Namath S Hussain

Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation.

Background Case reports and case control studies have suggested an association between chiropractic neck manipulation and cervical artery dissection (CAD), but a causal relationship has not been established. We evaluated the evidence related to this topic by performing a systematic review and meta-analysis of published data on chiropractic manipulation and CAD. Methods Search terms were entered into standard search engines in a systematic fashion. The articles were reviewed by study authors, graded independently for class of evidence, and combined in a meta-analysis. The total body of evidence was evaluated according to GRADE criteria. Results Our search yielded 253 articles. We identified two class II and four class III studies. There were no discrepancies among article ratings (i.e., kappa=1). The meta-analysis revealed a small association between chiropractic care and dissection (OR 1.74, 95% CI 1.26-2.41). The quality of the body of evidence according to GRADE criteria was “very low.” Conclusions The quality of the published literature on the relationship between chiropractic manipulation and CAD is very low. Our analysis shows a small association between chiropractic neck manipulation and cervical artery dissection. This relationship may be explained by the high risk of bias and confounding in the available studies, and in particular by the known association of neck pain with CAD and with chiropractic manipulation. There is no convincing evidence to support a causal link between chiropractic manipulation and CAD. Belief in a causal link may have significant negative consequences such as numerous episodes of litigation.

Clinical Utility of Thallium-201 Single Photon Emission Computed Tomography and Cerebrospinal Fluid Epstein-Barr Virus Detection Using Polymerase Chain Reaction in the Diagnosis of AIDS-Related Primary Central Nervous System Lymphoma

Objective: To determine the diagnostic efficiency of thallium-201 single photon emission computed tomography (SPECT) and Epstein-Barr virus (EBV) polymerase chain reaction (PCR) in the differentiation of primary central nervous system lymphoma (PCNSL) from other central nervous system processes in patients with HIV/AIDS. Design/Methods: Over 10 years, 68 thallium-201 SPECT scans were performed on neurologically symptomatic HIV+ patients with focal lesions on CT or MRI at the Johns Hopkins Hospital. Diagnoses were then established by either autopsy, biopsy, or clinical response to anti-toxoplasmosis therapy. Patients were categorized prior to a prospective clinical reading of the SPECT scans by nuclear medicine physicians. Results: In our patient sample overall, the diagnostic efficiency of thallium-201 SPECT was 79%. The diagnostic accuracy of EBV PCR testing alone in a subset of 22 patients in our study that had CSF analyzed was 73%. However, when both positive EBV PCR and positive thallium-201 SPECT results were used together, the diagnostic accuracy improved to 100% based on a sample of 13 patients where EBV PCR and SPECT imaging results were concordant. Conclusion: Thallium-201 SPECT has a relatively high positive predictive value with regards to the diagnosis of PCNSL, which suggests that patients with positive results could undergo empiric radiation treatment without resorting to brain biopsy. However, the predictive value can be increased by testing for CSF EBV using PCR. Alternatively, if CSF cannot be safely obtained because of mass effect, we believe that these data still suggest that empiric radiation treatment should be considered when discussing treatment options with patients with a positive thallium-201 SPECT.

Intravascular Ultrasound for Intracranial and Extracranial Carotid Artery Stent Placement

Intravascular ultrasound (IVUS) can provide valuable information regarding endoluminal morphology. We present the first description of IVUS-guided intracranial and extracranial carotid artery stent placement for arterial dissection. A 41-year-old female with a sudden-onset headache and blurred vision underwent a computed tomography (CT) angiogram imaging that revealed bilateral carotid artery dissections (BCAD) and a left vertebral artery dissection (VAD). Endovascular treatment (EVT) of a long segment right carotid artery dissection (CAD) was performed employing two Carotid WALLSTENT™ Monorails™ (8 x 36 mm, 10 x 31 mm) (Boston Scientific, Marlborough, MA). With the help of the IVUS, the distal stent was placed up to the petrous carotid artery, followed by the placement of the second stent in the immediate proximal location with some overlap that extended down to the carotid artery bulb. Intraoperative angiography and post-stenting IVUS revealed excellent stent placement with good resolution of the dissection and good luminal patency with pseudolumen obliteration. Stent use for intracranial circulation dissections will continue to be a favorable option given the decreased morbidity of endovascular therapy in this location. As endovascular surgeons become more facile with the use of IVUS, using it as a guide for stent placement and post-stenting confirmation will help them to ensure proper positioning and improved patency rates.

The Impact of Intracranial Tumor Proximity to White Matter Tracts on Morbidity and Mortality: A Retrospective Diffusion Tensor Imaging Study.

Background Using diffusion tensor imaging (DTI) in neurosurgical planning allows identification of white matter tracts and has been associated with a reduction in postoperative functional deficits. Objective This study explores the relationship between the lesion-to-tract distance (LTD) and postoperative morbidity and mortality in patients with brain tumors in order to evaluate the role of DTI in predicting postoperative outcomes. Methods Adult patients with brain tumors (n = 60) underwent preoperative DTI. Three major white matter pathways (superior longitudinal fasciculi [SLF], cingulum, and corticospinal tract) were identified using DTI images, and the shortest LTD was measured for each tract. Postoperative morbidity and mortality information was collected from electronic medical records. Results The ipsilesional corticospinal tract LTD and left SLF LTD were significantly associated with the occurrence rate of total postoperative motor (P = .018) and language (P < .001) deficits, respectively. The left SLF LTD was also significantly associated with the occurrence rate of new postoperative language deficits (P = .003), and the LTD threshold that best predicted this occurrence was 1 cm (P < .001). Kaplan–Meier log-rank survival analyses in patients having high-grade tumors demonstrated a significantly higher mortality for patients with a left SLF LTD <1 cm (P = .01). Conclusion Measuring tumor proximity to major white matter tracts using DTI can inform clinicians of the likelihood of postoperative functional deficits. A distance of 1 cm or less from eloquent white matter structures most significantly predicts the occurrence of new deficits with current surgical and imaging techniques.

Retraction: Cadaveric Study of Anatomic Far Distal Musculocutaneous and Median Nerve Communication.

[This retracts the article DOI: 10.7759/cureus.627.].

Cadaveric Study of Anatomic Far Distal Musculocutaneous and Median Nerve Communication

One of the more commonly reported variations in musculocutaneous and median nerves is a communication between the two. Such communications have been noted in the literature for well over a century, and numerous studies have attempted to quantify their rate of incidence and classify their different patterns. Most communications occur close to the brachial plexus in the proximal arm; communications distal to the musculocutaneous nerve perforation of the coracobrachialis have been reported with less frequency, and several rare and unique communication patterns have been reported as case studies. This paper describes a case of a communicating branch between the musculocutaneous and median nerves, distal to the origin of the brachialis muscle. This communication was found during a routine educational dissection and is closer to the level of the elbow than previously documented communications that are distal to the musculocutaneous perforation of the coracobrachialis. Identification and documentation of the variety of musculocutaneous and median nerve communications is relevant to clinical diagnosis of peripheral nerve pathologies, as well as for planning surgical approaches and procedures.

Hybrid Neurofibroma-Schwannoma

Neurofibromas and schwannomas are common lesions that may be idiopathic or may occur in association with neural crest genetic syndromes such as neurofibromatosis type 1, neurofibromatosis type 2, and schwannomatosis. A hybrid tumor that contains pathological characteristics of both neurofibroma and schwannoma has been described as a rare entity. We present the clinical, radiographic, and pathological findings of such a case.

A Unique Case of Intracranial Mucormycosis Following an Assault.

Intracranial mucormycosis is a very unusual presentation of an infection after a depressed skull fracture due to an assault. Only sporadic cases have been reported in the literature previously. A 30-year-old male with a traumatic brain injury following an assault, status-post debridement and elevation of a depressed skull fracture, was discharged home several weeks postoperatively. A CT scan of the head with contrast was obtained due to mental status changes and revealed an enhancing ring-shaped lesion in the right frontal lobe consistent with a brain abscess. The patient was taken to the operating room for image-guided excisional biopsy of the lesion, with pathology revealing mucormycosis.

Application of the Flexible CO2 Laser in Minimally Invasive Laminectomies: Technical Note

Background Minimally invasive laminectomy is a very effective surgical method for treating lumbar stenosis. However, this technique can be technically difficult, especially in patients suffering from severe stenosis. The contralateral decompression from a unilateral approach can result in durotomy during removal of the hypertrophied ligamentum flavum. This complication can be difficult to treat through a small working channel. Objective To detail our group’s operative experience with the CO2 laser and discuss our results and previous studies in the literature reporting results. Methods The CO2 laser (Omniguide, Boston, MA) was investigated in the surgical ablation of the contralateral ligamentum flavum during minimally invasive laminectomies. Forty levels have been investigated thus far. The amount of voltage needed to adequately desiccate and remove the ligamentum flavum safely as well as the effectiveness of this technique were investigated. Results The contralateral ligamentum flavum could be removed effectively using the 9 to 11 watt continuous wavelength (10,600 nanometer) power setting on the CO2 laser. Shrinkage of the contralateral ligamentum flavum facilitated its removal using a number 2 Kerrison Punch. No durotomies occurred, and the use of the laser did not significantly lengthen operative times. Conclusions The CO2 laser appears to be a useful tool in the armamentarium of instruments available to the minimally invasive spine surgeon and may help to reduce the incidence of durotomies when performing minimally invasive laminectomies.

Analysis of 1014 consecutive operative cases to determine the utility of intraoperative neurophysiological data.

Introduction: Intraoperative neurophysiological monitoring (IOM) during neurosurgical procedures has become the standard of care at tertiary care medical centers. While prospective data regarding the clinical utility of IOM are conspicuously lacking, retrospective analyses continue to provide useful information regarding surgeon responses to reported waveform changes. Methods: Data regarding clinical presentation, operative course, IOM, and postoperative neurological examination were compiled from a database of 1014 cranial and spinal surgical cases at a tertiary care medical center from 2005 to 2011. IOM modalities utilized included somatosensory evoked potentials, transcranial motor evoked potentials, pedicle screw stimulation, and electromyography. Surgeon responses to changes in IOM waveforms were recorded. Results: Changes in IOM waveforms indicating potential injury were present in 87 of 1014 cases (8.6%). In 23 of the 87 cases (26.4%), the surgeon responded by repositioning the patient (n = 12), repositioning retractors (n = 1) or implanted instrumentation (n = 9), or by stopping surgery (n = 1). Loss of IOM waveforms predicted postoperative neurological deficit in 10 cases (11.5% of cases with IOM changes). Conclusions: In the largest IOM series to date, we report that the surgeon responded by appropriate interventions in over 25% of cases during which there were IOM indicators of potential harm to neural structures. Prospective studies remain to be undertaken to adequately evaluate the utility of IOM in changing surgeon behavior. Our data is in agreement with previous observations in indicating a trend that supports the continued use of IOM.