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Study Design: Narrative review., Objective: Metastatic spine disease is an increasingly common clinical challenge that requires individualised multidisciplinary care from spine surgeons and oncologists. In this article, the authors describe the recent surgical advances in patients presenting with spinal metastases., Methods: We present an overview of the presentation, assessment, and management of spinal metastases from the perspective of the spine surgeon, highlighting advances in surgical technology and techniques, to facilitate multidisciplinary care for this complex patient group. Neither institutional review board approval nor patient consent was needed for this review., Results: Advances in radiotherapy delivery and systemic therapy (including immunotherapy and targeted therapy) have refined operative indications for decompression of neural structures and spinal stabilisation, while advances in surgical technology and technique enable these goals to be achieved with reduced morbidity. Formulating individualised management strategies that optimise outcome, while meeting patient goals and expectations, requires a comprehensive understanding of the factors important to patient management., Conclusion: Spinal metastases require prompt diagnosis and expert management by a multidisciplinary team. Improvements in systemic, radiation, and surgical therapies have broadened operative indications and increased operative candidacy, and future advances are likely to continue this trend., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Competing Interests: None

Pneumocephalus is the pathologic collection of air in the intracranial cavity. In sufficient volumes, it can contribute to symptoms ranging from headaches to death. For conservative treatment, oxygen use is commonplace. Although this is an accepted tenet of clinical practice, it is not necessarily founded on robust trials. An electronic search of databases EMBASE and MEDLINE and the Cochrane Library was undertaken as per the 2020 Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) statement. Three articles were included. Although the modes of oxygen delivery were heterogenous (non-rebreather versus endotracheal versus hyperbaric chamber), all studies concluded favorably on the use of oxygen therapy for increased reabsorption of pneumocephalus., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Incorrect level spinal surgery is an avoidable complication, with significant ramifications. Several pre-operative spinal marking techniques have been described to aid intraoperative localisation., Methods: A systematic search of Ovid MEDLINE, and EMBASE was performed from inception to July 2022. All publications describing cases of internal spinal marking were included for further analysis. 22 articles describing 503 patients satisfied our eligibility criteria., Results: A number of localisation techniques, including endovascular coiling (n = 16), fiducials (n = 177), dye (n = 109), needle/fixed wire (n = 199), cement (n = 4), and gadolinium tubes (n = 1) were described. The highest rates of technical success were observed with endovascular coiling, fiducials, cement and dye (100 %), and complication rates were lowest with endovascular coiling, fiducials and cement (0 %)., Conclusions: Overall, internal spinal marking was effective and safe. When considering practicality and efficacy, fiducial marking appears the optimal technique, as it can be performed in the outpatient setting under local anaesthesia. This review demonstrates the need for more targeted investigation into localisation methods in spinal surgery., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: MR imaging is key in the diagnostic work-up of Cushing disease. The sensitivity of MR imaging in Cushing disease is not known nor is the prognostic significance of "MR imaging-negative" disease., Purpose: Our aim was to determine the overall sensitivity and prognostic significance of MR imaging localization of Cushing disease., Data Sources: We performed a systematic review of the MEDLINE and PubMed databases for cohort studies reporting the sensitivity of MR imaging for the detection of adenomas in Cushing disease., Study Selection: This study included 57 studies, comprising 5651 patients., Data Analysis: Risk of bias was assessed using the methodological index for non-randomized studies criteria. Meta-analysis of proportions and pooled subgroup analysis were performed., Data Synthesis: Overall sensitivity was 73.4% (95% CI, 68.8%-77.7%), and the sensitivity for microadenomas was 70.6% (66.2%-74.6%). There was a trend toward greater sensitivity in more recent studies and with the use of higher-field-strength scanners. Thinner-section acquisitions and gadolinium-enhanced imaging, particularly dynamic sequences, also increased the sensitivity. The use of FLAIR and newer 3D spoiled gradient-echo and FSE sequences, such as spoiled gradient-echo sequences and sampling perfection with application-optimized contrasts by using different flip angle evolutions, may further increase the sensitivity but appear complementary to standard 2D spin-echo sequences. MR imaging detection conferred a 2.63-fold (95% CI, 2.06-3.35-fold) increase in remission for microadenomas compared with MR imaging-negative Cushing disease., Limitations: Pooled analysis is limited by heterogeneity among studies. We could not account for variation in image interpretation and tumor characteristics., Conclusions: Detection on MR imaging improves the chances of curative resection of adenomas in Cushing disease. The evolution of MR imaging technology has improved the sensitivity for adenoma detection. Given the prognostic importance of MR imaging localization, further effort should be made to improve MR imaging protocols for Cushing disease., (© 2023 by American Journal of Neuroradiology.)

Background and Importance: We report a case of nail gun-related penetrating brain injury, puncturing through the anterior third of superior sagittal sinus, which remained patent and was associated with an arteriovenous (AV) shunt revealed on catheter angiogram., Clinical Presentation: A previously well 35-year-old male patient presented with a self-inflicted pneumatic nail gun injury. Neurological examination was unremarkable. Computed tomography (CT) of the brain demonstrated the nail had penetrated through the skull, traversed the anterior third of the superior sagittal sinus (SSS), right frontal lobe parenchyma, frontal horn of right lateral ventricle, caudate, and right cerebral peduncle. CT angiogram showed no associated vascular injury, with CT venogram showing a short segment of filling defect within SSS adjacent to nail penetration. However, digital subtraction angiography revealed an associated arteriovenous shunt 8 mm anterior to the dural penetration site, which filled the SSS in arterial phase. Removal of the nail was performed using a double concentric craniotomy around the nail entry site. Before removal of the nail, the SSS anterior to the nail penetration site was tied off and divided along with coagulation and division of the falx, while the SSS posterior to the nail penetration site was also tied off to isolate the penetrated SSS segment. The patient recovered well with repeat digital subtraction angiography demonstrating no residual AV shunting., Conclusion: This case report aims to highlight the importance of performing a catheter angiogram and describe our stepwise considerations and approach in treating a penetrating injury involving the superior sagittal sinus with concurrent AV fistula., (Copyright © Congress of Neurological Surgeons 2022. All rights reserved.)

To investigate cerebral autoregulatory status in patients with severe traumatic brain injury (TBI), guidelines now suggest active manipulation of mean arterial pressure (MAP). There is a paucity of data, however, describing the effect on intracranial pressure (ICP) when MAP is raised. Consecutive patients with TBI requiring ICP monitoring were enrolled from November 2019 to April 2020. The MAP and ICP were recorded continuously, and clinical annotations were made whenever intravenous vasopressors were commenced or adjusted to defend cerebral perfusion pressure (CPP) targets. A significant change in MAP burden was defined as MAP >100min.mm Hg over 15 min. The primary outcome was the change in ICP burden over the same 15-min period. Bedside and clinical parameters were then compared between these groups. Twenty-eight patients were enrolled, providing 212 clinical events, of which 60 were deemed significant. Over the first 15 min, 65% were associated with a net negative ICP burden. A greater reduction in ICP burden was observed with events occurring in patients without a history of hypotension at scene ( p  = 0.016), after three days post-injury ( p  = 0.0018), and where the pressure-reactivity index (PRx) was <0.25 ( p  = 0.0005) or the ICP amplitude to CPP correlation coefficient (RAC) was <-0.10 ( p  = 0.0036) at the initiation of vasopressor changes. The ICP burden in the first 15 min was highly correlated with the next 15-min period. In patients with severe TBI requiring ICP monitoring, increasing MAP to pursue a CPP target was followed by a net negative ICP burden in approximately two-thirds of events. These data suggest a MAP challenge may be a useful adjunct in managing intracranial hypertension.

Glioblastoma (GBM) is a malignant cerebral neoplasm carrying poor prognosis. The importance of extent of resection (EoR) in GBM patient outcomes has been argued in the literature. Previous studies included tumors in eloquent regions of the brain. This confounds the role of EoR by including patients with intrinsically worse outcomes but will be over-represented in the reduced EoR category. In a homogenous group of patients in whom GTR was considered achievable, we investigated the effect of increasing EoR on survival. A retrospective review of 51 patients was undertaken. Quantitative, volumetric analysis of pre-operative and post-operative magnetic resonance image was compared with corresponding clinical details. The primary outcome measured was post-operative overall survival. Median overall survival was 18.3 months for GTR patients compared to 11.6 months for non-GTR (p = 0.025). Median pre-operative contrast-enhancing tumor volume for GTR patients was 54.7 cm 3 and 24.9 cm 3 for non-GTR. Post-operative median residual tumor volume was 1.1 cm 3 in the non-GTR cohort. In multivariate analyses, GTR (HR [95% CI] = 0.973 [0.954-0.994], p = 0.00559) and increasing EoR (HR [95% CI] = 0.964 [0.944-0.985], p = 0.000665) remained predictors of survival. Centile dichotomization of EoR revealed 74% (HR [95% CI] = 0.351 [0.128-0.958], p = 0.0409) as the lowest threshold conferring statistically significant survival benefit. Where technically feasible, both GTR and EoR remained as independent prognostic factors for survival. GTR remains the gold standard for surgical treatment of GBM in patients, 74% being the minimum EoR required to confer survival benefit., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Concurrent craniocervical dissociation in a multi-trauma patient requiring venous-venous extracorporeal membranous oxygenation (ECMO) poses significant challenges in its management., Purpose: This article describes the nuances of the surgical decision-making in a complex case of a polytrauma patient with craniocervical dissociation who required concurrent ECMO., Study Design/ Setting: Case report and literature review., Methods: The authors describe a complex case of a patient with craniocervical dissociation requiring ECMO and who was managed surgically in a level 1 trauma centre in Victoria, Australia after sudden neurological deterioration whilst in a halo-vest. A literature search using appropriate medical subject headings and keywords was performed to identify published cases of craniocervical dissociation in patients requiring concurrent ECMO., Results: Literature search yielded twenty-seven articles, with only two relevant articles identified for full text review. Only one article was found to be relevant, which however did not provide detailed discussion on surgical aspect of the pathology., Conclusion: To the authors' knowledge, this is the first report of management of craniocervical dissociation in a patient requiring ECMO due to polytrauma focused on the nuances of the complex surgical decision-making which is required for proper management of such critical condition., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2020 The Authors. Published by Elsevier Ltd on behalf of North American Spine Society.)

Introduction: Dural venous sinus thrombosis is an uncommon, but significant sequela that may occur after resection of a cerebellopontine angle lesion. The natural history and management of this pathology has not been sufficiently studied., Methods: All operative cases for cerebellopontine angle lesions performed in our local institution dating from 1 January 2005 to 30 June 2018 were retrospectively reviewed to identify patients who developed new post-operative dural venous sinus thrombosis. Patients who developed a significantly narrowed sinus without intrinsic thrombus were also identified. Progression of sinus thrombosis through time was followed, with comparisons made between complications amongst patients with and without a compromised sinus., Results: Of the 126 patients, 20 were found to have new sinus thrombosis, with another 16 developing a critically narrowed sinus without intrinsic thrombus. These cases are significantly associated with translabyrinthine resection of acoustic schwannoma. 4 patients amongst the thrombosed group were commenced on additional therapeutic anticoagulation or antiplatelets, whilst the rest were observed. Based on available follow up imaging, 10/17 patients had significantly improved sinus thrombosis on serial imaging, including 8/14 amongst those not given additional anticoagulation. Patients with a compromised sinus demonstrated a higher rate of cerebrospinal fluid leak requiring blindsac procedures. When involving a dominant sinus, there is also an association of an increased requirement for permanent CSF diversion., Conclusion: Therapeutic anticoagulation should be considered for symptomatic post-operative dural venous sinus thrombosis or if it involves a dominant sinus. Further prospective studies are warranted to better elucidate the risk-benefit justification of treatment for postoperative sinus thrombosis., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

New Zealand has one of the highest rates of melanoma in the world. In up to 10% of cases, the disease is metastatic at diagnosis. Cerebral metastatic involvement carries a particularly poor prognosis. 110 patients were included in the analysis. A retrospective consecutive series of patients treated surgically at Auckland City Hospital were studied, with parameters of demographics, tumour characteristics, surgery, pathology, systemic therapy and survival analysed. Mean age was 59.9 years (range 22-81 years). Median survival from date of surgery was 8.1 months (95% CI 6.9-9.4 months). Of the 58 patients tested for BRAF mutation, 28 were positive, similar to previously published data. This conferred a better prognosis with median overall survival of 12.3 months (95% CI 7.2-17.3 months) compared to 7.8 months (95% CI 5.6-10 months) for those who were negative (p < 0.05). Survival correlated positively with extent of surgical resection. Both BRAF positive status and targeted and/or immunotherapy were significant predictors of improved survival. In this cohort, radiation therapy did not show a statistically significant improvement in overall survival. Survival from resection of cerebral metastases from melanoma is improving. Survival benefit is conferred by BRAF mutation, solitary metastasis and gross total resection of lesion., (Copyright © 2019. Published by Elsevier Ltd.)

Study Design: Ambispective observational cohort study., Objectives: Synthetic graft usage avoids morbidity associated with harvest and reduces operative time. This study aims to evaluate outcomes of anterior cervical stabilization surgery using a synthetic cage in comparison with iliac crest bone graft (ICBG) following cervical spine trauma., Methods: An ambispective review was conducted on patients from the Alfred Trauma Registry. Consecutive patients treated at a level 1 trauma center, aged 18 years and older who were treated with standalone anterior cervical stabilization following spine trauma (2011-2016) were included in the study. Primary outcome measures were patient overall satisfaction, Neck Disability Index (NDI), neck pain 10-point visual analogue scale (VAS-neck) and arm pain 10-point visual analogue scale (VAS-arm). Secondary outcome measures were radiographic evidence of fusion and rate of revision surgery. All patients had follow-up for at least 1 year., Results: Between 2011 and 2016, 114 traumatic disc levels in 104 patients were treated. ICBG was used in 32% and polyetheretherketone (PEEK) cage in 68% of the patients. Both groups had similar demographic metrics. There was no significant difference in primary outcome measures between the graft types: (1) patient satisfaction ( P = .15), (2) NDI ( P = .11), (3) VAS-neck ( P = .13), and (4) VAS-arm ( P = .20). Radiology based fusion assessment 6 months postsurgery did not show statistical significance ( P = .10). The rates of revision surgery were similar., Conclusions: This study showed no significant difference in patient-reported outcome measures when comparing the usage of PEEK cage and ICBG in anterior stand alone cervical spine stabilization. Level 1 evidence studies are required to further investigate this finding., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Panspinal infection usually presents with fever, back pain, neurological deficit, and in advanced cases multi-organ failure and septic shock. The choice of treatment for panspinal infection is challenging because these patients are usually medically unstable with severe neurological compromise. The objective of this study is to review management and long term outcomes for patients with panspinal infection., Methods: A retrospective review of patients with panspinal infection treated in our center over a 5-year period [Jan 2010-Dec 2014] and a review of the current published literatures was undertaken., Results: We identified 4 patients with panspinal infection. One case was managed medically due to high perioperative risk, whilst the other three were managed surgically whilst on antibiotic therapy. All 3 cases managed surgically improved neurologically and infection subsided, whereas the patient managed medically did not change neurologically and infection subsided., Conclusions: Patients with panspinal infection should be treated surgically unless the medical risk of surgery or anaesthesia is prohibitive., Competing Interests: The authors have no conflicts of interest to declare.

Ossification of the ligamentum flavum (OLF) is an uncommon condition, which usually occurs amongst people of Asian descent, and most commonly in the thoracic spine region. Whilst often asymptomatic, OLF can cause spinal canal stenosis, with patients presenting with back pain, posterior cord syndrome or myelopathy. We present a rare case of acute spinal cord injury associated with OLF after a kite surfing accident, with the resulting paraplegia partially improved after decompression was performed. The prevalence, presentation and management of OLF are also discussed., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Field male Aedes aegypti (L.) and Aedes albopictus (Skuse) adults caught from fixed monitoring stations weekly for 1 yr were screened for dengue viruses (DEN-1, DEN-2, DEN-3, and DEN-4). The assay was carried out using a single-step reverse transcription (or transcriptase)-polymerase chain reaction (PCR) (RT-PCR) followed by a semi-nested PCR using an upstream consensus primer and four type-specific primers within the nonstructural protein three gene (NS3) of dengue viruses. The diagnostic fragments for DEN-1, DEN-2, DEN-3, and DEN-4 serotypes were of sizes 169, 362, 265, and 426 bp, respectively. Results showed that in Singapore 1.33% and 2.15% of Aedes aegypti and Aedes albopictus adult male mosquitoes, respectively, were positive for dengue viruses. The serotypes detected in male Ae. aegypti was DEN-1 (44%), followed by DEN-2 (22.2%) and DEN-3 (22.2%), and DEN-4 (11.1%). For Aedes albopictus males, the serotype was DEN-4 (38.9%), followed by DEN-2 (33.3%), DEN-3 (16.7%), and DEN-1 (11.1%).