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Paul M. Arnold

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Editorial

Metastatic spinal cord tumors

Mark N. Hadley

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Ming-Xiang Zou, Jing Li, Xiao-Bin Wang and Guo-Hua Lv

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Kuniaki Nakahara and Satoru Shimizu

Object

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.

Methods

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.

Conclusions

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.

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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

OBJECTIVE

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

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Camilo Molina, C. Rory Goodwin, Nancy Abu-Bonsrah, Benjamin D. Elder, Rafael De la Garza Ramos and Daniel M. Sciubba

Surgical interventions for spinal metastasis are commonly performed for mechanical stabilization, pain relief, preservation of neurological function, and local tumor reduction. Although multiple surgical approaches can be used for the treatment of metastatic spinal lesions, posterior approaches are commonly performed. In this study, the role of posterior surgical procedures in the treatment of spinal metastases was reviewed, including posterior laminectomy with and without instrumentation for stabilization, transpedicular corpectomy, and costotransversectomy. A review of the literature from 1980 to 2015 was performed using Medline, as was a review of the bibliographies of articles meeting preset inclusion criteria, to identify studies on the role of these posterior approaches among adults with spinal metastasis. Thirty-four articles were ultimately analyzed, including 1 randomized controlled trial, 6 prospective cohort studies, and 27 retrospective case reports and/or series. Some of the reviewed articles had Level II evidence indicating that laminectomy with stabilization can be recommended for improvement in neurological outcome and reduction of pain in selected patients. However, the use of laminectomy alone should be carefully considered. Additionally, transpedicular corpectomy and costotransversectomy can be recommended with the expectation of improving neurological outcomes and reducing pain in properly selected patients with spinal metastases. With improvements in the treatment paradigms for patients with spinal metastasis, as well as survival, surgical therapy will continue to play an important role in the management of spinal metastasis. While this review presents a window into determining the utility of posterior approaches, future prospective studies will provide essential data to better define the roles of the various options now available to surgeons in treating spinal metastases.

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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.

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Seba Ramhmdani, Marc Comair, Camilo A. Molina, Daniel M. Sciubba and Ali Bydon

Interspinous process devices (IPDs) have been developed as less-invasive alternatives to spinal fusion with the goal of decompressing the spinal canal and preserving segmental motion. IPD implantation is proposed to treat symptoms of lumbar spinal stenosis that improve during flexion. Recent indications of IPD include lumbar facet joint syndrome, which is seen in patients with mainly low-back pain. Long-term outcomes in this subset of patients are largely unknown. The authors present a previously unreported complication of coflex (IPD) placement: the development of a large compressive lumbar synovial cyst. A 64-year-old woman underwent IPD implantation (coflex) at L4–5 at an outside hospital for low-back pain that occasionally radiates to the right leg. Postoperatively, her back and right leg pain persisted and worsened. MRI was repeated and showed a new, large synovial cyst at the previously treated level, severely compressing the patient’s cauda equina. Four months later, she underwent removal of the interspinous process implant, bilateral laminectomy, facetectomy, synovial cyst resection, interbody fusion, and stabilization. At the 3-month follow-up, she reported significant back pain improvement with some residual leg pain. This case suggests that facet arthrosis may not be an appropriate indication for placement of coflex.

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Rafael De la Garza Ramos, Jonathan Nakhla, Daniel M. Sciubba and Reza Yassari

OBJECTIVE

In a meta-analysis, the authors sought to compare outcomes after iliac screw (IS) versus S2 alar-iliac (S2AI) screw fixation in adult patients.

METHODS

A PubMed/MEDLINE database search was performed for studies comparing IS and S2AI screw fixation techniques in adults. Levels of evidence were assigned based on the North American Spine Society guidelines. Three outcomes were examined: 1) revision surgery rate secondary to mechanical failure or wound complications, 2) surgical site infection rate, and 3) screw prominence/pain. Data were pooled and outcomes compared between techniques. Absolute risk reductions (ARRs) were also calculated for outcome measures.

RESULTS

Five retrospective cohort studies (all level III evidence) were included in our analysis. A total of 323 adult patients were included—147 in the IS group (45.5%) and 176 in the S2AI group (54.5%). Overall, revision surgery due to mechanical failure or wound complications was needed in 66 of 323 patients (revision surgery rate 20.4%)—27.9% in the IS group and 14.2% in the S2AI group (13.7% ARR; p < 0.001). Four studies reported wound infections among 278 total patients, with an infection rate of 12.6% (35/278)—25.4% in the IS group and 2.6% in the S2AI group (22.8% ARR; p < 0.001). Three studies examined development of screw prominence/pain; combined, these studies reported screw prominence/pain in 21 of 215 cases (9.8%)—18.1% in the IS group and 1.8% in the S2AI group (16.3% ARR; p < 0.001).

CONCLUSIONS

S2AI screw fixation in adults has a significantly lower mechanical failure and complication rate than IS fixation based on the current best available evidence.