Rajesh Reddy

Stand-alone anterior lumbar interbody fusion for treatment of degenerative spondylolisthesis.

We sought to evaluate the clinical and radiologic efficacy of stand-alone anterior lumbar interbody fusion (ALIF) for low grade degenerative spondylolisthesis, the favoured surgical management approach at our institution. The optimal approach for surgical management of spondylolisthesis remains contentious. We performed a prospective analysis of all consecutive patients with low grade lumbar spondylolisthesis who underwent ALIF between 2009 and 2013 by a single surgeon (n=27). The mean age was 64.9 years with a male to female ratio of 14:13. There were 32 levels operated and the average preoperative spondylolisthesis was 14.8%, which reduced to 6.4% postoperatively and 9.4% at the latest follow-up (p=0001). Postoperative disc height was increased to 175% of preoperative values and was statistically significant (p<0.001) and remained improved with an overall change of 139% at the latest follow-up. The radiological fusion rate was 91%. The 12-Item Short Form Health Survey (SF-12) mental and physical component summary improved from 31.7 to 43.0 (p=0.007) and from 35.4 to 51.7 (p=0.0026), respectively. The mean visual analogue scale pain score improved from 7.6 to 2.2 (p<0.001), and the mean Oswestry disability index improved from 56.9 to 17.8% (p<0.0001). The overall clinical success rate was 93%. The posterior disc height correlated with spondylolisthesis reduction (p=0.04) and the only clinical factor affecting reduction was body mass index (p=0.04). The present study provides encouraging short term results for stand-alone ALIF as a procedure for low grade lumbar degenerative spondylolisthesis. Future studies should include adequately powered, prospective, multicentre registry studies with long term follow-up to allow a better assessment of the relative benefits and risks.

Laparotomy vs minimally invasive laparoscopic ventriculoperitoneal shunt placement for hydrocephalus: A systematic review and meta-analysis

Ventriculoperitoneal shunt (VPS) surgery is the most commonly used method for the treatment of hydrocephalus. Traditionally, distal catheters in the VPS surgery have been placed either through a standard small open laparotomy or via a laparoscopic technique. Although there are many studies demonstrating the benefits of a minimally invasive approach, limited research has directly compared the two techniques used in VPS surgery. The present meta-analysis aims to provide the first comprehensive review of all published observational studies and randomized controlled trials reporting outcomes of laparotomy and laparoscopy in VPS. Electronic searches were performed using six databases from their inception to February 2015. Relevant studies comparing conventional laparotomy and a laparoscopic video-guided approach in VPS were included. Data were extracted and analyzed according to predefined clinical endpoints. A total of ten studies were identified for inclusion in the present analysis. Results indicated that the laparoscopic technique was associated with a slight but significant reduction in operating time (∼ 10 min), a significantly lower rate of abdominal malposition, distal obstruction and distal shunt failure. There was no difference between the laparotomic and laparoscopic approaches in the length of hospital stay, complication rate, proximal shunt failure or infection rate. The present systematic review and meta-analysis demonstrated that the laparoscopic technique in VPS surgery is associated with reduced shunt failure and abdominal malposition compared to the open laparotomy technique, with no significant difference in rates of infection or other complications. The lack of studies with high levels of evidence may contribute to bias in our conclusions and the long-term relative merits require validation by further prospective, randomized studies.

Durable thrombosis in a rat model of arteriovenous malformation treated with radiosurgery and vascular targeting

OBJECT Radiosurgical treatment of brain arteriovenous malformations (AVMs) has the significant shortcomings of being limited to lesions smaller than 3 cm in diameter and of a latency-to-cure time of up to 3 years. A possible method of overcoming these limitations is stimulation of thrombosis by using vascular targeting. Using an animal model of AVM, the authors examined the durability of the thrombosis induced by the vascular-targeting agents lipopolysaccharide and soluble tissue factor conjugate (LPS/sTF). METHODS Stereotactic radiosurgery or sham radiation was administered to 32 male Sprague-Dawley rats serving as an animal model of AVM; 24 hours after this intervention, the rats received an intravenous injection of LPS/sTF or normal saline. The animals were killed at 1, 7, 30, or 90 days after treatment. Immediately beforehand, angiography was performed, and model AVM tissue was harvested for histological analysis to assess rates of vessel thrombosis. RESULTS Among rats that received radiosurgery and LPS/sTF, induced thrombosis occurred in 58% of small AVM vessels; among those that received radiosurgery and saline, thrombosis occurred in 12% of small AVM vessels (diameter < 200 μm); and among those that received LPS/sTF but no radiosurgery, thrombosis occurred at an intermediate rate of 43%. No systemic toxicity or intravascular thrombosis remote from the target region was detected in any of the animals. CONCLUSIONS Vascular targeting can increase intravascular thrombosis after radiosurgery, and the vessel occlusion is durable. Further work is needed to refine this approach to AVM treatment, which shows promise as a way to overcome the limitations of radiosurgery.

DISC (Degenerate-disc Infection Study With Contaminant Control): Pilot Study of Australian Cohort of Patients Without the Contaminant Control.

Study Design. Prospective cohort study. Objective. To evaluate if degenerative disc–related back or neck pain and/or radicular symptoms are caused by infection with low virulent bacterial organisms. Summary of Background Data. The potential relationship between disc infection and disc degeneration–related symptoms remains controversial, with contradictory evidence available in the literature. Several studies have demonstrated the presence of infected extruded nucleus tissue from first-time disc herniation, implicating the role of disc microbial infection in disc degeneration. The current study is a pilot study evaluating if high infection rates are prevalent in the Australian degenerate disc cohort. Methods. Institutional ethics approval was obtained (HREC 13/218). The pilot project was a single spine center prospective cohort of patients undergoing spine surgery for degenerate disc disease. In each case, disc material was obtained and prolonged aerobic and anaerobic cultures performed as per methods used by Stirling et al. Results. To date, a total of 168 patients have been enrolled, with male: female = 1:1. Surgical caseload includes 17.9% anterior cervical fusion, 35.0% anterior lumbar fusion, 40.7% lumbar discectomy, and 5.7% posterior lumbar fusions; 34.1% patients presented with neck pain, 31.6% with arm pain, 59.3% with leg pain, and 64.2% with back pain, and 20.2% of the patients received transforaminal or epidural or facet joint injections prior to surgery. In this pilot study, 19.6% were culture positive, with P. acnes predominant in 50%. Disc-only cultures were positive in 27.8% of lumbar cases and 18.5% of cervical cases, with predominant organisms being P. acnes. Conclusion. Similar to the infection rates from previous studies, this Australian cohort had 19.6% infection rates when disc-only cultures are performed. P. acnes is the predominant organism followed by Streptococcus sp. It is imperative to perform contaminant controls as such high infection with skin bugs is a significant finding. Level of Evidence: 4

Successful endovascular and surgical treatment of spinal extradural metameric arteriovenous malformation. Case report.

A report of successful combined endovascular and surgical management of an unusual case of metameric (juvenile) spinal arteriovenous malformation (AVM) is presented. The malformation had extradural and paraspinal components, but no intradural elements. It had caused rapid neurological deterioration to near-complete paraplegia prior to treatment (American Spinal Injury Association [ASIA] Grade C). A combination of endovascular occlusion of major feeding vessels and excision of the malformation resulted in a complete neurological recovery (ASIA Grade E). The authors conclude that selected metameric AVMs can be successfully treated with multimodal therapy. This case further illustrates the fact that not all spinal vascular malformations are easily categorized.

How immunotherapies are targeting the glioblastoma immune environment

The diagnosis of glioblastoma remains one of the most dismal in medical practice, with current standard care only providing a median survival of 14.6 months. The need for new therapies is desperately clear. Components of the tumour microenvironment are demonstrating growing importance in the field, given they allow the tumour to utilise pathways involved in autoimmune prevention, something that enables the tumours establishment and growth. As with many different cancers, the search for a new standard has progressed to the design of immunotherapies, which aim to counteract the immune changes within this microenvironment. Serotherapy, adoptive lymphocyte transfer, peptide and dendritic cell vaccines and a range of other methods are currently under investigation, while intracranial infection has also been researched for its capacity to reverse glioblastoma mediated immunosuppression. Some of these new therapies have shown promise, but it is a long road ahead before their incorporation into glioblastoma standard therapy.

Standalone Anterior Lumbar Interbody Fusion for Spondylolisthesis

Introduction Debate continues over the optimal approach for fusion of isthmic and degenerative spondylolisthesis. We favor anterior lumbar interbody fusion (ALIF) as it permits liberal discectomy and placement of a large, lordotic device which restores disc height and sagittal balance, reduces listhesis, and indirectly decompresses exiting nerve roots. There are only a few articles in the literature looking at the degree of reduction and the durability over time in patients undergoing ALIF with spondylolisthesis. Material and Methods We studied the initial degree of reduction achieved, and the durability of this reduction over time when ALIF was used for patients with isthmic and degenerative spondylolisthesis. Analysis of prospectively collected radiographic data was conducted. All patients with lumbar spondylolisthesis who underwent standalone ALIF between 2009 and 2013 by a single surgeon (R. J. M.) were included. Radiological analysis of slip percentage and disc height on preoperative, postoperative, and latest follow-up imaging was performed with Surgimap Spine software. Demographic factors, surgical data and radiological results were compared. Results Average patient age was 64.5 years (range, 37–84) with 16 females, 15 males. There were 36 levels treated with 20 at L4/5, 15 at L5/S1, and one at L3/4. Mean listhesis was 16% which immediately postoperatively reduced to 2.3%, but at latest follow-up had recurred to 58% of the original value. An average disc height increase of 184% was observed postoperatively. Analysis of these measurements showed a high degree of inter- and intraclass correlation. Mean follow-up was 17 months. BMI correlated with immediate postoperative reduction (p = 0.004), as did posterior disc height (p = 0.04). The overall radiological fusion rate was 91%. Three patients required subsequent posterior instrumentation, which will be discussed. Conclusion ALIF achieves disc height restoration and indirect listhesis reduction in isthmic and degenerative spondylolisthesis. Although this reduction may regress over time, we found it remained reduced by approximately 50% at latest follow-up. Around 10% of patients required further strengthening by posterior pedicle screw fixation. Standalone ALIF without posterior pedicle screw fixation is successful in the majority of patients with spondylolisthesis.