Introduction
The external urethral sphincter reflex is a new neurmonitoring modality used to protect bowel, bladder, and sexual function during surgery. EUSR and bulbocavernosus reflex (BCR) assess the sacral segments of the spinal cord, cauda equina, and sacral nerve roots and provides a functional evaluation of the S2-S4 mediated reflex arc.
Objectives
We present a case study where we demonstrate for the first time the EUSR prognosticating postoperative bladder function independently of bowel function.
Methods
A 59-year-old female with hypertension and type 2 diabetes mellitus presented with a tumor causing cord compression at the T10 level. She underwent a T9-T11 laminectomy for tumor resection with a multimodal neuromonitoring paradigm including motor evoked potentials, somatosensory evoked potentials, EMG, BCR, and EUSR. The BCR and EUSR were activated using needle electrodes placed in the clitoris (cathode) and labia majora (anode) to activate the afferent sensory fibers of the dorsal clitoral nerves. Needle electrodes were placed in the left and right external anal hemisphincters to record the downstream motor component of the BCR. A specialized foley catheter embedded with 3D printed electrodes was used to record from the external urethral sphincter muscle for the EUSR.
Results
Baseline neuromonitoring data was acquired in all modalities except the EUSR. The
laminectomy and tumor resection were uneventful, and almost immediately following tumor removal, the EUSR began to reproduce and remained stable throughout the remainder of the procedure. The final pathology was benign schwannoma, and the patient was discharged intact on post-operative day 8. Follow-up at one month revealed cured urinary incontinence.
Conclusion
While this case study has limitations, it suggests that EUSR may not only provide redundancy to BCR monitoring but may discretely assess pathways associated with bladder function and prognosticate post-operative outcomes. More research with a larger cohort is needed to prove efficacy and statistical significance.

Prognostic Value of Intraoperative External Urethral Sphincter Reflexes in
Intradural Spinal Cord Surgery: A Case Report

Pancreaticoduodenectomy (PD) is a complex procedure with a high postoperative morbidity rate. Postoperative complications include pancreatic leak, intra-abdominal abscess, postpancreatectomy hemorrhage (PPH), and others. One of the most feared complications is PPH. This is a case of a patient status post robotic-assisted laparoscopic PD who suffered Gastroduodenal Artery (GDA) stump blowout leading to PPH and cardiac arrest. The Common Hepatic Artery (CHA) was subsequently embolized to control the PPH. This is the first report in existing literature to report embolization of CHA as a method of PPH management in the setting of a replaced left hepatic artery.

Coil embolization of Common Hepatic Artery as management of postpancreatectomy hemorrhage following Pancreaticoduodenectomy 


Morgagni hernias are a rare type of diaphragmatic hernias usually presenting as a congenital defect within the diaphragm at the foramen of Morgagni with a prevalence of 2-3% [1,6]. Although rare, these hernias are usually seen in infancy or early childhood but are uncommon within adulthood. Due to the location of the foramen of Morgagni, abdominal contents herniate anteriorly within the chest with the majority in the right chest (91%) and less commonly in the left (5%) or bilateral chests (4%) [5]. Patients often present with pulmonary symptoms including chest discomfort, shortness of breath, or pneumonia [6, 9]. Although most cases are found incidentally, due to the concern for incarceration these hernias are recommended for surgical repair [4]. Approaches for repair include laparotomy, thoracotomy, open thoracoabdominal approach, laparoscopy, video-assisted thoracoscopy (VATs) [2]. However, there seems to be very limited reports of a combined laparoscopic and VATs approach for the repair of a diaphragmatic hernia. Here we present a case of 76-year-old male who presented to our emergency department with shortness of breath, chest tightness and pain with oral intake found to have a Morgagni hernia with herniation of the omentum, small bowel, and colon into the left hemithorax. Using a combined laparoscopic and VATs approach, we were able to successfully repair his hernia with minimal complications demonstrating the combined approach as a safe and viable option.

Combined Video-Assisted Thoracoscopic and Laparoscopic Approach to a Morgagni Hernia Repair

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
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

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. 


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

Background
Primary CNS Vasculitis is an extremely rare vasculitis with an incidence of 2.4 cases/million person-years. It can manifest in various ways, including seizures, altered mental state, headaches, and cognitive decline. When different vascular territories are affected across episodes or when headaches are associated with cognitive decline and altered mental status, CNS Vasculitis should be considered. The diagnosis of Primary CNS Vasculitis is challenging due to the potential for
other conditions to mimic it, such as neoplasms like gliomatosis cerebri or intravascular B-cell lymphoma. Our case was complicated by previous treatment for these malignancies.
Case Presentation
In our case, a 35-year-old male with a history of alcohol and cocaine use and seizures presented with transient right hemiparesis, visual deficits, and aphasia. Brain MRI revealed T2 hyperintense lesions in the left cerebral hemisphere. A subsequent neurological workup was negative for encephalitis. Two months later, the patient was admitted again after another seizure, and MRI showed progression of the left-sided brain lesions. A brain biopsy targeting the left superior parietal lobule was inconclusive. The patient underwent chemotherapy and radiation but responded more to steroids, ruling out gliomatosis cerebri. A second biopsy of the left frontal
brain lesion revealed perivascular inflammation with necrosis consistent with vasculitis, although the effects of previous treatment complicated the diagnosis
Discussion
Primary CNS Vasculitis is a rare variant of vasculitis that is still poorly understood, with an unknown etiology and pathogenesis. Immune triggers and genetic predisposition have been identified as potential factors. The disorder primarily affects small and medium-sized vessels in the brain, but spinal cord involvement has also been documented. Clinical presentation varies but commonly includes headache, altered cognition, and hemiparesis. CSF analysis is often abnormal in PCNSV cases. Diagnostic tools like angiography and MRI are helpful but not
sufficient for diagnosis as PCNSV can mimic other disorders like intravascular large B-cell lymphoma and gliomatosis cerebri. Skin biopsy can help rule out the former. Brain biopsy is crucial for a definitive diagnosis, as it has been shown that a significant percentage of cases have an alternate diagnosis following biopsy.Treatment options for PCNSV include a combination of steroids and immunosuppressants, as well as methotrexate, cyclophosphamide, and azathioprine. Prognosis is generally fair, but mortality rates are higher in cases with focal neurological deficits, cognitive impairment, cerebral infarction, and large-vessel involvement. Early detection and treatment can improve the overall
prognosis.

Primary CNS Vasculitis Disguised as CNS Malignancy 


Bilateral ureteroinguinal hernia is a rare presentation with only five cases previously presented in the literature. We describe a 60-year-old male who was diagnosed with large bilateral hernias extending into the scrotum containing redundant ureters. Both hernias were repaired in staged fashion with retrograde temporary ureteral stent placement and modified Lichtenstein technique. Follow-up computerized tomography imaging with >5 years follow-up revealed intact repairs with no evidence of urinary obstruction.

Case Report: Bilateral Ureteroinguinal hernia into the Scrotum Repaired in a Staged Fashion

Background
Guillotine amputations involve amputating an extremity with the wound left open, and are indicated in the setting of contamination. With lower extremity amputation, surgical options include below-knee amputation (BKA), through-knee amputation or knee disarticulation (KD), and above-knee amputation (AKA). BKAs preserve the knee joint and have been shown to have fewer complications and improved rehabilitation compared to KDs and AKAs. When BKAs are not feasible for a traumatic injury, an AKA is often chosen, due to difficulty or lack of understanding of KD surgery. While few RCTs have compared KDs to AKAs, they may be a viable alternative to AKAs.
Case Presentation
A 28-year-old male presented to the ED after being hit by a truck while on a motorcycle. Physical exam revealed severe injuries to the left lower extremity (LLE), including open tibia and fibula fractures, degloving of the associated soft tissue, obliteration of the anterior compartment of muscles, and a cool foot with no identifiable pulse. Radiographs revealed open, comminuted fractures of the left tibia and fibula. CTA of the LLE revealed abrupt cut-off of contrast at the level of the distal trifurcation of the popliteal artery, proximally in the tibia. 
The patient was urgently taken to the OR, where a guillotine amputation was performed through the knee joint (KD), due to the proximal nature of the fractures and level of vessel tear. KD was chosen over AKA in order to preserve the thigh musculature and therefore maximal function in this young, healthy patient. Three days later, he underwent irrigation and debridement of the LLE with wound closure. The patient was discharged home five days after wound closure, or eight days after admission. Three months out of surgery, the patient has done well with physical therapy and prosthetic usage; he will continue to be followed closely for rehabilitation and recovery. 
Discussion
Factors to be considered in the level of amputation include soft tissue viability for bone coverage, blood vessel viability, and wound contamination. When BKA is not possible, KD can offer an alternative to AKA. KDs present concerns of poor wound healing and stump breakdown, as well as increased risk of revision surgery. However, compared to ambulating on a normal leg, patients undergoing AKAs require 70% more energy expenditure. As compared to AKA, KD preserves the adductor muscles, leading to improved stability and reduced metabolic expenditure with ambulation. Therefore, KDs may result in improved rehabilitation and increased long-term functionality.


A Case of Traumatic Guillotine Knee Disarticulation

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

**Abstract:**



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

Background
Parkinson’s disease (PD) involves the accumulation of alpha-synuclein (αS) in Lewy bodies in the substantia nigra of the brain. αS consists of an N-terminal 100-residue membrane-binding region and a 40-residue C-terminal tail. Molecular progression of PD throughout the brain is thought to occur as αS forms toxic aggregate species that are released from neurons and subsequently internalized by surrounding neurons to further seed aggregation of endogenous protein. Although the mechanism by which neurons internalize extracellular αS is unclear, one protein that is of interest as a putative receptor for αS is the presynaptic protein neurexin 1-beta (N1β). Previous work has shown that N1β drives cellular internalization of αS in a manner dependent on αS N-terminal acetylation (NTA); N-terminally acetylated αS (αSacetyl), the primary form of the protein in vivo, exhibits increased alpha-helical structure at its N-terminus compared to unmodified αS (αSunmod). Thus, αS appears to interact with N1β on neuronal membranes in an NTA-dependent manner, leading to neuronal uptake of extracellular αS and contributing to its intercellular propagation in PD. The objective of this study is to characterize αSacetyl-N1β binding with residue-specific resolution using nuclear magnetic resonance (NMR) spectroscopy. We hypothesized that this interaction primarily involves the N-terminal 10 residues of αS due to their known alpha-helical propensity with NTA. Mapping the αSacetyl-N1β interaction will offer insight into the specific regions of αS involved in its recognition and neuronal internalization, as well as inform potential therapeutic targets for inhibition of internalization and slowing of PD progression.

Methods
Established bacterial transformation, growth, and purification methods were used to generate αS samples. Heteronuclear single quantum coherence (HSQC) NMR studies were performed to generate chemical shift peaks corresponding to the local chemical environments of each residue for 15N-labeled αSunmod and αSacetyl either in the presence or absence of N1β. Changes in αS NMR peak position and/or intensity in the presence of N1β demonstrate involvement of the corresponding αS residues in αS-N1β binding.

Results
HSQC NMR studies demonstrated reduced NMR peak intensity in the N-terminal 100 residues of αSacetyl in the presence of N1β, with a more pronounced reduction in the first 11 residues.

Conclusion
αS interacts with N1β most strongly at its first 11 residues in an NTA-dependent manner, consistent with our hypothesis. However, αSacetyl also interacts with N1β across its 100-residue membrane-binding domain, suggesting that this entire region contributes to N1β-mediated αSacetyl internalization.

Structural characterization of the interaction between alpha-synuclein and neurexin-1 beta in the context of pathologic alpha-synuclein propagation in Parkinson's Disease

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.

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Prognostic Value of Intraoperative External Urethral Sphincter Reflexes in Intradural Spinal Cord Surgery: A Case Report

Coil embolization of Common Hepatic Artery as management of postpancreatectomy hemorrhage following Pancreaticoduodenectomy

Combined Video-Assisted Thoracoscopic and Laparoscopic Approach to a Morgagni Hernia Repair

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

A Case of Digital Gangrene in a Patient with Antiphospholipid Syndrome

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

Primary CNS Vasculitis Disguised as CNS Malignancy

Case Report: Bilateral Ureteroinguinal hernia into the Scrotum Repaired in a Staged Fashion

A Case of Traumatic Guillotine Knee Disarticulation

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

Structural characterization of the interaction between alpha-synuclein and neurexin-1 beta in the context of pathologic alpha-synuclein propagation in Parkinson's Disease

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

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