Temozolomide for recurrent or progressive high-grade malignant glioma: results of an Austrian multicenter observational study.

BACKGROUND: The use of chemotherapy in patients with malignant gliomas has remained a controversial issue even after the publication of favorable study data and a meta-analysis. The present study was initiated to support the use of chemotherapy in patients with relapsed high-grade gliomas (HGG). PATIENTS AND METHODS: Six Austrian centers recruited 43 patients with histologically confirmed HGG at first recurrence. Twelve chemotherapy-naïve patients received oral temozolomide at a dose of 200 mg/m(2) once a day for five consecutive days and 26 patients a dose of 150 mg/m(2) also for five days after various first-line chemotherapies. TMZ treatment was repeated every four weeks for a total of six cycles. RESULTS: Twenty-one patients (52.5 %) received at least six cycles of therapy. Two patients experienced complete remission and eight patients a partial response. Twenty patients survived at one year after enrolment in the study; eight patients survived beyond three years of follow-up. Hematological toxicities consisted of three thrombocytopenias G4 and 35 lymphocytopenias G3 and G4; these did not cause interstitial pneumonia or require inpatient treatment. Non-hematological toxicities were rare and without clinical relevance. Patients' quality of life was maintained during treatment. CONCLUSION: The study data confirm the feasibility and efficacy of chemotherapy with temozolomide in patients with relapsed/progressive HGG.

Microsurgical treatment of juxta facet cysts of the lumbar spine.

OBJECTIVES: Juxta facet cysts are a common cause of low back and radicular pain. They are mostly associated with degenerative facet joints and spondylolisthesis. The study focuses on long-term outcomes after microsurgical treatment without fusion. METHOD: From April 2002 to April 2004, 31 patients (23 female and 8 male) underwent microsurgical resection of lumbar juxta facet cysts. The patient age ranged from 31 to 83 years (mean 67.2 years). The most affected level was L4-L5 (19 patients), followed by L3-L4 (9 patients). Fourteen patients additionally had spondylolisthesis of the involved segment. All patients had signs of nerve root compression and had received conservative treatment preoperatively. We performed limited bone removal (sparing the facet joints) and cyst resection in 27 patients. In four patients, cyst resection and standard laminectomy were performed owing to spinal stenosis. RESULTS: Conservative treatment was without any effect in all patients. At follow-up, 12-30 months after surgery, excellent to good outcome was achieved in 25 of 31 patients (80.7%), and 6 patients (19.3%) showed fair results. Persistent low back pain was more common in patients with spondylolisthesis than in the other group (6/14 vs 3/17); this may be due to instability. Spondylolisthesis did not progress or become mobile after surgery radiographically in any of our patients. CONCLUSIONS: Conservative therapy does not adequately improve symptoms in patients with intraspinal juxta facet cysts and radicular signs. Juxta facet cysts can be treated effectively with a minimally invasive microsurgical approach. This may be of particular significance when the cysts are associated with spondylolisthesis, minimizing the risk of instability and the need for fusion. In a selected group of patients with persistent low back pain, fusion may become necessary to improve symptoms.

Intraoperative evaluation of implants in anterior cervical spine surgery by three-dimensional fluoroscopy.

OBJECTIVE: Accurate radiographic documentation of the proper placement of cages, plates, and screws following cervical spine surgery significantly impacts clinical outcome. Postoperative computed tomography scans clearly show that the position of implants is sometimes far from ideal. The morbidity of anterior cervical disc surgery is well documented, but the incidence and influence of the misplacement of interbody spacers, plates, and screws are underestimated. We used isocentered fluoroscopy with three-dimensional image reconstruction intraoperatively to evaluate the extent of bony decompression and position of implants before wound closure. METHODS: From October 2003 through April 2004, 27 patients had anterior cervical procedures: 22 one-level and 5 two-level operations. Herniated cervical discs were diagnosed in 21 individuals, whereas 6 exhibited spondylosis. A radiolucent operating table made of carbon fibers was used in all patients. Before wound closure, intraoperative three-dimensional fluoroscopy was performed to evaluate the location of cervical implants and anterior bone resection. RESULTS: The entire scanning procedure required 5 minutes; the actual scanning time was only 120 seconds. In all patients, we were able to adequately evaluate the placement of cage, plates, and screws. Utilization of intraoperative three-dimensional fluoroscopy revealed that two cages were malpositioned and required revision before wound closure. CONCLUSIONS: Intraoperative three-dimensional fluoroscopy is a valuable tool for the intraoperative imaging of bony decompression and implants in anterior cervical spine surgery. The technique is safe and reliable and should help us to avoid incomplete decompression or misplacement of implants and therefore improve long-term functional outcomes in the future.