Clinical outcome following decompression and short or long instrumented fusion in lumbar degenerative spinal stenosis. A prospective case-control analysis.

OBJECTIVES: There is limited data on the direct clinical comparison between short and long fusion following surgery for lumbar spinal stenosis. The hypothesis that regardless their baseline characteristics and morbidity, clinical outcome is similar in patients with lumbar stenosis treated with decompression plus posterior instrumented fusion in one or two versus three to five levels was tested. METHODS: Subjects were divided into Group A and Group B corresponding to stenotic pathology and instrumented fusion in one or two levels and three to five levels, respectively. Primary outcome measures at one year were the change in SF-36 physical component (PCS) and Oswestry Disability Index (ODI). Secondary outcome measures included the EuroQol-5D (EQ-5D), the Visual Analog Scale (VAS), the mental component (MCS) of SF-36 scale and the Zung Self-Rating Depression Scale. RESULTS: Seventy seven (77) patients were included (Group A, n = 42; Group B, n = 35). Patients in Group B were older, surgery lasted longer and intraoperative blood loss was greater than patients in Group A (p < 0.05). A significant clinical improvement was noted in both Groups on all scales (p < 0.01). Clinical outcome at one year was equally favorable in both Groups (p > 0.05). The evaluation of depression for Group A showed a significant improvement at one year (p = 0.02) compared to the preoperative status. CONCLUSIONS: Older individuals are more likely to have multilevel stenosis and more co-morbidities and they were associated with longer instrumentation. However, complications are similar and clinical outcome is equally favorable compared to short instrumented fusion for fewer levels of disease.

Infantile Atypical Teratoid Rhabdoid Tumor of the Spine Presenting with Acute Hydrocephalus.

INTRODUCTION: Central nervous system atypical teratoid rhabdoid tumors (ATRTs) are aggressive lesions usually presenting during the first 3 years of life. These tumors have a dismal prognosis with most patients dying within 1 year from presentation. Primary spinal location in infants is very rare. CASE PRESENTATION: We report a case of a 4-month-old boy who presented with a history of hypotonia, poor head control, and gradually reduced level of consciousness, over the past week. Computed tomography (CT) showed acute hydrocephalus with no underlying intracranial pathology. A ventriculoperitoneal shunt was inserted acutely. Postoperatively, ventilator weaning was unsuccessful. MRI of the brain and whole spine revealed an intraspinal extradural contrast-enhancing heterogenous mass in the subaxial cervical spine extending to the thoracic cavity. A biopsy was taken through a transthoracic approach, and histopathology confirmed the diagnosis of ATRT. Several cycles of radiation therapy and chemotherapy were given but the tumor progressed both locally and intracranially. Eventually, pupils became dilated and fixed. Brain CT scan showed widespread ischemic lesions and an extensive intracranial tumor extension with massive bleeding. The child eventually died 110 days after admission. CONCLUSIONS: In infants presenting with acute hydrocephalus where an obvious intracranial cause is not detected, the whole neuraxis should be screened. However, despite aggressive measures and advances in multimodality treatment, prognosis of ATRT remains dismal.

Long-term Outcome Following Three-Level Stand-Alone Anterior Cervical Discectomy and Fusion: Is Plating Necessary?

BACKGROUND: Anterior cervical discectomy with fusion (ACDF) is a proven method for the treatment of selected patients. The necessity of use of an anterior plate is controversial. The article aims to assess the fusion rates (FRs) and long-term outcomes following three-level ACDF. MATERIALS AND METHODS: Data were collected from the medical records of patients operated on due to degenerative cervical disease. All patients were treated with three-level ACDF employing polyether ether-ketone cages without anterior plating. Visual analog scale (VAS), neck disability index (NDI), and plain radiographs were used in the clinical and radiological postsurgery assessment. Fusion evaluation was performed according to the <1 mm motion between spinous processes rule. Subsidence was defined as a more than 2 mm decrease in the interbody height. RESULTS: A total of 234 treated levels on 78 patients were assessed. The mean presurgery NDI score was 23.07 ± 4.86, with a mean disability of 46.03% ± 9.64. The mean presurgery VAS score of the neck was 7.58 ± 0.85, while VAS score of the arm was 7.75 ± 1.008. Post surgery, NDI stated no disability, while VAS score of the neck and arm showed no presence of pain. The mean FR was 19.50 ± 21.71 levels per month, with a peak from 3rd to 6th month. Presurgery evaluation showed 12 (15.38%) patients with a high T2 sequence signal. Magnetic resonance imaging screening detected 31 (39.24%) patients with coexisting cervical and lumbar findings. Post surgery, transient dysphagia was reported by 1 patient (1.28%), while subsidence was registered in 15 (6.41%) levels, situated in 12 patients (15.38%), most often at C6-7 (66.6%). Clinical and radiological follow-up extended to 69.47 ± 11.45 months. CONCLUSION: Multilevel stand-alone ACDF is a safe, cost-effective procedure providing favorable clinical and radiological results with minimal complications. The incidence of subsidence is usually clinically insignificant and can be decreased with a careful surgical technique.

The effect of diabetes mellitus on in-hospital hyperglycemia, length of stay and survival in patients with brain tumor receiving dexamethasone: A descriptive and comparative analysis.

OBJECTIVES: To perform a comparative analysis on the impact of Type 2 Diabetes Mellitus (DM) on in-hospital hyperglycemia, length of stay (LOS) and survival of patients suffering from brain tumor who receive dexamethasone. PATIENTS AND METHODS: Patients with brain tumor hospitalized in a Neurosurgery department between 2011 and 2018, were studied. Data referring to medical history, clinical characteristics and in-hospital survival was collected and analyzed. Morning plasma glucose levels (PGL) were obtained for seven consecutive days after the start of dexamethasone. RESULTS: Fifty-six patients were identified. Of them, 21 (37.5%) were diabetic. During dexamethasone administration, a difference in morning PGL values during different days was noted (p = 0.003). No difference in glucose levels among different glucocorticoid doses was seen. DM was associated with higher average PGL (aMPGL), calculated as the mean of morning PGL values for the last six days (p = 0.001) and with higher rates of persistent hyperglycemia (p = 0.002). The change of aMPGL from the morning PGL value of day one did not differ between the two cohorts (p = 0.729). DM neither affected LOS nor in-hospital survival (p = 0.745 & p = 0.438, respectively). CONCLUSION: Although morning glucose values were higher in diabetic, compared to non-diabetic patients, their change from day one was similar between the two cohorts. LOS and in-hospital survival were not affected by DM.

Congenital Glioblastoma Multiforme: An Unusual and Challenging Tumor.

Congenital glioblastoma multiforme is a rare tumor of the central nervous system with unique features. The existing evidence on its pathogenesis, genetic and molecular profile, special characteristics, treatment, and prognosis is reviewed. An increased number of antenatal diagnoses and prolonged survival for those individuals who can tolerate combined surgical resection and chemotherapy has been noted. The overall prognosis, however, remains poor. A better understanding of this unusual entity is important. Further research is needed to discern tumor's pathogenesis and natural history. This will likely lead to the development and implementation of treatment strategies that may decrease mortality and morbidity in these patients.

Severe cervical spondylotic myelopathy with complete neurological and neuroradiological recovery within a month after surgery.

Cervical spondylotic myelopathy is a complex syndrome evolving in the presence of degenerative changes. The choice of care and prognostic factors are controversial. The use of appropriate surgical technique is very important. Posterior approach may be chosen when pathology is present dorsally and/or in the presence of neutral to lordotic alignment. Anterior approach is the golden standard in patients with kyphosis and/or stenosis due to ventral lesions, even with three or more affected levels. A 67-year-old man presented with progressive weakness and clumsiness (mJOA: 5; Nurick: 4). An anterior discectomy, osteophytectomy and bilateral foraminotomy of the C4-C5; C5-C6; C6-C7 were performed. Polyether-Ether-Ketone spacers and a titanium plate were placed. The patient was mobilized 3-hour post-surgery and was released the following day. Medicament therapy and a neck-conditioning program were prescribed. Clinical examinations were normal within a month. Magnetic resonance imaging showed no traces of the preoperatively registered intramedullary focal T2 hyper-intensity.

Nosocomial bloodstream infections in neurosurgery: a 10-year analysis in a center with high antimicrobial drug-resistance prevalence.

BACKGROUND: Data on nosocomial bloodstream infections (NBSI) in neurosurgery is limited. This study aimed to analyze the epidemiology, microbiology, outcome, and risk factors for death in neurosurgical patients with NBSI in a multidrug resistant setting. METHODS: Neurosurgical patients with a confirmed NBSI within the period 2003-2012 were retrospectively analyzed. NBSI was diagnosed when a pathogen was isolated from a blood sample obtained after the first 48 h of hospitalization. Patients' demographic, clinical, and microbiological data were recorded and analyzed using univariate and multivariate analysis. RESULTS: A total of 236 patients with NBSI were identified and 378 isolates were recovered from blood cultures. Incidence of NBSI was 4.3 infections/1000 bed-days. Gram-negative bacteria slightly predominated (54.5 %). The commonest bacteria were coagulase-negative staphylococci (CoNS, 26 %), Klebsiella pneumoniae (15.3 %), Pseudomonas aeruginosa (14.8 %), and Acinetobacter baumannii (13.2 %). Carbapenem resistance was found in 90 % of A. baumannii, in 66 % of P. aeruginosa, and in 22 % (2003-2007) to 77 % (2008-2012) of K. pneumoniae isolates (p < 0.05). Most CoNS and Staphylococcus aureus isolates (94 and 80 %, respectively) were methicillin-resistant. All Gram-negative isolates were sensitive to colistin and all Gram-positive isolates were sensitive to vancomycin and linezolid. Antimicrobial consumption decreased after 2007 (p < 0.05). Overall mortality was 50.4 %. In multivariate analysis, advanced age and stay in an Intermediate Care Unit (IMCU) were independent risk factors for in-hospital mortality (p < 0.05). CONCLUSIONS: Overall, high incidence of NBSI and considerable resistance of Gram-positive and particularly Gram-negative bacteria were noted in neurosurgical patients. Mortality was high with advanced age and stay in IMCU being the most important death-related factors.

Osteoporotic spinal burst fracture in a young adult as first presentation of systemic mastocytosis.

Osteoporotic vertebral fractures are uncommon in young adults and usually indicate an underlying disease. Systemic mastocytosis is a myeloproliferative neoplasm, which can be associated with osteoporosis. A previously healthy 30-year-old man presented with an L4 burst fracture after lifting a heavy object. He was operated with laminectomy and posterior lumbar instrumentation. During surgery, abnormally soft bone was noted. Postoperatively, osteoporosis was confirmed with measurement of bone mineral density. Further investigation revealed elevated serum tryptase levels while bone marrow biopsy findings showed systemic mastocytosis. He was also tested positive for D816V KIT mutation. Treatment with biphosphonates and interferon was initiated. No extraskeletal involvement was noted up to the last checkup, 18 months after the first presentation. Abrupt vertebral fractures in apparently healthy young individuals should raise the suspicion of an underlying pathology. Prompt identification and treatment of systemic mastocytosis is crucial in order to avoid unexpected sequelae.

Dermal Sinus Tract of the Thoracic Spine Presenting with Intramedullary Abscess and Cranial Nerve Deficits.

Congenital dermal sinus tract of the spine is an unusual developmental defect which represents a failure of the surface ectoderm and dermal elements to separate from the neuroectoderm. A 15-month-old female presented with high fever, severe right hemiparesis, difficulty breathing and cranial nerve deficits. Magnetic resonance imaging (MRI) of the spine revealed a congenital dermal sinus tract at the Th6 level, an intramedullary collection extending up to the brainstem and a probable intramedullary cystic lesion. The child was operated acutely with ligation of the sinus tract, drainage of the abscess and partial removal of the intramedullary lesion. Due to abscess recurrence, she was reoperated with complete excision of the dermal sinus tract, abscess redrainage and subtotal excision of the dermoid cyst (retaining a part of its capsule). Pus culture isolated Corynebacterium species and Peptococcus species and histology of the lesion showed a dermoid cyst. Postoperatively, after an initial neurologic deterioration, she progressively improved. An MRI scan at 15 months neither showed recurrence of the collection nor regrowth of the lesion. Spinal dermal sinus tracts that remain unnoticed or untreated can result in serious complications and should be operated as soon as possible to prevent undesirable sequelae.

A 57-year-old female with a cerebellar mass.

A 57-year-old female presented with recurrent episodes of nausea and vomit, as well as instability during walking. The patient had a history of uterine leiomyosarcoma, for which she underwent a hysterectomy and oophorectomy 8 months ago. CT scan revealed a calcified mass that was located in the left cerebellar hemisphere which was resected. Histologically, multiple tissue fragments displayed infiltration of cerebellar tissue by polymorphic spindle-shaped cells. The Ki-67 proliferation index was approximately 20%. The morphological and immunohistochemical data, in association with the past clinical history, were consistent with cerebellar metastasis of uterine leiomyosarcoma. Although adjuvant radiotherapy was introduced, the patient died of cardiopulmonary arrest 6 weeks after the surgical procedure. The present case adds to the body of literature being the second report of uterine leiomyosarcoma metastatic to the cerebellum.

Successful, combined long-term treatment of cerebral aspergillosis in a liver transplant patient.

Invasive aspergillosis has long been recognized as one of the most significant and often fatal opportunistic fungal infections in liver transplant recipients. We report a case of a liver transplant recipient who developed an Aspergillus fumigatus brain abscess that produced significant neurologic symptoms. The patient was managed successfully with a combination of surgery and medical treatment with Voriconazole. To our knowledge, this is the second such case reported in the literature.

Epstein-Barr virus associated primary intracranial leiomyoma in organ transplant recipient: case report and review of the literature.

INTRODUCTION: A 45 year old female renal transplant recipient presented with headaches of 3 months duration. Clinical and radiological evaluation revealed an approximately 4x4 cm rounded, enhancing mass at the left temporal pole. At surgery, the mass had dural attachment and clinically, radiographically, and macroscopically resembled a meningioma. Histopathological analysis revealed a leiomyoma. Epstein-Barr virus (EBV) DNA was demonstrated within the tumour cell nuclei by the in situ hybridisation technique. DISCUSSION: This is the first documentation of an EBV-associated primary intracranial leiomyoma in an organ transplant recipient and provides additional evidence of a possible relation between EBV infection and development of smooth-muscle tumours (SMT). CONCLUSION: With increasing numbers of individuals being on long-term immuno-suppression, EBV-associated SMTs may be encountered more frequently in the future.

Intraoperative facet joint injury during anterior cervical discectomy and fusion: an experimental study.

OBJECT: Disorders of the cervical spine can be successfully addressed by surgical intervention when the choice of such intervention takes into account the possible complications in the treated and adjacent structures. The aim of this study was to investigate the potential for intraoperative trauma in cervical zygapophysial joints and to describe possible pathological changes that may occur during cervical spine surgery. METHODS: Fifteen sheep underwent surgical intervention via an anterior cervical approach; discectomy at the C5-6 level was performed. In 10 animals, the discectomy was accompanied by titanium cage fusion. The sheep were killed immediately after completion of the operation. Radiological examination of the isolated cervical spines followed. Furthermore, the cervical spines were submitted to decalcification and incised using a microtome, and tissue sections were then studied using light microscopy. RESULTS: Radiological examination was used to assess vertebral alignment, vertebral body (VB) morphology, implant position, and endplate and facet joint gross morphology. Histological examination of the endplate and VB demonstrated degenerative lesions as well as cellular necrosis. The study of the facet joints at the treated as well as at adjacent segments (both above and below) revealed in some cases edema between the collagen fibers of the joint capsules, congestion, and microhemorrhages. Injuries were evident in animals in which the Caspar device was used. CONCLUSIONS: Histopathologically confirmed lesions occurred in facet joints while anterior cervical spine surgery was being performed in sheep. The findings were indicative of trauma and, in the case of human spine surgery, could possibly account for several postoperative complications and patient complaints.

Lumbar nerve root compression due to extramedullary hemopoiesis in a patient with thalassemia: complete clinical regression with radiation therapy. Case report and review of the literature.

The authors describe the case of a 24-year-old woman who had a history of beta3-thalassemia and presented with severe symptoms of lumbar nerve root compression due to extramedullary hemopoiesis in the intervertebral foramen. Radiation therapy (2000 cGy in six fractions) was delivered to the mass. The patient's neurological symptoms completely resolved following treatment. Follow-up images showed a reduction in lesion size. The results of this unique case supported by a review of the literature suggest that radiation therapy alone is an effective modality in the treatment of patients with compression of neural structures due to extramedullary hemopoietic tissue.