What have we learned from C5 palsy - A short communication

A study group on C5 palsy retrospectively reviewed 1001 cervical operations at their institutions in order to understand the incidence, prognosticators, pathogenesis, and outcome of C5 palsy after cervical operations. Three studies are summarized. C5 palsy was higher after posterior versus anterior operations. C4-C5 foraminotomy and age were the strongest predictors of C5 palsy after posterior surgeries and anterior cervical decompression-fusion, respectively. Among patients undergoing C4-C5 posterior laminoforaminotomy with instrumented fusion, cord shift on postoperative imaging was thought to be implicated in the pathogenesis of C5 palsy. Among affected patients, 81.4% recovered. Median time to resolution of C5 palsy was between 6 months to 1 year

Expandable Cage Technology-Transforaminal, Anterior, and Lateral Lumbar Interbody Fusion

This review of the literature will focus on the indications, surgical techniques, and outcomes for expandable transforaminal lumbar interbody fusion (TLIF), anterior lumbar interbody fusion (ALIF), and lateral lumbar interbody fusion (LLIF) operations. The expandable TLIF cage has become a workhorse for common degenerative pathology, whereas expandable ALIF cages carry the promise of greater lordotic correction while evading the diseased posterior elements. Expandable LLIF cages call upon minimally invasive techniques for a retroperitoneal, transpsoas approach to the disc space, obviating the need for an access surgeon and decreasing risk of injury to the critical neurovascular structures. Nuances between expandable and static cages for all 3 TLIF, ALIF, and LLIF operations are discussed in this review

Chronic thoracolumbar subdural empyema: Case report and surgical management.

BACKGROUND: Spinal cord abscesses and spinal subdural empyemas are rare and difficult to treat. CASE DESCRIPTION: A 35-year-old male presented to an outside institution with 2 months of progressive low back pain, weakness, and bowel incontinence; he was diagnosed with an L4 epidural abscess that was poorly managed. When the patient presented to our institution, magnetic resonance imaging (MRI) revealed a well-organized chronic subdural abscess at the thoracolumbar junction. Following resection, his back pain resolved but he was left with a residual paraparesis. CONCLUSION: Subdural abscesses are rare and should be considered among the differential diagnoses for intraspinal mass lesions. Treatment should include prompt surgical exploration and decompression combined with appropriate prolonged antibiotic treatment

A Survey of Chemoprophylaxis Techniques in Spine Surgery Among American Neurosurgery Training Programs

The North American Spine Section (NASS) published the Evidence-Based Clinical Guide for the use of antithrombotics in spine surgery. Many of the 14 clinical questions lacked clinical studies to establish evidence-based recommendations, as such expert consensuses were arrived at via a modified nominal group technique. On the clinical inquiry of chemoprophylaxis, the study published that “Unfortunately, scientific scrutiny of chemoprophylaxis in elective spinal surgery has been limited to case series involving discectomy and decompression…safety and efficacy have not been thoroughly studied. This knowledge gap in the optimal prevention of VTE events may be approximated with higher levels of evidence in spine surgery research, which should begin in first understanding chemoprophylaxis techniques across a wide geographical array of neurosurgical training programs. Of the 107 ACGME-approved residencies, contact information for 96 programs were available from ACGME, and responses from 69 unique neurosurgery residencies were collected. Thus, this survey study achieved a 64% respondent rate. Responses appeared equally distributed across the country. The first dose of chemoprophylaxis among patients undergoing surgery for degenerative/ deformity spinal disease started most commonly on postoperative day 1 in 75.3% of neurosurgery programs (n = 52) followed by postoperative day 2 in 10.1% of programs (n = 7), postoperative day 0 – same day of surgery in 8.7% of programs (n = 6), postoperative day 3 in 1.4% of programs (n = 1), and morning of surgery in 1.4% of programs (n = 1). Lastly, 2.9% of programs (n = 2) do not utilize any chemoprophylaxis. Among two of the three indications for spinal surgery, choice of postoperative chemoprophylaxis did not statistically significantly differ between prophylactic UFH versus prophylactic LMWH: 56.5% versus 50.7% in degenerative/ deformity pathologies (p=0.080) and 36.2% versus 43.4% in traumatic pathologies (p-0.535). However, neoplastic pathologies saw a statistically significantly higher proportion of prophylactic UFH (60.8%) compared to prophylactic LMWH (36.2%) (p=0.037). Of those neurosurgeons who documented “other”, one explained that the choice of chemoprophylaxis depends on comorbidities. Similarly, the other mentioned creatinine clearance and “risk factors” as determinants.https://scholarlycommons.henryford.com/merf2019qi/1012/thumbnail.jp

Minimally Invasive Techniques for Iliac Bolt Placement: 2-Dimensional Operative Video

As the popularity of minimally invasive surgery (MIS) continues to grow, novel techniques are needed to meet the demands of multi-segment fixation for advanced spinal diseases. In one such example, iliac bolts are often required to anchor large fusion constructs, but MIS technical notes are missing from the literature. A 67-yr-old female presented with a symptomatic coronal deformity: preoperative pelvic incidence = 47°, pelvic tilt = 19°, and lumbar lordosis = 29°, sagittal vertical axis = +5.4 cm with 30° of scoliosis. The operative plan included T10-ilium fusion with transforaminal interbody grafts at L2-3, L3-4, L4-5, and L5-S1. The intraoperative video is of minimally invasive placement of iliac bolts using the O-Arm Surgical Imaging System (Medtronic®). The patient consented to the procedure. A mini-open exposure that remains above the fascial planes allows for multilevel instrumentation with appropriate decompression at the interbody segments. After the placement of the pedicle screws under image-guidance, the direction is turned to the minimally invasive iliac bolts. Following the trajectory described in the standard open approach,1 the posterior superior iliac spine (PSIS) is identified with the navigation probe, which will guide the Bovie cautery through the fascia. This opening assists in the trajectory of the navigated-awl tap toward the anterior superior iliac spine (ASIS). Next, 8.5 mm x 90 mm iliac screws were placed in the cannulated bone under navigation. After intraoperative image confirmation of screw placement, the contoured rods are threaded under the fascia. The setscrews lock the rod in position. MIS approaches obviate cross-linking the rods, rendering pelvic fixation more facile. This technique allows for minimal dissection of the posterior pelvic soft tissue while maintaining adequate fixation

Trends in the Abscopal Effect After Radiation to Spinal Metastases: A Systematic Review

While the abscopal effect has been previously described, the phenomenon has been poorly defined with spinal metastases. This article is unique in that we present the first systematic review of the abscopal effect after radiation therapy to metastatic spinal cancer, especially since the spinal column represents one of the most common metastatic locations. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) resources, a systematic review identified relevant studies via a computer-aided search of MEDLINE and Embase. Ten publications that met the inclusion and exclusion criteria from the PRISMA flow diagram described a total of thirteen patients. Important findings in this review of spinal metastases include (1) abscopal effect is more commonly observed when systemic therapy includes immunomodulators; (2) abscopal effect has a higher likelihood of success when immunomodulators are administered in conjunction with or after radiation therapy to the spine; (3) higher doses of radiation in a smaller number of fractions likely increase the abscopal success; and (4) ionizing radiation to the bone marrow of the spinal column may increase circulating lymphocytes that attack cancerous lesions elsewhere in the body. These trends, however, still require further investigation with experimental and clinical studies.https://scholarlycommons.henryford.com/merf2019clinres/1038/thumbnail.jp

Penile Lymphangioma: review of the literature with a case presentation.

Background: Penile lymphangiomas are rare manifestations of lymphangiomas or lymphatic malformations which are more commonly found in the head or neck region of the body. Lymphangiomas are further categorized as lymphangioma circumscriptum, cavernous lymphangioma, cystic hygroma, or acquired lymphangiomas (also known as lymphangiectasia), based on their depth and etiology. Results: A literature review revealed only 30 cases of penile lymphangioma between 1947 and March 30, 2018. Several causes were attributed to the acquired penile lymphangiomas, including trauma, phimosis, and infection. While penile lymphangiomas can be initially mistaken for an infection, a thorough history and physical examination is sufficient to clinically diagnose a lymphangioma of the penis. Historically, surgical excision has been the gold standard of treatment for this condition. When asymptomatic, patients may opt for conservative management with avoidance of mechanical trauma alone. Other physicians have revealed novel treatment plans to rid patients of their penile lymphangioma such as a staged laser procedure. Conclusion: In this article, we elucidate the causes, symptoms, treatments, and outcomes associated with penile lymphangiomas found in the literature while also presenting the case of a 30-year-old African-American man diagnosed with acquired penile lymphangioma

Trends in the Abscopal Effect After Radiation to Spinal Metastases: A Systematic Review

Introduction: While the abscopal effect has been previously described, the phenomenon has been poorly defined with spinal metastases. This article presents the first systematic review of the abscopal effect after radiation therapy to metastatic spinal cancer, especially since the spinal column represents one of the most common metastatic locations. Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [Figure 1] in the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) resources, a systematic review identified relevant studies via a computer-aided search of MEDLINE and Embase. Ten publications that met the inclusion and exclusion criteria from the PRISMA flow diagram described a total of thirteen patients. Results: Two patients in two separate articles observed the abscopal effect following radiation therapy alone to the spine. The remaining eight articles commented on the abscopal effect in the setting of both systemic and radiation therapy. Conclusion: Important findings in this review of spinal metastases include (1) abscopal effect is more commonly observed when systemic therapy includes immunomodulators; (2) abscopal effect has a higher likelihood of success when immunomodulators are administered in conjunction with or after radiation therapy to the spine; (3) higher doses of radiation in a smaller number of fractions likely increase the abscopal success; and (4) ionizing radiation to the bone marrow of the spinal column may increase circulating lymphocytes that attack cancerous lesions elsewhere in the body. These trends, however, still require further investigation with experimental and clinical studies

Patient navigation in epilepsy care

The concept of patient navigation was first introduced in 1989 by the American Cancer Society and was first implemented in 1990 by Dr. Harold Freeman in Harlem, NY. The role of a patient navigator (PN) is to coordinate care between the care team, the patient, and their family while also providing social support. In the last 30 years, patient navigation in oncological care has expanded internationally and has been shown to significantly improve patient care experience, especially in the United States cancer care system. Like oncology care, patients who require epilepsy care face socioeconomic and healthcare system barriers and are at significant risk of morbidity and mortality if their care needs are not met. Although shortcomings in epilepsy care are longstanding, the COVID-19 pandemic has exacerbated these issues as both patients and providers have reported significant delays in care secondary to the pandemic. Prior to the pandemic, preliminary studies had shown the potential efficacy of patient navigation in improving epilepsy care. Considering the evidence that such programs are helpful for severely disadvantaged cancer patients and in enhancing epilepsy care, we believe that professional societies should support and encourage PN programs for coordinated and comprehensive care for patients with epilepsy