August 10, 2013, 16:38

August 8, 2013, 0:00

Sivashanmugam Dhandapani, Karamchand Sharma

Surgical Neurology International 2013 4(1):102-102

Background: Large highly vascular meningiomas are surgically challenging when preoperative embolization is not feasible. Case Description: We present an illustrative case of 'en bloc' excision of a highly vascular giant lateral sphenoid wing meningioma using the technique of 4 D's. After ruling out neurovascular encasement and significant brain interposition, our technique consisted of devascularization, diminutive dural opening, early detachment, and progressively deeper circumferential dissection. "En bloc" delivery was aided by the underlying brain pulsations and edema with no retraction or manipulation. This was successfully employed in a series of seven more patients with large meningiomas with less blood loss. All the patients recovered well with no clinical or radiological sequelae. Conclusion: In select large vascular meningiomas, en bloc excision appears to be a simple, safe, and effective alternative to piecemeal excision, which can be performed in any set-up.

August 6, 2013, 19:47

The University of Chicago Journal Club   Participating faculty: Roitberg B, Frim D, Lam S. Residents: Monim-Mansour N; Dey M; Khader-Eliyas J; Hobbs J; Stamates M Topic: Methylprednisolone for spinal cord injury. Is the controversy over?   Introduction: March 2013 saw the publication of new guidelines for the treatment of acute spinal cord injury, which … Continue reading Methylprednisolone for spinal cord injury. Is the controversy over? — Journal Club No. 1, 2013 →

July 23, 2013, 0:00

Atef Ben Nsir, Mohamed Boughamoura, Mezri Maatouk, Mohamed Kilani, Nejib Hattab

Surgical Neurology International 2013 4(1):96-96

Background: Metastatic Ewing's sarcoma to the central nervous system is an uncommon condition and debate concerning the true origin of its metastases is still up to date. To the best of our knowledge, only two cases of dural metastatic Ewing's sarcoma have been published in the English medical literature. We present an additional case in a 24-year-old female and discuss the pathogenesis of these unusual tumors with review of the relevant literature concerning their treatment and outcome. Case Description: A 24-year-old female with previous history of pelvis Ewing's sarcoma and recently discovered lung metastases, presented with moderate headache for the past 2 weeks and weakness in her left leg for the past 2 days. Computed tomography scan and magnetic resonance imaging revealed an extra-axial right frontoparietal mass invading the superior sagittal sinus but with clear delineation with brain parenchyma. Imaging features were suggestive of a meningioma as no abnormalities in the skull abutting to the tumor were noted. The patient underwent surgical removal of her tumor. Near total resection was achieved and histological examination showed evidence of metastatic Ewing's sarcoma. Postoperative adjuvant radiation and chemotherapy were administered. The patient improved well postoperatively with full recovery of her motor weakness. She is symptom free with no signs of progression, at most recent follow-up, 8 months after surgery. Conclusion: Despite its rarity, metastatic Ewing's sarcoma must be considered in the differential diagnosis of extra-axial dural masses particularly meningiomas.

July 17, 2013, 0:00

Miguel A Faria

Surgical Neurology International 2013 4(1):91-91

In the final installment to this three-part, essay-editorial on psychosurgery, we relate the history of deep brain stimulation (DBS) in humans and glimpse the phenomenal body of work conducted by Dr. Jose Delgado at Yale University from the 1950s to the 1970s. The inception of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1974-1978) is briefly discussed as it pertains to the "determination of the Secretary of Health, Education and Welfare regarding the recommendations and guidelines on psychosurgery." The controversial work - namely recording of brain activity, DBS, and amygdalotomy for intractable psychomotor seizures in patients with uncontrolled violence - conducted by Drs. Vernon H. Mark and Frank Ervin is recounted. This final chapter recapitulates advances in neuroscience and neuroradiology in the evaluation of violent individuals and ends with a brief discussion of the problem of uncontrolled rage and "pathologic aggression" in today's modern society - as violence persists, and in response, we move toward authoritarianism, with less freedom and even less dignity.

July 9, 2013, 0:00

Julius Höhne, Alexander Brawanski, Holger G Gassner, Karl-Michael Schebesch

Surgical Neurology International 2013 4(1):88-88

Background: With decompressive craniectomy for ischemic stroke, traumatic brain injury, and skull-infiltrating tumors, the need for cranioplasty has increased. Different materials for custom-made cranioplasties have been evaluated, but a gold standard could not yet be established. We report our experience with the new custom-made titanium CRANIOTOP ® cranioplasty (CL Instruments, Germany). Methods: A total of 50 consecutive patients received a CRANIOTOP cranioplasty within a 2 year interval. We reviewed the charts for time between initial surgery and cranioplasty, indication, complications, operative time, and cosmetic outcome. Postoperative imaging (computed tomography [CT] scan n = 48, magnetic resonance imaging (MRI) n = 5) was screened for fitting accuracy and for hemorrhages. Results: The most common indication for craniectomy were diffuse edema due to traumatic brain injury (n = 17, 34%) and ischemic stroke (n = 12, 24%). All patients were satisfied with the cosmetic result. In the postoperative CT scan accurate fitting was confirmed in all patients, the postoperative MRI was free of artifacts. Surgical revision was necessary in five patients because of empyema (n = 2), wound exposure (n = 2), and one cerebrospinal fluid fistula. Thus, the surgical morbidity was 10%. Conclusion: With due consideration of the limitations of this retrospective study, we feel the present data allow concluding that the custom-made titanium cranioplasty CRANIOTOP ® is safe and feasible.

July 9, 2013, 0:00

Nuno M Simas, João Paulo Farias

Surgical Neurology International 2013 4(1):86-86

Background: Sphenoid wing en plaque meningiomas are a subgroup of meningiomas defined by its particular sheet-like dural involvement and its disproportionately large bone hyperostosis. En plaque meningiomas represent 2-9% of all meningiomas and they are mainly located in the sphenoid wing. Total surgical resection is difficult and therefore these tumors have high recurrence rates. Methods: Eighteen patients with sphenoid wing en plaque meningiomas surgically treated between January 1998 and December 2008 were included. Clinical, surgical, and follow-up data were retrospectively analyzed. Results: Mean age was 52.2 years and 83% were female. Five patients presented extension of dural component into the orbit and six patients presented cavernous sinus infiltration. Adjuvant radiation therapy was performed in three patients. After a mean follow-up of 4.6 years, five patients developed tumor recurrence - two patients were submitted to surgical treatment and the other three were submitted to radiation therapy. No patient presented recurrence after radiation therapy, whether performed immediately in the postoperative period or performed after recurrence. Patients without tumor extension to cavernous sinus or orbital cavity have the best prognosis treated with surgery alone. When tumor extension involves these locations the recurrence rate is high, especially in cases not submitted to adjuvant radiation therapy. Conclusion: Cavernous sinus and superior orbital fissure involvement are frequent and should be considered surgical limits. Postoperative radiation therapy is indicated in cases with residual tumor in these locations.

June 13, 2013, 0:00

Ron Pawl

Surgical Neurology International 2013 4(6):330-333

Chronic pain syndromes either have no underlying organic explanation, or include patients whose chronic pain complaints (without focal deficits or significant radiographic findings) were not alleviated by surgery (in 80% of cases). Patients with chronic pain typically "turn off" members of the medical community; they are often "written off" as malingerers or psychiatric cases. The Minnesota Multiphasic Personality Inventory often shows elevations on the hysteria and hypochondriasis scales; together these constitute somatization defined as patients converting emotional distress into bodily complaints. Depression, anxiety, and borderline personality disorders are also often encountered. Secondary gain also plays a critical role in patients with chronic pain syndromes (e.g., includes avoiding onerous tasks/work, or rewards opioid-seeking behaviors). Tertiary gain pertains to the physicians' financial rewards for administering ineffective and repeated treatment of these patients, while validating for the patient that there is truly something organically wrong with them. Self-mutilation (part of Munchausen Syndrome/Fictitious Disorders) also brings these chronic pain patients to the attention of the medical community. They are also often involved in the legal system (e.g., workmen's compensation or tort action) that in the United States, unfortunately financially rewards "pain and suffering." The main purpose of this commentary is to reeducate spinal surgeons about the pitfalls of operating on patients with chronic pain syndromes in the absence of significant neurological deficits or radiographic findings, as such "last ditch surgery" invariably fails.

June 1, 2013, 0:00

Miguel A Faria

Surgical Neurology International 2013 4(1):75-75

Knowledge of neuroscience flourished during and in the wake of the era of frontal lobotomy, as a byproduct of psychosurgery in the late 1930s and 1940s, revealing fascinating neural pathways and neurophysiologic mechanisms of the limbic system for the formulation of emotions, memory, and human behavior. The creation of the Klüver-Bucy syndrome in monkeys opened new horizons in the pursuit of knowledge in human behavior and neuropathology. In the 1950s specialized functional neurosurgery was developed in association with stereotactic neurosurgery; deep brain electrodes were implanted for more precise recording of brain electrical activity in the evaluation and treatment of intractable mental disorders, including schizophrenia, "pathologic aggression," and psychomotor seizures in temporal lobe epilepsy. Psychosurgical procedures involved deep brain stimulation of the limbic system, as well as ablative procedures, such as cingulotomy and thalamotomy. The history of these developments up to the 21st century will continue in this three-part essay-editorial, exclusively researched and written for the readers of Surgical Neurology International.

May 28, 2013, 0:00

Ara J Deukmedjian, ST Jason Cutright, PA-C Augusto Cianciabella, Arias Deukmedjian

Surgical Neurology International 2013 4(1):68-68

Background: Deuk Laser Disc Repair &#174; is a new full-endoscopic surgical procedure to repair symptomatic cervical disc disease. Methods: A prospective cohort of 66 consecutive patients underwent cervical Deuk Laser Disc Repair &#174; for one (n = 21) or two adjacent (n = 45) symptomatic levels of cervical disc disease and were evaluated postoperatively for resolution of headache, neck pain, arm pain, and radicular symptoms. All patients were candidates for anterior cervical discectomy and fusion (ACDF) or arthroplasty. The Mann-Whitney Wilcoxon test was used to calculate P values. Results: All patients (n = 66) had significant improvement in preoperative symptoms with an average symptom resolution of 94.6%. Fifty percent (n = 33) had 100% resolution of all preoperative cervicogenic symptoms. Only 4.5% (n = 3) had less than 80% resolution of preoperative symptoms. Visual analog scale (VAS) significantly improved from 8.7 preoperatively to 0.5 postoperatively (P < 0.001) for the cohort. Average operative and recovery times were 57 and 52 minutes, respectively. There were no perioperative complications. Recurrent disc herniation occurred in one patient (1.5%). Average postoperative follow-up was 94 days and no significant intergroup difference in outcomes was observed (P = 0.111) in patients with <90 days (n = 52) or >90 days (n = 14, mean 319 days) follow-up. No significant difference in outcomes was observed (P = 0.774) for patients undergoing one or two level Deuk Laser Disc Repair &#174; . Patients diagnosed with postoperative cervical facet syndrome did significantly worse (P < 0.001). Conclusion: Deuk Laser Disc Repair &#174; is a safe and effective alternative to ACDF or arthroplasty for the treatment of one or two adjacent symptomatic cervical disc herniations with an overall success rate of 94.6%.