Minimally versus conventional-invasive transforaminal lumbar interbody fusion in patients with failed back surgery syndrome.

BACKGROUND: Failed back surgery syndrome is an important cause of back and leg pain after spinal surgery. Transforaminal lumbar interbody fusion (TLIF) is commonly used in revision surgery for failed back surgery syndrome. In the literature, there is a lack of evidence concerning the minimally and conventional-invasive TLIF and debates are ongoing. The purpose of the present study was to compare efficacy and safety of minimally versus conventional-invasive TLIF for failed back surgery syndrome. MATERIALS AND METHODS: This study was conducted according to the STROBE Statement. Between 2011 and 2014, thirty patients with failed back surgery syndrome underwent TLIF. Group I (15 patients) received minimally invasive TLIF through paramedian approach using microscopy and fluoroscopy. Group II (15 patients) received conventional-invasive TLIF. Minimum follow-up was 12 months. RESULTS: There was a significant improvement of Oswestry Disability Index (ODI) and visual analogue scale (VAS) in both groups postoperatively. There was no statistically significant difference between both groups regarding ODI, VAS, leg and back pain pre- and postoperatively. There was a tendency to better postoperative ODI and VAS scores in group I; however this did not reach the statistical significance. One case showed adjacent segment degeneration in group I. In group II, one case had screw mal-positioning with foot drop. Another case had dural injury with postoperative fistula. CONCLUSION: TLIF is a valuable option after failed back surgery syndrome providing statistically significant improvement postoperatively. Both minimally and conventional-invasive TLIF represent a safe and reliable treatment of patients with failed back syndrome, achieving satisfactory outcome along with low rate of complications. Although the minimally invasive TLIF scored better, these differences did not reach the threshold of significance.

Bilateral epilepsy surgery in a 4-year-old child.

OBJECTIVE: Reports on bilateral epilepsy surgical interventions are anecdotal because of the possible neurological deficits caused by them. METHODS: We report on a four-year-old amaurotic child with catastrophic epilepsy due to bilateral occipital cortical dysplasia. After video-EEG monitoring and intraoperative electrocorticography he underwent a two-step bilateral occipital lobectomy. RESULTS: The first resection resulted in only temporary seizure cessation; however, he became seizure-free after the second operation (follow-up: 20 months). CONCLUSION: Patients with catastrophic epilepsy due to bilateral epileptogenic lesions but without a high risk of additional postsurgical deficit may be good candidates for epilepsy surgery.

Regrowth of residual ruptured aneurysms treated by Guglielmi's Detachable Coils which demanded further treatment by surgical clipping: report of 7 cases and review of the literature.

OBJECT: The management of intracranial aneurysms has truly evolved after the introduction of endovascular treatment by Guglielmi Detachable Coils (GDC). In our department, for every case (ruptured or unruptured aneurysm) we discuss in the first place endovascular treatment. When coiling is feasible, it is done as a first choice. If not (intracranial compressive haematoma, coiling unfeasible or dangerous), the patient is operated upon. Failure of the endovascular technique, like incomplete treatment and regrowth of the residual sac, becomes a subject of discussion. Some cases need complementary treatment for large or unstable residual aneurysm. METHODS: Thus, between 1997 and 2000, 59 ruptured aneurysms were treated using an endovascular method by means of GDC. In 15 of this cases complementary treatment was needed, due to the size or instability of the residual aneurysm. In 8 cases a new embolization was possible and in 7 cases a complementary surgical procedure was needed, due to the impossibility of further endovascular treatment. RESULTS: Out of these 7 cases who were operated upon after coiling, clipping of the residual neck was possible in 4 cases; in 3 cases clipping was impossible due to the partial filling of the aneurysm neck by the coils. In these 3 cases, a ligation of the residual neck, associated with coagulation of the sac was performed. DISCUSSION: The difficulty of the treatment of an residual aneurysm after coiling is discussed as well as those surgical techniques alternative to clipping (wrapping or coagulation of the residual sac).

Intracranial ependymomas in adult patients: analyses of prognostic factors.

OBJECTIVE: The goal of our study is to identify significant prognostic factors for a series of intracranial ependymomas in an adult population. Age, location, histology, preoperative clinical status, extent of resection and radiotherapy were examined. METHODS: Our series includes 34 patients. Ten tumors were located in the brain parenchyma, 5 in the lateral ventricle, 8 in the third and 11 in the fourth ventricle. Seventeen ependymomas were grades 2 and 17 were anaplastic. Surgical resection was gross-total in 27 patients and partial in 7. RESULTS: At a mean follow-up of 9 years (+/- 1 year) 16 patients died and, among the 18 survivors 14 are in complete remission and 4 present a local recurrence. The 5- and 10-year overall survival rates were respectively 62% and 43%. The 5- and 10-year progression-free survivals were 47% and 43%. Univariate analysis revealed that location in the brain parenchyma and anaplasia are the only statistically significant predictors of poor outcome. CONCLUSION: We can make out three groups of patients from our series: the first encompasses patients operated on for an intraparenchymal tumor, in all our cases an anaplastic ependymoma, with a 5-year rate of tumor-related deaths of 100%. The second group includes fourth ventricle ependymomas, which are mostly grade 2 tumors. They display a 10-year survival rate of 90%. Last group entails lateral and third ventricle ependymomas, of both low and high grade, with a 10-year survival rate of 60% for lateral ventricle and 35% for third ventricle tumors.

Recurrent lumbosacral metastases from intracranial meningioma. Report of a case and review of the literature.

We report a case of a 31 year-old woman who in 1991 presented a clinical history of headaches, nausea and vomiting. CT scan showed a right frontotemporal meningioma. The first operation achieved a macroscopically complete resection. The tumour was histologically classified as a transitional meningioma. There were recurrences of the intracranial meningioma in 1994, 1996, 1997 and 1998. These recurrences were accompanied by differentiation to atypical and anaplastic meningioma. In all of these operations, a macroscopically complete resection of the tumour was performed. In 1996 adjuvant radiation therapy was given. In 1998 therapy with bromocriptine was adopted. In April 1999, the patient presented with lumbosacral pain associated with L5 bilateral sciatica. MRI showed a gadolinium enhancing mass lesion at L5-S1 level. Complete tumour resection was performed. The histological findings were the same as in 1998. In December 1999 the patient presented with perineal pain and MRI showed a L4 and S3 recurrence and the tumour was resected. The histological findings were those of a malignant meningioma. In February 2000 an intracranial recurrence was detected and operated on. The histological diagnosis was malignant meningioma. A review of the literature was undertake and is discussed.

Visceral cancer metastasis to pituitary adenoma: report of two cases.

BACKGROUND: We report two cases of metastases from visceral cancers to pituitary adenomas, and review the literature. CASE DESCRIPTION: Two female patients, aged 75 and 87 years, underwent transesophageal surgery for presumably benign pituitary adenomas. Using extensive immunostaining studies, histopathological examination showed that the surgical specimens from both patients were composed of metastatic deposits within gonadotropin adenomas. Fourteen cases of metastases to pituitary adenomas have been mentioned in 11 reports in the literature. In all cases, the correct diagnosis was made after autopsy or histopathological studies, even in patients known to suffer from visceral malignancies. In our cases, immunohistochemical studies were conclusive in characterizing the two distinct tumor components. The pathogenetic mechanisms favoring the development of metastases in pituitary adenomas are discussed, especially those altering the normal hypophyseal circulation. CONCLUSION: Neurosurgeons performing pituitary surgery should be aware of the possibility of metastases in pituitary adenomas.

Tentorial meningiomas. Report on twenty-seven cases.

OBJECTIVE: Report our experience with 27 tentorial meningiomas (TM) surgically treated between 1985 and 1998. METHODS: The records of 27 patients with TMs were retrospectively reviewed for clinical presentation, neuroradiological evaluation, surgical treatment and long-term outcome. The extent of tumor resection was scored according to the Simpson's grading for tumor removal. Long-term results were evaluated according to the Glasgow Outcome Score (GOS). RESULTS: The average age was 53 years. Female predominance was 74%. The most common complaints at presentation were headaches (51%), gait ataxia (33%), memory disturbances (30%) and hypoacousia (30%). A classification of TMs into 5 subgroups according to tumor site is proposed on the basis of imaging studies. A cerebrospinal fluid shunt was established prior to direct approach in 7 patients and as the sole procedure in one inoperable patient. Twenty-seven direct approaches were undertaken in 26 patients, including 17 infratentorial and 10 supratentorial approaches. Total tumor removal was achieved in 20 patients (77%) and subtotal removal in 6 (23%). Fifteen patients (55%) experienced 22 postoperative complications. One patient died three months after a subtotal resection (mortality = 3.7%). With a mean follow-up of 54 months, all 26 survivors are currently alive with 23 having resumed their normal activities and 3 needing assistance. Five of 6 patients with subtotal resection survived and were followed for a period ranging from 72 to 132 months: none showed residual tumor progression and no re-operation was considered. An additional patient experienced a () recurrence 6 years after total removal, with no tumor progression 2 years after his recurrence was recognized. DISCUSSION: The best surgical approach to TMs is still a controversial matter. The advantages and drawbacks of conventional versus transbasal approaches are reviewed. Our experience suggests that subtotal removal can be associated with long recurrence-free intervals and preserved quality of life. TMs located at the tentorial edge carried a definitely worse prognosis than peripheral forms.

Is reoperation for recurrence of glioblastoma justified?

The purpose of the present study was to determine the effect of surgery on the time length and quality of survival in patients with recurrent glioblastoma multiforme. Two groups were compared; the first included 18 patients who underwent surgery at the time of tumour recurrence. The second group included 36 patients who did not undergo surgery at the time of tumour recurrence. Both groups were matched according to the following criteria: gender, age, Karnofsky Performance Scale (KPS) score, at the time of initial surgery and of tumour recurrence, extent of initial surgery, interval between initial surgery and tumour reccurence. Both groups received conventional treatment after initial surgery. There are no statistically significant differences between the two groups as regards to the previously mentioned criteria. After tumour recurrence, the median survival time was 5 months in the group of patients undergoing a second resection and 2 months in the group of patients not undergoing repeat surgery. The difference was statistically significant on univariate analysis. Moreover, the median length of time spent in an acceptable condition (KPS >/=60) from the time of tumour recurrence was found to be significantly longer in patient who underwent a second resection (4 months) compared with patients who did not undergo repeat surgery (1 month). Even in a relatively favorable subgroup of reoperated patients, the survival benefit although significant was only 3 months. It was impossible to completely match the two groups of patients suggesting that the difference might have been even less. Although symptomatic improvement is modestly achieved by repeat surgery, its transient nature necessitates clear discussion with patient and family on an individual basis.