Real-time navigation guidance with intraoperative CT imaging for pedicle screw placement using an augmented reality head-mounted display: a proof-of-concept study.

OBJECTIVE: Augmented reality (AR) has the potential to improve the accuracy and efficiency of instrumentation placement in spinal fusion surgery, increasing patient safety and outcomes, optimizing ergonomics in the surgical suite, and ultimately lowering procedural costs. The authors sought to describe the use of a commercial prototype Spine AR platform (SpineAR) that provides a commercial AR head-mounted display (ARHMD) user interface for navigation-guided spine surgery incorporating real-time navigation images from intraoperative imaging with a 3D-reconstructed model in the surgeon's field of view, and to assess screw placement accuracy via this method. METHODS: Pedicle screw placement accuracy was assessed and compared with literature-reported data of the freehand (FH) technique. Accuracy with SpineAR was also compared between participants of varying spine surgical experience. Eleven operators without prior experience with AR-assisted pedicle screw placement took part in the study: 5 attending neurosurgeons and 6 trainees (1 neurosurgical fellow, 1 senior orthopedic resident, 3 neurosurgical residents, and 1 medical student). Commercially available 3D-printed lumbar spine models were utilized as surrogates of human anatomy. Among the operators, a total of 192 screws were instrumented bilaterally from L2-5 using SpineAR in 24 lumbar spine models. All but one trainee also inserted 8 screws using the FH method. In addition to accuracy scoring using the Gertzbein-Robbins grading scale, axial trajectory was assessed, and user feedback on experience with SpineAR was collected. RESULTS: Based on the Gertzbein-Robbins grading scale, the overall screw placement accuracy using SpineAR among all users was 98.4% (192 screws). Accuracy for attendings and trainees was 99.1% (112 screws) and 97.5% (80 screws), respectively. Accuracy rates were higher compared with literature-reported lumbar screw placement accuracy using FH for attendings (99.1% vs 94.32%; p = 0.0212) and all users (98.4% vs 94.32%; p = 0.0099). The percentage of total inserted screws with a minimum of 5° medial angulation was 100%. No differences were observed between attendings and trainees or between the two methods. User feedback on SpineAR was generally positive. CONCLUSIONS: Screw placement was feasible and accurate using SpineAR, an ARHMD platform with real-time navigation guidance that provided a favorable surgeon-user experience.

Vagal nerve stimulation for medically refractory epilepsy in Angelman syndrome: a series of three cases.

BACKGROUND: We describe three children with Angelman syndrome and medically refractory epilepsy. METHODS: Case series of three pediatric patients with Angelman syndrome and medically refractory epilepsy. All three patients failed medical treatment and were recommended for vagal nerve stimulator (VNS) implantation. RESULTS: Following VNS implantation, all three patients experienced reduction in seizure frequency greater than that afforded by medication alone. CONCLUSION: We present vagal nerve stimulator implantation as a viable treatment option for medically refractory epilepsy associated with Angelman syndrome.

Minimally manipulative extraction of polycystic cervical neurocysticercosis.

CLINICAL HISTORY: Intradural, extramedullary cervical spinal involvement is an uncommon manifestation of neurocysticercosis. CASE REPORT: A case of a middle-aged man with neurocysticercosis in the intradural extramedullary cervical spine and brain who originally presented with bilateral paresthesias of his extremities, with a progressively unsteady gait. Magnetic resonance imaging revealed cystic enhancing lesions in the brain and cervical region of the spine, with the largest cyst extending from the posterior fossa through C2, causing spinal cord compression. The patient underwent surgical resection of the intradural extramedullary cervical spinal lesions, and he has continued to improve clinically, with no recurrence of cystic lesions. CONCLUSION: When examining patients with clinical signs of a spinal mass lesion, the differential diagnosis should include neurocysticercosis of the spine.

Endoscopic endonasal transclival transodontoid approach for ventral decompression of the craniovertebral junction: operative technique and nuances.

The transoral approach is considered the gold-standard surgical route for performing anterior odontoidectomy and ventral decompression of the craniovertebral junction for pathological conditions that result in symptomatic cervicomedullary compression, including basilar invagination, rheumatoid pannus, platybasia with retroflexed odontoid processes, and neoplasms. Extended modifications to increase the operative corridor and exposure include the transmaxillary, extended "open-door" maxillotomy, transpalatal, and transmandibular approaches. With the advent of extended endoscopic endonasal skull base techniques, there has been increased interest in the last decade in the endoscopic endonasal transclival transodontoid approach to the craniovertebral junction. The endonasal route represents an attractive minimally invasive surgical alternative, especially in cases of irreducible basilar invagination in which the pathology is situated well above the palatine line. Angled endoscopes and instrumentation can also be used for lower-lying pathology. By avoiding the oral cavity and subsequently using a transoral retractor, the endonasal route has the advantages of avoiding complications related to tongue swelling, tracheal swelling, prolonged intubation, velopharyngeal insufficiency, dysphagia, and dysphonia. Postoperative recovery is quicker, and hospital stays are shorter. In this report, the authors describe and illustrate their method of purely endoscopic endonasal transclival odonotoidectomy for anterior decompression of the craniovertebral junction and describe various operative pearls and nuances of the technique for avoiding complications.

Mucosal-sparing posterior septectomy for endoscopic endonasal approach to the craniocervical junction.

Recent technological advances and developments in surgical technique have made the craniocervical junction (CCJ) accessible through the transnasal surgical corridor. Endoscopic endonasal transclival and transodontoid approaches have been previously described in the literature. Traditionally, these approaches entail a posterior bony and mucosal septectomy. This posterior bony and mucosal septectomy can compromise the integrity of the posterior septum and damage the vascularized pedicled nasoseptal flap (PNSF), a robust reconstructive option. With the possibility of an intraoperative cerebrospinal fluid (CSF) leak and the reported success of the PNSF for repair of these defects, preserving the integrity of the PNSF is beneficial during the endoscopic endonasal approach to the CCJ. Here, we present a new variation which preserves the mucosal integrity of the posterior nasal septum and PNSF. This mucosal-sparing variation of the traditional endoscopic endonasal transclival and transodontoid approaches allows for the preservation of posterior mucosal nasoseptal integrity, and salvages a reconstructive option for future usage. This is accomplished at no expense to visualization, surgical access, or maneuverability.

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.

Infection with bacteroides thetaiotaomicron during posterior decompression and dynamic stabilization of the lumbar spine: a case report and review of the literature.

Patient and surgical risk factors have often been implicated for postoperative posterior spinal wound infection. A 56-year-old male with widely disseminated multiple myeloma presented with severe back pain and lower extremity weakness as a result of fracture and collapse of the L4 vertebral body. Posterior decompression involving bilateral pedicle resection and partial L4 corpectomy was performed. Stabilization was performed by Dynesys instrumentation of L3-5, screw supplementation with polymethylmethacrylate, and posterolateral fusion was performed. Postoperatively, the patient suffered from multiple infections, including Bacteroides thetaiotaomicron, which were eventually resolved with antibiotic as well as incision and debridement treatment regimens. In cases with numerous perioperative risk factors for infections, the best therapeutic approach may be a preventative one. An understanding of the relevant risk factors may enable the physician to facilitate a perioperative condition best suited for optimal treatment. A case report of infection with Bacteroides thetaiotaomicron during lumbar decompression and dynamic stabilization as well as a review of the literature regarding infection risk factors are presented.

Quality assessment of online patient education resources for peripheral neuropathy.

Given its practicality, the internet is a primary resource for patients afflicted with diseases like peripheral neuropathy. Therefore, it is important that the readily available online resources on peripheral neuropathy are tailored to the general public, particularly concerning readability. Patient education resources were downloaded from the US National Library of Medicine, Mayo Clinic, National Institute of Neurological Disorders and Stroke, Neuropathy.org, GBS/CIDP Foundation International, Hereditary Neuropathy Foundation, Charcot-Marie-Tooth Association, Foundation for Peripheral Neuropathy, and Neuropathy Action Foundation websites. All patient education material related to peripheral neuropathy was evaluated for its level of readability using the Flesch Reading Ease (FRE) and Flesch-Kincaid Grade Level. The FRE scores averaged 43.4 with only the US National Library of Medicine scoring above 60 (76.5). The Flesch-Kincaid Grade Level scores averaged 11.0. All scores were above a seventh-grade level except the US National Library of Medicine, which had a score of a fifth-grade reading level. Most Americans may not fully benefit from patient education resources concerning peripheral neuropathy education on many of the websites. Only the US National Library of Medicine, which is written at a fifth-grade level, is likely to benefit the average American.

Palliative Care Effects on Survival in Glioblastoma: Who Receives Palliative Care?

BACKGROUND: High-grade glioma has a poor overall survival with profoundly negative effects on the patient's quality of life and their caregivers. In this study, we investigate the factors associated with receiving palliative care in patients diagnosed with glioblastoma (GBM) and the association of receiving or not receiving palliative care with overall survival. METHODS: The National Cancer Database was analyzed for patterns of care in patients ≥18 years old who were diagnosed with histologically confirmed grade IV GBM between 2004 and 2017. All statistical analyses were conducted based on univariate and multivariate regression models. RESULTS: A total of 85,380 patients with the diagnosis of GBM were identified. Of the study population, 2803 patients (3.28%) received palliative therapy. On multivariate logistic regression analysis, age ≥70 years (odds ratio [OR], 1.28; 95% confidence interval [CI], 1.04-1.58; P < 0.001), Medicare (OR, 1.348; CI, 1.13-1.61; P = 0.001), tumor size ≥5 cm (OR, 1.15; CI, 1.01-1.31; P = 0.036), tumor multifocality (OR, 1.69; CI, 1.47-1.96; P < 0.001), lobe overlapping tumor (OR, 2.09; CI, 1.13-3.86; P = 0.018), Charlson-Deyo score >0, receiving treatment at a nonacademic/research program, and medium volume of cancers managed at the treatment facility (OR, 1.19; CI, 1.02-1.38; P = 0.026) were independent risk factors associated with an increased chance of receiving palliative care. In contrast, a household income of ≥$40,227 and high volume of cancer managed at the treatment facility (OR, 0.75; CI, 0.58-0.96; P = 0.02) were independent risk factors associated with decreased palliative care. Patients who received no palliative care had a 2-year overall survival longer than those who received palliative care (22% vs. 8.8%; P < 0.001). In patients receiving palliative care, those who received recommended treatment had a 2-year overall survival longer than those who declined part or whole recommended treatment (9.1% vs. 3.8%; P = 0.009). CONCLUSIONS: In patients with high-grade glioma, receiving palliative care is associated with decreased survival. When receiving palliative care, recommended treatment increases the number of patients who survive more than 2 years approximately 3-fold compared with those declining part or whole treatment.

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.

Obstruction of Ventriculoperitoneal Shunt After Myelography-Report of a Unique Case and Its Treatment.

BACKGROUND: Myelography, frequently supplanted by noninvasive, efficient magnetic resonance imaging, remains a useful technique when evaluating the spinal canal in nerve root avulsion, radiation therapy treatment planning, cerebrospinal fluid (CSF) loculation, and CSF leak. Myelography is achieved through a lumbar puncture and instillation of nonionic, water-soluble intrathecal iohexol (Omnipaque, GE Healthcare, Marlborough, Massachusetts, USA) contrast. The aim of the study was to highlight a possible complication of obstruction of a shunt valve due to an increased viscosity of the CSF after intrathecal Omnipaque contrast administration during myelography. CASE DESCRIPTION: The authors report a case of myelography that resulted in obstruction of a ventriculoperitoneal (VP) shunt. A 23-year-old female with significant medical history of neurofibromatosis type I, obstructive hydrocephalus, anterior cervical diskectomy and fusion, and VP shunt placement underwent diagnostic computed tomography after myelography with Omnipaque contrast to assess possible CSF loculation and cord impingement from her cervical instrumentation. The patient experienced somnolence after myelography from obstruction of the VP shunt, with marked ventriculomegaly demonstrated by computed tomography of the head. A shunt tap and shunt pumping regimen resulted in resolution of the obstruction and hydrocephalus, with return to neurologic baseline. CONCLUSIONS: This is a recent case of VP shunt obstruction after myelography, of which previous cases reported are decades old. A shunt pumping regimen may be a nonoperative, effective mean for similar mechanical obstructions of VP shunts for restoration of flow and patency of the shunt system in these patients. We encourage physicians to consider the possibility of shunt obstruction after diagnostic myelography. Caution and close observation should be considered in patients undergoing myelography with a programmable VP shunt.

Surgical Treatment With Thoracic Pedicle Screw Fixation of Vertebral Osteomyelitis With Long-Term Follow-up.

BACKGROUND: While recent data has demonstrated the utility of lumbar pedicle screws for the treatment of vertebral osteomyelitis, the data are limited for thoracic pedicle screws. OBJECTIVE: To investigate the effectiveness of thoracic pedicle screws for the surgical treatment of vertebral osteomyelitis. METHODS: A retrospective review of all operations performed by 2 spinal neurosurgeons from 1999 to 2012 yielded 30 cases of vertebral osteomyelitis that were treated with thoracic pedicle screws. Sixteen (53%) of which underwent combined anterior and posterior fusion and 14 patients (47%) underwent standalone posterior fusion. Postoperative records were analyzed for pertinent clinical, laboratory, and radiographic data. RESULTS: Of the 30 patients, 21 were males (70%), 8 were females (27%), and 1 was transsexual (3%). The mean age was 47 yr (range 18-69). The most common organism cultured was Staphylococcus aureus in 12 cases (50%). The mean patient stay in the hospital was 12.4 d after surgery (range 5-38 d). The mean antibiotic duration after discharge was 8 wk (range 1-24 wk). Of the 25 patients with long-term follow-up (mean, 49 mo), 92% had improved back pain (6/25 marked improvement, 17/25 complete resolution), 83% had improved muscle weakness (8/18 marked improvement, 7/18 complete resolution), and 100% had improved urinary incontinence (3/8 marked improvement, 5/8 complete resolution). Two patients (7%) required additional surgical revision due to instrumentation failure or wound infection. CONCLUSION: This study demonstrates the efficacy of utilizing thoracic pedicle screws as a primary intervention to treat vertebral osteomyelitis.

Surgical management of long intramedullary spinal cord tumors.

OBJECT: Spinal cord tumors represent approximately 10-20% of primary central nervous system tumors. Only 20-30% of primary intradural tumors are intramedullary. The incidence of longitudinally extensive tumors involving the cervical, thoracic, and lumbar spine is very low (<1% of intramedullary lesions); hence, little literature exists on the management of this entity. MATERIALS AND METHODS: We retrospectively reviewed all patients undergoing surgical resection of longitudinally extensive intramedullary spinal cord tumors involving the majority of the spinal cord between 1990 and 2002. Clinical, radiographic, operative, and outcome variables were retrospectively recorded and reported. RESULTS: Thirteen patients (eight male, five female) were included in the study. Mean age was 15 years (range, 3-45) at the time of the initial resection. Gross total resection was achieved in eight cases and subtotal resection in five cases. Pathology revealed astrocytoma in six cases (two pilocytic, four grade II), gangliogliomas in four cases, oligodendroglioma in two cases (one anaplastic), and lipoma in one case. One (8%) patient died from progression of anaplastic oligodendroglioma, and two (15%) underwent reoperation for recurrent tumor (ganglioglioma, grade II astrocytoma). With a mean of 3.4 years (range, 1-12) after surgery, the modified McCormick score (MMS) had worsened in only two (15%) patients, improved in three (23%) patients, and remained stable in seven (54%) patients compared to preoperative MMS. Five (38%) patients required fusion for progressive spinal deformity. CONCLUSION: Gross total resection of holocord and longitudinally extensive intramedullary spinal cord tumors can be achieved with preservation of long-term neurological function in many cases. Serial imaging is recommended to guide subsequent resection for tumor recurrence and stabilization of progressive spinal deformity.

Meralgia Paresthetica After Spine Surgery on the Jackson Table.

Meralgia paresthetica is a non-life-threatening neurological disorder characterized by numbness, tingling, and burning pain over the anterolateral thigh due to impingement of the lateral femoral cutaneous nerve. This disorder has been seen in patients with diabetes mellitus and obesity, but has also been observed in patients after procedures such as posterior spine surgery, iliac crest bone grafts, lumbar disk surgery, hernia repair, appendectomies, and pelvic osteotomies that ultimately lead to compression or damage to the lateral femoral cutaneous nerve. Overall, permanent sequelae of meralgia paresthetica are rare, however, some cases do require intervention.

Sublaminar fixation for traumatic lumbar fracture subluxation with lateral listhesis in a 2-year-old patient.

Pediatric spinal trauma can present a surgeon with difficult management decisions given the rarity of these cases, pediatric anatomy, and a growing spine. The need to stabilize a traumatically unstable pediatric spine can be an operative challenge given the lack of instrumentation available. The authors present a surgical technique and an illustrative case that may offer a novel, less disruptive method of stabilization. A 2-year-old girl presented after an assault with an L1-2 fracture subluxation with lateral listhesis and fractured jumped facets exhibited on CT scans. CT also showed intact growth plates at the vertebral body, pedicles, and posterior elements. MRI showed severe ligamentous injury, conus medullaris compression, and an epidural hematoma. Neurologically, the patient moved both lower extremities asymmetrically. Given the severity of the deformity and neurological examination and disruption of the stabilizing structures, the authors made the decision to surgically decompress the L-1 and L-2 segments with bilateral laminotomies, evacuate the epidural hematoma, and reduce the deformity with sublaminar stabilization using braided polyester cables bilaterally, thus preserving the growth plates. They also performed a posterolateral onlay fusion at L-1 and L-2 using autograft and allograft placed due to the facet disruption. At the 42-month follow-up, imaging showed fusion of L-1 and L-2 with good alignment, and the hardware was subsequently explanted. The patient was neurologically symmetric in strength, ambulating, and had preserved alignment. Her bones and spinal canal continued to grow in relation to the other levels.

Tethered Cord as a Complication of Chronic Cerebral Spinal Fluid Diversion.

INTRODUCTION: The etiology and treatment of tethered cord syndrome remains controversial, especially in adults. We present an unusual case of tethered cord syndrome with an associated epidural lipomatosis likely due to chronic over shunting of cerebrospinal fluid (CSF). METHODS: A 25-year-old woman had a history of Chiari malformation, hydrocephalus, and a ventriculoperitoneal shunt. She demonstrated progressively worsening gait, which led to a diagnosis of myelopathy and a posterior cervical decompression and fusion was performed. Imaging revealed engorgement of the epidural veins ventral to the spinal cord which was causing cord compression. Magnetic resonance (MR) imaging of the lumbar spine demonstrated a low-lying conus at the level of L2-L3 with an absence of CSF in the lumbar cistern. This was associated with this was a widening of the epidural space with secondary epidural lipomatosis. She underwent a laminectomy of L5 as well as decompression of the inferior aspect of the L4 and superior aspect of the S1 lamina. No free flow of CSF could ever be appreciated as was suggested by postoperative MR imaging. Postoperatively, the patient did well and was discharged in stable condition. CONCLUSION: Tethering of the spinal cord, associated with epidural lipomatosis, may be secondary to over-drainage of CSF. Symptoms of back pain and tethered cord phenomenon may warrant surgical intervention.

Direct Midline Posterior Corpectomy and Fusion of a Lumbar Burst Fracture with Retrospondyloptosis.

BACKGROUND: Traumatic burst fractures of the lumbar spine can result in significant neurologic injury and mechanical instability. The ideal surgical approach for the treatment of unstable lumbar spine burst fractures remains debatable. CASE DESCRIPTION: A 37-year-old man presented with severe neurologic injury including loss of motor function below the level of the iliopsoas muscles bilaterally, saddle anesthesia, and absent rectal tone, after a fall from 18.28 m (60 ft). Computed tomography showed an L4 vertebral body comminuted burst fracture with complete posterior translation of L4 over L5. The patient was taken to the operating room for an L4 corpectomy and L2-S1 posterior fusion. The L4 vertebral body was visualized posterior to the posterior elements of L5 and resected in a piecemeal fashion. Because the thecal sac had been completely transected, a visible path down the L3-L4 and L4-L5 disk spaces was apparent, allowing direct posterior discectomies at these levels and completion of the L4 segment resection. The use of a direct posterior approach resulted in minimal blood loss, correction of sagittal alignment, and satisfactory outcomes comparable with the standard posterior transpedicular approach. Construct stability and solid bony fusion have been maintained for 4 years postoperatively. CONCLUSIONS: The use of a direct midline posterior corpectomy approach may be considered for patients with lumbar burst fractures, high-grade neurologic injury, and transection of the thecal sac.

Prognostic Differences: Epstein-Barr Virus-Associated Primary Leiomyosarcoma of the Spine Versus Spinal Leiomyosarcoma Metastases.

OBJECTIVE: The authors studied 6 cases of osseous leiomyosarcoma of the spine. Two of these cases were of immunocompromised human immunodeficiency virus (HIV)-positive patients with Epstein-Barr virus (EBV)-associated primary vertebral leiomyosarcomas. The remaining 4 cases were of patients with leiomyosarcoma metastases to the spine. METHODS: Each patient underwent surgical resection of their vertebral mass; however, the patients with the EBV-associated tumors had the best postoperative prognosis. RESULTS: The HIV-positive patients have had no further local recurrence, while the other 4 patients had rapid local recurrences requiring multiple surgical interventions. Furthermore, the patients living with HIV have lived longer with fewer leiomyosarcoma-related health complications. CONCLUSIONS: These findings suggest that EBV-associated vertebral leiomyosarcoma is of a less aggressive variety than metastatic leiomyosarcoma of the spine.

Optimal Timing of Whole-Brain Radiation Therapy Following Craniotomy for Cerebral Malignancies.

BACKGROUND: For patients with cerebral metastases that are limited in number, surgical resection followed by whole-brain radiation therapy is the standard of care. In addition, for high-grade gliomas, maximal surgical resection followed by local radiotherapy is considered the optimal treatment. Radiation is known to impair wound healing, including healing of surgical incisions. Radiotherapy shortly after surgical resection would be expected to minimize the opportunity for tumor regrowth or progression. Owing to these competing interests, the purpose of this study was to shed light on the optimal timing of radiotherapy after surgical resection of brain metastasis or high-grade gliomas. METHODS: A review of the literature was conducted on the following topics: radiation and wound healing, corticosteroid use and wound healing, radiotherapy for tumor control for cerebral metastases and high-grade gliomas, and whole-brain radiation therapy or focal radiotherapy after craniotomy with focus on the timing of radiotherapy after surgery. RESULTS: In animal models, wound integrity and healing was less impaired by radiotherapy administered 1 week after surgery. In humans, this timing would be expected to be significantly longer, on the order of several weeks. CONCLUSIONS: Given the limited literature, insufficient conclusions can be drawn. However, animal data suggest a period of at least 1 week (but it is likely several weeks in humans) is necessary for reconstitution of wound strength before initiation of radiation therapy. A randomized prospective study is recommended to understand better the effect of the timing of radiation therapy following surgical intervention for brain metastasis or high-grade gliomas.

Purely endoscopic endonasal surgery of the craniovertebral junction: A systematic review.

BACKGROUND: Endoscopic endonasal surgery (EES) is a relatively novel approach to the craniovertebral junction (CVJ). The purpose of this analysis is to determine the surgical outcomes of patients who undergo purely EES of the CVJ. METHODS: A search for articles related to EES of the CVJ was performed using the MEDLINE/PubMed database. A bibliographic search was done for additional articles. Demographics, presenting symptoms, imaging findings, complications, follow-up, and patient outcomes were analyzed. RESULTS: Eighty-five patients from 30 articles were included. The mean patient age was 47.9 ± 24.8 years (range, 3 to 96 years), with 44.7% being male. The most common presenting symptom was myelopathy (n = 64, 75.3%). The most common indications for surgery were brainstem compression secondary to basilar invagination (n = 41, 48.2%) and odontoid pannus (n = 20, 23.5%). Odontoidectomy was performed in 97.6% of cases. Intraoperative complications occurred in 16 patients (18.8%) and postoperative complications occurred in 18 patients (21.2%). Six patients developed postoperative respiratory failure necessitating a tracheostomy. Neurologic improvement was seen in 89.4% of patients at a mean follow-up of 22.2 months. CONCLUSION: Our analysis found that EES of the CVJ results in a high rate of neurologic improvement with acceptable complication rates. Given its minimally invasive nature and high success rate, this approach appears to be a reasonable alternative to the traditional transoral approach in select cases. This study represents the largest pooled sample size of EES of the CVJ to date. Increasing use of the endoscopic endonasal approach will allow for further studies with greater statistical power.