Distal Lumbar Lordosis is Associated With Reoperation for Adjacent Segment Disease After Lumbar Fusion for Degenerative Conditions.

STUDY DESIGN: A single centre retrospective review. OBJECTIVE: Recent studies have suggested that distal lordosis (L4-S1, DL) remains constant across all pelvic incidence (PI) subgroups, whilst proximal lordosis (L1-L4, PL) varies. We sought to investigate the impact of post-operative DL on adjacent segment disease (ASD) requiring reoperation in patients undergoing lumbar fusion for degenerative conditions. METHODS: Patients undergoing 1-3 level lumbar fusion with the two senior authors between 2007-16 were included. Demographic and radiographic data were recorded. Univariate, multivariate binary logistic regression, and Kaplan Meier survivorship analyses were performed. RESULTS: 335 patients were included in the final analysis. Most had single (67%) or two (31%) level fusions. The mean follow-up was 64-month. Fifty-seven patients (17%) underwent reoperation for ASD at an average of 78-month post-operatively (R group). The R group had a significantly lower mean post-operative DL (27.3 vs 31.1 deg, P < .001) and mean PI (55.5 vs 59.2 deg, P < .05). On univariate analysis, patients with a post-operative DL of <35 deg had higher odds of reoperation for ASD than those with a post-operative DL of ≥35 deg (OR 2.7, P = .016). In the multivariate model, post-operative DL, low/average PI, and spondylolisthesis were all significantly associated with reoperation for ASD. CONCLUSION: This study provides preliminary support to an association between post-operative distal lumbar lordosis and risk of reoperation for ASD in patients undergoing fusions for degenerative conditions. Further multicentre prospective study is needed to independently confirm this association and identify the impact of restoration of physiological distal lumbar lordosis on long term patient outcomes.

Pure epidural spinal cavernous haemangioma.

BACKGROUND: Pure epidural spinal cavernous hemangiomas (SCH) account for only 4% of all spinal epidural lesions. Our literature review identified 61 publications reporting on, a total of 175 cases in the magnetic resonance imaging era. Here, we reviewed those cases, and have added our case of what appeared to be a multifocal SCH. CASE DESCRIPTION: A 72-year-old male presented with a progressive paraparesis attributed to a T5/T6 dorsolateral extradural mass extending into the right T5/6 foramen. Surgical excision documented the lesion, histologically, was a SCH. A second similar lesion was noted involving the left C7/T1 foramen; as the patient was asymptomatic from this lesion, and no additional biopsy was performed. The patient returned to normal neurological function within 2 months postoperatively. CONCLUSIONS: Here, a 72-year-old male presented with a pathologically confirmed T5/T6 epidural SCH and a secondary C7/T1 foraminal lesion suspected to represent a secondary focus of an epidural SCH.

Sodium Fluorescein in Brain Tumor Surgery: Assessing Relative Fluorescence Intensity at Tumor Margins.

PURPOSE: The use of intraoperative 5-aminolevulinic acid fluorescence has been shown to increase the extent of resection in high-grade glioma surgery. Sodium fluorescein is an alternate fluorescence agent with advantages of low cost, low adverse effect profile, and ability to visualize anatomical detail under the fluorescence filter. Sodium fluorescein-based fluorescence is not specific to tumor cells, and the significance of residual fluorescence at tumor margins has been questioned. In this article, the authors sought to correlate fluorescence intensity at tumor margins with the presence of residual contrast-enhancing tumor on magnetic resonance imaging (MRI). METHODS: Eleven patients with a total of 12 lesions were enrolled in the study. Sodium fluorescein was administered at a dose of 5 mg/kg on induction of anesthesia. Relative intensity of fluorescence was extrapolated from intraoperative photographs through isolation of the green channel from the red/green/blue image, then graphically representing of pixel intensity through application of a thermal map. The correlation between areas of avid fluorescence at tumor cavity margins and the presence of residual contrast-enhancing tumor on postoperative MRI was evaluated. RESULTS: All tumors demonstrated fluorescence. The presence of avid fluorescence at tumor cavity margins had a sensitivity of 66.7% and specificity of 75% for the presence of residual contrast-enhancing tumor on postoperative MRI. There were no adverse effects of fluorescein administration. CONCLUSION: Quantification of relative fluorescence intensity allows easy identification of areas that are high risk for residual contrast-enhancing tumor. Graphical representation of green pixel intensity requires validation through histopathological analysis but has the potential for real-time clinical application.

The management of completely resected childhood intracranial ependymoma: the argument for observation only.

INTRODUCTION: The management of children with completely resected intracranial ependymomas is controversial. We favor deferring adjuvant radiotherapy in low-risk patients, whereas others recommend radiotherapy. REVIEW: This article reviews the available evidence for and against deferring radiotherapy in children with low-risk completely resected childhood ependymomas.

Assessment of age in ulcerative colitis patients with ileal pouch creation - an evaluation of outcomes.

INTRODUCTION: The aim of the study was to determine if age at the creation of an ileal pouchanal anastomosis (IPAA) has an impact on the outcomes in patients with ulcerative colitis (UC). MATERIALS AND METHODS: A retrospective review of all patients who underwent IPAA for UC from 1999 to 2011 was performed. Long-term functional outcome was assessed using both the Cleveland Clinic and St Mark's incontinence scores. RESULTS: Eighty-nine patients, with a median age of 46 (range, 16 to 71) years, formed the study group. The median duration of disease prior to their pouch surgery was 7 (0.5 to 39) years. There were 57 (64%) patients who were aged ≤50 years old and 32 (36%) who were >50 years old. Fifty-seven (64%) patients developed perioperative complications of which 51 (89.5%) were minor. High ileostomy output (n = 21, 23.6%) and urinary symptoms (n = 13, 14.6%) were the most commonly encountered complications. The older patients were more likely to have an ASA score ≥3 and a longer length of stay. Although there was a higher incidence of complications in the older group of patients, the difference was not statistically significant. There were no significant differences in the incidence of severe complications. Forty-nine (55%) patients completed our questionnaire on the evaluation of their functional outcomes. There were no significant differences in the Cleveland Clinic and St Mark's incontinence scores between the older (n = 19, 38.8%) and younger (n = 30, 61.2%) patients. There were also no significant differences in the frequency of bowel movements during the day or overnight after sleep between the 2 groups. CONCLUSION: IPAA procedure for patients with UC can be safely performed. Long-term functional outcome is not significantly influenced by the age at which the IPAA was created.