Delayed Chyle Leak Following Anterior Cervical Spinal Surgery: A Case Report and Management Algorithm.

Injury to the thoracic duct during anterior cervical spine surgery is a rare occurrence. A delayed chyle leak following an elective anterior cervical spinal surgery has not been reported in the literature. We present a report of a 59-year-old female with multiple prior neck surgeries who underwent an anterior cervical corpectomy and fusion (ACCF). The patient developed a delayed thoracic duct injury on postoperative day (POD) one, as no injury was noted intraoperatively. She was managed with conservative care involving a low-fat diet along with octreotide which led to the resolution of her symptoms. We present this case report because of its unique presentation and to assist spine surgeons with initial management. Surgeons should have increased awareness when performing anterior cervical approaches to the lower cervical and upper thoracic levels from the left side.

Instrumented fusion in the setting of primary spinal infection.

INTRODUCTION: The objective of this study is to investigate the morbidity and mortality associated with instrumented fusion in the setting of primary spinal infection. EVIDENCE ACQUISITION: A search was performed in the PubMed and Medline databases for clinical case series describing instrumented fusion in the setting of primary spinal infection between 2003 and 2013. The search was limited to the English language and case series including at least 20 patients. The primary outcome measure was postoperative infection (recurrent local infection) + surgical site infection (SSI); secondary outcome measures included reoperation rates, development of other complications, and perioperative mortality. EVIDENCE SYNTHESIS: There were 26 publications that met the inclusion criteria, representing 931 patients with spondylodiscitis who underwent decompression, debridement, and instrumented fusion. Spinal infections occurred most commonly in the lumbosacral spine (39.1%) followed by the thoracic spine (27.1%). The most common microorganisms were Staphylococcus spp. After decompression, debridement, and instrumented fusion, the overall rate of postoperative infection was 6.3% (1.6% recurrent infection rate + 4.7% SSI rate). The perioperative complication rate was 15.4%, and the mortality rate was estimated at 2.3%. Reoperation for wound debridement, instrumentation removal, pseudoarthrosis, and/or progressive neurological deficit was performed in 4.5% of patients. CONCLUSIONS: The findings in this literature review suggest that the addition of instrumentation in the setting of a primary spinal infection has a low local recurrent infection rate (1.6%). However, the combined risk of postoperative infection is 6.3% (recurrent infection + SSI), more than three-fold the current infection rate following instrumentation procedures for degenerative spine disease. Moreover, the addition of hardware does usher in complications such as instrumentation failure and pseudoarthrosis requiring reoperation.

Concurrent Intraventricular and Sacral Spinal Drop Metastasis of Ganglioglioma in an Adult Patient: A Case Report and Review of Literature.

Gangliogliomas are uncommon tumors of the central nervous system and rarely occur in the lateral ventricle or present with drop metastasis. We report a 49-year-old male who presented with a six-week history of left leg pain and numbness. Clinical examination revealed no focal neurological deficits. Magnetic resonance imaging (MRI) demonstrated enhancing nodular lesions in the sacral spine abutting the S2 nerve root. Further imaging of the neuroaxis demonstrated a cystic lesion in the left frontal horn of the lateral ventricle. Gross total surgical resection of the ventricular lesion was performed through a transcortical approach, followed by resection of the sacral spinal drop metastasis in a staged manner. A histopathological analysis revealed the diagnosis of low-grade ganglioglioma. To our knowledge, this is the first reported case of a low-grade intraventricular ganglioglioma presenting with symptoms associated with drop metastasis in an adult patient.

Primary lesion location influences postoperative survival in patients with metastatic colorectal spinal lesions.

Spinal metastasis from colorectal cancer occurs rarely. However, with increasing incidence of colorectal cancer in the setting of improved therapies, physicians are more likely to encounter such patients. We performed a retrospective review of patients who underwent spine surgery for metastatic colorectal cancer from 2005-2011. Preoperative, operative and postoperative factors; functional outcome as determined by Karnofsky Performance Status (KPS) and modified Rankin scale (mRS); and survival were recorded. Univariate analysis was performed, with patients stratified into two groups based on the position of the primary cancer, either proximal (colon) or distal (rectum) to the rectosigmoid junction. Fourteen patients, with a median age of 52 (interquartile range [IQR] 48-66)years, underwent 21 spine surgeries for metastatic colorectal cancer. Pain was the common presenting symptom (n=11, 79%), followed by motor weakness (n=8, 57%). Twenty-seven postoperative complications occurred in 11 (52%) patients. Baseline KPS and mRS remained stable in four (29%), improved in two (14%), worsened in six (43%), and was unknown in two (14%) at last follow-up. Patients with spinal metastasis from a rectal primary (n=6) had a significantly longer survival compared to those with a colon primary (n=8), with a median survival of 84 (IQR 56-103) versus 26 (IQR 19-44)months after primary diagnosis (p=0.002), 19 (IQR 13-27) versus five (IQR 3-9)months after spine metastasis diagnosis (p=0.010), and six (IQR 4-14) versus three (IQR 2-4)months after surgery (p=0.030). Patients with spinal metastasis arising from rectal primary lesions display longer survival compared to colon lesions. Consideration of these factors is essential to appropriately assess surgical candidacy.

Prospective evaluation of 1-year outcomes in single-level percutaneous lumbar transfacet screw fixation in the lateral decubitus position following lateral transpsoas interbody fusion.

PURPOSE: Lateral transpsoas lumbar interbody fusion (LTIF) is an accepted treatment for degenerative lumbar disc disease. Bilateral percutaneous transfacet (TF) fixation is a promising option for stabilization following LTIF. Here, we describe our experience with this technique and assess the clinical outcomes and efficacy. METHODS: Thirty-eight consecutive patients were identified who underwent LTIF followed by bilateral percutaneous transfacet fixation in the lateral position. Preoperative and 1-year postoperative VAS scores, and operative data were prospectively recorded. One-year outcomes were also assessed according to the MacNab criteria. Fusion was assessed at 1 year via computed tomography and dynamic radiography. Two-tailed Student's t test was used to compare VAS scores. RESULTS: Twenty-six patients underwent fusion at L4-5, 11 at L3-4, and one at L2-3; two patients were lost to follow-up. Mean operative time was 148.0 ± 47.9 min; mean blood loss was 33.0 ± 26.1 ml; mean hospital stay was 53.5 ± 51.2 h. Mean preoperative VAS scores for back and leg pain were 7.4 ± 3.0 and 7.0 ± 2.9, respectively; mean postoperative VAS scores for back and leg pain were 1.9 ± 2.4 (p < 0.0001) and 2.0 ± 3.0 (p < 0.0001), respectively. Most (89 %) patients had some relief, 72 % good to excellent and 17 % fair outcomes; eleven percent had little to no relief. There was one postoperative complication (pulmonary embolus). All patients had evidence of solid bony fusion. CONCLUSIONS: Percutaneous transfacet fixation in the lateral position is a safe and effective alternative for fixation after LTIF and may be associated with shorter operative time and less blood loss than other posterior fixation techniques.

Tokuhashi score is predictive of survival in a cohort of patients undergoing surgery for renal cell carcinoma spinal metastases.

PURPOSE: Renal cell carcinoma (RCC) is an aggressive disease that metastasizes to the spine often requiring surgery. However, selecting the appropriate surgical intervention can be challenging. The Tokuhashi scoring system can be used to predict survival and inform the surgical strategy. We set out to determine the Tokuhashi score for patients with RCC spine metastases and compare expected and observed survival. METHODS: Records were reviewed for all patients who underwent surgery for spinal metastases at a single institution from January 2000 to December 2011 to determine the Tokuhashi score and survival. Kaplan-Meier estimates and log-rank test for univariate analysis were performed with R version 2.15.12 (R Foundation, 2012). RESULTS: Thirty patients underwent 40 spinal operations for metastatic RCC. Median survival was 11.4 months. Preoperative Tokuhashi scores were: 12-15, 15 patients; 9-11, seven patients; 0-8, eight patients. Median survival was 32.9, 11.7, and 5.4 months, respectively. Bone (p=0.01) and visceral metastases (p=0.005), and KPS (p=0.002) significantly affected survival. Tokuhashi score predicted survival (p=0.016); survival differed between the high and low score groups (p=0.006). CONCLUSIONS: RCC is an aggressive disease with short life expectancy when metastatic to the spine. However, patients with low systemic disease burden and solitary spinal metastases can have long survival and benefit from excisional surgery. Tokuhashi score can be useful in selecting surgical intervention in patients with RCC spinal metastases, and may be more relevant than in other cancers with spinal metastases.

The rising psoas sign: an analysis of preoperative imaging characteristics of aborted minimally invasive lateral interbody fusions at L4-5.

Minimally invasive lateral interbody fusion for the treatment of degenerative disc disease, spondylolisthesis, or scoliosis is becoming increasingly popular. The approach at L4-5 carries the highest risk of nerve injury given the proximity of the lumbar plexus and femoral nerve. The authors present 3 cases that were aborted during the approach because of pervasive electromyography responses throughout the L4-5 disc space. Preoperative imaging characteristics of psoas muscle anatomy in all 3 cases are analyzed and discussed. In all cases, the psoas muscle on axial views was rising away from the vertebral column as opposed to its typical location lateral to it. Preoperative evaluation of psoas muscle anatomy is important. A rising psoas muscle at L4-5 on axial imaging may complicate a lateral approach.

Minimally invasive resection of lumbar synovial cysts from a contralateral approach.

Synovial cysts of the lumbar spine result from degeneration of the facet capsule and often mimic symptoms commonly seen with herniated intervertebral discs. In symptomatic patients, the prevalence of synovial cysts may be as high as 10%. Although conservative management is possible, the majority of patients will require resection. Traditional procedures for lumbar synovial cyst resection use an ipsilateral approach requiring partial or complete resection of the ipsilateral facet complex, possibly leading to further destabilization. A contralateral technique using minimally invasive tubular retractors for synovial cyst resection avoids facet disruption. The authors report 2 cases of a minimally invasive synovial cyst resection via a contralateral laminotomy. In both cases, complete resection of the cyst was achieved while sparing the facet joint.

Moyamoya disease and surgical intervention.

Stroke is an increasingly recognized cause of morbidity in the pediatric population. The incidence of ischemic stroke is 1.2 per 100,000 children. There are many known etiologies of childhood cerebral ischemia but moyamoya is one of the only ischemic conditions of childhood that can be effectively treated with surgery. Moyamoya disease is by definition idiopathic, whereas moyamoya syndrome refers to a similar disease course in conjunction with a known predisposing condition. The clinical manifestations and disease progression are similar. Furthermore, surgical treatment has been shown to be efficacious and safe in the treatment of moyamoya.

Extensive disease small cell lung cancer dose-response relationships: implications for resistance mechanisms.

BACKGROUND: Some studies (but not others) suggested that high doses are beneficial in small cell lung cancer (SCLC). We hypothesized that dose-response curve (DRC) shape reflects resistance mechanisms. METHODS: We reviewed published SCLC clinical trials and converted response rates into estimated mean tumor cell kill, assuming killing is proportional to reduction in tumor volume. Mean % cell survival was plotted versus planned dose intensity. Nonlinear and linear meta-regression analyses (weighted according to the number of patients in each study) were used to assess DRC characteristics. RESULTS: Although associations between dose and cell survival were not statistically significant, DRCs sloped downward for five of seven agents across all doses and for all seven when lowest doses were excluded. Maximum mean cell kill across all drugs and doses was approximately 90%, suggesting that there may be a maximum achievable tumor cell kill irrespective of number of agents or drug doses. CONCLUSIONS: Downward DRC slopes suggest that maintaining relatively high doses may possibly maximize palliation, although the associations between dose and slope did not achieve statistical significance, and slopes for most drugs tended to be shallow. DRC flattening at higher doses would preclude cure and would suggest that "saturable passive resistance" (deficiency of factors required for cell killing) limits maximum achievable cell kill. An example of factors that could flatten the DRC at higher doses and lead to saturable passive resistance would be presence of quiescent, noncycling cells.

Management of rash and other toxicities in patients treated with epidermal growth factor receptor-targeted agents.

Inhibition of the epidermal growth factor receptor (EGFR) represents one of the most important avenues for research and development in the field of cancer therapy. The EGFR is a member of the ErbB receptor tyrosine kinase (TK) family, which also includes ErbB-2 (HER2/neu), ErbB-3 (HER3), and ErbB-4 (HER4). Current EGFR therapies available for use include monoclonal antibodies, such as cetuximab, and small-molecule EGFR TK inhibition by agents such as erlotinib. Side effects of these agents include dermatologic manifestations without the bone marrow suppressive properties of chemotherapy. Understanding of rash and how it relates to EGFR inhibitor toxicity and, perhaps more importantly, EGFR inhibitor response must be more clearly defined with clinical trials. The optimum management of rash in patients receiving anti-EGFR therapy remains somewhat controversial; this is secondary to imprecise classification of rash as well as the lack of clinical trials to determine the most appropriate treatment algorithm for these patients. We propose a treatment strategy to help aggressively treat dermatologic side effects allowing patients to continue receiving therapy without dose interruption or drug discontinuation.

Angiogenesis inhibitors in the treatment of cancer.

The field of cancer research has seen a marked shift in the past decade towards the exploration and development of non-conventional antitumour agents. One of the most widely studied approaches to therapy during this period has been that of antiangiogenesis. The published clinical trials and subsequent FDA approval (in February 2004) of the anti-vascular endothelial growth factor (VEGF) monoclonal antibody bevacizumab (Avastin, Genentech) for the treatment of colorectal cancer marked a milestone for antiangiogenesis therapy. Currently, preclinical and clinical research involving therapeutic targeting of VEGF and other mediators of angiogenesis continues in multiple tumour types. In addition to colorectal cancer, angiogenesis inhibitors are being investigated in the treatment of renal cell carcinoma, head and neck carcinoma, lung cancer, breast cancer, prostate cancer, and a variety of haematological malignancies. This article will discuss the background of antiangiogenesis research, preclinical and clinical data relating to the use of bevacizumab in the treatment of colorectal cancer, other completed clinical trials involving antiangiogenesis agents, and the potential future utility of these agents in the treatment of malignancy.