Paul M. Arnold
Metastatic spinal cord tumors
Mark N. Hadley
Kuniaki Nakahara and Satoru Shimizu
The majority of shunt infections occur within 6 months of shunt placement and chiefly result from perioperative colonization of shunt components by skin flora. Antibiotic-impregnated shunt (AIS) systems have been designed to prevent such colonization. In this study, the authors evaluate the incidence of shunt infection after introduction of an AIS system in a population of children with hydrocephalus.
The authors retrospectively reviewed all pediatric patients who had undergone cerebrospinal fluid (CSF) shunt insertion at their institution over a 3-year period between April 2001 and March 2004. During the 18 months prior to October 2002, all CSF shunts included standard, nonimpregnated catheters. During the 18 months after October 2002, all CSF shunts included antibiotic-impregnated catheters. All patients were followed up for 6 months after shunt surgery, and all shunt-related complications, including shunt infection, were evaluated. The independent association of AIS catheter use with subsequent shunt infection was assessed via multivariate proportional hazards regression analysis.
A total of 211 pediatric patients underwent 353 shunt placement procedures. In the 18 months prior to October 2002, 208 (59%) shunts were placed with nonimpregnated catheters; 145 (41%) shunts were placed with AIS catheters in the 18 months after October 2002. Of patients with nonimpregnated catheters, 25 (12%) experienced shunt infection, whereas only two patients (1.4%) with antibiotic-impregnated catheters experienced shunt infection within the 6-month follow-up period (p < 0.01). Adjusting for intercohort differences via multivariate analysis, AIS catheters were independently associated with a 2.4-fold decreased likelihood of shunt infection.
The AIS catheter significantly reduced incidence of CSF shunt infection in children with hydrocephalus during the early postoperative period (< 6 months). The AIS system used is an effective instrument to prevent perioperative colonization of CSF shunt components.
Surgical management of giant presacral schwannoma: systematic review of published cases and meta-analysis
Presented at the 2019 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves
Zach Pennington, Erick M. Westbroek, A. Karim Ahmed, Ethan Cottrill, Daniel Lubelski, Matthew L. Goodwin and Daniel M. Sciubba
Giant presacral schwannomas are rare sacral tumors found in less than 1 of every 40,000 hospitalizations. Current management of these tumors is based solely upon case reports and small case series. In this paper the authors report the results of a systematic review of the available English literature on presacral schwannoma, focused on identifying the influence of tumor size, tumor morphology, surgical approach, and extent of resection (EOR) on recurrence-free survival and postoperative complications.
The medical literature (PubMed and EMBASE) was queried for reports of surgically managed sacral schwannoma, either involving 2 or more contiguous vertebral levels or with a diameter ≥ 5 cm. Tumor size and morphology, surgical approach, EOR, intraoperative and postoperative complications, and survival data were recorded.
Seventy-six articles were included, covering 123 unique patients (mean age 44.1 ± 1.4 years, 50.4% male). The most common presenting symptoms were leg pain (28.7%), lower back pain (21.3%), and constipation (15.7%). Most surgeries used an open anterior-only (40.0%) or posterior-only (30%) approach. Postoperative complications occurred in 25.6% of patients and local recurrence was noted in 5.4%. En bloc resection significantly improved progression-free survival relative to subtotal resection (p = 0.03). No difference existed between en bloc and gross-total resection (GTR; p = 0.25) or among the surgical approaches (p = 0.66). Postoperative complications were more common following anterior versus posterior approaches (p = 0.04). Surgical blood loss was significantly correlated with operative duration and tumor volume on multiple linear regression (both p < 0.001).
Presacral schwannoma can reasonably be treated with either en bloc or piecemeal GTR. The approach should be dictated by lesion morphology, and recurrence is infrequent. Anterior approaches may increase the risk of postoperative complications.
Ming-Xiang Zou, Jing Li, Xiao-Bin Wang and Guo-Hua Lv
Camilo Molina, Daniel M. Sciubba, Christopher Chaput, P. Justin Tortolani, George I. Jallo and Ryan M. Kretzer
Translaminar screws (TLSs) were originally described as a safer alternative to pedicle and transarticular screw placement at C-2 in adult patients. More recently, TLSs have been used in both the cervical and thoracic spine of pediatric patients as a primary fixation technique and as a bailout procedure when dysplastic pedicle morphology prohibits safe pedicle screw placement. Although authors have reported the anatomical characteristics of the cervical and thoracic lamina in adults as well as those of the cervical lamina in pediatric patients, no such data exist to guide safe TLS placement in the thoracic spine of the pediatric population. The goal of this study was to report the anatomical feasibility of TLS placement in the thoracic spine of pediatric patients.
Fifty-two patients (26 males and 26 females), with an average age of 9.5 ± 4.8 years, were selected by retrospective review of a trauma registry database after institutional review board approval. Study inclusion criteria were an age from 2 to 16 years, standardized axial bone-window CT images of the thoracic spine, and the absence of spinal trauma. For each thoracic lamina the following anatomical features were measured using eFilm Lite software: laminar width (outer cortical and cancellous), laminar height (LH), maximal screw length, and optimal screw trajectory. Patients were stratified by age (an age < 8 versus ≥ 8 years) and sex.
Collected data demonstrate the following general trends as one descends the thoracic spine from T-1 to T-12: 1) increasing laminar width to T-4 followed by a steady decrease to T-12, 2) increasing LH, 3) decreasing maximal screw length, and 4) increasing ideal screw trajectory angle. When stratified by age and sex, male patients older than 8 years of age had significantly larger laminae in terms of both width and height and allowed significantly longer screw placement at all thoracic levels compared with their female counterparts. Importantly, it was found that 78% of individual thoracic laminae, regardless of age or sex, could accept a 4.0-mm screw with 1.0 mm of clearance. As expected, when stratifying by age and sex, it was found that older male patients had the highest acceptance rates.
Data in the present study provide information regarding optimal TLS length, diameter, and trajectory for each thoracic spinal level in pediatric patients. Importantly, the data collected demonstrate no anatomical limitations within the pediatric thoracic spine to TLS instrumentation, although acceptance rates are lower for younger (< 8 years old) and/or female patients. Lastly, given the anatomical variation found in this study, CT scanning can be useful in the preoperative setting when planning TLS use in the thoracic spine of pediatric patients.
Matthew J. McGirt, Frank J. Attenello, Daniel M. Sciubba, Ziya L. Gokaslan and Jean-Paul Wolinsky
✓ Pediatric basilar invagination and cranial settling have traditionally been approached through a transoral–transpharyngeal route with or without extended maxillotomy or mandibulotomy for resection of the anterior portion of C-1 and the odontoid. The authors hypothesize that application of a recently described endoscopic transcervical odontoidectomy (ETO) technique would allow an alternative approach for the treatment of ventral pathological entities at the craniocervical junction in pediatric patients.
The authors performed ETO in a consecutive series of pediatric patients presenting with myelopathy or bulbar dysfunction resulting from basilar invagination or cranial settling. All clinical, radiographic, surgical, and follow-up data were prospectively collected. The initial experience with ETO in the pediatric population is analyzed and outcomes are reported. Three patients required ETO for basilar invagination and 1 required ETO with anterior C-1 arch and distal clivus resection for cranial settling. All patients presented with myelopathy. One patient was wheelchair bound with severe quadriparesis. The mean age was 14 ± 3 years (mean ± standard deviation [SD]) in the 2 male and 2 female patients. The ETO and posterior fusion were performed as a 2-stage procedure in 2 (50%) and as a single-stage procedure in 2 (50%) cases. Prolonged intubation or postoperative placement of a gastrostomy tube was not needed in any case. The postoperative hospitalization lasted 9 ± 4 days (mean ± SD). At last follow-up (mean 5 months), head and neck pain had resolved and motor strength had improved or stabilized in all cases. All 4 children were independently functioning and ambulatory at the last follow-up.
In the authors' initial experience, ETO has allowed ventral brainstem decompression without the need for prolonged intubation, worsening dysphagia requiring enteral tube feeding, or prolonged hospitalization, and has resulted in cosmetically appealing results. The ETO technique allows an alternative approach for the treatment of ventral pathological entities at the craniocervical junction in pediatric patients.
Jean-Paul Wolinsky, Daniel M. Sciubba, Ian Suk and Ziya L. Gokaslan
✓Symptomatic irreducible basilar invagination has traditionally been approached through a transoral–transpharyngeal route with resection of the anterior portion of C-1 and the odontoid. Modification of this exposure with either a Le Fort osteotomy or a transmandibular osteotomy and circumglossal approach has increased the access to pathological conditions in this region. These traditional routes all require traversing the oral cavity and accepting the associated potential complications. The authors have developed a novel surgical approach, an endoscopic transcervical odontoidectomy, which allows access for resection of the odontoid and for brainstem and spinal cord decompression without traversing the oral cavity. In this paper they describe the technique and its advantages and present three cases in which patients underwent the endoscopic transcervical odontoidectomy for basilar invagination.
Three consecutive patients (age range 42–74 years) who had irreducible basilar invagination underwent the endoscopic transcervical odontoidectomy. All were symptomatic and had neck pain and myelopathy. All were evaluated preoperatively and postoperatively with computed tomography and magnetic resonance imaging. In all cases the procedure resulted in complete decompression. There were no serious complications. No patient required prolonged intubation, tracheostomy, or enteral tube feeding. One patient had an intraoperative cerebrospinal fluid leak, which had no postoperative sequelae.
The authors present an alternative surgical approach for treating ventral compression of the brainstem and spinal cord. The technique is safe and effective for decompression and provides a surgical route that can be added to the armamentarium of treatments for pathological conditions in this region.
Risheng Xu, Daniel M. Sciubba, Ziya L. Gokaslan and Ali Bydon
Abnormal ossification of spinal ligaments is a well-known cause of myelopathy in East Asian populations, with ossification of the ligamentum flavum (OLF) and the posterior longitudinal ligament being the most prevalent. In Caucasian populations, OLF is rare, and there has been only 1 documented case of the disease affecting more than 5 spinal levels. In this report, the authors describe the clinical presentation, imaging characteristics, and management of the second published case of a Caucasian man with OLF affecting almost the entire thoracic spine. The literature is then reviewed with regard to OLF epidemiology, pathogenesis, presentation, and treatment.