Intraoperative neurophysiological monitoring of T9-T10 fracture in a patient with morbid obesity and ankylosing spondylitis: A case report with literature review.

INTRODUCTION: As the prevalence of obesity continues to rise, there is a growing need to identify practices that protect overweight patients from injury during spine surgery. Intraoperative neurophysiological monitoring (IONM) has been recommended for complex spine surgery, but its use in obese and morbidly obese patients is understudied. CASE REPORT: This case report describes a patient with morbid obesity and ankylosing spondylitis who was treated for a T9-T10 3-column fracture with a planned, minimally invasive approach. Forty minutes after positioning the patient to prone, the IONM team identified a positive change in the patient's motor responses in the bilateral lower extremities and alerted the surgical team in a timely manner. It turned out that the pressure exerted by gravity on the patient's large pannus resulted in further dislocation of the fracture and narrowing of the spinal canal. The surgical team acknowledged the serious risk of spinal cord compression and, hence, immediately changed the surgical plan to an urgent, open approach for decompression and reduction of the fracture. The patient's lower extremities' motor responses improved after decompression. The patient was ambulatory on post-operative day 2 and pain-free at six-weeks with no other neurologic symptoms. SIGNIFICANCE: The use of IONM in this planned minimally invasive spine surgery for a patient with morbid obesity prevented potentially serious iatrogenic injury. The authors include a literature review that situates this case study in the existing literature and highlights a gap in current knowledge. There are few studies that have examined the use of IONM during spine surgery for morbidly obese patients. More research is needed to elucidate best practices for the use of IONM in spine surgery for morbidly obese patients.

Subependymoma and dysembryoplastic neuroepithelial collision tumor in the foramen of Monro: case report.

Intracranial collision tumors have rarely been reported in the literature and generally include at least 1 malignant tumor component. Subependymoma with dysembryoplastic neuroepithelial tumor (DNET) is an as-yet unreported combination. Both components are uncommon tumors, and presentation in the foramen of Monro is even more unusual. A 16-year-old male patient with a past medical history significant for asthma presented with a 3-month history of headaches and radiographic evidence of mild obstructive hydrocephalus secondary to a nonenhancing ventricular lesion at the foramen of Monro. He underwent endoscopic biopsy and resection. Pathological analysis revealed distinct components of subependymoma and DNET. At the 1-year follow-up, the patient was doing well without regrowth of tumor. The authors describe a case of intracranial collision tumor demonstrating 2 grade I components: a novel combination of subependymoma and DNET.

False Localization of Ruptured Intracranial Dermoid Secondary to Subarachnoid Spread of Cyst Contents.

A 34-year-old right-handed female presented to the emergency department with a worsening headache, neck stiffness, intermittent abnormal sensation, and right arm weakness. Shortly after arrival, she had a generalized tonic-clonic seizure. A noncontrast head computed tomography scan revealed a right-sided, low-attenuating, lobulated mass ipsilateral to her arm symptoms. Magnetic resonance imaging revealed an abnormal signal throughout the subarachnoid space and increased fluid-attenuated inversion recovery sequence signal contralateral to the mass. This presentation suggested a false localization sign of sensory and motor disturbance ipsilateral to the mass likely caused by cyst rupture and sebum spread contralateral, causing cortical irritation (evidenced by increased fluid-attenuated inversion recovery sequence signal). During mass resection, sebum was visible throughout the subarachnoid space. The patient had an uneventful recovery from surgery and has been seizure free since the resection with steady improvement of symptoms. This case highlights the importance of avoiding cyst rupture of dermoid cysts.

Efficacy, Duration and Timing of Withdrawal of Prophylactic Treatment with Antiepileptic Drugs in Neurosurgical Conditions.

Seizure control is a critical component of care in many neurosurgical conditions. The development of seizures in patients without a previously identified seizure disorder occurs in a significant proportion of traumatic brain injury, subarachnoid hemorrhage, and brain tumor patients. In this literature review and synthesis, we will discuss the incidence of seizures in selected conditions, indications and evidence for the initiation of antiepileptic drugs (AEDs), suggested duration of usage for AEDs, and current AED guidelines by the American Academy of Neurology (AAN), Congress of Neurological Surgeons (CNS), American Academy of Neurological Surgeons (AANS) and international committees.

Methylation by Set9 modulates FoxO3 stability and transcriptional activity.

The FoxO family of transcription factors plays an important role in longevity and tumor suppression by regulating the expression of a wide range of target genes. FoxO3 has recently been found to be associated with extreme longevity in humans and to regulate the homeostasis of adult stem cell pools in mammals, which may contribute to longevity. The activity of FoxO3 is controlled by a variety of post-translational modifications that have been proposed to form a 'code' affecting FoxO3 subcellular localization, DNA binding ability, protein-protein interactions and protein stability. Lysine methylation is a crucial post-translational modification on histones that regulates chromatin accessibility and is a key part of the 'histone code'. However, whether lysine methylation plays a role in modulating FoxO3 activity has never been examined. Here we show that the methyltransferase Set9 directly methylates FoxO3 in vitro and in cells. Using a combination of tandem mass spectrometry and methyl-specific antibodies, we find that Set9 methylates FoxO3 at a single residue, lysine 271, a site previously known to be deacetylated by Sirt1. Methylation of FoxO3 by Set9 decreases FoxO3 protein stability, while moderately increasing FoxO3 transcriptional activity. The modulation of FoxO3 stability and activity by methylation may be critical for fine-tuning cellular responses to stress stimuli, which may in turn affect FoxO3's ability to promote tumor suppression and longevity.