Intraoperative localization and "snowman" muscle pledget repair for ventral dural defect in a case of spontaneous intracranial hypotension.

BACKGROUND: This image report with technical notes is the first to illustrate and describe the technique used to treat spinal cerebrospinal fluid (CSF) leaks with the "snowman" muscle pledget. A 49-year-old male presented with orthostatic headaches as well as the left abducens nerve palsy. Patient's workup including findings of diffuse meningeal enhancement on magnetic resonance imaging, lumbar puncture opening pressure of 4 cm H2O, and CT myelogram demonstrating evidence of ventral spinal thoracic CSF leak. CASE DESCRIPTION: Procedure took place in a hybrid biplane operating room so that simultaneous digital subtraction myelogram may also be performed for intraoperative localization. Dural defect was identified intraoperatively and repaired with thoracic laminectomy and "snowman" muscle pledget technique. Postoperatively, the patient did well with resolution of his symptoms. CONCLUSION: The authors have proposed a grading scale to aid in the work up and management of intracranial hypotension. The use of a hybrid biplane operating room and "snowman" muscle pledget technique is a safe and effective technique to treat spontaneous spinal CSF leaks resulting from dural defects.

The Financial and Radiation Burden of Early Reimaging in Neurosurgical Patients: An Original Study and Review of the Literature.

The computed tomographic (CT) scanner has become ubiquitous in healthcare. When trauma patients are imaged at facilities not equipped to care for them, imaging is often repeated at the receiving institution. CTs have clinical, financial, and resource costs, and eliminating unnecessary imaging will benefit patients, providers, and institutions. This paper reviews patterns of repetition of CT scans for transferred trauma patients and motivations underlying such behaviors via analysis of our Trauma Registry database and literature published in this area. Neurosurgeons are fundamentally impactful in this decision-making process. The most commonly repeated scan is a CT head (CTH). More than » of our patients receiving a clinically indicated repeat CTH also had a repeat scan of their cervical spine with no reason given for the cervical scan. Herein, we discuss our findings that both non-trauma center practitioners and non-neurosurgical staff at trauma centers cite a lower level of comfort with neuroradiology and fear of litigation as motivators in overzealous neuroimaging. As a result, inappropriate neurosurgical imaging is routinely ordered prior to transfer and again upon arrival at trauma centers. Education of non-neurosurgical staff is essential to prevent inappropriate neuroaxis imaging.

Use of O-arm With Intraoperative Arteriography for Localization and Stealth Navigation of the Vertebral Arteries During Posterior Cervical Spine Surgery.

BACKGROUND: Vertebral artery injury (VAI) can be a devastating complication during cervical spine surgery. Although considered a rare occurrence overall, incidences of VAI have been reported in the ranges of 0.07% to 8%. Such injuries have the potential for catastrophic consequences, including blood loss, permanent morbid neurologic injury, and even death. The introduction of intraoperative navigation using either preoperative or intraoperative imaging has now been widely adopted in current practice so as to try and minimize adverse outcomes while giving real-time, dynamic information of the operative field. The use of the O-arm Surgical Imaging System during cervical spine surgery allows one to obtain high-resolution, accurate intraoperative imaging, and when used in concert with forms of intraoperative navigation, it can help with instrumentation and safety. However, patients undergoing cervical spine surgery do not routinely undergo preoperative vascular imaging, particularly with regard to anterior cervical or posterior high-cervical surgeries, where the incidence of VAI, in comparison with other cervical surgeries, has been reported to be the highest. METHODS: Here we present the use of intraoperative O-arm-based arteriography for integration with navigation for vertebral artery localization during C1 to C3 posterior instrumentation and fusion of an unstable C2 fracture in a 54-year-old man. RESULTS: The patient did not experience any intraoperative VAI and was subsequently discharged with no focal neurologic deficits. CONCLUSIONS: Detailed in our report is our protocol and procedure for obtaining and using intraoperative angiographic images. CLINICAL RELEVANCE: Case report detailing O arm for intraoperative identification of vertebral arteries during C1-C3 posterior instrumentation and fusion with pre-operative unilateral vertebral artery injury.

Global Longitudinal Strain: Is It Time to Change the Preoperative Cardiac Assessment of Oncology Patients?

The introduction of new anticancer treatment modalities has improved survival rates, transforming cancer into a chronic disease in many instances. One of the most devastating complications of cancer treatment is cancer therapy-related cardiac dysfunction. Adequate preoperative assessment of any significant cancer therapy-related cardiac impairment is critical, and may be missed with conventional measures. The assessment of global longitudinal strain by speckle-tracking echocardiography is more sensitive for the early detection of cardiac contractility before a decline in ejection fraction can be discovered. Global longitudinal strain can also predict postoperative cardiac dysfunction, which makes it a good alternative for preoperative cardiac assessment in the oncology population when cancer therapies have been administered that can alter normal performance.

Preoperative, Multidisciplinary Clinical Optimization of Patients with Severely Depressed Left Ventricular Ejection Fraction Who Are Undergoing Coronary Artery Bypass Grafting.

Coronary artery bypass grafting (CABG) remains a routine operation despite major advancements in angioplastic procedures. Around 200,000 CABG procedures are performed annually in the U.S. Patients who are not candidates for angioplasty intervention often have advanced coronary disease and comorbidities that raise the risk of heart failure with decreased ejection fraction to around 25%. Over the years, significant developments in various preoperative interventions have occurred; in this paper, we suggest a multidisciplinary preoperative algorithm that can be included in a regularly scheduled multidisciplinary care plan.

The 100-most Cited Articles About Craniectomy and Hemicraniectomy: A Bibliometric Analysis.

Craniectomy is a life-saving procedure used in the setting of traumatic brain injury, stroke and increased intracranial pressure. The purpose of this study was to analyze and determine the most influential articles and authors in the field of craniectomy. Our study presents an analysis of the articles that include the word "craniectomy" or "hemicraniectomy" in the title and a detailed analysis of the top 100-cited articles in that selection. This search provided insight into how this procedure was initially documented and how it has been utilized over the years. We used the SCOPUS database to search "craniectomy OR hemicraniectomy" in the article title. We then sorted the top 100 most-cited articles. Bibliometric analysis was performed. An H-index was presented with each author. The citation count ranged from 71 to 5310. The most published author was Werner Hacke, a German researcher (n=6). The highest quantity of influential work was published in 2006 and 2007 (n=9/yr). The United States published the most articles (n=42). The Journal of Neurosurgery published 21 of the top 100 most-cited articles. The chronological timeline shows the evolution of decompression as it related to both stroke and trauma. It demonstrated that well-cited articles acted as turning points to direct further scientific endeavors while highlighting the hard work of certain authors. There is, to the best of our knowledge, a shortage of literature on a bibliometric analysis regarding the term craniectomy. Thus, the current bibliometric study was undertaken to highlight the work of authors who have advanced knowledge about this procedure. It provides an analysis of the top 100-cited articles with craniectomy in the title with dates ranging from 1892 to 2016. A review of its publication history shows how interventions in this field have advanced over the last several decades.

Primary Spinal Astrocytomas: A Literature Review.

Primary spinal astrocytoma is a subtype of glioma, the most common spinal cord tumor found in the intradural intramedullary compartment. Spinal astrocytomas account for 6-8% of all spinal cord tumors and are primarily low grade (World Health Organization grade I (WHO I) or WHO II). They are seen in both the adult and pediatric population with the most common presenting symptoms being back pain, sensory dysfunction, or motor dysfunction. Magnetic Resonance Imaging (MRI) with and without gadolinium is the imaging of choice, which usually reveals a hypointense T1 weighted and hyperintense T2 weighted lesion with a heterogeneous pattern of contrast enhancement. Further imaging which may aid in surgical planning includes computerized tomography, diffusion tensor imaging, and tractography. Median survival in spinal cord astrocytomas ranges widely. The factors most significantly associated with poor prognosis and shorter median survival are older age at initial diagnosis, higher grade lesion based on histology, and extent of resection. The mainstay of treatment for primary spinal cord astrocytomas is surgical resection, with the goal of preservation of neurologic function, guided by intraoperative neuromonitoring. Adjunctive radiation has been shown beneficial and may increase overall survival. The role of adjunctive chemotherapy is employed, however, its benefit has not been clearly defined. Primary spinal cord astrocytomas are rare and challenging to treat. The gold standard treatment is surgical resection. Second-line treatments include radiation and chemotherapy, although, the optimal regimen for adjunctive therapy has not yet been clearly defined.

Gender Disparity in Academic Neurosurgery.

Background In the 1960s, less than 10% of medical school graduates were women. Today, almost half of all medical school graduates are women. Despite the significant rise in female medical school graduates, there continues to be a large gender gap in most subspecialties, particularly surgical subspecialties such as neurosurgery. Objective The purpose of our study was to assess the factors contributing to differences in the academic ranks of male and female staff in academic neurosurgery programs in Canada and the United States (US). Methods Data about women in academic neurosurgery was collected from a number of sources, including Fellowship and Residency Electronic Interactive Database (FREIDA), Accreditation Council for Graduate Medical Education (ACGME), Canadian Resident Matching Service (CaRMS) FRIEDA, ACGME, CaRMS, Pubmed, and Scopus, to create a database of all neurosurgeons in the US and Canada. The analysis included neurosurgeons in academic and leadership ranks and also the H index, citations, publications, citations per year, and publications per year. Results Women represent only 12% of neurosurgeons in the US and Canada. When gender is further analyzed by academic appointment, women represent just over 12% of neurosurgeons at the assistant and associate professor levels (15.44% and 13.27%, respectively) but significantly less at the full professor level (5.84%). Likewise, only 7.45% of women hold first-in command leadership positions while 4.69% hold second-in-command positions within their institutions. Conclusions The existing data shows that women are significantly under-represented in academic neurosurgery. Lack of role models, experience, limited scientific output, and aspirations of a controlled lifestyle could be the potential contributing factors.