Augmented Reality Assisted Endoscopic Transforaminal Lumbar Interbody Fusion: 2-Dimensional Operative Video.

Augmented reality (AR) is a novel technology for spine navigation. This tracking camera-integrated head-mounted display (HMD) represents a novel stereotactic computer navigation modality that has demonstrated excellent precision and accuracy with spinal instrumentation.1 Standard computer-assisted spine navigation systems have two major shortcomings: attention shift and line-of-sight limitations. The HMD allows visualization of the surgical field and navigation data concurrently in the same field of view.2,3 However, the use of AR in spine surgery has been limited to use for instrumentation, not for endoscopy. Fully endoscopic transforaminal interbody fusion under conscious sedation is an effective treatment option for degenerative spondylolisthesis and spinal stenosis. Although this technique has a steep learning curve, the advantages are vast, including preservation of normal tissue, smaller incisional requirement, and reduced postoperative pain, all enabling rapid recovery after surgery. As with other endoscopic spine surgeries, this procedure has a steep learning curve and requires a robust understanding of foraminal anatomy in order to safely access the disc space.4,5 However, with the introduction of AR, the safety and precision of this procedure could be greatly improved upon. In this video, we present a case of a 60-yr-old female who presented with a grade 1 spondylolisthesis and severe spinal stenosis and was treated with an L4-L5 interbody fusion. All instrumentation steps and localization for the endoscopic portion of the case were performed with assistance from the AR-HMD system. Informed written consent was obtained from the patient. The participant and any identifiable individuals consented to the publication of his/her image.

Thoracolumbar Interfascial Plane Block and Transversus Abdominis Plane Block for Postoperative Analgesia: 2-Dimensional Operative Video.

While spinal fusion in properly selected patients has been shown to be effective in improving pain, function, and quality of life, many patients continue to have reservations regarding the historical morbidity associated with surgical intervention.1 Open lumbar fusion surgery traditionally is perceived as an intervention that is associated with significant pain, recovery time, and risk. Even though most patients ultimately recover from this procedure, they are often left scarred with the psychological, economic, and social costs.2 To combat these negative associations with spinal fusion, neurosurgeons have begun to adopt adjunctive treatment modalities, including thoracolumbar interfascial plane (TLIP) blocks and transversus abdominis plane (TAP) blocks to improve pain control and reduce postoperative opiate consumption.3,4 The TLIP block is done after the patient is intubated and prior to skin incision for our posterior lumbar cases. Recently, we have also begun placing TAP blocks for patients undergoing anterior lumbar interbody fusion (ALIF) using exclusively liposomal bupivacaine, as commonly practiced for other abdominopelvic surgeries, to lengthen the duration of analgesia.5 We have found that these blocks have ameliorated both intraoperative and postoperative pain management.6 In this video, we present a case of a 65-yr-old female who presented with a grade 1 spondylolisthesis and neuroforaminal compression from L4 to S1, who was treated with combined TAP and TLIP block followed by a L4 to S1 ALIF with posterolateral instrumentation. Informed written consent was obtained from the patient and her family.

Third ventricle World Health Organization Grade II meningioma presenting with intraventricular hemorrhage and obstructive hydrocephalus: A case report and literature review.

BACKGROUND: Third ventricular meningiomas are exceedingly rare intracranial tumors that may present with intraventricular hemorrhage. CASE DESCRIPTION: The patient is 46-year-old who initially presented with obstructive hydrocephalus from a presumed vascular lesion and who was treated with endoscopic third ventriculostomy. He presented 3 years later with acute intraventricular hemorrhage and hydrocephalus. The hemorrhage was evacuated and the third ventricular tumor was resected, and the patient made an excellent recovery. Histopathological analysis identified the tumor as the World Health Organization Grade II meningioma. CONCLUSION: Third ventricular meningioma is a rare tumor that may present with hemorrhage and obstructive hydrocephalus. Surgical resection can be helpful for this rare presentation of intracranial meningioma.

Type I split cord malformation and tethered cord syndrome in an adult patient: A case report and literature review.

BACKGROUND: In a split cord malformation (SCM), the spinal cord is divided longitudinally into two distinct hemicords that later rejoin. This can result in a tethered cord syndrome (TCS). Rarely, TCS secondary to SCM presents in adulthood. Here, we present an adult female with Type I SCM resulting in TCS and a review of literature. CASE DESCRIPTION: A 57-year-old female with a history of spina bifida occulta presented with a 2-year history of worsening back and left leg pain, difficulty with ambulation, and intermittent urinary incontinence; she had not responded to conservative therapy. Magnetic resonance imaging (MRI) revealed a tethered cord secondary to lumbar type I SCM. The patient underwent an L1-S1 laminectomy for resection of the bony septum with cord detethering. At 2-month follow-up, the patient had improvement in her motor symptoms and less pain. In literature, 25 cases of adult-onset surgically managed SCM with TCS were identified (between 1936 and 2018). Patients averaged 37 years of age at the time of diagnosis, and 56% were female. CONCLUSION: TCS can present secondary to SCM in adulthood and is characterized predominantly by back and leg pain.

Vagal Nerve Stimulator Lead Revision Using Needle-Tip Cautery: Case Series, Literature Review, and Technical Note.

BACKGROUND: Vagal nerve stimulators (VNs) have been in use in the United States since the 1990s as a palliative treatment option for drug-resistant epilepsy. Over time, the electrode coils wrapped around the vagus nerve become encapsulated by extensive scar tissue, making complete electrode removal challenging. We present a case series of lead revision surgeries with a unique way to remove the scar tissue around the vagus nerve, demonstrating a technique for complete electrode removal. METHODS: This was a case series of 9 consecutive patients who underwent complete removal of an existing VNs electrode using needle tip monopolar electrocautery. RESULTS: Complete removal of the entire VNs electrode array was achieved in all patients with no permanent complications seen at postoperative follow-up at 3 months. CONCLUSIONS: Complete VNs electrode array removal can be safely achieved by using needle tip monopolar electrocautery.

Epidural abscess presenting as severe depression with suicidal ideations: Case report.

BACKGROUND: Epidural abscess (EDA) is an uncommon form of intracranial infection that generally presents with fever, headache, and focal neurologic deficit. Imaging generally reveals a lentiform collection with diffusion restriction on diffusion weighted image. We present an interesting case in which a patient with EDA presented with three weeks of depression with suicidal ideations. The patient displayed no notable infectious signs and the imaging was suggestive of chronic subdural hematoma (SDH) rather than EDA. CASE DESCRIPTION: The patient is a 57-year-old man with past medical history significant for epilepsy and left hemiplegia secondary to remote traumatic brain injury who presented with a three-week history of depression, anxiety, and active suicidal ideation, resulting in psychiatric admission to an outside hospital. He had undergone three previous craniotomies for SDH many years ago and had no significant psychiatric history. Magnetic resonance imaging was consistent with subacute right SDH. On presentation, patient was at neurologic baseline and was afebrile with unremarkable labs. Operative findings demonstrated frank purulence in the epidural space. The patient was treated with antibiotics and both depression and suicidal ideations resolved postoperative day 5. CONCLUSIONS: EDA can present in atypical ways, especially in patients who have undergone previous cranial procedures. Depression is one possible atypical presentation.

Vagal Nerve Stimulator Malfunction with Change in Neck Position: Case Report and Literature Review.

BACKGROUND: Vagal nerve stimulation is a safe and well-tolerated treatment for drug-resistant epilepsy. Complications and failure of the device can result from lead fracture, device malfunction, disconnection, or battery displacement and can result in a variety of symptoms. We present an interesting case of stimulator malfunction with increased impedance change seen only with a change in head position. CASE DESCRIPTION: The patient is a 25-year-old male with a vagal nerve stimulator (VNs) placed for medically refractory epilepsy who presented with neck pain and an electrical pulling sensation in his neck whenever he turned his head to the right. Initial interrogation of the VNs showed normal impedance. Subsequent interrogation with the patient's head turned found increased impedance only when the head was turned to the right. The patient had successful removal and replacement of the device with resolution of his preoperative complaints. Partial lead fracture was seen at explant. CONCLUSION: VNs malfunction can present in atypical ways. Positional maneuvers may help with its timely diagnosis.

Rhabdomyolysis following minimally invasive transforaminal lumbar interbody fusion: Case report.

BACKGROUND: Rhabdomyolysis results from the release of large quantities of muscle cell contents into plasma resulting in a classic triad of symptoms - muscle pain, weakness, and brown urine. Only a handful of rhabdomyolysis cases occurring after spinal surgery have been reported. CASE DESCRIPTION: A 36-year-old male underwent an uneventful right-sided, minimally invasive transforaminal lumbar interbody fusion (miTLIF) for intractable lower back pain and right lower extremity radiculopathy attributed to L4-S1 degenerative spondylosis (DS). Postoperatively, the patient complained of intractable lower extremity pain resistant to medical management. He was subsequently diagnosed with rhabdomyolysis, and aggressive intravenous fluid resuscitation resulted in complete recovery. CONCLUSIONS: Rhabdomyolysis should be diagnosed and treated promptly with aggressive intravenous fluid resuscitation to avoid acute kidney injury following miTLIF surgery.

Palliative Coverage of Cranial Defect following Failed Cranial Flap for Advanced Squamous Cell Carcinoma: Case Report.

INTRODUCTION: With advanced-stage head and neck cancers, patients may develop large and/or complex wounds despite multiple reconstruction attempts. Wound coverage may require novel approaches to palliate the patient. METHOD: We present the case of a 56-year-old female with advanced squamous cell carcinoma of the scalp and skull who required multiple surgical interventions. Despite our best reconstructive efforts, the patient subsequently developed scalp infection and sepsis, necessitating further debridement for source control. She then required coverage of the exposed dura and skull to prevent further infection. RESULTS: The calvarial wound was covered with a dermal regeneration template and held in place by a vacuum-assisted closure (VAC) device. This coverage prevented additional infection and morbidity, was relatively easy and comfortable to manage, and demonstrated healing and development of granulation. Unfortunately, the patient succumbed to her systemic cancer before application of a palliative split-thickness skin graft. CONCLUSION: A VAC device and dermal regeneration template constituted an excellent modality for managing the complex calvarial wound encountered by otolaryngology, neurosurgery, and burn/wound services. The technique provided appropriate palliation for a patient with advanced head and neck cancer.

Chiari I malformation and syringomyelia in mucopolysaccharidosis type I (Hurler syndrome) treated with posterior fossa decompression: Case report and review of the literature.

BACKGROUND: Hurler Syndrome is the most severe phenotype of mucopolysaccharidosis type I. With bone marrow transplant and enzyme replacement therapy, the life expectancy of a child with Hurler syndrome has been extended, predisposing them to multiple musculoskeletal issues most commonly involving the spine. CASE DESCRIPTION: This is the case report of a 6-year-old male with Hurler syndrome who was diagnosed with Chiari I malformation and cervicothoracic syringomyelia on a preoperative magnetic resonance imaging (MRI) for his thoracolumbar kyphosis. This report details the successful management of a Chiari I malformation and syringomyelia with posterior fossa decompression in a child with Hurler syndrome. CONCLUSION: Children born with MPS I can have complex spine issues that require surgical management. The most common orthopedic spinal condition for these patients, thoracolumbar kyphosis, requires evaluation with an MRI before performing surgery. This resulted in the diagnosis of a Chiari I malformation and syringomyelia in our patient with Hurler syndrome. This was successfully treated with decompression of the posterior fossa.

Successful treatment of dysgeusia after middle-ear surgery with amitriptyline: Case report.

INTRODUCTION: The chorda tympani branches off of the facial nerve within the petrous portion of the temporal bone, and is responsible for controlling the taste in the anterior two-thirds of the tongue on each side. Due to its location, it is commonly injured during middle-ear surgery resulting in dysgeusia. METHOD: A case of a 59-year-old male had recurrent otitis media resulting in tympanic membrane perforation. Patient subsequently underwent lateral graft tympanoplasty. Shortly after surgery patient reported onset of dysgeusia consisting of metallic taste at the tip of the tongue and salty taste on the left side of the tongue. RESULTS: Treatment with Amitriptyline 50mg each night significantly improved the patient's symptoms of dysgeusia. CONCLUSIONS: Amitriptyline may be an effective treatment for dysgeusia occurring after middle-ear surgery.

Filling in the gaps of predeployment fleet surgical team training using a team-centered approach.

BACKGROUND: Teamwork and successful communication are essential parts of any medical specialty, especially in the trauma setting. U.S. Navy physicians developed a course for deploying fleet surgical teams to reinforce teamwork, communication, and baseline knowledge of trauma management. METHOD: The course combines 22 hours of classroom didactics along with 28 hours of hands-on simulation and cadaver-based laboratories to reinforce classroom concepts. It culminates in a 6-hour, multiwave exercise of multiple, critically injured victims of a mass casualty and uses the ?Cut Suit? (Human Worn Partial Task Surgical Simulator; Strategic Operations), which enables performance of multiple realistic surgical procedures as encountered on real casualties. Participants are graded on time taken from initial patient encounter to disposition and the number of errors made. Pre- and post-training written examinations are also given. The course is graded based on participants? evaluation of the course. RESULTS: The majority of the participants indicated that the course promoted teamwork, enhanced knowledge, and gave confidence. Only 51.72% of participants felt confident in dealing with trauma patients before the course, while 82.76% felt confident afterward (p = .01). Both the time spent on each patient and the number of errors made also decreased after course completion. CONCLUSION: The course was successful in improving teamwork, communication and base knowledge of all the team members.