Surgery for traumatic fractures of the upper thoracic spine (T1–T6)

Background: The management of traumatic upper thoracic spine fractures (T1–T6) is complex due to the unique biomechanical/physiological characteristics of these levels and the nature of the injuries. They are commonly associated with multiple other traumatic injuries and severe spinal cord injuries. We describe the safety and efficacy of surgery for achieving stability and maintaining reduction of upper thoracic T1–T6 spine fractures. Methods: We retrospectively analyzed a series of traumatic unstable upper thoracic (T1–T6) spine fractures treated at one institution between 1993 and 2016. All patients were assessed neurologically and underwent complete preoperative radiographic analysis of their T1–T6 spine fractures including assessment of instability. Neurological and radiographic outcomes including fusion rates, kyphotic deformity, and successful reduction of the fracture were evaluated along with hospital length of stay (LOS), intensive care unit LOS, and overall complication rates. Results: There were 43 patients (29 males, 14 females) with an average age of 37.7 years. Between 1993 and 1999, 8 patients were treated with hook/rod constructs, whereas between 1995 and 2016, 35 patients received pedicle screw fixation utilizing intraoperative fluoroscopy or computed tomography (CT) navigation. Forty‑three patients had a total of 178 levels fused. In this series, there were no intraoperative vascular or neurological complications. Instrumentation was removed in five patients due to pain, wound infection, or hardware failure. The mean hospital LOS was 21.1 days (range 4–59 days), and there was a 95% fusion rate based on follow‑up imaging (X‑rays or CT scan). Conclusions: Surgical treatment of upper thoracic spine fractures (T1–T6), although complex, is safe and effective. Reduction and fixation of these fractures decreases the risk of further neurological complications, allows for earlier mobilization, and correlates with shorter hospital LOS and improved outcomes

Multiple intraparenchymal cystic brain metastases - a rare manifestation of metastatic adenocarcinoma of the prostate

Intraparenchymal brain metastases are rare manifestations of prostatic adenocarcinoma. Similarly, cystic intracranial metastases are even more unusual. We report on a patient with known stage IV adenocarcinoma of the prostate who presented with a recent onset of dizziness. Cranial magnetic resonance imaging demonstrated multiple cystic and nodular lesions throughout the brain parenchyma and cerebellum. At the time of diagnosis, the patient had normal PSA levels. The patient underwent palliative whole brain radiation and survived for 3 months after diagnosis with intracranial disease. We review the literature highlighting the incidence, treatment, and ongoing research endeavors to improve understanding of prostate cancer brain metastases

Outcomes of intraoperative ultrasound for endoscopic endonasal transsphenoidal pituitary surgery in adenomas with parasellar extension

Background: Pituitary adenomas with parasellar extension present a technical challenge for adequate visualization and gross total resection (GTR). The endoscope improves identification of parasellar extension, however, additional intraoperative imaging adjuncts can further augment visualization. Intraoperative ultrasound (iUS) may provide a viable and cost-effective solution for intraoperative imaging. We sought to assess the ability of intraoperative ultrasound to predict extent of resection on 3-month postoperative magnetic resonance imaging (MRI) in pituitary adenomas with parasellar extension. Methods: Twenty consecutive patients undergoing endoscopic endonasal transsphenoidal surgery for pituitary adenomas with the assistance of intraoperative ultrasound were prospectively collected. Intraoperative ultrasound findings were recorded during each case. 3-month postoperative MRI studies were reviewed in a blinded fashion to assess for residual tumor and compared with the intraoperative ultrasound findings. Results: Median preoperative Knosp grade was 2. Cavernous sinus invasion was encountered intraoperatively in 3 patients, all of whom were Knosp grade 3 preoperatively. Median operative time was 152 min. Based on iUS findings, 17 patients were expected to have a GTR while 3 patients underwent subtotal resection. 18 patients completed a 3-month postoperative MRI. The iUS and MRI findings were concordant in 16 cases (88.9%) with only two instances of discordance. Conclusion: Intraoperative ultrasound can reliably predict tumor resection as assessed by 3-month postoperative MRI in pituitary adenomas with parasellar extension. Image capture and interpretation may vary based on operator experience. Ultrasound provides reliable immediate assessment of extent of resection, identification of normal pituitary gland and other important neurovascular structures