The utility of dynamic contrast-enhanced intranodal magnetic resonance lymphangiography (MRL) in the investigation of primary lymphatic anomalies.

AIM: The aim of this study was to describe the technique of DCMRL to identify central lymphatic abnormalities in patients with primary lymphatic anomalies and discuss utility of the findings. MATERIALS AND METHODS: Twenty-eight patients with primary lymphatic abnormalities underwent dynamic magnetic resonance imaging (MRI) following injection of gadolinium directly into inguinal lymph nodes at a tertiary lymphovascular referral center. RESULTS: Technical success was achieved in 23 patients (82.1%). Pathological imaging findings included obstructed, hypoplastic, or absent lymphatic channels with collateralization/rerouting or reflux of flow, lymphangiectasia, lymphatic pseudoaneurysms, and lymph leaks. Protocol modifications for improved imaging are highlighted including technical aspects of lymph node injection, image acquisition and MRI parameters. In two patients, imaging findings warranted embolization of the abnormal lymphatic channels with subsequent symptomatic improvement. CONCLUSION: DCMRL has been shown to be a safe, reproducible technique in patients with primary lymphatic anomalies enabling imaging of the central lymphatic system.

Session 2: Synchronous metastatic disease-liver first or primary first? The oncologist decides.

There have been no randomized trial data to guide teams with regard to the order of surgery in patients with synchronous metastatic disease. On the one hand patients with borderline resectable liver metastases may lose the opportunity to undergo curative liver resection if the primary is resected first. For other patients, a symptomatic primary cancer may not be amenable to a delay. In the absence of clear evidence-based outcomes, Professor Van Cutsem shares the recent expert consensus opinions on the current recommendations and an overview of the limited evidence base available.

Session 3: Boosting primary and recurrent rectal cancer: how far can we push the radiotherapy envelope?

Neoadjuvant pelvic radiotherapy is widely used for patients with advanced rectal cancer. The trade-off between dose and response is well-established, yet little consensus remains on the precise methods of delivery and doses given in different scenarios. Professor Vuong reviews the evidence base and trial evidence on the escalation of radiotherapy dose and the methods of achieving this.

Session 1: Colon cancer - 10 years behind the rectum.

The improvements in surgical technique brought about by the widespread adoption of total mesorectal excision plane dissection in rectal cancer has substantially improved survival and recurrence rates from this disease. For the first time in 50 years, the outcomes in rectal cancer have overtaken those of colon cancer. Professor Madoff's overview lecture and the experts' round table discussion address whether applying the surgical principles already achieved in rectal cancer can meet with similar success in colon cancer, how this can be achieved and the challenges we face.

Session 3: Beyond the boundaries of Total Mesorectal Excision - where surgeons fear to tread.

Approximately 10-15% of patients present with an advanced rectal cancer that extends beyond the conventional total mesorectal excision (TME) planes. In such cases extending the surgery to ensure resection with clear margins (R0 resection) is essential in order to achieve long-term cure. Professor Holm describes the techniques of beyond-TME exenterative surgery, the methods of patient selection and outcomes.

Session 2: Extramural vascular invasion and extranodal deposits: should they be treated the same?

Professor Nagtegaal has already highlighted that lymph nodes are probably not responsible for the development of liver metastases. If they are not, then is there another mechanism? Professor Haboubi addresses the question of extranodal deposits - their frequency and their importance in the development of metastatic disease. The experts review the evidence and discuss whether this information will alter treatment decisions and staging systems in the future.

Session 3: Intra-operative radiotherapy - creating new surgical boundaries.

In patients with advanced and recurrent colorectal cancer, surgical resection with clear margins is the greatest challenge and is limited by known anatomical constraints. Preoperative or intra-operative assessment of the limits of surgical dissection may help to explore the possibility of improving resectability through either targeted external beam radiotherapy or intra-operative radiotherapy. Professor Chang reviews the evidence base and potential advantages and disadvantages of this approach, whilst the expert panel agree a consensus on the evidence for assessment and therapy of such patients.

Session 1: The evolution and development of the multidisciplinary team approach: USA, European and UK experiences - what can we do better?

The process of determining the best treatments that should be offered to patients with newly diagnosed colon and rectal cancer remains highly variable around the world. The aim of this expert review was to agree the key elements of good quality preoperative treatment decision making.

Revealing non-analytic kinematic shifts in smooth goal-directed behaviour.

How do biological agents plan and organise a smooth accurate path to shift from one smooth mode of behaviour to another as part of graceful movement that is both plastic and controlled? This paper addresses the question in conducting a novel shape analysis of approach and adjustment phases in rapid voluntary target aiming and 2-D reaching hand actions. A number of mode changing experiments are reported that investigate these actions under a range of goals and conditions. After a typically roughly aimed approach, regular projective adjustment is observed that has height and velocity kinematic profiles that are scaled copies of one another. This empirical property is encapsulated as a novel self-similar shift function. The mathematics shows that the biological shifts consist of continual deviation from their full Taylor series everywhere throughout their interval, which is a deep form of plasticity not described before. The experimental results find the same approach and adjustment strategy to occur with behavioural trajectories over the full and varied range of tested goals and conditions. The trajectory shapes have a large degree of predictability through using the shift function to handle extensive variation in the trajectories' adjustment across individual behaviours and subjects. We provide connections between the behavioural features and results and various neural studies to show how the methodology may be exploited. The conclusion is that a roughly aimed approach followed by a specific highly plastic shift adjustment can provide a regular basis for fast and accurate goal-directed motion in a simple and generalisable way.

The Natural History of Coiled Cerebral Aneurysms Stratified by Modified Raymond-Roy Occlusion Classification.

OBJECTIVE: The natural history and long-term durability of Guglielmi detachable coil (GDC) embolization is still unknown. We hypothesize a stepwise decrease in durability of embolized cerebral aneurysms as stratified by the Modified Raymond-Roy Classification (MRRC). METHODS: First-time GDC-embolized cerebral aneurysms were retrospectively reviewed from 2004 to 2015. Loss of durability (LOD) was defined by change in aneurysm size or patency seen on serial radiographic follow-up. Kaplan-Meier survival analysis was performed to evaluate embolization durability. Multivariate Cox regression modeling was used to assess baseline aneurysm and patient characteristics for their effect on LOD. RESULTS: A total of 427 patients with 443 aneurysms met the inclusion criteria. Overall, 89 (21%) aneurysms met LOD criteria. Grade 1 aneurysms had statistically significantly greater durability than did all other MRRC grades. Grade 3b aneurysms had significantly worse durability than did all other aneurysm grades. There was no difference in durability between grade 2 and 3a aneurysms. Of aneurysms with LOD, 26 (29%) experienced worsening of MRRC grade. Thirty-five (24%) initial MRRC grade 2, 72 (45%) initial MRRC grade 3a, and 6 (22%) initial MRRC grade 3b aneurysms progressed to MRRC grade 1 without retreatment. In our multivariate analysis, only initial MRRC grade was statistically significantly associated with treatment durability (P < 0.001). CONCLUSIONS: MRRC grade is independently associated with first-time GDC-embolized cerebral aneurysm durability. Achieving MRRC grade 1 occlusion outcome is significantly associated with greater long-term GDC durability. Although few aneurysms experience further growth and/or recanalization, most incompletely obliterated aneurysms tend to remain stable over time or even progress to occlusion. Grading scales such as the MRRC are useful for characterizing aneurysm occlusion but may lack sensitivity and specificity for characterizing changes in aneurysm morphology over time.

Transforming Growth Factor-ß Promotes Axonal Regeneration After Chronic Nerve Injury.

When spinal cord injury (SCI) occurs, injured cells must survive and regenerate to close gaps caused by the injury and to create functional motor units. After peripheral nerve injury, Wallerian degeneration in the distal nerve stump creates a neurotrophic and growth-supportive environment for injured neurons and axons via Schwann cells and secreted cytokines/neurotrophins. In both SCI and peripheral nerve injury, injured motor and sensory neurons must regenerate axons, eventually reaching and reinnervating target tissue (SDC Figure 1, http://links.lww.com/BRS/B116). This process is often unsuccessful after SCI, and the highly complex anatomy of branching axons and nerves in the peripheral nervous system leads to slow recovery of function, even with careful and appropriate techniques.

Intra-operative antibiotic bead maker--point of technique.

Chronic osteomyelitis is a disease of soft tissue and bone and it is common in the developing countries. The management of this debilitating disease requires the delivery of the appropriate chemotherapeutic agent at the site of the infection after adequate debridement. The search for a suitable carrier for these chemotherapeutic agents is the advent of the 'septopal' or gentamycin-polymethylmethacrylate (gentamycin-PMMA) beads. Septopal beads are expensive and are not affordable by patients in the developing countries. Moreover, most of the micro-organisms (mixed flora) responsible for chronic osteomyelitis in our hospitals are sensitive to ceftriaxone and only in a few cases were gentamycin-sensitive micro-organisms isolated. Therefore, it was imperative that patient-specific and antibiotic-specific PMMA beads would be the way forward and this is the reasoning behind the production of the intra-operative antibiotic bead maker (IABM) and the point of technique is hereby presented.

Minimally invasive versus open transforaminal lumbar interbody fusion for degenerative spondylolisthesis grades 1-2: patient-reported clinical outcomes and cost-utility analysis.

BACKGROUND: Transforaminal lumbar interbody fusion (TLIF) is the standard surgical treatment for patients with lumbar degenerative spondylolisthesis who do not respond to a 6-week course of conservative therapy. A number of morbidities are associated with the conventional open-TLIF method, so minimally invasive surgery (MIS) techniques for TLIF (MIS-TLIF) have been introduced to reduce the trauma to paraspinal muscles and hasten postoperative recovery. Because providing cost-effective medical treatment is a core initiative of healthcare reforms, a comparison of open-TLIF and MIS-TLIF must include a cost-utility analysis in addition to an analysis of clinical effectiveness. METHODS: We compared patient-reported clinical functional outcomes and hospital direct costs in age-matched patients treated surgically with either open-TLIF or MIS-TLIF. Patients were followed for at least 1 year, and patient scores on the Oswestry Disability Index (ODI) and visual analog scale (VAS) were analyzed at 6 weeks, 6 months, and ≥1 year postoperatively in the 2 treatment groups. RESULTS: Compared to their preoperative scores, patients in both the open-TLIF and MIS-TLIF groups had significant improvements in the ODI and VAS scores at each follow-up point, but no significant difference in functional outcome occurred between the open-TLIF and MIS-TLIF groups (P=0.46). However, open-TLIF is significantly more costly compared to MIS-TLIF (P=0.0002). CONCLUSION: MIS-TLIF is a more cost-effective treatment than open-TLIF for patients with degenerative spondylolisthesis and is equally effective as the conventional open-TLIF procedure, although further financial analysis-including an analysis of indirect costs-is needed to better understand the full benefit of MIS-TLIF.

Midline minimally invasive placement of spinal cord stimulators: a technical note.

BACKGROUND: Spinal cord stimulators (SCSs) have conventionally been implanted through open approaches requiring extensive muscle dissection to perform laminectomies and permanently place the paddle lead. This approach could contribute to worsening the pain syndrome in patients who experience chronic pain. In an attempt to reduce operative times, minimize blood loss and postoperative pain, and ease the technical challenges of placing the paddle lead in the midline via a paramedian and off-midline incision, we designed a new minimally invasive surgery (MIS) technique to place the paddle lead using a tubular retractor system through a true midline approach. METHODS: We performed a retrospective review of all MIS paddle lead placements performed by the senior author between October 2010 and June 2013. Patient demographics; clinical indications for placement of paddle lead; location of paddle lead; and perioperative data including blood loss, length of surgery, and surgical and perioperative morbidity were recorded. RESULTS: Between October 2010 and June 2013, 78 patients had MIS placement of paddle lead SCSs. Patient ages ranged from 27 to 87 years old, with a mean age of 59. The most common levels for paddle lead placement were T8 and T9. No minor or major neurologic complications occurred in our patient population. No patient was readmitted after being discharged from the hospital and all surgeries were outpatient procedures. We had a migration rate comparable to open techniques and minimal blood loss. CONCLUSION: Our technique is safe and effective and carries minimal surgical morbidity compared to standard open techniques for placement of SCSs.

Intraoperative neurophysiological monitoring for minimally invasive 1- and 2-level transforaminal lumbar interbody fusion: does it improve patient outcome?

BACKGROUND: Despite the widespread use of intraoperative monitoring (IOM) in many types of spinal surgeries, an absence of data comparing monitored a nd unmonitored postoperative outcomes places IOM's efficacy into question. A lack of consensus among surgeons about when to use monitoring also raises concerns about its overuse in routine and low-risk procedures. METHODS: We performed a retrospective database review of 112 patients undergoing a 1- or 2-level minimally invasive surgery transforaminal lumbar interbody fusion (MIS-TLIF). Our analysis focused on patient demographics, use of IOM, length of surgery, hospital length of stay, the perioperative complication of pedicle screw malposition, and average hospital cost. RESULTS: For the 73 patients who underwent MIS-TLIF with intraoperative neuromonitoring, their hospital length of stay (P=0.8) and need for pedicle screw revisions (P=0.93) were not statistically significant compared to the 39 patients who underwent MIS-TLIF procedures without IOM. The incidence of reoperation was 5.48% and 5.13%, and average length of stay was 3.25 days and 3.13 days, respectively. However, the cost of surgery and the length of surgery were significantly higher in the monitored group compared to the nonmonitored group (P=0.008 and P=0.009, respectively). CONCLUSION: IOM is widely used in spine surgery, but our retrospective review shows that its use does not necessarily decrease the incidence of malpositioning of pedicle screws. In fact, no statistical difference was detected in the incidence of screw malposition in the 2 groups of patients. On the other hand, IOM adds cost and increases the length of surgery. Because the use of IOM did not make a difference in the incidence of pedicle screw malpositioning and because of the comparative cost analysis for both groups of patients, we believe that the use of IOM for MIS-TLIF provides no added benefit.

One-stage resection of giant invasive thoracic schwannoma: case report and review of literature.

BACKGROUND: Schwannomas comprise approximately 25% of all spinal tumors, being the third most frequent soft-tissue tumor after hemangiomas and lipomas. Grade 5 invasive giant schwannomas erode the vertebral bodies, involve 2 or more levels, and invade the myofascial planes. Because 3 compartments are involved, these tumors represent a surgical challenge and frequently require staged surgeries with a multidisciplinary surgical team. CASE REPORT: We report the case of a 62-year-old female who presented with intermittent upper back pain for 3 years. A magnetic resonance imaging scan of the thoracic spine showed a mass invading the vertebral body, pedicle, and lamina of T4 and part of T3 and T5. Needle biopsy confirmed the diagnosis of schwannoma. The patient underwent surgery using a parascapular extracavitary costotransversectomy approach. CONCLUSION: Giant invasive spinal schwannomas are rare in the thoracic spine, and surgical approaches usually have entailed multiple-stage surgeries with the assistance of other surgical specialties. Our 1-stage complete surgical resection of a giant invasive spinal schwannoma used a parascapular costotransversectomy approach that maintained spinal stability and thus avoided the need for instrumentation.

Resection and nerve grafting of a lipofibrohamartoma of the median nerve: case report.

OBJECTIVE AND IMPORTANCE: Our patient's symptomatology, history, physical examination, diagnosis, management, and functional outcome 1 year after surgical repair is presented and discussed in light of the current literature on lipofibrohamartomas. CLINICAL PRESENTATION: A 3-year-old boy presented to the Louisiana State University Nerve Clinic for evaluation and management because he was experiencing progressive symptoms of left hand swelling, dysesthesia, and impaired motor function. Physical examination demonstrated median nerve distribution motor impairment. Electromyographic/nerve conduction velocity studies also showed severely reduced conduction and amplitude of the median nerve response, and the magnetic resonance imaging findings were highly suggestive of lipofibrohamartoma. Hence, the presumed diagnosis was lipofibrohamartoma on the basis of imaging characteristics, location, and patient's age. INTERVENTION: The patient was brought to the operating room with the objectives of carpal tunnel release and biopsy. However, routine intraoperative nerve action potential recordings showed no or very poor responses, consistent with significant loss of median nerve function. On the basis of the intraoperative nerve action potentials, we opted to resect the tumor back to healthy median nerve fascicles and to perform graft repairs. Surgery proceeded uneventfully, without any complications. Pathology confirmed the diagnosis of lipofibrohamartoma. CONCLUSION: At 18 months postoperatively, the patient had excellent left hand function. On the basis of our experience with this patient, we believe that intraoperative nerve action potentials and the availability of usable proximal and distal nerve fascicles (which may be discernible on diagnostic imaging) are key factors in deciding whether a lipofibrohamartoma needs to be repaired or decompressed/biopsied. As illustrated by our case, we believe that resection and graft repair may be the best treatment option for some of these patients, and perhaps more so for pediatric patients.