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For over 70 years, interbody lumbar fusions have evolved from modifications to discectomy procedures to more advanced techniques such as the posterolateral interbody fusion (PLIF) and ultimately the transforaminal lumbar interbody fusion (TLIF). The advent of minimally invasive surgery (MIS) techniques provided advantages of decreased soft tissue dissection, lower blood loss, and decreased post-operative pain. 9 Recently, further developments have lead to the introduction of endoscopic techniques with an awake anesthesia protocol that has shown improved results over the standard MIS TLIF. 12. , 13. , 14. , 20 , 31 While the standard MIS TLIF has now become commonplace, endoscopic MIS TLIF will also see widespread adoption over time.

Risk factors for cerebral aneurysms typically include age, hypertension, smoking, and alcohol usage. However, the possible connection of aneurysms with genetic conditions such as Marfan's syndrome, polycystic kidney disease, and neurofibromatosis raises the question of possible genetic risk factors for aneurysm, and additionally, genetic risk factors for rupture. We conducted a literature review using the PubMed database for studies regarding genetic correlation with cerebral aneurysm formation as well as rupture from December 2008 to Jun 2015. Twenty-one studies related to IA formation and 10 concerning IA rupture that met our criteria were found and tabulated. The most studied gene and the strongest association was 9p21/CDKN2, which is involved in vessel wall remodelling. Other possible genes that may contribute to IA formation include EDNRA and SOX17; however, these factors were not studied as robustly as CDKN2. Multiple factors contribute to aneurysm formation and rupture and the contributions of blood flow dynamics and comorbidities as mentioned previously, cannot be ignored. While these elements are important to development and rupture of aneurysms, genetic influence may predispose certain patients to formation of aneurysms and eventual rupture.

Spinal cord tumors are relatively rare lesions, of which approximately 50% are intradural and extramedullary. The optimal treatment of these lesions is a gross total surgical resection with the traditional approach being through a posterior laminectomy. However, in cases where the tumors are located either lateral or anterior, or both, the laminectomy itself may not provide sufficient access to achieve total resection with a high degree of safety. Numerous other approaches to these tumors have been described and previously published which are outside the scope of this chapter. Enhancements available for intradural tumor surgery include newer neurophysiological tools, intraoperative ultrasound, and various devices including tumor aspirators and lasers. Combined with advances in preoperative imaging, these modalities of treatment offer a greater margin of safety and a larger opportunity for total resection and long-term cure from these lesions.

INTRODUCTION: Laser interstitial thermal therapy (LITT) is a novel, minimally-invasive adjuvant therapy that is well-suited for intracranial tumors in deep or critical areas, recurrences failing standard therapy, and poor open-surgical candidates. To better characterize safety and clinical outcomes, we present the largest single-institutional experience with LITT for recurrent brain metastases. METHODS: All patients undergoing LITT for single recurrent brain metastases from 2013–2018 at the University of Miami were included in this study. Primary outcomes included extent of ablation (EOA), time-to-recurrence (TTR), and overall survival (OS). Secondary endpoints include neurologic status and complication rate. Kaplan-Meier survival analysis was performed to quantify TTR and OS, compare outcomes by primary tumor of origin, and identify potential predictors of TTR and OS. RESULTS: Thirty-six patients underwent 44 LITT procedures; all had undergone prior treatment with stereotactic radiosurgery (SRS). Mean age was 56.8 years and 83.3% were female. Average pretreatment tumor volume was 6.6cm3. Patients were treated with a mean ablation dose of 12.4W (9.8-14W), achieving a median EOA of 100% (range 55–100%). At median follow-up of 11.6 months (IQR 4.6–19.1 months), 34 of 44 (87.3%) cases had tumor control on radiographic imaging and 22 of 36 (61.1%) of patients remain alive. Median TTR was 55.9 months; median OS was 25.5 months. Neither TTR nor OR differed significantly by primary tumor of origin (P >.05). EOA >88% predicted longer TTR (P=.01) Neurologic status was stable or improved in all surviving patients. No major complications occurred (0% rate). CONCLUSIONS: Our institutional experience demonstrates LITT is safe for intracranial metastases resistant to SRS and offers several advantages over open surgical treatment. TTR and OS were not associated with primary tumor of origin. A threshold EOA >88% predicted longer TTR. Randomized studies are needed to evaluate the role of LITT as a treatment adjunct.

Background Cervical facet dislocations are among the most common traumatic spinal injuries. Posterior, anterior, and combined surgical approaches have been described and are widely debated. Objective To demonstrate efficacy in anterior-only surgical management for subaxial cervical facet dislocations. Methods A consistent surgical algorithm for cervical facet dislocation was applied over a 19-yr period and analyzed retrospectively in adults with acute unilateral or bilateral facet dislocation of the subaxial cervical spine. The primary endpoint was maintenance of early cervical alignment. The need for additional posterior instrumented fusion was determined. Results A database search identified 96 patients (mean age = 37.9, range = 14-74 yr, 68 (70%) male. The most common affected levels were C4-C5 (30), C5-C6 (29), and C6-C7 (30). Bilateral dislocation occurred in 51 patients (53%). Seventy-eight (81%) patients had neurological deficits, 31 (32%) being complete (Abbreviated Injury Score A) spinal cord injuries. Preoperative closed reduction was attempted in 60 (63%) patients, with 33 (55%) achieving satisfactory alignment. After anterior cervical discectomy, reduction, allograft placement, and instrumentation, a total of 92 (96%) patients had achieved satisfactory realignment. Median time to surgery was 13.27 h. Eight (8%) patients required posterior fixation due to intraoperative determination of incomplete realignment (4; 4%) and development of early progressive deformity (4; 4%). Mean follow-up was 4.5 mo (range 0.5-24 mo) with 33 (34%) patients lost to follow-up. Conclusion Anterior approaches are viable for reduction and stabilization of cervical facet dislocations. Further prospective studies are required to evaluate clinical and long-term success.

Glioblastoma multiforme (GBM) is an aggressive tumor with poor survival outcomes and limited treatment options. We conducted a literature review to compare the survival outcomes of intra-arterial (IA) and intravenous (IV) chemotherapy delivery for GBM. Nine studies of IA chemotherapy infusion with 301 total patients met our criteria for inclusion and three studies contained IV treatment groups for comparison (n = 230 for IA, n = 71 for IV). The studies were grouped by either using newly diagnosed or recurrent GBM patients. In the newly diagnosed group, IV chemotherapy produced a statistically higher median overall survival (MOS; 16.3 months) compared with IA treatment (14.02 months). However, the total number of adverse events in IA chemotherapy was 1.08 per patient whereas for IV it was higher at 1.54 events per patient. Our recurrent GBM group includes only patients treated with IA chemotherapy which resulted in an average MOS of 10.84 months. This group had 2.7 adverse events per patient but no IV group is available for comparison. Historically, the survival of patients with recurrent GBM ranges from 3 to 9 months (Gil-Gil et al. Bevacizumab for the treatment of glioblastoma. Clin Med Insights Oncol 2013;7:123-35). For this reason, we believe IA chemotherapy to be a viable methodology in recurrent GBM patients to prolong survival at the risk of procedure-related complications and in newly diagnosed patients with the benefit of decreased complications.

Although anticancer drugs have existed for over 50 years, targeted drugs have only recently been marketed, and their side effects may not be completely understood. The patient is a 56-year-old woman with a gastrointestinal stromal tumor who presented with headache, nausea, and vomiting lasting 2 weeks. An MRI to rule out brain metastasis found a large right-hemispheric subdural hematoma without metastases. She denied trauma, seizures, or alcohol abuse. Laboratory test results were normal. Eight months prior, she had begun a dose escalation of imatinib, which became the suspected cause of her hemorrhage. The literature was reviewed for reports of intracranial hemorrhage with targeted chemotherapeutics excluding metastases, anticoagulation, and trauma. Multiple events have been documented but only one for imatinib with gastrointestinal stromal tumor. Imatinib is believed to cause platelet dysfunction (missed by standard testing), leading to intracranial hemorrhage. Intracranial hemorrhage risk may be under-reported and neurosurgical consultation for immediate treatment and oncology for reinitiation of chemotherapy are recommended.

Background Degenerative cystic lesions of atlantoaxial joints are rare and generally believed to be due to mechanical instability. There is currently no consensus on the management of such lesions in symptomatic and asymptomatic patients. Both conservative and surgical strategies have been described. Surgery may involve anterior or posterior approaches with and without decompression and instrumentation. Methods We present a case report of a 45-year-old man who presented with new onset weakness and ataxia. Physical examination revealed decreased motor function in all extremities as well as positive Hoffman sign and ankle clonus bilaterally. An MRI of cervical spine showed a large atlantoaxial, T-2 hyperintense cystic lesion with cord compression and cord signal changes. Results A C1 partial laminectomy was performed with resection of the cyst and C1-2 instrument fusion. Intra-operatively, the cystic lesion was found to be anatomically connected to the right C1-2 atlantoaxial joint with pathology showing fibroconnective tissue and chronic inflammatory changes. Post-operatively there were no complications and the patient was discharged to a rehabilitation facility. The patient was regaining gait and hand function by 3 months after surgery. Conclusions Atlantoaxial synovial cysts are rare and the optimal surgical approach has not been determined. We further conducted a literature review and found a total of 70 other cases of atlantoaxial synovial cysts reported to date in the literature. We attempt to analyze available data and evaluate anterior versus posterior approaches and the need for decompression, amount of cyst resection, and instrumentation.

Objective: Idiopathic intracranial hypertension (IIH) is a syndrome characterized by increased intracranial pressure (ICP) in the absence of an identifiable cause, and if untreated, can result in permanent vision loss. In symptomatic IIH patients, cerebrospinal fluid (CSF) diversion can lower ICP and protect vision; however, currently used CSF diversion systems are prone to malfunction in this population. Materials and Methods: In two IIH patients with histories of numerous prior shunt revisions that presented with proximal ventriculoperitoneal shunt malfunction, ICP reduction was achieved by an alternative surgical cerebrospinal fluid (CSF) diversion technique: Fluoroscopically guided, percutaneous placement of a catheter in the premedullary cistern and subsequent connection to the valve and distal shunt system. Results: Postoperatively, both patients' papilledema resolved, headaches improved, and the shunts were working well at 3-month follow-up. At 1-year follow-up, one patient was well without papilledema or symptom recurrence, and the second patient had the shunt system removed by an outside surgeon. Conclusion: This technique may hold promise as an alternative shunting strategy in IIH patients with numerous proximal shunt failures or who are poor candidates for ventricular and lumbar shunts.