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Courtney M. Schusse, Kris Smith and Cornelia Drees

OBJECTIVE

Hemispherectomy is a surgical technique that is established as a standard treatment in appropriately selected patients with drug-resistant epilepsy. It has proven to be successful in pediatric patients with unilateral hemispheric lesions but is underutilized in adults. This study retrospectively evaluated the clinical outcomes after hemispherectomy in adult patients with refractory epilepsy.

METHODS

This study examined 6 cases of hemispherectomy in adult patients at Barrow Neurological Institute. In addition, all case series of hemispherectomy in adult patients were identified through a literature review using MEDLINE and PubMed. Case series of patients older than 18 years were included; reports of patients without clear follow-up duration or method of validated seizure outcome quantification were excluded. Seizure outcome was based on the Engel classification.

RESULTS

A total of 90 cases of adult hemispherectomy were identified, including 6 newly added by Barrow Neurological Institute. Sixty-five patients underwent functional hemispherectomy; 25 patients had anatomical hemispherectomy. Length of follow-up ranged from 9 to 456 months. Seizure freedom was achieved in 80% of patients. The overall morbidity rate was low, with 9 patients (10%) having new or additional postoperative speech or language dysfunction, and 19 patients (21%) reporting some worsening of hemiparesis. No patients lost ambulatory or significant functional ability, and 2 patients had objective ambulatory improvement. Among the 41 patients who underwent additional formal neuropsychological testing postoperatively, overall stability or improvement was seen.

CONCLUSIONS

Hemispherectomy is a valuable surgical tool for properly selected adult patients with pre-existing hemiparesis and intractable epilepsy. In published cases, as well as in this series, the procedure has overall been well tolerated without significant morbidity, and the majority of patients have been rendered free of seizures.

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Ryan A. Gellner, Eamon T. Campolettano, Eric P. Smith and Steven Rowson

OBJECTIVE

Youth football attracts approximately 3.5 million participants every year, but concern has recently arisen about the long-term effects of experiencing repetitive head accelerations from a young age due to participation in football. The objective of this study was to quantify total involvement in high-magnitude impacts among individual players in youth football practices. The authors explored the relationship between the total number of high-magnitude accelerations in which players were involved (experienced either by themselves or by other players) during practices and the number of high-magnitude accelerations players experienced.

METHODS

A local cohort of 94 youth football players (mean age 11.9 ± 1.5, mean body mass 50.3 ± 16.4 kg) from 4 different teams were recruited and outfitted with helmet-mounted accelerometer arrays. The teams were followed for one season each for a total of 128 sessions (practices, games, and scrimmages). All players involved in high-magnitude (greater than 40g) head accelerations were subsequently identified through analysis of practice film.

RESULTS

Players who experienced more high-magnitude accelerations were more likely to be involved in impacts associated with high-magnitude accelerations in other players. A small subset of 6 players (6%) were collectively involved in 230 (53%) high-magnitude impacts during practice, were involved in but did not experience a high-magnitude acceleration 78 times (21% of the 370 one-sided high-magnitude impacts), and experienced 152 (30%) of the 502 high-magnitude accelerations measured. Quarterbacks/running backs/linebackers were involved in the greatest number of high-magnitude impacts in practice and experienced the greatest number of high-magnitude accelerations. Which team a player was on was an important factor, as one team showed much greater head impact exposure than all others.

CONCLUSIONS

This study showed that targeting the most impact-prone players for individualized interventions could reduce high-magnitude acceleration exposure for entire teams. These data will help to further quantify elevated head acceleration exposure and enable data-driven interventions that modify exposure for individual players and entire teams.

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Chao Li, Shuo Wang, Jiun-Lin Yan, Turid Torheim, Natalie R. Boonzaier, Rohitashwa Sinha, Tomasz Matys, Florian Markowetz and Stephen J. Price

OBJECTIVE

The objective of this study was to characterize the abnormalities revealed by diffusion tensor imaging (DTI) using MR spectroscopy (MRS) and perfusion imaging, and to evaluate the prognostic value of a proposed quantitative measure of tumor invasiveness by combining contrast-enhancing (CE) and DTI abnormalities in patients with glioblastoma.

METHODS

Eighty-four patients with glioblastoma were recruited preoperatively. DTI was decomposed into isotropic (p) and anisotropic (q) components. The relative cerebral blood volume (rCBV) was calculated from the dynamic susceptibility contrast imaging. Values of N-acetylaspartate, myoinositol, choline (Cho), lactate (Lac), and glutamate + glutamine (Glx) were measured from multivoxel MRS and normalized as ratios to creatine (Cr). Tumor regions of interest (ROIs) were manually segmented from the CE T1-weighted (CE-ROI) and DTI-q (q-ROI) maps. Perfusion and metabolic characteristics of these ROIs were measured and compared. The relative invasiveness coefficient (RIC) was calculated as a ratio of the characteristic radii of CE-ROI and q-ROI. The prognostic significance of RIC was tested using Kaplan-Meier and multivariate Cox regression analyses.

RESULTS

The Cho/Cr, Lac/Cr, and Glx/Cr in q-ROI were significantly higher than CE-ROI (p = 0.004, p = 0.005, and p = 0.007, respectively). CE-ROI had significantly higher rCBV values than q-ROI (p < 0.001). A higher RIC was associated with worse survival in a multivariate overall survival (OS) model (hazard ratio [HR] 1.40, 95% confidence interval [CI] 1.06–1.85, p = 0.016) and progression-free survival (PFS) model (HR 1.55, 95% CI 1.16–2.07, p = 0.003). An RIC cutoff value of 0.89 significantly predicted shorter OS (median 384 vs 605 days, p = 0.002) and PFS (median 244 vs 406 days, p = 0.001).

CONCLUSIONS

DTI-q abnormalities displayed higher tumor load and hypoxic signatures compared with CE abnormalities, whereas CE regions potentially represented the tumor proliferation edge. Integrating the extents of invasion visualized by DTI-q and CE images into clinical practice may lead to improved treatment efficacy.

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Ahmed Mansour, Toshiki Endo, Tomoo Inoue, Kenichi Sato, Hidenori Endo, Miki Fujimura and Teiji Tominaga

The authors report the case of a 78-year-old man with a craniocervical junction epidural arteriovenous fistula who presented with subarachnoid hemorrhage from a ruptured anterior spinal artery (ASA) aneurysm. Because endovascular embolization was difficult, a posterolateral approach was chosen and a novel endoscopic fluorescence imaging system was utilized to clip the aneurysm. The fluorescence imaging system provided clear and magnified views of the ventral spinal cord simultaneously with the endoscope-integrated indocyanine green videoangiography, which helped safely obliterate the ASA aneurysm. With the aid of this novel imaging system, surgeons can appreciate and manipulate complex vascular pathologies of the ventral spinal cord through a posterolateral approach, even when the lesion is closely related to the ASA.

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Dil V. Patel, Joon S. Yoo, Brittany E. Haws, Benjamin Khechen, Eric H. Lamoutte, Sailee S. Karmarkar and Kern Singh

OBJECTIVE

In a large, consecutive series of patients treated with anterior cervical discectomy and fusion (ACDF) performed by a single surgeon, the authors compared the clinical and surgical outcomes of patients who underwent ACDF in an inpatient versus outpatient setting.

METHODS

Patients undergoing primary ACDF were retrospectively reviewed and stratified by surgical setting: hospital or ambulatory surgical center (ASC). Data regarding perioperative characteristics, including hospital length of stay and complications, were collected. Neck Disability Index (NDI) and visual analog scale (VAS) scores were used to analyze neck and arm pain in the preoperative period and at 6 weeks, 3 months, 6 months, and 12 months postoperatively. Postoperative outcomes were compared using chi-square analysis and linear regression.

RESULTS

The study included 272 consecutive patients undergoing a primary ACDF, of whom 172 patients underwent surgery at a hospital and 100 patients underwent surgery at an ASC. Patients undergoing ACDF in the hospital setting were older, more likely to be diabetic, and had a higher comorbidity burden. Patients receiving treatment in the ASC were more likely to carry Workers’ Compensation insurance. Patients in the hospital cohort were more likely to have multilevel procedures, had greater blood loss, and experienced a longer length of stay. In the hospital cohort, 48.3% of patients were discharged within 24 hours, while 43.0% were discharged between 24 and 48 hours after admission. Both cohorts had similar VAS pain scores on postoperative day (POD) 0; however, the hospital cohort consumed more narcotics on POD 0. One patient in the ASC cohort had a pretracheal hematoma that was evacuated immediately in the same surgical center. There were 8 cases of dysphagia in the hospital cohort and 3 cases in the ASC cohort, all of which resolved before the 6-month follow-up. Both cohorts demonstrated similar NDI and VAS neck and arm pain scores preoperatively and at every postoperative time point.

CONCLUSIONS

Although patients undergoing ACDF in the hospital setting were older, had a greater comorbidity burden, and underwent surgery on more levels than patients undergoing ACDF at an outpatient center, this study demonstrated comparable surgical and clinical outcomes for both patient groups. Based on the results of this single surgeon’s experience, 1- to 2-level ACDFs may be performed successfully in the outpatient setting in appropriately selected patient populations.

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Vivien Chan, Alessandro Marro, Jeremy Rempel and Andrew Nataraj

OBJECTIVE

In this study the authors sought to compare the proportion of patients with lumbar spondylolisthesis detected to have dynamic instability based on flexion and extension standing radiographs versus neutral standing radiograph and supine MRI.

METHODS

This was a single-center retrospective study of all consecutive adult patients diagnosed with spondylolisthesis from January 1, 2013, to July 31, 2018, for whom the required imaging was available for analysis. Two independent observers measured the amount of translation, in millimeters, on supine MRI and flexion, extension, and neutral standing radiographs using the Meyerding technique. Interobserver and intraobserver correlation coefficients were calculated. The difference in amount of translation was compared between 1) flexion and extension standing radiographs and 2) neutral standing radiograph and supine MRI. The proportion of patients with dynamic instability, defined as a ≥ 3 mm difference in the amount of translation measured on different imaging modalities, was reported. Correlation between amount of dynamic instability and change in back pain and leg pain 1 year after decompression and instrumented fusion was analyzed using multivariate regression analysis.

RESULTS

Fifty-six patients were included in this study. The mean patient age was 57.1 years, and 55.4% of patients were female. The most commonly affected levels were L4–5 (60.7%) and L5–S1 (30.4%). The average translations measured on flexion standing radiograph, extension standing radiograph, neutral standing radiograph, and supine MRI were 12.5 mm, 11.9 mm, 10.1 mm, and 7.2 mm, respectively. The average difference between flexion and extension standing radiographs was 0.58 mm, with dynamic instability detected in 21.4% of patients. The average difference between neutral standing radiograph and supine MRI was 3.77 mm, with dynamic instability detected in 60.7% of patients. The intraobserver correlation coefficient ranged from 0.77 to 0.90 mm. The interobserver correlation coefficient ranged from 0.79 to 0.86 mm. In 44 patients who underwent decompression and instrumented fusion, the amount of dynamic instability between standing and supine imaging was significantly correlated with change in back pain (p < 0.001) and leg pain (p = 0.05) at the 12-month postoperative follow-up. There was no correlation between amount of dynamic instability between flexion and extension standing radiographs and postoperative back pain and leg pain.

CONCLUSIONS

More patients were found to have dynamic instability by using neutral standing radiograph and supine MRI. In patients who received decompression and instrumented fusion, there was a significant correlation between dynamic instability on neutral standing radiograph and supine MRI and change in back pain and leg pain at 12 months.

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Karim Mithani, Ying Meng, David Pinilla, Nova Thani, Kayee Tung, Richard Leung and Howard J. Ginsberg

A 52-year-old man with a 10-year history of treatment-resistant asthma presented with repeated exacerbations over the course of 10 months. His symptoms were not responsive to salbutamol or inhaled corticosteroid agents, and he developed avascular necrosis of his left hip as a result of prolonged steroid therapy. Physical examination and radiography revealed signs consistent with diffuse idiopathic skeletal hyperostosis (DISH), including a C7–T1 osteophyte causing severe tracheal compression. The patient underwent C6–T1 anterior discectomy and fusion, and the compressive osteophyte was removed, which completely resolved his “asthma.” Postoperative pulmonary function tests showed normalization of his FEV1/FVC ratio, and there was no airway reactivity on methacholine challenge. DISH is a systemic, noninflammatory condition characterized by ossification of spinal entheses, and it can present with respiratory disturbances due to airway compression by anterior cervical osteophytes. The authors present, to the best of their knowledge, the first documented case of asthma as a presentation of DISH.

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Eric Suero Molina, Christian Ewelt, Nils Warneke, Michael Schwake, Michael Müther, Stephanie Schipmann and Walter Stummer

OBJECTIVE

Recent efforts to improve visualization of 5-aminolevulinic acid (5-ALA)–induced protoporphyrin IX (PPIX) fluorescence resulted in a dual-labeling technique, combining it with fluorescein sodium in a prototype setup. Fluorescein identifies regions with blood-brain barrier breakdown in gliomas. However, normally perfused and edematous brain fluoresces unselectively, with strong background enhancement. The aim of this study was to test the feasibility of a novel, integrated filter combination using porphyrins for selective tumor identification and fluorescein for background enhancement.

METHODS

A microscope with a novel built-in filter system (YB 475) for visualizing both fluorescein and 5-ALA–induced porphyrins was used. Resection limits were identified with the conventional BLUE 400 filter system. Six patients harboring contrast ring-enhancing lesions were analyzed.

RESULTS

The complete surgical field could now be illuminated. Fluorescein was helpful for improving background visualization, and enhancing dura, edematous tissue, and cortex. Overlapping regions with both fluorophores harbored merged orange fluorescence. PPIX fluorescence was better visualized, even in areas beyond a normal working distance of approximately 25 cm, where the BLUE 400 filters recognized no or weak fluorescence.

CONCLUSIONS

The novel filter system improved general tissue brightness and background visualization, enhancing fluorescence-guided tumor resection. Furthermore, it appears promising from a scientific perspective, enabling the simultaneous and direct observation of areas with blood-brain barrier breakdown and PPIX fluorescence.

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Ori Barzilai, Lily McLaughlin, Eric Lis, Yoshiya Yamada, Mark H. Bilsky and Ilya Laufer

OBJECTIVE

As patients with metastatic cancer live longer, an increased emphasis is placed on long-term therapeutic outcomes. The current study evaluates outcomes of long-term cancer survivors following surgery for spinal metastases.

METHODS

The study population included patients surgically treated at a tertiary cancer center between January 2010 and December 2015 who survived at least 24 months postoperatively. A retrospective chart and imaging review was performed to collect data regarding patient demographics; tumor histology; type and extent of spinal intervention; radiation data, including treatment dose and field; long-term sequelae, including local tumor control; and reoperations, repeat irradiation, or postoperative kyphoplasty at a previously treated level.

RESULTS

Eighty-eight patients were identified, of whom 44 were male, with a mean age of 61 years. The mean clinical follow-up for the cohort was 44.6 months (range 24.2–88.3 months). Open posterolateral decompression and stabilization was performed in 67 patients and percutaneous minimally invasive surgery in 21. In the total cohort, 84% received postoperative adjuvant radiation and 27% were operated on for progression following radiation. Posttreatment local tumor progression was identified in 10 patients (11%) at the index treatment level and 5 additional patients had a marginal failure; all of these patients were treated with repeat irradiation with 5 patients requiring a reoperation. In total, at least 1 additional surgical intervention was performed at the index level in 20 (23%) of the 88 patients: 11 for hardware failure, 5 for progression of disease, 3 for wound complications, and 1 for postoperative hematoma. Most reoperations (85%) were delayed at more than 3 months from the index surgery. Wound infections or dehiscence requiring additional surgical intervention occurred in 3 patients, all of which occurred more than a year postoperatively. Kyphoplasty at a previously operated level was performed in 3 cases due to progressive fractures.

CONCLUSIONS

Durable tumor control can be achieved in long-term cancer survivors surgically treated for symptomatic spinal metastases with limited complications. Complications observed after long-term follow-up include local tumor recurrence/progression, marginal tumor control failures, early or late hardware complications, late wound complications, and progressive spinal instability or deformity.

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Nils H. Ulrich, Jakob M. Burgstaller, Isaac Gravestock, Giuseppe Pichierri, Maria M. Wertli, Johann Steurer, Mazda Farshad and François Porchet

OBJECTIVE

In this retrospective analysis of a prospective multicenter cohort study, the authors assessed which surgical approach, 1) the unilateral laminotomy with bilateral spinal canal decompression (ULBD; also called “over the top”) or 2) the standard open bilateral decompression (SOBD), achieves better clinical outcomes in the long-term follow-up. The optimal surgical approach (ULBD vs SOBD) to treat lumbar spinal stenosis remains controversial.

METHODS

The main outcomes of this study were changes in a spinal stenosis measure (SSM) symptoms score, SSM function score, and quality of life (sum score of the 3-level version of the EQ-5D tool [EQ-5D-3L]) over time. These outcome parameters were measured at baseline and at 12-, 24-, and 36-month follow-ups. To obtain an unbiased result on the effect of ULBD compared to SOBD the authors used matching techniques relying on propensity scores. The latter were calculated based on a logistic regression model including relevant confounders. Additional outcomes of interest were raw changes in main outcomes and in the Roland and Morris Disability Questionnaire from baseline to 12, 24, and 36 months.

RESULTS

For this study, 277 patients met the inclusion criteria. One hundred forty-nine patients were treated by ULBD, and 128 were treated by SOBD. After propensity score matching, 128 patients were left in each group. In the matched cohort, the mean (95% CI) estimated differences between ULBD and SOBD for change in SSM symptoms score from baseline to 12 months were −0.04 (−0.25 to 0.17), to 24 months −0.07 (−0.29 to 0.15), and to 36 months −0.04 (−0.28 to 0.21). For change in SSM function score, the estimated differences from baseline to 12 months were 0.06 (−0.08 to 0.21), to 24 months 0.08 (−0.07 to 0.22), and to 36 months 0.01 (−0.16 to 0.17). Differences in changes between groups in EQ-5D-3L sum scores were estimated to be −0.32 (−4.04 to 3.40), −0.89 (−4.76 to 2.98), and −2.71 (−7.16 to 1.74) from baseline to 12, 24, and 36 months, respectively. None of the group differences between ULBD and SOBD were statistically significant.

CONCLUSIONS

Both surgical techniques, ULBD and SOBD, may provide effective treatment options for DLSS patients. The authors further determined that the patient outcome results for the technically more challenging ULBD seem not to be superior to those for the SOBD even after 3 years of follow-up.