Showing papers in "Journal of Neurosurgery in 2009"
TL;DR: Before the age of angiography, studies of the na tura l his tory of subarachnoid hemorrhage and its various causes were necessarily founded on au topsy findings, and little could be done to establish the cause in those who lived.
Abstract: T HE true na tura l h is tory of a disease is notoriously difficult to delineate and in some respects exasperat ingly elusive. I t requires t h a t observations be made on a sufficiently large sample of the disease population to accommoda te na tura l variabil i ty, t ha t this sample be representat ive of the total populat ion of the disease and tha t the total disease populat ion can be numerical ly related to the populat ion-atlarge. The natural course of the disease is elusive because of an obstacle which in present-day medicine amounts to a contradict ion: the representat ive sample populat ion mus t come under close medical scrut iny and a t the same t ime not have its na tura l course modified by t reat men t ! Before the age of angiography, studies of the na tura l his tory of subarachnoid hemorrhage (SAH) and its various causes were necessarily founded on au topsy findings, and little could be done to establish the cause in those who lived. Angiography made possible
882 citations
TL;DR: In the authors' experience with both primary and secondary resection of malignant brain astrocytomas, increasing extent of resection was associated with improved survival independent of age, degree of disability, WHO grade, or subsequent treatment modalities used.
Abstract: Object With recent advances in the adjuvant treatment of malignant brain astrocytomas, it is increasingly debated whether extent of resection affects survival. In this study, the authors investigate this issue after primary and revision resection of these lesions. Methods The authors retrospectively reviewed the cases of 1215 patients who underwent surgery for malignant brain astrocytomas (World Health Organization [WHO] Grade III or IV) at a single institution from 1996 to 2006. Patients with deep-seated or unresectable lesions were excluded. Based on MR imaging results obtained < 48 hours after surgery, gross-total resection (GTR) was defined as no residual enhancement, near-total resection (NTR) as having thin rim enhancement of the resection cavity only, and subtotal resection (STR) as having residual nodular enhancement. The independent association of extent of resection and subsequent survival was assessed via a multivariate proportional hazards regression analysis. Results Magnetic resonance imagin...
693 citations
TL;DR: Revascularization surgery in patients with MMD carries a low risk, is effective at preventing future ischemic events, and improves quality of life, and patients in whom symptomatic MMD is diagnosed should be offered revascularized surgery.
Abstract: Object Moyamoya disease (MMD) is a rare cerebrovascular disease mainly described in the Asian literature. To address a lack of data on clinical characteristics and long-term outcomes in the treatment of MMD in North America, the authors analyzed their experience at Stanford University Medical Center. They report on a consecutive series of patients treated for MMD and detail their demographics, clinical characteristics, and long-term surgical outcomes. Methods Data obtained in consecutive series of 329 patients with MMD treated microsurgically by the senior author (G.K.S.) between 1991 and 2008 were analyzed. Demographic, clinical, and surgical data were prospectively gathered and neurological outcomes assessed in postoperative follow-up using the modified Rankin Scale. Association of demographic, clinical, and surgical data with postoperative outcome was assessed by chi-square, uni- and multivariate logistic regression, and Kaplan-Meier survival analyses. Results The authors treated a total of 233 adult p...
386 citations
TL;DR: Although the authors used the same interbody spacers and even higher dose of rhBMP-2 than in another report, there was no resorptions in their study.
Abstract: Although the authors used the same interbody spacers and even higher dose of rhBMP-2 (than the dose of rhBMP-2 was used in another report in which incidence of the resorptions after interbody fusions assisted with rhBMP-2 was 100%) there was no resorptions in their study. We asked for the authors' clarification of the strange phenomenon.
372 citations
TL;DR: The results of this meta-analysis support the safety and short-term efficacy of endoscopic pituitary surgery and future studies with long-term follow-up are required to determine tumor control.
Abstract: Object Surgery on the pituitary gland is increasingly being performed through an endoscopic approach. However, there is little published data on its safety and relative advantages over traditional microscope-based approaches. Published reports are limited by small sample size and nonrandomized study design. A meta-analysis allows for a description of the impact of endoscopic surgery on short-term outcomes. Methods The authors performed retrospective review of data from their institution as well as a systematic review of the literature. The pooled data were analyzed for descriptive statistics on short-term outcomes. Results Nine studies (821 patients) met inclusion criteria. Overall, the pooled rate of gross tumor removal was 78% (95% CI 67–89%). Hormone resolution was achieved in 81% (95% CI 71–91%) of adrenocorticotropic hormone secreting tumors, 84% (95% CI 76–92%) of growth hormone secreting tumors, and 82% (95% CI 70–94%) of prolactin secreting tumors. The pooled complication rates were 2% (95% CI 0–4...
317 citations
TL;DR: Minimally invasive spinal surgery techniques may reduce postoperative wound infections as much as 10-fold compared with other large, modern series of open spinal surgery published in the literature.
Abstract: Object Postoperative surgical site infections (SSIs) have been reported after 2–6% of spinal surgeries in most large series. The incidence of SSI can be 10% after instrumented fusions. Anecdotal evidence has suggested that there is a lower rate of SSI when minimally invasive techniques are used. Methods A retrospective review of prospectively collected databases of consecutive patients who underwent minimally invasive spinal surgery was performed. Minimally invasive spinal surgery was defined as any spinal procedure performed through a tubular retractor system. All surgeries were performed under standard sterile conditions with preoperative antibiotic prophylaxis. The databases were reviewed for any infectious complications. Cases of SSI were identified and reviewed for clinically relevant details. The incidence of postoperative SSIs was then calculated for the entire cohort as well as for subgroups based on the type of procedure performed, and then compared with ...
275 citations
TL;DR: Concomitant TMZ therapy in addition to Gliadel wafer implantation was associated with a median survival of nearly 21 months without increased perioperative morbidity, and Temozolomide can be safely administered to patients receiving GliAD wafers after resection of GBM.
Abstract: Object Gliadel (BCNU) wafer and concomitant temozolomide (TMZ) therapy, when used individually as adjuvant therapies, extend survival from that achieved by resection and radiation therapy (XRT) for glioblastoma multiforme (GBM). It remains unstudied whether combining Gliadel and TMZ therapy is safe or further improves survival in patients with newly diagnosed GBM. The authors reviewed their initial experience utilizing combined Gliadel, TMZ, and radiation therapy for the treatment of GBM. Methods All cases involving patients undergoing primary resection of GBM with or without Gliadel wafer (3.85% BCNU) implantation and adjuvant XRT over a 10-year period (1997–2006) were retrospectively reviewed. Beginning in 2004, concomitant TMZ became the standard of care at the authors' institution and all patients with Gliadel implantation also received concomitant TMZ (Stupp protocol). Overall survival and treatment-related morbidity were assessed for all patients treated with Gliadel plus concomitant TMZ (XRT + Glia...
260 citations
TL;DR: Initial results of the largest series to date in using the Enterprise for intracranial aneurysm treatment are reported, indicating the Enterprise is associated with a high rate of successful navigation and low occurrence of inaccurate stent deployment.
Abstract: Object The development of self-expanding stents dedicated to intracranial use has significantly widened the applicability of endovascular therapy to many intracranial aneurysms that would otherwise have been untreatable by endovascular techniques. Recent Food and Drug Administration approval of the Enterprise Vascular Reconstruction Device and Delivery System (Cordis) has added a new option for self-expanding stent-assisted intracranial aneurysm coiling. Methods The authors established a collaborative registry across multiple institutions to rapidly provide largevolume results regarding initial experience in using the Enterprise in real-world practice. Ten institutions (University at Buffalo, Thomas Jefferson University, University of Florida, Cleveland Clinic, Northwestern University, West Virginia University, University of Puerto Rico, Albany Medical Center Hospital, the Neurological Institute of Savannah, and the Barrow Neurological Institute) have provided consecutive data regarding their initial expe...
259 citations
TL;DR: Cerebral ischemia is the leading cause of preventable death in cases of major trauma with severe traumatic brain injury (TBI) and Intracranial pressure (ICP) control and cerebral perfusion pressure (CPP) manipulation have significantly reduced the mortality but not the morbidity rate in these patients.
Abstract: Object Cerebral ischemia is the leading cause of preventable death in cases of major trauma with severe traumatic brain injury (TBI). Intracranial pressure (ICP) control and cerebral perfusion pressure (CPP) manipulation have significantly reduced the mortality but not the morbidity rate in these patients. In this study, the authors describe their 5-year experience with brain tissue oxygen (PbtO2) monitoring, and the effect of a brain tissue oxygen–directed critical care guide (PbtO2-CCG) on the 6-month clinical outcome (based on the 6-month Glasgow Outcome Scale score) in patients with TBIs. Methods One hundred thirty-nine patients admitted to Creighton University Medical Center with major traumatic injuries (Injury Severity Scale [ISS] scores ≥ 16) and TBI underwent prospective evaluation. All patients were treated with a PbtO2-CCG to maintain a brain oxygen level > 20 mm Hg, and control ICP < 20 mm Hg. The role of demographic, clinical, and imaging parameters in the identification of patients at risk f...
254 citations
TL;DR: Antiangiogenic therapy using bevacizumab appears to improve survival in patients with recurrent high-grade glioma, and a possible change in the invasiveness of the tumor following therapy is worrisome and must be closely monitored.
Abstract: Object Antiangiogenic agents have recently shown impressive radiological responses in high-grade glioma. However, it is not clear if the responses are related to vascular changes or due to antitumoral effects. The authors report the mature results of a clinical study of bevacizumab-based treatment of recurrent high-grade gliomas. Methods Sixty-one patients with recurrent high-grade gliomas received treatment with bevacizumab at 10 mg/ kg every 2 weeks for 4 doses in an 8-week cycle along with either irinotecan or carboplatin. The choice of concomitant chemotherapeutic agent was based on the number of recurrences and prior chemotherapy. Results At a median follow-up of 7.5 months (range 1–19 months), 50 (82%) of 61 patients relapsed and 42 patients (70%) died of the disease. The median number of administered bevacizumab cycles was 2 (range 1–7 cycles). The median progression-free survival (PFS) and overall survival (OS) were 5 (95% confidence interval [CI] 2.3–7.7) and 9 (95% CI 7.6–10.4) months, respectiv...
247 citations
TL;DR: The intravenous infusion of MSCs appeared to result in significant acute or prolonged cerebral engraftment of cells nor to modify the recovery of motor or cognitive function, highlighting the potential shortcomings of acute, single-dose, intravenous MSC therapy for TBI.
Abstract: Object Cell therapy has shown preclinical promise in the treatment of many diseases, and its application is being translated to the clinical arena. Intravenous mesenchymal stem cell (MSC) therapy has been shown to improve functional recovery after traumatic brain injury (TBI). Herein, the authors report on their attempts to reproduce such observations, including detailed characterizations of the MSC population, non–bromodeoxyuridine-based cell labeling, macroscopic and microscopic cell tracking, quantification of cells traversing the pulmonary microvasculature, and well-validated measurement of motor and cognitive function recovery. Methods Rat MSCs were isolated, expanded in vitro, immunophenotyped, and labeled. Four million MSCs were intravenously infused into Sprague-Dawley rats 24 hours after receiving a moderate, unilateral controlled cortical impact TBI. Infrared macroscopic cell tracking was used to identify cell distribution. Immunohistochemical analysis of brain and lung tissues 48 hours and 2 we...
TL;DR: The clinical results of the FE interlaminar spinal decompression procedure are equal to those of the microsurgical technique, and there are advantages in the operation technique, such as reduced traumatization.
Abstract: Object Extensive decompression with laminectomy where appropriate is often still described as the method of choice in surgery for lateral recess stenosis. Nonetheless, tissue-sparing procedures are becoming more common. Endoscopic techniques have become the standard in many areas because of the advantages they offer in surgical technique and in rehabilitation. Transforaminal and interlaminar access provide 2 full-endoscopic (FE) techniques for lumbar spine surgery. The goal of this prospective randomized controlled study was to compare the surgical results for the FE technique via the interlaminar approach with those of the conventional microsurgical technique in patients with degenerative lateral recess stenosis. Methods A total of 161 patients with FE or microsurgical decompression underwent follow-up for 2 years. In addition to general and specific parameters, the following measuring instruments were used: visual analog scale, German version of the North American Spine Society instrument, and the Oswes...
TL;DR: In this paper, the authors determined the CSF shunt infection rates after initial shunt placement at multiple US pediatric hospitals and hypothesized that infection rates between hospitals would vary widely even after adjustment for patient, hospital, and surgeon factors.
Abstract: Object Reported rates of CSF shunt infection vary widely across studies. The study objective was to determine the CSF shunt infection rates after initial shunt placement at multiple US pediatric hospitals. The authors hypothesized that infection rates between hospitals would vary widely even after adjustment for patient, hospital, and surgeon factors. Methods This retrospective cohort study included children 0–18 years of age with uncomplicated initial CSF shunt placement performed between January 1, 2001, and December 31, 2005, and recorded in the Pediatric Health Information System (PHIS) longitudinal administrative database from 41 children's hospitals. For each child with 24 months of follow-up, subsequent CSF shunt infections and procedures were determined. Results The PHIS database included 7071 children with uncomplicated initial CSF shunt placement during this time period. During the 24 months of follow-up, these patients had a total of 825 shunt infections and 4434 subsequent shunt procedures. Ov...
TL;DR: The h index can be used as a tool, along with other evaluations, to evaluate an individual's productivity in the academic advancement process within the field of neurosurgery but should not be used for comparisons across medical specialties.
Abstract: Object Assessing academic productivity through simple quantification may overlook key information, and the use of statistical enumeration of academic output is growing. The h index, which incorporates both the total number of publications and the citations of those publications, has been recently proposed as an objective measure of academic productivity. The authors used several tools to calculate the h index for academic neurosurgeons to provide a basis for evaluating publishing by physicians. Methods The h index of randomly selected academic neurosurgeons from a sample of one-third of the academic programs in the US was calculated using data from Google Scholar and from the Scopus database. The mean h index for each academic rank was determined. The h indices were also correlated with various other factors (such as time spent practicing neurosurgery, authorship position) to identify how these factors influenced the h index. The h indices were then compared with other citation statistics to evaluate the ...
TL;DR: This anatomical study suggests that positioning the dilator and/or retractor in a posterior position of the disc space may result in nerve injury to the lumbosacral plexus, especially at the L4-5 level.
Abstract: Object Minimally invasive anterolateral approaches to the lumbar spine are options for the treatment of a number of adult degenerative spinal disorders. Nerve injuries during these surgeries, although rare, can be devastating complications. With an increasing number of spine surgeons utilizing minimal access retroperitoneal surgery to treat lumbar problems, the frequency of complications associated with this approach will likely increase. The authors sought to better understand the location of the lumbar contribution of the lumbosacral plexus relative to the disc spaces encountered when performing the minimally invasive transpsoas approach, also known as extreme lateral interbody fusion or direct lateral interbody fusion. Methods Three fresh cadavers were placed lateral, and a total of 3 dissections of the lumbar contribution of the lumbosacral plexus were performed. Radiopaque soldering wire was then laid along the anterior margin of the nerve fibers and the exiting femoral nerve. Markers were placed at ...
TL;DR: This is the largest reported experience with insular Grade II glioma surgery and the better knowledge of the insular pathophysiology and the use of intraoperative functional mapping allow the risk of permanent deficit to be minimized and even enable improvement in quality of life while increasing the extent of resection and thus the impact on the course of the disease.
Abstract: Object Few experiences of insular surgery have been reported. Moreover, there are no large surgical studies with long-term follow-up specifically dedicated to WHO Grade II gliomas involving the insula. In this paper, the author describes a personal consecutive series of 51 cases in which patients underwent surgery for an insular Grade II glioma. On the basis of the functional and oncological results, advances and limitations of this challenging surgery are discussed. Methods Fifty-one patients harboring an insular Grade II glioma (revealed by seizures in 50 cases) underwent surgery. Findings on preoperative neurological examination were normal in 45 patients (88%). All surgeries were conducted under cortico-subcortical stimulation, and in the case of 16 patients while awake. Results Despite an immediate postoperative worsening in 30 cases (59%), the condition of all but 2 patients (96%) returned to baseline or better. Postoperative MR imaging demonstrated that 77% of resections were total or subtotal. Ten...
TL;DR: In ventilation-treated patients with intracranial hypertension, ketamine effectively decreased ICP and prevented untoward ICP elevations during potentially distressing interventions, without lowering blood pressure and CPP, refute the notion that ketamine increases ICP.
Abstract: Object Deepening sedation is often needed in patients with intracranial hypertension. All widely used sedative and anesthetic agents (opioids, benzodiazepines, propofol, and barbiturates) decrease blood pressure and may therefore decrease cerebral perfusion pressure (CPP). Ketamine is a potent, safe, rapid-onset anesthetic agent that does not decrease blood pressure. However, ketamine's use in patients with traumatic brain injury and intracranial hypertension is precluded because it is widely stated that it increases intracranial pressure (ICP). Based on anecdotal clinical experience, the authors hypothesized that ketamine does not increase—but may rather decrease—ICP. Methods The authors conducted a prospective, controlled, clinical trial of data obtained in a pediatric intensive care unit of a regional trauma center. All patients were sedated and mechanically ventilated prior to inclusion in the study. Children with sustained, elevated ICP (> 18 mm Hg) resistant to first-tier therapies received a single...
TL;DR: The results of the authors' review of the literature suggest that MCS is safe and effective in the treatment of chronic neuropathic pain.
Abstract: Object The authors systematically reviewed the published literature to evaluate the efficacy of and adverse effects after motor cortex stimulation (MCS) for chronic neuropathic pain. Methods A search of the PubMed database (1991–2006) using the key words “motor cortex,” “stimulation,” and “pain” yielded 244 articles. Only original nonduplicated articles were selected for further analysis; 14 studies were identified for critical review. All were series of cases and none was controlled. The outcomes in 210 patients were assessed and expressed as the percentage of patients that improved with the procedure. Results A good response to MCS (pain relief ≥ 40–50%) was observed in ~ 55% of patients who underwent surgery and in 45% of the 152 patients with a postoperative follow-up ≥ 1 year. Visual analog scale scores were provided in 76 patients, revealing an average 57% improvement in the 41 responders. A good response was achieved in 54% of the 117 patients with central pain and 68% of the 44 patients with trige...
TL;DR: Most of the advantages of the endoscopic endonasal technique were noted during tumor dissection from the inferior aspect of the chiasm, the infundibulum, the third ventricle, and/or the retro- and parasellar areas.
Abstract: Object The management of recurrent or residual craniopharyngiomas remains controversial. Although possible, revision surgery is more challenging than primary surgery, and more often results in incomplete resection and an increased risk of death and complications. The extended (also called expanded) endoscopic endonasal transsphenoidal approach through the planum sphenoidale has been proposed over the past decade as an alternative surgical route for removal of various suprasellar tumors including craniopharyngiomas. In this study, the authors describe the feasibility and advantages of this technique in recurrent or symptomatic residual craniopharyngiomas. Methods Between January 2004 and June 2008, 22 patients underwent surgery via the extended endoscopic transsphenoidal approach for the treatment of recurrent or residual symptomatic craniopharyngiomas at either the University of Pittsburgh or the Universita degli Studi di Napoli. The lesions included 12 purely suprasellar craniopharyngiomas, 9 with both i...
TL;DR: An increased recruitment of patients at the center and an improvement in the diagnosis of craniosynostosis might explain the overall increase, however, other mechanisms should be examined to explain the great increase in the number of cases of trigonocephaly.
Abstract: Object The prevalence of the different subtypes of craniosynostosis varies greatly. The aim of this study was to analyze the prevalences of the different subtypes of craniosynostosis at a single major craniofacial center and their changes during a 20-year period. Methods The medical charts of 2808 children hospitalized between 1988 and 2007 for a true craniosynostosis were retrospectively reviewed. Patients were divided according to their subtype of craniosynostosis (sagittal, plagiocephaly, brachycephaly, metopic, oxycephaly, syndromic cases, or unclassifiable). Results The total number of patients according to their craniosynostosis subtype were as follows: 1224 cases of scaphocephaly, 315 cases of plagiocephaly, 598 cases of trigonocephaly, 105 cases of brachycephaly, 69 cases of oxycephaly, 396 syndromic cases, and 101 unclassifiable cases. The prevalences of these craniosynostoses evolved differently over time. The number of children hospitalized each year increased over time from 106 to 181 cases, b...
TL;DR: Males have a higher incidence of ependymoma than do females, consistent with hypotheses postulating distinct populations of radial glial stem cells within the CNS, and incidence appears to have increased over the past 3 decades, but only in adults.
Abstract: Object Previous small studies disagree about which clinical risk factors influence ependymoma incidence. The authors analyzed a large, population-based cancer registry to examine the relationship of incidence to patient age, sex, race, and tumor location, and to determine incidence trends over the past 3 decades. Methods Data were obtained from the Surveillance, Epidemiology, and End Results (SEER-9) study, which was conducted from 1973 to 2003. Histological codes were used to define ependymomas. Age-adjusted incidence rates were compared by confidence intervals in the SEER*Stat 6.2 program. Multiplicative Poisson regression and Joinpoint analysis were used to determine annual percentage change and to look for sharp changes in incidence, respectively. Results From the SEER database, 1402 patients were identified. The incidence rate per 100,000 person-years was significantly higher in male than in female patients (males 0.227 ± 0.029, females 0.166 ± 0.03). For children, the age at diagnosis differed signi...
TL;DR: The results in this study suggest that MTRs including tumor cells infiltrating adjacent brain parenchyma for a single brain metastasis provide better local tumor control.
Abstract: Object The goal of this study was to evaluate the therapeutic impact of the resection of metastatic brain tumor cells infiltrating adjacent brain parenchyma. Methods Between July 2001 and February 2007, 94 patients (67 males and 27 females, with a mean age of 55.0 ±12.0 years) underwent resection of a single brain metastasis, followed by systemic chemotherapy with or without radiotherapy. In 43 patients with tumors located in noneloquent areas, the authors performed microscopic total resections (MTRs) that included tumor cells infiltrating adjacent brain parenchyma, and they pathologically confirmed during surgery that the resection margins were free of tumor cells (MTR group). In 51 patients with lesions in eloquent locations, gross-total resections (GTRs) were performed without the removal of neighboring brain parenchyma (GTR group). The 2 groups were then compared for local recurrence and survival. Results The MTR group had better local control of the tumor than did the GTR group; 10 (23.3%) of 43 pati...
TL;DR: In a select group of patients with kyphotic deformity > or = 10 degrees , adequate correction of local sagittal alignment may help to maximize the chance of neurological improvement.
Abstract: Object The effects of sagittal kyphotic deformities or mechanical stress on the development of cervical spondylotic myelopathy, or the reduction and fusion of kyphotic sagittal alignment have not been consistently documented The aim in this study was to determine the effects of kyphotic sagittal alignment of the cervical spine in terms of neurological morbidity and outcome after 2 types of surgical intervention Methods The authors retrospectively reviewed the records of 476 patients who underwent cervical spine surgeries for spondylotic myelopathy between 1993 and 2006 at their university medical center Among these were identified 43 patients—30 men and 13 women, with a mean age of 588 years—who had cervical kyphosis exceeding 10° on preoperative sagittal lateral radiographs obtained in the neutral position, and their cases were analyzed in this study Anterior decompression with interbody fusion was conducted in 28 patients, and en bloc open-door C3–7 laminoplasty in 15 patients Both pre- and postop
TL;DR: Tumor volume and anatomy relate to the hearing level before radiosurgery and influence technique, and a low radiosurgical dose to the cochlea enhances hearing preservation.
Abstract: Object Many patients with acoustic neuromas (ANs) have hearing function at diagnosis and desire to maintain it. To date, radiosurgical techniques have been focused on conformal irradiation of the tumor mass, with less attention to inner ear structures for which there was scant radiobiological information. The authors of this study evaluated tumor control and hearing preservation as they relate to tumor volume, imaging characteristics, and nerve and cochlear radiation dose following stereotactic radiosurgery (SRS) using the Gamma Knife. Methods Seventy-seven patients with ANs had serviceable hearing (Gardner-Robertson [GR] Class I or II) and underwent SRS between 2004 and 2007. This interval reflected more recent measurements of inner ear dosimetry during the authors' 21-year experience. The median patient age was 52 years (range 22–82 years). No patient had undergone any prior treatment for the ANs. The median tumor volume was 0.75 cm3 (range 0.07–7.7 cm3), and the median radiation dose to the tumor margi...
University of Alabama at Birmingham1, University of California, Los Angeles2, Beth Israel Deaconess Medical Center3, University of Medicine and Dentistry of New Jersey4, Columbia University5, University of California, San Francisco6, University of Iowa Hospitals and Clinics7, Icahn School of Medicine at Mount Sinai8, Penn State Milton S. Hershey Medical Center9, University of Wisconsin-Madison10
TL;DR: The natural history of CSM is variable, which may affect treatment decisions and the level of evidence, and factors associated with clinical deterioration are identified.
Abstract: Object The objective of this systematic review was to use evidence-based medicine to delineate the natural history of cervical spondylotic myelopathy (CSM) and identify factors associated with clinical deterioration. Methods The National Library of Medicine and Cochrane Database were queried using MeSH headings and keywords relevant to the natural history of CSM. Abstracts were reviewed and studies meeting the inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I–III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons. Results The natural history of CSM is mixed: it may manifest as ...
TL;DR: An analysis of the UVA experience suggested that the 80-hour workweek leads to a notable increase in on-call duty hours with a profound decrease in the number of hours spent in conference and the operating room.
Abstract: Object Recently, the Institute of Medicine examined resident duty hours and their impact on patient safety. Experts have suggested that reducing resident work hours to 56 hours per week would further decrease medical errors. Although some reports have indicated that cutbacks in resident duty hours reduce errors and make resident life safer, few authors have specifically analyzed the effect of the Accreditation Council for Graduate Medical Education (ACGME) duty-hour limits on neurosurgical resident education and the perceived quality of training. The authors have evaluated multiple objective surrogate markers of resident performance and quality of training to determine the impact of the 80-hour workweek. Methods The United States Medical Licensing Examination (USMLE) Step 1 data on neurosurgical applicants entering ACGME-accredited programs between 1998 and 2007 (before and after the implementation of the work-hour rules) were obtained from the Society of Neurological Surgeons. The American Board of Neuro...
TL;DR: The results of this study support the role of a conservative "wait-and-scan" policy of management for small-sized vestibular schwannomas because most have a slow growth rate.
Abstract: Object The object of this study was to evaluate the natural history, pattern, and occurrence of tumor growth and its consequences for treatment of small-sized vestibular schwannomas (VSs). Methods From 1990 to 2005, 386 patients underwent conservative management for VS because of the following: age > 60 years, poor health/medical risks, risk of deterioration of good hearing, small tumor size, minimal or no incapacitating symptoms, and/or patient preference. Tumor size was measured by MR imaging according to the guidelines of the Committee on Hearing and Equilibrium. The first MR imaging study was performed 1 year after diagnosis, and subsequent imaging was performed yearly or every 2 years depending on the appearance of new symptoms, tumor growth, or both. Results Sixty-one patients were lost to follow-up the first year after presentation. Of the 325 patients for whom 1-year follow-up data were available, 39 showed tumor growth ≥ 3 mm. Conservative management was discontinued for these 39 patients. The pa...
TL;DR: This preliminary study showed that EPO seemed to reduce delayed cerebral ischemia following aSAH via decreasing severity of vasospasm and shortening impaired autoregulation.
Abstract: Object Delayed ischemic deficits (DIDs), a major source of disability following aneurysmal subarachnoid hemorrhage (aSAH), are usually associated with severe cerebral vasospasm and impaired autoregulation. Systemic erythropoietin (EPO) therapy has been demonstrated to have neuroprotective properties acting via EPO receptors on cerebrovascular endothelia and ischemic neurons. In this trial, the authors explored the potential neuroprotective effects of acute EPO therapy following aSAH. Methods Within 72 hours of aSAH, 80 patients (age range 24–82 years) were randomized to receive intravenous EPO (30,000 U) or placebo every 48 hours for a total of 90,000 U. Primary end points were the incidence, duration, and severity of vasospasm and impaired autoregulation on transcranial Doppler ultrasonography. Secondary end points were incidence of DIDs and outcome at discharge and at 6 months. Results Randomization characteristics were balanced except for age, with the EPO group being older (mean age 59.6 vs 53.3 years...
TL;DR: Although GKS achieves excellent rates of initial pain relief, these results suggest a steady rate of late failure, particularly among patients who had undergone prior invasive surgical treatment, particularly for patients who have had no prior invasive procedures.
Abstract: Object. Few longterm studies of Gamma Knife surgery (GKS) for trigeminal neuralgia (TN) exist. The authors report their longterm experience with the use of GKS in a previously reported cohort of patients with TN that has now been followed since 1996. Methods. One hundred twelve patients with TN were treated with GKS at the University of Maryland between June 1996 and July 2001. Of these, 67% had no invasive operations for TN prior to GKS, 13% had 1, 4% had 2, and 16% had ≥ 3. The right side was affected in 56% of cases, predominantly involving V2 (26%), V3 (24%), or a combination of both (18%) branches. The median age at diagnosis was 56 years, and median age at GKS was 64 years. The median prescription dose of 75 Gy (range 70–80 Gy) was delivered to the involved trigeminal nerve root entry zone. The authors assessed the degree of pain before and after GKS by using the Barrow Neurological Institute (BNI) pain scale. Results. In total, 102 patients took the survey at least once, for a response rate of 91%. Although not found to alter the conclusions of this study, 7 cases of atypical TN were found and these patients were removed, for a total of 95 cases herein analyzed. The median followup was 5.6 years (range 13–115 months). Before GKS, 88% of patients categorized their pain as BNI IV or V (inadequate control or severe pain on medication), whereas the remainder described their pain as BNI III (some pain, but controlled on medication). After GKS, 64% reported a BNI score of I (no pain, no medications), 5% had BNI II (no pain, still on medication), 12% had BNI III, and 19% reported a BNI score of IV or V. The median time to response was 2 weeks (range 0–12 weeks) and the median response duration was 32 months (range 0–112 months). Eightyone percent reported initial pain relief, and actuarial rates of freedom from treatment failure at 1, 3, 5, and 7 years were 60, 41, 34, and 22%, respectively. Response duration was significantly better for those who had no prior invasive treatment versus those in whom a previous surgical intervention had failed (32 vs 21 months, p < 0.02). New bothersome facial numbness was reported in 6% of cases. Conclusions. This study represents one of the longest reported median followup periods and actuarial results for a cohort of patients with classic TN treated with GKS. Although GKS achieves excellent rates of initial pain relief, these results suggest a steady rate of late failure, particularly among patients who had undergone prior invasive surgi cal treatment. Despite a higher than expected recurrence rate, GKS remains a viable treatment option, particularly for patients who have had no prior invasive procedures. Patients with recurrences can still be offered salvage therapy with either repeat GKS, microvascular decompression, or rhizotomy. (DOI: 10.3171/2009.2.JNS08977) Ke Y W or D s • trigeminal neuralgia • Gamma Knife • radiosurgery
TL;DR: The CD45(+)/CD11b(+) cells are the predominant inflammatory cell infiltrating human gliomas, and they may prove an important target for future glioma immunotherapy studies.
Abstract: Object To date, glioma immunotherapy has been focused mostly on stimulating antitumor peripheral lymphocyte responses; however, some data suggest that microglia and/or macrophages (not lymphocytes) are the predominant inflammatory cells infiltrating gliomas. To study this hypothesis further, the authors analyzed inflammatory cell infiltrates in fresh human malignant glioma specimens and primary cultures. Methods Single-cell suspensions from fresh operative malignant glioma specimens, obtained by stereotactic localization, were analyzed for CD11b and CD45 by using flow cytometry. A comparison was made with peripheral blood mononuclear cells. In a subset of patients, a more detailed flow cytometry analysis of Class I and II major histocompatibility complex, B7-1, B7-2, CD11c, and CD14 expression was performed. Macrophage-like cells in primary glioma cultures were similarly assessed. Results Operative samples were obtained from 9 newly diagnosed malignant gliomas. The mean percent of CD45+/CD11b− cells (lymp...