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Mark H. Bilsky


Patients with symptomatic herniated thoracic discs may require operation for intractable radiculopathy or functionally disabling myelopathy. In the past, laminectomy was the procedure of choice for the treatment of thoracic herniations, but it was found that the approach was associated with an unacceptably high rate of neurological morbidity. Several strategies have been developed to excise the disc without manipulating the spinal cord. The focus of this paper is the transpedicular approach.


The author retrospectively reviewed the cases of 20 consecutive patients presenting with herniated thoracic discs in whom surgery was performed via a transpedicular approach. Fourteen patients presented with acute myelopathy and six with radiculopathy. Of those with myelopathy six of six regained ambulation and six of seven regained normal bladder function. No patient with myelopathy experienced neurological worsening. In four patients presenting with radiculopathy postoperative pain resolved, and in two it remained unchanged. Three minor complications (15%) occurred. No patient suffered postoperative spinal instability–related pain or delayed kyphosis.


As experience accumulates in the use of multiple approaches for the treatment of thoracic disc herniations, the role of each is becoming more clearly defined. The transpedicular approach is most applicable to lateral or centrolateral calcified or soft discs. The more anterior (transthoracic or thoracoscopic) and lateral (costotransversectomy or lateral extracavitary) approaches may be more useful for excision of central calcified discs.

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Ilya Laufer and Mark H. Bilsky

An improved understanding of tumor biology, the ability to target tumor drivers, and the ability to harness the immune system have dramatically improved the expected survival of patients diagnosed with cancer. However, many patients continue to develop spine metastases that require local treatment with radiotherapy and surgery. Fortunately, the evolution of radiation delivery and operative techniques permits durable tumor control with a decreased risk of treatment-related toxicity and a greater emphasis on restoration of quality of life and daily function. Stereotactic body radiotherapy allows delivery of ablative radiation doses to the majority of spine tumors, reducing the need for surgery. Among patients who still require surgery for decompression of the spinal cord or spinal column stabilization, minimal access approaches and targeted tumor excision and ablation techniques minimize the surgical risk and facilitate postoperative recovery. Growing interdisciplinary collaboration among scientists and clinicians will further elucidate the synergistic possibilities among systemic, radiation, and surgical interventions for patients with spinal tumors and will bring many closer to curative therapies.

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Michael H. Lavyne and Mark H. Bilsky

✓ Intraoperative epidural corticosteroids have been used by some surgeons to decrease pain following surgery for a herniated lumbar disc. In this study, 84 consecutively treated, comparable patients with unilateral lumbar disc herniation were prospectively assigned randomly to receive either epidural corticosteroids (40 mg methylprednisolone acetate) or saline at the conclusion of the operative procedure. The postoperative morbidity of these two groups was evaluated by tabulating the following parameters: pain relief as measured by consumption of postoperative pain medications; the length of hospital stay; postoperative functional status; and the time interval from surgery until return to work. The mean postoperative analgesic medications consumed was 12.2 ± 1.9 mg of morphine equivalents in the corticosteroid group versus 12.2 ± 1.8 mg of morphine equivalents in the control group. The mean hospital stay was less than 2 days in each group, and the mean interval until return to work was 21.2 ± 2.7 days in the corticosteroid group versus 25.4 ± 3.1 days in the control group. Moreover, no statistically significant difference was measured between the steroid-treated and control groups when the data were stratified for sex, age, and site of disc herniation. The mean outcome scores, which are derived from a postoperative assessment of pain relief resulting from surgery, functional status, and interval until return to work, were identical in the corticosteroid and control groups. This study concludes that epidural corticosteroid administration after microsurgical lumbar discectomy for unilateral disc herniation does not lessen postoperative morbidity or improve functional recovery.

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Charles Fisher and Juliet Batke

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Walavan Sivakumar, J. Bradley Elder, and Mark H. Bilsky

Anterior cervical discectomy and fusion (ACDF) is a common neurosurgical procedure, and the benefits, long-term outcomes, and complications are well described in the literature. The development of a juxtafacet joint cyst resulting in radiculopathy is a rare outcome after ACDF and merits further description. The authors describe a patient in whom a juxtafacet joint cyst developed after ACDF procedures, resulting in surgical intervention. When a juxtafacet joint cyst develops after ACDF, symptoms can include radiculopathy, neck pain, and neurological symptoms such as paresthesias and motor weakness. The presence of a juxtafacet joint cyst implies instability in that region of the spine. Patients with this pathological entity may require decompression of neural elements and fusion across the segment involved with the cyst.

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Presacral ganglioneuromas

Report of five cases and review of the literature

Ashok Modha, Philip Paty, and Mark H. Bilsky

✓ Ganglioneuromas are rare, benign, slow-growing tumors belonging to the neuroblastoma group. The authors describe the presentation and treatment of five consecutive patients who presented with presacral ganglioneuromas; these cases represent the largest series to date. A review of the literature is also performed.

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Jatin P. Shah, Mark H. Bilsky, and Snehal G. Patel

Malignant tumors of the skull base have traditionally been difficult to control because of adjacent crucial anatomical structures and because of the inherent difficulty in accessing/resecting tumors and reconstructing surgical defects. Techniques in craniofacial surgery for malignant tumors of the skull base have advanced significantly since their first description. Advances in neuroimaging, surgical technique, perioperative care, and adjuvant treatment have contributed to improved results. Because the majority of malignant tumors requiring craniofacial resection involve the anterior skull base, this review focuses mainly on state-of-the-art surgical techniques as well as pertinent variations, complications and results.

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Theresa Kraetzig, Lily McLaughlin, Mark H. Bilsky, and Ilya Laufer


Myxopapillary ependymoma is a benign WHO Grade I tumor most commonly located in the conus–cauda equina region of the spine. Although this tumor is defined by an overall excellent survival, dissemination throughout the whole neuraxis occurs frequently. The current study evaluated the clinical characteristics and significance of myxopapillary ependymoma metastases.


Patients who underwent surgery from 2005 to 2015 for treatment of spinal myxopapillary ependymoma were included in the study. Charts were reviewed for primary tumor symptoms and initial treatment, local recurrence, response to salvage therapy, and presence and behavior of distant metastases.


Nineteen patients with spinal myxopapillary ependymoma were included in the study (52.6% female). The median age at first diagnosis was 32 years old (range 9–58 years old), and 26.3% were ≤ 18 years old. The median follow-up of all included patients was 48 months (range 6–456 months). Of the primary tumors, 84.2% were located in the lower thoracic or upper lumbar spine, spanning 1–3 levels in 94.7%. All patients underwent surgery for initial treatment: in 78.9% a gross-total resection (GTR) was achieved, with adjuvant radiation therapy (RT) in 20%. Of the 21.2% who underwent a subtotal resection (STR), 75% underwent postoperative RT. Tumor progression was noted in 26.3% of patients after a median 36-month follow-up (range 12–240 months). In 57.9% of patients, distant metastases were found, of which 36.4% were present at initial diagnosis. Further metastases occurred within a median of 20 months (range 2–360 months). Following a diagnosis of metastatic tumor, 72.7% did not show progression and no symptoms were observed during a median follow-up of 36 months (range 6–216 months). Metastases occurred in all parts of the neuroaxis, but were principally localized in the thoracic and sacral spine in 38.9% and 33.3%, respectively; the brain was involved in 11.1%. In 54.5%, more than 1 level was affected. Overall survival was 100% with an excellent clinical and neurological outcome in 78.9% of cases.


Metastatic dissemination within the CNS can be observed in many patients with myxopapillary ependymoma. GTR of the primary tumor should be the primary treatment goal, and additional RT is recommended after STR. For distant metastases of myxopapillary ependymoma without clinical manifestation, close clinical and MRI follow-up represents a sufficient strategy because most of the metastases remain asymptomatic and do not show progression over time. Additional resection or irradiation as salvage therapy would be recommended if metastases become symptomatic.