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1.
J Neurosurg Case Lessons ; 6(18)2023 Oct 30.
Artigo em Inglês | MEDLINE | ID: mdl-37903420

RESUMO

BACKGROUND: Synovial cysts are a common finding in degenerative spine disease, most frequently involving the facet joints of the lumbar spine. Synovial cysts are less common in the cervical spine and rarely involve the atlantoaxial junction. OBSERVATIONS: In this case report, the authors detail a unique presentation of a left atlantoaxial synovial cyst with large intracranial extension into the cerebellopontine angle causing progressive cranial nerve palsies resulting in tinnitus, vertigo, diminished hearing, gait imbalance, left trigeminal hypesthesia, left facial weakness, and dysarthria. The patient underwent a retromastoid craniectomy for resection of the synovial cyst, resulting in improvement and resolution of symptoms. Follow-up occurred at 6 weeks, 3 months, and 5 months postoperatively without recurrence on imaging. LESSONS: The authors describe acute and long-term management of a unique presentation of an atlantoaxial synovial cyst including retromastoid craniectomy, intervals for follow-up for recurrence, and possible treatment options in cases of recurrence. A systematic literature review was also performed to explore all reported cases of craniocervical junction synovial cysts and subsequent surgical management.

2.
J Neurosurg Case Lessons ; 3(16)2022 Apr 18.
Artigo em Inglês | MEDLINE | ID: mdl-36303492

RESUMO

BACKGROUND: This report describes an unusual meningioma with a large left frontal component and extensive growth within the sagittal sinus and its successful treatment with a staged approach: left frontal craniotomy followed by a sagittal craniotomy and intrinsic removal of the tumor from the sagittal sinus. OBSERVATIONS: A previously healthy 27-year-old presented with 6 months of progressively worsening bilateral headaches, visual changes, and nausea. On examination she had a left cranial nerve VI palsy and severe papilledema. Magnetic resonance imaging revealed a 5.1 × 3.8 × 4.1 cm homogenously enhancing left superior frontal parafalcine extra-axial mass with surrounding vasogenic edema and growth through the sagittal sinus extending just short of the torcula. LESSONS: This case report describes a fast-growing meningioma with a unique pattern of spread, growing through the sagittal sinus as if it were a conduit and resulting in complete occlusion of flow in the sinus. An important recognition in this case was that a robust parasagittal venous plexus had developed on either side of the falx cerebri with drainage to the inferior sagittal sinus. This collateral drainage pattern allowed for an extradural opening of the sagittal sinus from front to back and intrinsic resection of the tumor from the sinus with preservation of the lateral walls of the sinus.

3.
J Neurosurg Case Lessons ; 2(8): CASE21346, 2021 Aug 23.
Artigo em Inglês | MEDLINE | ID: mdl-35855088

RESUMO

BACKGROUND: Ossifying fibromyxoid tumor (OFMT) is a rare entity of soft tissue tumor that most commonly occurs in the subcutaneous tissues of trunk or extremities with occasional cases involving the head and neck; however, primary involvement of the skull has not been reported. While historically considered slow-growing benign to intermediate malignant, few cases of atypical or malignant features have been described. OBSERVATIONS: Herein, the authors present a case of malignant OFMT with primary skull and transcranial extension. The tumor caused lytic calvarial destruction with intra- and extracranial soft tissue components. Gross total resection was performed, and histopathology revealed malignant OFMT with 40 mitoses per 50 high-power fields and moderate nuclear atypia. LESSONS: OFMT can rarely occur in the head and neck and, as reported herein, may involve the skull with intracranial extension. While no uniformly recognized histological criteria for malignancy exist, a three-tiered classification has been proposed: typical, atypical, and malignant, based on features such as hypercellularity, mitotic activity, infiltrative growth, and/or nuclear atypia. Malignant variants should be considered along the high-grade sarcoma spectrum with elevated risk for recurrence or metastatic spread. Routine adjuvant radiotherapy is not typically recommended; however, surveillance imaging is advised.

4.
Cureus ; 11(3): e4282, 2019 Mar 20.
Artigo em Inglês | MEDLINE | ID: mdl-31183265

RESUMO

A 57-year-old male presented with severely altered mental status in the setting of diabetic ketoacidosis. Neuroimaging revealed two intracranial masses. Days following surgical resection of an olfactory groove meningioma, the patient developed Serratia marcescens bacteremia along with an enlarging epidural and subgaleal fluid collection. Subgaleal fluid aspiration was also positive. The patient later returned to the operating room for wound washout where purulent collections were discovered in the subgaleal, epidural, and left subdural spaces. The wound was evacuated and the bone flap was thoroughly cleansed with betadine and soaked in peroxide prior to replacement. Four drains were placed (two subgaleal and two epidural) with two serving as inlets and two as outlets. Continuous irrigation of the subgaleal and epidural spaces with gentamicin solution was performed for five days. The bone flap was successfully salvaged and the patient was discharged from inpatient rehab three weeks following washout.

5.
J Neurosurg ; : 1-7, 2019 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-31675697

RESUMO

The Department of Neurosurgery at the Medical College of Virginia/Virginia Commonwealth University (VCU) celebrates its 100th anniversary in 2019. It was founded by C. C. Coleman, who directed the US Army School of Brain Surgery during World War I and was one of the original members of the Society of Neurological Surgeons. Coleman began a residency program that was among the first four such programs in the United States and that produced such prominent graduates as Frank Mayfield, Gayle Crutchfield, and John Meredith. Neurosurgery at VCU later became a division under the medical school's surgery department. Division chairs included William Collins and Donald Becker. It was during the Becker years that VCU became a leading National Institutes of Health-funded neurotrauma research center. Harold Young oversaw the transition from division to department and expanded the practice base of the program. In 2015, Alex Valadka assumed leadership and established international collaborations for research and education. In its first 100 years, VCU Neurosurgery has distinguished itself as an innovator in clinical research and an incubator of compassionate and service-oriented physicians.

6.
Lancet Neurol ; 15(12): 1228-1237, 2016 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-27751554

RESUMO

BACKGROUND: Craniotomy, according to the results from trials, does not improve functional outcome after intracerebral haemorrhage. Whether minimally invasive catheter evacuation followed by thrombolysis for clot removal is safe and can achieve a good functional outcome is not known. We investigated the safety and efficacy of alteplase, a recombinant tissue plasminogen activator, in combination with minimally invasive surgery (MIS) in patients with intracerebral haemorrhage. METHODS: MISTIE was an open-label, phase 2 trial that was done in 26 hospitals in the USA, Canada, the UK, and Germany. We used a computer-generated allocation sequence with a block size of four to centrally randomise patients aged 18-80 years with a non-traumatic (spontaneous) intracerebral haemorrhage of 20 mL or higher to standard medical care or image-guided MIS plus alteplase (0·3 mg or 1·0 mg every 8 h for up to nine doses) to remove clots using surgical aspiration followed by alteplase clot irrigation. Primary outcomes were all safety outcomes: 30 day mortality, 7 day procedure-related mortality, 72 h symptomatic bleeding, and 30 day brain infections. This trial is registered with ClinicalTrials.gov, number NCT00224770. FINDINGS: Between Feb 2, 2006, and April 8, 2013, 96 patients were randomly allocated and completed follow-up: 54 (56%) in the MIS plus alteplase group and 42 (44%) in the standard medical care group. The primary outcomes did not differ between the standard medical care and MIS plus alteplase groups: 30 day mortality (four [9·5%, 95% CI 2·7-22.6] vs eight [14·8%, 6·6-27·1], p=0·542), 7 day mortality (zero [0%, 0-8·4] vs one [1·9%, 0·1-9·9], p=0·562), symptomatic bleeding (one [2·4%, 0·1-12·6] vs five [9·3%, 3·1-20·3], p=0·226), and brain bacterial infections (one [2·4%, 0·1-12·6] vs zero [0%, 0-6·6], p=0·438). Asymptomatic haemorrhages were more common in the MIS plus alteplase group than in the standard medical care group (12 [22·2%; 95% CI 12·0-35·6] vs three [7·1%; 1·5-19·5]; p=0·051). INTERPRETATION: MIS plus alteplase seems to be safe in patients with intracerebral haemorrhage, but increased asymptomatic bleeding is a major cautionary finding. These results, if replicable, could lead to the addition of surgical management as a therapeutic strategy for intracerebral haemorrhage. FUNDING: National Institute of Neurological Disorders and Stroke, Genentech, and Codman.


Assuntos
Hemorragia Cerebral/tratamento farmacológico , Hemorragia Cerebral/cirurgia , Fibrinolíticos/farmacologia , Avaliação de Resultados em Cuidados de Saúde , Hemorragia Pós-Operatória/etiologia , Trombectomia/métodos , Ativador de Plasminogênio Tecidual/farmacologia , Idoso , Hemorragia Cerebral/mortalidade , Terapia Combinada , Feminino , Fibrinolíticos/administração & dosagem , Fibrinolíticos/efeitos adversos , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos , Cirurgia Assistida por Computador , Trombectomia/efeitos adversos , Ativador de Plasminogênio Tecidual/administração & dosagem , Ativador de Plasminogênio Tecidual/efeitos adversos
7.
J Neurosurg Spine ; 22(1): 1-10, 2015 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-25360528

RESUMO

OBJECT: Bone allografts used for interbody spinal fusion are often preserved through either freeze drying or lowtemperature freezing, each having disadvantages related to graft preparation time and material properties. In response, a glycerol preservation treatment has been developed to maintain the biomechanical properties of allografts at ambient temperatures, requiring no thawing or rehydration and minimal rinsing prior to implantation. The authors conducted a prospective randomized study to compare the clinical results of glycerol-preserved Cloward dowels and those of freezedried Cloward dowels in anterior cervical discectomy and fusion. The primary outcome measures were evidence of fusion and graft subsidence, and the secondary outcome measures included adverse events, pain, and neck disability scores. METHODS: Of 106 patients, 53 (113 levels of surgery) were randomly assigned to the glycerol-preserved graft group and 53 (114 levels of surgery) to the freeze-dried graft group. Subsidence was assessed at 3 and 6 months after implantation. Evidence of fusion was evaluated radiographically at 6 months postimplantation. Subsidence was quantitatively assessed based on physical measurements obtained from radiographs by using calibrated comparators, whereas fusion was also evaluated visually. Surgeons were blinded to treatment type during visual and physical assessments of the patients and the radiographs. RESULTS: No one in either group had evidence of complete nonunion according to radiographic evaluation at the 6-month follow-up. Average subsidence for all graft-treated levels was 2.11 mm for the glycerol-preserved group and 2.73 mm for the freeze-dried group at the 3-month follow-up and 2.13 and 2.83 mm at the 6-month follow-up, respectively. The 2 treatment groups were statistically equivalent (p = 0.2127 and 0.1705 for the 3- and 6-month follow-up, respectively). No differences were noted between the graft types in terms of adverse event incidence or severity. CONCLUSIONS: Glycerol-preserved bone allografts exhibit fusion results and subsidence values similar to those of their freeze-dried counterparts, potentially more favorable biomechanical properties, and significantly shorter preparation times.


Assuntos
Transplante Ósseo/métodos , Vértebras Cervicais/cirurgia , Liofilização/métodos , Fusão Vertebral/métodos , Espondilose/cirurgia , Preservação de Tecido/métodos , Adolescente , Adulto , Idoso , Transplante Ósseo/efeitos adversos , Transplante Ósseo/economia , Vértebras Cervicais/diagnóstico por imagem , Crioprotetores , Avaliação da Deficiência , Discotomia/efeitos adversos , Discotomia/economia , Discotomia/métodos , Seguimentos , Glicerol , Custos Hospitalares , Humanos , Pessoa de Meia-Idade , Estudos Prospectivos , Radiografia , Fusão Vertebral/efeitos adversos , Fusão Vertebral/economia , Espondilose/diagnóstico por imagem , Transplante Homólogo , Resultado do Tratamento , Adulto Jovem
8.
Spine (Phila Pa 1976) ; 40(8): 505-13, 2015 Apr 15.
Artigo em Inglês | MEDLINE | ID: mdl-25646746

RESUMO

STUDY DESIGN: Prospective, 3:1 randomized, single-blind, multicenter investigational study. OBJECTIVE: To assess the safety and efficacy of a low-swell spinal sealant when used as an adjunct to sutured dural repair compared with standard of care methods to obtain watertight dural closure in subjects undergoing spinal surgery. SUMMARY OF BACKGROUND DATA: Watertight dural closure is paramount in spinal surgery to avoid complications of cerebrospinal fluid leak. Prior reports have proven the efficacy of a synthetic, absorbable polyethylene glycol (PEG) hydrogel sealant in spinal surgery compared with standard of care. Given the potential concerns of swelling in spinal applications, the hydrogel was modified to a low-swell formulation. METHODS: The primary endpoint was success rate in obtaining intraoperative watertight dural closure in subjects receiving PEG hydrogel sealant versus a control group of subjects receiving any standard method designed to provide intraoperative watertight closure. Subjects were evaluated at discharge and at 30 and 90 days postprocedure for cerebrospinal fluid leaks, surgical site infections, and adverse events. RESULTS: Between May 2007 and May 2009, 98 subjects (74 PEG hydrogel spinal sealant, 24 control) were randomized at 14 clinical sites in the United States. Patients treated with the PEG hydrogel spinal sealant had a significantly higher rate of watertight closure than the control (98.6% vs. 79.2%, P = 0.003). No statistical differences were seen in postoperative cerebrospinal fluid, infection, and wound healing. No neurological deficits were seen attributable to the sealant. CONCLUSION: The low-swell PEG hydrogel spinal sealant evaluated in this study has been proven safe and effective for providing watertight closure when used as an adjunct to sutured closure of intentional durotomies during spinal surgery. PEG hydrogel sealants have again proved superior to other standard of care technologies for safe, efficacious dural closure. LEVEL OF EVIDENCE: 2.


Assuntos
Vazamento de Líquido Cefalorraquidiano/prevenção & controle , Dura-Máter/cirurgia , Oligopeptídeos/uso terapêutico , Polietilenoglicóis/uso terapêutico , Complicações Pós-Operatórias/prevenção & controle , Adesivos Teciduais/uso terapêutico , Técnicas de Fechamento de Ferimentos , Adulto , Combinação de Medicamentos , Feminino , Humanos , Hidrogel de Polietilenoglicol-Dimetacrilato/química , Hidrogel de Polietilenoglicol-Dimetacrilato/uso terapêutico , Masculino , Pessoa de Meia-Idade , Oligopeptídeos/efeitos adversos , Oligopeptídeos/química , Polietilenoglicóis/efeitos adversos , Polietilenoglicóis/química , Estudos Prospectivos , Método Simples-Cego , Coluna Vertebral/cirurgia , Suturas , Adesivos Teciduais/química
9.
J Neurosurg ; 97(2 Suppl): 186-92, 2002 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-12296677

RESUMO

OBJECT: Bone grafts used in anterior cervical fusion (ACF) may subside postoperatively. The authors reviewed a recent series in which instrument-assisted ACF was performed to determine the degree of subsidence with respect to fusion length, use of segmental screws, and patient smoking status, age, and sex. METHODS: Charts and implant records were reviewed for all 70 patients who underwent instrument-assisted ACF during a 2-year period. The procedures, grafting materials, plate types/lengths, and patient smoking status were recorded. The immediate postoperative and follow-up lateral radiographs were analyzed. The plate lengths and lengths of the fused segments were measured in a standardized fashion. The mean intraoperative and follow-up fusion segment lengths were 54.3 and 51.9 mm, respectively. Greater subsidence occurred in multilevel fusions than in single-level fusions. There were noticeable changes in the position of plates or screws on 14 of 70 follow-up x-ray films. No new neurological deficits related to graft subsidence occurred, and the reoperation rate was 3%. There was no statistical relation between subsidence and the following variables: segmental fixation, smoking status, sex, age, or dowel size when corrected for length of the plate. Hardware migration correlated significantly with plate length in cases of two- and three-level fusions. CONCLUSIONS: The length of a fusion segment decreases in the immediate weeks following instrument-assisted ACF. Construct length is the most important determinant of subsidence. When designing multilevel cervical constructs, consideration of the effects of graft subsidence may help to avoid hardware-related complications.


Assuntos
Placas Ósseas , Parafusos Ósseos , Transplante Ósseo/instrumentação , Vértebras Cervicais/cirurgia , Sobrevivência de Enxerto/fisiologia , Complicações Pós-Operatórias/diagnóstico por imagem , Fusão Vertebral/instrumentação , Osteofitose Vertebral/cirurgia , Adulto , Idoso , Vértebras Cervicais/diagnóstico por imagem , Desenho de Equipamento , Falha de Equipamento , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/cirurgia , Radiografia , Reoperação , Fumar/efeitos adversos , Osteofitose Vertebral/diagnóstico por imagem , Suporte de Carga/fisiologia
10.
J Neurosurg ; 96(2): 244-7, 2002 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-11838797

RESUMO

OBJECT: The authors designed a study to compare low-profile titanium miniplate fixation to that in which stainless steel wire is used. METHODS: Before undergoing craniotomy, 40 patients gave informed consent and were randomized to receive either wire or miniplate fixation. After dural closure, bone flap fixation was timed. The bone flap was measured for inward or outward offset and mobility to manual pressure on its margin. Three months postoperatively the bone flap margins were graded for appearance or palpation of an offset and for the presence of burr hole depressions. Twenty-four patients were randomized to receive miniplate fixation and 16 to receive stainless steel wire fixation. The time required for wire fixation was approximately 40% longer than that for miniplates (11.8 +/- 5.1 minutes compared with 8.3 +/- 5 minutes, p = 0.02). The offset of bone flaps after wire fixation was significantly greater than that with miniplates (1.6 +/- 1 mm compared with 0.3 +/- 0.6 mm, p < 0.001), as was the mobility of the bone flap on digital pressure (1.2 +/- 0.9 mm compared with 0.2 +/- 0.5 mm, p < 0.001). At the 3-month follow-up review, two of 12 patients had suboptimal results after wire fixation, whereas none of 14 patients had suboptimal results after miniplate fixation. When dichotomized for excellent or less-than-excellent postoperative results, the data were significantly better for patients who underwent miniplate fixation (p < 0.05). CONCLUSIONS: Titanium miniplate cranial fixation provides more accurate and rigid reapproximation of the bone edges, with results that are significantly better on close inspection or palpation. The additional cost of miniplate fixation may thus be justified in many cases.


Assuntos
Placas Ósseas/economia , Fios Ortopédicos/economia , Encefalopatias/cirurgia , Craniotomia/economia , Fixação Interna de Fraturas/economia , Aço Inoxidável/economia , Titânio/economia , Adulto , Idoso , Encefalopatias/economia , Custos e Análise de Custo , Feminino , Seguimentos , Custos Hospitalares , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Tempo , Resultado do Tratamento
11.
Hand (N Y) ; 9(4): 484-7, 2014 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-25414609

RESUMO

BACKGROUND: Thoracic outlet syndrome is an uncommon cause of upper extremity neuropathy resulting from either neurogenic or vascular compromise in the thoracic outlet. Congenital anomalies as the cause of this disease process represent a minority of cases, and the literature regarding their surgical management is still evolving. CASE REPORT: A 42-year-old female without any relevant history presented to a clinic for evaluation of worsening neuropathic symptoms in the upper left extremity. Initial physical exam was unremarkable, and MRI identified an anomalous first rib, but no abnormality of the brachial plexus. The patient was managed conservatively for almost 4 years before symptoms became debilitating. Physical exam at that time found atrophy and weakness in the muscles supplied by the upper trunk of the brachial plexus, and CT demonstrated anomalies of the bone and brachial plexus not apparent on previous MRI. Neurolysis with local resection of the abnormal bone led to successful resolution of the patient's symptoms. CONCLUSION: Identification of a rare congenital anomaly allowed for a precise surgical treatment of the condition. The importance of careful selection of modality and review of imaging in diagnosis and operative planning is discussed.

12.
Spine (Phila Pa 1976) ; 32(21): 2285-93, 2007 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-17906567

RESUMO

STUDY DESIGN: Randomized, placebo-controlled, double-blind, multicenter, Phase IIa study. OBJECTIVE: To assess the safety and efficacy of recombinant-activated Factor VII (rFVIIa) in major spinal surgery. SUMMARY OF BACKGROUND: Spinal fusion surgery can cause substantial blood loss and blood product transfusions. Recombinant FVIIa is approved for treatment of bleeding in patients with coagulation abnormalities and has been shown to reduce blood loss and transfusion requirements in surgery in patients with no underlying coagulopathy. METHODS: Forty-nine patients undergoing fusion of 3 or more vertebral segments were randomized and treated on losing 10% of their estimated blood volume (with total expected surgical blood loss > or = 20%) and received 3 doses (2-hour intervals) of placebo (n = 13) or 30, 60, or 120 microg/kg rFVIIa (n = 12 per group). The primary endpoint was safety. A priori-defined efficacy endpoints included blood loss and transfusion requirements between placebo and each rFVIIa dose group, adjusted for surgery duration, number of segments fused, and estimated blood volume. RESULTS: Serious adverse events did not occur at any greater frequency in any of the treatment groups. One patient (3 x 30 microg/kg rFVIIa) with advanced cerebrovascular disease (undiagnosed, trial exclusion criterion) died 6 days after surgery due to an ischemic stroke. Mean blood loss was as follows: 2270 mL for placebo; 1909, 1262, and 1868 mL for 3 x 30, 3 x 60, and 3 x 120 microg/kg rFVIIa, respectively (differences not statistically significant). Mean adjusted surgical blood loss was as follows: 2536 mL for placebo; 1120, 400, and 823 mL for 3 x 30, 3 x 60, and 3 x 120 microg/kg rFVIIa, respectively (P < or = 0.001). Mean surgical transfusion volume was reduced by 27% to 50% with rFVIIa treatment (not significant). The mean adjusted surgical transfusion volume was reduced by 81% to 95% with rFVIIa treatment (P < or = 0.002). CONCLUSION: No safety concerns were indicated for the use of rFVIIa in patients at all doses tested; rFVIIa reduced adjusted blood loss and adjusted transfusions during spinal surgery.


Assuntos
Fator VII/administração & dosagem , Fator VII/metabolismo , Fusão Vertebral , Adolescente , Adulto , Idoso , Perda Sanguínea Cirúrgica/prevenção & controle , Relação Dose-Resposta a Droga , Método Duplo-Cego , Fator VIIa , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Proteínas Recombinantes/administração & dosagem , Proteínas Recombinantes/metabolismo , Doenças da Coluna Vertebral/tratamento farmacológico , Doenças da Coluna Vertebral/cirurgia , Fusão Vertebral/métodos
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