SARS-CoV-2 infection and spontaneous spinal hemorrhage: a systematic review.

The neurological manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, including spontaneous spinal hemorrhage (SSH), are diverse. SSH is a detrimental neurosurgical event requiring immediate medical attention. We aimed to investigate the association between SARS-CoV-2 and SSH and delineate a rational clinical approach. The authors searched PubMed, Scopus, Web of Science, and Google Scholar for studies published up to January 25, 2023, on SSH and SARS-CoV-2 infection. For each dataset, the authors performed pooled estimates examining three outcomes of interest: (1) early post-intervention neurological status, (2) mortality, and (3) post-intervention neurological rehabilitation outcomes. After reviewing 1341 results, seven datasets were identified for the final analysis. Fifty-seven percent of patients were females. Twenty-eight percent of the patients experienced severe systemic infection. The mean interval between the SARS-CoV-2 infection and neurological presentation was 18 days. Pain and sensorimotor deficits were the most common (57%). Spinal epidural hematoma (EDH) was the most common presentation (71.4%). Three patients were treated conservatively, while 4 received neurosurgical intervention. Pain and sensorimotor deficits had the best treatment response (100%), while the sphincter had the worst response (0%). Long-term follow-up showed that 71% of patients had good recovery. SARS-CoV-2-associated SSH is a rare complication of infection, with an often insidious presentation that requires high clinical suspicion. Patients with SARS-CoV-2 infection and new neurological symptoms or disproportionate neck or back pain require a neuroaxis evaluation. Neurosurgical intervention and conservative management are both viable options to treat SSH following COVID-19. Still, a homogenous approach to the treatment paradigm of SSH cannot be obtained, but lesions with space-occupying effects are suitable for neurosurgical evacuation-decompression while more indolent lesions could be treated conservatively. These options should be tailored individually until larger studies provide a consensus.

Subaxial Cervical Laminectomy Using a Misonix BoneScalpel®: A Guide to Operative Technique.

INTRODUCTION: Cervical laminectomy is a surgical technique that is used to decompress the spinal cord. The standard equipment for making bony cuts includes a high-speed drill (HSD) or osteotome; the ultrasonic BoneScalpel® (UBS) by Misonix (Farmingdale, NY) may be used for this purpose either alone or in combination with other instruments. OBJECTIVE: We describe the operative technique and principles behind the use of the Misonix BoneScalpel (MBS) for subaxial cervical laminectomy. METHODS: The features, functions and mechanism of the MBS are described. Use of a UBS for en bloc subaxial cervical laminectomy is outlined, including a description of the technique, the avoidance of complications, and perioperative considerations. RESULTS: Use of the MBS in cervical decompression is a safe and effective alternative to HSD when considering tissue selectivity, thermal control, and coagulative effects. CONCLUSION: While the initial upfront cost of the MBS is greater than that of similar equipment, the potential long-term savings in time and resources can yield a cost-effective return. The MBS should be progressively incorporated into the surgical protocol as dictated by the surgeon's comfort level.

Proliferative Index in Pediatric Pilocytic Astrocytoma by Region of Origin and Prediction of Clinical Behavior.

BACKGROUND/AIMS: Pilocytic astrocytomas are common pediatric tumors. Molecular profiles vary with location of origin. Comparisons of proliferation have not been reported. We sought to identify differences in growth by region and whether these predict clinical behavior. METHODS: A retrospective review of all patients undergoing surgery for a pilocytic astrocytoma at Children's Hospital LA from 2003 to 2015 was completed. Tumor location, determined by imaging, was stratified into infratentorial, supratentorial, or optic pathway. Proliferation was measured by Ki-67 immunostaining. A p value of 0.05 was deemed significant. RESULTS: 77 patients were identified. 51 had posterior fossa tumors, 12 had supratentorial tumors, and 14 had optic pathway tumors. Mean Ki-67 score was 3.67, 4.09, and 3.83%, respectively (p = 0.82). Ki-67 of ≥4% trended towards recurrence (p = 0.11), incomplete resection (p = 0.15), and younger age at presentation (p = 0.04). Ki-67 was weakly correlated with shorter survival after surgery (r = -0.103, p = 0.41). Partial resection strongest predicted recurrence (p < 0.001; OR = 13.0). CONCLUSION: Proliferative index does not change by location. Higher cell proliferation was seen in younger patients and associated with shorter time to and a higher risk of recurrence. Further study is needed to identify predictors for clinical behavior. Importance of Study: This study provides a detailed analysis of the proliferative indices of tumors arising from characteristic locations within the brain. With recent advances in our understanding of the differences in molecular and genetic profiles despite similar histologic diagnoses, we felt that it was important to review whether there were unique components of tumor behavior that could be identified. In turn, we sought to determine whether tumor behavior could be used to predict the clinical course. This knowledge is important, given that not every tumor may undergo complete surgical resection, and that some lesions may require more aggressive upfront adjuvant therapy or be closely monitored for recurrence.

Acute-onset cerebellar symptoms in Lhermitte-Duclos disease: case report.

Adult-onset Lhermitte-Duclos disease (LD), or dysplastic cerebellar gangliocytoma, is a hamartoma considered pathognomonic for Cowden disease. Classically, LD has a progressive and insidious onset of symptoms. In this case report, we present a patient having rapid neurological deterioration from acute-onset LD. There are only three reported cases of acute LD presentation. A 22-year-old female presented to the emergency department with diplopia, dysarthria, dysphagia, and gait instability which developed within 6 h. A non-contrast CT scan revealed diffuse attenuation in the left cerebellum and mild ventricular dilatation. LP revealed no organisms. Magnetic resonance imaging revealed salient "tiger stripe" appearance of the left cerebellar cortex and effacement of the fourth ventricle. The patient subsequently underwent suboccipital craniotomy and gross total resection of the lesion. The tumor histology showed distortion of normal cerebellar architecture with dysplastic ganglion cells, loss of Purkinje cells, atrophy of the white matter, and expansion of cerebellar folia. Findings were consistent with adult-onset Lhermitte-Duclos disease.

Radiolucent Carbon Fiber-Reinforced Implants for Treatment of Spinal Tumors-Clinical, Radiographic, and Dosimetric Considerations.

The management of spine tumors is multimodal and personalized to each individual patient. Patients often require radiation therapy after surgical fixation. Although titanium implants are used most commonly, they produce significant artifact, leading to decreased confidence in target-volume coverage and normal tissue sparing. Carbon-based materials have been found to have minimal effects on dose perturbation in postoperative radiation therapy and have shown biostability and biocompatibility that are comparable to titanium implants. Using the PubMed and Web of Sciences databases, we conducted a systematic review of carbon-based screw and rod fixation systems in the treatment of spinal tumors. We reviewed clinical studies regarding safety of spine fixation with carbon fiber-reinforced (CFR) implants and biomechanical studies, as well as radiation and dosimetric studies. The radiolucency of CFR-polyether ether ketone implants has the potential to benefit patients with spine tumor. Clinical studies have shown no increase in complications with implementation of CFR-polyether ether ketone implants, and these devices seem to have sufficient stiffness and pullout strength. However, further trials are necessary to determine if there is a clinically significant impact on local tumor control.

Retraction: Effects of the COVID-19 Pandemic on Stroke Patients.

[This retracts the article DOI: 10.7759/cureus.9995.].

Diagnosis, Management, and Treatment Options: A Cervical Spine Osteochondroma Meta-Analysis.

Osteochondroma is described as a capped benign bony neoplasm that forms on the outer surface of bone. These tumors affect nearly 6 million people per year. Although osteochondromas most often involve the appendicular skeleton, many involve the spine, with many cases located in the cervical spine. When osteochondromas involve the spine, they can present with a variety of symptoms, including pain, radiculopathy, and myelopathy, which may necessitate surgical treatment. Spinal osteochondromas can be classified into 2 types: multiple osteochondromas in the context of patients with multiple hereditary exostosis (MHE) and solitary osteochondroma or solitary exostosis (SE). Previous reviews have captured only some of the available literature on cervical osteochondromas and have generally focused on either SE or those associated with MHE. The purpose of our review was to provide an extensive review of all previously reported cervical osteochondromas and to compare osteochondroma characteristics, clinical presentation, and outcomes in the context of MHE and SE.

Effects of the COVID-19 Pandemic on Stroke Patients.

Introduction The severe acute respiratory syndrome coronavirus 2 (SARS2-CoV-2) induced pandemic (COVID-19 pandemic) has affected healthcare in all aspects, including stroke care. We sought to investigate this effect with analysis of our hospital's stroke treatment protocols as well as stroke volume on state, regional, and national levels. Methods This was a retrospective review of prospectively collected data from our stroke registry to assess the impact of the SARS2-CoV-2 induced pandemic on the volume of stroke patients presenting to our facility. Demographics collected included age, sex, race, National Institute of Health Stroke Scale (NIHSS) on admission, discharge modified Rankin Score (mRS), type of stroke (ischemic, hemorrhagic, or transient ischemic attack), time of symptom onset, and time to initial imaging. Data were also stratified by date and comparison was made between the intra-COVID-period (March and April 2020), pre-COVID period (March and April 2019), and peri-COVID period (January and February 2020). To determine stroke trends on a national level, we utilized the Get with the Guidelines (GWTG) stroke database to compare stroke volumes in the pre-COVID, peri-COVID, and intra-COVID periods between our hospital, all California hospitals, and the West and Pacific regions. Results There was a significant increase in last known well time (LKWT) to arrival to the emergency department (ED) (LKWT to door) as well as time from arrival to the ED to obtaining a computed tomography (CT) of the head (door to CT) in March 2020 compared to 2019 (p=0.0220 and p=0.0475, respectively). There were significantly fewer transient ischemic attacks (TIAs) in California hospitals as well as in March and April 2020 in comparison to January and February 2020 (p=0.0417). Similarly, there were significantly fewer TIAs in March and April 2019 compared to March and April 2020 (p=0.0360). The decrease in TIAs was also seen at our hospital in both time frame comparisons as well as in West Regional Hospitals in March and April 2020 compared to March and April 2019 (p=0.0111, p=0.0215, and p=0.0414, respectively). Conclusion Stroke care has been disrupted by the COVID-19 pandemic worldwide. We identified a delay in LKWT to door as well as time from door to CT in March 2020 compared to March 2019 at our institution. There was a statistically significant decrease in final diagnosis of TIA at our hospital, all California hospitals, and all West Regional hospitals during the March-April 2020 window, suggesting that some patients with minor stroke symptoms may not be presenting to the hospital in the midst of the pandemic. Strategies to minimize delays in care and maximize functional recovery must continue to evolve as new challenges are met during the COVID-19 pandemic.

Generalized Dystonia Treated With Deep Brain Stimulator: An Institutional Single Surgeon Experience.

Introduction Dystonia can cause severe disability when left untreated. Once a patient has exhausted medical management, surgical intervention may be the only treatment option. Although not curative, deep brain stimulation has been shown to be beneficial for patients affected by this condition. Our study sought to review patients undergoing deep brain stimulation for medically refractory dystonia to assess outcomes. Methods Our institution's operative database was reviewed retrospectively for all patients undergoing deep brain stimulator placement over the last six years. These medical records were reviewed for the severity of dystonia preoperatively and followed postoperatively for 24 months, focusing on the Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS). Patients with less than two-year postoperative follow-up were excluded from the study. The patients were further stratified by age into Group A, consisting of patients less than 40 years old, and Group B, patients greater than or equal to 40 years old. Other attributes such as age, sex, age of disease onset, disease duration at the time of surgery, genetic tests for dystonia-related genes, and any complication associated with surgery were also reviewed. Results Four hundred fifty-five operative cases for deep brain stimulator placement were reviewed, and 16 patients met inclusion criteria for the study. The mean age for our patient cohort was 43.75 years, with four males and 12 females. The average time from the age of disease onset to time of surgery was 9.7 years for Group A and 10.8 years for Group B; the overall average was 10.3 years. All patients had globus pallidus interna (GPi) as their surgical target. The first incidence of a statistically significant decrease in BFMDRS score was noted at three months postoperatively (p<0.001) when compared to preoperative values. Fourteen patients in our cohort underwent preoperative genetic testing for DYT gene mutations, out of which four were found to have a mutation. Conclusion Our review of outcomes for primary generalized dystonia at our institution found that deep brain stimulator targeting the GPi is safe and effective. We found an overall 88% response rate with younger patients (< 40-year-old) showing a better response at two years than older patients.

Cervical osteochondroma: surgical planning.

INTRODUCTION: Osteochondromas are benign bone tumors which occur as solitary lesions or as part of the syndrome multiple hereditary exostoses. While most osteochondromas occur in the appendicular skeleton, they can also occur in the spine. Most lesions are asymptomatic however some may encroach on the spinal cord or the nerve roots causing neurological symptoms. While most patients with osteochondromas undergo laminectomy without fusion, laminectomy with fusion is indicated in appropriately selected cases of spinal decompression. CASE PRESENTATION: We present a case of a 32-year-old male with history of multiple hereditary exostoses who presented with symptoms of bilateral upper extremity numbness and complaints of gait imbalance and multiple falls. He reported rapid progression of his symptoms during the 10 days before presentation. Computed tomography of the cervical spine revealed a lobulated bony tumor along the inner margin of the cervical 4 lamina. He underwent cervical 3 and 4 laminectomies, partial cervical 2 and 5 laminectomies and cervical 3-5 mass screw placement. Pathology was consistent with osteochondroma. The patient's symptoms had markedly improved at follow-up. CONCLUSION: According to our literature review, osteochondromas most commonly occur at cervical 2 and cervical 5. We present a case of an osteochondroma at a less common level, cervical 4. While most osteochondromas are addressed with laminectomy without arthrodesis, the decision of whether arthrodesis is necessary should be considered in all patients with osteochondroma as with any cervical decompression.

Impact of Chronic DMARD Therapy in Patients With Rheumatoid Arthritis Undergoing Surgery of the Craniovertebral Junction: A Multi-center Retrospective Study.

STUDY DESIGN: A multi-centered retrospective review from five institutions. OBJECTIVE: The aim of this study was to determine whether continuing or withholding disease-modifying antirheumatoid drugs (DMARDs) in the perioperative period affect outcomes in rheumatoid arthritis (RA) patients undergoing arthrodesis at the craniovertebral junction SUMMARY OF BACKGROUND DATA.: RA is a chronic systemic inflammatory disease that affects the cervical spine and is treated with DMARDs. Some advocate withholding DMARDs in the perioperative period due to concern for the cytotoxic effects of these medications. However, the impact of DMARDs in the perioperative period is not well understood. METHODS: A multicenter retrospective study from five affiliated institutions was performed. Adult patients with RA on chronic DMARDs undergoing posterior arthrodesis of the craniovertebral junction (occipital-cervical or atlanto-axial arthrodesis) were identified. Patients were stratified based on whether DMARD therapy was continued (C group) or discontinued (DC group) in the perioperative period. The primary outcome was the need for reoperation and reason for reoperation. RESULTS: Thirty-nine patients met inclusion criteria, 19 in C group and 20 in DC group. Average follow-up time was 42 months. Four patients (three in DC group and one in C group) required reoperation. Two patients from the DC group required readmission secondary to RA flare-up. CONCLUSION: Our cohort of RA patients who underwent occipital-cervical and C1/C2 posterior arthrodesis showed no significant differences in surgical complications when DMARD therapy was continued or discontinued in the perioperative period. The decision to continue or discontinue DMARD therapy in the perioperative period is at the discretion of the treating physician, but we encourage physicians to counsel patients regarding this theoretical risk and their tolerance of the medications as well as the risk of RA flare-up. Factors such as overall health, disease burden, nutrition, bone quality, smoking status, and other comorbid conditions are likely to have a larger influence on perioperative complications. LEVEL OF EVIDENCE: 3.

Brain metastases from cervical cancer reduce longevity independent of overall tumor burden.

BACKGROUND: Isolated brain metastasis (IBM) from cervical cancer is a very rare encounter in neurosurgery. We sought to understand how patients with isolated brain metastases differ from those with metastases in the setting of widespread disease. METHODS: A systematic review was completed using PubMed and the Cochrane Library. Patients with isolated brain metastases (IBM) and non-isolated brain metastases (NIBM, or brain metastases in the setting of disseminated disease), were compared. Two-sided statistical tests were used to determine significance. Survival function was carried out using the Kaplan-Meier method. RESULTS: A total of 89 patients, 25 with IBM and 64 with NIBM, were identified. The time interval between initial diagnosis of cervical cancer and diagnosis of brain lesion was significantly shorter in the IBM group (median 7.5 vs. 20.05 months, and IBM vs. NIBM, respectively; P = 0.006). Overall survival from initial diagnosis of cervical cancer was significantly shorter for the IBM group versus the NIBM group (7.63 vs. 26.3 months, respectively; P = 0.0005). Data demonstrate a 3.4-fold reduction of median life expectancy to 7.63 months. Survival after diagnosis of brain metastases did not differ between groups (median, IBM 7 months vs. NIBM 4 months, P = 0.08). CONCLUSION: Taken together, our data suggest that for cervical cancer patients with brain metastasis intracranial metastasis itself (and not overall tumor burden) represent a sentinel event in limiting longevity. While the present study is underpowered to compare treatment options directly, further work should be focused on determining the optimal treatment for these patients.

Clinical Efficacy of Frameless Stereotactic Radiosurgery in the Management of Spinal Metastases From Thyroid Carcinoma.

STUDY DESIGN: A retrospective data review. OBJECTIVE: To evaluate the efficacy of CyberKnife (CK) stereotactic radiosurgery (SRS) for thyroid spinal metastasis (SMs). SUMMARY OF BACKGROUND DATA: Thyroid carcinoma is an infrequent cause of SM. The absolute efficacy of SRS generally and CK in particular remains poorly characterized for thyroid SM. The current study is the first to specifically evaluate the efficacy of CK SRS for thyroid SMs. METHODS: A retrospective review of patients at our institution between 2003 and 2013 was done. Details about tumor location, radiographic findings before and after CK SRS, tumor recurrence, prescription isodose level, total and maximum dose, number of fractions, and gross tumor volume coverage were similarly collected. For comparison with other studies, the biologically effective dose and the equivalent total dose in 2 Gy fractions were calculated. Each patient was assessed for survival and local disease control from the time of the first CK session and survival analysis was carried out using the Kaplan-Meier method. Risk factors for local failure were assessed using multivariate logistic regression. RESULTS: A total of 12 patients with 32 spinal metastases from thyroid carcinoma that were treated with CK SRS were identified. Survival for 1, 2, and 3 years was 55%, 44%, and 33%, and local control was 67%, 56%, and 34% respectively. The study found that the single strongest factor associated with local control was prior radiotherapy (ß-coefficient -27.72, P = 0.01). No complications occurred in the immediate or late follow-up period. CONCLUSION: This was the first study to specifically investigate the efficacy of CK for treatment of thyroid SMs. Our findings suggest that CK can be safely used to treat spinal SMs from thyroid cancer and is associated with a high rate of local control. LEVEL OF EVIDENCE: 4.

MRI-Guided High-Intensity Focused Ultrasound as an Emerging Therapy for Stroke: A Review.

Stroke, either ischemic or hemorrhagic, accounts for significantly high morbidity and mortality rates around the globe effecting millions of lives annually. For the past few decades, ultrasound has been extensively investigated to promote clot lysis for the treatment of stroke, myocardial infarction, and acute peripheral arterial occlusions, with or without the use of tPA or contrast agents. In the age of modern minimal invasive techniques, magnetic resonance imaging-guided high-intensity focused ultrasound is a new emerging modality that seems to promise therapeutic utilities for both ischemic and hemorrhagic stroke. High-intensity focused ultrasound causes thermal heating as the tissue absorbs the mechanical energy transmitted by the ultrasonic waves leading to tissue denaturation and coagulation. Several in-vitro and in-vivo studies have demonstrated the viability of this technology for sonothrombolysis in both types of stroke and have warranted clinical trials. Apart from safety and efficacy, initiation of trials would further enable answers regarding its practical application in a clinical setup. Though this technology has been under study for treatment of various brain diseases for some decades now, relatively very few neurologists and even neurosurgeons seem to be acquainted with it. The aim of this review is to provide basic understanding of this powerful technology and discuss its clinical application and potential role as an emerging viable therapeutic option for the future management of stroke.

Multiple Extradural Spinal Meningiomas in a Patient with Acquired Immunodeficiency Syndrome: Case Report and Literature Review.

BACKGROUND: Purely extradural spinal meningiomas are uncommon. Due to their typical location in the neural foramen, they are often mistaken for schwannomas, neurofibromas, and epidural metastases. In addition, comorbid conditions such as immunodeficiency may obscure the diagnosis. We present a case of extradural spinal meningiomas in a patient with human immunodeficiency virus (HIV). This is the first reported case of multiple extradural spinal meningiomas in 2 separate regions of the spine. CASE DESCRIPTION: A 40-year-old male with a past medical history of HIV and hepatitis B infection presented with a 2-month history of progressive back pain radiating to the left flank and thigh. Magnetic resonance imaging of the thoracic and lumbar spine with intravenous gadolinium contrast revealed 2 extramedullary masses in the left neural foramina of T6 and L1. The patient underwent laminectomy, which revealed that the 2 lesions were entirely extradural. Both lesions were resected, and the histological diagnosis for both lesions was meningioma, World Health Organization grade I. CONCLUSIONS: Our experience with this 40-year-old male with AIDS who presented with radicular symptoms due to multiple purely extradural meningiomas underscores the importance of considering meningioma as a possible diagnosis in patients with tumors of the neural foramina. In addition, a wide differential diagnosis should be made for patients with spinal lesions and history of HIV, including illnesses that are related to immunodeficiency and those that are not.

Use of a Pediatric Craniotome Drill for Cervical and Thoracic Spine Decompression: Safety and Efficacy.

BACKGROUND: Laminectomy, using a high-speed drill with an unprotected cutting drill bit, can be rapid and effective, but it has been associated with known complications. Another technique uses a pediatric craniotome drill with the footplate attachment. At present, there are no studies comparing clinical outcomes between these 2 stated decompressive techniques. METHODS: A retrospective review was conducted at a single institution. Two cohorts of patients were considered based on the technical method of laminectomy for decompression. One group had decompression with utilization of a high-speed drill, whereas the other group had decompression with a pediatric craniotome drill with a footplate attachment. The outcomes from each group were compared based on the length of operation, estimated blood loss, and associated complications. RESULTS: A total of 91 patients were included in the final analysis. Forty-five of the patients underwent laminectomy using a footplate and 46, using a high-speed drill. The footplate group was associated with significantly shorter operative time (159 vs. 205 minutes; P = 0.008). In addition, the footplate technique demonstrated less estimated blood loss (254 vs. 349 mL), and less incidence of durotomies (2.2% vs. 10.9%); however, neither of these 2 outcomes achieved statistical significance. CONCLUSIONS: Despite being an older technique, there was a shorter operative time in the footplate group without increased blood loss or incidence of durotomy. Although comparable results are operator dependent, this technique is a safe alternative for performing cervical and thoracic laminectomies.

Posterior-only Stabilization for Traumatic Thoracolumbar Burst Fractures.

Background No consensus exists for the management of unstable thoracolumbar (TL) burst fractures. Surgical options include anterior, lateral, or posterior stabilization (or a combination), depending on the fracture. The potential benefits of anterior reconstruction come with increased operative time and associated morbidity. A posterior-only approach can offer stable correction without increased operative risks but may result in loss of kyphotic correction over time. Purpose To determine whether posterior-only stabilization is a viable treatment option for patients with traumatic TL fractures as opposed to anterior and combined approaches. Methods We performed a retrospective analysis of adult patients with TL burst fractures who underwent posterior--only surgical intervention from 2005 to 2015. Operations were performed at two levels above and below the fractured segment using pedicle screw-rod fixation constructs with autograft and allograft. All patients received TL bracing for at least three months. Patients lost to follow-up were excluded. Results Sixty-four consecutive patients with posterior--only stabilization were identified, with 18 lost to follow-up. Of the remaining 46 patients, 93% (n=43) were male and 7% (n=3) were female, with a mean age of 36.8 years. All patients were followed for 12 months. The mean time until the removal of the brace was 3.54 months. No patients required additional surgical intervention for spinal stabilization. Three patients experienced postoperative complications, all of which were related to infection. Conclusions Our data indicate that posterior--only stabilization for traumatic TL burst fractures is a durable and effective option in select patients. The approach offers surgical intervention with a decreased perioperative risk as well as reduced morbidity and mortality, with a minimal increase in the risk of kyphotic deformity. Further prospective studies are necessary to validate these findings clinically.

Will clinical parameters reliably predict external ventricular drain-associated ventriculitis: Is frequent routine cerebrospinal fluid surveillance necessary?

BACKGROUND: The placement of an external ventricular drain (EVD) for monitoring and treatment of increased intracranial pressure is not without risk, particularly for the development of associated ventriculitis. The goal of this study was to investigate whether changes in cerebrospinal fluid (CSF), serum, or clinical parameters are correlated with the development of ventriculitis before it occurs, allowing for the determination of optimal timing of CSF collection. METHODS: An observational retrospective study was conducted between January 2006 and May 2012. A total of 466 patients were identified as having an in-situ EVD placed. Inclusion criteria were age >18 years, glasgow coma scale (GCS) 4-15, and placement of EVD for any indication. Exclusion criteria included recent history of meningitis, cerebral abscess, cranial surgery or open skull fracture within the previous 30 days. A broad definition of ventriculitis was used to separate patients into three initial categories, two of which had sufficient patients to proceed with analysis: suspected ventriculitis and confirmed ventriculitis. CSF sampling was conducted on alternating weekdays. RESULTS: A total of 466 patients were identified as having an EVD and 123 patients were included in the final analysis. The incidence of ventriculitis was 8.8%. Only the ratio of glucose CSF: serum <0.5 was found to be of statistical significance, though not correlated to developing a ventriculitis. CONCLUSIONS: This study demonstrates no reliable tested CSF, serum, or clinical parameters that are effectively correlated with the development of ventriculitis in an EVD patient. Thus, we recommend and will continue to draw CSF samples from patients with in-situ EVDs on our current schedule for as long as the EVD remains in place.

Minimally Invasive Surgical Techniques for Management of Painful Metastatic and Primary Spinal Tumors.

Patients with metastatic spinal disease are affected by disabling pain. The treatment of spinal metastases is focused on pain reduction and improvement in quality of life. Until recently, many patients with metastatic spinal disease did not qualify as surgical candidates due to the risks of surgery and length of recovery period. However, recent advances in minimally invasive surgery such as kyphoplasty and vertebroplasty allow patients to safely undergo surgery for pain relief with a short recovery period. The studies reviewed here suggest that vertebral augmentation is successful in reducing pain and disability scores in patients with painful metastases and multiple myeloma and are a safe modality to provide lasting pain relief. As the use of kyphoplasty and vertebroplasty for treatment of vertebral metastases is becoming more common, new combinations of cement augmentation with other techniques such as percutaneous pedicle screws and radiofrequency ablation are being explored. The implementation of kyphoplasty and vertebroplasty, in conjunction with other minimally invasive surgical techniques as well as nonsurgical modalities, may lead to the best palliative management of cancer patients with spinal metastases and help them ultimately achieve a better quality of life.

Unusual Metastasis of Papillary Thyroid Cancer to the Thoracic Spine: A Case Report, New Surgical Management Proposal, and Review of the Literature.

Papillary thyroid carcinoma (PTC) is significantly more common than follicular thyroid carcinoma (FTC), yet FTC has a much higher tendency to metastasize to the spinal column. We present a rare case of a metastatic thoracic spinal column lesion originating from the PTC. Thyroid carcinoma is known to be highly vascular with a significant tendency to hemorrhage during surgical resection. This increased tendency to hemorrhage leads to unanticipated intraoperative risks when the type of cancer is not diagnosed before surgical resection. Complications related to intraoperative bleeding can be prevented by visualization using angiography and preoperative embolization. The type of cancer is ideally diagnosed before tumor resection either by the standard metastatic workup or histologically after the biopsy. However, limitations exist in these methods, therefore, hypervascular tumors such as metastatic thyroid cancer can go undiagnosed until after surgical resection. In addition to our case report, we present a review of the literature regarding diagnostic and treatment strategies for hypervascular thyroid tumors and propose a new algorithm for the surgical management of spinal tumors with an unknown origin for optimization of preoperative and perioperative care.