Outcomes of orbital exenteration for craniofacial lesions.

BACKGROUND: Orbital exenteration (OE) is an ablative procedure used in the management of malignancies of the orbit of either primary or secondary origin. Publications evaluating this procedure have suffered from small patient numbers, heterogeneity of pathologies, and poor patient follow-up. The purpose of this study was to assess patient outcomes in a large cohort of patients undergoing OE at a tertiary cancer center. METHODS: A retrospective review was conducted of 180 consecutive patients who underwent OE at the authors' institution. Overall survival (OS) was the primary end point measured in the study. Time to locoregional recurrence (progression-free survival [PFS]) and disease-free survival were secondary end points. RESULTS: Between the years 1993 and 2011, 180 consecutive patients received OE for craniofacial malignancy at the authors' institution. The median follow-up for the cohort was 9.7 years (116 months). The median OS was 73 months, and the median PFS was 96 months. The presence of perineural invasion was associated with shorter OS (P = .01) and PFS (P < .01). Magnetic resonance imaging was predictive of perineural invasion (P < .01). Positive margins were associated with shorter PFS than negative margins (P < .01) but with no change in OS (P = .15). The overall complication rate was 15%. The major complication rate (Clavien-Dindo 3b or greater) was 2.8% (n = 5), and there was 1 death observed (0.6%). CONCLUSIONS: Used judiciously in the setting of a multidisciplinary management plan, OE for tumor control is a safe therapy. LAY SUMMARY: Between the years 1993 and 2011, 180 consecutive patients received orbital exenteration for craniofacial malignancy at the MD Anderson Cancer Center. The median follow-up for the cohort was 9.7 years. The presence of perineural invasion was associated with shorter overall survival (P = .01) and progression-free survival (P < .01). Magnetic resonance imaging was predictive of perineural invasion (P < .01). Positive margins were associated with shorter progression-free survival than negative margins (P < .01). The overall complication rate was 15%. The major complication rate (Clavien-Dindo 3b or greater) was 2.8% (n = 5).

Dynamic stabilization: a nidus for infection?

INTRODUCTION: Dynamic stabilization offers an adjunct to fusion with motion preservation. In comparison, standard instrumented fusion (if) consists of titanium screws and rods/plates, which do not allow for motion at the level of the fusion. The reported infection rate following a standard if ranges from 0.2% to 7%. METHODS: a retrospective chart review of 142 patients who underwent posterior lumbar stabilization procedures was conducted. Ten patients received dynamic stabilization and 132 patients had a standard if. Rates of infection, requiring hardware removal, were compared between the aforementioned groups. RESULTS: Of the 132 patients undergoing posterior if, three developed a deep wound infection requiring removal of hardware (2.3%). Of the 10 patients undergoing dynamic stabilization, three developed a deep wound infection (30%) with 2 requiring removal of hardware (20%), secondary to persistent deep wound infection or osteomyelitis at the pedicle screw sites. There was a significantly increased risk of deep wound infection (p < 0.0001) with the use of dynamic stabilization compared to standard if. CONCLUSIONS: Our series demonstrates that the infection rate in patients undergoing dynamic stabilization is higher than the infection rate for instrumented fusion without a significant difference in comorbidity scores. We postulate that the polycarbonate urethane spacer acts as a medium for bacteria, whereas the titanium screws and rods are smooth, solid, and inert, resulting in a lower risk of infection.

Complete regression of papillary tumor of the pineal region after radiation therapy: case report and review of the literature.

Papillary tumor of the pineal region (PTPR) is a rare neuroepithelial tumor that arises in the pineal region. The optimal treatment for PTPR remains controversial, as no definitive treatment strategy exists for this lesion. It is not clear whether aggressive surgical removal is superior to biopsy followed by radiotherapy. The majority of cases in the literature have undergone attempted gross total resection with a supracerebellar-infratentorial or a transcallosal-transventricular approach. In this report, we describe a case of PTPR in a 23 year-old male that presented as a third ventricular mass causing obstructive hydrocephalus. An endoscopic third ventriculostomy was performed followed by an endoscopic biopsy. Postoperative radiotherapy resulted in complete regression of the tumor with no evidence of tumor recurrence at 25 months. This case highlights a minimally invasive strategy for a rare neoplasm that resulted in a favorable response to radiation therapy, thereby avoiding the risks of aggressive surgical removal. We also review the radiographic and histopathologic features of PTPR and discuss various options of treatment reported in the literature.

Ossification of the ligamentum flavum: a unique report of a Hispanic woman.

Ossification of the ligamentum flavum (OLF) is a disease of ectopic bone formation within the ligamentum flavum, which may result in mass effect and neurological compromise. The low thoracic region is the most common region of occurrence, and this is followed by the cervical, then lumbar, spine. The prevalence of OLF is significantly higher in the Japanese population compared with other nationalities and has a male preponderance. Ossification of the ligamentum flavum has been reported in association with the more common ligamentous pathological entities--ossification of the posterior longitudinal ligament and diffuse idiopathic skeletal hyperostosis. These latter two conditions have been linked to several metabolic processes, and a possible genetic basis has been hypothesized. Here, the authors present a unique case of OLF of the cervical spine in a patient with idiopathic hypercalcemia.

Surgical nuances for removal of retrochiasmatic craniopharyngioma via the endoscopic endonasal extended transsphenoidal transplanum transtuberculum approach.

Retrochiasmatic craniopharyngiomas are challenging tumors to remove given their deep location and proximity to critical neurovascular structures. Complete surgical removal offers the best chance of cure and prevention of recurrence. The endoscopic endonasal extended transsphenoidal approach offers direct midline access to the retrochiasmatic space through a transplanum transtuberculum corridor. Excellent visualization of the undersurface of the optic chiasm and hypothalamus can be obtained to facilitate bimanual extracapsular dissection to permit complete removal of these formidable tumors. In this report the authors review the endoscopic endonasal extended transsphenoidal approach, with specific emphasis on technical operative nuances in removing retrochiasmatic craniopharyngiomas. An illustrative intraoperative video demonstrating the technique is also presented.

Surgical nuances for removal of tuberculum sellae meningiomas with optic canal involvement using the endoscopic endonasal extended transsphenoidal transplanum transtuberculum approach.

Tuberculum sellae meningiomas frequently extend into the optic canals. Radical tumor resection including the involved dural attachment, underlying hyperostotic bone, and intracanalicular tumor in the optic canal offers the best chance of a Simpson Grade I resection to minimize recurrence. Decompression of the optic canal with removal of the intracanalicular tumor also improves visual outcome since this portion of the tumor is usually the cause of asymmetrical visual loss. The purely endoscopic endonasal extended transsphenoidal approach offers a direct midline trajectory and immediate access to tuberculum sellae meningiomas without brain retraction and manipulation of neurovascular structures. Although the endoscopic approach has been previously criticized for its inability to remove tumor within the optic canals, complete Simpson Grade I tumor removal including intracanalicular tumor, dural attachment, and involved hyperostotic bone can be achieved in properly selected patients. Excellent visualization of the suprasellar region and the inferomedial aspects of both optic canals allows for extracapsular, extraarachnoid dissection of the tumor from the critical structures using bimanual microsurgical dissection. In this report, the authors describe the operative nuances for removal of tuberculum sellae meningiomas with optic canal involvement using a purely endoscopic endonasal extended transsphenoidal (transplanum transtuberculum) approach. They specifically highlight the technique for endonasal bilateral optic nerve decompression and removal of intracanalicular tumor to improve postoperative visual function, as demonstrated in 2 illustrative cases. Special attention is also given to cranial base reconstruction to prevent CSF leakage using the vascularized pedicled nasoseptal flap.

Surgical nuances for removal of olfactory groove meningiomas using the endoscopic endonasal transcribriform approach.

Olfactory groove meningiomas represent 10% of intracranial meningiomas and arise in the midline of the anterior cranial fossa along the dura of the cribriform plate and planum sphenoidale. Hyperostosis of the adjacent underlying bone is common, and further extension into ethmoid sinuses and nasal cavity can occur in 15%-25% of cases. Radical tumor resection including the involved dural attachment and underlying hyperostotic bone offers the best chance of a Simpson Grade I resection to minimize recurrence. Incomplete removal of involved hyperostotic bone can result in tumor recurrence at the cribriform plate with extension into the paranasal sinuses. Resection has traditionally been performed using a bifrontal or pterional approach, both of which require some degree of brain retraction or manipulation to expose the tumor. The endoscopic endonasal transcribriform approach offers the most direct and immediate exposure to the tumor without brain retraction and manipulation of neurovascular structures. An endonasal "keyhole craniectomy" is performed in the ventral skull base directly over the basal dural attachment, extending from the posterior wall of the frontal sinus to the planum sphenoidale and tuberculum sellae in the anteroposterior plane, and from one medial orbit to the other in the coronal plane. Excellent panoramic visualization of the keyhole skull base defect can be obtained with a 30° endoscope after performing a modified Lothrop procedure. Because the dural attachment is adjacent to the paranasal sinuses, early devascularization and total Simpson Grade I removal of the tumor including the dural attachment and underlying hyperostotic bone can be achieved in properly selected patients. This approach is also very suitable for meningiomas that have recurred or extended into the paranasal sinuses. Extracapsular, extraarachnoid dissection of the tumor from the frontal lobes and neurovascular structures can be performed using conventional bimanual microsurgical techniques. In this report, we review the surgical technique and describe our operative nuances for removal of olfactory groove meningiomas, including recurrent tumors with extension into the nasal cavity, using a purely endoscopic endonasal transcribriform approach. In addition, we discuss the advantages, limitations, patient selection, and complications of this approach. We specifically highlight our technique for multilayer reconstruction of large anterior skull base dural defects using fascia lata and acellular dermal allograft supplemented by bilateral vascularized pedicled nasoseptal flaps. Three new cases of endoscopically resected olfactory groove meningiomas are also presented.

Nontraumatic spontaneous acute subdural hematoma in identical teenage twins 1 year apart.

OBJECTIVES: Acute subdural hematoma (ASDH) is a life-threatening injury with a high mortality rate. Most ASDH cases are a result of trauma; nontraumatic causes are relatively rare with an incidence rate of 3% to 5%. We report an unusual series of 2 patients, identical twins, who had nontraumatic subdural hematomas 1 year apart, one at age 15 and the other at age 16. METHODS (CASE PRESENTATIONS): Identical twin brothers presented 1 year and 10 days apart to an academic medical center after incurring confusion, decreased mental functioning, and a subsequent comatose state. The injuries occurred while the patients were playing football, but there was no evidence of traumatic blow to the head in either brother. RESULTS: Both patients had computed tomographic scans and both underwent emergency surgery for hematoma evacuation. Both patients recovered full neurological function and remained healthy 12 years after surgery. CONCLUSIONS: Acute spontaneous subdural hematoma is an emergent medical condition that may result in rapid neurological decline and must be addressed in a timely fashion. After evacuation of the hematoma, intracranial pressure decreases and cerebral perfusion pressure increases, which may allow normal perfusion of the brain. Consequently, prompt recognition and evacuation of an ASDH can drastically improve prognosis. Rarely, subdural hematoma can occur without head injury and should be in the differential diagnosis of athletes who rapidly become comatose.

Surgical nuances for removal of retrochiasmatic craniopharyngiomas via the transbasal subfrontal translamina terminalis approach.

Giant craniopharyngiomas in the retrochiasmatic space are challenging tumors, given the location and surrounding vital structures. Surgical removal remains the first line of therapy and offers the best chance of cure. For tumors with extension into the retrochiasmatic space, the authors use the translamina terminalis corridor via the transbasal subfrontal approach. Although the lamina terminalis can be accessed via anterolateral approaches (pterional or orbitozygomatic), the surgical view of the optic chiasm is oblique and prevents adequate visualization of the ipsilateral wall of the third ventricle. The transbasal subfrontal approach, on the other hand, offers the major advantage of direct midline orientation and access to the third ventricle through the lamina terminalis. This provides the significant advantage of visualization of both walls of the third ventricle and hypothalamus as well as inferior midline access to the interpeduncular cistern to permit safe neurovascular dissection and total tumor removal. In this report, the authors describe the transbasal subfrontal translamina terminalis approach, with specific emphasis on technical surgical nuances in removing retrochiasmatic craniopharyngiomas. An illustrative video demonstrating the technique is also presented.

Endovascular management of acute ischemic stroke.

The management of stroke has progressed significantly over the past 2 decades due to successful treatment protocols including intravenous and intraarterial options. The intravenous administration of tissue plasminogen activator within an established treatment window has been proven in large, well-designed studies. The evolution of endovascular strategies for acute stroke has been prompted by the limits of the intravenous treatment, as well as by the desire to demonstrate improved recanalization rates and improved long-term outcomes. The interventional treatment options available today are the intraarterial administration of tissue plasminogen activator and newer antiplatelet agents, mechanical thrombectomy with the MERCI device and the Penumbra system, and intracranial angioplasty and stent placement. In this review the authors outline the major studies that have defined the current field of acute stroke management and discuss the basic treatment paradigms that are commonly used today.

Giant serpentine aneurysms.

Segal and McLaurin first described giant serpentine aneurysms, based on their distinct angiographic features, in 1977. These lesions are >or= 25 mm, partially thrombosed aneurysms with a patent, serpiginous vascular channel that courses through the aneurysm. There is a separate inflow and outflow of the aneurysm, of which the outflow channel supplies brain parenchyma in the territory of the parent vessel. Given the large size, unique neck, and dependent distal vessels, these aneurysms pose a technical challenge in treatment. Initial management has included surgical obliteration, but as endovascular techniques have evolved, treatment options too have expanded. In this review the authors attempt to summarize the existing body of literature on this rare entity and describe some of their institutional management strategies.

The historical evolution of transsphenoidal surgery: facilitation by technological advances.

Over the past century, pituitary surgery has undergone multiple evolutions in surgical technique and technological advancements that have resulted in what practitioners now recognize as modern transsphenoidal surgery (TSS). Although the procedure is now well established in current neurosurgical literature, the historical maze that led to its development continues to be of interest because it allows a better appreciation of the unique contributions by the pioneers of the technique, and of the innovative spirit that continues to fuel neurosurgery. The early events in the history of TSS have already been well documented. This paper therefore summarizes the major early transitions along the timeline, and then further concentrates on some of the more recent advancements in TSS, such as the surgical microscope, fluoroscopy, endoscopy, intraoperative imaging, and frameless guidance. The account of each of these innovations is unique because they were each developed as a response to certain historical needs by the surgeon. An understanding of these more recent contributions, coupled with the early history, provides a more complete perspective on modern TSS.

Reconstruction of pterional defects after frontotemporal and orbitozygomatic craniotomy using Medpor Titan implant: cosmetic results in 98 patients.

OBJECTIVE: Reconstruction of pterional and temporal defects after frontotemporal (FT) and orbitozygomatic (OZ) craniotomy is important for avoidance of temporal hollowing, maintaining functional restoration, and achieving optimal cosmesis. The objective of this study is to describe our experience and cosmetic results with pterional reconstruction after FT and OZ craniotomy with the Medpor Titan implant. METHODS: Ninety-eight consecutive patients underwent reconstruction of pterional and temporal defects after FT and OZ craniotomy using the Medpor Titan implant. The implant was shaped to recreate the pterion to provide coverage for the cranial defect and to bolster the temporalis muscle to prevent temporal hollowing. The implant was then secured to the bone flap with titanium screws. Cosmetic evaluation was performed from both surgeon's and patient's perspective. RESULTS: Of 90 patients who underwent cosmetic assessment at the 3 month follow-up, temporalis asymmetry was noticed subjectively by three patients and noted in 7 patients by the surgeon. Orbital asymmetry was not noticed in any cases by either surgeon or patient. Overall patient satisfaction was found in 89 of 90 patients (98.9%). There were no cases of temporal hollowing. One patient had a delayed wound infection, and one had an inflammatory reaction that required removal of the implant. CONCLUSIONS: Our technique using the Medpor Titan implant is a fast and effective method for pterional reconstruction after FT and OZ craniotomy with excellent cosmetic results and patient satisfaction. The implant combines the advantages of both porous polyethylene and titanium mesh, including easy custom-shaping without sharp edges, structural support and relatively lower cost.

Double flap technique for reconstruction of anterior skull base defects after craniofacial tumor resection: technical note.

BACKGROUND: Successful reconstruction of large anterior skull base (ASB) defects after craniofacial resection of malignant skull base tumors is paramount for preventing cerebrospinal fluid (CSF) fistulas. The vascularized pedicled pericranial flap (PCF) has been the gold standard for repairing ASB defects after transbasal transcranial approaches. However, flap necrosis and delayed CSF leaks can occur after adjuvant radiation therapy. We describe a "double flap" reconstruction technique in which the PCF is augmented inferiorly by a secondary vascularized pedicled nasoseptal flap (NSF) that is harvested and rotated using an endoscopic endonasal approach. METHODS: This technique is illustrated in 2 patients who underwent a combined cranionasal (transbasal and endoscopic endonasal) approach for large sinonasal malignancies with significant intracranial extension (1 esthesioneuroblastoma, 1 sinonasal teratocarcinosarcoma). After tumor removal via a combined cranionasal approach, primary repair of the ASB dural defect was performed with a free patch graft. The ASB defect was then repaired using the double flap technique with a vascularized PCF from above and augmented with a vascularized NSF from below. RESULTS: Postoperatively, there were no complications of CSF leakage, meningitis, or tension pneumocephalus in both patients. After subsequent radiation therapy, the double flap repair remained intact at 2 years postoperatively in both patients. CONCLUSION: The double flap skull base reconstruction technique provides an additional barrier of vascularized tissue to prevent CSF leakage, meningitis, tension pneumocephalus, and postradiation necrosis. This technique is a viable option if a combined transcranial and transnasal endoscopic tumor resection is performed and postoperative radiation is anticipated.

Bone morphogenetic protein-induced inflammatory cyst formation after lumbar fusion causing nerve root compression.

Bone morphogenetic protein (BMP) has been reported to cause early inflammatory changes, ectopic bony formation, adjacent level fusion, radiculitis, and osteolysis. The authors describe the case of a patient who developed inflammatory fibroblastic cyst formation around the BMP sponge after a lumbar fusion, resulting in compressive lumbar radiculopathy. A 70-year-old woman presented with left L-4 and L-5 radiculopathy caused by a Grade I spondylolisthesis with a left herniated disc at L4-5. She underwent a minimally invasive transforaminal lumbar interbody fusion with BMP packed into the interbody cage at L4-5. Her neurological symptoms resolved immediately postoperatively. Six weeks later, the patient developed recurrence of radiculopathy. Radiological imaging demonstrated an intraspinal cyst with a fluid-fluid level causing compression of the left L-4 and L-5 nerve roots. Reexpoloration of the fusion was performed, and a cyst arising from the posterior aspect of the cage was found to compress the axilla of the left L-4 nerve root and the shoulder of the L-5 nerve root. The cyst was decompressed, and the wall was partially excised. A collagen BMP sponge was found within the cyst and was removed. Postoperatively, the patient's radiculopathy resolved and she went on to achieve interbody fusion. Bone morphogenetic protein can be associated with inflammatory cyst formation resulting in neural compression. Spine surgeons should be aware of this complication in addition to the other reported BMP-related complications.

Delayed postoperative pituitary apoplexy after endoscopic transsphenoidal resection of a giant pituitary macroadenoma.

Postoperative pituitary apoplexy is rare and usually occurs in the immediate postoperative period (within 12 hours) after subtotal resection of giant pituitary macroadenomas with fatal outcomes. We describe a unique patient with pituitary apoplexy occurring in a delayed fashion on the third postoperative day. Early detection and emergent endoscopic transsphenoidal exploration resulted in gross total removal of the residual tumor, decompression of the optic chiasm, and a favorable neurologic outcome.

Late prevertebral abscess after anterior cervical fusion.

STUDY DESIGN: We present a unique case of a 54-year-old woman who developed a prevertebral abscess 2 years after anterior cervical fusion in the absence of previously reported risk factors for late infection. The literature relevant to this topic is reviewed. OBJECTIVE: To report a rare complication of a commonly performed surgery. SUMMARY OF BACKGROUND DATA: Anterior cervical discectomy and fusion (ACDF) is one of the most commonly performed spinal surgeries. The complication rate is relatively low; the risk of infection is only 0.1% to 1.6%. In the late postoperative setting, more than 6 months, wound infections are very rare and are often associated with an esophageal perforation secondary to hardware migration. METHODS: We present a rare complication of a deep wound infection in a 54-year-old woman 2 years after an anterior cervical fusion. On serial radiograph imaging after surgery, the surgical level demonstrated progressive fusion. At 2 years, however, the patient presented with acute dysphagia. Computed tomography (CT) of the neck with contrast demonstrated a rim enhancing prevertebral mass, which was treated with wound exploration and debridement. Direct laryngoscopy at the time of surgery did not demonstrate a breach in the esophageal mucosa and inspection of the esophagus during surgery did not reveal a diverticulum, tear, or breach in the esophagus. RESULTS: After surgical exploration and debridement the patient was placed on a 6-week course of antibiotics. Her dysphagia improved significantly after debridement of the prevertebral abscess. CONCLUSION: Late occurring, deep wound infections are a rare complication of anterior cervical fusion. Dysphagia in the late postoperative setting should be considered carefully and evaluated for esophageal perforation or deep wound infection.