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Lei Zhao, Peng Wang, and Weixin Li

Os odontoideum is a rare anomaly of the second cervical vertebra, which can result in the compression and injury of cervical spinal cord. This deformity is surgically challenging. The authors presented a case of a 50-year-old man with a 2-year history of numbness and weakness in four limbs. The x-ray suggested the os odontoideum. MRI demonstrated a dramatic compression of the cervical spinal cord and an abnormally high signal intensity area in this region. The patient underwent a midline posterior approach for the treatment of this lesion. Postoperatively, the reduction results were satisfactory and the compression was relieved.

The video can be found here: https://youtu.be/3qDzR2kOz8k.

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Lei Zhao, Chao Cheng, Wei Zuo, Peng Wang, and Weixin Li

Open access

Lei Zhao, Shuo Zhang, Li Gong, Yan Qu, and Lijun Heng

Maffucci syndrome is an extremely rare disorder characterized by benign enchondromas, skeletal deformities, and cutaneous lesions composed of abnormal blood vessels. Enchondromas rarely arise in the cranial bones. Interdural pituitary transposition is an effective way to gain access to the posterior clinoid, without affecting the function of the pituitary gland. Here, the authors present a case of a posterior clinoid process enchondroma in a patient with Maffucci syndrome. The tumor was resected via an interdural pituitary transposition fashion. Four months postoperatively, the patient’s oculomotor function had recovered to normal and the function of the pituitary gland was preserved intact.

The video can be found here: https://youtu.be/EYgVwVZuC4g.

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Quan-chang Tan, Jian-wei Wu, Fei Peng, Yuan Zang, Yang Li, Xiong Zhao, Wei Lei, and Zi-xiang Wu

OBJECTIVE

This study investigated the optimum injection volume of polymethylmethacrylate (PMMA) to augment a novel fenestrated pedicle screw (FPS) with diameter-tapered perforations in the osteoporotic vertebral body, and how the distribution characteristics of PMMA affect the biomechanical performance of this screw.

METHODS

Two types of FPSs were designed (FPS-A, composed of 6 perforations with an equal diameter of 1.2 mm; and FPS-B, composed of 6 perforations each with a tapered diameter of 1.5 mm, 1.2 mm, and 0.9 mm from tip to head. Each of 28 human cadaveric osteoporotic vertebrae were randomly assigned to 1 of 7 groups: FPS-A1.0: FPS-A+1.0 ml PMMA; FPS-A1.5: FPS-A+1.5 ml PMMA; FPS-A2.0: FPS-A+2.0 ml PMMA; FPS-B1.0: FPS-B+1.0 ml PMMA; FPS-B1.5: FPS-B+1.5 ml PMMA; FPS-B2.0: FPS-B+2.0 ml PMMA; and conventional pedicle screws (CPSs) without PMMA. After the augmentation, 3D CT was performed to assess the cement distribution characteristics and the cement leakage rate. Axial pullout tests were performed to compare the maximum pullout force thereafter.

RESULTS

The CT construction images showed that PMMA bone cement formed a conical mass around FPS-A and a cylindrical mass around FPS-B. When the injection volume was increased from 1.0 ml to 2.0 ml, the distribution region of the PMMA cement was enlarged, the PMMA was distributed more posteriorly, and the risk of leakage was increased. When the injection volume reached 2.0 ml, the risk of cement leakage was lower for screws having diameter-tapered perforations. The pullout strengths of the augmented FPS-A groups and FPS-B groups were higher than that of the CPS group (p < 0.0001). All FPS-B groups had a higher pullout strength than the FPS-A groups.

CONCLUSIONS

The diameter of the perforations affects the distribution of PMMA cement. The diameter-tapered design enabled PMMA to form larger bone-PMMA interfaces and achieve a relatively higher pullout strength, although statistical significance was not reached. Study results indicated 1.5-ml of PMMA was a conservative volume for PMMA augmentation; more cement injection would significantly increase the risk of cement leakage.

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Lei Zhao, Liwei Peng, Peng Wang, and Weixin Li

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Lei Xia, Hongwei Zhang, Chunjiang Yu, Mingshan Zhang, Ming Ren, Yanming Qu, Haoran Wang, Mingwang Zhu, Dianjiang Zhao, Xueling Qi, and Kun Yao

Object

The aim of this study was to evaluate the clinical results and surgical outcomes of cystic vestibular schwannomas (VSs) with fluid-fluid levels.

Methods

Forty-five patients with cystic VSs and 86 with solid VSs were enrolled in the study. The patients in the cystic VSs were further divided into those with and without fluid-fluid levels. The clinical and neuroimaging features, intraoperative findings, and surgical outcomes of the 3 groups were retrospectively compared.

Results

Peritumoral adhesion was significantly greater in the fluid-level group (70.8%) than in the nonfluid-level group (28.6%) and the solid group (25.6%; p < 0.0001). Complete removal of the VS occurred significantly less in the fluid-level group (45.8%, 11/24) than in the nonfluid-level group (76.2%, 16/21) and the solid group (75.6%, 65/86; p = 0.015). Postoperative facial nerve function in the fluid-level group was less favorable than in the other 2 groups; good/satisfactory facial nerve function 1 year after surgery was noted in 50.0% cases in the fluid-level group compared with 83.3% cases in the nonfluid-level group (p = 0.038).

Conclusions

Cystic VSs with fluid-fluid levels more frequently adhered to surrounding neurovascular structures and had a less favorable surgical outcome. A possible mechanism of peritumoral adhesion is intratumoral hemorrhage and consequent inflammatory reactions that lead to destruction of the tumor-nerve barrier. These findings may be useful in predicting surgical outcome and planning surgical strategy preoperatively.

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Xiaofeng Deng, Kai Wang, Liang Wu, Chenlong Yang, Tao Yang, Lei Zhao, Jun Yang, Guihuai Wang, Jingyi Fang, and Yulun Xu

Object

Intraspinal hemangioblastomas are relatively uncommon benign tumors. The surgical strategies remain controversial, and the risk factors with regard to clinical outcome are unclear. The purpose of this study was to analyze the clinical characteristics, imaging findings, surgical strategies, and functional outcomes associated with intraspinal hemangioblastomas.

Methods

A series of 92 patients who underwent 102 operations for resection of 116 intraspinal hemangioblastomas at a single institution during 2007–2011 were consecutively enrolled in this study. Of these, 60 patients (65.2%) had sporadic hemangioblastomas and 32 (34.8%) had von Hippel-Lindau disease. Preoperatively, 13 patients underwent digital subtraction angiography (DSA), 15 patients underwent 3D CT angiography (3D CTA), and none underwent preoperative embolization. Clinical characteristics, imaging findings, and operative records were analyzed. The advantages and disadvantages of DSA and 3D CTA were compared. For identification of risk factors that affect prognosis, logistic analysis was performed.

Results

The male/female patient ratio was 1.8:1.0 (59 male and 33 female patients). Of the tumors, 41% were intramedullary, 37% were intramedullary-extramedullary, and 22% were primarily extramedullary. Three-dimensional CTA and DSA did not differ significantly in the ability to identify the feeding arteries (p = 1.000) and image qualities (p = 0.367). However, compared with 3D CTA, the effective x-ray dose of spinal DSA was 2.73 times higher and the mean amount of contrast media injected was 1.88 times higher. Spinal DSA was more time consuming (mean 120 minutes) than 3D CTA (scanning time < 1 minute). No complications were observed after 3D CTA; acute paraparesis developed in 1 patient after DSA.

Gross-total resection was achieved for 109 tumors (94.0%), and resection was subtotal for 7 tumors. Mean duration of follow-up was 50 months (range 24–78 months). At the most recent follow-up visit, the functional outcome was improved for 38 patients (41.3%), remained stable for 40 (43.5%), and deteriorated for 14 (15.2%). Logistic analysis showed that subtotal resection was a risk factor affecting prognosis (p = 0.003, OR 12.833, 95% CI 2.429–67.806).

Conclusions

The authors' study suggests that safe and effective treatment of intraspinal hemangioblastomas can be achieved for most patients, even without preoperative embolization. Gross-total resection, when safe to perform, leads to better outcomes. Compared with spinal DSA, 3D CTA is a promising technique because it is noninvasive, takes less time to perform, requires lower x-ray doses and less contrast media, results in fewer complications, and offers high accuracy for delineating the feeding arteries.

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Liang Wu, Tao Yang, Xiaofeng Deng, Chenlong Yang, Lei Zhao, Ning Yao, Jingyi Fang, Guihuai Wang, Jun Yang, and Yulun Xu

Object

Extradural en plaque meningiomas are very rare tumors in the spinal canal. Most studies on these lesions have been case reports with literature reviews. In this paper, the authors review their experience in a surgical series of 12 patients with histologically proven, purely extradural en plaque meningiomas and discuss their clinical features, radiological findings, and long-term outcomes.

Methods

Clinical and imaging data of 12 patients with spinal extradural en plaque meningiomas treated at a single institution were retrospectively analyzed.

Results

There were 5 male and 7 female patients, with a mean age of 39.9 years. The mean follow-up period was 74.8 months. Nine tumors were located in the cervical spine, 1 in the cervicothoracic spine, and 2 in the thoracic spine. All the tumors were confirmed as extradural en plaque meningiomas with sheetlike growth along the dura mater. Gross-total resection of the tumor with a well-demarcated dissection plane was achieved in 4 cases. Subtotal resection was achieved in 8 cases, 2 of whom underwent postoperative low-dose radiation therapy. The symptoms present before the surgery were improved in all cases at the last follow-up evaluation. The postoperative follow-up MRI showed no recurrence or regrowth in 4 cases with gross-total removal and 7 cases with subtotal removal during the mean follow-up periods of 58.0 months and 71.1 months, respectively. One patient experienced recurrence at 88 months after his initial subtotal removal and improved following a revision operation.

Conclusions

Spinal extradural en plaque meningiomas are amenable to surgery if complete removal can be achieved. Because of the encirclement of the dura that is characteristic of the tumors, complete resection is usually difficult, subtotal removal for spinal cord decompression is advised, and follow-up imaging is needed. The risk of long-term recurrence/regrowth of the lesions is low, and a good clinical outcome after total or subtotal removal can be expected.

Full access

Yuan Wang, Bolin Liu, Tianzhi Zhao, Binfang Zhao, Daihua Yu, Xue Jiang, Lin Ye, Lanfu Zhao, Wenhai Lv, Yufu Zhang, Tao Zheng, Yafei Xue, Lei Chen, Eric Sankey, Long Chen, Yingxi Wu, Mingjuan Li, Lin Ma, Zhengmin Li, Ruigang Li, Juan Li, Jing Yan, Shasha Wang, Hui Zhao, Xude Sun, Guodong Gao, Yan Qu, and Shiming He

OBJECTIVE

Although enhanced recovery after surgery (ERAS) programs have gained acceptance in various surgical specialties, no established neurosurgical ERAS protocol for patients undergoing elective craniotomy has been reported in the literature. Here, the authors describe the design, implementation, safety, and efficacy of a novel neurosurgical ERAS protocol for elective craniotomy in a tertiary care medical center located in China.

METHODS

A multidisciplinary neurosurgical ERAS protocol for elective craniotomy was developed based on the best available evidence. A total of 140 patients undergoing elective craniotomy between October 2016 and May 2017 were enrolled in a randomized clinical trial comparing this novel protocol to conventional neurosurgical perioperative management. The primary endpoint of this study was the postoperative hospital length of stay (LOS). Postoperative morbidity, perioperative complications, postoperative pain scores, postoperative nausea and vomiting, duration of urinary catheterization, time to first solid meal, and patient satisfaction were secondary endpoints.

RESULTS

The median postoperative hospital LOS (4 days) was significantly shorter with the incorporation of the ERAS protocol than that with conventional perioperative management (7 days, p < 0.0001). No 30-day readmission or reoperation occurred in either group. More patients in the ERAS group reported mild pain (visual analog scale score 1–3) on postoperative day 1 than those in the control group (79% vs. 33%, OR 7.49, 95% CI 3.51–15.99, p < 0.0001). Similarly, more patients in the ERAS group had a shortened duration of pain (1–2 days; 53% vs. 17%, OR 0.64, 95% CI 0.29–1.37, p = 0.0001). The urinary catheter was removed within 6 hours after surgery in 74% patients in the ERAS group (OR 400.1, 95% CI 23.56–6796, p < 0.0001). The time to first oral liquid intake was a median of 8 hours in the ERAS group compared to 11 hours in the control group (p < 0.0001), and solid food intake occurred at a median of 24 hours in the ERAS group compared to 72 hours in the control group (p < 0.0001).

CONCLUSIONS

This multidisciplinary, evidence-based, neurosurgical ERAS protocol for elective craniotomy appears to have significant benefits over conventional perioperative management. Implementation of ERAS is associated with a significant reduction in the postoperative hospital stay and an acceleration in recovery, without increasing complication rates related to elective craniotomy. Further evaluation of this protocol in large multicenter studies is warranted.

Clinical trial registration no.: ChiCTR-INR-16009662 (chictr.org.cn)