Neuromuscular choristoma-associated desmoid-type fibromatosis: Establishing a nerve territory concept.

INTRODUCTION: Desmoid-type fibromatosis (DTF) frequently arises in patients with neuromuscular choristoma (NMC). We hypothesize that NMC-associated DTF occurs in soft tissues innervated by the NMC-affected nerve, and arises from CTNNB1-mutated (myo) fibroblasts within or directly adjacent to the NMC. MATERIALS AND METHODS: A retrospective review of patients treated at our institution was performed for patients with biopsy-confirmed diagnosis of NMC-DTF. Clinical presentation, physical examination, electrodiagnostic findings and radiological features (MR and FDG PET/CT images for each NMC-DTF) and pathologic re-review of available materials were analyzed. A literature review was also performed. RESULTS: Eight patients from our institution met the inclusion criteria. All patients presented with neuropathic symptoms and soft tissue or bone changes in the nerve territory innervated by the NMC. All MR images (N=8 cases) showed the characteristic features of NMC, and also showed direct contact between unifocal (N=5) or multifocal (N=3) DTF(s) and the NMC-affected nerve NMC. FDG PET/CT (N=2 cases) showed diffuse, increased FDG uptake along the entire affected nerve segment, contiguous with the FDG-avid DTF. In all cases, the DTFs arose in the soft tissues of the NMC-affected nerve's territory. No patient developed DTF at any other anatomic site. CONCLUSIONS: These data demonstrate that NMC-DTF arises solely within the NMC-affected nerve territory, and has direct contact with the NMC itself. Based on all these findings and the multifocality of NMC in several cases, we recommend imaging and surveillance of the entire NMC-affected nerve (from spine to distal extremity) to identify clinically-occult DTF in patients with NMC.

Targeted fascicular biopsy in a patient with prostate cancer.

Patients who present with a history of cancer and the new onset of lumbosacral or peripheral neuropathy should be evaluated for the potential of metastasis. Targeted fascicular biopsy can be useful to diagnose atypical lesions within peripheral nerves in patients with major or progressive neurological deficits. In this video, the authors demonstrate the technique of targeted fascicular biopsy of the sciatic nerve in a 63-year-old man with a history of prostate cancer. The video can be found here: https://youtu.be/PTOX9XxNBDU .

Extensive perineural spread of an intrapelvic sciatic malignant peripheral nerve sheath tumor: a case report.

Perineural spread has been described in multiple neoplasms of neural and non-neural origin. The peripheral nervous system may represent a highway by which tumors can spread throughout the body. Malignant peripheral nerve sheath tumor (MPNST) is a neoplasm arising from peripheral nerves with high rates of local recurrence and distant metastases, leading to a poor 5-year overall survival. In many cases, the optimal treatment involves wide en bloc excision with negative margins as well as chemotherapy and radiation. Even in cases of negative surgical margins, recurrence rates are high, suggesting possible skip lesions or very distant infiltration along the involved nerve. We report a case of high-grade MPNST of the sciatic nerve with post-mortem dissection and histopathologic characterization of perineural spread of microscopic disease to sites significantly proximal and distal to areas with evidence of gross disease, which may help to explain the high rates of local and distal recurrence in MPNST.

Intraoperative intravenous fluorescein as an adjunct during surgery for peroneal intraneural ganglion cysts.

The intraoperative use of intravenous fluorescein is presented in a case of peroneal intraneural ganglion cyst. When illuminated with the operative microscope and yellow filter, this fluorophore provided excellent visualization of the abnormal cystic peroneal nerve and its articular branch connection. The articular (synovial) theory for the pathogenesis of intraneural cysts is further supported by this pattern of fluorescence. Further, our report presents a novel use of fluorescein in peripheral nerve surgery.

Accessory neuropathy after sternotomy: Clinico-anatomical correlation supporting an inflammatory cause.

Inflammatory etiologies are becoming increasingly recognized as explanations of some neuropathies, especially those occurring in the perioperative period. Although "brachial neuritis" is known to affect extraplexal nerves, accessory nerve palsy following median sternotomy has been attributed to stretch on the nerve. To better elucidate stretch as a potential cause, a cadaveric study was performed. Two patients who developed accessory nerve palsy following median sternotomy are presented to illustrate features consistent with the diagnosis of a perioperative inflammatory neuropathy. Five adult unembalmed cadavers underwent exposure of the bilateral accessory nerves in the posterior cervical triangle. A median sternotomy was performed and self-retaining retractors positioned. With the head in neutral, left rotation and right rotation, retractors were opened as during surgery while observing and recording any accessory nerve movements. The self-retaining sternal retractors were fully opened to a mean inter-blade distance of 13 cm. Regardless of head position, from the initial retractor click to maximal opening there was no gross movement of the accessory nerve on the left or right sides. Opening self-retaining sternal retractors does not appear to stretch the accessory nerve in the posterior cervical triangle. Based on our clinical experience and cadaveric results, we believe that inflammatory conditions, (i.e., idiopathic brachial plexitis) can involve the accessory nerve, and might be triggered by surgical procedures. Clin. Anat. 31:417-421, 2018. © 2017 Wiley Periodicals, Inc.

Predictive multivariate regression to increase the specificity of carotid duplex ultrasound for high-grade stenosis in asymptomatic patients.

BACKGROUND: Carotid duplex ultrasound (CDUS) is commonly used to screen for carotid artery stenosis. Specificities of CDUS criteria however are lower than sensitivities, potentially resulting in false-positive examinations with subsequent unnecessary imaging or surgery. Our objective was to establish a multivariate logistic regression to increase the specificity of CDUS for high-grade (≥70%) stenosis. METHODS: A retrospective review collected CDUS velocities and radiographic measurements from patients who underwent both CDUS and computed tomography angiography (CTA). After stratification with standard CDUS criteria, a logistic regression was created using peak systolic velocity (PSV), end diastolic velocity (EDV), and PSV ratio (PSV of internal carotid artery [ICA]/PSV of common carotid artery [CCA]) as predictor variables. A receiver operating characteristic curve was generated to test the model's predictive ability. A cutoff probability for unequivocal high-grade stenosis was chosen based on optimal specificity. The regression model was applied to patients with equivocal high-grade stenosis. Probabilities for detection of high-grade stenosis were calculated. Descriptive statistics were generated to quantify the accuracy of the model. RESULTS: A total of 244 vessels were included. Standardized velocity criteria for ≥70% stenosis yielded a sensitivity of 90.6% (95% confidence interval [CI], 82.3-95.6%), specificity of 63.5% (95% CI, 55.4-70.5%), positive predictive value (PPV) of 57.0% (95% CI, 48.8-65.5%), and negative predictive value (NPV) of 92.7% (95% CI, 85.8-96.5%). Regression analysis produced a model for predicting the probability of high-grade stenosis defined as probability = logit(-1) (-4.97 + [0.00938 × PSV] + [0.0135 × EDV] + [0.103 × PSV ICA/CCA ratio]). A cutoff probability of 0.65 for high-grade stenosis yielded a sensitivity of 54.7% (95% CI, 43.9-65.0%), specificity of 94.3% (95% CI, 89.3-97.2%), PPV of 83.9% (95% CI, 71.6-91.9%), and NPV of 79.3% (95% CI, 72.8-84.5%). A cutoff PSV of 400 cm/sec was chosen for unequivocal stenosis of ≥70%. A total of 94 patients were found to meet criteria for high-grade stenosis (PSV ≥ 230 cm/sec) but fall short of criteria for unequivocal high-grade stenosis (PSV < 400 cm/sec). Application of the regression model resulted in identification of 15 patients with probability ≥0.65 for high-grade stenosis and 79 patients with probability <0.65. This resulted in a 16% potential reduction in CTA scans. CONCLUSIONS: Our regression model provides increased specificity of CDUS for high-grade stenosis in patients who have met initial highly sensitive screening criteria. Application of this model may limit the need for additional imaging and increase the threshold for operative intervention in asymptomatic patients with equivocal high-grade carotid stenosis.

CT angiography-derived duplex ultrasound velocity criteria in patients with carotid artery stenosis.

BACKGROUND: Validation of carotid duplex ultrasound velocity criteria (CDUS VC) to grade the severity of extracranial carotid artery stenosis has traditionally been based on conventional angiography measurements. In the last decade, computed tomographic angiography (CTA) has largely replaced conventional arch and carotid arteriography (CA) for diagnostic purposes. Given the low number of CA being performed, it is impractical to expect noninvasive vascular laboratories to be validated using this modality. CDUS VC have not been developed with the use of CTA-derived measurements. The objective was to determine optimal CDUS VC from CTA-derived measurements with the North American Symptomatic Carotid Endarterectomy Trial (NASCET) method for 50% and 80% stenosis. METHODS: A retrospective review of all patients who underwent CDUS and CTA from 2000 to 2009 was performed. Vessel diameters were measured on CTA, and corresponding CDUS velocities were recorded. Percent stenosis was calculated using the NASCET method. Receiver operating characteristic (ROC) curves were generated for internal carotid artery (ICA) peak systolic velocity (PSV), ICA end diastolic velocity (EDV), and ICA PSV to common carotid artery PSV ratio (PSVR) for 50% and 80% stenosis. Velocity cut points were determined with equal weighting of sensitivity and specificity. RESULTS: A total of 575 vessels were analyzed to create the ROC curves. A 50% stenosis analysis yielded ideal cut points for PSV, EDV, and PSVR of 130 cm/sec, 42 cm/sec, and 1.75. An 80% stenosis analysis yielded ideal cut points for PSV, EDV, and PSVR of 297 cm/sec, 84 cm/sec, and 3.06. CONCLUSIONS: CTA-derived CDUS VC appeared to be reliable in defining 50% and 80% stenosis in patients with carotid artery stenosis. Although CDUS VC defined in this study were different from many of the previously published VC for the same percent stenosis, there were many similarities to those reported by the Society of Radiologists in Ultrasound consensus conference. We feel that CTA should be the gold standard imaging technique for validating CDUS VC.

The effects of socioeconomic status and race on pediatric neurosurgical shunting.

PURPOSE: It is established in the literature that disparities exist in the quality of healthcare for patients from disadvantaged backgrounds and lower socioeconomic status. There may be roadblocks within the field of neurosurgery preventing equal access and quality of care. Our goal was to study the similarities between pediatric patients with shunted hydrocephalus of different insurance types and race. METHODS: A retrospective chart review was performed on all pediatric patients who underwent ventriculoperitoneal shunting from 1990-2010 at our institution. Race and insurance type were recorded and assessed against specific outcome measures to statistically compare complication rates. RESULTS: A complete record was found for 373 patients who received 849 shunting procedures at our institution. No differences were found between racial groups and insurance type for overall shunt survival, total revision number, or average time to failure. However, nonwhite patients spent an average of 3 days longer in the hospital at initial shunting (p = 0.04), and those with public insurance stayed for 5 days longer (p = 0.002). Patients with public insurance were more likely to present with shunt failure from outside hospitals (p = 0.005) and be born prematurely (p < 0.001). Private patients were more likely to have a neoplasm present at time of initial shunt placement (p = 0.003). CONCLUSION: While overall revision rate was not affected by race or insurance status, there were significant delays in discharge for patients with public insurance. Moreover, potential disparities in outpatient access to primary physicians and specialists may be affecting care.

A Simple 3D Printed Model for Intracranial Vascular Anastomosis Practice and the Rochester Bypass Training Score.

BACKGROUND AND OBJECTIVES: Surgical simulation models in cranial neurosurgery are needed to allow affordable, accessible, and validated practice in resident education. Current bypass anastomosis practice models revolve around basic tube tying or complex animal and 3-dimensional models. This study sought to design and validate a 3-dimensional printed model for intracranial anastomosis training. METHODS: A computer-aided design (CAD) generic skull was uploaded into Meshmixer (v.3.5), and a 55-mm opening was created on the right side, mimicking a standard orbitozygomatic craniotomy. The model was rotated 15° upward and 35° left, before a 10-mm square frame was added 80-mm deep to the right orbit. The CAD model was uploaded to GrabCAD and printed using a J750 PolyJet 3D printer before being paired with a vascular anastomosis kit. The model was validated with standardized assessments of residents and attendings by simulating an "M2 to P2" bypass. The Rochester Bypass Training Score (RBTS) was created to assess bypass patency, back wall suturing, and suture quality. Postsimulation survey data regarding the realism and usefulness of the simulation were collected. RESULTS: Five junior residents (Postgraduate Year 1-4), 3 senior residents (Postgraduate Year 5-7), and 2 attendings were participated. The mean operative time in minutes was as follows: junior residents 78, senior residents 33, and attendings 50. The RBTS means were as follows: junior residents 2.4, senior residents 4.0, and attendings 5.0. Participants agreed that the model was realistic, useful for improving operative technique, and would increase comfort in bypass procedures. There are a few different printing options, varying in model infill and printing material used. For this experiment, a mix of Vero plastics were used totaling $309.09 per model; however, using the more common printing material polylactic acid brings the cost to $17.27 for a comparable model. CONCLUSION: This study presents an affordable, realistic, and educational intracranial vascular anastomosis simulator and introduces the RBTS for assessment.

Multi-institutional review of characteristics and management of gunshot wounds to the spine.

BACKGROUND CONTEXT: Gunshot wounds (GSWs) to the vertebral column represent an important cause of morbidity and mortality in the United States, constituting approximately 20% of all spinal injuries. The management of these injuries is an understudied and controversial topic, given its heterogeneity and lack of follow-up data. PURPOSE: To characterize the management and follow-up of GSWs to the spine. STUDY DESIGN/SETTING: A multi-institutional retrospective review of the experience of two urban Level 1 trauma centers. PATIENT SAMPLE: Patients with GSWs to the spine between 2010-2021. OUTCOME MEASURES: Measures included work status, follow-up healthcare utilization, and pain management were collected. METHODS: Charts were reviewed for demographics, injury characteristics, surgery and medical management, and follow-up. Statistical analysis included T-tests and ANOVA for comparisons of continuous variables and chi-square testing for categorical variables. All statistics were performed on SPSS v24 (IBM, Armonk, NY). RESULTS: A total of 271 patients were included for analysis. The average age was 28 years old, 82.7% of patients were black, 90% were male, and 76.4% had Medicare/Medicaid. The thoracic spine (35%) was most commonly injured followed by lumbar (33.9%) and cervical (25.6%). Cervical GSW was associated with higher mortality (p<.001); 8.7% of patients developed subsequent osteomyelitis/discitis, 71.3% received prophylactic antibiotics, and 56.1% of cervical GSW had a confirmed vertebral or carotid artery injury. ASIA scores at presentation were most commonly A (26.9%), D (20.7%), or E (19.6%), followed by C (7.4%) and B (6.6%). 18.8% of patients were unable to be assessed at presentation. ASIA score declined in only 2 patients, while 15.5% improved over their hospital stay. Those who improved were more likely to have ASIA B injury (p<.001). Overall, 9.2% of patients underwent spinal surgery. Of these, 33% presented as ASIA A, 21% as ASIA B, 29% as ASIA C, and 13% as ASIA D. Surgery was not associated with an improvement in ASIA score. CONCLUSIONS: Given the ubiquitous and heterogeneous experience with GSWs to the spine, rigorous attempts should be made to define this population and its clinical and surgical outcomes. Here, we present an analysis of 11 years of patients presenting to two large trauma centers to elucidate patterns in presentation, management, and follow-up. We highlight that GSWs to the cervical spine are most often seen in young black male patients. They were associated with high mortality and high rates of injury to vertebral arteries and that surgical intervention did not alter rates of discitis/osteomyelitis or propensity for neurologic recovery; moreover, there was no incidence of delayed spinal instability in the study population.

Management and outcomes of cerebrovascular injuries after gunshot wounds to the cervical spine.

STUDY DESIGN: This study was a multicenter retrospective analysis of cervical spine gunshot wound (GSW) patients. OBJECTIVE: The present study was conducted to evaluate the management and outcomes of vascular injuries following GSW involving the cervical spine. SUMMARY OF BACKGROUND DATA: Gunshot wounds (GSW) injuring the cervical spine are associated with high rates of vascular injury. METHODS: Charts of patients with GSW involving the cervical spine at two Level 1 trauma centers were reviewed from 2010 to 2021 for demographics, injury characteristics, management and follow-up. Statistical analysis included T tests and ANOVA for comparisons of continuous variables and chi-square testing for categorical variables, non-parametric tests were used when indicated. Beta-binomial models were used to estimate the probabilities outcomes. Bayesian regression models were utilized to compute risk ratios (RR) and their 95 % confidence intervals (CI) to enhance the inferential robustness. RESULTS: 40 patients with cervical spine GSW and associated cerebrovascular injury were included in our analysis. 15 % of patients had Biffl grade (BG) V injuries, 50 % grade IV, and 35 % grade III-I. Angiography was performed in 35 % of patients. 5 of these patients (BG V-III) required endovascular treatment for pseudoaneurysm obliteration or parent vessel sacrifice. 7 patients (22 %) showed evidence of progression. 70 % of patients were placed on antiplatelet therapy for stroke prevention. Bayesian regression models with a skeptical prior for cerebral ischemia revealed a mean RR of 4.82 (95 % CI 1.02-14.48) in the BG V group, 0.75 (95 % CI 0.13-2.26) in the BG IV group, and 0.61 (95 % CI 0.06-2.01) in the combined BG III-I group. For demise the mean RR was 3.41 (95 % CI 0.58-10.65) in the BG V group and 1.69 (95 % CI 0.29-5.97) in the BG IV group. In the high BG (V, IV) group, 54.55 % of patients treated with antiplatelet therapy had complications. None of the patients that were treated with antiplatelet therapy in the low BG (III-I) group had complications. CONCLUSIONS: Cervical spine GSWs are associated with high-grade vascular injuries and may require early endovascular intervention. Additionally, a high rate of injury progression was seen on follow up imaging, requiring subsequent intervention. Reintervention and demise were common and observed in high BG (V, IV) groups. The incidence of stroke was low, especially in low BG (I-III) groups, suggesting that daily aspirin prophylaxis is adequate for long-term stroke prevention.

Cross-sectional area for the calculation of carotid artery stenosis on computed tomographic angiography.

OBJECTIVE: The use of cross-sectional area (CSA) measurements obtained from computed tomographic angiography (CTA) for the calculation of carotid artery stenosis has been suggested but not yet validated in a large population. The objective of this study was to determine whether CTA-derived CSA measurements were able to predict carotid stenosis with a level of confidence similar to CTA-derived diameter measurements, using Strandness criteria applied to carotid duplex ultrasound (CDUS) as a surrogate for true stenosis. METHODS: A retrospective review was conducted to identify patients who underwent both CDUS and CTA between 2000 and 2009. Percent stenosis was calculated using the North American Symptomatic Carotid Endarterectomy Trial (NASCET) formula with diameter measurements and again with CSA measurements. A nonparametric correlation coefficient was calculated to detect correlation between the two groups. Two-dimensional receiver-operating characteristic curves with corresponding area under the curve (AUC) statistics were generated for >50% stenosis and >80% stenosis. Three-dimensional receiver-operating characteristic plots with corresponding volume under the surface (VUS) statistics were generated to measure the comparative accuracy of diameter-based and CSA-based stenosis for <50%, 50%-79%, and >80% stenosis. RESULTS: A total of 575 vessels in 313 patients were included in the study. Spearman's correlation coefficient between diameter and CSA-derived stenosis was ρ = 0.938 (95% confidence interval [CI], 0.927-0.947; P < .0001). For diameter-derived stenosis, AUC was 0.905 (95% CI, 0.878-0.932; P < .0001) for >50% stenosis and 0.950 (95% CI, 0.928-0.972; P < .0001) for 80%-99% stenosis. For CSA-derived percent stenosis, the AUC was 0.908 (95% CI, 0.882-0.935; P < .0001) for >50% stenosis and 0.935 (95% CI, 0.908-0.961; P < .0001) for 80%-99%. The nonparametric estimate for VUS in the diameter-based stenosis group was 0.761, whereas in the CSA-based group, the VUS was 0.735. The difference between VUS was 0.026 (95% CI, -0.022 and 0.077; P = .318). CONCLUSIONS: These data support the use of CTA as an accurate method of calculating carotid artery stenosis based on agreement with Strandness criteria applied to CDUS velocities. When additional imaging beyond CDUS is necessary, we report no significant difference between diameter and CSA measurements obtained from CTA for preoperative evaluation of carotid disease.

Delayed myelopathy after remote C1-2 sublaminar wire fixation: illustrative case.

BACKGROUND: Atlantoaxial sublaminar wiring complications, both early and delayed, have been documented. However, delayed neurological compromise 27 years after successful fusion is a rare but possible occurrence. OBSERVATIONS: A 76-year-old male, who had undergone C1-2 sublaminar wire fusion for atlantoaxial instability in 1995, presented with symptoms of progressive right arm weakness, falls, and incontinence of bowel and bladder over a 1-week period. Initial imaging workup revealed bowing of the C1-2 sublaminar wires resulting in cervical spinal cord compression and T2-weighted signal changes. A C1-2 laminectomy was performed to remove the wires and decompress the spinal cord with improvement in the patient's neurological status. LESSONS: This rare case highlights the potential for delayed cervical myelopathy and cord compression from sublaminar wires, even after a successful fusion. In patients with a history of sublaminar wiring who experience new neurological deficits, it is essential to evaluate the hardware for migration.

Treatment of hydrocephalus in an ovine model with an intraparenchymal stent.

OBJECTIVE: While CSF diversion is highly effective at treating hydrocephalus, shunting is unfortunately associated with a very high revision rate. Studies have demonstrated that proximal catheter obstruction is a major cause of failure. A novel proximal access device was developed, and pilot testing was performed in a sheep model of hydrocephalus. METHODS: Hydrocephalus was induced in 8 sheep using a cisternal injection of 4 ml of 25% kaolin, and the sheep were randomized to either a standard ventricular catheter or a novel intraparenchymal stent (IPS). Both groups received identical valves and distal catheters. The novel device included a 3D-printed stainless steel port and a 6 × 40-mm covered peripheral vascular stent. Animals were euthanized for signs of hydrocephalus or at a time point of 2 months. MRI was performed to determine ventricular size. Time to failure and Evans indices were compared using the Wilcoxon rank-sum test. RESULTS: All 4 experimental devices were placed without difficulty into the right lateral ventricle. There was a trend toward longer survival in the experimental group (40 vs 26 days, p = 0.24). Within the IPS group, 3 of the 4 sheep did not experience clinical symptoms of shunt failure and had an average of 37% decrease in Evans index. While 3 of 4 traditional proximal catheters demonstrated debris within the inlet holes, there was no obstructive material found in the IPSs. CONCLUSIONS: An IPS was successfully used to treat hydrocephalus in a sheep model. While statistical significance was not achieved, there were clear benefits to using a stent, including a decreased clog rate and the ability to perform a percutaneous revision. Further testing is needed to ensure efficacy and safety prior to human application.

Indications for pediatric external ventricular drain placement and risk factors for conversion to a ventriculoperitoneal shunt.

BACKGROUND/AIMS: The external ventricular drain (EVD) is commonly used for the treatment of hydrocephalus and intracranial pressure (ICP) monitoring. In this study, we retrospectively reviewed indications for EVD placement over the last 20 years in pediatric patients at our institution. Additionally, we evaluated the rate that an EVD needed to be converted to a ventriculoperitoneal shunt (VPS) and ascertained how hydrocephalus etiology impacted long-term drainage requirements. METHODS: Patients that received an EVD between 1990 and 2010 at our institution were identified using billing codes. Demographics, etiology of hydrocephalus, length of stay (LOS) and EVD duration were recorded. Only patients receiving their first EVD were included; those with any prior ventricular catheter (including prior shunts) were excluded from this study. RESULTS: A total of 180 patients underwent first-time placement of an EVD over the 20-year period. Of these, 78.9% were placed on the right side and 81.7% were performed through a frontal burr hole site. The average age of all patients at their initial procedure was 9.3 years (median 9.8; range 0-18), hospital LOS was 22.5 days (median 16; range 1-174) and EVD duration was 7.8 days (median 7; range 1-37). Trauma (43.3%) and neoplasms (32.2%) were the most common indications. Approximately, one quarter of the patients were unable to become EVD independent and, therefore, required a VPS. Only patients receiving an EVD for traumatic brain injury were significantly less likely to be converted to a shunt than other causes of hydrocephalus (relative risk, RR = 0.18, 95% confidence interval, CI = 0.07-0.46). Conversely, patients with neoplasms (RR = 3.56, 95% CI = 1.74-7.31), obstructive hydrocephalus (RR = 5.48, 95% CI = 1.37-22.0) and intraventricular hemorrhage (RR = 9.86, 95% CI = 1.05-92.3) were more likely to need a shunt. CONCLUSION: Traumatic brain injuries and neoplasms represent the most common indications for EVD placement in the pediatric population. While patients with neoplasm were much more likely to need conversion to a VPS for long-term cerebrospinal fluid diversion, the majority of EVDs in patients with head injuries were successfully weaned.

Meningitis due to intra-abdominal cerebrospinal fluid fistula following gunshot wound successfully treated with antibiotics and blood patch: A case report and literature review.

Background: Penetrating spinal cord injury (PSCI) represents an average of 5.5% of all SCIs among civilians in the United States. The formation of a cerebrospinal fluid (CSF) fistula following PSCI occurs in approximately 9% of cases. Intra-abdominal CSF fistulae are rarely reported. Case Description: We present the case of a 28-year-old Caucasian female who suffered a single gunshot wound to the abdomen with a missile fragment lodged within the left L2 pedicle and transverse process without obvious canal compromise. The patient developed bacterial meningitis 13 days after the initial injury, treated with IV antibiotics. CT myelogram demonstrated intra-abdominal ventral CSF fistula from the left L2-L3 neuroforamen. The patient was successfully treated with fluoroscopy-guided dorsal autologous blood patch graft. Conclusion: This case highlights a rare complication of PSCI successfully managed with the use of a blood patch graft.

Remote surgical education using synthetic models combined with an augmented reality headset.

Objective: The objective was to investigate the use of an augmented reality headset to remotely train clinicians on medical devices using anatomic models. Design: Disease-specific phantoms were developed to train physicians in mpMRI-guided fusion prostate biopsy, brachytherapy, and rectal spacer insertion. Training was remotely demonstrated using 1-way virtual video conferencing format. Participants responded to an educational content survey. A heads-up display with software and augmented reality was used for remote 2-way training with the proctor and student using on their own phantoms. Setting: The virtual video meeting took place during a prostate cancer conference in 2020, while the augmented reality training occurred in 2021. The proctor and student wore a heads-up display containing a projector and webcam where the ultrasound image was displayed onto a see-through optic along with the physician's hands. The heads-up display allowed the proctor to teach by line-of-sight while the student watched and repeated the steps. Participants: Faculty with expertise with the medical devices used in these procedures provided training to urologists unfamiliar with these techniques. Results: Participants responded that the 1-way training on the phantoms was realistic and mimicked human tissue. A total of 70.9% requested more training or training on the phantoms. The remote training platform was successfully beta tested at the 2 locations in transperineal prostate biopsy and rectal spacer insertion. Conclusion: Remote training using augmented reality eliminates the need for travel. For training programs and workshops, this technology may mitigate the risk of infectious exposures, reduce training cost, and increase proctor availability, allowing training from their own institution or clinic.This investigation qualifies for the Accreditation Council for Graduate Medical Education competency in medical knowledge.

Does neoadjuvant hormonal therapy improve urinary function when given to men with large prostates undergoing prostate brachytherapy?

PURPOSE: We evaluated the effect of neoadjuvant hormonal therapy on urinary function in men with a prostate volume of 50 cc or greater undergoing prostate brachytherapy. MATERIALS AND METHODS: A total of 395 men with 50 cc or greater glands were treated with 3 months of neoadjuvant hormonal therapy (204) or implantation alone (191). Urinary function was assessed by the International Prostate Symptom Score, the urinary retention incidence and subsequent transurethral prostate resection. RESULTS: Median patient age was 67 years and median followup was 6 years. Mean prostate volume in neoadjuvant hormonal therapy cases was 72.9 cc, which decreased to 54.3 cc after 3 months (p <0.001). Mean prostate volume in cases without hormonal therapy was 60.6 cc (p <0.001). Urinary retention occurred in 16 of 191 men (8.4%) without vs 25 of 204 (12.3%) with hormonal therapy (p = 0.207). The median duration of urinary retention was 42 days (range 2 to 243). There were no significant associations of urinary retention with prostate size, prostate or urethral dose, or pre-implantation International Prostate Symptom Score. Of patients without hormonal therapy retention occurred in 3 of 12 (25%) with a pre-implantation International Prostate Symptom Score of 15 or greater and in 13 of 168 (7.7%) with a score of less than 15 (OR 4.0, 95% CI 1-16, p = 0.04). In contrast, there was no difference in the retention rate in patients with hormonal therapy with an initial score of 15 or greater vs less than 15 (2 of 25 or 8% vs 11 of 102 or 10.8%, p = 0.614). Transurethral prostate resection was done in 11 of 191 men (5.8%) without vs 12 of 204 (5.9%) with hormonal therapy (p = 0.958). There was no difference in biochemical failure in the 2 groups. CONCLUSIONS: Neoadjuvant hormonal therapy has its greatest benefit in patients receiving brachytherapy who have a large prostate and an International Prostate Symptom Score of 15 or greater.

Go for the Gold: A "Plane" and Simple Technique for Resecting Benign Peripheral Nerve Sheath Tumors.

BACKGROUND: Intraneural dissection is a useful technique for achieving gross total resection and preserving functional fascicles for peripheral nerve tumors. Finding the correct tissue plane is the critical step for safe successful enucleation. The authors hypothesized that the yellow color of benign nerve tumors can be used to identify surgical planes. OBJECTIVE: To describe a technique to find the correct intraneural dissection plane based on a quantified yellow appearance during resection of benign peripheral nerve sheath tumors. METHODS: Intraoperative photographs were reviewed to determine the percentage of yellow that tumors appeared at different phases of surgery. A technique was developed to quantitatively measure the amount of yellow using Photoshop. Previously published journal articles containing color images of peripheral nerve tumor resections were also analyzed for yellow tumor color. RESULTS: There were 24 patients with suitable images to permit measurement of color for 3 steps of the procedure. The average percentages of yellow for tumor exposure, tumor resection, and removed specimen were 36.5%, 59.1%, and 80.4%, respectively (P < .001). Three publications were found that contained high-quality images of at least 2 phases of the surgery with average yellow content of 47.4% and 84% (P < .01). CONCLUSION: The simple observation that a benign nerve sheath tumor is yellow in color can be used to guide surgical resection and achieve excellent outcomes. Intraneural dissection through the pseudocapsule should be pursued layer by layer until a yellow true capsule is found. By sparing functional nervous tissue within the pseudocapsule, this technique may lead to improved neurological outcomes.