Iatrogenic cerebrospinal fluid leak and intracranial hypotension after gynecological surgery.

Perineural cysts are common lesions of the sacral spine. They have rarely been reported in a presacral location, leading to their misdiagnosis as a gynecological lesion. The authors report the second such case, in a patient undergoing fenestration of what was presumed to be a benign pelvic cyst, and the resultant high-flow CSF leak that occurred. They describe the clinical presentation and manifestations of intracranial hypotension, as well as the pertinent investigations. They also review the literature for the best management options for this condition. Although they are uncommon, large perineural cysts should be included in the differential diagnosis when examining patients with a pelvic lesion. Appropriate imaging investigations should be performed to rule out a perineural cyst. The CSF leak that occurs from iatrogenic cyst fenestration may not respond to traditional first-line treatments for intracranial hypotension and may require early surgical intervention. The authors would recommend neurosurgical involvement prior to definitive treatment.

What would I want for my surgery?

If you were to have an operation tomorrow, would you want your surgical team members to feel comfortable speaking up, to defy hierarchy, to interact with each other just as well as they perform technical aspects of the procedure? Would you want to feel like part of the team? Your answers to these admittedly leading questions are based on the culture of the surgical team and the interdependence of team members and are at the heart of a current debate around the surgical checklist's effectiveness. In British Columbia (BC), many individuals responded to the paper by Urbach et al. (2014) that described the minimal impact on patient mortality after implementation of the surgical safety checklist in Ontario. They wrote to the Surgical Quality Action Network (SQAN) to express their perspectives, and interestingly, some refuted and others supported the conclusions. Given the strong reaction this study created in the surgical community, a number of key stakeholders have prepared a response in order to provide another perspective to the article and emphasize the checklist's value for improving the culture of surgical teams.

Esophageal perforation from anterior cervical screw migration.

BACKGROUND: Esophageal perforation from anterior cervical instrumentation migration is an uncommon but potentially highly morbid or even fatal complication. Early recognition and aggressive investigation and treatment are essential to ensure good outcome. CASE DESCRIPTION: A 58-year-old man underwent C6 vertebrectomy and C5-7 interbody fusion with a cage and anterior cervical plate. After surgery he developed fever and recurrence of his symptoms and deficits, but was managed expectantly. He was then referred to the author's institution. A barium swallow demonstrated an esophageal fistula (a Gastrograffin swallow was falsely negative) caused by a migrated screw; serial radiographs confirmed its passage through the gastrointestinal tract. Revision surgery was required to repair the perforation and reconstruct the cervicothoracic spine. Intraoperative esophageal injection of methylene blue was helpful in demonstrating the site of leakage. Despite a prolonged postoperative course complicated by pulmonary embolus, the patient recovered with minimal residual deficit, and continues to do well 2 years later. CONCLUSIONS: A high index of suspicion followed by aggressive investigation are crucial in the setting of unexpected neck pain, new neurologic deficit, fever, or swallowing difficulties in the early postoperative period after anterior cervical spine instrumentation. If esophageal perforation is suspected, a barium swallow is recommended over Gastrograffin, which, although less irritating to the surrounding tissues, may be falsely negative. Intraoperative methylene blue injection into the esophageal lumen is useful in identifying the site of perforation.

Usefulness of intracranial EEG in the decision process for epilepsy surgery.

BACKGROUND AND PURPOSE: In patients with discordant results, non-localizing EEG, or bitemporal seizure onset, intracranial monitoring is done to confirm the seizure onset. Our aim was to assess the yield of intracranial recordings in patients with different clinical scenarios. METHODS: The records of all patients who underwent prolonged intracranial EEG monitoring (IEM) at the London Health Sciences Centre, University of Western Ontario, Canada, between 1993 and 1999, identified using our EEG patient database in continuous use since December 1972, were reviewed. Patients were analyzed in the following groups according to perceived increasing degrees of uncertainty of epileptic zone localization-group 1: lesion on MRI congruent with focal ictal and interictal scalp EEG, but findings are subtle and of low level of certainty (n=13), group 2: focal MRI, focal ictal and multifocal interictal scalp EEG (n=11), group 3: focal MRI, non-localizing or incongruent scalp EEG (n=73), group 4: normal of multifocal MRI, focal ictal scalp EEG (n=11), group 5: multifocal MRI, non-localizing scalp EEG (n=18), and group 6: normal MRI, multifocal scalp EEG (n=36). RESULTS: One hundred and seventy one patients underwent IEM at the London Health Sciences Centre between 1993 and 1999. All patients had localization-related epilepsy, plus or minus secondary generalization. IEM was helpful overall in 86% of patients, in 69% of group 1, 36% of group 2, 90% of group 3, 81% of group 4, 100 of group 5 and 92% of group 6. CONCLUSIONS: Our study shows that the yield of the IEM was higher in the groups of patients with lack of congruence between the MRI and the scalp EEG. The yield was lower in patients with congruent but subtle or uncertain scalp EEG and MRI findings.

Pseudogout of the transverse atlantal ligament: an unusual cause of cervical myelopathy.

BACKGROUND: Calcium pyrophosphate dihydrate deposition in the cervical spine is infrequently symptomatic. This is especially true at the craniocervical junction and upper cervical spine. CASE REPORT: A 70-year-old previously healthy woman presented with a progressive cervical myelopathy of four months duration. RESULTS: Examination revealed sensorimotor findings consistent with an upper cervical myelopathy. Radiological studies (plain radiographs, computed tomography, and magnetic resonance imaging) revealed C1-2 instability, and a well-defined extradural 3 cm x 1 cm retro-odontoid mass causing spinal cord compression. Transoral resection of the mass was performed followed by posterior C1-2 stabilization. Histological examination of the mass confirmed calcium pyrophosphate dihydrate deposition. Follow-up examination showed marked clinical and radiological improvement. CONCLUSION: Although uncommon, calcium pyrophosphate dihydrate deposition disease should be considered in the differential diagnosis of extradural mass lesions in the region of the odontoid.

Dexamethasone for morbidity after subdural electrode insertion--a randomized controlled trial.

BACKGROUND: Invasive monitoring with subdural electrodes (SDE) for investigation of medically intractable epilepsy may be associated with undesirable immediate postoperative morbidity such as headache, nausea, vomiting, fever, and meningism. We undertook to evaluate the potential beneficial role of perioperative dexamethasone in reducing these symptoms. METHODS: In a double-blind placebo controlled clinical trial 30 patients undergoing SDE insertion were randomized to receive either placebo or a course of dexamethasone beginning one hour prior to surgery and tapering to discontinue over 72 hours postoperatively. Pain, pain relief, nausea, nausea relief, temperature, and meningism were assessed regularly in the postoperative period, and analgesic, antipyretic, and antiemetic drug requirements were tabulated. RESULTS: One patient was withdrawn from the dexamethasone group due to lack of data. With regards to postoperative pain, the direction of benefit favoured dexamethasone but a significant treatment by time interaction prevented further analysis of treatment effect. The dexamethasone group did have significantly lower temperatures and higher nausea relief scores. There was no statistically significant difference between the groups with regards to pain relief, nausea, and meningism scores. The beneficial effects of dexamethasone were delayed in onset, of limited duration, and not uniform over the observation period. CONCLUSION: Dexamethasone appears to have a role in reducing immediate morbidity following SDE insertion but its effect is not uniform in the postoperative period; it appears to be delayed in onset, and of limited duration. Further study is necessary to determine the ideal dosing schedule.

Idiopathic free-floating thrombus of the common carotid artery.

BACKGROUND: The observation of an intraluminal common carotid artery thrombus overlying a wall defect at ultrasonography or angiography is unusual. To our knowledge, there are no previous reports of a free-floating thrombus in the common carotid artery. CASE REPORT: A 45-year-old woman who was previously healthy and on no medications presented with acute hemiparesis and aphasia. Following testing that included carotid duplex and transcranial Doppler ultrasonography, diffusion-weighted magnetic resonance imaging, and digital subtraction angiography, the patient underwent emergency open embolectomy. No underlying wall defect was seen at the time of imaging or surgery. No obvious hypercoagulable state could be identified. Her NIH Stroke Scale score improved from 26 at admission to 2 at three months and 1 at one year. CONCLUSIONS: Multimodal imaging may have improved diagnosis and management in this patient with a unique finding. The source of the thrombus remains obscure.