Cervical intradural traumatic neuroma without history of trauma: illustrative case.

BACKGROUND: Traumatic neuroma typically refers to a reactive process in the injured peripheral nerve, characterized by an excessive growth of axons, Schwann cells, and fibroblasts at the proximal end of the nerve after its interruption. The authors report a case of a traumatic neuroma in the cervical nerve root in a patient with no history of trauma. OBSERVATIONS: The patient presented with sensation loss in the right-hand ulnar distribution, right flank around the T4-11 region, and right small toe along with motor power weakness over the right upper and lower extremity. Magnetic resonance imaging revealed an intradural extramedullary mass lesion with extension along the C7 nerve root. Histological examination showed traumatic neuroma. A total resection of the lesion along with the resolution of sensory and motor deficits was achieved directly after surgery. LESSONS: Traumatic neuroma should always be kept in the armamentarium for diagnosis of an intradural nerve sheath tumor.

Image-Guided Percutaneous Multilevel Pediculosynthesis for Treatment of Contiguous Pedicle Stress Fractures: Technical Case Report.

BACKGROUND: Nontraumatic pedicle fracture is uncommon, with sparsely described cases of conservative management versus surgical treatment by open fusion or percutaneous fixation. METHODS: We report the case of a 60-year-old woman with nontraumatic L4 and L5 pedicle fracture who developed additional pedicle fractures at L3 while undergoing conservative management in a brace. The patient underwent percutaneous pediculosynthesis with screw fixation without fusion at L3-5 bilaterally. RESULTS: The treatment led to fracture healing with good radiographic result and resolution of her symptoms. CONCLUSIONS: A trial of conservative management is typically warranted in most cases of nontraumatic pedicle fracture, but there is risk of refractory or progressive symptoms and subsequent fracture. Minimally invasive fixation is a viable surgical option that can be used in multilevel fractures.

Accessory Nerve Disruption Following Core-Needle Biopsy: A Review of Iatrogenic Accessory Nerve Injuries and an Illustrative Case.

Iatrogenic spinal accessory neve (SAN) injury is a rare complication. It most commonly occurs after open lymph node biopsies. Needle biopsy is thought to present lower risk to the SAN. However, we describe a case of a 66-year-old man who underwent core needle biopsy for lymphadenopathy and subsequently experienced ipsilateral shoulder weakness and pain. Physical examination revealed shoulder depression, lateral scapular winging, and decreased range of motion. Subsequent studies and magnetic resonance imaging demonstrated complete paralysis and denervation of SAN muscles. The nonfunctional SAN was repaired by sural nerve grafting 3 months after the injury. The patient demonstrated improved shoulder strength, range of motion, and decreased pain at 6-month follow-up. SAN injuries can be challenging to diagnose and require prompt surgical intervention. This case represents an unusual case of complete SAN disruption and palsy after core needle biopsy treated with sural nerve grafting. We review the literature on iatrogenic SAN injuries, diagnostic strategies, options for SAN surgical repair, and outcomes. SAN injuries can be challenging to diagnose but are amenable to prompt surgical options based on the mechanism and type of SAN injury.

Genetic and serum markers in adult degenerative scoliosis: a literature review.

STUDY DESIGN: Literature review. OBJECTIVE: Adult degenerative scoliosis (ADS) is becoming a more prevalent diagnosis with an increasing elderly population. Our objective is to provide a literature review of genetic and serum markers in ADS. METHODS: A literature review was conducted in the various databases from their inception to July 2020. Studies that reviewed any genetic or serum markers of ADS whether in detection or progression were selected. Studies that reviewed congenital scoliosis or adolescent idiopathic scoliosis (AIS) were excluded. RESULTS: A total of 1447 titles were identified of which 14 were included in the final review. Two papers reported on serum markers pertaining to serum cartilage metabolites and pentosidine. Twelve studies reported on genetic markers including gene polymorphisms in estrogen receptors, parathyroid hormone receptors, interleukin 6, cyclooxygenase-2 (COX-2), COL2A1, GPRIN1, TRAIL, GRIN receptor, RIMS, LBX1 as well as copy number variations. CONCLUSIONS: Serum markers of osteoarthritis and sarcopenia have been found to be significantly elevated in ADS patients as well. Numerous polymorphisms have been found in a variety of genes playing key roles in bone formation and regulation. Further research is needed in validating previous studies as well as identifying other biomarkers for patients at risk for developing ADS.

Automated Pupillometry as a Triage and Assessment Tool in Patients with Traumatic Brain Injury.

OBJECTIVE: Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in young adults. Automated infrared pupillometry (AIP) has shown promising results in predicting neural damage in aneurysmal subarachnoid hemorrhage and ischemic stroke. We aimed to explore potential uses of AIP in triaging patients with TBI. We hypothesized that a brain injury severe enough to require an intervention would show Neurologic Pupil Index (NPI) changes. METHODS: We conducted a prospective pilot study at a level-1 trauma center between November 2019 and February 2020. AIP readings of consecutive patients seen in the emergency department with blunt TBI and abnormal imaging findings on computed tomography were recorded by the assessing neurosurgery resident. The relationship between NPI and surgical intervention was studied. RESULTS: Thirty-six patients were enrolled, 9 of whom received an intervention. NPI was dichotomized into normal (≥3) versus abnormal (<3) and was predictive of intervention (Fisher exact test; P < 0.0001). Six of the 9 patients had a Glasgow Coma Scale (GCS) score ≤8 and imaging signs of increased intracranial pressure (ICP) and underwent craniectomy (n = 4) or ICP monitor placement (n = 2) and had an abnormal NPI. Three patients underwent ICP monitor placement for GCS score ≤8 in accordance with TBI guidelines despite minimal imaging findings and had a normal NPI. The GCS score of these patients improved within 24 hours, requiring ICP monitor removal. NPI was normal in all patients who did not require intervention. CONCLUSIONS: AIP could be useful in triaging comatose patients after blunt TBI. An NPI ≥3 may be reassuring in patients with no signs of mass effect or increased ICP.

Systematic Review and Meta-Analysis of Management Strategies and Outcomes in Adult Spinal Neurocysticercosis.

OBJECTIVE: Spinal involvement in neurocysticercosis is rare and can lead to debilitating injury if not diagnosed and treated early. We aim to provide the reader with a thorough analysis of the best available evidence regarding patient characteristics, optimal treatment modality, and outcomes in cases of spinal neurocysticercosis. METHODS: A systematic review of the literature using PubMed, Google Scholar, and Web of Science electronic databases was made according to the PRISMA guidelines. An illustrative case of intramedullary-cervical spinal disease is also presented for illustrative purposes. RESULTS: A total of 46 reports of 103 patients fitting the screening criteria were identified. Isolated spinal involvement was seen in 46.15% of patients. Most infections (76.92%) had an intradural extramedullary localization, with 43.27% of cases involving >1 spinal cord level. The most common presenting symptoms were motor deficits (77.88%), pain syndromes (64.42%), and sensory deficits (53.85%). Combined surgical resection and pharmacologic therapy was the most frequently used treatment modality (49.04%) and had the highest proportion of patients reporting symptomatic improvement at follow-up (78.43%). Combination therapy had a significantly higher rate of neurologic recovery compared with surgery alone (P = 0.004) or medical treatment (P = 0.035). CONCLUSIONS: Spinal involvement in neurocysticercosis should be considered in patients from or who traveled to endemic areas presenting with ring-enhancing lesions. Combined treatment with surgery followed by cysticidal and steroid medication seems to be superior to surgery or medical treatment in isolation and seems to provide the highest chances of recovery.

Current concepts and recent advances in understanding and managing lumbar spine stenosis.

Lumbar spinal stenosis is a degenerative process that is extremely frequent in today's aging population. It can result in impingement on the nerves of the cauda equina or on the thecal sac itself, and lead to debilitating symptoms such as severe leg pain, or restriction in the perimeter of ambulation, both resulting in dependency in daily activities. The impact of the disease is global and includes financial repercussions because of its involvement in the active work force group. Risk factors for the disease include some comorbidities such as obesity or smoking, daily habits such as an active lifestyle, but also genetic factors that are not completely elucidated yet. The diagnosis of lumbar stenosis can be difficult, and involves a combination of radiological and clinical findings. Treatment ranges from conservative measures with physical therapy and core strengthening, to steroid injections in the facet joints or epidural space, to a more radical solution with surgical decompression. The evidence available in the literature regarding the causes, diagnosis and treatment of lumbar spine stenosis can be confusing, as no level I recommendations can be provided yet based on current data. The aim of this manuscript is to provide a comprehensive and updated summary to the reader addressing the multiple aspects of this disease.

Objective Pupillometry as an Adjunct to Prediction and Assessment for Oculomotor Nerve Injury and Recovery: Potential for Practical Applications.

BACKGROUND: Pupillary light reflex examinations are intrinsic to any good neurological examination. Consistent evidence has shown that automated pupillometry assessments provide superior accuracy and interrater correlation compared with bedside eye examinations. Pupillary indexes such as the neurological pupil index (NPI) can also provide several hours of warning before the advent of herniation syndromes or third nerve palsy. METHODS: We determined the unique temporal relationship between NPI changes and third nerve palsy occurrence and recovery in an initially neurologically intact hospitalized patient. A 53-year-old woman presented with aneurysmal subarachnoid hemorrhage and headaches. Her aneurysm was treated surgically without complications. After lumbar drainage for hydrocephalus, she developed isolated left third nerve palsy that slowly recovered over the following weeks. Pupilometer data were obtained throughout her hospital stay. RESULTS: A total of 121 pupillary measurement sets were obtained. The NPI had decreased to an abnormal level (<3) 12 hours before she became symptomatic. The NPI also started improving 24 hours before improvement in her clinical examination. The patient did not display signs of neurological dysfunction related to vasospasm during her stay. CONCLUSION: The NPI seems to reliably correlate with third nerve function and appears to possess predictive temporal properties that could allow practitioners to anticipate neurological injury and recovery. These findings could affect the fields of neurosciences, trauma, military medicine, critical care, and ophthalmology.

Effectiveness of cyanoacrylate microbial sealant in the reduction of surgical site infection in gynecologic oncology procedures: A phase III single institution prospective randomized trial.

OBJECTIVES: Surgery is a cornerstone for patients with gynecologic malignancies. Surgical site infections (SSI) remain a source of post-operative morbidity. Consequences range from escalated costs, delay in adjuvant therapy, and increased morbidity. Our primary objective was to evaluate the effectiveness of a cyanoacrylate microbial sealant (CMS) to reduce post-operative SSI following laparotomy for suspected gynecologic malignancy. METHODS: Patients were randomized using a 1:1 allocation to receive either standard skin preparation or standard preparation with CMS and stratified by BMI. Patients were followed for 6weeks for SSI. Demographic data was collected through the EMR. Associations between SSI, use of CMS, and clinicopathologic factors were explored using descriptive statistics, chi-square and multivariate analysis. RESULTS: 300 patients underwent randomization. Median age of the cohort was 58. Arms were matched and there was no difference in rate of medical comorbidities. Mean BMI was 38.8kg/m2 in patients randomized to BMI≥30 and 26.3kg/m2 randomized to BMI<30. Surgical characteristics for the entire cohort: 66% malignancy, 91% clean-contaminated, 21% bowel surgery, 25% transfusion. Seventy-six (25%) patients developed a SSI: 43 patients (28%) treated with CMS, compared to 33 (21%) patients treated without CMS (p=0.18). Multivariate model demonstrated that BMI≥30 (p<0.005), surgery for malignancy (p=0.010), transfusion in the OR (p<0.001), and closure with staples (p=0.0005) were associated with post-operative SSI. CONCLUSIONS: Patients presenting to a gynecologic oncologist for surgery frequently present with multiple risk factors for SSI and laparotomy is complicated by surgical-site complications in up to 30% of cases. The addition of CMS alone does not appear to reduce risk of overall SSI. Additional risk-reducing strategies including use of antimicrobial agents and optimization of modifiable risk factors prior to surgery should be explored as pathways for reducing this significant post-operative morbidity.