Multidisciplinary management of thoracic esophageal fistula secondary to traumatic upper thoracic fracture (T3-4) with associated discitis/osteomyelitis and spinal epidural abscess: illustrative case.

BACKGROUND: An esophageal fistula secondary to a traumatic upper thoracic (T3-4) fracture with resultant thoracic discitis/osteomyelitis and an epidural abscess with neurological compromise is a rare clinical entity. Early diagnosis is critical for an optimal clinical outcome avoiding grave and progressive spinal dissemination with structural instability and neurological deterioration. OBSERVATIONS: The following case, not clearly described previously in the literature, highlights the clinical course and multidisciplinary approach to management including a single-stage posterior cervicothoracic (C3-T6) decompression with vertebral reconstruction with an expandable interbody cage (T2-4) and posterior cervicothoracic fusion and instrumentation (C3-T6), followed by direct esophageal fistula closure with AlloDerm and a vascularized latissimus dorsi muscle flap. LESSONS: Early diagnosis and the potential treatment of a posttraumatic esophageal fistula requires a multidisciplinary approach.

Ruptured Distal Medial Lenticulostriate Artery Aneurysm Treated With Transcortical-Transventricular Approach.

We report a case of a 48-year-old female who presented with abulia and headaches. Head CT (HCT) demonstrated a left caudate intracerebral hemorrhage (ICH) with extension into the left lateral ventricle. Diagnostic cerebral angiogram showed a left distal medial lenticulostriate artery (MLSA) aneurysm with remote left parietal Spetzler-Martin grade 3 arteriovenous malformation (AVM). The patient underwent an endoscope-assisted transcortical-transventricular approach to the distal MLSA aneurysm with complete excision and evacuation of the intraventricular hemorrhage (IVH) postoperatively; the patient had no further neurologic deficits and recovered well from her initial hemorrhage. Ruptured MLSA aneurysms are a very rare cause of spontaneous ICH. Urgent treatment of these aneurysms is needed to prevent further rebleeding. We present a novel operative technique utilizing an endoscope-assisted transcortical-transventricular approach to a ruptured distal MLSA aneurysm with successful excision of the aneurysm.

Multidisciplinary Management of Low-velocity Nonmissile Penetrating Head Injuries.

Introduction Penetrating head injuries (PHIs) can have diverse presentations and mechanisms; therefore, treatment methods have not been clearly outlined. Vascular injury is common and foreign body removal is often required. We present three cases to illustrate low-velocity nonmissile penetrating head injuries (NPHIs) and discuss a multidisciplinary approach. Methods We present a case series from our institution that illustrates the importance of multidisciplinary treatment of these injuries. All injuries are low- velocity NPHIs with separate mechanisms and anatomical locations. Results Multidisciplinary management involving neurosurgery, otolaryngology, and neuroendovascular surgery is represented in our case series with all patients having good clinical outcomes. Our first case is a 34-year-old male who presented neurologically intact after a stabbing in the left temporal region with concerns for external carotid artery injury and maxillary sinus injury. Our second case is a 37-year-old male who presented with a self-inflicted nail gun injury that penetrated the right temporal bone, right temporal lobe, bilateral sphenoid sinus, and left petrous carotid canal with concerns of petrous internal carotid injury. Our third case is a 31-year-old male who presented after an accidental nail gun injury that penetrated through the oral cavity, hard palate, and left sphenoid sinus and ending in the left cavernous sinus with concerns of cavernous internal carotid injury. Conclusion  Careful consideration must be taken when evaluating low-velocity NPHIs. Particular attention must be given when an associated vascular injury is suspected. Our case series highlights the importance of a multidisciplinary approach in achieving good clinical outcomes in PHIs.

From Toothpick to Intraparenychmal Otogenic Pneumocephalus: A Case Report.

BACKGROUND: Intracranial pneumocephalus, the accumulation of air, occurs most frequently from trauma, tumor, cranial surgeries, or infection. Intraparenchymal otogenic pneumocephalus is a rare but well-documented development. We describe a patient who developed pneumocephalus in the context of eardrum perforation secondary to toothpick use for ear wax. CASE DESCRIPTION: An 86-year-old female presented to the emergency room with a 1-day history of dysarthria and a few days of cough and sneezing. History revealed she had recently been advised to avoid Q-Tips to clean her ears and instead was using toothpicks. She denied otalgia or otorrhea and had no signs of infection near the ear. On otoscopic examination, the right tympanic membrane was perforated. On head computed tomography, she was found to have a large right temporal pneumocephalus extending from the petrous bone. Magnetic resonance imaging of the brain revealed a defect in the right tegmen. She was started on empiric antibiotics and subsequently taken to the operating room for craniotomy and repair of bony and dural defects. CONCLUSIONS: Otogenic pneumocephalus is a rare occurrence. This is the first reported case of pneumocephalus related to self-induced middle ear trauma with a toothpick that ultimately required craniotomy for repair.

Ventral Herniation of the Cervical Cord After Single-Level Corpectomy.

BACKGROUND: Spinal cord herniation in the cervical spine is an exceptionally rare occurrence. It is most often cited in association with surgery and almost exclusively with a posterior approach. Herniation with an anterior approach has been reported in 3 cases after multilevel corpectomy, all of which involved herniation through a dural defect sustained during surgery. CASE DESCRIPTION: A 49-year-old man presented to the emergency room with generalized fatigue. He had a previous anterior C5 corpectomy and posterior cervical fusion from C2-T4 performed 17 years prior for a cervical kyphotic deformity that developed after a laminectomy. Magnetic resonance imaging of the cervical spine demonstrated a significant ventral cord herniation into the C5 ventral corpectomy site. The patient underwent a C4-6 vertebral corpectomy with C3-7 anterior reconstruction, fusion, and instrumentation with successful reduction and anatomic realignment of the spinal cord herniation. CONCLUSIONS: We present a case of cervical cord herniation that occurred into the ventral corpectomy site without obvious dural defect. We hypothesize that cerebral spinal pulsations over time degraded the corpectomy site and ultimately promoted herniation of the spinal cord. Here, we discuss the successful surgical management of this unique pathology and discuss a relevant review of the literature.

Multiple Intracranial Rosai-Dorfman Disease: A Case Report.

Rosai-Dorfman disease is an uncommon lymphoproliferative disorder, and multiple intracranial involvement in disseminated disease is exceedingly rare. We present a case of a 52 year-old female who presented with intractable headaches and a history of Rosai-Dorfman disease unresponsive to chemo- and radiation therapies. She was found to have new multiple intracranial masses that were treated with surgical excision. Pathology confirmed a diagnosis of intracranial Rosai-Dorfman. The disease presentation, radiographic appearance, histology, treatment, and prognosis are briefly reviewed.

Spontaneous Intraventricular Tension Pneumocephalus: Case Report and Review of the Literature.

BACKGROUND: Intracranial pneumocephalus is a well-known clinical entity most frequently caused by trauma and intracranial surgery. A less frequent cause of intracranial pneumocephalus is spontaneous pneumocephalus. Spontaneous pneumocephalus can have an intraventricular extension, causing tension intraventricular pneumocephalus. CASE DESCRIPTION: We present an exceptionally rare case of spontaneous otogenic intraventricular pneumocephalus in a 58-year-old female that resulted in a decline in mentation and neurologic deficit. The patient was subsequently treated with ventriculostomy and middle fossa craniotomy, with repair of a bony defect and dural closure. CONCLUSIONS: This case demonstrates an unusual presentation of spontaneous intraventricular tension pneumocephalus necessitating ventriculostomy in addition to the traditional repair of a cerebrospinal fluid fistula.