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OBJECTIVE In the era of modern medicine with an armamentarium full of state-of-the art technologies at our disposal, the incidence of wrong-level spinal surgery remains problematic. In particular, the thoracic spine presents a challenge for accurate localization due partly to body habitus, anatomical variations, and radiographic artifact from the ribs and scapula. The present review aims to assess and describe thoracic spine localization techniques. METHODS The authors performed a literature search using the PubMed database from 1990 to 2020, compliant with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A total of 27 articles were included in this qualitative review. RESULTS A number of pre- and intraoperative strategies have been devised and employed to facilitate correct-level localization. Some of the more well-described approaches include fiducial metallic markers (screw or gold), metallic coils, polymethylmethacrylate, methylene blue, marking wire, use of intraoperative neuronavigation, intraoperative localization techniques (including using a needle, temperature probe, fluoroscopy, MRI, and ultrasonography), and skin marking. CONCLUSIONS While a number of techniques exist to accurately localize lesions in the thoracic spine, each has its advantages and disadvantages. Ultimately, the localization technique deployed by the spine surgeon will be patient-specific but often based on surgeon preference.

Introduction Magnetic resonance neurography (MRN) is a newer imaging technique that is increasingly used for detailed visualization of peripheral nerves not reliably achieved with conventional imaging modalities. Although MRN has been previously characterized in the literature, few studies have assessed its utility to neurosurgery, where there is potentially substantial impact particularly with preoperative assessment. In this article, we performed a retrospective review of cases in which MRN was used for clinical evaluation and surgical decision making. Methods MRN, clinical assessment, and operative decision making were retrospectively assessed in 206 consecutive patients at our institution between 2015 and 2018. Results MRN was determined to lead to a change in diagnosis or surgical decision making in 44 patients (21.4%: 27 female, 17 male). These were classified into 6 major diagnostic categories: trauma, postsurgical evaluation, compressive/degenerative conditions, tumors, neuritis/inflammation, and other neurogenic lesions. Nine representative cases were selected from these categories to highlight the range of neurosurgical pathologies in which MRN was useful in diagnostic assessment and surgical decision making. Conclusions MRN is an underused resource with great potential value in the diagnoses, surgical planning, and postoperative assessment of various neurosurgical conditions. These present incremental utility to the neurosurgeon as well as socioeconomic benefit in the detection of potentially surgically treatable lesions.

Background Sacral tumors present a significant challenge to the spine surgeon. As new techniques have evolved in recent years, these lesions have become more amenable to aggressive surgical treatment. Although sacral tumors make up only a small minority of spinal tumors, their surgical management warrants special consideration. Methods Based on our experience, we highlight 3 important surgical nuances specifically for the treatment of sacral tumors: preservation and maximization of neurologic function, protection of ventral abdominal and pelvic structures, and lumbopelvic fixation. Results Two cases of patients with sacral tumors treated at our institution are presented to illustrate these points. Both patients had successful postoperative courses, and remained pain free, well-fixated, and neurologically intact at 3–4 month follow-up. They had no evidence of biomechanical instability. Conclusions To ensure a successful outcome, a goal-directed, methodical approach is required.

Objective Spontaneous cervical intradural disc herniation (IDH) is a rare occurrence with limited and disparate information available regarding its presentation, diagnosis, and treatment. However, its accurate detection is vital for planning surgical treatment. In this review of the literature, we collected data from all cervical IDHs described to date. Particular attention was paid to diagnostic findings, surgical approach, and causation for cervical IDH, especially at the cervicothoracic junction. Methods A review for cases of cervical IDH was performed via the following search criteria: (“neck”[MeSH Terms] OR “neck”[All Fields] OR “cervical”[All Fields]) AND intradural[All Fields] AND disc[All Fields]. Thirty-seven cases of cervical disc herniation were identified. Demographic variables identified included age, sex, cervical level of herniation, history of associated cervical trauma, presence of Brown-Sequard syndrome, Horner syndrome, and other neurologic findings, radiographic findings, direction of surgical approach, and postoperative outcomes. Results A total of 37 cases of cervical IDH were identified. Most of the cases occurred at the lower levels of the cervical spine, with 35.1% at the C5–C6 level, followed by 24.3% at C6–C7, and lower still at other levels. Of the patients reviewed, 44.4% had a previous history of trauma before manifestation of symptom, with the majority being spontaneous IDH with no previous history of trauma or spine surgery. Brown-Sequard syndrome was present in 43.2% of the patients, whereas 10.8% of patients experienced Horner syndrome. The most common presentations of IDH included quadriplegia, finger/gait ataxia, radiculopathy, and nuchal pain. The degree of neurologic recovery was not associated with patient age. Most of the cervical IDHs in the literature were treated surgically via an anterior approach, but a larger portion of patients who underwent a posterior approach had improved recovery. Conclusions Cervical IDH is a rare event, with this review of the literature outlining the clinical and radiographic parameters of its presentation as well as comparing common surgical strategies for treatment. We outline theories underlying the development of cervical IDH and argue for a posterior surgical approach in which the disc herniation is sequestrated with migration.

A large-scale study on postoperative complications of lumbar fusion surgery for spondylolisthesis comparing patients80 years old with younger patients has not been performed. The purpose of this study is to assess the effects of extreme age (80 years old) on early postoperative outcomes after single-level lumbar fusions for spondylolisthesis.From a validated multicenter surgical database, 2475 patients who underwent a single-level lumbar fusion procedure for spondylolisthesis were selected retrospectively. An extreme age cohort with 227 patients80 years old was compared with a typical age cohort with 2248 patients 45-65 years old.The preoperative characteristics and comorbidities were different between the typical age cohort and the extreme age cohort, with older patients having more preoperative comorbidities, including a lack of independent functional health status before surgery (P0.001), severe chronic obstructive pulmonary disease (P0.020), and hypertension requiring medication (P0.001). There was significantly greater morbidity among the80 cohort regarding urinary tract infection (P = 0.008; odds ratio = 3.30; 95% confidence interval, 1.47-7.40) and intraoperative and postoperative transfusions (P0.001; odds ratio = 2.186; 95% confidence interval, 1.54-3.11). There was significantly greater morbidity among the younger cohort regarding cardiac arrest requiring cardiopulmonary resuscitation (P = 0.043; odds ratio = 0.099; 95% confidence interval, 0.014-0.704).This is the first large study comparing the rates of postoperative complications of lumbar fusion surgery for spondylolisthesis in patients80 years old versus younger patients. The data support that age alone should not exclude a patient for this procedure. However, extra caution is warranted given the slightly increased morbidity.

Background Surgical-site infections (SSIs) are a major cause of morbidity and mortality, increasing the length and cost of hospitalization. In patients undergoing spine surgery, there are limited large-scale data on patient-specific risk factors for SSIs. Methods The American College of Surgeons National Surgical Quality Improvement Program database was reviewed for all spinal operations between 2006 and 2012. The rates of 30-day SSIs were calculated, and univariate analysis of selected preoperative risk factors was performed. Multivariate analysis was then used to identify independent predictors of SSIs. Results A total of 1110 of the 60,179 patients (1.84%) had a postoperative wound infection. There were 527 (0.87%) deep and 590 (0.98%) superficial infections. Patients with infections had greater rates of sepsis, longer lengths of stay, and more return visits to the operating room. Independent predictors of infection were female sex, inpatient status, insulin-dependent diabetes, preoperative steroid use greater than 10 days, hematocrit less than 35, body mass index greater than 30, wound class, American Society of Anesthesiologists class, and operative duration. Conclusions Analysis of a large national patient database revealed many independent risk factors for SSIs after spinal surgery. Some of these risk factors can be modified preoperatively to reduce the risk of postoperative infection.

Schwannomatosis is characterized by multiple non-intradermal schwannomas with patients often presenting with a painful mass in their extremities. In this syndrome malignant transformation of schwannomas is rare in spite of their large size at presentation. Non-invasive measures of assessing the biological behavior of plexiform neurofibromas in neurofibromatosis type 1 such as positron emission tomography (PET), CT scanning and MRI are well characterized but little information has been published on the use of PET imaging in schwannomatosis. We report a unique clinical presentation portraying the use of PET imaging in schwannomatosis. A 27-year-old woman presented with multiple, rapidly growing, large and painful schwannomas confirmed to be related to a constitutional mutation in the SMARCB1 complex. Whole body PET/MRI revealed numerous PET-avid tumors suggestive of malignant peripheral nerve sheath tumors. Surgery was performed on multiple tumors and none of them had histologic evidence of malignant transformation. Overall, PET imaging may not be a reliable predictor of malignant transformation in schwannomatosis, tempering enthusiasm for surgical interventions for tumors not producing significant clinical signs or symptoms.

Partial seizure disorders account for the majority of epilepsy (Sander et al., 1990). In one tertiary center cohort of 2,200 patients, partial epilepsy was more than twice as common as symptomatic, cryptogenic, and idiopathic generalized epilepsies combined. Moreover, in that study, two-thirds of the partial seizure disorders localized to the temporal lobe (Semah et al., 1998). Unfortunately, despite optimal medical therapy, approximately 30% of patients continue to experience recurrent seizures (Sander et al., 1990 Wiebe, et al. 2001). In a recent well-designed trial studying patients who failed initial medication trials, seizure freedom was achieved in only 8% of patients with continued medical therapy compared to 58% of patients undergoing anterior temporal lobectomy (Wiebe, et al. 2001). However, physicians may be reluctant to consider surgery for temporal lobe epilepsy when structural neuroimaging appears normal. Temporal lobectomy has been shown to render about 80% of patients seizure-free in the setting of a magnetic resonance imaging (MRI)–apparent structural abnormality concordant to the seizure onset zone, such as mesial temporal sclerosis (MTS) (Cascino, 2004). On the other hand, patients with temporal lobe epilepsy and normal MRI have received less attention. In order to demonstrate the absence of a potentially epileptogenic structural lesion, it is critical that patients have high-resolution seizure protocol MRI with both T1- and T2-weighted images (Jack, 1996; Cascino, 2004). There are relatively few studies examining temporal lobectomy in patients with normal modern seizure protocol MRI. Existing research suggests significantly disparate rates of successful surgery in patients with nonlesional MRI, ranging from 18–63% of patients becoming seizure-free (Berkovic et al., 1995; Theodore et al., 1997; Sylaja et al., 2004; Cohen-Gadol et al., 2005; Jeha et al., 2006). Many of these studies were conducted during the 1980s and early 1990s (Berkovic et al., 1995; Radhakrishnan et al., 1998; McIntosh et al., 2004), prior to the widespread use of epilepsy neuroimaging protocols that are more sensitive for detecting MTS (Jack, 1996; Jack et al., 1996). Some of these studies used pathologic findings to categorize patients (McIntosh et al., 2004; Cohen-Gadol et al., 2006), information that is not available preoperatively for clinical prognostication. Other studies include heterogeneous patient populations and only small numbers of patients with nonlesional MRI (Holmes et al., 2000; Sylaja et al., 2004; Cohen-Gadol et al., 2005). Therefore, we sought to examine the efficacy of epilepsy surgery and noninvasive predictors of favorable outcome for patients with medically refractory temporal lobe epilepsy and a nonlesional high-resolution seizure protocol MRI.

Study design: Retrospective case review. Introduction: Ischemic insults from blunt cerebrovascular injuries (BCVI) can lead to significant cranial and spinal injury. Specific spine fracture patterns have been identified as more predictive of BCVI, such as vertebral subluxation, fractures through the foramen transversarium, and C1 through C3 fractures. Adequate screening and early treatment has led to a decrease in devastating neurological deficits from associated strokes.1 However, BCVI in association with injuries of the craniocervical junction have been anecdotally reported but their true incidence is still unknown. We hypothesized that craniocervical dissociation (CCD), due to its distractive nature, is also associated with a high incidence of BCVI. Objective: To evaluate the incidence of BCVI in a large series of patients with CCD admitted to a single-level 1 trauma institution. Methods: A retrospective review of all consecutive patients diagnosed with unstable craniocervical distraction injuries (defined as abnormal widening of the C0-C1 and/or C1-2 joints) that were surgically treated from 2003–2009 was performed. All patients with CCD injuries who had a screening catheter angiogram or computed tomographic angiography (CTA) of the neck to exclude BCVI entered the study. Results: Among 39 consecutive patients identified with CCD (26 men [67%] and 13 women [33%] with a mean age of 28.8 years), 28 were screened for BCVI through catheter angiography or CTA. Additional injuries are displayed in Table 1. A total of 14 patients (50%) who were screened had 25 BCVI, with 12 carotid artery and 13 vertebral artery injuries. These injuries were further subclassified according to the Biffl classification system2 (Table 2): Biffl 1 (10 patients); Biffl 2 (6 patients); Biffl 3 (5 patients); Biffl 4 (3 patients), and Biffl 5 (1 patient). Among the 18 patients with a purely ligamentous injury of the craniocervical junction, 8 (44%) had a BCVI (10 carotid artery and 7 vertebral artery injuries). Among the 10 patients with additional spine fractures that are known risk factors for BCVI, 6 (60%) had a vessel injury (6 vertebral artery and 2 carotid artery injuries). Three patients among the 14 with BCVI had a stroke, as opposed to none among the other 14 without BCVI. There was no significant correlation between the presence of BCVI injuries and the presence of abnormal craniocervical distraction as measured by the Harris lines criteria.3 Table 1 Associated injuries in patients screened for BCVI.* Table 2 Biffl grading system for blunt traumatic cerebrovascular injuries. Conclusions: In patients with craniocervical distraction injuries, the incidence of BCVI is high. Those patients with purely ligamentous injuries had a higher incidence of carotid artery injuries whereas those with associated spine fracture patterns that are known predictive risk factors for BCVI had a higher incidence of vertebral artery injuries. We suggest inclusion of craniocervical distraction injuries as another spine fracture pattern indicative for routine screening of BCVI.

This patient has the hallmark of neurofibromatosis type 2 (NF2)–bilateral vestibular schwannomas (VS) – as well as multiple intracranial meningiomas. At the second operation, two tumours were found adjacent to each other on the left side. The caudal aspect of the left VS was removed followed by complete removal of the adjacent tentorial lesion-a meningioma. Subsequent further removal the left VS was limited by decreased amplitude of the brainstem evoked auditory response (BEAR). Resection was limited due to the need to retain hearing on the sole hearing side. Postoperatively, she recovered well and the left sided hearing was preserved. She had a left facial palsy immediately postoperatively, which improved to normal within one month. Histopathological examination demonstrated a VS on the right (MIB–1 labeling index 6%). On the left, the VS had a MIB–1 labeling index of 10%, which may explain its rapid growth. The other lesion was confirmed to be a meningioma (MIB–1 labeling index 5%). NF2 is an autosomal dominant inherited disorder. The responsible gene is located on chromosome 22q12. The diagnostic criteria for NF2 are

Highlights • Fungal osteomyelitis is a rare entity in the spectrum of spinal infections. • We present a case of spinal osteomyelitis secondary to Blastomyces dermatitides. • Infectious lytic lesions of the spine, when stable, may be managed conservatively. • In rare instances, vertebral re-ossification may occur with conservative management., Introduction We present a rare case of thoracic vertebral osteomyelitis secondary to pulmonary Blastomyces dermatitides. Presentation of case A 27-year-old male presented with three months of chest pains and non-productive cough. Examination revealed diminished breath sounds on the right. CT/MR imaging confirmed a right-sided pre-/paravertebral soft tissue mass and destructive lytic lesions from T2 to T6. CT-guided needle biopsy confirmed granulomatous pulmonary Blastomycosis. Conservative management with antifungal therapy was initiated. Neurosurgical review confirmed no clinical or profound radiographic instability, and the patient was stabilized with TLSO bracing. Serial imaging 3 months later revealed near-resolution of the thoracic soft tissue mass, with vertebral re-ossification from T2 to T6. Discussion Fungal osteomyelitis presents a rare entity in the spectrum of spinal infections. In such cases, lytic spinal lesions are classically seen in association with a large paraspinous mass. Fungal infections of the spinal column may be treated conservatively, with surgical intervention reserved for progressive cases manifesting with neurological compromise and/or spinal column instability. Here, we found unexpected evidence for vertebral re-ossification across the affected thoracic levels (T2-6) in response to IV antibiotic therapy and conservative bracing, nearly 3 months later.