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Paul S. Page, Garret P. Greeneway, Simon G. Ammanuel, and Daniel K. Resnick

OBJECTIVE

Lumbar synovial cysts (LSCs) represent a relatively rare clinical pathology that may result in radiculopathy or neurogenic claudication. Because of the potential for recurrence of these cysts, some authors advocate for segmental fusion, as opposed to decompression alone, as a way to eliminate the risk for recurrence. The objective of this study was to create a predictive score for synovial cyst recurrence following decompression without fusion.

METHODS

A retrospective chart review was completed of all patients evaluated at a single center over 20 years who were found to have symptomatic LSCs requiring intervention. Only patients undergoing decompression without fusion were included in the analysis. Following this review, baseline characteristics were obtained as well as radiological information. A machine learning method (risk-calibrated supersparse linear integer model) was then used to create a risk stratification score to identify patients at high risk for symptomatic cyst recurrence requiring repeat surgical intervention. Following the creation of this model, a fivefold cross-validation was completed.

RESULTS

In total, 89 patients were identified who had complete radiological information. Of these 89 patients, 11 developed cyst recurrence requiring reoperation. The Lumbar Synovial Cyst Score was then created with an area under the curve of 0.83 and calibration error of 11.0%. Factors predictive of recurrence were found to include facet inclination angle > 45°, canal stenosis > 50%, T2 joint space hyperintensity, and presence of grade I spondylolisthesis. The probability of cyst recurrence ranged from < 5% for a score of 2 or less to > 88% for a score of 7.

CONCLUSIONS

The Lumbar Synovial Cyst Score model is a quick and accurate tool to assist in clinical decision-making in the treatment of LSCs.

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Jaclyn J. Renfrow, Garret P. Greeneway, Lacey Carter, and Daniel E. Couture

Craniopharyngiomas frequently recur locally or less commonly along the path of prior resection. Ectopic recurrence is rare, although cases are reported along the neuraxis spanning from the subgaleal space down to the S1 nerve root. This case reports on a girl with a history of craniopharyngioma first resected at 23 months of age with two local suprasellar recurrences managed with repeat craniotomy and external beam radiation therapy. At age 14 she complained of worsening headaches and brain MRI demonstrated an enhancing 1.2-cm cystic lesion in the posterior body of the left lateral ventricle. Pathology following endoscopic resection of the lesion was consistent with an adamantinomatous craniopharyngioma. This case report serves to describe the first reported recurrence of a craniopharyngioma in the lateral ventricle and emphasizes the need for a high index of suspicion along with long-term follow-up of patients with a history of craniopharyngioma.

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Paul S. Page, Garret P. Greeneway, Wendell B. Lake, Nathaniel P. Brooks, Darnell T. Josiah, Amgad S. Hanna, and Daniel K. Resnick

OBJECTIVE

Extension fractures in the setting of diffuse idiopathic skeletal hyperostosis (DISH) represent highly unstable injuries. As a result, these fractures are most frequently treated with immediate surgical fixation to limit any potential risk of associated neurological injury. Although this represents the standard of care, patients with significant comorbidities, advanced age, or medical instability may not be surgical candidates. In this paper, the authors evaluated a series of patients with extension DISH fractures who were treated with orthosis alone and evaluated their outcomes.

METHODS

A retrospective review from 2015 to 2022 was conducted at a large level 1 trauma center. Patients with extension-type DISH fractures without neurological deficits were identified. All patients were treated conservatively with orthosis alone. Baseline patient characteristics and adverse outcomes are reported.

RESULTS

Twenty-seven patients were identified as presenting with extension fractures associated with DISH without neurological deficit. Of these, 22 patients had complete follow-up on final chart review. Of these 22 patients, 21 (95.5%) were treated successfully with external orthosis. One patient (4.5%) who was noncompliant with the brace had an acute spinal cord injury 1 month after presentation, requiring immediate surgical fixation and decompression. No other complications, including skin breakdown or pressure ulcers related to bracing, were reported.

CONCLUSIONS

Treatment of extension-type DISH fractures may be a reasonable option for patients who are not candidates for safe surgical intervention; however, a risk of neurological injury secondary to delayed instability remains, particularly if patients are noncompliant with the bracing regimen. This risk should be balanced against the high complication rate and potential mortality associated with surgical intervention in this patient population.

Open access

Cody J. Falls, Paul S. Page, Garret P. Greeneway, Daniel K. Resnick, and James A. Stadler III

BACKGROUND

Noonan syndrome (NS) is a rare genetic RASopathy with multisystem implications. The disorder is typically characterized by short stature, distinctive facial features, intellectual disability, developmental delay, chest deformity, and congenital heart disease. NS may be inherited or arise secondary to spontaneous mutations of genes in the Ras/mitogen activated protein kinase signaling pathways.

OBSERVATIONS

Numerous case reports exist detailing the association between NS and Chiari I malformation (CM-I), although this relationship has not been fully established. Patients with NS who present with CM-I requiring operation have shown high rates reoperation for failed decompression. The authors reported two patients with NS, CM-I, and syringomyelia who had prior posterior fossa decompressions without syrinx improvement. Both patients received reoperation with successful outcomes.

LESSONS

The authors highlighted the association between NS and CM-I and raised awareness that patients with these disorders may be at higher risk for failed posterior fossa decompression, necessitating reoperation.

Open access

Ayman W. Taher, Paul S. Page, Garret P. Greeneway, Simon Ammanuel, Katherine M. Bunch, Lars Meisner, Amgad Hanna, and Darnell Josiah

BACKGROUND

Fractures in patients with diffuse idiopathic skeletal hyperostosis (DISH) are considered highly unstable injuries with high risk for neurological injury. Surgical intervention is the standard of care for these patients to avoid secondary spinal cord injuries. Despite this, certain cases may necessitate a nonoperative approach. Herein within, the authors describe three cases of cervical, thoracic, and lumbar fractures in the setting of DISH that were successfully treated via orthosis.

OBSERVATIONS

The authors present three cases of fractures in patients with DISH. A 74-year-old female diagnosed with an acute fracture of a flowing anterior osteophyte at C6–C7 treated with a cervical orthosis. A 78-year-old male with an anterior fracture of the ankylosed T7–T8 vertebrae managed with a Jewett hyperextension brace. Finally, a 57-year-old male with an L1–L2 disc space fracture treated with a thoraco-lumbo-sacral orthosis. All patients recovered successfully.

LESSONS

In certain cases, conservative treatment may be more appropriate for fractures in the setting of DISH as an alternative to the surgical standard of care. Most fractures in the setting of DISH are unstable, therefore it is necessary to manage these patients on a case-by-case basis.