Oluwaseun O. Akinduro

Augmented reality for the surgeon: Systematic review

Since the introduction of wearable head‐up displays, there has been much interest in the surgical community adapting this technology into routine surgical practice.

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.

Cervical pseudomeningocele-induced hydrocephalus following traumatic brachial plexus injury-âÂÂa case report

Introduction: We report a case of a 49-year-old man who sustained a left brachial plexus injury and traumatic brain injury after a motor vehicle accident and subsequently developed a giant left cervical pseudomeningocele. The patient suffered multiple fractures in the cervical and thoracic ribs, transverse processes and the scapula. Physical examination revealed a giant left supraclavicular mass restricting his ability to turn his head ipsilaterally, with head tilted to the right, consistent with complete plexus avulsion. Neurological examination showed progressive muscular atrophy and a positive Tinel’s sign and paresthesias of the left hand. Methods: MRI and CT revealed a giant cervical pseudomeningocele. Left hemilaminectomy and partial medial facetectomy were performed for an extradural repair of the cyst. Three days later, the pseudomeningocele recurred; C6-T2 cervical laminectomy and a combined intra- and extradural repair of CSF leak with tensor fascia lata graft were performed. One day after the second surgery, the patient developed acute communicating hydrocephalus (CH) with progressive neurological decline. Results: Ventriculoperitoneal shunt placement successfully resolved neurological symptoms associated with CH. The patient continued receiving treatment for neuropathic pain and spams in the left upper arm at one-year follow up. Conclusion: We present one of the few documented cases of acute CH after a successful repair of a giant cervical pseudomeningocele. It is important for physicians to be aware of changes in CSF flow dynamics that occur in patients with traumatic brain injury. A repair of a large chronic pseudomeningocele can lead to acute CH in patients and cause rapid neurological decline. It is critical for clinicians to be mindful of the potential complication of acute hydrocephalus in patients who undergo repair of a large chronic pseudomeningocele secondary to trauma.

Stem cell therapy and its potential role in pituitary disorders

Purpose of review The pituitary gland is one of the key components of the endocrine system. Congenital or acquired alterations can mediate destruction of cells in the gland leading to hormonal dysfunction. Even though pharmacological treatment for pituitary disorders is available, exogenous hormone replacement is neither curative nor sustainable. Thus, alternative therapies to optimize management and improve quality of life are desired. Recent findings An alternative modality to re-establish pituitary function is to promote endocrine cell regeneration through stem cells that can be obtained from the pituitary parenchyma or pluripotent cells. Stem cell therapy has been successfully applied to a plethora of other disorders, and is a promising alternative to hormonal supplementation for resumption of normal hormone homeostasis. Summary In this review, we describe the common causes for pituitary deficiencies and the advances in cellular therapy to restore the physiological pituitary function.

Challenges of Managing Patients with Symptomatic Large Traumatic Cervical Pseudomeningoceles

BACKGROUND Traumatic cervical pseudomeningoceles (TCPs) occur secondary to traction of the cervical nerve roots resulting in violation of the dura. Surgical repair is not necessary in most cases because pseudomeningoceles have a high propensity to spontaneously resolve with conservative management alone. Currently, there are a limited number of cases of large TCPs (large is defined as ≥6 cm in greatest diameter), and there is no established guideline for the management of such lesions. CASE DESCRIPTION We describe the cases of 2 young men in their 20s who were involved in a motor vehicle accident. Both patients suffered a brachial plexus injury and developed large TCPs. Patient 1 was treated surgically for TCP using a combined intra-/extradural approach using a fascia lata graft. Patient 2 was ultimately treated nonsurgically because a spontaneous resolution of the pseudomeningocele was achieved over the period of 7 months after the accident. Both patients underwent brachial plexus repair surgery consisting of spinal accessory nerve transfer to the suprascapular nerve and intercostal nerve transfer to the musculocutaneous nerve. CONCLUSIONS Disease progression of TCPs is a dynamic process, and even large lesions may spontaneously resolve without surgical intervention. When surgery is indicated, a definitive dural repair using a fascia lata graft to cover the dural tear intra- and extradurally is an effective method. Surgery must be planned carefully on a case-by-case basis, and close follow-up with thorough physical examination and serial imaging is critical to monitor disease progression.

Ectopic Prolactinoma Presenting as Bacterial Meningitis: A Diagnostic Conundrum

BACKGROUND Prolactinomas may rarely present with meningitis and cerebrospinal fluid (CSF) rhinorrhea secondary to erosion of the wall of the sella turcica. It is even more uncommon for this abnormal communication to be caused by an ectopic prolactinoma arising from the sphenoid sinus and eroding into the sella. This atypical growth pattern makes diagnosis very difficult because there may be no displacement of the normal pituitary gland. The first reported case of a patient with an ectopic prolactinoma originating within the sphenoid sinus presenting primarily with meningitis is presented, and the management strategy and surgical and nonsurgical treatment options are discussed. CASE DESCRIPTION A 48-year-old woman presented with confusion, low-pressure headache, and fever. A lumbar puncture revealed Streptococcus pneumoniae meningitis, and she was placed on intravenous penicillin G. After initiation of antibiotics, she noticed salty tasting postnasal fluid leakage. Imaging was remarkable for bony erosion of the sphenoid sinus wall by a soft tissue mass growing from within the sinus, with no disruption of the normal pituitary gland. A biopsy was then performed with an endoscopic transnasal transsphenoidal approach, and the CSF leak was repaired with a pedicled nasoseptal flap. The final pathology was prolactinoma, and she was placed on cabergoline. CONCLUSIONS Ectopic prolactinomas may rarely present as meningitis secondary to retrograde transmission of bacteria through a bony defect in the sphenoid sinus, and must be included in the differential diagnosis of any sphenoid sinus mass. Management should first address the infection, followed by surgical repair of the bony defect.

Infection or Glioma? The False Dilemma of Primary Central Nervous System Histiocytic Sarcoma

BACKGROUND Primary central nervous system (CNS) histiocytic sarcoma is an extremely rare lymphoproliferative disorder that affects the CNS and behaves aggressively. Only 27 cases of primary CNS histiocytic sarcoma have been reported. The paucity of literature on this entity has made diagnosis and treatment difficult both for the surgeon and the pathologist. CASE DESCRIPTION In this case of primary CNS histiocytic sarcoma, a middle-aged woman presented from an outside institution with a supposed cerebellar abscess. Intraoperative frozen pathology was initially interpreted as high-grade glioma; however, final pathology demonstrated histiocytic sarcoma. CONCLUSIONS This report makes a significant contribution to the literature on this rare malignant disease by outlining a similar presentation among several cases and providing a thorough overview of existing criteria for diagnosis and management.

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.