Telemedicine and Spina Bifida Transition: A Pilot Randomized Trial.

OBJECTIVES: Transition of care is the planned movement of adolescents and young adults from pediatric to adult health care. Many studies have demonstrated the importance of an organized transition process. The purpose of this study is to determine the efficacy of a telemedicine intervention for improving transition readiness among adolescents with spina bifida. METHODS: The present study is a randomized, controlled trial, including children 14 years of age and older with myelomeningocele from a multidisciplinary spina bifida clinic. Subjects were randomized to standard care or to an intervention, consisting of video telemedicine contacts at 3, 6, and 9 months from the clinic visit. The primary outcome measure was a change in the Transition Readiness Assessment Questionnaire score from baseline to 1-year follow-up. RESULTS: Twenty-four patients were enrolled in the study and underwent randomization. The mean age at enrollment was 15.8 years. Ten patients (40%) were female, and the majority were White, non-Hispanic (67%). Despite enrolling 24 patients, only 1 patient in the telemedicine group completed any of the planned telemedicine sessions. No other participant completed any telemedicine counseling sessions. The study was stopped early for lack of participation in the intervention. In a single-group, as-treated analysis, there was no significant change in the Transition Readiness Assessment Questionnaire score between enrollment and 1-year follow-up (Δ = 0.36, P = 0.46). However, there were significant improvements in subscores for Managing Medications, Appointment Keeping, and Managing Daily Activities. CONCLUSIONS: The primary finding from this study was very low participation in a telemedicine video follow-up intervention among adolescents with myelomeningocele. Based on these results, this strategy alone is unlikely to significantly improve readiness for transition to adult care.

Developing Physician Leadership in Hospital Policy Development: A Case Study of Resident-Driven Policy Initiatives in the Department of Neurosurgery at the University of Alabama at Birmingham.

The bulk of a resident's daily work is patient care related; however, other aspects of residency training are vital both to a resident's education and to the advancement of the field. Basic science and clinical research are the more common academic activities in which residents participate after completion of daily patient care objectives. Less frequently, residents participate in a process vital to the delivery of efficient, cost-effective, and safe patient care: hospital policy development. Two policies were identified as outdated or absent: (1) the process for the declaration of brain death and (2) a policy for the use of hypertonic saline in the Neurosciences Intensive Care Unit. The policies were rewritten after review of the existing policy (when applicable), other institutions' examples, national guidelines, and state and federal laws. Once written, proposals were reviewed by department leadership, hospital ethics, legal counsel, ad hoc specialty committees, the Medical Directors Council, and the Medical Executive Committee. After multiple revisions, each proposal was endorsed by the above bodies and ratified as hospital policy. Residents may make a substantial impact on patient care through active participation in the authorship and implementation of hospital policy. The inclusion of residents in policy development has improved the process for declaring brain death and management of patients with devastating neurological pathology. Resident involvement in hospital policy initiatives can be successful, valuable to the institution, and beneficial to patient care. Resident involvement is predicated on faculty and institutional support of such endeavors.

Patients with "benign" Chiari I malformations require surgical decompression at a low rate.

OBJECTIVE: There are sparse published data on the natural history of "benign" Chiari I malformation (CM-I)-i.e., Chiari with minimal or no symptoms at presentation and no imaging evidence of syrinx, hydrocephalus, or spinal cord signal abnormality. The purpose of this study was to review a large cohort of children with benign CM-I and to determine whether these children become symptomatic and require surgical treatment. METHODS: Patients were identified from institutional outpatient records using International Classification of Diseases, 9th Revision, diagnosis codes for CM-I from 1996 to 2016. After review of the medical records, patients were excluded if they 1) did not have a diagnosis of CM-I, 2) were not evaluated by a neurosurgeon, 3) had previously undergone posterior fossa decompression, or 4) had imaging evidence of syringomyelia at their first appointment. To include only patients with benign Chiari (without syrinx or classic Chiari symptoms that could prompt immediate intervention), any patient who underwent decompression within 9 months of initial evaluation was excluded. After a detailed chart review, patients were excluded if they had classical Chiari malformation symptoms at presentation. The authors then determined what changes in the clinical picture prompted surgical treatment. Patients were excluded from the multivariate logistic regression analysis if they had missing data such as race and insurance; however, these patients were included in the overall survival analysis. RESULTS: A total of 427 patients were included for analysis with a median follow-up duration of 25.5 months (range 0.17-179.1 months) after initial evaluation. Fifteen patients had surgery at a median time of 21.0 months (range 11.3-139.3 months) after initial evaluation. The most common indications for surgery were tussive headache in 5 (33.3%), syringomyelia in 5 (33.3%), and nontussive headache in 5 (33.3%). Using the Kaplan-Meier method, rate of freedom from posterior fossa decompression was 95.8%, 94.1%, and 93.1% at 3, 5, and 10 years, respectively. CONCLUSIONS: Among a large cohort of patients with benign CM-I, progression of imaging abnormalities or symptoms that warrant surgical treatment is infrequent. Therefore, these patients should be managed conservatively. However, clinical follow-up of such individuals is justified, as there is a low, but nonzero, rate of new symptom or syringomyelia development. Future analyses will determine whether imaging or clinical features present at initial evaluation are associated with progression and future need for treatment.

Transitioning the Treatment Paradigm: How Early Palliative Care Service Involvement Affects the End-of-Life Course for Critically Ill Patients in the Neuro-Intensive Care Unit.

Background: Involvement of the palliative care service has potential for patient and family benefit in critically ill patients, regardless of etiology. Anecdotally, there is a lack of involvement of the palliative care (PC) service in the neuro-intensive care unit (neuro-ICU), and its impact has not been rigorously investigated in this setting. Objective: This study aims at assessing the effect of early involvement of the PC service on end-of-life care in the neuro-ICU. Design: Demographic variables and elements pertaining to the end-of-life care were obtained retrospectively via the electronic medical record from patients receiving their care at the University of Alabama at Birmingham Hospital neuro-ICU. The patient population was divided into two cohorts: patients who received PC services and patients who did not. Contingency analysis was performed to assess for associations with PC service involvement. Results: A total of 149 patients were included in the study. PC services were included in 56.4% of the cases. Involvement of the PC service led to more code status changes to comfort care-do-not-resuscitate p = 0.0021. This was more often a decremental change to less invasive measures rather than a direct change from full code to comfort care measures (p = 0.026). When PC specialists were involved, medications to treat anxiety/agitation, dyspnea/pain, and respiratory secretions were utilized more frequently (p < 0.001) and fewer procedures were performed on these critically ill patients within 48 hours of death (p < 0.001). Conclusion: Early involvement of the PC service has an impact on adjusting the treatment paradigm for patients suffering from devastating neurologic injuries. We recommend the creation of a standardized protocol to ensure early PC consultation in the neuro-ICU based on initial patient presentation parameters, imaging characteristics, and prognosis.

Thoracolumbar Injury Classification and Severity Score in Children: A Validity Study.

BACKGROUND: The Thoracolumbar Injury Classification and Severity Score (TLICS) has been shown to be a valid tool for assessing the need for surgical intervention in adult patients. There is limited insight into its usefulness in children. OBJECTIVE: To assess the validity of the TLICS system in pediatric patients. METHODS: The medical records for pediatric patients with acute, traumatic thoracolumbar fractures at two Level 1 trauma centers were reviewed retrospectively. A TLICS score was calculated for each patient using computed tomography and magnetic resonance images, along with the neurological examination recorded in the patient's medical record. TLICS scores were compared with the type of treatment received. Receiver operating characteristic (ROC) curve analysis was employed to quantify the validity of the TLICS scoring system. RESULTS: TLICS calculations were completed for 165 patients. The mean TLICS score was 2.9 (standard deviation ± 2.7). Surgery was the treatment of choice for 23% of patients. There was statistically significant agreement between the TLICS suggested treatment and the actual treatment received (P < 0.001). The ROC curve calculated using multivariate logistic regression analysis of the TLICS system's parameters as a tool for predicting treatment demonstrated excellent discriminative ability, with an area under the ROC curve of 0.96, which was also statistically significant (P < 0.001). CONCLUSION: The TLICS system demonstrates good validity for selecting appropriate thoracolumbar fracture treatment in pediatric patients.

Outcomes of Subdural Hematoma in the Elderly with a History of Minor or No Previous Trauma.

BACKGROUND: Subdural hematoma (SDH) in the elderly is an increasingly common entity because of increased use of antithrombotic medications, an aging population, and increasing frequency of geriatric trauma. The present study describes the functional outcomes and mortality of SDH in an elderly population and to identify potential prognostic factors. METHODS: Patients >65 years of age with SDH who were treated at our institution from 2005 to 2015 were identified. Patients with a history of preceding high-velocity trauma were excluded. Electronic medical records were retrospectively reviewed. The outcomes of interest were mortality, length of stay, and discharge Glasgow Outcome Score. RESULTS: A total of 671 patients were included in final statistical analyses. For patients with acute SDH, survival was 74.9%, 72.3%, and 69.8% at 30, 60, and 100 days, respectively. With respect to chronic SDH, survival was 87.0%, 83.7%, and 80.3% at 30, 60, and 100 days, respectively. On multivariate analysis, admission Glasgow Coma Scale (GCS) score was significantly predictive of mortality in both the acute and chronic populations. In the acute cohort, admission GCS score was a significant predictor of increased length of stay, whereas age >80 years, admission GCS score, contusion volume >10 cm3, SDH volume >50 cm3, and antiplatelet use were significant predictors of discharge functional status. CONCLUSIONS: SDH in the elderly carries high morbidity and mortality and several prognostic factors were identified. These results can be used to guide discussions with family regarding prognosis and perhaps aid in treatment decisions.

Thoracolumbar Injury Classification and Severity Score in children: a reliability study.

OBJECTIVE There are many classification systems for injuries of the thoracolumbar spine. The recent Thoracolumbar Injury Classification and Severity Score (TLICS) has been shown to be a reliable tool for adult patients. The aim of this study was to assess the reliability of the TLICS system in pediatric patients. The validity of the TLICS system is assessed in a companion paper. METHODS The medical records of pediatric patients with acute, traumatic thoracolumbar fractures at a single Level 1 trauma center were retrospectively reviewed. A TLICS was calculated for each patient using CT and MRI, along with the neurological examination recorded in the patient's medical record. TLICSs were compared with the type of treatment received. Five raters scored all patients separately to assess interrater reliability. RESULTS TLICS calculations were completed for 81 patients. The mean patient age was 10.9 years. Girls represented 51.8% of the study population, and 80% of the study patients were white. The most common mechanisms of injury were motor vehicle accidents (60.5%), falls (17.3%), and all-terrain vehicle accidents (8.6%). The mean TLICS was 3.7 ± 2.8. Surgery was the treatment of choice for 33.3% of patients. The agreement between the TLICS-suggested treatment and the actual treatment received was statistically significant (p < 0.0001). The interrater reliability of the TLICS system ranged from moderate to very good, with a Fleiss' generalized kappa (κ) value of 0.69 for the TLICS treatment suggestion among all patients; however, interrater reliability decreased when MRI was used to contribute to the TLICS. The κ value decreased from 0.73 to 0.57 for patients with CT only vs patients with CT/MRI or MRI only, respectively (p < 0.0001). Furthermore, the agreement between suggested treatment and actual treatment was worse when MRI was used as part of injury assessment. CONCLUSIONS The TLICS system demonstrates good interrater reliability among physicians assessing thoracolumbar fracture treatment in pediatric patients. Physicians should be cautious when using MRI to aid in the surgical decision-making process.

Intradural spine surgery may not carry an increased risk of shunt revision compared with extradural spine surgery in pediatric patients with myelomeningocele.

OBJECTIVE Patients with myelomeningocele are often affected by scoliosis and tethered cord syndrome, and frequently require spine surgery. Intradural spine surgeries may carry an inherently higher risk of inducing shunt malfunction due to entry into the subarachnoid space. In this study, the authors sought to compare rates of shunt malfunction after intradural and extradural spine surgeries among pediatric patients with myelomeningocele. METHODS The authors reviewed records of the National Spina Bifida Program Registry for Children's Hospital of Alabama. The Exago reporting function was used to identify patients who had received at least one of the following procedures: shunt revision, tethered cord release (TCR), or spinal fusion for deformity. The registry records were reviewed for all identified patients to determine if a shunt revision was performed within the 1st year after TCR or spinal fusion. RESULTS Final analyses included 117 patients, of whom 39 underwent spinal fusion and 78 underwent TCR. Among patients who underwent spinal fusion, shunt revision was performed within 30 days in 2 patients (5.1%), within 60 days in 2 (5.1%), within 90 days in 4 (10.3%), and within 1 year in 5 (12.8%). Among patients who underwent TCR, shunt revision was performed within 30 days in 7 patients (9.0%), within 60 days in 10 (12.8%), within 90 days in 11 (14.1%), and within 1 year in 17 (21.8%). Using the log-rank test, there was no significant difference in Kaplan-Meier curves between intradural and extradural groups (p = 0.59). CONCLUSIONS In a review of single-institution registry data, the authors found no statistically significant difference in the risk of shunt malfunction after intradural and extradural spine surgeries.

Suboccipital Craniotomy Versus Craniectomy: A Survey of Practice Patterns.

OBJECTIVE: Open surgical access to the posterior fossa traditionally has been achieved by permanent bone removal and remains the mainstay of posterior fossa surgery, although craniotomy is an alternative. Considerable variation exists at both the national and international levels within a variety of neurologic and neurosurgical disciplines. In this study, we surveyed current practice patterns regarding preference of suboccipital craniotomy or craniectomy. METHODS: The membership directory of the American Academy of Neurological Surgeons was reviewed. SurveyMonkey was used to distribute the survey to members of the American Academy of Neurological Surgeons via a modified Dillman method for e-mail correspondence. Comparisons of frequency distributions, means, and medians, as well as multiple logistic regression were used to determine surgical preferences for craniotomy versus craniectomy. RESULTS: We received 1102 responses (19.6%). Overall, 542 (49.7%) respondents prefer craniotomy and 548 (50.3%) prefer craniectomy. Respondents who prefer craniotomy had completed a residency more recently than respondents who preferred craniectomy (15.9 vs. 21.1 years, P < 0.0001) and were more likely to practice outside of North America (P < 0.01). Some 81.4% of pediatric neurosurgeons prefer craniotomy compared with 43.6% of adult neurosurgeons (P < 0.0001). Craniotomy was most highly preferred for tumor resection and vascular malformation. Within the United States, there was significant variation in preference for craniotomy based on geographic region, with New England most commonly preferring craniotomy and the Mid-Atlantic region most commonly preferring craniectomy. CONCLUSIONS: Our results show that preference for suboccipital craniotomy or craniectomy varies according to geographic location of practice, time since completing residency, and age of patient population.

Patient Expectations and Preferences in the Spinal Surgery Clinic.

BACKGROUND: Managing patient expectations is essential in the treatment of patients undergoing spinal surgery. Patient satisfaction is associated with improved clinical outcomes and can be improved when patient and surgeon expectations are aligned and patient preferences are met. METHODS: Patients presenting to clinic for management of spinal disease were asked to complete a questionnaire assessing demographics, current pain, reason for visit, and expectations and preferences surrounding the clinic experience. Variables were compared with χ2 tests to determine factors associated with patient expectations. Subsets of new patients and returning patients were compared by the use of matched pair tests. One-way analysis of variance was used to compare means of clinic expectations in patients depending on their level of education. RESULTS: A total of 240 patients were included. New patient evaluation was the most common reason for evaluation (26.6%), and pain relief was the most common chief concern (39.3%). Patients preferred their surgeon wash their hands in the room instead of before entering (P < 0.001) and wear professional attire over scrubs (P < 0.001). Patients believe their wait time will be longer than it should be (P = 0.002), they will spend longer in clinic than they should (P = 0.03), and they will get less face-to-face time with their surgeon than they should (P < 0.01) but also that the surgeon is not getting paid enough for the clinic visit (P = 0.02). CONCLUSIONS: Because spine surgery is largely elective, patients often seek treatment to improve quality of life and alleviate subjective symptoms. Understanding patient expectations is critical to ensure that patients and physicians are working toward similar goals.

Implications of transitioning to a resident night float system in neurosurgery: mortality, length of stay, and resident experience.

OBJECTIVE Many neurosurgical training programs have moved from a 24-hour resident call system to a night float system, but the impact on outcomes is unclear. Here, the authors compare length of stay (LOS) for neurosurgical patients admitted before and after initiation of a night float system at a tertiary care training hospital. METHODS The neurosurgical residency at the University of Alabama at Birmingham transitioned from 24-hour call to a night float resident coverage system in July 2013. In this cohort study, all patients admitted to the neurosurgical service for 1 year before and 1 year after this transition were compared with respect to hospital and ICU LOSs, adjusted for potential confounders. RESULTS A total of 4619 patients were included. In the initial bivariate analysis, night float was associated with increased ICU LOS (p = 0.032) and no change in overall LOS (p = 0.65). However, coincident with the transition to a night float system was an increased frequency of resident service transitions, which were highly associated with hospital LOS (p < 0.01) and ICU LOS (p < 0.01). After adjusting for resident service transitions, initiation of the night float system was associated with decreased hospital LOS (p = 0.047) and no change in ICU LOS (p = 0.35). CONCLUSIONS This study suggests that a dedicated night float resident may improve night-to-night continuity of care and decrease hospital LOS, but caution must be exercised when initiation of night float results in increased resident service transitions.

Identification and Cost of Potentially Avoidable Transfers to a Tertiary Care Neurosurgery Service: A Pilot Study.

BACKGROUND: Thousands of neurosurgical emergencies are transferred yearly to tertiary care facilities to assume a higher level of care. Several studies have examined how neurosurgical transfers influence patient outcomes, but characteristics of potentially avoidable transfers have yet to be investigated. OBJECTIVE: To identify whether potentially avoidable transfers represent a significant portion of transfers to a tertiary neurosurgical facility. METHODS: In this cohort study, we evaluated 916 neurosurgical patients transferred to a tertiary care facility over a 2-year period. Transfers were classified as potentially avoidable when no neurosurgical diagnostic test, intervention, or intensive monitoring was deemed necessary (n = 180). The remaining transfers were classified as justifiable (n = 736). The main outcomes and measures were age, sex, diagnosis, insurance status, intervention, distance of transfer, length of hospital and intensive care unit stay, mortality, discharge disposition, and cost. RESULTS: Nearly 20% of transfers were identified as being potentially avoidable. Although some of these patients had suffered devastating, irrecoverable neurological insults, many had innocuous conditions that did not require transfer to a higher level of care. Justifiable transfers tend to involve patients with nontraumatic intracranial hemorrhage and cranial neoplasm. Both groups were admitted to the intensive care unit at the same rate (approximately 70% of patients). Finally, the direct transportation cost of potentially avoidable transfers was $1.46 million over 2 years. CONCLUSION: This study identified the frequency and expense of potentially avoidable transfers. There is a need for closer examination of the clinical and financial implications of potentially avoidable transfers. ABBREVIATIONS: CI, confidence intervalIQR, interquartile rangeJT, justifiable transferOR, odds ratioPAT, potentially avoidable transferUAB, University of Alabama at Birmingham.

Predictors of delayed recovery following pediatric sports-related concussion: a case-control study.

OBJECT Pediatric sports-related concussions are a growing public health concern. The factors that determine injury severity and time to recovery following these concussions are poorly understood. Previous studies suggest that initial symptom severity and diagnosis of attention deficit hyperactivity disorder (ADHD) are predictors of prolonged recovery (> 28 days) after pediatric sports-related concussions. Further analysis of baseline patient characteristics may allow for a more accurate prediction of which patients are at risk for delayed recovery after a sports-related concussion. METHODS The authors performed a single-center retrospective case-control study involving patients cared for at the multidisciplinary Concussion Clinic at Children's of Alabama between August 2011 and January 2013. Patient demographic data, medical history, sport concussion assessment tool 2 (SCAT2) and symptom severity scores, injury characteristics, and patient balance assessments were analyzed for each outcome group. The control group consisted of patients whose symptoms resolved within 28 days. The case group included patients whose symptoms persisted for more than 28 days. The presence or absence of the SCAT2 assessment had a modifying effect on the risk for delayed recovery; therefore, stratum-specific analyses were conducted for patients with recorded SCAT2 scores and for patients without SCAT2 scores. Unadjusted ORs and adjusted ORs (aORs) for an association of delayed recovery outcome with specific risk factors were calculated with logistic regression analysis. RESULTS A total of 294 patients met the inclusion criteria of the study. The case and control groups did not statistically significantly differ in age (p = 0.7). For the patients who had received SCAT2 assessments, a previous history of concussion (aOR 3.67, 95% CI 1.51-8.95), presenting SCAT2 score < 80 (aOR 5.58, 95% CI 2.61-11.93), and female sex (aOR 3.48, 95% CI 1.43-8.49) were all associated with a higher risk for postconcussive symptoms lasting more than 28 days. For patients without SCAT2 scores, female sex and reporting a history of ADHD significantly increased the odds of prolonged recovery (aOR 4.41, 95% CI 1.93-10.07 and aOR 3.87, 95% CI 1.13-13.24, respectively). Concussions resulting from playing a nonhelmet sport were also associated with a higher risk for prolonged symptoms in patients with and without SCAT2 scores (OR 2.59, 95% CI 1.28-5.26 and OR 2.17, 95% CI 0.99-7.73, respectively). Amnesia, balance abnormalities, and a history of migraines were not associated with symptoms lasting longer than 28 days. CONCLUSIONS This case-control study suggests candidate risk factors for predicting prolonged recovery following sports-related concussion. Large prospective cohort studies of youth athletes examined and treated with standardized protocols will be needed to definitively establish these associations and confirm which children are at highest risk for delayed recovery.

Effect of resident handoffs on length of hospital and intensive care unit stay in a neurosurgical population: a cohort study.

OBJECT Handoffs and services changes are potentially modifiable sources of medical error and delays in transition of care. This cohort study assessed the relationship between resident service handoffs and length of stay for neurosurgical patients. METHODS All patients admitted to the University of Alabama at Birmingham neurosurgical service between July 1, 2012, and July 1, 2014, were retrospectively identified. A service handoff was defined as any point when a resident handed off coverage of a service for longer than 1 weekend. A conditional probability distribution was constructed to adjust length of stay for the increasing probability of a random handoff. The Student t-test and ANCOVA were used to assess relationships between resident service handoffs and length of hospital stay, adjusted for potential confounders. RESULTS A total of 3038 patients met eligibility criteria and were included in the statistical analyses. Adjusted length of hospital stay (5.32 vs 3.53 adjusted days) and length of ICU stay (4.38 vs 2.96 adjusted days) were both longer for patients who experienced a service handoff, with no difference in mortality. In the ANCOVA model, resident service handoff remained predictive of both length of hospital stay (p < 0.001) and length of ICU stay (p < 0.001). CONCLUSIONS Occurrence of a resident service handoff is an independent predictor of length of hospital and ICU stay in neurosurgical patients. This finding is novel in the neurosurgical literature. Future research might identify mechanisms for improving continuity of care and mitigating the effect of resident handoffs on patient outcomes.

The use of dual growing rods to correct spinal deformity secondary to a low-grade spinal cord astrocytoma.

Pediatric intramedullary spinal cord astrocytomas are rare, and the majority are low grade, typically carrying a low risk of mortality, but a high risk of morbidity. Quality of life is, therefore, an important consideration in treating concomitant progressive kyphoscoliosis. Compared with fusion-based spinal stabilization, fusionless techniques may limit some complications related to early instrumentation of the developing spine. Another consideration is the timing of radiation therapy relative to both spinal maturity and spinal instrumentation. To date, there have been no reports of the use of a fusionless technique to treat spinal deformity secondary to an intramedullary spinal cord tumor. Herein, we report the use of fusionless spinal stabilization with dual growing rods in a boy with low-grade spinal cord astrocytoma after radiation therapy.

Management of idiopathic pediatric syringohydromyelia.

OBJECT: Syringohydromyelia is frequently identified on spinal imaging. The literature provides little guidance to decision making regarding the need for follow-up or treatment. The purpose of this study was to review the authors' experience in managing pediatric syringohydromyelia of unknown cause. METHODS: A single-institution retrospective review of all cases involving pediatric patients who underwent spinal MRI from 2002 to 2012 was conducted. Patients with idiopathic syringohydromyelia (IS) were identified and categorized into 2 subgroups: uncomplicated idiopathic syrinx and IS associated with scoliosis. Clinical and radiological course were analyzed. RESULTS: Ninety-eight patients (50 female, 48 male) met the inclusion criteria. Median age at diagnosis of syrinx was 11.9 years. Median maximum syrinx size was 2 mm (range 0.5-17 mm) and spanned 5 vertebral levels (range 1-20 vertebral levels). Thirty-seven patients had scoliosis. The most common presenting complaint was back pain (26%). Clinical follow-up was available for 78 patients (80%), with a median follow-up of 20.5 months (range 1-143 months). A neurological deficit existed at presentation in 36% of the patients; this was either stable or improved at last follow-up in 64% of cases. Radiological follow-up was available for 38 patients (39%), with a median duration of 13 months (range 2-83 months). There was no change in syrinx size in 76% of patients, while 16% had a decrease and 8% had an increase in syrinx size. Thirty-six patients had both clinical and radiological follow-up. There was concordance between clinical and radiological course in 14 patients (39%), with 11 patients (31%) showing no change and 3 patients (8%) showing clinical and radiological improvement. No patients had concurrent deterioration in clinical and radiological course. One patient with scoliosis and muscular dystrophy underwent direct surgical treatment of the syrinx and subsequently had a deteriorated clinical course and decreased syrinx size. CONCLUSIONS: There remains a paucity of data regarding the management of pediatric IS. IS in association with scoliosis can complicate neurosurgical decision making. There was no concordance between radiological syrinx size increase and clinical deterioration in this cohort, indicating that surgical decision making should reflect clinical course as opposed to radiological course.

Gamma Knife radiosurgery for meningiomas in patients with neurofibromatosis Type 2.

OBJECT: Neurofibromatosis Type 2 (NF2) is a rare autosomal dominant disorder predisposing patients to meningiomatosis. The role of stereotactic radiosurgery (SRS) is poorly defined in NF2, and although the procedure has excellent control rates in the non-NF2 population, its utility has been questioned because radiation has been hypothesized to predispose patients to malignant transformation of benign tumors. To the authors' knowledge, this is the first study to examine the use of SRS specifically for meningiomas in patients with NF2. METHODS: The authors searched a tumor registry for all patients with NF2 who had undergone Gamma Knife radiosurgery (GKRS) for meningioma in the period from January 1, 1999, to September 19, 2013, at a single tertiary care cancer center. Medical records were retrospectively reviewed for patient and tumor characteristics and outcomes. RESULTS: Among the 12 patients who met the search criteria, 125 meningiomas were identified, 87 (70%) of which were symptomatic or progressive and thus treated with GKRS. The median age at the first GKRS was 31 years (interquartile range [IQR] 27-37 years). Five patients (42%) had multiple treatments with a median of 27 months (IQR 14-50 months) until the subsequent GKRS. The median follow-up in surviving patients was 43 months (IQR 34-110 months). The 5-year local tumor control and distant treatment failure rates were 92% and 77%, respectively. Toxicities occurred in 25% of the GKRS treatments, although the majority were Grade 1 or 2. At the last follow-up, 4 patients (33%) had died a neurological death at a median age of 39 years (IQR 37-46 years), and their cases accounted for 45% of all tumors, 55% of all treated tumors, and 58% of all GKRSs. Univariate analysis revealed several predictive variables for distant failure, including male sex (HR 0.28, 95% CI 0.086-0.92, p = 0.036), age at distant failure (HR 0.92, 95% CI 0.90-0.95, p < 0.0001), and prior number of GKRS treatments (HR 1.2, 95% CI 1.1-1.4, p = 0.0049). Local failure, maximum size of the treated tumor, delivered tumor margin dose, and WHO grade were not significant. On multivariate analysis, age at distant failure (HR 0.91, 95% CI 0.88-0.95, p < 0.0001) and prior number of GKRSs (HR 1.3, 95% CI 1.1-1.5, p = 0.004) remained significant. No malignant transformation events among treated tumors were observed. CONCLUSIONS: Radiosurgery represents a feasible modality with minimal toxicity for NF2-associated meningiomas. Increasing patient age was associated with a decreased rate of distant failure, whereas an increasing number of prior GKRS treatments predicted distant failure. Further studies are necessary to determine the long-term patterns of treatment failure in these patients.

Is there a tumor volume threshold for postradiosurgical symptoms? A single-institution analysis.

BACKGROUND: Single-fraction radiosurgery may carry a higher risk of symptomatic peritumoral edema than conventionally fractionated radiotherapy, with a reported incidence of 2.5% to 37%. Previous research has shown that larger tumor volume and margin dose >14 Gy are associated with increased risk of toxicity. Parasagittal location has been associated with toxicity in some studies, but not in others. OBJECTIVE: To determine risk factors for and patterns of postradiosurgical symptoms (PRS). METHODS: This single-institution retrospective chart review included 282 stereotactic radiosurgery procedures for an intracranial meningioma from January 1999 to March 2011. PRS were assessed by using the Common Terminology Criteria for Adverse Events (Version 4.0). Statistical analyses were conducted by using the 194 procedures for which treatment plans were available. RESULTS: PRS were observed after 65 procedures (23%); 35 (12%) were grade 2 or higher. Posttreatment edema occurred in 21% of grade I PRS, 68% of grade II PRS, and 71% of grade III PRS. Tumor volume ≥7.1 cc (adjusted hazards ratio = 4.9, P = .02), prior external beam radiotherapy (adjusted hazards ratio = 2.6, P = .03), and histological grade (P = .005) predicted PRS. On multivariate analysis, parasagittal location was not predictive of PRS, although skull base location predicted a lower risk of symptomatic posttreatment edema (adjusted hazards ratio = 0.133, P = .02). CONCLUSION: In our series, prior external beam radiotherapy, tumor volume, and tumor grade are risk factors for PRS, while pretreatment edema approached statistical significance. Peritumoral edema is the predominant mechanism of significant PRS, and skull base tumors have a lower risk of posttreatment edema.

Patterns of recurrence after stereotactic radiosurgery for treatment of meningiomas.

OBJECT: The purpose of this study was to evaluate patterns of failure after stereotactic radiosurgery (SRS) for meningiomas and factors that may influence these outcomes. METHODS: Based on a retrospective chart review, 279 patients were treated with SRS for meningiomas between January 1999 and March 2011 at Wake Forest Baptist Health. Disease progression was determined using serial imaging, with a minimum follow-up of 6 months (median 34.2 months). RESULTS: The median margin dose was 12.0 Gy (range 8.8-20 Gy). Local control rates for WHO Grade I tumors were 96.6%, 84.4%, and 75.7% at 1, 3, and 5 years, respectively. WHO Grade II and III tumors had local control rates of 72.3%, 57.7%, and 52.9% at 1, 3, and 5 years, respectively. Tumors without pathological grading had local control rates of 98.7%, 97.6%, and 94.2% at 1, 3, and 5 years, respectively. Of the local recurrences, 63.1% were classified as marginal (within 2 cm of treatment field). The 1-, 3-, and 5-year rates of distant failure were 6.5%, 10.3%, and 16.6%, respectively, for Grade I tumors and 11.4%, 17.2%, and 22.4%, respectively, for Grade II/III tumors. Tumors without pathological grading had distant failure rates of 0.7%, 3.2%, and 6.5% at 1, 3, and 5 years, respectively. Wilcoxon analysis revealed that multifocal disease (p < 0.001) and high-grade histology (WHO Grade II or III; p < 0.001) were significant predictors of local recurrence. Additionally, male sex was a significant predictor of distant recurrence (p = 0.04). Multivariate analysis also showed that doses greater than or equal to 12 Gy were associated with improved local control (p = 0.015). CONCLUSIONS: In this patient series, 12 Gy was the minimum sufficient margin dose for the treatment of meningiomas. Male sex is a risk factor for distant failure, whereas high-grade histology and multifocal disease are risk factors for local failure.

Gamma knife stereotactic radiosurgery for radiation-induced meningiomas.

BACKGROUND: Radiation-induced meningiomas present a unique clinical dilemma given the fact that patients with these tumors have often received a prior full course of radiotherapy. As such, traditional radiotherapy is limited by lifetime tissue tolerances to radiation, leaving surgery and radiosurgery as attractive treatment options. OBJECTIVES: To ascertain the safety and efficacy of Gamma Knife radiosurgery as a treatment for radiation-induced meningiomas. METHODS: A retrospective chart review was conducted to identify patients who received Gamma Knife radiosurgery for a meningioma and met the criteria for this being a radiation-induced tumor. Serial imaging was used to determine the outcome of treatment and clinical notes used to assess for toxicity. RESULTS: We present our series of 12 patients with radiation-induced meningiomas treated with Gamma Knife stereotactic radiosurgery over a 12-year period at our institution. With a median follow-up of 35 months, local control was 100%. Two patients experienced distant brain failure (>2 cm from previous radiosurgical volume). Two patients experienced posttreatment toxicity related to treatment-related edema. A review of data collected from the scientific literature suggests that tumor volume predicts for treatment failure of radiosurgery. CONCLUSIONS: Gamma Knife radiosurgery is both a safe and effective treatment for radiation-induced meningiomas.