The NOMS approach to metastatic tumors: Integrating new technologies to improve outcomes. / El enfoque de NOMS para los tumores metastásicos: integración de nuevas tecnologías para mejorar los resultados.

Treatment paradigms for patients with spine metastases have evolved significantly over the past two decades. The most transformative change to these paradigms has been the integration of spinal stereotactic radiosurgery (sSRS). sSRS allows for the delivery of tumoricidal radiation doses with sparing of nearby organs at risk, particularly the spinal cord. Evidence supports the safety and efficacy of radiosurgery as it currently offers durable local tumor control with low complication rates even for tumors previously considered radioresistant to conventional external beam radiation therapy. The role for surgical intervention remains consistent, but a trend has been observed toward less aggressive, often minimally invasive techniques. Using modern technologies and improved instrumentation, surgical outcomes continue to improve with reduced morbidity. Additionally, targeted agents such as biologics and checkpoint inhibitors have revolutionized cancer care by improving both local control and patient survival. These advances have brought forth a need for new prognostication tools and a more critical review of long-term outcomes. The complex nature of current treatment schemes necessitates a multidisciplinary approach including surgeons, medical oncologists, radiation oncologists, interventionalists and pain specialists. This review recapitulates the current state-of-the-art, evidence-based data on the treatment of spinal metastases and integrates these data into a decision framework, NOMS, which is based on four sentinel pillars of decision making in metastatic spine tumors: neurological status, Oocologic tumor behavior, mechanical stability and systemic disease burden and medical co-morbidities.

The NOMS approach to metastatic tumors: Integrating new technologies to improve outcomes.

Treatment paradigms for patients with spine metastases have evolved significantly over the past two decades. The most transformative change to these paradigms has been the integration of spinal stereotactic radiosurgery (sSRS). sSRS allows for the delivery of tumoricidal radiation doses with sparing of nearby organs at risk, particularly the spinal cord. Evidence supports the safety and efficacy of radiosurgery as it currently offers durable local tumor control with low complication rates even for tumors previously considered radioresistant to conventional external beam radiation therapy. The role for surgical intervention remains consistent, but a trend has been observed toward less aggressive, often minimally invasive techniques. Using modern technologies and improved instrumentation, surgical outcomes continue to improve with reduced morbidity. Additionally, targeted agents such as biologics and checkpoint inhibitors have revolutionized cancer care by improving both local control and patient survival. These advances have brought forth a need for new prognostication tools and a more critical review of long-term outcomes. The complex nature of current treatment schemes necessitates a multidisciplinary approach including surgeons, medical oncologists, radiation oncologists, interventionalists and pain specialists. This review recapitulates the current state-of-the-art, evidence-based data on the treatment of spinal metastases and integrates these data into a decision framework, NOMS, which is based on four sentinel pillars of decision making in metastatic spine tumors: Neurological status, Oncologic tumor behavior, Mechanical stability, and Systemic disease burden and medical co-morbidities.

The NOMS approach to metastatic tumors: Integrating new technologies to improve outcomes / El enfoque de NOMS para los tumores metastásicos: integración de nuevas tecnologías para mejorar los resultados

Los paradigmas de tratamiento para pacientes con metástasis de columna vertebral han evolucionado significativamente en las últimas dos décadas. El cambio más transformador de estos paradigmas ha sido la integración de la radiocirugía estereotáctica espinal (sSRS). La sSRS permite la administración de dosis de radiación lítica con preservación de los órganos cercanos en riesgo, particularmente la médula espinal. La evidencia apoya la seguridad y la eficacia de la radiocirugía, ya que actualmente ofrece un control tumoral local duradero con bajas tasas de complicaciones, incluso para tumores que anteriormente se consideraban radiorresistentes a la radioterapia convencional de haz externo. El papel de la intervención quirúrgica sigue siendo consistente, pero se ha observado una tendencia hacia técnicas menos agresivas, a menudo mínimamente invasivas. Utilizando tecnologías modernas e instrumentación mejorada, los resultados quirúrgicos continúan mejorando con una morbilidad reducida. Además, los agentes dirigidos, como los productos biológicos y los inhibidores de puntos de control, han revolucionado la atención del cáncer al mejorar tanto el control local como la supervivencia del paciente. Estos avances han dado lugar a la necesidad de nuevas herramientas de pronóstico y a una revisión más crítica de los resultados a largo plazo. La naturaleza compleja de los esquemas de tratamiento actuales requiere un enfoque multidisciplinario que incluya cirujanos, oncólogos médicos, oncólogos radioterápicos, intervencionistas y especialistas en dolor. Esta revisión recapitula los datos actuales basados en la evidencia sobre el tratamiento de las metástasis espinales e integra estos datos en un marco de decisión, NOMS, que se basa en cuatro pilares centinela de la toma de decisiones en tumores metastásicos de la columna vertebral: estado neurológico, comportamiento oncológico del tumor, estabilidad mecánica, y carga sistémica de la enfermedad y comorbilidades médicas.(AU)

Spinal metastases are a common oncologic challenge as 20–40% of cancer patients are affected during the course of their illness and up to 20% of those will become symptomatic from spinal cord compression.1–5 The magnitude of this problem is expected to grow commensurate with the exponential rise in the use of targeted therapies which have demonstrated markedly improved survivals for virtually all malignant tumors. Additionally, the increased availability of advanced diagnostic imaging such as magnetic resonance imaging and 18-FDG PET scans will also serve to increase detection of spine metastatic disease. Despite extended survivals conveyed by biologics and checkpoint inhibitors, the treatment goals for patients with spine metastases remain palliative and focused on the preservation or restoration of neurological function and spinal stability, improved pain control and health related quality of life (HRQOL), and durable tumor control. Scoring systems such as the Tomita score6 and Tokuhashi revised score7 historically have been used to estimate survival and dictate treatment but increasingly have become obsolete due to their inability to incorporate and account for advances in all domains of cancer treatment.(AU)

El enfoque de NOMS para los tumores metastásicos: integración de nuevas tecnologías para mejorar los resultados / The NOMS approach to metastatic tumors: Integrating new technologies to improve outcomes

Los paradigmas de tratamiento para pacientes con metástasis de columna vertebral han evolucionado significativamente en las últimas dos décadas. El cambio más transformador de estos paradigmas ha sido la integración de la radiocirugía estereotáctica espinal (sSRS). La sSRS permite la administración de dosis de radiación lítica con preservación de los órganos cercanos en riesgo, particularmente la médula espinal. La evidencia apoya la seguridad y la eficacia de la radiocirugía, ya que actualmente ofrece un control tumoral local duradero con bajas tasas de complicaciones, incluso para tumores que anteriormente se consideraban radiorresistentes a la radioterapia convencional de haz externo. El papel de la intervención quirúrgica sigue siendo consistente, pero se ha observado una tendencia hacia técnicas menos agresivas, a menudo mínimamente invasivas. Utilizando tecnologías modernas e instrumentación mejorada, los resultados quirúrgicos continúan mejorando con una morbilidad reducida. Además, los agentes dirigidos, como los productos biológicos y los inhibidores de puntos de control, han revolucionado la atención del cáncer al mejorar tanto el control local como la supervivencia del paciente. Estos avances han dado lugar a la necesidad de nuevas herramientas de pronóstico y a una revisión más crítica de los resultados a largo plazo. La naturaleza compleja de los esquemas de tratamiento actuales requiere un enfoque multidisciplinario que incluya cirujanos, oncólogos médicos, oncólogos radioterápicos, intervencionistas y especialistas en dolor. Esta revisión recapitula los datos actuales basados en la evidencia sobre el tratamiento de las metástasis espinales e integra estos datos en un marco de decisión, NOMS, que se basa en cuatro pilares centinela de la toma de decisiones en tumores metastásicos de la columna vertebral: estado neurológico, comportamiento oncológico del tumor, estabilidad mecánica, y carga sistémica de la enfermedad y comorbilidades médicas.(AU)

Spinal metastases are a common oncologic challenge as 20–40% of cancer patients are affected during the course of their illness and up to 20% of those will become symptomatic from spinal cord compression.1–5 The magnitude of this problem is expected to grow commensurate with the exponential rise in the use of targeted therapies which have demonstrated markedly improved survivals for virtually all malignant tumors. Additionally, the increased availability of advanced diagnostic imaging such as magnetic resonance imaging and 18-FDG PET scans will also serve to increase detection of spine metastatic disease. Despite extended survivals conveyed by biologics and checkpoint inhibitors, the treatment goals for patients with spine metastases remain palliative and focused on the preservation or restoration of neurological function and spinal stability, improved pain control and health related quality of life (HRQOL), and durable tumor control. Scoring systems such as the Tomita score6 and Tokuhashi revised score7 historically have been used to estimate survival and dictate treatment but increasingly have become obsolete due to their inability to incorporate and account for advances in all domains of cancer treatment.(AU)

Primary intracranial neoplasms in patients with HIV.

OBJECTIVE: To report a series of HIV-infected patients with intracranial tumors not known to be associated with immunodeficiency. BACKGROUND: The spectrum of HIV-associated diseases is changing with improved treatments and prolonged patient survival. Although primary central nervous system lymphoma (PCNSL) and toxoplasmosis continue to be the most common intracranial lesions in HIV-infected patients, the recognition of other pathologic entities is increasingly important. METHODS: The clinical characteristics and outcome of eight HIV-infected patients with nine intracranial neoplasms other than PCNSL are reported. In addition, all available pathologic specimens were tested for evidence of either HIV or Epstein-Barr virus (EBV) infection. An additional 28 patients reported in the literature are summarized. RESULTS: Five of eight patients had a glioblastoma multiforme; other tumors included an anaplastic ependymoma, a low-grade glioma, a subependymoma, and a leiomyosarcoma. More than half of the patients developed their tumor > or =6 years after the diagnosis of HIV infection. Patient prognosis and survival was best predicted by tumor histology. Treatment response and outcome did not appear to be influenced by HIV infection. Only the leiomyosarcoma demonstrated evidence of latent EBV infection. CONCLUSIONS: HIV-infected patients are at risk for intracranial neoplasms other than PCNSL, and benefit from aggressive tumor-specific therapy. It is possible that gliomas are occurring at a higher rate than in the general population. There was no evidence of HIV or EBV infection in any glial tumor.

Radiographic findings and morbidity in patients treated with stereotactic radiosurgery.

PURPOSE: To determine the prognostic significance of pretreatment edema, lesion size and location on morbidity following stereotactic radiosurgery (SRS). METHODS AND MATERIALS: Forty-seven evaluable patients with 63 lesions were treated on a 6-MV linear accelerator radiosurgery system at Memorial Sloan Kettering Cancer Center. All patients received a 10-mg intravenous bolus of dexamethasone sodium phosphate (Decadron) prior to SRS. Thirteen patients were treated for asymptomatic lesions while 34 were treated because of neurologic symptoms. The median dose delivered was 1800 cGy and the median prescription isodose curve was 85%. Pretreatment edema was measured on a transaxial T2-weighted MR image acquired within 1 month of the SRS. RESULTS: Ten patients experienced morbidity as a result of their treatment. The complication rate was measured by neurologic events following SRS and was not significantly influenced by the extent of peritumoral edema. Lesion size was also unrelated to the development of post-treatment symptoms as assessed by the ease of tapering steroids. The only parameter found to influence post-SRS complications was lesion location. Four of six (66%) patients treated to lesions in the motor cortex suffered post-SRS seizure activity, whereas only 6 of 37 (16%) patients treated to lesions elsewhere in the brain parenchyma experienced seizure activity. CONCLUSION: The presence of pretreatment edema and lesion size are not predictors of post-SRS complication rates or the ability to taper Decadron. Lesion location is predictive of post-SRS seizure activity.

A distinctive glioneuronal tumor of the adult cerebrum with neuropil-like (including "rosetted") islands: report of 4 cases.

Four examples of a novel glioneuronal neoplasm are presented. All tumors affected adults (including two males and two females aged 25-40 years) as supratentorial, cerebral hemispheric masses with associated seizure activity and, in one case, symptoms of raised intracranial pressure and progressive hemiparesis. CT scans in two cases revealed hypodense masses without calcification. MRI scans at presentation demonstrated, in all cases, solid T1-hypointense and T2-hyperintense tumors with mass effect in one instance but no edema or contrast enhancement. Only one was relatively circumscribed on neuroradiologic study. All were infiltrative in their histologic growth pattern and predominantly glial in appearance, being composed mainly of fibrillary, gemistocytic, or protoplasmic astroglial elements of WHO grade II to III. Their distinguishing feature was their content of sharply delimited, neuropil-like islands of intense synaptophysin reactivity inhabited and rimmed in rosetted fashion by cells demonstrating strong nuclear immunolabeling for the neuronal antigens NeuN and Hu. These cells included small, oligodendrocyte-like ("neurocytic") elements as well as larger, more pleomorphic forms. Two cases contained, in addition, well-differentiated neurons of medium to ganglion-cell size. Proliferative activity was observed principally within the glial compartment; two cases contained mitotic figures and exhibited relatively elevated MIB-1 indices (6.8% and 8.2%). One of the latter progressed and proved fatal at 30 months following subtotal resection and radiotherapy. The three other patients are alive at intervals of 14 to 83 months, two tumor-free and one with extensive disease associated with the appearance of enhancement on MRI. This glioneuronal tumor variant may pursue an unfavorable clinical course.

Factors determining outcome after surgical resection of T3 and T4 lung cancers of the superior sulcus.

BACKGROUND: The treatment of superior sulcus lung cancers is evolving and preoperative chemotherapy is increasingly used. To establish a historical benchmark against which new therapies can be assessed, we reviewed our 24-year experience with patients undergoing thoracotomy for lung cancers of the superior sulcus. METHODS: Data were acquired through retrospective chart review. Overall survival was calculated by the method of Kaplan and Meier, and prognostic factors were examined by log rank and Cox proportional hazards modeling. RESULTS: From 1974 to 1998, 225 patients underwent thoracotomy. The patients included 144 men (64%) and 81 women with a median age of 55 years. The majority of patients (55%) received preoperative radiation, but 35% did not have any preoperative treatment. Tumor stages were IIB (T3 N0) in 52%, IIIA in 15%, and IIIB in 27% of patients. Complete resection was achieved in 64% of T3 N0 tumors, 54% of T3 N2 tumors, and 39% of T4 N0 tumors. Operative mortality was 4%. Median survival was 33 months for stage IIB and 12 months for both stages IIIA and IIIB. Actuarial 5-year survivals were 46% for stage IIB, 0% for stage IIIA, and 13% for stage IIIB. By univariate and multivariable analyses, T and N status and complete resection had a significant impact on survival. Locoregional disease was the most common form of relapse. CONCLUSIONS: Our results provide a benchmark against which new treatment regimens can be evaluated. Control of locoregional disease remains the major challenge in treating lung cancers of the superior sulcus. The potential benefit of preoperative chemotherapy or chemoradiotherapy must be assessed by whether it leads to higher rates of complete resection and a lower risk of local relapse.

Tension pneumocephalus resulting from iatrogenic subarachnoid-pleural fistulae: report of three cases.

BACKGROUND: Symptomatic pneumocephalus may result from a cerebrospinal fluid leak communicating with extradural air. However, it is a rare event after thoracic surgical procedures, and its management and physiology are not widely recognized. METHODS: During the past 2 years, we have identified 3 patients who developed pneumocephalus after thoracotomy for tumor resection. Only 1 patient had a discernible spinal fluid leak identified intraoperatively. Two patients experienced delayed spinal fluid drainage from their chest tubes and subsequently developed profound lethargy, confusion, and focal neurologic signs. The third patient was readmitted to the hospital with a delayed pneumothorax and altered mental status. Radiographic imaging in all patients showed significant pneumocephalus of the basilar cisterns and ventricles. RESULTS: The first 2 patients were managed by discontinuation of the chest tube suction and bedrest. The third patient underwent surgical reexploration and nerve root ligation. All 3 patients had resolution of their symptoms within 72 hours. CONCLUSIONS: Pneumocephalus is a rare, but serious, complication of thoracotomy. Previous patients reported in the literature have been managed with reoperation to ligate the nerve roots. However, the condition resolved nonoperatively in 2 of our patients. Discontinuation of chest tube suction may be definitive treatment and is always the important initial management to decrease cerebrospinal fluid extravasation into the pleural space and allow normalization of neurologic symptoms.

Laparoscopic surgery in children with ventriculoperitoneal shunts: effect of pneumoperitoneum on intracranial pressure--preliminary experience.

OBJECTIVES: We monitored changes in intracranial pressure (ICP) in 2 children with myelodysplasia undergoing laparoscopic bladder autoaugmentation. Both children had ventriculoperitoneal shunts (VPS) secondary to Arnold-Chiari malformations (type II). METHODS: ICP was monitored through a 23-gauge needle placed into the shunt reservoir and connected to a pressure transducer and drainage system. Intraoperative mean arterial pressure, end-tidal CO2 (ETCO2), ICP, abdominal pressure, and cerebral perfusion pressures were all monitored. RESULTS: Both children demonstrated rapid onset and sustained increases in ICP of greater than 12 mm Hg above baseline to a maximum pressure of 25 mm Hg. The average cerebrospinal fluid removed from each patient was 30 cc, thereby lowering ICP with no adverse neurologic sequela. The pCO2 remained constant throughout the procedures, as measured by ETCO2. CONCLUSIONS: We believe that intracranial hypertension (IH) results from a "Valsalva-like" phenomenon, which causes cerebral vascular engorgement. In addition, the pneumoperitoneum may increase the resistance to outflow through the distal peritoneal catheter, causing a partial or complete shunt obstruction. Untreated IH may result in adverse neurologic sequelae from brain herniation in these children with hindbrain anomalies and potentially altered brain compliance. We believe it is prudent to perform intraoperative ICP monitoring in this subgroup of patients undergoing laparoscopic surgery and that IH should be treated by ventricular drainage.

Function-sparing surgery for desmoid tumors and other low-grade fibrosarcomas involving the brachial plexus.

OBJECTIVE: Low-grade fibrosarcomas and desmoid tumors present a surgical challenge in that they have a strong tendency for local invasion, surgical margins are poorly delineated, and complete resections are difficult. Nowhere is this more evident than in those lesions involving the brachial plexus. We review our experience with these difficult lesions. METHODS: From a prospective database of 2900 patients admitted for treatment of sarcoma between 1982 and 1996, we identified 15 patients with involvement of the brachial plexus by a low-grade fibrosarcoma or desmoid tumor. All patients underwent resection, with 13 of 15 receiving adjuvant radiotherapy. The 15 patients had a mean age at initial operation of 47 years. The male-to-female ratio was 8:7. The mean follow-up period was 65 months (median, 53 mo). RESULTS: Gross total resection was achieved in 12 patients (80%), although 11 of these patients had positive surgical margins. Overall, 64% of the tumors have recurred locally. There were no distant metastases, and no patients died as a result of their disease. One patient died as a result of unrelated cancer. An assessment of the functional outcomes revealed seven patients with normal function or mild neurological deficits and eight who were suffering from significant weakness, debilitation, or chronic pain. One patient required forequarter amputation. CONCLUSION: Surgical resection plus postoperative radiotherapy is the treatment of choice for low-grade fibrosarcomas and desmoid tumors involving the brachial plexus. However, aggressive surgical management with the goal of achieving a gross total resection with negative histological margins can produce unnecessary morbidity. Preserving function should be a primary goal of the operations, although this will be associated with residual disease and will risk local recurrence but rarely death resulting from the disease.

Sclerosing epithelioid fibrosarcomas involving the neuraxis: report of three cases.

OBJECTIVE AND IMPORTANCE: Sclerosing epithelioid fibrosarcoma (SEF) is a rare mesenchymal neoplasm composed of rounded, vimentin-immunoreactive tumor cells disposed in nests and cords within a hyalinized collagenous matrix. Most examples arise in the deep skeletal muscles of adults. The cases recorded to date have been characterized by protracted clinical evolutions with a tendency for stubborn local recurrence, followed by late metastasis. Accordingly, SEF has been regarded as a low-grade sarcoma. A single instance of brain and vertebral metastasis has been described. We report three examples of SEF distinguished by primary involvement of the neuraxis at initial presentation. CLINICAL PRESENTATION: Two tumors had intracranial, calvarial and extracalvarial, soft-tissue components, whereas the third tumor manifested as a paraspinal mass with extension into the T12-L1 neural foramen and invasion of the T12 nerve root. INTERVENTION: All three affected patients experienced local recurrence and distant metastasis after resection of the primary site. These complications appeared early in the disease course in two cases. In no case was there a response to adjuvant chemotherapy or radiotherapy. CONCLUSION: Our experience indicates that SEFs arising along the neuraxis may demonstrate unexpectedly aggressive clinical behavior, compared with those arising in the more typical location of deep skeletal muscles.

Ommaya reservoirs for the treatment of leptomeningeal metastases.

OBJECTIVE: Ommaya reservoirs are frequently used to deliver intraventricular chemotherapy in cancer patients with leptomeningeal metastases. We review techniques of catheter placement and complication avoidance. METHODS: Between January 1995 and June 1998, Ommaya reservoirs were placed in 107 patients for the treatment or prophylaxis of leptomeningeal metastases at the Memorial Sloan-Kettering Cancer Center. Patients with slit ventricles (total, 25) underwent preoperative pneumoencephalography for ventricular dilation. Intraoperative fluoroscopic guidance was used in 77 patients to confirm the catheter tip position at the foramen of Monro. Other intraoperative aids included endoscopy in 21 patients, ultrasound in 7, and stereotaxy in 6. No aids were used in 3 patients, more than one aid was used in 9, and the technique could not be determined retrospectively in 3. RESULTS: The median survival of patients treated for leptomeningeal metastases was 9 months (Kaplan-Meier method). Eight patients developed hydrocephalus requiring conversion of the Ommaya reservoir to a ventriculoperitoneal shunt and precluding delivery of chemotherapeutic agents. An additional 11 patients referred for Ommaya reservoir placement demonstrated elevated intracranial pressure requiring an initial ventriculoperitoneal shunt. Complications of Ommaya reservoir placement occurred in 10 patients (9.3%) and included two infections, five catheter malpositions, and three intracranial hemorrhages. Two deaths occurred secondary to intracranial hemorrhage: one after postoperative anticoagulation for a mechanical heart valve, and one attributed to treatment-related thrombocytopenia. Nine patients (8.4%) had treatment-related imaging abnormalities; seven were asymptomatic and two developed symptomatic leukoencephalopathy. CONCLUSION: Complications associated with Ommaya reservoirs can be minimized by intraoperative confirmation of the catheter position with fluoroscopic guidance and/or endoscopy. We recommend postoperative computed tomographic scans before initiation of intraventricular chemotherapy. Patients with elevated intracranial pressure may require shunting procedures in lieu of Ommaya reservoir placement.

Intralesional resection of primary and metastatic sarcoma involving the spine: outcome analysis of 59 patients.

OBJECTIVE: Surgery plays an important role in achieving local tumor control and cure for primary and metastatic tumors of the spine. As has been established with regard to sarcomas at extraspinal sites, these goals may best be achieved by en bloc resection with negative histological margins. Unfortunately, sarcomas of the spine often present with tumor patterns that are amenable only to intralesional resection, if neurological preservation is a priority. This study is a retrospective analysis of the long-term outcomes of patients who had operations for sarcomas of the spine using modern surgical approaches, intralesional resections, and spinal instrumentation. METHODS: Between 1985 and 1997, 59 patients had spinal operations for sarcoma involving the extrasacral spine. Data regarding tumor histology, grade, surgical indications, patterns of spinal tumor involvement, and neurological and functional outcomes were reviewed at presentation and at tumor recurrence. RESULTS: Thirty-five patients underwent a single operation, and 24 patients required reoperation for locally recurrent tumors. At presentation, only nine patients (15%) had tumors that were amenable to marginal or wide resections. Functional outcomes after initial spinal surgery and after operations performed at first tumor recurrence showed that 95% of patients had maintained or regained ambulation. Intradural extension of tumor was seen in 5 of 12 patients who had three or more operations for locally recurrent disease. The median survival from first spine operation was 18 months, and the median event-free interval between the first and second spine operations was 13 months. CONCLUSION: Surgery for sarcoma of the spine is useful for maintaining or improving neurological and functional outcomes, but local tumor recurrences are common. Because of the anatomy of the tumor at presentation and concern for neurological preservation, few patients are candidates for marginal or wide resections.

An integrated functional magnetic resonance imaging procedure for preoperative mapping of cortical areas associated with tactile, motor, language, and visual functions.

OBJECTIVE: To evaluate an integrated battery of preoperative functional magnetic resonance imaging (fMRI) tasks developed to identify cortical areas associated with tactile, motor, language, and visual functions. METHODS: Sensitivity of each task was determined by the probability that a targeted region was activated for both healthy volunteers (n = 63) and surgical patients with lesions in these critical areas (n = 125). Accuracy of each task was determined by the correspondence between the fMRI maps and intraoperative electrophysiological measurements, including somatosensory evoked potentials (n = 16), direct cortical stimulation (n = 9), and language mapping (n = 5), and by preoperative Wada tests (n = 13) and visual field examinations (n = 6). RESULTS: For healthy volunteers, the overall sensitivity was 100% for identification of the central sulcus, visual cortex, and putative Wernicke's area, and 93% for the putative Broca's area (dominant hemisphere). For patients with tumors affecting these regions of interest, task sensitivity was 97% for identification of the central sulcus, 100% for the visual cortex, 91% for the putative Wernicke's area, and 77% for the putative Broca's area. These sensitivities were enhanced by the use of multiple tasks to target related functions. Concordance of the fMRI maps and intraoperative electrophysiological measurements was observed whenever both techniques yielded maps and Wada and visual field examinations were consistent with fMRI results. CONCLUSION: This integrated fMRI task battery offers standardized and noninvasive preoperative maps of multiple critical functions to facilitate assessment of surgical risk, planning of surgical routes, and direction of conventional, intraoperative electrophysiological procedures. Thus, a greater range of structural and functional relationships is brought to bear in the service of optimal outcomes for neurosurgery.

Epidural steroids, postoperative morbidity, and recovery in patients undergoing microsurgical lumbar discectomy.

Intraoperative epidural corticosteroids have been used by some surgeons to decrease pain following surgery for a herniated lumbar disc. In this study, 84 consecutively treated, comparable patients with unilateral lumbar disc herniation were prospectively assigned randomly to receive either epidural corticosteroids (40 mg methylprednisolone acetate) or saline at the conclusion of the operative procedure. The postoperative morbidity of these two groups was evaluated by tabulating the following parameters: pain relief as measured by consumption of postoperative pain medications; the length of hospital stay; postoperative functional status; and the time interval from surgery until return to work. The mean postoperative analgesic medications consumed was 12.2 +/- 1.9 mg of morphine equivalents in the corticosteroid group versus 12.2 +/- 1.8 mg of morphine equivalents in the control group. The mean hospital stay was less than 2 days in each group, and the mean interval until return to work was 21.2 +/- 2.7 days in the corticosteroid group versus 25.4 +/- 3.1 days in the control group. Moreover, no statistically significant difference was measured between the steroid-treated and control groups when the data were stratified for sex, age, and site of disc herniation. The mean outcome scores, which are derived from a postoperative assessment of pain relief resulting from surgery, functional status, and interval until return to work, were identical in the corticosteroid and control groups. This study concludes that epidural corticosteroid administration after microsurgical lumbar discectomy for unilateral disc herniation does not lessen postoperative morbidity or improve functional recovery.

Extended anterior craniofacial resection for intracranial extension of malignant tumors.

OBJECTIVE: To review our experience with anterior craniofacial resection for malignant neoplasms with intracranial extension. Survival was analyzed in terms of presence of intracranial extension, extent of intradural disease, tumor histology, and histological status of margins. PATIENTS: In a retrospective review made at a tertiary cancer facility, 26 of the 115 consecutive patients undergoing craniofacial resection for malignant lesions of the anterior skull base had intracranial extension, defined as dural and/or brain extension. Survival was evaluated with the Kaplan-Meier product limit method, and comparisons between individual subgroups were performed using the log-rank test. RESULTS: Patients with intradural extension have a statistically worse disease-specific survival than patients without intracranial extension (P = 0.05). Surgical margins and tumor histology impact on survival. The incidence of local complications was 42% and of systemic complications, 8%. CONCLUSION: Anterior craniofacial resection is indicated for patients with resectable disease. The complication rate is comparable with that of patients without intracranial extension. Gross total resection with histologically negative margins portends a better prognosis. Esthesioneuroblastoma has a better prognosis than other tumor types.

Craniofacial resection for malignant tumors involving the anterior skull base.

OBJECTIVES: To review our experience with craniofacial resection for malignant neoplasms of the anterior skull base and report long-term results, and to analyze survival in terms of the overall experience, tumor histological diagnoses, and tumor extent. Also, to report complications of this surgical procedure. DESIGN: Retrospective review. SETTING: Tertiary cancer facility. PATIENTS: We evaluated 115 consecutive patients undergoing craniofacial resection for malignant neoplasms involving the anterior skull base. Forty-five (39%) presented with recurrent or persistent disease after prior therapy. MAIN OUTCOME MEASURES: Survival was evaluated with the Kaplan-Meier product limit method and comparisons between individual subgroups were performed using the log-rank test. RESULTS: The operative mortality rate was 3.5%. Major complications occurred in 40 patients (35%). For the entire group, disease-specific survival rates were 58% and 48% at 5 and 10 years, respectively. The highest survival rate was observed in patients with esthesioneuroblastoma and lowest in those with mucosal melanoma. Survival was significantly better for those whose tumors could be excised with a limited resection in comparison with those requiring an extended procedure (P = .009). CONCLUSIONS: A 23-year experience with craniofacial resection performed for malignant tumors involving the anterior skull base confirms the durable results obtained with this intervention. The diversity of histological diagnoses, site of origin, extent of tumor invasion, and impact of prior therapy hampers any attempt at reporting meaningful survival statistics for comparison with other series or other means of treatment.

Single-stage posterolateral transpedicle approach for spondylectomy, epidural decompression, and circumferential fusion of spinal metastases.

STUDY DESIGN: Retrospective review of prospectively maintained institutional spine database. OBJECTIVES: To assess the pain, neurologic, and functional outcome of patients with metastatic spinal cord compression using a posterolateral transpedicular approach with circumferential fusion. SUMMARY OF BACKGROUND DATA: Patients with spinal metastases often have patterns of disease requiring both an anterior and posterior surgical decompression and spinal fusion. For patients whose concurrent illness or previous surgery makes an anterior approach difficult, a posterior transpedicular approach was used to resect the involved vertebral bodies, posterior elements, and epidural tumor. This approach provides exposure sufficient to decompress and instrument the anterior and posterior columns. METHODS: During the past 15 months, 25 patients were operated on using a posterolateral transpedicular approach. The primary indications for surgery were back pain (15 patients) and neurologic progression (10 patients). All patients had vertebral body disease, and 21 patients had high-grade spinal cord compression from epidural disease as assessed by magnetic resonance imaging. Seven patients underwent preoperative embolization for vascular tumors. In each patient, the anterior column was reconstructed with polymethyl methacrylate and Steinmann pins and the posterior column with long segmental fixation. RESULTS: All patients achieved immediate stability. Pain relief was significant in all 23 patients who had had moderate or severe pain. Neurologic symptoms were stable or improved in 23 patients. One patient with an acutely evolving myelopathy was immediately worse after surgery, and one patient had a delayed neurologic worsening, progressing to paraplegia. CONCLUSIONS: The posterolateral transpedicular approach provides a wide surgical exposure to decompress and instrument the anterior and posterior spine. This technique avoids the morbidity associated with anterior approaches and provides immediate stability. Vascular tumors may be removed safely after embolization. Patients can be mobilized early after surgery.

Transpedicular approach for thoracic disc herniations.

OBJECT: Patients with symptomatic herniated thoracic discs may require operation for intractable radiculopathy or functionally disabling myelopathy. In the past, laminectomy was the procedure of choice for the treatment of thoracic herniations, but it was found that the approach was associated with an unacceptably high rate of neurological morbidity. Several strategies have been developed to excise the disc without manipulating the spinal cord. The focus of this paper is the transpedicular approach. METHODS: The author retrospectively reviewed the cases of 20 consecutive patients presenting with herniated thoracic discs in whom surgery was performed via a transpedicular approach. Fourteen patients presented with acute myelopathy and six with radiculopathy. Of those with myelopathy six of six regained ambulation and six of seven regained normal bladder function. No patient with myelopathy experienced neurological worsening. In four patients presenting with radiculopathy postoperative pain resolved, and in two it remained unchanged. Three minor complications (15%) occurred. No patient suffered postoperative spinal instability-related pain or delayed kyphosis. CONCLUSIONS: As experience accumulates in the use of multiple approaches for the treatment of thoracic disc herniations, the role of each is becoming more clearly defined. The transpedicular approach is most applicable to lateral or centrolateral calcified or soft discs. The more anterior (transthoracic or thoracoscopic) and lateral (costotransversectomy or lateral extracavitary) approaches may be more useful for excision of central calcified discs.