Transsphenoidal approaches for the extracapsular resection of midline suprasellar and anterior cranial base lesions.

OBJECTIVE: The transsphenoidal approach is an effective method for treating tumors contained within the sella or extending into the suprasellar cistern. The technique of tumor dissection is predicated on preservation of the integrity of the diaphragma, i.e., intracapsular removal. Gross total extracapsular dissection may, however, be accomplished either by using a standard approach to the pituitary fossa or by extending the exposure to include removal of a portion of the planum sphenoidale and division of the superior intercavernous sinus. METHODS: Included in this series were 14 patients with parasellar or sellar tumors with extension into the anterior fossa and/or suprasellar cistern. For 4 of 14 patients (29%), extracapsular access was gained by broaching the tumor capsule from within the pituitary fossa. For the remaining 10 of 14 patients (71%), the dura of the floor of the sella and the planum sphenoidale was exposed, using neuronavigation to verify the limits of bony dissection; extracapsular tumor resection was performed using the operating microscope and endoscopy as indicated. The dural defect was repaired with abdominal fat, the sellar floor and planum sphenoidale were reconstructed, and in selected cases a lumbar drain was placed. RESULTS: Seven of 14 tumors (50%) were craniopharyngiomas, 3 of 14 (21%) were pituitary adenomas, and 2 of 14 (14%) were meningiomas. There was one case of lymphocytic hypophysitis and one yolk sac tumor. Gross total resection was possible in 11 of 14 cases (79%). Immediate postoperative visual function worsened in 2 of 14 cases (14%), improved in 3 of 14 cases (21%), and was stable in the remainder of cases. Postoperatively, 2 of 14 patients (14%) developed bacterial meningitis. Overt postoperative cerebrospinal fluid rhinorrhea was not observed. CONCLUSION: Gross total extracapsular resection of midline suprasellar tumors via a transsphenoidal approach is possible but is associated with a higher risk of complications than is standard transsphenoidal surgery.

Cranial base reconstruction after transsphenoidal surgery with bioabsorbable implants.

OBJECTIVE: Reconstruction of the cranial base is often necessary after transsphenoidal surgery to prevent the occurrence of cerebrospinal fluid rhinorrhea and to maintain anatomic integrity. In most cases, sellar packing (fat, muscle, gelatin sponge) may be supported by bone or cartilage harvested at the time of surgery. The use of synthetic material, however, becomes desirable in cases in which an autograft is not available. Low-molecular-weight polylactide implants may serve as an effective alternative because they are immunologically inert, magnetic resonance imaging-compatible, and easily contoured to custom-fit a defect. METHODS AND RESULTS: MacroSorb (MacroPore, San Diego, CA) absorbable plates are made from amorphous 70:30 poly (L-lactide-co-D,L-lactide) polymers. Implants are malleable at temperatures of 70 degrees C and solidify at room or body temperature; plates are resorbed in 18 months. CONCLUSION: Polylactide polymer implants are effective adjuncts in transsphenoidal surgery when cranial base reconstruction is necessary and when an endogenous osseous or cartilaginous graft is unavailable.

Subarachnoid haemorrhage: epidemiology, risk factors, and treatment options.

The present review focuses on subarachnoid haemorrhage (SAH) secondary to the rupture of an intracranial aneurysm, a condition with a high case fatality rate. Additionally, many of the surviving patients are left with significant disabilities. Risk factors for aneurysmal SAH include both genetic and acquired conditions. The most common presenting symptom is sudden onset of severe headache. Since headache is very common in the general population, it is not unusual that SAH is misdiagnosed at its onset with often catastrophic consequences. Unlike other acute neurological disorders such as brain injury, in which patient outcome is closely related to the extent of the injury occurring at the time of the trauma, patients with aneurysmal SAH are at risk of subsequent deterioration from 'avoidable' complications such as rebleed, vasospasm, hydrocephalus, and several other non-neurological general medical complications. Thus, the critical care management of the patient with SAH is of utmost importance in order to maximise the chances of satisfactory recovery. Although surgical clipping of the ruptured aneurysm remains the gold standard therapy, with the continuing refinement of endovascular techniques, a new, 'less invasive' option is now available, especially for patients considered poor surgical candidates.

Incidence and outcome of kyphotic deformity following laminectomy for cervical spondylotic myelopathy.

OBJECT: The authors undertook a study to explore the predisposing risk factors, frequency of occurrence, and clinical implications of kyphosis following laminectomy for cervical spondylotic myelopathy (CSM). METHODS: Preoperative radiological studies were available in 46 patients with CSM who had undergone laminectomy. Records were reviewed to obtain demographic data and operative reports. Preoperative radiographs were assessed to determine spinal alignment. In a follow-up interview the authors established clinical outcome and patient satisfaction. Postoperative cervical alignment and mobility was also determined by assessing lateral neutral, flexion, and extension x-ray films. Preoperatively, the cervical spine was shown to be kyphotic in four (9%) of 46, straight in 20 (43%) of 46, and lordotic in 22 (48%) of 46 patients. Nine (21%) of 42 patients with either straight or lordotic alignment demonstrated in the preoperative period developed kyphosis after surgery. Kyphosis developed in six (30%) of 20 patients in whom straight spinal alignment was demonstrated preoperatively and in only three (14%) of 22 patients in whom lordosis was found preoperatively. Clinically, 13 (29%) of 45 patients improved and 19 (42%) of 45 remained unchanged after an average 4-year follow-up period; 36 (80%) patients believed that their surgery was successful (one patient, who was mentally retarded, could not respond to the follow-up questionnaire). Spinal alignment was not predictive of outcome; cervical mobility as demonstrated on flexion and extension, however, correlated with improved functional performance (p = 0.005). CONCLUSIONS: Kyphosis may develop in up to 21% of patients who have undergone laminectomy for CSM. Progression of the deformity appears to be more than twice as likely if preoperative radiological studies demonstrate a straight spine. In this study, clinical outcome did not correlate with either pre- or postoperative sagittal alignment.

Complications of posterior lumbar interbody fusion when using a titanium threaded cage device.

OBJECT: The authors reviewed their series of patients to quantify clinical and radiographic complications in those who underwent a posterior lumbar interbody fusion (PLIF) procedure in which a threaded interbody cage (TIC) was implanted. METHODS: Sixty-seven patients underwent a posterior lumbar interbody fusion procedure in which a TIC was used. The authors excluded patients who underwent procedures in which other instrumentation was used or a nondorsal approach was performed. Fifteen percent of the cases (10 patients) were complicated by laceration of the dura. In three cases, bilateral implantation could not be performed. The average blood loss was 670 ml for all cases, and blood transfusion was required in 25% of the cases (17 patients). The rate of minor wound complication was 4.5% (three patients). One patient died. The average period of hospitalization was 4.25 days. Twenty-eight patients (42%) experienced significant low-back pain 3 months postoperatively, and in 10 (15%) of these cases it persisted beyond 1 year. In 10 patients postoperative radiculopathy was demonstrated, and magnetic resonance imaging revealed epidural fibrosis in six patients, arachnoiditis in one, and a recurrent disc herniation in one. One patient incurred a permanent motor deficit with sexual dysfunction. Pseudarthrosis was suggested radiographically with evidence of motion on lateral flexion-extension radiographs (10 cases), lucencies around the implants (seven cases), and posterior migration of the cage (two cases). Additional procedures (in 14 patients) consisted primarily of transverse process fusion with pedicle screw and plate augmentation for persistent back pain and radiographically demonstrated signs of spinal instability. In two patients with radiculopathy, migration of the TIC required that it be removed. Graft material that extruded from one implant necessitated its removal. In one patient scarectomy was performed. CONCLUSIONS: Our high incidence of TIC-related complications in PLIF is inconsistent with that reported in previous studies.

Secondary gain influences the outcome of lumbar but not cervical disc surgery.

BACKGROUND: The expectation of monetary compensation has been associated with poor outcomes in lumbar discectomy, fueling a reluctance among surgeons to treat worker's compensation cases. This issue, however, has not been investigated in patients undergoing cervical disc surgery. This study analyzes the relationship between economic forms of secondary gain and surgical outcome in a group of patients with common pay scales, retirement plans, and disability programs. METHODS: All procedures were performed at the Portsmouth Naval Medical Center between 1993 and 1995; active duty military servicepersons who were treated for cervical radiculopathy were prospectively included. Clinical, demographic, and financial factors were analyzed to determine which were predictive for outcome. Financial data were used to create a compensation incentive (CI) which is proportional to the rank, years of service, potential disability, retirement eligibility, and base pay and reflects the monetary incentive of disability. The results of cervical surgery were compared to a previously reported companion population of patients treated for lumbar disc disease. A good outcome is defined as a return to active duty, whereas a referral for disability is considered a poor surgical result. RESULTS: One hundred percent follow-up was obtained for 269 patients who were treated with 307 cervical operations. Only 16% (43/269) of cervical patients received disability, whereas 24.7% (86/348) of lumbar patients obtained a poor result (p = 0.0082). Although economic forms of secondary gain were not associated with outcome in cervical disease, both the position (p = 0.002) and duration of an individual's military career were significant factors (p = 0.02). Of the medical variables tested, multilevel surgery (p = 0.03) and revision operations at the same level (p = 0.03) were associated with referral for medical discharge. CONCLUSIONS: Secondary gain in the form of economic compensation influences outcome in lumbar but not cervical disc surgery; this observation may in part account for the success of cervical surgery relative to lumbar discectomy. Social factors that are independent of the anticipation of economic compensation seem to influence the outcome of cervical disc surgery.

Posterior inferior cerebellar artery aneurysms associated with posterior fossa arteriovenous malformation: report of five cases and literature review.

BACKGROUND: The association of posterior inferior cerebellar artery (PICA) aneurysms with posterior fossa arteriovenous malformation (AVM) is uncommon. Over the past 3 years, five patients with this condition were treated at this institution. A review of the clinical history of these and other reported cases has illuminated common threads in the presentation, treatment, and outcome of these lesions. METHODS: The findings of 27 patients (5 from our institution and 22 from the medical literature) with PICA aneurysms associated with AVMs were reviewed. RESULTS: Eighty-four percent of individuals presented with sub-arachnoid hemorrhage (SAH); 89% of these episodes resulted from aneurysm rupture documented by either intraoperative inspection or autopsy. All aneurysms were located on a feeding artery to the AVM, and 81% originated from distal portions of PICA. The majority of patients presented with Hunt & Hess grade I SAH; all patients who presented with hemorrhage were treated surgically. Surgical strategy was directed both to secure the aneurysm and to resect the AVM during the course of a single procedure. Although four individuals either died on admission or in the perioperative period, overall outcome was excellent or good in 82% of patients. CONCLUSIONS: PICA aneurysms associated with AVMs most often involve the distal segments of the artery. Patients usually present with SAH secondary to aneurysmal rupture. Surgical clipping of the aneurysm and excision of the AVM is possible in a single procedure with minimal morbidity. Overall prognosis is favorable in 80% of the cases.

Estrogen receptors in prolactinomas: a clinico-pathological study.

BACKGROUND: Antiestrogens are effective in the treatment of estrogen receptor (ER) positive breast carcinoma. The use of antiestrogen therapy in pituitary adenomas, however, has not been explored. This study attempted to identify a population who may benefit from antiestrogen therapy. MATERIALS & METHODS: Prolactinomas from 29 patients (10 men, 19 women) were analyzed for ER and Ki-67 labeling index using immunohistochemistry. Nine of the 19 women were either amenorrheic or had not received exogenous estrogen for at least one year. Ten women were menstruating either spontaneously or as a result of estrogen administration. Factors including age, serum prolactin level, tumor size, evidence of tumor invasiveness and recurrence of tumor were evaluated to determine if they were predictive of ER expression. RESULTS: Tumors from 6/10 (60%) men were positive for ER. Among women who were having menses, 9/10 (90%) tumors were positive, whereas 6/9 (67%) tumors from amenorrheic women were positive. Statistical analysis revealed that none of the variables: gender, age, menstrual status, Ki-67 proliferative rate, exposure to dopamine agonists, preoperative prolactin level, tumor size, or invasiveness was predictive for the presence of the receptor. The incidence of ER, however, was significantly reduced in recurrent tumors (p = 0.03). CONCLUSIONS: ER expression is less likely in recurrent tumors. The efficacy of ER antagonists cannot be inferred by gender or estrogen exposure.

CT-guided percutaneous drainage of syringomyelia.

PURPOSE: Our purpose is to describe CT-guided percutaneous drainage of syringomyelia as a possible contribution in patient management. METHOD: CT-guided percutaneous drainage was performed on three patients with symptomatic syringomyelia. We determined the success of percutaneous decompression by subsequent CT and MRI. The effect of syringomyelia decompression in relation to the patient's symptoms was determined. This information was then used to help guide clinical management. RESULTS: In Case 1, percutaneous drainage of a large syrinx in a C5 quadriplegic patient with increasing lower extremity spasticity demonstrated significant decompression by imaging but did not result in clinical improvement. A surgical procedure to decompress the syrinx was not performed on the basis of this information. In Case 2, percutaneous drainage of a large syrinx in a quadriplegic patient with increasing upper extremity numbness and weakness demonstrated significant decompression by imaging and resulted in sustained clinical improvement, temporarily obviating the need for surgery. In Case 3, percutaneous drainage of the rostral aspect of a septated syrinx cavity in a patient with a Chiari I malformation and a syringoperitoneal shunt in place resulted in decompression by imaging but failed to relieve the patient's newly developed symptoms. An additional shunt was therefore not placed. In no case did the patient experience periprocedural complications or worsening of symptoms. CONCLUSION: CT-guided percutaneous drainage of syringomyelia is a safe and successful technique. It can be used diagnostically to identify patients that may or may not benefit from surgical syrinx decompression and in some cases may provide a temporary therapeutic alternative to surgery.

Successful excision of a large immature teratoma involving the cranial base: report of a case with long-term follow-up.

OBJECTIVE AND IMPORTANCE: Massive congenital intracranial teratomas with extracranial extension are rare. The prognosis in these cases has been poor, with stillbirth or immediate postpartum death as the usual outcome. With recent advances in fetal monitoring, neonatal care, and surgical techniques used for the management of complex tumors of the cranial base, some of these lesions may now be amenable to radical surgical resection and then immediate craniofacial reconstruction. CLINICAL PRESENTATION: A neonate with a large congenital immature teratoma involving the entire left side of the cranium and face was evaluated at our institution 1 day after birth. INTERVENTION: Total resection of the mass and then immediate reconstruction of the deformed orbit, maxilla, and mandible were performed at 9 days of age. Additional operations on the midface and mandible to allow for a functional bite were subsequently required as the child developed during the next 2 years. Four years after resection, the patient exhibited a reasonable cosmetic result and only mild developmental delay. CONCLUSION: We conclude that acceptable functional and cosmetic outcomes can be achieved by early intervention, consisting of radical resection and immediate craniofacial reconstruction, in some neonates with massive congenital craniofacial teratomas.

The influence of secondary gain on surgical outcome: a comparison between cervical and lumbar discectomy.

Although the expectation of monetary compensation has been associated with failures in lumbar discectomy, the issue has not been investigated in patients undergoing cervical disc surgery. The authors analyzed the relationship between economic forms of secondary gain and surgical outcome in a group of patients with a common pay scale, retirement plan, and disability program. All procedures were performed at the Portsmouth Naval Medical Center between 1993 and 1995; active-duty military servicepersons treated for cervical radiculopathy were prospectively included. Clinical, demographic, and financial factors were analyzed to determine which were predictive of outcome. Financial data were used to create a compensation incentive, which is proportional to the patient's rank, years of service, potential disability, retirement eligibility, and base pay and reflects the monetary incentive of disability. The results of cervical surgery were compared to a previously reported companion population of patients treated for lumbar disc disease. A good outcome was defined as a return to active duty, whereas a referral for disability was considered a poor surgical result. A 100% follow-up rate was obtained for 269 patients who underwent 307 cervical operations. Only 16% (43 of 269) of patients who underwent cervical operation received disability, whereas 24.7% (86 of 348) of patients who underwent lumbar discectomy obtained a poor result (p = 0.0082). Although economic forms of secondary gain were not associated with a poor outcome in cervical disease, both the rank (p = 0.002) and duration (p = 0.03) of an individual's military career were significant factors (p = 0.02). Of the medical variables tested, multilevel surgery (p = 0.03) and revision operations at the same level (p = 0.03) were associated with referral for medical discharge. Secondary gain in the form of economic compensation influences outcome in lumbar but not cervical disc surgery patients; the increased rate of disability referral in patients who underwent lumbar discectomy may reflect an expectation of economic compensation. Social factors that are independent of the anticipation of economic compensation seem to influence the outcome in cervical disc surgery patients.

Intraoperative chymopapain in lumbar laminotomy for disc disease: a less invasive technique.

The use of chymopapain in the treatment of lumbar disc herniation has been widely studied since Smith first described its use in humans in 1963. The authors describe the use of chymopapain intraoperatively in open lumbar microdiscectomy in 63 patients. When combined with the results of a previous study performed at the same institution, the authors found that this technique significantly reduces the rate of recurrent disc herniation when compared with traditional laminotomy with discectomy. This procedure maximizes the benefits of each approach taken separately, allowing for decompression of the nerve root from a free fragment or sequestered disc and preventing recurrence through dissolution of the nucleus pulposus. Overall, outcome was good or excellent immediately postoperatively in 73% of the 63 patients and in 64% at last follow-up evaluation. Additionally, this procedure is safe with no complications noted in the immediate perioperative period or at follow-up evaluation.

Hemorrhagic complications in embolization of a meningioma: case report and review of the literature.

We report a case of hemorrhage in a parasellar meningioma shortly after embolization of the dural cavernous carotid artery branches supplying the tumor. This represents the first report of hemorrhage within a meningioma resulting from embolization with small (50 to 150-microns) polyvinyl alcohol particles, as well as the first reported case of hemorrhage complicating meningioma embolization from internal rather than external carotid artery branch embolization. We also review previously reported cases of postembolization hemorrhage from meningiomas.