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The aim of this study is to present a case series of adult patients with lumbar degenerative scoliosis who underwent focused minimally invasive spine (MIS) surgery utilizing a new dual expandable cage technology. The study investigates the effectiveness of this approach in reducing the symptoms and progression of lumbar degenerative scoliosis (LDS). Adult patients with lumbar degenerative scoliosis were selected for focused MIS using the newly introduced expandable cage technology. Patient demographics, preoperative evaluations, surgical details, and postoperative outcomes were recorded. The primary outcome measures included the restoration of disc space height, an improvement in clinical outcomes, and a reduction in surgical complications. Analysis of the case series reveals promising outcomes following focused MIS with the utilization of the new expandable cage technology. The technique demonstrated successful restoration of intervertebral disc space heights and improved clinical outcomes in patients with lumbar degenerative scoliosis. Furthermore, a notable reduction in surgical complications was observed. The findings from this case series suggest that MIS with the implementation of the new expandable cage technology holds promise for patients with lumbar degenerative scoliosis. This approach appears to have the potential to effectively restore disc space heights, improve clinical outcomes, and minimize surgical complications. Here, we want to emphasize and add details to the improved clinical outcomes of this technology; however, further research and larger prospective studies are warranted to validate these preliminary results and establish the long-term benefits and safety profile of this innovative technique.

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Proton beam therapy is a common type of radiation treatment that delivers a beam of proton particles to treat cancer and minimize damage to nearby healthy tissue. In this paper, we describe a case of a 20-year-old male patient with osteosarcoma of the distal right femur that eventually metastasized to his thoracic cavity. The patient underwent radiation beam therapy treatment that was directed at his left thorax and nine months later presented with clinical and radiographic findings of delayed radiation myelopathy (RM).

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The most common underlying diagnosis of intracranial tumor pathology is metastatic disease, followed by primary brain tumors. Chondrosarcomatous metastatic disease of the brain is a rare subtype of this disease process. The patient presented with right-sided weakness. Her history was significant for femur chondrosarcoma which was resected and treated. Laboratory analysis revealed persistent hypercalcemia and hyperglycemia. MRI of the brain was completed, which revealed a left parietal-occipital lesion with smaller lesions in the left frontal and right parietal lobe. Multidisciplinary tumor board recommended surgery for lesion resection and pathology. Surgical pathologic diagnosis after lesion resection was metastatic chondrosarcoma. The patient's preoperative arm and leg weakness improved after surgery. Our paper delineates this unique case of intracranial spread of femur chondrosarcoma.

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Spinal cord stimulation (SCS) paddle leads placed via laminectomy procedures have become common as more data accumulates with regards to their clinical efficacy. In this paper, we describe a case of a 72-year-old male patient with failed back surgery syndrome (FBSS) who underwent a thoracic laminectomy for permanent paddle lead placement. He went on to develop a complication that resulted in a large cerebrospinal fluid leak with a cerebrospinal fluid fistula formation.

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OBJECTIVE Microcystic meningioma (MM) is a meningioma variant with a multicystic appearance that may mimic intrinsic primary brain tumors and other nonmeningiomatous tumor types. Dynamic susceptibility contrast (DSC) and dynamic contrast-enhanced (DCE) MRI techniques provide imaging parameters that can differentiate these tumors according to hemodynamic and permeability characteristics with the potential to aid in preoperative identification of tumor type. METHODS The medical data of 18 patients with a histopathological diagnosis of MM were identified through a retrospective review of procedures performed between 2008 and 2012; DSC imaging data were available for 12 patients and DCE imaging data for 6. A subcohort of 12 patients with Grade I meningiomas (i.e., of meningoepithelial subtype) and 54 patients with Grade IV primary gliomas (i.e., astrocytomas) was also included, and all preoperative imaging sequences were analyzed. Clinical variables including patient sex, age, and surgical blood loss were also included in the analysis. Images were acquired at both 1.5 and 3.0 T. The DSC images were acquired at a temporal resolution of either 1500 msec (3.0 T) or 2000 msec (1.5 T). In all cases, parameters including normalized cerebral blood volume (CBV) and transfer coefficient (kTrans) were calculated with region-of-interest analysis of enhancing tumor volume. The normalized CBV and kTrans data from the patient groups were analyzed with 1-way ANOVA, and post hoc statistical comparisons among groups were conducted with the Bonferroni adjustment. RESULTS Preoperative DSC imaging indicated mean (± SD) normalized CBVs of 5.7 ± 2.2 ml for WHO Grade I meningiomas of the meningoepithelial subtype (n = 12), 4.8 ± 1.8 ml for Grade IV astrocytomas (n = 54), and 12.3 ± 3.8 ml for Grade I meningiomas of the MM subtype (n = 12). The normalized CBV measured within the enhancing portion of the tumor was significantly higher in the MM subtype than in typical meningiomas and Grade IV astrocytomas (p < 0.001 for both). Preoperative DCE imaging indicated mean kTrans values of 0.49 ± 0.20 min-1 in Grade I meningiomas of the meningoepithelial subtype (n = 12), 0.27 ± 0.12 min-1 for Grade IV astrocytomas (n = 54), and 1.35 ± 0.74 min-1 for Grade I meningiomas of the MM subtype (n = 6). The kTrans was significantly higher in the MM variants than in the corresponding nonmicrocystic Grade 1 meningiomas and Grade IV astrocytomas (p < 0.001 for both). Intraoperative blood loss tended to increase with increased normalized CBV (R = 0.45, p = 0.085). CONCLUSIONS An enhancing cystic lesion with a normalized CBV greater than 10.3 ml or a kTrans greater than 0.88 min-1 should prompt radiologists and surgeons to consider the diagnosis of MM rather than traditional Grade I meningioma or high-grade glioma in planning surgical care. Higher normalized CBVs tend to be associated with increased intraoperative blood loss.

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[This retracts the article DOI: 10.7759/cureus.627.].

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Intracranial mucormycosis is a very unusual presentation of an infection after a depressed skull fracture due to an assault. Only sporadic cases have been reported in the literature previously. A 30-year-old male with a traumatic brain injury following an assault, status-post debridement and elevation of a depressed skull fracture, was discharged home several weeks postoperatively. A CT scan of the head with contrast was obtained due to mental status changes and revealed an enhancing ring-shaped lesion in the right frontal lobe consistent with a brain abscess. The patient was taken to the operating room for image-guided excisional biopsy of the lesion, with pathology revealing mucormycosis.

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Intravascular ultrasound (IVUS) can provide valuable information regarding endoluminal morphology. We present the first description of IVUS-guided intracranial and extracranial carotid artery stent placement for arterial dissection. A 41-year-old female with a sudden-onset headache and blurred vision underwent a computed tomography (CT) angiogram imaging that revealed bilateral carotid artery dissections (BCAD) and a left vertebral artery dissection (VAD). Endovascular treatment (EVT) of a long segment right carotid artery dissection (CAD) was performed employing two Carotid WALLSTENT™ Monorails™ (8 x 36 mm, 10 x 31 mm) (Boston Scientific, Marlborough, MA). With the help of the IVUS, the distal stent was placed up to the petrous carotid artery, followed by the placement of the second stent in the immediate proximal location with some overlap that extended down to the carotid artery bulb. Intraoperative angiography and post-stenting IVUS revealed excellent stent placement with good resolution of the dissection and good luminal patency with pseudolumen obliteration. Stent use for intracranial circulation dissections will continue to be a favorable option given the decreased morbidity of endovascular therapy in this location. As endovascular surgeons become more facile with the use of IVUS, using it as a guide for stent placement and post-stenting confirmation will help them to ensure proper positioning and improved patency rates.

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One of the more commonly reported variations in musculocutaneous and median nerves is a communication between the two. Such communications have been noted in the literature for well over a century, and numerous studies have attempted to quantify their rate of incidence and classify their different patterns. Most communications occur close to the brachial plexus in the proximal arm; communications distal to the musculocutaneous nerve perforation of the coracobrachialis have been reported with less frequency, and several rare and unique communication patterns have been reported as case studies. This paper describes a case of a communicating branch between the musculocutaneous and median nerves, distal to the origin of the brachialis muscle. This communication was found during a routine educational dissection and is closer to the level of the elbow than previously documented communications that are distal to the musculocutaneous perforation of the coracobrachialis. Identification and documentation of the variety of musculocutaneous and median nerve communications is relevant to clinical diagnosis of peripheral nerve pathologies, as well as for planning surgical approaches and procedures.

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Background Minimally invasive laminectomy is a very effective surgical method for treating lumbar stenosis. However, this technique can be technically difficult, especially in patients suffering from severe stenosis. The contralateral decompression from a unilateral approach can result in durotomy during removal of the hypertrophied ligamentum flavum. This complication can be difficult to treat through a small working channel. Objective To detail our group's operative experience with the CO2 laser and discuss our results and previous studies in the literature reporting results.  Methods The CO2 laser (Omniguide, Boston, MA) was investigated in the surgical ablation of the contralateral ligamentum flavum during minimally invasive laminectomies. Forty levels have been investigated thus far. The amount of voltage needed to adequately desiccate and remove the ligamentum flavum safely as well as the effectiveness of this technique were investigated. Results The contralateral ligamentum flavum could be removed effectively using the 9 to 11 watt continuous wavelength (10,600 nanometer) power setting on the CO2 laser. Shrinkage of the contralateral ligamentum flavum facilitated its removal using a number 2 Kerrison Punch. No durotomies occurred, and the use of the laser did not significantly lengthen operative times.  Conclusions The CO2 laser appears to be a useful tool in the armamentarium of instruments available to the minimally invasive spine surgeon and may help to reduce the incidence of durotomies when performing minimally invasive laminectomies.

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OBJECTIVE: To determine the diagnostic efficiency of thallium-201 single photon emission computed tomography (SPECT) and Epstein-Barr virus (EBV) polymerase chain reaction (PCR) in the differentiation of primary central nervous system lymphoma (PCNSL) from other central nervous system processes in patients with HIV/AIDS. DESIGN/METHODS: Over 10 years, 68 thallium-201 SPECT scans were performed on neurologically symptomatic HIV+ patients with focal lesions on CT or MRI at the Johns Hopkins Hospital. Diagnoses were then established by either autopsy, biopsy, or clinical response to anti-toxoplasmosis therapy. Patients were categorized prior to a prospective clinical reading of the SPECT scans by nuclear medicine physicians. RESULTS: In our patient sample overall, the diagnostic efficiency of thallium-201 SPECT was 79%. The diagnostic accuracy of EBV PCR testing alone in a subset of 22 patients in our study that had CSF analyzed was 73%. However, when both positive EBV PCR and positive thallium-201 SPECT results were used together, the diagnostic accuracy improved to 100% based on a sample of 13 patients where EBV PCR and SPECT imaging results were concordant.  CONCLUSION: Thallium-201 SPECT has a relatively high positive predictive value with regards to the diagnosis of PCNSL, which suggests that patients with positive results could undergo empiric radiation treatment without resorting to brain biopsy. However, the predictive value can be increased by testing for CSF EBV using PCR. Alternatively, if CSF cannot be safely obtained because of mass effect, we believe that these data still suggest that empiric radiation treatment should be considered when discussing treatment options with patients with a positive thallium-201 SPECT.

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Neurofibromas and schwannomas are common lesions that may be idiopathic or may occur in association with neural crest genetic syndromes such as neurofibromatosis type 1, neurofibromatosis type 2, and schwannomatosis. A hybrid tumor that contains pathological characteristics of both neurofibroma and schwannoma has been described as a rare entity. We present the clinical, radiographic, and pathological findings of such a case.

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BACKGROUND: Case reports and case control studies have suggested an association between chiropractic neck manipulation and cervical artery dissection (CAD), but a causal relationship has not been established. We evaluated the evidence related to this topic by performing a systematic review and meta-analysis of published data on chiropractic manipulation and CAD. METHODS: Search terms were entered into standard search engines in a systematic fashion. The articles were reviewed by study authors, graded independently for class of evidence, and combined in a meta-analysis. The total body of evidence was evaluated according to GRADE criteria. RESULTS: Our search yielded 253 articles. We identified two class II and four class III studies. There were no discrepancies among article ratings (i.e., kappa=1). The meta-analysis revealed a small association between chiropractic care and dissection (OR 1.74, 95% CI 1.26-2.41). The quality of the body of evidence according to GRADE criteria was "very low." CONCLUSIONS: The quality of the published literature on the relationship between chiropractic manipulation and CAD is very low. Our analysis shows a small association between chiropractic neck manipulation and cervical artery dissection. This relationship may be explained by the high risk of bias and confounding in the available studies, and in particular by the known association of neck pain with CAD and with chiropractic manipulation. There is no convincing evidence to support a causal link between chiropractic manipulation and CAD. Belief in a causal link may have significant negative consequences such as numerous episodes of litigation.

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STUDY DESIGN: This was a prospective clinical study that took place in an outpatient spine clinic. OBJECTIVE: To demonstrate the short-/long-term outcomes from a large cohort of patients undergoing minimally invasive transforaminal lumbar interbody fusion (MITLIF). SUMMARY OF BACKGROUND DATA: Long-term prospective outcomes in patients undergoing minimally invasive spinal fusion for debilitating back pain has not been well studied. METHODS: Presenting diagnosis was determined from clinical findings and radiographical (radiograph, magnetic resonance image, computed tomographic scan) evaluations preoperatively. Patients were assessed with outcome measures preoperatively, and postoperatively at 2 weeks, 3 months, 6 months, 12 months, 24 months, and annually 2 to 7 years (mean follow-up: 47 mo) final follow-up. The rate of postoperative complications and reoperations at the initial level of MITLIF and adjacent level(s) were followed. Fusion rates were assessed blinded and independently by radiograph. RESULTS: Visual analogue scale scores decreased significantly from 7.0 preoperatively to 3.5 at mean 47-month follow-up. Oswestry Disability Index scores declined from 43.1 preoperatively to 28.2 at mean 47-month follow-up. Short-Form 36 mental component scores increased from 43.8 preoperatively to 49.7 at 47-month follow-up. Short-Form 36 physical component scores increased from 30.6 preoperatively to 39.6 at 47-month follow-up (P < 0.05). CONCLUSION: This prospectively collected outcomes study shows long-term statistically significant clinical outcomes improvement after MITLIF in patients with clinically symptomatic spondylolisthesis and degenerative disc disease with or without stenosis. MITLIF resulted in a high rate of spinal fusion and very low rate of interbody fusion failure and/or adjacent segment disease requiring reoperation while reducing postoperative complications. LEVEL OF EVIDENCE: 3.

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OBJECT: Transient delayed postoperative hyponatremia (DPH) after transsphenoidal surgery (TSS) is common and can have potentially devastating consequences. However, the true prevalence of transient symptomatic and asymptomatic DPH has not been studied in a large patient cohort with close and accurate follow-up. METHODS: A retrospective analysis of a single-institution prospective database was conducted; all patients undergoing TSS for lesions involving the pituitary gland were followed up in a multidisciplinary neuroendocrine clinic, and demographic, imaging, and clinical data were prospectively collected. Patients were examined preoperatively and followed up postoperatively in a standardized fashion, and their postoperative sodium levels were measured at Weeks 1 and 2 postoperatively. Levels of hyponatremia were rated as mild (serum sodium concentration 130-134 mEq/L), moderate (125-129 mEq/L), or severe (< 125 mEq/L). Routine clinical questionnaires were administered at all postoperative office visits. Postoperative hyponatremia was analyzed for correlations with demographic and clinical features and with immediate postoperative physiological characteristics. RESULTS: Over a 4-year interval, 373 procedures were performed in 339 patients who underwent TSS for sellar and parasellar lesions involving the pituitary gland. The mean (± SD) age of patients was 48 ± 18 years; 61.3% of the patients were female and 46.1% were obese (defined as a body mass index [BMI] ≥ 30). The overall prevalence of DPH within the first 30 days postoperatively was 15.0%; 7.2% of the patients had mild, 3.8% moderate, and 3.8% severe hyponatremia. The incidence of symptomatic hyponatremia requiring hospitalization was 6.4%. The Fisher exact test detected a statistically significant association of DPH with female sex (p = 0.027) and a low BMI (p = 0.001). Spearman rank correlation detected a statistically significant association between BMI and nadir serum sodium concentration (r = 0.158, p = 0.002) and an inverse association for age (r = -0.113, p = 0.031). Multivariate analyses revealed a positive correlation between postoperative hyponatremia and a low BMI and a trend toward association with age; there were no associations between other preoperative demographic or perioperative risk factors, including immediate postoperative alterations in serum sodium concentration. Patients were treated with standardized protocols for hyponatremia, and DPH was not associated with permanent morbidity or mortality. CONCLUSIONS: Delayed postoperative hyponatremia was a common result of TSS; a low BMI was the only clear predictor of which patients will develop DPH. Alterations in immediate postoperative sodium levels did not predict DPH. Therefore, an appropriate index of suspicion and close postoperative monitoring of serum sodium concentration should be maintained for these patients, and an appropriate treatment should be undertaken when hyponatremia is identified.

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Injury to the lymphatic channels is a rare and relatively unknown complication of anterior approaches to the lumbar spine and can cause fluid to build up in the retroperitoneal space, resulting in a lymphocele. If they enlarge sufficiently, these collections of chyle in the abdomen can cause pain and bowel ischemia, and can compress nearby organs. The authors report 4 cases in which anterior approaches to the lumbar spine were complicated by a postoperative retroperitoneal chylous fluid collection. They describe the anatomy of the lymphatic system and pathophysiology of this disease entity, review the sparse literature on this subject, and recommend a treatment algorithm. Maintaining a high index of suspicion for this clinical entity in patients who have recently undergone an anterior approach to the thoracic or lumbar spine is vital to avoid delays in diagnosis and treatment.

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BACKGROUND AND IMPORTANCE: Applications of robotics to minimally invasive spine surgery have produced several benefits while sparing patients the morbidity of traditional open surgery. Minimally invasive spine surgery offers the advantages of less pain and less blood loss, along with quicker recovery and shorter hospital stays. The da Vinci robotic surgical system has recently been adapted to neurosurgical applications. This article details a posterior approach using a tubular retraction system in conjunction with an anterior approach using the da Vinci robot to completely remove large spinal schwannomas with intrathoracic extension. This technique is an example of a novel application of existing technology initially developed for other applications. CLINICAL PRESENTATION: Two patients with large thoracic schwannomas extending into the chest cavity are reviewed. We present images and video of the combined minimally invasive approach used to completely remove the lesions without complications. CONCLUSION: This report describes a novel neurosurgical application of an existing minimally invasive robotic surgical system.

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Spine surgery as we know it has changed dramatically over the past 2 decades. More patients are undergoing minimally invasive procedures. Surgeons are becoming more comfortable with these procedures, and changes in technology have led to several new approaches and products to make surgery safer for patients and improve patient outcomes. As more patients undergo minimally invasive spine surgery, more long-term outcome and complications data have been collected. The authors describe the common complications associated with these minimally invasive surgical procedures and delineate management options for the spine surgeon.

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Antenatal diagnosis of an intracranial neoplasm is extremely rare. The authors describe a case in which a 21-week-old fetus was found, by using fetal ultrasonography, to have a large intracranial mass. Fetal magnetic resonance (MR) images, obtained at 21 and 25 weeks' gestation, supported the diagnosis of a teratoma. As the tumor increased in size, near-complete brain atrophy ensued. Premature labor was induced, and a nonviable fetus died within minutes of delivery. Postmortem analysis confirmed a teratoma occupying a major portion of the intracranial space. In cases in which abnormal brain development is suspected in a fetus, the use of fetal MR imaging can give a clearer picture of the pathological entity, which may allow for a more accurate diagnosis. The usefulness of fetal MR imaging in monitoring brain development and tumor growth during treatment planning is discussed.

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