Targeted neurosurgical outreach: 5-year follow-up of operative skill transfer and sustainable care in Lima, Peru.

PURPOSE: This study evaluates the efficacy of operative skill transfer in the context of targeted pediatric outreach missions. In addition, the ability to implement surgical care improvements that are sustainable is investigated. METHODS: Three 1-week targeted neurosurgical missions were performed (2004-2006) to teach neuroendoscopy, which included donation of the necessary equipment so newly acquired surgical skills could be performed by local neurosurgeons in between and after the departure of the mission team. After the targeted missions were completed, 5 years of neuroendoscopy case follow-up data were obtained. RESULTS: After performing pediatric neurosurgery missions in 2004-2006, with a focus on teaching neuroendoscopy, the host team demonstrated the sustainability of our didactic efforts in the subsequent 5 years by performing cases independently for their citizens. To date, a total of 196 operations have been performed in the past 5 years independent of any visiting team. CONCLUSIONS: Effective operative skill transfer to host neurosurgeons can be accomplished with limited international team visits utilizing a targeted approach that minimizes expenditures on personnel and capital. With the priority being teaching of an operative technique, as opposed to perennially performing operations by the mission team, sustainable surgical care was achieved after missions officially concluded.

Failure in Adult Spinal Deformity Surgery: A Comprehensive Review of Current Rates, Mechanisms, and Prevention Strategies.

STUDY DESIGN: Literature review. OBJECTIVE: The aim of this review is to summarize recent literature on adult spinal deformity (ASD) treatment failure as well as prevention strategies for these failure modes. SUMMARY OF BACKGROUND DATA: There is substantial evidence that ASD surgery can provide significant clinical benefits to patients. The volume of ASD surgery is increasing, and significantly more complex procedures are being performed, especially in the aging population with multiple comorbidities. Although there is potential for significant improvements in pain and disability with ASD surgery, these procedures continue to be associated with major complications and even outright failure. METHODS: A systematic search of the PubMed database was performed for articles relevant to failure after ASD surgery. Institutional review board approval was not needed. RESULTS: Failure and the potential need for revision surgery generally fall into 1 of 4 well-defined phenotypes: clinical failure, radiographic failure, the need for reoperation, and lack of cost-effectiveness. Revision surgery rates remain relatively high, challenging the overall cost-effectiveness of these procedures. CONCLUSION: By consolidating the key evidence regarding failure, further research and innovation may be stimulated with the goal of significantly improving the safety and cost-effectiveness of ASD surgery.

Maria Auxiliadora Hospital in Lima, Peru as a model for neurosurgical outreach to international charity hospitals.

INTRODUCTION: A myriad of geopolitical and financial obstacles have kept modern neurosurgery from effectively reaching the citizens of the developing world. Targeted neurosurgical outreach by academic neurosurgeons to equip neurosurgical operating theaters and train local neurosurgeons is one method to efficiently and cost effectively improve sustainable care provided by international charity hospitals. The International Neurosurgical Children's Association (INCA) effectively improved the available neurosurgical care in the Maria Auxiliadora Hospital of Lima, Peru through the advancement of local specialist education and training. METHODS: Neurosurgical equipment and training were provided for the local neurosurgeons by a mission team from the University of California at San Diego. RESULTS: At the end of 3 years, with one intensive week trip per year, the host neurosurgeons were proficiently and independently applying microsurgical techniques to previously performed operations, and performing newly learned operations such as neuroendoscopy and minimally invasive neurosurgery. CONCLUSION: Our experiences may serve as a successful template for the execution of other small scale, sustainable neurosurgery missions worldwide.

Multilevel lateral extra-cavitary corpectomy and reconstruction for non-contiguous metastatic lesions to the spine: case report and literature review.

In patients with metastatic disease to their spine and compromise of neurologic function, the challenge is to accomplish decompression of the neural elements and maintain mechanical stability but limit the risk and morbidity to the patient. In this case report the lateral extracavitary approach is employed to accomplish these tasks through a single approach in a patient with multiple non-contiguous sites of dorsal as well as ventral cord compression.

Perioperative complications and clinical outcomes of multilevel circumferential lumbar spinal fusion in the elderly.

Combined anterior-posterior lumbar fusion across multiple levels is thought to be associated with increased perioperative morbidity and worse clinical outcomes when performed in elderly patients. We conducted a retrospective review of the medical, surgical, and radiological records of 73 patients who underwent multilevel anterior lumbar interbody fusion (ALIF) with posterolateral lumbar fusion with instrumentation for symptomatic lumbar degenerative disc disease. Mean follow-up was 19 months. Thirty patients were at least 65 years old and 43 patients were younger. There were no significant differences in the number of levels fused, operative time, mean length of hospital stay or perioperative complication rates in either group. Similarly, there were no statistically significant differences in the improvement in back pain or in the rates of fusion between the groups at last follow-up. Perioperative events, intermediate-term clinical outcomes, and fusion rates after multilevel 360-degree lumbar fusion in the elderly are comparable to those of younger patients.

Patient satisfaction and radiographic outcomes after lumbar spinal fusion without iliac crest bone graft or transverse process fusion.

Iliac crest bone graft (ICBG) remains the gold standard for promoting bony fusion of the spine. However, harvest-site infection and pain are two of the most significant drawbacks of using iliac crest autograft in spinal fusion procedures. The rationale for its continued use, despite these drawbacks, has been based on the relatively higher rate of fusion reported in the literature. Therefore, the objective of this study was to determine whether modern allograft and fusion-promoting materials combined with local bone graft results in acceptable fusion rates and patient satisfaction. We retrospectively reviewed the clinical, surgical, and radiographic records of 200 consecutive patients with symptomatic degenerative diseases of the lumbar spine who underwent non-revision fusion using local bone graft combined with recombinant human bone morphogenetic protein (rhBMP)-2 with or without allograft. Rates of radiographic fusion and patient satisfaction were analyzed at discharge, 6 months, and 12 months, and every year thereafter. Mean follow-up was 32 months. Fusion was performed across an average of 2.5 levels and the overall fusion rate was 97%. In patients undergoing posterior fixation only there was a 5% incidence of pseudarthrosis, while the incidence was only 0.5% for patients undergoing circumferential fixation. Overall patient satisfaction at discharge was good to excellent in over 90% of patients and did not significantly change at the 6 month, 12 month and 24 month follow-up. In conclusion, there is no significant difference in rates of spinal fusion using laminectomy bone autograft combined with rhBMP-2 with or without allograft, compared to historical controls using ICBG. Fusion rates may be further improved with the use of circumferential fixation. Patient satisfaction remained high and might be because the morbidity associated with harvesting ICBG was avoided, as was the additional muscle dissection required for the fusion of lateral transverse processes.

Relaxation of forces needed to distract cervical vertebrae after discectomy: a biomechanical study.

STUDY DESIGN: In vitro and in vivo biomechanical stress measurements are made of the intervertebral disc segment distraction force during anterior cervical discectomy. OBJECTIVE: The purpose of this study is to determine the short-term force relaxation of the native intervertebral disc segment and to determine the short-term force relaxation of the segment after removal of the intervertebral disc, as is commonly performed in anterior cervical discectomy with fusion and arthroplasty. SUMMARY OF BACKGROUND DATA: No published data examine the issue of intraoperative distraction force of the cervical intervertebral disc segment. This is a novel research in this area. METHODS: In vitro and in vivo studies under institutional review board approval were performed to determine the mechanical behavior of the normal and diseased cervical functional spinal unit. Seven in vitro and 11 in vivo spines were studied. Strain measurements between distracting Caspar-type pins were made before, at various points during, and after discectomy to assess how removal of the disc and other spinal components affects the force-displacement behavior of the spinal unit. RESULTS: The in vitro data show progressive reduction in force needed for distraction after discectomy and uncovertebral joint resection. Greatest reduction is noted after discectomy. The in vivo data indicate that, on average, the cervical functional spinal unit requires 20 N less force to achieve the same degree of distraction after removal of the intervertebral disc. CONCLUSIONS: A sharp reduction in the strain across the intervertebral space occurs after distraction. The removal of the cervical intervertebral disc significantly reduces the viscoelastic response of the cervical motion segment. The long-term force used to stabilize intervertebral grafts or implants is less than what is achieved at the time of distraction. The exact magnitude of the resultant force on graft or device at a given distraction force is unknown and would depend also upon fit.

Stem cell-mediated regeneration of the intervertebral disc: cellular and molecular challenge.

Regenerative medicine and stem cells hold great promise for intervertebral disc (IVD) disease. The therapeutic implications of utilizing stem cells to repair degenerated discs and treat back pain are highly anticipated by both the clinical and scientific communities. Although the avascular environment of the IVD poses a challenge for stem cell-mediated regeneration, neuroprogenitor cells have been discovered within degenerated discs, allowing scientists to revisit the hostile environment of the IVD as a target for stem cell therapy. Issues now under investigation include the timing of cell delivery and manipulation of stem cells to make them more efficient and adaptive in the IVD niche. This review covers the mechanisms underlying disc degeneration as well as the molecular and cellular challenges involved in directing stem cells to the desired cell type for intradiscal transplantation.

Stabilization of the atlantoaxial complex via C-1 lateral mass and C-2 pedicle screw fixation in a multicenter clinical experience in 102 patients: modification of the Harms and Goel techniques.

OBJECT: Stabilization of the atlantoaxial complex has proven to be very challenging. Because of the high mobility of the C1-2 motion segment, fusion rates at this level have been substantially lower than those at the subaxial spine. The set of potential surgical interventions is limited by the anatomy of this region. In 2001 Jürgen Harms described a novel technique for individual fixation of the C-1 lateral mass and the C-2 pedicle by using polyaxial screws and rods. This method has been shown to confer excellent stability in biomechanical studies. Cadaveric and radiographic analyses have indicated that it is safe with respect to osseous and vascular anatomy. Clinical outcome studies and fusion rates have been limited to small case series thus far. The authors reviewed the multicenter experience with 102 patients undergoing C1-2 fusion via the polyaxial screw/rod technique. They also describe a modification to the Harms technique. METHODS: One hundred two patients (60 female and 42 male) with an average age of 62 years were included in this analysis. The average follow-up was 16.4 months. Indications for surgery were instability at the C1-2 level, and a chronic Type II odontoid fracture was the most frequent underlying cause. All patients had evidence of instability on flexion and extension studies. All underwent posterior C-1 lateral mass to C-2 pedicle or pars screw fixation, according to the method of Harms. Thirty-nine patients also underwent distraction and placement of an allograft spacer into the C1-2 joint, the authors' modification of the Harms technique. None of the patients had supplemental sublaminar wiring. RESULTS: All but 2 patients with at least a 12-month follow-up had radiographic evidence of fusion or lack of motion on flexion and extension films. All patients with an allograft spacer demonstrated bridging bone across the joint space on plain x-ray films and computed tomography. The C-2 root was sacrificed bilaterally in all patients. A postoperative wound infection developed in 4 patients and was treated conservatively with antibiotics and local wound care. One patient required surgical debridement of the wound. No patient suffered a neurological injury. Unfavorable anatomy precluded the use of C-2 pedicle screws in 23 patients, and thus, they underwent placement of pars screws instead. CONCLUSIONS: Fusion of C1-2 according to the Harms technique is a safe and effective treatment modality. It is suitable for a wide variety of fracture patterns, congenital abnormalities, or other causes of atlantoaxial instability. Modification of the Harms technique with distraction and placement of an allograft spacer in the joint space may restore C1-2 height and enhance radiographic detection of fusion by demonstrating a graft-bone interface on plain x-ray films, which is easier to visualize than the C1-2 joint.

Two-level total en bloc lumbar spondylectomy with dural resection for metastatic renal cell carcinoma.

Only five reports of multilevel spondylectomy for tumor have been reported in the literature, mostly in the thoracic spine. We report a successful two-level spondylectomy with en bloc dural resection in a patient with metastatic renal carcinoma to the L3 and L4 vertebrae.

Partial spondylectomy: modification for lateralized malignant spinal column tumors of the cervical or lumbosacral spine.

Total en bloc spondylectomy is a useful technique in treating primary and secondary spinal malignancies, but requires extensive instrumentation to achieve difficult fusions, and requires extensive exposure of neurovascular structures that poses additional risk of nerve root and vascular injury. More limited resections may reduce these risks, especially in the cervical or lumbosacral spine. We report a technique used in two patients with lateralized primary vertebral tumors of the cervical or lumbosacral spine where tumor removal was achieved through a partial spondylectomy. The advantages of a partial spondylectomy included: (i) avoidance of injuring contralateral neurovascular structures during exposure; and (ii) supplementation of instrumentation by additional fixation at the level of spondylectomy. Partial spondylectomy can be an alternative to total en bloc spondylectomy in properly selected patients with lateralized encapsulated malignant spinal tumors and may be performed in the cervical or lumbosacral spinal regions.

Stand-alone anterior lumbar discectomy and fusion with plate: initial experience.

BACKGROUND: The stability of the lumbar spine after ALIF with lateral plate fixation and/or posterior fixation has previously been investigated; however, stand-alone ALDF with plate has not. Previous clinical studies have demonstrated poor fusion rates with stand-alone anterior interbody fusion in the absence of posterior instrumentation. We review our initial experience with stand-alone ALDF with segmental plate fixation for degenerative disc disease of the lumbar spine and compare these results with our experience with traditional ALIF and supplemental posterior instrumentation. METHODS: Forty-nine patients treated at the University of California, San Francisco between 2002 and 2005 were included in this analysis. The study was retrospective in nature. All patients presented with discogram-positive back pain and had failed conservative treatment. Twenty-four patients underwent ALDF with plate, and 25 underwent ALIF with posterior instrumentation. Patients underwent flexion/extension imaging at 6 weeks, 3 months, 6 months, and 1 year postoperatively. All patients completed ODI and VAS questionnaires at 3 months, 6 months, and 1 year postoperatively. RESULTS: Average follow-up was 11.6 and 21.7 months in the ALDF with plate and ALIF with instrumentation groups, respectively. All patients demonstrated radiographic evidence of fusion at last follow-up. None developed instability at the fusion level, and none developed hardware failure (plate back-out, screw lucency, etc). Average subsidence at 6 months postoperatively was 2.2 and 2.5 mm, respectively. The VAS and ODI scores are presented in Tables 3 and 4. CONCLUSIONS: Preliminary results of stand-alone ALDF with plate suggest it may be safe and effective for the surgical treatment of patients with degenerative disc disease of the lumbar spine. Long-term follow-up is clearly needed. Subsidence is diminished with ALDF and plating compared with ALIF with posterior instrumentation. It is unclear at this time which subset of patients may ultimately require posterior hardware supplementation, but those with circumferential stenosis or severe facet disease are not ideal candidates for ALDF with plate. For some patients in whom lumbar arthroplasty is not indicated, or as a salvage procedure, ALDF with plate may be a satisfactory alternative and may eliminate the need for a supplemental posterior procedure.

Corpectomy followed by the placement of instrumentation with titanium cages and recombinant human bone morphogenetic protein-2 for vertebral osteomyelitis.

OBJECT: The treatment of vertebral osteomyelitis includes antibiotics with or without surgical intervention. The decision to place instrumentation into an infected spinal column remains controversial. The use of recombinant human bone morphogenetic protein-2 (rhBMP-2) in patients with osteomyelitis is also extremely controversial. The authors review their experience in performing corpectomy and fusion with titanium cages and rhBMP-2 in patients with vertebral instability and/or neurological compromise due to vertebral osteomyelitis. METHODS: Data obtained in 15 patients treated between 2001 and 2005 were included in this analysis. Nine patients presented primarily with axial pain and six with radiculopathy or myelopathy. Seven patients had an associated epidural abscess. The cervical spine was affected in six patients, the thoracic spine in five, and the lumbar spine in four. All patients underwent corpectomy of the involved vertebral bodies; the authors then performed spinal reconstruction, placing a titanium cage-plate system with morcellized allograft/autograft and rhBMP-2. In 10 patients, supplemental posterolateral screw-rod fixation was conducted. A one-level corpectomy was performed in one patient, a two-level corpectomy in 13, and a six-level corpectomy in one. A morcellized allograft and rhBMP-2-filled titanium cage was used in 10 patients, and an autograft and rhBMP-2-filled cage in five patients. The most common pathogen was Staphylococcus aureus. All patients received intravenous antibiotics for at least 6 weeks postoperatively, and life-long antibiotic therapy was required in three patients with coccidiomycoses, candida, and tuberculosis osteomyelitis, respectively. There were no recurrent infections. Radiography demonstrated evidence of fusion in all patients at the last follow-up examination. The mean follow-up period was 20 months. CONCLUSIONS: Corpectomy followed by titanium cage-plate reconstruction and the placement of rhBMP-2 may be a safe and effective treatment for selected patients with vertebral osteomyelitis. This surgical therapy does not appear, at least based on preliminary results, to lead to recurrent hardware infections. Based on the results obtained in this limited series, the authors found that rhBMP-2 can be used in the setting of active infection with excellent fusion rates and without complication. The morbidity associated with the autograft donor site is avoided when using cages. Antibiotic therapy tailored to the specific organism should be continued for at least 6 weeks after surgery, and life-long therapy is required in cases of fungal or tuberculosis infections.

Results of the 2015 Scoliosis Research Society Survey on Single Versus Dual Attending Surgeon Approach for Adult Spinal Deformity Surgery.

STUDY DESIGN: An electronic survey administered to Scoliosis Research Society (SRS) membership. OBJECTIVE: To characterize surgeon practices and views regarding the use of two attending surgeons for adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND DATA: The use of two experienced attending surgeons can decrease the operative time, estimated blood loss, and perioperative complication rates. However, the current practice patterns for the use of two attending surgeons remains unknown. METHODS: An electronic, 27-question survey regarding single/dual attending surgeons was administered to the SRS membership. Determinants included: surgeon/practice demographics, assistant type/level of training, and questions regarding use of two attending surgeons. Overall reporting and comparisons between groups were made: US versus international, academic versus private practice, and experience <15 years versus >15 years. RESULTS: A total of 199 surgeons responded from 27 different countries. Overall and between the groups, the respondents significantly reported believing that two attending spine surgeons improves safety, decreases complications, and improves outcomes (P < 0.01). Approximately, 67.3% reported using a second attending ≤25% of the time (33.2% do not), and 24.1% use one ≥51% of the time (similar between groups); 51.1% that have a second attending feel it's limited by reimbursement and access concerns and 71.9% have difficulty getting the second attending reimbursed. 72.3% use a second attending for ALL of the following reasons (no difference between groups): "it's safer/reduces complications," "it decreases operative time," "it decreases blood loss," "it results in improved outcomes," "it's less work and stress for me." If reimbursement was equal/assured for a second attending, 67.5% would use one "more often" or "always." CONCLUSION: The respondents feel that having a second attending surgeon improves patient care, however most do not use one often. Reasons include reimbursement/access concerns and the majority would use one if reimbursement was equal and assured. Based on the current literature and these results, there is a need for working with third party payers to improve dual surgeon reimbursement rates in complex cases. LEVEL OF EVIDENCE: 5.

Complications of interhemispheric transcallosal approach in children: review of 15 years experience.

OBJECTIVE: The interhemispheric transcallosal approach to deep-seated lesions in and around the ventricular system avoids cortical manipulation and injury. Few case series discuss the morbidity associated with this approach. This study describes the 15-year experience of the senior author in Southern California. METHODS: All pediatric patients who have undergone interhemispheric, transcallosal resections of mass lesions over a 15-year period were identified. The surgical approach was uniform with respect to positioning of the patient. Intra-operative and post-operative data were collected retrospectively from the medical records. The need for bridging vein ligation as well as the incidence of hemiparesis, seizures, memory disturbances, and the need for subsequent cerebrospinal fluid (CSF) diversion were identified. RESULTS: Sixty-five patients were identified. The incidence of transient post-operative hemiparesis appeared to be higher in those patients who required ligation of one or two parasagittal veins (44.6% versus 18.5%) with no difference in long-term outcome. Nineteen percent (18.5%) of patients had post-operative seizures; however, no long-term seizure disorder was identified. Nine percent (9.2%) had reports of transient short-term memory deficits. Thirty-four percent (33.8%) of patients required secondary operative intervention for CSF diversion. The total complication rate, including need for CSF diversion, transient hemiparesis, infection, post-operative seizures, and memory disturbance was 36.9%. By 1 year, the total number of patients with persistent hemiparesis, memory disturbance, or seizures refractory to medication was 4 (6.2%). CONCLUSION: This series demonstrates that the interhemispheric transcallosal corridor is a versatile and safe approach in childhood, resulting in low post-operative permanent morbidity.

Lumbar diskectomy in a human-habituated mountain gorilla (Gorilla beringei beringei).

The authors report a case of a human-habituated mountain gorilla, Alvila, resident at the San Diego Zoo, who was found to have a herniated intervertebral lumbar disc after being attacked by the gorilla troop's silverback male gorilla. Ultimately, the gorilla required surgical intervention for her disease and made a full recovery. To our knowledge, this is the only known case of spine surgery. A 36-year-old female human-habituated mountain gorilla (Gorilla beringei beringei), resident at the San Diego Zoo, was noticed by caregivers to walk with a substantial limp after being attacked by the gorilla troop's silverback male gorilla. Magnetic resonance (MR) imaging of her lumbar spine revealed a large herniated disk at the L1-2 level on the right. This finding appeared to correlate well with the gorilla's symptoms. The gorilla underwent a lumbar diskectomy under loupe. Post-operatively the gorilla did very well. The right leg weakness was immediately improved post-operatively. The gorilla continued to "crutch walk" initially, swinging on the upper extremities and not bearing weight on the lowers. However, by 2 weeks the limp was no longer noticeable to the zoo caregivers. The wound healed well and there was no evidence of wound infection or CSF leak. The gorilla was reunited with her troop and has reintegrated well socially. With 10 months of follow-up, the gorilla continues to do well. This is the only known case of spine surgery in a gorilla. For best surgical results, one needs to consider the similarities and differences between the gorilla and human vertebral anatomy. We believe that careful pre-operative planning contributed to the good early post-operative result. Ultimate assessment of the long-term outcome will require additional follow-up.

The pathophysiologic mechanism of cerebellar mutism.

OBJECTIVE: Cerebellar mutism (CM) is a postoperative complication of mainly pediatric posterior fossa surgery. Multiple theories exist for explaining this phenomenon. We have made an attempt to further understand this entity given a particularly interesting case as it relates to multiple pathophysiologic pathways. METHODS: We have reviewed the details surrounding a particularly interesting case of CM. A retrospective analysis of this patient's clinical history and recovery is described. An extensive literature review has been performed in conjunction with an attempt to help elucidate details and a better understanding of CM. RESULTS: A thorough analysis of existing theories as to the pathophysiologic mechanism of CM has been performed as it relates to the details of this particular case. A case is described in which a child exhibiting CM abruptly improved and made a relatively quick recovery after the triggering of the melodic speech pathway by way of watching and beginning to sing along with a video. It appears that this incident involving a familiar song catalyzed various speech pathways, which apparently were in some state of shock. This phenomenon seems to be a temporary entity involving not only the mechanical coordination of speech production, but also the initiation of speech itself. CONCLUSIONS: Evidence exists for a pathophysiologic pathway for speech by way of coordinating phonation and articulation. In addition, there seems to exist a pathway by which the initiation of speech may be altered or halted by posterior fossa pathology, namely, vermian or dentate nuclear injury. In particular to this case, we found that the incidental appreciation of other forms of speech, melodic in this instance, may be the key to help stimulate and accelerate the recovery from CM.

Extreme Lateral Interbody Fusion (XLIF): a novel surgical technique for anterior lumbar interbody fusion.

BACKGROUND: Minimally disruptive approaches to the anterior lumbar spine continue to evolve in a quest to reduce approach-related morbidity. A lateral retroperitoneal, trans-psoas approach to the anterior disc space allows for complete discectomy, distraction, and interbody fusion without the need for an approach surgeon. PURPOSE: To demonstrate the feasibility of a minimally disruptive lateral retroperitoneal approach and the advantages to patient recovery. METHODS/RESULTS: The extreme lateral approach (Extreme Lateral Interbody Fusion [XLIF]) is described in a step-wise manner. There have been no complications thus far in the author's first 13 patients. CONCLUSIONS: The XLIF approach allows for anterior access to the disc space without an approach surgeon or the complications of an anterior intra-abdominal procedure. Longer-term follow-up and data analysis are under way, but initial findings are encouraging.

Successful outcome of six-level cervicothoracic corpectomy and circumferential reconstruction: case report and review of literature on multilevel cervicothoracic corpectomy.

UNLABELLED: The authors report the successful outcome of a six-level corpectomy across the cervico-thoracic spine with circumferential reconstruction in a patient with extensive osteomyelitis of the cervical and upper thoracic spine. To the authors' knowledge, this is the first report of a corpectomy extending across six levels of the cervico-thoracic spine. CLINICAL RELEVANCE: the authors recommend anterior cage and plate-assisted reconstruction and additional posterior instrumentation using modern spinal surgical techniques and implants.

Indirect revascularisation for paediatric moyamoya disease: the EDAMS technique.

Moyamoya disease can have devastating effects on paediatric patients as a result of cerebral ischaemia. Several direct and indirect surgical methods have been devised in order to facilitate revascularisation. Debate has long ensued about which methods are most efficacious and yet safe. The authors describe their experience with a straightforward method for performing the EDAMS (encephalo-duro-arterio-myo-synangiosis) technique.