Transoral digital reduction of complete anterior odontoid dislocation followed by fiducial-based navigated transcondylar screw fixation: illustrative case

BACKGROUND Posterior atlantoaxial dislocations (i.e., complete anterior odontoid dislocation) without C1 arch fractures are a rare hyperextension injury most often found in high-velocity trauma patients. Treatment options include either closed or open reduction and optional spinal fusion to address atlantoaxial instability due to ligamentous injury. OBSERVATIONS A 60-year-old male was struck while on his bicycle by a truck and sustained an odontoid dislocation without C1 arch fracture. Imaging findings additionally delineated a high suspicion for craniocervical instability. The patient had neurological issues due to both a head injury and ischemia secondary to an injured vertebral artery. He was stabilized and transferred to our facility for definitive neurosurgical care. LESSONS The patient underwent a successful transoral digital closed reduction and posterior occipital spinal fusion via a fiducial-based transcondylar, C1 lateral mass, C2 pedicle, and C3 lateral mass construct. This unique reduction technique has not been recorded in the literature before and avoided potential complications of overdistraction and the need for odontoidectomy. Furthermore, the use of bone fiducials for navigated screw fixation at the craniocervical junction is a novel technique and recommended particularly for placement of technically demanding transcondylar screws and C2 pedicle screws where pars anatomy is potentially unfavorable.

Minimally invasive endoscopic approach to perform complete coccygectomy in patients with chronic refractory coccydynia: illustrative case

BACKGROUND Coccydynia refers to debilitating pain in the coccygeal region of the spine. Treatment strategies range from conservative measures (e.g., ergonomic adaptations, physical therapy, nerve block injections) to partial or complete removal of the coccyx (coccygectomy). Because the surgical intervention is situated in a high-pressure location close to the anus, a possible complication is the formation of sacral pressure ulcers and infection at the incision site. OBSERVATIONS In this case report, the authors presented a minimally invasive, fully endoscopic approach to safely perform complete coccygectomy for treatment of refractory posttraumatic coccydynia. LESSONS Although this is a single case report, the authors hope that this novel endoscopic approach may achieve improved wound healing, reduced infection rates, and lower risk of penetration injury to retroperitoneal organs in patients requiring coccygectomy.

Paradoxical symptomatic cerebral blood flow decreases after combined revascularization surgery for patients with pediatric moyamoya disease: illustrative case

BACKGROUND Transient neurological deficits (TNDs) develop after cerebral revascularization in patients with moyamoya disease (MMD). The authors report a rare pediatric MMD case with extensive decreased cerebral blood flow (CBF) and prolonged TNDs after combined revascularization. OBSERVATIONS A 9-year-old boy presented with transient left upper limb weakness, and MMD was diagnosed. A right-sided combined surgery was performed. Two years after the surgery, frequent but transient facial (right-sided) and upper limb weakness appeared. The left internal carotid artery terminal stenosis had progressed. Therefore, a left combined revascularization was performed. The patient’s motor aphasia and right upper limb weakness persisted for approximately 10 days after surgery. Magnetic resonance angiography showed that the direct bypass was patent, but extensive decreases in left CBF were observed using single photon emission tomography. With adequate fluid therapy and blood pressure control, the neurological symptoms eventually disappeared, and CBF improved. LESSONS The environment of cerebral hemodynamics is heterogeneous after cerebral revascularization for MMD, and the exact mechanism of CBF decreases was not identified. TNDs are significantly associated with the onset of stroke during the early postoperative period. Therefore, appropriate treatment is desired after determining complex cerebral hemodynamics using CBF studies.

A red herring CVA with unexpected outcome: illustrative case

BACKGROUND Disruptions to the integrity of the inner table and trabeculae of the calvaria are rare phenomena. Increasingly rare is the phenomenon of herniation of brain parenchyma through the defects in the skull causing neurological deficit. Surgical intervention is commonly performed but is fraught with risk of brain tissue loss. OBSERVATIONS The authors present a case of a 78-year-old White male presenting with strokelike symptoms who was found to have an intradiploic encephalocele that was successfully treated with surgical intervention and neuroplastic reconstruction of the anatomical deficit. The patient had a marked recovery and had near-complete resolution of symptoms. LESSONS This notably rare phenomenon resolved with neurosurgical intervention, sparing the parenchyma, and provided the patient with perceivably normal contour of the head using a collaborative approach with neuroplastic intervention.

Critical care for concomitant severe traumatic brain injury and acute spinal cord injury in the polytrauma patient: illustrative case

BACKGROUND The occurrence of traumatic brain injury with spinal cord injury (SCI) in polytrauma patients is associated with significant morbidity. Clinicians face challenges from a decision-making and rehabilitative perspective. Management is complex and understudied. Treatment should be systematic beginning at the scene, focusing on airway resuscitation and hemodynamic stabilization, immobilization, and timely transport. Early operative interventions should be provided, followed by minimizing secondary pathophysiology. The authors present a case to delineate decision-making in the treatment of combined cranial and spinal trauma. OBSERVATIONS A 19-year-old man presented as a level I trauma patient after falling 30 feet as the result of scaffolding collapse. The patient was unresponsive and was intubated; he had an initial Glasgow Coma Scale score of 4. Computed tomography revealed multicompartmental bleeding and herniation, for which supra- and infratentorial decompressive craniectomies were performed. The patient also suffered from thoracic SCI that resulted in complete paraplegia. Multimodality monitoring was used. After stabilization and lengthy rehabilitation, the patient obtained significant functional improvement. LESSONS The approach to initial management of concomitant head and spine trauma is to establish intracranial stability followed by intraspinal stability. Patients can make considerable recovery, particularly younger patients, who are more likely to benefit from early aggressive interventions and medical treatment.

Eosinophilic meningitis following suboccipital craniotomy without bovine dural graft: illustrative case

BACKGROUND Eosinophilic meningitis is a rare known complication after brain surgery associated with duraplasty using artificial bovine graft. However, eosinophilic meningitis after craniotomy without bovine dural graft has not been reported. OBSERVATIONS A 48-year-old female presented with lateral medullary infarction caused by a vertebral artery dissecting aneurysm incorporating the posterior inferior cerebellar artery (PICA). The authors performed occipital artery–PICA anastomosis and repaired the dura by primary suture without bovine graft. Thereafter, endovascular internal trapping using coils was conducted. Severe headache developed at postoperative day 17, and the patient was diagnosed with eosinophilic meningitis. After administration of a high-dose corticosteroid for 2 weeks, her symptoms and laboratory findings were improved. LESSONS Postoperative eosinophilic meningitis is rarely related to craniotomy without using bovine graft. Neurosurgeons should consider the possibility of eosinophilic meningitis after craniotomy without a xenogeneic dural material.

Navigating norms and invisible rules: Explaining the case of business influence in international shipping regulation

This article develops a micro-level theoretical perspective of business influence in international negotiations. By drawing on organizational institutional theory, the article proposes that site-specific institutionalized norms can structure the nature and extent of business power. The article illustrates the value of this perspective through an illustrative case study of the International Maritime Organization (IMO) through interviews and participant observation of on-site dynamics during negotiations on environmental shipping regulation. The article shows how, in the case of the IMO, specific institutionalized norms and beliefs structure private actors’ possible influence and their claims to authority. In particular, strongly held beliefs about the nature of political deliberation in the IMO both constrain and enable business interests, sometimes overriding the general structural power of the shipping industry. This research implies that future scholarship of business power and lobbying should be attentive to specific institutionalized ideas structuring business actors’ range of legitimate activities, in particular in international institutions where individual negotiation sites can develop idiosyncratic norms and beliefs about the legitimacy of private actor participation.

Absence of residual tumor tissue after Gamma Knife radiosurgery followed by resection of a vestibular schwannoma: illustrative case

BACKGROUND Late pathology after vestibular schwannoma radiosurgery is uncommon. The authors presented a case of a resected hemorrhagic mass 13 years after radiosurgery, when no residual tumor was found. OBSERVATIONS A 56-year-old man with multiple comorbidities, including myelodysplastic syndrome cirrhosis, received Gamma Knife surgery for a left vestibular schwannoma. After 11 years of stable imaging assessments, the lesion showed gradual growth until a syncopal event occurred 2 years later, accompanied by progressive facial weakness and evidence of intralesional hemorrhage, which led to resection. However, histopathological analysis of the resected specimen showed hemorrhage and reactive tissue but no definitive residual tumor. LESSONS This case demonstrated histopathological evidence for the role of radiosurgery in complete elimination of tumor tissue. Radiosurgery for vestibular schwannoma carries a rare risk for intralesional hemorrhage in select patients.

Transient ventriculoperitoneal shunt malfunction in a pediatric patient: An illustrative case

Background: Ventriculoperitoneal shunt (VPS), the mainstay of the treatment for hydrocephalus, is associated with relatively high revision rates. Transient hydrocephalus due to intermittent VPS obstruction should be recognized as a cause of VPS malfunction. While transient VPS dysfunction is well-recognized complication, there is a relative paucity of well-documented cases in the literature. Case Description: We present the case of a 4-year-old boy with a history of vascular malformation and hydrocephalus secondary to intraventricular hemorrhage. The patient presented with transient, self-resolving hydrocephalus (without intervention), as documented by clinical and radiological findings. Conclusion: Transient hydrocephalus due to intermittent VPS dysfunction in children is a rare entity, but it should be suspected in certain patients with VPS presenting with transient or self-improving symptoms.