Neurological Surgery

Objectives: Decompressive craniectomy (DC) is a surgical therapy used to treat patients foreseen to be at risk for high
intracranial pressure (ICP). In this retrospective case control study, mortality, ICP values, neurocritical care (NCC) management necessity, and long-term neurologic status were examined in patients treated with DC and in a matched control group.
Methods: The primary end-points were all-cause mortality and functional status of NCC patients both at discharge and
at a 6 month follow-up. Secondary end-points were ICP values at established time points and the use of advanced NCC therapies. Patients who underwent primary DC were matched with individuals with similar demographic and pre-intervention ICP values who had been treated with standard NCC management alone.
Results: Neurologic status outcome at discharge and the 6 month follow-up was significantly better in patients treated with DC compared to those in the control group: Glasgow Outcome Scale (GOS) 4-5 in 15 versus 5 patients; p = 0.033, and 16 versus 6 patients, p = 0.033. Mortality at 6 months was similar in the study groups (10 versus 16 patients; p = 0.212). ICP values were similar at NCC admission but were better controlled 24 hours after DC than in the control group. Fewer
patients treated with DC needed advanced NCC medical therapies.
Conclusions: DC is an effective way to normalize ICP levels while reducing the need for aggressive medical therapies.
Survival rate and neurological outcome in patients treated with DC were found to be better than in those receiving only
medical treatment.
Keywords: Primary Decompressive Craniectomy; Neurocritical Care Patients; Elevated ICP Management; Neurologic Status; Neurosurgical Mortality.

BACKGROUND:
Traumatic thoracolumbar spinal fractures represent approximately 65% of all traumatic spinal fractures and are frequently associated to permanent disability with significant social and economic impact. These injuries create severe physical limitations depending on neurological status, level of fracture, severity of injury, patient age and comorbidities. Predicting neurological improvement in patients with traumatic spinal cord injuries (SCIs) is very difficult because it is related to different preoperative prognostic factors. We evaluated the neurological improvement related to the preoperative neurological conditions and the anatomic level of spinal cord injury.

METHODS:
From January 2004 to June 2010, we operated 207 patients for unstable thoracolumbar spinal fractures. We carried out a retrospective analysis of 69 patients with traumatic SCIs operated on by a posterior fixation performed within 24 hours from the trauma. The preoperative neurological conditions (ASIA grade), the type of the fracture, the anatomic level of spinal cord injury and the postoperative neurological improvement were evaluated for each patient.

RESULTS:
The ASIA grade at admission (P = 0,0005), the fracture type according to the AO spine classification (P = 0,0002), and the anatomic location of the injury (P = 0,0213) represented predictive factors of neurological improvement at univariate analysis. The preoperative neurological status (P = 0,0491) and the fracture type (P = 0,049) confirmed a positive predictive value also in the multivariate analysis.

CONCLUSIONS:
Our study confirms that the preoperative neurological status, the fracture type and the anatomic location of the fracture are predictive factors of the neurological outcome in patients with spinal cord injury.

STUDY DESIGN:
Retrospective review of a prospectively collected database.

OBJECTIVE:
This study compares patient demographics, incidence of comorbidities, procedure-related complications, and mortality following primary vs. revision adult spinal deformity surgerySummary of Background Data. While adult spinal deformity (ASD) surgery has been extensively investigated, no previous study has provided nationwide estimates of patient characteristics and procedure-related complications for primary vs. revision spinal deformity surgery comparatively.

METHODS:
Nationwide Inpatient Sample data collected between 2001 and 2010 was analyzed. Discharges with procedural codes for anterior and/or posterior thoracic and/or lumbar spinal fusion and refusion were included for patients aged 25+ and 4+ levels fused with any diagnoses specific for scoliosis. Patient demographics, comorbidity and procedure-related complications incidence were determined for primary vs. revision cohorts. Multivariate analysis reported as (OR [95% CI]).

RESULTS:
Discharges for 9133 primary and 850 revision cases were identified. Patients differed on the basis of demographic and hospital data. Average comorbidity indices for the cohorts were similar (p = 0.580), as was in-hospital mortality (p = 0.163). The incidence of procedure-related complications was higher for the revision cohort (46.96% vs. 71.97%, p = 0.001). The mean hospital course for the revision cohort was longer (6.37 vs. 7.13 days, p<0.0001). Revisions had an increased risk of complications involving the nervous system (1.34[1.10-1.6]), hematoma/seroma formation (2.31[1.92-2.78]), accidental vessel or nerve puncture (1.44[1.29-1.61]), wound dehiscence (2.18[1.48-3.21]), post-op infection (3.10[2.50-3.85]) and ARDS complications (1.43[1.28-1.60]). The primary cohort had a decreased risk for GI (0.65[0.55-0.76]) and GU complications (0.71[0.51-0.99]).

CONCLUSIONS:
Relative to primary cases, those undergoing revision correction of spinal deformity have a higher risk of many procedure-related complications with a longer hospital course despite similar baseline comorbidity burden and in-hospital mortality rate. This study provides clinically useful data for surgeons to educate patients at risk for morbidity and mortality and direct future research to improve outcomes.

A 71-year-old woman was referred to our clinic with a 4-year history of facial nerve paralysis on the left side. Her family first noted lower left facial asymmetry in 2008, and the patient was initially diagnosed with a transient ischemic attack. The facial weakness progressively worsened and eventually resulted in complete paralysis of the left side of the face. At that point, the patient was given a diagnosis of Bell palsy. The patient underwent lower eyelid surgery for ectropion, epiphora, and dry eye. The relevant medical history included previous skin resections for multiple cutaneous malignancies.

Objective To illustrate a unique instance of Ehlers-Danlos syndrome type VIII (EDS VIII) with blood blister-like aneurysm of the middle cerebral artery. Design This is a single patient case report. Setting University of Wisconsin-Madison Hospital. Participants A 42-year-old woman with diagnosis of EDS VIII presented with a sudden onset severe headache and altered mental status. She was diagnosed with Hunt and Hess grade IV subarachnoid hemorrhage. Angiography demonstrated a blood blister-like aneurysm of the left middle cerebral artery. After an unsuccessful coiling attempt in another facility, the patient was operated on with the intention to perform extracranial to intracranial bypass and trapping of the diseased segment of the artery. Results The patient&#39;s neurologic condition remained poor after surgery. On postoperative day 2, her neurologic examination unchanged, and care was withdrawn per the family&#39;s request. Conclusions Individuals with EDS VIII may be at risk for c...

The patient is an 89-year-old right-handed woman with past medical history significant for rheumatoid arthritis, hypertension, osteoporosis, and hypothyroidism. She presented with 2 days of dysarthric speech, drooling, and difficulty swallowing. She endorsed new constant "pressure" headaches that began 4 weeks prior to presentation that radiated to behind her left eye, ear, and jaw. She denied any previous history of headaches.

Primary neoplasms of the petrous apex are rare and include eosinophilic granuloma, chondroma, chondrosarcoma, chordoma, and schwannoma. We report just the second published case of an intraosseous schwannoma of the petrous apex and are the first to describe the entity using magnetic resonance imaging. By studying the computed tomography and magnetic resonance imaging features of this rare tumor, it is possible to suggest the diagnosis preoperatively.