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Surgical Specialist, Neurological Surgeon
29 years of experience

Video profile

Credentials

Education ?

Medical School
Istanbul Universitesi, Cerrahpasa (1983)
Foreign school

Awards & Distinctions ?

Awards  
One of America's Leading Experts on:
Brain Cancer (Brain Neoplasm)
Spinal Cord Cancer (Spinal Cord Neoplasm)
Spinal Cord Cancer (Spinal Neoplasm)
Spinal Fusion
Castle Connolly America's Top Doctors® (2010 - 2015)
Patients' Choice Award (2010 - 2012, 2014)
Compassionate Doctor Recognition (2010 - 2012, 2014)
On-Time Doctor Award (2014)
Appointments
Baylor College Of Medicine (1994 - Present)
Ut Mdanderson Cancer Center (1994 - Present)
Johns Hopkins Medical Center
Professor of Neurological Surgery Professor of Orthopedic Surgery Professor of Oncology Center
Associations
Congress of Neurological Surgeons
Scoliosis Research Society
American Board of Neurological Surgery
Cervical Spine Research Society
Depuymitek.com (back and Neck Pain)- (allaboutbackandneckpain.com)
American Association of Neurological Surgeons

Affiliations ?

Dr. Gokaslan is affiliated with 3 hospitals.

Hospital Affiliations

Score

Rankings

  • The Johns Hopkins Hospital
    600 N Wolfe St, Baltimore, MD 21287
    •  
    Top 25%
  • Johns Hopkins Bayview Medical Center
    4940 Eastern Ave, Baltimore, MD 21224
    •  
    Top 25%
  • Johns Hopkins Geriatrics Center
    5505 Hopkins Bayview Cir, Baltimore, MD 21224
  • Publications & Research

    Dr. Gokaslan has contributed to 196 publications.
    Title Clear-cell Chondrosarcoma of the Lumbar Spine: Case Report and Review of the Literature.
    Date May 2012
    Journal Neurosurgery
    Excerpt

    Clear-cell chondrosarcoma is a rare subtype of chondrosarcoma. These osseous tumors are most commonly found in the end of long bones. We report a rare case of clear-cell chondrosarcoma of the osseous spine.

    Title Primary Vertebral Tumors: a Review of Epidemiologic, Histological, and Imaging Findings, Part I: Benign Tumors.
    Date March 2012
    Journal Neurosurgery
    Excerpt

    Primary vertebral tumors, although less common than metastases to the spine, make up a heterogeneous group of neoplasms that can pose diagnostic and treatment challenges. They affect both the adult and the pediatric population and may be benign, locally aggressive, or malignant. An understanding of typical imaging findings will aid in accurate diagnosis and help neurosurgeons appreciate anatomic subtleties that may increase their effective resection. An understanding of the histological similarities and differences between these tumors is imperative for all members of the clinical team caring for these patients. In this first review of 2 parts, we discuss the epidemiological, histological, and imaging features of the most common benign primary vertebral tumors-aneurysmal bone cyst, chondroma and enchondroma, hemangioma, osteoid osteoma, and osteoblastoma-and lesions related to eosinophilic granuloma and fibrous dysplasia. In addition, we discuss the basic management paradigms for each of these diagnoses. In combination with part II of the review, which focuses on locally aggressive and malignant tumors, this article provides a comprehensive review of primary vertebral tumors.

    Title Generation of Chordoma Cell Line Jhc7 and the Identification of Brachyury As a Novel Molecular Target.
    Date December 2011
    Journal Journal of Neurosurgery
    Excerpt

    Chordoma is a malignant bone neoplasm hypothesized to arise from notochordal remnants along the length of the neuraxis. Recent genomic investigation of chordomas has identified T (Brachyury) gene duplication as a major susceptibility mutation in familial chordomas. Brachyury plays a vital role during embryonic development of the notochord and has recently been shown to regulate epithelial-to-mesenchymal transition in epithelial-derived cancers. However, current understanding of the role of this transcription factor in chordoma is limited due to the lack of availability of a fully characterized chordoma cell line expressing Brachyury. Thus, the objective of this study was to establish the first fully characterized primary chordoma cell line expressing gain of the T gene locus that readily recapitulates the original parental tumor phenotype in vitro and in vivo.

    Title Assessment of the Extent of Surgical Resection As a Predictor of Survival in Patients with Primary Osseous Spinal Neoplasms.
    Date November 2011
    Journal Clinical Neurosurgery
    Title Spinal Instability Neoplastic Score: an Analysis of Reliability and Validity from the Spine Oncology Study Group.
    Date August 2011
    Journal Journal of Clinical Oncology : Official Journal of the American Society of Clinical Oncology
    Excerpt

    Standardized indications for treatment of tumor-related spinal instability are hampered by the lack of a valid and reliable classification system. The objective of this study was to determine the interobserver reliability, intraobserver reliability, and predictive validity of the Spinal Instability Neoplastic Score (SINS).

    Title Resection of a Retropharyngeal Craniovertebral Junction Chordoma Through a Posterior Cervical Approach.
    Date February 2011
    Journal Journal of Spinal Disorders & Techniques
    Excerpt

    This illustrative case report is designed to provide technical data regarding the use of a posterior approach to resect a retropharyngeal chordoma involving the craniovertebral junction.

    Title Prevention of Facial Pressure Ulcers Using the Mayfield Clamp for Sacral Tumor Resection.
    Date January 2011
    Journal Journal of Neurosurgery. Spine
    Excerpt

    Sacral neoplasm resection is managed via partial or total sacrectomy that is performed via the Kraske approach. The combination of the patients positioning and the relatively long operative time required for this procedure increase the risk of pressure ulcers. Facial pressure ulcers can cause tissue necrosis and/or ulceration in a highly visible area, leading to a cosmetically disfiguring lesion. Here, the authors report the use of a Mayfield clamp in the positioning of patients undergoing sacral tumor resection to prevent facial pressure ulceration. After the patient is placed prone in the Kraske or Jackknife position, the hips and knees are flexed with arms to the side. Then while in the prone position, the patient is physically placed in pins, and the Mayfield clamp is fixated at the center of the metal arch via the Mayfield sitting adapter to the Andrews frame, suspending the head (and face) over the table. The authors find that this technique prevents the development of facial pressure ulcers, and it has the potential to be used in patients positioned in the Kraske position for other surgical procedures.

    Title Sacral Tumor Resection and the Impact on Pelvic Incidence.
    Date January 2011
    Journal Journal of Neurosurgery. Spine
    Excerpt

    pelvic incidence (PI) directly regulates lumbar lordosis and is a key determinant of sagittal spinal balance in normal and diseased states. Pelvic incidence is defined as the angle between the line perpendicular to the S-1 endplate at its midpoint and the line connecting this point to a line bisecting the center of the femoral heads. It reflects an anatomical value that increases with growth during childhood but remains constant in adulthood. It is not altered by changes in patient position or after traditional lumbosacral spinal surgery. There are only 2 reports of PI being altered in adults, both in cases of sacral fractures resulting in lumbopelvic dissociation and sacroiliac (SI) joint instability. En bloc sacral amputation and sacrectomy are surgical techniques used for resection of certain bony malignancies of the sacrum. High, mid, and low sacral amputations result in preservation of some or the entire SI joint. Total sacrectomy results in complete disruption of the SI joint. The purpose of this study was to determine if PI is altered as a result of total or subtotal sacral resection.

    Title Lumbopelvic Reconstruction After Combined L5 Spondylectomy and Total Sacrectomy for En Bloc Resection of a Malignant Fibrous Histiocytoma.
    Date January 2011
    Journal Neurosurgery
    Excerpt

    Primary sacral neoplasms that extend superiorly to involve the distal lumbar spine represent complex surgical problems. Treatment options for these patients are often limited to hemicorporectomy.

    Title Biomechanical Comparison Between C-7 Lateral Mass and Pedicle Screws in Subaxial Cervical Constructs. Presented at the 2009 Joint Spine Meeting. Laboratory Investigation.
    Date January 2011
    Journal Journal of Neurosurgery. Spine
    Excerpt

    The aim of this study was to conduct the first in vitro biomechanical comparison of immediate and postcyclical rigidities of C-7 lateral mass versus C-7 pedicle screws in posterior C4-7 constructs.

    Title Percutaneous Computed Tomography Fluoroscopy-guided Conformal Ultrasonic Ablation of Vertebral Tumors in a Rabbit Tumor Model. Laboratory Investigation.
    Date January 2011
    Journal Journal of Neurosurgery. Spine
    Excerpt

    Radiofrequency ablation (RFA) has proven to be effective for treatment of malignant and benign tumors in numerous anatomical sites outside the spine. The major challenge of using RFA for spinal tumors is difficulty protecting the spinal cord and nerves from damage. However, conforming ultrasound energy to match the exact anatomy of the tumor may provide successful ablation in such sensitive locations. In a rabbit model of vertebral body tumor, the authors have successfully ablated tumors using an acoustic ablator placed percutaneously via computed tomography fluoroscopic (CTF) guidance.

    Title Stereotactic Radiosurgery for Spine Tumors: Review of Current Literature.
    Date December 2010
    Journal Stereotactic and Functional Neurosurgery
    Excerpt

    Stereotactic radiosurgery (SR) is increasingly utilized for the treatment of intracranial and extracranial pathology. It is considered an important adjuvant to surgery, chemotherapy or fractionated radiotherapy, and the role of SR as a primary treatment modality continues to be explored. Although SR for spinal lesions is in its infancy, there is a growing body of literature supporting its efficacy. The purpose of this review is to summarize the pertinent literature regarding the use of SR for lesions of the spine and spinal cord. Particular emphasis will be placed on large clinical series of both primary and secondary spine tumors.

    Title A New Technique for Intraoperative Reduction of Occipitocervical Instability.
    Date December 2010
    Journal Neurosurgery
    Excerpt

    Occipitocervical instability with vertical migration of the odontoid is a rare but potentially debilitating anomaly of the craniocervical junction. Anterior decompression by means of a transoral or transcervical approach followed by posterior instrumentation commonly is used to treat this pathology.

    Title Recurrent Back and Leg Pain and Cyst Reformation After Surgical Resection of Spinal Synovial Cysts: Systematic Review of Reported Postoperative Outcomes.
    Date December 2010
    Journal The Spine Journal : Official Journal of the North American Spine Society
    Excerpt

    With improvements in neurological imaging, there are increasing reports of symptomatic spinal synovial cysts. Surgical excision has been recognized as the definitive treatment for symptomatic juxtafacet cysts. However, the role for concomitant fusion and the incidence of recurrent back pain and recurrent cyst formation after surgery remain unclear.

    Title Surgical Mystery: Where is the Missing Pituitary Rongeur Tip?
    Date November 2010
    Journal Spine
    Excerpt

    Case report.

    Title Posterior Vertebral Column Subtraction Osteotomy for the Treatment of Tethered Cord Syndrome: Review of the Literature and Clinical Outcomes of All Cases Reported to Date.
    Date September 2010
    Journal Neurosurgical Focus
    Excerpt

    Tethered cord syndrome (TCS) is a debilitating condition of progressive neurological decline caused by pathological, longitudinal traction on the spinal cord. Surgical detethering of the involved neural structures is the classic method of treatment for lumbosacral TCS, although symptomatic retethering has been reported in 5%-50% of patients following initial release. Subsequent operations in patients with complex lumbosacral dysraphic lesions are fraught with difficulty, and improvements in neurological function are modest while the risk of complications is high. In 1995, Kokubun described an alternative spine-shortening procedure for the management of TCS. Conducted via a single posterior approach, the operation relies on spinal column shortening to relieve indirectly the tension placed on the tethered neural elements. In a cadaveric model of TCS, Grande and colleagues further demonstrated that a 15-25-mm thoracolumbar subtraction osteotomy effectively reduces spinal cord, lumbosacral nerve root, and filum terminale tension. Despite its theoretical appeal, only 18 reports of the use of posterior vertebral column subtraction osteotomy for TCS treatment have been published since its original description. In this review, the authors analyze the relevant clinical characteristics, operative data, and postoperative outcomes of all 18 reported cases and review the role of posterior vertebral column subtraction osteotomy in the surgical management of primary and recurrent TCS.

    Title Adult Lumbar Scoliosis: Underreported on Lumbar Mr Scans.
    Date September 2010
    Journal Ajnr. American Journal of Neuroradiology
    Excerpt

    Adult lumbar scoliosis is an increasingly recognized entity that may contribute to back pain. We investigated the epidemiology of lumbar scoliosis and the rate at which it is unreported on lumbar MR images.

    Title The Surgical Management of Metastatic Epidural Compression of the Spinal Cord.
    Date August 2010
    Journal The Journal of Bone and Joint Surgery. British Volume
    Excerpt

    Metastatic epidural compression of the spinal cord is a significant source of morbidity in patients with systemic cancer. With improved oncological treatment, survival in these patients is improving and metastatic cord compression is encountered increasingly often. The treatment is mostly palliative. Surgical management involves early circumferential decompression of the cord with concomitant stabilisation of the spine. Patients with radiosensitive tumours without cord compression benefit from radiotherapy. Spinal stereotactic radiosurgery and minimally invasive techniques, such as vertebroplasty and kyphoplasty, with or without radiofrequency ablation, are promising options for treatment and are beginning to be used in selected patients with spinal metastases. In this paper we review the surgical management of patients with metastatic epidural spinal cord compression.

    Title Solitary Spinal Metastasis of Hürthle Cell Thyroid Carcinoma.
    Date August 2010
    Journal Journal of Clinical Neuroscience : Official Journal of the Neurosurgical Society of Australasia
    Excerpt

    Hürthle cell carcinoma is a rare variant of differentiated thyroid cancer that occasionally forms distant metastases. However, even in the presence of metastases, patients with Hürthle cell carcinoma have a relatively good prognosis. There are few reports of Hürthle cell carcinoma metastases to the vertebral column, and none describing aggressive resection of spinal metastases. Here, we report a 68-year-old woman with a solitary metastasis of Hürthle cell carcinoma to the T1 vertebral body causing severe kyphotic deformity, myelopathy, and pain. The patient was treated with aggressive excisional decompression of the spinal cord and T1 vertebral body resection from an entirely posterior approach. Reconstruction and stabilization of the anterior spine was accomplished with a transforaminal lumbar interbody fusion allograft spacer and posterior instrumentation. We discuss aspects of the diagnosis, management, patient selection, and surgical treatment of metastatic Hürthle cell carcinoma in reference to the literature.

    Title Spondylolysis of C-2 in 2 Athletically Active Individuals.
    Date August 2010
    Journal Journal of Neurosurgery. Spine
    Excerpt

    Cervical spondylolysis is an uncommon disorder involving a cleft at the pars interarticularis. It is most often found at the C-6 level, and clinical presentations have included incidental radiographic findings, neck pain, and rarely neurological compromise. Although subaxial cervical spondylolysis has been described in 150 patients, defects at the C-2 pedicles are rare. The authors present 2 new cases of C-2 spondylolysis in athletically active young persons who did not demonstrate instability or neurological deficits, were able to remain active, and are being managed conservatively with serial examinations and imaging. They also discuss the results of 22 previously reported cases of C-2 spondylolysis. Based on the literature and their own experience, the authors conclude that most patients with C-2 spondylolysis remain neurologically intact, maintain stability despite the bony defect, and can be managed conservatively. Surgery is reserved for patients who demonstrate severe instability or spinal cord compromise due to stenosis.

    Title Diagnosis and Management of Metastatic Spine Disease.
    Date August 2010
    Journal Journal of Neurosurgery. Spine
    Excerpt

    With continued growth of the elderly population and improvements in cancer therapies, the number of patients with symptomatic spinal metastases is likely to increase, and this is a condition that commonly leads to debilitating neurological dysfunction and pain. Advancements in surgical techniques of resection and spinal reconstruction, improvements in clinical outcomes following various treatment modalities, generally increased overall survival in patients with metastatic spine disease, and a recent randomized trial by Patchell and colleagues demonstrating the superiority of a combined surgical/radiotherapeutic approach over a radiotherapy-only strategy have led many to suggest increasingly aggressive interventions for patients with such lesions. Optimal management of spinal metastases encompasses numerous medical specialties, including neurosurgery, orthopedic surgery, medical and radiation oncology, radiology, and rehabilitation medicine. In this review, the clinical presentation, diagnosis, and management of spinal metastatic disease are discussed. Ultimately, the goal of treatment in patients with spinal metastases remains palliative, and clinical judgment is required to select the appropriate patients for surgical intervention.

    Title Factors Associated with Recurrent Back Pain and Cyst Recurrence After Surgical Resection of One Hundred Ninety-five Spinal Synovial Cysts: Analysis of One Hundred Sixty-seven Consecutive Cases.
    Date August 2010
    Journal Spine
    Excerpt

    Retrospective study.

    Title Short-term Progressive Spinal Deformity Following Laminoplasty Versus Laminectomy for Resection of Intradural Spinal Tumors: Analysis of 238 Patients.
    Date July 2010
    Journal Neurosurgery
    Excerpt

    Gross total resection of intradural spinal tumors can be achieved in the majority of cases with preservation of long-term neurological function. However, postoperative progressive spinal deformity complicates outcome in a subset of patients after surgery. We set out to determine whether the use of laminoplasty (LP) vs laminectomy (LM) has reduced the incidence of subsequent spinal deformity following intradural tumor resection at our institution.

    Title Transthoracic Surgical Treatment for Centrally Located Thoracic Disc Herniations Presenting with Myelopathy: a 5-year Institutional Experience.
    Date June 2010
    Journal Journal of Spinal Disorders & Techniques
    Excerpt

    Retrospective review.

    Title Transoral Approaches to the Cervical Spine.
    Date June 2010
    Journal Neurosurgery
    Excerpt

    A number of anterior approaches to the craniocervical junction have been described to allow exposure to the midline and lateral aspects of both the cranial base and upper cervical spine. The transoral-transpharyngeal approach, a technique that is well known to many spine surgeons, provides surgical access to the anterior clivus, C1, and C2. Transoral approaches provide the fundamental anatomy and technique upon which the more complex jaw-splitting approaches are based. This article discusses fundamental concepts regarding anatomy, perioperative considerations, and technical aspects critical to this important approach to the craniocervical junction. The transoral-transpharyngeal approach remains the "gold standard" for anterior approaches to the cervical spine. Endoscopic endonasal and endoscopic transcervical approaches are promising alternatives that may become more mainstream as experience with these approaches increases.

    Title Preoperative Radiographic Factors and Surgeon Experience Are Associated with Cortical Breach of C2 Pedicle Screws.
    Date June 2010
    Journal Journal of Spinal Disorders & Techniques
    Excerpt

    A retrospective review study.

    Title Refinements to the Simultaneous Anterior-posterior Approach to the Thoracolumbar Spine.
    Date May 2010
    Journal Journal of Neurosurgery. Spine
    Excerpt

    The treatment of complex thoracolumbar disorders occasionally requires combined anterior and posterior approaches. Traditionally, these are either sequentially staged to occur during the same anesthesia procedure or alternatively performed on separate days. A less common option is the simultaneous anterior-posterior approach. The authors discuss the rationale for this approach in selected cases and illustrate a number of modifications to previous descriptions of the procedure. By slightly altering the incision, the risk of wound breakdown and infection has been reduced. The use of newly available positioning devices has allowed easy incorporation of fluoroscopy to guide the placement of spinal instrumentation. The authors have also expanded the use of the approach beyond the original oncological indications to include trauma and infection.

    Title Minimally Invasive Circumferential Spinal Decompression and Stabilization for Symptomatic Metastatic Spine Tumor: Technical Case Report.
    Date May 2010
    Journal Neurosurgery
    Excerpt

    Metastatic epidural spinal cord compression is a potentially devastating complication of cancer and is estimated to occur in 5% to 14% of all cancer patients. It is best treated surgically. Minimally invasive spine surgery has the potential benefits of decreased surgical approach-related morbidity, blood loss, hospital stay, and time to mobilization.

    Title Image-guided, Endoscopic, Transcervical Resection of Cervical Chordoma.
    Date April 2010
    Journal Journal of Neurosurgery. Spine
    Excerpt

    Chordomas are rare tumors that arise from the sacrum, spine, and skull base. Surgical management of these tumors can be difficult, given their locally destructive behavior and predilection for growing near delicate and critical structures. En bloc resection with negative margins can be difficult to perform without damaging adjacent structures and causing significant clinical morbidity. For chordomas of the upper cervical spine, surgical options traditionally involve transoral or submandibular approaches. The authors report the use of the image-guided, endoscopic, transcervical approach to the upper cervical spine as an alternative to traditional techniques for addressing upper cervical spine tumors, particularly for tumors where gross-total resection is not feasible.

    Title Are Patients Satisfied After Surgery for Metastatic Spine Disease?
    Date April 2010
    Journal The Spine Journal : Official Journal of the North American Spine Society
    Title The Clinical Significance of Pneumorachis: a Case Report and Review of the Literature.
    Date April 2010
    Journal The Journal of Trauma
    Excerpt

    : Pneumorachis is a relatively rare phenomenon, where air enters the spinal canal. Because of its rarity, evaluation and management of this condition is poorly understood. This study describes a case of pneumorachis and performs a review of the current literature to understand the common causes, associated pathologies, presenting neurologic symptoms, treatment options, and neurologic outcomes for patients who develop pneumorachis.

    Title Biomechanical Comparison of Translaminar Versus Pedicle Screws at T1 and T2 in Long Subaxial Cervical Constructs.
    Date March 2010
    Journal Neurosurgery
    Excerpt

    The first in vitro biomechanical investigation comparing the immediate and postcyclical rigidities of thoracic translaminar versus pedicle screws in posterior constructs crossing the cervicothoracic junction (CTJ).

    Title Posterior-only Approach for Total En Bloc Spondylectomy for Malignant Primary Spinal Neoplasms: Anatomic Considerations and Operative Nuances.
    Date March 2010
    Journal Neurosurgery
    Excerpt

    MALIGNANT PRIMARY SPINAL tumors are rare tumors that are locally invasive and can metastasize. The majority of these tumors have a poor response rate to chemotherapy and conventional radiotherapy. Studies have shown that long-term survival and the potential for cure is best achieved with en bloc surgical excision of these tumors with negative surgical margins. Total en bloc spondylectomy involves removal of vertebral segment(s) in whole to achieve wide tumor excision. Total en bloc spondylectomy can be performed through staged or combined anterior and posterior approaches, or from a posterior-only approach. The posterior-only approach offers the advantage of achieving complete tumor excision and circumferential spinal reconstruction in a single setting. In this report, we discuss the operative management of malignant primary vertebral tumors using the posterior-only approach for total en bloc spondylectomy. The oncological considerations and surgical nuances that allow for safe but aggressive surgical excision of primary spinal tumors to achieve favorable oncological and neurological outcomes are highlighted.

    Title Giant Destructive Myxopapillary Ependymomas of the Sacrum.
    Date February 2010
    Journal Journal of Neurosurgery. Spine
    Excerpt

    Myxopapillary ependymomas rarely present as a primary intrasacral lesion, and extensive sacral osteolysis is unusual. The authors report a case series of 6 patients with these complex tumors causing extensive sacral destruction, who underwent resection, lumbopelvic reconstruction, and fusion. The operative procedure, complications, and outcome are summarized after a mean follow-up of 3.55 years (range 18-80 months).

    Title Surgical Management of Cervical Spondylotic Myelopathy with Laminectomy and Instrumented Fusion.
    Date January 2010
    Journal Neurological Research
    Excerpt

    The indications for treating cervical spondylotic myelopathy (CSM) with laminectomy and instrumented fusion remain ill-defined. Cervical laminectomy without instrumented fusion has been associated with suboptimal outcomes, particularly in the setting of cervical kyphosis. This work's purpose is to retrospectively review our experience in patients who underwent laminectomy with instrumented fusion for CSM and to assess the neurological and radiological outcomes of patients treated with this technique.

    Title Ewing and Osteogenic Sarcoma: Evidence for Multidisciplinary Management.
    Date January 2010
    Journal Spine
    Excerpt

    Systematic review of the literature and consensus recommendations by an international expert focus group.

    Title Chordoma of the Sacrum and Vertebral Bodies.
    Date January 2010
    Journal The Journal of the American Academy of Orthopaedic Surgeons
    Excerpt

    Chordomas are relatively rare tumors of bone. These primary malignant lesions occur throughout the spinal column and often show advanced growth at the time of diagnosis. Because such tumors are minimally responsive to radiation and chemotherapy, surgical resection is the mainstay of treatment. Patient survival and local control are associated with the ability to achieve wide surgical margins during excision. However, surgical morbidity may be substantial given the propensity for chordomas to abut or surround neural, vascular, and visceral structures. Thus, early recognition is essential, and treatment by a multidisciplinary team is ideal.

    Title Factors Associated with Progression-free Survival and Long-term Neurological Outcome After Resection of Intramedullary Spinal Cord Tumors: Analysis of 101 Consecutive Cases.
    Date December 2009
    Journal Journal of Neurosurgery. Spine
    Excerpt

    With the introduction of electrophysiological spinal cord monitoring, surgeons have been able to perform radical resection of intramedullary spinal cord tumors (IMSCTs). However, factors associated with tumor resectability, tumor recurrence, and long-term neurological outcome are poorly understood.

    Title En Bloc Spondylectomy for Treatment of Tumor-induced Osteomalacia.
    Date December 2009
    Journal Journal of Neurosurgery. Spine
    Excerpt

    En bloc spondylectomy represents a radical resection of a spinal segment most often reserved for patients presenting with a primary extradural spine tumor or a solitary metastasis in the setting of an indolent, well-controlled systemic malignancy. The authors report a case in which en bloc spondylectomy was conducted to control a metabolically active spine tumor. A 56-year-old woman, who suffered from severe tumor-induced osteomalacia, was found to have a fibroblast growth factor-23-secreting phosphaturic mesenchymal tumor in the T-8 vertebral body. En bloc resection was conducted, leading to resolution of her tumor-induced osteomalacia. This case suggests that radical spondylectomy may be beneficial in the management of metabolically or endocrinologically active tumors of the spine.

    Title Surgical Management of Thoracic Spinal Cord Herniation: Technical Consideration.
    Date December 2009
    Journal Journal of Spinal Disorders & Techniques
    Excerpt

    This report describes a case of spinal cord herniation (SCH) and the surgical technique used to repair the herniation.

    Title Long-term Clinical Outcomes Following En Bloc Resections for Sacral Chordomas and Chondrosarcomas: a Series of Twenty Consecutive Patients.
    Date November 2009
    Journal Spine
    Excerpt

    Retrospective study of 20 consecutive patients who underwent en bloc tumor excision of sacral chordomas and chondrosarcomas.

    Title Multidisciplinary Management of Primary Tumors of the Vertebral Column.
    Date November 2009
    Journal Current Treatment Options in Oncology
    Excerpt

    OPINION STATEMENT: Primary spinal neoplasms are rare tumors that can lead to significant morbidity secondary to local bone destruction and invasion into adjacent neurological and vascular structures. These tumors represent a clinical challenge to even the most experienced physicians and require a multidisciplinary approach to ensure optimal patient outcomes. This review will discuss the most common primary bone tumors and focus on recent surgical, medical, and radiation treatment advances.

    Title Recurrent Lumbar Disc Herniation After Single-level Lumbar Discectomy: Incidence and Health Care Cost Analysis.
    Date November 2009
    Journal Neurosurgery
    Excerpt

    Same-level recurrent lumbar disc herniation complicates outcomes after primary discectomy in a subset of patients. The health care costs associated with the management of this complication are currently unknown. We set out to identify the incidence and health care cost of same-level recurrent disc herniation after single-level lumbar discectomy at our institution.

    Title Thoracic Vertebrectomy and Spinal Reconstruction Via Anterior, Posterior, or Combined Approaches: Clinical Outcomes in 91 Consecutive Patients with Metastatic Spinal Tumors.
    Date October 2009
    Journal Journal of Neurosurgery. Spine
    Excerpt

    Adequate decompression of the thoracic spinal cord often requires a complete vertebrectomy. Such procedures can be performed from an anterior/transthoracic, posterior, or combined approach. In this study, the authors sought to compare the clinical outcomes of patients with spinal metastatic tumors undergoing anterior, posterior, and combined thoracic vertebrectomies to determine the efficacy and operative morbidity of such approaches.

    Title Neurological Outcome After Surgical Management of Adult Tethered Cord Syndrome.
    Date October 2009
    Journal Journal of Neurosurgery. Spine
    Excerpt

    Although postsurgical neurological outcomes in patients with tethered cord syndrome (TCS) are well known, the rate and development of neurological improvement after first-time tethered cord release is incompletely understood. The authors reviewed their institutional experience with the surgical management of adult TCS to assess the time course of symptomatic improvement, and to identify the patient subgroups most likely to experience improvement of motor symptoms.

    Title Epidural Steroid Injection Resulting in Epidural Hematoma in a Patient Despite Strict Adherence to Anticoagulation Guidelines.
    Date October 2009
    Journal Journal of Neurosurgery. Spine
    Excerpt

    Epidural steroid injections are relatively safe procedures, although the risk of hemorrhagic complications in patients undergoing long-term anticoagulation therapy is higher. The American Society for Regional Anesthesia and Pain Medicine has specific guidelines for treatment of these patients when they undergo neuraxial anesthetic procedures. In this paper, the authors present a case in which the current American Society for Regional Anesthesia and Pain Medicine guidelines were strictly followed with respect to withholding and reintroducing warfarin and enoxaparin after an epidural steroid injection, but the patient nevertheless developed a spinal epidural hematoma requiring emergency surgical evacuation. The authors compare the case with the 8 other published cases of postinjection epidural hematomas in patients with coagulopathy, and the specific risk factors that may have contributed to the hemorrhagic complication in this patient is analyzed.

    Title Pediatric Tethered Cord Syndrome: Response of Scoliosis to Untethering Procedures. Clinical Article.
    Date October 2009
    Journal Journal of Neurosurgery. Pediatrics
    Excerpt

    Tethered cord syndrome (TCS) is frequently associated with scoliosis in the pediatric population. Following spinal cord untethering, many patients continue to experience progression of spinal deformity. However, the incidence rate, time course, and risk factors for scoliosis progression following tethered cord release remain unclear. The aim of this study was to determine factors associated with scoliosis progression and whether tethered cord release alone would halt curve progression in pediatric TCS.

    Title Vertebral Compression Fractures in Patients Presenting with Metastatic Epidural Spinal Cord Compression.
    Date October 2009
    Journal Neurosurgery
    Excerpt

    Metastatic epidural spinal cord compression (MESCC) is a relatively common and debilitating complication of metastatic disease that often results in neurological deficits. Pathological fractures of the vertebral body in patients with MESCC are not uncommon. The goals of this study were to evaluate the effects of compression fractures on long-term neurological function, as well as understand the factors that predict the development of pathological fractures for patients with MESCC.

    Title Adjuvant Treatment with Locally Delivered Oncogel Delays the Onset of Paresis After Surgical Resection of Experimental Spinal Column Metastasis.
    Date September 2009
    Journal Neurosurgery
    Excerpt

    The optimal management of spinal column metastatic disease is controversial. Local chemotherapy delivery systems allow targeted high-dose adjuvant therapy. We evaluated whether injection of OncoGel paclitaxel-releasing biodegradable polymer (Protherics, Inc., West Valley City, UT) into the tumor resection cavity at the time of surgery would improve the efficacy of surgical resection with or without external beam radiotherapy (XRT) in a rat model of spinal column metastases.

    Title Radiographic and Clinical Evaluation of Free-hand Placement of C-2 Pedicle Screws. Clinical Article.
    Date August 2009
    Journal Journal of Neurosurgery. Spine
    Excerpt

    Stabilization of the cervical spine can be challenging when instrumentation involves the axis. Fixation with C1-2 transarticular screws combined with posterior wiring and bone graft placement has yielded excellent fusion rates, but the technique is technically demanding and places the vertebral arteries (VAs) at risk. Placement of screws in the pars interarticularis of C-2 as described by Harms and Melcher has allowed rigid fixation with greater ease and theoretically decreases the risk to the VA. However, fluoroscopy is suggested to avoid penetration laterally, medially, and superiorly to avoid damage to the VA, spinal cord, and C1-2 joint, respectively. The authors describe how, after meticulous dissection of the C-2 pars interarticularis, such screws can be placed accurately and safely without the use of fluoroscopy.

    Title Outcome Following Decompressive Surgery for Different Histological Types of Metastatic Tumors Causing Epidural Spinal Cord Compression. Clinical Article.
    Date August 2009
    Journal Journal of Neurosurgery. Spine
    Excerpt

    Metastatic epidural spinal cord compression (MESCC) is a relatively common and debilitating complication of metastatic disease that often results in neurological deficits. Recent studies have supported decompressive surgery over radiation therapy for patients who present with MESCC. These studies, however, have grouped all patients with different histological types of metastatic disease into the same study population. The differential outcomes for patients with different histological types of metastatic disease therefore remain unknown.

    Title Vertebroplasty and Kyphoplasty for the Treatment of Vertebral Compression Fractures: an Evidenced-based Review of the Literature.
    Date August 2009
    Journal The Spine Journal : Official Journal of the North American Spine Society
    Excerpt

    Vertebroplasty (VP) and kyphoplasty (KP) are routinely used to treat vertebral body compression fractures (VCFs) resulting from osteoporosis or vertebral body tumors in order to provide rapid pain relief. However, it remains debated whether VP or KP results in superior outcomes versus medical management alone in patients experiencing VCFs.

    Title Translaminar Versus Pedicle Screw Fixation of C2: Comparison of Surgical Morbidity and Accuracy of 313 Consecutive Screws.
    Date July 2009
    Journal Neurosurgery
    Excerpt

    C2 translaminar (TL) screws rigidly capture the posterior elements of C2, avoid risk of vertebral artery injury, and are less technically demanding than C2 pedicle (PD) screws. However, a C2-TL screw breach places the spinal cord at risk, and the durability of C2-TL screws remains unknown. It is unclear if TL versus PD screw fixation of C2 is truly associated with less operative morbidity, greater accuracy of screw placement, or equivalent durability.

    Title Assuring Optimal Physiologic Craniocervical Alignment and Avoidance of Swallowing-related Complications After Occipitocervical Fusion by Preoperative Halo Vest Placement.
    Date July 2009
    Journal Journal of Spinal Disorders & Techniques
    Excerpt

    A retrospective review.

    Title Posterior Vertebral Column Subtraction Osteotomy: a Novel Surgical Approach for the Treatment of Multiple Recurrences of Tethered Cord Syndrome.
    Date June 2009
    Journal Journal of Neurosurgery. Spine
    Excerpt

    Recurrent tethered cord syndrome (TCS) has been reported to develop in 5-50% of patients following initial spinal cord detethering operations. Surgery for multiple recurrences of TCS can be difficult and is associated with significant complications. Using a cadaveric tethered spinal cord model, Grande and colleagues demonstrated that shortening of the vertebral column by performing a 15-25-mm thoracolumbar osteotomy significantly reduced spinal cord, lumbosacral nerve root, and terminal filum tension. Based on this cadaveric study, spinal column shortening by a thoracolumbar subtraction osteotomy may be a viable alternative treatment to traditional surgical detethering for multiple recurrences of TCS. In this article, the authors describe the use of posterior vertebral column subtraction osteotomy (PVCSO) for the treatment of 2 patients with multiple recurrences of TCS. Vertebral column resection osteotomy has been widely used in the surgical correction of fixed spinal deformity. The PVCSO is a novel surgical treatment for multiple recurrences of TCS. In such cases, PVCSO may allow surgeons to avoid neural injury by obviating the need for dissection through previously operated sites and may reduce complications related to CSF leakage. The novel use of PVCSO for recurrent TCS is discussed in this report, including surgical considerations and techniques in performing PVCSO.

    Title Kyphoplasty with Intraspinal Brachytherapy for Metastatic Spine Tumors.
    Date June 2009
    Journal Journal of Neurosurgery. Spine
    Title Surgical Management of Prostate Cancer Metastatic to the Spine.
    Date June 2009
    Journal Journal of Neurosurgery. Spine
    Excerpt

    Significant improvements in neurological function and pain relief are the benefits of aggressive surgical management of spinal metastatic disease. However, there is limited literature regarding the management of tumors with specific histological features. In this study, a series of patients undergoing spinal surgery for metastatic prostate cancer were reviewed to identify predictors of survival and functional outcome.

    Title Recurrent Disc Herniation and Long-term Back Pain After Primary Lumbar Discectomy: Review of Outcomes Reported for Limited Versus Aggressive Disc Removal.
    Date April 2009
    Journal Neurosurgery
    Excerpt

    It remains unknown whether aggressive disc removal with curettage or limited removal of disc fragment alone with little disc invasion provides a better outcome for the treatment of lumbar disc herniation with radiculopathy. We reviewed the literature to determine whether outcomes reported after limited discectomy (LD) differed from those reported after aggressive discectomy (AD) with regard to long-term back pain or recurrent disc herniation.

    Title Diagnosis and Management of Sacral Tumors.
    Date April 2009
    Journal Journal of Neurosurgery. Spine
    Excerpt

    Sacral tumors pose significant challenges to the managing physician from diagnostic and therapeutic perspectives. Although these tumors are often diagnosed at an advanced stage, patients may benefit from good clinical outcomes if an aggressive multidisciplinary approach is used. In this review, the epidemiology, clinical presentation, imaging characteristics, treatment options, and published outcomes are discussed. Special attention is given to the specific anatomical constraints that make tumors in this region of the spine more difficult to effectively manage than those in the mobile portions of the spine.

    Title An Assessment of the Reliability of the Enneking and Weinstein-boriani-biagini Classifications for Staging of Primary Spinal Tumors by the Spine Oncology Study Group.
    Date April 2009
    Journal Spine
    Excerpt

    Reliability analysis based on expert panel case series review and grading per the Enneking and Weinstein-Boriani-Biagini classification systems.

    Title Effect of Hyperglycemia on Progressive Paraparesis in a Rat Etastatic Spinal Tumor Model.
    Date March 2009
    Journal Journal of Neurosurgery. Spine
    Excerpt

    Hyperglycemia has been shown to potentiate ischemic injury of the spinal cord by quenching vasodilators and potentiating tissue acidosis and free radical production. Steroid-induced hyperglycemia is a common event in the surgical management of metastatic epidural spinal cord compression (MESCC). The goal in this study was to determine whether experimentally induced hyperglycemia accelerates neurological decline in an established animal model of MESCC.

    Title Solitary Vertebral Metastasis.
    Date February 2009
    Journal The Orthopedic Clinics of North America
    Excerpt

    As survival time increases for many cancers, it is likely that the incidence and prevalence of spinal metastases will increase also. Given that most patients first present with solitary lesions in the spine, proper initial diagnosis and management are of paramount importance in minimizing pain, improving neurologic function, and potentially lengthening survival. Although pain control and standard radiation are still used, spinal stereotactic radiosurgery, vertebroplasty and kyphoplasty, and spinal cord decompression and fusion are now consistently used in aggressive management and offer exciting preliminary results.

    Title Evaluation of Factors Associated with Postoperative Infection Following Sacral Tumor Resection.
    Date January 2009
    Journal Journal of Neurosurgery. Spine
    Excerpt

    Resection of sacral tumors has been shown to improve survival, since the oncological prognosis is commonly correlated with the extent of local tumor control. However, extensive soft-tissue resection in close proximity to the rectum may predispose patients to wound complications and infection. To identify potential risk factors, a review of clinical outcomes for sacral tumor resections over the past 5 years at a single institution was completed, paying special attention to procedure-related complications.

    Title Ossification of the Ligamentum Flavum in a Caucasian Man.
    Date December 2008
    Journal Journal of Neurosurgery. Spine
    Excerpt

    Abnormal ossification of spinal ligaments is a well-known cause of myelopathy in East Asian populations, with ossification of the ligamentum flavum (OLF) and the posterior longitudinal ligament being the most prevalent. In Caucasian populations, OLF is rare, and there has been only 1 documented case of the disease affecting more than 5 spinal levels. In this report, the authors describe the clinical presentation, imaging characteristics, and management of the second published case of a Caucasian man with OLF affecting almost the entire thoracic spine. The literature is then reviewed with regard to OLF epidemiology, pathogenesis, presentation, and treatment.

    Title Magnetic Resonance Imaging of Spine Tumors: Classification, Differential Diagnosis, and Spectrum of Disease.
    Date November 2008
    Journal The Journal of Bone and Joint Surgery. American Volume
    Title Surgical Treatment of Cervical Spondylotic Myelopathy with Anterior Compression: a Review of 67 Cases.
    Date September 2008
    Journal Journal of Neurosurgery. Spine
    Excerpt

    OBJECT: In patients with cervical spondylotic myelopathy (CSM), ventral disease and loss of cervical lordosis are considered to be relative indications for anterior surgery. However, anterior decompression and fusion operations may be associated with an increased risk of swallowing difficulty and an increased risk of nonunion when extensive decompression is performed. The authors reviewed cases involving patients with CSM treated via an anterior approach, paying special attention to neurological outcome, fusion rates, and complications. METHODS: Retrospectively, 67 cases involving consecutive patients with CSM requiring an anterior decompression were reviewed: 46 patients underwent anterior surgery only (1-to3-level anterior cervical discectomy and fusion [ACDF] or 1-level corpectomy), and 21 patients who required > 3-level ACDF or > or = 2-level corpectomy underwent anterior surgery supplemented by a posterior instrumented fusion procedure. RESULTS: Postoperative improvement in Nurick grade was seen in 43 (93%) of 46 patients undergoing anterior decompression and fusion alone (p < 0.001) and in 17 (81%) of 21 patients undergoing anterior decompression and fusion with supplemental posterior fusion (p = 0.0015). The overall complication rate for this series was 25.4%. Interestingly, the overall complication rate was similar for both the lone anterior surgery and combined anterior-posterior groups, but the incidence of adjacent-segment disease was greater in the lone anterior surgery group. CONCLUSIONS: Significant improvement in Nurick grade can be achieved in patients who undergo anterior surgery for cervical myelopathy for primarily ventral disease or loss of cervical lordosis. In selected high-risk patients who undergo multilevel ventral decompression, supplemental posterior fixation and arthrodesis allows for low rates of construct failure with acceptable added morbidity.

    Title Mediastinal Lymphangioma Presenting As an Acute Epidural Hematoma.
    Date July 2008
    Journal Journal of Neurosurgery. Pediatrics
    Excerpt

    Lymphangiomas are benign collections of blind-ended lymphatic and vascular channels. Lesions typically occur in the soft tissues of the head and neck, although any region of the body can be affected. Involvement of the spine is very rare. A complete resection is generally curative. On rare occasions, these tumors are complicated by infection or hemorrhage. The authors present an unusual case of a hemorrhagic lymphangioma in a 1-year-old male child. The lesion originated in the mediastinum and extended into the cervicothoracic epidural space via a neural foramen. This resulted in an acute epidural hematoma and quadriparesis. Emergency decompression resulted in full neurological recovery. This may be the first report of a lymphangioma resulting in an acute epidural hematoma and quadriparesis.

    Title Factors Associated with Cervical Instability Requiring Fusion After Cervical Laminectomy for Intradural Tumor Resection.
    Date June 2008
    Journal Journal of Neurosurgery. Spine
    Excerpt

    OBJECT: The indications remain unclear for fusion at the time of cervical laminectomy for intradural tumor resection. To identify patients who may benefit from initial fusion, the authors assessed clinical, radiological/imaging, and operative factors associated with subsequent symptomatic cervical instability requiring fusion after cervical laminectomy for intradural tumor resection. METHODS: The authors reviewed 10 years of data obtained in patients who underwent cervical laminectomy without fusion for intradural tumor resection and who had normal spinal stability and alignment preoperatively. The association of pre- and intraoperative variables with the subsequent need for fusion for progressive symptomatic cervical instability was assessed using logistic regression analysis, and percentages were compared using Fisher exact tests when appropriate. RESULTS: Thirty-two patients (mean age 41 +/- 17 years) underwent cervical laminectomy without fusion for resection of an intradural tumor (18 intramedullary and 14 extramedullary). Each increasing number of laminectomies performed was associated with a 3.1-fold increase in the likelihood of subsequent vertebral instability (odds ratio 3.114, 95% confidence interval 1.207-8.034, p = 0.02). At a mean follow-up interval of 25.2 months, 33% (4 of 12) of the patients who had undergone a >or= 3-level laminectomy required subsequent fusion compared with 5% (1 of 20) who had undergone a <or= 2-level laminectomy (p = 0.03). Four (36%) of 11 patients initially presenting with myelopathic motor disturbance required subsequent fusion compared with 1 (5%) of 21 presenting initially with myelopathic sensory or radicular symptoms (p = 0.02). Age, the presence of a syrinx, intramedullary tumor, C-2 laminectomy, C-7 laminectomy, and laminoplasty were not associated with subsequent symptomatic instability requiring fusion. CONCLUSIONS: In the authors' experience with intradural cervical tumor resection, patients presenting with myelopathic motor symptoms or those undergoing a >or= 3-level cervical laminectomy had an increased likelihood of developing subsequent symptomatic instability requiring fusion. A >or= 3-level laminectomy with myelopathic motor symptoms may herald patients most likely to benefit from cervical fusion at the time of tumor resection.

    Title Intraoperative Localization of Thoracic Spine Level with Preoperative Percutaneous Placement of Intravertebral Polymethylmethacrylate.
    Date June 2008
    Journal Journal of Spinal Disorders & Techniques
    Excerpt

    OBJECTIVE: To evaluate the safety and utility of preoperative vertebroplasty for intraoperative localization of thoracic spinal levels. SUMMARY OF BACKGROUND DATA: Intraoperative fluoroscopy or plain radiographs are traditionally used to localize thoracic spine levels during thoracic spine operations. Unfortunately, such localization can occasionally be difficult in the midthoracic levels due to lack of landmarks, scapular shadows, and the body habitus of the morbidly obese. There are multiple techniques described in the literature that allow for preoperative localization of thoracic spinal levels during approaches to the posterior thoracic spine. For efficient and accurate intraoperative localization of thoracic spinal levels during anterior thoracic spine procedures, we describe a method that uses preoperative percutaneous placement of polymethylmethacrylate (PMMA) into the vertebral body using standard vertebroplasty technique. METHODS: Four patients with morbid obesity and symptomatic thoracic disc herniations underwent preoperative vertebroplasty procedures using standard percutaneous techniques. The PMMA cement was used to expeditiously identify thoracic spinal levels of interest using intraoperative fluoroscopy. RESULTS: All 4 patients underwent successful vertebroplasty procedures without complications. The PMMA cement was easily identified intraoperatively and led to the correct identification of the thoracic spinal levels of interest. CONCLUSIONS: Preoperative placement of PMMA into thoracic vertebral bodies using standard vertebroplasty technique provides a safe, efficient, and reliable method of localizing thoracic spine levels intraoperatively. Such procedures can be performed in the outpatient setting and can be associated with extremely low morbidity when done by experienced practitioners. This procedure should be reserved for patients in whom a surgeon anticipates difficulty using standard radiographs or fluoroscopy to localize thoracic spinal levels intraoperatively.

    Title Endoscopic Transcervical Odontoidectomy for Pediatric Basilar Invagination and Cranial Settling. Report of 4 Cases.
    Date May 2008
    Journal Journal of Neurosurgery. Pediatrics
    Excerpt

    Pediatric basilar invagination and cranial settling have traditionally been approached through a transoral-transpharyngeal route with or without extended maxillotomy or mandibulotomy for resection of the anterior portion of C-1 and the odontoid. The authors hypothesize that application of a recently described endoscopic transcervical odontoidectomy (ETO) technique would allow an alternative approach for the treatment of ventral pathological entities at the craniocervical junction in pediatric patients. The authors performed ETO in a consecutive series of pediatric patients presenting with myelopathy or bulbar dysfunction resulting from basilar invagination or cranial settling. All clinical, radiographic, surgical, and follow-up data were prospectively collected. The initial experience with ETO in the pediatric population is analyzed and outcomes are reported. Three patients required ETO for basilar invagination and 1 required ETO with anterior C-1 arch and distal clivus resection for cranial settling. All patients presented with myelopathy. One patient was wheelchair bound with severe quadriparesis. The mean age was 14 +/- 3 years (mean +/- standard deviation [SD]) in the 2 male and 2 female patients. The ETO and posterior fusion were performed as a 2-stage procedure in 2 (50%) and as a single-stage procedure in 2 (50%) cases. Prolonged intubation or postoperative placement of a gastrostomy tube was not needed in any case. The postoperative hospitalization lasted 9 +/- 4 days (mean +/- SD). At last follow-up (mean 5 months), head and neck pain had resolved and motor strength had improved or stabilized in all cases. All 4 children were independently functioning and ambulatory at the last follow-up. In the authors' initial experience, ETO has allowed ventral brainstem decompression without the need for prolonged intubation, worsening dysphagia requiring enteral tube feeding, or prolonged hospitalization, and has resulted in cosmetically appealing results. The ETO technique allows an alternative approach for the treatment of ventral pathological entities at the craniocervical junction in pediatric patients.

    Title Perioperative Challenges in the Surgical Management of Ankylosing Spondylitis.
    Date April 2008
    Journal Neurosurgical Focus
    Excerpt

    Patients with ankylosing spondylitis (AS) who present with spinal lesions are at an increased risk for developing perioperative complications. Due to the rigid yet brittle nature of the ankylosed spines commonly occurring with severe spinal deformity, patients are more prone to developing neurological deficits. Such risks are potentially increased not only during surgical manipulation or deformity correction, but also during image acquisition, positioning within the operating room, and intubation. In this review the complications of AS are reviewed, and recommendations are provided to avoid problems during each stage of patient management.

    Title Harms Titanium Mesh Cage Fracture.
    Date February 2008
    Journal European Spine Journal : Official Publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society
    Excerpt

    Interbody fusion has become a mainstay of surgical management for lumbar fractures, tumors, spondylosis, spondylolisthesis and deformities. Over the years, it has undergone a number of metamorphoses, as novel instrumentation and approaches have arisen to reduce complications and enhance outcomes. Interbody fusion procedures are common and successful, complications are rare and most often do not involve the interbody device itself. We present here a patient who underwent an anterior L4 corpectomy with Harms cage placement and who later developed a fracture of the lumbar titanium mesh cage (TMC). This report details the presentation and management of this rare complication, as well as discusses the biomechanics underlying this rare instrumentation failure.

    Title Epidemiology and Demographics for Primary Vertebral Tumors.
    Date February 2008
    Journal Neurosurgery Clinics of North America
    Excerpt

    The vertebral column is the most common osseous site for secondary malignancy. Conversely, primary tumors of the vertebral column are relatively rare, comprising only 10% or less of all tumors to the spine. This article outlines benign and malignant tumors of the spine in children and adults.

    Title Chordoma of the Spinal Column.
    Date February 2008
    Journal Neurosurgery Clinics of North America
    Excerpt

    Chordomas are the most common primary malignant tumor of the mobile spine and of the sacrum. Although considered not to possess significant metastatic potential, such lesions are locally aggressive, leading to neurologic compromise and lytic destruction of bone. En bloc resection has afforded patients the greatest chance of local control and disease-free survival. Such radical resections may be associated with significant surgical morbidity, however. Although considered generally resistant to radiation therapy and chemotherapy, recent advances in photon and proton radiation therapy and use of monoclonal antibodies may provide improved outcomes for poor surgical candidates and for tumors that recur after surgery.

    Title Surgery for Primary Vertebral Tumors: En Bloc Versus Intralesional Resection.
    Date February 2008
    Journal Neurosurgery Clinics of North America
    Excerpt

    The decision to select en bloc resection or intralesional resection needs to be tailored to each individual patient and circumstance. Though complete resection with long-term progression-free survival is the goal, it is not always feasible, nor advisable, depending on what the patient's expectations are and what the risk of complications may be. However, in cases with favorable circumstances and consensus agreement between physicians, surgeons, and patients, aggressive en bloc removal of spinal tumors can be extremely valuable and may offer the only chance at cure for otherwise devastating malignancies.

    Title Positive and Negative Prognostic Variables for Patients Undergoing Spine Surgery for Metastatic Breast Disease.
    Date January 2008
    Journal European Spine Journal : Official Publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society
    Excerpt

    The histology of the primary tumor in metastatic spine disease plays an important role in its treatment and prognosis. However, there is paucity in the literature of histology-specific analysis of spinal metastases. In this study, prognostic variables were reviewed for patients who underwent surgery for breast metastases to the spinal column. Respective chart review was done to first identify all patients with breast cancer over an 8-year period at a major cancer center and then to select all those with symptomatic metastatic disease to the spine who underwent spinal surgery. Univariate and multivariate analyses were used to assess several prognostic variables. Presence of visceral metastases, multiplicity of bony lesions, presence of estrogen receptors (ER), and segment of spine (cervical, thoracic, lumbar, sacral) in which metastases arose were compared with patient survival. Eighty-seven patients underwent 125 spinal surgeries. Those with estrogen receptor (ER) positivity had a longer median survival after surgery compared to those with estrogen receptor negativity. Patients with cervical location of metastasis had a shorter median survival compared with those having metastases in other areas of the spine. The presence of visceral metastases or a multiplicity of bony lesions did not have prognostic value. In patients with spinal metastases from breast cancer, aggressive surgical management may be an option for providing significant pain relief and preservation/improvement of neurological function. Interestingly, in patients undergoing such surgery, cervical location of metastasis is a negative prognostic variable, and ER-positivity is associated with better survival, while presence of visceral or multiple bony lesions does not significantly alter survival.

    Title Development of Scoliosis Following Intrathecally Placed Opioid Pump for Chronic Low Back Pain.
    Date December 2007
    Journal Spine
    Excerpt

    STUDY DESIGN: Case report. OBJECTIVE: To report a case and review the literature on development of scoliosis following intrathecally placed opioid pump for chronic low back pain. SUMMARY OF BACKGROUND DATA: Intrathecal opioid administration is a technique currently indicated for the management of chronic pain syndromes. Despite evidence of scoliosis occurring after baclofen pump insertion, there has been no evidence that development of scoliosis occurs following implantation of an intrathecally placed opioid pump for treatment of lower back pain (LBP). METHODS: A retrospective review of patients with adult onset scoliosis was performed at our institution. One patient was identified as showing significant scoliotic progression following implantation of an intrathecally placed opioid pump. Radiographs were analyzed to evaluate the magnitude and configuration of her kyphoscoliosis following pump insertion. RESULTS: A 50-year-old woman with intractable LBP underwent placement of a spinal cord stimulator (SCS) followed shortly by removal of the SCS and placement of an intrathecal opioid pump. Five years later, she presented with severe kyphoscoliosis involving a left thoracolumbar curve of 84 degrees and sagittal balance of 158 mm. Because of intractable pain and progressive deformity, she underwent multilevel osteotomies, instrumented fusion, and replacement of her Dilaudid pump. Postoperative radiographs demonstrated a residual 23 degrees thoracolumbar curve with restoration of her sagittal alignment. No major morbidity/mortality occurred with treatment. CONCLUSION: Although there may not be a direct correlation between implantation of an intrathecal opioid pump with subsequent development of adult onset scoliosis, deformity must be considered a potential sequela in patients treated with such neuromodulation.

    Title Surgical Treatment Strategies and Outcome in Patients with Breast Cancer Metastatic to the Spine: a Review of 87 Patients.
    Date November 2007
    Journal European Spine Journal : Official Publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society
    Excerpt

    Aggressive surgical management of spinal metastatic disease can provide improvement of neurological function and significant pain relief. However, there is limited literature analyzing such management as is pertains to individual histopathology of the primary tumor, which may be linked to overall prognosis for the patient. In this study, clinical outcomes were reviewed for patients undergoing spinal surgery for metastatic breast cancer. Respective review was done to identify all patients with breast cancer over an eight-year period at a major cancer center and then to select those with symptomatic spinal metastatic disease who underwent spinal surgery. Pre- and postoperative pain levels (visual analog scale [VAS]), analgesic medication usage, and modified Frankel grade scores were compared on all patients who underwent surgery. Univariate and multivariate analyses were used to assess risks for complications. A total of 16,977 patients were diagnosed with breast cancer, and 479 patients (2.8%) were diagnosed with spinal metastases from breast cancer. Of these patients, 87 patients (18%) underwent 125 spinal surgeries. Of the 76 patients (87%) who were ambulatory preoperatively, the majority (98%) were still ambulatory. Of the 11 patients (13%) who were nonambulatory preoperatively, four patients were alive at 3 months postoperatively, three of which (75%) regained ambulation. The preoperative median VAS of six was significantly reduced to a median score of two at the time of discharge and at 3, 6, and 12 months postoperatively (P < 0.001 for all time points). A total of 39% of patients experienced complications; 87% were early (within 30 days of surgery), and 13% were late. Early major surgical complications were significantly greater when five or more levels were instrumented. In patients with spinal metastases specifically from breast cancer, aggressive surgical management provides significant pain relief and preservation or improvement of neurological function with an acceptably low rate of complications.

    Title Are Computed Tomography Scans Adequate in Assessing Cervical Spine Pain Following Blunt Trauma?
    Date November 2007
    Journal Emergency Medicine Journal : Emj
    Excerpt

    Good quality three-view radiographs (anteroposterior, lateral, and open-mouth/odontoid) of the cervical spine exclude most unstable injuries, with sensitivity as high as 92% in adults and 94% in children. The diagnostic performance of helical computed tomography (CT) scanners may be even greater, with reported sensitivity as high as 99% and specificity 93%. Missed injuries are usually ligamentous, and may only be detected with magnetic resonance imaging (MRI) or dynamic plain radiographs. With improvements in the accessibility of advanced imaging (helical CT and MRI) and with improvements in the resolution of such imaging, dynamic screening is now used less commonly to screen for unstable injuries. This case involves a patient with an unstable cervical spine injury whose cervical subluxation was only detected following use of dynamic radiographs, despite a prior investigation with helical CT. In this way, the use of dynamic radiographs following blunt cervical trauma should be considered an effective tool for managing acute cervical spine injury in the awake, alert, and neurologically intact patient with neck pain.

    Title Fractionated, Single-port Radiotherapy Delays Paresis in a Metastatic Spinal Tumor Model in Rats.
    Date October 2007
    Journal Journal of Neurosurgery. Spine
    Excerpt

    OBJECT: Spinal column metastatic disease affects thousands of cancer patients every year. Radiation therapy frequently represents the primary treatment for this condition. Despite the enormous clinical impact of spinal column metastatic disease, the literature currently lacks an accurate animal model for testing the efficacy of irradiation on spinal column metastases. METHODS: After anesthesia was induced, female Fischer 344 rats underwent a transabdominal approach to the ventral vertebral body (VB) of L-6. A 2- to 3-mm-diameter bur hole was drilled for the implantation of a section of CRL-1666 breast adenocarcinoma. After the animals had recovered from the surgery, they underwent fractionated, single-port radiotherapy beginning on postoperative Day 7. Each group of animals underwent five daily fractions of radiation treatment. Group I animals received a total dose of 10 Gy in 200-cGy daily fractions, Group II animals received a total dose of 20 Gy in 400-cGy daily fractions, and Group III animals received a total dose of 30 Gy in 600-cGy daily fractions. A control group of rats with implanted VB lesions did not receive radiation. To test the effects of radiation toxicity alone, additional rats without implanted tumors received radiation treatments in the same fractions as the rats with tumors. Hindlimb function in all rats was rated before and after radiation treatment using the Basso-Beattie-Bresnahan locomotor rating scale. Histological analysis of spinal cord and vertebral column sections was performed after each animal's death. RESULTS: Functional assessments demonstrated a statistically significant delay in the onset of paresis between the three treatment groups and the control group (tumor implanted but no radiotherapy). The rats in the three treatment groups, however, did not exhibit any significant differences related to hindlimb function. A dose-dependent relationship was found for the percentage of animals who had become paralyzed at the time of death, with all members of the control group and no members of the 30-Gy group exhibiting paralysis. The results of this study do not indicate any overall survival benefit for any level of radiation dose. CONCLUSIONS: These findings demonstrate the efficacy of focal spinal irradiation in delaying the onset of paralysis in a rat metastatic spine tumor model, but without a clear survival benefit. Because of the dose-related toxicity observed in the rats treated with 30 Gy, this effect was most profound for the 20-Gy group. This finding parallels the observed clinical course of spinal column metastatic disease in humans and provides a basis for the future comparison of novel local and systemic treatments to augment the observed effects of focal irradiation.

    Title Ct Fluoroscopically Guided Percutaneous Placement of Transiliosacral Rod for Sacral Insufficiency Fracture: Case Report and Technique.
    Date October 2007
    Journal Ajnr. American Journal of Neuroradiology
    Excerpt

    Treatment of sacral insufficiency fractures (SIFs) has traditionally been conservative, but several patients have been treated with percutaneous sacroplasty. Unfortunately, in the setting of severe, bilateral SIFs, cement may not withstand shear forces present at the lumbosacral junction, and surgical hardware may not provide adequate fixation in osteoporotic, cancellous bone of the sacrum, leading to eventual pseudarthrosis. Thus, we propose a novel technique in which guidance with CT fluoroscopy allows placement of a transiliosacral bar in conjunction with sacroplasty.

    Title Local Delivery of Oncogel Delays Paresis in Rat Metastatic Spinal Tumor Model.
    Date August 2007
    Journal Journal of Neurosurgery. Spine
    Excerpt

    OBJECT: Spinal column metastatic disease clinically affects thousands of cancer patients every year. Local chemotherapy represents a new option in the treatment of metastatic disease of the spine. Despite the clinical impact of metastatic spine disease, the literature currently lacks an accurate animal model for the effective dosing of local chemotherapeutic agents within the vertebral column. METHODS: Female Fischer 344 rats, weighing 150 to 200 g each, were used in this study. After induction of anesthesia, a transabdominal approach to the ventral vertebral body of L-6 was performed. A small hole was drilled and 5 microL of ReGel (blank polymer), OncoGel (paclitaxel and ReGel) 1.5%, OncoGel 3.0%, or OncoGel 6.0% were immediately injected to determine drug toxicity. Based on these results, efficacy studies were performed by intratumoral injection of 5 microL of ReGel, OncoGel 3.0%, and OncoGel 6.0% on Day 6 in a CRL- 1666 breast adenocarcinoma metastatic spine tumor model. Hind limb function was tested pre- and postoperatively using the Basso-Beattie-Bresnahan rating scale. Histological analysis of the spinal cord and vertebral column was performed when the animal died or was killed. RESULTS: There were no signs of toxicity observed in association with any of the agents under study. No increased benefit was seen in the blank polymer group compared with the control group (tumor only). OncoGel 3.0% and OncoGel 6.0% were effective in delaying the onset of paralysis in the respective study groups. CONCLUSIONS: These findings demonstrate the potential benefit of OncoGel in cases of subtotal resections of metastatic spinal column tumors. OncoGel 6.0% is the most efficacious drug concentration and offers the best therapeutic option in this experimental model. These results provide promise for the development of local chemotherapeutic means to treat spinal metastases.

    Title Total L-5 Spondylectomy and Reconstruction of the Lumbosacral Junction. Technical Note.
    Date July 2007
    Journal Journal of Neurosurgery. Spine
    Excerpt

    The authors describe a technique for total L-5 spondylectomy and reconstruction of the lumbosacral junction. The technique, which involves separately staged posterior and anterior procedures, is reported in two patients harboring neoplasms that involved the L-5 level. The first stage consisted of a posterior approach with removal of all posterior bone elements of L-5 and radical L4-5 and L5-S 1 discectomies. Lumbosacral and lumbopelvic instrumentation included pedicle screws as well as iliac screws or a transiliac rod. The second stage consisted of an anterior approach with mobilization of vascular structures, completion of L4-5 and L5-S1 discectomies, and removal of the L-5 vertebral body. Anterior lumbosacral reconstruction included placement of a distractable cage and tension band between L-4 and S-1. Allograft bone was used for fusion in both stages. No significant complications were encountered. At more than 1 year of follow-up, both patients were independently ambulatory, without evidence of recurrent or metastatic disease, and adequate lumbosacral alignment was maintained. The authors conclude that this technique can be safely performed in appropriately selected patients with neoplasms involving L-5.

    Title Lumbar Disc Herniation--to Operate or Not to Operate?
    Date July 2007
    Journal Nature Clinical Practice. Neurology
    Title Diagnosis and Management of Metastatic Spine Disease.
    Date May 2007
    Journal Surgical Oncology
    Excerpt

    Spinal metastases are a significant source of morbidity in patients with systemic cancer. Roughly 30% of patients with cancer develop symptomatic spinal metastases during the course of their illness, and up to 90% of cancer patients possess metastatic lesions within the spine at the time of death with advances in the treatment of systemic disease, survival in such patients has increased. This factor combined with improved imaging modalities will undoubtedly increase the incidence in which spinal metastases are encountered by physicians. In this review, the authors not only attempt to present the myriad ways in which patient with spinal metastases present, but also the means by which they are currently diagnosed and managed. In addition, we propose a simple algorithm to aid in deciding which patients are ideally treated medically and which patients may benefit from surgery.

    Title Thoracic Kyphotic Deformity Reduction with a Distractible Titanium Cage Via an Entirely Posterior Approach.
    Date April 2007
    Journal Neurosurgery
    Excerpt

    OBJECTIVE: Surgical correction of thoracic kyphotic deformity is often associated with significant surgical and neurological morbidity and unsatisfactory reduction of kyphosis, especially in patients who cannot tolerate anterior thoracic procedures because of associated comorbidity. We describe a technique in which kyphotic deformity of the thoracic and thoracolumbar spine is corrected, decompressed, and stabilized with a circumferential fixation construct from a lone posterior approach. METHODS: We reviewed the radiographic and clinical outcomes of seven patients undergoing vertebrectomy via a bilateral modified costotransversectomy approach followed by posterior placement of a distractible cage, reduction of the deformity via cage distraction, and supplemental dorsal instrumentation. All patients possessed thoracic/thoracolumbar kyphosis; however, a transthoracic approach was thought to be high risk because of medical comorbidity. RESULTS: Seven patients underwent this procedure for thoracolumbar kyphosis resulting from a spinal tumor, osteomyelitis, and fracture. Vertebrectomies were performed at T2-T3, T4-T5, T5-T6, T12-L1, and L1. The mean preoperative kyphosis was 28.6 degrees, the mean postoperative kyphosis at the time of the final follow-up examination was 12.1 degrees, and the mean change in kyphosis was 53%. The mean long-term follow-up period was approximately 16 months. At the time of the final follow-up examination for all patients, there was no decline in neurological function, and pain management consisted of minimal use of oral narcotics. CONCLUSION: This technique allows for circumferential decompression of the spinal cord via a posterior approach in patients with thoracic kyphotic deformities who cannot tolerate anterior thoracic approaches. In addition, in situ distraction of the expandable cage allows correction of sagittal imbalance and restores height without the potential loss of spinal height associated with osteotomies.

    Title Endoscopic Image-guided Odontoidectomy for Decompression of Basilar Invagination Via a Standard Anterior Cervical Approach. Technical Note.
    Date March 2007
    Journal Journal of Neurosurgery. Spine
    Excerpt

    Symptomatic irreducible basilar invagination has traditionally been approached through a transoral-transpharyngeal route with resection of the anterior portion of C-1 and the odontoid. Modification of this exposure with either a Le Fort osteotomy or a transmandibular osteotomy and circumglossal approach has increased the access to pathological conditions in this region. These traditional routes all require traversing the oral cavity and accepting the associated potential complications. The authors have developed a novel surgical approach, an endoscopic transcervical odontoidectomy, which allows access for resection of the odontoid and for brainstem and spinal cord decompression without traversing the oral cavity. In this paper they describe the technique and its advantages and present three cases in which patients underwent the endoscopic transcervical odontoidectomy for basilar invagination. Three consecutive patients (age range 42-74 years) who had irreducible basilar invagination underwent the endoscopic transcervical odontoidectomy. All were symptomatic and had neck pain and myelopathy. All were evaluated preoperatively and postoperatively with computed tomography and magnetic resonance imaging. In all cases the procedure resulted in complete decompression. There were no serious complications. No patient required prolonged intubation, tracheostomy, or enteral tube feeding. One patient had an intraoperative cerebrospinal fluid leak, which had no postoperative sequelae. The authors present an alternative surgical approach for treating ventral compression of the brainstem and spinal cord. The technique is safe and effective for decompression and provides a surgical route that can be added to the armamentarium of treatments for pathological conditions in this region.

    Title Translaminar Screw Fixation in the Upper Thoracic Spine.
    Date January 2007
    Journal Journal of Neurosurgery. Spine
    Excerpt

    OBJECT: The use of pedicle screws (PSs) for instrument-assisted fusion in the cervical and thoracic spine has increased in recent years, allowing smaller constructs with improved biomechanical stability and repositioning possibilities. In the smaller pedicles of the upper thoracic spine, the placement of PSs can be challenging and may increase the risk of damage to neural structures. As an alternative to PSs, translaminar screws can provide spinal stability, and they may be used when pedicular anatomy precludes successful placement of PSs. The authors describe the technique of translaminar screw placement in the T-1 and T-2 vertebrae. METHODS: Seven patients underwent cervicothoracic fusion to treat trauma, neoplasm, or degenerative disease. Nineteen translaminar screws were placed, 13 at T-1 and six at T-2. A single asymptomatic T-2 screw violated the ventral laminar cortex and was removed. The mean clinical and radiographic follow up exceeded 14 months, at which time there were no cases of screw pullout, screw fracture, or progressive kyphotic deformity. CONCLUSIONS: Rigid fixation with translaminar screws offers an attractive alternative to PS fixation, allowing the creation of sound spinal constructs and minimizing potential neurological morbidity. Their use requires intact posterior elements, and care should be taken to avoid violation of the ventral laminar wall.

    Title Metastatic Disease from Spinal Chordoma: a 10-year Experience.
    Date November 2006
    Journal Journal of Neurosurgery. Spine
    Excerpt

    OBJECT: Metastastic lesions have been reported in 5 to 40% of patients with spinal and sacrococcygeal chordoma, but few contemporary series of chordoma metastastic disease exist in the literature. Additionally, the outcome in patients with chordoma-induced metastastic neoplasms remains unclear. The authors performed a retrospective review of the neurosurgery database at the University of Texas M. D. Anderson Cancer Center in Houston to determine the incidence of metastatic disease in a contemporary series of spinal and sacrococcygeal chordoma as well as to determine the outcomes. METHODS: Thirty-seven patients underwent surgery for spinal and sacrococcygeal chordoma between June 1, 1993, and March 31, 2004. All records were reviewed, and appropriate statistical analyses were used to compare patient data for preoperative characteristics, treatments, and outcomes. The authors identified seven patients (19%) in whom metastatic disease developed; in three the disease had metastasized to the lungs only, in two to the lungs and liver, and in two to distant locations in the spine. There were no significant differences in age, sex, tumor location, or history of radiation treatments between patients with and those without metastases. In cases with local recurrent tumors, metastastic disease was more likely to develop than in those without recurrence (28 compared with 0%, respectively; p = 0.07). In two (12%) of 17 patients who underwent en bloc resection, metastatic disease developed, whereas it developed in five (25%) of 20 patients treated by curettage (p = 0.42). The median time from first surgery to the appearance of metastatic disease, as calculated using the Kaplan-Meier method, was 143.4 months (95% confidence interval [CI] 66.8-219.9). The median survival duration of patients with metastatic disease after the first surgery was 106 months (95% CI 55.7-155.7), and this did not differ significantly from that in patients in whom no metastases developed (p = 0.93). CONCLUSIONS: Spinal chordoma metastasized to other locations in 19% of the patients in this series. In patients with local disease recurrence, metastatic lesions are more likely to develop. Metastatic lesions were shown to be aggressive in some cases. Surgery and chemotherapy can play a role in controlling metastatic disease.

    Title Frameless Stereotaxy in a Transmandibular, Circumglossal, Retropharyngeal Cervical Decompression in a Klippel-feil Patient: Technical Note.
    Date October 2006
    Journal European Spine Journal : Official Publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society
    Excerpt

    Frameless stereotaxy, while most commonly applied to intracranial surgery, has seen an increasing number of applications in spinal surgery. Its use in the spine has been described to a greater degree in posterior rather than anterior surgical approaches, presumably due to the relative paucity of anatomical landmarks appropriate for frameless stereotactic registration in the anterior spine. This technical note illustrates the previously undescribed, successful use of frameless stereotaxy to the transmandibular, circumglossal, retropharyngeal surgical approach in a patient with Klippel-Feil syndrome.

    Title Surgery Insight: Current Management of Epidural Spinal Cord Compression from Metastatic Spine Disease.
    Date September 2006
    Journal Nature Clinical Practice. Neurology
    Excerpt

    Metastatic epidural spinal cord compression (MESCC) is becoming a more common clinically encountered entity as advancing systemic antineoplastic treatment modalities improve survival in cancer patients. Although treatment of MESCC remains a palliative endeavor, emerging surgical techniques, in combination with imaging modalities that detect spinal metastatic disease at an early stage, are resulting in improved outcomes. Here, we review the clinical presentation, diagnostic work-up and management options in the management of MESCC. A treatment paradigm is outlined with emphasis on early circumferential surgical decompression of the spinal cord with concomitant spinal stabilization. Radiation therapy has a clearly defined role in the treatment of patients with MESCC, particularly those with radiation-sensitive tumors in the setting of non-bony spinal cord compression and those with a limited life expectancy. Spinal stereotactic radiosurgery, vertebroplasty, and kyphoplasty, are emerging treatment options that are beginning to be used in selected patients with MESCC.

    Title Preoperative Imaging of Cervical Spine Hemangioblastomas Using Three-dimensional Fusion Digital Subtraction Angiography. Report of Two Cases.
    Date September 2006
    Journal Journal of Neurosurgery. Spine
    Excerpt

    Angiography is often performed to identify the vascular supply of hemangioblastomas prior to resection. Conventional two-dimensional (2D) digital subtraction (DS) angiography and three-dimensional (3D) DS angiography provides high-resolution images of the vascular structures associated with these lesions. However, such 3D DS angiography often does not provide reliable anatomical information about nearby osseous structures, or when it does, resolution of vascular anatomy in the immediate vicinity of bone is sacrificed. A novel angiographic reconstruction algorithm was recently developed at The Johns Hopkins University to overcome these inadequacies. By combining two separate sequences of images of bone and blood vessels in a single 3D representation, 3D fusion DS (FDS) angiography provides precise topographic information about vascular lesions in relation to the osseous environment, without a loss of resolution. In this paper, the authors present the cases of two patients with cervical spine hemangioblastomas who underwent preoperative evaluation with FDS angiography and then successful gross-total resection of their tumors. In both cases, FDS angiography provided high-resolution 3D images of the hemangioblastoma anatomy, including each tumor's topographic relationship with adjacent osseous structures and the location and size of feeding arteries and draining veins. These cases provide evidence that FDS angiography represents a useful adjunct to magnetic resonance imaging and 2D DS angiography in the preoperative evaluation and surgical planning of patients with vascular lesions in an osseous environment, such as hemangioblastomas in the spinal cord.

    Title Concomitant Conus Medullaris Ependymoma and Filum Terminale Lipoma: Case Report.
    Date July 2006
    Journal Neurosurgery
    Excerpt

    OBJECTIVE: Ependymomas of the conus medullaris-cauda equina-filum terminale region are typically solitary lesions. In this report, we describe the clinical presentation, radiographic findings, operative details, and pathological features of a patient with a conus medullaris ependymoma and a filum terminale lipoma. CLINICAL PRESENTATION: A 40-year-old woman presented with increasing low back pain and bowel and bladder dysfunction. Magnetic resonance imaging revealed a partially cystic enhancing lesion at the conus medullaris and a T1-weighted hyperintense mass within the filum terminale. INTERVENTION: An L2-L3 laminotomy/laminoplasty was performed for gross total resection of the mass. Histopathological examination demonstrated a conus medullaris ependymoma and filum terminale lipoma. The patient experienced complete resolution of her preoperative symptoms. CONCLUSION: Spinal cord ependymomas are almost exclusively single lesions and their coexistence with other pathological entities is rare. In this report, we describe a patient with a concomitant conus medullaris ependymoma and filum terminale lipoma.

    Title Solitary Thoracic Osteochondroma: Case Report and Review of the Literature.
    Date May 2006
    Journal Neurosurgery
    Excerpt

    OBJECTIVE AND IMPORTANCE: Osteochondromas are common benign bone tumors that rarely arise in the vertebral column. Intraspinal presentation of these tumors is usually circumscribed to the cervical regions with few tumors presenting in the thoracic vertebrae. We report a case of a thoracic solitary osteochondroma arising from within the vertebral body, review the cases reported in the literature, and propose recommendations for the surgical management of these challenging lesions. CLINICAL PRESENTATION: A 26-year-old woman presented with clinical signs of spinal cord compression consisting of right lower extremity weakness and left lower extremity numbness. Magnetic resonance imaging showed a small enhancing epidural mass behind the vertebral body of T12. INTERVENTION: A T12 corpectomy was performed with thoracolumbar fixation and fusion. CONCLUSION: Our case is atypical in that the tumor arose from the posterior portion of the T12 body, causing spinal cord dysfunction that necessitated an anterior approach to T12 for corpectomy with thoracolumbar fixation and fusion. Surgical intervention was effective in completely resolving the patient's right lower extremity weakness.

    Title Spinal Instability and Deformity Due to Neoplastic Conditions.
    Date April 2006
    Journal Neurosurgical Focus
    Excerpt

    In addition to tumor resection, a major goal of spine surgery involving tumors is the preservation or achievement of spinal stability. The criteria defining stability, originally developed for use in trauma, are not directly applicable in the setting of neoplasia. The authors discuss the most common patterns of tumor-related instability and deformity at all levels of the spinal column and review the surgical options for treatment.

    Title A Novel Intravertebral Tumor Model in Rabbits.
    Date April 2006
    Journal Neurosurgery
    Excerpt

    OBJECTIVE: Although the majority of human epidural spinal metastases originate in the vertebral body, current animal models of spinal epidural tumors are limited to extraosseous tumor placement. We investigated the onset of paraparesis, radiographic changes (magnetic resonance imaging [MRI] and computed tomographic [CT] scans), and histopathological findings after intraosseous injection of VX2 carcinoma cells into the lower thoracic vertebrae of rabbits. METHODS: New Zealand white rabbits (n = 23) were injected with a 15-mul suspension containing 300,000 VX2 carcinoma cells in the lowest thoracic vertebral body. Lower extremity motor function was assessed daily. For the first 3 animals, MRI scans (T2-weighted and T1-weighted +/- gadolinium) were acquired at postoperative day (POD) 14 and at the onset of paraparesis. Noncontrast CT scans were obtained on POD 7 and at the time of paraparesis. At the onset of paraparesis, the animals ware killed and the spines were dissected. After demineralization, hematoxylin and eosin cross sections were obtained. RESULTS: Before the onset of paraparesis, the CT and MRI scans revealed no gross tumor. At the onset of paraparesis, CT scans demonstrated an osteolytic tumor centered at the junction of the left pedicle and vertebral body, and MRI scans demonstrated epidural tumor arising from the body and compressing the spinal cord. Histopathological examination confirmed carcinoma arising from the body and extending into the canal, with widespread osteolytic activity. By POD 28, 72% of the animals had become paraparetic, and by the termination of the experiment on POD 120, 89% had become paraparetic. CONCLUSION: We established a novel intraosseous intravertebral tumor model in rabbits and characterized it with respect to onset of paraparesis, imaging features, and histopathological findings.

    Title Ewing's Sarcoma of the Mobile Spine.
    Date February 2006
    Journal Spine
    Excerpt

    STUDY DESIGN: A retrospective analysis was performed. OBJECTIVES: To determine the oncological outcome of patients with nonmetastatic Ewing's sarcoma of the mobile spine treated with systemic multiagent chemotherapy combined with radiation therapy for definitive local control. SUMMARY OF BACKGROUND DATA: To our knowledge, there are no studies that evaluate the oncological outcome of patients with nonmetastatic Ewing's sarcoma of the mobile spine treated with systemic chemotherapy and radiation therapy for definitive local control. METHODS: Thirteen patients with nonmetastatic Ewing's sarcoma of the mobile spine were treated with high-dose multiagent chemotherapy combined with radiation therapy for definitive local control from 1971 to 2000 at a single institution. Patients were observed for a minimum of 2 years or until death. Neurological function, local recurrence, distant relapse, and treatment-related complications were evaluated. RESULTS: There were 8 females and 5 males with a mean age of 19 years (ranging from 7-26 years). The mean follow-up time was 65 months (median 28 months; ranging from 2 to 218 months). All patients presented with pain. Motor deficits were present in 6 patients. Ten patients had a decompressive laminectomy. Improved pain control, as determined by narcotic use, was noted in 12 (92%) patients. Ten patients maintained or improved motor function by at least 1 Frankel grade, while 3 had deterioration of motor function. The disease-free survival rate was 49% and 36% at 5 and 10 years. Five (38%) patients were free of disease at last follow-up. Seven patients developed metastatic disease. Three (23%) patients developed a local recurrence. One of these patients had paraplegia associated with the local recurrence. Five patients developed 8 treatment-related complications. Four of the 10 (40%) patients that had a laminectomy developed progressive kyphosis. Two of these patients also developed late-onset cauda equina syndrome along with the deformity. One of these patients also developed cardiomyopathy associated with adriamycin cardiotoxicity. One patient developed a nonhealing pressure ulcerover a prominent spinous process. CONCLUSIONS: The current study provides historical data on a relatively homogeneous group of patients withEwing's sarcoma of the mobile spine treated with multiagent chemotherapy combined with radiation therapy for definitive local control. Systemic chemotherapy combined with current spinal resection and reconstruction techniques may lead to improved oncological and clinical outcomes.

    Title The Application of Surgical Cordectomy in the Management of an Intramedullary-extramedullary Atypical Meningioma: Case Report and Literature Review.
    Date January 2006
    Journal Journal of Spinal Disorders & Techniques
    Excerpt

    BACKGROUND: The English literature describes only four cases of intraspinal tumors requiring surgical intervention in the form of cordectomy; none of these cases was for meningiomas. Intraspinal meningiomas, typically extramedullary-intradural, require treatment in the form of resection with dural margin excision. The presentation of an intramedullary atypical World Health Organization grade II meningioma is rare. The authors report a case of a transformed intramedullary-extramedullary atypical meningioma treated with cordectomy. METHODS: The patient was a 65-year-old woman who presented with a recurrent thoracic meningioma status post three attempted resections, radiation therapy, and a trial of hydroxyurea chemotherapy. The patient presented paraplegic with reports of burning paresthesias bilaterally in her upper extremities 12 months after her third resection attempt. RESULTS: Magnetic resonance imaging on this current presentation revealed a heterogeneously enhancing hypointense mass extending from T2 to T6. Extension of abnormal T2 signal within the cord superiorly to C7 was noted with a 1-cm enhancing extra-axial lesion at T10 and an extradural mass posteriorly T12 also noted. The patient underwent a T2-T7 laminectomy with a T2-T8 cordectomy. Two months postoperatively, the patient was doing well with no further deterioration in neurologic function. CONCLUSIONS: This case highlights the viability of surgical cordectomy in the treatment of varying intramedullary processes under appropriate indications.

    Title Use of Magnetic Resonance Imaging in Differentiating Compartmental Location of Spinal Tumors.
    Date January 2006
    Journal American Journal of Orthopedics (belle Mead, N.j.)
    Excerpt

    Magnetic resonance imaging (MRI) is the best imaging modality for evaluating most spinal tumors. In this review, we describe the MRI appearance of extradural, intradural-extramedullary, and intradural-intramedullary tumors as well as the image interpretation techniques that permit identification of the compartment in which a lesion is located. In addition, we review the literature and our experience in using an anatomic classification system to narrow the differential diagnosis for patients with spine tumors. This method permits successful identification of a narrow differential diagnosis, which can be used to guide additional evaluation and treatment.

    Title Spinal Pelvic Reconstruction After Total Sacrectomy for En Bloc Resection of a Giant Sacral Chordoma. Technical Note.
    Date January 2006
    Journal Journal of Neurosurgery. Spine
    Excerpt

    Although radical resection prolongs the disease-free survival period, surgical management of primary sacral tumors is challenging because of their location and often large size. Moreover, in cases of lesions for which a radical resection necessitates total sacrectomy, reconstruction is required. The authors have previously described a modified Galveston technique in which a liaison between the spine and pelvis is achieved using lumbar pedicle screws and Galveston rods embedded into the ilia; additionally, a transiliac bar reestablishes the pelvic ring. Although this reconstruction technique achieves stabilization, several biomechanical limitations exist. In the present report the authors present the case of a patient who underwent spinal pelvic reconstruction after a total sacrectomy was performed to remove a giant sacral chordoma. They describe a novel spinal pelvic reconstruction technique that addresses some of the biomechanical limitations.

    Title Bowel and Bladder Continence, Wound Healing, and Functional Outcomes in Patients Who Underwent Sacrectomy.
    Date January 2006
    Journal Journal of Neurosurgery. Spine
    Excerpt

    OBJECT: Total or partial sacrectomy is a rare procedure in patients with locally invasive tumors involving the sacrum; it may be associated with functional loss, such as bowel and bladder dysfunction and gait abnormality. In this study the authors examined functional outcome following sacrectomy. METHODS: The authors reviewed the charts of 50 consecutive patients who had undergone sacrectomy between July 1993 and August 2002. There were 23 male and 27 female patients whose mean age was 46 years (range 13-86 years). Twelve patients with rectal cancer underwent a separate analysis. The patients without rectal cancer were divided into two groups: those who had undergone colostomy for bowel diversion (Group 1, six cases), and those who had not (Group 2, 32 cases). In Group 1 patients the median hospital length of stay (LOS) was 48.5 days (the 25th% and 75th percentiles are 26 and 58, respectively), and in Group 2 patients the median LOS was 18.5 days (the 25th and 75th percentiles are 8 and 41, respectively; p = 0.14). In Group 2 (non-rectal cancer without colostomy), LOS was greater in patients in whom a myocutaneous flap was used compared with those in whom no flap was used (36 days compared with 8.5 days, respectively; p = 0.0012); in patients with bowel incontinence the median LOS was significantly longer than that in patients with bowel continence (39 days compared with 8 days, respectively; p = 0.0026). The incidence of bowel incontinence in Group 2 was closely related to the integrity of the S-3 nerve root (p = 0.05). CONCLUSIONS: Awareness of the association between S-3 nerve root resection and bowel and bladder incontinence may help surgeons' decision-making process.

    Title En Bloc Resection of Primary Sacral Tumors: Classification of Surgical Approaches and Outcome.
    Date January 2006
    Journal Journal of Neurosurgery. Spine
    Excerpt

    OBJECT: En bloc resection with adequate margins is associated with the highest probability of long-term tumor control or cure in most cases of primary sacral malignancies. The authors present their experience with a systematic approach to these lesions. They provide a novel classification of surgical techniques based on the level of nerve root sacrifice and evaluate the functional and oncological outcomes. METHODS: Seventy-eight consecutive patients underwent 94 resections of sacral neoplasms at The University of Texas M. D. Anderson Cancer Center in Houston between August 1993 and June 2002. The records of 29 consecutive patients who underwent en bloc resection of primary sacral tumors were retrospectively reviewed. The median follow-up period was 55 months (range 1-103 months). Chordoma was the most frequent tumor type (16 cases). Midline sacral amputation was performed in 25 patients (eight low, four middle, seven high, and five total sacrectomies; one hemicorporectomy). Lateral sacrectomy was undertaken in four patients (two unilateral excisions of the sacroiliac joint and two hemisacrectomies). The surgical margins were wide in 19 cases, marginal in nine, and contaminated in one. The type of sacrectomy correlated with characteristic outcomes with respect to bladder, bowel, and ambulatory functions. Duration of hospital stay was related to the extent of sacrectomy (p = 0.003, Wilcoxon signed-rank test). The median Kaplan-Meier disease-free survival for patients with chordoma was 68 months (95% confidence interval 46-90 months). CONCLUSIONS: Classification of en bloc sacral resection techniques by the level of nerve root transection is useful in predicting postoperative function and the potential for morbidity. Adequate surgical margins should not be compromised to preserve function when they are necessary to affect tumor control.

    Title Surgical Management of Metastatic Disease of the Lumbar Spine: Experience with 139 Patients.
    Date June 2005
    Journal Journal of Neurosurgery. Spine
    Excerpt

    OBJECT: The surgical treatment of metastatic spinal tumors is an essential component of the comprehensive care of cancer patients. In most large series investigators have focused on the treatment of thoracic lesions because 70% of cases involve this region. The lumbar spine is less frequently involved (20% cases), and it is unclear whether its unique anatomical and biomechanical features affect surgery-related outcomes. The authors present a retrospective study of a large series of patients with lumbar metastatic lesions, assessing neurological and pain outcomes, complications, and survival. METHODS: The authors retrospectively reviewed data obtained in 139 patients who underwent 166 surgical procedures for lumbar metastatic disease between August 1994 and April 2001. The impact of operative approach on outcomes was also analyzed. Among the wide variety of metastatic lesions, pain was the most common presenting symptom (96%), including local pain, radicular pain, and axial pain due to instability. Patients underwent anterior, posterior, and combined approaches depending on the anatomical distribution of disease. One month after surgery, complete or partial improvement in pain was demonstrated in 94% of the cases. The median survival duration for the entire population was 14.8 months. CONCLUSIONS: The surgical treatment of metastatic lesions in the lumbar spine improved neurological and ambulatory function, significantly reducing axial spinal pain; results were comparable with those for other spinal regions. Analysis of results obtained in the present study suggests that outcomes are similar when the operative approach mirrors the anatomical distribution of disease. When lumbar vertebrectomy is necessary, however, anterior approaches minimize blood loss and wound-related complications.

    Title Current Management of Sacral Chordoma.
    Date May 2005
    Journal Neurosurgical Focus
    Excerpt

    Sacral chordomas are relatively rare, locally invasive, malignant neoplasms. Although metastasis is infrequent at presentation, the prognosis for patients with chordoma of the sacrum is reported to be poor and attributable in most cases to intralesional resection. The value of adjuvant treatment is uncertain, and resection remains the primary mode of treatment. Chordomas are difficult to excise completely, but recent improvements in imaging and surgical techniques have allowed surgeons to perform more frequently en bloc sacral resections with wide surgical margins. The technical challenges of such operations, and the functional costs for the patient (with respect to anorectal and urogenital dysfunction) are significantly increased when the tumor involves high sacral levels. The authors review the clinical presentation and natural history of sacral chordoma and discuss the current treatment techniques and outcomes.

    Title A Novel Rat Model for the Study of Intraosseous Metastatic Spine Cancer.
    Date April 2005
    Journal Journal of Neurosurgery. Spine
    Excerpt

    OBJECT: Although metastatic spinal disease constitutes a significant percentage of all spinal column tumors, an accessible and reproducible animal model has not been reported. In this study the authors describe the technique for creating an intraosseous spinal tumor model in rats and present a functional and histological analysis. METHODS: Eighteen female Fischer 344 rats were randomized into two groups. Group 1 animals underwent a transabdominal exposure and implantation of CRL-1666 breast adenocarcinoma into the L-6 vertebral body (VB). Animals in Group 2 underwent a sham operation. Hindlimb function was tested daily by using the Basso-Beattie-Bresnahan scale. Sixteen days after tumor implantation, animals were killed and their spines were removed for histological assessment. Statistical analysis was performed using the Wilcoxon signed-rank test. By Day 15 functional analysis showed a significant decrease in motor function in Group 1 animals (median functional score 2 of 21) compared with Group 2 rats (median functional score 21 of 21) (p = 0.0217). The onset of paraparesis in Group 1 occurred within 14 to 16 days of surgery. Histopathological analysis showed tumor proliferation through the VB and into the spinal canal, with marked osteolytic activity and spinal cord compression. CONCLUSIONS: Analysis of these findings demonstrates the consistency of tumor growth in this model and validates the utility of functional testing for onset of paresis. This new rat model allows for the preclinical evaluation of novel therapeutic treatments for patients harboring metastatic spine disease.

    Title Anterior Stabilization of the Upper Thoracic Spine Via an "interaortocaval Subinnominate Window": Case Report and Description of Operative Technique.
    Date April 2005
    Journal Journal of Spinal Disorders & Techniques
    Excerpt

    Because of the limitations imposed by the thoracic cage and the paravertebral structures, anterior access to T3 remains a challenge, particularly for the application of anterior fixation devices. Specifically, the appropriate trajectory for the correct placement of T3 screws requires significant caudal access; this may necessitate the addition of a high-level thoracotomy to the traditional combined neck exposure/sternotomy approach to the cervicothoracic junction (ie, the "trap door" exposure). The authors describe a technique for the placement of the T3 screws of a T1-T3 spinal titanium alloy plate via an "interaortocaval subinnominate window" in a patient who underwent a T2 vertebrectomy and polymethylmethacrylate reconstruction. The case history, imaging studies, illustrations, and intraoperative photographs are presented. This novel technique allows for the optimal placement of anterior fixation devices in the upper thoracic spine without the need to extend the caudal exposure with an anterolateral thoracotomy.

    Title En Bloc Resection of Multilevel Cervical Chordoma with C-2 Involvement. Case Report and Description of Operative Technique.
    Date March 2005
    Journal Journal of Neurosurgery. Spine
    Excerpt

    Chordomas are locally aggressive neoplasms with an extremely high propensity to recur locally following resection, despite adjuvant therapy. This biological behavior has led most authors to conclude that en bloc resection provides the best chance for the patient's prolonged disease-free survival and possible cure. The authors present a case of an extensive upper cervical chordoma treated by en bloc resection, reconstruction, and long-segment stabilization. Total spondylectomy of C2-4 with sacrifice of the right C2-4 nerve roots and a segment of the right vertebral artery was performed. The inherent anatomical complexities of en bloc resection in the upper cervical spine are discussed. To the authors' knowledge, this represents the first report of an en bloc resection for multi-level cervical chordoma.

    Title En Bloc Spondylectomy for Spinal Metastases: a Review of Techniques.
    Date March 2005
    Journal Neurosurgical Focus
    Excerpt

    OBJECT: Spinal metastases are prevalent in the population of patients with cancer. Effective cancer therapy must incorporate treatment strategies for these lesions. Increasingly, surgery is being recognized as an effective treatment modality both for the patient's quality of life and potential oncological cure. En bloc spondylectomy is the surgical procedure of choice to obtain these goals. The purpose of this study was to examine critically the rationale, indications, and outcomes of en bloc spondylectomy for spinal metastases. METHODS: Outcomes in the authors' series of patients who underwent en bloc spondylectomy for spinal metastases are critically analyzed. The rationale and indications for this procedure are discussed. The Weinstein, Boriani, and Biagini surgical staging system for spinal tumors is described. A review of the literature is performed to examine further the rationale underlying this aggressive surgical approach to metastatic spinal disease. CONCLUSIONS: En bloc spondylectomy is the treatment of choice for solitary and oligometastatic spinal metastaseswith biologically favorable histological findings. In appropriately selected patients, neurological outcome, pain control, and oncological control are significantly better after en bloc spondylectomy compared with radiation therapy. Oncological outcomes also exceed those of intralesional techniques. The Weinstein, Boriani, and Biagini surgical staging system provides a standard with which to plan surgical approaches and to compare surgical outcomes.

    Title Evidence-based Review of the Surgical Management of Vertebral Column Metastatic Disease.
    Date March 2005
    Journal Neurosurgical Focus
    Excerpt

    OBJECT: Significant controversy exists over the most appropriate treatment for patients with metastatic disease of the vertebral column. Treatment options include surgical intervention, radiotherapy, or a combination of the two; nevertheless, a standard of care that yields the best survival, outcome, and quality of life has not been established. The purpose of this review was to determine the foundation in the literature of views favoring surgical intervention for spinal metastatic disease. METHODS: A search of the English-language literature published between 1964 and 2003 was performed for the subject of spinal metastatic disease. Papers were selected based on the inclusion criteria described, and evidentiary information was compiled and graded using previously described methods. CONCLUSIONS: Although there is insufficient evidence to support a standard for surgical treatment in patients with metastatic spinal disease, the authors present guidelines and recommendations based on the evidence provided by the current literature.

    Title Use of "maps" for Determining the Optimal Surgical Approach to Metastatic Disease of the Thoracolumbar Spine: Anterior, Posterior, or Combined. Invited Submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2004.
    Date February 2005
    Journal Journal of Neurosurgery. Spine
    Excerpt

    The surgical treatment of thoracolumbar metastases is controversial, and various approaches have been described. No single approach, however, is always applicable, and the optimal surgical strategy for any individual is determined by several interrelated factors. The authors have grouped these factors into four preoperative planning considerations that form the mnemonic "MAPS": 1) method of resection; 2) anatomy of spinal disease; 3) patient's level of fitness; and 4) stabilization. The choice of approach is also considered in light of the goals of surgery, including the relief of pain, neurological palliation, spinal stabilization, and oncological control.

    Title Anterior Approaches for Thoracolumbar Metastatic Spine Tumors.
    Date February 2005
    Journal Neurosurgery Clinics of North America
    Excerpt

    The management of patients with metastatic disease of the thoracolumbar spine should be highly individualized and depends on several factors, including the clinical presentation, duration of symptoms, tumor type, anticipated radio-sensitivity, tumor location, extent of extraspinal disease, integrity of the spinal column, and medical fitness and life expectancy of the patient.Although no single approach is always applicable, anterior approaches provide several advantages, including minimal removal of uninvolved bone, rapid extirpation of the tumor, improved hemostasis, effective reconstruction of the weight-bearing anterior column, short-segment fixation,and improved wound healing. Wider acceptance and judicious use of current surgical techniques for metastatic spine disease may improve the quality of life of patients too often denied such treatment.

    Title Metastatic Spine Disease.
    Date February 2005
    Journal Neurosurgery Clinics of North America
    Title Cauda Equina Syndrome Caused by Primary and Metastatic Neoplasms.
    Date October 2004
    Journal Neurosurgical Focus
    Excerpt

    Cauda equina syndrome (CES) is defined as the constellation of symptoms that includes low-back pain, sciatica, saddle anesthesia, decreased rectal tone and perineal reflexes, bowel and bladder dysfunction, and variable amounts of lower-extremity weakness. There are several causes of this syndrome including trauma, central disc protrusion, hemorrhage, and neoplastic invasion. In this manuscript the authors reviewed CES in the setting of both primary and secondary neoplasms. They examined the various primary tumor types in this region as well as those representative of metastatic spread. Both surgical and nonsurgical management in this setting were studied.

    Title Vertebral Synovial Chondromatosis. Report of Two Cases and Review of the Literature.
    Date September 2004
    Journal Journal of Neurosurgery. Spine
    Excerpt

    Synovial chondromatosis is an uncommon disorder characterized by the formation of multiple cartilaginous nodules within the synovium, most commonly affecting large joints. Its involvement with the spine is rare; only six cases have been reported. The authors describe two patients with synovial chondromatosis involving the cervical spine. In the first case, synovial chondromatosis arose from the left C1-2 facet joint. This patient underwent a two-stage procedure including a posterior approach for tumor resection and occipitocervical fusion as well as a transmandibular circumglossal approach to the anterior craniocervical junction to complete the tumor removal. Interestingly, on histopathological examination, scattered foci of low-grade chondrosarcoma were intermixed within the synovial chondromatosis. To the authors' knowledge, this is the first report of secondary low-grade chondrosarcoma arising in vertebral synovial chondromatosis. In the second case, synovial chondromatosis involved the left C4-5 facet joint. Tumor resection and cervical fusion were performed via a posterior approach. In this report, the authors describe the clinical presentation, radiographic findings, operative details, histopathological features, and clinicoradiological follow-up data obtained in these two patients and review the literature pertaining to this rare entity.

    Title Subarachnoid-pleural Fistula After Resection of Thoracic Tumors.
    Date April 2004
    Journal Journal of Neurosurgery
    Excerpt

    OBJECT: Little has been written about the appropriate diagnosis, investigation, and management of subarachnoid-pleural fistula (SPF). The authors report a series of patients with SPF that developed after resection of spinal tumor and discuss the diagnosis and treatment of this entity. METHODS: Between 1993 and 2002, nine patients with SPF observed after spinal surgery at the M. D. Anderson Cancer Center were prospectively followed. In all patients the tumors were located in the thoracic region, and the most common entity was vertebral body metastasis (six cases), with renal cell carcinoma being the most common form of the disease (three cases). All but one patient underwent surgery via a transthoracic approach; in only one patient an intradural approach was performed. The most common presentation was overt cerebrospinal fluid (CSF) leakage, manifesting as chest tube drainage (four cases) or as leakage through the wound (one case). A definitive diagnosis of SPF was established in four patients, with evidence of extraspinal leakage on an 111In-radionuclide CSF study. Although all patients initially underwent a trial of lumbar CSF drainage, all but one required open repair, including creation of intercostal muscle (three cases) and omental (one case) flaps. CONCLUSIONS: After spinal surgery in which the thorax is entered, a diagnosis of SPF should be considered in any patient with abnormal chest tube output, persistent pleural effusion, or clinical evidence of intracranial hypotension. The diagnosis should be confirmed by performing a radionuclide-labeled CSF study. Definitive open repair is required in most cases and preferentially consists of a vascularized tissue graft, which is most easily obtained from an intercostal muscle flap.

    Title Giant Cell Ependymoma of the Spinal Cord. Case Report and Review of the Literature.
    Date February 2004
    Journal Journal of Neurosurgery
    Excerpt

    Several rare histological variants of ependymoma have been described. The authors report on a patient in whom cervical spinal cord astrocytoma was originally diagnosed after evaluation of a limited biopsy specimen. More abundant tissue obtained during gross-total resection included areas of well-differentiated ependymoma. The histological features of the tumor were extremely unusual, with a major component of pleomorphic giant cells. Its histological, immunohistochemical, and electron microscopic features, however, were consistent with ependymoma. Only two cases of terminal filum and two of supratentorial giant cell variant of ependymoma have been reported. To the authors' knowledge, this represents the first case of giant cell ependymoma of the spinal cord. The clinical significance is the potential for misdiagnosis with anaplastic (gemistocytic) astrocytoma, especially in cases in whom limited biopsy samples have been obtained.

    Title Thoracolumbopelvic Stabilization for the Treatment of Instability Caused by Recurrent Myxopapillary Ependymoma.
    Date April 2003
    Journal Journal of Spinal Disorders & Techniques
    Excerpt

    The authors report a patient with recurrent lumbosacral myxopapillary ependymoma, followed for more than 20 years, who presented with severe axial pain resulting from osteolytic destruction at the lumbosacral junction. Because the patient had a long history of paraplegia despite three previous incomplete tumor resections, we chose not to attempt a fourth resection. Moreover, because viable fixation points were not present within the sacrum and most of the lumbar spine, instrumented fusion was extended from T7 to the ilia using a modified Galveston L-rod technique, which we believe to be unique in its application to this problem. This case demonstrates the long-term potential for instability from locally destructive myxopapillary ependymoma that is incompletely excised. We are not aware of any previous reports of lumbopelvic instability in association with myxopapillary ependymomas.

    Title Management of Atlantoaxial Metastases with Posterior Occipitocervical Stabilization.
    Date April 2003
    Journal Journal of Neurosurgery
    Excerpt

    OBJECT: The treatment of atlantoaxial spinal metastases is complicated by the region's unique biomechanical and anatomical characteristics. Patients most frequently present with pain secondary to instability; neurological deficits are rare. Recently, some authors have performed anterior approaches (transoral or extraoral) for resection of upper cervical metastases. The authors review their experience with a surgical strategy that emphasizes posterior stabilization of the spine and avoidance of poorly tolerated external orthoses such as the rigid cervical collar or halo vest. METHODS: The authors performed a retrospective review of 19 consecutively treated patients with C-1 or C-2 metastases who underwent surgery at The University of Texas M. D. Anderson Cancer Center between 1994 and 2001. Visual analog pain scores were reduced at 1 and 3 months (p < 0.005, Wilcoxon signed-rank test); however, evaluation of pain at 6 months and 1 year was limited by the remaining number of surviving patients. Analgesic medication consumption was unchanged. There were no cases of neurological decline or sudden death secondary to residual or recurrent atlantoaxial disease during the follow-up period. One patient underwent revision of hardware at 11 months. The mean follow-up period was 8 months (range 1-32 months). Median survival determined by Kaplan-Meier analysis was 6.1 months (95% confidence interval 2.99-9.21). CONCLUSIONS: Occipitocervical stabilization provided durable pain relief and preservation of ambulatory status over the remaining life span of patients. Because of the palliative goals of surgery, the authors have not found an indication for anterior-approach tumor resection in these patients. Successful stabilization obviates the need for an external orthosis.

    Title Percutaneous Vertebroplasty and Kyphoplasty for Painful Vertebral Body Fractures in Cancer Patients.
    Date February 2003
    Journal Journal of Neurosurgery
    Excerpt

    OBJECT: The current North American experience with minimally invasive vertebro- and kyphoplasty is largely limited to the treatment of benign osteoporotic compression fractures. The objective of this study was to assess the safety and efficacy of these procedures for painful vertebral body (VB) fractures in cancer patients. METHODS: The authors reviewed a consecutive group of cancer patients (21 with myeloma and 35 with other primary malignancies) undergoing vertebro- and kyphoplasty at their institution. Ninety-seven (65 vertebro- and 32 kyphoplasty) procedures were performed in 56 patients during 58 treatment sessions. The mean patient age was 62 years (+/- 13 years [standard deviation]) and the median duration of symptoms was 3.2 months. All patients suffered intractable spinal pain secondary to VB fractures. Patients noted marked or complete pain relief after 49 procedures (84%), and no change after five procedures (9%); early postoperative Visual Analog Scale (VAS) pain scores were unavailable in four patients (7%). No patient was worse after treatment. Reductions in VAS pain scores remained significant up to 1 year (p = 0.02, Wilcoxon signed-rank test). Analgesic consumption was reduced at 1 month (p = 0.03, Wilcoxon signed-rank test). Median follow-up length was 4.5 months (range 1 day-19.7 months). Asymptomatic cement leakage occurred during vertebroplasty at six (9.2%) of 65 levels; no cement extravasation was seen during kyphoplasty. There were no deaths or complications related to the procedures. The mean percentage of restored VB height by kyphoplasty was 42 +/- 21%. CONCLUSIONS: Percutaneous vertebro- and kyphoplasty provided significant pain relief in a high percentage of patients, and this appeared durable over time. The absence of cement leakage-related complications may reflect the use of 1) high-viscosity cement; 2) kyphoplasty in selected cases; and 3) relatively small volume injection. Precise indications for these techniques are evolving; however, they are safe and feasible in well-selected patients with refractory spinal pain due to myeloma bone disease or metastases.

    Title Early Sacral Stress Fracture After Reduction of Spondylolisthesis and Lumbosacral Fixation: Case Report.
    Date January 2003
    Journal Neurosurgery
    Excerpt

    OBJECTIVE AND IMPORTANCE: Early sacral fracture is an extremely rare complication of instrumented lumbosacral fusion seen in older, osteopenic women. Previous reports have attributed the problem to the use of multisegmental (three or more levels) fixation, with the transfer of stress forces from rigid spinal implants to the sacrum. We report the only case, to the best of our knowledge, of early sacral fracture after a two-level lumbosacral fusion and the only case of early sacral fracture after reduction of spondylolisthesis. CLINICAL PRESENTATION: A patient presented with a sudden recurrence of low back and buttock pain a few days after lumbosacral decompression, reduction of L5-S1 Grade II spondylolisthesis, and instrumented L5-S1 fusion, including posterior lumbar interbody fusion. A transverse sacral fracture was found on plain x-rays 4 weeks later. INTERVENTION: Symptoms improved with brace therapy and medical treatment for osteoporosis. CONCLUSION: Early sacral fracture is a rare cause of pain after instrumented lumbosacral fusion. Although the transfer of loads from rigid spinal implants to adjacent segments is particularly problematic for multisegmental fusions, patients with short-segment constructs may also be affected. Active reduction of spondylolisthesis may provide additional adjacent segment stress contributing to this complication.

    Title Spinal Cord Ependymoma: Radical Surgical Resection and Outcome.
    Date December 2002
    Journal Neurosurgery
    Excerpt

    OBJECTIVE: Several authors have noted increased neurological deficits and worsening dysesthesia in the postoperative period in patients with spinal cord ependymoma. We describe the neurological progression and pain evolution of these patients over the 1-year period after surgery. In addition, our favored method of en bloc tumor resection is illustrated, and the rate of complications, recurrence, and survival in this group of patients is addressed. METHODS: We operated on 26 patients (12 male and 14 female) with low-grade spinal cord ependymomas between 1975 and 2001. The median age at diagnosis was 42 years. Tumors extended into the cervical cord in 13 patients, the thoracic cord in 7 patients, and the conus medullaris in 6 patients. Eleven patients had previous surgery and/or radiation therapy. RESULTS: We achieved a gross total resection in 88% of patients, whereas 8% had a subtotal resection and 4% had a biopsy. Only 1 patient developed a recurrence over a mean follow-up period of 31 months. CONCLUSION: We conclude that radical surgical resection of spinal cord ependymomas can be safely achieved in the majority of patients. A trend toward neurological improvement from a postoperative deficit can be expected between 1 and 3 months after surgery and continues up to 1 year. Postoperative dysesthesias begin to improve within 1 month of surgery and are significantly better by 1 year after surgery. The best predictor of outcome is the preoperative neurological status.

    Title The Effect of Titanium Stabilization Rods on Spinal Cord Radiation Dose.
    Date November 2002
    Journal Medical Dosimetry : Official Journal of the American Association of Medical Dosimetrists
    Excerpt

    The purpose of this study was to investigate the dosimetric effect of a titanium-rod spinal stabilization system on surrounding tissue, especially the spinal cord. Ion chamber dosimetry was performed for 6- and 18-MV photon beams in a water phantom containing a titanium-rod spinal stabilization system. Isodose curves were obtained in the phantom with and without rods. To assess the ability of a treatment planning system to reproduce the effects of the stabilization system on the radiation dose delivered to surrounding tissue, dose distributions were calculated after appropriate modifications were made in the computed tomography number-to-density conversion table to account for the increased density of the titanium rods. The resultant heterogeneity-corrected plans were compared with uncorrected plans. At a 7-cm depth in the water phantom, corresponding to the depth of the spinal cord, the beam was attenuated by 4% under the rods alone and by 13% rods under the rods with screws for the 6-MV photon beam as compared with curves generated in the absence of rods. The beam was attenuated by 3% and 11%, respectively, for the 18-MV beam. Using anteroposterior (18-MV) and posteroanterior (6-MV) photon beams, with and without heterogeneity correction for the rods, the corrected isodose plan showed an approximately 2% beam attenuation 4 cm anterior to the rods as compared with the uncorrected plan. No significant difference in the spinal cord dose was observed between the 2 plans, however. The titanium-rod spinal stabilization system tested in this study caused a decrease in the dose delivered distal to the rods but did not significantly affect the dose delivered to the spinal cord.

    Title Total Cervical Spondylectomy for Primary Osteogenic Sarcoma. Case Report and Description of Operative Technique.
    Date November 2002
    Journal Journal of Neurosurgery
    Excerpt

    The authors describe a technique for total spondylectomy for lesions involving the cervical spine. The method involves separately staged anterior and posterior approaches and befits the unique anatomy of the cervical spine. The procedure is described in detail, with the aid of radiographs, intraoperative photographs, and illustrations. Unlike in the thoracic and lumbar spine--for which methods of total en bloc spondylectomy have previously been described--a strictly en bloc resection is not possible in the cervical spine because of the need to preserve the vertebral arteries and the nerve roots supplying the upper limbs. Although the resection described in this case is by definition intralesional, it is oncologically sound, given the development of effective neoadjuvent chemotherapeutic regimens for osteosarcoma.

    Title Long-term Follow-up of Patients with Giant Cell Tumor of the Sacrum Treated with Selective Arterial Embolization.
    Date September 2002
    Journal Cancer
    Excerpt

    BACKGROUND: Giant cell tumors of the bone can behave as aggressive and sometimes lethal tumors. In the sacrum, the tumor can be extremely difficult to manage. Standard treatments, including surgery and radiation, are associated with significant complications and recurrence rates. The goal of this study is to evaluate the long-term outcome of selective arterial embolization as an alternative treatment modality. METHODS: From 1975 to 2001, 18 patients were treated with selective intraarterial embolization. The embolization method was a combination of Gelfoam particles and coils for peripheral and central occlusions, respectively. The number of embolizations was based on clinical symptoms, radiographic response, and the vascularity of the tumor. Nine patients received intraarterial cisplatin as part of their treatment. The median follow-up was 105 months. RESULTS: Of 18 patients, 14 responded favorably to embolization with improvement in pain and neurologic symptoms. Computed tomographic and magnetic resonance imaging scans showed reossification and stabilization of tumor size. Arteriograms showed diminished vascularity. With long-term follow-up, three patients developed late disease recurrences within the sacrum. Kaplan-Meier analysis showed that the risk of local recurrence is 31% at 10 years and 43% at 15 and 20 years. The long-term outcome was not affected by intraarterial cisplatin. There was one death that occurred 1 day after embolization. CONCLUSIONS: Most patients demonstrate an objective early radiographic response to embolization. Long-term follow-up shows that the response is durable in approximately one half of the patients. Given the potential morbidity of other treatments, embolization should be included in the armamentarium of treatment for this difficult disease. Embolization may be used alone or in conjunction with other therapy. Long-term follow-up is recommended for all patients because late disease recurrence or sarcomatous change can occur.

    Title Sacrococcygeal Ganglioneuroma.
    Date September 2002
    Journal Journal of Spinal Disorders & Techniques
    Excerpt

    Ganglioneuromas are benign slow-growing masses that can be treated with complete surgical extirpation without any adjuvant therapy. Such lesions involving the sacrococcygeal region are exceedingly rare. The authors present the case of a 70-year-old woman with a sacrococcygeal ganglioneuroma treated by total en bloc resection. This patient also had a previous coccygeal fracture. To the authors' knowledge, there are no other reports of ganglioneuroma in association with a history of trauma.

    Title A Multivariate Analysis of 416 Patients with Glioblastoma Multiforme: Prognosis, Extent of Resection, and Survival.
    Date January 2002
    Journal Journal of Neurosurgery
    Excerpt

    OBJECT: The extent of tumor resection that should be undertaken in patients with glioblastoma multiforme (GBM) remains controversial. The purpose of this study was to identify significant independent predictors of survival in these patients and to determine whether the extent of resection was associated with increased survival time. METHODS: The authors retrospectively analyzed 416 consecutive patients with histologically proven GBM who underwent tumor resection at the authors' institution between June 1993 and June 1999. Volumetric data and other tumor characteristics identified on magnetic resonance (MR) imaging were collected prospectively. CONCLUSIONS: Five independent predictors of survival were identified: age, Karnofsky Performance Scale (KPS) score, extent of resection, and the degree of necrosis and enhancement on preoperative MR imaging studies. A significant survival advantage was associated with resection of 98% or more of the tumor volume (median survival 13 months, 95% confidence interval [CI] 11.4-14.6 months), compared with 8.8 months (95% CI 7.4-10.2 months; p < 0.0001) for resections of less than 98%. Using an outcome scale ranging from 0 to 5 based on age, KPS score, and tumor necrosis on MR imaging, we observed significantly longer survival in patients with lower scores (1-3) who underwent aggressive resections, and a trend toward slightly longer survival was found in patients with higher scores (4-5). Gross-total tumor resection is associated with longer survival in patients with GBM, especially when other predictive variables are favorable.

    Title Limitations of Stereotactic Biopsy in the Initial Management of Gliomas.
    Date December 2001
    Journal Neuro-oncology
    Excerpt

    Stereotactic biopsy is often performed for diagnostic purposes before treating patients whose imaging studies highly suggest glioma. Indications cited for biopsy include diagnosis and/or the "inoperability" of the tumor. This study questions the routine use of stereotactic biopsy in the initial management of gliomas. At The University of Texas M. D. Anderson Cancer Center, we retrospectively reviewed a consecutive series of 81 patients whose imaging studies suggested glioma and who underwent stereotactic biopsy followed by craniotomy/resection (within 60 days) between 1993 and 1998. All relevant clinical and imaging information was reviewed, including computerized volumetric analysis of the tumors based on pre- and postoperative MRI. Stereotactic biopsy was performed at institutions other than M. D. Anderson in 78 (96%) of 81 patients. The majority of tumors were located either in eloquent brain (36 of 81 = 44%) or near-eloquent brain (41 of 81 = 51%), and this frequently was the rationale cited for performing stereotactic biopsy. Gross total resection (>95%) was achieved in 46 (57%) of 81 patients, with a median extent of resection of 96% for this series. Diagnoses based on biopsy or resection in the same patient differed in 40 (49%) of 82 cases. This discrepancy was reduced to 30 (38%) of 80 cases when the biopsy slides were reviewed preoperatively by each of three neuropathologists at M. D. Anderson. Major neurologic complications occurred in 10 (12.3%) of 81 surgical patients and 3 (3.7%) of 81 patients undergoing biopsy. Surgical morbidity was probably higher in our series than it would be for glioma patients in general because our patients represent a highly selected subset of glioma patients whose tumors present a technical challenge to remove. Stereotactic biopsy is frequently inaccurate in providing a correct diagnosis and is associated with additional risk and cost. If stereotactic biopsy is performed, expert neuropathology consultation should be sought.

    Title Total En Bloc Lumbar Spondylectomy. Case Report.
    Date October 2001
    Journal Journal of Neurosurgery
    Excerpt

    The authors describe a technique for total en bloc spondylectomy that can be used for lesions involving the lumbar spine. The technique involves a combined anterior-posterior approach and takes into account the unique anatomy of the lumbar spine. This technique allows for the en bloc resection of lumbar vertebral tumors, thus optimizing outcome while minimizing the risk of neurological injury. The technique is described in detail with the aid of neuroimaging studies, photographs of gross pathological specimens, and illustrations, and a discussion of other authors' experiences is provided for comparison.

    Title Surgical Resection of Intrinsic Insular Tumors: Complication Avoidance.
    Date October 2001
    Journal Journal of Neurosurgery
    Excerpt

    OBJECT: Surgical resection of tumors located in the insular region is challenging for neurosurgeons, and few have published their surgical results. The authors report their experience with intrinsic tumors of the insula, with an emphasis on an objective determination of the extent of resection and neurological complications and on an analysis of the anatomical characteristics that can lead to suboptimal outcomes. METHODS: Twenty-two patients who underwent surgical resection of intrinsic insular tumors were retrospectively identified. Eight tumors (36%) were purely insular, eight (36%) extended into the temporal pole, and six (27%) extended into the frontal operculum. A transsylvian surgical approach, combined with a frontal opercular resection or temporal lobectomy when necessary, was used in all cases. Five of 13 patients with tumors located in the dominant hemisphere underwent craniotomies while awake. The extent of tumor resection was determined using volumetric analyses. In 10 patients, more than 90% of the tumor was resected; in six patients, 75 to 90% was resected; and in six patients, less than 75% was resected. No patient died within 30 days after surgery. During the immediate postoperative period, the neurological conditions of 14 patients (64%) either improved or were unchanged, and in eight patients (36%) they worsened. Deficits included either motor or speech dysfunction. At the 3-month follow-up examination, only two patients (9%) displayed permanent deficits. Speech and motor dysfunction appeared to result most often from excessive opercular retraction and manipulation of the middle cerebral artery (MCA), interruption of the lateral lenticulostriate arteries (LLAs), interruption of the long perforating vessels of the second segment of the MCA (M2), or violation of the corona radiata at the superior aspect of the tumor. Specific methods used to avoid complications included widely splitting the sylvian fissure and identifying the bases of the periinsular sulci to define the superior and inferior resection planes, identifying early the most lateral LLA to define the medial resection plane, dissecting the MCA before tumor resection, removing the tumor subpially with preservation of all large perforating arteries arising from posterior M2 branches, and performing craniotomy with brain stimulation while the patient was awake. CONCLUSIONS: A good understanding of the surgical anatomy and an awareness of potential pitfalls can help reduce neurological complications and maximize surgical resection of insular tumors.

    Title Surgical Resection of Calvarial Metastases Overlying Dural Sinuses.
    Date August 2001
    Journal Neurosurgery
    Excerpt

    OBJECTIVE: Few reports have addressed the surgical management of cranial metastases that overlie or invade the dural venous sinuses. To examine the role of surgery in the treatment of dural sinus calvarial metastases, we reviewed retrospectively 13 patients who were treated with surgery at the University of Texas M.D. Anderson Cancer Center between 1993 and 1999. We compared them with 14 patients who had calvarial metastases that did not involve a venous sinus. METHODS: Clinical charts, radiological studies, pathological findings, and operative reports were analyzed retrospectively. RESULTS: The median age of patients with dural sinus calvarial metastases was 54 years. Nine patients were men and four were women. Renal cell carcinoma and sarcoma were the most common primary tumors. Similar features were noted in the 14 patients with nonsinus calvarial metastases. Of the 13 dural sinus calvarial metastases, 11 involved the superior sagittal sinus, and 2 involved the transverse sinus. In nine patients, the involved sinus was resected, and in four patients, the sinus was reconstituted after tumor removal. Nine patients in the dural sinus calvarial metastases group received en bloc resection, and four received piecemeal resection. No operative deaths occurred. The overall median actuarial survival was 16.5 months. The survival times of the two groups were comparable. In the group with dural sinus calvarial metastases, transient postoperative neurological deficits occurred in two patients (15%), and a permanent deficit occurred in one patient (8%). No patients in the group with nonsinus calvarial metastases experienced deficits after resection. Compared with piecemeal resection, en bloc resection was associated with significantly less blood loss. CONCLUSION: Complete extirpation of calvarial metastases that overlie or invade a dural sinus can be achieved with only slightly more morbidity than complete removal of calvarial metastases that are located away from the sinuses. En bloc resection is as safe as piecemeal resection and is more effective in limiting operative blood loss. The overall recurrence and survival rates of patients with dural sinus calvarial metastases are similar to those of patients with calvarial metastases that do not involve the sinuses. Therefore, involvement of a dural venous sinus should not discourage resection of calvarial metastases. In carefully selected cancer patients, surgery provides effective palliation of symptomatic calvarial metastases that overlie or invade the venous sinuses.

    Title Simultaneous Anterior-posterior Approach to the Thoracic and Lumbar Spine for the Radical Resection of Tumors Followed by Reconstruction and Stabilization.
    Date April 2001
    Journal Journal of Neurosurgery
    Excerpt

    OBJECT: Thoracic or lumbar spine malignant tumors involving both the anterior and posterior columns represent a complex surgical problem. The authors review the results of treating patients with these lesions in whom surgery was performed via a simultaneous anterior-posterior approach. METHODS: The hospital records of 26 patients who underwent surgery via simultaneous combined approach for thoracic and lumbar spinal tumors at our institution from July 1994 to March 2000 were reviewed. Surgery was performed with the patients in the lateral decubitus position for the procedure. The technical details are reported. The mean survival determined by Kaplan-Meier analysis was 43.4 months for the 15 patients with primary malignant tumors and 22.5 months for the 11 patients with metastatic spinal disease. At 1 month after surgery, 23 (96%) of 24 patients who complained of pain preoperatively reported improvements (p < 0.001, Wilcoxon signed-rank test), and eight (62%) of 13 patients with preoperative neurological deficits were functionally improved (p = 0.01). There were nine major complications, five minor complications, and no deaths within 30 days of surgery. Two patients (8%) later underwent surgery for recurrent tumor. CONCLUSIONS: The simultaneous anterior-posterior approach is a safe and feasible alternative for the exposure tumors of the thoracic and lumbar spine that involve both the anterior and posterior columns. Advantages of the approach include direct visualization of adjacent neurovascular structures, the ability to achieve complete resection of lesions involving all three columns simultaneously (optimizing hemostasis), and the ability to perform excellent dorsal and ventral stabilization in one operative session.

    Title Metastatic Renal Cell Carcinoma of the Spine: Surgical Treatment and Results.
    Date January 2001
    Journal Journal of Neurosurgery
    Excerpt

    OBJECT: Renal cell carcinoma (RCC) is an aggressive malignancy that frequently metastasizes. When RCC metastasizes to the spine, significant pain and neurological dysfunction often follow. Because systemic therapy and radiotherapy have a limited effect in controlling spinal disease, surgery is frequently required; however, there are very few published series specifically addressing the role and benefits of the surgical treatment for this disease. The authors conducted a retrospective study to review their experience with the surgical treatment of metastatic RCC of the spine, paying particular attention to methodology and patient neurological status, pain relief, and survival. METHODS: Between January 1993 and April 1999, 79 patients (63 men and 16 women patients; average age 55 years, range 16-82 years) underwent 107 spinal operations for metastatic RCC. Indications for surgery included disabling pain (94 [88%] of 107 procedures) and/or neurological dysfunction (55 [51%] of 107 procedures). The anatomical location and extent of tumor determined the choice of an anterior, posterior, or combined surgical approach. Internal fixation was performed in all but three patients. Preoperative embolization was required in approximately one half of the patients. Radiotherapy was performed in 40 patients prior to surgery, and immuno- and chemotherapy were administered in 70 patients either pre- or postoperatively. After an average follow-up duration of 15 months, 57 patients had died. Kaplan-Meier analysis revealed a median postoperative survival of 12.3 months. Significant pain reduction, as indicated by a visual analog pain scale, was achieved in 84 (89%) of the 94 cases presenting with disabling pain. Neurological improvement was seen in 36 (65%) of the 55 patients. The major morbidity and 30-day mortality rates were 15% (16 of 107 procedures) and 2% (two of 107 procedures), respectively. CONCLUSIONS: In selected patients with metastatic RCC of the spine, resection followed by stabilization can provide pain relief and neurological preservation or improvement.

    Title Use of Pedicle Screw Fixation in the Management of Malignant Spinal Disease: Experience in 100 Consecutive Procedures.
    Date January 2001
    Journal Journal of Neurosurgery
    Excerpt

    OBJECT: Few reports are available on the use of pedicle screw fixation for cancer-related spinal instability. The authors present their experience with pedicle screw fixation in the management of malignant spinal column tumors. METHODS: Records for patients with malignant spinal tumors who underwent pedicle screw fixation at the authors' institution between September 1994 and December 1999 were retrospectively reviewed. RESULTS: Ninety-five patients with malignant spinal tumors underwent 100 surgeries involving pedicle screw fixation: metastatic spinal disease was present in 81 patients, and locally invasive tumors were demonstrated in 14 patients. Indications for surgery were pain (98%) and/or neurological dysfunction (80%). A posterior (48%) or a combined anterior-posterior (52%) approach was performed depending on the extent of tumor and the patient's condition. At the mean follow up of 8.2 months, 43 patients (45%) had died; median survival, as determined by Kaplan-Meier analysis, was 14.8 months. At I month postsurgery, self-reported pain had improved in 87% of cases (p < 0.001), which is a finding substantiated by reductions in analgesic use, and 29 (47%) of 62 patients with preoperative neurological impairments were functionally improved (p < 0.001). Postoperative complications were associated only with preoperative radiation therapy (p = 0.002) and with preexisting serious medical conditions (p = 0.04). In two patients asymptomatic violation of the lateral wall of the pedicle was revealed on postoperative radiography. The 30-day mortality rate was 1%. CONCLUSIONS: For selected patients with malignant spinal tumors, pedicle screw fixation after tumor resection may provide considerable pain relief and restore or preserve ambulation with acceptable rates of morbidity and mortality.

    Title Intraspinal Extradural Myxopapillary Ependymoma of the Sacrum Arising from the Filum Terminale Externa. Case Report.
    Date October 2000
    Journal Journal of Neurosurgery
    Excerpt

    Extradural ependymomas of the sacrococcygeal region are very rare, with most arising from the soft tissues of the presacral area or from the regions dorsal to the sacrum. In even rarer circumstances, the tumor may arise within the sacral canal, likely as a result of ependymal cells of the extradural filum terminale. Because of bone erosion caused by extension of the tumor into the pelvis or dorsal to the sacrum, a truly intraspinal extradural ependymoma in this region has until now never been clearly demonstrated. The authors present a patient with a myxopapillary ependymoma arising from the filum terminale externa in which there was no involvement of the intradural filum or extension outside the sacral canal. A review of the literature is presented, with emphasis on the pathogenesis and clinical management of these rare tumors.

    Title Closure of Hemicorporectomy with Bilateral Subtotal Thigh Flaps.
    Date May 2000
    Journal Plastic and Reconstructive Surgery
    Excerpt

    Hemicorporectomy is typically performed with a circumferential truncal incision, and the wound is closed primarily. Wound disruption is a common complication, especially at the base of the wound closure and posteriorly at the lumbar vertebral level. We report a case of the use of bilateral subtotal thigh flaps for the closure of a hemicorporectomy wound in a patient with a defect extending up to the high lumbar region. The subtotal thigh flap is a well-vascularized thick flap that provides a firm support for the abdominal viscera and is a large flap that can be used to close even a high lumbar defect.

    Title Coaxial Double-lumen Methylmethacrylate Reconstruction in the Anterior Cervical and Upper Thoracic Spine After Tumor Resection.
    Date April 2000
    Journal Journal of Neurosurgery
    Excerpt

    OBJECT: A unique method of anterior spinal reconstruction after decompressive surgery was used to prevent methylmethacrylate-dural contact in cancer patients who underwent corpectomy. The purpose of this study was to assess the efficacy and stability of polymethylmethacrylate (PMMA) anterior surgical constructs in conjunction with anterior cervical plate stabilization (ACPS) in these patients. METHODS: Approximately 700 patients underwent spinal surgery at The University of Texas M. D. Anderson Cancer Center over a 4-year period. The authors conducted a retrospective outcome study for 29 of these patients who underwent anterior cervical or upper thoracic tumor resections while in the supine position. These patients were all treated using the coaxial, double-lumen, PMMA technique for anterior spinal reconstruction with subsequent ACPS. No postoperative external orthoses were used. Twenty-seven patients (93%) harbored metastatic spinal lesions and two (7%) harbored primary tumors. At 1 month postsurgery, significant improvement was seen in spinal axial pain (p<0.001), radiculopathy (p<0.001), gait (p = 0.008), and Frankel grade (p = 0.002). A total of nine patients (31%) underwent combined anterior-posterior 360 degrees stabilization. Twenty-one patients (72%) experienced no complications. Complications related to instrumentation failure occurred in only two patients (7%). There were no cases in which the patients' status worsened, and there were no neurological complications or infections. The median Kaplan-Meier survival estimate for patients with spinal metastases was 9.5 months. At the end of the study, 13 patients (45%) had died and 16 (55%) were alive. Postoperative magnetic resonance images consistently demonstrated that the dura and PMMA in all patients remained separated. CONCLUSIONS: The anterior, coaxial, double-lumen, PMMA reconstruction technique provides a simple means of spinal cord protection in patients in the supine position while undergoing surgery and offers excellent results in cancer patients who have undergone cervical vertebrectomy.

    Title Melanoma Metastatic to the Spine: a Review of 133 Cases.
    Date April 2000
    Journal Melanoma Research
    Excerpt

    Although spine metastasis from melanoma is an uncommon event, it can pose a complex management problem. The presentation and natural history of melanoma metastatic to the spine has not been described in the medical literature. We have conducted a review of the records of 133 patients with melanoma metastatic to the spine in order to obtain retrospective data on demographic information, clinical presentation, disease course and survival. Patients with cutaneous, ocular and mucosal melanoma were all represented, but those with primary cutaneous tumours of the trunk were more prevalent than expected. Other sites of metastatic disease were present in nearly all patients and metastases to other skeletal sites were not unusual. Pain was the most common presenting symptom. The radiographic diagnosis was generally made easily by plain radiographs, computed tomography or magnetic resonance imaging, with the most frequent finding being a destructive lesion. Bone scan gave false-negative results 15% of the time. The median survival for the group was 4 months. It is concluded that melanoma metastatic to the spine represents a late event in the evolution of this illness. Palliation should be the goal of treatment, but symptom management should be individualized, bearing in mind the short anticipated survival of these patients.

    Title Gastric Cancer and Metastasis to the Brain.
    Date January 2000
    Journal Annals of Surgical Oncology
    Excerpt

    BACKGROUND: Metastasis of gastric carcinoma to the brain is very uncommon. At The University of Texas M. D. Anderson Cancer Center (M. D. Anderson), less than 1% of patients with primary gastric carcinoma are found to have brain metastases. Little has been published regarding the evaluation and treatment of these patients. The purpose of this study was to review our experience with gastric cancer metastatic to the brain and to describe the efficacy of the treatment used. METHODS: Between 1957 and 1997, a total of 218,690 patients were seen for evaluation of malignant tumors at M. D. Anderson. Of these patients, 3320 (1.5%) had a diagnosis of gastric cancer; however, only 24 patients (0.7%) were found to have brain metastases on imaging studies or at autopsy. We performed a retrospective review of these 24 patients and divided them into three groups on the basis of the treatment they received. RESULTS: Group 1 included patients who received steroids alone (16 mg of dexamethasone, daily). Group 2 patients received 3000 cGy of whole-brain radiation therapy (WBRT) delivered in 10 fractions in addition to steroids. Group 3 patients were managed with surgical resection, WBRT, and steroids. There were 18 male and 6 female patients, with a median age of 53 years. The most common presenting symptoms were weakness, difficulty with balance, and headache. Of the 19 patients diagnosed antemortem, 11 patients developed neurological symptoms after the primary diagnosis of gastric carcinoma, whereas 8 patients developed neurological symptoms before the diagnosis of gastric cancer. Forty-five percent of patients had a single brain metastasis, whereas 55% had multiple lesions. All patients had systemic disease, with bone, liver, and lung involvement seen in 46%, 42%, and 29%, respectively. Nineteen of 24 patients received treatment after diagnosis of brain metastases. Four patients received steroids only (group 1), 11 patients received WBRT and steroids (group 2), and 4 patients were treated with surgery, WBRT, and steroids (group 3). Median survival was approximately 2 months for patients in groups 1 and 2, whereas group 3 patients had a median survival of slightly greater than I year. CONCLUSIONS: Our results suggest that the overall prognosis of patients with brain metastases from gastric cancer is extremely poor (median survival, 9 weeks). WBRT, as an adjuvant to steroid treatment, was not effective in improving outcome in our series. In selected patients, most of whom were relatively young and had less advanced systemic disease, surgical resection followed by WBRT was associated with relatively long survival times (median survival, 54 weeks).

    Title Spinal-pelvic Fixation in Patients with Lumbosacral Neoplasms.
    Date January 2000
    Journal Journal of Neurosurgery
    Excerpt

    OBJECT: Primary and metastatic neoplasms of the lumbosacral junction frequently pose a complex problem for the surgical management and stabilization of the spine because of the anatomical and biomechanical factors of this transition zone between spine and pelvis. The authors have used a modification of the Galveston technique, originally described by Allen and Ferguson in the treatment of scoliosis, to achieve rigid spinal-pelvic fixation in patients with lumbosacral neoplasms. The authors retrospectively reviewed their experience, with particular attention to method, pain relief, and neurological status. METHODS: From July 1994 through December 1998, 13 patients at the authors' institution have required spinal-pelvic fixation secondary to instability caused by primary (eight cases) or metastatic (five cases) neoplasms. Previous treatment included spinal surgery in 10 (77%), radiation therapy in seven (54%), and/or chemotherapy in six (46%). Following tumor resection, fixation was achieved by intraoperative placement of contoured titanium rods bilaterally into the ilium. These rods were attached to the lumbar spine with pedicle screws and subsequently crosslinked. Arthrodesis was performed. In the follow-up period of 3 to 50 months (average 20 months), nine (69%) of 13 patients were still alive. There were no cases of surgery-related death. Seven weeks postoperatively instrumentation failure occurred in one patient and was corrected by performing double L-rod spinal-pelvic fixation. Two patients experienced neurological dysfunction (ankle weakness and neurogenic bladder) that was thought to be related to tumor resection rather than the fixation procedure. Neurological status improved in four patients and remained unchanged in seven patients. Ambulatory status improved in 62% (eight patients), remained unchanged in 23% (three patients), and worsened in 15% (two patients). Spinal pain, as measured by a visual analog pain scale and determined by medication consumption was significantly reduced in 85% (11 cases). CONCLUSIONS: In selected patients with primary or metastatic lumbosacral tumors, resection followed by modified Galveston L-rod spinal-pelvic fixation is an effective means of achieving stabilization that can provide significant pain relief and preserve ambulatory capacity.

    Title A Multidisciplinary Surgical Approach to Superior Sulcus Tumors with Vertebral Invasion.
    Date December 1999
    Journal The Annals of Thoracic Surgery
    Excerpt

    BACKGROUND: Vertebral body invasion by superior sulcus tumor has traditionally been considered a contraindication to surgical resection. Attempts at definitive radiation or chemoradiation have not been successful. Recent advances in spinal instrumentation have allowed more complete resection of vertebral body tumors. We, therefore, reviewed our recent experience with vertebral resection of superior sulcus tumors. METHODS: All patients (n = 17) undergoing resection of superior sulcus tumors with T4 involvement of the vertebrae from October 18, 1990 to September 21, 1998 at the University of Texas M.D. Anderson Cancer Center (MDACC) were evaluated. Their clinical and pathologic data were reviewed and analyzed for short- and long-term outcomes. RESULTS: Total vertebrectomy was performed in 7 patients (42%), partial vertebrectomy in 7 (42%), and 3 (18%) underwent neural foramina or transverse process resection. The median hospital stay was 11 days. Postoperative complications occurred in 7 patients (42%) and included pneumonia (6, 36%), arrhythmia (2, 12%), cerebrospinal fluid leak (2, 12%), wound breakdown (1, 6%), and reoperation for bleeding (1, 6%). Sixteen out of 17 patients received preoperative or postoperative radiation therapy. No perioperative mortality occurred. All patients remained ambulatory after spinal reconstruction. Overall actuarial survival at 2 years was 54%, with 11 patients still alive 2 to 50 months after resection. Locoregional tumor recurrence was noted in all 6 patients who had positive surgical margins, as opposed to 1 out of 11 patients (9%) with negative margins (p < 0.006). Additionally, the 2-year actuarial survival of patients with negative microscopic margins was 80% versus 0% for positive margins (p < 0.0006). CONCLUSIONS: An aggressive multidisciplinary approach to superior sulcus tumors with vertebral invasion can lead to long-term survival with acceptable morbidity if negative margins can be obtained. Vertebral body invasion should no longer be considered a contraindication for resection of superior sulcus tumors.

    Title Adenovirus-mediated Delivery of Antisense Gene to Urokinase-type Plasminogen Activator Receptor Suppresses Glioma Invasion and Tumor Growth.
    Date August 1999
    Journal Cancer Research
    Excerpt

    The urokinase-type plasminogen activator (uPA) and uPA receptor (UPAR) play important roles in the proteolytic cascade involved in the invasiveness of gliomas and other invasive tumors. High-level expression of uPAR has been correlated with high-grade glioma cell lines and tumors We report here that down-regulating uPAR levels by antisense strategy using an adenovirus construct (Ad-uPAR) inhibited glioma invasion in Matrigel and spheroid in vitro models. sc. (U87-MG) and intracranial (SNB19) injections of Ad-uPAR-infected glioma cells did not produce tumors in nude mice. However, injection of the Ad-uPAR construct into previously established so U87-MG tumors in nude mice caused regression of those tumors. Our results support the therapeutic potential of targeting the uPA-uPAR system for the treatment of gliomas and other cancers.

    Title Chondrosarcoma of the Spine: 1954 to 1997.
    Date July 1999
    Journal Journal of Neurosurgery
    Excerpt

    OBJECT: Primary chondrosarcoma of the spine is extremely rare. During the last 43 years only 21 patients with this disease were registered at The University of Texas M. D. Anderson Cancer Center. The purpose of this study was to examine the demographic characteristics, treatments, and outcomes of this set of patients. METHODS: Medical records for 21 patients were reviewed. Age, sex, race, clinical presentation, tumor histology, tumor location in the spinal column, treatments, surgical details, and response to treatment were recorded. Surgical procedures were categorized as either gross-total resection or subtotal excision of tumor. Neurological function was assessed using Frankel's functional classification. Time to recurrence and survival analyses were performed using the Kaplan-Meier method. The median age of patients was 51 years, with fairly equal gender representation. Eighteen patients underwent at least one surgical procedure for a total of 28 surgical procedures: seven radical resections and 21 subtotal excisions. Radiation therapy was used in conjunction with 10 of the 28 surgical procedures. The median Kaplan-Meier estimate of overall survival for the entire group was 6 years (range 6 months-17 years). Tumors recurred after 18 of the 28 procedures. Kaplan-Meier analysis revealed a statistically significant difference in the per-procedure disease-free interval after gross-total resection relative to subtotal excision (exact log rank 3.39; p = 0.04). The addition of radiation therapy prolonged the median disease-free interval from 16 to 44 months, although this was not statistically significant (exact log rank 2.63; p = 0.16). CONCLUSIONS: Our results suggest that gross-total resection of the chondrosarcoma provides the best chance for prolonging the disease-free interval in patients. Subtotal excision should be avoided whenever possible. Addition of radiation therapy does not appear to lengthen significantly the disease-free interval in this patient population.

    Title Combined Chest Wall Resection with Vertebrectomy and Spinal Reconstruction for the Treatment of Pancoast Tumors.
    Date July 1999
    Journal Journal of Neurosurgery
    Excerpt

    OBJECT: Traditionally, superior sulcus tumors of the lung that involve the chest wall and spinal column have been considered to be unresectable, and historically, patients harboring these tumors have been treated with local radiation therapy with, at best, modest results. The value of gross-total resection remains unclear in this patient population; however, with the recent advances in surgical technique and spinal instrumentation, procedures involving more radical removal of such tumors are now possible. At The University of Texas M. D. Anderson Cancer Center, the authors have developed a new technique for resecting superior sulcus tumors that invade the chest wall and spinal column. They present a technical description of this procedure and results in nine patients in whom stage IIIb superior sulcus tumors extensively invaded the vertebral column. METHODS: These patients underwent gross-total tumor resection via a combined approach that included posterolateral thoracotomy, apical lobectomy, chest wall resection, laminectomy, vertebrectomy, anterior spinal column reconstruction with methylmethacrylate, and placement of spinal instrumentation. There were six men and three women, with a mean age of 55 years (range 36-72 years). Histological examination revealed squamous cell carcinoma (three patients), adenocarcinoma (four patients), and large cell carcinoma (two patients). The mean postoperative follow-up period was 16 months. All patients are currently ambulatory or remained ambulatory until they died. Pain related to tumor invasion improved in four patients and remained unchanged in five. In three patients instrumentation failed and required revision. There was one case of cerebrospinal fluid leakage that was treated with lumbar drainage and one case of wound breakdown that required revision. Two patients experienced local tumor recurrence, and one patient developed a second primary lung tumor. CONCLUSIONS: The authors conclude that in selected patients, combined radical resection of superior sulcus tumors of the lung that involve the chest wall and spinal column may represent an acceptable treatment modality that can offer a potential cure while preserving neurological function and providing pain control.

    Title Occipitocervicothoracic Fixation for Spinal Instability in Patients with Neoplastic Processes.
    Date July 1999
    Journal Journal of Neurosurgery
    Excerpt

    OBJECT: Occipitocervicothoracic (OCT) fixation and fusion is an infrequently performed procedure to treat patients with severe spinal instability. Only three cases have been reported in the literature. The authors have retrospectively reviewed their experience with performing OCT fixation in patients with neoplastic processes, paying particular attention to method, pain relief, and neurological status. METHODS: From July 1994 through July 1998, 13 of 552 patients who underwent a total of 722 spinal operations at the M. D. Anderson Cancer Center have required OCT fixation for spinal instability caused by neoplastic processes (12 of 13 patients) or rheumatoid arthritis (one of 13 patients). Fixation was achieved by attaching two intraoperatively contoured titanium rods to the occiput via burr holes and Luque wires or cables; to the cervical spinous processes with Wisconsin wires; and to the thoracic spine with a combination of transverse process and pedicle hooks. Crosslinks were used to attain additional stability. In all patients but one arthrodesis was performed using allograft. At a follow-up duration of 1 to 45 months (mean 14 months), six of the 12 patients with neoplasms remained alive, whereas the other six patients had died of malignant primary disease. There were no deaths related to the surgical procedure. Postoperatively, one patient experienced respiratory insufficiency, and two patients required revision of rotational or free myocutaneous flaps. All patients who presented with spine-based pain experienced a reduction in pain, as measured by a visual analog scale for pain. All patients who were neurologically intact preoperatively remained so; seven of seven patients with neurological impairment improved; and six of seven patients improved one Frankel grade. There were no occurrences of instrumentation failure or hardware-related complications. In one patient a revision of the instrumentation was required 13.5 months following the initial surgery for progression of malignant fibrous histiosarcoma. CONCLUSIONS: In selected patients, OCT fixation is an effective means of attaining stabilization that can provide pain relief and neurological preservation or improvement.

    Title Expression and Localization of Urokinase-type Plasminogen Activator in Human Spinal Column Tumors.
    Date May 1999
    Journal Clinical & Experimental Metastasis
    Excerpt

    We have sought to determine the production and activity of serine proteases in primary and metastatic spinal tumors and the association of these enzymes with the invasive and metastatic properties of spinal column tumors. Using immunohistochemical techniques, the cellular localization and expression of urokinase-type plasminogen activator (uPA) was assessed, whereas its activity was determined by fibrin zymography, and the amounts of enzyme were measured by an enzyme-linked immunosorbent assay (ELISA) in primary spinal column tumors (chordoma, chondrosarcoma, and giant cell tumor) and metastatic tumors of the spine arising from various malignancies (breast, lung, thyroid, and renal cell carcinomas, and melanomas). Metastatic tumors displayed higher levels of uPA activity than did primary spinal tumors (P<0.001). Immunohistochemical analysis revealed that uPA expression was highest in metastases from lung and breast carcinomas and melanomas, followed by metastatic tumors from thyroid and renal cell carcinomas. Similar results were obtained for uPA activity and enzyme level as determined by fibrin zymography and ELISA, respectively. We conclude that metastatic spinal tumors possess higher levels of uPA expression and activity than the primary spinal tumors, which tend to be less aggressive and only locally invasive malignancies. The results suggest that the plasminogen system may participate in the metastasis of tumors to the spinal column.

    Title Expression and Role of Matrix Metalloproteinases Mmp-2 and Mmp-9 in Human Spinal Column Tumors.
    Date May 1999
    Journal Clinical & Experimental Metastasis
    Excerpt

    Matrix metalloproteinases (MMPs) have been implicated in the process of tumor invasion and metastasis formation. Thus, we determined the expression of MMPs in various primary and metastatic spinal tumors in order to assess the role of these enzymes in spinal invasion. MMP expression was examined by immunohistochemical localization, and quantitative evaluation of MMP protein content was determined by enzyme-linked immunosorbant assay (ELISA) and Western blotting. MMP enzyme activity was determined by gelatin zymography. Lung carcinomas and melanomas metastatic to the spine were shown to have higher levels of MMP-9 activity than those of breast, thyroid, renal metastases and primary spinal tumors. Immunohistochemical analysis revealed similar difference in expression of MMP-9 in tissue samples. When the tissue samples were subjected to gelatin zymography for examination of MMP-2 and MMP-9 activity and to ELISA and Western blotting for quantitative estimation of protein content, the most striking results were obtained for lung carcinomas and melanomas relative to the other tumors. Lung carcinomas and melanomas metastatic to the spine had considerably higher levels of MMP-9 activity than those of primary spinal tumor or breast, thyroid, and renal carcinoma metastases. Within the metastatic tumor category, neoplasms that are known to be associated with the shortest overall survival rates and most aggressive behavior, such as lung carcinomas and melanomas, had the highest levels of MMP-2 and MMP-9 activity compared to those less aggressive metastatic tumors such as breast, renal cell, and thyroid carcinomas. Our results suggest that MMPs may contribute to the metastases to the spinal column, and overexpression of these enzymes may correlate with enhanced invasive properties of both primary and metastatic spinal tumors.

    Title Sacral Chordoma: 40-year Experience at a Major Cancer Center.
    Date April 1999
    Journal Neurosurgery
    Excerpt

    OBJECTIVE: Sacral chordomas are relatively rare, locally invasive, malignant neoplasms. Despite surgical resection, adjuvant radiation therapy, and chemotherapy, recurrence is common. This study reviews our experience during the last 40 years at The University of Texas M.D. Anderson Cancer Center, to determine the effects of various treatment methods on the overall course of this disease process. METHODS: A retrospective study was performed. From 1954 to 1994, 27 patients with sacral chordomas were evaluated at our institution. RESULTS: There were 19 male and 8 female patients, with a mean age of 56 years (range, 27-80 yr). All except one of the patients presented with pain, and 17 of 27 showed evidence of autonomic dysfunction at initial presentation. Based on microscopic examination of surgical specimen margins, surgical procedures were categorized as either radical resection or subtotal excision. All patients underwent at least one surgical procedure, for a total of 67 procedures (28 radical resections and 39 subtotal excisions). Twelve patients underwent one operation, whereas nine underwent two procedures and six underwent more than two operations (range, 3-16 operations). Radiation therapy was used in conjunction with 13 of the 67 surgical procedures. The median Kaplan-Meier estimate of the overall survival time for the entire group was 7.38 years (range, 4 mo to 34 yr). Tumors recurred after 47 of the 67 procedures. The overall disease-free interval for patients undergoing radical resection was 2.27 years for each procedure, compared with 8 months for each procedure for patients treated with subtotal excision (log-rank test for the inequality between the two curves, 19.58; P<0.0001). The addition of radiation therapy prolonged the disease-free interval for patients undergoing subtotal resection (2.12 yr versus 8 mo; log-rank test for the inequality between the two curves, 5.82; P<0.02). CONCLUSION: Our results suggest frequent recurrences in the majority of patients with chordomas. Radical resection is associated with a significantly longer disease-free interval, compared with subtotal removal of the tumor. Addition of radiation after subtotal resection improves the disease-free interval, although radiation therapy can generally be used only once. Based on these findings, we think that, whenever possible, radical resection should be the treatment of choice for sacral chordomas.

    Title Elevated Levels of Urokinase-type Plasminogen Activator and Its Receptor During Tumor Growth in Vivo.
    Date January 1999
    Journal International Journal of Oncology
    Excerpt

    Urokinase-type plasminogen activator (uPA) and its receptor (uPAR) are important in the regulation of tumor tissue progenesis, cell differentiation, tumor cell motility, and tumor cell invasiveness. We have recently reported that the levels of uPA and uPAR were higher in malignant astrocytomas than in low-grade gliomas. In the present study, we measured the levels of uPA and uPAR during the growth of glioblastomas in nude mice. Using fibrin zymography, densitometry, and an enzyme-linked immunosorbent assay, we found that the enzyme activity and content of uPA were increased 4- to 10-fold during tumor formation. Using a receptor assay and an enzyme linked immunosorbent assay, we found the numbers and content of uPAR were increased 5- to 15-fold during tumor formation. In addition, immunohistochemical staining for uPA and uPAR revealed strong immunoreactivity in tumor cells with the staining more intense on day 28 than on day 14. These results suggest that the upregulation of uPA and uPAR plays a major role in the formation of gliomas.

    Title Increased Invasion of Neuroglioma Cells Transfected with Urokinase Plasminogen Activator Receptor Cdna.
    Date January 1999
    Journal International Journal of Oncology
    Excerpt

    The cell-surface urokinase plasminogen activator receptor (uPAR) plays a key role in regulating plasminogen cleavage during extracellular proteolysis. Our recent results demonstrated that uPAR expression is critical for the invasiveness of human gliomas and down regulation of uPAR caused by antisense cDNA transfection inhibits the invasion of these stable antisense uPAR-transfectant clones. To study the role of uPARs in glioma cell invasion, a human neuroglioma cell line (H4) that normally produces low numbers of uPARs was transfected with the expression vector containing full-length human uPAR cDNA. Stable transfectants were analyzed for uPAR mRNA expression, receptor number, in vitro invasion and secretion of uPA and MMP-2. The uPAR-overproducing clones showed a 4-fold increase in uPAR mRNA transcription and approximately 40% increase in receptor numbers. uPAR-overproducing clones also invaded through matrigel to a significantly greater extent than did parent cell line and vector clones. However, the uPAR-overexpressing clones and parent cell lines showed similar uPA and MMP-2 activities. These results suggest that the over-production of uPAR on the surface of neuroglioma cells enhances the invasiveness.

    Title Elevated Levels of Mr 92,000 Type Iv Collagenase During Tumor Growth in Vivo.
    Date November 1998
    Journal Biochemical and Biophysical Research Communications
    Excerpt

    Our previous studies demonstrated that matrix metalloproteinase (MMP-9) levels were significantly higher in human glioblastoma tissue samples than in low-grade brain tumors and normal brain tissue (Rao et al., Cancer Res. 53, 2208-2211, 1993). In the present study, we measured the levels of MMP-2 and MMP-9 during the growth of glial tumors in nude mice by intracerebral injection of glioblastoma cells. Using gelatin zymography, densitometry, and an enzyme-linked immunosorbent assay, we found that the enzyme activity and protein count of MMP-2 and MMP-9 were a respective 3- to 10- and 2- to 30-fold higher in tumors at day 14 and 28 than in normal tissue. Immunohistochemical staining for MMP-9 showed strong immunoreactivity in tumor cells and the staining intensity was much higher at day 28, compared to day 14. These results suggest that upregulation of MMP-9 plays a major role in the glioma tumor growth in vivo.

    Title Transthoracic Vertebrectomy for Metastatic Spinal Tumors.
    Date October 1998
    Journal Journal of Neurosurgery
    Excerpt

    OBJECT: Anterior approaches to the spine for the treatment of spinal tumors have gained acceptance; however, in most published reports, patients with primary, metastatic, or chest wall tumors involving cervical, thoracic, or lumbar regions of the spine are combined. The purpose of this study was to provide a clear perspective of results that can be expected in patients who undergo anterior vertebral body resection, reconstruction, and stabilization for spinal metastases that are limited to the thoracic region. METHODS: Outcome is presented for 72 patients with metastatic spinal tumors who were treated by transthoracic vertebrectomy at The University of Texas M. D. Anderson Cancer Center. The predominant primary tumors included renal cancer in 19 patients, breast cancer in 10, melanoma or sarcoma in 10, and lung cancer in nine patients. The most common presenting symptoms were back pain, which occurred in 90% of patients, and lower-extremity weakness, which occurred in 64% of patients. All patients underwent transthoracic vertebrectomy, decompression, reconstruction with methylmethacrylate, and anterior fixation with locking plate and screw constructs. Supplemental posterior instrumentation was required in seven patients with disease involving the cervicothoracic or thoracolumbar junction, which was causing severe kyphosis. After surgery, pain improved in 60 of 65 patients. This improvement was found to be statistically significant (p < 0.001) based on visual analog scales and narcotic analgesic medication use. Thirty-five of the 46 patients who presented with neurological dysfunction improved significantly (p < 0.001) following the procedure. Thirty-three patients had weakness but could ambulate preoperatively. Seventeen of these 33 regained normal strength, 15 patients continued to have weakness, and one patient was neurologically worse postoperatively. Of the 13 preoperatively nonambulatory patients, 10 could walk after surgery and three were still unable to walk but showed improved motor function. Twenty-one patients had complications ranging from minor atelectasis to pulmonary embolism. The 30-day mortality rate was 3%. The 1-year survival rate for the entire study population was 62%. CONCLUSIONS: These results suggest that transthoracic vertebrectomy and spinal stabilization can improve the quality of life considerably in cancer patients with spinal metastasis by restoring or preserving ambulation and by controlling intractable spinal pain with acceptable rates of morbidity and mortality.

    Title Induction of Matrix Metalloproteinase-9 Requires a Polymerized Actin Cytoskeleton in Human Malignant Glioma Cells.
    Date June 1998
    Journal The Journal of Biological Chemistry
    Excerpt

    Alterations in cytoskeleton and subsequent cell shape changes exert specific effects on the expression of various genes. Our previous results suggested that malignant human gliomas express elevated levels of matrix metalloproteinases compared with normal brain tissue and low grade gliomas. To understand the role of cell shape changes on matrix metalloproteinase expression in human glioma cells, we treated SNB19 cells with cytochalasin-D, an inhibitor of actin polymerization, and colchicine-B, a tubulin inhibitor, in the presence of phorbol 12-myristate 13-acetate. Cytochalasin-D treatment of SNB19 cells resulted in the loss of phorbol 12-myristate 13-acetate-induced matrix metalloproteinase-9 (also known as gelatinase-B) expression and coincided with inhibition of actin polymerization, resulting in cell rounding. Moreover, compared with monolayers, cells grown as spheroids or cell aggregates failed to express matrix metalloproteinase-9 in the presence of phorbol 12-myristate 13-acetate. Matrix metalloproteinase-9 expression was also inhibited by calphostin-C, a protein kinase inhibitor, suggesting the involvement of protein kinase C in matrix metalloproteinase-9 expression. Phorbol 12-myristate 13-acetate-induced invasion of SNB19 cells through Matrigel was inhibited by cytochalasin-D and calphostin-C. These results suggest that the actin polymerization transduces signals that modulate the expression of matrix metalloproteinase-9 expression and the subsequent invasion of human glioma cells.

    Title Anterior Approaches to the Thoracic Spine in Patients with Cancer: Indications and Results.
    Date February 1998
    Journal The Annals of Thoracic Surgery
    Excerpt

    BACKGROUND: Multidisciplinary surgical teams enable an aggressive approach to tumors involving the thoracic spine. METHODS: From February 1994 to July 1996, 61 patients underwent anterior resections of thoracic spine tumors. Their median age was 56 years. The indications for operation were curative in intent in 7 of 61 and palliative in 54 of 61 (to relieve intractable metastatic bone pain with neurologic compromise [n = 38] and pain alone [n = 16]). Sixteen patients came to our institution unable to ambulate with impending paraplegia. RESULTS: Anterior approaches included combined left side of the neck and median sternotomy for lesions involving vertebrae T-1 through T-3 (n = 9), posterolateral thoracotomy for T-3 through T-10 (n = 39), and thoracoabdominal approach at T-11 and T-12 (n = 13). Median hospital stay was 9.0 days (range, 4 to 57 days). Complications occurred in 18 of 61 (29.5%). In 55 of 61 (90%), pain was significantly improved after the operation. Twelve of the 16 patients who initially presented in wheelchairs regained ambulatory function. There were five perioperative deaths (8.2%). The 1-year cumulative survival for the entire group was 60%. CONCLUSIONS: An aggressive surgical approach in cancer patients with locally advanced or metastatic disease in the thoracic spine was associated with acceptable morbidity and mortality. There was significant improvement in their quality of life by control of intractable pain in 90% and recovery of ambulatory function in 75% of patients who presented with critical spinal cord compromise.

    Title Altered in Vitro Spreading and Cytoskeletal Organization in Human Glioma Cells by Downregulation of Urokinase Receptor.
    Date February 1998
    Journal Molecular Carcinogenesis
    Excerpt

    The interaction of urokinase-type plasminogen activator (uPA) with its cell-surface receptor (uPAR) is implicated in diverse biological processes such as cell migration, tissue remodeling, and tumor cell invasion. Recent studies indicated that uPAR can act as an extracellular matrix receptor during cell adhesion. Recently, we showed that transfection of the human glioma cell line SNB19 with antisense uPAR resulted in downregulation of uPAR at both the mRNA and protein levels. In this study, we used SNB19 to determine how the presence or absence of uPAR promotes cell spreading and associated changes in cell morphology. Microscopic analysis of cell spreading revealed that antisense uPAR-transfected cells were larger, remained round, and did not spread efficiently over extracellular matrix substrate type IV collagen and fibronectin, unlike parental SNB19 cells, which were smaller and spindle shaped. Biochemical studies showed that antisense uPAR-transfected cells, in addition to not spreading, exhibited increased expression of alpha 3 beta 1 integrin but not alpha 5 beta 1 integrin. However, we could not find a change in the expression of extracellular matrix components or altered growth rate in these cells. Furthermore, despite the increased alpha 3 beta 1 integrin expression, antisense uPAR-transfected cells failed to form an organized actin cytoskeleton when plated on type IV collagen or fibronectin, unlike parental SNB19 cells, which displayed an organized cytoskeleton. These findings show that the absence of uPAR in human glioma cells leads to morphological changes associated with decreased spreading and a disorganized cytoskeleton resulting in altered cell morphology, suggesting that coordinated expression of uPAR and integrin may be involved in spreading of antisense uPAR-transfected glioma cells.

    Title Total Sacrectomy and Galveston L-rod Reconstruction for Malignant Neoplasms. Technical Note.
    Date November 1997
    Journal Journal of Neurosurgery
    Excerpt

    Although radical resection is the best treatment for malignant sacral tumors, total sacrectomy for such tumors has been performed in only a few instances. Total sacral resection requires reconstruction of the pelvic ring plus establishment of a bilateral union between the lumbar spine and iliac bone. This technique is illustrated in two patients harboring large, painful, sacral giant-cell tumors that were unresponsive to prior treatment. These patients were treated with complete en bloc resection of the sacrum and complex iliolumbar reconstruction/stabilization and fusion. Surgery was performed in two stages, the first consisting of a midline celiotomy, dissection of visceral/neural structures, and ligation of internal iliac vessels, followed by an anterior L5-S1 discectomy. The second stage consisted of mobilization of an inferiorly based myocutaneous rectus abdominis pedicle flap for wound closure, followed by an L-5 laminectomy, bilateral L-5 foraminotomy, ligation of the thecal sac, division of sacral nerve roots, and transection of the ilia lateral to the tumor and sacroiliac joints. Placement of the instrumentation required segmental fixation of the lumbar spine from L-3 down by means of pedicle screws and the establishment of a bilateral liaison between the lumbar spine and the ilia by using the Galveston L-rod technique. The pelvic ring was then reestablished by means of a threaded rod connecting left and right ilia. Both autologous (posterior iliac crest) and allograft bone were used for fusion, and a tibial allograft strut was placed between the remaining ilia. The patients were immobilized for 8 weeks postoperatively and underwent progressive rehabilitation. At the 1-year follow-up review, one patient could walk unassisted, and the other ambulated independently using a cane. Both patients controlled bowel function satisfactorily with laxatives and diet and could maintain continence but required self-catheterization for bladder emptying. The authors conclude that in selected patients, total sacrectomy represents an acceptable surgical procedure that can offer not only effective local pain control, but also a potential cure, while preserving satisfactory ambulatory capacity and neurological function.

    Title Intraoperative Monitoring of Spinal Cord Function Using Motor Evoked Potentials Via Transcutaneous Epidural Electrode During Anterior Cervical Spinal Surgery.
    Date October 1997
    Journal Journal of Spinal Disorders
    Excerpt

    Because false-positive results are not infrequent when monitoring somatosensory evoked potentials during surgery, monitoring of motor evoked potentials (MEPs) has been proposed and successfully used during the removal of spinal cord tumors. However, this often requires direct visual placement of an epidural electrode after a laminectomy. We evaluated the use of MEPs, recorded via a transcutaneously placed epidural electrode, to monitor motor pathway functional integrity during surgery on the anterior cervical spine. Sixteen patients underwent anterior cervical vertebral decompression and fusion for cervical myelopathy and/or radiculopathy. Before surgery, an epidural monitoring electrode was placed transcutaneously at the midthoracic level and was used to record MEPs after transcranial cortical electrical stimulation. Electrode placement was successful in all patients but one, and satisfactory baseline spinal MEPs were obtained except for one patient who had cerebral palsy with significant motor dysfunction. Patients showed no significant changes in spinal MEPs during surgery, and all had baseline or better motor function postoperatively. None had complications from epidural electrode placement or electrical stimulation. We conclude that motor pathways can be monitored safely during anterior cervical spinal surgery using spinal MEPs recorded via a transcutaneously placed epidural electrode, that MEP preservation during surgery correlates with good postoperative motor function, and that cerebral palsy patients may possess too few functional motor fibers to allow MEP recording.

    Title Effect of Cisplatin and Bcnu on Mmp-2 Levels in Human Glioblastoma Cell Lines in Vitro.
    Date August 1997
    Journal Clinical & Experimental Metastasis
    Excerpt

    Matrix metalloproteinases (MMPs) play an important role in various physiological and pathological conditions such as tissue remodeling, and cancer cell invasion and metastasis. The aim of this study was to determine the effect of the antitumor compounds cis-dichlorodiammine platinum (ii) (cisplatin) and 1, 3 bis (2-chloroethyl)-1-nitrosourea (BCNU) on 72-kDa type IV collagenase activity (MMP-2) in human gliomas. Human glioblastoma cell lines were treated with cisplatin (25 microM), and BCNU (50 microM), and the levels of MMP-2 were estimated in serum-free conditioned medium and in cell extracts at different time intervals. Gelatin zymography revealed increased levels of MMP-2 in serum-free conditioned medium and in cell extracts of untreated glioblastoma cell cultures during a 72-h period. In contrast, MMP-2 levels were significantly decreased in cisplatin-treated cells both in conditioned medium and cell extracts. However, no significant changes of MMP-2 levels were noted in BCNU-treated cells. Quantitative analysis of MMP-2 enzyme activity by densitometry and amount of MMP-2 protein by ELISA showed significantly decreased levels of MMP-2 in cisplatin-treated cells compared to BCNU and untreated glioblastoma cells. The results indicate that decreased levels of MMP-2 might represent an additional mechanism by which cisplatin provides its antineoplastic effects.

    Title In Vitro Inhibition of Human Glioblastoma Cell Line Invasiveness by Antisense Upa Receptor.
    Date July 1997
    Journal Oncogene
    Excerpt

    The cell surface urokinase-type plasminogen activator receptor (uPAR) has been shown to be a key molecule in regulating plasminogen-mediated extracellular proteolysis. To investigate the role of uPAR in invasion of brain tumors, human glioblastoma cell line SNB19 was stably transfected with a vector capable of expressing an antisense transcript complementary to the 300 base pair of the 5' end of the uPAR mRNA. Parental and stably transfected (vector, sense, and antisense) cell lines were analysed for uPAR mRNA transcript by Northern blot analysis, and receptor protein levels were measured by radioreceptor assays and Western blotting. Significant reduction of uPAR sites was observed in the antisense transfected cell lines. The levels of uPAR mRNA were significantly decreased in antisense clones compared to control, vector and sense clones. The invasive potential of the cell lines in vitro was measured by Matrigel invasion assay and migration of cells from spheroids to monolayers. The antisense transfected cells showed a markedly lower level of invasion and migration than the controls. The antisense clones were more adhesive to the ECM components compared to parental, vector and sense clones. All transfected (vector, sense and antisense) clones and parental cells produced similar levels of uPA activity without any significant difference however, MMP-2 activity was decreased in antisense clones compared to controls. These results demonstrate that uPAR expression is critical for the invasiveness of human gliomas and down regulation of uPAR expression may be a feasible approach to decrease invasiveness.

    Title Spine Surgery for Cancer.
    Date December 1996
    Journal Current Opinion in Oncology
    Excerpt

    Spinal metastatic disease and spinal cord compression are major causes of morbidity and mortality in cancer patients. Treatment of metastatic disease of the spine frequently requires surgical decompression, reconstruction, and stabilization in addition to radiation and chemotherapy. Instability of the spinal column has been recognized as a significant cause of pain in cancer patients. During the past decade, various innovative surgical approaches and new methods of spinal instrumentation have been developed. Recent advances now enable the surgeon to achieve more radical resections of these neoplasms and to reconstruct and stabilize the spine more effectively. Surgeons dealing with the treatment of these patients should not only be familiar with all surgical approaches to the spinal column but also be proficient in using various reconstructive instruments. This article provides an overall review of the literature during the past 2 years for physicians who participate in the treatment of these cancer patients.

    Title Role of Extracellular Matrix Proteins in Regulation of Human Glioma Cell Invasion in Vitro.
    Date December 1996
    Journal Clinical & Experimental Metastasis
    Excerpt

    Primary brain tumors lack the metastatic behavior that is in part believed to be promoted by the extracellular matrix (ECM) components of the basement membrane. This study was intended to examine the influence of the ECM components present in the basement membrane that may act as natural barriers to tumor cell invasion. We examined the effect of type I and type IV collagens, fibronectin, laminin, and hyaluronic acid on the migration and invasion of four established glioblastoma cell lines, SNB19, U251, UWR1, and UWR2. Lower concentrations of all the ECM components induced the migration and invasion of all the cell lines. However, in the case of SNB19, laminin inhibited both migration and invasion in a concentration-dependent manner. We have also examined the influence of individual ECM components on the migration of cells from a spheroid to a monolayer on ECM component-coated coverslips. Consistent with the invasion studies using the modified Boyden chamber assays, lower concentrations of ECM components induced the migration of cells from spheroids to monolayer. Again, laminin inhibited the migration of cells from SNB19 spheroids. These results indicate that ECM components induce the invasion of glioma cells, apart from components like laminin, which may act as natural inhibitors.

    Title Expression of Cathepsin D During the Progression of Human Gliomas.
    Date November 1996
    Journal Neuroscience Letters
    Excerpt

    Recent studies suggest that aspartic proteinase cathepsin D may be implicated in tumor invasion and metastasis either directly by degrading extracellular matrix or indirectly by activating the cysteine proteinases such as procathepsin B, H, and L to mature forms or by inactivating cysteine proteinase inhibitors. In this study we determined for the first time whether increased levels of cathepsin D correlate with glioma progression by enzymatic assay, ELISA, and western blotting. Cathepsin D activity and content were higher in anaplastic astrocytoma and in glioblastoma tissue extracts especially when compared to normal brain tissue and low-grade gliomas. There was a significantly increased intensity of an M(r) 29,000 band in glioblastoma and anaplastic astrocytoma compared to low-grade glioma and normal brain tissue on Western blotting analysis using its specific antibodies. Cathepsin D antibody inhibited the invasion of glioblastoma cell lines in a dose-dependent manner. These results suggest that the expression of cathepsin D is dramatically upregulated in malignant gliomas, and that its increase correlates with the malignant progression of human gliomas in vivo.

    Title Expression and the Role of Cathepsin H in Human Glioma Progression and Invasion.
    Date July 1996
    Journal Cancer Letters
    Excerpt

    Proteinases and their inhibitors may play a role in the development and progression of many cancers. Several studies suggested that lysosomal proteinases cathepsin B, L, and D may be involved in the malignant progression of some human neoplastic diseases. In this study, we determined the levels of cathepsin H in human glioma progression and the significance of cathepsin H in glioma cell invasion. Levels of cathepsin H antigen were found to be significantly higher in glioblastomas and anaplastic astrocytoma when compared with normal brain tissue and low-grade gliomas. Western blotting confirmed the presence of authentic cathepsin H with a doublet at 27 and 25 kDa in normal brain tissue and tumor samples. However, the intensity of the band increased significantly in glioblastoma samples. Cathepsin H antibody inhibited the invasion of glioblastoma cell lines through Matrigel invasion assay. These data suggest that the tumor-specific increase in antigen may be a useful independent marker of tumor progression in central nervous system neoplasms.

    Title Modulation of Matrix Metalloprotease-2 and Invasion in Human Glioma Cells by Alpha 3 Beta 1 Integrin.
    Date July 1996
    Journal Cancer Letters
    Excerpt

    We have investigated the effect of integrin antibodies to a well-characterized alpha 5 beta 1 (fibronectin receptor) and to a multi-specific alpha 3 beta 1 (laminin, collagen, and fibronectin receptor), on the expression of matrix metalloproteases and the invasion ability of two human glioblastoma cell lines, SNB19 and U251. Cell adhesion assays indicated that both cell lines adhere to fibronectin, type IV collagen and laminin. Adhesion of cells to fibronectin was inhibited by a RGD peptide. Cells treated with anti-alpha 3 beta 1 or anti-alpha 5 beta 1 antibodies expressed increased levels of MMP-2. An in vitro matrigel assay also showed that the alpha 3 beta 1 antibody-treated cells had greater invasive ability than the controls. Immunofluorescence data showed that glioma cells treated with either anti-alpha 3 beta 1 or anti-alpha 5 beta 1 antibodies expressed diminished alpha 3 beta-1 and alpha 5 beta 1 integrins relative to the controls. The data show that treatment of cells with alpha 3 beta 1 antibody diminishes the integrin expression on the cell surface and increases the MMP-2 activity and invasiveness.

    Title Modulation of Serine Proteinases and Metalloproteinases During Morphogenic Glial-endothelial Interactions.
    Date June 1996
    Journal Journal of Neurochemistry
    Excerpt

    The regulation of microvessel formation and the expression of CNS-specific endothelial properties are attributed to perivascular astroglia. Specific proteolytic pathways mediate processes such as tissue remodeling, differentiation, invasion, and metastasis. We used a co-culture system in which C6 glial cells induce CNS microvascular endothelial cells to form capillary-like structures to examine the role of plasminogen activators and collagenases in CNS microvessel morphogenesis. Fibrin zymography revealed the presence of high-molecular weight urokinase-type plasminogen activator (uPA), low-molecular weight uPA, and uPA/inhibitor complexes within endothelial cultures and cocultures. Gelatin zymography revealed the presence of 92-, 72-, and 62-kDa type IV collagenases within endothelial cultures and cocultures. uPA activity was confirmed by incubating the extracts with amiloride, an inhibitor of uPA. Collagenase activity was confirmed by incubating the gels with EDTA, an inhibitor of metalloproteinases. Quantitative densitometry showed a six- to eightfold decrease in coculture uPA during capillary-like structure formation. Substantially less change in type IV 72-kDa procollagenase activity was seen in cocultures during capillary-like structure formation, but active type IV 62-kDa collagenase activity was significantly increased during capillary-like structure formation. These findings establish that uPA and activated type IV collagenase activity specifically regulates morphogenic endothelial responses to glial interactions and suggest mechanisms by which microvessels respond within the CNS.

    Title Immunohistochemical Localization of Extracellular Matrix Proteins in Human Glioma, Both in Vivo and in Vitro.
    Date June 1996
    Journal Cancer Letters
    Excerpt

    Expression of type IV collagen, fibronectin and laminin in various types of primary human brain tumor sections and normal brain tissue sections as well as cultured glioma cell lines was examined by an immunofluorescence technique. Type IV collagen, fibronectin, and laminin were mainly localized to the basement membrane of the vasculature in glioblastoma, anaplastic astrocytoma, low grade glioma, and in normal brain. However, positive staining for all the extracellular matrix (ECM) components tested was found only in glioblastoma sections both in the cells and in the ECM. In all other tumor types and in normal brain tissue, the cells did not stain for any of the ECM components. Four glioblastoma cell lines and autologous ECM synthesized by respective glioblastoma cell lines also showed positive staining for type IV collagen, fibronectin and laminin in vitro. These results suggest that glioblastoma cells both in vitro and in vivo express the extracellular matrix components that are involved in the regulation of tumor cell invasion.

    Title The Effect of Type Iii Collagen on Migration and Invasion of Human Glioblastoma Cell Lines in Vitro.
    Date May 1996
    Journal Cancer Letters
    Excerpt

    The effect of type III collagen, an extracellular matrix protein, on the in vitro migration and invasion of glioblastoma cells was assayed by chemotaxis using four cell lines. Migration and invasion of gliomablastoma cells was observed in the presence of varying concentrations of type III collagen. In contrast to control experiments in which the protein was not added, type III collagen significantly increased migration and invasion of glioblastoma cells in a dose dependent manner up to 10 micrograms/ml; however, higher concentrations of the protein eliminated this affect on migration and invasion as did the presence of a monoclonal type III collagen antibody. Type III collagen was also shown to stimulate the migration of glioblastoma cells from spheroids to monolayers. The results of this study indicate that type III collagen does influence the migration and invasion of human glioblastoma cells in vitro.

    Title Differential Expression of Membrane-type Matrix Metalloproteinase and Its Correlation with Gelatinase A Activation in Human Malignant Brain Tumors in Vivo and in Vitro.
    Date February 1996
    Journal Cancer Research
    Excerpt

    In this study, we investigated the expression of activated gelatinase A and membrane-type metalloproteinase (MT-MMP) induced by concanavalin A (ConA) in four highly invasive glioma cell lines (UWR2, UWR3, U251MG, and SNB-19). We also examined gelatinase A and MT-MMP expression in human brain tumor tissues in vivo. Gelatin zymography showed that all four cell lines expressed latent progelatinase A (M(r) 66,000). Activated gelatinase A (M(r) 62,000) was induced by ConA in only UWR2 or UWR3 cells. MT-MMP mRNA was present in all four cell lines prior to ConA treatment, and the relative hybridization signals were 1, 0.80, 0.25, and 0.15 in UWR2, UWR3, U251MG, and SNB-19 cells, respectively. These mRNA signals were dramatically increased (2,8-, 5.4-, and 2.2-fold in UWR2, UWR3, and U251MG cells, respectively) following ConA treatment; however, MT-MMP mRNA expression was unchanged in SNB-19 cells. MT-MMP protein was detected in various amounts in the four cell lines, but only after ConA pretreatment. The amount of MT-MMP mRNA was unchanged in SNB-19 after ConA treatment, and the MT-MMP mRNA level in ConA-treated U251MG was lower than in UWR2 and UWR3 without ConA treatment. MT-MMP protein was detected in SNB-19 and U251 cell lines only after ConA treatment. Gelatin zymography of human brain tumor tissues revealed that almost all samples examined contained a latent form of gelatinase A, whereas the activated form of gelatinase A was only seen in metastatic lung adenocarcinomas and malignant astrocytomas, and especially in glioblastomas. MT-MMP mRNA levels were significantly higher in malignant astrocytomas than in low-grade gliomas and normal brain tissues. These results were confirmed by PCR analysis, which showed that MT-MMP mRNA was absent or barely detectable in normal brain white matter but was easily detectable in malignant astrocytomas. Immunohistochemistry of MT-MMP in frozen sections showed that MT-MMP was localized in neoplastic astrocytes of malignant astrocytomas but was undetectable in normal white brain matter. The data indicate that MT-MMP is present in malignant human glial tumors and that MT-MMP expression correlates with expression and activation of gelatinase A during malignant progression in vivo. A direct correlation between the levels of MT-MMP protein and its transcripts was not found in vitro, suggesting that MT-MMP expression in glioma cell lines might be regulated either at the level of transcription message stability or at posttranscription. Altered MT-MMP expression might contribute, in part, to gelatinase A activation, which in turn facilitates invasion of these tumors.

    Title Expression and Localization of 92 Kda Type Iv Collagenase/gelatinase B (mmp-9) in Human Gliomas.
    Date January 1996
    Journal Clinical & Experimental Metastasis
    Excerpt

    Matrix metalloproteinases play an important regulatory role in tissue morphogenesis, cell differentiation and motility, and tumor cell invasiveness. We have recently demonstrated elevated activity of the 92 kDa type IV collagenase (MMP-9) in human glioblastoma and in the present study examine the relative amounts of MMP-9 protein and mRNA in human gliomas and as well as the distribution of MMP-9 in human glioma tumors in vivo. Using an enzyme-linked immunosorbent assay for the quantitative determination of MMP-9 protein, we found that levels were significantly higher in malignant astrocytomas, especially in glioblastoma multiforme, than in normal brain tissues and low-grade gliomas. In addition, the amount of MMP-9 mRNA, as determined by northern blot analysis was higher in anaplastic astrocytomas and glioblastoma multiforme than in normal brain tissue and low-grade gliomas. Immunocytochemical staining for MMP-9 showed strong cytoplasmic immunoreactivity in the tumor cells and the proliferating endothelial cells of glioblastoma multiforme and anaplastic astrocytomas. The staining intensity was lowe in low-grade astrocytomas, and was undetectable or very low in normal brain astrocytes. The results indicate that expression of MMP-9 is dramatically upregulated in highly malignant gliomas and correlates with the highly malignant progression of human gliomas in vivo, and support a role for the MMP-9 in facilitating the invasiveness seen in malignant gliomas in vivo.

    Title Expression and Immunohistochemical Localization of Cathepsin L During the Progression of Human Gliomas.
    Date January 1996
    Journal Clinical & Experimental Metastasis
    Excerpt

    Recent studies suggest that cysteine proteinase cathepsin L is involved in the process of tumor invasion and metastasis. We examined cathepsin L activity in brain tumor tissue samples by an enzymatic assay, and cathepsin L protein content by enzyme-linked immunoadsorbent assays and Western blotting to determine whether increased levels of cathepsin L correlate with the progression of human gliomas. Native and acid-activatable cathepsin L activities were highest in glioblastomas followed by anaplastic astrocytomas and were lowest in low-grade gliomas and normal brain tissues. Significantly higher amounts of an M(r) 29,000 cathepsin L were present in glioblastomas and anaplastic astrocytomas than in normal brain tissues and low-grade glioma tissue extracts. Using specific antibodies to cathepsin L, we also studied its cellular distribution by immunohistochemical procedures. Higher diffuse cathepsin L immunoreactivity was found in glioblastomas than in low-grade gliomas and normal brain tissue samples. Finally, the addition of cathepsin L antibody inhibits the invasion of glioblastoma cell lines through Matrigel invasion assay. These results suggest the expression of cathepsin L is dramatically upregulated in malignant gliomas and correlates with the malignant progression of human gliomas in vivo.

    Title Expression and Localization of 72 Kda Type Iv Collagenase (mmp-2) in Human Malignant Gliomas in Vivo.
    Date January 1996
    Journal Clinical & Experimental Metastasis
    Excerpt

    The 72 kDa type IV collagenase (gelatinase), a matrix metalloproteinase (MMP-2), has been proposed to potentiate the invasion and metastasis of malignant tumors. To determine the potential role of the MMP-2 in human gliomas and normal brain tissue, we examined the relative amounts of protein, mRNA, and distribution. Using gelatin zymography, densitometry, and an enzyme-linked immunosorbent assay for the quantitative determination of the MMP-2, we found that the enzyme's activity was significantly elevated in malignant astrocytomas, especially in glioblastoma multiforme, compared to low-grade glioma and normal brain tissues. As determined by Northern blot analysis, the amount of MMP-2 mRNA transcript was higher in anaplastic astrocytomas and glioblastoma multiforme tumors than in normal brain tissues or low-grade gliomas, a finding that was consistent with the amounts of MMP-2 protein detected in these tissues. Immunohistochemical studies demonstrated that MMP-2 was localized in tumor cells and vasculature cells of malignant astrocytomas. Staining intensity was clearly lower in low-grade astrocytomas, and immunoreactivity was very low or undetectable in normal brain astrocytes. The results suggest that expression of the MMP-2 is dramatically upregulated in malignant gliomas, correlating with the malignant progression of human gliomas in vivo.

    Title Cerebral Blood Flow, Arteriovenous Oxygen Difference, and Outcome in Head Injured Patients.
    Date September 1992
    Journal Journal of Neurology, Neurosurgery, and Psychiatry
    Excerpt

    Cerebral blood flow (CBF) and other physiological variables were measured repeatedly for up to 10 days after severe head injury in 102 patients, and CBF levels were related to outcome. Twenty five of the patients had a reduced CBF [mean (SD) 0.29 (0.05) ml/g/min]; 47 had a normal CBF, (0.41 (0.10) ml/g/min); and 30 had a raised CBF (0.62 (0.14) ml/g/min). Cerebral arteriovenous oxygen differences were inversely related to CBF and averaged 2.1 (0.7) mumol/ml in the group with reduced CBF, 1.9 (0.5) mumol/ml in the group with normal CBF, and 1.6 (0.4) mumol/ml in the group with raised CBF. Patients with a reduced CBF had a poorer outcome than patients with a normal or raised CBF. Mortality was highest in patients with a reduced CBF, and was 32% at three months after injury, whereas only 21% of the patients with a normal CBF and 20% of the patients with a raised CBF died. There were no differences in the type of injury, initial score on the Glasgow Coma Scale, mean intracranial pressure (ICP), highest ICP, or the amount of medical treatment required to keep the ICP less than 20 mm Hg in each group. Systemic factors did not significantly contribute to the differences in CBF among the three groups. A logistic regression model of the effect of CBF on neurological outcome was developed. When adjusted for variables which were found to be significant confounders, including age, initial Glasgow Coma Score, haemoglobin concentration, cerebral perfusion pressure and cerebral metabolic rate of oxygen, a reduced CBF remained significantly associated with an unfavourable neurological outcome.

    Title Clinical Experience with a Continuous Monitor of Intracranial Compliance.
    Date November 1989
    Journal Journal of Neurosurgery
    Excerpt

    Intracranial compliance, as estimated from a computerized frequency analysis of the intracranial pressure (ICP) waveform, was continuously monitored during the acute postinjury phase in 55 head-injured patients. In previous studies, the high-frequency centroid (HFC), which was defined as the power-weighted average frequency within the 4- to 15-Hz band of the ICP power density spectrum, was found to inversely correlate with the pressure-volume index (PVI). An HFC of 6.5 to 7.0 Hz was normal, while an increase in the HFC to 9.0 Hz coincided with a reduction in the PVI to 13 ml and indicated exhaustion of intracranial volume-buffering capacity. The mean HFC for individual patients in the present study ranged from 6.8 to 9.0 Hz, and the length of time that the HFC was greater than 9.0 Hz ranged from 0 to 104.8 hours. The mortality rate increased concomitantly with the mean HFC, from 7% when the mean HFC was less than 7.5 Hz to 46% when the mean HFC was 8.5 Hz or greater. The length of time that the HFC was 9.0 Hz or greater was also associated with an increased mortality rate, which ranged from 16% if the HFC was never above 9.0 Hz to 60% if the HFC was 9.0 Hz or greater for more than 12 hours. In 12 patients who developed uncontrollable intracranial hypertension or clinical signs of tentorial herniation during the monitoring period, 75% were observed to have had an increase in the HFC to 9.0 Hz or more 1 to 36 hours prior to the clinical decompensation. The more rapid the increase in the HFC, the more likely the deterioration was to be caused by an intracranial hematoma. Continuous monitoring of intracranial compliance by computerized analysis of the ICP waveform may provide an earlier warning of neurological decompensation than ICP per se and, unlike PVI, does not require volumetric manipulation of intracranial volume.

    Title Cerebral Arteriovenous Oxygen Difference As an Estimate of Cerebral Blood Flow in Comatose Patients.
    Date March 1989
    Journal Journal of Neurosurgery
    Excerpt

    The hypothesis that cerebral arteriovenous difference of oxygen content (AVDO2) can be used to predict cerebral blood flow (CBF) was tested in patients who were comatose due to head injury, subarachnoid hemorrhage, or cerebrovascular disease. In 51 patients CBF was measured daily for 3 to 5 days, and in 49 patients CBF was measured every 8 hours for 5 to 10 days after injury. In the latter group of patients, when a low CBF (less than or equal to 0.2 ml/gm/min) or an increased level of cerebral lactate production (CMRL) (less than or equal to -0.06 mumol/gm/min) was encountered, therapy was instituted to increase CBF, and measurements of CBF, AVDO2, and arteriovenous difference of lactate content (AVDL) were repeated. When data from all patients were analyzed, including those with cerebral ischemia and those without, AVDO2 had only a modest correlation with CBF (r = -0.24 in 578 measurements, p less than 0.01). When patients with ischemia, indicated by an increased CMRL, were excluded from the analysis, CBF and AVDO2 had a much improved correlation (r = -0.74 in 313 measurements, p less than 0.01). Most patients with a very low CBF would have been misclassified as having a normal or increased CBF based on the AVDO2 alone. However, when measurements of AVDO2 were supplemented with AVDL, four distinct CBF patterns could be distinguished. Patients with an ischemia/infarction pattern typically had a lactate-oxygen index (LOI = -AVDL/AVDO2) of 0.08 or greater and a variable AVDO2. The three nonischemic CBF patterns had an LOI of less than 0.08, and could be classified according to the AVDO2. Patients with a normal CBF (mean 0.42 +/- 0.12 ml/gm/min) had an AVDO2 between 1.3 and 3.0 mumol/ml. A CBF pattern of hyperemia (mean 0.53 +/- 0.18 ml/gm/min) was characterized by an AVDO2 of less than 1.3 mumol/ml. A compensated hypoperfusion CBF pattern (mean 0.23 +/- 0.07 ml/gm/min) was identified by an AVDO2 of more than 3.0 mumol/min. These studies suggest that reliable estimates of CBF may be made from AVDO2 and AVDL measurements, which can be easily obtained in the intensive care unit.

    Title Spinal Cord Stimulation for Failed Back Surgery Syndrome-does It Work and is It Cost-effective?
    Date
    Journal Nature Clinical Practice. Neurology
    Excerpt

    This Practice Point commentary discusses a study by Manca et al. that aimed to investigate the health-related quality-of-life and cost implications of spinal cord stimulation (SCS) plus nonsurgical conventional medical management (CMM) versus nonsurgical CMM alone. Manca et al. reported that the mean total 6-month health-care cost in the SCS group was significantly higher than that in the CMM alone group. However, the gain in health-related quality of life for patients undergoing SCS was significantly greater than that for patients undergoing CMM alone over this same period. In addition, patients in the SCS group used fewer analgesics and nondrug pain treatments (e.g. physical therapy), thus offsetting the upfront costs of SCS by 15%. The relevance of this study in providing an evaluation of health-care expenditures directed at treating low back pain relative to actual treatment outcomes is discussed.

    Title Maximizing the Potential of Minimally Invasive Spine Surgery in Complex Spinal Disorders.
    Date
    Journal Neurosurgical Focus
    Excerpt

    Minimally invasive surgery (MIS) in the spine was primarily developed to reduce approach-related morbidity and to improve clinical outcomes compared with those following conventional open spine surgery. Over the past several years, minimally invasive spinal procedures have gained recognition and their utilization has increased. In particular, MIS is now routinely used in the treatment of degenerative spine disorders and has been shown to be as effective as conventional open spine surgeries. Although the procedures are not yet widely recognized in the context of complex spine surgery, the true potential in minimizing approach-related morbidity is far greater in the treatment of complex spinal diseases such as spinal trauma, spinal deformities, and spinal oncology. Conventional open spine surgeries for complex spinal disorders are often associated with significant soft tissue disruption, blood loss, prolonged recovery time, and postsurgical pain. In this article the authors review numerous cases of complex spine disorders managed with MIS techniques and discuss the current and future implications of these approaches for complex spinal pathologies.

    Title Vertebroplasty and Kyphoplasty for Spinal Metastases.
    Date
    Journal Current Opinion in Supportive and Palliative Care
    Excerpt

    PURPOSE OF REVIEW: Pathologic fractures of the spine are extremely painful and cause significant disability and morbidity in patients suffering from metastatic cancer. Often, these patients are not candidates for open surgical procedures and cannot address mechanical instability and radiation therapy can take weeks to become effective. Minimally invasive surgical techniques have been developed over the past several years, offering a simple and effective way of managing painful pathologic fractures. RECENT FINDINGS: Vertebroplasty and kyphoplasty offer patients a minimally invasive, percutaneous procedure that dramatically reduces pain related to pathologic spinal fractures almost immediately with very low complication rates. Visual analog scale pain scores, narcotic usage and quality of life scales (SF-36) have all been shown to improve in a durable fashion for over 1 year. Also, these procedures can be performed before, after or concurrently with most radiation and chemotherapy protocols. SUMMARY: We recommend vertebroplasty or kyphoplasty in properly selected patients with painful pathologic fractures as early as possible. Newer biomaterials, which are softer than currently used cement, may offer better protection from adjacent level fracturing and lower complication rates.

    Title En Bloc Total Sacrectomy Performed in a Single Stage Through a Posterior Approach.
    Date
    Journal Neurosurgery
    Excerpt

    OBJECTIVE: Total sacrectomies are performed for extensive en bloc tumor resections. Exposure traditionally combines a posterior approach with a laparotomy to facilitate vascular control. We present a case of a total en bloc sacrectomy performed entirely through the posterior approach, thereby avoiding the need for a laparotomy. CLINICAL PRESENTATION: A 57-year-old man presented with sacral pain and loss of bowel and bladder function. A large sacral mass was identified and submitted to biopsy. Results were consistent with an osteoblastoma, although osteosarcoma could not be excluded on pathological examination. The patient was taken to the operating room for a total sacrectomy and en bloc resection of the mass. TECHNIQUE: Lateral iliac osteotomies were performed, followed by an L5-S1 discectomy and resection of the annulus, thus mobilizing the sacrum. Gradual distraction of the interspace coupled with upward traction of the sacrum provided an anterior exposure through which the internal iliac vessels were controlled, dissected, and divided. A combined transperineal approach completed the posterior dissection and the tumor was delivered en bloc. Lumbopelvic reconstruction was performed simultaneously. CONCLUSION: With the use of interspace distraction and sacral elevation to facilitate vascular control, a total sacrectomy was performed without the need for the anterior exposure of a laparotomy.

    Title Open Reduction of C1-c2 Subluxation with the Use of C1 Lateral Mass and C2 Translaminar Screws.
    Date
    Journal Neurosurgery
    Excerpt

    OBJECTIVE: Spinal cord compression secondary to a subluxation of one vertebral body over another can be achieved with reduction of the translational deformity. Intraoperative reduction of C1-C2 subluxations can be technically challenging when one uses traditional techniques (e.g., wiring and transarticular screw fixation). The popularization of C1 lateral mass and C2 pedicle screws has allowed surgeons to achieve a more complex realignment at this region of the spine. Control of both C1 and C2 with independent fixation can be used to obtain reduction. In certain instances, placement of C2 pedicle screws is not possible. The use of C2 translaminar screws (if the C2 lamina is present and suitable) is an alternative method of fixation in C2 and can be used for intraoperative reduction. CLINICAL PRESENTATION: A 15-year-old boy with juvenile rheumatoid arthritis presented with spinal cord compression secondary to a C1-C2 subluxation. The C2 pedicle anatomy precluded safe placement of C2 pedicle screws. An alternative method of fixation with the use of C2 translaminar screws and reduction was performed to obtain proper alignment and decompress the spinal cord. TECHNIQUE: C1 lateral mass screws and C2 translaminar screws are inserted in the usual fashion. Two contoured rods, two rod holders, and two distractors, combined with C1 lateral mass screws and C2 translaminar screws, were used to achieve reduction. Concomitant distraction between the C2 translaminar screw head and the rod holder resulted in ventral translation of C2 on C1, decompressing the spinal cord. The reduction was maintained by tightening the C2 locking nut onto the rod. CONCLUSION: The use of C2 translaminar screws (if the C2 lamina is present and suitable) is an alternative method of fixation in C2. C1 lateral mass and C2 translaminar screw fixation provide a powerful means of reducing C1-C2 subluxations and maintaining alignment, achieving indirect decompression of the spinal cord.

    Title [p. 292] Revision Surgery For Cervical Spondylotic Myelopathy: Surgical Results and Outcome.
    Date
    Journal Neurosurgery
    Title Revision Surgery for Cervical Spondylotic Myelopathy: Surgical Results and Outcome.
    Date
    Journal Neurosurgery
    Excerpt

    OBJECTIVE: The role of additional or revision surgery in patients with cervical spondylotic myelopathy (CSM) is challenging. Postoperative pseudoarthrosis, instability, hardware failure, and recurrent cervical stenosis are conditions that require detailed clinical and radiographic assessment to define the pathology and assess the need for surgical decompression and fusion. The purpose of this study is to assess the neurological outcome, radiological outcome, and complications of patients undergoing additional or revision surgery for CSM. METHODS: Between 2002 and 2006, 30 patients with CSM and postoperative pseudoarthrosis, instability, hardware failure, or recurrent stenosis underwent surgical decompression and stabilization. The specific procedure was selected according to each patient's medical condition, cervical sagittal alignment, and extent of stenosis. All patients underwent an anterior, posterior, or combined anterior and posterior decompression and instrumented fusion. The charts of these patients were reviewed to assess neurological and radiographic outcomes. RESULTS: Twenty-five patients (83%) improved postoperatively as measured by the Nurick Myelopathy Scale over a mean follow-up period of 19 months (range, 2-64 mo). The overall complication rate was 27%, consisting of transient monoradiculopathy (7%), dysphagia (10%), and infection (7%). The incidence of nonunion during the follow-up period was 3%. CONCLUSION: Although patients with CSM and postoperative pseudoarthrosis, instability, hardware failure, or junctional stenosis who require revision surgery may risk a substantial likelihood of surgical complications (25% in this series), a significant proportion of patients may experience improved neurological outcomes. In our experience, the cervical sagittal alignment and the extent of stenosis are critical factors to consider when selecting the eventual procedure.

    Title Surgical Resection Plus Adjuvant Radiotherapy is Superior to Surgery or Radiotherapy Alone in the Prevention of Neurological Decline in a Rat Metastatic Spinal Tumor Model.
    Date
    Journal Neurosurgery
    Excerpt

    OBJECTIVE: The optimal management of spinal column metastatic disease is controversial. Furthermore, the literature lacks an accurate animal model to study the efficacy of surgical treatment options for spinal column metastases. We compared the efficacy of surgery, radiotherapy, or surgery plus adjuvant radiotherapy in a rat model of metastatic epidural spinal cord compression. METHODS: Thirty-two Fischer 344 rats underwent a transabdominal approach for implantation of a CRL-1666 breast adenocarcinoma cell line within the vertebral body of L6. Animals were randomly assigned to receive one of four treatments (n = 8 per group) 7 days after tumor implantation: 1) control: no treatment; 2) external beam radiation therapy (XRT) (total 20 Gy in 400-cGy daily fractions); 3) surgery: L6 vertebral corpectomy, tumor resection, and polymethyl methacrylate reconstruction; and 4) surgery + XRT: corpectomy and tumor resection followed by XRT (total 20 Gy in 400-cGy daily fractions) 72 hours after surgery. Hind-limb function was tested daily after treatment using the Basso-Beattie-Bresnahan (BBB) scale (range, 1-21). RESULTS: All animals (n = 32) demonstrated normal hind-limb function (BBB score, 21) on posttreatment Day 1. The XRT, surgery, and surgery + XRT groups all experienced a delay in onset of paresis versus the control group. Compared to the XRT group, the surgery group demonstrated greater median BBB scores on Days 3 (21 versus 20, P = 0.02) through 9 (12 versus 8, P = 0.002) after treatment. Compared with the surgery group, the surgery + XRT group demonstrated even greater median BBB scores on Days 6 (21 versus 19, P = 0.0008) through 11 (16 versus 8, P = 0.0001) after treatment. Median time to loss of ambulation (BBB <or= 7) was greatest in the surgery + XRT group (15 d) when compared with the surgery (12 d, P = 0.001), XRT (9 d, P = 0.001), or control groups (7 d, P = 0.0005). CONCLUSION: In a rat model of metastatic epidural spinal cord compression, decompressive surgery followed by radiotherapy yielded the greatest efficacy in the prevention of neurological decline when compared with surgery or radiotherapy alone. Radiotherapy alone attenuated neurological decline but was the least efficacious treatment in this model. These results support this animal model as an effective platform to investigate novel interventions for metastatic spine tumors.

    Title Severe Dysphagia Secondary to Posterior C1-c3 Instrumentation in a Patient with Atlantoaxial Traumatic Injury: a Case Report and Review of the Literature.
    Date
    Journal Dysphagia
    Excerpt

    There are only a few reports of dysphagia cases in patients who underwent surgery for posterior cervical fusion, but none provides an explanation for the occurrence of dysphagia. To the best of our knowledge this is the first case report showing evidence of severe neurogenic dysphagia, possibly secondary to vagal nerve praxia, in a patient who underwent posterior fusion. A 61-year-old man presented with severe neck pain after he sustained a fall. Imaging studies in the emergency department showed a C2 fracture associated with anterior subluxation of C2 on C3. Given the instability of the injury, a C1-C3 posterior cervical fusion was performed. The surgery was uneventful. The patient's postoperative course was complicated by severe dysphagia. Fluoroscopic and endoscopic assessments of the patient's pharynx and larynx showed significantly decreased epiglottic inversion, hypokinesis of his pharyngeal wall, and decreased hyolaryngeal elevation. There was also mild vocal cord paresis bilaterally, with incomplete approximation of the glottis. He demonstrated intra- and post-deglutitive aspiration. The patient coughed (both immediate and delayed) in response to the aspiration but was not able to clear aspirated material completely from the airway. The patient had a percutaneous endoscopic gastrostomy (PEG) tube placed to provide him with nutrition. He was then discharged home. On postoperative follow-up visit 1 month later, the patient's swallowing function improved and he could tolerate pureed consistencies and thin liquids with tube feed supplement. The patient could swallow without coughing. Possible causes of dysphagia in this case include traumatized airways from anesthesia, mechanical compromise of the upper gastrointestinal tract, and neurogenic dysphagia. After excluding the other possibilities, we concluded that our patient was suffering from neurogenic dysphagia associated with vagal nerve dysfunction.

    Title Trans-foraminal Versus Posterior Lumbar Interbody Fusion: Comparison of Surgical Morbidity.
    Date
    Journal Neurological Research
    Excerpt

    Posterior lumbar interbody fusion (PLIF) and trans-foraminal lumbar interbody fusion (TLIF) are both accepted surgical approaches for spinal fusion in spondylolisthesis and degenerative disc disease. The unilateral approach of TLIF may minimize the risk of iatrogenic durotomy and nerve root injury; however, there is no definitive evidence to support either approach. We review our experience with TLIF versus PLIF to compare operative complications.

    Title A Novel Classification System for Spinal Instability in Neoplastic Disease: an Evidence-based Approach and Expert Consensus from the Spine Oncology Study Group.
    Date
    Journal Spine
    Excerpt

    Systematic review and modified Delphi technique.

    Title Metastasis to the Occipitocervical Junction: A Case Report and Review of the Literature.
    Date
    Journal Surgical Neurology International
    Excerpt

    The management of metastatic spinal disease is generally considered palliative, as the progression of systemic disease is likely to hinder survival. Although the occurrence of C1-C2 instability due to metastatic disease is not uncommon and thus treatment options have been well-defined, craniocervical instability due to lesions occurring at the junction of the occiput and atlas is more rare, and treatment for metastasis to this region is less well-defined.

    Title Successful Treatment of a Symptomatic L5/s1 Discal Cyst by Percutaneous Ct-guided Aspiration.
    Date
    Journal Surgical Neurology International
    Excerpt

    Discal cysts are a rare cause of lumbar radiculopathy. Benefits of percutaneous computed tomography (CT)-guided aspiration of the cyst include decreased rate of infection, avoidance of general anesthesia, and quicker recovery. However, since the publication of a case of cyst recurrence after CT-guided aspiration, few have utilized this potentially valuable technique.

    Title "no Clinical Puzzles More Interesting:" Harvey Cushing and Spinal Trauma, The Johns Hopkins Hospital 1896-1912.
    Date
    Journal Neurosurgery
    Excerpt

    Although Harvey Cushing played a central role in the establishment of neurosurgery in the United States, his work on the spine remains largely unknown. This paper is not only the first time that Cushing's spinal cases while he was at Johns Hopkins are reported, but also the first time his management of spinal trauma is described. We report twelve patients that Cushing treated from 1898-1911 who have never been published before, including blunt and penetrating injuries, complete and incomplete spinal cord lesions, and both immediate and delayed presentations. Cushing performed laminectomies within twenty-four hours on patients with immediate presentations-both complete and incomplete spinal cord lesions. Among those with delayed presentations, Cushing did laminectomies on patients with incomplete spinal cord injuries. By the end of his tenure at Hopkins, Cushing advocated non-operative treatment for all patients with complete spinal cord lesions. Four died while an inpatient, with meningitis and cystitis leading to the death of one and three patients, respectively. Cystitis was treated with intravesicular irrigation; an indwelling catheter was placed by a suprapubic cystostomy in four. Cushing was one of the first to report the usage of X-ray in a spine patient, in a case that may have been one factor leading to his interest in the nervous system; Cushing also routinely obtained radiographs in those with spinal trauma. These cases illustrate Cushing's dedication to and rapport with his patients, even in the face of a dismal prognosis.

    Title Safety and Efficacy of Concurrent Pediatric Spinal Cord Untethering and Deformity Correction.
    Date
    Journal Journal of Spinal Disorders & Techniques
    Excerpt

    STUDY DESIGN: A retrospective clinical records analysis of concurrent pediatric spinal cord deformity correction and tethered cord release compared with a 2-staged approach. OBJECTIVE: To compare the safety and efficacy of a single-staged approach for pediatric spinal deformity correction and tethered cord release to a conventional 2-staged approach. SUMMARY OF BACKGROUND DATA: Tethered cord syndrome (TCS) is frequently associated with scoliosis in the pediatric population. Conventional practice suggests waiting several months after untethering for scoliosis correction; however, some patients will experience progression of their spinal deformity. We report the efficacy and safety of concurrent tethered cord release and scoliosis and/or kyphosis deformity correction in a series of pediatric patients. METHODS: We retrospectively reviewed 15 consecutive pediatric cases of concurrent spinal cord untethering and deformity correction with fusion for scoliosis and/or kyphosis. The clinical and radiologic presentation, operative details, morbidity, and postoperative outcomes were evaluated. Outcomes of this cohort were then compared with 21 patients who underwent a 2-staged untethering surgery followed by scoliosis correction. We provide a review of the literature of the treatment of tethered cord associated with spine deformities. RESULTS: The mean age of patients undergoing concurrent untethering and curve correction was 9.6 years (5 male, 10 female). Tethered cord was because of myelomeningocele (5 patients), thickened filum terminale (5 patients), lipomyelomeningocele (4 patients), and retethering from an unknown primary TCS etiology (1 patient). The mean scoliosis Cobb angle (±SD) at presentation was 55.4±21.0 degrees (range, 32.3 degrees to 95.0 degrees) whereas average kyphosis was 112.7±43.6 degrees (range, 68.0 degrees to 155.0 degrees). Average postoperative scoliosis curve was 40.0 degrees, resulting in an average correction of 27%; kyphosis curve was 55.7 degrees resulting in an average correction of 50%. The average operation time was 8.6 hours (range, 3.9 to 13.7 h) and the average blood loss was 1266 mL (range, 400 to 5000 mL). Average length of hospitalization was 10.1 days (range, 4 to 34 d). New onset or worsening of neurologic deficits, bowel or bladder dysfunction, or TCS associated pain did not occur in any patients. At a mean follow-up of 5.7 years (range, 1.3 to 11.8 y), only 1 (7%) patient required subsequent surgery for pseudoarthrosis. The 2-staged cohort experienced a longer cumulative operative time (11.2 vs 8.6 h, P<0.05), more total blood loss (1534 vs 1266 mL, P<0.05), longer total days of hospitalization (14.8 vs 10.1 d, P<0.05), and a greater incidence of dural tear (9.5% vs 0%), wound infection (26% vs 0%), and retethering (9.5% vs 0%). CONCLUSION: Concurrent tethered cord release and spinal fusion for correction of scoliosis and/or kyphosis may be a safe and effective approach in patients likely to experience deformity progression.

    Title Accuracy of Free-hand Pedicle Screws in the Thoracic and Lumbar Spine: Analysis of 6816 Consecutive Screws.
    Date
    Journal Neurosurgery
    Excerpt

    Pedicle screws are used to stabilize all 3 columns of the spine, but can be technically demanding to place. Although intraoperative fluoroscopy and stereotactic-guided techniques slightly increase placement accuracy, they are also associated with increased radiation exposure to patient and surgeon as well as increased operative time.

    Title Survival of Patients with Malignant Primary Osseous Spinal Neoplasms: Results from the Surveillance, Epidemiology, and End Results (seer) Database from 1973 to 2003.
    Date
    Journal Journal of Neurosurgery. Spine
    Excerpt

    Object Malignant primary osseous spinal neoplasms are aggressive tumors that remain associated with poor outcomes despite aggressive multidisciplinary treatment measures. To date, prognosis for patients with these tumors is based on results from small single-center patient series and controlled trials. Large population-based observational studies are lacking. To assess national trends in histology-specific survival, the authors reviewed patient survival data spanning 30 years (1973-2003) from the Surveillance, Epidemiology, and End Results (SEER) registry, a US population-based cancer registry. Methods The SEER registry was queried to identify cases of histologically confirmed primary spinal chordoma, chondrosarcoma, osteosarcoma, or Ewing sarcoma using coding from the International Classification of Disease for Oncology, Third Edition. Association of survival with histology, metastasis status, tumor site, and year of diagnosis was assessed using Cox proportional-hazards regression analysis. Results A total of 1892 patients were identified with primary osseous spinal neoplasms (414 with chordomas, 579 with chondrosarcomas, 430 with osteosarcomas, and 469 with Ewing sarcomas). Chordomas presented in older patients (60 ± 17 years; p < 0.01) whereas Ewing sarcoma presented in younger patients (19 ± 11 years; p < 0.01) compared with patients with all other tumors. The relative incidence of each tumor type remained similar per decade from 1973 to 2003. African Americans comprised a significantly greater proportion of patients with osteosarcomas than other tumors (9.6% vs 3.5%, respectively; p < 0.01). Compared with the sacrum, the mobile spine was more likely to be the site of tumor location for chordomas than for all other tumors (47% vs 23%, respectively; p < 0.05). Osteosarcoma and Ewing sarcoma were 3 times more likely than chondrosarcoma and chordoma to present with metastasis (31% vs 8%, respectively). Resection was performed more frequently for chordoma (88%) and chondrosarcoma (89%) than for osteosarcoma (61%) and Ewing sarcoma (53%). Overall median survival was histology-specific (osteosarcoma, 11 months; Ewing sarcoma, 26 months; chondrosarcoma, 37 months; chordoma, 50 months) and significantly worse in patients with metastasis at presentation for all tumor types. Survival did not significantly differ as a function of site (mobile spine vs sacrum/pelvis) for any tumor type, but more recent year of diagnosis was associated with improved survival for isolated spinal Ewing sarcoma (hazard ration [HR] 0.95; p = 0.001), chondrosarcoma (HR 0.98; p = 0.009), and chordoma (HR 0.98; p = 0.10), but not osteosarcoma. Conclusions In this analysis of a 30-year, US population-based cancer registry (SEER), the authors provide nationally representative prognosis and survival data for patients with malignant primary spinal osseous neoplasms. Overall patient survival has improved for isolated spine tumors with advancements in care over the past 4 decades. These results may be helpful in providing historical controls for understanding the efficacy of new treatment paradigms, patient education, and guiding level of aggressiveness in treatment strategies.

    Title En-bloc Excision of Chordomas in the Cervical Spine: Review of 5 Consecutive Cases with over 4-year Follow-up.
    Date
    Journal Spine
    Excerpt

    ABSTRACT:: Study Design: Retrospective case series of 5 consecutive patients.Objective: To determine the oncological outcomes and morbidity rates following en bloc excision of cervical chordomas.Summary of Background Data: Studies have demonstrated that en bloc surgical excision of chordoma with negative margins results in improved local disease control and survival compared to intralesional resections. Chordomas arising from the cervical spine are rare and they present unique challenges for en bloc tumor excision. We present a series of five consecutive cases of cervical chordoma managed with en bloc tumor excision, which represents one of the largest surgical experiences of cervical chordomas reported to date.Methods: A retrospective review of our institutional spine tumor database identified five consecutive patients that underwent en bloc tumor excision for cervical spine chordoma from 2000-2007. We analyze their surgical margins, peri-operative complications, tumor recurrence rate, and survival.Results: Our review demonstrated that dysphagia and cervicalgia were the most common presenting symptoms for cervical chordoma. The mean age of diagnosis in this cohort was 52.4 years-old, and our mean follow-up is 54.7 months. All five patients required multi-stage procedures to achieve en bloc tumor excision. Independent analysis of the surgical margins by the pathologists revealed that marginal en bloc excisions were achieved in all five patients. Our 30-day peri-operative complication was significant for one wound infection. Other long-term complications included two cases with pseudoarthrosis with instrumentation failures requiring surgical revisions. There were no neurological or cerebrovascular complications. The mean disease-free survival following en bloc spondylectomy for cervical chordoma was 84.2 months in this cohort.Conclusion: En bloc excisions of chordoma with wide or marginal margins is most ideal for treatment to prolong disease-free survival. En bloc excision of chordoma in the cervical spine are technically complex procedures but they can be performed with acceptable safety and peri-operative morbidity.

    Title Three-level En Bloc Spondylectomy for Chordoma.
    Date
    Journal Neurosurgery
    Excerpt

    En bloc resection of spinal and sacral chordomas may convey a survival benefit. However, these procedures often are complex and require the surgeon to plan a procedure that results in negative tumor margins, protects vital neurovascular structures, and concludes with a viable biomechanical reconstruction.

    Title Primary Vertebral Tumors: a Review of Epidemiologic, Histological and Imaging Findings, Part Ii: Locally Aggressive and Malignant Tumors.
    Date
    Journal Neurosurgery
    Excerpt

    This second part of a comprehensive review of primary vertebral tumors focuses on locally aggressive and malignant tumors. As discussed in the earlier part of the review, both benign and malignant types of these tumors affect the adult and the pediatric population, and an understanding of their subtleties may increase their effective resection. In this review, we discuss the epidemiologic, histological, and imaging features of the most common locally aggressive primary vertebral tumors (chordoma and giant-cell tumor) and malignant tumors (chondrosarcoma, Ewing sarcoma, multiple myeloma or plasmacytoma, and osteosarcoma). The figures used for illustration are from operative patients of the senior authors (Z.L.G. and J.H.C.). Taken together, parts 1 and 2 of this article provide a thorough and illustrative review of primary vertebral tumors.

    Title Implications of Spinopelvic Alignment for the Spine Surgeon.
    Date
    Journal Neurosurgery
    Excerpt

    The relation of the pelvis to the spine has previously been overlooked as a contributor to sagittal balance. However, it is now recognized that spinopelvic alignment is important to maintain an energy-efficient posture in normal and disease states. The pelvis is characterized by an important anatomic landmark, the pelvic incidence (PI). The PI does not change after adolescence, and it directly influences pelvic alignment, including the parameters of pelvic tilt (PT) and sacral slope (SS) (PI = PT 1 SS), overall sagittal spinal balance, and lumbar lordosis. In the setting of an elevated PI, the spineadapts with increased lumbar lordosis. To prevent or limit sagittal imbalance, the spine may also compensate with increased PT or pelvic retroversion to attempt to maintain anupright posture. Abnormal spinopelvic parameters contribute to multiple spinal conditions including isthmic spondylolysis, degenerative spondylolisthesis, deformity, and impact outcome after spinal fusion. Sagittal balance, pelvic incidence, and all spinopelvic parameters are easily and reliably measured on standing, full-spine (lateral) radiographs, and it is essential to accurately assess and measure these sagittal values to understand their potential role in the disease process, and to promote spinopelvic balance at surgery. In this article, we provide a comprehensive review of the literature regarding the implications of abnormal spinopelvic parameters and discuss surgical strategies for correction of sagittal balance. Additionally, the authors rate and critique the quality of the literature cited in a systematic review approach to give the reader an estimate of the veracity of the conclusions reached from these reports.

    Title Strategies to Avoid Wrong-site Surgery During Spinal Procedures.
    Date
    Journal Neurosurgical Focus
    Excerpt

    Wrong-site surgery (WSS) is a rare occurrence that can have devastating consequences for patient care. There are several factors inherent to spine surgery that increase the risk of WSS compared with other types of surgery. Not only can a surgeon potentially operate on the wrong side of the spine or the wrong level, but there are unique issues related to spinal localization that can be challenging for even the most experienced clinicians. The following review discusses important issues that can help prevent WSS during spinal procedures.

    Title Complications of Spine Surgery.
    Date
    Journal Neurosurgical Focus

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