A Survey Assessment of Neurosurgeons' Interest in Osteopathic Medicine and Its Integration Into Their Practice.

INTRODUCTION: Osteopathic manipulative medicine (OMM) encompasses techniques guided by the tenets of osteopathy aimed at facilitating the body's natural self-healing capabilities as a treatment option for injury or illness. This approach recognizes the interrelationship of structure and function in promoting overall health. The clinical applications of OMM have been highly researched throughout different subspecialties of medicine; however, there is a notable lack of osteopathic-based research targeted toward neurosurgical patient populations. METHODS: This cross-sectional descriptive study was conducted via a survey generated using SurveyMonkey (SurveyMonkey, San Mateo, CA, USA; accessed at www.surveymonkey.com). Subjects for this survey were gathered using a convenience sampling method in which emails of all neurosurgeons listed in the "Member Directory" on the American Association of Neurological Surgeons website were compiled into a mailing list. The survey was sent to all 6,503 emails collected, and the responses were recorded over the next month. The responses for each survey question were averaged and, when appropriate, compared using a two-tailed T-test, with statistical significance defined as a p<0.05. Where applicable, simple linear regression analysis was used to assess correlations between survey data. The measured outcomes included neurosurgeons' (1) knowledge of and (2) attitudes toward OMM. RESULTS: Both MD and DO neurosurgeons reported using OMM (or referring their patients for OMM) less than once per year. In comparison to their MD colleagues, neurosurgeons carrying a DO degree ranked their familiarity with the tenets of osteopathic medicine (p<0.0001) and their knowledge of the applications of OMM in their practice (p=0.0018) significantly higher. Greater reported familiarity with the tenets of osteopathic medicine and applications of OMM showed a positive correlation with neurosurgeons' comfort in recommending OMM as a nonsurgical, preoperative treatment option, as a post-surgical, rehabilitative treatment option, and as a pain management option (p<0.0001 for all). There was a clear interest in seeing further osteopathic-based neurosurgery research by both MD and DO neurosurgeons, as well as a trend of interest in incorporating OMM into their practice if shown to be clinically beneficial. CONCLUSIONS: Both MD and DO neurosurgeons are interested in seeing more research into the applications of OMM in their patient populations and, most importantly, are likely to integrate OMM into their practice if presented with research detailing clinical benefits to their patients. This study highlights the clinical interest of neurosurgeons in further research into the applications of OMM specific to the field of neurosurgery.

Combining Endovascular Coiling and Open Evacuation for a Delayed-Onset Ruptured Post-traumatic Pseudoaneurysm of the Distal Paracentral Pericallosal Artery Branch.

Cerebrovascular pseudoaneurysm development and rupture is a rare, delayed sequelae of trauma. We present a case of a female patient in her sixties who presented after a fall without evidence of vascular injury on imaging. However, after one week, repeat imaging due to an abrupt change in mental status revealed a ruptured pseudoaneurysm, which was treated with a combination of coil embolization and open surgical evacuation of associated intracranial hematoma. This case illustrates the importance of continued surveillance beyond the acute traumatic period to identify late-onset complications in trauma patients requiring emergent treatment.

Tension pneumocephalus following bariatric surgery: case report.

Bariatric surgery is an effective treatment for patients with idiopathic intracranial hypertension (IIH), a condition that is associated with skull base defects. A 55-year-old woman presented with symptoms of intractable nausea and vomiting, followed by headache and confusion two weeks after an elective laparoscopic vertical sleeve gastrectomy procedure. She had a presumed diagnosis of IIH and a remote history of CSF oto/rhinorrhea treated with a lumbar peritoneal (LP) shunt. Computed tomography (CT) scan of the head revealed tension pneumocephalus with midline shift and dehiscence of the tegmen. The patient underwent emergent craniotomy for decompression of the air-filled temporal lobe, clamping of the LP shunt, and repair of the skull base defect. Caution should be exercised in obese patients with a history of CSF leak secondary to a middle fossa skull base defect when being evaluated for bariatric surgery.

Tuning-Target-Guided Inverse Planning of Brain Tumors With Abutting Organs at Risk During Gamma Knife Stereotactic Radiosurgery.

Purpose We proposed a planning strategy that utilized tuning targets to guide GammaKnife (GK) Inverse Planning (IP) to deliver higher dose to the tumor, while keeping acceptable dose to the abutting organ at risk (OAR). Methods Ten patients with a large portion of brain tumor abutting the OAR previously treated with GK stereotactic radiosurgery (SRS) were selected. For each patient, multiple tuning targets were created by cropping the target contour from three-dimensional (3D) expansions of the OAR. The number of the tuning targets depended on the complexity of the planning process. To demonstrate dose sparing effect, an IP plan was generated for each tuning target after one round of optimization without shot fine-tuning. In the dose enhancement study, a more aggressive target dose was prescribed to the tuning target with a larger margin and one to two shots were filled in the region with missing dose. The resulting plans were compared to the previously approved clinical plans. Results For all 10 patients, a dose sparing effect was observed, i.e. both target coverage and dose to the OARs decreased when the margins of 3D expansion increased. For one patient, a margin of 6 mm was needed to decrease the maximum dose to the optical chiasm and optical nerve by 44.3% and 28.4%, respectively. For the other nine patients, the mean dropping rate of V12Gyto brain stem were 28.2% and 59.5% for tuning targets of 1 and 2 mm margins, respectively. In the dose enhancement study, the tuning-target-guided plans were hotter than the approved treatment plans, while keeping similar dose to the OARs. The mean of the treatment and enhancement dose was 15.6 ± 2.2 Gy and 18.5 ± 3.2 Gy, respectively. The mean coverage of the target by prescription dose was slightly higher in the enhancement plans (96.9 ± 2.6% vs 96.3 ± 3.6%), whereas the mean coverage of the enhancement dose was 20.1% higher in the enhancement plans (89.6 ± 9.0% vs 74.6 ± 19.9%). Conclusions We demonstrated that an inverse planning strategy could facilitate target dose enhancement for challenging GK cases while keeping acceptable OAR dose.

Optic Nerve Sheath Diameter Assessment in Patients with Intracranial Pressure Monitoring.

Background Optic nerve sheath diameter (ONSD) has been found to have good correlation with intracranial pressure (ICP) measurements. Here, we aim to determine if the correlation between ONSD and ICP persists throughout the acute phase of neurologic injury through the evaluation of patients with ICP monitoring. We also aim to determine if the ONSD assessments at different depths (3, 6, or 9 mm) and a ratio of the ONSD and eyeball transverse diameter (ETD) are better correlated with ICP than the well-studied ONSD assessment at 3 mm beyond the globe.  Methods This retrospective study included 68 patients more than 18 years of age with ICP monitors with both traumatic and spontaneous intracranial injuries. Head computed tomography (CT) scans were reviewed by a radiology resident for assessment of the ETD and ONSD at depths of 3, 6 and 9 mm beyond the globe, and the readings were confirmed by a neuroradiologist. The mean ICP recordings two hours before and after a CT scan were used for assessing the correlation. Results We found that ONSD expansions during the acute phase of neurologic injury were seen even without ICP elevations. This lack of correlation persisted even when different depths of the ONSD assessment or ONSD/ETD ratios were studied. Conclusion This study suggests that ONSD assessment throughout the acute phase may not be a reliable method to monitor ICP. ONSD expansion can persist even after ICP control, and this may be the reason for ONSD expansions seen in our study even with normal ICPs. Further larger size studies are needed to confirm these findings.

Proposed Diagnostic Criteria, Classification Schema, and Review of Literature of Notochord-Derived Ecchordosis Physaliphora.

Ecchordosis physaliphora (EP) is a benign notochordal remnant derived from ectopic nests found along the craniospinal axis. It typically presents asymptomatically and is diagnosed using classic radiologic features, particularly location, T1-hypointensity, T2-hyperintensity, and lack of enhancement following gadolinium (Gd) contrast administration. Distinguishing EP from its malignant counterpart, chordoma, is of paramount importance, given the aggressive nature of the latter. Advances in imaging and immunohistochemistry have aided in diagnosis to an extent but, to our knowledge, identification of the genetic fingerprint of EP has yet to take place. Further cytological analysis of these lesions in search of a genetic link is warranted. We propose here a set of diagnostic criteria based on features consistently cited in the literature. In this literature review, 23 case reports were identified and collated into a summary of symptomatic cases of ecchordosis physaliphora. An illustrative case report of two patients was also included.

Traumatic coagulopathy: the effect of brain injury.

Traumatic coagulopathy has several possible mechanisms. In traumatic brain injury (TBI), the principal process involves the release of tissue factor (TF). There is no agreement how common this mechanism is following general trauma. Furthermore, when TF-induced coagulopathy occurs, it is unknown whether the source of TF (TBI or extracranial trauma) influences the course of coagulopathy. We undertook this investigation to address both questions. The temporal course of prothrombin times (PTs) were recorded in a group (n = 441) with isolated TBI (head Abbreviated Injury Scale [AIS] >or= 3, non-head AIS < 3) and a group (n = 101) with extracranial trauma (non-TBI; non-head AIS >or= 3; head AIS < 3). Data were arranged according to preset time intervals after injury. The PT values in both groups were elevated and not significantly different for the first 12 h after trauma. Values then fell to normal in TBI patients, but remained elevated in non-TBI injury. Traumatic coagulopathy can be explained at least in part by TF release into the general circulation with activation of the coagulation cascade in both TBI and non-TBI. We hypothesize that the different time courses of coagulopathy represented by PT values in these populations were due to reconstitution of the blood-brain barrier, although further investigation is warranted. Peripheral hematologic studies may not reflect persistent coagulopathy in cerebral circulation.

Contemporary Approaches to the Management of Neurosurgical Complications of Infective Endocarditis.

Infective endocarditis can often involve the nervous system, resulting in stroke, intracerebral hemorrhage, infectious aneurysm formation, cerebral abscess, and spinal epidural infection. Many of these problems require neurosurgical attention. Modern advances in neuro- surgical critical care, computerization, instrumentation, and radiologic imaging have affected the treatments available to patients with neurosurgical manifestations of infective endocarditis. This paper is a brief overview of the contemporary management of neurosurgical complications of infective endocarditis.