Paul K. Maurer

Cervical spondylotic myelopathy: treatment with posterior decompression and Luque rectangle bone fusion

Cervical spondylotic myelopathy appears to result from a combination of factors. The two major components are 1) compressive forces resulting from narrowing of the spinal canal, and 2) dynamic forces owing to mobility of the cervical spine. There is substantial evidence to suggest that the repetitive trauma to the spinal cord that is sustained with movement in a spondylotic canal may be a major cause of progressive myelopathy. Utilization of extensive anterior procedures that remove the diseased ventral features as well as eliminate the dynamic forces owing to the accompanying fusion have grown in popularity. Cervical laminectomy enlarges the spinal canal, but does not reduce the dynamic forces affecting the spinal cord, and may actually increase cervical mobility, leading to a perpetuation of the myelopathy. The authors propose the combination of posterior decompression and Luque rectangle bone fusion to deal with both the compressive and the dynamic factors that lead to cervical spondylotic myelopathy. Ten patients who had advanced myelopathy underwent the combined procedures. Nine of the 10 experienced significant neurological improvement, and the 10th has had no progression. The combination of posterior decompression and Luque rectangle bone fusion may offer a simple, safe, and effective alternative treatment for cervical spondylotic myelopathy.

Repeat intra-arterial papaverine for recurrent cerebral vasospasm after subarachnoid haemorrhage

Abstract We assessed the prevalence of recurrent vasospasm following failure of intra-arterial papaverine and the efficacy of repeat intra-arterial infusions of papaverine for control of recurrent vasospasm. Of 24 patients treated with intra-arterial papaverine for vasospasm following aneurysm surgery, 12 did not improve clinically after the initial treatment; 9 received second or third infusions on consecutive days; 6 received only a second infusion; and 3 received a third. Superselective infusion into the intracranial arteries was performed in all nine cases. Despite angiographic improvement after the initial or second infusions, all nine patients showed varying degrees of recurrent vasospasm at the time of the second or third treatment. Within 24 h of a second infusion, three of the six patients had significant clinical improvement, and one of these showed marked improvement soon after a third infusion. Our preliminary results suggest that repeat papaverine infusion may be a way of controlling recurrent or recalcitrant vasospasm.

Dural tail adjacent to acoustic neuroma : MR features

There have been several reports describing the presence of a dural tail on enhanced MR as being specific for or suggestive of meningioma. It has also been stated that it is a specific diagnostic sign in distinguishing meningioma from acoustic neuroma. We report a case of a dural tail in an acoustic neuroma.

Symptomatic Pineal Cyst: Case Report

Pineal cysts are being described with increasing frequency since the advent of magnetic resonance imaging. Although pineal cysts are incidental findings in as many as 4% of magnetic resonance imaging studies, symptomatic pineal cysts are quite rare. We present a case of pineal cyst causing aqueductal obstruction with symptomatic hydrocephalus and resultant headache and syncope, which was treated by surgical resection. A review of the relevant literature and discussion follow.

Restoration of Hearing after Removal of Cerebellopontine Angle Meningioma: Diagnostic and Therapeutic Implications

A case of cerebellopontine angle meningioma with restoration of hearing from a profoundly deaf state is presented. Meningiomas of the posterior fossa commonly present with decreased or absent hearing and can appear deceptively similar to acoustic neurinomas on radiographic and audiometric testing. Because total restoration of hearing can occur with meningioma, even with significant preoperative deficit, utilization of the translabyrinthine approach is less desirable if any preoperative question as to the diagnosis exists. Any hearing-impaired patient with a cerebellopontine angle mass that is not conclusively thought to represent acoustic neurinoma should be approached by the suboccipital technique to maximize the opportunity for restoration of hearing.

Blunt trauma to the carotid artery with transient deficit and early repair

Blunt trauma to the carotid artery is an uncommon but easily overlooked source of neurological deficit. The prompt diagnosis and angiographic definition of carotid-artery injuries can allow early operative intervention in these potentially devastating lesions. We describe a case report of blunt trauma with transient deficit in a patient who underwent direct repair via Dacron-patch angioplasty.

349 Safety of the Sitting Cervical Position for Elective Spine Surgery.

INTRODUCTION The sitting cervical position affords advantages over prone positioning for elective posterior cervical decompression and fusion. A potential disadvantage is the risk for venous air embolism. METHODS We retrospectively identified all adult elective posterior cervical surgeries at our institution between 2009 and January 2014. Using International Classification of Diseases, Ninth Revision coding, we searched for incidences of air embolism, myocardial infarction, pulmonary embolism, and deep vein thrombosis. Operative time, estimated blood loss, and case type distribution were also recorded. Surgeries for trauma, tumor, or that involved the occipital-cervical junction were excluded. RESULTS Between 2009 and January 2014, 560 surgeries were performed in the sitting cervical position and 20 in the prone position. No venous air embolisms were reported for either group. The average surgical time was 1 hour 46 minutes for prone-positioned patients and 1 hour 25 minutes for surgeries in the sitting position (P = .003). Thirty-day perioperative complications among the sitting-position patients included 2 myocardial infarctions, 1 pulmonary embolism attributed to venous thrombosis, and 2 deep venous thromboses, for a total cardiovascular complication rate of 0.9%. CONCLUSION Our study adds to the literature supporting the safety of the sitting cervical position. The sitting position is preferred by many surgeons at our institution. It provides a dry surgical field, easily verified spinal alignment prior to fusion, and superior visualization on intraoperative x-rays due to reduced shoulder artifact. Furthermore, our data suggest that operative times may be shorter. Although the risk of venous air embolism exists, clinically significant occurrences are extremely rare. Given our large volume of surgeries in the sitting position, we believe the advantages outweigh the risks.

The history of neurosurgery at the University of Rochester

The Department of Neurosurgery at the University of Rochester has a long legacy of excellent patient care and innovation in the neurosciences. The departments founder, Dr. William Van Wagenen, was a direct pupil of Harvey Cushing and the first president of the Harvey Cushing Society. His successor, Dr. Frank P. Smith, was also a leader in organized neurosurgery and helped to permanently memorialize his mentor with an endowed fellowship that today is one of the most prestigious training awards in neurosurgery. The first 2 chiefs are honored every year by the department with memorial invited lectureships in their names. The department is home to a thriving multidisciplinary research program that fulfills the lifelong vision of its founder, Dr. Van Wagenen.

Postoperative radiographic appearance of intracranial hemostatic gelatin sponge.

Hemostatic gelatin sponges were placed in hemispheric defects created in four dogs which were then periodically scanned by computed tomography to determine the postoperative appearance of the sponges. The hemostatic sponges appeared as low attenuation regions for 7-10 days. The attenuation value of these Gelfoam cavities was intermediate between fat and air. Subsequently, clinical cases were selected in which the location of gelatin sponges were known to demonstrate the appearance of the material in patients. In addition to enhancing the accuracy of computed tomographic interpretation, we have found that the gelatin sponge can be useful as a transient computed tomography marker for localization of surgical activity.

Conservative management of a cervical ligamentum flavum hematoma: Case report.

Background: Spontaneous epidural hematoma arising from the ligamentum flavum is a rare cause of acute spinal cord compression. There are only four reports in the cervical spine literature, and all were managed with surgery. Here, we describe an acute case of a spontaneous epidural hematoma arising from the ligamentum flavum in the cervical spine successfully managed without surgery. Case Description: A 69-year-old woman with a cervical spine epidural hematoma contained within the ligamentum flavum presented with paroxysmal neck pain and stiffness without a history of trauma. The magnetic resonance imaging (MRI) revealed a posterolateral epidural hematoma contained within the ligamentum flavum. As the patient was intact, she was managed conservatively with cervical orthosis. Three months later, she was symptom-free, and the hematoma resolved on the follow-up MRI study. Conclusion: Spontaneous epidural hematoma arising from ligamentum flavum is a rare cause of spinal cord compression. Previous reports have described success with surgical decompression. However, initial observation and conservative management may be successful as illustrated in this case.