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Current Postoperative Complications of Neurosurgery
CURRENT POSTOPERATIVE COMPLICATIONS OF NEUROSURGERY DONALD
B.
FRESHWATER
IT IS recognized that most of the problems faced by the neurosurgeon in his anxious postoperative observations are common to all surgical cases. There is always the possibility of an occasional wound infection, pulmonary embolus, atelectasis or phlebitis, as well as postoperative hematomas, even though every precaution is taken to prevent their occurrence. It is not my purpose, however, to attempt an exhaustive study or to overlap into the field of general surgery in an analysis of all possible postoperative complications. Likewjse, tomorrow may see the solution of today's problem. Our neurosurgical heritage is such as to make us perhaps extra sensitive to general postoperative hazards-the complications peculiar to neurosurgery being harrowing enough to make us feel that the additional burden imposed by infection, phlebitis or atelectasis may rob us of an otherwise good result. Needless to say, despite what appears to many to be an elaborate preoperative preparation and postoperative attention no stone should be left unturned, and the alertness of the staff is one of the most important and decisive elements in the successful campaign. The complications more identifiable with neurosurgery are best discussed under the specific headings of the disease and the operative procedure. Neither the procedure alone nor the diagnosis alone is a satisfactory category. For instance, brain tumor may be handled surgically by osteoplastic craniotomy, biopsy, decompression, roentgen therapy, or one may be forced to a halt after diagnostic procedures by inoperability. On the other hand, craniotomy is performed for lesions other than brain tumor. Finally, many complications are common to all neurosurgical procedures. TUMOR-CRANIOTOMY
Probably the most commonly hazardous postoperative situation is that met with in craniotomy for expanding intracranial tumor ..The alarming and progressive chain of symptoms of restlessness, confusion, respiratory irregularity, blood pressure fluctuation and deepening coma signifies abnormally increased intracranial pressure whether due to obstructive hydrocephalus, retained ventricular air, hemorrhage, passive congestion or brain swelling. Often the exact cause is determinable and specific treatment can immediately be instituted. The prophylaxis of such an occurrence is admittedly the best form of treatment and to 897
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this end constant ventricular drainage by means of a catheter7 has been routine following ventriculography and almost all brain tumor surgery. In addition, moderate restriction of fluids to reduce brain swelling, a low semi-Fowler position for most advantageous cerebral venous drainage, and constant attention to adequate respiratory exchange have been standard. The importance of the last cannot be overstressed; not only because of the increased tension attendant on respiratory obstruction and carbon dioxide accumulation, but the threat of atelectasis and bronchopneumonia is sufficient to demand around-the-clock control. The importance of early tracheotomy is a hard lesson to learn, but it must be accepted as the procedure of choice not only in cases of obvious ninth and tenth nerve paralysis but in questionable weaknesses of the pharynx and larynx and in any patient in whom the cough reflex is impaired and the accumulation of secretions is in any way beyond the control of ordinary aspiration. In this latter regard it must be the neurosurgeon's responsibility always to have in mind the patient's preoperative pulmonary status, know the risk involved in rendering a bronchiectatic patient even temporarily incapable of disposing of his large amount of sputum, and provide easy access to these secretions by tracheotomy. This is not to say that bronchoscopic aspiration will thereby be avoided, but the frequency of such a procedure which takes its own toll of the patient's strength can be materially reduced. It is to their very good credit and our good fortune that the members of our anesthesiology department are skilled in bronschoscopic aspiration. The neurosurgeon must himself become adept at performing rapidly a careful tracheotomy. This era of endotracheal anesthesia has occasioned paradoxically the situation of a two-horned dilemma. Inevitably the endotracheal tube must be removed in even the most precarious of postoperative conditions. Whether to remove the tube and hope for the best or to leave the tube temporarily in situ and ignore its potential complications is a decision which ultimately rests with the neurosurgeon. If the postoperative course promises to be a stormy one, an indwelling endotracheal tube is a great comfort, but perhaps more to the surgeon than to the patient. Then begins the inevitable procrastination with the tube-the repeated trials without the tube, the hasty replacements, perhaps by inexpert hands, the unparalleled burden of all this on a dangerously ill patient. It is. truly remarkable that any human being could survive such ministrations, to say nothing of a patient who has perhaps been hanging on to a thin thread of life following a prolonged cerebellar operation. The moral, of course, is to make the decision early as to whether tracheotomy will be necessary or not, and when in doubt perform the simpler, less devastating procedure of tracheotomy and be rewarded by fewer respiratory emergencies, less cerebral swelling, congestion and a.noxia, and . a lower incidence of mortality from atelectasis and pneumonia. If any-
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one be in doubt as to the above, let him consult with the successful thyroid surgeon. 4 As a final note of interest concerning postoperative pulmonary complications it is worth while to examine recent work which diminishes the supposed hazards of a properly administered inhalant anesthetic. 8 There is no excuse for complacency and "expectant treatment" either because local anesthesia was used or while early respiratory distress is being blamed on inhalant anesthesia. Of less frequency but great concern is the occurrence of postoperative hematomas. Subgaleal fluid collections are as frequent as the surgeon allows them to be by way of his attention to hemostasis and his preference for or against drainage. 9 These blood clots are a threat to wound healing and a potential culture medium for. bacteria. The decision is often debatable as to whether aspiration should be done to remove pressure on the suture line or whether it should be avoided because of the very real danger of contamination. Inmost cases an attempt should be made using the most careful asepsis, choosing those cases in which the diagnosis of a fluid collection is made as opposed to a clot. Absorption of subgaleal collections does occur, it must be remembered, and what superficially appears to be a large collection may well be an edematous scalp overlying a very small hematoma. The expanding intracranial hematoma, usually extradural, is the complication most feared by the neurosurgeon and demands the most meticulous prophylaxis. Careful attention to hemostasis goes without saying and must be impeccable when cavities resulting from tumor removal or lobectomy are left. What appears to be a reasonably "dry" wound under the relatively ideal conditions of operating room position, anesthesia and clear airway may become (and usually does) a steadily oozing, if not frankly hemorrhagic, one under a different set of conditions on the ward. The suboccipital craniectomy done in the erect position may be "dry" only until the patient is lowered to a conventional position in bed, allowing collapsed venules to reopen. The return of a low blood pressure to normal levels or above may occasion the blowing out of an artery previously satisfactorily controlled by cautery or thrombus. Obviously the above cannot always be guarded against simply by attention to bleeding points and by measures such as closed drainage of the cerebral cavity (in the same fashion as closed ventricular drainage). For this reason the dura mater is sutured to the bone edges and to the bone flap 6 to reduce, if not obliterate, a potential epidural space. Patients who have had cerebellar operations in the erect position are kept in that position for at least twenty-four hours, even while being transported from operating room to ward. Should a hematoma develop despite the above preventive measures, . it is usually heralded by the previously mentioned succession of symp-
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toms of increasing intracranial pressure. It must be quickly and adequately dealt with by re-elevation of the flap, evacuation of the clot and control of bleeding points. The formation of such a hematoma takes place at varying rates of speed, and although it is statistically true, perhaps, that the majority of re-elevations for acute postoperative clot are performed on the second or third postoperative day, such an average or mean is not of too much value in making the diagnosis. The usual clinical picture is one of a patient who has done quite well postoperatively until the second or third day when there is a rise in body temperature, unusual somnolence, moderate increase in pulse pressure, followed by focal seizures and increasing motor and sensory paresis compatible with the operative site. A valuable local sign is tenseness of a decompressive defect or bulging of the flap as the case may be. A lumbar puncture gives excellent confirmatory evidence, but the dangers are obvious. It is better to re-elevate when doubt exists even though at times no significant clot may be found. That it is not always possible to distinguish cerebral edema or brain swelling from clot formation is attested to by flap elevations negative for clot. One treads on dangerous ground in his differential diagnosis and must be wary of procrastination with measures to reduce edema. Nevertheless, a brain containing a glioma which has only been biopsied or partially removed will swell to an alarming degree, becoming clinically important during the same time interval as that common to postoperative clot. Dehydration measures with hypertonic solutions, magnesium sulfate and ventricular drainage are ordinarily effective. Prophylactically, subtemporal or suboccipital decompression can be done at the time of the craniotomy, but they are not always effective. We are becoming more and more aware of the benefits of deliberate incision of the tentorium cerebelli as a means of combating herniation of the uncus with its attendant compression of the brain stem. The problem of postoperative convulsions is handled uniformly in most neurosurgical clinics by routine postoperative anticonvulsant medication. There should be no exception to this when convulsions have been part of the history, and even with patients who have not had antecedent seizures, a few days of anticonvulsive therapy are in order. The effect of even one generalized convulsion in the postoperative period can be so devastating to the paient that every effort should be made to avoid it. Dilantin and phenobarbital are the drugs of choice. Occasionally status epilepticus is the major postoperative complication and requires vigorous treatment, but great precaution should be taken against overdosage with consequent respiratory failure. Consequently, medication at frequent intervals such as flodium amy tal given intravenously slowly until the seizure is controlled is safer than saturating a patient with slowly acting barbiturates. Paraldehyde because of its primary action
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on the cortex can be given by Levin tube or by rectum to control seizures without as great a depressant effect on the respiratory centers. Constant nursing attention is essential. In the mid postoperative period major vascular thomboses, either venous or arterial, are sudden tragedies occurring without warning. Their diagnosis is inextricably confused with other aforementioned complications and is relatively clear only on an elimination basis. Unfortunately, treatment is limited to the use of vasodilating drugs, cervical sympathetic procaine block and supportive measures, all being of dubious value. The serious consequences of craniotomy wound infection are obvious and need no elaboration beyond emphasis. Such a complication may lead to a chain of events of soft tissue destruction, osteomyelitis, meningitis, cerebritis and cerebral abscess. All of these may be successfully handled only to have a cerebrospinal cyst or fistula remaining as an extremely stubborn problem. Needless to say, exacting asepsis is uncompromisingly demanded. Delicate handling of all tissue, preservation of all possible blood supply, meticulous cleansing away of bone chips and dust as well as clots and devitalized tissue and careful suturing are acknowledged prerequisites for a low infection rate. Prophylactic antibiotics-usually crystacillinare given should any break in surgical asepsis be noted. It may be wise to instill penicillin into the operative area after particularly long procedures. Nevertheless, wound infections occur and announce themselves in no way significantly different from general surgical infections with the one exception that leptomeningitis may be the first indication of trouble. Inspection of the wound may be negative in the face of a cerebrospinal . fluid pleocytosis. On the other hand, the immediate postoperative course may be satisfactory only to deteriorate suddenly several weeks later by reason of osteomyelitis or cerebral abscess. This latter seems more likely to occur if antibiotics have been given-but in inadequate doses. Experience indicates tinie and time again that massive doses of penicillin have to be given or other antibiotics added if there is the slightest reason to believe the organism has become resistant. This is all too often the case-particularly when the antibiotic was given prophylactically. Culture and sensitivity studies should be made whenever possible, and the indicated drug given in adequate amounts, keeping in mind the great variation in the ability of these preparations to pass into the cerebrospinal fluid. Great confusion still exists as to the advisability of the intrathecal administration of antibiotics. Suffice it to say that often it appears advisable if the location of the infection throws serious doubt on the probability of the blood-borne antibiotic reaching it. That high concentrations of penicillin in contact with the cortex are epileptogenic
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is recognized. A recent experience with a massive subdural infectionthe first symptom of which arose three weeks following routine trephinations for subdural hematoma-treated by drainage· and lavage with penicillin through four subdural catheters made this very plain. Control of status epilepticus was impossible until it was thought safe to discontinue bathing the cortex with penicillin (2,000 units per cubic centimeter-20 cc. twice per day). There followed recovery both from the infection and the seizures. Failure of control of infection by drug therapy leads to a draining wound with underlying chronically infected soft and bony tissues. The ultimate solution is debridement and secondary closure. Cerebral "fungus," the harrowing complication of the not too distant past, has largely disappeared with the advent of more radical tumor removals and lobectomy. Finally, "metabolic" morbidity and mortality enter the picture and after elimination of those cases of known etiology there remains a group explainable only on a "central" basis. There is eviden~e to suggest that damage to areas other than the diencephalon may lead to fatal uremia." The control of such complications is, of course, individual--early recognition of chemical imbalance gives the most hope for correction, but all efforts are at times unavailing. ANEURYSM-CRANIOTOMY
Most of the previously discussed complications of "Tumor-Craniotomy" are encountered under this heading. There is perhaps less worry about intracranial hypertension, but massive hemorrhage is more to be feared. Intracranial exploration may reveal inoperability, or the surgeon may be forced into clipping major vascular channels, and massive cerebral infarction hangs in the balance. Routinely, these patients have constant special nursing, are placed in a partial Trendelenburg position and supplied with oxygen in as comfortable fashion as possible. The use of anticoagulants and cervical sympathetic block to combat thrombosis and cerebral ischemia is individualized. TIC DOULOUREUX-MIDDLE FOSSA RETROGASSERIAN NEUROTOMY
The invasion of the middle cranial fossa leaves the patient open to many of the previously discussed complications of craniotomy. These are fortunately very infrequent in the hands of a skilled operator who is well oriented at all times. The exposure of the posterior fifth nerve root is usually accomplished extradurally and need not be extensive, but the relation of the third, fourth and sixth cranial nerves, the cavernous sinus and the greater superficial petrosal nerve makes correct orientation of the greatest single importance. In many clinics an intradural route is
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chosen, avoiding several of the above structures but bringing with it the possibility of a new set of complications. Trauma to the third, fourth and sixth nerves brings the obvious deficit, and hemorrhage from or thrombosis in the cavernous sinus is possible but seldom encountered. On the other hand, transient facial palsy of the peripheral type occurs in 2 to 3 per cent of cases, probably from traction on the greater superficial petrosal nerve. The facial weakness may be noticed immediately following operation or its appearance may be delayed a day or two. The palsy should be distinguished from simple paralysis of the frontalis muscle which is the result of section of or trauma to peripheral branches of the seventh nerve because of an overgenerous soft tissue incision. Facial weakness is disturbing and is the basis for much adverse feeling toward the surgical treatment of tic douloureux. Actually, the condition usually clears up although it may take several months to do so. Permanent interruption of the motor fibers of the fifth nerve occurs occasionally but the frequency should be very low. It is a minor complication if unilateral, and seldom noticeable to the patient. If the first division fibers must be sectioned, the corneal anesthesia and lack of blink reflex lead to corneal desiccation, scarring by foreign body, ulceration and keratoconjunctivitis. A protective eye shield, sterile ointment and careful observation are routine in all patients until a corneal reflex is definitely obtained. When first division fibers have to be cut the protection must extend to a permanent dust shield which can be fitted to spectacles. Should corneal ulceration occur despite precautions, immediate canthtlrraphy is indicated and specialized ophthalmologic care instituted. The distressing complication of postoperative herpes2 may appear on the third to fifth day. The condition is self-limited and more disfiguring than discomforting to the patient. The patient must be cautioned about biting the anesthetized mucous membranes. Advice as to careful mastication is usually sufficient. "Losing" food in the mouth is a common early complaint but the patient soon learns to overcome this. Occasionally in this normally older group of patients the postoperative course is marred by a state of mental confusion and disorientation. It cannot be definitely ascribed to anyone cause, cerebral trauma, slowed cerebral circulation from the sitting position and anesthesia being indicted. The condition may persist for twenty-four to fortyeight hours before clearing. Finally, "paresthesias" or better, dysesthesias, in the distribution of the fifth cranial nerve may persist and be very troublesome despite complete facial anesthesia. They are more common in the unstable individual and are extremely stubborn of treatment.
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EXOPHTHALMOS-ORBITAL DECOMPRESSION
Superimposed on the usual craniotomy complications are the added difficulties one may experience with the orbital contents. In the early postoperative period the degree of decompression is not always sufficient to counteract the effects of edema. This is particularly true in exophthalmos of thyrotoxic origin. The orbital contents may swell to an alarming degree, endangering cornea, globe and optic nerve. Prevention by careful canthorrhaphy at the time of the orbital decompression and pressure dressing is far superior to secondary measures. If lid closure and effective counter pressure are maintained for seven to ten days without interruption, little trouble is experienced. Dislocation of the pressure dressing must be promptly corrected day or night. Pulsation of the decompressed orbits soon subsides, and need not be considered a serious complication. DIRECT VISION PREFRONTAL LOBOTOMY
In addition to craniotomy complications this procedure carries the added burden of a patient likely to be uncooperative, and postoperative wound contamination by the patient's ripping off the dressing must be expected and guarded against as well as possible. Superficial scalp infections must be handled carefully lest they extend to cerebrospinal fistula formation and meningitis. Chemotherapy and antibiotic therapy should be quickly instituted until the superficial infection is definitely under control. Should a cerebrospinal fistula develop, conservative handling is possible for a reasonable period of time but if resistant, the . bone button may have to be removed and secondary dural closure made. An immediate postoperative elevation of temperature and pleocytosis without demonstration of organisms is a frequent occurrence. It is selflimited, no cause for alarm and can be differentiated from true meningitis by absence of other clinical signs. Statistics from various clinics both in this country and abroad are in general agreement on mortality attributable to leukotomy. This is somewhat surprising in view of the variety of technics in use during the period of observation. Wilson and Warlund l2 in their analysis of 1000 cases found a 3 per cent operative mortality and Greenblatt'sl long-term follow-up of 205 cases disclosed 6 deaths related to lobotomy (2.9 per cent). Standardization of technic brings a reward of lowered mortality as evidenced by Poppen's8 report of a 1 per cent operative mortality on 470 cases, the mst 205 of which form the basis of Greenblatt's report. McLardy's· analysis of 122 deaths in leukotmoized patients leads one to believe approximately 30 per cent were due to causes accepted as operative complications and this correlates with Greenblatt's statement that 6 of 17 deaths in his group could be classed as related to leukotomy.
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Postoperative hemorrhage was the assignable cause of death in over 60 per cent of Wilson and Warlund's operative deaths. Scrutiny of McLardy's figures reveals a comparable figure; however, in Greenblatt's 6 mortalities, only one was on the basis of hemorrhage. Postoperative convulsive seizures must be expected in from 5 to 10 per cent of cases and must be handled by suppressive medication for varying periods of time. That the onset of seizures may be the indication of more serious things to come is emphasized by Greenblatt-4 of his 6 deaths were preceded by convulsive seizures. Some attention should be given to the postoperative metabolic complications. McLardy 5 makes some interesting observations on the relation of uremic and "trophic" deaths to the presence of trauma to certain areas of the orbital cortex. The efficacy of treatment of such conditions is open to doubt, but recognition is certainly the first step. Finally, it may be said that evaluation of large series of cases has led to no clear conclusions concerning personality changes (Wilson and Warlund12). In general, a change in affect will be noted and one of benefit to the patient hoped for and expected. The proper selection of cases for lobotomy will bring fewer disappointments on this score,u ANEURYSM-CAROTID LIGATION
Because carotid ligation is the most common procedure for the control of intracranial aneurysm it deserves special consideration from the viewpoint of complications. Whereas one escapes many of the hazards of an intracranial procedure, one creates one or two others peculiar to neck dissection and vascular surgery. The insidious appearance of contralateral hemiparesis (and aphasia if the dominant hemisphere is in question) must be watched for most c!lrefully. This may occur despite a negative preoperative test of carotid compression and subsequent daily compressions. Ligation is performed under regional anesthesia by an adventitial imbrication technic which allows release should hemiparesis develop within the next four to six hours. Beyond that time reopening of the vessel is probably useless. Hemiparesis or hemiplegia may develop at any time up to several weeks after operation, although it is questionable whether late hemiplegia is directly the result of operation. Early recognition of hemisphere ischemia is essential to the successful treatment of thrombosis with anticoagulants. Heparinization with round-the-clock supervision by a physician is the safest method if the added complication of hemorrhage is to be avoided. Continuous stellate block can be instituted and nicotinic acid and papaverine administered for whatever effect they may have in increasing cerebral blood flow. Increased oozing at the operative site in the neck may prove trouble-
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some if anticoagulants have to be administered early. This may reach an alarming stage and interdict the use of heparin. The latter may be readily inhibited by protamine. Rupture of the artery at the site of ligature is a very real though rare threat and may be a delayed complication. An immediate mortality usually results. Prevention of such a tragedy is best insured by choice of site of ligation well away from atheromatous plaques and the use of a plication technic. CEREBRAL ANGIOGRAPHY-PERCUTANEOUS
Although the skill of the operator plays the foremost role in determining the severity of complications, the selection of patients is of some significance. An aged, arteriosclerotic diabetic obviously stands a poorer chance of coming through unscathed than does the young adult. Hemiparesis and hemiplegia have been reported following carotid angiography but fortunately usually clear up under management of cerebral ischemia. Hematomas are commonly the result of either multiple, insecure punctures of the carotid or from inadvertent transfixion. They are usually not troublesome and are controlled by gentle compression and ice collar; however, tracheal compression must be guarded against. The occasional injection of 35 per cent diodrast into the perivascular areas is seldom serious. Thorotrast will excite a much more severe tissue reaction and subsequent dense scarring. To avoid severe reaction, a test for abnormal sensitivity to the contrast medium must be made. Injury to cervical roots should not occur in the perform,ance of carotid angiography. Percutaneous vertebral angiographylo demands placement of a needle into a vessel shielded by bony structures and in close relationship to cervical roots, and trauma may result. LAMINECTOMY FOR SPINAL CORD TUMOR
Early in the postoperative state cord compression by hematoma may lead to irreversible paralysis. Constant neurologic evaluation is absolutely essential and the diagnosis strongly suggested by deterioration of cord function. The degree of cord damage attendant on removal of tumor is never entirely predictable at the operating table. Interference with blood supply, thromboses and edema all may take their toll. These are the expected risks and may result in motor and sensory deficits. Secondary to these are decubitus ulcer, urinary and fecal retention or incontinence, trophic disorders and lowered morale commensurate with the degree of sensory and motor paresis. It is being recognized that successful handling of the paraplegic patient is obtained best through the combined efforts of neurosurgery, urology, orthopedics and physical medicine. Control of bladder function by evaluation of the problem, proper temporary and permanent method
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of drainage ,are much more adequately handled by the urologist. The orthopedist contributes in the development of the patient's remaining resources by surgical or prosthetic means, and the physical therapist carries the load of rehabilitation. The late complications of surgical procedures for spinal cord tumor comprise progression (if the lesion is not removable), adhesive arachnoiditis and occasional cerebrospinal fistulas. The latter are prone to occur if a subarachnoid block persists. Revision of the wound and release of the block must be done as a rule to obliterate a potential pathway for meningeal infection. Chronic adhesive arachnoiditis can be extremely resistant to any form of treatment, but when suspected to be developing and progressing in a case in which the dura'has been sutured, re-exploration may be made and the dura left open. RUPTURED LUMBAR INTERVERTEBRAL DISK-PARTIAL HEMILAMINECTOMY
In the early postoperative period of patients on whom a standardized procedure has been done great individual variation is found in degree of back pain and leg pain. Some patients are prone to paravertebral muscle spasm and its extreme discomfort. The preoperative sciatic pain may be miraculously absent immediately after the removal of a disk or it may persist for several days before subsiding. Usually the -first two postoperative days are most uncomfortable ones, and round-the-clock morphia in adequate dosage every three hours should be routine. The patient who has "p.r.n." orders may either be too spartan to request a "shot" or delays, or treatment i8 delayed, until he suffers needlessly. When severe muscle spasm renders a patient opisthotonic, accentuating his sciatica and creating terror, the usual "! of morphine" is totally inadequate. A quarter grain of morphine is considerably more dependable. Bowel distention following laminectomy is rather common, and measures to relieve it are greatly appreciated. The condition, fortunately, is only temporary and can be relieved frequently by the careful insertion of a rectal tube. Both distention and muscle spasm are helped by moist heat applied to back and abdomen. The use of parasympathomimetic drugs for distention as well as for the temporary urinary retention (often seen before the male patient is ambulatory) is well founded, but not always successful. Tubocurarine in oil and wax can be efficacious in relaxing muscle spasm, but the difficulty in proper preparation and i~jec tion plus the irregularity of absorption and action prevents it from being used routinely. If this drug is used, it must be remembered that prostigmine given for urinary retention quickly counteracts the action of the curare. Injury to a lumbar ,nerve root is occasionally unavoidable. Little deficit is evidenced at the usual lumbar disk levels (fourth and fifth lum-
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bar disks) except for the rare occurrence of foot-drop which is prone to occur from injury at the fourth lumbar level. A drop-foot brace may be necessary for a period of time. RUPTURED CERVICAL DISK-PARTIAL HEMILAMINECTOMY
The removal of a laterally herniated cervical disk is usually accomplished without dangerous exposure of the spinal cord. Needless to say, careful handling of cervical roots is mandatory if disabling neurologic deficits are to be avoided in the all important sixth, seventh and eighth cervical and first thoracic dermatomes. The less common midline cervical disk herniation constitutes a problem of greater magnitude because of the progressive, often irreversible, spinal cord damage. Operative handling of the lesion may be extremely difficult and the postoperative condition precarious. The neurosurgeon must be prepared to counteract phenomena attendant on cervical cord injury such as respiratory embarrassment, quadriparesis, spasticity, sphincter disturbances and trophic disorders. These conditions may pertain to a greater or lesser degree prior to operation, but the possibility of temporary and even permanent aggravation must be considered. HYPERTENSION-THORACOLUMBAR SYMPATHECTOMY
The most frequent complication of thoracolumbar sympathe~tomy is intercostal neuritic pain, at times a source of bitter complaint by the patient. The condition very often awaits the fourth or fifth day (when the postoperative condition is judged satisfactory by both patient and surgeon) before putting in its appearance. Although ordinarily of short duration and amenable to the appliction of heat and analgesics, in the occasional case it may call for procaine blocks. Rarely, the intercostal pain becomes an intractable disability particularly in the emotionally unstable individual. The early major postoperative dangers are circulatory and pulmonary. Shock: levels of blood pressure from a combination of blood loss, surgical trauma and vasomotor paralysis must be prevented. The problem ordinarily is not encountered following the first stage of the procedure, but must be expected following the second if extensive sympathectomy has been accomplished. Moderate Trendelenburg position, oxygen, adequate blood' and fluid replacement are usually sufficient. The rationale of use of neQsynephrin and similar vasopressor drugs is not entirely acceptable, and their use demands constant supervision. Occasionally if adrenal failure is suspected desoxycorticosterone is beneficial. Pneumothorax, hydropneumothorax and hemothorax of clinical significapce are occasional complications. Observation, percussion and auscultation of the chest are simple procedures that are diagnostic in most cases and a confirmatory chest roentgenogram can be made. The fluid or air must of course be evacuated by aspiration if of sufficient extent
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to embarrass respiration. Repeated aspirations may be necessary. Minor fluid collections in the retropleural space are relatively common and are ordinarily quickly absorbed. Proper lung inflation at the close of the procedure does much to eliminate these complications. If the selection of hypertensive patients for sympathectomy could always be unequivocal and letter perfect there would be no need to include renal failure as well as other organic decompensations as complications. Such perfection of choice is not possible, and unavoidable mortality occurs when a failing organ fails to rally to supportive measures. Sympathectomy limited in its extent either to the upper dorsal region for vasospastic disease or reflex sympathetic dystrophy or to the lumbar region for these conditions and the common, occlusive vascular disease carries with it fewer complications except those peculiar to the original disease process. Fortunately, the increase of circulation hoped for and usually found in sympathectomized patients leads to relief of ulceration, local pain and gangrene. Gangrene may not always be avoided, however, and a careful day to day watch must be kept so that amputation may be advised and performed when adjudged necessary.
REFERENCES 1. Arnot, R., Talbot, B. and Greenblatt, M.: One to four year follow-up of 205
2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
cases of bilateral prefrontal lobotomy. In Greenblatt, M., Arnot, R. and Solomon, H. C.: Studies in lobotomy. New York, Grune & Stratton, Inc., 1950, p. 87. Epstein, L.: Herpes zoster following operations for facial pain; clinical investigation on 830 cases. Acta psychiat. et neurol. 23:13-48, 1948. Holmes, F.: Analysis of pulmonary complications following anaesthesia and analgesia in 2,064 consecutive cases. Anaesthesia 3:67-72 (Apr.) 1948. Lahey, F. H. and Hoover, W. B.: Tracheotomy after thyroidectomy. Ann. Surg. 133: 65-76 (Jan.) 1951. McLardy, T.: Uraemic and trophic sheaths following leucotomy: neuro-anatomical findings. J. Neurol., Neurosurg. & Psychiat. 13:106-114 (May) 1950. Poppen, J. L.: Pre~ention of posoperative extradural hematoma. Arch. Neurol. & Psychiat. 34: 1068-1069 (Nov.) 1935. Poppen, J. L.: Ventricular drainage as a valuable procedure in neurosurgery; report of a satisfactory method. Arch. Neurol. & Psychiat. 50:587-589 (Nov.) 1943. Poppen, J. L.: Technic and complications of the standard prefrontal lobotomy. In Greenblatt, M., Arnot, R. and Solomon, H. C.: Studies in lobotomy. New York, Grune & Stratton, Inc., 1950, p. 67. Sachs, E.: Diagnosis and treatment of brain tumors and care of the neurosurgical patient. 2nd Ed. St. Louis, C. V. Mosby Co., 1949, pp. 552. Sugar, 0., Holden, L. B. and Powell, C. B.: Vertebral angiography. Am. J. Roentgenol. 61 :166-182 (Feb.) 1949. Watts, J. W. and Freeman, W.: Prefrontal lobotomy; complications and their treatment. J. Intern1l.t. ColI. Surgeons 11:343-350 (July-Aug.) 1948. Wilson,!. and Warlund, E. H.: Prefrontal leucotomy in a thousand cases. Board of Control (England and Wales), London, H. M. Stationery Office, . 1947.
B.
FRESHWATER
IT IS recognized that most of the problems faced by the neurosurgeon in his anxious postoperative observations are common to all surgical cases. There is always the possibility of an occasional wound infection, pulmonary embolus, atelectasis or phlebitis, as well as postoperative hematomas, even though every precaution is taken to prevent their occurrence. It is not my purpose, however, to attempt an exhaustive study or to overlap into the field of general surgery in an analysis of all possible postoperative complications. Likewjse, tomorrow may see the solution of today's problem. Our neurosurgical heritage is such as to make us perhaps extra sensitive to general postoperative hazards-the complications peculiar to neurosurgery being harrowing enough to make us feel that the additional burden imposed by infection, phlebitis or atelectasis may rob us of an otherwise good result. Needless to say, despite what appears to many to be an elaborate preoperative preparation and postoperative attention no stone should be left unturned, and the alertness of the staff is one of the most important and decisive elements in the successful campaign. The complications more identifiable with neurosurgery are best discussed under the specific headings of the disease and the operative procedure. Neither the procedure alone nor the diagnosis alone is a satisfactory category. For instance, brain tumor may be handled surgically by osteoplastic craniotomy, biopsy, decompression, roentgen therapy, or one may be forced to a halt after diagnostic procedures by inoperability. On the other hand, craniotomy is performed for lesions other than brain tumor. Finally, many complications are common to all neurosurgical procedures. TUMOR-CRANIOTOMY
Probably the most commonly hazardous postoperative situation is that met with in craniotomy for expanding intracranial tumor ..The alarming and progressive chain of symptoms of restlessness, confusion, respiratory irregularity, blood pressure fluctuation and deepening coma signifies abnormally increased intracranial pressure whether due to obstructive hydrocephalus, retained ventricular air, hemorrhage, passive congestion or brain swelling. Often the exact cause is determinable and specific treatment can immediately be instituted. The prophylaxis of such an occurrence is admittedly the best form of treatment and to 897
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this end constant ventricular drainage by means of a catheter7 has been routine following ventriculography and almost all brain tumor surgery. In addition, moderate restriction of fluids to reduce brain swelling, a low semi-Fowler position for most advantageous cerebral venous drainage, and constant attention to adequate respiratory exchange have been standard. The importance of the last cannot be overstressed; not only because of the increased tension attendant on respiratory obstruction and carbon dioxide accumulation, but the threat of atelectasis and bronchopneumonia is sufficient to demand around-the-clock control. The importance of early tracheotomy is a hard lesson to learn, but it must be accepted as the procedure of choice not only in cases of obvious ninth and tenth nerve paralysis but in questionable weaknesses of the pharynx and larynx and in any patient in whom the cough reflex is impaired and the accumulation of secretions is in any way beyond the control of ordinary aspiration. In this latter regard it must be the neurosurgeon's responsibility always to have in mind the patient's preoperative pulmonary status, know the risk involved in rendering a bronchiectatic patient even temporarily incapable of disposing of his large amount of sputum, and provide easy access to these secretions by tracheotomy. This is not to say that bronchoscopic aspiration will thereby be avoided, but the frequency of such a procedure which takes its own toll of the patient's strength can be materially reduced. It is to their very good credit and our good fortune that the members of our anesthesiology department are skilled in bronschoscopic aspiration. The neurosurgeon must himself become adept at performing rapidly a careful tracheotomy. This era of endotracheal anesthesia has occasioned paradoxically the situation of a two-horned dilemma. Inevitably the endotracheal tube must be removed in even the most precarious of postoperative conditions. Whether to remove the tube and hope for the best or to leave the tube temporarily in situ and ignore its potential complications is a decision which ultimately rests with the neurosurgeon. If the postoperative course promises to be a stormy one, an indwelling endotracheal tube is a great comfort, but perhaps more to the surgeon than to the patient. Then begins the inevitable procrastination with the tube-the repeated trials without the tube, the hasty replacements, perhaps by inexpert hands, the unparalleled burden of all this on a dangerously ill patient. It is. truly remarkable that any human being could survive such ministrations, to say nothing of a patient who has perhaps been hanging on to a thin thread of life following a prolonged cerebellar operation. The moral, of course, is to make the decision early as to whether tracheotomy will be necessary or not, and when in doubt perform the simpler, less devastating procedure of tracheotomy and be rewarded by fewer respiratory emergencies, less cerebral swelling, congestion and a.noxia, and . a lower incidence of mortality from atelectasis and pneumonia. If any-
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one be in doubt as to the above, let him consult with the successful thyroid surgeon. 4 As a final note of interest concerning postoperative pulmonary complications it is worth while to examine recent work which diminishes the supposed hazards of a properly administered inhalant anesthetic. 8 There is no excuse for complacency and "expectant treatment" either because local anesthesia was used or while early respiratory distress is being blamed on inhalant anesthesia. Of less frequency but great concern is the occurrence of postoperative hematomas. Subgaleal fluid collections are as frequent as the surgeon allows them to be by way of his attention to hemostasis and his preference for or against drainage. 9 These blood clots are a threat to wound healing and a potential culture medium for. bacteria. The decision is often debatable as to whether aspiration should be done to remove pressure on the suture line or whether it should be avoided because of the very real danger of contamination. Inmost cases an attempt should be made using the most careful asepsis, choosing those cases in which the diagnosis of a fluid collection is made as opposed to a clot. Absorption of subgaleal collections does occur, it must be remembered, and what superficially appears to be a large collection may well be an edematous scalp overlying a very small hematoma. The expanding intracranial hematoma, usually extradural, is the complication most feared by the neurosurgeon and demands the most meticulous prophylaxis. Careful attention to hemostasis goes without saying and must be impeccable when cavities resulting from tumor removal or lobectomy are left. What appears to be a reasonably "dry" wound under the relatively ideal conditions of operating room position, anesthesia and clear airway may become (and usually does) a steadily oozing, if not frankly hemorrhagic, one under a different set of conditions on the ward. The suboccipital craniectomy done in the erect position may be "dry" only until the patient is lowered to a conventional position in bed, allowing collapsed venules to reopen. The return of a low blood pressure to normal levels or above may occasion the blowing out of an artery previously satisfactorily controlled by cautery or thrombus. Obviously the above cannot always be guarded against simply by attention to bleeding points and by measures such as closed drainage of the cerebral cavity (in the same fashion as closed ventricular drainage). For this reason the dura mater is sutured to the bone edges and to the bone flap 6 to reduce, if not obliterate, a potential epidural space. Patients who have had cerebellar operations in the erect position are kept in that position for at least twenty-four hours, even while being transported from operating room to ward. Should a hematoma develop despite the above preventive measures, . it is usually heralded by the previously mentioned succession of symp-
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toms of increasing intracranial pressure. It must be quickly and adequately dealt with by re-elevation of the flap, evacuation of the clot and control of bleeding points. The formation of such a hematoma takes place at varying rates of speed, and although it is statistically true, perhaps, that the majority of re-elevations for acute postoperative clot are performed on the second or third postoperative day, such an average or mean is not of too much value in making the diagnosis. The usual clinical picture is one of a patient who has done quite well postoperatively until the second or third day when there is a rise in body temperature, unusual somnolence, moderate increase in pulse pressure, followed by focal seizures and increasing motor and sensory paresis compatible with the operative site. A valuable local sign is tenseness of a decompressive defect or bulging of the flap as the case may be. A lumbar puncture gives excellent confirmatory evidence, but the dangers are obvious. It is better to re-elevate when doubt exists even though at times no significant clot may be found. That it is not always possible to distinguish cerebral edema or brain swelling from clot formation is attested to by flap elevations negative for clot. One treads on dangerous ground in his differential diagnosis and must be wary of procrastination with measures to reduce edema. Nevertheless, a brain containing a glioma which has only been biopsied or partially removed will swell to an alarming degree, becoming clinically important during the same time interval as that common to postoperative clot. Dehydration measures with hypertonic solutions, magnesium sulfate and ventricular drainage are ordinarily effective. Prophylactically, subtemporal or suboccipital decompression can be done at the time of the craniotomy, but they are not always effective. We are becoming more and more aware of the benefits of deliberate incision of the tentorium cerebelli as a means of combating herniation of the uncus with its attendant compression of the brain stem. The problem of postoperative convulsions is handled uniformly in most neurosurgical clinics by routine postoperative anticonvulsant medication. There should be no exception to this when convulsions have been part of the history, and even with patients who have not had antecedent seizures, a few days of anticonvulsive therapy are in order. The effect of even one generalized convulsion in the postoperative period can be so devastating to the paient that every effort should be made to avoid it. Dilantin and phenobarbital are the drugs of choice. Occasionally status epilepticus is the major postoperative complication and requires vigorous treatment, but great precaution should be taken against overdosage with consequent respiratory failure. Consequently, medication at frequent intervals such as flodium amy tal given intravenously slowly until the seizure is controlled is safer than saturating a patient with slowly acting barbiturates. Paraldehyde because of its primary action
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901
on the cortex can be given by Levin tube or by rectum to control seizures without as great a depressant effect on the respiratory centers. Constant nursing attention is essential. In the mid postoperative period major vascular thomboses, either venous or arterial, are sudden tragedies occurring without warning. Their diagnosis is inextricably confused with other aforementioned complications and is relatively clear only on an elimination basis. Unfortunately, treatment is limited to the use of vasodilating drugs, cervical sympathetic procaine block and supportive measures, all being of dubious value. The serious consequences of craniotomy wound infection are obvious and need no elaboration beyond emphasis. Such a complication may lead to a chain of events of soft tissue destruction, osteomyelitis, meningitis, cerebritis and cerebral abscess. All of these may be successfully handled only to have a cerebrospinal cyst or fistula remaining as an extremely stubborn problem. Needless to say, exacting asepsis is uncompromisingly demanded. Delicate handling of all tissue, preservation of all possible blood supply, meticulous cleansing away of bone chips and dust as well as clots and devitalized tissue and careful suturing are acknowledged prerequisites for a low infection rate. Prophylactic antibiotics-usually crystacillinare given should any break in surgical asepsis be noted. It may be wise to instill penicillin into the operative area after particularly long procedures. Nevertheless, wound infections occur and announce themselves in no way significantly different from general surgical infections with the one exception that leptomeningitis may be the first indication of trouble. Inspection of the wound may be negative in the face of a cerebrospinal . fluid pleocytosis. On the other hand, the immediate postoperative course may be satisfactory only to deteriorate suddenly several weeks later by reason of osteomyelitis or cerebral abscess. This latter seems more likely to occur if antibiotics have been given-but in inadequate doses. Experience indicates tinie and time again that massive doses of penicillin have to be given or other antibiotics added if there is the slightest reason to believe the organism has become resistant. This is all too often the case-particularly when the antibiotic was given prophylactically. Culture and sensitivity studies should be made whenever possible, and the indicated drug given in adequate amounts, keeping in mind the great variation in the ability of these preparations to pass into the cerebrospinal fluid. Great confusion still exists as to the advisability of the intrathecal administration of antibiotics. Suffice it to say that often it appears advisable if the location of the infection throws serious doubt on the probability of the blood-borne antibiotic reaching it. That high concentrations of penicillin in contact with the cortex are epileptogenic
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DONALD B. FRESHWATER
is recognized. A recent experience with a massive subdural infectionthe first symptom of which arose three weeks following routine trephinations for subdural hematoma-treated by drainage· and lavage with penicillin through four subdural catheters made this very plain. Control of status epilepticus was impossible until it was thought safe to discontinue bathing the cortex with penicillin (2,000 units per cubic centimeter-20 cc. twice per day). There followed recovery both from the infection and the seizures. Failure of control of infection by drug therapy leads to a draining wound with underlying chronically infected soft and bony tissues. The ultimate solution is debridement and secondary closure. Cerebral "fungus," the harrowing complication of the not too distant past, has largely disappeared with the advent of more radical tumor removals and lobectomy. Finally, "metabolic" morbidity and mortality enter the picture and after elimination of those cases of known etiology there remains a group explainable only on a "central" basis. There is eviden~e to suggest that damage to areas other than the diencephalon may lead to fatal uremia." The control of such complications is, of course, individual--early recognition of chemical imbalance gives the most hope for correction, but all efforts are at times unavailing. ANEURYSM-CRANIOTOMY
Most of the previously discussed complications of "Tumor-Craniotomy" are encountered under this heading. There is perhaps less worry about intracranial hypertension, but massive hemorrhage is more to be feared. Intracranial exploration may reveal inoperability, or the surgeon may be forced into clipping major vascular channels, and massive cerebral infarction hangs in the balance. Routinely, these patients have constant special nursing, are placed in a partial Trendelenburg position and supplied with oxygen in as comfortable fashion as possible. The use of anticoagulants and cervical sympathetic block to combat thrombosis and cerebral ischemia is individualized. TIC DOULOUREUX-MIDDLE FOSSA RETROGASSERIAN NEUROTOMY
The invasion of the middle cranial fossa leaves the patient open to many of the previously discussed complications of craniotomy. These are fortunately very infrequent in the hands of a skilled operator who is well oriented at all times. The exposure of the posterior fifth nerve root is usually accomplished extradurally and need not be extensive, but the relation of the third, fourth and sixth cranial nerves, the cavernous sinus and the greater superficial petrosal nerve makes correct orientation of the greatest single importance. In many clinics an intradural route is
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903
chosen, avoiding several of the above structures but bringing with it the possibility of a new set of complications. Trauma to the third, fourth and sixth nerves brings the obvious deficit, and hemorrhage from or thrombosis in the cavernous sinus is possible but seldom encountered. On the other hand, transient facial palsy of the peripheral type occurs in 2 to 3 per cent of cases, probably from traction on the greater superficial petrosal nerve. The facial weakness may be noticed immediately following operation or its appearance may be delayed a day or two. The palsy should be distinguished from simple paralysis of the frontalis muscle which is the result of section of or trauma to peripheral branches of the seventh nerve because of an overgenerous soft tissue incision. Facial weakness is disturbing and is the basis for much adverse feeling toward the surgical treatment of tic douloureux. Actually, the condition usually clears up although it may take several months to do so. Permanent interruption of the motor fibers of the fifth nerve occurs occasionally but the frequency should be very low. It is a minor complication if unilateral, and seldom noticeable to the patient. If the first division fibers must be sectioned, the corneal anesthesia and lack of blink reflex lead to corneal desiccation, scarring by foreign body, ulceration and keratoconjunctivitis. A protective eye shield, sterile ointment and careful observation are routine in all patients until a corneal reflex is definitely obtained. When first division fibers have to be cut the protection must extend to a permanent dust shield which can be fitted to spectacles. Should corneal ulceration occur despite precautions, immediate canthtlrraphy is indicated and specialized ophthalmologic care instituted. The distressing complication of postoperative herpes2 may appear on the third to fifth day. The condition is self-limited and more disfiguring than discomforting to the patient. The patient must be cautioned about biting the anesthetized mucous membranes. Advice as to careful mastication is usually sufficient. "Losing" food in the mouth is a common early complaint but the patient soon learns to overcome this. Occasionally in this normally older group of patients the postoperative course is marred by a state of mental confusion and disorientation. It cannot be definitely ascribed to anyone cause, cerebral trauma, slowed cerebral circulation from the sitting position and anesthesia being indicted. The condition may persist for twenty-four to fortyeight hours before clearing. Finally, "paresthesias" or better, dysesthesias, in the distribution of the fifth cranial nerve may persist and be very troublesome despite complete facial anesthesia. They are more common in the unstable individual and are extremely stubborn of treatment.
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DONALD B. FRESHWATER
EXOPHTHALMOS-ORBITAL DECOMPRESSION
Superimposed on the usual craniotomy complications are the added difficulties one may experience with the orbital contents. In the early postoperative period the degree of decompression is not always sufficient to counteract the effects of edema. This is particularly true in exophthalmos of thyrotoxic origin. The orbital contents may swell to an alarming degree, endangering cornea, globe and optic nerve. Prevention by careful canthorrhaphy at the time of the orbital decompression and pressure dressing is far superior to secondary measures. If lid closure and effective counter pressure are maintained for seven to ten days without interruption, little trouble is experienced. Dislocation of the pressure dressing must be promptly corrected day or night. Pulsation of the decompressed orbits soon subsides, and need not be considered a serious complication. DIRECT VISION PREFRONTAL LOBOTOMY
In addition to craniotomy complications this procedure carries the added burden of a patient likely to be uncooperative, and postoperative wound contamination by the patient's ripping off the dressing must be expected and guarded against as well as possible. Superficial scalp infections must be handled carefully lest they extend to cerebrospinal fistula formation and meningitis. Chemotherapy and antibiotic therapy should be quickly instituted until the superficial infection is definitely under control. Should a cerebrospinal fistula develop, conservative handling is possible for a reasonable period of time but if resistant, the . bone button may have to be removed and secondary dural closure made. An immediate postoperative elevation of temperature and pleocytosis without demonstration of organisms is a frequent occurrence. It is selflimited, no cause for alarm and can be differentiated from true meningitis by absence of other clinical signs. Statistics from various clinics both in this country and abroad are in general agreement on mortality attributable to leukotomy. This is somewhat surprising in view of the variety of technics in use during the period of observation. Wilson and Warlund l2 in their analysis of 1000 cases found a 3 per cent operative mortality and Greenblatt'sl long-term follow-up of 205 cases disclosed 6 deaths related to lobotomy (2.9 per cent). Standardization of technic brings a reward of lowered mortality as evidenced by Poppen's8 report of a 1 per cent operative mortality on 470 cases, the mst 205 of which form the basis of Greenblatt's report. McLardy's· analysis of 122 deaths in leukotmoized patients leads one to believe approximately 30 per cent were due to causes accepted as operative complications and this correlates with Greenblatt's statement that 6 of 17 deaths in his group could be classed as related to leukotomy.
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905
Postoperative hemorrhage was the assignable cause of death in over 60 per cent of Wilson and Warlund's operative deaths. Scrutiny of McLardy's figures reveals a comparable figure; however, in Greenblatt's 6 mortalities, only one was on the basis of hemorrhage. Postoperative convulsive seizures must be expected in from 5 to 10 per cent of cases and must be handled by suppressive medication for varying periods of time. That the onset of seizures may be the indication of more serious things to come is emphasized by Greenblatt-4 of his 6 deaths were preceded by convulsive seizures. Some attention should be given to the postoperative metabolic complications. McLardy 5 makes some interesting observations on the relation of uremic and "trophic" deaths to the presence of trauma to certain areas of the orbital cortex. The efficacy of treatment of such conditions is open to doubt, but recognition is certainly the first step. Finally, it may be said that evaluation of large series of cases has led to no clear conclusions concerning personality changes (Wilson and Warlund12). In general, a change in affect will be noted and one of benefit to the patient hoped for and expected. The proper selection of cases for lobotomy will bring fewer disappointments on this score,u ANEURYSM-CAROTID LIGATION
Because carotid ligation is the most common procedure for the control of intracranial aneurysm it deserves special consideration from the viewpoint of complications. Whereas one escapes many of the hazards of an intracranial procedure, one creates one or two others peculiar to neck dissection and vascular surgery. The insidious appearance of contralateral hemiparesis (and aphasia if the dominant hemisphere is in question) must be watched for most c!lrefully. This may occur despite a negative preoperative test of carotid compression and subsequent daily compressions. Ligation is performed under regional anesthesia by an adventitial imbrication technic which allows release should hemiparesis develop within the next four to six hours. Beyond that time reopening of the vessel is probably useless. Hemiparesis or hemiplegia may develop at any time up to several weeks after operation, although it is questionable whether late hemiplegia is directly the result of operation. Early recognition of hemisphere ischemia is essential to the successful treatment of thrombosis with anticoagulants. Heparinization with round-the-clock supervision by a physician is the safest method if the added complication of hemorrhage is to be avoided. Continuous stellate block can be instituted and nicotinic acid and papaverine administered for whatever effect they may have in increasing cerebral blood flow. Increased oozing at the operative site in the neck may prove trouble-
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DONALD B. FRESHWATER
some if anticoagulants have to be administered early. This may reach an alarming stage and interdict the use of heparin. The latter may be readily inhibited by protamine. Rupture of the artery at the site of ligature is a very real though rare threat and may be a delayed complication. An immediate mortality usually results. Prevention of such a tragedy is best insured by choice of site of ligation well away from atheromatous plaques and the use of a plication technic. CEREBRAL ANGIOGRAPHY-PERCUTANEOUS
Although the skill of the operator plays the foremost role in determining the severity of complications, the selection of patients is of some significance. An aged, arteriosclerotic diabetic obviously stands a poorer chance of coming through unscathed than does the young adult. Hemiparesis and hemiplegia have been reported following carotid angiography but fortunately usually clear up under management of cerebral ischemia. Hematomas are commonly the result of either multiple, insecure punctures of the carotid or from inadvertent transfixion. They are usually not troublesome and are controlled by gentle compression and ice collar; however, tracheal compression must be guarded against. The occasional injection of 35 per cent diodrast into the perivascular areas is seldom serious. Thorotrast will excite a much more severe tissue reaction and subsequent dense scarring. To avoid severe reaction, a test for abnormal sensitivity to the contrast medium must be made. Injury to cervical roots should not occur in the perform,ance of carotid angiography. Percutaneous vertebral angiographylo demands placement of a needle into a vessel shielded by bony structures and in close relationship to cervical roots, and trauma may result. LAMINECTOMY FOR SPINAL CORD TUMOR
Early in the postoperative state cord compression by hematoma may lead to irreversible paralysis. Constant neurologic evaluation is absolutely essential and the diagnosis strongly suggested by deterioration of cord function. The degree of cord damage attendant on removal of tumor is never entirely predictable at the operating table. Interference with blood supply, thromboses and edema all may take their toll. These are the expected risks and may result in motor and sensory deficits. Secondary to these are decubitus ulcer, urinary and fecal retention or incontinence, trophic disorders and lowered morale commensurate with the degree of sensory and motor paresis. It is being recognized that successful handling of the paraplegic patient is obtained best through the combined efforts of neurosurgery, urology, orthopedics and physical medicine. Control of bladder function by evaluation of the problem, proper temporary and permanent method
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907
of drainage ,are much more adequately handled by the urologist. The orthopedist contributes in the development of the patient's remaining resources by surgical or prosthetic means, and the physical therapist carries the load of rehabilitation. The late complications of surgical procedures for spinal cord tumor comprise progression (if the lesion is not removable), adhesive arachnoiditis and occasional cerebrospinal fistulas. The latter are prone to occur if a subarachnoid block persists. Revision of the wound and release of the block must be done as a rule to obliterate a potential pathway for meningeal infection. Chronic adhesive arachnoiditis can be extremely resistant to any form of treatment, but when suspected to be developing and progressing in a case in which the dura'has been sutured, re-exploration may be made and the dura left open. RUPTURED LUMBAR INTERVERTEBRAL DISK-PARTIAL HEMILAMINECTOMY
In the early postoperative period of patients on whom a standardized procedure has been done great individual variation is found in degree of back pain and leg pain. Some patients are prone to paravertebral muscle spasm and its extreme discomfort. The preoperative sciatic pain may be miraculously absent immediately after the removal of a disk or it may persist for several days before subsiding. Usually the -first two postoperative days are most uncomfortable ones, and round-the-clock morphia in adequate dosage every three hours should be routine. The patient who has "p.r.n." orders may either be too spartan to request a "shot" or delays, or treatment i8 delayed, until he suffers needlessly. When severe muscle spasm renders a patient opisthotonic, accentuating his sciatica and creating terror, the usual "! of morphine" is totally inadequate. A quarter grain of morphine is considerably more dependable. Bowel distention following laminectomy is rather common, and measures to relieve it are greatly appreciated. The condition, fortunately, is only temporary and can be relieved frequently by the careful insertion of a rectal tube. Both distention and muscle spasm are helped by moist heat applied to back and abdomen. The use of parasympathomimetic drugs for distention as well as for the temporary urinary retention (often seen before the male patient is ambulatory) is well founded, but not always successful. Tubocurarine in oil and wax can be efficacious in relaxing muscle spasm, but the difficulty in proper preparation and i~jec tion plus the irregularity of absorption and action prevents it from being used routinely. If this drug is used, it must be remembered that prostigmine given for urinary retention quickly counteracts the action of the curare. Injury to a lumbar ,nerve root is occasionally unavoidable. Little deficit is evidenced at the usual lumbar disk levels (fourth and fifth lum-
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DONALD B. FRESHWATER
bar disks) except for the rare occurrence of foot-drop which is prone to occur from injury at the fourth lumbar level. A drop-foot brace may be necessary for a period of time. RUPTURED CERVICAL DISK-PARTIAL HEMILAMINECTOMY
The removal of a laterally herniated cervical disk is usually accomplished without dangerous exposure of the spinal cord. Needless to say, careful handling of cervical roots is mandatory if disabling neurologic deficits are to be avoided in the all important sixth, seventh and eighth cervical and first thoracic dermatomes. The less common midline cervical disk herniation constitutes a problem of greater magnitude because of the progressive, often irreversible, spinal cord damage. Operative handling of the lesion may be extremely difficult and the postoperative condition precarious. The neurosurgeon must be prepared to counteract phenomena attendant on cervical cord injury such as respiratory embarrassment, quadriparesis, spasticity, sphincter disturbances and trophic disorders. These conditions may pertain to a greater or lesser degree prior to operation, but the possibility of temporary and even permanent aggravation must be considered. HYPERTENSION-THORACOLUMBAR SYMPATHECTOMY
The most frequent complication of thoracolumbar sympathe~tomy is intercostal neuritic pain, at times a source of bitter complaint by the patient. The condition very often awaits the fourth or fifth day (when the postoperative condition is judged satisfactory by both patient and surgeon) before putting in its appearance. Although ordinarily of short duration and amenable to the appliction of heat and analgesics, in the occasional case it may call for procaine blocks. Rarely, the intercostal pain becomes an intractable disability particularly in the emotionally unstable individual. The early major postoperative dangers are circulatory and pulmonary. Shock: levels of blood pressure from a combination of blood loss, surgical trauma and vasomotor paralysis must be prevented. The problem ordinarily is not encountered following the first stage of the procedure, but must be expected following the second if extensive sympathectomy has been accomplished. Moderate Trendelenburg position, oxygen, adequate blood' and fluid replacement are usually sufficient. The rationale of use of neQsynephrin and similar vasopressor drugs is not entirely acceptable, and their use demands constant supervision. Occasionally if adrenal failure is suspected desoxycorticosterone is beneficial. Pneumothorax, hydropneumothorax and hemothorax of clinical significapce are occasional complications. Observation, percussion and auscultation of the chest are simple procedures that are diagnostic in most cases and a confirmatory chest roentgenogram can be made. The fluid or air must of course be evacuated by aspiration if of sufficient extent
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909
to embarrass respiration. Repeated aspirations may be necessary. Minor fluid collections in the retropleural space are relatively common and are ordinarily quickly absorbed. Proper lung inflation at the close of the procedure does much to eliminate these complications. If the selection of hypertensive patients for sympathectomy could always be unequivocal and letter perfect there would be no need to include renal failure as well as other organic decompensations as complications. Such perfection of choice is not possible, and unavoidable mortality occurs when a failing organ fails to rally to supportive measures. Sympathectomy limited in its extent either to the upper dorsal region for vasospastic disease or reflex sympathetic dystrophy or to the lumbar region for these conditions and the common, occlusive vascular disease carries with it fewer complications except those peculiar to the original disease process. Fortunately, the increase of circulation hoped for and usually found in sympathectomized patients leads to relief of ulceration, local pain and gangrene. Gangrene may not always be avoided, however, and a careful day to day watch must be kept so that amputation may be advised and performed when adjudged necessary.
REFERENCES 1. Arnot, R., Talbot, B. and Greenblatt, M.: One to four year follow-up of 205
2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
cases of bilateral prefrontal lobotomy. In Greenblatt, M., Arnot, R. and Solomon, H. C.: Studies in lobotomy. New York, Grune & Stratton, Inc., 1950, p. 87. Epstein, L.: Herpes zoster following operations for facial pain; clinical investigation on 830 cases. Acta psychiat. et neurol. 23:13-48, 1948. Holmes, F.: Analysis of pulmonary complications following anaesthesia and analgesia in 2,064 consecutive cases. Anaesthesia 3:67-72 (Apr.) 1948. Lahey, F. H. and Hoover, W. B.: Tracheotomy after thyroidectomy. Ann. Surg. 133: 65-76 (Jan.) 1951. McLardy, T.: Uraemic and trophic sheaths following leucotomy: neuro-anatomical findings. J. Neurol., Neurosurg. & Psychiat. 13:106-114 (May) 1950. Poppen, J. L.: Pre~ention of posoperative extradural hematoma. Arch. Neurol. & Psychiat. 34: 1068-1069 (Nov.) 1935. Poppen, J. L.: Ventricular drainage as a valuable procedure in neurosurgery; report of a satisfactory method. Arch. Neurol. & Psychiat. 50:587-589 (Nov.) 1943. Poppen, J. L.: Technic and complications of the standard prefrontal lobotomy. In Greenblatt, M., Arnot, R. and Solomon, H. C.: Studies in lobotomy. New York, Grune & Stratton, Inc., 1950, p. 67. Sachs, E.: Diagnosis and treatment of brain tumors and care of the neurosurgical patient. 2nd Ed. St. Louis, C. V. Mosby Co., 1949, pp. 552. Sugar, 0., Holden, L. B. and Powell, C. B.: Vertebral angiography. Am. J. Roentgenol. 61 :166-182 (Feb.) 1949. Watts, J. W. and Freeman, W.: Prefrontal lobotomy; complications and their treatment. J. Intern1l.t. ColI. Surgeons 11:343-350 (July-Aug.) 1948. Wilson,!. and Warlund, E. H.: Prefrontal leucotomy in a thousand cases. Board of Control (England and Wales), London, H. M. Stationery Office, . 1947.