Commentary on article: Laminoplasty versus laminectomy and fusion for multilevel cervical myelopathy: A meta-analysis of clinical and radiological outcomes by Chang-Hyun Lee et al

Nancy E. Epstein

Date of publication: 31-Aug-2015

Background:This is a commentary on the article laminoplasty versus laminectomy and fusion (LF) for multilevel cervical myelopathy: A meta-analysis of clinical and radiological outcomes by Chang-Hyun Lee et al. Here, the authors utilized seven studies to compare the efficacy of cervical expansive laminoplasty (EL) versus laminectomy and fusion (LF) to address three or more level multilevel cervical spondylotic myelopathy (CSM). Both procedures led to similar degrees of neurological recovery and short-term loss of lordosis, but found that LF led to more favorable long-term results.

Medicare payment data for spine reimbursement; important but flawed data for evaluating utilization of resources

Richard P. Menger, Michael E. Wolf, Sunil Kukreja, Anthony Sin, Anil Nanda

Date of publication: 31-Aug-2015

Background:Medicare data showing physician-specific reimbursement for 2012 were recently made public in the mainstream media. Given the ongoing interest in containing healthcare costs, we analyze these data in the context of the delivery of spinal surgery.

Spinal surgeons need to read patients’ studies to avoid missing pathology

Nancy E. Epstein, Renee D. Hollingsworth, Richard Silvergleid

Date of publication: 25-Jun-2015

Background:Many spine surgeons rely on reports of radiological studies for patients seen routinely in consultation. However, “best practice” should include the spine surgeon's individual assessment of the images themselves to better determine whether the diagnoses rendered were/are correct.

Techniques in distal access of wide-necked giant intracranial aneurysms during treatment with flow diversion

Peter Kan, Ajay Kumar Wakhloo, Maxim Mokin, Ajit Puri

Date of publication: 28-May-2015

Background:Accessing the normal distal vessel in treatment of wide-necked giant intracranial aneurysms with flow diversion can be difficult.

External ventricular drains: Management and complications

Rajanandini Muralidharan

Date of publication: 25-May-2015

Background:Insertion of an External Ventricular Drain (EVD) is arguably one of the most common and important lifesaving procedures in neurologic intensive care unit. Various forms of acute brain injury benefit from the continuous intracranial pressure (ICP) monitoring and cerebrospinal fluid (CSF) diversion provided by an EVD. After insertion, EVD monitoring, maintenance and troubleshooting essentially become a nursing responsibility.

Robotics in the neurosurgical treatment of glioma

Garnette R. Sutherland, Yaser Maddahi, Liu Shi Gan, Sanju Lama, Kourosh Zareinia

Date of publication: 13-Feb-2015

Background:The treatment of glioma remains a significant challenge with high recurrence rates, morbidity, and mortality. Merging image guided robotic technology with microsurgery adds a new dimension as they relate to surgical ergonomics, patient safety, precision, and accuracy.

The future of high-grade glioma: Where we are and where are we going

Emilie Le Rhun, Sophie Taillibert, Marc C. Chamberlain

Date of publication: 13-Feb-2015


High-grade glioma (HGG) are optimally treated with maximum safe surgery, followed by radiotherapy (RT) and/or systemic chemotherapy (CT). Recently, the treatment of newly diagnosed anaplastic glioma (AG) has changed, particularly in patients with 1p19q codeleted tumors. Results of trials currenlty ongoing are likely to determine the best standard of care for patients with noncodeleted AG tumors. Trials in AG illustrate the importance of molecular characterization, which are germane to both prognosis and treatment. In contrast, efforts to improve the current standard of care of newly diagnosed glioblastoma (GB) with, for example, the addition of bevacizumab (BEV), have been largely disappointing and furthermore molecular characterization has not changed therapy except in elderly patients. Novel approaches, such as vaccine-based immunotherapy, for newly diagnosed GB are currently being pursued in multiple clinical trials. Recurrent disease, an event inevitable in nearly all patients with HGG, continues to be a challenge. Both recurrent GB and AG are managed in similar manner and when feasible re-resection is often suggested notwithstanding limited data to suggest benefit from repeat surgery. Occassional patients may be candidates for re-irradiation but again there is a paucity of data to commend this therapy and only a minority of selected patients are eligible for this approach. Consequently systemic therapy continues to be the most often utilized treatment in recurrent HGG. Choice of therapy, however, varies and revolves around re-challenge with temozolomide (TMZ), use of a nitrosourea (most often lomustine; CCNU) or BEV, the most frequently used angiogenic inhibitor. Nevertheless, no clear standard recommendation regarding the prefered agent or combination of agents is avaliable. Prognosis after progression of a HGG remains poor, with an unmet need to improve therapy.

Bionanotechnology and the Future of Glioma

Peter A. Chiarelli, Forrest M. Kievit, Miqin Zhang, Richard G. Ellenbogen

Date of publication: 13-Feb-2015


Designer nanoscaled materials have the potential to revolutionize diagnosis and treatment for glioma. This review summarizes current progress in nanoparticle-based therapies for glioma treatment including targeting, drug delivery, gene delivery, and direct tumor ablation. Preclinical and current human clinical trials are discussed. Although progress in the field has been significant over the past decade, many successful strategies demonstrated in the laboratory have yet to be implemented in human clinical trials. Looking forward, we provide examples of combined treatment strategies, which harness the potential for nanoparticles to interact with their biochemical environment, and simultaneously with externally applied photons or magnetic fields. We present our notion of the “ideal” nanoparticle for glioma, a concept that may soon be realized.

Convection-enhanced drug delivery for gliomas

Andrew T. Healy, Michael A. Vogelbaum

Date of publication: 13-Feb-2015


In spite of aggressive multi-modality treatments, patients diagnosed with anaplastic astrocytoma and glioblastoma continue to display poor median survival. The success of our current conventional and targeted chemotherapies are largely hindered by systemic- and neurotoxicity, as well as poor central nervous system (CNS) penetration. Interstitial drug administration via convection-enhanced delivery (CED) is an alternative that potentially overcomes systemic toxicities and CNS delivery issues by directly bypassing the blood–brain barrier (BBB). This novel approach not only allows for directed administration, but also allows for newer, tumor-selective agents, which would normally be excluded from the CNS due to molecular size alone. To date, randomized trials of CED therapy have yet to definitely show survival advantage as compared with today's standard of care, however, early studies appear to have been limited by “first generation” delivery techniques. Taking into consideration lessons learned from early trials along with decades of research, newer CED technologies and therapeutic agents are emerging, which are reviewed herein.

Immunotherapy for malignant glioma

Carter M. Suryadevara, Terence Verla, Luis Sanchez-Perez, Elizabeth A. Reap, Bryan D. Choi, Peter E. Fecci, John H. Sampson

Date of publication: 13-Feb-2015


Malignant gliomas (MG) are the most common type of primary malignant brain tumor. Most patients diagnosed with glioblastoma (GBM), the most common and malignant glial tumor, die within 12–15 months. Moreover, conventional treatment, which includes surgery followed by radiation and chemotherapy, can be highly toxic by causing nonspecific damage to healthy brain and other tissues. The shortcomings of standard-of-care have thus created a stimulus for the development of novel therapies that can target central nervous system (CNS)-based tumors specifically and efficiently, while minimizing off-target collateral damage to normal brain. Immunotherapy represents an investigational avenue with the promise of meeting this need, already having demonstrated its potential against B-cell malignancy and solid tumors in clinical trials. T-cell engineering with tumor-specific chimeric antigen receptors (CARs) is one proven approach that aims to redirect autologous patient T-cells to sites of tumor. This platform has evolved dramatically over the past two decades to include an improved construct design, and these modern CARs have only recently been translated into the clinic for brain tumors. We review here emerging immunotherapeutic platforms for the treatment of MG, focusing on the development and application of a CAR-based strategy against GBM.