John Paul G. Kolcun

Laser thermal ablation for mesiotemporal epilepsy: Analysis of ablation volumes and trajectories

To identify features of ablations and trajectories that correlate with optimal seizure control and minimize the risk of neurocognitive deficits in patients undergoing laser interstitial thermal therapy (LiTT) for mesiotemporal epilepsy (mTLE).

Prophylactic vertebral cement augmentation at the uppermost instrumented vertebra and rostral adjacent vertebra for the prevention of proximal junctional kyphosis and failure following long-segment fusion for adult spinal deformity

BACKGROUND CONTEXT Proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) are common problems after long-segment (>5 levels) thoracolumbar instrumented fusions in the treatment of adult spinal deformity (ASD). No specific surgical strategy has definitively been shown to lower the risk of PJK as the result of a multifactorial etiology. PURPOSE The study aimed to assess the incidence of PJK and PJF in patients treated with prophylactic polymethylmethacrylate (PMMA) cement augmentation at the uppermost instrumented vertebrae (UIV) and rostral adjacent vertebrae (UIV+1). STUDY DESIGN/SETTING This is a retrospective cohort-matched surgical case series at an academic institutional setting. PATIENT SAMPLE Eighty-five adult patients over a 16-year enrollment period were identified with long-segment (>5 levels) posterior thoracolumbar instrumented fusions for ASD. OUTCOME MEASURES Primary outcomes measures were PJK magnitude and PJF formation. Secondary outcomes measures were spinopelvic parameters, as well as global and regional sagittal alignment. METHODS The impact of adjunctive PMMA use in long-segment (≥5 levels) fusion for ASD was assessed in adult patients aged 18 and older. Patients were included with at least one of the following: lumbar scoliosis >20°, pelvic tilt >25°, sagittal vertical axis >5 cm, central sacral vertical line >2 cm, and thoracic kyphosis >60°. The frequency of PJF and the magnitude of PJK were measured radiographically preoperatively, postoperatively, and at maximum follow-up in controls (Group A) and PMMA at the UIV and UIV+1 (Group B). RESULTS Eighty-five patients (64±11.1 years) with ASD were identified: 47 control patients (58±10.6) and 38 patients (71±6.8) treated with PMMA at the UIV and UIV+1. The mean follow-up was 27.9 and 24.2 months in Groups A and B, respectively (p=.10). Preoperative radiographic parameters were not significantly different, except the pelvic tilt which was greater in Group A (26.6° vs. 31.4°, p=.03). Postoperatively, the lumbopelvic mismatch was greater in Group B (14.6° vs. 7.9°, p=.037), whereas the magnitude of PJK was greater in controls (9.36° vs. 5.65°, p=.023). The incidence of PJK was 36% (n=17) and 23.7% (n=9) in Groups A and B, respectively (p=.020). The odds ratio of PJK with vertebroplasty was 0.548 (95% confidence interval=0.211 to 1.424). Proximal junctional kyphosis was observed in 6 (12.8%) controls only (p=.031). The UIV+1 angle, a measure of PJK, was significantly greater in controls (10.0° vs. 6.8°, p=.02). No difference in blood loss was observed. No complications were attributed to PMMA use. CONCLUSIONS The use of prophylactic vertebral cement augmentation at the UIV and rostral adjacent vertebral segment at the time of deformity correction appears to be preventative in the development of proximal junctional kyphosis and failure.

Minimally-Invasive versus Conventional Repair of Spondylolysis in Athletes: A Review of Outcomes and Return to Play

Spondylolysis from pars fracture is a common injury among young athletes, which can limit activity and cause chronic back pain. While current literature has examined the relative benefits of surgical and conservative management of these injuries, no study has yet compared outcomes between conventional direct repair of pars defects and modern minimally invasive procedures. The goals of surgery are pain resolution, return to play at previous levels of activity, and a shorter course of recovery. In this review, the authors have attempted to quantify any differences in outcome between patients treated with conventional or minimally invasive techniques. A literature search was performed of the PubMed database for relevant articles, excluding articles describing conservative management, traumatic injury, or high-grade spondylolisthesis. Articles included for review involved young athletes treated for symptomatic spondylolysis with either conventional or minimally invasive surgery. Two independent reviewers conducted the literature search and judged articles for inclusion. All studies were classified according to the North American Spine Society standards. Of the 116 results of our initial search, 16 articles were included with a total of 150 patients. Due to a paucity of operative details in older studies and inconsistencies in both clinical methods and reporting among most articles, little quantitative analysis was possible. However, patients in the minimally invasive group did have significantly higher rates of pain resolution (p<0.001). Short recovery times were also noted in this group. Both groups experienced low complication rates, and the majority of patients returned to previous levels of activity. Surgical repair of spondylolysis in young athletes is a safe and practical therapy. Current literature suggests that while conventional repair remains effective, minimally invasive procedures better clinical outcomes. We await further data to conduct a more thorough quantitative analysis of these techniques.

Scenario Planning: Playing the Expectations Game in Spine Surgery

Since the time of Hippocrates, accurate prognosis has been at the heart of medical practice. But as modern science equips physicians with tools of ever greater diagnostic and therapeutic power, authentic predictions of survival and quality-of-life have become paramount in selecting appropriate interventions for a variety of complex pathologies. Further, as medical ethics have evolved to place greater authority in the hands of patients, the ability to convincingly define what outcomes are achievable is key to educate patients who are making life-altering medical decisions. In a recent issue of the New England Journal of Medicine, Schwarze and Taylor present a case of trauma, malignancy, and uncertainty. In it, they illustrate a clinical application of scenario planning: an economic method for understanding and representing a nebulous future. Instead of quoting percentages and probabilities for discrete aspects of a clinical outcome, this approach describes a variety of integrated scenarios. Each possible scenario can then be ranked by likelihood and desirability. In this way, physicians can help patients better visualize and understand the impact of each clinical decision. The principles of scenario planning are highly applicable to the field of spinal neurosurgery. Our patients frequently have multiple medical comorbidities, chronic intractable pain, and a psychologic desperation born of the long course that led them to our clinics. For these reasons, many may have unrealistic expectations for what surgery can offer. In such cases, preoperative education may prove as important to outcomes as the surgery itself.

The Role of Dynamic Magnetic Resonance Imaging in Cervical Spondylotic Myelopathy

Dynamic spinal cord compression has been investigated for several years, but until the advent of open MRI, the use of dynamic MRI (dMRI) did not gain popularity. Several publications have shown that cervical cord compression is both static and dynamic. On many occasions the evaluation of cervical spondylotic myelopathy (CSM) is straightforward, but patients are frequently encountered with a significantly worse clinical examination than would be suggested by radiological images. In this paper, we present an extensive review of the literature in order to describe the importance of dMRI in various settings and applications. A detailed literature review was performed in the Medline and Pubmed databases using the terms “cervical spondylotic myelopathy”, “dynamic MRI”, “kinetic MRI”, and “myelomalalcia” for the period of 1980-2016. The study was limited to English language, human subjects, case series, retrospective studies, prospective reports, and clinical trials. Reviews, case reports, cadaveric studies, editorials, and commentaries were excluded. The literature search yielded 180 papers, 19 of which met inclusion criteria. However, each paper had evaluated results and outcomes in different ways. It was not possible to compile them for meta-analysis or pooled data evaluation. Instead, we evaluated individual studies and present them for discussion. We describe a number of parameters evaluated in 2661 total patients, including dynamic changes to spinal cord and canal dimensions, transient compression of the cord with changes in position, and the effects of position on the intervertebral disc. dMRI is a useful tool for understanding the development of CSM. It has found several applications in the diagnosis and preoperative evaluation of many patients, as well as certain congenital dysplasias and Hirayama disease. It is useful in correlating symptoms with the dynamic changes only noted on dMRI, and has reduced the incidence of misdiagnosis of myelopathy.

Patientem Fortuna Adiuvat: The Delayed Treatment of Surgical Acute Subdural Hematomas—A Case Series

BACKGROUND Current guidelines prescribe emergent decompression of acute subdural hematomas (aSDHs) with width 10 mm or larger or midline shift 5 mm or larger. A subset of patients who meet these criteria, including those with high Glasgow Coma Scale (GCS) scores and coagulopathy because of medication or multiple medical comorbidities, may be treated conservatively until the hematoma can be removed by burr hole drainage. We present a series of conservatively managed surgical patients with aSDH, examining their hospital course and outcomes. METHODS Patients were included who met guidelines for surgery on admission but who had decompression delayed until it could be accomplished by burr hole drainage. Charts were reviewed for presentation, computed tomography scan findings, and outcomes. Patients were classified according to outcome and whether their eventual surgery was scheduled or emergent. RESULTS Eighteen patients were included with a mean age of 70.2 years. Average GCS score at presentation was 14.6 ± 0.6. Most patients were using some form of blood-thinning medication at presentation (72.2%). Admission CT scan revealed aSDH with a mean width of 13.6 mm and midline shift of 6.6 mm. Average total length of stay was 28.4 ± 17.0 days, of which 14.2 ± 9.2 days were spent in the intensive care unit. Outcomes were generally acceptable, with an average Glasgow Outcome Scale score at discharge of 3.8 ± 1.4. There were only 2 deaths, neither of which was related to the initial trauma or a neurologic process. CONCLUSIONS Delayed treatment of aSDH by burr hole drainage is an effective option in certain patients who are suboptimal craniotomy candidates. Acceptable outcomes may be achievable with this conservative approach, when applied in appropriate patients.

Enhanced Recovery After Surgery™ Awake Minimally-Invasive Transforaminal Lumbar Interbody Fusion: 2-Dimensional Operative Video

This video demonstrates the awake endoscopic minimally-invasive transforaminal lumbar interbody fusion (MIS-TLIF) used in our institutions developing Enhanced Recovery After Surgery program. This technique relies on 6 key components, including (1) conscious sedation, (2) endoscopic visualization, (3) long-acting local anesthesia, (4) an expandable interbody device, (5) osteobiologics, and (6) percutaneous instrumentation. In joining these technologies, this procedure embodies the principles of minimally invasive surgery while achieving excellent clinical outcomes. We have previously described this procedure in detail, as well as its impact at our institution, including significant reductions in operative time, blood loss, postoperative length of stay, and hospital costs. The procedure depicted in this video involves the off-label use of bone morphogenetic protein-2 and the Spineology Optimesh allograft containment device. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The patient gave direct consent for the use of the video footage and associated information from this surgery for the making and publication of this surgical video.

Working Channel Endoscopic Interlaminar Microdiscectomy: 2-Dimensional Operative Video

This video demonstrates a working channel interlaminar microdiscectomy performed in a patient with significant back and leg pain due to a persistent disc herniation. We describe this technique in detail, describing the endoscopic anatomy and illustrating key steps to safely perform this operation. Due to the limited soft tissue destruction required to access the disc space with this approach, the patient was able to leave the hospital on the day of surgery, and required no pain medication by short-term follow-up a few weeks postoperatively. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The patient gave direct consent for the use of the endoscopic footage and associated information from this surgery for the making of this video.

Overview of CNS Vaccines—Pediatrics

Abstract Vaccine immunotherapy for pediatric CNS malignancy is a new and developing field, primarily aimed at glial tumors. Vaccines typically must be found safe and effective in adults before being tested in children. There are three major types of tumor vaccines: dendritic cell (DC), peptide, and vector-based. All vaccines directed at pediatric CNS tumors currently remain in pilot or Phase I trials, evaluating feasibility and safety, respectively. Immune response and improved clinical outcomes have been documented as secondary measures in some cases. In this chapter, we will present a thorough review of vaccine therapy for pediatric CNS tumors.

Robotic paravertebral schwannoma resection at extreme locations of the thoracic cavity

Solitary paravertebral schwannomas in the thoracic spine and lacking an intraspinal component are uncommon. These benign nerve sheath tumors are typically treated using complete resection with an excellent outcome. Resection of these tumors is achieved by an anterior approach via open thoracotomy or minimally invasive thoracoscopy, by a posterior approach via laminectomy, or by a combination of both approaches. These tumors most commonly occur in the midthoracic region, for which surgical removal is usually straightforward. The authors of this report describe 2 cases of paravertebral schwannoma at extreme locations of the posterior mediastinum, one at the superior sulcus and the other at the inferior sulcus of the thoracic cavity, for which the usual surgical approaches for safe resection can be challenging. The tumors were completely resected with robot-assisted thoracoscopic surgery. This report suggests that single-stage anterior surgery for this type of tumor in extreme locations is safe and effective with this novel minimally invasive technique.