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Shabari Girishan and Vedantam Rajshekhar

OBJECT

Intramedullary dermoid cysts are rare tumors of the spinal cord. Presentation with rapid onset of paraparesis or quadriparesis (onset within 2 weeks) is rarer still. The authors present their experience in the management and outcome of patients with such a presentation.

METHODS

Patient records between 2000 and 2014 were retrospectively reviewed to identify those with intraspinal dermoid cysts who presented with rapid-onset paraparesis or quadriparesis. Their clinical, radiological, operative, and follow-up data were analyzed.

RESULTS

Of a total of 50 patients with intraspinal dermoid cysts managed during the study period, 10 (20%) presented with rapid-onset paraparesis or quadriparesis; 9 patients ranged in age from 8 months to 2 years, and 1 patient was 25 years old. A dermal sinus was seen in the lumbar region of 4 patients, the sacral region of 3, and the thoracic region of 1, and in 1 patient no sinus was found. All except 1 patient presented with rapid-onset paraparesis secondary to infection of the intramedullary dermoid cyst. One patient presented with rupture of a dermoid cyst with extension into the central canal up to the medulla. Early surgery was done soon after presentation in all except 2 patients. Among the 9 patients who underwent surgery (1 patient did not undergo surgery), total excision of the intramedullary dermoid cyst was done in 3 patients, near-total excision in 4 patients, and partial excision in 2 patients. Of the 9 patients who underwent surgery, 8 showed significant improvement in their neurological status, and 1 patient remained stable. The 1 patient who did not undergo surgery died as a result of an uncontrolled infection after being discharged to a local facility for management of wound infection.

CONCLUSIONS

Early recognition of a dermal sinus and the associated intraspinal dermoid cyst and timely surgical intervention can eliminate the chances of acute deterioration of neurological function. Even after an acute onset of paraparesis or quadriparesis, appropriate antibiotic therapy and prompt surgery can provide reasonably good outcomes in these patients.

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Aditya Vedantam and Vedantam Rajshekhar

OBJECTIVE

The goal of this study was to investigate the prevalence and risk factors of clinical adjacent-segment pathology (CASP) following central corpectomy for cervical spondylotic myelopathy (CSM) or ossification of the posterior longitudinal ligament (OPLL).

METHODS

The authors reviewed 353 cases involving patients operated on by a single surgeon with a minimum 12-month follow-up after central corpectomy for CSM or OPLL between 1995 and 2007. Patients with symptoms consistent with CASP at follow-up were selected for the study. The authors analyzed the prevalence and risk factors for CASP after central corpectomy for CSM/OPLL.

RESULTS

Fourteen patients (13 male, 1 female; mean age 46.9 ± 7.7 years) were diagnosed with symptoms of CASP (3.9% of 353 patients) at follow-up. The mean interval between the initial surgery and presentation with symptoms of CASP was 95.6 ± 54.1 months (range 40–213 months). Preoperative Nurick grades ranged from 2 to 5 (mean 3.5 ± 1.2), and the Nurick grades at follow-up ranged from 1 to 5 (mean 3.0 ± 1.3, p = 0.27). Twelve patients had myelopathic symptoms and 2 had radiculopathy at follow-up. Patients with poorer preoperative Nurick grades had a higher risk for development of CASP (HR 2.6 [95% CI 1.2–5.3], p = 0.01).

CONCLUSIONS

In the present study, CASP was seen in 3.9% of patients following central corpectomy for CSM/OPLL. The risk of CASP after central corpectomy for CSM/OPLL was higher in patients with poorer preoperative Nurick grades.

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Sauradeep Sarkar, Bijesh R. Nair, and Vedantam Rajshekhar

OBJECTIVE

This study was performed to describe the incidence and predictors of perioperative complications following central corpectomy (CC) in 468 consecutive patients with cervical spondylotic myelopathy (CSM) or ossification of the posterior longitudinal ligament (OPLL).

METHODS

The authors performed a retrospective review of a cohort of patients who had undergone surgery for CSM (n = 338) or OPLL (n = 130) performed by a single surgeon over a 15-year period. All patients underwent uninstrumented CC with autologous iliac crest or fibular strut grafting. Preoperative clinical and imaging details were collected, and the type and incidence of complications were studied. Univariate and multivariate analyses were performed to establish risk factors for the development of perioperative complications.

RESULTS

Overall, 12.4% of patients suffered at least 1 complication following CC. The incidence of major complications was as follows: C-5 radiculopathy, 1.3%; recurrent laryngeal nerve injury, 0.4%; dysphagia, 0.8%; surgical-site infection, 3.4%; and dural tear, 4.3%. There was 1 postoperative death (0.2%). On multivariate analysis, patients in whom the corpectomy involved the C-4 vertebral body (alone or as part of multilevel CC) were significantly more likely to suffer complications (p = 0.004). OPLL and skip corpectomy were risk factors for dural tear (p = 0.015 and p = 0.001, respectively). No factors were found to be significantly associated with postoperative C-5 palsy, dysphagia, or acute graft extrusion on univariate or multivariate analysis. Patients who underwent multilevel CC were predisposed to surgical-site infections, with a slight trend toward statistical significance (p = 0.094). The occurrence of a complication after surgery significantly increased the mean duration of postoperative hospital stay from 5.0 ± 2.3 days to 8.9 ± 6 days (p < 0.001).

CONCLUSIONS

Complications following CC for CSM or OPLL are infrequent, but they significantly prolong hospital stay. The most frequent complication following CC is dural tear, for which a diagnosis of OPLL and a skip corpectomy are significant risk factors.

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Ranjith K. Moorthy and Vedantam Rajshekhar

✓ Recent advances in neuroimaging have resulted in a marked decrease in morbidity and death due to brain abscesses. The advent of computed tomography–guided stereotaxy has reduced morbidity in patients with deep-seated abscesses. Empirical therapy is best avoided in the present era, particularly given the availability of stereotactic techniques for aspiration and confirmation of diagnosis. Despite these advances, management of abscesses in patients with cyanotic heart disease and in immunosuppressed patients remains a formidable challenge. Unusual as well as more recently recognized pathogens are being isolated from abscesses in immunosuppressed patients. The authors provide an overview of the management of brain abscesses, highlighting their experience in managing these lesions in patients with cyanotic heart disease, stereotactic management of brain abscesses, and management of abscesses in immunosuppressed patients.

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Mazda K. Turel, Sumit Thakar, and Vedantam Rajshekhar

OBJECT

Prospective studies of quality of life (QOL) are infrequently performed in patients undergoing surgery for vestibular schwannoma (VS). The authors designed this to study to investigate health-related QOL (HR-QOL) in patients with large and giant VSs before and after surgery.

METHODS

Between January 2009 and December 2012, HR-QOL was measured prospectively before and after surgery, using the 36-Item Short Form Health Survey (SF-36), in 100 patients who underwent surgery for unilateral large or giant VS (tumor size ≥ 3 cm). The Glasgow Benefit Inventory (GBI) was also used to evaluate the effect of surgery.

RESULTS

A total of 100 patients were included in the study (65 men and 35 women). Their mean age (± SD) was 44.2 ± 11.5 years. The preoperative QOL was decreased in all SF-36 domains. A 1-year follow-up evaluation was conducted for all patients (mean 13.5 ± 5.3 months after surgery). The results showed an improvement in HR-QOL compared with preoperative status in all cases, with 63%–85% of patients showing a minimum clinically important difference (MCID) in various domains. A second follow-up evaluation was performed in 51 cases (mean time after surgery, 29.0 ± 8.3 months) and showed sustained improvement in SF-36 scores. In some domains there was further improvement beyond the first follow-up. On the GBI, 87% of patients reported improvement, 1% felt no change, and 12% of patients reported deterioration.

CONCLUSIONS

Patients harboring large or giant VSs score lower on all the QOL domains compared with the normative population. More than 60% showed a clinically significant improvement in HR-QOL 1 year after surgery, a result that was sustained at subsequent follow-up.

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Mazda K. Turel and Vedantam Rajshekhar

Object

Accurate intraoperative localization of small intradural extramedullary thoracolumbar (T-1 to L-3 level) spinal cord tumors is vital when minimally invasive techniques, such as hemilaminectomy, are used to excise these lesions. In this study, the authors describe a simple and effective method of preoperative MRI localization of small intradural extramedullary tumors using cod liver oil capsules.

Methods

Thirty-five patients with intradural tumors underwent preoperative MRI localization the evening prior to surgery. Patients were positioned prone in the MRI gantry, mimicking the intraoperative position. Nine capsules were placed in 3 rows to cover the lesion. This localization was used to guide the level for a minimally invasive approach using a hemilaminectomy to excise these tumors.

Results

The mean patient age was 51.5 ± 14.3 years, and the mean body mass index was 24.1 ± 3.5 kg/m2. Twenty-two tumors involved the thoracic spine, and 13 involved the upper lumbar spine from L-1 to L-3. The mean tumor size was 2.2 ± 1.0 cm. Localization was accurate in 34 patients (97.1%).

Conclusions

Accurate localization with the described method is quick, safe, cost-effective, and noninvasive with no exposure to radiation. It also reduces operating time by eliminating the need for intraoperative fluoroscopy.

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Vedantam Rajshekhar and Mathew J. Chandy

✓ The benefits of the use of computerized tomography (CT)-guided stereotactic surgical techniques for the management of intrinsic brainstem masses diagnosed from clinical evaluation and imaging studies were evaluated vis-à-vis the risks involved in 71 consecutive patients. Seventy-two procedures were performed. The masses were diffuse, involving two or three contiguous brainstem segments, in 60 patients and focal in 11 patients. On the CT scans, 25 patients had hypodense nonenhancing masses, two had isodense nonenhancing masses, 19 had ring-enhancing masses, and 25 had heterogeneously enhancing masses. A positive biopsy was obtained in 68 of 69 patients (98.5%) undergoing a biopsy procedure. In nine patients (12.6%) with suspected malignant masses a benign pathology was diagnosed (four tuberculomas, two epidermoid cysts, one pyogenic abscess, one epidermal cyst, and one case of encephalitis). Additionally, fluid from cystic masses could be aspirated in eight cases, providing benefit in six (four patients had benign lesions and two had neoplastic lesions). Thereby, a total of 13 patients (18.3%) were deemed to have benefited from the surgery (two patients were included in both categories). Patients with focal masses and ring-enhancing masses had the highest proportion of benign lesions (60% and 36.8%, respectively) and therefore derived the most benefit from histological verification. There was no procedurerelated mortality. One patient (1.4%) suffered permanent morbidity and four others (5.6%) had transient worsening attributable to the procedure. The authors conclude that CT-guided stereotactic surgery of the brainstem is safe and reliable. Histological verification of all enhancing (especially ring-enhancing) and focal brainstem masses should be undertaken to identify patients with benign nonneoplastic lesions. Selected patients with diffuse hypodense nonenhancing masses with atypical clinical or imaging features may also benefit from stereotactic biopsy. Even in these patients the lack of enhancement on a contrast-enhanced magnetic resonance image, rather than the diffuse location of the tumor alone, should form the basis for diagnosing a malignant glioma. The main value of stereotactic surgery lies in the identification of benign masses in a significant proportion of patients with intrinsic brainstem masses and in providing a rapid and safe method for evacuation of the contents of cystic masses.

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Nooti Venkata Srinivasa Rao and Vedantam Rajshekhar

Object

Distal-type cervical spondylotic amyotrophy (CSA) is a rare form of cervical spondylotic myelopathy (CSM). The authors documented the incidence, clinical presentation, radiological features, and outcome following central corpectomy (CC) in patients with this entity.

Methods

The authors performed a retrospective institutional database search of patients who underwent decompressive surgery for CSM between 1992 and 2006 to identify patients with distal-type CSA. Distal-type CSA was defined as weakness and wasting of hands and forearms without gait impairment (Nurick Grades 0 and 1) nor any sensory symptoms or signs in the lower limbs.

Results

The authors identified 7 male patients (1.1%) with distal-type CSA from among 653 patients who underwent either cervical laminectomy (135 patients) or CC (518 patients). There were sensory symptoms or signs in the upper limbs in all but 1 of the patients. Increased signal intensity in the cord was demonstrated on T2-weighted MR images in all patients. The compression was mainly at the C-6 vertebral level. At a mean follow-up of 46.5 months (range 12–98 months), 6 patients had improved by a mean patient perceived outcome score of 66.7% (range 20–100%). Patients' modified Japanese Orthopedic Association scores improved from a preoperative mean (± SD) of 16.1 ± 0.7, to a follow-up mean of 17.4 ± 0.5 (p = 0.004, paired t-test). One patient whose condition worsened 7 months after CC received a diagnosis of a coexistent motor neuron disease.

Conclusions

Distal-type CSA is a rare form of CSM that should be differentiated from motor neuron disease on the basis of subtle sensory symptoms or signs in the upper limbs, and the presence of significant cord compression on the MR imaging. Patient outcome after central corpectomy is good and long lasting.

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Edward C. Benzel

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Vivek Joseph and Vedantam Rajshekhar