Case report and recommendations for management
Sanjay S. Dhall, Luis M. Tumialán, Daniel J. Brat and Daniel L. Barrow
✓ The authors report on 32-year-old woman with a history of a previously resected suprasellar clear cell meningioma (CCM), who returned to their institution after 3 years suffering from progressively worsening leg and back pain associated with leg weakness and bowel and bladder dysfunction. A magnetic resonance image of the thoracic and lumbar spine demonstrated a homogeneously enhancing intradural mass that filled and expanded the thecal sac. The patient underwent multiple-level laminectomies for resection of the lesion. Results of pathological studies confirmed distant recurrence of a CCM.
Since its initial recognition as a rare but aggressive histological variant of meningothelial tumors, the body of literature on CCMs has grown to include more than 40 cases. Nevertheless, the natural history of this neoplastic entity remains ill defined, as are the recommendations for management. Of particular concern is the treatment of patients who have undergone subtotal resection or present with recurrence. To the authors' knowledge, the present case represents the sixth distant recurrence of CCM reported in the literature. The radiographic and histological studies are reviewed along with the current literature on this subtype of meningioma. Recommendations for surveillance and treatment are made.
Luis M. Tumialán, C. Michael Cawley and Daniel L. Barrow
✓ The authors report the case of a 53-year-old woman in whom a T1–T2 spinal arachnoid cyst with associated arachnoiditis developed, compressing the thoracic spinal cord 1 year after the patient had suffered a Hunt and Hess Grade IV subarachnoid hemorrhage (SAH). Development of spinal arachnoiditis with or without an arachnoid cyst is a rare complication of aneurysmal SAH. Risk factors may include posterior circulation aneurysms, the extent and severity of the hemorrhage, and the need for cerebrospinal fluid diversion. Surgical drainage, shunt placement, or cyst excision, when possible, is the mainstay of treatment.
Luis M. Tumialán and Timothy B. Mapstone
Luis M. Tumialán, Franklin Lin and Sanjay K. Gupta
✓The authors report their experience treating a polymicrobial ventriculoperitoneal (VP) shunt infection in a developmentally delayed 21-year-old woman. Cerebrospinal fluid (CSF) cultures grew Serratia marcescens and Proteus mirabilis. On admission and throughout her hospitalization, results of physical examination of her abdomen were normal, and radiographic studies showed no evidence of bowel perforation or pseudocyst formation. Contrast-enhanced computed tomography of the abdomen revealed a small fluid collection. After a course of intravenous gentamicin and imipenem with cilastatin in conjunction with intrathecal gentamicin, the infection was resolved and the VP shunt was reimplanted.
Although VP shunt infections are not uncommon, S. marcescens as a causative agent is exceedingly rare and potentially devastating. Only two previous cases of S. marcescens shunt infection have been reported in the literature. Authors reporting on S. marcescens infections in the central nervous system (CNS) have observed significant morbidity and death. Although more common, the presence of P. mirabilis in the CSF is still rare and highly suggestive of bowel perforation, which was absent in this patient. Spontaneous bacterial peritonitis was the likely source from which these bacteria gained entrance into the VP shunt system, eventually causing ventriculitis in this patient.
The authors conclude that in light of the high morbidity associated with S. marcescens infection of the CNS, intrathecal administration of gentamicin should be strongly considered as part of first-line therapy for S. marcescens infections in VP shunts.
Jason M. Highsmith, Luis M. Tumialán and Gerald E. Rodts Jr.
✓The widespread use of instrumentation in the lumbar spine has led to high rates of fusion. This has been accompanied by a marked rise in adjacent-segment disease, which is considered to be an increasingly common and significant consequence of lumbar or lumbosacral fusion. Numerous biomechanical studies have demonstrated that segments fused with rigid metallic fixation lead to significant amounts of supraphysiological stress on adjacent discs and facets. The resultant disc degeneration and/or stenosis may require further surgical intervention and extension of the fusion to address symptomatic adjacent-segment disease.
Recently, dynamic stabilization implants and disc arthroplasty have been introduced as an alternative to rigid fixation. The scope of spinal disease that can be treated with this novel technology, however, remains limited, and these treatments may not apply to patients who still require rigid stabilization and arthrodesis.
In the spectrum between rigid metallic fixation and motion-preserving arthroplasty is a semirigid type of stabilization in which a construct is used that more closely mirrors the modulus of elasticity of natural bone. After either inter-body or posterolateral arthrodesis is achieved, the fused segments will not generate the same adjacent-level forces believed to be the cause of adjacent-segment disease. Although this form of arthrodesis does not completely prevent adjacent-segment disease, the dynamic component of this stabilization technique may minimize its occurrence.
The authors report their initial experience with the use of posterior dynamic stabilization in which polyetheretherketone rods were used for a posterior construct. The biomechanics of dynamic stabilization are discussed, clinical indications are reviewed, and case studies for its application are presented.
Aaron S. Dumont, Avery J. Evans and Mary E. Jensen
Luis M. Tumialán, Y. Jonathan Zhang, C. Michael Cawley, Jacques E. Dion, Frank C. Tong and Daniel L. Barrow
The introduction of the Neuroform microstent has facilitated the embolization of complex cerebral aneurysms, which were previously not amenable to endovascular therapy. Typically, the use of this stent necessitates the administration of dual antiplatelet therapy to minimize thromboembolic complications. Such therapy may increase the risk of hemorrhage in patients who require concurrent external ventricular drainage and/or subsequent permanent cerebrospinal fluid diversion.
The authors' neurosurgical database was queried for all patients who underwent stent-assisted coil embolization for cerebral aneurysms and who required an external ventricular drain (EVD) or ventriculoperitoneal (VP) shunt placement for management of hydrocephalus.
Thirty-seven patients underwent stent-assisted coil embolization for intracranial aneurysms at the authors' institution over a recent 2-year period. Seven of these patients required placement of an EVD and/or a VP shunt. Three of the 7 patients suffered an immediate intraventricular hemorrhage (IVH) associated with placement or manipulation of an EVD; 1 experienced a delayed intraparenchymal hemorrhage and an IVH; 1 suffered an aneurysmal rehemorrhage; and the last patient had a subdural hematoma (SDH) that resulted from placement of a VP shunt. This patient required drainage of the SDH and exchange of the valve.
The necessity of dual antiplatelet therapy in the use of stent-assisted coil embolization increases the risk of intracranial hemorrhage and possibly rebleeding from a ruptured aneurysm. This heightened risk must be recognized when contemplating the appropriate therapy for a cerebral aneurysm and when considering the placement or manipulation of a ventricular catheter in a patient receiving dual antiplatelet therapy. Further study of intracranial procedures in patients receiving dual antiplatelet therapy is indicated.
Luis M. Tumialán, Jeff Pan, Gerald E. Rodts Jr. and Praveen V. Mummaneni
The goal in this study was to demonstrate the safety and efficacy of anterior cervical discectomy and fusion ([ACDF]; single- or multilevel procedure) performed using titanium plates and polyetheretherketone (PEEK) spacers filled with recombinant human bone morphogenetic protein–2 (rhBMP-2) impregnated in a type I collagen sponge to achieve fusion.
The authors retrospectively reviewed 200 patients who underwent a single- or multilevel ACDF with titanium plate fixation and PEEK spacer filled with a collagen sponge impregnated with low-dose rhBMP-2. Clinical outcomes were assessed using pre- and postoperative Nurick grades and the Odom criteria. Radiographic outcomes were assessed using dynamic radiographs and computed tomography (CT) scans.
The follow-up period ranged from 8 to 36 months (mean 16.7 months). A single-level ACDF was performed in 96 patients, 2-level ACDF in 62 patients, 3-level ACDF in 36 patients, and 4-level ACDF in 6 patients. Long-term follow-up was available for 193 patients. The Odom outcomes were rated as good to excellent in 165 patients (85%), fair in 24 (12.4%), and poor in 4 (2%). Among patients with myelopathy, Nurick grades improved from a preoperative mean of 1.42 to a postoperative mean of 0.26. All patients (100%) achieved solid radiographic fusion on dynamic radiographs and CT scans. Fourteen patients (7%) in this series experienced clinically significant dysphagia, and 4 (2%) required repeated operation for hematoma or seroma.
An ACDF performed using a PEEK spacer filled with rhBMP-2 leads to good to excellent clinical outcomes and solid fusion, even in multilevel cases and in patients who are smokers. The incidence of symptomatic dysphagia may be decreased with a lower dose of rhBMP-2 that is placed only within the PEEK spacer.