Posterior-only 2-level vertebrectomy and fusion in a medically complex patient with lumbar metastasis: illustrative case.

BACKGROUND: Spinal metastases are commonly seen in patients with cancer and often indicate a poor prognosis. Treatment can include curative or palliative surgery, chemotherapy, and radiation therapy. The surgical approach varies widely on the basis of the affected region of the spine, the location of the tumor (anterior versus posterior), the goal of surgery, the health of the patient, and surgeon preference. OBSERVATIONS: The authors present a case of a 68-year-old male with intractable lower-back pain and substantially diminished ambulation. Diagnostic imaging revealed a lumbar metastasis from a cholangiocarcinoma primary at L2-3 (4.5 cm anteroposterior × 5.7 cm transverse × 7.0 cm craniocaudal). The patient underwent a 2-level vertebrectomy with expandable cage placement and T10 to S2 fusion via a posterior-only approach. The patient regained much of his mobility and quality of life after the surgery. LESSONS: Although this was a high-risk surgery, the authors show that a posterior-only approach can be used for lumbar vertebrectomies and fusion when necessary. Palliative surgeries carrying a high risk, especially in the setting of a limited prognosis, should include multidisciplinary deliberations and a thorough discussion of the risks and outcome expectations with the patient.

Minimally Invasive Bilateral Decompressive Lumbar Laminectomy with Unilateral Approach Among Obese versus Nonobese Patients.

OBJECTIVE: Decompressive lumbar laminectomy (DLL) is a common procedure for lumbar stenosis. A unilateral approach, unlike the traditional open approach, spares the posterior elements to mitigate the risk of iatrogenic instability associated with a DLL. Various minimally invasive techniques have been described but little attention has been aimed toward this specific microsurgical approach, particularly regarding obese patients. We aimed to compare operative details, perioperative outcomes, and complication profiles between obese and nonobese patients. METHODS: One hundred and ninety-four patients who underwent bilateral laminectomy with a unilateral approach by the study surgeon from July 2013 to June 2018 were included. Of these patients, 105 were classified as obese, with body mass index (BMI) ≥30.0 kg/m2, and 89 were nonobese, with BMI <30.0 kg/m2. The obese and nonobese groups were compared; operative time, blood loss, and complications were assessed. RESULTS: Operative time was nonsignificantly increased in the obese group (177 vs. 166 minutes; P = 0.21) and estimated blood loss was nonsignificantly lower (91 mL vs. 97 mL; P = 1.00) in the obese group. Durotomy rates (3 [2.9%] obese vs. 2 [2.2%] nonobese; P = 0.789) and postoperative wound drainage rates (4 [3.8%] obese vs. 2 [3.8%] nonobese; P = 0.92) did not significantly differ between the 2 groups. Length of stay was significantly longer in the obese group (1.5 vs. 1.0 days; P = 0.0005). CONCLUSIONS: Compared with the nonobese group, the obese group had significantly longer length of hospitalization, as well as nonsignificantly increased length of operation and decreased blood loss. The 2 groups had similar perioperative complication rates.

Delayed Diagnosis of Cervical Epidural Hematoma in a 3-Year-Old Boy: A Case Report.

CASE: A 3-year-old boy presented to the emergency department with torticollis after a fall. With normal cervical radiographs and neurologic exam, he was diagnosed with cervical strain and discharged. After 2-week progressive symptoms, he was referred to a pediatric spine surgeon. Magnetic resonance imaging (MRI) revealed a cervical epidural hematoma, which was then surgically evacuated. He recovered fully and remains symptom-free 2 years later. CONCLUSION: Pediatric spinal epidural hematoma is a rare condition with potentially serious outcomes yet often nonspecific symptoms. Timely management based on a comprehensive evaluation of symptoms and imaging findings is crucial in improving patient outcomes.

Disseminated blastomycosis with an intracranial fungoma in an immunocompetent patient: illustrative case.

BACKGROUND: Blastomyces dermatitidis is a fungus endemic to central and southern North America. While infection most commonly results in pneumonia, a small number of infections progress to systemic disease, which may include intracranial lesions. Progression to systemic disease is most common in immunocompromised patients, such as those with human immunodeficiency virus. OBSERVATIONS: The authors present a 44-year-old immunocompetent male who presented following a tonic-clonic seizure. Initial workup revealed a 19-mm enhancing intracranial mass. There was avid uptake of fluorescein sodium, and an en bloc resection of the mass was performed. Histopathology revealed B. dermatitidis. Medical management included amphotericin B and azole therapy. Postoperative recovery was uneventful, and no focal neurological deficits were appreciated. LESSONS: This case highlights the neurosurgical management of a rare intracranial fungal manifestation in an immunocompetent patient. A literature review was also performed to better understand the role of neurosurgery in fungal infections. There were limited cases of intracranial Blastomyces reported in immunocompetent patients, and neurosurgical management varied (no intervention, biopsy, resection) and was underreported. Too few cases are reported to suggest neurosurgical intervention for blastomycosis improves outcomes. Medical management was relatively standard with azole and amphotericin therapy.

An Alternative Operative Approach to Lumbar Spondylolisthesis.

Lumbosacral spondylolisthesis is a frequently encountered pathology with high-grade spondylolisthesis being the least common. A circumferential construct is usually the preferred treatment as these can resist the shearing forces present at L5-S1. However, the severity of the slip, sacral inclination, and the slip angle may make a traditional anterior approach difficult to achieve. In this case series, we present three patients with axial back pain that were treated with an anterior L5-S1 transvertebral cage. This technique is intended for both grade II spondylolisthesis and high sacral slope. The L5-S1 transvertebral cage may be sufficient to prevent further listhesis, fuse the patient, and alleviate axial back pain.

Smaller Knife, Fewer Seizures? Recent Advances in Minimally Invasive Techniques in Pediatric Epilepsy Surgery.

Children with drug-resistant epilepsy are at high risk for developmental delay, increased mortality, psychiatric comorbidities, and requiring assistance with activities of daily living. Despite the advent of new and effective pharmacologic therapies, about one in 5 children will develop drug-resistant epilepsy, and most of these children continue to have seizures despite trials of other medication. Epilepsy surgery is often a safe and effective option which may offer seizure freedom or at least a significant reduction in seizure burden in many children. However, despite published evidence of safety and efficacy, epilepsy surgery remains underutilized in the pediatric population. Patient and family fears about the risks of surgery may contribute to this gap. Less invasive surgical techniques may be more palatable to children with epilepsy and their caregivers. In this review, we present recent advances in minimally invasive techniques for the surgical treatment of epilepsy as well as intriguing possibilities for the future. We describe the indications for, benefits of, and limits to minimally-invasive techniques including Stereo-encephalography, laser interstitial thermal ablation, deep brain stimulation, focused ultrasound, stereo-encephalography-guided radiofrequency ablation, endoscopic disconnections, and responsive neurostimulation.

Proximal basilar artery hemorrhage after submaximal angioplasty for intracranial atherosclerotic disease presenting as a large vessel occlusion treated with pipeline embolization device.

Iatrogenic vessel perforation from endovascular intervention is a devastating complication that commonly is treated with vessel sacrifice. We present a unique case of an iatrogenic proximal basilar artery perforation after submaximal angioplasty in a 67-year-old male presenting with an acute basilar artery occlusion with underlying intracranial atherosclerotic disease. Telescoping flow-diverting stents were then deployed to reconstruct the vessel wall with resulting active hemorrhage resolution. Our case documents a successful deployment of flow-diverting stents with resolution of active hemorrhage after an iatrogenic basilar artery perforation.

Return to Work Guidelines Following Neurosurgical Procedures.

Recovery time following surgical procedures is a consideration every practicing surgeon must deliberate upon throughout his or her career. The decision to restrict patients from returning to work or various activities encountered on a daily basis following an operation is dependent on many factors. Surgeons must take into account patient population, individual comorbid conditions, complexity and length of surgery, immediate postoperative course, and baseline functional abilities. Thus, returning to work and various activities, including physical activity, work-related activity, and recreational activity alike, following invasive procedures is individualized from patient to patient. Most spinal procedures are performed by neurosurgeons or orthopedic surgeons. This article suggests a framework to guide appropriate return to work and activity escalation time frames following various spinal procedures.

Delayed Rupture of a Cortical Traumatic Intracranial Aneurysm.

Traumatic intracranial aneurysms are rare lesions that occur after blunt or primarily penetrating mechanisms. These are extremely fragile vessel injuries associated with significant morbidity and mortality, especially after rupture. Disease natural history, surveillance strategies, and management are based on small case series. Here we present a case of a 29-year-old male with a large epidural hematoma after blunt trauma, who underwent emergent surgical intervention. Three months postoperatively, he presented with unusual cerebral bleeding. Clinical suspicion prompted a conventional angiogram, which diagnosed a ruptured cortical traumatic intracranial aneurysm. The patient was urgently treated by surgical clipping with a good outcome.