Isthmic spondylolisthesis, which is demonstrated in 4 to 8% of the general population, is one of the most common types of spondylolisthesis. The three subtypes of this condition all manifest some variation of a pars interarticularis defect as a result of recurrent injury to that structure. A multifactorial origin is postulated for this disease; mechanical, hereditary, and hormonal factors are believed to play a role. Presenting signs and symptoms may include those referable to neurological compromise or those related to the spinal deformity. The majority of patients with spondylolysis and spondylolisthesis respond to conservative, nonoperative treatment. Pain, neurological compromise, and cosmetic defects unresponsive to traditional therapies may require surgical intervention. Surgical options include any combination of the following: neural decompression, bone fusion, instrument-assisted fusion, and reduction. In this paper, the natural history and treatment options are presented, and the supporting literature is reviewed.
Anil K. Roy, Nicholas P. Slimack and Aruna Ganju
A syrinx is a fluid-filled cavity within the spinal cord that can be an incidental finding or it can be accompanied by symptoms of pain and temperature insensitivity. Although it is most commonly associated with Chiari malformation Type I, the advancement of imaging techniques has resulted in more incidental idiopathic syringes that are not associated with Chiari, tumor, trauma, or postinfectious causes. The authors present a comprehensive review and management strategies for the idiopathic variant of syringomyelia.
The authors retrospectively identified 8 idiopathic cases of syringomyelia at their institution during the last 6 years. A PubMed/Medline literature review yielded an additional 38 articles.
Two of the authors' patients underwent surgical treatment that included a combination of laminectomy, lysis of adhesions, duraplasty, and syrinx fenestration. The remaining 6 patients were treated conservatively and had neurologically stable outcomes. Review of the literature suggests that an etiology-driven approach is essential in the diagnosis and management of syringomyelia, although conservative management suffices for most cases. In particular, it is important to look at disturbances in CSF flow, as well as structural abnormalities including arachnoid webs, cysts, scars, and a diminutive posterior fossa.
The precise etiology for idiopathic syringomyelia (IS) is still unclear, although conceptual advances have been made toward the overall understanding of the pathophysiology of IS. Various theories include the cerebellar piston theory, intramedullary pulse pressure theory, and increased spinal subarachnoid pressure. For most patients with IS, conservative management works well. Continued progression of symptoms, however, could be approached using decompressive strategies such as laminectomy, lysis of adhesions, and craniocervical decompression, depending on the level of pathology. Management for patients with progressive neurological dysfunction and the lack of flow disturbance is unclear, although syringosubarachnoid shunting can be considered.
Aruna Ganju, Norbert Roosen, David G. Kline and Robert L. Tiel
Object. The authors conducted a retrospective study of 107 consecutive patients with 111 brachial plexus tumors surgically treated at the Louisiana State University Health Sciences Center (LSUHSC).
Methods. During a 12-year period, from 1986 to 1998, 371 patients with lesions of the brachial plexus underwent surgery at LSUHSC. Among this group, 107 patients harbored 111 tumors of the brachial plexus. Neural sheath tumors were the most commonly found and included 33 neurofibromas (20 of which were associated with von Recklinghausen disease), 36 schwannomas, and 12 malignant neural sheath tumors. Of the non—neural sheath tumors, 13 were benign and 17 were malignant. Presenting symptoms included pain (59%), palpable mass (52%), paresthesias (30%), and paresis (29%).
Anterior supraclavicular (82%) or posterior subscapular (18%) approaches were used to achieve gross-total (79%) or subtotal (21%) resection of tumor. The average follow-up period was 38.3 months or 3.2 years.
Seventy percent of patients with benign neural sheath tumors became free from pain postoperatively or reported improvement in their preoperative pain status. Function remained intact or improved in 50% and remained stable postoperatively in another 20% of cases.
Preservation of function was more likely in patients who presented intact and in those who had not undergone a previous attempted biopsy procedure or resection than in those in whom such manipulation had occurred.
Conclusions. Resection of most plexal tumors is technically feasible and associated with acceptable morbidity and mortality rates.
Patrick Shih, Ryan J. Halpin, Aruna Ganju, John C. Liu and Tyler R. Koski
Recurrent tethered cord syndrome (TCS) can lead to significant progressive disability in adults. The diagnosis of TCS is made with a high degree of clinical suspicion. In the adult population, many patients receive inadequate care unless they are seen at a multidisciplinary clinic. Successful detethering procedures require careful intradural dissection and meticulous wound and dural closure. With multiple revision procedures, vertebral column shortening has become an appropriate alternative to surgical detethering.
Devon Hoover, Aruna Ganju, Christopher I. Shaffrey, Henry Bartkowski and Michael J. Rauzzino
Jamal McClendon Jr., Patrick A. Sugrue, Aruna Ganju, Tyler R. Koski and John C. Liu
The management of thoracic ossification of the posterior longitudinal ligament has been studied by many spinal surgeons. Indications for operative intervention include progressive radiculopathy, myelopathy, and neurological deterioration. The ideal surgery for decompression remains highly debatable as various methods of surgical treatment of ossification of the posterior longitudinal ligament have been devised. Although numerous modifications to the 3 main approaches have been identified (anterior, posterior, or lateral), the indication for each depends on the nature of compression, the morphology of the lesion, the level of the compression, the structural alignment of the spine, and the neurological status of the patient. The authors discuss treatment techniques for thoracic ossification of the posterior longitudinal ligament, cite case examples from a single institution, and review the literature.
Matthew Walker, Saquib Khawar, Ali Shaibani, Sireen Reddy, Aruna Ganju and Manu Gupta
✓ Intramedullary spinal cord surgery can disrupt the blood—spinal cord barrier and cause intravascular contents to leak into the surgical cavity. Immediate postoperative Gd-enhanced magnetic resonance (MR) imaging can demonstrate leakage of contrast into the surgical bed and complicate the assessment of whether a residual enhancing tumor is present. The authors report a case in which the preoperative lesion was nonenhancing and not expected to enhance on postoperative imaging. A Gd-enhanced MR imaging study obtained less than 24 hours after surgery revealed that the intramedullary surgical cavity was filled with contrast material. Because of the time course and the lesion's preoperative appearance, this “enhancement” was known to be caused by the leakage of medium into the resection cavity rather than of pathological soft-tissue enhancement
Ralph G. Dacey Jr.
Mario J. Cardoso, Tyler R. Koski, Aruna Ganju and John C. Liu
The surgical management of compressive cervical ossification of the posterior longitudinal ligament (OPLL) can be challenging. Traditionally, approach indications for decompression of cervical spondylotic myelopathy have been used. However, the postoperative complication profile after cervical OPLL decompression is unique and may require an alternative approach paradigm. The authors review the literature on approach-related OPLL complications and suggest a management strategy for patients with single- or multiple-segment OPLL with or without greater than 50% canal stenosis.
Sunit Das, Aruna Ganju, Robert L. Tiel and David G. Kline
✓Tumors of the brachial plexus are relatively rare and present a clinical challenge for the neurosurgeon. The management of these tumors therefore requires not only an understanding of the complex anatomy of the brachial plexus but also an appreciation of the appropriate surgical approach to the various tumors that may be encountered. Over a 30-year period (1969–1999), 226 patients with brachial plexus tumors were evaluated and surgically treated by the senior authors (R.L.T., D.G.K.). In the present paper they review the most common benign and malignant brachial plexus tumors and discuss management and surgical principles established through their experience at the Louisiana State University Health Sciences Center.