Glioblastoma and malignant melanoma: Serendipitous or anticipated association?

We describe a patient who had primary glioblastoma (GB) and malignant melanoma (MM). A 78-year-old man presented with several weeks to months of history of gait disturbance, confusion, memory disturbance, and worsening speech. Imaging studies performed on admission revealed a large frontotemporal lobe mass associated with the surrounding zone of vasogenic edema. Given the patient's medical history of incomplete biopsy of a midback tumor performed three weeks before, the presumptive clinical diagnosis was metastatic MM. Pathological examination of frozen sections of fragmented specimens obtained at stereotactic biopsy performed on admission revealed a high-grade malignant neoplasm characterized by discohesive cells in a blue myxoid background and abundant foci of tumor necrosis. Given these features, in conjunction with the abovementioned pathological report, the frozen section diagnosis by the neuropathologist was "neoplasm identified, favor melanoma." Due to the paucity of lesional tissue, a limited immunohistochemistry performed on the permanent sections revealed positive staining of lesional cells for Sox10 alone using a multiplex MART1/Sox10 immunostain and S-100 protein, an immunohistochemical profile supporting the presumptive frozen section diagnosis. A tumor debulk procedure, performed two weeks later, revealed histopathologic features most compatible with GB, IDH wild-type. Thus, additional immunohistochemistry on the permanent sections revealed positive staining of glial fibrillary acidic protein (GFAP), Sox10, and S-100 protein as well as negative staining of gp100, a complex carbohydrate matrix protein in embryonic melanosomes, using a specific antibody HMB45. The concomitant occurrence of MM and GB in our patient underscores the association between these two entities. Our literature review suggests that the sporadic co-occurrence of these two conditions is likely not serendipitous.

Landmine Injury Resulting in Comminuted Lumbar Facet Fracture as a Cause of Lumbar Stenosis and Spondylolisthesis.

Lumbar facet fractures are rarely reported and have been linked to sports and spine surgery. We describe the case of a 77-year-old patient who sustained an injury from multiple landmine blasts during the Vietnam War. He had low back pain since that time, which was initially managed conservatively. However, the pain progressed over decades to severe neurogenic claudication that greatly restricted his quality of life. Neuroimaging revealed the presence of bone fragments impinging on the spinal canal at the L5/6 level (transitional anatomy) that resulted from a comminuted fracture of the lumbar facet at the inferior articular process. We performed an L5/6 decompressive laminectomy, with removal of these fragments, and posterior instrumented fusion, with substantial improvement in symptoms. This case illustrates a unique mechanism of lumbar facet fracture and the biomechanic origination, natural history, and optimal treatment of this entity. We expand on the spectrum of lumbosacral injuries associated with the combat blast injury that have only increased in prevalence in recent conflicts.

Neurosurgical Residency Training at Veterans Affairs Medical Centers, the Resident Perspective.

BACKGROUND AND OBJECTIVE: Department of Veteran's Affairs (VA) Medical Centers play a crucial role in training neurosurgery residents. Although previous studies have examined the impact of VA rotations from the attending perspective, the resident experience remains unexplored. We present a national survey of neurosurgery residents to assess their perceptions of VA rotations, focusing on operative experience, call burden, longitudinal patient care experiences, and overall strengths and limitations. METHODS: A 33-question survey was distributed by email to all neurosurgery residents who had previously completed a VA rotation within the past 7 years. RESULTS: Responses were received from 77 residents, representing 36 out of 40 neurosurgical residency programs with an active VA rotation. Most residents (79.2%) found their VA rotations adequate in length, having spent a median of 5 months at the VA. Residents completed an average of 11.7 (SD 7.2) cases per month while at the VA, including 8.9 (SD 5.5) spine, 1.7 (SD 2.0) cranial, and 1.4 (SD 1.6) peripheral nerve cases. Many residents reported completing a greater proportion of spine and peripheral nerve cases at the VA compared with their primary clinical sites. Across all postgraduate years, residents felt that the VA offered increased operative autonomy (79.0% agreement) at the expense of total operative volume (98.7% agreement) and complexity (81.9% agreement). Importantly, 94.8% of residents participated in longitudinal patient care experiences, and 59.7% followed all patients longitudinally. CONCLUSION: The resident experience at the VA varies, presenting both strengths and limitations. Addressing these factors could enhance the overall effectiveness of VA rotations in neurosurgical training programs in the future.

Brain tumors in United States military veterans.

BACKGROUND: Comprehensive analysis of brain tumor incidence and survival in the Veteran population has been lacking. METHODS: Veteran data were obtained from the Veterans Health Administration (VHA) Medical Centers via VHA Corporate Data Warehouse. Brain tumor statistics on the overall US population were generated from the Central Brain Tumor Registry of the US data. Cases were individuals (≥18 years) with a primary brain tumor, diagnosed between 2004 and 2018. The average annual age-adjusted incidence rates (AAIR) and 95% confidence intervals were estimated per 100 000 population and Kaplan-Meier survival curves evaluated overall survival outcomes among Veterans. RESULTS: The Veteran population was primarily white (78%), male (93%), and between 60 and 64 years old (18%). Individuals with a primary brain tumor in the general US population were mainly female (59%) and between 18 and 49 years old (28%). The overall AAIR of primary brain tumors from 2004 to 2018 within the Veterans Affairs cancer registry was 11.6. Nonmalignant tumors were more common than malignant tumors (AAIR:7.19 vs 4.42). The most diagnosed tumors in Veterans were nonmalignant pituitary tumors (AAIR:2.96), nonmalignant meningioma (AAIR:2.62), and glioblastoma (AAIR:1.96). In the Veteran population, survival outcomes became worse with age and were lowest among individuals diagnosed with glioblastoma. CONCLUSIONS: Differences between Veteran and US populations can be broadly attributed to demographic composition differences of these groups. Prior to this, there have been no reports on national-level incidence rates and survival outcomes for Veterans. These data provide vital information that can drive efforts to understand disease burden and improve outcomes for individuals with primary brain tumors.

Intraoperative hypovolemia as a possible precipitating factor for pituitary apoplexy: a case report.

BACKGROUND: Pituitary apoplexy is acute infarction with or without hemorrhage of the pituitary gland. It is a rare but potentially life-threatening emergency that most commonly occurs in the setting of pituitary adenoma. The mechanisms underlying pituitary apoplexy are not well understood, but are proposed to include factors of both hemodynamic supply and adenoma demand. In the case of patients with known pituitary macroadenomas undergoing major surgery for other indications, there is a theoretically increased risk of apoplexy in the setting of "surgical stress." However, risk stratification of patients with nonfunctioning pituitary adenomas prior to major surgery is challenging because the precipitating factors for pituitary apoplexy are not completely understood. Here we present a case in which intraoperative hypovolemia is a possible mechanistic precipitating factor for pituitary apoplexy. CASE PRESENTATION: A 76-year-old patient with a known hypofunctioning pituitary macroadenoma underwent nephrectomy for renal cell carcinoma, during which there was significant intraoperative blood loss. He became symptomatic with ophthalmoplegia on the second postoperative day, and was diagnosed with pituitary apoplexy. He was managed conservatively with cortisol replacement therapy, and underwent therapeutic anticoagulation 2 months after pituitary apoplexy for deep vein thrombosis. His ophthalmoplegia slowly resolved over months of follow-up. Pituitary apoplexy did not recur with therapeutic anticoagulation. CONCLUSIONS: When considering the risk of surgery in patients with a known pituitary macroadenoma, an operation with possible high-volume intraoperative blood loss may have increased risk of pituitary apoplexy because intraoperative hypovolemia may precipitate ischemia, infarction, and subsequent hemorrhage. This may be particularly relevant in the cases of elective surgery. Additionally, we found that we were able to therapeutically anticoagulate a patient 2 months after pituitary apoplexy for the management of deep vein thrombosis without recurrence of pituitary apoplexy.

Integration of Veterans Affairs Medical Centers Into Neurosurgical Residency Programs.

Veterans Affairs (VA) medical centers serve as a unique training environment for US residency programs. In this study, we aim to explore the scope and details of VA integration into neurosurgery resident training. We used data from the Accreditation Council for Graduate Medical Education database to provide an overview of neurosurgery training programs with an active VA affiliation and developed a multi-institutional survey to gather information related to rotation design, operative volume, expectations, and core training values. Of the 116 neurosurgery residency programs, 40 have an active affiliation with a VA medical center (34%). Residents most frequently rotated at the VA during their third postgraduate year, with an average rotation length of 7.5 months (range 2-21). Nearly all programs reported a weekly mix of clinic and operative days (96%), with residents longitudinally following patients throughout their rotations. Attending neurosurgeons from VA-affiliated programs reported operative experience (100%), independent decision-making (89%), and continuity of care (81%) as core values of VA neurosurgery rotations. Surgical volume varied between programs with an average of 13.4 ± 6.4 (SD) cases per month per rotating resident. A significant portion of neurosurgery residency programs in the United States incorporate VA rotations into resident training. Although rotation details vary from program-to-program, shared values include a strong operative experience, independent decision-making, and continuity of care. This analysis provides a comprehensive assessment of VA rotation structure across the country, which is valuable for programs considering implementing a VA rotation into their training program or modifying an existing rotation.

Intra- and postoperative very low dose intravenous ketamine infusion does not increase pain relief after major spine surgery in patients with preoperative narcotic analgesic intake.

OBJECTIVE: This study aims to demonstrate the analgesic efficacy and opioid-sparing effect of low dose ketamine in patients with preoperative narcotic intake undergoing major spine surgery. DESIGN: The study used a prospective, randomized, double-blinded, and placebo-controlled clinical trial. SETTINGS AND PATIENTS: We evaluated the analgesic efficacy and safety of low dose IV ketamine infusion after major spine surgery in patients with preoperative narcotic analgesic intake. Ketamine group received IV ketamine infusion (2 µg/kg/min) and saline group received saline intraoperatively and the first 24 hours postoperatively. In addition, all patients received IV patient-controlled hydromorphone and epidural bupivacaine. OUTCOME MEASURES: Pain scores, narcotic requirement, and side effects were compared between the groups for 48 hours postoperatively. RESULTS: Thirty patients completed the study (N = 15 in each group). No difference in pain scores at rest and movement was noted between the groups (P > 0.05). Patients in ketamine group received 40.42 ± 32.86 mg IV hydromorphone at 48 hours compared with 38.24 ± 26.19 mg in saline group (P = 0.84). Central nervous system side effects were observed in five (33%) ketamine group patients compared with nine (60%) in saline group (P = 0.29). CONCLUSION: The addition of IV very low dose ketamine infusion regimen did not improve postoperative analgesia. Side effects were not increased with low dose ketamine.

Wrong Site Spine Surgery in the Veterans Administration.

STUDY DESIGN: Basic descriptive analysis was performed for the incident characteristics of wrong level spinal surgery in the Veterans Health Administration (VHA). OBJECTIVE: To determine the frequency of reported occurrence of incorrect spine level surgery in the VHA, causal factors for the events, and propose solutions to the issue. SUMMARY OF BACKGROUND DATA: Wrong site surgery is one of the most common events reported to The Joint Commission. It has been reported that 50% of spine surgeons experience at least 1 wrong site surgery in their career, with events leading to signficant harm to patients. MATERIALS AND METHODS: We examined incorrect level spine surgery adverse events reported to the VHA National Center for Patient Safety (NCPS) from 2000 to 2017. A rate of wrong site spine surgery was determined by dividing the number of wrong site cases by the total number of spine surgeries during the study period. Similarly, a rate of wrong site surgery by orthopedist and neurosurgeons was calculated. RESULTS: There were 32 reported cases of wrong site spine surgery between 2000 and 2017. Fourteen cases involved the cervical region, 13 the lumbar region, and 5 the thoracic region. The majority of the root causes (69% or 48 of 69 root causes) fell into 2 broad categories: problems with the radiograph or problems with the intraoperative marker. These were not mutually exclusive and several root cause analyses involved >1 of these issues. CONCLUSIONS: Wrong level surgery of the spine is a significant safety issue facing the field that continues to occur despite surgical teams following guidelines. As poor radiograph quality and interpretability were the most common root causes of these events, interventions aimed at optimizing image quality and accurate interpretation would be a logical first action.

New approach to the management of acute disc herniation.

BACKGROUND: Over 500,000 percutaneous disc decompression procedures have been performed in the past 20 years. Various percutaneous techniques include chemonucleolysis, percutaneous lumbar discectomy, and laser discectomy which have reported success rates in the 70% to 75% range. This retrospective evaluation of 49 patients who underwent nucleoplasty procedures for treatment of herniated discs, evaluates the effectiveness of nucleoplasty in the reduction of pain, improvement of functional activity, and reduction of pain medication. OBJECTIVE: To illustrate the effectiveness of nucleoplasty in reducing low back pain in symptomatic patients with contained herniated discs. STUDY DESIGN: A retrospective, non-randomized study. METHODS: Forty-nine patients with either axial or radicular low back pain who had undergone the nucleoplasty procedure were included in this analysis. Patients were categorized in one of three different groups depending on time elapsed since the procedure was performed: less than 6 months, between 6 months and 1 year, and greater than 1 year. Pain reduction, work impairment, leisure impairment, medication use and patient satisfaction were all recorded during this study. Pain was quantified using a numeric pain scale from 0 to 10. Work and leisure impairment were measured on a scale of 1 to 5, with 1 signifying no impairment and 5 signifying extreme impairment. Medication use and patient satisfaction were also measured on a scale of 1 to 5. RESULTS: Significant pain relief, functional improvement, and a decrease in medication use were achieved following nucleoplasty. There were no complications associated with the procedure. CONCLUSION: Nucleoplasty should be used in those patients who fail conservative medical management including medication, physical therapy, behavioral management, psychotherapy, and who are unwilling to undergo a more invasive technique such as spinal surgery.

CT guided direct transoral approach to C2 for percutaneous vertebroplasty.

BACKGROUND: Percutaneous vertebroplasty is a well-established procedure consisting of the percutaneous injection of a biomaterial, usually Polymethyl methacrylate (PMMA), into a vertebral body. In most cases, this procedure affords significant pain relief and strengthens the bone. Vertebroplasty is most typically performed successfully with patients with acute compression fractures. OBJECTIVE: We report a case of percutaneous vertebroplasty via the transoral approach, performed with computed axial tomography (CT) scan guidance. METHODS: The procedure was performed in a 74-year-old male with a C2 vertebral body lytic lesion. RESULTS: This uncomplicated, minimally invasive procedure relieved the patient's pain. The transoral route is the most direct operative approach to the pathology in the upper cervical spine. CONCLUSION: When used with the CT scanner to facilitate accurate placement of the needle, the transoral approach provides a safe and precise operative approach to the upper cervical spine.

Diastematomyelia presenting as progressive weakness in an adult after spinal fusion for adolescent idiopathic scoliosis.

BACKGROUND CONTEXT: Diastematomyelia is uncommon and rarely presents in adulthood. This report draws attention to the fact that patients who underwent spinal fusion for deformity before the widespread use of computed tomography (CT) and magnetic resonance imaging (MRI) may have unrecognized spinal cord abnormalities. This should be considered if revision surgery is contemplated. PURPOSE: This case report focuses on the late presentation of lower-extremity weakness in a 44-year-old woman with a split cord malformation (diplomyelia), diastematomyelia and tethered cord syndrome. METHODS: The patient underwent instrumented posterior spinal fusion with a Harrington rod as a child for progressive thoracolumbar scoliosis. As an adult, she developed paraparesis after a traumatic event. The patient underwent decompressive laminectomy, subtotal resection of the old fusion mass and resection of the osseous septum. Postoperatively, an anterior spinal fluid leak in the lower thoracic region required repeated fascial grafting, resection of a pseudomeningocele and reverse left latissimus dorsi flap transfer. The leak was controlled, and the patient had near complete resolution of her paraparesis 1 year after her surgery. RESULTS: The case described herein is unusual in that patients with diplomyelia and diastematomyelia rarely are symptomatic in adulthood. However, trauma may precipitate the onset of neurologic symptoms. This patient underwent spinal surgeries to address deformity, pain and progressive lower-extremity weakness. Preoperative CT and MRI studies showed a split cord malformation and diastematomyelia at L1-L2 with spinal stenosis and tethering of both hemicords. CONCLUSIONS: Progressive weakness without any previous neurologic deficit or neurocutaneous stigmas of an underlying spinal cord abnormality may develop in the adult with unrecognized diastemotomyelia. This case demonstrates that a thorough preoperative workup of patients with complex spinal deformities is imperative.

Pseudo-Kümmel's disease: a unique application for vertebroplasty.

Compression fractures of the vertebrae are a major public health concern. There are approximately 700,000 compression fractures of the vertebrae diagnosed on an annual basis in the thoracolumbar spine. The etiology of senile osteoporosis is multifactorial with the most significant reason being age-related bone loss. Multiple effects of compression fractures include acute and chronic pain syndromes, inability to perform activities of daily living, insomnia and depression. Conventional treatment concepts relate to immobilization of the spine, medical pain control, bracing of the back and physical therapy. Vertebroplasty was developed in the 1980s as a treatment for painful cervical hemangiomas in France. Vertebroplasty has been utilized since 1993 to treat painful, osteoporotic compression fractures. In 1891, Kümmell described the disease with a posttraumatic osteitis in which patients developed a painful kyphosis after a period of being symptom free. Inferential evidence includes that vertebrae in this disease are being subjected to a form of avascular necrosis with intraosseous vacuum phenomenon. Patients with Kümmell's disease, treated with vertebroplasty, have been reported to do very well. In a patient with an advanced case of vertebrae plana, without so intending, authors placed air into the vertebral body and created so-called pseudo-Kümmell's disease. This case report describes with high risk or extreme vertebroplasty to alleviate symptomatology. It is concluded that as the clinical experience with percutaneous vertebroplasty continues to expand, the approaches to treatment can become more focused on the specific disease state and specific treatment paradigms.