bluuebunny/crossref_metadata_2025 huggingface dataset:
Subcostal nerve injury after laparoscopic lipoma surgery: an unusual culprit for an unusual complication
Authors: Abou-Al-Shaar Hussam , Mahan Mark A.
Published: February 2019

Endoscopic surgery has revolutionized the field of minimally invasive surgery. Nerve injury after laparoscopic surgery is presumably rare, with only scarce reports in the literature; however, the use of these techniques for new purposes presents the opportunity for novel complications. The authors report a case of subcostal nerve injury after an anterior laparoscopic approach to a posterior abdominal wall lipoma.

A 62-year-old woman presented with a left abdominal flank bulge (pseudohernia) that developed after laparoscopic posterior flank wall lipoma resection. Imaging demonstrated frank ballooning of the oblique muscles; denervation atrophy and thinning of the external oblique, internal oblique, and transverse abdominis muscles; and thinning of the rectus abdominis muscle. The patient underwent subcostal nerve repair and removal of a foreign plastic material from the laparoscopic procedure. At 8 months, she has regained substantial improvement in abdominal wall strength.

Although endoscopic procedures have resulted in significant reduction in morbidity, “minimally invasive” approaches should not be confused with “low risk” when approaching novel pathology. The subcostal nerve is at risk of injury in posterior abdominal wall surgery, whether laparoscopic or not. With the pseudohernia and abdominal bulge after this surgery, the cosmetic appeal of laparoscopic incisions was definitively undone. Selecting an approach based on the anatomy of adjacent structures may lead to a better functional result.
Resection and permanent intracranial brachytherapy using modular, biocompatible cesium-131 implants: results in 20 recurrent, previously irradiated meningiomas
Authors: Brachman David G. , Youssef Emad , Dardis Christopher J. , Sanai Nader , Zabramski Joseph M. , Smith Kris A. , Little Andrew S. , Shetter Andrew G. , Thomas Theresa , McBride Heyoung L. , Sorensen Stephen , Spetzler Robert F. , Nakaji Peter
Published: February 2019

OBJECTIVE

Effective treatments for recurrent, previously irradiated intracranial meningiomas are limited, and resection alone is not usually curative. Thus, the authors studied the combination of maximum safe resection and adjuvant radiation using permanent intracranial brachytherapy (R+BT) in patients with recurrent, previously irradiated aggressive meningiomas.

METHODS

Patients with recurrent, previously irradiated meningiomas were treated between June 2013 and October 2016 in a prospective single-arm trial of R+BT. Cesium-131 (Cs-131) radiation sources were embedded in modular collagen carriers positioned in the operative bed on completion of resection. The Cox proportional hazards model with this treatment as a predictive term was used to model its effect on time to local tumor progression.

RESULTS

Nineteen patients (median age 64.5 years, range 50–78 years) with 20 recurrent, previously irradiated tumors were treated. The WHO grade at R+BT was I in 4 (20%), II in 14 (70%), and III in 2 (10%) cases. The median number of prior same-site radiation courses and same-site surgeries were 1 (range 1–3) and 2 (range 1–4), respectively; the median preoperative tumor volume was 11.3 cm3 (range 0.9–92.0 cm3). The median radiation dose from BT was 63 Gy (range 54–80 Gy). At a median radiographic follow-up of 15.4 months (range 0.03–47.5 months), local failure (within 1.5 cm of the implant bed) occurred in 2 cases (10%). The median treatment-site time to progression after R+BT has not been reached; that after the most recent prior therapy was 18.3 months (range 3.9–321.9 months; HR 0.17, p = 0.02, log-rank test). The median overall survival after R+BT was 26 months, with 9 patient deaths (47% of patients). Treatment was well tolerated; 2 patients required surgery for complications, and 2 experienced radiation necrosis, which was managed medically.

CONCLUSIONS

R+BT utilizing Cs-131 sources in modular carriers represents a potentially safe and effective treatment option for recurrent, previously irradiated aggressive meningiomas.
Relationship between individual payload weight and spondylolysis incidence in Turkish land forces
Authors: Celtikci Emrah , Yakar Fatih , Celtikci Pinar , Izci Yusuf
Published: February 2019

OBJECTIVE

The aim of this study was to investigate the relationship between lumbar spondylolysis and payload weight between different combat units of Turkish land forces (TLF).

METHOD

The authors reviewed clinical and radiological data of the military personnel with low-back pain (LBP) admitted to their clinic between July 2017 and July 2018. Age, BMI, average payload weight, and military service unit were recorded. CT scans were evaluated for pars interarticularis fractures and spondylolisthesis, whereas MRI studies were evaluated for spondylolisthesis, Modic-type endplate changes, or signal loss on T2-weighted images compatible with disc degeneration.

RESULT

Following exclusion, a total of 642 all-male military personnel were included. Of these personnel, 122 were commandos, 435 were infantry, and 85 were serving in the artillery units. Bilateral pars interarticularis fracture was noted in 42 commandos (34.42%) and 2 infantrymen (0.45%). There was no spondylolysis in the artillery units. There was no multiple-level spondylolysis and the most common level of spondylolysis was L5. Commandos had a significantly higher incidence of spondylolysis and more average payload weight (p < 0.001). Twelve patients (27.2%) with spondylolysis had accompanying MRI pathologies at the same level, whereas 32 patients (72.7%) had no accompanying MRI pathologies.

CONCLUSIONS

Increased payload weight in military personnel is associated with spondylolysis, and commandos in the TLF have significantly heavier payloads, which causes an increased rate of spondylolysis compared to other units. Additionally, spondylolysis without adjacent-level changes on MRI could be undiagnosed. LBP in active military personnel who have a history of carrying heavy payloads should be evaluated extensively with both MRI and CT scans.
Reporting trends of p values in the neurosurgical literature
Authors: To Minh-Son , Jukes Alistair
Published: February 2019

OBJECTIVE

The objective of this study was to evaluate the trends in reporting of p values in the neurosurgical literature from 1990 through 2017.

METHODS

All abstracts from the Journal of Neurology, Neurosurgery, and Psychiatry (JNNP), Journal of Neurosurgery (JNS) collection (including Journal of Neurosurgery: Spine and Journal of Neurosurgery: Pediatrics), Neurosurgery (NS), and Journal of Neurotrauma (JNT) available on PubMed from 1990 through 2017 were retrieved. Automated text mining was performed to extract p values from relevant abstracts. Extracted p values were analyzed for temporal trends and characteristics.

RESULTS

The search yielded 47,889 relevant abstracts. A total of 34,324 p values were detected in 11,171 abstracts. Since 1990 there has been a steady, proportionate increase in the number of abstracts containing p values. There were average absolute year-on-year increases of 1.2% (95% CI 1.1%–1.3%; p < 0.001), 0.93% (95% CI 0.75%–1.1%; p < 0.001), 0.70% (95% CI 0.57%–0.83%; p < 0.001), and 0.35% (95% CI 0.095%–0.60%; p = 0.0091) of abstracts reporting p values in JNNP, JNS, NS, and JNT, respectively. There have also been average year-on-year increases of 0.045 (95% CI 0.031–0.059; p < 0.001), 0.052 (95% CI 0.037–0.066; p < 0.001), 0.042 (95% CI 0.030–0.054; p < 0.001), and 0.041 (95% CI 0.026–0.056; p < 0.001) p values reported per abstract for these respective journals. The distribution of p values showed a positive skew and strong clustering of values at rounded decimals (i.e., 0.01, 0.02, etc.). Between 83.2% and 89.8% of all reported p values were at or below the “significance” threshold of 0.05 (i.e., p ≤ 0.05).

CONCLUSIONS

Trends in reporting of p values and the distribution of p values suggest publication bias remains in the neurosurgical literature.
Intraoperative assessment of isocitrate dehydrogenase mutation status in human gliomas using desorption electrospray ionization–mass spectrometry
Authors: Alfaro Clint M. , Pirro Valentina , Keating Michael F. , Hattab Eyas M. , Cooks R. Graham , Cohen-Gadol Aaron A.
Published: February 2019

OBJECTIVE

The authors describe a rapid intraoperative ambient ionization mass spectrometry (MS) method for determining isocitrate dehydrogenase (IDH) mutation status from glioma tissue biopsies. This method offers new glioma management options and may impact extent of resection goals. Assessment of the IDH mutation is key for accurate glioma diagnosis, particularly for differentiating diffuse glioma from other neoplastic and reactive inflammatory conditions, a challenge for the standard intraoperative diagnostic consultation that relies solely on morphology.

METHODS

Banked glioma specimens (n = 37) were analyzed by desorption electrospray ionization–MS (DESI-MS) to develop a diagnostic method to detect the known altered oncometabolite in IDH-mutant gliomas, 2-hydroxyglutarate (2HG). The method was used intraoperatively to analyze tissue smears obtained from glioma patients undergoing resection and to rapidly diagnose IDH mutation status (< 5 minutes). Fifty-one tumor core biopsies from 25 patients (14 wild type [WT] and 11 mutant) were examined and data were analyzed using analysis of variance and receiver operating characteristic curve analysis.

RESULTS

The optimized DESI-MS method discriminated between IDH-WT and IDH-mutant gliomas, with an average sensitivity and specificity of 100%. The average normalized DESI-MS 2HG signal was an order of magnitude higher in IDH-mutant glioma than in IDH-WT glioma. The DESI 2HG signal intensities correlated with independently measured 2HG concentrations (R2 = 0.98). In 1 case, an IDH1 R132H–mutant glioma was misdiagnosed as a demyelinating condition by frozen section histology during the intraoperative consultation, and no resection was performed pending the final pathology report. A second craniotomy and tumor resection was performed after the final pathology provided a diagnosis most consistent with an IDH-mutant glioblastoma. During the second craniotomy, high levels of 2HG in the tumor core biopsies were detected.

CONCLUSIONS

This study demonstrates the capability to differentiate rapidly between IDH-mutant gliomas and IDH-WT conditions by DESI-MS during tumor resection. DESI-MS analysis of tissue smears is simple and can be easily integrated into the standard intraoperative pathology consultation. This approach may aid in solving differential diagnosis problems associated with low-grade gliomas and could influence intraoperative decisions regarding extent of resection, ultimately improving patient outcome. Research is ongoing to expand the patient cohort, systematically validate the DESI-MS method, and investigate the relationships between 2HG and tumor heterogeneity.
Pallidal deep brain stimulation combined with capsulotomy for Tourette’s syndrome with psychiatric comorbidity
Authors: Zhang Chencheng , Deng Zhengdao , Pan Yixin , Zhang Jing , Zeljic Kristina , Jin Haiyan , van der Stelt Odin , Gong Hengfen , Zhan Shikun , Li Dianyou , Sun Bomin
Published: February 2019

OBJECTIVE

A current challenge is finding an effective and safe treatment for severely disabled patients with Tourette’s syndrome (TS) and comorbid psychiatric disorders, in whom conventional treatments have failed. The authors aimed to evaluate the utility of globus pallidus internus deep brain stimulation (GPi-DBS) combined with bilateral anterior capsulotomy in treating these clinically challenging patients.

METHODS

The authors conducted a retrospective review of the clinical history and outcomes of 10 severely disabled patients with treatment-refractory TS and a psychiatric comorbidity, who had undergone GPi-DBS combined with bilateral anterior capsulotomy in their hospital. At the time of surgery, patients presented mainly with obsessive-compulsive disorder and affective disorders. Clinical outcome assessments of tic and psychiatric symptoms, as well as of general adaptive functioning and quality of life, were performed at the time of surgery and at 6, 12, and between 24 and 96 months postsurgery.

RESULTS

After surgery, all patients showed significant progressive improvements in tic and psychiatric symptoms, along with improvements in general adaptive functioning and quality of life. Tic alleviation reached 64% at 12 months and 77% at the last follow-up on the Yale Global Tic Severity Scale. At the final follow-up, patients had functionally recovered and displayed no or only mild tic and psychiatric symptoms. All patients tolerated treatment reasonably well, with no serious side effects.

CONCLUSIONS

GPi-DBS combined with bilateral anterior capsulotomy seems to offer major clinical benefits to severely disabled patients with otherwise treatment-refractory TS and psychiatric comorbidities.
A novel robot-guided minimally invasive technique for brain tumor biopsies
Authors: Minchev Georgi , Kronreif Gernot , Ptacek Wolfgang , Dorfer Christian , Micko Alexander , Maschke Svenja , Legnani Federico G. , Widhalm Georg , Knosp Engelbert , Wolfsberger Stefan
Published: February 2019

OBJECTIVE

As decisions regarding tumor diagnosis and subsequent treatment are increasingly based on molecular pathology, the frequency of brain biopsies is increasing. Robotic devices overcome limitations of frame-based and frameless techniques in terms of accuracy and usability. The aim of the present study was to present a novel, minimally invasive, robot-guided biopsy technique and compare the results with those of standard burr hole biopsy.

METHODS

A tubular minimally invasive instrument set was custom-designed for the iSYS-1 robot-guided biopsies. Feasibility, accuracy, duration, and outcome were compared in a consecutive series of 66 cases of robot-guided stereotactic biopsies between the minimally invasive (32 patients) and standard (34 patients) procedures.

RESULTS

Application of the minimally invasive instrument set was feasible in all patients. Compared with the standard burr hole technique, accuracy was significantly higher both at entry (median 1.5 mm [range 0.2–3.2 mm] vs 1.7 mm [range 0.8–5.1 mm], p = 0.008) and at target (median 1.5 mm [range 0.4–3.4 mm] vs 2.0 mm [range 0.8–3.9 mm], p = 0.019). The incision-to-suture time was significantly shorter (median 30 minutes [range 15–50 minutes] vs 37.5 minutes [range 25–105 minutes], p < 0.001). The skin incision was significantly shorter (median 16.3 mm [range 12.7–23.4 mm] vs 28.4 mm [range 20–42.2 mm], p = 0.002). A diagnostic tissue sample was obtained in all cases.

CONCLUSIONS

Application of the novel instrument set was feasible in all patients. According to the authors’ data, the minimally invasive robot-guidance procedure can significantly improve accuracy, reduce operating time, and improve the cosmetic result of stereotactic biopsies.
Spontaneous peripheral nerve palsy with hourglass-like fascicular constriction in the upper extremity
Authors: Wang Yang , Liu Ting , Song Liangsong , Zhang Zhixin , Zhang Yanan , Ni Jinsong , Lu Laijin
Published: February 2019

OBJECTIVE

Spontaneous paralysis from hourglass-like fascicular constriction of peripheral nerves is rare, its clinical manifestations are not well documented, and its pathogenesis remains unknown. The unclear origin of this disorder and difficulty in diagnosis result in its uncertain management. The authors sought to gain a more thorough understanding of this condition through describing the anatomy, clinical features, etiology, and treatment of hourglass-like constriction.

METHODS

The authors retrospectively reviewed 20 patients (22 nerves) with hourglass-like constriction. The patients’ clinical information was reviewed. Preoperative sonographic assessment and electrophysiological examination of involved nerves were performed. Surgical treatments included interfascicular neurolysis and neurorrhaphy. Samples of tissue subjected to resected constriction were sent for pathological analysis. The patients had regular face-to-face follow-up visits.

RESULTS

Acute pain was always the first symptom and was followed by paralysis. Paralysis progression was rapid and serious. Surgical exploration indicated an hourglass-like constricted segment completely unrelated to the compressive structures. Electrophysiological analysis showed severe denervation, and histopathological examination showed inflammatory cell infiltration, demyelination, and reduction of nerve fibers.

CONCLUSIONS

Hourglass-like fascicular constrictive neuropathy has an integrative effect from multiple different mechanisms. Surgical intervention is beneficial for selected patients who do not recover in a timely fashion and have hourglass-like lesions confirmed by preoperative ultrasound imaging. The authors recommend that early surgical intervention of the nerve be offered to patients who do not show any signs of recovery 3 months after onset. Both interfascicular neurolysis and neurorrhaphy are effective treatment methods. Mild to moderate constriction can usually be treated successfully by interfascicular neurolysis alone, whereas more advanced lesions with loss of fascicle continuity (severe constriction) may be best treated with resection and direct neurorrhaphy.
Multimodal management of pediatric carotid body tumors: a systematic review and case illustrations
Authors: Kuchakulla Manish , Shah Ashish H. , Armstrong Valerie , Jernigan Sarah , Bhatia Sanjiv , Niazi Toba N.
Published: February 2019

OBJECTIVE

Carotid body tumors (CBTs), extraadrenal paragangliomas, are extremely rare neoplasms in children that often require multimodal surgical treatment, including preoperative anesthesia workup, embolization, and resection. With only a few cases reported in the pediatric literature, treatment paradigms and surgical morbidity are loosely defined, especially when carotid artery infiltration is noted. Here, the authors report two cases of pediatric CBT and provide the results of a systematic review of the literature.

METHODS

The study was divided into two sections. First, the authors conducted a retrospective review of our series of pediatric CBT patients and screened for patients with evidence of a CBT over the last 10 years (2007–2017) at a single tertiary referral pediatric hospital. Second, they conducted a systematic review, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, of all reported cases of pediatric CBTs to determine the characteristics (tumor size, vascularity, symptomatology), treatment paradigms, and complications.

RESULTS

In the systematic review (n = 21 patients [includes 19 cases found in the literature and 2 from the authors’ series]), the mean age at diagnosis was 11.8 years. The most common presenting symptoms were palpable neck mass (62%), cranial nerve palsies (33%), cough or dysphagia (14%), and neck pain (19%). Metastasis occurred only in 5% of patients, and 19% of cases were recurrent lesions. Only 10% of patients presented with elevated catecholamines and associated sympathetic involvement. Preoperative embolization was utilized in 24% of patients (external carotid artery in 4 and external carotid artery and vertebral artery in 1). Cranial nerve palsies (cranial nerve VII [n = 1], IX [n = 1], X [n = 4], XI [n = 1], and XII [n = 3]) were the most common cause of surgical morbidity (33% of cases). The patients in the authors’ illustrative cases underwent preoperative embolization and balloon test occlusion followed by resection, and both patients suffered from transient Horner’s syndrome after embolization.

CONCLUSIONS

Surgical management of CBTs requires an extensive preoperative workup, anesthesia, and multimodal surgical management. Due to a potentially high rate of surgical morbidity and vascularity, balloon test occlusion with embolization may be necessary in select patients prior to resection. Careful thorough preoperative counseling is vital to preparing families for the intensive management of these children.
Predictors of patient satisfaction and survey participation after spine surgery: a retrospective review of 17,853 consecutive spinal patients from a single academic institution. Part 1: Press Ganey
Authors: Hopkins Benjamin S. , Patel Mit R. , Yamaguchi Jonathan Tad , Cloney Michael Brendan , Dahdaleh Nader S.
Published: February 2019

OBJECTIVE

Press Ganey surveys are common modalities used to assess patient satisfaction scores in an outpatient setting. Despite the existence of data, neurosurgical and orthopedic literature on patient satisfaction following spinal surgery is scarce.

METHODS

A total of 17,853 patients who underwent spinal procedures at the authors’ institution were analyzed retrospectively for Press Ganey survey participation. Appropriate demographic, surgical, comorbidity, and complication data were collected; 1936 patients had patient satisfaction survey data, and further survey metrics were collected for this subset of patients.

RESULTS

Male patients, patients with urgent/emergency procedures, and patients with longer length of stay (LOS) were less likely to fill out Press Ganey surveys (OR 0.822, p < 0.001; OR 0.781, p = 0.010; and OR 0.983, p < 0.001, respectively). Posterior approach was negatively associated with Press Ganey participation (OR 0.907, p = 0.055). Patients undergoing fusion procedures were more likely to participate in Press Ganey surveys (OR 1.419, p < 0.001). Of the patients who filled out surveys, there were no positive predictors associated with receiving perfect scores on Press Ganey surveys. High Charlson Comorbidity Index (OR 0.959, p = 0.02), increasing elapsed time since surgery or discharge (OR 0.996, p = 0.03), and increasing LOS (OR 0.965, p = 0.009) were all negatively associated with receiving a perfect score. Patients who underwent a posterior-approach procedure compared with other approaches were less likely to report a low Press Ganey score (OR 0.297, p = 0.046). Patient sex and race did not influence the likelihood of receiving perfect or low Press Ganey scores. Finally, the perceived skill of the surgeon was not a significant predictor for perfect (p > 0.99) or low (p = 0.828) Press Ganey scores.

CONCLUSIONS

Patient participation in Press Ganey surveys strongly correlated with preoperative factors such as procedure approach and type, as well as postoperative factors such as LOS and complications. No factors were associated with an increased likelihood of receiving a perfect Press Ganey score. Similarly, LOS and time elapsed since surgery to survey completion were significant negative predictors of perfect Press Ganey scores. Skill of surgeon, sex, and race did not correlate with a predictive value for Press Ganey outcomes. In addition, overall comorbid disease burden was found to be a significant negative predictor for high patient satisfaction scores. Further study on predictors of patient satisfaction within spine surgery is needed to better assist physicians in improving the surgical experience for patients.
Acute neurosurgical management of traumatic brain injury and spinal cord injury in French armed forces during deployment
Authors: Dagain Arnaud , Aoun Olivier , Sellier Aurore , Desse Nicolas , Joubert Christophe , Beucler Nathan , Bernard Cédric , Fouet Mathilde , Delmas Jean-Marc , Dulou Renaud
Published: February 2019

This article aims to describe the French concept regarding combat casualty neurosurgical care from the theater of operations to a homeland hospital. French military neurosurgeons are not routinely deployed to all combat zones. As a consequence, general surgeons initially treat neurosurgical wounds. The principle of this medical support is based on damage control. It is aimed at controlling intracranial hypertension spikes when neuromonitoring is lacking in resource-limited settings. Neurosurgical damage control permits a medevac that is as safe as can be expected from a conflict zone to a homeland medical treatment facility. French military neurosurgeons can occasionally be deployed within an airborne team to treat a military casualty or to complete a neurosurgical procedure performed by a general surgeon in theaters of operation. All surgeons regardless of their specialty must know neurosurgical damage control. General surgeons must undergo the required training in order for them to perform this neurosurgical technique.
Cost-effectiveness of adult spinal deformity surgery in a military healthcare system
Authors: Neal Chris J. , Mandell Kara , Tasikas Ellen , Delaney John J. , Miller Charles A. , Schlaff Cody D. , Rosner Michael K.
Published: February 2019

OBJECTIVE

Adult spinal deformity surgery is an effective way of treating pain and disability, but little research has been done to evaluate the costs associated with changes in health outcome measures. This study determined the change in quality-adjusted life years (QALYs) and the cost per QALY in patients undergoing spinal deformity surgery in the unique environment of a military healthcare system (MHS).

METHODS

Patients were enrolled between 2011 and 2017. Patients were eligible to participate if they were undergoing a thoracolumbar spinal fusion spanning more than 6 levels to treat an underlying deformity. Patients completed the 36-Item Short Form Health Survey (SF-36) prior to surgery and 6 and 12 months after surgery. The authors used paired t-tests to compare SF-36 Physical Component Summary (PCS) scores between baseline and postsurgery. To estimate the cost per QALY of complex spine surgery in this population, the authors extended the change in health-related quality of life (HRQOL) between baseline and follow-up over 5 years. Data on the cost of surgery were obtained from the MHS and include all facility and physician costs.

RESULTS

HRQOL and surgical data were available for 49 of 91 eligible patients. Thirty-one patients met additional criteria allowing for cost-effectiveness analysis. Over 12 months, patients demonstrated significant improvement (p < 0.01) in SF-36 PCS scores. A majority of patients met the minimum clinically important difference (MCID; 83.7%) and substantive clinical benefit threshold (SCBT; 83.7%). The average change in QALY was an increase of 0.08. Extended across 5 years, including the 3.5% discounting per year, study participants increased their QALYs by 0.39, resulting in an average cost per QALY of $181,649.20. Nineteen percent of patients met the < $100,000/QALY threshold with half of the patients meeting the < $100,000/QALY mark by 10 years. A sensitivity analysis showed that patients who scored below 60 on their preoperative SF-36 PCS had an average increase in QALYs of 0.10 per year or 0.47 over 5 years.

CONCLUSIONS

With a 5-year extended analysis, patients who receive spinal deformity surgery in the MHS increased their QALYs by 0.39, with 19% of patients meeting the $100,000/QALY threshold. The majority of patients met the threshold for MCID and SCBT at 1 year postoperatively. Consideration of preoperative functional status (SF-36 PCS score < 60) may be an important factor in determining which patients benefit the most from spinal deformity surgery.
Spine surgery in the International Security Assistance Force Role 3 combat support hospital in Mazar-e-Sharif, northern Afghanistan, 2007–2014
Authors: Schulz Chris , Mauer Uwe Max , Mathieu Renè , Freude Gregor
Published: February 2019

OBJECTIVE

Since 2007, a continuous neurosurgery emergency service has been available in the International Security Assistance Force (ISAF) field hospital in Mazar-e-Sharif (MeS), Afghanistan. The object of this study was to assess the number and range of surgical procedures performed on the spine in the period from 2007 to 2014.

METHODS

This is a retrospective analysis of the annual neurosurgical caseload statistics from July 2007 to October 2014 (92 months). The distribution of surgical urgency (emergency, delayed urgency, or elective), patient origin (ISAF, Afghan National Army, or civilian population), and underlying causes of diseases and injuries (penetrating injury, blunt injury/fracture, or degenerative disease) was analyzed. The range and pattern of diagnoses in the neurosurgical outpatient department from 2012 and 2013 were also evaluated.

RESULTS

A total of 341 patients underwent neurosurgical operations in the period from July 2007 to October 2014. One hundred eighty-eight (55.1%) of the 341 procedures were performed on the spine, and the majority of these surgeries were performed for degenerative diseases (127/188; 67.6%). The proportion of spinal fractures and penetrating injuries (61/188; 32.4%) increased over the study period. These spinal trauma diagnoses accounted for 80% of the cases in which patients had to undergo operations within 12 hours of presentation (n = 70 cases). Spinal surgeries were performed as an emergency in 19.8% of cases, whereas 17.3% of surgeries had delayed urgency and 62.9% were elective procedures. Of the 1026 outpatient consultations documented, 82% were related to spinal issues.

CONCLUSIONS

Compared to the published numbers of cases from neurosurgery units in the rest of the ISAF area, the field hospital in MeS had a considerably lower number of operations. In addition, MeS had the highest rates of both elective neurosurgical operations and Afghan civilian patients. In comparison with the field hospital in MeS, none of the other ISAF field hospitals showed such a strong concentration of degenerative spinal conditions in their surgical spectrum. Nevertheless, the changing pattern of spine-related diagnoses and surgical therapies in the current conflict represents a challenge for future training and material planning in comparable missions.
The shipboard Beirut terrorist bombing experience: a historical account and recommendations for preparedness in events of mass neurological injuries
Authors: Hubbard Zachary S. , Henderson Fraser , Armonda Rocco A. , Spiotta Alejandro M. , Rosenbaum Robert , Henderson Fraser
Published: February 2019

On a Sunday morning at 06:22 on October 23, 1983, in Beirut, Lebanon, a semitrailer filled with TNT sped through the guarded barrier into the ground floor of the Civilian Aviation Authority and exploded, killing and wounding US Marines from the 1st Battalion 8th Regiment (2nd Division), as well as the battalion surgeon and deployed corpsmen. The truck bomb explosion, estimated to be the equivalent of 21,000 lbs of TNT, and regarded as the largest nonnuclear explosion since World War II, caused what was then the most lethal single-day death toll for the US Marine Corps since the Battle of Iwo Jima in World War II. Considerable neurological injury resulted from the bombing. Of the 112 survivors, 37 had head injuries, 2 had spinal cord injuries, and 9 had peripheral nerve injuries. Concussion, scalp laceration, and skull fracture were the most common cranial injuries.

Within minutes of the explosion, the Commander Task Force 61/62 Mass Casualty Plan was implemented by personnel aboard the USS Iwo Jima. The wounded were triaged according to standard protocol at the time. Senator Humphreys, chairman of the Preparedness Committee and a corpsman in the Korean War, commented that he had never seen such a well-executed evolution. This was the result of meticulous preparation that included training not only of the medical personnel but also of volunteers from the ship’s company, frequent drilling with other shipboard units, coordination of resources throughout the ship, the presence of a meticulous senior enlisted man who carefully registered each of the wounded, the presence of trained security forces, and a drilled and functioning communication system.

Viewed through the lens of a neurosurgeon, the 1983 bombings and mass casualty event impart important lessons in preparedness. Medical personnel should be trained specifically to handle the kinds of injuries anticipated and should rehearse the mass casualty event on a regular basis using mock-up patients. Neurosurgery staff should participate in training and planning for events alongside other clinicians. Training of nurses, corpsmen, and also nonmedical personnel is essential. In a large-scale evolution, nonmedical personnel may monitor vital signs, work as scribes or stretcher bearers, and run messages. It is incumbent upon medical providers and neurosurgeons in particular to be aware of the potential for mass casualty events and to make necessary preparations.
Continuum of the United States military’s traumatic brain injury care: adjusting to the changing battlefield
Authors: Lazarus Rachel , Helmick Katherine , Malik Saafan , Gregory Emma , Agimi Yll , Marion Donald
Published: February 2019

Over the past 8 years, advances in the US Military Health System (MHS) have led to extensive changes in the way combat casualty care is provided to deployed service members with a traumatic brain injury (TBI). Changes include the application of cutting-edge Clinical Practice Guidelines, use of pioneering technologies, and advances in evacuation procedures. Compared with previous engagements, current operations occur on a much smaller scale, and more frequently in austere environments, such that effective medical support is increasingly challenging. In this paper, the authors describe key aspects of the current continuum of TBI care in the US military, from the point of injury through rehabilitation, with an emphasis on how emerging technologies and evidence-based Clinical Practice Guidelines assist MHS clinicians with providing the best clinical care possible in the changing battlefield.
Charles E. Locke Jr. (1895–1929): the founder of neurosurgery at the Cleveland Clinic
Authors: Soni Pranay , Habboub Ghaith , Kshettry Varun R. , Schlenk Richard , Lautzenheiser Frederick , Benzel Edward C.
Published: February 2019

The Cleveland Clinic was established in 1921 under the direction of 4 experienced and iconic physicians: George Crile, Frank Bunts, William Lower, and John Phillips. The Clinic initially employed a staff of only 6 surgeons, 4 internists, 1 radiologist, and 1 biophysicist, but Crile was quick to realize the need for broadening its scope of practice. He asked his close friend, Harvey Cushing, for assistance in finding a suitable candidate to establish a department of neurosurgery at the Cleveland Clinic. With his full endorsement, Cushing recommended Dr. Charles Edward Locke Jr., a former student and burgeoning star in the field of neurosurgery. Unfortunately, Locke’s life and career both ended prematurely in the Cleveland Clinic fire of 1929, but not before he would leave a lasting legacy, both at the Cleveland Clinic and in the field of neurosurgery.
Management of carotid artery stenosis in patients with coexistent unruptured intracranial aneurysms
Authors: Tallarita Tiziano , Sorenson Thomas J. , Rinaldo Lorenzo , Oderich Gustavo S. , Bower Thomas C. , Meyer Fredric B. , Lanzino Giuseppe
Published: February 2019

OBJECTIVE

Concomitant unruptured intracranial aneurysms (UIAs) are present in patients with carotid artery stenosis not infrequently and result in unique management challenges. Thus, we investigated the risk of rupture of an aneurysm after revascularization of a carotid artery in a contemporary consecutive series of patients seen at our institution.

METHODS

Data from patients who underwent a carotid revascularization in the presence of at least one concomitant UIA at our institution from 1991 to 2018 were retrospectively reviewed. Patients were evaluated for the incidence of aneurysm rupture within 30 days (early period) and after 30 days (late period) of carotid revascularization, as well as for the incidence of periprocedural complications from the treatment of carotid stenosis and/or UIA.

RESULTS

Our study included 53 patients with 63 concomitant UIAs. There was no rupture within 30 days of carotid revascularization. The overall risk of rupture was 0.87% per patient-year. Treatment (coiling or clipping) of a concomitant UIA, if pursued, could be performed successfully after carotid revascularization.

CONCLUSIONS

Carotid artery revascularization in the setting of a concomitant UIA can be performed safely without an increased 30-day or late-term risk of rupture. If indicated, treatment of the UIA can take place after the patient recovers from the carotid procedure.
Comparison of head impact exposure in practice drills among multiple youth football teams
Authors: Kelley Mireille E. , Espeland Mark A. , Flood William C. , Powers Alexander K. , Whitlow Christopher T. , Maldjian Joseph A. , Stitzel Joel D. , Urban Jillian E.
Published: February 2019

OBJECTIVE

Limiting contact in football practice can reduce the number of head impacts a player receives, but further research is needed to inform the modification of optimal drills that mitigate head impact exposure (HIE) while the player develops the skills needed to safely play the game. This study aimed to compare HIE in practice drills among 6 youth football teams and to evaluate the effect of a team on HIE.

METHODS

On-field head impact data were collected from athletes (ages 10–13 years) playing on 6 local youth football teams (teams A–F) during all practices using the Head Impact Telemetry System. Video was recorded and analyzed to verify and assign impacts to a specific drill. Drills were identified as follows: dummy/sled tackling, half install, install, install walk through, multiplayer tackle, Oklahoma, one-on-one, open field tackling, other, passing, position skill work, scrimmage, special teams, tackling drill stations, and technique. HIE was quantified in terms of impacts per player per minute (ppm) and peak linear and rotational head acceleration. Generalized linear models were used to assess differences in head impact magnitude and frequency among drills as well as among teams within the most common drills.

RESULTS

Among 67 athlete-seasons, a total of 14,718 impacts during contact practices were collected and evaluated in this study. Among all 6 teams, the mean linear (p < 0.0001) and rotational (p < 0.0001) acceleration varied significantly among all drills. Open field tackling had significantly (p < 0.001) higher mean linear acceleration than all other drills. Multiplayer tackle had the highest mean impact rate (0.35 ppm). Significant variations in linear acceleration and impact rate were observed among teams within specific drills. Team A had the highest mean linear acceleration in install, one-on-one, and open field tackling and the highest mean impact rate in Oklahoma and position skill work. Although team A spent the greatest proportion of their practice on minimal- or no-player versus player contact drills (27%) compared to other teams, they had the highest median (20.2g) and 95th percentile (56.4g) linear acceleration in practice.

CONCLUSIONS

Full-speed tackling and blocking drills resulted in the highest HIE. Reducing time spent on contact drills relative to minimal or no contact drills may not lower overall HIE. Instead, interventions such as reducing the speed of players engaged in contact, correcting tackling technique, and progressing to contact may reduce HIE more effectively.
Screening and surgery for foramen magnum stenosis in children with achondroplasia: a large, national database analysis
Authors: Nadel Jeffrey L. , Wilkinson D. Andrew , Garton Hugh J. L. , Muraszko Karin M. , Maher Cormac O.
Published: February 2019

OBJECTIVE

The goal of this study was to determine the rates of screening and surgery for foramen magnum stenosis in children with achondroplasia in a large, privately insured healthcare network.

METHODS

Rates of screening and surgery for foramen magnum stenosis in children with achondroplasia were determined using de-identified insurance claims data from a large, privately insured healthcare network of over 58 million beneficiaries across the United States between 2001 and 2014. Cases of achondroplasia and screening and surgery claims were identified using a combination of International Classification of Diseases diagnosis codes and Current Procedural Terminology codes. American Academy of Pediatrics (AAP) practice guidelines were used to determine screening trends.

RESULTS

The search yielded 3577 children age 19 years or younger with achondroplasia. Of them, 236 met criteria for inclusion in the screening analysis. Among the screening cohort, 41.9% received some form of screening for foramen magnum stenosis, whereas 13.9% of patients were fully and appropriately screened according to the 2005 guidelines from the AAP. The screening rate significantly increased after the issuance of the AAP guidelines. Among all children in the cohort, 25 underwent cervicomedullary decompression for foramen magnum stenosis. The incidence rate of undergoing cervicomedullary decompression was highest in infancy (28 per 1000 patient-years) and decreased with age (5 per 1000 patient-years for all other ages combined).

CONCLUSIONS

Children with achondroplasia continue to be underscreened for foramen magnum stenosis, although screening rates have improved since the release of the 2005 AAP surveillance guidelines. The incidence of surgery was highest in infants and decreased with age.
Odontoid cervical gout causing atlantoaxial instability: case report
Authors: Slavin Justin , DiStasio Marcello , Dellaripa Paul F. , Groff Michael
Published: February 2019

The authors present a case report of a patient discovered to have a rotatory subluxation of the C1–2 joint and a large retroodontoid pannus with an enhancing lesion in the odontoid process eventually proving to be caused by gout. This patient represented a diagnostic conundrum as she had known prior diagnoses of not only gout but also sarcoidosis and possible rheumatoid arthritis, and was in the demographic range where concern for an oncological process cannot fully be ruled out. Because she presented with signs and symptoms of atlantoaxial instability, she required posterior stabilization to reduce the rotatory subluxation and to stabilize the C1–2 instability. However, despite the presence of a large retroodontoid pannus, she had no evidence of spinal cord compression on physical examination or imaging and did not require an anterior procedure to decompress the pannus. To confirm the diagnosis but avoid additional procedures and morbidity, the authors proceeded with the fusion as well as a posterior biopsy to the retroodontoid pannus and confirmed a diagnosis of gout.
The Y-shaped trabecular bone structure in the odontoid process of the axis: a CT scan study in 54 healthy subjects and biomechanical considerations
Authors: Montemurro Nicola , Perrini Paolo , Mangini Vittoriano , Galli Massimo , Papini Andrea
Published: February 2019

OBJECTIVE

Odontoid process fractures are very common in both young and geriatric patients. The axial trabecular architecture of the dens appears to be crucial for physiological and biomechanical function of the C1–2 joint. The aim of this study is to demonstrate the presence of a Y-shaped trabecular structure of the dens on axial CT and to describe its anatomical and biomechanical implications.

METHODS

Fifty-four C2 odontoid processes in healthy subjects were prospectively examined for the presence of a Y-shaped trabecular structure at the odontocentral synchondrosis level with a dental cone beam CT scan. Length, width, and axial area of the odontoid process were measured in all subjects. In addition, measurements of the one-third right anterior area of the Y-shaped structure were taken.

RESULTS

The Y-shaped trabecular structure was found in 79.6% of cases. Length and width of the odontoid process were 13.5 ± 0.6 mm and 11.2 ± 0.9 mm, respectively. The mean area of the odontoid process at the odontocentral synchondrosis was 93.5 ± 4.3 mm2, whereas the mean one-third right anterior area of the odontoid process at the same level was 29.3 ± 2.5 mm2. The mean area of the odontoid process and its length and width were similar in men and women (p > 0.05). No significant difference was found in the mean area of the odontoid process in people older than 65 years (94 ± 4.2 mm2) compared to people younger than 65 years (93.3 ± 4.4 mm2; p > 0.05).

CONCLUSIONS

The authors identified a new anatomical entity, named the Y-shaped trabecular structure of the odontoid process, on axial CT scans. This structure appears to be the result of bone transformation induced by the elevated dynamic loading at the C1–2 level. The presence of the Y-shaped structure provides new insights into biomechanical responses of C2 under physiological loading and traumatic conditions.
Nuances of transradial approach for mechanical thombectomy in acute basilar artery occlusion
Authors: Rangel-Castilla Leonardo , Lanzino Giuseppe
Published: February 2019

In elderly patients with acute ischemic stroke, tortuosity of the proximal vertebral artery makes access from the transfemoral route challenging and time consuming. In such cases, a transradial approach (TA) offers a more direct vertebral artery (VA) access that overcomes proximal VA tortuosity. In this video the authors illustrate nuances of the TA for acute basilar artery occlusion in two patients with challenging proximal VA anatomy. Techniques, devices, and pitfalls are discussed. In both patients, mechanical clot retrieval was successful and resulted in significant recovery of function. The authors believe that the TA should be the initial approach for basilar artery (BA) occlusion management in elderly patients and should be considered for selected patients with other conditions requiring endovascular treatment.

The video can be found here: https://youtu.be/_Ym9tMKUy_4.
PulseRider treatment of an anterior communicating artery aneurysm
Authors: Srinivasan Visish M. , Vedantam Aditya , Kan Peter
Published: February 2019

We present a case of a patient with an anterior communicating artery aneurysm treated by PulseRider-assisted coil embolization. PulseRider is a new device, FDA approved for treatment of broad-necked aneurysms of the basilar apex or internal carotid artery terminus. The aneurysm was broad-necked and involved the anterior communicating artery and was considered for traditional stent-assisted coiling as well as PulseRider-assisted coiling. The authors present the treatment plan and strategy and then fluoroscopic recording of the PulseRider delivery and subsequent coiling phase. Nuances of technique for this new device used in a challenging setting are discussed.

The video can be found here: https://youtu.be/ont7ggqgLH8.
Endovascular management of basilar artery occlusion secondary to fusiform aneurysm with intraluminal thrombus
Authors: Beer-Furlan André , Dasenbrock Hormuzdiyar H. , Joshi Krishna C. , Chen Michael
Published: February 2019

Acute basilar artery occlusion is one of the most devastating subtypes of ischemic stroke with an extremely high morbidity and mortality rate. The most common causes include embolism, large-artery atherosclerosis, penetrating small-artery disease, and arterial dissection. The heart and vertebral arteries are the main source of emboli in embolic basilar occlusions. The authors present an uncommon acute basilar occlusion secondary to a fusiform aneurysm with intraluminal thrombus. The patient underwent a mechanical thrombectomy with successful recanalization, but persistent intraluminal thrombus. The authors discuss the management dilemma and describe their choice for placement of flow diverter stents.

The video can be found here: https://youtu.be/XzBdgxJPSWQ.
Utility of 3D rotational angiography road map in flow diverter deployment in a distal dissecting MCA aneurysm
Authors: Rustemi Oriela , Di Clemente Loris , Raneri Fabio , Volpin Lorenzo , Iannucci Giuseppe
Published: February 2019

Distal, dissecting, middle cerebral artery (MCA) aneurysms are changing surgically and endovascularly. Endovascular treatment requires flow diverter stenting. A good vessel visualization is crucial for safe navigation. Three-dimensional rotational digital subtraction angiography (3D-DSA) is used routinely in diagnostic imaging. The utilization of the 3D-DSA road map in vessel navigation and stent deployment is novel. An illustrative video of a distal, dissecting left MCA aneurysm treated with flow diverter stenting is presented. The technical issues were distal location, dissecting nature with double lumen, proximal stenosis, and vessel curves. The 3D-DSA road map helped to enhance visualization with a safer procedure.

The video can be found here: https://youtu.be/sS3o1Z0P8WE.