The use of robot-assisted surgery for the unstable traumatic spine: A retrospective cohort study.

Background: Robotic assistance has been shown to increase instrumentation placement accuracy in open and minimally invasive spinal fusion. These gains have been achieved without increases in operative times, blood loss, or hospitalization duration. However, most work has been done in the degenerative population and little is known of the utility of robotic assistance when applied to spinal trauma. This is largely due to the uncertainty stemming from the disruption of normal anatomy by the traumatic injury. Since the robot depends upon registration for instrumentation guidance according to the fiducials it uses, trauma can introduce unique challenges. The present study sought to evaluate the safety and efficacy of robotic assistance in a consecutive cohort of spine trauma patients. Methods: All patients with Thoracolumbar Injury Classification and Severity Scale (TLICS) >4 who underwent robot-assisted spinal fusion using the Globus ExcelsiusGPS at a single tertiary care center for trauma between 2020 and 2022 were identified. Demographic, clinical, and surgical data were collected and analyzed; the primary endpoints were operative time, fluoroscopy time, estimated blood loss, postoperative complications, admission time, and 90-day readmission rate. The paired t-test was used to compare differences between mean values when looking at the number of surgical levels. Results: Forty-two patients undergoing robot-assisted spinal surgery were included (mean age 61.3±17.1 year; 47% female. Patients were stratified by the number of operative levels, 2 (n = 10), 3-4 (n = 11), 5 to 6 (n = 13), or >6 (n = 8). There appeared to be a positive correlation between number of levels instrumented and odds of postoperative complications, admission duration, fluoroscopy time, and estimated blood loss. There were no instances of screw malposition or breach. Conclusions: This initial experience suggests robotic assistance can be safely employed in the spine trauma population. Additional experiences in larger patient populations are necessary to delineate those traumatic pathologies most amenable to robotic assistance.

Comparative analysis of outcomes following craniotomy and expanded endoscopic endonasal transsphenoidal resection of craniopharyngioma and related tumors: a single-institution study.

OBJECTIVE: Craniopharyngiomas and similar midline suprasellar tumors have traditionally been resected via transcranial approaches. More recently, expanded endoscopic endonasal transsphenoidal approaches have gained interest. Surgeons have advocated for both approaches, and at present there is no consensus whether one approach is superior to the other. The authors therefore compared surgical outcomes between craniotomy and endoscopic endonasal transsphenoidal surgery (EETS) for suprasellar tumors treated at their institution. METHODS: A retrospective review of patients undergoing resection of suprasellar lesions at Cedars-Sinai Medical Center between 2000 and 2013 was performed. Patients harboring suspected craniopharyngioma were selected for extensive review. Other pathologies or predominantly intrasellar masses were excluded. Cases were separated into 2 groups, based on the surgical approach taken. One group underwent EETS and the other cohort underwent craniotomy. Patient demographic data, presenting symptoms, and previous therapies were tabulated. Preoperative and postoperative tumor volume was calculated for each case based on MRI. Student t-test and the chi-square test were used to evaluate differences in patient demographics, tumor characteristics, and outcomes between the 2 cohorts. To assess for selection bias, 3 neurosurgeons who did not perform the surgeries reviewed the preoperative imaging studies and clinical data for each patient in blinded fashion and indicated his/her preferred approach. These data were subject to concordance analysis using Cohen's kappa test to determine if factors other than surgeon preference influenced the choice of surgical approach. RESULTS: Complete data were available for 53 surgeries; 19 cases were treated via EETS, and 34 were treated via craniotomy. Patient demographic data, preoperative symptoms, and tumor characteristics were similar between the 2 cohorts, except that fewer operations for recurrent tumor were observed in the craniotomy cohort compared with EETS (17.6% vs 42.1%, p = 0.05). The extent of resection was similar between the 2 groups (85.6% EETS vs 90.7% craniotomy, p = 0.77). An increased rate of cranial nerve injury was noted in the craniotomy group (0% EETS vs 23.5% craniotomy, p = 0.04). Postoperative CSF leak rate was higher in the EETS group (26.3% EETS vs 0% craniotomy, p = 0.004). The progression-free survival curves (log-rank p = 0.99) and recurrence rates (21.1% EETS vs 23.5% craniotomy, p = 1.00) were similar between the 2 groups. Concordance analysis of cases reviewed by 3 neurosurgeons indicated that individual surgeon preference was the only factor that determined surgical approach (kappa coefficient -0.039, p = 0.762) CONCLUSIONS: Surgical outcomes were similar for tumors resected via craniotomy or EETS, except that more CSF leaks occurred in the EETS cohort, whereas more neurological injuries occurred in the craniotomy cohort. Surgical approach appears to mostly reflect surgeon preference rather than specific tumor characteristics. These data support the view that EETS is a viable alternative to craniotomy, providing a similar extent of resection with less neurological injury.

Instrumenting the small thoracic pedicle: the role of intraoperative computed tomography image-guided surgery.

OBJECT: Traditionally, instrumentation of thoracic pedicles has been more difficult because of their relatively smaller size. Thoracic pedicles are at risk for violation during surgical instrumentation, as is commonly seen in patients with scoliosis and in women. The laterally based "in-out-in" approach, which technically results in a lateral breach, is sometimes used in small pedicles to decrease the comparative risk of a medial breach with neurological involvement. In this study the authors evaluated the role of CT image-guided surgery in navigating screws in small thoracic pedicles. METHODS: Thoracic (T1-12) pedicle screw placements using the O-arm imaging system (Medtronic Inc.) were evaluated for accuracy with preoperative and postoperative CT. "Small" pedicles were defined as those ≤ 3 mm in the narrowest diameter orthogonal to the long axis of the pedicle on a trajectory entering the vertebral body on preinstrumentation CT. A subset of "very small" pedicles (≤ 2 mm in the narrowest diameter, 13 pedicles) was also analyzed. Screw accuracy was categorized as good (< 1 mm of pedicle breach in any direction or in-out-in screws), fair (1-3 mm of breach), or poor (> 3 mm of breach). RESULTS: Twenty-one consecutive patients (age range 32-71 years) had large (45 screws) and small (52 screws) thoracic pedicles. The median pedicle diameter was 2.5 mm (range 0.9-3 mm) for small and 3.9 mm (3.1-6.7 mm) for large pedicles. Computed tomography-guided surgical navigation led to accurate screw placement in both small (good 100%, fair 0%, poor 0%) and large (good 96.6%, fair 0%, poor 3.4%) pedicles. Good screw placement in very small or small pedicles occurred with an in-out-in trajectory more often than in large pedicles (large 6.8% vs small 36.5%, p < 0.0005; vs very small 69.2%, p < 0.0001). There were no medial breaches even though 75 of the 97 screws were placed in postmenopausal women, traditionally at higher risk for osteoporosis. CONCLUSIONS: Computed tomography-guided surgical navigation allows for safe, effective, and accurate instrumentation of small (≤ 3 mm) to very small (≤ 2 mm) thoracic pedicles.

Anterior spinal artery syndrome in a patient with vasospasm secondary to a ruptured cervical dural arteriovenous fistula.

BACKGROUND: Spinal dural arteriovenous fistulas (DAVF) in the cervical spine are known to cause subarachnoid hemorrhage. Vasospasm after rupture of a DAVF, however, has not previously been reported. CASE PRESENTATION: A 48-year-old woman who presented with the sudden onset of altered mental status. Imaging demonstrated extensive subarachnoid hemorrhage and spinal DAVF at C1 to C2. The patient underwent a suboccipital craniotomy for DAVF ligation. On post-operative day three, she began having acute weakness in all her extremities with proprioception and vibration preserved, whereas pain and temperature sensation was lost. An angiogram demonstrated bilateral vertebral artery vasospasm with no filling of the anterior spinal artery. Bilateral angioplasty of the vertebral arteries was performed successfully and post-angioplasty, the right vertebral artery was filling the anterior spinal artery. The patient clinically improved. She subsequently required treatment with n-butyl cyanoacrylic acid (nBCA) embolization and gamma knife radiosurgery to achieve obliteration of the lesion. CONCLUSIONS: For patients with subarachnoid hemorrhage of unknown origin, differential diagnosis should include DAVF. This patient also presented with vasospasm in the context of ruptured DAVF, a complication previously unreported in the literature. This finding suggests that close monitoring for vasospasm after rupture of DAVF is warranted.

Varicella-Zoster-Mediated Radiculitis Reactivation following Cervical Spine Surgery: Case Report and Review of the Literature.

Varicella-zoster virus and herpes simplex virus types 1 and 2 are neurotropic viruses that can be reactivated after a surgical or stressful intervention. Although such cases are uncommon, consequences can be debilitating, and variable treatment responses merit consideration. We describe a 41-year-old male with a history of varicella-mediated skin eruptions, who presented with continuing right arm pain, burning, and numbness in a C6 dermatomal distribution following a C5-6 anterior cervical discectomy and fusion and epidural steroid injections. The operative course was uncomplicated and he was discharged home on postoperative day 1. Approximately ten days after surgery, the patient presented to the emergency department complaining of severe pain in his right upper extremity and a vesicular rash from his elbow to his second digit. He was started on Acyclovir and discharged home. On outpatient follow-up, his rash had resolved though his pain continued. The patient was started on a neuromodulating agent for chronic pain. This case adds to the limited literature regarding this rare complication, brings attention to the symptoms for proper diagnosis and treatment, and emphasizes the importance of prompt antiviral therapy. We suggest adding a neuromodulating agent to prevent long-term sequelae and resolve acute symptoms.

Atypical presentation of thoracic disc herniation: case series and review of the literature.

Modern imaging has revealed that thoracic disc herniation (TDH) has a prevalence of 11-37% in asymptomatic patients. Pain, sensory disturbances, myelopathy, and lower extremity weakness are the most common presenting symptoms, but other atypical extraspinal complaints, such as gastrointestinal or cardiopulmonary discomfort, may be reported. Our objective is to make providers familiar with TDH's atypical symptoms to help avoid potential serious consequences created by a delay in diagnosis. We report the cases of two patients who each presented with atypical extraspinal symptoms secondary to a TDH. One patient presented with a chronic history of nausea, emesis, and chest tightness and MRI showed a large right paramedian disc herniation at T7-8. A second patient reported chronic constipation, buttock and leg burning pain, gait instability, and urinary frequency; an MRI of his thoracic spine demonstrated a central disc herniation at T10-11. TDH can present with vague extraspinal symptoms and unfamiliarity with these symptoms can lead to misdiagnosis with progression of the disease and unnecessary diagnostic tests and medical procedures. Therefore, TDH should be included in the differential diagnosis of patients with negative gastrointestinal, genitourinary, and cardiopulmonary system basic studies.

Comparison of survival between cerebellar and supratentorial glioblastoma patients: surveillance, epidemiology, and end results (SEER) analysis.

BACKGROUND: Cerebellar glioblastoma multiforme (cGBM) is rare, and although there is a general belief that these tumors have a worse prognosis than supratentorial GBM (sGBM), few studies have been published to support this belief. OBJECTIVE: To investigate the effect of cerebellar location on survival through a case-control design comparing overall survival time of cGBM and sGBM patients. METHODS: The Surveillance, Epidemiology, and End Results (SEER) registry was used to identify 132 patients with cGBM (1973-2008). Each cGBM patient was matched with an sGBM patient from among 20,848 sGBM patients on the basis of age, extent of resection, decade of diagnosis, and radiation therapy using propensity score matching. RESULTS: Within the cGBM, 37% were older than 65 years of age, 62% were men, and 87% were white. Most patients underwent surgery and radiation (74%), whereas only 26% underwent surgical resection only. The median survival time for the cGBM and sGBM matched cohort was 8 months; however, the survival distributions differed (log-rank P = .04). Survival time for cGBM vs sGBM at 2 years was 21.5% vs 8.0%, and 12.7% vs 5.3% at 3 years. Multivariate analysis of survival among cGBM patients showed that younger age (P < .0001) and having radiation therapy (P < .0001) were significantly associated with reduced hazard of mortality. Among all patients, multivariate analysis showed that tumor location (P = .03), age (P < .0001), tumor size (P = .009), radiation (P < .0001), and resection (P < .0001) were associated with survival time in the unmatched cohort. CONCLUSION: Median survival time for cGBM and sGBM patients was 8 months, but cGBM patients had a survival time advantage as the study progressed. These findings suggest that cGBM patients should be treated as aggressively as sGBM patients with surgical resection and radiation therapy.

Multiple intracranial metastases from a gastric gastrointestinal stromal tumor.

Intracranial metastases are rare from gastrointestinal stromal tumor (GIST). We report a 60-year-old male with a history of stomach GIST who presented with ataxia 2.5 years after a partial gastrectomy. MRI revealed enhancing masses in the cerebellum and frontal lobe. A suboccipital craniotomy revealed metastatic GIST. With subsequent radiosurgical boost to the resection cavity and frontal lobe lesion, the patient is doing well 15 months postoperatively. To our knowledge, this is one of only a few reports on cerebral GIST metastases from the stomach.

Immunotherapy targeting glioma stem cells--insights and perspectives.

INTRODUCTION: Glioblastoma multiforme (GBM) is the most aggressive and lethal primary malignant brain tumor. Although progress has been made in current conventional therapies for GBM patients, the effect of these advances on clinical outcomes has been disappointing. Recent research into the origin of cancers suggest that GBM cancer stem cells (GSC) are the source of initial tumor formation, resistance to current conventional therapeutics and eventual patient relapse. Currently, there are very few studies that apply immunotherapy to target GSC. AREAS COVERED: CD133, a cell surface protein, is used extensively as a surface marker to identify and isolate GSC in malignant glioma. We discuss biomarkers such as CD133, L1-cell adhesion molecule (L1-CAM), and A20 of GSC. We review developing novel treatment modalities, including immunotherapy strategies, to target GSC. EXPERT OPINION: There are very few reports of preclinical studies targeting GSC. Identification and validation of unique molecular signatures and elucidation of signaling pathways involved in survival, proliferation and differentiation of GSC will significantly advance this field and provide a framework for the rational design of a new generation of antigen-specific, anti-GSC immunotherapy- and nanotechnology-based targeted therapyies. Combined with other therapeutic avenues, GSC-targeting therapies may represent a new paradigm to treat GBM patients.

Direct surgical repair of spondylolysis in athletes: indications, techniques, and outcomes.

OBJECT: Athletes present with back pain as a common symptom. Various sports involve repetitive hyperextension of the spine along with axial loading and appear to predispose athletes to the spinal pathology spondylolysis. Many athletes with acute back pain require nonsurgical treatment methods; however, persistent recurrent back pain may indicate degenerative disc disease or spondylolysis. Young athletes have a greater incidence of spondylolysis. Surgical solutions are many, and yet there are relatively few data in the literature on both the techniques and outcomes of spondylolytic repair in athletes. In this study, the authors undertook a review of the surgical techniques and outcomes in the treatment of symptomatic spondylolysis in athletes. METHODS: A systematic review of the MEDLINE and PubMed databases was performed using the following key words to identify articles published between 1950 and 2011: "spondylolysis," "pars fracture," "repair," "athlete," and/or "sport." Papers on both athletes and nonathletes were included in the review. Articles were read for data on methodology (retrospective vs prospective), type of treatment, number of patients, mean patient age, and mean follow-up. RESULTS: Eighteen articles were included in the review. Eighty-four athletes and 279 nonathletes with a mean age of 20 and 21 years, respectively, composed the population under review. Most of the fractures occurred at L-5 in both patient groups, specifically 96% and 92%, respectively. The average follow-up period was 26 months for athletes and 86 months for nonathletes. According to the modified Henderson criteria, 84% (71 of 84) of the athletes returned to their sports activities. The time intervals until their return ranged from 5 to 12 months. CONCLUSIONS: For a young athlete with a symptomatic pars defect, any of the described techniques of repair would probably produce acceptable results. An appropriate preoperative workup is important. The ideal candidate is younger than 20 years with minimal or no listhesis and no degenerative changes of the disc. Limited participation in sports can be expected from 5 to 12 months postoperatively.

Endometriosis in the Lumbar Plexus Mimicking a Nerve Sheath Tumor.

Endometriosis consists of ectopic endometrial tissue outside of the uterine cavity. It is typically benign. It may cause neurological symptoms if involving the central or peripheral nervous system. We present in this report a 46-year-old Caucasian female with progressively worsening lumbar pain with radiation to her left anterior thigh. MR imaging showed an enhancing mass in the L4 neural foramen, intrepreted as a nerve sheath tumor. At operation the nerve showed extrinsic and intrinsic abnormality, proven to be endometriosis. Postoperatively, the patient reported relief from her radiculopathy. We review the previous cases, discuss the pathogenesis and additional characteristics that highlight intraspinal endometriosis, although rare, should be considered as a potential cause of neurologic symptoms in women. Surgical resection is recommended in cases having severe or worsening neurologic symptoms or signs of cauda equina syndrome. Adjunctive treatment may be used in cases of residual or recurrent lesions.