Aria Fallah

Anterior Cervical Discectomy with Arthroplasty versus Arthrodesis for Single-Level Cervical Spondylosis: A Systematic Review and Meta-Analysis

Objective To estimate the effectiveness of anterior cervical discectomy with arthroplasty (ACDA) compared to anterior cervical discectomy with fusion (ACDF) for patient-important outcomes for single-level cervical spondylosis. Data sources Electronic databases (MEDLINE, EMBASE, Cochrane Register for Randomized Controlled Trials, BIOSIS and LILACS), archives of spine meetings and bibliographies of relevant articles. Study selection We included RCTs of ACDF versus ACDA in adult patients with single-level cervical spondylosis reporting at least one of the following outcomes: functionality, neurological success, neck pain, arm pain, quality of life, surgery for adjacent level degeneration (ALD), reoperation and dysphonia/dysphagia. We used no language restrictions. We performed title and abstract screening and full text screening independently and in duplicate. Data synthesis We used random-effects model to pool data using mean difference (MD) for continuous outcomes and relative risk (RR) for dichotomous outcomes. We used GRADE to evaluate the quality of evidence for each outcome. Results Of 2804 citations, 9 articles reporting on 9 trials (1778 participants) were eligible. ACDA is associated with a clinically significant lower incidence of neurologic failure (RR  = 0.53, 95% CI  = 0.37–0.75, p = 0.0004) and improvement in the Neck pain visual analogue scale (VAS) (MD  = 6.56, 95% CI  = 3.22–9.90, p = 0.0001; Minimal clinically important difference (MCID)  = 2.5. ACDA is associated with a statistically but not clinically significant improvement in Arm pain VAS and SF-36 physical component summary. ACDA is associated with non-statistically significant higher improvement in the Neck Disability Index Score and lower incidence of ALD requiring surgery, reoperation, and dysphagia/dysphonia. Conclusions There is no strong evidence to support the routine use of ACDA over ACDF in single-level cervical spondylosis. Current trials lack long-term data required to assess safety as well as surgery for ALD. We suggest that ACDA in patients with single level cervical spondylosis is an option although its benefits and indication over ACDF remain in question.

Predictors of seizure outcomes in children with tuberous sclerosis complex and intractable epilepsy undergoing resective epilepsy surgery: an individual participant data meta-analysis.

Objective To perform a systematic review and individual participant data meta-analysis to identify preoperative factors associated with a good seizure outcome in children with Tuberous Sclerosis Complex undergoing resective epilepsy surgery. Data Sources Electronic databases (MEDLINE, EMBASE, CINAHL and Web of Science), archives of major epilepsy and neurosurgery meetings, and bibliographies of relevant articles, with no language or date restrictions. Study Selection We included case-control or cohort studies of consecutive participants undergoing resective epilepsy surgery that reported seizure outcomes. We performed title and abstract and full text screening independently and in duplicate. We resolved disagreements through discussion. Data Extraction One author performed data extraction which was verified by a second author using predefined data fields including study quality assessment using a risk of bias instrument we developed. We recorded all preoperative factors that may plausibly predict seizure outcomes. Data Synthesis To identify predictors of a good seizure outcome (i.e. Engel Class I or II) we used logistic regression adjusting for length of follow-up for each preoperative variable. Results Of 9863 citations, 20 articles reporting on 181 participants were eligible. Good seizure outcomes were observed in 126 (69%) participants (Engel Class I: 102(56%); Engel class II: 24(13%)). In univariable analyses, absence of generalized seizure semiology (OR = 3.1, 95%CI = 1.2–8.2, p = 0.022), no or mild developmental delay (OR = 7.3, 95%CI = 2.1–24.7, p = 0.001), unifocal ictal scalp electroencephalographic (EEG) abnormality (OR = 3.2, 95%CI = 1.4–7.6, p = 0.008) and EEG/Magnetic resonance imaging concordance (OR = 4.9, 95%CI = 1.8–13.5, p = 0.002) were associated with a good postoperative seizure outcome. Conclusions Small retrospective cohort studies are inherently prone to bias, some of which are overcome using individual participant data. The best available evidence suggests four preoperative factors predictive of good seizure outcomes following resective epilepsy surgery. Large long-term prospective multicenter observational studies are required to further evaluate the risk factors identified in this review.

Neurocognitive and Seizure Outcomes of Selective Amygdalohippocampectomy versus Anterior Temporal Lobectomy for Mesial Temporal Lobe Epilepsy

Objective. To report our institutional seizure and neuropsychological outcomes for a series of patients with mesial temporal lobe epilepsy (mTLE) undergoing anterior temporal lobectomy (ATL) or selective amygdalohippocampectomy (SelAH) between 2004 and 2011. Methods. A retrospective study of patients with mTLE was conducted. Seizure outcome was reported using time-to-event analysis. Cognitive outcome was reported using the change principal in component factor scores, one each, for intellectual abilities, visuospatial memory, and verbal memory. The Boston Naming Test was used for naming assessment. Language dominant and nondominant resections were compared separately. Students t-test was used to assess statistical significance. Results. Ninety-six patients (75 ATL, 21 SelAH) were included; fifty-four had complete neuropsychological follow-up. Median follow-up was 40.5 months. There was no statistically significant difference in seizure freedom or any of the neuropsychological outcomes, although there was a trend toward greater postoperative decline in naming in the dominant hemisphere group following ATL. Conclusion. Seizure and neuropsychological outcomes did not differ for the two surgical approaches which is similar to most prior studies. Given the theoretical possibility of SelAH sparing language function in patients with epilepsy secondary to mesial temporal sclerosis and the limited high-quality evidence creating equipoise, a multicenter randomized clinical trial is warranted.

Surgical treatment of spontaneous intracranial hypotension secondary to degenerative cervical spine pathology: a case report and literature review

Objective and importanceA rare cause of intracranial hypotension is leakage of cerebrospinal fluid (CSF) through a dural breach from degenerative cervical spine pathology. To our knowledge there have been only four cases described in the English literature. Treatment is challenging and varies from case to case, with complete symptom resolution reported for only one patient. Herein we review the literature and describe our surgical management of a 46-year-old woman with symptomatic intracranial hypotension from the penetration of the cervical thecal sac.Clinical presentation The patient presented with a 3-month history of progressive orthostatic headaches. Magnetic resonance imaging demonstrated bilateral subdural hematomas and pachymeningeal gadolinium enhancement. An anterior epidural CSF collection commencing at a C4–5 calcified disc protrusion and osteophyte was evident on a computed tomography spinal myelogram.InterventionAfter three unsuccessful lumbar blood patches, we elected to attempt surgical removal of the causative pathology with exposure and primary closure of the dural defect by anterior cervical discectomy as described previously. After resection of the disc–osteophyte complex and dural exposure, immediate high volume egression of CSF mixed with blood at the surgical site. The dural defect was not visible but CSF egression promptly ceased. Cervical corpectomy for greater exposure and primary repair of the defect has been described, but we considered this unwarranted and felt the intraoperative blood collection formed a local blood patch. A collagen dural substitute membrane was inserted through the discectomy space for reinforcement.Conclusion Two months after this novel surgical blood patch procedure the patient was asymptomatic and follow-up imaging demonstrated complete resolution.

Admission and Acute Complication Rate for Outpatient Lumbar Microdiscectomy

OBJECTIVE Specialization is generally independently associated with improved outcomes for most types of surgery. This is the first study comparing the immediate success of outpatient lumbar microdiscectomy with respect to acute complication and conversion to inpatient rate. Long-term pain relief is not examined in this study. METHODS Two separate prospective databases (one belonging to a neurosurgeon and brain tumor specialist, not specializing in spine (NS) and one belonging to four spine surgeons (SS)) were retrospectively reviewed. All acute complications as well as admission data of patients scheduled for outpatient lumbar microdiscectomy were extracted. RESULTS In total, 269 patients were in the NS group and 137 patients were in the SS group. The NS group averaged 24 cases per year while the SS group averaged 50 cases per year. Chi-square tests revealed no difference in acute complication rate [NS (6.7%), SS (7.3%)] (p > 0.5) and admission rate [NS (4.1%), SS (5.8%)] (p = 0.4) while the SS group had a significantly higher proportion of patients undergoing repeat microdiscectomy [NS (4.1%), SS (37.2%)] (p < 0.0001). Excluding revision operations, there was no statistically significant difference in acute complication [NS (5.4%), SS (1.2%)] (p = 0.09) and conversion to inpatient [NS (4.3%), SS (4.6%)] (p > 0.5) rate. The combined acute complication and conversion to inpatient rate was 6.9% and 4.7% respectively. CONCLUSION Based on this limited study, outpatient lumbar microdiscectomy can be apparently performed safely with similar immediate complication rates by both non-spine specialized neurosurgeons and spine surgeons, even though the trend favored the latter group for both outcome measures.

Medically resistant pediatric insular-opercular/perisylvian epilepsy. Part 2: outcome following resective surgery

OBJECTIVE Seizure onset in the insular cortex as a cause of refractory epilepsy is underrepresented in the pediatric population, possibly due to difficulties localizing seizure onset in deep anatomical structures and limited surgical access to the insula, a complex anatomical structure with a rich overlying vascular network. Insular seizure semiology may mimic frontal, temporal, or parietal lobe semiology, resulting in false localization, incomplete resection, and poor outcome. METHODS The authors retrospectively reviewed the records of all pediatric patients who underwent insular cortical resections for intractable epilepsy at Miami Childrens Hospital from 2009 to 2015. Presurgical evaluation included video electroencephalography monitoring and anatomical/functional neuroimaging. All patients underwent excisional procedures utilizing intraoperative electrocorticography or extraoperative subdural/depth electrode recording. RESULTS Thirteen children (age range 6 months-16 years) with intractable focal epilepsy underwent insular-opercular resection. Seven children described symptoms that were suggestive of insular seizure origin. Discharges on scalp EEG revealed wide fields. Four patients were MRI negative (i.e., there were no insular or brain abnormalities on MRI), 4 demonstrated insular signal abnormalities, and 5 had extrainsular abnormalities. Ten patients had insular involvement on PET/SPECT. All patients underwent invasive investigation with insular sampling; in 2 patients resection was based on intraoperative electrocorticography, whereas 11 underwent surgery after invasive EEG monitoring with extraoperative monitoring. Four patients required an extended insular resection after a failed initial surgery. Postoperatively, 2 patients had transient hemiplegia. No patients had new permanent neurological deficits. At the most recent follow-up (mean 43.8 months), 9 (69%) children were seizure free and 1 had greater than 90% seizure reduction. CONCLUSIONS Primary insular seizure origin should be considered in children with treatment-resistant focal seizures that are believed to arise within the perisylvian region based on semiology, widespread electrical field on scalp EEG, or insular abnormality on anatomical/functional neuroimaging. There is a reasonable chance of seizure freedom in this group of patients, and the surgical risks are low.

Endoscopic third ventriculostomy and choroid plexus cauterization with a rigid neuroendoscope in infants with hydrocephalus

OBJECT Combining endoscopic third ventriculostomy (ETV) with choroid plexus cauterization (CPC) has been shown to improve the success rate compared with ETV alone in infants (less than 24 months) with hydrocephalus who were treated in developing countries. The authors sought to evaluate the safety and efficacy of this procedure, using a rigid neuroendoscope, in a single North American center, and to assess whether the ETV success score (ETVSS), the CURE Childrens Hospital of Uganda ETVSS (CCHU ETVSS), and other pre- and intraoperative variables could predict success. METHODS The authors performed a retrospective review of consecutive ETV/CPC procedures performed using a rigid neuroendoscope to treat infantile hydrocephalus. The infants underwent the procedure at Miami Childrens Hospital between January 2007 and 2014, with at least one postoperative follow-up. Duration of follow-up or time to failure of ETV/CPC, the primary outcome measure, was documented. A repeat CSF diversion procedure or death was considered as a failure of ETV/CPC. The time to event was measured using a Kaplan-Meier analysis. The authors analyzed ETVSS, CCHU ETVSS, and pre- and intraoperative variables to determine their suitability to predict success. RESULTS Eighty-five patients (45 boys) with a mean age of 4.3 months (range 1 day to 20 months) underwent ETV/CPC. Etiology included intraventricular hemorrhage of prematurity in 44 patients (51.7%), myelomeningocele (MMC) in 7 (8.2%), congenital aqueductal stenosis in 12 (14.1%), congenital communicating hydrocephalus in 6 (7.1%), Dandy-Walker complex in 6 (7.1%), postinfectious hydrocephalus in 5 (5.8%), and other cause in 5 (5.8%). Six procedure-related complications occurred in 5 (5.8%) patients, including 2 hygromas, 1 CSF leak, and 3 infections. There were 3 mortalities in this cohort. ETV/CPC was successful in 42.1%, 37.7%, and 36.8% of patients at 6, 12, and 24 months follow-up, respectively. The median (95% CI) time to ETV/CPC failure was 4.0 months (0.9-7.1 months). In univariate analyses, both the ETVSS (hazard ratio [HR] 1.03; 95% CI 1.01-1.05; p = 0.004) and CCHU ETVSS (HR 1.48; 95% CI 1.04-2.09; p = .028) were predictive of outcome following ETV/CPC. In multivariate analysis, the presence of prepontine scarring was associated with ETV/CPC failure (HR 0.34; 95% CI 0.19-0.63; p < 0.001). Other variables, such as radiological criteria (prepontine interval, prepontine space, aqueductal stenosis, Third Ventricular Morphology Index) and intraoperative findings (ventriculostomy pulsations, extent of CPC), did not predict outcome. CONCLUSIONS ETV/CPC is a feasible alternative to ETV and ventriculoperitoneal shunt in infants with hydrocephalus. Both the ETVSS and CCHU ETVSS predicted success following ETV/CPC in this single-center North American cohort of patients.

Systematic review of primary intracranial glioblastoma multiforme with symptomatic spinal metastases, with two illustrative patients

Glioblastoma multiforme is a malignant tumour with a universally fatal diagnosis. We report two patients with glioblastoma with symptomatic metastasis to the spinal cord and perform a systematic review all 35 reports of symptomatic glioblastoma dissemination to the spinal leptomeninges and/or intramedullary spinal axis. Our analysis of the data shows a median time to spinal metastasis of 10 months and a median time of three months from spinal metastasis to death. Treatments described include palliative laminectomies, radiotherapy and chemotherapy. No treatment strategy offered a therapeutic advantage as patients deteriorated rapidly regardless of intervention. Patients who underwent only a biopsy for intracranial glioblastoma had a shorter time to development of spinal metastasis. In addition, there may be an association between intramedullary metastasis and shorter survival. This paper highlights the importance of considering symptomatic spinal dissemination in glioblastoma multiforme. We also review the incidence and postulate mechanisms of tumour dissemination in the central nervous system. Clearly, further research into radiotherapeutic and chemotherapeutic options in this clinical setting is required.

Sacral intradural arteriovenous fistula treated indirectly by transection of the filum terminale: technical case report.

BACKGROUND AND IMPORTANCE:Type A intradural arteriovenous fistulae of the sacral filum terminale are rare lesions fed primarily by the distal anterior spinal artery. The artery is frequently too narrow or tortuous for endovascular obliteration, and direct surgical resection of the fistula requires an invasive sacrectomy. We present a less invasive indirect surgical approach through an L4 laminectomy and transection of the filum terminale rostral to the fistula. CLINICAL PRESENTATION:A 62-year-old man presented with a 6-month history of progressive bilateral lower extremity paresthesias and weakness and associated incontinence and impotence. Spinal magnetic resonance imaging demonstrated perimedullary flow voids. Selective spinal angiography revealed a fistula at S2-3 between the distal anterior spinal artery and an early draining vein returning cranially along the filum terminale, diagnostic of an intradural arteriovenous fistula. An L4 laminectomy and transection of the filum terminale rostral to the lesion were performed to disrupt the medullary arterial supply to the intradural fistula and outflow to the medullary venous plexus of the spinal cord. At 10-month clinical follow, up the patient had regained bowel and bladder continence, was able to ambulate with a cane, and reported subjective improvement of lower extremity paresthesias. Selective spinal angiography at 1 year demonstrated no residual arteriovenous shunt. CONCLUSION:Pathological venous hypertension of a type A intradural arteriovenous fistula of the sacral filum terminale can be treated by transection of the filum terminale at L4. This avoids posterior partial sacrectomy required for direct resection; however, subsequent clinical follow-up is necessary to monitor for reconstitution.

Ethical issues in surgical decision making concerning children with medically intractable epilepsy

The widespread inclusion of surgical strategies in the treatment of medically intractable epilepsy is largely justified by the medical and psychosocial burden of the illness. Performing these procedures in pediatric populations is associated with distinct challenges ranging from unique seizure etiologies to issues surrounding brain development and functional plasticity. As the trend toward more aggressive surgical intervention continues, the ethical foundation of current and emerging practices must be increasingly scrutinized. Here, we present the first article discussing ethical issues in the surgical management of medically intractable epilepsies in children. We discuss principles of informed consent, harm reduction, and justice in this vulnerable patient population. We also highlight the unique ethical challenge of surgical decision making concerning developmentally delayed children. The recognition of these issues is essential to providing patient-centered, responsible, and ethical care.