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  • Author or Editor: Manish K. Kasliwal x
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Manish Kumar Kasliwal, Shashank Sharad Kale, Aditya Gupta, Narayanam Anantha Sai Kiran, Manish Singh Sharma, Bhawani Shanker Sharma and Ashok K. Mahapatra

Object

Although the effects of Gamma Knife surgery (GKS) on the risk of hemorrhage are poorly understood, a certain subset of patients does suffer bleeding after GKS. This study was undertaken to analyze the outcome of patients sustaining hemorrhage after GKS; it is the most feared complication of radiosurgical management of cerebral arteriovenous malformations (AVMs).

Methods

Between May 1997 and June 2006, 494 cerebral AVMs in 489 patients were treated using a Leksell Gamma Knife Model B, and follow-up evaluations were conducted until June 2007 at the All India Institute of Medical Sciences in New Delhi. Fourteen patients who sustained a hemorrhage after GKS formed the study group. In most of these patients conservative management was chosen.

Results

The mortality rate was 0% and there was a 7% risk of sustaining a severe deficit following rebleeding after GKS. None of the patients sustained rebleeding after complete obliteration. Patients with Spetzler-Martin Grade III or less had increased chances of hemorrhage after GKS (p < 0.002). The presence of deep venous drainage, aneurysm, venous hypertension, or periventricular location on angiography was common in patients with hemorrhage after GKS.

Conclusions

The risk of hemorrhage that remains following GKS for cerebral AVMs is highest in the 1st year after treatment. The present study showed a relatively good outcome even in cases with hemorrhage following GKS, with no deaths and minimal morbidity, further substantiating the safety and efficacy of the procedure.

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Manish K. Kasliwal, Gary F. Rogers, Shakti Ramkissoon, Alexander Moses-Gardner, Kyle C. Kurek and Edward R. Smith

Psammomatoid ossifying fibroma (POF), a variant of ossifying fibroma, is a benign fibroosseous lesion typically arising within the nasal cavity, paranasal sinuses, and orbit. Cranial vault involvement is exceedingly rare, with very few cases reported in the literature. The authors report a case of POF in the neurocranium of an 11-year-old child, 4 years after chemotherapy and radiation therapy for acute lymphoblastic leukemia. This case is reported in view of its rarity, novelty of presentation, and the difficulty in diagnosis due to its radiological resemblance to aneurysmal bone cyst or monostotic cystic fibrous dysplasia, further aggravated by the clinical scenario. A novel technique of cranial reconstruction called autologous particulate exchange cranioplasty was used following tumor excision.

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Vincent C. Traynelis and Manish K. Kasliwal

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Albert H. Kim, Manish K. Kasliwal, Brendan McNeish, V. Michelle Silvera, Mark R. Proctor and Edward R. Smith

Object

Spinal cord tethering due to a thickened filum terminale is a well-described entity that can be treated surgically. Postoperative MR imaging of the lumbar spine is performed for unrelated issues or for the development of new symptoms suggestive of cord retethering. A lack of radiological criteria for successful detethering makes interpretation of postoperative MR images challenging. The delineation of postoperative radiological characteristics of a sectioned filum terminale is therefore valuable to clinicians managing these often complex cases.

Methods

The clinical data for 16 patients who underwent sectioning of a fatty and thickened filum between 2001 and 2010 and in whom pre- and postoperative MR imaging studies were available were analyzed. Medical records were interrogated for preoperative neurological examination, operative details, and postoperative follow-up. The MR images were examined by both a neurosurgeon and a neuroradiologist to assess postoperative radiological characteristics.

Results

The patients' age at time of surgery ranged from 0.3 to 19.8 years (mean 7.5 years). Postoperative MR imaging was performed between 0.03 and 7.36 years after the procedure (mean 2.5 years). Indications for postoperative imaging included new neurological symptoms (11 of 16 patients), routine interval imaging (3 of 16), and possible development of pseudomeningocele (2 of 16). Filum discontinuity was confirmed in 79% of cases postoperatively. Filum remnants appeared thicker after surgery in most cases (80%), a phenomenon most often appreciated in the cephalad end of the sectioned filum. Postoperatively, the conus was elevated in 5 cases (31%) and was found to be more ventrally located in 7 cases (44%).

Conclusions

Discontinuity, along with thickening of the upper and lower remnants of a sectioned filum, may constitute important radiological features of a detethered filum. Radiological signs of conus relaxation, signified by elevation or a more ventral position, although reassuring, were less reliably observed postoperatively. Because it may be difficult to know if the goals of surgery were met on purely clinical grounds in this patient population, knowledge of the postoperative characteristics of a sectioned filum may aid the practicing neurosurgeon in the management of these complex cases.

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Manish K. Kasliwal, Justin S. Smith, Christopher I. Shaffrey, Leah Y. Carreon, Steven D. Glassman, Frank Schwab, Virginie Lafage, Kai-Ming G. Fu and Keith H. Bridwell

Object

In many adults with scoliosis, symptoms can be principally referable to focal pathology and can be addressed with short-segment procedures, such as decompression with or without fusion. A number of patients subsequently require more extensive scoliosis correction. However, there is a paucity of data on the impact of prior short-segment surgeries on the outcome of subsequent major scoliosis correction, which could be useful in preoperative counseling and surgical decision making. The authors' objective was to assess whether prior focal decompression or short-segment fusion of a limited portion of a larger spinal deformity impacts surgical parameters and clinical outcomes in patients who subsequently require more extensive scoliosis correction surgery.

Methods

The authors conducted a retrospective cohort analysis with propensity scoring, based on a prospective multicenter deformity database. Study inclusion criteria included a patient age ≥ 21 years, a primary diagnosis of untreated adult idiopathic or degenerative scoliosis with a Cobb angle ≥ 20°, and available clinical outcome measures at a minimum of 2 years after scoliosis surgery. Patients with prior short-segment surgery (< 5 levels) were propensity matched to patients with no prior surgery based on patient age, Oswestry Disability Index (ODI), Cobb angle, and sagittal vertical axis.

Results

Thirty matched pairs were identified. Among those patients who had undergone previous spine surgery, 30% received instrumentation, 40% underwent arthrodesis, and the mean number of operated levels was 2.4 ± 0.9 (mean ± SD). As compared with patients with no history of spine surgery, those who did have a history of prior spine surgery trended toward greater blood loss and an increased number of instrumented levels and did not differ significantly in terms of complication rates, duration of surgery, or clinical outcome based on the ODI, Scoliosis Research Society-22r, or 12-Item Short Form Health Survey Physical Component Score (p > 0.05).

Conclusions

Patients with adult scoliosis and a history of short-segment spine surgery who later undergo more extensive scoliosis correction do not appear to have significantly different complication rates or clinical improvements as compared with patients who have not had prior short-segment surgical procedures. These findings should serve as a basis for future prospective study.

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D. Kojo Hamilton, Justin S. Smith, Tanya Nguyen, Vincent Arlet, Manish K. Kasliwal and Christopher I. Shaffrey

Object

Sexual function is an often-overlooked aspect of health-related quality of life among older adults treated for spinal deformity. The authors' objective was to assess sexual function among older adults following thoracolumbar fusion with pelvic fixation for spinal deformity.

Methods

This was a retrospective review of consecutive older adults (≥50 years) treated with posterior thoracolumbar instrumentation (including pelvic fixation) for spinal deformity and with a minimum 18-month follow-up. Patients completed the Changes in Sexual Function Questionnaire-14 (CSFQ-14), Oswestry Disability Index (ODI), and 12-Item Short-Form Health Survey (SF-12).

Results

Sixty-two patients (45 women and 17 men) with a mean age of 70 years (range 50–83 years) met the inclusion criteria. Eight women did not complete all questionnaires and were excluded from the subanalysis. The mean number of instrumented levels was 9.8 (range 6–18), and the mean follow-up was 36 months (range 19–69 months). Based on the CSFQ-14, 13 patients (24%) had normal sexual function, and 8 (15%), 10 (19%), and 23 (42%) had mild, moderate, and severe dysfunction, respectively. Thirty-nine percent of patients reporting severe sexual dysfunction did not have available partners—23% because of a partner's death and 16% because of a partner's illness)—or had significant medical comorbidities of their own (48%). Thirty-nine percent of assessed patients had either no or only mild sexual dysfunction. Patients with minimal or mild disability tended to have no or mild sexual dysfunction.

Conclusions

The authors of this study assessed sexual function in older adults following surgical correction of spinal deformity that included posterior instrumented fusion and iliac bolts. Nearly 40% of assessed patients had either no or only mild sexual dysfunction, suggesting that despite an older age and extensive spinopelvic instrumentation, it remains very possible to maintain or achieve satisfactory sexual function.

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Lee A. Tan, Manish K. Kasliwal and Vincent C. Traynelis

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Manish K. Kasliwal, Lee A. Tan and John E. O'Toole

Spinal metastases are the most common of spinal neoplasms and occur predominantly in an extradural location. Their appearance in an intradural location is uncommon and is associated with a poor prognosis. Cerebrospinal fluid dissemination accounts for a significant number of intradural spinal metastases mostly manifesting as leptomeningeal carcinomatoses or drop metastases from intracranial tumors. The occurrence of local tumor dissemination intradurally following surgery for an extradural spinal metastasis has not been reported previously. The authors describe 2 cases in which local intradural and intramedullary tumor recurrences occurred following resection of extradural metastases that were complicated by unintended durotomy. To heighten clinical awareness of this unusual form of local tumor recurrence, the authors discuss the possible etiology and clinical consequences of this entity.