Dorsal column mapping for intramedullary spinal cord tumor resection decreases dorsal column dysfunction.

STUDY DESIGN: Retrospective cohort study and technical report. OBJECTIVE: To demonstrate, through our institutional series of intramedullary spinal tumor resection, the potential avoidance of dorsal column dysfunction after using dorsal column mapping. SUMMARY OF BACKGROUND DATA: Surgical resection of intramedullary spinal cord tumors carries significant associated postoperative morbidity. Much of this morbidity is because of dorsal column dysfunction from the dorsal myelotomy. The inconsistency and distortion of anatomic landmarks for a midline myelotomy has posed a significant challenge for spine surgeons. Dorsal column mapping is a relative new technique that may decrease the morbidity associated with operative resection of intramedullary masses. METHODS: A cohort of patients operated upon at our institution for intramedullary lesions were retrospectively reviewed. Neurologic examination changes were assessed through clinic notes and chart review. A total of 91 intramedullary tumors were assessed, with 80 patients without dorsal column mapping and 11 patients with dorsal column mapping. RESULTS: In our cohort of 91 patients with intramedullary tumors undergoing resection over the past decade, postoperative dorsal column dysfunction was observed in 45%. Dorsal column mapping decreased the frequency of new postoperative posterior column dysfunction. Patients with dorsal column mapping had a statistically significant decrease rate of new postoperative posterior column dysfunction of 9% compared with 50% for without mapping (P=0.01). Tumor histology was not found to correlate with worsening posterior column dysfunction in patients undergoing tumor resection. CONCLUSIONS: With our surgical cohort as an internal control, we found a decreased rate of postoperative posterior column dysfunction when using intraoperative dorsal column mapping. Our findings show the ability of this evolving technology to provide useful intraoperative information to localize the physiological midline and decrease the rate of posterior column dysfunction after intramedullary spinal cord tumor resection.

Extreme lateral interbody fusion approach for isolated thoracic and thoracolumbar spine diseases: initial clinical experience and early outcomes.

STUDY DESIGN: Retrospective review of prospective collected data on 22 patients. OBJECTIVE: To describe our initial clinical experience and outcomes with the extreme lateral interbody fusion (XLIF) approach for spinal diseases requiring access to the thoracic cavity. SUMMARY OF BACKGROUND DATA: Minimally invasive anterior approaches to the thoracic spine have traditionally consisted of thoracoscopic and mini-open thoracotomy techniques. We present our initial experience with employing the XLIF technique to treat thoracic spine diseases. METHODS: Clinical, radiographic, operative, postoperative, and functional outcomes were analyzed. RESULTS: A total of 22 patients (15 females, 7 males, average age 64.6 y) with isolated thoracic and thoracolumbar spine diseases were treated between 2005 and 2009. The indications for surgery included degenerative scoliosis (11), pathological fractures from tumors (2), adjacent level disease from prior fusions (5), thoracic disc herniations (3), and discitis/osteomyelitis (1). A total of 47 levels were treated. In the subset of patients treated for degenerative scoliosis, the mean preoperative and postoperative coronal Cobb angles were 22 and 14, respectively. The mean preoperative and postoperative sagittal angles were 39 and 44, respectively. The average estimated blood loss and length of stay were 227.5 mL and 4.8 d, respectively. Three complications consisting of wound infection, subsidence, and adjacent level disease requiring additional procedures were encountered. There were no neural, vascular, visceral injuries, or death. At a mean follow-up of 16.4 months (range, 3-50), we observed a 95.5% substantial clinical benefit. All patients who had reached a minimum of 6 months (95.5%) demonstrated radiographic evidence of fusion. CONCLUSIONS: The XLIF technique can be expanded to treat diseases in the thoracic spine. Although the magnitude of deformity correction achieved is less than that of the traditional open approaches, the lesser invasiveness of this technique may be tolerable for the elderly and in patients with significant medical comorbidities.

Disappearing bone disease and Chiari I malformation.

Gorham's disease is a rare disorder in which massive osteolysis occurs within bone, and therefore earns its historical name: disappearing bone disease. We describe a case of Chiari I malformation in a patient with this rare disorder, with treatment consisting of a suboccipital craniectomy, C1 laminectomy, and duraplasty for Chiari decompression.

Delayed lead pulmonary emboli after a gunshot wound to the head. Case report.

Bullet fragment emboli are uncommon, and there have been only a few reports of intracranial-to-extracranial migration of these fragments. The authors present the case of an 11-year-old girl who was struck in the suboccipital region with a "soft nose" bullet fired at close range. Several months later, the patient was found to have asymptomatic pulmonary emboli. Similar cases are reviewed, and a management strategy is recommended.

Intrathecal baclofen therapy and multiple sclerosis: outcomes and patient satisfaction.

OBJECT: In this study the authors provide an assessment of intrathecal baclofen (ITB) therapy and evaluate patient outcomes and satisfaction. METHODS: Records for patients with multiple sclerosis who were selected as candidates for ITB therapy were reviewed for their response to test dose, surgical technique, surgery- and pump-related complications, and short- and long-term response to therapy. Family and caregiver assessments of the value of ITB therapy were also reviewed. CONCLUSIONS: Intrathecal baclofen therapy is safe and effective. Most patients and caregivers express satisfaction with the therapy and would recommend it to other patients. Spasm frequency appears to be the single most common variable positively affected by therapy.

Impact of tumor histology on resectability and neurological outcome in primary intramedullary spinal cord tumors: a single-center experience with 102 patients.

BACKGROUND: Surgical outcomes for intramedullary spinal cord tumors are affected by many variables including tumor histology and preoperative neurological function. OBJECTIVE: To analyze the impact of tumor histology on neurological outcome in primary intramedullary spinal cord tumors. METHODS: A retrospective review of 102 consecutive patients with intramedullary spinal cord tumors treated at a single institution between January 1998 and March 2009. RESULTS: Ependymomas were the most common tumors with 55 (53.9%), followed by 21 astrocytomas (20.6%), 12 hemangioblastomas (11.8%), and 14 miscellaneous tumors (13.7%). Gross total resection was achieved in 50 ependymomas (90.9%), 3 astrocytomas (14.3%), 11 hemangioblastomas (91.7%), and 12 miscellaneous tumors (85.7%). At a mean follow-up of 41.8 months (range, 1-132 months), we observed recurrences in 4 ependymoma cases (7.3%), 10 astrocytoma cases (47.6%), 1 miscellaneous tumor case (7.1%), and no recurrence in hemangioblastoma cases. When analyzed by tumor location, there was no difference in neurological outcomes (P = .66). At the time of their last follow-up visit, 11 patients (20%) with an ependymoma improved, 38 (69%) remained the same, and 6 (10.9%) worsened. In patients with an astrocytoma, 1 (4.8%) improved, 10 (47.6%) remained the same, and 10 (47.6%) worsened. One patient (8.3%) with a hemangioblastoma improved and 11 (91.7%) remained the same. No patient with a hemangioblastoma worsened. In the miscellaneous tumor group, 2 (14.3%) improved, 10 (71.4%) remained the same, and 2 (14.3%) worsened. Preoperative neurological status (P = .02), tumor histology (P = .005), and extent of resection (P < .0001) were all predictive of functional neurological outcomes. CONCLUSION: Tumor histology is the most important predictor of neurological outcome after surgical resection because it predicts resectability and recurrence.

Catecholamine-secreting paraganglioma of the thoracic spinal column: report of an unusual case and review of the literature.

BACKGROUND AND IMPORTANCE: Paragangliomas are rare tumors of neuroendocrine origin that arise from paraganglionic tissue of the extrachromaffin cell system. These lesions may be seen at various sites along the neuraxis. Primary thoracic paragangliomas have rarely been reported in the literature, with secretory thoracic lesions being exceedingly rare as only 3 previous cases have been cited. CLINICAL PRESENTATION: A 49-year-old woman presented with episodes of hypertension, palpitations, and diaphoresis. Workup revealed positive urine catecholamines and a thoracic spine mass extending into the thoracic apex. Preoperative α-blockade with phenoxybenzamine was used followed by posterior decompression and tumor resection. Arthrodesis from C5 to T4 was subsequently performed, and the patient received postoperative radiation. CONCLUSION: Two years postoperatively, the patient has continued to have regression of her symptoms. We report a rare case of a catecholamine-secreting primary thoracic paraganglioma in a 49-year-old woman. These tumors should be treated carefully by the neurosurgeon with preoperative assistance from endocrinology for α-blockade, followed by gross total resection and postoperative radiation if residual tumor remains.

Clipping of a cerebral aneurysm in a patient with Loeys-Dietz syndrome: case report.

BACKGROUND AND IMPORTANCE: his is the first case report of clipping a cerebral aneurysm in a patient with Loeys-Dietz syndrome (LDS). LDS is a newly described autosomal dominant connective tissue disease with systemic vascular involvement. Unique to this syndrome is the development of aneurysms at a young age with the propensity of dissection or rupture at a stage that is earlier than when surgical intervention is typically indicated. We describe the nuances in intraoperative and postoperative management. CLINICAL PRESENTATION: A 31-year-old woman who recently received a diagnosis of with LDS type II presented to neurosurgical attention for management of an unruptured right ophthalmic artery aneurysm. The patient underwent a right pterional craniotomy for clipping of the aneurysm, with lumbar drain placement before the procedure. Papaverine had to be used several times to counteract vasospasm of the vessels during arachnoid dissection. Because of vascular reactivity, temporary clipping was not used, and the aneurysm was clipped successfully. CONCLUSION: LDS is a newly described disorder that warrants awareness in the neurosurgical community because of its association with intracerebral aneurysms as well as craniosynostosis (19%), scoliosis (20%), cervical spine instability (7%), hydrocephalus, and Arnold-Chiari malformation. When clipping aneurysms in these patients, the surgeon should be aware of the potential for severe vascular reactivity during dissection and avoid temporary clipping when possible. Avoidance of lumbar drainage intraoperatively reduces the risk of intracranial hypotension after removal.

Treatment recommendations for primary extradural meningiomas.

Primary extradural meningiomas (PEMs) represent about 2% of all meningiomas and are often encountered by non-neurosurgeons. These lesions typically present as enlarging, painless, benign masses that can be surgically cured. Imaging is critical for defining involvement of adjacent structures; however, diagnosis depends on classic histologic patterns. Treatment for benign PEMs (WHO I) consists of resection with wide margins, whereas adjuvant therapy after resection of atypical (WHO II) or malignant (WHO III) PEMs should be considered. By using the collective experience from our comprehensive cancer center, including neuro-oncologists, neuroradiologists, and neurosurgeons, in addition to a complete literature review, the authors have established treatment guidelines not previously reported. This manuscript describes key features of these challenging tumors to aid in diagnosis, presents the largest published review of all reported PEMs (n = 163), and provides salient treatment guidelines to surgeons unfamiliar with these challenging tumors.

Minimally invasive lumbar interbody fusion in patients older than 70 years of age: analysis of peri- and postoperative complications.

BACKGROUND: The number of spine operations performed in the elderly population is rising. OBJECTIVE: To identify and describe perioperative and postoperative complications in patients 70 years and older who have undergone minimally invasive lumbar interbody spine fusion. METHODS: A retrospective analysis was performed on 66 consecutive patients aged 70 years or older who underwent a minimally invasive interbody lumbar fusion. Electronic medical records were analyzed for patient demographics, procedures, and perioperative and postoperative complications. RESULTS: Between 2000 and 2009, 66 patients with an average age of 74.9 years (range, 70-86 years) underwent 68 lumbar interbody fusions procedures. The mean follow-up was 14.7 months (range, 1.5-50 months). The minimally invasive approaches included 41 cases of extreme lateral interbody fusion and 27 minimally invasive transforaminal lumbar interbody fusions. We observed 5 major (7.4%) and 17 minor (25%) complications. The 5 major complications consisted of 4 cases of interbody graft subsidence and 1 adjacent level disease. There were no intraoperative medical complications. There were no myocardial infarctions, pulmonary embolisms, hardware complications requiring removal, wound infections, major visceral, vascular, neural injuries, or death in the study period. CONCLUSION: Minimally invasive interbody fusions can be performed in the elderly (ages 70 years and older) with an overall low rate of major complications. Graft subsidence in this population when not supplemented with posterior instrumentation is a concern. Age should not be a deterrent to performing complex minimally invasive interbody fusions in the elderly.

Impact of tumor histology on resectability and neurological outcome in primary intramedullary spinal cord tumors: a single-center experience with 102 patients.

BACKGROUND: Surgical outcomes for intramedullary spinal cord tumors are affected by many variables including tumor histology and preoperative neurological function. OBJECTIVE: To analyze the impact of tumor histology on neurological outcome in primary intramedullary spinal cord tumors. METHODS: A retrospective review of 102 consecutive patients with intramedullary spinal cord tumors treated at a single institution between January 1998 and March 2009. RESULTS: Ependymomas were the most common tumors with 55 (53.9%), followed by 21 astrocytomas (20.6%), 12 hemangioblastomas (11.8%), and 14 miscellaneous tumors (13.7%). Gross total resection was achieved in 50 ependymomas (90.9%), 3 astrocytomas (14.3%), 11 hemangioblastomas (91.7%), and 12 miscellaneous tumors (85.7%). At a mean follow-up of 41.8 months (range, 1-132 months), we observed recurrences in 4 ependymoma cases (7.3%), 10 astrocytoma cases (47.6%), 1 miscellaneous tumor case (7.1%), and no recurrence in hemangioblastoma cases. When analyzed by tumor location, there was no difference in neurological outcomes (P = .66). At the time of their last follow-up visit, 11 patients (20%) with an ependymoma improved, 38 (69%) remained the same, and 6 (10.9%) worsened. In patients with an astrocytoma, 1 (4.8%) improved, 10 (47.6%) remained the same, and 10 (47.6%) worsened. One patient (8.3%) with a hemangioblastoma improved and 11 (91.7%) remained the same. No patient with a hemangioblastoma worsened. In the miscellaneous tumor group, 2 (14.3%) improved, 10 (71.4%) remained the same, and 2 (14.3%) worsened. Preoperative neurological status (P = .02), tumor histology (P = .005), and extent of resection (P < .0001) were all predictive of functional neurological outcomes. CONCLUSION: Tumor histology is the most important predictor of neurological outcome after surgical resection because it predicts resectability and recurrence.

Glioblastoma Multiforme Oncogenomics and Signaling Pathways.

In the adult population, glioblastoma multiforme is one of the most common primary brain tumors encountered. Unfortunately, this highly malignant tumor represents over 50% of all types of primary central nervous system gliomas. The vast majority of GBMs develops quite rapidly without clinical, radiological, or morphologic evidence of a less malignant precursor lesion (primary or de novo GBMs), as compared to secondary GBMs that develop slowly by progression from diffuse low-grade astrocytomas. These GBM subtypes must be kept in mind because they may constitute distinct disease entities. Even though they look histologically quite similar, they likely involve different genetic alterations and signaling pathways. Decades of surgical therapy, radiotherapy, and chemotherapy have failed to drastically change survival. Clearly, we do not fully understand this tumor; however, the exciting genetic revolution in glioma research over the past decade is providing a promising outlook for exploring this tumor at the genetic level. Science has begun to elucidate the numerous genetic alterations and critical signaling pathways, and it has opened new exciting areas of research such as glioma stem cell biology and neoangiogenesis. This work has already begun to improve our understanding of GBM cell proliferation, migration, and invasion. Indeed, exciting novel targeted therapies are making their way to clinical trials based on this increased knowledge. This review provides the current understanding of GBM oncogenomics, signaling pathways, and glioma stem cell biology and discusses the potential new therapeutic targets on the horizon.

Temporomandibular joint cyst presenting as trigeminal neuropathy and middle fossa mass: case report.

OBJECTIVE: We describe the case of a temporomandibular joint cyst eroding into the middle fossa, initially causing compression of the trigeminal nerve and trigeminal neuropathy, and ultimately causing destruction of the second division of the nerve with facial numbness. CLINICAL PRESENTATION: A 50-year-old woman with rheumatoid arthritis on prednisone developed right-sided, initially lancinating facial pain that ultimately became dull in nature in the maxillary division of the trigeminal nerve. This change in pain was associated with the development of numbness in the same distribution. The facial pain gradually resolved, but the facial numbness persisted. Imaging revealed a heterogeneously enhancing mass in the middle fossa lateral to Meckel's cave. INTERVENTION: During surgery, the dura was elevated, and a smooth, firm lesion with several thinly encapsulated, cystic areas containing viscous, white fluid was identified. The mass had eroded through the floor of the middle cranial fossa. The thick, fibrous capsule was freed from the bone edges and was sectioned sharply extracranially. Pathological evaluation was consistent with a cyst originating from the temporomandibular joint. CONCLUSION: Extracranial mass lesions involving the middle fossa structures are uncommon and typically arise from the parotid gland. This case represents the first example of a middle fossa mass originating from an abnormal temporomandibular joint and a unique cause of trigeminal neuropathy. After excision, there has been no recurrence after 2 years of follow-up.