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William E. Bingaman

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Michael P. Steinmetz, Ann Warbel, Melvin Whitfield and William Bingaman

Object. Despite the wide use of anterior cervical instrumentation in the management of multilevel cervical spondylosis, the incidences of pseudarthrosis and instrument-related failure remain high. The use of a dynamic implant may aid in the prevention of these complications. The purpose of this study was to evaluate the DOC dynamic cervical implant in the treatment of multilevel cervical spondylosis.

Methods. The authors evaluated 34 cases in which anterior multilevel cervical decompression and fusion were performed using the DOC Ventral Cervical Stabilization System. Postoperatively, and at each follow-up visit, the sagittal angle and the degree of subsidence that developed were measured. Fusion rates and clinical outcomes were also evaluated.

The mean postoperative sagittal angle was 14° of lordosis. The mean change in the sagittal angle during the follow-up period was 0.4° of lordosis. By 6 months postoperatively some subsidence had occurred in most patients, with no subsidence occurring in only 15%. By 3 months greater than or equal to 2 mm of subsidence was demonstrated in 61% of cases. The overall fusion rate was 91%. In the majority of patients (79%) symptoms were judged to be improved or resolved.

Conclusions. The DOC dynamic cervical implant permitted controlled subsidence and prevented progression of kyphotic deformity. There was one construct failure (related to a motor vehicle accident) and an overall fusion rate of 91%. The DOC implant is a safe and effective cervical construct for multilevel spondylotic disease.

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Cumhur Kilinçer, Michael P. Steinmetz, Moon Jun Sohn, Edward C. Benzel and William Bingaman

Object. Although advances in patient care have enabled surgeons to perform posterior lumbar decompression and fusion (PLDF), increased age remains a major concern when designing a treatment strategy. The authors conducted a study to evaluate if increased age has any effect on lumbar fusion surgery in terms of perioperative events.

Methods. This retrospective study comprised 129 patients (age range 25–91 years) with spondylolisthesis, lumbar stenosis and/or disc degeneration/herniation with instability, or unsuccessful results after a failed previous PLDF. The patients were stratified by age: those younger than 65 years of age (85 patients) and those at least 65 years of age (44 patients). The parameters reviewed included comorbid conditions, American Society of Anesthesiologists score, instrumentation technique (pedicle screws, a combination of pedicle screw fixation [PSF] and posterior lumbar interbody fusion [PLIF], or non-instrumented fusions), number of fused levels, operative time, estimated blood loss (EBL), complications, and hospital length of stay (LOS).

Fusion strategies in the elderly tended to be more conservative. Repeated operations and PSF/PLIF procedures were less frequent in the older age group. Older age did not result in increased complications, EBL, and operative time. Longer hospital LOS was observed in the older age group (7 ± 3.5 days) compared with the younger age group (5.5 ± 1.9 days) (p = 0.022).

Conclusions. Complications and perioperative events following PLDF in the elderly are comparable with those observed in younger patients. Withholding lumbar spine fusion solely based on advanced age is not warranted.

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David W. Beck and Darren S. Lovick

Object. Although advances in patient care have enabled surgeons to perform posterior lumbar decompression and fusion (PLDF), increased age remains a major concern when designing a treatment strategy. The authors conducted a study to evaluate if increased age has any effect on lumbar fusion surgery in terms of perioperative events.

Methods. This retrospective study comprised 129 patients (age range 25–91 years) with spondylolisthesis, lumbar stenosis and/or disc degeneration/herniation with instability, or unsuccessful results after a failed previous PLDF. The patients were stratified by age: those younger than 65 years of age (85 patients) and those at least 65 years of age (44 patients). The parameters reviewed included comorbid conditions, American Society of Anesthesiologists score, instrumentation technique (pedicle screws, a combination of pedicle screw fixation [PSF] and posterior lumbar interbody fusion [PLIF], or noninstrumented fusions), number of fused levels, operative time, estimated blood loss (EBL), complications, and hospital length of stay (LOS).

Fusion strategies in the elderly tended to be more conservative. Repeated operations and PSF/PLIF procedures were less frequent in the older age group. Older age did not result in increased complications, EBL, and operative time. Longer hospital LOS was observed in the older age group (7 ± 3.5 days) compared with the younger age group (5.5 ± 1.9 days) (p = 0.022).

Conclusions. Complications and perioperative events following PLDF in the elderly are comparable with those observed in younger patients. Withholding lumbar spine fusion solely based on advanced age is not warranted.

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Michael P. Steinmetz, Jared Miller, Ann Warbel, Ajit A. Krishnaney, William Bingaman and Edward C. Benzel

Object

The cervicothoracic junction (CTJ) is the transitional region between the cervical and thoracic sections of the spinal axis. Because it is a transitional zone between the mobile lordotic cervical and rigid kyphotic thoracic spines, the CTJ is a region of potential instability. This potential for instability may be exaggerated by surgical intervention.

Methods

A retrospective review of all patients who underwent surgery involving the CTJ in the Department of Neurosurgery at the Cleveland Clinic Foundation during a 5-year period was performed. The CTJ was strictly defined as encompassing the C-7 vertebra and C7–T1 disc interspace. Patients were examined after surgery to determine if treatment had failed. Failure was defined as construct failure, deformity (progression or de novo), or instability. Variables possibly associated with treatment failure were analyzed. Statistical comparisons were performed using the Fisher exact test.

Between January 1998 and November 2003, 593 CTJ operations were performed. Treatment failed in 14 patients. Of all variables studied, failure was statistically associated with laminectomy and multilevel ventral corpectomies with fusion across the CTJ. Other factors statistically associated with treatment failure included histories of cervical surgery, tobacco use, and surgery for the correction of deformity.

Conclusions

The CTJ is a vulnerable region, and this vulnerability is exacerbated by surgery. Results of the present study indicate that laminectomy across the CTJ should be supplemented with instrumentation (and fusion). Multilevel ventral corpectomies across the CTJ should also be supplemented with dorsal instrumentation. Supplemental instrumentation should be considered for patients who have undergone prior cervical surgery, have a history of tobacco use, or are undergoing surgery for deformity correction.

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Jorge A. González-Martínez, William E. Bingaman, Steven A. Toms and Imad M. Najm

Object

The normal adult human telencephalon does not reveal evidence of spontaneous neuronal migration and differentiation despite the robust germinal capacity of the subventricular zone (SVZ) astrocyte ribbon that contains neural stem cells. This might be because it is averse to accepting new neurons into an established neuronal network, probably representing an evolutionary acquisition to prevent the formation of anomalous neuronal circuits. Some forms of epilepsy, such as malformations of cortical development, are thought to be due to abnormal corticogenesis during the embryonic and early postnatal periods. The role of postnatal architectural reorganization and possibly postnatal neurogenesis in some forms of epilepsy in humans remains unknown. In this study the authors used resected specimens of epileptic brain to determine whether neurogenesis could occur in the diseased tissue.

Methods

The authors studied freshly resected brain tissue obtained in 47 patients who underwent neurosurgical procedures and four autopsies. Forty-four samples were harvested in patients who underwent resection for the treatment of pharmacoresistant epilepsy.

Results

Using organotypic brain slice preparations cultured with 5-bromodeoxyuridine (a marker for cell proliferation), immunohistochemistry, and cell trackers, the authors demonstrate the presence of spontaneous cell proliferation, migration, and neuronal differentiation in the adult human telencephalon that starts in the SVZ and progresses to the adjacent white matter and neocortex in human neocortical pathological structures associated with epilepsy. No cell migration or neuronal differentiation was found in the control group.

Conclusions

The presence of spontaneous neurogenesis associated with some forms of human neocortical epilepsy may represent an erroneous and maladaptive mechanism for neuronal circuitry repair, or it may be an intrinsic part of the pathogenic process.

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Jorge A. González-Martínez, Gabriel Möddel, Zhong Ying, Richard A. Prayson, William E. Bingaman and Imad M. Najm

Object

Nitric oxide has been associated with epileptogenesis. Previous studies have shown increased expression of N-methyl-d-aspartate (NMDA) subunit NR2B receptors in epileptic dysplastic human neocortex. The expression of neuronal nitric oxide synthase (nNOS), and its relation to this subunit NR2B in epileptic dysplastic tissue has never been addressed.

Methods

Ten patients with medically intractable epilepsy caused by focal cortical dysplasia (CD), and 2 patients with mesial temporal sclerosis (control group) underwent pre- and/or intraoperative invasive monitoring evaluations. Cortical samples from epileptogenic and nonepileptogenic areas were collected from each patient intraoperatively. Samples were processed for cresyl violet staining, immunocytochemical tests with nNOS, NeuN, and NR2B, and immunofluorescence analyses to evaluate colocalized immunoreactivity between nNOS and NR2B.

Results

. All samples obtained in the patients with epilepsy revealed CD in various degrees. In the nonepileptic sample group, cresyl violet staining revealed normal cortical architecture in 9 samples, but a mild degree of CD in 3. The density and intensity of nNOS-stained neurons was remarkably increased in the epileptic tissue compared with nonepileptic samples (p < 0.05). Two types of nNOS-stained neurons were identified: Type I, expressing strong nNOS immunoreactivity in larger neurons; and Type II, expressing weak nNOS immunoreactivity in slightly smaller neurons. Different from Type I neurons, Type II nNOS-stained neurons revealed immunoreactivity colocalized with NR2B antibody.

Conclusions

The overexpression of nNOS in the epileptic samples and the immunoreactivity colocalization between nNOS and NR2B may suggest a possible role of nNOS and NO in the pathophysiological mechanisms related to in situ epileptogenicity.

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Nitin Tandon, Andreas V. Alexopoulos, Ann Warbel, Imad M. Najm and William E. Bingaman

Object

Occipital resections for epilepsy are rare. Reasons for this are the relative infrequency of occipital epilepsy, difficulty in localizing epilepsy originating in the occipital lobe, imprecisely defined seizure outcome in patients treated with focal occipital resections in the MR imaging era, and concerns about producing visual deficits. The impact of lesion location on vision and seizure biology, the management decision-making process, and the outcomes following resection need elaboration.

Methods

The authors studied 21 consecutive patients who underwent focal occipital resections for epilepsy at Cleveland Clinic Epilepsy Center over a 13-year period during which MR imaging was used. Demographics, imaging, and data relating to the epilepsy and its surgical management were collected. The collateral sulcus, the border between the medial surface and the lateral convexity, and the inferior temporal sulcus were used to subdivide the occipital lobe into medial, lateral, and basal zones. Lesions that did not involve most or all of the occipital lobe (sublobar) were spatially categorized into these zones. Visual function, semiology, and scalp electroencephalography were evaluated in relation to these spatial categories. Preresection and postresection visual function and seizure frequency were evaluated and compared. Lastly, an exhaustive review and discussion of the published literature on occipital resections for epilepsy was carried out.

Results

Five lesions were lobar and 16 were sublobar. Patients with medial or lobar lesions had a much greater likelihood of preoperative visual field defects. Those with basal or lateral lesions had a greater likelihood of having a visual aura preceding some or all of their seizures and a trend (not significant) toward having a concordant lateralized onset by scalp electroencephalography. Invasive recordings were used in 8 cases. All patients had lesions (malformations of cortical development, tumors, or gliosis) that were completely resected, as evaluated on postoperative MR imaging. At last follow-up, 17 patients (81%) were seizure free or had only occasional auras (Wieser Class 1 or 2). The remaining 4 patients (19%) had a worthwhile improvement in seizure control (Class 3 or 4). Of the patients for whom both pre- and postoperative visual testing data were available, 50% suffered no new visual deficits, and 17% each developed a new quadrantanopia or a hemianopia.

Conclusions

Lesional occipital lobe epilepsy can be successfully managed with resection to obtain excellent seizure-free rates. Individually tailored resections (in lateral occipital lesions, for example) may help preserve intact vision in a subset of cases (38% in this series). Invasive recordings may further guide surgical decision-making as delineated by an algorithm generated by the authors. The authors' results suggest that the spatial location of the lesion correlates both with the semiology of the seizure and with the presence of visual deficit.

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Shaila Gowda, Fortino Salazar, William E. Bingaman, Prakash Kotagal, Deepak L. Lachhwani, Ajay Gupta, Stephen Davis, Julie Niezgoda and Elaine Wyllie

Object

Few data are available concerning efficacy and safety of surgery for catastrophic epilepsy in the first 6 months of life.

Methods

The authors retrospectively analyzed epilepsy surgeries in 15 infants ranging in age from 1.5 to 6 months (median 4 months) and weight from 4 to 10 kg (median 7 kg) who underwent anatomical (4 patients) or functional (7 patients) hemispherectomy, or frontal (1 patient), frontoparietal (2 patients), or parietooccipital (1 patient) resection for life-threatening catastrophic epilepsy due to malformation of cortical development.

Results

No patient died. Intraoperative complications included an acute ischemic infarction with hemiparesis in our youngest, smallest infant. The most frequent complication was blood loss requiring transfusion, which was encountered in every case. The estimated blood loss was 3–214% (median 63%) of the total blood volume. At maximum follow-up of 6–121 months (median 60 months), 46% were seizure free.

Conclusions

Epilepsy surgery may be effective in young infants as it is in older children. However, intraoperative blood loss and risk of permanent postoperative neurological deficits present significant challenges.

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Oral Presentations

2010 AANS Annual Meeting Philadelphia, Pennsylvania May 1–5, 2010