Retroperitoneal hematoma: A rare complication of percutaneous pedicle screw in an osteoporotic patient.

Background: Percutaneous pedicle screw (PPS) placement is an established technique for minimally invasive surgery. However, life-threatening hematomas may occur in osteoporotic patients undergoing percutaneous screw placement. Case Description: An 80-year-old female with an osteoporotic T10 chance fracture developed a life-threatening hematoma following a T8-L3 posterior fusion performed with PPS. Prompt angiography diagnosed a life-threatening hematoma attributed to laceration of the left third lumbar artery occurring following pedicle screw (PS) placement into an osteoporotically fractured left L3 transverse process. This was immediately and successfully embolized. Conclusion: An 80-year-old female with multiple lumbar osteoporotic fractures developed a life-threatening hematoma during a T8-L3 PS fusion. When the lumbar computed tomography angiography diagnosed a laceration of the left L3 lumbar artery, immediate transarterial embolization proved life-saving.

Optimal Treatment of C3 Lamina in Cervical Laminoplasty.

STUDY DESIGN: Results of C4-C6 laminoplasty with C3 laminectomy and C3-C6 laminoplasty were compared retrospectively. OBJECTIVES: To clarify the difference between C3 laminectomy and C3 laminoplasty in cervical laminoplasty. SUMMARY OF BACKGROUND DATA: Intraoperative damage to the semispinalis cervicis has been shown to lead to postoperative axial symptoms and reduced range of motion (ROM). To prevent this event, C3 laminectomy in cervical laminoplasty is considered superior to C3 laminoplasty. METHODS: A total of 36 patients were included in this study: 20 patients (GroupA) of C3 laminectomy, C4-C6 laminoplasty compared with 16 patients (GroupB) of C3-C6 laminoplasty. We collected patient's background data, operative time, Japanese Orthopaedic Association (JOA) score, VAS score, and radiologic findings such as C2-C7 Cobb angle, ROM, C2 inter-spinous angle, and use of postoperative PRN medication were compared. RESULTS: There was no statistically significant difference in the C2-C7 Cobb angles between the 2 groups before and after surgery (P = 0.315). In ROM, there was a 17.7% decrease from 31.5 preoperatively to 25.9 postoperatively in Group A, and a 6.1% decrease from 29.3 preoperatively to 27.5 postoperatively in Group B. There was no statistically significant difference in ROM (P = 0.683). Postoperative neck pain (VAS) was significantly lower in Group A than in Group B both at 1 week (P = 0.015) and 1 month (P = 0.035) after surgery. The C2 inter-spinous angle was statistically significantly smaller in Group A than in Group B (P = 0.004). Clinical outcomes and surgical outcomes did not differ significantly between groups. CONCLUSIONS: If the C2 interspinous angle is wide and intraoperative semispinalis capitis damage can be minimized, it is worth trying C3 laminoplasty, but if the C2 inter-spinous angle is narrow, C3 laminectomy is recommended from the beginning.

"Dual Internal Shunts Technique" for Carotid Endarterectomy with Carotid Vertebral Anastomosis: Technical Note.

In revascularization of internal carotid stenosis with carotid vertebrobasilar anastomoses, attention should be paid not only to the anterior circulation but also to the posterior circulation cerebral infarction. A 74-year-old man was referred for treatment of carotid artery stenosis; NASCET 75% stenosis in the right internal carotid artery and acute cerebral infarction were confirmed. Occlusion of the left subclavian artery and vascular anastomosis between the right external carotid artery and the vertebral artery were indicated, such that the right external carotid artery may maintain blood flow to the vertebrobasilar artery. Therefore, dual shunts were used for the common and internal carotid arteries and the common and external carotid arteries to maintain blood flow during carotid endarterectomy. Management of the dual shunts is difficult due to the instable parallel placement of the common carotid artery shunt balloons. To solve this problem, the "dual internal shunts technique" was performed. The first shunt was inserted into the external and common carotid arteries, and the second into the internal and common carotid arteries. The shunt balloon on the common carotid artery side was placed distal to the first shunt balloon so that the dual balloons were placed in a tandem position. The proximal balloon was subsequently deflated gradually to improve flow in both shunts. The procedure is technically easy and safe.

[Three cases of mechanical thrombectomy in patients over 100 years old].

BACKGROUND: While several cases involving mechanical thrombectomy in patients >90 years old have been reported, only 1 case involving a patient >100 years old has been described. We herein report 3 cases of mechanical thrombectomy performed in patients >100 years old, along with a review of the literature.Case 1: A 102-year-old woman with a National Institute of Health Stroke Scale (NIHSS) score of 20 and diffusion weighted imaging (DWI)-Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of 8 points showed M1 occlusion. She was treated with tissue plasminogen activator followed by mechanical thrombectomy. Recanalization of thrombosis in cerebral infarction (TICI)-3 was obtained at 1 pass. After 90 days, her modified Rankin Scale (mRS) was 2, and she returned to living independently.Case 2: A 104-year-old woman with a NIHSS score of 13 and DWI-ASPECTS of 9 points showed M1 occlusion, so mechanical thrombectomy was performed. Recanalization of TICI-3 was obtained. She was admitted with an mRS of 5.Case 3: A 101-year-old woman with an NIHSS score of 8 and DWI-ASPECTS of 10 points showed right internal carotid artery occlusion, so mechanical thrombectomy was performed. Direct puncture of the right common carotid artery was performed due to access difficulties. Recanalization of TICI-3 was obtained. She was admitted with an mRS of 5. CONCLUSION: In all cases, occlusion access using techniques such as direct carotid puncture was possible, but two of the three patients had an mRS of 5, resulting in a poor prognosis. The indication for treatment in patients >100 years old should be carefully considered.

Intraoperative Cone-Beam Computed Tomography Assessment of Spinal Pedicle Screws Placement Precision Is in Full Agreement with Postoperative Computed Tomography Assessment.

OBJECTIVE: To assess agreement between pedicle screw placement evaluated on postoperative computed tomography (CT) and on intraoperative cone-beam CT (CBCT) and compare procedure characteristics when using first-generation and second-generation robotic C-arm systems in the hybrid operating room. METHODS: All patients who received pedicle screws for spinal fusion at our institution between June 2009 and September 2019 and underwent intraoperative CBCT and postoperative CT were included. The CBCT and CT images were reviewed by 2 surgeons to assess the screw placement using the Gertzbein-Robbins and the Heary classifications. Intermethod agreement of screw placement classifications as well as interrater agreement were assessed using Brennan-Prediger and Gwet agreement coefficients. Procedure characteristics using first-generation and second-generation generation robotic C-arm systems were compared. RESULTS: Fifty-seven patients were treated with 315 pedicle screws at thoracic, lumbar, and sacral levels. No screw had to be repositioned. On CBCT, accurate placement was found for 309 screws (98.1%) using the Gertzbein-Robbins classification and 289 (91.7%) using the Heary classification and on CT, these were 307 (97.4%) and 293 (93.0%), respectively. Intermethod between CBCT and CT and interrater agreements between the 2 raters were almost perfect (>0.90) for all assessment. There were no significant differences in mean radiation dose (P = 0.83) and fluoroscopy time (P = 0.82), but length of surgery using the second-generation system was estimated at 107.7 minutes (95% confidence interval, 31.9-183.5 minutes; P = 0.006) shorter. CONCLUSIONS: Intraoperative CBCT provides accurate assessment of pedicle screw placement and enables intraoperative repositioning of misplaced screws.

Preoperative assessment of dominant occipital sinus in patients with Chiari malformation type I: anatomical variations and implications for preventing potentially life-threatening surgical complications.

OBJECTIVE: The surgical treatment of Chiari malformation type I (CM-I) frequently involves dural incision at the posterior cranial fossa. In cases of persistent patent occipital sinus (OS), the sinus is usually obliterated and divided. However, there are some patients whose OS is prominent and requires crucial modification of the operative planning to avoid potentially life-threatening massive hemorrhage and disturbance of cerebral venous circulation. In the present study, the anatomical variations of the dominant OS in patients with CM-I were analyzed and the authors attempted to develop treatment recommendations for patients with CM-I with dominant OS. METHODS: The study included 213 patients with CM-I who underwent MR venography (MRV) prior to surgical treatment. OS dominance was assessed using 2D time-of-flight MRV or 3D phase-contrast MRV. Particular attention was paid to the pattern of venous outflow channels. The characteristics of the patients with dominant OS and the surgical outcomes were retrospectively reviewed. RESULTS: Dominant OS was identified in 7 patients (3.3%). The age in those with dominant OS was significantly younger than in those without (p = 0.0202). The incidence of concurrent scoliosis in the patients with dominant OS was significantly higher than in those without (p = 0.0366). All the dominant OSs were found to be of the oblique type. Unilateral oblique OS (OOS) with normal ipsilateral transverse sinus (TS) and hypoplastic contralateral TS was found in 2 patients (0.9%). The authors found 1 patient each (0.5%) who had unilateral OOS with hypoplastic ipsilateral TS and normal contralateral TS, unilateral OOS with bilateral hypoplastic TSs, and bilateral OOSs with bilateral normal TSs. Bilateral OOSs with bilateral hypoplastic TSs were found in 2 patients (0.9%). All these patients had syringomyelia. Instead of performing Y-shaped dural incision and duraplasty, surgical procedures were modified depending on the types of the OOSs to preserve their venous drainage routes. Although massive bleeding from the dominant OS during dural incision occurred in 1 patient, none suffered neurological deterioration. The syrinx volume decreased in all but 1 of the patients postoperatively. CONCLUSIONS: Assessment of the venous drainage pattern using MRV is indispensable for safe surgical treatment in patients with CM-I. The surgical procedure should be modified based on the type of dominant OS to minimize the surgical risks.

Closure of a dural defect as a cause of superficial siderosis: does early dural repair lead to a better outcome? Illustrative case.

BACKGROUND: Superficial hemosiderosis (SS) of the central nervous system is a rare condition that is caused by chronic, repeated hemorrhage into the subarachnoid space. The subsequent deposition of hemosiderin in the brain and spinal cord causes neurological deterioration. In this report, the authors describe a repair procedure for SS associated with a dural defect in the thoracic spine. OBSERVATIONS: A 75-year-old man presented with tinnitus symptoms that began about 1 year prior. Subsequently, his hearing loss progressed, and he gradually became unsteady on walking. Magnetic resonance imaging (MRI) of the head showed diffuse hemosiderin deposition on the surface of the cerebellum. Thoracic MRI showed ventral cerebrospinal fluid leakage of T2-7, and computed tomography myelography showed leakage of contrast medium that appeared to be a dural defect. Dural closure was successful, and MRI showed decreased fluid collection ventral to the dura. The patient's symptoms of wobbliness on walking and tinnitus improved dramatically from the postoperative period. LESSONS: Dural abnormalities of the spine must always be considered as one of the causes of SS. Early dural closure is an effective means of preventing the progression of symptoms.

A Surgical Case of Bow Hunter's Syndrome Diagnosed by Cervical Rotational MRA.

Bow hunter's syndrome is an ischemic manifestation of vertebrobasilar artery (VA) insufficiency due to stenosis or occlusion of the contralateral VA at the bony elements of the atlas and axis during neck rotation. In early reports, VA stenosis at the craniovertebral junction was the main cause, but later, symptoms due to VA occlusion at the middle and lower cervical vertebrae were also included in this pathology. Although the confirmed diagnosis is usually determined by dynamic digital subtraction angiography (DSA), we have experienced a method of minimally invasive MR angiogram (MRA) that provides the same diagnostic value as DSA and would like to present it here. The patient was a 61-year-old man who had been visiting the outpatient clinic for cervical spondylosis due to neck pain for 9 months. When he rotated his neck to the left side, dizziness and syncope appeared. Initial MRA in the neutral position did not show any steno-occlusive changes in the vertebrobasilar artery. In our hospital, repeated MRA with the neck rotated 45 degrees to the left demonstrated ipsilateral left VA severe stenosis. Subsequent DSA showed the same findings, with occlusion of the left VA. CT of the cervical spine revealed a ventral C3/4 osteophyte within the foramen. Based on these findings, instability at the C3-4 during head rotation was considered the cause of the vertebrobasilar insufficiency. The patient underwent anterior discectomy and fusion (ACDF) at the C3/4 level using a cylindrical titanium cage. Immediately after the surgery, the patient's symptoms improved dramatically and did not appear even when the neck were fully rotated to the left. More than 5 years have passed since the surgery, and the patient is still in good health.

Dysphagia after occipital cervical fusion for retro-odontoid pseudotumor with ossification of the anterior longitudinal ligament.

Background: Ossification of the anterior longitudinal ligament (OALL) of the cervical spine is a relatively rare disease. If patients present with dysphagia, hoarseness, and/or dyspnea, they may require surgery. Case Description: Over a 7-month period, a 55-year-old female with a history of cerebral palsy developed a progressive quadriparesis accompanied by diffuse sensory loss (i.e., clumsiness of the hand/legs and gait disturbance). The cervical spine X-rays showed atlanto-axial subluxation with instability, while the cervical MRI demonstrated "pseudotumor in the retro-odontoid" region. Following an occipital cervical fusion (C0-C2) surgery, her quadriparesis resolved. Nevertheless, she had persistent dysphagia that worsened over 6 months. Video fluoroscopy revealed severe mechanical stenosis of the pharynx, which was attributed to OALL extending from the C3-C6 levels. Following OALL resection through a right anterior approach utilizing diamond burrs and an ultrasonic bone curette, the dysphagia rapidly resolved. Conclusion: We report a rare case of retro-odontoid pseudotumor successfully treated with a posterior C0-C2 cervical fusion. Additional symptomatic C3-C6 OALL, responsible for progressive dysphagia, was later managed with focal anterior OALL resection.

Repeated-Manual Aspiration with Maximum Pressure (r-MAX): A New Technique of Mechanical Thrombectomy Using Syringe Aspiration.

Objective: We report a new contact aspiration technique using syringe aspiration called repeated-manual aspiration with maximum pressure (r-MAX). Case Presentation: From January 2020 to May 2021, 18 patients underwent mechanical thrombectomy with r-MAX for occlusion of the internal carotid artery, the first division of the middle cerebral artery (M1), and basilar artery occlusion. In this method, the aspiration catheter is first guided to the occlusion site, and then, two VacLok syringes are connected to the aspiration catheter. Next, the three-way stopcock is released in one direction. After 15 seconds, the direction of the three-way stopcock is switched. In the meantime, negative pressure is reapplied through the syringe, and the direction of the three-way stopcock is switched again. After reapplying negative pressure through the syringe and switching the three-way stopcock two more times, the aspiration catheter is removed. First-pass thrombolysis in cerebral infarction (TICI) scale 3 recanalization was achieved in 11 out of 18 patients (61.1%). In all, 11 patients (61.1%) achieved modified Rankin Scale scores of 0-2 at 90 days. Asymptomatic hemorrhage was observed in two patients (11.1%), and no patients had symptomatic hemorrhage. Conclusion: The r-MAX technique using syringe aspiration can be employed as one of the methods of contact aspiration.

Spinal subarachnoid hemorrhage after percutaneous kyphoplasty: a case report and literature review.

Background: Spinal intradural (subdural and subarachnoid) hematoma following percutaneous kyphoplasty is an extremely rare complication. In this report, we describe a case of subarachnoid hemorrhage with delayed paralysis after kyphoplasty and review the literature on similar cases to describe the complications of kyphoplasty and vertebroplasty (VP). Case Description: An 80-year-old man underwent percutaneous kyphoplasty at a local hospital an osteoporotic vertebral fracture (OVF) at the T12 and L1 level. On the second day after kyphoplasty for T12 OVF, he developed paralysis of the lower limbs. At his initial visit to our clinic, he had a complete loss of sensation below T11 and complete paralysis of both lower extremities. Thoracolumbar magnetic resonance imaging revealed an intradural hematoma on the ventral side of the spinal cord, in the spinal canal from T5 to T12, compressing the spinal cord. Thoracolumbar computed tomography showed a fracture line in the medial cortex of the right pedicle at T12 and a tract from the spinal canal to the vertebral body. An emergency posterior decompression from T11 to L1 was performed. A small hole was found on the right side of the pedicle at T12, and tear of the nerve and subarachnoid hematoma were observed in the vicinity of the T11 nerve root. The subarachnoid hematomas were removed. Postoperatively, the neurological symptoms improved rapidly. Eventually, he was able to walk and was transferred for rehabilitation. Conclusions: Percutaneous surgery through the pedicle might cause hematoma and bone cement leakage into the spinal canal. This can be a serious complication: hence prevention is important.

MRI characteristics of syringomyelia associated with foramen magnum arachnoiditis: differentiation from Chiari malformation.

BACKGROUND: It is important to distinguish foramen magnum arachnoiditis (FMA) from Chiari malformation (CM) before surgery because the operative strategies for these diseases differ. In the current study, we compared pretreatment magnetic resonance imaging (MRI) of FMA with CM and investigated the MRI findings useful to differentiate between these diseases. METHODS: We retrospectively reviewed patients with FMA or CM aged ≥ 18 years who underwent surgeries at our institution between 2007 and 2019. The morphologies of the syrinx, neural elements, and posterior cranial fossa were preoperatively evaluated with MRI. We used the receiver operating characteristic (ROC) curve for the fourth ventricle-to-syrinx distance (FVSD). RESULTS: Ten patients with FMAs and 179 with CMs were included. FVSD in the FMA group was significantly shorter than that in the CM group (7.5 mm [IQR, 2.8-10 mm] in FMA vs. 29.9 mm [IQR, 16.3-52.9 mm] in CM, p < 0.0001). The other MRI findings that showed the height, size, and length of the syrinx; size of the foramen magnum; degree of cerebellar tonsillar descent; shape of the cerebellar tonsil; and dorsal subarachnoid space at the foramen magnum differed significantly between the two groups. The ROC curve analysis showed that patients whose FVSD was less than 11 mm could be diagnosed with FMA with a specificity of 90% and sensitivity of 96%. CONCLUSIONS: A more cranial syrinx development (FVSD < 11 mm) appears to be the characteristic MRI finding in FMA.

COVID-19 Countermeasures in Acute Stroke.

The impact of coronavirus disease 2019 (COVID-19) is continuing, and the most important issue facing medical staff is how to provide medical care while preventing nosocomial infections. Since acute stroke treatment, particularly mechanical thrombectomy, is urgent, infection protection measures may not always be followed, which increases the risk of infection exposure. The measures and methods for patient screening, transport, zoning, and use of personal protective equipment (PPE) employed to prevent nosocomial infections of COVID-19 at our facility are described herein.