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Daniel M Sciubba,
E Clif Burdette,
Jennifer J Cheng,
William A Pennant,
Joseph C Noggle,
Rory J Petteys,
Christopher Alix,
Chris J Diederich,
Gabor Fichtinger, Ziya L Gokaslan,
Kieran P Murphy
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ABSTRACT: Radiofrequency ablation (RFA) has proven to be effective for treatment of malignant and benign tumors in numerous anatomical sites outside the spine. The major challenge of using RFA for spinal tumors is difficulty protecting the spinal cord and nerves from damage. However, conforming ultrasound energy to match the exact anatomy of the tumor may provide successful ablation in such sensitive locations. In a rabbit model of vertebral body tumor, the authors have successfully ablated tumors using an acoustic ablator placed percutaneously via computed tomography fluoroscopic (CTF) guidance.
Using CTF guidance, 12 adult male New Zealand White rabbits were injected with VX2 carcinoma cells in the lowest lumbar vertebral body. At 21 days, a bone biopsy needle was placed into the geographical center of the lesion, down which an acoustic ablator was inserted. Three multisensor thermocouple arrays were placed around the lesion to provide measurement of tissue temperature during ablation, at thermal doses ranging from 100 to 1,000,000 TEM (thermal equivalent minutes at 43°C), and tumor volumes were given a tumoricidal dose of acoustic energy. Animals were monitored for 24 hours and then sacrificed. Pathological specimens were obtained to determine the extent of tumor death and surrounding tissue damage. Measured temperature distributions were used to reconstruct volumetric doses of energy delivered to tumor tissue, and such data were correlated with pathological findings.
All rabbits were successfully implanted with VX2 cells, leading to a grossly apparent spinal and paraspinal tissue mass. The CTF guidance provided accurate placement of the acoustic ablator in all tumors, as corroborated through gross and microscopic histology. Significant tumor death was noted in all specimens without collateral damage to nearby nerve tissue. Tissue destruction just beyond the margin of the tumor was noted in some but not all specimens. No neurological deficits occurred in response to ablation. Reconstruction of measured temperature data allowed accurate assessment of volumetric dose delivered to tissues.
Using a rabbit intravertebral tumor model, the authors have successfully delivered tumoricidal doses of acoustic energy via a therapeutic ultrasound ablation probe placed percutaneously with CTF guidance. The authors have thus established the first technical and preclinical feasibility study of controlled ultrasound ablation of spinal tumors in vivo.
Journal of neurosurgery. Spine 12/2010; 13(6):773-9. · 1.61 Impact Factor
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ABSTRACT: Although Harvey Cushing played a central role in the establishment of neurosurgery in the United States, his work on the spine remains largely unknown. This article is not only the first time that Cushing's spinal cases while he was at Johns Hopkins have been reported, but also the first time his management of spinal trauma has been described. We report on 12 patients that Cushing treated from 1898 to 1911 who have never been reported before, including blunt and penetrating injuries, complete and incomplete spinal cord lesions, and both immediate and delayed presentations. Cushing performed laminectomies within 24 hours on patients with immediate presentations-both complete and incomplete spinal cord lesions. Among those with delayed presentations, Cushing did laminectomies on patients with incomplete spinal cord injuries. By the end of his tenure at Hopkins, Cushing advocated nonoperative treatment for all patients with complete spinal cord lesions. Four patients died while an inpatient, with meningitis and cystitis leading to the death of 1 and 3 patients, respectively. Cystitis was treated with intravesicular irrigation; an indwelling catheter was placed by a suprapubic cystostomy in four. Cushing was one of the first to report the use of x-ray in a spine patient, in a case that may have been one factor leading to his interest in the nervous system; Cushing also routinely obtained radiographs in those with spinal trauma. These cases illustrate Cushing's dedication to and rapport with his patients, even in the face of a dismal prognosis.
Neurosurgery 12/2010; 68(2):420-30; discussion 430. · 2.79 Impact Factor
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ABSTRACT: A retrospective clinical records analysis of concurrent pediatric spinal cord deformity correction and tethered cord release compared with a 2-staged approach.
To compare the safety and efficacy of a single-staged approach for pediatric spinal deformity correction and tethered cord release to a conventional 2-staged approach.
Tethered cord syndrome (TCS) is frequently associated with scoliosis in the pediatric population. Conventional practice suggests waiting several months after untethering for scoliosis correction; however, some patients will experience progression of their spinal deformity. We report the efficacy and safety of concurrent tethered cord release and scoliosis and/or kyphosis deformity correction in a series of pediatric patients.
We retrospectively reviewed 15 consecutive pediatric cases of concurrent spinal cord untethering and deformity correction with fusion for scoliosis and/or kyphosis. The clinical and radiologic presentation, operative details, morbidity, and postoperative outcomes were evaluated. Outcomes of this cohort were then compared with 21 patients who underwent a 2-staged untethering surgery followed by scoliosis correction. We provide a review of the literature of the treatment of tethered cord associated with spine deformities.
The mean age of patients undergoing concurrent untethering and curve correction was 9.6 years (5 male, 10 female). Tethered cord was because of myelomeningocele (5 patients), thickened filum terminale (5 patients), lipomyelomeningocele (4 patients), and retethering from an unknown primary TCS etiology (1 patient). The mean scoliosis Cobb angle (±SD) at presentation was 55.4±21.0 degrees (range, 32.3 degrees to 95.0 degrees) whereas average kyphosis was 112.7±43.6 degrees (range, 68.0 degrees to 155.0 degrees). Average postoperative scoliosis curve was 40.0 degrees, resulting in an average correction of 27%; kyphosis curve was 55.7 degrees resulting in an average correction of 50%. The average operation time was 8.6 hours (range, 3.9 to 13.7 h) and the average blood loss was 1266 mL (range, 400 to 5000 mL). Average length of hospitalization was 10.1 days (range, 4 to 34 d). New onset or worsening of neurologic deficits, bowel or bladder dysfunction, or TCS associated pain did not occur in any patients. At a mean follow-up of 5.7 years (range, 1.3 to 11.8 y), only 1 (7%) patient required subsequent surgery for pseudoarthrosis. The 2-staged cohort experienced a longer cumulative operative time (11.2 vs 8.6 h, P<0.05), more total blood loss (1534 vs 1266 mL, P<0.05), longer total days of hospitalization (14.8 vs 10.1 d, P<0.05), and a greater incidence of dural tear (9.5% vs 0%), wound infection (26% vs 0%), and retethering (9.5% vs 0%).
Concurrent tethered cord release and spinal fusion for correction of scoliosis and/or kyphosis may be a safe and effective approach in patients likely to experience deformity progression.
Journal of spinal disorders & techniques 12/2010; 24(6):401-5. · 1.21 Impact Factor
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Charles G Fisher,
Christian P DiPaola,
Timothy C Ryken,
Mark H Bilsky,
Christopher I Shaffrey,
Sigurd H Berven,
James S Harrop,
Michael G Fehlings,
Stefano Boriani,
Dean Chou, [......],
Laurence D Rhines,
Peter S Rose,
Daniel M Sciubba,
Narayan Sundaresan,
Katsuro Tomita,
Peter P Varga,
Luiz R Vialle,
Frank D Vrionis,
Yoshiya Yamada,
Daryl R Fourney
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ABSTRACT: Systematic review and modified Delphi technique.
To use an evidence-based medicine process using the best available literature and expert opinion consensus to develop a comprehensive classification system to diagnose neoplastic spinal instability.
Spinal instability is poorly defined in the literature and presently there is a lack of guidelines available to aid in defining the degree of spinal instability in the setting of neoplastic spinal disease. The concept of spinal instability remains important in the clinical decision-making process for patients with spine tumors.
We have integrated the evidence provided by systematic reviews through a modified Delphi technique to generate a consensus of best evidence and expert opinion to develop a classification system to define neoplastic spinal instability.
A comprehensive classification system based on patient symptoms and radiographic criteria of the spine was developed to aid in predicting spine stability of neoplastic lesions. The classification system includes global spinal location of the tumor, type and presence of pain, bone lesion quality, spinal alignment, extent of vertebral body collapse, and posterolateral spinal element involvement. Qualitative scores were assigned based on relative importance of particular factors gleaned from the literature and refined by expert consensus.
The Spine Instability Neoplastic Score is a comprehensive classification system with content validity that can guide clinicians in identifying when patients with neoplastic disease of the spine may benefit from surgical consultation. It can also aid surgeons in assessing the key components of spinal instability due to neoplasia and may become a prognostic tool for surgical decision-making when put in context with other key elements such as neurologic symptoms, extent of disease, prognosis, patient health factors, oncologic subtype, and radiosensitivity of the tumor.
Spine 10/2010; 35(22):E1221-9. · 2.08 Impact Factor
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ABSTRACT: With improvements in neurological imaging, there are increasing reports of symptomatic spinal synovial cysts. Surgical excision has been recognized as the definitive treatment for symptomatic juxtafacet cysts. However, the role for concomitant fusion and the incidence of recurrent back pain and recurrent cyst formation after surgery remain unclear.
To determine the cumulative incidence of postoperative symptomatic relief, recurrent back and leg pain after cyst resection and decompression, and synovial cyst recurrence.
Systematic review of the literature.
All published studies to date reporting outcomes of synovial cyst excision with and without spinal fusion.
Cyst recurrence and Kawabata, Macnab, Prolo, or Stauffer pain scales.
We performed a systematic literature review of all articles published between 1970 and 2009 reporting outcomes after surgical management of spinal synovial cysts.
Eighty-two published studies encompassing 966 patients were identified and reviewed. Six hundred seventy-two (69.6%) patients presented with radicular pain and 467 (48.3%) with back pain. The most commonly involved spinal level was L4-L5 (75.4%), with only 25 (2.6%) and 12 (1.2%) reported synovial cysts in the cervical or thoracic area, respectively. Eight hundred eleven (84.0%) patients were treated with decompressive surgical excision alone, whereas 155 (16.0%) received additional concomitant spinal fusion. Six hundred fifty-four (92.5%) and 880 (91.1%) patients experienced complete resolution of their back or leg pain after surgery, respectively. By a mean follow-up of 25.4 months, back and leg pain recurred in 155 (21.9%) and 123 (12.7%) patients, respectively. Sixty (6.2%) patients required reoperation, of which the majority (n=47) required fusion for correction of spinal instability and mechanical back pain. Same-level synovial cyst recurrence occurred in 17 (1.8%) patients after decompression alone but has been reported in no (0%) patients after decompression and fusion.
Surgical decompression results in symptomatic resolution in the vast majority of patients; however, recurrent back pain occurs in a significant number of patients. Cyst recurrence occurs in less than 2% of patients but has never been reported after cyst excision with concomitant fusion. The lack of cyst recurrence after concomitant fusion supports the need to investigate the value of fusion of the involved motion segment in the treatment of symptomatic synovial cysts of the spine.
The spine journal: official journal of the North American Spine Society 09/2010; 10(9):820-6. · 2.90 Impact Factor
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ABSTRACT: Case report.
We report the unusual case of a patient who was referred to our institution after she sustained an intraoperative injury to the common iliac vein during posterior lumbar discectomy at L5-S1 with a pituitary rongeur. There was only minimal bleeding with spontaneous hemostasis and no hemodynamic instability. Subsequently, the referring surgeon noted that the pituitary rongeur tip was missing.
Vascular injury during lumbar discectomy is a rare, but potentially devastating complication. Rapid diagnosis and treatment is traditionally targeted toward hemodynamic stabilization and repair of compromised structures.
Intraoperative fluoroscopy confirmed the presence of the tip anterior to the L3 vertebral body, indicating a possible intravascular migration of the foreign body. After completion of the surgical procedure, an abdominal computed tomography scan failed to confirm the metallic object within the abdominal cavity. Subsequent imaging studies demonstrated the presence of the rongeur tip in the left ventricle. Transthoracic echocardiogram and cardiac catheterization confirmed the presence of a patent foramen ovale and localized the rongeur tip within the papillary cords of the left ventricle, in close proximity of the mitral valve leaflets.
After failure to retrieve the foreign object during cardiac catheterization, the patient underwent sternotomy, removal of foreign metallic object, and closure of patent foramen ovale.
Close multidisciplinary collaboration allowed for proper diagnosis and the safe retrieval of the missing rongeur tip from the left ventricle.
Spine 08/2010; 35(17):E867-72. · 2.08 Impact Factor
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ABSTRACT: Primary sacral neoplasms that extend superiorly to involve the distal lumbar spine represent complex surgical problems. Treatment options for these patients are often limited to hemicorporectomy.
To detail our surgical technique for en bloc resection of a sarcoma involving the L5 vertebral segment and sacrum and the reconstruction of the lumbopelvic junction.
A 52-year-old woman presented with intractable pain secondary to a sarcoma involving the L5 vertebral segment and sacrum. She underwent a combined L5 spondylectomy and total sacrectomy for en bloc resection of her neoplasm. A novel lumbopelvic reconstruction technique was used to establish a liaison between the lumbar spine and pelvis.
Operative complications included a venous vascular injury and a nonviable myocutaneous flap. Postoperatively, the patient had complete resolution of her pain. Unfortunately, the patient developed metastatic disease and died 5 months after her initial surgical procedure.
We describe a patient who underwent a combined L5 spondylectomy and total sacrectomy for en bloc resection of a lumbosacral sarcoma. Additionally, we report a novel technique to reconstruct the lumbopelvic junction. The operative procedures are detailed with the aid of radiographs, intraoperative photographs, and illustrations.
Neurosurgery 08/2010; 67(2):E498-502. · 2.79 Impact Factor
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ABSTRACT: BACKGROUND: Primary sacral neoplasms that extend superiorly to involve the distal lumbar spine represent complex surgical problems. Treatment options for these patients are often limited to hemicorporectomy.
OBJECTIVE: To detail our surgical technique for en bloc resection of a sarcoma involving the L5 vertebral segment and sacrum and the reconstruction of the lumbopelvic junction.
METHODS: A 52-year-old woman presented with intractable pain secondary to a sarcoma involving the L5 vertebral segment and sacrum. She underwent a combined L5 spondylectomy and total sacrectomy for en bloc resection of her neoplasm. A novel lumbopelvic reconstruction technique was used to establish a liaison between the lumbar spine and pelvis.
RESULTS: Operative complications included a venous vascular injury and a nonviable myocutaneous flap. Postoperatively, the patient had complete resolution of her pain. Unfortunately, the patient developed metastatic disease and died 5 months after her initial surgical procedure.
CONCLUSION: We describe a patient who underwent a combined L5 spondylectomy and total sacrectomy for en bloc resection of a lumbosacral sarcoma. Additionally, we report a novel technique to reconstruct the lumbopelvic junction. The operative procedures are detailed with the aid of radiographs, intraoperative photographs, and illustrations.
Neurosurgery 07/2010; 67(2):E498–E502. · 2.79 Impact Factor
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ABSTRACT: This illustrative case report is designed to provide technical data regarding the use of a posterior approach to resect a retropharyngeal chordoma involving the craniovertebral junction.
The objective of this report is to emphasize the utility of the posterior approach when treating anterior tumors of the craniovertebral junction.
Traditionally, a transoral transpharyngeal or extended anterior approach was used to resect anterior tumors of the craniovertebral junction. These approaches have several limitations unique to these exposures, limitations not applicable to a posterior midline cervical approach.
A case report is provided that illustrates the use of a posterior cervical approach used to resect a retropharyngeal craniovertebral junction chordoma.
Gross total resection of a retropharyngeal chordoma was achieved using a posterior cervical approach. Although local tumor recurrence did occur, this was resected and adjuvant radiotherapy prescribed. This resulted in an ongoing 4-year recurrence free survival.
The posterior cervical midline exposure could be used to dissect and remove anterior retropharyngeal tumors, with minimal morbidity.
Journal of spinal disorders & techniques 07/2010; 23(5):359-65. · 1.21 Impact Factor
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ABSTRACT: Tethered cord syndrome (TCS) is a debilitating condition of progressive neurological decline caused by pathological, longitudinal traction on the spinal cord. Surgical detethering of the involved neural structures is the classic method of treatment for lumbosacral TCS, although symptomatic retethering has been reported in 5%-50% of patients following initial release. Subsequent operations in patients with complex lumbosacral dysraphic lesions are fraught with difficulty, and improvements in neurological function are modest while the risk of complications is high. In 1995, Kokubun described an alternative spine-shortening procedure for the management of TCS. Conducted via a single posterior approach, the operation relies on spinal column shortening to relieve indirectly the tension placed on the tethered neural elements. In a cadaveric model of TCS, Grande and colleagues further demonstrated that a 15-25-mm thoracolumbar subtraction osteotomy effectively reduces spinal cord, lumbosacral nerve root, and filum terminale tension. Despite its theoretical appeal, only 18 reports of the use of posterior vertebral column subtraction osteotomy for TCS treatment have been published since its original description. In this review, the authors analyze the relevant clinical characteristics, operative data, and postoperative outcomes of all 18 reported cases and review the role of posterior vertebral column subtraction osteotomy in the surgical management of primary and recurrent TCS.
Neurosurgical FOCUS 07/2010; 29(1):E6. · 2.87 Impact Factor
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ABSTRACT: Cervical spondylolysis is an uncommon disorder involving a cleft at the pars interarticularis. It is most often found at the C-6 level, and clinical presentations have included incidental radiographic findings, neck pain, and rarely neurological compromise. Although subaxial cervical spondylolysis has been described in 150 patients, defects at the C-2 pedicles are rare. The authors present 2 new cases of C-2 spondylolysis in athletically active young persons who did not demonstrate instability or neurological deficits, were able to remain active, and are being managed conservatively with serial examinations and imaging. They also discuss the results of 22 previously reported cases of C-2 spondylolysis. Based on the literature and their own experience, the authors conclude that most patients with C-2 spondylolysis remain neurologically intact, maintain stability despite the bony defect, and can be managed conservatively. Surgery is reserved for patients who demonstrate severe instability or spinal cord compromise due to stenosis.
Journal of neurosurgery. Spine 07/2010; 13(1):17-23. · 1.61 Impact Factor
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ABSTRACT: With continued growth of the elderly population and improvements in cancer therapies, the number of patients with symptomatic spinal metastases is likely to increase, and this is a condition that commonly leads to debilitating neurological dysfunction and pain. Advancements in surgical techniques of resection and spinal reconstruction, improvements in clinical outcomes following various treatment modalities, generally increased overall survival in patients with metastatic spine disease, and a recent randomized trial by Patchell and colleagues demonstrating the superiority of a combined surgical/radiotherapeutic approach over a radiotherapy-only strategy have led many to suggest increasingly aggressive interventions for patients with such lesions. Optimal management of spinal metastases encompasses numerous medical specialties, including neurosurgery, orthopedic surgery, medical and radiation oncology, radiology, and rehabilitation medicine. In this review, the clinical presentation, diagnosis, and management of spinal metastatic disease are discussed. Ultimately, the goal of treatment in patients with spinal metastases remains palliative, and clinical judgment is required to select the appropriate patients for surgical intervention.
Journal of neurosurgery. Spine 07/2010; 13(1):94-108. · 1.61 Impact Factor
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ABSTRACT: Occipitocervical instability with vertical migration of the odontoid is a rare but potentially debilitating anomaly of the craniocervical junction. Anterior decompression by means of a transoral or transcervical approach followed by posterior instrumentation commonly is used to treat this pathology.
To develop an innovative operative technique to correct reducible occipitocervical instability using a purely posterior approach.
Two patients presented to our institution with occipitocervical instability. One patient developed vertical migration of the odontoid secondary to a retropharyngeal abscess after radiation treatment. The second patient developed occipitocervical instability as a result of pathological destruction of C2 from a breast metastasis. Both patients were myelopathic with severe neck pain.
Both patients were brought to the operating room for intraoperative reduction and fixation using a purely posterior approach. This new technique obviated the need for an anterior decompression procedure or preoperative halo reduction. Postoperatively, both patients had excellent restoration of spinal alignment as well as improvement in both pain and myelopathy.
We achieved intraoperative reduction of occipitocervical instability through a purely posterior approach. This technique adds a tool to the armamentarium of techniques used for the treatment of occipitocervical instability.
Neurosurgery 06/2010; 66(6 Suppl Operative):319-23; discussion 323-4. · 2.79 Impact Factor
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ABSTRACT: Gross total resection of intradural spinal tumors can be achieved in the majority of cases with preservation of long-term neurological function. However, postoperative progressive spinal deformity complicates outcome in a subset of patients after surgery. We set out to determine whether the use of laminoplasty (LP) vs laminectomy (LM) has reduced the incidence of subsequent spinal deformity following intradural tumor resection at our institution.
We retrospectively reviewed the records of 238 consecutive patients undergoing resection of intradural tumor at a single institution. The incidence of subsequent progressive kyphosis or scoliosis, perioperative morbidity, and neurological outcome were compared between the LP and LM cohorts.
One hundred eighty patients underwent LM and 58 underwent LP. Patients were 46 +/- 19 years old with median modified McCormick score of 2. Tumors were intramedullary in 102 (43%) and extramedullary in 102 (43%). All baseline clinical, radiographic, and operative variables were similar between the LP and LM cohorts. LP was associated with a decreased mean length of hospitalization (5 vs 7 days; P = .002) and trend of decreased incisional cerebrospinal fluid leak (3% vs 9%; P = .14). Following LP vs LM, 5 (9%) vs 21 (12%) patients developed progressive deformity (P = .728) a mean of 14 months after surgery. The incidence of progressive deformity was also similar between LP vs LM in pediatric patients < 18 years of age (43% vs 36%), with preoperative scoliosis or loss of cervical/lumbar lordosis (28% vs 22%), or with intramedullary tumors (11% vs 11%).
LP for the resection of intradural spinal tumors was not associated with a decreased incidence of short-term progressive spinal deformity or improved neurological function. However, LP may be associated with a reduction in incisional cerebrospinal fluid leak. Longer-term follow-up is warranted to definitively assess the long-term effect of LP and the risk of deformity over time.
Neurosurgery 05/2010; 66(5):1005-12. · 2.79 Impact Factor
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ABSTRACT: The treatment of complex thoracolumbar disorders occasionally requires combined anterior and posterior approaches. Traditionally, these are either sequentially staged to occur during the same anesthesia procedure or alternatively performed on separate days. A less common option is the simultaneous anterior-posterior approach. The authors discuss the rationale for this approach in selected cases and illustrate a number of modifications to previous descriptions of the procedure. By slightly altering the incision, the risk of wound breakdown and infection has been reduced. The use of newly available positioning devices has allowed easy incorporation of fluoroscopy to guide the placement of spinal instrumentation. The authors have also expanded the use of the approach beyond the original oncological indications to include trauma and infection.
Journal of neurosurgery. Spine 05/2010; 12(5):456-61. · 1.61 Impact Factor
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ABSTRACT: Retrospective review.
Review clinical outcomes for myelopathic patients undergoing transthoracic discectomies for central calcified herniations.
Ideal surgical treatment for thoracic disc herniation is controversial due to variations in patient presentation, pathology, and possible surgical approach. Although discectomy may lead to improvements in neurologic function, it can be complicated by approach-related morbidity, especially for ventral calcified disc herniations. Review of clinical outcomes for myelopathic patients undergoing transthoracic discectomies for central calcified herniations was completed, paying special attention to neurologic status and procedure-related complications.
Between 2002 and 2007, 27 myelopathic patients were treated with 28 transthoracic surgeries for centrally located symptomatic calcified thoracic disc herniations over the last 5 years at a single institution. Demographic data, details of surgery, preoperative and postoperative Nurick and American Spinal Injury Association scores, length of stay, complications, and follow-up data were collected in all patients.
A total of 27 patients, 8 male (30%) and 19 female (70%) with an average age of 52.3 years (range: 19 to 72) underwent 28 thoracotomies. All had myelopathy whereas 6/27 also had radicular pain syndromes. Fourteen patients had anterior instrumentation alone, 3 had anterior and posterior instrumentation, and 1 had posterior instrumentation alone. Average Nurick grade was 2.5 preoperatively and 1.4 postoperatively. Of note, American Spinal Injury Association scores improved postoperatively in 12/27 patients (10D to 10E; 2C to 2D), remained unchanged in 13/27 (11E to 11E, 2D to 2D), and worsened in 2/27 (2D to 2C). Average length of stay was 7 days (range: 3 to 15). All patients required chest tube placement with average duration of 4 days (range: 1 to 7). Major complications occurred in 6 cases (21.4%) over an average follow-up of 12 months (range: 1 to 40 mo).
Thoracotomy for treatment of centrally located thoracic disc herniations is associated with improvement in or stabilization of myelopathic symptoms in the majority of patients with an acceptable rate of complications. Interestingly, most patients with weakness improved in strength (12/16, 75%), no patients with normal strength developed new weakness (10/10, 100%), and only 2 patients had new weakness noted postoperatively (7.4%).
Journal of spinal disorders & techniques 04/2010; 23(2):79-88. · 1.21 Impact Factor
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ABSTRACT: Chordomas are rare tumors that arise from the sacrum, spine, and skull base. Surgical management of these tumors can be difficult, given their locally destructive behavior and predilection for growing near delicate and critical structures. En bloc resection with negative margins can be difficult to perform without damaging adjacent structures and causing significant clinical morbidity. For chordomas of the upper cervical spine, surgical options traditionally involve transoral or submandibular approaches. The authors report the use of the image-guided, endoscopic, transcervical approach to the upper cervical spine as an alternative to traditional techniques for addressing upper cervical spine tumors, particularly for tumors where gross-total resection is not feasible.
Journal of neurosurgery. Spine 04/2010; 12(4):431-5. · 1.61 Impact Factor
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ABSTRACT: Metastatic epidural spinal cord compression is a potentially devastating complication of cancer and is estimated to occur in 5% to 14% of all cancer patients. It is best treated surgically. Minimally invasive spine surgery has the potential benefits of decreased surgical approach-related morbidity, blood loss, hospital stay, and time to mobilization.
A 36-year-old man presented with worsening back pain and lower extremity weakness. Workup revealed metastatic adenocarcinoma of the lung with spinal cord compression at T4 and T5.
T4 and T5 vertebrectomy with expandable cage placement and T1-T8 pedicle screw fixation and fusion were performed using minimally invasive surgical techniques.
The patient improved neurologically and was ambulatory on postoperative day 1. At the 9-month follow-up point, he remained neurologically intact and pain free, and there was no evidence of hardware failure.
Minimally invasive surgical circumferential decompression may be a viable option for the treatment of metastatic epidural spinal cord compression.
Neurosurgery 03/2010; 66(3):E620-2. · 2.79 Impact Factor
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ABSTRACT: : Pneumorachis is a relatively rare phenomenon, where air enters the spinal canal. Because of its rarity, evaluation and management of this condition is poorly understood. This study describes a case of pneumorachis and performs a review of the current literature to understand the common causes, associated pathologies, presenting neurologic symptoms, treatment options, and neurologic outcomes for patients who develop pneumorachis.
: The evaluation and management of a patient with pneumorachis who presented to our institution is described. In addition, a literature review of the Medline and Pubmed databases was conducted. The information collected from each study included the number of cases, proposed cause, associated findings, therapeutic interventions, and outcome.
: A total of 50 patients from 42 studies were identified. Pneumorachis typically occurred after injury to the respiratory system and was often associated with pneumothoraces, pneumomediastinum, and subcutaneous emphysema. This condition could also be seen after traumatic brain injury, especially with skull base and sinus fractures. Less common causes included primary spinal sources, visceral injuries, and fulminant infections. In most cases, pneumorachis was not associated with any spinal cord symptoms and typically resolved by addressing the underlying cause.
: This review demonstrates that intraspinal air is typically benign and resolves with conservative therapies. However, it should be realized that in a rare number of cases, pneumorachis can cause symptoms of cord compression and may even require decompressive surgery. Therefore, prompt evaluation and diagnosis remain important.
The Journal of trauma 03/2010; 68(3):736-44. · 2.48 Impact Factor
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ABSTRACT: Hürthle cell carcinoma is a rare variant of differentiated thyroid cancer that occasionally forms distant metastases. However, even in the presence of metastases, patients with Hürthle cell carcinoma have a relatively good prognosis. There are few reports of Hürthle cell carcinoma metastases to the vertebral column, and none describing aggressive resection of spinal metastases. Here, we report a 68-year-old woman with a solitary metastasis of Hürthle cell carcinoma to the T1 vertebral body causing severe kyphotic deformity, myelopathy, and pain. The patient was treated with aggressive excisional decompression of the spinal cord and T1 vertebral body resection from an entirely posterior approach. Reconstruction and stabilization of the anterior spine was accomplished with a transforaminal lumbar interbody fusion allograft spacer and posterior instrumentation. We discuss aspects of the diagnosis, management, patient selection, and surgical treatment of metastatic Hürthle cell carcinoma in reference to the literature.
Journal of Clinical Neuroscience 03/2010; 17(6):797-801. · 1.25 Impact Factor
