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

A letter to the editor is presented which discusses a case of a patient having a left occipital lobe giant arteriovenous malformation.

Meningiomas are the most prevalent primary intracranial tumors. The majority are benign but can undergo dedifferentiation into advanced grades classified by World Health Organization (WHO) into Grades 1 to 3. Meningiomas' tremendous variability in tumor behavior and slow growth rates complicate their diagnosis and treatment. A deeper comprehension of the molecular pathways and cellular microenvironment factors implicated in meningioma survival and pathology is needed. This review summarizes the known genetic and epigenetic aberrations involved in meningiomas, with a focus on neurofibromatosis type 2 ( NF2 ) and non- NF2 mutations. Novel potential biomarkers for meningioma diagnosis and prognosis are also discussed, including epigenetic-, RNA-, metabolomics-, and protein-based markers. Finally, the landscape of available meningioma-specific animal models is overviewed. Use of these animal models can enable planning of adjuvant treatment, potentially assisting in pre-operative and post-operative decision making. Discovery of novel biomarkers will allow, in combination with WHO grading, more precise meningioma grading, including meningioma identification, subtype determination, and prediction of metastasis, recurrence, and response to therapy. Moreover, these biomarkers may be exploited in the development of personalized targeted therapies that can distinguish between the 15 diverse meningioma subtypes.

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

Background: This study examines the impact of the COVID-19 pandemic on health care-associated infection (HAI) incidence in low- and middle-income countries (LMICs)., Methods: Patients from 7 LMICs were followed up during hospital intensive care unit (ICU) stays from January 2019 to May 2020. HAI rates were calculated using the International Nosocomial Infection Control Consortium (INICC) Surveillance Online System applying the Centers for Disease Control and Prevention's National Healthcare Safety Network (CDC-NHSN) criteria. Pre-COVID-19 rates for 2019 were compared with COVID-19 era rates for 2020 for central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), ventilator-associated events (VAEs), mortality, and length of stay (LOS)., Results: A total of 7,775 patients were followed up for 49,506 bed days. The 2019 to 2020 rate comparisons were 2.54 and 4.73 CLABSIs per 1,000 central line days (risk ratio [RR] = 1.85, p = .0006), 9.71 and 12.58 VAEs per 1,000 mechanical ventilator days (RR = 1.29, p = .10), and 1.64 and 1.43 CAUTIs per 1,000 urinary catheter days (RR = 1.14; p = .69). Mortality rates were 15.2% and 23.2% for 2019 and 2020 (RR = 1.42; p < .0001), respectively. Mean LOS for 2019 and 2020 were 6.02 and 7.54 days (RR = 1.21, p < .0001), respectively., Discussion: This study documents an increase in HAI rates in 7 LMICs during the first 5 months of the COVID-19 pandemic and highlights the need to reprioritize and return to conventional infection prevention practices., (Copyright © 2022 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Stroke is considered as the first cause of neurological dysfunction and second cause of death worldwide. Recombinant tissue plasminogen activator is the only chemical treatment for ischemic stroke approved by the US Food and Drug Administration. It was the only standard of care for a long time with a very narrow therapeutic window, which usually ranges from 3 to 4.5 h of stroke onset; until 2015, when multiple trials demonstrated the benefit of mechanical thrombectomy during the first 6 h. In addition, recent trials showed that mechanical thrombectomy can be beneficial up to 24 h if the patients meet certain criteria including the presence of magnetic resonance imaging/computed tomography perfusion mismatch, which allows better selectivity and higher recruitment of eligible stroke patients. However, magnetic resonance imaging/computed tomography perfusion is not available in all stroke centers. Hence, physicians need other easy and available diagnostic tools to select stroke patients eligible for mechanical thrombectomy. Moreover, stroke management is still challenging for physicians, particularly those dealing with patients with "wake-up" stroke. The resulting brain tissue damage of ischemic stroke and the subsequent pathological processes are mediated by multiple molecular pathways that are modulated by inflammatory markers and post-transcriptional activity. A considerable number of published works suggest the role of inflammatory and cardiac brain-derived biomarkers (serum matrix metalloproteinase, thioredoxin, neuronal and glial markers, and troponin proteins) as well as different biomarkers including the emerging roles of microRNAs. In this review, we assess the accumulating evidence regarding the current status of acute ischemic stroke diagnostic biomarkers that could guide physicians for better management of stroke patients. Our review could give an insight into the roles of the different emerging markers and microRNAs that can be of high diagnostic value in patients with stroke. In fact, the field of stroke research, similar to the field of traumatic brain injury, is in immense need for novel biomarkers that can stratify diagnosis, prognosis, and therapy., Competing Interests: Approval of the research protocol: N/A. Informed consent: N/A. Registry and registration no. of the study/trial: N/A. Animal studies: N/A. Conflict of interest: None., (© 2021 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

Spine fusion surgery is commonly performed for diverse indications, the most frequent one being degenerative spine diseases. Despite the growing importance of this surgery, there is limited evidence concerning the effects of drugs on the process of spine fusion and healing. While asymptomatic sometimes, nonunion of the spine can have tremendous repercussions on the patients' quality of life and the healthcare system rendering it an "expensive complication". This literature review identifies the role of some perioperative drugs in spine fusion and reveals their potential role in pseudarthrosis of the spine. This review also benefits spine surgeons looking for current evidence-based practices. We reviewed the data related to nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, vancomycin, bisphosphonates, proton pump inhibitors (PPIs), pregabalin, and opioids. From the available experimental and clinical studies, we conclude that bisphosphonates might positively influence the process of spine fusion, while steroids and vancomycin have shown variable effects, and the remaining medications likely disturb healing and union of the spine. We recommend spine surgeons be cautious about the drugs they resort to in the critical perioperative period until further clinical studies prove which drugs are safe to be used., (Copyright © 2021. Published by Elsevier B.V.)

Meningiomas are amongst the most commonly encountered intracranial tumors. The majority of these tumors arise intracranially, and the remaining incidents occur along the spinal cord. Meningiomas tend to grow gradually, with many tumors arising in inaccessible locations. Such sporadic behavior poses a therapeutic challenge to clinicians, causing incomplete tumor resections that often lead to recurrence. Therefore, ongoing research seeks to find alternative systematic treatments for meningiomas, with gene-based therapeutics of high interest. Subsequently, genetic studies characterized frequent somatic mutations in NF2 , TRAF7 , KLF4 , AKT1 , SMO , and PIK3CA . These genes are communally exhibited in 80% of sporadic meningiomas. In addition, other genes such as the DUSP family, the NR4 family, CMKOR , and FOSL2 , have been identified as key players in spinal meningiomas. In this perspective, we aim to investigate current genetic-based studies, with the ongoing research mainly focused on the above NF2 , TRAF7 , KLF4 , AKT1 , SMO , and PIK3CA genes and their involved pathways. In addition, this perspective can serve as a potential cornerstone for future genetic analyses of meningioma cases., Competing Interests: The authors declare no conflict of interest., (© 2021 The Author(s). Published by IMR Press.)

Most of the debilitating conditions following aneurysmal subarachnoid hemorrhage result from symptomatic cerebral vasospasm and delayed cerebral ischemia. Several scales are being used, but they still lack objectivity and fail to quantify complications considered essential for prognostication routine use of biomarkers to predict complications and outcomes after aneurysmal rupture is still experimental. Degradomics were studied extensively in traumatic brain injury, but there is no discussion of these biomarkers related to aneurysmal subarachnoid hemorrhage. Degradomics involve the activation of proteases that target specific substrates and generate specific protein fragments called degradomes. While the proteolytic activities constitute the pillar of development, growth, and regeneration of tissues, dysregulated proteolysis resulting from pathological conditions like aneurysmal subarachnoid hemorrhage ends up in apoptotic processes and necrosis. To our knowledge, this is the first overview that lists a panel of degradomics with cut-off values in serum and cerebrospinal fluid, where specificity and sensitivity are only found in Kallikrein 6, Ubiquitin C Terminal Hydrolase 1 and Alpha-II-Spectrin., Competing Interests: The authors declare no conflict of interest., (© 2021 The Author(s). Published by IMR Press.)

Competing Interests: The authors declare no conflict of interest.

Background: Stent-assisted coil embolization of ruptured wide-necked aneurysms is a controversial treatment modality due to concerns on the peri-procedural safety of anti-platelet therapy in the setting of acute subarachnoid hemorrhage. Our aim was to systematically review the literature on stent-assisted coil embolization of acutely ruptured wide-neck aneurysms to calculate the pooled prevalence of clinical outcome, thromboembolic and hemorrhagic complication rates and overall mortality., Methods: We searched PubMed and Google Scholar for articles published between 2009 and 2019 and stratified selected articles based on risk of publication bias. Data on thromboembolic and hemorrhagic complications, clinical outcomes and mortality rates were analyzed using quality-effects model and double arcsine transformation., Results: 24 articles were included featuring a total of 1582 patients. Thromboembolic and hemorrhagic complication rates were witnessed in 9.1% [95% CI: 6.0% - 12.7%; I 2  = 72.8%] and 8.7% [95% CI: 5.4 - 12.6%; I 2  = 77.2%] of patients, respectively. 245 patients received external ventricular drains, of which 33 (13.5%) had EVD-related hemorrhages. Total complication rate was 20.8% [95% CI: 14.2 - 28.1%; I 2  = 87.0%]. 57% of aneurysms were completely occluded and a favorable clinical outcome was reported in 74.7% [95% CI: 66.4 - 82.2%; I 2  = 86.0] of patients. Overall mortality rate came at 7.8% [95% CI: 4.8 - 11.6%; I 2  = 76.9%]., Conclusion: Stent-assisted coiling of ruptured intracranial aneurysm is a technically feasible procedure with controlled thromboembolic complication rate but may be associated with higher hemorrhagic and total complication rates compared to coiling alone. While stent-assisted coiling of ruptured wide-necked aneurysm seems to yield a lower rate of favorable clinical outcome, overall mortality is comparable to that of endovascular coiling alone.

Sarcomas, especially spine sarcomas, are rare yet debilitating and are underestimated types of cancer. Treatment options for spine sarcomas are limited to chemotherapy, radiotherapy and surgical intervention. Accumulating evidence suggests a complex course associated with the treatment of spine sarcomas as compared to other soft tissue sarcomas in the extremities since adjuvant therapy adds limited success to the oncological outcome. Likewise, the limitations of surgical interventions imposed by the proximity and high sensitivity of the spinal cord, leads to an increased recurrence and mortality rates associated with spine sarcomas. Finding novel treatment options to spine sarcomas as such is inevitable, necessitating a more thorough understanding of the different mechanisms of the underlying etiologies of these tumors. In this review, we discuss the most recent studies tackling the involvement of the immune system; a key player in the emergence of the different types of spine sarcomas and the promising immune-mediated targeted therapy that can be applied in these kind of rare cancers., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

At the dawn of the third millennium, cancer has become the bane of twenty-first century man, and remains a predominant public health burden, affecting welfare and life expectancy globally. Spinal osteogenic sarcoma, a primary spinal malignant tumor, is a rare and challenging neoplastic disease to treat. After the conventional therapeutic modalities of chemotherapy, radiation and surgery have been exhausted, there is currently no available alternative therapy in managing cases of spinal osteosarcoma. The defining signatures of tumor survival are characterised by cancer cell ability to stonewall immunogenic attrition and apoptosis by various means. Some of these biomarkers, namely immune-checkpoints, have recently been exploited as druggable targets in osteosarcoma and many other different cancers. These promising strides made by the use of reinvigorated immunotherapeutic approaches may lead to significant reduction in spinal osteosarcoma disease burden and corresponding reciprocity in increase of survival rates. In this review, we provide the background to spinal osteosarcoma, and proceed to elaborate on contribution of the complex ecology within tumor microenvironment giving arise to cancerous immune escape, which is currently receiving considerable attention. We follow this section on the tumor microenvironment by a brief history of cancer immunity. Also, we draw on the current knowledge of treatment gained from incidences of osteosarcoma at other locations of the skeleton (long bones of the extremities in close proximity to the metaphyseal growth plates) to make a case for application of immunity-based tools, such as immune-checkpoint inhibitors and vaccines, and draw attention to adverse upshots of immune-checkpoint blockers as well. Finally, we describe the novel biotechnique of CRISPR/Cas9 that will assist in treatment approaches for personalized medication., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Persons with paraplegia (PA) from thoracic spinal cord injury (T1-T12) are prone to thermal stress during exercise due to impaired thermoregulation. This study evaluates the effectiveness of phase change material (PCM) cooling vests on persons with PA of different levels of injury during exercise in hot exposure. Sixteen participants were recruited and divided to three groups based on injury level; high-thoracic T1-T3, mid-thoracic T4-T8, and low thoracic T9-T12 to perform a 30-min arm-crank exercise at a 30 °C room condition. Two types of PCM vests at melting temperature of 20 °C were tested: i) V1 with PCM covering the trunk of 3.4 kg overall vest mass and ii) V2 with PCM covering chest and upper back of 2.17 kg overall vest mass. High thoracic and low-thoracic groups performed NV and V1 tests; whereas, mid-thoracic group performed NV, V1, and V2 tests. Heart rate, core, and skin temperatures were monitored during 15-min preconditioning, 30-min exercise, and 15-min recovery. In addition, thermal comfort, sensation, skin wettedness, and perceived exertion were recorded during exercise only. The main findings were that the effectiveness of the cooling vest was dependent on injury level and portion of sensate skin of trunk covered by the PCM packets. Rise in core temperature (ΔT cr ) was reduced significantly for the low-thoracic group during exercise and recovery (ΔT cr =0.41°C, 0.26°C for NV and V1; respectively, p<0.05). For the mid-thoracic group, both V1 (p = 0.001) and V2 (p = 0.008) were effective in reducing ΔT cr compared to the NV test at the end of the recovery period (0.74°C,0.42°C,0.56°C, for NV, V1 and V2; respectively). For the high-thoracic group, V1 was not effective in reducing core temperature (p>0.05). For the mid-thoracic group, V2 at 36% lower mass significantly improved thermal comfort (p = 0.0004) compared to the NV test and was as effective compared to V1 in reducing core temperature., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

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

Foraminal disc herniation presents with an operative challenge, as it often requires facetectomy, which can result in segmental instability. The intraforaminal approach includes partial pars resection and medial facetectomy and allows for direct visualization of the nerve roots and herniated disc in the foramen without violating the joint, with good clinical outcomes. Herein, we describe a retrospective series of patients that underwent minimally invasive paramedian approach with hemilaminectomy, partial medial pars resection, medial facetectomy for foraminal disc herniation. Demographics and clinical outcomes were obtained from medical records. Improvement in functional outcomes was evaluated using the pre and post-operative Visual Analog Scale (VAS) and Oswestry Disability Index (ODI). A total of 23 patients were included in this study. The average age was 56.47 ± 9.4 yrs and body mass index was 31.92 ± 7.7 kg/m 2 . 47.8% of cases were L4-5 FDH. The estimated blood loss was 31.32 ± 19.8 ml. The average length of hospital stay was 1.11 ± 0.3 days. All patients were discharged home. Overall, there was a significant improvement in the VAS (pre-op: 8.21 ± 2.1; post-op: 2.59 ± 2.7; p-value: <0.0001) and ODI (pre-op: 57.16 ± 13.2; post-op: 21.47 ± 9.9; p-value: <0.0001). The minimally invasive paramedian approach provides satisfactory outcomes as a safe strategy in the treatment of foraminal disc herniation. Herein, there was a significant improvement in pain and functional outcomes, minimal blood loss and decreased hospital stay., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Cervical spinal cord injury (cSCI) is a major public health concern in the young population as per the estimation of the annual global report, which concluded that the amount of incidence in this area ranged between 11.5 and 53.4 cases per million population. Moreover, Despite the many evaluations conducted to unveil the physiological and thermo logical complications caused to the human body after a cervical spinal cord injury, the fundamental pathophysiology about this type of injury is still inconclusive., Objective: This review attempts to provide a better understanding to the various changes caused to the body after a cSCI. It focuses on the alterations in blood circulation, energy expenditure (EE), sweating, shivering responses and consequently disruption in body temperature regulation., Methods: Various research engines such as Scopus, PubMed, Embase, Web of Science, EBSCO, and Cochrane Library databases were searched by two independent investigators. 17 studies out of 102 were included based on eligibility criteria: patients with complete and/or incomplete cSCI; minimum of 5 patients as participants; and control group of able Bodied People (AB)., Results: Following cSCI, EE decreases by 10% (p < 0.05) due to reduction in lean body mass; cardiac output decrements by 27% (p < 0.05) following the change in arterial blood vessel structure, and finally; thermoregulatory responses were disturbed because of the absence or decrease in vasodilation, vasoconstriction, sudomotor (autonomic activation of sweat glands) and shivering responses., Conclusions: The body undergoes significant thermoregulatory changes following spinal cord injury. Understanding the pathophysiology of spinal cord injury and its effect on the human body can provide us an insight to develop adequate treatment modalities that tackle the problem of thermal dysregulation in people with cSCI., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

People with thoracic spinal cord injury (SCI), named people with paraplegia (PA), are vulnerable to thermal heat stress during exercise due to disruption in their thermal physiology. Using personal cooling vests with phase change material (PCM) or ice presents a possible solution for PA to suppress the increase in core temperature and body heat storage. With the limited published experimental studies about effective cooling vest for PA, this work aims to develop an altered PA bioheat model combined with cooling vest model to study cooling vest performance during exercise. The integrated PA bioheat and vest models predict core and skin temperatures, latent and sensible heat losses and change in body heat storage for PA with and without a cooling vest. The models were validated with published experimental data on PA without the cooling vest and on PA with two cooling vests; one using PCM at melting temperature of 15 °C and the other using ice packets during exercise. It was observed that sensible heat losses at the four torso segments (abdomen, lower back, chest and upper back) increased with the vest case compared to the no-vest case; while, latent heat losses decreased compared to the no-vest case. However, insignificant change was seen in core temperatures and body heat storage as was also reported experimentally. The performance of each of the cooling vest during exercise on PA was dependent on skin coverage area and melting temperatures., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

The objective of this work is to develop a Bioheat model to predict the thermal responses of people with tetraplegia (TP) under hot, cold and neutral ambient conditions as well as different physical activities suitable for their level of injury. The focus is on TP with impairment or loss of motor and/or sensory function in C1 to C7 segments of the spinal cord due to damage of neural elements within the spinal canal. Starting from transient multi-segmented Bioheat model of able-bodied (AB) people, specific modifications were performed reflecting the changes in physiology due to the injury affecting the blood circulation system, energy expenditure, and thermoregulatory functions in the body. The TP Bioheat model predicts the TP thermal responses under steady and transient thermal conditions, and different activity levels that are appropriate for the level of injury. The model was validated with published experimental data reporting physiological and thermal data measurements on cases of people with complete and incomplete tetraplegia under controlled environmental conditions and activity levels. In both transient and steady state environmental conditions, the predicted core and mean skin temperature values were compared against the experimental data with maximum error of 0.86 °C and 0.9 °C respectively. The TP Bioheat model can be used as a tool to propose appropriate personal cooling strategies for TP., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Direct lateral (DLIF) and transforaminal (TLIF) lumbar interbody fusions have been shown to produce satisfactory clinical outcomes with significant reduction in pain and functional disability. Despite their increasing use in complex spinal deformity surgeries, there is a paucity of data comparing outcome measures, which this study addresses., Methods: This is a retrospective, comparative study of patients who underwent minimally invasive, 1-level TLIF or DLIF between 2013 and 2015. Only patients 18 years and older were included. Preoperative and demographic variables were collected, and clinical outcome measures were compared between cohorts., Results: In total, 46 patients were included (DLIF: 17 patients; TLIF: 29 patients). Preoperatively, there was no difference in visual analog scale pain score or Oswestry Disability Index. Overall, there was a significant improvement in the postoperative visual analog scale score and Oswestry Disability Index in the separate cohorts, without significant difference when compared. The duration of postoperative narcotic use was similar in both cohorts (DLIF: 4.8 ± 4.7 months vs. TLIF: 5.2 ± 5.1 months, P = 0.82). Significantly more patients in DLIF cohort were cleared for work after surgery. Patients who underwent MIS TLIF had a significantly longer time to return to work (7.1 ± 4.8 months) compared with patients undergoing DLIF (2.3 ± 1.3, P = 0.006). There was a greater incidence of reoperation in the TLIF cohort., Conclusions: Both MIS TLIF and DLIF provide long-term improvement in pain andfunctional outcomes, with an overall reduction in postoperative narcotic requirement. However, there was a significantly longer time to return to work and a greater incidence of reoperation in the TLIF cohort compared with the patients who underwent DLIF., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Idiopathic spinal cord herniation represents an uncommon and unique diagnostic entity, most commonly affecting middle-aged individuals, with a nearly twofold female predilection. It most characteristically affects the mid-thoracic spine, with the herniation occurring ventrally or ventrolaterally. Clinical presentation is typically a slowly-progressive myelopathy, with Brown-Séquard syndrome occurring more frequently than spastic paraparesis. Diagnosis is made by imaging, with high-resolution or phase-contrast MR sequences and/or CT myelography. Treatment should be individualized, with options including conservative management with routine follow-up and surgical intervention. We review the literature on this interesting topic and report on, and present our technique for, operative reduction and repair of idiopathic spinal cord herniation in a 66 year-old woman., (Copyright © 2017. Published by Elsevier Ltd.)

Background: Bone morphogenetic protein (BMP) graft showed promising outcome during early phases of its use. However, unreported adverse events and off-label use shattered its safe profile and raised concerns regarding its indication. In 2008 the U.S. Food and Drug Administration prohibited its use in anterior cervical spine procedures due to the possibility of edema, hematoma, and need to intubate. At the molecular level, BMPs act as multifactorial growth factors playing a role in cartilage, heart, and bone formation. However, its unfavorable effect on bone overgrowth or heterotopic ossification post spine surgeries has been described. Reported cases in the literature were limited to epidural bone formation., Case Description: We present a rare and interesting case of a 59-year-old female, in whom BMP caused intradural bone growth several years after an anterior lumbar interbody fusion surgery., Conclusion: Caution must be exercised while using BMPs because of inadvertent complications., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: This review seeks to synthesize emerging literature on the effects of back muscle size on outcomes in spine surgery. Risk factors that contribute to poor surgical outcomes continue to be an area of interest in spine surgery because proper risk stratification can result in reduction in morbidity and enhanced patient care. However, the impact of muscle size on spine surgical outcomes is an understudied avenue with paucity of data evaluating the relationship among back muscles and surgical outcomes, patient's quality of life, and functional improvement postoperatively., Methods: This review was centered around identifying studies that assessed the impact of back muscle size on spine surgery outcomes., Results: Five retrospective studies were selected for review. All studies set out to see if differences in muscle size existed in patients with disparate post-operative outcomes as a primary objective. The studies support the association between larger back muscles and improved outcomes. The size and relative cross sectional area of paraspinal muscles and the size of the psoas muscle were associated with functional outcomes, incidence of complications and also fusion rates., Conclusion: With reduction in surgical complications and improvement in postoperative functional outcomes, back muscle morphometry ought to be included in the preoperative surgical planning as a predictor of outcomes., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: C5 palsy is a well-reported complication of cervical spine surgery. The implication of sagittal cervical alignment parameters and their changes after surgery on the incidence of C5 palsy remains unclear., Objective: We review cervical alignment changes in our cases of C5 palsy after cervical laminectomy and fusion., Methods: Cases of C5 palsy were retrospectively compared with a control group. Preoperative and postoperative upright plain film radiographs were analyzed in blinded fashion., Results: Spine registry analysis identified 148 patients who underwent cervical laminectomy and fusion by the senior author over 5 years. There were 18 (12%) cases complicated by postoperative C5 palsy. Nine of these 18 patients had prerequisite upright films and were compared with a randomly constructed case control group of 20 patients. There were no statistically significant differences between the 2 groups in age, proportion of males, and preoperative Nurick score. Measures of sagittal alignment did not differ significantly between the 2 groups on preoperative and postoperative imaging. When comparing the amount of alignment change between preoperative and postoperative upright imaging, however, patients with C5 palsy had a statistically higher amount of average C4-C5 Cobb angle change (-2.53 vs 0.78°; P = .01). Logistic regression analysis demonstrated that lordotic change in both C4-C5 and C2-C7 Cobb angles were associated with development of palsy., Conclusion: Lordotic cervical correction, as measured on upright imaging, was statistically larger in patients who had C5 palsy. The role of deformity correction in C5 palsy deserves further study and may inform intraoperative decision making., Abbreviation: CLF, cervical laminectomy and fusion.

Radiation therapy continues to play an extremely valuable role in the treatment of malignancy. The effects of radiation therapy on normal tissue can present in a delayed fashion, resulting in localized damage with pseudomalignant transformation, producing a compressive effect on the spinal cord or exiting nerve roots. Infiltration of inflammatory cells and the subsequent fibrotic response can result in the development of an inflammatory pseudotumor (benign tumor-like lesion) with subsequent mass effect. Herein, the authors present a rare case of inflammatory pseudotumor with fulminant cervicothoracic cord compression, developing 7 years after radiation therapy for breast cancer. The lesion recurred following resection but subsequently displayed complete and rapid resolution following steroid therapy. To the best of the authors' knowledge, no previous studies have reported such an incident.

Background: Intramedullary spinal cord tumors (IMSCT) account for about 2%-4% of tumors of the central nervous system. Surgical resection continues to be the most effective treatment modality for most intramedullary tumors, with gross total resection leading to preserved neurologic function and improved survival. However, surgical treatment is often difficult and carries significant risk of postoperative neurologic complications. Intraoperative neuromonitoring has been shown to be of clinical importance in the surgical resection of IMSCT. The main monitoring modalities include somatosensory evoked potentials, transcranial motor evoked potentials via limb muscles or spinal epidural space (D-waves), and dorsal column mapping. These monitoring modalities have been shown to inform surgeons intraoperatively and in many cases, have led to alterations in operative decision., Methods: We reviewed the literature on the usefulness of intraoperative neuromonitoring for intramedullary spinal tumor resection and its role in predicting postoperative neurologic deficits. A MEDLINE search was performed (2000-2015) and 13 studies were reviewed. Detailed information and data from the selected articles were assessed and compiled. Data were extracted showing the role of monitoring in outcomes of surgery., Conclusions: By using intraoperative somatosensory evoked potentials, transcranial motor evoked potentials, D-waves, and dorsal column mapping, spinal injury could be prevented in most cases, thereby improving postoperative neurologic functioning and outcome in patients undergoing surgery for IMSCT., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: In this article, we aim to describe the presentation and management of a case of spontaneous intracranial hypotension caused by a dural tear from a ventral thoracic osteophyte at the T12 level that was refractory to non-surgical treatment modalities. A review of the literature has been performed. Also a proposal of diagnostic and treatment algorithm is presented. Intracranial hypotension and CSF leak as a result of dural tear is a common phenomenon. However, the detection of the source of CSF leak from a thoracic spinal osteophyte has rarely been reported., Methods: Diagnostic workup including MRI and CT Myelogram as well as application of epidural blood patches and surgical technique of hemilaminectomy and osteophytectomy by transpedicular approach have been described. Literature review was conducted using relevant search terms in PubMed., Results: The patient's spontaneous intracranial hypotension symptoms resolved and this persisted on follow up visits. Review our experience as well as similar cases in the literature pointed us towards a diagnostic and treatment algorithm., Conclusions: Spontaneous resolution is the norm for intracranial hypotension of most etiologies and management of all such cases begins with fluid resuscitation coupled with bed rest. On failure of conservative therapy, autologous epidural blood patches into the spinal epidural space should be tried, which often produce an immediate relief of symptoms. Osteophyte-induced dural tear and consequent intracranial hypotension may require surgical intervention if the symptoms are refractory to conservative treatment. Under all circumstances a careful step-wise approach for diagnosis and treatment of spontaneous intracranial hypotension needs to be followed, as we have proposed in our article.

Background: Cerebrospinal fluid (CSF) leak during anterior cervical spine surgery can lead to complications, including wound breakdown, meningitis, headaches, need for lumbar drain, or additional surgery. These leaks can be difficult to manage given the limited field of view and lack of deep access. Herein, we describe 8 consecutive patients who underwent intraoperative repair of CSF leak, with no postoperative evidence of wound dehiscence or drainage., Methods: A retrospective review was performed on 8 cases where CSF leak was encountered during an anterior cervical spine surgery. Patients had ossification of the posterior longitudinal ligament, intradural disk herniation, or dural ectasia. Intraoperative repair was as follows. First, CSF was drained to low pressure, and durotomy was covered by dural substitute and sealant agent. Then the interbody graft used was manually undersized in the anteroposterior dimension to allow for expansion of the agents used. Anterior instrumentation was then performed. Finally, a wound drain was anchored to a biologic bag for shoulder level passive drainage., Results: In all 8 cases, there were no cases of wound dehiscence or CSF leak using this strategy. Likewise, there was no evidence of cord compression or neurologic deficits. No meningitis or persistent headaches were reported, and there was no need for lumbar drain placement at any time postoperatively., Conclusions: Once durotomy is encountered during anterior spine surgery, draining the CSF to a low pressure followed by dural substitute with a sealing agent, followed by a smaller anteroposterior size graft is an effective strategy of preventing complications in an inescapable problem., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction: Intradural spinal arachnoid cysts (SACs) are among many etiologies for syringomyelia. Consequentially, neurologic symptoms arise such as pain, gait disturbance, and bladder dysfunction. Identification of SAC on magnetic resonance imaging (MRI) can be challenging, as SACs can be fenestrated or in the form of fine webs., Methods: Imaging and clinical data for 7 patients who underwent surgical treatment for SAC associated with syringomyelia were reviewed. All previous publications of this pathology were reviewed via MEDLINE search., Results: Seven patients with a mean age 59 years were found to have a SAC causing syringomyelia. Intraoperative exploration confirmed SAC appearances of fine webs or a fluid-filled loculation impinging on the spinal cord. Common presentations were back pain, gait disturbance, and bladder incontinence. Diagnosis was made by MRI, although in 3 cases, the SAC was not identified on the initial review. Computed tomography myelogram was performed in one case due to the enlarged syringomyelia and lack of obvious spinal cord compression. Thoracic laminectomy/laminoplasty was performed for all patients, centered at the level of a subtle indentation of the cord; the syringomyelia proper was not directly addressed. Postoperatively, all patients had complete resolution of their symptoms with MRI demonstrating resolution of the syringomyelia., Conclusions: Careful evaluation of the MRI can demonstrate subtle indentation of the cord at the caudal or cephalad end of the syringomyelia and may obviate the need for additional imaging. Meticulous arachnoid dissection and establishment of good CSF flow is sufficient for resolution of the syringomyelia, averting the need for more aggressive procedures., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Management of type II odontoid fractures in elderly remains controversial to whether surgical treatment is favored over conservative one. This is a study of geriatric patients with asymptomatic type II dens fractures who after sustaining a fall were initially evaluated at community hospitals. They were placed in a rigid collar and were followed up in a spine clinic., Purpose: To assess the reliability of treating very old patients with type II dens fracture conservatively and whether surgical intervention if needed would affect the clinical outcome., Study Design: Retrospective study with the literature review., Patient Sample: Consecutive patients above 80 years of age, who sustained a clinically asymptomatic type II dens fracture and were observed after a conservative treatment plan, was initiated., Outcome Measures: Outcome measures included self-reported worsening neck pain, neurological function, and radiographic measures over the follow-up period., Materials and Methods: A retrospective clinical analysis of 5 active geriatric patients with type II asymptomatic dens fracture. After evaluating them, treatment options were discussed with patients and their family members. The decision was to continue to follow them with a rigid collar very closely since they were reluctant to undergo any surgical procedure., Results: Patients were followed for an average of 29 months. They were observed for any worsening neck pain, neurological deficit, or deterioration of fracture on follow-up imaging studies. At last follow-up, 2 of 5 patients continued to be asymptomatic, the 3(rd) died of unrelated causes while 2 others required surgeries at least 1-year post injury., Conclusions: Treatment of type II dens fractures in the elderly is controversial. Independent elderly patients who are asymptomatic at presentation may be safe to be followed up very closely with a neck brace and serial X-ray. Converting to surgical treatment can be done safely when needed without affecting the overall clinical out.

The relation of the pelvis to the spine has previously been overlooked as a contributor to sagittal balance. However, it is now recognized that spinopelvic alignment is important to maintain an energy-efficient posture in normal and disease states. The pelvis is characterized by an important anatomic landmark, the pelvic incidence (PI). The PI does not change after adolescence, and it directly influences pelvic alignment, including the parameters of pelvic tilt (PT) and sacral slope (SS) (PI = PT 1 SS), overall sagittal spinal balance, and lumbar lordosis. In the setting of an elevated PI, the spineadapts with increased lumbar lordosis. To prevent or limit sagittal imbalance, the spine may also compensate with increased PT or pelvic retroversion to attempt to maintain anupright posture. Abnormal spinopelvic parameters contribute to multiple spinal conditions including isthmic spondylolysis, degenerative spondylolisthesis, deformity, and impact outcome after spinal fusion. Sagittal balance, pelvic incidence, and all spinopelvic parameters are easily and reliably measured on standing, full-spine (lateral) radiographs, and it is essential to accurately assess and measure these sagittal values to understand their potential role in the disease process, and to promote spinopelvic balance at surgery. In this article, we provide a comprehensive review of the literature regarding the implications of abnormal spinopelvic parameters and discuss surgical strategies for correction of sagittal balance. Additionally, the authors rate and critique the quality of the literature cited in a systematic review approach to give the reader an estimate of the veracity of the conclusions reached from these reports.

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

Simultaneous hemifacial spasm (HFS) and trigeminal neuralgia caused by cranial nerve (CN) compression from a tortuous basilar artery (BA) is very rare. We report a case of a 66-year-old man who presented with both HFS and "atypical" trigeminal neuralgia. The patient had a tortuous BA compressing both CN V and VII. The patient underwent microvascular decompression after failing conservative medical management. To the best of our knowledge this is the first reported case of both HFS and "atypical" trigeminal neuralgia that were both successfully treated by surgical intervention. We report the management of this rare combination and review the literature.

The relation of the pelvis to the spine has previously been overlooked as a contributor to sagittal balance. However, it is now recognized that spinopelvic alignment is important to maintain an energy-efficient posture in normal and disease states. The pelvis is characterized by an important anatomic landmark, the pelvic incidence (PI). The PI does not change after adolescence, and it directly influences pelvic alignment, including the parameters of pelvic tilt (PT) and sacral slope (SS) (PI = PT + SS), [corrected] overall sagittal spinal balance, and lumbar lordosis. In the setting of an elevated PI, the spineadapts with increased lumbar lordosis. To prevent or limit sagittal imbalance, the spine may also compensate with increased PT or pelvic retroversion to attempt to maintain anupright posture. Abnormal spinopelvic parameters contribute to multiple spinal conditions including isthmic spondylolysis, degenerative spondylolisthesis, deformity, and impact outcome after spinal fusion. Sagittal balance, pelvic incidence, and all spinopelvic parameters are easily and reliably measured on standing, full-spine (lateral) radiographs, and it is essential to accurately assess and measure these sagittal values to understand their potential role in the disease process, and to promote spinopelvic balance at surgery. In this article, we provide a comprehensive review of the literature regarding the implications of abnormal spinopelvic parameters and discuss surgical strategies for correction of sagittal balance. Additionally, the authors rate and critique the quality of the literature cited in a systematic review approach to give the reader an estimate of the veracity of the conclusions reached from these reports.

Purpose: Epidermoid tumors are uncommon entities that usually occur intradurally in the cerebellopontine angle and parasellar cisterns. The few cases that have been reported to occur in the intraorbital location involve patients in the first four decades of life. To our knowledge, an elderly person presenting with an orbital epidermoid tumor has never been reported., Methods: A 67-year-old man presented with left-sided headache and eye pain. He was found to have a hemorrhagic lesion eroding bone of the greater and lesser wings of the sphenoid that was compressing the frontal and temporal lobes and displacing the globe. Significant edema of the frontal lobe was noted., Results: Aggressive surgical excision was performed with cranioplasty and orbital reconstruction. Near resolution of the patient's proptosis and eye pain was achieved. Histologic analysis revealed the lesion to be an epidermoid tumor., Conclusions: Hemorrhage into a growing intradiploic orbital epidermoid and surrounding frontal lobe edema created an unusual presentation of this rarely occurring entity in an elderly man. Surgical excision allowed appropriate histologic diagnosis and resolution of symptoms. Epidermoid tumor is a rare but possible entity in the differential diagnosis of elderly patients presenting with acute ocular pain and proptosis.

Contralateral hematoma formation following acute subdural hematoma (ASDH) evacuation is a well-described complication. The most common type of contralateral hematoma is an epidural hematoma. Rarely, ASDH develops on the contralateral side. We report an elderly woman who presented with a post-traumatic ASDH and underwent ipsilateral hematoma evacuation by craniotomy and subsequently developed a contralateral ASDH. Because of the potential consequences of a delayed ASDH, there should be a low threshold for early post-operative imaging following ASDH evacuation, especially in elderly patients and those with additional associated intracranial injuries., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Object: pelvic incidence (PI) directly regulates lumbar lordosis and is a key determinant of sagittal spinal balance in normal and diseased states. Pelvic incidence is defined as the angle between the line perpendicular to the S-1 endplate at its midpoint and the line connecting this point to a line bisecting the center of the femoral heads. It reflects an anatomical value that increases with growth during childhood but remains constant in adulthood. It is not altered by changes in patient position or after traditional lumbosacral spinal surgery. There are only 2 reports of PI being altered in adults, both in cases of sacral fractures resulting in lumbopelvic dissociation and sacroiliac (SI) joint instability. En bloc sacral amputation and sacrectomy are surgical techniques used for resection of certain bony malignancies of the sacrum. High, mid, and low sacral amputations result in preservation of some or the entire SI joint. Total sacrectomy results in complete disruption of the SI joint. The purpose of this study was to determine if PI is altered as a result of total or subtotal sacral resection., Methods: the authors reviewed a series of 42 consecutive patients treated at The Johns Hopkins Hospital between 2004 and 2009 for sacral tumors with en bloc resection. The authors evaluated immediate pre- and postoperative images for modified pelvic incidence (mPI) using the L-5 inferior endplate, as the patients undergoing a total sacrectomy are missing the S-1 endplate postoperatively. The authors compared the results of total versus subtotal sacrectomies., Results: twenty-two patients had appropriate images to measure pre- and postoperative mPI; 17 patients had high, mid, or low sacral amputations with sparing of some or the entire SI joint, and 5 patients underwent a total sacrectomy, with complete SI disarticulation. The mean change in mPI was statistically different (p < 0.001) for patients undergoing subtotal versus those undergoing total sacrectomy (1.6° ± 0.9° vs 13.6° ± 4.9° [± SD]). There was no difference between patients who underwent a high sacral amputation (partial SI resection, mean 1.6°) and mid or low sacral amputation (SI completely intact, mean 1.6°)., Conclusions: the PI is altered during total sacrectomy due to complete disarticulation of the SI joint and discontinuity of the spine and pelvis, but it is not changed if any of the joint is preserved. Changes in PI influence spinopelvic balance and may have postoperative clinical importance. Thus, the authors encourage attention to spinopelvic alignment during lumbopelvic reconstruction and fixation after tumor resection. Long-term studies are needed to evaluate the impact of the change in PI on sagittal balance, pain, and ambulation after total sacrectomy.

Sacral neoplasm resection is managed via partial or total sacrectomy that is performed via the Kraske approach. The combination of the patients positioning and the relatively long operative time required for this procedure increase the risk of pressure ulcers. Facial pressure ulcers can cause tissue necrosis and/or ulceration in a highly visible area, leading to a cosmetically disfiguring lesion. Here, the authors report the use of a Mayfield clamp in the positioning of patients undergoing sacral tumor resection to prevent facial pressure ulceration. After the patient is placed prone in the Kraske or Jackknife position, the hips and knees are flexed with arms to the side. Then while in the prone position, the patient is physically placed in pins, and the Mayfield clamp is fixated at the center of the metal arch via the Mayfield sitting adapter to the Andrews frame, suspending the head (and face) over the table. The authors find that this technique prevents the development of facial pressure ulcers, and it has the potential to be used in patients positioned in the Kraske position for other surgical procedures.

Cervical spondylolysis is an uncommon disorder involving a cleft at the pars interarticularis. It is most often found at the C-6 level, and clinical presentations have included incidental radiographic findings, neck pain, and rarely neurological compromise. Although subaxial cervical spondylolysis has been described in 150 patients, defects at the C-2 pedicles are rare. The authors present 2 new cases of C-2 spondylolysis in athletically active young persons who did not demonstrate instability or neurological deficits, were able to remain active, and are being managed conservatively with serial examinations and imaging. They also discuss the results of 22 previously reported cases of C-2 spondylolysis. Based on the literature and their own experience, the authors conclude that most patients with C-2 spondylolysis remain neurologically intact, maintain stability despite the bony defect, and can be managed conservatively. Surgery is reserved for patients who demonstrate severe instability or spinal cord compromise due to stenosis.

Expandable cages have been used successfully to reconstruct the anterior spinal column in the treatment of traumatic, neoplastic, infectious, and degenerative spine disease. To the best of our knowledge, no studies report the results of the use of expandable cages in patients undergoing multilevel corpectomies for cervical spine metastatic disease. We report our experience with the use of expandable cages in this subgroup of patients.From August 2006 to May 2008, 5 patients presenting with myelopathy, pain, and/or radiculopathy secondary to metastatic disease of the cervical spine underwent multilevel cervical corpectomies and placement of expandable cages in our institution. All procedures were supplemented with an anterior cervical plate and with posterior instrumentation to achieve a 360 degrees fusion. A visual analog scale (VAS), Nurick grade, Frankel grade, American Spinal Injuries Association (ASIA) grade, and Ranawat grade were used to evaluate patients pre- and postoperatively. The mean follow-up period was 13.2 months. Three patients underwent a 2-level corpectomy, 1 a 3-level corpectomy, and 1 a 4-level corpectomy. Postoperative imaging studies showed that all patients had correction of preoperative kyphosis. The mean VAS score was reduced from 6.4 to 1. All other indices of spinal cord injury measured improved postoperatively or were stabilized. Postoperative imaging studies showed stable constructs in 4 patients.The use of expandable cages in multilevel corpectomies for the treatment of metastatic cervical spine disease appears to be a safe and effective way to reconstruct the anterior column of the cervical spine, preventing further neurologic deterioration., (Copyright 2010, SLACK Incorporated.)

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

Study Design: Multicenter retrospective analysis., Objectives: To review the results of surgical treatment during the last 6 years of C2 fractures in patients over the age of 70., Summary of Background Data: Little information exists about the clinical outcome of surgical treatment of elderly patients with C2 fractures, their ability to return to their previous environment, and their postoperative level of independence., Methods: The medical records and radiographs of 29 patients who had undergone surgical treatment for C2 fractures were reviewed. The type of C2 fracture, neurologic examination at presentation, type of surgical treatment, perioperative morbidity and mortality, presence of osseous union, and stability of alignment were recorded. Long-term disposition was determined from office visits or by telephone interview., Results: Twenty-four of 29 patients had type II dens fractures alone. The remaining 5 had associated C1 fractures. All patients were neurologically intact at presentation except for 2 patients with signs and symptoms of central cord syndrome. Perioperative complications occurred in 3 patients (10.3%). One patient died on postoperative day 6 from a myocardial infarction. Mean+/-SD radiographic follow-up was 9+/-3.2 months (range, 3 to 24). Of the 16 patients who underwent odontoid screw fixation, 6 (37.5%) had osseous union, and 9 (56.2%) were stable on radiographs. An additional patient who had odontoid screw initially required a posterior approach reoperation. Of the 13 posterior fusions, 4 (30.7%) had osseous unions and 9 (69.2%) were stable on flexion extension radiographs. Mean+/-SD clinical follow-up was 18+/-2.2 months (range, 3 to 72 mo). Twenty-five of 29 patients (86.2%) returned to their previous environment. Two patients died of unrelated etiology., Conclusions: C2 fractures in the elderly can be treated surgically with both anterior and posterior approaches with acceptable morbidity and mortality rates. The majority of patients can be mobilized early and return to their previous levels of independence.

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

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

Objective: To analyze the long-term clinical outcomes and complication rates associated with percutaneous balloon compression (PBC) of the trigeminal ganglion in patients with recurrent trigeminal neuralgia (TN) who were treated surgically with procedures other than PBC., Methods: In this retrospective study, the authors reviewed the results of 29 patients who underwent 41 PBC procedures for recurrent TN between 1998 and 2006., Results: The overall mean length of follow-up was 49 months (range 1-101). Pain relief was immediate in 24 (83%) patients. There was no pain relief in 5 patients (17%). 2 patients were lost to follow-up. 12 (54.5%) of 22 patients remained pain-free during a mean follow-up period of 65 months (range 40-101). The other 10 patients (45.5%) who had immediate pain relief experienced recurrent pain, with a mean time to recurrence of 7.3 months (17 days to 38 months). PBC was repeated in 11 patients, and was performed a third time in 2 patients. Morbidities included minor dysesthesia (2 patients), masseter weakness (2 patients), corneal anesthesia (1 patient), anesthesia dolorosa (1 patient), and subarachnoid hemorrhage (1 patient with history of multiple myeloma)., Conclusion: PBC is a useful treatment for patients with recurrent TN who have already been treated surgically. Long-term relief of pain in this subset of TN patients is achieved nearly half of the time with side-effect profiles similar to those reported in published data., ((c) 2008 S. Karger AG, Basel)