A Randomized Trial of Vertebroplasty for Osteoporotic Spinal Fractures

NEJM (361): 569-579. Aug 6, 2009

Vertebroplasty is commonly used to treat painful, osteoporotic vertebral compression fractures.

Methods In this multicenter trial, we randomly assigned 131 patients who had one to three painful osteoporotic vertebral compression fractures to undergo either vertebroplasty or a simulated procedure without cement (control group). The primary outcomes were scores on the modified Roland–Morris Disability Questionnaire (RDQ) (on a scale of 0 to 23, with higher scores indicating greater disability) and patients’ ratings of average pain intensity during the preceding 24 hours at 1 month (on a scale of 0 to 10, with higher scores indicating more severe pain). Patients were allowed to cross over to the other study group after 1 month.

Results All patients underwent the assigned intervention (68 vertebroplasties and 63 simulated procedures). The baseline characteristics were similar in the two groups. At 1 month, there was no significant difference between the vertebroplasty group and the control group in either the RDQ score (difference, 0.7; 95% confidence interval [CI], –1.3 to 2.8; P=0.49) or the pain rating (difference, 0.7; 95% CI, –0.3 to 1.7; P=0.19). Both groups had immediate improvement in disability and pain scores after the intervention. Although the two groups did not differ significantly on any secondary outcome measure at 1 month, there was a trend toward a higher rate of clinically meaningful improvement in pain (a 30% decrease from baseline) in the vertebroplasty group (64% vs. 48%, P=0.06). At 3 months, there was a higher crossover rate in the control group than in the vertebroplasty group (43% vs. 12%, P<0.001). There was one serious adverse event in each group.

Conclusions Improvements in pain and pain-related disability associated with osteoporotic compression fractures in patients treated with vertebroplasty were similar to the improvements in a control group. (ClinicalTrials.gov number, NCT00068822 [ClinicalTrials.gov] .)

Infections associated with indwelling ventriculostomy catheters in a teaching hospital

International Journal of Infectious Diseases – 03 August 2009 (10.1016/j.ijid.2009.04.006)

Ventriculostomy-associated infections are a serious complication of external ventricular drains. The objective of this study was to analyze the clinical features of and risk factors for such infections.

Methods

We retrospectively collected demographic and clinical data on patients with indwelling ventriculostomy catheters hospitalized in a teaching hospital from July 2001 to June 2006, comparing those with and without ventriculostomy-associated infections.

Results

A total of 197 drains (2910 catheter-days) placed in 155 patients were studied. Infections developed in 28 of the 197 (14.2%) drains. The duration from insertion to infection ranged from 7 to 36 days. The cut-off point of duration from insertion to infection was 15.5 days. Re-insertion because of catheter malfunction carried a high risk of infection (p<0.001). Patients with infections had a longer intensive care unit stay (p=0.001), longer duration of catheterization (p=0.002), and a higher incidence of concurrent sepsis (p=0.018), urinary tract infection (p=0.011) and pneumonia (p=0.004). Gram-negative bacilli were the leading pathogens (84%); Pseudomonas aeruginosa was the most common isolate. Polymicrobial infections occurred later than monomicrobial infections (p=0.003).

Conclusions

Repeated insertion and longer duration of drains are major risk factors for ventriculostomy-associated infections.

EANS YOUNG NEUROSURGEONS MEETING 2010 21ST – 24TH FEBRUARY 2010

We are delighted to open registration for the EANS Young Neurosurgeons Meeting, to be held in February 2010.   This is intended as an event which will combine fierce scientific discussion and time to socialise in an informal atmosphere – please submit your application as soon as possible – the initial response to this event has been excellent, and we anticipate a good deal of interest.

However there is always a financial risk attached to the organisation of a new event, particularly in the current economic climate, and we need the firm financial commitment of a minimum number of participants by the end of the preliminary registration period (20th September 2009) if we are definitely to go ahead with the event.

This is intended as an event organised by Young Neurosurgeons for Young Neurosurgeons – so please, register now and play your part in making our event happen, keeping in mind that we have limited places available. We hope that many alumni from the EANS Training Courses will choose to attend, and are seeking to cultivate a similar atmosphere  – however we will also be delighted to welcome those who did not attend the courses, and those from outside Europe.

The morning sessions will consist of lectures from leading figures in European Neurosurgery and a series of “Challenging Topics” in which the merits of different approaches are considered, while the evening sessions will offer a valuable opportunity for recently qualified neurosurgical specialists to present their own work (abstracts to be submitted).

We hope that both sessions will give rise to animated discussions between both participants and faculty members – which can be continued during the afternoon on the ski slopes, when we anticipate that many people will choose to take advantage of the special ski deal which we have negotiated – though Innsbruck itself also has plenty to offer non skiers.

The event is focused particularly on those who have recently qualified, and the submission of abstracts is restricted to those within six years of specialist qualification.  However registration is open to those of all ages, and we hope that the event will provide the opportunity for discussion not only with your peers, but also with senior faculty members.

Please submit your registration form to Susie Hide susie.hide@btinternet.com as soon as possible.   Susie will then send you a link to our online payment facility.  As explained above, we need your firm financial commitment prior to September 20th, and will therefore require a minimum deposit of 300 Euros to be paid within this period.

Surgical treatment of the extratemporal epilepsies

Epilepsia, Aug 12 2009

Epilepsy that originates outside of the temporal lobe can present some of the most challenging problems for surgical therapy. These epilepsies can be broadly categorized as lesional or non-lesional, with the nonlesional cases being the most difficult to localize. Lesional cases can result from malformations of cortical development, tumors, vascular malformations, or areas of old injury. Some lesions, such as focal cortical dysplasia, can be challenging, in that the boundaries of the pathology can be difficult to define. Presurgical goals include defining the structural lesion, the physiologic abnormality, and normal function in the area. These goals can be achieved using a variety of noninvasive and invasive tests. Surgical techniques vary depending on location and pathology but they always include removal of the epileptic brain tissue while preserving en passage vessels and underlying white matter tracts. Surgical outcomes vary depending on the underlying pathology. Surgeries are usually planned with a goal of no expected postoperative deficits, although temporary deficits may be anticipated in some areas, such as the supplementary motor cortex. Extratemporal epilepsy can be managed well with surgical treatment; but proper patient selection, evaluation, and discussion of expected outcomes and risks are critical in this challenging patient population.

Use of the h index in neurosurgery

Journal of Neurosurgery, Aug 2009, Vol. 111, No. 2, Pages 387-392

Object
Assessing academic productivity through simple quantification may overlook key information, and the use of statistical enumeration of academic output is growing. The h index, which incorporates both the total number of publications and the citations of those publications, has been recently proposed as an objective measure of academic productivity. The authors used several tools to calculate the h index for academic neurosurgeons to provide a basis for evaluating publishing by physicians.

Methods
The h index of randomly selected academic neurosurgeons from a sample of one-third of the academic programs in the US was calculated using data from Google Scholar and from the Scopus database. The mean h index for each academic rank was determined. The h indices were also correlated with various other factors (such as time spent practicing neurosurgery, authorship position) to identify how these factors influenced the h index. The h indices were then compared with other citation statistics to evaluate the robustness of this metric. Finally, h indices were also calculated for a sampling of physicians in other medical specialties for comparison.

Results
As expected, the h index increased with academic rank and there was a statistically significant difference between each rank. A weighting based on position of authorship did not affect h indices. The h index was positively correlated with time since American Board of Neurological Surgery certification, and it was also correlated with other citation metrics. A comparison among medical specialties supports the assertion that h index values may not be comparable between fields, even closely related specialties.

Conclusions
The h index appears to be a robust statistic for comparing academic output of neurosurgeons. Within the field of academic neurosurgery, clear differences of h indices between academic ranks exist. On average, an increase of the h index by 5 appears to correspond to the next highest academic rank, with the exception of chairperson. The h index can be used as a tool, along with other evaluations, to evaluate an individual’s productivity in the academic advancement process within the field of neurosurgery but should not be used for comparisons across medical specialties.

Risk factors for postoperative systemic complications in elderly patients with brain tumors

In elderly patients with brain tumors, the prevention of postoperative systemic complications is extremely important, and identification of the risk factors would be useful for planning therapy. The authors investigated ways to avoid postoperative complications by identifying risk factors.

Methods
The study population included 84 patients, 70 years of age or older, who underwent surgical brain tumor removal. The following independent factors were assessed by univariate and multivariate analyses: sex, age, preoperative underlying diseases and complications, histopathological findings, preoperative Karnofsky Performance Scale (KPS) score, preoperative whole blood hemoglobin (Hb) level, preoperative serum total protein (TP) level, operation time, intraoperative blood loss, change in Hb level (difference between pre- and postoperative values), and change in TP level (difference between pre- and postoperative values). The cutoff values for significant independent factors were also determined.

Results
Overall, 35 (41.7%) of the 84 patients had a total of 56 postoperative systemic complications. Univariate analysis identified the preoperative KPS score, intraoperative blood loss, change in Hb level, and change in TP level as risk factors for postoperative complications, and multivariate analysis extracted the following risk factors: the preoperative KPS score (p = 0.0450, OR 4.020), intraoperative blood loss (p = 0.0104, OR 6.571), and change in Hb levels (p = 0.0023, OR 9.301). The cutoff values were: KPS score < 80%, intraoperative blood loss ≥ 350 ml, and change in Hb level ≥ 2.0 g/dl.

Conclusions
In elderly patients with brain tumors, low preoperative KPS score, high intraoperative blood loss, and a large difference between pre- and postoperative Hb levels are significant risk factors for postoperative systemic complications.

Endoscopic treatment of middle fossa arachnoid cysts: a series of 40 patients treated endoscopically in two centres

Child’s Nervous System

Purpose Middle fossa arachnoid cysts (MFAC) are a relatively common, benign pathology that pose a therapeutic challenge for both symptomatic and asymptomatic patients. The optimal surgical strategy and indication to treat are still debated by neurosurgeons. We reviewed our experience and results in a group of patients treated with endoscopic fenestration with the aim to assess indications to treat and clinical and neuroradiological results.
Methods The data on 40 patients operated with endoscopic fenestration for MFAC in two centres, “Anna Meyer” Children’s Hospital, Florence, Italy, and Royal Liverpool Children’s Hospital “Alder Hey”, Liverpool, UK, between 2001 and 2007 were retrospectively reviewed with prospective follow-up. We analysed clinical and neuroradiological presentation, indications to treat, surgical technique, complications, and clinical and neuroradiological follow-up.
Results There were 30 males and ten females: mean age, 7.8 years; mean follow-up, 21 months. The neuronavigation system was used in 12 patients in the English cohort. Thirty-seven patients (92.5%) had a satisfactory clinical outcome. The cyst was reduced in size or completely disappeared in 29 patients (72.5%). There was no death or significant morbidity associated with the procedure. Four patients required further surgical treatment. Four patients experienced a post-traumatic intracystic bleeding after surgery.
Conclusion Compared to microsurgical fenestration and cyst shunting, our experience with endoscopic fenestration was as effective and safe but less invasive. Each case must be assessed with its individual characteristics to define the optimal surgical strategy. Successful treatment may not reduce the risk of post-traumatic head injury haemorrhage.
DOI 10.1007/s00381-009-0952-1

Agraphia after awake surgery for brain tumor: new insights into the anatomo-functional network of writing

Surgical Neurology. Volume 72, Issue 3, Pages 223-241 (September 2009)

Background

Controversy still exists about neural basis underlying writing and its relation with the sites subserving oral language. Our objective is to study functional areas involved in writing network, based on the observations of different postoperative writing disorders in a population of patients without preoperative agraphia.

Methods

We analyzed the postoperative agraphia profiles in 15 patients who underwent surgery for cerebral LGGs in functional language areas, using electrical mapping under local anesthesia. These profiles were then correlated to the sites of the lesions, shown by preoperative cerebral imaging.

Results

Our findings showed that (1) spoken language and writing functions could be dissociated, and that (2) writing is subserved, at least partially, by a network of 5 areas located in the dominant hemisphere for language: the superior parietal region, the supramarginalis gyrus, the second and third frontal convolutions, the supplementary motor area, and the insula. Each of these areas seems to have a different role in writing, which will be detailed in this article. However, among the patients, only those with lesions of the supplementary motor area did not recover from agraphia in the postoperative period (in 50% of cases).

Conclusions

On the basis of these results, and in the light of the recent literature, we discuss the relevance of each area in this anatomo-functional network as well as the clinical implications of such better knowledge of the neural basis of writing, especially for brain surgery and functional rehabilitation.

Retreatment of trigeminal neuralgia with Gamma Knife radiosurgery: is there an appropriate cumulative dose?

J Neurosurg 111:359–364, 2009


Trigeminal neuralgia (TN) is a disorder of the trigeminal nerve that results in intense episodic pain. Primary treatment with Gamma Knife surgery (GKS) is well established; however, a significant number of patients experience recurrence of TN over time. Repeat GKS can be performed, but the retreatment dose has not been well established. In this study, the authors present their institutional retreatment results and compare them with other series.

Methods
Between December 2003 and January 2006, 28 patients were treated at Tufts Medical Center with repeat GKS for recurrence of TN. All patients had been initially treated with GKS at this institution, and only those with significant pain improvement were offered retreatment. The maximum dose was prescribed using a single isocenter; the 4-mm collimator was used. The initial median GKS dose was 80 Gy, the median retreatment dose was 45 Gy, and the median cumulative dose was 125 Gy. The median time between GKS procedures was 18.1 months. Facial pain outcomes were defined using the Marseille scale. Excellent outcome was defined as no pain (with or without medications), and good outcome was defined as > 50% pain relief. Toxicity was categorized as none, mild, or bothersome. The median clinical follow-up after the second GKS was 19.7 months. Our clinical outcomes were compared with 8 previously reported retreatment series (including 1 abstract), both for rate of pain control and for rate of complications.

Results
Outcomes after the second GKS were excellent in 29% (8 patients), good in 32% (9), and poor in 39% (11). Four patients (14%) experienced no improvement after repeat GKS. Eight patients (29%) experienced new trigeminal nerve dysfunction, including numbness (11%), paresthesia (14%), dysesthesia (4%), taste alteration (11%), and bite weakness (4%). None of these were bothersome. No patient developed corneal numbness. Univariate analysis failed to reveal any significant predictors of pain control or complications.

Seven published peer-reviewed retreatment series and the authors’ data (total 215 patients) were analyzed. There was a cumulative dose-response relationship for both pain control (p = 0.04) and new trigeminal dysfunction (p = 0.08). Successful pain control was strongly correlated with development of new dysfunction (p = 0.02). A cumulative dose > 130 Gy was more likely to result in successful (> 50%) pain control, but was also more likely (> 20%) to result in development of new dysfunction.

Conclusions
Successful retreatment of patients in whom the initial GKS treatment fails is feasible. Patients who respond initially may be at a higher risk of retreatment-related complications. There appears to be a dose-response relationship for both pain control and development of new side effects. It is important to counsel and treat patients individually based on this dose-response relationship.

Percutaneous radio-frequency thermocoagulation of the Gasserian ganglion guided by high-speed real-time CT fluoroscopy

Neuroradiology (2009) 51:563-566

Introduction Although Gasserian ganglion block is an established treatment for trigeminal neuralgia, the foramen ovale cannot always be clearly visualized by classical X-ray radiography. We present a new method for percutaneous radio-frequency thermocoagulation of the Gasserian ganglion, in which computed tomography (CT) fluoroscopy is used to guide needle placement.
Methods In the present study, 15 patients with trigeminal neuralgia underwent percutaneous radio-frequency thermocoagulation of the Gasserian ganglion guided by high-speed real-time CT fluoroscopy.
Results Trigeminal neuralgia was improved in all patients after treatment without any severe complications. Moderate dysesthesia occurred in only one case.
Conclusion CT fluoroscopy-guided percutaneous radio-frequency thermocoagulation of the Gasserian ganglion was safe, quick, and effective for patients with intractable idiopathic trigeminal neuralgia.

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