bluuebunny/crossref_metadata_2025 huggingface dataset:
A locus-driven mechanism for rapid and automated atlas-assisted analysis of functional images by using the Brain Atlas for Functional Imaging
Authors: Nowinski Wieslaw L. , Thirunavuukarasuu Arumugam
Published: January 2008

Object

Functional imaging is an established neurosurgical modality for studying the brain in health and disease. Identifying numerous activation loci on many functional images and reading their underlying cortical and subcortical anatomy, coordinates, and anatomical and functional values is a tedious, time-consuming, and error-prone task. In this study the authors propose a novel approach to this problem by using an electronic brain atlas in conjunction with a locus-driven mechanism.

Methods

The Brain Atlas for Functional Imaging containing an enhanced and extended electronic version of the Talairach–Tournoux brain atlas was used for analysis. It enables loading of anatomical and functional data, correlation of these data, identification of activation loci, and their labeling with Brodmann areas, gyri, and subcortical structures by means of the atlas. The Talairach proportional grid system transformation is used to register the anatomical and functional data with the atlas. The availability of numerous tools supports this process.

A locus-driven mechanism for analysis of activation loci is implemented. Locus placement within the activation region is supported by thresholding, and its location can be further edited in three dimensions on any orthogonal plane. Once all loci are identified and edited, their labels, coordinates, and anatomical/functional values are read automatically and saved in an external file. This mechanism enables the analysis to be performed in an automated, rapid, explicit, three-dimensionally consistent, and user-friendly way.

Conclusions

The electronic brain atlas with locus-driven mechanism is a useful tool for localization analysis of functional images.
A primer on diffusion tensor imaging of anatomical substructures
Authors: DaSilva Alexandre F. M. , Tuch David S. , Wiegell Mette R. , Hadjikhani Nouchine
Published: January 2008

In this article, the authors review the application of diffusion tensor (DT) magnetic resonance (MR) imaging to demonstrate anatomical substructures that cannot be resolved by conventional structural imaging. They review the physical basis of DT imaging and provide illustrative anatomical examples. The DT imaging technique measures the self-diffusion, or random thermal motion, of the endogenous water in nerve tissue. Because of the preferred diffusion of water molecules along the nerve fiber direction, DT imaging can measure the orientation of the neural fiber structure within each voxel of the MR image. The fiber orientation information yielded by DT imaging provides a new contrast mechanism that can be used to resolve images of anatomical substructures that cannot otherwise be visualized using conventional structural imaging. The authors illustrate how DT imaging can resolve individual pathways in the brainstem as well as individual nuclei of the thalamus and conclude by describing potential applications in neurosurgery.
Toward functional neuronavigation: implementation of functional magnetic resonance imaging data in a surgical guidance system for intraoperative identification of motor and language cortices
Authors: Rutten Geert-Jan , Ramsey Nick , Noordmans Herke-Jan , Willems Peter , van Rijen Peter , van der Sprenkel Jan Willem Berkelbach , Viergever Max , van Veelen Cees
Published: January 2008

In recent years, surgical navigation systems have become equipped to allow incorporation of data such as functional neuronavigation data. Functional magnetic resonance (fMR) imaging is a noninvasive modality that demonstrates various brain functions. Although still in an experimental stage, fMR imaging is a promising tool for mapping of motor and language functions. One advantage is that it can be implemented in presurgical imaging protocols and is therefore potentially widely available in general neurosurgical practice. In this paper the integration of fMR imaging and surgical navigation is described, and the potential advantages and pitfalls of its application in clinical practice are discussed.
Preoperative magnetic source imaging for brain tumor surgery: a quantitative comparison with intraoperative sensory and motor mapping
Authors: Schiffbauer Hagen , Berger Mitchel S. , Ferrari Paul , Freudenstein Dirk , Rowley Howard A. , Roberts Timothy P. L.
Published: January 2008

Object

The aim of this study was to compare quantitatively the methods of preoperative magnetic source (MS) imaging and intraoperative electrophysiological cortical mapping (ECM) in the localization of sensorimotor cortex in patients with intraaxial brain tumors.

Methods

Preoperative magnetoencephalography (MEG) was performed while patients received painless tactile somatosensory stimulation of the lip, hand, and foot. The early somatosensory evoked field was modeled using a single equivalent current dipole approach to estimate the spatial source of the response. Three-dimensional magnetic resonance image volume data sets with fiducials were coregistered with the MEG recordings to form the MS image. These individualized functional brain maps were integrated into a neuronavigation system. Intraoperative mapping of somatosensory and/or motor cortex was performed and sites were compared.

In two subgroups of patients we compared intraoperative somatosensory and motor stimulation sites with MS imaging–based somatosensory localizations. Mediolateral projection of the MS imaging source localizations to the cortical surface reduced systematic intermodality discrepancies. The distance between two corresponding points determined using MS imaging and ECM was 12.5 ± 1.3 mm for somatosensory–somatosensory and 19 ± 1.3 mm for somatosensory–motor comparisons. The observed 6.5 mm increase in site separation was systematically demonstrated in the anteroposterior direction, as expected from actual anatomy. In fact, intraoperative sites at which stimulation evoked the same patient response exhibited a spatial variation of 10.7 ± 0.7 mm.

Conclusions

Preoperative MS imaging and intraoperative ECM show a favorable degree of quantitative correlation. Thus, MS imaging can be considered a valuable and accurate planning adjunct in the treatment of patients with intraaxial brain tumors.
Diffuse large B-cell lymphoma presenting as a sacral tumor
Authors: Liu James K. , Kan Peter , Schmidt Meic H.
Published: January 2008

Primary lymphomas of the sacrum are rare tumors, reported only in a few cases in the literature. The authors describe two patients with diffuse large B-cell lymphomas presenting as a sacral tumor.

In the first case a 52-year-old man presented with progressive back pain, bilateral radicular pain, and saddle block anesthesia secondary to a lytic, expansile soft-tissue mass. The mass arose from the sacrum and eroded through the right S-1 to S-4 foramina and extended into the epidural space of the spinal canal. On magnetic resonance imaging, the sacral mass enhanced homogeneously with Gd. In the second case a 64-year-old man presented with left-sided radicular pain, paresthesias, and progressive weakness due to a lytic soft-tissue mass in the left sacral ala extending into the left L-5 and S-1 foramina. Metastatic workup in each patient demonstrated unremarkable findings. In both cases, an open biopsy procedure was performed after nondiagnostic examination of needle biopsy samples. Histopathological examination showed evidence consistent with diffuse large B-cell lymphoma in both patients. In the first case the disease was classified as Stage IAE, and the patient subsequently underwent four cycles of cyclophosphamide/doxorubicin/vincristine/prednisone (CHOP)– and rituximab-based chemotherapy followed by consolidation radiotherapy. In the second case the disease was also classified as Stage IAE, and the patient underwent CHOP-based chemotherapy and consolidation radiotherapy. In both cases radiography demonstrated a decrease in size of the sacral lymphomas.

The authors review the clinical, radiological, and histological features of sacral lymphomas. Lymphoma should be considered in the differential diagnosis of sacral tumors.
Sacral hemangioblastoma in a patient with von Hippel–Lindau disease
Authors: Pluta Ryszard M. , Wait Scott D. , Butman John A. , Leppig Kathleen A. , Vortmeyer Alexander O. , Oldfield Edward H. , Lonser Russell R.
Published: January 2008

Hemangioblastomas are histologically benign neoplasms that occur sporadically or as part of von Hippel–Lindau disease. Hemangioblastomas may occur anywhere along the neuraxis, but sacral hemangioblastomas are extremely rare. To identify features that will help guide the operative and clinical management of these lesions, the authors describe the management of a large von Hippel–Lindau disease–associated sacral hemangioblastoma and review the literature.

The authors present the case of a 38-year-old woman with von Hippel–Lindau disease and a 10-year history of progressive back pain, as well as left lower-extremity pain and numbness. Neurological examination revealed decreased sensation in the left S-1 and S-2 dermatomes. Magnetic resonance imaging demonstrated a large enhancing lesion in the sacral region, with associated erosion of the sacrum. The patient underwent arteriography and embolization of the tumor and then resection. The histopathological diagnosis was consistent with hemangioblastoma and showed intrafascicular tumor infiltration of the S-2 nerve root. At 1-year follow-up examination, pain had resolved and numbness improved.

Sacral nerve root hemangioblastomas may be safely removed in most patients, resulting in stabilization or improvement in symptomatology. Generally, hemangioblastomas of the sacral nerve roots should be removed when they cause symptoms. Because they originate from the nerve root, the nerve root from which the hemangioblastoma originates must be sacrificed to achieve complete resection.
Giant cell tumor of the sacrum
Authors: Randall R. Lor
Published: January 2008

Giant cell tumor (GCT) is a locally highly aggressive tumor of bone comprising 5 to 10% of all benign bone tumors. The sacrum is the third most common site of involvement. Patients with sacral GCTs present with localized pain in the lower back that may radiate to one or both lower limbs. Vague abdominal complaints and bowel and bladder symptoms may also be present. Neuroimaging workup should include advanced modalities, preferably magnetic resonance imaging, prior to obtaining a biopsy specimen. Giant cell tumor has a 1 to 5% rate of metastasizing to the lung and may convert to a fulminate malignant variant, which has a very poor prognosis. The standard treatment for GCT is curettage combined with adjuvant bone grafting or cement-augmented stabilization. In appropriately selected cases, sacral resection is a valuable procedure to effect local tumor control and overall survival. Embolization may also prove palliative and/or curative in cases in which the tumor is unresectable or refractory to treatment.
Current management of sacral chordoma
Authors: Fourney Daryl R. , Gokaslan Ziya L.
Published: January 2008

Sacral chordomas are relatively rare, locally invasive, malignant neoplasms. Although metastasis is infrequent at presentation, the prognosis for patients with chordoma of the sacrum is reported to be poor and attributable in most cases to intralesional resection. The value of adjuvant treatment is uncertain, and resection remains the primary mode of treatment. Chordomas are difficult to excise completely, but recent improvements in imaging and surgical techniques have allowed surgeons to perform more frequently en bloc sacral resections with wide surgical margins. The technical challenges of such operations, and the functional costs for the patient (with respect to anorectal and urogenital dysfunction) are significantly increased when the tumor involves high sacral levels. The authors review the clinical presentation and natural history of sacral chordoma and discuss the current treatment techniques and outcomes.
Postoperative wound infections of the spine
Authors: Beiner John M. , Grauer Jonathan , Kwon Brian K. , Vaccaro Alexander R.
Published: January 2008

Postoperative spinal wound infections occur in 1 to 12% of patients. The rate of infection is related to the type and duration of the procedure, comorbidities, nutritional status, and various other risk factors. Antibiotic prophylactic therapy has been clearly shown to decrease the rate of infection dramatically after lumbar surgery. These infections typically manifest with signs and symptoms of wound swelling, erythema, and drainage. Laboratory-detected values such as the erythrocyte sedimentation rate and C-reactive protein can be elevated beyond what is normal for the uncomplicated postoperative course following lumbar surgery, and combined with the clinical symptoms should alert the physician to the possibility of infection. When detected, these infections should be managed aggressively with operative debridment and irrigation, including the deep subfascial layer in all cases except those with clearly demarcated superficial infection. The choice of one versus multiple debridments can be made based on the appearance of the wound, patient factors, and nutritional status. Hardware and incorporated bone graft can be left in place in the majority of cases, adding to stability. Outcomes following aggressive treatment of this complication can be excellent, with no long-term loss of function and complete eradication of the infection.
Management of iatrogenic flat-back syndrome
Authors: Wiggins Gregory C. , Ondra Stephen L. , Shaffrey Christopher I.
Published: January 2008

Iatrogenic loss of lordosis is now frequently recognized as a complication following placement of thoracolumbar instrumentation, especially with distraction instrumentation. Flat-back syndrome is characterized by forward inclination of the trunk, inability to stand upright, and back pain. Evaluation of the deformity should include a full-length lateral radiograph obtained with the patient's knees and hips fully extended. The most common cause of the deformity includes the use of distraction instrumentation in the lumbar spine and pseudarthrosis.

Surgical treatment described in the literature includes opening (Smith-Petersen) osteotomy, polysegmental osteotomy, and closing wedge osteotomy. The authors will review the literature, cause, clinical presentation, prevention, and surgical management of flat-back syndrome.
Neonatal venous cerebral hemorrhage
Authors: Misra Sanjay N. , Misra Ashish K.
Published: January 2008

Intracranial pathological changes can occur as a result of impaired craniocervical venous return. Thrombosis of central venous access catheters was demonstrated in two neonates born at 38 and 27 weeks' gestation. Neither infant developed hemorrhage of prematurity as confirmed on cranial ultrasonography. Clinical evidence of vena cava thrombosis and associated spontaneous intraventricular hemorrhage developed on Day 24 and 36, respectively, and these findings were confirmed on imaging studies. In one infant the hemorrhage was accompanied by communicating hydrocephalus.

The cause of the intracranial disease was attributable to the retrograde cerebral venous congestion. This, together with the primitive venous bed developing in the periventricular region, was associated with the spontaneous hemorrhage in the region of the foramen of Monro.

To the authors' knowledge, this is the first report in the English-language literature of spontaneous neonatal intra-cerebral hemorrhage, due to thrombosis of the superior or inferior vena cava.

The natural history of this condition is resolution without sequelae after appropriate therapeutic intervention for the vena cava thrombosis.
Endovascular strategies for carotid cavernous and intracerebral dural arteriovenous fistulas
Authors: Ng Perry P. , Higashida Randall T. , Cullen Sean , Malek Reza , Halbach Van V. , Dowd Christopher F.
Published: January 2008

Interventional neuroradiology is a less invasive modality than open neurosurgery for the treatment of a wide range of neurovascular disorders. Refinements in technique and improvements in the design of microcatheters, guide wires, and embolic materials have yielded superior clinical outcomes and provided an impetus to treat more of these lesions endovascularly rather than surgically. Endovascular therapy is the standard of care for direct and indirect carotid artery cavernous sinus fistulas and may also be curative for dural arteriovenous fistulas (AVFs) in other locations.

The authors provide review of the clinical features, pathophysiology, and management of intracranial AVFs focusing on contemporary endovascular treatment options.
Transcranial color-coded Doppler ultrasonography for evaluation of children with hydrocephalus
Authors: de Oliveira Ricardo Santos , Machado Hélio Rubens
Published: January 2008

Object

Hydrocephalus is a common disease process. Transcranial color-coded Doppler (TCCD) ultrasonography is an accepted noninvasive method with which to quantify intracranial blood flow in adults and children. The authors studied the applications of TCCD ultrasonography and the alterations of the flow velocity of the cerebral arteries in children with hydrocephalus.

Methods

One hundred thirty-five children were divided into three groups: Group 1 comprised 40 infants with asymptomatic hydrocephalus who had well-functioning ventriculoperitoneal (VP) shunts; Group 2 comprised 10 children with symptomatic hydrocephalus who had malfunctioning shunts that were replaced; and Group 3 was a control group of 85 healthy infants. All patients underwent sequential measurements of cerebral blood flow (CBF) velocities (systolic and diastolic velocities) and resistivity index (RI). One group of patients underwent functional tests (compression of the anterior fontanelle and CO2 vasoreactivity) to determine hemodynamic changes in cerebral circulation.

A significant statistical change in RI measurements, end diastolic CBF velocity, and percentage of change in RI was shown in patients with malfunctioning shunts, and in infants with a well-functioning VP shunt vasomotor reactivity was severely reduced.

Conclusions

Transcranial color-coded Doppler ultrasonography can be used to perform follow-up assessments of normal and malfunctioning shunts in children with hydrocephalus; the functional tests are a noninvasive tool for evaluating the cerebral compliance and the cerebral autoregulation in infants with hydrocephalus. The autoregulatory capacity may partly or completely be lost in cases of long-term shunt-treated hydrocephalus, and loss of cerebral vasoreactivity may be responsible for long-term deficits commonly observed in children, which help explain some of symptoms related to slit ventricles.
Evidence-based review of the surgical management of vertebral column metastatic disease
Authors: Ryken Timothy C. , Eichholz Kurt M. , Gerszten Peter C. , Welch William C. , Gokaslan Ziya L. , Resnick Daniel K.
Published: January 2008

Object

Significant controversy exists over the most appropriate treatment for patients with metastatic disease of the vertebral column. Treatment options include surgical intervention, radiotherapy, or a combination of the two; nevertheless, a standard of care that yields the best survival, outcome, and quality of life has not been established. The purpose of this review was to determine the foundation in the literature of views favoring surgical intervention for spinal metastatic disease.

Methods

A search of the English-language literature published between 1964 and 2003 was performed for the subject of spinal metastatic disease. Papers were selected based on the inclusion criteria described, and evidentiary information was compiled and graded using previously described methods.

Conclusions

Although there is insufficient evidence to support a standard for surgical treatment in patients with metastatic spinal disease, the authors present guidelines and recommendations based on the evidence provided by the current literature.
Cervical spinal metastasis: anterior reconstruction and stabilization techniques after tumor resection
Authors: Liu James K. , Apfelbaum Ronald I. , Chiles Bennie W. , Schmidt Meic H.
Published: January 2008

Object

In a review of the literature, the authors provide an overview of various techniques that have evolved for reconstruction and stabilization after resection for metastatic disease in the subaxial cervical spine.

Methods

Reconstruction and stabilization of the cervical spine after vertebral body (VB) resection for metastatic tumor is an important goal in the surgical management of spinal metastasis. Generally, the VB defect is reconstructed with bone autograft or allograft, polymethylmethacrylate (PMMA), interbody spacers, and/or cages. In cases of PMMA-assisted reconstruction, internal devices are used to augment the fixation of PMMA. Stabilization is then achieved with anterior instrumentation, usually an anterior cervical locking plate. In some cases, posterior instrumentation may be necessary to supplement the anterior construct.

Conclusions

Anterior cervical corpectomy followed by reconstruction and stabilization is an effective strategy in the management of spinal metastases in patients.
Surgical treatment of tumors involving the cervicothoracic junction
Authors: Le Hoang , Balabhadra Raju , Park Jon , Kim Daniel
Published: January 2008

Object

Tumors involving the cervicothoracic junction can have a high propensity for causing instability, with kyphosis and spinal cord compression resulting. Treatment with decompression only can lead to further instability and worsening neurological status. In this article, the authors review their surgical experience in the treatment of 19 patients with tumors involving the cervicothoracic junction. The various approaches and instrumentation techniques involved in decompression and stabilization of the cervicothoracic junction are also reviewed.

Methods

Aggressive instrumentation-augmented fusion after decompression of the cervicothoracic region can provide for immediate stabilization and early rehabilitation. Recent development of new hardware such as dual-diameter transition rods, polyaxial screws, and interlocking devices have enhanced the ability to fashion a strong construct for stabilization of the cervicothoracic junction.

Conclusions

Familiarity with complex instrumentation techniques and various surgical approaches to the cervicothoracic junction will be required for effective treatment of tumors causing instability of this region.
Surgical management of aneurysmal bone cysts of the spine
Authors: Liu James K. , Brockmeyer Douglas L. , Dailey Andrew T. , Schmidt Meic H.
Published: January 2008

Object

Aneurysmal bone cysts of the spine are benign, highly vascular osseous lesions of unknown origin that may present difficult diagnostic and therapeutic challenges. They are expansile lesions containing thin-walled, blood-filled cystic cavities that cause bone destruction and sometimes spinal deformity and neurological compromise. The treatment of aneurysmal bone cysts of the spine remains controversial according to the literature. In this review, the authors discuss the clinical manifestations, pathophysiological features, neuroimaging characteristics, and treatment strategies for these lesions.

Methods

Treatment options include simple curettage with bone grafting, complete excision, embolization, and radiation therapy. Reconstruction and stabilization of the spine may be warranted if deformity and instability are present. Special factors need to be considered in the management of these lesions.

Conclusions

Complete excision of aneurysmal bone cysts offers the best chance of cure and spinal decompression if neurological deficits are present.
Osteoid osteomas and osteoblastomas of the spine
Authors: Zileli Mehmet , Çagli Sedat , Basdemir Gülçin , Ersahin Yusuf
Published: January 2008

Object

Osteoid osteomas and osteoblastomas are rare primary bone tumors that usually do not arise in the spine. In this report the authors analyze 16 cases of osteoid osteoma or osteoblastoma of the spine that were surgically treated over a 27-year period.

Methods

A retrospective study was conducted in which the following data were found: five patients had osteoid osteomas (two male and three female patients) and 11 had osteoblastomas (seven male and four female patients). The site of the tumor was the cervical spine in four, thoracic in six, and lumbar spine in six. In 14 patients, the tumor involved the posterior vertebral elements, with lumbar and thoracic levels being the most common. Only two patients had tumors in the body of a cervical vertebra. The mean age of the patients was 20 years for osteoid osteoma and 19 years for osteoblastoma. The most common symptom was local pain in the area of the tumor. Among 11 patients with osteoblastoma, six (two with paraparesis, four with monoparesis) had neurological deficits caused by extradural compression. None of the patients with osteoid osteoma had neurological deficits. The diameters of osteoblastomas were 3 to 8 cm (mean 4 cm), and those of osteoid osteomas were 1.5 to 2 cm (mean 1.7 cm). Although the peritumoral bone was normal in patients with osteoblastoma, a sclerotic rim was observed in all patients with osteoid osteoma.

All patients were treated with resection; tumor excision was complete in 15 cases. Follow-up periods ranged from 2 months to 13 years (mean 36 months). Complete pain relief was achieved in 15 patients; the other patient described mild pain with activity. There was no tumor recurrence except one regrowth in a patient with osteoblastoma who then received radiation therapy. There were two complications: one surgery was performed at the wrong level, and there was one instrument failure that required revision.

Conclusions

With the help of modern imaging modalities that aid in diagnosis and surgical planning, a complete removal and cure may be achieved for most of these rare tumors.
Outcome of severe traumatic brain injury: comparison of three monitoring approaches
Authors: Isa Ruwaida , Adnan Wan Aasim Wan , Ghazali Ghazaime , Idris Zamzuri , Ghani Abdul Rahman Izaini , Sayuthi Sani , Awang Mohamed Saufi , Ghazali Mazira Mohamad , Naing Nyi Nyi , Abdullah Jafri Malin
Published: January 2008

The determination of cerebral perfusion pressure (CPP) is regarded as vital in monitoring patients with severe traumatic brain injury. Besides indicating the status of cerebral blood flow (CBF), it also reveals the status of intracranial pressure (ICP). The abnormal or suboptimal level of CPP is commonly correlated with high values of ICP and therefore with poor patient outcomes. Eighty-two patients were divided into three groups of patients receiving treatment based on CPP and CBF, ICP alone, and conservative methods during two different observation periods. The characteristics of these three groups were compared based on age, sex, time between injury and hospital arrival, Glasgow Coma Scale score, pupillary reaction to light, surgical intervention, and computerized tomography scanning findings according to the Marshall classification system. Only time between injury and arrival (p = 0.001) was statistically significant. There was a statistically significant difference in the proportions of good outcomes between the multimodality group compared with the group of patients that underwent a single intracranial-based monitoring method and the group that received no monitoring (p = 0.003) based on a disability rating scale after a follow up of 12 months. Death was the focus of outcome in this study in which the multimodality approach to monitoring had superior results.
Assessment of critical thresholds for cerebral perfusion pressure by performing bedside monitoring of cerebral energy metabolism
Authors: Nordström Carl-Henrik
Published: January 2008

An intractable increase in intracranial pressure (ICP) leading to a progressive decrease in cerebral perfusion pressure (CPP) and cerebral blood flow (CBF) is the dominating cause of death in patients with severe brain trauma. Arterial hypotension may further compromise CPP (and CBF) and significantly contributes to death. In addition, the injured brain is sensitive to raised CPP due to an increased permeability of the blood–brain barrier (BBB) to crystalloids and an impaired pressure autoregulation of the CBF. Given these circumstances, an increase in CPP will cause a net transport of water across the BBB and a further elevation in ICP. Accordingly, the assessment of the lower critical threshold for CPP is important for neurological intensive care. This level varies among different patients and different areas of the brain. In fact, the penumbral zones surrounding focal brain lesions appear to be the most sensitive. In the individual patient, preservation of normal cerebral energy metabolism within areas at risk during a decrease in CPP can be guaranteed by performing intracerebral microdialysis and bedside biochemical analyses.
Spinal pseudomeningoceles and cerebrospinal fluid fistulas
Authors: Couture Daniel , Branch Charles L.
Published: January 2008

Spinal pseudomeningoceles and cerebrospinal fluid (CSF) fistulas are rare extradural collections of CSF that result following a breach in the dural–arachnoid layer. They may occur due to an incidental durotomy, during intradural surgery, or from trauma or congenital abnormality. The majority are iatrogenic and occur in the posterior lumbar region following surgery. Although they are often asymptomatic, they may cause low-back pain, headaches, and even nerve root entrapment. Leakage of CSF from the wound may cause a fistulous tract, which is a conduit for infection and should be repaired immediately.

Diagnosis can be confirmed on clinical examination or imaging studies including magnetic resonance imaging, computerized tomography myelography, and radionuclide myelography. Treatment must be specific to each patient because the timing, size, symptoms, and location of the dural breach all affect the choice of therapy. Nonsurgical methods may be used, but more frequently operative repair is required.

In this article, the authors review the diagnosis and treatment of spinal pseudomeningoceles and CSF fistulas.
History of instrumentation for stabilization of the subaxial cervical spine
Authors: Omeis Ibrahim , DeMattia Joseph A. , Hillard Virany Huynh , Murali Raj , Das Kaushik
Published: January 2008

In the past several decades methods have been developed to stabilize the subaxial cervical spine both posteriorly and anteriorly. Methods of posterior stabilization have progressed from interspinous wiring, through facet wiring and sublaminar wiring, to the lateral mass screws with plates and rods that are in use today. Plates for anterior stabilization have evolved from rigid plates requiring bicortical screws through those used with unicortical locking screws, to dynamic load-sharing plates used with variable angle screws. The original description of spinous process wiring was published by Hadra in 1891. In 1942 Rogers described the interspinous wiring method used for trauma-induced cervical instability, which was modified by Bohlman in 1985 (triple wiring technique). Luque rods with sublaminar wires were introduced in the late 1970s to address multilevel and occipitocervical instability. Facet wiring was developed in 1977 by Callahan to address the problem of stabilization when laminae are not present. Wiring remained the method used until Roy-Camille introduced the lateral mass screw–plate construct in the 1980s. The first plate for anterior stabilization was designed by Orozco and Llovet in 1970 and was later refined by Caspar; this was a rigid plate with bicortical screws. Morscher devised unicortical locking screws in the 1980s. The latest concept of dynamic load-sharing plates with variable angle screws was developed in 2000. In this article historical landmarks in surgical methods for the stabilization of the subaxial cervical spine are reviewed.
History of posterior thoracic instrumentation
Authors: Singh Harshpal , Rahimi Scott Y. , Yeh David J. , Floyd David
Published: January 2008

The term “backbone” appears in many expressions used in modern day society. In any scenario, it has one central meaning: stability. Best defined as a foundation that is able to sustain multiple stressors without adversely affecting integrity, the commonly and appropriately termed backbone of humans is the spinal column. As the central focus of stability in our species, the spine is subject to a great degree of trauma and mechanical forces. A variety of methods have been developed throughout history in the treatment of spinal column injury. Initial treatment involved the use of simple traction devices for the reduction of spinal fractures; these have evolved to include the current insertion of spinal instrumentation. The authors review the historical treatment and development of posterior instrumentation for thoracic spinal injury.
Colao A, Di Sarno A, Cappabianca P, et al: Withdrawal of long-term cabergoline therapy for tumoral and nontumoral hyperprolactinemia. N Engl J Med 349:2023–2033, 2003
Authors: Couldwell William T. , Weiss Martin H. , Laws Edward R.
Published: January 2008

Background

Whether the withdrawal of treatment in patients with nontumoral hyperprolactinemia, microprolactinomas, or macroprolactinomas is safe and effective has been unclear. We performed an observational, prospective study of cabergoline (a dopamine-receptor agonist) withdrawal in such patients.

Methods

The study population included 200 patients—25 patients with nontumoral hyperprolactinemia, 105 with microprolactinomas, and 70 with macroprolactinomas. Withdrawal of cabergoline was considered if prolactin levels were normal, magnetic resonance imaging (MRI) showed no tumor (or tumor reduction of 50 percent or more, with the tumor at a distance of more than 5 mm from the optic chiasm, and no invasion of the cavernous sinuses or other critical areas), and if follow-up after withdrawal could be continued for at least 24 months.

Results

Recurrence rates two to five years after the withdrawal of cabergoline were 24 percent in patients with nontumoral hyperprolactinemia, 31 percent in patients with microprolactinomas, and 36 percent in patients with macroprolactinomas. Renewed tumor growth did not occur in any patient; in 10 female patients (22 percent) and 7 male patients (39 percent) with recurrent hyperprolactinemia, gonadal dysfunction redeveloped. In all diagnostic groups, prolactin levels at the time of recurrence were significantly lower than at diagnosis (p < 0.001). The Kaplan–Meier estimated rate of recurrence at five years was higher among patients with macroprolactinomas and those with microprolactinomas who had small remnant tumors visible on MRI at the time of treatment withdrawal than among patients whose MRI scans showed no evidence of tumor at the time of withdrawal (patients with macroprolactinomas, 78 percent vs. 33 percent, P = 0.001; patients with microprolactinomas, 42 percent vs. 26 percent, P = 0.02).

Conclusions

Cabergoline can be safely withdrawn in patients with normalized prolactin levels and no evidence of tumor. However, because the length of follow-up in our study was insufficient to rule out a delayed increase in the size of the tumor, we suggest that patients be closely monitored, particularly those with macroprolactinomas, in whom renewed growth of the tumor may compromise vision.
History of spine surgery in the ancient and medieval worlds
Authors: Goodrich James Tait
Published: January 2008

There is a paucity of surviving texts from ancient and medieval times that can shed light on the early development of spine surgery. Nevertheless, the author reviews many of the available books and fragments and discusses early developments in the field of spine surgery from the point of view of physicians' personalities, general themes, and actual surgical practices. For purposes of an overview and to highlight changing trends in spine surgery, he divides the paper into four eras of medicine: 1) Egyptian and Babylonian; 2) Greek and early Byzantine; 3) Arabic; and 4) medieval.
Inverse correlation of epidermal growth factor receptor messenger RNA induction and suppression of anchorage-independent growth by OSI-774, an epidermal growth factor receptor tyrosine kinase inhibitor, in glioblastoma multiforme cell lines
Authors: Halatsch Marc-Eric , Gehrke Esther E. , Vougioukas Vassilios I. , Bötefür Ingolf C. , Borhani Farhad A.- , Efferth Thomas , Gebhart Erich , Domhof Sebastian , Schmidt Ursula , Buchfelder Michael
Published: January 2008

Object

Quantitative and qualitative alterations in the epidermal growth factor receptor (EGFR) commonly occur in many cancers in humans, including malignant gliomas. The aim of the current study was to evaluate molecular and cellular effects of OSI-774, a novel EGFR tyrosine kinase inhibitor, on nine glioblastoma multiforme (GBM) cell lines.

Methods

The effects of OSI-774 on expression of EGFR messenger (m)RNA and protein, proliferation, anchorage-independent growth, and apoptosis were examined using semiquantitative reverse transcription–polymerase chain reaction, immunocytochemical analysis, Coulter counting, soft agar cloning, and terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling/fluorescence-activated cell sorting, respectively. All p53 genes were completely and bidirectionally sequenced.

Suppression of anchorage-independent growth by OSI-774 was inversely correlated to the induction of EGFR mRNA during relative serum starvation (r = −0.74) and was unrelated to p53 status. Overall, suppression of anchorage-independent growth was a considerably stronger effect of OSI-774 than inhibition of proliferation. The extent of OSI-774–induced apoptosis positively correlated with both proliferation and anchorage-independent growth of GBM cell lines (r = 0.75 and 0.79, respectively). In a single cell line derived from a secondary GBM, exposure to concentrations of greater than or equal to 1 μmol/L resulted in a substantial net cell loss during proliferation studies.

Conclusions

The induction of EGFR mRNA may constitute a cellular mechanism to counteract the inhibitory effect of OSI-774 on the anchorage-independent growth of GBM cells. In contrast, no considerable correlation could be established between baseline expression levels of EGFR (both mRNA and protein) in GBM cell lines and their biological response to OSI-774. The OSI-774 induced greater (p53-independent) apoptosis in more malignant GBM phenotypes and may be a promising therapeutic agent against secondary GBM.
Embryology of myelomeningocele and anencephaly
Authors: Dias Mark S. , Partington Michael
Published: January 2008

The authors review current views on of the embryogenesis of the neural tube defects (NTDs) myelomeningocele and anencephaly. In this context, the following four approaches to the study of NTDs are discussed: normal morphogenesis and timing of early human neural development from conception to the ascent of the conus medullaris; mechanical and molecular biology of neural tube closure derived from experimental and animal models; morphological and biomechanical features of the NTDs myelomeningocele and anencephaly; and the experimental evidence for the importance of both genetic and environmental influences on human NTDs. Although considerable insight into both normal neural tube closure and the factor(s) by which this process may be disrupted has been reported in recent years, the exact mechanism(s) by which human myelomeningoceles and anencephaly arise remain elusive.
Chiari Type II malformation: past, present, and future
Authors: Stevenson Kevin L.
Published: January 2008

Object

The Chiari Type II malformation (CM II) is a unique hindbrain herniation found only in patients with myelomeningocele and is the leading cause of death in these individuals younger than 2 years of age. Several theories exist as to its embryological evolution and recently new theories are emerging as to its treatment and possible prevention. A thorough understanding of the embryology, anatomy, symptomatology, and surgical treatment is necessary to care optimally for children with myelomeningocele and prevent significant morbidity and mortality.

Methods

A review of the literature was used to summarize the clinically pertinent features of the CM II, with particular attention to pitfalls in diagnosis and surgical treatment.

Conclusions

Any child with CM II can present as a neurosurgical emergency. Expeditious and knowledgeable evaluation and prompt surgical decompression of the hindbrain can prevent serious morbidity and mortality in the patient with myelomeningocele, especially those younger than 2 years old. Symptomatic CM II in the older child often presents with more subtle findings but rarely in acute crisis. Understanding of CM II continues to change as innovative techniques are applied to this challenging patient population.
Computerized tomography evaluation of a resorbable implant after transforaminal lumbar interbody fusion
Authors: Kuklo Timothy R. , Rosner Michael K. , Polly David W.
Published: January 2008

Object

Synthetic bioabsorbable implants have recently been introduced in spinal surgery; consequently, the indications, applications, and results are still evolving. The authors used absorbable interbody spacers (Medtronic Sofamor Danek, Memphis, TN) packed with recombinant bone morphogenetic protein (Infuse; Medtronic Sofamor Danek) for single- and multiple-level transforaminal lumbar interbody fusion (TLIF) procedures over a period of 18 months. This is a consecutive case series in which postoperative computerized tomography (CT) scanning was used to assess fusion status.

Methods

There were 22 patients (17 men, five women; 39 fusion levels) whose mean age was 41.6 years (range 23–70 years) and in whom the mean follow-up duration was 12.4 months (range 6–18 months). Bridging bone was noted as early as the 3-month postoperative CT scan when obtained; solid arthrodesis was routinely noted between 6 and 12 months in 38 (97.4%) of 39 fusion levels. In patients who underwent repeated CT scanning, the fusion mass appeared to increase with time, whereas the disc space height remained stable. Although the results are early (mean 12-month follow-up duration), there was only one noted asymptomatic delayed union/nonunion at L5–S1 in a two-level TLIF with associated screw breakage. There were no infections or complications related to the cages.

Conclusions

The bioabsorbable cages appear to be a viable alternative to metal interbody spacers, and may be ideally suited to spinal interbody applications because of their progressive load-bearing properties.
Contemporary management of prolactinomas
Authors: Liu James K. , Couldwell William T.
Published: January 2008

Prolactin-secreting pituitary adenomas—prolactinomas—are the most common type of functional pituitary tumor. Treatment of hyperprolactinemia is indicated because of the consequences of infertility, gonadal dysfunction, and osteoporosis. Making the correct diagnosis is important because the first line of therapy is medical management with dopamine agonists. Medical therapy is effective in normalizing prolactin levels in more than 90% of patients, but long-term treatment may be required in some patients. Transsphenoidal surgery is usually indicated in those patients in whom medical therapy fails or cannot be tolerated, or in patients who harbor microprolactinomas. In experienced hands, a hormonal and oncological cure can be achieved in more than 90% of patients after transsphenoidal removal of microprolactinomas with minimal risks. Thus, surgery may be an option for microprolactinomas in a young patient who desires restoration of fertility and avoidance of long-term medical therapy. The authors review the diagnosis and management of prolactinomas, including medical therapy, surgical therapy, and stereotactic radiosurgery.
Pituitary tumor apoplexy: characteristics, treatment, and outcomes
Authors: Verrees Meg , Arafah Baha M. , Selman Warren R.
Published: January 2008

Pituitary tumor apoplexy is an uncommon event heralded by abrupt onset of severe headache, restriction of visual fields, deterioration of visual acuity, and weakness of ocular motility frequently coupled with clinical indications of decreased endocrine function. Hemorrhage into or necrosis of a preexisting sellar mass, usually a pituitary macroadenoma, produces an expansion of sellar contents. Compression of adjacent structures elicits the variable expression of symptoms referable to displacement of the optic nerves and chiasm and impingement of the third, fourth, and sixth cranial nerves. Damage to or destruction of the anterior pituitary leads to multiple acute and/or chronic hormone deficiencies in many patients. Medical management may be used in rare cases in which the signs and symptoms are mild and restricted to meningismus or ophthalmoplegia deemed to be stable. In patients with visual or oculomotor lability or an altered level of consciousness, expeditious surgical decompression, accomplished most commonly through a transsphenoidal approach, should be performed to save life and vision and to optimize the chance of regaining or maintaining pituitary function.
Delayed central nervous system superficial siderosis following brachial plexus avulsion injury
Authors: Cohen-Gadol Aaron A. , Krauss William E. , Spinner Robert J.
Published: January 2008

Chronic subarachnoid hemorrhage may cause deposition of hemosiderin on the leptomeninges and subpial layers of the neuraxis, leading to superficial siderosis (SS). The symptoms and signs of SS are progressive and fatal. Exploration of potential sites responsible for intrathecal bleeding and subsequent hemosiderin deposition may prevent disease progression. A source of hemorrhage including dural pathological entities, tumors, and vascular lesions has been previously identified in as many as 50% of patients with SS. In this report, the authors present three patients in whom central nervous system SS developed decades after brachial plexus avulsion injury. They believe that the traumatic dural diverticula in these cases may be a potential source of bleeding. A better understanding of the pathophysiology of SS is important to develop more suitable therapies.
Evaluation of suprascapular nerve neurotization after nerve grafting or transfer in the treatment of brachial plexus traction lesions
Authors: Malessy Martijn J. A. , de Ruiter Godard C. W. , de Boer Kees S. , Thomeer Ralph T. W. M.
Published: January 2008

Object

The aim of this retrospective study was to evaluate the restoration of shoulder function by means of supra-scapular nerve neurotization in adult patients with proximal C-5 and C-6 lesions due to a severe brachial plexus traction injury (BPTI). The primary goal of brachial plexus reconstructive surgery was to restore the biceps muscle function and, secondarily, to reanimate shoulder function.

Methods

Suprascapular nerve neurotization was performed by grafting the C-5 nerve in 24 patients and by accessory or hypoglossal nerve transfer in 29 patients. Additional neurotization involving the axillary nerve could be performed in 18 patients.

Postoperative needle electromyography studies of the supraspinatus, infraspinatus, and deltoid muscles showed signs of reinnervation in most patients; however, active glenohumeral shoulder function recovery was poor. In nine (17%) of 53 patients supraspinatus muscle strength was Medical Research Council (MRC) Grade 3 or 4 and in four (8%) infraspinatus muscle power was Grade 3 or 4. In 18 patients in whom deltoid muscle reinnervation was attempted, MRC Grade 3 or 4 function was demonstrated in two (11%). In the overall group, eight patients (15%) exhibited glenohumeral abduction with a mean of 44 ± 17° (standard deviation [SD]) (median 45°) and four patients (8%) exhibited glenohumeral exorotation with a mean of 48 ± 24° (SD) (median 53°). In only three patients (6%) were both functions regained.

Conclusions

The reanimation of shoulder function in patients with proximal C-5 and C-6 BPTIs following supra-scapular nerve neurotization is disappointingly low.