Comparative Analysis of the 3 Cervical Vertebral Bone Quality (C-VBQ) Score Methodologies and Their Correlations to the Lumbar Vertebral Bone Quality (VBQ) Score

OBJECTIVE

Common complications after spinal fusion, such as pseudoarthrosis, cage subsidence, or instrumentation failure, are affected by patients' bone quality. The cervical-vertebral bone quality (C-VBQ) score, a magnetic resonance imaging (MRI)-based adaption of the lumbar vertebral bone quality (VBQ) score, was developed by 3 separate research groups simultaneously to evaluate bone quality in cervical spinal fusion patients. We present the first analysis comparing these scoring methods to the well-validated VBQ score.

METHODS

A retrospective analysis of data for consecutive patients who underwent spine surgery at a single institution was completed. The VBQ score was calculated using the Ehresman et al.

METHOD

The C-VBQ scores, named according to placement of the region of interest within the cerebral spinal fluid, were calculated separately using the methods of Soliman et al. (C2-VBQ), Razzouk et al. (C5-VBQ), and Huang et al. (T1-VBQ). Linear regression models were utilized to evaluate correlations to the VBQ score.

RESULTS

A total of 105 patients were identified (mean age, 57.0 ± 11.9 years; women, 50.5%). Mean scores were C2-VBQ, 2.37 ± 0.55; C5-VBQ, 2.36 ± 0.61; and T1-VBQ, 2.64 ± 0.68. The C-VBQ scores for the C2 level were significantly higher than those for the C3-C6 levels (3.18 ± 0.96 vs. 2.63 ± 0.77, P < 0.001), whereas the C7 level was found to have significantly lower C-VBQ scores (2.42 ± 0.78 vs. 2.63 ± 0.77, P = 0.04). The C2-VBQ (r = 0.63) score had the strongest correlation to the VBQ score, compared to C5-VBQ (r = 0.41) and T1-VBQ (r = 0.43) (P < 0.001).

CONCLUSIONS

This study demonstrates that the C2-VBQ had the strongest correlation to the lumbar VBQ score among all C-VBQ scores.

Expansion and Subsequent Rupture of Carotid Pseudoaneurysm After Tandem Carotid and Middle Cerebral Artery Occlusion Treated With Mechanical Thrombectomy and Carotid Stenting

BACKGROUND AND IMPORTANCE

Extracranial carotid artery pseudoaneurysm is a rare entity with potential etiologies including infection, blunt trauma, postsurgical atherosclerotic disease, and invasive neoplasia. Although the natural history of carotid pseudoaneurysm is difficult to determine because of its rarity, complications such as stroke, rupture, and local mass effect may occur at staggering rates.

CLINICAL PRESENTATION

In this case, a middle-aged man presented with a tandem carotid, middle cerebral artery occlusion that was treated with a carotid stent and mechanical thrombectomy. He returned 3 weeks later with a ruptured carotid pseudoaneurysm that was then treated with a covered stent. He made a full recovery and was neurologically intact on follow-up.

CONCLUSION

This case illustrates a rare potential complication of carotid occlusion and stenting with possible catastrophic consequences. The goal of this report was to educate other clinicians in remaining vigilant in awareness of this complication and provide a framework for potential treatment if and when it occurs.

Use of Novel Automated Active Irrigation With Drainage Versus Passive Drainage Alone for Chronic Subdural Hematoma-A Propensity Score-Matched Comparative Study With Volumetric Analysis

BACKGROUND

Passive drainage post-surgical evacuation of symptomatic chronic subdural hematoma (cSDH) is currently standard of care. High rates of infection, drain occlusion, and recurrence are associated complications.

OBJECTIVE

To explore the use of a novel double-lumen active automated irrigation and aspiration system, IRRAflow (IRRAS), for patients with cSDH and compared procedural and clinical outcomes against passive drainage alone with propensity score matching (PSM) and volumetric analysis.

METHODS

A prospectively maintained database was retrospectively searched for consecutive patients presenting with cSDH. One-to-one PSM of covariates (including baseline comorbidities and presentation hematoma volume) in active and passive irrigation groups was performed to adjust for treatment selection bias. Rates of hematoma clearance, catheter-related occlusion, and infection; number of revisions; and length of hospital stay were recorded.

RESULTS

This study included 55 patients: active continuous irrigation-drainage-21 (21 post-PSM) and passive drainage-34 (21 post-PSM). For PSM groups, a significantly higher rate of hematoma clearance was obtained in the active irrigation-drainage group (0.5 ± 0.4 vs 0.4 ± 0.5 mL/day) and in the passive drainage group; odds ratio (OR) = 1.291 (CI: 1.062-1.570, P = .002) and a significantly lower rate of catheter-related infections (OR = 0.051; CI: 0.004-0.697, P = .039). A nonsignificantly lower hematoma expansion rate at discharge was noted in the active irrigation-drainage group (4.8% vs 23.8%; OR = 0.127; P = .186). No statistical difference in all-cause in-hospital mortality or discharge Glasgow Coma Scale score was observed between groups.

CONCLUSION

Active and automated continuous irrigation plus drainage after cSDH surgical evacuation resulted in faster hematoma clearance and led to favorable clinical outcomes and low complication and revision rates compared with passive irrigation.

Management of saccular superior cerebellar artery aneurysms: The Buffalo experience case series and systematic review

BACKGROUND

Results of the management of superior cerebellar artery (SCA) aneurysms are typically reported in combination with those for all posterior circulation aneurysms. We report our experience with the management of SCA aneurysms and a systematic review of the endovascular management of these rare aneurysms.

METHODS

Patients with saccular SCA aneurysms that were not associated with arteriovenous malformations and who presented to our institute between 2000 and 2017 were identified. Patient demographics, aneurysm characteristics, interventions, and follow-up data were collected, compared, and analyzed. For the review, data including number of aneurysm treated, outcomes, follow-up, and occlusion rates were collected.

RESULTS

Mean age of the 31 identified patients was 57.4 ± 12.3 years; 19.4% were men. Mean aneurysm size was 5.1 ± 2.9 mm. Seven of 21 patients with unruptured aneurysms were managed conservatively. Ten patients (32.3%) presented with ruptured aneurysms (mean aneurysm size, 6.2 ± 3.2 mm). Treatment was successfully completed in 22 patients: 13-primary coiling, 7-stent-assisted coiling, and 2-microsurgical clipping. Complete angiographic aneurysm occlusion after primary treatments was achieved in 19 (86.4%) patients. The total complication rate among treated patients was 4.2% (1 of 24 treated aneurysms). No minor complications occurred. However, in 2 patients, coil embolization was attempted but aborted due to coil protrusion into the parent artery. Clinical and angiographic follow-up data were available for 26 observed or treated patients. Mean follow-up duration was 5.3 ± 4.5 years. Six articles met our review inclusion criteria and demonstrated similar mean treated aneurysm sizes ranging from 4.6-7.7 mm, and follow-up from these articles ranged from 15.3-50 months.

CONCLUSIONS

Endovascularly treated patients with ruptured and unruptured SCA aneurysms, of which most were <7 mm, had good clinical outcomes with minimal complications.

Spinal cord detethering without laminectomy or laminotomy

Background:

Tethered cord syndrome occurs when there is abnormal tension on the distal spinal cord, which limits its elevation as patients grow. This results in stretching of the neural elements and microvasculature, resulting in both direct and ischemic injury.[7] Animal studies suggest that impairment of oxidative metabolic pathways may contribute to neuronal injury.[7] Associated conditions include myelomeningocele, lipomyelomeningocele, intraspinal lipomas, diastematomyelia, thickened/fatty filum terminale, and trauma.[2] Tethering may be asymptomatic or result in a variety of symptoms including lower extremity weakness/sensory deficits, bowel/bladder dysfunction, scoliosis, pes cavus, and back/leg pain.[6] Early surgical intervention has been shown to improve outcomes and may be performed prophylactically or to prevent symptom progression.[1,3] More specifically, retrospective studies demonstrate that surgical intervention in patients under the age of 2 years is associated with improved outcomes.[5] In some cases, detethering may result in clinical improvement.[3]

Case Description:

We present a case of a 6-month-old male with a low-lying conus medullaris, lumbar syrinx, mildly abnormal urodynamic studies, and asymmetric utilization of his lower extremities observed during the evaluation of a Y-shaped gluteal cleft. He underwent elective spinal cord detethering via the safe and effective, minimally invasive technique described in the video.

The patient’s parents gave informed consent for treatment and video recording. Institutional review board approval was deemed unnecessary.

Conclusion:

Given the variety of surgical techniques used for cord detethering, this video may assist other surgeons in developing techniques that require little to no compromise of the developing bony spinal column while achieving sufficient release of the spinal cord.[4]

Rare incidence of tension pneumocephalus 2 months after repeat microvascular decompression

Background:

Tension pneumocephalus is a rare complication after intracranial procedures and craniotomy. We report a rare case of intraventricular and subdural tension pneumocephalus occurring 2 months after repeat right-sided microvascular decompression (MVD) for recurrent trigeminal neuralgia.

Case Description:

The patient in this case was a 79-year-old woman who presented with acute-onset confusion, headaches, nausea, and vomiting. On computed tomography, substantial volumes of pneumocephalus in the fourth ventricle and subdural space at the site of the retrosigmoid exposure for the previous MVD were seen. She underwent emergent wound exploration, and no obvious dural defect or exposed mastoid air cells were identified. The dura was reopened, and the surgical site was copiously irrigated. Mastoid air cells were covered with ample amounts of bone wax, and the wound was closed. The patient recovered well postoperatively with complete resolution of the pneumocephalus by her 3-month follow-up evaluation.

Conclusion:

It is important to assess for cerebrospinal fluid leakage and that air cells are sealed off before wound closure to prevent a pathway for air to egress into the surgical cavity and corridor.