bluuebunny/crossref_metadata_2025 huggingface dataset:
Paracervical abscesses as life-threatening complications of outpatient pain treatment
Authors: Schütze Michael , Piek Jürgen
Published: January 2008

The authors present three cases of iatrogenic paracervical abscesses caused by infiltration therapy of pain medications used in conservative treatment in patients with chronic cervicobrachialgia. All three patients had received this therapy several times before presenting with clinical signs of a local infection. The diagnosis was made based on results of the clinical examination, laboratory tests, and magnetic resonance imaging. The organism isolated was Staphylococcus aureus in all cases. After immediate surgery and long-term antibiotic therapy, all patients had a good outcome.

The authors conclude that infectious complications after invasive outpatient treatment often go undiagnosed, but as shown in these three cases can lead to acute and sometimes life-threatening complications. If the disease is diagnosed early, immediate surgical evacuation combined with antibiotic therapy results in recovery. For medicolegal reasons it should kept in mind that even a routine injection may lead to such complications.
Sagittal alignment and the Bryan cervical artificial disc
Authors: Johnson J. Patrick , Lauryssen Carl , Cambron Helen O. , Pashman Robert , Regan John J. , Anand Neel , Bray Robert
Published: January 2008

Object

The authors evaluated cervical spine radiographs to determine sagittal alignment in patients who underwent one- or two-level arthroplasty with the Bryan cervical artificial disc prosthesis.

Methods

The curvature of the surgically treated spinal segments and the overall curvature of the cervical spine were evaluated in 13 patients who underwent 16 cervical arthroplasty device placements. Preoperative and postoperative lateral radiographs were reviewed and compared using standardized techniques for measuring spinal curvature. Patients who underwent a single-level cervical arthroplasty had a 4.7° mean reduction (p < 0.05) in lordosis after cervical artificial disc replacement. The three patients who underwent two-level cervical arthroplasty had no significant changes in the sagittal alignment.

Conclusions

Patients who underwent arthroplasty with a Bryan cervical artificial disc had a focal loss of lordosis (that is, kyphosis) at the treated levels after single-level procedures. Nevertheless, there was no significant change in the overall sagittal curvature of the cervical spine after single-level artificial disc replacements. The patients who underwent two-level artificial disc placement had no significant changes in lordosis at the treated levels or in the overall curvature. The likely source of this outcome appears to be the endplate milling procedures that reorient the vertebral endplates.
Diagnosis and management of adult pyogenic osteomyelitis of the cervical spine
Authors: Acosta Frank L. , Chin Cynthia T. , Quiñones-Hinojosa Alfredo , Ames Christopher P. , Weinstein Philip R. , Chou Dean
Published: January 2008

Establishing the diagnosis of cervical osteomyelitis in a timely fashion is critical to prevent catastrophic neurological injury. In the modern imaging era, magnetic resonance imaging in particular has facilitated the diagnosis of cervical osteomyelitis, even before the onset of neurological signs or symptoms. Nevertheless, despite advancements in diagnosis, disagreement remains regarding appropriate surgical treatment. The role of instrumentation and type of graft material after cervical decompression remain controversial. The authors describe the epidemiological features, pathogenesis, and diagnostic evaluation, and the surgical and nonsurgical interventions that can be used to treat osteomyelitis of the cervical spine. They also review the current debate about the role of instrumentation in preventing spinal deformity after surgical decompression for cervical osteomyelitis. Based on this review, the authors conclude that nonsurgical therapy is appropriate if neurological signs or symptoms, instability, deformity, or spinal cord compression are absent. Surgical decompression, debridement, stabilization, and deformity correction are the goals once the decision to perform surgery has been made. The roles of autogenous graft, instrumentation, and allograft have not been clearly delineated with Class I data, but the authors believe that spinal stability and decompression override creating an environment that can be completely sterilized by antibiotic drugs.
Surgical strategies for vertebral osteomyelitis and epidural abscess
Authors: Hsieh Patrick C. , Wienecke Robert J. , O'Shaughnessy Brian A. , Koski Tyler R. , Ondra Stephen L.
Published: January 2008

Pyogenic vertebral discitis and osteomyelitis (PVDO) has become an increasing problem for the spine surgeon. Despite recent advances in medical care and improved diagnostic neuroimaging, PVDO remains a major cause of illness and death in the elderly population. Infection of the spinal column often presents insidiously; however, if not treated appropriately and in a timely manner it can lead to severe neurological impairment, systemic septicemia, and progressive spinal deformity. In this paper the authors review the epidemiological and pathophysiological features and the clinical presentation of PVDO. Conventional medical therapy is described, with a particular focus on the methods of diagnosis. Surgical strategies for PVDO are then presented based on the literature and according to the practice of the senior author (S.L.O.), with an emphasis placed on structural considerations, implant selection, and techniques for augmenting vascular tissue to the site of infection.
Infected vertebroplasty
Authors: Walker David H. , Mummaneni Praveen , Rodts Gerald E.
Published: January 2008

Transpedicular vertebroplasty has been established as a safe and effective treatment for thoracic and lumbar compression fractures. Complications are rare and infectious complications requiring surgical management have only been reported once in the literature. In this paper the authors present two patients in whom osteomyelitis developed after vertebroplasty in which corpectomy was required. The serious nature of these infections, their surgical management, and complication avoidance are discussed.
Treatment of a chronic Scedosporium apiospermum vertebral osteomyelitis
Authors: German John W. , Kellie Susan M. , Pai Manjunath P. , Turner Paul T.
Published: January 2008

Scedosporium apiospermum is a rare cause of fungal vertebral osteomyelitis that may result in chronic infection requiring multiple surgical interventions and long-term medical therapy. This case is the seventh one reported in the literature and is the first to include salvage surgery of a previous major spinal reconstruction. This report is also the first to describe the use of the new antifungal agent voriconazole. In treating this case of chronic vertebral osteomyelitis, several principles are emphasized from both the surgical and medical perspectives. From a surgical perspective, the use of salvage surgery, temporary avoidance of spinal instrumentation, and an appropriate choice of graft materials are emphasized. From a medical perspective, confirmation of the diagnosis, the need for long-term antifungal therapy, the need for long-term patient compliance, and the use of the new antifungal agent voriconazole are emphasized. Application of these principles has led to an adequate 2-year outcome.
Procedure complications of carotid angioplasty and stent placement without cerebral protection devices
Authors: Kadkhodayan Yasha , Derdeyn Colin P. , Cross Dewitte T. , Moran Christopher J.
Published: January 2008

Object

The goal in this retrospective study was to examine the procedural complication rate for carotid angioplasty and stent placement performed without cerebral protection devices.

Methods

Between March 1996 and December 2003, 167 carotid angioplasty and/or stent placement procedures were performed without cerebral protection devices in 152 patients (57 women and 95 men whose mean age was 64 years, range 19–92 years). Seven of these patients underwent angioplasty alone. Eighty-nine patients presented with focal neurological symptoms. Indications for surgery included atherosclerosis, radiation-associated stenosis, dissection, pseudoaneurysm, and stretched endovascular coils from aneurysm treatment. In this study, the patients' medical records were reviewed for clinical characteristics, techniques used, and resulting intraprocedural and 30-day complication rates.

The intraprocedural stroke rate was four (2.4%) of 167; this included three hemispheric strokes and one retinal embolus. All events occurred in patients who had symptomatic stenosis. The procedural transient ischemic complication rate was six (3.6%) of 167, as was the procedural nonneurological complication rate. During the 30 days post-procedure, one patient had died and three had suffered permanent ischemic events (two cerebral and one ocular). The composite 30-day postprocedural stroke and death rate was eight (5%) of 160. The rate of asymptomatic angiographically confirmed abnormalities was 0.6% (one treated vessel that was occluded but asymptomatic). The 30-day rate of nonneurological complications was 2.5%. A strong association between intraprocedural thromboembolic events (eight cases) and prior ischemic symptoms was found (p = 0.01).

Conclusions

Carotid angioplasty and stent placement without cerebral protection devices is safe, particularly in patients without symptomatic stenosis.
Current endovascular treatment options for intracranial carotid artery atherosclerosis
Authors: Komotar Ricardo J. , Mocco J , Wilson David A. , Connolly E. Sander , Lavine Sean D. , Meyers Philip M.
Published: January 2008

A substantial number of strokes are caused by intracranial atherosclerosis, a disease that traditionally has been treated medically. Recent technological advancements, however, have revolutionized the treatment of this condition by enabling the use of endovascular methods. In this paper the authors focus on the internal carotid artery, and review relevant studies concerning angioplasty with stent placement for the management of intracranial atherosclerosis in this vessel. With continued experience and a multidisciplinary approach in the evaluation of these patients, favorable outcomes may be achieved.
Endovascular management of carotid artery disease after radiation therapy and radical neck dissection
Authors: Ecker Robert D. , Donovan Maureen T. , Hopkins L. Nelson
Published: January 2008

Object

More patients with head and neck cancers who undergo radical neck dissection and adjuvant radiation are experiencing prolonged survival times. Because of their improved survival, patients are living long enough to suffer the delayed effects of radiation therapy. Radiation-induced carotid artery (CA) stenosis in patients with or without radical neck dissection often requires extensive exposure and vessel reconstruction. The aim of this study was to evaluate the efficacy of endovascular treatment as an alternative therapy for radiation-induced CA stenosis.

Methods

Coinciding with the improved longevity of these patients, CA angioplasty and stent placement has become a definitive treatment strategy for this particularly challenging group of individuals. Long lesions are easily addressed with multiple telescoped stents. The tendency toward early restenosis can now be addressed with cutting balloon angioplasty. A review of the authors' institutional database yielded five patients (four men and one woman) with a history of radiation treatment ipsilateral to their CA stenosis. Three of five patients were symptomatic, and the interval between radiation therapy and endovascular treatment ranged from 1 to 47 years (mean 16.6 years). Four of the five patients were treated using distal embolic protection devices, and all patients underwent balloon dilation after stent placement.

Conclusions

As advancements are made in the technology and techniques for CA angioplasty and stent placement, the safety and durability of treatments in patients with radiation-induced atherosclerotic disease will improve.
Superior ophthalmic vein approach to carotid–cavernous fistulas
Authors: Bulsara Ketan R. , Vasudevan Ram , Erdem Eren
Published: January 2008

Endovascular procedures have revolutionized the treatment of carotid–cavernous fistulas through transarterial and transvenous routes. In some circumstances, however, traditional endovascular approaches may fail. Direct access to the superior ophthalmic vein (SOV) can be used to treat fistulas in this circumstance. The authors discuss the technical aspects of direct exposure of the SOV for access to the cavernous sinus.
Hydrogel-coated coils for the treatment of cerebral aneurysms: preliminary results
Authors: Arthur Adam S. , Wilson Stephanie A. , Dixit Sanat , Barr John D.
Published: January 2008

Object

The authors present a retrospective analysis of their initial experience with the recently developed MicroVention HydroCoil to treat patients with cerebral aneurysms. Unlike the bare metal coils initially available for endovascular treatment of aneurysms, HydroCoils have a layer of hydrogel polymer surrounding a platinum metallic core. The hydrogel polymer expands soon after making contact with blood. The expanded hydrogel polymer provides increased volumetric filling compared with bare metal coils and offers a more biocompatible surface, as demonstrated in animal models.

Methods

Over a 17-month period, the authors used HydroCoils to treat 30 patients with 33 aneurysms. All patients had been treated at least 6 months prior to data analysis. Initial treatment results as well as records of clinical and angiographic follow up were reviewed. Six-month posttreatment angiograms were available for 25 patients.

Conclusions

The HydroCoils were implanted with few complications. On angiographic follow up, a clearly defined radiolucent separation of the coils from the parent artery was noted in many of the aneurysms treated. The authors have not previously observed angiographically demonstrated lucencies separating the coils from the parent artery. This frequent, but not consistent, appearance on follow-up angiograms obtained in this study indicates that HydroCoils support significant neointimal formation across the neck of treated aneurysms. The preliminary results indicate that HydroCoils can be used safely and effectively to treat aneurysms and that these devices may allow for improved aneurysm filling.
Endovascular management of intracranial vertebral artery dissecting aneurysms
Authors: Albuquerque Felipe C. , Fiorella David J. , Han Patrick P. , Deshmukh Vivek R. , Kim Louis J. , Mcdougall Cameron G.
Published: January 2008

Object

Intracranial vertebral artery (VA) dissecting aneurysms often present with severe subarachnoid hemorrhage (SAH) and dramatic neurological injury. The authors reviewed the management of 23 cases in an effort to evaluate treatment efficacy and outcomes.

Methods

The records of 23 patients who underwent endovascular treatment were reviewed to determine symptoms, type of therapy, complications, and clinical outcomes. All patients were evaluated using records kept in a prospectively maintained database.

Ten men and 13 women (age range 35–72 years; mean age 49 years) were treated over an 8-year period. Twelve patients presented with poor-grade SAH, five with good-grade SAH, three with headache, and two with stroke. The other patient's aneurysm was discovered incidentally. Treatment included coil occlusion of the artery at the aneurysm in 21 patients and stent-assisted coil placement in two. Parent artery sacrifice was successful in all cases, whereas both patients treated with stent-assisted coil insertion suffered recurrences. No patient sustained permanent complications as a result of treatment. Two patients died due to the severity of their original SAH. Findings were normal in 14 patients on follow-up review (including five of the 12 presenting with poor-grade SAH), five had fixed neurological deficits but were able to care for themselves, and one was permanently disabled.

Conclusions

Despite their often aggressive neurological presentation, intracranial VA dissecting aneurysms can be managed safely with coil occlusion of the lesion and/or parent artery. Even patients presenting in poor neurological condition may improve dramatically.
Endovascular procedures for treating wide-necked aneurysms
Authors: Wells-Roth David , Biondi Alessandra , Janardhan Vallabh , Chapple Kyle , Gobin Y. Pierre , Riina Howard A.
Published: January 2008

Wide-necked aneurysms remain difficult to treat by either open microneurosurgical or endovascular procedures. Recent advances in the latter technology, including intracranial stents and bioactive coils, now allow an endovascular treatment option for cases in which this was not previously available. In this report the authors describe the new developments in endovascular technologies that make the treatment of wide-necked aneurysms possible. This includes discussion of intracranial stents and bioactive coils designed to promote obliteration of the aneurysm lumen. In addition, methods for coil insertion in wide-necked aneurysms are described, including balloon remodeling and various stent placement procedures. Wide-necked aneurysms previously thought to be untreatable by endovascular means can now be obliterated, thanks to new devices specifically designed for intracranial use.
Vertebroplasty and kyphoplasty: a comprehensive review
Authors: Burton Allen W. , Rhines Laurence D. , Mendel Ehud
Published: January 2008

Vertebroplasty and kyphoplasty are relatively new techniques used to treat painful vertebral compression fractures (VCFs). Vertebroplasty is the injection of bone cement, generally polymethyl methacrylate (PMMA), into a vertebral body (VB). Kyphoplasty is the placement of balloons (called “tamps”) into the VB, followed by an inflation/deflation sequence to create a cavity prior to the cement injection. These procedures are most often performed in a percutaneous fashion on an outpatient (or short stay) basis. The mechanism of action is unknown, but it is postulated that stabilization of the fracture leads to analgesia. The procedures are indicated for painful VCFs due to osteoporosis or malignancy, and for painful hemangiomas. These procedures may be efficacious in treating painful vertebral metastasis and traumatic VCFs. Much evidence favors the use of these procedures for pain associated with the aforementioned disorders. The risks associated with the procedures are low but serious complications can occur. These risks include spinal cord compression, nerve root compression, venous embolism, and pulmonary embolism including cardiovascular collapse. The risk/benefit ratio appears to be favorable in carefully selected patients. The technical aspects of the procedures are presented in detail along with guidelines for patient selection. A comprehensive review of the evidence for the procedures and the reported complications is presented.
Decreases in the number and severity of morphometrically defined vertebral body deformities after kyphoplasty
Authors: Ledlie Jon T. , Renfro Mark B.
Published: January 2008

Object

Vertebral body (VB) deformities have been associated with increased patient morbidity and mortality rates. The aim of this retrospective, consecutive single-center cohort study was to determine the effectiveness of kyphoplasty in reducing morphometrically defined VB deformity, including deformity shape types (wedge, biconcave, or crush) and grade (severity).

Methods

The authors identified 100 patients (70% women; mean age 76.1 years) in whom 138 vertebral fractures (T-4 through L-5; mean fracture age 2.7 months) that were treated between May 2000 and December 2001 were radiographically evaluated preoperatively and at the last follow-up visit (mean follow-up duration 16.9 months). Fractures were divided into four groups by level: T5–9 (28 fractures), T10–12 (41), L1–2 (42), and L3–5 (27). Anterior, mid-line, posterior, and predicted posterior vertebral heights for fractured and adjacent unfractured reference vertebrae were measured on lateral radiographs. The deformity type and grade were mathematically defined using the modified methods of McCloskey–Kanis and Black.

The total number of deformities decreased from 89.9 to 53.6% after kyphoplasty (p < 0.0001). The number of fractures with wedge, biconcave, or crush deformity decreased 22.5, 59.1, and 67.7% (p = 0.0699, p = 0.0222, p = 0.0007), respectively. The number of the more severe Grade 2 deformities decreased (79.7 to 37.0%; p < 0.0001). Kyphoplasty effectively decreased the number of deformed fractures in all vertebral level groups (T5–9, p = 0.0023; T10–12, p = 0.0105; L1–2, p < 0.0001; L3–5, p = 0.0028).

Conclusions

Kyphoplasty resulted in significant normalization of vertebral shapes in patients with symptomatic vertebral fractures, reducing the number and severity of deformed fractures postoperatively.
Immediate and early postoperative pain relief after kyphoplasty without significant restoration of vertebral body height in acute osteoporotic vertebral fractures
Authors: Feltes Carlos , Fountas Kostas N. , Machinis Theofilos , Nikolakakos Leonidas G. , Dimopoulos Vassilios , Davydov Rostislav , Kassam Mozaffar , Johnston Kim W. , Robinson Joe Sam
Published: January 2008

Object

Painful osteoporotic vertebral compression fractures (VCFs) are a significant cause of disability in the elderly population. Kyphoplasty, a recently developed minimally invasive procedure, has been advocated for the successful management of these fractures in terms of immediate pain relief, and also for restoration of the premorbid level of daily activities. In this retrospective study the authors report on their experience with the early management of VCFs with kyphoplasty.

Methods

A retrospective analysis was conducted in 13 patients (seven women and six men) whose ages ranged from 48 to 87 years (mean age 71.5 ± 11 years [mean ± standard deviation]). The interval between onset of symptoms and surgical intervention ranged from 4 to 9 weeks. Twenty levels (12 thoracic, eight lumbar) were treated in this cohort. Immediate and early postoperative (1-month follow-up visit) visual analog scale (VAS) pain scores, activity levels, and restoration of vertebral body (VB) height were assessed.

The mean preoperative VAS score was 8 ± 1, whereas the immediate and early postoperative scores were 1 ± 1. These findings reflected a resolution of 90 to 100% of preoperative pain. All patients resumed routine activities within hours of the procedure, although improvement in VB height was not accomplished in this cohort. No major complications were encountered in this clinical series.

Conclusions

Kyphoplasty is a safe and effective method for the treatment of osteoporotic VCFs. Failure to restore VB height does not seem to interfere with the excellent pain management and good functional outcome provided by this procedure.
Preliminary results of balloon kyphoplasty for vertebral compression fractures in organ transplant recipients
Authors: Deen H. Gordon , Aranda-Michel Jaime , Reimer Ronald , Putzke John D.
Published: January 2008

Object

Organ transplant recipients are at risk for vertebral compression fractures (VCFs). The goal of this study was to determine whether kyphoplasty is an effective treatment for VCFs that develop in this patient population.

Methods

Six consecutive patients who had undergone an organ transplant (five liver and one kidney transplant) had a total of 13 symptomatic VCFs that were treated with balloon kyphoplasty. Postprocedure follow-up duration ranged from 6 to 12 months. The mean visual analog scale pain score was 9.3 before treatment and declined to 1.8 after treatment. This improvement was highly significant (p < 0.001). Intake of narcotic drugs decreased or was eliminated in all patients, and there were no complications related to the procedure. There was one instance of clinically insignificant extraosseous cement extravasation. Sagittal alignment was improved by 5° in one patient and was unchanged in the remaining five. During the follow-up period, a new fracture developed adjacent to a treated level in one patient. This was successfully treated with an additional kyphoplasty procedure.

Conclusions

Kyphoplasty can be performed safely in organ transplant recipients with VCF, in whom results are just as favorable as those seen in patients with no history of organ transplantation.
Balloon kyphoplasty for treatment of sacral insufficiency fractures
Authors: Deen H. Gordon , Nottmeier Eric W.
Published: January 2008

Sacral insufficiency fracture is a painful injury, for which no effective treatment currently exists. The objective of this study was to report on the clinical outcomes and technical aspects of balloon kyphoplasty, which was used in three patients with this injury.

Three elderly women with intractable pain from sacral insufficiency fractures were treated with polymethyl methacrylate (PMMA) injections into the sacrum by using a modified balloon kyphoplasty procedure. The visual analog scale pain score improved by four points in each case. Functional status was improved and analgesic medication requirements were decreased in all three patients. There were no complications associated with the procedure.

Because of the unique anatomy of the sacrum, it was difficult to monitor instrument placement and PMMA injection by using conventional fluoroscopy. BrainLAB image guidance was used in one case, and was helpful in guiding instrument placement and assuring accurate PMMA deposition at the fracture site.

Balloon kyphoplasty may be a treatment alternative in selected patients with sacral insufficiency fractures. BrainLAB image guidance may offer some advantages over conventional fluoroscopy with regard to the monitoring of instrument placement and PMMA injection.
A history of cerebral localization
Authors: Kerr P. Benjamin , Caputy Anthony J. , Horwitz Norman H.
Published: January 2008

The brain has been known to be the center of voluntary movement, sensation, and intelligence for centuries. Nevertheless, it was not until the latter third of the 19th century that the functions of its different areas were discovered. It was the labor of several key men that made possible the accurate localization and, furthermore, the resection of brain neoplasms.
Early evolution of neurological surgery: conquering increased intracranial pressure, infection, and blood loss
Authors: Voorhees Jennifer R. , Cohen-Gadol Aaron A. , Spencer Dennis D.
Published: January 2008

At the end of the 19th century, the early evolution of the specialty of neurological surgery was restricted by complications related to infection, increased intracranial pressure, and excessive intraoperative blood loss. These complications often caused mortality rates of 30 to 50%. An improved understanding of pathophysiological factors involved in increased intracranial pressure, along with meticulous surgical techniques learned from William Halsted, allowed Harvey Cushing to increase the safety of neurosurgical procedures that were then in their infancy. Cushing's later development of the “silver clip” and incorporation of electrosurgical techniques facilitated safe resection of brain tumors previously assumed to be inoperable. These pivotal accomplishments paved the way for the establishment of our specialty.
The transsphenoidal approach
Authors: Kanter Adam S. , Dumont Aaron S. , Asthagiri Ashok R. , Oskouian Rod J. , Jane John A. , Laws Edward R.
Published: January 2008

Over the last century, the transsphenoidal approach has evolved into the first-line method of treatment for sellar as well as select groups of parasellar and suprasellar lesions. The journey to its current popularity has been marked by controversy and near abandonment in the late 1920s, followed by its renaissance in the late 1960s. Despite the profound skepticism with which this procedure was viewed, several visionary neurosurgeons persevered through its nadir in popularity, preserving this surgical corridor to the skull base. Advances in medical and surgical techniques, paralleling an improved understanding of pituitary pathophysiology, contributed to its resurgence. The transsphenoidal procedures now performed stem from an array of modifications and refinements accumulated through nearly 100 years of medical and surgical evolution. This era's critical innovations and neurosurgical personalities are the topic of this historical overview.
Percival Bailey and the classification of brain tumors
Authors: Ferguson Sherise , Lesniak Maciej S.
Published: January 2008

Throughout his illustrious career, Percival Bailey made numerous contributions to the fields of neurology, neuroanatomy, psychiatry, neuropathology, and, of course, neurosurgery. His expertise, his curiosity about the nervous system, and his desire to examine it from all angles were unique. With the exception of Harvey Cushing, Dr. Bailey made some of the greatest contributions in the area of neuro-oncology at the turn of the last century. In this essay the authors summarize the key episodes of Bailey's life and discuss his impact on the classification and treatment of human brain tumors.
Recurrent or refractory trigeminal neuralgia after microvascular decompression, radiofrequency ablation, or radiosurgery
Authors: Sanchez-Mejia Rene O. , Limbo Mary , Cheng Jason S. , Camara Joaquin , Ward Mariann M. , Barbaro Nicholas M.
Published: January 2008

Object

Trigeminal neuralgia (TN) is characterized by paroxysmal lancinating pain in the trigeminal nerve distribution. When TN is refractory to medical management, patients are referred for microvascular decompression (MVD), radiofrequency ablation, or radiosurgery. After the initial treatment, patients may have refractory or recurrent symptoms requiring retreatment. The purpose of this study was to determine what factors are associated with the need for retreatment and which modality is most effective.

Methods

To define this population further, the authors evaluated a cohort of patients who required retreatment for TN. The mean follow-up periods were 51 months from the first treatment and 23 months from the last one, and these were comparable among treatment groups.

Conclusions

Trigeminal neuralgia can recur after neurosurgical treatment. In this study the authors demonstrate that the number of patients requiring retreatment is not negligible. Lower retreatment rates were seen in patients who initially underwent radiosurgery, compared with those in whom MVD or radiofrequency ablation were performed. Radiosurgery was more likely to be the final treatment for recurrent TN regardless of the initial treatment. After retreatment, the majority of patients attained complete or very good pain relief. Pain relief after retreatment correlates with postoperative facial numbness.
Management of medically refractory trigeminal neuralgia in patients with multiple sclerosis
Authors: Cheng Jason S. , Sanchez-Mejia Rene O. , Limbo Mary , Ward Mariann M. , Barbaro Nicholas M.
Published: January 2008

Object

Trigeminal neuralgia (TN) is a painful disorder that frequently causes lancinating, electrical shock–like pain in the trigeminal distribution. Common surgical treatments include microvascular decompression (MVD), radio-surgery, and radiofrequency ablation, and complete pain relief is generally achieved with a single treatment in 70 to 85% of cases for all modalities. In a subset of patients with multiple sclerosis (MS), however, the rates of surgical treatment failure and the need for additional procedures are significantly increased compared with those in patients without MS. In this study the authors report their experience with a cohort of 11 patients with TN who also had MS, and assess the efficacy of MVD, gamma knife surgery (GKS), and radiofrequency ablation in achieving complete or partial long-term pain relief.

Methods

Eleven patients with TN and MS who were treated by the senior author (N.B.) at the University of California, San Francisco were included in this study. All patients underwent GKS and/or radiofrequency ablation, and four received MVD. A detailed clinical history and intraoperative findings were recorded for each patient and frequent follow-up evaluations were performed, with a mean follow-up duration of 40.6 months (range 1–96 months). Pain was assessed for each patient by using the Barrow Neurological Institute scale (Scores I–V).

Conclusions

Achieving complete pain relief in patients with TN and MS required significantly more treatments compared with all other patients with TN who did not have MS (p = 0.004). Even when compared with a group of 32 patients who had highly refractory TN, the cohort with MS required significantly more treatments (p = 0.05). Radiosurgery proved to be an effective procedure and resulted in fewer retreatments and longer pain-free intervals compared with MVD or radiofrequency ablation.
Role of the neurologist in the evaluation and treatment of patients with trigeminal neuralgia
Authors: Cohen Jeffrey
Published: January 2008

The neurologist, although not usually the first healthcare provider to evaluate a patient with trigeminal neuralgia (TN), is often involved in confirming the diagnosis and managing the patient's pain with medications. The neurologist has several other important roles for patients with TN: assessing and reducing the individual's pain, patient and family education, and encouraging referral to a neurosurgeon for pain-reducing procedures when appropriate. In general, surgical procedures for TN should be considered when the patient does not attain pain relief after adequate trials of two or three medications, or when pain relief is attained but the patient requires medication dosing at levels that result in significant drug toxicity. There is emerging evidence that surgical procedures for TN are more effective if performed earlier in the course of the patient's pain.
Cranial base strategies for resection of craniopharyngioma in children
Authors: Liu James K. , Cole Chad D. , Kestle John R. W. , Brockmeyer Douglas L. , Walker Marion L.
Published: January 2008

The optimal treatment of craniopharyngioma in children remains a challenge. The use of complete excision to minimize recurrence continues to be controversial because of the risk of postoperative morbidity and death. Advances in skull base approaches, modern microsurgical techniques, neuroimaging, and hormone replacement therapy, however, have allowed safe gross- or near-total resection in the majority of cases. Total removal of these tumors, if possible, offers the best chance of cure for the patient. Although craniopharyngiomas are not strictly tumors of skull base origin, their intimate relationship with the neurovascular structures of this region often requires a skull base approach to maximize the surgical corridor and facilitate adequate microsurgical resection. In this review, the authors focus on commonly used skull base approaches for the surgical management of craniopharyngioma. They discuss the relative indications, advantages, disadvantages, and complications associated with each approach. Illustrative cases and intra-operative videos are presented.
Subfrontal transbasal approach and technique for resection of craniopharyngioma
Authors: Aryan Henry E. , Ozgur Burak M. , Jandial Rahul , Levy Michael L.
Published: January 2008

A multimodality approach to craniopharyngioma, including minimally invasive stereotactic techniques, microsurgery, conventional radiotherapy, and radiosurgery has been recommended to tackle craniopharyngioma aggressively while minimizing harm to the patient. With all approaches, there are varying levels of risk for endocrinological morbidity, vascular complications, neuropsychological and behavioral disorders, neurocognitive disorders, and learning disabilities. Although many treatment options are available, total tumor resection remains the most commonly performed procedure for treatment of craniopharyngioma, and it is still believed to give the patient the greatest chance of having an independent and productive life with low risk of recurrences. The authors prefer the subfrontal transbasal approach for resection of these tumors, and they describe this approach and illustrate it with the accompanying figures.
Differentiation of choroid plexus tumors by advanced magnetic resonance spectroscopy
Authors: Krieger Mark D. , Panigrahy Ashok , McComb J. Gordon , Nelson Marvin D. , Liu Xiaodong , Gonzalez-Gomez Ignacio , Gilles Floyd , Bluml Stefan
Published: January 2008

Object

The management of pediatric intraventricular tumors is highly dependent on identification of the tumor type. Choroid plexus papillomas, a common intraventricular tumor in children, can be difficult to distinguish radiographically from choroid plexus carcinomas and other common pediatric central nervous system (CNS) tumors. In this study to overcome the limitations of current noninvasive imaging modalities, the authors use novel magnetic resonance (MR) spectroscopy techniques in vivo to elucidate the identifying biochemical features of choroid plexus tumors that may facilitate diagnosis and treatment.

Methods

Based on an Internal Review Board–approved protocol, six children with newly diagnosed, untreated intraventricular brain tumors were identified. On retrospective review, this series included three choroid plexus papillomas and three choroid plexus carcinomas. Single-voxel proton MR spectroscopy with a short echo time was performed, and absolute metabolite concentrations (in mmol/kg) were determined using fully automated quantitation. These results were compared with MR spectroscopy profiles obtained in 54 other untreated CNS neoplasms in children.

The myo-inositol (mI) level was significantly higher in choroid plexus papillomas (> 10 mmol/kg), uniquely distinguishing these tumors from choroid plexus carcinomas and all other tumors. Choroid plexus carcinomas, on the other hand, had significantly elevated levels of choline when compared with choroid plexus papillomas.

Conclusions

In this study the authors find that mI is a biochemical constituent that uniquely identifies choroid plexus papillomas and can be used as a noninvasive means of diagnosis and for follow-up evaluations in patients with this disease.
Hemorrhagic sequelae from intracranial neuroendoscopic procedures for intraventricular tumors
Authors: Luther Neal , Cohen Anders , Souweidane Mark M.
Published: January 2008

Object

Concern regarding the ability to accomplish adequate hemostasis during intracranial neuroendoscopy is often cited as a potential obstacle for primary endoscopic tumor management. In this study, the rate of clinically significant hemorrhage encountered as a result of endoscopic surgery for an intraventricular brain tumor is examined.

Methods

A total of 86 patients underwent an endoscopic biopsy procedure or resection of an intraventricular tumor. Recognized hemorrhagic sequelae occurred at a rate of 3.5% per patient. Visual obscuration due to the presence of intraventricular bleeding necessitated aborting the procedure before completion of the objective in two cases. There was a hemorrhagic event resulting in relevant morbidity in one patient, who suffered a bilateral diencephalic stroke after attempted tumor biopsy sampling.

Conclusions

The low hemorrhagic complication rate described in this series counters the misconception surrounding ineffective hemostasis during intracranial endoscopy for tumors and provides further evidence that this minimally invasive approach is a safe alternative to some conventional intracranial approaches.
Image-guided endoscopy: description of technique and potential applications
Authors: Mayberg Marc R. , LaPresto Eric , Cunningham Edwin J.
Published: January 2008

Object

Neuroendoscopic approaches to lesions of the central nervous system and spine are limited by the loss of stereoscopic vision and high-fidelity image quality inherent in the operating microscope. Image-guided endoscopy (IGE) and image-guided surgery (IGS) have the potential to overcome these limitations. The goal of this study was to evaluate IGE for its potential applications in neurosurgery.

Methods.

To determine the feasibility of IGE, a rigid endoscope was tracked using an IGS system that provided navigational data for the endoscope tip and trajectory as well as a computer-generated, three-dimensional, virtual representation of the image provided by the endoscope.

The IGE procedure was successfully completed in 14 patients (nine with pituitary adenomas, one with a temporal cavernous malformation, and four with unruptured aneurysms). No complications could be attributed to the procedure. Compared with direct microscopy performed using anatomical landmarks, registration of the endoscope, and virtual image were highly accurate.

Conclusions

This procedure offers many potential advantages for central nervous system and spinal endoscopy. Advances in IGE may enable its application to regions outside the central nervous system as well.
Percutaneous intraspinal navigation for access to the subarachnoid space: use of another natural conduit for neurosurgical procedures
Authors: Purdy Phillip D. , Fujimoto Takuya , Replogle Robert E. , Giles Brian P. , Fujimoto Hitomi , Miller Susan L.
Published: January 2008

Object

The purpose of this paper was to demonstrate the usefulness of various fiberoptic endoscopes for percutaneous intraspinal navigation of the spinal canal, posterior fossa, and ventricular system.

Methods

Fresh, unembalmed cadavers were used, in which lumbar punctures were made for access to the sub-arachnoid space (in the case of larger [3.8- and 5-mm-diameter] endoscopes, small laminotomies were performed). Static and video images of pertinent structures were acquired for comparison among devices. Endoscopes were compared for their maneuverability, durability, field of view, and image quality. Seven sizes and types of endoscopes were considered.

Overall, the devices offering a tip-deflecting mechanism were superior in maneuverability. Endoscopes in which a charged couple display chip was used at the tip of the scope for image acquisition offered improved image quality and field of view. Larger scopes, although more durable, were more rigid and may be limited in application. Multiple images from multiple devices are presented.

Conclusions

Percutaneous intraspinal navigation offers a promising neurosurgical approach to the spinal canal, the posterior fossa, and the ventricular system. Concerns regarding safety, management of complications, and the lack of adjunctive tools for intervention through the endoscopes or for use under fluoroscopic guidance represent areas that warrant further investigation and development.
Dynamic collimator optimization compared with fixed collimator angle in arc-based stereotactic radiotherapy: a dosimetric analysis
Authors: Lee Christopher M. , Watson Gordon A. , Leavitt Dennis D.
Published: January 2008

Object

The purpose of this study was to determine the effect of static and dynamic collimator optimization when using a micromultileaf collimator (mMLC) in dynamic-arc stereotactic radiosurgery (SRS) by evaluating the dose to healthy peritumoral tissue.

Methods

Thirty patients previously treated for intracranial lesions with the BrainLAB mMLC underwent retrospective replanning. Three collimator optimization strategies were compared for a simulated SRS treatment plan, as follows: Strategy 1, static collimation fixed at 90° throughout arcs; Strategy 2, static collimator settings optimized for each arc; and Strategy 3, dynamic collimator settings optimized every 10° throughout treatment arcs. Dose–volume histograms for a 0.7-cm shell of healthy peritumoral tissue were quantitatively compared.

Collimator optimization schemes (Strategies 2 and 3) significantly decreased the volume of peritumoral tissue that is irradiated when compared with static collimation at 90° (Strategy 1). The volume was reduced by 40.6% for Strategy 2 (95% confidence interval [CI] ± 11) and by 47.1% for Strategy 3 (95% CI ± 8.1) at the 95% isodose; by 28.4% for Strategy 2 (95% CI ± 4.9) and 39.1% for Strategy 3 (95% CI ± 6) at the 90% isodose; and by 18.2% for Strategy 2 (95% CI ± 8.1) and 25.4% for Strategy 3 (95% CI ± 7.1) at the 80% isodose. Serial collimator optimization throughout the treatment arcs (Strategy 3) reduced the mean volume of peritumoral tissue irradiated when compared with static collimator optimization (Strategy 2), by 16.1% (95% CI ± 1.5) at 95% isodose, by 11.7% (95% CI ± 1) at 90% isodose, and by 8.2% (95% CI ± 1.2) at 80% isodose regions. In specific cases, linear or polynomial functions were formulated to optimize collimator settings dynamically throughout treatment arcs.

Conclusions

Dynamic collimator optimization during arc-based SRS decreases the volume of healthy peritumoral tissue treated with high doses of radiation and appears to be an effective method of improving target conformality. This study is the first step toward determination of a smoothing function algorithm to allow for true dynamic collimation during SRS.
Endoscopic endonasal surgery of the midline skull base: anatomical study and clinical considerations
Authors: Cavallo Luigi M. , Messina Andrea , Cappabianca Paolo , Esposito Felice , de Divitiis Enrico , Gardner Paul , Tschabitscher Manfred
Published: January 2008

Object

The midline skull base is an anatomical area that extends from the anterior limit of the cranial fossa down to the anterior border of the foramen magnum. Resection of lesions involving this area requires a variety of innovative skull base approaches. These include anterior, anterolateral, and posterolateral routes, performed either alone or in combination, and resection via these routes often requires extensive neurovascular manipulation. The goals in this study were to define the application of the endoscopic endonasal approach and to become more familiar with the views and skills associated with the technique by using cadaveric specimens.

Methods

To assess the feasibility of the endonasal route for the surgical management of lesions in the midline skull base, five fresh cadaver heads injected with colored latex were dissected using a modified endoscopic endonasal approach.

Full access to the skull base and the cisternal space around it is possible with this route. From the crista galli to the spinomedullary junction, with incision of the dura mater, a complete visualization of the carotid and vertebrobasilar arterial systems and of all 12 of the cranial nerves is obtainable.

Conclusions

The major potential advantage of the endoscopic endonasal approach to the skull base is that it provides a direct anatomical route to the lesion without traversing any major neurovascular structures, obviating brain retraction. Many tumors grow in a medial-to-lateral direction, displacing structures laterally as they expand, creating natural corridors for their resection via an anteromedial approach.

Potential disadvantages of this procedure include the relatively restricted working space and the danger of an inadequate dural repair with cerebrospinal fluid (CSF) leakage and potential for meningitis resulting. These approaches often require a large opening of the dura mater over the tuberculum sellae and posterior planum sphenoidale, or retroclival space. In addition, they typically involve large intraoperative CSF leaks, which necessitate precise and effective dural closure.
Far-lateral transcondylar approach: surgical technique and its application in neurenteric cysts of the cervicomedullary junction
Authors: Liu James K. , Couldwell William T.
Published: January 2008

Neurenteric cysts are rare benign lesions of the central nervous system that are lined by endodermal cell–derived epithelium. Although they occur mostly in the spine, they can occur intracranially, most often in the posterior fossa. Neurenteric cysts that are located in the anterior cervicomedullary junction are even rarer and often require a skull base approach for adequate resection. The authors describe two cases of neurenteric cysts arising from the cervicomedullary junction that were resected via a far-lateral transcondylar approach. They discuss the surgical approach and operative nuances involved in removing these lesions, and review the clinical presentation of neurenteric cysts in this region as well as the neuroimaging characteristics, histopathological findings, and surgical management. Intraoperative videos are presented.