Lumbar Vertebral Body Tethering: Single Center Outcomes and Reoperations in a Consecutive Series of 106 Patients.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To evaluate the outcomes and reoperation rates in patients with adolescent idiopathic scoliosis (AIS) undergoing lumbar anterior vertebral body tethering (AVBT). SUMMARY OF BACKGROUND DATA: Anterior vertebral body tethering (AVBT) is a viable option in growing children. The benefit of motion preservation must be balanced by a higher reoperation rate. A paucity of reports has addressed lumbar AVBT. METHODS: A single-center retrospective study was conducted to identify all patients who underwent lumbar AVBT (lowest instrumented vertebra L3 or L4) with a minimum 2 years of follow-up. Clinical and radiographic parameters, including complications and reoperations, were also collected. Statistical analysis was performed using Student's t-test for qualitative variables. RESULTS: From a dataset of 551 patients, we identified 106 patients (89% female) who underwent a lumbar AVBT (33 lumbar only, 73 bilateral thoracic/lumbar) with mean follow-up of 4.1±1.6 years at which point 85% (90/106) had reached skeletal maturity. Preoperatively, these patients were skeletally immature (age: 12.8±1.3 y, Sanders: 3.3±0.8, R=0.6±0.9) with a lumbar coronal curve angle of 49.6°±11.2 which corrected to 19.9°±11.2 (P <0.0001) at most recent follow-up. At the latest follow-up, 76.4% (81/106) of the patients harbored a coronal curve angle of < 30°. Twenty patients (18.9%) underwent 23 reoperations, with overcorrection being the most common (10/23, 43%). Broken tethers led to reoperation in 3 instances (3/23, 13%). Six patients in the cohort needed a posterior spinal fusion (6/106, 5.4%). CONCLUSIONS: Vertebral body tethering is a viable treatment option for skeletally immature patients with idiopathic scoliosis. This report is the largest to date for lumbar AVBT, highlighting that 84% of patients harbored a curve < 35° at the latest follow-up but with an 18.9% reoperation rate. LEVEL OF EVIDENCE: 3.

Early outcomes in hybrid fixation for idiopathic scoliosis: posterior fusion combined with anterior vertebral body tethering. Patient series.

BACKGROUND: Anterior vertebral body tethering (AVBT) and posterior spinal fusion (PSF) are options for patients with idiopathic scoliosis. Combining both procedures in patients with double curves, a procedure in which PSF is performed for the thoracic curve and AVBT for the lumbar curve, provides maximal correction of the thoracic curve with a theoretical maintenance of motion in the lumbar spine. OBSERVATIONS: The authors retrospectively reviewed 20 skeletally immature patients diagnosed with idiopathic scoliosis at a single institution with an average age of 12.7 ± 1.6 years and who had undergone hybrid treatment with an average follow-up of 8 months. The PSF procedures averaged 276 ± 63 minutes with 442.8 ± 295 mL of blood loss, and the AVBT averaged 275 ± 54 minutes with 118.3 ± 80 mL of blood loss. Following the hybrid correction, the thoracic and lumbar coronal curve angles improved from 67.6° to 21.6° and from 65.2° to 24°, respectively. The three-dimensional kyphosis improved from 3.3° to 24°. LESSONS: A combined approach of PSF and AVBT is safe and effective for idiopathic scoliosis. This approach combines the gold standard of thoracic fusion with the motion preservation benefits of AVBT in the lumbar spine. This study will continue to refine indications for AVBT.

A Perennial Threat: A Case Series of Tree-Related Neurotrauma.

Background Despite their devastating nature, injuries due to tree-related- traumas are sparsely reported in the literature. Over the last several years, the incidence of tree-related traumatic injuries presenting to our level one trauma center, in Westchester, New York, has been concerning. The present study was undertaken to evaluate the clinical presentation, injury pattern, and outcomes of tree-related neurotrauma at our institution. In addition, we describe the injury pattern and medical management of several relevant cases of tree-related neurotrauma. Methods We conducted a retrospective analysis of tree-related neurotrauma over a five-year period from January of 2014 to March of 2019 at Westchester Medical Center (WMC) and Maria Fareri Children's Hospital, a level one trauma center. Patients presenting with neurotrauma that necessitated neurosurgical care were eligible for inclusion in this case series. Tree-related injury was defined as any trauma that was sustained as a direct result of collision with a tree. Results We identified 21 patients who sustained tree-related trauma. The cohort age ranged from 15 to 68 (mean=38 years). Injuries included seven skull fractures, four cases of subdural hematoma (SDH), six cases of intracranial hemorrhagic contusion, 14 spinal fractures, three cases of epidural hematoma (EDH), one case of spinal cord contusion, three vascular injuries, one case of dural laceration, and one case of pneumocephalus, with several patients suffering multiple injuries. Of the 21 patients, seven were female, and 12 were injured when their motor vehicle struck a tree. All but four patients were taken to the operating room for neurosurgical treatment, and nine of 21 patients were taken emergently to the operating room upon arrival. Conclusion The potential for serious head injuries with long-term neurologic sequelae exists with tree-related trauma. Clinicians should be advised of the challenging management of injuries secondary to tree-related trauma, and a greater emphasis should be placed on raising awareness of these accidental, but devastating injuries. Finally, a great majority of these injuries can be prevented or reduced in severity through helmet use and by adhering to safety guidelines.

Use of Vycor Tubular Retractors in the Management of Deep Brain Lesions: A Review of Current Studies.

BACKGROUND: Traditional manual retraction to access deep-seated brain lesions has been associated with complications related to vascular compromise of cerebral tissue. Various techniques have been developed over time to minimize injury, such as self-sustaining retractors, neuronavigation, and endoscopic approaches. Recently, tubular retractors, such as the ViewSite Brain Access System (VBAS), have been developed to reduce mechanical damage from retraction by dispersing the force of the retractor radially over the parenchyma. Therefore, we sought to review the current literature to accurately assess the indications, benefits, and complications associated with use of VBAS retractors. METHODS: A literature search for English articles published between 2005 and 2019 was performed using the MEDLINE database archive with the search terminology "Vycor OR ViewSite OR Brain-Access-System NOT glass." The VBAS website was also examined. Only articles detailing neurosurgical procedures using the VBAS tubular retractor system alone, or in combination with other retractors, were included. Postoperative morbidity and mortality were analyzed to estimate complications linked to using the retractor. RESULTS: Twelve publications (106 patients) met the inclusion criteria. The VBAS retractor was used for tumor resections, hematoma evacuations, cyst removal, foreign body extractions, and lesion resection in toxoplasmosis and multiple sclerosis. These cases were subdivided into groups based on lesion location, size, and resection volume for further analysis. Gross total resection was achieved in 63% of tumor excisions, and subtotal resection was achieved in 37%. Hematoma evacuation was successful in all cases. There were 3 short-term postoperative complications linked to the retractor, with an overall complication rate of 2.8%. CONCLUSIONS: This report is the first formal assessment of the VBAS, highlighting technical considerations of the retractor from the surgeon's perspective, patient outcomes, and complications. The retractor is a safe and efficacious tubular retraction system that can be used for tumor biopsy and resection, colloid cyst removal, hematoma evacuation, and removal of foreign bodies. However, further randomized controlled trials are indicated to accurately assess complication rates and outcomes.

Peripheral blood neutrophil-to-lymphocyte ratio in preterm infants with intraventricular hemorrhage.

OBJECTIVES: Intraventricular hemorrhage (IVH) remains a major complication of prematurity, affecting 20-25% of premature infants of very low birth weight. Preterm infants with IVH are at risk for developing significant complications, including posthemorrhagic hydrocephalus and seizures. Multiple studies have reported an association between the neutrophil-to-lymphocyte ratio (NLR) in peripheral blood and outcomes after acute intracranial hemorrhage in adults. However, the prognostic value of the NLR in preterm infants, particularly those with IVH, has not been investigated previously. PATIENTS AND METHODS: This retrospective, observational cohort study included premature infants with IVH and a neonatal reservoir placed between January 2013 and January 2018. For each patient, peripheral blood and available cerebrospinal fluid laboratory results within 50 days of IVH diagnosis were averaged. NLR was calculated by dividing the absolute neutrophil count by the absolute lymphocyte count. Differences in NLR levels for patients with seizures or shunt placement were analyzed. RESULTS: Data for 13 surviving preterm infants (mean gestational age, 26.5 ± 3.0 weeks) were analyzed. The mean peripheral NLR (n = 13) was 1.6 ± 1.3 for all patients. Patients who experienced seizures had significantly higher peripheral blood NLR (p = 1.2 × 10-6, t-test) than those who did not, and an NLR > 3 correlated with seizure outcomes (p = 0.0035, Fisher's exact). Patients with sepsis or meningitis also had NLR values >3 (p = 0.01 and 0.005, respectively) but there was no correlation between the sepsis/meningitis and seizures patients. No significant correlation was found between NLR and the development of hydrocephalus. CONCLUSION: The development of seizures in preterm infants with IVH is known to significantly increase morbidity. In this study, higher peripheral blood NLR (>3) correlated with the development of seizures, independent of sepsis or meningitis. Further prospective validation of the role of NLR as a predictive marker for seizures in preterm infants is warranted.

Report of an Isolated L5 Radiculopathy Caused by an L2-3 Disc Herniation and Review of the Literature.

Intervertebral disc herniation is a common cause of radiculopathy. Disc herniations occurring in the lumbar spine typically affect the nerve root exiting under the pedicle of the vertebral body, one level caudal. However, in rare cases, a disc herniation can cause remote isolated radicular symptoms. The authors present the case of a 70-year-old male who presented with an acute, new-onset, left-sided foot drop, low back pain, and a classic L5 monoradiculopathy. Imaging revealed a large, left-sided paracentral extruded L2-3 disc and the absence of any pathology at the L4/5 level. Although the patient's clinical presentation and imaging did not classically correlate, it was felt that the L2-L3 disc was the etiology of the patient's L5 radiculopathy and a left L2-3 microsurgical discectomy was performed. At the six-week follow-up, his foot drop was near normal, sensation was intact with minimal paresthesias, and he remained pain-free. At the one-year follow-up, he experienced full resolution of his foot drop and remained symptom-free. Although rare, disc herniations may cause isolated, remote, painful mononeuropathies not related to the direct level of nerve root compression and should be considered along with other etiologies of peripheral neuropathies.

Myelopathy from Intradural Extramedullary Metastasis as an Initial Presentation of Metastatic Melanoma.

The incidence of metastatic melanoma (MM) has been steadily rising, and it is the third most common metastatic lesion to the central nervous system (CNS). Spinal intradural extramedullary (IDEM) MM is rare, and it is associated with coexisting or antecedent brain metastasis. Metastatic disease to the CNS is a complication of advanced disease, and it generally occurs months to years after initial diagnosis and treatment. We describe the first case of an initial presentation of MM, presenting as cervical myelopathy secondary to spinal cord compression from IDEM spinal metastasis. Further work-up revealed additional lesions in the temporal lobe and cauda equina region as well as a scalp lesion that was presumed to be the primary site. MM should be considered in the differential of myelopathy secondary to a spinal intradural mass, particularly in those with a history of or risk factors for melanoma.

A rare case of perianal granular cell tumor: case report and literature review.

Granular cell tumor (GCT) is a rare submucosal neoplasm most commonly localized in the oral mucosa; with one-third of all cases found in the tongue, with less than 30 cases of perianal GCT reported in the literature, making it a rare anal neoplasm. Wide local excision is the gold standard of treatment and follow-up includes annual colonoscopy due to the high incidence of reoccurrence. Here we describe a rare case of benign perianal GCT in a 29-year-old female who presented asymptomatically; however, pathology report revealed a S100 positive immunostaining pattern. GCT is an important differential to be included when evaluating a patient with an asymptomatic perianal submucosal lesion. Since GCT and Squamous Cell Carcinoma present with similar pseudoepitheliomatous hyperplasia of the epithelium it is important that a biopsy and immunohistochemical analysis be performed to allow for accurate diagnosis and appropriate treatment.

Is Subdural Peritoneal Shunt Placement an Effective Tool for the Management of Recurrent/Chronic Subdural Hematoma?

UNLABELLED: OBJECTIVE : To describe a surgical technique and to report using a retrospective study the efficacy of peritoneal shunts for the treatment of recurrent/chronic subdural hematoma (CSDH). We describe the considerations, complications, and outcomes related to this technique. METHODS : In a retrospective cohort study, 125 charts with a diagnosis of subacute/chronic subdural hematoma were assigned for evaluation. Of the charts reviewed, 18 charts were found from subjects with a diagnosis of recurrent sub-acute or chronic subdural hematoma. All patients had undergone initial surgical treatment of their condition followed by peritoneal shunt placement to help alleviate intracranial pressure. Factors including the age, size of subdural hematoma, number of previous events, BMI, complications, survival, and clinical course were analyzed. RESULTS : After subdural peritoneal shunt placement all patients had full neurological recovery with no complaints of headaches, lethargy, weakness, confusion or seizures. None of the cases had new subdural hematoma episodes after placement for a minimum of a two-year period (mean 26.1 months) (range 24.3-48.6 months). No postoperative complications were reported. The rates of postoperative hemorrhage, infection, distal catheter revision, and perioperative seizures was found to be zero percent. Shunt drainage was successful in all cases, draining 85% of the blood in the first 48 hours. There was no significant relationship between complications and the use of anticoagulants four weeks after surgery. CONCLUSIONS: Peritoneal shunts, though rarely used, are a viable option in the treatment of sub-acute/chronic subdural hematomas. When pursuing this treatment, this technique is recommended to mitigate the risks of repeat surgical intervention and lessen perioperative time in high-risk patients.