Tumour response and morphological changes of acoustic neurinomas after radiosurgery

Summary Twenty-seven of the 1560 patients treated by radiosurgery during the period 1984–1993 had acoustic neurinomas. Four cases were excluded from this study because they had a follow-up of less than 2 years. There were 24 neurinomas treated in 23 patients as one patient had a bilateral tumour. Seven patients underwent radiosurgery for a recurrent tumour (already operated on once or twice), while it was the first treatment for 16 patients. The tumour volume ranged from 1.99 cm³ to 18.30 cm³, and the patient follow-up was from 2 to 8 years.To determine the target on CT/NMR for linear accelerator stereotactic irradiation, the Greitz-Bergström non-invasive head fixation device was used. It was again adopted for subsequent serial imaging, and for repeat radiosurgery when necessary. The total peripheral tumour dose ranged from 12 to 45 Gy.In 9 patients there was a reduction in tumour volume varying from 39 to 100%, while 14 of the neurinomas appeared stable after an average follow-up of 3 years. In one patient there was an increase in size of the tumour. Variable morphological changes were present in 66% of the neurinomas treated.Radiosurgery is indicated as an alternative to microsurgery for inoperable patients and for those who refuse surgery, for recurrent tumours, and as a post-operative complementary treatment for partially removed tumours.A gradual approach to radiosurgery, depending on tumour response, allows a greater efficacy with minimal risk. In the present series no complications were observed. Hearing was preserved at almost the same level as that prior to radiosurgery in all patients.     

CT-findings in cystic meningiomas

Summary Cystic meningiomas are rare, about 10% occuring in children. Only 61 cases have been reported in the literature 1,4,8,12. Based on 6 of our own cases and the reports in the literature typical CT-fmdings are described and differentiating features from other cystic mass lesions discussed.If a tumour on CT shows a cystic component, is smoothly outlined, enhances markedly and is attached to the dura, then a preoperative diagnosis of cystic meningioma should be taken into account. This holds especially true if the patient is a child.     

大型听神经瘤显微手术治疗和面神经保留

目的:总结65例听神经瘤采用显微外科技术的体会。方法:应用枕下乙状窦后入路采用显微外科技术切除肿瘤。结果:肿瘤全切除59例(91％),次全切除6例(9％)。面神经解剖保留54例(83％),功能保留46例(71％),面神经功能根据House-Brackmann,Ⅰ～Ⅱ级38例(58％),Ⅲ～Ⅳ级19例(29％),Ⅴ～Ⅵ级8例(13％)。结论:熟悉小脑桥脑角及周围区域的正常和病理解剖,采用显微外科技术,大多数大型听神经瘤均可保留面神经解剖完整的前提下手术全切。     

Spinal meningiomas: critical review of 131 surgically treated patients

This study was undertaken to analyze the functional outcome of surgically treated spinal meningiomas and to determine factors for surgical morbidity. Between January 1990 and December 2006 a total of 131 patients underwent surgical resection of a spinal menigioma. There were 114 (87%) female and 17 (13%) male patients. Age ranged from 17 to 88 years (mean 69 years). The mean follow-up period was 61 months (range 1–116 months) including a complete neurological examination and postoperative MRI studies. The pre- and postoperative neurological state was graded according to the Frankel Scale. Surgery was performed under standard microsurgical conditions with neurophysiological monitoring. In 73% the lesion was located in the thoracic region, in 16% in the cervical region, in 5% at the cervico-thoracic junction, in 4.5% at the thoraco-lumbar junction and in 1.5% in the lumbar region. Surgical resection was complete in 127 patients (97%) and incomplete in 4 patients (3%). At the last follow-up the neurological state was improved or unchanged in 126 patients (96.2%) and worse in 4 patients (3%). Permanent operative morbidity and mortality rates were 3 and 0.8%, respectively. Extensive tumour calcification proved to be a significant factor for surgical morbidity (P < 0.0001). Radical resection of spinal meningiomas can be performed with good functional results. Extensive tumor calcification, especially in elderly patients proved to harbor an increased risk for surgical morbidity.     

Simultaneous posterior and middle cranial fossa neurinomas

Summary A case of unilateral association of a neurinoma of the VIII nerve and a neurinoma of the temporal fossa in a 33-year-old woman without von Recklinghausen disease stigmata is presented.This uncommon association can mimic the picture of a trigeminal neurinoma with a dumb-bell extension into the posterior fossa.     

Multiple meningiomas in the posterior fossa

A case of multiple meningiomas in the posterior fossa is reported. Computed tomography scans clearly demonstrated the tumors. They were removed completely and the patient was discharged without any neurological deficits. The clinical features are discussed and the pertinent literature is reviewed.     

Tentorial meningiomas: follow-up review

Tentorial meningiomas comprise 3-5% of the intracranial meningiomas. Different locations and sinus invasion require special surgical skills. This study aimed to analyze factors influencing the outcome of 29 patients (30 tumors) with tentorial meningiomas surgically treated. The study included 22 female and seven male patients, with age of 18-76 years old, and a follow-up of 6-179 months. Eight tumors were located on the inner tentorial ring, 15 on the outer ring, four were falcotentorial, and three attached/invading the torcula. Outcome was analyzed using survival and recurrence-free survival (RFS) curves. Twenty-seven tumors were WHO grade I and three were grades II-III. Total and subtotal resections were reached in 87.5% and 12.5% of tumors. Survival was better for patients with grade I tumors and similar according to sex, location, size, and extent of resection. Recurrence/regrowing rate was 12.5%. RFS curves were better for patients with grade I or with radical resection and similar according to sex, location, and size. There was no operative mortality. Permanent postoperative cranial nerve deficits occurred in 9.7% (all inner ring tumors). Despite being many times large-sized, surgical treatment of tentorial meningiomas gives good results. Prognostic factors for recurrence were histopathologic grade III and subtotal resection. Radical resection allowed better results. Nevertheless, subtotal resection may be acceptable for cases with cranial nerves or sinuses invasions.     

Immediate and late outcome of operations for parasagittal and falx meningiomas. Report of 342 cases

The immediate results of surgery-for the most part radical surgery-in 342 cases of parasagittal and falx meningiomas are presented. The late outcome in 317 survivors observed for at least five years and possible ways of avoiding them are discussed with special reference to recurrences and disabling sequels.     

Spinal deformity changes in children with long-term vertical expandable prosthetic titanium rib treatment

Background Context

In several studies, vertical expandable prosthetic titanium rib (VEPTR) implants have shown good scoliosis control in children with the longest reported follow-up of 3.6 years. For growing rods, recent studies suggest a decreased efficiency of correction starting just after that time. To our knowledge, no long-term results of children with VEPTR treatment are available.

Gangliosides in meningiomas: Correlation of Glac 2 to intermediary filament

Summary Human meninges and 29 meningiomas were analyzed as to their glycosphingolipid composition. In the neutral fraction GSL, a mostly even distribution of mono-, di-, tri-and tetrahexoside was demonstrated. In the group of the gangliosides, G_lac 1 in one broad band in chromatogramms occurred in almost all meningiomas; G_lac 2 was present in 84% of tumours. Members of the G_tri-family were only found in a small minority of tumours while various G_tet-gangliosides were detectable in nearly half of them. No constant pattern or patterns emerged and no correlation to either morphological subtype or malignancy grade could be established. Immunohistochemistry revealed focal presence of G_lac 2 in a pattern similar to that of vimentin expression. Semiquantitative evaluation showed good correlation between both parameters.Abbreviations used WHO World Health Organization - GSL Glycosphingolipids - aGSL acidic GSL - nGSL neutral GSL - For Gangliosides G stands for ganglioside, the index denominates the sugar complex (lac=lactose, tri=triaose, tet=tetraose) and the following cipher denotes the number of sialic acids. The Svennerholm notation (1963) is sometimes given in brackets. G_lac1=GM₃, G_lac2=GD₃, G_tri1=GM₂, G_tri2=GD₂, G_tet1=GM₁, G_tet2a=GD₁ a and so on. - CMH Ceramid monohexoside - CDH Ceramid dihexoside - CTH Ceramid trihexoside - CTetH Ceramid tetrahexoside     

Potential doubling time and tumour doubling time in meningiomas and neurinomas

Summary Cell kinetic study plays an important role in treatment planning of brain tumour patients. MIB-1 antibody has recently become available, which detects Ki-67 antigen even in the formalin-fixed paraffin-embedded specimens. We performed MIB-1 immunostaining in 50 meningiomas and 50 neurinomas, and estimated the cell cycle time (tc) and potential doubling time (Tpot) from MIB-1 staining index (MIB-1 SI) and mitotic index (MI). MIB-1 SI logarithmically correlated with MI in both meningiomas and neurinomas. The tc and the Tpot were expressed as a function of the mitosis time (tm), while the tm is known to be around one hour and not exceeding two hours. When the tm was assumed to be one hour, the average tcs of meningiomas and neurinomas were 6.53±3.56 days and 7.67±3.27 days, respectively. The Tpots were447 × (MIB-1 SI)^–1.29 × tm in meningiomas, and490 × (MIB-1 SI) ^–0.98 × tm in neurinomas.The tumour doubling times (Tds) were calculated from serial imaging studies in 22 neurinomas and 15 meningiomas. The Tds were formulated as794 × (MIB-1 SI) ^–0.83 in meningiomas and1380 × (MIB-1 SI) ^–0.97 in neurinomas. Most of the Tds correlated well with the Tpots in meningiomas and neurinomas, and exceeded values of the Tpot when the tm is assumed to be one hour, although a few tumours showed unexpectedly longer Tds. The Tpot and the tc estimated from MIB-1 SI and MI are clinically useful parameters for predicting the growth potential of meningiomas and neurinomas where no other simple methods are available.     

Role of pia mater vascularization of the tumour in the surgical outcome of intracranial meningiomas

Summary The authors reviewed a personal series of 150 consecutive cases of intracranial meningiomas operated on between 1974 and 1988 with the aim of finding out the main prognostic factors determining surgical outcome. Severity of pre-operative clinical status and size of the tumour were found to be significant adverse factors, p<0.001 and p<0.01, respectively. In this article the authors stress on the role played in prognosis by pia mater vascularization of the tumour. When the tumour vascular supply predominated from pial-cortical arteries, in most cases cleavage could not be found in the arachnoid plane, but only in the subpial plane (because of incorporation of pia mater into the tumour capsule). Clinical consequences were that in the most eloquent areas (for example in the central region) a bad outcome — with transient or permanent deficit — frequently occured when cleaving could not be performed in the arachnoid plane (p<0.001). The neurological disorders were due to cortical and underlying sub-cortical ischaemia and haemorrhagic infarction. Participation of the pia mater in the tumour vascular supply can be predicted pre-operatively, directly on selective internal/external carotid angiograms, indirectly by the presence of an important peritumoural hypodensity on CT scan (which — according to our findings — is an indication of predominant pial-cortical vascular supply to the tumour). The positive correlation between cortical-pial supply (and its consequences) and tumour size (p<0.001), pleads for surgery of meningioma at the earliest possible stage provided there are no contra-indications.     

Intracranial meningiomas in the elderly in the CT scan era

Summary Intracranial meningiomas diagnosed and operated upon in similar five-year periods before and after CT scan are analysed. In the latter period the overall number of meningiomas and the average age of the patients have increasedtumours from 77 to 186, and average age from 50 to 56. All patients but one from the first group were operated on, while only 155 from the second group underwent surgery. Operation was rejected in 31 patients for different reasons. In the pre-CT scan epoch 25% of patients who were operated on were over 60 and 9% were over 65, whereas in the CT scan era these rates have risen to 35 and 21% respectively. Mortality and good recovery rate were the same in both groups up to 65 years of age.After 65, postoperative complications and mortality increased steeply: of the patients over 65 in whom the growth was excised 55% died. The radical surgery of intracranial meningiomas in geriatric patients over 65 still remains a tremendous challenge despite all the advances in operative technique, neuroanaesthesia and intensive care. On these grounds, in such patients surgical indications should be carefully evaluated.     

Multiple meningiomas. Case report and review of the literature

A case of multiple meningiomas without the stigmata of von Recklinghausen's disease is reported. The patient was followed up with serial computed tomography scanning over a 3-year period. The literature on multiple meningiomas is reviewed.     

MRI in the diagnosis of cystic meningiomas: Surgical implications

Summary Nine cases of cystic meningioma diagnosed by MRI are described. All cases were surgically confirmed. The lesion was extra-axial with a clear durai attachment. On T1-weighted images the solid component was iso-hypo-intense in 6 cases and iso-hyper-intense in 3; on T2-weighted images it was hyperintense in 7 cases, iso-intense in 2. After i.v. injection of gadolinium, the solid component enhanced in all cases and a durai tail were visible in 8 cases. No gadolinium enhancement of the cyst wall was observed in Nauta's types II and III.The authors found MRI to be very useful for diagnosis of cystic meningioma but insufficient for differential diagnosis between types II and III according to Nauta. This aspect requires further study, especially in view of the implications of this differentiation in terms of surgical management.     

Results of spinal meningioma surgery in patients with severe preoperative neurological deficits

Spinal meningiomas are usually benign, slow-growing tumours and are commonly associated with good patient outcome following surgery. However, the existence of a severe preoperative neurological deficit has been considered to be a possible predictor of poor functional outcome after surgery. We retrospectively reviewed data from 33 patients with 35 spinal meningiomas treated in our institution over the past 17 years and exhibiting severe preoperative deficits before surgery. Among them, 20 suffered from paraparesis and 13 were paraplegic. The mean follow-up duration was 70.7 months (range 12–183 months). By the 1-year follow-up, all patients had improved in comparison with their preoperative neurological status, and 60% of them had totally recovered. It can be concluded from this study, that, in the vast majority of cases, patients harbouring spinal meningioma with severe preoperative deficits can expect a good outcome.     

The influence of preoperative administration of methotrexate on the outgrowth of meningiomas and astrocytomas in tissue culture

Summary Explants from 30 human meningiomas and 29 human malignant astrocytomas (i.e., glioblastomas multiforme) were grown in tissue culture for four weeks. After preoperative administration of 50 mg methotrexate (MTX) to the patients outgrowth of the meningiomas in tissue culture was markedly inhibited, but a similar effect was not seen for the astrocytomas.This study was supported by Koningin Wilhelmina Fonds under Grant N 75.30.     

NASS Contemporary Concepts in Spine Care: Spinal manipulation therapy for acute low back pain

Background context

Low back pain (LBP) continues to be a very prevalent, disabling, and costly spinal disorder. Numerous interventions are routinely used for symptoms of acute LBP. One of the most common approaches is spinal manipulation therapy (SMT).

Purpose

To assess the current scientific literature related to SMT for acute LBP.

Patient sample

Not applicable.

Outcome measures

Not applicable.

Design

Systematic review (SR).

Methods

Literature was identified by searching MEDLINE using indexed and free text terms. Studies were included if they were randomized controlled trials (RCTs) published in English, and SMT was administered to a group of patients with LBP of less than 3 months. RCTs included in two previous SRs were also screened, as were reference lists of included studies. Combined search results were screened for relevance by two reviewers. Data related to methods, risk of bias, harms, and results were abstracted independently by two reviewers.

Results

The MEDLINE search returned 699 studies, of which six were included; an additional eight studies were identified from two previous SRs. There were 2,027 participants in the 14 included RCTs, which combined SMT with education (n=5), mobilization (MOB) (n=4), exercise (n=3), modalities (n=3), or medication (n=2). The groups that received SMT were most commonly compared with those receiving physical modalities (n=7), education (n=6), medication (n=5), exercise (n=5), MOB (n=3), or sham SMT (n=2). The most common providers of SMT were chiropractors (n=5) and physical therapists (n=5). Most studies (n=6) administered 5 to 10 sessions of SMT over 2 to 4 weeks for acute LBP. Outcomes measured included pain (n=10), function (n=10), health-care utilization (n=6), and global effect (n=5). Studies had a follow-up of less than 1 month (n=7), 3 months (n=1), 6 months (n=3), 1 year (n=2), or 2 years (n=1). When compared with various control groups, results for improvement in pain in the SMT groups were superior in three RCTs and equivalent in three RCTs in the short term, equivalent in four RCTs in the intermediate term, and equivalent in two RCTs in the long term. For improvement in function, results from the SMT groups were superior in one RCT and equivalent in four RCTs in the short term, superior in one RCT and equivalent in one RCT in the intermediate term, and equivalent in one RCT and inferior in one RCT in the long term. No harms related to SMT were reported in these RCTs.

Conclusions

Several RCTs have been conducted to assess the efficacy of SMT for acute LBP using various methods. Results from most studies suggest that 5 to 10 sessions of SMT administered over 2 to 4 weeks achieve equivalent or superior improvement in pain and function when compared with other commonly used interventions, such as physical modalities, medication, education, or exercise, for short, intermediate, and long-term follow-up. Spine care clinicians should discuss the role of SMT as a treatment option for patients with acute LBP who do not find adequate symptomatic relief with self-care and education alone.     

Gamma knife radiosurgical management of petroclival meningiomas results and indications

Summary ¶Background. Surgical treatment of petroclival meningiomas remains challenging. In order to refine indications for the use of stereotactic radiosurgery in the treatment of these tumours, we retrospectively evaluated our experience in this field. Methods. Thirty-two patients harboring a petroclival meningioma were treated consecutively using a Gamma knife between December 92 and June 1998. Eight patients underwent radiosurgery after one or more attempted surgical removals and 24 had radiosurgery as the primary treatment. The main symptoms before radiosurgery were cranial nerve palsies, including a sixth nerve deficit in 10 patients and a trigeminal nerve disturbance in 9. All patients underwent a conformal multi-isocentric treatment (mean isocenters number 8.8) and the dose delivered at the tumour margin ranged from 10 to 15Gy (mean dose 13Gy). Findings. The duration of follow-up varied from 24 to 118 months (mean clinical follow-up 56 months, mean radiological follow-up 52.6 months). All 32 patients survived. The tumour volume remained unchanged in 28 patients and decreased slightly in 4. Neurological status worsened permanently in 2 patients with a delayed hemiparesis due to focal pontine infarction. These complications were associated with large meningiomas with vascular involvement and ventral brainstem compression, and occurred at the very early stage of our experience. At last follow-up, preoperative fifth or sixth cranial nerve deficits had improved or recovered in 13 out of 19 patients and any delayed worsening or new cranial nerve deficits were not observed after radiosurgery. Conclusions. Stereotactic radiosurgery with a Gamma knife provides effective management of small to middle sized petroclival meningiomas and is an alternative to microsurgery. Careful selection of patients and use of major technical refinements should improve the safety of this treatment.Published online September 26, 2003     

Spinal muscular atrophy: Classification, aetiology, and treatment of spinal deformity in children and adolescents

Spinal muscular atrophy is a hereditary neurological condition, which presents with symmetrical limb and trunk weakness. Spine deformity is the most frequent orthopaedic manifestation of the disease in patients who survive beyond the first year of life. Scoliosis in this group of severely disabled children decreases their sitting tolerance, causes pain from impingement of the ribs against the pelvis, affects ambulatory ability, and creates further respiratory compromise accelerating their death. Spinal arthrodesis is the only treatment that has a well-documented positive impact in restoring trunk balance and preserving function. This is associated with significant technical challenges and a high rate of life-threatening complications. A comprehensive review of the condition and a strategy for treating spinal deformity are presented in this paper.