Disseminated intravascular coagulopathy in cranial surgery: case report and review of the literature

We present a rare case with multifocal osseous metastases of prostate cancer and disseminated intravascular coagulopathy (DIC). The patient received systemic tumor therapy, including antiandrogen agents as well as cerebral radiation. Due to rapid clinical deterioration, indication for surgery of the space-occupying calvarial metastasis was made as a salvage therapy procedure. Depleted clotting factors were substituted, and patient underwent tumor embolization prior to surgery. Although his neurological status improved postoperatively, the patient died suffering from multiple supra- and infratentorial infarctions. Our case report elucidates the laboratory results and difficulties of DIC in this case as well as possible treatment strategies

The impact of intraoperative neurophysiological monitoring in the surgical treatment of paediatric supratentorial and infratentorial tumors: single centre study [Abstract]

Intraoperative Neuromonitoring Parallel Session, September 25, 2023, 8:30 AM - 10:00 AM Background: This study seeks to evaluate the invaluable role and assistance of intraoperative neurophysiological monitoring (IONM) during surgical resection of supratentorial and infratentorial tumors in paediatric population. Methods: A retrospective analysis of a consecutive cohort of surgical treated paediatric intracranial lesions between January 2021 and January 2023 was performed. Motor evoked potentials (mMEPs) and somatosensory evoked potentials (SSEPs) recorded were performed in all cases. IONM changes were analysed and correlated with the neurological outcome before and after surgery with a minimum follow up of 6 weeks. Results: 24 children were identified (58% female and 42% male with a mean age of seven years). Lesions were located in the posterior fossa (67%) and the brain hemispheres (33%). In 67% of cases there were temporary (38%) and permanent (29%) MEP decline of more than 50% or disappearance of MEPs respectively. In 38% of patients a temporary (13 %) or permanent (25%) paresis occurred after surgery. In 33% of the cases the MEPs were stable throughout the procedure and none of the children developed any new neurological deficits. In 63% of cases complete resection was achieved. We observed no case of intraoperative seizure Conclusions: Intraoperative MEP monitoring in children is safe and provides a continuous assessment of the functional integrity of motor pathways with higher chance of early detecting a progressive mechanical or vascular injury. There is a correlation between the decline of MEPs >50 % and occurrence of new postoperative neurological deficit. Stable MEPs were correlated to stable outcome without neurological deficit. IONM is useful in paediatric tumor resection: Improving the neurological outcome while increasing Gross Total Resection rate (GTR)

Treatment of a symptomatic cervical cerebrospinal fluid fistula after full endoscopic cervical foraminotomy with CT-guided epidural fibrin patch

Background There is only limited data on the management of cerebrospinal fluid (CSF) fistulas after cervical endoscopic spine surgery. We investigated the current literature for treatment options and present a case of a patient who was treated with CT-guided epidural fibrin patch. Methods We present the case of a 47-year-old female patient with a suspected CSF fistula after endoscopic decompression for C7 foraminal stenosis. She was readmitted 8 days after surgery with dysesthesia in both upper extremities, orthostatic headache and neck pain, which worsened during mobilization. A CSF leak was suspected on spinal magnetic resonance imaging. A computer tomography (CT)-guided epidural blood patch was performed with short-term relief. A second CT-guided epidural fibrin patch was executed and the patient improved thereafter and was discharged at home without sensorimotor deficits or sequelae. We investigated the current literature for complications after endoscopic spine surgery and for treatment of postoperative CSF fistulas. Results Although endoscopic and open revision surgery with dura repair were described in previous studies, dural tears in endoscopic surgery are frequently treated conservatively. In our case, the patient was severely impaired by a persistent CSF fistula. We opted for a less invasive treatment and performed a CT-guided fibrin patch which resulted in a complete resolution of patient’s symptoms. Discussion and conclusion CSF fistulas after cervical endoscopic spine procedures are rare complications. Conservative treatment or revision surgery are the standard of care. CT-guided epidural fibrin patch was an efficient and less invasive option in our case

The rising burden of spondylodiscitis in Germany: an epidemiologic study based on the federal statistical office database [Abstract]

Introduction: Spondylodiscitis is the commonest form of infectious disease of the spine and harbours a high mortality rate of up to 20%. Recent demographic trends in Germany, such as an aging population, immunosuppression, and intravenous drug use, suggest that the incidence of spondylodiscitis may be on the rise. However, the exact epidemiological development of the disease remains uncertain. This study aims to analyse the burden on the tertiary healthcare system in Germany using data from the Federal Statistical Office of Germany (FSOG) database. Materials and Methods: All cases of spondylodiscitis diagnosed between 2005 and 2021 were identified from the FSOG database. The study characterised the mean duration of hospital stays, total and population-adjusted number of diagnoses made, age-stratified incidence, and outcomes of hospitalised patients. Results: A total of 131,982 diagnoses for spondylodiscitis were identified between 2005 and 2021. The number of diagnoses for spondylodiscitis has doubled during this period, from 5.4/100,000 population in 2005 to 11/100,000 population in 2021. The highest increase in admissions was recorded for those aged 90 years and above (+1307%), 80-89 (+376%) and 70-79 (+99%). Hospital discharges to rehabilitation facilities have increased by 160%, and discharges against medical advice by 91%. On the other hand, during the analysed period, the in-hospital mortality rate has decreased by 52%. Conclusion: The population-adjusted incidence of spondylodiscitis in Germany has more than doubled between 2005 and 2021, highlighting the clinical relevance of this disease. During the same period, in-hospital mortality dropped by half. These findings suggest the need for further investigation into optimal therapy, particularly the role and timing of surgical treatment

Implant selection in cervical spondylodiscitis plays a non-detrimental role - a single-center retrospective case series of 24 patients [Abstract]

Oral e-Poster Presentations - Booth 3: Spine 2 (Tumors), September 26, 2023, 4:10 PM - 4:50 PM Background: Cervical spondylodiscitis is an uncommon entity, with an incidence of 0.5 to 2.5 per 100.000 population, which is potentially extremely harmful. This type of discogenic and vertebral infection might cause a high rate of neurological impairment. Radical surgical debridement of the infected segment with fusion and intravenous antibiotic regimen remains the gold standard in most spine centers. We aimed to analyze the overall outcome in a tertiary spine center. Methods: In this study, we retrospectively included all patients suffering from cervical spondylodiscitis between 01/2017 and 05/2022, treated at the university hospital of Augsburg. Clinical and radiological parameters as well as type of implant were collected and evaluated. Descriptive statistics were performed using SPSS, and relevant correlations were examined using the t-test for independent samples and the Chi-square test. Results: 24 patients were identified and included. 17 patients (71%) suffered from sepsis on admission, 17 patients (71%) were diagnosed with epidural abscess on primary imaging and 5 patients (21%) had more than one discitis focus in a distant spinal segment. The presence of epidural abscess was significantly associated with systemic sepsis (OR=6.2; p=0.03) and myelopathy symptoms (OR= 14.4; p=0.00). Septic status was significantly associated with the occurrence of discitis in other spine segments (p=0.02), higher CCI (p=0.03) and Clavien Dindo scores (p=0.01), as well as a longer ICU stay (p=0.04) and the occurrence of nonunion (p=0.06). The most commonly detected germ was a multisensitive staphylococcus aureus (10 patients, 42%). A total of 6 patients (25%) died after a median of 20 days despite antibiogram-accurate therapy. The follow-up data of 15 patients (63%) was available with the evidence of permanent neurological damage in 9 patients (38%). The type of osteosynthesis was not significantly associated with subsidence (p=0.13), nonunion (p=0.21) or revision surgery (p=0.20). However the extent of instrumentation correlated significantly with the rate of nonunion (p=0.05). Conclusions: Cervical spondylodiscitis presents a severe infectious disease that occurs in multimorbid elderly patients and, despite adequate surgical and antibiotic treatment, is often associated with permanent neurological damage or a fatal outcome. Implant selection did not play a decisive role for the clinical and radiological outcome in this study

Novel outpatient treatment strategy for cranial infections – a single-center experience [Abstract]

Oral e-Poster Presentations - Booth 1: Trends & Innovation A, September 26, 2023, 1:00 PM - 2:30 PM Background: Antibiotic therapy of cranial infections is a resource-intensive process. On the background of the recommendation for longer-term antibiotic administration for cranial infections, we established an outpatient intravenous antibiotic administration in our hospital. Methods: The aim of this study was to evaluate the usefulness of outpatient antibiotic therapy in cranial neurosurgery. For this purpose, we included all patients who received a peripherally inserted central catheter (PICC line) for intravenous antibiotic therapy for cranial infections between 01/20 and 9/22. We evaluated the available patient data with regard to the infectiological and neurosurgical issues. All patients received intravenous antibiotics for at least 6 weeks (inpatient and outpatient). Results: In total, we were able to include 30 patients. The median age was 58.12 years (SD +/- 13.39 years). The proportion of female patients was 43%. The mean hospital stay was 18.4 days (SD +/- 4.97 days) for total inpatient treatment. Subsequent mean outpatient antibiotic therapy was admitted for 71.7 days (SD +/- 23.18 days). Outpatient mean IV therapy accounted for 53.88 days (SD +/- 18.56 days). The most common pathogens were Staphylococcus epidermis and cutibacteria. In 9%, microbiological samples were. In all patients, neither radiographic nor laboratory evidence of inflammation was found in the final control. During outpatient intravenous therapy, 12% of patients experienced a difficult patency of the PICC line due to the prolonged administration of antibiotics. This could be corrected radiologically in each case. In addition, one patient, independent of therapy, showed structural epilepsy after the abscess healing. Conclusions: Outpatient IV antibiotic therapy via a PICC line catheter is a safe and feasible method for long-term antibiotic treatment of cranial infections

Hydrocephalus, cerebral vasospasm, and delayed cerebral ischemia following non-aneurysmatic spontaneous subarachnoid hemorrhages: an underestimated problem

Non-aneurysmal subarachnoid hemorrhage (NASAH) is rare and mostly benign. However, complications such as cerebral vasospasm (CV), delayed cerebral ischemia (DCI), or post-hemorrhagic hydrocephalus (HC) may worsen the prognosis. The aim of this study was to evaluate the rate of these complications comparing perimesencephalic (PM) and non-perimesencephalic (NPM) SAH. Monocentric, retrospective analysis of patients diagnosed with NASAH from 01/2010 to 01/2021. Diagnosis was set only if vascular pathologies were excluded in at least one digital subtraction angiography, and NASAH was confirmed by cranial computed tomography (cCT) or lumbar puncture (LP). One hundred patients (62 female) with a mean age of 54.9 years (27–84) were identified. Seventy-three percent had a World Federation of Neurological Surgeons (WFNS) grading scale score I, while 9% were WFNS score IV or V at the time of admission. SAH was diagnosed by cCT in 86%, in 14% by lumbar puncture. Twenty-five percent necessitated short-term CSF diversion by extraventricular drainage or lumbar drainage, whereof 7 suffered from long-term HC treated with ventriculoperitoneal shunting (VPS). One patient without a short-term CSF drainage developed long-term HC. Ten percent developed CV, four of whom received intraarterial spasmolysis. Radiological DCI was diagnosed in 2%; none of these correlated with CV. Despite a mortality of 3% occurring solely in NPM SAH, the analyzed complication rate was comparable in both groups. We observed post-hemorrhagic complications in 35% of cases during the first 3 weeks after bleeding, predominantly in patients with NPM SAH. For this reason, close observation and cranial imaging within this time may be indicated not to overlook these complications

Increasing incidence of spondylodiscitis in England: an analysis of the national health service (NHS) hospital episode statistics from 2012 to 2021

Background Spondylodiscitis is a potentially life-threatening infection of the intervertebral disk and adjacent vertebral bodies, with a mortality rate of 2–20%. Given the aging population, the increase in immunosuppression, and intravenous drug use in England, the incidence of spondylodiscitis is postulated to be increasing; however, the exact epidemiological trend in England remains unknown. Objective The Hospital Episode Statistics (HES) database contains details of all secondary care admissions across NHS hospitals in England. This study aimed to use HES data to characterise the annual activity and longitudinal change of spondylodiscitis in England. Methods The HES database was interrogated for all cases of spondylodiscitis between 2012 and 2019. Data for the length of stay, waiting time, age-stratified admissions, and ‘Finished Consultant Episodes’ (FCEs), which correspond to a patient's hospital care under a lead clinician, were analysed. Results In total, 43135 FCEs for spondylodiscitis were identified between 2012 and 2022, of which 97.1% were adults. Overall admissions for spondylodiscitis have risen from 3 per 100,000 population in 2012/13 to 4.4 per 100,000 population in 2020/21. Similarly, FCEs have increased from 5.8 to 10.3 per 100,000 population, in 2012–2013 and 2020/21 respectively. The highest increase in admissions from 2012 to 2021 was recorded for those aged 70–74 (117% increase) and aged 75-59 (133% increase), among those of working age for those aged 60–64 years (91% increase). Conclusion Population-adjusted admissions for spondylodiscitis in England have risen by 44% between 2012 and 2021. Healthcare policymakers and providers must acknowledge the increasing burden of spondylodiscitis and make spondylodiscitis a research priority