Successful treatment of a brain-metastasized renal cell carcinoma.

Renal cell carcinoma is an uncommon type of cancer that rarely metastasizes to the brain. The prognosis after discovering brain metastasis has traditionally been dismal. We are presenting a case of renal cell carcinoma with multiple brain metastases that was successfully treated with multimodal therapy including a new type of medication.

Quantitative estimation of the recurrent laryngeal nerve irritation by employing spontaneous intraoperative electromyographic monitoring during anterior cervical discectomy and fusion.

STUDY DESIGN: Prospective, clinical study. OBJECTIVE: The objective of our study was to evaluate the role of laryngeal intraoperative electromyography (IEMG) in predicting the development of postoperative recurrent laryngeal nerve (RLN) palsy in patients undergoing anterior cervical discectomy and fusion (ACDF). We also attempted to develop a method to quantify the total IEMG irritation of the RLN. SUMMARY OF BACKGROUND DATA: RLN injury has been recognized as the most common ACDF-associated neurologic injury. It has been postulated, that the employment of laryngeal IEMG may identify the operative events leading to RLN injury and subsequent postoperative palsy. METHODS: Laryngeal IEMG monitoring was performed in 298 patients undergoing ACDF. Preexistent baseline EMG activity, amplitude, and duration of IEMG activity were recorded. The total amount of RLN irritation was expressed as an Irritation Score (IS) applying a specially designed mathematical equation incorporating the amplitude, the duration, and the presence of any baseline EMG irritation. The relationship of IEMG activity with parameters such as the number of operative levels, the duration of the procedure, the presence of any previous neck surgeries, and the type of the used retractor was examined. RESULTS: IEMG activity was recorded in 14.4% of our patients. Postoperative RLN injury occurred in 2.3% of our patients. The sensitivity of IEMG was 100%, the specificity 87%, the positive predictive value 16%, and its negative predictive value 97%. The calculated IS ranged between 0.28 and 3.47 (mean IS: 2.09). Significantly increased IEMG activity was found in patients with previous surgical intervention, patients undergoing multilevel procedures, long-lasting procedures, and cases in which self-retained retractors were used. Likewise, significantly increased IS were observed in patients with previous surgeries and in cases where self-retained retractors were used. CONCLUSIONS: Our study indicates that laryngeal IEMG is a high-sensitivity modality that can provide real-time information and can potentially minimize the risk of operative RLN injury.

Upper-limb somatosensory evoked potential monitoring in lumbosacral spine surgery: a prognostic marker for position-related ulnar nerve injury.

BACKGROUND CONTEXT: Somatosensory evoked potential (SSEP) is used to monitor integrity of the brain, spinal cord, and nerve roots during spinal surgery. It records the electrical potentials from the scalp after electrical stimulation of the peripheral nerves of the upper or lower limbs. The standard monitoring modality in lumbosacral spine surgery includes lower-limb SSEP and electromyography (EMG). Upper-limb SSEP monitoring has also been used to detect and prevent brachial plexopathy and peripheral nerve injury in thoracic and lumbosacral spine surgeries. We routinely monitor lower-limb SSEP and EMG in lumbosacral spine procedures at our institution. However, a few patients experienced postoperative numbness and/or pain in their ulnar distribution with uneventful lower-limb SSEP and EMG. PURPOSE: We hypothesized that the postoperative upper extremity paresis in lumbosacral surgeries may result from compression and/or stretch of the brachial plexus and/or ulnar nerve while the patients were in prone position. Using upper-limb SSEP, we investigated whether we observe any significant change in the SSEP, and if so, whether we can prevent or reduce frequency of postoperative upper extremity deficits. STUDY DESIGN/SETTING: In this prospective study, we monitored upper-limb SSEP, in addition to lower-limb SSEP and EMG, in 230 elective, posterior lumbosacral spinal procedures. All operations were performed by a group of four neurosurgeons. PATIENT SAMPLE: One hundred and thirty-one female and 99 male with an age range of 28 to 86 years between January 2004 and December 2005 were studied. OUTCOME MEASURES: Amplitude and latency of upper-limb or ulnar SSEP were continuously compared with those of the baseline. A greater than or equal to 50% decrease in SSEPs amplitude and/or a greater than or equal to 10% increase in latency were considered to be significant. METHODS: After intubation, patients were positioned prone on Jackson or Andrews spinal table. Anesthesia was maintained with inhalant gas (desflurane or sevoflurane) and propofol infusion with and without minimal infusion of narcotics (fentanyl, sufentanyl, or remifentanil). Intraoperative neurophysiologic monitoring of upper-limb or ulnar SSEP was achieved by continuously recording cortical and subcortical responses after alternate stimulation of the ulnar nerve at the wrist. In our institutional protocol, a greater than or equal to 50% decrease in SSEPs amplitude and/or a greater than or equal to 10% increase in latency were considered to be significant to alert the operating surgeons. When significant changes occurred, the surgeon was immediately notified. Also, reevaluation of vital signs, depth of anesthesia, and patient's position, and technical troubleshootings were subsequently followed. RESULTS: We observed a greater than or equal to 50% decrease in amplitude of ulnar SSEP in 10 patients without significant changes in lower-limb SSEP (peroneal or posterior tibial nerve SSEP) or EMG during surgery. Eight patients had changes in unilateral limbs, and two patients had changes in bilateral limbs. Two patients with significant changes in unilateral limbs showed changes twice. The mean SSEP amplitude for the 14 changes was 29.2+/-3.1% (mean+/-SEM, standard error of mean) of the baseline value at the average surgical time of 60+/-1.5 minutes. With repositioning of the arms, the amplitudes were immediately restored with the average of 70.2+/-7.1% (n=14) of the baseline value. The mean amplitude of upper-limb SSEP was 73.4+/-8.7% (n=12) of the baseline at wound closure. The average surgical time was 154+/-29.2 minutes per case for the 10 patients. There was no documented postoperative upper extremity paresis in all 230 patients. CONCLUSIONS: The present study demonstrates that upper-limb SSEP monitoring could detect position-related ulnar neuropathy in 5.2% of the patients undergoing lumbosacral spine surgery.

Cauda equina syndrome-think of cancer.

Leptomeningeal carcinomatosis (LC) is a serious complication found in approximately 1% to 8% of patients with solid cancer and carries substantial rates of morbidity and mortality. Up to 48% of patients may present with LC before the presence of systemic cancer is known. We present the case of a patient who presented with symptoms of cauda equina syndrome and for whom subsequent investigations revealed intrathecal metastases and locally advanced lung cancer without respiratory symptoms or brain or bone metastases. The case emphasizes the need for thorough investigation in the presence of the triad: back pain, weakness in the lower extremities, and urinary urgency/incontinence. Cauda equina syndrome due to intrathecal metastases should always be considered. Spine MRI with contrast is the most informative investigative study for these patients, and myelography remains an important diagnostic method.

Anterior cervical discectomy and fusion associated complications.

STUDY DESIGN: Retrospective review study with literature review. OBJECTIVE: The goal of our current study is to raise awareness on complications associated with anterior cervical discectomy and fusion (ACDF) and their early detection and proper management. SUMMARY OF BACKGROUND DATA: It is known that ACDF constitutes one of the most commonly performed spinal procedures. Its outcome is quite satisfactory in the majority of cases. However, occasional complications can become troublesome, and in rare circumstances, catastrophic. Although there are several case reports describing such complications, their rate of occurrence is generally underreported, and data regarding their exact incidence in large clinical series are lacking. Meticulous knowledge of potential intraoperative and postoperative ACDF-related complications is of paramount importance so as to avoid them whenever possible, as well as to successfully and safely manage them when they are inevitable. METHODS: In a retrospective study, 1015 patients undergoing first-time ACDF for cervical radiculopathy and/or myelopathy due to degenerative disc disease and/or cervical spondylosis were evaluated. A standard Smith-Robinson approach was used in all our patients, while an autologous or allograft was used, with or without a plate. Operative reports, hospital and outpatient clinic charts, and radiographic studies were reviewed for procedure-related complications. Mean follow-up time was 26.4 months. RESULTS: The mortality rate in our current series was 0.1% (1 of 1015 patients, death occurred secondary to an esophageal perforation). Our overall morbidity rate was 19.3% (196 of 1015 patients). The most common complication was the development of isolated postoperative dysphagia, which observed in 9.5% of our patients. Postoperative hematoma occurred in 5.6%, but required surgical intervention in only 2.4% of our cases. Symptomatic recurrent laryngeal nerve palsy occurred in 3.1% of our cases. Dural penetration occurred in 0.5%, esophageal perforation in 0.3%, worsening of preexisting myelopathy in 0.2%, Horner's syndrome in 0.1%, instrumentation backout in 0.1%, and superficial wound infection in 0.1% of our cases. CONCLUSION: Meticulous knowledge of the ACDF-associated complications allows for their proper management. Postoperative dysphagia, hematoma, and recurrent laryngeal nerve palsy were the most common complications in our series. Management of complications was successful in the vast majority of our cases.

Pain outcome and vertebral body height restoration in patients undergoing kyphoplasty.

INTRODUCTION: Kyphoplasty, a minimally invasive technique, has recently been developed to provide immediate pain relief, biomechanical stabilization, prevention of fracture progression, vertebral height restoration, and prevention or reversal of kyphosis to patients with osteoporotic vertebral compression fractures (VCF). MATERIALS AND METHODS: We retrospectively reviewed 24 patients treated with kyphoplasty. A total of 37 vertebral levels were augmented. Visual analog scale (VAS) scores were documented in the immediate pre- and postoperative period, as well as 4, 12, and 72 weeks after the procedure. Vertebral body height restoration was assessed on postoperative x-rays. RESULTS: Mean preoperative VAS score was 9.3 and improved to 5.4 in the immediate postoperative period. At 4, 12 and 72 weeks post-operatively, mean VAS scores were 5.1, 5.9, and 6.1 respectively. All patients returned to their daily activities within 24 hours. No significant restoration of vertebral body height was observed. CONCLUSION: In regards to pain relief and postoperative functional outcome, kyphoplasty is a safe and effective treatment modality for osteoporotic VCFs, even when no significant restoration of vertebral body height is achieved.

Surgical treatment of acute type II and rostral type III odontoid fractures managed by anterior screw fixation.

OBJECTIVES: In the present study, the authors comment on their experience with anterior odontoid screw fixation in the management of odontoid fractures, in an attempt to further assess the safety and the efficacy of this procedure. MATERIALS AND METHODS: A retrospective analysis of 50 consecutive patients with reducible type II or rostral type III odontoid fractures, operated at our hospital with anterior odontoid screw fixation. Radiographic bony fusion, complications, and clinical outcome were evaluated. RESULTS: Solid bony fusion was evident in 38 (90.5%) of the patients. One mechanical instrumentation-related complication occurred, without clinical significance. No other major complications related to the procedure were noted. A satisfactory range of motion in the cervical spine was observed in all patients. CONCLUSIONS: Anterior odontoid screw fixation is a safe and effective procedure for the treatment of type II and rostral type III odontoid fractures. Compliance to the specific indications and contraindications of this operation is crucial for optimal outcome.

Cerebrospinal fluid fistula secondary to dural tear in anterior cervical discectomy and fusion: case report.

STUDY DESIGN: A case of cerebrospinal fistula secondary to a dural tear during anterior cervical discectomy and fusion. OBJECTIVES: To report a quite rare complication associated with anterior cervical discectomy and remind the spinal surgeons that this infrequent complication can easily become a very serious one. SUMMARY OF BACKGROUND DATA: Anterior cervical discectomy represents one of the most commonly performed spinal procedures. Of the associated complications, accidental dural tear can lead to the development of a cerebrospinal fluid (CSF) fistula. Although this complication has been mentioned in several clinical series, the body of knowledge regarding incidence and appropriate treatment is definitely limited. METHODS: After undergoing anterior cervical discectomy and fusion for an extruded disc at the C4-C5 level, a CSF fistula developed in a 37-year-old patient as a result of a dural tear. The patient underwent a second procedure for surgical wound revision, meticulous dural opening coverage, and insertion of a lumbar drain for draining CSF for 5 days. RESULTS: The patient was hospitalized for 5 days and then discharged with no evidence of CSF leakage. His follow-up of 9 months revealed complete resolution of his preoperative symptomatology and no other problems associated with the complication of the CSF fistula. CONCLUSION: Early identification of this complication and aggressive treatment with insertion of lumbar drain, CSF drainage for 4-5 days, and coverage of the dural tear with fibrin sealant or autologous fascia graft can prevent the development of any consequences.

Immediate and early postoperative pain relief after kyphoplasty without significant restoration of vertebral body height in acute osteoporotic vertebral fractures.

OBJECT: Painful osteoporotic vertebral compression fractures (VCFs) are a significant cause of disability in the elderly population. Kyphoplasty, a recently developed minimally invasive procedure, has been advocated for the successful management of these fractures in terms of immediate pain relief, and also for restoration of the premorbid level of daily activities. In this retrospective study the authors report on their experience with the early management of VCFs with kyphoplasty. METHODS: A retrospective analysis was conducted in 13 patients (seven women and six men) whose ages ranged from 48 to 87 years (mean age 71.5 +/- 11 years [mean +/- standard deviation]). The interval between onset of symptoms and surgical intervention ranged from 4 to 9 weeks. Twenty levels (12 thoracic, eight lumbar) were treated in this cohort. Immediate and early postoperative (1-month follow-up visit) visual analog scale (VAS) pain scores, activity levels, and restoration of vertebral body (VB) height were assessed. The mean preoperative VAS score was 8 +/- 1, whereas the immediate and early postoperative scores were 1 +/- 1. These findings reflected a resolution of 90 to 100% of preoperative pain. All patients resumed routine activities within hours of the procedure, although improvement in VB height was not accomplished in this cohort. No major complications were encountered in this clinical series. CONCLUSIONS: Kyphoplasty is a safe and effective method for the treatment of osteoporotic VCFs. Failure to restore VB height does not seem to interfere with the excellent pain management and good functional outcome provided by this procedure.

Correlation of the amount of disc removed in a lumbar microdiscectomy with long-term outcome.

STUDY DESIGN: The authors conducted a prospective clinical study. OBJECTIVES: The objectives of this study were to investigate the relationship, if any, of the amount of removed disc in a standard first-time lumbar microdiscectomy and long-term outcome as well as recurrence and postoperative instability rates. SUMMARY OF BACKGROUND DATA: There is lack of data on the amount of disc that needs to be removed during a lumbar microdiscectomy. Anecdotal data and dogmatic recommendations make the subject even more controversial. MATERIAL AND METHODS: A total of 106 patients underwent a standard first-time lumbar microdiscectomy for medically refractory sciatica resulting from a herniated disc. The removed disc material was weighted. All patients were clinically followed for at least 2 years and outcome was evaluated by using pain intensity, presence of physical signs, functional capacity, return to work, and patients' opinion regarding their outcome. RESULTS: The mean amount of disc removed was calculated at 2.1 +/- 0.9 g. Ninety-one patients had an excellent outcome and returned to their preoperative work. Fifteen patients had persistent symptomatology and underwent extensive radiographic workup, which revealed a disc recurrence at the same level in 8 patients and first-degree instability in 3 patients. In the remaining 4 patients, no clinical or radiographic abnormality was proven and the patients were treated conservatively, whereas all of them had applied for disability. No relationship was proven between the amount of the removed disc and the intraoperative blood loss or the intraoperative complication rate. Our statistical analysis showed no correlation between the amount of the removed disc and the long- term outcome, recurrence rate, or postoperative instability. CONCLUSIONS: The degree of disc removal did not influence the outcome or complication rate in our clinical series.

Does intraoperative electromyographic monitoring in lumbar microdiscectomy correlate with postoperative pain?

OBJECTIVES: Our objective was to correlate the findings of intraoperative electromyographic (EMG) monitoring with immediate postoperative pain in patients undergoing lumbar microdiscectomy. METHODS: A total of 112 patients undergoing de novo lumbar microdiscectomy were prospectively randomized into a control group (n = 45) and a study group (n = 67) in which intraoperative EMG monitoring was used. Postoperative pain and postoperative narcotic consumption were recorded for each patient. RESULTS: The presence or absence of EMG monitoring did not influence the level of reported pain in any anatomic area. In the monitored group, the degree of recorded nerve root irritation did not correlate with reported pain or postoperative narcotic consumption. The level of back pain was found to be significantly higher than the level of hip and calf pain (P < 0.0001). CONCLUSIONS: In our study no correlation was found between intraoperative EMG findings and immediate postoperative pain.

Epidural intracranial abscess as a complication of frontal sinusitis: case report and review of the literature.

Two cases of epidural abscess as a complication of frontal sinusitis are presented. The diagnoses were suspected on the basis of history and were confirmed by magnetic resonance imaging and computed tomography. Both patients were treated successfully by means of surgery and intravenous antibiotics. One patient developed meningitis in the postoperative course and was treated by changing the antibiotic regimen. However, further follow-up in the outpatient clinic by physical examinations and brain computed tomography scans showed no longterm neurologic complications in either case. Intracranial suppuration, including epidural abscesses, can complicate acute and chronic frontal sinusitis. These complications are diagnosed by maintaining a high index of suspicion and using the appropriate neuroimaging studies without delay.

Intracranial temperature: is it different throughout the brain?

INTRODUCTION: Accurate knowledge of cerebral temperature is assuming increasing importance, because its manipulation is employed more frequently for cerebral protection. PURPOSE: This prospective clinical study was performed to examine how well intraventricular temperature reflects global cerebral temperature. METHODS: The intraventricular temperature was monitored in 61 patients who were admitted to the neurointensive care unit for various intracranial pathological entities. A temperature probe coupled to an intraventricular pressure monitor was inserted in the lateral ventricle. At the conclusion of the monitoring process, a second intraventricular temperature probe was inserted in the ipsilateral ventricle and the previous one was carefully and gradually removed. During that removal, the intraparenchymal temperature was monitored for 90 minutes at 1-cm intervals throughout the brain parenchyma. RESULTS: The mean intraventricular temperature was 37.84+/-1.03 degrees C, whereas the mean systemic (rectal) temperature was 37.65+/-0.68 degrees C. At 1 cm outward distance from the lateral ventricle, the mean intraparenchymal temperature was 38.21+/-0.32 degrees C, 38.39+/-0.33 degrees C at 2 cm, 38.27+/-0.31 degrees C at 3 cm, 38.26+/-0.29 degrees C at 4 cm, and, finally, 37.9+/-0.50 degrees C at 5 cm. Statistical analysis of the recordings showed no statistically significant differences between the intraventricular and intraparenchymal temperatures and intraventricular and rectal temperatures. No statistically significant correlation was established between the intraventricular temperature and parameters, such as the patient's age, sex, and admitting diagnosis. CONCLUSION: Cerebral temperature was relatively stable through the brain parenchyma in this study. Because intraventricular temperature accurate.