Acute intracranial hemorrhage during the installation of the LICOX microdialysis system: A case report.

Neuro-monitoring is widely employed for the evaluation of intubated patients in the intensive care unit with stroke, severe head trauma, subarachnoid hemorrhage and/or hepatic encephalopathy. The present study reports the case of a patient with acute intracranial hemorrhage following the insertion of neuromonitoring catheters, which required surgical management. The patient was a 14-year-old male who sustained a severe traumatic brain injury and underwent a right-sided hemicraniectomy. During the installation of the neuromonitoring catheters, an acute hemorrhage was noted with a rapidly elevating intracranial pressure. A craniotomy was performed to identify and coagulate the injured cortical vessel. As demonstrated herein, the thorough evaluation of the clotting profile of the patient, a meticulous surgical technique and obtaining a post-insertion computed tomography scan may minimize the risk of any neuromonitoring-associated hemorrhagic complications.

Reliability and applicability of a low-cost, camera-based gait evaluation method for clinical use.

BACKGROUND: There is the need for the development of reliable and easy to use in clinical setting gait assessment tools. An open-access video analysis software that administers the calculation of kinematical and spatio-temporal characteristics of human movement is Kinovea® however, its repeatability as a gait analysis tool has not been well addressed. The purpose of the study was to examine the applicability and reliability of an objective, quantitative, low-cost and easy to use in the clinical setting, gait evaluation method, using Kinovea® software. METHODS: Data collected from 44 healthy subjects recording gait in sagittal and frontal plane using two smartphones. Time consumption of the procedure was captured. Kinovea® software was used to calculate kinematical and spatial parameters. RESULTS: Intra- and inter-rater reliability of the video processing as well as intra-rater reliability of the measurement procedure represented good to excellent and there were less random measurement errors. There was no measurement error due to random variation for the most of the calculated parameters, except of the pelvis position. CONCLUSIONS: The results suggest that excepting low accuracy in calculation of pelvis position, gait evaluation using Kinovea® software is objective, quantitative, low-cost, reliable and easy to use in the clinical setting.

Comments on "Neonatal infratentorial subdural hematoma contributing to obstructive hydrocephalus in the setting of therapeutic cooling: A case report".

Although therapeutic hypothermia (TH) contributes significantly in the treatment of hypoxic ischemic encephalopathy (HIE), it could result in devastating complications such as intracranial hemorrhages. Laboratory examinations for possible coagulation disorders and early brain imaging can detect all these cases that are amenable to aggravation of HIE after the initiation of TH.

The Role of Cervical Muscles Morphology in the Surgical Treatment of Degenerative Disc Disease: Clinical Correlations Based on Magnetic Resonance Imaging Studies.

Cervical spine musculature still remains a less studied component of the cervical spine anatomical compartments, although it plays a significant role in the mobility of the head and the preservation of cervical spine alignment. The goal of this study was to extract any significant information from the literature regarding the role of cervical spine muscles morphology in the outcome of surgically treated patients for degenerative disc disease (DDD) based on preoperative magnetic resonance imaging (MRI) studies. Eleven clinical case series were found, from which four were prospective and seven were retrospective. Six studies were concentrated on anterior approaches and five studies on posterior approaches in the cervical spine. In posterior approaches aiming at the preservation of muscles attachments and overall less surgical manipulations, results on cervical lordosis, axial pain and patient's functionality were found superior to traditional laminectomies. The study of cross-sectional areas (CSAs) of deep paraspinal muscles in the cervical spine could add significant information for the spine surgeon such as the prediction of adjacent level disease (ALD), fusion failure, axial pain persistence, postoperative cervical alignment and patient's postoperative functionality. It seems that MRI studies focusing on muscle layers of the cervical spine could add significant information for the spinal surgeon regarding the final surgical outcome in terms of pain and function expression. Larger multicenter clinical studies are a necessity in defining the role of the muscle component of the cervical spine in the surgical treatment of DDD.

Brain abscess in a rheumatoid arthritis patient treated with leflunomide - A case presentation and review.

BACKGROUND: Immunosuppression is a significant parameter in the pathogenesis of brain abscesses (BA) and it could be the result of severe infections such as acquired immunodeficiency syndrome or drug-induced, by several medications used for systemic autoimmune diseases. Leflunomide is a pyrimidine synthesis inhibitor that affects the proliferation of lymphocytes and is used as a disease-modifying antirheumatic drug. Mild infections, particularly those of the respiratory tract and herpes zoster, are one of its most common adverse effects. However, atypical and severe infections have also been reported under treatment with leflunomide. CASE DESCRIPTION: A 70-year old female was referred to our hospital with headache, aphasia, and right-sided hemiparesis and a lesion of the left parietal lobe initially interpreted as a malignancy. Her medical history revealed a 12-year old history of rheumatoid arthritis under current treatment with leflunomide. A cerebral magnetic resonance imaging (MRI) revealed typical findings for a BA. She subsequently underwent a left craniotomy, which confirmed the MRI-based diagnosis. The abscess was evacuated and cultures were obtained intraoperatively. In the postoperative examination, the patient showed no neurological deficit. CONCLUSION: The differential diagnostic considerations in immunocompromised patients with neurologic deficits should include focal central nervous system infections such as a BA, even in the absence of fever or immunosuppressant-induced leukopenia. It also demonstrates the importance of early neurosurgical intervention for the prevention of sequelae. To the best of our knowledge, this is the second-to-date reported case of a BA under immunomodulatory therapy with leflunomide.

Holospinal epidural abscess in elderly patient: A case presentation and review.

BACKGROUND: Holospinal epidural abscess (HEA) is a rare pathological entity with significant morbidity and mortality rates. Here, we present a 74-year-old male with HEA treated with focal skip laminectomies and catheter irrigation. CASE DESCRIPTION: A 74-year-old male presented with fever, neck/back pain, and slight weakness in his legs bilaterally (4/5). The patient underwent a magnetic resonance imaging (MRI) of the entire spine showing an epidural collection extending from C5-C6 to the L4-L5 levels. Laboratory studies revealed a leukocytosis and an elevated C-reaction protein level. Blood cultures were positive for methicillin-sensitive Staphylococcus aureus. The patient underwent skip laminectomies at C6 and C7; T2, T3, T5, T6, T8, T9, T10, and T12; and L3, L4, and L5 with catheter irrigation between these levels; this minimized the risk of postoperative kyphosis and instability. His postoperative course was uneventful. Other surgical approaches to HEA described in literature include laminectomy, focal laminectomies, and skip laminectomies. CONCLUSION: In this case of a holospinal HEA, skip laminectomies and catheter irrigation avoided neurological deterioration and delayed spinal instability in a 74-year-old male.

Next-Generation Robotic Spine Surgery: First Report on Feasibility, Safety, and Learning Curve.

BACKGROUND: Pedicle screw placement is a commonly performed procedure. Robot-guided screw placement is a recent technological advance that has shown accuracy and reliability with first-generation platforms. OBJECTIVE: To report our initial experience with the safety, feasibility, and learning curve associated with pedicle screw placement utilizing next-generation robotic guidance. METHODS: A retrospective chart review was conducted to obtain data for 20 patients who underwent lumbar pedicle screw placement under robotic guidance after undergoing interbody fusion for lumbar spinal stabilization for degenerative disc disease with or without spondylolisthesis. The newest generation Mazor X (Mazor Robotics Ltd, Caesarea, Israel) was used. Accuracy of screw placement was determined to be grade I to IV. Grade I was in the pedicle (no breach/deviation), grade II was breach < 2 mm, grade III was breach 2 to 4 mm, and grade IV was breach >4 mm; breach direction (superior, lateral, inferior, or medial) was also recorded. RESULTS: Twenty patients underwent robotically assisted pedicle screw placement of 75 screws at 24 levels. Seventy-four screw placements (98.7%) were grade I; 1 (1.3%) was grade II (medial). No complications occurred. Mean time for screw insertion was 3.6 min. Mean fluoroscopy time was 13.1 s and mean radiation dose was 29.9 mGy. CONCLUSION: We found that next-generation robotic spine surgery was safe and feasible with reliable and precise accuracy and a minimal learning curve. As this technology improves, further novel applications are expected to develop. Further research is needed to determine long-term efficacy.

Comparing Next-Generation Robotic Technology with 3-Dimensional Computed Tomography Navigation Technology for the Insertion of Posterior Pedicle Screws.

OBJECTIVE: To study the differences between robot-guided (Mazor X, Mazor Robotics Ltd., Caesarea, Israel) and 3-dimensional (3D) computed tomography (CT) navigation (O-arm Surgical Imaging System, Medtronic, Minneapolis, Minnesota, USA) for the insertion of pedicle screws. METHODS: We reviewed the charts of 50 patients who underwent robot-guided pedicle screw insertion (between May 2017-October 2017), and 49 patients who underwent 3D-CT navigation pedicle screw insertion (between September 2015-August 2016). Variables included were age, sex, body mass index, blood loss, length of stay, lumbar level(s), operation time, fluoroscopy time, radiation dose, accuracy, and time-per-screw placement. RESULTS: Mean ages were 59.3 years in the robotic group and 58.2 years in the 3D-CT navigation group. Mean was 30.7 kg/m2 in the robotic group and 32.1 kg/m2 in the 3D-CT navigation group. Mean time-per-screw placement was 3.7 minutes for the robotic group and 6.8 minutes for the 3D-CT navigation group, P < 0.001. In the robotic group, 189 of 190 screws were placed with Ravi grade I accuracy, and 1 was grade II. In the 3D-CT navigation group, 157 of 165 screws were Ravi grade I, and 8 were grade II (P = 0.11). Fluoroscopy time (P < 0.001), time-per-screw placement (P < 0.001), and length of stay (P < 0.001) were significantly lower in the robotic group. CONCLUSIONS: Both technologies are safe and accurate. Robotic technology exposed patients to less fluoroscopy time, decreased time-per-screw placement and shorter hospital stay than 3D-CT navigation. Further studies are warranted to verify our results.

Bowel injury in lumbar spine surgery: a review of the literature.

Although rarely documented in the medical literature, bowel perforation injury can be a severe complication of spine surgery. Our goal was to review current literature regarding this complication and study possible methods of avoidance. We conducted a literature search in the PubMed database between January 1960 and March 2016 using the terms abrasion, bowels, bowel, complication, injury, intestine, intra-abdominal sepsis/shock, perforation, lumbar, spine, surgery, visceral. Diagnostic criteria, outcomes, risk factors, surgical approach, and treatment strategy were the parameters extracted from the search results and used for review. Thirty-one patients with bowel injury were recognized in the literature. Bowel injury was more frequent in patients who underwent lumbar discectomy and microdiscectomy (18 of 31 patients, 58.1%). Minimally invasive surgery and lateral techniques involving fusions accounted for 10 of the reported cases (32.3%). Finally, 2 cases (6.5%) were reported in conjunction with sacrectomies and 1 case (3.2%) with posterior fusion plus anterior longitudinal ligament (ALL) release. Diagnosis was made mostly by clinical signs/symptoms of acute abdominal pain, post-surgical wound infection, and abscess or enterocutaneous fistulas. Significant risk factors for postoperative bowel injury were complex surgical anatomy, medical history of previous abdominal surgeries or infections, irradiation before surgery, errors related to surgical technique, lack of surgical experience, and instrumentation failure. The overall mortality rate from bowel injury was 12.9% (4 of 31 patients). The overall morbidity rate was 87.1% (27 of 31 patients). According to our review of the literature, bowel injury is linked to significant morbidity and mortality. It can be prevented with meticulous pre-surgical planning. When it occurs, timely treatment reduces the risks of morbidity and mortality.

Cervical sagittal balance parameters after single-level anterior cervical discectomy and fusion: Correlations with clinical and functional outcomes.

BACKGROUND: Normal sagittal cervical alignment has been associated with improved outcome after anterior cervical discectomy and fusion (ACDF). OBJECTIVE: The aim of this study is to identify alterations of cervical sagittal balance parameters after single-level ACDF and assess correlations with postoperative functionality. METHODS: A retrospective chart review was performed between January 2010 and January 2014 to identify adult patients with no previous cervical spine surgery who underwent ACDF at any one level between C2 and C7 for the single-level degenerative disease. Tumor, infection, and trauma cases were excluded from the study. For the included cases, the following data were recorded preoperatively and 6 months-1 year after surgery: sagittal balance-marker measurements of the C1-C2 angle, C2-C7 angle, C7 slope, segmental angle at the operated level, and sagittal vertical axis (SVA) distance between C2 and C7, as well as the neck disability index and visual analog scale of pain. RESULTS: The present study included 47 patients (average age: 51.2 years; range: 28-86 years). A moderate negative correlation between a smaller C2-C7 angle and the presence of right arm pain before treatment was found (P = 0.0281). Postoperatively, functionality scores significantly improved in all patients. C1-C2 angle increased with statistical significance (P = 0.0255). C2-C7 angle, segmental angle, C7 slope, and SVA C2-C7 distance did not change with statistical significance after surgery. C7 slope significantly correlated with overall cervical sagittal balance (P < 0.05). CONCLUSIONS: Single-level ACDF significantly increases upper cervical lordosis (C1-C2) without significantly changing lower cervical lordosis (C2-C7). The C7 slope is a significant marker of overall cervical sagittal alignment (P < 0.05).

Correlation of Clinical and Radiological Outcome After Anterior Cervical Discectomy and Fusion With a Polyetheretherketone Cage.

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) with a polyetheretherketone (PEEK) cage is considered as the gold standard for patients with cervical disc disease. However, there are limited in vivo data on the impact of ACDF on the cervical kinematics and its association with patient-reported clinical outcomes. The purpose of this study was to investigate the impact of altered cervical sagittal alignment (cervical lordosis) and sagittal range of motion (ROM) on patients' self-reported pain and functional disability, after ACDF with a PEEK cage. METHODS: We prospectively studied 74 patients, who underwent single-, or consecutive two-level ACDF with a PEEK interbody cage. The clinical outcomes were assessed by using the pain numeric rating scale (NRS) and the neck disability index (NDI). Radiological outcomes included cervical lordosis and C2-C7 sagittal ROM. The outcome measures were collected preoperatively, at the day of patients' hospital discharge, and also at 6 and 12 months postoperatively. RESULTS: There was a statistically significant reduction of the NRS and NDI scores postoperatively at each time point (P < 0.005). Cervical lordosis and also ROM significantly reduced until the last follow-up (P < 0.005). There was significant positive correlation between NRS and NDI preoperatively, as well as at 6 and 12 months postoperatively (P < 0.005). In regard to the ROM and the NDI scores, there was no correlation preoperatively (P = 0.199) or postoperatively (6 months, P = 0.322; 12 months, P = 0.476). Additionally, there was no preoperative (P = 0.134) or postoperative (6 months, P = 0.772; 12 months, P = 0.335) correlation between the NDI scores and cervical lordosis. CONCLUSIONS: In our study, reduction of cervical lordosis and sagittal ROM did not appear to significantly influence on patients' self-reported disability. Such findings further highlight the greater role of pain level over the mechanical limitations of ACDF with a PEEK cage on patients' own perceived recovery.

The role of steroid administration in the management of dysphagia in anterior cervical procedures.

Dysphagia is a common postoperative symptom for patients undergoing anterior cervical spine procedures. The purpose of this study is to present the current literature regarding the effect of steroid administration in dysphagia after anterior cervical spine procedures. We performed a literature search in the PubMed database, using the following terms: "dysphagia," "ACDF," "cervical," "surgery," "anterior," "spine," "steroids," "treatment," and "complications." We included in our review any study correlating postoperative dysphagia and steroid administration in anterior cervical spine surgery. Studies, which did not evaluate, pre- and postoperatively, dysphagia with a specific clinical or laboratory methodology were excluded from our literature review. Five studies were included in our results. All were randomized, prospective studies, with one being double blinded. Steroid administration protocol was different in every study. In two studies, dexamethasone was used. Methylprednisolone was administrated in three studies. In four studies, steroids were applied intravenously, while in one study, locally in the retropharyngeal space. Short-term dysphagia and prevertebral soft tissue edema were diminished by steroid administration, according to the results of two studies. In one study, prevertebral soft tissue edema was not affected by the steroid usage. Furthermore, short-term osseous fusion rate was impaired by the steroid administration, according to the findings of one study. The usage of steroids in patients undergoing anterior cervical spine procedures remains controversial. Multicenter, large-scale, randomized, prospective studies applying the same protocol of steroid administration and universal outcome criteria should be performed for extracting statistically powerful and clinically meaningful results.

Anterior cervical spine surgery-associated complications in a retrospective case-control study.

Anterior cervical spine procedures have been associated with satisfactory outcomes. However, the occurrence of troublesome complications, although uncommon, needs to be taken into consideration. The purpose of our study was to assess the actual incidence of anterior cervical spine procedure-associated complications and identify any predisposing factors. A total of 114 patients undergoing anterior cervical procedures over a 6-year period were included in our retrospective, case-control study. The diagnosis was cervical radiculopathy, and/or myelopathy due to degenerative disc disease, cervical spondylosis, or traumatic cervical spine injury. All our participants underwent surgical treatment, and complications were recorded. The most commonly performed procedure (79%) was anterior cervical discectomy and fusion (ACDF). Fourteen patients (12.3%) underwent anterior cervical corpectomy and interbody fusion, seven (6.1%) ACDF with plating, two (1.7%) odontoid screw fixation, and one anterior removal of osteophytes for severe Forestier's disease. Mean follow-up time was 42.5 months (range, 6-78 months). The overall complication rate was 13.2%. Specifically, we encountered adjacent intervertebral disc degeneration in 2.7% of our cases, dysphagia in 1.7%, postoperative soft tissue swelling and hematoma in 1.7%, and dural penetration in 1.7%. Additionally, esophageal perforation was observed in 0.9%, aggravation of preexisting myelopathy in 0.9%, symptomatic recurrent laryngeal nerve palsy in 0.9%, mechanical failure in 0.9%, and superficial wound infection in 0.9%. In the vast majority anterior cervical spine surgery-associated complications are minor, requiring no further intervention. Awareness, early recognition, and appropriate management, are of paramount importance for improving the patients' overall functional outcome.

Spontaneous intraventricular rupture of a craniopharyngioma cyst: A case report.

Intraventricular rupture of craniopharyngioma cysts is an unusual event which is associated with a high risk of loculated or communicating hydrocephalus. A 75-year-old woman presented at the Emergency Department of our hospital with mental status deterioration due to chemical ventriculitis and acute hydrocephalus following the intraventricular rupture of a craniopharyngioma cyst. The patient was treated with stress-dose steroid therapy. In addition, she underwent placement of an external ventricular drain and endoscopy-assisted intra-cystic placement of an Ommaya reservoir for the aspiration of the cystic fluid. The patient's condition improved; she was shunted in an expeditious fashion and discharged from the Intensive Care Unit within 2 weeks of her admission with the reservoir in place for the continued drainage of the cyst.

The Role of Gait Analysis in the Evaluation of Patients with Cervical Myelopathy: A Literature Review Study.

BACKGROUND: Gait analysis represents one of the newest methodologies used in the clinical evaluation of patients with cervical myelopathy (CM). OBJECTIVE: To describe the role of gait analysis in the clinical evaluation of patients with CM, as well as its potential role in the evaluation of the functional outcome of any surgical intervention. METHODS: A literature review was performed in the PubMed, OVID, and Google Scholar medical databases, from January 1995 to August 2016, using the terms "analysis," "anterior," "cervical myelopathy," "gait," "posterior," and "surgery." Clinical series comparing the gait patterns of patients with CM with healthy controls, as well as series evaluating gait and walk changes before and after surgical decompression, were reviewed. Case studies were excluded. RESULTS: Nine prospective and 3 retrospective studies were found. Most of the retrieved studies showed the presence of characteristic, abnormal gait patterns among patients with CM, consisting of decreased gait speed, cadence, step length, stride length, and single-limb support time. In addition, patients with CM routinely present increased step and stride time, double-limb support time, and step width, and they have altered knee and ankle joint range of motion, compared with healthy controls. Moreover, gait and walk analysis may provide accurate functional assessment of the functional outcome of patients with CM undergoing surgical decompression. CONCLUSIONS: Gait analysis may well be a valuable and objective tool along with other parameters in the evaluation of functionality in patients with CM, as well as in the assessment of the outcome of any surgical intervention in these patients.

Percutaneous screw placement in the lumbar spine with a modified guidance technique based on 3D CT navigation system.

Several guidance techniques have been employed to increase accuracy and reduce surgical time during percutaneous placement of pedicle screws (PS). The purpose of our study was to present a modified technique for percutaneous placement of lumbar PS that reduces surgical time. We reviewed 23 cases of percutaneous PS placement using our technique for minimally invasive lumbar surgeries and 24 control cases where lumbar PS placement was done via common technique using Jamshidi needles (Becton, Dickinson and Company, Franklin Lakes, NJ, USA). An integrated computer-guided navigation system was used in all cases. In the technique modification, a handheld drill with a navigated guide was used to create the path for inserting guidewires through the pedicles and into the vertebral bodies. After drill removal, placement of the guidewires through the pedicles took place. The PS were implanted over the guidewires, through the pedicles and into the vertebral bodies. Intraoperative computed tomography was performed after screw placement to ensure optimal positioning in all cases. There were no intraoperative complications with either technique. PS placement was correct in all cases. The average time for each PS placement was 6.9 minutes for the modified technique and 9.2 minutes for the common technique. There was no significant difference in blood loss. In conclusion, this modified technique is efficient and contributes to reduced operative time.

Magnetic Resonance Spectroscopy and Single-Photon Emission Computed Tomography in the Evaluation of Cerebral Tumors: A Case Report.

In their daily clinical practice, physicians have to confront diagnostic dilemmas which cannot be resolved by the application of only one imaging technique. In this case report, we present a 66-year-old woman who was admitted to our institution for the surgical resection of a recently diagnosed brain tumor. The patient had a history of epileptic seizures and was hospitalized in the past for anti-phospholipid syndrome related to a non-Hodgkin lymphoma in remission. Magnetic resonance imaging (MRI) examination revealed an enhancing right parasagittal lesion with significant edema suggestive of a high grade glioma. Advanced MRI techniques including proton magnetic resonance spectroscopy (1H-MRS) showed findings compatible of glioma. An additional examination was performed as part of a protocol that we are routinely performing in our institution for all brain tumors including not only the gold standard advanced MRI techniques but also single-photon emission computed tomography (SPECT) with technetium-99m (Tc99m). Brain SPECT indicated the presence of a meningioma which was verified by the histopathology of the resected specimen. In conclusion, a multimodality approach for the pre-surgical assessment of brain tumors has significant advantages not only for the diagnosis but also for the evaluation of intracranial tumors histology.