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Little is known about socioeconomic differences in postoperative outcomes after neurosurgery. We assessed the relation between insurance status and postoperative complication risk, neurosurgical intensive care unit stay, and hospital stay after neurosurgery.We collected data on 918 consecutive craniotomy or spine-related neurosurgical cases in patients at least 18 years of age at the University of Michigan Hospitals after April 2006. Bivariate χ(2) tests and analysis of variance were used to assess bivariate relations, and multivariable logistic regression models and analysis of covariance were used to adjust for potential confounders.A total of 11.2% of privately insured patients, 23.6% of Medicare patients, 25.8% of Medicaid patients, and 27.3% of uninsured patients suffered complications within 30 days of surgery (P0.001). In adjusted models, odds of postoperative complications among Medicare (odds ratio [OR] = 2.1, 95% confidence interval [CI] 1.3-3.3), Medicaid (OR = 3.1, 95% CI 1.5-6.1), and uninsured patients (OR = 3.6. 95% CI 1.3-10.3) were higher than among privately insured patients. By analysis of covariance, only Medicaid patients had significantly longer intensive care unit (P = 0.040) and hospital stays (P = 0.028) than privately insured patients.Our findings suggest important socioeconomic disparities in outcomes after neurosurgical intervention. Access to postoperative outpatient care may mediate our findings.

We present our experience with sinonasal undifferentiated carcinoma at the University of Michigan over 13 years and review prior published data. We conducted a retrospective review of 19 patients who presented to a tertiary care academic center multidisciplinary skull base clinic with sinonasal undifferentiated carcinoma between 1995 and 2008. Overall survival was 22% at 5 years, and the estimated 5-year distant metastasis-free survival was 35%. At 2 years, local control was 83%, regional control was 50%, and distant control was 83%. Local control was best in those patients treated nonsurgically, as was median survival, though this was not statistically significant. Nodal disease in the neck, either at presentation or at recurrence, was noted in 26% of patients. Survival for sinonasal undifferentiated carcinoma remains poor. It is possible that up-front radiation or chemoradiation will lead to better local control rates, though surgery remains a mainstay of treatment. In all cases, the cervical nodes should be addressed with primary treatment.

Object Tethering of the spinal cord has been a recognized cause of neurological symptoms in pediatric patients and is increasingly being recognized as a cause of symptoms in adults as well. The pathophysiology surrounding spinal cord tethering has begun to be understood in the pediatric population but is still unclear in adult patients. Methods Using a PubMed database literature search, the authors reviewed the pathology and pathophysiology surrounding the tethered spinal cord, focusing particularly on the pathophysiology of adult tethered cord syndrome (TCS). Results Experimental data obtained in pediatric patients at surgery and in animal models indicate that spinal cord tethering causes a reduction in spinal cord blood flow and dysfunction of neuronal mitochondrial terminal oxidase. Retrospective analyses of patients undergoing surgery for adult TCS show that many adults developed symptoms following an event that could stretch the spinal cord, while others did not. Many patients also were found to have structural lesions in addition to a tethered spinal cord at diagnosis. Conclusions Both adult and pediatric TCSs are likely the result of a relative lack of blood flow to the spinal cord, causing dysfunction in mitochondrial oxidative phosphorylation. The likely reason the syndrome present later and differently in adults is that a secondary threshold of tension or a cumulative effect of repetitive, transient tension is placed on the cord before symptoms are recognized.

BACKGROUND AND PURPOSE: Few reports have described the embolization of head and neck lesions by using direct percutaneous techniques. We report our preliminary experience in the direct percutaneous embolization of hypervascular head and neck tumors by using Onyx in conjunction with standard endovascular embolization techniques. We describe the technical aspects of the procedure and its efficacy in reducing intraoperative blood loss. MATERIALS AND METHODS: We retrospectively studied 14 patients (3 females and 11 males; mean age, 33.4 years; range, 11–56 years) with 15 hypervascular tumors of the head and neck that underwent direct percutaneous embolization with Onyx in conjunction with particulate embolization. Nine paragangliomas and 6 JNAs underwent treatment. Documented blood loss was obtained from operative reports in these 15 patients with surgical resection performed 24–48 hours after the embolization. RESULTS: Intratumoral penetration with progressive blood flow stasis was achieved during each injection. A mean of 3.1 needles (20-gauge, 3.5-inch spinal needle) were placed percutaneously into the lesion (range, 1–6). The mean intraoperative blood loss was 780 mL (range

In cases of temporal horn entrapment caused by primary malignant central nervous system tumors, the goal is to restore physiological flow of cerebrospinal fluid (CSF) while preventing the spread of malignant tumor cells to distant sites. This goal is usually accomplished by placement of a traditional ventriculoperitoneal, ventriculopleural, or ventriculoatrial shunt. In this study, the authors describe a novel treatment approach using placement of a frontal-to-temporal horn shunt as an alternative to distal CSF diversion. Stereotactic surgery was used for placement of frontal-to-temporal horn shunts in 3 patients who presented with focal compressive symptoms caused by temporal horn dilation. Serial imaging studies confirmed temporal horn decompression with symptom resolution after a maximum of 20 months of follow-up (minimum 2 months in 1 patient who died of tumor progression). The authors believe this simple technique may be considered for use in all patients with neurological symptoms resulting from temporal horn dilation caused by malignant central nervous system neoplasms in which seeding of distant sites by CSF diversion is a concern.

Background Anterior cervical hyperosteophytosis describes the excessive formation of osteophytes along the ventral spine. Dysphagia due to ACH is considered an uncommon entity described mainly in case reports. Symptomatic ACH has been attributed to multiple etiologies including DISH, trauma, postlaminectomy syndromes, and cervical spondylosis. We report one of the largest series of patients with ACH-induced dysphagia requiring surgery. Methods After IRB approval, a retrospective chart review was completed. From 2001 to 2006, 9 patients presented with dysphagia due to ACH requiring surgical treatment. Results Eight patients were male, and the mean age was 65.1 years. Cervical spine x-rays and CT clearly demonstrated ACH in each case. Esophagram or a video fluoroscopic swallowing study was used to verify that dysphagia was caused by osteophytic overgrowth in all instances but one. In 2 patients, a focal osteophyte had formed adjacent to a previously fused segment. Of the remaining 7 patients, osteophytic formation was attributed to cervical spondylosis in 2 patients and DISH in 5 patients. All patients underwent osteophytectomy without spinal fusion. Average follow-up was 9.8 months. Although all 9 patients experienced resolution of dysphagia, improvement was delayed in 2 patients. Conclusions Diffuse idiopathic skeletal hyperostosis and spondylosis are the most common etiologies accounting for ACH-induced dysphagia. Adjacent segment disease may also be a potential cause of symptomatic ACH and has not been previously reported. Regardless of etiology, surgical resection is highly successful if conservative measures fail.

Introduction Juvenile nasopharyngeal angiofibroma is a locally invasive tumor in adolescent males. Surgical resection is the treatment of choice, but the tumor9s extensive vascular involvement necessitates preoperative embolization. In this retrospective cohort, we compare the effectiveness of a novel liquid embolic agent, Onyx (ethylene vinyl alcohol copolymer), to traditional particulate embolic agents in reducing estimated blood loss (EBL) during surgical resection of Juvenile nasopharyngeal angiofibroma. Methods We included 46 consecutive resections since 1995 for which preoperative embolization was either particulate (n=39) or Onyx only (n=7), and for which age at operation, date of operation, length of hospital stay, Fisch grade of tumor, resection approach, EBL during resection, and fluids during resection were available. In a subset of 26 resections, OR time was available. Results The mean EBL for the Onyx group was 658.6±858.7 ml and the mean EBL for the particulate group was 1348.6±932.2 ml (one tailed Student t test p=0.043). The mean units packed red blood cells (PRBCs) used in the Onyx group 0.29±0.76 units (p=0.003) and the mean PRBCs used in the particulate cohort was 1.56±2.01. The relationship between embolization type, EBL and embolization type, PRBCs remained significant in the subset of patients with Fisch grade=III (Onyx n=4, particulate n=18, EBL p=0.001 and PRBCs p=0.045), and other Fisch categories did not have enough patients for a statistical analysis. The relationship between embolization type and EBL remained significant after correcting for age at operation (p=0.033). The proportion of resections for which an endoscopic approach was used was significantly higher in the Onyx group than the particulate group (71.4% and 20.5%; p=0.009), and this was also significant in the subset of patients with Fisch grade=III (p=0.040). Conclusion Existing reports suggest that Onyx embolization decreases intraoperative EBL. Our study supports this result and also shows a reduction in units PRBC used intraoperatively. Although further studies are needed, Onyx appears to facilitate a less challenging surgical resection relative to traditional particulate embolization. Competing interests None.

Background JNAs are hypervascular tumors that may benefit from pre-operative devascularization to reduce intra-operative blood loss. The optimal method for devascularization of these tumors is not known. Methods A consecutive series of seven JNAs were treated with percutaneous embolization with EVOH as the sole embolic agent. 1—Fischer Type I, 1—Fischer Type II, 4—Fischer type IIIb, and 1 Fischer Type IVa tumors were treated. Results Complete devascularization of the seven JNAs was achieved in all cases percutaneously with only EVOH. There were no complications. The average intraoperative blood loss was 680 ml (range 10–1700 ml). Three of the type IIIb tumors were completely removed from only an endoscopic approach. Conclusions Our preliminary experience suggests that EVOH may offer a higher degree of devascularization when compared with other embolic agents. This may facilitate an easier surgical resection with lower blood loss. EVOH seems to be safe when percutaneously injected as the sole embolic agent into a JNA.

Figure 1B. Axial MRI sections demonstrate the typical character of skull base meningiomas. T2 weighted imaging (T2) shows a mass along the left frontal bone inner table causing contour distortion of the left frontal lobe. FLAIR imaging (FLAIR) shows the lesion is non-edemogenic (short arrow). Non-contrast T1 weighted imaging (T1) shows the brain-like signal character of the mass as well as a nearby bony reaction (“bone” with thin arrow). T1 weighted imaging after IV contrast (GAD) shows the marked pathologic contrast enhancement of the mass and its long dural tail (long arrow). Figure 1A. Coronal T1weighted MRI sections after IV contrast demonstrate the highly invasive character of this mass with bulky peridural intracranial spread (arrow), direct intraorbital extension (“O”), and direct paranasal sinus extension (“S”).