Neil Majmundar

First report of major vascular injury due to lateral transpsoas approach leading to fatality

Extreme lateral interbody fusion (XLIF) has gained popularity among spine surgeons for treating multiple conditions of the lumbar spine. In contrast to the anterior lumbar interbody fusion (ALIF) approach, the minimally invasive XLIF approach affords wide access to the lumbar disc space without an access surgeon and causes minimal tissue disruption. The XLIF approach offers many advantages over other lumbar spine approaches, with a reportedly low complication profile. The authors describe the first fatality reported in the literature following an XLIF approach. They describe the case of a 50-year-old woman who suffered a fatal intraoperative injury to the great vessels during a lateral transpsoas approach to the L4-5 disc space.

Mechanical thrombectomy – is time still brain? The DAWN of a new era

Abstract Purpose: The purpose of this study is to review the history of treatments for acute ischemic stroke, examine developments in endovascular therapy, and discuss the future of the management of acute ischemic stroke. Methods: A selective review of recent clinical trials for the treatment of acute ischemic stroke was conducted. Results: We reviewed completed trials of the management of acute ischemic stroke including intravenous thrombolytics, intraarterial thrombolytics, and thrombectomy. We also assessed the future direction of research by reviewing ongoing clinical trials. Conclusions: The advancement of endovascular treatment for stroke has led to improved morbidity and mortality for patients. Future challenges include delivering these treatments to stroke centers worldwide.

Bailout Strategies and Complications Associated with the Use of Flow-Diverting Stents for Treating Intracranial Aneurysms

Background: Flow-diverting stents (FDS) have revolutionized the endovascular management of unruptured, complex, wide-necked, and giant aneurysms. There is no consensus on management of complications associated with the placement of these devices. This review focuses on the management of complications of FDS for the treatment of intracranial aneurysms. Summary: We performed a systematic, qualitative review using electronic databases MEDLINE and Google Scholar. Complications of FDS placement generally occur during the perioperative period. Key Message: Complications associated with FDS may be divided into periprocedural complications, immediate postprocedural complications, and delayed complications. We sought to review these complications and novel management strategies that have been reported in the literature.

Pituitary Apoplexy following Endoscopic Retrograde Cholangiopancreatography

BACKGROUND Pituitary apoplexy is an uncommon neurosurgical emergency that may be the initial presentation of undiagnosed pituitary adenomas. Though the exact pathogenesis is unclear, there appears to be an association between pituitary apoplexy and medical interventions that disturb the blood supply and venous drainage of the abnormal sellar region. We present the first case of pituitary apoplexy occurring after an endoscopic retrograde cholangiopancreatography (ERCP). CASE DESCRIPTION A 43-year-old male who was several hours status post ERCP presented with a severe headache, bilateral ptosis, and multidirectional ophthalmoplegia. Computed tomography scan and magnetic resonance imaging of the brain revealed a hemorrhagic and necrotic sellar mass with suprasellar extension compressing the optic chiasm and bilateral extension displacing the cavernous carotid arteries laterally. The patient underwent emergent endoscopic endonasal transsphenoidal resection of the underlying pituitary tumor apoplexy with eventual resolution of his cranial nerve palsies. CONCLUSIONS Although pituitary apoplexy has been recognized as a sequela of surgical and laparoscopic procedures, it should also be considered in less invasive gastrointestinal procedures which may alter the intraabdominal pressures, such as ERCP. Early detection of this unusual complication allows for rapid diagnosis and timely surgical intervention in select cases to prevent debilitating cranial nerve palsies, preserve visual function, and retain normal pituitary function.

Stereotactic Body Radiation Therapy in Non-Surgical Patients with Metastatic Spinal Disease and Epidural Compression: A Retrospective Review

BACKGROUND In the setting of spinal metastases with epidural cord compression, radiosurgery is often only considered when there is sufficient separation between the epidural disease and the spinal cord. However, in patients who are nonsurgical candidates or those who prefer nonoperative management, there may be a benefit from stereotactic body radiation therapy, even when the epidural target is closer than the traditionally referenced 3 mm distance from the spinal cord. The purpose of this retrospective study is to evaluate our institutions experience in treating 20 such patients. METHODS We reviewed records of all patients treated with stereotactic body radiation therapy for spinal metastases at our institution from January 2010 to January 2016, with follow-up through December 2016. The primary end point was local progression of disease. Local progression was defined as clear radiographic disease growth on follow-up imaging or worsening clinical symptoms in the absence of evidence for radiation myelopathy. RESULTS Local control was obtained in 55% of patients meeting these criteria without a single case of radiation myelitis. Most patients with disease progression were able to undergo additional local treatment. CONCLUSIONS Although local control was less than expected when compared with spine radiosurgery with adequate separation between the target and spinal cord, this treatment appears to be a viable option in the nonsurgical candidate.

Post-Traumatic Pituitary Tumor Apoplexy After Closed Head Injury: Case Report and Review of the Literature

BACKGROUND Head trauma is a rare inciting factor of pituitary apoplexy (PA); however, there is a clear temporal relationship between trauma and apoplexy, and this is the first reported case of PA after an assault. CASE DESCRIPTION We present a rare case of a 63-year-old man who developed PA after sustaining a closed head injury from assault with a metal pole. The patient had a known pituitary tumor for which he had previously declined surgical resection. On initial computed tomography scan, there was no traumatic intracerebral hemorrhage or subarachnoid hemorrhage. There was sellar expansion but no obvious sellar hemorrhage. Within 48 hours of admission, the patient was presumed septic after developing altered mental status, fevers, hypotension, and tachycardia. Magnetic resonance imaging of the brain with and without gadolinium revealed a poorly enhancing, necrotic, and hemorrhagic pituitary mass, consistent with pituitary tumor apoplexy. After administration of intravenous glucocorticoids, the patient underwent emergent endoscopic transsphenoidal resection of the pituitary tumor apoplexy. Postoperatively, the patient had neurologic improvement with stable vision. CONCLUSIONS Early and accurate diagnosis is important to allow for timely neurosurgical intervention. Symptoms of fever, hypotension, and tachycardia in a patient with a known sellar mass should raise the suspicion of hypocortisolemia from pituitary tumor apoplexy.

Residency/Fellowship Training and the Complication

Medical errors are believed to be the third leading cause of death in the United States and can have profound socioeconomic implications within the healthcare system. The need for academic teaching hospitals to effectively train resident physicians while minimizing the incidence of medical errors and ensuing complications during patient care has proven a significant challenge. National political efforts over the past two decades have introduced several interventions which aim to reduce the incidence of medical errors at these academic medical institutions. The precise relationship between the frequencies of complications associated with resident error, however, has been poorly elucidated in the past. Here, we provide a review of the current data on the relationship between medical care administered by residents and the incidence of complications. We further examine the role of fatigue, burnout, and duty hour restrictions on complication rates and consider the legal ramifications of resident error.

What Is a Complication? The Philosophical and Psychological Aspects

A 56-year-old female patient with a past medical history of hypertension and type II diabetes mellitus undergoes a diagnostic aneurysm at 1 year after coil embolization of an anterior communicating artery aneurysm. Fortunately, the aneurysm had been coiled prior to rupture, and the patient had not suffered any neurological deficits. Other than some difficulty in gaining access to the right common carotid artery, the angiogram went without any particular setback. In the post-procedure recovery unit, the patient complained of left arm weakness. Upon examination, the patient was unable to move her left arm, and it had no tone. She was rushed back to the angiography suite, where she was discovered to have a thrombus in a distal MCA branch, unable to be treated. MRI showed an MCA territory infarction. She was sent back to the recovery unit, where the attending physician explained the undesired outcome and the steps which would be taken to optimize her long-term outcome with hope of regaining some function in the left arm. Was this a medical error resulting in neurological deficit, or was this a complication of the procedure?

Lung adenocarcinoma presenting as intramedullary spinal cord metastasis: Case report and review of literature

Intramedullary spinal cord metastasis (IMSCM) is a rare entity which lacks well-defined treatment guidelines, yet sees rising incidence. We report a case of a 67-year-old man who presented with severe neck pain and numbness in his right fourth and fifth digits, and was found to have a C5-7 IMSCM of previously unknown lung adenocarcinoma. He underwent gross total resection of the IMSCM, afatinib, and radiation treatment. He had full reversal of his pain and sensory deficit, and remained ambulatory without any focal neurological deficit. Additionally, we conducted a literature review of original case series of IMSCM published between 1983 and 2016, representing 138 unique cases, and discuss various treatments with a focus on surgical resection and general treatment of stage IV lung adenocarcinoma. 18.75% of cases of IMSCM were an initial presentation of underlying malignancy. Rapidly progressive pain and weakness was the most common presentation, often compromising ambulatory status. Median survival ranged from 3.8 to 11.6 months after treatment in patients who were deceased at time of publication. Treatments included corticosteroids, chemotherapy, various radiotherapies, and surgical resection. Surgical resection was found to greatly improve symptoms and preserve ambulatory status, and was associated with increased survival time up to double that of non-surgical treatments. Most authors recommended surgical resection only in symptomatic patients with reversible deficits, to palliate symptoms and preserve ambulation. IMSCM can herald an underlying malignancy, and surgical resection can preserve ambulatory status and palliate symptoms as well increase survival time in a subset of patients.

High-frequency spinal cord stimulation causing cardiac paresthesias after lead migration: a case report

Introduction: High-frequency (HF) spinal cord stimulation (SCS), a relatively new form of spinal cord stimulation, provides stimulation frequencies of up to 10 kHz and allows for paresthesia-free pain relief, an advantage that distinguishes it from traditional stimulation therapy. Without paresthesias, patients with HF SCS do not experience position-dependent painful stimulation and do not have to experience treatment interruption during sleep. Lead migration is a well-known complication of conventional spinal cord stimulation and usually results in a loss of efficacy along with other unpleasant sensory symptoms. In this case report, we present an incidence of lead migration in HF SCS that resulted in paresthesias, a symptom not expected to occur in this novel therapy. Case: The patient, a 60-year-old female with post-laminectomy syndrome, underwent a trial of HF SCS with standard lead placement at T8-T9. She initially had pain relief, but returned to the office on post-operative day 2 complaining of left chest wall and cardiac paresthesias, without frank pain or palpitations, in addition to loss of efficacy for her back and leg pain. Imaging showed that the leads had migrated, with one lead reaching the levels of T1-T3. Conclusion: While HF SCS has emerged as an effective paresthesia-free means of reducing back and leg pain, we provide the first report of paresthesias occurring with the HF SCS system as a result of cephalad lead migration. As HF SCS is only now being utilized as a treatment modality, we must remain cautious of potential adverse outcomes in patients, in particular above T8.