Samer Ghostine

Radiation therapy in the treatment of pituitary tumors

The treatment of pituitary tumors has progressed into a multidisciplinary approach that involves neurosurgeons, radiation oncologists, and endocrinologists. This has allowed improved outcomes in treatment of pituitary tumors due to a combination of surgical, medical, and radiation therapies. In this study, the authors review the role of radiation therapy in the treatment of pituitary adenomas.

Cervicothoracic junction kyphosis: surgical reconstruction with pedicle subtraction osteotomy and Smith-Petersen osteotomy. Presented at the 2009 Joint Spine Section Meeting. Clinical article.

OBJECT Sagittal plane deformities can be subdivided into kyphotic and lordotic forms and further characterized according to their global or regional (focal) presentation. Regional deformities of a significant magnitude constitute a gibbous deformity. Pedicle subtraction osteotomy (PSO) and interlaminar Smith-Petersen osteotomies have been used to correct sagittal plane deformities in the cervical, thoracic, and lumbar spine. By resecting a portion of the vertebral body and closing in the gap of this vertebra, the spine is placed in local lordosis and kyphosis is corrected. These osteotomies have generally been carried out in the lumbar or less frequently in the thoracic area. While PSO has been performed in the mid and lower thoracic spine, there have been no case series of patients undergoing PSO at the CTJ. Specifically, a PSO approach that addresses the challenges of the CTJ is needed. Here, the authors review their case series of PSOs performed in the CTJ. Their goal in the treatment of these patients was to correct the regional CTJ kyphosis, restore forward gaze, and reduce the pain associated with the deformity. METHODS Eight patients (5 males and 3 females, mean age 63 years) underwent PSO for the correction of CTJ kyphosis. Pedicle subtraction osteotomy was performed at C-7 or the upper thoracic vertebrae and was facilitated by a computer-guided intraoperative monitoring system. Surgical indications included postlaminectomy kyphosis, spinal cord tumor resection, posttraumatic kyphosis, and degenerative cervical spondylosis. RESULTS The mean follow-up was 15.3 months (range 12-20 months), and the mean preoperative CTJ kyphosis was 38.67° (range 25°-60°). Clinically satisfactory correction of the regional deformity was accomplished in all patients, achieving a mean correction of 35.63° (range 15°-66°) at the CTJ, with restoration of forward gaze and significant reduction in pain. CONCLUSIONS A CTJ deformity is a distinctive form of kyphosis that presents as a variable local deformity and requires complex spinal reconstructive techniques to restore sagittal balance and forward gaze. Pedicle subtraction osteotomy allows for significant correction through one spinal segment, and it can be used safely to correct the regional sagittal alignment of the cervical spine and head in relation to the pelvis. Pedicle subtraction osteotomy can be used alone or in combination with other techniques as some patients may require multistage procedures with anterior and posterior spinal reconstruction to obtain stable sagittal correction. All deformities in these patients were kyphotic in nature with only mild elements of scoliosis or coronal plane deformity. This is unlike lumbar and thoracic curves where the kyphosis is frequently associated with scoliosis.

Controlled lumbar drainage in medically refractory increased intracranial pressure. A safe and effective treatment

BACKGROUND A prospective study of lumbar CSF drainage in the setting of raised intra-cranial pressure refractory to medical management and ventriculostomy placement is presented. There have been no controlled trials of its use reported in the literature, to the best of our knowledge. METHOD An IRB approved prospective study was conducted. 8 patients with increased intracranial pressure secondary to traumatic brain injury or aneurysm rupture were initially managed with sedation, ventriculostomy placement, mild hyperventilation (pCO2 = 30-35), and hyperosmolar therapy (Na = 150-155). A lumbar drain was placed if ICP continued to be above 20 mmHg despite optimization of medical therapy. FINDINGS After lumbar drain placement, ICP was reduced from a mean of 27 +/- 7.8 to 9 +/- 6.3, an average decrease of 18 mm H2O (p < 0.05). Requirements for hypertonic saline and/or mannitol boluses and sedation to control ICP were also decreased. There were no complications noted. CONCLUSIONS We have shown that controlled lumbar drainage is a safe, efficacious and minimally invasive method for treatment of elevated ICP refractory to medical management. Ventriculostomies are always placed before utilizing lumbar drains to minimize the risk of cerebral herniation. We would advocate making controlled lumbar drainage a standard part of ICP control protocols.

Thoracic cord herniation through a dural defect: description of a case and review of the literature

BACKGROUND Spinal cord herniation through a dural defect is a cause of myelopathy and BSS that may be underdiagnosed. It may occur spontaneously, after trauma, or after surgery. CASE DESCRIPTION We present the case of a 47-year-old woman who presented with low back pain, progressive myelopathy, right proximal LEW, several episodes of falling, sensory changes below the lower part of the chest wall, and pathologic reflexes. Magnetic resonance imaging of the thoracic spine showed kinking of the spinal cord anteriorly at the level of T6-7. Posterior laminoplasty and intradural exploration revealed an anteriorly displaced spinal cord that was herniating through a ventral dural fold. The defect was repaired, and the spinal cord abnormality was reduced. Postoperatively, the patients strength, gait, and sensation improved immediately. CONCLUSIONS We discuss the successful surgical treatment of a thoracic spinal cord tethering from herniation through a ventral dural defect and review the literature regarding the proposed pathogenesis, surgical repair options, and reported outcomes.

Image-guided thoracoscopic resection of thoracic dumbbell nerve sheath tumors.

BACKGROUND: Surgical removal of dumbbell nerve sheath tumors (NSTs) remains challenging because these neoplasms occupy ≥ 2 spinal and extraspinal spaces. The presence of intraspinal extension, tumor dimension, and/or its location within the thoracic cavity have previously made the resection of these types of neoplasms difficult. OBJECTIVE: To describe the feasibility of performing minimally invasive thoracoscopic surgery, as facilitated by an image guidance system (IGS), to achieve gross total resection of select dumbbell NSTs located in the thoracic spine. METHODS: The 3 cases presented here contained small intraspinal or foraminal components. Preoperative symptoms included Horner syndrome and back and chest wall pain. We used IGS to help guide the complete thoracoscopic resection of select dumbbell NSTs, consisting of extradural, intraforaminal, and paravertebral tumor components, which previously would have been challenging with only a thoracoscopic approach. RESULTS: IGS provided continuous intraoperative anatomic orientation to achieve gross total resection in all 3 cases. All surgical and postsurgical outcomes were satisfactory; preoperative symptoms improved or resolved; and no adverse events were observed. CONCLUSION: Thoracic dumbbell NSTs that have small intraspinal or foraminal components could be resected thoracoscopically when facilitated by IGS. Image-guided thoracoscopic resection of such dumbbell tumors may not only improve the precision of resection, reduce recurrence, and avoid the need for spinal reconstruction but also obviate the need for more invasive or simultaneous posterior procedures. The IGS enhances the accuracy and safety of 2-dimensional thoracoscopic surgery and may reduce its learning curve.

A Case for Further Investigating the Use of Controlled Lumbar Cerebrospinal Fluid Drainage for the Control of Intracranial Pressure

OBJECTIVE Increased intracranial pressure (ICP) that is refractory to medical measures and ventriculostomy placement after severe traumatic brain injury or aneurysmal rupture is associated with high mortality. In some recent reports, authors have described the use of lumbar cerebrospinal fluid drainage in these patients. We report the results of a prospective study involving the use of lumbar drainage in 15 patients with elevated ICP that was refractory to medical management and ventriculostomy placement. METHODS A prospective study was designed to enroll patients at Loma Linda University Medical Center. Ten patients with traumatic brain injury and five patients with ruptured aneurysms were enrolled. Medical management included maintaining serum Na >150 mEq/L, mild hyperventilation, deep sedation, and maintenance of normothermia. A lumbar drain was placed when ICP was >20 mm Hg for an average of 3 hours despite the optimization of the aforementioned parameters. RESULTS After lumbar drain placement, ICP was reduced from a mean of 28.2 ± 6.5 mm Hg to 10.1 ± 7.1 mm Hg (P <0.001). Requirements for hyperosmolar therapy, sedatives, and paralytics were also significantly decreased (P < 0.05) after lumbar drain placement. One patient had unilateral papillary changes four hours after lumbar drain placement. The pupil returned to its normal state after decompressive craniectomy. There was no incidence of CSF infection. Three of the 15 patients died during the study period. CONCLUSIONS This study shows the beneficial role of lumbar cerebrospinal fluid drainage as an effective and safe treatment modality for elevated ICP.

Role of Controlled Lumbar CSF Drainage for ICP Control in Aneurysmal SAH

BACKGROUND a prospective study of lumbar CSF drainage in the setting of raised intra-cranial pressure refractory to medical management and ventriculostomy placement is presented. There has been increasing data that this may be a effective and safe intervention for reduction of ICP. METHOD an IRB approved prospective study was conducted. Six patients with increased intracranial pressure secondary to aneurysm rupture were initially managed with sedation, ventriculostomy placement, mild hyperventilation (pCO(2) = 30-35), and hyperosmolar therapy (Na = 150-155). A lumbar drain was placed if ICP continued to be above 20 mmHg despite optimization of medical therapy. FINDINGS after lumbar drain placement, ICP was reduced from 30.2 mmHg ± 6.7 to 9.7 mmHg ± 7.4, an average decrease of 20.5 mm H(2)O (P < 0.001). There was no significant change in CPP. Requirements for hypertonic saline and/or mannitol boluses and sedation to control ICP were decreased. There was no incidence of CSF infection or cerebral herniation. CONCLUSIONS we have shown that controlled lumbar drainage is a safe, efficacious and minimally invasive method for treatment of elevated ICP which refractory to medical management. Ventriculostomies are always placed before utilizing lumbar drains to minimize the risk of cerebral herniation. We would advocate making controlled lumbar drainage a standard part of ICP control protocols.

The rare case of an intramedullary cervical spinal cord teratoma in an elderly adult: case report and literature review.

Study Design. Case report and literature review. Objectives. To report the very rare case of a mature intramedullary teratoma with exophytic extension localized to the uppermost cervical spinal level in a 65-year-old woman and review the pertinent medical literature. Summary of Background Data. Cervical intramedullary teratomas are extremely rare in adults, especially in patients older than 50 years. Methods. The patient presented with progressive ataxia, mild bilateral kinetic hand tremors, and dizziness. Magnetic resonance imaging revealed an intramedullary 1.7 × 1.3 × 2.3 cm mass at C1 with exophytic extension. A C1–C2 laminectomy and a partial suboccipital craniotomy were performed, followed by a subtotal microscopic resection of the tumor. Pathology was consistent with a mature teratoma. Results. After surgery, the patients ataxia, tremor, and dizziness resolved almost immediately. Conclusion. This report presents the very rare case of a mature intramedullary teratoma located in the upper cervical spine of an elderly patient, possibly the oldest patient documented with this type of lesion. The authors recommend a conservative subtotal surgical resection of cervical intramedullary tumors because it may improve symptoms that relate to direct mechanical cord compression and avoid further harm from a gross resection.

Gliomatosis cerebri mimicking Rasmussen encephalitis. Case report.

Gliomatosis cerebri (GC) is a distinct malignant neuroepithelial neoplasm that is rarely found in children. The authors present the case of an 11-year-old girl in whom the initial presentation suggested possible early Rasmussen encephalitis (RE), but in whom a diagnosis of GC was made instead after examination of a brain biopsy specimen. Despite advances in magnetic resonance (MR) imaging and MR spectroscopy, this case shows the limitations of clinical and neuroimaging diagnosis and the essential role of biopsy procedures when early RE is suspected.

Identifying optimal treatment of common and complex sciatica pain

Received: June 05, 2017; Accepted: June 22, 2017; Published: June 23, 2017 Sciatica is one of the most common disorders affecting the peripheral nervous system, 90% of which is associated with a herniated disc and nerve compression. Vast majority of sciatica patients experience a favorable prognosis, with only ~30% experiencing a reoccurrence within their lifetime. Patients often present with unilateral lower extremity pain in the distribution of the L5 or S1 dermatome, originating from acute or chronic descent. Sciatica is traditionally diagnosed within patients presenting with primary complaints of unrelenting sharp pain, which travels profusely down the leg. Cases of mild to moderate sciatica are witnessed but at a much rarer occurrence, with patients presenting with mild to moderate pain and paresthesias [1-10]. Ordinary patients may present with or without neurological deficits such as numbness and weakness of the leg and/ or foot, in more severe cases patients may present with foot weakness causing difficulty and/or inability to ambulate. The etiology for sciatica is quite commonly a lumbar disc herniation, as briefly mentioned, that puts pressure upon the descending S1 nerve root. Magnetic resonance imaging (MRI) is typically utilized to obtain high resolution images leading to the diagnosis by which a physician identifies the offending agent compressing the nerve root. Given how commonly this pathology presents to primary care physicians and neurosurgeons, it is of no surprise that lumbar microdiscectomy remains as one of the most popular surgical procedures performed within the United States. Patients presenting with sciatica endure copious amounts of pain during most forms of physical activity, thus leading to their inability to work for extended periods of time. Utilization of healthcare resources and inability to work both integrate to cause significant depletion in healthcare resources while increasing treatment-costs and unemployment-subsidies all of which adversely affect the United States economic status [1-6].