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This study examines the impact of the COVID-19 pandemic on health care-associated infection (HAI) incidence in low- and middle-income countries (LMICs).Patients from 7 LMICs were followed up during hospital intensive care unit (ICU) stays from January 2019 to May 2020. HAI rates were calculated using the International Nosocomial Infection Control Consortium (INICC) Surveillance Online System applying the Centers for Disease Control and Prevention's National Healthcare Safety Network (CDC-NHSN) criteria. Pre-COVID-19 rates for 2019 were compared with COVID-19 era rates for 2020 for central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), ventilator-associated events (VAEs), mortality, and length of stay (LOS).A total of 7,775 patients were followed up for 49,506 bed days. The 2019 to 2020 rate comparisons were 2.54 and 4.73 CLABSIs per 1,000 central line days (risk ratio [RR] = 1.85, p = .0006), 9.71 and 12.58 VAEs per 1,000 mechanical ventilator days (RR = 1.29, p = .10), and 1.64 and 1.43 CAUTIs per 1,000 urinary catheter days (RR = 1.14; p = .69). Mortality rates were 15.2% and 23.2% for 2019 and 2020 (RR = 1.42; p.0001), respectively. Mean LOS for 2019 and 2020 were 6.02 and 7.54 days (RR = 1.21, p.0001), respectively.This study documents an increase in HAI rates in 7 LMICs during the first 5 months of the COVID-19 pandemic and highlights the need to reprioritize and return to conventional infection prevention practices.

Cervical spinal cord injury (cSCI) is a major public health concern in the young population as per the estimation of the annual global report, which concluded that the amount of incidence in this area ranged between 11.5 and 53.4 cases per million population. Moreover, Despite the many evaluations conducted to unveil the physiological and thermo logical complications caused to the human body after a cervical spinal cord injury, the fundamental pathophysiology about this type of injury is still inconclusive.This review attempts to provide a better understanding to the various changes caused to the body after a cSCI. It focuses on the alterations in blood circulation, energy expenditure (EE), sweating, shivering responses and consequently disruption in body temperature regulation.Various research engines such as Scopus, PubMed, Embase, Web of Science, EBSCO, and Cochrane Library databases were searched by two independent investigators. 17 studies out of 102 were included based on eligibility criteria: patients with complete and/or incomplete cSCI; minimum of 5 patients as participants; and control group of able Bodied People (AB).Following cSCI, EE decreases by 10% (p 0.05) due to reduction in lean body mass; cardiac output decrements by 27% (p 0.05) following the change in arterial blood vessel structure, and finally; thermoregulatory responses were disturbed because of the absence or decrease in vasodilation, vasoconstriction, sudomotor (autonomic activation of sweat glands) and shivering responses.The body undergoes significant thermoregulatory changes following spinal cord injury. Understanding the pathophysiology of spinal cord injury and its effect on the human body can provide us an insight to develop adequate treatment modalities that tackle the problem of thermal dysregulation in people with cSCI.

Persons with paraplegia (PA) from thoracic spinal cord injury (T1-T12) are prone to thermal stress during exercise due to impaired thermoregulation. This study evaluates the effectiveness of phase change material (PCM) cooling vests on persons with PA of different levels of injury during exercise in hot exposure. Sixteen participants were recruited and divided to three groups based on injury level; high-thoracic T1-T3, mid-thoracic T4-T8, and low thoracic T9-T12 to perform a 30-min arm-crank exercise at a 30 °C room condition. Two types of PCM vests at melting temperature of 20 °C were tested: i) V1 with PCM covering the trunk of 3.4 kg overall vest mass and ii) V2 with PCM covering chest and upper back of 2.17 kg overall vest mass. High thoracic and low-thoracic groups performed NV and V1 tests; whereas, mid-thoracic group performed NV, V1, and V2 tests. Heart rate, core, and skin temperatures were monitored during 15-min preconditioning, 30-min exercise, and 15-min recovery. In addition, thermal comfort, sensation, skin wettedness, and perceived exertion were recorded during exercise only. The main findings were that the effectiveness of the cooling vest was dependent on injury level and portion of sensate skin of trunk covered by the PCM packets. Rise in core temperature ( Δ T c r ) was reduced significantly for the low-thoracic group during exercise and recovery ( Δ T c r = 0.41 °C , 0.26 °C for NV and V1; respectively, p Δ T c r compared to the NV test at the end of the recovery period ( 0.74 °C , 0.42 °C , 0.56 °C , for NV, V1 and V2; respectively). For the high-thoracic group, V1 was not effective in reducing core temperature (p>0.05). For the mid-thoracic group, V2 at 36% lower mass significantly improved thermal comfort (p = 0.0004) compared to the NV test and was as effective compared to V1 in reducing core temperature.

Background Bone morphogenetic protein (BMP) graft showed promising outcome during early phases of its use. However, unreported adverse events and off-label use shattered its safe profile and raised concerns regarding its indication. In 2008 the U.S. Food and Drug Administration prohibited its use in anterior cervical spine procedures due to the possibility of edema, hematoma, and need to intubate. At the molecular level, BMPs act as multifactorial growth factors playing a role in cartilage, heart, and bone formation. However, its unfavorable effect on bone overgrowth or heterotopic ossification post spine surgeries has been described. Reported cases in the literature were limited to epidural bone formation. Case Description We present a rare and interesting case of a 59-year-old female, in whom BMP caused intradural bone growth several years after an anterior lumbar interbody fusion surgery. Conclusion Caution must be exercised while using BMPs because of inadvertent complications.

Foraminal disc herniation presents with an operative challenge, as it often requires facetectomy, which can result in segmental instability. The intraforaminal approach includes partial pars resection and medial facetectomy and allows for direct visualization of the nerve roots and herniated disc in the foramen without violating the joint, with good clinical outcomes. Herein, we describe a retrospective series of patients that underwent minimally invasive paramedian approach with hemilaminectomy, partial medial pars resection, medial facetectomy for foraminal disc herniation. Demographics and clinical outcomes were obtained from medical records. Improvement in functional outcomes was evaluated using the pre and post-operative Visual Analog Scale (VAS) and Oswestry Disability Index (ODI). A total of 23 patients were included in this study. The average age was 56.47 ± 9.4 yrs and body mass index was 31.92 ± 7.7 kg/m2. 47.8% of cases were L4-5 FDH. The estimated blood loss was 31.32 ± 19.8 ml. The average length of hospital stay was 1.11 ± 0.3 days. All patients were discharged home. Overall, there was a significant improvement in the VAS (pre-op: 8.21 ± 2.1; post-op: 2.59 ± 2.7; p-value

Introduction Intradural spinal arachnoid cysts (SACs) are among many etiologies for syringomyelia. Consequentially, neurologic symptoms arise such as pain, gait disturbance, and bladder dysfunction. Identification of SAC on magnetic resonance imaging (MRI) can be challenging, as SACs can be fenestrated or in the form of fine webs. Methods Imaging and clinical data for 7 patients who underwent surgical treatment for SAC associated with syringomyelia were reviewed. All previous publications of this pathology were reviewed via MEDLINE search. Results Seven patients with a mean age 59 years were found to have a SAC causing syringomyelia. Intraoperative exploration confirmed SAC appearances of fine webs or a fluid-filled loculation impinging on the spinal cord. Common presentations were back pain, gait disturbance, and bladder incontinence. Diagnosis was made by MRI, although in 3 cases, the SAC was not identified on the initial review. Computed tomography myelogram was performed in one case due to the enlarged syringomyelia and lack of obvious spinal cord compression. Thoracic laminectomy/laminoplasty was performed for all patients, centered at the level of a subtle indentation of the cord; the syringomyelia proper was not directly addressed. Postoperatively, all patients had complete resolution of their symptoms with MRI demonstrating resolution of the syringomyelia. Conclusions Careful evaluation of the MRI can demonstrate subtle indentation of the cord at the caudal or cephalad end of the syringomyelia and may obviate the need for additional imaging. Meticulous arachnoid dissection and establishment of good CSF flow is sufficient for resolution of the syringomyelia, averting the need for more aggressive procedures.

In this article, we aim to describe the presentation and management of a case of spontaneous intracranial hypotension caused by a dural tear from a ventral thoracic osteophyte at the T12 level that was refractory to non-surgical treatment modalities. A review of the literature has been performed. Also a proposal of diagnostic and treatment algorithm is presented. Intracranial hypotension and CSF leak as a result of dural tear is a common phenomenon. However, the detection of the source of CSF leak from a thoracic spinal osteophyte has rarely been reported. Diagnostic workup including MRI and CT Myelogram as well as application of epidural blood patches and surgical technique of hemilaminectomy and osteophytectomy by transpedicular approach have been described. Literature review was conducted using relevant search terms in PubMed. The patient’s spontaneous intracranial hypotension symptoms resolved and this persisted on follow up visits. Review our experience as well as similar cases in the literature pointed us towards a diagnostic and treatment algorithm. Spontaneous resolution is the norm for intracranial hypotension of most etiologies and management of all such cases begins with fluid resuscitation coupled with bed rest. On failure of conservative therapy, autologous epidural blood patches into the spinal epidural space should be tried, which often produce an immediate relief of symptoms. Osteophyte-induced dural tear and consequent intracranial hypotension may require surgical intervention if the symptoms are refractory to conservative treatment. Under all circumstances a careful step-wise approach for diagnosis and treatment of spontaneous intracranial hypotension needs to be followed, as we have proposed in our article.

Idiopathic spinal cord herniation represents an uncommon and unique diagnostic entity, most commonly affecting middle-aged individuals, with a nearly twofold female predilection. It most characteristically affects the mid-thoracic spine, with the herniation occurring ventrally or ventrolaterally. Clinical presentation is typically a slowly-progressive myelopathy, with Brown-Sequard syndrome occurring more frequently than spastic paraparesis. Diagnosis is made by imaging, with high-resolution or phase-contrast MR sequences and/or CT myelography. Treatment should be individualized, with options including conservative management with routine follow-up and surgical intervention. We review the literature on this interesting topic and report on, and present our technique for, operative reduction and repair of idiopathic spinal cord herniation in a 66 year-old woman.

Background Direct lateral (DLIF) and transforaminal (TLIF) lumbar interbody fusions have been shown to produce satisfactory clinical outcomes with significant reduction in pain and functional disability. Despite their increasing use in complex spinal deformity surgeries, there is a paucity of data comparing outcome measures, which this study addresses. Methods This is a retrospective, comparative study of patients who underwent minimally invasive, 1-level TLIF or DLIF between 2013 and 2015. Only patients 18 years and older were included. Preoperative and demographic variables were collected, and clinical outcome measures were compared between cohorts. Results In total, 46 patients were included (DLIF: 17 patients; TLIF: 29 patients). Preoperatively, there was no difference in visual analog scale pain score or Oswestry Disability Index. Overall, there was a significant improvement in the postoperative visual analog scale score and Oswestry Disability Index in the separate cohorts, without significant difference when compared. The duration of postoperative narcotic use was similar in both cohorts (DLIF: 4.8 ± 4.7 months vs. TLIF: 5.2 ± 5.1 months, P = 0.82). Significantly more patients in DLIF cohort were cleared for work after surgery. Patients who underwent MIS TLIF had a significantly longer time to return to work (7.1 ± 4.8 months) compared with patients undergoing DLIF (2.3 ± 1.3, P = 0.006). There was a greater incidence of reoperation in the TLIF cohort. Conclusions Both MIS TLIF and DLIF provide long-term improvement in pain andfunctional outcomes, with an overall reduction in postoperative narcotic requirement. However, there was a significantly longer time to return to work and a greater incidence of reoperation in the TLIF cohort compared with the patients who underwent DLIF.

Radiation therapy continues to play an extremely valuable role in the treatment of malignancy. The effects of radiation therapy on normal tissue can present in a delayed fashion, resulting in localized damage with pseudomalignant transformation, producing a compressive effect on the spinal cord or exiting nerve roots. Infiltration of inflammatory cells and the subsequent fibrotic response can result in the development of an inflammatory pseudotumor (benign tumor-like lesion) with subsequent mass effect. Herein, the authors present a rare case of inflammatory pseudotumor with fulminant cervicothoracic cord compression, developing 7 years after radiation therapy for breast cancer. The lesion recurred following resection but subsequently displayed complete and rapid resolution following steroid therapy. To the best of the authors' knowledge, no previous studies have reported such an incident.

Expandable cages have been used successfully to reconstruct the anterior spinal column in the treatment of traumatic, neoplastic, infectious, and degenerative spine disease. To the best of our knowledge, no studies report the results of the use of expandable cages in patients undergoing multilevel corpectomies for cervical spine metastatic disease. We report our experience with the use of expandable cages in this subgroup of patients. From August 2006 to May 2008, 5 patients presenting with myelopathy, pain, and/or radiculopathy secondary to metastatic disease of the cervical spine underwent multilevel cervical corpectomies and placement of expandable cages in our institution. All procedures were supplemented with an anterior cervical plate and with posterior instrumentation to achieve a 360° fusion. A visual analog scale (VAS), Nurick grade, Frankel grade, American Spinal Injuries Association (ASIA) grade, and Ranawat grade were used to evaluate patients pre- and postoperatively. The mean follow-up period was 13.2 months. Three patients underwent a 2-level corpectomy, 1 a 3-level corpectomy, and 1 a 4-level corpectomy. Postoperative imaging studies showed that all patients had correction of preoperative kyphosis. The mean VAS score was reduced from 6.4 to 1. All other indices of spinal cord injury measured improved postoperatively or were stabilized. Postoperative imaging studies showed stable constructs in 4 patients. The use of expandable cages in multilevel corpectomies for the treatment of metastatic cervical spine disease appears to be a safe and effective way to reconstruct the anterior column of the cervical spine, preventing further neurologic deterioration.

Study design Multicenter retrospective analysis. Objectives To review the results of surgical treatment during the last 6 years of C2 fractures in patients over the age of 70. Summary of background data Little information exists about the clinical outcome of surgical treatment of elderly patients with C2 fractures, their ability to return to their previous environment, and their postoperative level of independence. Methods The medical records and radiographs of 29 patients who had undergone surgical treatment for C2 fractures were reviewed. The type of C2 fracture, neurologic examination at presentation, type of surgical treatment, perioperative morbidity and mortality, presence of osseous union, and stability of alignment were recorded. Long-term disposition was determined from office visits or by telephone interview. Results Twenty-four of 29 patients had type II dens fractures alone. The remaining 5 had associated C1 fractures. All patients were neurologically intact at presentation except for 2 patients with signs and symptoms of central cord syndrome. Perioperative complications occurred in 3 patients (10.3%). One patient died on postoperative day 6 from a myocardial infarction. Mean+/-SD radiographic follow-up was 9+/-3.2 months (range, 3 to 24). Of the 16 patients who underwent odontoid screw fixation, 6 (37.5%) had osseous union, and 9 (56.2%) were stable on radiographs. An additional patient who had odontoid screw initially required a posterior approach reoperation. Of the 13 posterior fusions, 4 (30.7%) had osseous unions and 9 (69.2%) were stable on flexion extension radiographs. Mean+/-SD clinical follow-up was 18+/-2.2 months (range, 3 to 72 mo). Twenty-five of 29 patients (86.2%) returned to their previous environment. Two patients died of unrelated etiology. Conclusions C2 fractures in the elderly can be treated surgically with both anterior and posterior approaches with acceptable morbidity and mortality rates. The majority of patients can be mobilized early and return to their previous levels of independence.

Objective: To analyze the long-term clinical outcomes and complication rates associated with percutaneous balloon compression (PBC) of the trigeminal ganglion in patients with recurrent trigeminal neuralgia (TN) who were treated surgically with procedures other than PBC. Methods: In this retrospective study, the authors reviewed the results of 29 patients who underwent 41 PBC procedures for recurrent TN between 1998 and 2006. Results: The overall mean length of follow-up was 49 months (range 1–101). Pain relief was immediate in 24 (83%) patients. There was no pain relief in 5 patients (17%). 2 patients were lost to follow-up. 12 (54.5%) of 22 patients remained pain-free during a mean follow-up period of 65 months (range 40–101). The other 10 patients (45.5%) who had immediate pain relief experienced recurrent pain, with a mean time to recurrence of 7.3 months (17 days to 38 months). PBC was repeated in 11 patients, and was performed a third time in 2 patients. Morbidities included minor dysesthesia (2 patients), masseter weakness (2 patients), corneal anesthesia (1 patient), anesthesia dolorosa (1 patient), and subarachnoid hemorrhage (1 patient with history of multiple myeloma). Conclusion: PBC is a useful treatment for patients with recurrent TN who have already been treated surgically. Long-term relief of pain in this subset of TN patients is achieved nearly half of the time with side-effect profiles similar to those reported in published data.

Background C5 palsy is a well-reported complication of cervical spine surgery. The implication of sagittal cervical alignment parameters and their changes after surgery on the incidence of C5 palsy remains unclear. Objective We review cervical alignment changes in our cases of C5 palsy after cervical laminectomy and fusion. Methods Cases of C5 palsy were retrospectively compared with a control group. Preoperative and postoperative upright plain film radiographs were analyzed in blinded fashion. Results Spine registry analysis identified 148 patients who underwent cervical laminectomy and fusion by the senior author over 5 years. There were 18 (12%) cases complicated by postoperative C5 palsy. Nine of these 18 patients had prerequisite upright films and were compared with a randomly constructed case control group of 20 patients. There were no statistically significant differences between the 2 groups in age, proportion of males, and preoperative Nurick score. Measures of sagittal alignment did not differ significantly between the 2 groups on preoperative and postoperative imaging. When comparing the amount of alignment change between preoperative and postoperative upright imaging, however, patients with C5 palsy had a statistically higher amount of average C4-C5 Cobb angle change (-2.53 vs 0.78°; P = .01). Logistic regression analysis demonstrated that lordotic change in both C4-C5 and C2-C7 Cobb angles were associated with development of palsy. Conclusion Lordotic cervical correction, as measured on upright imaging, was statistically larger in patients who had C5 palsy. The role of deformity correction in C5 palsy deserves further study and may inform intraoperative decision making. Abbreviation CLF, cervical laminectomy and fusion.

Background Cerebrospinal fluid (CSF) leak during anterior cervical spine surgery can lead to complications, including wound breakdown, meningitis, headaches, need for lumbar drain, or additional surgery. These leaks can be difficult to manage given the limited field of view and lack of deep access. Herein, we describe 8 consecutive patients who underwent intraoperative repair of CSF leak, with no postoperative evidence of wound dehiscence or drainage. Methods A retrospective review was performed on 8 cases where CSF leak was encountered during an anterior cervical spine surgery. Patients had ossification of the posterior longitudinal ligament, intradural disk herniation, or dural ectasia. Intraoperative repair was as follows. First, CSF was drained to low pressure, and durotomy was covered by dural substitute and sealant agent. Then the interbody graft used was manually undersized in the anteroposterior dimension to allow for expansion of the agents used. Anterior instrumentation was then performed. Finally, a wound drain was anchored to a biologic bag for shoulder level passive drainage. Results In all 8 cases, there were no cases of wound dehiscence or CSF leak using this strategy. Likewise, there was no evidence of cord compression or neurologic deficits. No meningitis or persistent headaches were reported, and there was no need for lumbar drain placement at any time postoperatively. Conclusions Once durotomy is encountered during anterior spine surgery, draining the CSF to a low pressure followed by dural substitute with a sealing agent, followed by a smaller anteroposterior size graft is an effective strategy of preventing complications in an inescapable problem.

✓ Patients with sleep apnea often are treated by sleep disorder specialists and are studied in a sleep laboratory. The authors present two such patients who ultimately were found to harbor large benign anterior skull base lesions that caused their obstructive sleep apnea (OSA). The first patient had a massive pituitary tumor and had undergone a tracheostomy before the lesion was diagnosed. The second patient had a large frontoethmoidal encephalocele that was diagnosed at the same time as a recommendation for continuous positive airway pressure therapy was being considered. Such therapy in the presence of an encephalocele can be dangerous and even fatal. Although there are case reports of tumors causing OSA, nearly all of these lesions have been large pharyngeal lipomas (some of which were palpable in the neck during physical examination) or growth hormone—secreting pituitary adenomas. The patients reported here were completely unaware of the presence of these large lesions until imaging studies and/or nasal endoscopy were performed. These cases illustrate the need to perform nasopharyngeal endoscopy and also to obtain magnetic resonance images of the head before prescribing therapy for OSA. Neurosurgeons must be aware that large skull base lesions sometimes present only with OSA.

Study design We conducted a retrospective, case control study on patients undergoing surgery for spinal tumors. OBJECTIVE.: Our aim was to determine the incidence and to identify risk factors for surgical site infections (SSIs) in patients undergoing surgery for spinal tumors. Summary of background data SSIs after spinal tumor surgery may be particularly devastating as they may add to substantial surgical morbidity and may further exacerbate already existing neurologic deficits. Incidence and risk factors predisposing to SSIs in patients undergoing surgery for spinal tumors are not well studied yet. Methods Between January 1995 and February 2008, 971 procedures for spinal tumors were performed on 739 patients. Excluding sacral tumors from the current study, 895 procedures on 678 patients were reviewed to identify those cases with SSIs. Furthermore, 65 infected cases and a randomly selected subset of 162 controls were analyzed by logistic regression modeling to identify the risk factors associated with SSIs. Results There were 678 patients that were included in this study with 364 men (54%) and 314 women (46%), with an average age of 47.2 year. Sixty-five patients who developed SSIs underwent a total of 162 procedures including 78 procedures for wound debridement and washout. The incidence of SSIs was 8.89% for primary nonbony spinal tumors, 9.5% for metastatic spinal tumors, and 13.7% for primary bony spinal tumors. Staphylococcus aureus was the most commonly isolated organism (n = 22 of 65, 33%). In the multivariate logistic regression model, previous spinal surgeries, complex plastic closures, increasing number of comorbidities, presence of a hospital acquired infection at the time of a previous surgery, and increasing duration of hospital stay during primary surgery were significantly associated with increased likelihood of developing postoperative SSIs. Conclusion Surgery for spine tumors appears to be associated with a higher incidence of SSI than nontumor spine surgery. Identification of perioperative risk factors will help delineate this subset of patients with high risk for developing SSIs thus potentially allowing perioperative modification for such factors, which may lead to an overall better clinical outcome and patient satisfaction.

pelvic incidence (PI) directly regulates lumbar lordosis and is a key determinant of sagittal spinal balance in normal and diseased states. Pelvic incidence is defined as the angle between the line perpendicular to the S-1 endplate at its midpoint and the line connecting this point to a line bisecting the center of the femoral heads. It reflects an anatomical value that increases with growth during childhood but remains constant in adulthood. It is not altered by changes in patient position or after traditional lumbosacral spinal surgery. There are only 2 reports of PI being altered in adults, both in cases of sacral fractures resulting in lumbopelvic dissociation and sacroiliac (SI) joint instability. En bloc sacral amputation and sacrectomy are surgical techniques used for resection of certain bony malignancies of the sacrum. High, mid, and low sacral amputations result in preservation of some or the entire SI joint. Total sacrectomy results in complete disruption of the SI joint. The purpose of this study was to determine if PI is altered as a result of total or subtotal sacral resection.the authors reviewed a series of 42 consecutive patients treated at The Johns Hopkins Hospital between 2004 and 2009 for sacral tumors with en bloc resection. The authors evaluated immediate pre- and postoperative images for modified pelvic incidence (mPI) using the L-5 inferior endplate, as the patients undergoing a total sacrectomy are missing the S-1 endplate postoperatively. The authors compared the results of total versus subtotal sacrectomies.twenty-two patients had appropriate images to measure pre- and postoperative mPI; 17 patients had high, mid, or low sacral amputations with sparing of some or the entire SI joint, and 5 patients underwent a total sacrectomy, with complete SI disarticulation. The mean change in mPI was statistically different (p0.001) for patients undergoing subtotal versus those undergoing total sacrectomy (1.6° ± 0.9° vs 13.6° ± 4.9° [± SD]). There was no difference between patients who underwent a high sacral amputation (partial SI resection, mean 1.6°) and mid or low sacral amputation (SI completely intact, mean 1.6°).the PI is altered during total sacrectomy due to complete disarticulation of the SI joint and discontinuity of the spine and pelvis, but it is not changed if any of the joint is preserved. Changes in PI influence spinopelvic balance and may have postoperative clinical importance. Thus, the authors encourage attention to spinopelvic alignment during lumbopelvic reconstruction and fixation after tumor resection. Long-term studies are needed to evaluate the impact of the change in PI on sagittal balance, pain, and ambulation after total sacrectomy.

Sacral neoplasm resection is managed via partial or total sacrectomy that is performed via the Kraske approach. The combination of the patients positioning and the relatively long operative time required for this procedure increase the risk of pressure ulcers. Facial pressure ulcers can cause tissue necrosis and/or ulceration in a highly visible area, leading to a cosmetically disfiguring lesion. Here, the authors report the use of a Mayfield clamp in the positioning of patients undergoing sacral tumor resection to prevent facial pressure ulceration. After the patient is placed prone in the Kraske or Jackknife position, the hips and knees are flexed with arms to the side. Then while in the prone position, the patient is physically placed in pins, and the Mayfield clamp is fixated at the center of the metal arch via the Mayfield sitting adapter to the Andrews frame, suspending the head (and face) over the table. The authors find that this technique prevents the development of facial pressure ulcers, and it has the potential to be used in patients positioned in the Kraske position for other surgical procedures.

Cervical spondylolysis is an uncommon disorder involving a cleft at the pars interarticularis. It is most often found at the C-6 level, and clinical presentations have included incidental radiographic findings, neck pain, and rarely neurological compromise. Although subaxial cervical spondylolysis has been described in 150 patients, defects at the C-2 pedicles are rare. The authors present 2 new cases of C-2 spondylolysis in athletically active young persons who did not demonstrate instability or neurological deficits, were able to remain active, and are being managed conservatively with serial examinations and imaging. They also discuss the results of 22 previously reported cases of C-2 spondylolysis. Based on the literature and their own experience, the authors conclude that most patients with C-2 spondylolysis remain neurologically intact, maintain stability despite the bony defect, and can be managed conservatively. Surgery is reserved for patients who demonstrate severe instability or spinal cord compromise due to stenosis.

Background: Meningioangiomatosis (MA) is a rare benign disorder. It may occur sporadically or in association with neurofibromatosis (NF). The sporadic type typically presents with seizures, whereas that associated with NF is often asymptomatic. Of the 100 cases reported, only 14 are associated with NF. We now report 2 additional cases of MA associated with neurofibromatosis 2 (NF2) in a single family, with one occurring in the cerebellum. The etiology, pathology, and imaging features of MA are presented. Case Description: A 38-year-old woman (patient 1) presented with a 4-month history of ataxia. She had been diagnosed previously with NF2. Magnetic resonance imaging (MRI) scans of the brain revealed bilateral acoustic neuromas and multiple calcified intracranial lesions. Her 13-year-old daughter (patient 2) presented with complex partial seizures. MRI scans of the brain revealed bilateral acoustic neuromas and a right parietal mass.Patient 1 underwent a suboccipital craniotomy to resect the right-sided acoustic neuroma. A small portion of normal-appearing cerebellar cortex was resected to avoid undue retraction. Histopathologic examination showed the presence of a lesion consistent with MA. Patient 2 underwent a right temporal-parietal craniotomy to remove the enhancing epileptogenic right posterior temporoparietal lesion. Histopathologic analysis showed a lesion consistent with meningioma and MA. Conclusions: MA has been reported infrequently in association with NF2. We now report 2 cases of MA associated with NF2 in one family, and we add the cerebellum to possible locations of occurrence. MA should be considered in the differential diagnosis of cortical lesions, particularly in patients with NF2.

Tumors located in the region of the foramen of Monro often present with signs and symptoms of obstructive hydrocephalus. Various types of lesions occur in this location. We describe a case of a dysembryoplastic neuroepithelial tumor of the septum pellucidum presenting with obstructive hydrocephalus and its successful endoscopic excision. The surgical considerations and pathologic findings are discussed.

Contralateral hematoma formation following acute subdural hematoma (ASDH) evacuation is a well-described complication. The most common type of contralateral hematoma is an epidural hematoma. Rarely, ASDH develops on the contralateral side. We report an elderly woman who presented with a post-traumatic ASDH and underwent ipsilateral hematoma evacuation by craniotomy and subsequently developed a contralateral ASDH. Because of the potential consequences of a delayed ASDH, there should be a low threshold for early post-operative imaging following ASDH evacuation, especially in elderly patients and those with additional associated intracranial injuries.