Comparative Analysis of Efficacy and Safety of Multisession Radiosurgery to Single Dose Radiosurgery for Metastatic Brain Tumors

BACKGROUND: The purpose of this study is to compare the efficacy and safety of multisession radiosurgery to those of single dose radiosurgery for metastatic brain tumors. METHODS: Between February 2008 and February 2012, 90 patients with 196 metastatic brain tumors were treated with cyberknife radiosurgery, and we reviewed these patients retrospectively. Among them, 57 patients underwent single dose radiosurgery, and 33 patients multisession radiosurgery. Tumors involving the eloquent area and large tumors (>5 cc) were treated with multisession radiosurgery. The median tumor volume and the median treatment dose of single dose radiosurgery were 2.05+/-0.72 cc and 19.76+/-1.54 Gy respectively, and in the case of multisession radiosurgery, 5.30+/-1.70 cc and 29.6+/-1.70 Gy respectively. The frequency of multisession dose was 3 to 5 times, on average 3.55 times, and 8.91 Gy were given per 1 session on average. RESULTS: The overall survival (OS) of multisession radiosurgery was 16.0 months, whereas that of single dose radiosurgery was 11.5 months. The radiologic tumor response rates were 90% in single dose radiosurgery and 95.4% in multisession radiosurgery, respectively. Over 6-month and 1-year periods, the OS rates of single dose radiosurgery were 71.4% and 44.9%, whereas those of multisession radiosurgery were 69.1% and 58.3%, respectively (p=0.83). Toxicities were seen in 18.1% in the single dose radiosurgery group versus 4% in the multisession radiosurgery group. The difference was significant (p<0.05). CONCLUSION: In this study, the multisession radiosurgery group, despite the location and size constraints, did not differ from the single dose radiosurgery group when comparing the survival and recurrence rates, but complications and toxicity were lower. Thus, multisession radiosurgery is thought to be beneficial for treatment of large tumors and tumors located in the eloquent area.

Anterior Cervical Osteophytes Causing Dysphagia and Paradoxical Vocal Cord Motion Leading to Dyspnea and Dysphonia

Anterior cervical osteophytes are common and usually asymptomatic in elderly people. Due to mechanical compressions, inflammations, and tissues swelling of osteophytes, patients may be presented with multiple complications, such as dysphagia, dysphonia, dyspnea, and pulmonary aspiration. Paradoxical vocal cord motion is an uncommon disease characterized by vocal cord adductions during inspiration and/or expiration. This condition can create shortness of breath, wheezing, respiratory stridor or breathy dysphonia. We report a rare case demonstrating combined symptoms of dyspnea, dysphonia as well as dysphagia at the same time in a patient with asymptomatic anterior cervical osteophytes. Moreover, this is the first report demonstrating that anterior osteophytes can be a possible etiological factor for paradoxical vocal cord motion that induces serious respiratory symptoms.

Morphological Organization of Cauda Equina

OBJECTIVE: Topographic arrangement and morphometric pattern of cauda equina are studied. METHODS: In 10 adult formalin fixed cadavers, the entire dural sac of lumbosacral spine including extradural nerve roots was extracted. After paraffin fixation, serial cross section from sacral nerve roots to conus medullaris was performed. We investigated following structures at each disc level using a slide scanner after haematoxylin and eosin and Masson's trichrome stains: 1) location of filum terminale(FT), 2) arrangement of motor and sensory bundles, 3) morphometric characteristics of sensory bundles to motor bundle of each spinal nerve root. RESULTS: The FT was located in the dorsal half of midline at L2-3 disc level and in the most dorsal portion of midline from the L4-5 disc level and downward. All bundles of each nerve root showed an oblique arrangement. Motor bundle of each spinal nerve root was always located in the anterior or anteromedial portion of the corresponding sensory bundles. At L4-5 and L5-S1 disc levels, S1 to S4 nerve roots were arranged inverted V-shape centered FT. The sensory root was composed of several bundles whereas the motor root was always composed of a single bundle. The areas occupied by sensory bundles were larger than 2 to 4 times in S1-3 sacral nerve roots and 1.9 to 2.4 times in L3-5 lumbar nerve roots compared with those occupied by the corresponding motor roots. CONCLUSION: This study will be helpful to prevent the nerve root injury during the operation of cauda equina and predict postoperative complications.

Standardization of Disease, Diagnostic and Neurosurgical Procedures for the Investigation of Korean Neurosurgical Epidemiology - Part 1: Development of Model for Computerization -

OBJECTIVE: The the international classification of disease and surgical procedure has been found to be a lengthy and time-consuming text for use by neurosurgeons. A more subject matter related classification system is needed for use by this specialty. The author has developed a more comprehensive and standardized classification system specified for diagnosis of neurological disease and neurosurgical procedures. METHODS: Standardization of disease was completed by modifying the name of disease according to that which was used for daily report past 10 years, and from textbook of neurosurgery. The fields of international coding are continued in each. Neurosurgical procedures were designated and modified according to Current Procedure Terminology 96. Client-server system will be used for networking and database software applications have been developed. RESULTS: Disease was classified in 14 large categories and 379 subcategories. Diagnosis was classified in 12 large categories and 43 subcategories. Neurosurgical procedure has 20 large and 202 subcategories. The international coding system such as ICD-10 and ICD-9CM is maintained for the diagnosis and procedures to each category. CONCLUSIONS: It could be possible to make and use a standardized database model of disease, diagnosis and neurosurgical procedures to be used by physician.

Standardization of Disease, Diagnostic and Neurosurgical Procedures for the Investigation of Korean Neurosurgical Epidemiology - Part 2: Clinical Application -

OBJECTIVE: Using the standardization of disease diagnosis of disease, and surgical procedures, the authors have made a clinical application for the analysis of inpatient data with the ability to search for information pertinent for writing of clinical articles. METHODS: A client-server system and database software was developed for networking. For clinical application, a computerized daily report has been developed. Data from Neurosurgical patients admitted at Soonchunyang University Hospital from January to December 1998 were analyzed with this system. Data for clinical articles was obtained using the search mode, information such as orbital infarction syndrome following intracranial aneurysm surgery and epidemiological analysis or geriatric neurosurgical patients. RESULTS: For the daily report it takes approximately 10 minutes to input the patients demographic information, name of disease, diagnosis and surgical procedure. The daily report also numbers and sorts the inpatients according to large categories of diagnosis, reports the ratio between inpatients and operative patients. The annual report that was obtained was very accurate and gave rapid statistics for the one year. By retrospective study for the past 18 years, we calculated the incidence of orbital infarction syndrome following intracranial aneurysm surgery as 1.4%, and also estimated the population of geriatric inpatients as 18.3% by retrospective study. CONCLUSIONS: It has been found to be most useful to make a daily and annual report for tracking and research purposes. For use in clinical articles, it can be possible to do a search of the patients using the standardized disease, diagnosis and neurosurgical procedures application and obtain pertinent information in a timely manner.

Regenerative Effect of Microsuture Nerve Repair and Fibrin Glue after Rat Sciatic Nerve Section

To compare the regenerative effect of direct end-to-end suture, nerve graft and sutureless fibrin glue repair in the rat sciatic model, forty rats were divided into 4 groups: normal control group(NC-G, n=6), direct end-to-end suture group(DS-G, n=12), nerve graft group(NG-G, n=10) and sutureless fibrin glue group(FG-G, n=12). One half of each group except NC-G was sacrificed 4 weeks later and the other half was sacrificed 14 weeks later. The repair site was assessed by nerve conduction studies and quantitative morphometry. Regeneration index (RI) was defined as a total number of remyelinated axons in one quarter of 3X5 inch sized microphotograph. The comparison among groups was analyzed statistically by Kruskal-Wallis 1-way ANOVA and Mann-Whitney test. Nerve conduction study done 14 weeks later revealed that latency was 1.7ms+/-0.18(DS-G), 2.4ms+/-0.35(NG-G), 2.4ms+/-0.17(FG-G) and amplitude was 20.1mV+/-2.89(DS-G), 12.0mV+/-2.47(NG-G), 13.7mV+/-2.95(FG-G). RI was 281+/-37.5(DS-G), 227+/-14.4(NG-G) and 217+/-22.2(FG-G). There was a statistical difference in the latency, amplitude and RI between three groups(p0.05). Regenerative effect of fibrin glue is not different from that of nerve graft, therefore fibrin glue repair can facilitate inaccessible nerve repairs in skull base or spinal surgery.