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Meningiomas are amongst the most commonly encountered intracranial tumors. The majority of these tumors arise intracranially, and the remaining incidents occur along the spinal cord. Meningiomas tend to grow gradually, with many tumors arising in inaccessible locations. Such sporadic behavior poses a therapeutic challenge to clinicians, causing incomplete tumor resections that often lead to recurrence. Therefore, ongoing research seeks to find alternative systematic treatments for meningiomas, with gene-based therapeutics of high interest. Subsequently, genetic studies characterized frequent somatic mutations in NF2, TRAF7, KLF4, AKT1, SMO, and PIK3CA. These genes are communally exhibited in 80% of sporadic meningiomas. In addition, other genes such as the DUSP family, the NR4 family, CMKOR, and FOSL2, have been identified as key players in spinal meningiomas. In this perspective, we aim to investigate current genetic-based studies, with the ongoing research mainly focused on the above NF2, TRAF7, KLF4, AKT1, SMO, and PIK3CA genes and their involved pathways. In addition, this perspective can serve as a potential cornerstone for future genetic analyses of meningioma cases.

Background: The presence of retained foreign bodies in the spinal canal has been reported in the literature. They are attributed to retained pieces of medical equipment after surgery, or, following trauma, to residual bullets, glass fragments, or knife blades. Although some retained materials do not cause any neurological deficits in the short run, others may become symptomatic months later. Case Description: A 2-year-old male presented with a history of intermittent fever and mild lower extremity weakness. Notably, the original infectious workup was negative. However, a noncontrast CT scan later documented a needle-shaped foreign body in the spinal canal at the T10 level. During the T10 laminectomy, a needle (i.e. from a medical syringe) was removed, the patient remained neurologically intact. The foreign body turned out to be a medical syringe needle tip. Conclusion: A 2-year-old male presented with fevers and mild lower extremity weakness attributed to an intraspinal needle tip found utilizing CT at the T10 level. T10 laminectomy allowed for removal of a small needle tip. This shows the importance of removing retained spinal foreign bodies to avoid further/future neurological injury, and/or the potential risks/complications of foreign body migration/sequestration.

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.

People with thoracic spinal cord injury (SCI), named people with paraplegia (PA), are vulnerable to thermal heat stress during exercise due to disruption in their thermal physiology. Using personal cooling vests with phase change material (PCM) or ice presents a possible solution for PA to suppress the increase in core temperature and body heat storage. With the limited published experimental studies about effective cooling vest for PA, this work aims to develop an altered PA bioheat model combined with cooling vest model to study cooling vest performance during exercise. The integrated PA bioheat and vest models predict core and skin temperatures, latent and sensible heat losses and change in body heat storage for PA with and without a cooling vest. The models were validated with published experimental data on PA without the cooling vest and on PA with two cooling vests; one using PCM at melting temperature of 15 °C and the other using ice packets during exercise. It was observed that sensible heat losses at the four torso segments (abdomen, lower back, chest and upper back) increased with the vest case compared to the no-vest case; while, latent heat losses decreased compared to the no-vest case. However, insignificant change was seen in core temperatures and body heat storage as was also reported experimentally. The performance of each of the cooling vest during exercise on PA was dependent on skin coverage area and melting temperatures.

Phase change material (PCM) cooling vests were tested on people with thoracic (T1-T12) spinal cord injury (SCI), also called people with paraplegia (PA), during exercise in heat. The purpose was to reduce heat stress, limit the increase in core temperature, and improve thermal comfort for PA under high metabolic rates and hot ambient conditions. This health risk was a result of thoracic SCI and disruption of thermoregulatory responses in PA. The current study aims to evaluate the efficacy of cooling vest on PA during arm-crank exercise at two melting points, 20°C (V20) and 14°C (V14) compared to no vest test (NV). Eleven participants with high- (T1-T3) and mid-thoracic SCI (T4-T8) were selected to participate in three tests. Core and skin temperatures and heart rate values were measured during 15-min precondition, 30-min exercise and 15-min recovery. Subjective voting of thermal comfort, sensation, skin wettedness and perceived exertion were recorded during exercise only. The main findings revealed significant reduction in change in core temperature (0.42±0.3°C;0.38±0.2°C) in V20 and V14 compared to NV tests for mid-thoracic group. For high-thoracic group, V20 and V14 were least effective in reducing core temperature (p > 0.05). Improvements in thermal comfort was established when using V14 and V20 compared to NV by 85% and 30% for high-thoracic group and by 72% and 53% for mid-thoracic group.

Spine fusion surgery is commonly performed for diverse indications, the most frequent one being degenerative spine diseases. Despite the growing importance of this surgery, there is limited evidence concerning the effects of drugs on the process of spine fusion and healing. While asymptomatic sometimes, nonunion of the spine can have tremendous repercussions on the patients' quality of life and the healthcare system rendering it an "expensive complication". This literature review identifies the role of some perioperative drugs in spine fusion and reveals their potential role in pseudarthrosis of the spine. This review also benefits spine surgeons looking for current evidence-based practices. We reviewed the data related to nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, vancomycin, bisphosphonates, proton pump inhibitors (PPIs), pregabalin, and opioids. From the available experimental and clinical studies, we conclude that bisphosphonates might positively influence the process of spine fusion, while steroids and vancomycin have shown variable effects, and the remaining medications likely disturb healing and union of the spine. We recommend spine surgeons be cautious about the drugs they resort to in the critical perioperative period until further clinical studies prove which drugs are safe to be used.

Background Stent-assisted coil embolization of ruptured wide-necked aneurysms is a controversial treatment modality due to concerns on the peri-procedural safety of anti-platelet therapy in the setting of acute subarachnoid hemorrhage. Our aim was to systematically review the literature on stent-assisted coil embolization of acutely ruptured wide-neck aneurysms to calculate the pooled prevalence of clinical outcome, thromboembolic and hemorrhagic complication rates and overall mortality. Methods We searched PubMed and Google Scholar for articles published between 2009 and 2019 and stratified selected articles based on risk of publication bias. Data on thromboembolic and hemorrhagic complications, clinical outcomes and mortality rates were analyzed using quality-effects model and double arcsine transformation. Results 24 articles were included featuring a total of 1582 patients. Thromboembolic and hemorrhagic complication rates were witnessed in 9.1% [95% CI: 6.0% – 12.7%; I2 = 72.8%] and 8.7% [95% CI: 5.4 – 12.6%; I2 = 77.2%] of patients, respectively. 245 patients received external ventricular drains, of which 33 (13.5%) had EVD-related hemorrhages. Total complication rate was 20.8% [95% CI: 14.2 – 28.1%; I2 = 87.0%]. 57% of aneurysms were completely occluded and a favorable clinical outcome was reported in 74.7% [95% CI: 66.4 – 82.2%; I2 = 86.0] of patients. Overall mortality rate came at 7.8% [95% CI: 4.8 – 11.6%; I2 = 76.9%]. Conclusion Stent-assisted coiling of ruptured intracranial aneurysm is a technically feasible procedure with controlled thromboembolic complication rate but may be associated with higher hemorrhagic and total complication rates compared to coiling alone. While stent-assisted coiling of ruptured wide-necked aneurysm seems to yield a lower rate of favorable clinical outcome, overall mortality is comparable to that of endovascular coiling alone.

Hypothalamic hamartomas (HH) are rare, non-neoplastic heterotopic tissues which contains normal neurons and glia including oligodendrocytes and fibrillary astrocytes but in an abnormal distribution. They arise from the floor of the third ventricle, tuber cinereum, or mammillary bodies. Estimated incidence ranges from 1 in 50,000-1 in 1,000,000. Hypothalamic hamartomas are associated with different clinical presentations including various types of seizures, most characteristically; the gelastic seizures, precocious puberty, cognitive impairment, and behavioral changes. In this review, the authors discuss advancements in different diagnostic elements of hypothalamic hamartoma; including clinical features, EEG findings, and neuroimaging techniques. Moreover, different classifications described in the literature will be discussed.

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.

Study design Randomized experimental study. Objective Compared to able-bodied people, patients with paraplegia due to thoracic spinal cord injury (SCI) are at an increased risk of heat illnesses during exercise due to impaired thermoregulatory responses. To overcome this limitation, we investigated the performance of three phase change material (PCM) cooling vests of different melting temperatures (Eijsvogels, #49) and coverage area of the trunk. Methods Sixteen participants were divided into three groups according to their injury level. All were tested for V20 full vest (20°C Tm, 75% coverage). Mid-thoracic and high-thoracic groups were tested for V14 vest (14°C Tm, 75% coverage). The mid-thoracic group was tested for V20 half vest (20°C Tm, 50% coverage). The participants performed a 30-min arm-crank exercise followed by a recovery period inside a controlled hot climatic chamber. The heart rate, segmental skin (Tskin), and core temperature (Tcore) values were recorded, and subjective questionnaires were taken. Results Compared to no vest (NV) test, all the vests showed an effective decrease in Tskin values of the trunk. However, the decrease in Tskin was not enough to induce a significant decrease in Tcore in all three groups. Mid-thoracic and low-thoracic groups showed a reduction in the increasing Tcore by the end of the exercise and recovery period. Finally, the level of thermal comfort was enhanced for the three groups. Conclusion The effectiveness of cooling vests for persons with paraplegia is dependent on injury level and thus the ratio of sensate to insensate skin. Future studies necessitate the investigation of the cooling effects of PCM vests at a lower Tm with a larger sample size.

Background This review seeks to synthesize emerging literature on the effects of back muscle size on outcomes in spine surgery. Risk factors that contribute to poor surgical outcomes continue to be an area of interest in spine surgery because proper risk stratification can result in reduction in morbidity and enhanced patient care. However, the impact of muscle size on spine surgical outcomes is an understudied avenue with paucity of data evaluating the relationship among back muscles and surgical outcomes, patient's quality of life, and functional improvement postoperatively. Methods This review was centered around identifying studies that assessed the impact of back muscle size on spine surgery outcomes. Results Five retrospective studies were selected for review. All studies set out to see if differences in muscle size existed in patients with disparate post-operative outcomes as a primary objective. The studies support the association between larger back muscles and improved outcomes. The size and relative cross sectional area of paraspinal muscles and the size of the psoas muscle were associated with functional outcomes, incidence of complications and also fusion rates. Conclusion With reduction in surgical complications and improvement in postoperative functional outcomes, back muscle morphometry ought to be included in the preoperative surgical planning as a predictor of outcomes.

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

Degradomics is a proteomics sub-discipline whose goal is to identify and characterize protease-substrate repertoires. With the aim of deciphering and characterizing key signature breakdown products, degradomics emerged to define encryptic biomarker neoproteins specific to certain disease processes. Remarkable improvements in structural and analytical experimental methodologies as evident in research investigating cellular behavior in neuroscience and cancer have allowed the identification of specific degradomes, increasing our knowledge about proteases and their regulators and substrates along with their implications in health and disease. A physiologic balance between protein synthesis and degradation is sought with the activation of proteolytic enzymes such as calpains, caspases, cathepsins, and matrix metalloproteinases. Proteolysis is essential for development, growth, and regeneration; however, inappropriate and uncontrolled activation of the proteolytic system renders the diseased tissue susceptible to further neurotoxic processes. In this article, we aim to review the protease-substrate repertoires as well as emerging therapeutic interventions in spinal cord injury at the degradomic level. Several protease substrates and their breakdown products, essential for the neuronal structural integrity and functional capacity, have been characterized in neurotrauma including cytoskeletal proteins, neuronal extracellular matrix glycoproteins, cell junction proteins, and ion channels. Therefore, targeting exaggerated protease activity provides a potentially effective therapeutic approach in the management of protease-mediated neurotoxicity in reducing the extent of damage secondary to spinal cord injury.

Persons with thoracic spinal cord injury (SCI), also named as people with paraplegia (PA), are encouraged to participate in sport activities for sake of improving their quality of life and health. Yet, heat strain is a major consequence of SCI after which the body loses its ability to regulate its temperature. Disruption in body temperature regulation and instability in core temperature (Tcr) endangers the patient health especially when subjected to extreme ambient conditions or high level of physical activity. Since thermophysiology is disrupted after SCI, using conventional personal cooling methods may not be effective on PA in a way similar to that of able-bodied people (AB). Experimental studies evaluated the effect of phase change material (PCM) and ice cooling vests on thermal response of PA during exercise. Results showed no change in Tcr values for both types of vest during exercise. This study aims at studying the effectiveness of PCM cooling vest for PA during exercise at intensity level of 6.5 MET within 21.1–23.9 °C room temperature and 50% relative humidity. A multi-segmented bioheat model of PA coupled with PCM cooling vest model (fabric-PCM-PA model) was deployed to predict Tcr values at different design conditions of the vest. Segmental core and skin temperatures profiles and the sensible and latent heat losses were obtained for torso segments to assess the percentage of enhancement in the cooling vest performance. Results showed that Tcr value of the body and Tcr values of the torso segments didn’t change at different design conditions of the vest; yet sensible heat losses were increased for all torso segments and latent heat losses were reduced. Decreases in latent heat losses affected Tsk values at the torso. Simulations were performed using fabric-PCM model integrated with PA bioheat model applying variation of skin coverage area, melting point of PCM and combination of both designs. An effective design of the vest for PA was found when using PCM packet at 10°C melting point and coverage area about 40% of torso because sensible heat losses were the highest compared to the other design cases of the vest.

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.

Hypothalamic hamartomas (HH) are rare, non-neoplastic heterotopic tissues which contains normal neurons and glia including oligodendrocytes and fibrillary astrocytes but in an abnormal distribution. They arise from the floor of the third ventricle, tuber cinereum, or mammillary bodies. Estimated incidence ranges from 1 in 50,000 to 1 in 1,000,000. Hypothalamic hamartomas are associated with different clinical presentations including various types of seizures, most characteristically; the gelastic seizures, precocious puberty, cognitive impairment and behavioral changes. In this review, the authors discuss the recent advancements in different modalities of radiotherapy and their application in hypothalamic hamartomas management.

Connexins (Cxs) are a family of transmembrane proteins that assemble into groups of six, forming what is known as a connexon or a hemichannel. Connexins are named based on their molecular weight, e.g. Cx43 is the connexin protein that weighs 43 kDa. Two hemichannels, each from a different cell, can link up end-to-end forming a gap junction. In the nervous system, gap junctions facilitate metabolite exchange between neighboring cells, in addition to electrical and chemical impulses. Many animal studies have been conducted to investigate the role of different types of Cxs in spinal cord injury (SCI) - most notably Cx43 - and the potential for targeting them with inhibitors. In this review, the authors discuss these studies and provide an update on recent connexin specific pharmacological agents that may potentially pave the way for the use of connexin inhibition in the management of SCI in humans, if more translational studies are done.

Hypothalamic hamartomas (HH) are rare, non-neoplastic heterotopic tissues which contains normal neurons and glia including oligodendrocytes and fibrillary astrocytes but in an abnormal distribution. They arise from the floor of the third ventricle, tuber cinereum, or mammillary bodies. Estimated incidence ranges from 1 in 50,000 to 1 in 1,000,000. Hypothalamic hamartomas are associated with different clinical presentations including various types of seizures, most characteristically; the gelastic seizures, precocious puberty, cognitive impairment and behavioral changes. In this review, the authors discuss the recent advancements in the medical and surgical management of hypothalamic hamartoma that have been achieved over the past few decades. This review also discusses the advantages and disadvantages of each surgical line of management and factors determining the best individualized approach.

At the dawn of the third millennium, cancer has become the bane of twenty-first century man, and remains a predominant public health burden, affecting welfare and life expectancy globally. Spinal osteogenic sarcoma, a primary spinal malignant tumor, is a rare and challenging neoplastic disease to treat. After the conventional therapeutic modalities of chemotherapy, radiation and surgery have been exhausted, there is currently no available alternative therapy in managing cases of spinal osteosarcoma. The defining signatures of tumor survival are characterised by cancer cell ability to stonewall immunogenic attrition and apoptosis by various means. Some of these biomarkers, namely immune-checkpoints, have recently been exploited as druggable targets in osteosarcoma and many other different cancers. These promising strides made by the use of reinvigorated immunotherapeutic approaches may lead to significant reduction in spinal osteosarcoma disease burden and corresponding reciprocity in increase of survival rates. In this review, we provide the background to spinal osteosarcoma, and proceed to elaborate on contribution of the complex ecology within tumor microenvironment giving arise to cancerous immune escape, which is currently receiving considerable attention. We follow this section on the tumor microenvironment by a brief history of cancer immunity. Also, we draw on the current knowledge of treatment gained from incidences of osteosarcoma at other locations of the skeleton (long bones of the extremities in close proximity to the metaphyseal growth plates) to make a case for application of immunity-based tools, such as immune-checkpoint inhibitors and vaccines, and draw attention to adverse upshots of immune-checkpoint blockers as well. Finally, we describe the novel biotechnique of CRISPR/Cas9 that will assist in treatment approaches for personalized medication.

Sarcomas, especially spine sarcomas, are rare yet debilitating and are underestimated types of cancer. Treatment options for spine sarcomas are limited to chemotherapy, radiotherapy and surgical intervention. Accumulating evidence suggests a complex course associated with the treatment of spine sarcomas as compared to other soft tissue sarcomas in the extremities since adjuvant therapy adds limited success to the oncological outcome. Likewise, the limitations of surgical interventions imposed by the proximity and high sensitivity of the spinal cord, leads to an increased recurrence and mortality rates associated with spine sarcomas. Finding novel treatment options to spine sarcomas as such is inevitable, necessitating a more thorough understanding of the different mechanisms of the underlying etiologies of these tumors. In this review, we discuss the most recent studies tackling the involvement of the immune system; a key player in the emergence of the different types of spine sarcomas and the promising immune-mediated targeted therapy that can be applied in these kind of rare cancers.

The objective of this work is to develop a Bioheat model to predict the thermal responses of people with tetraplegia (TP) under hot, cold and neutral ambient conditions as well as different physical activities suitable for their level of injury. The focus is on TP with impairment or loss of motor and/or sensory function in C1 to C7 segments of the spinal cord due to damage of neural elements within the spinal canal. Starting from transient multi-segmented Bioheat model of able-bodied (AB) people, specific modifications were performed reflecting the changes in physiology due to the injury affecting the blood circulation system, energy expenditure, and thermoregulatory functions in the body. The TP Bioheat model predicts the TP thermal responses under steady and transient thermal conditions, and different activity levels that are appropriate for the level of injury. The model was validated with published experimental data reporting physiological and thermal data measurements on cases of people with complete and incomplete tetraplegia under controlled environmental conditions and activity levels. In both transient and steady state environmental conditions, the predicted core and mean skin temperature values were compared against the experimental data with maximum error of 0.86 °C and 0.9 °C respectively. The TP Bioheat model can be used as a tool to propose appropriate personal cooling strategies for TP.

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.

Background Intramedullary spinal cord tumors (IMSCT) account for about 2%–4% of tumors of the central nervous system. Surgical resection continues to be the most effective treatment modality for most intramedullary tumors, with gross total resection leading to preserved neurologic function and improved survival. However, surgical treatment is often difficult and carries significant risk of postoperative neurologic complications. Intraoperative neuromonitoring has been shown to be of clinical importance in the surgical resection of IMSCT. The main monitoring modalities include somatosensory evoked potentials, transcranial motor evoked potentials via limb muscles or spinal epidural space (D-waves), and dorsal column mapping. These monitoring modalities have been shown to inform surgeons intraoperatively and in many cases, have led to alterations in operative decision. Methods We reviewed the literature on the usefulness of intraoperative neuromonitoring for intramedullary spinal tumor resection and its role in predicting postoperative neurologic deficits. A MEDLINE search was performed (2000–2015) and 13 studies were reviewed. Detailed information and data from the selected articles were assessed and compiled. Data were extracted showing the role of monitoring in outcomes of surgery. Conclusions By using intraoperative somatosensory evoked potentials, transcranial motor evoked potentials, D-waves, and dorsal column mapping, spinal injury could be prevented in most cases, thereby improving postoperative neurologic functioning and outcome in patients undergoing surgery for IMSCT.

Object 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. Methods 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. Results 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 (p < 0.001) 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°). Conclusions 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.

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.

Problem statement: Salmonella spondylodiscitis is a rare condition that is more prevalent in patients with sickle cell disease or immunosuppression. However, it can also be found in immunocompetent patients. It usually responds well to proper antibiotics. However, surgery is rarely indicated when the infection is refractory to antibiotics, the spine is destabilized or there is an epidural component that is compressing the thecal sac and causing neurological deficit. We report the case of a 60 year-old African American woman with borderline diabetes mellitus controlled with diet, who presented with Salmonella osteomyelitis of the thoracic spine that was associated with an epidural abscess. Approach: The patient presented to an outside hospital with diarrhea, fever and chills. This occurred after eating a chicken sandwich. Stool and blood cultures were positive for Salmonella. Initially she was placed on triple antibiotics (ceftriaxone, vancomycin and levofloxacin) and was later switched to levofloxacin alone given that the bacteria were sensitive to this drug. Several weeks later, she presented with severe back pain. Imaging studies showed a significant lytic lesion in her thoracic spine at T11-12 with an epidural component. Given the instability of the lesion and the failure of medical treatment a decision was made for surgical intervention. Results: She underwent an extracavitary approach for partial T11-T12 corpectomies and fusion with instrumentation with continuous administration of the proper antibiotics. The patient was then discharged to an acute patient rehabilitation center. Postoperatively, she was able to ambulate with full strength in her extremitiesand her back pain had resolved. Conclusion/Recommendations: To the best of the authors' s knowledge this is the first reported case of Salmonella spondylodiscitis in an immunocompetent patient treated with a corpectomy via an extracavitary approach with the use of an expandable cage and posterior instrumentation.

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.

There are only a few reports of dysphagia cases in patients who underwent surgery for posterior cervical fusion, but none provides an explanation for the occurrence of dysphagia. To the best of our knowledge this is the first case report showing evidence of severe neurogenic dysphagia, possibly secondary to vagal nerve praxia, in a patient who underwent posterior fusion. A 61-year-old man presented with severe neck pain after he sustained a fall. Imaging studies in the emergency department showed a C2 fracture associated with anterior subluxation of C2 on C3. Given the instability of the injury, a C1-C3 posterior cervical fusion was performed. The surgery was uneventful. The patient's postoperative course was complicated by severe dysphagia. Fluoroscopic and endoscopic assessments of the patient's pharynx and larynx showed significantly decreased epiglottic inversion, hypokinesis of his pharyngeal wall, and decreased hyolaryngeal elevation. There was also mild vocal cord paresis bilaterally, with incomplete approximation of the glottis. He demonstrated intra- and post-deglutitive aspiration. The patient coughed (both immediate and delayed) in response to the aspiration but was not able to clear aspirated material completely from the airway. The patient had a percutaneous endoscopic gastrostomy (PEG) tube placed to provide him with nutrition. He was then discharged home. On postoperative follow-up visit 1 month later, the patient's swallowing function improved and he could tolerate pureed consistencies and thin liquids with tube feed supplement. The patient could swallow without coughing. Possible causes of dysphagia in this case include traumatized airways from anesthesia, mechanical compromise of the upper gastrointestinal tract, and neurogenic dysphagia. After excluding the other possibilities, we concluded that our patient was suffering from neurogenic dysphagia associated with vagal nerve dysfunction.

Object One mechanism that contributes to cerebral vasospasm is the impairment of potassium channels in vascular smooth muscles. Adenosine triphosphate–sensitive potassium channel openers (PCOs) appear to be particularly effective for dilating cerebral arteries in experimental models of subarachnoid hemorrhage (SAH). A mode of safe administration that provides timed release of PCO drugs is still a subject of investigation. The authors tested the efficacy of locally delivered intrathecal cromakalim, a PCO, incorporated into a controlled-release system to prevent cerebral vasospasm in a rat model of SAH. Methods Cromakalim was coupled to a viscous carrier, hyaluronan, 15% by weight. In vitro release kinetics studies showed a steady release of cromakalim over days. Fifty adult male Sprague-Dawley rats weighing 350–400 g each were divided into 10 groups and treated with various doses of cromakalim or cromakalim/hyaluronan in a rat double SAH model. Treatment was started 30 minutes after the second SAH induction. Animals were killed 3 days after treatment, and the basilar arteries were processed for morphometric measurements and histological analysis. Results Controlled release of cromakalim from the cromakalim/hyaluronan implant at a dose of 0.055 mg/kg significantly increased lumen patency in a dose-dependent manner up to 94 ± 8% (mean ± standard error of the mean) of the basilar arteries of the sham group compared with the empty polymer group (p = 0.006). Results in the empty polymer group were not different from those in the SAH-only group, with a lumen patency of 65 ± 12%. Lumen patencies of the cromakalim-only groups did not differ in statistical significance at low (64 ± 9%) or high (66 ± 7%) doses compared to the SAH-only group. Conclusions Treatment of SAH with a controlled-release cromakalim/hyaluronan implant prevented experimental cerebral vasospasm in this rat double hemorrhage model; this inhibition was dose-dependent. The authors' results confirm that sustained delivery of cromakalim perivascularly to cerebral vessels could be an effective therapeutic strategy in the treatment of cerebral vasospasm after SAH.

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: The pharmacological treatment of cerebral vasospasm (CVS) now includes the experimental use of controlled-release biocompatible compounds that deliver a desired drug locally into the subarachnoid space. A controlled-release system consists of an active material that is incorporated into a carrier, usually in the form of a pellet or a gel. With such systems, the desired agent is delivered slowly and continuously, for long periods of time, directly to the desired site. This technology makes it possible to achieve high local concentrations of therapeutic agents while minimizing systemic toxicity and circumventing the need to cross the blood-brain barrier. This review describes controlled-release systems developed to date for local drug delivery in the treatment of CVS in both animal models and humans. METHODS: A MEDLINE PubMed database search was performed for articles published from 1975 to 2007 with the following search topics: “controlled-release system/ polymer,” “controlled-release implants,” “cerebral vasospasm,” “subarachnoid hemorrhage,” “subarachnoid space,” and “intracranial drug delivery.” RESULTS: Over the past several decades, several controlled-release systems (lactic/ glycolic acid pellets, ethylene vinyl acetate copolymer, liposomes, silicone elastomers) have been developed to deliver various pharmacological agents (papaverine, nicardipine, ibuprofen, nitric oxide donor, calcitonin gene-related peptide, fasudil, recombinant tissue plasminogen activator) intracranially to treat subarachnoid hemorrhage in animal models (rats, rabbits, dogs, and primates). Animal studies have shown promising results, and the few human studies that have been published using controlled-release systems with papaverine or nicardipine report similarly encouraging outcomes. CONCLUSION: Controlled-release systems have evolved over the past few years and have been shown experimentally to be an effective strategy for the local delivery of drugs to treat CVS.

✓ Cysts occupying the third ventricle are rare lesions and may appear as an unusual cause of obstructive hydrocephalus. Various types of lesions occur in this location, and they generally have an arachnoidal, endodermal, or neuroepithelial origin. The authors present a case of acute hydrocephalus following minor trauma in a child due to cerebrospinal fluid outflow obstruction by a third ventricular cyst. Definitive diagnosis of this cystic lesion was possible only with contrast ventriculography and not routine computed tomography or magnetic resonance imaging. The investigation, treatment, and pathological findings are discussed.

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.

Background The placement of iliac screws is a biomechanically sound method for the stabilization of long multi-segment lumbar constructs. Traditional techniques for the placement of iliac screws often involve either substantial iliac muscle dissection for visualization of screw trajectory based on bony landmarks, or alternatively the use of intra-operative imaging to visualize these landmarks and guide screw placement. We describe an alternative free-hand method of iliac screw placement, one that needs neither significant muscle dissection nor intra-operative imaging. Methods We performed this technique in 10 consecutive patients. Patient demographics, spinal pathology, post-operative complications, and screw hardware characteristics are described. Results We have successfully used this technique for the placement 20 iliac screws based on anatomic landmarks in 10 consecutive patients. There were no cortical breeches of the ileum and no penetrations into the acetabulum on post-operative imaging. There were no instances of hardware failure. Two patients developed deep vein thromboses after surgery, 1 had a pulmonary embolism. Conclusions Based on our limited experience to date, free-hand placement of iliac screws is both easy to perform and safe for the patient. Further study and validation using this technique is warranted.