Russell G. Strom

Decreased risk of wound infection after posterior cervical fusion with routine local application of vancomycin powder.

Study Design. A retrospective cohort study. Objective. To assess the ability of local vancomycin powder to prevent wound infection after posterior cervical fusion. Summary of Background Data. Wound infections are a significant source of morbidity and cost associated with spine surgery. Intraoperative application of vancomycin powder to the wound edges has been shown to lower the infection risk after posterior instrumented thoracolumbar fusion. There is little data on the efficacy and safety of local vancomycin powder in cervical spine surgery. Methods. All cases of posterior cervical fusion by a single surgeon were reviewed from 2007 to 2011. Routine application of 1 gram of vancomycin powder was started in August 2009. Baseline characteristics, operative details, and rates of wound infection and pseudarthrosis were compared between untreated patients and those who received vancomycin powder. Results. A total 171 patients underwent posterior cervical fusion between 2007 and 2011. Baseline and operative variables were similar between untreated patients (n = 92) and those who received vancomycin powder (n = 79). Patients were followed for a minimum of 1 year (range, 1.1–5.7 yr). The infection rate fell from 10.9% to 2.5% (P = 0.0384) following the introduction of vancomycin powder. The untreated and treated groups had similar rates of pseudarthrosis (5.4% vs. 5.1%). No complications attributable to vancomycin powder were identified. Conclusion. Routine local application of vancomycin powder is a low-cost effective strategy for preventing wound infection after posterior cervical fusion. Further studies are needed to optimize dosing, assess long-term safety, and evaluate use in other spinal operations. Level of Evidence: 2

Lumbar laminectomy and fusion with routine local application of vancomycin powder: decreased infection rate in instrumented and non-instrumented cases.

OBJECTIVE Wound infections are one of the most common and potentially devastating complications of spinal surgery. Intra-wound application of vancomycin powder has been shown to lower the infection risk following posterior instrumented fusion, but little evidence supports use in other spinal operations. The goal of this study is to assess the efficacy of vancomycin powder for lumbar laminectomy and fusion, both instrumented and non-instrumented. METHODS All cases of lumbar laminectomy and posterior fusion (with or without pedicle screw fixation) by a single surgeon were reviewed from 2007 to 2011. Routine application of 1g vancomycin powder was started in August 2009. Baseline characteristics and operative data were compared between untreated patients and those who received vancomycin powder. Rates of wound infection were compared for all fusions, and then separately for instrumented and non-instrumented cases. RESULTS 253 patients underwent lumbar laminectomy and fusion between 2007 and 2011. Baseline and operative variables were similar between untreated patients (n=97) and those who received vancomycin powder (n=156). Patients were followed for at least one year. The infection rate fell significantly following introduction of vancomycin powder (from 11% to 0%, p=0.000018). Subgroup analysis revealed significant infection reduction for both instrumented cases (from 12% to 0%, p=0.000806) and non-instrumented cases (from 10% to 0%, p=0.0496). No complications attributable to vancomycin powder were identified. CONCLUSION Local vancomycin powder appears to lower the risk of wound infection following lumbar laminectomy and fusion, both instrumented and non-instrumented. Further studies are needed to optimize dosing of vancomycin powder, assess long-term safety and efficacy, and evaluate use in other spinal operations.

Low-molecular-weight heparin prophylaxis 24 to 36 hours after degenerative spine surgery: risk of hemorrhage and venous thromboembolism.

Study Design. Retrospective review. Objective. To assess the safety and efficacy of prophylactic low-molecular-weight heparin (LMWH) started 24 to 36 hours after degenerative spine surgery. Summary of Background Data. Venous thromboembolism (VTE) is a significant postoperative complication best averted with dual mechanical/pharmacological prophylaxis. Pharmacological prophylaxis is widely used in patients with spinal cord injury, but there is no consensus on its role in degenerative spine surgery, particularly after laminectomy with the concurrent risk of epidural hematoma. The literature suggests a small but potentially devastating hemorrhage risk when LMWH is started within 24 hours of spine surgery. An intermediate strategy is delayed LMWH initiation to minimize hemorrhage risk and retain benefits of dual prophylaxis. Methods. Operative reports of the senior author were retrospectively reviewed for all cases of cervical and lumbar laminectomy from 2007 to 2011. Single-level decompressions without fusion and all nondegenerative cases were excluded. Baseline and operative details were recorded. Mechanical prophylaxis was used throughout admission, and prophylactic LMWH was started postoperative day 1 at 10 PM. All cases of postoperative hemorrhage (epidural hematoma, superficial hematoma, persistent wound drainage), deep venous thrombosis, and pulmonary embolism were noted. Results. A total of 367 patients underwent multilevel laminectomy or laminectomy and fusion for degenerative disease. VTE risk factors (age >60 yr, smoking, obesity) were common. No patients receiving LMWH 24 to 36 hours after surgery developed postoperative hemorrhage (95% confidence interval: 0–0.8%). Nearly half of the study population underwent lower extremity ultrasonography or chest computed tomography, and acute VTE was diagnosed in 14 patients (3.8%; 95% confidence interval: 2.1–6.3). Conclusion. LMWH prophylaxis seems to carry a very low hemorrhage risk when started 24 to 36 hours after spine surgery. Larger, prospective studies are needed to assess the safety of early delayed LMWH administration more definitively. Even with aggressive prophylaxis, patients undergoing fusion or multilevel laminectomy for degenerative disease are at significant risk for VTE.

Preoperative Predictors of Spinal Infection within the National Surgical Quality Inpatient Database.

BACKGROUND Surgical-site infections (SSIs) are a major cause of morbidity and mortality, increasing the length and cost of hospitalization. In patients undergoing spine surgery, there are limited large-scale data on patient-specific risk factors for SSIs. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was reviewed for all spinal operations between 2006 and 2012. The rates of 30-day SSIs were calculated, and univariate analysis of selected preoperative risk factors was performed. Multivariate analysis was then used to identify independent predictors of SSIs. RESULTS A total of 1110 of the 60,179 patients (1.84%) had a postoperative wound infection. There were 527 (0.87%) deep and 590 (0.98%) superficial infections. Patients with infections had greater rates of sepsis, longer lengths of stay, and more return visits to the operating room. Independent predictors of infection were female sex, inpatient status, insulin-dependent diabetes, preoperative steroid use greater than 10 days, hematocrit less than 35, body mass index greater than 30, wound class, American Society of Anesthesiologists class, and operative duration. CONCLUSIONS Analysis of a large national patient database revealed many independent risk factors for SSIs after spinal surgery. Some of these risk factors can be modified preoperatively to reduce the risk of postoperative infection.

Idiopathic bilateral stenosis of the foramina of Monro treated using endoscopic foraminoplasty and septostomy.

Hydrocephalus caused by stenosis of the foramen of Monro is rare. The authors describe a 28-year-old female patient with bilateral foraminal stenosis treated using endoscopic septostomy and unilateral foraminal balloon plasty (foraminoplasty). The patients hydrocephalus and symptoms resolved postoperatively. Endoscopic strategies may be employed as first-line therapy in this condition.

Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing syndrome secondary to an epidermoid tumor in the cerebellopontine angle.

Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) syndrome is classified under trigeminal autonomic cephalalgias. This rare headache syndrome is infrequently associated with secondary pathologies. In this paper the authors report on a patient with paroxysmal left retroorbital pain with associated autonomic symptoms of ipsilateral conjunctival injection and lacrimation, suggestive of SUNCT syndrome. After failed medical treatment an MRI sequence was obtained in this patient, demonstrating an epidermoid tumor in the left cerebellopontine angle. The patients symptoms completely resolved after a gross-total resection of the tumor. This case demonstrates the effectiveness of resection as definitive treatment for SUNCT syndrome associated with tumoral compression of the trigeminal nerve. Early MRI studies should be considered in all patients with SUNCT, especially those with atypical signs and symptoms.

Malignant Meningiomas With Epithelial (Adenocarcinoma-Like) Metaplasia: A Study of 3 Cases

BACKGROUND:Meningiomas exhibit a wide range of histomorphologic features, including variable mesenchymal and epithelioid phenotypes. Meningiomas also represent the most common host tumors for systemic metastases, particularly carcinomas. Recently, however, 3 unique dural-based neoplasms were encountered, wherein malignant-appearing gland-like structures were intermixed with meningothelial elements, yet genetic data suggested epithelial metaplasia rather than metastatic carcinoma. OBJECTIVE:To describe and characterize a rare meningioma pattern with potential diagnostic pitfalls. METHODS:In addition to routine clinical, radiologic, and histopathological analyses, cases were studied with immunohistochemistry and fluorescence in situ hybridization (FISH) to elucidate the origins of 2 seemingly disparate tumoral components. RESULTS:Immunohistochemistry confirmed an epithelial ontogeny of gland-like structures, with extensive CK7 positivity suggesting possible lung or breast primaries. However, identical losses of chromosomes 1p, 14q, and 22q in meningothelial and epithelial components were identified by FISH, an observation consistent with a monoclonal derivation and supporting the diagnosis of malignant meningioma with adenocarcinoma-like metaplasia. Although this phenomenon was reminiscent of gland-like metaplasia in secretory meningioma, it differed in that the gland-forming cells were cytologically malignant, formed extracellular rather than intracellular lumina, and were unassociated with pseudopsammoma bodies. Nevertheless, intermingled secretory and adenocarcinoma-like features were seen in one case, suggesting some relationship between these 2 forms of epithelial metaplasia. CONCLUSION:Recognition of adenocarcinoma-like metaplasia in meningiomas can prevent a misdiagnosis of metastatic carcinoma, with all its associated implications for patient management.

Melanocytic tumor with GNA11 p.Q209L mutation mimicking a foramen magnum meningioma

Melanocytic tumors of the central nervous system arise from elanocytes normally found in the leptomeninges. They most comonly present as intradural-extramedullary lesions of the posterior ossa and cervical spine, but may occur throughout the neuraxis 1]. This group includes diffuse leptomeningeal melanocytosis and ocal tumors ranging from benign melanocytomas to malignant rimary CNS melanomas. Few tumors of intermediate grade (“atypcal” melanocytic tumors) have been reported [1]. Here we report n unusual intermediate-grade melanocytic tumor arising from he dura of the craniocervical junction. Its radiographic and gross ppearance were suggestive of a foramen magnum meningioma. Our ability to grade and treat CNS melanocytic tumors is limted by our poor understanding of their molecular derangements. here is some evidence that their pathogenesis resembles that of ther melanocytic neoplasms. In particular, uveal melanomas have een found to harbor frequent mutations of GNAQ [2] and GNA11 3], which encode components of two related G proteins. A recent

Progressive optic neuropathy caused by contact with the carotid artery: Improvement after microvascular decompression

Department of Neurosurgery, NYU Langone Medical Center, 462 First Avenue, Room 7S4, New York, NY 10016, United States Department of Neurology, NYU Langone Medical Center, 462 First Avenue, Room 7S4, New York, NY 10016, United States Department of Ophthalmology, NYU Langone Medical Center, 462 First Avenue, Room 7S4, New York, NY 10016, United States Department of Radiology, NYU Langone Medical Center, 462 First Avenue, Room 7S4, New York, NY 10016, United States

Technical modifications and decision-making to reduce morbidity in thoracic disc surgery: An institutional experience and treatment algorithm

BACKGROUND Symptomatic thoracic disc herniation (TDH) is an uncommon condition with significant treatment risks. OBJECTIVE To evaluate strategies to avoid and manage complications from thoracic disc surgery. METHODS All TDH cases by the senior author were retrospectively reviewed from 2000 to 2012. Complications were recorded, together with avoidance and management strategies. To reduce access-related morbidity, a thoracoscopic-tubular retractor approach was developed later in the series. RESULTS 64 patients were treated for TDH, the majority undergoing an anterior minimally-invasive approach. Complications occurred in 15 patients (23%). Three patients with intercostal neuralgia persisting for >3 months had pain resolution after intercostal nerve blocks and radiofrequency lesioning. Five of the six patients with dural tears during anterior surgery had no further events following dural repair, lumbar drain insertion, and placement of chest tube to water seal. One case of persistent CSF leakage was successfully treated with a laparoscopically-mobilized omental flap. Preoperative metallic marker placement was effective at guiding correct-level surgery. For anterior operations, no pneumothorax occurred with routine chest tube placement. Our approach and techniques evolved based on early experience, allowing us to reduce surgical morbidity. The thoracoscopic-tubular retractor approach was associated with low morbidity (no complications among 13 cases other than temporary intercostal neuralgia). CONCLUSIONS Several strategies may reduce morbidity from thoracic disc surgery: careful approach selection, preoperative level marking, use a tubular retractor with thoracoscopic guidance, rib resection at the mini-thoracotomy site, routine chest tube placement for anterior operations, and routine lumbar drain insertion in the event of a dural tear. Prospective comparative studies are needed to assess the efficacy of these techniques.