Intramedullary Spinal Cord Metastases and Radiation Therapy: A Case Report

Intramedullary spinal cord metastases (ISCM) are a clinically rare, although devastating, complication of disseminated cancer. These lesions have been reported to originate from many types of solid tumors, although primary lung carcinoma, particularly small cell, is the most common etiology. These metastases, which can occur anywhere along the spinal cord, often represent the end-stage of the disease process with limited survival outcomes. Patients with ISCM may develop a variety of neurological deficits with treatment goals aimed at palliation. Different modalities of treatment have been found to preserve or restore ambulation and neurological function. The options for therapeutic intervention include surgical, chemotherapeutic, and radiation therapy. We describe a case of ISCM in a patient with disseminated small cell lung cancer with magnetic resonance imaging that illustrates a complete tumor response to radiation therap

Case Report: Intramedullary Cervical Spinal Cord Hemangioblastoma with an Evaluation of von Hippel-Lindau Disease

History of Present Illness MO is a 49 year old male with a history of multiple sclerosis who presents with a one year history of progressive numbness in his shoulders bilateral and upper back. The patient describes occasional sharp pains that radiate to his first three fingers on his right hand. He denies weakness, clumsiness, difficulty walking, or bladder/bowel dysfunction. He describes no problems with handwriting, or fine motor skills

Cervical spondylotic myelopathy in the young adult: A review of the literature and clinical diagnostic criteria in an uncommon demographic

Background: Cervical spondylotic myelopathy (CSM) is typically encountered in the elderly population. Significant inconsistencies currently exist regarding the definition of the disorder, the true incidence of CSM in younger populations, and the established diagnostic criteria. Objective: To highlight the lack of standardization in the definition and diagnosis of CSM. Methods: A PubMed literature search was conducted spanning the years 2001 to 2011. The search was limited by the following terms: 1) English language, 2) Adults (19-44 years old), and 3) “cervical spondylotic myelopathy.” Each article was reviewed to determine if the presence of the definition of CSM existed in the article. The clinical characteristics used to make the diagnosis of CSM were recorded for each article. Cochran’s Q statistic was used to determine whether some clinical characteristics were more frequently used than others. Results: 93 papers were reviewed in detail and 16 case reports, reviews, and articles concerning less than three patients were excluded, resulting in 77 articles in the final analysis. The most common clinical definitions were gait disturbance (22/77 articles (28.6%)), upper limb paresthesias or sensory disturbance (21/77 (27.3%)), and clumsy hands (15/77 (19.5%)). Hyperreflexia, spasticity, and pathologically increased reflexes were identified as diagnostic criteria in a minority of patients. Conclusion: The literature employs a wide range of neurologic signs and symptoms to make the diagnosis of CSM, with a majority of studies failing to rely on strict diagnostic criteria. The clinician should not discount CSM as an explanation for the aforementioned findings, as it is well-reported in the literature among the ages 18-44

Case Report: Hemorrhage into an Occult Spinal Ependymoma after Epidural Anesthesia

Epidural anesthesia is a procedure which is well tolerated and has a low incidence of adverse events. In performing caesarean sections, regional anesthesia (spinal or epidural) is the preferred modality for anesthetic delivery. Although rare with continuous epidural anesthesia, epidural hematomas have been reported to occur with an incidence between 1:150,000 and 1:190,00010. An underlying bleeding diathesis has been implicated as a causative factor. We present the sixth reported case of hemorrhage into an occult intradural neoplasm after spinal or epidural anesthesia. Similar lesions have not been reported in the recent spine literature

Improving the Virtual Neurosurgery Residency Interview Experience

The residency selection process has proven a challenge in the face of the Covid-19 pandemic. In the neurosurgery match, residents are chosen based on objective metrics as well as their ability to effectively work as part of a team tasked with caring for medically complex patients faced with neurosurgical conditions. As there remain limitations on the number of externships students could participate in and the Step 1 examination is expected to be reported as either pass or fail in years to come, we will have fewer objective metrics to review in the student application. We conducted a study to best select neurosurgery resident applicants who could effectively work with our team to ultimately provide effective patientcentered care. Through a post-interview survey among applicants, we identified points of improvements for the neurosurgery residency application interview

Traumatic thoracic ASIA A examinations and potential for clinical trials

Study Design: Retrospective review of prospective database Objectives: To define the variability of neurologic examination and recovery after non-penetrating complete thoracic spinal cord injuries (ASIA A). Background Data: Neurologic examinations after SCI can be difficult and inconsistent. Unlike cervical SCI patients, alterations in thoracic (below T1) complete SCI (ASIA A – based on the ASIA Impairment Scale [AIS]) patients’ exams are based only on sensory testing, thus changes in the neurological level (NL) are determined only by sensory changes. Methods: A retrospective review of the placebo control patients in a multicenter prospective database utilized for the pharmacologic trial of Sygen. Patients were included if they had a complete thoracic SCI on initial evaluation, with completed ASIA examinations at follow-up weeks 4, 8, 16, 26 and 52. Specifically, pin prick (PP) and light touch (LT) were assessed and the absolute change was calculated as the number of spinal levels at a given observation time. Results 3165 patients were initially screened for the Sygen clinical trial, of which 57 were the control placebo patients used in this analysis. Alterations from the baseline exam (PP and LT) were fairly consistent and the median change/recovery in neurologic examination was one spinal level. Across all observations post-baseline, the average change for PP was 1.48 +/- 0.13 (mean +/- SE), and for LT, 1.40 +/-0.13. There were equal proportions of directional changes (none, improved, lost). Conclusions: Changes in a thoracic complete (ASIA A) SCI patient ASIA examination as measured through sensory modalities (PP/LT) are fairly uncommon. The overall examination had only 1-2 level variability across patients, indicating minimal change in the sensory exam over the follow-up period. Stability in the ASIA examination as measured through sensory modalities has thus been demonstrated over time, making it an excellent tool to monitor changes in neurologic function

Neurologic improvement after thoracic, thoracolumbar, and lumbar spinal cord (conus medullaris) injuries

Study Design. Retrospective. Objective. With approximately 10,000 new spinal cord injury (SCI) patients in the United States each year, predicting public health outcomes is an important public health concern. Combining all regions of the spine in SCI trials may be misleading if the lumbar and sacral regions (conus) have a neurologic improvement at different rates than the thoracic or thoracolumbar spinal cord. Summary of Background Data. Over a 10-year period between January 1995 to 2005, 1746 consecutive spinal injured patients were seen, evaluated, and treated through a level 1 trauma referral center. A retrospective analysis was performed on 150 patients meeting the criteria of T4 to S5 injury, excluding gunshot wounds. One-year follow-up data were available on 95 of these patients. Methods. Contingency table analyses (chi-squared statistics) and multivariate logistic regression. Variables of interest included level of injury, initial American Spinal Injury Association (ASIA), age, race, and etiology. Results. A total of 92.9% of lumbar (conus) patients neurologically improved one ASIA level or more compared with 22.4% of thoracic or thoracolumbar spinal cord-injured patients. Only 7.7% of ASIA A patients showed neurologic improvement, compared with 95.2% of ASIA D patients; ASIA B patients demonstrated a 66.7% improvement rate, whereas ASIA C had a 84.6% improvement rate. When the two effects were considered jointly in a multivariate analysis, ASIA A and thoracic/thoracolumbar patients had only a 4.1% rate of improvement, compared with 96% for lumbar (conus) and incomplete patients (ASIA B-D) and 66.7% to 72.2% for the rest of the patients. All of these relationships were significant to P \u3c 0.001 (chi-square test). There was no link to age or gender, and race and etiology were secondary to region and severity of injury. Conclusion. Thoracic (T4-T9) SCIs have the least potential for neurologic improvement. Thoracolumbar (T10-T12) and lumbar (conus) spinal cord have a greater neurologic improvement rate, which might be related to a greater proportion of lower motor neurons. Thus, defining the exact region of injury and potential for neurologic improvement should be considered in future clinical trial design. Combining all anatomic regions of the spine in SCI trials may be misleading if different regions have neurologic improvement at different rates. Over a ten-year period, 95 complete thoracic/thoracolumbar SCI patients had only a 4.1% rate of neurologic improvement, compared with 96.0% for incomplete lumbar (conus) patients and 66.7% to 72.2% for all others

Standardizing Postoperative Handoffs Using the Evidence-Based IPASS Framework Improves Handoff Communication for Postoperative Neurosurgical Patients in the Neuro-Intensive Care Unit

Aims for Improvement Within one year of initiation of the process improvement plan, we wanted to improve: Direct communication of airway and hemodynamic concerns Direct communication of operative events, complications, and perioperative management goals. Attendance at postoperative handoffs Confirmation of information by receiving teams Staff perceptions of handoff efficacy and teamwork

Improving quality in lumbar fusion surgery through correlation of surgical EBM indications with PROMs

The aim of this project was to improve overall lumbar spine patients’ care through selection of the most appropriate surgical lumbar fusion candidates by an evidence-based medicine (EBM) review and reanalysis of indications and defining outcomes based on patient reported outcomes measures (PROM). All lumbar fusion cases from March 2018 to August 2019 from a large academic medical center were prospectively evaluated and categorized based on North American Spine Society (NASS) payer coverage policy as concordant or discordant based on fusion indications. Baseline Oswestry Disability Indices (ODI) were collected along with clinical variables. The ODIs were reviewed 6-months postoperatively. Correlation analysis identified variables predictive of improved 6-month ODI and multiple logistic regression identified multivariable-adjusted Odds Ratio of EBM concordance. 309 total lumbar fusion patients were entered into the project and 325 were analyzed with 6 months follow up median preoperative ODI was 24.4 (IQR=19-31) with a median 6-month significant improvement of 7.0 points (IQR=4-13) (p\u3c0.0001). EBM concordance (p=0.0338), lower preoperative ODI (p\u3c0.001), lower ASA (p=0.0056), and primary surgeries (p=0.0004) were significantly associated with improved functional outcome. Age, BMI, smoking status, number levels fused, approach and surgeon were not significant predictors of ODI improvement in multivariate analysis. However, EBM concordance conferred a 3.04 (95% CI=1.10–8.40) times greater odds of achieving minimal clinically important difference in ODI at 6 months (p=0.0322), adjusting for other factors. EBM concordant cases had a greater than three times improved outcome compared to those not meeting EBM fusion indication criteria

Spinal Cord Injury Activation Alert: Revisiting and Revamping Protocols

Objective Our objective was to look at the current protocol for spinal cord injury activation alerts and to highlight deficiencies in the system. Currently, any physician at Jefferson can call this alert, which often leads to a misuse of resources and wrongful identification of true spinal cord injury. In order to refine the protocol, we believe that the Cord System should be used for the following guidelines: Identify patients w Spinal Cord Injury (SCI) Identify patients for SCI research trials Identify patients who require surgeryhttps://jdc.jefferson.edu/patientsafetyposters/1109/thumbnail.jp