Retropharyngeal/anterolateral approach for C2 corpectomy.

Instability of the high cervical spine, particularly C1 and C2, is commonly treated via a posterior approach. Access to this region via transoral approaches is often avoided due to the high risk of wound contamination, limited exposure, and lack of experience on the part of the surgeon. We present a 48-year-old man exhibiting complete C2 vertebral body involvement by multiple myeloma with a pathologic fracture, which we treated via the anterolateral/retropharyngeal approach to the high cervical spine. The anterolateral/retropharyngeal approach provides relatively easy access to the anterior arch of C1 and to the vertebral bodies of C2-4 and can be applied to a variety of different conditions. In addition, this approach may be a viable alternative to the transoral route and its associated morbidities.

Odontoid screw placement using Isocentric 3-dimensional C-arm fluoroscopy.

STUDY DESIGN: We describe the use of isocentric 3-dimensional fluoroscopy to place odontoid screws in 9 patients. OBJECTIVE: We wanted to show the benefits of using isocentric 3-dimensional fluroscopy in odontoid screw placement. SUMMARY OF BACKGROUND DATA: Odontoid screw fixation for treatment of type II odontoid fractures has gained popularity since its introduction in the early 1980s. During the last several years, a multitude of new techniques have improved the ease of odontoid screw placement, including biplanar fluoroscopy, cannulated screw systems, and beveled bedside-fixed retractor systems. The use of isocentric C-arm fluoroscopy can improve the ease and facilitate placement of odontoid screws. CLINICAL PRESENTATION: Nine patients, ranging in ages from 30 to 89 years, presented with type II odontoid fractures. All fractures were either nondisplaced or minimally displaced (<4 mm) and occurred as a result of acute trauma. No patient had evidence of transverse atlantal ligament disruption. METHODS: Isocentric 3-dimensional fluoroscopy, in conjunction with image-guided navigational software, was used to place 1 or 2 odontoid screws in each patient. Three-dimensional images were acquired intraoperatively, which were then reconstructed and uploaded to the navigational workstation. Screw trajectory was planned and performed with the use of tracked instruments. RESULTS: Successful screw placement, as judged by intraoperative computerized tomography, was attained in all 9 patients. CONCLUSIONS: Isocentric 3-dimensional fluoroscopy, in conjunction with an image-guided navigational software system, obviates the need for cumbersome biplanar fluoroscopy, allows for intraoperative image acquisition after surgical exposure, reduces intraoperative registration time, reduces both surgeon and patient radiation exposure, and allows immediate computerized tomographic imaging in the operating room to verify screw position.

Postoperative cranial fasciitis. Report of two cases and review of the literature.

The authors report two cases of cranial fasciitis occurring at prior craniotomy sites. They review the presentation and pathological features associated with cranial fasciitis and describe two unusual cases and their treatment. The first case is that of a 16-year-old girl who underwent suboccipital craniectomy for resection of medulloblastoma and 14 months later was found to have a 4-cm nontender mass at the incision site, with evidence of skull erosion on neuroimaging. Resection of the mass revealed cranial fasciitis. The patient later developed two more lesions in the cranial region, as well as lesions on the chest wall and abdomen consistent with nodular fasciitis; all of the lesions were resected. The second case is that of a 61-year-old man who underwent suboccipital craniectomy for hypertensive hemorrhage and 2 years later was found to have an enlarging mass at the incision site, causing compression of the cerebellum. The mass was resected and found to be consistent with cranial fasciitis. Cranial fasciitis is a rare, benign lesion of the cranial region. It is histologically identical to nodular fasciitis, a self-limiting fibroblastic process of the superficial and deep fascia. Although most cases of cranial fasciitis are reported to occur spontaneously in the very young, the two cases reported here involved older patients and lesions that developed at prior craniotomy sites in a delayed fashion, a phenomenon not previously reported. Interestingly, one patient exhibited lesions in other areas as well.

Image fusion of fluid-attenuated inversion recovery magnetic resonance imaging sequences for surgical image guidance.

BACKGROUND: Nonenhancing brain lesions can be relatively poorly defined on volumetric data sets routinely used for surgical guidance. Fluid-attenuated inversion recovery MRI sequences can provide better margin visualization of nonenhancing or poorly enhancing lesions. METHODS: Using image fusion programs, we combined data sets of SPGR imaging pulse sequence or volumetric CT with volumetrically acquired FLAIR sequences and subsequently used the fused data set for image-guided surgery. This technique was used in 50 surgical cases. Of these, 9 were nonenhancing intrinsic brain tumors, 13 were partially enhancing tumors, and 11 were enhancing tumors. In addition, FLAIR fusion was selectively used for 6 nontumoral lesions and in 11 nonlesional epilepsy surgery cases. RESULTS: Image guidance using the fused data set was accurate in all 50 cases. Despite the lack of enhancement, 3 of the 9 nonenhancing tumors were found to be high grade. One of the low-grade tumors was associated with considerable areas of gliotic change not considered to represent tumor on permanent histology. In all other cases, the FLAIR-bright resected margins were consistent with tumor, not gliosis. Radical resection (>95% volume) was achieved in 21 of 23 tumor cases in which this had been the preoperative intent. CONCLUSIONS: Nonenhancing lesions are often poorly demarcated not only on imaging studies, but also during surgery. Fluid-attenuated inversion recovery fusion allows resection of such lesions using intraoperative computer image guidance. Complementary FLAIR information can also occasionally be useful during surgical approaches to enhancing lesions or in nontumor cases. It must be kept in mind that FLAIR has high sensitivity but low specificity. Fluid-attenuated inversion recovery abnormalities do not obviate the need for mapping in potentially functional areas.

Zenker diverticulum: a rare complication after anterior cervical fusion.

Esophageal injury is a rare but serious complication occurring after anterior cervical spine surgery. Pharyngoesophageal, or Zenker, diverticulum is an acquired outpouching of the pharyngeal musculature just proximal to a functional esophageal stricture, clinically manifesting as dysphagia, aspiration, and weight loss. We report a case in which a patient developed a pharyngoesophageal diverticulum, accompanied by retropharyngeal abscess, first identified 2 years after a 3-level anterior cervical fusion with allograft and anterior plating. The inferior portion of the cervical plate was dislodged anteriorly. In addition, the patient harbored pulmonary and mediastinal infection at the time of presentation. Despite incision and drainage of the abscess with repair of the diverticulum, the patient died in the early postoperative period. Prompt recognition and frequent follow-up, as well as patient education, may prevent this catastrophic complication.

Tuberculosis infection presenting as brain abscess in an immunocompromised host.

Despite advances in modern treatment, tuberculosis remains an ever-present problem. With the HIV epidemic, the prevalence of tuberculosis has risen. Contributing to this trend has been the development of multi-resistant tuberculosis strains, as well as rising immigration from nations where tuberculosis is endemic. Although tuberculosis most commonly manifests as a pulmonary process, milary tuberculosis is also on the rise. Neurotuberculosis, a rare but dangerous progression of pulmonary tuberculosis, remains a difficult diagnostic and treatment dilemma to practitioners both in the United States and abroad. We describe an unusual presentation of neurotuberculosis infection in a previously asymptomatic patient. Early recognition and treatment of intracranial tuberculosis is important if mortality is to be prevented.

Hydrocephalus.

In treating patients with hydrocephalus, cerebral ventricular shunts and their complications are often encountered by the primary care provider. Caring for these patients can provoke anxiety and doubt in those who have had little exposure in dealing with shunts. Becoming familiar with the clinical findings, etiology, and treatment of hydrocephalus, as well as the signs and symptoms of cerebral ventricular shunt complications, will aid the primary care physician in the management, treatment, referral, and continuing care of these patients.