Kunal Vakharia

Posterior Reversible Encephalopathy Syndrome Resolving Within 48 Hours in a Normotensive Patient Who Underwent Thoracic Spine Surgery

Posterior reversible encephalopathy syndrome (PRES) usually manifests with severe headaches, seizures, and visual disturbances due to uncontrollable hypertension. A patient (age in the early 60s) with a history of renal cell cancer presented with lower-extremity weakness and paresthesias. Magnetic resonance imaging (MRI) of the thoracic spine revealed a T8 vertebral body metastatic lesion with cord compression at that level. The patient underwent preoperative embolization of the tumor followed by posterior resection and placement of percutaneous pedicle screws and rods. Postoperatively, the patient experienced decreased visual acuity bilaterally. Abnormal MRI findings consisted of T2 hyperintense lesions and fluid-attenuated inversion recovery changes in both occipital lobes, consistent with the unique brain imaging pattern associated with PRES. The patient’s blood pressure was normal and stable from the first day of hospitalization. The patient was kept on high-dose steroid therapy, which was started intraoperatively, and improved within 48 hours after symptom onset.

Large, spontaneous spinal subdural-epidural hematoma after epidural anesthesia for caesarean section: Conservative management with excellent outcome.

Background: Iatrogenic or spontaneous spinal hematomas are rarely seen and present with multiple symptoms that can be difficult to localize. Most spontaneous spinal hematomas are multifactorial, and the pathophysiology is varied. Here, we present a case of a scattered, multicomponent, combined subdural and epidural spinal hematoma that was managed conservatively. Case Description: A 38-year-old woman came to the emergency department (ED) complaining of severe neck and back pain. She had undergone a caesarean section under epidural anesthesia 4 days prior to her arrival in the ED. She was placed on heparin and then warfarin to treat a pulmonary embolism that was diagnosed immediately postpartum. Her neurological examination at presentation demonstrated solely the existence of clonus in the lower extremities and localized cervical and low thoracic pain. In the ED, the patients international normalized ratio was only mildly elevated. Spinal magnetic resonance imaging revealed a large thoracolumbar subdural hematoma with some epidural components in the upper thoracic spine levels. Spinal cord edema was also noted at the T6-T7 vertebral level. The patient was admitted to the neurosurgical intensive care unit for close surveillance and reversal of her coagulopathy. She was treated conservatively with pain medication, fresh frozen plasma, and vitamin K. She was discharged off of warfarin without any neurological deficit. Conclusions: Conservative management of spinal hematomas secondary to induced coagulopathies can be effective. This case suggests that, in the face of neuroimaging findings of significant edema and epidural blood, the clinical examination should dictate the management, especially in such complicated patients.

Bowel injury in lumbar spine surgery: a review of the literature

Although rarely documented in the medical literature, bowel perforation injury can be a severe complication of spine surgery. Our goal was to review current literature regarding this complication and study possible methods of avoidance. We conducted a literature search in the PubMed database between January 1960 and March 2016 using the terms abrasion, bowels, bowel, complication, injury, intestine, intra-abdominal sepsis/shock, perforation, lumbar, spine, surgery, visceral. Diagnostic criteria, outcomes, risk factors, surgical approach, and treatment strategy were the parameters extracted from the search results and used for review. Thirty-one patients with bowel injury were recognized in the literature. Bowel injury was more frequent in patients who underwent lumbar discectomy and microdiscectomy (18 of 31 patients, 58.1%). Minimally invasive surgery and lateral techniques involving fusions accounted for 10 of the reported cases (32.3%). Finally, 2 cases (6.5%) were reported in conjunction with sacrectomies and 1 case (3.2%) with posterior fusion plus anterior longitudinal ligament (ALL) release. Diagnosis was made mostly by clinical signs/symptoms of acute abdominal pain, post-surgical wound infection, and abscess or enterocutaneous fistulas. Significant risk factors for postoperative bowel injury were complex surgical anatomy, medical history of previous abdominal surgeries or infections, irradiation before surgery, errors related to surgical technique, lack of surgical experience, and instrumentation failure. The overall mortality rate from bowel injury was 12.9% (4 of 31 patients). The overall morbidity rate was 87.1% (27 of 31 patients). According to our review of the literature, bowel injury is linked to significant morbidity and mortality. It can be prevented with meticulous pre-surgical planning. When it occurs, timely treatment reduces the risks of morbidity and mortality.

Role of bevacizumab for treatment-refractory meningiomas: A systematic analysis and literature review

Background: Meningiomas are the most prevalent primary tumor of the central nervous system (CNS), and although the majority of these neoplasms are classified as benign, nearly one fourth of the lesions display an aggressive profile characterized by pleomorphic histology, high recurrence rates, and overall resistance to standard treatment. Despite the ubiquitous nature of these tumors, no adjuvant therapeutic regimen has been identified which effectively controls disease recurrence and progression after surgery and radiation, leading to a dismal prognosis in this patient population. The primary focus of this research study is, hence, to assess the recently emerging use of bevacizumab, an anti-angiogenic agent, in the treatment of meningiomas. This systematic literature review analyzes the efficacy and safety of therapeutic bevacizumab for treatment-refractory meningiomas. Methods: A systematic PubMed search was conducted according to PRISMA guidelines to identify all relevant reports investigating the anti-angiogenic agent bevacizumab in the treatment of intracranial meningiomas. The reported parameters from pertinent retrospective reviews, prospective studies, and case studies were volumetric reduction, radiographic response, clinical stability, overall survival (OS), and progression free survival (PFS) measured at 6 and 12 months postinitiation of treatment. Complications were cataloged based on the range and severity of the therapy-related toxicities. Results: A total of 11 articles, 5 retrospective series, 2 prospective trials, and 4 case reports, reporting on a total of 92 patients, were included in this review. The use of bevacizumab therapy for intracranial meningiomas demonstrated median overall PFS of 16.8 months (range: 6.5-22 months) and PFS-6 of 73% (range: 44%-93%). Conclusions: Therapeutic bevacizumab, either alone or with combination chemotherapies, for select patient populations with recurrent or progressive meningiomas, offers a treatment option that confers improved overall progression-free survival. To assess OS parameters, larger randomized controlled trials assessing the use of anti-angiogenic agents for recurrent/progressive meningiomas are warranted.

Management of Acute Ischemic Thrombosis

Acute ischemic thrombosis in patients who have undergone neurosurgical procedures is a leading cause of mortality and long-term disability. Endovascular therapy has become an important treatment modality for acute ischemic thrombosis in these patients. Noninvasive imaging has dramatically changed the understanding of cerebral blood flow and the concepts of cerebrovascular reserve and salvageable penumbra. Increasingly, reliance on perfusion imaging to discern tissue viability and potential outcomes has become standard of care. With the advent of recent acute ischemic stroke trials, therapy for occlusive cerebrovascular disease is evolving, and understanding when to intervene is becoming paramount.

Cervical sagittal balance parameters after single-level anterior cervical discectomy and fusion: Correlations with clinical and functional outcomes

Background: Normal sagittal cervical alignment has been associated with improved outcome after anterior cervical discectomy and fusion (ACDF). Objective: The aim of this study is to identify alterations of cervical sagittal balance parameters after single-level ACDF and assess correlations with postoperative functionality. Methods: A retrospective chart review was performed between January 2010 and January 2014 to identify adult patients with no previous cervical spine surgery who underwent ACDF at any one level between C2 and C7 for the single-level degenerative disease. Tumor, infection, and trauma cases were excluded from the study. For the included cases, the following data were recorded preoperatively and 6 months–1 year after surgery: sagittal balance-marker measurements of the C1–C2 angle, C2–C7 angle, C7 slope, segmental angle at the operated level, and sagittal vertical axis (SVA) distance between C2 and C7, as well as the neck disability index and visual analog scale of pain. Results: The present study included 47 patients (average age: 51.2 years; range: 28–86 years). A moderate negative correlation between a smaller C2–C7 angle and the presence of right arm pain before treatment was found (P = 0.0281). Postoperatively, functionality scores significantly improved in all patients. C1–C2 angle increased with statistical significance (P = 0.0255). C2–C7 angle, segmental angle, C7 slope, and SVA C2–C7 distance did not change with statistical significance after surgery. C7 slope significantly correlated with overall cervical sagittal balance (P < 0.05). Conclusions: Single-level ACDF significantly increases upper cervical lordosis (C1–C2) without significantly changing lower cervical lordosis (C2–C7). The C7 slope is a significant marker of overall cervical sagittal alignment (P < 0.05).

Steinmann Pins for C1 Lateral Mass Screw Placement During Atlantoaxial Stabilization

OBJECTIVE The authors describe a modified technique for placement of the C1 lateral mass screw using a Steinmann pin as a guide. This technique minimizes dissection and provides atlantoaxial stabilization during arthrodesis. METHODS In our technique, a nonthreaded 1.6-mm spade-tip Steinmann pin is placed into the lateral mass of C1 to serve as a guide over which a powered drill is used for screw insertion. Perioperative data were collected for consecutive patients who underwent a C1-2 arthrodesis that involved the modified technique between March 2010 and July 2016. Data included blood loss, operative times, and C2 nerve root injury. RESULTS The data for 93 patients were reviewed. Most (91.4%) patients presented with a fracture from an acute trauma. A mean of 1.97 levels was fused in these patients, with a mean blood loss of 76 mL and a mean operative time of 144 minutes. The overall morbidity and mortality rate was 10.7%. The morbidity rate of 7.5% included 30-day postoperative complications of respiratory failure and dysphasia. There were no postoperative vertebral artery injuries, hardware failures, or instances of occipital neuralgia. CONCLUSIONS The use of Steinmann pins to guide the placement of C1 lateral mass screws is safe and effective in C1-2 arthrodesis. Limiting dissection minimizes blood loss and injury, maintains efficient operative time, and assists in accurate placement of the screws. Furthermore, with less manipulation and retraction of the C2 nerve root, postoperative occipital neuralgia and the need for C2 root transection are avoided.

Lumbar laminectomy in a captive, adult polar bear (Ursus maritimus)

Background: Animals held in captivity tend to live longer than do their wild counterparts, and as such, are prone to developing age-related degenerative injuries. Here, we present a case of an adult female polar bear with symptomatic lumbar stenosis. There is a paucity of literature on large mammalian spine surgery, and anatomical differences between humans and other vertebrates must be taken into consideration. Case Description: A 24-year-old female polar bear residing at the zoo was found to have decreased motor function in her hind legs. Diagnostic myelography performed at the L7/S1 level demonstrated lumbar stenosis at L5/6 for which a laminectomy was performed. Postoperatively, she returned to premorbid functional level, with no apparent associated adverse sequelae. Conclusions: To our knowledge, this is the first reported case of spine surgery in a polar bear and demonstrates that neurosurgical diagnostic and operative techniques developed for humans can also be applied to large mammals with successful results.

Spontaneous intraventricular rupture of a craniopharyngioma cyst: A case report

Intraventricular rupture of craniopharyngioma cysts is an unusual event which is associated with a high risk of loculated or communicating hydrocephalus. A 75-year-old woman presented at the Emergency Department of our hospital with mental status deterioration due to chemical ventriculitis and acute hydrocephalus following the intraventricular rupture of a craniopharyngioma cyst. The patient was treated with stress-dose steroid therapy. In addition, she underwent placement of an external ventricular drain and endoscopy-assisted intra-cystic placement of an Ommaya reservoir for the aspiration of the cystic fluid. The patients condition improved; she was shunted in an expeditious fashion and discharged from the Intensive Care Unit within 2 weeks of her admission with the reservoir in place for the continued drainage of the cyst.

Anticoagulation and Thrombolysis in the Pediatric Population

Pediatric stroke is an underestimated disease process that affects 3–15/100,000 children per year. There are distinct etiologies that are more common in the pediatric population. Risk factors affecting this population include vasculopathies, congenital heart diseases, sickle cell anemia, and some metabolic disorders. The three primary disease processes that warrant specific discussion with respect to anticoagulation and thrombolysis-thrombectomy include ischemic stroke, cerebral venous sinus thrombosis, and hemorrhagic stroke. Current recommendations for anticoagulation and endovascular therapy are based on treatment for adults and center on antithrombotic therapy. Antiplatelet therapy and heparin therapy have been recommended across-the-board. The role of mechanical thrombolysis–thrombectomy in the treatment of pediatric stroke has increased with the development of more devices for this therapeutic approach.