Rotational Latissimus Dorsi Flap for Lateral Repair of Thoracic Cerebrospinal Fluid-Pleural Fistula: Case Report.

BACKGROUND AND IMPORTANCE: Giant calcified thoracic discs are challenging surgical pathologies that tend to be more centrally located and calcified. This complicates the removal process and potentiates the formation of dural defects, resulting in persistent cerebrospinal fluid (CSF) leaks and the formation of pleural fistulas. The typical intervention for this is CSF diversion through external ventricular drain or lumbar drain placement, followed by direct repair. However, if all these measures fail, subsequent salvage techniques have not been described previously. CLINICAL PRESENTATION: A 45-year-old man with past medical history of obesity (body mass index: 58), hypertension, and type 2 diabetes mellitus presented to the emergency department with thoracic myelopathy symptoms. MR demonstrated a giant calcified thoracic discs at T7-T8 with severe spinal cord compression. Intraoperatively, the disc was found fused to the dura and removal caused a large ventrolateral dural dehiscence. CSF diversion and direct repair were attempted unsuccessfully, so a salvage procedure with a rotational pedicled latissimus dorsi flap was performed. The patient's latissimus dorsi was exposed and resected from attachments, maintaining thoracodorsal blood supply, while removing thoracodorsal innervation. The flap was then rotated into the previous corpectomy site. The dural defect was repaired with a sealant patch, overlayed with a parietal pleural flap and the latissimus dorsi flap. By the patient's last follow-up, he had full functional independence at home. CONCLUSION: We present a surgical case highlighting the challenges of managing postoperative CSF-pleural fistula occurring after giant calcified thoracic disc removal and the successful use of a novel rotational latissimus dorsi flap to definitively repair the fistula after unsuccessful primary interventions.

Incline and peg spacing have interactive effects on the arboreal locomotor performance and kinematics of brown tree snakes, Boiga irregularis.

Many animals move using lateral undulations, but snakes are noteworthy for using this type of locomotion in an unusual diversity of environments, including trees in which both the spacing and orientation of branches vary considerably. Despite branches providing discrete locations for snakes to generate propulsive forces during lateral undulation, the consequences of branch spacing for the locomotion of snakes are poorly understood. Hence, we determined maximal speeds and kinematics of an arboreal snake (Boiga irregularis) crawling on horizontal and vertical cylinders with pegs that simulated different spacing between secondary branches. Peg spacing, perch orientation and their two-way interaction term had widespread, significant effects on both performance and kinematics. For the horizontal surfaces, maximal locomotor speed occurred with intermediate peg spacing, and it was nearly twice as fast as for both the smallest and largest peg spacings. By contrast, the locomotor speed of snakes on the vertical surfaces was unaffected by peg spacing, and was uniformly slower than that for the horizontal surfaces. For both perch orientations, the number of pegs touched by the snake decreased as peg spacing increased, and while touching only one peg the snakes crawled with apparent ease and steady speed. The snakes crawled vertically with only one peg as quickly as they did using 2-10 pegs. Pegs on a horizontal cylinder are probably important both for propulsion of snakes and prevention of long-axis rolling, whereas pegs protruding from vertical cylinders and those protruding from horizontal planar surfaces are probably used almost exclusively for propulsion.

Resection of intradural intramedullary subependymoma of the cervicothoracic spine: 2-dimensional operative video.

This video presents the case of a 44-year-old male with a 2-year history of pain in the left upper extremity that had worsened over the course of the last 6 months with associated weakened grip strength and had extended into his right arm. T2-weighted sagittal and axial MRI demonstrated an expansive nonenhancing solid intramedullary lesion extending from C5 to T1. The patient underwent a C5-T1 laminectomy and laminoplasty with near-complete resection of the intradural intramedullary subependymoma. At 3 months' follow-up, he reported doing well and had experienced significant improvement in motor strength with ongoing therapies.

Baseline parameters and the prediction of treatment failure in patients with intravenous drug use-associated spinal epidural abscesses.

OBJECTIVE: Despite the increasing incidence of spinal epidural abscess (SEA), the baseline parameters potentially predictive of treatment failure remain poorly characterized. In this study, the authors identify the relevant baseline parameters that predict multimodal treatment failure in patients with either intravenous drug use (IVDU)-associated SEA or non-IVDU-associated SEA. METHODS: The authors reviewed the electronic medical records of a large institutional series of consecutive patients with diagnosed SEA between January 2011 and December 2017 to characterize epidemiological trends as well as the complement of baseline measures that are predictive of failure after multimodal treatment in patients with and without concomitant IVDU. The independent impact of clinical and imaging factors in detecting treatment failure was assessed by performing stepwise binary logistic regression analysis. RESULTS: A total of 324 consecutive patients with diagnosed SEA were identified. Overall, 226 patients (69.8%) had SEA related to other causes and 98 (30.2%) had a history of recent IVDU. While non-IVDU SEA admission rates remained constant, year-over-year admissions of patients with IVDU SEA nearly tripled. At baseline, patients with IVDU SEA were distinct in many respects including younger age, greater unemployment and disability, less frequent diabetes mellitus (DM), and more frequent methicillin-resistant Staphylococcus aureus infection. However, differences in length of stay, loss to follow-up, and treatment failure did not reach statistical significance between the groups. The authors constructed independent multivariate logistic regression models for treatment failure based on identified parameters in the two cohorts. For the non-IVDU cohort, the authors identified four variables as independent factors: DM, hepatitis B/C, osteomyelitis, and compression deformity severity. In contrast, for patients with IVDU, the authors identified three variables: albumin, endocarditis, and endplate destruction. Receiver operating characteristic and area under the curve (AUC) analyses were undertaken for the multivariate models predicting the likelihood of treatment failure in the two cohorts (AUC = 0.88 and 0.89, respectively), demonstrating that the derived models could adequately predict the risk of multimodal treatment failure. Treatment failure risk factor point scales were derived for the identified variables separately for both cohorts. CONCLUSIONS: Patients with IVDU SEA represent a unique population with a distinct set of baseline parameters that predict treatment failure. Identification of relevant prognosticating factors will allow for the design of tailored treatment and follow-up regimens.

Radiographic and clinical outcomes in one- and two-level transforaminal lumbar interbody fusions: a comparison of bullet versus banana cages.

OBJECTIVE: The aim of this study was to determine whether cage morphology influences clinical and radiographic outcomes following short-segment transforaminal lumbar interbody fusion (TLIF) procedures. METHODS: The authors retrospectively reviewed one- and two-level TLIFs at a single tertiary care center between August 2012 and November 2019 with a minimum 1-year radiographic and clinical follow-up. Two cohorts were compared based on interbody cage morphology: steerable "banana" cage or straight "bullet" cage. Patient-reported outcome measures (PROMs), radiographs, and complications were analyzed. RESULTS: A total of 135 patients with 177 interbody levels were identified; 45 patients had 52 straight cages and 90 patients had 125 steerable cages. Segmental lordosis increased with steerable cages, while it decreased with straight cages (+3.8 ± 4.6 vs -1.9 ± 4.3, p < 0.001). Conversely, the mean segmental lordosis of adjacent lumbar levels decreased in the former group, while it increased in the latter group (-0.52 ± 1.9 vs +0.52 ± 2.1, p = 0.004). This reciprocal relationship results in global sagittal parameters, including pelvic incidence minus lumbar lordosis and lumbar distribution index, which did not change after surgery with either cage morphology. Multivariate analysis confirmed that steerable cage morphology, anterior cage positioning, and less preoperative index-level segmental lordosis were associated with greater improvement in index-level segmental lordosis. PROMs were improved after surgery with both cage types, and the degree of improvement did not differ between cohorts (p > 0.05). Perioperative and radiographic complications were similar between cohorts (p > 0.05). Overall reoperation rates, as well as reoperation rates for adjacent-segment disease within 2 years of surgery, were not significantly different between cohorts. CONCLUSIONS: Steerable cages are more likely to lie within the anterior disc space, thus increasing index-level segmental lordosis, which is accompanied by a reciprocal change in segmental alignment at the adjacent lumbar levels. The converse relationship occurs for straight cages, with a kyphotic change at the index levels and reciprocal lordosis occurring at adjacent levels.

Unilateral Nerve Root Ligation for Multilevel Vertebral Column Resection After Fixed Post-infectious Deformity.

Kyphotic deformity is a well-recognized complication of thoracic vertebral osteomyelitis, often requiring multi-level vertebral column resection for mobilization of the spine and reduction of the deformity. We present a case of severe post-infectious kyphosis treated with multi-level vertebral column resection via a unilateral approach. We obtained excellent decompression and deformity correction without neurologic decline. We review relevant literature regarding spinal cord blood supply and known potential complication of nerve root ligations.

Development of a postoperative ileus risk assessment scale: identification of intraoperative opioid exposure as a significant predictor after spinal surgery.

OBJECTIVE: Postoperative ileus (POI) is associated with abdominal pain, nausea, vomiting, and delayed mobilization that in turn lead to diminished patient satisfaction, increased hospital length of stay (LOS), and increased healthcare costs. In this study, the authors developed a risk assessment scale to predict the likelihood of developing POI following spinal surgery. METHODS: The authors undertook a retrospective review of a prospectively maintained registry of consecutive patients who underwent arthrodesis/fusion surgeries between May 2013 and December 2017. They extracted clinical information, including cumulative intraoperative and postoperative opioid doses using standardized converted morphine milligram equivalent (MME) values. Univariate and multivariate analyses were performed and several categorical and continuous variables were evaluated in a binary logistic regression model built with backward elimination to assess for independent predictors. A points-based prediction model was developed and validated to determine the risk of POI. RESULTS: A total of 334 patients who underwent spinal fusion surgeries were included. Fifty-six patients (16.8%) developed POI, more frequently in those who underwent long-segment surgeries compared to short-segment surgeries (33.3% vs 10.4%; p < 0.001). POI was associated with an increased LOS when compared with patients who did not develop POI (8.0 ± 4.5 days vs 4.4 ± 2.4 days; p < 0.01). The incidences of liver disease (16% vs 3.7%; p = 0.01) and substance abuse history (12.0% vs 3.2%; p = 0.04) were higher in POI patients than non-POI patients undergoing short-segment surgeries. While the incidences of preoperative opioid intake (p = 0.23) and cumulative 24-hour (87.7 MME vs 73.2 MME; p = 0.08) and 72-hour (225.6 MME vs 221.4 MME; p = 0.87) postoperative opioid administration were not different, remifentanil (3059.3 µg vs 1821.5 µg; p < 0.01) and overall intraoperative opioid (326.7 MME vs 201.7 MME; p < 0.01) dosing were increased in the POI group. The authors derived a multivariate model based on the 5 most significant factors predictive of POI (number of surgical levels, intraoperative MME, liver disease, age, and history of substance abuse) and calculated relative POI risks using a derived 32-point system. CONCLUSIONS: Intraoperative opioid administration, incorporated in a comprehensive risk assessment scale, represents an early and potentially modifiable predictor of POI. These data indicate that potential preventive strategies, implemented as part of enhanced recovery after surgery protocols, could be instituted in the preoperative phase of care to reduce POI incidence.

Deep Vein Thrombosis Prophylaxis in the Neurosurgical Patient.

The optimal approach for deep vein thrombosis (DVT) prophylaxis in the neurosurgery patient is a challenge of balancing the reduction in incidence of DVT and pulmonary embolus (PE) without risking an increase in catastrophic hemorrhages. In this article, the authors review the current literature on DVT/PE prophylaxis in neurosurgery. Mechanical and pharmacologic DVT prophylaxis strategies are discussed in terms of their efficacy in reducing DVT/PE rates as well as safety in terms of catastrophic hemorrhages. The authors offer recommendations regarding the best approach given the current state of the literature.

Predictors of Outcomes in Traumatic Brain Injury.

INTRODUCTION: The purpose of this study was to retrospectively evaluate patients treated for traumatic brain injuries (TBI) to determine how multiple organ trauma (MOT) and lung injuries sustained at the time of initial injury affect outcome. METHODS: A single institution retrospective review of all patients diagnosed with TBI at a level I trauma center from 2000 to 2014 was conducted. Clinical outcome was based on Glasgow Outcome Scale at hospital discharge. Lung injury was defined as the presence of pulmonary contusions, pneumothorax, hemothorax, rib fractures, or diaphragmatic rupture proven by x-ray or computed tomography scan. MOT was defined as trauma to one body region with an Abbreviated Injury Scale (AIS) score ≥3 plus trauma to 2 additional body regions with AIS scores ≥1. Regression analysis was conducted with SPSS 21. RESULTS: There were 409 patients reviewed. The majority of patients were male (73%), average age was 46 years (range, 16-94 years), average Glasgow Coma Scale (GCS) score was 7, and 71% had a severe TBI (GCS ≤8). Thirty percent of patients had poor outcome (Glasgow Outcome Scale = 1-2) Regression analysis indicated age (odds ratio [OR] 1.03, P < 0.001), initial GCS (OR 0.88, P < 0.001), Injury Severity Score (OR 1.03, P = 0.021), and head AIS ≥5 (OR 0.55, P = 0.019) were significant independent predictors of poor outcome. Sex, MOT, lung injury, and lung injury severity were not significant predictors of outcome. CONCLUSIONS: Age, GCS, Injury Severity Score, and critical head injuries (AIS ≥5) were significant tools in predicting outcome in this patient cohort. MOT and traumatic lung injury may cause significant damage to a patient suffering from a severe TBI, but these injuries do not predict mortality in this patient population.

Bilirubin Binding to PPARα Inhibits Lipid Accumulation.

Numerous clinical and population studies have demonstrated that increased serum bilirubin levels protect against cardiovascular and metabolic diseases such as obesity and diabetes. Bilirubin is a potent antioxidant, and the beneficial actions of moderate increases in plasma bilirubin have been thought to be due to the antioxidant effects of this bile pigment. In the present study, we found that bilirubin has a new function as a ligand for PPARα. We show that bilirubin can bind directly to PPARα and increase transcriptional activity. When we compared biliverdin, the precursor to bilirubin, on PPARα transcriptional activation to known PPARα ligands, WY 14,643 and fenofibrate, it showed that fenofibrate and biliverdin have similar activation properties. Treatment of 3T3-L1 adipocytes with biliverdin suppressed lipid accumulation and upregulated PPARα target genes. We treated wild-type and PPARα KO mice on a high fat diet with fenofibrate or bilirubin for seven days and found that both signal through PPARα dependent mechanisms. Furthermore, the effect of bilirubin on lowering glucose and reducing body fat percentage was blunted in PPARα KO mice. These data demonstrate a new function for bilirubin as an agonist of PPARα, which mediates the protection from adiposity afforded by moderate increases in bilirubin.