Retrospective observational comparative study of Hemilaminectomy versus Laminectomy for intraspinal tumour resection; Shorter Stays, Lower Analgesic Usage and Less Kyphotic Deformity.

INTRODUCTION: Intraspinal tumours are rare and principally managed surgically. Laminectomy, employed for access to the spinal canal, destroys the posterior tension band leading to a risk of kyphosis. Hemilaminectomy as an alternative may be less destructive, potentially reducing the risk of deformity and causing less post-operative pain. METHOD: We investigated this hypothesis by retrospectively reviewing a case series of 56 surgeries for a disparate and unselected group of intraspinal tumours utilizing a laminectomy or hemilaminectomy approach. RESULTS: No difference was found in length of operation, completeness of resection, complication rate and Frankel-score improvements. Hemilaminectomy (n = 22) is associated with reduced hospital stay (post-op days) 4.5 (2-6) versus 6 (3-8), (p = 0.026, Mann-Whitney), and a reduction in post-operative morphine use (mg) 10 (3.5-28) versus 30 (10-90), (p = 0.005, Mann-Whitney). Post-operative kyphosis was measured with the Harrison posterior tangent method on T2-weighted sagittal MR images. The average change in kyphosis angle was greater in the laminectomy group compared with the hemilaminectomy group, 3.6 (0.8-6.2) versus 0.4 (-0.2-1.2), statistically significant (p = 0.004, Mann-Whitney). CONCLUSION: Hemilaminectomy is as effective an access procedure for the resection of unselected intraspinal tumours as laminectomy, but is associated with shorter post-operative stays, lower analgesic requirements and less post-operative kyphosis.

Evaluating drug distribution in children and young adults with diffuse midline glioma of the pons (DIPG) treated with convection-enhanced drug delivery.

Aims: To determine an imaging protocol that can be used to assess the distribution of infusate in children with DIPG treated with CED. Methods: 13 children diagnosed with DIPG received between 3.8 and 5.7 ml of infusate, through two pairs of catheters to encompass tumor volume on day 1 of cycle one of treatment. Volumetric T2-weighted (T2W) and diffusion-weighted MRI imaging (DWI) were performed before and after day 1 of CED. Apparent diffusion coefficient (ADC) maps were calculated. The tumor volume pre and post CED was automatically segmented on T2W and ADC on the basis of signal intensity. The ADC maps pre and post infusion were aligned and subtracted to visualize the infusate distribution. Results: There was a significant increase (p < 0.001) in mean ADC and T2W signal intensity (SI) ratio and a significant (p < 0.001) increase in mean tumor volume defined by ADC and T2W SI post infusion (mean ADC volume pre: 19.8 ml, post: 24.4 ml; mean T2W volume pre: 19.4 ml, post: 23.4 ml). A significant correlation (p < 0.001) between infusate volume and difference in ADC/T2W SI defined tumor volume was observed (ADC, r = 0.76; T2W, r = 0.70). Finally, pixel-by-pixel subtraction of the ADC maps pre and post infusion demonstrated a volume of high signal intensity, presumed infusate distribution. Conclusions: ADC and T2W MRI are proposed as a combined parameter method for evaluation of CED infusate distribution in brainstem tumors in future clinical trials.

Implementation of the European Working Time Directive in neurosurgery reduces continuity of care and training opportunities.

BACKGROUND: Implementation of the European Working Time Directive (EWTD) raises questions about reduced surgical training opportunities and lost continuity of patient care. We studied the effect that the EWTD has had in these areas for residents in the neurosurgical unit at St. George's Hospital, London, UK. METHODS: Case notes for 50 emergency and 50 elective operative admissions were randomly selected before and after implementation of an EWTD compliant resident roster (total, 200 episodes). Each was objectively scored for continuity of care from the operating surgeon. Rosters from 3 months before and after implementation were compared to assess training opportunities available. RESULTS: A significant reduction was observed in continuity of emergency care following introduction of the EWTD compliant roster (P < 0.009). The same proportion of residents consented and operated on elective cases; however, a significant reduction in continuity of postoperative care was observed (P < 0.0001). Resident training opportunities were substantially affected with reduced involvement in outpatient (72% vs. 60%) and operating sessions (79% vs. 63%) with their nominated consultant. CONCLUSIONS: The EWTD has had a marked adverse impact on continuity of care for neurosurgical patients at St. George's Hospital. Residents' training opportunities were reduced.

Minimally invasive spinal surgery for trauma: a narrative review.

Over the past decade there has been a revolution in availability for minimally invasive techniques for the fixation of spinal fractures. In this narrative review we aimed to take a comprehensive look at these developments and their results from the Atlas to the Sacrum establishing the current evidence base for percutaneous fixation at each level of the spine.

Utility of routine biopsy at vertebroplasty in the management of vertebral compression fractures: a tertiary center experience.

OBJECT: The authors assess the utility of routine biopsy at vertebroplasty for vertebral compression fracture (VCF) as a tool in the early detection of malignancy in presumed benign VCF. METHODS: A prospective observational study was conducted on a cohort of consecutive patients undergoing vertebroplasty over a 5-year period between April 2006 and March 2011 at the Royal London Hospital. Polymethylmethacrylate cement injection was used in every procedure. Intraoperative vertebral body biopsy was performed routinely at every level of VCF. Pain visual analog scale (VAS) scores, Oswestry Disability Index (ODI) scores, analgesic usage, and complications were recorded preoperatively and at 1 day, 1 week, 1 month, 6 months, and 1 year postoperatively. RESULTS: A total of 202 levels were augmented in 147 patients. The most common levels augmented were T-12 (17%), L-1 (18%), and L-4 (10%). Analysis of 184 routine vertebral biopsies in 135 patients revealed that in 86 patients with presumed osteoporosis and no prior cancer diagnosis, 4 (4.7%) had a malignant VCF. In 20 known cancer patients presumed to be in remission, 2 (10%) had a malignant VCF. Routine vertebral biopsy returned an overall cancer diagnosis rate of 5.5% (6 of 109) when combining the 2 groups (patients with no prior history of cancer or cancer thought to be in remission). In these 6 patients, history, examination, laboratory tests, and preprocedure imaging all failed to suggest malignancy diagnosed at routine biopsy. Significant reductions in pain VAS and ODI scores were evident at Day 1 and were sustained at up to 1 year postoperatively (p < 0.001). They were not dependent on the level of fracture (T3-10, T11-L2, or L3-S1) (p > 0.05), number of levels treated (single level, 2 levels, or > 2 levels) (p > 0.05), or etiology of VCF (p > 0.05). The complication rate was 6% (9 of 147). There were 5 deaths, none of which were directly related to surgery. CONCLUSIONS: Routine vertebral biopsy performed at vertebroplasty may demonstrate cancer-related VCFs in unsuspected patients with no previous cancer diagnosis or active malignancy in patients previously thought to be in remission. This early diagnosis of cancer or relapsed disease will play an important role in expediting patients' subsequent cancer management. In cases of multiple-level VCF, the authors advocate biopsy at each level to maximize the diagnostic yield from the specimens and to avoid missing a malignancy at a single level.

The value of the Duke Activity Status Index (DASI) in predicting ischaemia in myocardial perfusion scintigraphy - a prospective study.

BACKGROUND: Functional capacity assessment may be a useful tool to stratify patients according to risk of coronary artery disease (CAD). The Duke Activity Status Index (DASI) is a functional assessment based on activities of daily living and cardiovascular fitness, assessed using a self-administered questionnaire. MATERIAL AND METHODS: We assessed the relationship between established clinical risk factors for CAD and the DASI with results of myocardial perfusion scintigraphy (MPS). The MPS results used in the analysis were the presence of reversible ischaemia and the resting left ventricular ejection fraction (LVEF). A DASI self-administered questionnaire was completed by 117 consecutive participants, and a patient history was taken to ascertain established risk factors. All participants underwent a stress test, and myocardial perfusion scintigraphy was performed. Statistical analysis consisted of logistic and linear regression using a statistical software package. RESULTS: The DASI was the only factor that correlated significantly with reversible ischaemia on MPS. None of the previously established risk factors had a significant association with reversible ischaemia within the model. Our study found a potential relationship between the DASI score and the left ventricular ejection fraction (LVEF) although this was not statistically significant. CONCLUSIONS: Our study findings suggest that the DASI may represent a powerful tool for risk stratification prior to investigation of CAD. A further study with a larger sample size will be required to investigate the predictive value of the DASI and the association with LVEF.

The use of fibrin glue to stop venous bleeding in the epidural space, vertebral venous plexus, and anterior cavernous sinus: technical note.

OBJECTIVE: Various techniques have been used to stop venous bleeding from the epidural space, vertebral venous plexus, and cavernous sinus. Here, we describe our experience with the use of fibrin glue to stop venous bleeding in these areas. METHODS: During the last 8 years, the senior author (LNS) has used injection of Tisseel fibrin glue (Baxter Healthcare Corp., Deerfield, IL) into the epidural space (n = 200 patients), anterior cavernous sinus (n = 46 patients), vertebral venous plexus (n = 20 patients), and superior petrosal sinus (n = 20 patients) to assist in hemostasis. The technical nuances are illustrated in three videos. RESULTS: Injection of fibrin glue in the epidural space, anterior cavernous sinus, and vertebral venous plexus yielded good results in assisting with hemostasis. Two patients experienced complications caused by occlusion of veins draining the brainstem after fibrin glue was injected into the superior petrosal sinus. CONCLUSION: Fibrin glue injection is an excellent option for hemostasis in the epidural space, anterior cavernous sinus, and vertebral venous plexus. However, based on our experience, fibrin glue injection into the superior petrosal sinus is not recommended.