Methods: A case of catastrophic failure of conservative treatment for a type II odontoid fracture in an elderly patient is presented. The patient presented six years after initial diagnosis and treatment of the fracture in a collar, with an acute SCI due to progressive instability and stenosis.

Results: Cervical Spine imaging revealed a posterior displaced type II odontoid fracture with sclerotic margins, severe stenosis at the level of C2-3 with cord compression and intrinsic cord signal abnormality.

Conclusion: Type II odontoid fractures have a high rate of non-union with non-surgical treatment and can result in cervical instability and spinal cord injury. Treatment options in the increasing elderly population with cervical spin trauma should include close observation in rigid immobilization as well as potential surgical fixation.

We report that case of an 86-year-old female who described 15-years of sharp, stabbing pain that radiated down the distribution of the second and third divisions of her right trigeminal nerve. She described two trigger points, one on her right cheek and a second intra-oral trigger. Her symptoms were often triggered by eating and she had begun to loose weight secondary to pain. She denied having any baseline pain between the episodes of lancinating pain. She denied any contralateral pain, dysasthetic pain or any burning pain sensation. She denied any pain along the first trigeminal division and did not recently undergo any dental work of have a history of dental carries. Her symptoms had been initially well controlled with Carbamazepine 200 mg BID, but had recently worsened despite increasing the dosage to 600 mg BID when she started to develop medication-related side effects. Her past medical history was unremarkable, an on examination she was neurologically intact. Her brain magnetic resonance imaging (MRI) showed no masses or gross abnormalities, and she was diagnosed with trigeminal neuralgia.

Methods: A unique case of a pedestrian struck by a motor vehicle that presented with acute paraplegia after an endovascular stent placement for a traumatic thoracic aorta dissection. The patient had no significant motor function in the lower extremeties, but full preservation of all sensory modalities. Initial admission computed tomography (CT) imaging was negative for intracranial trauma, but noted an acute cranial fracture; no spinal trauma was identified.

Results: The patient had a lumbar drain placed to maximize spinal perfusion pressures and was immediately evaluated with magnetic resonance imaging (MRI) of the neural axis. Acute bilateral posterior frontal contusions were identified on brain imaging, which were not present on pre-procedural CT head. No spinal cord injury or ischemia was seen on spinal imaging. The patient recovered and regained use of his lower extremeties following a short rehab stay.

Conclusions: In the setting of multi-system trauma, a high level of suspicion should exist for alternative etiologies of neurologic injuries. Thorough neurologic examinations and imaging assessments of the nervous system should be conducted to avoid misdiagnosis and improper management of occult injuries. This is the first reported case of acute paraplegia due to vertex trauma which may be a rare mechanism of injury and/or under-recognized.

The advent of evidence-based medicine has resulted in higher quality journal manuscripts in numerous medical disciplines. However, the impact in the neurosurgical literature has not been reported.

Objective:

To quantify the impact of evidence-based medicine on the quality of articles published in the Neurosurgery literature.

Methods:

Articles published in the journal Neurosurgery (founded in 1977) were reviewed for 1978, 1988, 1998, and 2008. Each decade’s sample was classified as therapeutic, diagnostic and prognostic based on a published system for determining level of evidence.

Results:

438 articles were reviewed. Articles not considered included any published under the heading “Case Report” (automatically Level IV evidence) and articles which otherwise did not directly look at patient outcome (i.e, cadaver or animal studies). The rate of Level I studies held steady at 4.5-6.0%. Level II evidence increased steadily from no articles in 1978 to 40.6% in 2008. The increases in Level I and II article publications was statistically significant (p < 0.001). Concurrently, Level IV articles decreased in rate (81.8% in 1978 to 42.4% in 2008), while Level III articles remained fairly constant (9.8%–13.6%). The largest category of Level II studies was prognostic, and the largest category for both Level III and IV studies was therapeutic. Among study types, the most dramatic increase was in the rate of prognostic studies (15.8% to 43.6%). Only 1% of all articles were economic analyses.

Conclusion:

The quality of neurosurgical literature has progressively improved over the last several decades. It is unclear how much of that is due to expanded activity in randomized, clinical trials or other Level I evidence as no significant increases were observed in Level I articles during the study period (1978–2008). Much of the literature improvement may be explained by the increase in retrospective, prognostic studies as neurosurgeons take advantage of years of accumulated data. The lack of any articles on economic and decision analyses suggests that the neurosurgical community has not yet studied the effect of costs in detail.

Persistent elevation of intracranial pressure (ICP), if untreated, may lead to brain ischemia or lack of brain oxygen and even brain death.1-6,10 When standard treatments for elevated ICP are exhausted without any signs of improvement, decompressive craniectomy can be an effective alternative solution.7,19 Decompressive craniectomies (DC) have been used as a method of controlling intracranial pressure in patients with cerebral edema secondary to cerebral ischemia, subarachnoid hemorrhage (SAH), and traumatic brain injury (TBI), among others. 8-10 Several studies over the years have demonstrated the efficacy of this procedure.7-9,11,35,36 However, consensus is still lacking in the utility of DC as an effective first tier treatment for intractable intracranial pressure due to the rudimentary neurological outcome assessments, and the many complications associated with this procedure.11,12,59 There are a limited number of studies that have looked at complications secondary to the procedure itself.13-18 The majority of these studies only investigated the impact of this procedure in patients with traumatic brain injury. The purpose of this study is to investigate the rates of various complications associated with the decompressive craniectomy procedure in patients that did not suffer from traumatic brain injury, and to determine whether the same associations between preoperative parameters and development of complications can be made.

Introduction

We present an interesting case of a type-D carotid cavernous fistula (CCF) that closed spontaneously with a paradoxical worsening of the symptoms due to thrombosis of the superior ophthalmic vein (SOV). The authors also give directives for the management of these extremely rare cases.

Bevacizumab can produce significant decrease in contrast enhancement as early as 1 to 2 days after the beginning of treatment, and often results in radiologic response rates of 25% to 60%. However, it has been noted that rapid improvement in radiographic response is not directly correlated to decreased tumor burden or improved survival. Furthermore, there are significant adverse effects associated with this agent that must be considered when tailoring therapy. These topics and current studies evaluating the use of bevacizumab for high-grade gliomas are discussed.

As such, few reports exist on the use of MIS techniques in the cervical spine. Clearly, the anatomic constraints of the cervical spine are different, but they arguably lend themselves more amenable to MIS approaches. We present two cases in which five-level posterior cervical fusion was achieved using a tubular retractor specifically designed for the cervical spine.