Contralateral recurrent laryngeal nerve palsy in revision anterior cervical discectomy and fusion (ACDF): A cautionary tale.

Revision anterior cervical spine surgery has a higher risk of recurrent laryngeal nerve palsy (RLNP). We describe a unique case of an isolated RLNP contralateral to the side of the surgical approach in a patient who underwent revision anterior cervical discectomy and fusion (ACDF) for cervical myelopathy, and in whom pre-operative laryngoscopic evaluation had excluded a pre-existing occult RLNP. Scarring around the recurrent laryngeal nerve at the previous surgical site may have rendered it less mobile, resulting in it being more susceptible to compression from an inflated endotracheal tube (ETT) cuff or traction from surgical retractors. This case illustrates that acute RLNP can rarely occur contralateral to the side of surgical approach in the setting of revision surgery. Surgeons performing revision ACDF can consider approaching from the same side as the index surgery or a posterior approach to reduce the risk of developing bilateral RLNP.

Pseudoaneurysm Resulting in Rebleeding After Evacuation of Spontaneous Intracerebral Hemorrhage.

BACKGROUND: Spontaneous intracerebral hemorrhage (ICH) is a devastating cerebrovascular disease with high morbidity and mortality. Branching pattern of the lenticulostriate arteries from the middle cerebral artery makes them susceptible to formation of microaneurysms, which have been implicated in hypertensive ICH. Recurrence of hematoma due to delayed development of pseudoaneurysm after initial surgical evacuation is uncommon. CASE DESCRIPTION: Our patient is a 61-year-old gentleman who underwent primary evacuation of a spontaneous right-sided ICH. The initial vascular imaging was unremarkable for any underlying vascular malformation. After initial neurologic recovery, the patient developed another rebleeding in the hematoma cavity nearly 10 days after presentation. A formal angiogram showed the presence of a pseudoaneurysm that was treated via endovascular means. CONCLUSIONS: The rates of rebleeding have ranged from 10%-40% in various studies and have been directly correlated with mortality. Since follow-up with angiograms are not a usual practice in spontaneous ICH management, such as pseudoaneurysmal rebleeds could go undiagnosed. This case report reinforces the need for a thorough angiographic evaluation in the event of a deviation from expected clinical course, rebleeding not in concordance with intraoperative findings and significantly delayed hematoma recurrence.

Right Parietal Skull Xanthoma Characterized as a Metastatic Deposit.

BACKGROUND: Xanthomas are benign lipomatous deposits that can be found systemically in various tissues including bones. Their presence in the skull remains a rare entity. Despite their benign characteristics, imaging modalities are often unable to distinguish them from malignant lesions. This leads to a diagnostic dilemma in patients with underlying malignancy. This case report highlights such a case where clinical history of prostate cancer and image findings were concordant with that of metastatic deposit in the parietal skull region. CASE DESCRIPTION: This 65-year-old gentleman was diagnosed with prostatic adenocarcinoma. During systemic workup for his tumor, he was found to have a right parietal skull lesion. Magnetic resonance imaging of the brain, as well as a bone scan, were consistent with that of a metastatic deposit. As treatment would be drastically affected by the diagnosis, an excision biopsy was performed. The histology was consistent with that of a bone xanthoma. CONCLUSIONS: Xanthomas are benign lesions that can be seen deposited in appendicular and axial skeleton. Skull lesions are rare with most case descriptions focusing on their presence in the frontoorbital regions and mandible and temporal bone. They usually have a benign course but may present with symptoms due to localized mass effect. Surgical intervention and histologic diagnosis may still be required in these lesions due to their lack of imaging characteristics that confirm their diagnosis through noninvasive methods.

Incidence of pedicle breach following open and minimally invasive spinal instrumentation: A postoperative CT analysis of 513 pedicle screws applied under fluoroscopic guidance.

BACKGROUND: Even though pedicle screw application is a common procedure, and in-spite of spine surgeons being proficient with the technique, mal-positioning of pedicle screws can still occur. We intend to determine by postoperative CT analysis, the incidence of pedicle screw breach in the thoracolumbar spine despite satisfactory intraoperative placement confirmed by fluoroscopy. MATERIALS AND METHODS: Consecutive patients diagnosed with thoracolumbar fractures who underwent open or minimally invasive posterior stabilization under fluoroscopic guidance were retrospectively reviewed. Postoperative CT scans of patients were analysed to determine the incidence of pedicle breach despite satisfactory intraoperative placement, and also to determine the factors that can predict a breach during intraoperative assessment. RESULTS: A total of 61 patients with 513 thoracolumbar pedicle screws were available for analysis. Based on our postoperative CT assessment, 28 screws (5.5%; 18 thoracic screws; 10 lumbar screws) had breached the pedicle. There were 14 minor (<3 mm) and 14 major (≥3 mm) breaches. The minimally invasive technique had a significantly lower breach rate compared to open surgery (1.9% vs. 7.9%). By retrospectively analysing the intra-operative fluoroscopic images, we determined certain parameters that could predict a breach during surgery. CONCLUSION: Pedicle breaches can still be present despite satisfactory placement of screws visualized intra-operatively. A medial breach is most likely when the length of the pedicle screw spans only up to 50% of the vertebral body as seen on the lateral view but the pedicle screw tip has already transgressed the midline as seen on an AP view. A lateral breach is likely when the tip of the pedicle screw is overlapped by the screw head or is only minimally visualized on an AP view.