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Background In January 2021, we published findings evaluating the validity of thoracolumbar injury classification and biomechanical approach in the clinical outcome of operative and non-operative treatments. A notable result in our study was patients with unstable burst fractures received an Arbeitsgemeinschaft für Osteosynthesefragen System (AO) score that recommended conservative treatment compared to a Thoracolumbar Injury Classification and Severity Scale (TLICS) score that recommended surgical intervention. We designed a survey to determine reported differences in thoracolumbar injury classification, including the percentage of thoracolumbar spine fractures, type of classification system(s) used, use of classification system by board-certified neurosurgeons and neurosurgical residents, reliance on classification system to guide management, use of MRI in the evaluation of the posterior ligamentous complex, and readmission rate < 90 days at treating facilities. This study aims to determine which areas of neurosurgical practice in spine trauma patients differ among surgeons in North America and East Africa, including Ethiopia, Kenya, and Sudan. Multiple classification systems have been proposed to describe thoracolumbar spine injuries. We hypothesized that there would be marked variability in the classification systems used to evaluate thoracolumbar spine injury among neurosurgeons in North America and East Africa. Methods The survey consisted of seven questions and was sent to 440 neurosurgeons practicing on the continents of North America and East Africa. Results A total of 67 surgeons responded, 50 from North America and 17 from East Africa, including Ethiopia, Kenya, and Sudan. A significant percentage of African respondents reported a higher thoracolumbar spine fracture rate than respondents in North America (53% and 30%, respectively). Regarding the classification system used, 65% of surgeons in East Africa reported using TLICS, whereas 62% of surgeons in North America reported using Denis 3-column classification. For patients with spine trauma, surgeons in East Africa and North America reported a similar percentage of readmission <90 days (47% and 52%, respectively). Conclusion Our findings vary in spine trauma classification for American and East African patients and still highlight crucial areas for improvement due to patient load, education, and resource accessibility.

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Background In 2020, we published findings on reported outcomes of anterior cervical decompression and fusion surgery among neurosurgeons in Africa and North America. We found more similarities in outcomes than expected, however, differences still existed. Most notable was the length of stay of patients postoperatively in Africa compared to North America. We sought to examine the neurosurgical practices more closely at a single hospital in Ethiopia and compare it to our own institution, the University of Missouri in Columbia (UMC). Methods Two authors spent one week at Aabet Hospital (AH) in Ethiopia. Throughout the week, one author rotated in the clinic and OR gathering the information. Data collection for patients at UMC was collected through retrospective chart review over one week. Results A total of eight elective surgeries and four emergency procedures occurred at AH and 18 clinic patients were included in the study. The intraoperative data was collected during the elective procedures at AH. At UMC there were 99 clinic patients, and 29 elective surgeries and one emergency procedure were performed. Procedures at both institutions included cranial, spinal, vascular, and implantable/other cases. Distance travelled by patients to UMC was an average of 57 miles compared to 85 miles at AH. The median pre-op and post-op stays at AH were 2.5 and 6 days compared to 0.2 and 2.1 at UMC, respectively. Blood loss was greater at AH with a median blood loss of 175 mL. Median blood loss at UMC was 50 mL. Conclusion We found notable differences among neurosurgical practice and patient demographics at AH compared to UMC. This information will serve as the cornerstone for gathering more information about neurosurgical practice in Ethiopia where electronic medical records are unavailable.

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Non-Hodgkin's lymphomas are a group of lymphoid neoplasms, with diffuse large B-cell lymphoma (DLBCL) being the most common subtype. Genetic alterations involving c-MYC, BCL-2, and BCL-6 have been implicated in the pathogenesis of subtypes of DLBCL with poor prognostic implications. This case report demonstrates a retropharyngeal mass with extension through the bilateral neuroforamina into the epidural space and posterior elements of the cervical spine (C2-C3), for which biopsy revealed diffuse large B-cell lymphoma. Here we present a unique case as it provides a solution for the dilemma on how to treat a patient with a known prior malignancy (gastrointestinal [GI] melanoma) with a retropharyngeal mass with epidural extension (dumbbell-shaped tumor) with an inconclusive initial CT-guided needle-core biopsy. A CT-guided biopsy only yielded that the mass was neoplasm; we had a choice between attempting gross total resection of the mass or open biopsy. Attempting gross total resection would have entailed an anterior approach (transoral with possible odontoidectomy or endoscopic endonasal with possible odontoidectomy) along with posterior instrumentation and fusion from occiput to C3, which is a rather morbid procedure that would subject the patient to a decreased quality of life as well as risks of vascular injury, dysphagia, and infection. We elected to perform an open biopsy of the epidural component of the mass through a decompressive laminectomy, which allowed for decompression of the spinal cord as well as a sampling of the mass. This provided treatment for possible increasing epidural compression from the mass, as well as diagnostic tissue. A multidisciplinary team discussed the case and developed a treatment plan for the patient with systemic and intrathecal chemotherapy in combination with radiotherapy.

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Prostate cancer is the most common cancer among men in the USA. A peptide derived from the active site of alpha-fetoprotein (AFP), known as AFPep, has been shown to be efficacious in inhibiting breast cancer growth. The role of this derived peptide AFPep in the development of prostate cancer has yet to be studied. To investigate the role of AFPep on prostate cancer, we used the PC-3 and DU-145 cell lines. We found that through key anti-apoptosis and pro-proliferation molecules, AFPep enhances the proliferation of DU-145 prostate cancer cells. The anti-proliferative molecules p18, p21, and p27, along with the pro-apoptotic molecules Fas and Bax, were all down-regulated in DU-145 cell lines treated with AFPep. Conversely, AFPep was not found to have a proliferative effect on the PC-3 prostate cancer cell line. This finding suggests the effects of AFPep to be cell line-specific in prostate cancer. Further investigation into the effects of AFPep could lead to new areas of treating prostate cancer.

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This review assesses the validity of a biomechanical approach using finite element analysis in the Thoracolumbar Injury Classification and Severity Score System (TLICS) by addressing the "gray zone" decision discrepancy of thoracolumbar spinal injuries. A systematic review was performed using the keywords "Thoracolumbar Injury Classification" AND "finite element analysis of the spinal column" to evaluate the validity of the TLICS and finite element analysis of the thoracolumbar spinal column. Results were classified according to the main conclusions and level of evidence. Thirteen articles are included. Four of the articles evaluated the TLICS in comparison to other classification systems of thoracolumbar spinal injuries. A notable finding is that the TLICS had inconsistencies with other classification systems in the treatment of burst fractures without neurological deficits. One article evaluated the TLICS with the inclusion of magnetic resonance imaging (MRI) in the evaluation, which decreased the agreement between the suggested and actual treatment. Among the three finite element analysis studies, limited data have been published on the posterior ligamentous complex (PLC) status when an injury is suspected or indeterminate. The TLICS has been a reliable classification system in the management of single-column fractures and three-column injuries treated with surgical stabilization. Special attention to enhancing the TLICS classification system by eliminating the "gray zone" of a TLICS score of 4 is essential. Biomedical computational modeling evaluating the PLC status of indeterminate or injury suspected is needed to enhance the current TLICS system and to clarify the decision discrepancy in the "gray zone."

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Objective While enhanced recovery after surgery (ERAS) protocols are associated with shorter length of stay and improved outcomes in multiple surgical specialties, its application to spine surgery has been limited. Anterior cervical discectomy and fusion (ACDF) is a common spinal procedure with a relative efficacy and safety profile that makes it suitable for the application of ERAS principles. Reviewing our outcomes and practice and incorporating evidence-based clinical studies, we propose the development of an ERAS pathway for ACDF. Methods This is a retrospective review of ACDF cases performed at a single institution by a single surgeon from 2014 to 2017. Primary outcome measures included length of stay, complications, and 30-day readmission rates. The 1- and 2-level and the 3- and 4-level groups were also each consolidated into a single cohort for comparison. A comprehensive review of evidence-based literature pertaining to ACDF was then performed. Best-practice recommendations derived from the literature were incorporated into the proposed ERAS protocol. Results In this series of 75 1-level, 77 2-level, 44 3-level and 20 4-level ACDF procedures, the average surgical time (minutes) was 68, 90, 118 and 141; length of stay (days) was 1, 1, 1.4, and 1.7; drain usage (%) was 1.3, 2.6, 13.6 and 10; and 30-day readmission rates (%) were 2.7, 3.9, 4.5, and 15, respectively. Combining the 1- and 2-level as a single group and 3- and 4-level as another cohort, the 3- and 4-level cohort had a significantly higher rate of drain usage and estimated blood loss (EBL) but there was not a difference in length-of-stay, complications or 30-day readmission rates. Conclusions Given the relative equivalent safety profile between 1- and 2-level as compared to 3- and 4-level ACDF, the proposed ERAS pathway can be applied to all patients, and not just restricted to 1-level or 2-level ACDF. Taking into account feasibility parameters as deduced from a review of institutional outcomes, this pathway can streamline same-day discharge and improve the patient experience. Its success will be predicated on an iterative improvement process deriving from optimal prospective outcome measurements.

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Histoplasmosis is a fungal disease caused by Histoplasma capsulatum var. capsulatum (Hcc) and H. capsulatum var. duboisii (Hcd). Central nervous system (CNS) involvement is rare. So far, the few cases reported having Histoplasmosis associated brain abscesses were caused by H. capsulatum var. capsulatum. Herein, we report a unique case of brain abscess caused by H. capsulatum var. duboisii occurring in a 42-year-old immunocompromised woman with HIV. Initially, she presented with hypothermia, vomiting, frontal headache, evolving over one month. She then progressed to have a generalized seizure. Brain MRI showed multifocal brain abscesses and a frontal osteitis. The frontal osteitis was biopsied and confirmed the diagnosis of H. capsulatum var. duboisii. She was successfully treated with liposomal amphotericin B (150 mg daily) for the first four weeks and itraconazole (200mg twice daily) for six months.

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BACKGROUND: Stereotactic radiosurgery (SRS) can be used to achieve local control of metastatic brain lesions. However, the temporal response of these lesions to SRS is incompletely understood and quantified. We aimed to examine the temporal response to SRS of single brain metastases from 4 different primary cancers. METHODS: A retrospective chart review was performed of patients who underwent SRS at our institution from 2009 to 2012. Clinical, treatment, and volumetric data were collected. All patients were treated according to Radiation Therapy Oncology Group 90-05 schema. RESULTS: This study included 204 patients (116 men and 88 women) with a median age of 61 years (range, 27-86 years). Of patients, 20 (10%) had breast cancer, 79 (39%) had non-small cell lung cancer, 69 (34%) had melanoma, and 36 (17%) had renal cell carcinoma. Initial overall median tumor volume was 0.8 cm3 (range, 0.02-16.9 cm3). Median tumor volume was 0.5 cm3 (range, 0.02-20.4 cm3) at 1 month after SRS, 0.3 cm3 (range, 0.02-10.8 cm3) at 3 months after SRS, and 0.4 cm3 (range, 0.02-18.6 cm3) at 6 months after SRS. Based on the joint model constructed from our results, we demonstrate a median 16% (95% confidence interval, 11%-20%) reduction in tumor volume every 30 days. CONCLUSIONS: The results of this study demonstrate a consistent reduction in tumor volume following SRS over a 6-month period. Responses were modest over the first 30 days but accelerated at 3 months and varied by tumor type.

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Odontoid fractures typically occur as a result of trauma: high-velocity injuries like motor vehicle accidents in young people and falls for the elderly. Odontoid fractures are the most common cervical spine fractures in patients over 65, with type II being the most common. However, spinal cord transections are rare with these types of injuries, especially without significant fracture displacement, translation or evidence of ligamentous disruption on post-injury imaging. We report a case of a patient who sustained a spinal cord transection secondary to an acute type II odontoid fracture from a ground-level fall, without computed tomography radiographic evidence of cord disruption or impingement.

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Extra-abdominal desmoid tumors (DTs) are rare tumors of apparent fibroblastic origin with unpredictable clinical behavior. Though histologically benign and slow growing, DTs can be proliferative, aggressive tumors, invading the surrounding areas. DTs located extra-abdominally are most commonly found in the extremities or proximal structures like the shoulders, chest wall, and neck. Spinal involvement is very rare. Here, we describe a case where an extra-abdominal DT mimicked a schwannoma in the posterior cervical spine. A 67-year-old female patient presented with acute neck and bilateral shoulder pain. After attempting conservative treatments with no symptomatic relief, a magnetic resonance imaging of the cervical spine was obtained, showing a paraspinal mass in the posterior elements from C2 to C4. The computed tomography guided needle biopsy showed rare spindle cells, suggestive of a spindle cell neoplasm, and complete surgical resection was performed. The pathology report was consistent with fibromatosis, leading to a final diagnosis of the extra-abdominal desmoid. This case demonstrates a rare presentation of an unusual tumor that often manifests with nonspecific symptoms or no symptoms at all.

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We report a case of an osteochondroma in a 47-year-old woman presenting with a 2-month history of thoracic back pain that radiated down her left arm. Based on imaging features, the osteochondroma was initially thought to represent a calcified meningioma. The unusual features of the case include the location of the tumor, patient age, the erosion of the vertebra, and the confusing neuroradiological features. We review reported cases in which a solitary costal osteochondroma impinges on the neural foramina or central spinal canal and we discuss reasons for the misdiagnosis in our case.

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A 2½-year-old male child with a prior history of a left anatomic hemispherectomy to treat refractory epilepsy fell down two steps, striking his head on the ipsilateral side of the hemispherectomy. He presented with non-consolable crying and emesis. CT scan of the head demonstrated a left frontal epidural hematoma beneath the site of his prior craniectomy. The patient was initially treated by close observation. However, due to an increase in the hematoma from 29.5 to 49.3 ml over a 12-hour period along with the patient's lack of clinical improvement, surgical evacuation was performed. Intraoperatively, the source of the hemorrhage was found to be the skull fracture. Postoperatively, he returned to his neurologic baseline and was discharged home on postoperative day 3.

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BACKGROUND AND IMPORTANCE: Epidural hematoma (EDH) has never been reported as a complication after placement of a bone-anchored hearing aid (BAHA). To our knowledge, this is the first case report of an EDH after placement of a BAHA. CLINICAL PRESENTATION: We report the case of a 15-year-old girl with an EDH after placement of a BAHA. Initially, she presented with a history of right ear conductive hearing loss and had a tympanomastoidectomy and placement of a BAHA at an outpatient surgical facility. Postoperatively, the patient was transferred to the postoperative care unit in stable neurological condition but was subsequently noted to be lethargic with dilated, nonreactive pupils and extensor posturing. A computed tomography scan revealed a large right temporal EDH with midline shift. She was then taken to the operating room emergently for craniotomy and evacuation of the EDH. After evacuation, she was admitted to the pediatric intensive care unit and slowly emerged from her coma with supportive care. She was discharged to inpatient rehabilitation and has made a good recovery. CONCLUSION: This report emphasizes the need for a high index of suspicion of this rare, but life-threatening complication of an EDH after the placement of a BAHA.

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Near-drowning predisposes one to infection by the fungus Scedosporium apiospermum, and brain abscess is the most common consequence. Vertebral osteomyelitis due to this organism is exceedingly rare. The authors report on a 43-year-old man who developed fungal spondylodiscitis several weeks after a near-drowning event. The rare nature of this infection led to a delay in diagnosis. A combination of surgical debridement, instrumentation, and antifungal therapy resulted in an excellent outcome at 1 year of follow-up.

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An 8-mer peptide (EMTOVNOG) derived from alpha-fetoprotein was compared with tamoxifen for activity against growth of human breast cancer xenografts implanted in immune-deficient mice. Both peptide and tamoxifen prevented growth of estrogen-receptor-positive MCF-7 and T47D human breast cancer xenografts. A subline of MCF-7, made resistant to tamoxifen by a 6-month exposure to this drug in culture, was found to be resistant to tamoxifen in vivo. Peptide completely prevented the xenograft growth of this tamoxifen-resistant subline of MCF-7. Neither peptide nor tamoxifen was effective in slowing the xenograft growth of the estrogen-receptor-negative MDA-MB-231 human breast cancer. A worrisome side effect of tamoxifen is its hypertrophic effect on the uterus. In this study, tamoxifen was shown to stimulate the growth of the immature mouse uterus in vivo, and the peptide significantly inhibited tamoxifen's uterotrophic effect. The mechanism of action of peptide is different from that of tamoxifen in that the peptide does not interfere with the binding of [(3)H]estradiol to the estrogen receptor. In conclusion, alpha-fetoprotein-derived peptide appears to be a novel agent that interferes with the growth of tamoxifen-sensitive as well as tamoxifen-resistant estrogen-receptor-positive human breast cancers; it inhibits the uterotrophic side effect of tamoxifen and, thus, it may be useful in combination with or in place of tamoxifen for treatment of estrogen-receptor-positive human breast cancers.

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