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Jonathan J. Stone, Corey T. Walker, Maxwell Jacobson, Valerie Phillips and Howard J. Silberstein

Object

Ventriculoperitoneal (VP) shunt placement remains the mainstay treatment for pediatric hydrocephalus. These devices have a relatively high complication and failure rate, often requiring multiple revisions. The authors present a single institution's experience of pediatric patients treated with VP shunts. With an average follow-up time of 20 years, this study is among the longest reports of VP shunt revision in the literature to date. Hydrocephalus origins, shunt revision rates, and causes of shunt failure are described. Patients who underwent their first shunt revision more than 10 years after initial shunt placement were also explored.

Methods

A retrospective chart review was performed on all pediatric patients who underwent VP shunt placement from January 1990 through November 1996 at the University of Rochester Medical Center. Only patients who had at least 15 years of follow-up since their initial shunting procedure were included.

Results

A total of 234 procedures were performed on 64 patients, with a mean follow-up of 19.9 years. Patients ranged from a few days to 17.2 years old when they received their original shunt, with a median age of 4 months; 84.5% of the patients required 1 or more shunt revisions and 4.7% required 10 or more. Congenital defects, Chiari Type II malformations, tumors, and intraventricular hemorrhage were the most common causes of hydrocephalus. Overall, patients averaged 2.66 revisions, with proximal (27%) and distal (15%) catheter occlusion, disconnection (11%), and infection (9%) comprising the most common reasons for shunt malfunction. Notably, 12.5% of patients did not require their first shunt revision until more than 10 years after initial device placement, a previously undescribed finding due to the short follow-up duration in previous studies.

Conclusions

This long-term retrospective analysis of pediatric VP shunt placement revealed a relatively high rate of complications with need for shunt revision as late as 17 years after initial placement. Catheter occlusion represented a significant percentage of shunt failures. Cerebrospinal fluid shunting has a propensity for mechanical failure and patients with VP shunts should receive follow-up through the transition to adulthood.

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Corey T. Walker, M. Yashar S. Kalani, Mark E. Oppenlander, Jakub Godzik, Nikolay L. Martirosyan, Robert J. Standerfer and Nicholas Theodore

OBJECTIVE

The authors report a novel paradigm for resection of the disc or dural complex to treat giant calcified transdural herniated thoracic discs, and they describe a technique for the repair of dural defects. These herniated thoracic discs are uncommon, complicated lesions that often require a multidisciplinary team for effective treatment. The intradural component must be removed to effectively decompress the spinal cord. The opening of the friable dura mater, which frequently adheres to the extradural component of the disc, can result in large defects and difficult-to-manage CSF leaks.

METHODS

The authors performed a retrospective study of the technique and outcomes in patients with a transdural herniated disc treated at St. Joseph’s Hospital and Medical Center within a 4-year period between 2012 and 2015.

RESULTS

During the study period, 7 patients (mean age 56.1 years) presented to the department of neurosurgery with clinical symptoms consistent with myeloradiculopathy. In all cases, 2-level corpectomies of the involved levels were combined with circumferential resection of the dura and complete decompression of the spinal cord. The dural defect was repaired with an onlay dural patch, and a large piece of AlloDerm (LifeCell Corp) graft was sewn to close the pleural defect. Every patient had a perioperative lumbar drain placed for CSF diversion. No patient suffered neurological decline related to the surgery, and 3 patients experienced clinically significant improvement in function. Two patients developed an early postoperative CSF leak that required operative revision to oversew the defects.

CONCLUSIONS

This novel technique for decompression of the spinal cord by dural resection for the removal of giant calcified transdural herniated thoracic discs is safe and results in excellent decompression of the spinal cord. The technique becomes necessary when primary repair of the dura is not possible, and it can be used in cases in which the resection of pathology includes the dura.

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Corey T. Walker, S. Harrison Farber, Tyler S. Cole, David S. Xu, Jakub Godzik, Alexander C. Whiting, Cory Hartman, Randall W. Porter, Jay D. Turner and Juan Uribe

OBJECTIVE

Minimally invasive anterolateral retroperitoneal approaches for lumbar interbody arthrodesis have distinct advantages attractive to spine surgeons. Prepsoas or transpsoas trajectories can be employed with differing complication profiles because of the inherent anatomical differences encountered in each approach. The evidence comparing them remains limited because of poor quality data. Here, the authors sought to systematically review the available literature and perform a meta-analysis comparing the two techniques.

METHODS

A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A database search was used to identify eligible studies. Prepsoas and transpsoas studies were compiled, and each study was assessed for inclusion criteria. Complication rates were recorded and compared between approach groups. Studies incorporating an analysis of postoperative subsidence and pseudarthrosis rates were also assessed and compared.

RESULTS

For the prepsoas studies, 20 studies for the complications analysis and 8 studies for the pseudarthrosis outcomes analysis were included. For the transpsoas studies, 39 studies for the complications analysis and 19 studies for the pseudarthrosis outcomes analysis were included. For the complications analysis, 1874 patients treated via the prepsoas approach and 4607 treated with the transpsoas approach were included. In the transpsoas group, there was a higher rate of transient sensory symptoms (21.7% vs 8.7%, p = 0.002), transient hip flexor weakness (19.7% vs 5.7%, p < 0.001), and permanent neurological weakness (2.8% vs 1.0%, p = 0.005). A higher rate of sympathetic nerve injury was seen in the prepsoas group (5.4% vs 0.0%, p = 0.03). Of the nonneurological complications, major vascular injury was significantly higher in the prepsoas approach (1.8% vs 0.4%, p = 0.01). There was no difference in urological or peritoneal/bowel injury, postoperative ileus, or hematomas (all p > 0.05). A higher infection rate was noted for the transpsoas group (3.1% vs 1.1%, p = 0.01). With regard to postoperative fusion outcomes, similar rates of subsidence (12.2% prepsoas vs 13.8% transpsoas, p = 0.78) and pseudarthrosis (9.9% vs 7.5%, respectively, p = 0.57) were seen between the groups at the last follow-up.

CONCLUSIONS

Complication rates vary for the prepsoas and transpsoas approaches owing to the variable retroperitoneal anatomy encountered during surgical dissection. While the risks of a lasting motor deficit and transient sensory disturbances are higher for the transpsoas approach, there is a reciprocal reduction in the risks of major vascular injury and sympathetic nerve injury. These results can facilitate informed decision-making and tailored surgical planning regarding the choice of minimally invasive anterolateral access to the spine.

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Corey T. Walker, Chiazo S. Amene, Jeffrey S. Pannell, David R. Santiago-Dieppa, Robert C. Rennert, Lawrence A. Hansen and Alexander A. Khalessi

The differential diagnosis of spinal tumors is guided by anatomical location and imaging characteristics. Diagnosis of rare tumors is made challenging by abnormal features. The authors present the case of a 47-year-old woman who presented with progressive subacute right lower-extremity weakness and numbness of the right thigh. Physical examination further revealed an extensor response to plantar reflex on the right and hyporeflexia of the right Achilles and patellar reflexes. Magnetic resonance imaging of the lumbar spine demonstrated an 8-mm intramedullary exophytic nodule protruding into a hematoma within the conus medullaris. Spinal angiography was performed to rule out an arteriovenous malformation, and resection with hematoma evacuation was completed. Pathological examination of the resected mass demonstrated a spindle cell neoplasm with dense bundles of collagen. Special immunostaining was performed and a diagnosis of solitary fibrous tumor (SFT) was made. SFTs are mesenchymally derived pleural neoplasms, which rarely present at other locations of the body, but have been increasingly described to occur as primary neoplasms of the spine and CNS. The authors believe that this case is unique in its rare location at the level of the conus, and also that this is the first report of a hemorrhagic SFT in the spine. Therefore, with this report the authors add to the literature the fact that this variant of an increasingly understood but heterogeneous tumor can occur, and therefore should be considered in the differential of clinically similar tumors.