Perspectives from the Inaugural "Spinal CSF Leak: Bridging the Gap" Conference: A Convergence of Clinical and Patient Expertise.

BACKGROUND AND PURPOSE: The inaugural "Spinal CSF Leak: Bridging the Gap" Conference was organized to address the complexities of diagnosing and treating spinal CSF leaks. This event aimed to converge the perspectives of clinicians, researchers, and patients with a patient-centered focus to explore the intricacies of spinal CSF leaks across 3 main domains: diagnosis, treatment, and aftercare. MATERIALS AND METHODS: Physician and patient speakers were invited to discuss the varied clinical presentations and diagnostic challenges of spinal CSF leaks, which often lead to misdiagnosis or delayed treatment. Patient narratives were interwoven with discussions on advanced radiologic techniques and clinical assessments. Treatment-focused sessions highlighted patient experiences with various therapeutic options, including epidural blood patches, surgical interventions, and percutaneous and endovascular therapies. The intricacies of immediate and long-term postprocedural management were explored. RESULTS: Key outcomes from the conference included the recognition of the need for increased access to specialized CSF leak care for patients and heightened awareness among health care providers, especially for atypical symptoms and presentations. Discussions underscored the variability in individual treatment responses and the necessity for personalized diagnostic and treatment algorithms. Postprocedural challenges such as managing incomplete symptom relief and rebound intracranial hypertension were also addressed, emphasizing the need for effective patient monitoring and follow-up care infrastructures. CONCLUSIONS: The conference highlighted the need for adaptable diagnostic protocols, collaborative multidisciplinary care, and enhanced patient support. These elements are vital for improving the recognition, diagnosis, and management of spinal CSF leaks, thereby optimizing patient outcomes and quality of life. The event established a foundation for future advancements in spinal CSF leak management, advocating for a patient-centered model that harmonizes procedural expertise with an in-depth understanding of patient experiences.

The Spatial Relationship between Spinal Osteoarthritis and CSF Venous Fistulas in Patients with Spontaneous Intracranial Hypotension.

BACKGROUND AND PURPOSE: CSF venous fistula leads to spontaneous intracranial hypotension. The exact mechanisms underlying the development of CSF venous fistula remain unclear: Some researchers have postulated that underlying chronic intracranial hypertension may lead to damage to spinal arachnoid granulations, given that many patients with CSF venous fistulas have an elevated body mass index (BMI). However, individuals with higher BMIs are also more prone to spinal degenerative disease, and individuals with CSF venous fistulas also tend to be older. CSF venous fistula tends to occur in the lower thoracic spine, the most frequent location of thoracic degenerative changes. The current study aimed to examine whether CSF venous fistulas are more likely to occur at spinal levels with degenerative changes. MATERIALS AND METHODS: Forty-four consecutive patients with CSF venous fistulas localized on dynamic CT myelography were included in analyses. Whole-spine CT was scrutinized for the presence of degenerative changes at each spinal level. The proportion of levels positive for CSF venous fistula containing any degenerative findings was compared to levels without CSF venous fistula using the Fisher exact test. The Pearson correlation coefficient was calculated to explore the association between the burden of degenerative disease and BMI and age and between BMI and opening pressure. RESULTS: Forty-four patients with 49 total CSF venous fistulas were analyzed (5 patients had 2 CSF venous fistulas). Mean patient age was 62.3 (SD, 9.5) years. Forty-seven CSF venous fistulas were located in the thoracic spine; 1, in the cervical spine; and 1, in the lumbar spine. Within the thoracic spine, 39/49 (79.6%) fistulas were located between levels T7-8 and T12-L1. Forty-four of 49 (89.8%) CSF venous fistulas had degenerative changes at the same level. The levels without CSF venous fistulas demonstrated degenerative changes at 694/1007 (68.9%) total levels. CSF venous fistulas were significantly more likely to be present at spinal levels with associated degenerative changes (OR = 4.03; 95% CI, 1.58-10.27; P = .001). Age demonstrated a positive correlation with the overall burden of degenerative disease (correlation coefficient: 0.573, P < .001), whereas BMI did not (correlation coefficient: 0.076, P = .625). There was a statistically significant positive correlation between BMI and opening pressure (correlation coefficient: 0.321, P = .03). CONCLUSIONS: Results suggest a potential association between spinal degenerative disease and development of CSF venous fistula.

A Single Dermatome Clinical Prediction Rule for Independent Walking 1 Year After Spinal Cord Injury.

OBJECTIVE: To derive and validate a simple, accurate CPR to predict future independent walking ability after SCI at the bedside that does not rely on motor scores and is predictive for those initially classified in the middle of the SCI severity spectrum. DESIGN: Retrospective cohort study. Binary variables were derived, indicating degrees of sensation to evaluate predictive value of pinprick and light touch variables across dermatomes. The optimal single sensory modality and dermatome was used to derive our CPR, which was validated on an independent dataset. SETTING: Analysis of SCI Model Systems dataset. PARTICIPANTS: Individuals with traumatic SCI. The data of 3679 participants (N=3679) were included with 623 participants comprising the derivation dataset and 3056 comprising the validation dataset. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Self-reported ability to walk both indoors and outdoors. RESULTS: Pinprick testing at S1 over lateral heels, within 31 days of SCI, accurately identified future independent walkers 1 year after SCI. Normal pinprick in both lateral heels provided good prognosis, any pinprick sensation in either lateral heel provided fair prognosis, and no sensation provided poor prognosis. This CPR performed satisfactorily in the middle SCI severity subgroup. CONCLUSIONS: In this large multi-site study, we derived and validated a simple, accurate CPR using only pinprick sensory testing at lateral heels that predicts future independent walking after SCI.

A causative role for remote dural puncture and resultant arachnoid bleb in new daily persistent headache: A case report.

A 24-year-old woman experienced a postdural puncture headache following a labor epidural, recovered following bedrest, and was then without headache for 12 years. She then experienced sudden onset of daily, holocephalic headache persisting for 6 years prior to presentation. Pain reduced with prolonged recumbency. MRI brain, MRI myelography, and later bilateral decubitus digital subtraction myelography showed no cerebrospinal fluid (CSF) leak or CSF venous fistula, and normal opening pressure. Review of an initial noncontrast MRI myelogram revealed a subcentimeter dural outpouching at L3-L4, suspicious for a posttraumatic arachnoid bleb. Targeted epidural fibrin patch at the bleb resulted in profound but temporary symptom relief, and the patient was offered surgical repair. Intraoperatively, an arachnoid bleb was discovered and repaired followed by remission of headache. We report that a distant dural puncture can play a causative role in the long delayed onset of new daily persistent headache.

Algorithmic Multimodality Approach to Diagnosis and Treatment of Spinal CSF Leak and Venous Fistula in Patients With Spontaneous Intracranial Hypotension.

Spontaneous intracranial hypotension (SIH) is a disorder of CSF dynamics that causes a complex clinical syndrome and severe disability. SIH is challenging to diagnose because of the variability of its presenting clinical symptoms, the potential for subtle imaging findings to be easily overlooked, and the need for specialized diagnostic testing. Once SIH is suggested by clinical history and/or supported by initial neuroim-aging, many patients may undergo initial nontargeted epidural blood patching with variable and indefinite benefit. However, data suggest that precise localization of the CSF leak or CSF-venous fistula (CVF) can lead to more effective and durable treatment strategies. Leak localization can be achieved using a variety of advanced diagnostic imaging techniques, although these may not be widely performed at nontertiary medical centers, leaving many patients with the potential for inadequate workup or treatment. This review describes imaging techniques including dynamic fluoroscopic and CT myelography as well as delayed MR myelography and treatment options including percutaneous, endovascular, and surgical approaches for SIH. These are summarized by an algorithmic framework for radiologists to approach the workup and treatment of patients with suspected SIH. The importance of a multidisciplinary approach is emphasized.

Intracranial malignant triton tumor in a patient with neurofibromatosis type 1: case report and review of the literature.

We report the fourth case of an intracranial malignant triton tumor not associated with a cranial nerve in a 26-year-old male with a clinical history of neurofibromatosis type 1. The patient was found unresponsive and displayed confusion, lethargy, hyperreflexia, and dysconjugate eye movements upon arrival at the emergency room. MRI revealed a large bifrontal mass. Biopsy demonstrated a high-grade spindle cell tumor with focal areas of rhabdomyoblasts that stained positive for desmin, myogenin, and muscle-specific actin. Electron microscopy showed skeletal muscle differentiation. Based on the clinical history of NF1 and the pathologic results, a diagnosis of malignant triton tumor was made. The differential diagnosis, immunohistochemistry, molecular genetics, and treatment of malignant triton tumor are reviewed.

Utilization of a civilian academic center as a force multiplier in support of NATO special operations medicine - a pilot demonstration.

This work describes a NATO-university telemedicine collaboration established to perform a teleneurosurgery consult to assist a deployed soldier with a spinal cord injury.

Spinal cord compression from a foreign body reaction to spinal cord stimulation: a previously unreported complication.

STUDY DESIGN: Case study. OBJECTIVE: The study presents a complication that is thought to have never before been reported with this therapeutic intervention. Results from this report are discussed with intentions to inform the neurosurgery, spine and pain management community of an additional complication associated with spinal cord stimulation (SCS). SUMMARY OF BACKGROUND DATA: SCS is a common intervention used to treat refractory neuropathic pain. Complications from this procedure are uncommon, but they do occur. METHODS: A unique complication of SCS was identified and treated. A search of the entire PubMed/Medline database failed to find any similar such complication. RESULTS: An epidural mass which caused significant cervical stenosis and spinal cord compression at the site of a previous SCS electrode was identified. Decompressive laminectomies and resection of the mass were performed. The mass was characterized as fibrous tissue with foreign body giant cell reaction. CONCLUSION: This is a unique complication of SCS about which all professionals evaluating patients who have similar implanted devices, even if they have already been removed, should be made aware of.

Clinical course and surgical management of massive cerebral infarction.

OBJECTIVE: Acute occlusion of the proximal middle cerebral artery (MCA) can lead to rapid development of fatal brain swelling and ischemic strokes. Decompressive surgery, if performed early in this subpopulation of patients, can reduce mortality and result in a favorable outcome. In this article, we describe our surgical approach for treating malignant MCA syndrome and compare it with other management strategies. METHODS: This is a retrospective review of patients who developed acute occlusion of the proximal MCA and underwent aggressive surgical decompression (large craniectomy, anterior temporal lobectomy, resection of infarcted tissue, and duraplasty). The outcome of this management strategy is compared with the previously published outcomes of hemicraniectomy and dural augmentation. RESULTS: Twelve patients were included in the study. The group consisted of six men and six women (mean age, 46.8 yr). Nine patients had right MCA stroke, and three had left MCA infarction. The causes of the strokes were cardioembolic, iatrogenic, small-vessel occlusive disease, and others. The interval between infarction and clinical evidence of herniation varied from 24 hours to 10 days. Two patients died, five were independent or had moderate disabilities, and five had severe disability. CONCLUSION: Surgical decompression consisting of a large craniectomy, anterior temporal lobectomy, resection of infarcted tissue, and duraplasty is beneficial to a significant number of patients with massive MCA stroke and clinical signs of herniation.

The effect of wearing a restrictive neck brace on driver performance.

OBJECTIVE: Thousands of Americans are prescribed cervical orthoses each year. These orthoses restrict motion, which may influence the patient's driving performance. No legal restrictions exist that prohibit patients from wearing cervical orthoses while driving. No study addressing this issue has been published to date. Thus, we sought to assess the effects of wearing a restrictive neck brace on driver performance on the open road. METHODS: We conducted a prospective, randomized block design study in 23 volunteers. Twenty-three adult licensed drivers from the state of Iowa were recruited. Evaluation of neck motion was performed with and without the rigid cervical orthosis. On-road performance testing was conducted with the use of a state-of-the-art mobile laboratory. Drivers were randomly assigned to one of two testing groups. Each driver was evaluated during two separate drives. Volunteers in Group A (n = 11) wore a neck brace for the first drive but not during the second. Participants in Group B (n = 12) did not wear a neck brace in the first drive but did for the second. The assessment included velocity, acceleration, cervical axial rotation, and evaluation of the driver's blind spot. RESULTS: Driving performance measures were collected and analyzed for both drives. Wearing a cervical orthosis resulted in decreased velocity (P < 0.05), decreased lateral acceleration (P < 0.05), decreased axial rotation (P < 0.05), inadequate evaluation of intersection traffic, and an increase in the blind spot. CONCLUSION: A rigid cervical orthosis alters driver performance.

Common chemical agent threats.

The events of September 11, 2001, highlight the fact that we live in precarious times. National and global awareness of the resolve and capabilities of terrorists has increased. The possibility that the civilian neurosurgeon may confront a scenario involving the use of chemical warfare agents has heightened. The information reported in this paper serves as a primer on the recognition, decontamination, and treatment of trauma patients exposed to chemical warfare agents.