Surgical management of traumatic thoracic spondyloptosis: review of 2 cases.

Spondyloptosis due to trauma is a very rare injury typically associated with motor vehicle accidents and typically at the lumbosacral junction. This report describes two patients with T6-7 and T12-L1 spondyloptosis secondary to trauma. The former was a 36-year-old man who was pinned under a 200 kg hay bale, suffering immediate paraplegia and undergoing successful posterior reduction and stabilization via a single stage posterior approach. Two years after his injury he has not developed any new deformity or neurological deterioration. The latter was a 22-year-old miner who was thrown against the ceiling of a coalmine and suffered a hyperflexion injury resulting in an immediate T12 paraplegia. Again successful reduction and stabilization was able to be achieved through pedicle screw instrumentation via a single-stage posterior approach. These two patients are the first reported cases of traumatic thoracic spondyloptosis. This report describes the rationale, likely mechanisms and surgical technique required for operative reduction and stabilization via a single-stage posterior approach.

Complications with cervical arthroplasty.

OBJECT: Spinal arthroplasty is becoming more widely performed in the treatment of degenerative cervical disc disease. Although this new technology may offer benefits over arthrodesis, it also requires that the surgeon acquire new operative techniques, and new potential complications are introduced. To determine the incidence and distribution of perioperative complications, the authors analyzed their early data obtained in a series of patients treated with the Bryan Cervical Disc prosthesis. METHODS: The authors prospectively recorded operative data, complications, and clinical and radiographic outcome data in all patients treated with Bryan prosthesis-based arthroplasty at two tertiary care centers since 2001. Patients underwent standard anterior cervical discectomy followed by one- to three-level arthroplasty. Ninety-six discs were implanted in 74 patients. The perioperative complication rate was 6.2% per treated level. In one patient a retropharyngeal hematoma developed, requiring evacuation. Neurological worsening occurred in three patients. Intraoperative migration of the prosthesis was observed in one two-level case, whereas delayed migration occurred in one patient with postoperative segmental kyphosis. In another patient with severe postoperative segmental kyphosis, revision was required with a customized lordotic prosthesis. Heterotopic ossification and spontaneous fusion occurred in two cases; motion was preserved in the remaining 94 prostheses. Partial dislocation of the prosthesis in extension occurred in one patient with preoperative segmental hypermobility, the first reported failure of a Bryan prosthesis. Twenty-five percent of patients reported neck and shoulder pain during the late follow-up period. There was a trend toward increased kyphosis of the C2-7 curvature postoperatively. CONCLUSIONS: The Bryan prosthesis was effective in maintaining spinal motion. Major perioperative and device-related complications were infrequent.

Posterior cervical decompression and fusion for circumferential spondylotic cervical stenosis: review of 50 consecutive cases.

PURPOSE OF STUDY: This study presents a clinical and radiological evaluation of 50 consecutive patients with symptomatic spondylotic cervical myelopathy and circumferential spinal cord compression who were managed with a single stage wide posterior laminectomy and lateral mass instrumented fusion. METHODS USED: 50 consecutive patients (33 male, 17 female) over a 4 year period presenting with symptomatic cervical myelopathy due to circumferential cervical spondylotic spinal stenosis were evaluated and operated upon by a single surgeon and followed in a prospective fashion. All patients underwent pre- and postoperative clinical, radiological and MRI evaluation. SUMMARY OF FINDINGS: No deaths occurred and no instrumentation-related neural or vascular injuries were noted. No patient required reoperation for ventral compression and in all cases CSF was visible anterior to the cord on postoperative MRI scanning, with relief of the circumferential compression. Most patients improved by at least 1 Nurick grade. Three patients (6%) had single level screw pullouts which did not affect clinical outcome, and required no intervention. Slight worsening of kyphosis occurred in 4% of cases but as group there was no measured difference in sagittal balance (P=0.10). Oswestry Neck Disability Scores improved from 25.7+/-3.6 to 16.6+/-7.1 (P<0.05). One patient required a foraminotomy/posterior discectomy 12 months postoperatively at an adjacent level. CONCLUSIONS: This study demonstrates that multisegmental spondylotic circumferential cervical stenosis causing symptomatic myelopathy can be managed by single stage decompression and fusion via a posterior approach with very low morbidity and excellent clinical and radiological outcome. The incidence of adjacent segment disease is lower than for anterior interbody fusions with a 1%/year incidence at follow up to date.

Cervical arthroplasty after previous surgery: results of treating 24 discs in 15 patients.

OBJECT: The potential role of cervical arthroplasty in patients who have undergone previous cervical surgery is unknown. The authors performed a prospective study involving nonrandomized clinical and radiological assessment in patients who had undergone either previous posterior cervical foraminotomy or anterior interbody fusion and who suffered new or persistent arm/neck symptoms related to neural compression. METHODS: During a 30-month period, 15 patients who had previously undergone cervical spinal surgery underwent cervical arthroplasty that involved placement of the Bryan disc for neck or arm symptoms related to cervical disc disease. A total of 24 devices were implanted. Six of the 15 patients had undergone a previous posterior foraminotomy, and in nine cases an anterior interbody fusion had been perfomed at some stage prior to surgery. Clinical and radiological evaluations were performed preoperatively and after surgery to assess outcomes. A total of 24 arthroplasties were performed encompassing between one and three levels. There were no major perioperative complications or immediate device-related failures. Two patients were lost to follow up. The follow-up period ranged from 12 to 43 months (mean 24.2 +/- 10.5 months). Good results were obtained in all cases as reflected by an increase in the visual analog scale score of 6.4 in terms of neck/arm pain (p < 0.05). There was no difference in Oswestry Disability Index scores for neck pain (p > 0.05) and no patient required surgery at the same level. In one patient hypermobility developed with internal subluxation of the device, which suggested a compromise adjacent to a two-level fusion at 21 months. The segment was hypermobile preoperatively. The patient has experienced recurrent neck pain but otherwise remains clinically well and has not required revision surgery to date. CONCLUSIONS: Insertion of the Bryan artificial cervical disc in patients who have previously undergone cervical fusion or posterior foraminotomy, in general, appears to be safe. It provided encouraging early clinical results, although patients with preoperative hypermobility should be treated with caution. Issues such as accelerated device-related wear and the use of arthroplasty after aggressive facetectomy resection will need further study; however, in carefully selected patients who have undergone previous surgery cervical arthroplasty may provide an additional tool in the management of cervical disc disease.

Cervical arthroplasty complicated by delayed spontaneous fusion. Case report.

The authors describe the case of a 55-year-old woman who presented with a left C-6 radiculopathy and neck pain and in whom there was evidence of disc/osteophyte compression of the left C-6 nerve root. The patient underwent a C5-6 anterior cervical decompression and placement of a Bryan disc prosthesis. More than 7000 cervical discs have been inserted worldwide. Postoperatively, dynamic imaging demonstrated loss of motion at the instrumented level. The patient suffered persistent neck and arm pain that was slow to resolve. Seventeen months after the initial surgery osseous fusion was observed across the interspace and posterior surface of the prosthesis. This is the first documented case of fusion occurring at the level at which cervical arthroplasty had been performed. The precise reason for this phenomenon is unclear, but potential contributing factors include patient-related issues, poor motion due to neck pain, or possibly implant-related issues. To date, this is an exceedingly rare complication and warrants careful and prolonged follow up of all arthroplasty-treated cases.

Protection of the C1 posterior arch in atlantal lateral mass fixation: technical case report.

Screw fixation of the C1 lateral mass is a relatively new technique designed to allow for C1/C2 fixation in scenarios where transarticular screw fixation is not safe or possible. In order to place the screw at the base of the C1 arch, it has been recommended to drill at the junction of the C1 posterior arch and the lateral mass of C1, to accommodate the screw head. This may, however, weaken the C1 arch, making it prone to fracture. In this new technique, we describe a modification to the current technique to allow placement of this screw without compromising the C1 arch. A case of atlantoaxial instability secondary to os odontoideum is described. C1 lateral mass fixation is achieved by selecting a screw 10 mm longer than required and placing the screw 10 mm above the bony entry point, for easier placement of the rod and avoidance of drilling at the base of the C1 arch. Adequate and safe C1/C2 fixation was achieved. Sublaminar wiring was performed around the C1 arch with no weakening or fracture of the arch. We believe that in order to place reasonable C1 lateral mass screws, it is inadvisable to drill the base of the junction between the C1 posterior arch and lateral mass as this may lead to arch weakening and failure. Easier instrumentation can be performed and the integrity of the C1 arch maintained using this alternate technique.

What progress has been made in surgical management of patients with astrocytoma and oligodendroglioma in Australia over the last two decades?

BACKGROUND: Most primary brain cancers are associated with a dismal prognosis because of their aggressive behaviour and high mortality. Surgical resection with adjuvant radiotherapy is a major treatment for these cancers but little has been published about their surgical management in Australia. OBJECTIVE: To determine changes since 1977 in demographic characteristics, tumour frequencies, surgical management, morbidity and survival for 1,339 patients discharged with astrocytoma (A) and oligodendroglioma (O), which comprise the majority of primary brain cancers, recorded prospectively in northern Sydney neurosurgery databases. Discharges were grouped into eras reflecting changes in diagnostic and surgical technology. RESULTS: Between eras 1977-79 and 1999-2002, mean age increased by 9.5 years, and inpatient stay fell from 21 to 9 days. The proportion of O rose as A fell. Of 144 re-biopsies, 16% had less anaplastic pathology, 54% the same and 30% more anaplastic pathology than the first biopsy. Stereotactically assisted surgery increased, with overall rates of burr hole for biopsy decreasing and of craniotomy rising. Between 1980-86 and 1999-2002, inpatient mortality declined from 7.3 to 2.3% of discharges, reopening of craniotomy and wound complication rates fell, while postoperative neurological deficit rose. Deep vein thrombosis and pulmonary embolism rates for discharges increased significantly. Age and histopathologic grade were predictors of survival from 1980. Sex and era of diagnosis did not influence survival. After adjustment for age using proportional hazards regression, survival improved only for anaplastic A, with a 60% improvement for patients diagnosed in era 3, and a 50% improvement for patients diagnosed in era 4 relative to those in era 1. CONCLUSIONS: Although markers of inpatient care have improved since the 1980s, age-adjusted survival has not increased except for patients with anaplastic A.

Multiple cerebral and leptomeningeal metastases from ovarian carcinoma: unusual early presentation.

Although virtually any systemic malignancy is capable of metastasizing to the brain, ovarian carcinoma, one of the more common female genital malignancies, is one of the rarer forms of brain metastases. In general, the outcome for ovarian carcinoma with brain metastases is extremely poor as most of these patients have widespread lesions elsewhere. This report describes the first known case of multiple cerebral and leptomeningeal metastases as the initial manifestation of ovarian carcinoma in a 41-year old woman who presented with a one-week history of headache, vomiting and confusion. CT scan of the brain was unremarkable, but lumbar puncture revealed atypical cells in the CSF. MRI scan of the brain showed multiple small enhancing lesions. Craniotomy for excision of one of these lesions demonstrated metastatic adenocarcinoma. A large ovarian tumour identified on pelvic CT scan was resected and the patient subsequently received chemotherapy and radiotherapy. Unfortunately she continued to decline and died within six months. Unlike primary tumours such as malignant melanoma, ovarian carcinoma does not have a predilection for the central nervous system (CNS), but the rare instances with CNS involvement occur at an advanced stage of the disease. Once the CNS is involved, the outcome is abysmal, even with multimodality therapy. It is extremely unusual for ovarian carcinoma to present with multiple CNS involvement.

Risk factors and prophylaxis for deep venous thrombosis in neurosurgery.

Acceptance is increasing for pharmacological prophylaxis against deep vein thrombosis (DVT) and pulmonary embolism (PE) for most types of surgery, but its use remains controversial in neurosurgical patients because of the threat of catastrophic hemorrhage. Consequently, mechanical measures such as sequential calf compression and graduated compression stockings are currently the preferred prophylaxis for neurosurgical patients. However, some patients remain at high risk despite these measures and may require prophylaxis with low molecular weight heparins or unfractionated heparin. In neurosurgical patients, known risk factors for DVT or PE include advanced age, malignancy, limb weakness, prolonged surgery, and cranial as opposed to spinal surgery. Using comprehensive neurosurgery databases, the authors identify more specific neurosurgical diagnoses and procedures as risk factors for DVT and PE, and show increases in the frequency of DVT and PE for the wider neurosurgery population and for glioma patients over time. DVT prophylaxis is compared in public and private hospital settings. This chapter contributes to the changing picture of DVT and PE in neurosurgical patients over the last two decades.

Cervical arthroplasty in the management of spondylotic myelopathy: 18-month results.

OBJECT: Cervical spinal cord compression managed via an anterior approach with an arthrodesis may be associated with a decreased range of motion and accelerated adjacent-segment degeneration. Artificial cervical disc replacement may address these problems. METHODS: The author presents a series of 11 patients (seven men and four women, ages 31-55 years) with anterior cervical decompression and placement of a total of 15 artificial disc prostheses. Clinical and radiological follow-up review was performed at 24 hours, 6 weeks, 3 months, 6 months, and then yearly (mean follow-up period 18.4 months, range 10-32 months). There were no major complications. There was an improvement in the Nurick grade by 0.91 grades (p < 0.001) and in the Oswestry Neck Disability Index by 41.5 percentage points (p < 0.001). In one case fusion was attained at 17 months postoperatively and one patient had a transient worsening of preoperative symptoms postoperatively, with focal kyphosis. The spinal cord was decompressed on postoperative imaging in all cases. CONCLUSIONS: Cervical arthroplasty after anterior cervical decompression at one or more levels represents an exciting tool in the management of spinal cord compression caused by spondylotic disease or acute disc prolapse. Results obtained in this study add further weight to the potential role of cervical arthroplasty for cervical myelopathy and longer follow up is provided on a previously reported series. It is suggested that care must be taken in using this unconstrained prosthesis if there is a preexisting spinal deformity. Longer follow up will reveal any delayed problems with artificial disc implantation, but in the short to medium term, this technique offers an excellent outcome.

Spinal epidural abscess: appearance on magnetic resonance imaging as a guide to surgical management. Report of five cases.

Spinal epidural abscess is associated with considerable rates of morbidity and mortality despite its infrequent occurrence. Advances in magnetic resonance (MR) imaging technology have allowed easier diagnosis of this potentially devastating condition. It is also possible to predict the intraoperative appearance of each case of spinal epidural abscess prior to the procedure, based on the MR findings. Surgical treatment of this condition usually involves extensive decompressive laminectomy, which predisposes patients to spinal instability and deformity. Recent advances in surgical approaches to spinal epidural abscess have included the institution of less invasive techniques to manage this condition, including saline washes of the epidural space through catheters introduced via limited laminotomy. The cases reported here illustrate the ability to predict the intraoperative findings in patients with spinal epidural abscess, and to adjust the surgical approach accordingly to minimize the extent of potentially destabilizing procedures without impinging on the effectiveness of treatment.

Prophylaxis for deep venous thrombosis in neurosurgical oncology: review of 2779 admissions over a 9-year period.

OBJECT: Management of disease in patients undergoing neurosurgical treatment for tumors requires balancing the competing risks of hemorrhage and thrombosis. The authors compared the incidence of clinically apparent deep venous thrombosis (DVT) and pulmonary embolism (PE) in patients admitted for treatment of intracranial and spinal tumors at three institutions. At the public hospital (the Royal North Shore Hospital [RNSH]) nonsequential calf compression was used, and at the other two private neurosurgery services sequential calf compression with low-molecular-weight heparin was used in patients undergoing spinal surgery. All patients wore compression stockings and underwent follow-up scanning after surgery. METHODS: The authors identified from their neurosurgery databases 2779 discharges of patients with tumor from the RNSH and private hospitals between January 1, 1995 and December 31, 2003. Patient admissions were relatively well matched for age, sex, duration of stay, and tumor type. For patients who underwent spinal surgery, the incidence of DVT was higher in the RNSH (2.6% of admissions) than in private hospitals, where no case of DVT was seen (p = 0.02). The incidence of PE was higher in admissions patients who had been treated for cranial tumors in the RNSH (2.9%) than in those treated in the private hospitals (1.3%, p = 0.01). Possible reasons for these discrepancies include a higher proportion of ambulatory patients before and after surgery in the group treated at private hospitals. More emergency and semi-emergency surgery was performed in the RNSH than in the private hospitals. Nevertheless, fewer patients discharged from the RNSH had undergone surgery, which is a known risk factor for DVT. CONCLUSIONS: Patients with intracranial tumors had a higher incidence of PE than those with spinal tumors. The incidence of DVT and PE was higher in patients admitted to the public hospital. The incidence of DVT in patients undergoing spinal procedures was lower when low-molecular-weight heparin was used judiciously, but the incidence of PE in patients undergoing cranial procedures was lower with the private hospital protocol, which did not include prophylaxis with anticoagulating agents.

Two-level artificial disc placement for spondylotic cervical myelopathy.

This report describes a 49-year-old woman who presented with a myeloradiculopathy with two-level spinal cord compression. She underwent C5-6 and C6-7 anterior cervical decompressions and placement of two Bryan disc (Medtronic Sofamor-Danek. Memphis, TN) prostheses. Whilst single-level cervical arthroplasty using the Bryan disc prosthesis has been described before, this is the first two-level case reported in the literature and opens the way for the possible future management of multilevel cervical cord compression in a way that maintains cervical motion, avoids donor site bone graft problems, and may reduce the incidence of adjacent segment disease.

A quarter of a century of neurosurgery: the value of a relational database to document trends in neurosurgical practice of a tertiary referral hospital.

OBJECTIVE AND IMPORTANCE: Increasing interest in evidence-based medicine has created a demand for accurate and accessible information on activity and trends in clinical practice. A database of all neurosurgery admissions at a teaching hospital maintained by a scientist has been utilised to examine changes in practice and complications from 1977 to 2001. METHODS: A relational database, set up in 1982, now contains an unbroken record of all neurosurgical admissions at Royal North Shore Hospital (RNSH) since 1976. It supplies information for morbidity and mortality meetings, research and administrative purposes. A total of 23,766 admissions from 1977 to 2001 were examined. Statistical analysis of trends in age, gender, length of stay (LOS), diagnostic mix, surgery rates and complications in admissions was based on diagnostic groupings. RESULTS: Proportions of vascular admissions rose and of trauma admissions fell. Mean age increased significantly for tumour, trauma and spinal patients; geometric mean LOS declined significantly for tumour, spine, vascular, cranial nerve and peripheral nerve groups. Concurrently, inpatient death rate fell significantly for tumour and vascular patients. Deep vein thrombosis (DVT) rose significantly for trauma, vascular, tumour, spinal and infection patients; pulmonary embolism (PE) rose significantly for tumour, trauma and spinal patients. There was no significant change in wound infection rate at approximately 3.5% of all operated patients. Wound haematoma rates fell significantly from 4.0% to 2.9% while the rate of postoperative cerebrospinal fluid (CSF) leak rose significantly from 0.5% to 2.0% of all operated patients. CONCLUSION: The value of the database is demonstrated by its ability to provide analysis which shows statistically significant changes over time. Declining death rate and LOS indicate improved efficiency in managing patients, but these are offset by rising rates of CSF leak, DVT and PE. Such rises reflect the changing patterns of casemix and surgery performed, and increasing financial pressures on hospital departments.

Haemorrhagic brain metastasis from a thymic carcinoma.

Brain metastasis from thymic carcinoma is extremely rare, and there is still no consensus regarding the best management of thymic metastasis to the central nervous system. Here, we report the first-known Australian case. A review of the current literature and the characteristics of thymic tumours with brain metastasis indicate that aggressive management may be able to improve long-term outcomes for these patients. A 49-year-old man presented 2 weeks after thoracotomy for thymic carcinoma resection with a 2-day history of headache, right-sided weakness and expressive dysphasia. CT and MR scans revealed two metastatic brain lesions, one within the left frontal lobe with cystic necrosis and haemorrhage, the other deep in the parietal lobe adjacent to the left ventricle with a lesser degree of haemorrhage. The patient underwent frameless stereotactic craniotomy for excision of the frontal lesion. Histopathology confirmed poorly differentiated thymic carcinoma. Post-operatively his weakness and speech improved dramatically, and he was discharged home within a week, with radiotherapy and chemotherapy to follow. However, he represented with rapidly worsening symptoms and died within a week. Thymic carcinoma is a rare tumour, displaying malignant features clinically and histopathologically with local invasion to adjacent organs. Metastasis is predominantly to lung, bone, liver and kidney, with less predilection for the central nervous system. Treatment for thymic carcinoma is multimodal, but outcome remains poor and life expectancy is very short when brain metastasis with haemorrhage is present.

Magnetic resonance imaging clarity of the Bryan, Prodisc-C, Prestige LP, and PCM cervical arthroplasty devices.

STUDY DESIGN: Prospective, randomized, controlled and double-blinded study on imaging of artificial discs. OBJECTIVE: The purpose of this study is to compare postoperative imaging characteristics of the 4 currently available cervical arthroplasty devices at the level of implantation and at adjacent levels. SUMMARY OF BACKGROUND DATA: Cervical arthroplasty is being performed increasingly frequently for degenerative disc disease and, in most cases, with frank neural compression. Unlike lumbar arthroplasty, performed mainly for axial back pain, decompression of neural elements may need to be confirmed with postoperative imaging after cervical arthroplasty. METHODS: Preoperative and postoperative magnetic resonance imaging scans of 20 patients who had undergone cervical arthroplasty were assessed for imaging quality. Five cases each of the Bryan (Medtronic Sofamor Danek, Memphis, TN), Prodisc-C (Synthes Spine, Paoli, PA), Prestige LP (Medtronic Sofamor Danek), and PCM devices (Cervitech, Rockaway, NJ) were analyzed. Six blinded spinal surgeons scored twice sagittal and axial T2-weighted images using the Jarvik 4-point scale. Statistical analysis was performed comparing quality before surgery and after disc implantation at the operated and adjacent levels and between implant types. RESULTS.: Moderate intraobserver and interobserver reliability was noted. Preoperative images of patients in all implant groups had high-quality images at operative and adjacent levels. The Bryan and Prestige LP devices allowed satisfactory visualization of the canal, exit foramina, cord, and adjacent levels after arthroplasty. Visualization was significantly impaired in all PCM and Prodisc-C cases at the operated level in both the spinal canal and neural foramina. At the adjacent levels, image quality was statistically poorer in the PCM and Prodisc-C than those of Prestige LP or Bryan. CONCLUSIONS.: Postoperative visualization of neural structures and adjacent levels after cervical arthroplasty is variable among current available devices. Devices containing nontitanium metals (cobalt-chrome-molybdenum alloys in the PCM and Prodisc-C) prevent accurate postoperative assessment with magnetic resonance imaging at the surgical and adjacent levels. Titanium devices, with or without polyethylene (Bryan disc or Prestige LP), allow for satisfactory monitoring of the adjacent and operated levels. This information is crucial for any surgeon who wishes to assess adequacy of neural decompression and where monitoring of adjacent levels is desired.

The influence of fracture mechanism and morphology on the reliability and validity of two novel thoracolumbar injury classification systems.

STUDY DESIGN: The Thoracolumbar Injury Severity Score (TLISS) and the Thoracolumbar Injury Classification and Severity Score (TLICS) were prospectively evaluated. OBJECTIVES: To compare the reliability and validity of the TLISS and TLICS schemes to determine the importance of injury mechanism and morphology to the identification and treatment of thoracolumbar fractures. SUMMARY OF BACKGROUND DATA: Two novel algorithms have been developed for the categorization and management of thoracolumbar injuries: the TLISS system emphasizing injury mechanism and the TLICS scheme involving injury morphology. METHODS: The clinical and radiographic findings of 25 patients with thoracolumbar fractures were prospectively presented to 5 groups of surgeons with disparate levels of training and experience with spinal trauma. These injuries were consecutively scored, first using the TLISS and then 3 months later with the TLICS. The recommended treatments proposed by the 2 schemes were compared with the actual management of each patient. RESULTS: For both algorithms, the interrater kappa statistics of all subgroups (mechanism/morphology, status of the posterior ligaments, total score, predicted management) were within the range of moderate to substantial reproducibility (0.45-0.74), and there were no statistically significant differences noted between the respective kappa values. Interrater correlation was higher for the TLISS paradigm on mechanism/morphology, integrity of the posterior ligaments, and proposed management (P < or = 0.01). The TLISS and TLICS schemes both exhibited excellent overall validity. CONCLUSIONS: Although both schemes were noted to have substantial reproducibility and validity, our results indicate the TLISS is more reliable than the TLICS, suggesting that the mechanism of trauma may be a more valuable parameter than fracture morphology for the classification and treatment thoracolumbar injuries. Since these injury characteristics are interrelated and are critical to the maintenance of spinal stability, we think that both concepts should be considered during the assessment and management of these patients.

The presence of necrosis and/or microvascular proliferation does not influence survival of patients with anaplastic oligodendroglial tumours: review of 98 patients.

Accurate prognosis for patients with anaplastic oligodendroglial gliomas is increasingly difficult to make. Characterisation of these tumours remains challenging, increasing proportions of oligodendroglial diagnoses in gliomas are reported, and no WHO 2000 grade IV exists for them, so that highly anaplastic tumours can only be grouped with glioblastoma (GBM) or with grade III oligodendroglioma, which have differing clinical behaviour. Longer survival times reported for patients with glioblastoma containing an oligodendroglial element (GBMO) suggest that a grade IV for oligodendroglial tumours might exist. In patients with anaplastic gliomas containing an oligodendroglial element, we explored whether microvascular proliferation (MVP) and necrosis were associated with shorter survival, sufficient to create a grade IV. Biopsies for 98 patients with anaplastic oligodendroglioma, anaplastic oligoastrocytoma or tumours with an oligodendroglial and GBM element, discharged 1998-2004, were identified from databases at three allied neurosurgery units. Pathology reports were reviewed for the presence of MVP and necrosis. Anaplastic oligoastrocytoma and GBMO were combined to measure the effect of an astrocytic element on survival. For anaplastic oligodendroglioma patients, median survival time was 24 months, while for anaplastic oligoastrocytoma or GBMO patients, it was 9 months. Age 60 or over (P=0.006) and astrocytic element (P=0.01) were the only independent predictors of survival. Patients 60 and over with an astrocytic element had 4.6 times the risk of death of patients under 60 with anaplastic oligodendroglioma.A grade IV cannot be created using necrosis or MVP since neither feature predicted survival after adjustment for age and an astrocytic element. However age and an astrocytic element were strong predictors of poorer survival in patients with anaplastic oligodendroglial tumours.

Reversal of anterior cervical fusion with a cervical arthroplasty prosthesis.

This case report describes a 38-year-old-man who initially underwent a C5-C6 anterior cervical decompression and interbody fusion and plating for a right C6 radiculopathy. Within a few months of his surgery, he developed bilateral C7 radiculopathies, with imaging confirming adjacent segment foraminal stenosis. Repeat imaging suggested some subsidence of the original interbody graft but no overt pseudoarthrosis, and flexion/extension films showed no evidence of movement at the fused level. Six months after the original surgery, he underwent re-exploration. Decompression and arthroplasty were effected at the C6-C7 level. The old fusion was removed at the C5-C6 level and remobilized, and an arthroplasty was performed. At discharge, the patient's neck pain and hand symptoms had improved, and he had motion demonstrable on radiologic imaging at C5-C6. This is the first reported case of reversal of a cervical fusion with re-establishment of motion and represents an alternate acceptable management of pseudoarthrosis or recent spinal fusion.