The Emergence of Zoonotic Onchocerca lupi Infection in the United States--A Case-Series.

This case-series describes the 6 human infections with Onchocerca lupi, a parasite known to infect cats and dogs, that have been identified in the United States since 2013. Unlike cases reported outside the country, the American patients have not had subconjunctival nodules but have manifested more invasive disease (eg, spinal, orbital, and subdermal nodules). Diagnosis remains challenging in the absence of a serologic test. Treatment should be guided by what is done for Onchocerca volvulus as there are no data for O. lupi. Available evidence suggests that there may be transmission in southwestern United States, but the risk of transmission to humans is not known. Research is needed to better define the burden of disease in the United States and develop appropriately-targeted prevention strategies.

Patient-specific polyetheretherketone implants for repair of craniofacial defects.

BACKGROUND: Large cranial defects represent reconstructive challenges. Polyetheretherketone (PEEK) implants are preoperatively tailored to the exact size of the defect and exhibit an excellent combination of strength, durability, and environmental resistance. This study presents our experience with patient-specific PEEK implants with computer modeling. METHODS: A retrospective chart review was conducted on all patients who underwent cranioplasty treated by a PEEK implant between 2007 and 2012. Analysis of the preoperative and perioperative data as well as outcome analysis was performed. RESULTS: A total of 11 patients were included. Mean age was 46 years. The indication for cranioplasty was bone flap infection and subsequent removal in 8 patients, traumatic bone loss in 2 patients, and acquired defect due to cancer resection in 1 patient. The mean time to PEEK cranioplasty since the patient's last operation was 16 months. The mean defect size was 74 cm(2). The mean surgical blood loss was 124 mL. The mean length of stay was 3 days. Complications included 1 postoperative bleeding that required reoperation, but the PEEK implant was successfully salvaged. The mean time to follow-up was 6 months. CONCLUSIONS: Use of patient-specific PEEK implants is a good alternative for alloplastic cranioplasty. It is associated with low morbidity as reported in our series, with additional advantages including strength, stiffness, durability, and inertness. It would be beneficial to assess the longer-term outcomes; however, it appears at first glance that PEEK implants show great promise in calvarial reconstruction.

Airway risk associated with patients in halo fixation.

Background: The halo fixation device introduces a significant obstacle for clinicians attempting to secure a definitive airway in trauma patients with cervical spine injuries. The authors sought to determine the airway-related mortality rate of adult trauma patients in halo fixation requiring endotracheal intubation. Methods: This study was a retrospective chart review of patients identified between 2007 and 2012. Only adult trauma patients who were intubated while in halo fixation were included in the study. Results: A total of 46 patients underwent 60 intubations while in halo. On five occasions, (8.3%) patients were unable to be intubated and required an emergent surgical airway. Two (4.4%) of the patients out of our study population died specifically due to airway complications. Elective intubations had a failure rate of 5.8% but had no related permanent morbidity or mortality. In contrast to that, 25% of non-elective intubations failed and resulted in the deaths of two patients. The association between mortality and non-elective intubations was statistically highly significant (P = 0.0003). Conclusion: The failed intubation and airway-related mortality rates of patients in halo fixation were substantial in this study. This finding suggests that the halo device itself may present a major obstacle in airway management. Therefore, heightened vigilance is appropriate for intubations of patients in halo fixation.

Laminectomy for acute transverse sacral fractures with compression of the cauda equina: A neurosurgical perspective.

Introduction: Optimal management of transverse sacral fractures (TSF) remains inconclusive. These injuries may present with neurological deficits including cauda equina syndrome. We present our series of laminectomy for acute TSF with cauda equina compression. Methods: This was a retrospective chart review of all patients that underwent sacral laminectomy for treatment of cauda equina compression in acute TSF at our institution between 2007 through 2023. Results: A total of 9 patients (5 male and 4 female) underwent sacral laminectomy to decompress the cauda equina in the setting of acute high impact trauma. Surgeries were done early within a mean time of 5.9 days. All but one patient had symptomatic cauda equina syndrome. In one instance surgery was applied due to significant canal stenosis present on imaging in a patient with diminished mental status not allowing proper neurological examination. Torn sacral nerve roots were repaired directly when possible. All patients regained their neurological function related to the sacral cauda equina on follow up. The rate of surgical site infection (SSI) was 33%. Conclusion: Acute early sacral laminectomy and nerve root repair as needed was effective in recovering bowel and bladder function in patients after high impact trauma and TSF with cauda equina compression. A high SSI rate may be reduced by delaying surgery past 1 week from trauma, but little data exists at this time for clear recommendations.

Brown-Sequard syndrome associated with hangman fracture after blunt trauma: A case report.

Background: The association of Brown-Sequard syndrome (BSS) and hangman fracture (HF) is rarely reported. Case Description: We present a case of a 28-year-old female with a HF sustained after a motor vehicle accident and BSS. Diagnosis was established based on typical loass of motor function ipsilaterally and loss of pain and temperature sensation contralaterally. Furthermore, magnetic resonance imaging delineated the location of the injury to the right side of the spinal cord at cervical level 2. Near-complete neurological recovery was achieved after anterior fusion and fixation at cervical level 2-3 after 8 months of follow-up. Conclusion: HF from blunt trauma can be directly associated with BSS. Surgery was effective and associated with a near-complete resolution of symptoms.

Blunt traumatic posterior cord syndrome.

INTRODUCTION: Posterior cord syndrome (PCS) is rare and insufficiently assessed in the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). CASE PRESENTATION: A 39-year-old male was involved in a motorcycle collision and presented with paresthesia of the entire body, neck pain, subjective right arm weakness, and loss of position sense in all extremities. Imaging of the cervical spine revealed fractures of the upper cervical spine including a teardrop fracture and hangman fracture. Patient underwent anterior cervical interbody fusion and plating and halo orthosis. He ultimately regained near full function. Follow-up imaging clearly depicted the traumatic lesion to the level of the posterior spinal cord. DISCUSSION: PCS is uncommon, but may be underdiagnosed. We would like to emphasize the importance of a full neurological exam in order to properly diagnose and manage patients with PCS. Our case is unique since we were able to anatomically delineate the focus of spinal cord injury to the posterior column on follow up MRI at 10 months. Therefore, a delayed MRI obtained sub-acutely may facilitate the anatomical diagnosis of PCS.

Risk factors for blunt cerebrovascular injury in children: do they mimic those seen in adults?

BACKGROUND: Eastern Association for the Surgery of Trauma guideline for the evaluation of blunt cerebrovascular injury (BCVI) states that pediatric trauma patients should be evaluated using the same criteria as the adult population. The purpose of our study was to determine whether adult criteria translate to the pediatric population. METHODS: Retrospective evaluation was performed at a Level I trauma center of blunt pediatric trauma patients (age <15 years) presenting over a 5-year period. Data obtained included patient demographics, presence of adult risk factors for BCVI (Glasgow coma scale ≤8, skull base fracture, cervical spine fracture, complex facial fractures, and soft tissue injury to the neck), presence of signs/symptoms of BCVI, method of evaluation, treatment, and outcome. RESULTS: A total of 1,209 pediatric trauma patients were admitted during the study period. While 128 patients met criteria on retrospective review for evaluation based on Eastern Association for the Surgery of Trauma criteria, only 52 patients (42%) received subsequent radiographic evaluation. In all, 14 carotid artery or vertebral artery injuries were identified in 11 patients (all admissions, 0.9% incidence; all screened, 21% incidence). Adult risk factors were present in 91% of patients diagnosed with an injury. Major thoracic injury was found in 67% of patients with carotid artery injuries. Cervical spine fracture was found in 100% of patients with vertebral artery injuries. Stroke occurred in four patients (36%). Stroke rate after admission for untreated patients was 38% (3/8) versus 0.0% in those treated (0/2). Mortality was 27% because of concomitant severe traumatic brain injury. CONCLUSION: Risk factors for BCVI in the pediatric trauma patient appear to mimic those of the adult patient.

Location of Traumatic Cranial Epidural Hematoma Correlates with the Source of Hemorrhage: A 12-Year Surgical Review.

BACKGROUND: Epidural hematoma (EDH) can result in a catastrophic outcome of traumatic brain injury. Current management guidelines do not consider the source of hemorrhage in decision making. The purpose of this study was to examine the relationship between EDH location and the source of hemorrhage. METHODS: We report retrospectively reviewed, prospectively obtained surgical data of patients with acute traumatic cranial EDH treated between 2007 and 2018. Computed tomography (CT) scans were used to categorize EDH location as lateral or medial. The source of hemorrhage was identified intraoperatively by a single surgeon. RESULTS: Overall, of 92 evacuated EDHs (in 87 patients), 71 (77.2%) were in the lateral location. Arterial bleeding was the cause of EDH in 63.4% of the lateral EDHs and 9.2% of the medial EDHs (P < 0.0001). In the cases where surgery was done primarily to treat EDH, 65.3% had an arterial bleed source (P < 0.0001). In those treated for primary reasons other than EDH evacuation, 75% had a venous bleed source (P = 0.002). CONCLUSIONS: The location of EDH correlates with the source of hemorrhage. The decision to operate on EDH may be influenced by this factor.

Natural History of a Patient with Sacral Chordoma: Case Report and Literature Review.

BACKGROUND: Chordomas are rare, slow-growing, locally aggressive, malignant tumors of the spine. Chordomas are conventionally treated with surgical resection with or without radiation. There is an absence of literature documenting the natural history of a primary sacral chordoma. CASE DESCRIPTION: A 65-year-old man presented with rectal pain, constipation, urinary and fecal incontinence, S1 radiculopathy, and a palpable rectal mass. A needle biopsy confirmed the pathologic diagnosis of sacral chordoma. The patient declined to have surgery because of the surgical risks involved. He was managed conservatively with supportive care only. The patient was routinely followed in clinic and had a subjective and objective excellent quality of life with adequate pain management. Meanwhile, his neurologic status did not deteriorate. During follow-up, some posterolateral aspects of the chordoma regressed. However, the bulk of the lesion continued to slowly progress. The patient survived for 7.5 years. He eventually succumbed to urosepsis and new-onset peritoneal metastasis. CONCLUSIONS: To our knowledge, the patient is the only documented case in the literature of an untreated biopsy-proven sacral chordoma. The patient's tumor was intended for resection, and therefore comparable with data from treated chordomas. The patient's survival is similar to the median survival in treated chordomas. The patient's survival was despite negative prognosticators, such as advanced age of the patient and high sacral location above S2.

Atlanto-Occipital Transarticular Screw Fixation for the Treatment of Traumatic Occipitocervical Instability in the Pediatric Population.

BACKGROUND: Atlanto-occipital transarticular screw fixation (AOTSF) has rarely been reported for fixation of the craniovertebral junction (CVJ). METHODS: A retrospective chart review of all pediatric patients (less than 18 years of age) with an attempt of AOTSF for fixation of traumatic CVJ instability was conducted. RESULTS: A total of 4 patients (2 boys and 2 girls; ages 2, 3, 5, and 8 years) who suffered from acute traumatic CVJ instability managed during 2007-2018 underwent an attempted AOTSF. In 2 patients, this method was technically successful. In the other 2 instances, we were not able to engage the screw into the occipital condyle. These were converted to standard occipital plate, rod, and screw fixation. All were placed in a halo subsequently for a minimum of 3 months. Three patients were fused at last follow-up (range, 17-48 months). One patient after successful AOTSF did not fuse. There were no surgical complications or revision procedures. CONCLUSIONS: AOTSF was feasible in half of pediatric patients suffering from traumatic CVJ instability. Therefore, intraoperative salvage options and strategies should be on hand readily. In the pediatric population, where bony anatomy may pose challenges to fixation, this technique may offer a viable first-line option in selected cases, despite the overall modest success rate.

Significant pediatric morbidity and mortality from intracranial ballistic injuries caused by nonpowder gunshot wounds. A case series.

Nonpowder (ball-bearing and pellet) weapons derive their source of energy from compressed air or carbon dioxide. Such weapons are dangerous toys that cause serious injuries and even death to children and adolescents. A retrospective chart review study was undertaken to describe nonpowder gun injuries at a southwestern US urban level I adult and pediatric trauma center. Specific emphasis was placed on intracranial injuries. Over the past 6 years, a total of 29 pediatric and 7 adult patients were identified as having nonpowder firearm injuries. The patient population was overwhelmingly male (89.7%; mean age, 11 years). Overall, 17 out of 29 pediatric patients (56.8%) sustained serious injury. Nine patients (30.0%) required operation, 6 (20.7%) sustained significant morbidity, and there were 2 deaths (6.9%). Injuries to the brain, eye, head, and neck were the most common sites of injury (65.6%). Specific intracranial injuries in 3 pediatric patients are described that resulted in the death of 2 children. We suggest that age warning should be adjusted to 18 years or older for unsupervised use to be considered safe of these potentially lethal weapons.

The role of surgery in the management of metastatic spinal tumors.

The role of surgery in the treatment of metastatic spinal tumors causing epidural compression traditionally consisted of posterior decompression. This procedure plus radiotherapy, however, could not be demonstrated to provide any benefit over radiotherapy alone, and surgery fell into disfavor in managing metastatic vertebral tumors. The advent of newer, more sophisticated approaches, along with improved spinal instrumentation and reconstruction techniques, which allowed direct decompression of neural elements and resection of the tumor, have revived the use of surgery in these tumors. These modern spinal surgery techniques, in combination with radiotherapy, have yielded significantly superior functional outcomes and prolonged survival in symptomatic metastatic epidural compression when compared to radiotherapy alone. Management of spinal metastases is evolving, and a multitude of factors determine the indication for and the technique and goals of surgical intervention. Between 1993 and 2005, 21.1% of patients with metastatic spinal tumors evaluated at The University of Texas M.D. Anderson Cancer Center were treated surgically by the Department of Neurosurgery. The most common spinal metastasis operated upon was metastatic kidney cancer (31.5%), even though kidney cancer was only the third most common primary tumor (after lung and breast cancers) giving rise to vertebral metastases observed during the same time period at this institution. This highlights the importance of the histology of the primary cancer (among other factors) in determining the indication for surgical intervention.

Biomechanical comparison of occipitoatlantal screw fixation techniques.

OBJECT: The stability provided by 3 occipitoatlantal fixation techniques (occiput [Oc]-C1 transarticular screws, occipital keel screws rigidly interconnected with C-1 lateral mass screws, and suboccipital/sublaminar wired contoured rod) were compared. METHODS: Seven human cadaveric specimens received transarticular screws and 7 received occipital keel-C1 lateral mass screws. All specimens later underwent contoured rod fixation. All conditions were studied with and without placement of a structural graft wired between the skull base and C-1 lamina. Specimens were loaded quasistatically using pure moments to induce flexion, extension, lateral bending, and axial rotation while recording segmental motion optoelectronically. Flexibility was measured immediately postoperatively and after 10,000 cycles of fatigue. RESULTS: Application of Oc-C1 transarticular screws, with a wired graft, reduced the mean range of motion (ROM) to 3% of normal. Occipital keel-C1 lateral mass screws (also with graft) offered less stability than transarticular screws during extension and lateral bending (p < 0.02), reducing ROM to 17% of normal. The wired contoured rod reduced motion to 31% of normal, providing significantly less stability than either screw fixation technique. Fatigue increased motion in constructs fitted with transarticular screws, keel screws/lateral mass screw constructs, and contoured wired rods, by means of 19, 5, and 26%, respectively. In all constructs, adding a structural graft significantly improved stability, but the extent depended on the loading direction. CONCLUSIONS: Assuming the presence of mild C1-2 instability, Oc-C1 transarticular screws and occipital keel-C1 lateral mass screws are approximately equivalent in performance for occipitoatlantal stabilization in promoting fusion. A posteriorly wired contoured rod is less likely to provide a good fusion environment because of less stabilizing potential and a greater likelihood of loosening with fatigue.

Surgical management of primary and metastatic sarcoma of the mobile spine.

OBJECT: Sarcomas of the spine are a challenging problem due to their frequent and extensive involvement of multiple spinal segments and high recurrence rates. Gross-total resection to negative margins, with preservation of neurological function and palliation of pain, is the surgical goal and may be achieved using either intralesional resection or en bloc excision. The authors report outcomes of surgery for primary and metastatic sarcomas of the mobile spine in a large patient series. METHODS: A retrospective review of patients undergoing resection for sarcomas of the mobile spine between 1993 and 2005 was undertaken. Sarcomas were classified by histology study results and as either primary or metastatic. Details of the surgical approach, levels of involvement, and operative complications were recorded. Outcome measures included neurological function, palliation of pain, local recurrence, and overall survival. RESULTS: Eighty patients underwent 110 resections of either primary or metastatic sarcomas of the mobile spine. Twenty-nine lesions were primary sarcomas (36%) and 51 were metastatic sarcomas (64%). Intralesional resections were performed in 98 surgeries (89%) and en bloc resections were performed in 12 (11%). Median survival from surgery for all patients was 20.6 months. Median survival for patients with a primary sarcoma of the spine was 40.2 months and was 17.3 months for patients with a metastatic sarcoma. Predictors of improved survival included a chondrosarcoma histological type and a better preoperative functional status, whereas osteosarcoma and a high-grade tumor were negative influences on survival. Multivariate analysis showed that only a high-grade tumor was an independent predictor of shorter overall survival. American Spinal Injury Association scale grades were maintained or improved in 97% of patients postoperatively, and there was a significant decrease in pain scores postoperatively. No significant differences in survival or local recurrence rates between intralesional or en bloc resections for either primary or metastatic spine sarcomas were found. CONCLUSIONS: Surgery for primary or metastatic sarcoma of the spine is associated with an improvement in neurological function and palliation of pain. The results of this study show a significant difference in patient survival for primary versus metastatic spine sarcomas. The results do not show a statistically significant benefit in survival or local recurrence rates for en bloc versus intralesional resections for either metastatic or primary sarcomas of the spine, but this may be due to the small number of patients undergoing en bloc resections.

Microsurgical management of spinal schwannomas: evaluation of 128 cases.

OBJECT: The authors conducted a study to evaluate the clinical characteristics and surgical outcomes in patients with spinal schwannomas and without neurofibromatosis (NF). METHODS: The data obtained in 128 patients who underwent resection of spinal schwannomas were analyzed. All cases with neurofibromas and those with a known diagnosis of NF Type 1 or 2 were excluded. Karnofsky Performance Scale (KPS) scores were used to compare patient outcomes when examining the anatomical location and spinal level of the tumor. The neurological outcome was further assessed using the Medical Research Council (MRC) muscle testing scale. RESULTS: Altogether, 131 schwannomas were treated in 128 patients (76 males and 52 females; mean age 47.7 years). The peak prevalence is seen between the 3rd and 6th decades. Pain was the most common presenting symptom. Gross-total resection was achieved in 127 (97.0%) of the 131 lesions. The nerve root had to be sacrificed in 34 cases and resulted in minor sensory deficits in 16 patients (12.5%) and slight motor weakness (MRC Grade 3/5) in 3 (2.3%). The KPS scores and MRC grades were significantly higher at the time of last follow-up in all patient groups (p = 0.001 and p = 0.005, respectively). CONCLUSIONS: Spinal schwannomas may occur at any level of the spinal axis and are most commonly intradural. The most frequent clinical presentation is pain. Most spinal schwannomas in non-NF cases can be resected totally without or with minor postoperative deficits. Preoperative autonomic dysfunction does not improve significantly after surgical management.

Efficacy of Trans-septal Trans-sphenoidal Surgery in Correcting Visual Symptoms Caused by Hematogenous Metastases to the Sella and Pituitary Gland.

The rate of symptomatic improvement of visual symptoms associated with hematogenous metastases to the sella and pituitary was evaluated retrospectively in seven patients (five men, two women; mean age, 52.3 years) with primarily visual symptoms (diplopia alone in three, diplopia with blurred vision in one, blurred vision alone in one, loss of peripheral vision in one, and unilateral complete blindness in one). Symptom duration ranged from 0.5 to 2 months. The primary diseases were non-small cell lung cancer in two patients, renal cell carcinoma in two patients, prostate cancer in two patients, and medullary thyroid carcinoma in one patient. All patients had widespread metastatic disease. Three patients had a suprasellar tumoral component. One patient had a clival extension, and one patient had extension into the cavernous sinus. All underwent trans-sphenoidal surgery to correct visual symptoms. Gross total resection was achieved in three patients. Subtotal resections and a partial resection were performed in three patients and one patient, respectively. Surgical blood loss averaged 282 mL. One patient died from sepsis. Five patients developed complications (cerebrospinal fluid leakage in three, diabetes insipidus in two, anterior pituitary dysfunction in two, and colitis in one). At a mean follow-up of 15 months, three patients were alive. Visual symptoms improved in five patients and were unchanged in two. Trans-sphenoidal surgery helped improve visual symptoms in most patients. The morbidity rate was high and likely related to the locally destructive and extensive nature of the lesions in overall morbid patients with widespread metastatic disease. Unless nonoperative measures can provide equal results, however, this approach provides reasonable palliation.

Postoperative acute sialadenitis after skull base surgery.

During retrosigmoid and far-lateral skull base surgical approaches, the head may be positioned at the extreme limits of rotation and flexion. In rare instances, patients may develop acute sialadenitis after surgery as a result of this positioning technique. Over a 4-year period, five patients developed postoperative sialadenitis after undergoing either a retrosigmoid craniotomy in the supine position (n = 4) or a far-lateral craniotomy in the park-bench position. Based on all the retrosigmoid and far-lateral approaches performed by the senior author (RFS), the incidence of sialadenitis was 0.84%. In all five patients, the acute sialadenitis was not clinically apparent at the conclusion of the operation. However, the diagnosis was evident within 4 hours of surgery. In each case, the neck swelling in the vicinity of the submandibular gland was contralateral to the craniotomy site. All patients were treated with intravenous hydration and antibiotic therapy. One patient was extubated immediately after surgery with no obvious evidence of sialadenitis. However, she required emergent reintubation due to airway compromise. The mechanism of acute sialadenitis in these patients was obstruction of the salivary duct caused by surgical positioning. This previously unreported observation in patients undergoing skull base surgery deserves consideration during perioperative and postoperative management.

Proposed classification for the transbasal approach and its modifications.

The transbasal approach offers extradural exposure of the anterior midline skull base transcranially. It can be used to treat a variety of conditions, including trauma, craniofacial deformity, and tumors. This approach has been modified to enhance basal access. This article reviews the principle differences among modifications to the transbasal approach and introduces a new classification scheme. The rationale is to offer a uniform nomenclature to facilitate discussion of these approaches, their indications, and related issues.

Epidural venous plexus engorgement due to inferior vena cava thrombosis resulting in cauda equina syndrome: Case report and literature review.

BACKGROUND: Epidural venous plexus congestion at L5-S1 due to inferior vena cava (IVC) thrombosis led to an acute cauda equina syndrome (CES). Laminectomy to rule out an epidural abscess, allowing for resection of the dilated veins, led to immediate symptom resolution. CASE DESCRIPTION: A 47-year-old male presented with acute urinary retention and left greater than right lower extremity paresis of 2 weeks duration. Magnetic resonance imaging (MRI) revealed a contrast-enhancing space-occupying anterior epidural L5-S1 level lesion resulting in cauda equina compression. As the patient was septic, he underwent an emergency laminectomy for a presumed epidural abscess. Intraoperative findings, however, documented a markedly dilated epidural venous plexus secondary to a newly diagnosed IVC thrombus. One day postoperatively, the patient was symptom-free and neurologically intact. CONCLUSIONS: Here we report a patient who uniquely presented with a CES characterized by acute paraparesis. This was attributed to a massively engorged anterior lumbar epidural venous plexus attributed to newly diagnosed IVC thrombus.