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Athan G. Zavras, Navya Dandu, Michael T. Nolte, Alexander J. Butler, Vincent P. Federico, Arash J. Sayari, T. Barrett Sullivan, and Matthew W. Colman

OBJECTIVE

As an alternative procedure to anterior cervical discectomy and fusion, total disc arthroplasty (TDA) facilitates direct neural decompression and disc height restoration while also preserving cervical spine kinematics. To date, few studies have reported long-term functional outcomes after TDA. This paper reports the results of a systematic review and meta-analysis that investigated how segmental range of motion (ROM) at the operative level is maintained with long-term follow-up.

METHODS

PubMed and MEDLINE were queried for all published studies pertaining to cervical TDA. The methodology for screening adhered strictly to the PRISMA guidelines. All English-language prospective studies that reported ROM preoperatively, 1 year postoperatively, and/or at long-term follow-up of 5 years or more were included. A meta-analysis was performed using Cochran’s Q and I2 to test data for statistical heterogeneity, in which case a random-effects model was used. The mean differences (MDs) and associated 95% confidence intervals (CIs) were reported.

RESULTS

Of the 12 studies that met the inclusion criteria, 8 reported the long-term outcomes of 944 patients with an average (range) follow-up of 99.86 (60–142) months and were included in the meta-analysis. There was no difference between preoperative segmental ROM and segmental ROM at 1-year follow-up (MD 0.91°, 95% CI −1.25° to 3.07°, p = 0.410). After the exclusion of 1 study from the comparison between preoperative and 1-year ROM owing to significant statistical heterogeneity according to the sensitivity analysis, ROM significantly improved at 1 year postoperatively (MD 1.92°, 95% CI 1.04°–2.79°, p < 0.001). However, at longer-term follow-up, the authors again found no difference with preoperative segmental ROM, and no study was excluded on the basis of the results of further sensitivity analysis (MD −0.22°, 95% CI −1.69° to −1.23°, p = 0.760). In contrast, there was a significant decrease in ROM from 1 year postoperatively to final long-term follow-up (MD −0.77°, 95% CI −1.29° to −0.24°, p = 0.004).

CONCLUSIONS

Segmental ROM was found to initially improve beyond preoperative values for as long as 1 year postoperatively, but then ROM deteriorated back to values consistent with preoperative motion at long-term follow-up. Although additional studies with further longitudinal follow-up are needed, these findings further support the notion that cervical TDA may successfully maintain physiological spinal kinematics over the long term.

Open access

Isabella Watson, Patrick J. McDonald, Paul Steinbok, Brendon Graeber, and Ashutosh Singhal

BACKGROUND

Arachnoid cysts are benign, often asymptomatic intracranial mass lesions that, when ruptured, may cause seizures, raised intracranial pressure, hemorrhage, and/or loss of consciousness. There is no widely agreed upon treatment, and there is debate as to whether a nonoperative or surgical approach is the best course of action. The carbonic anhydrase inhibitor acetazolamide may be an effective nonoperative approach in treating ruptured arachnoid cysts.

OBSERVATIONS

The Pediatric Neurosurgery Clinical Database at BC Children’s Hospital from 2000 to 2020 was queried, and four pediatric patients who were treated with acetazolamide after presentation with a ruptured middle cranial fossa arachnoid cyst were identified. All patients showed some degree of symptom improvement. Three of the patients showed complete reabsorption of their subdural collections in the ensuing 6 months. One patient had an inadequate response to acetazolamide and required surgical management.

LESSONS

Acetazolamide is a safe and reasonable primary treatment option in pediatric patients with ruptured middle cranial fossa arachnoid cysts, and it may help avoid the need for surgery.

Open access

Fumiaki Kanamori, Yoshio Araki, Kinya Yokoyama, Kenji Uda, Takashi Mamiya, Shota Nohira, Kai Takayanagi, Kazuki Ishii, Masahiro Nishihori, Takashi Izumi, and Ryuta Saito

BACKGROUND

In patients with moyamoya disease (MMD) who receive superficial temporal artery (STA) to middle cerebral artery (MCA) bypass, hypoperfusion remote from the anastomosis site rarely occurs. Watershed shift due to direct bypass has been proposed as the mechanism; however, no report has confirmed this phenomenon using angiography.

OBSERVATIONS

A 48-year-old man presented with transient weakness in his left arm. Angiography revealed severe bilateral stenosis of the MCAs and moyamoya vessels. The right anterior cerebral artery (ACA) had short stenosis at A2 but ample blood supply to the cortical area of the right ACA and MCA regions. The patient was diagnosed with MMD and received a single STA-MCA bypass. The next day, he had difficulty communicating, and a cerebral infarction away from the anastomosis site was identified. Perfusion examination revealed hyperperfusion around the direct bypass and hypoperfusion away from the anastomosis site. Angiography revealed bypass patency; however, the original anterograde flow of the right ACA decreased significantly at the stenosed point, indicating an improper watershed shift.

LESSONS

STA-MCA bypass for patients with MMD can cause an improper watershed shift decreasing cerebral flow. Donor flow should be prepared based on each angiographic characteristic, and the risk of the improper watershed shift should be considered.

Open access

Daniel D. Cummins, Ramin A. Morshed, Tarik Tihan, and Sandeep Kunwar

BACKGROUND

There are numerous atypical lesions of the sellar and suprasellar region that are often mistaken for pituitary adenomas. It is important to consider rare mimics of more common pathologies in this region.

OBSERVATIONS

The authors detail the case of a 37-year-old woman with hypopituitarism who was found to have an atypical sellar mass with slow growth on interval imaging. The lesion was debulked via a microscopic endonasal transsphenoidal approach and found to be a calcifying pseudoneoplasm of the neuraxis (CAPNON).

LESSONS

CAPNON is a rare disease entity that may affect the sellar region. CAPNON should be on the differential diagnosis for sellar masses that are associated with T1 and T2 hypointensity on magnetic resonance imaging with minimal enhancement. Although CAPNON is not at risk for malignant progression, these benign lesions can continue to grow after a subtotal resection and require follow-up.

Open access

Akiya Kawanishi, Motoyuki Umekawa, Satoru Miyawaki, Shigeta Fujitani, Takeaki Ishizawa, Tetsuo Ushiku, Hiroki Hongo, Yu Teranishi, Masaaki Shojima, Masahiro Shin, Kiyoshi Hasegawa, and Nobuhito Saito

BACKGROUND

Gastrointestinal stromal tumors (GISTs) are common subepithelial tumors that rarely metastasize to the intracranial space. Because the standard treatment for metastatic intracranial GISTs has not been established, multimodal therapies are needed, especially in the case of skull base metastasis. However, its outcome has not always been favorable. The authors report the longest known surviving case of skull base metastasis of GIST treated with imatinib only.

OBSERVATIONS

A 52-year-old male with a history of GIST presented with left facial swelling and numbness. Examinations revealed a 70-mm tumor occupying the left middle cranial fossa and the orbit. The authors performed transnasal endoscopic tumor biopsy for definitive diagnosis and reintroduced imatinib treatment. The tumor significantly decreased in size early after the introduction of imatinib, and symptoms completely disappeared within several weeks. The lesion has remained shrunk radiologically for 63 months, and the patient is continuously being followed up under imatinib treatment.

LESSONS

The authors reported a rare case of skull base metastasis of GIST successfully treated solely with systemic therapy with a tyrosine kinase inhibitor, achieving tumor control for over 5 years. This case suggests that tyrosine kinase inhibitors might play a key role in the multidisciplinary treatment for skull base metastases of GIST.

Open access

Megan Rajagopal, Jamie Toms, and R. Scott Graham

BACKGROUND

This report describes an unusual meningioma with a large left frontal component and extensive growth within the sagittal sinus and its successful treatment with a staged approach: left frontal craniotomy followed by a sagittal craniotomy and intrinsic removal of the tumor from the sagittal sinus.

OBSERVATIONS

A previously healthy 27-year-old presented with 6 months of progressively worsening bilateral headaches, visual changes, and nausea. On examination she had a left cranial nerve VI palsy and severe papilledema. Magnetic resonance imaging revealed a 5.1 × 3.8 × 4.1 cm homogenously enhancing left superior frontal parafalcine extra-axial mass with surrounding vasogenic edema and growth through the sagittal sinus extending just short of the torcula.

LESSONS

This case report describes a fast-growing meningioma with a unique pattern of spread, growing through the sagittal sinus as if it were a conduit and resulting in complete occlusion of flow in the sinus. An important recognition in this case was that a robust parasagittal venous plexus had developed on either side of the falx cerebri with drainage to the inferior sagittal sinus. This collateral drainage pattern allowed for an extradural opening of the sagittal sinus from front to back and intrinsic resection of the tumor from the sinus with preservation of the lateral walls of the sinus.

Open access

Lisa B. E. Shields, Vasudeva G. Iyer, John E. Harpring, Abigail J. Rao, Yi Ping Zhang, and Christopher B. Shields

BACKGROUND

Double crush syndrome consists of two compression sites along a peripheral nerve and is rare in the lower extremities. Electrodiagnostic and ultrasound (US) studies may be helpful in evaluating foot drop involving overlapping pathologies.

OBSERVATIONS

Case 1 involved a man who presented with left dorsiflexor weakness and left foot numbness. Electromyography (EMG) revealed a left common fibular nerve entrapment neuropathy and left L5 radiculopathy. US and magnetic resonance imaging (MRI) revealed a large cystic lesion of the left common fibular nerve treated by cyst removal. The left foot drop persisted postoperatively. Lumbar computed tomography myelography revealed severe left foraminal stenosis at L5–S1. Multilevel lumbar laminectomies and facetectomies with an L5–S1 fusion were performed. Within 1 month postoperatively, the left foot drop had improved. Case 2 involved a man who developed a right foot drop caused by right lumbar foraminal stenosis at L4–5 and L5–S1. EMG and US of the right common fibular neuropathy showed large fascicles involving the right common fibular nerve. MRI revealed a hyperintense signal of the right common fibular nerve. Spontaneous improvement occurred within 6 months without surgery.

LESSONS

Spine surgeons should recognize double crush in the lower extremities. EMG and US are valuable in detecting peripheral nerve abnormalities, especially in cases with overlapping lumbar pathology.

Open access

Keisuke Onoda, Ryohei Sashida, Ren Fujiwara, Tomihiro Wakamiya, Yuhei Michiwaki, Tatsuya Tanaka, Kazuaki Shimoji, Eiichi Suehiro, Fumitaka Yamane, Masatou Kawashima, and Akira Matsuno

BACKGROUND

Vaccines against coronavirus disease 2019 have a high level of efficacy and safety across all populations. However, numerous case series have been published on neurological disorders, including Bell’s palsy, Guillain-Barre syndrome, transverse myelitis, and multiple sclerosis. The authors presented a case of trigeminal neuropathy after coronavirus vaccination in a patient who had undergone microvascular decompression (MVD) for trigeminal neuralgia (TN).

OBSERVATIONS

A 77-year-old woman presented with acute trigeminal neuropathy after receiving a Pfizer-BioNtech vaccination (tozinameran) against severe acute respiratory syndrome coronavirus 2. The patient had undergone MVD for TN and the facial pain completely disappeared. One month later, she received the first injection of the tozinameran vaccine. Twelve hours after vaccination, she presented with numbness and pain induced by touching any place on the entire right face. No eruption was observed on her face. The serum herpes zoster virus antibodies were confirmed within the normal range. Magnetic resonance imaging revealed no abnormalities. The authors suspected a right trigeminal neuropathy after vaccination. Administration of carbamazepine and pregabalin improved TN but facial numbness persisted, especially in the mandibular division.

LESSONS

The coronavirus is a possible etiology of secondary trigeminal neuropathy in the case of MVD for TN.

Open access

Mosaab Alsuwaihel, Dana El-Mughayyar, Matthew MacLennan, and Najmedden Attabib

BACKGROUND

Unilateral agenesis of a cervical pedicle is a known rare entity that has been well described over the past 70 years. It is usually an incidental or minimally symptomatic presentation with no significant clinical repercussion. No previous report has described concurrent non-osseous developmental abnormalities alongside this unique pathology.

OBSERVATIONS

This case reported a cervical hemangioma with associated unilateral pedicle agenesis and an incidental finding of callosal dysgenesis and lipoma. The initial presentation consisted solely of persistent neck pain, with cervical radiography illustrating significant kyphotic deformity secondary to apparent anterolisthesis of C3-C4. The patient underwent a combined approach: anterior cervical corpectomy at C4-C5 with supplemental posterior fusion. The authors provided a review of the literature concerning developmental pedicle abnormalities and vertebral hemangioma. Pedicle agenesis is known to be associated with multiple pathologies, but the authors have not found evidence of a clinical paradigm consisting of a vertebral hemangioma in the presence of cervical pedicle agenesis, callosal dysgenesis, or callosal lipoma.

LESSONS

Careful evaluation of radiographs with appropriate subsequent multimodal imaging is key to identifying unique pathologies in the spine that complement a patient’s history and clinical findings. If multiple abnormalities are noted, a novel clinical etiology or syndrome must be considered.

Restricted access

S. Hassan A. Akbari, Alexander T. Yahanda, Laurie L. Ackerman, P. David Adelson, Raheel Ahmed, Gregory W. Albert, Philipp R. Aldana, Tord D. Alden, Richard C. E. Anderson, David F. Bauer, Tammy Bethel-Anderson, Karin Bierbrauer, Douglas L. Brockmeyer, Joshua J. Chern, Daniel E. Couture, David J. Daniels, Brian J. Dlouhy, Susan R. Durham, Richard G. Ellenbogen, Ramin Eskandari, Herbert E. Fuchs, Gerald A. Grant, Patrick C. Graupman, Stephanie Greene, Jeffrey P. Greenfield, Naina L. Gross, Daniel J. Guillaume, Todd C. Hankinson, Gregory G. Heuer, Mark Iantosca, Bermans J. Iskandar, Eric M. Jackson, George I. Jallo, James M. Johnston, Bruce A. Kaufman, Robert F. Keating, Nicklaus R. Khan, Mark D. Krieger, Jeffrey R. Leonard, Cormac O. Maher, Francesco T. Mangano, J. Gordon McComb, Sean D. McEvoy, Thanda Meehan, Arnold H. Menezes, Michael S. Muhlbauer, Brent R. O’Neill, Greg Olavarria, John Ragheb, Nathan R. Selden, Manish N. Shah, Chevis N. Shannon, Joshua S. Shimony, Matthew D. Smyth, Scellig S. D. Stone, Jennifer M. Strahle, Mandeep S. Tamber, James C. Torner, Gerald F. Tuite, Elizabeth C. Tyler-Kabara, Scott D. Wait, John C. Wellons III, William E. Whitehead, Tae Sung Park, and David D. Limbrick Jr.

OBJECTIVE

The aim of this study was to determine differences in complications and outcomes between posterior fossa decompression with duraplasty (PFDD) and without duraplasty (PFD) for the treatment of pediatric Chiari malformation type I (CM1) and syringomyelia (SM).

METHODS

The authors used retrospective and prospective components of the Park-Reeves Syringomyelia Research Consortium database to identify pediatric patients with CM1-SM who received PFD or PFDD and had at least 1 year of follow-up data. Preoperative, treatment, and postoperative characteristics were recorded and compared between groups.

RESULTS

A total of 692 patients met the inclusion criteria for this database study. PFD was performed in 117 (16.9%) and PFDD in 575 (83.1%) patients. The mean age at surgery was 9.86 years, and the mean follow-up time was 2.73 years. There were no significant differences in presenting signs or symptoms between groups, although the preoperative syrinx size was smaller in the PFD group. The PFD group had a shorter mean operating room time (p < 0.0001), fewer patients with > 50 mL of blood loss (p = 0.04), and shorter hospital stays (p = 0.0001). There were 4 intraoperative complications, all within the PFDD group (0.7%, p > 0.99). Patients undergoing PFDD had a 6-month complication rate of 24.3%, compared with 13.7% in the PFD group (p = 0.01). There were no differences between groups for postoperative complications beyond 6 months (p = 0.33). PFD patients were more likely to require revision surgery (17.9% vs 8.3%, p = 0.002). PFDD was associated with greater improvements in headaches (89.6% vs 80.8%, p = 0.04) and back pain (86.5% vs 59.1%, p = 0.01). There were no differences between groups for improvement in neurological examination findings. PFDD was associated with greater reduction in anteroposterior syrinx size (43.7% vs 26.9%, p = 0.0001) and syrinx length (18.9% vs 5.6%, p = 0.04) compared with PFD.

CONCLUSIONS

PFD was associated with reduced operative time and blood loss, shorter hospital stays, and fewer postoperative complications within 6 months. However, PFDD was associated with better symptom improvement and reduction in syrinx size and lower rates of revision decompression. The two surgeries have low intraoperative complication rates and comparable complication rates beyond 6 months.