Lumbar plexus safe working zones with lateral lumbar interbody fusion: a systematic review and meta-analysis.

PURPOSE: Significant risk of injury to the lumbar plexus and its departing motor and sensory nerves exists with lateral lumbar interbody fusion (LLIF). Several cadaveric and imaging studies have investigated the lumbar plexus position with respect to the vertebral body anteroposterior plane. To date, no systematic review and meta-analysis of the lumbar plexus safe working zones for LLIF has been performed. METHODS: This systematic review was conducted according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Relevant studies reporting on the position of the lumbar plexus with relation to the vertebral body in the anteroposterior plane were identified from a PubMed database query. Quantitative analysis was performed using Welch's t test. RESULTS: Eighteen studies were included, encompassing 1005 subjects and 2472 intervertebral levels. Eleven studies used supine magnetic resonance imaging (MRI) with in vivo subjects. Seven studies used cadavers, five of which performed dissection in the left lateral decubitus position. A significant correlation (p < 0.001) existed between anterior lumbar plexus displacement and evaluation with in vivo MRI at all levels between L1-L5 compared with cadaveric measurement. Supine position was also associated with significant (p < 0.001) anterior shift of the lumbar plexus at all levels between L1-L5. CONCLUSIONS: This is the first comprehensive systematic review and meta-analysis of the lumbar neural components and safe working zones for LLIF. Our analysis suggests that the lumbar plexus is significantly displaced ventrally with the supine compared to lateral decubitus position, and that MRI may overestimate ventral encroachment of lumbar plexus.

Functional outcomes after extracapsular dissection with partial facial nerve dissection for small and large parotid neoplasms.

PURPOSE: Multiple surgical options exist for benign parotid tumors without agreement upon a single, best approach. We evaluated the short-term outcomes and rate of complications using the ECD-FND technique for small and large parotid neoplasms involving the superficial and deep lobes of the parotid gland using a categorical approach. MATERIAL AND METHODS: A single surgeon retrospective cohort study with analysis of patient demographics, outcomes, and complication rates was conducted of patients undergoing the ECD-FND for benign parotid neoplasm. Cases from May 2014 to May 2020 with at least 6 months follow up were considered. Complications were assessed by chart review and tumors were categorized by size and by European Salivary Gland Society (ESGS) classification assigned by a neuroradiologist. RESULTS: Fifty-one patients who underwent ECD-FND of suspected benign parotid mass met inclusion criteria. The most common histology was pleomorphic adenoma (56.9%) followed by Warthin's tumor (19.6%). Overall rate of complications was 31.4% with no major complications. Most patients (88.2%) had normal facial nerve function immediately after surgery and all recovered completely in the post operative period. Sialocele occurred in 15.7% of patients with 87.5% resolved within one month and seromas occurred in four patients (7.8%). There was no significant difference in complication rates between the size of tumor (p = 0.889), depth (p = 0.770), or ESGS classification (p = 0.846). CONCLUSIONS: The ECD-FND technique achieved excellent facial nerve outcomes among our cohort, which included a - proportion of large (>3 cm) and deep lobe tumors. Complications rates and outcomes were similar for larger and deep lobe tumors that underwent a ECD-FND approach. LEVEL OF EVIDENCE: 3.

Atypical Teratoid/Rhabdoid Tumor of the Conus Medullaris.

INTRODUCTION: Atypical teratoid/rhabdoid tumor (AT/RT) is a rare tumor of the central nervous system, especially when involving the spinal column or spinal cord. CASE PRESENTATION: We present a case of a 5-year-old girl with progressive bilateral lower extremity pain found to have a discrete nodular lesion of the conus with mild heterogeneous enhancement. Surgical decompression and resection demonstrated a pathologic tumor consistent with AT/RT with loss of INI1 protein on immunohistochemistry. DISCUSSION AND CONCLUSION: AT/RT lesions of the conus medullaris are exceedingly rare and associated with extensive disease. We report a rare case of AT/RT with selective involvement of the conus medullaris, as well as describe the surgical, radiographic, and pathologic findings of this tumor.

Post-operative antibiotic prophylaxis in spine surgery patients with thoracolumbar drains: A meta analysis.

Objective: Closed-suction drains are commonly placed after thoracolumbar surgery to reduce the risk of post-operative hematoma and neurologic deterioration, and may stay in place for a longer period of time if output remains high. Prolonged maintenance of surgical site drains, however, is associated with an increased risk of surgical site infection (SSI). The present study aims to examine the literature regarding extended duration (≥24 h) prophylactic antibiotic use in patients undergoing posterior thoracolumbar surgery with closed-suction drainage. Methods: This systematic review was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Relevant studies reporting the use of 24-h post-operative antibiotics compared with extended duration post-operative antibiotics in patients undergoing posterior thoracolumbar surgery with closed-suction drainage were identified from a PubMed database query. Results: Six studies were included for statistical analysis, encompassing 1003 patients that received 24 h of post-operative antibiotics and 984 patients that received ≥24 h of post-operative antibiotics. The SSI rate was 5.16 % for the shorter duration group (24 h) and 4.44 % (p = 0.7865) for the longer duration group (≥24 h). Conclusions: There is no significant difference in rates of SSI in patients receiving 24 h of post-operative antibiotics compared with patients receiving ≥24 h of post-operative antibiotics. Shorter durations of post-operative antibiotics in patients with thoracolumbar drains have similar outcomes compared to patients receiving longer courses of antibiotics. Shorter durations of antibiotics could potentially help lead to lower overall cost and length of stay for these patients.

Recurrent IgG4-Related Meningeal Disease of the Cervicothoracic Spine: A Case Report and Review of the Literature.

Background: IgG4-related disease is a rare, recently recognized chronic inflammatory disease. IgG4-related hypertrophic pachymeningitis (IgG4-RHP) of the central nervous system predominantly involves the cranial meninges. Spinal involvement remains rare. Objective: We report a case of recurrent cervicothoracic IgG4-RHP and review the surgical literature. Methods and Materials: A 35-year-old woman presented with a 6-month history of neck and right shoulder pain, progressive right triceps weakness and paresthesias in the right C8 and T1 dermatomes. MRI demonstrated a T2 hypointense epidural soft tissue mass extending from C6-T1. The patient underwent C6-T1 laminoforaminotomy and partial resection with near complete symptom resolution. Histopathology was consistent with diagnosis of IgG4-RHP. Eighteen months postoperatively, she experienced symptom recurrence necessitating re-operation and adjuvant postoperative prednisone with complete resolution at 40-months' follow-up. Results and Conclusions: Of the now nineteen confirmed cases of IgG4-RHP, fifteen underwent surgery. A majority achieved partial resection. Three surgical patients did not receive adjuvant therapy with symptomatic recurrence between 2 and 18 months.

Preoperative Transvenous Liquid Embolization for a Symptomatic Lumbar Spinal Epidural Varix Mimicking Radiculopathy.

Background: Symptomatic spinal epidural veins (SEV) are a rare cause of neurologic dysfunction. Treatment is centered upon addressing the underlying venous pathology to relieve mechanical compression of the neurologic structures. However, open surgical ligation is often associated with considerable blood loss. Objective: We discuss a unique case of a large symptomatic epidural venous varix and potential treatment strategy. Methods and Materials: A 15-year-old female presented with a 1-year history of left L5 radicular pain and weakness. Lumbar MRI demonstrated a central L5/S1 herniated disc and a large extradural anomalous SEV compressing the exiting left L5 nerve root at the L5/S1 neuroformina. The SEV was treated using a transvenous liquid embolic agent providing symptomatic relief. At 16-months follow-up, she reported recurrent symptoms. She ultimately underwent a left L5/S1 MIS decompression without complication. Conclusion: Transvenous liquid embolization of large symptomatic SEV may provide temporary neurologic relief and decrease morbidity associated with open surgical treatment options.

Keyhole Superior Interhemispheric Transfalcine Approach for Tuberculum Sellae Meningioma: Technical Nuances and Visual Outcomes.

BACKGROUND: Tuberculum sellae meningiomas are challenging tumors often compressing the optic apparatus and involving the optic canals. Traditional approaches provide wide exposure, but optic canal access can remain difficult. Endonasal approaches offer a less invasive option that allows access to the medial optic canals, but larger tumors can still be challenging along with a higher risk of postoperative spinal fluid leak. We present the use of a keyhole superior interhemispheric approach for tuberculum sellae meningioma resection. METHODS: Five patients with tuberculum sellae meningioma who underwent a keyhole superior interhemispheric approach were retrospectively reviewed. Preoperative tumor volumes, visual outcomes, extent of resection, pathologic grading, perioperative complications, recurrence rates, operative times, and hospital length of stays were analyzed. RESULTS: The average age of the patients was 68.6 ± 7.7 years old (range 57-78). Average tumor volume was 8 ± 1.8 cm3. All patients had a gross total resection. Three out of 5 patients had World Health Organization grade 1 meningioma, and the other 2 had World Health Organization grade 2 meningioma. There were no recurrences over an average follow-up of 18.6 months (range 1-44). On preoperative visual assessment, 9 out of 10 eyes (90%) had a deficit. Postoperative visual assessment found 9 out of 9 eyes with preoperative deficits had improvement (100%). There were no perioperative or postoperative complications. CONCLUSIONS: The keyhole superior interhemispheric approach provides a transcranial alternative that allows excellent exposure of the vasculature and both optic canals, resulting in good extents of resection and recovery of vision.

Surgical Resection of Clinoidal Meningiomas without Routine Use of Clinoidectomy.

OBJECTIVE: Meningiomas of the anterior clinoid process (ACP) present significant surgical challenges given their anatomic relation to critical neurovascular structures. Routine anterior clinoidectomy is often described as a critical step in the resection of these tumors to reduce recurrence and improve visual outcomes. Anterior clinoidectomy, however, is not without risk and its benefits have not been clearly delineated. We present the outcomes of our series of surgically managed ACP meningiomas in which an anterior clinoidectomy was not routinely employed. METHODS: A retrospective review of all ACP meningiomas operated on between August 1997 and March 2019 was conducted. Patients with a recurrent tumor or with <6 months of follow-up were excluded. Resection was typically carried out via a frontotemporal craniotomy followed by intradural removal of the tumor. Anterior clinoidectomy was only performed if hyperostosis of the ACP caused mass effect on the optic nerve. RESULTS: Twenty-nine patients were included in this study. Anterior clinoidectomy was performed in 3 patients (10.3%). Gross total resection was achieved in 22 patients (75.9%). Of the 21 patients (72.4%) who presented with visual deficits, vision improved in 18 patients (85.7%) and worsened in 2 (9.5%). Tumor recurrence occurred in 5 patients (17.2%) at a mean follow-up of 64.9 months. Perioperative morbidity was 10.3%. Permanent morbidity and mortality were 6.9% (vision deterioration) and 0%, respectively. CONCLUSIONS: Resection of ACP meningiomas without routine anterior clinoidectomy minimizes potential risk while achieving gross total resection, recurrence, and visual improvement rates comparable with those in previously reported series.

Embolization of an Exophytic Posterior Neck Mass Secondary to a Cutaneous Renal Cell Carcinoma Metastasis.

Renal cell carcinoma (RCC) commonly metastasizes to the lung, liver, bones, and brain; however, cutaneous metastases remain rare with few reported cases. Since RCCs have the propensity to metastasize to highly vascular areas, the scalp and skin of the head and neck region are likely locations for cutaneous metastases. We report a rare case of a large, exophytic, cauliflower-like, hemorrhagic, metastatic mass of the posterior neck. This is the first reported case of a head and neck cutaneous RCC metastasis treated with endovascular embolization prior to surgical resection. Due to the increased vascularity of RCCs and risk of excessive hemorrhage during resection, adjunctive embolization of cutaneous head and neck metastasis may have a role. Essential characteristics to our treatment strategy are discussed with a review of pertinent literature.