Rectal Foreign Body Removal in the Emergency Department: A Case Report.

INTRODUCTION: Rectal foreign bodies (RFB) pose a challenge to emergency physicians. Patients are not often forthcoming, which can lead to delays to intervention. Thus, RFBs require a heightened clinical suspicion. In the emergency department (ED), extraction may require creative methods to prevent need for surgical intervention. CASE REPORT: The authors present a case of a successful extraction of a RFB in the ED and review of the literature. CONCLUSION: Retained RFBs are an unusually problematic reason for an ED visit. Thus, it is important for emergency physicians to be comfortable managing such cases appropriately.

Removal of Migrating Lumbar Spine Bullet: Case Report and Surgical Video.

BACKGROUND: Gunshot wounds to the spine are devastating injuries. Rarely, the bullet has been reported to migrate. Migration is associated with progressive neurologic deficits that often improve with bullet removal. The authors report a case of removal of a migrating lumbar spine bullet. This is supplemented by an operative video and a review of the literature. CASE DESCRIPTION: A 31-year-old man presented to the emergency department with multiple gunshot wounds and lower-extremity paresthesia. A ballistic injury occurred with an entry wound in the right posterior soft tissues, traversing the right paraspinal muscle and fracturing the left lumbar 5 pedicle and left lumbar 4 transverse process. The bullet was positioned within the spinal canal at the lumbar 3/4 interspace. His spinal injury was managed nonoperatively due to his traumatic injuries and findings of minimal neurologic deficit without cerebrospinal fluid leak. The patient returned to the neurosurgery clinic a year later and was found to have worsening low back pain, decreased sensation throughout the left leg, and radiating pain throughout the right leg. Imaging demonstrated the bullet had migrated caudally to the midlumbar 5 vertebral body. Given the patient's progressive symptoms and migration of the bullet fragment, informed consent was obtained for a laminectomy and removal of the intradural bullet fragment. CONCLUSIONS: Neurosurgical treatment for gunshot wounds remains controversial. Cauda equina or lumbosacral level wounds are often incomplete and may improve with surgical decompression and bullet removal. Migrating bullet fragments throughout the spine and brain lead to worsened neurologic function, which can be reversed by removal. Movement of the bullet during surgery should be expected, and intraoperative fluoroscopy and patient positioning can help to properly localize the bullet and aid in its removal.

Robot-Assisted Pedicle Screw Placement: Learning Curve Experience.

OBJECTIVES: To describe the learning curve of pedicle screw placement using robot-assisted spine surgery of an experienced neurosurgeon and 2 supervised neurosurgical fellows. METHODS: The first 120 cases of robot-assisted spine surgery at our institution were assessed. Patient variables included age, body mass index, and indication for surgery. Intraoperative variables included the vertebral level of screw placement, number of screws placed by each operator, intraoperative blood loss, and operative time. Postoperative variables included length of stay, discharge disposition, 30-day readmissions, wound complications, and hardware revisions. Screw accuracy was determined with image overlay analysis comparing planned screw trajectory on the navigation software with the intraoperative computed tomography scan with final screw placement. Two-dimensional accuracy was determined for the tip of the screw, tail of the screw, and angle at the screw was placed. The supervising physician and first fellow began utilizing the robot concurrently upon its arrival, and the second fellow began using the robot after the system had been in place for 7 months. RESULTS: Both experienced surgeon and first fellow displayed a learning curve and achieved statistically significant improvement of accuracy after 30 screws. The second fellow had significantly better accuracy than the experienced surgeon in his first 30 screws. There were no complications from hardware placement in either group. There were no returns to the operating room for hardware issues. CONCLUSIONS: Robot-assisted spine surgery is a safe, accurate method of pedicle screw instrumentation. Our data show similar learning adaptation rates for the first fellow and the experienced surgeon. Techniques learned by the attending surgeon were immediately transferable to a new learner, who was able to achieve a faster learning curve than both the first fellow and the experienced surgeon.