An early case of successful peripheral nerve repair in 1880: Francis L. Parker, MD.

The modern technique of epineural suture repair, along with a detailed reporting of functional restoration, came from Carl Hueter in 1873. While there is extensive information on peripheral nerve surgery throughout recorded history leading up to the 1800s, little early American scientific literature is available. While Schwann, Nissl, and Waller were publishing their work on nerve anatomy and physiology, Francis LeJau Parker was born. The South Carolina native would go on to describe one of the first American cases of peripheral nerve repair with the restoration of function. Francis Parker was born in 1836 in Abbeville, South Carolina. He gained local notoriety as one of the first American surgeons to suture a severed nerve, resulting in restored function. The case dates back to 1880, when a patient presented to his clinic with severing of the posterior interosseous nerve. The details of this case come from the archives of the South Carolina Medical Association. The authors reviewed these records in detail and provide a case description of nerve repair not previously reported in the modern literature. The history, neurological examination, and details of the case provide insight into the adroit surgical skills of Dr. Parker.

Infantile traumatic pericallosal aneurysm: illustrative case.

BACKGROUND: Traumatic aneurysms are a rare sequela of nonaccidental head trauma in infants. The rate of nonaccidental trauma (NAT) in the pediatric population is increasing; therefore, traumatic aneurysms are an important consideration in the evaluation of pediatric patients with abusive head trauma. OBSERVATIONS: A 24-day-old infant with no significant past medical or birth history presented with twitching and poor oral intake for 1 day. The patient was found to have bilateral subdural hematomas, multifocal contusions, and traumatic subarachnoid hemorrhage. NAT work-up was remarkable for a period of repeated and prolonged abuse. Magnetic resonance angiography revealed a right pericallosal traumatic aneurysm that was treated by means of coil and Onyx embolization. LESSONS: Traumatic intracranial aneurysms are a rare but serious sequela of pediatric abusive trauma. Traumatic intracranial aneurysms should be considered in the setting of intracranial pathology associated with high-energy trauma. Despite new methods for the management of traumatic aneurysms, this pathology remains challenging to identify and treat, and the prognosis remains poor because of the diffuse injury often involved in these patients.

A Case of Extremely Rapid Progression in Foix-Alajouanine Syndrome.

Foix-Alajouanine syndrome is a rare cause of spinal dural arteriovenous fistula that can cause irreversible myelopathy and paraplegia if not treated promptly. The complex nature of this pathology often leads to missed or delayed diagnosis regardless of broad workups executed. We present a symptomatically classic Foix-Alajouanine 68-year-old patient with an accelerated progression reaching stages of severe myelopathy in less than a year. Even with endovascular intervention, our patient was unable to recover neurologically. Including appropriate spinal imaging early in the workup for Foix-Alajouanine syndrome is necessary to halt or treat this disease process.

Exoscope Efficacy and Feasibility in Pediatric Spinal Neurosurgery: A Single-Institution Cohort Case Series.

BACKGROUND: The exoscope has emerged as an efficacious microscope in adult spinal neurosurgery providing improved operative field visibility and surgeon ergonomics. However, outcome data and feasibility are underrepresented in the pediatric literature. We present the largest case series aimed at assessing operative and clinical outcomes in pediatric patients undergoing various exoscope-assisted spinal surgeries. METHODS: A retrospective review was conducted on all consecutive pediatric (age <18 years) spinal surgeries performed with the use of an exoscope by 3 senior surgeons at a single institution from 2020-2023. Demographics and clinical and operative outcomes were reviewed and analyzed. RESULTS: Ninety-six exoscope-assisted pediatric spine surgeries were performed on 89 unique patients, 41 (42.7%) of which were male. The mean age at surgery was 12 (±5.3) years. Spinal cord detethering (55.8%) was the most common procedure performed. The overall mean operative time for all procedures was 155 (±86) minutes, and the mean estimated blood loss was 18 (±41) mL. The mean length of stay was 5.4 (±6.5) days. There were 14 (14.6%) patients with complications in this cohort. At final follow-up, 64 (83.1%) of symptomatic patients reported neurologic symptom improvement. CONCLUSIONS: Using the exoscope in a variety of pediatric spinal surgeries resulted in an acceptable average operative time, estimated blood loss, length of stay, and rate of neurologic symptom improvement. The exoscope appears to be an efficacious option for pediatric neurosurgical spinal procedures.

A case of primary central nervous system lymphoma presenting as a shunt complication.

The authors describe an 82-year-old female with a right frontal ventriculoperitoneal (VP) shunt for long-standing normal pressure hydrocephalus (NPH) who presented with worsening incontinence and gait instability. She was found to have right lateral ventricle collapse around the shunt catheter and subsequently underwent shunt revision, which failed to improve her symptoms. Magnetic resonance imaging (MRI) was obtained on postoperative day two, which demonstrated a ventricular lesion. Endoscopic brain biopsy was performed and a diagnosis of primary central nervous system lymphoma (PCNSL) was made. The authors believe this is the first published case of PCNSL presenting as a VP shunt complication in a patient with NPH.

Chronic subdural hematoma recurrence due to contralateral neovascularization following middle meningeal artery embolization.

INTRODUCTION: Chronic subdural hematoma (CSDH) is one of the most commonly encountered neurosurgical diseases. Middle meningeal artery embolization (MMAE) is a technique for the management of CSDH that has elicited promising results. Despite the encouraging results of MMAE, recurrence does occur. One uncommon mechanism for recurrence of CSDH is by means of neovascularization of the contralateral middle meningeal artery (MMA). We describe two cases of CSDH recurrence by means of contralateral middle meningeal artery neovascularization treated with contralateral MMAE. METHODS: We identified two cases of recurrent subdural hematoma secondary to neovascularization following treatment with contralateral MMAE. RESULTS: Two patients initially treated with MMAE were identified with CSDH recurrence secondary to contralateral MMA neovascularization. There was no traumatic or coagulopathic contribution to CSDH recurrence. In both cases, patients underwent contralateral MMAE. Both patients were neurologically intact with radiographic improvement of CSDH at follow up. CONCLUSIONS: Re-accumulation of SDH following MMAE by means of contralateral MMA neovascularization is a rare subtype of subdural hematoma (SDH) recurrence following MMAE. Within the context of re-accumulation of SDH following MMAE, catheter angiography is an important diagnostic investigation to elucidate the etiology of the recurrence. Furthermore, when angiography reveals neovascularization of the contralateral MMA, embolization of the contralateral MMA achieves good clinical and radiographic result.

Endoscopic decompression of epidural spinal metastasis causing lumbar radiculopathy through a transforaminal approach: report of two cases.

Radiculopathy in patients with metastatic spine disease (MSD) may be palliated with open or microsurgical techniques. However, delay of chemoradiation, infection risk, extended hospitalization periods, and surgical site pain may complicate surgical efforts to improve these patients' lives. Endoscopic approaches, heretofore used almost exclusively in degenerative spine disease, may also palliate debilitating pain while mitigating the drawbacks of surgical intervention in providing focal tumor debulking. Specimen for histopathologic diagnosis, which is of increasing importance in oncology treatments, may also be obtained by the endoscopic approach. The first case is of a 61-year-old woman with right thigh pain and weakness referable to a foraminal component of metastatic disease who underwent transforaminal endoscopic decompression through a single port with resolution of her primary pain complaint. The second case is of a 50-year-old man with history of urothelial cancer who presented with L5 radicular pain referable to foraminal tumor compression who underwent similar procedure with stabilization of his primary pain complaints. Adequate tissue biopsy was obtained in both cases. Endoscopic technique may allow direct visualization with minimal morbidity for effective decompression of symptomatic metastatic disease resulting from compression of the exiting and traversing nerve roots. Patients compromised from systemic disease may benefit from this less invasive approach that requires neither endotracheal intubation nor extended hospital stay.

Economic benefit of neurosurgical intervention for infant hydrocephalus in Haiti.

OBJECTIVE: Previous models have been utilized in other low- and middle-income countries (LMICs) to explore and assess the cost, sustainability, and effectiveness of infant hydrocephalus treatment. However, similar models have not been implemented in Haiti due to a paucity of data, epidemiology, and outcomes for hydrocephalus. Therefore, the authors utilized previously described economic modeling to estimate the annual cost and benefit of treating hydrocephalus in infants at a neurosurgery referral center, Hospital Bernard Mevs (HBM), in Port-au-Prince, Haiti. METHODS: The authors conducted a retrospective review of data obtained in all children treated for hydrocephalus at the HBM from 2008 to 2015. The raw data were pooled with previously described surgical outcomes for hydrocephalus in other LMICs. Modeling was performed to determine outcomes, neurosurgical costs, disability-adjusted life years (DALYs), and economic benefits of Haitian hydrocephalus treatment during this time frame. Standard account methodology was employed to calculate cost per procedure. Using these formulas, the net economic benefit and cost/DALY were determined for hydrocephalus treatment at HBM from 2008 to 2015. RESULTS: Of the 401 patients treated during the study period, 158 (39.4%) met criteria for postinfectious hydrocephalus, 54 (13.5%) had congenital hydrocephalus, 38 (9.5%) had myelomeningocele, 19 (4.7%) had aqueductal stenosis, and 132 (33%) were not placed into a category. Overall, 317 individuals underwent surgical treatment of their hydrocephalus, averting 3077 DALYs. The total cost of the procedures was $754,000, and the cost per DALY ranged between $86 and $245. The resulting net economic benefit for neurosurgical intervention ranged from $2.5 to $5.5 million. CONCLUSIONS: This work demonstrates the substantial economic benefit of neurosurgical intervention for the treatment of pediatric hydrocephalus at a single hospital in Haiti. Based on DALYs averted, the need for additional centers offering basic neurosurgical services is apparent. A single center offering these services for several days each month was able to generate between $2.5 to $5.5 million in economic benefits, suggesting the need to develop neurosurgical capacity building in Haiti. Ultimately, prevention, screening, and early surgical treatment of these infants represent a public health and socioeconomic requisite for Haiti.

The shipboard Beirut terrorist bombing experience: a historical account and recommendations for preparedness in events of mass neurological injuries.

On a Sunday morning at 06:22 on October 23, 1983, in Beirut, Lebanon, a semitrailer filled with TNT sped through the guarded barrier into the ground floor of the Civilian Aviation Authority and exploded, killing and wounding US Marines from the 1st Battalion 8th Regiment (2nd Division), as well as the battalion surgeon and deployed corpsmen. The truck bomb explosion, estimated to be the equivalent of 21,000 lbs of TNT, and regarded as the largest nonnuclear explosion since World War II, caused what was then the most lethal single-day death toll for the US Marine Corps since the Battle of Iwo Jima in World War II. Considerable neurological injury resulted from the bombing. Of the 112 survivors, 37 had head injuries, 2 had spinal cord injuries, and 9 had peripheral nerve injuries. Concussion, scalp laceration, and skull fracture were the most common cranial injuries.Within minutes of the explosion, the Commander Task Force 61/62 Mass Casualty Plan was implemented by personnel aboard the USS Iwo Jima. The wounded were triaged according to standard protocol at the time. Senator Humphreys, chairman of the Preparedness Committee and a corpsman in the Korean War, commented that he had never seen such a well-executed evolution. This was the result of meticulous preparation that included training not only of the medical personnel but also of volunteers from the ship's company, frequent drilling with other shipboard units, coordination of resources throughout the ship, the presence of a meticulous senior enlisted man who carefully registered each of the wounded, the presence of trained security forces, and a drilled and functioning communication system.Viewed through the lens of a neurosurgeon, the 1983 bombings and mass casualty event impart important lessons in preparedness. Medical personnel should be trained specifically to handle the kinds of injuries anticipated and should rehearse the mass casualty event on a regular basis using mock-up patients. Neurosurgery staff should participate in training and planning for events alongside other clinicians. Training of nurses, corpsmen, and also nonmedical personnel is essential. In a large-scale evolution, nonmedical personnel may monitor vital signs, work as scribes or stretcher bearers, and run messages. It is incumbent upon medical providers and neurosurgeons in particular to be aware of the potential for mass casualty events and to make necessary preparations.

Preoperative Hypoglycemia and Hyperglycemia Are Related to Postoperative Infection Rates in Implant-Based Breast Reconstruction.

OBJECTIVES: Diabetic patients undergoing surgery are known to have a higher risk for infection. However, current literature does not adequately investigate the effects of preoperative hypoglycemia or hyperglycemia on postoperative infection risk. METHODS: A retrospective review of a national private payer database within the PearlDiver Supercomputer application (Warsaw, IN) for patients undergoing breast reconstruction with implant/expander (BR) was conducted. These patients were identified by Current Procedural Terminology (CPT) and International Classification of Disease (ICD-9) ninth revision codes. Glucose ranges were identified by filtering for Logical Observation Identifiers Names and Codes ranging from 25 to 219 mg/dL, in 15 mg/mL increments. Patients with preexisting diabetes diagnoses were excluded. These patients were longitudinally tracked for infection at the 90 d and 1-y postoperative period using ICD-9 codes. RESULTS: The search query yielded 13,237 BR procedures with preoperative glycemic levels ranging from 25 to 219 mg/mL. Most procedures (34.6%) were performed on patients with preoperative glycemic levels ranging from 70 to 99 mg/dL. Of the total procedures performed (n = 13,237), 19.4% (n = 2564) resulted in infections documented at the 90-d interval, and 24.8% (n = 3285) resulted in infections documented at the 1-y interval. BR patients within the 40-54 mg/dL range had the highest rate of infection (90 d: 30.1%; 1 y: 53.4%). There was a statistically higher incidence of infection among patients with preoperative hypoglycemia (<70 mg/dL). CONCLUSIONS: The incidence of infection remains high in preoperatively hyperglycemic patients undergoing breast reconstruction procedures. However, our results show that preoperatively hypoglycemic patients also have an increased incidence of infection.

Economic benefit of carpal tunnel release in the Medicare patient population.

OBJECTIVE The epidemiology of carpal tunnel syndrome (CTS) has been extensively researched. However, data describing the economic burden of CTS is limited. The purpose of this study was to quantify the disease burden of CTS and determine the economic benefit of its surgical management. METHODS The authors utilized the PearlDiver database to identify the number of individuals with CTS in the Medicare patient population, and then utilized CPT codes to identify which individuals underwent surgical management. These data were used to calculate the total number of disability-adjusted life years (DALYs) associated with CTS. A human capital approach was employed and gross national income per capita was used to calculate the economic burden. RESULTS From 2005 to 2012 there were 1,500,603 individuals identified in the Medicare patient population with the diagnosis of CTS. Without conservative or surgical management, this results in 804,113 DALYs without age weighting and discounting, and 450,235 DALYs with age weighting and a discount rate of 3%. This amounts to between $21.8 and $39 billion in total economic burden, or $2.7-$4.8 billion per year. Surgical management of CTS has resulted in the aversion of 173,000-309,000 DALYs. This has yielded between $780 million and $1.6 billion in economic benefit per year. Endoscopic carpal tunnel release provided between $11,683 and $23,186 per patient at 100% success while open carpal tunnel release provided between $10,711 and $22,132 per patient at 100% success. The benefit-cost ratio at its most conservative is 2.7:1, yet could be as high as 6.9:1. CONCLUSIONS CTS is prevalent in the Medicare patient population, and is associated with a large amount of economic burden. The surgical management of CTS leads to a large reduction in this burden, yielding extraordinary economic benefit.

Endoscopic versus Open In Situ Cubital Tunnel Release: A Systematic Review of the Literature and Meta-Analysis of 655 Patients.

BACKGROUND: Cubital tunnel syndrome is the second most common peripheral entrapment syndrome. To date, there is no true consensus on the ideal surgical management. A minimally invasive, endoscopic approach has gained popularity but has not been adequately compared to the more traditional, open approach. METHODS: With compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic review was performed to identify studies published between 1990 and 2016 that compared the efficacy of endoscopic cubital tunnel release to open cubital tunnel release. A meta-analysis was then performed through a random-effects model with inverse variance weighting to calculate I values for heterogeneity analysis. Forest plots were constructed for each analysis group. RESULTS: Five studies involving 655 patients (endoscopic cubital tunnel release, n = 226; open cubital tunnel release, n = 429) were included. Meta-analysis revealed no significant superiority of open release in achieving an "excellent" or "good" Bishop score (OR, 1.27; 95 percent CI, 0.59 to 2.75; p = 0.54) and reduction in visual analogue scale score (mean difference, -0.41; 95 percent CI, -1.49 to 0.67; p = 0.46). However, in the endoscopic release cohort, lower rates of new-onset scar tenderness/elbow pain were found (OR, 0.19; 95 percent CI, 0.07 to 0.53; p = 0.002), but there was a higher incidence of postoperative hematomas (OR, 5.70; 95 percent CI, 1.20 to 27.03; p = 0.03). The reoperation rate in the endoscopic and open release groups was 4.9 and 4.1 percent, respectively (p = 0.90). CONCLUSIONS: The authors demonstrated equivalent overall clinical improvement between endoscopic and open cubital tunnel release in terms of Bishop score and visual analogue scale score reduction. Because of the low power of most studies, further investigations with a larger patient population and longer follow-up are needed to better characterize the role of endoscopic cubital tunnel release.

Trends in Open and Endoscopic Cubital Tunnel Release in the Medicare Patient Population.

BACKGROUND: Cubital tunnel syndrome (CUT) is the second most common peripheral neuropathy with an annual incidence of 24.7 per 100 000, affecting nearly twice as many men as women. With increasing focus on cost-effectiveness and cost-containment in medicine, a critical understanding of utilization of health care resources for open and endoscopic approaches for cubital tunnel release is of value. The purpose of this study was to evaluate the costs and utilization trends of open and endoscopic cubital tunnel release. METHODS: We performed a retrospective review of a Medicare database within the PearlDiver Supercomputer (Warsaw, Indiana) for procedures performed from 2005 to 2012. Annual utilization, charges, reimbursement, demographic data, and compound annual growth rate were evaluated. RESULTS: Our query returned 262 104 patients with CUT, of which 69 378 (26.5%) and 4636 (1.8%) were surgically managed with open and endoscopic release respectively. Average charges were higher in endoscopic release ($3798) than open release ($3197) while reimbursements were higher in open releases ($1041) than endoscopic release, ($866). Both were performed most commonly in the <65 years age range. CONCLUSIONS: Despite the unexpectedly lower reimbursement rate with endoscopic release, endoscopy utilization is growing faster than open releases in the Medicare population. Lower reimbursement is likely related to lack of a dedicated current procedural terminology code for endoscopic cubital tunnel release.

Trends in open and endoscopic carpal tunnel release utilization in the Medicare patient population.

BACKGROUND: Surgical management of carpal tunnel syndrome (CTS) is performed with an open or endoscopic approach. Current literature suggests that the endoscopic approach is associated with higher costs and a steeper learning curve. This study evaluated the billing and utilization trends of both approaches. METHODS: A retrospective review of a Medicare database within the PearlDiver Supercomputer (Warsaw, IN) was performed for patients undergoing open carpal tunnel release (OCTR) or endoscopic carpal tunnel release (ECTR) from 2005-2012. Annual utilization, charges, reimbursement, demographic data, and compound annual growth rate (CAGR) were evaluated. RESULTS: Our query returned 1,500,603 carpal tunnel syndrome patients, of which 507,924 (33.8%) and 68,768 (4.6%) were surgically managed with OCTR and ECTR respectively (remainder treated conservatively). Compound annual growth rate was significantly higher in ECTR (5%) than OCTR (0.9%; P < 0.001). Average charges were higher in OCTR ($3820) than ECTR ($2952), whereas reimbursements were higher in ECTR (mean $1643) than OCTR (mean $1312). Both were performed most commonly in the age range of 65-69 y, females, and southern geographic region. CONCLUSIONS: ECTR is growing faster than OCTR in the Medicare population. Contrary to previous literature, our study shows that ECTR had lower charges and reimbursed at a higher rate than OCTR.

Effect of Hypoglycemia on the Incidence of Revision in Total Knee Arthroplasty.

BACKGROUND: It is well established that diabetic patients undergoing total knee arthroplasty (TKA) are more susceptible to infection, problematic wound healing, and overall higher complication rates. However, a paucity in current literature exists. The purpose of this study was to determine the effect of hypoglycemia on TKA revision (rTKA) incidence by analyzing a national private payer database for procedures performed between 2007 and 2015 Q1 Q2. METHODS: A retrospective review of a national private payer database within the PearlDiver Supercomputer application for patients undergoing TKA with blood glucose levels from 20 to 219 mg/mL, in 10-mg/mL increments, was conducted. Patients who underwent TKA were identified by Current Procedural Terminology (CPT) and International Classification of Disease (ICD) codes. Glucose ranges were identified by filtering for Logical Observation Identifiers Names and Codes within the PearlDiver database. Patients with diagnosed diabetes mellitus type I or II were excluded by using ICD-9 codes 250.00-250.03, 250.10-250.13, and 250.20-250.21. rTKA causes including mechanical loosening, failure/break, periprosthetic fracture, osteolysis, infection, pain, arthrofibrosis, instability, and trauma were identified with CPT and ICD-9 codes. Statistical analysis was primarily descriptive. RESULTS: Our query returned 264,824 TKAs, of which 12,852 (4.9%) were revised. Most TKAs were performed with a glucose of 70-99 mg/mL (26.1%), followed by 100-109 mg/mL (18.5%). Patients with TKAs performed with glucose 20-29 mg/mL had the highest rate of revision (17.2%; P < .001). Infection was the most common cause of revision among all glucose ranges (P < .001). CONCLUSION: Infection remains one of the most common causes of rTKA irrespective of glucose level. Our results suggest that hypoglycemia may increase revision rates among TKA patients. Tight glycemic control before and during surgery may be warranted.