Time of Surgery in the Outcome of Cervical Spinal Cord Injury: the University of Puerto Rico Experience.

OBJECTIVE: The purpose of this study was to determine the effect of the timing of surgery on the neurological function of patients with a cervical spinal cord injury. METHODS: Retrospectively, an analysis was done of patients who underwent decompression and/or spinal cord stabilization surgeries from 2010 through 2014 for cervical trauma. All patients were older than 18 years of age, had had surgery at our facility, and had made at least 1 follow-up visit. American Spinal Injury Association (ASIA) Impairment Scale (AIS) scores were compared for patients who underwent early surgeries (less than 72 hours after trauma) and for those who underwent late surgeries (more than 72 hours after trauma). RESULTS: There were a total of 107 patients. Sixty-two patients had spinal cord injuries. The average age was 38.6 years, and 84% of the participants were male. The most common mechanism of trauma was motor vehicle accident. Twenty-nine percent of the patients developed neurogenic shock and 27% experienced respiratory failure during the first week after admission. Seventeen patients died during the study period. A multivariate analysis of AIS score improvement revealed that the only significant factor was incomplete neurological injury. There was no significant difference in the percentage of patients that improved with early surgery compared to that of those that improved after late surgery. CONCLUSION: Traumatic cervical spinal cord injury is associated with high mortality and morbidity. Early surgery was not associated with an improved neurological outcome at long-term follow-up. The benefit of early surgery was seen only in terms of decreasing each patient's length of hospital stay.

Circumferential Stabilization of the Thoracolumbar Junction Via Posterior-Only Approach for the Management of Burst Fractures.

OBJECTIVE: The management of thoracolumbar burst fractures often includes combined anterior/posterior approaches with prolonged operative time and complications. The transpedicular approach offers a posterior only approach with circumferential reconstruction and decompression. We aim to present the experience of a single center in the management of thoracolumbar burst fractures using a posterior-only approach for circumferential stabilization and report on this technique's effectiveness in restoring the alignment of the thoracolumbar junction. METHODS: A case review of the medical records of patients admitted to the adult neurosurgery service (from January 2011 through June 2014) with traumatic non-pathological thoracolumbar burst fractures and subsequently treated with a transpedicular corpectomy (including the placement of an expandable cage) was performed, retrospectively. RESULTS: A total of 20 patients underwent a posterior transpedicular corpectomy consisting of anterior column reconstruction using an expandable cage with supplementary posterior fixation within 72 hours of injury. The average pre-operative canal compromise was 69%. The average pre-operative kyphotic angle was 21.6°. The average post-operative kyphotic angle was 5.15°, with an average correction of 16.45°. There were 11 patients with pre-operative neurological compromises, of which patients, 8 experienced variable degrees of recovery. The average operating time was 410.5 minutes (range, 240-550 min). The average blood loss was 880 mL (range, 650-1500). Three patients experienced complications during surgery; 1 patient died. CONCLUSION: The transpedicular approach for circumferential reconstruction and stabilization provides an alternative technique for the management of thoracolumbar fractures, having an acceptable risk and the associated lower morbidity of a posterioronly approach.

Chordoid Glioma with Psychosis: Case Report.

OBJECTIVE: A rare, low-grade tumor found in the hypothalamus and anterior third ventricle, a chordoid glioma presents a challenge to neurosurgeons: Its successful resection is complicated by its inconvenient location. CASE DESCRIPTION: A 42-year-old male patient presented with a 1-year history of major depressive disorder, with psychotic features associated with generalized tonic-clonic seizures. Brain magnetic resonance imaging (MRI) with contrast revealed a suprasellar mass extending into the third ventricle To resect the lesion, an interhemispheric transcallosal transventricular subfornical approach was used. Pathology revealed a chordoid glioma. The patient had a complicated post-operative period that included the development of neurogenic diabetes insipidus, followed by intractable hyponatremia and death (caused by malignant brain edema). CONCLUSION: A chordoid glioma is a rare neoplasm that, in 2000, was incorporated into the World Health Organization (WHO) classification of central nervous system tumors. Due to its rarity, it is seldom considered in the differential diagnosis of suprasellar masses. Moreover, its unusual presentation and difficult location present a challenge for surgical and medical management.

An uncommon presentation of follicular thyroid carcinoma: when chronic back pain should raise a flag.

Follicular thyroid carcinoma is the second most common type of thyroid cancer, and its incidence has increased dramatically in recent years. Although it typically presents as a thyroid nodule, it can spread to distant sites via hematogenous dissemination. Bone metastasis is diagnosed clinically in 2%-13% of patients with differentiated thyroid cancer; nevertheless spinal cord compression complicating thyroid carcinoma is rare and only few cases has been reported in the literature. This case illustrates a strange case of a minimally invasive follicular carcinoma that showed an aggressive behavior, and thus the importance of considering metastatic thyroid carcinoma in the differential diagnosis of chronic back pain progressing to spinal cord compression carrying a severe morbidity.

UNCOMMON PRESENTATION OF FOLLICULAR THYROID CARCINOMA: WHEN CHRONIC BACK PAIN SHOULD RAISE A FLAG.

Follicular thyroid carcinoma is the second most common type of thyroid cancer, and its incidence has increased dramatically in recent years. Although it typically presents as a thyroid nodule, it can spread to distant sites via hematogenous dissemination. Spinal cord compression complicating thyroid carcinoma is rare with only few cases reported in the literature. This case illustrates a minimally invasive follicular carcinoma that showed such an aggressive behavior, and thus the importance of considering metastatic thyroid carcinoma in the differential diagnosis of chronic back pain, which may possibly progress to spinal cord compression carrying severe morbidity.

Acute adrenal insufficiency in cervical spinal cord injury.

BACKGROUND: Adequate adrenal response is fundamental for the maintenance of physiological homeostasis in the setting of trauma and severe illness. Patients with neurogenic shock are at risk of severe consequences if adrenal insufficiency (AI) is not rapidly identified and treated. OBJECTIVE: To analyze the incidence of AI in patients with acute cervical spinal cord injury and its effect on in-hospital complications. METHODS: The medical records of patients older than 18 years who were admitted to the adult neurosurgery service at the University District Hospital as the result of neurogenic shock after acute cervical spinal cord injury from January 2004 to December 2009 were reviewed retrospectively. RESULTS: One hundred ninety-nine patients were admitted with acute cervical spinal cord injury. A total of 37 patients met the pre-established criteria for neurogenic shock. The incidence of AI in patients with neurogenic shock was 22%. The average random cortisol was 9.3 µg/dL in patients with AI versus 29.2 µg/dL in non-AI. The presence of AI was positively correlated with complications and an increase in the risk of intubation (P = 0.01 and P = 0.002). The 30-day mortality rate in patients with AI was 13% compared with the 3% in the non-AI group (P = 0.39). CONCLUSIONS: Adrenal insufficiency is a poorly recognized complication in patients with acute cervical spinal cord injury and its aggressive treatment is of utmost importance to avoid further neurological injury.

Fibrotendinous band causing neurogenic Thoracic Outlet Syndrome in adolescent with bilateral cervical ribs.

Thoracic Outlet Syndrome (TOS) describes a variety of symptoms caused by the compression of the neurovascular structures in the cervicoaxillary region as they leave the thorax toward the upper limbs. Causes of TOS are vascular and neurogenic, with neurogenic symptoms being the most common presentation (95% of patients). Symptoms related to neurogenic TOS include intrinsic hand muscle and thenar region atrophy and weakness, as well as medial hand and forearm numbness, which are all suggestive of lower trunk involvement. This condition is very rare in the pediatric population. We are reporting a case of true neurogenic TOS caused by a fibrotendinous band in an adolescent with bilateral cervical ribs who was submitted for surgical treatment at the right side.

Pediatric brain tumors in Puerto Rico.

OBJECTIVE: To determine the frequency of pediatric brain tumors treated at the University Pediatric Hospital of Puerto Rico over a 6-year period and examine the demographic data and tumor histology of patients in different age groups. METHODS: A retrospective study was undertaken at the University Pediatric Hospital. We included patients with brain tumors that had been newly diagnosed during the period covering from January 2002 to December 2007. All cases were analyzed by age, gender, histologic diagnosis, and affected area. RESULTS: One hundred thirty-six patients were included in the study. Overall, males were more frequently affected than were females. Children in the 1 to 4 years old age group had the highest number of newly diagnosed brain tumors. Regarding anatomic location, supratentorial tumors were more frequent than were infratentorial tumors. The most common single tumor was the pilocytic astrocytoma (WHO grade I), representing 31% of the total pediatric brain tumors. CONCLUSION: Our results provide an objective platform for further epidemiological studies and for the development of local health strategies for the timely diagnosis and treatment of the most common pediatric tumors in Puerto Rico.

Preservation of nonviable cranial bone after class IV electrical burns.

BACKGROUND: It has been suggested that preservation of nonviable cranial bone is possible in some selected cases in the absence of infection. METHODS: A series of ten male patients, mean age 29 +/- 7 with severe electrical scalp burns and nonviable cranial bone were managed conservatively. The patients were treated initially by soft-tissue debridement until the wound presented viable, clean margins. At 22 +/- 6 days after the burn, multiple burr holes were made in the nonviable bone, and the defect immediately covered with a well-vascularized scalp flap. Each patient's progress was documented during the hospital stay and during the follow-up for at least one year. RESULTS: The multiple burr holes filled with fibrous tissue and the contour of the skull was maintained in all 10 patients making the need of a secondary cranioplasty unnecessary. No postoperative infection, osteomyelitis, or cranial bone sequestration occurred. CONCLUSIONS: Even with moderately delayed management of contaminated electrical burns, partial excision of the necrotic bone with burr holes and flap coverage appears to be adequate.