Reoperation for brain metastases.

We report the results of reoperation for brain metastases in 21 patients with recurrent tumors following initial successful resection. The tumor recurrences were local (original site) in 14 patients, and occurred at other sites in the brain in the remaining seven. Time to CNS recurrence ranged from 3 to 30 months. At time of repeat craniotomy, disease was limited to the CNS in 12 (57%) of the patients. Median survival following second craniotomy was 9 months, and the actuarial 2-year survival was 25%. Neurological improvement was seen in two thirds of the patients; the median duration of neurological improvement was 6 months. There was no mortality, and only one patient developed increased deficit following surgery. We conclude that repeat resection of brain metastases is an important therapeutic option in selected patients, and should be considered in symptomatic patients with accessible mass lesions before the use of other experimental treatment.

Surgical treatment of spinal cord compression from epidural metastasis.

PURPOSE: A retrospective study of the results of neoplastic cord compression was undertaken to determine the effectiveness of surgical treatment and to assess quality of life in patients undergoing extensive procedures with potential morbidity. PATIENTS AND METHODS: Over a 5-year period (1989 to 1993), a total of 110 patients underwent surgery. Fifty-five patients (50%) had undergone prior treatment, including 47 (43%) who had failed to respond to prior irradiation (RT). Before surgery, 48 patients (44%) were nonambulatory, with severe paresis being present in 20. Surgery included staged anterior-posterior resections in 53 patients (48%), anterior resections in 33 (30%), and posterior resection in six (5%), all of whom required spinal instrumentation for reconstruction; only 18 patients underwent resection without instrumentation. RESULTS: Postoperatively, 90 patients (82%) were improved, both in terms of pain relief and ambulatory status. Fifty-three patients (48%) experienced postoperative complications, related statistically to the following three factors: age over 65 years, prior treatment, and presence of paraparesis. The overall median survival duration was 16 months, with 46% alive at 2 years. Apart from primary tumor, the presence of preoperative paraparesis had the most significant impact on survival. CONCLUSION: Our data suggest that the effective surgical treatment of neoplastic compression requires anterior-posterior resection in most patients to achieve the goal of total tumor resection, with the majority requiring instrumentation. Long-term survival is feasible in a subset of patients with this aggressive surgical approach.

Dural arteriovenous malformation of the major venous sinuses: an acquired lesion.

Arteriovenous malformations of the dura are thought to be congenital. However, arteriographic investigations of four patients who, after a head injury, developed dural arteriovenous fistulae with features of congenital malformations suggest that these abnormal communications may also be acquired. Thrombosis or thrombophlebitis in the dural sinus or vein may be the primary event in their formation. The pathogenesis is probably "growth" of the dural arteries normally present in the walls of the sinuses during the organization of an intraluminal thrombus. This may result in a direct communication between artery and vein or sinus, establishing an abnormal shunt. Ultimate fibrosis of the sinus wall and intraluminal thrombus may be the factors responsible for the spontaneous disappearance of such malformations.

Ependymal cyst of the quadrigeminal plate: case report.

A patient with an ependymal cyst of the quadrigeminal plate is reported. The patient presented with headache, diplopia, and evidence of increased intracranial pressure. A nonenhancing cyst with hydrocephalus was demonstrated by computed tomographic scan. The cyst was subtotally resected using a transtentorial approach. The causes, clinical presentation, and treatment of quadrigeminal plate ependymal cysts are discussed, together with a review of the literature.

Malignant meningioma within the third ventricle: a case report.

A case of a malignant meningioma within the 3rd ventricle is presented. Although malignant transformation of meningiomas has been described, occurrence within the ventricular system is extremely rare.

Ependymomas of the third ventricle.

Third ventricular ependymomas are rare tumors that have not been specifically examined. Four cases of these tumors are reported. The presenting symptoms included headache, ataxia, vertigo, and Parinaud's syndrome. All the patients underwent computed tomographic scanning and cerebral angiography, followed by craniotomy and microsurgical resection of the tumor. In addition, all patients had or developed symptomatic obstructive hydrocephalus requiring shunting procedures. Three of the patients are alive with a follow-up of 4 to 12 years. It is remarkable that these tumors are so rare, given that the ependymal surface area of the third ventricle is greater than that of the fourth. The management of these tumors should include aggressive surgical resection, radiation therapy, and cerebrospinal fluid diversion.

Congenital fourth ventricular midline outlet obstruction. Report of two cases.

Obstruction of the foramen of Magendie unrelated to illness or trauma is rare in adults. Two cases of congenital membranous occlusion of the foramen of Magendie in adults are presented. Analysis of the reported cases of fourth ventricular outlet obstruction disclosed only three similar cases.

Treatment of spinal metastases from kidney cancer by presurgical embolization and resection.

Surgical treatment of bone metastases from kidney cancer is often complicated by profuse blood loss. The authors report the results of a retrospective review of 30 consecutive patients who underwent surgery for spinal metastases from kidney cancer. Seventeen patients (57%) were operated on after failing radiation therapy. Prior to operation, selective spinal angiography and embolization were performed in 17 patients with no permanent neurological deficits resulting. Gross total resection of the tumor and stabilization of the spine were then accomplished with acceptable blood loss. Twenty-seven (90%) of the 30 patients improved neurologically following surgery. There was a median survival time of 16 months, a 2-year survival rate of 33%, and a 5-year survival rate of 15%. Major surgical complications in this series were related to excessive blood loss in patients without embolization. These data suggest that patients with spinal metastases from kidney cancer should undergo spinal angiography and embolization prior to resection of the tumor. To improve upon current results, such treatment should be carried out prior to external radiation therapy.

Radiation-induced meningiomas: experience at the Mount Sinai Hospital and review of the literature.

From the records of The Mount Sinai Hospital, seven cases which met established criteria for radiation-induced meningiomas were identified. This represents the largest series of radiogenic meningiomas documented in North America and includes both intracranial and intraspinal tumors. The records and pathological specimens were reviewed and these data analyzed with other cases retrieved from the world literature. This study reveals that radiation-induced meningiomas can be categorized into three groups based on the amount of radiation administered: 1) low dose; 2) moderate dose and miscellaneous; and 3) high dose. The overwhelming majority of cases had received low-dose irradiation (800 rad) to the scalp for tinea capitis and the second largest group resulted from high-dose irradiation for primary brain tumors (greater than 2000 rad). The unique features distinguishing radiation-induced meningiomas from other meningiomas are reviewed. Although histologically atypical tumors were common in this series, overt malignancy was not encountered. The preoperative management of these lesions should include angiography to evaluate for large-vessel occlusive vasculopathy, a known association of meningiomas induced by high-dose irradiation. Given the propensity these tumors possess for recurrence, a wide bony and dural margin is recommended at surgical resection.

Indications and results of combined anterior-posterior approaches for spine tumor surgery.

Spinal instrumentation currently allows gross-total resection and reconstruction in cases of malignancies at all levels of the spine. The authors analyzed the results in 110 patients who underwent surgery for primary and metastatic spinal tumors over a 5-year period (1989-1993) at a single institution. Major primary sites of tumor included breast (14 cases), chordoma (14 cases), lung (12 cases), kidney (11 cases), sarcoma (13 cases), plasmacytoma (10 cases), and others (36 cases). Prior to surgery, 55 patients (50%) had received prior treatment. Forty-eight patients (44%) were nonambulatory, and severe paraparesis was present in 20 patients. Fifty-three patients (48%) underwent combined anterior-posterior resection and instrumentation. 33 (30%) underwent anterior resection with instrumentation, 18 (16%) underwent anterior or posterior resection alone, and the remaining six patients (5%) underwent posterior resection and instrumentation. Major indications for anterior-posterior resection included three-column involvement, high-grade instability, involvement of contiguous vertebral bodies, and solitary metastases. Postoperatively, 90 patients improved neurologically. The overall median survival was 16 months, with 46% of patients surviving 2 years. Fifty-three patients (48%) suffered postoperative complications. Despite the high incidence of complications, the majority of patients reported improvement in their quality of life at follow-up review. Our findings suggest that half of all patients with spinal malignancies require combined anterior-posterior surgery for adequate tumor removal and stabilization.

Posttraumatic pseudomeningomyelocele (enlarging fracture?) in a vertebral body. Case report.

An unusual case is reported in which a posttraumatic peudomeningomyelocele developed over many years inside the body of a fractured lumbar vertebra, eroding the pedicle and causing progressive neurological deficit. The wall of the sac was mostly formed by the scalloped bar bone, and partly by a membrane resembling the dura. The terminal part of the conus medullaris and some nerve roots of the cauda equina formed the contents and parts of the wall of the outpouching of the subarachnoid space into the vertebral body. A comparison is drawn between this lesion and formation of an "enlarging fracture" of the skull. The surgical technique used for obliteration of this pseudomeningomyelocele is described.

Esthesioneuroblastoma: surgical treatment without radiation.

This study compares the treatment of two groups of patients diagnosed with esthesioneuroblastoma limited to the nasal cavity without evidence of cribriform plate erosion. Five patients were treated with radiation and extracranial excision, and eight patients were treated by craniofacial resection only. The incidences of local recurrence were 60% and 12%, respectively. The paper also presents a new staging classification for these tumors.

Multiple intracranial mucoceles associated with phaeohyphomycosis of the paranasal sinuses.

The purpose of this article is to alert clinicians to a new pathogenic fungus of the paranasal sinuses called Exserohilum rostratum. Exserohilum species are one of the etiologic agents of phaeohyphomycosis, a constellation of entities caused by dematiaceous fungi. This class of fungal sinus infection has emerged only in the past decade; it occurs primarily in immunocompetent individuals and produces a tenacious, progressive pansinusitis. To our knowledge, this study describes the first case of multiple intracranial mucoceles secondary to E rostratum. The diagnostic workup includes computed tomography and magnetic resonance imaging followed by direct microscopic examination of tissue biopsy specimens. A craniotomy followed by a bilateral external ethmoidectomy was necessary for complete extirpation of the infected mucoceles. Aggressive surgical management of this mycotic infection is described.

Anterior-approach cervical diskectomy under the operating microscope.

Since Cloward's description of it in 1958, the anterior approach to the cervical spine for excision of degenerated cervical disk causing radiculopathy and myelopathy and for excision of secondary bony spurs has become relatively standard for most spine surgeons. The procedure is easy to perform in trained hands, is a low-risk surgical operation, and has gratifying results provided patients are well selected. Many surgeons use an operating microscope while doing the procedure. The obvious advantages of the microscope are better magnification, enhanced stereoscopic visibility in a small field, better visualization of the anatomic structures, and added safety. The focused lighting is valuable in achieving satisfactory decompression of the nerve root and the spinal cord. The microscope is also a valuable teaching tool at the time of surgery. Our technique for the procedure employing the microscope is described and stereoscopic photographs taken during surgery are presented.

Operative microphotography: a Malis legacy.

An account of the methods and equipment used by Dr. Malis for the development of operative microphotography is presented. Attention to the critical evaluation of technology became part of the legacy provided to those he trained. Current microphotographic innovations are described.

The prone-oblique surgical position.

The prone-oblique surgical position as introduced and used by Dr. Malis at Mount Sinai Hospital is presented. The advantages of this position over the prone and knee-chest positions are noted. Recommendations for the safe use of the prone-oblique position are made.

Thoracic herniated discs: review of the literature and 12 cases.

In comparison with herniations of lumbar or cervical intervertebral discs, symptomatic thoracic disc herniation is rare. Between 1986 and 1991, 12 cases of thoracic herniated discs were treated at The Mount Sinai Hospital, New York City. Most patients had back pain or myelopathy. Nine of the disc herniations occurred at the lowest six thoracic interspaces. Eight patients underwent costotransversectomy and discectomy. Seven of these patients improved without complication. One patient was subsequently found to have a spinal arteriovenous malformation below an incidental herniation that had been identified by magnetic resonance imaging. Because of the nonspecificity of the signs and symptoms, as well as the prevalence of incidental herniations on imaging, a careful clinical and radiologic correlation is mandatory when diagnosing this uncommon pathology.

Synovial cysts of the lumbar facet joint.

A study of 42 synovial cysts arising from the lumbar facet joint is presented. Intraspinal cysts caused radicular pain and cauda equina syndrome in 11 patients. In a series of 1,400 lumbar laminotomies for a herniated disk, 31 incidental nodules arising from the exposed facet as paraarticular masses were found and excised. The limited number of reports in the orthopedic and neurosurgical literature has not dealt adequately with the etiology or incidence of these benign lesions. The neuroradiologic appearance and histopathologic findings are briefly discussed.

Ossified spinal meningioma en plaque.

Ossified spinal meningiomas alone are uncommon lesions and spinal meningiomas en plaque are even more. A rare case is presented of ossified meningioma en plaque in the midthoracic spine, which was totally removed. Characteristics of this tumor with reference to relatively pathognomonic neuroimagings are discussed. Microsurgical outcome of this type of tumor is expected to be good.

Subacute cervical spine instability.

A case of delayed onset of C5-6 subluxation after a motor vehicle accident, with normal initial cervical spine roentgenograms and neurological findings consistent with concomitant cerebral trauma, is presented. Damage to the cervical spine was due to fractures of the C-6 body and superior articular facet undetected by routine radiologic studies.