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Rod J. Oskouian and J. Patrick Johnson

Object

The purpose of this investigation was to evaluate surgical and neurological outcomes in thoracic disc surgery in a prospective fashion.

Methods

Quantifiable outcome data such as operating time, blood loss, duration of chest tube drainage, narcotic drug use, length of hospital stay (LOS), and long-term follow up of neurological function and pain-related symptoms were collected prospectively.

In patients with myelopathy there was an improvement of two Frankel grades in the thoracoscopic discectomy group and one Frankel grade in the patients treated with thoracotomy; however, patients in the thoracotomy group were significantly worse preoperatively. None of the patients experienced worsened pain, and pain related to radiculopathy was improved by 75% in the thoracoscopic group.

Conclusions

Thoracoscopic discectomy yields acceptable surgical results and has several distinct advantages, with reduced postoperative pain, morbidity, and LOS.

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J. Patrick Johnson, Doniel Drazin, Wesley A. King and Terrence T. Kim

V ideo-assisted thoracoscopic surgery (VATS) for treatment of spinal disorders was first reported in 1993. 12 , 19 , 20 , 26 The procedure attracted great interest as a prototype for minimally invasive spinal (MIS) surgery for thoracic disc disease but had several disadvantages. It was an unfamiliar procedure, for an infrequent pathology; there were technical difficulties with early instrumentation and surgeons had difficulty with spatial and 3D orientation on a 2D monitor. 1 , 4 , 6 , 8 , 11 , 15–18 To overcome these challenges, we pursued the concept

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Jonathan Stuart Citow, J. Patrick Johnson, Duncan Q. McBride and Mario Ammirati

Object

Neurocysticercosis (NCC) is the most common parasitic infection of the central nervous system, and its prevalence is continuing to increase in the United States. The diagnosis of intraventricular NCC (IVNCC) may be difficult, and surgery frequently fails to resolve symptoms. A retrospective review of magnetic resonance (MR) imaging characteristics and surgery-related outcomes may improve management strategies of this disease.

Methods

The authors report the presentations, neuroimaging characteristics, surgical management, and outcomes of 30 patients with IVNCC treated over a 10-year period (mean follow-up period 4 years). Cysts were located in the lateral ventricles (five cases), the third ventricle (five cases), and the fourth ventricle (21 cases). One patient had lesions in both the lateral and fourth ventricles. Presenting symptoms were related to hydrocephalus or mass effect from the lesions.

All patients underwent computerized tomography (CT) and MR imaging of the brain. Treatment consisted of shunt implantation or primary excision of an IVNCC lesion. Outcomes after operations and reoperations were evaluated in light of enhancement characteristics on MR imaging.

Computerized tomography scanning demonstrated IVNCC lesions in 10% of cases, and MR revealed lesions in 100% of cases. In patients in whom gadolinium (Gd) enhancement of IVNCC lesions was demonstrated on MR imaging, the surgery-related failure rate was higher and patients required reoperation, and in those in whom gadolinium enhancement was absent the surgery-related failure rate was lower (64 and 19%, respectively; p < 0.0002).

Conclusions

Magnetic resonance imaging is superior to CT scanning for detecting IVNCC lesions. The absence of pericystic Gd enhancement on MR imaging is an indication for excision of the lesions. If pericystic enhancement is present, shunt surgery should be performed, and craniotomy reserved for treatment of those patients with symptomatic lesions secondary to mass effect. A treatment algorithm based on patient symptoms, cyst location, and MR imaging Gd enhancement characteristics is proposed.

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Langston T. Holly, J. Patrick Johnson, Jeffrey E. Masciopinto and Ulrich Batzdorf

The authors review the management of five patients with posttraumatic syringomyelia (PTS) associated with an uncorrected spinal deformity. Patients with evidence of progressive neurological deterioration underwent ventral spinal decompressive surgery.

The mean patient age at the time of injury was 39 years, and the time between injury and the diagnosis of PTS ranged from 2 to 22 years. Mechanisms of injury consisted of fracture/subluxations in three patients and burst fractures in two. All patients experienced delayed neurological deterioration consistent with PTS. Magnetic resonance imaging revealed ventral deformities, and the spinal canal stenosis ranged from 20 to 50% (mean 39%). All patients underwent ventral epidural spinal decompressive surgery to correct the bone deformity and restore the spinal canal.

The mean follow-up period was 38 months. The decompressive intervention was initially successful in treating the neurological deterioration in all patients. Symptoms resolved completely in four patients, and the other experienced neurological improvement. Postoperative magnetic resonance imaging revealed a reduction in the size of syrinx cavity in the patients whose symptoms resolved and no change in the remaining patient. Two patients required a subsequent second-stage posterior intradural exploration and duraplasty for recurrence of symptoms and/or syrinx.

Posttraumatic spinal deformity may cause spinal canal stenosis and alter subarachnoid cerebrospinal fluid (CSF) flow in certain patients. Ventral epidural spinal decompressive surgery may result in neurological improvement and a reduction of the syrinx cavity, avoiding the need for placement of a shunt or other intradural procedures. However, some patients will also require reconstruction of the posterior subarachnoid space with duraplasty if the ventral decompressive procedure achieves only partial restoration of the subarachnoid CSF flow.

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Lutfi T. Al-Khouja, Eli M. Baron, J. Patrick Johnson, Terrence T. Kim and Doniel Drazin

. Currently, the threshold for this value is controversial, but most studies use less than $50,000–$100,000/QALY gained to deem a new strategy as cost-effective. In 2003, spine surgery costs accumulated to more than $1 billion in Medicare spending and spiraled to more than $3.9 billion in the 2012 fiscal year (October 1, 2011 to September 30, 2012). Total spine-related heath expenditures have topped $85.9 billion, with some estimates reporting $90 billion with an additional $10–$20 billion in indirect costs. 6 , 8 One study by Martin et al. reported a 65% increase in

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J. Patrick Johnson, Chinyere Obasi, Michael S. Hahn and Paul Glatleider

Thoracic sympathectomy has evolved as a treatment option for patients with hyperhidrosis and pain disorders. In the past surgical procedures were highly invasive and caused significant morbidity, but the minimally invasive thoracoscopic procedure provides detailed visualization of the sympathetic ganglia and is associated with minimal postoperative morbidity. In a previously published series the authors performed 60 thorascopic procedures in 39 patients; in this paper, they report the addition of 52 procedures performed in 26 patients, for a total of 112 procedures in 65 patients. Overall, the outcomes were equivalent to those for previously established open surgical techniques; however, the rate of surgery-related morbidity, length of hospital stay, and time until return to normal activity were substantially reduced. Complications and recurrence of symptoms were comparable with those demonstrated in previous reports. Overall patient satisfaction and willingness to undergo a repeat operative procedure ranged from 66 to 99%. Postoperatively, higher satisfaction rates were observed in patients with hyperhidrosis whereas in those with pain syndromes, satisfaction rates were lower. Minimally invasive thoracoscopic sympathectomy procedures are useful in treating sympathetically mediated disorders, and the results indicated that the procedure is associated with reduced morbidity and similar outcome when compared with results obtained after open surgery. Hyperhidrosis is well treated, but patients with pain syndromes have significantly poorer outcomes.

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Joseph C. Hsieh, Doniel Drazin, Alexander O. Firempong, Robert Pashman, J. Patrick Johnson and Terrence T. Kim

I nstrumentation is commonly used during spine surgery for stabilization and arthrodesis. The accuracy of instrumentation insertion is of paramount importance to reducing unintended bone, soft tissue, or neurological injuries, and the costs associated with postoperative morbidity, and even mortality. Accuracy rates with current techniques of pedicle instrumentation in which traditional fluoroscopic imaging is used have been previously reported in the literature to be as high as 5%–15%. 2 , 5 Over the last 2 decades, intraoperative neuronavigation

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Doniel Drazin, Terrence T. Kim, David W. Polly Jr and J. Patrick Johnson

, Foley and Smith published a paper presenting a broader clinical application of IGS technology to spine surgery procedures. 9 Following these initial publications, IGS for spinal procedures in various regions of the spinal column were reported by surgeons from across the country. 2 , 5 , 15 , 20 , 38 Accuracy Since the earliest development of stereotactic procedures, data from preoperative imaging has needed to be entered manually into a computer to achieve “registration” (matching the anatomy with the preoperative imaging features) before a surgical procedure

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Doniel Drazin, Ziya L. Gokaslan, Ehud Mendel and J. Patrick Johnson

It has been 12 years since an issue of Neurosurgical Focus has focused on tumors of the spine. It was therefore with great enthusiasm that we invited authors to submit original research or review articles that explored new advances in the field of intradural spinal tumor surgery for this issue of Neurosurgical Focus. We were especially interested in presenting articles regarding specific techniques including clinical indications and outcomes as well as evaluations of current evidence regarding management of intradural spinal tumors. We were pleasantly

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Doniel Drazin, Ziya L. Gokaslan and J. Patrick Johnson

list to the best 18 original articles on the current state of the art in surgery for tumors of the spinal column. The issue begins with 4 thorough systematic review articles. Bakar et al. reviewed decompression surgery for spinal metastases. Ravindra et al. reviewed primary osseous tumors of the pediatric spine. Galgano et al. reviewed osteoblastomas of the spine. Karhade et al. reviewed the national surgical quality improvement program on 30-day readmissions and reoperation after surgery for spine tumors. These 4 articles encompass surgical outcomes, readmissions