Bahie Ezzat

BACKGROUND: Spinal epidermoid cysts are rare tumors typically found in the lumbosacral region in the intradural extramedullary space. These tumors are usually caused by defects in neural tube closure or acquired through iatrogenic or traumatic insult, with either mechanism leading to the inclusion of epidermal cells in cystic compartments in the spine. Although benign, these cysts can cause symptoms including back pain and weakness, and patients often undergo resection. OBSERVATIONS: We present a unique case of an intramedullary spinal epidermoid cyst appearing in the T6–7 region of a 69-year-old male. Furthermore, subcutaneous epidermoid cysts within the same region as the spinal tumor were observed. A review of the literature revealed that while intramedullary spinal epidermoid cysts are rare, their concurrent appearance with subcutaneous cysts has not been observed, demonstrating the novelty of this case. LESSONS: This case demonstrates the possible occurrence of epidermoid cysts in the intramedullary space, in superior spinal regions, and in the older population. Additionally, such cysts should remain on the differential in individuals with myelopathic symptoms and associated subcutaneous inclusion cysts on the back. Careful imaging to guide diagnoses and surgical planning is crucial. https://thejns.org/doi/10.3171/CASE26313

BACKGROUND: Cranioplasty is a common procedure following decompressive craniectomy for traumatic brain injury or stroke, among other reasons, in order to repair a skull defect. Cranioplasty failure is an infrequent occurrence, but in the case of synthetic implants, it is usually caused by infection and incorrect sizing. However, trauma-induced displacement, breakage, and deformities of cranioplasty implants are less common. OBSERVATIONS: The authors present a unique case of a cranioplasty failure due to displacement of a polyetheretherketone (PEEK) implant secondary to catastrophic breakage of the titanium fixation plates. The cause of displacement is unknown but is suspected to be trauma. A subsequent review of the literature contextualizes common reasons for failure among synthetic implants and suggests that fracture of synthetic implants or their fixation plates is extremely rare. LESSONS: The displacement of a PEEK cranioplasty implant due to breakage of titanium fixation plates is a rare, albeit possible, complication of this neurosurgical procedure. Lifestyle modifications are paramount to reduce trauma risk and resultant cranioplasty failure. The addition of miniplates may also reduce implant displacement risk. Finally, since rates of failure differ by material, careful consideration of the type of material used for the implant should be incorporated into neurosurgical planning. https://thejns.org/doi/10.3171/CASE2694

BACKGROUND: Intradural extramedullary anaplastic ependymomas are rare, aggressive spinal tumors for which optimal management strategies remain unclear. OBSERVATIONS: This case describes ongoing survival at 35 months in a 65-year-old male with an intradural extramedullary anaplastic ependymoma treated with subtotal resection and proton beam therapy. MRI revealed a T2–3 dorsal intradural extramedullary lesion with leptomeningeal spread in the lumbar spine. Subtotal resection was performed due to dense adherence to the cord, with approximately 10% tumor left in situ. Pathological evaluation confirmed MYCN-amplified WHO grade 3 ependymoma. Adjuvant proton beam therapy was initiated within 2 weeks of surgery, consisting of craniospinal irradiation (3600 cGy in 20 fractions) followed by a boost to a total of 5400 cGy in 30 fractions. Postoperative recovery included full return of strength and function. Serial brain and spine MRI studies at 6, 12, 18, and 22 months showed stable spinal dissemination with no intracranial spread. LESSONS: This case supports the role of subtotal resection followed by proton beam therapy as a viable treatment strategy for MYCN-amplified intradural extramedullary anaplastic ependymomas, particularly when gross-total resection is contraindicated. https://thejns.org/doi/10.3171/CASE25804

Given the prevalence of mild traumatic brain injury (mTBI) and sports-related concussion, the development of efficient diagnosis methods is essential. Although magnetic resonance imaging (MRI) and computed tomography are standard imaging modalities in traumatic brain injury assessment, they frequently fail to detect the subtle structural and metabolic changes associated with mTBI. Furthermore, while cognitive tests like the Immediate Post-Concussion Assessment and Cognitive Testing and the Sports Concussion Assessment Tool 5 have been developed, fluid-based biomarkers provide a cheaper and quicker method to identify mTBI. Using the PubMed database, we searched for English-language articles on mTBI biomarkers. Conventional biomarkers (e.g., glial fibrillary acidic protein, neuron-specific enolase, tau) frequently show statistically significant group-level differences after mTBI, but their individual-level diagnostic performance is often moderate, with overlapping distributions. As a result, single markers alone may not reliably distinguish mTBI from controls or from other neurological conditions. Biomarkers can detect differences between mTBI and control patients, but the literature suggests that detectors such as neurogranin are not significant indicators of mTBI. Moreover, studies showed that alpha-synuclein increases during the acute phase of mTBI, yet it has been found that lower α-synuclein levels are associated with mTBI in trauma patients. Due to these discrepancies, multi-biomarker panels may be the most comprehensive way to detect mTBI in the acute phase. While some developments are promising, the limitations associated with the current biomarkers warrant comprehensive studies to assess their effectiveness. In clinical practice, these proteins are measured using automated electrochemiluminescence immunoassays that are inexpensive, allow single-sample testing, and yield results in ∼20 min. Access is the constraint, as these analyzers are hospital-based; therefore, point-of-care (e.g., finger-prick) tests remain a priority. Conventional enzyme-linked immunosorbent assay are research tools and are less suitable for acute-care workflows. Attention should be directed toward the development of technologies to measure mTBI biomarkers pitch-side so that head injuries can be diagnosed immediately after injury.

Study Design: Bibliometric analysis. Objective: To identify and analyze the top 100 most-cited articles in cervical spine surgery, highlighting influential research, key authors, and major contributing institutions. Summary of Background Data: Cervical spine surgery has evolved significantly with advancements in surgical techniques and technology. Bibliometric analysis provides insights into the most impactful research, shaping clinical practice and guiding future studies. Methods: A bibliometric analysis was conducted using the Web of Science database (1900–April 2024). Articles were identified using the search terms “cervical,” “spine,” and “surgery,” then ranked by citation count. The top 100 most-cited articles were selected based on relevance. Extracted variables included title, year, authors, affiliations, journal, keywords, and citation count. Data analysis was performed using VOSviewer and Bibliometrix. Results: The top 100 articles, published between 1954 and 2016 across 32 journals, were authored by 523 researchers, with only two single-author publications. The articles included 86 original research papers and 14 reviews, with a mean citation count of 410.2 per article and a total citation count of 41,002. Spine published the most articles (34), followed by the Journal of Bone and Joint Surgery (11) and the Journal of Neurosurgery (7). The University of California System (53 articles) and the University of Toronto (29 articles) were the most prolific institutions. Abumi K. and Kaneda K. were the most frequently published authors, each contributing five articles. A 20% international co-authorship rate was observed, indicating extensive global collaboration. Network and cluster analyses identified stabilization, fusion, and decompression as primary research themes. Conclusion: This study highlights the bibliometric impact of technological and procedural innovations in cervical spine surgery. The findings emphasize the field’s collaborative nature and the dominant role of North American institutions in advancing cervical spine surgery research, providing a foundation for future clinical and academic developments.

BACKGROUND: Malignant melanotic nerve sheath tumors (MMNSTs) are rare neoplasms of Schwann cell origin that often arise along spinal nerves. They exhibit an estimated prevalence of 1% among primary peripheral nerve sheath tumors and carry an estimated mortality rate of 26%. This disease most commonly presents with localized pain and may also present with symptoms of cord compression. After radiographic imaging to identify suspected lesions, a definitive diagnosis is usually made through identification of PRKAR1A gene mutations. Typical management consists of tumor resection with adjuvant radiotherapy or chemotherapy, depending on case specifics. However, misdiagnosis due to tumor mimicking may slow correct diagnoses and subsequent treatment. OBSERVATIONS: The authors present a unique case of MMNST mimicking a benign nerve sheath lesion that resulted in neuropathy. Initial pathology reports identified the lesion to be of metastatic melanoma, but reexamination resulted in an ultimate diagnosis of MMNST. Rapid progression of the disease was observed. A subsequent review of the literature identified diagnostic considerations, treatment strategies, and avenues of research that may aid in diagnosis and treatment. LESSONS: MMNST should be considered when encountering suspicious peripheral nerve sheath lesions. Promptly performing appropriate biopsies and molecular testing is critical due to this condition’s poor prognosis. https://thejns.org/doi/abs/10.3171/CASE25314

Objective To identify predictors for time to first treatment modality (TTT) in patients diagnosed with spinal metastatic disease. Methods Our radiology database was retrospectively queried to identify patients with spinal metastases (01/2017-12/2021). Demographics, setting of initial imaging (inpatient/outpatient/ED), histology, treatment modality, and TTT were collected. Several different early TTT thresholds were explored (≤ 30, ≤ 21, ≤14, and ≤ 7 days). After controlling for age, gender, diagnostic setting, pathology, type of treatment multivariable linear and logistic regressions were performed for the primary and secondary thresholds at different time-points. Results A total of 1009 patients with spinal metastases were included, with a median age of 65 years (IQR 15) and 529 (52.4%) males. Diagnoses occurred in the inpatient (37%), outpatient (50%), and emergency department (13%) settings. The most common primary tumors were breast (22.4%), prostate (19.5%), and non-small cell lung cancer (12.8%). Treatment modalities included surgery (14.6%), chemotherapy (54.5%), and radiation therapy (43.5%). The median time to treatment (TTT) was 13 days (SD 27, range 0–676), with no significant difference by setting (p = 0.2). In multivariable linear regression, surgery was associated with shorter TTT (p = 0.037). Logistic regression using different early-TTT thresholds identified age, surgical intervention, lymphoma, and outpatient setting as significant predictors across models. Sensitivity analyses excluding TTT outliers showed that surgery was no longer a significant predictor, while other covariates remained stable. Conclusions Surgical intervention and lymphoma independently predicted earlier TTT of any modality in spinal metastases, whereas older age and outpatient diagnosis were associated with delays.

Despite the surge in Anterior Cervical Discectomy and Fusion (ACDF) and Posterior Cervical Decompression and Fusion (PCDF) procedures over the past two decades, there remains a paucity of data on their comparative costs in geriatric patients with cervical disc herniation. This study provides a comprehensive cost analysis of ACDF and PCDF in this patient population. A total of 282 geriatric patients who underwent ACDF or PCDF for cervical disc herniation over a 12-year period were analyzed to assess total surgical costs, including pre-operative, procedural, and post-operative expenses. ANOVA with post-hoc Tukey HSD Test was used in a propensity score-matched cohort to compare cost differences between ACDF and PCDF across various cost categories. In a geriatric cohort of 282 patients with cervical disc herniation meeting inclusion criteria, 221 (78.4%) underwent ACDF and 61 (21.6%) received PCDF (2-4 levels). The average age was 71.3±5.6 years, with no significant demographic differences between groups. On ANOVA, rehabilitation costs were 1.88 times higher (p<0.001), and blood bank costs were 2.16 times higher (p=0.04) for PCDF patients, corresponding with significantly greater estimated blood loss (209.9±217.7 mL vs. 66.7±107.0 mL, p<0.001). After propensity score matching, PCDF remained associated with significantly higher rehabilitation costs (+170.79%, p<0.001), blood bank costs (+139.29%, p=0.005), and total procedural costs (+33.92%, p=0.015). ACDF procedures in geriatric patients with cervical disc herniation are significantly cheaper than PCDF in terms of rehabilitation and blood bank costs, offering valuable insights for optimizing neurosurgical decision-making and high-value care.