Introduction: The management of thoraco-lumbar burst fractures remains controversial. Different a... more Introduction: The management of thoraco-lumbar burst fractures remains controversial. Different authors have advocated immobilisation, external bracing or internal fixation by either anterior or posterior approaches. Advocates of posterior fixation have in general performed stabilisation one level above and one level below the site of the fracture, resulting in fixation of two motion segments. It is known that multi-segmental spinal fusion produces undesirable biomechanics. To stabilise the site of the fracture and avoid unnecessary fixation of an uninjured segment the senior author (T.S.) for selected patients has been using a novel technique of monosegmental fixation with placement of pedicle screws directly into the fractured vertebral body. Methods: All patients with thoraco-lumbar burst fractures admitted to St Vincents and Concord Hospitals between January 2001 and October 2003 were considered for monosegmental fixation. Patients with severe osteoporosis or complete loss of vertebral body height (“vertebra plana”) were excluded. All patients underwent surgical decompression and fixation within 10 days of injury. Fixation was obtained with 4 titanium pedicle screws and a single transverse connector (Xia System Stryker Spine). Reduction of kyphotic deformity was carried out in selected patients. Average blood loss for the procedure was 250 ml with no patients requiring transfusion. All patients had a minimum of 6 months radiological and clinical follow-up. Results: Since January 2001, 18 patients with thoracolumbar burst fractures (T10-L2) were treated with single-level pedicle screw fixation. All patients were mobilised within 10 days of surgery. One patient experienced a minor superficial wound infection. There were no other postoperative complications. All patients had a stable fusion construct at 6 weeks following surgery. No patient experienced neurological deficit or have developed a delayed kyphotic deformity. There were no instances of instrument failure. 17 out of 18 patients report no significant back pain with any limitation of function by three months following surgery. One patient reports mild mechanical lower back pain 12 months following the injury. Discussion: Single level fixation for selected cases of thoracolumbar burst fracture is a safe and effective procedure to decompress the neural elements and obtain fixation and fusion of the fractured segment. It allows for rapid mobilisation and avoids a two-level fusion procedure with its subsequent detrimental effect on spinal biomechanics. It is considerably less invasive than anterior/lateral approaches which require extensive muscle dissection, rib removal and even diaphragmatic division.
The Journal of the Australasian College of Road Safety, Mar 1, 2012
ABSTRACT Introduction: Road trauma remains a leading cause of death and permanent disability. The... more ABSTRACT Introduction: Road trauma remains a leading cause of death and permanent disability. The authors investigated differences between road user groups, mortality rates and pattern of injuries. Methods: Data were prospectively collected on trauma presentations to the St George Public Hospital (SGH) from January 2002 to June 2008 (n=5118). Injury severity and patterns were evaluated using the Injury Severity Score (ISS), the New Injury Severity Score (NISS) and the Abbreviated Injury Score (AIS). Multiple regression analysis was used to analyse data. Results: Risk of death was 5 times higher for injured pedestrians than drivers (OR=5.0 95% C.I 2.97-8.57, p<0.001). Patients with head injuries had an increased risk of death compared to patients without head injuries (adjusted OR=6.04, 95% C.I. 3.79-9.64, p<0.0001). Conclusion: Vulnerable road users had a significantly higher mortality rate than other road users. These findings highlight the need for further research into factors contributing to pedestrian injury such as road design and pedestrian crossings
Pineal apoplexy is a rare clinical presentation of pineal parenchymal tumors. We report the curat... more Pineal apoplexy is a rare clinical presentation of pineal parenchymal tumors. We report the curative treatment of a case of pineal parenchymal tumor of intermediate differentiation with spontaneous apoplectic hemorrhage. This case is shown through computed tomography and magnetic resonance imaging of the brain, and is confirmed via histopathological studies. Recurrent upward gaze paresis was observed after the stereotactic biopsy. The paresis required an expeditious tumor resection. The mechanism of the pineal apoplectic hemorrhage remains unclear although it has been observed in different pineal region lesions. Clinical and radiological evidence of the cure 5 years post-surgery is available.
✓ A case of spinal epidural leiomyoma is reported in a 52-year-old man infected with the human im... more ✓ A case of spinal epidural leiomyoma is reported in a 52-year-old man infected with the human immunodeficiency virus (HIV). The tumor arose in the epidural region at the T-3 vertebral level, and the patient presented with radicular pain in the right T-3 dermatome. While soft-tissue tumors such as Kaposi's sarcoma and lymphomas have been well documented in association with HIV infection, this is the first reported case of primary spinal leiomyoma. Isolated cases of leiomyomas and leiomyosarcomas in unusual locations have been reported, notably in pediatric HIV-positive patients, perhaps indicating a causal relationship. This case may represent further evidence of such an association.
A 64-year-old lady was referred for investigation of longstanding neck pain. She had no evidence ... more A 64-year-old lady was referred for investigation of longstanding neck pain. She had no evidence of radiculopathy or myelopathy on history or examination. Her magnetic resonance imaging was unremarkable except for an anomalous right vertebral artery, traversing the right C6–C7 foramen (Figure). An intraforaminal vertebral artery has only been described in 0.6% of patients and may represent a rare cause of radiculopathy [1,2].
Conventional magnetic resonance imaging (MRI) is the technique of choice for diagnosis of cerebra... more Conventional magnetic resonance imaging (MRI) is the technique of choice for diagnosis of cerebral tumours, and has become an increasingly powerful tool for their evaluation; however, the diagnosis of common contrast-enhancing lesions can be challenging, as it is sometimes impossible to differentiate them using conventional imaging. Histopathological analysis of biopsy specimens is the gold standard for diagnosis; however, there are significant risks associated with the invasive procedure and definitive diagnosis is not always achieved. Early accurate diagnosis is important, as management differs accordingly. Advanced MRI techniques have increasing utility for aiding diagnosis in a variety of clinical scenarios. Dynamic susceptibility-weighted contrast-enhanced (DSC) MRI is a perfusion imaging technique and a potentially important tool for the characterisation of cerebral tumours. The percentage of signal intensity recovery (PSR) and relative cerebral blood volume (rCBV) derived from DSC MRI provide information about tumour capillary permeability and neoangiogenesis, which can be used to characterise tumour type and grade, and distinguish tumour recurrence from treatment-related effects. Therefore, PSR and rCBV potentially represent a non-invasive means of diagnosis; however, the clinical utility of these parameters has yet to be established. We present a review of the literature to date.
Multi-layer reconstruction has become standard in endoscopic skull base surgery. The inlay compon... more Multi-layer reconstruction has become standard in endoscopic skull base surgery. The inlay component used can vary among autografts, allografts, xenografts and synthetics, primarily based on surgeon preference. The short- and long-term outcomes of collagen matrix in skull base reconstruction are described. A case series of patients who underwent endoscopic skull base reconstruction with collagen matrix inlay were assessed. Immediate peri-operative outcomes (cerebrospinal fluid leak, meningitis, ventriculitis, intracranial bleeding, epistaxis, seizures) and delayed complications (delayed healing, meningoencephalocele, prolapse of reconstruction, delayed cerebrospinal fluid leak, ascending meningitis) were examined. Of 120 patients (51.0 ± 17.5 years, 41.7 per cent female), peri-operative complications totalled 12.7 per cent (cerebrospinal fluid leak, 3.3 per cent; meningitis, 3.3 per cent; other intracranial infections, 2.5 per cent; intracranial bleeding, 1.7 per cent; epistaxis, 1.7 per cent; and seizures, 0 per cent). Delayed complications did not occur in any patients. Collagen matrix is an effective inlay material. It provides robust long-term separation between sinus and cranial cavities, and avoids donor site morbidity, but carries additional cost.
Neuropathology and Applied Neurobiology, Dec 1, 2000
The aim of the study was to assess the relationship between the rate of clinical tumour growth an... more The aim of the study was to assess the relationship between the rate of clinical tumour growth and various histological features, including Ki67 labelling index, in skull base chordoma. Cases of skull base chordoma from 19 patients (six female, 13 male; age range 8–63 years) were reviewed and the diagnosis confirmed based on histological and immunohistochemical features. In each biopsy cellularity, pleomorphism, mitotic activity, apoptotic bodies, necrosis and inflammatory cell infiltrate were graded and Ki67 labelling index (LI) calculated as a measure of proliferation. Tumour doubling time was assessed by quantitative analysis of tumour volumes in post‐operative magnetic resonance images and correlated with age, sex, histological parameters and Ki67 LI. It was shown that increasing patient age, the presence of mitotic figures or a Ki67 LI in excess of 6% were associated with faster growing tumours.
Introduction: The management of thoraco-lumbar burst fractures remains controversial. Different a... more Introduction: The management of thoraco-lumbar burst fractures remains controversial. Different authors have advocated immobilisation, external bracing or internal fixation by either anterior or posterior approaches. Advocates of posterior fixation have in general performed stabilisation one level above and one level below the site of the fracture, resulting in fixation of two motion segments. It is known that multi-segmental spinal fusion produces undesirable biomechanics. To stabilise the site of the fracture and avoid unnecessary fixation of an uninjured segment the senior author (T.S.) for selected patients has been using a novel technique of monosegmental fixation with placement of pedicle screws directly into the fractured vertebral body. Methods: All patients with thoraco-lumbar burst fractures admitted to St Vincents and Concord Hospitals between January 2001 and October 2003 were considered for monosegmental fixation. Patients with severe osteoporosis or complete loss of ve...
Recurrence of trigeminal neuralgia following MVD poses a management challenge with no evidence-ba... more Recurrence of trigeminal neuralgia following MVD poses a management challenge with no evidence-based guidelines for treatment. Repeat MVD has been advocated for medically intractable cases . Repeat MVD has a lower rate of finding vascular compression than at initial surgery . Initial series of repeat MVD were associated with high complication rates prompting authors not to recommend repeat surgery . Percutaneous procedures such as glycerol or radiofrequency rhizotomy were instead initially favored, however recent series have reported good outcomes with repeat MVD .
Introduction: The management of thoraco-lumbar burst fractures remains controversial. Different a... more Introduction: The management of thoraco-lumbar burst fractures remains controversial. Different authors have advocated immobilisation, external bracing or internal fixation by either anterior or posterior approaches. Advocates of posterior fixation have in general performed stabilisation one level above and one level below the site of the fracture, resulting in fixation of two motion segments. It is known that multi-segmental spinal fusion produces undesirable biomechanics. To stabilise the site of the fracture and avoid unnecessary fixation of an uninjured segment the senior author (T.S.) for selected patients has been using a novel technique of monosegmental fixation with placement of pedicle screws directly into the fractured vertebral body. Methods: All patients with thoraco-lumbar burst fractures admitted to St Vincents and Concord Hospitals between January 2001 and October 2003 were considered for monosegmental fixation. Patients with severe osteoporosis or complete loss of vertebral body height (“vertebra plana”) were excluded. All patients underwent surgical decompression and fixation within 10 days of injury. Fixation was obtained with 4 titanium pedicle screws and a single transverse connector (Xia System Stryker Spine). Reduction of kyphotic deformity was carried out in selected patients. Average blood loss for the procedure was 250 ml with no patients requiring transfusion. All patients had a minimum of 6 months radiological and clinical follow-up. Results: Since January 2001, 18 patients with thoracolumbar burst fractures (T10-L2) were treated with single-level pedicle screw fixation. All patients were mobilised within 10 days of surgery. One patient experienced a minor superficial wound infection. There were no other postoperative complications. All patients had a stable fusion construct at 6 weeks following surgery. No patient experienced neurological deficit or have developed a delayed kyphotic deformity. There were no instances of instrument failure. 17 out of 18 patients report no significant back pain with any limitation of function by three months following surgery. One patient reports mild mechanical lower back pain 12 months following the injury. Discussion: Single level fixation for selected cases of thoracolumbar burst fracture is a safe and effective procedure to decompress the neural elements and obtain fixation and fusion of the fractured segment. It allows for rapid mobilisation and avoids a two-level fusion procedure with its subsequent detrimental effect on spinal biomechanics. It is considerably less invasive than anterior/lateral approaches which require extensive muscle dissection, rib removal and even diaphragmatic division.
The Journal of the Australasian College of Road Safety, Mar 1, 2012
ABSTRACT Introduction: Road trauma remains a leading cause of death and permanent disability. The... more ABSTRACT Introduction: Road trauma remains a leading cause of death and permanent disability. The authors investigated differences between road user groups, mortality rates and pattern of injuries. Methods: Data were prospectively collected on trauma presentations to the St George Public Hospital (SGH) from January 2002 to June 2008 (n=5118). Injury severity and patterns were evaluated using the Injury Severity Score (ISS), the New Injury Severity Score (NISS) and the Abbreviated Injury Score (AIS). Multiple regression analysis was used to analyse data. Results: Risk of death was 5 times higher for injured pedestrians than drivers (OR=5.0 95% C.I 2.97-8.57, p<0.001). Patients with head injuries had an increased risk of death compared to patients without head injuries (adjusted OR=6.04, 95% C.I. 3.79-9.64, p<0.0001). Conclusion: Vulnerable road users had a significantly higher mortality rate than other road users. These findings highlight the need for further research into factors contributing to pedestrian injury such as road design and pedestrian crossings
Pineal apoplexy is a rare clinical presentation of pineal parenchymal tumors. We report the curat... more Pineal apoplexy is a rare clinical presentation of pineal parenchymal tumors. We report the curative treatment of a case of pineal parenchymal tumor of intermediate differentiation with spontaneous apoplectic hemorrhage. This case is shown through computed tomography and magnetic resonance imaging of the brain, and is confirmed via histopathological studies. Recurrent upward gaze paresis was observed after the stereotactic biopsy. The paresis required an expeditious tumor resection. The mechanism of the pineal apoplectic hemorrhage remains unclear although it has been observed in different pineal region lesions. Clinical and radiological evidence of the cure 5 years post-surgery is available.
✓ A case of spinal epidural leiomyoma is reported in a 52-year-old man infected with the human im... more ✓ A case of spinal epidural leiomyoma is reported in a 52-year-old man infected with the human immunodeficiency virus (HIV). The tumor arose in the epidural region at the T-3 vertebral level, and the patient presented with radicular pain in the right T-3 dermatome. While soft-tissue tumors such as Kaposi's sarcoma and lymphomas have been well documented in association with HIV infection, this is the first reported case of primary spinal leiomyoma. Isolated cases of leiomyomas and leiomyosarcomas in unusual locations have been reported, notably in pediatric HIV-positive patients, perhaps indicating a causal relationship. This case may represent further evidence of such an association.
A 64-year-old lady was referred for investigation of longstanding neck pain. She had no evidence ... more A 64-year-old lady was referred for investigation of longstanding neck pain. She had no evidence of radiculopathy or myelopathy on history or examination. Her magnetic resonance imaging was unremarkable except for an anomalous right vertebral artery, traversing the right C6–C7 foramen (Figure). An intraforaminal vertebral artery has only been described in 0.6% of patients and may represent a rare cause of radiculopathy [1,2].
Conventional magnetic resonance imaging (MRI) is the technique of choice for diagnosis of cerebra... more Conventional magnetic resonance imaging (MRI) is the technique of choice for diagnosis of cerebral tumours, and has become an increasingly powerful tool for their evaluation; however, the diagnosis of common contrast-enhancing lesions can be challenging, as it is sometimes impossible to differentiate them using conventional imaging. Histopathological analysis of biopsy specimens is the gold standard for diagnosis; however, there are significant risks associated with the invasive procedure and definitive diagnosis is not always achieved. Early accurate diagnosis is important, as management differs accordingly. Advanced MRI techniques have increasing utility for aiding diagnosis in a variety of clinical scenarios. Dynamic susceptibility-weighted contrast-enhanced (DSC) MRI is a perfusion imaging technique and a potentially important tool for the characterisation of cerebral tumours. The percentage of signal intensity recovery (PSR) and relative cerebral blood volume (rCBV) derived from DSC MRI provide information about tumour capillary permeability and neoangiogenesis, which can be used to characterise tumour type and grade, and distinguish tumour recurrence from treatment-related effects. Therefore, PSR and rCBV potentially represent a non-invasive means of diagnosis; however, the clinical utility of these parameters has yet to be established. We present a review of the literature to date.
Multi-layer reconstruction has become standard in endoscopic skull base surgery. The inlay compon... more Multi-layer reconstruction has become standard in endoscopic skull base surgery. The inlay component used can vary among autografts, allografts, xenografts and synthetics, primarily based on surgeon preference. The short- and long-term outcomes of collagen matrix in skull base reconstruction are described. A case series of patients who underwent endoscopic skull base reconstruction with collagen matrix inlay were assessed. Immediate peri-operative outcomes (cerebrospinal fluid leak, meningitis, ventriculitis, intracranial bleeding, epistaxis, seizures) and delayed complications (delayed healing, meningoencephalocele, prolapse of reconstruction, delayed cerebrospinal fluid leak, ascending meningitis) were examined. Of 120 patients (51.0 ± 17.5 years, 41.7 per cent female), peri-operative complications totalled 12.7 per cent (cerebrospinal fluid leak, 3.3 per cent; meningitis, 3.3 per cent; other intracranial infections, 2.5 per cent; intracranial bleeding, 1.7 per cent; epistaxis, 1.7 per cent; and seizures, 0 per cent). Delayed complications did not occur in any patients. Collagen matrix is an effective inlay material. It provides robust long-term separation between sinus and cranial cavities, and avoids donor site morbidity, but carries additional cost.
Neuropathology and Applied Neurobiology, Dec 1, 2000
The aim of the study was to assess the relationship between the rate of clinical tumour growth an... more The aim of the study was to assess the relationship between the rate of clinical tumour growth and various histological features, including Ki67 labelling index, in skull base chordoma. Cases of skull base chordoma from 19 patients (six female, 13 male; age range 8–63 years) were reviewed and the diagnosis confirmed based on histological and immunohistochemical features. In each biopsy cellularity, pleomorphism, mitotic activity, apoptotic bodies, necrosis and inflammatory cell infiltrate were graded and Ki67 labelling index (LI) calculated as a measure of proliferation. Tumour doubling time was assessed by quantitative analysis of tumour volumes in post‐operative magnetic resonance images and correlated with age, sex, histological parameters and Ki67 LI. It was shown that increasing patient age, the presence of mitotic figures or a Ki67 LI in excess of 6% were associated with faster growing tumours.
Introduction: The management of thoraco-lumbar burst fractures remains controversial. Different a... more Introduction: The management of thoraco-lumbar burst fractures remains controversial. Different authors have advocated immobilisation, external bracing or internal fixation by either anterior or posterior approaches. Advocates of posterior fixation have in general performed stabilisation one level above and one level below the site of the fracture, resulting in fixation of two motion segments. It is known that multi-segmental spinal fusion produces undesirable biomechanics. To stabilise the site of the fracture and avoid unnecessary fixation of an uninjured segment the senior author (T.S.) for selected patients has been using a novel technique of monosegmental fixation with placement of pedicle screws directly into the fractured vertebral body. Methods: All patients with thoraco-lumbar burst fractures admitted to St Vincents and Concord Hospitals between January 2001 and October 2003 were considered for monosegmental fixation. Patients with severe osteoporosis or complete loss of ve...
Recurrence of trigeminal neuralgia following MVD poses a management challenge with no evidence-ba... more Recurrence of trigeminal neuralgia following MVD poses a management challenge with no evidence-based guidelines for treatment. Repeat MVD has been advocated for medically intractable cases . Repeat MVD has a lower rate of finding vascular compression than at initial surgery . Initial series of repeat MVD were associated with high complication rates prompting authors not to recommend repeat surgery . Percutaneous procedures such as glycerol or radiofrequency rhizotomy were instead initially favored, however recent series have reported good outcomes with repeat MVD .
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Papers by Timothy Steel