An intriguing tale of pneumomediastinum and subcutaneous emphysema in staphylococcal pneumonia: a rare case and literature review of subcutaneous drain insertion.

Debilitating subcutaneous emphysema, which can result in upper airway compromise, requires urgent intervention to avoid respiratory arrest. It can be treated using subcutaneous chest drain insertion to provide immediate relief of air pressure. https://bit.ly/3I2oV1k.

Can sub-cutaneous drain safely counter debilitating surgical emphysema? A retrospective study in quest for an answer.

Literature evidence on sub-cutaneous drain insertion in severe surgical emphysema (SE) is lacking. We retrospectively reviewed the clinical notes of 5 patients who underwent insertion of sub-cutaneous drains to manage SE of various aetiologies between September 2022 to August 2023 in a single district general hospital in the UK. Case history, outcome following sub-cutaneous drain insertion, and side effects due to the procedure were collected. Clinical decompression were noticed within an hour of drain insertion in all patients. Radiological resolution ranged between 2 and 10 days with a median 3 days and mean of 4.8 days. Patients with uni-lateral sub-cutaneous drain required more time for radiological improvement than patients on bi-lateral drains (median 6.5 vs. 2, mean 6.5 vs. 3.6). Maximum duration for resolution was 10 days for patients receiving uni-lateral sub-cutaneous drain versus 7 days in patients having bi-lateral drains. Only one patient had no prior lung disease making it difficult to comment if having healthy lungs affects outcomes. Sub-cutaneous drain insertion is a safe procedure which can accelerate recovery in severe SE.

Multimodal Intraoperative Neurophysiological Monitoring in Cranial and Spinal Tumour Surgeries: A Descriptive Observational Study.

Intraoperative neurophysiological monitoring (IONM) involves monitoring the functional integrity of critical brain regions and pathways as well as identifying and preserving functionally viable neural tissues (mapping) during surgery using electrophysiological techniques. Multimodality combines various neurophysiological techniques to optimise diagnostic effectiveness and to improve the outcomes of the surgeries. The present study is a case series with comprehensive and illustrative descriptions of the neurophysiological changes in five neuromonitored cases of cranial and spinal cord tumour surgeries conducted with a multimodal approach. The cases were monitored with somatosensory evoked potentials (SSEP), transcranial motor evoked potentials (TcMEP), and both free run and triggered electromyography (fEMG and tEMG). No false negative outcomes were identified in the cases studied as there was an association of absence of change in SSEP and TcMEP both, with no neurological deficit postoperatively. Two cases were identified as having true positive neuromonitoring alerts. No false positive alerts were found in any case. Multimodal monitoring using SSEP, TcMEP, and EMG (fEMG and tEMG) in cranial and spinal tumour surgeries can improve performance with fewer false-negative and false-positive results. Neuromonitoring approaches used in combination can provide reliable information regarding postoperative neurological outcomes.

Pneumothorax Ex-vacuo or Trapped Lungs Appearing as Iatrogenic Hydropneumothorax: A Case Report and Review of Non-expandable Lungs (NEL).

Non-expandable lungs are usually diagnosed after a pleural intervention. It can be challenging to differentiate between an iatrogenic pneumothorax and a new diagnosis of non-expandable lungs following a pleural intervention. The correct assessment can save the patient from undergoing the insertion of an unnecessary intercostal chest drain, which often leads to catastrophe. Suspicion and early evaluation remain the keys, particularly in patients with chronic effusion. Often the diagnosis is reached through a combination of history, pleural fluid analysis, and radiological features such as the absence of a straight line in the chest X-ray, which is commonly found in a true hydropneumothorax, along with computed tomographic evidence of chronic effusion with thick pleural rind. Although not routinely performed, pleural manometry can confirm the diagnosis of trapped lungs. We present our case, where a 64-year-old woman with metastatic oesophageal cancer developed a right-sided effusion. The post-procedure chest X-ray following therapeutic aspiration of the pleural fluid gave an impression of iatrogenic hydropneumothorax, which on further careful assessment revealed a rather pneumothorax ex-vacuo along with effusion due to underlying trapped lungs. We present a review of non-expandable lungs.

A Quest to Find the Aetiology of Pulmonary Embolism Beyond the Common: A Case of Dyshypofibrinogenemia Presenting as Pulmonary Embolism.

Hypodysfibrinogenemia-related thromboembolic disorder is a rarely encountered clinical entity. We present such a case of a 34-year-old lady with no known co-morbidities presenting to the accident and emergency unit with left-sided pleuritic chest pain associated with non-productive cough and breathlessness. Laboratory tests revealed fibrinogen level of 0.42 g/l (1.5-4g/l) with prolonged prothrombin time (PT), activated partial thromboplastin time (aPTT) along with elevated d-dimer, N-terminal pro-B-type natriuretic peptide (NT-proBNP), and troponin. CT pulmonary angiogram (CTPA) found bilateral pulmonary embolism with right heart strain. Functional/antigenic fibrinogen ratio was 0.38. Genetic testing eventually revealed a heterozygous missense mutation in exon 8-p.1055G>C; p.Cys352Ser in the sequencing of the fibrinogen gene FGG (gamma chain) confirming the diagnosis of dyshypofibrinogenemia. She was treated with anticoagulants with fibrinogen replacement therapy and later discharged on apixaban.

Bilateral pleural effusion and pneumomediastinum: rare complication resulting from punctured left subclavian vein following insertion of PICC line for total parenteral nutrition.

This is a rare case of development of bi-lateral chylous pleural effusion (containing parenteral nutrition material) along with pneumomediastinum due to punctured left subclavian vein following insertion of a peripherally inserted central venous catheter (PICC) line. Parenteral nutrition is usually preferred for patients unable to tolerate enteral feeding. Due to hypertonicity of the total parenteral nutrition material, it is usually administered via internal jugular or subclavian vein which have a rapid blood flow; therefore, resulting in adequate mixing. Literature studies are yet to clearly explain the communications between two pleural cavities; therefore, development of bilateral pleural effusions in association with pneumomediastinum makes this case more intriguing. We present the journey of a 43-year-old woman who required insertion of bilateral chest drains, followed by sternotomy and repair of the left subclavian vein after she was found in hypoxic respiratory failure 2 days following insertion of PICC line into her left subclavian vein.

A tale of two extremities: A dynamic case of Covid-19 induced hypokalemia and bradycardia leading into Torsade's de pointes.

INTRODUCTION: As researchers and academics around the world scramble ahead to dissect and analyse every aspect of the SARS-CoV2 virus, one such study explored the various underlying electrolyte abnormalities that were precipitated in patients suffering from a confirmed COVID-19 infection. A significant proportion of such patients were noted to be hypokalemic. Hypokalemia can be life threatening as it is known to cause cardiac arrhythmia. CASE PRESENTATION: Our encounter with said presentation was incidental. The on-call medical team was involved in a cardiac arrest call for a 74-year -old gentleman who developed torsades de pointes, Retrospective analysis of the clinical picture pointed out the fact that he was found to be persistently hypokalemic and bradycardic solely triggered as a result of COVID-19. CONCLUSION: Although initially thought to be a pulmonary disease but along with time extra-pulmonary manifestations of Covid-19 has demonstrated significant consequences. Electrolyte abnormalities and cardiac dysfunction are examples of such extra-pulmonary pathologies. Therefore, it is important to keep close monitoring for such abnormalities otherwise could lead into life threatening arrythmias.

A unique tale of COVID-19 induced concomitant overt disseminated intravascular coagulation and acute bilateral pulmonary embolism.

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV-2), a novel coronavirus, originated as an epidemic respiratory illness in Wuhan, China. COVID-19 eventually spread to almost all countries and has now been declared a global pandemic disease by the World Health Organisation. A plethora of research has explored the dynamics of different clinical entities related to SARS-COV-2, in particular, COVID-19 associated coagulopathy. A large scale of patients have been reported to have developed pulmonary embolism without any other standard triggers or risk factors, leading to speculation that COVID-19 is an independent risk factor for venous thromboembolism. In addition to the development of thromboembolic complications such as pulmonary embolism, COVID-19 has also been reported to have triggered disseminated intravascular coagulation (DIC); however, it is unclear whether pulmonary embolism was due to COVID-19-induced thrombosis or a result of coagulopathy secondary to DIC. We describe a unique case of a COVID-19 associated coagulopathy in a patient with confirmed pulmonary embolism along with an overt DIC. Following diagnosis, the challenge was to identify the appropriate treatment modality for this unique situation. The patient was treated with anticoagulants and steroids along with blood products. The patient's condition markedly improved and was clinically stable on discharge.

Bilateral Ossified Chronic Subdural Hematoma Presenting as Diabetes Insipidus-Case Report and Literature Review.

Calcified chronic subdural hematomas are an occurrence rarely seen in neurosurgical clinical practice. And when they occur bilaterally, the radiologic image they present is fascinating, as is the clinical presentation, but their management may be challenging. They have been reported to present with a multitude of neurologic deficits but never with diabetes insipidus, which is described here. Due to the rarity of this pathology, the management protocol is not well defined, though there have been quite a few papers on this condition. This review article gathers information published over the years on this rare entity to suggest a treatment protocol.

Growing skull fractures: guidelines for early diagnosis and surgical management.

BACKGROUND: Growing skull fracture (GSF) is a rare complication of pediatric head trauma and causes delayed onset neurological deficits and cranial defect. GSF usually develops following linear fracture with underlying dural tear resulting in herniation of the brain. Early diagnosis and treatment are essential to avoid complications. However, there are no clear-cut guidelines for the early diagnosis of GSF. The present study was conducted to identify the criteria for the early diagnosis of GSF. MATERIAL AND METHODS: From 2010 to 2015, all pediatric patients of head trauma with linear fracture were evaluated. Patients of age <5 years with cephalhematoma, bone diastasis of 4 mm or more with underlying brain contusion were subjected to contrast brain MRI to find out the dural tear and herniation of the brain matter. Patients with contrast MRI showing dural tear and herniation of the brain matter were considered high risk for the development of GSF and treated surgically within 1 month of trauma. Patients with contrast brain MRI not showing dural tear and herniation of the brain matter were regularly followed for any signs of GSF. RESULTS: A total of 20 patients were evaluated, out of which 16 showed dural defects with herniation of the brain matter and were subjected to duraplasty. Four patients in which MRI did not show dural tear and herniation of the brain matter were regularly followed-up and have not shown any sign of GSF later on follow-up. CONCLUSION: Early diagnosis of GSF can be made based on the four criteria, i.e., (1) age <5 year with cephalhematoma, (2) bone diastasis 4 mm or more (3) underlying brain contusion (4) contrast MRI showing dural tear and herniation of the brain matter. Dural tear with herniation of the brain matter is the main etiopathogenic factor for the development of GSF. Early diagnosis and treatment of GSF can yield a good outcome.

Early versus delayed decompression in acute subaxial cervical spinal cord injury: A prospective outcome study at a Level I trauma center from India.

AIMS: This study was done with the aim to compare the clinical outcome and patients' quality of life between early versus delayed surgically treated patients of acute subaxial cervical spinal cord injury. The current study was based on the hypothesis that early surgical decompression and fixations in acute subaxial cervical spinal cord trauma is safe and is associated with improved outcome as compared to delayed surgical decompression. MATERIALS AND METHODS: A total of 69 patients were recruited and divided into early decompression surgery Group A (operated within 48 h of trauma; n = 23) and late/delayed decompression surgery Group B (operated between 48 h and 7 days of trauma; n = 46). The patients in both groups were followed up, and comparative differences noted in the neurological outcome, quality of life, and bony fusion. RESULTS: The early surgery group spent lesser days in the intensive care unit and hospital (Group A 28.6 vs. Group B 35 days) had lesser postoperative complications (Group A 43% vs. Group B 61%) and a reduced mortality (Group A 30% vs. Group B 45%). In Group A, 38% patients had 1 American Spinal Injury Association (ASIA) grade improvement while 31% experienced >2 ASIA grade improvement. In Group B, the neurological improvement was 27% and 32%, respectively (P = 0.7). There was a significant improvement in the postoperative quality of life scores in both groups. CONCLUSION: Early surgery in patients with acute subaxial cervical spine injury should be considered strongly in view of the lesser complications, early discharge, and reduced mortality.

Comparison of polyetheretherketone cages with femoral cortical bone allograft as a single-piece interbody spacer in transforaminal lumbar interbody fusion.

OBJECT: Transforaminal lumbar interbody fusion (TLIF) is an accepted alternative to circumferential fusion of the lumbar spine in the treatment of degenerative disc disease, spondylolisthesis, and recurrent disc herniation. To maintain disc height while arthrodesis takes place, the technique requires the use of an interbody spacer. Although titanium cages are used in this capacity, the two most common spacers are polyetheretherketone (PEEK) cages and femoral cortical allografts (FCAs). The authors compared the clinical and radiographic outcomes of patients who underwent TLIF with pedicle screw fixation, in whom either a PEEK cage or an FCA was placed as an interbody spacer. METHODS: The charts and x-ray films obtained in 39 patients (age range 33-68 years, mean 44.7 years) who underwent single-level TLIF between October 2001 and April 2004 and in whom either a PEEK cage (18 patients) or FCA (21 patients) was placed as an interbody spacer were evaluated in a retrospective study. Radiological outcome was based on fusion rate and a comparison of the initial postoperative lordotic angle on standing lateral radiographs with that at long-term follow up (mean follow up 15.1 months, minimum 12 months). To control for variations in radiographic magnification, the authors used lordotic angle as an indirect measure of disc space height. Clinical outcome was assessed using the Oswestry Disability Index (ODI). There were no major complications in either group. Radiographically documented fusion occurred in all patients in the PEEK group and 95.2% of those in the FCA group. Pseudarthrosis developed in one patient in the FCA group, and this patient underwent additional surgery. In both groups, the mean lordotic angle changed by less than 2.20 degrees during the postoperative period, and the mean postoperative ODI score was more than 40 points lower than the mean preoperative score. There was no significant difference between the two groups in mean change in lordotic angle (p = 0.415) and mean change in ODI score (p = 0.491). CONCLUSIONS: Both PEEK cages and FCAs are highly effective in promoting interbody fusion, maintaining postoperative disc space height, and achieving desirable clinical outcomes in patients who undergo TLIF with pedicle screw fixation. The advantages of PEEK cages include a lower incidence of subsidence and their radiolucency, which permits easier visualization of bone growth.