The role of surgery in the management of acute spinal cord or cauda equina injuries remains controversial. The present study analyzed ten admission features and three outcome variables in 208 patients treated in an Acute Spinal Cord Injury Unit, 116 (56%) of whom underwent at least one spinal operation. The surgical and non-surgical groups showed no significant differences in the following seven clinical features: age, sex, distance travelled to the Unit, time interval between trauma and admission, type of accident, severity of injuries to the spinal cord, and severity of associated injuries. However, the two groups showed significant differences in level and type of vertebral column injury, and in the frequency of pre-existing spinal abnormalities. These differences were due to management policies which selected certain injuries for surgical or non-surgical treatment. One-third of the operative procedures were performed primarily for neural decompression, one-third primarily for reduction of bony structures and one-third for fusion. However, 95% of the operative patients had a fusion at the initial operation. Operative treatment was associated with a lower overall mortality rate (6.1%) than non-operative (15.2%), despite a higher frequency of thrombo-embolic complications in the surgical group. Overall, there was no difference between operated and non-operated patients in length of stay or neurological recovery. Surgical management of patients with acute spinal cord injury appears safe in terms of mortality rate and neurological recovery, but it has not been proven to improve the latter.

In the three year period of 1982 to 1985, 152 patients with intracranial vascular malformations were referred to the Bicetre Hospital in Paris, France and the Toronto Western Hospital in Canada. Sixty-six patients with cerebral vascular malformations and 48 patients with dural vascular malformations underwent endovascular treatment. In 8 patients surgery was performed in combination with the embolization procedure. Detailed analysis of the angio-architecture of the vascular malformation reveals certain characteristics which may be of value in predicting the clinical outcome. Comprehensive data analysis and long term follow-up is necessary to assess the role of embolization in the treatment of intracranial vascular malformations.

Management of patients with symptomatic spinal metastasis is designed to (1) relieve pain, and (2) restore or preserve neurologic function. The surgical strategy must include provisions for decompression of the dural sac and nerve roots, and stabilization of the spinal column. The optimal surgical approach, whether from in front or from behind is determined by a number of factors including (1) tumour location, (2) spinal level, (3) fixation factors, (4) patient debility.

This report describes the results of microsurgical discectomy in a prospective study of 200 consecutive patients with intractable sciatica, followed independently by a pain clinic. Post operative morbidity was minimal, the complication rate very low, and patients were discharged home early. Leg pain was relieved in almost all patients, but back pain was relieved in only 72% of patients. The rate of return to work at one, three and twelve months post-operatively was 50%, 83% and 95% respectively. Microsurgical discectomy is an effective and safe procedure.

The optimal timing of definitive aneurysm repair following subarachnoid hemorrhage remains a controversial issue. In order to examine whether the timing of surgery alters the incidence of certain technical difficulties and complications associated with intracranial aneurysm repair, data from two recent co-operative studies were examined. The cases submitted to the International Co-operative Study on Timing of Aneurysm Surgery by the University of Toronto hospitals, and the cases submitted from multiple centres to the Three-Dose Multicentre Randomized Double-Blind Nimodipine Study were evaluated with regard to operative difficulties and complications, comparing early (≤ 3 days) and late (≥ 4 days) surgery following subarachnoid hemorrhage. No significant differences were found in the incidence of such technical problems between the early and late surgical groups. If differences in outcome occur between comparable groups of patients operated early and late after aneurysm rupture, factors other than surgical technical complications may be responsible.

Spontaneous dissection of a major subarachnoid artery is an uncommon cause of stroke in young and apparently healthy individuals. Such dissection does not correlate well with systemic conditions such as emboli, thrombotic or hemorrhagic tendencies or hypertension, nor with disease of blood vessels such as atherosclerosis, fibromuscular dysplasia, cystic medial necrosis or Moya-Moya disease. Unusual exertion has been implicated as a factor in some cases. Gap defects were found in the internal elastic lamina near the site of dissection in three of four cases of spontaneous dissection reported here. It is suggested that such defects, because of their unusual size or number, may be responsible for initiating dissection in susceptible individuals. A detailed study of the major cerebral arteries in cases of dissection and control cases to document the size and frequency of such defects could shed light on the pathogenesis of spontaneous dissection. The subsequent course of events tends to differ in the internal carotid and vertebro-basilar systems. In most cases, the dissection in the internal carotid system is sub-intimal leading to thrombosis and cerebral infarction, while in the vertebrobasilar system dissection lies between the media and adventitia leading to subarachnoid hemorrhage. It is not known what structural differences of the two arterial systems may underlie this difference in the pattern of arterial dissection.

In an attempt to overcome some of the difficulties inherent in vascular anastomosis using standard suture methods, we have developed a technique that allows for rapid non-suture anastomosis of blood vessels. The technique has been used in over 400 anastomoses, including interposition vein grafts in rat, rabbit and dog vessels ranging in size from 0.7 mm to 3 mm in diameter. Animals have been followed for over 1 year ostoperatively with serial angiography and histological evaluation including scanning electron microscopy. Stress studies have compared the biomechanical properties of both non-suture and suture anastomosis. The overall patency rate in non-suture end-to-end anastomoses using an interposition vein graft was 85% at 1 year follow up. Histological evaluation revealed a healing pattern that was temporally similar to that of the suture technique. Stress tests revealed no significant difference between suture and non-suture technique. These studies reveal that the non-suture technique compares favourably with the suture technique, and demonstrate the feasibility of applying this technique to man.