Contemporary Management of Blunt Liver Trauma: An Analysis of the Trauma Quality Improvement Program Registry (2007-2019).

PURPOSE: To evaluate the effectiveness of management strategies for blunt liver injuries in adult patients. MATERIALS AND METHODS: Patients aged ≥18 years with blunt liver injuries registered via the Trauma Quality Improvement Program (2007-2019) were identified. Management strategies initiated within 24 hours of hospital presentation were classified as nonoperative management (NOM), embolization, surgery, or combination therapy. Patients were stratified by injury grade. Linear models estimated each strategy's effect on hospital length of stay (LOS), intensive care unit (ICU) LOS, ventilator dependence, and mortality. RESULTS: Of 78,127 included patients, 88.7%, 8.7%, 1.8%, and 0.8% underwent NOM, surgery, embolization, and combination therapy, respectively. Among patients with low-grade (n = 62,237) and high-grade (n = 15,890) injuries and compared with all other management strategies, NOM was associated with the shortest hospital LOS and ICU LOS. Among patients with low-grade injuries and compared with surgery, embolization was associated with a shorter hospital LOS (9.7 days; P < .001; Cohen d = 0.32) and ICU LOS (5.3 days; P < .001; Cohen d = 0.36). Among patients with high-grade injuries and compared with surgery, embolization was associated with a shorter ICU LOS (6.0 days; P < .01; Cohen d = 0.24). Among patients with low- and high-grade injuries and compared with embolization, surgery was associated with higher odds of mortality (P < .001). CONCLUSIONS: Among patients presenting with blunt liver injuries and compared with surgery, embolization was associated with a shorter ICU LOS and lower risk of mortality.

Comparison of ABC/2 estimation and a volumetric computerized method for measurement of meningiomas using magnetic resonance imaging.

INTRODUCTION: Measurement of tumor growth rates over time for patients with meningiomas has important prognostic and therapeutic implications. Our objective was to compare two methods of measuring meningioma volume: (1) the simplified ellipsoid (ABC/2) method; and (2) perimetric volume measurements using imaging software modules. METHODS: Patients with conservatively managed meningiomas for at least 1.5 years were retrospectively identified from the VCU Brain and Spine Tumor Registry over a 10-year period (2005-2015). Tumor volumes were independently measured using the simplified ellipsoid and computerized perimetric methods. Intra class correlations (CC) and Bland-Altman analyses were performed. RESULTS: A total of 26 patients representing 29 tumors were identified. Across 146 images, there were 24 (16%) images that were non-measurable using standard application commands with the computerized perimetric method. The mean volume obtained using the ABC/2 and computerized perimetric methods were 3.2 ± 3.4 cm3 and 3.4 ± 3.5 cm3, respectively. The mean volume difference was 0.2 cm3 (SE = 0.12; p = 0.10) across measurement methods. The concordance correlation coefficient (CCC) between methods was 0.95 (95% CI 0.91, 0.98). CONCLUSIONS: There is excellent correlation between the simplified ellipsoid and computerized perimetric methods of volumetric analysis for conservatively managed meningiomas. The simplified ellipsoid method remains an excellent method for meningioma volume assessment and had an advantage over the perimetric method which failed to allow measurement of roughly one in six tumors on imaging.

Focal traumatic rupture of a dermoid cyst in a pediatric patient: case report and literature review.

BACKGROUND: Dermoid cysts are rare congenital teratomas that can occasionally rupture and cause chemical meningitis, neurological deficit, or hydrocephalus. Rarely, dermoid cysts in the pediatric population can rupture spontaneously and even more rarely rupture due to trauma. To date, there are only five documented cases of traumatic rupture of a dermoid cyst. A 2-year-old male presented with 5 days of left eye ptosis and ophthalmoplegia after suffering a fall and was found to have a ruptured left anterior clinoid dermoid cyst that was surgically resected. The patient had significant improvement postoperatively. SIGNIFICANCE: To the authors' knowledge, this is the first reported case in the literature of a ruptured dermoid cyst after trauma in a pediatric patient and the first case of a traumatically ruptured dermoid cyst presenting with neurological deficit.

Wilms tumor 1 gene, CD97, and the emerging biogenetic profile of glioblastoma.

Glioblastoma multiforme (GBM) is the most common type of primary brain tumor, and current treatment regimens are only marginally effective. One of the most vexing and malignant aspects of GBM is its pervasive infiltration into surrounding brain tissue. This review describes the role of the Wilms tumor 1 gene (WT1) and its relationship to GBM. WT1 has several alternative splicing products, one of which, the KTS(+) variant, has been demonstrated to be involved in the transcriptional activation of a variety of oncogenes as well as the inhibition of tumor suppressor genes. Further, this paper will examine the relationship of WT1 with CD97, a gene that codes for an epidermal growth factor receptor family member, an adhesion G-protein-coupled receptor, thought to promote tumor invasiveness and migration. The authors suggest that further research into WT1 and CD97 will allow clinicians to begin to deal more effectively with the infiltrative behavior displayed by GBM and design new therapies that target this deadly disease.

Novel placement of cortical bone trajectory screws in previously instrumented pedicles for adjacent-segment lumbar disease using CT image-guided navigation.

OBJECT: Symptomatic adjacent-segment lumbar disease (ASLD) after lumbar fusion often requires subsequent surgical intervention. The authors report utilizing cortical bone trajectory (CBT) pedicle screw fixation with intraoperative CT (O-arm) image-guided navigation to stabilize spinal levels in patients with symptomatic ASLD. This unique technique results in the placement of 2 screws in the same pedicle (1 traditional pedicle trajectory and 1 CBT) and obviates the need to remove preexisting instrumentation. METHODS: The records of 5 consecutive patients who underwent lumbar spinal fusion with CBT and posterior interbody grafting for ASLD were retrospectively reviewed. All patients underwent screw trajectory planning with the O-arm in conjunction with the StealthStation navigation system. Basic demographics, operative details, and radiographic and clinical outcomes were obtained. RESULTS: The average patient age was 69.4 years (range 58-82 years). Four of the 5 surgeries were performed with the Minimal Access Spinal Technologies (MAST) Midline Lumbar Fusion (MIDLF) system. The average operative duration was 218 minutes (range 175-315 minutes). In the entire cohort, 5.5-mm cortical screws were placed in previously instrumented pedicles. The average hospital stay was 2.8 days (range 2-3 days) and there were no surgical complications. All patients had more than 6 months of radiographic and clinical follow-up (range 10-15 months). At last follow-up, all patients reported improved symptoms from their preoperative state. Radiographic follow-up showed Lenke fusion grades of A or B. CONCLUSIONS: The authors present a novel fusion technique that uses CBT pedicle screw fixation in a previously instrumented pedicle with intraoperative O-arm guided navigation. This method obviates the need for hardware removal. This cohort of patients experienced good clinical results. Computed tomography navigation was critical for accurate CBT screw placement at levels where previous traditional pedicle screws were already placed for symptomatic ASLD.

Efficacy of passive helmet therapy for deformational plagiocephaly: report of 1050 cases.

OBJECT: There has been a tremendous increase in the incidence of deformational plagiocephaly in children throughout the world. Therapeutic options include observation, active counterpositioning, external orthotics, and surgery. The current treatment in the US is highly debated, but it typically includes external orthotic helmets in patients with moderate to severe plagiocephaly presenting between 4 and 10 months of age or in children with significant comorbidities limiting passive (no-pressure) therapy. The present study was designed to evaluate 3 key issues: 1) the accuracy of the Argenta classification in defining a progressive degree of severity, 2) identification of an upper age limit when treatment is no longer effective, and 3) the effectiveness of an off-the-shelf prefabricated helmet in correcting deformational plagiocephaly. METHODS: An institutional review board-approved retrospective study was conducted of all patients at the authors' clinic in whom deformational plagiocephaly was assessed using the Argenta classification system over a 6-year period; the patients underwent helmet therapy, and a minimum of 3 clinic visits were recorded. Inclusion criteria consisted of an Argenta Type II-V plagiocephalic deformity. Patients' conditions were categorized both by severity of the deformity and by patients' age at presentation. Statistical analysis was conducted using survival analysis. RESULTS: There were 1050 patients included in the study. Patients with Type III, IV, and V plagiocephaly required progressively longer for deformity correction to be achieved than patients with Type II plagiocephaly (53%, 75%, and 81% longer, respectively [p < 0.0001]). This finding verified that the Argenta stratification indicated a progressive severity of deformity. No statistically significant difference in the time to correction was noted among the different age categories, which suggests that the previously held upper time limit for correction may be inaccurate. An overall correction rate to Type I plagiocephaly of 81.6% was achieved irrespective of severity and degree of the original deformity. This suggests that an inexpensive off-the-shelf molding helmet is highly effective and that expensive custom-fitted orthoses may not be necessary. The patients in the older age group (> 12 months) did not have a statistically significant longer interval to correction than the patients in the youngest age group (< 3 months). The mean length of follow-up was 6.3 months. CONCLUSIONS: Patients treated with passive helmet therapy in the older age group (> 12 months) had an improvement in skull shape within the same treatment interval as the patients in the younger age group (< 3 months). This study supports the use of passive helmet therapy for improvement in deformational plagiocephaly in infants from birth to 18 months of age and verifies the stratification of degree of deformity used in the Argenta classification system.

Mid-to-long-term outcomes with image-guided placement of de novo low-profile gastrojejunostomy tubes in pediatric patients.

OBJECTIVE: De novo low-profile gastrojejunostomy (GJ) tubes are advantageous in children that require prolonged supplemental nutrition. However, few institutions place these devices at the time of initial feeding tube placement. We aim to build upon our previously published initial experience with this procedure to study mid-to-long-term outcomes of pediatric patients who have had de novo, image-guided, percutaneous low-profile GJ tube placement. METHODS: All de novo, image-guided, percutaneous, low-profile GJ tube placements at a single children's hospital were retrospectively reviewed between May 2014 and March 2021. Technical parameters, including fluoroscopy time, tube size, technical success, and complications were recorded. Clinical data, including age, indication, weight gain and transition to gastric/oral feeds were analyzed. RESULTS: 64 de novo low-profile GJ tubes were successfully placed in 65 patients (mean age: 4.6 years, median: 1, range: 0.2-19; mean pre-procedural weight: 16.8 kg, median: 8.2, range: 4.4-66.7). Average clinical follow-up 23.4 months (range: 0.1-75, median 10.4). Average weight gain was 6.1 kg. Average increase in weight percentile was 7.3%. 19 (19/64; 29.7%) patients had conversion from GJ to G tube. 11 (11/64; 17.2%) patients had their enteric tube removed completely. There were 7 minor complications (7/65; 10.7%), most common being excessive skin irritation (6/7) and 9 major complications (9/65; 13.8%), most common being tube dislodgment within the first 30 days (6/9). CONCLUSIONS: These results further support that de novo, image-guided, percutaneous, low-profile GJ tube placement is technically feasible and efficacious in children requiring post-pyloric nutritional supplementation with a favorable safety profile.

Imaging of Soft Tissue Infections.

Although superficial infections can often be diagnosed and managed clinically, physical examination may lack sensitivity and specificity, and imaging is often required to evaluate the depth of involvement and identify complications. Depending on the area of involvement, radiography, ultrasound, CT, MR imaging, or a combination of imaging modalities may be required. Soft tissue infections can be nonnecrotizing or necrotizing, with the later having a morbid and rapid course. Infectious tenosynovitis most commonly affects the flexor tendon sheaths of the hand, characterized by thickened and enhancing synovium with fluid-filled tendon sheaths.

Management of Hematometra and Hematocolpos in Obstructive Mullerian Anomalies by Image-Guided Drainage with Interventional Radiology: A Multi-Institutional Case Series.

STUDY OBJECTIVE: To describe cases of image-guided drainage of symptomatic hematometrocolpos from obstructive Müllerian anomalies as a temporizing measure to manage acute pain symptoms and delay definitive management of the obstructive Müllerian anomalies that require complex reconstruction METHODS: Institutional Review Board exemption from all included institutions was obtained. A retrospective case series from 3 academic children's hospitals of 8 females under the age of 21 with symptomatic hematometrocolpos due to obstructive Müllerian anomalies drained by image-guided percutaneous transabdominal vaginal or uterine drainage with interventional radiology was reviewed and described. RESULTS: Eight pubertal patients with obstructive Müllerian anomalies (6 patients with distal vaginal agenesis, 1 patient with an obstructed uterine horn, and 1 patient with a high obstructed hemi-vagina) and symptomatic hematometrocolpos are reported. All patients with distal vaginal agenesis had greater than 3 cm lower vaginal agenesis, which would usually require complex vaginoplasty and use of postoperative stents. Given their immaturity and inability to use stents or dilators postoperatively or medical complexity, they subsequently underwent ultrasound-guided drainage of hematometrocolpos with interventional radiology to relieve pain symptoms, followed by menstrual suppression. The patients with obstructed uterine horns had complex medical and surgical histories requiring perioperative planning; they also underwent ultrasound-guided drainage of hematometra as a temporizing measure to manage acute symptoms. CONCLUSION: Patients presenting with symptomatic hematometrocolpos due to obstructive Müllerian anomalies might not be psychologically mature enough to undergo definitive complex reconstruction, which requires vaginal stent or dilator use postoperatively to prevent stenosis and other complications. Image-guided percutaneous drainage of symptomatic hematometrocolpos serves as a temporizing measure by offering pain relief until patients are ready to undergo surgical management and/or to allow time for complex surgical planning.

Growth Analysis of Untreated Meningiomas under Observation.

BACKGROUND: When meningiomas are small or asymptomatic, the decision to observe rather than treat requires balancing the growth potential of the lesion with the outcome and side effects of treatment. The aim of this study is to characterize the growth patterns of untreated meningiomas to better inform the clinical decision-making process. METHODS: Patients with meningiomas were identified from 2005 to 2015. Those without treatment who had been followed for 1.5 years, with three magnetic resonance imaging (MRI) scans, were identified. Scans were measured with orthogonal diameters, geometric mean diameters, and volumes using the ABC/2 method. Regression modeling determined what growth pattern these parameters best approximated. RESULTS: Two hundred and fifteen MRI scans for 34 female (82.9%) and 7 male (17%) patients with 43 tumors were evaluated. Initial tumor volumes ranged from 0.13 to 9.98 mL. The mean and median initial volumes were 2.44 and 1.52 mL, respectively. Follow-up times ranged from 21 to 144 months, with a median of 70 months. There were 12 tumors (28%) whose growth rates were significantly greater than zero. For all tumors, use of a linear regression model allowed accurate prediction of the future size using prior data. CONCLUSION: Three-quarters of presumptive meningiomas managed conservatively do not grow significantly. The remainder have significant growth over time, and the behavior could be approximated with linear regression models.

A brain tumor reporting and data system to optimize imaging surveillance and prognostication in high-grade gliomas.

BACKGROUND AND PURPOSE: High-grade glioma (HGG), including glioblastoma, is the most common primary brain neoplasm and has a dismal prognosis. After initial treatment, follow-up decisions are guided by longitudinal MRI performed at routine intervals. The Brain Tumor Reporting and Data System (BT-RADS) is a proposed structured reporting system for posttreatment brain MRIs. The purpose of this study is to determine the relationship between BT-RADS scores and overall survival in HGG patients. METHODS: Chart review of grade 4 glioma patients who had an MRI at a single institution from November 2018 to November 2019 was performed. BT-RADS scores, tumor characteristics, and overall survival were recorded. Likelihood of improvement, stability, or worsening on the subsequent study was calculated for each score. Survival analysis was performed using Kaplan-Meier method, log-rank test, and a time-dependent cox model. Significance level of .05 was used. RESULTS: The study identified 91 HGG patients who underwent a total of 538 MRIs. Mean age of patients was 57 years old. Score with the highest likelihood for worsening on the next follow-up was 3b. The risk of death was 53% higher with each incremental increase in BT-RADS scores (hazard ratio, 1.53; 95% confidence interval [CI], 1.07-2.19; p = .019). The risk of death was 167% higher in O-6-methylguanine-DNA-methyltransferase unmethylated tumors (hazard ratio, 2.67; 95% CI, 1.34-5.33; p = .005). CONCLUSIONS: BT-RADS scores can be used as a reference guide to anticipate whether patients' subsequent MRI will be improved, stable, or worsened. The scoring system can also be used to predict clinical outcomes and prognosis.

Resolution and Re-ossification of Orbital-Wall Langerhans Cell Histiocytosis Following Stereotactic Needle Biopsy.

Introduction Langerhans cell histiocytosis (LCH) is a rare disease that encompasses a spectrum of clinical syndromes. It is characterized by the proliferation and infiltration of white blood cells into organs or organ systems. Reports of management of these lesions have included biopsy, resection, curettage, radiation, and/or chemotherapy. Case Presentation A 40-year-old man presented with a history of right proptosis and retro-orbital pain and was found to have a lytic mass involving the greater wing of the sphenoid extending into the right orbit. A stereotactic needle biopsy using neuronavigation demonstrated this to be LCH. After no further treatment, the mass spontaneously resolved, with virtual normalization of the orbital magnetic resonance imaging at 10 months following the needle biopsy. The bony defect of the temporal bone caused by the mass also re-ossified following the needle biopsy. Discussion This report highlights the potential for an isolated LCH lesion to regress after simple needle biopsy, an outcome only rarely reported previously. Thus, expectant management of such lesions following biopsy or initial debridement should be considered prior to proceeding with additional treatment.

Initial Experience Using Intraoperative Magnetic Resonance Imaging During a Trans-Sulcal Tubular Retractor Approach for the Resection of Deep-Seated Brain Tumors: A Case Series.

BACKGROUND: Treatment of deep-seated subcortical intrinsic brain tumors remains challenging and may be improved with trans-sulcal tubular brain retraction techniques coupled with intraoperative magnetic resonance imaging (iMRI). OBJECTIVE: To conduct a preliminary assessment of feasibility and efficacy of iMRI in tubular retractor-guided resections of intrinsic brain tumors. METHODS: Assessment of this technique and impact upon outcomes were assessed in a preliminary series of brain tumor patients from 2 centers. RESULTS: Ten patients underwent resection with a tubular retractor system and iMRI. Mean age was 53.2 ± 9.0 yr (range: 37-61 yr, 80% male). Lesions included 6 gliomas (3 glioblastomas, 1 recurrent anaplastic astrocytoma, and 2 low-grade gliomas) and 4 brain metastases (1 renal cell, 1 breast, 1 lung, and 1 melanoma). Mean maximal tumor diameter was 2.9 ± 0.95 cm (range 1.2-4.3 cm). The iMRI demonstrated subtotal resection (STR) in 6 of 10 cases (60%); additional resection was performed in 5 of 6 cases (83%), reducing STR rate to 2 of 10 cases (20%), with both having tumor encroaching on eloquent structures. Seven patients (70%) were stable or improved neurologically immediately postoperatively. Three patients (30%) had new postoperative neurological deficits, 2 of which were transient. Average hospital length of stay was 3.4 ± 2.0 d (range: 1-7 d). CONCLUSION: Combining iMRI with tubular brain retraction techniques is feasible and may improve the extent of resection of deep-seated intrinsic brain tumors that are incompletely visualized with the smaller surgical exposure of tubular retractors.

Management of idiopathic pediatric syringohydromyelia.

OBJECT: Syringohydromyelia is frequently identified on spinal imaging. The literature provides little guidance to decision making regarding the need for follow-up or treatment. The purpose of this study was to review the authors' experience in managing pediatric syringohydromyelia of unknown cause. METHODS: A single-institution retrospective review of all cases involving pediatric patients who underwent spinal MRI from 2002 to 2012 was conducted. Patients with idiopathic syringohydromyelia (IS) were identified and categorized into 2 subgroups: uncomplicated idiopathic syrinx and IS associated with scoliosis. Clinical and radiological course were analyzed. RESULTS: Ninety-eight patients (50 female, 48 male) met the inclusion criteria. Median age at diagnosis of syrinx was 11.9 years. Median maximum syrinx size was 2 mm (range 0.5-17 mm) and spanned 5 vertebral levels (range 1-20 vertebral levels). Thirty-seven patients had scoliosis. The most common presenting complaint was back pain (26%). Clinical follow-up was available for 78 patients (80%), with a median follow-up of 20.5 months (range 1-143 months). A neurological deficit existed at presentation in 36% of the patients; this was either stable or improved at last follow-up in 64% of cases. Radiological follow-up was available for 38 patients (39%), with a median duration of 13 months (range 2-83 months). There was no change in syrinx size in 76% of patients, while 16% had a decrease and 8% had an increase in syrinx size. Thirty-six patients had both clinical and radiological follow-up. There was concordance between clinical and radiological course in 14 patients (39%), with 11 patients (31%) showing no change and 3 patients (8%) showing clinical and radiological improvement. No patients had concurrent deterioration in clinical and radiological course. One patient with scoliosis and muscular dystrophy underwent direct surgical treatment of the syrinx and subsequently had a deteriorated clinical course and decreased syrinx size. CONCLUSIONS: There remains a paucity of data regarding the management of pediatric IS. IS in association with scoliosis can complicate neurosurgical decision making. There was no concordance between radiological syrinx size increase and clinical deterioration in this cohort, indicating that surgical decision making should reflect clinical course as opposed to radiological course.

En bloc spondylectomy for primary malignant fibrous histiocytoma of the thoracic spine with aortic involvement: case report.

In this article, the authors describe a 48-year-old man who initially presented with progressively worsening back pain. Magnetic resonance imaging revealed a soft-tissue mass involving the T10-11 vertebral bodies with extension anteriorly into the aorta as well as epidural extension without spinal cord compression. A biopsy of the mass showed findings consistent with a malignant fibrous histiocytoma (MFH). A total en bloc spondylectomy with resection and reconstruction of the involved aorta using a vascular graft was performed. The patient received postoperative radiation therapy and is neurologically intact at 18 months postoperatively. To the authors' knowledge, this is the first reported case of a spinal MFH resection with aortic reconstruction.

The endonasal approach for treatment of cerebral aneurysms: A critical review of the literature.

The last two decades of neurosurgery have seen flourishing use of the endonasal approach for the treatment of skull base tumors. Safe and effective resections of neoplasms requiring intracranial arterial dissection have been performed using this technique. Recently, there have been a growing number of case reports describing the use of the endonasal approach to surgically clip cerebral aneurysms. We review the use of these approaches in intracranial aneurysm clipping and analyze its advantages, limitations, and consider future directions. Three major electronic databases were queried using relevant search terms. Pertinent case studies of unruptured and ruptured aneurysms were considered. Data from included studies were analyzed. 8 case studies describing 9 aneurysms (4 ruptured and 5 unruptured) treated by the endonasal approach met inclusion criteria. All studies note the ability to gain proximal and distal control and successful aneurysm obliteration was obtained for 8 of 9 aneurysms. 1 intraoperative rupture occurred and was controlled, and delayed complications of cerebrospinal fluid leak, vasospasm, and hydrocephalus occurred in 1, 1, and 2 patients, respectively. Described limitations of this technique include aneurysm orientation and location, the need for lower profile technology, and challenges with handling intraoperative rupture. The endonasal approach for clipping of intracranial aneurysms can be an effective approach in only very select cases as demonstrated clinically and through cadaveric exploration. Further investigation with lower profile clip technology and additional studies need to be performed. Options of alternative therapy, limitations of this approach, and team experience must first be considered.

The clinical features of periorbital ecchymosis in a series of trauma patients.

INTRODUCTION: Periorbital ecchymosis (PE) is caused by blood tracking along tissue plains into periorbital tissues, causing discoloration in the upper and lower eyelids. This clinical feature is most commonly associated with basal skull fractures. Our objective is to present the first patient series describing the clinical features associated with traumatically induced PE. METHODS: The authors retrospectively reviewed 36 consecutive cases of patients presenting to the emergency department with PE over a three-year period at St. Michael's Hospital in Toronto. Data were obtained using a standardised data acquisition template. RESULTS: All patients presented to the emergency department with PE. The mean age in our series was 39 years (range 19-88 years), 31 patients were male. PE was associated with a variety of injuries including: 15 basal skull fractures, 9 soft tissue injuries without fractures, 8 convexity fractures, and 3 facial fractures. The other classic signs of basal skull fracture (Battle's sign, hemotympanum, cerebrospinal fluid otorrhea, cerebrospinal fluid rhinorrhea) were observed in 3, 7, 1, and 3 patients with PE, respectively. The most common clinical feature associated with PE was cranial nerve injury, observed in 10 patients. Surgical intervention was required in 8 patients. Five patients were discharged to a rehabilitation centre. No meningitis, cerebral abscess, encephalitis or deaths were observed. CONCLUSION: Periorbital ecchymosis is a useful clinic sign that should alert the clinician to assess for skull fractures, intracranial haemorrhage, and cranial nerve injury. However, this series shows that PE can be associated with a variety of clinical features, is rarely accompanied by other classic signs of basal skull fracture, and most patients with PE do not have injuries severe enough to require surgical intervention or post-discharge rehabilitation.

Malignant transformation of an intramedullary epidermoid cyst in the thoracic region of the spinal cord: case report.

Malignant transformation of epidermoid cysts (ECs) to squamous cell carcinomas (SCCs) in the CNS is exceedingly rare and has only been described in intracranial ECs. In this article, the authors describe a 53-year-old man with a history of a previously resected T3-4 EC, who presented with a 2-month history of progressively worsening weakness in the left side of his body. Magnetic resonance imaging revealed an enhancing mass in the T3-4 region, the exact location of the previous cyst. The mass was resected in gross-total fashion, and pathological analysis revealed an SCC. Postoperatively, the patient regained full strength in his lower extremities. After the resection, he received radiotherapy administered at an isodose of 50 Gy. To the authors' knowledge, this is the first reported case of malignant transformation of an intramedullary spinal EC in the literature.

Racial disparities in outcomes after spinal cord injury.

Spinal Cord Injury (SCI) is an acute trauma to the neural elements resulting in temporary or permanent sensory and motor deficit. Studies have indicated that although 66% of SCI occur in Caucasians, there are a growing number of other racial groups affected by SCI. Furthermore, there has been a lack of research concerning racial disparities in outcomes following SCI. As such, a retrospective analysis using the National Trauma Data Bank (NTDB) from 2000 to 2009 was performed. African Americans, Caucasians, Hispanics, Asians, and Native Americans were included in the study. We calculated adjusted odds ratios (OR) to examine the relationship between racial backgrounds and mortality, length of intensive care unit (ICU) stay, length of hospital stay, in-hospital complications, and patient disposition. Our results showed that significant differences were found in length of hospital stay, with African American and Hispanic populations having longer hospital stays than Caucasian and Asians. For all type complications, African Americans (OR 1.228, confidence interval [CI] 1.11-1.356) and Native Americans (OR 1.618, CI 1.083-2.419) were more likely than Caucasian and Hispanic patients to have in-hospital complications. For disposition status, African Americans (OR 0.844, CI 0.730-0.976) and Asians (OR 0.475, CI 0.297-0.760) were much less likely than Caucasians or Hispanic populations to be discharged to an acute rehabilitation program. The results from this large-scale study (n=18,671) demonstrate a number of racial disparities following SCI at the national level, including rate of complications, length of stay, and disposition to acute rehabilitation centers. This should raise awareness to cultural differences but also serve as an opportunity to reduce gaps in care across ethnicities for this universally life-altering condition.