Pediatric parapharyngeal infection resulting in cervical instability and occipital-cervical fusion-case report and review of the literature.

Parapharyngeal infection is the most common deep neck space infection in children and, in rare instances, can result in bony destruction of the cervical spine. We report one such case that required occipital to cervical fusion and halo-vest fixation. We also review the literature and discuss the etiology, diagnosis, and treatment options for managing pediatric cervical bony destruction secondary to infection.

Stereotactic radiosurgery for central nervous system hemangioblastoma: systematic review and meta-analysis.

Hemangioblastomas are rare, benign, vascular tumors of the central nervous system (CNS), often associated with von-hippel lindau (VHL) disease. Current therapeutic options include microsurgical resection or stereotactic radiosurgery (SRS). With no randomized controlled studies and minimal data beyond single-institution reviews, the optimal management approach for patients with CNS hemangioblastomas is unclear. We completed a Pubmed/SCOPUS literature search from January 1990 to January 2017 for eligible studies on SRS for CNS hemangioblastomas. Relevant articles were identified and reviewed in accordance to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. 26 studies met eligibility criteria for qualitative synthesis, representing 596 subjects and 1535 tumors. The Gamma Knife was the most published SRS method for CNS hemangioblastomas. After critical study appraisal for intra-study bias, 14 studies were used for quantitative meta-analysis of 5-year progression free survival (PFS). The pooled 5-year PFS across all eligible studies was 88.4%. No difference was observed between spine versus intracranial studies. Individual patient data (IPD) was extracted from 14 studies, representing 322 tumors. Univariate analysis of IPD revealed that VHL patients were younger, and had smaller tumors compared to those with sporadic disease. Adverse events were associated with increasing marginal dose, independent of tumor volume. VHL status, sex, radiosurgical method, tumor location, and tumor volume were not found to be significantly associated with tumor progression. Multiple studies show excellent tumor control at 5-year follow up, however, the long-term efficacy of SRS for CNS hemangioblastomas still needs to be investigated, and the studies exploring the role of SRS for early treatment of asymptomatic lesions is wanting.

Navigated lumbar drain placement: A description of technique and case example.

Background: Lumbar drain (LD) placement can be a difficult procedure leading to postprocedure complications, particularly in patients with persistent cerebrospinal fluid leaks or a large body habitus. The objective of this technical case report is to describe the use of Medtronic's SureTrak Navigation system for navigated LD placement. Case Description: The patient was an 18-year-old morbidly obese male who initially underwent a suboccipital craniectomy with duraplasty and a C1 laminectomy for Chiari Malformation. Postoperatively, he developed a pseudomeningocele and was taken to the operating room for wound revision, duraplasty repair, and LD placement. Medtronic's SureTrak Navigation system was used for LD placement before wound revision. Successful LD placement was achieved in a single pass using the SureTrak Navigation. The patient did well postoperatively, and LD removal occurred on postoperative day 6. The patient was discharged in good condition without evidence of a cerebral spinal fluid leak. Conclusion: Navigation using the SureTrak system is a reasonable option to use in patients with a high body mass index and a persistent cerebrospinal fluid leak. When the patient is already undergoing an operative procedure, it can aid in an efficient low-risk intervention completed in a single prone positioning.

The Device for Intraventricular Entry guide: a novel solution to a perpetual problem.

OBJECTIVE: The authors designed a low-profile device for reliable ventricular access and prospectively studied its safety, efficacy, and accuracy at a large academic center. METHODS: A novel device for ventricular entry, the Device for Intraventricular Entry (DIVE) guide, was designed and created by the first and senior authors. Fifty patients undergoing external ventricular drainage (EVD) or shunt placement were prospectively enrolled for DIVE-assisted catheter placement at a single academic center. The primary outcome was the catheter tip location on postprocedural CT. Secondary outcomes included number of catheter passes, clinically significant hemorrhages, and procedure-related infections. RESULTS: Fifty patients were enrolled. Indications included subarachnoid hemorrhage, intraventricular hemorrhage, traumatic brain injury, hydrocephalus, pseudotumor, and postsurgical wound drainage. In total, 76% (38/50) of patients underwent right-sided placement and 24% (12/50) underwent left-sided placement. All 100% (50/50) of patients had successful cannulation with an average of 1.06 passes. Postprocedural head CT confirmed ipsilateral frontal horn or third ventricle placement (Kakarla grade 1) in 92% (46/50) of patients and placement in the contralateral lateral ventricle in 8% (4/50) (Kakarla grade 2). There were no clinically significant track hemorrhages or procedural infections. CONCLUSIONS: This single-center prospective study investigated the safety and efficacy of DIVE-assisted ventricular access. In total, 100% of procedures had successful ventricular cannulation, with 92% achieving Kakarla grade 1, with an average of 1.06 passes without any clinical complications.

Neurosurgeons Deliver Similar Quality Care Regardless of First Assistant Type: Resident Physician versus Nonphysician Surgical Assistant.

OBJECTIVE: There are limited data evaluating the outcomes of attending neurosurgeons with different types of first assistants. This study considers a common neurosurgical procedure (single-level, posterior-only lumbar fusion surgery) and examines whether attending surgeons deliver equal patient outcomes, regardless of the type of first assistant (resident physician vs. nonphysician surgical assistant [NPSA]), among otherwise exact-matched patients. METHODS: The authors retrospectively analyzed 3395 adult patients undergoing single-level, posterior-only lumbar fusion at a single academic medical center. Primary outcomes included readmissions, emergency department visits, reoperation, and mortality within 30 and 90 days after surgery. Secondary outcome measures included discharge disposition, length of stay, and length of surgery. Coarsened exact matching was used to match patients on key demographics and baseline characteristics known to independently affect neurosurgical outcomes. RESULTS: Among exact-matched patients (n = 1402), there was no significant difference in adverse postsurgical events (readmission, emergency department visits, reoperation, or mortality) within 30 days or 90 days of the index operation between patients who had resident physicians and those who had NPSAs as first assistants. Patients who had resident physicians as first assistants demonstrated a longer length of stay (mean: 100.0 vs. 87.4 hours, P < 0.001) and a shorter duration of surgery (mean: 187.4 vs. 213.8 minutes, P < 0.001). There was no significant difference between the two groups in the percentage of patients discharged home. CONCLUSIONS: For single-level posterior spinal fusion, in the setting described, there are no differences in short-term patient outcomes delivered by attending surgeons assisted by resident physicians versus NPSAs.

Rapid intraoperative diagnosis of pediatric brain tumors using Raman spectroscopy: A machine learning approach.

Background: Surgical resection is a mainstay in the treatment of pediatric brain tumors to achieve tissue diagnosis and tumor debulking. While maximal safe resection of tumors is desired, it can be challenging to differentiate normal brain from neoplastic tissue using only microscopic visualization, intraoperative navigation, and tactile feedback. Here, we investigate the potential for Raman spectroscopy (RS) to accurately diagnose pediatric brain tumors intraoperatively. Methods: Using a rapid acquisition RS device, we intraoperatively imaged fresh ex vivo brain tissue samples from 29 pediatric patients at the Lucile Packard Children's Hospital between October 2018 and March 2020 in a prospective fashion. Small tissue samples measuring 2-4 mm per dimension were obtained with each individual tissue sample undergoing multiple unique Raman spectra acquisitions. All tissue samples from which Raman spectra were acquired underwent individual histopathology review. A labeled dataset of 678 unique Raman spectra gathered from 160 samples was then used to develop a machine learning model capable of (1) differentiating normal brain from tumor tissue and (2) normal brain from low-grade glioma (LGG) tissue. Results: Trained logistic regression model classifiers were developed using our labeled dataset. Model performance was evaluated using leave-one-patient-out cross-validation. The area under the curve (AUC) of the receiver-operating characteristic (ROC) curve for our tumor vs normal brain model was 0.94. The AUC of the ROC curve for LGG vs normal brain was 0.91. Conclusions: Our work suggests that RS can be used to develop a machine learning-based classifier to differentiate tumor vs non-tumor tissue during resection of pediatric brain tumors.

Impact of the 2016 American College of Surgeons Guideline Revision on Overlapping Lumbar Fusion Cases at a Large Academic Medical Center.

OBJECTIVE: The American College of Surgeons (ACS) updated its guidelines on overlapping surgery in 2016. The objective was to examine differences in postoperative outcomes after overlapping surgery either pre-ACS guideline revision or post-guideline revision, in a coarsened exact matching sample. METHODS: A total of 3327 consecutive adult patients undergoing single-level posterior lumbar fusion from 2013 to 2019 were retrospectively analyzed. Patients were separated into a pre-ACS guideline revision cohort (surgery before April 2016) or a post-guideline revision cohort (surgery after October 2016) for comparison. The primary outcomes were proportion of cases performed with any degree of overlap, and adverse events including 30-day and 90-day rates of readmission, reoperation, emergency department visit, morbidity, and mortality. Subsequently, coarsened exact matching was used among overlapping surgery patients only to assess the impact of the ACS guideline revision on overlapping outcomes, and controlling for attending surgeon and key patient characteristics known to affect surgical outcomes. RESULTS: After the implementation of the ACS guidelines, fewer cases were performed with overlap (22.0% vs. 53.7%; P < 0.001). Patients in the post-ACS guideline revision cohort experienced improved rates of readmission and reoperation within 30 and 90 days. However, when limited to overlapping cases only, no differences were observed in overlap outcomes pre-ACS versus post-ACS guideline revision. Similarly, when exact matched on risk-associated patient characteristics and attending surgeon, overlapping surgery patients pre-ACS and post-ACS guideline revision experienced similar rates of 30-day and 90-day outcomes. CONCLUSIONS: After the ACS guideline revision, no discernable impact was observed on postoperative outcomes after lumbar fusion performed with overlap.

Spatiotemporal changes in along-tract profilometry of cerebellar peduncles in cerebellar mutism syndrome.

Cerebellar mutism syndrome, characterised by mutism, emotional lability and cerebellar motor signs, occurs in up to 39% of children following resection of medulloblastoma, the most common malignant posterior fossa tumour of childhood. Its pathophysiology remains unclear, but prior studies have implicated damage to the superior cerebellar peduncles. In this study, the objective was to conduct high-resolution spatial profilometry of the cerebellar peduncles and identify anatomic biomarkers of cerebellar mutism syndrome. In this retrospective study, twenty-eight children with medulloblastoma (mean age 8.8 ± 3.8 years) underwent diffusion MRI at four timepoints over one year. Forty-nine healthy children (9.0 ± 4.2 years), scanned at a single timepoint, served as age- and sex-matched controls. Automated Fibre Quantification was used to segment cerebellar peduncles and compute fractional anisotropy (FA) at 30 nodes along each tract. Thirteen patients developed cerebellar mutism syndrome. FA was significantly lower in the distal third of the left superior cerebellar peduncle pre-operatively in all patients compared to controls (FA in proximal third 0.228, middle and distal thirds 0.270, p = 0.01, Cohen's d = 0.927). Pre-operative differences in FA did not predict cerebellar mutism syndrome. However, post-operative reductions in FA were highly specific to the distal left superior cerebellar peduncle, and were most pronounced in children with cerebellar mutism syndrome compared to those without at the 1-4 month follow up (0.325 vs 0.512, p = 0.042, d = 1.36) and at the 1-year follow up (0.342, vs 0.484, p = 0.038, d = 1.12). High spatial resolution cerebellar profilometry indicated a site-specific alteration of the distal segment of the superior cerebellar peduncle seen in cerebellar mutism syndrome which may have important surgical implications in the treatment of these devastating tumours of childhood.

Age-dependent Intracranial Artery Morphology in Healthy Children.

PURPOSE: Evaluation of intracranial artery morphology plays an important role in diagnosing a variety of neurovascular diseases. In addition to clinical symptoms, diagnosis currently relies on qualitative rather than quantitative evaluation of vascular imaging sequences, such as magnetic resonance angiography (MRA). However, there is a paucity of literature on normal arterial morphology in the pediatric population across brain development. We aimed to quantitatively assess normal, age-related changes in artery morphology in children. METHODS: We performed retrospective analysis of pediatric MRA data obtained from a tertiary referral center. An MRA dataset from 98 children (49 boys/49 girls) aged 0.6-20 years (median = 11.5 years) with normal intracranial vasculature was retrospectively collected between 2011 and 2018. All arteries were automatically segmented to determine the vessel radius. Using an atlas-based approach, the average radius and density of arteries were measured in the three main cerebral vascular territories and the radius of five major arteries was determined at corresponding locations. RESULTS: The radii of the major arteries as well as the average artery radius and density in the different vascular territories in the brain remained constant throughout childhood and adolescence (|r| < 0.369 in all cases). CONCLUSION: This study presents the first automated evaluation of intracranial vessel morphology on MRA across childhood. Our results can serve as a framework for quantitative evaluation of cerebral vessel morphology in the setting of pediatric neurovascular diseases.

Fluoroscopic versus CT-guided cortical bone trajectory pedicle screw fixation: Comparing trajectory related complications.

Cortical bone trajectory (CBT) pedicle screw fixation is an emerging technique for treatment of degenerative spine disease which requires either intraoperative fluoroscopy or intraoperative CT guidance (iCT). To date, there has been no direct comparison of these two navigation modalities; here we compare fluoroscopic versus iCT navigation for CBT pedicle screw fixation. We retrospectively reviewed all patients who underwent CBT screw fixation with either fluoroscopic or iCT guidance for lumbar degenerative disease by the senior author. Trajectory-related complications such as medial or lateral breach were compared on postoperative CT, in addition to the incidence of trajectory-related dural tear. We also compared general surgical complications such as postoperative infection and decompression related durotomies. Thirty-eight patients (19 fluoroscopic, 19 CT-guided) who underwent placement of 182 cortical screws (88 fluoroscopic, 94 CT-guided) were identified. In terms of trajectory-related complications, the iCT cohort had fewer medial breaches (1/94) compared to the fluoroscopic cohort (6/88) (p = 0.05). Each group had one lateral breach (p = 0.73). There was one case of CSF leak from screw placement in the fluoroscopic cohort, but none in the iCT cohort (p = 0.48). Overall, there were eight trajectory-related complications in the fluoroscopic cohort versus two in the iCT cohort (p = 0.04). Our data suggests statistically significant decreased trajectory-related complications with iCT-guided CBT screw fixation as compared to fluoroscopically guided. In terms of general surgical complications, while we observed increased postoperative infections in our fluoroscopic cohort, there was no statistically significant difference.

Metastatic Paraganglioma of the Spine With SDHB Mutation: Case Report and Review of the Literature.

BACKGROUND: Paragangliomas (PGLs) are rare neuroendocrine tumors that can arise from any autonomic ganglion of the body. Most PGLs do not metastasize. Here, we present a rare case of metastatic PGL of the spine in a patient with a germline pathogenic succinate dehydrogenase subunit B (SDHB) mutation. METHODS: In addition to a case report we provide a literature review of metastatic spinal PGL to highlight the importance of genetic testing and long-term surveillance of these patients. RESULTS: A 45-year-old woman with history of spinal nerve root PGL, 17 years prior, presented with back pain of several months' duration. Imaging revealed multilevel lytic lesions throughout the cervical, thoracic, and lumbar spine as well as involvement of the right mandibular condyle and clavicle. Percutaneous biopsy of the L1 spinal lesion confirmed metastatic PGL and the patient underwent posterior tumor resection and instrumented fusion of T7-T11. Postoperatively the patient was found to have a pathogenic SDHB deletion. CONCLUSIONS: Patients with SDHx mutation, particularly SDHB, have increased risk of developing metastatic PGLs. Consequently, these individuals require long-term surveillance given the risk for developing new tumors or disease recurrence, even years to decades after primary tumor resection. Surgical management of spinal metastatic PGL involves correcting spinal instability, minimizing tumor burden, and alleviating epidural cord compression. In patients with metastatic PGL of the spine, genetic testing should be considered.

Molecular correlates of cerebellar mutism syndrome in medulloblastoma.

BACKGROUND: Cerebellar mutism syndrome (CMS) is a common complication following resection of posterior fossa tumors, most commonly after surgery for medulloblastoma. Medulloblastoma subgroups have historically been treated as a single entity when assessing CMS risk; however, recent studies highlighting their clinical heterogeneity suggest the need for subgroup-specific analysis. Here, we examine a large international multicenter cohort of molecularly characterized medulloblastoma patients to assess predictors of CMS. METHODS: We assembled a cohort of 370 molecularly characterized medulloblastoma subjects with available neuroimaging from 5 sites globally, including Great Ormond Street Hospital, Christian Medical College and Hospital, the Hospital for Sick Children, King Hussein Cancer Center, and Lucile Packard Children's Hospital. Age at diagnosis, sex, tumor volume, and CMS development were assessed in addition to molecular subgroup. RESULTS: Overall, 23.8% of patients developed CMS. CMS patients were younger (mean difference -2.05 years ± 0.50, P = 0.0218) and had larger tumors (mean difference 10.25 cm3 ± 4.60, P = 0.0010) that were more often midline (odds ratio [OR] = 5.72, P < 0.0001). In a multivariable analysis adjusting for age, sex, midline location, and tumor volume, Wingless (adjusted OR = 4.91, P = 0.0063), Group 3 (adjusted OR = 5.56, P = 0.0022), and Group 4 (adjusted OR = 8.57 P = 9.1 × 10-5) tumors were found to be independently associated with higher risk of CMS compared with sonic hedgehog tumors. CONCLUSIONS: Medulloblastoma subgroup is a very strong predictor of CMS development, independent of tumor volume and midline location. These findings have significant implications for management of both the tumor and CMS.

Arterial spin labeling perfusion changes of the frontal lobes in children with posterior fossa syndrome.

OBJECTIVE: Posterior fossa syndrome (PFS) is a common complication following the resection of posterior fossa tumors in children. The pathophysiology of PFS remains incompletely elucidated; however, the wide-ranging symptoms of PFS suggest the possibility of widespread cortical dysfunction. In this study, the authors utilized arterial spin labeling (ASL), an MR perfusion modality that provides quantitative measurements of cerebral blood flow without the use of intravenous contrast, to assess cortical blood flow in patients with PFS. METHODS: A database of medulloblastoma treated at the authors' institution from 2004 to 2016 was retrospectively reviewed, and 14 patients with PFS were identified. Immediate postoperative ASL for patients with PFS and medulloblastoma patients who did not develop PFS were compared. Additionally, in patients with PFS, ASL following the return of speech was compared with immediate postoperative ASL. RESULTS: On immediate postoperative ASL, patients who subsequently developed PFS had statistically significant decreases in right frontal lobe perfusion and a trend toward decreased perfusion in the left frontal lobe compared with controls. Patients with PFS had statistically significant increases in bilateral frontal lobe perfusion after the resolution of symptoms compared with their immediate postoperative imaging findings. CONCLUSIONS: ASL perfusion imaging identifies decreased frontal lobe blood flow as a strong physiological correlate of PFS that is consistent with the symptomatology of PFS. This is the first study to demonstrate that decreases in frontal lobe perfusion are present in the immediate postoperative period and resolve with the resolution of symptoms, suggesting a physiological explanation for the transient symptoms of PFS.

Posterior fossa syndrome and increased mean diffusivity in the olivary bodies.

OBJECTIVE: Posterior fossa syndrome (PFS) is a common postoperative complication following resection of posterior fossa tumors in children. It typically presents 1 to 2 days after surgery with mutism, ataxia, emotional lability, and other behavioral symptoms. Recent structural MRI studies have found an association between PFS and hypertrophic olivary degeneration, which is detectable as T2 hyperintensity in the inferior olivary nuclei (IONs) months after surgery. In this study, the authors investigated whether immediate postoperative diffusion tensor imaging (DTI) of the ION can serve as an early imaging marker of PFS. METHODS: The authors retrospectively reviewed pediatric brain tumor patients treated at their institution, Lucile Packard Children's Hospital at Stanford, from 2004 to 2016. They compared the immediate postoperative DTI studies obtained in 6 medulloblastoma patients who developed PFS to those of 6 age-matched controls. RESULTS: Patients with PFS had statistically significant increased mean diffusivity (MD) in the left ION (1085.17 ± 215.51 vs 860.17 ± 102.64, p = 0.044) and variably increased MD in the right ION (923.17 ± 119.2 vs 873.67 ± 60.16, p = 0.385) compared with age-matched controls. Patients with PFS had downward trending fractional anisotropy (FA) in both the left (0.28 ± 0.06 vs 0.23 ± 0.03, p = 0.085) and right (0.29 ± 0.06 vs 0.25 ± 0.02, p = 0.164) IONs compared with age-matched controls, although neither of these values reached statistical significance. CONCLUSIONS: Increased MD in the ION is associated with development of PFS. ION MD changes may represent an early imaging marker of PFS.

Deep Learning-Assisted Diagnosis of Cerebral Aneurysms Using the HeadXNet Model.

Importance: Deep learning has the potential to augment clinician performance in medical imaging interpretation and reduce time to diagnosis through automated segmentation. Few studies to date have explored this topic. Objective: To develop and apply a neural network segmentation model (the HeadXNet model) capable of generating precise voxel-by-voxel predictions of intracranial aneurysms on head computed tomographic angiography (CTA) imaging to augment clinicians' intracranial aneurysm diagnostic performance. Design, Setting, and Participants: In this diagnostic study, a 3-dimensional convolutional neural network architecture was developed using a training set of 611 head CTA examinations to generate aneurysm segmentations. Segmentation outputs from this support model on a test set of 115 examinations were provided to clinicians. Between August 13, 2018, and October 4, 2018, 8 clinicians diagnosed the presence of aneurysm on the test set, both with and without model augmentation, in a crossover design using randomized order and a 14-day washout period. Head and neck examinations performed between January 3, 2003, and May 31, 2017, at a single academic medical center were used to train, validate, and test the model. Examinations positive for aneurysm had at least 1 clinically significant, nonruptured intracranial aneurysm. Examinations with hemorrhage, ruptured aneurysm, posttraumatic or infectious pseudoaneurysm, arteriovenous malformation, surgical clips, coils, catheters, or other surgical hardware were excluded. All other CTA examinations were considered controls. Main Outcomes and Measures: Sensitivity, specificity, accuracy, time, and interrater agreement were measured. Metrics for clinician performance with and without model augmentation were compared. Results: The data set contained 818 examinations from 662 unique patients with 328 CTA examinations (40.1%) containing at least 1 intracranial aneurysm and 490 examinations (59.9%) without intracranial aneurysms. The 8 clinicians reading the test set ranged in experience from 2 to 12 years. Augmenting clinicians with artificial intelligence-produced segmentation predictions resulted in clinicians achieving statistically significant improvements in sensitivity, accuracy, and interrater agreement when compared with no augmentation. The clinicians' mean sensitivity increased by 0.059 (95% CI, 0.028-0.091; adjusted P = .01), mean accuracy increased by 0.038 (95% CI, 0.014-0.062; adjusted P = .02), and mean interrater agreement (Fleiss κ) increased by 0.060, from 0.799 to 0.859 (adjusted P = .05). There was no statistically significant change in mean specificity (0.016; 95% CI, -0.010 to 0.041; adjusted P = .16) and time to diagnosis (5.71 seconds; 95% CI, 7.22-18.63 seconds; adjusted P = .19). Conclusions and Relevance: The deep learning model developed successfully detected clinically significant intracranial aneurysms on CTA. This suggests that integration of an artificial intelligence-assisted diagnostic model may augment clinician performance with dependable and accurate predictions and thereby optimize patient care.

Minimally Invasive Lumbar Pedicle Screw Fixation Using Cortical Bone Trajectory: Functional Outcomes.

Background Pedicle screw fixation is currently the mainstay technique for lumbar spinal fusion; however, more minimally invasive techniques are available such as cortical screw fixation. Numerous studies have proven biomechanical equivalence or superiority for cortical screws but few studies have examined clinical outcomes in patients. Our study aims to examine functional outcomes, as well as fusion rates, in patients who underwent pedicle screw fixation using a cortical trajectory. Methods We retrospectively reviewed prospectively collected functional outcomes data on 10 patients with a degenerative lumbar disease who underwent cortical screw placement by the senior author. Oswestry Disability Index (ODI) and Roland Morris (RM) scoring were calculated preoperatively, at six to 12 weeks and at six to eight months. The Kruskal-Wallis test and Dunn's multiple comparison were used to analyze differences in scores over time. Results We found that over time, cortical screw fixation resulted in a mean decrease of 27 from the baseline ODI at six to eight months (p = 0.014). Additionally, six out of seven (86%) patients who had at least 12 months of radiographic follow-up showed fusion. Conclusions Cortical screw fixation showed a decrease of 27 from the baseline ODI at six to eight months, which is comparable to changes from the baseline ODI reported in three, recent, large clinical trials examining functional outcomes following traditional pedicle screw fixation.

Transoral Endoscopic Resection of High Cervical Osteophytes with Long-Term Symptom Resolution: Case Series, Imaging, and Literature Review.

BACKGROUND: Anterior cervical osteophytes (ACOs) are a common radiologic finding in the elderly; rarely, they can cause dysphagia, dysphonia, and dyspnea. Symptomatic ACOs are most commonly found between C4 and C7 and much less commonly at higher cervical levels. Here, we present a case series, with an example case of a 57-year-old woman with high cervical osteophytes at C1-C2 causing globus sensation, dysphagia, and dysphonia. Additionally, we provide a literature review regarding the causes, diagnosis, and treatment of ACOs, with a focus on management of high ACOs. CASE DESCRIPTION: A 57-year-old smoker with a history of chronic neck pain and previous cervical spinal instrumentation presented with several months of globus sensation, dysphagia, and dysphonia. Imaging revealed 2 large anterior osteophytes at C1-C2. She underwent endoscopic transoral osteophytectomy, with resolution of symptoms. Five other patients are also presented who underwent similar procedures. CONCLUSIONS: ACOs are a potential cause of dysphagia, and their diagnosis is best made with computed tomographic imaging and oropharyngeal swallow study. Although high ACOs at C1-C2 are a rare finding, here we show with an exemplary case and small case series that they can be effectively treated with transoral endoscopic osteophytectomy.