Mena G. Kerolus

The role of minimally invasive spine surgery in the management of pyogenic spinal discitis

Background: Diagnostic yields for spondylodiscitis from CT guided biopsy is low. In the recent years, minimally invasive surgery (MIS) has shown to have a low morbidity and faster recovery. For spinal infections, MIS surgery may offer an opportunity for early pain control while obtaining a higher diagnostic yield than CT-guided biopsies. The aim of this study was to review our patients who underwent MIS surgery for spinal infection and report outcomes. Methods: A retrospective review of seven patients who underwent MIS decompression and/or discectomy in the setting of discitis, osteomyelitis, spondylodiscitis, and/or an epidural abscess was identified. Patient data including symptoms, visual analog score (VAS), surgical approach, antibiotic regimen, and postoperative outcomes were obtained. Results: Of the 7 patients, 5 patients had lumbar infections and two had thoracic infections. All seven patients improved in VAS immediately after surgery and at discharge. The average VAS improved by 4.4 ± 1.9 points. An organism was obtained in 6 of the 7 (85%) patients by the operative cultures. All patients made an excellent clinical recovery without the need for further spine surgery. All patients who received postoperative imaging on follow-up showed complete resolution or dramatically improved magnetic resonance imaging changes. The follow-up ranged from 2 to 9 months. Conclusions: MIS surgery provides an opportunity for early pain relief in patients with discitis, osteomyelitis, spondylodiscitis, and/or epidural abscess by directly addressing the primary cause of pain. MIS surgery for discitis provides a higher diagnostic yield to direct antibiotic treatment. MIS surgery results in good long-term recovery.

Atlantoaxial instability of inflammatory origin in adults: case reports, literature review, and rationale for early surgical intervention.

BACKGROUND AND IMPORTANCE Acquired atlantoaxial instability of inflammatory origin (Grisel syndrome) is a rare condition. It usually occurs in children with benign upper airway problems and responds well to immobilization, rarely requiring C1-2 arthrodesis. Our recent experience with 2 adult cases suggests this may not be true in an older subpopulation. CLINICAL PRESENTATION A 71-year-old man developed C1-2 instability in the setting of culture-negative endocarditis. Initial immobilization was attempted for 8 weeks but new imaging revealed progressive destruction of the odontoid and worsening instability. Symptoms resolved after C1-4 arthrodesis. A 35-year-old woman developed C1-2 instability after a molar extraction and otitis media. Despite 12 weeks of immobilization and antibiotics, symptoms persisted and the atlantodental interval increased. She was successfully treated with a C1-2 arthrodesis. CONCLUSION A literature review revealed 13 reports (14 cases) of inflammatory atlantoaxial instability in patients aged 18 and older since 1830. Including the 2 cases reported here, 11 cases underwent initial nonoperative treatment with durable satisfactory results in only 2 of them (18.2%). Aspiration of the C1-2 phlegmon was diagnostic in only 4 of these 16 cases. Destruction of the odontoid was seen in a minority of cases (5/16, 31.3%). In this first review of the topic since the introduction of screw-based C1-2 fixation, it is suggested that nonoperative treatment is futile for inflammatory atlantoaxial instability in adults and strong consideration should be given to C1-2 arthrodesis. This procedure can reliably produce good outcomes with minimal morbidity.

Persistent Aneurysm Growth Following Pipeline Embolization Device Assisted Coiling of a Fusiform Vertebral Artery Aneurysm: A Word of Caution!

The complex morphology of vertebrobasilar fusiform aneurysms makes them one of the most challenging lesions treated by neurointerventionists. Different management strategies in the past included parent vessel occlusion with or without extra-intracranial bypass surgery and endovascular reconstruction by conventional stents. Use of flow diversion has emerged as a promising alternative option with various studies documenting its efficacy and safety. However, there are various caveats associated with use of flow diversion in patients with fusiform vertibrobasilar aneurysms especially in patients presenting with acute subarachnoid hemorrhage (SAH). We report a rare case of persistent aneurysmal growth after coiling and placement of the Pipeline Embolization Device (PED; ev3, Irvine, California, USA) for SAH from a fusiform vertebral artery aneurysm. As consequences of aneurysm rupture can be devastating especially in patients with a prior SAH, the clinical relevance of recognizing and understanding such patterns of failure cannot be overemphasized as highlighted in the present case.

Use of intraoperative CT to predict the accuracy of microelectrode recording during deep brain stimulation surgery. A proof of concept study.

OBJECTIVES Intraoperative computed tomography (iCT) is currently used to confirm the target location of the microelectrode (ME) during microelectrode recording (MER) and ultimate location of deep brain stimulation (DBS) leads at our institution. We evaluated whether iCT can be used to predict the trajectory and accuracy of the ME track. PATIENTS AND METHODS Intraoperative imaging profiles of ten consecutive patients who had undergone DBS surgery were retrospectively reviewed. We found that cranial iCT, in addition to visualizing the target, also visualizes the extra-cranial segment of the guide tube (ECGT) used to insert the ME. We propose a hypothetical technique that extrapolates the trajectory of only the ECGT down to target depth using planning software. In order to provide a proof of concept analysis of this hypothetical technique, we retrospectively assessed post MER placement iCT studies and used planning software to visualize only the ECGT. An extrapolated vector was drawn along the long axis of the ECGT down to the same depth (z) as the ME. The obtained x and y coordinates were subsequently recorded and compared to the x and y coordinates of the ME tip to validate this technique. RESULTS The average radial error between ECGT trajectory coordinates and final ME tip coordinates was 0.93±0.1mm (mean±SEM). CONCLUSION The use of iCT to predict accuracy of microelectrode location is feasible. In the future, performing iCT before guide tube penetration of dura can allow for trajectory prediction and if needed, correction of the ME, thereby potentially improving accuracy and reducing the number of MER tracks.

Pigmented ganglioglioma in a patient with chronic epilepsy and cortical dysplasia

We report a rare case of a 22-year-old woman with biopsy-proven pigmented ganglioglioma. The patient initially underwent a right temporal lobectomy for intractable seizures at the age of 9 and remained seizure free for several years but subsequently developed complex partial seizures. Due to enhancement of a left mesial occipital lesion on preoperative MRI of the brain, the patient underwent a left subdural electrode placement and simultaneous biopsy of the left mesial occipital lesion. Biopsy results revealed a rare pigmented ganglioglioma, World Health Organization Grade I. The seizure focus was identified in the left mesial occipital lobe and the patient underwent tumor resection. An extensive literature search revealed that our patient is the fourth case of pigmented ganglioglioma described in the literature and was positive for BRAF V600E mutation by molecular studies.

Stand-alone anterior lumbar interbody fusion: indications, techniques, surgical outcomes and complications

ABSTRACT Introduction: Anterior lumbar interbody fusion (ALIF) is a well-established technique to achieve lumbar spine fusion with various indications including degenerative disk disease, spondylolisthesis, recurrent disk herniation, adjacent level disease, pseudoarthrosis, as well as being used as part of the overall strategy to restore sagittal balance. ALIF can be an extremely useful tool in any spine surgeon’s armamentarium. However, like any surgical procedure, proper patient selection is key to success. A solid understanding of the biomechanics, careful surgical planning, along with clear knowledge of the advantages and disadvantages of stand-alone ALIF will ensure optimal clinical outcome. Stand-alone ALIF may be a suitable surgical option in carefully selected patients that can provide good clinical results and adequate fusion rates without the need for posterior instrumentation. Areas covered: A brief overview of the indications, techniques, biomechanics, surgical outcome and complications of stand-alone ALIF is provided in this article with a review of the pertinent literature. Expert commentary: In this review we discuss the clinical evidence of using a stand-alone ALIF compared to other fusion techniques of the lumbar spine. The development of interbody cages with integrated screws has increased the arthrodesis rate and improved clinical outcomes while decreasing morbidity and operative time.

Ossified ligamentum flavum of the thoracic spine presenting as spontaneous intracranial hypotension: case report

Ossification of the ligament flavum in the thoracic spine is an uncommon radiological finding in the Western population but can present with back pain, varying degrees of myelopathy, and even paraplegia on occasion. The authors here present the case of a 50-year-old woman with a history of progressive back pain and symptoms of spontaneous intracranial hypotension who was found to have an ossified ligamentum flavum of the thoracic spine resulting in a dural erosion cerebrospinal fluid leak. Surgery involved removal of the ossified ligament flavum at T10-11, facetectomy, ligation of the nerve root, and primary closure of the dura, which resulted in complete resolution of the patients symptoms. Radiological, clinical, and intraoperative findings are discussed to assist surgeons with an accurate diagnosis and treatment in the setting of this unusual presentation.

Intradural cavernous lymphangioma of the thoracic spine: case report, technical considerations, and review of the literature

BACKGROUND CONTEXT Cavernous lymphangioma is a rare slow-growing tumor that can cause neurologic compromise when it involves the central nervous system. Involvement of the spinal column is rare but may involve the osseous structures or the epidural space of the spinal column. PURPOSE We report the first case of an intradural, extramedullary cavernous lymphangioma involving the thoracic spinal cord. METHODS An 83-year-old woman presented with progressive gait ataxia, bilateral lower extremity weakness, and a band-like sensation in the middle and lower thoracic dermatomes. Magnetic resonance imaging of the thoracic spinal cord revealed hyperintensity on T2 and enhancement of an intradural cystic mass along the dorsal aspect of the T5-T8 levels with significant compression of the spinal cord. RESULTS Complete surgical resection was difficult owing to the adherence of the tumor to the pial surface and microvasculature of the thoracic spinal cord. Recurrence of the mass was ultimately treated with cystic fluid diversion into the peritoneum. At her follow-up visit after 28 months, the patient was able to ambulate with minimal assistance. A comparative literature review is presented. There are no reports of intradural thoracic spinal cord involvement in the literature. CONCLUSIONS Intradural cavernous lymphangioma of the spine poses a unique surgical challenge for complete resection. Cystic fluid diversion appears to be a viable treatment option with lasting benefit if complete resection is not achieved.

Treatment of a giant vertebral artery pseudoaneurysm secondary to gunshot wound to the neck using pipeline embolization device

A 27-year-old man with history of gunshot wound to the neck resulting in quadriplegia three years ago presented with progressive neck pain and dysphagia. Neurological examination revealed complete spinal cord injury from C6 spinal cord level down. Computed tomography (CT) of the cervical spine demonstrated a retained bullet in the cervical spinal canal at C6-7 (Figure 1(A)). CT angiogram of the neck demonstrated a giant pseudoaneurysm of the left vertebral artery measuring 3.2 3.0 cm arising from the V2 segment (Figure 1(B)), with significant mass effect on the hypopharyngeal structures including the trachea and esophagus. Given patient’s progressive neck pain and dysphagia, as well as the risk of delayed rupture, treatment of the vertebral pseudoaneurysm was deemed necessary. Because surgical approach to V2 segment of the vertebral artery is challenging, endovascular treatment using flow-diverting stents was chosen. The patient was brought to the angiography suite and underwent general endotracheal anesthesia. The left vertebral artery was selectively catheterized, and a cerebral angiogram was performed which again demonstrated the pseudoaneurysm (Figure 1(C)). With the microcatheter was in the desired position, the Pipeline Embolization Device was loaded into the microcatheter and successfully deployed across the targeted location. The patient was neurologically stable post-operatively and was maintained on dual anti-platelets therapy. At three-month follow-up, repeat angiogram (Figure 1(D)) demonstrated complete occlusion of the pseudoaneurysm. The patient was clinically stable without progression of symptoms. Pseudoaneurysms often occur as a vascular complication from gunshot wound and account for up to 25% of all traumatic arterial injuries. While many pseudoaneurysms are asymptomatic, symptomatic lesions can cause mass effect on adjacent structures along with more serious complications including bleeding, vascular occlusion and ischemic stroke.(2) The optimal treatment strategy of pseudoaneurysms is still a topic of debate, with treatment options ranging from conservative management with close observation, to endovascular and/or surgical repairs. Herrera et al. reported a series of 18 traumatic injuries of the vertebral artery where endovascular therapy resulted in immediate pseudoaneurysm total occlusion in 89% patients and 100% pseudoaneurysm occlusion at follow-up. The Pipeline Emboilization Device has been used to treat aneurysms of posterior circulation with success. However, its utility in treating traumatic pseudoaneurysm has not been well documented. Our case demonstrates that PED can be a valuable option for endovascular treatment of giant vertebral pseudoaneurysms. The advantage of using PED compared to conventional stent with coiling is that PED can minimize the risk of persistent mass effect from coils while achieve occlusion of the pseudoaneurysm. The drawback of endovascular approach is the need for dual antiplatelets therapy, which may not be possible in patients with other solid organ injuries where bleeding is a concern.

Minimally Invasive Posterior Cervical Decompression

Minimally invasive surgical (MIS) procedures for posterior cervical laminectomy, laminoforaminotomy and discectomy techniques were developed to reduce muscle dissection and soft tissue trauma. MIS posterior cervical laminoforaminotomy has been shown to reduce operative times, blood loss, postoperative pain and duration of hospital stays. In carefully selected patients with lateral foraminal disease, excellent surgical results can be expected. In this chapter, we will discuss the indications, contraindications, surgical technique and common surgical nuances involved in a posterior cervical decompression. A video illustration of an MIS posterior cervical laminoforaminotomy is also included.