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1.  Medicare payment data for spine reimbursement; important but flawed data for evaluating utilization of resources 
Surgical Neurology International  2015;6(Suppl 14):S391-S397.
Medicare data showing physician-specific reimbursement for 2012 were recently made public in the mainstream media. Given the ongoing interest in containing healthcare costs, we analyze these data in the context of the delivery of spinal surgery.
Demographics of 206 leading surgeons were extracted including state, geographic area, residency training program, fellowship training, and academic affiliation. Using current procedural terminology (CPT) codes, information was evaluated regarding the number of lumbar laminectomies, lumbar fusions, add-on laminectomy levels, and anterior cervical fusions reimbursed by Medicare in 2012.
In 2012 Medicare reimbursed the average neurosurgeon slightly more than an orthopedic surgeon for all procedures ($142,075 vs. $110,920), but this was not found to be statistically significant (P = 0.218). Orthopedic surgeons had a statistical trend illustrating increased reimbursement for lumbar fusions specifically, $1187 versus $1073 (P = 0.07). Fellowship trained spinal surgeons also, on average, received more from Medicare ($125,407 vs. $76,551), but again this was not statistically significant (P = 0.112). A surgeon in private practice, on average, was reimbursed $137,495 while their academic counterparts were reimbursed $103,144 (P = 0.127). Surgeons performing cervical fusions in the Centers for Disease Control West Region did receive statistically significantly less reimbursement for that procedure then those surgeons in other parts of the country (P = 0.015). Surgeons in the West were reimbursed on average $849 for CPT code 22,551 while those in the Midwest received $1475 per procedure.
Medicare reimbursement data are fundamentally flawed in determining healthcare expenditure as it shows a bias toward delivery of care in specific patient demographics. However, neurosurgeons, not just policy makers, must take ownership to analyze, investigate, and interpret these data as it will affect healthcare reimbursement and delivery moving forward.
PMCID: PMC4566303  PMID: 26425400
Healthcare economics; Medicare; reimbursement; spinal surgery
2.  Commentary on article: Laminoplasty versus laminectomy and fusion for multilevel cervical myelopathy: A meta-analysis of clinical and radiological outcomes by Chang-Hyun Lee et al 
Surgical Neurology International  2015;6(Suppl 14):S379-S382.
This is a commentary on the article laminoplasty versus laminectomy and fusion (LF) for multilevel cervical myelopathy: A meta-analysis of clinical and radiological outcomes by Chang-Hyun Lee et al. Here, the authors utilized seven studies to compare the efficacy of cervical expansive laminoplasty (EL) versus laminectomy and fusion (LF) to address three or more level multilevel cervical spondylotic myelopathy (CSM). Both procedures led to similar degrees of neurological recovery and short-term loss of lordosis, but found that LF led to more favorable long-term results.
For patients with three or more level CSM, laminectomy followed by an instrumented fusion (LF) has major advantages; open bilateral decompression of the nerve roots, while minimizing the risk of inadvertent injury to the cord, and the fusion's maintenance of lordosis.
Some would argue that inadvertent cord/root injury is greater utilizing any of the EL techniques; e.g., unilateral, bilateral, or spinous process splitting techniques. In short, why risk cord/root injury by manipulating the compressive posterior/posterolateral elements, which are already threatening neural function.
Although the results of EL versus LF appeared comparable in the short-term in these seven articles, LF resulted in better long-term outcomes. Some would also argue that LF, utilizing an open approach offers safer bilateral neural exposure and decompression.
PMCID: PMC4566304  PMID: 26425397
Cervical surgery; efficacy; fusion; laminectomy; laminoplasty; safety; spondylotic myelopathy
3.  Synovial chondromatosis presenting as an epidural mass 
Surgical Neurology International  2015;6(Suppl 14):S388-S390.
Synovial chondromatosis is an uncommon disorder characterized by the formation of multiple cartilaginous nodules in the synovium of the facet joint. It most commonly affects large joints such as hip or shoulder. Commonly seen features are bony erosion and calcifications. Synovial chondromatosis is rare in the spine and there are few previous reports of extension into the spinal canal.
Case Description:
A 58-year-old man presented with a 2 year history of progressive numbness in the right upper extremity without objective weakness. A several month course of conservative management, including physical therapy, failed to alleviate symptoms. Magnetic resonance imaging of the cervical spine demonstrated the erosion of the right facet C5–C6 joint with listhesis and foraminal enlargement secondary to a lesion. Treatment was offered to the patient in the form of surgical resection. The lesion was removed in piecemeal fashion using curettes and Cavitron ultrasonic surgical aspirator. Histological examination demonstrated atypical well-differentiated cartilaginous proliferation.
This patient had an uncomplicated postoperative course and experienced complete resolution of right upper extremity sensory symptoms. Synovial chondromatosis may compromise cervical spinal cord and nerve roots if it extends into the spinal canal. Although it remains rare, it should be included in the differential diagnosis for upper extremity radiculopathy and myelopathy. Surgical resection is a viable treatment option for symptomatic patients with this pathology. In some cases, adequate resection may necessitate stabilization with instrumentation.
PMCID: PMC4566305  PMID: 26425399
Chondromatosis; epidural; foraminal; radiculopathy; synovial chondromatosis
4.  Unnecessary multiple epidural steroid injections delay surgery for massive lumbar disc: Case discussion and review 
Surgical Neurology International  2015;6(Suppl 14):S383-S387.
Epidural steroid injections (ESI) in the lumbar spine are not effective over the long-term for resolving “surgical” lesions. Here, we present a patient with a massive L2–L3 lumbar disk herniation whose surgery was delayed for 4 months by multiple unnecessary ESI, resulting in a cauda equina syndrome.
A 54-year-old male acutely developed increased low back and radiating left leg pain in October of 2014. In December of 2014, a magnetic resonance imaging (MRI) scan showed a massive central/left sided disk herniation at the L2–L3 level resulting in marked thecal sac and left L2 foraminal and L3 lateral recess root compression. Despite the marked degree of neural compression, pain management treated him with 3 ESI over the next 3 months.
At the end of April of 2015, he presented to spine surgeon with a cauda equina syndrome. When the new MRI scan confirmed the previously documented massive central-left sided L2–L3 disk herniation, the patient emergently underwent an L1–L3 laminectomy with central-left sided L2–L3 lateral/foraminal diskectomy. Postoperatively, the patient was neurologically intact.
Pain specialists performed multiple unnecessary lumbar ESI critically delaying spinal surgery for 4 months in this patient with a massive lumbar disk herniation who ultimately developed a cauda equina syndrome. Unfortunately, pain specialists (e.g., radiologists, anesthesiologists, and physiatrists), not specifically trained to perform neurological examinations or spinal surgery, are increasingly mismanaging spinal disease with ESI/variants. It is time for spine surgeons to speak out against this, and “take back” the care of patients with spinal surgical disease.
PMCID: PMC4566306  PMID: 26425398
Cauda equina syndrome; epidural steroid injections/variants; lumbar disk herniation; massive discs; pain specialists; spinal surgeons; unnecessary delay
5.  Stereotactic radiosurgery for brain metastases from malignant melanoma 
Surgical Neurology International  2015;6(Suppl 12):S355-S365.
Surgical resection and stereotactic radiosurgery (SRS) are well-established treatment methods for patients with brain metastases, yet their respective roles in the management of brain metastases remain incompletely defined.
To report on the role of SRS in the treatment of patients with brain metastases from malignant melanoma, a retrospective analysis of 381 intracranial melanoma metastases in 103 consecutive patients who underwent SRS between 2005 and 2011 at Beth Israel Deaconess Medical Center was conducted. The Cyberknife® SRS system was used to treat all patients. Clinical, technical, and radiographic data were recorded at presentation and on follow-up.
The patient cohort consisted of 40 female (39%) and 63 male (61%) patients with a median age of 57 years. The median overall survival from the time of radiosurgery for the entire patient cohort was 7.6 months. The local control rate at 1-year was 72% for the patients who received surgery followed by SRS and 55% for the entire patient population. Surgery followed by SRS was associated with significantly improved overall survival compared with SRS alone or whole-brain radiation therapy followed by salvage SRS (P < 0.0057).
Both surgery plus SRS and SRS provide comparable local control. Despite the difference in lesion size in the subgroups who received surgery plus SRS and radiosurgery alone, similar outcomes were achieved in both groups, suggesting that surgical treatment of larger lesions can yield results that are not significantly different from small lesions treated by SRS alone.
PMCID: PMC4553636  PMID: 26392919
Brain metastasis; CyberKnife; melanoma; stereotactic radiosurgery
6.  Cavernous hemangioma of the dura mater mimicking meningioma 
Surgical Neurology International  2015;6(Suppl 13):S375-S378.
Cavernomas are benign lesions that most commonly occur intra-parenchymally, but occasionally they have been described as arising from the dura mater. Extra-axial cavernous angiomas (or hemangiomas) account for 0.4–2% of all intracranial vascular malformations, and they usually occur in the middle cranial fossa, associated with the cavernous sinus. Other possible localizations (e.g. tentorium, convexity, anterior cranial fossa, cerebellopontine angle, Meckel's cave, sella turcica and internal auditory meatus) are rare, and they account only for 0.2–0.5%.
Case Description:
We report a case of a 30-year-old female presenting with a 2 years history of headache unresponsive to drug therapy. The magnetic resonance imaging showed a dural-based lesion in the left frontal region; the lesion size was: 1.5 cm × 3.5 cm. The appearance suggested a convexity meningioma. A left frontal craniotomy was performed, and the histopathological diagnosis deposed for a cavernous hemangioma of the dura mater. The follow-up at 1-year was good without any neurologic deficit.
Dural-based cavernous hemangiomas of the convexity are uncommon lesions. Up to now, only 13 cases have been described in the literature. The authors have discussed clinical aspects, radiological features, surgical treatment, and operative findings.
PMCID: PMC4553634  PMID: 26421218
Convexity; dural cavernous hemangioma; meningioma
7.  A case of intravascular lymphoma presenting as myelopathy diagnosed with a skin biopsy 
Surgical Neurology International  2015;6(Suppl 13):S367-S370.
Intravascular lymphoma (IVL) is a rare subtype of non-Hodgkin lymphoma with exclusively or predominantly intravascular proliferation. Without therapeutic intervention, the neurologic involvement is rapidly progressive and inevitably fatal. Most of the IVL patients have prominent or exclusive manifestations in the nervous system and there are several reports of patients presenting with spinal symptoms.
Case Description:
A 68-year-old male patient admitted with the complaints of progressive paraparesis. T2-weighted magnetic resonance imaging (MRI) of the spinal cord showed hyperintense lesions in the thoracic cord. A diagnosis of myelitis of unknown etiology was assumed, and steroid pulse therapy was administered, which temporarily improved the patient's symptoms. However, the paraparesis recurred, and other symptoms, such as vertigo, psychosis, and seizures, developed 1-month after the initial treatment. Multiple high-intensity lesions were detected in the bilateral subcortical white matter on DW MRI. Based on the patient's clinical course, IVL was suspected; however, obtaining histological confirmation was not possible, as no Gd-enhanced brain or spinal lesions were identified and repeated cerebrospinal fluid examinations were negative for tumor cells. Therefore, a random skin biopsy was performed, and IVL was diagnosed. Obtaining a comparatively favorable outcome was possible owing to the subsequent administration of R-CHOP chemotherapy.
IVL should be included in the differential diagnosis of atypical case of presumed myelitis. An early diagnosis and chemotherapy is crucial for improving the patient's outcome. When obtaining a diagnosis based on tissues other than skin is difficult, a random skin biopsy should be considered in patients with suspected IVL.
PMCID: PMC4553635  PMID: 26421216
Intravascular lymphoma; myelopathy; skin biopsy
8.  Treatment of giant congenital cysts of the midline in adults: Report of two cases and review of the literature 
Surgical Neurology International  2015;6(Suppl 13):S371-S374.
Giant cysts of the midline, not associated to a tumor, are exceptional finding in the brain of adults. Here we present two cases of symptomatic giant cerebral cysts of the midline occurred in an elderly and in a young adult patients both treated with mini-invasive unilateral neuroendoscopic procedure. In the recent literature (since 1999) similar cases have not been reported. Beside the clinical report, review of literature and major anatomical features of the region are described.
Case Description:
These two adults (82 and 41 years old respectively) had a slow progressive development of headache, gait disturbances, memory impairment and urinary incontinence. Magnetic resonance imaging showed giant cyst of the midline and hydrocephalus. Surgery with the endoscopic procedure, through a right frontal burr hole, was followed by clinical and radiological improvement.
Giant cerebral cysts of the midline in adults can be successfully treated through a neuroendoscopic monolateral approach that comprehends multiple openings, diffuse coagulation of the capsule, and careful releasing of capsule-ependyma adherences. Knowledge of major anatomical and developmental details of the septal region is necessary to avoid complication in a mini-invasive surgical procedure.
PMCID: PMC4553637  PMID: 26421217
Cyst; midline; neuroendoscopy; septum pellucidum
9.  CSF hydrothorax without intrathoracic catheter migration in children with ventriculoperitoneal shunt 
Surgical Neurology International  2015;6(Suppl 11):S330-S333.
Thoracic complications of ventriculoperitoneal (VP) shunts have been extensively reported in the literature. Cerebrospinal fluid (CSF) hydrothorax without catheter migration, however, has been rarely described and poorly understood.
Case Description:
We describe development of pleural effusion and respiratory distress in a 3-year-old boy with no evidence of VP shunt catheter displacement on plain radiograph and stable ventricle size on rapid sequence magnetic resonance imaging (MRI) brain. Chest X-ray revealed complete opacity of right hemithorax. Pleural effusion was consistent with transudate. Beta-2 transferrin returned positive. The patient underwent externalization of VP shunt, and upon resolution of effusion, re-internalization with new distal shunt catheter. A literature review of CSF hydrothorax in children without intrathoracic shunt migration was performed. Eleven cases were identified in the English literature. Age at VP shunt placement ranged from birth to 8 years of age. Interval from VP shunt placement to CSF hydrothorax ranged from 1.5 months to 5 years. History of shunt revision was reported in two cases. Presenting symptoms also included ascites and inguinal hernia or hydrocele. Reported diagnostic studies consist of CSF culture, radionuclide shuntogram, beta-2 transferrin, and beta-trace protein. Laterality of the VP shunt and development of pleural effusion were predominantly right sided. Definitive surgical treatment included VA shunt, repositioning of the peritoneal catheter, and endoscopic choroid plexus coagulation.
CSF hydrothorax is a rare thoracic complication of VP shunt placement with no radiographic evidence of shunt migration or malfunction. Postulated mechanisms include limited peritoneal capacity to resorb CSF in children and microscopic communications present in congenital diaphragmatic hiatuses.
PMCID: PMC4521309
Cerebrospinal fluid hydrothorax; shunt malfunction; ventriculoperitoneal shunt
10.  Trigeminal neuralgia associated with Chiari 1 malformation: symptom resolution following craniocervical decompression and duroplasty: Case report and review of the literature 
Surgical Neurology International  2015;6(Suppl 11):S327-S329.
Trigeminal neuralgia (TN) may rarely be the presenting or only symptom of Chiari 1 malformation (CM). Isolated case reports have described resolution of TN following craniocervical decompression where TN is present in association with CM.
Case Report:
This report discusses an unusual case of pure TN associated with CM that was successfully treated with craniocervical decompression and duroplasty and reviews the limited literature on the subject.
TN may be the sole presenting symptom of CM and can be successfully managed with craniocervical decompression. Clinicians should be aware of the association of TN with CM and consider surgical management.
PMCID: PMC4521310
Chiari malformation; craniocervical decompression; duroplasty; trigeminal neuralgia
11.  Management of hydrocephalus in children with posterior fossa tumors 
Surgical Neurology International  2015;6(Suppl 11):S346-S348.
PMCID: PMC4521311
Endoscopic third ventriculostomy; hydrocephalus; pediatric; posterior fossa tumor; ventriculoperitoneal shunt
12.  “Countersinking” of reservoir in an irradiated patients can decrease tension on scalp closure 
Surgical Neurology International  2015;6(Suppl 11):S334-S336.
Subcutaneous reservoirs are used to provide therapy by establishing access to cerebrospinal fluid. However, it is associated with complications such as hemorrhage, infection, malfunction, and malpositioning. In an irradiated field with thin skin, use of reservoir can result in wound dehiscence, wound infection, and device extrusion.
Case Description:
We introduced a “countersinking” technique for the reservoir placement which involves the creation of bony recess in the skull to effectively accommodate the reservoir and decrease the protrusion. “Countersinking” of the reservoir can result in tension-free closure of the scalp and allow durable coverage of the reservoir. In the representative case, the incisional wound healed completely without any concern for wound dehiscence and the countersink technique may have contributed to effective healing of the radiated scalp.
Countersinking of the reservoir can be a strategy to prevent complications such as wound dehiscence, and device extrusion in any patient, but in irradiated patients with very thin skin it also enables tension-free closure of the wound.
PMCID: PMC4521312
Countersinking; ommaya reservoir; wound dehiscence
13.  How I Do It: Management of spina bifida in a hospital in The People's Republic of China 
Surgical Neurology International  2015;6(Suppl 11):S337-S345.
We present our personal experience on patients with Spina Bifida. It is the result of having treated 1600 children for 12 years at Shanghai Children's Medical Center. We classify the cases on Spina Bifida Manifesta (myelomeningocele, myelocele, lypomyelomeningocele) or Spina Bifida Oculta (lipoma, dermal sinus and thickened filum terminale). For the former, we recommend surgery within 24–48 h after birth. For the latter we recommend preventive surgery months after birth. We acknowledge that the diameter of the spinal canal is a problem for large remnant lesions. In cases of myelomeningocele, we prefer to place the shunt and close the defect in the same procedure, it reduces the risks inherent to exposure to anesthesia, reduces hospital stay, and related costs. If there is a suspicious of infection, we do not place the shunt on the same procedure. The personal description of the preferred techniques for closure of the different defects is described.
PMCID: PMC4521313
Myelomeningocele; spina bifida; surgical technique; spinal lipoma; tethered cord
14.  Huge familial colloid cyst of the third ventricle: An extraordinary presentation 
Surgical Neurology International  2015;6(Suppl 11):S349-S353.
Since the use of computed tomography and magnetic resonance imaging, colloid cysts (CCs) are discovered more frequently and subsequently their true incidence exceeds the numbers previously estimated. In 1986, the first familial case was reported in two identical twin brothers. To date, a total of 17 of these cases have been reported, all differing in the pattern of affected family members.
Case Description:
Here, we describe a unique presentation of a familial case and review the relevant literature on CCs and their natural history to improve our understanding of these cases.
Familial CC can present in various patterns, sizes, and forms. A genetic factor is likely to be responsible in these cases, and further research is warranted to clarify this phenomenon.
PMCID: PMC4521314
Colloid cyst; familial; genetics; tumor
15.  Strategy for endovascular coil embolization of a penetrating vertebral artery injury 
Penetrating vertebral artery injuries (VAIs) are even rarer than carotid artery injuries. For anatomical reasons, the surgical management of VAI is difficult, and endovascular management often yields a good outcome. We report our strategy for the endovascular treatment of a patient with a penetrating VAI at the V2 segment of the left vertebral artery.
Case Description:
In a fall on a large rake, a 76-year-old man was stabbed in the left neck by three tines. Although he manifested no neurological deficits, computed tomography (CT) suggested penetrating VAI. Digital subtraction angiography confirmed VAI and extravasation, and he underwent endovascular coil embolization. Two microcatheters, inserted proximal and distal to the injury sites, were used for successful endovascular coil embolization. Postoperative magnetic resonance imaging - and single photon emission CT studies denied cerebral infarction and a decrease in cerebral perfusion. The patient exhibited no neurological deficits and was able to leave the hospital on foot.
This is the rare documentation of a patient whose penetrating VAI was treated by simultaneous coil embolization and foreign body removal. Imaging studies confirmed the patency and perfusion of the intracranial artery. Our treatment strategy produced a good outcome in this unusual patient.
PMCID: PMC4513296
Embolization; penetrating neck trauma; stab wound; traumatic vertebral artery injury
16.  The odontoid process invagination in normal subjects, Chiari malformation and Basilar invagination patients: Pathophysiologic correlations with angular craniometry 
Craniometric studies have shown that both Chiari malformation (CM) and basilar invagination (BI) belong to a spectrum of malformations. A more precise method to differentiate between these types of CVJM is desirable. The Chamberlain's line violation (CLV) is the most common method to identify BI. The authors sought to clarify the real importance of CLV in the spectrum of craniovertebral junction malformations (CVJM) and to identify possible pathophysiological relationships.
We evaluated the CLV in a sample of CVJM, BI, CM patients and a control group of normal subjects and correlated their data with craniocervical angular craniometry.
A total of 97 subjects were studied: 32 normal subjects, 41 CM patients, 9 basilar invagination type 1 (BI1) patients, and 15 basilar invagination type 2 (BI2) patients. The mean CLV violation in the groups were: The control group, 0.16 ± 0.45 cm; the CM group, 0.32 ± 0.48 cm; the BI1 group, 1.35 ± 0.5 cm; and the BI2 group, 1.98 ± 0.18 cm. There was strong correlation between CLV and Boogard's angle (R = 0.82, P = 0.000) and the clivus canal angle (R = 0.7, P = 0.000).
CM's CLV is discrete and similar to the normal subjects. BI1 and BI2 presented with at least of 0.95 cm CLV and these violations were strongly correlated with a primary cranial angulation (clivus horizontalization) and an acute clivus canal angle (a secondary craniocervical angle).
PMCID: PMC4513301
Arnold–Chiari malformation; basilar impression; cephalometry; platybasia
17.  Craniocervical junction tuberculosis: Usual pathology at an unusual site 
Tuberculosis (TB) of the craniocervical junction is rare even where the condition is endemic. It poses problems in both diagnosis and management if not managed in time it may cause life-threatening complications.
Case Description:
An 18-year-old male patient presented with pain in the nape of the neck since 12 months duration which was not improving with medication. After magnetic resonance imaging of cervical spine, he was diagnosed as craniocervical junction TB. We did a transoral decompression of abscess with biopsy along with posterior decompression of cord and occipitocervical fusion. Biopsy of pathological material came as TB. He was advised for anti-tubercular therapy for 18 months.
Although craniocervical junction TB is a rare disease, the outcome of treatment is good. Antituberculous drug therapy remains the mainstay of treatment after confirming the diagnosis. The surgical management options include transoral decompression with or without posterior fusion, depending upon the presence and persistence of atlantoaxial instability.
PMCID: PMC4513297
Craniocervical junction; posterior fusion; transoral decompression; tuberculosis
19.  The role of preoperative angiography in the management of giant meningiomas associated to vascular malformation 
The role of preoperative digital subtraction angiography (DSA) in meningiomas is currently under discussion because of the introduction of noninvasive magnetic resonance imaging (MRI) angiography to study vascular anatomy associated to the tumor. Preoperative DSA is mainly performed to obtain embolization of the lesion, although a number of complications have been reported after this procedure. Nonetheless, the coexistence of meningiomas with vascular malformations has previously been reported and it has been evidenced that this event could be underestimated because of neglect of preoperative DSA. Here, we report on two challenging cases of giant meningiomas associated to vascular malformations and we discuss the pertinent literature.
Case Descriptions:
In the first case: A large right temporal meningioma with erosion of the sphenoid greater wing and extension toward infratemporal fossa and right orbit - a large pseudoaneurysm of right middle cerebral artery branch was found end embolized during DSA. In the second case: A giant parieto-temporal meningioma - DSA permitted the full visualization of an abnormal drainage of superior sagittal sinus like a “sinus pericranii” that was respected during the following surgery.
We think that MRI angiography is the exam of choice to study vascular anatomy in meningiomas. Nonetheless, DSA remains a useful tool in giant meningiomas not only to embolizate the lesion but also to treat tumor associated vascular malformation and to achieve the full knowledge of vascular anatomy. We think that a wide communication between interventionalist and surgeon is essential for the optimal management of these patients.
PMCID: PMC4496841  PMID: 26167366
Aneurysm; diagnosis; magnetic resonance imaging; meningioma; preoperative angiography; vascular malformations
20.  Large and giant skull base meningiomas: The role of radical surgical removal 
The large and giant skull base meningiomas are challenging lesions, and the involvement of crucial neurovascular structures needs the surgical removal as the primordial treatment. The authors report on a series of patients with large and giant skull base meningiomas who were treated with the goal of radical removal.
A retrospective study including 49 patients with large and giant skull base meningiomas was carried out. Tumors presenting 3 cm or larger were included.
The meningiomas in the sample included the following types: 10 olfactory groove, 8 sphenoorbital, 8 petroclival, 8 tentorial, 4 clinoidal, 4 cavernous sinus, 3 temporal floor, 2 tuberculum sellae and 2 foramen magnum. The average age was 53 years, the mean follow-up period was 52 months, Simpson Grades I and II were obtained in 75.5%. The overall mortality was 5%. Transient cranial nerve deficits occurred in 32% with definite cranial nerve lesion in 18%. Cerebrospinal fluid leak occurred in 14%.
The surgical treatment is a mandatory option for large and giant skull base meningiomas. The radical removal is achievable and should be considered an alternative with a good outcome and an acceptable morbidity for such challenge lesions.
PMCID: PMC4496843  PMID: 26167365
Meningioma; Simpson grade; skull base; surgical treatment
21.  Disruptive behavior 
Surgical Neurology International  2015;6(Suppl 8):S289.
PMCID: PMC4496828  PMID: 26167371
22.  Brain metastasis from a lung mucoepidermoid carcinoma mimicking a brain abscess 
Surgical Neurology International  2015;6(Suppl 9):S300-S303.
Mucoepidermoid carcinoma (MEC) is a rare tumor of the lung that accounts for 0.1–0.2% of all pulmonary tumors. To the best of our knowledge, brain metastasis from lung MEC is rare and magnetic resonance imaging (MRI) findings of this lesion have not been documented.
Case Description:
We herein report the case of a 72-year-old male. MRI revealed a left parietal tumor showing ring enhancement with medium gadolinium contrast and an evident high intensity area in the nonenhanced central portion on diffusion-weighted images (DWI) mimicking a brain abscess. Histologically, MEC is composed of a mixture of different cell types including mucin-secreting glandular cells and squamous cells. Accordingly, we suggest that the high DWI signal can be explained by the development of intracellular and intraluminal mucin, which have a high viscosity.
Further accumulation of cases with brain metastasis from MEC is needed to establish the characteristic image findings, which would lead to prompt and adequate treatment.
PMCID: PMC4496829  PMID: 26167374
Brain metastasis; brain abscess; diffusion-weighted images; mucoepidermoid carcinoma
23.  Preliminary study showing safety/efficacy of nanoss bioactive versus vitoss as bone graft expanders for lumbar noninstrumented fusions 
Surgical Neurology International  2015;6(Suppl 10):S318-S322.
The lateral fusion mass for multilevel lumbar laminectomies with noninstrumented posterolateral fusions now often utilizes lamina autograft and bone marrow aspirate (BMA) mixed with one of two bone graft expanders: either Vitoss (Orthovita, Malvern, PA, USA) or NanOss Bioactive (Regeneration Technologies Corporation: RTI, Alachua, FL, USA).
Here, we compared two sequential prospective the times to fusion, fusion rates, complications, and infection rates for two prospective cohorts of patients utilizing either Vitoss (first 213 patients) or NanOss (subsequent 45 patients) respectively, undergoing multilevel lumbar laminectomies (average 4.6 vs. 4.5 levels) with noninstrumented fusions (average 1.3 vs. 1.2 levels). Surgery addressed stenosis/ossification of the yellow ligament (OYL) (all patients), with subsets exhibiting degenerative spondylolisthesis synovial cysts, and disc disease. Fusion was documented by two independent neuroradiologists blinded to the study design, utilizing dynamic X-rays and two dimensional computed tomography (2D-CT) studies up to 6 months postoperatively, and up to 1 year where indicated.
Comparison of patients receiving Vitoss versus NanOss as bone graft expanders revealed nearly comparable; times to fusion (5.3 months vs. 4.8 months), fusion rates (210 [98.6%] vs. 45 [100%] patients), pseudarthroses (3 [1.4%] vs. 0), postoperative seromas (2 [0.94%] vs. 0), and deep wound infections (2 [0.94%] vs. 0).
In this preliminary study of patients undergoing multilevel lumbar lamienctomies with posterolateral noninstrumented fusions, results were nearly comparable utilizing Vitoss or NanOss as bone graft expanders. Although the number of NanOss patients was substantially lower, the comparable efficacy and absence of postoperative complications for noninstrumented fusions is promising.
PMCID: PMC4496830  PMID: 26167369
Autograft; Beta-TriCalcium phosphate; noninstrumented lumbar fusion; NanOss Bioactive; pseudarthrosis rates; Vitoss
24.  Spinal surgeons need to read patients’ studies to avoid missing pathology 
Surgical Neurology International  2015;6(Suppl 10):S313-S317.
Many spine surgeons rely on reports of radiological studies for patients seen routinely in consultation. However, “best practice” should include the spine surgeon's individual assessment of the images themselves to better determine whether the diagnoses rendered were/are correct.
A now 54-year-old male had an original enhanced magnetic resonance imaging (MR) scan of the cervical spine performed in 2012 that was read as showing mild spondylotic changes at multiple levels.
In 2015, the patient presented with a severe spastic quadriparesis, right greater than left, which had markedly worsened over the prior 3 months. Review of the original enhanced MR from 2012 revealed a right-sided C5–C6 tumor (e.g., likely meningioma) filling the right neural foramen with extension into the spinal canal (7 mm × 8 mm × 11 mm): The tumor was originally “missed”. The new 2015 enhanced MR scan documented the tumor had enlarged 6.7 fold (measuring 17 mm × 11 mm × 2.2 cm), and now filled 2/3 of the spinal canal, markedly compressing the cord and right C6 nerve root. Following a C4–C6 laminectomy, and a challenging tumor removal, and the patient was neurologically intact.
This case underscores the need for spine surgeons to carefully review both images and reports of prior diagnostic studies that accompany patients. In this case, the original failure to recognize the tumor led to a 2.5-year delay in surgery that resulted in the patient's severe preoperative quadriparesis, and a much more challenging surgery.
PMCID: PMC4496831  PMID: 26167368
Computed tomography; enhanced magnetic resonance imaging; magnetic resonance imaging; meningioma; radiology; read studies; spinal surgery; surgeon; quadriparesis
25.  A case of dumbbell-shaped epidural cavernous angioma in the lumbar spine 
Surgical Neurology International  2015;6(Suppl 10):S309-S312.
Most spinal cavernous haemangiomas occur in the vertebral body and purely extradural cavernous hemangiomas without any vertebral body involvement is rare and account for only 4% of all extradural spinal tumors. Dumbbell-shaped spinal cavernous angioma is extremely rare, only 10 cases have been reported in the literature.
Case Description:
A 77-year-old female presented with a one-year history of lumbago and right-sided L3 dermatomal hypoesthesia. A dumbbell mass at the L2/3 vertebral level was identified on lumbar MRI. The lesion was irregularly shaped and isointense on T1W and hyperintense on T2W and DWI images with homogenous contrast enhancement. A presumptive diagnosis was schwannoma, but other malignant neoplasms were also considered because of its irregular shape, minimally dilated neural foramen and the involvement of the non-enhanced L3 nerve root. The patient underwent surgery with a lateral extracavitary approach. A histopathological examination revealed cavernous hemangioma.
Cavernous hemangioma should be included in the differential diagnosis of dumbbell-shaped spinal tumors when the intervertebral foramina is not highly dilated and non-enhanced nerve root is identified in the tumor.
PMCID: PMC4496832  PMID: 26167367
Cavernous hemangioma; differential diagnosis; dumbbell; epidural; lumbar

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