the improvement was maintained in twothirds of the cases. The author concluded thatapproximately 30 to 4000 of the spondylotic myelo-pathies showed significant improvement two tothree years after surgery (though only two patientswent back to their normal working life) and thatresults seemed to be comparatively better in patientssubmitted to laminectomy.

COMBINED CISTERNAL AND LUMBAR PRESSURE RECORD-INGS IN THE SITTING POSITION USING DIFFERENTIAL

MANOMETRYBERNARD WILLIAMS (Hull) suggested that onclinical grounds pulsatile hydrodynamic factorsaffecting cerebrospinal fluid movement were opera-tive in several diseases, in particular in communica-ting syringomyelia, syringobulbia, cough headache,intraspinal and intracranial subarachnoid cysts,arachnoid pouches in relation to nerve root sheathsand, when combined with hydrostatic factors, inmeningocele and hydrocephalus. He stated that thegreatest movement and pressure changes within thecerebrospinal fluid cavities were the result of trans-mission of energy from the abdominothoracic cavityby the venous plexuses surrounding the spinal cord,which were in free communication with the veins ofthe head. In an attempt to study such energy trans-mission, combined lumbar and cisternal pressurerecordings in the sitting position had been carriedout on 17 patients suffering from cervical myelo-pathy. Pressure changes had been recorded simul-taneously, together with a differential trace in mostinstances. Arterial pulsation, respiratory excursion,Valsalva's manoeuvre, and coughing had beenrecorded together with the response to the patientblowing down a mouth piece to maintain a pressureof 40 mm HgThe most interesting results had been derived from

a consideration of the cough impulse. Patients soonlearned to produce a sharp cough impulse of about0 7 seconds duration with amplitude between 200and 1,000 mm H20 (15-75 mm Hg) which wassuitable for analysis. Such waveforms were easilyreproducible and consistent for any patient and theypermitted analysis of both the lumbar and cisternalwaveform and therefore constituted a variety of'impulse testing' of the cerebrospinal fluid pathways.The following characteristics had been foundconsistently.

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The cough impulse in the lumbar theca always hada higher amplitude than in the cistern. It invariablyrose before that in the cistern, usually by 0 004 secat least. The rate of rise of pressure in the lumbartheca was around 150 to 900 mm H20 in the fastest1/1Oth of a second (110-650 mm Hg/sec). The rate offall was usually of the same order, sometimes fasterand sometimes below the previous resting pressure.The cisternal pressure always rose later to a lesseramplitude and less quickly but also fell less quickly.The cisternal impulse always took longer than thelumbar impulse.At one point towards the end of the impulse the

lumbar and cisternal pressures were equal. This wasthe crossover point (X) after which the cisternalpressure was higher than the lumbar pressure and,where there was not a complete block, flow whichhad previously been upward, reversed and becamedownward. The flow of cerebrospinal fluid wasdependent upon there being no block and upon thedifference in pressure. The upward impulse wasdependent upon the lumbar pressure exceeding thecisternal pressure and the amount of flow dependedupon the time for which it was present. The areabetween the curve of the lumbar pressure wave andthe resting baseline before the crossover point (ALX)minus that of the cisternal curve before the crossoverpoint (ACX) was a measure of the upward impulse.This could be displayed by the use of a differentialmanometer which showed the lumbar pressure minusthe cisternal pressure and which therefore crossed itsown resting baseline at the crossover point X. Theupward impulse, ALX-ACX, was equal to the areabeneath the part of the differential curve giving theupward impulse (ADu); the downward impulse wasgiven by the downward area of the differential curveafter the crossover point (ADd).

In patients with partial spinal block the followingfeatures were seen: the amplitude of the cisternalimpulse was attenuated, the area ACX was less,there was a delay in the rise of the cisternal impulse,the rate of rise was impaired and the length of timefor the impulse to be completed was lengthened. Theratios ALC/ACX and ADu/ADd were increased togreater than 2 in anything approaching a severeblockage.The author was of the opinion that any of these

measurements might prove a more sensitive measureof spinal block than the traditional Queckenstedttest, since the amplitude of pressure changes wasaround four times greater and the speed of pressurechange around ten times greater than for Quecken-stedt's test. Rise and fall and upward and downwardimpulse could all be compressed within less than asecond, which permitted more accurate analysis ofdynamic change. This test could easily be combinedwith Myodil or air myelography for assessment ofcervical spondylosis. It was intended that further usewould be made of the test by correlations with radio-

graphic and clinical methods of assessing partialblockage of the cerebrospinal fluid pathways and itwas hoped that this method of investigation mightprove of value in revealing analogous relationshipsbetween pulsation and flow patterns, such as 'tidalmovement' along the aqueduct in response to intra-cranial arterial pulsation.

INTRACRANIAL PRESSURE CHANGES AFTER SEVERE

HEAD INJURY

I. H. JOHNSTON and W. B. JENNETT (Glasgow) hadstudied in 52 patients the changes in intracranialpressure which might follow a severe head injury.Intracranial pressure was continuously monitored,using an intraventricular catheter, a diaphragmpressure transducer and a paper chart recorder, forperiods of 12 to 120 hours. The patients were placedin three groups according to the maximum meanhourly intracranial pressure levels reached; group I(low), less than 20 mm Hg, group II (medium), lessthan 40 mm Hg, and group III (high), greater than400 mm Hg. Twelve patients fell into the 'lowpressure' group, 21 into the 'medium pressure'group, and 19 into the 'high pressure' group. Veryhigh morbidity and mortality were seen in the 'lowpressure' group (nine deaths, two severely disabledsurvivors) and in the 'high pressure' group (11deaths, five severely disabled survivors). Patients inthe 'medium pressure' group fared better, 11 makinga satisfactory recovery. All patients in the 'lowpressure' group were immediately and deeply un-conscious from the time of injury and showed adecerebrate motor pattern together with primarydisturbances of vegetative function. Six patients inthe 'high pressure' group had a relatively lucidperiod before progressive neurological deterioration.In the individual patient both clinical and radio-logical findings could be misleading as indicators ofsubstantial changes in intracranial pressure. Con-tinuous measurement of intracranial pressure was ofconsiderable value in the management of thesepatients. Twenty-three of the 27 patients in this studywho died had post-mortem examinations. Patho-logical evidence of raised intracranial pressurecorrelated poorly with the evidence from monitoring.All patients showing diffuse destruction of the sub-cortical white matter fell into the 'low pressure'group. Patients in each of the three groups showedischaemic damage in the neocortex and no clearcorrelation between raised intracranial pressure andthis type of secondary damage had yet emerged.

PROTECTIVE EFFECT OF STEROIDS AND SELECTIVE LOCAL

COOLING ON EXPERIMENTAL CEREBRAL OEDEMA PRO-

DUCED BY FREEZING LESIONS

E. RODA, F. VILA, and F. LOPEZ (Madrid) describedthe production of cerebral oedema by freezinglesions in the parietal cortex of 60 dogs. The tracer

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used in these experiments was 10% Fluoresceingiven by intravenous injection 30 minutes beforekilling the animal.

Cerebral oedema produced by this method per-sisted for six to eight days in the dogs used as con-

trols. In other dogs protected with cold circulating

saline at the site of the cortical lesion and also inthose treated with high doses of steroids the im-mediate and delayed oedematous reactions were

considerably reduced. The macroscopic and micro-scopic appearances of these lesions were demon-strated.

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