Neal, Matthew T.

BACKGROUND Intramedullary spinal cord tumors represent a minority of intradural tumors. Among intramedullary spinal cord tumors, hemangioblastomas are uncommon, and schwannomas are extremely rare. Collision tumors are histologically distinct tumors that are intermingled and growing together. OBSERVATIONS In this report, the authors describe a patient with a cervical intramedullary collision tumor involving a hemangioblastoma and schwannoma. To the authors’ knowledge, no prior spinal intramedullary collision tumor involving multiple neoplasms has been described. The patient’s presentation and management are described. LESSONS Clinicians should consider the possibility of collision tumors when evaluating intramedullary spinal cord tumors, especially when patient presentation and radiographic findings are atypical. When tumors with similar radiographic characteristics form collision tumors, distinction using preoperative imaging can be extremely challenging. In addition, surgical management of intramedullary collision tumors, like that for all intramedullary spinal cord tumors, should involve meticulous perioperative care and a methodical surgical technique. Maximal safe resection will depend upon histopathological diagnosis, anatomical location of the tumor, presence of distinct dissection planes, and stability of neuromonitoring. Finally, ongoing research on the genetics of intramedullary spinal cord tumors may identify underlying genetic links for intramedullary hemangioblastomas and schwannomas.

BACKGROUND Anterior lumbar fusion procedures have many benefits and continue to grow in popularity. The technique has many potential approach- and procedure-related complications. Symptomatic retroperitoneal fluid collections are uncommon but potentially serious complications after anterior lumbar procedures. Collection types include hematomas, urinomas, chyloperitoneum, cerebrospinal fluid collections, and deep infections. OBSERVATIONS The authors present an unusual case of a patient with persistent symptoms related to a retroperitoneal collection over a 5-year period following anterior lumbar fusion surgery. To the authors’ knowledge, no similar case with such extensive symptom duration has been described. The patient had an infected encapsulated fluid collection. The collection was presumed to be a postoperative lymphocele that was secondarily infected after serial percutaneous drainage procedures. LESSONS When retroperitoneal collections occur after anterior retroperitoneal approaches, clinical clues, such as timing of symptoms, hypotension, acute anemia, urinary tract infection, hydronephrosis, elevated serum creatinine and blood urea nitrogen, low-pressure headaches, anorexia, or systemic signs of infection, can help narrow the differential. Retroperitoneal collections may continue to be symptomatic many years after anterior lumbar surgery. The collections may become infected after serial percutaneous drainage or prolonged continuous drainage. Encapsulated, infected fluid collections typically require surgical debridement of the capsule and its contents.

Background:Among the elderly, chronic subdural hematoma is a relatively common neurosurgical condition. Presenting symptoms range from headache and focal neurological deficits to seizure and coma depending on location and extent of brain compression. Functional recovery following surgery for chronic subdural hematoma is central to quality of life and ongoing health for elderly patients; however, there is a paucity of data regarding functional recovery in this population.Methods:In this study, the physical activity of patients who underwent surgical evacuation of chronic subdural hematoma was surveyed, as well as participation in physical therapy following surgery. In total, 38 patients completed the survey.Results:Of the 30 patients who exercised regularly before surgery, 28 (90.3%) returned to exercise within 1 year after surgery. Of 13 patients who reported playing hobby sports before surgery, 9 (69.2%) returned to those sports. 17/38 (44.7%) patients participated in physical therapy after surgery. 35/38 (92.1%) of patients reported that the surgery improved their quality of life.Conclusion:The majority of patients who underwent surgery for chronic subdural hematoma were able to return to exercise within 1 year. Participation in physical therapy was associated with return to exercise and sports. Further study is needed to determine which factors contribute to a return to baseline levels of physical activity following surgery for chronic subdural hematoma.

Case Report. Spine surgery in patients with Parkinson’s disease (PD) involves increased risk. We describe a case of cervical myelopathy in a patient with PD, multiple fractures involving the atlas and axis vertebrae, and spasmodic torticollis. The patient was successfully treated with an upper cervical decompression and occipital-cervical (OC) fusion surgery. Strategies for torticollis reduction and successful surgical outcome are discussed. Risks and benefits must be carefully weighed when considering occipital cervical fusion in PD patients. Conclusion. Intraoperative manual reduction of laterocollis is possible after general endotracheal anesthesia, and continuous neuromonitoring is established. Use of optimizing strategies such as perioperative botulinum injections and intraoperative O-arm navigation should be considered.

Case Report. Escherichia coli is a rare cause of vertebral osteomyelitis. It is more common in adults and males. We present a case of an immunocompetent adult male presenting with a several month history of progressive systemic symptoms and subsequent neurologic compromise. We discuss the neurosurgical evaluation of a patient with a progressive vertebral osteomyelitis and treatment options. Surgical debridement and spinal stabilization were performed and confirmed the diagnosis. The patient successfully completed a prolonged antimicrobial therapy course. The patient made a complete neurologic recovery. We discuss the presentation of a patient with Escherichia coli vertebral osteomyelitis and the successful surgical management.

Lumbar spondylolysis is a unilateral or bilateral defect of the pars interarticularis, an isthmus of bone connecting the superior and inferior facet surfaces in the lumbar spine at a given level. Spondylolysis is common in young athletes participating in sports, particularly those requiring repetitive hyperextension movements. The majority of young athletes are able to return to full sport participation following accurate diagnosis and conservative management, including a structured treatment program. Surgical intervention for isolated pars injuries is seldom necessary. A progressive physical therapy (PT) program is an important component of recovery after sustaining an acute pars fracture. However, there is a paucity of literature detailing PT programs specific to spondylolysis. Here, we provide an overview of the epidemiology, natural history, radiographic evaluation, and management of pars fractures in young athletes. In addition, a detailed description of a physiotherapy program for this population that was developed at a spine center within an academic medical center is provided.

Case Report.Aspergillusosteomyelitis is a destructive and progressive infection that has been described both in immunosuppressed and in immunocompetent hosts. We describe a case of lumbar vertebral osteomyelitis in a 61-year-old immunocompetent patient due toAspergillus nidulansthat was successfully treated with a combination of extensive surgical debridement, spinal stabilization, and a prolonged course of antifungal therapy. Imaging demonstrated findings consistent with L3 discitis. The biopsy grewAspergillusfungus and was treated with vorconizole. Imaging showed progressive destructive osteomyelitis at L3-L4. Patient underwent anterior L3 and L4 partial corpectomies, anterior interbody fusion L3-L5, and posterior T11-S2 pedicle screw and rod fixation. Antifungal treatment resulted in resolution of infection.Aspergillusmarkers remain negative. One year following definitive treatment, the patient’s back pain remains resolved.Conclusion. Definitive surgical resection of the infection, spinal stabilization, and aggressive antifungal therapy were required to eradicate the infection.

Abstract BACKGROUND AND IMPORTANCE Deep brain stimulation (DBS) is a well-established treatment for medically refractory Parkinson's disease (PD), essential tremor (ET), and dystonia. The field of DBS is expanding and techniques are under investigation for the treatment of several neurological disorders. A critical component of the success of these procedures depends significantly on the reliability and durability of devices implanted. Immediate feedback during surgery often gives the surgeon and patient a sense of confidence of long term success. When impedances are found to be elevated during the implantation of the DBS leads, appropriate trouble shooting measures are critical. CLINICAL PRESENTATION We present a 73-yr-old male undergoing awake subthalamic DBS with microelectrode recordings for severe PD. Once the optimal trajectory and depth were ascertained, the permanent DBS electrode was placed. High impedances were recorded. Troubleshooting procedures were performed and were all negative as to the cause of the values. Correct impedance levels of the DBS electrode was confirmed with extracranial testing, but continued high values were found again with intracranial positioning of the electrode. A postoperative computerized tomography (CT) scan confirmed intracranial air surrounding all of the contacts. The patient went on to outpatient programming with excellent clinical results. CONCLUSION The presence of pneumocephalus surrounding the DBS lead contacts at the target nucleus may have accounted for the intraoperative impedance findings. When all troubleshooting checks have not identified an explanation for the high impedances, intraoperative imaging may demonstrate pneumocephalus around the lead contacts, which should resolve and impedances return to normal values.