Seizure Prophylaxis in Traumatic Brain Injury: A Comparative Study of Levetiracetam and Phenytoin Cerebrospinal Fluid Levels in Trauma Patients with Signs of Increased Intracranial Pressure Requiring Ventriculostomy

Background

One of the most common life-threatening injuries to trauma patients arriving in the emergency department (ED) is traumatic brain injury (TBI). Traditionally, intravenous medications have been given as seizure prophylaxis in patients demonstrating signs of increased intracranial pressure (ICP), as post-traumatic seizures in trauma patients are associated with higher morbidity and mortality. Medications traditionally given for this indication such as phenytoin have been established to reach therapeutic levels in the cerebrospinal fluid (CSF) quickly and are effective in preventing post-traumatic seizures but often have a large side-effect profile. A newer medication that is being used for seizure prophylaxis in patients with epilepsy is levetiracetam. Levetiracetam typically has a better side effect profile, but it has not been demonstrated that the drug reaches therapeutic levels in the CSF as quickly as phenytoin. Studies have shown levetiracetam and phenytoin to be equivocal in the prevention of post-TBI seizure prophylaxis.

Methods

This was a prospective, randomized, case-control study at a Level II trauma center of adult patients (age >/= 18 years) who suffered severe TBI (sTBI) requiring the placement of an external ventricular drain (EVD) from May 2017 to June 2018. Twelve patients were randomly placed into one of two groups for the administration of antiepileptic medication (either levetiracetam or phenytoin), allowing for the subsequent serial collection of CSF for the analysis of therapeutic levels of antiepileptic medications. Levetiracetam or phenytoin was administered at standardized fixed doses per our neurosurgical center standard protocol. CSF was collected before either drug was administered, 60 minutes after completion of administration and 360 minutes after completion of drug administration. Data analysis was performed to compare the time frame for which therapeutic levels of the medications were achieved in the CSF. The published steady-state and therapeutic CSF level of levetiracetam is 32 mcg/ml and phenytoin is 2 mcg/ml.

Results

A trend was observed in which the closer the fixed dosage approximated the weight-based dosing of phenytoin, the more their CSF phenytoin level increased (and approximated the therapeutic range) with an associated R-squared value of 0.6274. This trend was not found in patients receiving levetiracetam.

Conclusions

Levetiracetam does not reach levels needed for seizure prophylaxis in human CSF when loaded at standard dosing regimens in the acute setting. Phenytoin does reach levels needed for seizure prophylaxis in human CSF with standardized regimen dosing when dosages approximate weight-based dosing. If needed, in the acute setting phenytoin should have additional doses given prior to six hours after the loading dose to achieve therapeutic CSF levels. 

Impressions of Osteopathic Neurosurgeon on Preparedness for Practice: Survey Results from the American College of Osteopathic Surgeons

Introduction Neurosurgeons trained in the US are rigorously educated on the surgical management of neurosurgical conditions. These neurosurgeons have been trained through one of two avenues: the Accreditation Council for Graduate Medical Education (ACGME) or the American Osteopathic Association (AOA). With the formation of a single accreditation system from the AOA and ACGME accrediting bodies and significant changes introduced in the training of neurosurgeons from both bodies, we sought to identify common practice parameters and perceptions of preparedness of AOA-trained neurosurgeons. Methods  A survey was conducted through the neurosurgery section of the American College of Osteopathic Surgeons (ACOS), requesting responses from attending neurosurgeons who completed AOA neurosurgery residency. Responses were obtained through an anonymous, web-based system using single-select multiple-choice questions. Results  In total, 52 neurosurgeons participated in the survey. The majority of the 52 respondents practiced in non-academic settings in urban areas and were exposed to a wide variety of practice environments in terms of case volume and clinical responsibilities. Significantly, 96.15% of the respondents said they felt adequately prepared for neurosurgical practice after their AOA training.  Conclusion  Overall, this study highlights both the similarities and variances in practices of osteopathic neurosurgeons. The majority of the participants feel that their training has appropriately prepared them for practice and they are skilled surgeons capable of caring for the safety and well-being of numerous patients in a variety of settings. Most of them practice primarily in private-practice settings at urban centers. Overall, osteopathic neurosurgeons trained in AOA programs report that their training has equipped them well for careers in neurosurgery.

Prevalence of Catheter-Associated Urinary Tract Infections in Neurosurgical Intensive Care Patients - The Overdiagnosis of Urinary Tract Infections

Background: Hospital-acquired infections (HAIs) are profound causes of prolonged hospital stay and worse patient outcomes. HAIs pose serious risks, particularly in neurosurgical patients in the intensive care unit, as these patients are seldom able to express symptoms of infection, with only elevated temperatures as the initial symptom. Data from Center for Disease Control (CDC) and the Infectious Disease Society of America (IDSA) have shown that of all HAIs, urinary tract infections (UTIs) have been grossly over-reported, resulting in excessive and unnecessary antibiotic usage.

Methods: We conducted a retrospective analysis of 686 adult patients that were evaluated by the neurosurgery service at Arrowhead Regional Medical Center between July 2018 and March 2019. Inclusion criteria were adults greater than 18 years of age with neurosurgical pathology requiring a minimum of one full day admission to the intensive care unit (ICU), and an indwelling urinary catheter. Exclusion criteria were patients under the age of 18, those who did not spend any time in the ICU, or with renal pathologies such as renal failure.

Results: We reviewed 686 patients from the neurosurgical census. In total, 146 adult patients with indwelling urinary catheters were selected into the statistical analysis. Most individuals spent an average of 8.91 ± 9.70 days in the ICU and had an indwelling catheter for approximately 8.14 ± 7.95 days. Forty-two out of the 146 individuals were found to have a temperature of 100.4°F or higher. Majority of the patients with an elevated temperature had an infectious source other than urine, such as sputum (22 out of 42, 52.38%), blood (three out of 42, 7.14%) or CSF (one out of 42, 2.38%). We were able to find only two individuals (4.76%) with a positive urine culture and no evidence of other positive cultures or deep vein thrombosis.

Conclusions: Our analysis shows evidence to support the newest IDSA guidelines that patients with elevated temperatures should have a clinical workup of all alternative etiologies prior to testing for a urinary source unless the clinical suspicion is high. This will help reduce the rate of unnecessary urine cultures, the over-diagnosis of asymptomatic bacteriuria, and the overuse of antibiotics. Based on our current findings, all potential sources of fever should be ruled out prior to obtaining urinalysis, and catheters should be removed as soon as they are not needed. Urinalysis with reflex to urine culture should be reserved for those cases where there remains a high index of clinical suspicion for a urinary source.

Effectiveness of Method of Repair of Incidental Thoracic and Lumbar Durotomies: A Comparison of Direct Versus Indirect Repair

Introduction

Incidental durotomy (ID) is a well-known complication in spine surgery. Surveys have not identified a consensus for repair method among neurosurgeons. IDs may lead to complications such as cerebrospinal fluid (CSF) fistula, which may predispose patients to infection, additional procedures, increased length of stay and morbidity. This study aims to compare durotomy repair methods with clinical outcomes.

Methods

The neurosurgery database at a single institution, Arrowhead Regional Medical Center, was screened for all patients who underwent thoracic and lumbar spine surgery from 2007-2017. Retrospective chart review of operative reports identified patients with an ID. Data collection included: length of stay, infection, additional procedures, time lying flat, CSF fistula formation (primary endpoint) with analysis using t-tests.

Results

A total of 384 patients underwent initial analysis. Of the 384 patients, 25 had an incidental durotomy based on operative reports. Four patients were excluded from this subset: two were repaired with muscle graft (low N), two were excluded for unclear repair method. The remaining 21 were stratified into two groups, those repaired directly with suture with or without adjunct (N=9) and those repaired indirectly with sealant (N=12). No patients developed a CSF fistula. The indirect group had a length of stay of six days, while the direct group had a length of stay of four days, p=0.184. Two of the nine patients in the direct group and two of the twelve patients in the indirect group developed an infection, p=0.586.

Conclusion

No patients developed CSF fistulas. Secondary endpoints of length of stay and infection rate did not differ. This study was unable to determine if direct versus indirect repair was a more effective repair method for ID. It is possible that if an incidental durotomy is identified and repaired with a water-tight seal, the repair method does not affect the outcome. It is up to the surgeon to individualize repair based on ability and circumstances.

Tight Control of Systolic Blood Pressure in Spontaneous Intraparenchymal Brain Hemorrhage

Background Tight blood pressure control is critical in neurosurgical patients. Systolic blood pressure (SBP) must be low enough to avoid injury and minimize intraparenchymal hemorrhage (IPH) but high enough to maintain cerebral perfusion. American Heart Association (AHA) guidelines recommend SBP <140 in intracerebral hemorrhage. This paper sought to elucidate the effect of early control of SBP on IPH expansion. Methods 134 patients with spontaneous IPH between 2011 and 2015 were analyzed utilizing chart review. Initial versus follow-up bleed size, presentation and discharge condition, discharge disposition, and blood pressure control adequacy were analyzed using the generalized linear model. Results Altered mental status was the most common presenting complaint (78%). Presenting GCS failed to demonstrate a significant main effect. Age, initial IPH volume, presenting SBP, and one-hour SBP significantly affected IPH percent expansion (p=0.002, =0.002, <0.0005, and =0.026). Several two-way interactions affected IPH percent change implying synergistic effects of the predictor variables. Conclusion Patients aged 60-70 years had the largest percent IPH expansion followed by patients aged 20-30 years. Initial IPH volume of 65.23-78.26 ml showed the largest expansion. Initial IPH volume of 52.18-65.22 ml demonstrated the least percentage of IPH expansion. One-hour control of SBP to binned groups of 111-121 mmHg or 121-132 mmHg portends relative minima in bleed expansion corresponding with AHA recommendations for IPH patients. This study suggests that this degree of early and aggressive control of SBP is achievable, safe, and may minimize IPH expansion. Future studies are needed to elucidate the role of co-morbidities and to confirm these findings in broader populations.

Efficacy of Trauma Catheter and Mushroom Tip Catheter in Evacuation of Chronic Subdural Hematoma and Complications of Drain Placement

Objective The aim of this study was to assess the efficacy and complications of trauma catheter versus mushroom tip catheter placement in the evacuation of chronic subdural hematoma via twist drill craniostomy with closed system drainage. Background Chronic subdural hematoma (cSDH) is one of the most frequent neurosurgical pathologies in patients >70 years of age with an estimated incidence of 8.2 per 100,000 people per year. The most common risk factors for cSDH are advanced age, alcohol abuse, seizures, cerebrospinal fluid (CSF) shunts, coagulopathies, blood thinners, and patients at risk for falling. Twist drill craniostomy can be performed at the bedside under local anesthesia, making it an attractive treatment option, especially in poly-morbid patients who are poor surgical candidates. A closed drainage system is placed at the time of surgery to allow continuous drainage and promote postoperative brain expansion. Despite the increasing prevalence, limited literature exists to guide surgical management, particularly in terms of drain management and selection of catheter.  Methods This is a retrospective review of 205 patients from January 2007 to May 2017 at two-level high volume centers for the evaluation and treatment of cSDH. Inclusion criteria include patients >18 years of age with the radiographic presence of a subdural hematoma for greater than three weeks. All patients were managed with either a trauma catheter or mushroom tip catheter. All patients received computed tomography (CT) of the head without contrast prior to subdural drain placement and within 24 hours after subdural drain removal. Exclusion criteria include patients <18 years of age and patients with depressed skull fractures, vascular malformations, subdural empyema, subdural hygroma, or who initially underwent open craniotomy or burr-hole craniotomy. Results Drain efficiency in evacuating the cSDH was assessed using both radiographic and clinical markers. Analysis of 205 patients treated by twist drill craniostomy and the subsequent closed system drainage utilizing either the mushroom tip catheter or trauma catheter revealed that neither catheter was superior in producing a statistically significant change in the maximum thickness of the cSDH (p = 0.35) and midline shift (p = 0.45). Furthermore, when assessing patients clinically via utilization of the Glasgow Coma Scale (GCS), both the trauma catheter and the mushroom catheter did not show a statistically significant difference in improving GCS after the evacuation of the cSDH (p = 0.35). Neither catheter was associated with an increased incidence of hemorrhage with drain placement requiring open surgery (p = 0.12), need for additional drain placement (p = 0.13) or decline in GCS with intervention (p = 0.065). Conclusion Analysis of the 205 patients treated by twist drill craniostomy with closed system drainage for the evacuation of chronic subdural hematoma utilizing either the mushroom tip or trauma catheters revealed that neither catheter was statistically significant in radiographic or clinical improvement in evacuating cSDH. Furthermore, neither catheter was found to be associated with an increased complication risk.

The Use of Computed Tomography Perfusion on Admission to Predict Outcomes in Surgical and Nonsurgical Traumatic Brain Injury Patients

Introduction: The objective of this study was to investigate if data obtained from a computed tomography (CT) perfusion study on admission could correlate to outcomes for the patient, including the patient’s length of stay in the hospital and their initial and final Glasgow Coma Scale (GCS), as well as the modified Rankin Scale (mRS) on discharge. We present an initial subset of patients fulfilling the inclusion criteria: over the age of 18 with mild, moderate, or severe traumatic brain injury (TBI). Patients admitted with a diagnosis of TBI had CT perfusion studies performed within 48 hours of admission. GCS, length of stay, mRS, and discharge location were tracked, along with the patient’s course of hospitalization. Initial results and discussion on the utility of CT perfusion for predicting outcomes are presented.

Methods: Patients exhibiting mild, moderate, or severe TBI were assessed using CT perfusion within 48 hours of admission from January to July 2019 at the Arrowhead Regional Medical Center (ARMC). The neurosurgery census and patient records were assessed for progression of outcomes. Data obtained from the perfusion scans were correlated to patient outcomes to evaluate the utility of CT perfusion in predicting outcomes in surgical and nonsurgical TBI patients.

Results: Preliminary data were obtained on six patients exhibiting TBI, ranging from mild to severe. The mean GCS of our patient cohort on admission was eight, with the most common mechanism of injury found to be falls (50%) and motor vehicle accidents (50%). Cerebral blood volume (CBV) seemed to increase with Rankin value (Pearson's correlations coefficient = 0.43 but was statistically insignificant (P = 0.21)). Cerebral blood flow (CBF) was found to be correlated with CBV, and both increased with Rankin score (Pearson's correlation coefficient = 0.56) but were statistically insignificant (P = 0.27). These results suggest that with a larger sample size, CBV and CBF may be correlated to patient outcome.

Conclusion: Although more data is needed, preliminary results suggest that with larger patient populations, CT perfusion may provide information that can be correlated clinically to patient outcomes. This study shows that CBF and CBV may serve as useful indicators for prognostication of TBI patients.

Minimization of Intraparenchymal Hemorrhagic Stroke Size by Optimization of Serum Lipids

Introduction

Intraparenchymal hemorrhages (IPHs) are the most common type of hemorrhagic stroke. One of the main associated risk factors is total cholesterol (TC) above 200. A severely decreased level of TC potentially interferes with the stabilization of the cell membrane and can potentially lead to a larger hemorrhage. Previous population-based studies have confirmed an association between low TCs and a high incidence of hemorrhagic stroke. It has been established that a TC below 200 decreases the potential for cardiovascular disease. This study suggests that the balance that needs to be achieved between these two extremes presents a unique possibility for an optimal therapeutic range of total cholesterol levels.

Materials & methods

Inclusion criteria included all adult patients with International Classification of Diseases (ICD)-9/10 code for hemorrhagic stroke, from June 2007 to June 2017. A total of 300 patients met the criteria (N=300). For each patient, the following data were collected: NIH Stroke Scale, TC level, triglyceride level, low-density lipoprotein (LDL) and high-density lipoprotein (HDL), cholesterol reducing medications, size of hemorrhage on computed tomography (CT) of the head, location of hemorrhage, and patient disposition. Statistical analysis was done using the Generalized Linear Modeling with Wald Chi-square as the statistical determinant.

Results

Intracerebral hemorrhage size is dependent on the intracranial location with brain lobes having larger bleeds. Minimum hemorrhage size was noted in TC 188-196 and this effect was statistically significant independent of location. HDL has a significant independent effect on hemorrhage size with overall minimum bleed occurring in the range of 43-51 mg/dL HDL (98-106 mg/dL for men and 43-51 mg/dL for women). This sex effect within HDL on hemorrhage size is statistically significant. There was a differential effect of HDL dependent on patient race. Asian and black patients had least IPH volume with HDL 70-79 mg/dL, while Hispanic patients had a minimum at 43-51 mg/dL. White patients required a higher HDL, 80-88 mg/dL to minimize the IPH size. The triglyceride level had a statistically significant independent effect on the bleed size with the minimum hemorrhage size occurring in the range of 205-224 mg/dL. This effect was nuanced by patient race with statistically significant minimum IPH size occurring at 144-164 mg/dL for white patients, 124-143 mg/dL for Hispanic and black patients, and 84-103 mg/dL for Asian patients. Post-hospital patient disposition was not significantly affected by any of the above predictor variables.

Conclusion

This study found TC, HDL and triglycerides in specific ranges are associated with significantly decreased hemorrhage size across all genders and hemorrhage locations. The ranges with the strongest hemorrhage-limiting effect are as follows: TC 188-196 mg/dL, HDL 43-51 mg/dL (98-106 mg/dL for men and 43-51 mg/dL for women), triglycerides 205-224 mg/dL. Lipids both below and above these ranges yield larger bleeds. It also found larger brain areas will have more extensive hemorrhage than smaller brain areas. Future work in this arena should include collaboration with cardiology to determine ideal ranges for both cardio- and neuroprotection as well as a prospective study to validate the applicability of these findings in patient care.

Inflammatory Markers and Severity of Intracerebral Hemorrhage

Background and purpose

The pathogenesis of brain injury after intracerebral hemorrhage is thought to be due to mechanical damage followed by ischemic, cytotoxic, and inflammatory changes in the underlying and surrounding tissue.In recent years, there has been a greater research interest into the various inflammatory biomarkers and growth factors that are secreted during intracerebral hemorrhage. The biomarkers investigated in this study are tumor necrosis factor alpha (TNF alpha), C-reactive protein (CRP), homocysteine (Hcy), and vascular endothelial growth factor (VEGF). The aim of this study was to further investigate the effects of these biomarkers in predicting the acute severity outcome of intracerebral hemorrhage (ICH).

Methods

We conducted a retrospective chart review of patients with spontaneous ICH with TNF alpha, CRP, VEGF, and Hcy levels drawn on admission. Forty-two patients with spontaneous ICH with at least one of the above labs were included in the study. Primary outcomes included death, Glasgow Coma Scale (GCS) on admission, early neurologic decline (END), and hemorrhage size. Secondary outcomes included GCS on discharge, ICH score, functional outcome risk stratification scale of intracerebral hemorrhage (FUNC score), change in hemorrhage size, need for surgical intervention, and length of intensive care unit (ICU) stay.

Results

Forty-two patients with spontaneous intracerebral hemorrhage (ICH) were analyzed, 12 patients (28.5%) required surgical intervention, and four patients (9.5%) died. Only low VEGF serum values were found to predict mortality. TNF alpha, CRP, Hcy, and VEGF levels in our patients with ICH were not found to predict early neurologic decline and were not correlated with GCS on admission, initial hemorrhage size, change in hemorrhage size, need for surgical intervention, ICH score, FUNC score, midline shift, and length of ICU stay. CRP and Hcy were elevated in 58% and 31% of patients tested, respectively. GCS on admission and ICH score were significantly associated with mortality.

Conclusion

After careful statistical review of the data obtained from this patient population, only low VEGF values were found to be a significant predictor of mortality. However, elevated CRP and Hcy levels were associated with a non-significant trend in hemorrhage size and mortality suggesting that CRP and Hcy-lowering therapies may decrease hemorrhagic stroke risk and severity.

Novel Method of Non-contact Remote Measurement of Neuronal Electrical Activity

Measuring the electrical potential of a neuron cell currently requires direct contact with the cell surface. This method requires invasive probing and is limited by the deflection of electricity from baseline. From a clinical perspective, the electrical potential of the brain's surface can only be measured to a depth of one centimeter using an electroencephalogram (EEG), however, it cannot measure much deeper structures. In this trial, we attempt a novel method to remotely record the electromagnetic field (EMF) of action potential provoked from hippocampal neurons without contact.

A bipolar stimulating electrode was placed in contact with the CA1 region of viable hippocampal slice from donor mice. The specimen was bathed in artifical cerebrospinal fluid (aCSF) to simulate in vivo conditions. This setup was then placed into a magnetic shielded tube. Very low-frequency EMF sensors were used to obtain recordings. The impedance of the aCSF and hippocampal slice were measured after each stimulation individually and in combination.

An electromagnetic signal was detected in three out of four scenarios: (a) aCSF alone with electrical stimulus without a hippocampal slice, (b) Hippocampal slice in aCSF without electrical stimulus and, (c) Hippocampal slice in aCSF with an electric stimulus applied. Therefore, our trial suggests that EMFs from neuronal tissue can be recorded through non-invasive non-contact sensors.

The neurosurgical wound and factors that can affect cosmetic, functional, and neurological outcomes

Surgically accessing pathological lesions located within the central nervous system (CNS) frequently requires creating an incision in cosmetic regions of the head and neck. The biggest factors of surgical success typically tend to focus on the middle portion of the surgery, but a vast majority of surgical complications tend to happen towards the end of a case, during closure of the surgical site incisions. One of the most difficult complications for a surgeon to deal with is having to take a patient back to the operating room for wound breakdowns and, even worse, wound or CNS infections, which can negate all the positive outcomes from the surgery itself. In this paper, we discuss the underlying anatomy, pharmacological considerations, surgical techniques and nutritional needs necessary to help facilitate appropriate wound healing. A successful surgery begins with preoperative planning regarding the placement of the surgical incision, being cognizant of cosmetics, and the effects of possible adjuvant radiation therapy on healing incisions. We need to assess patient's medications and past medical history to make sure we can optimise conditions for proper wound reepithelialisation, such as minimizing the amount of steroids and certain antibiotics. Contrary to harmful medications, it is imperative to optimise nutritional intake with adequate supplementation and vitamin intake. The goals of this paper are to reinforce the mechanisms by which surgical wounds can fail, leading to postoperative complications, and to provide surgeons with the reminder and techniques that can help foster a more successful surgical outcome.

Severe Traumatic Brain Injury Requiring Surgical Decompression in the Young Adult: Factors Influencing Morbidity and Mortality - A Retrospective Analysis

INTRODUCTION

Severe traumatic brain injury (TBI) is a leading cause of morbidity and mortality among young adults. The clinical outcome may also be difficult to predict. We aim to identify the factors predictive of favorable and unfavorable clinical outcomes for youthful patients with severe TBI who have the option of surgical craniotomy or surgical craniectomy.

METHODS

A retrospective review at a single Level II trauma center was conducted, identifying patients aged 18 to 30 years with isolated severe TBI with a mass-occupying lesion requiring emergent (< 6 hours from time of arrival) surgical decompression. Glasgow Coma Scale (GCS) score on arrival, type of surgery performed, mechanism of injury, length of hospital stay, Glasgow Outcome Score (GOS), mortality, and radiographic findings were recorded. A favorable outcome was a GOS of four or five at 30 days post operation, while an unfavorable outcome was GOS of 1 to 3.

RESULTS

Fifty patients were included in the final analysis. Closed head injuries (skull and dura intact), effacement of basal cisterns, disproportional midline shift (MLS), and GCS 3-5 on arrival all correlated with statistically significant higher rate of mortality and poor 30-day functional outcome. All mortalities (6/50 patients) were positive for each of these findings.

CONCLUSIONS

Closed head injuries, the presenting GCS 3-5, the presence of MLS disproportional to the space occupying lesion (SOL), and effacement of basal cisterns on the initial computed tomography of the head all correlated with unfavorable 30-day outcome. Future prospective studies investigating a larger cohort may provide further insight into patients suffering from severe TBI.

Posterior-only Stabilization for Traumatic Thoracolumbar Burst Fractures

Background

No consensus exists for the management of unstable thoracolumbar (TL) burst fractures. Surgical options include anterior, lateral, or posterior stabilization (or a combination), depending on the fracture. The potential benefits of anterior reconstruction come with increased operative time and associated morbidity. A posterior-only approach can offer stable correction without increased operative risks but may result in loss of kyphotic correction over time.

Purpose

To determine whether posterior-only stabilization is a viable treatment option for patients with traumatic TL fractures as opposed to anterior and combined approaches.

Methods

We performed a retrospective analysis of adult patients with TL burst fractures who underwent posterior­-only surgical intervention from 2005 to 2015. Operations were performed at two levels above and below the fractured segment using pedicle screw-rod fixation constructs with autograft and allograft. All patients received TL bracing for at least three months. Patients lost to follow­up were excluded.

Results

Sixty-four consecutive patients with posterior­-only stabilization were identified, with 18 lost to follow­up. Of the remaining 46 patients, 93% (n=43) were male and 7% (n=3) were female, with a mean age of 36.8 years. All patients were followed for 12 months. The mean time until the removal of the brace was 3.54 months. No patients required additional surgical intervention for spinal stabilization. Three patients experienced postoperative complications, all of which were related to infection.

Conclusions

Our data indicate that posterior­-only stabilization for traumatic TL burst fractures is a durable and effective option in select patients. The approach offers surgical intervention with a decreased perioperative risk as well as reduced morbidity and mortality, with a minimal increase in the risk of kyphotic deformity. Further prospective studies are necessary to validate these findings clinically.

Unusual Metastasis of Papillary Thyroid Cancer to the Thoracic Spine: A Case Report, New Surgical Management Proposal, and Review of the Literature

Papillary thyroid carcinoma (PTC) is significantly more common than follicular thyroid carcinoma (FTC), yet FTC has a much higher tendency to metastasize to the spinal column. We present a rare case of a metastatic thoracic spinal column lesion originating from the PTC. Thyroid carcinoma is known to be highly vascular with a significant tendency to hemorrhage during surgical resection. This increased tendency to hemorrhage leads to unanticipated intraoperative risks when the type of cancer is not diagnosed before surgical resection. Complications related to intraoperative bleeding can be prevented by visualization using angiography and preoperative embolization. The type of cancer is ideally diagnosed before tumor resection either by the standard metastatic workup or histologically after the biopsy. However, limitations exist in these methods, therefore, hypervascular tumors such as metastatic thyroid cancer can go undiagnosed until after surgical resection. In addition to our case report, we present a review of the literature regarding diagnostic and treatment strategies for hypervascular thyroid tumors and propose a new algorithm for the surgical management of spinal tumors with an unknown origin for optimization of preoperative and perioperative care.

Minimally Invasive Surgical Techniques for Management of Painful Metastatic and Primary Spinal Tumors

Patients with metastatic spinal disease are affected by disabling pain. The treatment of spinal metastases is focused on pain reduction and improvement in quality of life. Until recently, many patients with metastatic spinal disease did not qualify as surgical candidates due to the risks of surgery and length of recovery period. However, recent advances in minimally invasive surgery such as kyphoplasty and vertebroplasty allow patients to safely undergo surgery for pain relief with a short recovery period.

The studies reviewed here suggest that vertebral augmentation is successful in reducing pain and disability scores in patients with painful metastases and multiple myeloma and are a safe modality to provide lasting pain relief. As the use of kyphoplasty and vertebroplasty for treatment of vertebral metastases is becoming more common, new combinations of cement augmentation with other techniques such as percutaneous pedicle screws and radiofrequency ablation are being explored. The implementation of kyphoplasty and vertebroplasty, in conjunction with other minimally invasive surgical techniques as well as nonsurgical modalities, may lead to the best palliative management of cancer patients with spinal metastases and help them ultimately achieve a better quality of life.

Histoplasmosis with Deep CNS Involvement: Case Presentation with Discussion and Literature Review

Central nervous system (CNS) histoplasmosis is rare and difficult to diagnose because it is often overlooked or mistaken for other pathologies due to its nonspecific symptoms. A 32-year-old Hispanic man with advanced acquired immunodeficiency virus presented with altered mental status and reported confusion for the past 3 months. He had a Glasgow Coma Scale of 12, repetitive nonfluent speech, and a disconjugate gaze with a right gaze preference. Lung computed tomography (CT) findings indicated a pulmonary histoplasmosis infection. Magnetic resonance imaging of the brain revealed a ring-enhancing lesion in the left caudate nucleus. A CT-guided left retroperitoneal node biopsy was performed and indicated a benign inflammatory process with organisms compatible with fungal yeast. Treatment with amphotericin B followed by itraconazole was initiated in spite of negative cerebrospinal fluid (CSF) cultures and proved effective in mitigating associated CNS lesions and resolving neurologic deficits. The patient was discharged 3 weeks later in stable condition. Six weeks later, his left basal ganglia mass decreased. Early recognition of symptoms and proper steps is key in improving outcomes of CNS histoplasmosis. Aggressive medical management is possible in the treatment of intracranial deep mass lesions, and disseminated histoplasmosis with CNS involvement can be appropriately diagnosed and treated, despite negative CSF and serology studies.

Supratentorial primitive neuroectodermal tumor in an adult: a case report and review of the literature

INTRODUCTION

Supratentorial primitive neuroectodermal tumors predominantly occur in children, and are rare in the adult population. Less than 100 cases of supratentorial primitive neuroectodermal tumor have been reported in adults internationally. Our case study reports this rare incident.

CASE PRESENTATION

A 22-year-old Hispanic man presented with headaches, blurry vision, diplopia, intermittent vomiting, and grossly decreased vision. A magnetic resonance image showed a left posterior parietal heterogeneously enhancing mass measuring 4.2cm × 7.2cm × 7.0cm. After craniotomy for resection and decompression, the mass was histologically revealed to be a supratentorial primitive neuroectodermal tumor. Standardized immunohistochemical studies for this mass were carried out.

CONCLUSION

We have concluded that immunohistochemical and genetic workup should be included in the standardized pathological workup for primitive neuroectodermal tumors in order to provide more prognostic information. Based on our current literature review, we propose an immunohistochemical panel.

Methods and implications of limiting resident duty hours

CONTEXT

Current limitations on residency duty hours came about after the death of a patient in 1984 in a New York City hospital. This tragedy served as the catalyst for a new public awareness and subsequent change in philosophy regarding resident duty hours, fatigue factors, and risks to patients from the long and tedious shifts of residency. However, it has proven difficult to limit resident physician duty hours.

OBJECTIVE

To analyze the impact of resident duty hour limitation (RDHL) implementation on residents, faculty, and patients.

METHODS

The authors conducted a survey of faculty and resident attitudes and experiences regarding RDHLs in the graduate medical education department at Arrowhead Regional Medical Center (ARMC) in Colton, California. They also conducted a review of the literature on faculty and resident attitudes and experiences before and after implementation of RDHLs.

RESULTS

Of 60 surveys sent to ARMC faculty members in 2009, 12 (20.0%) were returned. Of 140 surveys sent to ARMC residents, 96 (68.6%) were returned. The survey results and literature review indicated that most faculty physicians initially believed that decreasing resident duty hours would limit the time available to residents for educational experiences and participation in treatment procedures, operations, and consultations. In addition, faculty initially believed that fewer training hours would diminish the quality of residents' educational experiences. Residents also expected negative outcomes from RDHLs. However, statistical data on actual outcomes revealed that residency programs are not adversely affected by limiting resident work hours to 80 hours per week. Furthermore, benefits of RDHLs appear to include improved patient care and well-rounded and psychologically balanced residents.

CONCLUSION

A survey and literature review revealed a number of benefits of RDHLs. It is unclear, however, whether additional limitations of resident work hours are necessary or could accommodate the growing amount of information and skills that are required to become a competent physician.

Effect of pedal pump and thoracic pump techniques on intracranial pressure in patients with traumatic brain injuries

CONTEXT

Although osteopathic manipulative treatment (OMT) is used to manage myriad conditions, there has been some hesitation regarding the safety of applying OMT to patients with intracranial injuries or elevated intracranial pressure (ICP).

OBJECTIVE

To assess the safety of two OMT techniques--pedal pump and thoracic pump--on ICP and cerebral perfusion pressure (CPP) in patients with traumatic brain injuries (Glasgow Coma Scale score < or =8).

METHODS

We prospectively enrolled consecutive patients admitted to the intensive care unit (ICU) for traumatic brain injury. Patients between the ages of 18 and 75 years and with abnormal CT scans were included in the present study. Patients with baseline ICP values of 20 mm Hg or lower were assigned to group 1, and those with ICP levels greater than 20 mm Hg, group 2. Patients underwent continuous ICP and CPP monitoring, with ICP measured using a ventricular catheter and fiber optic device. Values of ICP and CPP were recorded at baseline, during application of the OMT techniques, and 5 minutes after the two OMT techniques were completed. Patients received up to three treatment cycles. Ventricular drains remained open (stopcock open) during OMT, allowing continued cerebral spinal fluid drainage, except for brief periodic closures (stopcock closed) every minute to register accurate ICP values. Statistical analysis was performed using a dependent t test with repeated measures.

RESULTS

Twenty-four comatose patients, aged 18 to 69 years, received a total of 50 sessions of pedal pump and thoracic pump techniques. In group 1 patients, a slight decrease in ICP values (mean, -0.586 mm Hg) and an increase in CPP values (mean, 1.1613 mm Hg) was noted post-OMT. Patients in group 2 also had decreased mean ICP values (-1.20 mm Hg) and increased mean CPP values (2.2105 mm Hg). Changes were not statistically significant in either group.

CONCLUSION

According to the present limited study, pedal pump and thoracic pump techniques may be used safely in patients with severe brain injuries.

Plasma concentrations of glutamate and its metabolites in patients with Alzheimer's disease

Neurologic and psychologic tests without brain tissue biopsy do not establish the diagnosis of Alzheimer's disease. This pilot study demonstrates significant increases in the activity of plasma glutamate dehydrogenase and the plasma concentrations of aspartate, glutamate, and alpha-ketoglutarate in nursing home residents with previously diagnosed Alzheimer's disease when compared with that in other nursing home residents without Alzheimer's disease who had no complicating conditions. Plasma concentrations of gamma-aminobutyric acid, glutamine, and activities of plasma glutamate decarboxylase, glutaminase, and glutamine synthetase were not significantly different in the two groups. A discriminant analysis number, based on the four significantly different compounds, is obtained that may be used as the basis for an inexpensive, non-invasive, and accurate screening test for Alzheimer's disease.

Plasma concentrations of glutamate and its metabolites in patients with Alzheimer's disease

Neurologic and psychologic tests without brain tissue biopsy do not establish the diagnosis of Alzheimer's disease. This pilot study demonstrates significant increases in the activity of plasma glutamate dehydrogenase and the plasma concentrations of aspartate, glutamate, and a-ketoglutarate in nursing home residents with previously diagnosed Alzheimer's disease when compared with that in other nursing home residents without Aldzheimer's disease who had no complicating conditions. Plasma concentrations of -y-aminobutyric acid, glutamine, and activities of plasma glutamate decarboxylase, glutaminase, and glutamine synthetase were not significantly different in the two groups. A discriminant analysis number, based on the four significantly different compounds, is obtained that may be used as the basis for an inexpensive, noninvasive, and accurate screening test for Alzheimer's disease.