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Intraoperative electromyography monitoring in minimally invasive transforaminal lumbar interbody fusion

Rajesh K. Bindal and Subrata Ghosh


Minimally invasive transforaminal lumbar interbody fusion (TLIF) is an increasingly popular method for achieving lumbar decompression and fusion. The procedure is technically more demanding than open fusion, with correspondingly more theoretical risk of complication. The authors describe the use of intraoperative electromyography (EMG) as an adjunct to surgery to reduce the risk of complications.


Between August 2005 and April 2006, 25 consecutive patients underwent minimally invasive TLIF in which a total of 105 pedicle screws were placed. Intraoperative EMG was performed and included passive recordings during decompression and interbody graft placement, as well as active recording during the placement of the pedicle access needle and testing of the pedicle tap. A uniform protocol for active monitoring was used, with the pedicle access needle set at 7 mA. To assess hardware placement, all patients underwent postoperative radiography and 20 underwent postoperative computed tomography (CT) scanning.

In no patient did the authors observe significant EMG activation during decompression. In five cases, intermittent nerve root firing was noted after the interbody graft was placed, but this did not correlate with any postoperative deficits. Using the active stimulation protocol, 76.2% of screw placements required one or more changes to the trajectory of the pedicle access needle. With successful placement of the pedicle access needle, in all 105 screws, the pedicle tap nerve root stimulation threshold was greater than 15 mA. Postoperative radiography was performed in all patients and CT scanning was performed in 20 patients (with 85 screws being placed). Postoperative imaging revealed only three cases of pedicle breach. In all cases, the breach was at the lateral wall of the pedicle and not thought to be clinically relevant.


A continuous stimulation pedicle access needle alerts the surgeon to incorrect medial trajectories and may lead to safer pedicle cannulation. As a result of electrophysiological feedback, the pedicle access needle trajectory was altered in 76.2% of the reported cases. The use of the authors’ protocol resulted in a 0% incidence of clinically relevant malpositioned hardware and a low overall neurological complication rate. Intraoperative nerve root monitoring is a useful adjunct to minimally invasive TLIF.

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Management of intracranial plasmacytoma

Ajay K. Bindal, Rajesh K. Bindal, Harry van Loveren, and Raymond Sawaya

✓ The authors report on a study of eight cases of intracranial plasmacytoma to identify the risk of progression to multiple myeloma and suggest the treatment required for cure of solitary lesions. The diagnosis of multiple myeloma or myelomatous changes was made in the immediate postoperative period in four patients (50%), two of whom had skull base lesions. Of the four remaining patients, three were treated with complete surgical resection and radiation therapy and had no recurrence of plasmacytoma or progression to multiple myeloma during mean follow up of 12 years (range 2–25 years); one patient underwent subtotal surgical resection and had recurrence of the tumor despite radiation therapy.

It is concluded that multiple myeloma is unlikely to develop during the long term in patients with intracranial plasmacytoma who do not develop multiple myeloma or myelomatous changes in the early postoperative period. However, lesions that infiltrate the skull base are not likely to be solitary, and patients who harbor these neoplasms should undergo complete evaluation and close follow-up review to exclude multiple myeloma. A recurrence of solitary intracranial plasmacytoma is possible with subtotal surgical resection despite radiation therapy. Definitive treatment should consist of complete surgical resection with adjuvant radiation therapy.

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Surgical treatment of multiple brain metastases

Rajesh K. Bindal, Raymond Sawaya, Milam E. Leavens, and J. Jack Lee

✓ The authors conducted a retrospective review of the charts of 56 patients who underwent resection for multiple brain metastases. Of these, 30 had one or more lesions left unresected (Group A) and 26 underwent resection of all lesions (Group B). Twenty-six other patients with a single metastasis who underwent resection (Group C) were selected to match Group B by type of primary tumor, time from first diagnosis of cancer to diagnosis of brain metastases, and presence or absence of systemic cancer at the time of surgery. Statistical analysis indicated that Groups A and B were also homogeneous for these prognostic indicators. Median survival duration was 6 months for Group A, 14 months for Group B, and 14 months for Group C. There was a statistically significant difference in survival time between Groups A and B (p = 0.003) and Groups A and C (p = 0.012) but not between Groups B and C (p > 0.5). Brain metastasis recurred in 31% of patients in Group B and in 35% of those in Group C; this difference was not significant (p > 0.5). Symptoms improved after surgery in 65% of patients in Group A, 83% in Group B, and 84% in Group C. Symptoms worsened in 13% of patients in Group A, 6% in Group B, and 0% in Group C. Groups A, B, and C had complication rates per craniotomy of 8%, 9%, and 8%, and 30-day mortality rates of 3%, 4%, and 0%, respectively. Guidelines for management of patients with multiple brain metastases are discussed. The authors conclude that surgical removal of all lesions in selected patients with multiple brain metastases results in significantly increased survival time and gives a prognosis similar to that of patients undergoing surgery for a single metastasis.

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Surgery versus radiosurgery in the treatment of brain metastasis

Ajay K. Bindal, Rajesh K. Bindal, Kenneth R. Hess, Almon Shiu, Samuel J. Hassenbusch, Wei Ming Shi, and Raymond Sawaya

✓ Surgery and radiosurgery are effective treatment modalities for brain metastasis. To compare the results of these treatment modalities, the authors followed 31 patients treated by radiosurgery and 62 patients treated by surgery who were retrospectively matched. Patients were matched according to the following criteria: histological characteristics of the primary tumor, extent of systemic disease, preoperative Karnofsky Performance Scale score, time to brain metastasis, number of brain metastases, and patient age and sex. For patients treated by radiosurgery, the median size of the treated lesion was 1.96 cm3 (range 0.41–8.25 cm3) and the median dose was 20 Gy (range 12–22 Gy). The median survival was 7.5 months for patients treated by radiosurgery and 16.4 months for those treated by surgery; this difference was found to be statistically significant using both univariate (p = 0.0018) and multivariate (p = 0.0009) analyses. The difference in survival was due to a higher rate of mortality from brain metastasis in the radiosurgery group than in the surgery group (p < 0.0001) and not due to a difference in the rate of death from systemic disease (p = 0.28). Log-rank analysis showed that the higher mortality rate found in the radiosurgery group was due to a greater progression rate of the radiosurgically treated lesions (p = 0.0001) and not due to the development of new brain metastasis (p = 0.75).

On the basis of their data, the authors conclude that surgery is superior to radiosurgery in the treatment of brain metastasis. Patients who undergo surgical treatment survive longer and have a better local control. The data lead the authors to suggest that the indications for radiosurgery should be limited to surgically inaccessible metastatic tumors or patients in poor medical condition. Surgery should remain the treatment of choice whenever possible.

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Reoperation for recurrent metastatic brain tumors

Rajesh K. Bindal, Raymond Sawaya, Milam E. Leavens, Kenneth R. Hess, and Sarah H. Taylor

✓ Results of reoperation in 48 patients who developed recurrent brain metastases between January 1984 and April 1993 are presented. Median time from first craniotomy to diagnosis of recurrence (time to recurrence) was 6.7 months. Median Karnofsky performance scale (KPS) score prior to reoperation was 80. Recurrence was local in 30 patients, distant in 16 patients, and both local and distant in two patients. Median survival time after reoperation was 11.5 months. There were no operative mortalities. Multivariate analysis revealed that presence of systemic disease (p = 0.008), KPS scores less than or equal to 70 (p = 0.008), time to recurrence of less than 4 months (p = 0.008), age greater than or equal to 40 years (p = 0.51), and primary tumor type of breast or melanoma (p = 0.028) negatively affected patient survival time. These five factors were used to develop a grading system (Grades I–IV). Patients categorized in Grade I had a 5-year survival rate of 57%, whereas the median survival time of patients in Grades II, III, and IV was 13.4, 6.8, and 3.4 months, respectively (p < 0.0001).

Overall, 26 patients developed a second recurrence after reoperation. Seventeen patients underwent a second reoperation, whereas nine did not. Patients undergoing a second reoperation survived a median of 8.6 additional months versus 2.8 months for those who did not (p < 0.0001).

This study concludes that reoperation for recurrent brain metastasis can prolong survival and improve quality of life. A second reoperation can also increase survival. Five factors influence survival: status of systemic disease, KPS score, time to recurrence, age, and type of primary tumor. The grading system using these five factors correlates with survival time. Reoperation should be approached with caution in Grade IV patients because of their poor prognosis.

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Surgeon and patient radiation exposure in minimally invasive transforaminal lumbar interbody fusion

Clinical article

Rajesh K. Bindal, Sharon Glaze, Meghann Ognoskie, Van Tunner, Robert Malone, and Subrata Ghosh


Minimally invasive transforaminal lumbar interbody fusion (TLIF) is an increasingly popular procedure. The technique involves use of fluoroscopy to assist with pedicle screw (PS) placement. The potential exists for both the surgeon and the patient to become exposed to significant amounts of radiation. The authors undertook this study to quantify the radiation dose to the surgeon and patient during minimally invasive TLIF.


The authors undertook a prospective study of 24 consecutive patients who underwent minimally invasive TLIF. All surgeries were performed by the senior author (R.K.B.), who used techniques previously described. The surgeon wore a radiation monitor under an apron-style lead shield at waist level, at an unshielded collar location, and as a sterile ring badge containing a thermoluminescent dosimeter on the dominant (right) hand ring finger. Dosimeter readings were obtained for each case. A total of 33 spinal levels were treated in 24 patients. All treated levels were between L3–4 and L5–S1. In all cases of 1-level disease, 4 PSs were placed, and in all cases of 2-level disease, 6 screws were placed.


. Mean fluoroscopy time was 1.69 minutes per case (range 3.73–0.82 minutes). Mean exposure per case to the surgeon on his dominant hand was 76 mRem, at the waist under a lead apron was 27 mRem, and at an unprotected thyroid level was 32 mRem. Mean exposure to the patient's skin was 59.5 mGy (range 8.3–252 mGy) in the posteroanterior plane and 78.8 mGy (range 6.3–269.5 mGy) in the lateral plane.


To the authors' knowledge, this is the first study of radiation exposure to the surgeon or patient in minimally invasive TLIF. Patient exposures were low and compare favorably with exposures involving other common interventional fluoroscopically guided procedures. Surgeon exposures are limited but require careful monitoring. Annual dose limits could be exceeded if a large number of these and other fluoroscopically guided procedures were performed.