Griffin R. Baum

Esophageal perforation after anterior cervical spine surgery: a systematic review of the literature

OBJECTIVE Esophageal perforation is a rare but well-known complication of anterior cervical spine surgery. The authors performed a systematic review of the literature to evaluate symptomatology, direct causes, repair methods, and associated complications of esophageal injury. METHODS A PubMed search that adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines included relevant clinical studies and case reports (articles written in the English language that included humans as subjects) that reported patients who underwent anterior spinal surgery and sustained some form of esophageal perforation. Available data on clinical presentation, the surgical procedure performed, outcome measures, and other individual variables were abstracted from 1980 through 2015. RESULTS The PubMed search yielded 65 articles with 153 patients (mean age 44.7 years; range 14-85 years) who underwent anterior spinal surgery and sustained esophageal perforation, either during surgery or in a delayed fashion. The most common indications for initial anterior cervical spine surgery in these cases were vertebral fracture/dislocation (n = 77), spondylotic myelopathy (n = 15), and nucleus pulposus herniation (n = 10). The most commonly involved spinal levels were C5-6 (n = 51) and C6-7 (n = 39). The most common presenting symptoms included dysphagia (n =63), fever (n = 24), neck swelling (n = 23), and wound leakage (n = 18). The etiology of esophageal perforation included hardware failure (n = 31), hardware erosion (n = 23), and intraoperative injury (n = 14). The imaging modalities used to identify the esophageal perforations included modified contrast dye swallow studies, CT, endoscopy, plain radiography, and MRI. Esophageal repair was most commonly achieved using a modified muscle flap, as well as with primary closure. Outcomes measured in the literature were often defined by the time to oral intake following esophageal repair. Complications included pneumonia (n = 6), mediastinitis (n = 4), osteomyelitis (n = 3), sepsis (n = 3), acute respiratory distress syndrome (n = 2), and recurrent laryngeal nerve damage (n = 1). The mortality rate of esophageal perforation in the analysis was 3.92% (6 of 153 reported patients). CONCLUSIONS Esophageal perforation after anterior cervical spine surgery is a rare complication. This systematic review demonstrates that these perforations can be stratified into 3 categories based on the timing of symptomatic onset: intraoperative, early postoperative (within 30 days of anterior spinal surgery), and delayed. The most common source of esophageal injury is hardware erosion or migration, each of which may vary in their time to symptomatic manifestation.

External ventricular drain practice variations: results from a nationwide survey

OBJECTIVE While guidelines exist for many neurosurgical procedures, external ventricular drain (EVD) insertion has yet to be standardized. The goal of this study was to survey the neurosurgical community and determine the most frequent EVD insertion practices. The hypothesis was that there would be no standard practices identified for EVD insertion or methods to avoid EVD-associated infections. METHODS The American Association of Neurological Surgeons membership database was queried for all eligible neurosurgeons. A 16-question, multiple-choice format survey was created and sent to 7217 recipients. The responses were collected electronically, and the descriptive results were tabulated. Data were analyzed using the chi-square test. RESULTS In total, 1143 respondents (15.8%) completed the survey, and 705 respondents (61.6%) reported tracking EVD infections at their institution. The most common self-reported infection rate ranged from 1% to 3% (56.1% of participants), and 19.7% of respondents reported a 0% infection rate. In total, 451 respondents (42.7%) indicated that their institution utilizes a formal protocol for EVD placement. If a respondents institution had a protocol, only 258 respondents (36.1%) always complied with the protocol. Protocol utilization for EVD insertion was significantly more frequent among residents, in academic/hybrid centers, in ICU settings, and if the institution tracked EVD-associated infection rates (p < 0.05). A self-reported 0% infection rate was significantly more commonly associated with a higher level of training (e.g., attending physicians), private center settings, a clinician performing 6 to 10 EVD insertions within the previous 12 months, and prophylactic continuous antibiotic utilization (p < 0.05). CONCLUSIONS This survey demonstrated heterogeneity in the practices for EVD insertion. No standard practices have been proposed or adopted by the neurosurgical community for EVD insertion or complication avoidance. These results highlight the need for the nationwide standardization of technique and complication prevention measures.

Implications of Isolated Transverse Process Fractures: Is Spine Service Consultation Necessary?

BACKGROUND Acute traumatic isolated transverse process fractures (ITPFs) are increasingly identified in trauma patients owing to the increased use of routine computed tomography imaging. Despite repeated demonstrations that these fractures are treated only symptomatically, patterns of consultation with a spine service have not changed. We aim to provide information on long-term outcomes following conservative treatment to help clarify the role of the spine service in the treatment of ITPFs. METHODS A retrospective chart review of 306 patients presenting with ITPFs was conducted to identify both short-term and long-term patient outcomes. A subsection of patients was identified with no other traumatic injuries besides isolated ITPFs (iITPFs). RESULTS No patient required surgical intervention for an ITPF, and 97.7% of all patients and 100% of the patients with iITPFs did not require bracing. At last follow-up, all patients were neurologically intact, 97.8% were fully ambulatory, and 87.9% had no ITPF-related back pain. When only patients with 6 or more months of follow-up were considered, all patients were fully ambulatory, and only 1.1% of all patients and none of the patients with iITPFs had persistent back pain. CONCLUSIONS ITPFs can be treated conservatively without concern for long-term outcome sequelae such as pain, neurologic deficits, or ambulatory difficulties. Consequently, a spine service consult is not required for patients with ITPFs.

Intracranial dural arteriovenous fistula as a cause for symptomatic superficial siderosis: A report of two cases and review of the literature

Background: Superficial siderosis (SS) is the occult deposition of hemosiderin within the cerebral cortex due to repeat microhemorrhages within the central nervous system. The collection of hemosiderin within the pia and superficial cortical surface can lead to injury to the nervous tissue. The most common presentation is occult sensorineural hearing loss although many patients have been misdiagnosed with diseases such as multiple sclerosis and amyotrophic lateral sclerosis before being diagnosed with SS. Only one case report exists in the literature describing an intracranial dural arteriovenous fistula (dAVF) as the putative cause for SS. Case Description: We describe two cases of SS caused by a dAVF. Both patients had a supratentorial, cortical lesion supplied by the middle meningeal artery with venous drainage into the superior sagittal sinus. In both patients, symptoms improved after endovascular embolization. The similar anatomic relationship of both dAVFs reported presents an interesting question about the pathogenesis of SS. Similar to the pathologic changes seen in the formation of intracranial arterial aneurysms; it would be possible that changes in the blood vessel lining and wall might predispose a patient to chronic, microhemorrhage resulting in SS. Conclusions: We describe the second and third cases of a dAVF as the cause of SS, and the first cases of successful treatment of SS-associated dAVF with endovascular embolization. As noninvasive imaging techniques become more sensitive and easily obtained, one must consider their limitations in detecting occult intracranial vascular malformations such as dAVF as a possible etiology for SS.

Baastrup's Disease: An Often Missed Etiology for Back Pain.

Baastrup’s disease is a relatively common disorder of the vertebral column, characterized by low back pain arising from the close approximation of adjacent posterior spinous processes and resultant degenerative changes, most commonly at L4-L5. Though fairly common, Baastrup’s disease is overwhelmingly underdiagnosed and often missed due to a lack of knowledge and/or improper diagnostic techniques, leading to frequent mistreatment. We present a case of a 56-year-old man who presented with chronic, ongoing low back pain of several years duration. His pain was relieved by flexion of the spine, and aggravated by extension. Imaging studies revealed “kissing” posterior spinous processes, consistent with a diagnosis of Baastrup’s Disease. He was treated with subcutaneous steroid injections and showed considerable clinical improvement.

Neurological outcomes following iatrogenic vascular injury during posterior atlanto-axial instrumentation.

BACKGROUND Iatrogenic vascular injury is a feared complication of posterior atlanto-axial instrumentation. A better understanding of clinical outcome and management options following this injury will allow surgeons to better care for these patients. The object of the study was to systematically review the neurologic outcomes after iatrogenic vascular injury during atlanto-axial posterior instrumentation. METHODS We performed a systematic review of the Medline database following PRISMA guidelines. In our analysis, we included any retrospective cohort studies, prospective cohort studies, case reports, cases series, or systematic reviews with patients who had undergone posterior atlanto-axial fusion via screw rod constructs (SRC) or transarticular screws (TAS) that reported a patient with an injury to an arterial vessel directly attributable to the surgical procedure. RESULTS Sixty cases of vascular injury were reported in 2078 (2.9%) patients over 27 publications. The average age for this patient population was 55.7+/-17.9. Vascular injury following posterior C1/2 instrumentation resulted in ipsilateral stroke in 10.0% (n=6/60) and non-persistent neurologic deficit in 6.7% (n=4/60) of cases with the deficit being permanent (not including death) in 1.7% (n=1/60) of cases. Four patients (6.7%) died. Arteriovenous fistula or pseudoaneurysm occurred in 8.3% (n=5/60) and 3.3% (n=2/60) of cases, respectively. Eight patients (13.3%) underwent endovascular repair of the injury with no permanent deficit. CONCLUSION Neurological morbidity after iatrogenic vascular injury during posterior C1/2 fixation is higher than previously reported in literature. Some patients may benefit from endovascular treatment. Surgeons should be aware of normal and anomalous vertebral artery anatomy to avoid this potentially catastrophic complication.

Percutaneous pedicle screw fixation for an unstable thoracic spine fracture after a traumatic degloving injury.

Unstable spinal fractures require urgent surgical intervention to relieve compression of the spinal cord, correct spinal deformity, stabilise the spine and prevent further neurological injury. We report the case of a young man with a thoracic chance fracture in the setting of a devastating degloving injury, whose fracture was stabilised using minimally invasive, percutaneous pedicle screw fixation. We discuss the advantages of using a minimally invasive technique for spinal fixation and its role in the treatment of complicated, multisystem trauma patients.

Motion-preserving, 2-stage transoral and posterior treatment of an unstable Jefferson fracture in a professional football player

The authors report the case of a patient who suffered a Jefferson fracture during a professional football game. The C-1 (atlas) fracture was widely displaced anteriorly, but the transverse ligament was intact. In an effort to enable a return to play and avoid intersegmental (C1-2) fusion, the patient underwent a transoral approach for open reduction and internal fixation of the fracture. The associated posterior ring fracture displacement widened after this procedure, and a subsequent posterior arthrodesis and fixation of the fracture site was performed 6 months later when the fracture failed to heal with rigid collar immobilization. The approach maintained the normal range of motion at the atlantoaxial and atlantooccipital joints, which would have been sacrificed by an atlantoaxial or occipitocervical fusion, as is traditionally performed. Ultimately, the patient decided not to return to the football field, but this approach could avoid the more significant loss of motion associated with atlantoaxial or occipitocervical fusion for unstable Jefferson fractures.

Adult Intramedullary Teratoma of the Spinal Cord: A Case Report and Review of Literature

BACKGROUND Teratomas of the spinal cord constitute 0.1% of all spinal tumors, and these lesions are extremely rare in adults. The authors describe a rare case of intradural intramedullary teratoma of the conus medullaris and perform review of literature of intramedullary teratomas seen in the thoracolumbar region. CASE DESCRIPTION A 48-year-old man presented with fasciculations in the bilateral upper and lower extremities. Radiologic findings revealed an L2-L3 level intradural, nonenhancing, extramedullary cystic mass measuring 15 × 13 mm with a 6-mm enhancing nodule at the level of the conus medullaris. The patient was followed up for 1 year, during which time enlargement of the lesion with new areas of patchy contrast enhancement were observed. L1-L2 decompressive laminectomies were performed, and gross total resection of the lesion was achieved. Histopathologic examination confirmed the diagnosis of benign mature cystic teratoma. A literature review revealed no incidence difference in intramedullary teratomas between males and females (P > 0.05). The mean age at the time of diagnosis was 36.4 ± 12.3 years for men and 41.3 ± 11.6 for women (P < 0.05). The mean symptom duration before treatment was 64.6 ± 79.4 months for females and 20.7 ± 13.8 months for men (P < 0.05). Complete resection was achieved in 48.1% of the cases. CONCLUSIONS Teratomas should be taken into consideration in the differential diagnosis of intramedullary lesions when the imaging reveals variable signal intensity because of tissue heterogeneity. A partial resection is a viable treatment option when the lesion is attached to vital structures because of the low recurrence rates reported in the literature.

Neurological Outcomes Following Iatrogenic Vascular Injury during Posterior Atlanto-axial Instrumented Fusion

Introduction Iatrogenic vascular injury is a feared complication of posterior atlanto-axial instrumented fusion. A better understanding of clinical course following this injury will allow surgeons to better care for these patients. The object of the study was to systematically review the neurologic outcomes after iatrogenic vascular injury during atlanto-axial posterior instrumented fusion. Methods A systematic review of the PubMed database was performed, following the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The extracted data was recorded in an excel spreadsheet. To be included, the patients must have undergone fusion of the C1/C2 joint using posterior instrumentation with injury to an arterial vessel directly attributable to the surgical procedure. Results 86 incidences of vascular injury were found in 41 articles with 11200 patients. The average age of included patients was 46.4 +/− 24.1 for the screw rod construct (SRC) group and 36.2 +/− 28.2 for the transarticular screw (TAS) group. Vascular injury in SRC cases resulted in ipsilateral stroke in 15.9% (n = 7/44) of patients and neurologic deficit in 22.7% (n = 10/44) of patients with a permanent neurologic deficit occurring in 11.4% (n = 5/44) of patients. Vascular injury following TAS fixation resulted in ipsilateral stroke in 11.9% of cases (n = 5/42) and neurologic deficit in 23.8% of cases with the deficit being permanent in 9.5% (n = 4/42) of cases. Death was the result of injury in 9.1% (n = 4/44) of SRC cases and 7.1% (n = 3/42) of TAS cases. Conclusions Neurological morbidity after iatrogenic vascular injury during posterior C1/2 fixation is higher than previously reported in literature. There has been no large-volume studies aimed at identifying a rate of neurologic complications after iatrogenic injury. Surgeons should be aware of the normal and anomalous vertebral artery anatomy to avoid this potentially catastrophic injury.