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Daniel Couture and Charles L. Branch Jr.

Spinal pseudomeningoceles and cerebrospinal fluid (CSF) fistulas are rare extradural collections of CSF that result following a breach in the dural–arachnoid layer. They may occur due to an incidental durotomy, during intradural surgery, or from trauma or congenital abnormality. The majority are iatrogenic and occur in the posterior lumbar region following surgery. Although they are often asymptomatic, they may cause low-back pain, headaches, and even nerve root entrapment. Leakage of CSF from the wound may cause a fistulous tract, which is a conduit for infection and should be repaired immediately.

Diagnosis can be confirmed on clinical examination or imaging studies including magnetic resonance imaging, computerized tomography myelography, and radionuclide myelography. Treatment must be specific to each patient because the timing, size, symptoms, and location of the dural breach all affect the choice of therapy. Nonsurgical methods may be used, but more frequently operative repair is required.

In this article, the authors review the diagnosis and treatment of spinal pseudomeningoceles and CSF fistulas.

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Daniel E. Couture and Charles L. Branch Jr.

Object

The goal of this prospective study was to review a series of 27 patients who underwent bilateral posterior lumbar interbody fusion with instrumented pedicle fixation and two HYDROSORB (known generically as 70:30 poly[L-lactide-co-D,L-lactide]) rectangular cages packed with locally harvested autograft at a total of 48 levels, and to assess the safety and efficacy of this novel technique. This analysis, conducted at a mean of 26 months of follow up, is the first report of a long-term evaluation of this technique. Fusion rates and clinical outcomes are presented.

Methods

A prospective clinical and radiographic review of findings in 27 consecutive patients was performed. Fusion rates and clinical outcome were assessed at 6-month intervals up to the 32-month follow-up end point. Two patients with four corresponding fusion levels were lost to follow up.

Radiographic evidence of satisfactory fusion was achieved in 42 (95.5%) of 44 levels fused. Satisfactory fusion at all levels was achieved in 23 (92%) of 25 patients. Two patients required repeated operations for treatment of symptomatic pseudarthrosis during the study period. The likelihood of all levels attaining fusion in a given patient decreased as the number of levels treated increased, which is consistent with previously published studies. Nonetheless, fusion rates per treated level were similar for patients in whom one to three levels were treated. No significant surgical complication occurred.

Conclusions

Posterior lumbar interbody fusion in which the HYDROSORB bioabsorbable implant packed with locally harvested autograft and segmental internal fixation are used appears to be an interbody fusion alternative whose efficacy is comparable with previously reported procedures.

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James L. West, Kyle M. Fargen, Wesley Hsu, Charles L. Branch Jr. and Daniel E. Couture

Global access to neurosurgical care is still a work in progress, with many patients in low-income countries not able to access potentially lifesaving neurosurgical procedures. “Big Data” is an increasingly popular data collection and analytical technique predicated on collecting large amounts of data across multiple data sources and types for future analysis. The potential applications of Big Data to global outreach neurosurgery are myriad: from assessing the overall burden of neurosurgical disease to planning cost-effective improvements in access to neurosurgical care, and collecting data on conditions which are rare in developed countries. Although some global neurosurgical outreach programs have intelligently implemented Big Data principles in their global neurosurgery initiatives already, there is still significant progress that remains to be made. Big Data has the potential to drive the efficient improvement of access to neurosurgical care across low- and medium-income countries.

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Christopher J. Balamucki, Volker W. Stieber, Thomas L. Ellis, Stephen B. Tatter, Allan F. DeGuzman, Kevin P. McMullen, James Lovato, Edward G. Shaw, Kenneth E. Ekstrand, J. Daniel Bourland, Michael T. Munley, Michael Robbins and Charles Branch

Object

Gamma Knife surgery (GKS) is a treatment option for patients with refractory typical trigeminal neuralgia (TN), TN with atypical features, and atypical types of facial pain. The Gamma Knife’s 201 60Co sources decay with a half-life of 5.26 years. The authors examined whether the decrease in dose rate over 4.6 years between Co source replacements affected the control rates of facial pain in patients undergoing GKS.

Methods

The authors collected complete follow-up data on 239 of 326 GKS procedures performed in patients with facial pain. Patients were classified by their type of pain. The isocenter of a 4-mm collimator helmet was targeted at the proximal trigeminal nerve root, and the dose (80–90 Gy) was prescribed at the 100% isodose line. Patients reported the amount of pain control following radiosurgery by answering a standardized questionnaire.

Eighty percent of patients experienced greater than 50% pain relief, and 56% of patients experienced complete pain relief after GKS. Neither dose rate nor treatment time was significantly associated with either the control rate or degree of pain relief. A significant association between the type of facial pain and the pain control rate after GKS was observed (p < 0.001; Pearson chi-square test).

In their statistical analysis, the authors accounted for changes in prescription dose over time to prevent the dose rate from being a confounding variable. There was no observable effect of the dose rate or of the treatment duration within the typical period to source replacement.

Conclusions

Patients with facial pain appear to receive consistent treatment with GKS at any time during the first half-life of the Co sources.