An arachnoid web is a pathological formation of the arachnoid membrane. It is a rare phenomenon but is known to lead to syrinx formation in the spinal cord along with pain and neurological deficits. On imaging, the 'scalpel sign' is pathognomonic for an arachnoid web. The etiology of syrinx formation from an arachnoid web is currently unknown. This report documents the only two cases of arachnoid webs with an extensive syrinx in which a likely pathophysiologic mechanism is identified. Both cases presented with motor deficits. The patients had no history of trauma or infection. After extensive workup in both patients and observation of the scalpel sign an arachnoid web was suspected. In both cases, the patients were treated surgically after an arachnoid web was suspected. Intra-operative ultrasound visualized in both cases demonstrates a fenestration in the web that allowed passage of cerebrospinal fluid in a rostral-caudal direction due to a ball-valve effect.

BACKGROUND: After microvascular decompression (MVD) for hemifacial spasm (HFS), a minority of patients realize little to no relief of spasms. In some patients, the absence of relief of spasms results from incomplete or inadequate decompression of vascular compression of the facial nerve, and these patients represent excellent candidates for repeat MVD. However, in other patients, repeat MVD is not appropriate because adequate decompression and resolution of neurovascular compression, as determined by postoperative high-resolution MRI, was achieved with the initial operation. OBJECTIVE: To present a cohort of patients with a history of HFS refractory to MVD, with no evidence of neurovascular compression on postoperative MRI, who underwent facial nerve massage (FNM) in the posterior fossa in an attempt to relieve spasms. METHODS: Thirteen patients with a history of incomplete relief of spasms after technically adequate MVD surgery for hemifacial spasm underwent FNM. Immediate and long-term degree of spasm relief and complications after FNM were documented through in-person or telemedicine interview. RESULTS: At follow-up after FNM, 7 of 12 patients (58.3%) reported complete spasm relief (grade I), 2 of 12 patients (16.7%) reported >75% spasm relief (grade II), 0 patient (0%) reported >50% spasm relief (grade III), 3 of 12 (25.0%) patients reported <50% spasm relief (grade IV), and 1 patient was lost to follow-up. One patient experienced a delayed facial paresis, and another patient experienced high-frequency hearing loss. CONCLUSION: After FNM, durable and, at least, partial relief of spasms with a relatively low complication rate was observed in most patients with HFS with incomplete relief of spasms after technically adequate prior MVD.

BACKGROUND: Anterior cervical diskectomy and fusion(ACDF) is a standard surgical procedure used widely in the treatment of degenerative cervical spine conditions. Although the safety and effectiveness of single-level ACDF is well supported in the literature, reports of multilevel ACDF are sparse and present mixed results. There is concern for greater complications with increasing levels of fusion given the increased complexity, procedure duration, and invasiveness of multilevel ACDF. METHODS: In this retrospective review, we report complications data for 105 adult neurosurgical patients who underwent elective multilevel ACDF at a single institution by a single surgeon between 2004 and 2016. RESULTS: Fifty-four patients underwent 3-level ACDF Di patients underwent 4-level ACDF with a mean follow-up of 2.7 +/- 1.9 years. Although patients with 4-level fusion were more likely than those with 3-level fusion to have estimated blood loss >= 100 mL (P = 0.04), we found no significant differences in other peri- and postoperative complications, need for revision, and presence of symptoms at the time of last follow-up between groups. CONCLUSIONS: This study suggests that 4-level ACDF is necessarily associated with a greater number of or more severe complications than 3-level ACDF.

Background: There is extensive debate on the role of fixed pressure shunts in the adult population. Most studies assessing fixed pressure valves do not consider the potential for changes in technique and management of shunts. We sought to examine the natural history of fixed pressure. Methods: We conducted a retrospective chart review of 169 patients undergoing shunt placement by the senior author Daniel Wecht (DW). The etiology of shunt placement, shunt failure rates, and outcome data was assessed for each patient. Results: Overall, 126 patients underwent initial shunt placement. Thirty-three (26.2%) patients required at least one shunt revision during follow-up. The most common cause of first time revision was mechanical shunt malfunction (13, 39.4%), followed by infection (7, 21.2%), and shunt migration (6, 18.2%). Three patients (9.1%) required revision due to misplaced catheters. Underdrainage or overdrainage of shunts each resulted in revisions for 2 (6.1%) patients. The mean follow-up length was 28.1 ± 6.1 months. Conclusion: Fixed pressure shunts failed primarily because of shunt malfunction and occurred most commonly in patients developing hydrocephalus as a result of hemorrhage or normal pressure hydrocephalus (NPH). The overall failure rate between these two groups was proportionally equivalent. Both overdrainage or underdrainage were found to be rare indications for revision.

BACKGROUND:Studies have demonstrated that physicians are often unaware of prescription drug, laboratory, diagnostic, and surgical supply costs. OBJECTIVE:To investigate the effects of increased physician awareness on infection incidence and surgical device cost containment. METHODS:Within our institution, physicians were informed of individual, independently adjudicated, craniotomy and ventricular shunt infection incidence and rankings among peers, after which a protocol aimed at reducing skin bacterial burden was implemented for craniotomies. Physicians were also made aware of the costs for shunts and dural substitutes as well as available alternatives. RESULTS:The combined craniotomy and ventricular shunt infection incidence significantly decreased by 37.5% from 3.2% over May 2011 to April 2015 (132 infections/4137 procedures) to 2.1% over May 2015 to April 2016 (26 infections/1250 procedures; P = .041). The average annual cost savings was $234 175 from preventing postoperative craniotomy infections and $121 125 from preventing postoperative ventricular shunt infections. Total supply costs of ventricular shunts significantly decreased by 26% from $2345 per procedure in fiscal year 2015 to $1747 per procedure in fiscal year 2016 (P < .001). Total supply cost of dural grafts significantly decreased by 54% from $191 per procedure in fiscal year 2015 to $88 per procedure in fiscal year 2016 (P < .001). In total, all initiatives in this study resulted in an estimated annual savings of $567 062. CONCLUSION:Physician awareness of outcomes and costs resulted in increasing the quality of care, while at the same time reducing the cost.

Stroke is a devastating complication after intracranial aneurysm clipping. Understanding the risk factors that prognosticate perioperative stroke may help to identify patients that would benefit from neuroprotective therapy. This study assesses patient-specific independent predictors of perioperative stroke in relation to surgical aneurysm clipping. Additionally, this study evaluates the postoperative complications of stroke. We performed a retrospective chart review of 437 patients with ruptured and unruptured intracranial aneurysms, which underwent surgical clipping from 2006 to 2013. Multivariate logistical regression was utilized to assess the effect of age, race, gender, subarachnoid hemorrhage, Hunt and Hess (H/H) grade, aneurysm location, and intraoperative somatosensory evoked potentials (SSEPs) changes on the frequency of perioperative stroke. Thirty-five (8.0%) patients developed a stroke within 24 h postoperatively. Patients with significant intraoperative SSEP changes were 7.33 (95% confidence interval [CI]: 3.51-15.31) times more likely to develop perioperative strokes. In patients who presented with H/H grade 5, the odds ratio for developing perioperative stroke was 9.21 (95% CI: 1.28-66.13) respectively. In the absence of aneurysm rupture, patients presenting with new-onset stroke were more likely to suffer postoperative complications, stay in the intensive care unit longer, and be discharged to in-patient rehabilitation compared to patients without new-onset stroke. This study suggests that severity of subarachnoid hemorrhage based on the patient's clinical condition increases the risk of perioperative stroke in patients with surgical aneurysm clipping. SSEP changes and high-grade H/H scores can serve as independent predictors of perioperative stroke, with the latter having the greatest predictive value. (C) 2017 Elsevier Ltd. All rights reserved.

INTRODUCTION: Several studies in the literature have demonstrated that physicians are often unaware of prescription drug, laboratory, diagnostic, and surgical supply costs. Other studies have suggested that increased physician awareness of supply cost contributes to reduced overall cost. In this study, we investigated the effects of such increased awareness on neurosurgical cost containment. METHODS: Within the Department of Neurological Surgery at the University of Pittsburgh Medical Center, physicians were informed of the prices of various ventricular shunt brands, such as the more expensive Medtronic shunts vs the more economic fixed Integra shunt. In addition, the costs of DuraGen vs alternative materials used during craniotomy such as Gelfoam were reviewed with faculty neurosurgeons. RESULTS: The total supply cost of ventricular shunts in fiscal year 2015 was $383 026 and the estimated total supply cost of shunts in fiscal year 2016, based on fiscal year 2015 volume, was $273 553. Supply costs of ventricular shunts decreased from $1916 per procedure in fiscal year 2015 to $1375 per procedure in fiscal year 2016. The total supply cost of DuraGen in fiscal year 2015 was $344 689 and the estimated total supply cost of DuraGen in fiscal year 2016, based on fiscal year 2015 volume, was $195 021. Supply costs of DuraGen decreased from $279 per procedure in fiscal year 2015 to $159 per procedure in fiscal year 2016. CONCLUSION: Physician awareness of surgical supply costs within our department of neurosurgery successfully resulted in significant cost savings.

Ice hockey is an aggressive and fast-paced sport which has a high risk of injury, concussions in particular. Although serious head injury has been recognized for nearly 50 years, an increase in mainstream media attention in recent years has led to unprecedented public awareness. As a result, the National Hockey League (NHL) and other professional leagues around the world have initiated concussion protocols in order to better prevent, recognize, and treat concussions. With over 1,000,000 youth hockey participants in Canada and the USA combined, concussion is an issue that reaches beyond the professional level. In this report we review the incidence, evaluation, treatment, return-to-play protocol, and prevention efforts related to concussion in ice hockey.

Object The use of commercially available topical hemostatic adjuncts has increased the safety profile of surgery as a whole. Cranial surgery has also benefited from the development of numerous agents designed to permit more rapid achievement of hemostasis. Flowable topical hemostatic agents applied via syringe injection are now commonly employed in many neurosurgical procedures, including cranial surgery. Intravascular use of these strongly thrombogenic agents is contraindicated, but in certain settings, inadvertent intravascular administration can occur, resulting in vascular occlusion, thrombosis, and potential dissemination. To date, there have no reports detailing the presence and incidence of this complication. Methods The authors conducted a retrospective review of all cranial surgeries performed at Presbyterian University Hospital by members of the University of Pittsburgh Medical Center's Department of Neurological Surgery between 2007 and 2009. Cases complicated by vascular occlusion due to inadvertent intravascular administration of flowable topical hemostatic matrix (FTHM) were identified and analyzed. Results Iatrogenic vascular occlusion induced by FTHM was identified in 5 (0.1%) of 3969 cranial surgery cases. None of these events occurred in 3318 supratentorial cases, whereas 5 cases of cerebral venous sinus occlusion occurred in 651 infratentorial cases (0.8%). The risk of accidental vessel occlusion was significantly associated with infratentorial surgery, and all events occurred in the transverse and/or sigmoid sinus. No episodes of inadvertent vascular occlusion occurred during endoscopic surgery. No cases of arterial occlusion were identified. Of the 5 patients with FTHM-related cerebral venous sinus occlusion, none developed long-term neurological sequelae referable to the event. Conclusions Inadvertent intravascular administration of FTHM is a rare complication associated with cranial surgery that occurs most commonly during infratentorial procedures around the transverse and/or sigmoid sinuses. Modifications in the choice of when to use an FTHM and the method of application may help prevent accidental venous sinus administration.

A dural arterio-venous fistula (DAVF) is an abnormal communication between an artery and a vein contained within the two layers of the dura. The etiology is still debated but is likely thrombosis within a dural sinus. The high venous pressure produced by the fistula is responsible for the presenting symptoms which vary according to its location: fistulas in the transverse/sigmoid sinus junction may present with pulsatile tinnitus while DAVF in the cavernous sinus might manifest with eye symptoms like chemosis, proptosis or decreased vision. Independently from their location, DAVFs can also present with headache, seizures or intracranial hemorrhage. They need to be treated urgently if there is radiological evidence of cortical venous retrograde flow, signifying an arterial type of pressure within weak walled cortical veins and therefore higher risk of hemorrhage. There are three ways of treating a DAVF: surgery, endovascular embolization or radiosurgery. From published series of DAVFs in the anterior cranial fossa, surgical ligation or excision of the fistula through a craniotomy is considered the preferred treatment option. Endovascular embolization is possible by catheterizing directly the ophthalmic artery, however this needs to be sufficiently dilated and the risk of visual compromise from embolic occlusion of the central retinal artery needs to be taken into consideration. We report the first case of an unruptured dural arteriovenous fistula (DAVF) treated via a fully endoscopic endonasal approach. The patient, a 58-year-old man, presented with sudden onset of retro-orbital pain and had an MRI scan raising the possibility of an aneurysm. For this reason he underwent a cerebral angiogram which showed instead a DAVF next to the crista galli, (figure 1) The fistula was fed on the left by the anterior ethmoidal artery, a branch of the ophthalmic artery and on the right by ethmoidal branches of the internal maxillary artery. The venous drainage was to the superior sagittal sinus predominantly via an asymmetrically prominent superficial cortical vein. The endonasal approach we used to treat this DAVF is similar to what we employ for pathologies of the anterior cranial fossa such as meningiomas, esthesioneuroblastomas or nasopharyngeal carcinomas and avoids a craniotomy. The procedure was performed under general anesthesia, utilizing image guidance and neurophysiological monitoring and required a team composed of an ENT and a neurosurgeon working side by side through both nostrils of the patient. The approach involved resecting the superior part of the nasal septum to provide wide exposure of the anterior skull base followed by removal of the most anterior portion of the cribriform plates and crista galli. The anterior ethmoidal arteries were ligated in order to “cut off” the arterial supply to the fistula. After a wide exposure of the DAVF and surrounding healthy dura, the major draining vein was finally coagulated (figure 2) allowing for complete excision of the area of dura containing the fistula. The patient tolerated the procedure well and the retro-orbital pain improved immediately following the operation, which was completed without complication. He was able to be discharged the next day after surgery. The main advantages of this approach when compared to an open one through a craniotomy are the use of a safe anatomical corridor leading directly to the arterial feeders of the fistula, the absence of brain retraction and a better cosmetic result without visible external scars, not to mention shorter hospital stay. We would like to stress the fact that this type of approach requires the surgeons to be familiar with the endoscopic anatomy of this region, ideally having developed the necessary skills after performing a certain number of procedures within multidisciplinary team composed of an ENT and a neurosurgeon. We conclude that this is a safe and feasible new option in the armamentarium of treatments available for DAVFs in the anterior cranial fossa. • (Fig. 1) Digital subtraction angiogram, sagittal view, left carotid artery injection: blush is visible at the end of the ophthalmic artery with contrast filling the superior sagittal sinus during arterial phase (arrow); (Fig. 2) Endoscopic endonasal view of the falx cerebri divided and ligated. The enlarged cortical vein is visualized before being cauterized and divided. 1

Background: Recent research showed 82% of 233 retired National Football League players under age 50 had abnormal narrowing and blockages in arteries compared to the general population of the same age. It has been suggested that early screening and intervention in this at-risk population be a priority. Hypothesis: Omega-3 essential fatty acid has been shown to improve cardiovascular lipid risk factors and should improve lipid profiles in professional football players to help reduce their recently shown accelerated risk of developing cardiovascular disease. Methods: A total of 36 active national football players were randomly assigned to 2 groups: the first group (n = 20) was provided fish oil capsules (2200 mg of mixed docosahexaenoic acid and eicosapentaenoic acid and 360 mg of other omega-3s), and the second group (n = 16) served as controls during a 60-day trial. Vertical Auto Profile cholesterol tests directly measuring serum low-density lipoprotein, high-density lipoprotein, and other subfractions were performed. Compliance, side effects, and seafood consumption data were also collected. Baseline, midpoint, and poststudy blood work measured plasma docosahexaenoic acid and eicosapentaenoic acid. Results: Treatment increased high-density lipoprotein (average percent change: +25.96, control +14.16), decreased triglycerides treatment (–8.06, control +43.98), very low-density lipoprotein treatment (–13.98, control +23.18), intermediate density lipoprotein (–27.58, control +12.07), remnant lipoproteins (–23.86, control +8.33), and very low-density lipoprotein-3 (–17.10, control +7.77). An average increase of 106.67% for docosahexaenoic acid and 365.82% for eicosapentaenoic acid compared to control was also shown. Conclusion: Omega-3 supplementation significantly improved the lipid profile of active players randomized to treatment. These results suggest that fish oil supplementation is an effective way to increase eicosapentaenoic acid and docosahexaenoic acid levels in plasma and should be considered as a method to improve modifiable cardiovascular risk lipid factors in professional football players. Clinical Relevance: A prospective study examining the effects of 60 days of a highly purified fish oil supplementation in professional football players.

BACKGROUND CONTEXT: Multilevel fusions, the use of allograft bone, and smoking have been associated with an increased risk of nonunion after anterior cervical discectomy and fusion (ACDF) procedures. Pulsed electromagnetic field (PEMF) stimulation has been shown to increase arthrodesis rates after lumbar spine fusion surgery, but there are minimal data concerning the effect of PEMF stimulation on cervical spine fusion.PURPOSE: To determine the efficacy and safety of PEMF stimulation as an adjunct to arthrodesis after ACDF in patients with potential risk factors for nonunion.STUDY DESIGN: A randomized, controlled, prospective multicenter clinical trial.PATIENT SAMPLE: Three hundred and twenty-three patients with radiographic evidence (computed tomography-myelogram [CT-myelo] or magnetic resonance imaging [MRI) of a compressed cervical nerve root and symptomatic radiculopathy appropriate to the compressed root that had failed to respond to nonoperative management were enrolled in the study. The patients were either smokers (more than one pack per day) and/or were undergoing multilevel fusions. All patients underwent ACDF using the Smith-Robinson technique. Allograft bone and an anterior cervical plate were used in all cases.OUTCOME MEASURES: Measurements were obtained preoperatively and at each postoperative interval and included neurologic assessment, visual analog scale (VAS) scores for shoulder/arm pain at rest and with activity, SF-12 scores, the neck disability index (NDI), and radiographs (anteroposterior, lateral, and flexion-extension views). Two orthopedic surgeons not otherwise affiliated with the study and blinded to treatment group evaluated the radiographs, as did a blinded radiologist. Adverse events were reported by all patients throughout the stud), to determine device safety. METHODS: Patients were randomly assigned to one of two groups: those receiving PEMF stimulation after surgery (PEMF group, 163 patients) and those not receiving PEMF stimulation (control group, 160 patients). Postoperative care was otherwise identical. Follow-up was carried out at 1, 2, 3, 6, and 12 months postoperatively.RESULTS: The PEMF and control groups were comparable with regard to age, gender, race, past medical history, smoking status, and litigation status. Both groups were also comparable in terms of baseline diagnosis (herniated disc, spondylosis, or both) and number of levels operated (one, two, three, or four). At 6 months postoperatively, the PEMF group had a significantly higher fusion rate than the control group (83.6% vs. 68.6%, p=.0065). At 12 months after surgery, the stimulated group had a fusion rate of 92.8% compared with 86.7% for the control group (p=.1129). There were no significant differences between the PEMF and control groups with regard to VAS pain scores, NDI, or SF-12 scores at 6 or 12 months. No significant differences were found in the incidence of adverse events in the groups.CONCLUSIONS: This is the first randomized, controlled trial that analyzes the effects of PEMF stimulation on cervical spine fusion. PEMF stimulation significantly improved the fusion rate at 6 months postoperatively in patients undergoing ACDF with an allograft and an anterior cervical plate, the eligibility criteria being patients who were smokers or had undergone multilevel cervical fusion. At 12 months postoperatively, however, the fusion rate for PEMF patients was not significantly different from that of the control group. There were no differences in the incidence of adverse events in the two groups, indicating that the use of PEMF stimulation is safe in this clinical setting. (C) 2008 Elsevier Inc. All rights reserved.

OBJECT:Neurapraxia, transient posttraumatic paralysis of the motor and/or sensory tracts in the spinal cord, may be a career-ending event in an athlete. Management, rehabilitation, and return-to-play decisions remain controversial.METHODS:Five elite football players were evaluated after experiencing episodes of neurapraxia. All patients experienced bilateral paresthesias--three in all four extremities and two in the upper extremities--lasting a few minutes to more than 24 hours. Transient motor deficits occurred in two individuals but caused no permanent sequelae. Neuroimaging confirmed the presence of herniated discs, focal cord compression, and no parenchymal changes in all cases. All patients underwent anterior cervical microdiscectomy and fusion, and cervical plates were placed in four. After aggressive rehabilitation and confirmation of fusion ranging from 9 weeks to 8 months postoperatively, the players were allowed to return to active play. Two of the players developed recurrent career-ending disc herniations, one above and the other below the fusion level. One player required repeated spinal cord decompression.CONCLUSIONS:Neurologically intact athletes with focal cord compression due to a single-level herniated disc may safely return to football after undergoing decompressive surgery and confirmation of fusion. It appears, however, that there may be an increased chance of repeated herniation above or below a fused level.

This chapter discusses the carotid cavernous fistulas (CCFs) and other cranial dural arteriovenous malformations (DAVMs). DAVMs are defined as arteriovenous shunts with dural arterial feeders and dural venous drainage. The optimal means of classifying these lesions includes a description of the region of dura affected and the nature of the venous drainage. The site of arteriovenous shunting in DAVMs is confined exclusively within the leaflets of the dura, and this is the primary feature that distinguishes this lesion from the more common pial arteriovenous malformation. DAVMs have been shown to develop after episodes of trauma. These lesions have been found at the site of direct injury and also at remote sites. DAVMs of the tentorial incisura are best approached subtemporally. With the use of irrigating bipolar electrocautery and titanium hemoclips, the pathological dural leaflet should be excised whenever possible. It is suggested that if excision is not possible, the pathological dural leaflet ought to be extensively coagulated and leptomeningeal arterialized venous drainage interrupted. It is found that stereotactic radiosurgery may be a viable treatment option for these DAVMs, especially in elderly or high risk patients.