Decompression Alone Versus Interspinous/Interlaminar Device Placement for Degenerative Lumbar Pathologies: Systematic Review and Meta-Analysis.

INTRODUCTION: Interspinous devices (ISDs) and interlaminar devices (ILDs) are marketed as alternatives to conventional surgery for degenerative lumbar conditions; comparisons with decompression alone are limited. The present study reviews the extant literature comparing the cost and effectiveness of ISDs/ILDs with decompression alone. METHODS: Articles comparing decompression alone with ISD/ILD were identified; outcomes of interest included general and disease-specific patient-reported outcomes, perioperative complications, and total treatment costs. Outcomes were analyzed at <6 weeks, 3 months, 6 months, 1 year, 2 years, and last follow-up. Analyses were performed using random effects modeling. RESULTS: Twenty-nine studies were included in the final analysis. ILD/ISD showed greater leg pain improvement at 3 months (mean difference, -1.43; 95% confidence interval, [-1.78, -1.07]; P < 0.001), 6 months (-0.89; [-1.55, -0.24]; P = 0.008), and 12 months (-0.97; [-1.25, -0.68]; P < 0.001), but not 2 years (P = 0.22) or last follow-up (P = 0.09). Back pain improvement was better after ISD/ILD only at 1 year (-0.87; [-1.62, -0.13]; P = 0.02). Short-Form 36 physical component scores or Zurich Claudication Questionnaire (ZCQ) symptom severity scores did not differ between the groups. ZCQ physical function scores improved more after decompression alone at 6 months (0.35; [0.07, 0.63]; P = 0.01) and 12 months (0.23; [0.00, 0.46]; P = 0.05). Oswestry Disability Index and EuroQoL 5 dimensions scores favored ILD/ISD at all time points except 6 months (P = 0.07). Reoperations (odds ratio, 1.75; [1.23, 2.48]; P = 0.002) and total care costs (standardized mean difference, 1.19; [0.62, 1.77]; P < 0.001) were higher in the ILD/ISD group; complications did not differ significantly between the groups (P = 0.41). CONCLUSIONS: Patient-reported outcomes are similar after decompression alone and ILD/ISD; the observed differences do not reach accepted minimum clinically important difference thresholds. ISD/ILDs have higher associated costs and reoperation rates, suggesting current evidence does not support ILD/ISDs as a cost-effective alternative to decompression alone.

Surgical Management of Hirayama Disease (Monomelic Amyotrophy): Systematic Review and Meta-Analysis of Patient-Level Data.

BACKGROUND: Hirayama disease or juvenile-onset monomelic amyotrophy is a clinical syndrome that disproportionately affects young males. Standard of care revolves around conservative management, but some patients experience disease progression that may benefit from surgical intervention. METHODS: Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic review of previous reports of surgical treatment for Hirayama disease was performed. Studies were included if they provided individual patient-level data, described the clinical presentation and surgical intervention, and reported neurological improvement at last follow-up. Comparison between those who improved and those with stable symptoms at last follow-up was performed. Decision-tree analysis was used to identify the best predictors of neurological improvement by last follow-up. RESULTS: Of 624 unique articles, 30 were included in the qualitative review and 23 in the meta-analysis. Among the 70 patients in the meta-analysis, mean age was 21.2 ± 6.3 years, 91% were male, and mean symptom duration at presentation was 43.3 ± 61.8 months. Fifty-nine patients (84.3%) had improvement in their neurological symptoms by last follow-up. Univariable analysis showed the only significant predictor of improvement in neurological symptoms by last follow-up was the use of stabilization-alone versus decompression with or without stabilization. Baseline clinical symptoms nor radiographic features predicted outcome. Decision-tree analysis showed surgical strategy (stabilization-alone vs. decompression ± stabilization), age (<20 vs. ≥20), and surgical approach (anterior-only vs. posterior-only or anterior-posterior) predicted a higher likelihood of neurological improvement by last follow-up. CONCLUSIONS: Nearly 85% of patients experienced improvement in neurological symptoms. Improvement was best for those who underwent stabilization-alone, and decision-tree analysis suggested that the likelihood of improvement was also superior for patients under 20 years of age and those treated with an anterior versus posterior or staged approach.

Operative Treatment of Bertolotti Syndrome: Resection Versus Fusion.

OBJECTIVE: To compare the outcomes of joint resection versus fusion in patients who undergo operative treatment for Bertolotti syndrome. METHODS: A chart review identified patients with Bertolotti syndrome who underwent operative treatment, consisting of either Bertolotti joint decompression/resection or fusion across the abnormal transitional lumbosacral vertebrae. Patients with other symptomatic operative spinal disease were excluded. RESULTS: Twenty-seven patients (9 men, 18 women) were identified for inclusion in the study with an average age of 40 ± 16 years, body mass index of 27 ± 5, and follow-up of 39 ± 48 months. Most patients presented with back pain (74%) or leg pain (48%) for an average duration of 61 ± 54 months. Nineteen (70%) presented with a Castellvi subtype 2a Bertolotti joint with computed tomography as the most common method for radiographic diagnosis (56%). When comparing long-term pain improvement (>12 months) after fusion (n = 9) versus joint resection (n = 18), more fusion patients reported improvement in their pain (78%) compared to joint resection (28%, P = 0.037). There was not a statistically significant difference in the short-term pain improvement (<6 months) between the fusion (100%) and resection (78%) patients (P = 0.27). There was no statistically significant difference between the two groups in terms of age, sex, body mass index, presenting symptoms, symptom duration, Bertolotti injection response, follow up, Castellvi subtype, and complications. CONCLUSIONS: Patients with Bertolotti syndrome who underwent surgical fusion across the transitional lumbosacral vertebrae had a higher rate of long-term pain improvement compared to patients who had resection of the abnormal pseudoarticulation.

Medial Temporal Encephalocele and Medically Intractable Epilepsy: A Tailored Inferior Temporal Lobectomy and Case Report.

BACKGROUND AND IMPORTANCE: Temporal lobe encephaloceles are increasingly recognized as a potential cause of medically refractory epilepsy and surgical treatment has proven effective. Resection of the encephalocele and associated cortex is often sufficient to provide seizure control. However, it is difficult to determine the extent of adjacent temporal lobe that should be resected. We present a case report and our technique of a tailored inferior temporal pole resection. CLINICAL PRESENTATION: A 32-yr-old man with an 11-yr history of medically refractory epilepsy. Prolonged electroencephalography (EEG) revealed frequent left and rare right frontotemporal sharp waves. Numerous seizures were captured with EEG, all of which originated from the left temporal region. Statistical parametric mapping (SPM) subtraction ictal-interictal SPECT coregistered with magnetic resonance imaging (MRI) (SISCOM) demonstrated ictal hyperperfusion in the anterior left temporal lobe. MRI showed 2 encephaloceles in the left anterior temporal lobe with the accompanying bony defects in the floor of the middle cranial fossa apparent on the computed tomography scan. The patient underwent left temporal craniotomy with intraoperative electrocorticography, resection of the encephaloceles, and a tailored inferior temporal lobectomy (IFTL) and repair of the middle fossa defects. At 7 mo follow up he reported seizure-freedom since surgery. CONCLUSION: Resection of temporal encephalocele and adjacent cortex is safe and effective procedure for select patients with medically refractory epilepsy. This video demonstrates our technique which provides a more standardized approach to the resection.

Ruptured Posterior Inferior Cerebellar Artery Dural Fistula After Vestibular Schwannoma Resection.

A 50-year-old man with a history of left-sided retrosigmoid craniotomy for vestibular schwannoma (VS) resection 19 years prior presented with severe headache and left cerebellopontine angle subarachnoid hemorrhage (SAH). Digital subtraction angiography demonstrated a dissected, nonfunctional left posterior inferior cerebellar artery with direct fistulization at the left transverse sinus (Video 1). The lesion was treated with endovascular Onyx embolization. The patient recovered without neurologic deficit. Five additional cases of new dural arteriovenous fistula arising after VS resection have been described; we report the first such case presenting with SAH, suggesting that postoperative magnetic resonance angiography may be of value in long-term VS follow-up imaging protocols.