Browse

You are looking at 11 - 20 of 33,299 items for

Restricted access

Yoji Ogura, Yoshio Shinozaki, Yoshiomi Kobayashi, Takahiro Kitagawa, Yoshiro Yonezawa, Yohei Takahashi, Kodai Yoshida, Akimasa Yasuda and Jun Ogawa

OBJECTIVE

The importance of global sagittal alignment is well known. Patients with lumbar spinal stenosis (LSS) generally tend to bend forward to relieve their neurological symptoms, i.e., they have a positive sagittal vertical axis (SVA). We hypothesized that the positive SVA associated with LSS is symptom related and should improve after surgery. However, little is known about the changes in sagittal alignment in LSS patients after decompression surgery. In this study the authors aimed to evaluate midterm radiographical changes in sagittal spinopelvic alignment after decompression surgery for LSS and to determine the factors influencing the improvement in sagittal spinopelvic alignment.

METHODS

The authors retrospectively reviewed 89 patients who underwent lumbar decompression without fusion between January 2014 and September 2015 with a minimum follow-up of 2 years. Standing whole-spine radiographs at the preoperative stage and at the final follow-up were examined. We analyzed SVA, lumbar lordosis (LL), pelvic tilt (PT), pelvic incidence (PI), thoracolumbar kyphosis (TLK), and thoracic kyphosis (TK).

RESULTS

LL and TK were significantly increased postoperatively. SVA and PI minus LL (PI-LL) were significantly decreased. There were no significant differences between the preoperative and postoperative PT, PI, SS, or TLK. Twenty-nine patients had preoperative sagittal malalignment with SVA > 50 mm. Thirteen of the 29 patients improved to SVA < 50 mm after decompression surgery. Lower ASA grade, preoperative higher LL, and lower PI-LL were related to patient improvement. A receiver operating characteristic curve for the preoperative PI-LL had an area under the curve value of 0.821, indicating moderate accuracy (p = 0.003). A cutoff value for preoperative PI-LL of 19.2° showed a sensitivity of 93.5% and a specificity of 71.4%.

CONCLUSIONS

Lumbar decompression can lead to a reactive improvement in the lumbar and global sagittal alignment. However, some of the sagittal malalignment in LSS was irreversible. Preoperative PI-LL was a useful predictor to distinguish reversible from irreversible sagittal malalignment.

Restricted access

Ping Zhu, Xianglin L. Du, Jay-Jiguang Zhu and Yoshua Esquenazi

OBJECTIVE

The present study was designed to explore the association between facility type (academic center [AC] vs non-AC), facility volume (high-volume facility [HVF] vs low-volume facility [LVF]), and outcomes of glioblastoma (GBM) treatment.

METHODS

Based on the National Cancer Database (NCDB), GBM patients were categorized by treatment facility type (non-AC vs AC) and volume [4 categories (G1–G4): < 5.0, 5.0–14.9, 15.0–24.9, and ≥ 25.0, cases/year]. HVF was defined based on the 90th percentile of annual GBM cases (≥ 15.0 cases/year). Outcomes include overall survival (OS), the receipt of surgery and adjuvant therapies, 30-day readmission/mortality, 90-day mortality, and prolonged length of inpatient hospital stay (LOS). Kaplan-Meier methods and accelerated failure time (AFT) models were applied for survival analysis, and multivariable logistic regression models were performed to compare differences in the receipt of treatment and related short-term outcomes by facility type and volume.

RESULTS

A total of 40,256 GBM patients diagnosed between 2004 and 2014 were included. Patients treated at an AC & HVF experienced the longest survival (median OS: 13.3, 11.8, 11.1, and 10.3 months; time ratio [TR]: 1.00 [Ref.], 0.96, 0.92, and 0.89; for AC & HVF, AC & LVF, non-AC & HVF, and non-AC & LVF, respectively), regardless of care transition/treatment referral. Tumor resection, radiotherapy, and chemotherapy were most frequently utilized in AC & HVF. Prolonged LOS, 30-day readmission, and 90-day mortality were decreased by 20%, 22%, and 16% (p ≤ 0.001), respectively, at AC & HVF.

CONCLUSIONS

This study provides evidence of superior outcomes when GBM patients are treated at AC and HVF. Standardization of health care across facility type and/or volume and comprehensive neuro-oncological care should be a potential goal in the management of GBM patients.

Restricted access

Daniel W. Fults, Michael D. Taylor and Livia Garzia

Leptomeningeal dissemination (LMD) is the defining pattern of metastasis for medulloblastoma. Although LMD is responsible for virtually 100% of medulloblastoma deaths, it remains the least well-understood part of medulloblastoma pathogenesis. The fact that medulloblastomas rarely metastasize outside the CNS but rather spread almost exclusively to the spinal and intracranial leptomeninges has fostered the long-held belief that medulloblastoma cells spread directly through the CSF, not the bloodstream. In this paper the authors discuss selected molecules for which experimental evidence explains how the effects of each molecule on cell physiology contribute mechanistically to LMD. A model of medulloblastoma LMD is described, analogous to the invasion–metastasis cascade of hematogenous metastasis of carcinomas. The LMD cascade is based on the molecular themes that 1) transcription factors launch cell programs that mediate cell motility and invasiveness and maintain tumor cells in a stem-like state; 2) disseminating medulloblastoma cells escape multiple death threats by subverting apoptosis; and 3) inflammatory chemokine signaling promotes LMD by creating an oncogenic microenvironment. The authors also review recent experimental evidence that challenges the belief that CSF spread is the sole mechanism of LMD and reveal an alternative scheme in which medulloblastoma cells can enter the bloodstream and subsequently home to the leptomeninges.

Restricted access

Zhiyuan Yu, Jun Zheng, Lu Ma, Chao You and Hao Li

Restricted access

Andrew Dapaah, William Sage and Harshal Ingale

Restricted access

Harsh Deora, Nishant S. Yagnick and Manjul Tripathi

Restricted access

Charu Singh, Jack M. Qian, James B. Yu and Veronica L. Chiang

OBJECTIVE

Concurrent use of anti-PD-1 therapies with stereotactic radiosurgery (SRS) have been shown to be beneficial for survival and local lesional control in melanoma patients with brain metastases. It is not known, however, if immunotherapy (IT) confers the same outcome advantage in lung cancer patients with brain metastases treated with SRS.

METHODS

The authors retrospectively reviewed 85 non–small cell lung cancer (NSCLC) patients with brain metastases who were treated with SRS between January 2006 and December 2016. Thirty-nine PD-L1 antibody–positive patients received anti-PD-1 therapy with SRS (IT group) and 46 patients received chemotherapy (CT) with SRS (CT group). Results were obtained using chi-square, Kaplan-Meier, and Mann-Whitney U tests and Cox regression analyses.

RESULTS

Median survival following first radiosurgical treatment in the whole study group was 11.6 months (95% CI 8–15.5 months). Median survival times in the IT group and CT group were 10 months (95% CI 8.3–13.2 months) and 11.6 months (95% CI 7.7–15.6 months), respectively (p = 0.23). A Karnofsky Performance Status (KPS) score < 80 (p = 0.001) and lung-specific molecular marker Graded Prognostic Assessment (lungmol GPA) score < 1.5 (p = 0.02) were found to be predictive of worse survival.

Maximal percent lesional shrinkage and time to maximal shrinkage were not significantly different between the CT and IT groups. Of the lesions for which a complete response occurred, 94.8% had pre-SRS volumes < 500 mm3. The amount of lesion shrinkage and time to maximal shrinkage were not different between the IT and CT groups for lesions with volumes < 500 mm3. However, in lesions with volume > 500 mm3, 90% of lesions shrank after radiosurgery in the IT group compared with 47.8% in the CT group (p = 0.001). Median times to initial response and times to maximal shrinkage were faster in the IT group than in the CT group: initial response 49 days (95% CI 33.7–64.3 days) versus 84 days (95% CI 28.1–140 days), p = 0.001; maximal response 105 days (95% CI 59–150 days) versus 182 days (95% CI 119.6–244 days), p = 0.12.

CONCLUSIONS

Unlike patients with melanoma, patients with NSCLC with brain metastases undergoing SRS showed no significant benefit—either in terms of survival or total amount of lesional response—when anti-PD-1 therapies were used. However, in lesions with volume > 500 mm3, combining SRS with IT may result in a faster and better volumetric response which may be particularly beneficial in lesions causing mass effect or located in neurologically critical locations.

Restricted access

Matthew J. Zdilla, Brianna K. Ritz and Nicholas S. Nestor

OBJECTIVE

The first attempt to cannulate the foramen ovale is oftentimes unsuccessful and requires subsequent reattempts, thereby increasing the risk of an adverse event and radiation exposure to the patient and surgeon. Failure in cannulation may be attributable to variation in soft-tissue–based landmarks used for needle guidance. Also, the incongruity between guiding marks on the face and bony landmarks visible on fluoroscopic images may also complicate cannulation. Therefore, the object of this study was to assess the location of the foramen ovale by way of bony landmarks, exclusive of soft-tissue guidance.

METHODS

A total of 817 foramina ovalia (411 left-sided, 406 right-sided) from cranial base images of 424 dry crania were included in the study. The centroid point of each foramen ovale was identified. A sagittal plane through the posterior-most molar (molar plane) and a coronal plane passing through the articular eminences of the temporal bones (inter-eminence plane) were superimposed on images. The distances of the planes from the centroids of the foramina were measured. Also, counts were taken to assess how often the planes and their intersections crossed the boundary of the foramen ovale.

RESULTS

The average distance between the molar plane and the centroid of the foramen was 1.53 ± 1.24 mm (mean ± SD). The average distance between the inter-eminence plane and the centroid was 1.69 ± 1.49 mm. The molar and inter-eminence planes crossed through the foramen ovale boundary 83.7% (684/817) and 81.6% (667/817) of the time, respectively. The molar and inter-eminence planes passed through the boundary of the foramen together 73.5% (302/411) of the time. The molar and inter-eminence planes intersected within the boundary of the foramen half of the time (49.4%; 404/817).

CONCLUSIONS

The results of this study provide a novel means of identifying the location of the foramen ovale. Unlike the soft-tissue landmarks used in the many variations of the route of Härtel, the bony landmarks identified in this study can be palpated, marked on the face, appreciated fluoroscopically, and do not require any measurement from soft-tissue structures. Utilizing the molar and inter-eminence planes as cannulation guides will improve the approach to the foramen ovale and decrease the amount of radiation exposure to both the patient and surgeon.

Restricted access

MirHojjat Khorasanizadeh, Mahmoud Yousefifard, Mahsa Eskian, Yi Lu, Maryam Chalangari, James S. Harrop, Seyed Behnam Jazayeri, Simin Seyedpour, Behzad Khodaei, Mostafa Hosseini and Vafa Rahimi-Movaghar

OBJECTIVE

Predicting neurological recovery following traumatic spinal cord injury (TSCI) is a complex task considering the heterogeneous nature of injury and the inconsistency of individual studies. This study aims to summarize the current evidence on neurological recovery following TSCI by use of a meta-analytical approach, and to identify injury, treatment, and study variables with prognostic significance.

METHODS

A literature search in MEDLINE and EMBASE was performed, and studies reporting follow-up changes in American Spinal Injury Association (ASIA) Impairment Scale (AIS) or Frankel or ASIA motor score (AMS) scales were included in the meta-analysis. The proportion of patients with at least 1 grade of AIS/Frankel improvement, and point changes in AMS were calculated using random pooled effect analysis. The potential effect of severity, level and mechanism of injury, type of treatment, time and country of study, and follow-up duration were evaluated using meta-regression analysis.

RESULTS

A total of 114 studies were included, reporting AIS/Frankel changes in 19,913 patients and AMS changes in 6920 patients. Overall, the quality of evidence was poor. The AIS/Frankel conversion rate was 19.3% (95% CI 16.2–22.6) for patients with grade A, 73.8% (95% CI 69.0–78.4) for those with grade B, 87.3% (95% CI 77.9–94.8) for those with grade C, and 46.5% (95% CI 38.2–54.9) for those with grade D. Neurological recovery was significantly different between all grades of SCI severity in the following order: C > B > D > A. Level of injury was a significant predictor of recovery; recovery rates followed this pattern: lumbar > cervical and thoracolumbar > thoracic. Thoracic SCI and penetrating SCI were significantly more likely to result in complete injury. Penetrating TSCI had a significantly lower recovery rate compared to blunt injury (OR 0.76, 95% CI 0.62–0.92; p = 0.006). Recovery rate was positively correlated with longer follow-up duration (p = 0.001). Studies with follow-up durations of approximately 6 months or less reported significantly lower recovery rates for incomplete SCI compared to studies with long-term (3–5 years) follow-ups.

CONCLUSIONS

The authors’ meta-analysis provides an overall quantitative description of neurological outcomes associated with TSCI. Moreover, they demonstrated how neurological recovery after TSCI is significantly dependent on injury factors (i.e., severity, level, and mechanism of injury), but is not associated with type of treatment or country of origin. Based on these results, a minimum follow-up of 12 months is recommended for TSCI studies that include patients with neurologically incomplete injury.