Raheel Ahmed

Preservation of spinal instrumentation after development of postoperative bacterial infections in patients undergoing spinal arthrodesis.

Study Design This is a retrospective review. Objective The purpose of this study is to evaluate the efficacy of medical and surgical management of postoperative infections after the placement of spinal instrumentation in the context of retaining the instrumentation. Summary of Background Data The implementation of spinal instrumentation for the treatment of various spinal conditions is associated with a risk of developing a postoperative wound infection. An aggressive medical and surgical approach is necessary for eradication of subfascial infections and treatment is often performed with the guidance of infectious diseases consultants. These medical specialists frequently recommend removal of the implanted spinal instrumentation due to the concern for the potential of persistent microbial infection resulting from the formation of bacteria harboring biofilm on the indwelling spinal hardware. Methods Of 854 consecutive patients who had undergone spinal instrumentation by the senior author, 17 patients were identified who developed postoperative infections, 16 of which were treated by the senior author. Results All patients underwent surgical debridement and received antimicrobial therapy in consultation with the infectious diseases consultants. Spinal instrumentation was preserved in all cases. Two patients had clinical and radiologic evidence of nonunion and later underwent a staged instrumentation revision procedure. Eradication of the infection was successful in all patients. The mean follow‐up period was 2.1 years (range, 12 mo to 4.5 y). Conclusions A combination of aggressive surgical debridement with microbial‐guided pharmacotherapy enabled infection cure in all patients with postoperative bacterial infections after spinal instrumentation. Adjunct measures including the use of wound vacuum devices and long‐term suppressive antimicrobial therapy were also used in high‐risk patients. These results show that postoperative bacterial infections in the setting of spinal instrumentation can be successfully treated without removing titanium alloy instrumentation.

Primary atlantoaxial bone tumors in children: management strategies and long-term follow-up

OBJECT Atlantoaxial tumors account for a substantial proportion of primary bone tumors in children. Before resection, surgeons must consider the complex regional anatomy, the potential for neurological compromise, craniocervical instability, and the question of tumor resectability in a growing spine. Using current technology, the authors analyzed surgical cases in this light and present outcomes and treatment recommendations after long-term patient follow-up. METHODS The authors reviewed clinical records for 23 children whose primary atlantoaxial bone tumors were treated from 1996 through 2010. RESULTS Pathological lesions among the 23 patients were 4 aneurysmal bone cysts, 2 osteochondromas, 5 chordomas, 4 osteoblastomas, 3 fibrous dysplasias, 4 eosinophilic granulomas, and 1 Ewings sarcoma. Clinical presentation consisted of neck pain (n = 23), headaches and occipital pain (n = 16), myelopathy (n = 8), and torticollis (n = 4). Selective angiography and coil embolization were undertaken for all patients with aneurysmal bone cysts and osteoblastomas, 2 patients with chordomas, 1 patient with fibrous dysplasia, and 1 patient with Ewings sarcoma. Primary embolization treatment of radiation-induced aneurysmal bone cyst of the atlas showed complete reossification. Results of CT-guided needle biopsy were diagnostic for 1 patient with eosinophilic granuloma and 1 with Ewings sarcoma. Needle biopsies performed before referral were associated with extreme blood loss for 1 patient and misdiagnosis for 2 patients. Surgery involved lateral extrapharyngeal, transoral, posterior, and posterolateral approaches with vertebral artery rerouting. Complete resection was possible for 9 patients (2 with osteochondroma, 3 with fibrous dysplasia, 2 with chordoma, and 2 with osteoblastoma). Decompression and internal fusion were performed for 3 patients with aneurysmal bone cysts. Of the 23 patients, 7 underwent dorsal fusion and 4 underwent ventral fusion of the axis body. Chemotherapy was necessary for the patients with eosinophilic granuloma with multifocal disease and for the patient with Ewings sarcoma. There was no morbidity, and there were no deaths. All patients with benign lesions were free of disease at the time of the follow-up visit (mean ± SD follow-up 8.8 ± 1.1 years; range 2-18 years). Chordomas received proton or LINAC irradiation, and as of 4-15 years of follow-up, no recurrence has been noted. CONCLUSIONS Because most atlantoaxial tumors in children are benign, an intralesional procedure could suffice. Vascular control and staged resection are critical. Ventral transoral fusion or lateral extrapharyngeal fusion has been successful. Resection with ventral fusion and reconstruction are essential for vertebral body collapse. Management of eosinophilic granulomas must be individualized and might require diagnosis through needle biopsy.

Cordectomy for intramedullary spinal cord glioblastoma with a 12-year survival.

Background: Prognosis of patients with spinal cord glioblastoma is poor, with an average survival of 18 months. There are reports in the literature describing cordectomy as a treatment option for patients with spinal cord tumors. Case Description: This is a case report of a patient with spinal cord glioblastoma who, in addition to radiation and chemotherapy, was treated with cordectomy. Outcome of treatment resulted in 12-year survival. Conclusion: Cordectomy in spinal cord glioblastoma can result in prolonged and meaningful survival.

Disease outcomes for skull base and spinal chordomas: A single center experience ,

OBJECTIVE Chordomas carry significant morbidity due to their growth patterns and surgical constraints in resection. En bloc resection, when feasible, is the ideal treatment goal, but is associated with significant morbidity. We sought to elucidate the relationship between extent of surgery, location and radiotherapy in relation to overall disease and progression free survival (PFS). METHODS We reviewed case records for all patients with a primary histopathological diagnosis of clival and spinal chordomas that was presented to our institution between 1978 and 2010. RESULTS A total of 49 patients (location: n=30, skull base/clival; n=12 vertebral column; n=7 sacrum) were identified with mean follow-up period of 6.3 years (range 0.25 months-33 years). Improved 5 year and 10 year survival rates were noted following gross total resection (n=8, 5 year and 10 year survival=88%) as compared to patients that underwent subtotal resection (n=41, 55% and 31%, respectively), (p-value>0.05, GTR versus STR). Adjuvant high-dose stereotactic fractionated radiotherapy (HS-FSRT) significantly improved 5 year PFS in craniocervical chordoma patients (70%, n=13) as compared to standard dose radiation therapy (20%, n=16; p-value=0.03). Overall 10 year survival for craniocervical patients undergoing HD-FSRT (40%) was however not significantly different in comparison with conventional radiotherapy (45%). Sacral chordomas had the worst prognosis with 3 year survival of 28.6%. CONCLUSIONS GTR offers the best prognosis for improved long-term survival. Adjuvant HD FSRT for cranio-cervical/clival chordomas significantly improves disease free survival though the long-term benefits on survival have yet to be established. Sacral chordomas are associated with a worse prognosis and poor long-term survival.

Role of resection and adjuvant therapy in long-term disease outcomes for low-grade pediatric intramedullary spinal cord tumors.

OBJECTIVE Surgical excision is the mainstay treatment for resectable low-grade intramedullary spinal cord tumors (IMSCTs) in the pediatric age group. Chemotherapy and radiation treatments are generally reserved for progressive or recurrent disease. Given the indolent nature of low-grade tumors and the potential side effects of these approaches, their long-term treatment benefits are unclear. The aim of the study was to determine long-term disease outcomes and the therapeutic roles of surgery and adjuvant therapies in pediatric patients with low-grade IMSCTs over an extended follow-up period. METHODS Case records for all pediatric patients (< 21 years of age) with a histopathological diagnosis of low-grade IMSCT were selected over a period from January 1975 to January 2010. Outcome variables including McCormick functional grade, overall survival (OS), and progression-free survival (PFS) were analyzed with respect to demographic and treatment variables. RESULTS Case records of 37 patients with low-grade IMSCTs were identified, with a mean follow-up duration of 12.3 ± 1.4 years (range 0.5-37.2 years). Low-grade astrocytomas were the most prevalent histological subtype (n = 22, 59%). Gross-total resection (GTR) was achieved in 38% of patients (n = 14). Fusion surgery was required in 62% of patients with pre- or postoperative deformity (10 of 16). On presentation, functional improvement was observed in 87% and 46% of patients in McCormick Grades I and II, respectively, and in 100%, 100%, and 75% in Grades III, IV, and V, respectively. Kaplan-Meier PFS rates were 63% at 5 years, 57% at 10 years, and 44% at 20 years. OS rates were 92% at 5 years, 80% at 10 years, and 65% at 20 years. On multivariate analysis, shunt placement (hazard ratio [HR] 0.33, p = 0.01) correlated with disease progression. There was a trend toward improved 5-year PFS in patients who received adjuvant chemotherapy and radiation therapy (RT; 55%) compared with those who did not (36%). Patients who underwent subtotal resection (STR) were most likely to undergo adjuvant therapy (HR 7.86, p = 0.02). CONCLUSIONS This extended follow-up duration in patients with low-grade IMSCTs beyond the first decade indicates favorable long-term OS up to 65% at 20 years. GTR improved PFS and was well tolerated with sustained functional improvement in the majority of patients. Adjuvant chemotherapy and RT improved PFS in patients who underwent STR. These results emphasize the role of resection as the primary treatment approach, with adjuvant therapy reserved for patients at risk for disease progression and those with residual tumor burden.

Management of operative complications related to occipitocervical instrumentation.

BACKGROUND: The continued evolution of instrumentation techniques for fusions at the craniovertebral junction has enabled surgical treatment of a wide range of developmental, neoplastic, traumatic, and degenerative conditions. There has been an increased recognition of the morbidity associated with the complications secondary to occipitocervical instrumentation. OBJECTIVE: To present representative complications secondary to occipitocervical instrumentation in patients who presented to our institution and to emphasize underlying principles in diagnosis and management of craniovertebral disease conditions through illustrative examples of their presentation, management, and follow-up. METHODS: Clinical records for patients referred to the senior author (A.H.M.) between 2005 and 2010 for evaluation and management of their symptoms arising as a consequence of surgical intervention by a different primary neurosurgeon were reviewed. RESULTS: Eight patients were identified with representative complications secondary to occipitocervical instrumentation. These complications included incorrect surgical technique, persistent instability, hardware misplacement with potential for vascular injury, associated neural injury, and secondary complications of wound healing resulting from methyl methacrylate use. Surgical revision was required in 2 patients. The remaining patients improved with removal of the offending hardware and acrylic cement. All patients reported symptom resolution, and dynamic imaging studies on follow-up indicated stable alignment and bony fusion. CONCLUSION: These cases serve as illustrative examples of the spectrum of neural, vascular, biomechanical, and instrument-related complications associated with occipitocervical arthrodesis. Basic principles of occipitocervical instrumentation that enable safe and successful treatment of craniovertebral junction disease conditions have been highlighted. Potential complications and management strategies are discussed. ABBREVIATION: VAS, Visual Analog Scale

Acutely unstable cervical spine injury with normal CT scan findings: MRI detects ligamentous injury

MRI can detect ligamentous injury not detectable with CT scan. The authors present a trauma patient with normal CT imaging despite dislocation on standing radiograph. MRI detected disruption of the C5-C6 posterior ligamentous complex that requires surgery.

Clinical presentation and management of proatlas segmentation defect presenting with palatal myoclonus: case report

Clinical presentation of craniovertebral junction disorders may range from acute catastrophic neurological deficits to insidious signs and symptoms that may mask the underlying etiology. Prompt recognition and treatment is essential to avert long-term neurological morbidity. Proatlas segmentation disorders are a rare group of developmental disorders involving the craniocervical junction. Abnormal bony segmentation leads to malformed bony structures that can in turn lead to neurological deficits through bony compression of the cervicomedullary junction. This report details a proatlas segmentation defect presenting as palatal myoclonus, a rare movement disorder. The clinical presentation, surgical management, and neuroanatomical basis for the disorder is presented. This report highlights the myriad clinical presentations of craniovertebral disorders and emphasizes a rare but treatable etiology for palatal myoclonus.

Junctional susceptibility of the pediatric spine: a case report

The incidence of pediatric spinal injury is relatively less common than in adults [1, 2, 6, 10, 14, 15, 19, 22]. Because of age-dependent anatomical, biomechanical, and biochemical variations of the human spine, the location of spinal cord injury varies [7, 15, 19, 22]. We present a case of a 4-year-old child who suffered from a traumatic spinal cord injury. Emphasis is made on the mechanism of trauma, location, and extent of injuries observed to the immature pediatric spine.