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## Temporosylvian arachnoid cysts in children. Part 2: Postoperative neuropsychological and clinical improvement

### OBJECTIVE

The authors’ objective was to study clinical, imaging, and neuropsychological changes in children who underwent surgery for a temporal arachnoid cyst (TAC).

### METHODS

Thirty-four children were prospectively assessed similarly at diagnosis and postoperatively (mean 14 months) with clinic visits, images, cognitive tests, and parental questionnaires on mood/behavior and executive functions. The scores were compared pre- and postoperatively for the entire cohort and individually. The scores of 25 children were also compared with a control group of 23 healthy age-matched children. Parents were administered an outcome questionnaire on average 4 years postoperatively.

### RESULTS

The 34 children selected for surgery had signs of raised intracranial pressure (74%) and/or selective neuropsychological disorders presumably linked to cyst location (learning difficulties in 65%, cognitive difficulties in 56%, and mood/behavior difficulties in 47%). The majority of patients had a convex cyst (85%) and underwent microsurgical fenestration (85%). The TAC volume decreased ≥ 50% for 59% of children. On the Wechsler Intelligence Scale, the entire cohort significantly improved on Full Scale IQ and verbal and perceptual nonverbal indexes. Individually, nearly half of the children (47%) highly increased their scores (≥ 15 points) on at least one IQ index and 26% on at least two indexes. Language, working memory, episodic memory, and executive functions were also significantly improved. Improvements were more pronounced in patients with a preoperative heterogeneous profile with isolated lower scores and a left-sided cyst. Parental questionnaires showed reduction in anxiety, aggressiveness, social problems, and daily life executive disorders. Preschool-aged children improved significantly in language and verbal IQ, as did middle/high school–aged children in many domains. Individual analyses revealed improvement in 76% of cases. Cognitive scores were lower for patients preoperatively than for controls and were no longer significantly different postoperatively in verbal fluency, visual memory, and working memory. Four years later, 97% of parents described an improvement in their child, correlated with cognitive improvements.

### CONCLUSIONS

Among children with a TAC, some have no clinical signs or neuropsychological difficulties, and others may show signs of raised intracranial pressure and/or specific neuropsychological disorders that impact daily life and require significant and long-lasting rehabilitation. In these cases, consideration may be given to surgical decompression. It is interesting to note that 76% of this surgically treated cohort improved regardless of the child’s age, particularly in patients with selective disorders and an impact on daily life. However, a larger number of children will need to be investigated before the true benefit of such treatment can be known.

Open access

## Asymptomatic spinal subdural epiarachnoid hygroma after lumbar laminectomy for lumbar spinal canal stenosis: illustrative case

### BACKGROUND

Spinal subdural epiarachnoid hygroma (SSEH) after lumbar laminectomy is an extremely rare complication.

### OBSERVATIONS

An 84-year-old man presented to the hospital with lower back pain, radicular pain, and numbness in the lateral aspect of the left leg. Magnetic resonance imaging (MRI) revealed anterior lumbar spondylolisthesis at L3, severe disc herniation at L3–4, and severe lumbar spinal canal stenosis at L3–4 and L4–5. Lumbar laminectomy at L3–4 and L4–5 and discectomy at L3–4 were performed without complications such as cerebrospinal fluid (CSF) leakage and durotomy intraoperatively. Although lower back pain and numbness at the lateral aspect of the left leg were resolved postoperatively, postoperative MRI showed spinal nerve deviation to the ventral side due to SSEH from T12 to S1. Conservative therapy was performed for asymptomatic SSEH, and MRI 1 week postoperatively indicated improved ventral spinal nerve deviation and reduced SSEH.

### LESSONS

SSEHs after posterior decompression without durotomy are extremely rare. Asymptomatic SSEHs may resolve with conservative treatment. However, surgery should be performed to decompress hygroma in patients with symptomatic SSEH.

Open access

## Conservative management of intraventricular migration of a gelatin sponge: illustrative case

### BACKGROUND

Gelatin sponges, such as Gelfoam, are used as hemostatic agents during surgery and are generally absorbed over the course of 4–6 weeks in most body cavities. The time course of the dissolution of Gelfoam sponges within the cerebral ventricles has not been described.

### OBSERVATIONS

The authors present a case of intraventricular migration of Gelfoam after ventriculoperitoneal shunt placement in a 6-week-old infant. The infant was imaged regularly after ventriculoperitoneal shunt placement, and the Gelfoam sponge persisted within the ventricles on all images until 11 months after surgery. At no time during follow-up did the patient have any symptoms of hydrocephalus requiring retrieval of the sponge or shunt revision.

### LESSONS

This is the first case describing time until absorption of a gelatin sponge within the ventricle and successful conservative management.

Open access

## Spinal fractures in the setting of diffuse idiopathic skeletal hyperostosis conservatively treated via orthosis: illustrative cases

### BACKGROUND

Fractures in patients with diffuse idiopathic skeletal hyperostosis (DISH) are considered highly unstable injuries with high risk for neurological injury. Surgical intervention is the standard of care for these patients to avoid secondary spinal cord injuries. Despite this, certain cases may necessitate a nonoperative approach. Herein within, the authors describe three cases of cervical, thoracic, and lumbar fractures in the setting of DISH that were successfully treated via orthosis.

### OBSERVATIONS

The authors present three cases of fractures in patients with DISH. A 74-year-old female diagnosed with an acute fracture of a flowing anterior osteophyte at C6–C7 treated with a cervical orthosis. A 78-year-old male with an anterior fracture of the ankylosed T7–T8 vertebrae managed with a Jewett hyperextension brace. Finally, a 57-year-old male with an L1–L2 disc space fracture treated with a thoraco-lumbo-sacral orthosis. All patients recovered successfully.

### LESSONS

In certain cases, conservative treatment may be more appropriate for fractures in the setting of DISH as an alternative to the surgical standard of care. Most fractures in the setting of DISH are unstable, therefore it is necessary to manage these patients on a case-by-case basis.

Open access

## Transcranial magnetic stimulation tractography and the facilitation of gross total resection in a patient with a motor eloquent glioblastoma: illustrative case

### BACKGROUND

In patients with perieloquent tumors, neurosurgeons must use a variety of techniques to maximize survival while minimizing postoperative neurological morbidity. Recent publications have shown that conventional anatomical features may not always predict postoperative deficits. Additionally, scientific conceptualizations of complex brain function have shifted toward more dynamic, neuroplastic theories instead of traditional static, localizationist models. Functional imaging techniques have emerged as potential tools to incorporate these advances into modern neurosurgical care. In this case report, we describe our observations using preoperative transcranial magnetic stimulation data combined with tractography to guide a nontraditional surgical approach in a patient with a motor eloquent glioblastoma.

### OBSERVATIONS

The authors detail the use of preoperative functional and structural imaging to perform a gross total resection despite tumor infiltration of conventionally eloquent anatomical structures. The authors resected the precentral gyrus, specifically the paracentral lobule, localized using intraoperative mapping techniques. The patient demonstrated mild transient postoperative weakness and made a full neurological recovery by discharge 1 week later.

### LESSONS

Preoperative functional and structural imaging has potential to not only optimize patient selection and surgical planning, but also facilitate important intraoperative decisions. Innovative preoperative imaging techniques should be optimized and used to identify safely resectable structures.

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## Association between lower Hounsfield units and proximal junctional kyphosis and failure at the upper thoracic spine

### OBJECTIVE

The aim of this study was to analyze risk factors and avoidance techniques for proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) in the upper thoracic spine with an emphasis on bone mineral density (BMD) as estimated by Hounsfield units (HU).

### METHODS

A retrospective chart review identified patients at least 50 years of age who underwent instrumented fusion extending from the pelvis to an upper instrumented vertebra (UIV) between T1 and T6 and had a preoperative CT, pre- and postoperative radiographs, and a minimum follow-up of 12 months. HU were measured in the UIV, the vertebral body cephalad to the UIV (UIV+1), and the L3 and L4 vertebral bodies. Numerous perioperative variables were collected, including basic demographics, smoking and steroid use, preoperative osteoporosis treatment, multiple frailty indices, use of a proximal junctional tether, UIV soft landing, preoperative dual-energy x-ray absorptiometry, spinopelvic parameters, UIV screw tip distance to the superior endplate, UIV pedicle screw/pedicle diameter ratio, lumbar lordosis distribution, and postoperative spinopelvic parameters compared with age-adjusted normal values.

### RESULTS

Eighty-one patients were included in the study (21 men and 60 women) with a mean (SD) age of 66 years (6.9 years), BMI of 29 (5.5), and follow-up of 38 months (25 months). Spinal fusion constructs at the time of surgery extended from the pelvis to a UIV of T1 (5%), T2 (15%), T3 (25%), T4 (33%), T5 (21%), and T6 (1%). Twenty-seven patients (33%) developed PJK and/or PJF; 21 (26%) had PJK and 15 (19%) had PJF. Variables associated with PJK/PJF with p < 0.05 were included in the multivariable analysis, including HU at the UIV/UIV+1, HU at L3/L4, DXA femoral neck T-score, UIV screw tip distance to the superior endplate, UIV pedicle screw/pedicle diameter ratio, and postoperative lumbar lordosis distribution. Multivariable analysis (area under the curve = 0.77) demonstrated HU at the UIV/UIV+1 to be the only independent predictor of PJK and PJF with an OR of 0.96 (p = 0.005). Patients with < 147 HU (n = 27), 147–195 HU (n = 27), and > 195 HU (n = 27) at the UIV/UIV+1 had PJK/PJF rates of 59%, 33%, and 7%, respectively.

### CONCLUSIONS

In patients with upper thoracic–to-pelvis spinal reconstruction, lower HU at the UIV and UIV+1 were independently associated with PJK and PJF, with an optimal cutoff of 159 HU that maximizes sensitivity and specificity.

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## A broad and variable lumbosacral myotome map uncovered by foraminal nerve root stimulation

### OBJECTIVE

The human myotome is fundamental to the diagnosis and treatment of neurological disorders. However, this map was largely constructed decades ago, and its breadth, variability, and reliability remain poorly described, limiting its practical use.

### METHODS

The authors used a novel method to reconstruct the myotome map in patients (n = 42) undergoing placement of dorsal root ganglion electrodes for the treatment of chronic pain. They electrically stimulated nerve roots (n = 79) in the intervertebral foramina at T12–S1 and measured triggered electromyography responses.

### RESULTS

L4 and L5 stimulation resulted in quadriceps muscle (62% and 33% of stimulations, respectively) and tibialis anterior (TA) muscle (25% and 67%, respectively) activation, while S1 stimulation resulted in gastrocnemius muscle activation (46%). However, L5 and S1 both resulted in abductor hallucis (AH) muscle activation (17% and 31%), L5 stimulation resulted in gastrocnemius muscle stimulation (42%), and S1 stimulation in TA muscle activation (38%). The authors also mapped the breadth of the myotome in individual patients, finding coactivation of adductor and quadriceps, quadriceps and TA, and TA and gastrocnemius muscles under L3, L4, and both L5 and S1 stimulation, respectively. While the AH muscle was commonly activated by S1 stimulation, this rarely occurred together with TA or gastrocnemius muscle activation. Other less common coactivations were also observed throughout T12–S1 stimulation.

### CONCLUSIONS

The muscular innervation of the lumbosacral nerve roots varies significantly from the classic myotome map and between patients. Furthermore, in individual patients, each nerve root may innervate a broader range of muscles than is commonly assumed. This finding is important to prevent misdiagnosis of radicular pathologies.

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## Dr. Ruth Jackson: the legacy of the first female spine surgeon

Dr. Ruth Jackson, born in 1902, was the first female spine surgeon on record. Her story of remarkable resilience and sacrifice is even more relevant given the stark gender disparities in orthopedic surgery and neurosurgery that remain today. Dr. Jackson entered the field during the Great Depression and overcame significant barriers at each step along the process. In 1937, she became the first woman to pass the American Board of Orthopedic Surgery examination and join the American Academy of Orthopedic Surgeons as a full member. Her work in the cervical spine led to a notable lecture record and the publication of several articles, as well as a book, The Cervical Syndrome, in which she discussed the anatomy, etiology, and treatment of cervical pathologies. Additionally, Dr. Jackson developed the Jackson CerviPillo, a neck support that is still in use today. She left a legacy that continues to resonate through the work of the Ruth Jackson Orthopedic Society, which supports women at all levels of practice and training. From the story of Dr. Jackson’s life, we can appreciate her single-minded determination that blazed a path for women in spine surgery, as well as consider the progress that remains to be made.

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## Erratum. A survival analysis of ventricular access devices for delivery of cerliponase alfa

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## Evaluating caregiver stress in craniosynostosis patients

### OBJECTIVE

Caregiver stress from a child’s diagnosis can impact a caregiver’s ability to participate in treatment decisions, comply, and manage long-term illness. The aim of this study was to compare caregiver stress in children with craniosynostosis at diagnosis and postoperatively.

### METHODS

This prospective study included caregivers of pediatric patients with craniosynostosis receiving operative intervention. Demographics and Parenting Stress Index, Short Form (PSI-SF) and Pediatric Inventory for Parents (PIP) surveys at baseline (preoperatively) and 3 and 6 months postoperatively were completed. PSI-SF scores between 15 and 80 are considered normal, with > 85 being clinically significant and requiring follow-up. Higher PIP scores represent increased frequency and difficulty of stressful events due to the child’s illness. Pairwise comparisons were performed using the Wilcoxon signed-rank test. Multivariate analysis was performed to assess for PSI-SF and PIP predictors.

### RESULTS

Of 106 caregivers (84% Caucasian), there were 62 mothers and 40 fathers. There were 68 and 45 responses at 3 and 6 months postoperatively, respectively. Regarding the baseline group, more than 80% were between 20 and 40 years of age and 58% had less than 2 years of college education. The median household income fell in the $45,001–$60,000 bracket. There was no significant difference between median baseline PSI-SF score (65, IQR 51–80) and those at 3 months (p = 0.45) and 6 months (p = 0.82) postoperatively. Both median PIP frequency (89 vs 74, p < 0.01) and difficulty (79 vs 71, p < 0.01) scores were lower at 3 months, although no significant difference was observed at 6 months (frequency: 95 vs 91, p = 0.67; difficulty: 82 vs 80, p = 0.34). Female sex, uninsured status, and open surgery type were all risk factors for higher parental stress.

### CONCLUSIONS

Stress levels ranged from normal to clinically significant in the caregivers, with sex, uninsured status, and open repair predicting higher stress. Stress decreased at 3 months postoperatively before increasing at 6 months. Intervention targeting caregiver stress should be explored to maintain lower stress observed at 3 months after surgery.