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With the exception of oligoastrocytoma, mixed gliomas are rarely encountered, and the astrocytic component of mixed oligoastrocytoma is almost always fibrillary and diffusely infiltrative. Pleomorphic xanthoastrocytoma (PXA) has occasionally been described in conjunction with ganglioglioma, as well as in 1 case of oligodendroglioma. In this latter case, described by Perry et al., 1p/19q codeletions were not detected. The authors report on a 25-year-old woman with a combined PXA/oligodendroglioma in which concurrent 1p/19q codeletions were detected in the oligodendroglial component only. The patient presented with a 1-month history of headaches. Neuroimaging revealed a heterogeneous left temporal mass with focal enhancement, cystic changes, hemorrhage, and left-to-right midline shift. The patient underwent a craniotomy and gross-total resection. Pathological examination revealed a glial tumor composed of 2 apparently distinct components. The largest component exhibited a prominent fascicular, reticulin-rich, spindle cell arrangement admixed with areas of highly pleomorphic cells, with bizarre cytological features reminiscent of PXA. A smaller component was composed of cellular sheets and lobules of oligodendroglial cells. Both components were characterized by anaplastic features. Dual-color fluorescence in situ hybridization for 1p/19q codeletions was performed. Only the oligodendroglial component showed the combined 1p/19q deletions. This case represents the first instance in which PXA has been reported in conjunction with an oligodendroglioma exhibiting the “molecular signature” characteristic of oligodendroglial neoplasms. The different genetic alterations seen in the 2 components of this neoplasm argue in favor of a “collision tumor” rather than a mixed glioma of the same genotype.

Object Organ transplantation for renal, liver, cardiac, and pulmonary failure has become more common in recent years, and patients are living longer as a result of improved organ preservation methods, immunosuppressive regimens, and general posttransplant care. Some of these patients undergo spine fusion surgery following organ transplantation, and there is little available information concerning outcomes. The authors report on their experience with and the outcomes of spine fusion in this rare and unique immunosuppressed patient group. Methods Using the Current Procedural Terminology and ICD-9 codes for solid organ transplants, bone marrow transplantations (BMTs), and spine fusion surgeries, the authors searched their patient database between 1997 and 2008. Data points of interest included primary diagnosis, type of organ transplant, immunosuppressant drug therapy, complications from spine surgery, and radiographic analysis of spine fusion. Spine fusion was assessed with CT or radiography at the latest follow-up. Results The database search results revealed 5999 patients who underwent heart, lung, liver, kidney, pancreas, intestine, or bone marrow transplant between 1997 and 2008. Eighteen of the 5999 patients underwent a spine fusion surgery while receiving immunosuppressive therapy. Organ transplants included kidney, liver, heart, pancreas, and allogenic BMT. There were 3 deaths unrelated to spine fusion within 1 year of the surgery and 1 death immediately after spine surgery. Graft-versus-host disease developed in 1 patient when prednisone was stopped prior to the spine surgery. Thirteen patients underwent follow-up radiographic imaging at an average of 25 months after spine surgery; 12 demonstrated radiographic fusion. Conclusions The results suggest that spine fusion rates are adequate despite immunosuppressive therapy in patients undergoing spinal fusion after transplant procedures. The data also illustrate the high morbidity and mortality rates found in the organ transplant patient population.

Object Endoscopic surgery has been reported to be more cost-effective and safer than open craniotomy for resection of colloid cysts, despite a 5–10% conversion rate to craniotomy, a 5% recurrence rate, a 5–10% ventricular shunting rate, a 5–10% epilepsy rate, and a 3–4 day hospital stay. In 1985, the authors developed a interhemispheric, transcallosal, subchoroidal, fornix-sparing approach that allowed safe total resection of the colloid cyst and that appeared to be superior to the endoscopic approach. The long-term results are analyzed and compared with findings in the literature. Methods Fifty-seven consecutive colloid cysts were totally removed via a 3 ×3–in paramedian craniotomy flap and a microscopic interhemispheric, transcallosal, subchoroidal approach sparing the ipsilateral fornix. The length of the callosotomy was 1.5–2 cm in all patients. The mean follow-up duration was 12 years (range 2–22 years). A retrospective analysis comparing the authors' results with those reported in the endoscopic literature was performed. Results All patients had 1-year postoperative imaging studies (CT or MR imaging) documenting gross-total resection with no deaths, infection, hemiparesis, seizures, or disconnection syndrome. One surgery was complicated by bilateral subdural hematomas, which were successfully treated. There has been a zero recurrence rate. Three patients required a permanent ventriculoperitoneal shunt (including 2 who required emergency ventriculostomy before surgery). The mean hospital stay was 4.8 days (range 2–24 days). There was 1 patient with permanent short-term memory loss who presented with a herniation syndrome requiring emergency ventriculostomy. Conclusions The interhemispheric, transcallosal, subchoroidal, fornix-sparing approach to gross-total resection of colloid cysts is safe and led to a zero recurrence rate with no permanent neurological sequelae including epilepsy, and these results are superior to any reported results with endoscopy.

✓ Eighty-eight consecutive patients underwent anterior cervical discectomy (ACD) with banked fibula fusion and internal fixation using the locking cervical plate. Pathology included cervical spondylotic radiculopathy in 48, cervical spondylotic radiculomyelopathy in 30, cervical facet dislocations with associated disc herniations in six, and autologous iliac crest graft collapse pseudoarthrosis with recurrent symptoms in four patients. Operations were single-level banked fibula fusion with plating in 37, multilevel banked fibula fusion with plating in 45, and combined single-level ACD banked fibula fusion with plating and posterior fusion in six patients. The only perioperative complication was transient hoarseness. There were no transfusions, infections, neurological injuries, or deaths. The mean time in the hospital for the nontraumatic cases was 1.8 days. The mean follow up was 22 months (range 12–30 months). There has been no motion at the fused level on flexion/extension films, no kyphosis, no screw plate backout, and no banked fibula has suffered graft collapse. Following a high-speed motor vehicle accident 6 months after a multilevel fusion, one alcoholic man suffered a fractured plate with transient worsening of neck pain, and the plate has remained in place for an additional 11 months of follow-up care. Compared to 100 consecutive autologous iliac crest fusions performed by the same surgeon, there were significantly fewer graft-related complications (p < 0.001). There was a significantly greater chance of autologous iliac crest collapsing with the passage of time as compared to banked fibula. Time until return to work was shorter by 5 weeks for the plate/banked fibula group (p < 0.05). When fusion is considered following ACD, the combination of banked fibula and locking cervical plates is significantly superior to autologous iliac crest grafts.

✓ The authors report the case of patient with a lumbar vertebral body osteoporotic compression fracture who underwent percutaneous transpedicular polymethylmethacrylate (PMMA)—assisted vertebroplasty in whom extravasation of the cement into the spinal canal caused immediate neurological deterioration. Lateral lumbar radiography and computerized tomography scanning demonstrated the presence of intraspinal PMMA. The patient suffered severe low-back pain, left-sided sciatica, and profound left L2–4 distribution weakness and numbness. She underwent immediate L-2 laminectomy, the extra- and intradural PMMA was removed, and instrumentation-assisted lateral mass fusion was performed. The patient recovered without incident and her neurological deficit improved. Extravasation of cement into the spinal canal, neural foramen, paraspinal veins, or disc space has been reported in 11 to 73% of percutaneous transpedicular PMMA-assisted vertebroplasty procedures. It is disturbing that more than one group of authors has documented symptomatic spinal canal PMMA extravasation and that the patients were left severely handicapped because of a stated fear that surgery to remove the cement would be difficult and make them worse. The results achieved in this case refute that published notion. It is important to document that decompressive surgery and PMMA removal from the spinal canal are easy and can lead to immediate neurological improvement. With the increasing popularity of percutaneous transpedicular PMMA-assisted vertebroplasty, the authors suspect that more of these cases will be seen.

✓ Suprascapular nerve entrapment is an acquired neuropathy secondary to compression of the nerve in the bony suprascapular notch. A series of 27 cases, the largest reported to date, is presented and examined as to the best and most appropriate method of diagnosis and treatment. The entity is described in detail as to its origin, anatomy, and pathophysiology.

✓ Automated percutaneous discectomy has been performed in 57 patients at the author's institution since 1989, representing 4% of all lumbar spine surgeries. All 57 patients had unilateral sciatica. There were 33 women and 24 men ranging from 24 to 49 years of age, with a mean age of 45 years. All patients underwent computerized tomography (CT) in the prone position and CT and magnetic resonance imaging in the supine position. Diffuse versus eccentric disc bulging was determined for each patient. Four patients underwent surgery at the L3–4 level, four at L5–S1, and 49 at L4–5. One L5–S1 case could not be cannulated and surgery was aborted. There have been no complications related to surgery. Fifty patients (88%) stated they had reduced sciatica in the first 2 postoperative weeks. Forty (70%) had reduced sciatica 2 months postoperatively. The mean follow-up period was 27 months (range 6 to 45 months), with no patient lost to follow up. At their last follow-up examination, 33 patients (58%) showed improvement in their sciatica but only three (5%) were completely pain free. Of the 17 recurrences of sciatica, 11 patients have undergone microdiscectomy, with eight showing improvement. Chi-square analysis demonstrated a significantly better chance of improvement in patients with discs bulging eccentrically to the side of sciatica (p < 0.05) compared to patients with diffusely bulging discs. Automated percutaneous discectomy is safe and in selected patients can reduce sciatica, but only completely eliminated sciatica in 5% of patients with a follow-up period of 2.5 years.