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William J. Mack, Kavon P. Rezai-Zadeh, and Stephen J. Korn

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José M. González-Darder and Pau Capilla-Guasch

In this paper, the authors trace the history of cranial temporary resection, described by Wilhelm Wagner (1848–1900) in 1889, which changed the paradigm of the cranial opening from trephining to the craniotomy. The objective of the temporary resection was to obtain wide openings in the skull, keeping the cranial flap attached to the soft tissues to maintain bone vitality. The cranial temporary resection was reproduced by the authors in an anatomical study faithfully following the original technique, demonstrating the feasibility of the surgical procedure as described by Wagner. Surgical steps include a large omega-shaped skin incision and a beveled cut of the bone with the chisel and mallet until reaching the dura mater, lifting the bone flap en bloc along with all superficial soft tissues. A literature review shows that the temporary cranial resection became a great success at that time because it allowed physicians to improve a number of constraints of the cranial opening using the crown trephine: bone vitality; a wide cranial window; easy, safe, and quick surgery; and economy of surgical instruments. The crude, primitive proposal of the temporary resection was ameliorated to quickly build the successful model of the modern craniotomy.

Open access

Elliot T. Varney, Charlotte S. Taylor, Allen G. Crosthwait, Kristin Weaver, and Todd Nichols

BACKGROUND

Dural arteriovenous fistulas (dAVFs) are direct, aberrant connections between dural arteries and cerebral veins. In neonates, delayed diagnosis results in grim outcomes. Treatment involves endovascular management because of its success and tolerability. Here, the authors present a case of a complex dAVF initially recognized with an in utero neurosonogram and fetal magnetic resonance imaging (MRI).

OBSERVATIONS

A 21-week fetal ultrasound of a nonspecific brain mass was confirmed with fetal MRI as a 2.7-cm T1-hyperintense posterior fossa mass. Although a large flow void in the left middle cranial fossa was present, postnatal computed tomography angiography ultimately revealed a high-flow dAVF communicating with the left transverse sinus. In the early postnatal period, the patient developed hydrocephalus. After successful partial embolization, 6-week postangiogram brain MRI indicated disease progression with the development of a venous varix causing brainstem compression. Repeat embolization resulted in complete cessation of early venous drainage.

LESSONS

Neonatal dAVFs are exceedingly rare and result in futile outcomes; however, detection in utero is possible. Although definitive therapy must be performed postnatally, constant monitoring and early delivery can prevent complications. Attention to fetal ultrasound is essential, and knowledge of fetal MRI in the detection of these complex lesions can significantly improve outcomes.

Open access

Yu Nomura, Ai Mizukami, Kota Ueno, Ryota Watanabe, Shohei Kinoshita, Nozomi Fujiwara, Kiyohide Kakuta, Takahiro Morita, Kenichiro Asano, and Atsushi Saito

BACKGROUND

Mycobacterium avium complex (MAC) generally causes localized pulmonary infections in immunocompromised hosts, but rarely in other organs and tissues, which is called disseminated MAC infection.

OBSERVATIONS

The authors herein present a 48-year-old male patient with disseminated MAC infectious lesions in the lungs and on the cranial, vertebral, femoral, and pelvic bones, a normal CD4 count, and immunopositivity for the interferon-ɤ (IFN-ɤ) neutralization antibody. Cranial lesions were multiple osteolytic lesions associated with abscesses in the cranial bones. The patient initially received conservative treatment with multiple antibiotics; however, cranial lesions worsened. Therefore, multiple cranial lesions were removed via osteoplastic craniectomy and the postoperative course was uneventful. Pathological findings revealed MAC infection. The patient was discharged without recurrence or complications.

LESSONS

Multiple cranial MAC dissemination with immunopositivity for the IFN-ɤ antibody is rare. The authors herein present the clinical course of a rare surgical case of MAC dissemination with a literature review.

Open access

Clifford Yudkoff, Aria Mahtabfar, Keenan Piper, and Kevin Judy

BACKGROUND

Anaplastic meningioma are rare, cancerous tumors of the central nervous system that often require multimodal therapy for tumor control. Both laser interstitial thermal therapy (LITT) and brachytherapy with implanted cesium-131 metallic seeds have demonstrated efficacy in the treatment of recurrent and resistant anaplastic meningioma; however, their safety as a dual therapy has never been reported.

OBSERVATIONS

In this report, the authors present a case of a 53-year-old female who received LITT in combination with brachytherapy after surgical and radiation treatment options had been exhausted. The authors discuss the unique safety concern of thermal injury with this treatment combination and demonstrate their method for the safe administration of these treatments together. Furthermore, the authors provide a review of the literature on LITT as an emerging therapy for anaplastic meningioma.

LESSONS

The use of LITT in combination with brachytherapy remains an option for salvage therapy in patients with recurrent meningioma that provides durable local control of tumor.

Open access

Tsegazeab Laeke, Mestet Yibeltal, and Young Dae Kwon

BACKGROUND

Angiomyolipoma (AML) of the spine is a rare benign neoplasm (accounting for 0.14%–1.2% of all spine tumors) that is often described along with angiolipoma because of their similarities. They occur almost exclusively in the extradural space, with the thoracic spine being the commonest level.

OBSERVATIONS

The authors present the clinical presentation, diagnosis, and treatment of an extremely rare case of thoracic spine AML in a 47-year-old male patient. The patient underwent laminectomy and gross total resection of the tumor and had an excellent immediate postoperative neurological recovery and long-term functional neurological outcome.

LESSONS

It is always wise to consider rare benign spinal epidural neoplasms such as spinal AMLs in the differential diagnosis of spinal epidural mass, despite metastasis being the commonest epidural tumor with variable modes of treatment, because the management of benign spinal epidural masses such as spine AML is always surgical and associated with an excellent long-term outcome.

Open access

Bernardo de Andrada Pereira, Benjamen M. Meyer, Angelica Alvarez Reyes, Jose Manuel Orenday-Barraza, Leonardo B. Brasiliense, and R. John Hurlbert

BACKGROUND

Spinal hematomas are a rare entity with broad etiologies, which stem from idiopathic, tumor-related, and vascular malformation etiologies. Less common causes include traumatic blunt nonpenetrating spinal hematomas with very few cases being reported. In the present manuscript presents a case report and review of the literature of a rare traumatic entity of a cervical subarachnoid hematoma in association with Brown-Séquard syndrome in a patient on anticoagulants. Searches were performed on PubMed and Embase for specific terms related.

OBSERVATIONS

A well-documented case of an 83-year-old female taking anticoagulants with traumatic cervical subarachnoid hematoma presenting as Brown-Séquard syndrome was reported. Six similar cases were identified, scrutinized, and analyzed in the literature review.

LESSONS

Traumatic blunt nonpenetrating cervical spine subarachnoid hematomas are a rare entity that can happen more specifically in anticoagulant users and in patients with arthritic changes and stenosis of the spinal canal. Rapid neurological deterioration and severe disability warrant early aggressive surgical treatment. This report has the intention to record this case in the medical literature for registry purposes.

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Panjie Xu, Zhiping Huang, Hang Xiao, Junyu Lin, Qingan Zhu, and Wei Ji

OBJECTIVE

Atlanto-occipital instability is commonly treated with posterior fixation. However, in patients with congenital or acquired factors, posterior fixation may not be possible. For these situations, a novel anterior atlanto-occipital transarticular screw (AATS) fixation technique has been introduced recently. However, biomechanical study of this technique is lacking. This study was designed to evaluate the biomechanical stability of AATS fixation for the atlanto-occipital joint and compare it with conventional posterior occipitocervical fixation (POCF).

METHODS

Six cadaveric specimens (occiput–C4) were tested in four conditions, including intact, injury, injury + AATS, and injury + POCF states. A pure moment of 1.5 Nm was applied to specimens in flexion, extension, lateral bending, and axial rotation. The range of motion (ROM) and neutral zone (NZ) were calculated and compared from the occiput to C1.

RESULTS

The AATS fixation constrained ROMs to 0.4° in flexion (p < 0.001), 0.4° in extension (p < 0.001), 1.0° in lateral bending (p < 0.001), and 0.7° in axial rotation (p < 0.001) when compared with the injury state. In all directions, there was no statistically significant difference observed in ROMs and NZs between AATS fixation and POCF (p > 0.05).

CONCLUSIONS

This study identified that the novel AATS fixation, as stand-alone anterior fixation, was equivalent to POCF in all directions. The results suggest that anterior transarticular screw fixation is a biomechanically effective salvage technique for posterior atlanto-occipital fixation, and may also serve as supplemental fixation.

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Michael M. Safaee, Jue Lin, Dana L. Smith, Marissa Fury, Justin K. Scheer, John F. Burke, Crystal Bravate, Dennis Lambert, and Christopher P. Ames

OBJECTIVE

Risk stratification is a critical element of surgical planning. Early tools were fairly crude, while newer instruments incorporate disease-specific elements and markers of frailty. It is unknown if discrepancies between chronological and cellular age can guide surgical planning or treatment. Telomeres are DNA-protein complexes that serve an important role in protecting genomic DNA. Their shortening is a consequence of aging and environmental exposures, with well-established associations with diseases of aging and mortality. There are compelling data to suggest that telomere length can provide insight toward overall health. The authors sought to determine potential associations between telomere length and postoperative complications.

METHODS

Adults undergoing elective surgery for spinal deformity were prospectively enrolled. Telomere length was measured from preoperative whole blood using quantitative polymerase chain reaction and expressed as the ratio of telomere (T) to single-copy gene (S) abundance (T/S ratio), with higher T/S ratios indicating longer telomere length. Demographic and patient data included age, BMI, and results for the following rating scales: the Adult Spinal Deformity Frailty Index (ASD-FI), Oswestry Disability Index (ODI), Scoliosis Research Society-22r (SRS-22r), American Society of Anesthesiology (ASA) classification, and Charlson Comorbidity Index (CCI). Operative and postoperative complication data (medical or surgical within 90 days) were also collected.

RESULTS

Forty-three patients were enrolled, including 31 women (53%), with a mean age of 66 years and a mean BMI of 28.5. The mean number of levels fused was 11, with 21 (48.8%) combined anterior-posterior approaches. Twenty-two patients (51.2%) had a medical or surgical complication. Patients with a postoperative complication had a significantly lower T/S ratio (0.712 vs 0.813, p = 0.008), indicating shorter telomere length, despite a mild difference in age compared with patients without a postoperative complication (68 vs 63 years, p = 0.069). Patients with complications also had higher CCI scores than patients without complications (2.3 vs 3.8, p = 0.004). There were no significant differences in sex, BMI, ASD-FI score, ASA class, preoperative ODI and SRS-22r scores, number of levels fused, or use of three-column osteotomies. In a multivariate model including age, frailty, ASA class, use of an anterior-posterior approach, CCI score, and telomere length, the authors found that short telomere length was significantly associated with postoperative complications. Patients whose telomere length fell in the shortest quartile had the highest risk (OR 18.184, p = 0.030).

CONCLUSIONS

Short telomere length was associated with an increased risk of postoperative complications despite only a mild difference in chronological age. Increasing comorbidity scores also trended toward significance. Larger prospective studies are needed; however, these data provide a compelling impetus to investigate the role of biological aging as a component of surgical risk stratification.

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Jeffrey P. Blount and Michael D. Partington