Anterior To Psoas lumbar and lumbosacral combined with posterior reconstruction in Adult Spinal Deformity: A bicentric European study.

Introduction: Lateral lumbar fusion via the trans-psoas approach is popular in adult deformity reconstruction. To overcome its limitations (neurological damage to the plexus and lack of applicability to the lumbosacral junction), a modified anterior-to-psoas (ATP) approach has been described and used. Research question: To investigate the results of ATP lumbar and lumbosacral fusion, in a cohort of adult patients treated with combined anteroposterior approaches for adult spinal deformity (ASD). Materials and methods: ASD patients surgically treated at two tertiary spinal centres were followed up. Forty patients were treated with combined ATP and posterior surgery: 11 with open lumbar lateral interbody-fusions (lumbotomy LLIF) and 29 with lesser invasive oblique lateral interbody-fusions (OLIF). Preoperative demographics, aetiology, clinical characteristics, and spinopelvic parameters were comparable between the two cohorts. Results: At a minimum 2-year follow-up, both cohorts showed significant improvements in patient reported outcome measures (PROMs), i.e. Visual Analogue Scale and Core Outcome Measures Index, as well as radiological parameters, with no significant differences based on the type of surgical approach. No significant differences were found in major (P â€‹= â€‹0.457) and minor (P â€‹= â€‹0.071) complications between the two cohorts. Discusson and conclusion: Anterolateral lumbar interbody fusions, whether performed via a direct or oblique approach, proved to be safe and effective adjuvants to posterior surgery in patients with ASD. No significant complication differences were noted between techniques. In addition, the anterior-to-psoas approaches limited the risks of post-operative pseudoarthrosis by providing solid anterior support to lumbar and lumbosacral segments, demonstrating a positive impact on PROMS.

Comparison of clinical outcomes in anterior cervical discectomy versus foraminotomy for brachialgia.

AIM: The choice between anterior cervical discectomy & fusion (ACD) or posterior cervical foraminotomy (PCF) for the treatment of cervical brachialgia is controversial. This study aimes to compare clinical outcomes between these two operative inteventions for brachialgia. METHODS: Retrospective review of prospectively collected data was performed. Patients receiving a primary ACD or PCF to treat brachialgia, in a single tertiary neurosurgical unit were included. Surgical details, and patient reported outcomes (COMI-Neck questionnaire) were extracted from a prospectively maintained spinal procedure database. Minimum clinically important difference (MCID) was defined as a change in COMI score of -2 at 12 months. The student t-test, Chi-square test, and linear regression were used to compare groups. RESULTS: Between June 2011 ad February 2016 there were 634 ACD procedures (Median age 49; 321 Male), and 54 PCF procedures (Median age 50; 37 Male) perfomed for brachialgia. Age, ASA and pre-operative COMI were similar between the groups (p > .05). Complete outcome data was recorded at twelve months in 312 ACD and 36 PCF patients. Both ACD and PCF were associated with an improvement in COMI at 3 and 12 months (all p < .01). Mean change in COMI at 3 months was -2.38 for ACD, versus -2.31 for PCF (p = .88); at twelve months it was -2.94 for ACD, versus -2.67 for PCF (p = .55). MCID was seen in 59% of ACD cases, versus 58% of PCF cases at twelve months (p = .91). CONCLUSION: There was no significant difference between outcomes in the ACD and PCF groups. This is supportive of published literature. The proposed multicenter RCTs may inform further.

Indications for intracranial reservoirs: a six-year study.

OBJECTIVES: For patients with intracranial recurrent cysts, reservoir placement can offer symptomatic control at relatively low risk, allowing repeated outpatient aspiration. Predicting which patients will require repeated drainage is not always straightforward. The aim of this study was to examine a series of patients treated with reservoir system placement, and examine the factors that may be relevant to repeated drainage and morbidity. METHODS: We retrospectively reviewed all adult patients who had intracranial reservoir placement between 2005 and 2011 at a single neurosurgical centre. Information was gathered on the indications for placement, demographics, diagnosis, imaging, disease characteristics, complications and clinical outcome. RESULTS: Forty-one adult patients had reservoir placement over the 6-year period, of which 31 had cystic lesions, 4 had hydrocephalus, and 6 were for intrathecal therapy. Of the 31 cystic lesions, 14 were high-grade gliomas, 6 craniopharyngiomas, 4 low-grade gliomas, 5 cystic metastases, 1 acoustic neuroma, and 1 arachnoid cyst. The 30 patients with malignant disease had 1-6 postoperative aspirations at a median of 290 days after surgery. In patients with hydrocephalus the reservoir was not used postoperatively. Eighty-three per cent of patients with cystic lesions who had recurrent aspirations (26/36) resulted in clinical improvement. For the three categories of cystic lesions with the most number of aspirations; 100% showed clinical improvement in low-grade lesions, 68.4% in high-grade lesions, and 66.7% in craniopharyngiomas. Four patients experienced complications, including reservoir malfunction (2), infection (1), and misplacement (1). CONCLUSIONS: Intracranial reservoirs provide significant clinical improvement when used for recurrent aspiration in patients with cystic tumours. In particular, it is clear that ommaya reservoirs are of significant advantage in high-grade lesions, where the majority of patients undergo recurrent aspirations with clinical improvement.

Antimicrobial treatment options for neurosurgical ventricular shunt infections in children from 1993 to 2012: a systematic review.

PURPOSE: The aim of this systematic review was to review studies that existed from 1993 to 2012 regarding antimicrobial treatment options of paediatric neurosurgical shunt. METHODS: Studies were identified from MEDLINE, Scopus and Cochrane databases using a search strategy that was registered on the PROSPERO database. Studies were included if they had two or more patients, aged less than 18 years, and also specified the organism and antimicrobial treatment that was used. RESULTS: The search yielded 2,985 articles, and 76 articles were suitable for full review. In the final qualitative analysis, only eight studies were included, involving 86 participants. The most common antimicrobial regimens for Gram-positive infections was intravenous and intrathecal vancomycin (n = 7), followed by intravenous vancomycin monotherapy. CONCLUSION: This systematic review has shown that there are no prospective randomised studies of antimicrobial treatment options for paediatric neurosurgical patients in the last 20 years, and larger prospective studies are urgently required for this serious infection. There is some limited case series showing the benefits of certain antimicrobials such as vancomycin and ceftriaxone, but a larger case series or randomised controlled trial is required, particularly to establish the benefit, if any, of additional intraventricular antimicrobials.

Intracranial granuloma mimicking a brain tumor in a patient with scleroderma.

BACKGROUND: Intracranial granulomatous masses presenting as space occupying lesions, although rare, have been described in the literature. Causes include infections, systemic granulomatous disorders, and iatrogenic from previous surgery. We present a case demonstrating that spontaneous intracranial granuloma can exist, often mimicking a brain tumor. CASE DESCRIPTION: A 62-year-old female presented with a short history of left sided partial seizures and a left hemiparesis. Magnetic resonance imaging revealed a right sided parafalcine lesion. Histopathology demonstrated chronic inflammation of granulomatous type. She responded to steroid treatment. CONCLUSION: She responded to steroid treatment. Our case demonstrated that spontaneous intracranial granuloma exists. Although rare, it should be considered in patients presenting with space occupying lesions. They can successfully be managed with steroid treatment.

Cognitive and functional outcome in spina bifida-Chiari II malformation.

PURPOSE: The long-term outcome in spina bifida-Chiari II-hydrocephalus complex is poorly understood. Traditional neurosurgical outcome measures are crude. Neuropsychological testing is increasingly important in outcome assessment. We investigated the health, disability, lifestyle and cognitive function in adults who had myelomeningocoele closure at birth. METHODS: Adult patients under routine follow-up were assessed in a joint neurosurgery/neuropsychology clinic. Patients completed lifestyle questionnaires, the hydrocephalus outcome questionnaire (HOQ) and underwent cognitive testing. Clinical variables including number of shunt revisions, shunt infection and surgical decompression of foramen magnum, which may influence outcome, were investigated. RESULTS: Twenty-one adults with a median age of 35 years were investigated. All had treated hydrocephalus, and eight had foramen magnum decompression for headache or progressive brainstem symptoms with stabilisation of symptoms in seven and improvement in one. Only eight patients were living independently, five were in paid employment and five work voluntarily. HOQ scores for cognitive function were lower (0.56 ± 0.20; mean ± standard deviation (SD)) than those for physical (0.64 ± 0.15) and social-emotional (0.65 ± 0.17) health. Cognitive function varied across the cohort with attention most severely affected (73.9 ± 17.0; mean ± SD). Repeated episodes of shunt malfunction or foramen magnum decompression were not associated with a worse cognitive function. CONCLUSIONS: Despite intervention in childhood and adequate cerebrospinal fluid diversion the prognosis for independent living into adulthood remains poor. All patients have elements of cognitive impairment. Structural brain abnormalities may be more important determinants of cognitive outcome than shunt malfunction.

Malignant peripheral nerve sheath tumor of the paranasal sinuses.

Malignant peripheral nerve sheath tumors of the nose and paranasal sinuses are extremely uncommon. We report the case of a 65-year-old woman who presented with a rapid emergence of "nasal polyps" that completely obstructed her nasal passages. Six years earlier she had been assessed elsewhere for nasal polyps. At presentation, the patient exhibited gross polyposis, with lesions protruding from both nostrils. Histology confirmed a diagnosis of a malignant peripheral nerve sheath tumor This case demonstrates that symptoms of nasal obstruction are not always secondary to simple causes. We discuss the clinical picture of nasal and paranasal malignant peripheral nerve sheath tumor, its pathology, and its treatment.