The first neurosurgical service in Texas: neurosurgery at the University of Texas Medical Branch (1937-2023)

The authors present a historical analysis of the first neurosurgical service in Texas. Initially established as a subdivision within the Department of Surgery in the early 1900s, this service eventually evolved into the Department of Neurosurgery at the University of Texas Medical Branch (UTMB). The pivotal contributions of individual chiefs of neurosurgery throughout the years are highlighted, emphasizing their roles in shaping the growth of the neurosurgery division. The challenges faced by the neurosurgical division are documented, with particular attention given to the impact of hurricanes on Galveston Island, Texas, which significantly disrupted hospital operations. Additionally, a detailed account of recent clinical and research expansions is presented, along with the future directions envisioned for the Department of Neurosurgery. This work offers a comprehensive historical narrative of the neurosurgical service at UTMB, chronicling its journey of growth and innovation, and underscoring its profound contributions to Galveston's healthcare services, extending its impact beyond the local community.

Late Testicular Yolk Sac Tumor With Cerebellar Metastasis and a Rapid Recurrence After a Gross Total Resection: A Case Report

Yolk sac tumor (YST) is the most common prepubertal testicular tumor. It is considered a subtype of non-seminoma germ cell tumor (NSGCT) that is presumed to have an aggressive behavior with high malignant potential, thus requiring multimodality treatment with resection and chemotherapy. Treatment is curative for the majority of patients, even the ones with relapse after a few years. Here, we describe for the first time an atypical case of YST recurrence 17 years after primary treatment of YST. This is a case of YST in a 32-year-old man who presented with a large cerebellar mass consistent with YST recurrence after being in remission for 17 years. He underwent suboccipital craniotomy and complete excision of the tumor, as evident on postoperative MRI with a plan for stereotactic radiosurgery with dose and fractionation determined by MRI at four weeks postoperatively. However, the four-week MRI postoperatively revealed a large mass that was engulfing the prior resection cavity, indicative of unusual rapid tumor recurrence despite evidence of complete resection. The highly aggressive nature of this tumor should prompt clinicians to consider chemotherapy and radiation earlier than four weeks postoperatively.

Disseminated enterogenous cells at the cervicomedullary junction causing communicating hydrocephalus

The authors present a unique case of a patient with communicating hydrocephalus and repeated ventriculoperitoneal shunt obstructions resulting from mucin-secreting enterogenous cell deposits at the cervicomedullary junction. Pathological examinations revealed that these cellular deposits lacked characteristic cystic architecture and the patient had no history of previous cyst with dissemination. Because of the repeated shunt obstructions and inability to surgically resect the lesion in its entirety, the authors elected radiation therapy to the cervicomedullary junction, encompassing the radiological abnormality. As of this writing, the patient has remained at neurological baseline and has not required further shunt revisions for obstruction.

Comparison of inpatient vs. outpatient anterior cervical discectomy and fusion: a retrospective case series

Background

Spinal surgery is increasingly being done in the outpatient setting. We reviewed our experience with inpatient and outpatient single-level anterior cervical discectomy and fusion with plating (ACDF+P).

Methods

All patients undergoing single-level anterior cervical discectomy and fusion with plating between August 2005 and May 2007 by two surgeons (RPB or JAF) were retrospectively reviewed. All patients underwent anterior cervical microdiscectomy, arthrodesis using structural allograft, and titanium plating. A planned change from doing ACDF+P on an inpatient basis to doing ACDF+P on an outpatient basis was instituted at the midpoint of the study. There were no other changes in technique, patient selection, instrumentation, facility, or other factors. All procedures were done in full-service hospitals accommodating outpatient and inpatient care.

Results

64 patients underwent ACDF+P as inpatients, while 45 underwent ACDF+P as outpatients. When outpatient surgery was planned, 17 patients were treated as inpatients due to medical comorbidities (14), older age (1), and patient preference (2). At a mean follow-up of 62.4 days, 90 patients had an excellent outcome, 19 patients had a good outcome, and no patients had a fair or poor outcome. There was no significant difference in outcome between inpatients and outpatients. There were 4 complications, all occurring in inpatients: a hematoma one week post-operatively requiring drainage, a cerebrospinal fluid leak treated with lumbar drainage, syncope of unknown etiology, and moderate dysphagia.

Conclusion

In this series, outpatient ACDF+P was safe and was not associated with a significant difference in outcome compared with inpatient ACDF+P.

Cauda equina syndrome, diskospondylitis, and a paravertebral abscess caused by Rhodococcus equi in a foal

A 4-month-old male Quarter Horse was referred for evaluation of urinary incontinence. Physical examination revealed clinical signs consistent with cauda equina syndrome. Radiography revealed diskospondylitis of S2 through S4. Infected bone was surgically curretted, and drainage was established for an associated paravertebral abscess. Rhodococcus equi was isolated from specimens of bone and from fluid samples obtained from the paravertebral abscess. Bethanechol was administered to stimulate urination. Erythromycin and rifampin were administered for 120 days. The foal's neurologic dysfunction resolved completely. Two years after discharge, the horse remained neurologically normal and did not have apparent effects as a result of its previous disorder.

Immunohistochemical localization of seven different peptides in the human spinal cord

It is necessary to study the normal chemical contents in the human spinal cord in order to understand neurochemical changes that might occur under pathological conditions. In the present study, the comparative distribution of seven peptides was examined immunohistochemically in four levels (cervical, C; thoracic, T; lumbar, L; sacral, S) of the human spinal cord by means of the peroxidase-antiperoxidase technique. The peptides examined included bombesin (BOM), substance P (SP), cholecystokinin (CCK), somatostatin (SOM), methionine-enkephalin (M-ENK), vasoactive intestinal polypeptide (VIP), and thyrotropin releasing hormone (TRH). Among the seven peptides examined, four (BOM, CCK, SOM, and TRH) have never been described in the human spinal cord and the present work clearly demonstrates their existence in specific patterns. The terminals that were immunostained for BOM and CCK were localized in high concentration in the superficial dorsal horn (laminae I-II), in moderate amounts in the lateral part of laminae V and VII, and lesser amounts in the intermediate gray (lamina VII) and the dorsal part of the central gray (lamina X). Whereas BOM showed a similar distribution pattern at all spinal levels, CCK was mainly found in thoracic and lumbar levels. The SOM terminals were localized in the superficial dorsal horn (the highest density in lamina II but very few in lamina I), the intermediolateral cell column, intermediate gray, and central gray. This peptide was more widely distributed in the sacral cord with its terminal field extending into the ventral horn. The TRH terminals were mainly located in the ventral horn. Frequently, TRH terminals were seen adjacent to large ventral horn neurons. Furthermore, many neurons in the ventral and intermediate gray and Clarke's column demonstrated TRH immunoreactivity. The other three peptides (SP, M-ENK, and VIP) have been previously demonstrated in the human spinal cord and the present study confirmed their general spinal distribution with minor differences.

Evidence for unmyelinated sensory fibres in the posterior columns in man

The human posterior columns are generally described as a myelinated fibre pathway. The present study demonstrates that more than 25% of the component axons are unmyelinated. Many of these unmyelinated axons are labelled by antibodies to calcitonin gene-related peptide (CGRP), a substance found in sensory cells, axons and terminals. On this basis we suggest that there are significant numbers of unmyelinated primary afferent axons in the human posterior columns. These results indicate that unmyelinated sensory axons are more widespread than previously thought, and that they should be taken into account when considering stimulation of the posterior columns to relieve pain.

Calcitonin gene-related peptide (CGRP) in the human spinal cord: a light and electron microscopic analysis

The distribution of CGRP immunoreactivity in the cervical, thoracic, lumbar, and sacral levels of the human spinal cord was mapped at the light microscopic level with the aid of a rabbit-generated antiserum against human calcitonin gene-related peptide (CGRP). CGRP-positive fibers formed a dense plexus in lamina I, II, the reticulated region of lamina V, and the tract of Lissauer at all spinal cord levels. The distribution of fibers showed some variations dependent on the cord level analyzed. At the light microscopic level, intervaricose fiber diameters consistently measured 1.0 micron or less, and two types of CGRP varicosities were observed: a small (1 to 2 microns in diameter), relatively round profile and a larger, (3 to 4 microns in diameter) oval or oblong profile. At the electron microscopic level, immunostained varicosities contained a mixture of round clear vesicles and vesicles that contained dense cores. The CGRP immunoreaction product was often associated with vesicles containing dense cores. The reaction product was also seen associated with clear round vesicles or in the cytoplasmic matrix. Postsynaptic elements included dendritic spines, small and large diameter dendritic shafts and vesicle containing profiles. The presence of CGRP in the superficial dorsal horn of human spinal cord is highly suggestive of a role in primary afferent transmission as postulated in lower vertebrates. This study establishes the distribution of CGRP at four different spinal levels in human cord and will serve as a basis for future studies related to the pathologic conditions affecting sensory systems.

Computed tomogram-guided stereotactic brain biopsy in the pediatric patient

Experience with computed tomogram-guided stereotactic biopsy is described with special reference to technical considerations important to the application of the Brown-Roberts-Wells system in pediatric patients. Eleven procedures were performed in 9 patients aged 9 months to 16 years of age. In all cases, the lesion was either deep seated or related to deficit prone areas making open biopsy hazardous. Since the stereotactic frame may interfere with intubation, it is important to apply it only after the patient has been anesthetized and intubated. In very small children, special attention is required to avoid over tightening of the fastening pins and to avoid excessive pressure when making the calvarial opening. In an effort to reduce the risk of hemorrhage, vasculature at the entry site was visualized and avoided by making a standard burr hole opening. Improved imaging of the vasculature at the deep biopsy site was obtained in most cases by intra-arterial contrast enhancement. No complications of the procedure were encountered and a diagnosis was obtained in all cases, although in 2 cases the procedure was repeated before adequate tissue was obtained. In 3 cases the procedure was therapeutic as well as diagnostic in that a tumor cyst or abscess could be drained.