Mini-open stabilization of a sacral fracture: technical case report.

BACKGROUND AND IMPORTANCE: Comminuted sacral fractures present significant challenges for operative management. Open and percutaneous sacroiliac screws have been used for stabilization but carry not insignificant rates of complications, including wound infection for the former and malposition and neurological injury for the latter. We report the use of a novel mini-open lumbar-ilium fixation for stabilization of a patient with a comminuted sacral fracture. CLINICAL PRESENTATION: A 33-year-old man with intact neurologic function was admitted after a fall of approximately 25 ft. A comminuted sacral fracture was diagnosed. The patient was unable to tolerate conservative management because of pain in upright positions. The patient was taken to the operating room for stabilization with a "mini-open" procedure involving L4 and L5 pedicle screws and bilateral iliac screws. Four 2-in paramedian incisions were made overlying the L4-L5 facet joints and medial to the sacroiliac joints. Minimally invasive retractors were placed to expose bony landmarks. L4-L5 pedicle screws and bilateral iliac screws were placed with minimal fluoroscopic guidance. Titanium rods were tunneled inferior-superiorly between incisions and affixed to screw heads. Total operative time was approximately 3.5 hours. The patient remained neurologically intact and had an uncomplicated recovery. One-year follow-up computed tomography showed successful healing of the sacrum. CONCLUSION: We report the first case of a mini-open procedure to treat a comminuted sacral fracture. Use of this procedure offers a straightforward method for sacral stabilization with minimal blood loss and minimal radiation exposure. If indicated, this method could be combined with decompressive procedures.

Postoperative stereotactic radiosurgery without whole-brain radiation therapy for brain metastases: potential role of preoperative tumor size.

PURPOSE: Radiation therapy following resection of a brain metastasis increases the probability of disease control at the surgical site. We analyzed our experience with postoperative stereotactic radiosurgery (SRS) as an alternative to whole-brain radiotherapy (WBRT), with an emphasis on identifying factors that might predict intracranial disease control and overall survival (OS). METHODS AND MATERIALS: We retrospectively reviewed all patients through December 2008, who, after surgical resection, underwent SRS to the tumor bed, deferring WBRT. Multiple factors were analyzed for time to intracranial recurrence (ICR), whether local recurrence (LR) at the surgical bed or "distant" recurrence (DR) in the brain, for time to WBRT, and for OS. RESULTS: A total of 49 lesions in 47 patients were treated with postoperative SRS. With median follow-up of 9.3 months (range, 1.1-61.4 months), local control rates at the resection cavity were 85.5% at 1 year and 66.9% at 2 years. OS rates at 1 and 2 years were 52.5% and 31.7%, respectively. On univariate analysis (preoperative) tumors larger than 3.0 cm exhibited a significantly shorter time to LR. At a cutoff of 2.0 cm, larger tumors resulted in significantly shorter times not only for LR but also for DR, ICR, and salvage WBRT. While multivariate Cox regressions showed preoperative size to be significant for times to DR, ICR, and WBRT, in similar multivariate analysis for OS, only the graded prognostic assessment proved to be significant. However, the number of intracranial metastases at presentation was not significantly associated with OS nor with other outcome variables. CONCLUSIONS: Larger tumor size was associated with shorter time to recurrence and with shorter time to salvage WBRT; however, larger tumors were not associated with decrements in OS, suggesting successful salvage. SRS to the tumor bed without WBRT is an effective treatment for resected brain metastases, achieving local control particularly for tumors up to 3.0 cm diameter.

Robotic image-guided depth electrode implantation in the evaluation of medically intractable epilepsy.

OBJECT: The authors describe their experience with a technique for robotic implantation of depth electrodes in patients concurrently undergoing craniotomy and placement of subdural monitoring electrodes for the evaluation of intractable epilepsy. METHODS: Patients included in this study underwent evaluation in the Dartmouth Surgical Epilepsy Program and were recommended for invasive seizure monitoring with depth electrodes between 2006 and the present. In all cases an image-guided robotic system was used during craniotomy for concurrent subdural grid electrode placement. A total of 7 electrodes were placed in 4 patients within the time period. RESULTS: Three of 4 patients had successful localization of seizure onset, and 2 underwent subsequent resection. Of the patients who underwent resection, 1 is now seizure free, and the second has only auras. There was 1 complication after subpial grid placement but no complications related to the depth electrodes. CONCLUSIONS: Robotic image-guided placement of depth electrodes with concurrent craniotomy is feasible, and the technique is safe, accurate, and efficient.