Background
Antiphospholipid syndrome (APS), a thrombo-inflammatory systemic autoimmune disease, refers to the presence of persistent procoagulatory antiphospholipid antibodies (APLA) in the setting of arterial/venous thrombosis and/or recurrent obstetric morbidity. Primary APS refers to disease manifestation in the absence of clinical or laboratory evidence of another disease. Secondary APS occurs in the presence of another autoimmune disorder, infection, drugs, or malignancy. APS is known to induce a hypercoagulable state which, in rare circumstances following surgical procedures, could present as acute upper limb ischemia. Successful limb salvage and revascularization requires a timely diagnosis and localization of the arterial occlusion.
Case Presentation
We present a case of a 40-year-old female, 10 days post breast implant surgery and reduction abdominoplasty, who developed arterial thrombosis of the right upper extremity and subsequently the right lower extremity. The patient has a 25-pack year smoking history. On her physical exam she had a cold, mottled, cyanotic right hand, thenar area, and thumb. The patient underwent multiple surgical procedures, including a thrombectomy with thrombolytic therapy for a right subclavian clot, subsequent arteriotomy for radial artery occlusion, a femoral and popliteal thrombectomy, and eventually multiple digital amputations, secondary to digital necrosis, with application of a groin flap. Following this procedure, she fell dehiscing the groin flap requiring three additional debridement procedures. Additional testing revealed positive ANA and lupus anticoagulants. She was subsequently diagnosed with antiphospholipid syndrome, explaining the cascade of thrombotic events.
Discussion
Taking into account patients' risk factors is essential in considering the diagnosis of APS. Timely recognition and diagnosis of APS is not only important to guide treatment and management, but also contributes to physicians’ understanding of the psychosocial impact of APS. The patient’s complications were not limited to physical manifestations, as there is a demonstrated psychosocial impact to the diagnosis of APS. This sequence of events contributed to her feelings of depression, which led to her pursuing psychiatric treatment. The large delay in finding the underlying cause of her symptoms certainly added to her anxiety and stress. Further demonstrating the need for consideration and further research investigating the psychiatric manifestations of APS, with an emphasis on depression. Additional considerations should be made regarding the timely diagnosis of APS in order to more aptly care for patients and limit the patients’ psychological toll.

A Case of Digital Gangrene in a Patient with Antiphospholipid Syndrome

Chronic Venous Insufficiency is a prevalent condition characterized by dysfunctional venous hemodynamics, resulting in a spectrum of clinical manifestations such as venous leg ulcers (VLUs). Herein, we report the case of a symptomatic 54-year-old male with bilateral VLUs persisting for four years despite adherence to compression therapy. Comprehensive ultrasound examinations revealed bilateral lower extremity venous incompetence and reflux. Shortly thereafter, multipronged interventions comprising radiofrequency endovenous ablation, ultrasound-guided sclerotherapy, and endovenous laser ablation targeted the venous insufficiency; however, the recalcitrant VLUs persisted despite symptom improvement. Exploratory imaging elucidated previously undetected bilateral perforators, as a post-surgical hemodynamic equilibrium might have decreased local blood stagnation and enhanced perforator perfusion. Compellingly, the follow-up interventions resulted in complete ulcer healing and symptom resolution. Altogether, our case underscores the collective impact of care continuity, meticulous spatiotemporal vascular mapping, and a patient-tailored approach to treat recalcitrant VLUs.

Undetected Perforator Vein Incompetence Responsible for Recalcitrant Leg Ulcers

Introduction : Glaucoma, a leading cause of irreversible blindness, presents a significant challenge in ophthalmology. While numerous treatment modalities exist, management becomes complex when patients exhibit intolerance to conventional treatments. This case highlights a patient with open angled glaucoma(AOG) who is unable to tolerate common glaucoma medications. 
Patient’s Main Concerns and Important Clinical Findings: A 79-year-old woman presents with a longstanding history of AOG, strongly influenced by her family history. The patient underwent significant obstacles due to intolerance to standard glaucoma eyedrops, including those that increase outflow (ie. Latanoprost) and aqueous suppressants for reduced inflow. 
Primary Diagnoses, Interventions, and Outcomes: The patient’s management involved multiple surgical interventions: two trabeculectomies were performed in the left eye (OS) in 1995 and 2006, with adjunctive 5-fluorouracil and mitomycin to inhibit fibroblast proliferation and increase the success rate of the surgery. Additionally, postoperative argon laser suture lysis was employed after both trabeculectomies to prevent hypotony. In the right eye (OD), the patient underwent argon laser trabeculoplasty in 2004, repeated as selective laser trabeculoplasty in 2007, and finally micropulse laser trabeculoplasty in 2009 and 2018. This series of procedures aimed to improve aqueous outflow through the trabecular meshwork. A trabeculectomy was also performed OD in 2018. As of the patient’s last examination on April 5, 2023, the patient’s vision was 20/80 OD and 20/500 OS, with intraocular pressures of 12 OD and 10 OS. Her visual fields showed stable superior and inferior loss, greater in OD than OS. 
Conclusion: This case illustrates the complexity of managing advanced glaucoma in patient’s intolerant to traditional medications. It highlights the necessity for personalized treatment strategies and the importance of building a supportive, ongoing relationship with patients dealing with lifelong diseases. Multiple surgeries may be required to control the disease, emphasizing the necessity for careful follow-up and dynamic treatment plans to preserve visual function. The case underscores the essence of ophthalmology - not just managing a disease, but guiding patients along a lifelong journey. 


Management Challenges in Advanced Open-Angle Glaucoma: A Case Report

Background:
Small bowel obstruction (SBO) is a life-threatening condition that typically presents with abdominal pain, distention, nausea and/or vomiting in a patient with a history of abdominal/pelvic surgery. SBOs are rare in virgin abdomens but can be seen in patients with internal hernias such as a left paraduodenal hernia (PDH). A left PDH is a rare anomaly of midgut rotation that often goes undiagnosed until presenting as a SBO in adulthood. CT imaging is the best diagnostic modality for visualization of a left PDH. Effective surgical management poses a challenge due to its rarity.
Case Summary:
This is the case of a 35-year-old male with acute onset abdominal pain and no history of abdominal or pelvic surgery. Classic CT findings were central in making the diagnosis of SBO secondary to a left PDH. Definitive surgical management was achieved via laparotomy.
Conclusion:
In patients with a virgin abdomen who present with signs and symptoms concerning for SBO, a high index of suspicion for PDH should be maintained. In these cases, diagnosis and treatment necessitate knowledge of typical imaging features and surgical techniques.

Left Paraduodenal Hernia: A Rare Diagnosis in a Common ED Presentation

Background
Fournier’s Gangrene is a type of necrotizing fasciitis that is rare and life-threatening if not treated promptly. It commonly affects the penis, scrotum, and perineal tissue in men between the ages 50-60. With fascial necrosis progressing as fast as 2-3 cm/hour, early and rapid diagnosis and treatment is critical in decreasing mortality and adverse outcomes. This case report presents a 22-year-old male patient with Fournier’s gangrene and describes the symptoms, physical examination, treatment plan and expected clinical course. 

Case Presentation
A 22-year-old male presented to the emergency room with nausea, vomiting and an evolving painful sore on the posterior medial thigh. He had a history of uncontrolled type 1 diabetes mellitus and was noncompliant with medicine. The patient’s vital signs at admission were as follows: BMI of 35.0, blood pressure of 141/84 mmHg, pulse rate of 126 bpm, respiratory rate of 18/min, temperature of 38.11C, and oxygen saturation of 97% on room air. His labs were significant for elevated glucose at 330 mg/dL with mild diabetic ketoacidosis and increase WBC count of 25.1 x 103/L with 81.4% neutrophil. In the ER the patient was started on empiric antibiotic therapy and initial differential diagnosis include medication intolerance, gastroenteritis and diabetic ketoacidosis. Two hours later, his temperature rose to 39.33C and blood pressure dropped to 107/58 mmHg. After another 5+ hours, general surgery was consulted for irrigation and debridement. Surgery was performed; skin and necrotic subcutaneous tissue was excision extending until healthy tissue was reached. This excision spread from the posterior medial thigh just below the buttock to the deep perineum and anterior medial thigh. Post-operation antibiotic regimen was altered to include clindamycin, vancomycin and piperacillin-tazobactam. After narrowing antibiotics and continuous clean wound dressing changes, a vacuum-assisted closure (VAC) was applied to the wound in the OR on post-operative day three. On post-operative day five, patient was discharged with 14 day course of oral Augmentin and home-health care for assisted dressing changes.

Discussion
This unusual age caused delayed treatment and missed diagnosis originally. This case presentation might change emergency and surgical physician’s differential diagnoses and plan of action for younger patients that present with worrying symptoms of Fournier’s Gangrene. By expanding the age range and keeping different diagnosis wide, this can keep younger populations from slipping through and being eliminated on initial presentation. When it comes to Fournier’s Gangrene, time is essential and earlier diagnosis can be the difference in limb loss or even mortality.


A Case Report of Fournier’s Gangrene in an Unusual Age Group

Background: Wound dehiscence is a known postoperative complication but, in cervical spine surgery, it is rare and there is a lack of documented literature. This clinical vignette reports novel complications of wound dehiscence in a patient treated with spinous process ostectomies after posterior cervical surgeries.

Case Presentation
A 41-year-old male initially presented to the emergency department (ED) with a chief complaint of middle thoracic back pain, numbness and tingling in the T4 dermatome and bilateral lower extremity motor deficits. MRI showed T2-T3 discitis, osteomyelitis and a thoracic epidural abscess, central cord remodeling, and a paraspinal soft tissue abscess that measured 2.2 x 1.2 x 2.3 cm. The patient ultimately underwent a T2-T3 decompression with left pedicle subtraction, irrigation, and debridement (I&D) of the T2-T3 disc space, and C7-T5 posterior spinal fusion.
Following an uneventful postoperative course, at five months postoperatively the patient felt a tear over the incision and was found to have a full thickness wound dehiscence with protrusion of the spinous processes. 
The patient underwent operative intervention for resection of the spinous process, I&D, and approximation of the muscle tissue and fascia. The spinous processes of T4 and T5 that were visible were removed. Flaps were raised to allow for adequate coverage of scar and fascia. At the two-week follow-up, the incision showed positive signs of healing overall, although there was some blistering noted; the sutures remained in place for another week. The spinous process at the level above the incision (C6, C7, and T1) was more prominent postoperatively which were not prominent prior to surgery. One week later, sutures were removed, and the wound looked well healed overall despite some erythema.
Six weeks following the second surgery, the spinous process at C6, C7, and T1 had eroded through the skin. The patient was scheduled for resection of those spinous processes and a large paraspinal flap for wound coverage. At the two-week, one-month, and six-month follow-up visits, the incision looked well healed with no signs of dehiscence

Discussion
This clinical vignette documents the successful treatment of cervical wound dehiscence which is a rare postoperative complication of cervical spinal surgery. We believe that this clinical vignette demonstrates successful treatment of cervical wound dehiscence with notable prominence of spinous processes, a topic that is not well documented in the literature. This information is valuable as treatment strategies and research into cervical wound dehiscence are limited to a single case report.




Cervicothoracic Wound Dehiscence Following Internal Fixation of the Cervical and Thoracic Spine

Background: Adrenal myelolipomas are benign, lipid-filled masses containing elements of interspersed myeloid cells and comprise approximately 3-6% of all adrenal masses. Epidemiologically, adrenal myelolipomas affect both sexes equally and are often discovered in middle age. These masses are typically unilateral and variable in size, with macroscopic fat as a diagnostic feature on imaging. Notably, patients with congenital adrenal hyperplasia (CAH) are more likely to present with large bilateral myelolipomas, and, as such, patients presenting with these features should be evaluated for concurrent CAH.
Case presentation: In this report, a 34-year-old male presented to the emergency department following an alleged assault on his abdomen. During his trauma evaluation, he received a CT scan of the abdomen, demonstrating large bilateral adrenal incidentalomas with pathognomonic features of macroscopic fat (Hounsfield unit -90 to -120) consistent with adrenal myelolipomas. The left and right adrenal masses were reported at 20 cm and 14 cm, respectively. On further questioning, he endorsed a past medical history of CAH and noncompliance with glucocorticoid and mineralocorticoid therapy associated with a chronic history of abdominal discomfort. On physical exam, palpable bilateral abdominal masses at the levels of adrenals were appreciated. This patient received appropriate lab and imaging to confirm the diagnosis of bilateral adrenal myelolipomas. He successfully underwent bilateral open adrenalectomy, is currently on maintenance glucocorticoid and fludrocortisone therapy, and is doing well one year post-operation.
Discussion: Adrenal myelolipomas are benign masses of mature adipocytes and scattered myeloid cells. They are the second most common benign adrenal masses following adrenal adenomas. While they are usually found unilaterally and incidentally, they can present bilaterally and symptomatically, especially in CAH, a group of genetic enzyme deficiencies involving steroidogenesis. There are three working hypotheses explaining adrenal myelolipoma's prevalence in CAH: 1) Increased adrenocorticotropic hormone (ACTH) leads to constitutive stimulation of the adrenal cortices, resulting in hyperplasia 2) Stress, infection, and trauma induce metaplastic transformation of the reticuloendothelial cells in the adrenal gland and 3) Granulocyte stimulating factor recruiting mesenchymal stem cells and circulating bone marrow which adrenocortical adipocytes are derived from.
The size and presence or severity of symptoms are essential in guiding management. Larger masses (> 4 cm) more commonly present with mass effects and possible complications of hemorrhage and, therefore, are surgically excised. Smaller masses and asymptomatic cases can be followed yearly with imaging. For masses larger than 10 cm, as in this patient, midline laparotomy is preferred to the laparoscopic surgical approach.

Large Bilateral Adrenal Myelolipomas in a 34-year old Male with Congenital Adrenal Hyperplasia

Background
Spinal manipulation is one of many therapies for back pain. It is typically done by a chiropractor or physical therapist. A systemic review and meta-analysis concluded that spinal manipulation has moderate-quality evidence for improvement in pain scale and function. However, there is insufficient data for chronic back pain treatment. Like most treatments, there are risks associated with spinal manipulation. While serious adverse effects of spinal manipulation are rare, they include disc herniation, cauda equina syndrome, vertebrobasilar and carotid dissection. The incidence of serious adverse events range between 1/100,000 and 1/6 million manipulations. More commonly, minor complaints (dizziness, lightheadedness, headache, and numbness) are reported following spinal manipulation with rates between 25-60%. In this case, a 50-year-old patient underwent chiropractic spinal manipulation for back pain, resulting in bilateral lower extremity paralysis requiring spinal surgery.
Case Presentation
A 50-year-old male with no past medical history presented with back pain. The patient reported that he had back pain for about a month after lifting a heavy object. He went to the chiropractor for an adjustment two weeks prior to admission. Following the adjustment, he felt better, but the next day he had bilateral leg weakness, numbness, and tingling. He couldn’t walk for two weeks and was using a wheelchair. Sensation was intact. Two days ago, he started experiencing urinary incontinence but no bowel incontinence. On examination, the patient had bilateral leg weakness and saddle anesthesia. Thoracic MRI showed a disc extrusion and epidural hematoma at T10-T11 extending superiorly to the T10 superior endplate and inferiorly to the mid-T11 vertebral body with severe mass effect on the spinal cord and canal stenosis. The patient was started on dexamethasone 4-mg q6-hours. A left thoracotomy, T10-11 left transthoracic corpectomy, and T9-11 anterior-lateral interbody arthrodesis was performed and well tolerated. After two months of inpatient rehab, the patient was able to ambulate using a walker, discharged home, and scheduled for outpatient rehab.
Discussion
This case demonstrates an interesting and rare serious adverse event of spinal manipulation. Generally, it is important to avoid spinal manipulation in patients with documented or suspected disc herniation. In this case, it is unknown whether the patient had a pre-existing herniation but considering that the back pain originally began shortly after lifting a heavy object, it is possible that there was a degree of herniation prior to the chiropractor visit that progressed after the spinal manipulation, causing a mass effect and spinal stenosis.

Thoracic Spine Injury Requiring Neurosurgery following Chiropractic Manipulation: A Case Report

**Scoring is only possible in the semifinals hall**

**Abstract:**



Incidental Finding of Fahr’s Disease in Patient with Stroke-Like Symptoms Without Acute Infarction

Background
Carotid cavernous fistulas (CCF) are a serious condition that involves spontaneous or trauma-induced disruption in the carotid arteries within the cavernous sinus. This disruption causes blood to leak into the sinus, which impedes the function of cranial nerves III, IV, V1, V2, and VI. Early signs of CCF often include proptosis, glaucoma, severe headaches, partial blindness, and conjunctival hyperemia- especially in patients with preexisting conditions such as atherosclerosis, hypertension, diabetes. If left untreated, patients can develop periorbital disfigurement and permanent vision loss. Despite effective methods of diagnosis using angiography and blood vessel repair, this condition is often misdiagnosed due to it making up only 1.5% of endovascular-treated ruptured aneurysms and its similarity in presentation to cerebrospinal fluid (CSF) leaks. Therefore, CCFs have been under-investigated, and additional research is required to delineate the cause, unique features, and proper treatment of this phenomenon.

Case Presentation
Six weeks following an uncomplicated L4-S1 posterior instrumented fusion with partial laminectomy and bilateral facetectomy, a 78-year-old female developed moderate bifrontal headaches and neck discomfort. In the following weeks, the headaches grew severe with periorbital swelling despite a negative brain CT scan and no findings in an exploratory surgery. Worsening symptoms prompted a brain MRI that showed abnormal superior ophthalmic veins. Diagnostic angiography confirmed a left CCF, and the patient was successfully treated via transvenous embolization in the intercavernous sinus and left cavernous sinus. 

Discussion
Carotid-cavernous fistulas (CCF) are pathological shunts between the cavernous sinus and carotid artery or its meningeal branches. Symptoms include conjunctival injection, blurred vision, pulsating proptosis, and cranial nerve six palsy – all of which may be exacerbated with delayed diagnosis. Historically, etiologies of CCFs have included trauma, ruptured ICA aneurysms, connective tissue diseases, or iatrogenic injury. We present the first reported case of a CCF that occurred in conjunction with spine surgery. We describe the association of prolonged operative time in the prone position and development of CCF using radiographical images and thorough clinical workup. We also describe how the clinical history and symptomology originally indicated a dural tear, although subsequent workup led to the diagnosis of CCF. This case demonstrates a difficult diagnosis of CCF and its potential relationship with spinal surgery.


Carotid Cavernous Fistula and Its Association with Spine Surgery

Intracellular Signaling Pathways of TLR2/1 and TLR2/6 Initiated Reactive Oxygen Species Production in Neutrophils

Background
Patients who present with cervical dystonia may also present with cervical myelopathy. This presentation can be problematic because patients with cervical myelopathy need fusion surgery such as an anterior discectomy and fusion (ACDF) to stabilize the spine and prevent damage to the spinal cord. The involuntary tremor caused by cervical dystonia can result in problems with boney fusion in the post-operative period. Deep Brain Stimulation (DBS) provides a potential solution to this problem when more conservative treatments like medication, halo vests, and botulinum toxin fail to reduce tremor.
Case Presentation
A 46-year-old female presented to our center with a chief complaint of neck pain. The patient also presented with bilateral upper extremity radiculopathy, paresthesia, and a myelopathic gait. She had a 15-year history of cervical dystonia and had tried various medications and botulinum toxin injections without resolution of symptoms. In addition to this the patient had cervical myelopathy caused by disc herniation at the C5-C6 and C6-C7 level. Although the patient was a candidate for ACDF, she was advised to have her dystonic tremor treated before ACDF to prevent pseudoarthrosis and hardware failure because of the tremor. The patient underwent bilateral DBS in the Globus pallidus interna (GPi) utilizing an Abbott InfinityTM DBS system. After placement of the DBS-GPi leads, batteries were placed, and the system was turned on which was able to provide significant relief of the patient’s tremor. The patient was followed up at 3 months and had a >75% reduction in her tremors. After the significant reduction in tremor, the patient underwent C5-C6 and C6-C7 ACDF at 6 months post DBS-GPi. The patient reported that the paresthesia had improved significantly, and the weakness had gradually improved at 3 months post ACDF. There was no radiographic evidence of hardware loosening or malalignment.
Discussion
The presentation of both Cervical Dystonia and Cervical Myopathy concurrently is a challenging couple of pathologies to manage. Bilateral DBS-GPi prior to ACDF is a viable strategy for managing these pathologies surgically. 


Underline digital video library

A Case of Digital Gangrene in a Patient with Antiphospholipid Syndrome

Undetected Perforator Vein Incompetence Responsible for Recalcitrant Leg Ulcers

Management Challenges in Advanced Open-Angle Glaucoma: A Case Report

Left Paraduodenal Hernia: A Rare Diagnosis in a Common ED Presentation

A Case Report of Fournier’s Gangrene in an Unusual Age Group

Cervicothoracic Wound Dehiscence Following Internal Fixation of the Cervical and Thoracic Spine

Large Bilateral Adrenal Myelolipomas in a 34-year old Male with Congenital Adrenal Hyperplasia

Thoracic Spine Injury Requiring Neurosurgery following Chiropractic Manipulation: A Case Report

Incidental Finding of Fahr’s Disease in Patient with Stroke-Like Symptoms Without Acute Infarction

Carotid Cavernous Fistula and Its Association with Spine Surgery

Intracellular Signaling Pathways of TLR2/1 and TLR2/6 Initiated Reactive Oxygen Species Production in Neutrophils

DBS before ACDF for a patient with Cervical Dystonia and Cervical Myelopathy

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