bluuebunny/crossref_metadata_2025 huggingface dataset:
Bone morphogenetic proteins and spinal fusion
Authors: Walker David H. , Wright Neill M.
Published: January 2008

Bone morphogenetic proteins (BMPs) have increasingly become a focus of research in the laboratory, with animal models, and in human clinical trials for the treatment of spinal disorders. Basic science research has elucidated the putative mechanism of action of BMPs, and the efficacy of BMPs in inducing bone formation has been evaluated in multiple animal models of anterior and posterior spinal fusion. Not only has BMP been shown to improve the quality and amount of bone formation when used as a supplement to autograft, it has also been shown to promote superior fusion in the absence of autograft, even in high-risk fusion models involving the use of nicotine or nonsteroidal antiinflam-matory agents. Both completed and ongoing clinical trials have demonstrated the efficacy of recombinant BMP, leading to the first BMP product being approved for clinical use earlier this year.

Animal models and clinical trials have also been used to evaluate the safety of BMPs. Although few complications have been reported, BMPs can induce heterotopic bone formation, especially when placed adjacent to exposed neural elements. Potentially more serious, antibody formation has been seen in up to 38% of patients in some clinical trials. No clinical sequelae have been reported despite the development of antibodies against BMP, a naturally occurring human protein implicated in processes other than osteoinduction.

The future directions of biological manipulation of the osteoinduction process include further understanding of the interactions of the BMP subtypes, the interactions of BMP with its receptors, and exploring other molecules capable of osteoinduction.
Combined anterior–posterior fusion with laterally placed threaded interbody cages and pedicle screws for Scheuermann kyphosis
Authors: Moquin Ross R. , Rosner Michael K. , Cooper Patrick B.
Published: January 2008

The authors report their preferred method for correcting Scheuermann disease via a combined anterior–posterior approach; their procedure is associated with a lower morbidity rate than the standard approach. Twenty-month follow-up examination demonstrated excellent maintenance of correction. The results satisfied the requirements to function without restriction in a vigorous military environment.
Thoracolumbar spinal deformity in achondroplasia
Authors: Misra Sanjay N. , Morgan Howard W.
Published: January 2008

The authors review the management of thoracolumbar kyphotic deformity in cases of achondroplasia. The presence of angular thoracolumbar kyphosis in achondroplasia is well recognized. In children this is initially a nonfixed deformity that persists, however, in more than 10% of individuals and becomes a fixed thoracolumbar kyphotic deformity. Additionally, with the coexistent spinal canal stenosis, neurological damage can occur and manifest as spinal cord or cauda equina compression. The nature of this condition, the natural history, and management options are discussed. Anatomical and biomechanical factors relevant to the condition are specifically highlighted. Avoidance of pitfalls in the management of these patients is discussed for both pediatric and adult patients.
Pathogenesis, presentation, and treatment of lumbar spinal stenosis associated with coronal or sagittal spinal deformities
Authors: Fraser Justin F. , Huang Russel C. , Girardi Federico P. , Cammisa Frank P.
Published: January 2008

Sagittal- or coronal-plane deformity considerably complicates the diagnosis and treatment of lumbar spinal stenosis. Although decompressive laminectomy remains the standard operative treatment for uncomplicated lumbar spinal stenosis, the management of stenosis with concurrent deformity may require osteotomy, laminectomy, and spinal fusion with or without instrumentation. Broadly stated, the surgery-related goals in complex stenosis are neural decompression and a well-balanced sagittal and coronal fusion. Deformities that may present with concurrent stenosis are scoliosis, spondylolisthesis, and flatback deformity. The presentation and management of lumbar spinal stenosis associated with concurrent coronal or sagittal deformities depends on the type and extent of deformity as well as its impact on neural compression. Generally, clinical outcomes in complex stenosis are optimized by decompression combined with spinal fusion. The need for instrumentation is clear in cases of significant scoliosis or flatback deformity but is controversial in spondylolisthesis. With appropriate selection of technique for deformity correction, a surgeon may profoundly improve pain, quality of life, and functional capacity. The decision to undertake surgery entails weighing risk factors such as age, comorbidities, and preoperative functional status against potential benefits of improved neurological function, decreased pain, and reduced risk of disease progression. The purpose of this paper is to review the pathogenesis, presentation, and treatment of lumbar spinal stenosis complicated by scoliosis, spondylolisthesis, or flat-back deformity. Specific attention is paid to surgery-related goals, decision making, techniques, and outcomes.
Pediatric supratentorial high-grade gliomas
Authors: Tamber Mandeep S. , Rutka James T.
Published: January 2008

The purpose of this review is to highlight some of the pertinent concepts and controversies surrounding the diagnosis and treatment of pediatric supratentorial high-grade gliomas. Unlike the adult counterparts, pediatric high-grade gliomas are likely derived from distinct cytogenetic and molecular alterations. Surgery has been shown to play a role in extending patient survival. Some success is associated with the provision of chemotherapy. Radiotherapy remains an important adjunct in children older than age 3 years. The challenges involved in improving the poor prognosis of children in whom these very aggressive tumors have been diagnosed will be discussed, as well as some of the novel approaches being investigated to improve patient survival and quality of life.
Therapy of glioblastoma multiforme improved by the antimutagenic chloroquine
Authors: Briceño Eduardo , Reyes Sandra , Sotelo Julio
Published: January 2008

Object

Therapy of malignant tumors is frequently curtailed by the emergence of chemoresistant cell clones. Experimentally, the authors have demonstrated that chemotherapy for glioma in rats is markedly improved by the administration of the antimutagenic quinacrine. They studied the effects of chloroquine, an antimutagenic with an optimal pharmacological profile for human use, as adjuvant for the treatment of patients with glioblastoma multiforme (GBM).

Methods

In a prospective controlled randomized trial, 18 patients with GBM underwent standard treatment with surgery, chemotherapy, and radiotherapy; nine received an additional 150-mg dose of chloroquine daily starting 1 day after surgery and continued through the observation period. Nine matched patients were included as controls. Neuroimaging studies and clinical response were periodically compared. The follow-up period ranged from 24 to 50 months.

Survival time was defined as the main outcome measure. Survival was significantly longer in chloroquine-treated patients than in controls (33 ± 5 and 11 ± 2 months, respectively [p < 0.0002]). At the end of the observation period, four patients (46%) treated with chloroquine were alive, two had evidence of tumor remission after 2 years; in another two, tumor recurrence developed after 2 and 4 years of remission, respectively. No control patient survived more than 22 months after surgery.

Conclusions

Chronic administration of chloroquine greatly enhanced the response of GBM to antineoplastic treatment. Because the cytotoxicity of chloroquine on malignant cells is negligible, these favorable results appear mediated by its strong antimutagenic effect that precludes the appearance of resistant clones during radiotherapy and chemotherapy.
Intracranial pressure following aneurysmal subarachnoid hemorrhage: monitoring practices and outcome data
Authors: Mack William J. , King Ryan G. , Ducruet Andrew F. , Kreiter Kurt , Mocco J , Maghoub Ahmed , Mayer Stephan , Connolly E. Sander
Published: January 2008

Object

Elevated intracranial pressure (ICP) is an important consequence of aneurysmal subarachnoid hemorrhage (SAH) that often results in decreased cerebral perfusion and secondary clinical decline. No definitive guidelines exist regarding methods and techniques for ICP management following aneurysm rupture. The authors describe monitoring practices and outcome data in 621 patients with aneurysmal SAH admitted to their neurological intensive care unit during an 8-year period (1996–2003).

Methods

A fiberoptic catheter tip probe or external ventricular drain (EVD) was used to record ICP values. The percentage of monitored patients varied, as expected, according to admission Hunt and Hess grade (p < 0.0001). Intracranial pressure monitoring devices were used in 27 (10%) of 264 Grade I to II patients, 72 (38%) of 189 Grade III patients, and 134 (80%) of 168 Grade IV to V patients. There was a strong propensity to favor transduced ventricular drains over parenchymal fiberoptic bolts, with the former used in 221 (95%) of 233 cases. This tendency was particularly strong in the poor-grade cohort, in which EVDs were placed in 99% of monitored individuals. The rates of cerebrospinal fluid infection in patients in whom ICP probes (0%) and ventricular drains (12%) were placed accorded with those in the literature.

Conclusions

Following aneurysmal SAH, ICP monitoring prevalence and techniques differ with respect to admission Hunt and Hess grade and are associated with the patient's functional status at discharge.
The role of radiosurgery for hemangiopericytomas
Authors: Chang Steven D. , Sakamoto Gordon T.
Published: January 2008

Object

Hemangiopericytomas represent a small subset of meningeal tumors. Despite their relatively uncommon nature, they are aggressive tumors known for recurrence. Resection is the standard treatment in most, although regrowth and metastases are common even after resection. The authors evaluate the role of stereotactic radiosurgery in the treatment of recurrent hemangiopericytomas.

Methods

In a review of the Stanford radiosurgery patient database between 1989 and 2002, the authors found eight patients with recurrent hemangiopericytoma who underwent stereotactic radiosurgery. The mean age of this population was 45.1 years (range 24–67 years). All patients had been previously treated with resection, and five patients (63%) had undergone conventional radiotherapy. The mean radiosurgery dose to the tumor margin was 20.5 Gy (range 16–24 Gy). The mean clinical and radiographic follow-up period was 44 months (range 8–77 months). Of the eight tumors treated with radiosurgery, six decreased in size and two ultimately progressed. There were no radiosurgery-related complications.

Conclusions

Stereotactic radiosurgery of hemangiopericytomas can result in increased tumor control and should be considered as a treatment option for patients in whom the diagnosis has been established and in whom residual tumor is demonstrated postoperatively. Close clinical and radiographic follow-up evaluation is necessary in this patient population because of the high rate of local recurrence and distant metastases.
CyberKnife frameless single-fraction stereotactic radiosurgery for benign tumors of the spine
Authors: Gerszten Peter C. , Ozhasoglu Cihat , Burton Steven A. , Vogel William J. , Atkins Barbara A. , Kalnicki Shalom , Welch William C.
Published: January 2008

Object

The role of stereotactic radiosurgery in the treatment of benign intracranial lesions is well established. Its role in the treatment of benign spinal lesions is more limited. Benign spinal lesions should be amenable to radiosurgical treatment similar to their intracranial counterparts. In this study the authors evaluated the effectiveness of the CyberKnife for benign spinal lesions involving a single-fraction radiosurgical technique.

Methods

The CyberKnife is a frameless radiosurgery system in which an orthogonal pair of x-ray cameras is coupled to a dynamically manipulated robot-mounted linear accelerator possessing six degrees of freedom, whereby the therapy beam is guided to the intended target without the use of frame-based fixation. Cervical spine lesions were located and tracked relative to skull osseous landmarks; lower spinal lesions were tracked relative to percutaneously placed fiducial bone markers. Fifteen patients underwent single-fraction radiosurgery (12 cervical, one thoracic, and two lumbar). Histological types included neurofibroma (five cases), paraganglioma (three cases), schwannoma (two cases), meningioma (two cases), spinal chordoma (two cases), and hemangioma (one case).

Radiation dose plans were calculated based on computerized tomography scans acquired using 1.25-mm slices. Planning treatment volume was defined as the radiographic tumor volume with no margin. The tumor dose was maintained at 12 to 20 Gy to the 80% isodose line (mean 16 Gy). Tumor volume ranged from 0.3 to 29.3 ml (mean 6.4 ml). Spinal canal volume receiving more than 8 Gy ranged from 0.0 to 0.9 ml (mean 0.2 ml). All patients tolerated the procedure in an outpatient setting. No acute radiation-induced toxicity or new neurological deficits occurred during the follow-up period. Pain improved in all patients who were symptomatic prior to treatment. No tumor progression has been documented on follow-up imaging (mean 12 months).

Conclusions

Spinal stereotactic radiosurgery was found to be feasible, safe, and effective for the treatment of benign spinal lesions. Its major potential benefits are the relatively short treatment time in an outpatient setting and the minimal risk of side effects. This new technique offers an alternative therapeutic modality for the treatment of a variety of benign spinal neoplasms in cases in which surgery cannot be performed, in cases with previously irradiated sites, and in cases involving lesions not amenable to open surgical techniques or as an adjunct to surgery.
Comparison of management options for patients with acoustic neuromas
Authors: Kondziolka Douglas , Lunsford L. Dade , Flickinger John C.
Published: January 2008

Management options for patients with vestibular schwannomas (acoustic neuromas) include observation, tumor resection, stereotactic radiosurgery, and fractionated radiotherapy. In this report the authors review their 15-year experience with radiosurgery and discuss indications and expectations in relation to the different approaches. They conducted a survey of neurosurgeons to determine management preferences in two different cases of intra- and extra-canalicular tumor presentations. Patient decisions must be based on quality information derived from peer-reviewed literature.
Preservation of functional hearing after gamma knife surgery for vestibular schwannoma
Authors: Litvack Zachary N. , Norén Georg , Chougule Prakash B. , Zheng Zhen
Published: January 2008

Object

The goal of this retrospective study was to define the rates of preservation of functional hearing and growth control of vestibular schwannomas (VS) treated by gamma knife surgery (GKS) involving a consistent 12-Gy prescription dose.

Methods

One hundred thirty-four patients with unilateral VS underwent GKS between 1994 and 2000. The mean magnetic resonance (MR) imaging follow-up period was 31.7 months (maximum 72 months), and the mean audiometry follow-up interval was 26.3 months (maximum 60 months). The mean marginal dose was 12 ± 0.6 Gy. The mean maximum dose delivered to the tumor center was 25.4 Gy (range 17.4–34.3 Gy). The tumor control rate, defined as no change or a reduction in size at last follow up, was 96.7%. Of the patients studied, 97.7% remained free from the need to undergo tumor resection. Overall functional hearing preservation was 61.7%; the preservation rate for intra-canalicular tumors was 63.6%, for those with an intracranial diameter less than 1.5 cm it was 54.5%, for those between 1.5 and 3 cm it was 68.2%, and for those larger than 3 cm it was 33.3%. Early in the series, three patients (2.2%) developed temporary facial weakness (House–Brackmann Grade II–III) in the posttreatment period, but this resolved within a few weeks. No case of facial weakness occurred after 1996.

Conclusions

The authors demonstrated the efficacy, safety, and in many ways, the advantage of GKS over microsurgery for VS. Patients harboring tumors 3 cm or smaller in intracranial diameter, regardless of their age and medical condition, should be given the option of undergoing GKS as primary treatment.
Update on treatment modalities for optic nerve sheath meningiomas
Authors: Liu James K. , Forman Scott , Moorthy Chitti R. , Benzil Deborah L.
Published: January 2008

Optic nerve sheath meningiomas (ONSMs) represent 1 to 2% of all meningiomas and one third of all optic nerve tumors. The management of ONSMs is controversial. Traditional surgical removal often results in postoperative blindness in the affected eye and thus has been abandoned as a treatment option in most patients. Surgery may be unnecessarily aggressive, especially if the patient has useful vision. When these tumors are left untreated, however, ensuing progressive visual impairment may lead to complete blindness. More recently, radiotherapy has gained wider acceptance as a treatment for these lesions. The authors of some reports have suggested that fractionated stereotactic radiosurgery (SRS) may be the best option for treating primary ONSMs. In patients with documented progressive visual deterioration, fractionated SRS may be effective in improving or stabilizing remaining functional vision. The authors review the clinical presentation, radiographic characteristics, and management of ONSMs, emphasizing the use of fractionated SRS.
Spinal meningiomas: surgical management and outcome
Authors: Gottfried Oren N. , Gluf Wayne , Quinones-Hinojosa Alfredo , Kan Peter , Schmidt Meic H.
Published: January 2008

Advances in imaging and surgical technique have improved the treatment of spinal meningiomas; these include magnetic resonance imaging, intraoperative ultrasonography, neuromonitoring, the operative microscope, and ultrasonic cavitation aspirators. This study is a retrospective review of all patients treated at a single institution and with a pathologically confirmed diagnosis of spinal meningioma. Additionally the authors analyze data obtained in 556 patients reported in six large series in the literature, evaluating surgical techniques, results, and functional outcomes. Overall, surgical treatment of spinal meningiomas is associated with favorable outcomes. Spinal meningiomas can be completely resected, are associated with postoperative functional improvement, and the rate of recurrence is low.
Anatomical basis of approaches to foramen magnum and lower clival meningiomas: comparison of retrosigmoid and transcondylar approaches
Authors: Suhardja Agustinus , Agur Anne M. R. , Cusimano Michael D.
Published: January 2008

Object

Meningiomas of the lower clivus and foramen magnum are among the most challenging of all neurosurgical lesions. Debate continues regarding the most appropriate approach to this eloquent anatomical region. This anatomical study was undertaken to measure and compare the area of surgical exposures of the lower clivus achieved using the retrosigmoid and the extreme-lateral transcondylar (ELT) approaches.

Methods

Thirteen embalmed cadaveric heads were dissected bilaterally via the retrosigmoid approach on one side and the ELT approach on the other. The circumference of the area of exposure was delineated using beaded pins placed into the dura. After removal of the brain, the longest longitudinal and transverse axes of the pinned areas were measured and surface area calculated. The area of surgical exposure was also expressed as a percentage of the total area of the lower clivus. Normalized and adjusted surface areas were calculated using the bimastoid diameter. The areas of exposure were compared using the two-tailed paired Student t-test.

The mean area of exposure required using the retrosigmoid approach was 19.8 ±14.7 mm2 (range 6–49 mm2) and that using the ELT approach was 27.8 ±22.8 mm2 (range 10–90 mm2). The mean percentage of the lower clivus exposed by the retrosigmoid approach was 14.9 ±3.6% (range 10–22%) and that exposed by the ELT approach was 20.5 ± 4.9% (range 10–25%). The ELT approach provided significantly greater area of operative exposure and allowed a significantly higher percentage of lower clivus and foramen magnum exposure than did the retrosigmoid approach (p <0.05). Normalized and adjusted surface areas, taking into consideration the bimastoid diameter, were also statistically significant in favor of the ELT approach.

Conclusions

The ELT approach provided a significantly greater area of exposure than did the retrosigmoid approach.
Comparison of conscious sedation and general anesthesia for motor mapping and resection of tumors located near motor cortex
Authors: Vitaz Todd W. , Marx William , Victor Jonathan D. , Gutin Philip H.
Published: January 2008

Object

The surgical treatment of tumors located near eloquent cortex carries a high risk of inducing worsening neurological deficits. Intraoperative electrocorticography techniques have been developed to help identify these areas at the time of surgery in an effort to minimize such risks. The optimal anesthetic technique for conducting these procedures, however, has never been determined.

Methods

The authors conducted a retrospective study to compare patients who underwent intraoperative motor mapping between September 2000 and May 2002. Demographic and neurophysiological monitoring data were collected from the hospital records. Patients were divided into two groups based on the anesthetic technique used for surgery: in Group 1 general anesthesia was used, and in Group 2 conscious sedation.

Group 1 comprised 24 patients (mean age 47 years) with 16 right- and eight left-sided lesions. Group 2 consisted of 21 patients (mean age 46 years) with 18 right- and three left-sided lesions. Pathological diagnoses were similar between the two groups. Motor stimulation was elicited in 12 patients (50%) in Group 1 and in 21 patients (100%) in Group 2 (p < 0.001). In addition, the mean stimulation amplitude required was significantly higher (13 mA) in patients in whom conscious sedation was used as opposed to general anesthesia (5 mA, p < 0.0001). Electrographic evidence of seizures was seen in 29% of Group 1 cmpared with 10% of Group 2 patients (p > 0.05).

Conclusions

The use of conscious sedation as an anesthetic technique for motor mapping not only improves the chances of achieving successful stimulation and identification of motor cortex in relationship to the lesion, but it also allows for repetitive monitoring of the patient's motor function during resection of the lesion.
Surgical management of unruptured posterior carotid artery wall aneurysms
Authors: O'Shaughnessy Brian A. , Getch Christopher C. , Bendok Bernard R. , Batjer H. Hunt
Published: January 2008

Intracranial aneurysms arising from the posterior wall of the supraclinoid carotid artery are extremely common lesions. The aneurysm dilation typically occurs in immediate proximity to the origin of the posterior communicating artery and, less commonly, the anterior choroidal artery (AChA). Because of the increasingly widespread use of non-invasive neuroimaging methods to evaluate patients believed to harbor cerebral lesions, many of these carotid artery aneurysms are now documented in their unruptured state, prior to occurrence of subarachnoid hemorrhage. Based on these factors, the management of unruptured posterior carotid artery (PCA) wall aneurysms is an important element of any neurosurgical practice.

Despite impressive recent advances in endovascular therapy, the placement of microsurgical clips to exclude aneurysms with preservation of all afferent and efferent vasculature remains the most efficacious and durable therapy. To date, an optimal outcome is only achieved when the neurosurgeon is able to combine systematic preoperative neurovascular assessment with meticulous operative technique. In this report, the authors review their surgical approach to PCA wall aneurysms, which is greatly based on the extensive neurovascular experience of the senior author. Focus is placed on their methods of preoperative evaluation and operative technique, with emphasis on neurovascular anatomy and the significance of oculomotor nerve compression. They conclude by discussing surgery-related complications, with a particular focus on intraoperative rupture of aneurysms and their management, and the postoperative ischemic AChA syndrome.
Imaging of sacral tumors
Authors: Manaster Betty Jean , Graham Travis
Published: January 2008

Sacral tumors are somewhat unique to the skeletal system in that the prevalence of various neoplasms is different from that at other osseous sites. There are also unique imaging-related considerations, related in part to diagnosis, but particularly to the evaluation site for tumor biopsy sampling and resection. In this report, the authors describe imaging features of the most common sacral lesions, provide numerous radiological examples, and give suggestions for optimal imaging of this region of the body.
Microendoscopic discectomy for recurrent disc herniations
Authors: Isaacs Robert E. , Podichetty Vinod , Fessler Richard G.
Published: January 2008

Object

The use of microendoscopic discectomy (MED) for the treatment of primary lumbar disc herniations has become fairly well accepted; its role in recurrent disc herniations is less clear. The reluctance of many surgeons to use this technique stems, in part, from the concern of undertaking an endoscopic discectomy in a patient in whom the anatomy is distorted from a previous operation. It appears counterintuitive to operate through a limited working area when the traditional open approach for recurrence favors wider exposure of the surgical field. Given that operating on previously exposed tissue can be associated with even greater morbidity than on virginal tissue, the authors describe their experience with performing MED for recurrent disc herniation.

Methods

Unilateral MED was performed in patients with classic symptoms of lumbar radiculopathy, a previous operation at that level, and findings of recurrent disc herniation on magnetic resonance imaging. The approach was similar to a standard MED. Aided by fluoroscopic guidance, a working cannula was docked on the laminofacet junction at the level of the nerve root, with care taken to ensure a slightly more lateral initial trajectory. A good decompression of the nerve root could then be achieved through the use of the endoscope with preservation of the paraspinous musculature and much of the remaining facet capsule.

Ten consecutive patients undergoing the procedure were analyzed prospectively and compared with the previous 25 who underwent routine single-level MED. Use of the MED technique provided excellent visualization and decompression of the nerve root; no conversions to open procedures were necessary in either group. The average operative time in the experimental group was 98.5 minutes, with a mean blood loss of 33 ml and an approximate hospital stay of 7.3 hours. In this respect, there was no statistical difference between the two groups (analysis of variance, p = 0.39, 0.68, and 0.51, respectively). There was one cerebrospinal fluid leak in each group.

Conclusions

Microendoscopic discectomy for recurrent disc herniation can be safely performed without an increase in surgery related morbidity.
Clinical outcomes after minimal-access surgery for recurrent lumbar disc herniation
Authors: Le Hoang , Sandhu Faheem A. , Fessler Richard G.
Published: January 2008

Object

Experience with minimal-access surgical approaches for revision lumbar surgery has not been previously reported.

Methods

During a 7-month period, 10 consecutive patients with recurrent disc herniations underwent revision operations in which microendoscopic discectomy (MED) was performed. Perioperative data and clinical outcomes (according to Macnab criteria) were compared with those obtained in 25 consecutive patients who underwent routine single-level MED as well as with previously published data. Overall, outcome of the MED-treated revision group was excellent or good in 90% during a mean follow-up period of 18.5 months (minimum 12 months). Operative blood loss, duration, complications, and length of hospital stay were not significantly different between the revision and primary MED-treated groups.

Conclusions

Analysis of these early data suggests equivalent or superior results are obtained when performing MED compared with historical controls in which conventional surgery was conducted for recurrent disc surgery. The procedure appears to be a safe and effective alternative in cases in which recurrent lumbar disc herniation causes radiculopathy.
Spontaneous intracerebral hemorrhage due to coagulation disorders
Authors: Quinones-Hinojosa Alfredo , Gulati Mittul , Singh Vineeta , Lawton Michael T.
Published: January 2008

Although intracranial hemorrhage accounts for approximately 10 to 15% of all cases of stroke, it is associated with a high mortality rate. Bleeding disorders account for a small but significant risk factor associated with intracranial hemorrhage. In conditions such as hemophilia and acute leukemia associated with thrombocytopenia, massive intracranial hemorrhage is often the cause of death. The authors present a comprehensive review of both the physiology of hemostasis and the pathophysiology underlying spontaneous ICH due to coagulation disorders. These disorders are divided into acquired conditions, including iatrogenic and neoplastic coagulopathies, and congenital problems, including hemophilia and rarer diseases. The authors also discuss clinical features, diagnosis, and management of intracranial hemorrhage resulting from these bleeding disorders.
Malignant meningioma of the lateral ventricle
Authors: Erman Tahsin , Göçer A. Ýskender , Tuna Metin , Erdođan ªeyda , Zorludemir Suzan
Published: January 2008

This 65-year-old man presented with a very rare malignant meningioma in the trigonum of the right lateral ventricle. Neurological examination showed bilateral papilledema. Magnetic resonance imaging revealed a solid, enhancing tumor in the right trigonum with a hypointense cystic component located in the center of the tumor. The lesion was totally resected via a superior parietooccipital transcortical approach. Histological examination showed an anaplastic (malignant) meningioma with architectural disarray, high mitotic activity (20/10 hpf), necrosis, and cytological atypism. As in our case, heterogeneous signal, due to necrotic tissue and frequently demonstrated on both T1- and T2-weighted sequences, is suggestive of an aggressive type of meningioma.
Surgical management of metastatic spinal neoplasms
Authors: Vrionis Frank D. , Small John
Published: January 2008

Object

In this study the authors retrospectively review outcomes in patients treated for metastases to the spine. Surgery for metastatic tumors to the spine remains an important part of the treatment armamentarium. Maximum tumor resection with a minimum number of complications is one of the goals of surgery. Current surgical procedures include tumor resection and spinal stabilization for optimal results.

Methods

The records of 96 patients who underwent surgery for a metastatic spine tumor at the authors' institution were reviewed. Spinal instrumentation was used in the majority of patients. Ambulatory status was maintained in 91% and pain improved in 94% of patients. Complications included infection (5.2%), cerebrospinal fluid leak (2%), and delayed hardware failure (3.1%). The mortality rate was 4.1%; the main cause was due to tumor progression.

Conclusions

Surgery is indicated in a select group of patients with metastatic tumors to the spine. A multidisciplinary approach is recommended for patient selection and complication avoidance. Surgical options, including approach, type of reconstruction and extent of resection (including en bloc spondylectomy) need to be addressed for optimal outcomes.
Surgical treatment of primary sacral tumors: complications associated with sacrectomy
Authors: Zileli Mehmet , Hoscoskun Cüneyt , Brastianos Priscilla , Sabah Dündar
Published: January 2008

Object

Sacral tumors are relatively rare, and experience related to resection of these tumors is therefore usually limited to a small number of patients. The purpose of this retrospective study was to review the authors' experience with sacral neoplasms over the last 12 years.

Methods

Based on a review of records in 11 patients who underwent sacrectomy, and the various patient characteristics, presenting symptoms, histological findings for their tumors, as well as the type of surgical treatment used (including a whole spectrum of sacral amputations), and their outcome are reported.

Conclusions

Despite the potential for complications, sacrectomy can be performed successfully, and is an important procedure in the treatment of primary sacral tumors.
Treatment of atlantoaxial instability in pediatric patients
Authors: Rahimi Scott Y. , Stevens E. Andrew , Yeh David John , Flannery Ann Marie , Choudhri Haroon Fiaz , Lee Mark R.
Published: January 2008

The atlantoaxial region has been extensively described as a spinal segment especially prone to injury in children. In this clinical review, the authors evaluate and summarize the management of 23 pediatric cases of atlantoaxial instability treated between March 1990 and October 2002. Four broad categories of atlantoaxial problems were observed—atlantoaxial rotatory subluxation in six patients, anterior–posterior atlantoaxial instability caused by ligamentous injury or congenital ligamentous laxity (10 patients), atlantoaxial fracture with or without dislocation (five patients), and atlantooccipital dislocation (two patients). Most cases (60.9%) were treated without surgical intervention, resulting in excellent outcomes; however, 21.7% of cases were treated with a cervical halo (mean patient age 72.6 months) alone for 3 months. Various techniques of surgical stabilization including transarticular screws with sublaminar wiring, trans-oral decompression with posterior plating, and laminectomy with Steinmann pin occipital–cervical fusion were used with good results. Both patients with atlantooccipital dislocation underwent immediate Locksley occipital–cervical fusion, with marked neurological improvement. Individualized case management must be based on clinical presentation, with internal fixation being the last resort.
Intracranial hypotension syndrome: a comprehensive review
Authors: Paldino Michael , Mogilner Alon Y. , Tenner Michael S.
Published: January 2008

Intracranial hypotension may have variable clinical presentations, but has a rather uniform component of postural headache among its symptomatology. Its symptoms are explainable given the effects of the hypotension and attempts within the craniospinal axis to maintain volume homeostasis in the face of cerebrospinal fluid leakage (Monro–Kellie hypothesis). The imaging corollaries of the consequences of intracranial hypotension are especially well depicted on magnetic resonance imaging studies.
Epidural hematomas of the posterior cranial fossa
Authors: Bor-Seng-Shu Edson , Aguiar Paulo Henrique , de Almeida Leme Ricardo Jose , Mandel Mauricio , de Andrade Almir Ferreira , Marino Raul
Published: January 2008

Object

The authors present their experience in the management of posterior fossa epidural hematoma (PFEDH), which involved an aggressive diagnostic approach with the extensive use of head computerized tomography (CT) scanning.

Methods

The authors treated 43 cases of PFEDH in one of the largest health centers in Brazil. Diagnosis was established in all patients with the aid of CT scanning because the clinical manifestations were frequently nonspecific. Cases were stratified by clinical course, Glasgow Coma Scale score, and their radiological status. Based on clinical and radiological parameters the patients underwent surgical or conservative management.

Conclusions

Compared with outcomes reported in the available literature, good outcome was found in this series. This is primarily due to the broad use of CT scanning for diagnostic and observational purposes, which, in the authors' opinion, led to early diagnosis and prompt treatment.
Intrauterine closure of myelomeningocele: an update
Authors: Tulipan Noel
Published: January 2008

Preliminary evidence suggests that intrauterine myelomeningocele repair may benefit patients by reducing the both incidence of hydrocephalus and the severity of the Chiari malformation; however, this benefit remains unproved. Furthermore, the procedure entails substantial risks not associated with conventional therapy. A randomized controlled trial of intrauterine and conventional therapies is underway. This study should definitively establish the procedure-related risks and benefits. Regardless of the outcome, it is clear that the risks of intrauterine intervention need to be reduced before myelomeningocele, or other congenital malformations, can be effectively treated prior to birth. To that end, studies are being conducted to assess the potential advantages of applying state-of-the-art endoscopic techniques to intrauterine therapy. If benefit can be proven and risks reduced, intrauterine myelomeningocele repair has the potential to become the preferred therapy for patients suffering from this debilitating disease.
Primary closure of open myelomeningocele
Authors: Gaskill Sarah J.
Published: January 2008

Object

The purpose of this paper is to describe the technique of closing an open myelomeningocele in the newborn infant.

Methods

The anatomical rationale behind the closure techniques will be specifically reviewed. Avoidance of complications will be discussed. The management of unusual developmental anatomical abnormalities, such as the management of unusually large skin defects and kyphotic deformities will be discussed. Complications and the postoperative care will be reviewed and specifics regarding postoperative care will be summarized.

Conclusions

A multidisciplinary team approach is critical to the long-term management of these patients.
Instrumented transforaminal lumbar interbody fusion with bioabsorbable polymer implants and iliac crest autograft
Authors: Coe Jeffrey D.
Published: January 2008

Object

The purpose of this study was to evaluate the clinical and radiographic results in 31 patients from one center who underwent instrumented transforaminal lumbar interbody fusion (TLIF) for primarily degenerative indications.

Methods

Bioabsorbable polymer spacers manufactured with a copolymer of 70:30 poly(L-lactide-co-D,L-lactide) and filled with iliac crest autograft bone were used for the TLIF procedure. In this paper the details of this procedure, intermediate (1- to 2-year) clinical and radiographic outcomes, and the basic science and rationale for the use of bioabsorbable polymers are discussed. At a mean of 18.4 months of follow up, 30 patients (96.8%) were judged to have attained solid fusions and 25 patients (81%) had good to excellent results. Three patients (9.7%) experienced complications, none of which were directly or indirectly attributable to the use of the bioabsorbable polymer implant. Only one implant in one patient (3.2%) demonstrated mechanical failure on insertion, and that patient experienced no clinical sequelae.

Conclusions

This is the first clinical series to be published in which the mean follow-up duration equals or exceeds the biological life expectancy of this material (12–18 months). Both the clinical and radiographic results of this study support the use of interbody devices manufactured from biodegradable polymers for structural interbody support in the TLIF procedure.
Craniofacial reconstruction with a fast resorbing polymer: a 6- to 12-month clinical follow-up review
Authors: Cohen Steven R. , Holmes Ralph E. , Meltzer Hal S. , Levy Michael L. , Beckett Miles Z.
Published: January 2008

Object

Resorbable polymer implants have become a compelling option in the treatment of acquired and congenital craniofacial deformities. In particular, the resorbable polylactide and polyglycolide polymers have demonstrated excellent safety profiles in multiple in vitro, animal, and clinical studies and are currently being used in a wide variety of craniofacial applications. In pediatric craniofacial reconstruction a desirable attribute of fixation is early resorption, which may limit the duration of any effect on cranial growth. In this paper the authors discuss the biomaterial properties of a fast resorbing polymer (FRP) and the clinical results in a series of patients who participated in a 6- to 12-month study.

Methods

The authors performed craniofacial reconstruction by using FRP implants in 29 patients beginning in August 2002. All patients experienced maintenance of stable bone fixation followed by bone healing. Cosmetic results were rated satisfactory or excellent, except for one unsatisfactory cosmetic result caused by disease progression.

Conclusions

Results of this study support the effectiveness of an FRP implant in a variety of craniofacial surgical procedures including craniosynostoses, fibrous dysplasia, cranial defects, and encephaloceles.
The use of bioabsorbable implants in spine surgery
Authors: Robbins Matthew M. , Vaccaro Alexander R. , Madigan Luke
Published: January 2008

The use of bioabsorbable implants in spine surgery is expanding at a rapid pace. These implants are mimicking the roles of traditional metallic devices and are demonstrating similar efficacy in terms of maintaining stability and acting as carriers for grafting substances. Biomechanical studies have demonstrated their ability to stabilize effectively a degenerative cervical and lumbar motion segment. In numerous animal models, researchers have illustrated the ability of bioabsorbable implants to function satisfactorily as an interbody spacer and to achieve satisfactory bone fusion. Investigators have explored various opportunities for these implants to replace their metallic counterparts in clinical studies conducted in humans. The gradual resorption of these implants appears effectively to transfer gradual loads to the grafting substances promoting the biological mechanisms of fusion.

Novel uses of bioabsorbable technology are constantly evolving. Their future as a carrier of biological agents such as bone morphogenetic proteins and bone graft extenders, their radiolucency, and their eventual resorption make them an ideal implant for use in spinal degenerative disease.
Spinal epidural lipomatosis: a review of its causes and recommendations for treatment
Authors: Fassett Daniel R. , Schmidt Meic H.
Published: January 2008

Spinal epidural lipomatosis is most commonly observed in patients receiving long-term exogenous steroid therapy, but can also be seen in patients with endogenous steroid overproduction, obesity, or idiopathic disease. With this condition, there is hypertrophy of the epidural adipose tissue, causing a narrowing of the spinal canal and compression of neural structures. A majority of patients will present with progressive myelopathy, but radicular symptoms are also common. Conservative treatment—weaning from steroids or weight loss—can reverse the hypertrophy of the adipose tissue and relieve the neural compression. If conservative management fails, surgery with decompressive laminectomy is also very successful at improving the patient's neurological symptoms.
A review of neurophysiological testing
Authors: Lehman Richard M.
Published: January 2008

The rapid advances in the technology of, and accumulation of pertinent data in, electrophysiological testing has increased exponentially in the past decade. This is attributable to continued advances in computer technology, biomedical engineering, and now the coregistration of the electrophysiological data with neuroimaging results. Knowledge of normal function and electrophysiological response at rest or on stimulation of the central and peripheral nervous systems is important to the neurosurgeon. Only by a basic understanding of normal and abnormal recordings may diagnoses and localizations be achieved. Intraspinal and intracranial surgical procedures are predicated on nontrauma to the neuraxis. This can be accomplished by performing electrophysiological testing to monitor the function of the spinal and cranial nerves, spinal cord, brainstem, basal ganglia, and cerebrum. If the surgeon cannot delineate critical cortex or pathways, he or she will be unable to avoid these areas in the patient.
The biochemical investigation of Cushing syndrome
Authors: Simard Marie
Published: January 2008

Cushing syndrome is an insidious illness that warrants an early diagnosis to avoid the effects of prolonged hyper-cortisolism. The variability in the clinical features of the disease and the occasional inconsistencies between different biochemical tests performed to identify it render the diagnosis challenging. In this paper the author discusses the various biochemical tests that are useful for the diagnoses of Cushing syndrome and Cushing disease, with an emphasis on the respective sensitivities and specificities of these tests. The measurement of evening salivary cortisol and the combined low-dose dexamethasone–corticotropin-releasing hormone stimulation test have improved overall sensitivity and specificity in the evaluation of Cushing syndrome and Cushing disease.
Surgical repair of brachial plexus injury: a multinational survey of experienced peripheral nerve surgeons
Authors: Belzberg Allan J. , Dorsi Michael J. , Storm Phillip B. , Moriarity John L.
Published: January 2008

Background

Brachial plexus injuries (BPIs) are often devastating events that lead to upper-extremity paralysis, rendering it a painful extraneous appendage. Fortunately, there are several nerve repair techniques that provide restoration of some function. Although there is general agreement in the medical community concerning which patients may benefit from surgical intervention, the actual repair technique for a given lesion is less clear.

Object

The authors sought to identify and better define areas of agreement and disagreement among experienced peripheral nerve surgeons regarding the management of BPIs.

Methods

The authors developed a detailed survey in two parts: one part addressing general issues related to BPI and the other presenting four clinical cases. The survey was mailed to 126 experienced peripheral nerve physicians of whom 49 (39%) participated in the study. The respondents represented 22 countries and multiple surgical subspecialties. They performed a mean of 34 brachial plexus reconstructions annually. Areas of significant disagreement included the timing and indications for surgical intervention in birth-related palsy, management of neuroma-in-continuity, the best transfers to achieve elbow flexion and shoulder abduction, the use of intra- or extraplexal donors for motor neurotization, and the use of distal compared with proximal coaptation during nerve transfer.

Conclusions

Experienced peripheral nerve surgeons disagreed in important respects as to the management of BPI. The decisions made by the various treating physicians underscored the many areas of disagreement regarding the treatment of BPI including the diagnostic approach to defining the injury, timing of and indications for surgical intervention in birth-related palsy, management of neuroma-in-continuity, choice of nerve transfers to achieve elbow flexion and shoulder abduction, use of intra- or extraplexal donors for neurotization, and the use of distal or proximal coaptation during nerve transfer.