Rescue Implantation of Expandable Cages for Severe Osteolysis and Cage Dislocation in the Lumbosacral Junction.

BACKGROUND: Osteolysis and implant loosening are commonly encountered problems after spinal instrumentation. CASE DESCRIPTION: In a patient who had previously undergone a posterior lumbar interbody fusion procedure, fusion did not occur, and a secondary cage dislocation led to an impingement of the L5 nerve root with severe radiculopathy. Revision surgery was performed. Intraoperatively, osteolysis was found to be so severe that conventional cages did not fill the void to allow for sufficient anterior column support. We used expandable transforaminal lumbar interbody fusion cages and implanted them bilaterally to replace the dislodged posterior lumbar interbody fusion cages. Clinical follow-up was uneventful. Imaging performed at 1 year showed satisfactory cage position and fusion. CONCLUSIONS: We propose the use of cages with the ability of ventral distraction in similar rescue interventions with cage dislocation and bone resorption. This may prevent a second surgery via a ventral approach.

Concomitant and adjuvant temozolomide of newly diagnosed glioblastoma in elderly patients.

OBJECTIVE: The effect of concomitant and adjuvant temozolomide in glioblastoma patients above the age of 65 years lacks evidence. However, after combined treatment became standard at our center all patients were considered for combined therapy. We retrospectively analyzed the effect of temozolomide focused on elderly patients. METHODS: 293 patients with newly diagnosed glioblastoma treated single-centered between 1998 and 2010, by radiation alone or concomitant and adjuvant radiochemotherapy, were included. Treatment groups were analyzed by multi- and univariate analysis. Matched pairs for age, by a 5-year-caliper, extent of resection and general state was generated for all patients and elderly subgroups. RESULTS: 103 patients received radiation only and 190 combined treatment. Multivariate and matched pair analysis revealed a benefit due to combined temozolomide (HR 1.895 and 1.752, respectively). For patients older than 65 years median survival was 3.6 (95% CI 3.2-4.7) and 8.7 months (6.3-11.8) for radiotherapy only and combined treatment (HR 3.097, p<0.0001, n=90). Over the age of 70 and 75 years median survival was 3.2 (2.3-4.2) vs. 7.5 (5.1-10.9, HR 4.453, p<0.0001, n=62) and 3.2 (1.4-3.9) vs. 9.2 months (4.7-13.5; HR 9.037, p<0.0001, n=24), respectively. In 8/56 (14%) patients over the age of 70 years temozolomide was terminated due to toxicity. CONCLUSION: Retrospective matched pair analysis gives class 2b evidence for prolonged survival due to concomitant and adjuvant temozolomide in elderly glioblastoma patients. Until prospective data for combined radiochemotherapy in elderly patients will be available concomitant and adjuvant temozolomide therapy should not be withheld.

Cranioplasty after decompressive hemicraniectomy: underestimated surgery-associated complications?

OBJECTIVE: Decompressive hemicraniectomy (DC) and duroplasty after malignant brain infarction or traumatic brain injury is a common surgical procedure. Usually, preserved bone flaps are being reimplanted after resolution of brain swelling. Alloplast cranioplasties are seldom directly implanted due to the risk of wound healing disorders. While numerous studies deal with DC, little is known about the encountered problems of bone flap reimplantation. Thus, aim of the study was to identify surgery-associated complications after bone flap reimplantation. METHODS: We performed a retrospective chart analysis of patients that underwent DC and subsequent bone flap reimplantation between 2001 and 2011 at our institution. We registered demographic data, initial clinical diagnosis and surgery-associated complications. RESULTS: We identified 136 patients that underwent DC and subsequent reimplantation. Forty-one patients (30.1%) had early or late surgery-associated complications after bone flap reimplantation. Most often, bone flap resorption and postoperative wound infections were the underlying causes (73%, n=30/41). Multivariate analysis identified age (p=0.045; OR=16.30), GOS prior to cranioplasty (p=0.03; OR=2.38) and nicotine abuse as a prognostic factor for surgery-associated complications (p=0.043; OR=4.02). Furthermore, patients with early cranioplasty had a better functional outcome than patients with late cranioplasty (p<0.05). CONCLUSIONS: Almost one-third of the patients that are operated on for bone flap reimplantation after DC suffer from surgery-associated complications. Most often, wound healing disorders as well as bone flap resorption lead to a second or even third operation with the need for artificial bone implantation. These results might raise the question, if subsequent operations can be avoided, if an artificial bone is initially chosen for cranioplasty.

Indocyanine green angiography in endoscopic third ventriculostomy.

BACKGROUND: Endoscopic third ventriculostomy (ETV) has become a well-established method for the treatment of noncommunicating hydrocephalus with a high success rate and a relatively low morbidity rate. However, vessel injury has been repeatedly reported, often with a fatal outcome. Vessel injury is considered to be the most threatening complication. The use of indocyanine green (ICG) angiography has become an established tool in vascular microneurosurgery. OBJECTIVE: We report our initial experience with endoscopic ICG angiography in ETV for intraoperative visualization of the basilar artery and its perforators to reduce the risk of vascular injury. METHODS: Eleven patients with noncommunicating hydrocephalus underwent ETV. Before opening of the third ventricular floor, ICG angiography was performed using a prototype neuroendoscope for intraoperative visualization of ICG fluorescence. RESULTS: In 10 patients, ETV and ICG angiography were successfully performed. In 1 case, ICG angiography failed. Even in the presence of an opaque floor of the third ventricle (n = 5), ICG angiography clearly demonstrated the course of the basilar artery and its major branches and was considered useful. CONCLUSION: ICG angiography has the potential to become a useful adjunct in ETV for better visualization of vessel structures, especially in the presence of aberrant vasculature, a nontranslucent floor of the third ventricle, or in case of reoperations.

Fluorescence-guided operation in recurrent glioblastoma multiforme treated with bevacizumab-fluorescence of the noncontrast enhancing tumor tissue?

The oral application of 5-aminolevulinic acid (ALA) leads to an accumulation of fluorescent porphyrins in malignant glioma tissue, which simplifies complete tumor resection. If pretreated with bevacizumab, a vascular endothelial growth factor (VEGF) antibody, these patients might not show a contrast enhancement on magnetic resonance imaging (MRI) despite tumor progression. As VEGF antibodies induce a normalization of the tumor vasculature, it is not known whether fluorescence-guided surgery is of any value in patients pretreated with this antibody. One might speculate that missing contrast enhancement on MRI could result in minor or missing fluorescence after the application of ALA. Attempting to give some answers, we report the case of a patient who underwent fluorescence-guided reoperation of recurrent glioblastoma multiforme pretreated with bevacizumab.

The role of neuronavigation in intracranial endoscopic procedures.

In occlusive hydrocephalus, cysts and some ventricular tumours, neuroendoscopy has replaced shunt operations and microsurgery. There is an ongoing discussion if neuronavigation should routinely accompany neuroendoscopy or if its use should be limited to selected cases. In this prospective clinical series, the role of neuronavigation during intracranial endoscopic procedures was investigated. In 126 consecutive endoscopic procedures (endoscopic third ventriculostomy, ETV, n = 65; tumour biopsy/resection, n = 36; non-tumourous cyst fenestration, n = 23; abscess aspiration and hematoma removal, n = 1 each), performed in 121 patients, neuronavigation was made available. After operation and videotape review, the surgeon had to categorize the role of neuronavigation: not beneficial; beneficial, but not essential; essential. Overall, neuronavigation was of value in more than 50% of the operations, but its value depended on the type of the procedure. Neuronavigation was beneficial, but not essential in 16 ETVs (24.6%), 19 tumour biopsies/resections (52.7%) and 14 cyst fenestrations (60.9%). Neuronavigation was essential in 1 ETV (2%), 11 tumour biopsies/resections (30.6%) and 8 cyst fenestrations (34.8%). Neuronavigation was not needed/not used in 48 ETVs (73.9%), 6 endoscopic tumour operations (16.7%) and 1 cyst fenestration (4.3%). For ETV, neuronavigation mostly is not required. In the majority of the remaining endoscopic procedures, however, neuronavigation is at least beneficial. This finding suggests integrating neuronavigation into the operative routine in endoscopic tumour operations and cyst fenestrations.