C5 palsy following esophageal diverticulum resection.

Background: C5 palsy (C5P) is a recognized potential postoperative complication of cervical spine surgery but has rarely been reported following an open esophageal diverticulectomy. Methods: A 61-year-old underwent an open esophageal diverticulectomy for symptomatic Zencker's diverticulum. Results: Postoperatively, she presented with right upper extremity weakness and sensory deficits consistent with a C5P that was later confirmed by electromyography. Conclusion: The potential for C5P after esophageal diverticulectomy for symptomatic Zencker's diverticulum is rare. Postoperative recognition and appropriate management are critical to recovery.

Pseudogout mimicking cervical spine osteomyelitis and ventral epidural abscess: A case report and literature review.

Background: Calcium pyrophosphate deposition disease (CPPD), also known as "pseudogout," is a crystal deposition arthropathy involving the synovial and periarticular tissues. Pseudogout rarely presents in the axial spine. Here, we present the case of an 80-year-old female patient admitted after a mechanical fall, initially misdiagnosed on computed tomography (CT)/magnetic resonance studies with cervical osteodiscitis/ventral epidural abscess that proved to be pseudogout. Case Description: An 80-year-old female was admitted after a mechanical fall. The initial cervical CT scan showed multilevel degenerative changes with an acute C6 anterior wedge compression fracture, focal kyphosis, C5-6 disc space collapse, and endplate destruction. The magnetic resonance imaging showed marked contrast enhancement of the C5-6 vertebral bodies and disc space. An interventional radiology-guided biopsy of the C5-6 vertebral bodies and disc space was consistent with calcium pyrophosphate deposits, was diagnostic for pseudogout, and was negative for infection. She was managed conservatively with a rigid collar and seven days of oral prednisone. Conclusion: CPPD involvement in the axial spine is rare. Prompt pathologic diagnosis should be pursued to rule out an infectious process.

Thymoma metastatic to the epidural thoracic spine.

Background: Thymomas rarely metastasize to the spine. Here, we present a 69-year-old female diagnosed with stage IV thymoma, which subsequently developed a symptomatic epidural thoracic spinal lesion causing thoracic myelopathy. Case Description: The patient initially presented with paraspinal rib pain, lower extremity weakness, and gait imbalance. The magnetic resonance revealed a T10 vertebral body lesion with epidural extension causing severe spinal cord compression. A T9-T10 hemilaminotomy for tumor resection was performed; this was followed by adjuvant chemotherapy and radiation. Gross total resection was achieved, and the final pathology was metastatic thymoma. Postoperatively, the patient significantly improved. Conclusion: Metastatic thymomas to the thoracic spine are rare. For those presenting with epidural lesions causing myelopathy, surgical resection is beneficial and may be accompanied by adjunctive radiation and chemotherapy.

Recurrent Spontaneous Intracranial Hypotension (SIH) and the Durability of Repeat Epidural Blood Patch (EBP).

OBJECTIVE: Spontaneous intracranial hypotension (SIH) remains a rare and difficult clinical entity to diagnose and treat. Epidural blood patch (EBP) of the dural sac is the mainstay definitive treatment for refractory cases and has mixed efficacy. We sought to evaluate the recent efficacy and outcomes of EBP for SIH at our institution. METHODS: Twenty-three patients (14 women, 9 men, mean age 49) were seen and treated for SIH between Summer 2009 and Spring 2018 at the same institution. All patients underwent brain MRI with and without gadolinium contrast and T2-weighted spine MRI. Targeted EBP was placed one or two vertebral levels below areas of suspected leak, while the patient was positioned in the lateral decubitus position. Patients were seen in the outpatient setting within a week following initial EBP and repeat EBP was offered to patients with persistent symptoms. Patients were followed if symptoms persisted or for 6 months following clinical relief of symptoms. RESULTS: 22/23 (95.7%) patients presented with complaints of orthostatic headache, and 3 (13%) patients presented with altered mental status (AMS) or focal neurologic deficit. Brain MRI demonstrated pachymeningeal enhancement in 16/23 (69.6%) patients, and 5/23 (21.7%) patients had a subdural hematoma (SDH) present. Dural leaks were successfully identified in 18/23 (78.3%) patients. 12/23 (52.2%) patients had symptomatic relief with initial EBP, and 5/23 (21.7%) patients received further EBPs for persistent disease with all achieving relief after repeat EBP. 5/12 (41.7%) of patients had recurrent symptoms after initial relief with EBP, and 4/5 (80%) were successfully treated with a second EBP. The mean initial EBP volume and number of EBPs per patient were 21.7 mL (median 20 mL, 7-40 mL) and 3.54 (median 1, 1-13) respectively. There was one complication from initial EBP (cervical dural tear requiring operative closure) treated with open surgical management successfully. In total, 18/23 (78.2%) patients are currently asymptomatic with regard to their SIH. The mean follow-up in this cohort was 2.6 years (median 1.8 years, 1.8 months-9.27 years). CONCLUSIONS: EBP is a viable and effective option for the treatment of recurrent SIH caused by cerebrospinal fluid (CSF) leaks.

Scoping review of the risk factors and time frame for development of post-traumatic hydrocephalus.

Post-traumatic hydrocephalus (PTH) following traumatic brain injury (TBI) may develop within or beyond the acute phase of recovery. Recognition and subsequent treatment of this condition leads to improved neurologic outcomes. In this scoping review, we identify statistically significant demographic, clinical, radiographic, and surgical risk factors as well as a predictive time frame for the onset of PTH in order to facilitate timely diagnosis. Two researchers independently performed a scoping review of the PubMed and Cochrane databases for articles relevant to risk factors for PTH. Articles that met inclusion and exclusion criteria underwent qualitative analysis. Twenty-seven articles were reviewed for statistically significant risk factors and a proposed time frame for the onset of PTH. Variables that could serve as proxies for severe brain injuries were identified as risk factors. The most commonly identified risk factors included either very young or old age, intracranial hemorrhage including intraventricular hemorrhage, hygroma, and need for decompressive craniectomy. Although the timeframe for diagnosis of PTH varied widely from within one week to 31.5 months after injury, the first 50 days were more likely. Established risk factors and timeframe for PTH development may assist clinicians in the early diagnosis of PTH after TBI. Increased consistency in diagnostic criterion and reporting of PTH may improve recognition with early treatment of this condition in order to improve outcomes.

Correction to: Iatrogenic obstructive hydrocephalus resulting from Gelfoam accumulation within the cerebral aqueduct: a case report.

The original version of this article unfortunately contained an error. The authors apologize to have miss looked a typo of author name "Joseph Diver". The correct name is "Joseph Driver".

Abdominal Lymphocele Following Anterior Lumbar Interbody Fusion: A Case Report.

Anterior lumbar interbody fusion (ALIF) is commonly utilized for surgical management of degenerative lumbar pathology. Although it is a reasonably safe procedure, it can potentially lead to major complications in case of neurovascular injuries. Occurrence of lymphocele after an ALIF is however rare. We present a case of a rare abdominal lymphocele in a 56-year-old man who underwent L3-S1 ALIF and subsequently developed an abdominal lymphocele. A lymphocele can manifest in numerous ways which can affect and possibly delay diagnoses. In addition to a high index of suspicion, numerous tests such as imaging studies, fluid analysis, gram stain and culture are used to confirm the diagnosis. Various options exist for the treatment of lymphoceles, including laparoscopic marsupialization, ultrasound-guided aspiration, sclerotherapy, peritoneal window, and external drainage. Timely diagnosis and treatment of a lymphocele results in a successful resolution in most cases.

Full Recovery After a Bihemispheric Gunshot Wound to the Head: Case Report, Clinical Management, and Literature Review.

BACKGROUND: Nearly 33,600 people die each year in the United States as a result of gunshot wounds (GSWs). Penetrating craniocerebral GSWs are often fatal with a nearly 70% death rate at the scene of the trauma. Overall combined mortality rate for patients who die at the scene or at the hospital is almost 91%. Poor outcome is associated with initial low Glasgow Coma Scale score and bihemispheric and transventricular gunshot trajectory. We summarize current understanding in management, prognostic factors, and survival outcomes in patients with a penetrating GSWs to the head. We report a patient with return to full function despite bihemispheric, multilobar involvement. Full function is defined here as ability to return to previous work and perform activities of daily living. CASE DESCRIPTION: A 33-year-old man sustained a GSW to the head under unknown circumstances. On initial presentation, he had a Glasgow Coma Scale score of 15. He was verbalizing and communicating but was amnestic for the event. From a left frontal entry wound, the bullet traversed both frontal lobes of the brain reaching the right frontal-parietal junction. Physical examination and vital signs were normal. Appropriate surgical and medical management resulted in complete recovery. CONCLUSIONS: Craniocerebral GSWs have a high mortality rate and usually require aggressive management. Evaluation of most GSWs requires appropriate imaging studies followed by proactive treatment against infection, seizure, and increased intracranial pressure. Surgical intervention is often necessary and ranges from local wound débridement to craniectomy, decompression, and wound exploration.

The Effect of Keppra Prophylaxis on the Incidence of Early Onset, Post-traumatic Brain Injury Seizures.

OBJECTIVE: Traumatic brain injury (TBI) is a leading cause of long-term disability. Early onset post-traumatic seizures (PTS) after traumatic injury to the brain is a strong predictor of adverse outcomes in these patients. Our study investigates the role of Keppra in early PTS prophylaxis compared to no treatment, taking into account risk factors including injury severity, seizure history, and anti-epileptic drug (AED) use. METHODS: This was a retrospective cohort study based on patient chart data from January 2013 to January 2017 at a level one trauma center in the United States. A t-test was performed with P<0.05 as significant; we utilized a 95% confidence interval (CI) for our findings. Subgroup analysis was performed, with respect to the Glasgow Coma Scale (GCS) score (Group A: Mild GCS=13-15, Keppra N=135, Non-Keppra N=122; Group B: Moderate GCS=9-12, Keppra N=23, Non-Keppra N=19; Group C: Severe GCS= <8, Keppra N=69, Non-Keppra=35). RESULTS: Of 403 patients included in the study, 227 were given Keppra. Demographics between treatment groups were similar. Whole cohort analysis confirmed six patients with PTS, and no significant difference between groups (Keppra N=3, Non-Keppra N=3, OR=0.77, P=0.75, 95% CI=(0.154-3.87)). Subgroup analysis revealed reduction in seizure incidence in Keppra groups A (OR=0.18, P=0.27, 95% CI=(0.008-3.80)) and B (OR=0.82, P=0.92, 95% CI=(0.015-43.7)), but this reduction was not statistically significant. Those with the severe TBI in group C accounted for the majority of seizures (n=4, OR=1.52, P=0.71, 95% CI=(0.15-15.4)).  Conclusion: Patients with more severe TBI suffered a higher incidence of early-onset post-traumatic seizures. Data of the cohort as a whole revealed a trend towards a lower seizure incidence in patients who were treated with Keppra prophylaxis. Despite this trend, the decrease in seizure incidence did not reach statistical significance.

Iatrogenic obstructive hydrocephalus resulting from Gelfoam accumulation within the cerebral aqueduct: a case report.

The authors present the case of a previously healthy 12-year-old male with intractable seizures localized to a right frontal area of encephalomalacia and porencephalic cyst who underwent resection of the seizure focus. The surgical resection cavity extended into the right lateral ventricle, and due to encountered hemorrhage, Gelfoam was used for optimal hemostasis. The patient did well following the procedure, but presented 5 months later with headaches and emesis and was discovered to have obstructive hydrocephalus on imaging studies. Endoscopic third ventriculostomy (ETV) was performed, where Gelfoam was encountered in the third ventricle, obstructing the cerebral aqueduct. After the completion of the ETV, the patient did well and continues to be asymptomatic 1 year following the procedure.

Affinity of Mucormycosis for Basal Ganglia in Intravenous Drug Users: Case Illustration and Review of Literature.

Central nervous system mucormycosis is an aggressive fungal infection often ending in fatality. The usual circumstance is an immunocompromised individual presenting with rapidly progressive rhinocerebral involvement. An extremely rare variant of central nervous system mucormycosis isolated to the basal ganglia in an immunocompetent intravenous drug user is detailed in this manuscript. The patient was aggressively treated with aspiration of the fungal abscess and long-term intravenous antifungal agents.

Treatment of Penetrating Nonmissile Traumatic Brain Injury. Case Series and Review of the Literature.

INTRODUCTION: Penetrating traumatic brain injuries (TBIs), with the exception of gunshot wounds, are relatively rare occurrences and affect all ages. Clinical presentation varies depending on the mechanism of the injury. Prompt surgical treatment is often indicated and is influenced by patient clinical examination, anatomic trajectory, and the penetrating object's size, shape, and velocity. METHODS: We present 3 cases of penetrating TBI. Their similarities and differences affecting operative and medical management are compared. We relate our experience with management of penetrating intracranial foreign bodies in general and discuss the relevant literature. RESULTS: Our first case was a 12-year-old male who presented with a self-inflicted transfacial transcranial injury by a crossbow. The arrow passed through the left sphenoid and cavernous sinus and exited through the parietal calvarium. Our second case was a 37-year-old man with a transoral intracranial stab wound by a knife. In our third case, we present a 46-year-old male who accidentally fired a nail gun into his right ear. The nail traversed the posterior wall of the external auditory canal into the posterior fossa, ending in the cerebellar vermis. Each case was treated with craniotomy and foreign body removal. All resulted in good outcomes after surgical treatment. CONCLUSION: Surgery in penetrating TBI is the treatment of choice. Our cases demonstrate how certain principles applied to individual patient scenarios may optimize clinical results. Severity of the injury and operative approach are among the most important considerations to achieve the best patient outcomes.

Refractory Thoracolumbar Cerebrospinal Fluid Leak after Multiple Spinal Ependymoma Resections Treated with External Ventricular Drainage.

Study Design Case report. Objective Temporary external ventricular drainage for refractory thoracolumbar cerebrospinal fluid (CSF) leak is not reported in the literature. We describe a recent case that utilized this technique. Methods Retrospective review of the patient's case notes was performed and the literature on this subject reviewed. Results The patient underwent multiple complex spinal surgeries for resection of innumerable metastatic ependymoma lesions. A case of significant refractory CSF leak developed and as a last resort a right frontal external ventricular drain was placed. The CSF leak ceased, and the patient was eventually discharged home without further complication. Conclusion External ventricular drainage can be a viable option for temporary proximal CSF diversion to treat refractory thoracolumbar CSF leaks.