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ABSTRACT: The authors report the case of a 14-year-old girl with a residual malignant peripheral nerve sheath tumor after thoracotomy, chemotherapy, and radiation therapy. The residual tumor, which involved the intercostal muscles, aorta, and neural foramina of T4-10, was completely resected through a costotransversectomy and multiple hemilaminotomies with the patient in the prone position and was stabilized using a T1-12 pedicle screw fusion. Postoperatively, the patient developed several infections requiring multiple washouts and prolonged antibiotics. Thirty months after surgery, she developed a bronchocutaneous fistula. The hardware was removed, and a vascularized latissimus dorsi free flap was placed over the lung. She continued to have an air leak and presented 3 weeks later with a 40° left thoracic curve. She returned to the operating room for a T2-L2 fusion with a vascularized fibular graft. On postoperative Day 1, she underwent a bronchoscopy and had her left lower lobe airways occluded with multiple novel one-way endobronchial valves. She is now 5 years out from her tumor resection and 3 years out from her definitive fusion. She has no evidence of residual tumor, infection, or pseudarthrosis and continues to remain asymptomatic.
Journal of Neurosurgery Pediatrics 05/2011; 7(5):543-8. · 1.53 Impact Factor
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ABSTRACT: Surgical correction is generally indicated as the primary form of management in children with severe early onset scoliosis. Even so, conservative, nonsurgical treatment is always considered first, as surgical correction carries significant concomitant consequences, including but not limited to crankshaft phenomenon and, more importantly, inhibition of further spine, lung, and chest growth in skeletally immature patients. Fusionless surgical procedures assuage some of these risks, as they are characteristically associated with techniques necessitating spinal fusion. One device looks particularly promising in treating and managing severe early onset scoliosis, the vertical expandable prosthetic titanium rib (VEPTR)-a device that was initially targeted toward children with thoracic insufficiency syndrome (TIS). Despite its promising results in correction of severe early onset scoliosis, as well as associated rib and chest wall deformities, the VEPTR nevertheless has a complication rate comparable to other fusionless techniques. Continued modifications and research will hopefully beget a device that permits thoracic and spinal growth in skeletally immature patients yet with fewer postoperative complications. In this chapter, the authors review the clinical experience with VEPTR to date and present their results in 16 children with congenital scoliosis cared for at Shriners Hospital of Philadelphia.
Surgical technology international 02/2009; 18:223-9.
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ABSTRACT: To review and define principles and features of treatment for adult degenerative scoliosis, the most common cause of adult spinal deformities.
We conducted a comprehensive review of the literature and our clinical experience.
A systematic review of Medline was conducted, including journal articles published in March 2007 and before. We searched for articles related to adult spinal deformities (scoliosis) and treatments.
Degenerative scoliosis is a complex disorder. The primary surgical aims are to decompress the neural elements, normalize both sagittal balance and coronal and rotational deformity, fixate to the sacrum/ilium when appropriate, and optimize conditions for osteogenesis and fusion.
Neurosurgery 09/2008; 63(3 Suppl):94-103. · 2.79 Impact Factor
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ABSTRACT: The purpose of this study is to analyze anterior communicating artery (AComA) aneurysm morphology and its relationship to the limitations and feasibility of endovascular coil embolization.
One hundred twenty-three patients were treated with endovascular coil embolization for AComA aneurysms. Aneurysm morphology was classified into six categories according to the projection of the aneurysm (anterior, posterior/superior, or inferior) and neck size (< 4 mm or >or= 4 mm). The following categories were used: Class A1, anterior projection and neck of aneurysm less than 4 mm; Class A2, anterior projection and neck of aneurysm 4 mm or more; Class B1, posterior (superior) projection and neck of aneurysm less than 4 mm; Class B2, posterior (superior) projection and neck of aneurysm 4 mm or more; Class C1, inferior projection and neck of aneurysm less than 4 mm; and Class C2, inferior projection and neck of aneurysm 4 mm or more. Endovascular procedures were categorized as either successful or unsuccessful according to specific criteria. In addition, patients were followed for recanalization. Clinical follow-up data was obtained at discharge and after 6 months and was classified according to the Glasgow Outcome Scale.
Complete or near complete aneurysm occlusion was observed in 108 (88%) patients, partial embolization was performed in three (2.4%) patients, and embolization was attempted in 12 (9.7%) patients. Successful embolization for AComA aneurysms was performed in 86 out of 123 (70%) patients or 77.5% (86 out of 111 patients) of those patients in whom embolization was possible. Statistical analysis demonstrated that anterior projecting aneurysms were more likely to be successfully coiled than either inferior or posterior/superior directed AComA aneurysms. In addition, inferiorly projecting AComA aneurysms and wide-neck aneurysms had a significantly higher rate of recanalization.
Endovascular coil embolization of AComA aneurysms shows good outcome in our study. Despite advanced modern techniques, there are limitations in the endovascular approach to AComA aneurysms. Consideration of aneurysm morphology may be used to guide approaches in the treatment of AComA aneurysms.
Neurosurgery 08/2006; 59(1):43-52; discussion 43-52. · 2.79 Impact Factor
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ABSTRACT: OBJECTIVE: The purpose of this study is to analyze anterior communicating artery aneurysm (ACoA) morphology and its relationship to the limitations and feasibility of endovascular coil embolization.
METHODS: One-hundred-twenty-three patients were treated with endovascular coil embolization for ACoA. Aneurysm morphology was classified into six categories according to projection of aneurysm (anterior, posterior/superior or inferior) and neck size (less than 4 mm or greater than/equal to 4 mm). The following categories were used, class A1: anterior projection and neck of aneurysm < 4 mm, class A2: anterior projection and neck of aneurysm ≥ 4 mm, class B1: posterior (superior) projection and neck of aneurysm < 4 mm, class B2: posterior (superior) projection and neck of aneurysm ≥ 4 mm, class C1: inferior projection and neck of aneurysm < 4 mm, and class C2: inferior projection and neck of aneurysm ≥ 4 mm. Endovascular procedures were categorized as either successful or unsuccessful according to specific criteria. Additionally, patients were followed for recananlization. Clinical follow-up was obtained at discharge and at 6 months, and was classified according to Glasgow Outcome Scale (GOS).
RESULTS: Complete/near complete aneurysm occlusion was observed in 108 patients (88%); partial embolization was performed in 3 patients (2.4%); and embolization was attempted in 12 patients (9.7%). Successful embolization for ACoA was performed in 86 patients of 123 patients (70%) or 77.5% (86 of 111 patients) of those patients where embolization was possible. Statistical analysis demonstrated that anterior projecting aneurysms were more likely to be successfully coiled than either inferior or posterior/superior directed ACoA. Additionally, inferiorly projecting ACoA as well as wide neck aneurysms had a significantly higher rate of recanalization.
CONCLUSION: Endovascular coil embolization of ACoA shows good outcome in our study. Despite advanced modern techniques, there are limitations in the endovascular approach to ACoA. Consideration of aneurysm morphology may be used to guide approaches in treatment of ACoA.
Neurosurgery 06/2006; 59(1):43-52. · 2.79 Impact Factor
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ABSTRACT: Chronic pain conditions are a complex and multifactorial problem generally requiring a multidisciplinary-type approach. The central nervous system at some point clearly becomes involved in the processing of these painful conditions with an integration of complex changes in neurophysiology and behavior. Many ablative techniques have been employed in the past to interrupt these signals. However, the results were often temporary and symptoms tended to recur. The more modern approach has suggested that modulation of the nervous elements may be a more resilient approach for treating such chronic pain disorders. We are realizing that many of these pain conditions are also dynamic and evolving, and as such need a similar treatment modality. Neurostimulation, thus, provides the ability of therapeutically dosing electrical current in a variety of pulse forms, amplitudes, pulse widths, and frequencies, to affect that system. Furthermore, it is not destructive, it is reversible, and it can be remotely adjusted and programmed over time; clear advantages to previous surgical therapies. This chapter reports on the current evidence for the use of neurostimulation (i.e. spinal cord stimulation, motor cortex stimulation and deep brain stimulation) in the treatment of chronic pain conditions.
Progress in neurological surgery 02/2006; 19:197-207.
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ABSTRACT: We report an extremely rare case of primary intramedullary germinoma in the cervical spinal cord arising in an 18-year-old man who had not undergone previous surgery or irradiation.
The patient had a 2-month history of intermittent neck pain and a 4-week history of bilateral hand paresthesias and weakness. A magnetic resonance imaging scan demonstrated a heterogeneous cervical spine lesion with marked contrast enhancement extending from C3 to C6.
The patient underwent a cervical laminotomy with tumor resection, and pathological examination revealed the tumor to be a germinoma. He recovered well from the surgery with minimal neurological deficits. A postoperative magnetic resonance imaging scan of the brain and spinal cord did not show any other tumors. In addition, imaging studies of the mediastinum, testes, and the rest of the body also did not demonstrate any other tumors. The patient received local radiation as well as three courses of chemotherapy.
To our knowledge, this is the first report of an intramedullary cervical spine germinoma with confirmed tissue diagnosis. Although extremely uncommon, the possibility of germinoma should be included in the differential diagnosis for primary intramedullary spinal cord tumors.
Neurosurgery 01/2005; 55(6):1432. · 2.79 Impact Factor
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ABSTRACT: Summary of Background Data: Five cases of hemorrhage into a spinal neoplasm after spinal or epidural anesthesia are reported in the literature. Presentation ranges from severe low back pain to acute cauda equina syndrome.Methods: A case study of a patient who hemorrhaged into an intradural, extramedullary spinal cord mass was performed. A detailed literature review is also provided.Results: A 27 year old female underwent epidural anesthesia for Cesarean section delivery. She presented with a 3 week history of increasing low back pain with bilateral radiculopathy. Imaging studies revealed a large hemorrhagic intradural mass compressing the lower conus medullaris and cauda equina, which operatively was confirmed to be a myxopapillary ependymoma.Conclusions: We report a case of hemorrhage into a previously unrecognized ependymoma after epidural anesthesia. Underlying tumors may rarely complicate regional anesthesia in the lumbar spine.
Department of Orthopaedic Surgery Faculty Papers.
