Paul Santiago

Minimally Invasive Resection of Intradural-Extramedullary Spinal Neoplasms

OBJECTIVE: Spinal intradural-extramedullary neoplasms are uncommon lesions that usually cause pain or neurological deficit secondary to neural compression. Traditional treatment of these tumors includes open laminectomy with intradural resection. We describe an alternative minimally invasive surgical technique in a consecutive series of patients undergoing treatment for symptomatic lesions. METHODS: Six patients (four men, two women) presented with symptoms including pain (five out of six) and/or neurological deficit (two out of six) with radiographic evidence of intradural pathology. All patients underwent surgical resection using a minimally invasive, unilateral approach. Pain relief was analyzed using the visual analog scale and magnetic resonance imaging to evaluate the extent of resection. Traditional laminectomy for tumor resection disrupts the muscular, ligamentous, and bony structures of the spine, which may contribute to pain and instability. Minimally invasive resection of intradural tumors offers the option of reducing approach morbidity when resecting these lesions. Using a tubular retractor system (X-Tube, Medtronic Sofamor-Danek, Memphis, TN) and microscopic surgical techniques, we were able to resect different intradural lesions successfully. RESULTS: All patients underwent successful, complete resection of their intradural-extramedullary tumors. The average patient age was 47 years (range, 41–60 yr) with one cervical, one thoracic, and four lumbar lesions. The mean operative time was 247 minutes (range, 180–320 min), the estimated blood loss was 56 mLs (range, 40–75 mLs), and the hospital stay was 57 hours (range, 48–80 h). Histologically, five tumors were determined to be schwannomas and one was identified as a myxopapillary ependymoma. There were no complications associated with this surgical technique. Postoperative magnetic resonance imaging demonstrated complete resection in all cases. CONCLUSION: Intradural-extramedullary neoplasms can be safely and effectively treated with minimally invasive techniques. Potential reduction in blood loss, hospitalization and disruption to local tissues suggest that, in the hands of an experienced surgeon, this technique may present an alternative to traditional open tumor resection.

Minimally Invasive Surgical Treatment of Lumbar Synovial Cysts

OBJECTIVESynovial cysts are a rare cause of lumbar radiculopathy and back pain. Surgical treatment is directed at complete excision of the cyst. We used minimally invasive surgical techniques for a series of patients, to assess the effectiveness of this approach for resection of synovial cysts. METHODSSeventeen patients (10 female and 7 male patients) with presumed synovial cysts, as indicated on magnetic resonance imaging scans, underwent surgical resection with the 18-mm METRx tubular retractor system (Medtronic Sofamor Danek, Memphis, TN). A unilateral approach was used, with either an operating microscope (13 cases) or a magnifying endoscope (4 cases), depending on the preference of the surgeon. Outcomes were reported by using modified MacNab criteria. RESULTSThe average patient age was 64 years (range, 46–82 yr). The L4–L5 level was most commonly affected (82% of cases). Grade 1 spondylolisthesis at the level harboring the synovial cyst was observed for 47% of the patients; all cases of spondylolisthesis involved the L4–L5 level. The mean operative time was 97 minutes, and the average blood loss was 35 ml. Excellent or good results were achieved for 94% of the patients. A dural tear that did not violate the arachnoid membrane occurred during surgery for one patient but did not require further treatment. CONCLUSIONSynovial cysts can be effectively treated with a tubular retractor system in conjunction with an endoscope or microscope. Use of the tubular retractor minimizes soft-tissue trauma, incision length, blood loss, and disruption of ligamentous and bony structures. This may be particularly significant when synovial cysts are associated with spondylolisthesis, minimizing the risk of progressive instability and the need for fusion.

Are readmission rates on a neurosurgical service indicators of quality of care

OBJECT The goal of this study was to examine the reasons for early readmissions within 30 days of discharge to a major academic neurosurgical service. METHODS A database of readmissions within 30 days of discharge between April 2009 and September 2010 was retrospectively reviewed. Clinical and administrative variables associated with readmission were examined, including age, sex, race, days between discharge and readmission, and insurance type. The readmissions were then assigned independently by 2 neurosurgeons into 1 of 3 categories: scheduled, adverse event, and unrelated. The adverse event readmissions were further subcategorized into patients readmitted although best practices were followed, those readmitted due to progression of their underlying disease, and those readmitted for preventable causes. These variables were compared descriptively. RESULTS A total of 348 patients with 407 readmissions were identified, comprising 11.5% of the total 3552 admissions. The median age of readmitted patients was 55 years (range 16-96 years) and patients older than 65 years totaled 31%. There were 216 readmissions (53% of 407) for management of an adverse event that was classified as either preventable (149 patients; 37%) or unpreventable (67 patients; 16%). There were 113 patients (28%) who met readmission criteria but who were having an electively scheduled neurosurgical procedure. Progression of disease (48 patients; 12%) and treatment unrelated to primary admission (30 patients; 7%) were additional causes for readmission. There was no significant difference in the proportion of early readmissions by payer status when comparing privately insured patients and those with public or no insurance (p = 0.09). CONCLUSIONS The majority of early readmissions within 30 days of discharge to the neurosurgical service were not preventable. Many of these readmissions were for adverse events that occurred even though best practices were followed, or for progression of the natural history of the neurosurgical disease requiring expected but unpredictably timed subsequent treatment. Judicious care often requires readmission to prevent further morbidity or death in neurosurgical patients, and penalties for readmission will not change these patient care obligations.

Thoracic microendoscopic discectomy: a human cadaver study.

Study Design. Feasibility analysis of percutaneous posterolateral thoracic microendoscopic discectomy in a human cadaver model. Objective. To describe a new, minimally invasive, posterolateral approach to the thoracic spine for the treatment of disc herniations. Summary of Background. Thoracoscopic discectomy offers surgeons direct ventral access to thoracic disc herniations but requires entry into the chest. Many surgeons favor a posterolateral approach to the thoracic spine, thereby avoiding morbidity associated with entry into the thoracic cavity. By adapting minimal access surgical techniques to the thoracic spine, effective treatment of thoracic disc herniations should be possible and may help expedite recovery. Methods. Two cadaveric human torsos were used. Using simple adaptations of our standard lumbar microendoscopic discectomy technique, endoscopic discectomies were performed throughout the mid and lower thoracic spine. Operative time was recorded. The extent of the discectomy as well as the extent of bony removal was evaluated using computed tomography myelography. Results. Nine discectomies were performed in two cadaveric specimens, from T5–T6–T9–T10. Operative times ranged from 46 to 77 minutes (mean 60 minutes). The procedure required removing 3.4 mm (±1.9 mm) of the ipsilateral facet, which amounted to 35.4% (±17.5%) of the facet complex. Canal decompression averaged 73.5% (±7.9%). Conclusions. Thoracic microendoscopic discectomy allows for a posterolateral approach to thoracic disc herniation without entry into the chest cavity that consistently gives access to the majority of the canal while requiring only a minimal amount of bone removal. This technique provides an approach angle similar to that obtained with other posterolateral discectomy techniques while limiting the morbidity associated with exposure.

Acute traumatic posteroinferior cerebellar artery aneurysms: report of three cases.

OBJECTIVE AND IMPORTANCE Posterior fossa subarachnoid hemorrhage secondary to blunt head trauma is rarely associated with traumatic aneurysms of the posterior circulation. CLINICAL PRESENTATION We present three cases of posterior fossa subarachnoid hemorrhage from ruptured posteroinferior cerebellar artery (PICA) aneurysms after blunt head trauma. In each case, there was no associated penetrating injury or cranial fracture. All three patients presented with acute hydrocephalus requiring ventriculostomy. Two of the three patients had a proximal PICA aneurysm visible on emergent angiography. The remaining patients aneurysm, although not visible on his initial angiogram, was detected on a subsequent angiogram 72 hours later. INTERVENTION All patients underwent successful surgical clipping of their aneurysms. Two cases required sacrificing of the parent vessels because of the friable nature of the false aneurysms. In each case, severe symptomatic vasospasm occurred, requiring angioplasty. All three patients also required a ventriculoperitoneal shunt for persistent hydrocephalus. CONCLUSION Features of these three cases and similar cases reported in the literature support the theory that vascular ruptures and traumatic aneurysms of the proximal PICA may be related to anatomic variability of the PICA as it transverses the brainstem. This variability predisposes individuals to vascular lesions, which occur in a continuum based on the severity of the injury. Posterior fossa subarachnoid hemorrhage after head injury requires a high index of suspicion and warrants aggressive diagnostic and therapeutic interventions.

Implementation and preliminary clinical experience with the use of ceiling mounted mobile high field intraoperative magnetic resonance imaging between two operating rooms.

OBJECTIVE Intraoperative magnetic resonance imaging (ioMRI) provides immediate feedback and quality assurance enabling the neurosurgeon to improve the quality of a range of neurosurgical procedures. Implementation of ioMRI is a complex and costly process. We describe our preliminary 16 months experience with the integration of an IMRIS movable ceiling mounted high field (1.5 T) ioMRI setup with two operating rooms. METHODS Aspects of implementation of our ioMRI and our initial 16 months of clinical experience in 180 consecutive patients were reviewed. RESULTS The installation of a ceiling mounted movable ioMRI between two operating rooms was completed in April 2008 at Barnes-Jewish Hospital in St. Louis. Experience with 180 neurosurgical cases (M:F-100:80, age range 1-79 years, 71 gliomas, 57 pituitary adenomas, 9 metastases, 11 other tumor cases, 4 Chiari decompressions, 6 epilepsy resections and 22 other miscellaneous procedures) demonstrated that this device effectively provided high quality real-time intraoperative imaging. In 74 of all 180 cases (41%) and in 54% of glioma resections, the surgeon modified the procedure based upon the ioMRI. Ninety-three percent of ioMRI glioma cases achieved gross/near total resection compared to 65% of non ioMRI glioma cases in this time frame. CONCLUSION A movable high field strength ioMRI can be safely integrated between two neurosurgical operating rooms. This strategy leads to modification of the surgical procedure in a significant number of cases, particularly for glioma surgery. Long-term follow up is needed to evaluate the clinical and financial impact of this technology in the field of neurosurgery.

Intramedullary capillary hemangioma of the thoracic spine: case report and review of the literature

Capillary hemangiomas are benign vascular neoplasms. When associated with the spine, these growths frequently involve the vertebral body, but rarely have they been reported to occur as intradural lesions, while even more rarely occurring in a true intramedullary location. We report a rare case of an intramedullary capillary hemangioma of the thoracic spinal cord and a review of the literature.

Giant cell tumor of the thoracic spine: case report and review of the literature ☆

BACKGROUND Giant cell tumors are benign tumors of the bone that most commonly occur at the ends of the long bones; they are rarely found in the spine above the sacrum. The management of patients with giant cell tumors of the spine represents a challenge, and the clinical approach to this problem continues to evolve with improvements in surgical and adjunctive therapies. CASE DESCRIPTION A 19-year-old woman with localized back pain and a spinal compression deformity was found to harbor a giant cell tumor of the T7 vertebral body. The patient was first treated with arterial embolization of the hypervascular region observed on angiography. Subsequently, the patient underwent a one-stage transthoracic T7 corpectomy followed by anterior spinal reconstruction and stabilization. Postoperatively, the patients kyphotic deformity was corrected. To optimize local disease control, the patient underwent IMRT delivered to the site of tumor resection. She remains neurologically intact at 1 year postoperatively without evidence of disease recurrence. CONCLUSION The literature and approaches to the management of spinal giant cell tumors are reviewed.

Minimally invasive surgery for the management of cervical spondylosis.

DORSAL SURGICAL PROCEDURES have a well-established role in the treatment of both radiculopathy and myelopathy caused by cervical spondylosis. Laminectomy and laminoplasty procedures can both lead to postoperative kyphosis because of the removal of the dorsal supporting structures of the neck. Minimally invasive or minimal-access spinal surgery procedures of the dorsal cervical spine are evolving techniques with the goal of decompressing the neural structures with minimal disruption of the dorsal supporting structures. We think that this will lead to less postoperative pain and a decreased incidence of postdecompression kyphotic deformity. Patient selection, techniques, and results are discussed for both minimally invasive cervical laminoforaminotomy and stenosis decompression.

Intramedullary tuberculoma mimicking primary CNS lymphoma

The incidence of primary central nervous system lymphoma (PCNSL) has been on the rise in the setting of immunodeficiency syndromes such as acquired immune deficiency syndrome (AIDS). Its diagnosis has been facilitated by the advent of a cerebrospinal fluid (CSF) Epstein–Barr virus (EBV) PCR assay. The reported high sensitivity and specificity of this assay has made it the cornerstone of diagnosis of PCNSL, replacing more traditional methods such as an open CNS biopsy. Here, we have described a patient with a known history of C3 AIDS presenting with lower extremity weakness and eventual myelopathy who was later diagnosed as having intramedullary PCNSL after detection of EBV DNA in his CSF. After failing to respond to radiotherapy, he underwent a spinal cord biopsy revealing intramedullary tuberculoma. This case illustrates the risk of misdiagnosis with this assay and the importance of histological confirmation of a pathological lesion prior to implementation of therapy.