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Double-level noncontiguous thoracic Chance fractures treated with percutaneous stabilization: illustrative case

Matthew H. MacLennan, Dana El-Mughayyar, and Najmedden Attabib

BACKGROUND

Chance fractures are unstable due to horizontal extension of the injury, disrupting all three columns of the vertebra. Since being first described in 1948, Chance fractures have been commonly found at a single level near the thoracolumbar junction. Noncontiguous double-level Chance fractures that result from a single traumatic event are rarely reported in the literature.

OBSERVATIONS

The authors report a case of an 18-year-old male who presented to the emergency department after a rollover motor vehicle accident. The patient complained of severe back pain when at rest and had no neurological deficits. Computed tomography revealed two unstable Chance fractures of bony subtype located at T6 and T11. The patient underwent percutaneous stabilization from T4 to T12. The postoperative assessment revealed continued 5/5 power bilaterally in all extremities, back pain, and the ability to ambulate with a walker. At 3 months after the operation, clinical assessment revealed no significant back pain and the ability to walk independently. Imaging confirmed stable fixation of the spine with no acute osseous or hardware complications.

LESSONS

This report complements previous studies demonstrating support for more extensive stabilization for such unique fractures. Additionally, rapid radiological imaging is needed to identify the full injury and lead patients to appropriate treatment.

In Journal of Neurosurgery: Case Lessons Volume 2 (2021): Issue 23 (Dec 2021)

Open access

IgG4-related pachymeningitis masquerading as foramen magnum meningioma: illustrative case

Haggai Suisa, Jean Francois Soustiel, and Yuval Grober

BACKGROUND

Immunoglobulin G4-related disease (IgG4-RD) is an immune-mediated inflammatory condition with potential multiorgan involvement. Common manifestations include autoimmune pancreatitis and retroperitoneal fibrosis. Pathological analysis reveals lymphoplasmacytic infiltrate rich in IgG4-positive cells and characteristic storiform fibrosis. Early treatment with glucocorticoids may prevent progression to poorly responsive fibrotic disease.

OBSERVATIONS

A 63-year-old female patient presented with reports of left-sided headaches, nausea, and photophobia in addition to recently diagnosed chronic rhinosinusitis (CRS). Neurological examination revealed dysarthria secondary to left hypoglossal nerve palsy. Computed tomography (CT) revealed a contrast-enhancing extraaxial mass at the left craniocervical junction, CRS with secondary hyperostotic reaction, and multiple hypodense lesions involving the occipital bone. Magnetic resonance imaging revealed a dural-based lesion involving the foramen magnum and invading the left hypoglossal canal. The patient underwent a far-lateral craniotomy. Histopathological analysis revealed severe lymphoplasmacytic inflammation, storiform fibrosis and rich plasma-cell population positive for IgG4. Serum IgG4 was markedly elevated. Total-body CT showed no systemic involvement. The patient was diagnosed with IgG4-RD and was prescribed prednisone, with normalization of her IgG4 levels after 1 month.

LESSONS

IgG4-RD may mimic a variety of diseases, including skull-base meningiomas and CRS. Accurate diagnosis and expedited administration of steroids may prevent unnecessary interventions and progression to treatment-resistant fibrosis.

In Journal of Neurosurgery: Case Lessons Volume 2 (2021): Issue 23 (Dec 2021)

Open access

Increase in clivo-axial angle is associated with clinical improvement in children undergoing occipitocervical fusion for complex Chiari malformation: patient series

Neelan J. Marianayagam, John K. Chae, Ibrahim Hussain, Amanda Cruz, Ali A. Baaj, Roger Härtl, and Jeffrey P. Greenfield

BACKGROUND

The authors analyzed the pre- and postoperative morphometric properties of pediatric patients with complex Chiari malformation undergoing occipitocervical fusion (OCF) to assess clinical outcomes and morphometric properties that might influence postoperative outcomes.

OBSERVATIONS

The authors retrospectively reviewed 35 patients younger than 22 years with Chiari malformation who underwent posterior fossa decompression and OCF with or without endoscopic endonasal odontoidectomy at their institution (13 with and 22 without odontoidectomy). Clivo-axial angle (CXA), pB-C2, atlantodental interval, basion-dens interval, basion-axial interval, and canal diameter at the level of C1 were measured on preoperative and approximately 3-month postoperative computed tomography or magnetic resonance imaging. The authors further stratified the patient cohort into three age groups and compared the three cohorts. The most common presenting symptoms were headache, neck/shoulder pain, and dysphagia; 80% of the cohort had improved clinical outcomes. CXA increased significantly after surgery. When stratified into those who showed postoperative improvement and those who did not, only the former showed a significant increase in CXA. After age stratification, the significant changes in CXA were observed in the 7- to 13-year-old and 14- to 21-year-old cohorts.

LESSONS

CXA may be the most important morphometric predictor of clinical outcomes after OCF in pediatric patients with complex Chiari malformation.

In Journal of Neurosurgery: Case Lessons Volume 2 (2021): Issue 23 (Dec 2021)

Open access

Posterior intraprosthetic dislocation of cervical arthroplasty: illustrative case

Marc Prod’homme, Didier Grasset, and Duccio Boscherini

BACKGROUND

Cervical disc herniation is a common condition usually treated with anterior cervical discectomy and fusion (ACDF) or, more recently, with cervical disc arthroplasty (CDA). Both treatments offer similar clinical results. However, CDA has been found to offer fewer medium- to long-term complications as well as potential reduction of long-term adjacent disc degeneration.

OBSERVATIONS

A 40-year-old man was treated with cervical discectomy and arthroplasty due to a C6–C7 disc herniation with left C7 radiculopathy. After the treatment, his postoperative follow-up appointments were uneventful for 9 months. However, after 9 months, he reported cervical pain and a right C7 radiculopathy after neck extension. Imaging confirmed a posterior intraprosthetic dislocation, the first case reported to date. The patient was received emergency surgery under neuromonitoring, and the prosthesis was replaced by an ACDF and anterior plate. The insert presented a rupture of the anterior horn. The patient presented no preoperative or postoperative neurological deficit, and his follow-up review revealed no issues.

LESSONS

Posterior intraprosthetic dislocation is an extremely rare complication. It may occur with Mobi-C cervical arthroplasty in the case of rupture and oxidation of the polyethylene insert. Spine surgeons should be aware of this potential major complication.

In Journal of Neurosurgery: Case Lessons Volume 2 (2021): Issue 23 (Dec 2021)

Open access

Postoperative spinal subdural hygroma without incidental durotomy: illustrative cases

Garrett Q. Barr and Peter L. Mayer

BACKGROUND

Spinal subdural hygroma (SSH) is a rare pathological entity occurring as a complication of spinal surgery. It is different from spinal subdural hematoma due to blunt trauma, anticoagulation therapy, spinal puncture, and rupture of vascular malformations.

OBSERVATIONS

The authors presented five patients with SSH who received decompression for lumbar stenosis. None had incidental durotomy. All presented postoperatively with unexpectedly severe symptoms, including back and leg pain and weakness. Postoperative magnetic resonance imaging (MRI) revealed SSH with a characteristic imaging finding termed the “flying bat” sign. Four patients underwent evacuation of SSH, with immediate and complete resolution of symptoms in three patients and improvement in one patient. One patient improved without additional surgery. At surgery, subdural collections were found to be xanthochromic fluid in three patients and plain cerebrospinal fluid (CSF) in one patient.

LESSONS

Unexpectedly severe back and leg pain and weakness after lumbar or thoracic spine surgery should raise suspicion of SSH. MRI and/or computed tomography myelography shows the characteristic findings termed the flying bat sign. Surgical evacuation is successful although spontaneous resolution can also occur. The authors hypothesized that SSH is due to CSF entering the subdural space from the subarachnoid space via a one-way valve effect.

In Journal of Neurosurgery: Case Lessons Volume 2 (2021): Issue 23 (Dec 2021)

Open access

Spontaneous intracranial hypotension complicated by diffuse cerebral edema and episodes of severely elevated intracranial pressure: illustrative case

Jeffrey P. Turnbull and Vittorio M. Morreale

BACKGROUND

Spontaneous intracranial hypotension (SIH) is a well-documented condition that typically follows a defined clinical course. Previously published studies describing the pathophysiology of SIH have demonstrated extensive evidence of low intracranial pressure (ICP) driving the clinical features of the condition. Through lumbar puncture and use of intracranial monitoring devices, however, both low and normal cerebrospinal fluid (CSF) pressures have been documented. This report outlined and discussed the unique finding of elevated ICP associated with clinical features of SIH.

OBSERVATIONS

Here, the authors presented a case of a patient with spontaneous spinal CSF leak who developed tonsillar herniation, cerebral edema, and subsequent episodes of elevated ICP. Although more diverse presentations of SIH are being reported, the authors believed the case to be unique because SIH was accompanied by elevated ICP.

LESSONS

This case adds to the growing body of literature surrounding SIH by demonstrating that patients can develop elevated CSF pressures associated with acute encephalopathy.

In Journal of Neurosurgery: Case Lessons Volume 2 (2021): Issue 23 (Dec 2021)

Open access

Can intraoperative electrocorticography be used to minimize the extent of resection in patients with temporal lobe epilepsy associated with hippocampal sclerosis?

Hidenori Sugano, Yasushi Iimura, Hiroharu Suzuki, Samantha Tamrakar, Takumi Mitsuhashi, Takuma Higo, Tetsuya Ueda, Kazuki Nishioka, Kostadin Karagiozov, and Madoka Nakajima

OBJECTIVE

Tailored surgery to extensively resect epileptogenic lesions using intraoperative electrocorticography (ioECoG) may improve seizure outcomes. However, resection of large areas is associated with decreased memory function postoperatively. The authors assessed whether ioECoG could provide useful information on how to minimize the focus resection and obtain better seizure outcomes without memory deterioration. They examined the postoperative seizure-free period and memory alteration in a retrospective cohort of patients with mesial temporal lobe epilepsy (TLE) due to hippocampal sclerosis (HS) in whom the extent of removal was determined using ioECoG findings.

METHODS

The authors enrolled 82 patients with TLE associated with HS who were treated surgically. Transsylvian amygdalohippocampectomy was indicated as the first step. When visual inspection identified interictal epileptic discharges from the lateral temporal lobe on ioECoG, anterior temporal lobectomy (ATL) was eventually performed. The patients were divided into the selective amygdalohippocampectomy (SA, n = 40) and ATL (n = 42) groups. Postoperative seizure outcomes were assessed at 1, 2, 3, 5, and 7 years postoperatively using the International League Against Epilepsy classification. The Kaplan-Meier survival analysis was applied to evaluate the period of seizure recurrence between the SA and ATL groups. Factors attributed to seizure recurrence were analyzed using the Cox proportional hazards model, and they were as follows: epileptic focal laterality; age at seizure onset (< 10 or ≥ 10 years old); seizure frequency (more than weekly or less than weekly seizures); history of focal to bilateral tonic-clonic seizure; infectious etiology; and surgical procedure. The Wechsler Memory Scale–Revised was used to evaluate memory function pre- and postoperatively.

RESULTS

Seizure outcomes were significantly worse in the SA group than in the ATL group at 2 years postoperatively (p = 0.045). The International League Against Epilepsy class 1 outcomes at 7 years postoperatively in the SA and ATL groups were 63% and 81%, respectively. Kaplan-Meier analysis showed that seizure recurred significantly earlier in the SA group than in the ATL group (p = 0.031). The 2-way ANOVA analysis was used to compare the SA and ATL groups in each memory category, and revealed that there was no significant difference regardless of the side of surgery.

CONCLUSIONS

Visual assessment of ioECoG cannot be used as an indicator to minimize epileptic focus resection in patients with TLE associated with HS. ATL is more effective in obtaining seizure-free outcomes; however, both ATL and SA can preserve memory function.

In Journal of Neurosurgery Publish Before Print

Restricted access

Concurrent decompression and resection versus decompression with delayed resection of acutely ruptured brain arteriovenous malformations

Rajeev D. Sen, Isaac Josh Abecassis, Jason Barber, Michael R. Levitt, Louis J. Kim, Richard G. Ellenbogen, and Laligam N. Sekhar

OBJECTIVE

Brain arteriovenous malformations (bAVMs) most commonly present with rupture and intraparenchymal hemorrhage. In rare cases, the hemorrhage is large enough to cause clinical herniation or intractable intracranial hypertension. Patients in these cases require emergent surgical decompression as a life-saving measure. The surgeon must decide whether to perform concurrent or delayed resection of the bAVM. Theoretical benefits to concurrent resection include a favorable operative corridor created by the hematoma, avoiding a second surgery, and more rapid recovery and rehabilitation. The objective of this study was to compare the clinical and surgical outcomes of patients who had undergone concurrent emergent decompression and bAVM resection with those of patients who had undergone delayed bAVM resection.

METHODS

The authors conducted a 15-year retrospective review of consecutive patients who had undergone microsurgical resection of a ruptured bAVM at their institution. Patients presenting in clinical herniation or with intractable intracranial hypertension were included and grouped according to the timing of bAVM resection: concurrent with decompression (hyperacute group) or separate resection surgery after decompression (delayed group). Demographic and clinical characteristics were recorded. Groups were compared in terms of the primary outcomes of hospital and intensive care unit (ICU) lengths of stay (LOSs). Secondary outcomes included complete obliteration (CO), Glasgow Coma Scale score, and modified Rankin Scale score at discharge and at the most recent follow-up.

RESULTS

A total of 35/269 reviewed patients met study inclusion criteria; 18 underwent concurrent decompression and resection (hyperacute group) and 17 patients underwent emergent decompression only with later resection of the bAVM (delayed group). Hyperacute and delayed groups differed only in the proportion that underwent preresection endovascular embolization (16.7% vs 76.5%, respectively; p < 0.05). There was no significant difference between the hyperacute and delayed groups in hospital LOS (26.1 vs 33.2 days, respectively; p = 0.93) or ICU LOS (10.6 vs 16.1 days, respectively; p = 0.69). Rates of CO were also comparable (78% vs 88%, respectively; p > 0.99). Medical complications were similar in the two groups (33% hyperacute vs 41% delayed, p > 0.99). Short-term clinical outcomes were better for the delayed group based on mRS score at discharge (4.2 vs 3.2, p < 0.05); however, long-term outcomes were similar between the groups.

CONCLUSIONS

Ruptured bAVM rarely presents in clinical herniation requiring surgical decompression and hematoma evacuation. Concurrent surgical decompression and resection of a ruptured bAVM can be performed on low-grade lesions without compromising LOS or long-term functional outcome; however, the surgeon may encounter a more challenging surgical environment.

In Journal of Neurosurgery Publish Before Print

Restricted access

Effects of an opioid stewardship program on opioid consumption and related outcomes after multilevel lumbar spine fusion: a pre- and postimplementation analysis of 268 patients

Marie-Jacqueline Reisener, Alexander P. Hughes, Ichiro Okano, Jiaqi Zhu, Artine Arzani, Julianna Kostas, Jennifer Shue, Andrew A. Sama, Frank P. Cammisa, Federico P. Girardi, and Ellen M. Soffin

OBJECTIVE

Opioid stewardship programs combine clinical, regulatory, and educational interventions to minimize inappropriate opioid use and prescribing for orthopedic and spine surgery. Most evaluations of stewardship programs quantify effects on prescriber behavior, whereas patient-relevant outcomes have been relatively neglected. The authors evaluated the impact of an opioid stewardship program on perioperative opioid consumption, prescribing, and related clinical outcomes after multilevel lumbar fusion.

METHODS

The study was based on a retrospective, quasi-experimental, pretest-posttest design in 268 adult patients who underwent multilevel lumbar fusion in 2016 (preimplementation, n = 141) or 2019 (postimplementation, n = 127). The primary outcome was in-hospital opioid consumption (morphine equivalent dose [MED], mg). Secondary outcomes included numeric rating scale pain scores (0–10), length of stay (LOS), incidence of opioid-induced side effects (gastrointestinal, nausea/vomiting, respiratory, sedation, cognitive), and preoperative and discharge prescribing. Outcomes were measured continuously during the hospital admission. Differences in outcomes between the epochs were assessed in bivariable (Wilcoxon signed-rank or Fisher’s exact tests) and multivariable (Wald’s chi-square test) analyses.

RESULTS

In bivariable analyses, there were significant decreases in preoperative opioid use (46% vs 28% of patients, p = 0.002), preoperative opioid prescribing (MED 30 mg [IQR 20–60 mg] vs 20 mg [IQR 11–39 mg], p = 0.003), in-hospital opioid consumption (MED 329 mg [IQR 188–575 mg] vs 199 mg [100–372 mg], p < 0.001), the incidence of any opioid-related side effect (62% vs 50%, p = 0.03), and discharge opioid prescribing (MED 90 mg [IQR 60–135 mg] vs 60 mg [IQR 45–80 mg], p < 0.0001) between 2016 and 2019. There were no significant differences in postanesthesia care unit pain scores (4 [IQR 3–6] vs 5 [IQR 3–6], p = 0.33), nursing floor pain scores (4 [IQR 3–5] vs 4 [IQR 3–5], p = 0.93), or total LOS (118 hours [IQR 81–173 hours] vs 103 hours [IQR 81–132 hours], p = 0.21). On multivariable analysis, the opioid stewardship program was significantly associated with decreased discharge prescribing (Wald’s chi square = 9.45, effect size −52.4, 95% confidence interval [CI] −86 to −19.0, p = 0.002). The number of lumbar levels fused had the strongest effect on total opioid consumption during the hospital stay (Wald’s chi square = 16.53, effect size = 539, 95% CI 279.1 to 799, p < 0.001), followed by preoperative opioid use (Wald’s chi square = 44.04, effect size = 5, 95% CI 4 to 7, p < 0.001).

CONCLUSIONS

A significant decrease in perioperative opioid prescribing, consumption, and opioid-related side effects was found after implementation of an opioid stewardship program. These gains were achieved without adverse effects on pain scores or LOS. These results suggest the major impact of opioid stewardship programs for spine surgery may be on changing prescriber behavior.

In Journal of Neurosurgery: Spine Publish Before Print

Restricted access

High-resolution magnetic resonance vessel wall imaging–guided endovascular recanalization for nonacute intracranial artery occlusion

Zhikai Hou, Long Yan, Zhe Zhang, Jing Jing, Jinhao Lyu, Ferdinand K. Hui, Weilun Fu, Ying Yu, Rongrong Cui, Min Wan, Jia Song, Yongjun Wang, Zhongrong Miao, Xin Lou, and Ning Ma

OBJECTIVE

On the basis of the characteristics of occluded segments on high-resolution magnetic resonance vessel wall imaging (MR-VWI), the authors evaluated the role of high-resolution MR-VWI–guided endovascular recanalization for patients with symptomatic nonacute intracranial artery occlusion (ICAO).

METHODS

Consecutive patients with symptomatic nonacute ICAO that was refractory to aggressive medical treatment were prospectively enrolled and underwent endovascular recanalization. High-resolution MR-VWI was performed before the recanalization intervention. The characteristics of the occluded segments on MR-VWI, including signal intensity, occlusion morphology, occlusion angle, and occlusion length, were evaluated. Technical success was defined as arterial recanalization with modified Thrombolysis in Cerebral Infarction grade 2b or 3 and residual stenosis < 50%. Perioperative complications were recorded. The characteristics of the occluded segments on MR-VWI were compared between the recanalized group and the failure group.

RESULTS

Twenty-five patients with symptomatic nonacute ICAO that was refractory to aggressive medical treatment were consecutively enrolled from April 2020 to February 2021. Technical success was achieved in 19 patients (76.0%). One patient (4.0%) had a nondisabling ischemic stroke during the perioperative period. Multivariable logistic analysis showed that successful recanalization of nonacute ICAO was associated with occlusion with residual lumen (OR 0.057, 95% CI 0.004–0.735, p = 0.028) and shorter occlusion length (OR 0.853, 95% CI 0.737–0.989, p = 0.035).

CONCLUSIONS

The high-resolution MR-VWI modality could be used to guide endovascular recanalization for nonacute ICAO. Occlusion with residual lumen and shorter occlusion length on high-resolution MR-VWI were identified as predictors of technical success of endovascular recanalization for nonacute ICAO.

In Journal of Neurosurgery Publish Before Print