Timing in the surgical evacuation of spinal epidural abscesses.

OBJECT: One often overlooked aspect of spinal epidural abscesses (SEAs) is the timing of surgical management. Limited evidence is available correlating earlier intervention with outcomes. Spinal epidural abscesses, once a rare diagnosis carrying a poor prognosis, are steadily becoming more common, with one recent inpatient meta-analysis citing an approximate incidence of 1 in 10,000 admissions with a mortality approaching 16%. One key issue of contention is the benefit of rapid surgical management of SEA to maximize outcomes. Timing of surgical management is definitely one overlooked aspect of care in spinal infections. Therefore, the authors performed a retrospective analysis in which they evaluated patients who underwent early (evacuation within 24 hours) versus delayed surgical intervention (> 24 hours) from the point of diagnosis, in an attempt to test the hypothesis that earlier surgery results in improved outcomes. METHODS: A retrospective review of a prospectively maintained adult neurosurgical database from 2009 to 2011 was conducted for patients with the diagnostic heading: epidural abscess, infection, osteomyelitis, osteodiscitis, spondylodiscitis, and abscess. The primary end point for each patient was neurological grade, measured as an American Spinal Injury Association Impairment Scale grade using hospital inpatient records on admission and discharge. Patients were divided into early surgical (< 24 hours) and delayed surgical cohorts. RESULTS: Eighty-seven consecutive patients were identified (25 females; mean age 55.5 years, age range 18-87 years). Fifty-four patients received surgery within 24 hours of admission (mean time from admission to incision, 11.2 hours), and 33 underwent surgery longer than 24 hours (mean 59 hours) after admission. Of the 54 patients undergoing early surgery 45 (85%) had a neurological deficit, whereas in the delayed surgical group 21 (64%) of 33 patients presented with a neurological deficit (p = 0.09). Patients in the delayed surgery cohort were significantly older by 10 years (59.6 vs 51.8 years, p = 0.01). With regard to history of prior revision, body mass index, intravenous drug abuse, tobacco use, prior radiation therapy, diabetes, chronic systemic infection, and prior osteomyelitis, there were no significant differences. There was no significant difference between early and delayed surgery groups in neurological grade on presentation, discharge, or location of epidural abscess. The most common organism isolated was Staphylococcus aureus (n = 51, 59.3%). The incidence of methicillin-resistant S. aureus was 21% (18 of 87). CONCLUSIONS: Evacuation within 24 hours appeared to have a relative advantage over delayed surgery with regard to discharge neurological grade. However, due to a limited, variable sample size, a significant benefit could not be shown. Further subgroup analyses with larger populations are required.

Neuromotor synapses in Escobar syndrome.

The Escobar variant of multiple pterygium syndrome (OMIM #265000) is a rare, autosomal recessive disorder associated with mutations in the γ-subunit of the nicotinic acetylcholine receptor (CHRNG). CHRNG is expressed in fetal muscle during motor development and contributes to the formation of neuromuscular junctions (NMJs). Anomalies in NMJ structure and function have not been investigated in patients with Escobar syndrome. We report five patients identified as having Escobar syndrome, from four families. In three families, the same mutation (c.459dupA) was identified in CHRNG. A biopsy from brachioradialis muscle was collected from a patient from one of these families and analyzed for NMJ organization using fluorescence microscopy. Compared to spinalis muscle from control patients with idiopathic scoliosis or cerebral palsy (CP), the patient with Escobar syndrome had a significantly higher degree of acetylcholine receptor present outside acetylcholinesterase and significantly less acetylcholinesterase outside acetylcholine receptors. Given the role of the acetylcholine receptor γ-subunit in fetal neuromuscular signal transduction and in establishing the primary encounter of muscle and motor nerve terminal, the CHRNG mutations described in Escobar syndrome may cause a broader disruption of postsynaptic proteins and result in aberrant development of the NMJ due to impaired prenatal neuromuscular transmission and/or abnormal neuromuscular synaptogenesis.

Suture Choice in Lumbar Dural Closure Contributes to Variation in Leak Pressures: Experimental Model.

STUDY DESIGN: Open-label laboratory investigational study; non-animal surgical simulation. OBJECTIVE: The authors perform a comparison of dural closure strength in a durotomy simulator across 2 different suture materials. SUMMARY OF BACKGROUND DATA: Incidental durotomy leading to persistent cerebrospinal fluid leak adds considerable morbidity to spinal procedures, often complicating routine elective lumbar spinal procedures. Using an experimental durotomy simulation, the authors compare the strength of closure using Gore-Tex with other suture types and sizes, using various closure techniques. METHODS: A comparison of dural closures was performed through an analysis of the peak pressure at which leakage occurred from a standardized durotomy closure in an established cerebrospinal fluid repair model with a premade L3 laminectomy. Nurolon was compared with Gore-Tex sutures sizes (for Gore-Tex, CV-6/5-0 and CV-5/4-0 was compared with Nurolon 4-0, 5-0, and 6-0). RESULTS: Thirty-six trials were performed with Nurolon 4-0, 5-0, and 6-0, whereas 21 trials were performed for 4-0 and 5-0 Gore-Tex. The mean peak pressure at which fluid leakage was observed was 21 cm H2O for Nurolon and 34 cm H2O for Gore-Tex. Irrespective of suture choice, all trials were grouped by closure technique: running suture, locked continuous, and interrupted suture. No significant difference was noted between the groups. For each of the 3 trials groups by closure technique, running, locked continuous, and interrupted, Gore-Tex closures had a significantly higher peak pressure to failure. Interrupted Gore-Tex was significantly higher than Interrupted Nurolon (P=0.007), running Gore-Tex was significantly higher than running Nurolon (P=0.034), and locked Gore-Tex was significantly higher than locked Nurolon (P=0.014). CONCLUSIONS: Durotomy closure in the lumbar spine with Gore-Tex suture may be a reasonable option for providing a watertight closure. In this laboratory study, Gore-Tex suture provided watertight dural closures that withstood higher peak pressures.

Improved patient quality of life following intradural extramedullary spinal tumor resection.

OBJECTIVE Resection significantly improves the clinical symptoms and functional outcomes of patients with intradural extramedullary tumors. However, patient quality of life following resection has not been adequately investigated. The aim in this retrospective analysis of prospectively collected quality of life outcomes is to analyze the efficacy of resection of intradural extramedullary spinal tumors in terms of quality of life markers. METHODS A retrospective review of a single institutional neurosurgical administrative database was conducted to analyze clinical data. The Oswestry Disability Index (ODI), visual analog scale (VAS) for pain, and the EQ-5D-3 L descriptive system were used to analyze quality of life preoperatively, less than 1 month postoperatively, 1-3 months postoperatively, 3-12 months postoperatively, and more than 12 months postoperatively. RESULTS The ODI scores increased perioperatively at the < 1-month follow-up from 36 preoperatively to 47. Relative to preoperative values, the ODI score decreased significantly at 1-3, 3-12, and > 12 months to 23, 17, and 20, respectively. VAS scores significantly decreased from 6.1 to 3.5, 2.4, 2.0, and 2.9 at the < 1-month, 1- to 3-, 3- to 12-, and > 12-month follow-ups, respectively. EQ-5D mobility significantly worsened at the < 1-month follow-up but improved at the 3- to 12-and > 12-month follow-ups. EQ-5D self-care significantly worsened at the < 1-month follow-up but significantly improved by the 3- to 12-month follow-up. EQ-5D usual activities improved at the 1- to 3-, 3- to 12-, and > 12-month follow-ups. EQ-5D pain and discomfort significantly improved at all follow-up points. EQ-5D anxiety and depression significantly improved at 1- to 3-month and 3- to 12-month follow-ups. CONCLUSIONS Resection of intradural extramedullary spine tumors appears to significantly improve patient quality of life by decreasing patient disability and pain and by improving each of the EQ-5D domains.

C-5 palsy after cerebrospinal fluid diversion in posttraumatic syringomyelia: case report.

Syringomyelia is a potentially debilitating disease that involves abnormal CSF flow mechanics; its incidence after traumatic spinal cord injury (SCI) is approximately 15%. Treatment consists of restoration of CSF flow, typically via arachnoidolysis and syrinx decompression. The authors present a case of pronounced syringomyelia in a patient with concomitant severe cervical myelomalacia to demonstrate unilateral C-5 palsy as a potential complication of aggressive syrinx decompression at a remote level. A 56-year-old man with a remote history of SCI at T-11 (ASIA [American Spinal Injury Association] Grade A) presented with complaints of ascending motor and sensory weakness into the bilateral upper extremities that had progressed over 1 year. MRI demonstrated severe distortion of the spinal cord at the prior injury level of T10-11, where an old anterior column injury and prior hook-rod construct was visualized. Of note, the patient had a holocord syrinx with demonstrable myelomalacia. To restore CSF flow and decompress the spinal cord, T-2 and T-3 laminectomies, followed by arachnoidolysis and syringopleural shunt placement, were performed. Postoperatively on Day 1, with the exception of a unilateral deltoid palsy, the patient had immediate improvement in upper-extremity strength and myelopathy. He was discharged from the hospital on postoperative Day 5; however, at his 2-week follow-up visit, a persistent unilateral deltoid palsy was noted. MRI demonstrated a significant reduction in the holocord syrinx, no neural foraminal stenosis, and a significant positional shift of the ventral spinal cord. Further motor recovery was noted at the 8-month follow-up. Syringomyelia is a debilitating disease arising most often as a result of traumatic SCI. In the setting of myelomalacia with a pronounced syrinx, C-5 palsy is a potential complication of syrinx decompression.

Surgical management in 40 consecutive patients with cervical spinal epidural abscesses: shifting toward circumferential treatment.

STUDY DESIGN: Retrospective database review of a prospectively maintained neurosurgical database. OBJECTIVE: The surgical management of cervical spinal epidural abscesses (CSEA) is reviewed examining the shift from single to staged anteroposterior decompression and stabilization. SUMMARY OF BACKGROUND DATA: CSEA management is guided by small case series. METHODS: A retrospective review from 1997 to 2011 was conducted for patients with the diagnostic headings: cervical epidural abscess, infection, osteomyelitis, osteodiscitis, spondylodiscitis, and abscess. Comorbidities, risk factors, surgical approach, neurologic grade, and outcomes were recorded. RESULTS: Forty consecutive patients (mean age 53 years, age range 23-74, SD ±14, 10 female) were identified with CSEA in the operative database from 1997 to 2010. Twenty one patients had a body mass index more than 25 (53%), 6 (15%) had diabetes mellitus, 6 (15%) had a prior malignancy with 2 having prior neck irradiation, and 9 (23%) used tobacco products. The most common risk factor associated with CSEA was intravenous drug abuse, found in 10 patients (25%). The most common level of discitis involvement was C6-C7 in 12 (30%) followed by C5-C6 disc in 11 (28%) and least often at C1-C2 level in 2(5%) and C7-T1 in 2(5%). The most common neurologic grades at presentation were AIS D in 20 (50%) followed by AIS E in 9 (28%). All patients received magnetic resonance imaging identifying 17 (43%) with dorsal, 12 ventral (30%), and 11 circumferential epidural abscesses (28%). The majority of patients underwent anterior followed by posterior decompression and stabilization (n = 26, 65%); 8 (20%) underwent a ventral approach and six underwent a dorsal approach (15%). Fusion was achieved in 39 of 40 (97.5%) and not significantly influenced halo use in 10 patients. CONCLUSIONS: In this series, patients underwent acute evacuation and spinal cord decompression, and the shift toward staged treatment did not lead to an increased periprocedural complication rate. LEVEL OF EVIDENCE: 3.

Cryptococcal ventriculoperitoneal shunt infection.

The standard treatment of hydrocephalus is placement of a ventriculoperitoneal (VP) shunt. While infection is a common complication, rarely are fungal organisms implicated. Cryptococcus neoformans has been reported in only nine cases of shunt infection to our knowledge. The timing from shunt placement to symptom onset varies widely from 10 days to 15 months. We present a patient who developed a cryptococcal infection of his VP shunt more than two decades following shunt placement.

Management of asymptomatic cervical spinal stenosis in the setting of symptomatic tandem lumbar stenosis: a review.

INTRODUCTION: This article reviews the literature regarding tandem asymptomatic cervical stenosis in the setting of symptomatic lumbar stenosis. The presenting features of cervical spondylotic myelopathy are insidious and consistent with upper motor neuron loss. Often, asymptomatic cervical stenosis is encountered in the clinical setting during the workup of a symptomatic lumbar stenosis and degenerative disease. METHODS: A PubMed (1966 to July 2013) electronic database search was conducted for articles pertaining to the diagnosis of incidentally discovered cervical cord compression. Keywords and MESH terms were limited to asymptomatic cervical stenosis, asymptomatic cervical compression, asymptomatic spinal stenosis, asymptomatic cervical spondylosis, and asymptomatic cervical cord signal. The primary literature topics for manuscript inclusion were the development of symptomatic myelopathy from asymptomatic cord signal edema, as well as the presence of tandem stenosis as defined above by incidental cervical stenosis during the workup of lumbar degenerative disease. RESULTS: There were no previous systematic reviews, randomized trials, or prospective studies on the management of tandem cervical and thoracic stenosis. Five studies, all retrospective reviews containing relevant data were included in the review. Asymptomatic cervical stenosis encountered in the investigation of lumbar symptoms was had a 23% incidence. A risk of 5% per year of development of myelopathy previously reported. CONCLUSIONS: There is insufficient evidence in the literature to support the need for preemptive decompression for asymptomatic cervical cord compression with or without a correlative T2 hyperintense cord signal. Early diagnosis of radiculopathy or myelopathy in patients with cervical stenosis (i.e., through conversion of asymptomatic to symptomatic state) is important as each patient with in this clinical setting should be followed closely, as the literature shows the tendency for a clinical progression to eventual cervical myelopathy.