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The purpose of this study was to identify the ideal start site for a retrograde intramedullary fibular cortical screw based on its relationship to the surrounding soft tissue structures and to assess for damage to the surrounding soft tissue structures caused during placement of the screw. Four fresh frozen cadavers underwent fluoroscopic placement of a 3.5 mm cortical screw utilizing a standardized protocol. No damage to the peroneal tendons were noted in any cadaver with the foot in an inverted and plantarflexed position. The closest structure to the center of the screw head was the anterior talofibular ligament anteriorly (3.33 mm range: 3-4 mm) and the calcaneofibular ligament posteriorly (2.66 mm, range: 2-3 mm). Two screws violated the malleolar fossa medially and were noted to impinge on the lateral process of the talus. The ideal start site for a 3.5 mm intramedullary fibular screw is at the midline on the lateral radiograph and 3.0 mm lateral to the malleolar fossa on the AP radiograph. This avoids damage to the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) and prevents impingement on the lateral process of the talus. (Journal of Surgical Orthopaedic Advances 30(2):078-081, 2021).

To evaluate orthopedic resident perceptions of a didactic curriculum presented in traditional and case-based formats.Prospective cohort study using anonymous web-based survey after each conference evaluating resident perceptions of faculty participation, didactic delivery, content, and overall conference value. Conferences were structured as primarily case-based or traditional lecture. Logistic analysis was performed to determine factors predictive of rating a conference as valuable time spent.Orthopedic residency training program at single institution over an academic year.Orthopedic residents in postgraduate training year 1 to 5 attending mandatory didactic conference.Cased-based conferences received higher Likert ratings on residents' perception of faculty participation, instructor delivery, and improvement in topic understanding when compared to traditional lecture-based conferences (p0.0001 for each factor). Residents also were more likely to rate case-based conferences as valuable time spent (p0.0001). In our logistic model, factors associated with a negative likelihood of rating a conference as valuable were lecture format (odds ratio [OR] = 0.155, 95% CI: 0.115-0.208), PGY-2 level presenter (OR = 0.288, 95% CI: 0.169-0.490), and PGY-3 level presenter (OR = 0.433, 95% CI: 0.269-0.696). Timing in the year, surgical subspeciality, and conference identity were not significant predictors of conference value rating.Longitudinal resident feedback demonstrates highly favorable resident perceptions toward case-based formats in didactic sessions. Junior levels residents are not perceived as effective as senior residents and faculty in presenting material in either format. These methods allow for a dynamic approach to identifying strengths and weaknesses in a resident curriculum as a well as a means for more focused and real-time improvements.

Background:Measuring ankle range of motion (ROM) following injury or intervention is necessary for monitoring recovery as well as for calculating permanent impairment ratings in workers’ compensation cases. In recent years, smartphone application developers have created applications (apps) that emulate ROM measurement tools like the universal goniometer. This study assessed the correlation between smartphone ROM measurements and universal goniometer measurements, as well as the reliability and usability of these apps in clinical practice.Methods:Three raters used the Goniometer app (Gonio), Clinometer app (Clino), DrGoniometer app (DrG), and a universal goniometer (UG) to assess the ankle ROM in plantarflexion and dorsiflexion of 24 patients with ankle pathology. Each patient completed a survey on the usability of the apps.Results:Lin’s concordance correlation coefficient test showed moderate correlation between the smartphone and UG measurements (Lin‘s correlation coefficient [rLC] = 0.931, 95% confidence interval [CI] = 0.911-0.946 for UG-Gonio; rLC = 0.908, 95% CI = 0.881-0.929 for UG-Clino; rLC = 0.935, 95% CI = 0.915-0.950 for UG-DrG). A 2-way mixed model showed good to excellent interrater reliability for each app for plantarflexion and dorsiflexion (ICCp= 0.836, ICCd= 0.912, P < .001 for Gonio; ICCp= 0.788, ICCd= 0.893, P < .001 for Clino; ICCp= 0.777, ICCd= 0.897, P < .001 for DrG). Most participants surveyed were very comfortable with having their ankle ROM measured by a smartphone.Conclusion:Smartphone apps may be a more convenient way to measure ankle ROM than UG. Physicians can use these apps to measure a patient’s ROM in clinic, a patient could send a picture of his or her dorsiflexed or plantarflexed ankle to the physician to remotely track ROM, or a patient could measure his or her own ROM at home using a personal smartphone.Level of Evidence:Level IV, case series.

Leclercia adecarboxylata is an infrequently reported pathogen, typically encountered in immunocompromised patients. Previous literature has demonstrated the predilection of this pathogen for immunocompromised patients. In the rare cases of infection in immunocompetent patients, water exposure typically preceded the soft tissue infection. No case report has been published with L. adecarboxylata causing osteomyelitis of the lower extremity. In this case report, we describe an immunocompetent patient who developed L. adecarboxylata osteomyelitis in the lower extremity after stepping on a wooden pallet.

The study evaluated the physical,mental, and functional outcomes following below-the-knee amputation (BKA) for management of chronic, debilitating lower extremity pain. The hypothesis was that patients who undergo a BKA to alleviate chronic pain achieve a greater level of function, experience decreased pain, and benefit from improved health-related quality of life. Patients who received a BKA attended an orthopaedic clinic and completed questionnaires examining their overall health, functional status, mental health, and pain. Thirty-seven patients were identified as eligible for study participation; 15 agreed to participate. Although most participants continued to experience pain in their residual limb after BKA, they reported their pain decreased to a manageable level. Participants experienced a statistically significant improvement in their perceived physical health. The authors believe a BKA for chronic pain is a reasonable treatment option for patients who continue to experience lower extremity pain after failed medical and surgical management of chronic pain. (Journal of Surgical Orthopaedic Advances 26(4):200-205, 2017).

Lessons learned from battle have been fundamental to advancing the care of injuries that occur in civilian life. Equally important is the need to further refine these advances in civilian practice, so they are available during future conflicts. The Major Extremity Trauma Research Consortium (METRC) was established to address these needs.METRC is a network of 22 core level I civilian trauma centers and 4 core military treatment centers-with the ability to expand patient recruitment to more than 30 additional satellite trauma centers for the purpose of conducting multicenter research studies relevant to the treatment and outcomes of orthopaedic trauma sustained in the military. Early measures of success of the Consortium pertain to building of an infrastructure to support the network, managing the regulatory process, and enrolling and following patients in multiple studies.METRC has been successful in maintaining the engagement of several leading, high volume, level I trauma centers that form the core of METRC; together they operatively manage 15,432 major fractures annually. METRC is currently funded to conduct 18 prospective studies that address 6 priority areas. The design and implementation of these studies are managed through a single coordinating center. As of December 1, 2015, a total of 4560 participants have been enrolled.Success of METRC to date confirms the potential for civilian and military trauma centers to collaborate on critical research issues and leverage the strength that comes from engaging patients and providers from across multiple centers.

Vascular injury associated with extremity trauma occurs in

Background: Lisfranc joint injuries are often misdiagnosed, leading to significant morbidity. Methods for anatomic reduction of the tarsometatarsal joint include closed reduction with casting or surgical stabilization with either Kirschner wires and/or cortical screw fixation. Controversy exists as to which fixation technique offers optimal stability. In the present study, the biome-chanical stability of three fixation methods was tested: (1) four Kirschner wires, (2) three cortical screws plus two Kirschner wires, and (3) five cortical screws. Methods: Ten matched pairs of fresh-frozen cadaveric feet were dissected to their ligamentous and capsular elements. The tarsometatarsal ligaments were completely transected to replicate a Lisfranc dislocation; the “injury” was reduced and stabilized using one of the three methods. Biomechanical studies were performed by applying a 100-N cyclic load physiologically distributed to the plantar aspect of the metatarsal heads. Displacement and force measurements were taken from the first and fifth metatarsal heads. Average stiffness of each construct was calculated from the force displacement curves. Results and Conclusions: Method 2 provided significantly more stability than Kirschner wire fixation. Method 3 created more stiffness than method 2 at the medial portion of the foot; no statistical difference between the two methods was evident at the lateral foot. Clinical Relevance: Cortical screw fixation provides a more rigid and stable method of fixation for Lisfranc injuries as compared to Kirschner wire fixation. This fixation method allows maintenance of anatomic reduction and possibly earlier mobilization with a decreased risk of posttraumatic arthrosis.

Chronic pain from complex regional pain syndrome (CRPS) or reflex sympathetic dystrophy (RSD) of the foot and ankle presents a myriad of diagnostic and therapeutic challenges to the foot and ankle surgeon. The disease involves multiple organ systems, including neural, vascular, bony, and soft tissue structures [1–5]. CRPS is a descriptive term defining a complex disorder or group of disorders that may develop as a consequence of trauma affecting the limbs, with or without an identifiable nerve lesion. To differentiate the presence or absence of nerve trauma, the two categories of CRPS type 1, with no identifiable nerve injury, and CRPS type 2, with identifiable nerve injury, have been proposed. CRPS consists of pain and related sensory abnormalities, abnormal blood flow and sweating, abnormalities in the motor system, changes in structure in both superficial and deep tissues (trophic changes), or functional impairment. It does not exist in the absence of pain. CRPS may be sympathetically independent (SIP) or sympathetically maintained (SMP) [6,7]. Sympathetically maintained pain is defined as significant pain decreased or relief after sympathetic intervention by oral medications (eg, amytriptylene) or parenteral intervention (eg, IV phentolamine, stellate ganglion block). SMP is more completely characterized than SIP, is more responsive to treatment, and has a better prognosis. A hallmark feature of SMP is thermoregulatory and vasomotor instability responding to sympatholytic intervention. A mechanical or neural precipitating or exacerbating event is termed nociceptive.

A synthetic composite bone graft material, composed of fibrillar collagen, hydroxyapatite, and tricalcium phosphate, was evaluated in canine femoral shaft defects and compared to ungrafted defects and defects grafted with autogenous bone. The results of mechanical testing of the grafted femora in torsion at 1 year postoperatively were previously reported. This report details the histological and microscopic features of the graft sites. The results of this study suggest that the healing of the graft site is not yet complete at 1 year and that healing may be more complete in defects that received the synthetic graft as compared to ungrafted sites and autogenous bone graft. The bone tissue appears to respond to the graft particles as if they were bone particles.

Considerable controversy surrounds the management of talar neck fractures regarding the rate of post-traumatic arthrosis, secondary procedures, avascular necrosis, and the effect of the interval to surgery on these variables. A data search using PubMed was performed with the keywords "talus" and "fracture." The search found 1280 studies. Ultimately, 21 reports involving 943 talar neck fractures were analyzed. Data concerning open fractures, the interval to surgery and its relationship to the incidence of avascular necrosis, and the rates of malunion and nonunion, post-traumatic arthrosis, secondary salvage procedures, and functional outcomes were collected and analyzed. The variables examined were not uniformly reported in all studies. The overall rate of avascular necrosis was 33%, with no demonstrated relationship between the interval to surgery and the rate of avascular necrosis. Malunion occurred approximately 17% of the time, with nonunion occurring approximately 5% of the time. Post-traumatic arthrosis occurred in 68% of patients, although secondary salvage procedures were only performed in 19% of patients. Functional outcomes were difficult to assess, given the variability of reported outcomes and unvalidated measures. The optimal management of talar neck fractures has yet to be determined. Although the present review has improved understanding of these difficult fractures, additional studies that use validated outcomes measures are warranted to determine the effect of delayed surgery on final outcomes and optimal treatment methods.

Lower extremity amputations and foot ulcers are complications associated with diabetes, and have been shown to affect diabetic African Americans (AA) three times as often as diabetic non-Hispanic Whites (NHW). Possible causes for the increased risk include ethnic differences in structure and function within the dermis of the lower extremity. Testing this hypothesis requires studying the mechanical properties of skin from different ethnic groups with and without the diagnosis of noninsulin-dependent diabetes. The purpose of this study was to develop a testing method to investigate changes in tensile mechanical properties resulting from static and cyclic compression of dermis harvested from patients undergoing lower extremity amputations. Full thickness dermal samples were obtained from 15 patients undergoing below-knee amputations. Sections of each sample were conditioned with a compressive static pressure (170 mmHg) or cyclic pressures (110-170 mmHg) for 4 hours to elicit collagen bundle remodeling. Skin samples were then tested in tension to obtain sub-plastic stress vs. strain mechanical behavior. Length of the stress-strain toe-region was examined to quantify the effect of collagen bundle remodeling. Toe-region mean lengths were 0.141±0.041, 0.146±0.034, and 0.164±0.064 strains for the control, cyclic, and statically compressed samples respectively (p.05). These results suggest that the preconditioning regimes did not produce sufficient collagen remodeling to affect the tensile properties of full-thickness dermis. Future work will examine histology from each specimen to identify microstructural features associated with this trend.

Fifty standing dorsoplantar and lateral foot radiographs were obtained on a consecutive series of patients seen in an orthopaedic foot and ankle clinic. These radiographs were duplicated, and eight common foot measurements were made on each pair by six experienced examiners. Measurements were made in two ways: first by a subjective visual assessment, and second by quantitative evaluation made according to strictly defined criteria. All measurements were made under controlled, ideal conditions with similar high quality goniometers. The results demonstrated overall greater reliability in the quantitative methods than the non-quantitative methods. For each of the quantitative techniques, a cumulated frequency distribution of differences between examiners was calculated. The approximate 95% bounds for these measures were: hallux-metatarsophalangeal angle = 6 degrees, first intermetatarsal angle = 4 degrees, metatarsophalangeal-5 angle = 11 degrees, fourth intermetatarsal angle = 4 degrees, AP talocalcaneal angle = 20 degrees, lateral talocalcaneal angle = 12 degrees, sesamoid station = 2 grades, and forefoot width = 5 mm. Physicians using these parameters to make decisions regarding patient care and clinical outcomes need to keep in mind these potential errors in making foot radiographic measurements.

Forty-three comminuted fractures of the proximal radius and ulna in 34 patients were treated with operative stabilization using AO/ASIF techniques. The patients were divided into three groups, according to the type of injury: Group I, isolated comminuted fractures of the olecranon (18 patients); Group II, isolated fractures of the radial head (eight patients); Group III, combined olecranon and radial head fractures (eight patients). All fractures were followed until union. The average follow-up period was 18 months (range, 12-48 months). At the time of this review, the average limits of elbow motion were 20 degrees extension, 118 degrees flexion, 65 degrees pronation, and 62 degrees supination. Two patients were unable to return for follow-up examination. Using the functional classification of Broberg and Morrey, results were rated as excellent in nine cases, good in 15, fair in five, and poor in three. The complication rate in this series was 19%: Two patients developed nonunion, and one patient lost reduction during rehabilitation. All of these patients required reoperation, with eventual satisfactory outcome. Three patients developed heterotopic ossification, two of which were minor and one of which produced ankylosis of the elbow joint. Each of these patients had delayed (more than 72 hours postinjury) stabilization. A functional elbow was achieved in 29 of the 32 patients who returned for follow-up examination. Operative stabilization of comminuted fractures of the proximal radius and ulna provides a stable painless joint with a functional, but not full, range of motion.

Background: Interactions between the peripheral nervous system and the healing skeleton are poorly understood. Various clinical observations suggest that the nervous system interacts with and promotes fracture-healing. The purpose of this study was to examine the effect of selective sensory denervation on fracture-healing. Methods: Fifty-one Sprague-Dawley rats underwent unilateral placement of an intramedullary rod followed by creation of a standardized femoral fracture. One group of these rats underwent sensory denervation by means of a localized capsaicin injection, and the other did not. Subgroups were allocated for analysis of mRNA expression of collagen I and II and osteocalcin at three, seven, and fourteen days after the fracture. Additionally, histological examination was performed at four weeks; micro-computed tomography, at five weeks; and biomechanical testing, at six weeks. Results: The sensory-denervated group had significantly less collagen-I upregulation than the sensory-intact group at three days after the fracture (difference in means, forty-four-fold [95% confidence interval = 22.7 to 65.5-fold]; p < 0.001) and significantly less collagen-II upregulation at seven days after the fracture (difference in means, ninefold [95% confidence interval = 4.3 to 13.8-fold]; p < 0.001). In the sensory-denervated group, the fracture callus had a significantly larger cross-sectional area (difference in means, 15.6 mm2 [95% confidence interval = 0.78 to 30.5 mm2]; p = 0.043) and was less dense. Biomechanical testing revealed that sensory denervation significantly decreased the load to failure (difference in means, 28.7 N [95% confidence interval = 1.2 to 56.2 N]; p = 0.022). Conclusions: Sensory denervation negatively affects fracture-healing. These results offer insight into the nerve-bone interaction following injury. Clinical Relevance: These results are relevant to clinicians and researchers who are seeking to improve fracture-healing in patients with associated peripheral nerve injury or peripheral neuropathy.

Hip fractures include fractures of the head, neck, intertrochanteric, and subtrochanteric regions. Head fractures commonly accompany dislocations. Neck fractures and intertrochanteric fractures occur with greatest frequency in elderly patients with a low bone mineral density and are produced by low-energy : mechanisms. Subtrochanteric fractures occur in a pre' dominantly strong cortical osseous region that is exposed to large compressive stresses. Implants used to address these fractures must accommodate significant loads while the fractures consolidate. Complications secondary to hip fractures produce significant morbidity and include infection, nonunion, malunion, decubitus ulcers, fat emboli, deep venous thrombosis, pulmonary embolus, pneumonia, myocardial infarction, stroke, and death.

Nineteen patients underwent surgical synovectomy and debridement for the clinical diagnosis of stage I posterior tibial tendon (PTT) dysfunction. Stage I PTT dysfunction is characterized by pain and swelling along the medial aspect of the ankle. Fourteen patients (74%) reported complete relief of pain, 3 patients (16%) reported minor pain, and 1 patient (5%) had moderate pain, and 1 (5%) had continued severe pain. Sixteen (84%) of the patients subjectively reported being “much better” and had a return of function of the PTT, as evidenced by their ability to perform a single limb-heel-rise test. Two patients (10%) underwent subtalar arthrodesis for progressive foot deformity and continued pain. Based on these results, surgical release, tenosynovectomy, and debridement are recommended for the treatment of stage I PTT dysfunction.

The Rochester bone trephine is a useful instrument for performing small joint arthrodesis in the foot. The technique involves harvesting a dowel graft from the iliac crest and then inserting the graft into a recipient bed across the small joints in the foot. Minimal surgical trauma and patient discomfort result from this technique. Three cases are presented to illustrate the usefulness and diversity of this system.

Summary Low threshold H reflexes were recorded from the anterolateral muscles in 5 of 12 patients with phenylketonuria. A similar incidence was noted in patients with a congenital or infantile hemiparesis. It is felt that the enhancement of this reflex activity is related to damage of developing pathways within the central nervous system.

• Myoclonic contractions of muscles in the abdominal wall and lower extremities developed in a 47-year-old paraplegic woman. The spinal cord was compressed from T-3 to T-8 by an extradural renal cell carcinoma metastasis. To our knowledge, previous studies of patients with spinal myoclonus have not reported a pathologic correlation. In our patient, a focal morphologic change that consisted of vacuolar degeneration and chromatolysis of anterior horn cells was found at the levels of the spinal cord corresponding to the involved muscles. The myoclonus may be spinal in origin and due to an increased excitability of anterior horn cells during the period of sublethal injury.

Mixed venous oxygen saturation (SvO2) was measured continuously with a fiberoptic pulmonary artery catheter in 25 patients during the first 24 hours after cardiac surgery and was compared with the thermodilution cardiac index (CI). The mean correlation coefficient between SvO2 and CI was 0.05 +/- 0.42, and was not significantly different from zero. Although the mean correlation coefficient between the change in SvO2 and the change in CI was significant (p less than .05), the magnitude of the coefficient (0.19 +/- 0.44) indicates poor predictive value. The correlation did not improve when adjusted for multiple clinical variables, and the SvO2 was not predictive of a CI less than 2 L/min/m2, a level of cardiac performance that might require intervention. In conclusion, SvO2 was not predictive of CI postoperatively in the cardiac surgical patient.

Twenty-five patients hospitalized with injuries sustained from tire explosions from 1980 to 1987 were reviewed. Injuries occurred directly from the tire rim or parts of its assembly, from the patient being thrown against adjacent unyielding structures, or a combination of these. Lethal or life-threatening injuries do occur, so these patients initially must be triaged as polytrauma patients. Resuscitation and expeditious attention to life-threatening injuries must be provided when necessary. Serious head, facial, eye, and upper extremity injuries occurred frequently. Pelvic and long-bone fractures, particularly those of the femur, are stabilized primarily as part of the overall treatment of the polytraumatized patient. Open fractures and fractures with arterial injuries and/or compartment syndromes are primarily decompressed, debrided, and appropriately stabilized. After life-threatening and limb-threatening injuries are attended, eye injuries that threaten sight should be addressed. While hand, wrist, and other upper extremity injuries that do not fall in the above categories may not require immediate or primary treatment, they are often critical in determining the patient's final outcome. This is particularly true since most patients are manual workers, often mechanics. Therefore, hand, wrist, and upper extremity injuries should be treated as early as possible and in parallel with other injuries to achieve optimal results and minimize impairment, disability, and time and economic loss from work. Strong emphasis should be placed on education and safety training in preventing this severe form of civilian trauma.(ABSTRACT TRUNCATED AT 250 WORDS)

Ten patients with the diagnosis of systemic sclerosis developed cranial nerve involvement. A trigeminal sensory neuropathy evolved insidiously in all patients and in five of these it was a presenting complaint. The glossopharyngeal nerve was involved in one patient. Taste was impaired in one patient and a unilateral loss of taste with fasciculations of the tongue were noted in another. Tinnitus was a complaint in three patients, two of whom had bilateral impairment of hearing. Facial weakness was noted in five patients. In three, this weakness was bilateral, while in the others the weakness was unilateral, and a past history of acute onset was obtained. The microangiopathy of systemic sclerosis is felt to be primarily responsible for these neurological deficits. The deposition of fibrous tissue may be a secondary phenomenon and contribute to the process by compression of nerves.

SUMMARYCrossed adductor reflexes were recorded electromyographically in ten patients with bilateral lesions of the upper motor neuron. Three of these had a femoral neuropathy. Following blows directed to either the tendon of the adductor muscle or to the medial epicondyle of the femur, large amplitude responses of short latency were recorded from the ipsilateral adductor muscle while small amplitude responses of short latency and large amplitude responses of long latency were recorded from the contralateral adductor. The responses of short latency which were recorded from the ipsilateral and contralateral adductor muscles ranged from 18 to 27 ms. The contralateral responses of long latency ranged from 60 to 67 ms. On tapping the patella or patellar tendon, large amplitude responses of short latency were recorded from the contralateral adductor muscles while the ipsilateral adductor responses were absent. These responses resulted from stretch of the ipsilateral and contralateral adductor muscles. The contralateral responses were mediated across the midline by an extraspinal mechanical pathway.

This study comprises follow-up information or pathologic material, or both, from 34 adult patients with acute transverse myelopathy of unknown cause. These patients had no antecedent neurologic or underlying systemic disease. Five patients died during the first four months of illness. Follow-up information was obtained from the remaining 29 patients 5 to 42 years after onset, and postmortem material also was available in three of these cases. During follow-up a clinical diagnosis of multiple sclerosis was made in only one patient. Two thirds of the patients recovered and became ambulatory, while one third remained paraplegic. The only factor which correlated with prognosis was the observation that patients who retained tendon reflexes and posterior column function had a better recovery than those who exhibited spinal shock.

Deep abdominal reflexes were recorded electromyographically in six patients with lesions of the upper motor neuron. The responses were bilateral, usually with identical latencies which ranged from 16.5 to 25 ms. Individual variation was never greater than 2 ms. It is postulated that these bilateral responses of abdominal muscles were independent stretch reflexes and were not mediated across the midline through an intraspinal pathway.

In seven patients with spastic hemiparesis and in three normal subjects, latencies of the brachioradialis reflex and forearm flexor responses to blows at the styloid process of the radius were identical. Moreover, these latencies were similar to those of independently obtained finger flexor reflexes. H reflexes, obtained only in hemiplegic arms, were of similar latency from brachioradialis and forearm flexor muscles following stimulation of the appropriate nerves. These findings indicate that the brachioradialis reflex and associated contraction of forearm flexor muscles result from independent myotatic reflexes and not from intraspinal spread.

Introduction Reflex motor responses of skeletal muscle to a variety of peripheral stimuli have long been recognized to fall into many distinctive and predictable patterns. 1 In some instances, physiological features and integrative arrangements have now been clarified to a sufficient degree that these in themselves indicate a biological meaning of the reflex responses. For example, myotatic reflexes, controlled by the gamma efferent system, clearly play an important part in postural adjustment and movement. 2 Even these, however, constitute merely a portion of the excitatory events which lead to the coordinated discharge of motoneurons in effective motor activity. 3 Other reflex responses, including some in clinical use, have been less clearly defined and, for the most part, their basic functional roles have escaped detection. Among these are superficial abdominal and plantar responses. Both are basically spinal reflexes. 4-10 The fiber spectrum of their efferent pathways is broad. 4,11 Some fibers

Rosenbach, 20 in 1876, first described visible contractions of abdominal musculature evoked by gentle scratching of skin. Since the zone of effective stimulation was not necessarily limited to areas immediately adjacent to the site of muscular response, and since the contractions were abolished by appropriate motoneuron lesions, the responses were justifiably considered reflex in origin. They have, in fact, been commonly termed superficial abdominal reflexes, although considerable doubt exists concerning their basic mechanisms. Since these reflexes may be depressed or absent in patients with rostrally situated lesions of the central nervous system, some observers, including Astwazaturow 1 and Monrad-Krohn, 17 have postulated that the intrinsic reflex arc in normal persons must traverse the highest levels of the nervous system. The superficial abdominal reflex may be retained, however, on the corresponding side after ablation of the premotor cortex (Bucy 3 ), after removal of the cortex of the hemisphere (Dandy 6 ), and

Three patients with the clinical features of extramedullary compression of the spinal cord due to meningioma and neurinoma all presented with an incomplete Brown-Sequard syndrome. A striking improvement in gait occurred postoperatively in all three patients. The erroneous diagnosis in one patient was posterolateral sclerosis; in another it was rheumatoid arthritis; and in the third, Parkinson's disease and peripheral neuritis. In these cases, the correct diagnosis was made by careful attention to the neurological findings. In view of the exceptionally good prognosis following surgery in extramedullary tumors of this type, it is imperative that this diagnosis should be seriously considered in all patients with a history of progressive difficulty in walking. The importance of visualizing the entire spinal canal while performing myelographic studies is stressed.