"No clinical puzzles more interesting": Harvey Cushing and spinal trauma, the Johns Hopkins Hospital 1896-1912

Although Harvey Cushing played a central role in the establishment of neurosurgery in the United States, his work on the spine remains largely unknown. This article is not only the first time that Cushing's spinal cases while he was at Johns Hopkins have been reported, but also the first time his management of spinal trauma has been described. We report on 12 patients that Cushing treated from 1898 to 1911 who have never been reported before, including blunt and penetrating injuries, complete and incomplete spinal cord lesions, and both immediate and delayed presentations. Cushing performed laminectomies within 24 hours on patients with immediate presentations-both complete and incomplete spinal cord lesions. Among those with delayed presentations, Cushing did laminectomies on patients with incomplete spinal cord injuries. By the end of his tenure at Hopkins, Cushing advocated nonoperative treatment for all patients with complete spinal cord lesions. Four patients died while an inpatient, with meningitis and cystitis leading to the death of 1 and 3 patients, respectively. Cystitis was treated with intravesicular irrigation; an indwelling catheter was placed by a suprapubic cystostomy in four. Cushing was one of the first to report the use of x-ray in a spine patient, in a case that may have been one factor leading to his interest in the nervous system; Cushing also routinely obtained radiographs in those with spinal trauma. These cases illustrate Cushing's dedication to and rapport with his patients, even in the face of a dismal prognosis.     

Oncocytic neoplasms of the adrenal gland

OBJECTIVE: Our study was aimed at review of the radiologic findings on oncocytic neoplasms to identify the features that differentiate these tumors from other adrenal neoplasms. CONCLUSION: Benign and malignant oncocytic neoplasms could not be differentiated on the basis of the CT and MRI criteria used for differentiating adrenal cortical adenoma from carcinoma. Oncocytic neoplasms should be considered in the differential diagnosis of indeterminate adrenal tumors.     

Chordoma of the spinal column

Chordomas are the most common primary malignant tumor of the mobile spine and of the sacrum. Although considered not to possess significant metastatic potential, such lesions are locally aggressive, leading to neurologic compromise and lytic destruction of bone. En bloc resection has afforded patients the greatest chance of local control and disease-free survival. Such radical resections may be associated with significant surgical morbidity, however. Although considered generally resistant to radiation therapy and chemotherapy, recent advances in photon and proton radiation therapy and use of monoclonal antibodies may provide improved outcomes for poor surgical candidates and for tumors that recur after surgery.