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Scott L. Zuckerman, Jacob L. Goldberg, and K. Daniel Riew

Ankylosing spondylitis (AS) is an inflammatory disorder leading to ossification of joints and ligaments, resulting in autofusion throughout the spinal column. In patients with fixed, kyphotic cervical deformities, which cause an impaired horizontal gaze and severe neck pain, surgical intervention is warranted. Although several articles have described the anterior and/or posterior surgical treatments used to address the fixed kyphosis, few sources present the key operative steps and technical nuances. The purpose of this technical report was to provide detailed surgical steps, representative photographs, and an operative video demonstrating multilevel anterior cervical osteotomies, uncinatectomies, and a posterior osteotomy for the correction of a fixed cervical deformity secondary to AS.

Free access

Joseph A. Carnevale, Christopher S. Babu, Jacob L. Goldberg, Reginald Fong, and Theodore H. Schwartz

OBJECTIVE

Visual deterioration after endoscopic endonasal transsphenoidal surgery (EETS) for sellar and parasellar masses is a rare but serious complication caused by either compressive or ischemic mechanisms. Timely diagnosis and intervention may restore vision if instituted appropriately. The associated risk factors and their relation to the success of intervention are not well understood.

METHODS

The authors examined a series of 1200 consecutive EETS cases performed by the senior author at Weill Cornell/NewYork-Presbyterian Hospital from 2010 to 2020. Cases with postoperative visual deterioration were identified. Pre- and postoperative clinical data, mechanism of visual decline, latency to intervention, and long-term visual outcome were retrospectively collected and analyzed with appropriate statistical methods.

RESULTS

Twenty-one patients (1.75%) complained of early postoperative visual deterioration. The most common pathology associated with postoperative visual loss was craniopharyngioma (7.69%), followed by meningioma (5.43%) and then pituitary adenoma (1.94%). Timely intervention restored vision in 81% of patients for a 0.33% rate of permanent visual deterioration. Average time to visual deterioration was 28.8 hours, and over 70% of patients experienced vision loss within the first 13 hours. Compressive etiology (n = 11), consisting of either hematoma (n = 8) or graft displacement (n = 3), occurred 7.3 hours and 70.3 hours after surgery, respectively, and was more common in adenomas. Acute postoperative visual deterioration was more common in firm closures (4.78%) compared with soft closures (1.03%; p = 0.0006). Ischemic etiology (n = 10) occurred 10.3 hours after surgery and was more common with craniopharyngiomas and meningiomas (p = 0.08). Sixteen patients (76.2%) underwent early reoperation to explore and decompress the optic apparatus. Vision was restored to baseline after reoperation in all 11 compressive cases, whereas 6/10 ischemic cases improved with supplemental oxygen and hypervolemic hypertensive therapy (p = 0.02). Fluid expansion from 8 to 16 hours (p = 0.034) and systolic blood pressure elevation from 32 to 48 hours (p = 0.05) after surgery were significantly higher in those ischemic patients who recovered some vision compared with those with persistent visual deficits.

CONCLUSIONS

Visual deterioration after EETS is a rare event but can be effectively treated if acted upon appropriately and in a timely fashion. Compressive etiology is reversible with early reoperation. Ischemic etiology can be successfully treated in roughly half of cases with supplemental oxygen and hypertensive hypervolemic therapy but may result in permanent visual deterioration if not instituted appropriately or if delayed with unnecessary exploratory surgery.

Free access

Joseph A. Carnevale, Christopher S. Babu, Jacob L. Goldberg, Reginald Fong, and Theodore H. Schwartz

OBJECTIVE

Visual deterioration after endoscopic endonasal transsphenoidal surgery (EETS) for sellar and parasellar masses is a rare but serious complication caused by either compressive or ischemic mechanisms. Timely diagnosis and intervention may restore vision if instituted appropriately. The associated risk factors and their relation to the success of intervention are not well understood.

METHODS

The authors examined a series of 1200 consecutive EETS cases performed by the senior author at Weill Cornell/NewYork-Presbyterian Hospital from 2010 to 2020. Cases with postoperative visual deterioration were identified. Pre- and postoperative clinical data, mechanism of visual decline, latency to intervention, and long-term visual outcome were retrospectively collected and analyzed with appropriate statistical methods.

RESULTS

Twenty-one patients (1.75%) complained of early postoperative visual deterioration. The most common pathology associated with postoperative visual loss was craniopharyngioma (7.69%), followed by meningioma (5.43%) and then pituitary adenoma (1.94%). Timely intervention restored vision in 81% of patients for a 0.33% rate of permanent visual deterioration. Average time to visual deterioration was 28.8 hours, and over 70% of patients experienced vision loss within the first 13 hours. Compressive etiology (n = 11), consisting of either hematoma (n = 8) or graft displacement (n = 3), occurred 7.3 hours and 70.3 hours after surgery, respectively, and was more common in adenomas. Acute postoperative visual deterioration was more common in firm closures (4.78%) compared with soft closures (1.03%; p = 0.0006). Ischemic etiology (n = 10) occurred 10.3 hours after surgery and was more common with craniopharyngiomas and meningiomas (p = 0.08). Sixteen patients (76.2%) underwent early reoperation to explore and decompress the optic apparatus. Vision was restored to baseline after reoperation in all 11 compressive cases, whereas 6/10 ischemic cases improved with supplemental oxygen and hypervolemic hypertensive therapy (p = 0.02). Fluid expansion from 8 to 16 hours (p = 0.034) and systolic blood pressure elevation from 32 to 48 hours (p = 0.05) after surgery were significantly higher in those ischemic patients who recovered some vision compared with those with persistent visual deficits.

CONCLUSIONS

Visual deterioration after EETS is a rare event but can be effectively treated if acted upon appropriately and in a timely fashion. Compressive etiology is reversible with early reoperation. Ischemic etiology can be successfully treated in roughly half of cases with supplemental oxygen and hypertensive hypervolemic therapy but may result in permanent visual deterioration if not instituted appropriately or if delayed with unnecessary exploratory surgery.

Free access

Justin Schwarz, Joseph A. Carnevale, Jacob L. Goldberg, Alexander D. Ramos, Thomas W. Link, and Jared Knopman

OBJECTIVE

Chronic subdural hematoma (cSDH) is a common and challenging pathology to treat due to both the historically high recurrence rate following surgical evacuation and the medical comorbidities inherent in the aging patient population that it primarily affects. Middle meningeal artery (MMA) embolization has shown promise in the treatment of cSDHs, most convincingly to avoid surgical evacuation in relatively asymptomatic patients. Symptomatic patients requiring surgical evacuation may also benefit from perioperative MMA embolization to prevent cSDH recurrence. The goal of this study was to determine the utility of perioperative MMA embolization for symptomatic cSDH requiring surgical evacuation and to assess if there is a decrease in the cSDH recurrence rate compared to historical recurrence rates following surgical evacuation alone.

METHODS

Symptomatic cSDHs were evacuated using a subdural evacuating port system (SEPS) with 5-mm twist-drill craniostomy in an intensive care unit or by performing a craniotomy in the operating room, using either a small (silver dollar, < 4 cm) or large (≥ 4 cm) craniotomy. MMA embolization was performed perioperatively using angiography, selective catheterization of the MMA, and infusion of polyvinyl particles. Outcomes were assessed clinically and radiographically with interval head CT imaging.

RESULTS

There were 44 symptomatic cSDHs in 41 patients, with 3 patients presenting with bilateral symptomatic cSDH. All cSDHs were evacuated using an SEPS (n = 18), a silver-dollar craniotomy (n = 16), or a large craniotomy (n = 10). Prophylactic MMA embolization was performed successfully in all cSDHs soon after surgical evacuation. There were no deaths and no procedural complications. There was an overall reduction of greater than 50% or resolution of cSDH in 40/44 (90.9%) cases, regardless of the evacuation procedure used. Of the 44 prophylactic cases, there were 2 (4.5%) cases of cSDH recurrence that required repeat surgical evacuation at the 1-year follow-up. These 2 cSDHs were initially evacuated using an SEPS and subsequently required a craniotomy, thereby representing an overall 4.5% recurrence rate of treated cSDH requiring repeat evacuation. Most notably, of the 26 patients who underwent surgical evacuation with a craniotomy followed by MMA embolization, none had cSDH recurrence requiring repeat intervention.

CONCLUSIONS

Perioperative prophylactic MMA embolization in the setting of surgical evacuation, via either craniotomy or SEPS, may help to lower the recurrence rate of cSDH.

Open access

Joseph A. Carnevale, Jacob L. Goldberg, Gary Kocharian, Andrew L. A. Garton, Alexander Ramos, Justin Schwarz, Srikanth Reddy Boddu, Y. Pierre Gobin, and Jared Knopman

The treatment of cerebral aneurysms includes open microsurgical options (e.g., clipping, trapping/bypass) and evolving endovascular techniques. Following the landmark trials that propelled endovascular treatment to the forefront, flow diversion has shown high aneurysm cure rates with minimal complications. Flow diversion stents are placed in the parent vessel, redirecting blood flow from the aneurysm, promoting reendothelization across the neck, and resulting in complete occlusion of the aneurysm. As a result, flow diversion has become increasingly used as the primary treatment for unruptured aneurysms; however, its applications are being pushed to new frontiers. Here, the authors present three cases showcasing the treatment of intracranial aneurysms with flow diversion.

The video can be found here: https://stream.cadmore.media/r10.3171/2022.7.FOCVID2253

Free access

Jacob L. Goldberg, Ibrahim Hussain, Joseph A. Carnevale, Alexandra Giantini-Larsen, Ori Barzilai, and Mark H. Bilsky

OBJECTIVE

Paraspinal ganglioneuromas are rare tumors that arise from neural crest tissue and can cause morbidity via compression of adjacent organs and neurovascular structures. The authors investigated a case series of these tumors treated at their institution to determine clinical outcomes following resection.

METHODS

A retrospective review of a prospectively collected cohort of consecutive, pathology-confirmed, surgically treated paraspinal ganglioneuromas from 2001 to 2019 was performed at a tertiary cancer center.

RESULTS

Fifteen cases of paraspinal ganglioneuroma were identified: 47% were female and the median age at the time of surgery was 30 years (range 10–67 years). Resected tumors included 9 thoracic, 1 lumbar, and 5 sacral, with an average maximum tumor dimension of 6.8 cm (range 1–13.5 cm). Two patients had treated neuroblastomas that matured into ganglioneuromas. One patient had a secretory tumor causing systemic symptoms. Surgical approaches were anterior (n = 11), posterior (n = 2), or combined (n = 2). Seven (47%) and 5 (33%) patients underwent gross-total resection (GTR) or subtotal resection with minimal residual tumor, respectively. The complication rate was 20%, with no permanent neurological deficits or deaths. No patient had evidence of tumor recurrence or progression after a median follow-up of 68 months.

CONCLUSIONS

Surgical approaches and extent of resection for paraspinal ganglioneuromas must be heavily weighed against the advantages of aggressive debulking and decompression given the complication risk of these procedures. GTR can be curative, but even patients without complete tumor removal can show evidence of excellent long-term local control and clinical outcomes.

Free access

Fabian Sommer, Francois Waterkeyn, Ibrahim Hussain, Jacob L. Goldberg, Sertac Kirnaz, Rodrigo Navarro-Ramirez, Alaaeldin Azmi Ahmad, Massimo Balsano, Branden Medary, Hamisi Shabani, Amanda Ng, Pravesh Shankar Gadjradj, and Roger Härtl

OBJECTIVE

Telemedicine technology has been developed to allow surgeons in countries with limited resources to access expert technical guidance during surgical procedures. The authors report their initial experience using state-of-the-art wearable smart glasses with wireless capability to transmit intraoperative video content during spine surgery from sub-Saharan Africa to experts in the US.

METHODS

A novel smart glasses system with integrated camera and microphone was worn by a spine surgeon in Dar es Salaam, Tanzania, during 3 scoliosis correction surgeries. The images were transmitted wirelessly through a compatible software system to a computer viewed by a group of fellowship-trained spine surgeons in New York City. Visual clarity was determined using a modified Snellen chart, and a percentage score was determined on the smallest line that could be read from the 8-line chart on white and black backgrounds. A 1- to 5-point scale (from 1 = unrecognizable to 5 = optimal clarity) was used to score other visual metrics assessed using a color test card including hue, contrast, and brightness. The same scoring system was used by the group to reach a consensus on visual quality of 3 intraoperative points including instruments, radiographs (ability to see pedicle screws relative to bony anatomy), and intraoperative surgical field (ability to identify bony landmarks such as transverse processes, pedicle screw starting point, laminar edge).

RESULTS

All surgeries accomplished the defined goals safely with no intraoperative complications. The average download and upload connection speeds achieved in Dar es Salaam were 45.21 and 58.89 Mbps, respectively. Visual clarity with the modified white and black Snellen chart was 70.8% and 62.5%, respectively. The average scores for hue, contrast, and brightness were 2.67, 3.33, and 2.67, respectively. Visualization quality of instruments, radiographs, and intraoperative surgical field were 3.67, 1, and 1, respectively.

CONCLUSIONS

Application of smart glasses for telemedicine offers a promising tool for surgical education and remote training, especially in low- and middle-income countries. However, this study highlights some limitations of this technology, including optical resolution, intraoperative lighting, and internet connection challenges. With continued collaboration between clinicians and industry, future iterations of smart glasses technology will need to address these issues to stimulate robust clinical utilization.

Restricted access

Alexander Ramos, Joseph A. Carnevale, Kashif Majeed, Gary Kocharian, Ibrahim Hussain, Jacob L. Goldberg, Justin Schwarz, David I. Kutler, Jared Knopman, and Philip Stieg

OBJECTIVE

Carotid body tumors (CBTs) are rare, slow-growing neoplasms derived from the parasympathetic paraganglia of the carotid bodies. Although inherently vascular lesions, the role of preoperative embolization prior to resection remains controversial. In this report, the authors describe an institutional series of patients with CBT successfully treated via resection following preoperative embolization and compare the results in this series to previously reported outcomes in the treatment of CBT.

METHODS

All CBTs resected between 2013 and 2019 at a single institution were retrospectively identified. All patients had undergone preoperative embolization performed by interventional neuroradiologists, and all had been operated on by a combined team of cerebrovascular neurosurgeons and otolaryngology–head and neck surgeons. The clinical, radiographic, endovascular, and perioperative data were collected. All procedural complications were recorded.

RESULTS

Among 22 patients with CBT, 63.6% were female and the median age was 55.5 years at the time of surgery. The most common presenting symptoms included a palpable neck mass (59.1%) and voice changes (22.7%). The average tumor volume was 15.01 ± 14.41 cm3. Most of the CBTs were Shamblin group 2 (95.5%). Blood was predominantly supplied from branches of the ascending pharyngeal artery, with an average of 2 vascular pedicles (range 1–4). Fifty percent of the tumors were embolized with more than one material: polyvinyl alcohol, 95.5%; Onyx, 50.0%; and N-butyl cyanoacrylate glue, 9.1%. The average reduction in tumor blush following embolization was 83% (range 40%–95%). No embolization procedural complications occurred. All resections were performed within 30 hours of embolization. The average operative time was 173.9 minutes, average estimated blood loss was 151.8 ml, and median length of hospital stay was 4 days. The rate of permanent postoperative complications was 0%; 2 patients experienced transient hoarseness, and 1 patient had medical complications related to alcohol withdrawal.

CONCLUSIONS

This series reveals that endovascular embolization of CBT is a safe and effective technique for tumor devascularization, making preoperative angiography and embolization an important consideration in the management of CBT. Moreover, the successful management of CBT at the authors’ institution rests on a multidisciplinary approach whereby endovascular surgeons, neurosurgeons, and ear, nose, and throat–head and neck surgeons work together to optimally manage each patient with CBT.

Free access

Joseph A. Carnevale, Brandon S. Imber, Graham M. Winston, Jacob L. Goldberg, Ase Ballangrud, Cameron W. Brennan, Kathryn Beal, Viviane Tabar, and Nelson S. Moss

OBJECTIVE

Stereotactic biopsy is increasingly performed on brain metastases (BrMs) as improving cancer outcomes drive aggressive multimodality treatment, including laser interstitial thermal therapy (LITT). However, the tract recurrence (TR) risk is poorly defined in an era defined by focused-irradiation paradigms. As such, the authors aimed to define indications and adjuvant therapies for this procedure and evaluate the BrM-biopsy TR rate.

METHODS

In a single-center retrospective review, the authors identified stereotactic BrM biopsies performed from 2002 to 2020. Surgical indications, radiographic characteristics, stereotactic planning, dosimetry, pre- and postoperative CNS-directed and systemic treatments, and clinical courses were collected. Recurrence was evaluated using RANO-BM (Response Assessment in Neuro-Oncology Brain Metastases) criteria.

RESULTS

In total, 499 patients underwent stereotactic intracranial biopsy for any diagnosis, of whom 25 patients (5.0%) underwent biopsy for pathologically confirmed viable BrM, a proportion that increased over the time period studied. Twelve of the 25 BrM patients had ≥ 3 months of radiographic follow-up, of whom 6 patients (50%) developed new metastatic growth along the tract at a median of 5.0 months post-biopsy (range 2.3–17.1 months). All of the TR cases had undergone pre- or early post-biopsy stereotactic radiosurgery (SRS), and 3 had also undergone LITT at the time of initial biopsy. TRs were treated with resection, reirradiation, or observation/systemic therapy.

CONCLUSIONS

In this study the authors identified a nontrivial, higher than previously described rate of BrM-biopsy tract recurrence, which often required additional surgery or radiation and justified close radiographic surveillance. As BrMs are commonly treated with SRS limited to enhancing tumor margins, consideration should be made, in cases lacking CNS-active systemic treatments, to include biopsy tracts in adjuvant radiation plans where feasible.

Restricted access

Vikram B. Chakravarthy, Ibrahim Hussain, Ilya Laufer, Jacob L. Goldberg, Anne S. Reiner, Jemma Villavieja, William Christopher Newman, Ori Barzilai, and Mark Bilsky

OBJECTIVE

The cervicothoracic junction (CTJ) is a challenging region to stabilize after tumor resection for metastatic spine disease. The objective of this study was to describe the outcomes of patients who underwent posterolateral decompression and instrumented fusion (i.e., separation surgery across the CTJ for instability due to metastatic disease).

METHODS

The authors performed a single-institution retrospective study of a prospectively collected cohort of patients who underwent single-approach posterior decompression and instrumented fusion across the CTJ for metastatic spine disease between 2011 and 2018. Adult patients (≥ 18 years old) who presented with mechanical instability, myelopathy, and radiculopathy secondary to metastatic epidural spinal cord compression (MESCC) of the CTJ (C7–T1) from 2011 to 2018 were included.

RESULTS

Seventy-nine patients were included, with a mean age of 62.1 years. The most common primary malignancies were non–small cell lung (n = 17), renal cell (11), and prostate (8) carcinoma. The median number of levels decompressed and construct length were 3 and 7, respectively. The average operative time, blood loss, and length of stay were 179.2 minutes, 600.5 ml, and 7.7 days, respectively. Overall, 58 patients received adjuvant radiation, and median dose, fractions, and time from surgery were 27 Gy, 3 fractions, and 20 days, respectively. All patients underwent lateral mass and pedicle screw instrumentation. Forty-nine patients had tapered rods (4.0/5.5 mm or 3.5/5.5 mm), 29 had fixed-diameter rods (3.5 mm or 4.0 mm), and 1 had both. Ten patients required anterior reconstruction with poly-methyl-methacrylate. The overall complication rate was 18.8% (6 patients with wound-related complications, 7 with hardware-related complications, 1 with both, and 1 with other). For the 8 patients (10%) with hardware failure, 7 had tapered rods, all 8 had cervical screw pullout, and 1 patient also experienced rod/screw fracture. The average time to hardware failure was 146.8 days. The 2-year cumulative incidence rate of hardware failure was 11.1% (95% CI 3.7%–18.5%). There were 55 deceased patients, and the median (95% CI) overall survival period was 7.97 (5.79–12.60) months. For survivors, the median (range) follow-up was 12.94 (1.94–71.80) months.

CONCLUSIONS

Instrumented fusion across the CTJ demonstrated an 18.8% rate of postoperative complications and an 11% overall 2-year rate of hardware failure in patients who underwent metastatic epidural tumor decompression and stabilization.