Open Thoracic Cordotomy for Cancer Pain with Intraoperative Neuromonitoring: A Case Series and Critical Review of the Literature.

OBJECTIVE: Cordotomy is a viable option for patients with intractable cancer pain and limited survival. Open thoracic cordotomy is offered when patients are not candidates for percutaneous cordotomy. After the open procedure, traditionally performed purely based on anatomic landmarks, up to 22% of patients experience postoperative limb weakness. The objective of this study is to report our experience with neurophysiology-guided open cordotomy along with a critical review of the literature. METHODS: Between 2019 and 2022, 5 open thoracic cordotomies were performed in our center. Intraoperative neurophysiologic monitoring was used in all cases to guide the lesion and standard single-level laminectomy or hemilaminectomy was performed for exposure. Outcome measures were retrospectively reviewed focusing on pain control and neurologic status. Existing literature on cordotomy was critically reviewed. RESULTS: There was satisfactory pain relief with preservation of motor function in all 5 cases. Temperature sensation was preserved in all but 1 patient, who lost it after the previous ipsilateral percutaneous cordotomy (PCC). No procedural complications were experienced. We found that the neurophysiology monitoring lesion was guided anterior compared with what would have been lesioned on an anatomic basis. CONCLUSIONS: Open thoracic cordotomy is a safe and effective procedure for intractable cancer-related pain. Technical advancements significantly reduced mortality and major morbidity of PCC. Our series suggests that neurophysiology monitoring alters the location of the lesion and may help better targeting of pain fibers within the spinothalamic tract and preserve other long tracts. The safety profile of open cordotomy with neurophysiology compares favorably with the PCC.

Compartmentalisation of the inflammatory response following aneurysmal subarachnoid haemorrhage.

INTRODUCTION: There is some evidence to suggest that a systemic and central nervous system (CNS) inflammatory response occurs following aneurysmal subarachnoid haemorrhage (aSAH) which may be related to the pathophysiology of early brain injury and delayed ischaemic neurological deficit (DIND). The aim of this study was to measure inflammatory mediator levels in plasma and cerebrospinal fluid (CSF) in the days following aSAH and to determine their association with aSAH, DIND and clinical outcome. MATERIAL AND METHODS: Plasma and CSF samples were obtained prospectively from patients with aSAH on days 1-3, 5, 7 and 9 and profiled for interleukin (IL)-1α, IL-1ß, IL-4, IL-6, IL-8, IL-10, IL-15, IL-17, IL-18, macrophage chemotactic protein (MCP)-1, vascular endothelial growth factor (VEGF) and tumour necrosis factor (TNF)-α. Plasma and CSF samples from non-aSAH patients undergoing spinal anaesthesia were used as controls. RESULTS: The CSF levels of all cytokines investigated except for IL-1α were significantly higher in aSAH compared to controls in the first seven days of ictus. CSF levels of IL-1α (p = 0.014), IL-18 (p = 0.016), IL-6 (p = 0.0006) and IL-8 (p = 0.006) showed significant increases in the days following aSAH. Conversely IL-17 demonstrated a decrease. In particular, IL-4 was higher in the CSF of patients who had DIND at all time-points (p = 0.032). Plasma IL-6 and IL-8 levels were higher, and IL-1α levels lower, than controls at most time-points. All mediators demonstrated persistent elevation in the CSF compared to plasma apart from IL-1α and IL-18 which followed the opposite trend. Day 3 plasma IL-6 levels predicted poor outcome at six months (Exp(B) 1.12 1.03-1.22, P = 0.012), although this association was lost in the second analysis incorporating Fisher grade, WFNS grade and age. CONCLUSION: The post aSAH inflammatory response peaks on days 5-7 post ictus and remains largely compartmentalised within the CNS. IL-4 may have a particular association with DIND although its precise role in the pathophysiology of the disorder remains unclear. IL-6 predicted poor outcome but not independently of clinical grade, suggesting that it may be a surrogate marker of early brain injury.

Frontal skull osteoblastoma with aneurysmal bone cyst-like changes associated with trauma during pregnancy: a case report.

We report the case of a large osteoblastoma arising in the frontal bone of a 20-year-old female. The lesion was first noted after a fall, and grew steadily in size following further head injury during pregnancy. Initial plain radiography demonstrated an area of radiolucency, with subsequent cross-sectional imaging revealing the extent of the lesion. Following successful surgical resection, histological features were suggestive of an aggressive osteoblastoma with aneurysmal bone cyst-like changes. We consider the influence of pregnancy and trauma on osteoblastoma behavior.

Surgical outcome for foot drop in lumbar degenerative disease.

Controversy exists regarding the timing and outcome of surgery for lumbar degenerative disease (LDD) associated with foot drop. In this work, we report the results of a retrospective observational study from our center. We had a sample size of 26 patients with a minimum follow-up of 6 months. Of the 26 patients, 88% improved, with complete recovery observed in 61%. Thus, our data support the view that there is good recovery from operative management of foot drop secondary to LDD. Adjusting for preoperative strength, preoperative duration of weakness was a significant predictor of extent of recovery (odds ratio = 0.93; 95% confidence interval 0.88 to 0.98; p = 0.019). The model explained 50% of the variance in outcome in this study.

A retrospective analysis of revision endoscopic third ventriculostomy.

PURPOSE: Endoscopic third ventriculostomy (ETV) has gained favour as an effective treatment for obstructive hydrocephalus. However, the timing of ETV failure and the long-term efficacy of revision ETV remain poorly documented. METHODS: A retrospective review was performed of patients undergoing revision ETV between 1999 and 2007. Only those patients in whom there was evidence of a good sustained clinical improvement after the initial ETV were considered candidates for ETV revision. All other patients underwent insertion of a ventriculoperitoneal shunt at the time of ETV failure. Failures that were selected for repeat ETV were subdivided into; "early" if the revision occurred within the first 3 months of the primary procedure and "late" if occurring after this. RESULTS: Ten patients underwent revision ETV (6% of all ETVs performed). Age ranged from 2 months to 32 years (mean 13.6 years). Three "early" revision ETV were performed at a mean of 1.3 months, and there were seven "late" revisions performed at a mean of 27 months. The stoma was closed in seven patients and narrowed in one patient, and a second membrane was found under the original patent stoma in a further two patients. In two patients, a third ETV procedure was performed (both at 1 month after second ETV), and the stoma was closed in both these patients. No patients have required a shunt. CONCLUSION: At last follow-up (mean 38 months), all patients remain well. Revision ETV appears a safe and effective means of managing hydrocephalus-providing there is clinical evidence that the primary procedure was initially effective. It is important to emphasise that patients with an initially successful ETV are by no means "cured".

Bilateral extradural hematoma formation following excision of a thoracic intradural lesion.

The authors report an unusual case of a 15-year-old girl who previously underwent resection of a posterior fossa medulloblastoma, and later underwent resection of a thoracic extramedullary metastatic lesion. Her consciousness deteriorated hours after removal of her spinal metastasis. A CT head scan identified bilateral extradural cranial hematomas, which were evacuated. To the authors' knowledge, this is the first report of a patient developing bilateral acute cranial extradural hematomas following excision of a thoracic intradural lesion.

Endoscopic biopsy during third ventriculostomy in paediatric pineal region tumours.

OBJECTS: The goal of the study was to establish if endoscopic biopsy during third ventriculostomy contributes to morbidity in the management of paediatric pineal region tumours presenting with hydrocephalus. MATERIALS AND METHODS: This study was a retrospective descriptive study in patients less than 18 years of age who have presented with a pineal region tumour between 2000 and 2006. Data were obtained from case notes. Twelve patients had presented with a pineal region mass with symptomatic hydrocephalus. Of these, eight had endoscopic biopsy during third ventriculostomy. CONCLUSIONS: No mortality or permanent morbidity was seen following endoscopic biopsy. Two cases of transient worsening of pre-operative diplopia were noted. Diagnostic sensitivity for endoscopic biopsy is 75%. Tumour markers were not significantly raised in any plasma and cerebrospinal fluid samples. Endoscopic biopsy during third ventriculostomy in paediatric pineal region tumours is safe and results in good diagnostic yields. It should play an integral role in the initial management of patients in this setting.