Airway Management for Emergency Spinal Epidural Hematoma Evacuation With Awake Spine Surgery: Case Report and Literature Review.

BACKGROUND: Postoperative spinal epidural hematomas (pSEHs) are a rare complication of microdiscectomy surgery. The hematoma may be unnoticed intraoperatively, but timely treatment may prevent permanent neurologic impairment. Airway management in patients with a full stomach is generally performed with rapid sequence intubation and general anesthesia. Awake spine surgery without intravenous analgesia or sedation may be beneficial in patients with a full stomach who are at higher risk for pulmonary aspiration with general anesthesia due to a loss of non-per-oral (NPO) status. The authors propose that it can also be performed in cases of urgent/emergent postsurgical epidural hematoma evacuation. METHODS: We present the airway management of a 41-year-old man who underwent a minimally invasive microdiscectomy with normal strength immediately after surgery but developed progressive weakness with right foot dorsiflexion, right extensor hallucis longus muscle weakness, and progressive right lower extremity ascending numbness over the course of the first 2 hours after surgery due to an epidural hematoma. RESULTS: The patient underwent urgent awake epidural hematoma evacuation with a spinal anesthetic. Afterward, the patient recovered neurological function and was discharged the following morning. CLINICAL RELEVANCE: pSEHs are a rare complication of microdiscectomy surgery. The purpose of this article is to describe the novel use of awake spine surgery in emergent epidural hematoma evacuation and demonstrate its feasibility. CONCLUSIONS: In emergencies, when a patient is not NPO, awake spine surgery can safely be performed with no sedation, ensuring the patient can protect their airway and avoid the risk of aspiration.

Ultrasound-guided bilateral erector spinae plane nerve blocks: a novel application for the management of acute postoperative pain in awake spine surgery. Illustrative case.

BACKGROUND: Postoperative pain management is a limiting factor for early ambulation and discharge following spine fusion surgery. Awake spinal surgery, when combined with minimally invasive transforaminal lumbar interbody fusion, is associated with enhanced recovery in well-selected patients. Some neurosurgeons have recently aimed to further improve outcomes by utilizing erector spinae plane block catheters, allowing for a continuous infusion of local anesthetic to improve the management of acute postoperative pain following minimally invasive transforaminal lumbar interbody fusion. OBSERVATIONS: A patient who underwent a minimally invasive transforaminal lumbar interbody fusion with perioperatively placed erector spinae plane catheters at the T12 level ambulated 30 minutes after surgery and was discharged the same day (length of stay, 4.6 hours). The total amount of narcotics administered during the hospital stay was 127.5 morphine milligram equivalents. LESSONS: The placement of bilateral erector spine plane nerve block catheters at the T12 level with an ambulatory infusion pump may help to improve acute postoperative pain management for patients undergoing lumbar spinal fusion.

Delayed Diagnosis of TSH-Secreting Adenoma Attributed to Worsening Post-Traumatic Stress Disorder Symptoms in a Military Veteran Because of Provider Anchoring Bias.

INTRODUCTION: Anchoring bias occurs when clinicians hold on to previously known information about a patient, with failure to consider the full realm of possibilities to explain new findings. We present a case of delayed diagnosis of thyroid-stimulating-hormone-secreting pituitary adenoma (TSHoma), a rare disorder, in a military veteran whose symptoms were misconstrued as being caused from worsening of his prior diagnosis of post-traumatic stress disorder (PTSD). Anchoring bias in this case led to 2-year delay in the correct diagnosis. METHODS: The clinical, laboratory, radiologic, and pathologic results are presented. RESULTS: We report a case of a 44-year-old retired male Army soldier with a prior diagnosis of PTSD who was evaluated for new symptoms including headaches, blurry vision, palpitations, and anxiety. These symptoms were considered by multiple services as worsening of his PTSD, with acknowledgment of normal thyroid hormone levels from 2 years prior, but with no levels at the time of the new presentation. Attempts to treat with standard PTSD therapies were unsuccessful. When thyroid hormone levels were eventually rechecked 2 years later, he was found to have an inappropriately normal level of thyroid-stimulating hormone (1.9 mcIU/mL) in the setting of elevated free thyroxine (2.30 pg/mL) and free triiodothyronine (5.8 ng/dL). With magnetic resonance imaging revealing a 1.4-cm pituitary macroadenoma, he was diagnosed with a TSHoma. A trial of octreotide, a somatostatin analog, was attempted to shrink the tumor size. However, because of the patient's intolerance of this medication, he underwent endoscopic transsphenoidal surgery as definitive treatment. Pathologic analysis of his tumor was consistent with TSHoma. On various follow-up intervals, he had normalization of thyroid function tests, no evidence of residual tumor on 6-month postoperative imaging, and reported improvement in his symptoms. CONCLUSION: This case highlights the details of a rare diagnosis of TSHoma, which has an estimated 1 to 2 cases per million in the general population and an unknown prevalence in the military population, in a veteran who had symptoms that were presumed to be worsening PTSD. While understandable to attribute new symptoms to pre-existing diagnoses such as PTSD, clinicians should consider the possibility of alternative diagnoses and perform the routine workup when indicated.

Failure pressures after repairs of 2-cm × 2.5-cm rhinologic dural defects in a porcine ex vivo model.

BACKGROUND: The objective of this study was to determine failure pressures of 6 rhinologic repair techniques of large skull base/dural defects in a controlled, ex vivo model. METHODS: Failure pressures of 6 dural repairs in a porcine model were studied using a closed testing apparatus; 24-mm × 19-mm dural defects were created; 40-mm × 34-mm grafts composed of porcine Duragen (Integra), fascia lata, and Biodesign (Cook) were used either with or without Tisseel (Baxter International Inc.) to create 6 repairs: Duragen/no glue (D/NG), Duragen/Tisseel (D/T), fascia lata/no glue (FL/NG), fascia lata/Tisseel (FL/T), Biodesign/no glue (B/NG), and Biodesign/Tisseel (B/T). Saline was infused at 30 mL/hour, applying even force to the underside of the graft until repair failure. Five trials were performed per repair type for a total of 30 repairs. RESULTS: Mean failure pressures were as follows: D/NG 1.361 ± 0.169 cmH2 O; D/T 9.127 ± 1.805 cmH2 O; FL/NG 0.200 ± 0.109 cmH2 O; FL/T 7.833 ± 2.657 cmH2 O; B/NG 0.299 ± 0.109 cmH2 O; and B/T 2.67 ± 0.619 cmH2 O. There were statistically significant differences between glued (Tisseel) and non-glued repairs for each repair category (p < 0.05). CONCLUSION: All glued repairs performed better than non-glued repairs. Both D/T and FL/T repairs performed better than B/T repairs. No repair tolerated pressures throughout the full range of adult supine intracranial pressure.

Direct demonstration of Staphylococcus biofilm in an external ventricular drain in a patient with a history of recurrent ventriculoperitoneal shunt failure.

External ventricular drains (EVD) are associated with a high infection rate. Early detection of infection is frequently problematic due to a lack of clinical signs and the time period required for culturing. Bacterial biofilms have been suggested to play an important role in the infection of EVD, but direct evidence is as yet lacking. We report the case of a 17- year-old male with Dandy-Walker malformation who presented with headache, nausea and drowsiness; a CT scan revealed enlarged ventricles. The patient had a history of ventriculoperitoneal shunt revision 3 weeks prior to admission. The shunt was removed on suspicion of infection and an EVD placed. Daily surveillance cultures through the EVD were negative and the EVD was replaced on day 5. Examination of the initial EVD by confocal microscopy demonstrated clear intraluminal biofilm formation; molecular analysis by PCR identified Staphylococcus aureus resident on the catheter. To our knowledge, this is the first direct demonstration of an intraluminal biofilm compromising an EVD. Despite the presence of biofilm on this catheter, the patient demonstrated no clinical signs of infection, and the routine surveillance culture was negative. Undetected biofilm may pose a latent risk on EVD and other neurosurgical catheters.

A survey of ventriculostomy and intracranial pressure monitor placement practices.

BACKGROUND: Over the past 3 decades, the incidence of ICP monitoring has consistently increased and the indications for placement have expanded. Although ventriculostomy and ICP monitor placement are among the most commonly performed neurosurgical procedures, few studies have examined the current practice patterns of these procedures. METHODS: A 10-question survey was sent to 3100 practicing neurosurgeons and a similar 11-question survey to 720 neurosurgery residents. Basic demographic information and estimated rates of proper ventriculostomy placement were sought. RESULTS: Nine hundred thirty-four practicing neurosurgeons and 100 neurosurgery residents responded to our survey. Respondents estimated a mean of 1.4 passes per ventriculostomy procedure for practicing neurosurgeons, 1.4 for senior residents, and 2.4 for junior residents. Estimated rate of successful cannulation of the ipsilateral ventricle ranged from 72% to 84% for these groups. CONCLUSIONS: This survey gives a sketch of the current state of practice and the attitudes of practitioners toward the placement procedure. Both residents and practicing neurosurgeons admit to frequently using multiple passes and frequent catheter placement outside the ipsilateral frontal horn. Despite these imperfections, survey respondents were reluctant to embrace technology that could improve placement accuracy if it increased procedure time. Intracranial pressure monitor placement is an ideal topic for prospective study. The prevalence of the procedure would allow the morbidity associated with various monitors and emerging technologies to be quickly and accurately established. Results of such study could be applied to the tens of thousands of patients undergoing these procedures annually.

Role of biofilms in neurosurgical device-related infections.

Bacterial biofilms have recently been shown to be important in neurosurgical device-related infections. Because the concept of biofilms is novel to most practitioners, it is important to understand that both traditional pharmaceutical therapies and host defense mechanisms that are aimed at treating or overcoming free-swimming bacteria are largely ineffective against the sessile bacteria in a biofilm. Bacterial biofilms are complex surface-attached structures that are composed of an extruded extracellular matrix in which the individual bacteria are embedded. Superimposed on this physical architecture is a complex system of intercellular signaling, termed quorum sensing. These complex organizational features endow biofilms with numerous microenvironments and a concomitant number of distinct bacterial phenotypes. Each of the bacterial phenotypes within the biofilm displays a unique gene expression pattern tied to nutrient availability and waste transport. Such diversity provides the biofilm as a whole with an enormous survival advantage when compared to the individual component bacterial cells. Thus, it is appropriate to view the biofilm as a multicellular organism, akin to metazoan eukaryotic life. Bacterial biofilms are much hardier than free floating or planktonic bacteria and are primarily responsible for device-related infections. Now that basic research has demonstrated that the vast majority of bacteria exist in biofilms, the paradigm of biofilm-associated chronic infections is spreading to the clinical world. Understanding how these biofilm infections affect patients with neurosurgical devices is a prerequisite to developing strategies for their treatment and prevention.