Open Surgical Placement of T9-T12 Dorsal Root Ganglion Stimulators With Titanium Plate Anchor Fixation in a Patient With Recalcitrant Post-herpetic Neuralgia

Dorsal root ganglion stimulators (DRGS) have been used to treat patients with neuropathic pain due to multiple etiologies. Typically, DRGS are inserted percutaneously with fluoroscopic guidance epidurally into the neuroforamina over a pathologic dorsal root ganglion. In patients with unfavorable anatomy due to extensive surgical scarring, an open surgical approach has been described in the literature for DRGS placement. We document an alternative open surgical approach for DRGS placement in a patient with recalcitrant post-herpetic neuralgia.

Return to Work Guidelines Following Neurosurgical Procedures

Recovery time following surgical procedures is a consideration every practicing surgeon must deliberate upon throughout his or her career. The decision to restrict patients from returning to work or various activities encountered on a daily basis following an operation is dependent on many factors. Surgeons must take into account patient population, individual comorbid conditions, complexity and length of surgery, immediate postoperative course, and baseline functional abilities. Thus, returning to work and various activities, including physical activity, work-related activity, and recreational activity alike, following invasive procedures is individualized from patient to patient. Most spinal procedures are performed by neurosurgeons or orthopedic surgeons. This article suggests a framework to guide appropriate return to work and activity escalation time frames following various spinal procedures. 

Pneumorrhachis After an Upper Respiratory Infection: A Case Report of a Rare Phenomenon

Pneumorrhachis (PR) is the presence of free air within the spinal canal. It is generally benign and improves with conservative management. Case reports and a literature review exist documenting the existence and potential pathogenesis of this phenomenon, but no evidence-based guidelines exist documenting what treatment, if any, is indicated for this condition. We present a case of a 21-year-old male who developed PR after a preceding upper respiratory tract infection. His symptoms improved with expectant management and administration of high-flow oxygen. The purpose of this case report is to add to the scarce existing literature reporting this condition and to provide a short review of literature detailing the pathogenesis of PR.

The Use of Sublaminar Wiring in the Sub-Axial Cervical Spine as an Adjuvant to Lateral Mass and Pedicle Screw Fixation in a Patient with Metastatic Carcinoma of the Upper Thoracic Spine

A 60-year-old male presented with kyphotic deformity caused by a non-small cell lung cancer metastasis in the cervical-thoracic junction. His pathology caused spinal cord compression and segmental instability. The patient underwent a posterior decompression to try and improve neurological function as well as posterior lateral mass and pedicle screw fixation crossing the cervical-thoracic junction to stabilize his instability. A novel technique incorporating sublaminar wiring across a cross-link was utilized to increase pull out strength of the superior lateral mass screws. Also included is a discussion regarding the safe use of sublaminar wires, the history of posterior cervical and thoracic fusion, and the prevalence of instrumentation failure.

Tethered cord release: a long-term study in 114 patients

OBJECT

All children born with a myelomeningocele at the authors' institution undergo aggressive treatment to maintain or improve functional outcome. Consequently, when any neurological, orthopedic, and/or urological changes are noted, a search for the cause is initiated. The most common cause of decline in a child born with a myelomeningocele is shunt malfunction. The second most common cause is tethering of the distal spinal cord at the site of the original back closure. In this report, the authors review the indicators of symptomatic spinal cord tethering and discuss the surgical interventions and outcomes in the children with myelomeningocele who underwent treatment at Children's Memorial Hospital from 1975 to 2008.

METHODS

Among the 502 children who underwent original closure at Children's Memorial Hospital, a symptomatic tethered spinal cord developed in 114 (23%). Eighty-one patients (71%) have undergone 1 untethering procedure, and 33 patients (29%) have undergone multiple untetherings, for a total of 163 total surgeries. The indicators of symptomatic spinal cord tethering include scoliosis, decline in lower-extremity (LE) motor strength, LE contractures, LE spasticity, gait change, urinary changes, and pain.

RESULTS

Pain has shown the best response to surgical untethering, with 100% of children experiencing postoperative improvement. The results of long-term follow-up (average 12 years, range 1 month-23.3 years) in this cohort demonstrated scoliosis progression after surgical untethering in 52% of patients, with 28% requiring spinal fusion. On the 3-month postoperative manual muscle test, 70% of patients showed improved LE muscle strength compared to preoperatively. Gait was also similarly improved after untethering as evaluated by an orthopedic surgeon. Spasticity improved in two-thirds of the cohort, and as expected, LE contractures were stable (78%) postoperatively, as assessed by orthopedic and rehabilitation medicine specialists. Urologically, 64% of patients showed improvements on postoperative bladder evaluation.

CONCLUSIONS

Although this is a clinical outcome study with no control group, the authors' experience has been that tethered cord release is beneficial in maintaining neurological, urological, and orthopedic functioning in children born with a myelomeningocele.

Reactivation of dormant lumbar methicillin-resistant Staphylococcus aureus osteomyelitis after 12 years

The adequate treatment of methicillin-resistant Staphylococcus aureus (MRSA) osteomyelitis has intrigued clinicians for some time. As the resistance of these pathogens, coupled with the increase in community-acquired cases, continues steadily to rise, clinicians are finding it useful to employ multi-modal approaches for efficacious treatment. The authors present a single case report of a patient with recurrent MRSA osteomyelitis, lumbar paraspinal and epidural abscess. He was found to have decreased muscle strength and was hyporeflexic in the involved extremity. Serum testing demonstrated MRSA bacteremia. Neuroimaging studies revealed evidence of paraspinal abscess and a presumed herniated nucleus pulposus at the L5/S1 interspace with significant nerve root compromise. Despite antimicrobials, his symptoms persisted, necessitating surgical exploration. At surgery, paraspinal and epidural abscesses were encountered and debrided; however, no herniated disc was visualized. This case demonstrates the diagnostic and therapeutic dilemmas with which these lesions present. We postulate that the MRSA osteomyelitis/discitis pathogens were walled off in the disc space and subsequently inoculated the soft tissues with ensuing bacteremia. We concur that antimicrobial treatment should be the first line of therapy for these patients; however, surgical debridements and cautious spinal instrumentation should be employed where appropriate.