Edward Kachur

Biopsy versus partial versus gross total resection in older patients with high-grade glioma: a systematic review and meta-analysis

BACKGROUND Optimal extent of surgical resection (EOR) of high-grade gliomas (HGGs) remains uncertain in the elderly given the unclear benefits and potentially higher rates of mortality and morbidity associated with more extensive degrees of resection. METHODS We undertook a meta-analysis according to a predefined protocol and systematically searched literature databases for reports about HGG EOR. Elderly patients (≥60 y) undergoing biopsy, subtotal resection (STR), and gross total resection (GTR) were compared for the outcome measures of overall survival (OS), postoperative karnofsky performance status (KPS), progression-free survival (PFS), mortality, and morbidity. Treatment effects as pooled estimates, mean differences (MDs), or risk ratios (RRs) with corresponding 95% confidence intervals (CIs) were determined using random effects modeling. RESULTS A total of 12 607 participants from 34 studies met eligibility criteria, including our current cohort of 211 patients. When comparing overall resection (of any extent) with biopsy, in favor of the resection group were OS (MD 3.88 mo, 95% CI: 2.14-5.62, P < .001), postoperative KPS (MD 10.4, 95% CI: 6.58-14.22, P < .001), PFS (MD 2.44 mo, 95% CI: 1.45-3.43, P < .001), mortality (RR = 0.27, 95% CI: 0.12-0.61, P = .002), and morbidity (RR = 0.82, 95% CI: 0.46-1.46, P = .514) . GTR was significantly superior to STR in terms of OS (MD 3.77 mo, 95% CI: 2.26-5.29, P < .001), postoperative KPS (MD 4.91, 95% CI: 0.91-8.92, P = .016), and PFS (MD 2.21 mo, 95% CI: 1.13-3.3, P < .001) with no difference in mortality (RR = 0.53, 95% CI: 0.05-5.71, P = .600) or morbidity (RR = 0.52, 95% CI: 0.18-1.49, P = .223). CONCLUSIONS Our findings suggest an upward improvement in survival time, functional recovery, and tumor recurrence rate associated with increasing extents of safe resection. These benefits did not result in higher rates of mortality or morbidity if considered in conjunction with known established safety measures when managing elderly patients harboring HGGs.

Intraparenchymal supratentorial neurenteric cyst.

BACKGROUND Neurenteric cysts are congenital cysts of the central nervous system that are believed to be of endodermal origin. In this report we present the unique case of a supratentorial neurenteric cyst that is contained entirely within the brain parenchyma. METHODS A patient presented with an intraparenchymal cystic lesion that was subsequently identified as a neurenteric cyst. This lesion is reviewed in light of the available literature. CASE REPORT A 35-year-old female presented with a one year history of progressive headaches and seizure-like episodes. Her examination revealed no deficits. Magnetic resonance imaging showed a 4 cm x 4 cm x 4 cm cystic lesion within the parenchyma of the right frontal lobe. A right frontal craniotomy and complete excision of the cystic lesion was performed. Pathologic examination confirmed that it was a neurenteric cyst. Postoperatively the patients symptoms improved. CONCLUSION Review of the literature revealed this to be the first case of a surgically excised, pathologically confirmed supratentorial neurenteric cyst, contained entirely within the brain parenchyma.

Castleman's disease and spinal cord compression: case report.

OBJECTIVE AND IMPORTANCE Castleman’s disease is a rare lymphoproliferative disorder most often found in the mediastinum. Localized forms are usually benign, whereas multicentric forms may be aggressive . We report a patient with Castleman’s disease who presented with spinal cord compression, and we review previously published cases of Castleman’s disease involving the central nervous system. To our knowledge, this is only the second case of Castleman’s disease presenting as a spinal epidural mass with cord compression. CLINICAL PRESENTATION A 44-year-old otherwise healthy woman presented acutely with difficulty walking. Examination revealed mild myelopathy in her legs. Magnetic resonance imaging revealed a posterior epidural mass compressing the thoracic spinal cord at T3–T5. INTERVENTION Thoracic laminectomy and gross total resection of the lesion were performed. Pathological examination of the lesion identified the hyaline-vascular type of Castleman’s disease. The patient’s symptoms resolved postoperatively. CONCLUSION Castleman’s disease presenting as a spinal epidural mass lesion with cord compression is rare. Surgical treatment can result in an excellent outcome.

Myelopathic signs and functional outcome following cervical decompression surgery: a proposed myelopathy scale

OBJECTIVE Cervical spondylotic myelopathy (CSM) is the most common cause of spinal cord dysfunction in adults. In spite of this, the impact of the changes in myelopathic signs following cervical decompression surgery and their relationship to functional outcome measures remains unclear. The main goals of our study were to prospectively assess changes in myelopathic signs with a functional outcome scale (the modified Japanese Orthopaedic Association [mJOA] scale) following cervical decompression surgery and to objectively test a proposed new myelopathy scale (MS). METHODS Between 2008 and 2011, 36 patients with CSM were observed following cervical decompression surgery. Patient data including mJOA and MS scores were prospectively collected and analyzed preoperatively and at 1 year after surgery. RESULTS In this cohort, reflex, Babinski, and proprioception signs showed statistically significant improvement following surgery at 1 year (p = < 0.001, p = 0.008, and p = 0.015, respectively). A lesser degree of improvement was observed with the Hoffman sign (p = 0.091). No statistically significant improvement in clonus occurred (p = 0.368). There was a significant improvement in mJOA (p ≤ 0.001) and MS (p ≤ 0.001) scores at 1 year compared with the preoperative scores. The results showed an inverse correlation between MS and mJOA scores both pre- and postoperatively (Spearmans correlation coefficient = -0.202 preoperatively and -0.361 postoperatively). CONCLUSIONS Improvement in myelopathic signs was noted following cervical decompression surgery in patients with CSM. The newly devised MS scale demonstrated these findings, and the new MS scale correlates with improvement in mJOA scores in this patient cohort.

Os Odontoideum: an unusual association of compressive synovial cyst. Case report and review of the literature

Background: Os odontoideum is a rare cervical abnormality that harbours a potential risk for atlantoaxial instability. In rare circumstances, synovial cysts may develop and compromise the spinal cord. Therefore, cyst excision has been suggested as part of the surgical management. However, in recent reports, it has been shown that atlantoaxial stabilization alone is sufficient for synovial cyst regression. Methodology: 48-year-old woman presented with symptoms and signs of cervical myelopathy secondary to os odontoideum with atlantoaxial instability. A large synovial cyst was diagnosed with significant spinal cord compression. In addition, her spinal and cranial imaging was suggestive of multiple sclerosis which was confirmed clinically thereafter with one episode of MS flare up and positive cerebrospinal fluid analysis. Results: After she had recovered from her MS flare up, posterior atlantoaxial instrumentation and fusion was performed without synovial cyst resection. Postoperatively, her clinical condition improved substantially and complete regression of the synovial cyst was noted on cervical MRI. Interestingly, she has not had any MS recurrent episodes after the surgery. Conclusion: Degenerative changes in os odontoideum are consequences of atlantoaxial instability. Compressive synovial cysts may develop with associated cord compression. We recommend posterior atlantoaxial stabilization alone in such conditions while preserving cyst fenestration or excision for persistent symptoms related to unresolved synovial cysts.