Faculty Bibliography

BACKGROUND:There is a growing population of refugees within North America and an increasing awareness of their unique medical requirements. These requirements include both a well-recognized need to understand the different pathologies that can present in these patients as well as the rarely described need to understand their unique perspective and how this can impact their medical care, especially for routine neurosurgical conditions. This paper highlights a refugee's perspective toward the medical system in North America and documents how several aspects of this unique perspective hindered or delayed the care for the management of this patient with a cervical cord tumor. CASE DESCRIPTION/METHODS:A 34-year-old female Somalian refugee presented with an ependymoma to Vancouver General Hospital 3 days after arriving in North America. The tumor was removed through a standard posterior cervical laminectomy approach. The patient and her care workers were interviewed 6 months postoperatively to determine if any aspects of care were negatively impacted by her refugee status. Problems related to communication, medical history, mistrust of care workers, familial support, and access to follow-up care were recognized and recommendations for improvements provided. CONCLUSIONS:It is well known that the North American physicians must be familiar with the unique spectrum of medical conditions within the refugee community. This paper highlights that physicians must also be aware that refugees may have a unique perspective on our health care system that can negatively influence their care for even routine neurosurgical conditions.

A novel method of spinopelvic ring reconstruction after partial sacrectomy for a chondrosarcoma is described. Chondrosarcoma is one of the most common primary malignant bone tumors, and en bloc resection is the mainstay of treatment. Involvement of the pelvis as well as the sacrum and lumbar spine can result in a technically difficult challenge for en bloc resection and for achievement of appropriate load-bearing reconstruction. After en bloc resection in their patient, the authors achieved reconstruction with a rod and screw construct including vascularized fibula graft as the main strut from the lumbar spine to the pelvis. Additionally, a cadaveric allograft strut was used as an adjunct for the pelvic ring. This is similar to a modified Galveston technique with vascularized fibula in place of the Galveston rods. The vascularized fibula provided appropriate biomechanical support, allowing the patient to return to independent ambulation. There was no tumor recurrence; neurological status remained stable; and the allograft construct integrated well and even increased in size on CT scans and radiographs in the course of a follow-up longer than 7 years.

BACKGROUND:Cerebrospinal fluid (CSF) leakage is a complication of intradural spinal surgery and is associated with poor wound healing and infection. The incidence of CSF leak is reported at ∼16% in adults, but little information is available in children. PURPOSE/OBJECTIVE:The aim of this study is to determine the CSF leak rate and predisposing factors after intradural pediatric spinal surgeries. METHODS:This study was a retrospective chart review of 638 intradural spinal operations at BC Children's Hospital. CSF leak was defined as pseudomeningocele or CSF leak through incision. Primary operations to untether lipomyelomeningoceles, myelomeningocele/meningocele closure, and Chiari decompressions were excluded. RESULTS:CSF leaks occurred in 7.1%, with 3% having overt CSF leaks through skin (OCSF leak). CSF leaks, specifically OCSF leaks, were associated with postoperative wound infection (P = 0.0016). Sixteen of 45 cases of CSF leak required reoperation. The type of dural suture used, site of operation, or use of fibrin glue did not affect CSF leak rates. Previous spinal surgery (P < 0.0001), use of dural graft (P = 0.0043), method of dural suturing (P = 0.0023), and procedure performed (P < 0.001) were associated with postoperative CSF leakage. Patients with CSF leak were older than those without leak (98 vs. 72 months, P = 0.002). CONCLUSIONS:Our results provide evidence on intraoperative factors that may predispose to CSF leaks after spinal intradural surgery and may help guide surgical practice. This study confirms that the pediatric population shares many of the same risk factors for CSF leak as in adult populations. Further research is needed to explain how specific factors are associated with CSF leaks.

INTRODUCTION/BACKGROUND:Sacral agenesis is a congenital condition associated with multiple orthopedic, spinal, abdominal and thoracic organ deformities. Meningocele is commonly found among patients with sacral agenesis. DESCRIPTION/METHODS:We present the first case in the literature describing a delayed presentation of terminal (posterior) meningocele in an adult patient born with sacral agenesis. CONCLUSION/CONCLUSIONS:Surgical repair was performed and is the best treatment option for significantly large lesions, with postoperative CSF leak being the main complication.

Nitric oxide produced by inducible nitric oxide synthase (iNOS) contributes importantly to acute lung injury (ALI), but the specific contribution of neutrophil iNOS has not been defined. Thus, we defined the role of neutrophils and specifically neutrophil iNOS in a murine model of septic ALI. Four hours after cecal ligation/perforation, ALI was characterized by increases in pulmonary neutrophil infiltration (tissue myeloperoxidase activity, bronchoalveolar lavage neutrophils), microvascular leak of Evans blue (EB) dye-labeled albumin, and oxidant stress (8-isoprostane levels). Septic ALI was neutrophil dependent, as pretreatment with anti-CD18 before cecal ligation/perforation significantly (P < 0.05) attenuated septic increases in pulmonary myeloperoxidase (39 ± 11 vs. 85 ± 14 mU/mg protein), bronchoalveolar lavage neutrophils (0.5% ± 0.2% vs. 2.1% ± 0.6%), microvascular EB-albumin leak (1.3 ± 0.3 vs. 2.6 ± 0.7 μg EB/g per minute), and 8-isoprostane content (74 ± 15 vs. 115 ± 16 pg/mg protein). The role of neutrophil iNOS was assessed by creation of neutrophil-iNOS chimeric mice: iNOS(+/+) versus iNOS(-/-) mice were bone marrow depleted by irradiation and selectively reconstituted with iNOS(+/+) versus iNOS(-/-) neutrophils. Cecal ligation/perforation resulted in significant septic ALI in + to - neutrophil-iNOS chimeric mice (iNOS(+/+) neutrophils in iNOS(-/-) mice), but not in - to + neutrophil depleted-reconstituted mice (iNOS(-/-) neutrophils in iNOS(+/+) mice). There were no significant differences between iNOS(+/+) and iNOS(-/-) neutrophils in phagocytosis, respiratory burst, or CD11a/b/CD18 surface expression, although septic shedding of CD62L was blunted in iNOS(-/-) neutrophils. Neutrophil iNOS contributes importantly to murine septic ALI in vivo, but not simply through a change in neutrophil phenotype. We speculate that neutrophil iNOS may modulate neutrophil-endothelial interactions in complex fashion, including regulation of transendothelial neutrophil migration and pulmonary neutrophil infiltration.

INTRODUCTION/BACKGROUND:Surgical activity is probably the most important component of surgical training. During the first year of surgical residency, there is an early opportunity for the development of surgical skills, before disparities between the skill sets of residents increase in future years. It is likely that surgical skill is related to operative volumes. There are no published guidelines that quantify the number of surgical cases required to achieve surgical competency. The aim of this study was to describe the current trends in surgical activity in a recent cohort of first-year Canadian neurosurgical trainees. METHODS:This study utilized retrospective database review and survey methodology to describe the current state of surgical training for first-year neurosurgical trainees. A committee of five residents designed this survey in an effort to capture factors that may influence the operative activity of trainees. RESULTS:Nine out of a cohort of 20 first-year Canadian neurosurgical trainees that began training in July of 2008 participated in the study. The median number of cases completed by a resident during the initial three month neurosurgical rotation was 66, within which the trainee was identified as the primary surgeon in 12 cases. Intracranial hemorrhage and cerebrospinal fluid diversion procedures were the most common operations to have the trainee as primary surgeon. CONCLUSION/CONCLUSIONS:Based on this pilot study, it appears that the operative activity of Canadian first-year residents is at least equivalent to the residents of other studied training systems with respect to volume and diversity of surgical activity.