Month: October 2012

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Giant anterior clinoidal meningiomas: surgical technique and outcomes

J Neurosurg 117:654–665, 2012

Surgery for giant anterior clinoidal meningiomas that invade vital neurovascular structures surrounding the anterior clinoid process is challenging. The authors present their skull base technique for the treatment of giant anterior clinoidal meningiomas, defined here as globular tumors with a maximum diameter of 5 cm or larger, centered around the anterior clinoid process, which is usually hyperostotic.

Methods. Between 2000 and 2010, the authors performed 23 surgeries in 22 patients with giant anterior clinoidal meningiomas. They used a skull base approach with extradural unroofing of the optic canal, extradural clinoidectomy (Dolenc technique), transdural debulking of the tumor, early optic nerve decompression, and early identification and control of key neurovascular structures.

Results. The mean age at surgery was 53.8 years. The mean tumor diameter was 59.2 mm (range 50–85 mm) with cavernous sinus involvement in 59.1% (13 of 22 patients). The tumor involved the prechiasmatic segment of the optic nerve in all patients, invaded the optic canal in 77.3% (17 of 22 patients), and caused visual impairment in 86.4% (19 of 22 patients). Total resection (Simpson Grade I or II) was achieved in 30.4% of surgeries (7 of 23); subtotal and partial resections were each achieved in 34.8% of surgeries (8 of 23). The main factor precluding total removal was cavernous sinus involvement. There were no deaths. The mean Glasgow Outcome Scale score was 4.8 (median 5) at a mean of 56 months of follow-up. Vision improved in 66.7% (12 of 18 patients) with consecutive neuroophthalmological examinations, was stable in 22.2% (4 of 18), and deteriorated in 11.1% (2 of 18). New deficits in cranial nerve III or IV remained after 8.7% of surgeries (2 of 23).

Conclusions. This modified surgical protocol has provided both a good extent of resection and a good neurological and visual outcome in patients with giant anterior clinoidal meningiomas.

 

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Unilateral Extradural Motor Cortex Stimulation Is Safe and Improves Parkinson Disease at 1 Year

Neurosurgery 71:815–825, 2012

The primary motor cortex, which is part of the corticobasal ganglia loops, may be an alternative option for the surgical treatment of Parkinson disease.

OBJECTIVE: To report on the 1-year safety and efficacy of unilateral extradural motor cortex stimulation in Parkinson disease.

METHODS: A quadripolar electrode strip was extradurally implanted over the motor cortex. Stimulation was continuously delivered through the electrode paddle contralateral to the most affected clinical side. Subjects were prospectively evaluated by the Unified Parkinson’s Disease Rating Scale (UPDRS) and the Parkinson’s Disease Quality of Life Questionnaire. In addition, an extensive cognitive and behavioral assessment and electroencephalogram recording were performed.

RESULTS: Nine patients were included in this study. No surgical complications or adverse events occurred. Moreover, no cognitive or behavioral changes were observed. Under the off-medication condition, the UPDRS III at baseline was decreased by 14.1%, 23.3%, 19.9%, and 13.2%, at 1, 3, 6, and 12 months, respectively. The motor effects were bilateral, appeared after 3 to 4 weeks of stimulation, and outlasted the stimulation itself for 3 to 4 weeks in 1 case of stimulator accidental switching off. The UPDRS IV was decreased by 40.8%, 42.1%, and 35.5% at 1, 3, and 12 months, respectively. The scores on the Parkinson’s Disease Quality of Life Questionnaire were increased at months 3, 6, and 12.

CONCLUSION: Extradural motor cortex stimulation is a safe procedure. After 12 months, the patients demonstrated a moderate improvement of motor symptoms (particularly axial symptoms) and quality of life.

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Who Should Have Surgery for Spinal Stenosis?

Spine 2012 ; 37 : 1791 – 1802

Study Design. Combined prospective randomized controlled trial and observational cohort study of spinal stenosis (SpS) with an as-treated analysis.

Objective. To determine modifiers of the treatment effect (TE) of surgery (the difference between surgical and nonoperative outcomes) for SpS using subgroup analysis.

Summary of Background Data. The Spine Patient Outcomes Research Trial demonstrated a positive surgical TE for SpS at the group level. However, individual characteristics may affect TE. No previous studies have evaluated TE modifiers in SpS.

Methods. SpS patients were treated with either surgery (n = 419) or nonoperative care (n = 235) and were analyzed according to treatment received. Fifty-three baseline variables were used to define subgroups for calculating the time-weighted average TE for the Oswestry Disability Index (ODI) over 4 years (TE = ΔODI surgery – ΔODI nonoperative ). Variables with significant subgroup × treatment interactions ( P < 0.05) were simultaneously entered into a multivariate model to select independent TE predictors.

Results. Other than smokers, all analyzed subgroups including at least 50 patients improved signifi cantly more with surgery than with nonoperative treatment ( P < 0.05). Multivariate analysis demonstrated: baseline ODI ≤ 56 (TE –15.0 vs. –4.4, ODI > 56, P < 0.001), not smoking (TE –11.7 vs. –1.6 smokers, P < 0.001), neuroforaminal stenosis (TE –14.2 vs. –8.7 no neuroforaminal stenosis, P = 0.002), predominant leg pain (TE –11.5 vs. –7.3 predominant back pain, P = 0.035), not lifting at work (TE –12.5 vs . –0.5 lifting at work, P = 0.017), and the presence of a neurological deficit (TE –13.3 vs . –7.2 no neurological deficit, P < 0.001) were associated with greater TE.

Conclusion. With the exception of smokers, patients who met strict inclusion criteria improved more with surgery than with nonoperative treatment, regardless of other specific characteristics. However, TE varied significantly across certain subgroups, and these data can be used to individualize shared decision making discussions about likely outcomes. Smoking cessation should be considered before surgery for SpS.

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