Arachnoid webs causing rostral syrinx due to ball-valve effect: an illustrative report of two cases

An arachnoid web is a pathological formation of the arachnoid membrane. It is a rare phenomenon but is known to lead to syrinx formation in the spinal cord along with pain and neurological deficits. On imaging, the 'scalpel sign' is pathognomonic for an arachnoid web. The etiology of syrinx formation from an arachnoid web is currently unknown. This report documents the only two cases of arachnoid webs with an extensive syrinx in which a likely pathophysiologic mechanism is identified. Both cases presented with motor deficits. The patients had no history of trauma or infection. After extensive workup in both patients and observation of the scalpel sign an arachnoid web was suspected. In both cases, the patients were treated surgically after an arachnoid web was suspected. Intra-operative ultrasound visualized in both cases demonstrates a fenestration in the web that allowed passage of cerebrospinal fluid in a rostral-caudal direction due to a ball-valve effect.

Facial Nerve Massage for the Treatment of Hemifacial Spasm Refractory to Microvascular Decompression: Outcomes and Complications

BACKGROUND

After microvascular decompression (MVD) for hemifacial spasm (HFS), a minority of patients realize little to no relief of spasms. In some patients, the absence of relief of spasms results from incomplete or inadequate decompression of vascular compression of the facial nerve, and these patients represent excellent candidates for repeat MVD. However, in other patients, repeat MVD is not appropriate because adequate decompression and resolution of neurovascular compression, as determined by postoperative high-resolution MRI, was achieved with the initial operation.

OBJECTIVE

To present a cohort of patients with a history of HFS refractory to MVD, with no evidence of neurovascular compression on postoperative MRI, who underwent facial nerve massage (FNM) in the posterior fossa in an attempt to relieve spasms.

METHODS

Thirteen patients with a history of incomplete relief of spasms after technically adequate MVD surgery for hemifacial spasm underwent FNM. Immediate and long-term degree of spasm relief and complications after FNM were documented through in-person or telemedicine interview.

RESULTS

At follow-up after FNM, 7 of 12 patients (58.3%) reported complete spasm relief (grade I), 2 of 12 patients (16.7%) reported >75% spasm relief (grade II), 0 patient (0%) reported >50% spasm relief (grade III), 3 of 12 (25.0%) patients reported <50% spasm relief (grade IV), and 1 patient was lost to follow-up. One patient experienced a delayed facial paresis, and another patient experienced high-frequency hearing loss.

CONCLUSION

After FNM, durable and, at least, partial relief of spasms with a relatively low complication rate was observed in most patients with HFS with incomplete relief of spasms after technically adequate prior MVD.

Exclusive use of fixed pressure valves for cerebrospinal fluid diversion in a modern adult cohort

Background

There is extensive debate on the role of fixed pressure shunts in the adult population. Most studies assessing fixed pressure valves do not consider the potential for changes in technique and management of shunts. We sought to examine the natural history of fixed pressure.

Methods

We conducted a retrospective chart review of 169 patients undergoing shunt placement by the senior author Daniel Wecht (DW). The etiology of shunt placement, shunt failure rates, and outcome data was assessed for each patient.

Results

Overall, 126 patients underwent initial shunt placement. Thirty-three (26.2%) patients required at least one shunt revision during follow-up. The most common cause of first time revision was mechanical shunt malfunction (13, 39.4%), followed by infection (7, 21.2%), and shunt migration (6, 18.2%). Three patients (9.1%) required revision due to misplaced catheters. Underdrainage or overdrainage of shunts each resulted in revisions for 2 (6.1%) patients. The mean follow-up length was 28.1 ± 6.1 months.

Conclusion

Fixed pressure shunts failed primarily because of shunt malfunction and occurred most commonly in patients developing hydrocephalus as a result of hemorrhage or normal pressure hydrocephalus (NPH). The overall failure rate between these two groups was proportionally equivalent. Both overdrainage or underdrainage were found to be rare indications for revision.

Reducing Surgical Infections and Implant Costs via a Novel Paradigm of Enhanced Physician Awareness

BACKGROUND

Studies have demonstrated that physicians are often unaware of prescription drug, laboratory, diagnostic, and surgical supply costs.

OBJECTIVE

To investigate the effects of increased physician awareness on infection incidence and surgical device cost containment.

METHODS

Within our institution, physicians were informed of individual, independently adjudicated, craniotomy and ventricular shunt infection incidence and rankings among peers, after which a protocol aimed at reducing skin bacterial burden was implemented for craniotomies. Physicians were also made aware of the costs for shunts and dural substitutes as well as available alternatives.

RESULTS

The combined craniotomy and ventricular shunt infection incidence significantly decreased by 37.5% from 3.2% over May 2011 to April 2015 (132 infections/4137 procedures) to 2.1% over May 2015 to April 2016 (26 infections/1250 procedures; P = .041). The average annual cost savings was $234 175 from preventing postoperative craniotomy infections and $121 125 from preventing postoperative ventricular shunt infections. Total supply costs of ventricular shunts significantly decreased by 26% from $2345 per procedure in fiscal year 2015 to $1747 per procedure in fiscal year 2016 (P < .001). Total supply cost of dural grafts significantly decreased by 54% from $191 per procedure in fiscal year 2015 to $88 per procedure in fiscal year 2016 (P < .001). In total, all initiatives in this study resulted in an estimated annual savings of $567 062.

CONCLUSION

Physician awareness of outcomes and costs resulted in increasing the quality of care, while at the same time reducing the cost.

Concussion in ice hockey

Ice hockey is an aggressive and fast-paced sport which has a high risk of injury, concussions in particular. Although serious head injury has been recognized for nearly 50 years, an increase in mainstream media attention in recent years has led to unprecedented public awareness. As a result, the National Hockey League (NHL) and other professional leagues around the world have initiated concussion protocols in order to better prevent, recognize, and treat concussions. With over 1,000,000 youth hockey participants in Canada and the USA combined, concussion is an issue that reaches beyond the professional level. In this report we review the incidence, evaluation, treatment, return-to-play protocol, and prevention efforts related to concussion in ice hockey.

Iatrogenic cerebral venous sinus occlusion with flowable topical hemostatic matrix

Object

The use of commercially available topical hemostatic adjuncts has increased the safety profile of surgery as a whole. Cranial surgery has also benefited from the development of numerous agents designed to permit more rapid achievement of hemostasis. Flowable topical hemostatic agents applied via syringe injection are now commonly employed in many neurosurgical procedures, including cranial surgery. Intravascular use of these strongly thrombogenic agents is contraindicated, but in certain settings, inadvertent intravascular administration can occur, resulting in vascular occlusion, thrombosis, and potential dissemination. To date, there have no reports detailing the presence and incidence of this complication.

Methods

The authors conducted a retrospective review of all cranial surgeries performed at Presbyterian University Hospital by members of the University of Pittsburgh Medical Center's Department of Neurological Surgery between 2007 and 2009. Cases complicated by vascular occlusion due to inadvertent intravascular administration of flowable topical hemostatic matrix (FTHM) were identified and analyzed.

Results

Iatrogenic vascular occlusion induced by FTHM was identified in 5 (0.1%) of 3969 cranial surgery cases. None of these events occurred in 3318 supratentorial cases, whereas 5 cases of cerebral venous sinus occlusion occurred in 651 infratentorial cases (0.8%). The risk of accidental vessel occlusion was significantly associated with infratentorial surgery, and all events occurred in the transverse and/or sigmoid sinus. No episodes of inadvertent vascular occlusion occurred during endoscopic surgery. No cases of arterial occlusion were identified. Of the 5 patients with FTHM-related cerebral venous sinus occlusion, none developed long-term neurological sequelae referable to the event.

Conclusions

Inadvertent intravascular administration of FTHM is a rare complication associated with cranial surgery that occurs most commonly during infratentorial procedures around the transverse and/or sigmoid sinuses. Modifications in the choice of when to use an FTHM and the method of application may help prevent accidental venous sinus administration.

Evaluation of lipid profiles and the use of omega-3 essential Fatty Acid in professional football players

BACKGROUND

Recent research showed 82% of 233 retired National Football League players under age 50 had abnormal narrowing and blockages in arteries compared to the general population of the same age. It has been suggested that early screening and intervention in this at-risk population be a priority.

HYPOTHESIS

Omega-3 essential fatty acid has been shown to improve cardiovascular lipid risk factors and should improve lipid profiles in professional football players to help reduce their recently shown accelerated risk of developing cardiovascular disease.

METHODS

A total of 36 active national football players were randomly assigned to 2 groups: the first group (n = 20) was provided fish oil capsules (2200 mg of mixed docosahexaenoic acid and eicosapentaenoic acid and 360 mg of other omega-3s), and the second group (n = 16) served as controls during a 60-day trial. Vertical Auto Profile cholesterol tests directly measuring serum low-density lipoprotein, high-density lipoprotein, and other subfractions were performed. Compliance, side effects, and seafood consumption data were also collected. Baseline, midpoint, and poststudy blood work measured plasma docosahexaenoic acid and eicosapentaenoic acid.

RESULTS

Treatment increased high-density lipoprotein (average percent change: +25.96, control +14.16), decreased triglycerides treatment (-8.06, control +43.98), very low-density lipoprotein treatment (-13.98, control +23.18), intermediate density lipoprotein (-27.58, control +12.07), remnant lipoproteins (-23.86, control +8.33), and very low-density lipoprotein-3 (-17.10, control +7.77). An average increase of 106.67% for docosahexaenoic acid and 365.82% for eicosapentaenoic acid compared to control was also shown.

CONCLUSION

Omega-3 supplementation significantly improved the lipid profile of active players randomized to treatment. These results suggest that fish oil supplementation is an effective way to increase eicosapentaenoic acid and docosahexaenoic acid levels in plasma and should be considered as a method to improve modifiable cardiovascular risk lipid factors in professional football players.

CLINICAL RELEVANCE

A prospective study examining the effects of 60 days of a highly purified fish oil supplementation in professional football players.

Randomized, prospective, and controlled clinical trial of pulsed electromagnetic field stimulation for cervical fusion

BACKGROUND CONTEXT

Multilevel fusions, the use of allograft bone, and smoking have been associated with an increased risk of nonunion after anterior cervical discectomy and fusion (ACDF) procedures. Pulsed electromagnetic field (PEMF) stimulation has been shown to increase arthrodesis rates after lumbar spine fusion surgery, but there are minimal data concerning the effect of PEMF stimulation on cervical spine fusion.

PURPOSE

To determine the efficacy and safety of PEMF stimulation as an adjunct to arthrodesis after ACDF in patients with potential risk factors for nonunion.

STUDY DESIGN

A randomized, controlled, prospective multicenter clinical trial.

PATIENT SAMPLE

Three hundred and twenty-three patients with radiographic evidence (computed tomography-myelogram [CT-myelo] or magnetic resonance imaging [MRI]) of a compressed cervical nerve root and symptomatic radiculopathy appropriate to the compressed root that had failed to respond to nonoperative management were enrolled in the study. The patients were either smokers (more than one pack per day) and/or were undergoing multilevel fusions. All patients underwent ACDF using the Smith-Robinson technique. Allograft bone and an anterior cervical plate were used in all cases.

OUTCOME MEASURES

Measurements were obtained preoperatively and at each postoperative interval and included neurologic assessment, visual analog scale (VAS) scores for shoulder/arm pain at rest and with activity, SF-12 scores, the neck disability index (NDI), and radiographs (anteroposterior, lateral, and flexion-extension views). Two orthopedic surgeons not otherwise affiliated with the study and blinded to treatment group evaluated the radiographs, as did a blinded radiologist. Adverse events were reported by all patients throughout the study to determine device safety.

METHODS

Patients were randomly assigned to one of two groups: those receiving PEMF stimulation after surgery (PEMF group, 163 patients) and those not receiving PEMF stimulation (control group, 160 patients). Postoperative care was otherwise identical. Follow-up was carried out at 1, 2, 3, 6, and 12 months postoperatively.

RESULTS

The PEMF and control groups were comparable with regard to age, gender, race, past medical history, smoking status, and litigation status. Both groups were also comparable in terms of baseline diagnosis (herniated disc, spondylosis, or both) and number of levels operated (one, two, three, or four). At 6 months postoperatively, the PEMF group had a significantly higher fusion rate than the control group (83.6% vs. 68.6%, p=.0065). At 12 months after surgery, the stimulated group had a fusion rate of 92.8% compared with 86.7% for the control group (p=.1129). There were no significant differences between the PEMF and control groups with regard to VAS pain scores, NDI, or SF-12 scores at 6 or 12 months. No significant differences were found in the incidence of adverse events in the groups.

CONCLUSIONS

This is the first randomized, controlled trial that analyzes the effects of PEMF stimulation on cervical spine fusion. PEMF stimulation significantly improved the fusion rate at 6 months postoperatively in patients undergoing ACDF with an allograft and an anterior cervical plate, the eligibility criteria being patients who were smokers or had undergone multilevel cervical fusion. At 12 months postoperatively, however, the fusion rate for PEMF patients was not significantly different from that of the control group. There were no differences in the incidence of adverse events in the two groups, indicating that the use of PEMF stimulation is safe in this clinical setting.

Cervical neurapraxia in elite athletes: evaluation and surgical treatment

Object

Neurapraxia, transient posttraumatic paralysis of the motor and/or sensory tracts in the spinal cord, may be a career-ending event in an athlete. Management, rehabilitation, and return-to-play decisions remain controversial.

Methods

Five elite football players were evaluated after experiencing episodes of neurapraxia. All patients experienced bilateral paresthesias—three in all four extremities and two in the upper extremities—lasting a few minutes to more than 24 hours. Transient motor deficits occurred in two individuals but caused no permanent sequelae. Neuroimaging confirmed the presence of herniated discs, focal cord compression, and no parenchymal changes in all cases.

All patients underwent anterior cervical microdiscectomy and fusion, and cervical plates were placed in four. After aggressive rehabilitation and confirmation of fusion ranging from 9 weeks to 8 months postoperatively, the players were allowed to return to active play. Two of the players developed recurrent career-ending disc herniations, one above and the other below the fusion level. One player required repeated spinal cord decompression.

Conclusions

Neurologically intact athletes with focal cord compression due to a single-level herniated disc may safely return to football after undergoing decompressive surgery and confirmation of fusion. It appears, however, that there may be an increased chance of repeated herniation above or below a fused level.

A brief history of chronic subdural hematomas

Examination of human remains tells us that subdural hematomas have been with mankind for thousands of years. Their recognition as distinct clinical entities is considerably more recent, and it has only been in the last century that the cause of chronic subdural hematomas has been adequately elucidated. The history of this discovery process is interesting and sheds light on the nature of scientific progress in general.

Occipital lobe vascular malformations: prevalence of visual field deficits and prognosis after therapeutic intervention

BACKGROUND

The prevalence of visual field (VF) deficits in association with vascular malformations of the occipital lobe is not known, and the prognosis of the VF after therapeutic intervention has not been systematically documented.

METHODS

We reviewed the clinical records of 23 consecutive patients who were managed at a single institution during a 3-year period with intracranial vascular malformations extending within the anatomic borders of the occipital lobe. Lesion location and treatment rendered were correlated with formal VF testing performed before and after therapeutic intervention.

RESULTS

Twenty-one of the 23 patients underwent treatment of their lesions. Treatment included resection after preoperative embolization (12 patients), resection alone (2 patients with arteriovenous malformations and 3 patients with cavernous malformations), and stereotactic radiosurgery (4 patients; preceded by embolization in 3 of the 4). One patient was followed expectantly, and another died as a result of hemorrhage soon after undergoing endovascular embolization. The VFs were assessed before and after therapeutic intervention (follow-up assessment, 2-29 mo). New VF deficits or worsening of preexisting VF deficits were documented in 5 of the 21 treated patients (24%), but only 2 of these patients (9.5%) had persistent deficits at the time of their follow-up examinations. Among the 10 patients with pretreatment VF deficits, 5 improved and the other 5 were unchanged after treatment.

CONCLUSION

Patients with occipital lobe vascular malformations frequently present with associated VF deficits. Surgical resection or stereotactic radiosurgery (with or without previous embolization) of these lesions can be performed with little risk of causing new VF deficits or worsening of preexisting ones. Many VF deficits can be expected to improve or resolve after therapy.

Endovascular coil embolisation of metachronous mycotic aneurysms. Case presentation and review of technical and management issues

SUMMARY

While receiving optimal antibiotic therapy for subacute bacterial endocarditis (SBE), a teenage girl with mild congenital mitral insufficiency presented with two separate episodes of subarachnoid haemorrhage from two rapidly evolving metachronous mycotic aneurysms within the vertebrobasilar circulation. Both aneurysms were successfully treated by endovascular coil embolisation with the GDC system. This permitted at the minimum, successful amelioration of the short term risk of rerupture of the aneurysms, and facilitated operative management of the patient's infected mitral valve. The case further illustrates the utility and effectiveness of endovascular therapy for managing not only the neurovascular sequelae of SBE, but also perhaps the enhanced ability to optimally manage the source of mycotic aneurysms. In addition, the potential limitations and risks of this therapeutic strategy are assessed.

Lesions of the calvaria: surgical experience with 42 patients

BACKGROUND

Lesions of the calvaria (cranial vault), whether benign or malignant, are rare, and the number that require surgical attention is very limited. During a 13-year period, 42 patients ranging in age from 13 to 82 years were treated surgically at our institution for lesions involving primarily the calvaria. The patients were found to have 16 benign lesions, 21 malignant lesions, and 5 pathologically ill-defined lesions. At last follow-up, 23 patients were still alive.

METHODS

Criteria for choosing surgery as the preferred therapeutic modality included (a) uncertain diagnosis; (b) benign lesions with a high probability of total removal; 3) malignant lesions that represented the only residue of a systemic malignancy that was in remission; or (d) lesions that were rapidly enlarging, were causing significant symptoms, or were unresponsive to radiation or chemotherapy.

RESULTS

Preoperative needle biopsy was useful for some patients in establishing a definitive diagnosis and in providing the basis for the most effective treatment strategy. Most lesions were treated with either craniectomy alone (n = 16) or with craniectomy and cranioplasty (n = 26). Six of the 42 patients had postoperative complications. There was no operative mortality.

CONCLUSION

This review of a series of patients with calvarial lesions provides an outline of the overall diagnostic workup and management of this unique patient population.