A case report of intramedullary tuberculoma is presented. Only one other case of intramedullary tuberculoma has been reported in the North American literature in the last 30 years. It is also unique because it is the only documented case of the paradoxical enlargement of an intramedullary tuberculoma after the initiation of antituberculous chemotherapy. Excellent results were obtained with a combination of medical and surgical management.

Object Neurocysticercosis (NCC) is the most common parasitic infection of the central nervous system, and its prevalence is continuing to increase in the United States. The diagnosis of intraventricular NCC (IVNCC) may be difficult, and surgery frequently fails to resolve symptoms. A retrospective review of magnetic resonance (MR) imaging characteristics and surgery-related outcomes may improve management strategies of this disease. Methods The authors report the presentations, neuroimaging characteristics, surgical management, and outcomes of 30 patients with IVNCC treated over a 10-year period (mean follow-up period 4 years). Cysts were located in the lateral ventricles (five cases), the third ventricle (five cases), and the fourth ventricle (21 cases). One patient had lesions in both the lateral and fourth ventricles. Presenting symptoms were related to hydrocephalus or mass effect from the lesions. All patients underwent computerized tomography (CT) and MR imaging of the brain. Treatment consisted of shunt implantation or primary excision of an IVNCC lesion. Outcomes after operations and reoperations were evaluated in light of enhancement characteristics on MR imaging. Computerized tomography scanning demonstrated IVNCC lesions in 10% of cases, and MR revealed lesions in 100% of cases. In patients in whom gadolinium (Gd) enhancement of IVNCC lesions was demonstrated on MR imaging, the surgery-related failure rate was higher and patients required reoperation, and in those in whom gadolinium enhancement was absent the surgery-related failure rate was lower (64 and 19%, respectively; p < 0.0002). Conclusions Magnetic resonance imaging is superior to CT scanning for detecting IVNCC lesions. The absence of pericystic Gd enhancement on MR imaging is an indication for excision of the lesions. If pericystic enhancement is present, shunt surgery should be performed, and craniotomy reserved for treatment of those patients with symptomatic lesions secondary to mass effect. A treatment algorithm based on patient symptoms, cyst location, and MR imaging Gd enhancement characteristics is proposed.

No abstract

Isolated, primary extranodal Hodgkin's disease of the spine is extremely rare. Seven other cases were reported in 1954. Although the Hodgkin's disease in these cases may arise in the bone of the spine, the possibility of origin in the paraspinous soft tissues also cannot be excluded.

A 31-year-old woman with acquired immunodeficiency syndrome (AIDS) was found to harbor both a pulmonary smooth-muscle tumor and an intracranial extraaxial smooth-muscle tumor of the parasellar region. The frequency of smooth-muscle tumors (leiomyoma and leiomyosarcoma) has increased with AIDS, but much more so in children than in adults. Only nine cases of human immunodeficiency virus-related smooth-muscle tumors have been previously reported in adults, and only one of these was located intracranially.

OBJECTIVEWith the costs related to the United States medical system constantly rising, efforts are being made to turn traditional inpatient procedures into outpatient same-day surgeries. In this study the authors looked at the various comorbidities and perioperative complications and their impact on readmission rates of patients undergoing outpatient versus inpatient 3- and 4-level anterior cervical discectomy and fusion (ACDF).METHODSThis was a retrospective study of 337 3- and 4- level ACDF procedures in 332 patients (5 patients had both primary and revision surgeries that were included in this total of 337 procedures) between May 2012 and June 2017. In total, 331 procedures were analyzed, as 6 patients were lost to follow-up. Outpatient surgery was performed for 299 procedures (102 4-level procedures and 197 3-level procedures), and inpatient surgery was performed for 32 procedures (11 4-level procedures and 21 3-level procedures). Age, sex, comorbidities, number of fusion levels, pain level, and perioperative complications were compared between both cohorts.RESULTSAnalysis was performed for 331 3- and 4-level ACDF procedures done at 6 different hospitals. The overall 30-day readmission rate was 1.2% (outpatient 3 [1.0%] vs inpatient 1 [3.1%], p = 0.847). Outpatients had increased readmission risk, with comorbidities of coronary artery disease (OR 1.058, p = 0.039), autoimmune disease (OR 1.142, p = 0.006), diabetes (OR 1.056, p = 0.001), and chronic kidney disease (OR 0.933, p = 0.035). Perioperative complications of delirium (OR 2.709, p < 0.001) and surgical site infection (OR 2.709, p < 0.001) were associated with increased risk of 30-day hospital readmission in outpatients compared to inpatients.CONCLUSIONSThis study demonstrates the safety and effectiveness of 3- and 4-level ACDF surgery, although various comorbidities and perioperative complications may lead to higher readmission rates. Patient selection for outpatient 3- and 4-level ACDF cases might play a role in the safety of performing these procedures in the ambulatory setting, but further studies are needed to accurately identify which factors are most pertinent for appropriate selection.

Object Intraoperative radiographic localization within the cervical spine can be a challenge because of the anatomical relation of the musculoskeletal structures of the pectoral girdle. On standard cross-table lateral radiographs, these structures can produce shadowing that obscure the anatomical features of the cervical vertebrae, particularly at the caudal levels. Surgical guidelines recommend accurate intraoperative localization as a means to reduce wrong-level spine surgery, and unobstructed visualization is needed for fluoroscopy-guided placement of spinal instrumentation. In this article, the authors describe and evaluate a novel device designed to provide transient intraoperative caudal displacement of the shoulders to improve and simplify radiographic visualization of the cervical spine. Methods A 2-center prospective study was conducted to evaluate the device. The study included a total of 80 patients undergoing cervical spine surgery. The device was evaluated in a cohort of 50 patients undergoing elective single-level anterior discectomy and fusion and also in a second cohort of 30 patients at an independent institution. The patients in this second cohort were undergoing a variety of cervical spine procedures for multiple indications and were included in the study to allow the authors to assess the effectiveness of the device in a general neurosurgical practice. After the patients were anesthetized and positioned, consecutive standard cross-table lateral radiographs or intraoperative fluoroscopic were obtained before and after use of the device. The images were compared in order to determine the difference in lowest vertebral level visible. Results There was an average difference in cervical spine visualization of +2.8 ± 0.9 vertebral levels in the first cohort, while in the second the improvement was +1.2 ± 0.7 levels (p < 0.0001 between cohorts, unpaired t-test). There was one complication, a minor shoulder abrasion, which required no specific management. Conclusions This device is safe and effective for increasing the radiographic visualization of the cervical spine for intraoperative localization.

No abstract