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Erica C. Johnson, Patrick F. O’Brien, and William C. Broaddus

BACKGROUND

The authors report a case of a 66-year-old male who presented acutely with a subdural hematoma who was managed operatively with craniotomy. His course was complicated by a postoperative epidural hematoma, which, on the basis of intraoperative findings at the second surgery, was managed with evacuation of the hematoma and removal of the bone flap.

OBSERVATIONS

The patient’s subsequent recovery was remarkable for a reproducible positional aphasia in the early postoperative period with an ultimate diagnosis of syndrome of the trephined. The patient’s cerebral edema permitted early autologous cranioplasty, which resulted in resolution of the patient’s symptoms.

LESSONS

The authors believe this case to be the first described of isolated positional aphasia as a manifestation of syndrome of the trephined. Recognition and treatment of the syndrome resulted in a positive patient outcome.

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Ketan Verma, Anne H. Freelin, Kelsey A. Atkinson, Robert S. Graham, and William C. Broaddus

OBJECTIVE

The aim of this study was to assess whether flat bed rest for > 24 hours after an incidental durotomy improves patient outcome or is a risk factor for medical and wound complications and longer hospital stay.

METHODS

Medical records of consecutive patients undergoing thoracic and lumbar decompression procedures from 2010 to 2020 were reviewed. Operative notes and progress notes were reviewed and searched to identify patients in whom incidental durotomies occurred. The need for revision surgery related to CSF leak or wound infection was recorded. The duration of bed rest, length of hospital stay, and complications (pulmonary, gastrointestinal, urinary, and wound) were recorded. The rates of complications were compared with regard to the duration of bed rest (≤ 24 hours vs > 24 hours).

RESULTS

A total of 420 incidental durotomies were identified, indicating a rate of 6.7% in the patient population. Of the 420 patients, 361 underwent primary repair of the dura; 254 patients were prescribed bed rest ≤ 24 hours, and 107 patients were prescribed bed rest > 24 hours. There was no statistically significant difference in the need for revision surgery (7.87% vs 8.41%, p = 0.86) between the two groups, but wound complications were increased in the prolonged bed rest group (8.66% vs 15.89%, p = 0.043). The average length of stay for patients with bed rest ≤ 24 hours was 4.47 ± 3.64 days versus 7.24 ± 4.23 days for patients with bed rest > 24 hours (p < 0.0001). There was a statistically significant increase in the frequency of ileus, urinary retention, urinary tract infections, pulmonary issues, and altered mental status in the group with prolonged bed rest after an incidental durotomy. The relative risk of complications in the group with bed rest ≤ 24 hours was 50% less than the group with > 24 hours of bed rest (RR 0.5, 95% CI 0.39–0.62; p < 0.0001).

CONCLUSIONS

In this retrospective study, the rate of revision surgery was not higher in patients with durotomy who underwent immediate mobilization, and medical complications were significantly decreased. Flat bed rest > 24 hours following incidental durotomy was associated with increased length of stay and increased rate of medical complications. After primary repair of an incidental durotomy, flat bed rest may not be necessary and appears to be associated with higher costs and complications.

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Joseph C. Watson, William C. Broaddus, Maurice M. Smith, and Wayne S. Kubal

✓ Myelopathy from cervical spondylosis is often accompanied by hyperreflexia of the upper-extremity deep tendon reflexes (DTRs). Reflexes such as the pectoralis jerk and the deltoid jerk may only be apparent in the context of hyperreflexia. Although the nerve roots involved in the reflex arcs are well described, levels of cervical spinal cord compression that lead to the hyperreflexia are not as clear. This is of particular significance for patients with multilevel cervical spondylosis in determining the levels responsible for their symptoms. The authors examined 15 consecutive patients who presented for treatment of cervical myelopathy. The clinical examination was then correlated with levels of cervical spinal cord compression by cervical magnetic resonance imaging or computerized tomography with intrathecal contrast enhancement. The presence of a prominent pectoralis jerk was seen only in patients with spinal cord compression at the C2–3 and/or C3–4 levels (nine patients). No patient with compression at or below the C4–5 disc space without coexisting compression at a higher level had hyperactive pectoralis reflexes. This association between the C3–4 level and a hyperactive pectoralis reflex was significant (p < 0.004, Fisher's exact test). The deltoid reflex was tested in the last nine consecutive patients. It was present in patients with compression of the upper spinal cord at levels C3–4 and C4–5 (four of five patients) but appeared in only one of four patients with compression below C4–5. This association did not attain statistical significance. The presence of a hyperactive pectoralis reflex is specific for lesions of the upper cervical spinal cord. Examination of upper-extremity DTRs may be helpful in planning the appropriate levels for surgical decompression in patients with multilevel spondylosis and myelopathy.

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John A. Jane, Charles S. Haworth, William C. Broaddus, Joung H. Lee, and Jacek Malik

✓ A technique for exposing far-lateral intervertebral disc herniations without disrupting the facet is described. This technique is a simple modification of the standard neurosurgical approach.

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Johnny B. Delashaw, John A. Persing, William C. Broaddus, and John A. Jane

✓ Skull growth after single suture closure was described in 1851 by Virchow, who noted that growth in the plane perpendicular to a fused suture was restricted. However, this observation failed to predict compensatory growth patterns that produce many of the deformities recognized as features of individual syndromes. The deformities resulting from premature closure of a coronal, sagittal, metopic, or lambdoid suture can be predicted on the basis of the following observations: 1) cranial vault bones that are prematurely fused secondary to single suture closure act as a single bone plate with decreased growth potential; 2) asymmetrical bone deposition occurs mainly at perimeter sutures, with increased bone deposition directed away from the bone plate; 3) sutures adjacent to the prematurely fused suture compensate in growth more than those sutures not contiguous with the closed suture; and 4) enhanced symmetrical bone deposition occurs along both sides of a non-perimeter suture that is a continuation of the prematurely closed suture. These observations regarding growth in craniosynostosis are illustrated with clinical material in this report.

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R. Mark Richardson, Helen L. Fillmore, Kathryn L. Holloway, and William C. Broaddus

Object. Given the success and limitations of human fetal primary neural tissue transplantation, neuronal stem cells (NSCs) that can be adequately expanded in culture have been the focus of numerous attempts to develop a superior source of replacement cells for restorative neurosurgery. To clarify recent progress toward this goal, the transplantation into the adult brain of NSCs, expanded in vitro before grafting, was reviewed.

Methods. Neuronal stem cells can be expanded from a variety of sources, including embryos, fetuses, adult bone marrow, and adult brain tissue. Recent investigations of each of these expanded stem cell types have generated a large body of information along with a great number of unanswered questions regarding the ability of these cells to replace damaged neurons. Expanded NSCs offer many advantages over their primary tissue predecessors, but also may exhibit different functional abilities as grafted cells. Because expanded NSCs will most likely ultimately replace primary tissue grafting in clinical trials, this review was undertaken to focus solely on this distinct body of work and to summarize clearly the existing preclinical data regarding the in vivo successes, limits, and unknowns of using each expanded NSC type when transplanted into the adult brain.

Conclusions. Embryonic stem cell—derived cells have demonstrated appropriate neuronal phenotypes after transplantation into nonneurogenic areas of the adult brain. Understanding the mechanisms responsible for this may lead to similar success with less studied adult neuronal progenitor cells, which offer the potential for autologous NSC transplantation with less risk of tumorigenesis.

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Archana Chidambaram, Helen L. Fillmore, Timothy E. Van Meter, Catherine I. Dumur, and William C. Broaddus

Object

The Wilms tumor 1 (WT1) protein—a developmentally regulated transcription factor—is aberrantly expressed in gliomas and promotes their malignant phenotype. However, little is known about the molecular allies that help it mediate its oncogenic functions in glioma cells.

Methods

The authors used short interfering RNA (siRNA) to suppress WT1 expression in glioblastoma (GBM) cells and evaluated the effect of this on GBM cell invasiveness. Gene expression analysis was then used to identify the candidate genes that were altered as a result of WT1 silencing. One candidate target, CD97, was then selected for further investigation into its role by suppressing its expression using siRNA silencing, followed by proliferation and invasion assays.

Results

WT1 levels were reliably and reproducibly suppressed by siRNA application. This resulted in a significant decrease in cellular invasiveness. Microarray analyses identified the gene products that were consistently downregulated (27) and upregulated (11) with WT1 silencing. Of these, CD97 expression was consistently suppressed across the 3 different GBM cell lines studied and was found on further investigation to significantly impact GBM cell invasiveness.

Conclusions

Although CD97 expression in gliomas has not been described previously, we conclude that the possible upregulation of CD97 mediated by WT1 promotes cellular invasiveness—one of the most characteristic and challenging aspects of glial tumor cells. Further studies are needed to clarify the nature of this regulation and its impact, as CD97 could represent a novel target for antiglioma therapies.

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T. S. Park, William C. Broaddus, Mark Harris, John A. Persing, and John A. Jane

✓ In surgical correction of multiple-suture synostosis, placing the patient in the modified prone position permits access to the calvarium from the supraorbital ridge to the occipital bone below the transverse sinus. The modified prone position thereby enables surgeons to perform cranial remodeling procedures at one stage under direct vision, contributing to improved surgical results. However, no satisfactory head-frame for this position has been available.

The authors report the successful use of a vinyl bag filled with styrofoam beads to achieve the modified prone position in young children. This widely available, economical device provides a safe, reliable means of positioning the child's head for cranial remodeling procedures.

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Gary W. Tye, R. Scott Graham, William C. Broaddus, and Harold F. Young

Object. Bone grafts used in anterior cervical fusion (ACF) may subside postoperatively. The authors reviewed a recent series in which instrument-assisted ACF was performed to determine the degree of subsidence with respect to fusion length, use of segmental screws, and patient smoking status, age, and sex.

Methods. Charts and implant records were reviewed for all 70 patients who underwent instrument-assisted ACF during a 2-year period. The procedures, grafting materials, plate types/lengths, and patient smoking status were recorded. The immediate postoperative and follow-up lateral radiographs were analyzed. The plate lengths and lengths of the fused segments were measured in a standardized fashion.

The mean intraoperative and follow-up fusion segment lengths were 54.3 and 51.9 mm, respectively. Greater subsidence occurred in multilevel fusions than in single-level fusions. There were noticeable changes in the position of plates or screws on 14 of 70 follow-up x-ray films. No new neurological deficits related to graft subsidence occurred, and the reoperation rate was 3%. There was no statistical relation between subsidence and the following variables: segmental fixation, smoking status, sex, age, or dowel size when corrected for length of the plate. Hardware migration correlated significantly with plate length in cases of two- and three-level fusions.

Conclusions. The length of a fusion segment decreases in the immediate weeks following instrument-assisted ACF. Construct length is the most important determinant of subsidence. When designing multilevel cervical constructs, consideration of the effects of graft subsidence may help to avoid hardware-related complications.

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Ann M. Ritter, Barbara H. Amaker, R. Scott Graham, William C. Broaddus, and John D. Ward

✓ Leiomyosarcomas (LMSs) of the central nervous system are extremely rare; however, they are becoming more prevalent in immunocompromised patients. The authors present the cases of two patients with acquired immunodeficiency syndrome: one with LMS of the thoracic vertebral body and the other with LMS originating from the region of the cavernous sinus. The epidemiological and histological characteristics of LMS and its association with latent Epstein—Barr virus are discussed, as well as the treatments for this neoplasm.