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The aim of the present study was to outline a new surgical technique and describe how, in a clinical setting, computer-generated image-guidance can assist in the planning and accurate placement of transarticular C1/C2 screws inserted using a minimally invasive exposure. Forty-six patients with atlanto-axial instability due to rheumatoid arthritis underwent posterior stabilisation with transarticular screws. This was achieved with a minimal posterior exposure limited to C1 and C2 and percutaneous screw insertions via minor stab incisions. The Stealth Station (Medtronic Sofamor Danek, Memphis, Tenn., USA) was used for image guidance to navigate safely through C2. Reconstructed computed tomographic (CT) scans of the atlanto-axial complex were used for image guidance. It was possible to perform preoperative planning of the screw trajectory taking into account the position of the intraosseous portion of the vertebral arteries, the size of the pars interarticularis and the quality of bone in C2. Screws could be inserted percutaneously over K-wires using a drill guide linked to the image-guidance system. Preoperative planning was performed in all 46 patients and accurate registration allowed proposed screw trajectories to be identified. Thirty-eight patients had bilateral screws inserted and eight had a unilateral screw. A total of 84 screws were inserted using the Stealth Station. There were no neurovascular injuries. This technique for placing transarticular screws is accurate and safe. It allows a minimally invasive approach to be followed. Image guidance is a useful adjunct for the surgeon undertaking complex spinal procedures. [ABSTRACT FROM AUTHOR]

Background: The climate crisis is one of the greatest threats to public health and surgery is a significant contributor to carbon emissions generated by the NHS. In this paper, we describe our experience of sustainable operating by using evidence-based methods to reduce our carbon footprint across three neurosurgical theatres during our 'Green operating day'., Methods: The Green operating day was run at a single site over a 12-hour operative day and included 10 neurosurgical cases. Following discussions with the theatre, anaesthetic and sustainability team, each operative case was reviewed and changes in the consumables, surgical instruments and utilities recorded. Carbon footprint was calculated using an environmentally extended input-output model for baseline and Green operating day. Qualitative data was collected on the participants of the Green operating day to assess attitudes and behaviours towards sustainability in neurosurgery., Results: There was a total reduction of carbon emissions by 31%, equivalent to 1.04 tonnes CO 2 e. Reductions were seen across different aspects of surgery including anaesthetics, surgical instruments, waste and utilities., Discussion: This study demonstrates the feasibility of carbon footprint reduction within neurosurgical theatres which was not associated with increases in operative duration or adverse patient outcomes. This study advocates for environmentally conscious decision making in neurosurgical procedures.

Objective: Case series presentation and literature review of patient group suffering from symptomatic tension subdural extra-arachnoid hygroma following decompressive surgery for degenerative lumbar stenosis or disc disease. The purpose was to better understand this rare post-operative complication with a pathognomic radiological sign to help recommend optimal strategies for clinical management., Methods: Retrospective case series comprising seven cases from one tertiary Neurosurgical centre spanning a 10-year period from 2011 to 2021. Patients included were those known to have undergone a spinal procedure and subsequently to have developed a symptomatic spinal subdural extra-arachnoid hygroma (SSEH). A literature review was conducted using PubMed, MEDLINE and EMBASE (keywords 'subdural hygroma', 'lumbar CSF hygroma', 'extra arachnoid hygroma', 'extra-arachnoid CSF collection', 'CSF tension hygroma', 'lumbar extra arachnoid hygroma', 'lumbar spinal hygroma', 'post-operating spinal hygroma', 'post-operative spinal CSF collection') and through reading references cited in relevant articles. Articles involving post-operative SSEH following lumbar spinal surgery were included., Results: Rare complication with only five other cases in the literature. Dural breach described intra-operatively in only 5 of 12 total cases from our series and the literature. 5 patients in our series were managed surgically with 2 being managed conservatively. All patients in our series improved symptomatically and radiologically following surgical or conservative management., Conclusions: This is a rare post-lumbar surgery complication that can cause rapidly deteriorating lower limb and sphincteric function. Surgical management with wide durotomy and arachnoid marsupialisation can lead to reversal of neurological deterioration and excellent clinical results. A delayed presentation with pseudomeningocele formation may be managed conservatively if neurology is stable or improving. It is a condition that it is important for the clinician to recognise in order to instigate appropriate management in a time-dependent fashion.

Background: Since 2005, the Lung Allocation Score (LAS) has prioritized patient benefit and post-transplant survival, reducing waitlist to transplant time to <200 days and decreasing mortality on the waitlist. A current challenge is the wait for the waitlist-the time between the patient's transplant-eligible diagnosis and waitlist registration., Methods: We investigated whether sociodemographic (age, sex, race, insurance, marital status, median household income) and clinical (forced expiratory volume in 1 second [FEV 1 ] percent of predicted, body mass index, depression/anxiety, alcohol/substance misuse, absolute/relative contraindications) factors influenced referral and waitlist registration. We conducted a retrospective cohort study through chart review of hospitalized patients on the University of Chicago general medicine service from 2006 to 2014 who met transplant-eligible criteria and ICD-9 billing codes for cystic fibrosis (CF) and pulmonary fibrosis (PF). We analyzed the times from transplant eligibility to referral, work-up and waitlisting using Kaplan-Meier curves and log-rank tests., Results: Overall, the referral rate for transplant-eligible patients was 64%. Of those referred, approximately 36% reach the lung transplant waitlist. Referred CF patients were significantly more likely to reach the transplant waitlist than PF patients (CF 60% vs PF 22%, p < 0.05). In addition, CF patients had a shorter wait from transplant eligibility to waitlist than PF patients (329 vs 2,369 days, respectively [25th percentile], p < 0.05). Patients with PF and CF both faced delays from eligibility to referral and waitlist., Conclusions: Quality improvement efforts are needed to better identify and refer appropriate patients for lung transplant evaluation. Targeted interventions may facilitate more efficient evaluation completion and waitlist appearance., (Copyright © 2017 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Background: Although postoperative predicted forced expiratory volume in the first second and diffusing capacity of lung (ppoFEV1% and ppoDLCO%, respectively) have been identified as independent predictors of postoperative pulmonary complications after open lobectomy, it has been suggested that their predictive abilities may not extend to patients undergoing minimally invasive lobectomy., Methods: We evaluated outcomes in 805 patients undergoing isolated lobectomy through open (n = 585) or minimally invasive approaches (n = 220) using a prospective database. Demographic and physiologic data were extracted and compared with complications classified as pulmonary, cardiac, other, mortality, and any., Results: Patients included 428 women and 377 men; mean age was 65.0 years. Minimally invasive patients were older (66.6 versus 64.3 years, p = 0.006), had better ppoFEV1% (71.5% versus 65.6%, p < 0.001) and performance status (0,1 94.1% versus 88.4%, p = 0.017), and less often underwent induction therapy (0.5% versus 4.8%, p = 0.003). Pulmonary and other complications were less common after minimally invasive lobectomy (3.6% versus 10.4%, p = 0.0034; 8.6% versus 15.8%, p = 0.008). Operative mortality occurred in 1.4% of minimally invasive patients and 3.9% of open patients (p = 0.075). Pulmonary complication incidence was related to predicted postoperative lung function for both minimally invasive and open approaches. On multivariate analysis with stratification for stage, ppoFEV1% and ppoDLCO% were predictive of pulmonary complications for both minimally invasive and open approaches., Conclusions: Our results suggest that the predictive abilities of ppoFEV1% and ppoDLCO% are retained for minimally invasive lobectomy and can be used to estimate the risk of pulmonary complications., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose of Review: This review presents a concise update on clinical donation after cardiac death (DCD or DDCD) lung transplantation. Lung allografts have predominantly been procured from donors after determination of neurologic death but will not meet the existing demand. A steadily increasing need for lungs is evident worldwide, especially in an era of improved outcomes for recipients. Other solid organ utilization from donors after determination of cardiac death has markedly increased internationally, but the utilization rate of lungs from such donors is still considerably less. The multifaceted reasons for this discrepancy are considered, and the recent evidence available supporting DCD for lung transplantation in clinical practice is presented in context. The recent experimental research studies are not within the remit of this appraisal., Recent Findings: The more recent and markedly increased lung recipient cohorts showed very satisfactory survival outcomes for DCD transplantation in several programs. The overall utilization rate, however, remains low. The background and the rationale of lung donor allograft expansion to proactively include DCD allografts from controlled (Maastricht category III donors) is re-emphasized in this review. The feasibility of other DCD categories for lung transplantation is considered. This is particularly prudent with the advent of the ex-vivo lung perfusion modality in pulmonary procurement., Summary: Despite evidence for adequate survival outcomes and reported favorable primary graft dysfunction rates, DCD lung transplantation remains underutilized in most countries. Waiting times could be notably reduced and mortality of lung candidates arguably decreased by a more decided and appropriate implementation of proven DCD lung transplant strategies.

We present two cases of symptomatic, post-lumbar surgery cauda equina compression due to formation of a dissecting subdural extra-arachnoid cerebrospinal fluid (CSF) collection (hygroma) under tension. In both cases, a small inadvertent durotomy was sustained during the initial surgery. Surgical re-exploration confirmed a tension subdural extra-arachnoid hygroma due to one-way flow of CSF through a pinhole puncture in the arachnoid. The mechanism and clinico-radiological features of this rare post-operative complication are discussed.

The omentum is a sheet-like tissue attached to the greater curvature of the stomach and contains secondary lymphoid organs called milky spots. The omentum has been used for its healing potential for over 100 years by transposing the omental pedicle to injured organs (omental transposition), but the mechanism by which omentum helps the healing process of damaged tissues is not well understood. Omental transposition promotes expansion of pancreatic islets, hepatocytes, embryonic kidney, and neurons. Omental cells (OCs) can be activated by foreign bodies in vivo. Once activated, they become a rich source for growth factors and express pluripotent stem cell markers. Moreover, OCs become engrafted in injured tissues suggesting that they might function as stem cells.Omentum consists of a variety of phenotypically and functionally distinctive cells. To understand the mechanism of tissue repair support by the omentum in more detail, we analyzed the cell subsets derived from the omentum on immune and inflammatory responses. Our data demonstrate that the omentum contains at least two groups of cells that support tissue repair, immunomodulatory myeloid derived suppressor cells and omnipotent stem cells that are indistinguishable from mesenchymal stem cells. Based on these data, we propose that the omentum is a designated organ for tissue repair and healing in response to foreign invasion and tissue damage.

Myelopathy associated with rheumatoid arthritis (RA) usually involves the craniocervical junction or mid-cervical spine. We present an unusual case of an encasing circumferential inflammatory mass at the cervico-thoracic junction down to the mid-thoracic spine. The need to consider inflammatory lesions even in unusual anatomical locations in patients with RA is illustrated.

Background: Rat lung allograft rejection is mediated by collagen type V (col(V)) specific T-helper-cell 17 (Th17) cells. Adoptive transfer of these cells is sufficient to induce rejection pathology in isografts, whereas tolerance to col(V) suppresses allograft rejection. Therefore, we tested whether regulatory T cells from tolerant rats could suppress the Th17-mediated rejection in the syngeneic model of lung transplantation., Methods: Rats were subjected to syngeneic left lung transplantation, and acute rejection was induced by adoptive transfer of lymph node cells from col(V)-immunized rats. Tolerance was induced by intravenous injection of col(V), and spleen lymphocytes were used for adoptive transfer. CD4+ T cells were depleted using magnetic beads. Lung isografts were analyzed using micro-positron emission tomography imaging and histochemistry. The transvivo delayed type hypersensitivity assay was used to analyze the Th17 response., Results: Adoptive cotransfer of col(V)-specific effector cells with cells from col(V)-tolerized rats suppressed severe vasculitis and bronchiolitis with parenchymal inflammation, and the expression of interleukin (IL)-17 transcripts in mediastinal lymph nodes induced by effector cells alone. Analysis by transvivo delayed type hypersensitivity showed that the reactivity to col(V) was dependent on the presence of tumor necrosis factor-alpha and IL-17 but not interferon-gamma. Depletion of CD4+ T cells from the suppressor cell population abrogated the col(V)-specific protection., Conclusion: Th17-mediated acute rejection after lung transplantation is ameliorated by CD4+ col(V)-specific regulatory T cells. The mechanism for this Th17 suppression is consistent with tolerance induction to col(V). The goal of transplantation treatment, therefore, should target Th17 development and not suppression of T-cell activation by suppressing IL-2.

Morgagni hernias are uncommon congenital diaphragmatic deficiencies that may remain asymptomatic till adulthood. We report a case of Morgagni hernia presenting with subacute bowel obstruction in a bilateral lung transplant recipient. This diaphragmatic deficiency was not evident during bilateral lung transplantation surgery via clamshell incision. To our knowledge this is the first report of a congenital defect evident after lung transplantation.

Mitral valve dysfunction after orthotopic heart transplantation may cause symptoms refractory to medical therapy. In this report, we present a patient who underwent mitral annuloplasty for severe symptomatic mitral valve insufficiency 9 years after heart transplantation, and we critically appraise the literature available for mitral valve dysfunction in this setting. Mitral valve repair, when feasible, should be considered for mitral insufficiency after transplantation to improve functional status and reduce the risk of retransplantation--this is particularly prudent in view of chronic donor shortage.

Background: Combined heart-kidney transplantation (HKTx) is increasing in frequency, but long-term outcomes are unknown and appropriately comparative analysis is lacking., Methods: This study was a retrospective review of prospectively collected data for 19 HKTx patients. Patient and graft survival, graft rejection and coronary allograft vasculopathy (CAV) were compared for HKTx vs recipients of a heart (n = 515) or kidney alone (n = 3,188) or both organs at separate time-points (n = 8)., Results: Patient and graft survival did not differ for HKTx vs any group. HKTx time to first rejection episode was significantly prolonged for both organs vs single-organ recipients. The incidence of CAV was significantly lower for HKTx., Conclusions: HKTx provides outcomes similar to those for solitary heart or kidney transplantation. There may be an immunologic advantage to receiving organs in a combined fashion. Such allocation of organs seems medically appropriate; however, more refined strategies are needed to identify optimal recipient populations.

Background: It remains unclear which donor and recipient factors influence long-term allograft function in lung transplantation (LTx)., Methods: From October 1988 to February 2005, a total of 280 recipients underwent LTx at our center. Donor data and cause of death (CoD) were analyzed. The CoD was categorized according to rate of increase in intracranial pressure at the time of death. Each donor and recipient factor was correlated with long-term graft function. Recipient details, type of transplant, indication for transplant, and time on waiting list were analyzed. Recipients were stratified based on allograft ischemia time (AIT): 0 to 6, 6 to 8, 8 to 10, and >10 hours., Results: Mean donor age was 30.9 years (36.7% male); 49.8% were cytomegalovirus (CMV) positive. Donor CoD was characterized by a slow rise in intracranial pressure (ICP) in 34.4%, rapid ICP in 18.7%, an intermediate ICP in 44.3%, and with no rise in 2.6%. A graft survival benefit was seen with female donors (P = .048); 34.4% of recipients ultimately developed graft failure at long term follow-up. Mean recipient age was 48 years; 63% were male and mean body-mass index (BMI) was 23.6; 60.2% had single lung transplantation, and mean wait list time was 323 days. Mean AIT totaled 421 minutes. Graft survival was longer with AIT of 8 to 10 hours compared to 6 to 8 hours (P = .03)., Conclusions: Donor factor analysis implied only female donor status conferred a long-term graft survival advantage. Intracranial pressure rise differences appear clinically unimportant. Prolonged cold ischemic time (>10 hours) or low recipient BMI did not adversely affect allograft function in our review.

We present a case of a solitary metastasis of an adenocarcinoma to a dorsal root ganglion (DRG) following a disease free interval of 12 years after resection of a Duke's C carcinoma. The presentation of this unusually placed metastasis was associated with a 3-year complex pain syndrome and radiological appearances consistent with benign disease. The case highlights the importance of not dismissing unusual lesions as innocent in the presence of a history of malignant disease.

Object: The authors report the preservation of motion at surgically treated and adjacent spinal segments after placing an artificial cervical joint (ACJ) and they describe the influence of interbody fusion on changes in angulation occurring in the sagittal plane at adjacent levels in the treatment of cervical spondylosis., Methods: The authors conducted a prospective nonrandomized study of patients in whom an ACJ was placed or autologous bone graft interbody fusion was performed. Angular measurements at levels adjacent to that surgically treated were calculated using plain flexion-extension radiographs obtained at 6-month intervals. Analyses of qualitative data, such as increase or decrease in adjacent-level motion, and the degree of disc degeneration were performed. Quantitative data were also analyzed. In the fusion group a significant increase in adjacent-level movement was demonstrated at the 12-month follow-up visit compared with the group of patients in whom ACJs were placed (p < 0.001). The increase in movement occurred predominantly at intervertebral discs that were preoperatively regarded as normal (p < 0.02). An overall reduction in adjacent-level movement was observed in patients who underwent joint replacement, although this was compensated for by the movement provided by the ACJ itself., Conclusions: Fusion results in increased motion at adjacent levels. The increase in adjacent-level motion derives from those discs that appear radiologically normal prior to surgery. It remains unknown whether ACJs have a protective influence on adjacent intervertebral discs.

Object: The authors undertook a study to demonstrate that frameless stereotaxy can be applied safely to the cervical and thoracic spine to minimize complications and associated morbidity., Methods: A retrospective review of cases was conducted involving the use of an image-guidance system for the accurate placement of surgical implants or for resection of lesions within the cervical and thoracic spine. The outcome measures considered were neural injury, vascular injury, wound infection, surgical revision, and death., Conclusions: Image-guidance systems are useful intraoperative tools that can be applied accurately to spinal surgery. In addition, such systems can be of great use in the preoperative planning of complex spinal surgery.