Subhas Konar

Association of risk factors with unfavorable outcomes after resection of adult benign intradural spine tumors and the effect of hospital volume on outcomes: an analysis of 18, 297 patients across 774 US hospitals using the National Inpatient Sample (2002−2011)

OBJECT Because of the limited data available regarding the associations between risk factors and the effect of hospital case volume on outcomes after resection of intradural spine tumors, the authors attempted to identify these associations by using a large population-based database. METHODS Using the National Inpatient Sample database, the authors performed a retrospective cohort study that involved patients who underwent surgery for an intradural spinal tumor between 2002 and 2011. Using national estimates, they identified associations of patient demographics, medical comorbidities, and hospital characteristics with inpatient postoperative outcomes. In addition, the effect of hospital volume on unfavorable outcomes was investigated. Hospitals that performed fewer than 14 resections in adult patients with an intradural spine tumor between 2002 and 2011 were labeled as low-volume centers, whereas those that performed 14 or more operations in that period were classified as high-volume centers (HVCs). These cutoffs were based on the median number of resections performed by hospitals registered in the National Inpatient Sample during the study period. RESULTS Overall, 18,297 patients across 774 hospitals in the United States underwent surgery for an intradural spine tumor. The mean age of the cohort was 56.53 ± 16.28 years, and 63% were female. The inpatient postoperative risks included mortality (0.3%), discharge to rehabilitation (28.8%), prolonged length of stay (> 75th percentile) (20.0%), high-end hospital charges (> 75th percentile) (24.9%), wound complications (1.2%), cardiac complications (0.6%), deep vein thrombosis (1.4%), pulmonary embolism (2.1%), and neurological complications, including durai tears (2.4%). Undergoing surgery at an HVC was significantly associated with a decreased chance of inpatient mortality (OR 0.39; 95% CI 0.16-0.98), unfavorable discharge (OR 0.86; 95% CI 0.76-0.98), prolonged length of stay (OR 0.69; 95% CI 0.62-0.77), high-end hospital charges (OR 0.67; 95% CI 0.60-0.74), neurological complications (OR 0.34; 95% CI 0.26-0.44), deep vein thrombosis (OR 0.65; 95% CI 0.45-0.94), wound complications (OR 0.59; 95% CI 0.41-0.86), and gastrointestinal complications (OR 0.65; 95% CI 0.46-0.92). CONCLUSIONS The results of this study provide individualized estimates of the risks of postoperative complications based on patient demographics and comorbidities and hospital characteristics and shows a decreased risk for most unfavorable outcomes for those who underwent surgery at an HVC. These findings could be used as a tool for risk stratification, directing presurgical evaluation, assisting with surgical decision making, and strengthening referral systems for complex cases.

Role of apolipoprotein E polymorphism as a prognostic marker in traumatic brain injury and neurodegenerative disease: a critical review.

OBJECT The difference in course and outcome of several neurodegenerative conditions and traumatic injuries of the nervous system points toward a possible role of genetic and environmental factors as prognostic markers. Apolipoprotein E (Apo-E), a key player in lipid metabolism, is recognized as one of the most powerful genetic risk factors for dementia and other neurodegenerative diseases. In this article, the current understanding of APOE polymorphism in various neurological disorders is discussed. METHODS The English literature was searched for various studies describing the role of APOE polymorphism as a prognostic marker in neurodegenerative diseases and traumatic brain injury. The wide ethnic distribution of APOE polymorphism was discussed, and the recent meta-analyses of role of APOE polymorphism in multiple diseases were analyzed and summarized in tabular form. RESULTS Results from the review of literature revealed that the distribution of APOE is varied in different ethnic populations. APOE polymorphism plays a significant role in pathogenesis of neurodegeneration, particularly in Alzheimers disease. APOE ε4 is considered a marker for poor prognosis in various diseases, but APOE ε2 rather than APOE ε4 has been associated with cerebral amyloid angiopathy-related bleeding and sporadic Parkinsons disease. The role of APOE polymorphism in various neurological diseases has not been conclusively elucidated. CONCLUSIONS Apo-E is a biomarker for various neurological and systemic diseases. Therefore, while analyzing the role of APOE polymorphism in neurological diseases, the interpretation should be done after adjusting all the confounding factors. A continuous quest to look for associations with various neurological diseases and wide knowledge of available literature are required to improve the understanding of the role of APOE polymorphism in these conditions and identify potential therapeutic targets.

Neuromodulation in intractable pain management: outcomes and predictors of revisions of spinal cord stimulators.

OBJECTIVE Spinal cord stimulators (SCSs) appear to be safe and efficacious for chronic intractable back pain. Although there are many reports on percutaneous SCSs, there are very few studies on outcomes of paddle lead SCSs. In addition, the predictors of requirement for SCS revision have not been well established. Here, the authors review the outcome of a case series and attempt to identify the predictors of SCS revisions. METHODS The clinical and radiological information of 141 patients with intractable chronic pain who underwent SCS implantation within the past 20 years was retrospectively reviewed. Paddle lead SCSs were used in this series. Statistical analysis was conducted using Kaplan-Meier curves and Cox proportional-hazards regression. RESULTS Among 141 cases, 90 (64%) did not require any revision after SCS implantations. Removal of the SCS was required in 14 patients. The average pain score was significantly reduced (preimplantation score of 8 vs postimplantation score of 1.38; p < 0.0001). Younger age, male sex, obesity, a preimplantation pain score ≥ 8, and the presence of neuromuscular pain were identified as predictors of the overall requirement for SCS revision. However, only a preimplantation pain score ≥ 8 was identified as a predictor of early failure of the SCS. CONCLUSIONS Implantation of a paddle lead SCS is a relatively less invasive, safe, and effective procedure for patients with intractable back pain. Revision of the procedure depends on many factors, including younger age, male sex, associated neuromuscular pain, and severity of the pain. Therefore, patients with these factors, for whom implantation of an SCS is planned, should be closely followed for the possible requirement for revision.

Solitary juvenile xanthogranuloma in cervical spine: case report and review of the literature.

Solitary juvenile xanthogranuloma (JXG) in the spinal column is extremely rare. Here, we report and characterize the case of xanthogranuloma of the upper cervical spine. A 18-year-old male presented with neck pain for 3 months, along with progressive quadriparesis and sensory loss of 2 months duration with urinary retention. Motor examination revealed spastic quadriparesis with power of 2/5 in all the 4 limbs. Magnetic Resonance Imaging (MRI) spine with contrast showed a dorsally placed intradural extramedullary lesion at the level of C2-C4 vertebral body. The lesion, measuring 2.9x1.7x1.4 cm, was isointense on T1WI, hypointense on T2WI, and enhanced homogenously on contrast. He underwent an emergency C2-C4 laminectomy and complete excision of the lesion. At 3-month follow-up, he was asymptomatic except for mild neck pain. MRI scan of the cervical spine done at follow-up, revealed complete excision of tumor without any residual lesion. Histopathological examination of the mass revealed a polymorphous population of sheets of bloated pale foamy histiocytes (xanthoma cells), numerous admixed mature lymphocytes and several Touton giant cells. The cells were positive for CD68, a histiocytic marker, and negative for CD1a (excludes LCH) and S-100 (excludes RDD).

A pure non-gestational ovarian choriocarcinoma with delayed solitary brain metastases: Case report and review of the literature

Choriocarcinoma is the most malignant tumour of gestational trophoblastic origin. Most ovarian choriocarcinomas are gestational in origin and usually metastasize to the ovary from uterine or tubal choriocarcinoma. Non gestational choriocarcinoma (NGOC) of the ovary is exceedingly rare and usually seen along with other germ cell tumors. Non gestational choriocarcinoma has been found to be resistant to single-agent chemotherapy and has a worse prognosis than gestational choriocarcinoma. We are reporting long term follow up of published rare case of pure non gestational ovarian choriocarcinoma (NGOC) with concurrent metastases to the spleen and adrenal glands, who developed a delayed solitary brain metastases, two years after completion of primary treatment. Surgery along with triple agent chemotherapy and radiotherapy was found to give good remission in this aggressive disease.

Tuberculous lumbar arachnoiditis mimicking conus cauda tumor: A case report and review of literature

Tuberculous spinal arachnoiditis involving cauda equina is rare. A patient with lumbar tuberculous arachnoiditis in the absence of both vertebral and meningeal tuberculosis, which was mimicking spinal intradural extramedullary tumor is described here. Diagnosis was made based on intraoperative findings and was confirmed by histopathology. Surgical decompression along with a combination of steroid and antitubercular therapy resulted in a good outcome. At 3 months follow-up, the patient regained bladder control and was able to walk with support. Clinical features, magnetic resonance imaging, and intraoperative findings are described. Pathology and the relevant literature are discussed. Based on the patients clinical and radiologic findings, it was believed that the patient had a conus cauda tumor and was operated on. Histologic examination of the mass revealed tuberculoma. Surgical decompression followed by antituberculosis medication resulted in good outcome. Hence tuberculous arachnoiditis should be considered in differential diagnosis of conus cauda tumors.

Isadore Max Tarlov (1905–1977) and the controversial Tarlov cyst: historical perspective

Isadore Max Tarlov, an early neurosurgeon, made several important contributions to the field of spine surgery. He described sacral perineural cysts, now known as Tarlov cysts. Dr. Tarlov also introduced the knee-chest patient position to facilitate exposure and hemostasis in lumbar surgery. In addition, he developed the use of fibrin glue in nerve repair. His book on mechanisms of spinal compression was published in 1957. He published a book of essays titled Principles of Parsimony in Medical Practice that remains highly relevant in todays medical world.

Arteriovenous malformation associated with cyst in a child: Case report and review of literature

Cysts associated with arteriovenous malformations (AVMs) are either secondary to hemorrhage or after radiosurgery. Untreated and unruptured AVMs with large cysts are rare. We here describe a child with medial parietal AVM associated with cyst, without any history of hemorrhage or radiosurgery. Surgical excision led to cure for the patient.

Clival tumor presenting with acromegaly.

Sir, A 51‐years‐old lady presented with coarsening of facial features and amenorrhea since 20 years. She presented with voice change and visual blurring of three months duration. She had features of acromegaly. Examination of ocular fundi showed bilateral optic atrophy and visual acuity was 4/60 in right eye and 6/36 in left eye. Serum growth hormone (GH) was 96 ng/ml and other hormonal profile was normal. Magnetic resonance imaging (MRI) of brain showed a tumor in clivus, sphenoid and left ethmoid sinuses with extension into cavernous sinus till orbital apex, and sella. The tumor was isointense on T1‐weighted and T2‐weighted images with some areas of blooming on gradient sequences. Pituitary gland was not seen separately [Figure 1]. As she had clinical features of acromegaly for 20 years without visual dysfunction, we presume that the tumor origin was primarily in clivus and then invaded all around. She underwent microscopic transnasal‐transsphenoidal decompression of tumor. The tumor could not be removed totally because of multi‐compartmental extension. Serum GH level fell to 48 ng/ml in immediate post‐operative period. Histology and immunohistochemistry of the excised lesion revealed GH secreting pituitary adenoma [Figure 2]. Except for CSF rhinorrhea, which was managed with lumbar drain, her post‐operative period was uneventful and she was sent for radiotherapy for residual tumor.

Posterior interhemispheric approach and microsurgical resection of a pineal parenchymal neoplasm of intermediate differentiation

Owing to a deep-seated location and intricate venous anatomy, pathologies of the posterior third ventricular region pose formidable challenges to the operating neurosurgeon. In this video, we present a case of an elderly Caucasian female with a rare histological variant of a pineal parenchymal mass who presented with gait disturbances and worsening retro-orbital headache. Radiological and clinco-histopathological correlates of this rare tumor pathology having intermediate differentiation are highlighted. Briefly outlined are surgical pearls and strategies to minimize complications, as the tumor is approached through the posterior interhemispheric corridor, to achieve a gross-total decompression. The video can be found here: https://youtu.be/KXwclZ7Ei84 .