Determining Contemporary Barriers to Effective Multidisciplinary Team Meetings in Neurological Surgery: A Review of the Literature.

OBJECTIVE: The integration of multidisciplinary team meetings (MDTMs) for neurosurgical care has been accepted worldwide. Our objective was to review the literature for the limiting factors to MDTMs that may introduce bias to patient care. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analysis was used to perform a literature review of MDTMs for neuro-oncology, pituitary oncology, cerebrovascular surgery, and spine surgery and spine oncology. Limiting factors to productive MDTMs and factors that introduce bias were identified, as well as determining whether MDTMs led to improved patient outcomes. RESULTS: We identified 1264 manuscripts from a PubMed and Ovid Medline search, of which 27 of 500 neuro-oncology, 4 of 279 pituitary, and 11 of 260 spine surgery articles met our inclusion criteria. Of 224 cerebrovascular manuscripts, none met the criteria. Factors for productive MDTMs included quaternary/tertiary referral centers, nonhierarchical environment, regularly scheduled meetings, concise inclusion of nonmedical factors at the same level of importance as patient clinical information, inclusion of nonclinical participants, and use of clinical guidelines and institutional protocols to provide recommendations. Our review did not identify literature that described the use of artificial intelligence to reduce bias and guide clinical care. CONCLUSIONS: The continued implementation of MDTMs in neurosurgery should be recommended but cautioned by limiting bias.

Systematic Review of Traumatic Thoracic Spondyloptosis and Presentation of a Novel Approach for Management With Quad Rod Construct.

BACKGROUND: Traumatic thoracic spondyloptosis (TTS) is a rare but devastating spinal injury often secondary to high-impact trauma. TTS is typically managed with surgical fusion and stabilization. OBJECTIVE: To evaluate current surgical management of TTS while presenting a novel surgical technique for reduction and fusion. METHODS: We performed a systematic review of surgical management of TTS using Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Individual Participant Data guidelines with 2 independent reviewers. We identified patient demographics, level of spondyloptosis, American Spinal Injury Association grade, level of spinal fusion, surgical approach, type of construct used, and reduction of fracture. RESULTS: Seventeen articles with 37 patients with TTS managed surgically were identified. The male:female ratio was 31:6. The average age was 33 years (±15). Motorized injury including motor vehicle accident, road traffic accident, and motor vehicle collision (16 patients, 43%) and fall including fall from height, stairs, train, or standing (16 patients, 43%) were equivalent. The middle (15 patients 40%) and lower (18 patients, 49%) thoracic regions were similar for the level of spondyloptosis. Thirty-four patients (92%) were American Spinal Injury Association A. Thirty-six patients (97.3%) underwent posterior only surgery and 1 (2.7%) underwent a combined posterior-anterior approach. There were 29 (78%) dual rod constructs and 8 (22%) dual rod with connectors or crosslinks. Complete reduction was obtained in 24 (65%) patients, incomplete in 11 (30%), and 2 (5%) patients were not reported. Two of our patients underwent novel quad rod reconstruction with complete reduction. CONCLUSION: Surgical management of TTS is typically posterior only with complete fracture reduction. We have presented a novel quad rod approach for reduction of TTS.

Spinal column shortening for tethered cord syndrome: a systematic review and individual patient data meta-analysis.

OBJECTIVE: Tethered cord release (TCR) is the gold standard treatment for tethered cord syndrome (TCS); however, there are significant shortcomings including high rates of retethering, especially in complex and recurrent cases. Spinal column shortening (SCS) is an alternative treatment for TCS intended to avoid these shortcomings. Early studies were limited to case reports and smaller case series; however, in recent years, larger case series and small cohort studies have been conducted. Given the increase in available data, a repeat systematic review and meta-analysis is warranted to assess the safety and efficacy of SCS for TCS. METHODS: The authors conducted a systematic review using MEDLINE (OVID), Embase (Elsevier), and Web of Science records dating from 1944 to July 2021 to identify all articles investigating SCS for TCS. They performed standard and individual patient data (IPD) meta-analyses, with 2 independent reviewers using PRISMA-IPD guidelines. Primary outcomes were improvement of preoperative clinical symptoms of pain, motor weakness, and bladder and bowel dysfunction, and also surgical complication rate. Secondary outcomes included urodynamic improvement and health-related quality-of-life outcomes determined using patient-reported outcome tools. Individual study quality assessment was performed using a standardized assessment tool for case reports/series, and publication bias was assessed using funnel plot analyses. RESULTS: The review yielded 15 studies with 191 cases of TCS treated with SCS. IPD were available in 11 studies with 89 cases. The average age at time of surgery was 28.0 years (range 5-76 years). The average follow-up time was 33.2 months (range 7-132 months). Improvement was observed at last follow-up in 60 of 70 (85.7%) patients with preoperative pain, in 38 of 60 (60.3%) patients with preoperative weakness, and in 36 of 76 (47.4%) patients with preoperative bladder or bowel dysfunction. Complications of CSF leak, new neurological deficit, wound infection, or reoperation occurred in 4 of 89 (4.5%) patients. CONCLUSIONS: SCS may be considered a safe and efficacious treatment option for TCS in children and adults (level C evidence; class IIb recommendation), especially for recurrent and complex cases. Current evidence is likely to be affected by selection and publication bias. Prospective comparative studies of SCS and TCR for TCS are recommended to determine long-term duration of outcomes, long-term safety in skeletally immature children, and exact indications of SCS versus traditional TCR.

Anterior Lumbar Interbody Fusion With Robotic-Assisted Percutaneous Screw Placement: A Case Report.

Recently, there has been an increase in robotic-assisted spine fusion for degenerative spondylosis of the lumbar spine. We present the case of a 60-year-old female with grade 1 spondylolisthesis at L4/5 and L5/S1 who underwent L4-S1 anterior lumbar interbody fusion (ALIF) with percutaneous robotic-assisted pedicle screw fixation. We provide a detailed analysis of the procedure including the speed of robotic screw placement and pitfalls of this surgical approach.

Spinal column shortening for secondary tethered cord syndrome: radiographic, clinical, patient-reported, and urodynamic short-term outcomes.

OBJECTIVE: Tethered cord syndrome (TCS) is a clinical and radiographic diagnosis of pathological stretching of the spinal cord leading to progressive loss of neurological function. The gold standard treatment for TCS is a tethered cord release. However, detethering involves significant risks of spinal cord injury and high rates of retethering. To mitigate these risks, the concept of spinal column shortening (SCS) to decrease spinal cord tension has become an alternative to detethering. In this study, the authors applied SCS to a pediatric and emerging adult population affected by secondary TCS. METHODS: A retrospective review of a prospective database at the authors' tertiary pediatric institution was performed. The Pediatric Quality of Life Inventory, patient- and parent-reported outcomes, and urodynamics were used to evaluate the outcomes of TCS treated with SCS. RESULTS: A total of 41 patients with secondary TCS were treated with SCS. The average age at the time of surgery was 15.9 years (range 5-55 years). Preoperative symptoms evaluated included pain (33 patients), weakness (30 patients), and bladder/bowel dysfunction (39 patients). The most common level of spinal column osteotomy was T12, with spinal fusion between T10 and L2. The mean follow-up time was 22.6 months (range 8-45 months). For patients with at least 12 months of follow-up, subjective clinical improvements were reported in 21/23 (91.3%) of those with preoperative pain (p < 0.01); in 16/24 (66.7%) of patients with weakness (p < 0.01), and in 15/29 (51.7%) of those with bladder/bowel dysfunction (p < 0.01). The median differences in initial and most recent Pediatric Quality of Life Inventory results were +5 for patient-reported scores (n = 19, p = 0.04) and +5 for parent-reported scores (n = 19, p = 0.08). Formal urodynamics performed at a median of 3.5 months after surgery documented stable to improved bladder function in 16/17 patients, with a median improvement in one classification category (n = 17, p = 0.01). CONCLUSIONS: SCS continues to represent a safe and efficacious alternative to traditional spinal cord untethering for TCS in children and emerging adults, as documented by objective formal urodynamics and patient- and parent-reported outcomes.

Rapid Improvement Project: Improving Caregivers' Understanding of Safety Recommendations for Neurosurgical Devices.

There has been a proliferation in the development of indwelling neuromodulatory devices with varied safety recommendations, making it difficult for providers to remain up-to-date. This deficit presents an opportunity for significant improvement in patient safety. METHODS: We performed a search for monopolar electrocautery and magnetic resonance imaging safety recommendations for several indwelling neuromodulatory devices. We developed a questionnaire followed by an educational compendium and a posttest for 50 care providers. RESULTS: Overall, there was a poor performance on the pretest (mean 39%, SD 19%) but significant improvement on the posttest (mean 71%, SD 16%), P < 0.0001. We placed the educational compendium that included all manufacturer recommendations in the operating room for easy reference. A 2.4 times decrease in the case start times of vagus nerve stimulator cases is evidence of its effectiveness. CONCLUSIONS: The authors highlight the lack of knowledge about manufacturer safety recommendations for indwelling neurosurgical devices, which led to the creation of operating room supplements and educational devices.

Institutional review of the management of type II odontoid fractures: associations and outcomes with fibrous union.

OBJECTIVE: Type II odontoid fractures may be managed operatively or nonoperatively. If managed with bracing, bony union may never occur despite stability. This phenomenon is termed fibrous union. The authors aimed to determine associations with stable fibrous union and compare the morbidity of patients managed operatively and nonoperatively. METHODS: The authors performed a retrospective review of their spine trauma database for adults with type II odontoid fractures between 2015 and 2019. Two-sample t-tests and Fisher's exact tests identified associations with follow-up stability and were used to compare operative and nonoperative outcomes. Sensitivity, specificity, and predictive values were calculated to validate initial stable upright cervical radiographs related to follow-up stability. RESULTS: Among 88 patients, 10% received upfront surgical fixation, and 90% were managed nonoperatively, of whom 22% had fracture instability on follow-up. Associations with instability after nonoperative management include myelopathy (OR 0.04, 95% CI 0.0-0.92), cerebrovascular disease (OR 0.23, 95% CI 0.06-1.0), and dens displacement ≥ 2 mm (OR 0.29, 95% CI 0.07-1.0). Advanced age was not associated with follow-up instability. Initial stability on upright radiographs was associated with stability on follow-up (OR 4.29, 95% CI 1.0-18) with excellent sensitivity and positive predictive value (sensitivity 89%, specificity 35%, positive predictive value 83%, and negative predictive value 46%). The overall complication rate and respiratory failure requiring ventilation on individual complication analysis were more common in operatively managed patients (33% vs 3%, respectively; p = 0.007), even though they were generally younger and healthier than those managed nonoperatively. Operative or nonoperative management conferred no difference in length of hospital or ICU stay, discharge disposition, or mortality. CONCLUSIONS: The authors delineate the validity of upright cervical radiographs on presentation in association with follow-up stability in type II odontoid fractures. In their experience, factors associated with instability included cervical myelopathy, cerebrovascular disease, and fracture displacement but not increased age. Operatively managed patients had higher complication rates than those managed without surgery. Fibrous union, which can occur with nonoperative management, provided adequate stability.

Comparative Anatomy of the Mammalian Corneal Subbasal Nerve Plexus.

Purpose: The subbasal nerve plexus (SNP) is the densest and most recognizable component of the mammalian corneal innervation; however, the anatomical configuration of the SNP in most animal models remains incompletely described. The purpose of the current study is to describe in detail the SNP architecture in eight different mammals, including several popular animal models used in cornea research. Methods: Corneal nerves in mouse, rat, guinea pig, rabbit, dog, macaque, domestic pig, and cow eyes were stained immunohistochemically with antiserum directed against neurotubulin. SNP architecture was documented by digital photomicrography and large-scale reconstructions, that is, corneal nerve maps, using a drawing tube attached to a light microscope. Results: Subbasal nerve fibers (SNFs) in mice, rats, guinea pigs, dogs, and macaques radiated centrally from the corneoscleral limbus toward the corneal apex in a whorl-like or spiraling pattern. SNFs in rabbit and bovine corneas swept horizontally across the ocular surface in a temporal-to-nasal direction and converged on the inferonasal limbus without forming a spiral. SNFs in the pig cornea radiated centrifugally in all directions, like a starburst, from a focal point located equidistant between the corneal apex and the superior pole. Conclusions: The results of the present study have demonstrated for the first time substantial interspecies differences in the architectural organization of the mammalian SNP. The physiological significance of these different patterns and the mechanisms that regulate SNP pattern formation in the mammalian cornea remain incompletely understood and warrant additional investigation.

Endovascular treatment of ruptured tiny (⩽3mm) intracranial aneurysms in the setting of subarachnoid hemorrhage: A case series of 20 patients and literature review.

Successful endovascular coiling of ruptured tiny saccular intracranial aneurysms (⩽3mm) is technically challenging and traditionally has been associated with technical failures, as well as morbidity related to thromboembolic events and high intraoperative rupture rates. This study analyzes the feasibility, technical efficacy, and clinical outcomes of coil embolization of ruptured tiny intracranial aneurysms using current coil and microcatheter technology and techniques. We performed a retrospective review of 20 patients with 20 ruptured tiny aneurysms treated with endovascular coil embolization from 2013 to 2016 at a single high-volume academic tertiary care practice. The mean aneurysm size was 2.4mm (median 2.5mm, 1-3). Complete occlusion was achieved in 12 of 20 patients (60%), the remaining 7 of 20 patients (35%) had a small neck remnant, and there was 1 failure (5%) converted to microsurgical clipping. Two patients had a failed attempted surgical clip reconstruction and were subsequently coiled. There was 1 intraprocedural rupture (5%) and 1 severe parent artery vasospasm (5%) during coiling. At discharge, 60% of patients were living independently. At follow-up three patients were deceased. Mean angiographic follow-up was 139days (SD 120). There were no aneurysm recurrences among occluded patients and there were no retreatments among those with neck remnants. Coiling of ruptured aneurysms ⩽3mm is feasible with high occlusion rates and low complication rates. The availability of softer coils with flexible detachment zones has led to safe and effective endovascular treatment of tiny ruptured aneurysms.