A Technical Nuance to Avoid Lumbar Five Radiculopathy with Anterior Lumbar Fusion and Posterior Instrumentation

The anterior lumbar interbody fusion (ALIF) is a well-established procedure used to treat a multitude of spinal pathologies. When performed at the L5-S1 level, the ALIF is often supplemented with posterior pedicle screw and rod fixation. Because the interbody device can restore disk and foraminal height, one benefit of the ALIF procedure is indirect neural decompression in the spinal canal and neural foramina. If the contour of the posterior rod is not matched to the exact position of the tulip heads on the pedicle screws, spondylolisthesis can be introduced, leading to foraminal stenosis and nerve compression. This concern is particularly germane when the posterior instrumentation is placed percutaneously without any direct foraminal decompression. In this report, we describe a patient who had an L4-S1 ALIF, resulting in new L5-S1 retrolisthesis and worsening L5 radiculopathy. Technical nuances and avoidance strategies are discussed

Gamma Knife surgery combined with resection for treatment of a single brain metastasis: preliminary results.

OBJECT: Resection and whole-brain radiation therapy (WBRT) have classically been the standard treatment for a single metastasis to the brain. The objective of this study was to evaluate the use of Gamma Knife surgery (GKS) as an alternative to WBRT in patients who had undergone resection and to evaluate patient survival and local tumor control. METHODS: The authors retrospectively reviewed the charts of 150 patients treated with a combination of stereotactic radiosurgery and resection of a cranial metastasis at their institution between April 1997 and September 2009. Patients who had multiple lesions or underwent both WBRT and GKS were excluded, as were patients for whom survival data beyond the initial treatment were not available. Clinical and imaging follow-up was assessed using notes from clinic visits and MR imaging studies when available. Follow-up data beyond the initial treatment and survival data were available for 68 patients. RESULTS: The study included 37 women (54.4%) and 31 men (45.6%) (mean age 60 years, range 28-89 years). In 45 patients (66.2%) there was systemic control of the primary tumor when the cranial metastasis was identified. The median duration between resection and radiosurgery was 15.5 days. The median volume of the treated cavity was 10.35 cm(3) (range 0.9-45.4 cm(3)), and the median dose to the cavity margin was 15 Gy (range 14-30 Gy), delivered to the 50% isodose line (range 50%-76% isodose line). The patients\u27 median preradiosurgery Karnofsky Performance Scale (KPS) score was 90 (range 40-100). During the follow-up period we identified 27 patients (39.7%) with recurrent tumor located either local or distant to the site of treatment. The median time from primary treatment of metastasis to recurrence was 10.6 months. The patients\u27 median length of survival (interval between first treatment of cerebral metastasis and last follow-up) was 13.2 months. For the patient who died during follow-up, the median time from diagnosis of cerebral metastasis to death was 11.5 months. The median duration of survival from diagnosis of the primary cancer to last follow-up was 30.2 months. Patients with a pretreatment KPS score ≥ 90 had a median survival time of 23.2 months, and patients with a pretreatment KPS score \u3c 90 had a median survival time of 10 months (p \u3c 0.008). Systemic control of disease at the time of metastasis was not predictive of increased survival duration, although it did tend to improve survival. CONCLUSIONS: Although the debate about the ideal form of radiation treatment after resection continues, these findings indicate that GKS combined with surgery offers comparable survival duration and local tumor control to WBRT for patients with a diagnosis of a single metastasis

Craniofacial Approaches to Large Juvenile Angiofibromas: Clinical Article

Object. Craniofacial approaches provide excellent exposure to lesions in the anterior and middle cranial fossae. The authors review their experience with craniofacial approaches for resection of large juvenile nasopharyngeal angiofibromas. Methods. Between 1992 and 2009, 22 patients (all male, mean age 15 years, range 9-27 years) underwent 30 procedures. These cases were reviewed retrospectively. Results. Gross-total resection of 17 (77%) of the 22 lesions was achieved. The average duration of hospitalization was 8.2 days (range 3-20 days). The rate of recurrence and/or progression was 4 (18%) of 22, with recurrences occurring a mean of 21 months after the first resection. All patients underwent preoperative embolization. Nine patients (41%) developed complications, the most common of which was CSF leakage (23%). The average follow-up was 27.7 months (range 2-144 months). The surgery-related mortality rate was 0%. Based on their mean preoperative (90) and postoperative (90) Karnofsky Performance Scale scores, 100% of patients improved or remained the same. Conclusions. The authors\u27 experience shows that craniofacial approaches provide an excellent avenue for the resection of large juvenile nasopharyngeal angiofibromas, with acceptable rates of morbidity and no deaths

A brief human history of ankylosing spondylitis: A scoping review of pathogenesis, diagnosis, and treatment.

BackgroundAnkylosing spondylitis (AS) is a chronic, progressive, inflammatory disease of the spine and SI joints. Diagnostic criteria and treatments have continued to evolve, necessitating a historical compendium of AS and its management. This paper aims to review the historical context underlying the discovery of AS, as well as the major diagnostic and therapeutic discoveries in the last two centuries.MethodsA scoping review of the literature pertaining to AS was performed via the Pubmed, Scopus, and Web of Science databases. Future directions of AS treatments were assessed by querying the clinicaltrials.gov website.ResultsThe history of AS can be traced as far back as ancient Egypt (as evidenced by the discovery of its presence in ancient Egyptian mummies) to the late 20th century, when the inherited nature of AS was linked to a genetic factor, HLA-B27. Each discovery made throughout the years led to further investigations into the pathophysiology, diagnosis, and treatment of AS. The criteria to differentiate AS from rheumatoid arthritis were first reported in 1893. Since then, diagnostic criteria for AS have undergone a series of changes before the present-day diagnostic criteria for AS were ultimately determined in 2009 by the Assessment of Spondyloarthritis International Society.ConclusionAs the pathophysiology of AS is better understood, healthcare providers are able to diagnose and treat the condition more effectively. In particular, earlier diagnosis and multiple treatment options have facilitated efficient and more effective treatment

Essential Step-by-Step Techniques for Minimally Invasive Spinal Surgery

The ultimate resource for learning and mastering minimally invasive spine surgery techniques An estimated 1.5 million instrumented spinal procedures are performed every year in the US. The majority of decompressions and about 50% of fusion procedures can be performed completely or partially using minimally invasive spine surgery (MISS) techniques. The full potential of MISS techniques has yet to be realized. Essential Step-by-Step Techniques for Minimally Invasive Spinal Surgery by internationally renowned MISS neurosurgeon Roger Härtl, spine-neurosurgeon Rodrigo Navarro-Ramirez, and an impressive group of global multidisciplinary contributors is the most comprehensive and detailed textbook written to date on this topic. The foundation of the book is built on six interacting principles critical to surgical success, and MISS in particular: Target, Technology, Technique, Teaching and Training, Testing, and Talent. The text starts with an opening chapter on the definition of MISS and introduction of these principles. Fifty-six subsequent chapters provide a comprehensive discussion on how to utilize an MISS approach for a full spectrum of spinal pathologies using nuanced variations specific to the operating surgeon. To ensure readers are well versed in all aspects of MISS, these chapters include painstaking details on indications, contraindications, pathoanatomy, operating room set-up, step-by-step techniques, and postoperative management. Key Highlights Contributions from master spine surgeons across the world provide a balanced global perspective on mastering and incorporating diverse techniques into practice Invaluable clinical pearls including tips/tricks and complication avoidance High-quality images, figures, anatomic drawings, and imaging studies illustrate relevant anatomic approaches and corridors and delineate why anatomic masteryis critical to MISS Twenty-five videos enhance the ability to learn and implement MISS approaches This is a must-have resource for practicing spine surgeons interested in MISS who wish to learn the latest techniques from master surgeons and achieve optimal patient outcomes. The text and videos also provide a robust training tool for senior-level orthopaedic and neurosurgery residents and spine fellows