Delayed postoperative erosion of hypopharynx after anterior hardware extrusion: A case report.

Background: Esophageal breach or pharynx perforations are serious and potentially fatal complications of anterior cervical corpectomy/fusion (ACF). They are either recognized intraoperatively or are diagnosed within several postoperative days. Here, a 76-year-old male presented with the retropharyngeal extrusion of an anterior cervical expandable cage that occurred two years postoperatively. Case Description: A 76-year-old male with a history of an anterior corpectomy/fusion (C3-C6, corpectomy C4, C5) performed two years ago presented with persistent dysphagia for three months. Cervical X-rays showed anterior migration of the expandable cage and that was also confirmed by computed tomography (CT) scans. During intubation, the anesthesiologist observed that the cage had directly penetrated the hypopharynx. Following routine removal of the cage, ENT could not identify (using the operating microscope) any direct perforation of the esophagus or hypopharynx; presumably, the esophageal breach was small, and the esophageal wall spontaneously closed the gap following cage excision. Conclusion: Pharyngeal perforation after ACF is typically associated with significant morbidity and mortality. Stringent preoperative assessment, utilizing X-rays, magnetic resonance/CT studies, and ENT specialists to perform indirect laryngoscopy, may optimize postoperative outcomes.

Lumbar discectomy and fusion: Organs' dose and effective dose estimation using Monte Carlo simulation.

In this study, the effect of patient- and procedure-related parameters on organs' dose (OD), peak skin dose (PSD) and effective dose (ED) during lumbar discectomy and fusion (LDF) was assessed. Intra-operative parameters obtained from 102 LDFs were inserted into VirtualDose-IR software implementing sex-specific and BMI-adjustable anthropomorphic phantoms for dosimetric calculations. Fluoroscopy time (FT), kerma-area product (KAP), cumulative and incident air-kerma (Kair) were also recorded from the dosimetric report of the mobile C-arm. An increase in KAP, Kair, PSD and ED was found for male or higher BMI patients, multi-level or fusion or L5/S1 procedures. However, a significant difference was found only for PSD and incident Kair between normal and obese patients and for FT between discectomy and discectomy and fusion procedures. The spleen, kidneys and colon received the highest doses. The BMI have a significant impact only for kidneys, pancreas, and spleen doses when comparing obese to overweight and for urinary bladder when comparing overweight to normal patients. Multi-level and fusion procedures resulted in significantly higher doses for lungs, heart, stomach, adrenals, gallbladder and kidneys, while pancreas and spleen doses significantly increased only for multi-level procedures. Additionally, a significant increase was found only for urinary bladder, adrenals, kidneys, and spleen ODs when comparing L5/S1 and L3/L4 levels. The mean ODs were lower compared to the literature. These data may aid neurosurgeons in optimising exposure techniques during LDF to keep patients' dose as low as is practicably possible.

Spontaneous thoracolumbar epidural hematoma in an apixaban anticoagulated patient.

BACKGROUND: Spontaneous spinal epidural hematomas (SSEHs) are often attributed to anticoagulation. Although they are rare, they may contribute to significant morbidity and mortality. CASE DESCRIPTION: An 83-year-old female with a history of atrial fibrillation on apixaban, presented with 4 days of back pain, progressive lower extremity weakness and urinary retention. When the patient's MRI showed a dorsal thoracolumbar SSEH, the patient underwent a T10-L3 laminectomy for hematoma evacuation. Within 2 postoperative months, her neurological deficits fully resolved. CONCLUSION: Apixaban is associated with SSEH resulting in severe neurological morbidity and even mortality. Prompt MRI imaging followed by emergency surgical decompressive surgery may result in full resolution of neurological deficits.

Hemorrhage of a Cavernous Hemangioma of the Brainstem Presenting with Fever of Unknown Origin: A Case Report.

BACKGROUND Cavernous malformations (CMs) or hemangiomas are benign vascular hamartomas of the central nervous system (CNS) that constitute 5-15% of all CNS vascular malformations. Most patients with brainstem CMs present with a sudden onset of seizures, intracranial hemorrhage, cranial nerve deficits, headache, or ataxia. Up to 20% to 50% of patients are asymptomatic, and their CMs are diagnosed incidentally on brain magnetic resonance imaging. CASE REPORT We present a case of a 42-year-old man with a brainstem cavernous hemangioma presenting with fever of unknown origin and mild headache without meningismus. The patient underwent a midline suboccipital craniectomy and removal of a ruptured brainstem cavernous hemangioma and the surrounding thrombus. Postoperatively, the patient developed left facial nerve palsy, left abducens nerve palsy, and xerostomia. Abducens palsy and xerostomia resolved spontaneously days after the operation. At the 6-month follow-up, the patient showed stable improvement with resolution of his neurological deficits. CONCLUSIONS To our knowledge, there is no reported case of a patient with a ruptured brainstem cavernoma presenting with fever of unknown origin as the main symptom. We assume that the minimal intraventricular hemorrhage triggered the hypothalamic thermoregulating mechanism. Thus, it would be useful for physicians to raise the suspicion of a ruptured brainstem cavernous malformation with further imaging evaluation when investigating fever of unknown origin.

Effects of COVID-19 on the admissions of aneurysmal subarachnoid hemorrhage: the West Greece experience.

BACKGROUND: Acute subarachnoid hemorrhage (SAH) due to aneurysmal rupture is a devastating vascular disease accounting for 5% of strokes. COVID-19 pandemic resulted in a decrease in elective and emergency admissions in the majority of neurosurgical centers. The main hypothesis was that fear of COVID-19 may have prevented patients with critical medical or surgical emergencies from actively presenting in emergency departments and outpatient clinics. METHODS: We conducted a single-center, retrospective, observational study searching our institutional data regarding the incidence of spontaneous subarachnoid hemorrhage (SAH) and compare the admissions in two different periods: the pre COVID-19 with the COVID-19 period. RESULTS: The study cohort was comprised of a total of 99 patients. The mean (SD) weekly case rate of patients with SAH was 1.1 (1.1) during the pre-COVID-19 period, compared to 1.7 (1.4) during the COVID-19 period. Analysis revealed that the volume of admitted patients with SAH was 1.5-fold higher during the COVID period compared to the pre-COVID period and this was statistically significant (ExpB = 1.5, CI 95% 1-2.3, p = 0.044). Difference in mortality did not reach any statistical significance between the two periods (p = 0.097), as well as patients' length of stay (p = 0.193). CONCLUSIONS: The presented data cover a more extended time period than so far published reports; it is reasonable that our recent experience may well be demonstrating a general realistic trend of overall increase in aneurysmal rupture rates during lockdown. Hospitalization of patients with SAH cannot afford any reductions in facilities, equipment, or personnel if optimum outcomes are desirable.

Tubular laminectomy and percutaneous vertebroplasty for aggressive vertebral hemangioma.

BACKGROUND: Vertebral hemangiomas (VH) are the most common benign vascular neoplasms of the spine. Aggressive VH (AVH) may become symptomatic due to soft-tissue expansion/extraosseous extension into the paraspinal and/or epidural spaces. There are several options for treating painful AVH, including radiotherapy and/or open surgery. CASE DESCRIPTION: A 59-year-old male presented with a 2-year history of intermittent back pain and progressive thoracic myelopathy in the past 2 months. MRI revealed a T9 level lesion, with high-intensity signal on both T1 and T2 images and an extraosseous component with significant cord compression. We performed minimally invasive tubular unilateral laminotomy for bilateral decompression of the thoracic spine at the T9 level, followed by bilateral percutaneous vertebroplasty with biopsy. Postoperatively, the pain was immediately relieved, and the myelopathy improved. The biopsy confirmed the diagnosis of a VH. CONCLUSION: Combining minimally invasive techniques consisting of tubular laminectomy and percutaneous vertebroplasty are safe and effective ways for treating AVHs.

Neck angioedema after anterior cervical discectomy and fusion with coexistent epiglottic cyst.

BACKGROUND: We present a case and reviewed the literature regarding airway obstruction and angioedema after an anterior cervical discectomy and fusion (ACDF). CASE DESCRIPTION: A 60-year-old female with degenerative cervical myelopathy and a previously undiagnosed epiglottic cyst underwent a C5-C6 ACDF; notably, the anesthesiologist found an epiglottic cyst when the patient was first intubated. Two hours postoperatively, the patient acutely developed severe neck swelling with airway obstruction due to angioedema. She was immediately treated with hydrocortisone and required a tracheostomy. The edema decreased markedly in the next 12 h and by the 3rd postoperative day it resolved. Three months later, she had no residual medical sequelae. CONCLUSION: Patients with epiglottic cysts who need cervical spine surgery should either first have the cyst treated or should be closely monitored postoperatively.