Fractured Lumbar Drain Catheter Retrieval Using an Endoscopic Transforaminal Approach to the Lumbar Spine.

BACKGROUND AND IMPORTANCE: Lumbar drain placement is a common neurosurgical procedure, with several surgical and medical indications extending even beyond the specialty. One complication of placement is a fractured catheter fragment. In some circumstances, catheter retrieval is necessary which is classically performed through an open approach. Here, we present the only reported case of a retained lumbar drain catheter which was retrieved using a transforaminal endoscopic approach to the lumbar spine. CLINICAL PRESENTATION: This is a 39 year-old woman who underwent an elective craniotomy with planned perioperative lumbar drain placement for cerebrospinal fluid diversion using a 14-gauge Tuohy needle. Placement was noted to be technically challenging, and during the final attempt on removal of the system, it was noted that the distal end of the catheter had been sheared and retained in the thecal sac. Postoperatively a computed tomography scan of the lumbar spine was obtained showing the catheter fragment which entered the thecal sac dorsally at the L3-4 level but penetrated the ventral dura traveling in the epidural space caudally and terminating in the left lateral recess of L4-5. Given its presumed epidural location near the left L4-5 lateral recess and foramen, the decision was made to attempt a left transforaminal endoscopic approach for catheter retrieval before resorting to a standard open surgery. CONCLUSION: As minimally invasive spine techniques for spine surgery continue to evolve, we have highlighted the versatility of the endoscope in spine surgery as it was implemented in our case, allowing for reduced perioperative morbidity associated with retained spinal catheter retrieval.

The Role of Instrumentation in the Surgical Treatment of Spondylodiscitis and Spinal Epidural Abscess: A Single-Center Retrospective Cohort Study.

BACKGROUND: Despite the high incidence of spinal infections that require an operation, there is no consensus on the most appropriate initial surgical management for these patients regarding decompression with vs without instrumented fusion. In this study, we investigated the differences in clinical outcomes, complication rates, and reoperation rates between patients with spinal epidural abscess who underwent decompression alone vs decompression with instrumented fusion. METHODS: Records of patients undergoing operative intervention for spondylodiscitis with spinal epidural abscess at the authors' institution between 2011 and 2018 were reviewed. Two cohorts were observed: patients who underwent decompression alone and patients who underwent decompression with instrumented fusion as the initial operation. Patient demographics and primary outcomes were analyzed and compared. RESULTS: Medical records of 74 patients with spinal infection were reviewed, and 47 patients met the inclusion criteria. There were 27 (57.4%) patients who underwent decompression alone and 20 (42.6%) patients who underwent decompression and fusion. There were no significant differences in the comorbidities, level, and/or extent of infectious involvement between the decompression alone cohort and the decompression with fusion cohort. Although no significant differences were seen between groups with regard to complication rates and neurological outcomes, the reoperation rate was significantly higher in the patients who underwent decompression alone (51.9% vs 10%, P = 0.004). CONCLUSIONS: Decompression with instrumented fusion delivers neurological outcomes and complication rates similar to those seen with decompression alone in patients with spondylodiscitis. However, there was a significantly higher reoperation rate in the decompression only cohort compared to the decompression and fusion cohort.

Acute aortic occlusion leading to spinal cord ischemia in a 73-year-old: A case report.

Background: Cauda equina syndrome (CES) is typically caused by a compressive etiology from a herniated disk, tumor, or fracture of the spine compressing the thecal sac. Here, we report a CES mimic - acute aortic occlusion (AAO), a rare disease that is associated with high morbidity and mortality. AAO can compromise spinal cord blood supply and leads to spinal cord ischemia. Case Description: Our patient presented with an acute onset of bilateral lower extremity pain and weakness with bowel/bladder incontinence, a constellation of symptoms concerning for CES. However, on initial imaging, there was no compression of his thecal sac to explain his symptomology. Further, investigation revealed an AAO. The patient underwent an emergent aortic thrombectomy with resolution of symptoms. Conclusion: AAO can mimic CES and should be considered in one's differential diagnosis when imaging is negative for any spinal compressive etiologies.

The utility of intraoperative neuromonitoring on simple posterior lumbar fusions-analysis of the National Inpatient Sample.

BACKGROUND: Several studies have demonstrated the utility of intraoperative neuromonitoring (IOM) including somatosensory evoked potentials (SSEPs), motor-evoked potentials (MEPs), and electromyography (EMG), in decreasing the risk of neurologic injury in spinal deformity procedures. However, there is limited evidence supporting the routine use of IOM in elective posterolateral lumbar fusion (PLF). METHODS: The National Inpatient Sample (NIS) was analyzed for the years 2012-2015 to identify patients undergoing elective PLF with (n=22,404) or without (n=111,168) IOM use. Statistical analyses were conducted to assess the impact of IOM on length of stay, total charges, and development of neurologic complications. These analyses controlled for age, gender, race, income percentile, primary expected payer, number of reported comorbidities, hospital teaching status, and hospital size. RESULTS: The overall use of IOM in elective PLFs was found to have increased from 14.6% in the year 2012 to 19.3% in 2015. The total charge in hospitalization cost for all patients who received IOM increased from $129,384.72 in 2012 to $146,427.79 in 2015. Overall, the total charge of hospitalization was 11% greater in the IOM group when compared to those patients that did not have IOM (P<0.001). IOM did not have a statistically significant impact on the likelihood of developing a neurological complication. CONCLUSIONS: While there may conceivably be benefits to the use of this technology in complex revision fusions or pathologies, we found no meaningful benefit of its application to single-level index PLF for degenerative spine disease.

The utility of routine post-hospitalization CT imaging in patients with non-operative mild to moderate traumatic brain injury.

Primary Objective: The purpose of this study was to determine the utility of CT imaging in patients with non-operative mild-moderate TBI with respect to changes in management.Methods: We conducted a retrospective analysis for 191 patients over a 5-year interval to examine whether follow-up CT initiated a change in management. We created a logistic regression model to incorporate different variables contributing to change in management.Results: Of 191 patients, 31 (16.2%) underwent a change in management. Change in management was associated with older age (65 yo vs. 55 yo, p = .011), diagnosis of subdural hematoma (p = .041), antiplatelet/anticoagulant therapy (p = .009), imaging performed (p = .16), and increased blood products on CT (p = <0.0001). For patients on antiplatelet/anticoagulant therapy, only those with worsening findings on CT required a change in management (p = .0002, 0.039). Surgical intervention was indicated in two patients.Conclusions: Limited clinical value exists in repeat CT scans for patients with mild TBI. Most patients with traumatic SAH, contusions, or asymptomatic patients should not have repeat imaging, as our study revealed only 2% of patients with positive CT finding and 0.6% requiring surgical intervention.

Outcomes Associated With 4-Factor Prothrombin Complex Concentrate Administration to Reverse Oral Factor Xa Inhibitors in Bleeding Patients.

Compared with vitamin K antagonists (VKAs), oral factor Xa inhibitors are associated with at least equivalent efficacy and a lower incidence of major bleeding. Despite this benefit, bleeding remains the most common adverse event. Prior to the approval of andexanet alfa, alternative agents such as 4-factor prothrombin complex concentrate (4F-PCC) were utilized for reversal. This was a retrospective, descriptive study conducted on patients 18 years of age or older who received 4F-PCC for reversal of oral factor Xa inhibitors-associated bleeding. Patients were excluded if they received a VKA or dabigatran in the previous 48 hours. A subgroup analysis comparing 4F-PCC with andexanet alfa was conducted on patients who met the inclusion and exclusion criteria of the ANNEXA-4 trial. The primary end point of this study was to evaluate the incidence of hemostasis and associated dosing strategies in patients receiving 4F-PCC for reversal of oral factor Xa inhibitors-associated bleeding. Thirty-eight patients were included, and 28 patients (74%) achieved hemostasis. The median dose of 4F-PCC was 50 units/kg. In patients who achieved hemostasis, the median dose was 50 units/kg, and in those who failed to reach hemostasis, a median dose of 30 units/kg was seen. Within the subgroup analysis, there was no difference in overall rates of hemostasis between the 4F-PCC and andexanet alfa groups. Remaining a reasonable option to utilize for reversal of oral factor Xa inhibitors is 4F-PCC, especially when andexanet alfa is unavailable, with 50 units/kg appearing to be the most effective dose to achieve hemostasis. Further studies are needed to determine a preferential agent.

Neuroinflammation and blood-brain barrier disruption following traumatic brain injury: Pathophysiology and potential therapeutic targets.

Traumatic Brain Injury (TBI) is the most frequent cause of death and disability in young adults and children in the developed world, occurring in over 1.7 million persons and resulting in 50,000 deaths in the United States alone. The Centers for Disease Control and Prevention estimate that between 3.2 and 5.3 million persons in the United States live with a TBI-related disability, including several neurocognitive disorders and functional limitations. Following the primary mechanical injury in TBI, literature suggests the presence of a delayed secondary injury involving a variety of neuroinflammatory changes. In the hours to days following a TBI, several signaling molecules and metabolic derangements result in disruption of the blood-brain barrier, leading to an extravasation of immune cells and cerebral edema. The primary, sudden injury in TBI occurs as a direct result of impact and therefore cannot be treated, but the timeline and pathophysiology of the delayed, secondary injury allows for a window of possible therapeutic options. The goal of this review is to discuss the pathophysiology of the primary and delayed injury in TBI as well as present several preclinical studies that identify molecular targets in the potential treatment of TBI. Additionally, certain recent clinical trials are briefly discussed to demonstrate the current state of TBI investigation.

Endosurgical Remodeling of Wide-Necked Bifurcation Aneurysms.

Background: Wide-necked cerebral aneurysms at a bifurcation can be difficult to treat with endovascular techniques despite recent advancements. Objective: We describe a new technique of micro-scaffold remodeling of the aneurysm neck of wide-necked bifurcation aneurysms by placing one or more microcatheters and/or wires in the efferent vessels. We hypothesize that this technique would be a better choice to change the branch angulation, allowing for an improved configuration to stably deploy coils. We present a retrospective case series to illustrate this technique. Methods: 17 wide-necked bifurcation aneurysms in 17 patients were coil embolized using this technique during a 3 year study period. Branch-vessel microcatheters and/or microwires were used to remodel the aneurysm neck and support the coil mass. Statistical analysis of the branch angulation and neck-width changes were performed during treatment. Long-term clinical outcome and follow-up angiography was obtained in 8 patients. Results: Eleven patients had complete occlusion of their aneurysm (Raymond-Roy Class I), and 6 patients had Raymond-Roy Class 2 immediately after treatment. Efferent vessels demonstrated a statistically significant change in angulation with insertion of microcatheters or microwires, while neck width did not change significantly. There were four intraoperative complications and no neurological morbidity in the immediate post-operative period. Complete occlusion was documented for all 10 subjects with long-term follow-up. Conclusions: The micro-scaffold endosurgical remodeling technique is a useful adjunct in treating wide-necked bifurcation aneurysms. By elevating branch vessels away from the aneurysm neck, this technique allows for dense coil packing while decreasing the need for balloon or stent assistance.

Successful Endovascular Bailout Strategy for Retained Accunet Embolic Protection Device During Vertebral Artery Stenting.

Introduction: Vertebral artery stenosis can lead to posterior circulation TIAs and stroke. Stenting is often performed to treat symptomatic vertebral artery stenosis. As with carotid stenting, embolic protection devices (EPD) are increasingly used when stenting a vertebral artery stenosis. In general, EPDs may rarely become detached or retained in the circulation during stent revascularization. We discuss a 77-year-old male with a history of cerebral atherosclerosis and prior left occipital lobe and right insular infarcts who presented with increasing left sided weakness and was found to have severe stenosis of the proximal left vertebral artery. We report the only known case and successful endovascular bailout for an irretrievable EPD occurring during vertebral artery stenting. Methods: Systematic reviews of the medical literature were performed using PubMed and multiple combinations of keywords to search for irretrievable EPDs in either the carotid or vertebral arteries. The bibliographies of the results were used to identify additional publications until this process was exhausted. Results: No prior reports were found for retained or detached vertebral artery EPD. A total of six cases were found where an EPD was lost in the carotid circulation. In three of the cases, a carotid arteriotomy was required to retrieve the EPD. In two other cases, diagnostic catheters were used to retrieve the EPD. In our case, an EverFlex Biliary Stent was used to flatten the irretrievable EPD into the vertebral artery wall while preserving robust vertebral artery perfusion. 21-month clinical and 16-month imaging follow-up demonstrated durable vertebral artery patency and no ischemic symptoms. Conclusion: Successful bailout strategy for a retained vertebral artery EPD during stenting may be achieved with a self-expanding stent. The resultant revascularization remained durable and without clinical sequelae.

A Direct Aspiration First Pass Technique for Mechanical Thrombectomy in the Setting of a Suspected Cerebral Aneurysm.

There is little guidance in the literature on which thrombectomy technique is preferred in patients with acute ischemic stroke and concomitant aneurysms. Here, we present the case of a 58-year-old female with an acute ischemic stroke requiring emergent thrombectomy that was complicated by the presence of multiple, nonruptured intracranial aneurysms. Imaging confirmed an occlusion of the right middle cerebral artery and multiple nonruptured intracranial aneurysms. The patient was administered intravenous recombinant tissue plasminogen activator and the thrombus was aspirated via a direct aspiration first pass technique (ADAPT). Her symptoms improved significantly postoperatively with a consequent National Institutes of Health Stroke Scale (NIHSS) score of 0. The purpose of this case report is to give an overview and compare various techniques that can help guide the physician for safe, early revascularization while reducing recanalization time in patients having an ischemic stroke who also harbor intracranial aneurysms.

Spectrum of orocutaneous disease associations: Genodermatoses and inflammatory conditions.

The oral cavity and cutaneous organ systems share a close embryologic origin. Therefore, there are numerous dermatologic conditions presenting with concomitant oral findings of which the dermatologist must be aware. The second article in this continuing medical education series reviews inflammatory orocutaneous conditions and a number of genodermatoses. It is essential for dermatologists to be familiar with oral cavity manifestations associated with dermatologic diseases for prompt diagnosis, management, and appropriate referral to stomatology and dentistry.

Spontaneous Intracranial Hypotension Presenting as a "Pseudo-Chiari 1.

Spontaneous intracranial hypotension (SIH) is classified as a decrease in cerebrospinal fluid (CSF) pressure secondary to a CSF leakage and consequent descent of the brain into the foramen magnum. Diagnosing SIH can be difficult due to its overlapping findings with Arnold-Chiari type 1 Malformation (CM1) where the cerebellar tonsils herniate into the foramen magnum. The similarity of both conditions calls for a more reliable imaging technique to localize the CSF leak which could narrow the differential diagnosis and aid in choosing the correct treatment. Here, we present a case of a 28-year-old female, ten weeks post-partum with symptoms similar to SIH. MRI of the brain was remarkable for tonsillar herniation below the foramen magnum. Literature was reviewed for additional neuroradiology techniques that would aid in narrowing our differential diagnosis. Interestingly, computed tomography-, digital subtraction-, and magnetic resonance myelography with intrathecal gadolinium are the preferred techniques for diagnosis of high flow and low flow CSF leaks, respectively. These modalities further aid in choosing the correct treatment while avoiding complications. Literature suggests that treatment for CM1 involves posterior fossa decompression, whereas the mainstay of treatment for SIH involves an epidural blood patch (EBP). Thus, our patient was treated with an EBP and recovered without complication.

Traumatic Cervical Nerve Root Avulsion with Pseudomeningocele Formation.

Cervical nerve root avulsion is a well-documented result of motor vehicle collision (MVC), especially when occurring at high velocities. These avulsions are commonly traction injuries of nerve roots that may be accompanied by a tear in the meninges through the vertebral foramina with associated collections of cerebrospinal fluid (CSF), thereby resulting in a pseudomeningocele. We present a case of a 19-year-old male who experienced an MVC and was brought to the emergency department (ED) with right arm paralysis and other injuries. A neurological examination demonstrated intact sensation but 0/5 muscle strength in the right upper extremity. A magnetic resonance imaging (MRI) of the spinal cord demonstrated massive epidural hematomas extending the length of the cervical spine caudally from C2. An MRI of the right brachial plexus showed C3-C7 anterior horn cell edema and associated traumatic nerve root avulsion with pseudomeningoceles on the right from C5-C8. The development of spinal cord hematoma with these injuries has rarely been documented in the literature and the multiple level avulsion described here with extensive hematoma is a rare clinical presentation. A literature review was conducted to determine the diagnostic requirements, treatment strategies, and complications of such an injury. Our patient received conservative treatment of the right brachial plexus injury and was transferred to an inpatient rehabilitation facility 13 days later.

Coil Now, Pipe Later: Two-stage Treatment for Acute Intracranial Aneurysm Rupture.

The two main treatment modalities of acute intracranial aneurysm rupture are endovascular embolization and surgical clipping, each with its own benefits and risks. Endovascular treatment is associated with better outcomes compared to surgical clipping, but is also associated with high recurrence rates. We present the case of a patient with an acutely ruptured intracranial aneurysm, who subsequently underwent partial endovascular coiling acutely, and later underwent flow diversion therapy with the Pipeline Embolization Device. We also review the literature on this topic for further recommendations on treatment options of acute intracranial aneurysm rupture.