Posterolateral approach for decompression with anterior and posterior fusion: a less invasive surgical technique for stabilization of the thoracic spine. Case report

The goals of surgery in unstable thoracic fractures or tumors involving the thoracic spine are neural decompression, correction of deformity, and stabilization. Several different approaches can be used to achieve these goals. The anterior, combined anterior and posterior, and more recently thoracoscopic approaches are well described in the literature and are extremely effective in achieving the goals mentioned. However, they do carry with them significant morbidity and mortality rates in patients who are elderly, who have associated medical problems, or for whom there are contraindications to thoracic surgery. The authors believe the posterolateral approach is a viable alternative that is reasonably well tolerated in this select patient population. One can achieve circumferential neural decompression as well as anterior and posterior arthrodesis through a single incision. Most neurosurgeons are familiar with the anatomical landmarks and technical steps in the posterolateral approach, and the authors believe it is a less invasive method that can be especially useful and should not be overlooked in this subgroup of patients.

Practical and technical aspects of trans-sphenoidal surgery

Trans-sphenoidal surgery was first described more than a century ago. Today, this approach occupies a crucial place in the armamentarium of the neurosurgeon for the management of sellar, suprasellar, and parasellar pathological conditions. Over the years, the procedure has witnessed multiple modifications, benefitting from technological advances and from innovative ideas of pioneering neurosurgeons and otolaryngologists. The introduction of the microscope and then the endoscope allowed progressive improvement of visualization, illumination, and magnification in this restricted surgical corridor. With enhanced knowledge and understanding of the surgical anatomy of the skull base, the application of extended transsphenoidal approaches became possible, thus widening significantly the anatomical area that can be reached through this approach. In addition, the continuous improvement in imaging, image guidance, and microinstruments allowed better planning and precision during surgery. In sum, thanks to recent technological advance, trans-sphenoidal surgery can now be applied to a large area of the skull base and for a wide range of pathological conditions. With growing experience, the procedure is performed with enhanced safety and greater efficacy. In this paper, we review the historical evolution of trans-sphenoidal surgery and describe the modern applications and modifications of the procedure.

Malignant clival chordoma with postoperative cutaneous metastases

The authors report the case of a chordoma with malignant cytologic features, presenting as a mass lesion in the clival and infratemporal region at the level of the craniocervical junction in an 8-year-old female. Following gross resection of the mass, the patient subsequently developed distant subcutaneous and peritoneal metastases from the lesion. The rare histologic features, the surgical approach to the lesion, and the follow-up management of this unique case are discussed.

Reconstruction of the skull base and cranium adjacent to sinuses with porous polyethylene implant: preliminary report

Surgical reconstruction of the skull base and cranium adjacent to open paranasal sinuses with alloplastic materials is problematic secondary to an increased risk of implant infection in these locations. The authors report their initial experience with the use of a porous polyethylene implant for closure of defects in these locations in 20 patients, in 14 of these with the implant placed in direct contact with the mastoid or paranasal simuses. The implant is flexible, which facilitates surgical reconstruction of the cranial base, and porous in nature, which enhances soft tissue and bone ingrowth in decrease the risk of infection. The implant is radiolucent on plain roentgenograms and CT, and produces no imaging artifact on MRI. The implant was utilized for a variety of skull base of cranium adjacent to sinus reconstructive applications with no infectious complications, with a follow-up period ranging from 8 to 50 months. This preliminary experience suggests that the alloplast may be a useful adjunct in skull base reconstruction, and further evaluation of its use in this application is warranted.

Staged use of the transsphenoidal approach to resect superior third ventricular craniopharyngiomas

INTRODUCTION

Craniopharyngiomas are benign tumors, usually originating from the infundibulum or tuber cinereum. Their surgical treatment is challenging because of their relationship to neural and vascular structures. Large craniopharyngiomas that invade the upper third of the third ventricle are a common reason for patients to need a second operation to accomplish a gross total resection. Transsphenoidal approaches are being increasingly used in the treatment of craniopharyngiomas. Large craniopharyngiomas involving the superior third ventricle are most commonly resected through a staged approach, often involving a transcortical or interhemispheric route.

CASE REPORT

The authors describe the use of an extended transsphenoidal approach as a second-stage operation to resect the intraventricular component of a large craniopharyngioma in an illustrative case.

CONCLUSION

The authors find this to be an excellent indication for an endoscopic extended transsphenoidal approach in selected cases.

Bilateral testicular enlargement and seminoma in a patient with acromegaly

Growth hormone (GH) excess has been associated with soft tissue changes and an increase in the incidence of colonic polyps and gastrointestinal cancer. We describe a patient with endogenous GH excess caused by a pituitary tumour, resulting in acromegaly. The patient had bilateral testicular enlargement, with tumour of the right testicle. Pituitary MRI revealed a macroadenoma. After resection of the pituitary tumour, GH levels fell below 0.5 ng/ml, with acromegaly resolution. Testicular resection revealed seminoma. Following acromegaly resolution, the enlarged remaining testicle decreased in size. The implications of the testicular enlargement and seminoma in the presence of a GH-secreting tumour are discussed.

The use of the Olympus EndoArm for spinal and skull-based transsphenoidal neurosurgery

Minimally invasive surgical techniques have evolved to reduce soft-tissue injury associated with open surgical techniques. The use of endoscopic visualization allows the exposure of deep structures and provides a mechanism to perform all the components of an open surgical procedure through small portals, thus satisfying a basic requirement of minimally invasive surgical procedures. Surgeons in the field of skull-base and spine surgery are now taking advantage of the benefits of such endoscopes. The pneumatically powered EndoArm endoscopic holder has been used extensively in both cranial and spinal neurosurgical cases at the University of Utah. These cases include minimally invasive cervical and lumbar decompression procedures, as well as more recently the resection of larger and more extensive pituitary tumors. In this paper, the multiple advantages of the Olympus EndoArm endoscopic holder are described in detail. As more surgeons gain experience with endoscopes in skull-base surgery, the hope is that operative times will be shorter and more extensive surgical resections will be possible with less patient morbidity.

Radiographic features of tumefactive giant cavernous angiomas

BACKGROUND

Giant cavernous angiomas (GCAs) are very rare, and imaging features of GCAs can be very different from those of typical cavernous angiomas (CAs), making them a diagnostic challenge. The purpose of the study was to evaluate the radiographic features of GCAs, with an emphasis on the differentiating features from neoplastic lesions.

METHODS

The neuroradiological findings of 18 patients who harbored a histologically verified GCA (CA of 4 cm or larger) were reviewed retrospectively. The magnetic resonance imaging (MRI) appearance, enhancement pattern, presence of edema or mass effect, size, and location of each lesion were recorded. When available, pertinent clinical information, including age, sex, and mode of presentation, was obtained.

FINDINGS

Seizures, neurologic deficits, hemorrhage, and hydrocephalus were the most common presenting symptoms. The lesions were hyperdense and nonenhancing on computed tomography with frequent calcifications. On MRI, the lesions most commonly had a multicystic appearance, representing blood of various ages, and multiple complete hemosiderin rings. GCAs can present in any location with associating edema and mass effect, giving them a tumefactive appearance. No developmental venous anomaly was observed with any lesion.

CONCLUSIONS

Most GCAs in our series presented as multicystic lesions with complete hemosiderin rings on MRI, giving a "bubbles of blood" appearance. Although this characteristic feature is helpful in the diagnosis of many cases of GCAs, the correct diagnosis in the remaining cases may not be apparent until histopathological evaluation of the specimen is made.

Recurrent infrasellar clival craniopharyngioma

The patient is a 44-year-old man who underwent resection of a posterior nasopharynx tumor 12 years earlier via left lateral rhinotomy approach. The final pathological analysis indicated the tumor was a craniopharyngioma, and the patient subsequently underwent focal radiation. The patient returned to medical attention complaining of dysequilibrium. A neurologic exam was nonfocal. Magnetic resonance imaging revealed a clival mass, separate from the sella turcica, with imaging characteristics concerning for chordoma or primary bone tumor (Fig. 1). The lesion was resected via an endoscope-assisted endonasal transsphenoidal approach, with gross total resection achieved. Intraoperatively, the mass was noted to erode through the posterior nasopharynx, without extension superiorly into the sella or posteriorly through the clival dura (i.e., lesion was infrasellar). The final pathological results indicated the tumor was adamantinomatous craniopharyngioma.

Symptomatic subdural hygroma and temporal lobe edema after translabyrinthine removal of acoustic neuroma

The translabyrinthine approach is familiar to most neurosurgeons and neuro-otologists and is frequently used to remove acoustic neuromas. Some of the complications associated with this surgery include cerebrospinal fluid (CSF) leaks, meningitis, and rarely fat graft prolapse. The authors report a 60-year-old woman who underwent a translabyrinthine approach and microsurgical resection of a right-sided 1-cm acoustic neuroma. Initially, she was discharged home after an uneventful postoperative course. Four days later, she sought treatment in the emergency room complaining of headaches, dizziness, and lethargy. A computed tomographic (CT) scan showed a large right-sided subdural hygroma and right temporal lobe edema. The patient underwent burr hole evacuation of the collection and placement of a subdural drain, after which the edema in the temporal lobe and hygroma resolved. We speculate that the underlying mechanism was the result of inadvertant damage to the venous drainage and an arachnoid tear that was not appreciated during surgery. Neurosurgeons and neuro-otogists should be aware of this unusual complication of translabyrinthine surgery and its possible underlying mechanisms.

Spontaneous regression of a cystic cavum septum pellucidum

A persistent cavum septum pellucidum (CSP) is present in approximately 0.73% of adults, although its incidence ranges from 0.14 to 18.9% depending on the detection method. Cystic CSP is even rarer. A cyst causing mass within the CSP can obstruct the intraventricular foramen, leading to blockage of CSF flow and possible hydrocephalus, often justifying surgical intervention. We describe spontaneous decompression of a cystic CSP in a 36-year-old man. Initial MRI showed a cystic CSP with lateral bowing of the septal walls to 1.9 cm. Follow-up MRI 15 months later demonstrated no lateral bowing, and the septal wall width was 1.0 cm. This spontaneous decompression was not explained by the one previously described case report of cystic CSP regression.

Incidental giant arachnoid granulation

Arachnoid granulations may expand the dural sinuses or inner table of the skull. Although usually incidental, giant arachnoid granulations that are of sufficient size to fill the lumen of a dural sinus and cause local dilation or filling defects can rarely cause symptoms due to sinus obstruction leading to venous hypertension. This 31-year-old man presented with a 3-month history of progressive bifrontal headaches and a giant arachnoid granulation at the posterior superior sagittal sinus. Intrasinus pressure measurements showed no significant pressure difference across the lesion to explain the headaches, which were then treated medically. Dural sinus pressure measurement, in certain cases of giant arachnoid granulations, can be used to exclude the lesion as the cause of the patient's symptoms.

Remote cerebellar hemorrhage

Remote cerebellar hemorrhage (RCH) is a rare but benign, self-limited complication of supratentorial craniotomies that, to the best of our knowledge, has not been described in the imaging literature. RCH can be an unexpected finding on routine postoperative imaging studies and should not be mistaken for more ominous causes of bleeding such as coagulopathy, hemorrhagic infarction, or cortical vein occlusion. Cerebellar hemorrhage in the typical setting can be identified as RCH and does not require more extensive or invasive evaluation.

Thrombosed basilar apex aneurysm presenting as a third ventricular mass and hydrocephalus

Aneurysms presenting as third ventricular masses are uncommon; most are giant aneurysms arising from the basilar apex. We present a case of a thrombosed basilar apex aneurysm presenting as a third ventricular mass and hydrocephalus in a 55-year-old man. The case is unique in the literature as the aneurysm was completely thrombosed and angiographically occult. The lesion was explored to verify the diagnosis and a third ventriculostomy resolved the patient's symptoms. Completely thrombosed aneurysms should be considered in the differential diagnosis of symptomatic third ventricular masses, even when angiographic studies are negative. The literature on aneurysms presenting as third ventricular masses is reviewed.

Distal ventriculoperitoneal shunt failure secondary to Clostridium difficile colitis

Distal ventriculoperitoneal shunt obstruction is typically associated with cerebrospinal fluid (CSF) infection, fluid pseudocysts, bowel obstruction, bowel perforation, or improper shunt placement in the abdomen. We describe a unique etiology for distal shunt obstruction secondary to Clostridium difficile pancolitis that occurred because of inflammation and ascites, which led to incomplete drainage and absorption of CSF. This case illustrates the importance of considering distal shunt obstruction in a patient with signs of abdominal pathology in the setting of mental status changes, and the effective treatment of this patient initially with distal catheter externalization followed by internalization of a new distal catheter after resolution of the pancolitis.

Revision of vagal nerve stimulator electrodes: technical approach

BACKGROUND

As the number of implanted vagal nerve stimulators grows, the need for removal or revision of the devices will become more frequent. Our purpose was to demonstrate the feasibility of complete removal of the vagal nerve stimulator electrode using microsurgical technique.

METHODS

. Operative databases at the University of Utah (1995 through 2002), Westchester Medical Center (1995 through 2001), and University of Arizona Health Sciences Center (1995 through 1999) were retrospectively reviewed. Patients who had undergone removal or revision of a previously placed vagal nerve stimulator electrode were identified. Patients who had a vagal nerve stimulator device removed but had the lead trimmed and incompletely removed were excluded.

FINDINGS

Seven patients underwent complete removal of the lead. Microsurgical dissection allowed removal of the helical electrode from the vagus nerve without apparent physiological consequences. Four patients had a new electrode placed just proximal to the original lead site. The operative procedure required an additional 30 minutes to complete compared with initial device placement. The four patients who underwent replacement of the electrode demonstrated normal device function and lead resistance at the time of postoperative follow-up. Each experienced a return to prior stimulation response and seizure control.

CONCLUSIONS

This series suggests that the electrode can be removed from the vagus nerve and repositioned without significant consequence in most cases.

Endoscopic-assisted craniofacial resection of esthesioneuroblastoma: minimizing facial incisions--technical note and report of 3 cases

The surgical management of esthesioneuroblastoma with anterior skull base involvement has traditionally been craniofacial resection, which combines a bifrontal craniotomy with a transfacial approach. The latter usually involves a disfiguring facial incision, mid-facial degloving, lateral rhinotomy, and/or extensive facial osteotomies, which may be cosmetically displeasing to the patient. The advent of angled endoscopes has provided excellent magnification and illumination for surgeons to remove tumors using minimally invasive techniques. The authors describe their experience with three cases of esthesioneuroblastoma, which were surgically removed using a transnasal endoscopic approach, avoiding transfacial incisions. Preoperative radiographs were reviewed and tumors were staged according to the Kadish staging system. One patient had a recurrent esthesioneuroblastoma (Kadish stage B), which was removed entirely through a transnasal endoscopic approach. Two patients had intracranial extension (Kadish stage C), which were resected with a combined approach, endoscopically from below and a bifrontal craniotomy from above, to remove intracranial disease. All patients underwent reconstruction of the anterior skull base. Esthesioneuroblastomas confined to the nasal and paranasal cavities (Kadish stage A and B) were readily accessible through the transnasal endoscopic approach. If there was significant intracranial disease (Kadish stage C), adding a bifrontal craniotomy provided excellent exposure for complete resection of involved tumor. All patients underwent complete tumor resection with negative margins. None developed a cerebrospinal fluid (CSF) leak. The endoscopic-assisted craniofacial approach for the surgical management of esthesioneuroblastomas provides excellent exposure, adequate visualization, and the cosmetic benefit of avoiding an external facial incision.

Enlargement of a vestibular schwannoma after stereotactic radiotherapy

BACKGROUND

Radiosurgery has been increasingly advocated as a primary treatment for vestibular schwannoma (VS), and recently fractionation of the dose has been proposed as a method to decrease the risk of radiation injury when treating larger tumors.

METHOD

The authors describe a 48-year-old woman who presented with right-sided hearing loss and new-onset tinnitus, with a progressive decrease in facial sensation. The diagnosis of a large right cerebellopontine angle VS was made on magnetic resonance imaging (MRI). The patient was treated with a course of fractionated stereotactic radiotherapy (SRT) (5 treatments of 4 Gy to the 90% isodose line over a 3-week period).

FINDINGS

Six months after the initiation of therapy, her symptoms increased, and a repeat MRI scan demonstrated that her tumor had increased in size, producing significant brainstem compression. She then underwent complete surgical resection of the tumor, with resolution of her symptoms.

INTERPRETATION

Stereotactic radiosurgery has been effective in controlling small VSs with low complication rates. Larger tumors pose a risk for increasing in size and producing symptoms from mass effect with SRT. There are at present limited data demonstrating safety and efficacy of fractionated SRT for the treatment of larger tumors.

Vertebral arterial dissection associated with Klippel-Feil syndrome in a child

BACKGROUND

Vertebral artery dissection resulting in stroke is rare in children. We report here on a 7-year-old boy with Klippel-Feil abnormality, who presented with a pontine infarction after a supervised swimming session.

METHODS

Evaluation after a second acute neurological event included a formal cerebral angiogram, which revealed a complete upper basilar artery occlusion and right vertebral arterial dissection. Cervical spine radiographs demonstrated an associated fusion of the C2 and C3 vertebrae. Anticoagulation therapy was initiated, and the neurological deficits associated with the pontine infarction resolved. Anticoagulation was discontinued after 6 months of therapy, with no recurrence of symptoms.

CONCLUSION

Vertebral artery dissection may rarely be associated with Klippel-Feil abnormality in children.

Laparoscopic anterior lumbar interbody fusion precipitating pituitary apoplexy

OBJECTIVE

Pituitary apoplexy may be the first presentation of a previously undiagnosed pituitary adenoma. Although many mechanisms of pituitary apoplexy have been proposed in the literature, the exact pathogenesis remains unclear. Many predisposing events have been implicated in the pathogenesis, however, the role of laparoscopy precipitating pituitary apoplexy has not been previously described. The authors present a case of pituitary apoplexy in a previously undiagnosed pituitary adenoma, which presented in the immediate post-operative period after a laparoscopic anterior lumbar interbody fusion.

CLINICAL PRESENTATION

A 45-year-old man presented with a sudden onset of headache, photophobia, diplopia, visual field deficits, and decreased visual acuity in the immediate post-operative period after an uneventful laparoscopic anterior lumbar interbody fusion. Results of computed tomography of the brain revealed a hyperdense suprasellar mass without any signs of subarachnoid blood. The patient underwent magnetic resonance imaging, which revealed a hemorrhagic pituitary tumor with lateral and suprasellar extension, with compression of the cavernous sinus and optic chiasm, respectively. An urgent transsphenoidal decompression of the hemorrhagic pituitary adenoma was performed. Post-operatively, the patient demonstrated marked neurological improvement with recovery of visual acuity and extraocular movements.

CONCLUSION

To the authors' knowledge, this is the first case reported in the literature of a laparoscopic procedure precipitating pituitary apoplexy. Recognition of this rare complication of laparoscopic surgery, and the importance of rapid diagnosis and urgent surgical treatment are emphasized.

Reversal of radiographically impending stroke with multiple intraarterial papaverine infusions in severe diffuse cerebral vasospasm induced by subarachnoid hemorrhage

BACKGROUND

Selective intraarterial infusion of papaverine is used in the treatment of symptomatic cerebral vasospasm induced by aneurysmal subarachnoid hemorrhage (SAH). Delays in instituting therapy for vasospasm can lead to irreversible cerebral infarction and a devastating outcome. Endovascular papaverine treatment of vasospasm in the presence of low-attenuation lesions on computed tomography (CT) is controversial, because of the fear of reperfusion hemorrhage in completed infarcts.

METHOD

Two patients with aneurysmal SAH who subsequently developed severe diffuse vasospasm were identified. In both patients, large areas of low-attenuation change suggesting impending cerebral infarction were seen on CT scans. The patients received multiple infusions of intraarterial papaverine in an effort to treat vasospasm refractory to medical management.

FINDINGS

After multiple intermittent administrations of papaverine, which initially appeared to increase the low-attenuation changes, there was dramatic reversal of the radiographic findings. There was also improvement in circulation time, transcranial Doppler velocities, and clinical outcome.

INTERPRETATION

These findings suggest that in some patients, intraarterial infusions of papaverine initiated in the earliest stages of ischemia may exacerbate the radiographic appearance of low-attenuation changes, but may ultimately reverse the evolution of cerebral infarction.

The history and evolution of transsphenoidal surgery

Initial attempts at transcranial approaches to the pituitary gland in the late 1800s and early 1900s resulted in a mortality rate that was generally considered prohibitive. Schloffer suggested the use of a transsphenoidal route as a safer, alternative approach to the sella turcica. He reported the first successful removal of a pituitary tumor via the transsphenoidal approach in 1906. His procedure underwent a number of modifications by interested surgeons, the culmination of which was A. E. Halstead's description in 1910 of a sublabial gingival incision for the initial stage of exposure. From 1910 to 1925, Cushing, combining a number of suggestions made by previous authors, refined the transsphenoidal approach and used it to operate on 231 pituitary tumors, with a mortality rate of 5.6%. As he developed increasing expertise with transcranial surgery, however, Cushing reduced his mortality rate to 4.5%. With the transcranial approach, he was able to verify suprasellar tumors and achieve better decompression of the optic apparatus, resulting in better recovery of vision and a lower recurrence rate. As a result he and most other neurosurgeons at the time abandoned the transnasal in favor of the transcranial approaches. Norman Dott, a visiting scholar who studied with Cushing in 1923, returned to Edinburgh, Scotland, and continued to use the transsphenoidal procedure while others pursued transcranial approaches. Dott introduced the procedure to Gerard Guiot, who published excellent results with the transsphenoidal approach and revived the interest of many physicians throughout Europe in the early 1960s. Jules Hardy, who used intraoperative fluoroscopy while learning the transsphenoidal approach from Guiot, then introduced the operating microscope to further refine the procedure; he thereby significantly improved its efficacy and decreased surgical morbidity. With the development of antibiotic drugs and modern microinstrumentation, the transsphenoidal approach became the preferred route for the removal of lesions that were confined to the sella turcica. The evolution of the transsphenoidal approaches and their current applications and modifications are discussed.

X-irradiation of the contusion site improves locomotor and histological outcomes in spinal cord-injured rats

We have determined whether X-irradiation of the injury site can oppose tissue loss and improve recovery of locomotor function following contusion injury of the spinal cord. Contusion injury was produced in rats at the level of T10 with a weight drop device. Localized X-irradiation (20 Gy) of the injury site was performed at 20 min and 1, 2, 4, 7, and 17 days postinjury. Locomotor recovery was then determined with the 21-point Basso, Beattie, and Bresnahan (BBB) scale. X-irradiation enhanced recovery of locomotor function during a subsequent 6-week observation period when administered 20 min and 1 or 2 days following contusion injury (final BBB score approximately 7-8). X-irradiation at 4-17 days postinjury did not significantly affect final locomotor scores compared with unirradiated rats (final BBB score approximately 2), in marked contrast to previous studies where X-irradiation applied only at 17-18 days benefitted transection injury. The extent of recovery was directly related to measurements of sparing of spinal cord tissue at the contusion center. Because the treatment time window occurred earlier in contusion than reported for transection injury, the results suggest that contusion injury rapidly initiates underlying radiation-sensitive processes that occur only following a delay of several weeks after transection injury. Further optimization of X-ray treatment may lead to a useful therapeutic modality for use in spinal cord contusion injury.

Effect of absorbable topical hemostatic agents on the relaxation time of blood: an in vitro study with implications for postoperative magnetic resonance imaging

OBJECT

Absorbable topical hemostatic agents are commonly used in neurosurgery. In this study the authors examine the longitudinal relaxation time (T1) of blood in contact with these agents over time, measured in vitro, to determine if their presence could affect the interpretation of postoperative magnetic resonance (MR) images.

METHODS

Coagulated and anticoagulated blood were used, both oxygenated and deoxygenated. The effects of a collagen-based agent (Collastat) and a cellulose-based agent (Surgicel) on the pH and T1 values of blood and on those of saline (used as a control) were investigated. The T1 was measured as a function of magnetic field strength and time by using a field-cycling relaxometer. This instrument measures 1/T1, the rate of T1, from which the T, value is computed. The T1 values of blood were compared with those of hemostat-induced blood clots and with those of both gray and white matter of the brain. Signal changes on T1-weighted MR images were predicted on the basis of altered T, values in vitro. Postoperative images were visually examined for the predicted changes. With the addition of Surgicel, blood had decreased pH and significantly shortened T1 at all fields, essentially within minutes, although it affected the T1 of saline only minimally. The effect of Surgicel increasingly shortened the T1 for 4 days in oxygenated blood. Collastat had no significant effect. The presence of some paramagnetic methemoglobin in Surgicel-induced clots was demonstrated using the relaxometer at a time when diamagnetic oxyhemoglobin would be present in naturally occurring blood clots. A bright signal that could mimic residual tumor on contrast-enhanced images was predicted and confirmed on postoperative T1-weighted MR images obtained in patients in whom Surgicel lined the tumor bed. It was not present in cases in which Surgicel was not used.

CONCLUSIONS

Surgicel alters the appearance of early postoperative MR images. To avoid misinterpretation, clinicians should be aware of this phenomenon.

Irving S. Cooper and the early surgical management of movement disorders. Video history

Irving S. Cooper was a pioneer in the field of functional neurosurgery. During his very productive and controversial career, he proposed the surgical treatment of Parkinson disease (PD) by ligating the anterior choroidal artery to control tremor and rigidity. Subsequently, he developed seminal techniques for chemopallidectomy and cryothalamectomy for PD. He also attempted to use electrical stimulation of the cerebellum or the thalamus to treat spasticity. Cooper continued his work on brain stimulation until his death in 1985. He made video recordings of nearly all of his patients during his tenure (1977-1985) at New York Medical College. Cooper's clinical video recordings were reviewed, and selected footage was compiled into a video history of Cooper's surgical management of various movement disorders. Included are pre-, post-, and some intraoperative recordings that Cooper made to document his treatment of patients with PD, tremor, Wilson disease, cerebral palsy, chorea, dystonia musculorum deformans, and some rarer entities.

No ordinary time, no ordinary men: the relationship between Harvey Cushing and Franklin D. Roosevelt, 1928-1939

The authors elucidate the strong personal relationship that developed between Dr. Harvey Cushing and Franklin Delano Roosevelt (FDR) from 1928 to 1939, as manifested in their frequent letters to each other. The relationship was initiated by the marriage of their children. Through his correspondence with FDR, Cushing was able to affect several medical issues of the period. The relationship of these two individuals is set within the historical, social, and political contexts of the times.

Giant petrous carotid aneurysm treated by submandibular carotid—saphenous vein bypass

✓ Petrous and cavernous sinus carotid artery (CA) aneurysms that are not amenable to clip ligation or endovascular therapy may be successfully treated by a saphenous vein bypass, thereby preserving the patency of the CA. The authors report the unique case of a 47-year-old man with a giant fusiform aneurysm of the petrous CA, who presented with a rapid onset of a lateral rectus palsy and diplopia. The lesion was treated by trapping the aneurysm and performing a saphenous vein bypass from the cervical to the intracranial CA. The saphenous vein graft was routed beneath the condyle of the mandible to reduce the overall length of the graft, thereby increasing the likelihood of long-term patency and offering protection to the graft by the mandible, temporal muscle zygomatic process, and masseter and temporal muscles. The presentation and technical aspects of the bypass graft in this unique case are discussed.

Use of cylindrical titanium mesh and locking plates in anterior cervical fusion. Technical note

After performing anterior cervical corpectomy or discectomy for cervical spondolytic myelopathy or radiculopathy, iliac crest bone graft and fibular auto- or allograft is often used to achieve arthrodesis in the cervical spine. The purpose of this study was to evaluate the use of a cylindrical titanium mesh and locking plate system as an alternative technique in achieving anterior cervical fusion and maintaining lordosis. Hospital records and radiographs of 38 patients who underwent anterior cervical discectomies (28 patients) or corpectomies (10 patients) from 1995 to 1997 were reviewed retrospectively. All patients had undergone arthrodesis in which autograft and a cylindrical titanium mesh and anterior locking plate fixation were used after discectomy or corpectomy. There were 20 men and 18 women (mean age 46.1 years; range 34-72 years). Presenting symptoms included radiculopathy (61%), myelopathy (37%), and neck pain (2%). Preoperative and postoperative radiographs were studied, and data were obtained on the following: overall lordosis or kyphosis of the cervical spine, segmental lordosis or kyphosis at each surgically treated level, and evidence of fusion. In all of the patients in whom lordosis was present preoperatively, lordosis was maintained during the follow-up period. The overall fusion rate was 100%. The average change in overall lordosis or kyphosis related to the fixation devices was 1.2 degrees (range 1-5 degrees) the average segmental change was 2.3 degrees (range 0-5 degrees); and the mean follow up was 16 months (range 12-36 months). Anterior cervical fusion with cylindrical titanium mesh and cervical locking plate system is an effective method of achieving arthrodesis and maintaining alignment in the cervical spine. The construct may provide additional load-sharing function, and it avoids the use of cadaveric bone or the need for harvesting tricortical iliac crest autograft.

Approaches to the sellar and parasellar region: anatomic comparison of endonasal-transsphenoidal, sublabial-transsphenoidal, and transethmoidal approaches

Various surgical approaches have been described for treating lesions which arise in the sellar region. The popular transnasal-transsphenoidal and transethmoidal-transsphenoidal approaches avoid the morbidity associated with transcranial operations while allowing enough exposure to successfully remove most lesions that arise in and around the sella. The goal of the present study was to accurately quantify the amount of exposure to the sellar and suprasellar region that the transethmoidal-transsphenoidal, endonasal-transphenoidal, and sublabial-transsphenoidal approaches provide. Each of the three approaches was performed on 14 formalin fixed heads with the aid of the operative microscope. The distances of relevant surgical landmarks, and the amount of exposure superior and anterior to the dorsum sella as well as the lateral exposure obtained through each of these approaches was carefully recorded. The mean distances were then used to calculate the volume of exposure offered by each approach. It was found that the sublabial-transsphenoidal approach afforded the greatest volume of exposure superior and anterior to the dorsum sella. The endonasal-transsphenoidal and the transethmoidal approaches were both found to offer less suprasellar volume exposure, with the transethmoidal approach offering the least. The authors believe the information obtained through this study illustrates some important anatomical relationships which can be used to advantage by the surgeon to tailor the most appropriate approach, depending upon the precise location of the lesion either within the sella or suprasellar region.

Tamoxifen-induced enhancement of calcium signaling in glioma and MCF-7 breast cancer cells

The antiestrogen tamoxifen is commonly used to treat breast cancer, but it also has therapeutic activity in several other types of cancer. Many of these tumors, including malignant gliomas, are estrogen receptor negative. Nonetheless, high concentrations of tamoxifen can directly reduce cell proliferation in some of these tumors and induce apoptosis. In this study, the role of tamoxifen in calcium signaling and calcium-induced cell death was studied in both malignant glioma cell lines and MCF-7 breast cancer cells. Tamoxifen potently increased the spatial expansion of calcium waves by 30-150% while significantly enhancing and prolonging agonist-induced calcium elevations. Furthermore, tamoxifen pretreatment accelerated calcium ionophore-induced death by more than 20 min, suggesting that tamoxifen lowered cellular resistance to calcium loads. In contrast to its potentiating of calcium signaling in tumors, tamoxifen had no significant effect on calcium signaling in cultures of primary astrocytes from either human or rat brain. This study demonstrates the existence of calcium signaling in breast cancer and glioma cells and identifies tamoxifen as a potential modulator of tumor-associated calcium signaling.

Rupture of a large ophthalmic segment saccular aneurysm associated with closed head injury: case report

OBJECTIVE AND IMPORTANCE

Although each year approximately 30,000 to 50,000 cases of subarachnoid hemorrhage in the United States are caused by the rupture of intracranial saccular aneurysms, there is little information in the literature documenting the association of aneurysmal rupture with closed head injury.

CLINICAL PRESENTATION

A 61-year-old woman presented after a motor vehicle accident with multiple injuries, including a severe closed head injury. Computed tomography revealed a diffuse basal subarachnoid hemorrhage. Angiography revealed the source as a large aneurysm arising from the ophthalmic segment of the left carotid artery.

INTERVENTION

After the patient was stabilized for her multiple injuries, she underwent craniotomy and clipping of the aneurysm. She recovered without developing new neurological deficits.

CONCLUSION

Although the association of head trauma and aneurysmal subarachnoid hemorrhage is rare, the presence of significant basal subarachnoid blood on a computed tomographic scan should alert the physician to the possibility of a ruptured aneurysm.

Type IV spinal arteriovenous malformation in association with familial pulmonary vascular malformations: case report

OBJECTIVE AND IMPORTANCE

Type IVc arteriovenous malformations (AVMs) of the spinal cord consist of multiple high-flow feeding vessels, and they often present a challenging management situation. Their location is intradural and extramedullary, and they are rare malformations that are difficult to treat owing to the risk of thrombosis of the anterior spinal artery. The authors report a case of Type IVc spinal AVM in a patient with a family history of three siblings with pulmonary AVMs. Spinal AVMs have been reported to be associated with inherited syndromes such as familial cutaneous hemangiomas and Kartagener's syndrome, but an association with pulmonary AVMs has not previously been described.

CLINICAL PRESENTATION

A 27-year-old man presented with sudden onset of occipital headache with cervical radiation while weightlifting. Results of computed tomography of the brain were normal, but lumbar puncture revealed a subarachnoid hemorrhage. The patient had a 1-year history of a neurogenic bladder and exhibited marked left calf muscle wasting.

INTERVENTION

The patient underwent spinal magnetic resonance imaging, which revealed the AVM in the conus region. Selective spinal angiography was performed for diagnostic purposes. A laminectomy was performed, and the vessels feeding the AVM were clipped, as was the fistula.

CONCLUSION

The patient remained neurologically stable, and angiography confirmed obliteration of the AVM. This is the first case report of a patient with a spinal AVM who had multiple siblings with pulmonary malformations or AVMs.

In vitro neurogenesis by progenitor cells isolated from the adult human hippocampus

Neurogenesis persists in the adult mammalian hippocampus. To identify and isolate neuronal progenitor cells of the adult human hippocampus, we transfected ventricular zone-free dissociates of surgically-excised dentate gyrus with DNA encoding humanized green fluorescent protein (hGFP), placed under the control of either the nestin enhancer (E/nestin) or the Talpha1 tubulin promoter (P/Talpha1), two regulatory regions that direct transcription in neural progenitor cells. The resultant P/Talpha1:hGFP+ and E/nestin:enhanced (E)GFP+ cells expressed betaIII-tubulin or microtubule-associated protein-2; many incorporated bromodeoxyuridine, indicating their genesis in vitro. Using fluorescence-activated cell sorting, the E/nestin:EGFP+ and P/Talpha1:hGFP+ cells were isolated to near purity, and matured antigenically and physiologically as neurons. Thus, the adult human hippocampus contains mitotically competent neuronal progenitors that can be selectively extracted. The isolation of these cells may provide a cellular substrate for re-populating the damaged or degenerated adult hippocampus.

Approaches to the sellar and parasellar region: a retrospective comparison of the endonasal-transsphenoidal and sublabial-transsphenoidal approaches

Tumors of the hypophysis are often managed surgically by the neurosurgeon and the otolaryngologist. Three widely used anterior routes to the sella are the endonasal (transcolumellar) transsphenoidal, sublabial transsphenoidal, and transethmoidal approaches. We reviewed the charts of 60 patients who underwent surgery, 42 transcolumellar and 18 sublabial, for sellar and parasellar adenomas and compared the two transsphenoidal approaches. None of the patients in our study underwent the transethmoidal approach. Furthermore, 26 of the patients underwent an extensive interview to assess postoperative progress. Clinically, neither approach had any significant complications, and none of the patients in either group reported significant postoperative morbidity. On the basis of these results, we believe there is minimal difference in patient subjective reports and objective morbidity when comparing the sublabial and transcolumellar approaches.

Extradural extranasal combined transmaxillary transsphenoidal approach to the cavernous sinus: a minimally invasive microsurgical model

The authors have previously described an extradural transmaxillary approach to the anterior compartment of the cavernous sinus. In an effort to expand the surgical access to that area without necessitating a craniotomy or wide transfacial dissection, they present a modification of the transmaxillary approach to the sellar region and cavernous sinus.

METHODS

The approach was developed on 12 fresh and 12 embalmed cadaveric specimen, and 2 dry skulls. The initial sublabial incision is followed by a maxillotomy to expose the course of the infraorbital nerve (terminal branch of maxillary branch of the trigeminal nerve) on the roof of the maxillary sinus. The route of the infraorbital nerve is traced to the pterygopalatine fossa as a guide to the foramen rotundum. Superomedial drilling of the foramen rotundum is then performed to reveal the contents of the superior orbital fissure. After the nerves are safely identified in the superior orbital fissure, medial enlargement of the window into the cavernous sinus is made possible by drilling the lateral and posterior wall and septum of the sphenoid sinus.

RESULTS

The combined transmaxillary transsphenoidal approach offers an excellent exposure of the sellar and infrasellar region. The approach offers clear visualization of the ipsilateral loop of the carotid artery, the pituitary fossa, and the cranial nerves of the ipsilateral cavernous sinus. Mean operative reach is 38 mm from the posterior wall of the maxillary sinus to the ipsilateral carotid loop and 56 mm to the contralateral loop. The width of the operative window is 26 mm at the base within the cavernous sinus.

CONCLUSION

The model offers a minimally invasive approach that avoids the need for craniotomy or violating the nasal cavity. It may be safely employed to access vascular as well as invasive lesions of the sellar and infrasellar region. The approach offers excellent visualization of the ipsilateral intracavernous carotid artery with both proximal and distal control, as well as cranial nerves III, IV, VI, V2, the hypophyseal region, and the medial aspect of the contralateral cavernous sinus.

Promoter-targeted selection and isolation of neural progenitor cells from the adult human ventricular zone

Adult humans, like their nonhuman mammalian counterparts, harbor persistent neural progenitor cells in the forebrain ventricular lining. In the absence of adequate surface markers, however, these cells have proven difficult to isolate for study. We have previously identified and selected neural progenitor cells from both the fetal and adult rodent ventricular zone (VZ), by sorting forebrain cells transfected with plasmid DNA encoding the gene for green fluorescent protein driven by the early neuronal promoter for Talpha1 tubulin (P/Talpha1:hGFP). We have now extended this approach by purifying both P/Talpha1:hGFP tubulin-defined neuronal progenitors, as well as potentially less committed E/nestin:hGFP-defined neural progenitor cells, from the adult human VZ. The ventricular wall of the temporal horn of the lateral ventricle was dissected from temporal lobes obtained from four adult patients undergoing therapeutic lobectomy. These samples were dissociated, and the cultured cells transduced with either P/Talpha1:hGFP or E/nestin:EGFP plasmid DNA. A week later, the cells were redissociated, selected via fluorescence-activated cell sorting (FACS) on the basis of neural promoter-driven GFP expression, and replated. The majority of these cells expressed the early neuronal protein betaIII-tubulin upon FACS; within the week thereafter, most matured as morphologically evident neurons that coexpressed betaIII-tubulin and microtubule-associated protein (MAP)-2. Many of these neurons had incorporated bromodeoxyuridine in vitro in the days before FACS, indicating their mitogenesis in vitro. Thus, the use of fluorescent transgenes under the control of early neural promoters permits the enrichment of neuronal progenitor cells from the adult human ventricular zone. The specific acquisition, in both purity and number, of residual neural progenitor cells from the adult human brain may now permit hitherto unfeasible studies of both their biology and practical application.

Glucocorticoids-potent modulators of astrocytic calcium signaling

Glucocorticoids are the first line of choice in the treatment of cerebral edema associated with brain tumors. High-dose glucocorticoids reduce the extent of edema within hours, often relieving critical increases in intracranial pressure, but the mechanisms by which glucocorticoids modulate brain water content are not well-understood. A possible target of action may be glucocorticoid receptor-expressing astrocytes, which are the primary regulators of interstitial ion homeostasis in brain. In this study, we demonstrate that two glucocorticoids, methylprednisolone and dexamethasone, potentiate astrocytic signaling, via long-range calcium waves. Glucocorticoid treatment increased both resting cytosolic calcium (Ca2+i) level and the extent and amplitude of Ca2+ wave propagation two-fold, compared to matched controls. RU-486, a potent steroid receptor antagonist, inhibited the effects of methylprednisolone. The glucocorticoid-associated potentiation of Ca2+ signaling may result from upregulation of the cellular ability to mobilize Ca2+ and release ATP, because both agonist-induced Ca2+i increments (via ATP and bradykinin) and ATP release were proportionally enhanced by glucocorticoids. In contrast, neither gap junction expression (as manifested connexin 43 immunoreactivity) nor functional coupling was significantly affected by methylprednisolone. Confocal microscopy revealed both the expression of glucocorticoid receptors and nuclear translocation of these receptors when exposed to methylprednisolone. We postulate that the edemolytic effects of glucocorticoids may result from enhanced astrocytic calcium signaling.

Approaches to the sellar and parasellar region: anatomic comparison of the microscope versus endoscope

OBJECTIVE

Traditionally, surgical approaches to the sellar region require the use of the operating microscope. Over the past decade endoscopic surgery has gained much popularity because of advances in optics and illumination. Endoscopic surgery of the sellar region has been performed successfully. The goal of the present study was to quantify the amount of exposure to the sellar and suprasellar region that the endoscope provides versus the microscope, with three different anterior approaches to the sellar region.

METHODS

The transethmoidal, endonasal-transsphenoidal, and sublabial-transsphenoidal approaches were performed on 14 formalin-fixed cadaver heads with a 0 degrees endoscope and repeated with the operative microscope. The distances of relevant surgical landmarks and the amount of exposure superior and anterior to the dorsum sella, as well as the lateral exposure, were measured. The mean distances were then used to calculate the volume of exposure for each of the approaches.

RESULTS

It was found that the endoscope provided greater view than the operating microscope in all three approaches. The difference was statistically significant using a paired Student t test and a signed-rank test (P<.001).

CONCLUSION

The authors believe that endoscopic surgery of the sellar region can be performed safely and effectively, while providing the surgeon with a view that is superior to that afforded by the operating microscope.

Direct gap junction communication between malignant glioma cells and astrocytes

Gap junctions are intercellular channels that connect the interiors of coupled cells. We sought to determine the extent to which malignant glioma cells form gap junction channels with astrocytes from either adult human brain or rat forebrain. The astrocytic gap junction protein, connexin 43 (Cx43), was identified in immunoreactive plaques at areas of cell-to-cell contact between cocultured glioma cells and astrocytes. These gap junction plaques were composed of functional channels, because extensive dye coupling was evident between the glioma cells and astrocytes from both human and rat brain. Calcium signaling was also readily transmitted from glioma cells to astrocytes and vice versa. In live rat brain, injection of glioma cells prelabeled with the gap junction tracer, dicarboxy-dichlorofluorescein, revealed extensive dye transfer to host cells, demonstrating that malignant glioma cells directly couple with normal brain cells. These observations suggest that intercellular communication via gap junctions may play a role in regulating cellular interactions during tumor invasion. In fact, the presence of gap junctions between astrocytes and glioma cells was sufficient to induce a transformation of astrocytic phenotype. Astrocytes cocultured with C6 glioma cells overexpressing Cx43 were significantly smaller and expressed a lower level of glial fibrillary acidic protein than astrocytes cocultured with otherwise identical mock-transfected, gap junction-deficient C6 cells. Thus, direct cellular coupling with glioma cells result in a phenotypic transformation of astrocytes that may contribute to the susceptibility of surrounding tissue to glioma invasion.

Pediatric intracranial epidural abscess secondary to an infected scalp vein catheter

The authors present a case of a 5-week-old infant developing a retrotorcular epidural abscess as a result of an infected scalp vein catheter. The abscess developed in the absence of sinusitis, otitis, trauma, or prior surgery. The diagnosis of epidural abscess was made on the basis of magnetic resonance imaging and ultrasound-guided aspiration of the fluid collection. An identified strain of Staphylococcus epidermidis was cultured from both the intravenous catheter and the abscess. The patient underwent a suboccipital craniectomy with drainage of the abscess and a 6-week total course of intravenous antibiotics. Magnetic resonance imaging 4 months after the procedure and 2.5-year pediatric clinic follow-up have demonstrated no evidence of neurologic deficit or recurrence. When present, a scalp vein catheter must be considered as an etiologic agent for an intracranial epidural abscess in this age-group.

Irving S. Cooper (1922-1985): a pioneer in functional neurosurgery

Irving S. Cooper (1922-1985), the son of a salesman, worked his way through high school, college, and medical school to become one of the pioneers in functional neurosurgery. He developed several novel techniques for the surgical management of Parkinson's disease and other crippling movement disorders. A keen interest in the physiology of movement disorders was kindled by his doctoral research and continued during his neurosurgical training. He began to apply this knowledge to surgical practice in 1952 when he began his faculty career as Assistant Professor of Surgery at New York University. At the time, surgical treatment of parkinsonian tremor focused on various techniques used to interrupt the pyramidal tract. During a subtemporal approach for a cerebral pedunculotomy, he inadvertently injured and, subsequently, was forced to occlude the anterior choroidal artery. Much to Cooper's surprise, following emergence from anesthesia the patient's tremor and rigidity were abolished without any residual hemiparesis. This serendipitous observation, together with Meyer's earlier work on the role of the basal ganglia in motor control, helped focus surgical efforts on targets within the basal ganglia and, subsequently, within the thalamus to alleviate the movement disorders associated with Parkinson's disease. While at New York University, Cooper developed chemopallidectomy and, later at St. Barnabas Hospital in the Bronx (1954-1977), he used cryothalamectomy as a surgical technique for primary control of tremor in patients with Parkinson's disease. Cooper authored many original papers on surgical techniques and several textbooks on the lives of patients afflicted with Parkinson's disease and other crippling movement disorders. Although considered controversial, this fascinating and complex neurosurgeon made significant contributions to this field.

Tamoxifen and carboplatin combinational treatment of high-grade gliomas. Results of a clinical trial on newly diagnosed patients

Between April, 1992 and December, 1995, forty consecutive patients with a cerebral malignant glioma (WHO Grade III and IV) were enrolled in a trial consisting in surgery and post-operative administration of radiotherapy (4500-6000 cGy), carboplatin (CBDCA; dose of 450-600 mg/m2), and oral tamoxifen (TAM; at doses of 40, 80 or 120 mg/day). Two patients of the TAM group died in the postoperative period from a pulmonary embolism and myocardial infarction, respectively. The patients (all dosages combined) had a median survival time of 13 months from the time of diagnosis. The 12-month and 24-month survival rates were 52% and 32%, respectively. The median relapse-free survival time was 7 months. Patients treated with higher doses of TAM (80-120 mg/day) demonstrated a longer median survival rate (13 months both) and a longer 12-month survival result (58% and 76%, respectively). Patients who assumed TAM for a period longer than 3 months (group +3) have a higher median survival rate (16 months) and better 12-month and 24-month results (62% and 40%, respectively). Moreover, the median relapse-free survival time was 10 months (versus 6 months in group -3; p = 0.0038). However, it is not possible to exclude that patients of group +3 had a slower growing or a stable tumor and were well enough to assume TAM for a longer period. The results observed in the TAM-group have been compared with those of 40 matched controls treated with surgery, radiotherapy and CBDCA. These patients had a median survival time of 9 months (p = 0.04) and the 12-month and 24-month survival rates were 30% and 0%, respectively. The median relapse-free survival time was 4 months (p = 0.0014). These data suggest a potential role for combinational TAM-CBDCA therapy in the post-operative treatment of cerebral malignant gliomas; further clinical phase III trials, especially those with higher dosages of TAM are warranted.

Loss of Rb expression in an ACTH-secreting pituitary carcinoma

Little is known about the molecular mechanisms of tumor progression in the pituitary. However, animal studies suggest that the Rb gene may be involved in the development of pituitary carcinoma. Pathologic examination of a pituitary tumor that included both benign and malignant components provided insight into this mechanism. Both benign and malignant tumors were immunoreactive for ACTH. The benign adenoma showed strong nuclear immunoreactivity for Rb, however, both the adjacent sellar carcinoma and its metastases were Rb-negative. This study suggests that loss of Rb may in some cases be important in the progression of pituitary adenoma to carcinoma.

Experience in the surgical management of 82 symptomatic herniated thoracic discs and review of the literature

OBJECT

The authors aimed to develop management strategies for the treatment of herniated thoracic discs and to define indications for selection of surgical approaches. Symptomatic thoracic discs requiring surgery are rare. Between 1971 and 1995, 71 patients with 82 herniated thoracic discs were surgically treated by the authors. The treated group included 34 men and 37 women whose ages ranged from 19 to 75 years, with a mean age of 48 years. The most common sites of disc herniation requiring surgery were from T-8 to T-11. Evidence of antecedent trauma was present in 37% of the patients. Preoperative symptoms included pain (localized, axial, or radicular) in 54 (76%) of the 71 patients, evidence of myelopathy, that is, motor impairment in 43 (61%), hyperreflexia and spasticity in 41 (58%), sensory impairment in 43 (61%), and bladder dysfunction in 17 (24%).

METHODS

Radiological diagnosis for the patients in this series was accomplished by means of myelography, computerized tomography myelography, or magnetic resonance imaging. Classification of the disc location into two groups reveals that 94% were centrolateral and 6% were lateral. Evidence of calcification was present in 65% of patients, and in 7% intradural extension was noted at surgery. Ten patients (14%) were found to have multiple herniations. Four surgical approaches were used for the removal of these 82 disc herniations: transthoracic in 49 (60%), transfacet pedicle-sparing in 23 (28%), lateral extracavitary in eight (10%), and transpedicular in two (2%). Postoperative evaluation revealed improvement or resolution of pain in 47 (87%) of 54, hyperreflexia and spasticity in 39 (95%) of 41, sensory changes in 36 (84%) of 43, bowel/bladder dysfunction in 13 (76%) of 17, and motor impairment in 25 (58%) of 43. Complications occurred in a total of 12 (14.6%) of 82 discs treated surgically. Major complications were seen in three patients and included perioperative death from cardiopulmonary compromise, instability requiring further surgery, and an increase in the severity of a preoperative paraparesis.

CONCLUSIONS

Review of this series, with the attendant complications, together with evaluation of several contemporary thoracic disc series, has facilitated the authors' decision-making process when considering the comprehensive management of these patients, including the selection of a surgical approach.