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STUDY DESIGN: Retrospective cohort analysis. OBJECTIVE: To examine the effect of resection on survival and neurological outcome in a modern cohort of patients with spinal cord astrocytomas and identify prognostic factors for survival. SUMMARY OF BACKGROUND DATA: There are currently no clear treatment guidelines for the management of spinal cord astrocytomas. Additionally there is no conclusive evidence for the surgical resection of these tumors, with some studies even demonstrating worse survival with surgery. However, most studies have examined patients treated prior to the routine use of magnetic resonance imaging and advanced microsurgical techniques. METHODS: We performed a retrospective review of 46 consecutive patients with spinal cord astrocytomas treated at our institution from 1992 to 2012. Univariate and multivariate analyses were used to identify variables associated with survival. RESULTS: The majority of patients (67.4%) underwent surgical resection, with the remaining only receiving biopsy. Of those who underwent resection, only 12.5% of patients underwent gross total resection, all of whom had low-grade astrocytomas. Of all patients, 30.7% worsened compared with their preoperative baseline. The occurrence of worsening increased with high tumor grade (52.9% vs. 27.6%, P = 0.086) and an increased extent of resection (66.7% vs. 18.8%, P = 0.0069). Resection did not provide a survival benefit compared with biopsy alone (P = 0.53). Multivariate analysis revealed high-grade histology (hazard ratio, 11.3; 95% confidence interval, 2.41-53.2; P = 0.0021), tumor dissemination (hazard ratio, 4.24; 95% confidence interval, 1.22-14.8; P = 0.023), and an increasing number of tumor involved levels (hazard ratio, 1.31; 95% confidence interval, 0.99-1.74; P = 0.058) to be associated with worse survival. CONCLUSION: As surgical intervention is associated with a higher rate of neurological complications and lacks a clear benefit, the resection of spinal cord astrocytomas should be reserved for select cases and should be used sparingly.Level of Evidence: 4. [ABSTRACT FROM AUTHOR]

A 34-year-old man with a history of spina bifida occulta, fetal alcohol syndrome and mutism presented with an acute on chronic decline of unsteady gait and right arm and leg weakness over the period of a few months. The patient was non-verbal and communicated using hand gestures. MRI of the cervical spine showed severe stenosis at C4-5 with T2 signal abnormalities. Brain MRI demonstrated mild ventriculomegaly. The patient underwent an anterior cervical discectomy and fusion for severe cervical spine stenosis. Postoperatively the patient's myelopathic symptoms improved. He also became verbal and engaged in conversation. Ten months after surgery, the patient who had previously been non-verbal had developed a vocabulary of more than 50 words. [ABSTRACT FROM AUTHOR]

In this study, we have described our initial experience and surgical technique of extreme angle screw placement in the cervical and upper thoracic spine of a cohort of patients undergoing posterior fusion. This extreme angle screw facilitates rod placement without need for any coronal contouring of the rod or offset connectors despite the varied entry site locations for posterior instrumentation and the different trajectories and pathways of these screws. From ruary 2011 to July 2011, extreme angle screws were placed in twenty consecutive adult patients who underwent posterior cervical, occipital-cervical or cervical-thoracic fusions. The primary diagnosis was cervical spondylotic myelopathy (13), trauma (4), and pseudoarthrosis with stenosis (3). Eight patients had gross instability. A total of 196 screws were placed; half of the cases involved instrumentation at or within the C3-7 segments (10) and the others included constructs extending to occipital bone, C2, T1, or T2 (10). Of all twenty cases, there were no perioperative hardware complications. At long-term follow-up, two patients required reoperation, one for hardware failure and the other for single level symptomatic pseudoarthrosis. We conclude that extreme angle screw use in the posterior cervical spine provides an evolution in posterior instrumentation that maximizes the biomechanical strength of a construct, allows for easy rod placement, and may improve the restoration of sagittal alignment. Overall, extreme angle screws facilitate rod placement even for screws offset from the natural plane of the rod, thereby avoiding the need for coronal contouring or placement of offset connectors.

Spinous process fixation (SPF) is presented as less invasive than pedicle screws. There has been little quantitative data to support this assertion, and "minimally invasive" has not been well defined in spine surgery. Length of stay (LOS) and blood loss (BL) were chosen as surrogate measures of "minimally invasive." A chart review was conducted on 192 lumbar fusion patients (374 levels). A backward-selection multiple-linear-regression was performed to determine what variables contribute to LOS and estimated blood loss (EBL). A logistic regression controlling for age and number of levels on complication rates was also performed. Number of levels with supplementary screw fixation (SSF) was significantly associated with LOS (p = 0.003). Controlling for number of surgical levels, LOS increased by 0.30 days (95% CI: 0.02-0.58) for each level with SSF. For each additional level including SSF, BL increases by 25.31 cc (95% CI: 3.50-47.12, p = 0.023). Interbody fusion increases blood loss by 68.16 cc (95% CI: 17.18-119.13, p = .009). For each additional level with SSF, odds of perioperative complications increase by OR = 2.34 (95% CI: 1.35-4.05). Long-term complications were not affected by instrumentation. LOS and BL are increased in patients with SSF vs. SPF only. Odds of perioperative complications are increased in patients with SSF relative to those treated with SPF alone.

Glioblastoma multiforme (GBM) is the most common primary brain tumor in adults and is universally fatal. Despite surgical resection, radiotherapy, and systemic chemotherapy, the median overall survival is less than 15 months. As current therapies are not tumor-specific, treatment commonly results in toxicity. The epidermal growth factor receptor variant III (EGFRvIII) is a naturally occurring mutant of EGFR and is expressed on approximately 20% to 30% of GBMs. As it is not expressed on normal cells, it is an ideal therapeutic target. Rindopepimut is a peptide vaccine which elicits EGFRvIII-specific humoral and cellular immune responses. Phase I and II clinical trials have demonstrated significantly higher progression-free and overall survival times in vaccinated patients with EGFRvIII-expressing GBM tumors. Side effects are minimal and mainly consist of hypersensitivity reactions. Due to the efficacy and safety of rindopepimut, it is a promising therapy for patients with GBM. Currently, rindopepimut is undergoing clinical testing in an international Phase III trial for newly diagnosed GBM and a Phase II trial for relapsed GBM.