Quantifying the Association Between Surgical Spine Approach and Tracheostomy Timing After Traumatic Cervical Spinal Cord Injury.

BACKGROUND AND OBJECTIVES: Recent evidence suggests earlier tracheostomy is associated with fewer complications in patients with complete cervical spinal cord injury (SCI). This study aims to evaluate the influence of spine surgical approach on the association between tracheostomy timing and in-hospital adverse events treating patients with complete cervical SCI. METHODS: This retrospective cohort study was performed using Trauma Quality Improvement Program data from 2017 to 2020. All patients with acute complete (American Spinal Injury Association-A) cervical SCI who underwent tracheostomy and spine surgery were included. Tracheostomy timing was dichotomized to early (within 1 week after surgery) and delayed (more than 1 week after surgery). Primary outcome was the occurrence of major in-hospital complications. Secondary outcomes included occurrences of immobility-related complications, surgical-site infection, hospital and intensive care unit length of stay, and time on mechanical ventilation. RESULTS: The study included 1592 patients across 358 trauma centers. Mean time to tracheostomy from surgery was 8.6 days. A total of 495 patients underwent anterior approach, 670 underwent posterior approach, and 427 underwent combined anterior and posterior approach. Patients who underwent anterior approach were significantly more likely to have delayed tracheostomy compared with posterior approach (53% vs 40%, P < .001). Early tracheotomy significantly reduced major in-hospital complications (odds ratio 0.67, 95% CI 0.53-0.84) and immobility complications (odds ratio = 0.78, 95% CI 0.6-1.0). Those undergoing early tracheostomy spent 6.0 (95% CI -8.47 to -3.43) fewer days in hospital, 5.7 (95% CI -7.8 to -3.7) fewer days in the intensive care unit, and 5.9 (95% CI -8.2 to -3.7) fewer days ventilated. Surgical approach had no significant negative effect on the association between tracheostomy timing and the outcomes of interest. CONCLUSION: Earlier tracheostomy for patients with cervical SCI is associated with reduced complications, length of stay, and ventilation time. This relationship appears independent of the surgical approach. These findings emphasize that tracheostomy need not be delayed because of the SCI treatment approach.

Cushing Syndrome due to Adrenocortical Carcinoma During Pregnancy.

Cushing syndrome resulting from adrenocortical carcinoma in pregnancy is exceedingly rare. There are no validated guidelines to establish a diagnosis or guide management in pregnancy. We provide a case of a 31-year-old woman presenting for management of diabetes in pregnancy who appeared cushingoid. She was subsequently diagnosed with ACTH-independent Cushing syndrome and experienced preterm labor at 33 weeks' gestation, delivering a healthy infant. Four weeks postpartum, the patient underwent a left adrenalectomy and was subsequently diagnosed with adrenocortical carcinoma.

Characterization of Spinal Cord Injury Patients for Arm Functional Restoration through Nerve Transfer.

INTRODUCTION: Traumatic spinal cord injuries (tSCI) are common, often leaving patients irreparably debilitated. Therefore, novel strategies such as nerve transfers (NT) are needed for mitigating secondary SCI damage and improving function. Although different tSCI NT options exist, little is known about the epidemiological and injury-related aspects of this patient population. Here, we report such characteristics to better identify and understand the number and types of tSCI individuals who may benefit from NTs. MATERIALS AND METHODS: Two peripheral nerve experts independently evaluated all adult tSCI individuals < 80 years old admitted with cervical tSCI (C1-T1) between 2005 and 2019 with documented tSCI severity using the ASIA Impairment Scale for suitability for NT (nerve donor with MRC strength ≥ 4/5 and recipient ≤ 2/5). Demographic, traumatic injury, and neurological injury variables were collected and analyzed. RESULTS: A total of 709 tSCI individuals were identified with 224 (32%) who met the selection criteria for participation based on their tSCI level (C1-T1). Of these, 108 (15% of all tSCIs and 48% of all cervical tSCIs) were deemed to be appropriate NT candidates. Due to recovery, 6 NT candidates initially deem appropriate no longer qualified by their last follow-up. Conversely, 19 individuals not initially considered appropriate then become eligible by their last follow-up. CONCLUSION: We found that a large proportion of individuals with cervical tSCI could potentially benefit from NTs. To our knowledge, this is the first study to detail the number of tSCI individuals that may qualify for NT from a large prospective database.

Earlier Tracheostomy Reduces Complications in Complete Cervical Spinal Cord Injury in Real-World Practice: Analysis of a Multicenter Cohort of 2001 Patients.

BACKGROUND AND OBJECTIVES: It is believed that early tracheostomy in patients with traumatic cervical spinal cord injury (SCI) may lessen the risk of developing complications and reduce the duration of mechanical ventilation and critical care stay. This study aims to assess whether early tracheostomy is beneficial in patients with traumatic cervical SCI. METHODS: We conducted a retrospective cohort study using data from the American College of Surgeons Trauma Quality Improvement Program database from 2010 to 2018. Adult patients with a diagnosis of acute complete (ASIA A) traumatic cervical SCI who underwent surgery and tracheostomy were included. Patients were stratified into those receiving early (at or before 7 days) and delayed tracheostomy. Propensity score matching was used to assess the association between delayed tracheostomy and the risk of in-hospital adverse events. Risk-adjusted variability in tracheostomy timing across trauma centers was investigated using mixed-effects regression. RESULTS: The study included 2001 patients from 374 North American trauma centers. The median time to tracheostomy was 9.2 days (IQR: 6.1-13.1 days), with 654 patients (32.7%) undergoing early tracheostomy. After matching, the odds of a major complication were significantly lower for early tracheostomy patients (OR: .90; 95% CI: .88-.98). Patients were also significantly less likely to experience an immobility-related complication (OR: .90; 95% CI: .88-.98). Patients in the early group spent 8.2 fewer days in the critical care unit (95% CI: -10.2 to -6.61) and 6.7 fewer days ventilated (95% CI: -9.44 to -5.23). There was significant variability in tracheostomy timeliness between trauma centers with a median odds ratio of 12.2 (95% CI: 9.7-13.7), which was not explained by case-mix and hospital-level characteristics. CONCLUSION: A 7-day threshold to implement tracheostomy seems to be associated with reduced in-hospital complications, time in the critical care unit, and time on mechanical ventilation.

Multicenter retrospective cohort study of the association between surgery for odontoid fractures in the elderly and in-hospital outcomes.

Odontoid fractures are increasingly prevalent in older adults and associated with high morbidity and mortality. Optimal management remains controversial. Our study aims to investigate the association between surgical management of odontoid fractures and in-hospital mortality in a multi-center geriatric cohort. We identified patients 65 years or older with C2 odontoid fractures from the Trauma Quality Improvement Program database. The primary study outcome was in-hospital mortality. Secondary outcomes were in-hospital complications and hospital length of stay. Generalized estimating equation models were used to compare outcomes between operative and non-operative cohorts. Among the 13,218 eligible patients, 1100 (8.3%) were treated surgically. The risk of in-hospital mortality did not differ between surgical and non-surgical groups, after patient and hospital-level adjustment (OR: 0.94, 95%CI: 0.55-1.60). The risks of major complications and immobility-related complications were higher in the operative cohort (adjusted OR: 2.12, 95%CI: 1.53-2.94; and OR: 2.24, 95%CI: 1.38-3.63, respectively). Patients undergoing surgery had extended in-hospital length of stay compared to the non-operative group (9 days, IQR: 6-12 days vs. 4 days, IQR: 3-7 days). These findings were supported by secondary analyses that considered between-center differences in rates of surgery. Among geriatric patients with odontoid fractures surgical management was associated with similar in-hospital mortality, but higher in-hospital complication rates compared to non-operative management. Surgical management of geriatric patients with odontoid fractures requires careful patient selection and consideration of pre-existing comorbidities.

Cervical Spine Research Society-Cervical Stiffness Disability Index (CSRS-CSDI): Validation of a Novel Scoring System Quantifying the Effect of Postarthrodesis Cervical Stiffness on Patient Quality of Life.

STUDY DESIGN: Cross-sectional study. OBJECTIVE: The aim was to create and validate a novel patient-reported outcome measure (PROM) focusing on stiffness-related patient functional limitations after cervical spine fusion. SUMMARY OF BACKGROUND DATA: Cervical arthrodesis is a common treatment for myelopathy/radiculopathy, however, results in increased neck stiffness as a collateral outcome. No current PROM exists quantifying the impact of postoperative stiffness on patient function. METHODS: The Cervical Spine Research Society-Cervical Stiffness Disability Index (CSRS-CSDI) was created through a modified Delphi process. The resultant 10-item questionnaire yields a score out of 100 with higher scores indicating increased functional difficulty related to neck stiffness. Cross-sectional study of control and postoperative patients was completed for CSRS-CSDI validation. Retest reliability (intraclass correlation coefficient), internal consistency (Cronbach alpha), responsiveness (levels fused vs. CSRS-CSDI scores), and discriminatory validation (CSRS-CSDI vs. neck disability index) scores) were completed. RESULTS: Fifty-seven surgical and 24 control patients completed the questionnaire. Surgical patients underwent a variety of procedures: 11 (19%) motion preserving operations, nine (16%) subaxial 1-2 level fusions, seven (12%) subaxial 3-5 level fusions, five (9%) C1-subaxial cervical spine fusions, 20 (35%) C2-upper thoracic spine fusions, five (9%) occiput-subaxial or thoracic spine fusions. The questionnaire demonstrated high internal consistency (Cronbach alpha=0.92) and retest reliability (intraclass correlation coefficient=0.95, P <0.001). Good responsiveness validity with a significant difference between fusion cohorts was found ( P <0.001, rs =0.63). Patient CSRS-CSDI scores also correlated with neck disability index scores recorded ( P <0.001, r =0.70). CONCLUSION: This is the first study to create a PROM addressing the functional impact of cervical stiffness following surgical arthrodesis. The CSRS-CSDI was a reliable and valid measure of postoperative stiffness impact on patient function. This may prove useful in counseling patients regarding their expected outcomes with further investigation demonstrating its value in a prospective fashion.

Resident peripheral nerve surgery competence: An assessment of procedural exposure, self-reported competence and technical ability.

BACKGROUND: Identifying peripheral nerve surgery procedure (PNSP) competencies is crucial to ensure adequate resident training. We examine PNSP training at neurosurgical centers in the US and Canada to compare resident-reported competence, PNSP exposure, and resident technical abilities in performing 3 peripheral nerve coaptations (PNC). METHODS: Resident-reported PNSP competence and PNSP exposure data were collected using questionnaires from neurosurgical residents at North American neurosurgical training centers. Exposure and self-reported competency were correlated with technical skills. Technical PNC variables collected included: time-to-completion, nerve-handling from video-analysis, independent and blinded visual-analog-scale (VAS) PNC quality grading by 3 judges, and training level. RESULTS: A total of 40 neurosurgical residents participated in the study. Although self-reported competency scores correlated with procedural exposure (P < 0.01, rs = 0.88), a discrepancy was found between the degree of self-reported competency and amount of exposure. The discrepancy was greater in senior residents. A significant VAS difference was found between PNC types with the direct-suture and connector-assister groups scoring higher than connector-only (P = 0.02, P < 0.01, respectively). No difference was observed between training level and VAS grading, nor time-to completion (P = 0.33 and 0.25, respectively). No correlation was found between self-reported competency performing PNSPs and PNC VAS scores, nor nerve handling. CONCLUSIONS: Despite more exposure and a higher self-reported PNSP competency in senior residents, no difference was seen between senior/junior residents in PNC quality. A discrepancy in PNSP exposure and self-reported competency exists. This information will provide guidance for the direction of resident PNS training.

Peripheral nerve surgical competency in plastic surgery and neurosurgery residents.

OBJECTIVE: To assess the case volume and self-perceived competence of current mandatory skills in peripheral nerve surgery. DESIGN: Cross sectional survey based study examining case volume and self-reported competence in peripheral nerve surgery. SETTING: Canadian Neurosurgery and Plastic Surgery accredited residency programs PARTICIPANTS: All Canadian Neurosurgery and Plastic Surgery senior trainees (PGY 3+) invited to participate RESULTS: Much variability exists in both exposure to cases and perceived senior resident competence for both plastic and neurosurgery residents. Confidence in surgical ability as perceived competency is lower in trainees for more advanced peripheral nerve procedures. Self- reported confidence increased with post-graduate experience. CONCLUSIONS: Overall, the findings in this study highlight the importance of increasing operative experience in complex peripheral nerve surgery among surgical residents.

Complications in the Elderly Population Undergoing Spinal Deformity Surgery: A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic Review and Meta-Analysis. OBJECTIVES: The elderly have an increased risk of perioperative complications for Adult Spinal Deformity (ASD) corrections. Stratification of these perioperative complications based on risk type and specific risk factors, however, remain unclear. This paper will systematically review perioperative risk factors in the elderly undergoing ASD correction stratified by type: medical, implant-related, proximal junctional kyphosis (PJK), and need for revision surgery. METHODS: A systematic review was performed using the PRISMA guidelines. A query of PubMed was performed to identify publications pertinent to ASD in the elderly. Publications included in this review focused on patients ≥65 years old who underwent operative management for ASD to assess for risk factors of perioperative complications. RESULTS: A total of 734 unique citations were screened resulting in ten included articles for this review. Pooled incidence of perioperative complications included medical complications (21%), implant-related complications (16%), PJK (29%), and revision surgery (13%). Meta-analysis calculated greater preoperative PT (WMD 2.66; 95% Cl .36-4.96; P = .02), greater preoperative SVA (WMD 2.24; 95% Cl .62-3.86; P = .01), and greater postoperative SVA (WMD .97; 95% Cl .03-1.90; P = .04) to significantly correlate with development of PJK with no evidence of publication bias or concerns in study heterogeneity. CONCLUSIONS: There is a paucity of literature describing perioperative complications in the elderly following ASD surgery. Appropriate understanding of modifiable risk factors for the development of medical and implant-related complications, proximal junctional kyphosis, and revision surgeries presents an opportunity to decrease morbidity and improve patient outcomes.

The lexicon of multirod constructs in adult spinal deformity: a concise description of when, why, and how.

The use of multirod constructs in the setting of adult spinal deformity (ASD) began to prevent rod fracture and pseudarthrosis near the site of pedicle subtraction osteotomies (PSOs) and 3-column osteotomies (3COs). However, there has been unclear and inconsistent nomenclature, both clinically and in the literature, for the various techniques of supplemental rod implantation. In this review the authors aim to provide the first succinct lexicon of multirod constructs available for the treatment of ASD, providing a universal nomenclature and definition for each type of supplementary rod. The primary rod of ASD constructs is the longest rod that typically spans from the bottom of the construct to the upper instrumented vertebrae. The secondary rod is shorter than the primary rod, but is connected directly to pedicle screws, albeit fewer of them, and connects to the primary rod via lateral connectors or cross-linkers. Satellite rods are a 4-rod technique in which 2 rods span only the site of a 3CO via pedicle screws at the levels above and below, and are not connected to the primary rod (hence the term "satellite"). Accessory rods are connected to the primary rods via side connectors and buttress the primary rod in areas of high rod strain, such as at a 3CO or the lumbosacral junction. Delta rods span the site of a 3CO, typically a PSO, and are not contoured to the newly restored lordosis of the spine, thus buttressing the primary rod above and below a 3CO. The kickstand rod itself functions as an additional means of restoring coronal balance and is secured to a newly placed iliac screw on the side of truncal shift and connected to the primary rod; distracting against the kickstand then helps to correct the concavity of a coronal curve. The use of multirod constructs has dramatically increased over the last several years in parallel with the increasing prevalence of ASD correction surgery. However, ambiguity persists both clinically and in the literature regarding the nomenclature of each supplemental rod. This nomenclature of supplemental rods should help unify the lexicon of multirod constructs and generalize their usage in a variety of scientific and clinical scenarios.

The Intradiscal Osteotomy: An Alternative Technique for Adult Spinal Deformity Correction.

Adult spinal deformity (ASD) correction has changed considerably since the initial description of a Smith-Petersen osteotomy (SPO), including pedicle subtraction osteotomies (PSO), and more minimally invasive techniques. Here, we introduce and describe the intradiscal osteotomy (IDO), a novel variation of Schwab type 3 and 4 osteotomies allowing pedicle and vertebral body preservation, and its advantages and disadvantages. After pedicle screw placement, the posterior elements (except pedicles) are removed from the appropriate vertebrae, including the superior/inferior articulating processes, laminae, and spinous processes. An osteotome is used to remove the posterior aspect of the superior and inferior endplate, followed by the entire disc, creating more working room for eventual cage insertion. After the careful release of the annulus, an intradiscal distractor is used to distract the endplates and allow interbody cage insertion as anteriorly as possible. Pedicle and vertebral body preservation allow increased fixation and endplate cage support, which lengthens the anterior column and acts as a fulcrum when compressing posteriorly to restore lordosis. By allowing for anterior and posterior column release, the IDO technique provides a feasible, all-posterior approach for the correction of fixed or flexible kyphoscoliotic curves. This technical report introduces and describes the IDO as an alternative method for thoracic and/or lumbar ASD correction. More studies are required to fully elucidate its outcome vs. complication profile compared to other deformity correction techniques.

Reality of Accomplishing Surgery within 24 Hours for Complete Cervical Spinal Cord Injury: Clinical Practices and Safety.

Substantial clinical data support an association between superior neurological outcomes and early (within 24 h) surgical decompression for those with traumatic cervical spinal cord injury (SCI). Despite this, much discussion persists around feasibility and safety of this time threshold, particularly for those with a complete cervical SCI. This study aims to assess clinical practices and the safety profile of early surgery across a large sample of North American trauma centers. Data were derived from the Trauma Quality Improvement Program database from 2010-2016. Adult patients with a complete cervical SCI (American Spinal Injury Association [ASIA] A) who underwent surgery were included. Patients were stratified into those receiving surgery at or before 24 h and those receiving delayed intervention. Risk-adjusted variability in surgical timing across trauma centers was investigated using mixed-effects regression. In-hospital adverse events including death, major complications, and immobility-related complications were compared between groups after propensity score matching. There were 2862 patients from 353 North American trauma centers included; 1760 (61.5%) underwent surgery within 24 h. Case-mix and hospital-level characteristics explained only 6% of the variability in surgical timing both between centers and within centers. No significant differences in adverse events were identified between groups. These findings suggest a relatively large proportion of patients are not receiving surgery within the recommended time frame, despite apparent safety. Moreover, patient and hospital-level characteristics explain little of the variability in time-to-surgery. Further knowledge translation is needed to increase the proportion of patients in whom surgery is performed before the 24-h threshold so patients might reach their greatest potential for neurological recovery.

Diagnostic Accuracy of MRI for the Detection of Malignant Peripheral Nerve Sheath Tumors: A Systematic Review and Meta-Analysis.

OBJECTIVE. This systematic review and meta-analysis evaluates the diagnostic accuracy of MRI for differentiating malignant (MPNSTs) from benign peripheral nerve sheath tumors (BPNSTs). MATERIALS AND METHODS. A systematic review of MEDLINE, Embase, Scopus, the Cochrane Library, and the gray literature from inception to December 2019 was performed. Original articles that involved at least 10 patients and that evaluated the accuracy of MRI for detecting MPNSTs were included. Two reviewers independently extracted clinical and radiologic data from included articles to calculate sensitivity, specificity, PPV, NPV, and accuracy. A meta-analysis was performed using a bivariate mixed-effects regression model. Risk of bias was evaluated using QUADAS-2. RESULTS. Fifteen studies involving 798 lesions (252 MPNSTs and 546 BPNSTs) were included in the analysis. Pooled and weighted sensitivity, specificity, and AUC values for MRI in detecting MPNSTs were 68% (95% CI, 52-80%), 93% (95% CI, 85-97%), and 0.89 (95% CI, 0.86-0.92) when using feature combination and 88% (95% CI, 74-95%), 94% (95% CI, 89-96%), and 0.97 (95% CI, 0.95-0.98) using diffusion restriction with or without feature combination. Subgroup analysis, such as patients with neurofibromatosis type 1 (NF1) versus those without NF1, could not be performed because of insufficient data. Risk of bias was predominantly high or unclear for patient selection, mixed for index test, low for reference standard, and unclear for flow and timing. CONCLUSION. Combining features such as diffusion restriction optimizes the diagnostic accuracy of MRI for detecting MPNSTs. However, limitations in the literature, including variability and risk of bias, necessitate additional methodologically rigorous studies to allow subgroup analysis and further evaluate the combination of clinical and MRI features for MPNST diagnosis.

Foraminal Origin of the Dorsal Scapular Nerve: An Anatomical Study.

BACKGROUND: Although distal dorsal scapular nerve (DSN) anatomy has been well characterized, a paucity of literature exists detailing its proximal origin. To our knowledge, this is the first study examining DSN origin and its anatomy relative to the C5 nerve root, which may help localize pathology and provide insight into timing of DSN or C5 nerve root clinical and electrophysiological recovery. METHODS: Eighteen cadaveric dissections were performed using a posterior-midline approach. Calipers were used for DSN branching and course characterization with statistical analysis completed for the following measurements: DSN diameter, C5 nerve root diameter, distance of DSN branch-point from the C5 ganglion, dural edge, and posterior foraminal tubercle (intra-vs. extraforaminal origin), as well as C5 root-SC branch-point distance. RESULTS: Average/mean measurements (standard error) were as follows: DSN diameter: 3.7 mm (0.3 mm), C5 nerve root diameter: 6.2 mm (0.5 mm), DSN origin to C5 DRG: 12.4 mm (1.9 mm) distal, DSN origin to dural edge: 19. 6mm (1.8 mm), DSN origin to C5 root origin: 23.3 mm (2.2 mm), DSN origin to the posterior foraminal tubercle: 2.3 mm (2.5 mm) proximal/intraforaminal (first branch from C5 in all cases, and the majority [12 of 18, 67%] of DSNs originating from the C5 spinal nerve root within the foramen). CONCLUSIONS: The C5 nerve root contributed to the DSN in all specimens that originated from the proximal, intraforaminal, C5 nerve root in the majority of specimens. As the first C5 nerve branch, surgeon knowledge of this proximal DSN pattern will help localize lesional pathology, as well as may help monitor clinical and electrophysiological recovery.

Foraminal Ligaments Tether Upper Cervical Nerve Roots: A Potential Cause of Postoperative C5 Palsy.

Background Nerve root tethering upon dorsal spinal cord (SC) migration has been proposed as a potential mechanism for postoperative C5 palsy (C5P). To our knowledge, this is the first study to investigate this relationship by anatomically comparing C5-C6 nerve root translation before and after root untethering by cutting the cervical foraminal ligaments (FL). Objective The aim of this study is to determine if C5 root untethering through FL cutting results in increased root translation. Methods Six cadaveric dissections were performed. Nerve roots were exposed via C4-C6 corpectomies and supraclavicular brachial plexus exposure. Pins were inserted into the C5-C6 roots and adjacent foraminal tubercle. Translation was measured as the distance between pins after the SC was dorsally displaced 5 mm before and after FL cutting. Clinical feasibility of FL release was examined by comparing root translation between standard and extended (complete foraminal decompression) foraminotomies. Translation of root levels before and after FL cutting was compared by two-way repeated measures analysis of variance. Statistical significance was set at 0.05. Results Significantly more nerve root translation was observed if the FL was cut versus not-cut, p = 0.001; no difference was seen between levels, p = 0.33. Performing an extended cervical foraminotomy was technically feasible allowing complete FL release and root untethering, whereas a standard foraminotomy did not. Conclusion FL tether upper cervical nerve roots in their foramina; cutting these ligaments untethers the root and increases translation suggesting they could be harmful in the context of C5P. Further investigation is required examining the value of root untethering in the context of C5P.

Electrical Stimulation as a Tool to Promote Plasticity of the Injured Spinal Cord.

Unlike their peripheral nervous system counterparts, the capacity of central nervous system neurons and axons for regeneration after injury is minimal. Although a myriad of therapies (and different combinations thereof) to help promote repair and recovery after spinal cord injury (SCI) have been trialed, few have progressed from bench-top to bedside. One of the few such therapies that has been successfully translated from basic science to clinical applications is electrical stimulation (ES). Although the use and study of ES in peripheral nerve growth dates back nearly a century, only recently has it started to be used in a clinical setting. Since those initial experiments and seminal publications, the application of ES to restore function and promote healing have greatly expanded. In this review, we discuss the progression and use of ES over time as it pertains to promoting axonal outgrowth and functional recovery post-SCI. In doing so, we consider four major uses for the study of ES based on the proposed or documented underlying mechanism: (1) using ES to introduce an electric field at the site of injury to promote axonal outgrowth and plasticity; (2) using spinal cord ES to activate or to increase the excitability of neuronal networks below the injury; (3) using motor cortex ES to promote corticospinal tract axonal outgrowth and plasticity; and (4) leveraging the timing of paired stimuli to produce plasticity. Finally, the use of ES in its current state in the context of human SCI studies is discussed, in addition to ongoing research and current knowledge gaps, to highlight the direction of future studies for this therapeutic modality.

Antibiotic-impregnated polymethylmethacrylate strut graft as a treatment of spinal osteomyelitis: case series and description of novel technique.

OBJECTIVE: The surgical treatment of osteomyelitis and discitis of the spine often represents a challenging clinical entity for a multitude of reasons, including progression of infection despite debridement, development of spinal deformity and instability, bony destruction, and seeding of hardware. Despite advancement in spinal hardware and implantation techniques, these aforementioned challenges not uncommonly result in treatment failure, especially in instances of heavy disease burden with enough bony endplate destruction as to not allow support of a modern titanium cage implant. While antibiotic-infused polymethylmethacrylate (aPMMA) has been used in orthopedic surgery in joints of the extremities, its use has not been extensively described in the spine literature. Herein, the authors describe for the first time a series of patients treated with a novel surgical technique for the treatment of spinal osteomyelitis and discitis using aPMMA strut grafts with posterior segmental fusion. METHODS: Over the course of 3 years, all patients with spinal osteomyelitis and discitis at a single institution were identified and included in the retrospective cohort if they were surgically treated with spinal fusion and implantation of an aPMMA strut graft at the nidus of infection. Basic demographics, surgical techniques, levels treated, complications, and return to the operating room for removal of the aPMMA strut graft and placement of a traditional cage were examined. The surgical technique consisted of performing a discectomy and/or corpectomy at the level of osteomyelitis and discitis followed by placement of aPMMA impregnated with vancomycin and/or tobramycin into the cavity. Depending on the patient's condition during follow-up and other deciding clinical and radiographic factors, the patient may return to the operating room nonurgently for removal of the PMMA spacer and implantation of a permanent cage with allograft to ultimately promote fusion. RESULTS: Fifteen patients were identified who were treated with an aPMMA strut graft for spinal osteomyelitis and discitis. Of these, 9 patients returned to the operating room for aPMMA strut graft removal and insertion of a cage with allograft at an average of 19 weeks following the index procedure. The most common infections were methicillin-sensitive Staphylococcus aureus (n = 6) and methicillin-resistant S. aureus (n = 5). There were 13 lumbosacral infections and 1 each of cervical and thoracic infection. Eleven patients were cured of their infection, while 2 had recurrence of their infection; 2 patients were lost to follow-up. Three patients required unplanned return trips to the operating room, two of which were for wound complications, with the third being for recurrent infection. CONCLUSIONS: In cases of severe infection with considerable bony destruction, insertion of an aPMMA strut graft is a novel technique that should be considered in order to provide strong anterior-column support while directly delivering antibiotics to the infection bed. While the active infection is being treated medically, this structural aPMMA support bridges the time it takes for the patient to be converted from a catabolic to an anabolic state, when it is ultimately safe to perform a definitive, curative fusion surgery.

Coronavirus disease 2019 (COVID-19) in neurology and neurosurgery: A scoping review of the early literature.

Coronavirus disease 2019 (COVID-19) is a devastating respiratory illness that has dramatically changed the medical landscape around the world. In parallel with a rise in the number of cases globally, the COVID-19 literature has rapidly expanded with experts around the world disseminating knowledge and collaborating on best practices. To date, the literature has predominantly consisted of case reports, case series, and systemic protocols for dealing with this deadly disease from a plethora of specialties with larger observational and randomized studies only now starting to emerge. This scoping review of MEDLINE, EMBASE, SCOPUS, and the Cochrane Library aims to evaluate and summarize the current status of the COVID-19 literature at it applies to neurology and neurosurgery. Neurological symptomatology, neurological risk factors for poor prognosis, pathophysiology for neuroinvasion, and actions taken by neurological or neurosurgical services to manage the current COVID-19 crisis are reviewed.

Ultrasound for Neurogenic Thoracic Outlet Obstruction Remains Theoretical.

We enjoyed reading Povleson et al.'s review entitled "Diagnostic thoracic outlet syndrome: current approaches and future directions" [...].