Background: Meningiomas represent the commonest benign intracranial tumor and surgical resection is the first line treatment. Tumor recurrence after surgical resection is common. The aim of this study is to identify peri-operative predictors of meningioma recurrence following surgical resection Methods: This was a retrospective hospital-based study of all surgical cases between January 1990 and June 2014. Information regarding age, gender, peri-operative imaging parameters such as peri-tumoral edema or post-operative hemorrhage or residual, and grade were collected. Linear and volumetric measurements (of both tumor volume and volume of edema) were collected as well. Results: Overall, 464 patients were reviewed; n=154(34%) percent of patients were male. The grade distribution was: 296 (74.6%) were Grade I, 78 (19.6%) Grade II, and 23 (5.8%) Grade III. Post-operative tumor bed hemorrhage, noted in 119 (29.9%) of cases, and preoperative peri-tumoral edema volume were significant predictors of tumor recurrence following resection (P= 0.002 and 0.037, respectively). These parameters did not correlate with the MIB-1 index, tumour residual, grade of the tumour, or primary versus recurrent presentation. Conclusions: Pre-operative peri-tumoral edema and post-operative tumor bed hemorrhage are independent predictive of tumor recurrence. Identification of other molecular and/or radiological predictive of recurrence factors could add in our understanding of meningioma behavior.

Background: The impact of second surgery on recurrence remains unclear, with few definitive studies to date. This study sought to identify major predictors of survival after second surgery. Methods: A retrospective chart review was conducted for 21 patients who underwent elective surgery for GBM recurrence, at our institution, in the past 6 years. Kaplan Meier was applied to determine the significance of the variables on survival time. The Mann Whitney U test was used to determine whether the median survival time differed significantly between groups, for the factors of interest. Results: Among variables examined, age, less than ≥50 (P=0.04) was significant. Patients younger than 50, had a median survival period of 11.8 months, while patients, age 50 or older, survived a median time of 4.2 months. Though chemotherapy after reoperation was not found to statistically significantly extend survival time on Kaplan-Meier (P=0.08), the median survival time was found to be significantly higher in patients that received chemotherapy (10.6 months) after reoperation, compared with those who did not (3.9 months), using the Mann Whitney U test (P=0.05). Conclusions: These results confirm that younger patients survive longer after second surgery and indicate that a second round of chemotherapy may prolong survival.

Background: Gamma knife radiosurgery (GKR) is an effective treatment modality for local control of brain metastases. The predictors of response of cystic brain metastases (CBM) to GKR is not well understood. To measure progression and determine treatment prognostic factors, we quantified the percentage cystic and solid components of brain metastases before and after GKR treatment. Methods: 71 patients with CBM treated with GKR from 2006 to 2010 were selected from our institution’s database. Volumetric analysis was performed on MRIs done on treatment date and the latest MRI. Clinical data and dosimetry parameters were reviewed to identify factors that predicted a response of cystic component and overall tumour control. Results: Metastatic lesions from the lung had significantly larger cystic components (by volume) prior to GKR than metastasis of colorectal origin (p=0.039), and also had significantly larger cystic/total ratios than metastases from the breast (p=0.023). Post-treatment, a trend of >25% improvement in both cystic and solid components of tumours was seen in lung primaries (p=0.239). Metastatic brain tumours of colorectal origin demonstrated the best treatment response of the cystic component. Conclusion: The primary cancer pathology of the CBM has an effect on the response to GKR, and can be used as a prognosticator of changes in cystic and solid volumes of lesions.

Introduction: This study sought to determine the overall and disease-specific latency period for radiological appearance of new intracranial metastases for patients with metastatic involvement of the brain. Methods: A retrospective chart review of patients with intracranial metastases between 2008–2010 was conducted. For each patient, the following were recorded: cancer type, gender, age at diagnosis of primary cancer and first intracranial metastases, treatments (chemotherapy, whole-brain-radiotherapy (WBRT), radiosurgery), and latency period for radiological appearance of new intracranial metastases. Results: 137 patients with multiple metastatic tumors were included in our study. Majority (>90%) of patients received chemotherapy and WBRT. The latency periods for appearance of new metastases for different cancer types were (in months): breast 12.7, lung 11.3, colorectal 9.0, melanoma 6.6, renal cell 8.1, other 8.1. The overall average latency period was 10.1 months. There was no relation between latency period for new metastases and the following: age at diagnosis of metastases(p=0.174), age at treatment(p=0.199), and cancer type(p=0.124). The latency period for new metastatic lesions differed significantly between males (8.1 months) and females (11.7 months) (p=0.009). Conclusions: The average latency period for new metastases is approximately 10 months. Our data suggests that males develop new metastatic tumors at a faster rate.

Background: Intramedullary spinal cord metastasis (ISCM) are rare with primary lung, breast and melanoma accounting for up to 80% of cases. Diagnosis is often delayed or incorrect and these lesions can often be mistaken for primary astrocytoma or ependymoma given similar radiologic features. Methods: We present the case of an 80 year-old male with rapidly progressive quadriparesis and an enhancing intramedullary lesion at C4-7 with diffuse peri-lesional edema. The patient had previously undergone resection of non-metastatic esophageal carcinoma. Results: Bone scan revealed no evidence of skeletal or organ metastases. The patient underwent C5-7 laminectomy and resection of tumor with intra-operative monitoring. Final pathology revealed metastatic adenocarcinoma consistent with esophageal primary. PETCT revealed recurrent esophageal disease and pleural-based metastatic deposits. The patient went on to receive palliative radiotherapy to the cervicothoracic spine. Neurologic status improved marginally. Conclusions: ISCM from primary esophageal carcinoma is extremely rare. We present to our knowledge one of three reports of such in the literature. Hematogenous dissemination via Batson’s plexus and peri-veretebral plexuses is thought to be the likely route of spread. Treatment is primarily palliative, however surgical resection should be considered in the absence of metastatic disease.

Background: Gangliocytoma is a WHO grade 1 tumour which is typically found in the brain. Incidence of this pathology occurring in the spinal cord is rare, accounting for 0.1%-0.4% of intramedullary spinal cord tumors. Methods: We present the case of a previously healthy 23-year-old male with bilateral weakness and accompanying sensory deficits progressing over several months. Magnetic resonance imaging (MRI) of the spine showed a C3-C6 enhancing, intramedullary mass. C3-6 laminoplasty and resection of the tumour was preformed under neurophysiologic monitoring. Post-operatively the patient had no new neurologic deficits. Results: Final histopathology was consistent for gangliocytoma with extensive calcifications as confirmed by two separate neuropathologists. Gross total resection was not possible due to decreased motor evoked potentials detected by electrophysiologic monitoring. Post-operative MRI revealed a residual tumour measuring 58×15×25 mm with no further abnormal foci of enhancement. Conclusions: Gangliocytoma of the cervical cord is exceedingly rare, however its natural history is unclear. In our experience, maximal safe resection is warranted with the goal of preserving neurological status.

Paragangliomas are extra-adrenal neuroendocrine tumours that derive from neural crest. They are benign tumours in general but few cases had shown their tendency to metastasize. Malignant forms have been reported previously with intracranial metastasis from duodenal origin but primary intracranial origin represent a rare and unusual location for such tumours. We report a rare case for a 48 year old lady who presented with symptomatic right sided insular mass with negative metastatic work up. A complete surgical resection had been done with an unexpected diagnosis of primary gangliocytic paraganglioma with malignant features.

Background: Blood breakdown products such as bilirubin and bilirubin oxidation products damage cortex and white matter after intracerebral hemorrhage(ICH). Here, we tested whether albumin can antagonize axonal damage caused by bilirubin. Methods: The effect of albumin on white matter injury was investigated using brain slices in vitro. After CD-1 mice brain slices were cut using a vibratome, they were incubated in one of five solutions: artificial cerebral spinal fluid (ACSF), bilirubin ACSF, bilirubin and albumin ACSF, bilirubin ACSF that had albumin added 1 hour(h) later, and bilirubin and denatured albumin ACSF. All solutions were continuously aerated with 95% O2 and 5% CO2. Subsequently, electrophysiological recordings of axonal response to electrical stimulation were performed 8h after incubation of brain slices. Results: Bilirubin treatment profoundly damaged both myelinated and unmeylinated axons in brain slices, but had a greater effect on myelinated axons. Unmyelinated axons were found to be more susceptible to damage from denatured albumin. Albumin treatment at 0 h and 1 h significantly diminished bilirubin toxicity for both myelinated and unmyelinated axons, with 1 h delayed albumin treatment conferring greater neuroprotection. Conclusions: These results implicate the role of albumin in preventing bilirubin-induced axonal damage following ICH and its potential therapeutic value for hemorrhagic stroke.

Background: Studies in the literature suggest preoperative laboratory investigations and cross-match are performed unnecessarily and rarely lead to changes in clinical management. This study explored whether preoperative laboratory investigations in neurosurgical children alter clinical management and to determine the utilization of cross-matched blood perioperatively in elective pediatric neurosurgical cases. Methods: We reviewed patient charts for elective neurosurgery procedures (2010-2014) at our institution. Variables collected include preoperative complete blood count (CBC), electrolytes, coagulation, group and screen, and cross-match. Instances of altered clinical management as a consequence of preoperative investigation were noted. The number of cross-matched blood transfused perioperatively was also determined. Results: 477 electively scheduled pediatric neurosurgical patients were reviewed. Preoperative CBC was done on 294 and 39.8% had at least one laboratory abnormality. Electrolytes and coagulation panels were abnormal in 23.8% and 24.5% respectively. The preoperative investigations led to a change in clinical management in three patients, two of which were associated with significant past medical history. 57.9% had blood cross-matched and 3.6% of patients received perioperative blood transfusions. The cross-match to transfusion ratio was 16. Conclusion: This study suggests that the results of preoperative laboratory exams have limited value, apart from cases with oncology and complex pre-existing conditions. Additionally, cross-matching might be excessively conducted in elective pediatric neurosurgical cases.

Objective: The impact of spinal alignment on neurological recovery among myelopathy patients has not been thoroughly investigated. This study evaluated the impact of sagittal cervical alignment on neurological recovery in a prospective surgical series of myelopathy patients. Methods: Prospective data was analyzed from surgical CSM patients at a tertiary-care neurosurgical centre. Demographic data and clinical preoperative and postoperative measures of neurological disability (mJOA, Nurick, NDI scores) were analyzed for dependency on cervical spine imaging parameters. Results: Among 124 CSM patients, 34% exhibited kyphotic alignment. Surgical intervention was more frequently anterior or combined anterior/posterior among this group than those with preserved lordosis. Most patients exhibited postoperative neurological improvement for myelopathy severity, however the extent of this improvement was dichotomous based on preoperative sagittal alignment. Improvement was greater among patients with preoperative lordosis (ΔmJOA of 3.1) than those with preoperative kyphosis (ΔmJOA of 1.4, p=0.02). Surgical correction of spinal malalignment did not provide for heightened neurological recovery, although whether it protects against symptomatic adjacent segment disease is unclear. Conclusion: Most CSM patients showed postoperative neurological improvement. Patients with preoperative lordotic alignment exhibited greater improvement than those with preoperative kyphotic alignment. Neither correction of the spinal alignment nor surgical approach in this series specifically affected the extent of neurological recovery.

Objective: While acute disc-herniation radiculopathy frequently resolves without clinical sequelae, some patients experience long-term sensory or motor dysfunction. This study examined chronic sensitivity of the rodent hindpaw after resolution of an acute inflammatory neuropathy. Methods: C57BL/6 mice underwent mid-thigh sciatic nerve exposure, with sham animals exposed and experimental animals injured by placement of littermate tail nucleus pulposus (NP). Animals were evaluated for mechanical allodynia (Von Frey), thermal sensitivity (heat withdrawal and acetone latency), and gait stability (RotaRod), until the acute nociceptive phenotype resolved. Thereafter, animals were injected with intraplantar subthreshold capsaicin or vehicle followed by the same testing. At sacrifice, sciatic nerves were assessed for macrophage infiltration by immunohistochemistry, and dorsal root ganglion (DRG) explants were assessed for capsaicin sensitivity using cobalt staining. Results: NP-treated animals were allodynic after subthreshold capsaicin delivery compared with sham-operated controls and NP-treated animals delivered vehicle only. Early intraneural macrophage infiltration at one week dissipated by this three week timepoint. DRGs derived from NP-treated animals exhibited greater cobalt staining upon capsaicin exposure compared with shams. Conclusion: Non-compressive disc herniation creates long-term sensitization in the sciatic nerve distribution. This persists despite resolution of acute intraneural macrophage migration, and the demonstrated role of TRPV1 provides insight into the transformation of acute inflammatory pain into chronic neuropathic pain.

Background: Several studies have demonstrated that obese patients are at increased risk of perioperative complication during lumbar spine surgery. Herein we quantify the association between blood loss and obesity during lumbar fusion. Methods: Outcomes were collected in the setting of a single center randomized control trial conducted among patients undergoing elective lumbar fusion. A univariate analysis of potential risk factors (gender, age, body mass index [BMI], number of levels fused, previous use of anticoagulants, and previous use of non-steroidal anti-inflammatories) for operative blood loss was performed. Logistic regression was conducted to estimate adjusted odds ratios (ORs) and 95% confidence intervals. Results: Among 85 patients, the mean estimated blood loss (EBL) was 563 ml, 47.1% were male, and the median number of levels fused was one. Obesity (BMI ≥30−kg/m2) was a significant risk (OR 2.46, P=0.025) for increased blood loss (EBL > 500 ml). Number of levels fused was similarly associated with EBL (P<0.01) while gender confounded the association between obesity and EBL. Conclusions: Surgeons should anticipate greater blood loss when performing lumbar fusion in obese patients. To reduce operative morbidity, consideration should be given to preoperative weight loss whenever possible.

Anterior Cervical Discectomy and Fusion (ACDF) is the gold standard treatment for cervical spondylosis but there is a lack of consensus in the literature regarding which type of bone graft is superior: autograft or allograft. The purpose of this study is to evaluate fusion after ACDF using a stand-alone intervertebral cage packed with autologous cervical bone shavings acquired during the procedure. Twenty patients that underwent single-level ACDF from 2011 to 2014 using a stand-alone polyetheretherketone (PEEK) cage were recruited. Patients were evaluated for evidence of bone fusion by plain films and CT scan. Fusion was primarily assessed by grading the level of trabecular bridging bone across the bone-graft interface. Odom’s criteria were used to assess clinical outcome. All interbody disc spaces achieved successful fusion at follow-up. A total of 80% (16/20) of patients had radiographic evidence of trabecular bone present both within and around the cage. The other 20% exhibited bridging bone within the cage but had evidence of minor radiolucent gaps and lack of bridging bone completely surrounding the cage. Eighty percent of patients reported excellent/good clinical outcomes. ACDF using a PEEK stand-alone cage with autograft bone shavings has a high rate of fusion and avoids potential complications of classic autograft harvesting and decreased allograft fusion rates.

Background: Intrathecal morphine (ITM) is an efficacious method of providing post-operative analgesia. Despite adoption in many surgical fields, ITM has yet to become a standard of care in lumbar spine surgery. This may in part be attributed to concerns over precipitating a cerebrospinal fluid (CSF) leak following dural puncture. Methods: The dural sac is penetrated obliquely at a 30° angle to prevent overlap of dural and arachnoid puncture sites. Oblique injection in instances of limited dural exposure is made possible by introducing a 60° bend to a standard 30-gauge needle. Participating spinal surgeons were provided with brief instructions outlining the injection technique. Adherence and complications were collected prospectively. Results: The technique was applied to 98 cases of elective lumbar fusion at our institution. Two cases (2.0%) of non-adherence followed pre-injection dural tear. 96 cases of oblique ITM injection resulted in no attributable instances of post-operative CSF leakage. Two cases (2.1%) of transient, self-limited CSF leakage immediately following ITM injection were observed without associated sequelae or requirement for further intervention. Conclusions: Oblique dural puncture is not associated with increased incidence of post-operative CSF leakage. This safe and reliable method of delivery of ITM should be routinely considered in lumbar spine surgery.

Background: Surgical approaches to stabilize Type-II odontoid fractures include posterior atlantoaxial fixation (PAF) and anterior screw fixation (ASF). While ASF may theoretically allow for greater preservation of neck motion compared to PAF, there is a lack of evidence that one method preserves rotation and function better than the other. Methods: Single-centre study involving patients under 75 years old who underwent surgery for Type-II odontoid fracture. Following chart review, degree of neck rotation was assessed in patients using goniometric measurements. Participants completed questionnaires to investigate their perception of neck function and overall health (Neck Disability Index, Short Form-12, and EuroQol 5-D). Results: Patient recruitment is ongoing. To date, eleven patients have been reviewed (7 PAF, 4 ASF). Mean patient age was 61+/−12 years in the PAF group and 52+/−16 years in the ASF group. Measured neck rotation was lower in the PAF group compared to the ASF group (mean 58 vs. 110.5 degrees). However, the PAF group also reported fewer functional complaints. Conclusions: Preliminary data suggest that patients who receive ASF tend to be younger. While range of neck rotation is superior in ASF patients, their perception of functional ability does not correlate, suggesting that perceived neck function is multifactorial.

Background: Spinal infections are one of the most difficult, complex, and multi-disciplinary health conditions. The purpose of this paper was to gather demographic information of the patients with spinal infections and to identify factors that would influence their management. Methods: Retrospective chart review of 146 adult patients with osteomyelitis, discitis or epidural abscesses admitted to the Royal University Hospital, Saskatchewan, from 2007-2014. Results: Patient demographics included 59% male, 41% female, mean age 53 years. 36% of patients required surgery, 44% were IV drug users, and 71% were managed by surgeons. Presence of a neurological deficit, higher white blood cell count, and longer hospital admission, in relation to poor outcomes, were statistically significant. Higher age and shorter duration between onset of symptoms and admission showed a trend toward a poorer outcome. Epidural abscess and presence of a neurological deficit are variables isolated as being statistically significant in relation to need for surgery. 57.1% of patients with epidural abscess and 51.7% with neurological deficit required surgery. Conclusions: We were able to identify high-risk patients as to the need for surgery and poor outcome. Based on this information, we can better tailor our management strategy of this difficult condition.

Introduction: Degenerative disc disease (DDD) is a common cause of lower back pain. Calcification of the intervertebral disc (IVD) has been correlated with DDD. The role of IVD calcification in the development DDD is unknown. We noticed an increase in ionic calcium content and expression of the extracellular calcium-sensing receptor (CaSR) in the degenerate discs, however, its role in DDD remains unclear. Material and Methods: IVD Cells: Bovine and human NP and AF cells were incubated in culture media supplemented with various concentrations of calcium, and a CaSR agonist IVD Cultures: IVDs from bovine tails were isolated and the vertebral bone was removed. IVDs were cultured for 6 weeks in culture medium supplemented with calcium (1.0, 2.5, or 5.0 mM), or a CaSR agonist. Western blotting was performed on extracts to assess for aggrecan and Col II. Results: The expression of aggrecan and Col II decreased dose-dependently in both NP and AF cells, as well as in the organ culture model following supplementation with calcium or the CaSR agonist. Conclusion: Our results suggest that changes in the local concentrations of calcium are not benign, and that activation of the CaSR may be a contributing factor in IVD degeneration.

Background: Os odontoideum is a rare cervical abnormality that harbours a potential risk for atlantoaxial instability. In rare circumstances, synovial cysts may develop and compromise the spinal cord. Therefore, cyst excision has been suggested as part of the surgical management. However, in recent reports, it has been shown that atlantoaxial stabilization alone is sufficient for synovial cyst regression. Methodology: 48-year-old woman presented with symptoms and signs of cervical myelopathy secondary to os odontoideum with atlantoaxial instability. A large synovial cyst was diagnosed with significant spinal cord compression. In addition, her spinal and cranial imaging was suggestive of multiple sclerosis which was confirmed clinically thereafter with one episode of MS flare up and positive cerebrospinal fluid analysis. Results: After she had recovered from her MS flare up, posterior atlantoaxial instrumentation and fusion was performed without synovial cyst resection. Postoperatively, her clinical condition improved substantially and complete regression of the synovial cyst was noted on cervical MRI. Interestingly, she has not had any MS recurrent episodes after the surgery. Conclusion: Degenerative changes in os odontoideum are consequences of atlantoaxial instability. Compressive synovial cysts may develop with associated cord compression. We recommend posterior atlantoaxial stabilization alone in such conditions while preserving cyst fenestration or excision for persistent symptoms related to unresolved synovial cysts.