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Objective: The Open Payments Program (OPP) was a database started in 2013 by the US government to report payments made by the medical device and pharmaceutical industry to physicians. Neurosurgery is a technologically advanced field that relies heavily on the latest innovations for complex treatment of its patient population. This study sought to explore the financial relationship between academic neurosurgeons and the industry., Methods: OPP data were reviewed for the year 2021 of all faculty neurosurgeons affiliated with a neurosurgery residency program. Trends related to general payments, research payments, associated research funding, ownership and investment interest, name of the companies making payments, monetary amount of payments per company, and number of payments per company were analyzed., Results: Industry payments to 1151 US academic neurosurgeons were reviewed. These neurosurgeons received $121.4 million in payments. Three hundred thirty-two companies made 18,466 payments. The average payment per neurosurgeon was approximately six-fold higher than that of all other physicians. Vascular and spine subspecialties received the highest payments. A higher proportion of research money was allocated to the Pacific division, while all other categories (including total amount) were higher in the Eastern US. Most financial contributions were made by a small number of companies., Conclusions: Neurosurgery has been rated by many as a field fueled by research, innovation, and technology. In 2021, academic neurosurgeons had a strong relationship with the medical device and pharmaceutical industry as reflected in the OPP data. While the true impact on patient care cannot be directly measured, the advancement of the field relies heavily on these collaborations.

Object: The purpose of this study was to identify the complications associated with the inferior temporal gyrus approach to anterior mesial temporal lobe resection for temporal lobe epilepsy., Methods: This retrospective study examined complications experienced by 483 patients during the 3 months after surgery. All surgeries were performed during 1998-2012 by the senior author (F.L.V.)., Results: A total of 13 complications (2.7%) were reported. Complications were 8 delayed subdural hematomas (1.6%), 2 superficial wound infections (0.4%), 1 delayed intracranial hemorrhage (0.2%), 1 small lacunar stroke (0.2%), and 1 transient frontalis nerve palsy (0.2%). Three patients with subdural hematoma (0.6%) required readmission and surgical intervention. One patient (0.2%) with delayed intracranial hemorrhage required readmission to the neuroscience intensive care unit for observation. No deaths or severe neurological impairments were reported. Among the 8 patients with subdural hematoma, 7 were older than 40 years (87.5%); however, this finding was not statistically significant (p = 0.198)., Conclusions: The inferior temporal gyrus approach to mesial temporal lobe resection is a safe and effective method for treating temporal lobe epilepsy. Morbidity and mortality rates associated with this procedure are lower than those associated with other neurosurgical procedures. The finding that surgical complications seem to be more common among older patients emphasizes the need for early surgical referral of patients with medically refractory epilepsy.

Epilepsy surgery is an effective treatment for medically resistant temporal lobe epilepsy (TLE). To minimize complication rates and potentially improve neuropsychology outcomes, stereotactic radiosurgery (SRS) has been explored as an alternative. Two pilot trials have demonstrated the effectiveness of SRS for the treatment of medically resistant TLE, with seizure-free outcomes for approximately 65% of patients at last follow-up. Despite encouraging results, no conclusive long-term outcomes are available for SRS. This article discusses a single patient who presented with recurrent seizures, worsening headaches, and persistent abnormal MRI findings 7 years and 8 months after SRS. This 29-year-old woman with a history of medically refractory complex partial seizures since childhood was referred for evaluation. Medical management had failed in this patient. The workup was compatible with left mesial temporal lobe onset, with MRI findings suggestive of mesial temporal sclerosis. In 2003, at the age of 23 years, she underwent Gamma Knife surgery (GKS) targeting the left temporal mesial area with a dose of 24 Gy at the 50% marginal isodose line. After GKS, the patient's seizures decreased in frequency over several months, but auras were persistent. Nine months after treatment, she developed worsening headaches. A follow-up MRI study demonstrated a thick, irregular, enhancing lesion in the medial part of the temporal lobe. She was placed on corticosteroids, with resolution of her headaches. Her seizures and headaches recurred in March 2010. An MRI study showed a 2.2-cm, ill-defined, enhancing cystic lesion in the left mesial temporal lobe with T2 and FLAIR hyperintensity, which was presumably radiation induced. At that time, the patient opted for left temporal lobe resection to control her seizures. Histological examination showed moderately severe, remote, longstanding sclerosis at the level of the hippocampus. A vascular lesion was identified, and it was most consistent with radiation-induced capillary hemangioma. The entorhinal region was severely damaged, with hemorrhage, necrosis, neuronal loss, astrogliosis, and hemosiderin deposition. There was evidence of radiation vasculopathy. Radiation-induced lesions after SRS for the treatment of epilepsy are not well documented. Although GKS is a promising technique for the treatment of medically resistant TLE, the ideal candidate is not yet well defined. The selection of the appropriate technical parameters to obtain a desirable functional effect without histological damage to the surrounding neural tissue remains a challenge. This case illustrates the need for long-term follow-up when radiosurgery is used for epilepsy.

Object: The aim of this study was to analyze the national health care burden of patients diagnosed with epilepsy in the US and to analyze any changes in the length of stay, mean charges, in-hospital deaths (mortality), and disposition at discharge., Methods: A retrospective review of the Nationwide Inpatient Sample (NIS) database for epilepsy admissions was completed for the years from 1993 to 2008. The NIS is maintained by the Agency for Healthcare Research and Quality and represents a 20% random stratified sample of all discharges from nonfederal hospitals within the U.S. Patients with epilepsy were identified using ICD-9 codes beginning with 345.XX. Approximately 1.1 million hospital admissions were identified over a span of 15 years., Results: Over this 15-year period (between 1993 and 2008), the average hospital charge per admission for patients with epilepsy has increased significantly (p < 0.001) from $10,050 to $23,909, an increase of 137.9%. This is in spite of a 33% decrease in average length of stay from 5.9 days to 3.9 days. There has been a decrease in the percentage of in-hospital deaths by 57.9% and an increase in discharge to outside medical institutions., Conclusions: The total national charges associated with epilepsy in 2008 were in excess of $2.7 billion (U.S. dollars, normalized). During the studied period, the cost per day for patients rose from $1703.39 to $6130.51. In spite of this drastic increase in health care cost to the patient, medical and surgical treatment for epilepsy has not changed significantly, and epilepsy remains a major source of morbidity.

Object: The object of the current study was to review the electrophysiology and pathological substrate of failed temporal lobe surgery in patients with mesial temporal sclerosis., Methods: A systematic review of the literature was performed for the years 1999-2010 to assess the cause of failure and to identify potential reoperation candidates., Results: Repeat electroencephalographic evaluation documenting ipsilateral temporal lobe onset was the most frequent cause for recurrent epileptogenesis, followed by contralateral temporal lobe seizures. Less frequently, surgical failures demonstrated an electroencephalogram that was compatible with extratemporal localization. The generation of occult or new epileptogenic zones as well as residual epileptogenic tissue could explain these findings., Conclusions: The outcome of temporal lobe surgery for epilepsy is challenged by a somewhat consistent failure rate. Reoperation results in improved seizure control in properly selected patients. A detailed knowledge of the pathophysiology is beneficial for the reevaluation of these patients.

Object: The objective of this study was to investigate a national health care database and analyze demographics, hospital charges, and treatment trends of patients diagnosed with lumbar spine fractures in the US over a 5-year period., Methods: Clinical data were derived from the Nationwide Inpatient Sample (NIS) for the years 2003 through 2007. The NIS is maintained by the Agency for Healthcare Research and Quality and represents a 20% random stratified sample of all discharges from nonfederal hospitals within the US. Patients with lumbar spine fractures were identified using the appropriate ICD-9-CM code. Data on the number of vertebral body augmentation procedures were also retrieved. National estimates of discharges, hospital charges, discharge patterns, and treatment with spinal fusion trends were retrieved and analyzed., Results: More than 190,000 records of patients with lumbar spine fractures were abstracted from the database. During the 5-year period, there was a 17% increase in hospitalizations for lumbar spine fractures. This was associated with a 27% increase in hospital charges and a 55% increase in total national charges (both adjusted for inflation). The total health care bill associated with lumbar spine fractures in 2007 exceeded 1 billion US dollars. During this same time period, there was a 24% increase in spinal fusions for lumbar fractures, which was associated with a 15% increase in hospital charges. The ratio of spinal fusions to hospitalizations (surgical rate) during this period, however, was stable with an average of 7.4% over the 5-year period. There were an estimated 13,000 vertebral body augmentation procedures for nonpathological fractures performed in 2007 with a total national bill of 450 million US dollars., Conclusions: An increasing trend of hospitalizations, surgical treatment, and charges associated with lumbar spine fractures was observed between 2003 and 2007 on a national level. This trend, however, does not appear to be as steep as that of surgical utilization in degenerative spine disease. Furthermore, the ratio of spinal fusions to hospitalizations for lumbar fractures appears to be stable, possibly indicating no significant changes in indications for surgical intervention over the time period studied.

Object: Occipital condyle screws serve as an alternative fixation point in occipital-cervical fusion. Their placement requires a thorough understanding of the anatomy of the occipital condyles and associated structures. This study is a CT-based morphometric analysis of occipital condyles as related to occipital condyle-cervical fusion., Methods: A total of 170 patients were examined with CT scans of the craniocervical junction at a single institution, for a total of 340 occipital condyles, between March 6, 2006, and July 30, 2006. All CT scans were negative for traumatic, degenerative, and neoplastic pathological entities. Condylar anteroposterior (AP) length, transverse width, height, projected screw angle, and projected screw lengths were measured on an EBW Portal 2.5 CT Viewer Workstation (Philips Electronics). The longest axis in the AP orientation of the occipital condyle was accepted as the length. The transverse width was a line perpendicular to the midpoint of the long axis. The height was measured in the coronal projection that had the thickest craniocaudal portion of the condyle. The screw trajectory started 5 mm lateral to the medial edge of the condyle and a line was directed anteromedially in the longest axis. The angle was measured relative to the sagittal midline. The screw length was measured from the outer cortex of the posterior wall to the outer cortex of the anterior wall., Results: The mean ± SD values for occipital condyle measurements were as follows: AP length was 22.38 ± 2.19 mm (range 14.7-27.6 mm); width was 11.18 ± 1.44 mm (range 7.4-19.0 mm); height was 9.92 ± 1.30 mm (range 5.1-14.3 mm); screw angle was 20.30° ± 4.89° (range 8.0°-34.0°); and screw length was 20.30 ± 2.24 mm (range 13.0-27.6 mm)., Conclusions: These measurements correlate with previous cadaveric and radiographic studies of the occipital condyle, and emphasize the role of preoperative planning for the feasibility of placement of an occipital condyle screw.

Object: The pediatric Chance fracture (PCF) is an uncommon injury, but it has been increasingly reported. Knowledge is limited to few case reports and short series. To understand the various aspects of this injury, the authors reviewed the current literature., Methods: A literature search was conducted using the PubMed and Ovid online databases and relevant key words. All articles that were in English and provided information regarding PCF as a sole or part of the objective were retrieved., Results: Seventy-three articles were found to fulfill the inclusion criteria. Relevant information about PCF collected from these articles included: 1) mode of trauma, 2) associated injuries, 3) radiological classification, and 4) treatment., Conclusions: Chance fractures in children are potentially devastating injuries largely caused by motor vehicle collisions, and these fractures may be more common than previously thought. Concomitant intraabdominal injuries are common and should be suspected, particularly when a seat belt sign is observed. Blunt abdominal aortic injuries are rarely associated, but should be evaluated for and treated appropriately. Magnetic resonance imaging is best for defining ligamentous injury, which aids in defining the pattern of injury, facilitating appropriate treatment regimens.

Object: Unstable fractures at the thoracolumbar junction often require extended, posterior, segmental pedicular fixation. Some surgeons have reported good clinical outcomes with short-segment constructs if additional pedicle screws are inserted at the fractured level. The goal of this study was to quantify the biomechanical advantage of the index-level screw in a fracture model., Methods: Six human cadaveric T10-L4 specimens were tested. A 3-column injury at L-1 was simulated, and 4 posterior constructs were tested as follows: one-above-one-below (short construct) with/without index-level screws, and two-above-two-below (long construct) with/without index-level screws. Pure moments were applied quasistatically while 3D motion was measured optoelectronically. The range of motion (ROM) and lax zone across T12-L2 were measured during flexion, extension, left and right lateral bending, and left and right axial rotation., Results: All constructs significantly reduced the ROM and lax zone in the fractured specimens. With or without index-level screws, the long-segment constructs provided better immobilization than the short-segment constructs during all loading modes. Adding an index-level screw to the short-segment construct significantly improved stability during flexion and lateral bending; there was no significant improvement in stability when an index-level screw was added to the long-segment construct. Overall, bilateral index-level screws decreased the ROM of the 1-level construct by 25% but decreased the ROM of the 2-level construct by only 3%., Conclusions: In a fracture model, adding index-level pedicle screws to short-segment constructs improves stability, although stability remains less than that provided by long-segment constructs with or without index-level pedicle screws. Therefore, highly unstable fractures likely require extended, long-segment constructs for optimum stability.

Object: The minimally invasive lateral retroperitoneal transpsoas approach is increasingly used to treat various spinal disorders. Accessing the retroperitoneal space and traversing the abdominal wall poses a risk of injury to the major nervous structures and adds significant morbidity to the procedure. Most of the current literature focuses on the anatomy of the lumbar plexus within the substance of the psoas muscle. However, there is sparse knowledge regarding the trajectory of the lumbar plexus nerves that travel along the retroperitoneum and abdominal wall muscles in relation to the lateral approach to the spine. The objective of this study is to define the anatomical trajectories of the major motor and sensory branches of the lumbar plexus that are located outside the psoas muscle., Methods: Six adult fresh frozen cadaveric specimens were dissected and studied (12 sides). The relationship between the retroperitoneum, abdominal wall muscles, and the lumbar plexus nerves was analyzed in reference to the minimally invasive lateral retroperitoneal approach. Special attention was given to the lumbar plexus nerves that run outside of psoas muscle in the retroperitoneal cavity and within the abdominal muscle wall., Results: The skin and muscles of the abdominal wall and the retroperitoneal cavity were dissected and analyzed with respect to the major motor and sensory branches of the lumbar plexus. The authors identified 4 nerves at risk during the lateral approach to the spine: subcostal, iliohypogastric, ilioinguinal, and lateral femoral cutaneous nerves. The anatomical trajectory of each of these nerves is described starting from the spinal column until their termination or exit from the pelvic cavity., Conclusions: There is risk of direct injury to the main motor/sensory nerves that supply the anterior abdominal muscles during the early stages of the lateral retroperitoneal transpsoas approach while obtaining access to the retroperitoneum. There is also a risk of injury to the ilioinguinal, iliohypogastric, and lateral femoral cutaneous nerves in the retroperitoneal space where they travel obliquely during the blunt retroperitoneal dissection. Moreover, there is a latent possibility of lesioning these nerves with the retractor blades against the anterior iliac crest.

Object: The lateral retroperitoneal transpsoas approach is being increasingly employed to treat various spinal disorders. The minimally invasive blunt retroperitoneal and transpsoas dissection poses a risk of injury to major nervous structures. The addition of electrophysiological monitoring potentially decreases the risk of injury to the lumbar plexus. With respect to the use of the direct transpsoas approach, however, there is sparse knowledge regarding the relationship between the retroperitoneum/psoas muscle and the lumbar plexus at each lumbar segment. The authors undertook this anatomical cadaveric dissection study to define the anatomical safe zones relative to the disc spaces for prevention of nerve injuries during the lateral retroperitoneal transpsoas approach., Methods: Twenty lumbar segments were dissected and studied. The relationship between the retroperitoneum, psoas muscle, and the lumbar plexus was analyzed. The area between the anterior and posterior edges of the vertebral body (VB) was divided into 4 equal zones. Radiopaque markers were placed in each disc space at the midpoint of Zone III (middle posterior quarter). At each segment, the psoas muscle, lumbar plexus, and nerve roots were dissected. The distribution of the lumbar plexus with reference to the markers at each lumbar segment was analyzed., Results: All parts of the lumbar plexus, including nerve roots, were found within the substance of the psoas muscle dorsal to the posterior fourth of the VB (Zone IV). No Zone III marker was posterior to any part of the lumbar plexus with the exception of the genitofemoral nerve. The genitofemoral nerve travels obliquely in the substance of the psoas muscle from its origin to its innervations. It emerges superficially and anterior from the medial border of the psoas at the L3-4 level and courses along the anterior medial fourth of the L-4 and L-5 VBs (Zone I). The nerves of the plexus that originate at the upper lumbar segments emerge from the lateral border of the psoas major and cross obliquely into the retroperitoneum in front of the quadratus lumborum and the iliacus muscles to the iliac crest., Conclusions: With respect to prevention of direct nerve injury, the safe anatomical zones at the disc spaces from L1-2 to L3-4 are at the middle posterior quarter of the VB (midpoint of Zone III) and the safe anatomical zone at the L4-5 disc space is at the midpoint of the VB (Zone II-Zone III demarcation). There is risk of direct injury to the genitofemoral nerve in Zone II at the L2-3 space and in Zone I at the lower lumbar levels L3-4 and L4-5. There is also a potential risk of injury to the ilioinguinal, iliohypogastric, and lateral femoral cutaneous nerves in the retroperitoneal space where they travel obliquely, inferiorly, and anteriorly to the reach the iliac crest and the abdominal wall.

OBJECT The objective of this work was to search a national health care database of patients diagnosed with cervical spine fractures in the US to analyze discharge, demographic, and hospital charge trends over a 10-year period. METHODS Clinical data were derived from the Nationwide Inpatient Sample (NIS) for the years 1997 through 2006. The NIS is maintained by the Agency for Healthcare Research and Quality and represents a 20% random stratified sample of all discharges from nonfederal hospitals within the US. Patients with cervical spine fractures with and without spinal cord injury (SCI) were identified using the appropriate ICD-9-CM codes. The volume of discharges, length of stay (LOS), hospital charges, total national charges, discharge pattern, age, and sex were analyzed. National estimates were calculated using the HCUPnet tool. RESULTS Approximately 200,000 hospitalizations were identified. In the non-SCI group, there was a 74% increase in hospitalizations and charges between 1997 and 2006, but LOS changed minimally. There was no appreciable change in the rate of in-hospital mortality (< 3%), but discharges home with home health care and to skilled rehabilitation or nursing facilities increased slightly. In the SCI group, hospitalizations and charges increased by 29 and 38%, respectively. There were no significant changes in LOS or discharge status in this group. Spinal cord injury was associated with increases in LOS, charges, and adverse outcomes compared with fractures without SCI. Total national charges associated with both groups combined exceeded $1.3 billion US in 2006. CONCLUSIONS During the studied period, increases in hospitalizations and charges were observed in both the SCI and non-SCI groups. The percentage increase was higher in the non-SCI group. Although SCI was associated with higher adverse outcomes, there were no significant improvements in immediate discharge status in either group during the 10 years analyzed.

Object: The DuraSeal dural sealant system, a polyethylene glycol hydrogel, has been shown to be safe and effective when used with commercial and autologous duraplasty materials. The authors report on the safety and effectiveness of this sealant when used in conjunction with nonautologous duraplasty materials., Methods: In this retrospective, nonrandomized, multicenter study, the safety and efficacy of a dural sealant system was assessed in conjunction with primarily collagen-based nonautologous duraplasty materials in a sample of 66 patients undergoing elective cranial procedures at 3 institutions. This cohort was compared with 50 well-matched patients from the DuraSeal Pivotal Trial who were treated with this sealant system and autologous duraplasty material., Results: The key end points of the study were the incidences of CSF leaks, surgical site infections, and meningitis 90 days after surgery. The incidence of postoperative CSF leakage was 7.6% in the study group (retrospective population) and 6.0% in the Pivotal Trial population. The incidence of meningitis was 0% and 4.0% in the retrospective and Pivotal Trial groups, respectively. There were no serious device-related adverse events or unanticipated adverse device effects noted for either population., Conclusions: This study demonstrates that the DuraSeal sealant system is safe and effective when used for watertight dural closure in conjunction with nonautologous duraplasty materials.

Object: Delayed esophageal perforation is an uncommon but well-known complication after anterior cervical spine surgery. To the authors' knowledge there is no consensus to the optimal management of these patients in the literature., Methods: The authors performed a retrospective review of 5 cases involving patients who were referred to their institution for the management of delayed esophageal perforations after undergoing anterior cervical spine surgery for a variety of reasons., Results: The primary presenting symptom in all 5 patients was dysphagia. All patients initially underwent primary closure of the perforation with a sternocleidomastoid muscle flap. One patient required multiple surgeries to correct the perforation and ultimately required a free flap., Conclusions: The authors recommend a multidisciplinary approach that involves otolaryngological surgeons as well as spine surgeons. They recommend removal of all anterior hardware and believe that it is essential to the treatment of esophageal perforations. If the patient does not have evidence of fusion at the time of presentation, then posterior cervical instrumentation is a viable alternative.

Enthusiasm for cervical disc arthroplasty is based on the premise that motion-preserving devices attenuate the progression of adjacent-segment disease (ASD) in the cervical spine. Arthrodesis, on the other hand, results in abnormal load transfer on adjacent segments, leading to the acceleration of ASD. It has taken several decades of pioneering work to produce clinically relevant devices that mimic the kinematics of the intervertebral disc. The goal of this work is to trace the origins of cervical arthroplasty technology and highlight the attributes of devices currently available in the market.

Vagus nerve stimulation (VNS) is a key tool in the treatment of patients with medically refractory epilepsy. Although the mechanism of action of VNS remains poorly understood, this modality is now the most widely used nonpharmacological treatment for drug-resistant epilepsy. The goal of this work is to review the history of VNS and provide information on recent advances and applications of this technology.

Object: The purpose of this study was to identify the causes of failed temporal lobe resection in patients with mesial temporal sclerosis (MTS) and the role of repeat surgery for seizure control., Methods: This is a retrospective study of 105 patients who underwent temporal lobe resection for MTS with unilateral electroencephalographic findings. The mean follow-up duration was 36 months (range 24-84 months). Surgeries were all performed by the senior author (F.L.V.)., Results: Following initial surgical intervention, 97 patients (92%) improved to Engel Class I or II (Group A), and 8 (8%) did not have significant improvement (Engel Class III or IV; Group B). These 8 patients were restudied using video-electroencephalography (EEG) and MR imaging. All major surgical failures occurred within 1 year after initial intervention. Reevaluation demonstrated 3 patients (37.5%) with contralateral temporal EEG findings. Five patients (62.5%) had evidence of ipsilateral recurrent discharges. Four patients underwent extended neocortical resection along the previous resection cavity. Their outcomes ranged from Engel Class I to Class III. Only 1 patient (12.5%) who failed to improve after initial surgery was found to have incomplete resection of mesial structures. This last patient underwent reoperation to complete the resection and improved to Engel Class I., Conclusions: Failure of temporal lobe resection for MTS is multifactorial. The cause of failure lies in the pathological substrate of the epileptogenic area. Complete seizure control cannot be predicted solely by conventional preoperative workup. Initial surgical failures from temporal lobe resection often benefit from reevaluation, because reoperation may be beneficial in selected patients. Based on this work, the authors have proposed a management and treatment algorithm for these patients.

Chance-type fractures of the spine have been associated with seat-belt injuries in the pediatric population. Nonoperative management is appropriate in most cases of Chance fractures, but surgical intervention is occasionally warranted to deter progression of kyphosis and neurological deterioration. Internal fixation using pedicle screws has been widely used in the surgical repair of this injury. The authors report on a 6-year-old girl who suffered an L-2 Chance fracture with facet disruption, kyphosis, and significant posterior ligamentous injury. She underwent open reduction and internal fixation using Songer cable wiring augmented with bilateral lamina plating. At the 18-week follow-up, she continued to be free of any neurological deficits and her alignment was stable on plain radiographs of flexion-extension. The authors have therefore described a feasible option in the surgical management of Chance-type fractures in the pediatric spine.

Object: In this retrospective review, the authors examine the clinical characteristics, diagnosis, and outcome of surgery in 25 consecutive patients with mesial basal temporal lobe (MBTL) tumors. A limited access approach to the inferior temporal gyrus (ITG) was used., Methods: Patients with MBTL tumors were identified from the epilepsy and tumor surgery database at the authors' institution. Intraaxial tumors localized to the mesial basal structures, and without involvement of the cortical surface of the temporal lobe, temporal stem, and basal ganglia were included. Preoperative and postoperative MR images were obtained in all patients. The mean follow-up period was 24 months (range 9-36 months). Preoperative symptoms, neurological deficits, outcomes, surgical complications, and a technical description of the approach are discussed., Results: Intraaxial MBTL tumors in 25 patients (mean age 44 years, range 8-76 years) were resected using a limited access approach via the ITG. The largest groups of tumors were high-grade gliomas and dysembryoblastic neuroepithelial tumors (8 in each group), followed by oligodendrogliomas, cerebral metastases, and gangliogliomas. Seizures, headaches, and disorientation were the most common preoperative symptoms. Postoperative MR images demonstrated gross-total resection in all cases. There were 2 surgical complications (a superficial wound infection and a transient frontalis branch palsy). There were no permanent neurological complications or significant new hemianoptic defects., Conclusions: A limited access ITG approach performed with intraoperative image guidance offers an alternative corridor for resection of MBTL tumors (Schramm Type A). This approach may be technically less demanding than the transsylvian or subtemporal approach. Gross-total resection is feasible utilizing this approach and compares favorably with other, more classical approaches.

Object: Vagus nerve stimulation (VNS) plays a significant role in the treatment of intractable epilepsy. The goal of this study was to analyze trends in the use of VNS for epilepsy in the US by using a nationwide database., Methods: Data for patients undergoing VNS were obtained from the nationwide inpatient sample for the years 1998-2005. Trends regarding number of procedures, length of stay (LOS), hospital charges, patient sex, and payer information were retrieved and analyzed., Results: The number of VNS procedures for epilepsy increased between 1998 and 2003 but decreased in the subsequent 2 years. The LOS and hospital charges showed yearly increases. Female patients underwent VNS implantation more than males did, and most procedures were performed in the 18- to 64-year-old age group. The combination of Medicare and Medicaid provided most of the funding for VNS from 2002 through 2005. The VNS procedures were performed mostly in teaching hospitals., Conclusions: Trends from a national database reveal consistent use of VNS for intractable epilepsy. Greater use of the procedure appears to be reflected in the female population, and the procedure has been performed most often at tertiary care teaching hospitals, where a comprehensive evaluation for all forms of therapy is arguably best able to target appropriate patients for appropriate therapies. With the recent application of VNS to target populations without epilepsy, such as patients with refractory depression, the trend of continued use of this treatment for epilepsy appears likely.

Ankylosing spondylitis (AS) is a chronic, progressive inflammatory rheumatic disease involving primarily the sacroiliac joints and the axial skeleton. The main clinical features are back pain and progressive stiffness of the spine. Oligoarthritis of the hips and shoulders, enthesopathy, and anterior uveitis are common, and involvement of the heart and lungs is rare. The current understanding of the pathogenesis of this disorder is limited. Despite the strong association between human leukocyte antigen B27 (HLA-B27) and susceptibility to AS reported over the past 30 years, the exact pathogenic role of HLA-B27 in AS and other spondyloarthropathies has yet to be determined. The authors present a review of the literature pertaining to the pathogenesis of AS over the past several decades. Ankylosing spondylitis is a polygenic disorder, with HLA-B27 playing a critical causative role in its pathogenesis. Animal studies of the immunobiology of HLA-B27 have provided significant insight into the pathogenic role of HLA-B27. The search for the antigenic peptide to support the "arthritogenic peptide" hypothesis has been disappointing. Over the past decade there has been increasing interest in the critical role of the misfolding and unfolded protein response of the heavy chain HLA-B27 in the modulation of the inflammatory response. Although there have been significant new findings in the understanding of the pathogenesis of AS, the exact mechanisms have yet to be identified. There is considerable optimism that additional susceptibility genes, predisposing factors, and regulators of the inflammatory process will be identified that will provide avenues for future treatment.