L5 Nerve Root Radiculopathy as a Rare Complication Following Oblique Lateral Interbody Fusion at L5/S1 Combined With Posterior Fixation via Percutaneous Pedicle Screws for Adult Spinal Deformity.

Oblique lateral interbody fusion (OLIF) is an established and less invasive surgical approach for patients with adult spinal deformities. This method can also be applied to the L5/S1 region (termed "OLIF51"); however, reports on L5 nerve root radiculopathy as a rare complication of OLIF51 are limited. Here, we present the case of a 77-year-old woman with progressive adult spinal deformity who was followed up after an initial OLIF for the L3/4 and L4/5 levels. An additional operation was performed to resolve ambulation difficulty and back pain related to adult spinal deformity. Circumferential fixation was performed over two sessions. Initially, OLIF51 was performed concurrently with OLIF for L1/2 and L2/3. Eight days later, posterior fixation surgery from T10 to the ilium via percutaneous pedicle screws was performed. Two days after the second operation, the patient started complaining of left L5 nerve root radiculopathy, for which medication and rehabilitation were both ineffective. Retrospectively, we identified that the left L5/S1 foramen narrowed after the lordotic correction by OLIF51 and posterior fixation. Additionally, posterior facetectomy for L5/S1 was performed, and the left L5 nerve root radiculopathy was resolved. L5 nerve root radiculopathy can develop as a rare complication of OLIF51. Neurosurgeons should be aware of this rare complication related to OLIF51.

Unexpected coil mass migration during transvenous embolization of a dural arteriovenous fistula resolved with guidewire-assisted snaring technique.

Endovascular embolization is a standard treatment for dural arteriovenous fistulas (dAVFs). Although it is considered relatively safe, intraoperative and postoperative complications can occur. Herein, a rare case of unexpected coil mass migration requiring a retrieval procedure during sinus occlusion for a transverse-sigmoid sinus dAVF (TSdAVF) is described. An 83-year-old man presented with worsening decline in cognitive function. Magnetic resonance angiography showed a TSdAVF. Since his symptoms seemed to be a result of the TSdAVF, transvenous embolization preserving the normal cranial venous circulation was planned. During sinus occlusion, including embolization of the shunted pouch of the TSdAVF, unexpected migration of the coil mass to the confluence of the superior sagittal sinus and the transverse sinus occurred. The migrated coil mass impeded venous circulation in the superior sagittal sinus. Since the presence of the coil mass at the confluence could have had catastrophic sequelae, the coil mass was retrieved using a guidewire-assisted snaring technique. Sinus occlusion was subsequently completed with repositioning of the coil mass at the target site. The TSdAVF resolved, with no recurrence confirmed for 1 year. Clinicians should be aware that coil mass migration can unexpectedly occur during sinus occlusion performed for treatment of a TSdAVF. The guidewire-assisted snaring technique might be effective in resolving this intraoperative complication.

Chronic Subdural Hematoma in a Middle-Aged Amateur Scuba Diver: A Case Report.

Scuba diving has become a common and popular activity, and adverse events can occur following this activity. Among those events, intracranial hemorrhage is very rare, and only intracerebral hemorrhage and subarachnoid hemorrhage are reported. However, the occurrence of chronic subdural hematoma (CSDH), possibly as an adverse event following scuba diving, has not been described. A 49-year-old man with no significant medical history visited our hospital complaining of memory disturbance and aphasia. He had experienced a minor head trauma five months before and had gone scuba diving six times between the traumatic episode and the visit to our hospital. A brain computed tomography scan revealed a left CSDH. The patient underwent burr-hole surgery to remove the CSDH, and his symptoms resolved. We report the first case of CSDH possibly related to scuba diving. No recurrence of CSDH was observed at 28 months postoperatively.

Diffusion tensor imaging combined with the dual-echo steady-state (DESS) protocol for the evaluation of the median nerve in the carpal tunnel: A preliminary study.

Background: Carpal tunnel syndrome (CTS) is diagnosed based on neurological, electrophysiology, and radiological findings. Due to the technical development of magnetic resonance imaging (MRI), the median nerve is evaluated with several MRI protocols. However, diffusion tensor imaging (DTI) combined with a dual-echo steady-state (DESS) protocol is not frequently used to evaluate the median nerve of CTS. This study aimed to evaluate the median nerve in the carpal tunnel using DTI combined with a DESS protocol. Methods: Five healthy volunteers and seven patients with CTS were enrolled. The patients underwent MRI for CTS pre- and post-operatively. The median nerve was evaluated using a 3-T MRI scanner. The parameters of the DESS protocol were as follows: Repetition time (TR)/echo time (TE) = 10.83/3.32 ms, slice thickness = 0.45 mm, field of view (FoV) = 350 × 253 × 350 mm, and 3D voxel size = 0.5 × 0.5 ×0.4 mm. The parameters of the DTI sequence were as follows: TR/TE = 4000/86 ms, slice thickness = 3 mm, FoV = 160 × 993 × 90 mm, 3D voxel size = 1.2 × 1.2 ×3.0 mm, and b value = 0.1000 s/mm2. The apparent diffusion coefficient (ADC) and fractional anisotropy (FA) values of the median nerve were statistically analyzed. Statistical significance was set at P< 0.05. Results: The FA value of healthy volunteers was 0.576 ± 0.058, while those of the patients were 0.357 ± 0.094 and 0.395 ± 0.062 pre-and post-operatively, respectively. Statistically significant differences were identified between the FA values of healthy volunteers and pre-operative/post-operative patients. The ADC values of healthy volunteers and pre-operative patients were 0.931 ± 0.096 and 1.26 ± 0.282 (10-3 mm2/s), respectively (P< 0.05). Conclusion: This MRI protocol may be useful for evaluating the median nerve in the carpal tunnel.

A Novel Method for Acquired Sex Chromosome Mosaicism.

The phenomenon of sex chromosome loss from hematopoietic cells is an emerging indicator of biological aging. While many methods to detect this loss have been developed, enhancing the field, these existing methods often suffer from being labor-intensive, expensive, and not sufficiently sensitive. To bridge this gap, a novel and more efficient technique is developed, named the SinChro assay. This method employs multiplexed single-cell droplet PCR, designed to detect cells with sex chromosome loss at single-cell resolution. Through the SinChro assay, the age-dependent increase in Y chromosome loss in male blood is successfully mapped. The age-dependent loss of the X chromosome in female blood is also identified, a finding that has been challenging with existing methods. The advent of the SinChro assay marks a significant breakthrough in the study of age-related sex mosaicism. Its utility extends beyond blood analysis, applicable to a variety of tissues, and it holds the potential to deepen the understanding of biological aging and related diseases.

Factors Related to Favorable Outcomes in Older Adults Undergoing Home-Visit Rehabilitation Therapy.

BACKGROUND: Increasing elderly population is a major health concern worldwide, requiring various at-home care services. The aim of home-visit rehabilitation therapy is to support at-home living of the elderly and to promote their participation in social activities. There is a paucity of data about the clinical conditions of this population that can contribute to the achievement of goals in-home visit rehabilitation therapy. AIM: This study aimed to clarify clinical variables that could be related to the achievement of goals in-home visit rehabilitation therapy. METHODS: We collected retrospective clinical data of the older adults who underwent home-visit rehabilitation therapy between July 2006 and June 2021. We searched the clinical variables of home-visit rehabilitation therapy users and their frequency of utilization of home-visit rehabilitation therapy services from the clinical record. The initial and final clinical variables evaluated in this study included the abilities of daily living, degree of being bedridden, dementia rating, and levels of support or long-term care. Those variables were evaluated by rehabilitation therapists and doctors. The users were divided into three groups according to the reason for terminating rehabilitation therapy: goal achievement (achieved group), aggravation of underlying disease (aggravated group), and treatment suspension because of their own/others' wish (suspended group). The clinical parameters concerning the rehabilitation program, care level, and activities of daily living were evaluated among the groups. The clinical parameters concerning the rehabilitation program, care level, and activities of daily living were statistically evaluated among those three groups, using the chi-square test and Kruskal-Wallis test. RESULTS: In the achieved, aggravated, and suspended groups, 45, 190, and 38 users were respectively enrolled. The aggravated group showed significantly higher final care level (p = 0.002), degree of being bedridden (p=0.001), and dementia rating (p = 0.017) and significantly lower Barthel index scores (p < 0.001) and Frenchay Activities Index scores (p = 0.001) than the achieved group. Persons requesting the therapy were significantly older adults themselves in the achieved group (p = 0.018). The therapy was significantly performed more than once per week in the achieved group (p = 0.018). CONCLUSIONS: Older adults undergoing self-motivated home-visit rehabilitation therapy more than once per week may contribute to the achievement of the goal.

Two-Stage Cervical and Thoracic-Lumbar-Sacral Circumferential Fixation for Pyogenic Spondylitis: A Case Report.

Pyogenic spondylitis is a rare life-threatening condition. Conservative treatment with antibiotics is indicated; however, surgery can be considered in refractory cases. The surgical strategy varies, as pyogenic spondylosis can occur from the cervical to sacral regions. To our knowledge, although there is less invasiveness as an advantage in the following management, cervical and thoracic-lumbar-sacral circumferential fixations in two sessions for pyogenic spondylitis have not been previously described. An 84-year-old man complained of ambulation disturbances and pain in the neck and upper and lower extremities (the Japan Orthopaedic Association cervical myelopathy evaluation questionnaire score of 5/17). Magnetic resonance imaging revealed pyogenic spondylitis of the cervical, thoracic, and lumbar regions. Epidural abscesses and spondylodiscitis were concurrently diagnosed with multi-level skipping lesions from the cervical to the sacral regions. As these lesions were resistant to antibiotic treatment and the neurological symptoms worsened, surgical treatment was planned. Anterior cervical discectomy and fusion, and posterior cervical fixation were followed by oblique and posterior lumbar intervertebral fusions with long-level fixation from T12 to the ilium using percutaneous pedicle screws. The surgeries were performed in two sessions to avoid the invasiveness of surgeries in a single session. The patient's condition improved after a second surgery. The patient was discharged on postoperative day 116. No recurrence was observed for six months, and the patient was able to ambulate independently. Two-stage cervical and thoracic-lumbar-sacral circumferential fixation for pyogenic spondylitis contributed to a favorable outcome (the Japan Orthopaedic Association cervical myelopathy evaluation questionnaire score of 13/17).

Risk of Bone Wax Migration During Retrosigmoid Craniotomy for Microvascular Decompression: Case-Control Study.

BACKGROUND AND OBJECTIVES: Bone wax is a flexible hemostatic agent commonly used for surgery in the posterior cranial fossa to control bleeding from the mastoid emissary vein. A large amount of bone wax can migrate into the sigmoid sinus through the mastoid emissary canal (MEC). We aimed to identify clinical factors related to intraoperative bone wax migration through the MEC during microvascular decompression (MVD) surgery, which may result in sigmoid sinus thrombosis. METHODS: We retrospectively collected the clinical data of patients with trigeminal neuralgia, hemifacial spasm, or trigeminal neuralgia accompanied by painful tic convulsif who underwent MVD. Basic information and the residual width and length (from the bone surface to the sigmoid sinus) of the MEC on computed tomography images were collected. We compared the collected clinical data between 2 groups of cases with and without intraoperative bone wax migration in the sigmoid sinus. RESULTS: Fifty-four cases with intraoperative bone wax migration and 187 patients without migration were enrolled. The t -test revealed significant differences in the width and length of the MEC ( P = .013 and P = .003, respectively). These variables were identified as significant factors in predicting intraoperative bone wax migration using multivariate logistic regression analysis. CONCLUSION: The large size of the MEC may be related to intraoperative bone wax migration into the sigmoid sinus in MVD. Neurosurgeons should be aware of these risks. Bone wax should be applied appropriately and hemostasis should be considered to control bleeding from the mastoid emissary vein in patients with a large MEC.

Vertebral Fracture in a Short Period Following Posterior Decompression and Fixation for Degenerative Lumbar Spondylolisthesis.

Posterior decompression and fixation are established therapeutic modalities for degenerative lumbar spondylolisthesis (DLS). Postoperative complications associated with these procedures may require supplementary interventions, potentially resulting in subsequent vertebral fractures. However, vertebral fractures that occur within a short period after posterior decompression and fixation for DLS are rare. An 80-year-old woman presented with right leg pain and ambulatory difficulties attributed to DLS. The patient was administered medications, including prednisolone, for managing diabetes mellitus and rheumatoid arthritis. Subsequently, the patient underwent posterior decompression from L3 to S1, coupled with fixation extending from L4 to S1 using percutaneous pedicle screws. The symptoms disappeared, and the patient was discharged two weeks after the surgery. However, two months after the surgery, the patient visited our outpatient clinic, complaining of sudden backache and motor weakness in the bilateral lower extremities. A vertebral fracture of L4 was identified on computed tomography (CT). Long-level fusion from Th10 to the iliac bone was performed to correct the thoracic-lumbar deformity. Following rehabilitation therapy after the second surgery, the patient was discharged on day 45 post-surgery. As observed in this case, vertebral fractures following posterior decompression and fixation surgery for DLS can occur within a relatively short period. Neurosurgeons should be aware of these rare complications.

A Progressive Spontaneous Cervical Compression Fracture Over Years Following Long-Term Corticosteroid Use.

Spontaneous vertebral compression fractures in the cervical region can have a significant impact on a patient's condition even after surgical management. Due to the rarity of spontaneous cervical vertebral compression fractures and the lack of a comprehensive description of this condition, the establishment of a clear understanding of its natural course remains incomplete. In this case study, a 73-year-old woman on long-term corticosteroid therapy underwent combined anterior and posterior fixation for a spontaneous vertebral compression fracture at the C3-C4 level. The vertebral compression fracture gradually worsened over a span of four years. Following the surgery, the patient experienced a temporary improvement in her neurological symptoms. However, seven months after the second operation, an instrumentation failure resulted in the patient becoming bedridden. This highlights the importance of considering the potential long-term implications and monitoring patients closely even after surgical intervention.

Cervical dumbbell-type tumor spontaneously shrinking following an ischemic stroke.

Background: Asymptomatic cervical dumbbell-type tumors can be incidentally diagnosed. Notably, the chronological changes in the size of these tumors have not been satisfactorily described. Case Description: A 57-year-old man was clinically followed for an asymptomatic cervical dumbbell-type tumor that had the appearance of a schwannoma on magnetic resonance (MR) images obtained over a 7-year period. Notably, the tumor compressed both the spinal cord and the right vertebral artery. At the end of the 7-year period, the patient sustained a cerebral infarction due to atherosclerosis of the right vertebral artery; the angiogram revealed both atherosclerosis and the tumor compressing the right vertebral artery. After the stroke/ischemic event, the tumor progressively shrunk on MR images obtained for the following 4 years, and the spinal cord compression was similarly relieved. Conclusion: Here, we report on a 57-year-old man with cervical MR images revealing that a cervical dumbbell schwannoma was progressively compressing both the spinal cord and the right vertebral artery. However, following a cerebral infarction, the tumor underwent spontaneous shrinkage over the next 4 years, thus relieving the compression.

Functionality and Usability of the Exoscope in Microvascular Decompression for Hemifacial Spasm and Trigeminal Neuralgia.

BACKGROUND: Studies on the functionality and usability of the exoscope in neurosurgical procedures against surgical microscopes (SMs) are limited. This study aimed to examine the functionality and usability of the exoscope during microvascular decompression (MVD) surgery. METHODS: Seven neurosurgeons evaluated the usefulness of a 4 K, 3-dimension digital exoscope in MVD by answering a questionnaire. The questionnaire inquired about the functionality and usability of the exoscope by utilizing a visual analog scale (VAS; 1-10). A score of 5 on VAS was equivalent to the corresponding quality of the SM. The learning effect of the exoscope was evaluated using mean VAS scores in the first and last 3 cases for each neurosurgeon. RESULTS: The functionality of the exoscope in MVD was superior to that in SM (P < 0.001). In the last 3 surgeries, the mean VAS scores of the exoscope were excellent in terms of ease of arm handling, exchange of surgical instruments, ease of surgical procedure, and intraoperative physical stress. The mean VAS scores of the exoscope in intraoperative asthenopia were significantly higher than those of the SM (P < 0.001). No statistical significance was found in operation time, discharge outcome, and 1-year post-surgery outcome between MVD performed using the exoscope and SM. CONCLUSIONS: Neurosurgeons may experience reduced stress levels during MVD when using the exoscope. As the outcome of MVD using the exoscope did not demonstrate a statistical difference compared with MVD using the SM, the exoscope may prove to be a useful tool for performing MVD.

Postoperative vasospasm and cerebral infarction in a patient with large pituitary adenoma and cerebral superficial siderosis.

Background: Cerebral vasospasm and infarction are rare complications of transsphenoidal surgery for pituitary adenoma. Cerebral superficial siderosis may result from subarachnoid hemorrhage from a pituitary adenoma. The constellation of cerebral superficial siderosis, cerebral vasospasm, and pituitary adenoma is rare. We describe an extremely rare clinical constellation of immediately postoperative cerebral vasospasm and consequent cerebral infarction in a case with a large pituitary adenoma and cerebral superficial siderosis. Case Description: A 70-year-old man presented with a pituitary adenoma causing a worsening headache. Preoperative magnetic resonance (MR) images revealed cerebral superficial siderosis, suggesting subarachnoid hemorrhage from pituitary apoplexy. MR angiography (MRA) showed no vasospasm. During the transsphenoidal surgery, an intratumoral hematoma was found. The arachnoid membrane was partially torn and intratumoral hematoma entered the subarachnoid space. Intraoperatively, the intracranial vessels remained intact. The suprasellar tumor was almost entirely resected; however, the patient remained comatose postoperatively. Computed tomography revealed ischemic lesions in the bilateral insular and frontotemporal cortex. MRA revealed cerebral vasospasm in the bilateral middle cerebral arteries. The patient was treated with levetiracetam for nonconvulsive status epilepticus and underwent a lumbar peritoneal shunt surgery for secondary hydrocephalus. However, the patient remained listless. Conclusion: Postoperative cerebral vasospasm and infarction are severe but rare complications for a pituitary adenoma after transsphenoidal surgery. Preoperative and intraoperative subarachnoid hemorrhage might have been a risk factor in our case. Similar cases should be warranted to analyze whether cerebral superficial siderosis may also indicate the risk of severe postoperative vasospasm immediately after transsphenoidal surgery for pituitary adenoma.

The Clinical Variables Predicting the Acquisition of Independent Ambulation in the Acute Phase of Stroke: A Retrospective Study.

BACKGROUND: Predictive factors associated with independent ambulation post-stroke are less commonly reported for patients during the acute phase of stroke. This study aimed to identify the clinical variables predicting ambulation independence in the acute phase of stroke and test the superiority of their prediction accuracy. METHODS: Sixty-nine patients, hospitalized in the acute phase for an initial unilateral, supratentorial stroke lesion, were divided into independent (n = 24) and dependent ambulation (n = 45) groups, with functional ambulation category scores of 4-5 and ≤ 3, respectively. They were evaluated upon admission using the modified Rankin scale (mRS), Stroke Impairment Assessment Set (SIAS) concerning the motor function of the lower extremities, Ability for Basic Movement Scale modified version 2 (ABMS2), and Functional Independence Measure (FIM). RESULTS: The scores of the four measures were significantly different between the groups. A univariate logistic regression analysis identified these variables as prognostic factors for independent ambulation. A receiver operating characteristic curve analysis identified the cutoff values (area under the curve) for the mRS, SIAS, FIM, and ABMS2 as 3 (0.74), 12 (0.73), 55 (0.85), and 23 (0.84), respectively. CONCLUSION: In summary, the FIM and ABMS2 may be more accurate in predicting ambulation independence in patients with stroke during the acute phase.

Bilateral Percutaneous Transpedicular Drainage under Local Anesthesia for Thoracic Tuberculous Spondylitis.

Tuberculous spondylitis is a common spinal infection. If surgical intervention is necessary, anterior debridement and anterior fixation are typically performed. However, a minimally invasive surgical strategy under local anesthesia seems rarely implemented. A 68-year-old man presented with severe pain in the left flank. Whole spinal magnetic resonance imaging revealed abnormal intensity of vertebral bodies from T6-9. A bilateral paravertebral abscess extending from T4-10 was suspected. The T7/T8 intervertebral disc was destroyed, but severe vertebral deformity or spinal cord compression was not observed. Bilateral percutaneous transpedicular drainage under local anesthesia was planned. The patient was set in the prone position. Under the guide of a biplanar angiographic system, the bilateral drainage tubes were placed paravertebrally in the abscess cavity. The left flank pain improved after the procedure. Laboratory culture of the pus specimen confirmed a diagnosis of tuberculosis. A chemotherapy regimen for tuberculosis was soon initiated. The patient was discharged during postoperative week 2, with continuation of chemotherapy for tuberculosis. Percutaneous transpedicular drainage under local anesthesia can be effective in the management of thoracic tuberculous spondylitis without severe vertebral deformity or compression of the spinal cord by an abscess.

Successful Continuation of Oral Intake in a Dysphagic and Tetraplegic Patient With Alternate Right and Left Complete Lateral Decubitus Positions in Rehabilitation.

Cervical spinal cord injury can result in dysphagia and tetraplegia. Dysphagia therapy can be required to avoid aspiration pneumonia during oral intake for persons with cervical spinal cord injury. Complete lateral decubitus position may be a specific position for safe swallowing. However, the literature on dysphagia therapy in complete lateral decubitus position for persons with tetraplegia and dysphagia is limited. We present the case of a 76-year-old man with dysphagia and tetraplegia secondary to cervical cord injury. As the patient wished for oral intake, swallowing training in an elevated position of the head at 60° was already initiated. Two days after admission, aspiration pneumonia occurred. As the spasticity increased continuously, the patient could not comfortably undertake swallowing training in an elevated head position of 60°. The flexible endoscopic evaluation of swallowing (FEES) was performed for the patient. The patient did not swallow water or jelly safely in an elevated head position. However, the patient swallowed jelly safely in the right complete lateral decubitus position. Two months after the initiation of oral intake in the right complete lateral decubitus position, the second FEES revealed that the patient swallowed jelly and food in the form of paste safely in the left complete lateral decubitus position. To relieve the pain of the right shoulder induced by continuous right complete lateral decubitus position, the patient retained oral intake in the left or right complete lateral decubitus position alternately for six months without recurrent aspiration pneumonia. Right and left complete lateral decubitus positions when alternately performed in swallowing training can be useful and safe for a patient with dysphagia and tetraplegia secondary to cervical spinal cord injury.

A case of anterior arch fracture of the atlas associated with C1 laminectomy.

Background: Spontaneous anterior arch fracture of the atlas after a C1 laminectomy (CIL) is an extremely rare complication. Case Description: A 72-year-old male presented with the sudden onset of neck pain. His prior history included; a CIL for atlantoaxial subluxation, shunt closure for a spinal dural arteriovenous fistula at C3, a cervical laminoplasty from C3 to C6 for stenosis, and a prior anterior C4/5 and C5/6 fusion 14 years ago. Once the computed tomography documented a right C1 anterior arch fracture, and occipital-cervical fusion was performed utilizing C2 laminar screws and C4 pedicle screws with halo-vest placement. Postoperatively, the neck pain resolved and he remained stable. Conclusion: Neurosurgeons should be aware of the risk of anterior arch fractures following a CIL and may alternatively consider a C1 laminoplasty in the future.

Intramedullary feeder aneurysm of a cervical epidural arteriovenous fistula causing myelopathy: a case report and literature review.

While a craniocervical junction (CCJ) epidural arteriovenous fistula (EDAVF) may present with hemorrhagic myelopathy from an associated feeder aneurysm on rare occasions, non-hemorrhagic myelopathy from such an aneurysm remains unreported. A woman in her late sixties presented with cervical myelopathy due to a non-hemorrhagic intramedullary aneurysm associated with CCJ-EDAVF. The intramedullary aneurysm originated from the spinal pial artery supplied by the anterior spinal artery. Direct surgical fistula coagulation and feeder obliteration resulted in the disappearance of the aneurysm and myelopathy improvement. This report illustrates the first case of a non-hemorrhagic intramedullary aneurysm associated with CCJ-EDAVF successfully treated with direct surgery.