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T-cell dysfunction contributes to tumor immune escape in patients with cancer and is particularly severe amidst glioblastoma (GBM). Among other defects, T-cell lymphopenia is characteristic, yet often attributed to treatment. We reveal that even treatment-naïve patients and mice with GBM can harbor AIDS-level CD4 counts, as well as contracted, T-cell deficient lymphoid organs. Missing naïve T-cells are instead found sequestered in large numbers in the bone marrow. This phenomenon characterizes not only GBM but a variety of other cancers, although only when tumors are introduced into the intracranial compartment. T-cell sequestration is accompanied by tumor-imposed loss of S1P1 from the T-cell surface and is reversible upon precluding S1P1 internalization. In murine models of GBM, hindering S1P1 internalization and reversing sequestration licenses T-cell-activating therapies that were previously ineffective. Sequestration of T-cells in bone marrow is therefore a tumor-adaptive mode of T-cell dysfunction, whose reversal may constitute a promising immunotherapeutic adjunct.

Background:We present a rare case of comorbid relapsed acute myeloid leukemia (AML) with the involvement of the central nervous system (CNS) and subdural seeding of vancomycin-resistantEnterococcusfaecium(VRE). The safety profile, treatment approach with pharmacokinetic considerations, and evaluation of success for bilateral subdural administration of daptomycin after subdural hematoma (SDH) are assessed.Case Description:A 45-year-old male with a history of AML who underwent chemotherapy (induction with 7 + 3) was admitted to oncology with relapsed AML confirmed by bone marrow biopsy, complicated by neutropenic fever and VRE bacteremia. After acute neurological changes with image confirmation of mixed- density bilateral SDHs secondary to thrombocytopenia, the patient was admitted to the neurosurgery unit and underwent bilateral burr hole craniotomies for subdural evacuation with the placement of the left and right subdural drains. Culture of the subdural specimen confirmed VRE seeding of the subdural space. The patient received the first dose of daptomycin into the bilateral subdural spaces 2 days after evacuation and was noted to have acute improvement on neurological examination, followed by a second administration to the left subdural space 5 days after evacuation with bilateral drains pulled thereafter.Conclusion:In this patient, the complication of relapsed AML may have contributed to the rare extension of VRE into the CNS space. Screening for patients at risk of AML with CNS involvement and addressing coagulopathy and risk of infection may help mitigate morbidity. Bilateral administration of subdural daptomycin bolus into the subdural space was tolerated and possibly contributed to the patient’s neurological improvement during an extended hospital course.

In the version of this article originally published, the figure callout in this sentence was incorrect: “Furthermore, in S1P1-KI mice themselves, whereas PD-1 blockade was ineffectual as monotherapy, the effects of 4-1BB agonism and checkpoint blockade proved additive, with the combination prolonging median survival and producing a 50% long-term survival rate (Fig. 6f).” The callout should have been to Supplementary Fig. 6b. The error has been corrected in the PDF and HTML versions of the article.

The use of intraoperative image guided navigation (NAV) in spine surgery is increasing. NAV is purported to improve the accuracy of pedicle screw placement but has been criticized for potentially increasing surgical cost, a component of which may be prolongation of total operative time due to time required for setup and intra-operative imaging and registration. In this study, we examine the effect of the introduction of O-Arm conical CT spinal navigation on surgical duration. We retrospectively analyzed consecutive freehand (FH) (n=63) and NAV (n=70) 1-level lumbar transpedicular instrumentation cases at a single institution by a single surgeon. We recorded setup and procedure time for each case. NAV was associated with significantly shorter total operative time for 1-level lumbar fusions compared to FH (4:30+/-0:42 hours vs. 4:53+/-0:39hours, p=0.0013). This shortening of total operative time was realized despite a trend toward slightly longer setup times with NAV. We also found a significant decrease in operative length over time in NAV but not FH cases, indicative of a "learning curve" associated with NAV. The use of NAV in 1-level lumbar transpedicular instrumentation surgery is associated with significantly shorter total operative time compared to the FH technique, and its efficiency improves over time. These data should factor into cost-effectiveness analyses of the use of NAV for these cases.

Background Atlantoaxial instability, which can arise in the setting of trauma, degenerative diseases, and neoplasm, is often managed surgically with C1-C2 arthrodesis. Classical C1-C2 fusion techniques require placement of instrumentation in close proximity to the vertebral artery and C2 nerve root. Objective To report a novel C1-C2 fusion technique that utilizes C2 translaminar screws and C1 sublaminar cables to decrease the risk of injury to the vertebral artery and C2 nerve root. Methods To facilitate fixation to the atlas, while minimizing the risk of injury to the vertebral artery and to the C2 nerve root, we sought to determine the feasibility of using a soft cable around the C1 arch and affixing it to a rod connected to C2 laminar screws. We reviewed our experience in 3 patients. Results We used this technique in patients in whom we anticipated difficult C1 screw placement. Three patients were identified through a review of the senior author's cases. Atlantoaxial instability was associated with trauma in 2 patients and chronic degenerative changes in 1 patient. Common symptoms on presentation included pain and limited range of motion. All patients underwent C1-C2 fusion with C2 translaminar screws with sublaminar cable harnessing of the posterior arch of C1. There were no reports of postoperative complications or hardware failure. Conclusion We demonstrate a novel, technically straightforward approach for C1-C2 fusion that minimizes risk to the vertebral artery and to the C2 nerve root, while still allowing for semirigid fixation in instances of both traumatic and chronic degenerative atlantoaxial instability.

Spinal nerve root metastasis of renal cell carcinoma is a rare occurrence. In addition to treatment of the primary lesion, surgical resection of the nerve root metastasis, occasionally with sacrifice of the involved nerve, is the accepted standard of treatment. Resection often resolves presenting motor and pain symptoms due to relief of neural compression. We describe two patients with nerve root metastasis of renal cell carcinoma and their management. While locally advanced and metastatic renal cell carcinoma has been shown to be chemo- and radio-resistant, immunotherapy is a promising treatment. Given the high prevalence of systemic disease in patients with intradural metastases, systemic (and possibly intracranial) imaging can be used to identify other potential areas of disease.

Object It is not known whether adding fusion to lumbar decompression is necessary for all patients undergoing surgery for degenerative lumbar spondylolisthesis with symptomatic stenosis. Determining specific radiographic traits that might predict delayed instability following decompression surgery might guide clinical decision making regarding the utility of up-front fusion in patients with degenerative Grade I spondylolisthesis. Methods Patients with Grade I degenerative lumbar spondylolisthesis (3–14 mm) with symptomatic stenosis were prospectively enrolled from a single site between May 2002 and September 2009 and treated with decompressive laminectomy without fusion. Patients with mechanical back pain or with gross motion (> 3 mm) on flexion-extension lumbar radiographs were excluded. The baseline radiographic variables measured included amount of slippage, disc height, facet angle, motion at spondylolisthesis (flexion-extension), and sagittal rotation angle. Data were analyzed using multivariate forward selection stepwise logistic regression, chi-square tests, Student t-test, and ANOVA. Results Forty patients were enrolled and treated with laminectomy without fusion, and all patients had complete radiographic data sets that were available for analysis. Reoperation was performed in 15 (37.5%) of 40 patients, with a mean follow-up duration of 3.6 years. Reoperation was performed for pain caused by instability at the index level in all 15 cases. Using multivariate stepwise logistic regression with a threshold p value of 0.35, motion at spondylolisthesis, disc height, and facet angle were predictors of reoperation following surgery. Facet angle > 50° was associated with a 39% rate of reoperation, disc height > 6.5 mm was associated with a 45% rate of reoperation, and motion at spondylolisthesis > 1.25 mm was associated with a 54% rate of reoperation. Patients with all 3 risk factors for instability had a 75% rate of reoperation, whereas patients with no risk factors for instability had a 0% rate of reoperation (p = 0.14). Conclusions Patients with motion at spondylolisthesis > 1.25 mm, disc height > 6.5 mm, and facet angle > 50° are more likely to experience instability following decompression surgery for Grade I lumbar spondylolisthesis. Identification of key risk factors for instability might improve patient selection for decompression without fusion surgery. Clinical trial registration no.: NCT00109213

Chordoma is a rare bone cancer that is aggressive, locally invasive, and has a poor prognosis. Chordomas are thought to arise from transformed remnants of notochord and have a predilection for the axial skeleton, with the most common sites being the sacrum, skull base, and spine. The gold standard treatment for chordomas of the mobile spine and sacrum is en-bloc excision with wide margins and postoperative external-beam radiation therapy. Treatment of clival chordomas is unique from other locations with an enhanced emphasis on preservation of neurological function, typified by a general paradigm of maximally safe cytoreductive surgery and advanced radiation delivery techniques. In this Review, we highlight current standards in diagnosis, clinical management, and molecular characterisation of chordomas, and discuss current research.

Cervical radiculopathy is a common condition that usually results from compression and inflammation of the cervical nerve root or roots in the region of the neural foramen. It is frequently caused by cervical disc herniation and cervical spondylosis. The diagnosis can be established by history and physical examination, but care should be taken, as diagnoses can mimic or coexist with cervical radiculopathy, such as entrapment neuropathies. The pathophysiology, presentation, and clinical evaluation of cervical radiculopathy are discussed.

Neurosurgeons encounter a number of pigmented tumors of the central nervous system in a variety of locations, including primary central nervous system melanoma, blue nevus of the spinal cord, and melanotic schwannoma. When examined through the lens of embryology, pigmented lesions share a unifying connection: They occur in structures that are neural crest cell derivatives. Here, we review the important progress made in the embryology of neural crest cells, present 3 cases of pigmented tumors of the nervous system, and discuss these clinical entities in the context of the development of melanoblasts. Pigmented lesions of the nervous system arise along neural crest cell migration routes and from neural crest-derived precursors. Awareness of the evolutionary clues of vertebrate pigmentation by the neurosurgical and neuro-oncological community at large is valuable for identifying pathogenic or therapeutic targets and for designing future research on nervous system pigmented lesions. When encountering such a lesion, clinicians should be aware of the embryological basis to direct additional evaluation, including genetic testing, and to work with the scientific community in better understanding these lesions and their relationship to neural crest developmental biology.

Object Over the past 15 years, vertebroplasty has emerged as a treatment for vertebral compression fractures. This technique, however, does not restore vertebral height and is associated with a high rate of cement leakage. Recently, kyphoplasty was developed in an effort to circumvent this problem. Although its immediate results have been reported, it is unclear whether the benefits endure. Methods Seventy-eight consecutive patients underwent 188 kyphoplasty procedures. The patients responded to Short Form—36 (SF-36) questionnaires, a visual analog scale (VAS) for pain rating, and the Oswestry disability index (ODI) instrument; additionally they underwent detailed neurological and radiographic examinations pre- and postoperatively. The preoperative SF-36, VAS, and ODI scores, the neurological examination results, and the radiographic data were compared with the postoperative findings. Thirteen patients died of disease progression or unrelated illness. Of the surviving patients, complete data were available in 62% (minimum follow-up period 12 months, mean 18 months). Complications included one myocardial infarction and five cases of asymptomatic cement extravasation. No case of neurological deterioration occurred during the follow-up period. Significant improvements in seven measures of the SF-36 inventory as well as on the ODI and VAS were noted early postoperatively, and these persisted throughout the follow-up period, despite a statistically insignificant decline in the measure of general health at last follow-up examination. Conclusions Kyphoplasty is an effective treatment for vertebral compression fractures. The benefits presented in the early postoperative period and persisted at 1 year posttreatment.

Spinal cord injury (SCI) removes descending input to spinal cord circuitry and results in loss of function below the level of injury. Interventions designed to increase the intrinsic capacity of CNS neurons for growth and other interventions to create a favorable environment at and below the lesion site result in increased regrowth and recovery of function. It is unlikely that any single intervention will restore function completely. After SCI in rats, transplants of fetal spinal cord tissue and the exogenous application of neurotrophic factors restore supraspinal input and permit recovery of skilled movement and locomotion. Delay of treatment leads to greater axon regeneration and recovery of function than immediate application of transplants and neurotrophic factors.

Ligamentum flavum is generally resected with impunity when a laminectomy is performed; it is a strong ligament and its removal may not be inconsequential. We sought to examine the consequence of resection of ligamentum flavum as it pertains to the formation of synovial cysts. Following IRB approval, we retrospectively reviewed the charts of consecutive patients who underwent a laminectomy for any diagnosis during the years 2009-2010. Exclusions were made for patients undergoing resection of a synovial cyst, laminectomy done as part of a fusion, and microdiscectomy. A total of 201 laminectomies were performed. 10 instances of post-laminectomy synovial cyst occurred in only the lumbar spine. Synovial cysts occurred exclusively after surgery for stenosis (n = 10). Laminectomy and resection of the ligament flavum is a risk factor for the subsequent formation of a synovial cyst. Secondary synovial cyst formation should be suspected in individuals who develop radiculopathy after laminectomy for stenosis.

Objective We investigated the mechanical and in vivo properties of a novel device, called the telescopic plate spacer (TPS), designed to promote restoration of height, alignment, and stability after cervical corpectomy for tumor. Methods The device first underwent mechanical testing. Comparisons were made with a commercially available anterior cervical plate. A caprine study was then performed. Twelve goats underwent a cervical corpectomy and placement of either a TPS filled with autograft or a plate and autograft. The animals were killed at 28 weeks and assessed for fusion. A prospective human study was then conducted. Fifteen patients with cervical or cervicothoracic tumors underwent corpectomy and placement of allograft-filled TPS. End points included pain scores and radiographic assessment of vertebral height, alignment, and stability. Results In the mechanical study, the TPS outperformed the anterior cervical plate in all modalities except for torsion stiffness and tension-bending failure load. The caprine study demonstrated fusion in six of six cases at 28 weeks in the TPS group, compared with four of six cases in the plate and autograft group. In the human study, patients (n = 15) were stabilized with the TPS after corpectomy (range, 1-3 levels; average, 1.7 levels). There were no failures of instrumentation or neurological deterioration. Stability was achieved in all patients, with an average follow-up of 9 months. Durable improvements in pain scores (P = 0.001), vertebral height (P = 0.002), and reduction of kyphosis (P = 0.046) were achieved. Conclusion The TPS can be used to restore height, alignment, and stability after corpectomy.

Jugular foramen syndrome is a condition characterized by unilateral paresis of cranial nerves IX, X, and XI in the setting of extrinsic compression. Here, the authors describe the case of a giant cervical osteophyte resulting in compression of the jugular foramen. A 74-year-old man who presented with progressive dysphagia and dysarthria was found to have right-sided tongue deviation, left palatal droop, and hypophonia. His dysphagia had progressed to the point that he had lost 25 kg over a 4-month period, necessitating a gastrostomy to maintain adequate nutrition. He underwent extensive workup for his dysphagia with several normal radiographic studies. Ultimately, CT scanning and postcontrast MRI revealed a posterior osteophyte arising from the C1–2 joint space and projecting into the right jugular foramen. This resulted in a jugular foramen syndrome in addition to delayed filling of the patient's right internal jugular vein distal to the osteophyte. Although rare, a posterior cervical osteophyte should be considered in cases of jugular foramen syndrome.

Objective To describe the effective treatment of a ruptured lateral sacral artery aneurysm presenting as a spinal epidural hematoma. Design Case report and literature review. Setting University teaching hospital, neurovascular center. Participant A man with a history of renal allograft who presented with sudden onset low back pain. Intervention The patient underwent emergent decompressive surgery, diagnostic angiogram and endovascular embolization. Main outcome measure Obliteration of aneurysm and restoration of neurological function. Results Surgery resulted in decompression of the cauda equina. The patient9s aneurysm was endovascularly obliterated. There was complete restoration of neurological function. Conclusion Lateral sacral artery aneurysm formation and rupture is a rare cause of epidural hemorrhage and one described only in patients who have undergone renal transplantation. It may be caused by high flow from transpelvic collaterals between both internal iliac arteries. Treatment includes endovascular obliteration and may necessitate operative decompression in the setting of neurological compromise.

✓ Although the use of carotid artery stents is increasing, the management of recurrent stenosis after their placement is undefined. The authors report on a patient who underwent two left carotid endarterectomies followed by left carotid angioplasty and stent placement for recurrent stenosis. A third symptomatic recurrence was subsequently managed by placement of a saphenous vein interposition graft from the common carotid artery to the distal cervical internal carotid artery. The patient remained without hemispheric or retinal ischemia at his 5-month follow-up visit. Interposition grafting should be considered as a treatment option for carotid restenosis after initial endarterectomy and stent placement.

Calcified lesions described within the neural axis are classified as either an ossification of the posterior longitudinal ligament, diffuse idiopathic skeletal hyperostosis, or ossification of the ligamentum flavum. We aim to describe a unique pathologic entity: the giant thoracic osteophyte. We identified four patients who were surgically treated at the Massachusetts General Hospital from 2006 to 2012 with unusual calcified lesions in the ventral aspect of the spinal canal. In order to differentiate giant thoracic osteophytes from calcified extruded disc material, disc volumetrics were performed on actual and simulated disc spaces. All patients underwent operative resection of the calcific lesion as they had signs and/or symptoms of spinal cord compression. The lesions were found to be isolated, large calcific masses that originated from the posterior aspect of adjacent thoracic vertebral bodies. Pathological examination was negative for tumor. Adjacent disc volumes were not significantly different from the index disc (p=0.91). A simulated calculation hypothesizing that the calcific mass was extruded disc material demonstrated a significant difference (p=0.01), making this scenario unlikely. In conclusion, giant thoracic osteophyte is a unique and rare entity that can be found in the thoracic spine. The central tenant of surgical treatment is resection to relieve spinal cord compression.

Neurosurgical patients are at a high risk for infectious sequelae following operations. For neurosurgery in particular, the risk of surgical site infection has a unique implication given the proximity of the CSF and the CNS. Patient factors contribute to some degree; for example, cancer and trauma are often associated with impaired nutritional status, known risk factors for infection. Additionally, care-based factors for infection must also be considered, such as the length of surgery, the administration of steroids, and tissue devascularization (such as a craniotomy bone flap). When postoperative infection does occur, attention is commonly focused on potential lapses in surgical “sterility.” Evidence suggests that the surgical field is not free of microorganisms. The authors propose a paradigm shift in the nomenclature of the surgical field from “sterile” to “clean.” Continued efforts aimed at optimizing immune capacity and host defenses to combat potential infection are warranted.

Incidental vertebral lesions on imaging of the spine are commonly encountered in clinical practice. Contributing factors include the aging population, the increasing prevalence of back pain, and increased usage of MR imaging. Additionally, refinements in CT and MR imaging have increased the number of demonstrable lesions. The management of incidental findings varies among practitioners and commonly depends more on practice style than on data or guidelines. In this article we review incidental findings within the vertebral column and review management of these lesions, based on available Class III data.

Isolated bilateral abducens (sixth) nerve palsy is rare in the setting of trauma. To date, most cases have been reported in patients who sustain cranial fractures or have other acute intracranial pathologies, including acute hemorrhage. We describe the case of a 41-year-old man who presented with bilateral abducens nerve palsy in the setting of acute head trauma without evidence of cranial fractures or other acute intracranial pathology. Six months after the initial injury, he regained bilateral function of his abducens nerves with intact extraocular muscle movements. Full recovery is the natural history in the majority of traumatic abducens nerve palsies, and this is an important consideration when counseling patients with such injuries.

Iatrogenic injury to the vertebral artery during posterior cervical fusion is a rare and potentially disastrous complication. Differentiating arterial from brisk venous bleeding would be ideal to assist in the intra-operative management. Definitive angiography is typically not feasible during most routine spine surgery.We describe the case of a patient undergoing an occipitocervical fusion, where brisk bleeding was encountered during dissection of the CB lateral mass. While the dissection was thought to be superficial to critical structures, the nature of the hemorrhage could not be definitely determined by visual inspection by two senior surgeons. The hemorrhage did not readily cease with standard maneuvers such as, the application of various hemostatic agents. Simultaneous blood gas analysis was performed on samples obtained from the patient's radial artery and from the hemorrhage in the operative bed. Comparative analysis concluded that the bleeding encountered in the surgical field was venous in nature.Blood gas analysis can be a useful adjunct in determining the nature of hemorrhage from vascular structures in spine surgery when visual inspection is indeterminate.

Disability secondary to disorders of the spine is a significant problem worldwide. In the USA, there has been a recent surge in the costs associated with caring for spinal pathology; from 1997 to 2005, there was a growth of 65% in healthcare expenditures on spinal disease, totalling $86 billion in 2005. Increasingly, there has been media and public scrutiny over the rapid rise in the volume of procedures with spinal instrumentation; some have suggested that this rise has been fuelled by non-medical drivers such as the financial incentives involved with the use of instrumentation; others suggest that innovation in spine technology and devices has led to improved options for the treatment of spine pathology.In this context, we conducted a review of the literature to assess the use of instrumentation in lumbar procedures and its relationship to successful fusion and patient outcome. Our review suggests that there is data supporting the thesis that lumbar instrumentation improves rates of fusion. However, there is no consistent correlation between increased rates of fusion and improved patient outcomes.

Spine injury resulting from migration of previously implanted appendicular skeleton fixation hardware is rare. We present a 41-year-old man who had Steinmann fixation pins placed for a left clavicular fracture 2 years prior. He presented with a burning sensation over his biceps bilaterally and numbness over the left anterior chest and abdomen following a significant blunt traumatic injury. A CT scan revealed migration of a fractured Steinmann pin entering the left C8 neural foramen, traversing anterior to the spinal cord. The patient underwent a left C7 hemilaminectomy, foraminal decompression, and first rib resection to identify the extraforaminal portion of the pin and remove it under direct vision. He recovered uneventfully. We conclude that a principle of safe surgical removal includes adequate exposure to allow for direct visualization of the pin and neural structures. We review the evaluation and management strategies of this unusual condition.

Bone graft volume decreases postoperatively without known etiology. We sought to determine the bone graft volume over time in 15 consecutive patients undergoing a single-level, instrumented, posterolateral lumbar fusion for degeneration causing mechanical pain or spondylolisthesis, and to identify factors associated with bone graft resorption. Following Institutional Review Board approval, a retrospective analysis was performed. Immediate and 3-month postoperative lumbar spine CT scans were imported into imaging software for volumetric analysis. We found that the 15 patients averaged approximately 11% graft volume loss at 3 months postoperatively. All patients exhibited volumetric graft loss on each side (range, 0.3-45%). A paired t-test revealed that immediate postoperative graft volume on a patient's left or right did not reflect graft volume on that side 3 months postoperatively (p=0.0008). Gender, age, history of prior operation, history of regular exercise, body mass index, level fused, operative time, initial graft volume, and laterality did not influence percentage volumetric loss (p=0.1-0.5). Interestingly, people who smoked cigarettes (range, 10-40 pack-years) exhibited 27% graft loss, compared to 7% in those who did not (Spearman p=0.009 graft loss versus pack-years smoked). We concluded that bone graft exhibited resorption 3 months postoperatively on both sides of all patients in this series, and that smoking was significantly associated with increased bone graft resorption.

BACKGROUND: Cervical spondylotic myelopathy (CSM) is the most common cause of spinal cord dysfunction. OBJECTIVE: To determine the feasibility of a randomized clinical trial comparing the clinical effectiveness and costs of ventral vs dorsal decompression with fusion surgery for treating CSM. METHODS: A nonrandomized, prospective, clinical pilot trial was conducted. Patients ages 40 to 85 years with degenerative CSM were enrolled at 7 sites over 2 years (2007-2009). Outcome assessments were obtained preoperatively and at 3 months, 6 months, and 1 year postoperatively. A hospital-based economic analysis used costs derived from hospital charges and Medicare cost-to-charge ratios. RESULTS: The pilot study enrolled 50 patients. Twenty-eight were treated with ventral fusion surgery and 22 with dorsal fusion surgery. The average age was 61.6 years. Baseline demographics and health-related quality of life (HR-QOL) scores were comparable between groups; however, dorsal surgery patients had significantly more severe myelopathy (P < .01). Comprehensive 1-year follow-up was obtained in 46 of 50 patients (92%). Greater HR-QOL improvement (Short-Form 36 Physical Component Summary) was observed after ventral surgery (P = .05). The complication rate (16.6% overall) was comparable between groups. Significant improvement in the modified Japanese Orthopedic Association scale score was observed in both groups (P < .01). Dorsal fusion surgery had significantly greater mean hospital costs ($29 465 vs $19 245 ; P < .01) and longer average length of hospital stay (4.0 vs 2.6 days; P < .01) compared with ventral fusion surgery. CONCLUSION: Surgery for treating CSM was followed by significant improvement in disease-specific symptoms and in HR-QOL. Greater improvement in HR-QOL was observed after ventral surgery. Dorsal fusion surgery was associated with longer length of hospital stay and higher hospital costs. The pilot study demonstrated feasibility for a larger randomized clinical trial.

BACKGROUND: Herniated intervertebral discs can result in pain and neurological compromise. Treatment for this condition is categorized as surgical or non-surgical. We sought to identify trends in inpatient surgical management of herniated intervertebral discs using a national database. METHODS: Patient discharges identified with a principal procedure relating to laminectomy for excision of herniated intervertebral disc were selected from the Nationwide Inpatient Sample (Healthcare Cost and Utilization Project - Agency for Healthcare Research and Quality, Rockville, MD), under the auspices of a data user agreement. These surgical patients did not undergo instrumented fusion. To account for the Nationwide Inpatient Sample weighting schema, design-adjusted analyses were used. The estimates of standard errors were calculated using SUDAAN software (Research Triangle International, NC, USA). This software is based on the International Classification of Diseases, 9(th) Revision, Clinical Modification (ICD-9-CM); a uniform and standardized coding system. RESULTS: Using International Classification of Disease 9(th) Revision clinical modifier (ICD-9 CM) procedure code 80.51, we were able to identify disc excision, in part or whole, by laminotomy or hemilaminectomy. The incidence of laminectomy for the excision of herniated intervertebral disc has decreased dramatically from 1993 where 266,152 cases were reported [CI = 22,342]. In 2007, only 123,398 cases were identified [CI = 12,438]. The average length of stay in 1993 was 4 days [CI = 0.17], and in 2007 it decreased to just 2 days [CI = 0.17]. Both these comparisons were significantly different at P < 0.001. The average inflation adjusted (2007 buying power) charge of the procedure in 1993 was 14,790.87 USD [CI = 916.85]. This value rose in 2007 to 24,639 USD [CI = 1,485.51]. This difference was significant at P < 0.001. CONCLUSIONS: National estimates indicate that the incidence of inpatient laminectomy for the excision of herniated intervertebral disc has decreased significantly. This trend is multifactorial and is likely related to developments in outcomes research, the growing popularity of alternative procedures (intervertebral instrumented fusion), and transition to an ambulatory setting of surgical care.

A 75-year-old woman with a history of stage IV metastatic melanoma underwent treatment with the CTLA-4 blocking agent Ipilimumab. She presented 2 months after initiating treatment with a severe headache. Laboratories were consistent with severe hyponatremia. MRI of the brain revealed enlargement of the pituitary gland, enhancement of the infundibulum, and an enhancing, centrally necrotic foci in the anterior pituitary. Based on the clinical and radiographic findings, she was diagnosed with treatment-related syndrome of inappropriate antidiuretic hormone secretion (SIADH). Effective treatment consisted of fluid restriction, hyperosmolar therapy, and steroids.

We report a 92-year-old female with ankylosing spondylitis who suffered a non-displaced cervical fracture of the C4 vertebral body as the result of a mechanical fall. A rigid cervical collar was used to maintain stability. The patient later went on to develop upper airway obstruction as a result of fracture displacement. She was emergently intubated for airway protection. To our knowledge, this is the first report of interval, acute onset upper airway obstruction caused by cervical instability following trauma and fracture in a patient with ankylosing spondylitis. This example highlights one of the potential complications of rigid cervical collar immobilization in patients with spinal instability.

Approximately 50 to 70% of all cancer patients ultimately develop skeletal metastases, and the spine is the most common site of metastatic deposition. Most patients with spinal metastases are treated nonsurgically, commonly with radiation therapy, chemotherapy, radiopharmaceutical therapy, hormonal therapy, and antiresorptive therapy with bisphosphonates and analgesics (1,2). Usually, surgery is considered only for patients with intractable pain, neurological compromise, and overt or impending instability. The goals of spinal tumor surgery are to decompress the spinal cord and nerve roots, stabilize the spine, alleviate pain, and, in some cases, establish a diagnosis. Occasionally, the goal of surgery for a patient with a primary neoplasm of the spine is to effect a cure.

Despite its reduced use since the advent of magnetic resonance imaging, the high cervical myelogram remains a common diagnostic test in the evaluation of patients whose symptoms suggest cervical stenosis. We report a case of subarachnoid hematoma, hydrocephalus, and aseptic meningitis after a high cervical myelogram. A 52-year-old woman presented with headache, slurred speech, worsened neck pain and stiffness, and diffuse extremity weakness leading to gait instability beginning several hours after a cervical myelogram. Computed tomography (CT) scan revealed a C1-C2 hematoma below the dura, blood in the fourth and lateral ventricles, and hydrocephalus. An external ventricular drain was placed, and cerebrospinal fluid profile was consistent with aseptic meningitis. A suboccipital craniectomy and C1-C2 laminectomies were performed, followed by a C1-C2 durotomy, which revealed a large subarachnoid blood clot in the region of the cisterna magna extending down to the upper aspect of C2, which was evacuated by incising the arachnoid. In the midline at C1, an active source of intramedullary arterial bleeding on the dorsal surface of the spinal cord was coagulated. Spinal subarachnoid hematoma is a rare complication of high cervical myelogram. The extension of blood into the ventricular system with associated hydrocephalus has never been previously reported after myelography. Thus, severe persistent pain after cervical myelography should be evaluated by CT scans of the brain and cervical spine.

Earlier studies suggested that while after spinal cord lesions and transplants at birth, the transplants serve both as a bridge and as a relay to restore supraspinal input caudal to the injury (Bregman, 1994), after injury in the adult the spinal cord transplants serve as a relay, but not as a bridge. We show here, that after complete spinal cord transection in adult rats, delayed spinal cord transplants and exogenous neurotrophic factors, the transplants can also serve as a bridge to restore supraspinal input (Fig. 9). We demonstrate here that when the delivery of transplants and neurotrophins are delayed until 2 weeks after spinal cord transection, the amount of axonal growth and the amount of recovery of function are dramatically increased. Under these conditions, both supraspinal and propriospinal projections to the host spinal cord caudal to the transection are reestablished. The growth of supraspinal axons across the transplant and back into the host spinal cord caudal to the lesion was dependent upon the presence of exogenous neurotrophic support. Without the neurotrophins, only propriospinal axons were able to re-establish connections across the transplant. Studies using peripheral nerve or Schwann cell grafts have shown that some anatomical connectivity can be restored across the injury site, particularly under the influence of neurotrophins (Xu et al., 1995a,b; Cheng et al., 1996; Ye and Houle, 1997). Without neurotrophin treatment, brainstem axons do not enter [figure: see text] the graft (Xu et al., 1995a,b; Cheng et al., 1996; Ye and Houle, 1997). Similarly, cells genetically modified to secrete neurotrophins and transplanted into the spinal cord influence the axonal growth of specific populations of spinally projecting neurons (Tuszynski et al., 1996, 1997; Grill et al., 1997; Blesch and Tuszynski, 1997). Taken together, these studies support a role for neurotrophic factors in the repair of the mature CNS. The regrowth of supraspinal and propriospinal input across the transection site was associated with consistent improvements in hindlimb locomotor function. Animals performed alternating and reciprocal hindlimb stepping with plantar foot contact to the treadmill or stair during ascension. Furthermore, they acquired hindlimb weight support and demonstrated appropriate postural control for balance and equilibrium of all four limbs. After spinal cord injury in the adult, the circuitry underlying rhythmic alternating stepping movements is still present within the spinal cord caudal to the lesion, but is now devoid of supraspinal control. We show here that restoring even relatively small amounts of input allows supraspinal neurons to access the spinal cord circuitry. Removing the re-established supraspinal input after recovery (by retransection rostral to the transplant) abolished the recovery and abolished the serotonergic fibers within the transplant and spinal cord caudal to the transplant. This suggests that at least some of the recovery observed is due to re-establishing supraspinal input across the transplant, rather than a diffuse influence of the transplant on motor recovery. It is unlikely, however, that the greater recovery of function in animals that received delayed transplant and neurotrophins is due solely to the restoration of supraspinal input. Recent work by Ribotta et al. (2000) suggests that segmental plasticity within the spinal cord contributes to weight support and bilateral foot placement after spinal cord transection. This recovery of function occurs after transplants of fetal raphe cells into the adult spinal cord transected at T11. Recovery of function appears to require innervation of the L1-L2 segments with serotonergic fibers, and importantly, animals require external stimulation (tail pinch) to elicit the behavior. In the current study, animals with transection only did not develop stepping overground or on the treadmill without tail pinch, although the transplant and neurotrophin-treated groups did so without external stimuli. Therefore both reorganization of the segmental circuitry and partial restoration of supraspinal input presumably interact to yield the improvements in motor function observed. It is unlikely that the recovery of skilled forelimb movement observed can be mediated solely by reorganization of segmental spinal cord circuitry. We suggest that the restoration of supraspinal input contributes to the recovery observed. It is likely that after CNS injury, reorganization occurs both within the spinal cord and at supraspinal levels, and together contribute to the recovery of automatic and skilled forelimb function and of locomotion. In summary, the therapeutic intervention of tissue transplantation and exogenous neurotrophin support leads to improvements in supraspinal and propriospinal input across the transplant into the host caudal cord and a concomitant improvement in locomotor function. Paradoxically, delaying these interventions for several weeks after a spinal cord transection leads to dramatic improvements in recovery of function and a concomitant restoration of supraspinal input into the host caudal spinal cord. These findings suggest that opportunity for intervention after spinal cord injury may be far greater than originally envisioned, and that CNS neurons with long-standing injuries may be able to re-initiate growth leading to improvement in motor function.

Frontal sinus fractures are heterogeneous, and management of these fractures is often modified based on injury pattern and institutional experience. The optimal initial treatment of frontal sinus fractures is controversial. Treatment strategies are aimed at correcting cosmetic deformity, as well as at preventing delayed complications, including CSF fistulas, mucocele formation, and infection. Existing treatment options include observation, reconstruction, obliteration, cranialization, or a combination thereof. Modalities for treatment encompass both open surgical approaches and endoscopic techniques. In the absence of Class I data, the authors review the existing literature related to treatment strategies of frontal sinus fractures, particularly as they relate to CSF fistulas, to provide recommendations based on the best available evidence.