Vivek Joseph

Heterotopic bone formation with the use of rhBMP2 in posterior minimal access interbody fusion: a CT analysis.

Study Design. Observational study with prospective CT analysis. Objective. To assess the incidence and clinical sequelae of epidural bone formation following the adjunctive use of recombinant bone morphogenetic protein 2 (rhBMP2) with local autogenous bone graft use of (rhBMP2) in minimal access interbody (PLIF and TLIF) fusions. Summary of Background Data. The use of rhBMP2 for interbody fusion is associated with high fusion rates. However, for posterior approaches, concerns regarding heterotopic bone formation within the epidural space have been raised. Methods. An independent CT analysis of 33 consecutive patients following minimal access lumbar fusion (PLIF [n = 10] or TLIF [n = 23]) with [n = 23] and without [n = 10] rhBMP2 was performed. Bone formation was graded in a centrifugal manner (intradiscal, anular/ALL/PLL, epidural [canal/foramen] and beyond the spine). In all BMP cases, a constant dose of 4.2 mg/disc level was administered (lowest commercially available dose). In all cases, local autograft was used. Review and assessment of prospectively collected outcomes data were performed. Results. Average clinical and CT (minimum 6 months) follow-up was 25.0 and 7.9 months, respectively. Bridging bone (fusion) was seen in 100% of the BMP group and 90% without BMP. Epidural bone formation occurred in 20.8% with the use of BMP (5 levels: n = 1 spinal canal and n = 4 within the foramen) compared with 8.3% (1 level: canal) without BMP. Foraminal bone formation was seen only in the TLIF group. All epidural bone formation was heterotopic, and no ectopic bone formation occurred. There were no clinical sequelae associated with heterotopic bone formation. The mean preoperative and postoperative Oswestry Disability Index was 50.2% (range, 25%–75%) and 11.3% (range, 0%–38%) respectively. Conclusion. Although the adjunctive use of rhBMP2 is associated with a higher incidence of heterotopic bone, there does not seem to be any associated clinical sequelae.

Cerebrospinal fluid leak during cervical corpectomy for ossified posterior longitudinal ligament: incidence, management, and outcome.

Study Design. Retrospective. Objective. To study the incidence of intraoperative cerebrospinal fluid (CSF) leak in patients with ossified posterior longitudinal ligament (OPLL) undergoing central cervical corpectomy (CC) and to describe a reliable technique for treating the leak after CC. Summary of Background Data. The rate of dural tear after CC is higher in patients with OPLL compared to other causes of cervical spinal stenosis. Various techniques have been described to deal with dural tears with CSF leak in OPLL. We assessed the efficacy of the repair technique used to deal with this complication in our patients with OPLL who had undergone CC. Methods. A retrospective study was performed of all patients diagnosed with OPLL (n = 144) who had undergone CC between July 1992 and June 2007 (15 years). The dural defect was repaired with an onlay graft of crushed muscle/fascia and a layer of gelatin sponge. Bed rest and a lumbar subarachnoid drain were used for 5 days after surgery. Results. Intraoperative CSF leak was noted in 9 patients (6.3%). The dural defects ranged in size from a few mm to about 15 mm (10–75 mm2). All patients had a successful repair with no patient requiring reoperation for the CSF leak. Conclusion. Intraoperative CSF leak was encountered in 6.3% of patients undergoing CC for OPLL. A successful repair was achieved using fascial graft, gelatin sponge, lumbar CSF drainage, and bed rest.

Supratentorial extra-axial anaplastic ependymoma mimicking a meningioma

A 35-year-old male presented with a four-month history of multiple episodes of right upper limb partial motor seizures and a single secondary generalized seizure. Examination revealed no neurological deficits. Magnetic resonance imaging (MRI) brain showed a well-defined, enhancing, 1.8 × 1.4 × 1.5 cm mass in the middle third of the falx on the left side [Figure 1]. The tumor was adjacent to the motor cortex. Considering the preoperative diagnosis of a meningioma, small size of the tumor and its proximity to the motor cortex, the option of stereotactic radiosurgery was strongly suggested to the patient. He however, opted to undergo surgery, in spite of being aware of the risk of lower limb weakness. The tumor was approached using a left parietal craniotomy. At surgery, the tumor was found to be free from the falx. It had a

Cervical intramedullary schwannoma mimicking a glioma

We present a case of a cervical intramedullary schwannoma (IS), which resembled a glioma on radiology. Somatic and root pain, the most common presenting complaints of IS, were lacking in our patient, and the characteristic magnetic resonance finding of an enhancing thickened nerve root in IS, was absent in our case. Preoperative diagnosis of a cervical IS is not always possible. Complete tumor resection is the ideal treatment for IS. Intraoperative frozen section can be a useful for decision making though the tumor-cord plane will ultimately decide if the tumor can be radically excised.

Temporal progression and spatial distribution of "normal" prevertebral soft tissue swelling following central corpectomy for cervical spondylotic myelopathy

OBJECTIVE To document the temporal progression and spatial distribution of prevertebral soft tissue swelling (PSTS) after central corpectomy (CC) and to determine the variables affecting its severity. BACKGROUND The natural attributes of PSTS following CC for cervical spondylotic myelopathy (CSM) have not been characterized in literature. MATERIALS AND METHODS PSTS was measured at the C2 level and midpoint of the operated segment on lateral radiographs of the cervical spine taken pre-operatively and post-operatively (day 0, day 3/4, day 5 and day 6/7) in 93 patients with CSM undergoing one to three level uninstrumented CC. Patients age, weight, Nuricks grade, number of corpectomy levels and intubation time were correlated with the PSTS. RESULTS Proportionately, the swelling was maximal at the C2 level rather than at the level of CC, on all days, irrespective of the level of surgery. At the C2 level, the increase in PSTS was maximum by day 3/4 (P = 0.0001), whereas at the CC level, the PSTS continued to increase till day 5 (P = 0.0001). PSTS was higher in patients undergoing a three-level CC and in those with inclusion of C4 in the CC (P = 0.002). CONCLUSION Patients undergoing CC are at risk for upper airway obstruction mainly at the C2 level in the first 3 days after surgery due to the PSTS. Those undergoing three-level CC, or having inclusion of C4 in the CC, have a greater degree of PSTS and have a higher risk of post-operative airway obstruction.