Traumatic Lumbar Subdural Hematoma in the Absence of Intracranial Disease.

BACKGROUND: Traumatic spinal subdural hematoma is an exceedingly rare condition, with those occurring in the absence of intracranial disease being particularly uncommon. Only 13 such cases have been reported. Although theories exist to describe the pathophysiology of traumatic spinal subdural hematoma, the precise mechanism and guidelines for management remain unclear. CASE DESCRIPTION: This report describes a 37-year-old woman who suffered a traumatic assault who developed progressive low back pain with radicular symptoms 2 days after presentation. Magnetic resonance imaging revealed a lumbar subdural hematoma extending from L1 to L5. No intracranial disease was detected on imaging. CONCLUSIONS: Definitive guidelines for management of this condition are uncertain; however, successful use of conservative management, lumbar drainage, and surgical evacuation has been reported. This patient underwent a lumbar laminectomy with evacuation of the hematoma, resulting in immediate pain relief and resolution of symptoms within 1 week of the procedure.

Malignant carotid body tumor presenting with myelopathy: case report.

Malignant carotid body tumors are rare, with spread of the tumor mostly noted in regional lymph nodes. Vertebral metastases are an exceedingly rare presentation, only reported in isolated case reports, and present a diagnostic and management challenge. A case of widespread vertebral metastasis, presenting with myelopathy, from a carotid body tumor is discussed in this paper, along with management strategies.

Intracranial hemorrhage in patient treated with rivaroxaban.

Rivaroxaban is an oral factor Xa inhibitor used for stroke prevention in atrial fibrillation. There are currently no evidence-based guidelines for the treatment of hemorrhagic side effects of factor Xa inhibitors. We report a case of a thalamic hemorrhage in an 84 year-old right-handed female on rivaroxaban for treatment of atrial fibrillation. The patient had fallen down steps and became unresponsive. She was found to have diffuse scattered acute subarachnoid hemorrhage as well as intraventricular hemorrhage. Neurosurgical intervention was not required in this case, but controversy over decision making to pursue pro-coagulant therapy in the setting of worsening hemorrhage requiring emergent surgery is discussed.

Inhibition of x-irradiation-enhanced locomotor recovery after spinal cord injury by hyperbaric oxygen or the antioxidant nitroxide tempol.

OBJECT: Hyperbaric oxygen (HBO), the nitroxide antioxidant tempol, and x-irradiation have been used to promote locomotor recovery in experimental models of spinal cord injury. The authors used x-irradiation of the injury site together with either HBO or tempol to determine whether combined therapy offers greater benefit to rats. METHODS: Contusion injury was produced with a weight-drop device in rats at the T-10 level, and recovery was determined using the 21-point Basso-Beattie-Bresnahan (BBB) locomotor scale. Locomotor function recovered progressively during the 6-week postinjury observation period and was significantly greater after x-irradiation (20 Gy) of the injury site or treatment with tempol (275 mg/kg intraperitoneally) than in untreated rats (final BBB Scores 10.6 [x-irradiation treated] and 9.1 [tempol treated] compared with 6.4 [untreated], p < 0.05). Recovery was not significantly improved by HBO (2 atm for 1 hour [BBB Score 8.2, p > 0.05]). Interestingly, the improved recovery of locomotor function after x-irradiation, in contrast with antiproliferative radiotherapy for neoplasia, was inhibited when used together with either HBO or tempol (BBB Scores 8.2 and 8.3, respectively). The ability of tempol to block enhanced locomotor recovery by x-irradiation was accompanied by prevention of alopecia at the irradiation site. The extent of locomotor recovery following treatment with tempol, HBO, and x-irradiation correlated with measurements of spared spinal cord tissue at the contusion epicenter. CONCLUSIONS: These results suggest that these treatments, when used alone, can activate neuroprotective mechanisms but, in combination, may result in neurotoxicity.

Comparison of polyetheretherketone cages with femoral cortical bone allograft as a single-piece interbody spacer in transforaminal lumbar interbody fusion.

OBJECT: Transforaminal lumbar interbody fusion (TLIF) is an accepted alternative to circumferential fusion of the lumbar spine in the treatment of degenerative disc disease, spondylolisthesis, and recurrent disc herniation. To maintain disc height while arthrodesis takes place, the technique requires the use of an interbody spacer. Although titanium cages are used in this capacity, the two most common spacers are polyetheretherketone (PEEK) cages and femoral cortical allografts (FCAs). The authors compared the clinical and radiographic outcomes of patients who underwent TLIF with pedicle screw fixation, in whom either a PEEK cage or an FCA was placed as an interbody spacer. METHODS: The charts and x-ray films obtained in 39 patients (age range 33-68 years, mean 44.7 years) who underwent single-level TLIF between October 2001 and April 2004 and in whom either a PEEK cage (18 patients) or FCA (21 patients) was placed as an interbody spacer were evaluated in a retrospective study. Radiological outcome was based on fusion rate and a comparison of the initial postoperative lordotic angle on standing lateral radiographs with that at long-term follow up (mean follow up 15.1 months, minimum 12 months). To control for variations in radiographic magnification, the authors used lordotic angle as an indirect measure of disc space height. Clinical outcome was assessed using the Oswestry Disability Index (ODI). There were no major complications in either group. Radiographically documented fusion occurred in all patients in the PEEK group and 95.2% of those in the FCA group. Pseudarthrosis developed in one patient in the FCA group, and this patient underwent additional surgery. In both groups, the mean lordotic angle changed by less than 2.20 degrees during the postoperative period, and the mean postoperative ODI score was more than 40 points lower than the mean preoperative score. There was no significant difference between the two groups in mean change in lordotic angle (p = 0.415) and mean change in ODI score (p = 0.491). CONCLUSIONS: Both PEEK cages and FCAs are highly effective in promoting interbody fusion, maintaining postoperative disc space height, and achieving desirable clinical outcomes in patients who undergo TLIF with pedicle screw fixation. The advantages of PEEK cages include a lower incidence of subsidence and their radiolucency, which permits easier visualization of bone growth.

Surgical management of cervical myelopathy: indications and techniques for multilevel cervical discectomy.

BACKGROUND CONTEXT: Surgery is usually required for treatment of cervical myelopathy to decompress the neural elements, restore lordosis, and stabilize the spine. By addressing these problems, the neurological deterioration may be halted. PURPOSE: Multilevel cervical discectomy and fusion offers several advantages over other approaches. The authors describe the technique, discuss the indications, and present the potential complications associated with it. METHODS: Decompression is achieved via discectomy and subsequent removal of the osteophytes using a curetting technique. Preparation of end plates in a parallel fashion allows for gapless grafting of allograft bone for enhancement of fusion. A dynamic plate and screw system strengthens the construct. RESULTS: A high rate of fusion can be obtained using the technique of multilevel cervical discectomy and fusion with acceptable levels of complications. It is especially useful in cases of spondylosis that have a kyphotic deformity because, in addition to anterior decompression, it allows reconstruction of the spine to help restore a lordotic curvature. CONCLUSIONS: Multilevel cervical discectomy and fusion has proven to be very effective in decompressing and stabilizing the spine for treatment of cervical myelopathy.

Tempol, a nitroxide antioxidant, improves locomotor and histological outcomes after spinal cord contusion in rats.

We have determined whether the nitroxide antioxidant, tempol, can oppose tissue loss and improve recovery of locomotor function following contusion injury of the spinal cord. Contusion injury was produced in rats at the level of T10 with a weight-drop device and locomotor recovery was determined with the 21-point Basso, Beattie and Bresnahan (BBB) scale. Locomotor function recovered progressively during the 6-week postinjury observation period and was significantly greater in tempol-treated (275 mg/kg i.p., 20 min postinjury) compared to vehicle-treated rats (final BBB scores: 9.1 versus 6.4). Similarly enhanced locomotor recovery was observed with doses of tempol in the range of 138-550, but not 69 mg/kg, and with injection at 48 h postinjury indicating a therapeutic time-window of at least several days. The extent of recovery correlated with measurements of sparing of spinal cord white matter in a region several millimeters in length extending rostrally from the contusion epicenter. In contrast, loss of gray matter was unaffected by tempol treatment. Since tempol acts by scavenging reactive oxygen species (ROS) such as superoxide and hydroxyl radicals, the improved locomotor recovery and spared spinal cord tissue following contusion injury provides evidence of a direct role of ROS-mediated neurodegeneration in spinal cord injury.

Safety of multiple stereotactic radiosurgery treatments for multiple brain lesions.

BACKGROUND: Stereotactic radiosurgery (SRS) is a widely used therapy for multiple brain lesions, and studies have clearly established the safety and efficacy of single-dose SRS. However, as patient survival has increased, the recurrence of tumors and the development of metastases to new sites within the brain have made it desirable to repeat treatments over time. The cumulative toxicity of multi-isocenter, multiple treatments has not been well defined. We have retrospectively studied 10 patients who received multiple SRS treatments for multiple brain lesions to assess the cumulative toxicity of these treatments. METHODS: In a retrospective review of all patients treated with SRS using the X-knife (Radionics, Burlington, MA) at Westchester Medical Center/New York Medical College between December 1995 and December 2000, 10 patients were identified who received at least two treatments to at least 3 isocenters and had a minimum follow-up period of 6 months. Image fusion technique was used to determine cumulative doses to targeted lesions, whole brain and critical brain structures. Toxicities and complications were identified by chart and radiological review. RESULTS: The average of the maximum doses (cGy) to a point within the whole brain was 2402 (range 1617-3953); to the brainstem, 1059 (range 48-4126); to the right optic nerve, 223 (range 14-1012); to the left optic nerve, 159 (range 17-475); and to the optic chiasm, 219 (range 15-909). There were no focal neurological toxicities, including visual disturbances, cranial nerve palsies, or ataxia in any of the 10 patients. There were also no global toxicities, including cognitive decline or secondary tumors. Only one patient developed seizures that were difficult to control in association with radiation necrosis. CONCLUSIONS: Multiple SRS treatments at the cumulative doses used in our study are a safe therapy for patients with multiple brain lesions.