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BACKGROUND Eagle syndrome can be a rare cause of neck pain and headache. The elongated styloid process typically irritates and compresses adjacent neurovascular structures in the neck, leading to insidious signs and symptoms classic of Eagle syndrome. However, neck pain after traumatic events can be the only sign of elongated styloid processes. Therefore, knowledge of this syndrome is necessary to prevent misdiagnosis and futile attempts at treatment, especially in the setting of trauma. CASE REPORT In this article, we report the case of a 20-year-old man who presented with throbbing neck pain and headache immediately after a motor vehicle accident. The patient's symptoms did not improve with analgesics and muscle relaxants. He was then admitted for overnight monitoring while awaiting computed tomography imaging of the head and neck, which revealed elongated styloid processes on both sides. CONCLUSIONS One of the most challenging aspects of diagnosing Eagle syndrome is the need for high clinical suspicion combined with adequate understanding of the neck anatomy and its structures. Owing to the proximity of the elongated styloid process to important neurovascular structures, such as the carotid arteries and vagus nerve, early diagnosis of Eagle syndrome is necessary to guide the clinical decision-making and provide optimal care for patients.

Sacubitril/valsartan (S/V) is a pharmaceutical strategy that increases natriuretic peptide levels by inhibiting neprilysin and regulating the renin-angiotensin-aldosterone pathway, blocking AT1 receptors. The data for this innovative medication are mainly based on the PARADIGM-HF study, which included heart failure with reduced ejection fraction (HFrEF)-diagnosed patients and indicated a major improvement in morbidity and mortality when S/V is administrated compared to enalapril. A large part of the observed favorable results is related to significant reverse cardiac remodeling confirmed in two prospective trials, PROVE-HF and EVALUATE-HF. Furthermore, according to a subgroup analysis from the PARAGON-HF research, S/V shows benefits in HFrEF and in many subjects having preserved ejection fraction (HFpEF), which indicated a decrease in HF hospitalizations among those with a left ventricular ejection fraction (LVEF) < 57%. This review examines the proven benefits of S/V and highlights continuing research in treating individuals with varied HF characteristics. The article analyses published data regarding both the safeness and efficacy of S/V in patients with HF, including decreases in mortality and hospitalization, increased quality of life, and reversible heart remodeling. These benefits led to the HF guidelines recommendations updating and inclusion of S/V combinations a key component of HFrEF treatment.

Oxidative stress is a complex biological process characterized by the excessive production of reactive oxygen species (ROS) that act as destroyers of the REDOX balance in the body and, implicitly, inducing oxidative damage. All the metabolisms are impaired in oxidative stress and even nucleic acid balance is influenced. ROS will promote structural changes of the tissues and organs due to interaction with proteins and phospholipids. The constellation of the cardiovascular risk factors (CVRFs) will usually develop in subjects with predisposition to cardiac disorders. Oxidative stress is usually related with hypertension (HTN), diabetes mellitus (DM), obesity and cardiovascular diseases (CVDs) like coronary artery disease (CAD), cardiomyopathy or heart failure (HF), that can develop in subjects with the above-mentioned diseases. Elements describing the complex relationship between CVD and oxidative stress should be properly explored and described because prevention may be the optimal approach. Our paper aims to expose in detail the complex physiopathology of oxidative stress in CVD occurrence and novelties regarding the phenomenon. Biomarkers assessing oxidative stress or therapy targeting specific pathways represent a major progress that actually change the outcome of subjects with CVD. New antioxidants therapy specific for each CVD represents a captivating and interesting future perspective with tremendous benefits on subject's outcome., (Copyright © 2022 The Authors. Published by Elsevier Masson SAS.. All rights reserved.)

Diabetes exacerbates the progression of atherosclerosis and is associated with increased risk of developing acute coronary syndrome (ACS). Approximatively 25-30% of patients admitted for ACS have diabetes. ACS occurs earlier in diabetics and is associated with increased mortality and a higher risk of recurrent ischemic events. An increased proinflammatory and prothrombotic state is involved in the poorer outcomes of diabetic patients. In the past decade advancement in both percutaneous coronary intervention (PCI) and coronary artery by-pass graft (CABG) techniques and more potent antiplatelet drugs like prasugrel and ticagrelor improved outcomes of diabetic patients with ACS, but this population still experiences worse outcomes compared to non-diabetic patients. While in ST elevation myocardial infarction urgent PCI is the method of choice for revascularization, in patients with non-ST elevation ACS an early invasive approach is suggested by the guidelines, but in the setting of multivessel (MV) or complex coronary artery disease (CAD) the revascularization strategy is less clear. This review describes the accumulating evidence regarding factors involved in promoting increased incidence and poor prognosis of ACS in patients with diabetes, the evolution over time of prognosis and outcomes, revascularization strategies and antithrombotic therapy studied until now., (Copyright © 2022 The Authors. Published by Elsevier Masson SAS.. All rights reserved.)

The lateral lumbar interbody fusion technique for lumbar arthrodesis is gaining popularity and being added as an option to traditional posterior and anterior approaches. In light of this, we analyzed the literature to identify the 25 most cited articles regarding lateral lumbar interbody fusion. The Thomson Reuters Web of Science was systematically searched to identify papers pertaining to lateral lumbar interbody fusion. The results were sorted in order to identify the top cited 25 articles. Statistical analysis was applied to determine metrics of interest, and observational studies were further classified. A search of all databases in the Thomson Reuters Web of Science identified 379 articles pertaining to lateral lumbar interbody fusion, with a total of 3800 citations. Of the 25 most cited articles, all were case series, reporting on a total of 2981 patients. These 25 articles were cited 2232 times in the literature and total citations per article ranged from 29 to 433. The oldest article was published in 2006, whereas the most recent article was published in 2015. The most cited article, by Ozgar et al., was cited 433 times, and the journal Spine published 7 of the 25 most cited articles. Herein, we report and analyze the 25 most cited articles on lateral lumbar interbody fusion, which include 25 cases series reporting a variety of data on a total of 2513 patients. Such data might assist in the design and interpretation of future studies pertaining to this topic.

Background: Traumatic spinal injuries can be life-threatening conditions. Despite numerous epidemiological studies, reports on specific spinal regions affected are lacking., Hypothesis: We hypothesized that fractures at specific regions, such as the cervical spine (including the axis segment), have been affected to a greater degree. We also hypothesized that advanced age may be a significant contributing factor., Objective: To longitudinally analyze trend of spine fractures and specific fracture subtypes., Study Design: Longitudinal trend analysis of discharged patient state database., Patient Sample: Discharged patient's data from 15 years (2003-2017) METHODS: We retrieved pertinent ICD-9 and 10 codes depicting fractures involving the entire spine and specific subtypes. To assess possible association with age, we analyzed the trend of the average age in patients discharged with and without spinal fractures as well as in specific fracture subtypes. Similar analysis was performed for other common fragility fractures. FDA device/drug status: The manuscript submitted does not contain information about medical device(s) or drug(s)., Results: We found that within 15 years, the overall proportion of spinal fractures has increased by 64% (from 0.47 to 0.77% of all discharged patients) with the greatest increase noted in fractures of the cervical spine (123%) and specifically of the second cervical vertebra (84%). Age was found to have increased more in patients with spinal fractures than in the general discharged population. Surprisingly, other non-spinal fractures among patients above 60 remained relatively stable, demonstrating a spine-specific effect., Conclusions: Our findings confirm a recent increase in all spinal fractures and in the cervical and sacral regions in particular. Advanced age may be an important underlying factor.

Competing Interests: Conflict of interest The authors declare that they do not have any conflict of interest.

Background: Spinal cord injury (SCI) carries debilitating lifelong consequences and, therefore, requires careful review of different treatment strategies., Methods: An extensive review of the English literature (PubMed 1990 and 2019) was performed regarding recent advances in the treatment of SCI; this included 46 articles written over 28 years., Results: Results of this search were divided into five major modalities; neuroprotective and neuroregenerative pharmaceuticals, neuromodulation, stem cell-based therapies, and various external prosthetic devices. Lately, therapeutic strategies were mainly focused on two major areas: neuroregeneration and neuroprotection., Conclusion: Despite recent advancements, more clinical trials on a larger scale and further research are needed to provide better treatment modalities of this devastating neurological disease., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Surgical Neurology International.)

Background: Intracranial migration of odontoid screws is a rare but serious complication of anterior odontoid screw fixation not often reported in literature by neurosurgeons. Here, we describe the second case in literature of intracranial migration of an odontoid screw., Case Description: A 64-year-old neurologically intact patient with a type II odontoid fracture secondary to trauma underwent anterior odontoid screw fixation without any intraoperative complications. He tolerated the procedure well, and postoperative imaging demonstrated near anatomic correction of the fracture with satisfactory placement of the lag screw. Unfortunately, the patient was subsequently lost to follow up and he presented 7 months later for a routine outpatient computed tomography (CT) of the cervical spine, which demonstrated upward migration of the screw into the intracranial cavity abutting the medulla, with CT angiography of the neck also confirming the screw lying between the two vertebral arteries. Magnetic resonance imaging of the cervical spine also demonstrated the odontoid screw lying within close proximity to the ventral cervicomedullary junction, marginating the left vertebral artery. Subsequently, the patient was managed with removal of the odontoid screw and posterior cervical arthrodesis and instrumented fusion., Conclusion: Our case demonstrates the rare but serious complication of intracranial odontoid screw migration, which we bring to the attention of the neurosurgical community. The recognition of risk factors for this complication and optimized management of this rare occurrence is important for surgeons to recognize., Competing Interests: There are no conflicts of interest., (Copyright: © 2019 Surgical Neurology International.)

Gunshot wounds represent the second most frequent cause of spinal cord injury after vehicular trauma. The thoracic region is most commonly involved, followed by the thoracolumbar spine. Numerous studies have demonstrated that improvement of neurological recovery, especially after decompression surgery, is likely to be seen in lumbosacral spine, but not in the thoracic or cervical spine. Herein, we present a case of a gunshot wound causing lumbar 5 th nerve root compression with neurological deficits that improved remarkably after urgent decompression surgery. This signifies a potential neurological benefit to prompt surgical intervention in lumbar gunshot wounds with radiographic evidence of neural compression. A relevant review of the literature was performed along with discussion, the clinical history, and radiological findings., Competing Interests: The authors have declared financial relationships, which are detailed in the next section., (Copyright © 2019, Brash et al.)

Background: Excision of coil mass during clipping of recurrent or residual aneurysms after prior endovascular coiling is challenging. We evaluated the use of the carbon dioxide laser for safe and effective removal of coils during aneurysm surgery. Two cases are presented., Case Description: The first patient was a 56-year-old man with a previously coiled ruptured anterior communicating artery aneurysm. Angiography at 3-year follow-up showed recurrent aneurysm, which could not be coiled again owing to technical reasons. An aneurysm clip could not be safely applied owing to the weight of the coil mass compromising the parent vessel lumen. Laser-assisted coil mass resection was performed before permanent clip application. Intraoperative cerebral angiography showed complete obliteration of the aneurysm. The second patient was a 69-year-old woman with a previously coiled unruptured middle cerebral artery aneurysm. Angiography at 2-year follow-up showed recurrence of the aneurysm, which could not be coiled again owing to technical reasons. Laser-assisted coil mass resection was performed before the aneurysm was safely clipped. Intraoperative angiography showed complete obliteration of the aneurysm. No complications occurred using the carbon dioxide laser. At 1-year follow-up, both patients were asymptomatic with no evidence of aneurysmal recurrence., Conclusions: Excision of coil mass is required while treating recurrent and/or residual intracranial aneurysms that were previously treated by endovascular technique. The use of carbon dioxide laser assistance while retrieving these coils is safe and effective., (Copyright © 2018. Published by Elsevier Inc.)

Study Design: Systematic review., Objectives: In patients undergoing posterior spinal fusion: (1) What are the types and risks of wound complications in major (≥3 levels) surgery, and does the risk vary by number of levels fused? (2) What types of fascial closure result in the fewest wound complications? (3) What subcutaneous closure technique is more effective in preventing wound complications for obese patients (body mass index >30 kg/m 2 )? (4) What type of skin closure results in the fewest wound complications? (5) What type of dressing results in the fewest wound complications?, Methods: Electronic databases and reference lists of key articles were searched from January 1, 2000 to December 4, 2017 to identify studies meeting inclusion criteria., Results: Six lower quality retrospective studies (evidence level III) met the inclusion criteria. The risk of wound complications in patients with ≥3 level posterior spine fusion ranges from 1.5% to 3.7% depending on the definition of wound complications. Skin closure with sutures resulted in fewer wound infections compared with staples (0.0% vs 8.0%, P = .023). We were unable to demonstrate an association between the number of levels fused and infection risk. Wound infections, primarily superficial, occurred less frequently with Silverlon dressing versus routine dressing., Conclusions: We were unable to determine if infection risk changed with increasing number of levels fused. There is a lack of evidence for optimal wound closure technique in posterior spine surgery. Several questions still remain unanswered, such as the optimal fascial closure technique or the optimal subcutaneous closure technique in obese patients., 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.

The authors describe a 67-year-old man with a prior history of alcohol abuse who presented with a complaint of worsening low back pain. Four months prior to his presentation, the patient had undergone extreme lateral interbody fusion (XLIF) of his lumbar 3-4 segment for the treatment of his chronic low back and legs pain. Imaging revealed a loosening of his interbody fusion implant on top of his prior lumbar spine instrumentation. In surgery, the removal of his loose implant was followed by decompression, the stabilization of the collapsed segment, and the implant of antibiotic-impregnated polymethyl-methacrylate (PMMA) spacer and beads. At a later stage, the patient underwent an interbody fusion of the affected segment as well as a segmental fusion from T10 to his pelvis. Whereas all aerobes and anaerobes stains were negative for organisms, multiple fungal smears from the failed segment were positive for yeast, and the patient was placed on oral fluconazole. Infections complicating the surgical site of interbody fusions performed by minimally invasive techniques are rare. To the best of our knowledge and after reviewing the literature, this is the first report of an extreme lateral interbody fusion implant complicated by fungal osteomyelitis., Competing Interests: The authors have declared that no competing interests exist.

The facultative human pathogen Vibrio cholerae changes its transcriptional profile upon oral ingestion by the host to facilitate survival and colonization fitness. Here, we used a modified version of recombination-based in vivo expression technology to investigate gene silencing during the in vivo passage, which has been understudied. Using a murine model of cholera, we screened a V. cholerae transposon library composed of 10,000 randomly generated reporter fusions and identified 101 in vivo repressed ( ivr ) genes. Our data indicate that constitutive expression of ivr genes reduces colonization fitness, highlighting the necessity to down-regulate these genes in vivo. For example, the ivr gene clcA , encoding an H + /Cl - transporter, could be linked to the acid tolerance response against hydrochloric acid. In a chloride-dependent manner, ClcA facilitates survival under low pH (e.g., the stomach), but its presence becomes detrimental under alkaline conditions (e.g., lower gastrointestinal tract). This pH-dependent clcA expression is controlled by the LysR-type activator AphB, which acts in concert with AphA to initiate the virulence cascade in V. cholerae after oral ingestion. Thus, transcriptional networks dictating induction of virulence factors and the repression of ivr genes overlap to regulate in vivo colonization dynamics. Overall, the results presented herein highlight the impact of spatiotemporal gene silencing in vivo. The molecular characterization of the underlying mechanisms can provide important insights into in vivo physiology and virulence network regulation., Competing Interests: The authors declare no conflict of interest., (Copyright © 2018 the Author(s). Published by PNAS.)

When image guidance is not available or when there is a need to confirm the findings of such technology, superficial landmarks can still play a role in providing surgeons with estimations of the position of deeper anatomical structures. To our knowledge, surface landmarks for the position of the odontoid process have not been investigated. We have therefore performed an anatomical study to investigate such a landmark. One-centimeter metallic rods were placed on the philtrum of the upper lip of 20 cadaveric head specimens. To assess the position relative to the odontoid process, we took lateral and anteroposterior radiographs and recorded the measurements. Descriptive findings from radiographic observations indicated a reasonable approximation between the philtrum and the midpoint of the odontoid process. Based on our results, we suggest that the philtrum of the upper lip can serve as a first line estimation of the position of the odontoid process and can assist in verifying this bony structure following the use of image guidance.

Introduction
 The extreme lateral interbody fusion technique (XLIF) is a modification of the retroperitoneal approach to the lumbar spine. This is a minimally invasive technique allowing direct access to the disc space without peritoneal or posterior paraspinal musculature damage. Nevertheless, the retroperitoneal part of the colon can be injured in this operative technique. To our knowledge, a study analyzing the anatomical considerations of the extreme lateral interbody fusion technique with regards to potential colon injuries has not been previously performed. Therefore, the aim of this study was to evaluate the potential risk of colon injuries during the extreme lateral approach to the lumbar spine. Materials and Methods
 The extreme lateral approach to the lumbar spine was performed on four fresh-frozen cadaveric sides. K-wires were placed into the intervertebral discs and positioned at L1/L2, L2/L3, L3/L4, and L4/L5 levels. Next, the distances from the wires to the most posterior aspect of the adjacent ascending or descending colon were measured.
 Results
 The mean distance from the intervertebral disc space to the ascending or descending colon was 23.2 mm at the L2/L3 level, 29.5 mm at the L3/L4 level, and 40.3 mm at the L4/L5 level. The L1/L2 level was above the colon on both sides.
 Conclusion
 Our study quantified the relationship of the retroperitoneal colon during an extreme lateral interbody fusion approach. Our results, as well as previously described cases of bowel perforations, suggest a greater risk for colon injuries at the L2/3 and L3/4 levels.​​​​​​​., Competing Interests: The authors have declared that no competing interests exist.

Objective Since the extreme lateral lumbar interbody fusion procedure was first reported by Ozgur in 2006, a large number of clinical studies have been published. Anatomical studies which explore methods to avoid visceral structures, such as the kidney, with this approach have not been examined in detail. We dissected the retroperitoneal space to analyze how the extreme lateral transpsoas approach to the lumbar spine could damage the kidney and related structures. Methods Eight sides from four fresh Caucasian cadavers were used for this study. The latissimus dorsi muscle and the thoracolumbar fascia were dissected to open the retroperitoneum. The fat tissue was removed. Steel wires were then put into the intervertebral disc spaces. Finally, the closest distance between kidney and wires on each interdiscal space was measured. Results The closest distance from the wire in the interdiscal space on L1/2, L2/3 and L3/4 to the kidney ranged from 13.2 mm to 32.9 mm, 20.0 mm to 27.7 mm, and 20.5 mm to 46.6 mm, respectively. The distance from the kidney to the interdiscal space at L4/5 was too great to be considered applicable to this study. Conclusions The results of this study might help surgeons better recognize the proximity of the kidney and avoid injury to it during the extreme lateral transpsoas approach to the lumbar spine., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Standalone cages have gained popularity because of their ease of implantation, reduced operating time, and lower profile compared with traditional plate and cage systems. The aim of this study was to compare the risk of chronic dysphagia between those who undergwent anterior cervical discectomy and fusion (ACDF) with traditional plating techniques and those who underwent standalone procedures., Material and Methods: Between 2014 and 2015, we identified 377 consecutive patients who met the study criteria (standalone, n = 211; plate-cage, n = 166). Patient-specific characteristics and surgical characteristics were collected preoperatively. In addition, the Dysphagia Disability Index (DDI) was collected 2 years postoperatively by telephone interview., Results: Among the patients who underwent a standalone procedure, 84% (n = 177) were available for their 2-year follow-up visit in comparison with 75% (n = 124) for plate-cage procedures. There was no statistically significant difference in postoperative DDI scores between the 2 groups, controlling for prior surgery and smoking. However, the strongest risk factors for higher DDI scores were prior cervical surgery (mean 6.0 points higher) and smoking (mean 6.2 points higher). Twenty-seven patients (8.9%) experienced chronic dysphagia. The risk was higher in the plate-cage group (n = 15, 12.1%) than in the standalone group (n = 12, 6.7%), but this difference did not reach statistical significance., Conclusion: Despite similar mean DDI scores, patients who undergo anterior cervical discectomy with a plate-cage may be at a higher risk for chronic dysphagia than are those with a standalone approach, but further studies with larger sample sizes are necessary to establish this relationship with greater confidence., (Copyright © 2017 Elsevier Inc. All rights reserved.)

The authors describe a 48-year-old woman suffering from bilateral upper-extremity numbness and axial radiating pain. Magnetic resonance imaging revealed soft-tissue edema and enhancement surrounding the dorsal tip of the C7 spinous process. Excisional biopsy of the lesion revealed a mildly inflamed bursa, with no evidence of an active infection. Removal of the inflamed bursa resulted in complete resolution of the upper-extremity numbness and improvement in her neck pain. Although similar cases have been reported to be associated with rheumatologic conditions, most notably polymyalgia rheumatica (PMR), the current report underlines the presentation of radicular-like complaints associated with interspinous bursitis in the absence of other conditions affecting the musculoskeleton., Competing Interests: The authors have declared that no competing interests exist.

Air embolism developing from an atrial-esophageal fistula that was created as a complication from an atrial ablation procedure is a rare, yet usually fatal diagnosis. Neurologic manifestations such as meningitis, altered mental status, seizures, strokes, transient ischemic attacks (TIAs), psychiatric changes, and coma can ensue. Imaging of the brain might reveal infarcts, cerebral edema, as well as signs of pneumocephalus. This case describes a 42-year-old male with recent cardiac ablation procedure at an outside hospital for refractory atrial fibrillation (A-fib) who presented with altered mental status, dyspnea and diaphoresis. His initial head computed tomography (CT) scan revealed pneumocephalus. He was started on a heparin drip for a non-ST elevation myocardial infarction (NSTEMI), but developed severe coagulopathy. The patient's mental status quickly deteriorated. Given recent cardiac ablation procedure, the cause of his air embolism was thought to be from a created left atrial-esophageal fistula. Despite medical management, he was too unstable to undergo any surgical intervention for his atrial-esophageal fistula or to transfer to a hyperbaric oxygen therapy center, and expired on the second day following his hospital admission. To our knowledge, few reports have been published in the literature describing delayed cerebral air embolism from an atrial-esophageal fistula. Prompt diagnosis, hyperbaric oxygen therapy, and surgical intervention are essential to avoid mortality in these patients. This article aims to increase awareness of such a rare, but significant complication., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Neurologic deficits from lumbar plexus nerve injuries commonly occur in patients undergoing lateral approaches. However, it is not yet clear what types of injury occur, where anatomically they are located, or what mechanism causes them. We aimed to study 1) the topographic anatomy of lumbar plexus nerves and their injuries in human cadavers after lateral transpsoas approaches to the lumbar spine, 2) the structural morphology of those injuries, and 3) the topographic anatomy of the lumbar plexus throughout the mediolateral approach corridor., Methods: Fifteen adult fresh frozen cadaveric torsos (26 sides) underwent lateral approaches (L1-L5) by experienced lateral spine surgeons. The cadavers were subsequently opened and the entire plexus dissected and examined for nerve injuries. The topographic anatomy of the lumbar plexus and its branches, their injuries, and the morphology of these injuries were documented., Results: Fifteen injuries were found with complete or partial nerve transections (Sunderland IV and V). Injuries were found throughout the mediolateral approach corridor. At L1/2, the iliohypogastric, ilioinguinal, and subcostal nerves were injured within the psoas major muscle, the retroperitoneal space, or the outer abdominal muscles and subcutaneous tissues. Genitofemoral nerve injuries were found in the retroperitoneal space. Nerve root injuries occurred within the retroperitoneal space and psoas muscle. Femoral nerve injuries were found only within the psoas major muscle. No obturator nerve injuries occurred., Conclusions: Lateral approaches can lead to structural nerve damage. Knowledge of the complex plexus anatomy, specifically its mediolateral course, is critical to avoid approach-related injuries., (Copyright © 2017 Elsevier Inc. All rights reserved.)

This case report discusses the rare issue of an atrophic cervical pedicle at the C6 level in a patient found unconscious with a jumped facet and an unknown mechanism of injury. A means to discern between traumatic jumped facets versus congenital anomalies is addressed, including missing pedicles, which is encountered at the C6 level in this case. A literature review revealed that the most common level where this occurs is at the C6 level. The structural anatomic pathologies and the variants relative to congenital facet atrophy are identified, including the location and the surrounding vasculature; more specifically, the vertebral arteries. This information is helpful to assist clinicians when discerning between a traumatic subluxation injury that requires instrumentation and reduction versus a congenital anomaly that can usually be managed conservatively., Competing Interests: The authors have declared that no competing interests exist.

Study Design: Retrospective cohort study., Objective: The objective of this study is to compare the incidence of infection in patients who do and do not receive blood transfusions in major deformity surgery (>8 levels)., Summary of Background Data: Postoperative infections increase morbidity and mortality rates in spine surgery and generate additional costs for the health care system. It has been proposed that blood transfusions increase the risk of wound infection, urinary tract infection, pneumonia, and sepsis., Methods: A total of 56 patients met the study criteria, receiving spine surgery involving the fusion of 8 levels or more. Patient-specific characteristics, starting and ending hematocrits, number of units transfused and infections including urinary tract infection, wound infection, pneumonia, and sepsis were documented. Differences in infection risk between those who did and did not undergo a transfusion and their 95% confidence intervals were calculated., Results: Groups were similar with respect to baseline and surgical characteristics except for smoking status, operative time, estimated blood loss, and ending hematocrit. The overall infection rate was greater in patients who underwent transfusion than those who did not (36% vs. 10%; P=0.03). Wound infections (n=5) were only observed in those who underwent a transfusion. Smokers were more likely to receive a transfusion and more likely to experience infection. A stratified analysis demonstrated an increased risk of infection associated with transfusion; however, the risk was greater in smokers, suggesting the effect of transfusion on infection could be modified by smoking. Patients undergoing transfusion experienced a significantly longer hospital stay (P=0.01)., Conclusions: Allogeneic red blood cell transfusion in major spine surgery could be a risk factor for postoperative infection. This increased risk seems to be magnified in those who smoke. Further studies are warranted, and risks of blood loss and transfusion-related complications in smokers also potentially merit exploration., Level of Evidence: Level 3.

Background Context: Injuries to the lumbar plexus during lateral approaches to the spine are not uncommon and may result in permanent deficits. However, the literature contains few studies that provide landmarks for avoiding the branches of the lumbar plexus., Purpose: The present anatomical study was performed to elucidate the course of these nerves in relation to lateral approaches to the lumbar spine., Study Design: This is a quantitative anatomical cadaveric study., Methods: The lumbar plexus and its branches were dissected on 12 cadaveric sides. Metal wires were laid on the nerves along their paths on the posterior abdominal wall. Fluoroscopy was performed in the anteroposterior and lateral positions. The relationships between regional bony landmarks and the branches of the lumbar plexus were observed., Results: When viewed laterally, the greatest concentration of nerves occurred from the posteroinferior aspect of L4, inferior along the posterior one-third of the body of L5, then at the level of the sacral promontory. On the basis of our study, approaches to the anterior two-thirds of the L4 vertebra and anterior third of L5 will result in the lowest chance of lumbar plexus nerve injury. In addition, lateral muscle dissection through the psoas major should be in a superior to inferior direction in order to minimize nerve injury. Laterally, the widest corridor between branches in the abdominal wall was between the subcostal and iliohypogastric nerves., Conclusions: The findings of our cadaveric study provide surgeons who approach the lateral lumbar spine with data that could decrease injuries to the branches of the lumbar plexus, thus lessening patient morbidity., (Copyright © 2017 Elsevier Inc. All rights reserved.)

OBJECTIVE Posterior atlantoaxial stabilization and fusion using C-1 lateral mass screw fixation has become commonly used in the treatment of instability and for reconstructive indications since its introduction by Goel and Laheri in 1994 and modification by Harms in 2001. Placement of such lateral mass screws can be challenging because of the proximity to the spinal cord, vertebral artery, an extensive venous plexus, and the C-2 nerve root, which overlies the designated starting point on the posterior center of the lateral mass. An alternative posterior access point starting on the posterior arch of C-1 could provide a C-2 nerve root-sparing starting point for screw placement, with the potential benefit of greater directional control and simpler trajectory. The authors present a cadaveric study comparing an alternative strategy (i.e., a C-1 screw with a posterior arch starting point) to the conventional strategy (i.e., using the lower lateral mass entry site), specifically assessing the safety of screw placement to preserve the C-2 nerve root. METHODS Five US-trained spine fellows instrumented 17 fresh human cadaveric heads using the Goel/Harms C-1 lateral mass (GHLM) technique on the left and the posterior arch lateral mass (PALM) technique on the right, under fluoroscopic guidance. After screw placement, a CT scan was obtained on each specimen to assess for radiographic screw placement accuracy. Four faculty spine surgeons, blinded to the surgeon who instrumented the cadaver, independently graded the quality of screw placement using a modified Upendra classification. RESULTS Of the 17 specimens, the C-2 nerve root was anatomically impinged in 13 (76.5%) of the specimens. The GHLM technique was graded Type 1 or 2, which is considered "acceptable," in 12 specimens (70.6%), and graded Type 3 or 4 ("unacceptable") in 5 specimens (29.4%). In contrast, the PALM technique had 17 (100%) of 17 graded Type 1 or 2 (p = 0.015). There were no vertebral artery injuries found in either technique. All screw violations occurred in the medial direction. CONCLUSIONS The PALM technique showed statistically fewer medial penetrations than the GHLM technique in this study. The reason for this is not clear, but may stem from a more angulated "up-and-in" screw direction necessary with a lower starting point.

Epidural anesthesia is a versatile technique widely used in treating lumbar spinal pain syndromes. Complications during these procedures can arise either from needle placement or from administration of medication. Potential risks include infection, hematoma, intravascular or subdural injections of medication, direct nerve trauma, air embolism, entry into a disc space, urinary retention, radiation exposure, and hypersensitivity reactions. The objective of this article is to review the complications of lumbar epidural injections and discuss the potential pitfalls related to these procedures. We searched Medline comprehensively for relevant case reports, clinical trials, and review articles. Complications from lumbar epidural injections are extremely rare. Most if not all of them can be avoided by careful techniques with accurate needle placement, sterile precautions, and a thorough understanding of the relevant anatomy and contrast patterns on fluoroscopic imaging. Clin. Anat. 30:342-346, 2017. © 2017 Wiley Periodicals, Inc., (© 2017 Wiley Periodicals, Inc.)

Introduction: Spinal cord tumors (SCT) are relatively uncommon and usually require surgical treatment. Readmission within 30days after discharge is an important indicator of health care quality. The aim of this study was to investigate the rates and causes of unplanned readmissions and reoperations after SCT surgery., Methods: A retrospective analysis of patients' charts at a single center from May 2007 to September 2015 was completed., Inclusion Criteria: history of laminectomy with excision of neoplasm in the spinal cord., Exclusion Criteria: (1) surgery outside the timeframe; (2) less than 19years old; (3) non-neoplastic intramural pathologies; (4) previous resection at the same location; (5) metastatic lesions., Results: We found 131 patients that met criteria. Six patients (4.5%) were readmitted within 30days and two within 90days (1.5%). Four underwent reoperation: one for a cerebrospinal fluid leak, two for pseudomenigoceles, and one for repeat laminectomy. Resection of intramedullary tumors resulted in twice the risk of having one or more complications compared to extramedullary tumors (RR 2.0; 95% CI: 1.0-4.2; p=0.057), and nearly four times the risk of having a neurological complication (RR 3.8; 95% CI 1.5-9.5; p=0.005)., Conclusion: This study analyzes readmission, reoperation and complication rates for the surgical care of SCT highlighting how SCT surgery is still involved with morbidity in experienced and specialized centers. This information is useful both for health care enhancement projects and for evidence-based patient counseling., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Spinal hematomas are a rare but serious complication of spinal epidural anesthesia and are typically seen in the epidural space; however, they have been documented in the subdural space. Spinal subdural hematomas likely exist within a traumatically induced space within the dural border cell layer, rather than an anatomical subdural space. Spinal subdural hematomas present a dangerous clinical situation as they have the potential to cause significant compression of neural elements and can be easily mistaken for spinal epidural hematomas. Ultrasound can be an effective modality to diagnose subdural hematoma when no epidural blood is visualized. We have reviewed the literature and present a full literature review and a case presentation of an 82-year-old male who developed a thoracolumbar spinal subdural hematoma after spinal epidural anesthesia. Anticoagulant therapy is an important predisposing risk factor for spinal epidural hematomas and likely also predispose to spinal subdural hematomas. It is important to consider spinal subdural hematomas in addition to spinal epidural hematomas in patients who develop weakness after spinal epidural anesthesia, especially in patients who have received anticoagulation., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Regional neurovascular structures must be avoided during invasive spine hardware placement. During C1 lateral mass screw placement, the C2 nerve root is put in harm's way. Therefore the current anatomic study was performed to identify techniques that might avoid such neural injury., Materials and Methods: On 10 cadaveric sides, dissection was carried down to the craniocervical junction. The C2 nerve root was identified, and its distal branches were traced out into the surrounding posterior cervical musculature. Once dissected, the nerve was displaced inferiorly away from the lateral mass of C1., Results: On all sides, the C2 nerve root could be easily detethered from surrounding tissues. On all sides, this allowed lateral mass screw placement without compression of the nerve., Conclusion: On the basis of our cadaveric study, the C2 nerve root can be detethered enough at the level of the posterior lateral mass of C1 to avoid its injury during screw placement into this area., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Study Design  Systematic review. Clinical Questions  (1) When used as an assistive device, do wearable exoskeletons improve lower extremity function or gait compared with knee-ankle-foot orthoses (KAFOs) in patients with complete or incomplete spinal cord injury? (2) When used as a rehabilitation device, do wearable exoskeletons improve lower extremity function or gait compared with other rehabilitation strategies in patients with complete or incomplete spinal cord injury? (3) When used as an assistive or rehabilitation device, are wearable exoskeletons safe compared with KAFO for assistance or other rehabilitation strategies for rehabilitation in patients with complete or incomplete spinal cord injury? Methods  PubMed, Cochrane, and Embase databases and reference lists of key articles were searched from database inception to May 2, 2016, to identify studies evaluating the effectiveness of wearable exoskeletons used as assistive or rehabilitative devices in patients with incomplete or complete spinal cord injury. Results  No comparison studies were found evaluating exoskeletons as an assistive device. Nine comparison studies (11 publications) evaluated the use of exoskeletons as a rehabilitative device. The 10-meter walk test velocity and Spinal Cord Independence Measure scores showed no difference in change from baseline among patients undergoing exoskeleton training compared with various comparator therapies. The remaining primary outcome measures of 6-minute walk test distance and Walking Index for Spinal Cord Injury I and II and Functional Independence Measure-Locomotor scores showed mixed results, with some studies indicating no difference in change from baseline between exoskeleton training and comparator therapies, some indicating benefit of exoskeleton over comparator therapies, and some indicating benefit of comparator therapies over exoskeleton. Conclusion  There is no data to compare locomotion assistance with exoskeleton versus conventional KAFOs. There is no consistent benefit from rehabilitation using an exoskeleton versus a variety of conventional methods in patients with chronic spinal cord injury. Trials comparing later-generation exoskeletons are needed.

Venous air embolism (VAE) is a known neurosurgical complication classically and most frequently occurring in patients undergoing posterior cranial fossa or cervical spine surgery in a sitting or semi-sitting position. The authors present a case of VAE that occurred during posterior cervical spine surgery in a patient in the prone position, a rare intraoperative complication. The patient was a 65-year-old man who was undergoing a C1-2 fusion for a nonunion of a Type II dens fracture and developed a VAE. While VAE in the prone position is uncommon, it is a neurosurgical complication that may have significant clinical implications both intraoperatively and postoperatively. The aim of this review is 2-fold: 1) to improve the general knowledge of this complication among surgeons and anesthesiologists who may not otherwise suspect air embolism in patients positioned prone for posterior cervical spine operations, and 2) to formulate preventive measures as well as a plan for prompt diagnosis and treatment should this complication occur.

Once considered anomalous structures, transforaminal ligaments are not widely known and the criteria for identifying and classifying them are not universal. They are, however, of potential importance during neurological procedures, as their entrapment might lead to radicular pain. Transforaminal ligaments are not present in all patients, but when they are, the incidence of all types of ligaments is significantly higher, with the most common type being the superior corporotransverse ligament. By diminishing the overall amount of space available for the spinal nerve to pass, many early studies concluded that transforaminal ligaments were the cause of nerve root entrapment, resulting in radicular pain. However, more recent studies conducted have claimed that the ligaments do not cause radicular pain but rather are more for the protection of nerves and vessels. The contribution of transforaminal ligaments to radicular pain is still a topic of debate, but their role in the protection of nerves and vessels is certain. The clinician who performs interventional procedures directed toward the intervertebral foramen and the surgeon operating in this region should have a good working knowledge of the anatomy and proposed functions of the transforaminal ligaments., Competing Interests: The authors have declared that no competing interests exist.

Objective: Knowledge of the course of the vertebral artery during instrumentation is of paramount importance. It has been shown that erosion of the C2 pedicle and body can occur due to pulsations of the adjacent vertebral artery. This often results in a "cave" for this segment of the artery. The descriptions of this anatomy are limited. The current study was performed with the hope that these data will be of use to spine surgeons during C2 instrumentation., Methods: In 40 human adult C2 bone specimens, the position of the vertebral artery in relation to the undersurface of the superior articular facet, pedicle, and C2 body was observed. A classification system was used to better describe these relationships. Pedicle screws were then placed into selected examples of each type., Results: We found type 0 specimens, with no cave, on 8 sides (10%). Types I, II, and III caves with minimal, moderate, and significant encroachment of the pedicle were observed on 40%, 35%, and 27.5% sides, respectively. Type IV caves with erosion into the lateral C2 body and undersurface of the superior articular facet were observed on 12.5% of sides. Although larger caves were found on left sides, this did not reach statistical significance. Pedicle screw placement for types III and IV were most likely to enter the vertebral artery cave (P < 0.05)., Conclusions: Additional osteologic data regarding the course of the vertebral artery while within C2 may decrease morbidity during surgery in this region., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Superior mesenteric artery (SMA) syndrome is a rare clinical entity. We report a female patient presenting with abdominopelvic pain and diagnosed with superior mesenteric artery syndrome. Direct venography revealed a large ovarian varix that was treated with hysterectomy and unilateral oophorectomy. SMA syndrome can have many presentations often with small bowel obstruction. Obstruction of only the ovarian vein with resultant ovarian varix is an unusual presentation., Competing Interests: The authors have declared that no competing interests exist.

A 69-year-old female with a history of breast cancer and hypertension presented with a rare case of herpes simplex encephalitis (HSE) isolated to her left parietal lobe. The patient's first biopsy was negative for herpes simplex virus (HSV) I/II antigens, but less than two weeks later, the patient tested positive on repeat biopsy. This initial failure to detect the virus and the similarities between HSE and symptoms of intracranial hemorrhage (ICH) suggests repeat testing for HSV in the presence of ICH. Due to the frequency of patients with extra temporal HSE, a diagnosis of HSE should be more readily considered, particularly when a patient may not be improving and a concrete diagnosis has not been solidified., Competing Interests: The authors have declared that no competing interests exist.

The epidural space contains the internal vertebral venous plexus, adipose, and other connective tissues. In the anatomical literature, there are nonspecific descriptions of varying fibrous connective tissue bands in the epidural space, mainly mentioned in the lumbar region, that tether the dural sac to the posterior longitudinal ligament, the vertebral canal, and the ligamentum flavum. These ligaments have been termed as Hofmann's ligaments. This review expands on the anatomy and function of Hofmann's ligaments, increasing the awareness of their presence and serves as an impetus for further study of their histology, innervation, and function., Competing Interests: The authors have declared that no competing interests exist.

Of patients who have undergone lateral approaches to the thoracic spine, surgical site postoperative pain appears to be greater among those who have undergone transection and removal of a rib segment than those who have not. Therefore, techniques that conserve anatomical position and minimize tissue disruption would theoretically result in less pain and a quicker recovery. Herein, we describe a rib-sparing osteoplastic technique used when rib segments need to be displaced in order to create an unobscured corridor to the operative target. Our approach minimizes soft tissue disruption and restores the anatomical function of the rib. Based on our experience, these patients report less pain, mobilize earlier, and are discharged sooner than those who have had rib segments sacrificed as part of a lateral approach to the spine.

Most prolactin-secreting pituitary adenomas demonstrate slow growth and are effectively managed with medical/surgical therapy. Rarely, these tumors can behave aggressively with rapid growth and invasion of local tissues, and are refractory to medical, surgical, or radio-surgical therapies. We report a case of a prolactin-secreting adenoma in a young woman, which became progressively aggressive and refractory to usual treatment modalities, but responded to treatment with the chemotherapeutic agent temozolomide. In addition, we review the literature for treatment of refractory adenomas with temozolomide. The clinical and pathologic characteristics of aggressive prolactin-secreting adenomas are reviewed, as well as their response to dopamine agonists, surgery, radiotherapy, and chemotherapy.

The C2 pedicle screw is more biomechanically stable and provides patients with increased postoperative range of motion in comparison to other methods of C2 fixation. However, as a result of the proximity of the C2 pedicle to the transverse foramen, there is a considerable risk of intraoperative morbidity due to vertebral artery injury laterally or vertebral canal breach medially. Other than the use of cadavers for the demonstration and practice of C2 pedicle screw placement, there are currently few other readily available teaching aids for the training of residents and fellows. Herein, we describe a simple and cost effective modality for the demonstration, evaluation, and practice of C2 pedicle screw placement in a laboratory setting.

Lumbar stenosis has become one of the most common spinal pathologies and one that results in neurogenic claudication, back and leg pain, and disability. The standard procedure is still an open laminectomy, which involves wide muscle retraction and extensive removal of the posterior spinal structures. This can lead to instability and the need for additional spinal fusion. We present a systemized and detailed approach to unilateral laminotomy for bilateral decompression, which we believe is superior to the standard open laminectomy in terms of intraoperative visualization, postoperative stability, and degree of invasiveness.

Objective: Spinal epidural steroid injections are generally considered a safe, effective treatment for radicular pain in a variety of spinal conditions. Complications secondary to these injections, although rare, can result in devastating neurologic symptoms. Patients with preexisting moderate-to-severe spinal stenosis and recent use of chronic anticoagulation pose a challenging dilemma when making treatment decisions, as a history of both can increase the risk of complications., Case Report: The following case study provides a description of a patient with spinal stenosis who discontinued anticoagulation therapy according to the recommended guidelines but who experienced a subsequent acute epidural hematoma and significant neurologic injury., Conclusions: This case report describes the potential risk factors present in this patient. Presence of spinal stenosis and the interlaminar approach seem to be significant risk factors in this case. Presence of an intrinsic coagulopathy was not determined.

Cavernous angiomas usually occur in the parenchyma of both the supra and infratentorial compartments. At times, they can both clinically and radiologically mimic other dural-based lesions. We present a case of a patient with chronic occipital headaches, initially thought to have a meningioma, but proven to be a cavernoma with histological analysis.

Aims: Lateral transtemporal approaches are useful for addressing lesions located ventral to the brainstem, especially when the pathologic diagnosis of the tumor dictates that a gross or near total resection improves outcomes. One approach, the presigmoid approach receives little attention in the pediatric population thus far. We sought to characterize morphometric changes, particularly the clival depth and the petroclival Cobb angle, that occur in the temporal bones of children and draw implications about doing a presigmoid approach in children., Settings and Design: This study was a retrospective study performed at John Sealy Hospital, a level-one trauma center that takes care of pediatric injuries as well., Subjects and Methods: We performed a morphometric analysis of noncontrast computed tomography head studies in 96 boys and 67 girls. Central clival depth and petroclival angle were obtained in the axial plane at the level of the internal auditory meatus using the method described by Abdel Aziz et al., Statistical Analysis Used: Descriptive statistics and Student's t-test to compare groups were calculated using Microsoft Excel., Results: We found no gender difference in mean central clival depth or petroclival angle (P = 0.98 and P = 0.61, respectively). However, when we broke our cohort by age into those younger than 9 years of age and those 10 years or older, we found the petroclival angle decreased by 6.2° which was statistically significant (P < 0.000000006)., Conclusions: These findings suggest that a presigmoid retrolabyrinthine approach is useful for children 9 years of age and younger as the petroclival angle appears to decrease resulting in a shallower clival depression in these patients.

Sequestered disc fragments typically occur ventrally but can also migrate dorsally or intradurally. At times, atypical disc herniations can be misinterpreted on imaging as other lesions, such as neoplasms, hematomas, or abscesses. We present an uncommon case of a patient presenting with cauda equina syndrome secondary to an enhancing sequestered disc fragment mimicking a tumor.

The operative microscope has been a staple instrument in the neurosurgical operating room over the last 50 years. With advances in optoelectronics, options such as robotically controlled high magnification have become available. Such robotically controlled optoelectronic systems may offer new opportunities in surgical technique and teaching. However, traditionally trained surgeons may find it hard to accept newer technologies due to an inherent bias emerging from their previous background. We, therefore, studied how a medically naïve population in a pilot study would meet set microsurgical goals in a cadaver experiment using either a conventional operative microscope or BrightMatter™ Servo system, ​a robotically controlled optoelectronic system (Synaptive Medical, Toronto, Ontario, Canada). We found that the relative ease in teaching medical novices with a robotically controlled optoelectronic system was more valuable when compared to using a modern-day surgical microscope.

Intraoperative neurophysiological monitoring is a commonly used practice during spine surgery. Complications of electromyography (EMG) needle electrode placement are very uncommon. We present a patient who was infected with necrotizing fasciitis in her left thigh due to an EMG needle electrode during a two-stage complex spine procedure. This case demonstrates that providers should continue to meticulously adhere to protocol when inserting and removing EMG needles, but also be cognizant during postoperative observation of the possibility of infection caused by EMG needles.

Fetal brain perfusion is supplied by the primitive dorsal aorta anteriorly, longitudinal neural arteries posteriorly, and anastomotic transverse segmentals. Most notable of these connections are the primitive trigeminal, otic, hypoglossal, and proatlantal arteries. With cranial-cervical circulatory maturation and development of the posterior communicating segments and vertebro-basilar system, these primitive segmental anastomoses normally regress. Anomalous neurovascular development can result in persistence of these anastomoses. Due to its territory of perfusion, the persistent primitive hypoglossal artery (PPHA) is associated with vertebral artery and posterior communicating artery hypoplasia or aplasia. As a consequence, primary blood supply to the hindbrain comes chiefly from this single artery. Although usually clinically silent, PPHA is susceptible to common cerebrovascular disorders including athero-ischemic disease and saccular aneurysmal dilation to name a few. We present a case of transient ischemic attack in a patient with a PPHA and proximal atherosclerotic disease treated by endovascular stenting.

Spinal epidural hematoma (SEH) occurring after chiropractic spinal manipulation therapy (CSMT) is a rare clinical phenomenon. Our case is unique because the patient had an undiagnosed cervical spinal arteriovenous malformation (AVM) discovered on pathological analysis of the evacuated hematoma. Although the spinal manipulation likely contributed to the rupture of the AVM, there was no radiographic evidence of the use of excessive force, which was seen in another reported case. As such, patients with a known AVM who have not undergone surgical intervention should be cautioned against symptomatic treatment with CSMT, even if performed properly. Regardless of etiology, SEH is a surgical emergency and its favorable neurological recovery correlates inversely with time to surgical evacuation.