Robert J. Hacker and Christopher G. Miller
Object. Anterior cervical foraminotomy has been advocated as a procedure that preserves the motion segment while treating radiculopathy due to degenerative cervical disc disease. Because the medical literature contains no long-term follow up or randomized studies related to this procedure, the authors reviewed their results, specifically examining cases of failure to determine the efficacy of the approach.
Methods. The authors identified 23 patients in whom unilateral cervical radiculopathy due to degenerative cervical disc disease was refractory to conservative therapy and in whom anterior cervical foraminotomy was performed between 1998 and 2000. The procedure involves ipsilateral exposure, microsurgical removal of the uncovertebral joint to identify the nerve root, and partial removal of the lateral anulus and or disc fragments. Data in those patients who underwent reoperation(s) were reviewed specifically for the procedure type, interval between index procedure and reoperation, and whether multiple procedures were performed. Of the 23 patients, 30% required at least one additional procedure. A good or excellent outcome at last follow-up examination was achieved in only 12 patients.
Conclusions. In the current study the authors found a reoperation rate that is considerably higher than that in most series of anterior cervical surgery for radiculopathy. The presumed benefit of anterior cervical foraminotomy is preservation of the disc interspace; however, in this study, a significant number of patients failed to experience a satisfying outcome. Currently the authors do not recommend anterior cervical foraminotomy as a stand-alone procedure.
A pathological case report
C. Miller Fisher and Robert G. Ojemann
✓ In a case of subarachnoid hemorrhage, the arteries of the circle of Willis were left undisturbed and undissected at postmortem examination. A block of frontal lobe tissue with the attached vessels was serially sectioned disclosing in its entirety a saccular aneurysm that had ruptured at the base rather than the dome. The histology of the hemostatic process was clearly depicted.
John M. Cilluffo, Stephen G. Harner and Ross H. Miller
✓ Patients with adenocarcinoma of the ceruminous gland arising in the middle ear have a typical syndrome consisting of unilateral hearing loss, otalgia, facial paresis, and a middle-ear mass. Adjacent cranial nerves also may be affected. Some patients may have an ipsilateral cerebellar ataxia if the lesion extends into the cerebellopontine angle and compresses the cerebellar hemisphere. Obstructive hydrocephalus may occur secondary to obstruction of the aqueduct or fourth ventricle. The initial clinical findings may be those of a jugular foramen syndrome. These lesions are usually slow-growing and may be associated with a very prolonged clinical course. Although the tumors are rare, the physician should be aware of their existence if proper care is to be given.
Jimmy D. Miller, Mary C. Miller and Marsha G. Lucas
Interspinous process spacers have recently become available for treatment of symptomatic lumbar spinal stenosis. To date, there have been few data regarding the causes of failure. The authors present 2 cases in which there was erosion of the spinous processes adjacent to the interspinous process spacers. In 1 patient, the recurrence of symptoms was likely related to the erosive changes. Such abnormal changes allow settling of the posterior spinal elements and probably results from continued motion at the treated levels.
Nnenna Mbabuike, Kelly Gassie, Benjamin Brown, David A. Miller and Rabih G. Tawk
Tandem occlusions continue to represent a major challenge in patients with acute ischemic stroke (AIS). The anterograde approach with proximal to distal revascularization as well as the retrograde approach with distal to proximal revascularization have been reported without clear consensus or standard guidelines.
The authors performed a comprehensive search of the PubMed database for studies including patients with carotid occlusions and tandem distal occlusions treated with endovascular therapy. They reviewed the type of approach employed for endovascular intervention and clinical outcomes reported with emphasis on the revascularization technique. They also present an illustrative case of AIS and concurrent proximal cervical carotid occlusion and distal middle cerebral artery occlusion from their own experience in order to outline the management dilemma for similar cases.
A total of 22 studies were identified, with a total of 790 patients with tandem occlusions in AIS. Eleven studies used the anterograde approach, 3 studies used the retrograde approach, 4 studies used both, and in 4 studies the approach was not specified. In the studies that reported Thrombolysis in Cerebral Infarction (TICI) grades, an average of 79% of patients with tandem occlusions were reported to have an outcome of TICI 2b or better. One study found good clinical outcome in 52.5% of the thrombectomy-first group versus 33.3% in the stent-first group, as measured by the modified Rankin Scale (mRS). No study evaluated the difference in time to reperfusion for the anterograde and retrograde approach and its association with clinical outcome. The patient in the illustrative case had AIS and tandem occlusion of the internal carotid and middle cerebral arteries and underwent distal revascularization using a Solitaire stent retrieval device followed by angioplasty and stent treatment of the proximal cervical carotid occlusion. The revascularization was graded as TICI 2b; the postintervention National Institutes of Health Stroke Scale (NIHSS) score was 17, and the discharge NIHSS score was 7. The admitting, postoperative, and 30-day mRS scores were 5, 1, and 1, respectively.
In stroke patients with tandem occlusions, distal to proximal revascularization represents a reasonable treatment approach and may offer the advantage of decreased time to reperfusion, which is associated with better functional outcome. Further studies are warranted to determine the best techniques in endovascular therapy to use in this subset of patients in order to improve clinical outcome.
Kai J. Miller, Taylor J. Abel, Adam O. Hebb and Jeffrey G. Ojemann
Emerging research in evoked broadband electrocorticographic (ECoG) measurement from the cortical surface suggests that it might cleanly delineate the functional organization of cortex. The authors sought to demonstrate whether this could be done in a same-session, online manner to identify receptive and expressive language areas.
The authors assessed the efficacy of simple integration of “χ-band” (76–200 Hz) change in the ECoG signal by implementing a simple band-pass filter to estimate broadband spectral change. Following a brief (less than 10-second) period to characterize baseline activity, χ-band activity was integrated while 7 epileptic patients with implanted ECoG electrodes performed a verb-generation task.
While the patients were performing verb-generation or noun-reading tasks, cortical activation was consistently identified in primary mouth motor area, superior temporal gyrus, and Broca and Wernicke association areas. Maps were robust after a mean time of 47seconds (using an “activation overlap” measure). Correlation with electrocortical stimulation was not complete and was stronger for noun reading than verb generation.
Broadband ECoG changes can be captured online to identify eloquent cortex. This demonstrates the existence of a powerful new tool for functional mapping in the operative and chronic implant setting.
Neeraj Kumar, Gary M. Miller, David G. Piepgras and Bahram Mokri
A source of bleeding is often not evident during the evaluation of patients with superficial siderosis of the CNS despite extensive imaging. An intraspinal fluid-filled collection of variable dimensions is frequently observed on spine MR imaging in patients with idiopathic superficial siderosis. A similar finding has also been reported in patients with idiopathic intracranial hypotension. The authors report on a patient with superficial siderosis and a longitudinally extensive intraspinal fluid-filled collection secondary to a dural tear. The patient had a history of low-pressure headaches. His spine MR imaging and spine CT suggested the possibility of an underlying vascular malformation, but none was found on angiography. Repair of the dural tear resulted in resolution of the intraspinal fluid collection and CSF abnormalities. The significance of the association between superficial siderosis and idiopathic intracranial hypotension, and potential therapeutic and pathophysiological implications, are the subject of this report.
Neurosurgical needs of a community
Glen G. Glista, Ross H. Miller, Leonard T. Kurland and Mark L. Jereczek
✓ To help determine neurosurgical needs within communities and within the nation, operations and diagnostic procedures performed by neurosurgeons on residents of Olmsted County, Minnesota, in the 5 years of 1970 through 1974, were tabulated. This county was studied because its medical records are virtually complete. Annual rates (per 100,000 population) were 42 for lumbar disc removal, six for cervical disc removal, and seven for brain-tumor therapy. Other less frequent occasions for neurological surgery are also tabulated.