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OBJECTIVE In the era of modern medicine with an armamentarium full of state-of-the art technologies at our disposal, the incidence of wrong-level spinal surgery remains problematic. In particular, the thoracic spine presents a challenge for accurate localization due partly to body habitus, anatomical variations, and radiographic artifact from the ribs and scapula. The present review aims to assess and describe thoracic spine localization techniques. METHODS The authors performed a literature search using the PubMed database from 1990 to 2020, compliant with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A total of 27 articles were included in this qualitative review. RESULTS A number of pre- and intraoperative strategies have been devised and employed to facilitate correct-level localization. Some of the more well-described approaches include fiducial metallic markers (screw or gold), metallic coils, polymethylmethacrylate, methylene blue, marking wire, use of intraoperative neuronavigation, intraoperative localization techniques (including using a needle, temperature probe, fluoroscopy, MRI, and ultrasonography), and skin marking. CONCLUSIONS While a number of techniques exist to accurately localize lesions in the thoracic spine, each has its advantages and disadvantages. Ultimately, the localization technique deployed by the spine surgeon will be patient-specific but often based on surgeon preference.

Treatments for symptomatic or unstable basilar invagination (BI) include posterior decompression, distraction/fusion, trans-nasal or trans-oral anterior decompression, and combined techniques, with the need for occipitocervical fusion based on the degree of craniocervical instability. Variations of the far lateral transcondylar approach are described in limited case series for BI, but have not been widely applied.A single-institution, retrospective review of consecutive patients undergoing a far lateral transcondylar approach for odontoidectomy (± resection of the inferior clivus) followed by occipitocervical fusion over a 6-year period (1/1/2016 to 12/31/2021) is performed. Detailed technical notes are combined with images from cadaveric dissections and patient surgeries to illustrate our technique using a lateral retroauricular incision.Nine patients were identified (3 males, 6 females; mean age 40.2 ± 19.6 years). All patients had congenital or acquired BI causing neurologic deficits. There were no major neurologic or wound-healing complications. 9/9 patients (100%) experienced improvement in preoperative symptoms.The far lateral transcondylar approach provides a direct corridor for ventral brainstem decompression in patients with symptomatic BI. A comprehensive knowledge of craniovertebral junction anatomy is critical to the safe performance of this surgery, especially when using a lateral retroauricular incision.

The authors report an unusual case of an odontoid synchondrosis fracture causing chronic translational anterior atlanto-axial subluxation and present a discussion of the unique management of this case. Traumatic translational anterior atlanto-axial subluxation is a rare manifestation within pediatrics. Patients with preexisting abnormalities in ligamentous or bony structures may present with unusual symptomatology, which could result in delay of treatment. A 6-year-old male patient with autism who presented with acute respiratory arrest was noted to have an odontoid synchondrosis fracture and severe anterior translational atlanto-axial subluxation. Initial attempts at reduction with halo traction were tried for first-line treatment. However, because of concern regarding possible inadvertent worsening of the impingement, the presence of comorbid macrocephaly, and possible instability with only C1–2 fusion, a posterior C1 laminectomy was performed. Further release of the C1–2 complex and odontoid peg from extensive fibrous tissue allowed for complete reduction. Acute injuries of the C1–2 complex may not present as expected, and the presence of pain is not a reliable symptom. Halo traction is an appropriate initial treatment, but some patients may require surgical realignment and stabilization.

Objective The prevalence of physicians experiencing work-related musculoskeletal disorders is high. Traditionally, minimally invasive surgery (MIS) sacroiliac joint (SIJ) fusions are performed with the patient oriented in the prone position, with an incision made inferior to the iliac crest. However, a novel technique that orients the patient in the lateral decubitus position has the potential of significantly enhancing ergonomics and ease of approach. The primary objectives of this study were to quantify surgical parameters, describe this 'lateral-decubitus MIS' technique, and identify imaging angle parameters that predict feasibility. Methods A prospective cohort of patients who underwent MIS SIJ arthrodesis in the lateral decubitus position was evaluated at a single institution between 2017 and 2020. Medians and ranges of intraoperative blood loss, operative time, revision rate, infection, and total radiation dose were recorded. Sacral inlet and outlet angles were defined and collected to assess for operative candidacy. Results Thirty-nine cases were identified in 34 patients who underwent the technique with an age range of 31–78 years. Median blood loss was 22.5 mL, operating room time was 32.5 minutes, and radiation dose was 30.9 rads. Average sacral inlet was 24.51° and average sacral outlet was 65.44°. Median length of stay was 0.94 days. No cases were aborted or required revision. A total of 93% of study participants reported improvement in pain. Operative parameters were comparable to the traditional prone approach. Conclusions The aim was to provide an insight into outcomes and metrics observed from pioneering this style of procedure. A future study comparing traditional perioperative parameters together with surgical ergonomics is needed.

Introduction Magnetic resonance neurography (MRN) is a newer imaging technique that is increasingly used for detailed visualization of peripheral nerves not reliably achieved with conventional imaging modalities. Although MRN has been previously characterized in the literature, few studies have assessed its utility to neurosurgery, where there is potentially substantial impact particularly with preoperative assessment. In this article, we performed a retrospective review of cases in which MRN was used for clinical evaluation and surgical decision making. Methods MRN, clinical assessment, and operative decision making were retrospectively assessed in 206 consecutive patients at our institution between 2015 and 2018. Results MRN was determined to lead to a change in diagnosis or surgical decision making in 44 patients (21.4%: 27 female, 17 male). These were classified into 6 major diagnostic categories: trauma, postsurgical evaluation, compressive/degenerative conditions, tumors, neuritis/inflammation, and other neurogenic lesions. Nine representative cases were selected from these categories to highlight the range of neurosurgical pathologies in which MRN was useful in diagnostic assessment and surgical decision making. Conclusions MRN is an underused resource with great potential value in the diagnoses, surgical planning, and postoperative assessment of various neurosurgical conditions. These present incremental utility to the neurosurgeon as well as socioeconomic benefit in the detection of potentially surgically treatable lesions.

Background Sacral tumors present a significant challenge to the spine surgeon. As new techniques have evolved in recent years, these lesions have become more amenable to aggressive surgical treatment. Although sacral tumors make up only a small minority of spinal tumors, their surgical management warrants special consideration. Methods Based on our experience, we highlight 3 important surgical nuances specifically for the treatment of sacral tumors: preservation and maximization of neurologic function, protection of ventral abdominal and pelvic structures, and lumbopelvic fixation. Results Two cases of patients with sacral tumors treated at our institution are presented to illustrate these points. Both patients had successful postoperative courses, and remained pain free, well-fixated, and neurologically intact at 3–4 month follow-up. They had no evidence of biomechanical instability. Conclusions To ensure a successful outcome, a goal-directed, methodical approach is required.

Objective Spontaneous cervical intradural disc herniation (IDH) is a rare occurrence with limited and disparate information available regarding its presentation, diagnosis, and treatment. However, its accurate detection is vital for planning surgical treatment. In this review of the literature, we collected data from all cervical IDHs described to date. Particular attention was paid to diagnostic findings, surgical approach, and causation for cervical IDH, especially at the cervicothoracic junction. Methods A review for cases of cervical IDH was performed via the following search criteria: (“neck”[MeSH Terms] OR “neck”[All Fields] OR “cervical”[All Fields]) AND intradural[All Fields] AND disc[All Fields]. Thirty-seven cases of cervical disc herniation were identified. Demographic variables identified included age, sex, cervical level of herniation, history of associated cervical trauma, presence of Brown-Sequard syndrome, Horner syndrome, and other neurologic findings, radiographic findings, direction of surgical approach, and postoperative outcomes. Results A total of 37 cases of cervical IDH were identified. Most of the cases occurred at the lower levels of the cervical spine, with 35.1% at the C5–C6 level, followed by 24.3% at C6–C7, and lower still at other levels. Of the patients reviewed, 44.4% had a previous history of trauma before manifestation of symptom, with the majority being spontaneous IDH with no previous history of trauma or spine surgery. Brown-Sequard syndrome was present in 43.2% of the patients, whereas 10.8% of patients experienced Horner syndrome. The most common presentations of IDH included quadriplegia, finger/gait ataxia, radiculopathy, and nuchal pain. The degree of neurologic recovery was not associated with patient age. Most of the cervical IDHs in the literature were treated surgically via an anterior approach, but a larger portion of patients who underwent a posterior approach had improved recovery. Conclusions Cervical IDH is a rare event, with this review of the literature outlining the clinical and radiographic parameters of its presentation as well as comparing common surgical strategies for treatment. We outline theories underlying the development of cervical IDH and argue for a posterior surgical approach in which the disc herniation is sequestrated with migration.

A large-scale study on postoperative complications of lumbar fusion surgery for spondylolisthesis comparing patients80 years old with younger patients has not been performed. The purpose of this study is to assess the effects of extreme age (80 years old) on early postoperative outcomes after single-level lumbar fusions for spondylolisthesis.From a validated multicenter surgical database, 2475 patients who underwent a single-level lumbar fusion procedure for spondylolisthesis were selected retrospectively. An extreme age cohort with 227 patients80 years old was compared with a typical age cohort with 2248 patients 45-65 years old.The preoperative characteristics and comorbidities were different between the typical age cohort and the extreme age cohort, with older patients having more preoperative comorbidities, including a lack of independent functional health status before surgery (P0.001), severe chronic obstructive pulmonary disease (P0.020), and hypertension requiring medication (P0.001). There was significantly greater morbidity among the80 cohort regarding urinary tract infection (P = 0.008; odds ratio = 3.30; 95% confidence interval, 1.47-7.40) and intraoperative and postoperative transfusions (P0.001; odds ratio = 2.186; 95% confidence interval, 1.54-3.11). There was significantly greater morbidity among the younger cohort regarding cardiac arrest requiring cardiopulmonary resuscitation (P = 0.043; odds ratio = 0.099; 95% confidence interval, 0.014-0.704).This is the first large study comparing the rates of postoperative complications of lumbar fusion surgery for spondylolisthesis in patients80 years old versus younger patients. The data support that age alone should not exclude a patient for this procedure. However, extra caution is warranted given the slightly increased morbidity.

Background Surgical-site infections (SSIs) are a major cause of morbidity and mortality, increasing the length and cost of hospitalization. In patients undergoing spine surgery, there are limited large-scale data on patient-specific risk factors for SSIs. Methods The American College of Surgeons National Surgical Quality Improvement Program database was reviewed for all spinal operations between 2006 and 2012. The rates of 30-day SSIs were calculated, and univariate analysis of selected preoperative risk factors was performed. Multivariate analysis was then used to identify independent predictors of SSIs. Results A total of 1110 of the 60,179 patients (1.84%) had a postoperative wound infection. There were 527 (0.87%) deep and 590 (0.98%) superficial infections. Patients with infections had greater rates of sepsis, longer lengths of stay, and more return visits to the operating room. Independent predictors of infection were female sex, inpatient status, insulin-dependent diabetes, preoperative steroid use greater than 10 days, hematocrit less than 35, body mass index greater than 30, wound class, American Society of Anesthesiologists class, and operative duration. Conclusions Analysis of a large national patient database revealed many independent risk factors for SSIs after spinal surgery. Some of these risk factors can be modified preoperatively to reduce the risk of postoperative infection.

Background: Neurofibromatosis is an autosomal dominant disorder of the nerves, resulting in café-au-lait spots, axillary freckling, macules, and neurofibromas throughout the nervous system. Diagnosis of this condition has in the past been mainly clinical, but the usage of magnetic resonance imaging neurography (MRN) is a new diagnostic modality. Here, we report on a case of neurofibromatosis type I (NF-1) that was diagnosed using MRN after a protracted clinical course. Case Description: A 23-year-old female presented with several months of worsening right upper and lower quadrant abdominal pain. The patient underwent computed tomography (CT) of the abdomen and pelvis demonstrating multiple neurofibromas involving the psoas muscle and mesentery of the lower abdomen. Subsequent total neuronal axis magnetic resonance imaging (MRI) using the neurography protocol (MRN) showed multiple neurofibromas in both the right brachial plexus and lumbar plexus. Conclusion: We present a case of NF-1 that was diagnosed using MRN following a protracted clinical course. MRN is a diagnostic modality for NF-1 and other peripheral nerve disorders.

Schwannomatosis is characterized by multiple non-intradermal schwannomas with patients often presenting with a painful mass in their extremities. In this syndrome malignant transformation of schwannomas is rare in spite of their large size at presentation. Non-invasive measures of assessing the biological behavior of plexiform neurofibromas in neurofibromatosis type 1 such as positron emission tomography (PET), CT scanning and MRI are well characterized but little information has been published on the use of PET imaging in schwannomatosis. We report a unique clinical presentation portraying the use of PET imaging in schwannomatosis. A 27-year-old woman presented with multiple, rapidly growing, large and painful schwannomas confirmed to be related to a constitutional mutation in the SMARCB1 complex. Whole body PET/MRI revealed numerous PET-avid tumors suggestive of malignant peripheral nerve sheath tumors. Surgery was performed on multiple tumors and none of them had histologic evidence of malignant transformation. Overall, PET imaging may not be a reliable predictor of malignant transformation in schwannomatosis, tempering enthusiasm for surgical interventions for tumors not producing significant clinical signs or symptoms.

In this video, the authors demonstrate a minimally invasive approach and resection of a paraspinal schwannoma. Using an expandable retractor, the authors were able to identify important adjacent bony landmarks and hence visualize and remove this peripheral nerve sheath tumor. While a tubular retractor is commonly used for interbody fusion procedures, the location of the tumor allowed this minimally invasive approach resulting in excellent access, minimal soft-tissue injury, and a short hospital stay. The authors present this approach as a less invasive and yet effective technique for resection of otherwise difficult-to-access nerve lesions.The video can be found here: https://youtu.be/89OY5wdMB_k.

Background: Currarino syndrome (CS) is a rare genetic condition that presents with the defining triad of anorectal malformations, sacral bone deformations, and presacral masses, which may include teratoma. Neurosurgeons are involved in the surgical treatment of anterior meningoceles, which are often associated with this condition. The accepted surgical treatment is a staged anterior-posterior resection of the presacral mass and obliteration of the anterior meningocele. Case Description: This case involved a 36-year-old female who presented with late onset of symptoms attributed to CS (e.g., presacral mass, anterior sacral meningocele, and sacral agenesis). She successfully underwent multidisciplinary single-stage approach for treatment of the anterior sacral meningocele and resection of the presacral mass. This required obliteration of the meningocele and closure of the dural defect. One year later, her meningocele had fully resolved. Conclusion: While late presentations with CS are rare, early detection and multidisciplinary treatment including single-state anterior may be successful for managing these patients.

Background and Methods: As with any evolving surgical discipline, it is difficult to predict the future of the practice and science of spine surgery. In the last decade, there have been dramatic developments in both the techniques as well as the tools employed in the delivery of better outcomes to patients undergoing such surgery. In this article, we explore four specific areas in spine surgery: namely the role of minimally invasive spine surgery; motion preservation; robotic-aided surgery and neuro-navigation; and the use of biological substances to reduce the number of traditional and revision spine surgeries. Results: Minimally invasive spine surgery has flourished in the last decade with an increasing amount of surgeries being performed for a wide variety of degenerative, traumatic, and neoplastic processes. Particular progress in the development of a direct lateral approach as well as improvement of tubular retractors has been achieved. Improvements in motion preservation techniques have led to a significant number of patients achieving arthroplasty where fusion was the only option previously. Important caveats to the indications for arthroplasty are discussed. Both robotics and neuro-navigation have become further refined as tools to assist in spine surgery and have been demonstrated to increase accuracy in spinal instrumentation placement. There has much debate and refinement in the use of biologically active agents to aid and augment function in spine surgery. Biological agents targeted to the intervertebral disc space could increase function and halt degeneration in this anatomical region. Conclusions: Great improvements have been achieved in developing better techniques and tools in spine surgery. It is envisaged that progress in the four focus areas discussed will lead to better outcomes and reduced burdens on the future of both our patients and the health care system.

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.

Tc-99m ethyl cysteinate diethylester (ECD) and Tc-99m hexamethyl propylene amine oxime (HMPAO) are commonly used for single-photon emission computed tomography (SPECT) studies of a variety of neurologic disorders. Although these tracers have been very helpful in diagnosing and guiding treatment of neurologic disease, data describing the distribution and laterality of these tracers in normal resting brain are limited. Advances in quantitative functional imaging have demonstrated the value of using resting studies from control populations as a baseline to account for physiologic fluctuations in cerebral perfusion. Here, we report results from 30 resting Tc-99m ECD SPECT scans and 14 resting Tc-99m HMPAO scans of normal volunteers with no history of neurologic disease. Scans were analyzed with regions of interest and with statistical parametric mapping, with comparisons performed laterally (left vs. right), as well as for age, gender, and handedness. The results show regions of significant asymmetry in the normal controls affecting widespread areas in the cerebral hemispheres, but most marked in superior parietotemporal region and frontal lobes. The results have important implications for the use of normal control SPECT images in the evaluation of patients with neurologic disease.

Although subtraction ictal SPECT coregistered to MRI (SISCOM) is clinically useful in epilepsy surgery evaluation, it does not determine whether the ictal-interictal subtraction difference is statistically different from the expected random variation between 2 SPECT studies. We developed a statistical parametric mapping and MRI voxel-based method of analyzing ictal-interictal SPECT difference data (statistical ictal SPECT coregistered to MRI [STATISCOM]) and compared it with SISCOM.Two serial SPECT studies were performed in 11 healthy volunteers without epilepsy (control subjects) to measure random variation between serial studies from individuals. STATISCOM and SISCOM images from 87 consecutive patients who had ictal SPECT studies and subsequent temporal lobectomy were assessed by reviewers blinded to clinical data and outcome.Interobserver agreement between blinded reviewers was higher for STATISCOM images than for SISCOM images (kappa = 0.81 vs kappa = 0.36). STATISCOM identified a hyperperfusion focus in 84% of patients, SISCOM in 66% (p0.05). STATISCOM correctly localized the temporal lobe epilepsy (TLE) subtypes (mesial vs lateral neocortical) in 68% of patients compared with 24% by SISCOM (p = 0.02); subgroup analysis of patients without lesions (as determined by MRI) showed superiority of STATISCOM (80% vs 47%; p = 0.04). Moreover, the probability of seizure-free outcome was higher when STATISCOM correctly localized the TLE subtype than when it was indeterminate (81% vs 53%; p = 0.03).Statistical ictal SPECT coregistered to MRI (STATISCOM) was superior to subtraction ictal SPECT coregistered to MRI for seizure localization before temporal lobe epilepsy (TLE) surgery. STATISCOM localization to the correct TLE subtype was prognostically important for postsurgical seizure freedom.

Partial seizure disorders account for the majority of epilepsy (Sander et al., 1990). In one tertiary center cohort of 2,200 patients, partial epilepsy was more than twice as common as symptomatic, cryptogenic, and idiopathic generalized epilepsies combined. Moreover, in that study, two-thirds of the partial seizure disorders localized to the temporal lobe (Semah et al., 1998). Unfortunately, despite optimal medical therapy, approximately 30% of patients continue to experience recurrent seizures (Sander et al., 1990 Wiebe, et al. 2001). In a recent well-designed trial studying patients who failed initial medication trials, seizure freedom was achieved in only 8% of patients with continued medical therapy compared to 58% of patients undergoing anterior temporal lobectomy (Wiebe, et al. 2001). However, physicians may be reluctant to consider surgery for temporal lobe epilepsy when structural neuroimaging appears normal. Temporal lobectomy has been shown to render about 80% of patients seizure-free in the setting of a magnetic resonance imaging (MRI)–apparent structural abnormality concordant to the seizure onset zone, such as mesial temporal sclerosis (MTS) (Cascino, 2004). On the other hand, patients with temporal lobe epilepsy and normal MRI have received less attention. In order to demonstrate the absence of a potentially epileptogenic structural lesion, it is critical that patients have high-resolution seizure protocol MRI with both T1- and T2-weighted images (Jack, 1996; Cascino, 2004). There are relatively few studies examining temporal lobectomy in patients with normal modern seizure protocol MRI. Existing research suggests significantly disparate rates of successful surgery in patients with nonlesional MRI, ranging from 18–63% of patients becoming seizure-free (Berkovic et al., 1995; Theodore et al., 1997; Sylaja et al., 2004; Cohen-Gadol et al., 2005; Jeha et al., 2006). Many of these studies were conducted during the 1980s and early 1990s (Berkovic et al., 1995; Radhakrishnan et al., 1998; McIntosh et al., 2004), prior to the widespread use of epilepsy neuroimaging protocols that are more sensitive for detecting MTS (Jack, 1996; Jack et al., 1996). Some of these studies used pathologic findings to categorize patients (McIntosh et al., 2004; Cohen-Gadol et al., 2006), information that is not available preoperatively for clinical prognostication. Other studies include heterogeneous patient populations and only small numbers of patients with nonlesional MRI (Holmes et al., 2000; Sylaja et al., 2004; Cohen-Gadol et al., 2005). Therefore, we sought to examine the efficacy of epilepsy surgery and noninvasive predictors of favorable outcome for patients with medically refractory temporal lobe epilepsy and a nonlesional high-resolution seizure protocol MRI.

Summary: Purpose: Because focal encephalomalacia is an important cause of medically intractable partial epilepsy and few studies have evaluated the efficacy and the safety of resecting focal encephalomalacias to improve seizure control, we studied a cohort of 17 consecutive patients who underwent resection of encephalomalacias in the frontal lobes as a treatment of their intractable epilepsy. Methods: We evaluated several factors for their value in predicting postsurgical seizure control. Pre- and postsurgical magnetic resonance imaging (MRI) scans were reviewed independently by 2 blinded investigators. Results: At a median of 3 years of follow-up (range 0.67.5 years), 12 patients (70%) were seizure-free or had only rare seizures. The presence of a focal fast frequency discharge (focal ictal p pattern) at the beginning of seizures on scalp EEG was predictive of seizure-free outcome (p = 0.017), even among patients who had complete resection of their encephalomalacias (p = 0.016). There was no significant differences in outcome with regard to age at the time of the injury that caused encephalomalacia, interval between injury and onset of seizures, duration of presurgical seizure history, presurgical seizure frequency, age at surgery, or the completeness of encephalomalacia resection. The analysis regarding completeness of encephalomalacia resection almost reached significance, suggesting that it may also be an important predictive factor (p = 0.051). Conclusions: We conclude that surgery is a very effective treatment for intractable frontal lobe epilepsy (FLE) secondary to encephalomalacias. Patients are more likely to become seizure-free if they have a focal ictal /3 discharge on their scalp EEG. Complete resection of the encephalomalacia should be attempted, since our results suggest that this may be a favorable predictive factor. Moreover, the operative strategy for our patients entailed, whenever possible, complete resection of the encephalomalacias and of the adjacent electrophysiologically abnormal tissues. Key Words: Epilepsy-Surgery-Encephalomalacia-Posttraumatic-Frontal Lobectomy.

We describe the case of a 42-year-old female presenting with subarachnoid haemorrhage from a posterior inferior cerebellar artery (PICA) aneurysm rupture on intracranial digital subtraction angiography (DSA). One year postoperatively, the patient was followed with CT angiography and was reported to show a de novo aneurysm at the bifurcation of the left inferior cerebellar artery (ICA). Subsequent DSA revealed an aberrant vein crossing over the ICA bifurcation on mask phase images. This is the first reported case of a such a reason for a ‘false positive’ on CT angiography (CTA). The case demonstrates that although CTA has a reported high specificity, careful interpretation of multiple views is required to diagnose intracranial aneurysms when compared to the ‘gold’ standard of CTA.

Background context Adjacent segment disease (ASD) after lumbar spinal fusion has been an important reason behind the development of nonfusion stabilization technology. However, the incidence, prevalence, and factors contributing to adjacent segment degeneration in the lumbar spine remain unclear. A range of prevalence rates for ASD have been reported in the lumbar spinal literature, but the annual incidence has not been widely studied in this region. Conflicting reports exist regarding risk factors, especially fusion length. Purpose To determine the annual incidence and prevalence of further surgery for adjacent segment disease (SxASD) after posterior lumbar arthrodesis and examine possible risk factors. Study design Retrospective cohort study. Patient sample Nine hundred twelve patients who underwent 1,000 consecutive posterior lumbar interbody fusion procedures, with mean follow-up duration of 63 months (range, 5 months–16 years). Outcome measures Further surgery for ASD or surgery-free survival. Methods A postal and telephone survey. Follow-up rate: 91% of patients. The annual incidence and prevalence of ASD requiring further surgery were determined using Kaplan–Meier survivorship analysis. Cox proportional-hazards (Cox) regression was used for multivariate analysis of possible risk factors. Significance was set at p Results Further surgery for ASD occurred following 130 of 1,000 or 13% of procedures at a mean time of 43 months (range, 2.3–162 months). The mean annual incidence of SxASD over the first 10 years, in all patients, was 2.5% (95% confidence interval [95% CI], 1.9–3.1) with prevalences of 13.6% and 22.2% at 5 and 10 years, respectively. Cox regression modeling found that the number of levels fused (p≤.0003), age of the patient, fusing to L5, and performing an additional laminectomy adjacent to a fusion all independently affect the risk of SxASD. The mean annual incidence figures in the first 10 years after a lumbar fusion were 1.7% (95% CI, 1.3–2.2) after fusion at single levels, 3.6% (2.1–5.2) after two levels, and 5.0% (3.3–6.7) after three and four levels. The 5- and 10-year prevalences were 9% and 16%, 17% and 31%, and 29% and 40% after single-, two-, and three-/four-level fusions, respectively. The risk of SxASD in patients younger than 45 years was one-quarter (95% CI, 10–64) the risk of patients older than 60 years (p=.003). A laminectomy adjacent to a fusion increases the relative risk by 2.4 times (95% CI, 1.1–5.2; p=.03). Stopping a fusion at L5 is associated with a 1.7-fold increased risk (95% CI, 1.2–2.4; p=.007) of SxASD compared with a fusion to S1, for fusions of the same length. Conclusion The overall annual incidence and predicted 10-year prevalence of further surgery for ASD after lumbar arthrodesis were 2.5% and 22.2%, respectively. These rates varied widely depending on the identified risk factors. Although young patients who underwent single-level fusions were at low risk, patients who underwent fusion of three or four levels had a threefold increased risk of further surgery, compared with single-level fusions (p

Background Reinitiating warfarin sodium therapy in a patient with a recent warfarin-related intracerebral hemorrhage (WAICH) is a difficult clinical decision. Therefore, it is important to assess the outcome of resumption or discontinuation of warfarin therapy after WAICH. Objective To compare patients who survived an episode of WAICH and restarted warfarin therapy with a group of WAICH patients who did not resume warfarin therapy. Design, Setting, and Patients We conducted a follow-up study from November 1, 2001, through December 31, 2005, in a cohort from a single center. Long-term outcome was assessed at last clinical follow-up or via questionnaire. Main Outcome Measures Recurrent WAICH and thromboembolic events. Results Fifty-two patients were discharged from the hospital after a diagnosis of WAICH. Four patients were lost to follow-up. Mean follow-up among all patients was 43 (range, 1-108) months. Of the 23 patients who restarted warfarin therapy, 1 had a recurrent nontraumatic WAICH, 2 had traumatic intracerebral hemorrhages, and 2 had major extracranial hemorrhages. Of the 25 patients who did not restart warfarin therapy, 3 had a thromboembolic stroke, 1 had a pulmonary embolus, and 1 had a distal arterial embolus. Conclusions Restarting warfarin therapy in patients with a recent WAICH is associated with a low risk of recurrence, but patients are subjected to known, substantial risks of warfarin use. Withholding warfarin therapy is associated with a risk of thromboembolization.

Study design: Retrospective case review. Introduction: Ischemic insults from blunt cerebrovascular injuries (BCVI) can lead to significant cranial and spinal injury. Specific spine fracture patterns have been identified as more predictive of BCVI, such as vertebral subluxation, fractures through the foramen transversarium, and C1 through C3 fractures. Adequate screening and early treatment has led to a decrease in devastating neurological deficits from associated strokes.1 However, BCVI in association with injuries of the craniocervical junction have been anecdotally reported but their true incidence is still unknown. We hypothesized that craniocervical dissociation (CCD), due to its distractive nature, is also associated with a high incidence of BCVI. Objective: To evaluate the incidence of BCVI in a large series of patients with CCD admitted to a single-level 1 trauma institution. Methods: A retrospective review of all consecutive patients diagnosed with unstable craniocervical distraction injuries (defined as abnormal widening of the C0-C1 and/or C1-2 joints) that were surgically treated from 2003–2009 was performed. All patients with CCD injuries who had a screening catheter angiogram or computed tomographic angiography (CTA) of the neck to exclude BCVI entered the study. Results: Among 39 consecutive patients identified with CCD (26 men [67%] and 13 women [33%] with a mean age of 28.8 years), 28 were screened for BCVI through catheter angiography or CTA. Additional injuries are displayed in Table 1. A total of 14 patients (50%) who were screened had 25 BCVI, with 12 carotid artery and 13 vertebral artery injuries. These injuries were further subclassified according to the Biffl classification system2 (Table 2): Biffl 1 (10 patients); Biffl 2 (6 patients); Biffl 3 (5 patients); Biffl 4 (3 patients), and Biffl 5 (1 patient). Among the 18 patients with a purely ligamentous injury of the craniocervical junction, 8 (44%) had a BCVI (10 carotid artery and 7 vertebral artery injuries). Among the 10 patients with additional spine fractures that are known risk factors for BCVI, 6 (60%) had a vessel injury (6 vertebral artery and 2 carotid artery injuries). Three patients among the 14 with BCVI had a stroke, as opposed to none among the other 14 without BCVI. There was no significant correlation between the presence of BCVI injuries and the presence of abnormal craniocervical distraction as measured by the Harris lines criteria.3 Table 1 Associated injuries in patients screened for BCVI.* Table 2 Biffl grading system for blunt traumatic cerebrovascular injuries. Conclusions: In patients with craniocervical distraction injuries, the incidence of BCVI is high. Those patients with purely ligamentous injuries had a higher incidence of carotid artery injuries whereas those with associated spine fracture patterns that are known predictive risk factors for BCVI had a higher incidence of vertebral artery injuries. We suggest inclusion of craniocervical distraction injuries as another spine fracture pattern indicative for routine screening of BCVI.

This patient has the hallmark of neurofibromatosis type 2 (NF2)–bilateral vestibular schwannomas (VS) – as well as multiple intracranial meningiomas. At the second operation, two tumours were found adjacent to each other on the left side. The caudal aspect of the left VS was removed followed by complete removal of the adjacent tentorial lesion-a meningioma. Subsequent further removal the left VS was limited by decreased amplitude of the brainstem evoked auditory response (BEAR). Resection was limited due to the need to retain hearing on the sole hearing side. Postoperatively, she recovered well and the left sided hearing was preserved. She had a left facial palsy immediately postoperatively, which improved to normal within one month. Histopathological examination demonstrated a VS on the right (MIB–1 labeling index 6%). On the left, the VS had a MIB–1 labeling index of 10%, which may explain its rapid growth. The other lesion was confirmed to be a meningioma (MIB–1 labeling index 5%). NF2 is an autosomal dominant inherited disorder. The responsible gene is located on chromosome 22q12. The diagnostic criteria for NF2 are

Highlights • Fungal osteomyelitis is a rare entity in the spectrum of spinal infections. • We present a case of spinal osteomyelitis secondary to Blastomyces dermatitides. • Infectious lytic lesions of the spine, when stable, may be managed conservatively. • In rare instances, vertebral re-ossification may occur with conservative management., Introduction We present a rare case of thoracic vertebral osteomyelitis secondary to pulmonary Blastomyces dermatitides. Presentation of case A 27-year-old male presented with three months of chest pains and non-productive cough. Examination revealed diminished breath sounds on the right. CT/MR imaging confirmed a right-sided pre-/paravertebral soft tissue mass and destructive lytic lesions from T2 to T6. CT-guided needle biopsy confirmed granulomatous pulmonary Blastomycosis. Conservative management with antifungal therapy was initiated. Neurosurgical review confirmed no clinical or profound radiographic instability, and the patient was stabilized with TLSO bracing. Serial imaging 3 months later revealed near-resolution of the thoracic soft tissue mass, with vertebral re-ossification from T2 to T6. Discussion Fungal osteomyelitis presents a rare entity in the spectrum of spinal infections. In such cases, lytic spinal lesions are classically seen in association with a large paraspinous mass. Fungal infections of the spinal column may be treated conservatively, with surgical intervention reserved for progressive cases manifesting with neurological compromise and/or spinal column instability. Here, we found unexpected evidence for vertebral re-ossification across the affected thoracic levels (T2-6) in response to IV antibiotic therapy and conservative bracing, nearly 3 months later.