Un-LINQed: Spontaneous extrusion of newer generation implantable loop recorders.

BACKGROUND: Insertable cardiac monitors (ICMs) are often used for long-term monitoring of cardiac rhythm. The Medtronic's LINQ Reveal ™ is a new generation wireless, automated, and patient responsive subcutaneous ECG monitoring device. Despite several advantages to its small size we have noted an unusually high incidence of extrusion at our center. METHODS: & Results: We conducted a retrospective case analysis to review Reveal LINQs implanted at our center. All devices were inserted using the provided insertion tools. Patients with extruded devices were identified and details regarding the site and technique of insertion, incision closure, use of peri-operative antibiotics, and follow-up details were collected. 81 patients underwent 85 Reveal LINQ implants at a tertiary care University Hospital referral center. The most common reason for implant was suspected arrhythmia with or without structural heart disease or unexplained syncope. There were 4 spontaneous extrusions occurring within 7-24 days after insertion with an incidence rate of 4.7%. One extruded device was anchored to subcutaneous tissue, and no pocket/device infections or hematomas were noted. CONCLUSIONS: Device migration and erosion through skin are important potential adverse events for the Reveal LINQ implantable loop recorder. This study reports an unexpectedly high rate of extrusion without infection. The authors suggest that the depth of the incision is the main factor impacting extrusions. Larger studies are recommended, however, and a proposed measure to avoid spontaneous extrusion is the design of a longer manufacturer's blade in order to increase the depth of the incision and insertion.

Occipital Bony Abnormality and Multiple Strokes in a Pediatric Patient: Case Report and Review of the Current Literature.

This study presents a case of a 15-year-old boy who had a right vertebral artery dissection with distal embolization from repeated trauma from an occipital bony spicule. The authors hypothesize that this bony spicule was contacting the left vertebral artery during head rotation, resulting in trauma to the vessel and formation of emboli which then showered distally, causing strokes in the posterior circulation of the brain. This specific phenomenon has previously been reported three times, only one of which was in pediatric literature. It is important for individuals to be aware of this rare anatomic cause of vertebral artery dissection in patients presenting with an odd constellation of symptoms related to strokes from vertebro-basilar system. Treatment options including early intervention with intravascular coil embolization are also discussed.

A biomechanical study on the effects of rib head release on thoracic spinal motion.

PURPOSE: Idiopathic scoliosis is generally treated by surgical derotation of the spine. A secondary goal of surgery is minimization of the "rib hump" deformity. Previous studies have evaluated the effects of surgical releases such as diskectomy, costo-vertebral joint release, facetectomy, and costoplasty on spine mobilization and overall contribution to thoracic stability. The present study was designed to evaluate the biomechanical effects of the rib head joints alone on axial rotation, lateral bending, and segmental rotation, without diskectomy or disruption of anterior or posterior elements. METHODS: Four female cadaver thoracic spines with intact sternums and rib cages were mounted in an Instron servo-hydraulic bi-axial MTS. In a 12-step sequence, the costo-vertebral and costo-transverse ligaments were released, first unilaterally from T10-T7, then bilaterally until complete disarticulation between the rib heads and the vertebral bodies. After each release, biomechanical testing, including axial rotation and lateral bending, was performed. Vertebral body displacement was also measured using electromagnetic trackers. RESULTS: We found that rib displacement during axial rotation was significantly increased by unilateral rib head release, and torque was decreased with each successive cut. We also found increased vertebral displacement with sequential rib head release. CONCLUSIONS: Our results show that sequential costo-vertebral joint releases result in a decrease in the force required for axial rotation and lateral bending, coupled with an increase in the displacement of vertebral bodies. These findings suggest that surgical release of the costo-transverse and costo-vertebral ligaments can facilitate segmental correction in scoliosis by decreasing the torso's natural biomechanical resistance to this correction.