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BACKGROUND: Pedicle screw impingement on vessel walls has the potential for complications due to pulsatile effects and wall erosion. Artifacts from spinal instrumentation create difficulty in accurately evaluating this interface. The authors present the first case of intravascular ultrasound (IVUS) used to characterize a pedicle screw breach into the aortic lumen. OBSERVATIONS: A 21-year-old female with surgically corrected scoliosis underwent computed tomography angiography (CTA) 3 years postoperatively, which revealed a pedicle screw within the thoracic aorta lumen. Metal artifact distorted the CTA images, which prompted the decision to use intraoperative IVUS. The IVUS confirmed the noninvasive imaging findings and guided final decisions regarding aortic endograft size and location during spine hardware revision. LESSONS: For asymptomatic patients presenting with pedicle screws malpositioned in or near the aorta, treatment decisions revolve around the extent of vessel wall penetration. Intraluminal depth can be obscured by artifact on computed tomography or magnetic resonance imaging or inadequately evaluated by a transesophageal echocardiogram. In our intraoperative experience, IVUS confirmed the depth of vessel lumen violation by a single pedicle screw and no wall penetration by two additional screws of concern. This was useful in deciding on thoracic endovascular aortic repair graft size and landing zone and facilitated safe spinal instrumentation removal and revision.
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BACKGROUND: Aneurysmal bone cysts (ABCs) comprise 1%-2% of all bone tumors. ABCs involving the upper cervical spine in pediatric patients complicate intervention because of an immature skeleton and nearby neurovascular elements. Treatment often consists of surgical intervention with preoperative embolization to mitigate blood loss. During selective arterial embolization, it is important to be aware of extracranial-intracranial anastomoses from tumor feeding vessels. We describe a C2 vertebrae ABC that had multiple tumor arteries anastomosing with bilateral vertebral arteries. CASE DESCRIPTION: A 3-year-old healthy girl presented with 1 month of progressive neck pain and palpable posterior neck mass. Imaging was most consistent with an ABC of the C2 vertebra. Preoperative embolization was planned. Angiography demonstrated tumor arterial supply anastomosing with the left and right vertebral artery stemming from the ascending and deep cervical artery branches. Tumor embolization was therefore carried out using coils and larger embolization particles to decrease ischemic stroke risk. Follow-up angiography showed successful tumor embolization with no vertebrobasilar complications. Surgical excision was uncomplicated and the patient's cervical spine has remained stable without fusion. CONCLUSIONS: Preoperative embolization for ABC resection is common, but thorough angiography must be done to rule out dangerous extracranial-intracranial anastomoses. This case demonstrated 2 key anastomoses with the vertebral artery that if not recognized, could lead to disastrous consequences. Comprehensive angiographic evaluation is necessary because previous reports have described ischemic complications from embolization because of unrecognized vertebrobasilar anastomoses. If any angiographic evidence is seen, then larger particle size, coil embolization, or abandoning the case should be considered.
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Vértebra Cervical Axis , Quistes Óseos Aneurismáticos/irrigación sanguínea , Embolización Terapéutica/métodos , Procedimientos Neuroquirúrgicos/métodos , Enfermedades de la Columna Vertebral/terapia , Arteria Vertebral/diagnóstico por imagen , Quistes Óseos Aneurismáticos/diagnóstico por imagen , Quistes Óseos Aneurismáticos/terapia , Angiografía Cerebral , Vértebras Cervicales , Preescolar , Femenino , Humanos , Imagenología Tridimensional , Imagen por Resonancia Magnética , Enfermedades de la Columna Vertebral/diagnóstico por imagenRESUMEN
BACKGROUND/OBJECTIVE: Following cranial neurosurgical procedures, intensive care unit (ICU) admission is routine; however, our institution's growing referral network has led to more frequent bed shortages. Consequently, there are increased requests to transfer our postoperative patients out of the ICU early in the monitoring window. We aimed to find risk factors to prioritize which postoperative neurosurgical patients that should remain in the unit. PATIENTS AND METHODS: An unmatched case-control study was conducted following retrospective chart review of patients who underwent common cranial procedures between August 2015 and June 2016 at our institution. Patients receiving postoperative ICU intervention were defined as cases. Several perioperative events were investigated for association with postoperative ICU level care. Individual risk factors were analyzed using Chi-squared tests for categorical variables (reported as odds ratio) and independent sample two tailed t-tests for continuous variables. Regression models were used for multivariate analysis. RESULTS: We identified 282 patients who met inclusion criteria, with 148 cases and 134 controls and no statistically significant differences between group demographics. Elective cases carried an odds ratio (OR 0.12, 95 % CI 0.05-0.26, p < 0.001), suggesting decreased likelihood of postoperative intensivist intervention. Single variable analysis showed ICU level of care was more more likely with general anesthesia (OR 3.72, 95 % CI 1.90-7.25, p < 0.001) and American Society of Anesthesiologists (ASA) class IV patients (OR 3.28, 95 % CI 1.59-6.78, p < 0.001). Continuous variables (blood loss and operative time) both demonstrated statistically significant differences (p < 0.001) between case and control groups with higher blood loss (100 ± 167 mL) and operative times (245 ± 119 min) seen in the ICU intervention group. Our regression model identified non-elective cases, operative time, and blood loss having associations with postoperative intensivist intervention. CONCLUSION: Growing demand for ICU beds at our institution has us looking for more objective data guiding decisions on lower-risk patients who could transfer early out of the ICU in times of overcapacity. Elective endovascular aneurysm treatment and DBS are cranial procedures least likely to receive postoperative ICU level intervention. Consideration to procedural blood loss of 100 cc or more and operative time greater than 4 h should also be given as these risk factors were associated with more likely needing postoperative ICU intervention. These results should not spur drastic changes in ICU protocols, but continued quality improvement projects should investigate these correlations to add more objective data for ICU utilization.
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Pérdida de Sangre Quirúrgica/estadística & datos numéricos , Encefalopatías/cirugía , Cuidados Críticos/estadística & datos numéricos , Procedimientos Quirúrgicos Electivos/estadística & datos numéricos , Procedimientos Endovasculares , Procedimientos Neuroquirúrgicos , Cuidados Posoperatorios/estadística & datos numéricos , Adulto , Anciano , Ocupación de Camas , Biopsia , Encéfalo/patología , Neoplasias Encefálicas/cirugía , Urgencias Médicas , Femenino , Humanos , Neuroestimuladores Implantables , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Tempo Operativo , Transferencia de Pacientes , Implantación de Prótesis , Reoperación/estadística & datos numéricos , Medición de Riesgo , Factores de Riesgo , Hemorragia Subaracnoidea/cirugíaRESUMEN
This operative video is a detailed look at minimally invasive transforaminal lumbar interbody fusion. We provide a step-by-step guide with appropriate narration and operative video to enhance the educational experience. We review clinical and radiographic evaluation, patient positioning, intraoperative navigation, localization, percutaneous pedicle screw placement, minimally invasive approach, disc space preparation, placement of interbody device, and closure. By presenting up-to-date minimally invasive and intraoperative navigation techniques, this video provides educational benefit to all neurosurgeons regardless of training level.
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BACKGROUND: Chordomas arise from remnants of the notochord and occur throughout the neuroaxis. En bloc resection of chordomas can prove especially challenging in the upper cervical spine secondary to the unique structural anatomy and intimate relationship to the vertebral arteries and spinal cord. CASE DESCRIPTION: We describe the resection of a C2-C3 chordoma in a 55-year-old woman in 2-stage fashion with preservation of the vertebral arteries. First, a posterior instrumented fusion and removal of the posterior elements was performed, followed by an anterior transmandibular en bloc resection with cage reconstruction with kick-plate support achievable with off-the-shelf products. CONCLUSIONS: Chordomas in the upper cervical spine pose a surgical challenge but are amenable to en bloc resection. With careful planning and intraoperative adaptability, the surgeon can achieve a suitable reconstruction with off-the-shelf products.