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The role of systemic therapy in primary or advanced and metastatic chordoma has been traditionally limited because of the inherent resistance to cytotoxic therapies and lack of specific or effective therapeutic targets. Despite resection and adjuvant radiation therapy, local recurrence rates in clival chordoma remain high and the risk of systemic metastases is not trivial, leading to significant morbidity and mortality. Recently, molecular targeted therapies (MTTs) and immune checkpoint inhibitors (ICIs) have emerged as promising therapeutic avenues in chordoma. In recent years, preclinical studies have identified potential targets based on intrinsic genetic dependencies, epigenetic modulators, or newly identified tumor-associated cell populations driving treatment resistance and recurrence. Nonetheless, the role of systemic therapies in the neoadjuvant or adjuvant setting for primary, locally progressive, and distant metastatic chordomas is still being investigated. Herein, an overview of current and emerging systemic treatment strategies in advanced clival chordoma is provided. Furthermore, several molecular biomarkers have been recently uncovered as potential predictors of the response to specific molecular therapeutics. The authors describe the recently discovered role of 1p36 and 9p21 deletions as biomarkers capable of guiding drug selection. Then they discuss completed and ongoing clinical trials of MTTs, including several tyrosine kinase inhibitors used as monotherapy or in combination, such as imatinib, sorafenib, dasatinib, and lapatinib, among others, as well as mammalian target of rapamycin inhibitors such as everolimus and rapamycin. They present their experience and other recent studies demonstrating vast benefits in advanced chordoma from ICIs. Additionally, they provide a brief overview of novel systemic strategies such as adoptive cell transfer (CAR-T and NK cells), oncolytic viruses, epigenetic targeting (KDM6, HDAC, and EZH2 inhibitors), and several promising preclinical studies with high translational potential. Finally, the authors present their institutional multidisciplinary protocol for the incorporation of systemic therapy for both newly diagnosed and recurrent chordomas based on molecular studies including upfront enrollment in MTT trials in patients with epidermal growth factor receptor upregulation or INI-1 deficiency or enrollment in ICI clinical trials for patients with high tumor mutational burden or high PD-L1 expression on tumor cells or in the tumor microenvironment.
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Cordoma , Neoplasias da Base do Crânio , Humanos , Cordoma/terapia , Cordoma/tratamento farmacológico , Neoplasias da Base do Crânio/terapia , Terapia de Alvo Molecular/métodos , Terapia de Alvo Molecular/tendências , Inibidores de Checkpoint Imunológico/uso terapêuticoRESUMO
OBJECTIVE: The aging global population presents an increasing challenge for spine surgeons. Advancements in spine surgery, including minimally invasive techniques, have broadened treatment options, potentially benefiting older patients. This study aims to explore the clinical outcomes of spine surgery in septuagenarians and octogenarians. METHODS: This retrospective analysis, conducted at a US tertiary center, included patients aged 70 and older who underwent elective spine surgery for degenerative conditions. Data included the Charlson Comorbidity Index (CCI), ASA classification, surgical procedures, intraoperative and postoperative complications, and reoperation rates. The objective of this study was to describe the outcomes of our cohort of older patients and discern whether differences existed between septuagenarians and octogenarians. RESULTS: Among the 120 patients meeting the inclusion criteria, there were no significant differences in preoperative factors between the age groups (P > 0.05). Notably, the septuagenarian group had a higher average number of fused levels (2.36 vs. 0.38, P = 0.001), while the octogenarian group underwent a higher proportion of minimally invasive procedures (P = 0.012), resulting in lower overall bleeding in the oldest group(P < 0.001). Mobility outcomes were more favorable in septuagenarians, whereas octogenarians tended to maintain or experience a decline in mobility(P = 0.012). A total of 6 (5%) intraoperative complications and 12 (10%) postoperative complications were documented, with no statistically significant differences observed between the groups. CONCLUSIONS: This case series demonstrates that septuagenarians and octogenarians can achieve favorable clinical outcomes with elective spine surgery. Spine surgeons should be well-versed in the clinical and surgical care of older adults, providing optimal management that considers their increased comorbidity burden and heightened fragility.
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Complicações Pós-Operatórias , Humanos , Masculino , Feminino , Idoso de 80 Anos ou mais , Idoso , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Resultado do Tratamento , Doenças da Coluna Vertebral/cirurgia , Fatores Etários , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Procedimentos Neurocirúrgicos/efeitos adversos , Procedimentos Neurocirúrgicos/métodos , Fusão Vertebral/efeitos adversos , Fusão Vertebral/métodos , Complicações Intraoperatórias/epidemiologia , Complicações Intraoperatórias/etiologiaRESUMO
BACKGROUND: Decompressive hemicraniectomy (DHC) is performed to relieve life-threatening intracranial pressure elevations. After swelling abates, a cranioplasty is performed for mechanical integrity and cosmesis. Cranioplasty is costly with high complication rates. Prior attempts to obviate second-stage cranioplasty have been unsuccessful. The Adjustable Cranial Plate (ACP) is designed for implantation during DHC to afford maximal volumetric expansion with later repositioning without requiring a second major operation. METHODS: The ACP has a mobile section held by a tripod fixation mechanism. Centrally located gears adjust the implant between the up and down positions. Cadaveric ACP implantation was performed. Virtual DHC and ACP placement were done using imaging data from 94 patients who had previously undergone DHC to corroborate our cadaveric results. Imaging analysis methods were used to calculate volumes of cranial expansion. RESULTS: The ACP implantation and adjustment procedures are feasible in cadaveric testing without wound closure difficulties. Results of the cadaveric study showed total volumetric expansion achieved was 222 cm3. Results of the virtual DHC procedure showed the volume of cranial expansion achieved by removing a standardized bone flap was 132 cm3 (range, 89-171 cm3). Applied to virtual craniectomy patients, the total volume of expansion achieved with the ACP implantation operation was 222 cm3 (range, 181-263 cm3). CONCLUSIONS: ACP implantation during DHC is technically feasible. It achieves a volume of cranial expansion that will accommodate that observed following survivable hemicraniectomy operations. Moving the implant from the up to the down position can easily be performed as a simple outpatient or inpatient bedside procedure, thus potentially eliminating second-stage cranioplasty procedures.
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Craniectomia Descompressiva , Procedimentos de Cirurgia Plástica , Humanos , Craniectomia Descompressiva/métodos , Complicações Pós-Operatórias/cirurgia , Crânio/diagnóstico por imagem , Crânio/cirurgia , Cadáver , Estudos RetrospectivosRESUMO
OBJECTIVE: Endoscopic repair of skull base defects is required following resection of intracranial pathology via the endoscopic endonasal approach (EEA). Many closure techniques have been described, but choosing between techniques remains controversial. We report outcomes of 560 EEA procedures of skull base reconstruction performed on 508 patients over a 15-year-period. Halfway through this period, we adopted the use of a rigid, bioabsorbable extrasellar plate for reconstruction, enabling a comparison between this technique and those used previously. METHODS: All patients undergoing EEA from 2005 to 2019 at our institution were retrospectively reviewed. Demographic information, surgical pathology, tumor dimensions and radiographic features, reconstructive technique, and patient-related outcomes were collected and analyzed with univariate and multivariate statistical modeling. RESULTS: Five-hundred sixty procedures were performed on 508 patients. The series complication rate was 8.2%. Overall, cerebrospinal fluid (CSF) leak rate was 5.0% but varied significantly across closure techniques (p < 0.001). Critically, the CSF leak rate in the 272 cases prior to our 2013 adoption of the Resorb-X Plate (RXP) was 8.5%, whereas leak rate in the subsequent 288 cases was 1.7%. RXP was protective against CSF leak (p = 0.001), whereas gross total resection (GTR) correlated with increased leak rate (p = 0.001). Patient BMI was significantly associated with risk of leak (p = 0.047). Other variables did not impact leak risk. CONCLUSION: Reconstructive technique, extent of resection, and patient BMI significantly contributed to CSF leak rate. GTR was associated with increased leak risk while the RXP was protective. The bioabsorbable RXP is an effective option for rigid skull base repair with comparatively few complications. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:1092-1098, 2023.
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Procedimentos de Cirurgia Plástica , Neoplasias da Base do Crânio , Humanos , Retalhos Cirúrgicos/cirurgia , Neoplasias da Base do Crânio/patologia , Estudos Retrospectivos , Implantes Absorvíveis , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Endoscopia/métodos , Base do Crânio/cirurgia , Base do Crânio/patologia , Vazamento de Líquido Cefalorraquidiano/etiologia , Vazamento de Líquido Cefalorraquidiano/cirurgiaRESUMO
OBJECTIVE: Spinal cord stimulation (SCS) has become a popular nonopioid pain intervention. However, the treatment failure rate for SCS remains significantly high and many of these patients have poor sagittal spinopelvic balance, which has been found to correlate with increased pain and decreased quality of life. The purpose of this study was to determine if poor sagittal alignment is correlated with SCS treatment failure. MATERIALS AND METHODS: Comparative retrospective analysis was performed between two cohorts of patients who had undergone SCS placement, those who had either subsequent removal of their SCS system (representing a treatment failure cohort) and those that underwent generator replacement (representing a successful treatment cohort). The electronic medical record was used to collect demographic and surgical characteristics, which included radiographic measurements of lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS). Also included were data on pain medication usage including opioid and nonopioid therapies. RESULTS: Eighty-one patients met inclusion criteria, 31 had complete removal, and 50 had generator replacements. Measurement of sagittal balance parameters demonstrated that many patients had poor alignment, with 34 outside normal range for LL (10 vs 24 in removal and replacement cohorts, respectively), 30 for PI (12 [38.7%] vs 18 [36.0%]), 46 for PT (18 [58.1%] vs 28 [56.0%]), 38 for SS (18 [58.1%] vs 20 [40.0%]), and 39 for PI-LL mismatch (14 [45.2%] vs 25 [50.0%]). There were no significant differences in sagittal alignment parameters between the two cohorts. CONCLUSIONS: This retrospective cohort analysis of SCS patients did not demonstrate any relationship between poor sagittal alignment and failure of SCS therapy. Further studies of larger databases should be performed to determine how many patients ultimately go on to have additional structural spinal surgery after failure of SCS and whether or not those patients go on to have positive outcomes.
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Lordose , Vértebras Lombares , Estimulação da Medula Espinal , Humanos , Vértebras Lombares/diagnóstico por imagem , Vértebras Lombares/cirurgia , Dor/prevenção & controle , Pelve , Qualidade de Vida , Estudos Retrospectivos , Medula Espinal , Falha de TratamentoRESUMO
Objective Anterior skull base meningiomas include olfactory groove, planum sphenoidale, and tuberculum sellae lesions. Traditionally, standard craniotomy approaches have been used to access meningiomas in these locations. More recently, minimally invasive techniques including supraorbital and endonasal endoscopic approaches have gained favor; however there are limited published series comparing the use of these two techniques for these meningiomas. Using our patent database, we identified patients who underwent these two approaches, and conducted a retrospective chart review to compare outcomes between these two techniques. Methods A total of 32 patients who underwent minimally invasive approaches were identified: 20 supraorbital and 11 endoscopic endonasal. Radiographic images, presenting complaints and outcomes, were analyzed retrospectively. The safety of each approach was evaluated. Results The mean extent of resection through a supraorbital approach was significantly greater than that of the endoscopic endonasal approach, 88.1 vs. 57.9%, respectively ( p = 0.016). Overall, preoperative visual acuity and anopsia deficits were more frequent in the endonasal group that persisted postoperatively (visual acuity: p = 0.004; anopsia: p = 0.011). No major complications including cerebrospinal fluid (CSF) leaks or wound-related complications were identified in the supraorbital craniotomy group, while the endonasal group had two CSF leaks requiring lumbar drain placement. Length of stay was shorter in the supraorbital group (3.4 vs. 6.1 days, p < 0.001). Conclusion Anterior skull base meningiomas can be successfully managed by both supraorbital and endoscopic endonasal approaches. Both approaches provide excellent direct access to tumor in carefully selected patients and are safe and efficient, but patient factors and symptoms should dictate the approach selected.
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STUDY DESIGN: Retrospective cohort study OBJECTIVE: The aim of this study was to investigate the effect of body mass index (BMI) on the reoperation rate and cervical sagittal alignment of patients who underwent posterior cervical decompression and fusion for cervical spondylotic myelopathy (CSM). SUMMARY OF BACKGROUND DATA: Cervical sagittal balance has been correlated with postoperative clinical outcomes. Previous studies have shown worse postoperative sagittal alignment and higher reoperation rates in patients with high BMI undergoing anterior decompression and fusion. Similar evidence for the impact of obesity in postoperative sagittal alignment for patients with (CSM) undergoing posterior cervical decompression and fusion (PCF) is lacking. METHODS: A retrospective analysis of 198 patients who underwent PCF for cervical myelopathy due to degenerative spine disease was performed. Demographics, need for reoperation, and perioperative radiographic parameters were collected. Cervical lordosis (CL), C2-7 sagittal vertical axis (SVA), and T1 slope (T1S) was measured on standing lateral radiographs. Comparative analysis of the patient cohort was performed by stratifying the sample population into three BMI categories (<25, 25-30, ≥30). RESULT: Of the 198 patients that met inclusion criteria, 53 had BMI normal (<25), 65 were overweight (25-30), and 80 were obese (≥30). Mean SVA increased postoperatively in all groups, 4 mm in the normal group, 13 mm in the overweight group, and 13 mm in the obese group (p = 0.003). There was no significant difference in the postoperative change of cervical lordosis or T1 slope between the groups. Multivariate analysis demonstrated fusions involving the cervicothoracic junction and those involving 5 or more levels significantly affected alignment parameters. There were 27 complications requiring reoperation (14%) with no significant differences among the groups stratified by BMI (p = 0.386). CONCLUSIONS: Overweight patients (BMI>25) with CSM undergoing PCF had a greater increase in SVA than normal weight patients while reoperation rates were similar. In addition, preoperative CL increased with increasing BMI, although this trend was not Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation significant and there was not found to be a significant difference between the change in CL from baseline to post-fusion between BMI cohorts. This study further highlights the importance of considering BMI when attempting to optimize sagittal alignment in patients undergoing PCF.
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Vértebras Cervicais , Descompressão Cirúrgica , Avaliação de Resultados em Cuidados de Saúde , Sobrepeso , Reoperação , Doenças da Medula Espinal/cirurgia , Fusão Vertebral , Espondilose/cirurgia , Adulto , Idoso , Índice de Massa Corporal , Vértebras Cervicais/patologia , Vértebras Cervicais/cirurgia , Comorbidade , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Obesidade/epidemiologia , Sobrepeso/epidemiologia , Estudos Retrospectivos , Doenças da Medula Espinal/epidemiologia , Doenças da Medula Espinal/etiologia , Espondilose/complicações , Espondilose/epidemiologiaRESUMO
BACKGROUND: Chiari Malformation Type I (CM-I) is defined as cerebellar tonsil displacement more than 5 mm below the foramen magnum. This displacement can alter cerebrospinal fluid flow at the cervicomedullary junction resulting in Valsalva-induced headaches and syringomyelia and compress the brainstem resulting in bulbar symptoms. However, little is known about cognitive and psychological changes in CM-I. OBJECTIVE: To prospectively assess cognitive and psychological performance in CM-I and determine whether changes occur after surgical decompression. METHODS: Blinded evaluators assessed symptomatic CM-I patients ages ≥18 with a battery of neuropsychological and psychological tests. Testing was conducted preoperatively and 6 to 18 mo postoperatively. Data were converted to Z-scores based on normative data, and t-tests were used to analyze pre-post changes. RESULTS: A total of 26 patients were included, with 19 completing both pre- and post-op cognitive assessments. All patients had resolution of Valsalva-induced headaches and there was improvement in swallowing dysfunction (P < .0001), ataxia (P = .008), and sleep apnea (P = .021). Baseline performances in visual perception and construction (z = -1.11, P = .001) and visuospatial memory (z = -0.93, P = .002) were below average. Pre-post comparisons showed that CM-I patients had stable cognitive and psychological functioning after surgery, without significant changes from preoperative levels. CONCLUSION: CM-I patients had below average performance in visuospatial and visuoconstructional abilities preoperatively. Prospective longitudinal data following surgery demonstrated improved neurologic status without any decline in cognition or psychological functioning. Routine pre- and postoperative formal neuropsychological assessment in CM-I patients help quantify cognitive and behavioral changes associated with surgical decompression.
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Malformação de Arnold-Chiari , Siringomielia , Malformação de Arnold-Chiari/complicações , Malformação de Arnold-Chiari/cirurgia , Cognição , Descompressão Cirúrgica/métodos , Forame Magno/cirurgia , Humanos , Imageamento por Ressonância Magnética , Estudos Prospectivos , Siringomielia/complicações , Resultado do TratamentoRESUMO
BACKGROUND: Surgical site infection (SSI) after a craniotomy is traditionally treated with wound debridement and disposal of the bone flap, followed by intravenous antibiotics. The goal of this study is to evaluate the safety of replacing the bone flap or performing immediate titanium cranioplasty. METHODS: All craniotomies at single center between 2008 and 2020 were examined to identify 35 patients with postoperative SSI. Patients were grouped by bone flap management: craniectomy (22 patients), bone flap replacement (seven patients), and titanium cranioplasty (six patients). Retrospective chart review was performed to identify patient age, gender, index surgery indication and duration, diffusion restriction on MRI, presence of gross purulence, bacteria cultured, sinus involvement, implants used during surgery, and antibiotic prophylaxis/ treatment. These variables were compared to future infection recurrence and wound breakdown. RESULTS: There was no significant difference in infection recurrence or future wound breakdown among the three bone flap management groups (P = 0.21, P = 0.25). None of the variables investigated had any significant relation to infection recurrence when all patients were included in the analysis. However, when only the bone flap replacement group was analyzed, there was significantly higher infection recurrence when there was frank purulence present (P = 0.048). CONCLUSION: Replacing the bone flap or performing an immediate titanium cranioplasty is safe alternatives to discarding the bone flap after postoperative craniotomy SSI. When there is gross purulence present, caution should be used in replacing the bone flap, as infection recurrence is significantly higher in this subgroup of patients.
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BACKGROUND: Renal cell carcinoma with metastases to the spine (RCCMS) requires a multidisciplinary approach. We reviewed our institutional experience with RCCMS patients undergoing spinal surgery in order to identify factors that may affect clinical outcomes, survival, and complications. METHODS: Patients with RCCMS who underwent operative intervention from 2007 to 2020 were reviewed retrospectively. RESULTS: Forty-four patients with the diagnosis of RCCMS were identified. Pain was the most common symptom, and neurologic dysfunction was present in one third of cases. Thoracic spine was the most common location (N = 27), followed by the lumbar (N = 12) and cervical (N = 5) regions. The overall survival from diagnosis of renal cell carcinoma was 25 (2 - 194) months and 8 (0.3 - 92) months after spinal surgery. Gender, age, spinal level, postoperative radiation, and nephrectomy had no bearing on survival. Survival for patients with a Tokuhashi score of 0 - 8, 9 - 11, and 12 - 15 was 6.5 (1.5 - 23.5), 8.9 (0.3 - 91.6), and 23.4 (2.5 - 66) months, respectively (P = 0.03). The postoperative American Spinal Cord Injury Association score of E (hazard ratio 0.109 [95% confidence interval 0.022 - 0.534, P = 0.006) also bore a significant influence on survival. There was a total of 10 complications in 7 of 44 (16%) patients. CONCLUSIONS: Median postoperative survival of patients with RCCMS was 8 (0.3 - 92) months. Higher Tokuhashi score and ASIA E score at follow-up correlated with improved overall survival. Complication rate was 16%. Spinal surgery in RCCMS is indicated for the preservation of function and prevention of neurologic deterioration. Multimodality therapy with improved chemotherapy and stereotactic spinal radiation is expected to impact quality and length of survival positively.
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Carcinoma de Células Renais/secundário , Carcinoma de Células Renais/cirurgia , Neoplasias Renais/patologia , Neoplasias da Coluna Vertebral/secundário , Neoplasias da Coluna Vertebral/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma de Células Renais/diagnóstico por imagem , Terapia Combinada , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Doenças do Sistema Nervoso/etiologia , Procedimentos Neurocirúrgicos , Dor/etiologia , Complicações Pós-Operatórias/epidemiologia , Prognóstico , Radiocirurgia , Estudos Retrospectivos , Neoplasias da Coluna Vertebral/diagnóstico por imagem , Análise de Sobrevida , Vértebras Torácicas/cirurgia , Resultado do TratamentoRESUMO
OBJECTIVE: Chiari malformation type I (CM-I) is a congenital and developmental abnormality that results in tonsillar descent 5 mm below the foramen magnum. However, this cutoff value has poor specificity as a predictor of clinical severity. Therefore, the authors sought to identify a novel radiographic marker predictive of clinical severity to assist in the management of patients with CM-I. METHODS: The authors retrospectively reviewed 102 symptomatic CM-I (sCM-I) patients and compared them to 60 age-matched normal healthy controls and 30 asymptomatic CM-I (aCM-I) patients. The authors used the fourth ventricle roof angle (FVRA) to identify fourth ventricle "bowing," a configuration change suggestive of fourth ventricle outlet obstruction, and compared these results across all three cohorts. A receiver operating characteristic (ROC) curve was used to identify a predictive cutoff for brainstem dysfunction. Binary logistic regression was used to determine whether bowing of the fourth ventricle was more predictive of brainstem dysfunction than tonsillar descent, clival canal angle, or obex position in aCM-I and sCM-I patients. RESULTS: The FVRA had excellent interrater reliability (intraclass correlation 0.930, 95% CI 0.905-0.949, Spearman r2 = 0.766, p < 0.0001). The FVRA was significantly greater in the sCM-I group than the aCM-I and healthy control groups (59.3° vs 41.8° vs 45.2°, p < 0.0001). No difference was observed between aCM-I patients and healthy controls (p = 0.347). ROC analysis indicated that an FVRA of 65° had a specificity of 93% and a sensitivity of 50%, with a positive predictive value of 76% for brainstem dysfunction. FVRA > 65° was more predictive of brainstem dysfunction (OR 5.058, 95% CI 1.845-13.865, p = 0.002) than tonsillar herniation > 10 mm (OR 2.564, 95% CI 1.050-6.258, p = 0.039), although increasing age was also associated with brainstem dysfunction (OR 1.045, 95% CI 1.011-1.080, p = 0.009). A clival canal angle < 140° (p = 0.793) and obex below the foramen magnum (p = 0.563) had no association with brainstem dysfunction. CONCLUSIONS: The authors identified a novel radiographic measure, the FVRA, that can be used to assess fourth ventricular bowing in CM-I and is more predictive of brainstem dysfunction than tonsillar herniation. The FVRA is easy to measure, has excellent interrater variability, and can be a reliable universal radiographic measure. The FVRA will be useful in further describing CM-I radiographically and clinically by identifying patients more likely to be symptomatic as a result of brainstem dysfunction.
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BACKGROUND: Sphenoid wing meningiomas are a challenging surgical disease with relatively high perioperative morbidity. Most studies to date have focused on resection strategies as it relates to disease recurrence. Few have examined the optimal strategy as it relates to overall patient survival. We retrospectively reviewed our case series and evaluated extent of resection and perioperative stroke as it relates to all cause and disease-specific survival. PATIENTS/METHODS: Ninety-four patients were included in the study. Demographics, clinical features, operative features and clinical course, and time to mortality evaluation were collected. Extent of resection (EOR) was defined as gross total (GTR, 100%), near total (NTR, ≥ 95%), and subtotal (STR,<95%). RESULTS: The overall mean EOR was 94.5% with 70.2% of cases achieving GTR, 12.8% achieved NTR, and 17% achieved STR. Postoperative stroke only occurred with GTR or NTR (p=0.041). Age alone was significant on Cox regression analysis for all cause mortality (p=0.042, HR 1.054 [95% CI 1.002 - 1.109]). Postoperative stroke was associated with worse disease-specific mortality (p=0.046, HR 23.337 [95% CI 1.052 - 517.782) with no impact from extent of resection (p=0.258). CONCLUSIONS: Although maximizing resection and minimizing recurrence is ideal, GTR or NTR confer a significantly higher stroke risk. Most patients do not die from their meningioma, as all cause mortality was associated only with age. However, perioperative stroke conferred decreased survival throughout follow up. This series demonstrates that an overly aggressive surgical philosophy negatively impacted disease specific survival.
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Neoplasias Meníngeas , Meningioma , Humanos , Neoplasias Meníngeas/cirurgia , Meningioma/cirurgia , Recidiva Local de Neoplasia/cirurgia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVE: Tethered cord syndrome (TCS) has been well described in pediatric patients. Many recent reports of TCS in adult patients have grouped retethering patients with newly diagnosed ones without separately analyzing each entity and outcome. The authors reviewed their experience of newly diagnosed adult TCS patients to identify and explore TCS misdiagnosis, recognition, subtype pathology, and individual objective outcomes. METHODS: This study included 24 adult patients (20 female and 4 male) who fit the criteria of being newly diagnosed and aged 20 years and older (age range 20-77 years). Preexisting dermal sinus was present in 6 patients, hypertrichosis in 5, skin tag/cleft/dimple and fatty subcutaneous masses in 5, scoliosis in 2, and neurological abnormalities in 4 patients. The pathology consisted of TCS with taut filum in 8 patients, conus lipoma with TCS in 7, diastematomyelia in 7, and cervical cord tethering in 2 patients. Of the 24 study patients, nondermatomal low-back or perineal pain occurred in 19 patients, bladder dysfunction in 21, and motor, sensory, and reflex abnormalities in 21 patients. Aggravating factors were repeated stretching, multiple pregnancies, heavy lifting, and repeated bending. Urological evaluation included bladder capacity, emptying, postvoid residuals, detrusor function, pelvic floor electromyography (EMG), bladder sensitivity, and sphincter EMG, which were repeated at 6 months and 1 year postoperatively. The follow-up was 1 to 30 years. Detailed postoperative neurological findings and separate patient outcome evaluations were recorded. Four of the 24 patients did not have an operation. RESULTS: Resolution of pain occurred in 16 of the 19 patients reporting low-back or perineal pain. Motor and sensory complaints resolved in 17 of 20 patients. Regarding bladder dysfunction, in the 20 patients with available data, bladder function returned to normal in 12 patients, improved in 3 patients, and was unchanged in 5 patients. If the symptom duration was less than 6-8 months, there was recovery of all parameters of pain, bladder dysfunction, and neurological deficit, and recovery from hyperreflexia matched that from neurological deficit. Fifteen patients were employed preoperatively and returned to work, and an additional 3 others who were unable to work preoperatively were able to do so postoperatively. CONCLUSIONS: Most adults with newly diagnosed TCS have unrecognized neurocutaneous abnormalities and neurological deficits. The triad of nondermatomal sacral or perineal pain, bladder dysfunction, and neurological deficit should not be confused with hip or degenerative lumbosacral disease. Addressing the primary pathology often leads to successful results.
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BACKGROUND: Ossified posterior longitudinal ligament (OPLL) of the cervical spine can lead to spinal stenosis and become clinically symptomatic. The optimal approach in addressing OPLL is a debated topic and dependent on factors such as preoperative lordosis and levels affected. METHODS: In this study, we retrospectively identified patients undergoing operative management for OPLL. Demographics, operative details, radiographic parameters, outcome measurements, and complications were compared between the different approaches for OPLL treatment. RESULTS: We identified a total of 44 patients with 16 undergoing laminoplasty (Plasty), 18 anterior corpectomy and diskectomy (Ant), and 10 laminectomy and instrumentation (Linst). Ant had least OPLL levels with median (range) 3 (2-5), compared with Plasty 4 (2-7) and Linst 4 (3-6). Plasty was associated with the shortest operative time and hospital stay. Ant showed significant correction in kyphosis from 0.5° (-13 to 16°) to 9.5° (-7 to 20°). There was loss in lordosis in Plasty and Linst. Sagittal balance significantly increased irrespective of surgical approach with the least increase in the Ant group. Complications were least in the Plasty group with similar overall improvement in outcome measurements. CONCLUSIONS: All 3 approaches in the management of OPLL were associated with clinical improvement without 1 approach surpassing the others. Laminoplasty had the advantage of addressing more levels of stenosis than the anterior approach and was associated with a shorter operating time. Laminoplasty patients had a shorter hospital stay than those undergoing laminectomy and instrumentation and appeared to have fewer complications than the other approaches. Laminoplasty is the preferred approach in patients with preserved motion and lordosis, with the anterior approach effective in the correction of kyphosis.
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Procedimentos Neurocirúrgicos/métodos , Ossificação do Ligamento Longitudinal Posterior/cirurgia , Adulto , Idoso , Vértebras Cervicais/diagnóstico por imagem , Vértebras Cervicais/cirurgia , Discotomia , Feminino , Humanos , Cifose/cirurgia , Laminoplastia , Tempo de Internação , Lordose/diagnóstico por imagem , Lordose/cirurgia , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Estenose Espinal/cirurgia , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Adulto JovemRESUMO
Introduction Pituitary apoplexy commonly presents with visual and hormonal deficits. While traditionally regarded as an emergency, there have been increasing trends toward conservative management. Our institutional practice consists of early surgery; therefore, we reviewed our series evaluating vision outcomes, hormone function, and complications compared with the present literature. Methods We retrospectively reviewed our institution's medical records to identify pituitary apoplexy patients who were treated via the endoscopic endonasal approach by a single neurosurgeon (senior author). We recorded basic demographics, radiographic and operative features, and preoperative and postoperative vision and hormone status. Univariate and multivariate statistical analyses were performed. Pooled data analysis of visual outcomes in the current literature using Bayesian inference was performed. Results We identified 44 patients with histologically confirmed pituitary apoplexy treated by endoscopic transsphenoidal decompression; 77% were treated within 24 hours of presentation. Total 45% had cranial nerve (CN) palsy, 36% anopsia, and 20% had visual acuity deficits. Postoperatively, 100% of CN palsies improved, 81% of anopsias improved, and 66.7% of visual acuity deficits improved. Long-lasting panhypopituitarism (25%) and hypothyrodism (22%) were common. Cavernous sinus involvement predicted residual tumor ( p = 0.006). Pooled Bayesian inference showed 30% improvement in vision outcomes with surgical management compared with medical management with a number needed to treat of 3.3. Conclusion Early surgery for pituitary apoplexy was associated with excellent visual outcomes and the need for long-term hormone replacement is common. Cavernous sinus involvement is an independent predictor of residual tumor. Pooled statistical analysis favors aggressive surgical management of apoplexy for improved visual outcomes.
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BACKGROUND: Many techniques have been utilized for reconstruction of the anterior skull base. Each method has advantages and disadvantages with respect to effectiveness, morbidity, strength, and cost. Rigid reconstruction may provide advantages in certain patients. OBJECTIVE: We evaluated all patients who had placement of rigid absorbable reconstruction plates in the anterior skull base in a variety of extrasellar locations and describe results and complications compared with other published techniques. METHODS: A retrospective review was conducted of consecutive patients at a tertiary referral institution who underwent endoscopic extrasellar skull base reconstruction, 2012-2019, using resorbable poly (D,L) lactic acid plates (Resorb-X Sellar Wall Plate; KLS Martin; Jacksonville, FL). Data reviewed included demographic information, indication for surgery, location and size of defect, pathology, peri-operative use of cerebrospinal fluid (CSF) diversion, postoperative complications, post-operative CSF leak, adjuvant therapy, and length of follow-up. RESULTS: Twenty-four subjects and 25 operative procedures met inclusion criteria. Mean age was 53 years (range 11-77). Average BMI was 34 kg/m2. Mean follow-up time was 30 months (range 1-78). Indications for surgery were CSF rhinorrhea (spontaneous, post-traumatic, or iatrogenic) or reconstruction after tumor resection. Four cases were revision procedures. Twenty patients had lumbar drains placed intraoperatively. Only two nasoseptal flaps and two free mucosal grafts were used. None of the patients had a postoperative CSF leak. There was no mortality or morbidity related to the skull base reconstruction or implanted material. CONCLUSION: The Resorb-X resorbable rigid plate provides an effective, customizable, bioabsorbable option that is easily manipulated for skull base reconstruction of defects of a variety of sizes in diverse locations. Reconstruction incorporating this plate provides an effective alternative to other previously described techniques.
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Implantes Absorvíveis , Placas Ósseas , Endoscopia/métodos , Procedimentos de Cirurgia Plástica/métodos , Base do Crânio/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Vazamento de Líquido Cefalorraquidiano , Rinorreia de Líquido Cefalorraquidiano/cirurgia , Criança , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Poliésteres , Estudos Retrospectivos , Neoplasias da Base do Crânio/cirurgia , Resultado do Tratamento , Adulto JovemRESUMO
OBJECTIVE: The histopathology of intramedullary spinal cord tumors (IMSCT) can be suspected from the MRI features and characteristics. Ultimately, the confirmation of diagnosis requires surgery. This retrospective study addresses MRI features including homogeneity of enhancement, margination, and associated syrinx in intramedullary astrocytomas (IMA) and ependymomas (IME) that assist in diagnosis and predict resectability of these tumors. METHODS: Single-center retrospective analysis of IMA and IME cases since 2005 extracted from the departmental registry/electronic medical records post IRB approval (IRB 201,710,760). We compared imaging findings (enhancement, margination, homogeneity, and associated syrinxes) between tumor types and examined patient outcomes. RESULTS: There were 18 IME and 21 IMA. On preoperative MRI, IME was favored to have homogenous enhancement (OR 1.8, pâ¯=â¯0.0001), well-marginated (pâ¯<â¯0.0001, OR 0.019 [95 % CI 0.002-0.184]), and associated syrinx (pâ¯=â¯0.015, OR 0.192 [95 % CI 0.049-0.760]). Total excision, subtotal excision, and biopsy were performed in 12, 5, and 1 patients in the IME cohort, respectively. In the IMA group, tumors were heterogeneous and poorly marginated in 20 of the 21 patients. Total excision, subtotal excision, and biopsy were undertaken in 2, 13, and 6 patients, respectively. The success of excision was predicted by MRI, with a significant difference in the extent of resection between IME and IMA (X2â¯=â¯14.123, pâ¯=â¯0.001). In terms of outcome, ordinal regression analysis showed that well-margined tumors and those with homogeneous enhancement were associated with a better postoperative McCormick score. Extent of resection had statistically significant survival (pâ¯=â¯0.026) and recurrence-free survival (pâ¯=â¯0.008) benefits. CONCLUSION: The imaging characteristics of IME and IMA have meaningful clinical significance. Homogeneity, margination, and associated syrinxes in IME can predict resectability and complexity of surgery.
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Glioma/diagnóstico por imagem , Glioma/cirurgia , Imageamento por Ressonância Magnética/métodos , Procedimentos Neurocirúrgicos/métodos , Neoplasias da Medula Espinal/diagnóstico por imagem , Neoplasias da Medula Espinal/cirurgia , Adolescente , Adulto , Vértebras Cervicais/diagnóstico por imagem , Vértebras Cervicais/cirurgia , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cuidados Pré-Operatórios/métodos , Estudos Retrospectivos , Vértebras Torácicas/diagnóstico por imagem , Vértebras Torácicas/cirurgia , Adulto JovemRESUMO
Retinal diseases are frequently characterized by the accumulation of excessive scar tissue found throughout the neural retina. However, the pathophysiology of retinal fibrosis remains poorly understood, and the cell types that contribute to the fibrotic response are incompletely defined. Here, we show that myofibroblast differentiation of mural cells contributes directly to retinal fibrosis. Using lineage tracing technology, we demonstrate that after chemical ocular injury, Myh11+ mural cells detach from the retinal microvasculature and differentiate into myofibroblasts to form an epiretinal membrane. Inhibition of TGFßR attenuates Myh11+ retinal mural cell myofibroblast differentiation, and diminishes the subsequent formation of scar tissue on the surface of the retina. We demonstrate retinal fibrosis within a murine model of oxygen-induced retinopathy resulting from the intravitreal injection of adipose Myh11-derived mesenchymal stem cells, with ensuing myofibroblast differentiation. In this model, inhibiting TGFßR signaling does not significantly alter myofibroblast differentiation and collagen secretion within the retina. This work shows the complexity of retinal fibrosis, where scar formation is regulated both by TGFßR and non-TGFßR dependent processes involving mural cells and derived mesenchymal stem cells. It also offers a cautionary note on the potential deleterious, pro-fibrotic effects of exogenous MSCs once intravitreally injected into clinical patients.
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Diferenciação Celular , Cicatriz/patologia , Fibrose/patologia , Células-Tronco Mesenquimais/patologia , Miofibroblastos/patologia , Cadeias Pesadas de Miosina/metabolismo , Doenças Retinianas/patologia , Animais , Células Cultivadas , Cicatriz/metabolismo , Feminino , Fibrose/metabolismo , Masculino , Células-Tronco Mesenquimais/metabolismo , Camundongos , Camundongos Endogâmicos C57BL , Miofibroblastos/metabolismo , Doenças Retinianas/metabolismo , Transdução de SinaisRESUMO
OBJECTIVE: Microvascular decompression (MVD) is the standard surgical procedure for patients with medically refractory trigeminal neuralgia (TN). Stereotactic radiosurgery (SRS) has gained increasing popularity as a less invasive technique. We report our institution's outcome in the surgical treatment of TN (MVD vs. SRS), taking patient's age and gender into consideration. METHODS: We retrospectively reviewed a prospectively collected database of patients undergoing MVD or SRS for type 1 idiopathic TN between 2004 and 2019 at the University of Iowa. Standardized data collection focused on preoperative clinical characteristics and postoperative outcomes including the Barrow Neurological Institute (BNI) Pain Intensity Score. RESULTS: A total of 111 patients underwent MVD and 103 patients underwent SRS for TN. Patients were younger in the MVD (median, 60 years) than SRS (median, 72 years) group. More females (58%) than males (42%) had TN. Multivariate ordinal regression analysis showed that an outcome of BNI score I-II (P = 0.365) and III (P = 0.736) can be achieved with either MVD or SRS; however, BNI score IV (P = 0.031) and V (P = 0.022) were more associated with SRS. Six percent of patients in the MVD group and 26% in the SRS group developed pain recurrence and required a second operation. Nine of 10 patients who underwent MVD after failed SRS had complete pain relief. CONCLUSIONS: Factoring in patients' age and gender, both MVD and SRS can achieve a favorable outcome for medically refractory TN, although BNI scores of IV and V were more common with SRS.