World Neurosurgery - Articles in Press

Surgery:a cost-effective option for drug-resistant epilepsy in China - Accepted Manuscript

Jianbin Chen, Ding Lei — 2012-05-14

Standardization of Surgical Procedures: Beyond Checklists? - Accepted Manuscript

Dennis R. Buis, Sander Idema, Ricardo Feller, W. Peter Vandertop — 2012-05-09

Abstract: After introduction of the NATOPS standardization system the incidence of mishaps in the United States Navy decreased substantially. NATOPS includes standardized programs as the basis for development of an efficient and sound operational procedure. In order to improve patient safety and analogous to NATOPS we propose a standardization program for parts of surgical procedures.

Endoscopic Endonasal Transmaxillary Approach - Accepted Manuscript

Mauro Loyo-Varela, Ramiro del Valle Robles, Tenoch Herrada, Juan Barges Coll — 2012-05-01

Type II Odontoid Fractures, What to do? - Accepted Manuscript

James S. Harrop — 2012-04-30

Cavernous Malformations of the Thalamus: A Relatively Rare but Controversial Entity - Accepted Manuscript

Adib A. Abla, Robert F. Spetzler — 2012-04-30

Atlantoaxial Stabilization: A Minimally Invasive Alternative - Accepted Manuscript

Volker K.H. Sonntag — 2012-04-30

Perspective Suprasellar Cysts - Accepted Manuscript

Ivan S. Ciric — 2012-04-30

Neurocysticercosis: Is Medical Management Innocuous? - Accepted Manuscript

Gerardo Guinto, Yoshiaki Guinto — 2012-04-30

The Challenge of Managing Type II Odontoid Fractures - Accepted Manuscript

David Hart — 2012-04-30

Development of neurological symptoms in patients with asymptomatic cerebral cysticercosis undergoing albendazol therapy for intestinal parasites - Accepted Manuscript

Mauro Loyo-Varela, Bruno Estañol, Salvador Manrique-Guzman — 2012-04-30

Intracranial Dural Arteriovenous Fistulas: A Treatment Paradigm in Flux - Accepted Manuscript

Sharon Webb, L. Nelson Hopkins — 2012-04-30

Historic Background of Spinal Disorders - Accepted Manuscript

Oreste de Divitiis, Andrea Elefante, Enrico de Divitiis — 2012-04-30

Metal on metal lumbar total disc arthroplasty: Ready for prime time? - Accepted Manuscript

Michael Y. Wang — 2012-04-30

Adrenal Insufficiency Following SCI: An under recognized cause of hemodynamic instability? - Accepted Manuscript

Michael Y. Wang — 2012-04-30

A Perspective on Spinal Anatomy in an essential illustrated medical treatise of the late Ottoman Era Mir'āt al-Abdān fī Tashrīḥ-i A'ḍāi'l-Insān (Mirror of the Bodies in the Dissection of the Members of the Human Body) - Accepted Manuscript

James Tait Goodrich — 2012-04-30

Endovascular Deconstruction of the Carotid Artery: Is there a role in the era of flow diversion? - Accepted Manuscript

Ferdinand K. Hui, Peter A. Rasmussen — 2012-04-30

Angiogenesis detection in Cerebral AVM: mediators and gene expression, Treatment hopes for the future - Accepted Manuscript

Mohamed El-Fiki — 2012-04-30

When do unruptured aneurysms deserve treatment based on natural history? Data and outcomes data from the National Inpatient Sample Database - Accepted Manuscript

Adib A. Abla, L. Nelson Hopkins — 2012-04-30

A Critical Analysis of the Literature Review in “Stereotactic Radiosurgery for Trigeminal Pain Secondary to Benign Skull Base Tumors” by Tanaka et al. and Presentation of an Algorithm for Management of These Tumors - Accepted Manuscript

Judith A. Murovic, Steven D. Chang — 2012-04-30

DBS and SCS for vegetative state and minimally conscious state - Accepted Manuscript

2012-04-26

Abstract: Objective: On the basis of the findings of the electrophysiological evaluation of vegetative state (VS) and minimally conscious state (MCS), the effect of deep brain stimulation (DBS) was examined on the basis of long-term follow-up results. The results of spinal cord stimulation (SCS) on MCS was also examined and compared with that of DBS. Methods: One hundred and seven patients in VS and 21 patients in MCS were evaluated neurologically and electrophysiologically over three months after the onset of brain injury. Among the 107 VS patients, 21 were treated by DBS. Among the 21 MCS patients, five were treated by DBS and 10 by SCS. Results: Eight of the 21 patients recovered from VS and were able to follow verbal instructions. These eight patients showed desynchronization on continuous EEG frequency analysis. The Vth wave of the auditory brainstem response (ABR) and N20 of somatosensory evoked potential (SEP) were recorded even with a prolonged latency, and pain-related P250 was recorded with an amplitude of over 7 μV. In addition, DBS and SCS induced a marked functional recovery in MCS patients who satisfied the electrophysiological inclusion criteria. Conclusion: DBS for VS and MCS patients and SCS for MCS patients may be useful, when the candidates are selected on the basis of the electrophysiological inclusion criteria. Only 16 (14.9%) of the 107 VS patients and 15 (71.4%) of the 21 MCS patients satisfied the electrophysiological inclusion criteria.

Educate One to Save a Few. Educate a Few to Save Many - Corrected Proof

Benjamin C. Warf — 2012-04-20

Roughly one-third of the world's nearly 7 billion people are covered by approximately 1/20 of its neurosurgeons. Neurosurgeons in the more developed countries have a moral obligation to increase access to neurosurgical care for the rest of the world. This can be achieved most effectively through neurosurgical education. Many neurosurgeons have already contributed greatly in this regard. Because of insufficient access to neurosurgical care, most children with hydrocephalus in Africa go untreated. Possibly as many as 2000 infants per neurosurgeon per year will develop hydrocephalus in sub-Saharan Africa. We have adopted a disease-specific strategy for training and equipping centers to provide evidence-based endoscopic treatment of hydrocephalus to save lives while avoiding the danger of shunt dependence, which is magnified in this context. In Uganda, we have successfully educated one to save a relative few. Our aim is to educate a few to save many. Such a disease-specific approach may provide a useful strategy for increasing access to care for other common, treatable neurosurgical conditions in resource-poor settings.

Employment of the Sniff Test - Accepted Manuscript

Edward Benzel — 2012-04-19

The Pitfalls of the “Sniff Test”, a Commentary on: The Employment of the “Sniff Test” - Accepted Manuscript

Brandon Bucklen — 2012-04-19

Gamma Knife Surgery of Colorectal Brain Metastases: A High Prescription Dose of 25 Gy May Improve Growth Control - Corrected Proof

2012-04-18

Objective: There are few reports on the effect of gamma knife surgery (GKS) for brain metastases from colorectal cancer. The purpose of this study was to identify prognostic factors for local control, complications, and survival in our series of patients treated with GKS. Methods: Eighty patients (36 males, 44 females) with 140 metastases who received GKS between 1996 and 2008 were retrospectively reviewed. The mean tumor volume was 6.13 (0.01–35.5) cm3; the prescription dose was 21.1 (10–25.1) Gy and the maximum dose 42.7 (17.2–66.7) Gy; and the tumor cover was 95.0% (72%–100%). Results: Growth control was achieved in 93 of 121 tumors (76.9%) and 42 of 68 (61.8%) patients, while treatment failure was seen in 28 of 121 tumors (23.1%). Local control was better if a high prescription dose of 25 Gy was used, 88.4% vs. 71.4% (P = 0.017), or if tumor volume was <5 cm3 (86.4%), compared with 69.9% for 5–20 cm3 and 51.9% for >20 cm3 (P = 0.002). The hazard ratio for local failure with lower prescription doses was 2.8 (P = 0.026) in the unadjusted, and 8.5 (P = 0.055) in the adjusted multivariate analysis (tumor volumes >5 cm3). The median survival was 6 months (range 0–75) after GKS. Age <70 years (P < 0.001) and high RPA class (P = 0.032) were associated with longer survival. Fifteen patients (22.1%) had persistent edema on follow-up MRI, possibly because of radiation damage to the tumor. Radiation-induced edema was asymptomatic in 93.8%. We found neither a decrease in the incidence of new metastases nor improved survival when whole-brain radiation therapy was given prior to GKS. Conclusions: GKS provides reasonable local tumor control. Local control rate is highest if the margin dose is 25 Gy and the tumor volume <5 cm3. Radiation edema was common but rarely symptomatic. Survival is longest for young, well-functioning patients.

Cochlea Radiation Dose Correlates with Hearing Loss Following Stereotactic Radiosurgery of Vestibular Schwannoma - Accepted Manuscript

2012-04-09

Brainstem Cavernous Malformations: 1,390 Surgical Cases From the Literature - Accepted Manuscript

Bradley A. Gross, H. Hunt Batjer, Issam A. Awad, Bernard R. Bendok, Rose Du — 2012-04-09

Abstract: Introduction: Although surgical resection of brainstem cavernous malformations (CM) has been reviewed, numerous large surgical series have been recently reported. Methods: Eighteen new surgical series with 710 patients were found via a Pubmed search, in addition to our previous meta-analysis. Complete excision, complication and long-term outcome results were compiled across these series. They were then compared and subsequently combined with those of our prior report. Results: We combined results of 68 surgical series with 1390 patients, incorporating results from our prior meta-analysis. Across 61 series, 1178/1291 (91%) CM were completely excised. Of 105 partially resected CMs with ample follow-up, 65 rebled (62%). Across 46 series providing information on early neurologic morbidity, the overall rate was 45%. Specifically, 12% of patients required tracheostomy and/or gastrostomy procedures. Overall long-term condition was improved in 62% of patients across 51 series. Across 60 series, overall long-term condition was improved or the same in 84% of patients, with worsening in the remaining 16%. The overall surgical and/or cavernoma related mortality rate for all 1390 patients was 1.5%. Notably, these results did not differ significantly between our initial review and the combined data from the subsequent 18 surgical series recently reported in the literature. Conclusion: Surgical resection of brainstem CM continues to present a considerable challenge with resultant morbidity akin to another CM hemorrhage. We therefore prefer to offer surgery only to patients with at least one prior hemorrhage with CM pial representation. Appropriate patient counseling about expected early morbidity and the potential for long-term worsening is crucial.

Minimally Invasive Intradural Spinal Dural Arteriovenous Fistula Ligation - Accepted Manuscript

2012-04-09

Abstract: Background: Dural arteriovenous fistulas (DAVF) have traditionally been approached through a bilateral laminectomy procedure with intradural exploration and ligation of the fistulae. A minimally invasive approach for DAVF ligation may be associated with fewer complications and a shorter recovery than the traditional laminectomy procedure. Our objective was to determine the feasibility, safety and efficacy of intradural DAVF ligation using a minimally invasive microsurgical technique. Methods: 7 patients with thoracolumbar DAVFs were microsurgically treated with a minimally invasive technique. The procedure entailed localization using fluoroscopy followed by a midline 2.2 cm skin opening. Exposure was facilitated using a tubular retractor. Intradural access was obtained after hemilaminectomy and the fistula was identified and ligated. Dural closure was facilitated by the use of self-closing nitinol clips. The incidence of post-operative complications, blood loss, and length of hospital stay were reviewed. Results: Each patient tolerated the procedure well. There were no intraoperative or postoperative complications. Specifically, there were no new neurological deficits and no cerebrospinal fluid leaks. Each patient was ambulatory within 18 hours with only mild incisional back pain. Mean length of stay was 1.6 days. One year follow-up demonstrated obliteration of the fistula with improvement or stabilization of neurological deficits in all cases. Conclusions: The minimally invasive approach for intradural ligation of DAVFs appears to be a reasonable alternative to bilateral full laminectomies. Although no direct comparison with the more extensive bilateral laminectomy approach has been performed, our initial experience suggests that this novel approach may reduce blood loss and length of hospital stay.

Intravascular Ultrasound in the Evaluation and Management of Cerebral Venous Disease - Accepted Manuscript

2012-04-09

Abstract: Background: Intravascular ultrasound (IVUS) is an important diagnostic tool in many interventions, particularly coronary and carotid artery angioplasty and stenting. In contrast, its application in the management of diseases of the cerebral venous system remains an unexplored territory. We report three patients in whom IVUS was used during angiography when evaluating venous flow obstruction secondary to venous sinus thrombosis, venous sinus stenosis, and a transverse sinus mass lesion, respectively. In addition, we review current literature to summarize previous experience, focusing on the advantages and limitations of IVUS technology in interventional cardiology, carotid artery disease, and venous disease. Case Descriptions: In all three cases, IVUS was used without any complications and provided critical information that guided further management of these distinct diseases. IVUS helped diagnose the presence of intraluminal thrombus, severe stenosis, and a mass lesion in the transverse sinuses, and also helped assess the response to angioplasty of the stenotic regions. Conclusions: IVUS is a promising tool that has potential to improve diagnostic accuracy and to guide the management of several diseases of the cerebral venous system. The cases we describe suggest that IVUS can be successfully used when performing endovascular interventions in patients with obstruction of venous outflow secondary to venous sinus stenosis, thrombosis, or mass lesions.

Evaluation of Interspinous Process Distraction Device (X-STOP) in a Representative Patient Cohort - Accepted Manuscript

2012-04-09

Abstract: Objective: Test the hypothesis that the level of clinical efficacy reported in the investigational-device-exemption (IDE) study of the X-STOP device that led to approval by the U.S. Food and Drug Administration (FDA) could also be achieved in patients representative of the population approved for treatment, irrespective of whether all the stringent requirements of the IDE study were met. Methods: A retrospective analysis was conducted of a consecutive series of 31 patients who received the X-STOP interspinous process distraction device as treatment for neurogenic intermittent claudication (NIC). Outcome was assessed at an average of 2 years after surgery using the Zurich Claudication Questionnaire (ZCQ), employing the definition of clinical success used in the IDE study. Results: On the basis of the ZCQ, clinically significant improvement occurred in 38% of the evaluable patients (21 patients), compared with 48.4% in the IDE study; at the sites other than those of the device’s inventors the improvement level was 37%. Four patients needed additional surgery, which was a rate comparable to that reported in the IDE study. Conclusions: The success level in the controlled IDE study that established the safety and efficacy of the X-STOP device was achieved in a representative patient cohort that did not necessarily meet all the strict requirements of the IDE plan. Nevertheless, the overall results were not good, suggesting that the ZCQ definition of success might not have captured the true outcome of surgical treatment with the X-STOP device.

Intramedullary spinal cord metastases: a 20-year institutional experience with comprehensive literature review - Accepted Manuscript

2012-04-09

Abstract: Object: The objective of this study is to review previous reports as well as our past institutional experience to address the issues regarding patient management and also to assess the predisposing factors that might influence outcome and survival. Methods: We undertook a 20-year (1989-2009) retrospective study of a series of 8 patients diagnosed with intramedullary spinal cord metastases (ISCM) in our institute. We further reviewed 293 cases of ISCM reported in the English literature since 1960. Characteristics regarding the site of the primary cancer, location of ISCM, presence of other metastases, presenting neurological symptoms/signs, duration of symptoms, and the time interval from diagnosis of the primary tumour to ISCM were pooled. We analysed the different treatment approaches, the functional outcome and the factors influencing survival. Results: Lung and breast cancers appear to be the most frequent source of ISCM with cervical, thoracic, and lumbar spine being equally affected. Motor weakness predominates as the commonest symptom at presentation, followed by pain and sensory disturbance. At diagnosis, most patients with ISCM have a known primary cancer often associated with cerebral and other systemic metastases. Overall survival of ISCM is poor (median: 4 months from the time of diagnosis). Survival in surgical patients is 6 months, compared to 5 months in those conservatively managed. Clinical improvement was observed in more than half of those treated surgically, whereas neurological status was maintained in most patients treated conservatively. Conclusion: ISCM is an unusual site for metastasis. Regardless of the treatment, its prognosis is generally poor as its presence often signifies end stage cancer. However, with early diagnosis and appropriate treatment, selected patients may benefit from improved neurological outcome and quality of life.

Characteristics of brain arteriovenous malformations presenting with non-hemorrhagic neurological deficits - Accepted Manuscript

Xianli Lv, Youxiang Li, Xinjian Yang, Chuhan Jiang, Zhongxue Wu — 2012-04-09

Abstract: Objective: To test predictors of brain arteriovenous malformations (AVMs) for a clinical presentation of non-hemorrhagic neurological deficits. Method: Between 1999 and 2008, 302 consecutive patients with AVMs referred to our institution. Twenty-four patients (8.4%) presented with neurological deficits without hemorrhage before treatment. We tested for statistical associations between angioarchitectural characteristics and neurological deficits presentation. Results: When we compared the 24(8.4%) patients with non-hemorrhagic neurological deficits with the 278 patients who did not experience neurological deficits initially (total of 302 patients), female sex(P=0.002), deep AVM location(P=0.015), AVM size of more than 3 cm(P=0.001), more than 3 arterial feeders(P=0.004), only perforating feeding artery(P=0.007), more than 3 draining veins(P=0.016), presence of varices in the venous drainage(P=0.013) and Spetzler-Martin grade of III to V (P=0.004) were statistically associated with neurological deficits. Patient age, eloquent location, deep venous drainage, venous drainage restriction and coexisting aneurysms were not statistically associated with neurological deficits without hemorrhage. Conclusion: The characteristics of AVM associated with non-hemorrhagic neurological deficits without hemorrhage include female sex, deep AVM location, more than 3 arterial feeders, only perforating feeding artery, more than 3 draining veins, presence of varices in the venous drainage and Spetzler-Martin grade of III to V.

Uncorrected Proof

Tiit Mathiesen — 2012-04-06

Core Techniques in Operative Neurosurgery is a modern surgical manual for typical neurosurgical operations. The editors are (in this order) Janidal Rahul, Paul C. McCormick, Peter M. Black; the two latter being internationally recognized experts and neurosurgical leaders.

Evolution and Rebirth of Functional Stereotaxy in the Subthalamus - Uncorrected Proof

Richard M. Lehman, James R. Augustine — 2012-04-05

The first human stereotactic surgery based on intracerebral landmarks and Cartesian coordinates was performed in 1947. With this followed the publication of a number of stereotactic frames and atlases. The intercommissural line joining the anterior and posterior commissures was to define stereotactic coordinate systems used in movement disorders and other functional neurosurgical procedures. Initially the target for Parkinson disease was the globus pallidus internus (GPi), but many investigators soon turned to the thalamus or parts of the subthalamus, but not the subthalamic nucleus. Microelectrode recording was introduced in 1961. With the apparent clinical efficacy of L-DOPA in 1965 interest in stereotactic surgery for Parkinson disease declined. The failure of prolonged, consistent pharmacologic management of bradykinesia and tremor, the side effects of dyskinesias, and the fading therapeutic success of medical treatment of movement disorders led to a resurgence of interest in the surgical management of movement disorders. With advances in understanding of the functional anatomy of the corticobasal ganglia circuit, advances in brain imaging, more sophisticated electrophysiologic recordings, and the use of deep brain stimulation as a reversible lesion, stereotactic surgery returned as a viable option for the treatment of movement disorders. The posterior medial part of the globus pallidus, Vim of the thalamus, and the subthalamus, its nuclei and pathways, are sites for interrupting pathophysiologic circuits. Not only has this been applied to movement disorders, but to epilepsy, chronic pain, and behavioral disorders.

An Anatomic Study of the Occipital Transtentorial Keyhole Approach - Uncorrected Proof

Yuyuan Ma, Qing Lan — 2012-04-05

Objective: To provide an anatomic basis of the occipital transtentorial keyhole approach (OTKA), then explore its feasibility and surgical indication. Methods: Eight cadaveric heads were prepared for this anatomic study. A longitudinal linear 4-cm skin incision that begun at the upper margin of the transverse sinus, 1.5 cm away from the superior sagittal sinus. This was designed for the OTKA. The keyhole craniotomy and conventional craniotomy were performed sequentially for observation and measurement. Results: The interhemispheric corridor and the supratentorial corridor can be used in the OTKA. The surgical field extended superior to the splenium, inferior to the superior medullary velum, ipsilateral to the middle and posterior parts of the medial and inferior temporal lobe, contralateral to the pulvinar, and anterior to the massa intermedia in the third ventricle. The exposure area of the OTKA was 72.05 ± 6.26 mm2 and 182.97 ± 14.65 mm2 before and after the tentorial incision, respectively. The exposure area of the conventional craniotomy was 187.28 ± 20.16 mm2, which had no significant difference to the OTKA. The working angles of the five target points were all smaller for the OTKA than for the conventional approach. The depth of the posterior third ventricle that could be observed was 14.70 ± 2.54 mm with the OTKA. Conclusions: Compared with the conventional approach, the OTKA is a more minimally invasive surgical procedure for treatment of the lesions in the pineal region and the middle and posterior parts of the medial and inferior temporal lobe. However, the working angles are relatively narrow.

Outcomes for Clip Ligation and Hematoma Evacuation Associated with 102 Patients with Ruptured Middle Cerebral Artery Aneurysms - Uncorrected Proof

2012-04-05

Objective: Few studies have investigated the implications of intracerebral hematoma (ICH) due to rupture of a middle cerebral artery (MCA) aneurysm and patient outcomes. We hypothesized that patients with Hunt-Hess (HH) grade IV-V may not benefit from aggressive measures. Methods: A prospectively acquired aneurysm database was examined. We found 144 patients who harbored a ruptured MCA aneurysm and suffered from ICH or intrasylvian hematoma with or without subarachnoid hemorrhage. The mean age of our patients was 52.5 years (range, 10–82 years) with 87 women and 57 men. Of these, 122 (84.7%) underwent a combination of interventions, including clip ligation, hematoma evacuation, and/or endosaccular coiling; most patients underwent clip ligation at the same time as their hematoma was evacuated. The discharge information was not available for two patients. We examined significant associations among presenting details (e.g., age, sex, admission HH grade) and patients' final outcome. Results: The total in-hospital mortality rate was 49% (70 of 142 patients); 42% (51 of 120) for the patients who underwent an intervention and 86.4% (19 of 22) for those who did not undergo any intervention. Among our patients, approximately 52% with an admission HH grade of IV/V died in-hospital after surgery, whereas 21% with admission HH grade of I-III expired during the same time. In the patient cohort with presenting with HH grade IV and V, 4% (3 of 76) demonstrated Glasgow outcome scale 4-5 at discharge, whereas 15% (12 of 78) displayed Glasgow outcome scale 4-5 at 6-month follow-up. Age and sex did not affect outcome. Conclusions: Aggressive clip ligation and hematoma evacuation remains a reasonable option for patients suffering from an ICH associated with a ruptured MCA aneurysm. Admission HH grade is the primary prognostic factor for outcome among this patient population as more than half of patients with HH grade IV and V expired during their hospitalization despite aggressive treatment of their hematoma and aneurysm. Long-term functional outcome was poor in up to 85% of surviving patients with HH grade IV-V. It may be beneficial to discuss these prognostic factors with the family before implementing aggressive measures.

Surgery for Psychiatric Disorders - Uncorrected Proof

2012-04-05

Surgery in psychiatric disorders has a long history and has regained momentum in the past few decades with deep brain stimulation (DBS). DBS is an adjustable and reversible neurosurgical intervention using implanted electrodes to deliver controlled electrical pulses to targeted areas of the brain. It holds great promise for therapy-refractory obsessive-compulsive disorder. Several double-blind controlled and open trials have been conducted and the response rate is estimated around 54%. Open trials have shown encouraging results with DBS for therapy-refractory depression and case reports have shown potential effects of DBS on addiction. Another promising indication is Tourette syndrome, where potential efficacy of DBS is shown by several case series and a few controlled trials. Further research should focus on optimizing DBS with respect to target location and increasing the number of controlled double-blinded trials. In addition, new indications for DBS and new target options should be explored in preclinical research.

Deep Brain Stimulation for Obsessive-Compulsive Disorder: Subthalamic Nucleus Target - Uncorrected Proof

2012-04-05

Because of its reversibility and adaptability, deep brain stimulation (DBS) has recently gained interest in psychiatric disorders, such as obsessive-compulsive disorders (OCD) and depression. In OCD, DBS is now an alternative procedure to lesions of fascicles such as the anterior capsule, which links the orbitofrontal cortex, the cingulum, and the thalamus, and has been applied to new target such as the nucleus accumbens, with promising results. However, a recent interest has been developed toward the subthalamic nucleus (STN), a key structure of the basal ganglia that connects the motor, limbic, and associative systems. It is known from patients with Parkinson disease that STN-DBS can have significant effects on mood and cognition. Those transient effects are usually seen as “side effects” in Parkinson disease, but are clues to the underappreciated role that STN plays in the limbic circuitry, a role whose precise details are as yet unknown and under active investigation. We present the rationale supporting the use of nonmotor STN as a therapeutic target to treat OCD. In particular, we discuss the recent experience and preliminary results of our group after 6 months of nonmotor STN-DBS in patients with severe OCD.

Worldwide Survey on the Use of Navigation in Spine Surgery - Uncorrected Proof

2012-04-05

Objective: Computer-assisted surgery (CAS) can improve the accuracy of screw placement and decrease radiation exposure, yet this is not widely accepted among spine surgeons worldwide. The current viewpoint of the spine surgeon on navigation in their everyday practice is an important issue that has not been studied. A survey-based study assessed opinions on CAS to describe the current global attitudes of surgeons on the use of navigation in spine surgery. Methods: A 12-item questionnaire focusing on the number and type of surgical cases, the type of equipment available, and general opinions toward CAS was distributed to 3348 AOSpine surgeons (a specialty group within the AO [Arbeitsgemeinschaft für Osteosynthesefragen] Foundation). Latent class analysis was used to investigate the existence of specific groups based on the respondent opinion profiles. Results: A response rate of 20% was recorded. Despite a widespread distribution of navigation systems in North America and Europe, only 11% of surgeons use it routinely. High-volume procedure surgeons, neurological surgeons, and surgeons with a busy minimal invasive surgery practice are more likely to use CAS. “Routine users” consider the accuracy, potential of facilitating complex surgery, and reduction in radiation exposure as the main advantages. The lack of equipment, inadequate training, and high costs are the main reasons that “nonusers” do not use CAS. Conclusions: Spine surgeons acknowledge the value of CAS, yet current systems do not meet their expectations in terms of ease of use and integration into the surgical work flow. To increase its use, CAS has to become more cost efficient and scientific data are needed to clarify its potential benefits.

Seizure Control for Patients Undergoing Meningioma Surgery - Uncorrected Proof

2012-04-05

Objective: Seizures are common among patients with meningiomas and are a significant cause of morbidity and poor quality of life. The factors associated with the onset of seizures as well as factors associated with seizure control remains poorly understood. Methods: Adult patients who underwent primary resection of a supratentorial World Health Organization grade I meningioma at a single institution between 1996 and 2006 were retrospectively reviewed. Multivariate logistical regression analyses were used to identify associations with preoperative seizures, and multivariate proportional hazards regression analyses were used to identify associations with prolonged seizure control after surgical resection. Results: Of the 626 patients in this series, 84 (13%) presented with seizures. The factors independently associated with preoperative seizures were Karnofsky performance score ≤80 (P< 0.0001), absence of headaches (P = 0.0006), and vasogenic edema (P = 0.007). At 48 months postoperatively, 90% were Engel class I, 3% were class II, 0 were class III, and 7% were class IV. The factors independently associated with decreased seizure control after surgical resection were uncontrolled preoperative seizures (P = 0.04), parasagittal tumors (P = 0.03), and tumors along the sphenoid wing (P = 0.05). The association between seizure recurrence and tumor recurrence trended toward but did not achieve statistical significance (P = 0.11). Conclusions: With the widespread availability of various neuroimaging modalities, there will be increased detection of intracranial meningiomas. The identification and consideration of factors associated with seizure onset and prolonged seizure control may help guide treatment strategies aimed at improving the quality of life for patients with meningiomas.

Atlantoaxial Fusion with Transarticular Screws: Meta-analysis and Review of the Literature - Uncorrected Proof

2012-04-05

Objective: To review published series describing C1-2 posterior instrumented fusions and summarize clinical and radiographic outcomes of patients treated with transarticular screw (TAS) fixation. Methods: Online databases were searched for English-language articles published between 1986 and April 2011 describing posterior atlantoaxial instrumentation with C1-2 TAS fixation. There were 45 studies including 2073 patients treated with TAS that fulfilled inclusion criteria. Meta-analysis techniques were used to calculate outcomes. Results: All studies provided class III evidence. The 30-day perioperative mortality rate was 0.8%, and the incidence of neurologic injury was 0.2%. The incidence of clinically significant malpositioned screws was 7.1% (confidence interval [CI], 5.7%–8.8%), the incidence of vertebral artery injury was 3.1% (CI, 2.3%–4.3%), and the rate of fusion with the TAS technique was 94.6% (CI, 92.6%–96.1%). Conclusions: TAS fixation is a safe and effective treatment option for C1-2 instability with high rates of fusion (approximately 95%). Screw malposition and vertebral artery injury occurred in approximately 5% of patients. The successful insertion of TAS requires a thorough knowledge of atlantoaxial anatomy.

Atlantoaxial Fusion with Screw-Rod Constructs: Meta-Analysis and Review of Literature - Uncorrected Proof

2012-04-05

Objective: To review published series describing C1-2 posterior instrumented fusions and summarize clinical and radiographic outcomes of patients treated with screw-rod constructs (SRC). Methods: Online databases were searched for English-language articles published between 1991 and April 2011 describing posterior atlantoaxial instrumentation with C1-2 SRC. There were 24 studies including 1073 patients treated with SRC that fulfilled inclusion criteria. Meta-analysis techniques were used to compare outcomes. Results: All studies provided class III evidence. The 30-day perioperative mortality rate was 0.6%, and neurologic injury occurred in two patients with vertebral artery injury (VAI) from screw malpositions (0.2%). The incidence of clinically significant screw malpositions was 2.4% (confidence interval [CI], 1.1%–4.1%), the incidence of VAI was 2.0% (CI, 1.1%–3.4%), and the rate of fusion with the SRC technique was 97.5% (CI, 95.9%–98.5%). Conclusions: SRC is a safe and effective treatment option for C1-2 instability. The low but nonzero incidence of screw malposition and VAI emphasizes the necessity of having a thorough knowledge of atlantoaxial anatomy for successful insertion of screws.

Gamma Knife Radiosurgery for Resectable Brain Metastasis - Uncorrected Proof

Zhiyuan Xu, Mohamed Elsharkawy, David Schlesinger, Jason Sheehan — 2012-04-05

Background: Surgical resection is most often performed for superficially located brain metastasis. We evaluate the use of gamma knife radiosurgery (GKS) for resectable non–small cell lung cancer (NSCLC) brain metastases located <3 cm away from the outer cortical surface. Methods: Between 1999 and 2009, 306 patients were treated for brain metastasis from NSCLC at the University of Virginia. The current study included patients with 3 or fewer resectable brain metastases, with resectable being defined as <3 cm from the nearest outer cortical surface of the brain. Sixty-four patients with 111 metastatic brain lesions were eligible for the study. Survival, tumor control, and need for a craniotomy and tumor resection after GKS were evaluated. Results: The mean overall survival rate in this cohort is 13.5 months (median, 8 months) after GKS, and the mean overall survival after diagnosis of the primary lesion was 31.5 months (median, 19 months). Factors related to prolonged survival after GKS were gender, Karnofsky performance score (KPS), recursive partitioning analysis (RPA) class, age at GKS, number of metastatic lesions, development of new intracranial lesions, and number of lobes involved with metastatic disease. The actuarial local tumor control rate was 84% at 6 months. Two patients (3%) underwent a craniotomy and tumor resection for their progressive superficial metastasis after GKS. Conclusions: GKS for NSCLC brain metastases is effective in patients with 3 or fewer resectable tumors. The need for a craniotomy in this subgroup of patients after GKS is very low.

Is External Cervical Orthotic Bracing Necessary After Posterior Atlantoaxial Fusion with Modern Instrumentation: Meta-Analysis and Review of Literature - Uncorrected Proof

2012-04-05

Background: No guidelines exist regarding external cervical orthoses (ECO) after atlantoaxial fusion. We reviewed published series describing C1-2 posterior instrumented fusions with screw-rod constructs (SRC) or transarticular screws (TAS) and compared rates of fusion with and without postoperative ECO. Methods: Online databases were searched for English-language articles between 1986 and April 2011 describing ECO use after posterior atlantoaxial instrumentation with SRC or TAS. Eighteen studies describing 947 patients who had SRC (± ECO: 254 of 693 patients), and 33 studies describing 1424 patients with TAS (± ECO: 525 of 899 patients) met inclusion criteria. Meta-analysis techniques were applied to estimate rates of fusion with and without ECO use. Results: All studies provided class III evidence, and no studies directly compared outcomes with or without ECO use. There was no significant difference in the proportion of patients who achieved successful fusion between patients treated with ECO and without ECO for SRC or TAS patients. Point estimates and 95% confidence intervals (CI) for rates of fusion ± ECO were 97.4% (CI: 95.2% to 98.6%) versus 97.9% (CI: 93.6% to 99.3%) for SRC and 93.6% (CI: 90.7% to 95.6%) versus 95.3% (CI: 90.8% to 97.7%) for TAS. There was no correlation between duration of ECO treatment and fusion (dose effect). Conclusions: After C1-2 fusion with modern instrumentation, ECO may be unnecessary (class III). Some centers recommend ECO use with patients with softer bone quality (class IV). Prospective, randomized studies with validated radiographic and clinical outcome metrics are necessary to determine the utility of ECO after C1-2 fusion and its impact on patient comfort and cost.

The Nervus Intermedius: A Review of Its Anatomy, Function, Pathology, and Role in Neurosurgery - Uncorrected Proof

R. Shane Tubbs, Dominik T. Steck, Martin M. Mortazavi, Aaron A. Cohen-Gadol — 2012-04-05

Background: Geniculate neuralgia, although uncommon, can be a debilitating pathology. Unfortunately, a thorough review of this pain syndrome and the clinical anatomy, function, and pathology of its most commonly associated nerve, the nervus intermedius, is lacking in the literature. Therefore, the present study aimed to further elucidate the diagnosis of this pain syndrome and its surgical treatment based on a review of the literature. Methods: Using standard search engines, the literature was evaluated for germane reports regarding the nervus intermedius and associated pathology. A summary of this body of literature is presented. Results: Since 1968, only approximately 50 peer-reviewed reports have been published regarding the nervus intermedius. Most of these are single-case reports and in reference to geniculate neuralgia. No report was a review of the literature. Conclusions: Neuralgia involving the nervus intermedius is uncommon, but when present, can be life altering. Microvascular decompression may be effective as a treatment. Along its cisternal course, the nerve may be difficult to distinguish from the facial nerve. Based on case reports and small series, long-term pain control can be seen after nerve sectioning or microvascular decompression, but no prospective studies exist. Such studies are now necessary to shed light on the efficacy of surgical treatment of nervus intermedius neuralgia.

Gamma Knife Surgery versus Reoperation for Recurrent Glioblastoma Multiforme - Accepted Manuscript

2012-04-05

Abstract: Objective: The optimal management of patients with recurrent glioblastoma multiforme (GBM) is a subject of controversy. These patients may be candidates for both reoperation, and/or Gamma Knife Surgery (GKS). Few studies have addressed the role of GKS for relapsing gliomas and the results have not been compared with reoperation. In order to validate the efficacy and safety of GKS, we compared the survival and complication rates of GKS and reoperation for recurrent GBMs. Methods: We retrospectively reviewed 77 consecutive patients with histopathologically confirmed GBMs retreated for recurrent GBM between 1996 and 2007. Thirty-two patients underwent GKS, 26 reoperation and 19 both procedures. Results: Median time from second intervention to tumor progression was longer after GKS than after resection, p=0.009. Median survival after retreatment was 12 months for the 51 patients receiving GKS compared to 6 months for reoperation only (p=0.001, HR 2.4), and 19 months vs. 16 months from the time of primary diagnosis (p=0.021, HR 1.8). A multivariate analysis adjustied for possible confounding factors (tumor volume, RPA-class, neurological deficits, time to recurrence, adjuvant therapy and tumor location), showed significantly longer survival for patients treated with GKS both from retreatment (p=0.013, HR 4.1) and primary diagnosis (p= 0.002, HR 5.8). The adjusted results were still significant after separate analysis according to tumor volume < 5 cm³, 5-20 cm³ and >20 cm³. The complications rate was 9.8% after GKS and 25.2 % after reoperation. Conclusion: GKS may be an alternative to open surgery for small GBMs at the time of recurrences with a significantly lower complication rate and a possible survival benefit compared with reoperation.

Microsurgical findings of Tolosa-Hunt syndrome - Accepted Manuscript

2012-04-05

Abstract: Background: Tolosa-Hunt syndrome (THS), a nonspecific chronic inflammation of the cavernous sinus, is a rarely needed surgical manipulation, even for diagnosis, because corticosteroid therapy is markedly effective against this condition. Case Description: A 59-year-old man presented with left trigeminal neuralgia and right abducens nerve palsy two months after the improvement of right oculomotor nerve palsy by corticosteroid therapy. Radiological examinations showed a mass lesion in the left cavernous sinus. The clinical course indicated THS; however, hematological examination showed a positive tuberculous test. The authors performed a biopsy to rule out tuberculoma in the cavernous sinus. Results: The biopsy was via a left frontotemporal interdural approach. The dura propria over the cavernous sinus was thickened and tightly adhered to the inner layer. The cavernous sinus was occupied by whitish elastic-hard tissue, and it was partially resected through the anterolateral triangle. Histopathological examination showed thick fibrous tissue with numerous degenerated cells and partial inflammatory cell infiltrations without any findings of tuberculoma. The final diagnosis was THS, and corticosteroid therapy was effective despite the chronic fibrous change of the cavernous sinus lesion. Conclusion: The authors present details of surgical findings of THS, which have not been demonstrated in any previous reports.

Comparisons of 30-day mortalities and 90-day functional recoveries after first and recurrent primary intracerebral hemorrhage attacks: A multi-institute based retrospective study - Accepted Manuscript

Kyu Hong Kim, Hyung Dong Kim, Young Zoon Kim — 2012-04-05

Abstract: Objective: The aim of this study was to determine and compare 30-day mortalities and 90-day functional recoveries after first and recurrent primary intracerebral hemorrhage (PICH) attacks. The authors sought to identify factors predisposing 30-day mortality and functional recovery and to compare patients after first and recurrent PICH attacks. Methods: The medical records of 1856 PICH patients treated in Samsung Changwon Hospital and Dong-A University Medical Center from January 2000 to December 2010 were retrospectively evaluated. Results: Of these 1856 patients, 1499 were included. Mean patient age was 66.4±16.3 years, and there were 742 males (49.5%). Recurrent PICH occurred in 142 (9.5%) patients. Thirty day mortality was 13.6% for first PICH patients and 14.1% for recurrent PICH patients (p=0.824). Good functional recovery at 90 days after ictus was achieved by 52.2% of first PICH patients and by 31.0% of recurrent patients (p=0.003). In both groups, multivariate analysis showed unconsciousness, pupillary abnormality, surgery, and underlying disease were associated with high mortality, and that consciousness, a lobal location, a small hemorrhagic volume, and conservative treatment were associated with good functional recovery. After excluding recurrent patients with a previous moderate to severe disability due to the sequelae of PICH, no difference was found between the first (25.1%) and recurrent groups (19.0%) in terms of functional recovery (p=0.083). Conclusion: The factors found to predispose clinical outcome were similar in the two groups. This study shows that given optimal treatment, recurrent PICH patients can achieve the same clinical outcomes as first PICH patients.

Anterior thigh compartment syndrome and local myonecrosis after posterior spine surgery on a Jackson table: report of two cases - Accepted Manuscript

Faiz U. Ahmad, Karthik Madhavan, Ryan Trombly, Allan D. Levi — 2012-04-05

Abstract: Introduction: Acute compartment syndrome (ACS) after posterior spinal surgery is very uncommon. Most of the reported cases have ACS in the legs related to positioning in the knee chest position; post-operative ACS in the thighs is exceedingly rare with only one reported case (17). Methods: case report Results: We report 2 patients who had local muscle necrosis/ACS after spine surgery in prone position and discuss preventive measures. Both of our complications were probably related to reversing the position of the iliac crest and hip pads on a Jackson operating table, which was done to achieve better lumbar lordosis. Conclusions: Our cases indicate the need for high index of suspicion of ACS in patients who have persistent unresolved pain and local swelling. Tissue pressure monitoring is an option in suspected cases. IC and thigh pads should not be reversed during positioning on Jackson table.

Posttraumatic Benedikt's Syndrome: A Rare Entity with Unclear Anatomopathological Correlations - Uncorrected Proof

2012-04-05

Background: This study sought to present a very rare case of a posttraumatic midbrain lesion producing a debilitating constellation of symptoms identified as Benedikt's syndrome. Methods: A 20-year-old woman with traumatic brain injury presented with ipsilateral internal and external ophthalmoplegia, and contralateral hemiataxia, proprioception disturbances, hypertonicity, slight hemiparesis, and hyperactive tendon reflexes. A bibliographic search was performed in PubMed. Results: Neuroimaging revealed a left midbrain lesion at the level of the superior colliculi. In the literature, virtually all Benedikt's syndrome cases, rare anyway, are due to midbrain infarcts (basilar or posterior cerebral artery branches). There is only one case from 1963, reported as a posttraumatic Benedikt-type dyskinesia (French language). The historical evolution of the anatomopathologic correlations of the syndrome is also discussed. Conclusions: Benedikt's syndrome is a very rare condition, usually of vascular etiology. Our case is just the second one of traumatic pathogenesis ever reported, the first in the English language literature.

Hangman's Fracture in an Osteogenesis Imperfecta Patient: A Case Report - Accepted Manuscript

Cedric Shorter, Esther Wylen, Anil Nanda — 2012-04-05

Abstract: Traumatic spondylolisthesis of the axis (TSA), also known as a Hangman's fracture, is a well-described entity, but is relatively uncommon (4). There are only two published reports of these fractures occurring in pediatric patients with osteogenesis imperfecta, a disorder that predisposes patients to long bone fractures (6,7,8). We present a unique case of an adult female with osteogenesis imperfecta who sustained a Type II Hangman's fracture.