Surgical outcomes and predictors of complication in elderly patients with meningiomas.

BACKGROUND: Surgical management of symptomatic meningioma in elderly is still a high-risk surgery due to increased incidence of complication rate. Many scoring systems have been proposed to expect the surgical risk and the outcome.The study tries to assess cranial meningioma surgery in elderly using the Ibañez grade for complication rate and the Geriatric Scoring System (GSS) for the surgical outcome (GSS). METHODS: A clinical and radiological data were studied retrospectively in 42 patients with a primary intracranial meningioma at or above the age of 65. Complication rate, surgical risk, and outcome were statistically analyzed. RESULTS: The mean Geriatric Scoring System (GSS) score on admission was 15.4 ± 2.6. Ibañez grade of severe complication or death (grades III-IV) were experienced in 26.2% of patients. It was more common in male and in emergency cases, but it was significant in relation to the comorbidities (P < 0.004). Most patients had World Health Organization (WHO) grades I lesions, accounted for 85.7% of patients. MRI evidence of post-surgical residual was 14.4%, and 83.3% of patients had recurrence-free survival (RFS). The GSS score >16 were more frequent in the patient with RFS than those of < 16, and it was statistically significant (P < 0.06). Patient with Karnofsky performance status (KPS) < 70, the mean GSS was 14.5 and KPS > 70, the mean GSS was 18.9, and it was statistically significant (P < 0.002). CONCLUSION: The surgical technique for resection of elderly meningioma still had numbered cases of morbidity and mortality. The complication rate is related to preoperative co-morbidity and frequently associated with male and urgent surgery. Karnofsky score > 70, and RFS are favorable prognosis and related to GSS > 16 scores. The recurrence rate is usually attributed to high tumor grade and skull base tumor. Such scoring systems are valuable for elderly meningioma.

Radiological and anatomical evaluation of the atlantoaxial transarticular screw fixation technique.

Sixty-one patients treated with C1-2 transarticular screw fixation for spinal instability participated in a detailed clinical and radiological study to determine outcome and clarify potential hazards. The most common condition was rheumatoid arthritis (37 patients) followed by traumatic instability (15 patients). Twenty-one of these patients (one-third) underwent either surgical revision for a previously failed posterior fusion technique or a combined anteroposterior procedure. Eleven patients underwent transoral odontoidectomy and excision of the arch of C-1 prior to posterior surgery. No patient died, but there were five vertebral artery (VA) injuries and one temporary cranial nerve palsy. Screw malposition (14% of placements) was comparable to another large series reported by Grob, et al. There were five broken screws, and all were associated with incorrect placement. Anatomical measurements were made on 25 axis bones. In 20% the VA groove on one side was large enough to reduce the width of the C-2 pedicle, thus preventing the safe passage of a 3.5-mm diameter screw. In addition to the obvious dangers in patients with damaged or deficient atlantoaxial lateral mass, the following risk factors were identified in this series: 1) incomplete reduction prior to screw placement, accounting for two-thirds of screw complications and all five VA injuries; 2) previous transoral surgery with removal of the anterior tubercle or the arch of the atlas, thus obliterating an important fluoroscopic landmark; and 3) failure to appreciate the size of the VA in the axis pedicle and lateral mass. A low trajectory with screw placement below the atlas tubercle was found in patients with VA laceration. The technique that was associated with an 87% fusion rate requires detailed computerized tomography scanning prior to surgery, very careful attention to local anatomy, and nearly complete atlantoaxial reduction during surgery.

Is the technique of posterior transarticular screw fixation suitable for rheumatoid atlanto-axial subluxation?

The rheumatoid patient with atlanto-axial subluxation presents a major challenge to the spinal surgeon, owing to the poor wound healing and bone quality. Traditional wiring techniques are associated with a high complication and failure rate. Posterior transarticular screw fixation of the atlanto-axial joint offers a credible alternative and when combined with a Gallie construct offers immediate true 3-point stability. It is, however, a difficult and demanding technique which carries a risk of vertebral artery, cranial nerve and spinal cord damage. The question that arises therefore is "Do the improved stability rates afforded by this technique really justify the risks of arterial and neurological damage?" To date there have been no studies of this technique dealing solely with the rheumatoid patient, with most reports dealing with a heterogeneous patient population, mainly trauma-related cases. The purpose of this report is to analyse critically our results with particular reference to the complications that we have encountered and the technical reasons for their occurrence. We analysed the clinical and radiological data of 38 rheumatoid patients (six males: 32 females, mean age of 54 years) with atlanto-axial subluxation who underwent transarticular screw fixation. Our analysis centred on screw malposition and complications. Parametric and non parametric statistical analysis was performed. Significance was accepted at the 5% level (p < 0.05). Our analysis revealed that three vertebral arteries were damaged. Two of these were recognized at the time of surgery, with the remaining case only suspected following postoperative CT to assess screw positioning. Vertebral artery occlusion was subsequently confirmed by angiography. All three patients were asymptomatic from their arterial injury. There was only one neurological complication in this series, and this was caused by a high screw, which damaged the hypoglossal nerve with a temporary nerve palsy ensuing. Four screws broke, all were made of titanium, but more importantly, all were also associated with contralateral screw malposition. Stability was achieved in 95% of cases overall. The high stability rates afforded by this technique do appear to justify the inherent risks of this procedure. If unilateral screw fixation only is achieved, we would recommend a period of halo immobilization until osseous union occurs.

Biocompatible osteoconductive polymer versus iliac graft. A prospective comparative study for the evaluation of fusion pattern after anterior cervical discectomy.

STUDY DESIGN: One hundred fifteen patients having symptomatic cervical disc disease were recruited prospectively for this study. They were allocated randomly for either autologous iliac bone graft or biocompatible osteoconductive polymer implants. Both groups were compared clinically and radiologically. OBJECTIVES: Complications, long-term clinical and radiologic outcome, and hospital stay were compared to determine if biocompatible osteoconductive polymer was an improvement on iliac bone graft in terms of reduced donor site pain and shortened hospital stay. SUMMARY OF BACKGROUND DATA: Donor site morbidity is a significant problem in anterior cervical fusion. Hospital stay is another factor in the recent era of cost consciousness. Biocompatible osteoconductive polymer has been used in many centers as a biodegradable implant to circumvent these problems. METHODS: Smith-Robinson technique was used in 74 patients, and Cloward technique was used in 41 patients. Sixty-five patients had biocompatible osteoconductive polymer implants, and 50 patients had iliac bone graft. Patients were followed-up routinely in the outpatient clinic where pain visual analogue scale and Odom's criteria were used for outcome evaluation. Plain radiography, computed tomography scan, and magnetic resonance imaging were used for radiologic evaluation. RESULTS: The mean hospital stay was 4.8 days for those with iliac bone graft and 4.7 days for those with biocompatible osteoconductive polymer. Clinical outcome was identical in both groups. The incidence of partial graft protrusion and postoperative intersegmental kyphosis was statistically higher with iliac bone graft (P = 0.018 and P = 0.02, respectively). "Sclerosis" started to form around biocompatible osteoconductive polymer like a "halo" at 2 months. It increased with time, and sometimes was associated with new osteophyte formation; however, there was no biocompatible osteoconductive polymer incorporation or biodegradation CONCLUSIONS: Biocompatible osteoconductive polymer acts as a good "spacer" that reduces graft collapse and intersegmental kyphosis. However, it did not show any radiologic evidence of biodegradation or incorporation during the follow-up period of 24 months.

Pineal region meningioma without dural attachment.

A pineal region meningioma without dural attachment is rare. We present a case and review 12 cases reported in the literature. The preoperative diagnosis is difficult, but a vertebral angiogram if correlated to the MRI and clinical picture may give a clue. The infratentorial supracerebellar approach is suitable for this type of tumour.