Management of postoperative cervical pseudomeningocele with percutaneous aspiration and epidural blood patch.

INTRODUCTION: While epidural blood patch can be an effective management option in lumbar pseudomeningoceles in certain clinical settings, its utility in the cervical spine is unclear. The aim of this study was to evaluate the safety and effectiveness of percutaneous aspiration and autologous blood patch for post-operative durotomy related pseudomeningoceles within the cervical spine. METHODS: A single institution retrospective review detailing 3 patients with durotomy related pseudomeningocele following posterior cervical spine surgery was completed. RESULTS: In all three cases, aspiration with subsequent injection of autologous epidural blood patch successfully treated each pseudomeningocele. One patient required more than one intervention, while the other two were successfully treated after one procedure. All three patients improved clinically without need for additional surgery. CONCLUSION: Percutaneous aspiration and epidural blood patch can be used to safely manage post-operative pseudomeningoceles within the posterior cervical spine.

Cervical puncture to deliver nusinersen in patients with spinal muscular atrophy.

OBJECTIVE: To report our experience delivering intrathecal nusinersen through cervical puncture in patients with spinal muscular atrophy (SMA) with no lumbar access. BACKGROUND: SMA is a neuromuscular disorder characterized by profound muscle weakness, atrophy, and paralysis due to degeneration of the anterior horn cells. Nusinersen, the first Food and Drug Administration-approved treatment for SMA, is administered intrathecally via lumbar puncture; however, many patients with SMA have scoliosis or solid spinal fusion with hardware that makes lumbar access impossible. Studies in primates have demonstrated better spinal cord tissue concentration with intrathecal injections than with intracerebral ventricular injections. Therefore we have used C1/C2 puncture as an alternative to administer nusinersen. METHOD: Retrospective chart review. RESULTS: Intrathecal nusinersen via cervical puncture was given to 3 patients who had thoracic and lumbosacral spinal fusion: a 12-year-old girl with type 1 SMA and 2 17-year-old girls with type 2 SMA. Cervical puncture was performed without deep sedation under fluoroscopic guidance using a 25-G or a 24-G Whitacre needle in the posterior aspect of C1-C2 interspace and full dose of nusinersen (12 mg/5 mL) was injected after visualizing free CSF flow. Patients completed their 4 loading doses and first maintenance dose of nusinersen, and 15 procedures were successful and well-tolerated. CONCLUSION: Cervical puncture is a feasible alternative delivery route to administer intrathecal nusinersen in patients with longstanding SMA and spine anatomy precluding lumbar access when done by providers with expertise in this procedure.

Novel Technique of Percutaneous Fat Graft for Repair of Persistent Large Pseudomeningocele.

BACKGROUND: Pseudomeningocele is an uncommon but problematic complication in lumbar spine surgery. Initial conservative measures frequently are successful, but persistence requires additional management. The current surgical approach can involve a range of techniques, including blood patches, hydrogel/fibrin sealants, drains, open surgical repair of the dura, or a combination of the all techniques if symptoms persist. This report demonstrates a novel technique for repair via a percutaneous approach to deliver an autologous fat graft into the pseudomeningocele. CASE DESCRIPTION: A 64-year-old woman with a history of multiple complex lumbar spinal surgeries with previous durotomy had persistent positional headaches from an unresolved pseudomeningocele from L3 to L5. The defect and symptoms remained after all available surgical options were exhausted, including blood patches, hydrogel sealants (Duraseal), and open surgical repair with muscle and Gelfoam grafts. After autologous fat harvest, the patient underwent percutaneous repair of the pseudomeningocele with simultaneous aspiration of cerebrospinal fluid and injection of fat into the defect space. CONCLUSIONS: At 3 months postoperatively, the patient's symptoms were resolved with no clinical or radiographic findings of nerve root or thecal sac impingement and complete obliteration of the pseudomeningocele. This less-invasive approach offers the option of open surgical repair for persistent pseudomeningocele with the use of autologous graft material.

Pseudomeningocele Aspiration and Blood Patch Effectively Treats Positional Headache Associated With Postoperative Lumbosacral Pseudomeningocele.

STUDY DESIGN: Retrospective chart review with limited prospective follow-up survey. OBJECTIVE: To evaluate the efficacy and safety of blood patch injection for the treatment of positional headaches caused by postoperative lumbosacral pseudomeningoceles. SUMMARY OF BACKGROUND DATA: Pseudomeningocele is one of the most common complications after posterior lumbosacral spinal surgery. Common treatments include bedrest, abdominal binder use, subarachnoid lumbar drainage, and surgical re-exploration for durotomy closure. To date, only small case reports support the use of epidural blood patch injection for symptomatic pseudomeningocele treatment. METHODS: A retrospective chart review analyzed the outcomes and complications of 19 consecutive patients who underwent blood patch injection, with and without pseudomeningocele aspiration, for symptomatic postoperative lumbosacral pseudomeningoceles between 2009 and 2015. An attempt was made to survey patients by phone regarding satisfaction. RESULTS: As of last follow-up (average time = 22.3 months), 16 patients (84%) experienced headache resolution after blood patch injection and did not require further treatment of their pseudomeningocele. In addition to symptomatic improvement, 12 of the 16 successful patients had imaging, which demonstrated pseudomeningocele resolution. Persistent pseudomeningoceles were demonstrated on imaging among all three unsuccessful patients. CONCLUSION: Pseudomeningocele aspiration followed by blood patch is an effective treatment for symptomatic postoperative lumbosacral pseudomenigocele. This is a minimally invasive alternative to surgical re-exploration with durotomy closure. Injections are most effective when performed early after pseudomeningocele development. LEVEL OF EVIDENCE: 4.

CT perfusion in acute stroke: know the mimics, potential pitfalls, artifacts, and technical errors.

The CT perfusion (CTP) imaging of brain has been established as a clinically useful tool in multimodality imaging of acute stroke. All abnormalities seen on perfusion CT are not specifically related to acute infarct. There are many neurologic diseases causing symptoms simulating cerebrovascular disease produce an alteration of brain perfusion and thus can result in perfusion CT abnormalities. There are many pitfalls and artifacts in acquiring the data, calculation of maps and choosing arterial input function. We analyze and classify all these aspects, to allow the technician and the radiologist to know exactly what to avoid and what to choose, and we indicate the way to improve the quality of examination. The knowledge of mimics and pitfalls in acute stroke imaging can be helpful in accurate interpretation of these examinations.

Analysis of radiation exposure to the orthopaedic trauma patient during their inpatient hospitalisation.

PURPOSE: There has been considerable concern regarding radiation exposure to both the patient and treating surgeon and the possible risk of resulting malignancy. We sought to analyse the total effective dose of radiation that a cohort of orthopaedic trauma patients are exposed to during their inpatient hospitalisation and determine risk factors for greater exposure levels. METHODS: Following approval from the Institution Review Board, a search was conducted of a level I trauma centre database for radiation exposures to patients over a 1 year period. Patients were included if they had an ICD-9 code from 805 to 828, indicating a fracture involving the trunk (805-811) or extremities (812-828). We compared the total effective radiation dose in various injury patterns as well as those considered to be polytrauma patients to those who were not according to their injury severity score (ISS). RESULTS: The records of 1357 trauma patients were available for review. The average patient age was 40.6 years and the mean ISS was 14.1. The average effective radiation dose for all patients during their hospitalisation was 31.6 mSv. There was a statistically significant difference in radiation exposure between patients with an ISS greater than 16 (48.6 mSv) versus those with an ISS equal to or less than 16 (23.5 mSv), p<0.001. Patients with spine trauma can be expected to get more than 15 mSv more radiation than non-spine patients, p<0.001. Extremity injuries received the least amount of radiation, spine only patients were next, then finally spine and extremity injury patients had the greatest exposures. Having a spine fracture, a pelvic fracture, a chest wall injury, or a long bone fracture were all risk factors for having more than 20 mSv of effective dose exposure. Patients under the age of 18 years did receive less radiation than the remainder of the cohort, p<0.001. CONCLUSIONS: The average orthopaedic patient receives a total effective radiation dose of more than 30 mSv, much greater than is considered acceptable as a recommended permissible annual dose by the International Commission on Radiological Protection (20 mSv). These findings indicate that the average trauma patient (in particular those with polytrauma or fractures involving the spine, pelvis, chest wall, or long bones) is exposed to high levels of radiation during their inpatient hospitalisation. The treating physicians of such patients should take into consideration the large amounts of radiation their patients receive just during their initial hospitalisation, and be prudent with the ordering of imaging studies involving radiation exposure.

Improved diagnosis of actively bleeding aneurysm on CT angiography using delayed CT images.

Computed tomographic angiography (CTA) is being increasingly utilized in the non-invasive diagnosis of aneurysmal subarachnoid hemorrhage (SAH). There are emerging reports of diagnosis of active aneurysmal bleeding on CTA, furthering our understanding of imaging features of active extravasation on cross-sectional studies. We demonstrate imaging characteristics of two such cases of active contrast extravasation from intracranial aneurysms. Additionally, we demonstrate that delayed CT images greatly improve the confidence of this diagnosis by demonstrating pooling of contrast in the subarachnoid space. Prompt recognition and management can improve prognosis of this potentially lethal condition.

Human vocal tract analysis by in vivo 3D MRI during phonation: a complete system for imaging, quantitative modeling, and speech synthesis.

We present a complete system for image-based 3D vocal tract analysis ranging from MR image acquisition during phonation, semi-automatic image processing, quantitative modeling including model-based speech synthesis, to quantitative model evaluation by comparison between recorded and synthesized phoneme sounds. For this purpose, six professionally trained speakers, age 22-34y, were examined using a standardized MRI protocol (1.5 T, T1w FLASH, ST 4mm, 23 slices, acq. time 21s). The volunteers performed a prolonged (> or = 21s) emission of sounds of the German phonemic inventory. Simultaneous audio tape recording was obtained to control correct utterance. Scans were made in axial, coronal, and sagittal planes each. Computer-aided quantitative 3D evaluation included (i) automated registration of the phoneme-specific data acquired in different slice orientations, (ii) semi-automated segmentation of oropharyngeal structures, (iii) computation of a curvilinear vocal tract midline in 3D by nonlinear PCA, (iv) computation of cross-sectional areas of the vocal tract perpendicular to this midline. For the vowels /a/,/e/,/i/,/o/,/ø/,/u/,/y/, the extracted area functions were used to synthesize phoneme sounds based on an articulatory-acoustic model. For quantitative analysis, recorded and synthesized phonemes were compared, where area functions extracted from 2D midsagittal slices were used as a reference. All vowels could be identified correctly based on the synthesized phoneme sounds. The comparison between synthesized and recorded vowel phonemes revealed that the quality of phoneme sound synthesis was improved for phonemes /a/, /o/, and /y/, if 3D instead of 2D data were used, as measured by the average relative frequency shift between recorded and synthesized vowel formants (p < 0.05, one-sided Wilcoxon rank sum test). In summary, the combination of fast MRI followed by subsequent 3D segmentation and analysis is a novel approach to examine human phonation in vivo. It unveils functional anatomical findings that may be essential for realistic modelling of the human vocal tract during speech production.

MRI sign of nodular fasciitis: a case report.

Soft tissue masses of the facial region have common clinical and radiological features resulting in varied differential diagnosis. Nodular fasciitis is a benign proliferation of fibroblasts and myofibroblasts that may be mistaken for a sarcomatous lesion because of its rapid growth. Buccal space, although an uncommon site for the lesion, can be involved by nodular fasciitis. Diagnosis is usually provided by histopathology. A case of nodular fasciitis of buccal space is reported. This case demonstrated characteristic thickening and enhancement of the adjacent fascial plane, supporting the preoperative specific diagnosis of the lesion.

Preoperative evaluation of spinal vascular malformation by MR angiography: how reliable is the technique: case report and review of literature.

Contrast-enhanced MR angiography (MRA) has been increasingly used in the evaluation of spinal vascular malformations. Even though MR spinal angiography has several advantages over catheter spinal angiography (DSA), however, spinal DSA must never be omitted before operation, even if the vascular malformation is nicely demonstrated by MR angiography. We report a case of spinal vascular malformation in which MR angiography provided great images which almost convinced everyone about the type and site of malformation/fistula. The images were so convincing that it was almost decided to skip catheter based angiography, citing reason of disadvantages of catheter based angiography over MR angiography. However, spinal DSA was luckily done which completely changed the type and site of malformation and helped in avoiding failed surgery. We conclude that even though catheter based spinal angiography has disadvantages over MRA, it should never be omitted from the diagnostic protocol.

Diffusion tensor MR imaging of the cervical spinal cord in patients with multiple sclerosis.

Our purpose was to evaluate the ability of diffusion tensor imaging (DTI) to characterize cervical spinal cord white matter (WM) in patients with multiple sclerosis (MS). DTI were obtained in 21 MS patients and 21 control subjects (CS). Regions of interest (ROIs) were placed at C2/3, C3/4, and C4/5 within the right, left, and dorsal (WM) to calculate fractional anisotropy (FA) and the apparent diffusion coefficient (ADC). Measurements in plaques and normal-appearing white matter (NAWM) of MS patients were compared with mean FA and ADC of WM in CS. FA was significantly lower in all regions in MS patients than in CS. ADC was significantly higher in all regions in MS patients than in CS except for in the dorsal WM at C2/3 and the bilateral WM at C4/5. The mean FA was 0.441 for plaques and 0.542 for NAWM, as compared with 0.739 in CS. The mean ADC was 0.810 x 10(-3) mm(2)/s for plaques and 0.722 x 10(-3) mm(2)/s for NAWM, as compared with 0.640 x 10(-3) mm(2)/s for CS. FA and ADC showed significant differences between plaques, NAWM and control WM(P < 0.01).

Cement leakage during vertebroplasty can be predicted on preoperative MRI.

OBJECTIVE: Previous studies have shown that cement leakage into an adjacent disk space is a risk factor for new fracture after vertebroplasty. The purpose of this study was to investigate the use of preoperative MRI for predicting such cement leakage. MATERIALS AND METHODS: Our institutional review board approved this retrospective study and waived the requirement of informed consent. We studied preoperative MRI of 46 vertebroplasty patients (107 vertebral bodies). Endplate cortical defect, abnormal T2 hyperintensity in adjacent disk space, intravertebral cleft, degree of compression, and wedge angle were correlated to the incidence of cement leakage into the adjacent disk. Patient age, sex, and location of treated vertebral body were also evaluated. We used logistic regression analysis and Fisher's exact probability test to analyze the association between cement leakage and these observations. RESULTS: Cortical defect in the endplate of the treated vertebral body, abnormal T2 hyperintensity in the adjacent intervertebral disk, and absence of intravertebral cleft were associated with cement leakage into the disk space (p < 0.05). There was no statistically significant association between cement leakage into the disk and degree of compression, wedge angle, location of treated vertebral body, patient age, or sex (p > 0.05). CONCLUSION: Cement leakage into an adjacent disk is more common when there is a cortical defect in the endplate and increased T2 signal in the adjacent disk and is less common if there is an intravertebral cleft.

Fractional anisotropy is higher in Heschl's gyrus than in superior temporal gyrus in normal subjects.

RATIONALE AND OBJECTIVES: The first Heschl's gyrus (HG) is believed to receive the core projection of the acoustic radiation. We examined if it were possible to differentiate the subcortical white matter of the HG from the superior temporal gyrus (STG) using diffusion tensor (DT) imaging. MATERIALS AND METHODS: The study was approved and informed consent was obtained in accordance with the guidelines of our Institutional Review Board for human subject studies. We examined six healthy adult volunteers with DT images using 20 orientations and repeated 11 times. The fractional anisotropy (FA) and the apparent diffusion coefficient (ADC) were calculated. RESULTS: The mean FA of the subcortical white matter of the HG (0.37) was higher than that of the STG (0.27) on both sides (P < .01). There was no statistically significant difference when comparing left and right HG and STG (P > .05). There was no statistically significant difference in mean ADC of the HGs and STGs (0.75 x 10(-3) mm(2)/sec, P > .05). CONCLUSIONS: The FA in the subcortical white matter of the HG was higher than that of the STG in both hemispheres. These changes in DT imaging may be accounted for by the presence of the auditory radiations.

Nonsynostotic occipital plagiocephaly: radiographic diagnosis of the "sticky suture".

BACKGROUND: While the clinical differences between nonsynostotic occipital plagiocephaly and lambdoid craniosynostosis have been described, the radiographic differentiation between the two remains obscure. The aim of this study was to characterize morphological differences in the lambdoid suture between nonsynostotic occipital plagiocephaly and lambdoid craniosynostosis. METHODS: Computed tomography scans of children clinically diagnosed with nonsynostotic occipital plagiocephaly (n = 26) were compared with computed tomography scans from children diagnosed with lambdoid craniosynostosis (n = 7). Suture and cranial morphology, ear position, and endocranial base angles were qualitatively and quantitatively compared. RESULTS: Nonsynostotic occipital plagiocephaly sutures demonstrated areas of focal fusion (25 percent), endocranial ridging (78 percent), narrowing (59 percent), sclerosis (19 percent), and changes from overlapping to end-to-end orientation (100 percent). No sutures demonstrated ectocranial ridging. All cases of nonsynostotic occipital plagiocephaly presented with ipsilateral occipital flattening, 85 percent with ipsilateral frontal, and 95 percent with contralateral occipital bossing producing parallelogram morphology. In contrast, a greater frequency of sutures in lambdoid craniosynostosis patients demonstrated nearly complete obliteration (p < 0.001) with ectocranial ridging (p < 0.001); significantly more of these patients presented with ipsilateral occipital flattening with compensatory ipsilateral mastoid (p < 0.001) and contralateral parietal (p < 0.01) bossing, producing a trapezoid morphology. Sutures from nonsynostotic occipital plagiocephaly patients showed endocranial ridging, focal fusions, and narrowing, previously reported as lambdoid craniosynostosis. CONCLUSIONS: In contradiction to previous reports, lambdoid craniosynostosis is not radiographically unique among suture fusions. This work establishes the radiographic diagnosis of nonsynostotic occipital plagiocephaly.