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1.  Carotico-clinoid foramina and a double optic canal: A case report with neurosurgical implications 
Background:
The lesser wing of the sphenoid is a clinically important structure, particularly with regard to its anatomical relationship with neurovascular structures including the optic nerve, ophthalmic artery, and internal carotid artery. Anterior clinoidectomy, a neurosurgical procedure utilized to access paraclinoid aneurysms and neoplasms, is often complicated by the presence of anatomical variants including the carotico-clinoid foramen and the accessory optic canal.
Case Description:
A rare case report is presented documenting the simultaneous occurrence of bilateral carotico-clinoid foramina and a unilateral accessory optic canal.
Conclusion:
The presence of an accessory optic canal may be misconstrued as a carotico-clinoid foramen or pneumatization of the anterior clinoid process, lesser sphenoidal wing, or optic strut. The case report documents two clinically important variant structures occurring ipsilaterally, each with the potential to masquerade as the other radiographically and present complications to both neurosurgeons and radiologists. Knowledge of the unique combination of anatomical variants presented in this report may prevent adverse surgical events during anterior clinoidectomy procedures including hemorrhage of the ophthalmic artery or internal carotid artery and subsequent vision loss or death.
doi:10.4103/2152-7806.150456
PMCID: PMC4314831  PMID: 25657866
Anterior clinoidectomy; internal carotid artery; ophthalmic artery; ophthalmic foramen; optic foramen; paraclinoid aneurysm
2.  Bilateral assymetric epidural hematoma 
Background:
Acute bilateral extradural hematoma is a rare presentation of head trauma injury. In sporadic cases, they represent 0.5–10% of all extradural hematomas. However, higher mortality rates have been reported in previous series.
Case Description:
The authors described the case of a 28-year-old male presenting head injury, comatose, Glasgow Coma Scale of 6, anisocoric pupils without puppilary light reflex. Computed tomography showed asymmetric bilateral epidural hematomas, effacement of the lateral ventricles and sulci, midline shift and a bilateral skull fracture reaching the vertex. Surgical evacuation was performed with simultaneous hematoma drainage. Patient was discharged on the 29th postoperative day with no neurological deficit.
Conclusion:
The correct approach on bilateral epidural hematomas depends on the volume, moment of diagnosis, and neurological deficit level. Simultaneous drainage of bilateral hematomas has been demonstrated to be an effective technique for it, which soon decreases the intracranial pressure and promotes an efficient resolution to the neurological damage.
doi:10.4103/2152-7806.150458
PMCID: PMC4314832  PMID: 25657867
Bilateral; extradural; hematoma; trauma; traumatic brain injury
3.  Programming for physicians: A crash course 
doi:10.4103/2152-7806.150460
PMCID: PMC4314833  PMID: 25657868
4.  A modified anterior temporal approach for low-position aneurysms of the upper basilar complex 
Background:
Although surgery for aneurysms of the upper basilar complex is generally accomplished by a pterional or subtemporal approach, both techniques have disadvantages. Therefore, attempts have been made to combine both the approaches, such as an anterior temporal approach, which exposes the anterior aspect of the temporal lobe during standard fronto-temporal craniotomy. However, in all these techniques, the temporal vein is sacrificed to allow posterior retraction of the temporal lobe, which may cause venous infarction in the temporal lobe.
Methods:
Our institutional review board approved this prospective study. We modified the anterior temporal approach for low-position aneurysms of the upper basilar complex by performing posterior clinoidectomy as necessary, thereby preventing the sacrifice of all vessels.
Results:
From 2007 to 2014, seven patients were operated on using this modified approach, and four patients underwent additional posterior clinoidectomy. Complete clip ligation was performed for all aneurysms without sacrificing any vessels, and there were no permanent complications attributable to manipulation for clipping or posterior clinoidectomy.
Conclusions:
The modified anterior temporal approach allows a wider operating field within the retro-carotid space, without sacrificing any vessels, and permits safer posterior clinoidectomy and aneurysm clipping in patients with low-position aneurysms of the basilar complex.
doi:10.4103/2152-7806.149843
PMCID: PMC4310043  PMID: 25657863
Anterior temporal approach; basilar artery; posterior clinoidectomy; surgery
5.  Vacuum-assisted closure of necrotic and infected cranial wound with loss of dura mater: A technical note 
Background:
Complex cranial wounds can be a problematic occurrence for surgeons. Vacuum-assisted closure devices have a wide variety of applications and have recently been used in neurosurgical cases involving complex cranial wounds. There is only one report regarding the use of a vacuum-assisted closure device with loss of dura mater. We report a complicated case of a necrotic cranial wound with loss of dura mater.
Case Description:
A 68-year-old female underwent an evacuation of a subdural hematoma. Postoperatively, the patient developed a wound infection that required removal of the bone flap. The wound developed a wedge-shaped necrosis of the scalp with exposure of brain tissue due to loss of dura mater from previous surgeries. She underwent debridement and excision of the necrotic tissue with placement of a synthetic dural graft (Durepair®, Medtronic, Inc.) and placement of a wound vac. The patient underwent a latissismus dorsi muscle flap reconstruction that subsequently failed. After the wound vac was replaced, the synthetic dural graft was replaced with a fascia lata graft and an anterolateral thigh free flap reconstruction. We describe the technical nuances of this complicated case, how the obstacles were handled, and the literature that discusses the utility.
Conclusion:
We describe a case of a complex cranial wound and technical nuances on how to utilize a wound-vac with loss of dura mater.
doi:10.4103/2152-7806.149846
PMCID: PMC4310057  PMID: 25657864
Infection; necrosis; subdural hematoma; vacuum-assisted closure
6.  Fibro-osseous lesion of the cranium in an adolescent patient 
Background:
Fibrous dysplasia, ossifying fibroma, and desmoplastic fibroma are rare benign calvarial lesions, which can have local aggressive behavior. These tumors can present with similar clinical and radiologic characteristics making diagnosis difficult at times.
Case Description:
A 16-year-old male presents after noting an indentation of his skull. Comparison with current and previous imaging revealed progressive erosion of the skull underlying the indentation.
Conclusion:
Fibrous dysplasia, ossifying fibroma, and desmoplastic fibroma are rare fibro-osseous tumors with similar characteristics radiographically. Accurate diagnosis of these tumors can be difficult even with the combination of clinical presentation, imaging, and pathology. The treatment of choice is resection and cranial reconstruction, if necessary, with close follow-up as recurrence can occur.
doi:10.4103/2152-7806.149848
PMCID: PMC4310058  PMID: 25657865
Desmoplastic fibroma; fibrous dysplasia; intraosseous; ossifying fibroma; skull lesion
7.  Symptomatic foramen of Magendie arachnoid cyst in an elderly patient 
Background:
Arachnoid cysts (ACs) are congenital anomalies of the central nervous system and arise in virtually all locations where the arachnoid membrane exists. Posterior fossa ACs are considered to develop in the posterior aspect of the rhombencephalic roof plate and do not communicate freely with the fourth ventricle or perimedullary subarachnoid space. Although posterior fossa ACs have been reported a number of times, ACs arising from the foramen of Magendie are very rare.
Case Description:
We report here on a 76-year-old female who presented with progressive gait disturbance. Magnetic resonance imaging of the head showed a large AC in the foramen of Magendie that was compressing the inferior vermis and medial aspects of the cerebellar hemisphere without causing hydrocephalus. Neurological examination revealed cerebellar ataxia without Romberg's sign. A nearly total excision of the cyst was safely performed via a median suboccipital approach. The patient's postoperative course was excellent and her neurological recovery was remarkable.
Conclusion:
Most cases of ACs located in the foramen of Magendie are reported in children, and it is extremely rare to observe such ACs in the elderly. In fact, to our knowledge, a symptomatic foramen Magendie AC has never been reported previously in an elderly person. Our results indicate that proper surgical intervention can yield highly positive outcomes in such cases.
doi:10.4103/2152-7806.149611
PMCID: PMC4310131  PMID: 25657860
Arachnoid cyst; elderly; foramen of Magendie; midline; posterior fossa
8.  Rapid aneurysm growth and rupture in systemic lupus erythematosus 
Background:
Subarachnoid hemorrhage (SAH) due to intracranial aneurysm rupture is a major neurosurgical emergency associated with significant morbidity and mortality. Rapid aneurysm growth is associated with rupture. Systemic lupus erythematosus (SLE) is a multi-system autoimmune disorder whose complications can include cerebral vasculitis and vasculopathy. Intracranial aneurysms are not known to occur more frequently in SLE patients than the general population; however, aneurysm growth rates have not been studied in SLE.
Case Description:
We present a 43-year-old female with SLE on prednisone, hydroxychloroquine, and azathioprine with moderate disease activity who presented with severe, acute-onset headache and was found to have Hunt and Hess grade II SAH due to rupture of an 8 mm saccular anterior communicating artery (ACoA) aneurysm. The patient developed severe vasospasm, re-ruptured, and was taken for angiography and embolization, which was challenging due to a high degree of vasospasm and arterial stenosis. Review of imaging from less than 2 years prior demonstrated a normal ACoA complex without evidence of an aneurysm.
Conclusion:
We review the literature and discuss the risk factors and pathophysiology of rapid aneurysm growth and rupture, as well as the pathologic vascular changes associated with SLE. Although SLE patients do not develop intracranial aneurysm at an increased rate, these changes may predispose them to higher incidence of growth and rupture. This possibility-coupled with increased morbidity and mortality of SAH in SLE-suggests that SAH should be considered in SLE patients presenting with headache, and advocates for more aggressive treatment of SLE patients with unruptured aneurysms.
doi:10.4103/2152-7806.149617
PMCID: PMC4310132  PMID: 25657862
Aneurysm growth; intracranial aneurysms; subarachnoid hemorrhage; systemic lupus erythematosus
9.  Anti-epileptic prophylaxis in traumatic brain injury: A retrospective analysis of patients undergoing craniotomy versus decompressive craniectomy 
Background:
Seizures account for significant morbidity and mortality early in the course of traumatic brain injury (TBI). Although there is sufficient literature suggesting short-term benefits of antiepileptic drugs (AEDs) in post-TBI patients, there has been no study to suggest a time frame for continuing AEDs in patients who have undergone a decompressive craniectomy for more severe TBI. We examined trends in a level-II trauma center in southern California that may provide guidelines for AED treatment in craniectomy patients.
Methods:
A retrospective analysis was performed evaluating patients who underwent decompressive craniectomy and those who underwent a standard craniotomy from 2008 to 2012.
Results:
Out of the 153 patients reviewed, 85 were included in the study with 52 (61%) craniotomy and 33 (39%) craniectomy patients. A total of 78.8% of the craniotomy group used phenytoin (Dilantin), 9.6% used levetiracetam (Keppra), 5.8% used a combination of both, and 3.8% used topiramate (Topamax). The craniectomy group used phenytoin 84.8% and levetiracetam 15.2% of the time without any significant difference between the procedural groups. Craniotomy patients had a 30-day seizure rate of 13.5% compared with 21.2% in craniectomy patients (P = 0.35). Seizure onset averaged on postoperative day 5.86 for the craniotomy group and 8.14 for the craniectomy group. There was no significant difference in the average day of seizure onset between the groups P = 0.642.
Conclusion:
Our study shows a trend toward increased seizure incidence in craniectomy group, which does not reach significance, but suggests they are at higher risk. Whether this higher risk translates into a benefit on being on AEDs for a longer duration than the current standard of 7 days cannot be concluded as there is no significant difference or trend on the onset date for seizures in either group. Moreover, a prospective study will be necessary to more profoundly evaluate the duration of AED prophylaxis for each one of the stated groups.
doi:10.4103/2152-7806.149613
PMCID: PMC4310133  PMID: 25657861
Craniotomy; craniectomy; levetiracetam; phenytoin; seizure; traumatic brain injury; topiramate
10.  Neurosurgery concepts: Key perspectives on dendritic cell vaccines, metastatic tumor treatment, and radiosurgery 
Background:
This is a laboratory study to investigate the effect of adding brain-derived-neurotrophic factor (BDNF) in a poly (N-isopropylacrylamide-g-poly (ethylene glycol) scaffold and its effect on spinal cord injury in a rat model.
Methods:
This is a laboratory investigation of a spinal cord injury in a rat model. A dorsolateral funiculotomy was used to disrupt the dorsolateral funiculus and rubrospinal tract. Animals were then injected with either the scaffold polymer or scaffold polymer with BDNF. Postoperatively, motor functions were assessed with single pellet reach to grasp task, stair case reaching task and cylinder task. Histological study was also performed to look at extent of glial scar and axonal growth.
Results:
Animals received BDNF containing polymer had an increased recovery rate of fine motor function of forelimb, as assessed by stair case reaching task and single pellet reach to grasp task compared with control animals that received the polymer only. There is no significant difference in the glial scar formation. BDNF treated animals also had increased axon growth including increase in the number and length of the rubrospinal tract axons.
Conclusion:
BDNF delivered via a scaffold polymer results in increased recovery rate in forelimb motor function in an experimental model of spinal cord injury, possibly through a promotion of growth of axons of the rubrospinal tract.
doi:10.4103/2152-7806.149389
PMCID: PMC4310042  PMID: 25657859
Radiosurgery; Gamma Knife; metastasis; immunotherapy; glioblastoma; dens fracture; meningiomas
11.  Characteristics of the stroke alert process in a general Hospital 
Background:
The organized stroke alert is critical in quickly evaluating and treating patients with acute stroke. The purpose of this paper was to further understand how this process functions in a moderate sized general hospital by exploring the effects of patient location and time of day on the pace of evaluation and the eventual outcome of evaluation.
Methods:
Retrospective chart review.
Results:
The rate of stroke alerts depended on the time of day and patient location. There was a low probability (41%) that the eventual diagnosis was stroke after a stroke alert, but there was no effect of diagnosis on the pace of evaluation. The time between stroke alert and a computed tomography (CT) scan being read was shortest for patients in the emergency room (ER) and longer for patients in the intensive care unit (ICU) or medical/surgical floors. Patients evaluated on medical/surgical floors were less likely to receive tissue plasminogen activator (tPA) than those evaluated in the ER, even though the comorbidities were similar. This may be due to the greater severity of the comorbidities in patients who were already admitted to the hospital.
Conclusion:
The rate of tPA administration was lower for stroke alerts called from medical/surgical floors than from the ER. Stroke alerts were most frequent in late afternoon.
doi:10.4103/2152-7806.149387
PMCID: PMC4310046  PMID: 25657858
Stroke; tissue plasminogen activator; treatment
12.  Binswanger disease may benefit from omental arteries 
doi:10.4103/2152-7806.148848
PMCID: PMC4310055  PMID: 25657857
13.  A proposed grading system for endovascular treatment of cerebral arteriovenous malformations: Buffalo score 
Background:
The Spetzler–Martin arteriovenous malformation (AVM) grading system has proven to be useful in guiding treatment of cerebral AVMs with craniotomy. It is based on anatomical characteristics each of which makes surgical resection of an AVM more difficult, namely, deep venous drainage, eloquence of surrounding tissue, and large nidus size. A higher score correlates with more complications after treatment. Although this grading system has proven reliable over time, it does not reflect the major determinants of risk associated with endovascular treatment. The authors developed a grading system unique to endovascular treatment of cerebral AVMs.
Methods:
The proposed grading system accounts for the principal AVM anatomical and physiological features that make endovascular embolization more difficult and, thus, the likelihood of complications greater. These include number of arterial pedicles, diameter of arterial pedicles, and eloquent location of AVM nidus. The proposed grading system was retrospectively applied to 50 patients undergoing endovascular AVM embolization, and its ability to predict complications was compared to the Spetzler–Martin grading system.
Results:
Perioperative complications among the 50 patients included 4 major and 9 minor complications. The proposed grading system was predictive of complication risk, with an increasing rate of perioperative complications associated with an increasing AVM grade. An improved correlation of perioperative complication incidence was noted with the proposed system (P = 0.002), when compared with the Spetzler–Martin grading system (P = 0.33).
Conclusion:
This grading system for the endovascular treatment of AVMs is simple, easily reproduced, and clinically valuable.
doi:10.4103/2152-7806.148847
PMCID: PMC4310056  PMID: 25657856
Cerebral arteriovenous malformations; complications; endovascular glue embolization
14.  Posterior fossa giant tumefactive perivascular spaces: 8-year follow-up in an adolescent 
Background:
Cystic masses in the posterior fossa are ominous appearing lesions with broad differential diagnosis. Giant tumefactive perivascular spaces (GTPS) are rarely occurring pathological findings in the posterior fossa with unclear etiology and ill-defined long-term prognosis.
Case Description:
We present a case of a 15-year-old male diagnosed with posterior fossa GTPS. The patient remained asymptomatic during the 8-year follow-up after diagnosis with the serial magnetic resonance imaging (MRI) showing no change in the size and morphology of the lesion.
Conclusion:
This case supports prior literature on supratentorial GTPS suggesting that the natural history of GTPS is mostly benign. Identification of GTPS in the posterior fossa could prevent the patient from unnecessary surgery or other aggressive treatment modalities.
doi:10.4103/2152-7806.148547
PMCID: PMC4310044  PMID: 25657855
Cerebral cyst; giant tumefactive perivascular spaces; posterior fossa; prognosis
15.  A clinical scale to communicate surgical urgency for traumatic brain injury: A preliminary study 
Background:
While the Glasgow Coma Scale (GCS) provides a tool for evaluating traumatic brain injury (TBI) patients, there is no widely used scale that provides guidance for surgical management. This study introduces a scoring system that physicians potentially could use to determine and communicate the need for surgical decompression in TBI patients. The proposed system is designed to be both comprehensive and easy to use.
Methods:
The Surgical Intervention for Traumatic Injury (SITI) scale uses radiographic and clinical findings. Patients were graded based on their GCS: GCS >12 received 0 points, GCS 9-12 received 1 point, and GCS <9 received 2 points. An enlarged unilateral pupil added 2 points. Computed tomography findings were also graded: midline shift <5 mm received 0 points, 5-10 mm received 2 points, and >10 mm received 4 points. The presence of temporal pathology added 1 point, and epidural hematoma (EDH) ≥10 mm added 2 points. Retrospective analysis of 48 patients was then performed using the SITI scale.
Results:
Of the 48 patients reviewed, 24 patients underwent craniotomy and the other 24 were treated non-operatively. The mean SITI score was 5.7 (range 3-10) for operative patients and 2.5 (range 1-4) for non-operative patients.
Conclusions:
The proposed SITI scale is designed to be a simple, objective system for assisting in communication between clinical services and for suggesting the need for surgical decompression for TBI. Based upon our initial review, a SITI score of 3 or less correlated with non-operative management and a score of 5 or greater correlated with operative management. Given the results of this study, we believe that further development and research of the SITI scale are warranted.
doi:10.4103/2152-7806.148541
PMCID: PMC4310045  PMID: 25657854
Computed tomography; emergency medicine; Glasgow Coma Scale; neurosurgery; traumatic brain injury
16.  Gamma knife radiosurgery to the trigeminal ganglion for treatment of trigeminal neuralgia secondary to vertebrobasilar ectasia 
Surgical Neurology International  2014;5(Suppl 16):S580-S585.
Background:
We report the result obtained using Gamma knife stereotactic radiosurgery on the trigeminal ganglion (TG) in a patient with trigeminal neuralgia (TN) secondary to vertebrobasilar ectasia (VBE).
Case Description:
Retrospective review of medical records corresponding to one patient with VBE-related trigeminal pain treated with radiosurgery. Because of the impossibility of visualization of the entry zone or the path of trigeminal nerve through the pontine cistern, we proceeded with stereotactic radiosurgery directed to the TG. The maximum radiation dose was 86 Gy with a 8-mm and a 4-mm collimator. The follow-up period was 24 months. The pain disappeared in 15 days, passing from Barrow Neurological Institute (BNI) grade V to BNI grade IIIa in 4 months and then to grade I. The patient did not experience noticeable subjective facial numbness.
Conclusions:
This experience showed that Gamma knife radiosurgery was effective in the management of VBE-related trigeminal pain, using the TG as radiosurgical target.
doi:10.4103/2152-7806.148056
PMCID: PMC4287894  PMID: 25593782
Gamma knife radiosurgery; trigeminal neuralgia; trigeminal ganglion; vertebrobasilar ectasia
17.  A blast from the past!: The value of adding single slice magnetic resonance myelography sequence to magnetic resonance imaging of the spine; a flashback to the conventional myelography of the past 
Surgical Neurology International  2014;5(Suppl 15):S523-S528.
Background:
The study was undertaken to determine whether a single slice magnetic resonance (MR) myelogram sequence improves the interpretation and diagnostic yield for magnetic resonance imaging (MRI) of the spine.
Methods:
A total of 100 cases with positive findings were retrospectively reviewed. All patients had initial imaging with sagittal T1-weighted (T1-W) and T2-weighted (T2-W) scans, followed by axial T2-W images. Subsequently, a heavily T2-W single slice MR myelogram sequence was acquired in coronal and sagittal planes. The MR myelogram images were evaluated initially by a radiologist, and, further independently reviewed, by a neurologist, neurosurgeon, and spine surgeon. The utility of the MR myelogram in establishing the diagnosis was graded on a 4-point scale.
Results:
Out of 100 cases, 53% showed degenerative spine or disc disease, 14% space occupying lesions, 13%, congenital lesions, 7% infection, and 7% other conditions. The MR myelogram contributed additional information in 50-74% cases. The intraclass correlation coefficient showed overall good agreement between observers in grading the utility of MR myelogram.
Conclusion:
Single slice MR myelography is noninvasive avoiding the complications associated with lumbar punctures/intrathecal contrast injections, while image acquisition takes only an added 6-8 s. Although MR myelogram has no value as a stand-alone sequence, its inherent advantage is that it completes the overview of the spinal pathology in entirety, and adds vital three-dimensional information in 50-74% of cases.
doi:10.4103/2152-7806.148018
PMCID: PMC4287895  PMID: 25593771
Magnetic resonance imaging; magnetic resonance myelography; myelogram; spine
18.  Progression of cerebellar chronic encapsulated expanding hematoma during late pregnancy after gamma knife radiosurgery for arteriovenous malformation 
Surgical Neurology International  2014;5(Suppl 16):S575-S579.
Background:
The etiology and appropriate management strategy of chronic encapsulated expanding hematoma during pregnancy after gamma knife radiosurgery for arteriovenous malformation (AVM) remain unclear.
Case Description:
A 34-year-old female developed chronic encapsulated expanding hematoma during late pregnancy, after angiographic disappearance of cerebellar AVM following two courses of gamma knife radiosurgery. The present case implicates pregnancy as a potential promoter of growth and enlargement of chronic encapsulated expanding hematoma, which may become life-threatening and require surgical intervention.
Conclusion:
Immediate surgical management after delivery may be associated with a favorable outcome, so close follow-up management and patient education are very important in women planning pregnancy.
doi:10.4103/2152-7806.148054
PMCID: PMC4287896  PMID: 25593781
Arteriovenous malformation; gamma knife; pregnancy; radiosurgery
19.  Commentary: Utility of the O-Arm in spinal surgery 
Surgical Neurology International  2014;5(Suppl 15):S517-S519.
Background:
More studies report the intraoperative benefits vs. risks of utilizing the O-Arm in performing pedicle screw insertion in spinal surgery.
Methods/Results:
Several studies document the utility of CT-guided O-arm placement of pedicle/lateral mass screws. Singh et al. documented the efficacy of CT guided-O Arm placement of pedicle screws and lateral mass screws in the upper cervical spine.[4] Specifically, 10 patients with unstable hangman's fractures (ages 17-80) required 52 screws; C2 pedicle screws (20), C3 lateral mass screws (20), C4 lateral mass screws (12) and one C2 pedicle screw. Of these only 5% were misplaced, and none had new neuorlogical deficits. Kim et al. demonstrated the safety/efficacy of the CT/O-arm in minimally invasive spine surgery (MIS) (posterior percutaneous spinal fusions).[1] Of 290 pedicle screws, 280 (96.6%) were acceptably placed. Kotani et al. compared the placement of 222 pedicle screws (29 patients operated upon with CT-based navigation) vs. 416 screws (32 having surgery using O-arm-based navigation); postoperative CT studies confirmed the accuracy of screw placement, and no significant differences in the frequency of grade 2-3 perforations between the two groups. Nelson et al. analyzed the radiation exposure delivered to the operating room staff utilizing C-arm fluoroscopy (C-arm), portable X-ray (XR) radiography, and portable cone-beam computed tomography (O-arm); the surgeon and assistant were exposed to higher levels of scatter radiation from the C-arm, with a 7.7-fold increase in radiation exposure on the tube vs. detector sides.[3]
Conclusion:
There are several pros and a few cons (radiation dosage) for the use of the O-arm in spine surgery.
doi:10.4103/2152-7806.148001
PMCID: PMC4287897  PMID: 25593769
O Arm; radiation dosage; spinal surgery; utility
20.  Cavernous sinus lesions biopsy with neuronavigation and tip-cut needle 
Surgical Neurology International  2014;5(Suppl 16):S586-S589.
Background:
Transoval biopsy of cavernous sinus (CS) lesions is the last non-invasive diagnostic option in those 15% of patients in whom etiology remains unclear in spite of extensive neuroradiological imaging, clinical assessment, and laboratory evaluation. However, there are no guidelines defining indications and the most appropriate technique for this procedure.
Case Description:
We present four patients in whom we performed X-ray and neuronavigation-assisted transoval CS biopsies using tip-cut needles.
Conclusion:
The technique described allows the operator to determine the optimal angle for entering the CS, avoiding the complications due to distorted anatomy, and facilitating orientation once inside the CS. It reduces both radiation exposure as well as general anesthesia duration.
doi:10.4103/2152-7806.148057
PMCID: PMC4287898  PMID: 25593783
Cavernous sinus lesions; foramen ovale biopsy; minimally invasive biopsy; tip-cut needle; transoval approach
21.  The pathophysiology, classification, treatment, and prognosis of a spontaneous thoracic spinal cord herniation: A case study with literature review 
Surgical Neurology International  2014;5(Suppl 15):S564-S566.
Background:
Spinal cord herniation was first described in 1974. It generally occurs in middle-aged adults in the thoracic spine. Symptoms typically include back pain and progressive paraparesis characterized by Brown-Séquard syndrome. Surgical reduction of the hernia improves the attendant symptoms and signs, even in patients with longstanding deficits.
Case Description:
A 66-year-old female with back pain for 7 years, accompanied by paresthesias and a progressive paraparesis, underwent a thoracic MRI which documented a ventral spinal cord herniation at the T4 level. Following a laminectomy, with reduction of the hernia and ventral dural repair, the patient improved.
Conclusion:
Herniation of the thoracic cord, documented on MR, may produce symptomatic paraparesis which may resolve following laminectomy with ventral dural repair.
doi:10.4103/2152-7806.148042
PMCID: PMC4287899  PMID: 25593778
Laminectomy; magnetic resonance imaging; microsurgery; neurosurgical procedures; spinal cord diseases
22.  Public awareness of the bone morphogenic protein controversy: Evidence from news publications 
Surgical Neurology International  2014;5(Suppl 15):S529-S535.
Background:
Use of recombinant human bone morphogenic protein-2 (rhBMP-2) in spinal fusion has seen a tremendous increase. Public awareness of rhBMP-2 and its complications has not been assessed. The authors studied published news media articles to analyze information provided to the public on this bone graft substitute.
Methods:
We utilized the academic database, LexisNexis, to locate newspaper articles published between January 2001 and July 2013. All articles were coded by a coder and reviewed by the principal investigator.
Results:
The search identified 87 national and 99 local newspaper articles. Complications mentioned in national newspapers included cancer (24%), retrograde ejaculation (24%), and abnormal bone growth (14%). Local newspapers cited cancer (14%), inflammation (14%), and retrograde ejaculation (9.2%) most frequently. Fifty national (59%) and 35 local (54%) articles had no mention of complications. Sources of evidence cited by articles were (in order of frequency): Governmental agencies, medical research or published studies, healthcare personnel or patients, and companies or corporations.
Conclusions:
Only a small percentage of newspaper articles presented potential complications. Despite lack of clear scientific causal relationship between rhBMP-2 and cancer, this risk was disproportionately reported. Additionally, many did not cite scientific sources. Lack of reliable information available to the public reiterates the role of physicians in discussing risks and benefits BMP use in spinal surgery, assuring that patients are making informed decisions. Future news media articles should present risks in an impartial and evidence-based manner. Collaboration between advocacy groups, medical institutions, and media outlets would be beneficial in achieving this goal.
doi:10.4103/2152-7806.148025
PMCID: PMC4287900  PMID: 25593772
Bone morphogenic protein; BMP; news media; public; rhBMP-2; spine fusion surgery
23.  Cervical laminoforaminotomy for radiculopathy: Symptomatic and functional outcomes in a large cohort with long-term follow-up 
Surgical Neurology International  2014;5(Suppl 15):S536-S543.
Background:
The efficacy and safety of cervical laminoforaminotomy (FOR) in the treatment of cervical radiculopathy has been demonstrated in several series with follow-up less than a decade. However, there is little data analyzing the relative effectiveness of FOR for radiculopathy due to soft disc versus osteophyte disease. In the present study, we review our experience with FOR in a single-center cohort, with long-term follow-up.
Methods:
We examined the charts of patients who underwent 1085 FORs between 1990 and 2009. A cohort of these patients participated in a telephone interview designed to assess improvement in symptoms and function.
Results:
A total of 338 interviews were completed with a mean follow-up of 10 years. Approximately 90% of interviewees reported improved pain, weakness, or function following FOR. Ninety-three percent of patients were able to return to work after FOR. The overall complication rate was 3.3%, and the rate of recurrent radiculopathy requiring surgery was 6.2%. Soft disc subtypes compared to osteophyte disease by operative report were associated with improved symptoms (P < 0.05). The operative report of these pathologic subtypes was associated with the preoperative magnetic resonance imaging (MRI) interpretation (P < 0.001).
Conclusions:
These results suggest that FOR is a highly effective surgical treatment for cervical radiculopathy with a low incidence of complications. Radiculopathy due to soft disc subtypes may be associated with a better prognosis compared to osteophyte disease, although osteophyte disease remains an excellent indication for FOR.
doi:10.4103/2152-7806.148029
PMCID: PMC4287901  PMID: 25593773
Cervical radiculopathy; laminoforaminotomy; posterior cervical foraminotomy; surgical outcomes
24.  Recurrent atlantoaxial synovial cyst resection via a navigation-guided, endoscope-assisted posterior approach 
Surgical Neurology International  2014;5(Suppl 15):S567-S569.
Background:
Atlantoaxial cysts are rare, and only 46 histologically confirmed cases have been reported.
Case Description:
A 75-year-old male presented 2 years ago with headache, neck pain, loss of balance, and episodic dysphagia, for which he had undergone posterior cervical drainage of a left-sided atlantoaxial cyst. Although his original symptoms resolved, they recurred 2 years later and were correlated with an enhanced MR that showed a recurrent left C1-C2 synovial cyst causing marked cervical cord compression. It was successfully resected through a navigation-guided, endoscope-assisted posterior approach. The patient's symptoms/signs resolved completely, and he has remained symptom-free for over 30 months postoperatively, with no evidence of recurrence on MR or craniocervical instability.
Conclusions:
A patient who successfully underwent resection of a recurrent synovial cervical cyst using a navigation-guided, endoscope-assisted posterior approach has been reported here.
doi:10.4103/2152-7806.148048
PMCID: PMC4287902  PMID: 25593779
Atlantoaxial joint; endoscopic assistance; intraoperative navigation; posterior approach; semi-sitting position; synovial cyst
25.  K-Wire fracture during minimally invasive transforaminal lumbar interbody fusion: Report of six cases and recommendations for avoidance and management 
Surgical Neurology International  2014;5(Suppl 15):S520-S522.
Background:
Although rare, minimally invasive spine techniques do have the risk of intraoperative device failure. Kirschner wire (K-wire) fractures during minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) have not been previously reported. This report focuses on the incidence of k-wire fractures following MI-TLIF and describes techniques to help avoid and treat these fractures when they occur.
Methods:
Inclusion criteria: (i) patients underwent 1, 2, or 3 level MI-TLIF over a 10-year period and (ii) had a k-wire fracture leading to a retained fragment. Exclusion criteria included: >10° coronal curves, significant sagittal malalignment, infection, and preoperative instrumentation failure.
Results:
Of 513 patients undergoing MI-TLIF, 6 (1.2%) sustained k-wire fracture (3 males, 3 females, mean age 43 ± 13 years). Complications included k-wire fracture alone (4 patients), cerebrospinal fluid (CSF) leak (1 patient), and both ileus and revision for hardware removal (1 patient). All six patients went home postoperatively. The mean follow-up duration was 27.7 ± 37.4 months. All retained k-wire fragments were located in the vertebral bodies at the tip of the pedicle screws; none breached the anterior cortex of the vertebral bodies. None of the k-wires migrated at final follow-up 7.8 years (93.7 months) postoperatively. Furthermore, no complications were attributed to retained k-wires.
Conclusions:
K-wire fractures during MI-TLIF are rare (incidence of 1.2%) and retained k-wire segments led to no postoperative complications (e.g. no migration).
doi:10.4103/2152-7806.148009
PMCID: PMC4287903  PMID: 25593770
Complications; Kirschner wire; K-wire; minimally invasive; transforaminal lumbar interbody fusion; TLIF

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