Complex surgical reconstruction for spinopelvic instability caused by a giant Tarlov cyst eroding the sacrum: A case report.

Background: Tarlov cysts (TC), also known as perineural cysts are meningeal dilations of the posterior nerve root sheath that typically affect sacral nerve roots. TC are usually asymptomatic and found incidentally. We present the case of a patient with an enlarging sacral TC causing pain from spinopelvic instability secondary to extensive bone erosion. Such illustrative case is intended to increase awareness of the potential need for complex spinopelvic reconstruction in atypical instances of large TC. Case Description: A 29-year-old female presented to clinic reporting progressive bilateral sacroiliac joint pain that was essentially mechanical in nature. The patient had a normal neurological exam except for a known left drop foot with numbness in the left sural nerve distribution, both attributed to a previously resected peripheral nerve sheath tumor. Magnetic resonance imaging revealed a large multilobulated lesion with imaging characteristics consistent with TC adjacent to the left side of the sacrum, extending outward from the left S1 and S2 neural foramina and measuring 6.7 × 3.7 cm in the axial plane and and 5.6 cm in the sagittal plane. Six weeks of conservative management consisting of physical therapy and pain management was unsuccessful, and the patient reported worsening pain. Surgical reconstruction consisting of L5-S1 transforaminal lumbar interbody fusion, L4 to pelvis navigation-guided instrumentation and posterolateral fusion, and bilateral sacroiliac joint fusion was successfully performed. Outcomes: At 12 weeks follow-up appointment after surgery, the patient reported resolution of sacroiliac mechanical pain. Conclusions: Sacral TC are asymptomatic in their vast majority of cases but may occasionally cause neurological deficits secondary to mass effect. Rarely, however, giant TC can also lead to significant bone erosion or the sacrum with secondary spinopelvic instability. In this brief report, we describe a giant TC generating significant spinopelvic instability, which was successfully treated with complex spinopelvic reconstruction, leading to complete resolution of the reported axial mechanical pain.

Delayed peritoneal shunt catheter migration into the pulmonary artery with indolent thrombosis: A case report and narrative review.

Background: Ventriculoperitoneal (VP) shunts are the preferred surgical treatment for hydrocephalus, and rarely, these operations may be complicated by catheter migration to ectopic sites. We present the case of an asymptomatic VP shunt patient with delayed peritoneal catheter migration into the pulmonary artery shunt catheter migration into the pulmonary artery (SCMPA) complicated by knotting and indolent thrombosis, necessitating open-heart surgery for system retrieval. Methods: We conducted a literature review in PubMed, Scopus, and Web of Science of prior similar reported cases and present the results of 24 cases of SCMPA. Results: An asymptomatic 12-year-old male presented with SCMPA noted on routine annual follow-up imaging. Preoperative CT angiogram indicated extensive catheter looping into the pulmonary artery without evidence of thrombosis. Less invasive attempts to retrieve the retained catheter were unsuccessful, and open-heart surgery was required. Intraoperatively, a nonocclusive pulmonary arterial thrombus surrounding the knotted catheter was discovered that was lysed successfully before system retrieval. Conclusion: VP shunt catheter migration into the pulmonary artery (SCMPA) with concurrent large vessel thrombosis can develop in pediatric patients incidentally without any clinical symptoms. Our report suggests that preoperative CT angiogram may be insufficient to detect arterial thrombosis in the presence of extensive intravascular catheter knotting. An open-chest approach may be the only viable surgical option for catheter retrieval in the presence of complex catheter coiling. The use of anticoagulation following open-heart surgery for retrieval of a migrated VP shunt catheter remains unclear, we here propose that continuation of long-term therapeutic anticoagulation may successfully prevent thrombus relapse.

Urothelial Carcinoma of the Bladder With Primary Metastasis to the Brain: A Case Report and Literature Review.

Brain metastases are the most common type of brain tumor in adults, commonly arising from primary tumor sites of the lung, breast, skin (melanoma), colon, and kidney. Isolated central nervous system (CNS) metastasis arising from urothelial carcinoma (UC) is a rare presentation yielding a poor prognosis. A 71-year-old male patient with a history of urothelial carcinoma, treated one year prior with partial cystectomy and adjuvant gemcitabine and cisplatin (GC) therapy, presented with worsening neurological symptoms, including progressively worsening dizziness, shuffling gait, drifting, expressive aphasia, and confusion. MRI revealed a left frontal 4.0 x 3.6 cm brightly contrast-enhancing tumor with possible hemorrhage, extensive vasogenic edema, and moderate mass effect. An additional smaller right cerebellar lesion was also noted. Outpatient CT of his chest, abdomen, and pelvis revealed no evidence of other malignant sites. He ultimately underwent a left craniotomy with a total resection of his left frontal mass. Pathological examination revealed a urothelial primary. Post-operative MRI revealed complete resection of the left frontal mass and the patient was discharged with no neurologic deficits on exam. In many cases, brain metastases may present years later following initial therapy of UC as the CNS may act as a sanctuary site during systemic chemotherapy. Chemotherapeutics such as gemcitabine with better penetration of the blood-brain barrier may be beneficial in delaying the onset of these metastases.

Endoscope-Assisted Evacuation of Acute-on-Chronic Subdural Hematomas: A Single-Center Series.

PURPOSE: Acute subdural hematomas are frequent, highly morbid, and affect all age groups. The most common mechanism of injury is a low-velocity fall, and the incidence of the disease is growing due to increasingly aggressive antithrombotic and anticoagulant therapies. In this study, we aimed to share our experience with the endoscopic-assisted evacuation of acute subdural hematoma, a less invasive procedure compared to standard craniotomy. METHODS: We retrospectively reviewed data of all consecutive patients aged 18 years and older who underwent endoscopic-assisted evacuation of acute-on-chronic subdural hematoma at our institution from 2015 to 2019. Preoperative, intraoperative, postoperative, and follow-up data were collected and reported. Statistical tests were done using Python statistical packages. RESULTS: Of the 35 patients that underwent this procedure, 32 were 18 years and older. The median age was 69.5 years and 37.5% were female. Twenty patients (62.5%) were on antiplatelet therapy, and six patients (18.75%) were on anticoagulants upon presentation. A fall was the most common cause of trauma (71.88%). The median operative time was 107 minutes. The median length of stay in days and Glasgow Coma Scale (GCS) at discharge were 8.5 and 15, respectively. There were no surgical site infections or in-hospital mortality in this series. At the latest follow-up, the median GCS and modified Rankin Scale were 15 and 1, respectively. CONCLUSION: Evacuation of acute-on-chronic subdural hematomas can be performed safely and efficiently via a smaller craniotomy and with the assistance of an endoscope. This may represent a less invasive alternative than standard craniotomy/craniectomy in selected patients.

Cervical Disc Arthroplasty Migration Following Mechanical Intubation: A Case Presentation and Review of the Literature.

BACKGROUND: Cervical arthroplasty has established itself as a safe and efficacious alternative to fusion in management of symptomatic cervical degenerative disease. Recent literature has indicated a trend toward decreased risk of reoperation with cervical arthroplasty, and reoperation in this subset commonly occurs secondary to recurrent pain and device-related complications. The instance of cervical arthroplasty migration, particularly in the setting of trauma, is particularly rare. Here, we report the first case of implant migration secondary to iatrogenic trauma following neck manipulation during direct laryngoscopy for mechanical intubation. CASE DESCRIPTION: A 53-year-old smoker with cervical spondylosis underwent a cervical 3/4 arthroplasty with a ProDisc-C implant. About a month postoperatively, he was intubated via direct laryngoscopy for community acquired pneumonia and began experiencing new dysphonia and dysphagia after extubation. Delayed imaging revealed anterior migration of the implant. The patient immediately underwent removal of the implant and conversion to anterior cervical discectomy and fusion. CONCLUSIONS: Supraphysiologic forces exerted through neck manipulation in mechanical intubation mimicked low-energy trauma, and in the setting of ligamentous resection necessary for cervical arthroplasty and inadequate osseous integration, led to migration of the implant. We recommend the integration of fiberoptic technique or video laryngoscopy with manual in line stabilization for intubation of post cervical arthroplasty patients when airway management is necessary within 10 months after cervical arthroplasty. Clinicians and anesthesiologists should have a high clinical suspicion for prompt and early workup with spine imaging in the setting of persistent postintubation symptoms such as dysphonia and/or dysphagia.