Revision of Failed Sacroiliac Joint Posterior Interpositional Structural Allograft Stabilization with Lateral Porous Titanium Implants: A Multicenter Case Series.

Background: Distraction arthrodesis (DA) and stabilization of the sacroiliac (SI) joint by placing standalone structural allograft (SA) into the joint from a posterior trajectory has recently been introduced as a surgical procedure for chronic SI joint pain refractory to non-operative care. Methods: Retrospective case series of patients with recurrent and/or persistent pain after placement of one or more interpositional/intraarticular standalone SAs between the ilium and sacrum using a posterior procedure to treat SI joint pain/dysfunction. Patients subsequently underwent surgical revision with porous titanium fusion implants using a lateral transfixing procedure. The demographic, clinical, and radiographic features of these cases are described. Results: Data were available for 37 patients. The average (SD) age was 57 (13) years, 62% were female, and the average BMI was 31 (5.4). On average, two SA implants were placed per joint; 46% of cases were bilateral. At follow-up, two common themes were identified: lucencies around the implants and suboptimal implant position. None of the cases showed radiographic fusion of the SI joint prior to revision. One patient had an inflammatory reaction to the SA. All patients presented for revision due to either continued (49%) or recurrence (51%) of pain. In one revision case, the SA was forced ventrally, resulting in a sacral fracture, which was treated conservatively without sequelae. Conclusions: The popularity of standalone SA for SI joint stabilization/fusion with a posterior procedure is increasing. This case series demonstrates that clinical failures from this procedure may require surgical revision. The proposed fusion strategy (DA) for these products is unproven in the SI joint, and, therefore, properly conducted prospective randomized clinical trials with long-term clinical and radiographic follow-up are important to establish the safety and efficacy of this approach. In the meantime, the placement of lateral titanium implants appears to be an effective revision strategy.

Neurosarcoidosis presenting as an incidental solitary cranial ring-enhancing lesion.

Isolated neurosarcoidosis without prior systemic symptoms is extremely rare, occurring in approximately 2% of patients with neurosarcoidosis. Due to its rarity, mistakes in diagnosis and treatment occur commonly. We present a case of a 47-year-old female who was found to have an incidentally discovered solitary intracranial lesion that mimicked a high-grade neoplasm, but was later confirmed to be neurosarcoidosis. Incidental solitary neurosarcoid granulomas are difficult to diagnose due to its nonspecific clinical and imaging presentations. Early diagnosis by biopsy in these rare incidental cases remains paramount for adequate treatment.

The role of whole-brain radiation therapy after stereotactic radiation surgery for brain metastases.

The benefit of whole-brain radiation therapy (WBRT) following stereotactic radiation surgery (SRS) for brain metastases is controversial. We conducted a systematic analysis of published literature to explore the outcome of brain metastases treated with SRS and WBRT versus SRS alone using PubMed and MEDLINE. Outcomes including survival, control, salvage therapy, and other quality of life measures were reported. Three randomized controlled trials involving 389 patients with 1 to 4 brain metastases were selected. In 2 of these trials (n = 190), the mean 1-year survival was 33.2% for SRS + WBRT and 38.7% for SRS alone (P = .5233); 1-year local control was 89% for SRS + WBRT and 71% for SRS alone (P < .001). Mean crude distant recurrence rate for SRS + WBRT was 36.6% and 54% for SRS alone (P < .001). Patients without WBRT were over 3 times more likely to require salvage therapy (P < .001). The addition of WBRT was associated with a decreased health-related quality of life assessment, mini mental status exam, and Hopkins Verbal Learning Test (P < .05). Five retrospective studies (n = 1122) were also included in a separate analysis and yielded findings that supported results from the randomized trials. Our systematic analysis demonstrates that adjuvant WBRT following SRS for the treatment of oligometastases in the brain is more effective at controlling local and distant recurrence than SRS alone, but there is no apparent benefit for survival or symptomology. The proven cognitive decline and neurotoxicity present with WBRT should be weighed against the benefit of local control. Prognosis of brain metastasis is poor regardless of current treatment and further exploration for alternative adjuvant treatment for SRS is warranted.

Recognizing and correcting failures in glioblastoma treatment.

While current treatment remains universal for glioblastoma, recent evidence has demonstrated marked heterogeneity in their molecular profiles. Due to the near universal rate of recurrence, attention has focused on individualized treatment and subgroup population differences that may influence the efficacy of adjuvant therapy. Recent studies have implicated chemo-radioresistant GBM stem cells (GSCs) in the propagation of heterogeneous tumor profiles. As a result, there has been a shift to classify and target GSCs in order to increase survival and delay relapse. The overall objective of our editorial is to highlight current failures in GBM treatment and to propose novel personalized methods to correct our shortcomings in GBM treatment.

Awake craniotomy for brain tumor resection: the rule rather than the exception?

OBJECTIVE: Awake craniotomy (AC) has seen an expanded role in brain tumor surgery over the past few decades. AC allows intraoperative cortical mapping and the continuous assessment of neurophysiological parameters, which are otherwise unattainable under general anesthesia (GA). The ability of AC to analyze eloquent brain areas makes it a powerful method for reducing the risks associated with tumor resection, especially in motor and language cortex. We present a review of the literature to examine the benefits and limits of using AC over GA. METHODS: A literature search was performed using the Medline and PubMed databases from 1970 and 2012 that compared craniotomy for tumor resection under GA and AC. Data of interest included length of hospital stay, operating time, extent of resection, and neurological sequelae. RESULTS: A total of 8 studies with 951 patients (411 utilizing AC and 540 utilizing GA) were included in this review. Our interpretation of the literature suggests that AC (4 d, n=110) results in a shorter hospital stay than GA (9 d, n=116). Mean extent of resection was slightly less under awake conditions (41%, n=321) versus GA (44%, n=444), and postoperative deficits were less frequent under awake conditions (7%, n=411) versus GA (23%, n=520). Surgery time was slightly less in the AC group (165 min, n=324) versus GA (168 min, n=477). CONCLUSIONS: Given the effectiveness of AC for resection of eloquent tumors, the data suggests an expanded role for AC in brain tumor surgery regardless of tumor location.

Ossification of the posterior longitudinal ligament in non-Asians: demographic, clinical, and radiographic findings in 43 patients.

OBJECT: Ossification of the posterior longitudinal ligament (OPLL) is a disorder afflicting as many as 2% of East Asians. However, reports of OPLL in non-Asians have been sporadic in the medical literature. This study describes clinical and radiographic findings with OPLL in non-Asians at a tertiary care center treating a diverse multiethnic population. METHODS: Over a 6-year period, 43 patients not of East Asian descent presented to an urban tertiary medical center with OPLL. Patient data, including ethnicity, spinal cord function, Nurick grade, radiographic findings, OPLL subtype, and degree of cervical stenosis, were recorded. RESULTS: The average patient age was 59 years (range 32-92 years) with 18 women and 25 men. There were 22 Caucasian patients, 17 Hispanic patients, and 4 Black patients. With respect to the radiographic findings, OPLL morphology was continuous in 19, segmental in 17, mixed in 6, and other in 1. Average canal diameter was 7.6 mm (range 4.2-9.0 mm) at the most stenotic points. The mean Nurick grade was 2.95 at presentation, but 7 of the patients had OPLL identified incidentally and with early or minimal symptoms and signs of myelopathy. CONCLUSIONS: Ossification of the posterior longitudinal ligament in non-Asians demonstrates similar demographic and radiographic characteristics as in East Asians. The representation of different ethnic groups mirrors the demographics of the medical center population in general, showing no specific predilection for particular ethnic groups. Surgical decompression in appropriately selected patients results in similar rates of improvement when compared with the Japanese literature.