Migratory schwannoma of the cauda equina with a change in radicular pattern: illustrative case.

BACKGROUND: Intradural spinal tumors are an uncommon entity with a variety of pathologies and symptom patterns. Few cases reports in the literature have described tumor migration within the spinal canal. OBSERVATIONS: A 38-year-old male presented with bilateral upper lumbar radicular symptoms of anterior thigh pain, with an enhancing tumor of the cauda equina initially located at L1-2. He declined surgery initially, and at a follow-up 3 years later, his symptoms were unchanged but the tumor was now located at T12-L1. He again declined surgery, but 3 months later, he had a significant change in his pain distribution, which was now along his posterolateral right leg to his foot with associated dorsiflexion and extensor hallicus longus weakness. At this time, the tumor had migrated to L2-3. He underwent laminectomy and tumor resection with resolution of his radicular symptoms and improvement in his strength back to baseline by the 1-month follow-up. Pathology was consistent with a World Health Organization grade I schwannoma. LESSONS: Migratory schwannoma is a rare entity but should be considered when radicular symptoms acutely change in the setting of a known intradural tumor. Repeat imaging should be performed to avoid wrong-level surgery. Intraoperative imaging can also be used for tumor localization.

Patient perception of spinal cord injury through social media: An analysis of 703 Instagram and 117 Twitter posts.

Introduction: Social media has developed exponentially over the last decade as a means for individuals and patients to connect to others and has provided a unique opportunity for physicians to provide broader information to the general public to attempt to positively modify health behavior. The purpose of this study was to assess the patient's perception of spinal cord injury (SCI) on social media. Methods: Instagram and Twitter social media platforms were analyzed to determine posts written by patients with SCI. The initial search for Instagram posts tagged with "#spinalcordinjury" yielded over 270,000 posts in April 2021. Posts pertaining to the patient's experience were retrospectively collected from January 2020 to April 2021. Twitter posts that included "#spinalcordinjury," "@spinalcordinjury," and "spinal cord injury" were retrospectively collected in April 2021. One hundred seventeen tweets were found that were directly from a patient with SCI. Themes associated with patients' experiences living with SCI were coded. Results: The most common theme on Instagram was spreading positivity and on Twitter was the appearance of the wheelchair (75.8% and 37.3%, respectively). Other common themes on Instagram were the appearance of a wheelchair (71.8%), recovery or rehabilitation (29.9%), and life satisfaction (29.0%). Prevalent themes on Twitter included spreading positivity (23.2%) and recovery or rehabilitation (21.3%). Conclusion: The prevalence of themes of positivity and awareness may indicate the utilization of social media as a support mechanism for patients living with SCI. Identification of prevalent themes is important for the holistic treatment of SCI survivors.

Chasing the Cup: A Comprehensive Review of Spinal Cord Injuries in Hockey.

Ice hockey is a high-speed sport with a high rate of associated injury, including spinal cord injury (SCI). The incidence of hockey-related SCI has increased significantly in more recent years. A comprehensive literature search was conducted with the PubMed, Medline, Google Scholar, and Web of Science databases using the phrases "hockey AND spinal cord injuries" to identify relevant studies pertaining to hockey-related SCIs, equipment use, anatomy, and biomechanics of SCI, injury recognition, and return-to-play guidelines. Fifty-three abstracts and full texts were reviewed and included, ranging from 1983 to 2021. The proportion of catastrophic SCIs is high when compared to other sports. SCIs in hockey occur most commonly from a collision with the boards due to intentional contact resulting in axial compression, as well as flexion-related teardrop fractures that lead to spinal canal compromise and neurologic injury. Public awareness programs, improvements in equipment, and rule changes can all serve to minimize the risk of SCI. Hockey has a relatively high rate of associated SCIs occurring most commonly due to flexion-distraction injuries from intentional contact. Further investigation into equipment and hockey arena characteristics as well as future research into injury recognition and removal from and return to play is necessary.

The Validity of the Koos Classification System With Respect to Facial Nerve Function.

BACKGROUND: The Koos classification of vestibular schwannomas is designed to stratify tumors based on extrameatal extension and compression of the brainstem. Our prior study demonstrated excellent reliability. No study has yet assessed its validity. OBJECTIVE: To present a retrospective study designed to assess the validity of the Koos grading system with respect to facial nerve function following treatment of 81 acoustic schwannomas. METHODS: We collected data retrospectively from 81 patients with acoustic schwannomas of various Koos grades who were treated with microsurgical resection or stereotactic radiosurgery. House-Brackmann (HB) scores were used to assess facial nerve function and obtained at various time points following treatment. We generated Spearman's rho and Kendall's tau correlation coefficients along with a logistic regression curve. RESULTS: We found no significant difference in the presence or absence of facial dysfunction by Koos classification when looking at all patients. There was a positive but fairly weak correlation between HB score and Koos classification, which was only significant at the first postoperative clinic appointment. There was a statistically significant difference in the presence or absence of facial dysfunction between patients treated with surgery vs radiation, which we expected. We found no statistically significant difference when comparing surgical approaches. Logistic regression modeling demonstrated a poor ability of the Koos grading system to predict facial nerve dysfunction following treatment. CONCLUSION: The Koos grading system did not predict the presence of absence of facial nerve dysfunction in our study population. There were trends within subgroups that require further exploration.

Molecular and cellular intratumoral heterogeneity in primary glioblastoma: clinical and translational implications.

Glioblastoma (GBM), the most common primary malignant brain tumor in adults, is associated with significant morbidity and mortality despite maximal safe resection followed by chemo- and radiotherapy. GBMs contain self-renewing, tumorigenic glioma stem cells that contribute to tumor initiation, heterogeneity, therapeutic resistance, and recurrence. Intratumoral heterogeneity (ITH) of GBMs is also a major contributing factor to poor clinical outcomes associated with these high-grade glial tumors. Herein, the authors summarize recent discoveries and advances in the molecular and phenotypic characterization of GBMs with particular focus on ITH. In so doing, they attempt to highlight recent advances in molecular signatures/properties and metabolic alterations in an effort to clarify translational implications that may ultimately improve clinical outcomes.

Vertebral height restoration following kyphoplasty.

BACKGROUND: Kyphoplasty is a minimally invasive surgery developed to restore height and stabilize painful vertebral compression fractures (VCFs). Only small retrospective studies have addressed the correlation between the degree of vertebral height restoration as it relates to pain relief and postoperative activity levels. No definitive correlations have been established. The objective of this analysis is to determine how height restoration correlates with improvements in pain, disability and quality of life. METHODS: We assessed outcomes following kyphoplasty in 59 Medicare-eligible patients with 1-3 painful VCFs between T5 and L5 due to osteoporosis or cancer. Pre and postoperative lateral radiographs were available for fifty-nine patients and were used to measure anterior, middle and posterior vertebral body (VB) heights. The Visual Analog Scale (VAS) [range: 0 (none) to 10 (worst)] was used to prospectively measure back pain pre and post-operatively in all patients. Pre and post-operative measurements of disability and quality of life were retrospectively collected using the Roland Morris Disability Index (RMDI) [range: 0 (no disability) to 24 (high disability)] and EuroQol5-Domain scale (EQ5D) [range: -0.11 (poor quality of life) to 1.0 (perfect health)]. Pearson correlations and linear regression models were analyzed for association of VB height improvement with outcomes. RESULTS: Neither Pearson correlations (r coefficient range: 0.001-0.152) nor linear regression models (R2 value range: 0.0002-0.1133) revealed correlation or association between VB height improvements and outcomes. CONCLUSIONS: This is one of the largest studies to date assessing associations of VB height restoration following kyphoplasty with prospective measurements of pain and retrospective evaluation of disability and quality of life using validated instruments. Although a majority of patients in this cohort demonstrated increased vertebral heights and significant improvements in outcomes, none of the outcomes showed association with height improvements. Regardless of vertebral height improvements, most patients had improved pain, function and quality of life.

Whole blood aggregometry prior to Pipeline embolization device treatment of intracranial aneurysms: defining an optimal platelet inhibition cutoff value for clopidogrel.

OBJECTIVEDual antiplatelet therapy is required for the treatment of intracranial aneurysms with the Pipeline embolization device (PED). Platelet function testing (PFT) is often used to assess the efficacy of the antiplatelet regimen prior to PED placement. The optimal impedance values for whole blood aggregometry in this setting have not been defined.METHODSA retrospective review of a prospectively maintained database was performed for the years 2011-2015 to identify patients with intracranial aneurysms treated with the PED who underwent pretreatment PFT using whole blood aggregometry. Antiplatelet therapy was not altered based on PFT results; all patients remained on standard doses of aspirin and clopidogrel. Clinical, radiographic, and laboratory data were analyzed to identify the optimal cutoff impedance value for clopidogrel responsiveness using the receiver operating characteristic curve and Youden's index.RESULTSForty-nine patients underwent 53 endovascular procedures for the treatment of 76 aneurysms using the PED. The majority of these aneurysms were located in the anterior circulation (90.8%) and affected the internal carotid artery (89.5%). Patients in 30 procedures (56.6%) were identified as clopidogrel responders based on the manufacturer cutoff value (< 6 Ω). Thromboembolic complications occurred in 13 (24.5%) procedures; patients in 6 (11.3%) cases were symptomatic and those in 3 (5.7%) cases had ischemic strokes. Eleven of the 13 (84.6%) thromboembolic complications occurred in clopidogrel nonresponders. An impedance value of ≥ 6 Ω was independently associated with thromboembolic complications. The optimal electrical impedance value was identified as ≥ 6 Ω (sensitivity 84.6%, specificity 70.0%, area under the curve 0.77) for identifying clopidogrel nonresponders.CONCLUSIONSThromboembolic complications are more common following PED placement in patients who do not respond adequately to clopidogrel. Clopidogrel nonresponders can be identified using pretreatment whole blood aggregometry. The optimal cutoff value to categorize a patient as a clopidogrel nonresponder when using whole blood aggregometry is ≥ 6 Ω.

Prior video game utilization is associated with improved performance on a robotic skills simulator.

Laparoscopic surgery and robotic surgery, two forms of minimally invasive surgery (MIS), have recently experienced a large increase in utilization. Prior studies have shown that video game experience (VGE) may be associated with improved laparoscopic surgery skills; however, similar data supporting a link between VGE and proficiency on a robotic skills simulator (RSS) are lacking. The objective of our study is to determine whether volume or timing of VGE had any impact on RSS performance. Pre-clinical medical students completed a comprehensive questionnaire detailing previous VGE across several time periods. Seventy-five subjects were ultimately evaluated in 11 training exercises on the daVinci Si Skills Simulator. RSS skill was measured by overall score, time to completion, economy of motion, average instrument collision, and improvement in Ring Walk 3 score. Using the nonparametric tests and linear regression, these metrics were analyzed for systematic differences between non-users, light, and heavy video game users based on their volume of use in each of the following four time periods: past 3 months, past year, past 3 years, and high school. Univariate analyses revealed significant differences between heavy and non-users in all five performance metrics. These trends disappeared as the period of VGE went further back. Our study showed a positive association between video game experience and robotic skills simulator performance that is stronger for more recent periods of video game use. The findings may have important implications for the evolution of robotic surgery training.