Posts

Posted on

Cervical spondylotic myelopathy associated with kyphosis or sagittal sigmoid alignment: outcome after anterior or posterior decompression

J Neurosurg Spine 11:521–528, 2009. DOI: 10.3171/2009.2.SPINE08385

The effects of sagittal kyphotic deformities or mechanical stress on the development of cervical spondylotic myelopathy, or the reduction and fusion of kyphotic sagittal alignment have not been consistently documented. The aim in this study was to determine the effects of kyphotic sagittal alignment of the cervical spine in terms of neurological morbidity and outcome after 2 types of surgical intervention.

Methods. The authors retrospectively reviewed the records of 476 patients who underwent cervical spine surgeries for spondylotic myelopathy between 1993 and 2006 at their university medical center. Among these were identified 43 patients—30 men and 13 women, with a mean age of 58.8 years—who had cervical kyphosis exceeding 10° on preoperative sagittal lateral radiographs obtained in the neutral position, and their cases were analyzed in this study. Anterior decompression with interbody fusion was conducted in 28 patients, and en bloc open-door C3–7 laminoplasty in 15 patients. Both pre- and postoperative neurological, radiographic, and MR imaging findings were assessed in both surgical groups.

Results. The mean preoperative kyphotic angle in all 43 patients was 15.9 ± 5.9° in the neutral position. Seg- mental instability was noted in 26 patients (61%) and reversed dynamic spinal canal stenosis at the level above the local kyphosis in 22 (51%). Preoperative T2-weighted MR images showed high-intensity signal within the cord at and around the level of maximal compression or segmental instability in 28 patients (65%). The mean kyphotic angle in both the neutral and flexion positions was significantly smaller at 4–6 weeks after surgery in the anterior spondylectomy group than in the laminoplasty group (p < 0.001). Furthermore, the angle in the neutral position was significantly smaller on follow-up in the anterior spondylectomy group than in the laminoplasty group (p = 0.034). The transverse area of the spinal cord was significantly larger in the anterior spondylectomy group than in the lamino- plasty group on follow-up (p = 0.037). Preoperative neurological scores (assessed using the Japanese Orthopaedic Association scale) and improvement on follow-up ≥ 2 years after treatment (average 3.3 years) were not significantly different between the 2 groups; however, there was a significant difference in Japanese Orthopaedic Association score at 4–6 weeks postoperatively (p = 0.047).

Conclusions. Kyphotic deformity and mechanical stress in the cervical spine may play an important role in neurological dysfunction. In a select group of patients with kyphotic deformity ≥ 10°, adequate correction of local sagittal alignment may help to maximize the chance of neurological improvement

Posted on

Shunt­dependent hydrocephalus after aneurysmal subarachnoid hemorrhage

J Neurosurg 111:1029–1035, 2009. DOI: 10.3171/2008.9.JNS08881

Chronic shunt­dependent hydrocephalus is a recognized complication of aneurysmal subarachnoid hem­ orrhage. While its incidence and risk factors have been well described, the long­term performance of shunts in this setting has not been not widely reported.

Methods. Using administrative databases, the authors derived a retrospective cohort of patients undergoing treat­ ment of a ruptured aneurysm in Ontario, Canada, between 1995 and 2005. The authors determined the incidence of shunt­dependent hydrocephalus and analyzed putative risk factors. Mortality rates and indicators of morbidity were recorded. Patients were followed up for the occurrence of shunt failure over time.

Results. Of 3120 patients in the cohort, 585 (18.75%) developed shunt-dependent hydrocephalus. On multivari­ ate analysis, age, acute hydrocephalus, ventilation on admission, aneurysms in the posterior circulation and giant aneurysms were all significant predictors of shunt-dependent hydrocephalus. The mortality rate was not increased in patients with chronic hydrocephalus (hazard ratio 1.04, p = 0.63); however, indicators of morbidity were increased in these patients. Of the 585 patients with shunt-dependent hydrocephalus, only 173 (29.6%) underwent a subsequent revision procedure. Ninety-eight percent of these revisions were completed within 6 months. Subsequent revisions occurred more frequently. On multivariate analysis, significant predictors of shunt revision included aneurysm loca­ tion in the posterior circulation and endovascular treatment of the initial ruptured aneurysm.

Conclusions. Shunt-dependent hydrocephalus affects a significant proportion of subarachnoid hemorrhage sur­ vivors, contributing to additional morbidity among these patients. Shunt failures occur less frequently in patients who underwent treatment for a ruptured aneurysm than with other forms of hydrocephalus. Most failures occur within 6 months, suggesting that shunt dependency may be transient in the majority of patients.

Posted on

Long-term outcome and survival of surgically treated supratentorial low-grade glioma in adult patients

Acta Neurochir (2009) 151:1359–1365. DOI 10.1007/s00701-009-0435-x

The appropriate management of low-grade gliomas is still a matter of debate. So far, there are no randomized studies that analyze the impact of surgical

resection on patient outcome. The value of the data obtained from the few retrospective reports available is often limited.

Patients and methods In the present study, we performed an analysis on data of 130 adult low-grade glioma patients. Extent of the resection was evaluated in correlation to the overall survival (OS) and progression-free survival (PFS) using Cox regression multivariate analysis.

Results Extended surgery was shown to prolong OS and PFS significantly. Re-surgery in the case of a tumor relapse has a significant impact on OS and PFS, too.

Conclusions In summary, we could retrospectively evaluate a large case series of well-defined low-grade gliomas patients with a long follow-up period showing that

extended surgery would be the most effective therapy for low-grade glioma patients even in recurrent diseases

Posted on

Cerebral venous sinus thrombosis: review of the demographics, pathophysiology, current diagnosis, and treatment

Neurosurg Focus 27 (5):E3, 2009. DOI: 10.3171/2009.8.FOCUS09167

Cerebral venous sinus thrombosis (CVST) is a rare clinicopathological entity. The incidence of CVST in chil- dren and neonates has been reported to be as high as 7 cases per million people, whereas in adults the incidence is 3–4 cases per million. The predisposing factors to this condition are mainly genetic and acquired prothrombotic states and infection. The clinical picture of CVST is nonspecific, highly variable, and can mimic several other clinical conditions. Diagnosis of CVST is established with the implementation of neuroimaging studies, especially MR imaging and venography. Identification and elimination of the underlying cause, anticoagulation, proper management of intracranial hypertension, and anticonvulsant prophylaxis constitute cornerstones of CVST treatment. Newer treatment strategies such as endovascular thrombolysis and decompressive craniectomy have been recently used in the treatment of patients with CVST with variable success rates. Further clinical research must be performed to delineate the exact role of these newer treatments in the management of severe cases of CVST. The recent advances in the diagnosis and treatment of patients with CVST have significantly lowered the associated mortality and morbidity and have improved the outcome of these patients.

Posted on

Long-term survivors of glioblastoma: clinical features and molecular analysis

Acta Neurochir (2009) 151:1349–1358. DOI 10.1007/s00701-009-0387-1

Glioblastoma is a highly lethal neoplasm with a median survival of 12–14 months; only 2–5% of patients survive >3 years.

Methods At our institute, patients with glioblastoma are initially treated with maximum tumor resection followed by radiation and the intravenous injection of nimustine hydrochloride (ACNU).

Results Using this strategy, 18 of 123 (14.6%) patients treated at our hospital survived >3 years; 7 manifested no recurrence, and the other 11 had early recurrence and received additional therapies. To identify factors associated with prolonged survival, we compared these patients with 21 short-term (<1.5 years) glioblastoma survivors. In the long-term survivors, the MGMT promoter methylation was significantly more frequent. The rate of p53 mutation was lower, and the rate of PTEN mutations and the proliferation index were slightly higher in short-term survivors.

Conclusion By multivariate analysis,  we found that a younger age and MGMT promoter methylation were significant favorable factors in patients with glioblastoma.

Posted on

Limits of endoscopic treatment of sylvian arachnoid cysts in children

Childs Nerv Syst. DOI 10.1007/s00381-009-0977-5

The optimal surgical management of sylvian arachnoid cysts is debated. We present our experience in children who were treated endoscopically, focusing on the limits and complications of this approach.

Materials and methods: Seventeen children with a temporo- sylvian arachnoid cyst have been treated using a purely temporal endoscopic approach.

Results: In all but one case, the recognition of anatomical landmarks was obtained at the insertion of the endoscope. In one child, the orientation and opening of the basal cisterns were more difficult due to the thickness and opacity of the membranes. Nevertheless, it was possible to perform the cysto-cisternostomy endoscopically in all children with several stomies in 13. In one child, a venous bleeding occurred. There were no other intraoperative complications. There were no postoperative cerebrospinal fluid leaks. In two patients, a symptomatic subdural collection developed which required a transient subdural-peritoneal shunt. No subdural collection was noted on a delayed follow-up (mean, 23 months). Preoperative symptoms related to the mass effect exerted by the cyst resolved in all children. Two children presented a recurrence, 12 and 20 months after endoscopic surgery, respectively. At the redo-endoscopy, the stomies were found to be closed. Their reopening resulted in the disappearance of the symptoms.

Conclusions: An endoscopic approach can be used safely in the management of sylvian arachnoid cysts. An effective opening of the deep arachnoid membranes into the basal cisterns could be performed in all patients with the resolution of the preoperative symptoms. However, the long-term efficacy of the stoma needs to be assessed.

Posted on

Craniotomy for resection of meningioma in the elderly: a multicenter, prospective analysis from the National Surgical Quality Improvement Program

J Neurol Psychiatry. DOI:10.1136/jnnp.2009.185074

Whether there is an increased surgical risk in elderly patients who undergo craniotomy for meningioma resection, remains a point of controversy. Utilizing multicenter, prospective data from the National Surgical Quality Improvement Program, the present study sought to address this controversy.

All patients who underwent a craniotomy for resection of intracranial meningioma between 1997 and 2006 at 123 VA hospitals around the country were included. After controlling for preoperative factors such as ASA class, race, diabetes mellitus, disseminated cancer, tobacco use, tumor location, and functional health status in a multivariate logistic regression model, the effect of elderly age (age greater than 70 years) on 30-day mortality was determined.

Our study included 1,281 patients who underwent surgical resection of an intracranial meningioma. The elderly cohort, represented 21.2% (n=258) of our total study population. Elderly patients had a higher 30-day mortality (12.0%) than younger subjects (4.6%) (P < 0.0001). Similarly, elderly patients were more likely to have one or more complications (29.8% vs. 13.1%, P < 0.0001). Multivariate logistic regression identified age, functional status, preoperative disseminated cancer, and tumor location as important predictors of 30-day mortality. After controlling for preoperative comorbidities and risk factors, the odds of perioperative mortality in elderly patients were 3 times that of younger patients (95% CI = 1.7 – 5.3, P = 0.0102).

After carefully controlling for various patient characteristics, ASA class and functional status, elderly patients have poorer outcome after surgical resection of intracranial meningioma than younger subjects.

Posted on

Detection of changes in cerebrospinal fluid space in idiopathic normal pressure hydrocephalus using voxel-based morphometry

Neuroradiology DOI 10.1007/s00234-009-0610-z

We attempted to detect alterations in the cerebrospinal fluid (CSF) space in patients with idiopathic normal pressure hydrocephalus (iNPH) using voxel-based morphometry (VBM).

Methods. We obtained sagittal volume images of the entire head by three-dimensional T1-weighted magnetic resonance imaging and compared the regional distribution of CSF in 12 patients with iNPH, 14 patients with Alzheimer’s disease (AD), and 17 healthy individuals using VBM with automatically extracted CSF objects.

Results. VBM demonstrated significant widening at the lateral ventricles and Sylvian fissures and narrowing of the CSF space at the high convexity/midline areas in iNPH patients, compared to the AD patients and healthy controls (p<0.05, after correction with a false-discovery rate). In addition, the ratio of the CSF volume in the lateral ventricle/Sylvian fissure area to that in the high convexity/midline area in iNPH patients (3.9 ± 1.2) was remarkably greater than that in AD patients (1.2 ± 0.3) ANOVA, p < 0.001; post hoc Tukey’s test, p < 0.001); we could discriminate iNPH patients from those in the other two groups without any overlap, when using a cutoff level of 1.9.

Conclusion. VBM using CSF objects can be used to delineate the characteristic alteration of the CSF space in iNPH patients, which has been evaluated by visual interpretation.

Posted on

Primary CNS lymphoma in the elderly: temozolomide therapy and MGMT status

J Neurooncol. DOI 10.1007/s11060-009-0032-0

This retrospective series explores temozolomide monotherapy in elderly patients with primary CNS lymphoma (PCNSL) and severe comorbidities. In 17 patients (62–90 years old), the complete response rate was 47%, median progression-free survival was 5 months, and median overall survival was 21 months. Five of 17 patients (29.4%) had prolonged responses for at least 12 months and survived for more than 24 months. Three of these patients had a methylated O6-methylguanine-DNA methyltransferase (MGMT) promoter, while the MGMT status was not assessable in the remaining two patients.

Temozolomide monotherapy appears to be effective in a subgroup of elderly PCNSL patients and deserves further evaluation.

Posted on

Basioccipital hypoplasia in Chiari malformation Type I

J Neurosurg 111:1046–1052, 2009. DOI: 10.3171/2009.2.JNS08284

The chronic tonsillar herniation defining Chiari malformation Type I (CMI) is thought to result from overcrowding of a normally developing hindbrain within a congenitally small posterior cranial fossa (PCF) due to occipital hypoplasia. The goals in the present study were to authenticate the cranioencephalic disproportion in a group of patients with CMI and to discuss new developmental aspects according to which part of the occipital bone was underdeveloped.

Methods. The authors retrospectively examined a group of 17 patients with CMI. Measurements of osteotento- rial and neural structures of the PCF were made on MR images of the brain. The results were compared with findings in 30 healthy controls by using the Mann-Whitney U-test.

Results. Dimensions of the neural structures did not differ between the 2 groups of patients. The mean length of the basiocciput was significantly shorter in the CMI group (19.4 mm) compared with the control group (25.7 mm; p = 0.0003). The mean diameter of the foramen magnum was larger in the CMI group, but this difference was not statistically significant. The dimensions of the supraocciput and the mean angle of the cerebellar tentorium were identical in the 2 groups.

Conclusions. Data in this study support the idea that occipital hypoplasia is the main cause of overcrowding within the PCF. Basioccipital shortness is a cardinal feature of the resultant shallow PCF and could proceed from a congenital disorder of the cephalic mesoderm of the parachordal plate or occur later in the infancy because of prema- ture stenosis of the sphenooccipital synchondrosis

Posted on

Efficacy of antibiotic-impregnated shunt catheters in reducing shunt infection: data from the United Kingdom Shunt Registry

J Neurosurg Pediatrics 4:389–393, 2009. (DOI: 10.3171/2009.4.PEDS09210)

In recent years CSF shunt catheters impregnated with rifampicin and clindamycin have been introduced to the United Kingdom (UK) market. These catheters have been shown to be effective in vitro against cultures of Staphylococcus epidermidis. The authors used data collected by the UK Shunt Registry to assess the efficacy of antibiotic-impregnated catheters (AICs) against shunt infection by using a matched-pair study design.

Methods. The UK Shunt Registry contains data on nearly 33,000 CSF shunt-related procedures. The authors identified 1139 procedures in which impregnated catheters had been used, and accurate information was known about diagnosis, number of revisions, sex, and age in these cases. The database was ordered chronologically and searched forward and backward for cases with these same characteristics but involving conventional catheters. Matches were found for 994 procedures.

Results. Among the 994 procedures in which AICs had been used, 30 shunts were subsequently revised because of shunt infection. Among the 994 controls, 47 were subsequently revised for infection (p = 0.048, chi-square test).

Conclusions. The UK Shunt Registry does not collect data on causative organisms, and the surgeon is relied on entirely for the diagnosis of infection. However, with the large number of matched pairs evaluated, the authors attempted to reduce bias to a minimum. Their data suggest that AICs have the potential to significantly reduce shunt infections.


Posted on

Surgical results of cervical myelopathy in patients older than 80 years of age

J Neurosurg Spine 11:421–426, 2009. DOI: 10.3171/2009.4.SPINE08584

In this prospective analysis the authors describe the clinical results of surgical treatment in patients > 80 years of age in whom spinal function was evaluated with motor evoked potential (MEPs) monitoring.

Methods. The authors included 57 patients > 80 years of age who were suspected of having cervical myelopathy. The mean age of the patients was 83.0 years (range 80–90 years). The central motor conduction time (CMCT) was calculated from the latencies of the MEPs following transcranial magnetic stimulation and from M and F waves fol- lowing peripheral nerve stimulation.

Results. Preoperative electrophysiological evaluation demonstrated significant elongation of CMCT or abnor- malities in MEP waveforms in 37 patients (65%), and 35 patients of these underwent laminoplasty. In 30 patients cervical spondylotic myelopathy was diagnosed and 5 patients ossification of the posterior longitudinal ligament was diagnosed. The preoperative mean Japanese Orthopaedic Association Scale score was 8.6 (range 3–12.5) and the mean postoperative score was 12.6 (range 6–14.5) with an average recovery rate of 45% (range −21 to 100%). There were no major complications in any of the patients during the operative period and there were no cases of death resulting from operative intervention.

Conclusions. Sufficient clinical results are expected even in patients with myelopathy who are older than 80 years of age, provided the patients are correctly selected by electrophysiological evaluation with MEPs and CMCT.


Posted on

Three-dimensional simulation for aneurysm surgery

Neurosurgery 65:719–726, 2009 DOI: 10.1227/01.NEU.0000354350.88899.07

OBJECTIVE: With improvements in endovascular techniques, fewer aneurysms are treated by surgical clipping, and those aneurysms targeted for open surgery are often complex and difficult to treat. We devised a hollow, 3-dimensional (3D) model of individual cerebral aneurysms for preoperative simulation and surgical training. The methods and initial experience with this model system are presented.

METHODS:The 3D hollow aneurysm models of 3 retrospective and 8 prospective cases were made with a prototyping technique according to data from 3D computed tomographic angiograms of each patient. Commercially available titanium clips used in our routine surgery were applied, and the internal lumen was observed with an endoscope to confirm the patency of parent vessels. The actual surgery was performed later.

RESULTS: In the 8 prospective cases, the clips were applied during surgery in the same direction and configuration as in the preoperative simulation. Fine adjustments were necessary in each case, and 2 patients needed additional clips to occlude the atherosclerotic aneurysmal wall. With these 3D models, it was easy for neurosurgical trainees to grasp the vascular configuration and the concept of neck occlusion. Practicing surgery with these models also improved their handling of the instruments used during

aneurysm surgery, such as clips and appliers.

CONCLUSION: Using the hollow 3D models to simulate clipping preoperatively, we could treat the aneurysms confidently during live surgery. These models allow easy and concrete recognition of the 3D configuration of aneurysms and parent vessels.

Posted on

Intraoperative mapping and monitoring of brain functions for the resection of low-grade gliomas

Neurosurg Focus 27 (4):E4, 2009. (DOI: 10.3171/2009.8.FOCUS09137)

Low-grade gliomas ([LGGs] WHO Grade II) are slow-growing intrinsic cerebral lesions that diffusely infiltrate the brain parenchyma along white matter tracts and almost invariably show a progression toward malignancy. The treatment of these tumors forces the neurosurgeon to face uncommon difficulties and is still a subject of debate. At the authors’ institution, resection is the first option in the treatment of LGGs. It requires the combined efforts of a multidisciplinary team of neurosurgeons, neuroradiologists, neuropsychologists, and neurophysiologists, who together contribute to the definition of the location, extension, and extent of functional involvement that a specific lesion has caused in a particular patient. In fact, each tumor induces specific modifications of the brain functional network, with high interindividual variability. This requires that each treatment plan is tailored to the characteristics of the tumor and of the patient. Consequently, surgery is performed according to functional and anatomical boundaries to achieve the maximal resection with maximal functional preservation. The identification of eloquent cerebral areas, which are involved in motor, language, memory, and visuospatial functions and have to be preserved during surgery, is performed through the intraoperative use of brain mapping techniques. The use of these techniques extends surgical indications and improves the extent of resection, while minimizing the postoperative morbidity and safeguarding the patient’s quality of life.

In this paper the authors present their paradigm for the surgical treatment of LGGs, focusing on the intraoperative neurophysiological monitoring protocol as well as on the brain mapping technique. They briefly discuss the results that have been obtained at their institution since 2005 as well as the main critical points they have encountered when using this approach.

Posted on

Cross-sectional magnetic resonance imaging study of lumbar disc degeneration in 200 healthy individuals

J Neurosurg Spine 11:501–507, 2009. (DOI: 10.3171/2009.5.SPINE08675)

Object. The current cross-sectional observational MR imaging study aimed to investigate the prevalence and risk factors of lumbar disc degeneration in a healthy population and to establish the baseline data for a prospective longitudinal study.

Methods. Two hundred healthy volunteers participated in this study after providing informed consent. The status of lumbar disc degeneration was assessed by 3 independent observers, who used sagittal T2-weighted MR imaging. Demographic data collected included age, sex, body mass index, episode(s) of low-back pain, smoking status, hours of standing and sitting, and Roland-Morris Disability Questionnaire scores. There were 68 men and 132 women whose mean age was 39.7 years (range 30–55 years). Eighty-two individuals (41%) were smokers, and the Roland- Morris Disability Questionnaire scores were averaged to 0.6/24.

Results. The prevalence of disc degeneration was 7.0% in L1–2, 12.0% in L2–3, 15.5% in L3–4, 49.5% in L4–5, and 53.0% in L5–S1. A herniated disc was observed at the corresponding levels in 0.5, 3.5, 6.5, 25.0, and 35.0% of cases respectively. Spondylolisthesis was observed in < 3% of this population. Multiple logistic regression analysis demonstrated that age and hours sitting were significantly related to L4–5 disc herniation. Episode of low-back pain, smoking status, body mass index, and hours standing did not affect the prevalence of disc degeneration.

Conclusions. The current study established the baseline data of lumbar disc degeneration in a 30- to 55-year-old healthy population for a prospective longitudinal study. Hours spent sitting significantly increased the prevalence of disc herniation, but episode of low-back pain, smoking status, obesity, and standing hours were not significant risk factors.

Posted on

Intracranial infectious aneurysms: a comprehensive review

Neurosurg Rev DOI 10.1007/s10143-009-0233-1

Intracranial infectious aneurysms, or mycotic aneurysms, are rare infectious cerebrovascular lesions which arise through microbial infection of the cerebral arterial wall. Due to the rarity of these lesions, the variability in their clinical presentations, and the lack of population-based epidemiological data, there is no widely accepted management methodology. We undertook a comprehensive literature search using the OVID gateway of the MEDLINE database (1950–2009) using the following keywords (singly and in combination): “infectious,” “mycotic,” “cerebral aneurysm,” and “intracranial aneurysm.” We identified 27 published clinical series describing a total of 287 patients in the English literature that presented demographic and clinical data regarding presentation, treatment, and outcome of patients with mycotic aneurysms. We then synthesized the available data into a combined cohort to more closely estimate the true demographic and clinical characteristics of this disease. We follow by presenting a comprehensive review of mycotic aneurysms, highlighting current treatment paradigms. The literature supports the administration of antibiotics in conjunction with surgical or endovascular intervention depending on the character and location of the aneurysm, as well as the clinical status of the patient. Mycotic aneurysms comprise an important subtype of potentially life-threatening cerebrovascular lesions, and further prospective studies are warranted to define outcome following both conservative and surgical or endovascular treatment.


Posted on

Hyponatremia in Neurosurgical Patients: Clinical Guidelines Development

Neurosurgery. 65(5):925-936, November 2009. DOI: 10.1227/01.NEU.0000358954.62182.B3

OBJECTIVE: Neurosurgical patients have a high risk of hyponatremia and associated complications. We critically evaluated the existing literature to identify the determinants for the development of hyponatremia and which management strategies provided the best outcomes.

METHODS: A multidisciplinary panel in the areas of neurosurgery, nephrology, critical care medicine, endocrinology, pharmacy, and nursing summarized and classified hyponatremia literature scientific studies published in English from 1950 through 2008. The panel’s recommendations were used to create an evaluation and treatment protocol for hyponatremia in neurosurgical patients at the University of Florida.

RESULTS: Hyponatremia should be further investigated and treated when the serum sodium level is less than 131 mmol/L (class II). Evaluation of hyponatremia should include a combination of physical examination findings, basic laboratory studies, and invasive monitoring when available (class III). Obtaining levels of hormones such as antidiuretic hormone and natriuretic peptides is not supported by the literature (class III). Treatment of hyponatremia should be based on severity of symptoms (class III). The serum sodium level should not be corrected by more than 10 mmol/L/d (class III). Cerebral salt wasting should be treated with replacement of serum sodium and intravenous fluids (class III). Fludrocortisone may be considered in the treatment of hyponatremia in subarachnoid hemorrhage patients at risk of vasospasm (class I). Hydrocortisone may be used to prevent natriuresis in subarachnoid hemorrhage patients (class I). Hyponatremia in subarachnoid hemorrhage patients at risk of vasospasm should not be treated with fluid restriction (class II). Syndrome of inappropriate antidiuretic hormone may be treated with urea, diuretics, lithium, demeclocycline, and/or fluid restriction (class III).

CONCLUSION: The summarized literature on the evaluation and treatment of hyponatremia was used to develop practice management recommendations for hyponatremia in the neurosurgical population. However, the practice management recommendations relied heavily on expert opinion because of a paucity of class I evidence literature on hyponatremia.

Posted on

Primary Intramedullary Tumors of the Spinal Cord

SPINE Volume 34, Number 22S, pp S69 –S77, 2009

Study Design. Clinically based systematic review.

Objective. To define optimal clinical care for primary intramedullary spinal cord tumors using a systematic re- view with expert opinion.

Methods. Focused questions on the treatment of primary intramedullary spinal cord tumors were refined by a panel of spine oncology surgeons, medical and radiation oncologist. Keyword were searched through Medline database and pertinent abstracts and manuscripts obtained. The quality of literature was rated as high, moderate, low, or very low. Using the GRADE evidence based review system the proposed questions were answered using the literature review and expert opinion. These treatment recommendations were then rated as either strong or weak based on the quality of evidence and clinical expertise.

Results. The literature searches revealed low and very low quality evidence with no prospective or randomized studies. The MEDLINE search engine returned 9000 articles which was restricted to articles about human subjects and written in the English language. The subsequent search resulted in a return of: “spinal cord tumor” (5053), “ependymoma” (580), “astrocytoma” (420), and “glioma” (235) articles. Seventeen articles referenced timing of surgical intervention and symptomatology for intramedullary spinal cord tumors. One hundred fifty-eight chemotherapy and 183 radiation therapy articles for intramedullary spinal cord tumors were reviewed.

Conclusion. The most important factor in determining the IMSCT patient’s long-term neurologic and functional outcome after surgery is the patient’s preoperative neurologic status. However, this must be taken in the context of the underlying tumor histology. Therefore, resection is reserved for progressive neurologic decline and serial monitoring for asymptomatic individuals. Adjuvant therapy is an option for high grade astrocytomas (WHO grades 3–4).


Posted on

Removal of giant extraforaminal dumbbell tumors of cervical spine

The Spine Journal 9 (2009) 822–829. doi:10.1016/j.spinee.2009.06.023

Removal of cervical dumbbell tumors can be particularly challenging because of unique exposure requirements and proximity of the vertebral artery (VA). There are no reports describing the treatment of giant cervical spine dumbbell tumors (CSDTs).

PURPOSE: To introduce an extensive posterolateral approach to CSDTs involving total lateral mass resection and laminectomy.

STUDY DESIGN: Prospective study of all the patients with multilevel CSDTs treated by  this new procedure between December 2002 and March 2006.

PATIENT SAMPLE: Sixteen patients (3 men and 13 women) with CSDTs underwent the procedure we describe. The follow-up periods ranged from 9 to 51 months (average 9 months). Average age at surgery was 45 years (range 23–68 years).

OUTCOME MEASURES: Axial symptoms and Japanese Orthopedic Association scores were recorded. Pre- and postoperative ranges of neck motion were measured on lateral flexion and extension radiographs.

METHODS: After making a midline incision, we preferred exposing the extraforaminal component of the tumor before performing a semilaminectomy and lateral mass resection. Any lateral extensión of a tumor can be attained by detachment of the adjacent three or more segments of the lateral mass muscle insertion. The most lateral portion can be separated beneath the tumor’s superficial muscle flap, and then when the tumor is retracted medially, the whole portion of the lateral component can be totally exposed. We then performed total lateral mass resection and laminectomy to expose the tumor at the foramina and cervical canal.

RESULTS: We were able to completely resect the tumors in every patient. The average duration of surgery was 150 minutes. Blood loss was minimal (average 400 mL). All patients were monitores for a minimum of 9 months (range 9–51 months; mean 28 months). The follow-up period was uneventful, and no patients developed spinal instability.

CONCLUSIONS: Extensive posterolateral exposure enables surgeons to reach the lateralmost portion of CSDTs and also facilitates septation of the VA and resection of vertebral body encroachment of the tumor.


Posted on

Improving the prognosis for patients with glioblastoma: the rationale for targeting Src

J Neurooncol (2009) 95:151–163 DOI 10.1007/s11060-009-9916-2

Glioblastoma is the most common and aggressive form of primary brain tumor. The prognosis for patients diagnosed with glioblastoma is poor, with a median survival of 12–14 months and a 5-year survival rate of <5%. The upfront standard treatment for patients with newly diagnosed glioblastoma, consisting of surgery followed by chemotherapy combined with radiotherapy, provides only short-term survival benefits. Recurrent glioblastoma is an extremely challenging therapeutic setting because of the aggressive and resistant nature of the tumor. A set of key molecular targets in oncology is the Src family of non-receptor protein kinases. Dysregulated signaling via the Src kinases has been shown to underlie glioma-related proliferation, angiogenesis, migration, and survival. Here we review the biologic role of Src in malignant glioma and discuss key preclinical studies demonstrating the potential utility of inhibiting Src in glioma. Proof of clinical benefit is forthcoming from the first clinical studies involving the newest generation of small molecule Src inhibitors currently in clinical trials for recurrent glioblastoma. Blocking Src alone will likely not translate into a significant clinical benefit; thus, strategies for combining Src inhibitors with potential synergistic therapeutic modalities will be discussed. This review focus on dasatinib, the most advanced Src inhibitor being tested in glioblastoma, which is currently in phase I/II trials in this setting.


Proudly powered by WordPress