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Ehud Mendel, Eric N. Milefchik, Jamshid Amadi and Peter Gruen

✓ Coccidioidomycosis is an infection originating in the San Joaquin Valley of southern California, but is now seen with increasing frequency throughout southern California and the southwestern United States. A central nervous system involvement is usually manifested as meningitis.

The authors present the case of a young man with pulmonary coccidioidomycosis who developed a brain lesion that proved to be a coccidioidal abscess. This manifestation may now be more frequently seen and therefore should be included in the differential diagnosis of any patient presenting with a brain mass who is from an area in which this disease is endemic.

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Narendra Nathoo, Atom Sarkar, Gandhi Varma and Ehud Mendel

Although nail-gun injuries are a common form of penetrating low-velocity injury, impalement with barbed nails has been underreported to date. Barbed nails are designed to resist dislodgment once embedded, and any attempt at removal may splay open the barbs along the path of entry, with the potential for significant soft-tissue and neurovascular injury. A 25-year-old man sustained a nail impalement of the cervical spine from accidental discharge of a nail gun. The patient was noted to be fully conscious with no neurological deficits. Cervical Zone 2 impalement was noted, with only the head of the nail visible. Angiography revealed the nail lying just anterior to the right vertebral artery (VA), with compression of the vessel. Preoperatively, analysis of a similar nail revealed that orientation of the head determined position of the barbs. A deep neck dissection was then performed to the lateral aspect of the C-3 body, using the nail as a guide. Prior to removal, the nail was turned 180° to change the position of the barbs, to prevent injury to the VA. Nail removal was uneventful. The authors present a simple technique for treatment of a nail-gun injury with a barbed nail. Prior to removal, radiographic analysis of the impaled nail must be performed to determine the presence of barbs. If possible, the surgeon should request a similar nail for analysis prior to surgery. Last, the treating surgeon must have knowledge of the barbs' position at all times during nail removal, to prevent damage to critical structures.

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Novel use of a threadwire saw for high sacral amputation

Technical note and description of operative technique

Robert J. Bohinski, Ehud Mendel and Laurence D. Rhines

✓ The authors describe and demonstrate an innovative modification of the osteotomy procedure required to achieve a supraforaminal high sacral amputation in a patient harboring a large sacral chordoma. Via a combined anterior—posterior approach, three carefully placed threadwire saws were used to create releasing osteotomies through specific portions of the dorsal iliac crests and through the axial midportion of the S-1 vertebral body. The threadwire saws are pulled away from neurovascular and visceral structures, ensuring greater protection. Other advantages include markedly reduced blood loss while performing the osteotomies, a high degree of cutting accuracy, negligible bone loss, and ease and speed of bone cutting.

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Ehud Mendel, Eric N. Milefchik, Jamshid Ahmadi and Peter Gruen

✓ Coccidioidomycosis is an infection originating in the San Joaquim Valley of southern California, but now seen with increasing frequency throughout southern California and the southwestern United States. Central nervous system involvement is usually manifested as meningitis.

The authors present the case of a young man with pulmonary coccidioidomycosis who developed a brain lesion that proved to be a coccidioidomycotic abscess. With the increasing incidence of the disease, this manifestation may be encountered more often and should therefore be included in the differential diagnosis of any patient from an endemic area who presents with a brain mass.

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Doniel Drazin, Ziya L. Gokaslan, Ehud Mendel and J. Patrick Johnson

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Tobias A. Mattei, Michael Higgins, Flynn Joseph and Ehud Mendel

Ectopic extramedullary hematopoiesis (EMH), defined as the formation of blood cells outside the bone marrow, usually occurs in a scenario of chronic anemia when, even after conversion of the bony yellow marrow to red marrow, the body is still unable to meet the demand for red blood cells. Ectopic extramedullary hematopoiesis most commonly occurs in the liver and spleen but may, in fact, occur almost anywhere in the body. Although previous reports have documented EMH presenting as paraspinal masses, such lesions have almost always been associated with a predisposing hematological disorder such as hemolytic anemia, myelofibrosis or myelodysplastic syndromes, thalassemia, polycythemia vera, leukemia, or lymphoma.

The authors of this report describe the first reported instance of EMH in a patient presenting with a symptomatic epidural and paraspinal cervical lesion arising from the posterior spinal elements and no known predisposing hematological disease. Initial radiographs revealed a bony lesion arising posteriorly from the C2–3 laminae and spinous processes. Subsequent imaging suggested the diagnosis, which was confirmed by CT-guided biopsy, peripheral blood smears, and bone marrow aspirate. Despite epidural compression and slight displacement of the cervical cord and thecal sac, the patient's symptoms were limited to pain and diminished cervical range of motion. Therefore, surgery was deferred in favor of nonsurgical therapy. Several alternative modalities for the treatment of EMH have been suggested in the literature, including cytotoxic agents and radiotherapy. The authors opted for an approach utilizing directed low-dose radiotherapy of a total of 25 Gy divided in 2.5-Gy fractions. At the 3-month follow-up, the patient continued to be asymptomatic, and MRI demonstrated a significant reduction in the dimensions of the lesion.

Extramedullary hematopoiesis with spinal cord compression in the absence of a preexisting hematological disorder has not been described in the context of clinical neurosurgical practice. Recognizing that EMH may present as an epidural or paraspinal lesion is important since chemotherapy and radiotherapy are effective therapeutic options in the majority of patients who suffer few if any symptoms. Extensive evaluation for underlying hematological disorders is necessary before undertaking directed therapy. Inadvertent resection of these highly vascularized masses may risk catastrophic intraoperative hemorrhage with no proven benefit as compared with medical treatment, which usually provides excellent long-term outcomes.

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Allen W. Burton, Laurence D. Rhines and Ehud Mendel

Vertebroplasty and kyphoplasty are relatively new techniques used to treat painful vertebral compression fractures (VCFs). Vertebroplasty is the injection of bone cement, generally polymethyl methacrylate (PMMA), into a vertebral body (VB). Kyphoplasty is the placement of balloons (called “tamps”) into the VB, followed by an inflation/deflation sequence to create a cavity prior to the cement injection. These procedures are most often performed in a percutaneous fashion on an outpatient (or short stay) basis. The mechanism of action is unknown, but it is postulated that stabilization of the fracture leads to analgesia. The procedures are indicated for painful VCFs due to osteoporosis or malignancy, and for painful hemangiomas. These procedures may be efficacious in treating painful vertebral metastasis and traumatic VCFs. Much evidence favors the use of these procedures for pain associated with the aforementioned disorders. The risks associated with the procedures are low but serious complications can occur. These risks include spinal cord compression, nerve root compression, venous embolism, and pulmonary embolism including cardiovascular collapse. The risk/benefit ratio appears to be favorable in carefully selected patients. The technical aspects of the procedures are presented in detail along with guidelines for patient selection. A comprehensive review of the evidence for the procedures and the reported complications is presented.

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Stephen J. Hentschel, Ehud Mendel, Sanjay Singh and Laurence D. Rhines

✓ Despite the relatively high incidence of prostate carcinoma involving the spinal column, those that are associated with spinal intradural extramedullary metastases are rare. The role of surgery for metastases to this spinal compartment is limited and palliative because presentation tends to be late in the course of the disease, particularly for prostate carcinoma. It is also considered to be part of the spectrum of leptomeningeal carcinomatosis and is associated with a high incidence of brain metastases. The authors review a rare case of prostate carcinoma metastatic to the spinal intradural extramedullary space and discuss its clinical presentation, imaging features, and surgical management.

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Stephen J. Hentschel, Allen W. Burton, Daryl R. Fourney, Laurence D. Rhines and Ehud Mendel

Object. The purpose of this study was to examine a group of patients with cancer who underwent a vertebroplasty or a kyphoplasty for a vertebral body (VB) fracture, even though the procedure may have been considered contraindicated based on previous reports in the literature.

Methods. The electronic database maintained by the Departments of Neurosurgery and Anesthesiology—Pain Management at the University of Texas M. D. Anderson Cancer Center was searched for patients who underwent vertebroplasty or kyphoplasty between January 2001 and July 2003. The criteria defining a contraindicated procedure were based on a review of the literature. Group I consisted of patients who did not undergo a contraindicated vertebroplasty or kyphoplasty, whereas Group II consisted of patients who underwent one of these procedures even though it may have been considered contraindicated.

There were 53 patients with fractures at 132 levels who met the criteria for the study. Of these, 17 patients with fractures at 18 levels (14% of total) were considered to have undergone a contraindicated vertebroplasty or kyphoplasty (Group II). There were 12 complications (11%) in the 114 levels in Group I and seven complications (39%) in the 18 levels in Group II (p = 0.03). The most common complication was cement extrusion from the anterior VB that did not involve the venous system. No patient required an open surgical procedure to remove extruded cement.

Conclusions. Vertebroplasty and kyphoplasty appear to be safe and effective in the setting of severe back pain caused by VB fracture that is unresponsive to other therapies, even in the presence of relative contraindications to the procedures.

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Mirza N. Baig, Martin Lubow, Phillip Immesoete, Sergio D. Bergese, Elsayed-Awad Hamdy and Ehud Mendel

✓In recent studies spinal surgery has replaced cardiac surgery as a leading cause of postoperative vision loss (POVL). Estimates of the incidence of POVL after spinal surgery range from 0.028 to 0.2%, but with advances in complex spinal instrumentation and the rise in annual spinal operations, POVL may see an ominous increase in its incidence. Postoperative vision loss is an uncommon but devastating complication, with unknown origin and pathogenesis. The authors undertook a literature review and summarize the current understanding of its pathophysiology, highlight the limitations of existing knowledge, and recommend practical guidelines for avoiding this devastating outcome.