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OBJECTIVE The use of intraoperative stereotactic navigation has become more available in spine surgery. The authors undertook this study to assess the utility of intraoperative CT navigation in the localization of spinal lesions and as an intraoperative tool to guide resection in patients with spinal lesions. METHODS This was a retrospective multicenter study including 50 patients from 2 different institutions who underwent biopsy and/or resection of spinal column tumors using image-guided navigation. Of the 50 cases reviewed, 4 illustrative cases are presented. In addition, the authors provide a description of surgical technique with image guidance. RESULTS The patient group included 27 male patients and 23 female patients. Their average age was 61 ± 17 years (range 14–87 years). The average operative time (incision to closure) was 311 ± 188 minutes (range 62–865 minutes). The average intraoperative blood loss was 882 ± 1194 ml (range 5–7000 ml). The average length of hospitalization was 10 ± 8.9 days (range 1–36 days). The postoperative complications included 2 deaths (4.0%) and 4 radiculopathies (8%) secondary to tumor burden. CONCLUSIONS O-arm 3D imaging with stereotactic navigation may be used to localize lesions intraoperatively with real-time dynamic feedback of tumor resection. Stereotactic guidance may augment resection or biopsy of primary and metastatic spinal tumors. It offers reduced radiation exposure to operating room personnel and the ability to use minimally invasive approaches that limit tissue injury. In addition, acquisition of intraoperative CT scans with real-time tracking allows for precise targeting of spinal lesions with minimal dissection.

With the increasing prevalence and decreasing cost of MRI scans, incidental discovery of vestibular schwannoma (VS) has become more common. Scarce literature exists regarding management of the tumors in those patients with incidentally discovered VSs, and clear guidelines for management do not exist. In this review, the authors examine the available literature for insights into management of incidentally diagnosed VS and provide an algorithm for their management.

Any traumatic spinal cord injury (SCI) may cause symptoms ranging from pain to complete loss of motor and sensory functions below the level of the injury. Currently, there are over 2 million SCI patients worldwide. The cost of their necessary continuing care creates a burden for the patient, their families, and society. Presently, few SCI treatments are available and none have facilitated neural regeneration and/or significant functional improvement. Research is being conducted in the following areas: pathophysiology, cellular therapies (Schwann cells, embryonic stem cells, induced pluripotent stem cells, mesenchymal stem cells, olfactory ensheathing cells), growth factors (BDNF), inhibitory molecules (NG2, myelin protein), and combination therapies (cell grafts and neurotrophins, cotransplantation). Results are often limited because of the inhibitory environment created following the injury and the limited regenerative potential of the central nervous system. Therapies that show promise in small animal models may not transfer to nonhuman primates and humans. None of the research has resulted in remarkable improvement, but many areas show promise. Studies have suggested that a combination of therapies may enhance results and may be more effective than a single therapy. This paper reviews and discusses the most promising new SCI research including combination therapies.

Background Admitting facility may significantly affect outcome for spontaneous subarachnoid hemorrhage patients. We assessed outcomes of patients admitted directly to a comprehensive stroke center with those initially admitted to a general hospital and subsequently transferred. The comprehensive stroke center included a neurocritical care ICU, cerebrovascular neurosurgeons and endovascular specialists. Methods We identified 107 consecutive spontaneous subarachnoid hemorrhage cases. Of these cases, 31 (29%) patients were admitted directly and 76 (71%) were transferred from general hospitals. Univariate and multivariate analyses evaluated differences in mortality, complications, discharge disposition, and in-hospital length of stay. Results Differences in baseline parameters (age, gender, admission Glasgow Coma Scale, Fisher grade, admission Hunt and Hess grade) were not statistically significant between direct-admit and transfer patients at our institution. Transferred patients developed vasospasm more frequently (58% vs. 32%; P < 0·05) and had a longer delay time to surgery (3·9-days vs. 2·4-days: P < 0·05). Multivariate analysis showed that the likelihood of vasospasm was significantly higher for transfer patients (OR 3·46, CI: 1·2–10·3, P = 0·03). In addition, longer in-hospital stays and higher odds of non-routine discharge were observed in transferred patients ( P < 0·01). No differences in outcome could be identified for surgical vs. endovascular treatment rates between direct-admit and transfer patients. An association, but no causative link, can be made between the effect of transfer and the outcomes of SAH patients due to the retrospective nature of our study. Conclusions Spontaneous subarachnoid hemorrhage patients admitted directly to our comprehensive stroke center showed less complications compared to those transferred from general hospitals. This improvement was independent of time to treatment. Additional research in multiple centers using prospective analysis should be conducted to confirm that preferential direct transport to a comprehensive stroke center would likely yield considerable improvements in public health.

High-resolution neuroimaging modalities are used often in studies involving healthy volunteers. Subsequently, a significant increase in the incidental discovery of asymptomatic intracranial abnormalities raised the important ethical issues of when follow-up and treatment may be necessary. We examined the literature to establish a practical set of criteria for approaching incidental findings. Our objective is to develop an algorithm for when follow-up may be important and to provide recommendations that would increase the likelihood of follow-up. A systematic literature search was performed using the PubMed and MEDLINE databases to identify articles describing brain tumors and intracranial aneurysms. The treatment algorithm we present suggests that incidental intracranial masses suspicious for glioma should be biopsied or resected, while other masses are to be followed with serial imaging based on the expected growth pattern. Lack of follow-up can result in adverse outcomes that can be mitigated by using technology to facilitate communication and improve follow-up care. The importance of training physicians to be good communicators is also stressed. New technology including automated telephone systems, texting and email will improve access to patients and hopefully encourage compliance and follow-up.

Low back pain is widely recognized as one of the most prevalent pathologies in the developed world. In the United States, low back pain is the most common health problem for adults under the age of 50, resulting in significant societal and personal costs. While the causes of low back pain are myriad, it has been significantly associated with intervertebral disc (IVD) degeneration. Current first-line therapies for IVD degeneration such as physical therapy and spinal fusion address symptoms, but do not treat the underlying degeneration. The use of tissue engineering to treat IVD degeneration provides an opportunity to correct the pathological process. Novel techniques are currently being investigated and have shown mixed results. One major avenue of investigation has been stem cell injections. Mesenchymal stem cells (MSCs) have shown promise in small animal models, but results in larger vertebrates have been mixed.

Scoliosis is a significant cause of disability and health-care resource utilization in the United States.Our aim was to evaluate potential disparities in the selection of treatments and outcomes for idiopathic scoliosis patients on a national level. To date, only one study has examined inpatient complications, discharge disposition, and mortality with respect to scoliosis treatment on a national scale.Retrospective review of cases having a primary diagnosis of idiopathic scoliosis using the nationwide inpatient sample (NIS) administrative data from 1998 to 2007.The NIS data were queried to identify patients with a primary diagnosis of idiopathic scoliosis (International Classification of Diseases, Ninth Revision [ICD-9] diagnosis code: 737.30) admitted routinely. Surgically treated patients were identified as those patients who underwent a spinal fusion (ICD-9-Clinical Modification code: 81.08) as a principal procedure.Rates of surgical versus nonsurgical treatments were measured as were inhospital complications and mortality rates.No external funding was received for this work. Univariate and multivariate analyses evaluated race, sex, socioeconomic factors, and hospital characteristics as predictors of surgical versus nonsurgical treatments, as well as inhospital complications and mortality rates.The study analyzed 9,077 surgically and 1,098 nonsurgically treated patients with idiopathic scoliosis. Univariate analysis showed both patient- and hospital-level variables as strongly associated with surgical versus nonsurgical treatments and outcomes. Multivariate analysis revealed that Caucasians and private insurance patients were more likely to undergo surgical treatment (p.05) even when controlling for comorbidities. Additionally, Caucasians had a reduced risk of nonroutine discharge compared with non-Caucasians (p=.03). Large hospitals had higher surgery rates (p=.08) than small- or medium-sized facilities and a lower risk of mortality (p=.04). Caucasians (65.1%) were more commonly admitted to large teaching hospitals than African American (59.8%) or Hispanic (41.8%) patients.Differences were found in the selection of surgical versus nonsurgical treatments, as well as inhospital morbidity for hospitalized idiopathic scoliosis patients based on ethnic and socioeconomic variables. This may in part be because of differences in access to the resources of large teaching hospitals for different ethnic and socioeconomic groups or variability in severity of scoliosis among these groups that was not captured in this database.

Spinal dural arteriovenous fistulas (DAVF) in the cervical spine are known to cause subarachnoid hemorrhage. Vasospasm after rupture of a DAVF, however, has not previously been reported.A 48-year-old woman who presented with the sudden onset of altered mental status. Imaging demonstrated extensive subarachnoid hemorrhage and spinal DAVF at C1 to C2. The patient underwent a suboccipital craniotomy for DAVF ligation. On post-operative day three, she began having acute weakness in all her extremities with proprioception and vibration preserved, whereas pain and temperature sensation was lost. An angiogram demonstrated bilateral vertebral artery vasospasm with no filling of the anterior spinal artery. Bilateral angioplasty of the vertebral arteries was performed successfully and post-angioplasty, the right vertebral artery was filling the anterior spinal artery. The patient clinically improved. She subsequently required treatment with n-butyl cyanoacrylic acid (nBCA) embolization and gamma knife radiosurgery to achieve obliteration of the lesion.For patients with subarachnoid hemorrhage of unknown origin, differential diagnosis should include DAVF. This patient also presented with vasospasm in the context of ruptured DAVF, a complication previously unreported in the literature. This finding suggests that close monitoring for vasospasm after rupture of DAVF is warranted.

Object Athletes present with back pain as a common symptom. Various sports involve repetitive hyperextension of the spine along with axial loading and appear to predispose athletes to the spinal pathology spondylolysis. Many athletes with acute back pain require nonsurgical treatment methods; however, persistent recurrent back pain may indicate degenerative disc disease or spondylolysis. Young athletes have a greater incidence of spondylolysis. Surgical solutions are many, and yet there are relatively few data in the literature on both the techniques and outcomes of spondylolytic repair in athletes. In this study, the authors undertook a review of the surgical techniques and outcomes in the treatment of symptomatic spondylolysis in athletes. Methods A systematic review of the MEDLINE and PubMed databases was performed using the following key words to identify articles published between 1950 and 2011: “spondylolysis,” “pars fracture,” “repair,” “athlete,” and/or “sport.” Papers on both athletes and nonathletes were included in the review. Articles were read for data on methodology (retrospective vs prospective), type of treatment, number of patients, mean patient age, and mean follow-up. Results Eighteen articles were included in the review. Eighty-four athletes and 279 nonathletes with a mean age of 20 and 21 years, respectively, composed the population under review. Most of the fractures occurred at L-5 in both patient groups, specifically 96% and 92%, respectively. The average follow-up period was 26 months for athletes and 86 months for nonathletes. According to the modified Henderson criteria, 84% (71 of 84) of the athletes returned to their sports activities. The time intervals until their return ranged from 5 to 12 months. Conclusions For a young athlete with a symptomatic pars defect, any of the described techniques of repair would probably produce acceptable results. An appropriate preoperative workup is important. The ideal candidate is younger than 20 years with minimal or no listhesis and no degenerative changes of the disc. Limited participation in sports can be expected from 5 to 12 months postoperatively.

The direct lateral interbody fusion (DLIF), a minimally invasive lateral approach for placement of an interbody fusion device, does not require nerve root retraction or any contact with the great vessels and can lead to short operative times with little blood loss. Due to anatomical restrictions, this procedure has not been used at the lumbosacral (L5-S1) junction. Lumbosacral transitional vertebrae (LSTV), a structural anomaly of the lumbosacral spine associated with low back pain, can result in a level being wrongly identified pre-operatively due to misnumbering of the vertebral levels. To our knowledge, use of the DLIF graft in this patient is the first report of an interbody fusion graft being placed at the disc space between the LSTV and S1 via the transpsoas route. We present a review of the literature regarding the LSTV variation as well as the lateral placement of interbody fusion grafts at the lumbosacral junction.

In a 41-year-old woman with a ruptured anterior communicating artery aneurysm, cerebral angiography incidentally showed an absence of the right common carotid artery. The right internal and external carotid artery originated from the ipsilateral inominate artery. The absence of the common carotid artery is extremely rare and association with a ruptured cerebral aneurysm is even less common. A description of the case and review of the literature are reported.

Patients with cervical carotid and intracranial stenting are routinely premedicated with antithrombotic agents, clopidogrel and aspirin (ASA), and intraprocedurally with heparin. The levels of antithrombotic therapy necessary for these neurovascular therapies have yet to be well defined.A retrospective review of 52 patients who underwent neurovascular stenting procedures was carried out. Measurements obtained intraoperatively included: activating clotting time, antiplatelet inhibition (from Accumetrics) recorded as ASA reaction units (ARU), P2Y12 reaction units (PRU), baseline (BASE), and percentage inhibition. Percentage P2Y12 platelet inhibition20% and ARU550 were defined as suboptimal clopidogrel and ASA responses, respectively.52 patients (mean age 62.6 years) underwent stent implantation for wide necked aneurysms (28, 54%), symptomatic intracranial stenosis (13, 25%) and cervical carotid stenosis (11, 21%). Mean ARU assays were 463.0 ± 84.7. The response was suboptimal in seven patients. For clopidogrel, the mean BASE, PRU and percentage inhibition were 374.0± 54.9, 279.5 ± 78.5 and 30.7% ± 22.6%, respectively. 19 patients (36.5%; p0.01) showed suboptimal responses for percentage inhibition. Multivariate analysis showed that body weight (82.0 ± 11 vs 73.6 ± 14 kg; p =0.04) and body mass index were significant predictors (OR 1.18, 95% CI 1.01 to 1.18; p =0.003) in the suboptimal group. One case of intraprocedural thrombosis (2%) was observed in the suboptimal group and no cases were seen in the therapeutic group.Data obtained in this study suggest a suboptimal clopidogrel response in patients with greater body weight and body mass index. Adjusted dosing according to weight may help achieve adequate therapeutic platelet inhibition and reactivity while decreasing thromboembolic complications.

Giant cell tumors (GCTs) are rare lesions of the cervical spine, with only 14 previously reported pediatric cases in the literature, all occurring in females. The authors present the case of a 15-year-old boy with neck pain who was found to have a lytic GCT of the odontoid process. Following resection, recurrent disease was treated with radiotherapy and chemotherapy and then a final resection. He has remained tumor free for more than 10 years. The rarity of GCTs can make their diagnosis difficult in the cervical spine. Because of their aggressive behavior and relative resistance to adjuvant therapy, GCTs must be monitored diligently and treated aggressively.

While endovascular techniques play a significant and expanding role in the management of basilar trunk aneurysms, open surgical clipping remains necessary in select cases. Expanded endonasal transclival approaches offer the advantage of direct access and visualization of the midline vertebrobasilar system, benefits ideally suited to a basilar trunk aneurysm. A 59-year old woman with subarachnoid hemorrhage was found to have a ruptured basilar trunk aneurysm associated with a feeding vessel to a small cerebellar arteriovenous malformation (AVM). An expanded endoscopic endonasal transclival approach was used to successfully clip the basilar trunk aneurysm and feeding AVM vessel. The patient was subsequently discharged home without any neurological deficits. Transclival clipping of basilar trunk aneurysms is technically feasible and plays an important role in management when other strategies fail. The technical benefits of this approach include proximal and distal control of the basilar artery and improved visualization of the brainstem and perforators. Endoscopic transclival approaches should be considered in the management of complex basilar trunk aneurysms.

Endometriosis consists of ectopic endometrial tissue outside of the uterine cavity. It is typically benign; however, in some cases, it may cause neurological symptoms if involving the central or peripheral nervous system. We present in this report a 46-year-old Caucasian female with lumbar pain progressively worsening for the last 3 years in her left hip and buttock with radicular symptoms radiating to her left anterior thigh with MR imaging showed an enhancing mass in the L4 neural foramen, interpreted as a nerve sheath tumor. At operation the nerve showed extrinsic and intrinsic abnormality, proven to be endometriosis. Postoperatively, the patient reported relief from her radiculopathy. We review the previous cases, discuss the pathogenesis and additional characteristics that highlight that intraspinal endometriosis, although rare, and must be considered as a potential cause of lumbar pain in women. Surgical resection is recommended in cases having severe or worsening neurologic symptoms or signs of cauda equina syndrome but care must be taken to avoid injuring the nerve. Adjunctive treatment may be used in cases of residual or recurrent lesions. doi:10.4021/wjon413w

Bacillus cereus meningitis is a rare disease with a very high mortality rate in neonates. The authors present the rare case of a premature infant with B. cereus bacteremia and subsequent intracranial abscesses. In addition to aggressive medical therapy, surgical drainage was performed via a left frontal mini-craniotomy. At 15 months of age, the patient had mild developmental delay, cortical blindness, and sensorineural hearing loss. The clinical case is described and difficulties in the management of B. cereus meningoencephalitis in infants are discussed.

Tamoxifen has been shown to be a potent neuroprotectant against stroke in rodents. Because other neuroprotectant medications have failed in human trials, a study of tamoxifen in a large-animal model was necessary to further assess the drug's effectiveness. For this study, the authors developed an endovascular model of anterior circulation infarction in canines to mimic the human clinical condition. They assessed the following hypotheses: 1) that they will be able to consistently produce an internal carotid artery (ICA) terminus infarction and 2) that tamoxifen is an effective neuroprotectant against stroke in canines.In 24 male beagles (weight 9-11 kg), bilateral femoral artery cutdowns were performed, and the vertebral artery and left ICA were each selectively catheterized. Under fluoroscopic guidance, a microcatheter was introduced via the vertebral artery, guiding the catheter into the basilar artery, posterior communicating artery, and ICA terminus. A 1-ml clot was injected in the terminus, occluding the middle cerebral artery (MCA) and anterior cerebral artery (ACA) origin. In the first 12 canines, the occlusions were confirmed by angiography. A Canine Stroke Score (CSS) was assigned (score range 0-18 [0 = intact on examination, 18 = comatose]). The animals were then killed and their brains stained with 2,3,5-triphenyltetrazolium chloride (TTC). The subsequent 12 canines underwent a blinded randomized study in which the authors compared the results of tamoxifen (5 mg/kg) infused intravenously 1 hour after clot injection with an equal volume of vehicle (dimethylsulfoxide). After 3 hours, the animals underwent MR imaging, were extubated, and clinical examinations were performed. The canines were killed at 8 hours after clot injection, and TTC staining was used.In the first group, infarct volume and CSSs were consistent with the extent of the occlusion of the angiographic vessels. An occlusion of the ACA, MCA, and posterior cerebral artery resulted in larger infarcts and higher stroke scores than occlusion of the ACA and MCA. In the second group, tamoxifen significantly reduced infarct size and improved clinical outcomes. In tamoxifen-treated animals, the mean infarct volume reduction was 40% (p0.05) and the mean CSS was significantly less than vehicle-treated animals (p0.001). There were significant correlations among MR imaging-determined volume, TTC-determined volume, and neurological clinical outcome (p0.05).Using this endovascular model of stroke, the authors were able to consistently produce an infarction in the canines that was similar in scope to a carotid terminus occlusion in humans. Also, angiography could predict subsequent clinical course and infarct size. Tamoxifen was effective at significantly improving the canine neurological deficits and reducing the size of the stroke. This study took the first step in demonstrating the effectiveness of a promising human neuroprotectant in a large animal.

Nonaccidental trauma has become a leading cause of death in infants and toddlers. Compared with children suffering from accidental trauma, many children with nonaccidental trauma present with injuries requiring neurosurgical management and operative interventions.A retrospective review was performed concerning the clinical and radiological findings, need for neurosurgical intervention, and outcomes in infants and toddlers with head injuries who presented to Albany Medical Center between 1999 and 2007. The Fisher exact probability test and ORs were computed for Glasgow Coma Scale (GCS) scores, hyperdense versus hypodense subdural collections, and discharge and follow-up King's Outcome Scale for Childhood Head Injury (KOSCHI) scores.There were 218 patients, among whom 164 had sustained accidental trauma, and 54 had sustained nonaccidental trauma (NAT). The patients with accidental traumatic injuries were more likely to present with GCS scores of 13-15 (OR 6.95), and the patients with NATs with of GCS scores 9-12 (OR 6.83) and 3-8 (OR 2.99). Skull fractures were present in 57.2% of accidentally injured patients at presentation, and 15% had subdural collections. Skull fractures were present in 30% of nonaccidentally injured patients, and subdural collections in 52%. Patients with evidence of hypodense subdural collections were significantly more likely to be in the NAT group (OR 20.56). Patients with NAT injuries were also much more likely to require neurosurgical operative intervention. Patients with accidental trauma were more likely to have a KOSCHI score of 5 at discharge and follow-up (ORs 6.48 and 4.58), while patients with NAT had KOSCHI scores of 3a, 3b, 4a, and 4b at discharge (ORs 6.48, 5.47, 2.44, and 3.62, respectively), and 3b and 4a at follow-up.Infant and toddler victims of NAT have significantly worse injuries and outcomes than those whose trauma was accidental. In the authors' experience, however, with aggressive intervention, many of these patients can make significant neurological improvements at subsequent follow-up visits.

The pathogenesis and genetics of moyamoya disease (MMD) remain a mystery. Here we report a case of female Caucasian adult twins with similar presentations of bilateral MMD that were treated with different surgical modalities. One twin was treated with a bypass and remains event free (defined as either transient ischemic event or stroke) at her 4-year follow-up. The second twin underwent angioplasty to treat a left middle cerebral artery stenosis as well as the placement of a Wingspan stent to treat a right supraclinoid ICA stenosis on separate occasions. The left middle cerebral artery angioplasty thrombosed due to the discontinuation of clopidogrel resulting in recurrent symptoms, principally aphasia, and the Wingspan stent underwent angioplasty for in-stent stenosis. Despite this, the stent has been patent and the patient has remained event free at her 2-year follow-up, post-placement. The relatively new Wingspan stent has been used in the past for intracerebral atherosclerotic lesions, however, this is the first report of it being used in a case of MMD. An overview of the MMD literature in twins and endovascular therapy is given.

BACKGROUND Vertebral artery origin stenosis is a known cause of stroke that is treatable with angioplasty and stenting. Previous studies have demonstrated that this technique is safe but is limited by high rates of in-stent stenosis. Anti-proliferative drug-eluting stents are an alternative for reducing in-stent stenosis at the vertebral artery origin. METHODS This retrospective study included five consecutive patients treated with anti-proliferative drug-eluting stents. The patients' demographics, indications for treatment, procedural technique, and clinical and radiographic follow-up are presented along with a review of the literature. RESULTS No peri-procedural complications occurred. One patient had a transient ischemic attack (TIA) during the follow-up period. No patients had hemodynamically significant (>50%) in-stent stenosis at follow-up. Among the 287 cases reported in the literature, there were two strokes (.7%), four TIAs (1.4%), and no procedurally related deaths. Among patients undergoing angiographic follow-up, 26% were found to have >50% in-stent stenosis. CONCLUSIONS Anti-proliferative drug-eluting stents hold promise for reducing in-stent stenosis at the vertebral artery origin.

Short-lasting, unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) syndrome was first described in 1978 as one of the trigeminal autonomic cephalgias. In this paper the authors present a patient with a growth hormone–secreting pituitary adenoma who experienced resolution of SUNCT syndrome after transsphenoidal tumor resection.

Object Medical care has been evolving with the increased influence of a value-based health care system. As a result, more emphasis is being placed on ensuring cost-effectiveness and utility in the services provided to patients. This study looks at this development in respect to minimally invasive spine surgery (MISS) costs. Methods A literature review using PubMed, the Cost-Effectiveness Analysis (CEA) Registry, and the National Health Service Economic Evaluation Database (NHS EED) was performed. Papers were included in the study if they reported costs associated with minimally invasive spine surgery (MISS). If there was no mention of cost, CEA, cost-utility analysis (CUA), quality-adjusted life year (QALY), quality, or outcomes mentioned, then the article was excluded. Results Fourteen studies reporting costs associated with MISS in 12,425 patients (3675 undergoing minimally invasive procedures and 8750 undergoing open procedures) were identified through PubMed, the CEA Registry, and NHS EED. The percent cost difference between minimally invasive and open approaches ranged from 2.54% to 33.68%—all indicating cost saving with a minimally invasive surgical approach. Average length of stay (LOS) for minimally invasive surgery ranged from 0.93 days to 5.1 days compared with 1.53 days to 12 days for an open approach. All studies reporting EBL reported lower volume loss in an MISS approach (range 10–392.5 ml) than in an open approach (range 55–535.5 ml). Conclusions There are currently an insufficient number of studies published reporting the costs of MISS. Of the studies published, none have followed a standardized method of reporting and analyzing cost data. Preliminary findings analyzing the 14 studies showed both cost saving and better outcomes in MISS compared with an open approach. However, more Level I CEA/CUA studies including cost/QALY evaluations with specifics of the techniques utilized need to be reported in a standardized manner to make more accurate conclusions on the cost effectiveness of minimally invasive spine surgery.

Background Otorrhagia is an uncommon but severe symptom of patients with large glomus jugulare tumors that erode through the tympanic membrane. In this case report we describe the use of transarterial embolization for long-term palliative management of otorrhagia in a patient with an unresectable glomus jugulare tumor. Case Description A 53-year-old woman presented with intermittent otorrhagia 10 years after subtotal resection of a glomus jugulare tumor. Follow-up magnetic resonance imaging showed progressive enlargement of the tumor with significant extension into the posterior fossa. Resection was thought to be impractical; therefore, transarterial embolization was offered as a palliative measure to help reduce the frequency and severity of bleeding episodes. Results Long-term control of otorrhagia was achieved after three rounds of intra-arterial embolization. In round one, the tumor was embolized from multiple external carotid artery feeding branches by the use of polyvinyl alcohol particles. In round two, the internal carotid artery was sacrificed by embolizing the cavernous and petrous segments with coils. In round three, persistent feeders from the cervical internal carotid artery were embolized with Onyx. In 6 years of clinical follow-up, the patient has had no otorrhagia or new neurological deficits. Serial magnetic resonance imaging revealed there has been no significant interval tumor growth. Conclusion Long-term control of otorrhagia from glomus jugulare tumors can be safely achieved by intravascular embolization with Onyx.

Object Revision spine surgery, which is challenging due to disrupted anatomy, poor fluoroscopic imaging, and altered tactile feedback, may benefit from CT image-guided surgery (CT-IGS). This study evaluates accuracy of CT-IGS–navigated screws in primary versus revision spine surgery. Methods Pedicle and pelvic screws placed with the O-arm in 28 primary (313 screws) and 33 revision (429 screws) cases in which institutional postoperative CT scans were available were retrospectively reviewed for placement accuracy. Screw accuracy was categorized as 1) good (< 1-mm pedicle breach in any direction or “in-out-in” thoracic screws through the lateral thoracic pedicle wall and in the costovertebral joint); 2) fair (1- to 3-mm breach); or 3) poor (> 3-mm breach). Results Use of CT-IGS resulted in high rates of good or fair screws for both primary (98.7%) and revision (98.6%) cases. Rates of good or fair screws were comparable for the following regions: C7–T3 at 100% (good or fair) in primary versus 100% (good or fair) in revision; T4–9 at 96.8% versus 100%; T10–L2 at 98.2% versus 99.3%; L3–5 at 100% versus 99.2%; and pelvis at 98.7% versus 98.6%, respectively. On the other hand, revision sacral screws had statistically significantly lower rates of good placement compared with primary (100% primary vs 80.6% revision, p = 0.027). Of these revision sacral screws, 11.1% had poor placement, with bicortical screws extending > 3 mm beyond the anterior cortex. Revision pelvic screws demonstrated the highest rate of fair placement (28%), with the mode of medial breach in all cases directed into the sacral-iliac joint. Conclusions In the cervical, thoracic, and lumbar spine, CT-IGS demonstrated comparable accuracy rates for both primary and revision spine surgery. Use of 3D imaging of the bony pedicle anatomy appears to be sufficient for the spine surgeon to overcome the difficulties associated with instrumentation in revision cases. Although the bony structures of sacral pedicles and pelvis are relatively larger, the complexity of local anatomy was not overcome with CT-IGS, and an increased trend toward inaccurate screw placement was demonstrated.

Image-guided surgery (IGS) has been evolving since the early 1990s and is now used on a daily basis in the operating theater for spine surgery at many institutions. In the last 5 years, spinal IGS has greatly benefitted from important enhancements including portable intraoperative CT (iCT) coupled with high-speed computerized stereotactic navigation systems and optical-based camera tracking technology.

Object Intraoperative CT image–guided navigation (IGN) has been increasingly incorporated into minimally invasive spine surgery (MIS). The vast improvement in image resolution and virtual real-time images with CT-IGN has proven superiority over traditional fluoroscopic techniques. The authors describe their perioperative MIS technique using the O-arm with navigation, and they report their postoperative experience, accuracy results, and technical aspects. Methods A retrospective review of 48 consecutive adult patients undergoing minimally invasive percutaneous posterior spinal fusion with intraoperative CT-IGN between July 2010 and August 2013 at Cedars-Sinai Medical Center was performed. Two surgeons assessed 290 screws in a blinded fashion on intraoperative O-arm images and postoperative CT scans for bony pedicle wall breach. Grade 1 breach was defined to be < 2 mm, Grade 2 breach to be between 2 and 4 mm, and a Grade 3 breach to be > 4 mm. Additionally, anterior vertebral body breach was recorded. Results Of 290 pedicle screws placed, 280 (96.6%) were in an acceptable position without cortical wall or anterior breach. Of the 10 breaches (3.4%) 5 were lateral (50%), 4 were medial, and 1 was anterior; 90% of breaches were Grade 1–2 and all medial breaches were Grade 1. The one Grade 3 breach was lateral. No vascular or neurological complications were observed intraoperatively, and no significant postoperative complications were noted. The mean clinical follow-up period was 18 months (range 3–39 months). The overall clinical outcomes, measured using the visual analog scale (back pain scores), were improved significantly postoperatively at 3 months compared with preoperatively (visual analog score 6.35 vs 3.57; p < 0.0001). No revision surgery was performed for screw misplacement or neurological deterioration. Conclusions New CT-IGN with the mobile O-arm scanner has increased the accuracy of pedicle screw/instrumentation placement using MIS techniques. The authors' high (96.6%) accuracy rate in MIS compares favorably with historical published accuracy rates for fluoroscopy-based techniques. Additional advantages of CT-IGN over fluoroscopic imaging methods are lower occupational radiation exposure for the surgical team, reduced need for postoperative imaging, and decreased rates of revision surgery. For now, the authors simply conclude that use of intraoperative CT-IGN is safe and accurate.

Background: Use of recombinant human bone morphogenic protein-2 (rhBMP-2) in spinal fusion has seen a tremendous increase. Public awareness of rhBMP-2 and its complications has not been assessed. The authors studied published news media articles to analyze information provided to the public on this bone graft substitute. Methods: We utilized the academic database, LexisNexis, to locate newspaper articles published between January 2001 and July 2013. All articles were coded by a coder and reviewed by the principal investigator. Results: The search identified 87 national and 99 local newspaper articles. Complications mentioned in national newspapers included cancer (24%), retrograde ejaculation (24%), and abnormal bone growth (14%). Local newspapers cited cancer (14%), inflammation (14%), and retrograde ejaculation (9.2%) most frequently. Fifty national (59%) and 35 local (54%) articles had no mention of complications. Sources of evidence cited by articles were (in order of frequency): Governmental agencies, medical research or published studies, healthcare personnel or patients, and companies or corporations. Conclusions: Only a small percentage of newspaper articles presented potential complications. Despite lack of clear scientific causal relationship between rhBMP-2 and cancer, this risk was disproportionately reported. Additionally, many did not cite scientific sources. Lack of reliable information available to the public reiterates the role of physicians in discussing risks and benefits BMP use in spinal surgery, assuring that patients are making informed decisions. Future news media articles should present risks in an impartial and evidence-based manner. Collaboration between advocacy groups, medical institutions, and media outlets would be beneficial in achieving this goal.

In the beginning of this millennium, personal digital assistants (PDAs) started to get used increasingly. This also resulted in scientific articles about the added value of their use, including a short humoristic essay about an updated version of the residents’ palmomental reflex.[2] Later, a good review was published by Baumgart et al., which, less than 10 years later, clearly is outdated by the rapid developments in this field.[1] Since the introduction of the iPhone in 2007, things have changed dramatically for the good. Modern smartphones are capable of more than we ever imagined, with a usability that is even better than regular personal computers. We are equipped with multitouch multimedia platforms with excellent audiovisual capacities, GPS tracking systems, accelerometers, high-quality cameras with videoconferencing built-in, persistent internet connection at high speed, and app stores with a large variety of applications that can be downloaded immediately. Tablets have been added to the hardware portfolio, and a variety of operating systems are available based on personal preference. This also led to a large number of medical apps. With that comes the responsibility to classify these apps. The U.S. Food and Drug Administration (FDA) and other organizations are demanding for quality assurance programs or certifications because some apps are to be considered as medical devices. To decide upon whether an app is actually a medical device or not, several guidelines are available based on the underlying organization. Besides these top-down regulations, many bottom-up evaluations have been performed. This happens either online by weblogs dedicated to medical apps (e.g., iMedicalApps.com) or by publications in peer-reviewd journals. This article by Zaki and Drazin offers a recent overview of what we need to know about medical apps for neurosurgery. Neurosurgery in the app era: It really is “all in the wrist”!

Object Positional plagiocephaly (PP) has been on the rise in recent years. In this review, the authors' aim was to assess the effectiveness of current recommendations to parents on this exceedingly common problem through a comprehensive literature search. Additionally, the current treatment options and the most recent studies on PP are reviewed. Methods A search of the existing literature was conducted to obtain all relevant studies on guidelines, recommendations, parental and clinician practices, and epidemiological aspects. Results Although the incidence and risk factors for PP have been well delineated, there continues to be debates on its management and association with developmental delays. Current guidelines and recommendations on prevention set by the American Association of Pediatrics may not be easily followed by both parents and clinicians. There is also evidence that certain populations, including those with lower education, socioeconomic status, and in particular geographic regions may be more affected by the condition. Additionally, the marketing and financial aspects of PP treatments exist and should be addressed. Conclusions Better awareness and education are necessary to inform the population as a whole, although certain populations should be given special attention. Additionally, current guidelines and recommendations can be modified to foster a better grasp of the condition by both parents and clinicians. Adjusting current recommendations, introducing initiatives, and offering elaborate educational campaigns would help deliver these aims. Educating parents on PP as early as possible through clearer guidelines and close monitoring is central to preventing and managing this common condition.

Occurrence of hemangiopericytoma (HPC) in the central nervous system is rare. Spinal HPCs with intramedullary involvement are even more unusual. We present a case of a craniovertebral intradural HPC with both extra- and intra-medullary extensions. Though the patient presented with vague cervical symptoms, imaging was indicative of an intradural lesion from the occiput to C4 and a second smaller, subclinical lesion, at the T2-3 level. He underwent gross total surgical resection of the craniovertebral lesion and did well post-operatively. The thoracic lesion was treated with radiosurgery and the patient is neurologically at baseline 5 years later. Gross total resection of HPCs is the recommended treatment when possible. Histopathology is crucial for diagnosis due to both its rarity and similar characteristics to other tumors on physical and radiographic evaluations. Recognizing that these uncommon tumors can occur with both extra-medullary and intra-medullarly locations are important for diagnosis and treatment recommendations. Future studies using national surgical databases that contain histology will be needed to understand the long-term clinical outcomes.

To the Editor. — We recently examined a home-schooled, 8-year-old girl with bilateral amblyopia whose decreased vision was not detected during her early childhood years. There were no records available of pediatric vision screening. She was referred to us for frontal headaches and poor vision. Examination of this healthy female revealed uncorrected visual acuity at 20 feet of 20/100 in each eye. At 33 inches, uncorrected vision was 20/50 in …

Object The elderly population (age > 60 years) is the fastest-growing age group in the US. Spinal deformity is a major problem affecting the elderly and, therefore, the demand for surgery for spinal deformity is becoming increasingly prevalent in elderly patients. Much of the literature on surgery for adult deformity focuses on patients who are younger than 60 years, and therefore there is limited information about the complications and outcomes of surgery in the elderly population. In this study, the authors undertook a review of the literature on spinal deformity surgery in patients older than 60 years. The authors discuss their analysis with a focus on outcomes, complications, discrepancies between individual studies, and strategies for complication avoidance. Methods A systematic review of the MEDLINE and PubMed databases was performed to identify articles published from 1950 to the present using the following key words: “adult scoliosis surgery” and “adult spine deformity surgery.” Exclusion criteria included patient age younger than 60 years. Data on major Oswestry Disability Index (ODI) scores, visual analog scale (VAS) scores, patient-reported outcomes, and complications were recorded. Results Twenty-two articles were obtained and are included in this review. The mean age was 74.2 years, and the mean follow-up period was 3 years. The mean preoperative ODI was 48.6, and the mean postoperative reduction in ODI was 24.1. The mean preoperative VAS score was 7.7 with a mean postoperative decrease of 5.2. There were 311 reported complications for 815 patients (38%) and 5 deaths for 659 patients (< 1%). Conclusions Elderly patient outcomes were inconsistent in the published studies. Overall, most elderly patients obtained favorable outcomes with low operative mortality following surgery for adult spinal deformity.

The authors report a case of restenosis in the bilateral internal carotid arteries (ICAs) following angioplasty for cerebral vasospasm. This 53-year-old woman suffering subarachnoid hemorrhage due to a ruptured posterior communicating artery aneurysm had severe vasospasm and underwent angioplasty of the left and right ICAs and middle cerebral arteries. Two months later, a follow-up CT angiogram revealed bilateral ICA stenoses. Transluminal angioplasty leads to long-term connective tissue damage in the medial and adventitial layers from the disruption of the arrangement of collagen fibers due to stretching and tearing, resulting in loss of transmission of contractile forces. Furthermore, following endothelial cell denudation and stretching and rupture of internal elastic lamina from angioplasty, reendothelialization of the intimal layer composed of smooth muscle cells may also explain the contractile properties of restenosis. Other factors such as macrophage-induced inflammation and reactive oxygen species accumulation may also contribute to restenosis. This is the second reported case of restenosis following angioplasty to treat vasospasm, although restenosis is a known complication of angioplasty for treatment of atherosclerosis. In addition, this is the first case of restenosis in the bilateral ICAs following angioplasty for vasospasm. This report presents an illustrative case study and reviews the pathophysiology of angioplasty and restenosis.

Objective Cavernous carotid aneurysms (CCAs) can present with visual symptoms or with subarachnoid hemorrhage (SAH). As surgical treatment of these aneurysms can be technically challenging, endovascular management has emerged as the preferred treatment modality. Methods A retrospective review was conducted of 113 patients who underwent endosaccular treatment for CCAs. Presenting symptoms, aneurysm size, use of stent assistance, rate of thromboembolic complications, presence of SAH and angiographic follow-up were reviewed. Results 29 patients (26%) with CCAs presented with diplopia due to cranial nerve palsies. Mean aneurysm size in this group was 17 mm. Three patients (2.6%) presented with SAH with a mean aneurysm size of 15.3 mm. Mean length of stay for ruptured versus non-ruptured aneurysms was 11.7 and 1.7 days, respectively. Clinically significant thromboembolic complications occurred in four cases (3.5%). Stent assistance was required in 53 cases (47%). Of the 86 patients (76%) returning for follow-up angiography (mean 6.2 months), 58 (75%) had no residual aneurysm and 14 (12%) showed regrowth. Thirteen patients (11.5%) underwent repeat endovascular treatment. Conclusions CCAs commonly produce diplopia and cranial nerve palsies when a critical size is reached (mean 17 mm in our series). Aneurysm obliteration with internal carotid artery preservation is the preferred treatment modality and can be accomplished with coil embolization with or without stent assistance. Although recurrence and retreatment can occur, the thromboembolic risk of endovascular treatment is low. Consideration should be given to treatment of asymptomatic CCAs 15 mm or larger due to potential risks of cranial neuropathy and SAH.