Biomedical subjects
M H Savitz
Publications and source records attributed to M H Savitz.
Topical irrigation with polymyxin and bacitracin for spinal surgery.
BACKGROUND: The purpose of the present study was to evaluate constant irrigation with saline containing 50,000 units each of polymyxin and bacitracin in a regimen of antimicrobial prophylaxis for clean spinal surgery at two community hospitals with a zero infection rate. METHODS: The focus was on the bactericidal effects of prophylactic topical antibiotics by assessing random contamination in neurosurgical wounds from: 1) the flora of the integument and nares of the operating team, 2) the surgical apparel, 3) the patient's skin, 4) air-borne organisms in the operating theater, and 5) the surgeon's gloves. RESULTS: Based on individual biotyping of bacteria and antimicrobial sensitivity testing, no consistent source or pattern could be uncovered for the organisms recovered from the operative site. Relying on longitudinal data, the incidence of intraoperative bacterial growth with continuous saline lavage was reduced from 64 to 4% when the combination of topical polymyxin and bacitracin was added. CONCLUSIONS: Although the virtual elimination of bacterial growth in the surgical site was accomplished, the efficacy of topical antibiotics in the prevention of wound infection remains unproven.
Another look at ventriculosubgaleal shunting procedures.
Ventriculosubgaleal shunts were available at the turn of the century as a treatment for hydrocephalus. Almost 80 years later, Perret and Graf advocated such shunting for the temporary decompression of ventricles enlarged by tumors or by hydrocephalus. The use of a subgaleal shunt in acute head trauma was first published in 1983. No direct measurement of intracranial pressure was attempted in 30 cases. Evidence by computed tomography of compressed ventricles and cerebral contusion correlated well with elevated pressure. When the Camino intracranial pressure monitor became available, the device was inserted before placement of the shunt to assess the appropriateness and efficacy of the method in 21 patients. An additional 22 cases of intraventricular hemorrhage with acute hydrocephalus were treated over a 17-year period. The simple method of shunting into the subgaleal space has broad application for the temporary relief of increased intracranial or high-pressure hydrocephalus.
Microneurosurgery in suburbia.
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Meta-analysis of antibiotic prophylaxis.
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Pigmented villonodular synovitis.
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Same-day microsurgical arthroscopic lateral-approach laser-assisted (SMALL) fluoroscopic discectomy.
The 2-year experience of one neurosurgeon with Kambin's orthopedic instruments and frame for arthroscopic microdiscectomy is reported. Arthroscopy using a unilateral approach and monoportal technique is a valuable adjunct to fluoroscopic monitoring. One hundred patients underwent same-day microsurgical arthroscopic lateral-approach laser-assisted (SMALL) fluoroscopic discectomy. In addition, suspected spinal tumors in three patients were treated by biopsy and infection of the disc space was drained in one. A prototype operating discoscope was employed for delivery of the neodymium:yttrium-aluminum-garnet laser beam to assist with hemostasis. Seventy-five "ideal" cases were identified that exhibited the following features: 1) up to a 6-month history of unilateral sciatica symptoms, which responded to bed rest; 2) mechanical signs of nerve root irritation when the patient was erect; 3) computerized tomography or magnetic resonance imaging studies interpreted as showing one protruding or prolapsed disc without extrusion; 4) no segmental spondylosis at the level of a herniated nucleus pulposus; 5) no motor weakness; 6) no prior disc surgery; 7) no obesity; and 8) no diabetes mellitus. Twenty-five "nonideal" cases failed to meet one or more of the above criteria. Good outcome rates were not substantially different in the two groups, success being judged in part by patient satisfaction. Complete success was evidenced in two-thirds of cases by early return to work, but improvement was also determined by increased mobility and a reduction in pain medication from narcotic to analgesic agents. Three patients underwent repeat surgery (laminotomy), but only one improved. Two years has provided sufficient clinical experience to determine that a percutaneous endoscopic procedure under neuroleptanalgesia may become a significant surgical alternative.
Preoperative and postoperative neuroradiologic evaluation of cervical disk disease.
For over five years, a 2.0 Tesla superconductive magnetic resonance imager (Elscint) has been available in Rockland County for neuroradiologic evaluation of cervical disk herniation, stenosis, and spondylosis. Refinement in surface coil design, software, and scanning technique seems to have overcome the problems of providing thin, artifact-free sections with high signal to noise and contrast to noise in a short amount of time. Noninvasive magnetic resonance imaging has been used routinely to preoperatively screen and to postoperatively diagnose patients with cervical radiculopathy and myelopathy. The only patients who underwent conventional myelography or computerized-tomographic myelography were extremely claustrophobic or had a contraindication to MRI such as an aneurysm clip or pacemaker.
Minimalist approach to anterior cervical diskectomy.
Since 1975 I have performed a series of 500 anterior cervical diskectomies in my suburban practice. Simple supine positioning and tension in the anterior cervical region created by a folded sheet under the shoulders and posterior neck allowed intraoperative as well as preoperative confirmation of the correct level. The incision was 4.5 cm in length to the left of the midline, and only a small number of standard Cloward instruments were employed. A fiberoptic head light and 4.5x binocular loupes provided adequate illumination and magnification of the entire intervertebral disk space. Removal of degenerative disk material with pituitary rongeurs yielded 4-6 gm of specimen. Microcurettes aided in exploration of the foraminal areas. Use of a power drill facilitated removal of osteophytic ridging. The overall results compared favorably to those of series reporting the results of spinal fusion: minimal blood loss, little tissue swelling, less need for narcotics, fewer days in the hospital, earlier return to normal activity, no wound infection or diskitis, and low rate of reoperation.
Investigations of the bacteriologic factors in cervical disk surgery.
A study was undertaken to evaluate the potential risk of wound infection in cervical disk disease, the appropriateness of the current prophylactic regimen of intravenous cefazolin at Good Samaritan Hospital, and the increasing resistance of coagulase-negative staphylococci in nosocomial infections. In addition, the methodology used in three prior studies was used to verify that double-gloving is a more effective barrier to bacterial contamination than single-gloving and that topical streptomycin lavage is superior to constant irrigation with plain saline. No wound infections were documented in the 40 patients who underwent cervical disk surgery in a 12-month period. Coagulase-negative Staphylococcus species were the most common bacterial isolate, but only 20% were resistant to cefazolin. Of the 11 S. aureus isolates, 9 were sensitive to cefazolin and 2 were methicillin resistant. A remarkable 95% (114/120) of the intraoperative wound cultures were free of bacteria. In only 2 cases was there a serial increase in colonies of the same organism over the course of the operation. There was one positive glove culture--coagulase-negative Staphylococcus sensitive to cefazolin. The patient's skin was identified as the source of contamination in 3 intraoperative cultures of the wound and 2 cultures of the ambient operating room air. Neither individual biotyping of bacteria nor antimicrobial susceptibility testing uncovered any consistent source or pattern to account for the organisms in the surgical wound or ambient operating room air. Bacteria resistant to cefazolin were found in 36% of the intraoperative environmental cultures but in only 16% of the isolates from patients' skin.(ABSTRACT TRUNCATED AT 250 WORDS)
Investigations of the bacteriological factors in clean neurosurgical wounds.
A number of questions remained unanswered by the empirical success of antimicrobial prophylaxis for neurosurgical patients at The Mount Sinai Hospital during a 15-year period. Vancomycin (1 g intravenously) and tobramycin (80 mg intramuscularly) were administered in the induction room. Streptomycin (50 mg) was mixed into each liter of saline used to irrigate the surgical incision. A series of 45 consecutive clean neurosurgical operations were investigated. The potential sources of random contamination of the surgical wound that were studied included the following: 1) the patient's skin; 2) the flora of the skin and nares of the operating team; 3) the surgical apparel; 4) the surgeons' gloves; and 5) the airborne organisms in the operating theater. No wound infections were documented during a 4-month period between June and September of 1991. A remarkable 98% of the intraoperative cultures of the surgical wounds were free of bacteria. Positive cultures of glove imprints were found in 29% of the operations, and the bacterial source was traced to four different surgeons in four operations (9%). The surgeons' gloves were also a source of potential pathogens (Staphylococcus aureus) in two instances, but the bacterial species were also recovered from cultures of the environment. Based on individual biotyping of bacteria and antibiotic susceptibility testing, no consistent source or pattern could be uncovered for the bacteria in the surgical wound or the operating room air.(ABSTRACT TRUNCATED AT 250 WORDS)
Cyst of the ligamentum flavum: report of six cases.
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Magnetic resonance imaging in the preoperative evaluation of cervical radiculopathy.
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Prophylactic antibiotics.
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Percutaneous radiofrequency rhizotomy of the lumbar facets: ten years' experience.
Over a 10-year period, 142 percutaneous radiofrequency facet rhizotomies were performed at a suburban community hospital on patients with incapacitating low back pain after various modalities of conservative treatment had failed. Neuroradiologic studies were negative or failed to reveal a herniated disk in all patients. The initial series reported in 1986 included 56 patients who had undergone previous spinal surgery and 59 patients who had lumbosacral radiculitis. An additional 27 patients with lumbosacral radiculitis have been treated. The combined use of fine thermocouple electrodes, image intensifier, nerve stimulator, and radiofrequency lesion generator provided a simple and safe technique for the relief of pain. Improvement, assessed by reduced medication requirement and increased employment, occurred in 60% of the patients.
Synovial cysts of the lumbar facet joint.
A study of 42 synovial cysts arising from the lumbar facet joint is presented. Intraspinal cysts caused radicular pain and cauda equina syndrome in 11 patients. In a series of 1,400 lumbar laminotomies for a herniated disk, 31 incidental nodules arising from the exposed facet as paraarticular masses were found and excised. The limited number of reports in the orthopedic and neurosurgical literature has not dealt adequately with the etiology or incidence of these benign lesions. The neuroradiologic appearance and histopathologic findings are briefly discussed.