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While neurosurgeons are experienced in treating penetrating brain injuries (PBIs) in civilian settings, much less is known about management and outcomes of PBIs in military settings.A systematic review was performed according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Data extracted included surgical management, age, gender, location/type of injury, initial Glasgow Coma Scale (GCS) score, and outcomes. The primary outcomes were last reported Glasgow Outcome Score (GOS) and mortality. The secondary outcomes included central nervous system infections, seizures, and cerebrospinal fluid leak/fistula. Odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were used for outcome analysis.Twelve studies with 1738 patients treated for PBIs in military settings were included. The weighted mean age was 27.8 years, 86.7% were male, and 64.3% underwent neurosurgical intervention. Most patients (64.3%) presented with a GCS score8, while 31.0% presented in a coma (GCS score8). Over a median last follow-up time of 9 months, 68.6% achieved a favorable (GOS = 4-5) outcome and 34.2% achieved a poor (GCS score = 1-3) outcome. The overall mortality was 18.0%. A meta-analysis was performed using 5 of 12 studies to evaluate the effect of the presenting GCS score on primary outcomes. Patients with an initial GCS score8 had statistically significant lower odds of a favorable (GOS = 4-5) outcome (OR: 0.03; 95% CI: 0.00-0.19; P: 0.000) and higher odds of mortality (OR: 28.46; 95% CI: 8.62-94; P: 0.000) than patients with an initial GCS score8. The pooled rates of central nervous system infection, seizures, and cerebrospinal fluid leak/fistula were 13.8%, 13.2%, and 5.4%, respectively.In this first systematic review and meta-analysis of outcomes following combat-related PBIs, a GCS score8 at presentation was found to be an important predictor of a favorable GOS and decreased mortality.

Study design Multicenter propensity score-adjusted retrospective cohort study. Objective To determine baseline 30-day complication rates for anterior cervical discectomy and fusion (ACDF) and compare clinical complications for patients undergoing single-level ACDFs between inpatient and outpatient settings. Summary of background data ACDF remains the most common procedure in the treatment of a variety of cervical disc pathologies, making it a focus of quality improvement initiatives. Outpatient single-level ACDFs are becoming more common and offer advantages including reducing nosocomial infections and costs, as well as improved patient satisfaction. Materials and methods The 2011-2013 NSQIP datasets were queried to identify all patients who underwent single-level ACDF procedures using current procedural terminology codes. Outpatient and inpatient cohorts were matched 1:1 using propensity score analysis to assess short-term outcomes. The outcomes assessed included 30-day medical and surgical complications, reoperation, readmission, and mortality. Results In total, 6940 patients underwent a single-level ACDF with an overall complication rate of 4.2%. A total of 5162 patients (74.4%) had an inpatient hospital stay after surgery, whereas 1778 patients (25.6%) had outpatient surgery. After matching based on preoperative and operative characteristics to account for potential confounders, the overall complication rate was higher in the inpatient arm compared with the outpatient arm (2.5% vs. 1.2%; P=0.003). The 30-day readmission rate was also higher but not significant in the inpatient group than the outpatient group (2.2% vs. 1.8%; P=0.355). Mortality was the same with 0.1% in both groups (P=0.564). Conclusions Patients undergoing outpatient single-level ACDF had a lower 30-day complication rates than those undergoing it in the inpatient setting. Outpatient surgery for single-level ACDF is safe and a favorable option for suitable patients. Level of evidence Level 3.

OBJECTIVEVenous thromboembolism (VTE) after spinal surgery is a major cause of morbidity, but chemoprophylactic anticoagulation can prevent it. However, there is variability in the timing and use of chemoprophylactic anticoagulation after spine surgery, particularly given surgeons’ concerns for spinal epidural hematomas. The goal of this study was to provide insight into the safety, efficacy, and timing of anticoagulation therapy after spinal surgery.METHODSThe authors retrospectively examined records from 6869 consecutive spinal surgeries performed in their departments at Northwestern University. Data on patient demographics, surgery, hospital course, timing of chemoprophylaxis, and complications, including deep venous thrombosis (DVT), pulmonary embolism (PE), and spinal epidural hematomas requiring evacuation, were collected. Data from the patients who received chemoprophylaxis (n = 1904) were compared with those of patients who did not (n = 4965). The timing of chemoprophylaxis, the rate of VTEs, and the incidence of spinal epidural hematomas were analyzed.RESULTSThe chemoprophylaxis group had more risk factors, including greater age (59.70 vs 51.86 years, respectively; p < 0.001), longer surgery (278.59 vs 145.66 minutes, respectively; p < 0.001), higher estimated blood loss (995 vs 448 ml, respectively; p < 0.001), more comorbid diagnoses (2.69 vs 1.89, respectively; p < 0.001), history of VTE (5.8% vs 2.1%, respectively; p < 0.001), and a higher number were undergoing fusion surgery (46.1% vs 24.7%, respectively; p < 0.001). The prevalence of VTE was higher in the chemoprophylaxis group (3.62% vs 2.03%, respectively; p < 0.001). The median time to VTE occurrence was shorter in the nonchemoprophylaxis group (3.6 vs 6.8 days, respectively; p = 0.0003, log-rank test; hazard ratio 0.685 [0.505–0.926]), and the peak prevalence of VTE occurred in the first 3 postoperative days in the nonchemoprophylaxis group. The average time of initiation of chemoprophylaxis was 1.46 days after surgery. The rates of epidural hematoma were 0.20% (n = 4) in the chemoprophylaxis group and 0.18% (n = 9) in the nonchemoprophylaxis group (p = 0.622).CONCLUSIONSThe risks of spinal epidural hematoma among patients who receive chemoprophylaxis and those who do not are low and equivalent. Administering anticoagulation therapy from 1 day before to 3 days after surgery is safe for patients at high risk for VTE.

Study Design: Retrospective cohort study. Objective: To describe the readmission rate and identify risk factors associated with 30-day readmission after transforaminal lumbar interbody fusion (TLIF) surgery. Methods: Patients who underwent elective single level TLIF surgery from 2011 to 2013 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Emergency or trauma cases were excluded. Preoperative, intraoperative, and postoperative variables were extracted. A multivariate binary regression identified predictors correlated with 30-day readmission. Results: A total of 4992 patients were included in the analysis. The overall 30-day readmission rate was 5.51% (275/4992) for readmissions reported between 2011 to 2013. The mean age of patients readmitted was 62.40 years (standard error [SE] = 0.78) and 60.92 years (SE = 0.20) among those whom were not readmitted ( P = .05). The top three causes for readmission included postoperative pain control, deep or superficial surgical site infections. Predictors associated with 30-day readmission in a multivariate analysis included female gender (odds ratio [OR] = 1.27, 95% CI = 0.97-1.65), history of severe chronic obstructive pulmonary disease (OR = 1.81, 95% CI = 1.11-2.96), and in the postoperative period, American Society of Anesthesiologists class (OR = 1.30, 95% CI = 1.04-1.63), presence of superficial surgical site infection (OR= 18.23, 95% CI = 10.36-32.08), or urinary tract infection (OR = 4.93, 95% CI = 2.84-8.58). Conclusions: The readmission rate, risk factors, and causes following TLIF surgery are comparable to other lumbar spinal procedures reported from the ACS-NSQIP database.

Study Design: A retrospective, blinded analysis of imaging studies. Summary of Background Data: To evaluate changes in paraspinal muscle cross-sectional area (CSA) after surgical treatment for lumbar stenosis and to compare these changes between minimally invasive and standard open approaches. The open approach to lumbar stenosis is effective, but it involves retraction and resection of muscle from the spinous process, which can result in ischemia and denervation of paraspinal musculature and may lead to muscle atrophy and pain. Objective: It is hypothesized that the microendoscopic decompression of stenosis (MEDS) technique will better preserve the paraspinal muscles compared with the open procedure. Materials and Methods: A total of 18 patients underwent a 1-level posterior decompression for lumbar stenosis, (9 open, 9 MEDS). Lumbar magnetic resonance imaging was obtained before surgery and after surgery (open approach average 16.3 mo; MEDS average 16.6 mo). CSA of paraspinal muscles were averaged over the distance of the surgical site. Results: The mean age of patients treated with the open and MEDS approaches were 55.2 and 66.4 years, respectively (P=0.07). Paraspinal muscle CSA decreased by an average of 5.4% (SD=10.6%; range, −24.5% to +7.7%) in patients treated with the open approach and increased by an average of 9.9% (SD=14.4%; range, −9.8% to +33.1%) in patients treated with MEDS (P=0.02). For the open approach, changes in CSA did not differ significantly between the left and right sides for erector spinae (P=0.35) or multifidus muscles (P=0.90). After the MEDS approach there were no significant differences between the dilated and contralateral sides with regard to change in CSA for erector spinae (P=0.85) or multifidus muscles (P=0.95). Conclusions: Compared with the open approach for lumbar stenosis, MEDS had significantly less negative impact on the paraspinal muscle CSA. Previous reports have documented negative effects of paraspinal muscle injury, including weakness, disability, and pain. Collectively, these data suggest that the MEDS approach for lumbar decompression is less destructive to the paraspinous muscles than the open approach and may facilitate better clinical outcomes.

Study design A retrospective, multivariate analyses of a prospectively collected multicenter database. Objective The aim of this study was to evaluate the risk factors for postoperative airway complications following single- and multilevel anterior cervical discectomy and fusion (ACDF). Summary of background data Airway compromise following ACDF may result in catastrophic outcome. However, its predictors have not been identified by a multi-institutional study. Methods Patients who underwent ACDF between 2011 and 2013 were selected from the American College of Surgeons National Surgical Quality Improvement Program database. Multiple logistic regression analysis was performed to identify the risk factors for airway compromise following ACDF. Results Twelve thousand one hundred eighty-five patients were analyzed in this study. Our multivariate analysis identified older age, male gender, dependent functional status, chronic obstructive pulmonary disease, bleeding disorder, American Society of Anesthesiology class >2, Wound Class >2, and prolonged operative durations as significant predictors of postoperative airway compromise following ACDF. Surprisingly, multilevel and corpectomy procedures were not significant risk factors for airway complication following ACDF. Conclusion We identified significant risk factors for airway compromise following ACDF procedures. While ACDF is considered a safe procedure, postoperative airway complication can lead to disastrous outcome. Continued efforts to elucidate preoperative risk factors and subsequent optimization are warranted to improve outcomes in ACDF. Level of evidence 3.

A major future challenge is combining forces between the current care offered by hospital-based global leadership (leadership needs a plan which is executable) and patient population needs. In this chapter, the need is specifically in regards to what leadership skills are valued to plan and execute the foundation of a surgical center that specializes in robot-assisted neurosurgery. This leads to a phronesic challenge whereby global leadership combines robotic practicality with the individual surgeon’s unique wisdom. The patient remains very real. Moving outside of availability heuristics, thanks to new money-saving technologies, overall patients’ treatment challenges will be assessed at the global leadership level using fundamental research and regression analysis.

The US health care system is struggling with rising costs, poor outcomes, waste, and inefficiency. The Patient Protection and Affordable Care Act represents a substantial effort to improve access and emphasizes value-based care. Value in health care has been defined as health outcomes for the patient per dollar spent. However, given the opacity of health outcomes and cost, the identification and quantification of patient-centered value is problematic. These problems are magnified by highly technical, specialized care (eg, neurosurgery). This is further complicated by potentially competing interests of the 5 major stakeholders in health care: patients, doctors, payers, hospitals, and manufacturers. These stakeholders are watching with great interest as health care in the United States moves toward a value-based system. Market principles can be harnessed to drive costs down, improve outcomes, and improve overall value to patients. However, there are many caveats to a market-based, value-driven system that must be identified and addressed. Many excellent neurosurgical efforts are already underway to nudge health care toward increased efficiency, decreased costs, and improved quality. Patient-centered shared value can provide a philosophical mooring for the development of health care policies that utilize market principles without losing sight of the ultimate goals of health care, to care for patients.

ObjectUnplanned hospital readmission represents a large financial burden on the Centers for Medicare and Medicaid Services, commercial insurance payers, hospitals, and individual patients, and is a principal target for cost reduction. A large-scale, multi-institutional study that evaluates risk factors for readmission has not been previously performed in patients undergoing lumbar decompression procedures. The goal of this multicenter retrospective study was to find preoperative, intraoperative, and postoperative predictive factors that result in unplanned readmission (UR) after lumbar decompression surgery.MethodsThe National Surgical Quality Improvement Program (NSQIP) database was retrospectively reviewed to identify all patients who received lumbar decompression procedures in 2011. Risk-adjusted multivariate logistic regression analysis was performed to estimate independent predictors of UR.ResultsThe overall rate of UR among patients undergoing lumbar decompression was 4.4%. After multivariate logistic regression analysis, anemia (odds ratio [OR] 1.48), dependent functional status (OR 3.03), total operative duration (OR 1.003), and American Society of Anesthesiologists Physical Status Class 4 (OR 3.61) remained as independent predictors of UR. Postoperative complications that were significantly associated with UR included overall complications (OR 5.18), pulmonary embolism (OR 3.72), and unplanned reoperation (OR 56.91).ConclusionsThere were several risk factors for UR after lumbar spine decompression surgery. Identification of high-risk patients and appropriate allocation of resources to reduce postoperative incidence may reduce the readmission rate.

STUDY DESIGN Retrospective cohort study. OBJECTIVE To determine the incidence of and factors predicting 30-day readmission after anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA ACDF is being performed on an increasing basis on a wider population of patients, which is accompanied by rising costs. Readmissions have the potential to further deplete health care resources. Although past studies have shown that readmissions after surgery are driven by operative complications, specific predictors of readmission after ACDF are not well researched. METHODS All patients who underwent ACDF or anterior corpectomy and fusion procedures in 2011 were selected from the American College of Surgeon's National Quality Improvement database. Readmissions were analyzed on the basis of demographics, comorbidities, operative characteristics, and complications were compared in univariate analyses. Multivariate logistic regression models were created to isolate the independent effects of preoperative and postoperative factors on readmission. RESULTS The nationwide readmission rate after ACDF surgery in this study is 2.5%. Pulmonary complications (8.5%), wound complications (8.5%), and urinary tract infections (8.5%) are the most common complications seen in readmitted patients. Readmitted patients were significantly older (58 vs. 53, P = 0.003), with higher rates of diabetes and hypertension (28.8% vs. 13.9%, P = 0.001; 64.4% vs. 42.6%, P = 0.001, respectively). Although certain preoperative factors such as age 65 years or more and preoperative stay more than 24 hours increase the odds of operative complications (odds ratio, 3.5; 95% confidence interval, 2.0-6.0 and odds ratio, 6.2; 95% confidence interval, 3.4-11.1, respectively), hypertension may independently increase the likelihood of readmission outside of any effect on complications (odds ratio, 1.8; 95% confidence interval, 1.0-3.4). CONCLUSION The data in this study suggests that surgeons are already controlling readmission rates by limiting peri- and postoperative complications, but patients with a history of hypertension could have an increased likelihood of being readmitted despite avoiding a complication. LEVEL OF EVIDENCE 3.

Sir Victor Horsley'S many contributions to neurological surgery include experimental and clinical studies of gunshot wounds (GSW) of the head. Horsley's publications from 1894 to 1897 and 1914 to 1915 on GSWs were reviewed. Horsley described GSWs in animal and clay models, illustrating characteristics of the primary missile tract and secondary cavitation. A transcranial GSW model in 67 dogs related intracranial damage to the projectile's velocity and sectional area, producing a marked sudden increase in intracranial pressure that presumably "tunneled" to the medullary respiratory and cardiac centers. If the resultant sudden apnea was treated with artificial respiration and prompt surgical decompression, the animal often survived. In these animal experiments, Horsley clearly described increased intracranial pressure, hypertension, and bradycardia-later recognized as the Cushing response or triad. With the onset of World War I, Horsley again reviewed the ballistics of military weaponry, emphasizing projectile spin and velocity as the main wounding mechanisms. He was outspoken against the "wicked tradition" of neglecting cranial GSWs and personally treated cases with aggressive respiratory support and prompt decompression of devitalized tissue. Horsley's contributions to the experimental and clinical aspects of GSWs to the head are consistent with his other important contributions to neurosurgery and have largely stood the test of time.

Background Defensive medicine is prevalent among US neurosurgeons due to the high risk of malpractice claims. This study provides national estimates of US neurosurgeons' defensive behaviors and perceptions. Objective To examine the relationship of defensive medicine-both "assurance" behaviors and "avoidance" behaviors-to the liability environment. Methods A 51-question online survey was sent to 3344 US neurosurgeon members of the American Board of Neurological Surgeons (ABNS). The survey was anonymous and conducted over 6 weeks in the spring of 2011. The previously validated questionnaire contained questions on neurosurgeon, patient, and practice characteristics; perceptions of the liability environment; and defensive-medicine behaviors. Bivariate and multivariate analyses examined the state liability risk environment as a predictor of a neurosurgeon's likelihood of practicing defensive medicine. Results A total of 1026 neurosurgeons completed the survey (31% response rate). Neurosurgeons' perceptions of their state's liability environment generally corresponded well to more objective measures of state-level liability risk because 83% of respondents correctly identified that they were practicing in a high-risk environment. When controlling for surgeon experience, income, high-risk patient load, liability history, and type of patient insurance, neurosurgeons were 50% more likely to practice defensive medicine in high-risk states compared with low-risk-risk states (odds ratio: 1.5, P Conclusion Both avoidance and assurance behaviors are prevalent among US neurosurgeons and are correlated with subjective and objective measures of state-level liability risk. Defensive medicine practices do not align with patient-centered care and may contribute to increased inefficiency in an already taxed health care system.

The evaluation and treatment of spinal cord injury continues to evolve, enhanced by new imaging modalities. Their application in reference to the cervical, thoracic, and lumbar spine is discussed. Treatment options, both conservative and surgical, are outlined.

The case of 16-year-old boy who incurred a subdural hematoma in the posterior fossa and an intracerebellar hematoma after a tangential civilian gunshot wound is reported. The skull was not fractured, and yet surgically significant clots required removal. The patient recovered. The discussion centers on the mechanism of injury and seriousness of tangential gunshot wounds and traumatic hematomas in the posterior fossa.

A recent modification of the occipital transtentorial approach to the pineal region and medial-posterior hemisphere is described. The patient is operated upon in a lateral reclining (park bench) position with the side to undergo occipitoparietal craniotomy, slightly dependant. Following dural opening to the margins of the superior sagittal and lateral sinuses, gentle traction with a brain spatula facilitates the occipital transtentorial and transfalcine approach to the incisural region. Ventricular or spinal fluid drainage is often helpful. The occipital lobe falls away from the midline and falcotentorial regions by gravity. Absence of occipital parasagittal bridging veins is a helpful feature and careful convexity dural opening allows the occipital lobe to move laterally. Microsurgical treatment of pineal, splenial, falcotentorial and medial posterior hemisphere lesions may be greatly facilitated. Our experience with six cases is presented. To date, published results of this operative approach have been excellent with the risk of hemianopsia, parenchymal venous infarction, and air embolus much lessened or eliminated.

Extradural angiolipomas are rare tumors that can produce spinal cord compression. Two patients with thoracic spinal angiolipoma are presented that were treated with surgical resection and radiation. The histological and clinical features of the 18 previously reported cases of these tumors are discussed.

The case of a soldier with multiple cervical fractures without neurologic deficit sustained after a helicopter crash during Operation Desert Storm is presented. The fractures involved the C2 body and the right facet joint and pedicle of C4. This fracture pattern, in association-with lack of neurologic deficit, is the first such case reported in the literature.

The authors present an unusual case of solitary intramedullary plasmacytoma. Awareness of this entity can facilitate appropriate surgical planning, which may include a limited biopsy prior to considering more extensive skull base surgery.

A follow-up study is presented of the initial neurosurgical treatment of 20 patients who sustained penetrating craniocerebral injuries during "Operation Desert Storm". Fifteen of these patients had received intracranial debridement through a craniectomy and five patients had received care of scalp wounds only. Following treatment and stabilisation in a frontline hospital, these patients were transferred to the Riyadh Armed Forces Hospital for further evaluation and management. On admission, all the patients received a computerised tomographic scan which revealed shrapnel fragments inside their brain. No attempt had been made to remove the metal fragments. A patient with an infected scalp wound was treated with a course of appropriate antibiotics and the wound dressed. Dexamethasone was not used. Anticonvulsants were used only in one patient who had been treated for a presumed cerebral abscess. The neurological status of the patients improved along with the reduction of oedema and the swelling of the brain as shown in the follow-up CT scans. No patient died or developed a seizure disorder. These results suggest that re-operation for removal of retained fragments is unnecessary. It is concluded that the initial treatment of shrapnel wounds of the brain should be to preserve maximal cerebral tissue and function either by limiting the wound debridement performed through a craniectomy or by care of scalp wounds only.

A study was undertaken to elicit the hidden factors that, when identified, would signal the presence of cervical spine instability. Data were derived from the records and radiographs of 21 patients having sustained traumatic injury to the lower cervical spine (C3-C7) and who failed a single-stage posterior stabilization procedure necessitating a second (or combined) anterior-posterior arthrodesis. Mechanism of injury most frequently identified in this group was the distraction-flexion (locked facets) pattern (nine patients) and the "tear drop" compression-flexion injury pattern (seven patients). All 21 patients underwent a posterior wiring and bone graft stabilization procedure with persistent postoperative instability. Thus, failure to recognize the presence of "three-column" instability, the sine qua non of this group, resulted in the failure of posterior tension band stabilization as a means of gaining cervical spine stability. Three-column cervical spine instability is suspected in the presence of: 1) retrolisthesis and angulation of the superior vertebra on the next inferior vertebra; 2) distraction of the posterior interspinous ligaments sufficient to allow subluxation or dislocation of the facets; in conjunction with 3) a "shear" dislocation of one vertebra on another. Anterior shearing force through the disc space is capable of disrupting the intervertebral disc, along with disruption of the anterior and posterior longitudinal ligaments, each contributing to the presence of anterior and middle column cervical spine instability.

We present a case of falcine chondrosarcoma in a 58-year-old man. Only a few other examples of chondrosarcomas in this location and a total of approximately 50 intracranial cases have been reported. Because its rarity prevents any group of neurosurgeons from collecting a large experience in managing this tumor, we reviewed descriptions of previous cases to determine the natural history of intracranial chondrosarcomas. The distinguishing features of this rare tumor are compared with previous examples of intracranial tumors derived from cartilage and more common tumors in the parasagittal region, such as meningioma.

Functional neuromuscular stimulation (FNS) provides a mechanism for the activation of muscles paralyzed by injury to the spinal cord. Although this technique was first used to treat patients with spinal cord injury over 20 years ago, only recent advances in electronics and biomechanics have made it a promising aid for the rehabilitation of these patients. Thus far, restoration of palmar prehension and lateral prehension in quadriplegics and of standing and biped gait in paraplegics has been achieved under carefully controlled laboratory conditions. This article reviews the current status of FNS and its potential as a practical tool to aid spinal cord-injured patients. Neurosurgeons who care for these patients might be expected to be involved in the future use of FNS if implantable systems are developed and tested.

Case records of 88 patients with low-velocity gunshot injuries of the terminal spinal cord and cauda equina treated by laminectomy at Cook County Hospital between 1969 and 1987 were reviewed. Sixty-one patients were operated upon within 72 hours of injury, 29 of whom (47.5%) experienced neurological improvement or pain relief. Twenty-seven patients were operated upon at a later time for associated injuries, 13 of whom (48.1%) experienced neurological improvement or pain relief. When laminectomy was delayed for more than 2 weeks, either arachnoid adhesions (15%) or occult abscesses (17%) were observed. From this review as well as from the literature, it appears that the timing of laminectomy for gunshot injuries of the thoracolumbar and lumbosacral spine is not essential to neurological recovery. It appears, however, that adequate debridement of these injuries, performed as soon as the patient is stable from any associated injuries, may help to mitigate the late sequelae of arachnoiditis, infection, and pain syndromes in the lower extremities.

A 15-year-old black female student came to the hospital because of disturbance of her gait. On examination, there was a dermal sinus in the skin overlying the spine of the seventh cervical vertebra, and myelography with computed tomography scan demonstrated a block to the flow of metrizamide contrast material at T-5 with cephalad extension of an intradural cystic lesion to the C-5 level. An x-ray examination of the abdomen at the time demonstrated a tooth-shaped radiodensity in the left hypogastrium. On exploration of the spine via C5-T5 laminectomy an intramedullary cystic teratoid tumor was found which was partially excised. At later exploration of the abdomen, a teratoma of the left ovary was removed. The pathology and natural history of teratomas and teratoid tumors is discussed along with surgical management of these tumors.

Eight patients with atlantoaxial instability secondary to trauma or rheumatoid arthritis were treated with posterior C1-C2 arthrodesis using the Halifax interlaminar clamp and autogenous bone graft or methylmethacrylate. Thus far, with an average follow-up of 6 months, satisfactory stability has been achieved with no instrument failure. (Neurosurgery 22:429-431, 1988)

The case of a patient with multiple contiguous fractures of the cervical and upper thoracic spine without neurological deficit or spinal instability is presented. Injury to each of the cervical vertebrae plus the upper two thoracic vertebrae is unusual and has not been previously reported.

This study measures standing stability of four individuals with paraplegia using knee-ankle-foot orthoses (KAFOs) with a center-of-force monitoring platform as compared with similar data from 10 neurologically healthy subjects. Both groups were compared under conditions of quiet standing with eyes open and closed and with hands on and off parallel bars. Individuals with paraplegia were also tested under similar conditions with the ankles of their KAFOs mechanically unlocked and with bilateral functional neuromuscular stimulation of the quadriceps muscles. Sway path, mean amplitude, and mean frequency were measured for each subject. We found that postural stability in paraplegic individuals using KAFOs compared favorably with the control group under conditions of eyes open and closed with hands on parallel bars; however, visual information was much more important for paraplegic individuals during quiet stance. Unlocking the ankles of the KAFOs resulted in an increase in swap path and mean frequency. Functional muscular stimulation of the quadriceps muscles resulted in standing stability slightly less than with KAFOs. Although KAFOs may not be the ideal assistive device for various reasons, postural stability appears reasonable, and other proposed orthoses must be comparable in order to be considered as an alternative.

A large hemangiopericytoma was located posterocentrally. The patient presented with headaches and papilledema. Surgical management consisted of total gross excision by a combined right occipital transtentorial and right occipitoparietal transfalcine approach under magnification in three stages over a 6-week period. Removal was aided by dilatation of the right temperooccipital horn ("trapped ventricle") and meningioma-like encapsulation allowed separation of the tumor from the brain and surrounding structures after internal debulking of the tumor. Subsequent peritoneal shunting of the trapped ventricular horn and 5000 rads of radiotherapy were given to the patient. She remains well with an inferior quadrantanopsia on the left side more than 1 year after treatment. Meningiomas of the pineal region, the relationship of meningioma to hemangiopericytoma and malignant mesenchymal tumors (sarcomas) are considered in reference to presumed cells of origin.

✓ A retrospective review of the surgical experience in treating 18 patients with osteomyelitis of the cervical spine is reported. The patients ranged in age from 20 to 60 years and all complained of neck pain upon admission. Ten patients had a prior history of intravenous drug abuse, three had previously suffered penetrating injuries of the neck, and one had an extraspinal site of osteomyelitis. Bacteria were isolated in 13 cases and tuberculosis in three. Neurological abnormalities were present in over one-half of the patients, consisting of myelopathy (nine cases) or radiculopathy (four cases). Plain cervical spine films and polytomography demonstrated vertebral and end-plate destruction, spinal instability, and increased paravertebral soft-tissue shadow in all cases. Computerized tomography and, more recently, magnetic resonance imaging have proven helpful in detecting bone involvement and the presence of epidural extension associated with cervical osteomyelitis. The risk of vertebral body collapse, kyphosis, and myelopathy in the osteomyelitic cervical spine has standardized the management of this problem in this institution to consist of skeletal traction, needle aspiration or blood culture for organism identification, anterior cervical debridement, autogenous iliac graft fusion, and intravenous administration of antibiotics. Spinal stability and neurological improvement were achieved in all 18 patients.

Intrasellar extradural placement of a detachable vascular balloon via a transsphenoidal approach was performed successfully in a patient with primary empty sella syndrome, relieving headache and visual field defect. This technique offers an alternative approach to other methods of treating symptomatic empty sella syndrome that require packing of the sella with fat, muscle, cartilage, or bone.

Instability of the spine caused by metastatic spread of primary tumors represents a serious risk for spinal cord or nerve root compression. In order to restore stability and relieve neural compression, a variety of surgical techniques originally used for reduction of nonpathologic spinal fractures have been applied to the problem of spinal metastases. Recently, we have utilized a technique developed primarily for correction of scoliosis to the treatment of metastatic spinal fractures. Six patients with spinal instability and neural compression secondary to metastatic tumors had segmental spinal stabilization with Luque rods, sublaminar wiring, and methyl methacrylate. Restoration of stability was successful in all cases with alleviation of preoperative pain and return to full activity. No evidence of instability occurred in this group of patients. As demonstrated by this experience and that of a few other small series, Luque rod stabilization provides a valuable addition to the techniques available for stabilization of metastatic fractures of the spine. Although the precise role of Luque rod segmental spinal stabilization in treatment of metastatic disease of the spine continues to be defined, thus far it has proved beneficial for cases of multiple vertebral body involvement or instability beyond one vertebral level.

Most cases of neurological deterioration after laminectomy for cervical radiculomyelopathy occur several weeks to months postoperatively, except when there has been direct trauma to the spinal cord or nerve roots during surgery. Four patients are described who developed episodes of neurological deterioration during the postoperative recovery period that could not be attributed to direct intraoperative trauma nor to epidural haematoma or instability of the cervical spine as a consequence of laminectomy. Following laminectomy for cervical radiculomyelopathy four patients were unchanged neurologically from their pre-operative examinations, but as they were raised into the upright position for the first time following surgery focal neurological deficits referrable to the spinal cord developed. Hypotension was present in all four cases during these episodes and three of the four patients had residual central cervical cord syndromes. These cases represent the first reported instances of spinal cord ischaemia occurring with post-operative hypotensive episodes after decompression for cervical spondylosis.

Preoperative radiological evaluation with magnetic resonance imaging and computed tomography was valuable in planning the surgical management of a destructive lesion of the posterior elements of the thoracic spine that was causing spinal cord compression in an 18-year-old woman. Preoperative recognition of bilateral involvement of the pedicles in addition to the laminae and spinous process led to use of prophylactic segmental stabilization of the spine with Luque rods after successful excision of an aneurysmal bone cyst. This case provides an example of the usefulness of computed tomographic scanning and magnetic resonance imaging in assessing the distribution and location of vertebral tumor and its potential effect on spinal stability. The efficacy of combining radical excision with stabilization for treatment of aneurysmal bone cysts of the spine is emphasized.

A variety of surgical techniques is available for treatment of metastatic disease of the spine. Prior emphasis on the use of these procedures has been on their benefit as a palliative measure to relieve signs and symptoms of spinal cord and nerve root compression not aided by radiation therapy and corticosteroid administration. More recently, development of surgical techniques that combine neural decompression with restoration of spinal stability has brought about consideration of additional indications for surgery in the treatment of metastatic disease of the spine. The present scope of such surgical procedures is reviewed along with identification of the most reliable selection factors for surgical candidates in order to improve functional outcome from surgical treatment of metastatic disease of the spine. Over 70 surgical series with more than 2,000 patients treated were reviewed.