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Symptomatic spinal epidural veins (SEV) are a rare cause of neurologic dysfunction. Treatment is centered upon addressing the underlying venous pathology to relieve mechanical compression of the neurologic structures. However, open surgical ligation is often associated with considerable blood loss.We discuss a unique case of a large symptomatic epidural venous varix and potential treatment strategy.A 15-year-old female presented with a 1-year history of left L5 radicular pain and weakness. Lumbar MRI demonstrated a central L5/S1 herniated disc and a large extradural anomalous SEV compressing the exiting left L5 nerve root at the L5/S1 neuroformina. The SEV was treated using a transvenous liquid embolic agent providing symptomatic relief. At 16-months follow-up, she reported recurrent symptoms. She ultimately underwent a left L5/S1 MIS decompression without complication.Transvenous liquid embolization of large symptomatic SEV may provide temporary neurologic relief and decrease morbidity associated with open surgical treatment options.

OBJECTIVEThe evolution of microsurgical and endoscopic techniques has allowed the development of less invasive transcranial approaches. The authors describe a purely endoscopic transpterional port craniotomy to access lesions involving the cavernous sinus and the anterolateral skull base.METHODSThrough single- or dual-port incisions and with direct endoscopic visualization, the authors performed an endoscopic transpterional port approach (ETPA) using a 4-mm straight endoscope in 8 sides of 4 formalin-fixed cadaveric heads injected with colored latex. A main working port incision is made just below the superior temporal line and behind the hairline. An optional 0.5- to 1-cm second skin port incision is made on the lateral supraorbital region, allowing multiangle endoscopic visualization and maneuverability. A 1.5- to 2-cm craniotomy centered over the pterion is done through the main port, which allows an extradural exposure of the cavernous sinus region and extra/intradural exposure of the frontal and temporal cranial fossae. The authors present a pilot surgical series of 17 ETPA procedures and analyze the surgical indications and clinical outcomes retrospectively.RESULTSThe initial stage of this work on cadavers provided familiarity with the technique, standardized its steps, and showed its anatomical limits. The clinical ETPA was applied to gain access into the cavernous sinus, as well as for aneurysm clipping and meningioma resection. Overall, perioperative complications occurred in 1 patient (6%), there was no mortality, and at last follow-up all patients had a modified Rankin Scale score of 0 or 1.CONCLUSIONSThe ETPA provides a less invasive, focused, and direct route to the cavernous sinus, and to the frontal and temporal cranial fossae, and it is feasible in clinical practice for selected indications with good results.

To document the outcomes and quality of follow-up compliance after planned subtotal, near-total and gross-total resection (STR, NTR, and GTR) of vestibular schwannomas (VSs).This is a retrospective study of 294 consecutive patients, who underwent excision of a previously untreated VS, between 2005 and 2015. Outcomes including long-term tumor control, facial nerve outcomes, and compliance with follow-up advice were studied.The mean diameter of the tumors was 4.2 cm (±0.8 cm; range: 2.2-7.5 cm). Less than total excision was performed in 55 cases (18.7%), of which NTR was performed in 65% of the cases (n = 36) and STR in the remaining 35%. In the GTR group, 29.3% of patients had a good facial outcome (House and Brackmann [HB] grades 1-3) whereas 81.8% of patients undergoing NTR/STR had a good facial outcome. Follow-up was available in 94.5% of patients undergoing NTR/STR whereas only 69.5% of patients undergoing GTR could be followed up. Only 61.8% of the patients who had NTR/STR were compliant with our follow-up advice and were on either regular radiological surveillance or underwent stereotactic radiosurgery (SRS) as advised. In this group of patients, those with larger tumors and those who underwent a more extensive resection of their tumor were less likely to be compliant with follow-up advice (P = 0.043 and 0.007, respectively). Among patients who had GTR, nine patients (3.7%) were detected to have tumor recurrence at a mean interval of 5.5 years after surgery."Incomplete" microsurgical excision followed by SRS is an effective strategy that fulfills the twin objectives of preservation of function and long-term tumor control. Considering follow-up attrition due to various causes, upfront SRS at the first follow-up visit-even for a small residue-may be a prudent strategy in selected patients.

During the last two decades evolution of the endoscopic endonasal approaches (EEA) has offered the option of minimally invasive techniques in the management of esthesioneuroblastomas (ENB), either as endoscope assisted cranial resection or as pure endoscopic procedures. This study presents the use of pure EEA in the management of ENB in our center, along with a literature review. We retrospectively reviewed the clinical, radiology and pathology records of patients with ENB treated during the period July 2006 to January 2016. During the above period, ten patients with ENB were treated using pure EEA. The mean age was 47.5 years. The gender distribution was: eight males, two females. The most common presenting symptoms were nasal obstruction and discharge or epistaxis (8/10). The mean duration of symptoms was 1.5 years. All patients had preoperative confirmation of ENB by biopsy. Five patients received neoadjuvant radiation and four underwent postoperative radiation. One patient did not receive any radiotherapy and no patient received chemotherapy. Gross total resection was achieved in all patients and intraoperative microscopically negative surgical margins achieved in 9/10 (90%). No major intraoperative complications occurred. The most common postoperative complication was nasal infection. Cerebrospinal fluid leak was noted in one patient. During the follow-up period of 6–120 months (mean 74.8) two cases of neck lymph node recurrence were observed. No deaths due to the disease occurred during the follow-up period. Pure EEA offer excellent results in the management of ENB. Neoadjuvant radiation treatment is promising although more studies need to establish its role.

OBJECTIVEMultiple meningiomas account for 1%–10% of meningiomas. This study describes epidemiological aspects of the disease and its management, which is more challenging than for single tumors.METHODSA consecutive series of adult patients with ≥ 2 spatially separated meningiomas was reviewed. Patients with neurofibromatosis Type 2 were excluded. The authors collected clinical, imaging, histological, and treatment data to obtain information on epidemiology, management options, and outcomes of active treatment and surveillance.RESULTSA total of 133 consecutive patients were included over 25 years, with a total of 395 synchronous and 53 metachronous meningiomas, and a median of 2 tumors per patient. One hundred six patients had sporadic disease, 26 had radiation-induced disease, and 1 had familial meningiomatosis. At presentation, half of the patients were asymptomatic. In terms of their maximum cross-sectional diameter, the tumors were small (≤ 2 cm) in 67% and large (> 4 cm) in 11% of the meningiomas. Fifty-four patients had upfront treatment, and 31 had delayed treatment after an observation period (mean 4 years). One in 4 patients had ≥ 2 meningiomas treated. Overall, 64% of patients had treatment for 142 tumors—67 with surgery and 18 with radiotherapy alone. The mean follow-up was 7 years, with 13% of treated patients receiving salvage therapy. Approximately 1 in 4 patients who underwent surgery had ≥ 1 WHO Grade II or III meningioma. Meningiomas of different histological subtypes and grades in the same patient were not uncommon.CONCLUSIONSMultiple meningiomas are often asymptomatic, probably because the majority are small and a significant proportion are induced by radiation. Approximately two-thirds of patients with multiple meningiomas require therapy, but only one-third of all meningiomas need active treatment. The authors recommend surveillance for stable and asymptomatic meningiomas and therapy for those that are symptomatic or growing.

Ossification of the ligament flavum in the thoracic spine is an uncommon radiological finding in the Western population but can present with back pain, varying degrees of myelopathy, and even paraplegia on occasion. The authors here present the case of a 50-year-old woman with a history of progressive back pain and symptoms of spontaneous intracranial hypotension who was found to have an ossified ligamentum flavum of the thoracic spine resulting in a dural erosion cerebrospinal fluid leak. Surgery involved removal of the ossified ligament flavum at T10–11, facetectomy, ligation of the nerve root, and primary closure of the dura, which resulted in complete resolution of the patient’s symptoms. Radiological, clinical, and intraoperative findings are discussed to assist surgeons with an accurate diagnosis and treatment in the setting of this unusual presentation.

Sacroiliac fusion and instrumentation extension for correction of failed lumbosacral fusions traditionally requires a long revision surgery. Reopening of the prior surgical incision to expose the prior instrumentation requires a large incision with increased blood loss, increased operative time, increased risk of infection, and longer hospitalization times. We describe the first case series using a minimally invasive surgical sacroiliac screw technique for extension of a prior fusion to the pelvis. Using two small 3-cm paramedian incisions on each side, we were able to obtain autologous iliac crest bone graft, place the sacroiliac screw minimally invasive, perform an arthrodesis, and connect the prior surgical hardware to the sacroiliac screw safely. A detailed review of surgical technique, clinical cases, and brief review of the literature is discussed.

While there is little controversy regarding the treatment of symptomatic colloid cysts, the optimal management of “incidentally” detected and asymptomatic colloid cyst remains unclear. The age of the patient, duration and significance of symptoms related to the cyst, size and radiological characteristics of the cyst and the presence of hydrocephalus are all factors to be considered before considering surgery. While surgery most often provides good results in the majority of patients, complications do occur. Despite growing literature about the natural history of this condition, to date, only three cases of spontaneous resolution of colloid cyst

Background Lateral approaches to treat anterior cranial fossa lesions have evolved since the first frontotemporal approach described by Dandy in 1918. We describe a less invasive approach to perform extradural anterior clinoidectomy through a lateral supraorbital (LSO) approach for anterior circulation aneurysms and anterolateral skull base lesions. Methods The extended LSO approach involves performing a standard lateral supraorbital craniotomy followed by drilling of the sphenoid wing and lateral wall of the orbit through the frontal bony opening of the LSO approach, without any temporal extension of the craniotomy. This creates a frontopterio-orbital window exposing the periorbita; superior, medial, and anterior aspect of the temporal dura mater; and superior orbital fissure. After unroofing the superior orbital fissure, the meningo-orbital fold is cut, and the temporal dura mater is peeled from the lateral wall of the cavernous sinus to expose the anterior clinoid process allowing a standard opening of the optic canal and anterior clinoidectomy. Results The extended LSO approach and extradural anterior clinoidectomy allowed access to 4 sphenoid wing/anterior clinoidal meningiomas, 5 anterior circulation aneurysms, 2 temporomesial lesions, and 1 orbital/cavernous sinus abscess. Postoperatively, 2 patients had transient hemiparesis, 2 patients had transient third nerve palsy, and 1 patient had minimal visual field deterioration. All patients had a modified Rankin Scale score ≤1 at 8-week follow-up. Conclusion The extended LSO approach opens a new route (frontopterio-orbital window) to perform extradural anterior clinoidectomy safely and increases surgical exposure, angles, and operability of a less invasive keyhole craniotomy (LSO approach) to treat anterior cranial fossa lesions.

Thoracic endoscopic procedures carry significant benefits to open surgery for many spinal pathologies. However, due to the risk to the adjacent spinal cord, significant technical expertise should be acquired with lumbar endoscopic procedures before endoscopic surgery of the thoracic spine is attempted. This chapter considers the relevant anatomical considerations for these surgeries and details the indications for endoscopic thoracic surgery.

Background: The use of cervical interfacet spacers (CISs) to augment stability and provide solid arthrodesis at the atlantoaxial joint has not been studied in detail. The aim of this work is to report the outcomes with the use of machined allograft CISs at C1-2. Methods: A retrospective review of 19 patients who underwent an atlantoaxial fusion with the use of CISs was performed. All patients had instability documented with flexion and extension lateral radiographs. This instability was due to trauma, degenerative stenosis, symptomatic C1-2 arthropathy, and os odontoideum. Clinical and radiological outcomes were assessed. Fusion was determined based on a lack of hardware failure, absence of motion on flexion and extension plain X-ray films, and presence of bridging trabecular bone which was most often demonstrated by a computed tomography. Results: The mean age was 69.1 ± 12.9 years. Eight patients had traumatic fractures, six patients had degenerative stenosis, two patients had C2 neuralgia due to C1-2 arthropathy, two patients had C1-2 ligamentous subluxation, and one patient had an unstable os odontoideum. The occiput or subaxial spine was included in the arthrodesis in 10 patients. Rib autograft was utilized in most patients. No patient had postoperative neurological worsening, malposition of hardware, or vertebral artery injury and there were no mortalities. The fusion rate was 95%. The mean follow-up was 12.1 ± 5.5 months. Conclusions: CIS is a promising adjuvant for the treatment of atlantoaxial instability.

Anterior lumbar interbody fusion (ALIF) is a well-established technique to achieve lumbar spine fusion with various indications including degenerative disk disease, spondylolisthesis, recurrent disk herniation, adjacent level disease, pseudoarthrosis, as well as being used as part of the overall strategy to restore sagittal balance. ALIF can be an extremely useful tool in any spine surgeon's armamentarium. However, like any surgical procedure, proper patient selection is key to success. A solid understanding of the biomechanics, careful surgical planning, along with clear knowledge of the advantages and disadvantages of stand-alone ALIF will ensure optimal clinical outcome. Stand-alone ALIF may be a suitable surgical option in carefully selected patients that can provide good clinical results and adequate fusion rates without the need for posterior instrumentation. Areas covered: A brief overview of the indications, techniques, biomechanics, surgical outcome and complications of stand-alone ALIF is provided in this article with a review of the pertinent literature. Expert commentary: In this review we discuss the clinical evidence of using a stand-alone ALIF compared to other fusion techniques of the lumbar spine. The development of interbody cages with integrated screws has increased the arthrodesis rate and improved clinical outcomes while decreasing morbidity and operative time.

Despite recommendations and guidelines, surgical antibiotic prophylaxis protocol for neurosurgical cases is not uniformly followed.To report trends in the use of prophylactic antibiotics by Indian neurosurgeons for non-trauma neurosurgical cases.An email survey consisting of 17 questions was sent in 2018 to 2,175 surgical members with a registered email in the Neurological Society of India (NSI) registry. Three reminders were sent at 3-month intervals. The results were analyzed for the number, type, and duration of antibiotic use for different surgical procedures. The differences in the antibiotic policy in different practice settings were also studied.The response rate was less than 5% (103 responses). Almost all (98.1%) surgeons used prophylactic antibiotics. A single antibiotic was most used for cranial surgeries (85%) and least for spine surgeries with instrumentation (64%) (P = 0.001). One dose or 1 day of antibiotics was used by the least number of responders (29%) for spinal instrumentation surgeries and the most responders (66.7%) for spinal surgery without instrumentation (P0.0001). Surgeons working in corporate teaching hospitals or non-teaching hospitals were more likely to use antibiotics for longer duration than surgeons working in government/trust teaching hospitals.Substantial numbers of surgeons use prophylactic antibiotics for more than 1 day with a higher proportion of surgeons working in corporate teaching and non-teaching hospitals pursuing such a policy.

Cervical radiculopathy is one of the most common conditions treated by a spine surgeon. Disc herniation usually occurs in patients with mild to moderate degenerative changes. The initial evaluation includes a careful history, which is important for distinguishing between vascular, infectious, neoplastic, and traumatic etiologies of the symptoms. In this chapter, with the help of a case illustration, the authors discus the clinical features, radiology management issues, decision-making process, operative options, and postoperative care in a young patient with a cervical disc prolapse. This will serve as an important guide to resident and young neurosurgeons in the optimal management of similar cases.

Technological advances in neurosurgery, aided by improvements in anesthesia have resulted in surgery that is faster, simpler and safer with excellent perioperative recovery. As a result of improved outcomes, several centers are performing certain neurosurgical procedures on an outpatient basis; where patients arrive at the hospital the morning of their procedure and leave the hospital the same evening, thus avoiding an overnight stay in the hospital. Apart from the medical benefits of the outpatient procedure, its impact on patient satisfaction is substantial. The economic benefits are extremely favorable for the patient, physician, as well as the hospital. However, due to skepticism surrounding medico-legal aspects, and how radical the concept at first sounds, these procedures have not gained widespread popularity. We provide an overview of outpatient neurosurgery discussing results, outcomes related to patients' quality of life, and impact on the economic burden on currently burgeoning health care costs.

Delayed intracranial hemorrhage is a rare complication of treatment for central nervous system tumors. This may be secondary to malignant transformation of the tumor or vasculopathy related to radiation therapy (RT). While most reports on radiation-induced vasculopathy in children with optic pathway gliomas are associated with ischemic complications, there are only two reports of hemorrhagic complications in these patients. In both cases, the hemorrhage was asymptomatic and remote from the site of the original tumor but within the field of irradiation. We describe a female patient who underwent surgery for an optico-chiasmatic pilocytic astrocytoma (PA) at the age of 12 followed by RT at the age of 17 for tumor progression. The patient was followed with serial magnetic resonance imaging (MRI) scans showing marginal regression and no subsequent evidence of tumor recurrence, including the most recent MRI done only 6 months before the latest presentation. She then developed a symptomatic intratumoral hemorrhage at the age of 32 for which she underwent emergent surgery. To our knowledge, this is the first report of a nonaneurysmal-delayed hemorrhage within the site of previous surgery, several years after RT for a suprasellar PA. We review literature on delayed vasculopathy following the treatment of pediatric optic pathway gliomas and discuss the possible mechanisms of hemorrhage in our case. These long-term follow-up outcomes add significant insight and have implications in patient management.

Idiopathic spinal cord herniation is a rare and often missed cause of thoracic myelopathy. The clinical presentation and radiological appearance is inconsistent and commonly confused with a dorsal arachnoid cyst and often is a misdiagnosed entity. While ventral spinal cord herniation through a dural defect has been previously described, intravertebral herniation is a distinct entity and extremely rare. We present the case of a 70-year old man with idiopathic thoracic transdural intravertebral spinal cord herniation and discuss the clinico-radiological presentation, pathophysiology and operative management along with a review the literature of this unusual entity.

Minimally invasive surgical (MIS) procedures for posterior cervical laminectomy, laminoforaminotomy and discectomy techniques were developed to reduce muscle dissection and soft tissue trauma. MIS posterior cervical laminoforaminotomy has been shown to reduce operative times, blood loss, postoperative pain and duration of hospital stays. In carefully selected patients with lateral foraminal disease, excellent surgical results can be expected. In this chapter, we will discuss the indications, contraindications, surgical technique and common surgical nuances involved in a posterior cervical decompression. A video illustration of an MIS posterior cervical laminoforaminotomy is also included.

Aim: This study aimed to describe the application of minimally invasive surgery (MIS) in separation surgery combined with postoperative stereotactic body radiation therapy (SBRT) in patients with symptomatic metastatic epidural spinal disease. Methods: Three techniques are described: (1) MIS posterior separation surgery alone, (2) MIS posterolateral separation surgery with percutaneous pedicle screw placement, and (3) MIS lateral corpectomy with percutaneous pedicle screw placement. Seven representative cases are presented in which the above techniques were applied and after which postoperative SBRT was performed. Results: The seven representative patients (3 male, 4 female) had a mean age of 54 years (range, 46–62 years). Two patients had a primary diagnosis of cholangiocarcinoma and in one patient each a diagnosis of breast, renal, lung adenocarcinoma, melanoma, and urothelial squamous cell carcinoma as their primary tumor. All patients had additional multiorgan disease apart from the metastatic spine involvement. Three patients underwent operations in the lumbar spine, two in the thoracic spine, and one in each of the thoraco-lumbar and lumbo-sacral spine. The average operating time was 149 ± 60.3 min (range, 90–240 min). The mean estimated blood loss was 188.8 cc. The mean length of stay in the hospital was 4 days (range, 3–7 days). There were no surgical complications. All patients received postoperative SBRT (typically 24 Gy in 3 fractions) at a mean of 43.2 days after surgery (range, 30–83). Conclusions: Early reports such as this suggest that MIS techniques can be successfully and safely applied in accomplishing “separation surgery” with adjuvant SBRT in the management of metastatic spinal disease. The potential advantages conferred by MIS techniques such as shortened hospital stay, decreased blood loss, reduced perioperative complications, and earlier initiation of adjuvant radiation are highly desirable in the treatment of this challenging patient population.

Object Accurate intraoperative localization of small intradural extramedullary thoracolumbar (T-1 to L-3 level) spinal cord tumors is vital when minimally invasive techniques, such as hemilaminectomy, are used to excise these lesions. In this study, the authors describe a simple and effective method of preoperative MRI localization of small intradural extramedullary tumors using cod liver oil capsules. Methods Thirty-five patients with intradural tumors underwent preoperative MRI localization the evening prior to surgery. Patients were positioned prone in the MRI gantry, mimicking the intraoperative position. Nine capsules were placed in 3 rows to cover the lesion. This localization was used to guide the level for a minimally invasive approach using a hemilaminectomy to excise these tumors. Results The mean patient age was 51.5 ± 14.3 years, and the mean body mass index was 24.1 ± 3.5 kg/m2. Twenty-two tumors involved the thoracic spine, and 13 involved the upper lumbar spine from L-1 to L-3. The mean tumor size was 2.2 ± 1.0 cm. Localization was accurate in 34 patients (97.1%). Conclusions Accurate localization with the described method is quick, safe, cost-effective, and noninvasive with no exposure to radiation. It also reduces operating time by eliminating the need for intraoperative fluoroscopy.

Object T2-weighted intramedullary increased signal intensity (ISI) on MRI in patients with cervical spondylotic myelopathy (CSM) appears to represent a wide spectrum of pathological changes that determine reversibility of cord damage. Although sharp T2-weighted ISI on preoperative imaging may correlate with poorer surgical outcomes, there are limited data on how these changes progress following surgery. In this study, the authors characterized pre-and postoperative ISI changes in patients undergoing surgery for CSM and studied their postoperative evolution in an attempt to quantify their clinical significance. Methods The preoperative and postoperative MR images obtained in 56 patients who underwent oblique cervical corpectomy for CSM were reviewed, and the ISI was classified into 4 subtypes based on margins and intensity: Type 0 (none), Type 1 (“fuzzy”), Type 2 (“sharp”), and Type 3 (“mixed”). The locations of the ISI were further classified as focal if they represented single discrete lesions, multifocal if there were multiple lesions with intervening normal cord, and multisegmental if the lesions were continuous over more than 1 segment. The maximum craniocaudal length of the ISI was measured on each midsagittal MR image. The Nurick grade and Japanese Orthopaedic Association (JOA) score were used to assess clinical status. The mean duration of follow-up was 28 months. Results T2-weighted ISI changes were noted preoperatively in 54 patients (96%). Most preoperative ISI changes were Type 1 (41%) or Type 3 (34%), with a significant trend toward Type 2 (71%) changes at follow-up. Multi-segmental and Type 3 lesions tended to regress significantly after surgery (p = 0.000), reducing to Type 2 changes at follow-up. Clinical outcomes did not correlate with ISI subtype; however, there was a statistically significant trend toward improvement in postoperative Nurick Grade in patients with a > 50% regression in ISI size. In addition, patients with more than 18 months of follow-up showed significant regression in ISI size compared with patients imaged earlier. On logistic regression analysis, preoperative Nurick grade and duration of follow-up were the only significant predictors of postoperative improvement in functional status (OR 4.136, p = 0.003, 95% CI 1.623–10.539 and OR 6.402, p = 0.033, 95% CI 1.165–35.176, respectively). Conclusions There is a distinct group of patients with multisegmental Type 3 intramedullary changes who show remarkable radiological regression after surgery but demonstrate a residual sharp focal ISI at follow-up. A regression of the ISI by > 50% predicts better functional outcomes. Patients with a good preoperative functional status remain the most likely to show improvement, and the improvement continues to occur even at remote follow-up. The clinical relevance of the quality of the T2-weighted ISI changes in patients with CSM remains uncertain; however, postoperative regression of the ISI change is possibly a more important correlate of patient outcome than the quality of the ISI change alone.

BACKGROUND The role of expanded endonasal endoscopic surgery for primary and recurrent craniopharyngioma is not yet fully established. OBJECTIVE To report and evaluate our experience with the endoscopic endonasal approach (EEA) for the resection of primary and recurrent craniopharyngiomas. METHODS This is a retrospective cohort analysis of 43 consecutive EEA procedures in 40 patients operated from September 2006 to February 2012 for suprasellar craniopharyngiomas. In 21 patients (48.8%) the disease was recurrent. We have assessed the surgical results, visual, endocrinological, and functional outcomes and resection rates in this patient cohort. RESULTS At presentation, 31 (72.1%) patients had visual deficits, 15 patients (34.9%) complained of headaches, 25 patients (58.1%) had anterior pituitary insufficiency, and 14 (32.5%) had diabetes insipidus. Total resection was achieved in 44.2% surgeries, of which 77.3% were in primary lesions and 9.5% in recurrent lesions (P

To determine whether motion preservation following oblique cervical corpectomy (OCC) for cervical spondylotic myelopathy (CSM) persists with serial follow-up. We included 28 patients with preoperative and at least two serial follow-up neutral and dynamic cervical spine radiographs who underwent OCC for CSM. Patients with an ossified posterior longitudinal ligament (OPLL) were excluded. Changes in sagittal curvature, segmental and whole spine range of motion (ROM) were measured. Nathan’s system graded anterior osteophyte formation. Neurological function was measured by Nurick’s grade and modified Japanese Orthopedic Association (JOA) scores. The majority (23 patients) had a single or 2-level corpectomy. The average duration of follow-up was 45 months. The Nurick’s grade and the JOA scores showed statistically significant improvements after surgery (p

Introduction With the advent of skull base endoscopy, tuberculum sellae meningiomas (TSMs) are currently operated both from the traditional transcranial (TC) route as well as the extended endonasal endoscopic trasns-sphenoidal approach (EETS). The aim of this study was to conduct a systematic review of TSMs excised via the TC route in the modern era when the EETS excision is gaining popularity. Evidence acquisition We performed a systematic review in the medical literature following the PRISMA guidelines. A medical librarian retrieved a list of 3443 articles published from 2006-2016 from the Medline, Embase and Cochrane Central databases. Two of the authors independently screened for titles and abstracts and excluded 3340 of them. We reviewed the full text of the remaining 103 articles and included in our analysis 31 that met the following inclusion criteria: 1) 5 or more cases reported; and 2) report of the extent of resection, visual outcomes and complications specifically for TSMs were documented. Evidence synthesis Thirty-one articles were selected for this systematic review with a total number of 983 patients with TSM. The mean age was 54.1±4.6 years, 75% of them being female. The follow-up was 43.9±20.7 months. The mean tumor diameter was 27.8±4.9 mm. Gross total resection was achieved in 84% while subtotal or near total resection was 14%. Vision improved, worsened and remained unchanged in 65.5%, 10.4%, and 24.7% respectively. The CSF leak rate was 3.4%. Transient or permanent pituitary dysfunction was reported in 6.9% of patients. There was a vascular injury in 5.1% of the patients with the majority (4.3%) being symptomatic. The recurrence rate was 3.8% and mortality 1.1%. Conclusions In the past decade, the ETTS excision of TSMs has gained popularity and in some centers has become the approach of choice. However the TC route still remains the most common approach for most TSMs meningiomas and for the majority of neurosurgeons. The evolution of transcranial surgery including the use of minimally invasive techniques, such as endoscope-assisted transcranial resection are associated with relatively high resection rates and improved visual outcomes with low morbidity and mortality. A direct comparison with TS approaches was not done for the purpose of this review analysis. Given the limited availability and heterogeneity of comparative observational studies, a meta-analysis was deemed inappropriate.

OBJECTIVE The treatment of recurrent and residual craniopharyngiomas is challenging. In this study the authors describe their experience with these tumors and make recommendations on their management. METHODS The authors performed an observational study of adult patients (≥ 18 years) with recurrent or residual craniopharyngiomas that were managed at their tertiary center. Retrospective data were collected on demographics and clinical, imaging, and treatment characteristics from patients who had a minimum 2-year follow-up. Descriptive statistics were used and the data were analyzed. RESULTS There were 42 patients (27 male, 15 female) with a mean age of 46.3 ± 14.3 years. The average tumor size was 3.1 ± 1.1 cm. The average time to first recurrence was 3.6 ± 5.5 years (range 0.2–27 years). One in 5 patients (8/42) with residual/recurrent tumors did not require any active treatment. Of the 34 patients who underwent repeat treatment, 12 (35.3%) had surgery only (transcranial, endoscopic, or both), 9 (26.5%) underwent surgery followed by adjuvant radiation therapy (RT), and 13 (38.2%) received RT alone. Eighty-six percent (18/21) had a gross-total (n = 4) or near-total (n = 14) resection of the recurrent/residual tumors and had good local control at last follow-up. One of 5 patients (7/34) who underwent repeat treatment had further treatment for a second recurrence. The total duration of follow-up was 8.6 ± 7.1 years. The average Karnofsky Performance Scale score at last follow-up was 80 (range 40–90). There was 1 death. CONCLUSIONS Based on this experience and in the absence of guidelines, the authors recommend an individualized approach for the treatment of symptomatic or growing tumors. This study has shown that 1 in 5 patients does not require repeat treatment of their recurrent/residual disease and can be managed with a “scan and watch” approach. On the other hand, 1 in 5 patients who had repeat treatment for their recurrence in the form of surgery and/or radiation will require further additional treatment. More studies are needed to best characterize these patients and predict the natural history of this disease and response to treatment.

The current trend in all fields of surgery is towards less invasive procedures with shorter hospital stays. The reasons for this change include convenience to patients, optimal resource utilization, and cost saving. Technological advances in neurosurgery, aided by improvements in anesthesia, have resulted in surgery that is faster, simpler, and safer with excellent perioperative recovery. As a result of improved outcomes, some centers are performing brain tumor surgery on an outpatient basis, wherein patients arrive at the hospital the morning of their procedure and leave the hospital the same evening, thus avoiding an overnight stay in the hospital. In addition to the medical benefits of the outpatient procedure, its impact on patient satisfaction is substantial. The economic benefits are extremely favorable for the patient, physician, as well as the hospital. In high volume centers, a day surgery program can exist alongside those for elective and emergency surgeries, providing another pathway for patient care. However, due to skepticism surrounding the medicolegal aspects, and how radical the concept at first sounds, these procedures have not gained widespread popularity. We provide an overview of outpatient brain tumor surgery in the western world, discussing the socioeconomic, medicolegal, and ethical issues related to its adaptability in a developing nation.

The endonasal endoscopic approach (EEA) for the resection of tuberculum sellae meningiomas (TSMs) has, more recently, been advocated as an alternative approach to deal with this challenging tumor. The aim of this study was to conduct a systematic review of publications of TSMs excised through the transsphenoidal route in the past 10 years and review data on the extent of excision, visual outcomes and complication rates.We performed a thorough systematic review of the medical literature following the PRISMA guidelines. A medical librarian retrieved a list of 3443 articles published from 2006-2015 from the MEDLINE, EMBASE and Cochrane Central databases. Two of the authors independently screened for titles and abstracts and excluded 3340 of them. We reviewed the full text of the remaining 103 articles and included in our analysis 12 that met the following inclusion criteria: 1) 5 or more cases reported; 2) the extent of resection, visual outcomes and complication rates that were specifically documented for TSMs excised through the transsphenoidal route.Twelve studies that included 150 patients were analyzed. The mean age was 55 years. The mean tumor volume, reported in 2 studies, was 6.6 cc and mean maximum diameter, reported in 11 studies, was 25 mm. The gross total resection rate was 77.2%. Vision improved in 79.5% of cases and deteriorated in 7.3%. CSF leak postoperatively occurred in 15.3% of patients. In the 11 studies that reported hormonal outcomes, there was a 9.4% transient hyponatremia or diabetes insipidus and 2.2% of patients developed a new permanent endocrine dysfunction. A symptomatic vascular injury was reported in 2.6% of patients. There was one mortality (0.6%).The endonasal endoscopic transsphenoidal excision of TSMs is a feasible, safe and effective surgical option with a low morbidity and mortality. The use of this approach has evolved in the last 10 years and in some centers has replaced the transcranial route for selected cases. Given the limited availability and heterogeneity of comparative observational studies, a direct comparison with transcranial approaches was not performed for the purpose of this review analysis. Likewise, from an epidemiological and statistical perspective a meta-analysis was deemed inappropriate.

Telangiectatic osteosarcoma (TOS) is one of the 8 subtypes of osteosarcoma that infrequently affects the spine. The radiopathological features of TOS overlap with those of more benign entities, most commonly the aneurysmal bone cyst), and therefore is a significant diagnostic challenge. It is a rare but well-described entity in the thoracolumbar and sacral spine, and to the authors' knowledge has not been previously reported in the cervical spine. The authors report the case of a 15-year-old boy who presented with a 6-month history of neck pain and torticollis. He underwent preoperative glue embolization followed by a staged subtotal C-5 spondylectomy and posterior fusion for a C-5 vertebral body lytic expansile lesion. Histopathological examination showed the lesion to be TOS. The surgery was followed by adjuvant radiation and chemotherapy with a favorable outcome at the 1-year follow-up. This report reiterates that TOS is an important differential diagnosis for aneurysmal bone cyst and giant-cell tumor of the spine, as its biological behavior and clinical outcome differ from those of these more benign lesions, which it mimics.

Neurocristic cutaneous hamartoma of the scalp, a rare entity, may be either congenital or acquired. The former must be distinguished from other forms of congenital nodular and plaque-like lesions such as giant congenital nevi, common and cellular blue nevi, and melanoma. We describe the clinicopathologic features of an example occurring in a 2-month-old girl presenting with a large parietooccipital swelling. The literature is reviewed.

Supratentorial hemangioblastomas (HBLs) are exceedingly uncommon. They account for less than 5% of all central nervous system HBLs. The commonest location is the cerebral cortex. Rarely, they can involve the visual pathway. Most of the reports have focused on the differential diagnosis, since depending on the location they can often resemble optic nerve gliomas or meningiomas of the optic nerve sheath. In this study, we describe a 67-year-old man with progressive diminution of vision in the left eye with an optic nerve hemangioblastoma. There was no history of von Hippel-Lindau disease. We discuss the diagnostic challenges, and review the visual presentation and visual outcomes in these patients. This report, we believe, may add further clarity in counseling patients with an optic nerve lesion and the factors in surgical decision-making.

Background: The incidence of adjacent segment disease (ASD) after lumbar spine surgery is a condition that has become increasingly common as the rate of lumbar spine surgery continues to rise. Minimally invasive techniques continue to be refined and offer an opportunity to treat ASD with minimal tissue disruption, lower blood loss, a shorter hospital stay, and decreased morbidity. The aim of this report is to describe the various minimally invasive options for ASD with a comprehensive review of the existing literature. Materials and Methods: A retrospective chart review of patients undergoing minimally invasive spine surgery (MIS) for ASD of the lumbar spine was conducted. Four basic techniques and their modifications were identified to address ASD. Illustrative cases, surgical techniques, and post-surgical outcomes are described. Results: Four MIS techniques were identified as common surgical methods to correct ASD. (1) Non-instrumented discectomy, foraminotomy, or decompression, (2) anterior lumbar interbody fusion (ALIF), (3) transforaminal lumbar interbody fusion (TLIF), and (4) lateral lumbar interbody fusion (LLIF) were found to be MIS techniques that address ASD. ALIF and LLIF provide indirect decompression of the neural foramina, while TLIF provides direct decompression. The addition and removal of screws and rods can be combined with any of these techniques. Conclusions: MIS techniques provide decompression of the neural elements, stabilization, and, potentially, fusion for patients with ASD. These illustrated cases and the review of MIS surgical techniques can provide a comprehensive framework for addressing ASD.

Background: Primary central nervous system lymphomas (PCNSL) constitute a rare group of extranodal non-Hodgkin's lymphomas (NHLs). Aim: To study the clinical and immunophenotypic profile of patients with a PCNSL who presented between the years 2000 and 2013 in a tertiary care center in South India. Materials and Methods: This was a retrospective study. Demographic and clinical data were obtained from the clinical case records. Inclusion criteria: Cases of PCNSL involving brain. Exclusion criteria: Cases of PCNSL involving the spinal cord, meninges and orbit as well as intravascular large B-cell lymphoma, lymphomas with evidence of systemic disease or secondary lymphomas. Archived slides and tissue blocks were retrieved. All cases had hematoxylin and eosin stained sections and immunohistochemistry for CD20, CD3, and MIB-1. Additional immunohistochemistry was performed for CD10, BCL6, and MUM1 on paraffin blocks with sufficient tissue. Results: There were a total of 73 cases with the mean age of presentation being 45.9 years (range 8-71 years) and with a male predominance (male: female (M:F) = 2.3:1). Headache was the commonest presenting complaint. The mean duration of symptoms was 10.6 weeks. All patients were immunocompetent. Most tumors were supratentorial in location. Out of 73 cases, 70 presented with a diffuse large B-cell lymphoma (DLBCL), two with a Burkitt's lymphoma, and one with a lymphomatoid granulomatosis. Only 51 of the DLBCL cases had sufficient tissue for additional studies. Non-germinal center was the most common phenotype seen in 65.7% (33/51) of cases. Germinal center B-cell (GCB) phenotype was seen in 18/51 cases (34.3%). Conclusion: DLBCL constituted the majority of PCNSLs and although non-germinal center was the predominant phenotype, more than a third of the cases were of the GCB phenotype. As the germinal center phenotype is known to have a better prognosis, further studies to explore its relevance in the Asian population are indicated.

OBJECT Prospective studies of quality of life (QOL) are infrequently performed in patients undergoing surgery for vestibular schwannoma (VS). The authors designed this to study to investigate health-related QOL (HR-QOL) in patients with large and giant VSs before and after surgery. METHODS Between January 2009 and December 2012, HR-QOL was measured prospectively before and after surgery, using the 36-Item Short Form Health Survey (SF-36), in 100 patients who underwent surgery for unilateral large or giant VS (tumor size ≥ 3 cm). The Glasgow Benefit Inventory (GBI) was also used to evaluate the effect of surgery. RESULTS A total of 100 patients were included in the study (65 men and 35 women). Their mean age (± SD) was 44.2 ± 11.5 years. The preoperative QOL was decreased in all SF-36 domains. A 1-year follow-up evaluation was conducted for all patients (mean 13.5 ± 5.3 months after surgery). The results showed an improvement in HR-QOL compared with preoperative status in all cases, with 63%–85% of patients showing a minimum clinically important difference (MCID) in various domains. A second follow-up evaluation was performed in 51 cases (mean time after surgery, 29.0 ± 8.3 months) and showed sustained improvement in SF-36 scores. In some domains there was further improvement beyond the first follow-up. On the GBI, 87% of patients reported improvement, 1% felt no change, and 12% of patients reported deterioration. CONCLUSIONS Patients harboring large or giant VSs score lower on all the QOL domains compared with the normative population. More than 60% showed a clinically significant improvement in HR-QOL 1 year after surgery, a result that was sustained at subsequent follow-up.

Background: Despite advances in vestibular schwannoma (VS) surgery and intraoperative electrophysiological monitoring, immediate and delayed facial nerve outcomes are difficult to accurately predict consistently. Objective: To determine the utility of proximal to distal facial nerve amplitude and latency ratios in predicting the long-term postoperative facial nerve function in patients undergoing excision of VS. Materials and Methods: One hundred consecutive patients undergoing surgery for VS with intraoperative facial nerve monitoring were included. Clinical, radiological, electrophysiological, and postoperative outcome data were prospectively entered into a database. Other parameters such as brainstem distance, size of the porus acousticus, and facial nerve length were also analyzed. Results: Of the 100 patients, 53 were women. The mean age was 42.5 ± 14.1 years (range, 14-71 years) and the average tumor size was 4.1 ± 0.8 cm (range, 2.4-6.5 cm). Total excision was done in 89% of patients. Intraoperatively, the facial nerve was anatomically preserved in 86 patients, but electrophysiological responses were obtained from the root entry zone (REZ) in only 77 patients at the end of surgery, 75% of which had good facial function at long-term follow-up. In nine patients where no responses were obtained but the facial nerve was anatomically intact, 50% had good facial function at long-term follow-up. Proximal and distal amplitude and latency ratios, size or consistency of the tumor, brainstem distance, size of the porus acousticus, and length of the facial nerve were not useful in predicting long-term functional outcome. Conclusions: While a positive response to facial nerve stimulation at the end of VS surgery is a good predictor of long-term postoperative function, the absence of responses in an anatomically intact nerve does not preclude good function in the long term. Proximal to-distal amplitude and latency ratios did not correlate with the final facial function.

Henoch The aim of the study was to evaluate the efficacy of preoperative embolization in the management of carotid body tumours. Of the 15 patients admitted to the Department of Vascular Surgery (General Surgery Unit II), Christian Medical College, Vellore, from January 1st 2002 to December 31st 2006 for management of carotid body tumours, 4 patients underwent preoperative embolization and were grouped together. Of the remaining 9 patients who underwent surgical excision, there were 5 with comparable tumour size and these were grouped together into the control group. Surgical outcome of both the groups were compared in terms of operating time, intraoperative blood loss, nerve injury, postoperative morbidity and mortality. There was statistically significant reduction in blood loss and duration of surgery in patients who underwent preoperative embolization. In conclusion, the preoperative embolization is effective in the management of Shamblin type III carotid body tumours.

We thank J.M. Duart Clemente et al. for their interest in our article and raising important issues. Interestingly, the incidence of preoperative neck pain was low in our series despite this being a younger cohort of patients without degenerated and fused spines. In addition, neck pain was not a complaint noted during the follow-up period though we have not presented this in the results. We agree that the main goal of surgery is decompression for neurological improvement and not motion preservation. Ours was a unique group of younger patients with soft discs that stands in contrast to the older set of patients with degenerated and largely fused spines reported in Western series [1]. Having performed the oblique corpectomy with good outcomes, we noted the preservation of motion in the short term as a secondary finding that has not been reported previously with this technique. We have also documented a reduction in cervical motion with longer follow-up indicating that the body tends to fuse the spine with production of anterior osteophytes in this relentlessly progressive degenerative disease [2]. Furthermore, the analysis of data from our consecutive series of 153 patients demonstrated that the neurological function and thereby functional outcome was markedly improved following oblique corpectomy. This improved status remained without secondary worsening on long-term follow-up [3]. The technique of oblique corpectomy ensures the removal of the entire posterior surfaces of the affected vertebrae compressing the cord at presentation. The subsequent “cervicoarthrosis” that could reform on the long term are predominantly at the anterior surfaces of the vertebrae and cannot, therefore, endanger the decompressed spinal cord. This would explain the lack of progressive neurological deterioration at least due to a compressive element at the segments treated. We agree wholeheartedly that although motion preservation is not the primary objective of this surgery, we could avoid or at least retard the development of adjacent segment disease. Long-term follow-up is, of course, mandatory to ensure that these patients do not develop progressive kyphosis or adjacent segment disease.

To document the clinical and radiological outcomes in a large series of patients undergoing the oblique cervical corpectomy (OCC) for spondylotic myelopathy.We retrospectively analyzed our series of 153 patients undergoing OCC for cervical spondylotic myelopathy (CSM) over the last 10 years. A mean clinical follow-up of 3 years was obtained in 125 patients (81.7%), while 117 patients (76.5%) were followed up radiologically. Neurological function was measured by the Nurick grade and the modified Japanese Orthopedic Association score (JOA). Plain radiographs and magnetic resonance images (MRI) were reviewed.Ninety-two percent were men with a mean age of 51 years and a mean duration of symptoms of 18 months. Sixty-one had a single level corpectomy, 66 had a 2-level, 24 had a 3-level, and two had a 4-level OCC. There was statistically significant improvement (p0.05) in both the Nurick grade and the JOA score at mean follow-up of 34.6 ± 25.4 months. Permanent Horner's syndrome was seen in nine patients (5.9%), postoperative C5 radiculopathy in five patients (3.3%), dural tear with CSF leak in one patient (0.7%), and vertebral artery injury in one patient (0.7%). Of the 117 patients who were followed up radiologically, five patients (4.3%) developed an asymptomatic kyphosis of the cervical spine while 22 patients (25.6%) with preoperative lordotic spines had a straightening of the whole spine curvature.The OCC is a safe procedure with good outcomes and a low morbidity for treating cervical cord compression due to CSM. This procedure avoids graft-related complications associated with the central corpectomy, but is technically demanding.

OBJECTIVE The aim of this paper was to comprehensively review each of the Food and Drug Administration (FDA)–approved labels of 7 total cervical disc replacements, assess the exact methodology in which the trial was conducted, and provide a broad comparison of these devices to allow each surgeon to determine which disc best suits his or her specific treatment goals based on the specific labels and not the studies published. METHODS The FDA-approved labels for each of the 7 artificial discs were obtained from the official FDA website. These labels were meticulously compared with regard to the statistical analysis performed, the safety and efficacy data, and the randomized controlled trial that each artificial disc was involved in to obtain the FDA approval for the product or device. Both single-level and 2-level approvals were examined, and primary and secondary end points were assessed. RESULTS In the single-level group, 4 of the 7 artificial discs—Prestige LP, Prestige ST, Bryan, and Secure-C—showed superiority in overall success. Prestige ST showed superiority in 3 of 4 outcome measures (neurological success, revision surgery, and overall success), while the other aforementioned discs showed superiority in 2 or fewer measures (Prestige LP, neurological and overall success; Bryan, Neck Disability Index [NDI] and overall success; Secure-C, revision surgery and overall success; Pro-Disc C, revision surgery). The PCM and Mobi-C discs demonstrated noninferiority across all outcome measures. In the 2-level group, Prestige LP and Mobi-C demonstrated superiority in 3 outcome measures (NDI, secondary surgery, and overall success) but not neurological success. CONCLUSIONS This paper provides a comprehensive analysis of 7 currently approved and distributed artificial discs in the United States. It compares specific outcome measures of these devices against those following the standard of care, which is anterior cervical discectomy and fusion. This information will provide surgeons the opportunity to easily answer patients' questions and remain knowledgeable when discussing devices with manufacturers.