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Incidental durotomy is a frequent complication of lumbar spinal surgery. The number and complexity of spinal procedures is increasing, leading to a greater prevalence of dural tears; therefore, it is imperative that spine surgeons be familiar with safe and effective closure techniques. Occasionally, a tear may not be recognized during the procedure, so that one must recognize the signs and symptoms of a cerebrospinal fluid leak postoperatively. Several newer treatment concepts show promise. The current study represents an extensive review of the recent literature on the prevalence, mechanism, diagnosis, treatment, and outcomes of dural tears. The authors provide an overview of the problem, an update on current treatment strategies, and describe the senior author's technique of repair, which is easy to do and is effective in stopping additional leakage of cerebrospinal fluid.

Recorded here is a comprehensive review of the current literature on high tibial osteotomy with emphasis on postponing an inevitable total knee arthroplasty (TKA). Accompanying this review is a confirmatory, retrospective study of 35 patients with 39 high tibial osteotomies with an average follow-up study of 8.5 years (range, 3.8-15.1 years). Twenty-two of the patients (57%) had good results, seven (18%) fair, and ten (25%) poor at final follow-up examination. Nine of the 35 patients required TKA at an average of 4.7 years post-osteotomy. The percentage of good results diminished with time of follow-up study, starting at two years with 87% good results and ending at 15 years with only 57% of the patients remaining in that category. Patients lost an average of 8 degrees of flexion post-osteotomy, regardless of good, fair, or poor result. Patients with favorable results were usually younger than 60 years of age, and had less than 12 degrees of angular deformity, pure unicompartmental disease, ligamentous stability, and a preoperative range of motion are of at least 90 degrees.

Although total knee arthroplasty (TKA) has been studied extensively, objective muscle testing has not been reported. Isokinetic testing of 68 patients with degenerative joint disease scheduled for unilateral TKA revealed that marked muscular deficits in flexion and extension were present preoperatively in the involved knee. Postoperatively, hamstring peak-torque values were able to attain strength levels of the uninvolved knee within the period of seven to 12 months after surgery, whereas the quadriceps mechanism still showed a residual deficit at two years follow-up evaluation. In addition, the ratio of flexion to extension peak torques in the operated knee returned to normal values as the quadriceps mechanism was rehabilitated. A comprehensive evaluation system consisting of Cybex II isokinetic testing, gait mat analysis, and the Hospital for Special Surgery knee rating scale is also presented. Isokinetic testing correlated well with gait analysis. Patients with a nearly balanced quadriceps-to-hamstring ratio walked with a more symmetrical gait pattern. The knee rating scale was less reliable in assessing functional outcome. Functional testing and evaluation at the authors' institution has provided an important source of objective information that allows better planning and evaluation of TKAs. These isokinetic studies enable more critical planning of the rehabilitation program. Hamstring or quadricep exercises may be emphasized as required. The authors conclude that a balanced hamstring to quadriceps mechanism is needed for resumption of normal gait.

Computerized tomographic (CT) scanning of the fourth and fifth lumbar disc spaces with the GE CT/T8800 scanner followed by metrizamide myelography was obtained for 134 consecutive patients with suspected lumbar disc disease. There was an overall concordance rate of 85% between CT scanning and myelography. In those 52 patients treated by surgery, concordance between the CT and the myelogram was similar at 86.5%. Myelography and surgical findings were in agreement in 94.2% of cases, while CT findings and surgical finding agreed in 92.3% of cases. The authors' data indicate that the CT scan is as accurate as myelography in the diagnosis of lumbar disc disease. When the CT scan interpretation is supported by clinical findings, the myelogram may be eliminated in the preoperative patient. Myelography may be reserved for equivocal cases.

Although epidural cortisone injections are commonly used for treatment of lumbosciatic pain, insufficient critical analysis of the end result can be found in the literature. The present study is a retrospective critical analysis of 367 patients with leg pain who were engaged for a minimum of two weeks or an average of two months in multifaceted conservative management without relief of pain. Injections of 10 cm3 of 0.5% bupivacaine and 100 mg of methylprednisolone were given to inpatients treated by the same anesthesiologist. The average follow-up period was 21.4 months (range, 6-36 months). Results were analyzed according to duration of pain and history of prior lumbar spine surgery. The most favorable results (approaching 70% offd-excellent) were observed in patients with subacute radicular leg pain (of less than three months' duration) and chronic leg pain (of greater than three months' duration) with no prior surgery. Negative myelograms and electromyograms (EMGs), in the absence of reflex or motor deficits on physical examination, also pointed toward optimal results. Those patients with chronic pain who had had prior lumbar spine surgery had the least satisfactory results.

A substantial drop in blood volume occurs in patients being treated by total knee arthroplasty (TKA). Of 140 TKAs (108 patients) studied to analyze this blood loss, 70 required transfusion and 70 did not. The average transfusion was 2.6 units per arthroplasty. Blood loss in the nontransfused group was 1.8 units per arthroplasty. The overall mean blood loss was 2.2 units per TKA. Insertion of a constrained TKA resulted in a statistically significant increase in blood loss. Preoperative diagnosis, anesthetic technique, revision arthroplasty, patellofemoral arthroplasty, and tourniquet technique did not statistically affect the blood loss. The bulk of the blood loss is collected postoperatively in the suction drainage system.

Muscle biopsy is often incorrectly performed despite the fact that it is a relatively simple procedure. A consistently reproducible surgical technique in 93 open vastus lateralis muscle biopsies implemented in conjunction with neuromuscular and malignant hyperthermia research demonstrated 14 cases of malignant hyperthermia and a variety of forms of neuromuscular pathology. No wound complications or disabilities have resulted from this procedure. The procedure includes careful selection of biopsy site, regional anesthesia, atraumatic dissection, and immediate processing of the biopsy sample. A new muscle biopsy clamp is described. The authors recommend the vastus lateralis for the biopsy site unless another area of involvement is specifically indicated. Careful attention to technical details is required for optimal results.