An Alternative Operative Approach to Lumbar Spondylolisthesis.

Lumbosacral spondylolisthesis is a frequently encountered pathology with high-grade spondylolisthesis being the least common. A circumferential construct is usually the preferred treatment as these can resist the shearing forces present at L5-S1. However, the severity of the slip, sacral inclination, and the slip angle may make a traditional anterior approach difficult to achieve. In this case series, we present three patients with axial back pain that were treated with an anterior L5-S1 transvertebral cage. This technique is intended for both grade II spondylolisthesis and high sacral slope. The L5-S1 transvertebral cage may be sufficient to prevent further listhesis, fuse the patient, and alleviate axial back pain.

"Growing cerebellum" requiring operative decompression following perinatal ventriculoperitoneal shunting.

INTRODUCTION: While cases of acquired Chiari I malformation following ventriculoperitoneal shunting for posthemorrhagic hydrocephalus have been reported, true disproportionate cerebellar growth is rare, with no previous cases requiring posterior fossa decompression reported. CLINICAL PRESENTATION: We present a premature neonate who underwent ventriculoperitoneal shunt placement for suspected posthemorrhagic hydrocephalus. He subsequently developed a symptomatic Chiari I malformation with volumetric measurements demonstrating disproportionate growth of the cerebellum. He did not demonstrate thickening of the supratentorial or posterior fossa cranium. The patient underwent an extradural posterior fossa decompression, with resolution of symptoms. OUTCOME AND CONCLUSIONS: We review the extant literature regarding the development of Chiari malformation type I as a manifestation of craniocerebral disproportion (CCD) following shunt placement for posthemorrhagic hydrocephalus of prematurity. Most previous reports reflect a mechanism that includes underdevelopment of the intracranial posterior fossa (or supratentorial) volume. The case presented in this report, as well as one additional case, indicates that there may exist a variant mechanism, characterized by rapid growth of the cerebellum itself, in the absence of one of the rare syndromes associated with primary macrocerebellum. While this case was effectively managed with extradural posterior fossa decompression, previous reports indicate that supratentorial cranial expansion procedures are preferable in some cases. As such, pediatric neurosurgeons should be able to distinguish the patterns of craniocerebral disproportion when considering treatment options for these patients. Further investigation regarding these uncommon patients may better describe the underlying mechanisms.

Multidisciplinary Management of Low-velocity Nonmissile Penetrating Head Injuries.

Introduction Penetrating head injuries (PHIs) can have diverse presentations and mechanisms; therefore, treatment methods have not been clearly outlined. Vascular injury is common and foreign body removal is often required. We present three cases to illustrate low-velocity nonmissile penetrating head injuries (NPHIs) and discuss a multidisciplinary approach. Methods We present a case series from our institution that illustrates the importance of multidisciplinary treatment of these injuries. All injuries are low- velocity NPHIs with separate mechanisms and anatomical locations. Results Multidisciplinary management involving neurosurgery, otolaryngology, and neuroendovascular surgery is represented in our case series with all patients having good clinical outcomes. Our first case is a 34-year-old male who presented neurologically intact after a stabbing in the left temporal region with concerns for external carotid artery injury and maxillary sinus injury. Our second case is a 37-year-old male who presented with a self-inflicted nail gun injury that penetrated the right temporal bone, right temporal lobe, bilateral sphenoid sinus, and left petrous carotid canal with concerns of petrous internal carotid injury. Our third case is a 31-year-old male who presented after an accidental nail gun injury that penetrated through the oral cavity, hard palate, and left sphenoid sinus and ending in the left cavernous sinus with concerns of cavernous internal carotid injury. Conclusion  Careful consideration must be taken when evaluating low-velocity NPHIs. Particular attention must be given when an associated vascular injury is suspected. Our case series highlights the importance of a multidisciplinary approach in achieving good clinical outcomes in PHIs.

Neurosurgical Outcomes of Isolated Hemorrhagic Mild Traumatic Brain Injury.

Introduction Mild traumatic brain injury (TBI) is common but its management is variable. Objectives To describe the acute natural history of isolated hemorrhagic mild TBI. Methods This was a single-center, retrospective chart review of 661 patients. Inclusion criteria were consecutive patients with hemorrhagic mild TBI. Exclusion criteria were any other acute traumatic injury and significant comorbidities. Variables recorded included neurosurgical intervention and timing, mortality, emergency room disposition, intensive care unit (ICU) length of stay (LOS), discharge disposition, repeat computed tomography head (CTH) indications and results, neurologic exam, age, sex, Glasgow Coma Scale (GCS) score, and hemorrhage type. Results Overall intervention and unexpected delayed intervention rates were 9.4% and 1.5%, respectively. The mortality rate was 2.4%. A 10-year age increase had 26% greater odds of intervention (95% CI, 9.6-45%; P<.001) and 53% greater odds of mortality (95% CI, 11-110%; P=.009). A one-point GCS increase had 49% lower odds of intervention (95% CI, 25-66%; P<.001) and 50% lower odds of mortality (95% CI, 1-75%; P=.047). Subdural and epidural hemorrhages were more likely to require intervention (P=.02). ICU admission was associated with discharge to an acute care facility (OR, 2.9; 95% CI, 1.4-6.0; P=.003). Neurologic exam changes were associated with a worsened CTH scan (OR, 12.3; 95% CI, 7.0-21.4; P<.001) and intervention (OR, 15.1; 95% CI, 8.4-27.2; P<.001). Conclusions Isolated hemorrhagic mild TBI patients are at a low, but not clinically insignificant, risk of intervention and mortality.

Spontaneous Intraventricular Tension Pneumocephalus: Case Report and Review of the Literature.

BACKGROUND: Intracranial pneumocephalus is a well-known clinical entity most frequently caused by trauma and intracranial surgery. A less frequent cause of intracranial pneumocephalus is spontaneous pneumocephalus. Spontaneous pneumocephalus can have an intraventricular extension, causing tension intraventricular pneumocephalus. CASE DESCRIPTION: We present an exceptionally rare case of spontaneous otogenic intraventricular pneumocephalus in a 58-year-old female that resulted in a decline in mentation and neurologic deficit. The patient was subsequently treated with ventriculostomy and middle fossa craniotomy, with repair of a bony defect and dural closure. CONCLUSIONS: This case demonstrates an unusual presentation of spontaneous intraventricular tension pneumocephalus necessitating ventriculostomy in addition to the traditional repair of a cerebrospinal fluid fistula.