Lumbar discal cyst and post-operative discal pseudocyst: a case series

Four cases of lumbar cyst (2 discal cysts and 2 post-operative discal pseudocysts) who presented predominantly with features of sciatica without any motor, sensory or sphincteric disturbances. The patients were treated conservatively, and the management was aimed to avert any untoward surgical intervention taking into consideration patient safety and care. Two had previous lumbar decompressive discectomy. During the mean follow-up period of 13 months, there was progressive recovery of symptoms in all our 4 patients. All our patients were successfully managed by conservative approach. An intervertebral disc cyst should be considered in young patients in the differential diagnosis of any extradural intraspinal mass ventral to the thecal sac, notwithstanding its rarity. Alongside, conservative management can be offered as first line of management with appropriate patient selection that is absence of any motor/sensory/sphincteric disturbances. Facetal micro-instability could be one of the aetiologies of this pathology which necessitates further study.

Missed cervical spine subluxation leading to bilateral facet dislocation with severe deformity requiring 360 fixation

A 41 year-old male that presented after a fall downstairs and the initial imaging was misinterpreted, missing a subtle abnormality, C5/6 subluxation. The patient presented later with neck pain and further imaging demonstrated bilateral facet dislocation with severe deformity requiring 360 spinal fixation.

Chordomas and chondrosarcomas of the skull base: treatment and outcome analysis in a consecutive case series of 24 patients

Background

We present our 9-year consecutive case series of skull base chordomas and chondrosarcomas from a UK tertiary referral centre, discussing treatments offered and outcomes. This was carried out to improve understanding around current treatment and to better inform the management of future patients.

Methods

Consecutive case series over a 9-year period (2007–2016). Retrospective data analysis from the electronic skull base multidisciplinary team database and the digital patient records at a UK tertiary referral centre

Results

Twenty-four patients were identified (11 chordomas, 13 chondrosarcomas, mean age 52). Nineteen had proton beam therapy (PBT) postoperatively; two had intensity-modulated radiotherapy; two had no further treatment. One patient was lost to follow-up. All chordomas were resected via a transnasal endoscopic approach. Of the 19 patients undergoing resection with PBT, 13 were disease free at latest follow-up, and six patients had local recurrence, of which two died (mean follow up 7.4 years). Of the three patients treated with surgery then IMRT/TomoTherapy, one died 4 years post-treatment, and the other two are alive after 4 and 5 years of follow-up respectively. Of the two patients treated with surgery alone, one was lost to follow-up, and the other is alive after more than 8 years. Chondrosarcoma 5-year survival was 91.6%, and chordoma 4-year survival was 75%.

Conclusion

Skull base chordomas and chondrosarcomas can be challenging to resect, and most cases require adjuvant therapy to achieve control. Where complete resection is not possible, it is critical to undertake sufficient resection to permit high-dose radiation.

Utility of Arterial Spin Labeling Magnetic Resonance Imaging in Differentiating Sellar Region Meningiomas from Pituitary Adenomas

BACKGROUND

Differentiating sellar region meningiomas from pituitary adenomas on standard magnetic resonance imaging (MRI) sequences can be difficult. Arterial spin labeling (ASL) is a noninvasive technique of magnetic resonance perfusion imaging. The range of applications of ASL in neurosurgery has increased, and the information provided can be unique and complementary to other MRI sequences. Here we investigate the utility of ASL MRI in differentiating between sellar region meningiomas and pituitary adenomas.

METHODS

This was a retrospective comparison of quantitative assessments on absolute and normalized tumor blood flow in histologically proven meningiomas versus pituitary adenomas.

RESULTS

A total of 15 patients with sellar region lesions were identified, including 9 meningiomas and 6 pituitary adenomas. Mean absolute tumor blood flow and normalized tumor blood flow were significantly higher in meningiomas (131 mL/100 g/min and 2.22) than adenomas (47 mL/100 g/min and 0.92; P < 0.05).

CONCLUSIONS

ASL MRI is a useful adjunct sequence in differentiating sellar region meningiomas, which exhibit high perfusion, from pituitary adenomas, which exhibit relatively low perfusion.

Abstract P4-01-18: Correlation between circulating tumor DNA (ctDNA) alterations and circulating tumor cells (CTC) uncovers new mechanisms of metastasis for patients with metastatic breast carcinoma (MBC)

Introduction:Novel molecular diagnostics including CTCs and ctDNA have been proved to predict disease metastasis and survival. However, the frequency of detection of actionable mutations using CTCs and ctDNA is variable based upon tumor related factors and diagnostic platform sensitivity. Herein, we evaluated a novel NGS technology in the ability of detecting driver and clonal genomic abnormalities in samples from MBC patients, and compared ctDNA alterations with CTCs and CTC-cluster. This study demonstrated several novel correlation between some specific ctDNA alterations and CTCs or CTCs related biomarkers, which opened new insight on mechanisms of metastasis for MBC.

Methods: This study included 52 samples from 26 patients with stage III/IV BCa treated at NMH (2016-2017) and who received standard systemic treatments based on disease subtypes. Whole blood samples (7.5ml/each) were used for CTC enrichment and enumeration in FDA approved CELLTRACKS ANALYZERII® System (Menarini). ctDNA from clinical plasma samples was analyzed by using PredicinePLUS, a NGS-based assay (Predicine Inc) with a 180-gene panel for genomic alterations mutations. Results of CTCs and ctDNA alterations were linked to clinical database. Matched pairs variations between CTCs and ctDNA alterations was compared by Wilcoxon signed-ranks test and Kruskal-Wallis test.

Results: Genomic Alterations (SNVs, Indels and copy number variations) were detected on 52 genes by PredicinePLUS assay. All samples (100%) demonstrated at least 1 somatic alterations. There were 75 mutations detected within 29 genes, and the variant frequency of mutated genes ranges from 0.11% to 68.56%. Increased CTCs were highly significantly correlated with genomic alterations in the genes (wild type vs alterations) including GATA3 (8vs 37), ESR1 ( 2.5 vs 41.3), CDH1 (3.5 vs 50.5) and CCND1 (4 vs 120) (P&lt;0.01). Decreased CTCs were correlated with alterations of CDKN2A (20.5 vs 0) (P=0.025). CTC-cluster appear associated predominantly with alterations of CDH1 (P=0.0018), CCND1 (P=0.008) and BRCA1 (P=0.04). Furthermore, in HER positive CTCs group, ERBB2 mutations caused increased CTCs in compared with ERBB2 wild type (0 vs 5), when CCND1, CDKN2A, GATA3 and TP53 alterations were associated with increase of HER2 negative CTCs.

Conclusions: By using the novel diagnostic platform with the ability to identify ctDNA mutation and copy number variation, this study demonstrated several novel genes alterations which were highly correlated with CTCs, CTC-cluster and HER2. Some genes (CCND1 and CDH1) got involved into the changes on both CTCs and CTC-cluster, when some genes (CCND1, CDKN2A, ESR1 and GATA3) were related with change of CTCs and HER2 expression. Correlation of CTCs and ctDNA can be reliably and routinely used as non-invasive method for monitoring disease metastasis and predict the prognosis in MBC in clinic.

Citation Format: Davis A, Zhang Q, Gerratana L, Zhang Y, Flaum L, Shad A, Behdad A, Gradishar W, Platanias L, Cristofanilli M. Correlation between circulating tumor DNA (ctDNA) alterations and circulating tumor cells (CTC) uncovers new mechanisms of metastasis for patients with metastatic breast carcinoma (MBC) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-01-18.

The value of prolactin in predicting prolactinοma in hyperprolactinaemic polycystic ovarian syndrome

BACKGROUND

To identify a serum prolactin (PRL) cut-off value indicative of a PRL-producing adenoma in women with polycystic ovarian syndrome (PCOS) and hyperprolactinaemia and characterize such patients.

MATERIALS AND METHODS

In the present retrospective case-control study, the medical records of 528 PCOS women were reviewed. Pituitary magnetic resonance imaging (MRI) was performed in PCOS patients with PRL levels ≥94.0 ng/mL and/or symptoms suspicious of a pituitary adenoma (PA). Prolactinoma diagnosis was made in the presence of an MRI-identifiable PA with biochemical and radiological response to dopamine agonists. Receiver operating characteristic (ROC) curve analysis was performed to determine a serum PRL threshold that could identify hyperprolactinaemic PCOS subjects with prolactinomas. Clinical, metabolic and endocrine parameters were also analysed.

RESULTS

Among 528 patients with PCOS, 60 (11.4%) had elevated PRL levels. Of 44 (73.3%) patients who had pituitary imaging, 19 had PAs, 18 normal MRI and 7 other abnormalities. Patients harbouring prolactinomas had significantly higher PRL levels compared to patients without adenomas (median PRL 95.4 vs 49.2 ng/mL, P < .0001). A PRL threshold of 85.2 ng/mL could distinguish patients with prolactinomas with 77% sensitivity and 100% specificity [Area Under the curve (AUC) (95%) 0.91(0.8-1.018), P = .0001]. PCOS women with prolactinomas were younger and had lower LH levels compared to women without prolactinomas.

CONCLUSIONS

In women with PCOS, PRL levels exceeding 85.2 ng/mL are highly suggestive of a prolactinoma warranting pituitary imaging. Pituitary MRI could also be considered in young PCOS patients with milder PRL elevation and low LH levels.

Factors affecting the survival following surgical treatment of chronic subdural haematoma: Single institutional experience

BACKGROUND

Chronic subdural haematoma (CSDH) is one of the most commonly treated condition in neurosurgery. It affects elderly populations who often have significant medical co-morbidities resulting in poor prognosis. The study aimed at identifying clinical factors influencing the survival following surgical management of CSDH.

METHODS

Retrospective study included 267 cases that underwent surgery for CSDH and followed over 5-year period (2010-2015); data retrieved with reference to operation details, radiology reports and discharge. Using logistic and Cox regression analysis, the patient survival data was analysed with respect to patient demographics, type of surgery, co-morbidities, anticoagulation treatment, and discharge destination.

RESULTS

The overall survival in the cohort was 37.0months (IQR: 20.0-60.0). The median age of the patients was 76years (IQR: 66-82) and the median length of hospital stay was 10days (range 1-126days; IQR: 6-17days). The recurrence rate was 6.37% (n=17). Fifty-three (19.85%) patients recorded deceased on the IPM database as of October 2016 and of those 11 died in hospital. Univariate Cox-regression analysis revealed increased age (HR: 1.80; 95%CI: 1.04-3.11), length of hospital stay (HR: 2.50; 95%CI: 1.41-4.41) and number of co-morbidities (HR: 2.19; 95%CI: 1.26-3.79) were associated with poor prognosis. Glasgow coma scale (GCS) at discharge was found to be significantly associated with survival whilst anticoagulation treatment did not. Multivariate analysis confirmed similar findings significant statistically.

CONCLUSION

Age at admission, median length of hospital stay, number of co-morbidities, GCS at discharge and discharge destination have been found to influence survival significant statistically.

A rare case of symmetrical four limb gangrene following emergency neurosurgery

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Postoperative sepsis and limb gangrene are uncommon but important complications of neurosurgery.

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Peripheral gangrene should be suspected at the first signs of distal ischaemia.

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Early diagnosis and intervention is crucial.

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Early specialist and multi-disciplinary team input with close monitoring ensures better outcomes.

Introduction

The authors report a case of symmetrical peripheral gangrene (SPG) following emergency neurosurgery.

Presentation of case

A 35-year-old female presented to hospital in Thailand with nausea, headache, and subsequent seizures. She was found to have a large intracranial space-occupying lesion with mass effect. Following emergency surgical debulking and decompression, she suffered from severe sepsis with multiple organ failure, treated with high dose intravenous vasopressors and developed secondary gangrene in all four limbs. She was repatriated to the UK with a baseline GCS of 8 and multiple postoperative medical complications. With initial conservative management, the patient made a prolonged but satisfactory progression to recovery prior to semi-elective debridement and selected digit amputation of the gangrene.

Discussion

This is the first reported case of four limb symmetrical peripheral gangrene following an emergency craniotomy.

Conclusion

Although rare, SPG is a substantial complication with high mortality and morbidity and therefore should be especially taken into account for emergency intracranial pathologies in neurosurgical patients, particularly if they require emergency surgery.

Anterior clinoid mucocele--clinical presentation, investigations, and management by endoscopic excision: review of literature

Mucoceles in the anterior clinoid location are exceptionally rare. They present with visual failure and are often misdiagnosed as unilateral optic neuritis. Early recognition with imaging studies and prompt surgical excision is the treatment of choice. Endoscopic surgery achieves this with the least surgical trauma and hospitalization. We report two cases of anterior clinoid mucocele that were treated successfully by endoscopic surgery and also review its management.

N-of-1 Trials for Assessing the Efficacy of Deep Brain Stimulation in Neuropathic Pain

The objective of this study is to determine the usefulness of single-patient, randomised, controlled trials (N-of-1 trials) in assessing the efficacy of deep brain stimulation (DBS) in neuropathic pain. Seven patients with various causes of intractable neuropathic pain underwent insertion of deep brain stimulating electrodes into the periventricular gray area or ventroposterolateral nucleus of the thalamus. Preoperatively, pain was measured using Visual Analog Scales (VAS) and the McGill Pain Questionnaire (MPQ). At 6 months, these pain assessments were repeated. At this point all patients were entered into a N-of-1 trial with the DBS on and off. Data were analyzed using the Wilcoxon and Student t-tests. Following placement of the deep brain stimulator, VAS scores were significantly reduced in six of seven patients. McGill Pain Scores (MPS) showed pain reduction in four of seven. The results of the N-of-1 trials were most similar to the MPQ scores and showed that three of seven patients could accurately predict whether the DBS was on or off. In the N-of-1 trials, the time between changing the DBS from on to off (or vice versa) had an effect on the results and probably underestimated the efficacy. We conclude that N-of-1 trials are a useful tool for assessing DBS efficacy.

Haemorrhage into juxta-facet cysts causing bilateral foot drop

An 89 year old gentleman awaiting surgery for carcinoma of caecum presented with sudden back pain and developed foot drop two weeks later. MRI revealed multiple spinal metastases with a cyst in the canal at L4/5 causing spinal canal stenosis. Surgery revealed a juxta articular synovial cyst with haemorrhage in it. We discuss the presentation and management of juxtarticular cysts with a review of the literature.

Traumatic bleeding of spinal angiolipoma presenting with subacute paraparesis--a case report and histopathological aspects

Spinal angiolipoma is a rare benign tumour. It usually presents as a slowly progressive compressive lesion. Bleeding in this tumour is extremely rare and is spontaneous and acute. This is the first reported case of post-traumatic bleeding from a spinal angiolipoma, who developed subacute progressive paraparesis. The pathological definition of this rare entity is not well established. Histologically it is distinct from cutaneous angiolipoma.

Use of the novel ANSPACH bone collector for bone autograft in anterior cervical discectomy and cage fusion

BACKGROUND

The use of interbody cages with bone autograft following anterior cervical discectomy is well documented. The use of high-speed drills in the drilling of the posterior osteophyte results in the production of bone dust with viable osteophytes. We report the use of the ANSPACH bone collector device, which can be connected to standard suction circuitry and used to collect this bone dust.

METHOD/RESULTS

A group of six patients undergoing anterior cervical discectomies at one (4) or two levels (2). The bone collector was attached to the suction system. Following collection of the desired bone dust from the devices' collection chambers, it was fitted into the previously sized interbody cages and impacted into the disc spaces. The bone collector is a single-use, disposable device, delivered sterile, designed to connect to standard 6-mm suction tubing. The use of the bone collector provided sufficient bone material for complete filling of the interbody cages in all of the patients.

DISCUSSION

The use of autogenous cancellous bone material is the gold standard with regards to bone graft. The collection of bone dust during the use of high-speed drills has a number of applications and could provide a useful source of viable osteogenic material in spinal, cranial and craniofacial procedures.

CONCLUSION

The use of the ANSPACH bone collector incorporated into a standard suction system provides an efficient method of autograft collection, removing the need for an adjunctive procedure with associated donor-site morbidity.

Tumoural calcinosis of the cervical spine: case report, pathogenesis and differential diagnosis

A rare case of tumoural calcinosis of the cervical spine is presented. Tumoural calcinosis presents with masses of dystrophic calcification in juxta-articular areas. It is very rare in the cervical spine with few cases described in the literature so far. It remains part of the differential diagnosis for any calcified spinal compressive lesion.

Straight sinus stenosis as a proposed cause of perimesencephalic non-aneurysmal haemorrhage

Perimesencephalic nonaneurysmal haemorrhage (PMNH), a term first coined in 1985, is a diagnosis of exclusion. It is considered a benign form of subarachnoid haemorrhage with a good prognosis and a low risk of rebleeding. Its precise aetiology has not yet been determined. Haemorrhage of venous origin has been proposed as a cause, and has been demonstrated to be associated with venous abnormalities of the basal vein of Rosenthal. We present a patient with PMNH in whom an 80% stenosis at the union of the vein of Galen with the straight sinus is demonstrated. We thus propose hypertensive venous rupture secondary to venous sinus stenosis as an alternative cause for PMNH.

Aberrant immunophenotype in acute myeloid leukemia (AML): High frequency and association with dysplasia

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Background: Asynchronous expression of immunophenotypic markers on AML myeloblasts has been well described, but the association of aberrant phenotype with morphologic subclasses has not been reported previously. Methods: Multiparameter flow cytometry (MFC) data were analyzed for all patients (pts) diagnosed with AML at our institution from 2000–2006. MFC was done on fresh bone marrow aspirate and/or peripheral blood samples using the following panel of monoclonal antibodies in triple staining: CD2, CD3, CD4, CD5, CD7, CD8, CD10, CD11c, CD13, CD14, CD15, CD16, CD19, CD20, CD22, CD24, CD33, CD56, CD34, CD117, HLA-DR and TdT. Identification of myeloblasts was performed using Side Scatter (SS) characteristics and CD45 expression. Acute lymphoblastic leukemia (ALL) cases or cases with mixed lineage acute leukemia were excluded from the study. Results: We identified 76 pts with AML; median age 57, (range 10 weeks to 89 years), with 32 males and 44 females. The patients had the following French American British classification of AML: M0 (n=1), M1 (n=11), M2 (m=10), M3 (n=5), M4 (n=13), M5 (n=14), M6 (n=1), M7 (n=4) and not otherwise categorized non- M3 AML (n=17). Twenty two pts had AML with multilineage dysplasia (AML-MD) as classified by World Health Organization. Coexpression of TdT on myeloblasts was observed in 4 pts, one of these coexpressed CD5. T-cell lymphoid associated antigens (CD2, CD5 and/or CD7) were coexpressed on myeloblasts from12 pts. B cell lymphoid associated antigens (CD19 and/or CD20) were expressed on myeloblasts from11 pts. Both T and B cell lymphoid associated antigens were present on myeloblasts in 4 pts. Myeloblasts from 13 pts demonstrated the presence of the NK cell marker CD56. A total of 43 patients had AML with immunophenotypic lineage infidelity manifested by coexpression of one or more aberrant antigens on myeloblasts. The distribution of cases with lineage infidelity was higher in 22 pts with AML-MD (n=17, 77%) versus in 54 pts with no dysplasia (n=26, 48%), Chi square =5.4, p=0.02. Conclusions: Abnormal coexpression of lymphoid and NK cell markers was observed in significant number of AML pts and correlated with the presence of multilineage dysplasia. This finding may indicate an earlier stem cell origin of AML-MD.

No significant financial relationships to disclose.

Pineal germinoma presenting as anorexia nervosa: Case report and review of the literature

OBJECTIVE

Tumors of the hypothalamic-pineal region may present with a wide variety of symptoms, including disturbed eating. We present a case where such a tumor was misdiagnosed as anorexia nervosa.

METHOD

We describe a case of pineal germinoma invading the hypothalamus, which was initially diagnosed as anorexia nervosa.

RESULTS

Clinical features included weight loss, vomiting, pyrexia, hypernatraemia, and visual disturbance and the typical psychopathology of anorexia nervosa was absent.

CONCLUSION

Organic disorder should always be considered before making a diagnosis of anorexia nervosa, particularly if the presentation is atypical.

Penetration and activity of antibiotics in brain abscess

Penetration of antimicrobial agents into the cerebrospinal fluid is dependent on numerous factors, including their serum protein binding, molecular size and lipid solubility, and degree of local inflammation. The choice of an appropriate agent is further complicated by diverse bacterial flora involved in brain abscess, local resistant patterns and activity of the drug in abscess environment. This update examines the conventional and newer agents in the above context for their role in the management of brain abscess.

Penetration and activity of antibiotics in brain abscess

Penetration of antimicrobial agents into the cerebrospinal fluid is dependent on numerous factors, including their serum protein binding, molecular size and lipid solubility, and degree of local inflammation. The choice of an appropriate agent is further complicated by diverse bacterial flora involved in brain abscess, local resistant patterns and activity of the drug in abscess environment. This update examines the conventional and newer agents in the above context for their role in the management of brain abscess.

Use of the Solis cage and local autologous bone graft for anterior cervical discectomy and fusion: early technical experience

Object. The authors prospectively evaluated the clinical and radiological outcomes after anterior cervical discectomy and fusion (ACDF) involving placement of a Solis cage and local autograft in patients who presented with symptomatic cervical spondylosis.

Methods. Twenty-two consecutive patients underwent ACDF for radiculopathy (13 cases), myeloradiculopathy (eight cases), or myelopathy alone (one case) and were assessed at 3, 6, and 12 months. Plain cervical spine radiography demonstrated a significant change in both local (p < 0.05) and regional (p < 0.05) kyphotic angles as well as an increase in segmental height (p < 0.05). At 12 months, plain radiography demonstrated Grades I, II, and III new bone formation in two, three, and 17 patients, respectively. Clinical outcomes were assessed using a visual analog scale for both neck and arm pain and a modified Japanese Orthopaedic Association (JOA) scale for myelopathy. There was a significant improvement in both arm (p < 0.05) and neck pain (p < 0.05). At 12 months, 16 (84%) of 19 and 19 (86%) of 22 patients reported complete resolution of arm pain and neck pain, respectively. There was a significant improvement in JOA scores following surgery (p < 0.05). There were two complications in the series: one case of deep venous thrombosis and one case of postoperative arm pain that resolved after conservative treatment. There were no technical complications.

Conclusions. Early experience with Solis cage—augmented ACDF indicates good clinical and radiological outcomes; additionally, there are the advantages of absent donor site morbidity and anterior plate system—related morbidity.

Awake stereotactic biopsy of brain stem lesions: technique and results

BACKGROUND

Brain stem lesions are a heterogenous pathological group. In adults, pre-operative radiological diagnoses prove to be wrong in 10 to 20% of cases. It is therefore imperative to have a tissue diagnosis for appropriate therapeutic measures. Unless these lesions have a sizeable exophytic component, open biopsy and/or resection is marred by low diagnostic yield and prohibitive mortality/morbidity rates.

METHODS

We describe our experience with awake stereotactic biopsy of brain stem lesions. Keeping the patient awake and monitoring clinically during the procedure allows us to make necessary changes in the trajectory of the biopsy probe to minimize the morbidity. A series of 13 brain stem lesions were stereotactically biopsied using CT guidance. Seven had midbrain lesions; four had pontine and two had Ponto-medullary lesions. A frontal, pre-coronal, transcortical trajectory was used in all patients.

FINDINGS

Histological diagnosis was established in all but one patient. There was no procedural mortality, and morbidity was minimal and temporary, occurring in three patients.

CONCLUSION

Awake stereotactic biopsy is a safe technique when combined with clinical monitoring.

Cervical dural arteriovenous fistulae manifesting as subarachnoid hemorrhage: report of two cases and literature review

Dural arteriovenous fistulas (DAVFs) in the craniocervical junction are rare but clinically important. DAVFs can be associated with subarachnoid hemorrhage (SAH), a feature distinguishing them from DAVFs in the thoracolumbar region. These lesions are often overlooked at cerebral angiography performed to assess SAH and account for a small proportion of angiographically negative SAHs. After managing two cases of cervical spinal DAVF manifesting as SAH, we analyzed all cases in the literature to identify features associated with bleeding at presentation.

Increased risk of lead fracture and migration in dystonia compared with other movement disorders following deep brain stimulation

Deep brain stimulation (DBS) therapy is a continually expanding field in the functional neurosurgical treatment of movement disorders. However, the occurrence of adverse events related to implanted hardware cannot be overlooked. We report on a specific feature noted in our experience of DBS-related complications. From 1998 until present we have found an overall rate of 5.3% of DBS electrode lead dysfunction (out of 133 patients) in our series (slipped leads 2.3%, lead fracture 3.8%). Interestingly, all of these failures occurred in dystonia patients (18.4% of all dystonia patients and 9.2% of all electrodes). We postulate on mechanisms that may explain why these complications predominate in this group of patients.

Anterior correction of cervical kyphotic deformity: effects on myelopathy, neck pain, and sagittal alignment

OBJECT

Cervical myelopathy may develop as a result of spinal cord compression with or without deformity. The effect of persistent kyphotic deformity on the ability of the cervical cord to recover following decompressive surgery is not known.

METHODS

Between 1997 and 2000, a total of 28 patients with progressive myelopathy and kyphotic deformity underwent anterior decompression, deformity correction (0-4 degrees of lordosis), and fusion with anterior plating. Patients received clinical and radiological follow-up care, with independent analysis. Variables assessed included patient characteristics, severity of preoperative myelopathy, neck pain, and cervical sagittal alignment. Twenty-six patients (93%) underwent follow-up review for a minimum of 18 months. Two patients died: one died in the perioperative period and was excluded from further analysis, and in the other only 3 months of follow-up data could be obtained. Local deformity was corrected to neutral or lordosis in 24 cases (89%), and the overall cervical curve was corrected to neutral or lordosis in 20 cases (74%). There was a significant improvement in myelopathy scores in those patients in whom the target (0 to 4 degrees of lordosis) local angle was achieved (p = 0.04). There was a variable change in overall cervical sagittal alignment following local correction. Improvement in myelopathy was unrelated to patient age, previous surgery, or number of segments fused. Improvement in pain score was not related to correction of kyphotic angle.

CONCLUSIONS

The correction of sagittal alignment may promote recovery in spinal cord function in patients with kyphotic deformity.

Internal fixation for osteomyelitis of cervical spine: the issue of persistence of culture positive infection around the implants

BACKGROUND

We describe the management of osteomyelitis of the cervical spine, utilizing internal fixation with subsequent removal and culture of the implants. Four out of five patients had evidence of bacterial colonisation in close proximity to the internal fixation device.

METHODS

Five consecutive patients (all female, ranging in age from 50 to 74 yrs) presenting with unstable cervical osteomyelitis were treated by surgical decompression, primary internal fixation followed by three months of intravenous antibiotics. The internal fixation was removed in 4 out of 5 cases within a year of stopping the intravenous regime. The remaining patient was deemed medically unfit for further operation. Multiple specimens from the screw sites were taken at the time of metal removal. A final course of oral antibiotics was prescribed based on the results of these specimens.

FINDINGS

Four patients, who had removal of the implants, had positive cultures growing different bacteria from the primary infection, at the time of removal of the implant. None of the patients developed instability after removal of the implant.

INTERPRETATION

Asymptomatic bacterial colonisation of a metallic implant has profound management implications. We recommend long-term oral antibiotic regimes after insertion of internal fixation devices in the face of infection and eventual removal of these implants and microbiological re-sampling.

The Application of Implant Technology for Cybernetic Systems

OBJECTIVE

To assess the usefulness, compatibility, and long-term operability of a microelectrode array into the median nerve of the left arm of a healthy volunteer, including perception of feedback stimulation and operation of an instrumented prosthetic hand.

SETTING

The study was carried out from March 14 through June 18, 2002, in England and the United States.

RESULTS

The blindfolded subject received feedback information, obtained from force and slip sensors on the prosthetic hand, and subsequently used the implanted device to control the hand by applying an appropriate force to grip an unseen object. Operability was also demonstrated remotely via the Internet, with the subject in New York, NY, and the prosthetic hand in Reading, England. Finally, the subject was able to control an electric wheelchair, via decoded signals from the implant device, to select the direction of travel by opening and closing his hand. The implantation did not result in infection or any perceivable loss of hand sensation or motion control. The implant was finally extracted because of mechanical fatigue of the percutaneous connection. Further testing after extraction has not indicated any measurable long-term defects in the subject.

CONCLUSIONS

This implant may allow recipients to have abilities they would otherwise not possess. The response to stimulation improved considerably during the trial, suggesting that the subject learned to process the incoming information more effectively.

Craniocervical fusion for rheumatoid arthritis: comparison of sublaminar wires and the lateral mass screw craniocervical fusion

The majority of rheumatoid arthritis patients with C1/2 instability causing neck pain and neurological compromise can be treated with unisegmental fusion. However, a minority will require decompression and more extensive craniocervical fusion. Two cohorts of patients with rheumatoid arthritis requiring decompression and craniocervical fusion were included in a retrospective study comparing sublaminar wiring (Ransford Loop, n = 10, follow-up = 36 +/- 9.5 months) and lateral mass screws (Cervifix system, n = 11; follow-up = 39.7 +/- 7.9 months). Both cohorts of patients experienced significant improvements in high cervical pain scores [McGill 5-point score; preop = 4.5 +/- 0.75 for Cervifix and 4.5 +/- 0.75 for Ransford loop; postop = 1.17 +/- 0.9 (p = 0.003) for Cervifix (at 39.7 months +/-7.9) and 2.8 +/- 1.6 (p = 0.011) for Ransford loop (at 36 +/- 9.5 months)]. Lateral mass screws for craniocervical fusion (seven out of 11 pain free) appear to produce better early results for rheumatoid arthritis patients suffering high cervical neck pain than sublaminar wire techniques (three out of 10 pain free).

A clinical evaluation of the Codman MicroSensor for intracranial pressure monitoring

The strain-gauge Codman MicroSensor intracranial pressure (ICP) transducer has shown consistently good laboratory performance. To assess the practical performance of the system in patients following acute brain injury, 10 patients were fitted with a MicroSensor and a second ICP monitor. In five cases this was a fibre-optic transducer and in five cases an intraventricular fluid-filled device. Paired ICP values were recorded every 5 min. ICP values ranged from 0 to 31 mmHg. Altman-Bland plots showed that individual readings could differ by as much as 9 mmHg. Further analysis showed that much of this disagreement could be explained by a constant offset on each occasion. Comparison traces of ICP in individual patients show high agreement in timing and size of changes. The unexplained constant offset leads to uncertainty about the true ICP. Treatment decisions are often based upon absolute levels of ICP and patient care may therefore differ depending upon the monitor used.

Additional chemotherapy agents improve treatment outcome for children and adults with advanced B-cell lymphomas

We report the updated results of an intensive treatment protocol for children (< 18 years) and adults (> or = 18 years) with advanced B-cell lymphomas. The protocol consists of two chemotherapy regimens: A, consisting of cyclophosphamide, doxorubicin, vincristine and high-dose methotrexate (CODOX-M), and B, consisting of ifosfamide, etoposide, and high-dose cytarabine (IVAC). Both cycles included intrathecal chemotherapy (cytarabine or methotrexate). Patients received a total of four cycles in the following sequence: A, B, A, B. Sixty-six previously untreated patients, enrolled before October 1996, were included in the present analysis. Of these, 55 had Burkitt's or Burkitt's-like lymphoma and 11 had diffuse large B-cell lymphoma. There were 53 males ad 13 females; 40 were children and 26 were adults (age range, 3 to 57 years). To date, 61 patients have achieved a complete response to therapy. Two patients subsequently relapsed, but one of these is a long-term survivor after further therapy and a bone marrow transplant. The event-free survival rate is 85% at I year and beyond. The median potential follow-up period is 48 months (range, 12 to 96 months) for patients remaining in complete remission. Neutropenia occurred in 98% of cycles and infection in 46% of A cycles and 50% of B cycles, but the duration was shortened in B cycles by the administration of granulocyte colony-stimulating factor. Positive blood cultures were observed in 21% of A cycles and 28% of B cycles, and there have been three toxic deaths. These results are better than those achieved with an earlier version of CODOX-M, suggesting that the addition of the IVAC regimen is responsible for the improved results. The similarity of the outcome in children and adults, however, confirms our previous observation that, at least in adults younger than 60 years with Burkitt's or Burkitt's-like lymphomas, treatment with regimens similar to those used in children is warranted.

Non-Hodgkin's lymphoma

Pediatric lymphomas are the third most common group of malignancies in children and adolescents. Unlike lymphomas in adults, pediatric lymphomas are diffuse, aggressive neoplasms with a propensity for widespread dissemination. Intensification of conventional treatment approaches along with improvements in supportive care have resulted in dramatic improvement in event-free survival rates of close to 90% in patients with B-cell lymphomas and only slightly lower in patients with T-cell lymphomas. Lymphoid neoplasms arise because of genetic changes that result in altered growth and differential patterns of lymphoid cells. The characterization of these molecular abnormalities and an understanding of their consequences has led to new approaches to diagnosis and the detection of minimal residual disease and also provides the basis for the future development of novel treatment approaches targeted specifically to the neoplastic cells.

Epstein-Barr virus (EBV)-associated smooth-muscle tumor arising in a post-transplant patient treated successfully for two PT-EBV-associated large-cell lymphomas. Case report

The association of Epstein-Barr virus (EBV) with smooth-muscle tumors was recently reported in the setting of acquired immunodeficiency syndrome (AIDS) and post-transplantation. We report a case of an EBV-associated smooth-muscle tumor arising in a post-transplant (PT) patient who previously was treated successfully for two EBV-associated PT large-cell lymphomas. A 4-year-old girl required cardiac transplantation for dilated cardiomyopathy when she was aged 23 months. Her PT regimen included cyclosporine, azothiaprine, and diltiazem. At 16 months PT, she presented with anemia, guaiac-positive stools, and an abdominal mass diagnosed as diffuse large-cell lymphoma of B-cell phenotype. Immunosuppressive therapy was reduced, and interferon and i.v. immunoglobulin were initiated. She rapidly developed signs of rejection, and a cardiac biopsy was performed, revealing grade IIIB rejection. Subsequently, immunosuppressive therapy increased. At 23 months PT, a biopsy was done of a large pelvic mass that was diagnosed as immunoblastic large-cell lymphoma. After treatment with chemotherapy and retinoic acid, the size of the mass markedly decreased. Follow-up computed tomography scan revealed multiple liver nodules. A needle biopsy of the liver showed a smooth-muscle tumor of indeterminate grade. Both the lymphomas and the smooth-muscle tumor contained EBV within > 95% of tumor cells by Epstein-Barr (EBER1) in situ hybridization, were of strain type A by Epstein-Barr nuclear antigen-2 (EBNA-2) polymerase chain reaction (PCR) and contained an identical 30 base-pair deletion (amino acids 346-355) of the latent membrane protein (LMP)-1 oncogene by PCR analysis. Notably, the initial large-cell lymphoma and the subsequent immunoblastic lymphoma each contained a unique p53 mutation, suggesting that they were distinct. These data suggest that the same virus contributed to the pathogenesis of both the malignant lymphomas and the smooth-muscle tumor.

Adults and children with small non-cleaved-cell lymphoma have a similar excellent outcome when treated with the same chemotherapy regimen

PURPOSE

We have used identical treatment protocols for adults and children with small non-cleaved-cell lymphoma (SNCL) for many years and report here the results of two successive treatment regimens in these age groups.

PATIENTS AND METHODS

Seventy-two patients (39 adults and 33 children) were treated with protocol 77-04 between 1977 and 1985. All patients, except those with resected abdominal disease, received 15 cycles of a combination of cyclophosphamide (CTX), doxorubicin (ADR), prednisone (PRED), vincristine (VCR), high-dose methotrexate (MTX), and intrathecal (IT) therapy. Forty-one patients (20 adults and 21 children) were treated with protocol 89-C-41, which has been used since 1989. High-risk patients received four alternating cycles (with a total duration of 12 to 15 weeks) of an intensified version of protocol 77-04 without PRED (CODOX-M), and a new drug combination consisting of ifosfamide, etoposide, high-dose cytarabine (ara-C), and IT MTX (IVAC). Low-risk patients received three cycles of the CODOX-M regimen. High-risk patients were randomized to either receive or not receive granulocyte-macrophage colony-stimulating factor (GM-CSF).

RESULTS

Event-free survival (EFS) in protocol 77-04 was 56% at 2 years and beyond. EFS in protocol 89-C-41 was 92% at 2 years and beyond. GM-CSF was associated with increased thrombocytopenia.

CONCLUSION

Adults and children with SNCL have a similar prognosis when treated with the same chemotherapy. EFS in high-risk patients has been markedly improved by including IVAC in protocol 89-C-41, and excellent results can be achieved with only four cycles of therapy. In protocol 89-C-41, GM-CSF was not beneficial.