Glioblastoma multiforme (GBM) is one of the most common and aggressive primary brain tumors, composing 12%–20% of all intracranial tumors in adults. Average life expectancy is merely 12–14 months following initial diagnosis. Patients with this neoplasm have one of the worst 5-year survival rates among all cancers despite aggressive multimodal treatment consisting of maximal tumor resection, radiation therapy, and adjuvant chemotherapy. With recent advancements in management strategies, there has been improvement in the overall trend in patient outcomes; however, recurrence remains nearly inevitable. While most tumors recur locally, metastases to distal locations have become more common. Specifically, the last decade has seen an increased incidence of spinal metastases, representing an emerging complication in patients with intracranial GBM. However, the literature regarding prevention strategies and the presentation of spinal metastases has remained scarce. As local control of primary lesions continues to improve, more cases of spinal metastases are likely to be seen. In this review the authors present a new case of metastatic GBM to the L-5 nerve root, and they summarize previous cases of intracranial GBM with leptomeningeal spinal metastatic disease. They also characterize key features of this disease presentation and discuss areas of future investigation necessary for enhanced prevention and treatment of this complication.
Cort D. Lawton, Daniel T. Nagasawa, Isaac Yang, Richard G. Fessler and Zachary A. Smith
Nader S. Dahdaleh, Alexander T. Nixon, Cort D. Lawton, Albert P. Wong, Zachary A. Smith and Richard G. Fessler
Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is used to treat a wide variety of lumbar degenerative disorders. Although there are some reports showing efficacy of unilateral instrumentation during MIS-TLIF, a controlled randomized prospective study has not been done.
Forty-one patients were randomly assigned to receive either bilateral or unilateral instrumentation following 1-level unilateral MIS-TLIF. Four patients were lost to follow-up in the unilateral group and 1 patient was lost to follow-up in the bilateral group. Preoperative and postoperative scores on a visual analog scale (VAS) for back pain and leg pain (VAS-BP and VAS-LP, respectively), Oswestry Disability Index (ODI), and 36-Item Short Form Healthy Survey version 2 (SF-36v2) were collected. Additionally, preoperative and postoperative segmental Cobb angles and radiographic evidence of fusion were analyzed.
There was no statistically significant difference in baseline demographic characteristics between the 2 groups. The VAS-BP, VAS-LP, ODI, and SF-36v2 physical component scores improved significantly after surgery in both groups (p < 0.05); there was no statistically significant between-groups difference in the degree of improvement. Blood loss was significantly higher in the bilateral instrumentation group and hospital stay was longer in the unilateral instrumentation group. There was no statistically significant between-groups difference with respect to change in segmental lordosis or fusion rate. The average duration of follow-up was 12.4 months for the bilateral instrumentation group and 11.4 months for the unilateral instrumentation group.
Clinical and radiographic outcomes of unilateral and bilateral instrumentation for unilateral MISTLIF are similar 1 year after surgery.
Nader S. Dahdaleh, Cort D. Lawton, Tarek Y. El Ahmadieh, Alexander T. Nixon, Najib E. El Tecle, Sanders Oh, Richard G. Fessler and Zachary A. Smith
Evidence-based medicine is used to examine the current treatment options, timing of surgical intervention, and prognostic factors in the management of patients with traumatic central cord syndrome (TCCS).
A computerized literature search of the National Library of Medicine database, Cochrane database, and Google Scholar was performed for published material between January 1966 and February 2013 using key words and Medical Subject Headings. Abstracts were reviewed and selected, with the articles segregated into 3 main categories: surgical versus conservative management, timing of surgery, and prognostic factors. Evidentiary tables were then assembled, summarizing data and quality of evidence (Classes I–III) for papers included in this review.
The authors compiled 3 evidentiary tables summarizing 16 studies, all of which were retrospective in design. Regarding surgical intervention versus conservative management, there was Class III evidence to support the superiority of surgery for patients presenting with TCCS. In regards to timing of surgery, most Class III evidence demonstrated no difference in early versus late surgical management. Most Class III studies agreed that older age, especially age greater than 60–70 years, correlated with worse outcomes.
No Class I or Class II evidence was available to determine the efficacy of surgery, timing of surgical intervention, or prognostic factors in patients managed for TCCS. Hence, there is a need to perform well-controlled prospective studies and randomized controlled clinical trials to further investigate the optimal management (surgical vs conservative) and timing of surgical intervention in patients suffering from TCCS.
Albert P. Wong, Zachary A. Smith, Alexander T. Nixon, Cort D. Lawton, Nader S. Dahdaleh, Ricky H. Wong, Brenda Auffinger, Sandi Lam, John K. Song, John C. Liu, Tyler R. Koski and Richard G. Fessler
Transforaminal lumbar interbody fusion (TLIF) has become one of the preferred procedures for circumferential fusion in the lumbar spine. Over the last decade, advances in surgical techniques have enabled surgeons to perform the TLIF procedure through a minimally invasive approach (MI-TLIF). There are a few studies reported in the medical literature in which perioperative complication rates of MI-TLIF were evaluated; here, the authors present the largest cohort series to date. They analyzed intraoperative and perioperative complications in 513 consecutive MI-TLIF–treated patients with lumbar degenerative disc disease.
The authors performed a retrospective review of prospectively collected data on 513 consecutive patients treated over a 10-year period for lumbar degenerative disc disease using MI-TLIF. All patients undergoing either a first-time or revision 1- or 2-level MI-TLIF procedure were included in the study. Demographic, intraoperative, and perioperative data were collected and analyzed using bivariate analyses (Student t-test, analysis of variance, odds ratio, chi-square test) and multivariate analyses (logistic regression).
A total of 513 patients underwent an MI-TLIF procedure, and the perioperative complication rate was 15.6%. The incidence of durotomy was 5.1%, and the medical and surgical infection rates were 1.4% and 0.2%, respectively. A statistically significant increase in the infection rate was seen in revision MI-TLIF cases, and the same was found for the perioperative complication rate in multilevel MI-TLIF cases. Instrumentation failure occurred in 2.3% of the cases. After analysis, no statistically significant difference was seen in the rates of durotomy during revision and multilevel surgeries. There was no significant difference between the complication rates when stratified according to presenting diagnosis.
To the authors' knowledge, this is the largest study of perioperative complications in MI-TLIF in the literature. A total of 513 patients underwent MI-TLIF (perioperative complication rate 15.6%). The most common complication was a durotomy (5.1%), and there was only 1 surgical wound infection (0.2%). There were significantly more perioperative infections in revision MI-TLIF cases and more perioperative complications in multilevel MI-TLIF cases. The results of this study suggest that MI-TLIF has a similar or better perioperative complication profile than those documented in the literature for open-TLIF treatment of degenerative lumbar spine disease.
Albert P. Wong, Rishi R. Lall, Nader S. Dahdaleh, Cort D. Lawton, Zachary A. Smith, Ricky H. Wong, Michael J. Harvey, Sandi Lam, Tyler R. Koski and Richard G. Fessler
Patients with symptomatic intradural-extramedullary (ID-EM) tumors may be successfully treated with resection of the lesion and decompression of associated neural structures. Studies of patients undergoing open resection of these tumors have reported high rates of gross-total resection (GTR) with minimal long-term neurological deficit. Case reports and small case series have suggested that these patients may be successfully treated with minimally invasive surgery (MIS). These studies have been limited by small patient populations. Moreover, there are no studies directly comparing perioperative outcomes between patients treated with open resection and MIS. The objective of this study was to compare perioperative outcomes in patients with ID-EM tumors treated using open resection or MIS.
A retrospective review was performed using data collected from 45 consecutive patients treated by open resection or MIS for ID-EM spine tumors. These patients were treated over a 9-year period between April 2003 and October 2012 at Northwestern University and the University of Chicago. Statistical analysis was performed to compare perioperative outcomes between the two groups.
Of the 45 patients in the study, 27 were treated with the MIS approach and 18 were treated with the open approach. Operative time was similar between the two groups: 256.3 minutes in the MIS group versus 241.1 minutes in the open group (p = 0.55). Estimated blood loss was significantly lower in the MIS group (133.7 ml) compared with the open group (558.8 ml) (p < 0.01). A GTR was achieved in 94.4% of the open cases and 92.6% of the MIS cases (p = 0.81).
The mean hospital stay was significantly shorter in the MIS group (3.9 days) compared with the open group (6.1 days) (p < 0.01). There was no significant difference between the complication rates (p = 0.32) and reoperation rates (p = 0.33) between the two groups. Multivariate analysis demonstrated an increased rate of complications in cervical spine tumors (OR 15, p = 0.05).
Thoracolumbar ID-EM tumors may be safely and effectively treated with either the open approach or an MIS approach, with an equivalent rate of GTR, perioperative complication rate, and operative time. Patients treated with an MIS approach may benefit from a decrease in operative blood loss and shorter hospital stays.