Bridging the literacy gap for surgical consents: an AI-human expert collaborative approach.

Despite the importance of informed consent in healthcare, the readability and specificity of consent forms often impede patients' comprehension. This study investigates the use of GPT-4 to simplify surgical consent forms and introduces an AI-human expert collaborative approach to validate content appropriateness. Consent forms from multiple institutions were assessed for readability and simplified using GPT-4, with pre- and post-simplification readability metrics compared using nonparametric tests. Independent reviews by medical authors and a malpractice defense attorney were conducted. Finally, GPT-4's potential for generating de novo procedure-specific consent forms was assessed, with forms evaluated using a validated 8-item rubric and expert subspecialty surgeon review. Analysis of 15 academic medical centers' consent forms revealed significant reductions in average reading time, word rarity, and passive sentence frequency (all P < 0.05) following GPT-4-faciliated simplification. Readability improved from an average college freshman to an 8th-grade level (P = 0.004), matching the average American's reading level. Medical and legal sufficiency consistency was confirmed. GPT-4 generated procedure-specific consent forms for five varied surgical procedures at an average 6th-grade reading level. These forms received perfect scores on a standardized consent form rubric and withstood scrutiny upon expert subspeciality surgeon review. This study demonstrates the first AI-human expert collaboration to enhance surgical consent forms, significantly improving readability without sacrificing clinical detail. Our framework could be extended to other patient communication materials, emphasizing clear communication and mitigating disparities related to health literacy barriers.

Outcomes of Mechanical Thrombectomy in Patients With Neurological Disorders: A National Inpatient Sample Database Analysis.

INTRODUCTION: Mechanical thrombectomy (MT) has changed the standard of care for patients presenting with acute ischemic stroke (AIS). The window of treatment has significantly increased the number of patients who would benefit from intervention and operators may be confronted with patients harboring preexistent neurological disorders. Still, the epidemiology of patients with AIS and neurological disorders has not been established. METHODS: This is a retrospective study, which utilizes data from the National Inpatient Sample (NIS) between 2012 and 2016. Patients with the major neurological comorbidities in the study were included: Alzheimer's dementia (AD), Parkinson's disease (PD), amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), and myasthenia gravis (MG). These patients were divided into groups and analyzed based on discharged home status, length of hospital stay (LOS), and inpatient mortality. These outcomes were also compared between patients who underwent MT versus those who did not. RESULTS: In this study, 460,070 patients with AIS were identified and included. MT was performed less often when the patient had a neurological diagnosis compared to those without a neurological disease (p<0.0001). However, patients with AIS who have underlying neurological disorders such as AD, PD, and MS have shown similar outcomes after MT to those who do not have these disorders. CONCLUSION: Patients with preexisting neurological disorders were less likely to undergo MT. Further studies are required to elucidate the implications of having a neurological disorder in the setting of an AIS.

Al-Zahrawi (936-1013 AD): On the Surgical Treatment of Neurological Disorders by the Father of Operative Surgery.

BACKGROUND: Medical knowledge during the medieval ages flourished under the influence of great scholars of the Islamic Golden age such as Ibn Sina (Latinized as Avicenna), Abu Bakr al-Razi (Rhazes), and Abu al-Qasim Khalaf ibn al-Abbas al-Zahrawi, known as Albucasis. Much has been written on al-Zahrawi's innovation in various disciplines of medicine and surgery. In this article, we focus for on the contributions of al-Zahrawi toward the treatment of neurological disorders in the surgical chapters of his medical encyclopedia, Kitab al-Tasrif (The Method of Medicine). METHODS: Excerpts from a modern copy of volume 30 of al-Zahrawi's Kitab al-Tasrif were reviewed and translated by the primary author from Arabic to English, to further provide specific details regarding his neurosurgical knowledge. In addition, a literature search was performed using PubMed and Google Scholar to review prior reports on al-Zahrawi's neurosurgical instructions. RESULTS: In addition to what is described in the literature of al-Zahrawi's teachings in cranial and spine surgery, we provide insight into his diagnosis and management of cranial and spinal trauma, the devices he used, and prognostication of various traumatic injuries. CONCLUSIONS: Al-Zahrawi was a renowned physician during the Islamic Golden age who made significant contributions to the diagnosis and treatment of neurological conditions, particularly cranial and spinal cord injuries. He developed innovative surgical techniques for trephination and spinal traction, which are still used in modern neurosurgery. His insights make him worthy of recognition as an important figure in the history of neurological surgery.

Exploring the Role of the Pulvinar Nucleus of the Thalamus in Occipital Lobe Epilepsy: A Case Report.

Understanding the role of the pulvinar nucleus may be critical for guiding circuit-targeted neurosurgical intervention in some patients. In this report, a 33-year-old female presented with focal onset occipital epilepsy with secondary generalization and with a previously radiated arteriovenous malformation within the right primary visual cortex. Phase II monitoring demonstrated the pulvinar nucleus was not involved in subclinical seizures restricted to the primary visual cortex, but it did become involved in clinical events with more extensive seizure spread into higher visual cortical regions. She underwent responsive neurostimulation (RNS) with implantation of leads within the primary visual cortex. This case demonstrates the late propagation of epileptic activity from the visual cortex to the pulvinar nucleus and illustrates the pulvinar nucleus' connections with higher-order visual areas.

Laser amygdalohippocampotomy reduces contralateral hippocampal sub-clinical activity in bitemporal epilepsy: A case illustration of responsive neurostimulator ambulatory recordings.

Responsive neurostimulation (RNS) is a valuable tool in the diagnosis and treatment of medication refractory epilepsy (MRE) and provides clinicians with better insights into patients' seizure patterns. In this case illustration, we present a patient with bilateral hippocampal RNS for presumed bilateral mesial temporal lobe epilepsy. The patient subsequently underwent a right sided LITT amygdalohippocampotomy based upon chronic RNS data revealing predominance of seizures from that side. Analyzing electrocorticography (ECOG) from the RNS system, we identified the frequency of high amplitude discharges recorded from the left hippocampal lead pre- and post- right LITT amygdalohippocampotomy. A reduction in contralateral interictal epileptiform activity was observed through RNS recordings over a two-year period, suggesting the potential dependency of the contralateral activity on the primary epileptogenic zone. These findings suggest that early targeted surgical resection or laser ablation by leveraging RNS data can potentially impede the progression of dependent epileptiform activity and may aid in preserving neurocognitive networks. RNS recordings are essential in shaping further management decisions for our patient with a presumed bitemporal epilepsy.

Demographic Representation in 3 Leading Artificial Intelligence Text-to-Image Generators.

Importance: The progression of artificial intelligence (AI) text-to-image generators raises concerns of perpetuating societal biases, including profession-based stereotypes. Objective: To gauge the demographic accuracy of surgeon representation by 3 prominent AI text-to-image models compared to real-world attending surgeons and trainees. Design, Setting, and Participants: The study used a cross-sectional design, assessing the latest release of 3 leading publicly available AI text-to-image generators. Seven independent reviewers categorized AI-produced images. A total of 2400 images were analyzed, generated across 8 surgical specialties within each model. An additional 1200 images were evaluated based on geographic prompts for 3 countries. The study was conducted in May 2023. The 3 AI text-to-image generators were chosen due to their popularity at the time of this study. The measure of demographic characteristics was provided by the Association of American Medical Colleges subspecialty report, which references the American Medical Association master file for physician demographic characteristics across 50 states. Given changing demographic characteristics in trainees compared to attending surgeons, the decision was made to look into both groups separately. Race (non-White, defined as any race other than non-Hispanic White, and White) and gender (female and male) were assessed to evaluate known societal biases. Exposures: Images were generated using a prompt template, "a photo of the face of a [blank]", with the blank replaced by a surgical specialty. Geographic-based prompting was evaluated by specifying the most populous countries on 3 continents (the US, Nigeria, and China). Main Outcomes and Measures: The study compared representation of female and non-White surgeons in each model with real demographic data using χ2, Fisher exact, and proportion tests. Results: There was a significantly higher mean representation of female (35.8% vs 14.7%; P < .001) and non-White (37.4% vs 22.8%; P < .001) surgeons among trainees than attending surgeons. DALL-E 2 reflected attending surgeons' true demographic data for female surgeons (15.9% vs 14.7%; P = .39) and non-White surgeons (22.6% vs 22.8%; P = .92) but underestimated trainees' representation for both female (15.9% vs 35.8%; P < .001) and non-White (22.6% vs 37.4%; P < .001) surgeons. In contrast, Midjourney and Stable Diffusion had significantly lower representation of images of female (0% and 1.8%, respectively; P < .001) and non-White (0.5% and 0.6%, respectively; P < .001) surgeons than DALL-E 2 or true demographic data. Geographic-based prompting increased non-White surgeon representation but did not alter female representation for all models in prompts specifying Nigeria and China. Conclusion and Relevance: In this study, 2 leading publicly available text-to-image generators amplified societal biases, depicting over 98% surgeons as White and male. While 1 of the models depicted comparable demographic characteristics to real attending surgeons, all 3 models underestimated trainee representation. The study suggests the need for guardrails and robust feedback systems to minimize AI text-to-image generators magnifying stereotypes in professions such as surgery.

Metastatic cervical carcinoma to the brain masquerading as a butterfly glioma: A case report.

Background: Metastatic cervical cancer to the brain is a rare occurrence, representing approximately 1.5% of metastatic cases. We report a rare presentation of cervical cancer with brain metastasis to the corpus callosum. The patient was initially suspected to have a primary glioma but was diagnosed with a metastatic cervical carcinoma lesion through both stereotactic and then opens biopsy. Case Description: A 53-year-old female, with Stage III adenosquamous cervical carcinoma, presented with a large heterogeneously enhancing mass in the corpus callosum body with extension in the cingulate gyrus concerning for glioma. A stereotactic biopsy revealed hypercellular and gliotic brain tissue, while an open biopsy showed an epithelioid neoplasm consistent with metastatic cervical adenosquamous carcinoma. The patient underwent a craniotomy and recovered well and was discharged in stable condition. Conclusion: Brain metastases from cervical cancer are uncommon. We present a rare case of metastatic cervical carcinoma which appeared on imaging to mimic a butterfly glioma. The patient's history and histopathological examination were essential in determining the correct diagnosis and receiving timely treatment.

Minimizing blood loss with direct percutaneous polymethylmethacrylate embolization before corpectomy for vascular spinal tumors.

Background: Standard surgical treatment for vascular spinal tumors, including renal cell carcinomas and hemangiomas, may result in significant blood loss despite preoperative arterial tumor embolization. Methods: This is a retrospective review of 12 patients who underwent direct percutaneous polymethylmethacrylate embolization (DPPE) with or without feeding artery embolization before partial or complete corpectomy for the resection of vascular spinal tumors (2013-2018). Estimated blood loss (EBL) was compared to the blood loss reported in the literature and to patients receiving standard arterial embolization before surgery. Results: The mean EBL for 12 patients was 1030 mL; three of 12 patients required blood transfusions. For the single level corpectomies, the EBL ranged from 100 mL to 3900 mL (mean 640 mL). This mean blood loss was not increased in patients receiving only DPPE preoperatively versus those patients receiving preoperative arterial embolization in addition to DPPE (1005 vs. 1416 mL); in fact, the EBL was significantly reduced for those undergoing DPPE alone. Conclusion: In this initial study, nine patients treated with DPPE embolization alone before spinal tumor resection demonstrated reduction of intraoperative blood loss compared to three patients having arterial embolization with DDPE.

Seizure and anatomical outcomes of repeat laser amygdalohippocampotomy for temporal lobe epilepsy: A single-institution case series.

OBJECTIVE: In patients with treatment-refractory temporal lobe epilepsy (TLE), a single stereotactic laser interstitial thermotherapy (LITT) procedure is sometimes insufficient to ablate epileptogenic tissue, particularly the medial structures often implicated in TLE. In patients with seizure recurrence after initial ablation, the extent to which a second ablation may achieve improved seizure outcomes is uncertain. The objective of this study was to investigate the feasibility and potential efficacy of repeat LITT amygdalohippocampotomy as a worthwhile strategy for intractable temporal lobe epilepsy by quantifying changes to targeted mesial temporal lobe structures and seizure outcomes. METHODS: Patients who underwent two LITT procedures for drug-resistant mesial TLE at our institution were included in the study. Lesion volumes for both procedures were calculated by comparing post-ablation intraoperative sequences to preoperative anatomy. Clinical outcomes after the initial procedure and repeat procedure were classified according to Engel scores. RESULTS: Five consecutive patients were included in this retrospective case series: 3 with right- and 2 with left-sided TLE. The median interval between LITT procedures was 294 days (range: 227-1918). After the first LITT, 3 patients experienced class III outcomes, 1 experienced a class IV, and 1 experienced a class IB outcome. All patients achieved increased seizure freedom after a second procedure, with class I outcomes (3 IA, 2 IB). CONCLUSIONS: Repeat LITT may be sufficient to achieve satisfactory seizure outcomes in some individuals who might otherwise be considered for more aggressive resection or palliative neuromodulation. A larger study to establish the potential value of repeat LITT amygdalohippocampotomy vs. other re-operation strategies for persistent, intractable temporal lobe epilepsy is worth pursuing.

Thalamic neuromodulation in epilepsy: A primer for emerging circuit-based therapies.

INTRODUCTION: Epilepsy is a common, often debilitating disease of hyperexcitable neural networks. While medically intractable cases may benefit from surgery, there may be no single, well-localized focus for resection or ablation. In such cases, approaching the disease from a network-based perspective may be beneficial. AREAS COVERED: Herein, the authors provide a narrative review of normal thalamic anatomy and physiology and propose general strategies for preventing and/or aborting seizures by modulating this structure. Additionally, they make specific recommendations for targeting the thalamus within different contexts, motivated by a more detailed discussion of its distinct nuclei and their respective connectivity. By describing important principles governing thalamic function and its involvement in seizure networks, the authors aim to provide a primer for those now entering this fast-growing field of thalamic neuromodulation for epilepsy. EXPERT OPINION: The thalamus is critically involved with the function of many cortical and subcortical areas, suggesting it may serve as a compelling node for preventing or aborting seizures, and so it has increasingly been targeted for the surgical treatment of epilepsy. As various thalamic neuromodulation strategies for seizure control are developed, there is a need to ground such interventions in a mechanistic, circuit-based framework.

Time of Discharge and 30-Day Re-Presentation to an Acute Care Setting After Elective Lumbar Decompression Surgery.

BACKGROUND: Evidence regarding the consequence of efforts to increase patient throughput and decrease length of stay in the context of elective spine surgery is limited. OBJECTIVE: To evaluate whether early time of discharge results in increased rates of hospital readmission or return to emergency department for patients admitted after elective, posterior, lumbar decompression surgery. METHODS: We conducted a retrospective cohort study of 779 patients admitted to hospital after undergoing elective, posterior, lumbar decompression surgery. Multiple logistic regression evaluated the relationship between time of discharge and the primary outcome of return to acute care within 30 days, while controlling for sociodemographic, procedural, and discharge characteristics. RESULTS: In multiple logistic regression, time of discharge earlier in the day was not associated with increased odds of return to acute care within 30 days (odds ratio [OR] 1.18, 95% CI 0.92-1.52, P = .19). Weekend discharge (OR 1.99, 95% CI 1.04-3.79, P = .04) increased the likelihood of return to acute care. Surgeon experience (<1 year of attending practice, OR 0.43, 95% CI 0.19-1.00, P = .05 and 2-5 years of attending practice, OR 0.50, 95% CI 0.25-1.01, P = .054), weekend discharge (OR 0.49, 95% CI 0.27-0.89, P = .02), and physical therapy evaluation (OR 0.20, 95% CI 0.12-0.33, P < .001) decreased the likelihood of discharge before noon. CONCLUSION: Time of discharge is not associated with risk of readmission or presentation to the emergency department after elective lumbar decompression. Weekend discharge is independently associated with increased risk of readmission and decreased likelihood of prenoon discharge.

The Surgical Histopathology of the Filum Terminale: Findings from a Large Series of Patients with Tethered Cord Syndrome.

This study investigated the prevalence of embryonic and connective tissue elements in the filum terminale (FT) of patients with tethered cord syndrome (TCS), examining both typical and pathological histology. The FT specimens from 288 patients who underwent spinal cord detethering from 2013 to 2021 were analyzed. The histopathological examination involved routine hematoxylin and eosin staining and specific immunohistochemistry when needed. The patient details were extracted from electronic medical records. The study found that 97.6% of the FT specimens had peripheral nerves, and 70.8% had regular ependymal cell linings. Other findings included ependymal cysts and canals, ganglion cells, neuropil, and prominent vascular features. Notably, 41% showed fatty infiltration, and 7.6% had dystrophic calcification. Inflammatory infiltrates, an underreported finding, were observed in 3.8% of the specimens. The research highlights peripheral nerves and ganglion cells as natural components of the FT, with ependymal cell overgrowth and other tissues potentially linked to TCS. Enlarged vessels may suggest venous congestion due to altered FT mechanics. The presence of lymphocytic infiltrations and calcifications provides new insights into structural changes and mechanical stress in the FT, contributing to our understanding of TCS pathology.

Neighborhood-level socioeconomic status, extended length of stay, and discharge disposition following elective lumbar spine surgery.

Background: In the context of increased attention afforded to hospital efficiency and improved but safe patient throughput, decreasing unnecessary hospital length of stay (LOS) is imperative. Given that lumbar spine procedures may be among a hospital's most profitable services, identifying patients at risk of increased healthcare resource utilization prior to surgery is a valuable opportunity to develop targeted pre- and peri-operative intervention and quality improvement initiatives. The purpose of the present investigation was to examine patient factors that predict prolonged LOS as well as discharge disposition following elective, posterior, lumbar spine surgery. Methods: We employed a retrospective cohort analysis on 779 consecutive patients treated with lumbar surgery without fusion. Our primary outcome measures were extended LOS (three or more midnights) and discharge disposition. Patient sociodemographic, procedural, and discharge characteristics were adjusted for in our analysis. Sociodemographic variables included Area of Deprivation Index (ADI), a comprehensive metric of socioeconomic status, utilizing income, education, employment, and housing quality based on patient zip code. Multivariable logistic regression and ordinal logistic regression analyses were performed to assess whether covariates were independently predictive of extended LOS and discharge disposition, respectively. Results: 779 patients were studied, with a median age of 66 years (±15) and a median LOS of 1 midnight (range, 1-10 midnights). Patients in the most disadvantaged ADI quintile (adjusted odds ratio, aOR 2.48 95% CI 1.15-5.47), those who underwent a minimally-invasive or tubular retractor surgery (aOR 3.03 95% CI 1.02-8.56), those who had an intra-operative drain placed (aOR 4.46 95% CI 2.53-7.26), who had a cerebrospinal fluid leak (aOR 3.46 95% CI 1.55-7.58), who were discharged anywhere but home (aOR 17.11 95% CI 9.24-33.00), and those who were evaluated by physical therapy (aOR 7.23 95% CI 2.13-45.30) or OT (aOR 2.20 95% CI 1.13-4.22) had a significantly increased chance of an extended LOS. Preoperative opioid use was not associated with an increased LOS following surgery (aOR 1.12 95% CI 0.56-1.46). Extended LOS was not associated with post-discharge emergency department representation or unplanned readmission within 90 days following discharge (p=0.148). Patients who were older (aOR 1.99 95% CI 1.62-2.48), in higher quintiles on ADI (3rd quintile; aOR 1.90 95% CI 1.12-3.23, 4th quintile; aOR 1.79, 95% CI 1.05-3.05, 5th quintile; aOR 2.16 95% CI 1.26-3.75), who had a CSF leak (aOR 2.18 95% CI 1.22-3.86), or who had a longer procedure duration (aOR 1.38 95% CI 1.17-1.62) were more likely to require additional services or be sent to a subacute facility upon discharge. Conclusions: Patient sociodemographics, along with procedural factors, and discharge disposition were all associated with an increased likelihood of prolonged LOS and resource intensive discharges following elective lumbar spine surgery. Several of these factors could be reliably identified pre-operatively and may be amenable to targeted preoperative intervention. Improving discharge disposition planning in the peri-operative period may allow for more efficient use of hospitalization and inpatient and post-acute resources.

Development of posttraumatic frontal brain abscess in association with an orbital roof fracture and odontogenic abscess: A case report.

Background: Brain abscess is a potentially fatal condition. Orbital fractures caused by penetrating injury may be associated with intracranial infection. Such complication associated with blunt trauma, orbital roof fractures, and odontogenic abscesses is exceedingly rare. Case Description: We report the case of a 40-year-old transgender female with a frontal abscess presenting several weeks following a motor vehicle crash from which she suffered multiple facial fractures and an odontogenic abscess. On computed tomography scan, the patient had multiple right-sided facial fractures, including a medial orbital wall fracture and a right sphenoid fracture extending into the superior orbital roof. There was hemorrhage notable in the right frontal lobe. Communication with the ethmoid sinuses likely provided a conduit for bacterial spread through the orbit and into the intracranial and subdural spaces. Conclusion: Skull base fractures that communicate with a sinus, whether it be frontal, ethmoid, or sphenoid may increase the risk of brain abscess, especially in patients who develop an odontogenic abscess. Surgical repair of the defect is essential, and treating patients prophylactically with antibiotics may be beneficial.

Pedicle Screw Placement Using Intraoperative Computed Tomography and Computer-Aided Spinal Navigation Improves Screw Accuracy and Avoids Postoperative Revisions: Single-Center Analysis of 1400 Pedicle Screws.

OBJECTIVE: Intraoperative computed tomography and navigation (iCT-Nav) is increasingly used to aid spinal instrumentation. We aimed to document the accuracy and revision rate of pedicle screw placement across many screws placed using iCT-Nav. We also assess patient-level factors predictive of high-grade pedicle breach. METHODS: Medical records of patients who underwent iCT-Nav pedicle screw placement between 2015 and 2017 at a single center were retrospectively reviewed. Screw placement accuracy was individually assessed for each screw using the 2-mm incremental grading system for pedicle breach. Predictors of high-grade (>2 mm) breach were identified using multiple logistic regression. RESULTS: In total, 1400 pedicle screws were placed in 208 patients undergoing cervicothoracic (29; 13.9%), thoracic (30; 14.4), thoracolumbar (19; 9.1%) and lumbar (130; 62.5%) surgeries. iCT-Nav afforded high-accuracy screw placement, with 1356 of 1400 screws (96.9%) being placed accurately. In total, 37 pedicle screws (2.64%) were revised intraoperatively during the index surgery across 31 patients, with no subsequent returns to the operating room because of screw malpositioning. After correcting for potential confounders, males were less likely to have a high-grade breach (odds ratio [OR] 0.21; 95% confidence interval [CI] 0.10-0.59, P = 0.003) whereas lateral (OR 6.21; 95% CI 2.47-15.52, P < 0.001) or anterior (OR 5.79; 95% CI2.11-15.88, P = 0.001) breach location were predictive of a high-grade breach. CONCLUSIONS: iCT-Nav with postinstrumentation intraoperative imaging is associated with a reduced need for costly postoperative return to the operating room for screw revision. In comparison with studies of navigation without iCT where 1.5%-1.7% of patients returned for a second surgery, we report 0 revision surgeries due to screw malpositioning.

Toward more accurate documentation in neurosurgical care.

OBJECTIVE: Accurate clinical documentation is foundational to any quality improvement endeavor as it is ultimately the medical record that is measured in assessing change. Literature on high-yield interventions to improve the accuracy and completeness of clinical documentation by neurosurgical providers is limited. Therefore, the authors sought to share a single-institution experience of a two-part intervention to enhance clinical documentation by a neurosurgery inpatient service. METHODS: At an urban, level I trauma, academic teaching hospital, a two-part intervention was implemented to enhance the accuracy of clinical documentation of neurosurgery inpatients by residents and advanced practice providers (APPs). Residents and APPs were instructed on the most common neurosurgical complications or comorbidities (CCs) and major complications or comorbidities (MCCs), as defined by Medicare. Additionally, a "system-based" progress note template was changed to a "problem-based" progress note template. Prepost analysis was performed to compare the CC/MCC capture rates for the 12 months prior to the intervention with those for the 3 months after the intervention. RESULTS: The CC/MCC capture rate for the neurosurgery service line rose from 62% in the 12 months preintervention to 74% in the 3 months after intervention, representing a significant change (p = 0.00002). CONCLUSIONS: Existing clinical documentation habits by neurosurgical residents and APPs may fail to capture the extent of neurosurgical inpatients with CC/MCCs. An intervention that focuses on the most common CC/MCCs and utilizes a problem-based progress note template may lead to more accurate appraisals of neurosurgical patient acuity.

Short- and long-term opioid use in survivors of subarachnoid hemorrhage.

OBJECTIVES: Opioids are frequently used for analgesia in patients with acute subarachnoid hemorrhage (SAH) due to a high prevalence of headache and neck pain. However, it is unclear if this practice may pose a risk for opioid dependence, as long-term opioid use in this population remains unknown. We sought to determine the prevalence of opioid use in SAH survivors, and to identify potential risk factors for opioid utilization. METHODS: We analyzed a cohort of consecutive patients admitted with non-traumatic and suspected aneurysmal SAH to an academic referral center. We included patients who survived hospitalization and excluded those who were not opioid-naïve. Potential risk factors for opioid prescription at discharge, 3 and 12 months post-discharge were assessed. RESULTS: Of 240 SAH patients who met our inclusion criteria (mean age 58.4 years [SD 14.8], 58% women), 233 (97%) received opioids during hospitalization and 152 (63%) received opioid prescription at discharge. Twenty-eight patients (12%) still continued to use opioids at 3 months post-discharge, and 13 patients (6%) at 12-month follow up. Although patients with poor Hunt and Hess grades (odds ratio 0.19, 95% CI 0.06-0.57) and those with intraventricular hemorrhage (odds ratio 0.38, 95% CI 0.18-0.87) were less likely to receive opioid prescriptions at discharge, we did not find significant differences between patients who had long-term opioid use and those who did not. CONCLUSION: Opioids are regularly used in both the acute SAH setting and immediately after discharge. A considerable number of patients also continue to use opioids in the long-term. Opioid-sparing pain control strategies should be explored in the future.

Demand for Essential Nonambulatory Neurosurgical Care Decreased While Acuity of Care Increased During the Coronavirus Disease 2019 (COVID-19) Surge.

BACKGROUND: In times of health resource reallocation, capacities must remain able to meet a continued demand for essential, nonambulatory neurosurgical acute care. This study sought to characterize the demand for and provision of neurosurgical acute care during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: This single-center cross-sectional observational analysis compared nonambulatory neurosurgical consult encounters during the peri-surge period (March 9 to May 31, 2020) with those during an analogous period in 2019. Outcomes included consult volume, distribution of problem types, disease severity, and rate of acute operative intervention. RESULTS: A total of 1494 neurosurgical consults were analyzed. Amidst the pandemic surge, 583 consults were seen, which was 6.4 standard deviations below the mean among analogous 2016-2019 periods (mean 873; standard deviation 45, P = 0.001). Between 2019 and 2020, the proportion of degenerative spine consults decreased in favor of spinal trauma (25.6% vs. 34% and 51.9% vs. 41.4%, P = 0.088). Among aneurysmal subarachnoid hemorrhage cases, poor-grade (Hunt and Hess grades 4-5) presentations were more common (30% vs. 14.8%, P = 0.086). A greater proportion of pandemic era consults resulted in acute operative management, with an unchanged absolute frequency of acutely operative consults (123/583 [21.1%] vs. 120/911 [13.2%], P < 0.001). CONCLUSIONS: Neurosurgical consult volume during the pandemic surge hit a 5-year institutional low. Amidst vast reallocation of health care resources, demand for high-acuity nonambulatory neurosurgical care continued and proportionally increased for greater-acuity pathologies. In our continued current pandemic as well as any future situations of mass health resource reallocation, neurosurgical acute care capacities must be preserved.

A minimally invasive lateral approach with CT navigation for open biopsy and diagnosis of Nocardia nova L4-5 discitis osteomyelitis: illustrative case.

BACKGROUND: Lumbar spine osteomyelitis can be refractory to conventional techniques for identifying a causal organism. In cases in which a protracted antibiotic regimen is indicated, obtaining a conclusive yield on biopsy is particularly important. Although lateral transpsoas approaches and intraoperative computed tomography (CT) navigation are well documented as techniques used for spinal arthrodesis, their utility in vertebral biopsy has yet to be reported in any capacity. OBSERVATIONS: In a 44-year-old male patient with a history of Nocardia bacteremia, CT-guided biopsy failed to confirm the microbiology of an L4-5 discitis osteomyelitis. The patient underwent a minimally invasive open biopsy in which a lateral approach with intraoperative guidance was used to access the infected disc space retroperitoneally. A thin film was obtained and cultured Nocardia nova, and the patient was treated accordingly with a long course of trimethoprim-sulfamethoxazole. LESSONS: The combination of a lateral transpsoas approach with intraoperative navigation is a valuable technique for obtaining positive yield in cases of discitis osteomyelitis of the lumbar spine refractory to CT-guided biopsy.