Osteoporosis as a Risk Factor for Intraoperative Complications and Long-term Instrumentation Failure in Patients With Scoliotic Spinal Deformity.

STUDY DESIGN: A retrospective review study. OBJECTIVE: This study aims to determine the effect of osteoporosis on spine instrumentation. SUMMARY OF BACKGROUND DATA: Osteoporosis is a common skeletal pathology that affects systemic cortical bone maintenance and remodeling. This disease accelerates the degeneration of the spine, often necessitating spinal surgery for progressive vertebral deformity, pathologic fracture, bony canal stenosis, and/or neural element decompression. There is a paucity of literature describing the role of osteoporosis as it relates to both perioperative complications and outcomes after spine fusion surgery. MATERIALS AND METHODS: A retrospective review was conducted of a prospectively maintained database for patients undergoing spine surgery between January 1, 2006 and October 3, 2017. Inclusion criteria included age 18 years and above and surgery performed for the correction of thoracolumbar scoliosis. Data collected included various demographic, clinical, and operative variables. RESULTS: A total of 532 patients met inclusion criteria, including 144 (27%) patients with a diagnosis of osteoporosis. Osteoporosis was significantly associated with increased blood volume loss (P=0.003). Postoperatively, osteoporosis was associated with increased rates of instrumentation failure (19% vs. 10%; P=0.008) and the need for revision surgery (33% vs. 16%; P<0.001). Multivariate analysis confirmed osteoporosis to be an independent risk factor for increased mean number of spinal segments fused (P<0.05), mean blood volume loss (P<0.05), rate of postoperative deep venous thrombosis/pulmonary embolism (P<0.05), rate of instrumentation failure (P<0.05), and need for revision surgery (P<0.05). CONCLUSION: Osteoporosis is a significant risk factor for instrumentation failure and need for revision surgery following arthrodesis for scoliosis correction. Furthermore, patients with osteoporosis have a significantly higher risk of intraoperative blood volume loss and postoperative thromboembolic events.

Headache and Other Symptoms in Chiari Malformation Type I Are Associated with Cerebrospinal Fluid Flow Improvement After Decompression: A Two-Institutional Study.

OBJECTIVE: Chiari malformation type I (CMI) is a common neurologic condition and surgery is the standard treatment. We aim to establish the cerebrospinal fluid (CSF) flow change as a potential objective indicator of surgical efficacy to improve symptoms. METHODS: We performed a retrospective 2-center analysis of surgically treated patients with CMI. Qualitative CSF flow studies obtained preoperatively and postoperatively were analyzed by the neuroradiologist, seeking improvement in CSF flow. Symptom status, including headache and neck pain, were recorded. RESULTS: Forty-nine patients were identified between 2010 and 2017. The average age was 36 years, with 47 females. After decompression, CSF flow was improved in 41 patients (group A) and unchanged in 8 (group B). Group A and B had a mean age of 34 and 42 years (P < 0.05) and an average tonsillar herniation of 8.3 and 8.5 mm (P = 0.40), respectively. Group A had improved clinical outcomes, compared with group B (P = 0.024), more specifically, in headache (50% vs. 37%), neck pain (66% vs. 33%), dizziness (78% vs. 50%), vision symptoms (84% vs. 80%), and weakness (100% vs. 66%), respectively. Group B had the only patient who did worse on clinical follow-up. CONCLUSIONS: Patients with CMI often present with a constellation of symptoms. We showed a significant association between improved CSF flow after decompression and symptom alleviation. Further, our study suggests that the presence of improved CSF flow postoperatively could represent an objective indicator for improved patient outcomes.

A Population-Based Study of Patients with Sleep-Wake Disorders Undergoing Elective Instrumented Spinal Surgery.

BACKGROUND: Sleep-wake disorders (SWDs) are associated with multiple systemic pathologies; however, the clinical risk that such disorders carry for spinal surgery patients is not well understood. In the present population-based study, we comprehensively evaluated the significance of sleep-related risk factors on instrumented spinal surgery outcomes. METHODS: National Inpatient Sample data for the hospitalization of patients who had undergone elective instrumented spine surgery from 2008 to 2014 were analyzed using national estimates. The cohorts were defined as those admissions with or without a coexisting SWD diagnosis identified by International Classification of Diseases, ninth revision, codes. Postoperative complications, mortality rate, length of stay, discharge status, and the total cost of admission were compared between the groups using bivariate and multivariate analyses. RESULTS: A coexisting SWD was present in 234,640 of 2,171,167 instrumented spinal surgery hospitalizations (10.8%). Multivariate binary logistic regression accounting for these variables confirmed that a SWD is a significant risk factor for postoperative complications (odds ratio [OR], 1.160; 95% confidence interval [CI], 1.140-1.179; P < 0.0001), length of stay greater than the 75th percentile (OR, 1.303; 95% CI, 1.288-1.320; P < 0.0001), nonroutine discharge (OR, 1.147; 95% CI, 1.131-1.163; P < 0.0001), and death (OR, 1.533; 95% CI, 1.131-2.078; P < 0.01), but not for total charges greater than the 75th percentile (OR, 0.975; 95% CI, 0.962-0.989; P < 0.001). CONCLUSIONS: SWDs confer an increased risk of morbidity and mortality for elective instrumented spine surgery. Understanding the specific contributions of SWDs to postoperative morbidity and mortality will help physicians implement prophylactic measures to reduce complications and improve postoperative patient recovery.

Recrudescent infection after deep brain stimulator reimplantation.

OBJECTIVE: The efficacy of deep brain stimulation (DBS) in treating the symptoms of movement disorders can be life changing for patients. Thus, the 5%-15% incidence of stimulator-related infection requiring removal of the device can be particularly disheartening. Although DBS system reimplantation is generally successful, this is not always the case. The literature is replete with publications describing the incidence of infection and the associated features. However, the literature is sparse in terms of information on the incidence of recurrent or recrudescent infection after system reimplantation. The goal of this paper was to evaluate factors leading to unsuccessful reimplantation of a DBS system following initial infection. METHODS: Data were reviewed for all DBS procedures performed by one surgeon (K.L.H.) over 19 years including the infectious agent, location of infection, treatment regimen, and subsequent reimplantation of a DBS system and long-term outcome. RESULTS: In this series of 558 patients who had undergone DBS surgery, 37 (6.6%) subsequently developed an infection. Infections with methicillin-sensitive Staphylococcus aureus, Enterobacter species, or coagulase-negative staphylococci were predominant. Four patients had cerebritis, one had meningitis, and the rest had soft tissue infections of the pocket or scalp. All had their entire DBS system explanted, followed by 4-6 weeks of intravenous antibiotics and surveillance for recrudescence for an additional period of at least 30 days. Twenty-five patients subsequently underwent DBS system reimplantation, and the procedure was successful in 22. Three of the 4 patients with cerebritis developed a subsequent wound infection after system reimplantation. None of the other 22 patients developed a recurrence. The odds ratio for developing a recurrent infection after cerebritis was 28.5 (95% CI 1.931-420.5, p = 0.007). CONCLUSIONS: This study, the largest series of DBS system reimplantations following infection, demonstrated that most patients can have successful reimplantations without recurrent infection. However, patients who have had DBS-related cerebritis have a nearly 30-fold increased risk of developing reinfection after reimplantation. Alternative strategies for these patients are discussed.

Magnetic resonance-guided focused ultrasound treatment for essential tremor shows sustained efficacy: a meta-analysis.

Although magnetic resonance-guided focused ultrasound (MRgFUS) is a viable treatment option for essential tremor, some studies note a diminished treatment benefit over time. A PubMed search was performed adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were included if hand tremor scores (HTS), total Clinical Rating Scale for Tremor (CRST) scores, or Quality of Life in Essential Tremor Questionnaire (QUEST) scores at regular intervals following MRgFUS treatment for essential tremor were documented. Data analyses included a random effects model of meta-analysis and mixed-effects model of meta-regression. Twenty-one articles reporting HTS for 395 patients were included. Mean pre-operative HTS was 19.2 ± 5.0. Mean HTS at 3 months post-treatment was 7.4 ± 5.0 (61.5% improvement, p < 0.001). Treatment effect was mildly decreased at 36 months at 9.1 ± 5.4 (8.8% reduction). Meta-regression of time since treatment as a modifier of HTS revealed a downward trend in effect size, though this was not statistically significant (p = 0.208). Only 4 studies included follow-up ≥ 24 months. Thirteen included articles reported total CRST scores with standardized follow-up for 250 patients. Mean pre-operative total CRST score decreased by 46.2% at 3 months post-treatment (p < 0.001). Additionally, mean QUEST scores at 3 months post-treatment significantly improved compared to baseline (p < 0.001). HTS is significantly improved from baseline ≥ 24 months post-treatment and possibly ≥ 48 months post-treatment. There is a current paucity of long-term CRST and QUEST score reporting in the literature.

M2 segment thrombectomy is not associated with increased complication risk compared to M1 segment: A meta-analysis of recent literature.

INTRODUCTION: Recent clinical comparisons of M1 and M2 segment endovascular thrombectomy have reached incongruous results in rates of complication and functional outcomes. This study aims to clarify the controversy surrounding this rapidly advancing technique through literature review and meta-analysis. METHODS: A Pubmed search was performed (January 2015-September 2019) using the following keywords: "M2 AND ("stroke" OR "occlusion") AND ("thrombectomy" OR "endovascular")". Safety and clinical outcomes were compared between segments via weighted Student's t-test, Chi-square and odds ratio while study heterogeneity was analyzed using Cochran Q and I2 tests. RESULTS: Pubmed identified 208 articles and eleven studies were included after full-text analysis, comprising 2,548 M1 and 758 M2 mechanical thrombectomy segment cases. Baseline National Institutes of Health Stroke Scale scores were comparatively lower in patients experiencing an M2 occlusion (16 ± 1.25 vs 13.6 ± 0.96, p < 0.01). Patients who underwent M2 mechanical thrombectomy were more likely to experience both good clinical outcomes (modified Rankin Scale 0-2) (48.6% vs 43.5% respectively, OR 1.24; CI 1.05-1.47, p = 0.01) and excellent clinical outcomes (modified Rankin Scale 0-1) (34.7% vs. 26.5%%, OR 1.6; CI 1.28-1.99, p < 0.01) at 90 days compared to M1 mechanical thrombectomy. Neither recanalization rates (75.3% vs 72.8%, OR 0.92, CI 0.75-1.13, p = 0.44) nor symptomatic intracranial hemorrhage rates (5.6% vs 4.9%, OR 0.92; CI 0.61-1.39, p= 0.7) were significantly different between M1 and M2 cohorts. Mortality was less frequent in the M2 cohort compared to M1 (16.3% vs 20.7%, OR 0.73; CI 0.57-0.94, p = 0.01). M1 and M2 cohorts did not differ in symptom onset-to-puncture (238.1 ± 46.7 vs 239.8 ± 43.9 min respectively, p=0.488) nor symptom onset-to recanalization times (318.7 ± 46.6 vs 317.7 ± 71.1 min respectively, p = 0.772), though mean operative duration was shorter in the M2 cohort (61.8 ± 25.5 vs 54.6 ± 24 min, p < 0.01). CONCLUSIONS: Patients who underwent M2 mechanical thrombectomy had a higher prevalence of good and excellent clinical outcomes compared to the M1 mechanical thrombectomy cohorts. Additionally, our data suggest lower mortality rates in the M2 cohort and symptomatic intracranial hemorrhage rates that are similar to the M1 cohort. Therefore, M2 segment thrombectomy likely does not pose a significantly elevated operative risk and may have a positive impact on patient outcomes.

Reconstruction of Complex Cranial and Orbit Fractures with Associated Hemorrhages: Case Report and Review of the Literature.

We present our experience following a unique case of coincident intracranial hemorrhage and comminuted fractures of both the squamous temporal bone and zygomaticofrontal orbit. Surgical techniques and outcome for this presentation have yet to be sufficiently described. A 55-year-old male presented following trauma with Glasgow Coma Scale score of 7. Radiographic evaluation revealed comminuted fractures of the squamous temporal bone with extension into the lateral orbit, along with zygomatic process fracture extending 2.5 cm medially into the orbital roof. Zygomaticofrontal orbital roof fragments reached superiorly into the middle cranial fossa and inferiorly into the orbit. Surgical intervention was deemed necessary to address underlying epidural hematoma, subarachnoid hemorrhage, correction of cranial bone defects, and decompression of the optic nerve and other intraorbital nerves. A frontotemporal approach was employed. Repair of temporal and orbital fractures was accomplished using a combination of wire mesh screws and titanium miniplates. Postoperative imaging demonstrated bony approximation and successful evacuation of traumatic hemorrhage. The patient remains functionally and neurologically intact apart from a sluggishly responsive left eye presumed to result from a left optic nerve or ciliary ganglion lesion. Although rapid reconstruction of complex cranial-orbital trauma and hematoma evacuation can permit acceptable gross functional neurological outcome following massive trauma, orbital fracture and subsequent hemorrhagic processes may be the nidus of neurological sequelae in this complex traumatic constellation. Thus, alterations in surgical approach and reconstruction are appropriate in order to maximize neurological function while supporting restoration of cosmetic space.

Does the Setting of External Ventricular Drain Placement Affect Morbidity? A Systematic Literature Review Comparing Intensive Care Unit versus Operating Room Procedures.

INTRODUCTION: External ventricular drain (EVD) placement can be performed at the bedside in the neurosurgical intensive care unit (ICU) or in the operating room (OR). Systematic review and meta-analysis may permit stronger recommendations to improve accuracy and complication rates. METHODS: Systematic review of PubMed was performed (inception-December 12, 2019) following PRISMA guidelines. RESULTS: Our search yielded 356 articles, of which 37 studies underwent full-text analysis. Nine studies met inclusion criteria. Studies were segregated into OR only (n = 3; 1011 patients), ICU only (n = 3; 325 patients), and OR + ICU (n = 3; 613 patients) cohorts. Studies were in addition divided by outcome measures, including catheter placement accuracy (ICU, 4 studies, n = 280 [68.29%] vs. OR, 2 studies, n = 198 [84.25%]); iatrogenic hemorrhagic complications (ICU, 4 studies, n = 112 [18.16%] vs. OR, 2 studies, n = 35 [17.50%]); and ventriculostomy-related infection rates (ICU, 4 studies, n = 48 [7.28%] vs. OR: 5 studies, n = 92 [8.06%]). CONCLUSIONS: There are likely specific patient populations who would benefit from EVD placement in the ICU versus OR setting. The literature comparing efficacy and morbidity between EVDs placed in the ICU and OR settings is overall inconclusive in both sample size and congruence of methodology. Agreement in outcome metrics and data reporting on this topic is necessary to synthesize high-quality evidence to form practice-changing recommendations for this debated topic.

Renal Transplantation Is Associated with Increased Complications Following Spinal Fusion Operations: Analysis of a National Database.

BACKGROUND: Improved postoperative care for renal transplant recipients has advanced both duration and overall quality of life. However, degenerative spinal pathology is increasingly prevalent after transplant. Outcomes following spinal fusion among the renal transplant population in the United States are rarely addressed. METHODS: The Healthcare Cost and Utilization Project National Inpatient Sample database was employed. Cases in years 2008-2014 for patients ≥18 years old receiving spinal fusion, exploration/decompression, and/or spinal revision/re-fusion surgeries were included. Cases were divided into kidney transplant recipients (KTR) and non-kidney transplant recipients. Complications, demographics, and socioeconomic outcomes were compared between cohorts. RESULTS: Of 579,726 patients who met inclusion criteria, 685 (0.1%) were KTRs. The KTR population was older and included more men compared with the non-kidney transplant recipient population (60.1 years vs. 56.6 years, P < 0.001; 58% male vs. 45.5% male, P < 0.001). KTRs experienced higher total complication rates (29.8% vs. 18.9%, P < 0.001). Prevalence of acute posthemorrhagic anemia and need for transfusion was markedly higher for KTRs (15.8% vs. 9.1%, P < 0.001; 13.6% vs. 6.2%, P < 0.001). Multivariate analysis revealed longer length of stay (median 1.23 days, interquartile range 0.94-1.53, P < 0.001), lower routine discharge (odds ratio = 0.57, 95% confidence interval 0.48-0.69, P < 0.001), and higher discharge to alternative care facilities (odds ratio = 1.91, 95% confidence interval 1.57-2.33, P < 0.001) for KTRs. The inpatient course for KTRs undergoing spinal operations was significantly costlier ($87,445 vs. $71,589, P < 0.001). CONCLUSIONS: History of renal transplant was associated with increased inpatient medical and socioeconomic complications following spinal fusion. Physicians and patients must understand and respect the potentially increased perioperative challenges facing KTRs.

Usefulness and Impact of Intraoperative Imaging for Glioma Resection on Patient Outcome and Extent of Resection: A Systematic Review and Meta-Analysis.

BACKGROUND: Diffusion tensor imaging (DTI), functional magnetic resonance imaging (fMRI), and intraoperative magnetic resonance imaging (iMRI) permit greater visualization and more accurate presurgical planning. Meta-analysis of these techniques for maximizing resection, postoperative functionality, and survival may further validate purported strengths of these techniques compared with standard neuronavigation. METHODS: A systematic search of the PubMed database was conducted in line with the PRISMA guidelines for meta-analysis with the following keywords: "Diffusion tensor imaging" OR "intraoperative MRI" OR "functional MRI" AND "glioma surgery resection outcome." Articles found to meet inclusion criteria were segregated and analyzed and resulting data were compared with standard neuronavigation (control cohort). RESULTS: A total of 435 articles were identified, with 29 distinct studies meeting inclusion criteria, including DTI (n = 3), fMRI (n = 5), and iMRI (n = 21). Nine studies directly compared results with standard navigation. Mean gross total resection (GTR) rates were not different among cases using DTI, fMRI, iMRI, or traditional neuronavigation (P = 0.136). On controlling for covariates, more patients received GTR in the advanced imaging cohort, although statistically insignificant (46.5% [95% confidence interval, 38.0%-55.0%] vs. 30.4% [95% confidence interval, 11.6%-49.1%]; P = 0.127; partial η2 = 0.217). Patients undergoing advanced imaging showed attenuated incidence of postsurgical permanent neurologic deficits, although also statistically insignificant (11.3% vs. 13.8%; P = 0.838). CONCLUSIONS: Current data are overall insufficient to support the notion that advanced imaging techniques are superior, either as a combined cohort or individually, in achieving GTR, improved symptom resolution, or survival compared with traditional neuronavigation.

Patients with Parkinson Disease Experience Increased Perioperative Complications Following Cervical Decompression and Fusion: A Retrospective Review of the National Inpatient Sample.

BACKGROUND: Despite improved medical management, the incidence of spinal pathology remains high in patients with Parkinson disease (PD). Several studies have investigated lumbar spine surgery in this population, but data regarding costs and perioperative complications for patients undergoing cervical decompression/fusion on a nationwide scale are lacking. METHODS: Cases of cervical spinal decompression, fusion, or exploration in years 2008-2014 were collected via the Healthcare Cost and Utilization Project National Inpatient Sample. Demographics, complications, outcome, and total charges were compared in patients with and without PD (NPD). Confounding variables were identified for multivariate analysis. RESULTS: Data were available for 195,341 cervical spine cases, of which PD was prevalent in 779 cases (0.4%). Cases with PD experienced greater overall complication rates (12.5 vs. 7.6%; P < 0.001). Multivariate analysis revealed longer lengths of stay for the PD cohort (mean = 1.21 days longer; P < 0.001) and decreased routine discharge (odds ratio = 0.308; P < 0.001). There was no significant difference in mean total charges between PD and NPD (-$1532; P = 0.337). Mortality rates did not significantly differ for either group. CONCLUSIONS: Although patients with PD experience greater complication rates and non-home discharges following cervical spine surgery compared with NPD patients, the overall clinical impact of these results may be minimal relative to surgery at other spinal levels in this population.

A Successful Outcome Despite Delayed Intervention for Cauda Equina Syndrome in a Young Patient with a Posterior Epidural Disc Extrusion.

Epidural disc extrusion is extremely rare and may cause cauda equina syndrome. This is a surgical emergency and needs rapid decompression. Although cauda equina is commonly caused by disc herniation, this is an unusual presentation with epidural disc extrusion. We present a very rare case of Cauda Equina syndrome, resulting from an epidural disc extrusion at L3-L4 level. Patient care and progress notes were reviewed along with pre-, post-, and intra-operative radiological imaging. Here, a 19-year-old male with a past medical history of type I diabetes mellitus, fell asleep on a chair at home in an unusual position and was unable to walk on awakening. The patient developed progressive neurological deficits including bilateral foot drop along with bowel and bladder dysfunction. In addition, he experienced paresthesia and severe lower back pain unresponsive to steroids. Pre-operative magnetic resonance imaging (MRI) demonstrated a herniated disk epidurally with disc extrusion and mass effect and compression at the L3-L4 level, wrapping around the posterior aspect of the dura. A diagnosis of cauda equina syndrome was made and surgical decompression was performed. Using microsurgical technique and fluoroscopic guidance, a bilateral laminectomy of L3 was achieved with bilateral partial laminectomy of L4, with bilateral foraminotomy of L4. After removal of the lamina, a mass was immediately visualized in the posterior epidural space. Further dissection of the substance and following it posteriorly, identified the mass as a portion of the extruded disc. Post-operatively, the patient experienced rapid recovery. In conclusion, this case demonstrates that a disc extrusion can occur within the epidural space and can cause cauda equina syndrome. As this presentation is unusual, surgeons must be aware that they may encounter disc mass in unexpected locations, in a clinically delayed setting, long after the initial onset of symptoms.

An NMR-Guided Screening Method for Selective Fragment Docking and Synthesis of a Warhead Inhibitor.

Selective hits for the glutaredoxin ortholog of Brucella melitensis are determined using STD NMR and verified by trNOE and (15)N-HSQC titration. The most promising hit, RK207, was docked into the target molecule using a scoring function to compare simulated poses to experimental data. After elucidating possible poses, the hit was further optimized into the lead compound by extension with an electrophilic acrylamide warhead. We believe that focusing on selectivity in this early stage of drug discovery will limit cross-reactivity that might occur with the human ortholog as the lead compound is optimized. Kinetics studies revealed that lead compound 5 modified with an ester group results in higher reactivity than an acrylamide control; however, after modification this compound shows little selectivity for bacterial protein versus the human ortholog. In contrast, hydrolysis of compound 5 to the acid form results in a decrease in the activity of the compound. Together these results suggest that more optimization is warranted for this simple chemical scaffold, and opens the door for discovery of drugs targeted against glutaredoxin proteins-a heretofore untapped reservoir for antibiotic agents.