Digital Subtraction Angiography May Reduce the Rate of Radiographic Hemorrhage in Stereoelectroencephalography.

OBJECTIVE: To study the effect of preoperative digital subtractive angiography (DSA) for planning stereoelectroencephalography (sEEG) electrode trajectories on the rate of postoperative radiographic hemorrhage. METHODS: A retrospective, single-center observational study was conducted examining every sEEG implantation consisting of 72 implantations of 1028 total electrodes with each patient having received a preoperative planning DSA. Postimplant imaging was analyzed for the presence of hemorrhage. Postoperative computed tomography were then merged and coregistered with preoperative DSA to determine if a collision or near-miss (within 1 mm) occurred between the perihemorrhage electrodes and a vessel. Statistical analysis was then conducted. RESULTS: Six patients (8.3%) had hemorrhage seen on computed tomography with a bleeding rate of 0.6% per electrode. Five patients were asymptomatic (6.94%) and one symptomatic (1.39%). One patient suffered permanent neurologic deficits, and there have been zero deaths. In the hemorrhage group, there were 3 subdural, 2 subarachnoid, and 2 intraparenchymal. All subdural and subarachnoid hemorrhages had electrodes that were found to collide or near-miss a vessel when compared with preoperative DSA. Half of the intraparenchymal hemorrhages had no obvious vessel in proximity to the electrodes. Our data show that preoperative DSA is a viable screening test and portends a 94.7% sensitivity and 53.6% specificity for predicting post operative radiographic hemorrhage. CONCLUSIONS: Analysis of our sEEG series reveals a substantially lower rate of postimplant hemorrhage when compared with the recent cohort studies. Our data indicate that preoperative DSA may be efficacious in reducing the incidence of sEEG postimplant hemorrhages.

Costs Associated with Laser Interstitial Thermal Therapy Are Lower Than Anterior Temporal Lobectomy for Treatment of Temporal Lobe Epilepsy.

BACKGROUND: Laser interstitial thermal therapy (LITT) is a minimally invasive alternative to anterior temporal lobectomy (ATL) for treatment of temporal lobe epilepsy. It has gained popularity as familiarity with technique increases and outcomes are better characterized. There has been no direct cost comparison between the 2 techniques in literature to date. The current study directly compares hospital costs associated with LITT with those of ATL patients and analyzes the factors potentially responsible for those costs. METHODS: Patients who underwent ATL (27) and LITT (15) were retrospectively reviewed for total hospital costs along with demographic, surgical, and postoperative factors potentially affecting cost. T-tests were used to compare costs and independent linear regressions, and hierarchical regressions were used to examine predictors of cost for each procedure. RESULTS: Mean hospital costs of admission for single-trajectory LITT ($104,929.88) were significantly less than for ATL ($134,980.04) (P = 0.001). In addition, length of stay, anesthesia costs, operative room costs, and postoperative hospitalization costs were all significantly lower in LITT. CONCLUSIONS: Given the minimally invasive nature of LITT, it is associated with shorter length of stay and lower hospital costs than ATL in the first head-to-head comparison of procedural costs in literature to date. Long-term efficacy as it relates to these costs associated with LITT and ATL should be further investigated to better characterize the utility of LITT in temporal lobe epilepsy patients.

Intradural extramedullary capillary hemangioma of the cauda equina: case report of a rare spinal tumor.

INTRODUCTION: Intradural extramedullary capillary hemangiomas of the cauda equina are exceedingly rare, with only 20 previous cases reported. In the adult population, these tumors are rare and can arise in the central and peripheral nervous systems from the dura or spinal nerve roots. Intradural capillary hemangiomas of the cauda equina can yield symptoms such as lower extremity weakness, pain, and bladder and bowel dysfunction. The clinical symptomology and surgical management of this rare spinal lesion are reviewed in this case report. CASE PRESENTATION: A 50-year-old male presented with progressive bilateral lower extremity weakness for 2 years, with recent bladder and bowel dysfunction. On physical exam, strength was symmetrically impaired in both lower extremities. Pre-operative magnetic resonance imaging (MRI) of the lumbar spine demonstrated a gadolinium-enhanced intradural lesion at the L4 level. Laminectomy was performed and the lesion was resected. Histopathological analysis determined that the tumor demonstrated features consistent with a capillary hemangioma. DISCUSSION: Clinically, patients with capillary hemangiomas of the cauda equina present with space-occupying compressive deficits, including progressive low back and lower extremity pain, motor deficits, paresthesias, sensory loss, and bowel and bladder dysfunction. Acute presentation can transpire following a hemorrhagic episode, although this is more associated with cavernous rather than capillary hemangiomas. Our patient demonstrated non-acute, progressive weakness, and late-onset bladder and bowel dysfunction. This report demonstrates that this rare lesion should be included in the differential diagnosis of cauda equina lesions.

Neurosurgical Evaluation for Patients with Chronic Lower Back Pain.

PURPOSE OF REVIEW: Chronic low back pain (CLBP) is a major cause of disability in the USA, and it affects approximately 1 in 4 Americans. CLBP patients are commonly referred to or seek out neurosurgical evaluations and opinions for treatment and management. RECENT FINDINGS: Literature shows that only a minority of patients with CLBP may benefit from a surgical procedure. These patients that present to clinic often have been ailing for a considerable amount of time and are eager for effective treatment to alleviate pain. However, determining if a patient with CLBP is a surgical candidate is predicated upon having no success of pain relief with non-operative management. Patients with CLBP require thorough and adequate imaging, clinical exam, and diagnostic evaluation. When adequate non-operative management was provided, and proven fruitless, the patient may be considered an operative candidate. In this manuscript, a framework is presented for workup and evaluation of patients with CLBP.

Internal Neurolysis with and without Microvascular Decompression for Trigeminal Neuralgia: Case Series.

OBJECTIVE: Microvascular decompression (MVD) has remained the first-line surgical treatment of trigeminal neuralgia when an offending vessel can be identified that is causing neurovascular compression. However, patients without neurovascular compression can either develop trigeminal neuralgia or recurrence after MVD. In addition, patients with venous and less severe arterial compression have been shown to have reduced efficacy after MVD. Internal neurolysis is a surgical technique used to separate the fascicles of the trigeminal nerve and might be a good option for patients with trigeminal neuralgia but without vascular compression. METHODS: A retrospective, institutional review board-approved medical record review was performed of adult patients with trigeminal neuralgia who had undergone internal neurolysis. The search resulted in 32 patients who had been treated from 2016 to 2019. The Barrow Neurological Institute (BNI) pain intensity scale and hypesthesia scale (HS) were used to determine the outcomes. RESULTS: The average follow-up was 20 months (range, 3-40 months). The postoperative outcomes showed a BNI pain intensity scale score of I for 50%, with excellent control in 56%, successful control in 78%, adequate control in 94%, and poor control in 6%. Significantly more patients without previous treatment had had successful pain control (95% vs. 54%). Six patients (19%) experienced pain recurrence and were significantly more likely to experience pain recurrence compared with patients without a previous procedure (39% vs. 5%). The overall BNI-HS score postoperatively was I for 28%, II for 69%, and III for 3%. CONCLUSIONS: Internal neurolysis with and without MVD has shown efficacy in treating trigeminal neuralgia in carefully selected patients.

Atypical presentation of spinal intramedullary astrocytoma in a patient presenting with isolated signs of intracranial hypertension.

INTRODUCTION: Intramedullary spinal tumors are rare entities that typically present with signs of spinal cord dysfunction including myelopathy, weakness, hypoesthesia, or bladder dysfunction. However, they can present in more insidious ways without signs of spinal cord dysfunction, as we will discuss in this case. Our patient presented with isolated signs of intracranial hypertension including headache and progressive vision loss. Although idiopathic intracranial hypertension (IIH) is significantly more common than spinal cord tumors, a full evaluation to rule out other diagnoses should always occur, as this is an exclusionary diagnosis. CASE PRESENTATION: We describe an interesting case of an obese, middle-aged female who presented with signs and symptoms of elevated intracranial pressure (ICP) including progressive headache, visual changes, and papilledema. This led to a presumptive diagnosis of idiopathic intracranial hypertension (IIH). However, a careful review of her cerebrospinal fluid (CSF) analysis revealed a significantly elevated protein level. This prompted a more thorough workup, including a spinal MRI, that revealed an intramedullary astrocytoma. On her presenting physical exam, she had no upper or lower motor signs, no weakness, and no pathological reflexes. DISCUSSION: In the evaluation of a patient with isolated signs of increased ICP concerning for IIH, it is important to conduct a thorough workup as this remains a diagnosis of exclusion. Many intracranial and intraspinal pathologies can manifest with similar vague neurological symptoms and masquerade as a more benign disease as shown in our patient who, unfortunately, died from a spinal astrocytoma.

Robot-Assisted Instrumented Fusion of a T8-9 Extension Distraction Fracture and Epidural Hematoma Evacuation: 2-Dimensional Operative Video.

The utilization of robotics has been gaining increased popularity in spine surgery. It can be used to assist in pedicle screw insertion when anatomy is complex in deformity surgery, but is also helpful in degenerative spine as it can minimize tissue dissection and fluoroscopy use.1-6 We present an operative video that demonstrates the use of a robotic system (Globus Excelsius GPS, Audubon, Pennsylvania) for thoracic instrumentation in an unstable fracture. The patient we present is a 64-yr-old male who sustained a T8-9 distraction extension fracture after falling down a flight of stairs. His computed tomography (CT) scan showed ossification of the anterior longitudinal ligament making ankylosing spondylitis the likely underlying condition.7,8 His magnetic resonance imaging showed an epidural hematoma extending from T7 to T11. Due to the unstable nature of this fracture and the presence of the hematoma, informed consent was obtained and the patient underwent thoracic pedicle screw fixation from T7 to T11 and laminectomy for hematoma evacuation. A preoperative CT was done for screw trajectory planning. Paraspinal muscle dissection was limited to the hematoma level to allow for laminectomy and evacuation. After registration of the patient to the robotic system using C-arm fluoroscopy, pilot burr holes are drilled using a rigid robotic arm and with optical tracking in real time. This reduces the degrees of freedom and allows for higher precision of screw placement. To the authors' knowledge, this video is the first one to show the utilization of robotics for thoracic instrumentation in an acute fracture.

Cavernous-Carotid Fistula Presenting with Intracerebral Hemorrhage in the Absence of Ocular Symptoms.

BACKGROUND: Cavernous-carotid fistulas (CCFs) can present with a variety of symptoms depending on the anatomy of the fistula and its venous drainage. Patients most commonly present with scleral injection, pulsatile exophthalmos, and/or chemosis. CASE DESCRIPTION: We report a patient who presented with intraparenchymal hemorrhage in the absence of any of the commonly associated ocular symptoms and signs. After multiple imaging studies, the CCF was diagnosed and treated with endovascular embolization that resulted in complete occlusion of the fistula and reflux of embolysate into one of its connecting veins. CONCLUSIONS: The morphology of the venous drainage can lead to atypical hemorrhagic presentation, whereas dilatation of one of the tributary veins with cortical venous reflux should warn the interventionist the path the embolysate may follow. We provide our experience with this unique presentation and its treatment.

Contrasting patient, family, provider, and societal goals at the end of life complicate decision making and induce variability of care after trauma.

BACKGROUND: End-of-life (EoL) decision making during critical illness and injury is important in facilitating compassionate care that is congruent with patient, family, and societal expectations. Herein, we evaluate factors that may effect and induce variability in practitioner EoL decision making, particularly years in practice, use of advance directives (ADs), and cost. METHODS: An anonymous, online survey was offered to all active members of the Eastern Association for the Surgery of Trauma (n = 1,359) in June 2012. Demographic information and a series of questions dealing with common potentially influential factors were included. Responses were 5-point Likert scale based. RESULTS: A total of 375 responses (27.6%) were received. Ninety-two percent of the respondents were physicians, 70% were male, and 77% were from Level 1 trauma centers. Of respondents, 65.8% rely on family to make EoL decisions most or all of the time, while 80.7% feel family members are rarely or only sometimes in appropriate emotional states to make such choices. A significant number of practitioners felt comfortable making decisions without family input at all, more so with experienced practitioners as compared with those in practice for less than 15 years (38.2% and 24.1% respectively, p < 0.01).Of the practitioners, 59.6% rely on ADs most or all of the time, only 61.1% agree or strongly agree that ADs are useful, and only 56.3% feel families follow their loved one's ADs most or all of the time. A patient's family support or ability to pay for aftercare was rarely or never considered important by 80.1% of the practitioners, despite 85.1% reporting that quality of life postillness/injury was important most or all of the time. CONCLUSION: Practitioner comfort and motivation to influence EoL decision making varies with experience level. ADs are not uniformly perceived to be helpful, and costs are uncommonly considered. To improve EoL quality, these factors need to be considered. LEVEL OF EVIDENCE: Care management study, level IV.