A Prospective Validation Study of the First 3D Digital Exoscope for Visualization of 5-ALA-Induced Fluorescence in High-Grade Gliomas.

BACKGROUND: We report on the first use of a digital 3-dimensional (3D) exoscope equipped with a 5-aminolevulinic acid (5-ALA) fluorescence visual system. METHODS: We conducted a prospective clinical trial to evaluate the utility and sensitivity/specificity of the Olympus Orbeye 3D digital exoscope when used to visualize 5-ALA-induced fluorescence in patients with high-grade glioma undergoing a clinically indicated craniotomy. At least 2 tissue samples were each obtained from regions of strong, weak. and no fluorescence and evaluated in a blinded manner by a neuropathologist. RESULTS: Twenty patients were enrolled. Intraoperative fluorescence was observed in 100% of subjects. One hundred twenty-one surgical specimens were collected for histopathological analysis; 40 with strong, 40 weak, and 41 with no visible fluorescence. Histopathology demonstrated 62.8% of samples (n = 76) contained abundant, 20.7% (n = 25) scarce, and 16.5% (n = 20) no tumor cells. Thirty-three of the 40 specimens (82.5%) in the strong fluorescence group correlated with abundant tumor cells and 7 (17.5%) with scarce. Twenty-nine of the 40 specimens (72.5%) in the weak fluorescence group correlated with abundant tumor cells, 7 (17.5%) with scarce, and 4 (10%) with none. Fourteen of the 41 (34.2%) specimens in the no fluorescence group had abundant tumor cells, 11 (26.8%) had scarce, and 16 (39%) had none. The sensitivity was 75% and specificity was 80%. The positive predictive value was 95% and negative predictive value was 39%. CONCLUSIONS: Visualization of 5-ALA-induced tumor fluorescence with use of the Orbeye 3D digital exoscope was feasible and associated with a high positive predictive value.

Surgical Adjuncts for Glioblastoma.

Although surgical resection of the solid tumor component of glioblastoma has been shown to provide a survival advantage, it will never be a curative procedure. Yet, systemically applied adjuvants (radiation therapy and chemotherapy) also are not curative and their options are limited by the inability of most agents to cross the blood-brain barrier. Direct delivery of adjuvant therapies during a surgical procedure potentially provides an approach to bypass the blood-brain barrier and effectively treat residual tumor cells. This article summarizes the approaches and therapeutics that have been evaluated to date, and challenges that remain to be overcome.

Multiple myeloma presenting as an intramedullary spinal cord tumor: a case report and review of the literature.

BACKGROUND: Extramedullary disease in multiple myeloma often portends a worse diagnosis. In approximately 1% of cases, multiple myeloma may metastasize to the central nervous system as either leptomeningeal involvement or an intracranial, intraparenchymal lesion. Spinal cord metastases, however, are exceedingly rare. We present a case of spinal cord multiple myeloma as well as a literature review of reported cases. CASE PRESENTATION: A 66-year-old African American man with multiple myeloma presented with acute midthoracic pain and lower extremity paresis and paresthesia. Magnetic resonance imaging of the spine revealed two contrast-enhancing intramedullary enhancing lesions in the T1-T2 and T6-T7 cord. Resection with biopsy yielded a diagnosis of metastatic multiple myeloma. CONCLUSION: To date, only six cases of extramedullary disease to the spinal cord in patients with multiple myeloma have been reported, including our patient's case. In all cases, neurologic deficit was observed at presentation, and magnetic resonance imaging of the spine revealed an intramedullary, homogeneously enhancing lesion. Current evidence suggests worse prognosis in patients with extramedullary disease to the central nervous system, and treatment paradigms remain debatable.

Pseudohypoxic Brain Swelling After Elective Lumbar Spinal Surgery: Case Report.

Pseudohypoxic brain swelling (or the more recent term, postoperative intracranial hypotension-associated venous congestion) is a rare and potentially deadly complication that can occur after routine spine or brain surgery. The mechanism of this injury has been described as a rapid cerebral spinal fluid drainage leading to venous cerebral congestion. The clinical and radiographic findings mimic those found in a patient who has suffered an anoxic brain injury. We present the third reported case of postoperative intracranial hypotension-associated venous congestion following spinal surgery.

Repair integrity and clinical outcome after arthroscopic rotator cuff repair using single-row anchor fixation: a prospective study of single-tendon and two-tendon tears.

This prospective study determined whether single-row anchor fixation would reliably improve clinical outcome and maintain structural integrity after arthroscopic repair of single-tendon and 2-tendon rotator cuff tears. In 39 patients, 21 shoulders had single-tendon tears and 18 had 2-tendon tears. Mean follow-up was 38 months (minimum, 24 months). A standardized assessment was done preoperatively and postoperatively at yearly intervals. Postoperative magnetic resonance imaging (MRI) was performed at a minimum 1-year follow-up. Mean forward elevation, pain, satisfaction, and American Shoulder and Elbow Surgeons scores significantly improved for both groups (P < .01). Postoperative MRI examinations showed 19 cuffs (90%) were intact for single-tendon tears and 15 (83%) were intact for 2-tendon tears. A recurrent tear on postoperative MRI was significantly correlated with the intraoperative finding of asymmetric retraction. Arthroscopic rotator cuff repair using single-row anchor fixation resulted in significant improvements in clinical outcome and reliable repair integrity for both single-tendon and 2-tendon tears.

Decreased range of motion following arthroscopic remplissage.

The Hill-Sachs lesion is an impression fracture of the posterolateral margin of the humeral head that commonly results from impaction with the anterior glenoid rim during subluxation or dislocation of the shoulder. This bony defect has been implicated as an etiology of recurrent instability of the shoulder. The "remplissage" technique described by Wolf is an arthroscopic method of filling the Hill-Sachs defect via infraspinatus tenodesis and posterior capsulodesis. The purpose of this technique is to prevent recurrent instability by making the Hill-Sachs lesion extra-articular thereby eliminating engagement of the defect with the anterior glenoid rim. In addition, the infraspinatus tenodesis acts as a checkrein by preventing anterior translation of the humeral head. We report a complication of this recently described technique. A 28-year-old man who failed conservative management underwent an arthroscopic Bankart repair with a concomitant remplissage procedure. Two years postoperatively, the patient continued to struggle with the loss of external rotation. Conservative management with physical therapy and range of motion exercises failed. The patient was treated with an arthroscopic release of the tenodesed infraspinatus, which improved external rotation by 202 in circle intraoperatively. At 6 months postoperatively, the patient has maintained a significant increase external rotation. We hypothesize that the loss in external rotation occurred as a result of the tenodesis of the infraspinatus and posterior capsule into the Hill-Sachs defect. The tenodesed cuff and capsular tissue acted as a mechanical block to external rotation of the shoulder.