Predicting metalwork following posterior fixation of thoracolumbar fractures.

OBJECTIVES: Surgical fusion through posterior instrumentation and pedicle screw placement is a long established method for stabilising traumatic spinal fractures. Post-surgical complications include infection and metal work failure, the most common aetiology of which is pedicle screw fracture. Metal work failure rates vary from 15% to 60%. Research relating to factors which predict metal work failure in post-traumatic thoracolumbar spinal fixation is lacking. This study aimed to identify potential risk factors for metalwork failure in patients who had posterior fixation for traumatic thoracolumbar spine fractures. METHODS: This retrospective cohort analysis was conducted by interrogating the hospital database for neurosurgical post-traumatic thoracolumbar fixation cases between 2015 and 2018 with at least 2 years follow up. Data was collected through electronic medical notes and PACS. Nineteen different patient factors (gender, age, mechanism of injury, presence of concomitant injury spinal or extra-spinal injury, pedicle cross-sectional area, pedicle cancellous bone density, pedicle total bone density, vertebral body bone density, erector spinae muscle density and lumbar spine subcutaneous fat thickness, Charlson comorbidity index, fracture location, surgical approach, long/short segment fixation, whether decompression was done, whether the index level was fixed, and presence of wound infection) were compared. RESULTS: We identified 92 patients with 97 operations, and 9 cases of metal work failure. Two factors were statistically significantly associated with metal work failure: Post-operative wound infection (p = 0.029) and lumbar spine fat thickness (p = 0.024). The relative risk calculated in patients with a wound infection was 3.76. Lumbar spine fat thickness was on average 11.9 mm greater than patients not experiencing metal work failure. CONCLUSIONS: This study has identified two factors associated with increased rates of metal work failure: Post-operative wound infection and lumbar spine fat thickness. When assessing surgical candidates these factors may be incorporated into surgical planning.

A radiological study of the natural history of diffuse idiopathic skeletal hyperostosis (DISH): a story of incomplete fusion.

Introduction: DISH is an ankylosing disease, when fractured can be challenging to manage. A retrospective radiological study was conducted to evaluate the natural history and radiological characteristics of DISH on Computed tomography (CT).Methods: Paired CT scans with DISH that are separated at least two years apart were used to perform the following radiological measurements: Degree of disc space fusion, Osteophyte and vertebral body linear attenuation coefficients (LAC), and Osteophyte axial area size and location.Results: 164 patients were analysed with a mean duration of 4.49 years between scans. 38.14% (442/1159) of disc spaces had at least partial calcification. Most osteophytes were right sided before becoming more circumferential over time. The average fusion score was 54.17. Most of the changes in fusion occurred in the upper and lower thoracic regions. The thoracic region when compared to the lumbar region had a greater proportion of its disc spaced being fully fused. Disc level osteophyte areas were larger than Body level osteophytes. Disc osteophytes size growth rate drops over time from 10.89mm2/year in Stage 1 to 3.56mm2/year in Stage 3. Stage 3 disc spaces (-11.01HU/year) was also found to have had a reduction in their LAC over time when compared to Stage 1 disc spaces (17.04HU/year). This change in osteophyte LAC was not mirrored in the change in vertebral body LAC. We predict that the age of onset and complete thoracolumbar ankylosis of DISH to be 17.96 years and 100.59 years, respectively.Conclusion: DISH ankylosis of the spine a slow process that starts in the mid to lower thoracic region before extending cranially and caudally. After the bridging osteophyte has fully formed, remodelling of the osteophyte occurs.

Assessing the safety and learning curve of a neurosurgical trainee in performing a microvascular decompression (MVD).

Purpose: MVD is complex procedure when done safely can be effective in managing Trigeminal Neuralgia. Here we assess the safety and learning curve of a surgical trainee in performing a MVD. Methods: A retrospective analysis of patients who have undergone MVD by the trainee (07/2014-07/2017) and by the senior neurosurgeon (03/2011-04/2015). Data such as surgery time, length of stay, outcomes and complications were collected. Results: Out of the 18 cases of MVD were performed by the trainee, 10 were supervisor trainer unscrubbed (STU) or performed (P) and 8 were supervisor trainer scrubbed (STS). Mean surgical time was 2:30 hrs and mean length of stay was 6.33 days. The mean outcome score was 2.33/3 with 89% cases a positive outcome. The complication rate was 16.7%, of which one had meningitis, one had CSF leak and one developed a pseudomeningocele. The trainee's surgery time, outcomes and complication rates were comparable to trainer and the literature. There was a statistically significant correlation between number MVD performed and operative time (R = -0.50, p < .05), intervals between MVDs and complication rates (R = 0.64, p < .05), and interval between MVDs and outcome scores (R = -0.66, p < .05). We estimate the time between cases should be below 40 days. Conclusions: Training a trainee is safe and does not add much burden to the hospital. A trainee will benefit the most if they have the same supervisor at least for the first eight cases and that each case should be done within 40 days of each other.

Management of CSF leak in base of skull fractures in adults.

AIMS: CSF leaks are not uncommon after a base of skull fracture. Currently there is no standardised algorithm for the investigation and management of post-traumatic CSF leaks. In this paper we aim to provide an evidence-based framework for managing post-traumatic CSF leaks. METHODS: We searched the English literature over the past 45 years using CINAHL, EMBASE and MEDLINE for the terms (1) post-traumatic CSF leaks or fistulas, and (2) basilar or base of skull fractures, but excluded papers on post-operative and non-traumatic CSF leaks, and papers on paediatric post- traumatic CSF leaks. RESULTS: The diagnosis of a base of skull fracture and any resultant CSF leak can be challenging. Therefore a combination of biochemical and radiological studies are needed to optimise the diagnosis of this condition. Post-traumatic CSF leaks are generally treated conservatively, and a majority of them resolve without further surgical management. However for patients who are refractory to such treatments, surgical closure of the CSF fistula is necessary. Surgical obliteration of CSF leaks can be challenging and requires the involvement of multiple surgical specialties such as neurosurgery, otolaryngology, and maxillofacial surgery. CONCLUSION: Although we have formulated a simple algorithm to aid the investigation and management of post-traumatic CSF leaks, there are still many important unresolved questions requiring further well powered studies to answer.

Postpartum Regression of a Presumed Cavernous Meningioma.

Meningiomas are known to be more common in females than males. They are also known in rare cases to grow in size during pregnancy, which can complicate its management. We describe a 31-year-old Caucasian woman who presented with blurring of her vision and diplopia during the third trimester of her pregnancy. Magnetic resonance imaging (MRI) showed a small left cavernous sinus meningioma. The patient was treated conservatively until her uncomplicated delivery. A postpartum MRI scan showed complete regression of the suspected meningioma. Currently the patient is contemplating a further pregnancy.