Meningitis due to intra-abdominal cerebrospinal fluid fistula following gunshot wound successfully treated with antibiotics and blood patch: A case report and literature review.

Background: Penetrating spinal cord injury (PSCI) represents an average of 5.5% of all SCIs among civilians in the United States. The formation of a cerebrospinal fluid (CSF) fistula following PSCI occurs in approximately 9% of cases. Intra-abdominal CSF fistulae are rarely reported. Case Description: We present the case of a 28-year-old Caucasian female who suffered a single gunshot wound to the abdomen with a missile fragment lodged within the left L2 pedicle and transverse process without obvious canal compromise. The patient developed bacterial meningitis 13 days after the initial injury, treated with IV antibiotics. CT myelogram demonstrated intra-abdominal ventral CSF fistula from the left L2-L3 neuroforamen. The patient was successfully treated with fluoroscopy-guided dorsal autologous blood patch graft. Conclusion: This case highlights a rare complication of PSCI successfully managed with the use of a blood patch graft.

Mechanical ventilation in aneurysmal subarachnoid hemorrhage: systematic review and recommendations.

OBJECTIVE: Mechanical ventilation (MV) has a complex interplay with the pathophysiology of aneurysmal subarachnoid hemorrhage (aSAH). We aim to provide a review of the physiology of MV in patients with aSAH, give recommendations based on a systematic review of the literature, and highlight areas that still need investigation. DATA SOURCES: PubMed was queried for publications with the Medical Subject Headings (MeSH) terms "mechanical ventilation" and "aneurysmal subarachnoid hemorrhage" published between January 1, 1990, and March 1, 2020. Bibliographies of returned articles were reviewed for additional publications of interest. STUDY SELECTION: Study inclusion criteria included English language manuscripts with the study population being aSAH patients and the exposure being MV. Eligible studies included randomized controlled trials, observational trials, retrospective trials, case-control studies, case reports, or physiologic studies. Topics and articles excluded included review articles, pediatric populations, non-aneurysmal etiologies of subarachnoid hemorrhage, mycotic and traumatic subarachnoid hemorrhage, and articles regarding tracheostomies. DATA EXTRACTION: Articles were reviewed by one team member, and interpretation was verified by a second team member. DATA SYNTHESIS: Thirty-one articles met the inclusion criteria for this review. CONCLUSIONS: We make recommendations on oxygenation, hypercapnia, PEEP, APRV, ARDS, and intracranial pressure monitoring.

Descriptive Analysis of 1972 Cervical Corpectomy Patients and 30-Day Postoperative Outcomes.

BACKGROUND: There exists no large, multi-institutional analysis of patients undergoing cervical corpectomy for common degenerative spinal disease, including patient demographics and comorbidities as well as postoperative complications. METHODS: Using Current Procedural Terminology and International Classification of Diseases codes, 1972 patients who underwent a cervical corpectomy for degenerative spinal disease were identified from the American College of Surgeons National Surgical Quality Improvement Program data sets from 2012 to 2015. A descriptive analysis of the patients who underwent the procedure as well as 30-day outcomes and adverse events were collected. Multivariate logistic regression models were used to determine the effect of any preoperative factors identified from a univariate logistic regression analysis (variables with P < .10) of complications. RESULTS: The total complication rate, defined as major or minor adverse event, mortality, unplanned readmission, unplanned reoperation, or admission >30 days, was 13.28%. The percentage of patients who had ≥1 major or minor adverse events was 5.02%. Several factors commonly associated with an increased risk of perioperative complications, including smoking and diabetes, were found not to be independently associated with complications in this cohort. CONCLUSIONS: This study is the largest analysis of cervical corpectomies. The results of the multivariate analysis provide guidance on risk factors associated with perioperative complications. These data could help develop risk-appropriate strategies for minimizing the effects of certain preoperative factors on perioperative complications.

Lead Toxicity From Intradiscal Retained Bullet Fragment: Management Considerations and Recommendations.

BACKGROUND: Lead toxicity (plumbism) secondary to retained lead missiles in synovial joint spaces is a rare complication after gunshot injuries. Management of lead missiles in the intradiscal space regarding potential lead toxicity is less certain. CASE DESCRIPTION: We reviewed the literature regarding lead toxicity secondary to intradiscal bullets particularly concerning incidence, management, and outcomes. A lack of high-quality published data precludes a meta-analysis from taking place. Only four reports of lead toxicity secondary to missiles in the intradiscal space have been published. Including an additional case presented in this report, our review of the literature has led us to make several management recommendations, largely based on both the available literature and our current report. CONCLUSIONS: First, there is insufficient evidence for removing retained lead missiles solely to mitigate the risk of lead toxicity. Second, chelation therapy in addition to surgical removal of the lead source is a valuable adjunct in the perioperative period and should be undertaken with the assistance of medical toxicology. Third, a retained missile does not mandate a simultaneous stabilization procedure in lieu of other indications based on the data available at this time.

Risk factors and associated complications with unplanned intubation in patients with craniotomy for brain tumor.

Patients undergoing surgical resection of a brain tumor have the potential risk for beingintubated post-operatively, which may be associated with significant morbidity and/or mortality after surgery. This study was analyzed various preoperative patient characteristics, postoperative outcomes, and complications to identify risk factors for unplanned intubation (UI) in adult patients undergoing craniotomy for a brain tumor and created a risk score framework for that cohort. Patients undergoing surgery for a brain tumor were identified according to primary Current Procedural Terminology codes, and information found in The American College of Surgeons (ACS) National Surgical Quality Improvement Project (NSQIP) database from 2012 to 2015 was reviewed. A total of 18,642 adult brain tumor patients were included in the ACS-NSQIP. The rate of unplanned intubation in this cohort was 2.30% (4 2 8). The mortality rate of patients who underwent UI after surgical resection of brain tumor was 24.78% compared to an overall mortality of 2.46%. During the first 30 days after surgery, 33% of patients who underwent UI had an unplanned reoperation, compared to 4.76% of patients who did not undergo unplanned intubation. Bivariate and multivariate analyses identified several predictors and computed a risk score for UI. A risk score based on patient factors for those undergoing a craniotomy for a brain tumor predicts the postoperative UI rate. This could aid in surgical decision-making by identify patients at a higher risk of UI, while modifying perioperative management may help prevent UI.

Retrospective Review of Revision Surgery After Image-guided Instrumented Spinal Surgery Compared With Traditional Instrumented Spinal Surgery.

STUDY DESIGN: Retrospective cohort series. OBJECTIVE: The objective of this study was to determine if the use of image-guided navigation offers a clinically significant advantage over fluoroscopy-assisted pedicle screw and non-navigated screw placement in reducing the risk of revision surgery for malpositioned screws in instrumented spinal surgery. SUMMARY OF BACKGROUND DATA: Use image-guided navigation has become increasingly commonplace in instrumented spine surgery, but there is a lack of information regarding differences in the rates of clinically relevant screw malposition with image-guided compared with non-navigated screw placement. MATERIALS AND METHODS: This is a retrospective cohort series of consecutive patients who underwent instrumented spinal surgery by the senior authors at 2 academic tertiary care centers in New York. RESULTS: A total of 663 instrumented spinal surgeries were analyzed, including 271 instances with image-guided navigation. For the image-guided navigation cohort, 110 of the patients underwent screw placement using O-Arm image-guidance, yielding data on 1115 screws. The remaining 161 surgeries utilizing image-guided screw placement were performed using Brainlab Spine Navigation, for a total of 1001 screws. A fluoroscopy-assisted technique or freehand technique was used in 419 instances, with a total of 3689 screws. Of the non-navigated cohort, 10 patients required a surgical revision of screw placement, for a total of 15 malpositioned screws. Amongst the image-guided navigation cohort, 1 patient in the O-Arm group and 2 in the Brainlab group required revision surgery, with 3 malpositioned screws in total. The rate of revision surgery for a malpositioned screw placed via non-navigated techniques was 2.39%. This risk was decreased to 1.11% with the use of the intraoperative image-guided navigation. However, no comparisons between non-navigated and image-guided screw placement reached statistical significance. CONCLUSION: Although not reaching statistical significance, these data suggest there may be an advantage offered by image-guided screw placement in instrumented spinal surgery.

Solitary intraventricular Hodgkin lymphoma post-transplant lymphoproliferative disease (HL-PTLD): Case report.

Lymphomas affecting the central nervous system (CNS), both primarily and secondarily, are uncommon malignancies. Immunosuppressed states, including iatrogenic immunosuppression following organ transplantation, are the most significant risk factors for developing primary CNS lymphoma (PCNSL). Post-transplant lymphoproliferative disease (PTLD) is a well described complication following bone marrow or solid organ transplantation. PTLD is usually a systemic disease with occasional CNS involvement. The incidence of CNS involvement in PTLD is low, and the majority of these cases tend to be PCNSL. Hodgkin lymphoma PTLD (HL-PTLD) constitutes only a very small percentage of PTLD. We report a rare case of a primary intraventricular CNS classical HL-PTLD in a male patient, 18 years following renal transplantation. The location allowed for safe neurosurgical intervention which resolved the symptom of elevated intracranial pressure and allowed for induction of a Rituximab-based chemotherapy regimen. Both the ventricular location of the PTLD and Hodgkin Lymphoma PTLD are themselves individually quite rare and have not previously been reported together. The unique location allowed safe neurosurgical intervention which quickly resolved the symptom of elevated intracranial pressure and allowed for induction of a Rituximab-based chemotherapy regimen.

Comparative Analysis of Decompression Versus Decompression and Fusion for Surgical Management of Lumbar Spondylolisthesis.

OBJECTIVE: When lumbar stenosis involves spondylolisthesis, many surgeons include fixation. Two recent trials have shown no consensus to definitive treatment. We aimed to add to the discourse of fusion versus decompression in patients with lumbar spondylolisthesis by providing a large-scale generalizable study. METHODS: We used multicenter, prospectively collected data from the American College of Surgeons National Surgical Quality Improvement Program database to compare 30-day outcomes for decompression alone versus combination decompression and fusion in the treatment of lumbar spondylolisthesis. Logistic regression models were used to analyze the effect of surgical type on multiple characteristics. Univariate 2-tailed χ2 analyses were used to identify further outcome differences. RESULTS: In total, 9606 patients with treated lumbar spondylolisthesis were identified (907 decompression only, 8699 decompression and fusion). The fusion group tended to be younger (P < 0.001) and was more likely to be smokers (P = 0.01). Unplanned return to surgery was 3.02% in the fusion group, compared with 1.02% (P = 0.011). Minor adverse events occurred in 12.8% of the fusion group versus 4.9% (P < 0.001). Major adverse events occurred in 4.5% of the fusion group versus 3.1% (P = 0.0498). There was no significant difference in 30-day mortality, prolonged admission, or 30-day readmission. CONCLUSIONS: Unplanned return to the operating room and major and minor adverse events were greater for patients undergoing fusion. This could influence future decision-making in lumbar spondylolisthesis. This study indicates that further investigation is warranted but that decompression may be associated with less morbidity in the properly selected patient.

Risk Factors and Associated Complications of Symptomatic Venous Thromboembolism in Patients with Craniotomy for Meningioma.

OBJECTIVE: Patients undergoing surgical resection of meningioma are at increased risk for developing venous thromboembolism (VTE). The aim of this study was to assess occurrence of VTE in patients who underwent surgical resection of meningioma to determine risk factors and associated complications of VTE. METHODS: The American College of Surgeons National Surgical Quality Improvement Project database from 2012 to 2015 was reviewed for patients who had undergone meningioma resection according to primary Current Procedural Terminology codes and International Classification of Diseases, Ninth Revision. RESULTS: The study included 5036 patients with meningioma. Rate of VTE was 3.38%, with pulmonary embolism rate of 1.47% and deep venous thrombosis rate of 2.42%. During the first 30 days after surgery, patients with VTE had a mortality rate of 5.88% compared with 1.15% for patients without VTE. Multivariate binary logistic regression analysis determined 5 risk factors for VTE,: age ≥60 years, American Society of Anesthesiologists classification III, operative time ≥310 minutes, ventilator dependence, and preoperative transfusions. Univariate analysis revealed a number of complications significantly associated with VTE occurrence, including unplanned intubation, ventilator use for >48 hours, stroke, sepsis, septic shock, pneumonia, urinary tract infection, and transfusions. CONCLUSIONS: Risk factors of VTE and associated complications were identified. Understanding these risk factors provides physicians with further insight in managing this subgroup of patients in a personalized fashion in the perioperative period to minimize the incidence and morbidity of VTE.

Solid non-enhancing cerebellar pilocytic astrocytoma case report.

Pilocytic astrocytomas (PA) are slow-growing low-grade gliomas, commonly diagnosed as cerebellar tumors among the pediatric and adolescent population. Characteristic neuroradiologic findings in PA include a cystic mass with enhancing solid nodule. While uncommon radiologic features of PA, including non-enhancing cystic tumors, have been previously described, we present a unique case of a patient with a non-enhancing solid cerebellar PA. The main clinical, radiologic, and pathologic findings are discussed and the relevant literature reviewed. To our knowledge, this is the first reported patient with these radiologic features of PA, highlighting the need for awareness of uncommon presentations when discussing differential diagnosis and pre-operative planning for cerebellar tumors in the relevant age group.

Anatomical Study of Percutaneous Trigeminal Compressive Balloon Positioning on Merged 3-D Rotational X-Ray and Preprocedural Magnetic Resonance Imaging.

BACKGROUND: Percutaneous trigeminal rhizotomy or balloon compression for trigeminal neuralgia carries a potential risk for the brainstem, the carotid artery, and the basilar artery. OBJECTIVE: To detail the relation of critical neural and vascular structures to expanded balloons used for percutaneous compression of the trigeminal ganglion. METHOD: A retrospective analysis of preprocedural magnetic resonance imaging (MRI) and procedural X-ray-based imaging for 9 patients detailed balloon proximity to the brainstem, carotid artery, and basilar artery. RESULTS: Balloons extended 10.96 ± 5.54 mm (mean ± SD) posterior to the clival line. The average distance from the balloon to the brainstem was 6.89 mm, and that to the basilar artery was 12.12 mm (range: 0-18.2). The medial edge of the balloon was an average distance of 1.39 mm from the baseline position of the carotid lumen. CONCLUSION: Preprocedural MRI, merged with 3-D rotational angiography suite imaging, detailed the proximity of the balloon to critical neural and vascular structures. Our study found that the standard technique for percutaneous trigeminal compression, with balloon placement at an average depth of 10.96 mm posterior to the clival line, on average, provided an additional 6.89 mm of space before the brainstem would have been encountered, demonstrating safe positioning.

Use of image-guided bone scalpel for resection of spine tumors: technical note.

In the literature, the use of navigation for spine tumor surgery has largely centered on implant placement. We describe the cases of two patients with spinal tumors on whom we utilized our resection technique of registering an ultrasonic bone scalpel (UBS) to a navigation system. In both cases, we achieved a satisfactory tumor resection with negative margins and excellent neurologic outcomes. We feel that using the navigation-registered UBS is a valuable tool to increase the operator's ability to achieve desired resections while minimizing the neurologic deficits and operative morbidity associated with these challenging surgical cases.

Intraventricular Hemangiopericytoma: A Case Report and Literature Review.

BACKGROUND: Hemangiopericytomas are rare intracranial neoplasms that generally occur in the fifth decade of life and are commonly dural-based, supratentorial tumors. They are classified as World Health Organization grade II or III because of their aggressive nature with high rates of local recurrence and distant metastasis. This case is of an intraventricular hemangiopericytoma in a 23-year-old man. Intraventricular locations are rare, with only 10 cases reported in the literature. Our patient is the youngest to be diagnosed with an intraventricular hemangiopericytoma outside a pediatric case discovered at autopsy. CLINICAL PRESENTATION: A 23-year-old man with a left intraventricular hemangiopericytoma presenting with headache, word-finding difficulties, blurred vision, nausea, vomiting, photophobia, and right-sided weakness and numbness. Using a left superior parietal lobule approach, a piecemeal resection was completed, achieving radiographic gross total resection. Pathology was consistent with a hemangiopericytoma. He was treated adjunctively with 60 Gy of local radiation. At 6-month follow-up, the patient had resolution of his aphasia and improvement in his headaches, with no signs of recurrence or metastasis on imaging. CONCLUSIONS: Standard treatment for central nervous system hemangiopericytoma includes aggressive surgical resection. The role of adjuvant radiation is less well defined but is commonly pursued postoperatively. Regardless of extent of resection or adjuvant treatment, close follow-up to evaluate for evidence of local recurrence and distant metastasis is essential.

Fetal Myelomeningocele After Maternal Methotrexate Administration: A Case Report.

Background: Folate supplementation in women of reproductive age has a well-established role in the prevention of neural tube defects. Methotrexate is a commonly used drug which functions by inhibiting normal folate metabolism in active cells. An association between fetal methotrexate exposure and myelomeningocele might be expected, considering this relationship. However, to our knowledge, no cases of myelomeningocele secondary to in utero methotrexate exposure have been reported. Case: We present the case of a gravid patient who, having received methotrexate for management of an ectopic pregnancy, was lost to follow-up and returned several weeks later carrying an intrauterine pregnancy. The fetus was found prenatally to be suffering from multiple congenital anomalies. At birth the infant demonstrated many of the abnormalities commonly associated with fetal methotrexate syndrome, including craniosynostosis and talipes equinovarus. Most interestingly, the newborn was also diagnosed with a lumbar myelomeningocele and concomitant type II Chiari malformation, as is often associated with such a neural tube defect. Conclusion: Methotrexate exposure may impact the fetal risk of myelomeningocele. Patients should be counseled thoroughly on the importance of follow-up care.