Myoepithelial Carcinoma of Soft Tissue: Report of Two Cases.

CASE: A 40-year-old man was evaluated for a painful mass on his right calf, and a 36-year-old woman presented with a painless mass on her right foot. Final pathology revealed marked nuclear atypia and positivity for S100/SOX10 and AE1/AE3 confirming diagnoses of myoepithelial carcinoma. Both patients underwent surgical resection and are without evidence of local recurrence or metastatic disease at 1-year follow-up. CONCLUSION: Soft-tissue tumors presenting in the extremities warrant careful evaluation and timely histopathologic diagnosis. Myoepithelial carcinomas are rare, aggressive tumors with a propensity for local recurrence and metastasis. Treatment of these tumors should be discussed by a multidisciplinary tumor team.

Impact of Faculty Mentorship in the Orthopedic Surgery Interest Group at a New Medical School: A Blueprint for Future Initiatives.

OBJECTIVES: Orthopedic surgery is a highly competitive field. The residency applicant pool is expected to grow with the increasing number of new medical schools in the United States, posing significant challenges for applicants. This study explored the impact of an engaged faculty mentor in an orthopedic surgery interest group (OSIG) at a new medical school and the impact it has on students. The study aimed to uncover the most valuable features of an OSIG at a new medical school to create a blueprint for other student-leaders and/or faculty in future initiatives. METHODS: An observational study was conducted via survey responses from active OSIG members at a new medical school in Texas. Questions were mostly in a "before and after" format asking about students' perspectives of the group before and after the addition of an engaged faculty advisor. Descriptive and inferential statistics were used to analyze the data. RESULTS: Twenty of 21 (95.2%) eligible OSIG members participated in the study. The survey results revealed that faculty engagement significantly enhanced the OSIG and its members' medical school experience. Following faculty involvement, average OSIG event attendance more than tripled, there was a statistically significant increase in medical student well-being, and confidence in their ability to be a competitive orthopedic surgery applicant nearly doubled. OSIG participation influenced their career interests significantly more after faculty engagement. A total of 93.3% of participants voted that they felt having an engaged faculty advisor is critical for the OSIG. CONCLUSIONS: Mentorship was identified as the most crucial activity for career development, followed by clinical exposure and research. The study provides valuable insights for new medical schools in establishing and optimizing OSIGs and potentially other interest groups, particularly in competitive specialties.

Measuring Value in Elective Spine Surgery.

Objective: To summarize the main findings from research on measuring the value in spine surgery. Summary of Background Data: Determining the value of surgical interventions, which is defined by the quality and efficacy of care received divided by the cost to deliver healthcare, is inherently complex. The two most fundamental components of value-quality and total cost-are multifactorial and difficult to quantify. Methods: A narrative review of all the relevant papers known to the author was conducted. Results: It is straightforward to calculate the aggregate hospital cost following a surgical procedure, but it is not simple to estimate the total cost of a procedure-including the direct and indirect costs. These individual metrics can help providers make more educated decisions with regards to improving patient quality of life and minimizing unnecessary costs. A consensus of the appropriate cost-per-quality-adjusted life-year threshold of different spine surgeries needs to be established. As these metrics become more commonplace in spine surgery, the potential for personalized health care will continue to be developed. Conclusions: As the healthcare system shifts toward value-based care, there is a substantial need for research assessing the value as defined by the quality and efficacy of care received divided by the cost to deliver healthcare of specific spine surgery procedures. Studies on different predictors-both patient-specific and surgical-that may influence outcomes, cost, and value are required.

Factors associated with greater patient satisfaction in outpatient neurosurgical clinics: Recommendation for surgery, older age, cranial chief complaint, and public health insurance.

OBJECTIVE: Patient satisfaction has increasingly played a role in determining care quality. Surveys are used to gauge patient experience, satisfaction of care, and likelihood to recommend providers and facilities. The aim of the study is to evaluate whether clinical and demographic data predict greater patient satisfaction with providers in the outpatient neurosurgery clinic. METHODS: Press-Ganey (Press Ganey Associates, South Bend, IL) evaluations of 1521 patients were reviewed in an academic neurosurgical clinic from January 1, 2019 through February 1, 2021. We analyzed associations between Press-Ganey ratings and patient demographics, chief complaint, psychiatric comorbidities, number of orders placed, medication prescriptions, surgical recommendation, payor status, and referral source. We used univariate logistic regression to assess for associations between independent variables and Press-Ganey ratings. Multivariable logistic regression was used for associated factors. RESULTS: For the Likelihood to Recommend question, older age (p = 0.003), cranial chief complaint (p = 0.046), and recommendations for surgery (p < 0.001) were significantly associated with "good" ratings. For the rating of Care Received, older age (p = 0.002), cranial chief complaint (p = 0.05), and recommendations for surgery (p = 0.002) were significantly associated with "good" ratings. For Confidence in Care Provider question, recommendations for surgery (p = <0.001) and government insurance type (p = 0.002) were significantly associated with "good" ratings. CONCLUSIONS: Patients with older age, cranial pathologies, a recommendation for surgery, and government health insurance were significantly associated with favorable patient satisfaction with providers in the outpatient neurosurgery clinic. Prospective studies should target patient populations who are younger, have spinal complaints, have non-surgical needs, and have commercial insurance to improve satisfaction.

High-Grade B-Cell Lymphoma of the Sciatic Nerve That Mimicked a Schwannoma: A Case Report.

CASE: A 41-year-old woman with a history of high-grade B-cell lymphoma status-post chemotherapy was evaluated for a painful left posterior thigh mass and significant weakness with sensory changes. Imaging revealed a benign-appearing mass consistent with schwannoma; however, intraoperative frozen section suggested high-grade B-cell lymphoma. Subsequent restaging studies revealed metastatic disease. CONCLUSION: A history of lymphoma warrants careful investigation of a posterior thigh mass, despite imaging findings consistent with nerve sheath tumor. Surgical removal of lymphomas of the nerve often proves futile, so these lesions are usually managed with medical treatment or radiation.

Carbon fiber-reinforced PEEK instrumentation in the spinal oncology population: a retrospective series demonstrating technique, feasibility, and clinical outcomes.

OBJECTIVE: The authors aimed to demonstrate the feasibility and advantages of carbon fiber-reinforced PEEK (CFRP) composite implants in patients with both primary and secondary osseous spinal tumors. METHODS: Twenty-eight spinal tumor patients who underwent fixation with CFRP hardware were retrospectively identified in a Spine Tumor Quality Database at a single institution. Demographic, procedural, and follow-up data were retrospectively collected. RESULTS: The study population included 14 females and 14 males with a mean age of 60 years (range 30-86 years). Five patients had primary bone tumors, and the remaining patients had metastatic tumors. Breast cancer was the most common metastatic tumor. The most common presenting symptom was axial spine pain (25 patients, 89%), and the most common Spine Instability Neoplastic Score was 7 (range 6-14). Two patients in this series had anterior cervical procedures. The remaining patients underwent posterior thoracolumbar fixation. The average fusion length included 4.6 vertebral segments (range 3-8). The mean clinical follow-up time with surgical or oncology teams was 6.5 months (range 1-23 months), and the mean interval for last follow-up imaging (CT or MRI) was 6.5 months (range 1-22 months). Eighteen patients received postoperative radiation at the authors' institution (16 with photon therapy, 2 with proton therapy). Eleven of the patients (39%) in this series died. At the last clinical follow-up, 26 patients (93%) had stable or improved neurological function compared with their preoperative status. At the last imaging follow-up, local disease control was observed in 25 patients (89%). Two patients required reoperation in the immediate postoperative period, one for surgical site infection and the other for compressive epidural hematoma. One patient was noted to have lucencies around the most cephalad screws 3 months after surgery. No hardware fracture or malfunction occurred intraoperatively. No patients required delayed surgery for hardware loosening, fracture, or other failure. Early tumor recurrence was detected in 3 patients. Early detection was attributed to the imaging characteristics of the CFRP hardware. CONCLUSIONS: CFRP spinal implants appear to be safe and comparable to conventional titanium implants in terms of functionality. The imaging characteristics of CFRP hardware facilitate radiation planning and assessment of surveillance imaging. CFRP hardware may enhance safety and efficacy, particularly with particle therapy dosimetry. Larger patient populations with longer-term follow-up are needed to confirm the various valuable aspects of CFRP spinal implants.

Surgical site infection in paediatric posterior fossa surgery: does pathology matter?

OBJECTIVES: The aim of this study was to explore the rates and potential risks of surgical site infection (SSI) after posterior fossa surgery for tumour resection in children. METHODS: We retrospectively reviewed our local paediatric (age < 16 years) database for all cases of posterior fossa (PF) brain tumour surgery between November 2008 and November 2019. We collected patient demographics, tumour histology/location, and the event of postoperative surgical site infection. RESULTS: Overall, 22.1% (n=15) developed SSI out of sixty-eight children undergoing PF surgery for resection of brain tumours; 73.3% of them had a confirmed diagnosis of medulloblastoma. There was no statistically significant difference in the age (5.1 ± 0.60 vs. 6.2 ± 0.97 years; p=0.47) and duration of operation (262 vs. 253 min; p = 0.7655) between the medulloblastoma group and other tumours. Although the rate of postoperative hydrocephalus was higher in the medulloblastoma group (12.9% vs. 0%), this was not associated with increased SSI. Rates of CSF leak between the 2 groups were not different. CONCLUSION: Medulloblastoma as a pathological entity seems to carry higher risk of postoperative surgical site infection compared to other types of paediatric posterior fossa tumours. Further larger studies are required to look into this causal relationship and other risk factors that might be involved.

The need for hair removal in paediatric brain tumour surgery?

INTRODUCTION: Preoperative hair removal is conventional practice within neurosurgery in an attempt to maintain antisepsis. However, there is a lack of evidence to suggest that it makes a difference with regards to infection. This article aims to relate preoperative hair removal to SSIs for paediatric patients. METHODS AND MATERIALS: A retrospective analysis was conducted from a single paediatric neurosurgical database at the University Hospital of Wales. Patients were grouped according to whether they underwent preoperative hair removal or not. Findings were reviewed in light of the previously published literature. RESULTS: One hundred eighty two paediatric intracranial tumours were operated on between November 2008 and 2019. A total of twenty-six patients (14%) developed an infection post-operatively, of which meningitis was the most common (77%). Eighty-nine operations were undertaken without preoperative hair removal, of which there were a total of fifteen infections (17%). In the hair removal group, there were a total of eleven infections out of ninety-three operations (12%). Overall, the patients without hair removal had a higher infection rate when compared to those with hair removal (17 and 12% respectively), however, this result was not statistically significant (p-value 0.3989). CONCLUSION: We did not find evidence that hair removal in paediatric neurosurgery effects postoperative infection risk.

An unusual case of a persistent, infected retroperitoneal fluid collection 5 years after anterior lumbar fusion surgery: illustrative case.

BACKGROUND: Anterior lumbar fusion procedures have many benefits and continue to grow in popularity. The technique has many potential approach- and procedure-related complications. Symptomatic retroperitoneal fluid collections are uncommon but potentially serious complications after anterior lumbar procedures. Collection types include hematomas, urinomas, chyloperitoneum, cerebrospinal fluid collections, and deep infections. OBSERVATIONS: The authors present an unusual case of a patient with persistent symptoms related to a retroperitoneal collection over a 5-year period following anterior lumbar fusion surgery. To the authors' knowledge, no similar case with such extensive symptom duration has been described. The patient had an infected encapsulated fluid collection. The collection was presumed to be a postoperative lymphocele that was secondarily infected after serial percutaneous drainage procedures. LESSONS: When retroperitoneal collections occur after anterior retroperitoneal approaches, clinical clues, such as timing of symptoms, hypotension, acute anemia, urinary tract infection, hydronephrosis, elevated serum creatinine and blood urea nitrogen, low-pressure headaches, anorexia, or systemic signs of infection, can help narrow the differential. Retroperitoneal collections may continue to be symptomatic many years after anterior lumbar surgery. The collections may become infected after serial percutaneous drainage or prolonged continuous drainage. Encapsulated, infected fluid collections typically require surgical debridement of the capsule and its contents.

Spinal intramedullary hemangioblastoma and schwannoma collision tumor: illustrative case.

BACKGROUND: Intramedullary spinal cord tumors represent a minority of intradural tumors. Among intramedullary spinal cord tumors, hemangioblastomas are uncommon, and schwannomas are extremely rare. Collision tumors are histologically distinct tumors that are intermingled and growing together. OBSERVATIONS: In this report, the authors describe a patient with a cervical intramedullary collision tumor involving a hemangioblastoma and schwannoma. To the authors' knowledge, no prior spinal intramedullary collision tumor involving multiple neoplasms has been described. The patient's presentation and management are described. LESSONS: Clinicians should consider the possibility of collision tumors when evaluating intramedullary spinal cord tumors, especially when patient presentation and radiographic findings are atypical. When tumors with similar radiographic characteristics form collision tumors, distinction using preoperative imaging can be extremely challenging. In addition, surgical management of intramedullary collision tumors, like that for all intramedullary spinal cord tumors, should involve meticulous perioperative care and a methodical surgical technique. Maximal safe resection will depend upon histopathological diagnosis, anatomical location of the tumor, presence of distinct dissection planes, and stability of neuromonitoring. Finally, ongoing research on the genetics of intramedullary spinal cord tumors may identify underlying genetic links for intramedullary hemangioblastomas and schwannomas.

Subclinical Tuberculosis Disease-A Review and Analysis of Prevalence Surveys to Inform Definitions, Burden, Associations, and Screening Methodology.

While it is known that a substantial proportion of individuals with tuberculosis disease (TB) present subclinically, usually defined as bacteriologically-confirmed but negative on symptom screening, considerable knowledge gaps remain. Our aim was to review data from TB prevalence population surveys and generate a consistent definition and framework for subclinical TB, enabling us to estimate the proportion of TB that is subclinical, explore associations with overall burden and program indicators, and evaluate the performance of screening strategies. We extracted data from all publicly available prevalence surveys conducted since 1990. Between 36.1% and 79.7% (median, 50.4%) of prevalent bacteriologically confirmed TB was subclinical. No association was found between prevalence of subclinical and all bacteriologically confirmed TB, patient diagnostic rate, or country-level HIV prevalence (P values, .32, .4, and .34, respectively). Chest Xray detected 89% (range, 73%-98%) of bacteriologically confirmed TB, highlighting the potential of optimizing current TB case-finding policies.

Return to Golf, Tennis, and Swimming After Elective Cervical Spine Surgery.

Background After surgery for degenerative cervical spine problems, most patients hope to return to non-competitive sports and other leisure activities. Limited data are available to counsel patients about return to play (RTP) in non-competitive sports after cervical surgery. Methods Participants had cervical surgery for degenerative diagnoses from April 1, 2007, to April 1, 2018. Demographic data were collected, and participants were asked to complete a survey regarding sports participation before and after cervical surgery.  Results Of the 73 participants who responded to the study, the majority (81.1%) were able to return to one or multiple hobby sports after elective spine surgery. RTP rates at 12 months for golf, tennis, and swimming were 67.6%, 31.2%, and 81.6%, respectively. Younger age and lack of preoperative motor deficit were significant predictors of return to swimming after surgery. After surgery, 54.3% of golfers reported similar or improved levels of play.  Conclusions After elective cervical spine surgery, the majority of hobby athletes can expect to return to athletics. The majority of golfers returned to play with similar or improved frequency and quality of play compared to preoperative levels. Future prospective studies will further elucidate factors predicting RTP after different types of elective cervical surgeries.

Outcomes with respect to extent of surgical resection for pediatric atypical teratoid rhabdoid tumors.

PURPOSE: To evaluate overall survival for atypical teratoid rhabdoid tumors (ATRTs) in relation to extent of surgical resection. METHODS: The neurosurgical tumor databases from three UK Pediatric centers (University Hospital of Wales, Alder Hey and Royal Manchester Children's Hospital) were analyzed. Patients with a diagnosis of ATRT were identified between 2000 and 2018. Data was collected regarding demographics, extent of resection, complications, and overall survival. RESULTS: Twenty-four patients diagnosed with ATRT underwent thirty-eight operations. The age range was 20 days to 147 months (median 17.5 months). The most common location for the tumor was the posterior fossa (nine patients; 38%). Six patients (25%) underwent a complete total resection (CTR), seven (29%) underwent a near total resection (NTR), eight (33.3%) underwent a subtotal resection (STR), and three patients (12.5%) had biopsy only. Two-thirds of patients who underwent a CTR are still alive, as of March 2019, compared to 29% in the NTR and 12.5% in the STR groups. Out of the thirty-eight operations, there were a total of twenty-two complications, of which the most common was pseudomeningocele (27%). The extent of surgical resection (p = 0.021), age at surgery (p = 0.00015), and the presence of metastases at diagnosis (0.015) significantly affected overall survival. CONCLUSIONS: Although these patients are a highly vulnerable group, maximal resection is recommended where possible, for the best chance of long-term survival. However, near total resections are likely beneficial when compared with subtotal resections and biopsy alone. Maximal surgical resection should be combined with adjuvant therapies for the best long-term outcomes.

Functional recovery following surgery for chronic subdural hematoma.

BACKGROUND: Among the elderly, chronic subdural hematoma is a relatively common neurosurgical condition. Presenting symptoms range from headache and focal neurological deficits to seizure and coma depending on location and extent of brain compression. Functional recovery following surgery for chronic subdural hematoma is central to quality of life and ongoing health for elderly patients; however, there is a paucity of data regarding functional recovery in this population. METHODS: In this study, the physical activity of patients who underwent surgical evacuation of chronic subdural hematoma was surveyed, as well as participation in physical therapy following surgery. In total, 38 patients completed the survey. RESULTS: Of the 30 patients who exercised regularly before surgery, 28 (90.3%) returned to exercise within 1 year after surgery. Of 13 patients who reported playing hobby sports before surgery, 9 (69.2%) returned to those sports. 17/38 (44.7%) patients participated in physical therapy after surgery. 35/38 (92.1%) of patients reported that the surgery improved their quality of life. CONCLUSION: The majority of patients who underwent surgery for chronic subdural hematoma were able to return to exercise within 1 year. Participation in physical therapy was associated with return to exercise and sports. Further study is needed to determine which factors contribute to a return to baseline levels of physical activity following surgery for chronic subdural hematoma.

Retrospective radiographic analysis of anterior lumbar fusion for high grade lumbar spondylolisthesis.

BACKGROUND: High-grade spondylolisthesis (>50% slippage) is infrequently encountered in adults and frequently requires surgical treatment. The optimal surgical treatment is controversial with limited literature guidance as to optimal approach to treatment. An observational study to examine the technique and radiographic outcomes of adult patients treated with anterior lumbar interbody fusion (ALIF) and posterior percutaneous instrumentation for high-grade spondylolisthesis. METHODS: ALIF was performed in 5 consecutive patients (3/5 female, 2/5 male) aged 29-67 years old who presented with low back pain and L5 radiculopathy. All patients failed conservative treatment and were treated with L4-5 and L5-S1 ALIF followed by posterior percutaneous L4-S1 pedicle screw and rod fixation. Pre- and postoperative clinical data was collected including L5-S1 posterior disk height in millimeters, millimeters of spondylolisthesis at L5-S1, degrees of segmental lordosis (L4-S1), lumbar lordosis (L1-S1), and lumbar lordosis pelvic incidence (LL-PI) mismatch. RESULTS: Six weeks following surgery, no patient reported residual L5 radicular symptoms. At last follow up, patient satisfaction, according to Modified Macnab Criteria, was excellent in 4/5 patients and good in 1/5 patient. In the 4 patients with greater than 1 year radiographic follow up, fusion rate was 100% on computed tomography (CT). Mean increase in posterior disk height was 12.5 mm (range, 11.4-13.5 mm). Mean reduction in spondylolisthesis was 58.7% (range, 20.2-100%). Mean segmental (L4-S1) and overall (L1-S1) lumbar lordosis increased by 23.6% (range, 6.5-41.7%) and 16.6% (2.5-31.5%), respectively. Following surgery, LL-PI mismatch decreased from a mean of 16.4 to 10.2 degrees. CONCLUSIONS: ALIF with posterior percutaneous instrumentation is a safe and effective treatment for high-grade lumbosacral spondylolisthesis in properly selected adults. This technique improves lumbar sagittal parameters and reduces spondylolisthesis. The indirect neural decompression from simultaneous disk height restoration and spondylolisthesis reduction may be associated with lower neurological injury rate compared to posterior-only. Future prospective study is needed to validate this hypothesis.