World Neurosurg
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Review Meta Analysis Comparative Study
The endoscope-assisted ventral approach compared with open microscope-assisted surgery for clival chordomas.
The current management paradigm for clival chordomas includes cytoreductive surgery with adjuvant radiotherapy. Surgical approaches have traditionally utilized the microscope to remove these lesions through approaches that require extensive bone drilling, brain retraction, and mobilization of normal anatomy to create a suitably large corridor. The endoscopic ventral approaches provide a direct route to the tumor using natural orifices. Little data exist comparing these 2 surgical strategies. We conducted a systematic review of case series and case reports in hope of furthering our understanding of the role of endoscopy in the management of these difficult cranial base lesions. ⋯ Our systematic analysis supports the endoscopic ventral approaches as a safe and effective alternative for the treatment of certain clival chordomas. Although the overall literature supports this technique in carefully selected patients, longer follow-up is needed to more definitively address therapeutic efficacy. Careful patient selection and meticulous multilayer closure are critical to obtaining maximal resection and acceptably low cerebrospinal fluid leak rates.
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Endovascular treatment is an established option for treatment of cerebral arteriovenous malformations (AVMs). However, embolization has been associated with postprocedural neurological complications. We sought to evaluate the usefulness of intra-arterial pharmacologic provocative (superselective Wada) testing before embolization of occipital lobe AVMs. ⋯ Pharmacologic provocative testing is a useful and effective method of determining the safety of occipital AVM embolization. Our results support the performance of these procedures under conscious sedation.
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Spinal cord stimulation is an effective treatment for chronic neuropathic pain after spinal surgery. In addition to the most common placement of electrodes at the thoracic level for low back and leg pain, electrodes can also be placed on a cervical level in patients with chronic neck and upper limb pain. Surgical insertion of plate electrodes via an orthodromal direction requires a partial laminectomy. Therefore, the authors describe a surgical technique using retrograde insertion of a plate electrode to avoid laminectomy. ⋯ This retrograde placement of plate electrodes enables cervical lordosis to be overcome and results in adequate stimulation of the upper cervical region, which is mandatory to reduce neck and shoulder pain without laminectomy.
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An intramedullary spinal cord abscess is a rare, albeit widely publicized entity. Classically, patients have an acute onset of symptoms with fevers and leukocytosis supporting the diagnosis. We present a case of intramedullary spinal cord without classic history or imaging characteristics in which the diagnosis was made with diffusion weighted magnetic resonance imaging (MRI). ⋯ The use of diffusion weighted imaging in the spine is a novel application of technology that provided an accurate preoperative diagnosis and allowed us to tailor our surgical approach and provide a rapid focal decompression.
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Patients with central nervous system (CNS) hemorrhage who receive anticoagulation (AC) therapy are at high risk for progressive or recurrent hemorrhagic and thromboembolic (TE) events. The authors conducted a survey at the 2010 American Association of Neurological Surgeons (AANS) annual meeting to determine how these patients are currently being managed by neurosurgeons. ⋯ This study is the first to describe how patients with CNS hemorrhage who receive AC therapy are currently being managed by clinicians. An apparent neurosurgical preference to avoid hemorrhagic complications is at odds with a suggested early risk for TE. These data suggest that the neurosurgical management of patients with CNS hemorrhage who receive AC therapy is an area that could benefit from consensus-based practice guidelines and an organized effort at knowledge translation and mobilization.