Predicting the Need for Surgery in Patients with Lumbar Disc Herniation: A New Internally Validated Scoring System

Study Design Prospective study. Purpose To propose a scoring system for predicting the need for surgery in patients with lumbar disc herniation (LDH). Overview of Literature The indications for surgery in patients with LDH are well established. However, the exact timing of surgery is not. According to surgeons, patients with failed conservative treatment who underwent delayed surgery, often after 6 months post-symptom initiation, have poor functional recovery and outcome. Methods The current study included patients with symptomatic LDH. Patients with an indication for emergent surgery such as profound or progressive motor deficit, cauda equina syndrome, and diagnoses other than single-level LDH were excluded from the analysis. All patients followed a conservative treatment regimen (a combination of physical therapy, pain medications, and/or spinal epidural steroid injections). Surgery was indicated for patients who continuously experienced pain despite maximal conservative therapy. Results In total, 134 patients met the inclusion and exclusion criteria. Among them, 108 (80.6%) responded to conservative management, and 26 (19.4%) underwent unilateral laminotomy and microdiscectomy. The symptom duration, disc degeneration grade on magnetic resonance imaging (Pfirrmann disc grade), herniated disc location and type, fragment size, and thecal sac diameter significantly differed between patients who responded to conservative treatment and those requiring surgery. The area under the receiver operating characteristic curve of the scoring system based on the anteroposterior size of the herniated disc fragment and herniated disc location and type was 0.81. Conclusions A scoring system based on herniated disc/fragment size, location, and type can be applied to predict the need for surgery in patients with LDH. In the future, this tool can be used to prevent unnecessarily prolonged conservative management (>4–8 weeks)

Therapeutic impact of cytoreductive surgery and irradiation of posterior fossa ependymoma in the molecular era: a retrospective multicohort analysis

PURPOSE: Posterior fossa ependymoma comprises two distinct molecular variants termed EPN_PFA and EPN_PFB that have a distinct biology and natural history. The therapeutic value of cytoreductive surgery and radiation therapy for posterior fossa ependymoma after accounting for molecular subgroup is not known. METHODS: Four independent nonoverlapping retrospective cohorts of posterior fossa ependymomas (n = 820) were profiled using genome-wide methylation arrays. Risk stratification models were designed based on known clinical and newly described molecular biomarkers identified by multivariable Cox proportional hazards analyses. RESULTS: Molecular subgroup is a powerful independent predictor of outcome even when accounting for age or treatment regimen. Incompletely resected EPN_PFA ependymomas have a dismal prognosis, with a 5-year progression-free survival ranging from 26.1% to 56.8% across all four cohorts. Although first-line (adjuvant) radiation is clearly beneficial for completely resected EPN_PFA, a substantial proportion of patients with EPN_PFB can be cured with surgery alone, and patients with relapsed EPN_PFB can often be treated successfully with delayed external-beam irradiation. CONCLUSION: The most impactful biomarker for posterior fossa ependymoma is molecular subgroup affiliation, independent of other demographic or treatment variables. However, both EPN_PFA and EPN_PFB still benefit from increased extent of resection, with the survival rates being particularly poor for subtotally resected EPN_PFA, even with adjuvant radiation therapy. Patients with EPN_PFB who undergo gross total resection are at lower risk for relapse and should be considered for inclusion in a randomized clinical trial of observation alone with radiation reserved for those who experience recurrence

Therapeutic Impact of Cytoreductive Surgery and Irradiation of Posterior Fossa Ependymoma in the Molecular Era: A Retrospective Multicohort Analysis

Posterior fossa ependymoma comprises two distinct molecular variants termed EPN_PFA and EPN_PFB that have a distinct biology and natural history. The therapeutic value of cytoreductive surgery and radiation therapy for posterior fossa ependymoma after accounting for molecular subgroup is not known

Carotid Artery Stenosis: What You Should Know

The information provided in this handout does not necessarily reflect the views of the University of Minnesota Medical School physicians and faculty. These materials are provided for informational purposes only and are in no way intended to take the place of the advice and recommendations of your personal health care provider. You use the information provided in these handouts at your own risk.Carotid artery stenosis, or CAS, can increase you risk of having a stroke. There are several things you can do to lower your risk including stopping smoking, controlling your weight, eating a good diet, and exercising regularly. Currently it is not recommended that you get screened for CAS if you are not having symptoms. If you are found to have CAS, there are several treatment options available to lower your risk of stroke

Hypertensive posterior reversible encephalopathy syndrome causing posterior fossa edema and hydrocephalus.

Posterior reversible encephalopathy syndrome (PRES) is a well characterized entity resulting from the inability of cerebral autoregulation to adequately protect the brain from uncontrolled hypertension. It primarily affects the occipital lobes, but can also involve the structures in the posterior fossa including the brainstem and cerebellum. Treatment usually consists of strict blood pressure control, but more aggressive management may be indicated with acutely worsening neurological status. We present a patient with hypertensive encephalopathy that resulted in hydrocephalus and brainstem compression necessitating surgical decompression requiring ventriculostomy and suboccipital craniectomy. In rare cases, PRES can present with severe brainstem compression requiring emergent posterior fossa decompression. When brainstem signs are present on exam, emergent posterior fossa decompression may be safer than ventriculostomy alone

Risk Factors and Outcomes in Thoracic Stenosis with Myelopathy. A Single Center Experience.

OBJECTIVE: Identify risk factors predisposing to thoracic spinal stenosis and myelopathy (TS) and address treatment options and outcomes. METHODS: A retrospective review of our center\u27s experience with TS over 10 years. Clinical and magnetic resonance imaging (MRI) data, surgical intervention and outcomes using Frankel and Japanese Orthopedic Association (JOA) scales were collected. RESULTS: A total of 44 patients with TS were identified. There were 30 men and 14 women with a mean age±SD of 66±15years. Neurological performance was evaluated using the Frankel scale (A-E or 1-5), and JOA scale for myelopathy (0-11). Frankel scores (1-5) and JOA scores (0-11) on admission were 3.5±0.9 and 6.8±2.6 respectively. At follow-up, Frankel scores had improved to 4.1±0.8 (p=0.041) and JOA scores had improved to 8.3±2.4 (p=0.021). The presence on admission of increased signal from the cord on T2-weighted MRI was associated with lower Frankel and JOA scores (3.3±0.9, and 6.2±2.5 respectively) than in those with absent increased signal (4.0±0.4 and 8.6±2.1, p=0.02 and p=0.008 respectively). There were 4 complications, requiring exploration and debridement for dehiscence in 3 and an epidural hematoma in the fourth that necessitated evacuation, with a good outcome. A fifth patient underwent reoperation at the same level 18 months later for persistent stenosis. CONCLUSION: Thoracic stenosis with myelopathy should be entertained in patients with myelopathy. Over half of our patients with TS were over the age of 70, and men outnumbered women by a ratio of 2:1. Nearly half the patients with TS had concomitant cervical and/or lumbar degenerative disease warranting surgery also. Increased signal intensity on T2-weighted MRI images correlated with lower Frankel and JOA scores compared to those without. Decompression for thoracic stenosis is associated with neurological improvement

Traumatic intracranial hemorrhage in patients taking dabigatran: report of 3 cases and review of the literature.

BACKGROUND AND IMPORTANCE: Dabigatran is a direct thrombin inhibitor gaining popularity as a stroke prevention agent in patients with atrial fibrillation. In comparison with warfarin, dabigatran showed superiority in stroke prevention, but lower rates of major hemorrhage and intracerebral hemorrhage. Although warfarin has a well-established reversal strategy, there is far less experience reversing dabigatran. CLINICAL PRESENTATION: We present our experience with 3 patients who experienced an intracranial hemorrhage either spontaneously or after low-energy cranial trauma and review the available literature describing dabigatran use in patients with traumatic brain injury. CONCLUSION: Intracranial hemorrhage in patients taking anticoagulants and/or antiplatelets can have either a benign or malignant clinical course. At this time, there is little experience with dabigatran reversal; however, several strategies for rapid reversal have been proposed. All patients with intracranial hemorrhage taking dabigatran should be admitted for close neurological monitoring and serial imaging