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Yoon-Hee Cha, John H. Chi and Nicholas M. Barbaro

✓ Spinal subdural hematomas (SDHs) are a rare cause of cord compression and typically occur in the setting of spinal instrumentation or coagulopathy. The authors report the first case of a spontaneous spinal SDH occurring in conjunction with low-molecular-weight heparin use in a patient with a history of spinal radiotherapy.

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Nicholas M. Barbaro

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Brian T. Andrews, Philip R. Weinstein, Mark L. Rosenblum and Nicholas M. Barbaro

✓ Five patients had intradural arachnoid cysts of the thoracic spinal canal associated with syringomyelia or posttraumatic intramedullary spinal cord cysts. Three cases were diagnosed 6 to 18 years after spinal surgery and two 14 to 17 years after spinal cord trauma. In each case, delayed progression of symptoms led to the identification of the lesions. The diagnosis was assisted by the use of myelography and delayed computerized tomography scanning in two cases and by magnetic resonance imaging in all five. In each case, the arachnoid cyst appeared to compress the spinal cord or nerve roots; in three cases, the syrinx cavities appeared to exert a significant mass effect. In the two trauma-related cases, the intramedullary cysts were small and may have represented areas of cystic myelomalacia. In four cases, intraoperative real-time ultrasonography helped to localize the arachnoid and intramedullary cavities. All five patients were treated by fenestration of the arachnoid cyst; additional peritoneal shunting of the cyst was performed in one case and of the intramedullary cavity in three. In one patient, the two lesions appeared to have a balancing effect; after drainage of the arachnoid cyst, the syrinx cavity expanded and had to be treated separately. The neurological deficits were reduced in four patients and stabilized in one. Intradural arachnoid cysts and intramedullary cysts may occur together as a late complication of spinal surgery or spinal cord trauma, and either or both lesions may cause delayed neurological deterioration.

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Nicholas M. Barbaro

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Devin K. Binder, Justin S. Smith and Nicholas M. Barbaro

Object

The authors report on the treatment of primary brachial plexus tumors in 25 patients at the University of California, San Francisco. They compare their findings with those obtained in similar series.

Methods

The authors reviewed the electronic and medical records, radiological images, operative reports, and pathological findings in 25 consecutive cases of primary brachial plexus tumors. Cases of metastatic lesions or adjacent neoplasms extending into and involving the brachial plexus were excluded.

At presentation patients ranged in age from 19 to 71 years (mean 47 ±15 years), and neurofibromatosis was present in eight patients (32%). Presenting signs and symptoms included palpable mass (60%), numbness/paresthesias (44%), radiating pain (44%), local pain (16%), and weakness (12%). Duration of symptoms ranged from 2 months to 10 years. Neuroimaging revealed lesions ranging widely in size (volume ~1 to >100 ml). Pathological diagnoses included schwannoma (15 [60%]), neurofibroma (five [20%]), malignant peripheral nerve sheath tumor (four [16%]), and desmoid tumor (one [4%]).

Conclusions

Primary tumors arising in the brachial plexus are rare. Careful workup, surgical technique, and attention to pathological diagnosis optimize management.

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Adam N. Mamelak, Nicholas M. Barbaro, John A. Walker and Kenneth D. Laxer

✓ Corpus callosotomy is valuable for controlling medically intractable generalized seizures in appropriate patients, but postoperative development of language disorders, neuropsychological impairment, and motor dysfunction have all been noted. The extent of callosum resection has been implicated as a possible determinant of outcome, but this hypothesis has not been formally tested. Analysis of the records of all patients who underwent corpus callosotomy at the University of California, San Francisco, from 1986 to 1991 showed that, of 15 patients who underwent anterior or complete callosotomy, seven were entirely or nearly seizure-free, four had at least a 50% reduction in seizure frequency, and four had no change.

To determine callosal size and extent of callosotomy, preoperative and postoperative magnetic resonance images were measured with computer-based planimetry. Seizure outcome was not significantly associated with preoperative callosal size or extent of callosotomy. Intelligence quotient scores did not change significantly after callosotomy. No severe neuropsychological deficits developed after anterior or complete callosotomy, even in patients with mixed cerebral dominance or bilateral language representation. These results indicate that division of the anterior one-half to two-thirds of the corpus callosum is nearly as effective as more extensive anterior sectioning or complete callosotomy in reducing drop-attack and generalized tonic-clonic seizures in appropriate patients, and that the extent of callosotomy is not an important factor on outcome when at least 50% to 65% of the callosum is divided. Mixed cerebral dominance and other unusual patterns of language and memory organization do not appear to increase the postoperative risk for neuropsychological deficits, regardless of the extent of anterior section.

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Devin K. Binder, Daniel C. Lu and Nicholas M. Barbaro

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Vincent Y. Wang, Edward F. Chang and Nicholas M. Barbaro

Focal cortical dysplasia (FCD) is found in approximately one-half of patients with medically refractory epilepsy. These lesions may involve only mild disorganization of the cortex, but they may also contain abnormal neuronal elements such as balloon cells. Advances in neuroimaging have allowed better identification of these lesions, and thus more patients have become surgical candidates. Molecular biology techniques have been used to explore the genetics and pathophysiological characteristics of FCD. Data from surgical series have shown that surgery often results in significant reduction or cessation of seizures, especially if the entire lesion is resected.

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Tejas Sankar and Andres M. Lozano

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Nicolas W. Villelli, Hong Yan, Jian Zou and Nicholas M. Barbaro

OBJECTIVE

Several similarities exist between the Massachusetts health care reform law of 2006 and the Affordable Care Act (ACA). The authors’ prior neurosurgical research showed a decrease in uninsured surgeries without a significant change in surgical volume after the Massachusetts reform. An analysis of the payer-mix status and the age of spine surgery patients, before and after the policy, should provide insight into the future impact of the ACA on spine surgery in the US.

METHODS

Using the Massachusetts State Inpatient Database and spine ICD-9-CM procedure codes, the authors obtained demographic information on patients undergoing spine surgery between 2001 and 2012. Payer-mix status was assigned as Medicare, Medicaid, private insurance, uninsured, or other, which included government-funded programs and workers’ compensation. A comparison of the payer-mix status and patient age, both before and after the policy, was performed. The New York State data were used as a control.

RESULTS

The authors analyzed 81,821 spine surgeries performed in Massachusetts and 248,757 in New York. After 2008, there was a decrease in uninsured and private insurance spine surgeries, with a subsequent increase in the Medicare and “other” categories for Massachusetts. Medicaid case numbers did not change. This correlated to an increase in surgeries performed in the age group of patients 65–84 years old, with a decrease in surgeries for those 18–44 years old. New York showed an increase in all insurance categories and all adult age groups.

CONCLUSIONS

After the Massachusetts reform, spine surgery decreased in private insurance and uninsured categories, with the majority of these surgeries transitioning to Medicare. Moreover, individuals who were younger than 65 years did not show an increase in spine surgeries, despite having greater access to health insurance. In a health care system that requires insurance, the decrease in private insurance is primarily due to an increasing elderly population. The Massachusetts model continues to show that this type of policy is not causing extreme shifts in the payer mix, and suggests that spine surgery will continue to thrive in the current US health care system.