Glen R. Manzano

A Prospective, Randomized Trial Comparing Expansile Cervical Laminoplasty and Cervical Laminectomy and Fusion for Multilevel Cervical Myelopathy

BACKGROUND: Controversy exists as to the best posterior operative procedure to treat multilevel compressive cervical spondylotic myelopathy. OBJECTIVE: To determine clinical, radiological, and patient satisfaction outcomes between expansile cervical laminoplasty (ECL) and cervical laminectomy and fusion (CLF). METHODS: We performed a prospective, randomized study of ECL vs CLF in patients suffering from cervical spondylotic myelopathy. End points included the Short Form-36, Neck Disability Index, Visual Analog Scale, modified Japanese Orthopedic Association score, Nurick score, and radiographic measures. RESULTS: A survey of academic North American spine surgeons (n = 30) demonstrated that CLF is the most commonly used (70%) posterior procedure to treat multilevel spondylotic cervical myelopathy. A total of 16 patients were randomized: 7 to CLF and 9 to ECL. Both groups showed improvements in their Nurick grade and Japanese Orthopedic Association score postoperatively, but only the improvement in the Nurick grade for the ECL group was statistically significant (P < .05). The cervical range of motion between C2 and C7 was reduced by 75% in the CLF group and by only 20% in the ECL group in a comparison of preoperative and postoperative range of motion. The overall increase in canal area was significantly (P < .001) greater in the CLF group, but there was a suggestion that the adjacent level was more narrowed in the CLF group in as little as 1 year postoperatively. CONCLUSION: In many respects, ECL compares favorably to CLF. Although the patient numbers were small, there were significant improvements in pain measures in the ECL group while still maintaining range of motion. Restoration of spinal canal area was superior in the CLF group.

Transplantation of human bone marrow-derived stromal cells into the contused spinal cord of nude rats.

OBJECT Human bone marrow stromal cells (hMSCs) constitute a potential source of pluripotent stem cells. In the present study, hMSCs were transplanted into an area of spinal cord contusion in nude rats to determine their survival, differentiation, potential for neuroprotection, and influence on axonal growth and functional recovery. METHODS Twenty-nine animals received 6 x 10(5) hMSCs in 6 microl medium 1 week after a contusion, while 14 control animals received an injection of 6 microl medium alone. Basso-Beattie-Bresnahan (BBB) tests were performed weekly. The spinal cords were collected at 6 weeks posttransplantation for histological analysis and assessment of tissue injury. RESULTS Immunostaining with anti-human mitochondria antibody and pretransplantation labeling with green fluorescent protein demonstrated that the grafted hMSCs survived and were capable of achieving a flattened appearance in the grafted area; however, none of the transplanted cells stained positively for human-specific neuronal, anti-neurofilament H or glial fibrillary acidic protein within the sites of engraftment. While neuronal or astrocytic differentiation was not seen, cells lining blood vessels in the vicinity of the transplant stained positively for anti-human endothelium CD105 antibody. Staining for anti-neurofilament H antibody demonstrated abundant axonlike structures around the transplanted area in the hMSC group. Tissue sparing analysis showed that animals with grafted hMSCs had a smaller area of contusion cyst compared with controls, but there was no significant difference between the two groups in BBB scores. CONCLUSIONS The grafted hMSCs survived for > or = 6 weeks posttransplantation, although they did not differentiate into neural or glial cells. Cells with human endothelial characteristics were observed. Spinal cord-injured rats grafted with hMSCs had smaller contusion cavities, which did not have a significant influence on functional recovery.

Third ventricular glioblastoma multiforme: Case report

Intraventricular neoplasms of the third ventricle represent a small minority of intracranial tumors. Furthermore, few cases of solitary, third ventricular glioblastoma multiforme were reported in the literature. The authors report a case of a fifty-nine year olf man who presented with progressive gait disturbance, disorientation, diffuse headache, and vomiting. Computed tomography and magnetic resonance imaging (MRI) confirmed a solitary third ventricular ringenhancing lesion and obstructive hydrocephalus. The final pathology of the lesion upon permanent section was glioblastoma multiforme (GBM). The clinical course, radiologic findings, the possible origin of this lesion, as well as possible treatment regimen are discussed.

Cavernous malformation of the oculomotor nerve mimicking a partially thrombosed posterior communicating artery aneurysm: report of two cases.

BACKGROUND AND IMPORTANCE:Cavernous malformations of the cranial nerves are exceedingly rare. The classic radiographic appearance of cavernous malformations may not be obvious when located in a cranial nerve. CLINICAL PRESENTATION:We present 2 cases of acute oculomotor paresis caused by cavernous malformations of the oculomotor nerve that were mistaken for a thrombosed posterior communicating artery aneurysm on magnetic resonance imaging, magnetic resonance angiography, and digital subtraction angiography. Both patients underwent a craniotomy with exploration of the lesion. Both cavernous malformations were completely resected while the integrity of the third cranial nerve was maintained. One patient experienced complete resolution of the oculomotor palsy. CONCLUSION:Although rare, cavernous malformations should be included in the differential diagnosis of a partially thrombosed posterior communicating artery aneurysm. Exploration and complete lesional resection are possible with improvement of the cranial nerve function.

Primary spinal cord glioblastoma multiforme treated with temozolomide

Since virtually no trials have evaluated the effectiveness of temozolomide (TMZ) in the treatment of spinal cord (SC) glioblastoma multiforme (GBM), we conducted a systematic review to evaluate its efficacy. Primary SC GBM is rare. Its management remains unclear, even though treatment guidelines have been established since 2005 for its cranial counterpart. We performed a medical subject heading search with the terms “glioblastoma” and “primary spinal cord neoplasms, intramedullary”. We stratified the papers into two groups according to the use of TMZ, and analyzed survival rates using the Kaplan–Meier method with a two-sided log-rank scale. The TMZ subgroup contained nine articles and a total of 19 patients with primary SC GBM who were treated with adjuvant TMZ. The non-TMZ group consisted of 19 articles including 45 patients who underwent other treatment modalities. The TMZ subgroup had an overall survival of 16 months, compared to the non-TMZ group with a median overall survival of 10 months. The difference between these two groups was not statistically significant (p = 0.57). While this review did not demonstrate a statistically significant difference in long term survival between patients with SC GBM treated with TMZ versus those not treated with TMZ, a slightly longer survival time was seen in the TMZ group. The small number of patients is likely a contributing factor to the lack of statistical significance. Our analysis highlights the need for a multi-institutional, prospective, controlled study to evaluate the use of TMZ in the treatment of SC GBM.

Laser Interstitial Thermal Therapy: Lighting the Way to a New Treatment Option in Neurosurgery.

ABBREVIATIONS LITT, laser interstitial therapyNd:YAG, neodymium-doped yttrium aluminum.

Preoperative skin antisepsis with chlorhexidine gluconate versus povidone-iodine: a prospective analysis of 6959 consecutive spinal surgery patients

OBJECTIVE The aim of this study was to determine the efficacy of 2 common preoperative surgical skin antiseptic agents, ChloraPrep and Betadine, in the reduction of postoperative surgical site infection (SSI) in spinal surgery procedures. METHODS Two preoperative surgical skin antiseptic agents-ChloraPrep (2% chlorhexidine gluconate and 70% isopropyl alcohol) and Betadine (7.5% povidone-iodine solution)-were prospectively compared across 2 consecutive time periods for all consecutive adult neurosurgical spine patients. The primary end point was the incidence of SSI. RESULTS A total of 6959 consecutive spinal surgery patients were identified from July 1, 2011, through August 31, 2015, with 4495 (64.6%) and 2464 (35.4%) patients treated at facilities 1 and 2, respectively. Sixty-nine (0.992%) SSIs were observed. There was no significant difference in the incidence of infection between patients prepared with Betadine (33 [1.036%] of 3185) and those prepared with ChloraPrep (36 [0.954%] of 3774; p = 0.728). Neither was there a significant difference in the incidence of infection in the patients treated at facility 1 (52 [1.157%] of 4495) versus facility 2 (17 [0.690%] of 2464; p = 0.06). Among the patients with SSI, the most common indication was degenerative disease (48 [69.6%] of 69). Fifty-one (74%) patients with SSI had undergone instrumented fusions in the index operation, and 38 (55%) patients with SSI had undergone revision surgeries. The incidence of SSI for minimally invasive and open surgery was 0.226% (2 of 885 cases) and 1.103% (67 of 6074 cases), respectively. CONCLUSIONS The choice of either ChloraPrep or Betadine for preoperative skin antisepsis in spinal surgery had no significant impact on the incidence of postoperative SSI.

Epidemiology and etiology of secondary piriformis syndrome: A single-institution retrospective study

Piriformis syndrome (PS) is a rare etiology of extra-spinal sciatica in which pathologies associated with or around the piriformis muscle (PM) irritate the adjacent sciatic nerve (SN), however, there is scarcity in the literature regarding its exact etiologies, thus, we performed a retrospective study to elucidate the epidemiology of PS and assess various causes of the syndrome. Our study included patients assessed at our institution who presented with sciatica of non-spinal origin between May 2014 and December 2015. Radiology reports of all patients who received pelvic MRI were examined for positive findings involving PM and SN. Of the 143 patients recognized with sciatica and negative lumbar pathology, 24 patients (17%) exhibited positive PM and SN findings. Average patient age was 50.0 ± 15.1 years (range: 21-75), and 17 were female. Seven patients (5%; 4M/3F) presented with tumor, seven patients (5%) had chronic inflammatory changes, one patient had SN adhesions to obturator muscle, three patients (2%, 3F) had aberrant anatomy, and the remaining patients had positive MRI findings, such as nerve atrophy or PM hypertrophy without identifiable cause. Seven patients received steroid injections in the peri-sciatic fossa, and four displayed poor response. Our findings suggested possible trends in extra-spinal sciatica. Affected males appeared more likely to present with tumor, while affected females were more likely to present younger, but with aberrant anatomy. Steroid injections appeared to be suboptimal in most cases. Pelvic MRI is helpful in patients with sciatica and negative spine imaging to rule out neoplastic involvement.