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Roel H. L. Haeren, Jim Dings, M. Christianne Hoeberigs, Robert G. Riedl and Kim Rijkers

Intraosseous cavernous hemangiomas of the skull are rare lesions for which the origin is unclear. The authors present a case in which there was a radiologically documented history of trauma preceding the development of a hemangioma in the frontal bone.

In a review of the literature the authors found 83 cases of skull hemangiomas, and 43% of the lesions were located in the frontal bone. In 25% of these lesions, previous trauma was reported anamnestically. The present case and radiological findings related to it suggest a causal relationship between trauma and the development of intraosseous hemangioma.

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Kim Rijkers, Jasper van Aalst, Erkan Kurt, Marc A. Daemen, Emile A. M. Beuls and Geert H. Spincemaille

The authors present the case of a 49-year-old female patient with complex regional pain syndrome–Type I (CRPSI) who was suffering from nonhealing wounds and giant bullae, which dramatically improved after spinal cord stimulation (SCS). The scientific literature concerning severe cutaneous manifestations of CRPS-I and their treatment is reviewed. Nonhealing wounds and bullae are rare manifestations of CRPS-I that are extremely difficult to treat. Immediate improvement of both wounds and bullae after SCS, such as in this case, has not been reported previously in literature. Considering the rapidly progressive nature of these severe skin manifestations, immediate treatment, possibly with SCS, is mandatory.

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Erwin M. J. Cornips, Julie Staals, Angela Stavast, Kim Rijkers and Robert J. Van Oostenbrugge

✓ The authors present a rare case of fatal cerebral and cerebellar hemorrhagic infarction following an uneventful thoracoscopic microdiscectomy. They hypothesize that this complication was associated with cortical venous thrombosis secondary to intracranial hypotension, which was caused by an unnoticed leak of cerebrospinal fluid (CSF) into the thoracic cavity. Cortical venous thrombosis and intrathoracic CSF were confirmed at autopsy. The former disorder is the most severe manifestation of the pathophysiological mechanism occurring to a lesser degree in patients affected by mild intracranial hypotension, and occurs more frequently in these patients. Intracranial hypotension (of an orthostatic nature or not) must be considered in the differential diagnosis of every patient who complains of headaches after thoracoscopic or open transthoracic microdiscectomy.

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Inge J. M. H. Caelers, Kim Rijkers, Sander M. J. van Kuijk, Henk van Santbrink, Rob A. de Bie and Wouter L. W. van Hemert

OBJECTIVE

The risk of novel postoperative neurological events due to pedicle screw malpositioning in lumbar fusion surgery is minimized by using one of the several image-guided techniques for pedicle screw insertion. These techniques for guided screw insertion range from intraoperative fluoroscopy to intraoperative navigation. A practical technique consists of anatomical identification of the screw entry point followed by lateral fluoroscopy used for guidance during insertion of the screw. This technique is available in most clinics and is less expensive than intraoperative navigation. However, the safety of lateral fluoroscopy–guided pedicle screw placement with regard to novel postoperative neurological events due to screw malposition has been addressed only rarely in the literature. In this study the authors aimed to determine the rate of novel postoperative neurological events due to intraoperative and postoperatively established screw malpositioning during lateral fluoroscopy–assisted screw insertion.

METHODS

Included patients underwent lateral fluoroscopy–assisted lumbosacral screw insertion between January 2012 and August 2017. The occurrence of novel postoperative neurological events was analyzed from patient files. In case of an event, surgical reports were screened for the occurrence of intraoperative screw malposition. Furthermore, postoperative CT scans were analyzed to identify and describe possible screw malposition.

RESULTS

In total, 246 patients with 1079 screws were included. Novel postoperative neurological events were present in 36 patients (14.6%). In 8 of these 36 patients (3.25% of the total study population), the neurological events could be directly attributed to screw malposition. Screw malpositioning was caused either by problematic screw insertion with immediate screw correction (4 patients) or by malpositioned screws for which the malposition was established postoperatively using CT scans (4 patients). Three patients with screw malposition underwent revision surgery without subsequent symptom relief.

CONCLUSIONS

Lateral fluoroscopy–assisted lumbosacral screw placement results in low rates of novel postoperative neurological events caused by screw malposition. In the majority of patients suffering from novel postoperative neurological events, these events could not be attributed to screw malpositioning, but rather were due to postoperative neurapraxia of peripheral nerves, neuropathy, or intraoperative traction of nerve roots.

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Kim Rijkers, Yasin Temel, Veerle Visser-Vandewalle, Linda Vanormelingen, Marjan Vandersteen, Peter Adriaensens, Jan Gelan and Emile A. M. Beuls

✓High-frequency stimulation of the subthalamic nucleus (STN) is a widely performed method to treat advanced Parkinson disease. Due to the limitations of current imaging techniques, the 3D microanatomy of the STN and its surrounding structures in the mesencephalon are not well known. Using images they obtained using a 9.4-tesla magnetic resonance (MR) imaging unit, the authors developed a 3D reconstruction of the STN and its immediate surroundings. During the postmortem investigation of a human brain, a sample of tissue in the area around the STN was isolated. This brain tissue was scanned in the three orthogonal planes at 1-mm slice thickness. The images generated were compared with photographs of conventionally stained brain tissue slices in different neuroanatomical books, and a 3D reconstruction was made. High-field MR imaging is an appropriate method for visualizing the microanatomy of the STN and its surroundings. The images allow an optimal analysis of the microenvironment of the STN in the three orthogonal planes and can be used for 3D reconstructions of this area with possible clinical applications in the future.