Spinal Fractures during Touristic Motorboat Sea Cruises: An Underestimated and Avoidable Phenomenon.

PURPOSE: Each summer, many vacationers enjoy the Mediterranean Sea shores. Among the recreational nautical activities, motorboat cruise is a popular choice that leads to a significant number of thoracolumbar spine fractures at our clinic. This phenomenon seems to be underreported, and its injury mechanism remains unclear. Here, we aim to describe the fracture pattern and propose a possible mechanism of injury. METHODS: We retrospectively reviewed the clinical, radiological, and contextual parameters of all motorboat-related spinal fracture cases during a 14-year period (2006-2020) in three French neurosurgical level I centers bordering the Mediterranean Sea. Fractures were classified according to the AOSpine thoracolumbar classification system. RESULTS: A total of 79 patients presented 90 fractures altogether. Women presented more commonly than men (61/18). Most of the lesions occurred at the thoracolumbar transition region between T10 and L2 (88.9% of the levels fractured). Compression A type fractures were seen in all cases (100%). Only one case of posterior spinal element injury was observed. The occurrence of neurological deficit was rare (7.6%). The most commonly encountered context was a patient sitting at the boat's bow, without anticipating the trauma, when the ship's bow suddenly elevated while crossing another wave, resulting in a "deck-slap" mechanism hitting and propelling the patient in the air. CONCLUSIONS: Thoracolumbar compression fractures are a frequent finding in nautical tourism. Passengers seated at the boat's bow are the typical victims. Some specific biomechanical patterns are involved with the boat's deck suddenly elevating across the waves. More data with biomechanical studies are necessary to understand the phenomenon. Prevention and safety recommendations should be given before motorboat use to fight against these avoidable fractures.

Resection of ruptured spinal pial arteriovenous fistula under ultrasound control: how I do it.

BACKGROUND: Spinal pial arteriovenous fistulae are rare intradural superficial vascular lesion consisting in a direct shunt between spinal pial arteries and veins. The presentation of pial arteriovenous fistula is caused by venous congestion with spinal cord ischemia, mass effect, or hemorrhage. The treatment is surgery or endovascular procedure. METHODS: We illustrate the case of thoracic pial arteriovenous fistula in a 66-year-old female operated with posterior midline approach and B-mode US. CONCLUSION: Posterior midline approach with targeted laminotomy using high-speed drill affords an ideal surgical exposure. B-mode US is helpful to detect the fistula and study their relationship with the surrounding structures.

Endoscopic resection of a low-grade ependymoma of the pineal region.

BACKGROUND: Full endoscopic resection of solid brain tumors represents a challenge for neurosurgeons. This can be achieved with modern technology and advanced surgical tools. CASE DESCRIPTION: A 23-years-old male was referred to our unit with raised intracranial pressure. Head computed tomography and magnetic resonance imaging (MRI) revealed obstructive hydrocephalus and a third ventricle lesion. Endoscopic third ventriculostomy and biopsy were performed, a left frontal external ventricular drain was left in place. A second-look surgery for endoscopic removal was planned. Decision to proceed with an endoscopic removal was supported by the following characteristics found during the first surgery: tumor exophytic, soft texture, scarce vascularity, and low-grade appearance. A rescue strategy for microscopic resection via transcallosal approach was decided. A straight trajectory to the tumor was planned with navigation. A further anterior left frontal burr-hole was performed, and the ventricular system was entered via the left frontal horn. Resection was carried out alternating laser for hemostasis and cutting, endoscopic ultrasonic aspirator, and endoscopic forceps for piecemeal resection. Laser hemostasis and cutting (1 Watt power at tip, continuous wave mode) were useful at the ventricular wall-tumor interface. Relevant landmarks guided the approach and the resection (foramen of Monro, mammillary bodies, aqueduct, pineal and suprapineal recess, and posterior commissure). The surgery was carried uneventfully. Histopathology confirmed a lowgrade ependymoma. Post-operative MRI showed residual tumor within the lower aqueduct. At 3 years follow-up, residual tumor is stable. CONCLUSION: In selected cases, endoscopic resection for third ventricular tumors is feasible and safe, and represents a valid alternative to microsurgical approaches.

Isolated subarachnoid hemorrhage in mild traumatic brain injury: is a repeat CT scan necessary? A single-institution retrospective study.

BACKGROUND: Traumatic brain injury (TBI) with isolated subarachnoid hemorrhage (iSAH) is a common finding in the emergency department. In many centers, a repeat CT scan is routinely performed 24 to72 h following the trauma to rule out further radiological progression. The aim of this study is to assess the clinical utility of the repeat CT scan in clinical practice. METHODS: We reviewed the medical charts of all patients who presented to our institution with mild TBI (mTBI) and isolated SAH between January 2015 and October 2017. CT scan at admission and control after 24 to 72 h were examined for each patient in order to detect any possible change. Neurological deterioration, antiplatelet/anticoagulant therapy, coagulopathy, SAH location, associated injuries, and length of stay in hospital were analyzed. RESULTS: Of the 649 TBI patients, 106 patients met the inclusion criteria. Fifty-four patients were females and 52 were males with a mean age of 68.2 years. Radiological iSAH progression was found in 2 of 106 (1.89) patients, and one of them was under antiplatelet therapy. No neurological deterioration was observed. Ten of 106 (9.4%) patients were under anticoagulation therapy, and 28 of 106 (26.4%) were under antiplatelet therapy. CONCLUSION: ISAH in mTBI seems to be a radiological stable entity over 72 h with no neurological deterioration. The clinical utility of a repeat head CT in such patients is questionable, considering its radiation exposure and cost. Regardless of anticoagulation/antiplatelet therapy, neurologic observation and symptomatic treatment solely could be a reasonable alternative.

How I do it: mini invasive transforaminal lumbar interbody fusion.

BACKGROUND: Minimally invasive approaches for lumbar fusion are aimed at reducing soft tissue injury in order to minimize surgical morbidity and facilitate recovery. METHOD: Applied to lumbar fusion, such an approach is described as a mini-open transforaminal lumbar interbody fusion (TLIF). Important anatomical landmarks are reviewed. Indications, advantages, and limitations are discussed, and a step-by-step description of the procedure is presented. RESULTS: Decompression, fixation, and bone grafting can be achieved efficiently through this approach with lesser blood loss, shorter hospital stay, reduced rate of general complications, and infections as well as a lower readmission rate. CONCLUSION: The mini-open TLIF technique, as presented here, is a safe and efficient procedure to achieve lumbar fusion with a reduced rate of complications related to surgery.