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Telecollaboration via web-based platforms has emerged as a tool to relieve constraints on the establishment of tumor boards for neurosurgical oncology. Challenging tumor cases arising in low- and middle-income countries may benefit from the use of such models. The case of a 5-year-old boy presenting in Western Kenya with a challenging tumor and symptomatic hydrocephalus was presented on a novel web platform to a multi-national audience of neurosurgeons. The treating neurosurgeon invited a physician network to review the case vignette and radiographic images. Respondents independently offered input during a prescribed response period. Three respondents provided surgical opinions during a 24-h response period. The treating neurosurgeon utilized the pooled input to determine a course of action for the patient. When a web-based platform is available, lone neurosurgeons in low-resource settings may nevertheless apply multi-national, multi-institutional perspectives to challenging oncology cases.
Assuntos
Hidrocefalia , Neurocirurgia , Pré-Escolar , Humanos , Hidrocefalia/diagnóstico por imagem , Hidrocefalia/cirurgia , Quênia , Masculino , Neurocirurgiões , Procedimentos NeurocirúrgicosRESUMO
OBJECTIVE AND SUMMARY OF BACKGROUND DATA: Surgical treatment of lumbar disk herniation is traditionally accomplished by removal of the extruded fragment as well as an aggressive decompression of the disk space. This retrospective study evaluates the long-term results of limited discectomy, otherwise known as fragmentectomy, for lumbar disk herniation using a minimally invasive technique. Although there are ample studies in literature regarding short-term outcome after limited microdiscectomy, there is a paucity of literature for long-term outcomes after fragmentectomy. We present long-term outcomes averaging 7 years after limited discectomy. STUDY DESIGN AND METHODS: A total of 152 patients were operated on between January 1, 2001 and June 30, 2003 for single-level herniated lumbar disks. All patients had microsurgical fragmentectomy performed through a small skin incision off the midline using a tubeless retraction system. Fifty-four patients participated in the study, whereas 98 patients were lost to long-term follow-up. Long-term outcome was assessed by telephone survey or mail-in survey using the Oswestry Low Back Pain Disability Index and a patient outcome survey. After Institutional Review Board approval and patient consent, all 54 patients had a thorough chart review for evaluation of further lumbar surgeries. The mean long-term follow-up was 86.2 months (range, 72-104 mo) or about 7.2 years. RESULTS: Forty-eight of the 54 patients (88.9%) reported an excellent (26 patients) or good (22 patients) long-term outcome with surgery. Long-term back and leg pain improvement was seen in 44 of 49 (89.8%) and 44 of 50 (88.0%) patients reporting back or leg pain, respectively. The mean Oswestry Disability Index for long-term follow-up was 8.89, indicating minimal disability. Same-level recurrences requiring reoperation were seen in 6 of the 54 patients who participated (11.1%) within the average 86.2-month follow-up. Four of 34 (11.85%) known contained herniations and 2 of 20 (10.0%) known extruded herniations presented for same-level surgical recurrence. All recurrences were successfully treated with reexploration and fragmentectomy. Two patients from the recurrence group and 1 from the original 54 progressed to need an arthrodesis at the initial operated level (5.6%). One patient in the same-level recurrence group and 2 patients from the original 54 developed an operative herniated disk at an adjacent level (5.6%). CONCLUSIONS: Our long-term outcome study shows that a minimally invasive approach to microdiscectomy with removal of the fragment only is an effective way to treat lumbar disk herniation. The rate of recurrence in our long-term study seems slightly higher compared with previously published studies, which generally had shorter follow-up periods. Long-term patient outcomes for back and leg pain were also very low. No appreciable difference in operative reherniation could be found with patients who had contained verses extruded fragments. It is difficult to predict from this study whether a simple fragmentectomy was the cause of the progression to further surgeries or whether this was the natural progression of a degenerative spine. Further prospective trials are necessary to fully understand the factors associated with limited microdiscectomy.
Assuntos
Discotomia/métodos , Deslocamento do Disco Intervertebral/cirurgia , Vértebras Lombares/cirurgia , Microcirurgia/métodos , Adulto , Idoso , Feminino , Pesquisas sobre Atenção à Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Cuidados Pré-Operatórios , Recidiva , Estudos Retrospectivos , Inquéritos e Questionários , Fatores de Tempo , Resultado do TratamentoRESUMO
Dorsal root ganglion stimulators (DRGS) have been used to treat patients with neuropathic pain due to multiple etiologies. Typically, DRGS are inserted percutaneously with fluoroscopic guidance epidurally into the neuroforamina over a pathologic dorsal root ganglion. In patients with unfavorable anatomy due to extensive surgical scarring, an open surgical approach has been described in the literature for DRGS placement. We document an alternative open surgical approach for DRGS placement in a patient with recalcitrant post-herpetic neuralgia.
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Recovery time following surgical procedures is a consideration every practicing surgeon must deliberate upon throughout his or her career. The decision to restrict patients from returning to work or various activities encountered on a daily basis following an operation is dependent on many factors. Surgeons must take into account patient population, individual comorbid conditions, complexity and length of surgery, immediate postoperative course, and baseline functional abilities. Thus, returning to work and various activities, including physical activity, work-related activity, and recreational activity alike, following invasive procedures is individualized from patient to patient. Most spinal procedures are performed by neurosurgeons or orthopedic surgeons. This article suggests a framework to guide appropriate return to work and activity escalation time frames following various spinal procedures.
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A 60-year-old male presented with kyphotic deformity caused by a non-small cell lung cancer metastasis in the cervical-thoracic junction. His pathology caused spinal cord compression and segmental instability. The patient underwent a posterior decompression to try and improve neurological function as well as posterior lateral mass and pedicle screw fixation crossing the cervical-thoracic junction to stabilize his instability. A novel technique incorporating sublaminar wiring across a cross-link was utilized to increase pull out strength of the superior lateral mass screws. Also included is a discussion regarding the safe use of sublaminar wires, the history of posterior cervical and thoracic fusion, and the prevalence of instrumentation failure.
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Pneumorrhachis (PR) is the presence of free air within the spinal canal. It is generally benign and improves with conservative management. Case reports and a literature review exist documenting the existence and potential pathogenesis of this phenomenon, but no evidence-based guidelines exist documenting what treatment, if any, is indicated for this condition. We present a case of a 21-year-old male who developed PR after a preceding upper respiratory tract infection. His symptoms improved with expectant management and administration of high-flow oxygen. The purpose of this case report is to add to the scarce existing literature reporting this condition and to provide a short review of literature detailing the pathogenesis of PR.
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Vertebral body fractures are well-known sources of axial back pain with the potential to cause neurological deficits. Duplication of a component of the vertebral column is a rare phenomenon; however, vertebral pedicle duplication is an unreported phenomenon, and has not been reported in association with a vertebral burst fracture and kyphotic deformity. We present a unique case of vertebral pedicle duplication in association with a T11 vertebral burst fracture in a 72-year-old female. In addition to her risk factors, it is the belief of the authors that the anatomic anomaly increased the segmental kyphosis at the level of the T11 vertebral body, thereby increasing the axial load on that segment, and increasing the risk for fracture.
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We report an uncommon case of posterior epidural migration of a lumbar disc fragment (PEMLDF) in a patient presenting with acute, progressive back pain, radiculopathy, and weakness. PEMLDF can be mistaken for neoplastic or infectious etiologies on imaging, presenting a diagnostic and management challenge. Our patient underwent an urgent decompressive lumbar laminectomy, which revealed a PEMLDF intraoperatively. He went on to achieve good neurologic recovery.
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Primary sarcomas of the sellar region are uncommon, although a wide variety have been reported. To date, no cases of primary synovial sarcoma have been described as occurring at this site. We report an immunohistochemically and molecular genetically confirmed primary synovial sarcoma involving the sellar/parasellar region and cavernous sinus in an adult male. Subtotal resection and radiosurgery proved to be efficacious. The spectrum of primary sellar region sarcomas is summarized.
Assuntos
Sarcoma Sinovial/patologia , Sarcoma Sinovial/terapia , Sela Túrcica/patologia , Neoplasias da Base do Crânio/patologia , Neoplasias da Base do Crânio/terapia , Seio Cavernoso/patologia , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/patologia , Procedimentos Neurocirúrgicos , Proteínas de Fusão Oncogênica , Radiocirurgia , Reação em Cadeia da Polimerase Via Transcriptase Reversa , Sarcoma Sinovial/genética , Neoplasias da Base do Crânio/genética , Translocação GenéticaRESUMO
The adequate treatment of methicillin-resistant Staphylococcus aureus (MRSA) osteomyelitis has intrigued clinicians for some time. As the resistance of these pathogens, coupled with the increase in community-acquired cases, continues steadily to rise, clinicians are finding it useful to employ multi-modal approaches for efficacious treatment. The authors present a single case report of a patient with recurrent MRSA osteomyelitis, lumbar paraspinal and epidural abscess. He was found to have decreased muscle strength and was hyporeflexic in the involved extremity. Serum testing demonstrated MRSA bacteremia. Neuroimaging studies revealed evidence of paraspinal abscess and a presumed herniated nucleus pulposus at the L5/S1 interspace with significant nerve root compromise. Despite antimicrobials, his symptoms persisted, necessitating surgical exploration. At surgery, paraspinal and epidural abscesses were encountered and debrided; however, no herniated disc was visualized. This case demonstrates the diagnostic and therapeutic dilemmas with which these lesions present. We postulate that the MRSA osteomyelitis/discitis pathogens were walled off in the disc space and subsequently inoculated the soft tissues with ensuing bacteremia. We concur that antimicrobial treatment should be the first line of therapy for these patients; however, surgical debridements and cautious spinal instrumentation should be employed where appropriate.
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Abscesso/tratamento farmacológico , Antibacterianos/uso terapêutico , Vértebras Lombares/microbiologia , Osteomielite/microbiologia , Infecções Estafilocócicas/tratamento farmacológico , Abscesso/microbiologia , Abscesso/cirurgia , Acetamidas/uso terapêutico , Adulto , Bacteriemia/tratamento farmacológico , Bacteriemia/etiologia , Bacteriemia/microbiologia , Desbridamento , Quimioterapia Combinada , Humanos , Deslocamento do Disco Intervertebral/microbiologia , Deslocamento do Disco Intervertebral/patologia , Laminectomia , Linezolida , Vértebras Lombares/patologia , Masculino , Resistência a Meticilina , Osteomielite/tratamento farmacológico , Osteomielite/cirurgia , Oxazolidinonas/uso terapêutico , Recidiva , Rifampina/uso terapêutico , Infecções Estafilocócicas/cirurgia , Staphylococcus aureus , Fatores de Tempo , Resultado do Tratamento , Vancomicina/uso terapêuticoRESUMO
Sacral insufficiency fractures (SIFs) are a common, under-recognized cause of debilitating low back pain, particularly in elderly patients with osteoporotic bone disease or risk factors for bone demineralization. Conservative therapy has been the mainstay of treatment for these types of fractures. This places patients at increased risk for the development of secondary illnesses associated with prolonged immobility, which might prevent a full return to the preinjury level of function. Surgical intervention for SIFs has increased over the past two decades in an attempt to overcome these complications and improve patient functionality. Sacroplasty and iliosacral screw stabilization are two specific procedures performed to treat SIFs. The purpose of this case report is to further document the existence of this condition, as well as to detail a novel approach for surgically treating this condition with a combination of the above procedures.
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Pituitary carcinomas are defined as pituitary tumors with craniospinal and/or systemic metastasis. These are rare and highly aggressive lesions. We present an unusual case of a 52-year-old male who had a pituitary adenoma removed via craniotomy. The tumor recurred three years post-op near the surgical tract, and slowly enlarged before removal two years later. Technically, this lesion was defined as a pituitary carcinoma, even though the histology and clinical course were atypical. There is no standardized grading system for pituitary tumors and ideal criteria should correlate clinically. Treatment for pituitary carcinoma is multimodal and largely empiric. We believe this case illustrates that current definitions of pituitary carcinoma are incomplete.
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OBJECT: All children born with a myelomeningocele at the authors' institution undergo aggressive treatment to maintain or improve functional outcome. Consequently, when any neurological, orthopedic, and/or urological changes are noted, a search for the cause is initiated. The most common cause of decline in a child born with a myelomeningocele is shunt malfunction. The second most common cause is tethering of the distal spinal cord at the site of the original back closure. In this report, the authors review the indicators of symptomatic spinal cord tethering and discuss the surgical interventions and outcomes in the children with myelomeningocele who underwent treatment at Children's Memorial Hospital from 1975 to 2008. METHODS: Among the 502 children who underwent original closure at Children's Memorial Hospital, a symptomatic tethered spinal cord developed in 114 (23%). Eighty-one patients (71%) have undergone 1 untethering procedure, and 33 patients (29%) have undergone multiple untetherings, for a total of 163 total surgeries. The indicators of symptomatic spinal cord tethering include scoliosis, decline in lower-extremity (LE) motor strength, LE contractures, LE spasticity, gait change, urinary changes, and pain. RESULTS: Pain has shown the best response to surgical untethering, with 100% of children experiencing postoperative improvement. The results of long-term follow-up (average 12 years, range 1 month-23.3 years) in this cohort demonstrated scoliosis progression after surgical untethering in 52% of patients, with 28% requiring spinal fusion. On the 3-month postoperative manual muscle test, 70% of patients showed improved LE muscle strength compared to preoperatively. Gait was also similarly improved after untethering as evaluated by an orthopedic surgeon. Spasticity improved in two-thirds of the cohort, and as expected, LE contractures were stable (78%) postoperatively, as assessed by orthopedic and rehabilitation medicine specialists. Urologically, 64% of patients showed improvements on postoperative bladder evaluation. CONCLUSIONS: Although this is a clinical outcome study with no control group, the authors' experience has been that tethered cord release is beneficial in maintaining neurological, urological, and orthopedic functioning in children born with a myelomeningocele.