The endaural subtemporal keyhole: a novel minimally invasive approach to the middle cranial fossa.

OBJECTIVE: The goal of this study was to evaluate the feasibility of a minimally invasive approach to the middle cranial fossa using a novel endaural keyhole. METHODS: The charts of all patients who underwent this novel minimally invasive approach to the middle cranial fossa were retrospectively reviewed. In addition, cadaveric dissection was performed to demonstrate the feasibility of the endaural keyhole to the middle cranial fossa. RESULTS: Six patients (5 female and 1 male; age range 47-77 years) who underwent craniotomy for CSF leak (n = 3), intracerebral hematoma evacuation (n = 2), and tumor resection (n = 1) via the endaural subtemporal approach were identified. There were no approach-related complications noted. Representative imaging from cadaveric dissection is provided with a stepwise discussion of the procedure. CONCLUSIONS: The endaural subtemporal keyhole craniotomy provides a novel approach to middle fossa skull base pathology, as well as a minimally invasive approach to intra-axial pathology of the temporal lobe and basal ganglia. Further research is needed to establish the limitations and potential complications of this novel approach.

Tandem cranial and spinal cerebrospinal fluid leaks presenting with otogenic tension pneumocephalus: illustrative case.

BACKGROUND: Cranial and spinal cerebrospinal fluid (CSF) leaks are associated with opposite CSF fluid dynamics. The differing pathophysiology between spontaneous cranial and spinal CSF leaks are, therefore, mutually exclusive in theory. OBSERVATIONS: A 66-year-old female presented with tension pneumocephalus. The patient underwent computed tomography (CT) scanning, which demonstrated left-sided tension pneumocephalus, with an expanding volume of air directly above a bony defect of the tegmen tympani and mastoideum. The patient underwent a left middle fossa craniotomy for repair of the tegmen CSF leak. In the week after discharge, she developed a recurrence of positional headaches and underwent head CT. Further magnetic resonance imaging of the brain and thoracic spine showed bilateral subdural hematomas and multiple meningeal diverticula. LESSONS: Cranial CSF leaks are caused by intracranial hypertension and are not associated with subdural hematomas. Clinicians should maintain a high index of suspicion for intracranial hypotension due to spinal CSF leak whenever "otogenic" pneumocephalus is found. Close postoperative follow-up and clinical monitoring for symptoms of intracranial hypotension in any patients who undergo repair of a tegmen defect for otogenic pneumocephalus is recommended.

Campylobacter fetus seeding of a cavernous malformation resulting in brain abscess: case report and literature review.

Microbial seeding of a cerebral cavernous malformation is an extremely rare occurrence with only 3 cases reported in the literature thus far. Campylobacter fetus is an opportunistic pathogen that rarely causes neurological infection with only 3 cases of C. fetus cerebral abscesses and 38 cases of C. fetus meningitis reported in the literature. There have been no cases of cerebral cavernous malformation seeding by C. fetus reported to date. We report the first case of cerebral cavernous malformation seeding by C. fetus, a case occurring in a previously healthy 16-year-old female who presented with suspected left cerebellar cavernous malformation with subacute hemorrhage. She underwent a suboccipital craniectomy for the resection of the cavernous malformation with additional intraoperative findings suggestive of cerebral abscess. Following positive blood and CSF cultures and surgical pathology results, the patient was diagnosed with C. fetus meningoencephalitis with co-infected left cerebellar cavernous malformation. This is the fourth reported case of microbial seeding of a cerebral cavernous malformation, and to our knowledge, the first case of a C. fetus-infected cavernous malformation. Compared to previous reports, the clinical events of this case strongly support the presence of a preexisting lesion that was secondarily seeded versus de novo formation as a result of prior infection.

A Microcurrent Dressing Reduces Cutibacterium Acnes Colonization in Patients Undergoing Shoulder Arthroplasty or Arthroscopy: A Prospective Case Series.

Background: Cutibacterium acnes infections in the shoulder remain a significant concern in the setting of shoulder arthroplasty. Purpose: We sought to evaluate the efficacy of a microcurrent dressing in reducing C. acnes skin colonization and thereby reducing the risk of periprosthetic joint infection of the shoulder. Methods: This study was designed as a prospective case series. From October 2017 to February 2019, patients undergoing elective shoulder arthroplasty or arthroscopic shoulder surgery at a major academic medical center were offered enrollment; they signed an informed consent to participate. Patients under the age of 18, scheduled for revision shoulder arthroplasty, or with sensitivity or allergy to silver, zinc, or latex were excluded. Subjects underwent skin culture swab of the shoulder in the mid-point of the planned deltopectoral incision. The JumpStart (Arthrex; Naples, FL) microcurrent dressing was then placed over the area of the planned incision, and a full-thickness skin biopsy was harvested from the incision at the initiation of the surgical procedure. All specimens were cultured for C. acnes by the hospital's clinical microbiology laboratory with standard anaerobic technique. Results: Thirty-one subjects were enrolled in the study. Those who demonstrated no growth at baseline for the control specimen were excluded from further analysis (N = 11), given the absence of preoperative C. acnes colonization. Culture results from the 20 remaining subjects revealed significantly diminished C. acnes skin growth at the time of surgery compared to baseline. Sixty percent (12 of 20) of the subjects with positive skin swabs at baseline demonstrated no growth in the skin biopsy specimens at the time of surgery. There were no adverse events associated with the application of the microcurrent dressing. Conclusion: This prospective case series found that preoperative application of a microcurrent dressing resulted in significantly diminished C. acnes skin burden at the time of surgery in patients undergoing elective shoulder arthroplasty or arthroscopic shoulder surgery. Further study is warranted to investigate whether this preoperative intervention may contribute to a reduction in perioperative infections, including prosthetic joint infection.

Contralateral interhemispheric transfalcine approach to precuneal glioblastoma: fluorescein guided microsurgical resection and endoscopic microinspection tool.

Maximum safe resection remains a primary goal in the treatment of glioblastoma, with gross-total resection conveying additional survival benefit. Multiple intraoperative visualization techniques have been developed to improve the extent of resection. Herein, the authors describe the use of fluorescein and endoscopic assistance with a novel microinspection device in achieving a gross-total resection of a deep seated precuneal glioblastoma. An interhemispheric transfalcine approach was utilized and microsurgical resection was completed with fluorescein guidance. A 45° endoscope was then used to inspect the resection bed, and remaining areas of concern were then resected under endoscopic visualization. The video can be found here: https://stream.cadmore.media/r10.3171/2021.10.FOCVID21195.

In Vivo Static Retraction and Dynamic Elongation of Rotator Cuff Repair Tissue After Surgical Repair: A Preliminary Analysis at 3 Months.

Background: Rotator cuff repair is a common orthopaedic procedure that provides pain relief for many patients, but unfortunately, an estimated 20% to 70% of repair procedures will fail. Previous research has shown that elongation (ie, retraction) of a repaired tendon is common even in patients with a repair construct that appears intact on magnetic resonance imaging. However, it is unknown how this repair tissue functions under dynamic conditions. Purpose: To quantify static retraction and maximum dynamic elongation of repair tissue after rotator cuff repair. Study Design: Case series; Level of evidence, 4. Methods: Data from 9 patients were analyzed for this study. During surgery, a 3.1-mm tantalum bead was sutured to the supraspinatus tendon, medial to the repair site. Glenohumeral kinematics were assessed at 1 week (static) and 3 months (static and during scapular-plane abduction) after surgery using a biplanar videoradiographic system. The 3-dimensional position of the bead was calculated relative to the tendon's insertion on the humerus (ie, bead-to-insertion distance). Static retraction was calculated as the change in the bead-to-insertion distance under static conditions between 1 week and 3 months after surgery, and maximum dynamic elongation was calculated as the maximal positive change in the bead-to-insertion distance during dynamic motion relative to the start of motion. The magnitudes of static retraction and maximum dynamic elongation were assessed with 1-sample t tests. Results: At 3 months after surgery, static retraction occurred in all patients by a mean of 10.0 ± 9.1 mm (P = .01 compared with no elongation). During scapular-plane abduction, maximum dynamic elongation averaged 1.4 ± 1.0 mm (P < .01 compared with no elongation). Descriptively, dynamic elongation consistently took 1 of 2 forms: an initial increase in the bead-to-insertion distance (mean, 2.0 ± 0.6 mm) before decreasing until the end of motion or an immediate and substantial decrease in the bead-to-insertion distance at the onset of motion. Conclusion: Repair tissue elongation (static retraction and maximum dynamic elongation) appeared to be a common and significant finding at 3 months after arthroscopic rotator cuff repair. Dynamic elongation of repair tissue during scapular-plane abduction exhibited 1 of 2 distinct patterns, which may suggest different patterns of supraspinatus mechanical and neuromuscular function.

Multifocal metastases to choroid plexus from papillary thyroid carcinoma: illustrative case.

BACKGROUND: Choroid plexus metastases are extremely rare from all types of malignancy, with only 42 cases reported in the literature thus far. Most of these originate from renal cell carcinoma and present as a solitary choroid plexus lesion; only two cases of multifocal choroid plexus metastases have been reported to date. OBSERVATIONS: The authors report the third case of multifocal metastases to the choroid plexus, that of a 75-year-old man who developed three measurable choroid plexus lesions approximately 3.5 years after undergoing total thyroidectomy and chemotherapy for papillary thyroid carcinoma. He underwent intraventricular biopsy of the largest lesion and subsequently died of hydrocephalus after opting for comfort care only. LESSONS: This is the third case of multifocal choroid plexus metastasis in the literature and the second case of multifocal metastasis from thyroid carcinoma. As such, the natural disease course is not well characterized. This case is compared with the previous eight reports of choroid plexus metastases from thyroid carcinoma, seven of which involved solitary lesions. The eight prior cases are evaluated with attention to treatment modalities used and factors potentially influencing prognosis, specifically those that might contribute to hydrocephalus, a reported complication for this pathology.

The Use of Recombinant Human Growth Hormone to Protect Against Muscle Weakness in Patients Undergoing Anterior Cruciate Ligament Reconstruction: A Pilot, Randomized Placebo-Controlled Trial.

BACKGROUND: Anterior cruciate ligament (ACL) tears are common knee injuries. Despite undergoing extensive rehabilitation after ACL reconstruction (ACLR), many patients have persistent quadriceps muscle weakness that limits their successful return to play and are also at an increased risk of developing knee osteoarthritis (OA). Human growth hormone (HGH) has been shown to prevent muscle atrophy and weakness in various models of disuse and disease but has not been evaluated in patients undergoing ACLR. HYPOTHESIS: Compared with placebo treatment, a 6-week perioperative treatment course of HGH would protect against muscle atrophy and weakness in patients undergoing ACLR. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: A total of 19 male patients (aged 18-35 years) scheduled to undergo ACLR were randomly assigned to the placebo (n = 9) or HGH (n = 10) group. Patients began placebo or HGH treatment twice daily 1 week before surgery and continued through 5 weeks after surgery. Knee muscle strength and volume, patient-reported outcome scores, and circulating biomarkers were measured at several time points through 6 months after surgery. Mixed-effects models were used to evaluate differences between treatment groups and time points, and as this was a pilot study, significance was set at P < .10. The Cohen d was calculated to determine the effect size. RESULTS: HGH was well-tolerated, and no differences in adverse events between the groups were observed. The HGH group had a 2.1-fold increase in circulating insulin-like growth factor 1 over the course of the treatment period (P < .05; d = 2.93). The primary outcome measure was knee extension strength, and HGH treatment increased normalized peak isokinetic knee extension torque by 29% compared with the placebo group (P = .05; d = 0.80). Matrix metalloproteinase-3 (MMP3), which was used as an indirect biomarker of cartilage degradation, was 36% lower in the HGH group (P = .05; d = -1.34). HGH did not appear to be associated with changes in muscle volume or patient-reported outcome scores. CONCLUSION: HGH improved quadriceps strength and reduced MMP3 levels in patients undergoing ACLR. On the basis of this pilot study, further trials to more comprehensively evaluate the ability of HGH to improve muscle function and potentially protect against OA in patients undergoing ACLR are warranted. REGISTRATION: NCT02420353 ( ClinicalTrials.gov identifier).

Nonbiologic Injections in Sports Medicine.

Nonbiologic medications (local anesthetics, corticosteroids, and nonsteroidal anti-inflammatory drugs) are commonly administered to athletes for analgesia after injury. However, the risks of nonbiologic injections often are overlooked simply because of their long-term market availability. A thorough understanding of the mechanism of action, the reported benefits, and the potential risks of nonbiologic medications is crucial prior to their use, especially in the treatment of young athletes. Sports medicine physicians and surgeons must be aware of the systemic and local effects of these medications to ensure an appropriate drug choice that minimizes side effects and avoids recently reported toxicity to myocytes, tenocytes, and chondrocytes.

Headache, Chiari I malformation and foramen magnum decompression.

PURPOSE OF REVIEW: With increasing use of MRI, more patients are being diagnosed with Chiari I malformation (CM1), many of whom are asymptomatic. When symptoms are present, headache is the most frequent presenting feature, although symptoms can be variable. The purpose of this review is to help primary care clinicians better understand the relationship between an individual's presenting symptoms and the presence of radiographic CM1, and to describe the expected outcomes for patients who undergo decompression surgery. RECENT FINDINGS: Recent literature has shown that asymptomatic patients with CM1 tend to have a benign natural history. For symptomatic Chiari malformation, headache is the most common presenting symptom and the majority of patients that present with headache will have symptom improvement after foramen magnum decompression. This improvement is most reliable for patients with classic Chiari-type headache, which are described as occipital or cervical and tussive in nature, but has also been shown in patients with atypical headaches who have undergone surgery. SUMMARY: CM1 is a common radiographic finding and associated symptoms can be variable. The relevance of this finding to a particular patient and need for intervention must be made on an individual basis.

Contamination level and location of recreational freshwater influence the ability to predict Escherichia coli concentration by qPCR targeting Bacteroides.

Fecal bacteria are common microbial contaminants in freshwater with the potential to cause human illness. Detection of these microbes have traditionally relied on microbial plating to enumerate colonies of fecal indicator bacteria (FIB) such as Escherichia coli (E. coli), which can take 24 h or longer to complete. Quantitative PCR (qPCR) is a rapid and sensitive method for detection of FIB in recreational water that could compliment or potentially substitute for microbial plating. In this study, we have isolated DNA from the beach water on the shoreline at three different locations of Lake Erie and subjected these samples to qPCR to examine the relative abundance of Bacteroides. These values were compared to colony forming units (CFU) of E. coli. The resultant linear regressions between these different measurements of microbe concentration were used to determine the efficacy of qPCR targeting Bacteroides at predicting E. coli concentrations that are relevant for decision making by recreational water managers. Our findings indicate that the ability of Bacteroides to serve as an early predictive tool for E. coli CFU concentration depends on sample location and level of bacterial contamination, but can be used in some cases to supplement recreational water quality measurement and consequential management.

Correlation of shiga toxin gene frequency with commonly used microbial indicators of recreational water quality.

Shiga toxin (Stx) genes produce proteins that are pathogenic to humans, leading to severe gastrointestinal illness. This work focuses on examining the abundance and distribution of stx genes in relation to common microbial indicators in beach water and streams in the vicinity of Presque Isle State Park in Erie, PA. By use of quantitative PCR, the relative abundance levels of stx DNA in over 700 samples in the sampling area were determined. The results demonstrate that the abundance and distribution of stx genes are variable and do not correlate with the abundance of Escherichia coli bacteria, enterococci, or viral particles. These results suggest that microbial indicators of water quality are not adequate in predicting the occurrence of organisms that harbor stx genes and highlight the need for standardized pathogen-specific detection protocols for waters utilized for recreational swimming.