Endoscopic transforaminal treatment of a thoracic perineural cyst: a case report.

BACKGROUND AND IMPORTANCE: To describe the first case of a thoracic perineural cyst successfully treated using a direct thoracic transforaminal endoscopic approach. METHODS: Case report. CLINICAL PRESENTATION: A 66-year-old male presented with right-sided radicular pain in a T4 distribution. MRI of the thoracic spine revealed a right T4 perineural cyst caudally displacing the root in the T4-5 foramen. He had failed attempts at nonoperative management. The patient underwent an all endoscopic transforaminal perineural cyst decompression and resection as a same-day surgical procedure. Postoperatively, the patient noted near complete resolution of the preoperative radicular pain. A thoracic MRI with and without contrast was performed 3 months after surgery and showed no evidence of the preoperative perineural cyst and no symptom recurrence was noted by the patient. CONCLUSION: This case report presents the first safe and successful report of an all endoscopic transforaminal decompression and resection of a perineural cyst in the thoracic spine.

Short-Term Outcomes of Glenoid Bone Block Augmentation for Complex Anterior Shoulder Instability in a High-Risk Population.

PURPOSE: To describe the short-term clinical outcomes of glenoid bone block augmentation in a high-demand population, as well as to describe its clinical success and complications at greater than 2 years' follow-up in an at-risk military population. METHODS: All patients undergoing anterior capsulorrhaphy with coracoid process transfer or anterior bone block augmentation (Current Procedural Terminology code 23662 or 23460) for shoulder instability between 2006 and 2012 were isolated from the Military Health System Management Analysis and Reporting Tool. Demographic and occupational parameters were identified, and multiple surgical factors and clinical outcomes were extracted from the medical record and US Defense Manpower Data Center. RESULTS: A total of 64 service members (65 shoulders) underwent anterior bone block procedures, including coracoid transfer (n = 59, 90.8%), distal tibial allograft (n = 3, 4.6%), and autologous or allograft iliac crest bone graft (n = 3, 4.6%). This group was predominately comprised of men (n = 59), and the mean age was 25.9 years (range, 19 to 45 years). A total of 19 perioperative complications, including 8 neurologic injuries, 6 infections, and 4 hardware failures, occurred in 16 patients (25%). At a mean 2.4-year follow-up, 21 patients (32.8%) reported persistent shoulder pain and 15 patients (23.4%) disclosed subjective apprehension or recurrent instability. Secondary surgical procedures were performed in 12 patients (18.8%), including 4 revisions (6.3%). Ultimately, 20 patients (31.3%) underwent a medical discharge for persistent shoulder disability. Univariate analysis showed that the presence of a perioperative complication (P = .049) and tobacco use (P = .038) were associated with increased risk of subsequent surgical failure. CONCLUSIONS: Anterior glenoid bone block procedures for shoulder instability with concomitant bone loss enable a return to high-demand physical function. The short-term complication profile (25%), recurrence rate (23%), and persistence of shoulder pain (33%) should be emphasized during preoperative counseling, particularly in an active military population and revision setting. Although moderately successful in the military, anterior bone block procedures for complex shoulder instability can be associated with significant short-term complications and morbidity. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Determining the Effect of Intraoperative TXA on Postoperative Blood Loss in ACDF.

STUDY DESIGN: Retrospective cohort study using prospectively collected data. OBJECTIVE: To determine the effectiveness of intraoperative tranexamic acid (TXA) in anterior cervical discectomy and fusion (ACDF) on postoperative blood loss. SUMMARY OF BACKGROUND DATA: TXA has been proven to be a safe and effective agent in reducing blood loss after cervical surgery; however, its efficacy when used intraoperatively for ACDF surgeries had yet to be researched. Currently, there are few studies examining the effects of intraoperative TXA in cervical spinal fusion, and none specifically examining TXA use in ACDF. METHODS: A tertiary medical center's prospectively collected spine registry was queried between 1/1/18 and 12/1/21 for all patients who underwent elective ACDF surgery and received a drain postoperatively. Patients were separated into 2 groups; those who had received intraoperative TXA and those who did not. Baseline demographic and operative variables were collected from the registry. The primary outcome was postoperative blood loss over a 24-hour period. Secondary outcomes included total drain output, intraoperative estimated blood loss, operative duration, drain duration, changes in preoperative to postoperative hemoglobin and hematocrit levels, and rate of transfusions, complications, revisions, and reoperations. Univariate and multivariate regression analyses were performed. RESULTS: Two hundred eighty-six patients were included. One hundred ninety patients underwent ACDF and did not receive intraoperative TXA, whereas 96 patients underwent ACDF and did receive TXA. There were no differences in any demographic or baseline variables. Multivariate analysis showed intraoperative TXA was associated with shorter drain duration (ß=-5.74, 95% CI: -10.9 to -0.53, P =0.031) and reduction in 24-hour drain output (ß=-12.2, 95% CI: -19.4 to -4.89, P =0.001) and total drain output (ß=-14.0, 95% CI: -22.9 to -5.05, P =0.002). CONCLUSIONS: TXA use during ACDF procedures leads to a decrease in perioperative blood loss and faster drain removal. TXA is an effective and safe agent for reducing perioperative blood loss in ACDF surgery. LEVEL OF EVIDENCE: III.

Epidemiology of Posterior Glenohumeral Instability in a Young Athletic Population.

BACKGROUND: While several studies have observed the incidence of posterior glenohumeral instability in selected populations, there are no data from large-scale population-based studies with corresponding athletic exposure data to calculate incidence rates (IRs) and associated risk factors. PURPOSE: To determine risk factors for posterior glenohumeral instability within the physically active population at the United States Military Academy. STUDY DESIGN: Descriptive epidemiology study. METHODS: A longitudinal cohort study was performed over a 6-year period from 2006 to 2012 at the United States Military Academy utilizing the Cadet Illness and Injury Tracking System. Exposure data were collected from daily attendance data documented for every practice and game at the intramural, club, or varsity sport level. The primary outcomes calculated were the IRs of posterior glenohumeral joint instability per 1000 person-years at risk and per 1000 athlete-exposures. IR ratios and confidence intervals were calculated between male and female cadets and between intercollegiate and intramural athletes. RESULTS: Between 2006 and 2012, there were 1348 shoulder injuries in total, with 633 instability events. During the study period, 113 posterior shoulder instability injuries (17.9% of instability events) and 26,408 person-years at risk were documented, for an overall IR of 4.28 per 1000 person-years. The overall IR of posterior instability was 0.08 per 1000 athlete exposures. In male athletes, 105 sustained a posterior shoulder instability event, for an IR of 4.67 per 1000 person-years. Female athletes were less likely to sustain a posterior instability event, accounting for only 8 events, for an IR of 2.04 per 1000 person-years. A total of 6670 athletes were at risk for posterior shoulder instability injury during the study period. A total of 55 injuries were documented, for an IR of 8.25 per 1000 person-years. Intercollegiate wrestlers had the highest IR: 34.15 per 1000 person-years. The sport with the highest injury rate among intramural sports was football, at 2.79 per 1000 person-years. Three athletes had a history of a posterior shoulder dislocation, while no significant difference was found for subluxation versus pain as the presenting symptom. Of the 113 posterior shoulder instability injuries, 77.0% required surgical stabilization. All injuries associated with weight lifting required surgical stabilization. CONCLUSION: Among athletes, intercollegiate athletes are at an increased risk of posterior glenohumeral instability when compared with intramural athletes. Intercollegiate athletes and weight lifters demonstrate a high likelihood of requiring surgical treatment as compared with intramural athletes.

Preliminary Results of Primary Gastrocnemius-Soleus Recession for Midfoot Charcot Arthropathy.

UNLABELLED: Background Treatment of Charcot arthopathy of the foot can be challenging. The goal of this investigation was to determine whether primary gastrocnemius-soleus recession could decrease rate of new ulcers, progression of deformity, and amputation in patients with Charcot arthropathy of the midfoot.Methods A retrospective chart review revealed 28 feet in 24 diabetic patients with radiographic evidence of Charcot arthropathy of the midfoot. They were treated with primary gastrocnemius-soleus recession. Eleven feet in 11 patients had concurrent plantar midfoot ulcers. Three feet in 3 patients were lost to follow-up. Twenty-five feet in 21 patients were followed for an average of 37 months postoperatively (range = 18-79).Results A favorable outcome was defined as healing of existing ulcers, no new ulcers, no obvious progression of deformity, and no amputation. Favorable outcomes were obtained in 22 of 25 feet (18 of 21 patients). Only one patient had a persistent ulcer after gastrocnemius-soleus recession. The other 10 patients with preexisting ulcers healed. Deformity of midfoot progressed in one patient, leading ultimately to transtibial amputation. Another patient developed a knee joint infection and had a transfemoral amputation at another institution.Discussion These preliminary data suggest that primary gastrocnemius-soleus recession is followed by a much lower rate of persistent, recurrent, and new ulceration than previously reported studies. Gastrocnemius-soleus recession seems to aid in the treatment of Charcot arthropathy of the midfoot. LEVELS OF EVIDENCE: Level IV.