Methods of surgical stabilization for metastatic disease of the spine.

A variety of surgical techniques is available for treatment of metastatic disease of the spine. Prior emphasis on the use of these procedures has been on their benefit as a palliative measure to relieve signs and symptoms of spinal cord and nerve root compression not aided by radiation therapy and corticosteroid administration. More recently, development of surgical techniques that combine neural decompression with restoration of spinal stability has brought about consideration of additional indications for surgery in the treatment of metastatic disease of the spine. The present scope of such surgical procedures is reviewed along with identification of the most reliable selection factors for surgical candidates in order to improve functional outcome from surgical treatment of metastatic disease of the spine. Over 70 surgical series with more than 2,000 patients treated were reviewed.

Outcome of laminectomy for civilian gunshot injuries of the terminal spinal cord and cauda equina: review of 88 cases.

Case records of 88 patients with low-velocity gunshot injuries of the terminal spinal cord and cauda equina treated by laminectomy at Cook County Hospital between 1969 and 1987 were reviewed. Sixty-one patients were operated upon within 72 hours of injury, 29 of whom (47.5%) experienced neurological improvement or pain relief. Twenty-seven patients were operated upon at a later time for associated injuries, 13 of whom (48.1%) experienced neurological improvement or pain relief. When laminectomy was delayed for more than 2 weeks, either arachnoid adhesions (15%) or occult abscesses (17%) were observed. From this review as well as from the literature, it appears that the timing of laminectomy for gunshot injuries of the thoracolumbar and lumbosacral spine is not essential to neurological recovery. It appears, however, that adequate debridement of these injuries, performed as soon as the patient is stable from any associated injuries, may help to mitigate the late sequelae of arachnoiditis, infection, and pain syndromes in the lower extremities.

Intrasellar balloon inflation for treatment of symptomatic empty sella syndrome.

Intrasellar extradural placement of a detachable vascular balloon via a transsphenoidal approach was performed successfully in a patient with primary empty sella syndrome, relieving headache and visual field defect. This technique offers an alternative approach to other methods of treating symptomatic empty sella syndrome that require packing of the sella with fat, muscle, cartilage, or bone.

Lower extremity functional neuromuscular stimulation in cases of spinal cord injury.

Functional neuromuscular stimulation (FNS) provides a mechanism for the activation of muscles paralyzed by injury to the spinal cord. Although this technique was first used to treat patients with spinal cord injury over 20 years ago, only recent advances in electronics and biomechanics have made it a promising aid for the rehabilitation of these patients. Thus far, restoration of palmar prehension and lateral prehension in quadriplegics and of standing and biped gait in paraplegics has been achieved under carefully controlled laboratory conditions. This article reviews the current status of FNS and its potential as a practical tool to aid spinal cord-injured patients. Neurosurgeons who care for these patients might be expected to be involved in the future use of FNS if implantable systems are developed and tested.

Hematoma in the posterior fossa secondary to a tangential gunshot wound of the occiput: case report and discussion.

The case of 16-year-old boy who incurred a subdural hematoma in the posterior fossa an intracerebellar hematoma after a tangential civilian gunshot wound is reported. The skull was not fractured, and yet surgically significant clots required removal. The patient recovered. The discussion centers on the mechanism of injury and seriousness of tangential gunshot wounds and traumatic hematomas in the posterior fossa.

Use of Halifax interlaminar clamps for posterior C1-C2 arthrodesis.

Eight patients with atlantoaxial instability secondary to trauma or rheumatoid arthritis were treated with posterior C1-C2 arthrodesis using the Halifax interlaminar clamp and autogenous bone graft or methylmethacrylate. Thus far, with an average follow-up of 6 months, satisfactory stability has been achieved with no instrument failure.

Falcine chondrosarcoma: case report and literature review.

We present a case of falcine chondrosarcoma in a 58-year-old man. Only a few other examples of chondrosarcomas in this location and a total of approximately 50 intracranial cases have been reported. Because its rarity prevents any group of neurosurgeons from collecting a large experience in managing this tumor, we reviewed descriptions of previous cases to determine the natural history of intracranial chondrosarcomas. The distinguishing features of this rare tumor are compared with previous examples of intracranial tumors derived from cartilage and more common tumors in the parasagittal region, such as meningioma.

Multiple fractures of the cervical and upper thoracic spine without neurological deficit: case report.

The case of a patient with multiple contiguous fractures of the cervical and upper thoracic spine without neurological deficit or spinal instability is presented. Injury to each of the cervical vertebrae plus the upper two thoracic vertebrae is unusual and has not been previously reported.

Aneurysmal bone cyst of the thoracic spine: treatment by excision and segmental stabilization with Luque rods.

Preoperative radiological evaluation with magnetic resonance imaging and computed tomography was valuable in planning the surgical management of a destructive lesion of the posterior elements of the thoracic spine that was causing spinal cord compression in an 18-year-old woman. Preoperative recognition of bilateral involvement of the pedicles in addition to the laminae and spinous process led to use of prophylactic segmental stabilization of the spine with Luque rods after successful excision of an aneurysmal bone cyst. This case provides an example of the usefulness of computed tomographic scanning and magnetic resonance imaging in assessing the distribution and location of vertebral tumor and its potential effect on spinal stability. The efficacy of combining radical excision with stabilization for treatment of aneurysmal bone cysts of the spine is emphasized.

Spinal cord compression from a thoracic paraganglioma: case report.

A 34-year-old man with a 4-month history of midthoracic back pain sought treatment for a recent onset of lower extremity paresthesia and stiffness. A myelogram and computed tomographic myelogram disclosed an extradural block at the level of the 8th thoracic vertebral body with involvement of the pedicles, lamina, and spinous process. A posterior decompression of the spinal cord with subtotal resection of a highly vascular tumor was performed. The tumor was identified as a paraganglioma. In a second stage, the remainder of the tumor was embolized preoperatively, and gross total excision and sequential stabilization of the spine with a Luque rectangle and sublaminar wires were performed. The patient has been symptom free and without signs of a recurrence in the spine for over 13 months. A large abdominal paraganglioma was recently resected from its probable origin from the adventitia of the abdominal aorta.

Anterior cervical debridement and strut-grafting for osteomyelitis of the cervical spine.

A retrospective review of the surgical experience in treating 18 patients with osteomyelitis of the cervical spine is reported. The patients ranged in age from 20 to 60 years and all complained of neck pain upon admission. Ten patients had a prior history of intravenous drug abuse, three had previously suffered penetrating injuries of the neck, and one had an extraspinal site of osteomyelitis. Bacteria were isolated in 13 cases and tuberculosis in three. Neurological abnormalities were present in over one-half of the patients, consisting of myelopathy (nine cases) or radiculopathy (four cases). Plain cervical spine films and polytomography demonstrated vertebral and end-plate destruction, spinal instability, and increased paravertebral soft-tissue shadow in all cases. Computerized tomography and, more recently, magnetic resonance imaging have proven helpful in detecting bone involvement and the presence of epidural extension associated with cervical osteomyelitis. The risk of vertebral body collapse, kyphosis, and myelopathy in the osteomyelitic cervical spine has standardized the management of this problem in this institution to consist of skeletal traction, needle aspiration or blood culture for organism identification, anterior cervical debridement, autogenous iliac graft fusion, and intravenous administration of antibiotics. Spinal stability and neurological improvement were achieved in all 18 patients.

Spinal cord injury.

The evaluation and treatment of spinal cord injury continues to evolve, enhanced by new imaging modalities. Their application in reference to the cervical, thoracic, and lumbar spine is discussed. Treatment options, both conservative and surgical, are outlined.

Multiple cervical spine fractures without neurologic deficit after a helicopter crash. Case report.

The case of a soldier with multiple cervical fractures without neurologic deficit sustained after a helicopter crash during Operation Desert Storm is presented. The fractures involved the C2 body and the right facet joint and pedicle of C4. This fracture pattern, in association-with lack of neurologic deficit, is the first such case reported in the literature.

Complications in three-column cervical spine injuries requiring anterior-posterior stabilization.

A study was undertaken to elicit the hidden factors that, when identified, would signal the presence of cervical spine instability. Data were derived from the records and radiographs of 21 patients having sustained traumatic injury to the lower cervical spine (C3-C7) and who failed a single-stage posterior stabilization procedure necessitating a second (or combined) anterior-posterior arthrodesis. Mechanism of injury most frequently identified in this group was the distraction-flexion (locked facets) pattern (nine patients) and the "tear drop" compression-flexion injury pattern (seven patients). All 21 patients underwent a posterior wiring and bone graft stabilization procedure with persistent postoperative instability. Thus, failure to recognize the presence of "three-column" instability, the sine qua non of this group, resulted in the failure of posterior tension band stabilization as a means of gaining cervical spine stability. Three-column cervical spine instability is suspected in the presence of: 1) retrolisthesis and angulation of the superior vertebra on the next inferior vertebra; 2) distraction of the posterior interspinous ligaments sufficient to allow subluxation or dislocation of the facets; in conjunction with 3) a "shear" dislocation of one vertebra on another. Anterior shearing force through the disc space is capable of disrupting the intervertebral disc, along with disruption of the anterior and posterior longitudinal ligaments, each contributing to the presence of anterior and middle column cervical spine instability.

Spinal extradural angiolipoma: a report of two cases and review of the literature.

Extradural angiolipomas are rare tumors that can produce spinal cord compression. Two patients with thoracic spinal angiolipoma are presented that were treated with surgical resection and radiation. The histological and clinical features of the 18 previously reported cases of these tumors are discussed.

Spinal cord decompression via a modified costotransversectomy approach combined with posterior instrumentation for management of metastatic neoplasms of the thoracic spine.

Fifteen patients with thoracic spinal cord compression from metastatic neoplastic processes were managed by spinal canal decompression via a modified costotransversectomy approach. Ten of the patients also underwent sequential posterior stabilization with Luque or Harrington instrumentation based upon proximity of the lesion to the thoracolumbar junction, prognosis for regaining or maintaining ambulatory ability, and additional spinal stability considerations. A modified lateral decubitus position with the scapula falling away from the side of exposure was used for T1-5 segment lesions, and a prone position was used for the (T-6)-(T-12) segment. Adequate decompression of the spinal canal was achieved in all cases. All patients who were ambulating preoperatively maintained ambulatory ability, and pain and/or further neurological improvement as well occurred in 75%.

Intramedullary cystic teratoid tumor of the cervical spinal cord in association with a teratoma of the ovary.

A 15-year-old black female student came to the hospital because of disturbance of her gait. On examination, there was a dermal sinus in the skin overlying the spine of the seventh cervical vertebra, and myelography with computed tomography scan demonstrated a block to the flow of metrizamide contrast material at T-5 with cephalad extension of an intradural cystic lesion to the C-5 level. An x-ray examination of the abdomen at the time demonstrated a tooth-shaped radiodensity in the left hypogastrium. On exploration of the spine via C5-T5 laminectomy an intramedullary cystic teratoid tumor was found which was partially excised. At later exploration of the abdomen, a teratoma of the left ovary was removed. The pathology and natural history of teratomas and teratoid tumors is discussed along with surgical management of these tumors.

Luque rod stabilization for metastatic disease of the spine.

Instability of the spine caused by metastatic spread of primary tumors represents a serious risk for spinal cord or nerve root compression. In order to restore stability and relieve neural compression, a variety of surgical techniques originally used for reduction of nonpathologic spinal fractures have been applied to the problem of spinal metastases. Recently, we have utilized a technique developed primarily for correction of scoliosis to the treatment of metastatic spinal fractures. Six patients with spinal instability and neural compression secondary to metastatic tumors had segmental spinal stabilization with Luque rods, sublaminar wiring, and methyl methacrylate. Restoration of stability was successful in all cases with alleviation of preoperative pain and return to full activity. No evidence of instability occurred in this group of patients. As demonstrated by this experience and that of a few other small series, Luque rod stabilization provides a valuable addition to the techniques available for stabilization of metastatic fractures of the spine. Although the precise role of Luque rod segmental spinal stabilization in treatment of metastatic disease of the spine continues to be defined, thus far it has proved beneficial for cases of multiple vertebral body involvement or instability beyond one vertebral level.

Excision of a large pineal region hemangiopericytoma (angioblastic meningioma, hemangiopericytoma type).

A large hemangiopericytoma was located posterocentrally. The patient presented with headaches and papilledema. Surgical management consisted of total gross excision by a combined right occipital transtentorial and right occipitoparietal transfalcine approach under magnification in three stages over a 6-week period. Removal was aided by dilatation of the right temperooccipital horn ("trapped ventricle") and meningioma-like encapsulation allowed separation of the tumor from the brain and surrounding structures after internal debulking of the tumor. Subsequent peritoneal shunting of the trapped ventricular horn and 5000 rads of radiotherapy were given to the patient. She remains well with an inferior quadrantanopsia on the left side more than 1 year after treatment. Meningiomas of the pineal region, the relationship of meningioma to hemangiopericytoma and malignant mesenchymal tumors (sarcomas) are considered in reference to presumed cells of origin.