Development and Internal Validation of the Postoperative Analgesic Intake Needs Score: A Predictive Model for Post-Operative Narcotic Requirement after Spine Surgery.

STUDY DESIGN: Retrospective Cohort. OBJECTIVE: The aim of this study was to develop a clinical tool to pre-operatively risk-stratify patients undergoing spine surgery based on their likelihood to have high postoperative analgesic requirements. METHODS: A total of 1199 consecutive patients undergoing elective spine surgery over a 2-year period at a single center were included. Patients not requiring inpatient admission, those who received epidural analgesia, those who had two surgeries at separate sites under one anesthesia event, and those with a length of stay greater than 10 days were excluded. The remaining 860 patients were divided into a derivation and validation cohort. Pre-operative factors were collected by review of the electronic medical record. Total postoperative inpatient opioid intake requirements were converted into morphine milligram equivalents to standardize postoperative analgesic requirements. RESULTS: The postoperative analgesic intake needs (PAIN) score was developed after the following predictor variables were identified: age, race, history of depression/anxiety, smoking status, active pre-operative benzodiazepine use and pre-operative opioid use, and surgical type. Patients were risk-stratified based on their score with the high-risk group being more likely to have high opioid consumption postoperatively compared to the moderate and low-risk groups in both the derivation and validation cohorts. CONCLUSION: The PAIN Score is a pre-operative clinical tool for patients undergoing spine surgery to risk stratify them based on their likelihood for high analgesic requirements. The information can be used to individualize a multi-modal analgesic regimen rather than utilizing a "one-size fits all" approach.

Applying 3-Dimensional Printing and Modeling for Preoperative Reconstruction and Instrumentation Placement Planning in Complex Deformity Surgery.

BACKGROUND: Advances in three-dimensional (3D) printing technology have enabled the development of customized instrumentation and surgical training platforms. However, no existing studies have assessed how patient-specific 3D-printed spine models can facilitate patient education and operative planning in complex spinal deformity correction. OBJECTIVE: To present a cost-effective technique for constructing personalized 3D-printed spine models for patients with severe spinal deformities and to outline how these models can promote informed consent, trainee education, and planning for instrumentation placement and alignment correction. METHODS: We present 2 patients who underwent surgical correction of progressive thoracolumbar deformities. Full-scale 3D-printed models of each patient's spine were produced preoperatively and used during clinic evaluations, surgical planning, and as intraoperative references. RESULTS: Each model took 9 days to build and required less than 60 US dollars of material costs. Both patients were treated with a posterior approach and contiguous multilevel osteotomies. Postoperatively, their alignment parameters and neurological deficits improved. CONCLUSION: Personalized 3D-printed spine models can aid in patient education, surgical training, visualization, and correction of complex spinal deformities.

Percutaneous screw fixation versus open fusion for the treatment of traumatic thoracolumbar fractures: A retrospective case series of 185 Patients with a single-level spinal column injury.

STUDY DESIGN: Retrospective Single-Center Review of Data at a Level 1 Trauma Center. OBJECTIVE: Compare deformity correction and surgical outcomes of percutaneous instrumentation and open fusion in traumatic thoracolumbar fractures. METHODS: In our retrospective study, all patients undergoing elective spine surgery for TL fractures at a Level 1 trauma center between 2000 and 2017 were reviewed. Patients who underwent percutaneous fixation were given the option of hardware removal after the fracture had healed. RESULTS: A total of 185 patients were included in the study, with 109 treated with an open fusion, and 76 with percutaneous fixation. Twenty-five patients in the latter group had the instrumentation removed after the fracture had healed. None of them required reoperation. In the open fusion group 54.1% of patients required a decompressive laminectomy. Percutaneous fixation patients had a shorter operative time (98.3 min vs 214 min, p < 0.0001), shorter length of stay (9.8 days vs 13.5 days, p = 0.04), and less blood loss (68.4 cc vs 691 cc, p < 0.001). They also had a better correction of their traumatic kyphosis after surgery (p = 0.005). CONCLUSION: Percutaneous fixation is a valuable option for the treatment of TL fractures in cases without evidence of neural compression. It is still unclear whether hardware removal helps prevent adjacent segment degeneration. Percutaneous fixation could allow for better reduction of the fracture with improvement of postoperative alignment.

Pancreatic Cancer Metastasis to the Spine: A Systematic Review of Management Strategies and Outcomes with Case Illustration.

OBJECTIVE: We aim to provide a thorough review of the literature regarding patient characteristics, treatment options, and outcomes of pancreatic cancer metastasis to the spine. We also provide an illustrative case from our institution of a patients with pancreatic adenocarcinoma presenting initially as cervical radiculopathy with an isolated cervical spine lesion. METHODS: Using the PRISMA guidelines, the literature in PubMed, Google Scholar, and Web of Science databases was searched. We excluded systematic reviews and meta-analyses that did not provide novel cases, as well as reports of metastatic disease from other nonpancreatic primary cancers. RESULTS: Thirty-two patients across 21 studies met the inclusion criteria. The patients were predominantly male (58%), with a mean age of 59 years. Of patients, 64% presented with back pain, 39% with motor deficits, and 15% with bladder or bowel dysfunction. For treatment, chemotherapy was used in 55% of cases and radiotherapy in 42%. Surgical treatment was performed in 42% of cases, with complete tumor resection achieved in 24% of cases. The mean patient survival after treatment was 28 weeks (range, 1-83 weeks), with patients undergoing treatment involving surgery having increased survival (44 weeks) compared with noninvasive treatment alone (18 weeks). CONCLUSIONS: Spinal metastasis of pancreatic cancer is rare and typically portends a poor prognosis. It is vital to recognize the presence of spinal involvement early in the disease course and initiate treatment.

Primary peripheral T-cell central nervous system lymphoma.

BACKGROUND: Primary peripheral T-cell central nervous system lymphoma (PCNSL) is a rare, aggressive tumor that arises in the craniospinal axis and has an increased risk in individuals who are immunocompromised. This lesion often mimics other benign and malignant processes on radiographic imaging, leading to misdiagnosis and delays in treatment. We present a case of a patient with a history of Sjögren's syndrome and progressive neurologic symptoms who underwent craniotomy for diagnosis. CASE DESCRIPTION: A 61-year-old woman with a history of Sjögren's syndrome, progressive aphasia, left facial droop, and right-sided paresthesias for 4 months presented for evaluation and management. An enhancing, infiltrative lesion in the left frontal lobe with underlying vasogenic edema was appreciated and suggestive of a primary or metastatic neoplasm. The patient underwent an open biopsy for further evaluation of the lesion. Extensive histopathologic evaluation revealed a diagnosis of T-cell PCNSL. The patient was started on induction methotrexate and temozolomide followed by consolidative radiotherapy. CONCLUSION: Autoimmune conditions are a risk factor for T-cell PCNSL development. T-cell PCNSL has radiographic and gross histologic features that are consistent with a broad differential, including gliomas and inflammatory processes. Prompt diagnosis and extensive histopathological evaluation is essential to ensure appropriate treatment.

Bertolotti Syndrome With Articulated L5 Transverse Process Causing Intractable Back Pain: Surgical Video Showcasing a Minimally Invasive Approach for Disconnection: 2-Dimensional Operative Video.

Bertolotti syndrome is a commonly missed cause of intractable back pain that affects 4% to 8% of the general population. It involves the congenital malformation of a transitional lumbosacral vertebra, with total or partial and unilateral or bilateral transverse process (TP) fusion or articulation to the sacrum. The pain can be debilitating, and the tethering of the spine to the sacrum can encourage deformity formation in the coronal plane and lead to early degenerative changes, especially if present only unilaterally. We present the case of a 24-yr-old woman with no notable prior medical history who presented with years of lower axial back pain radiating to her thighs, which limited her activities of daily living and was resistant to conservative management. Her imaging showed an abnormally large left L5 TP, which was articulated to the sacrum, and signs of early coronal deformity. She had responded almost completely to repeated steroid injections into the TP-sacral joint, but that effect was very transient. Informed patient consent was obtained prior to her surgery. She underwent a minimally invasive tube disconnection of the abnormal joint with partial distal resection of the TP, and her symptoms completely resolved. This case highlights the importance of correlating clinical symptoms with aberrant anatomy, and the role of selective surgery in providing symptomatic relief. This case report was written in compliance with our institutional ethical review board approval, and patient consent was waived in light of the retrospective and deidentified nature of the data presented in accordance with the University of Texas Southwestern institutional review board.

Ventriculoperitoneal Shunt Outcomes of Normal Pressure Hydrocephalus: A Case Series of 116 Patients.

Background Permanent cerebrospinal fluid (CSF) diversion with a ventriculoperitoneal shunt (VPS) is a treatment option for patients with normal pressure hydrocephalus (NPH). Objectives Herein, we examine the outcomes, complication rates, and associations between predictors and outcomes after VPS in patients with NPH. Methods This was a retrospective review of 116 patients (68 males, 48 females) with NPH who underwent VPS placement from March 2008 to September 2017 after demonstrating objective and/or subjective improvement after a lumbar drain trial. The Chi-square test of independence was used to examine associations between predictors and clinical improvement after shunting. Complications associated with the VPS procedure were recorded. Results The mean age was 77 years (range 52-93). The mean duration of disturbance in gait, cognition, and continence were 29, 32, and 28 months, respectively. Of the 116 patients, 111 followed up at two weeks; of these, improvement in gait, incontinence, and cognition were reported in 72, 20, and 23 patients, respectively. Gait improved more than incontinence or cognition. A shorter duration of gait disturbance predicted an improvement in gait after shunting (p<0.01). Being on a cognition-enhancing medication predicted an improvement in cognition and/or incontinence after shunting (p<0.05). Complications included misplaced proximal catheters (n=6), asymptomatic catheter tract hemorrhages (n=3), bilateral hygromas (n=7), subdural hematomas (SDH) (n=5), and CSF leak (n=1). Conclusion VPS placement in patients with NPH is well-tolerated and associated with improved outcomes at least in the short-term follow-up (<6 months). A shorter duration of gait disturbance and being on a cognition-enhancing medication are associated with greater improvement after VPS.

Clinical outcomes of normal pressure hydrocephalus in 116 patients: objective versus subjective assessment.

OBJECTIVE: Objective assessment tests are commonly used to predict the response to ventriculoperitoneal (VP) shunting in patients with normal pressure hydrocephalus (NPH). Whether subjective reports of improvement after a lumbar drain (LD) trial can predict response to VP shunting remains controversial. The goal in this study was to compare clinical characteristics, complication rates, and shunt outcomes of objective and subjective LD responders who underwent VP shunt placement. METHODS: This was a retrospective review of patients with NPH who underwent VP shunt placement after clinical improvement with the LD trial. Patients who responded after the LD trial were subclassified into objective LD responders and subjective LD responders. Clinical characteristics, complication rates, and shunt outcomes between the 2 groups were compared with chi-square test of independence and t-test. RESULTS: A total of 116 patients received a VP shunt; 75 were objective LD responders and 41 were subjective LD responders. There was no statistically significant difference in patient characteristics between the 2 groups, except for a shorter length of stay after LD trial seen with subjective responders. The complication rates after LD trial and VP shunting were not significantly different between the 2 groups. Similarly, there was no significant difference in shunt response between objective and subjective LD responders. The mean duration of follow-up was 1.73 years. CONCLUSIONS: Reports of subjective improvement after LD trial in patients with NPH can be a reliable predictor of shunt response. The currently used objective assessment scales may not be sensitive enough to detect subtle changes in symptomatology after LD trial.

H3 K27M Mutations in Thalamic Pilocytic Astrocytomas with Anaplasia.

BACKGROUND: The revised World Health Organization classification of central nervous system tumors, published in 2016, has recognized the H3 K27M mutation as a critical genetic signature defining a new group of infiltrative astrocytomas designated as diffuse midline glioma, H3 K27M mutant. Although most H3 K27M mutations arise in the setting of diffusely infiltrative tumors, there are rare reports of compact tumors with low-grade histologic features harboring this mutation. The prevalence and clinical significance of this mutation in pilocytic astrocytomas remain unclear. CASE DESCRIPTION: We report 2 young adult patients with H3 K27M-mutated thalamic pilocytic astrocytomas who presented to medical attention with symptomatic hydrocephalus requiring urgent intervention. We present our experience with this unusual tumor and recommend a treatment paradigm of maximal safe surgical resection followed by chemotherapy and radiation. CONCLUSIONS: Stereotactic biopsies may undergrade some adult thalamic pilocytic astrocytomas. Therefore, we recommend that all these tumors be evaluated for the H3 K27M mutation. Further, we think H3 K27M-mutant thalamic pilocytic astrocytomas require aggressive multimodality treatment and these treatments should be guided by the molecular findings, as opposed to the histologic ones.

Lumbar drain trial outcomes of normal pressure hydrocephalus: a single-center experience of 254 patients.

OBJECTIVE: A short-term lumbar drain (LD) trial is commonly used to assess the response of normal pressure hydrocephalus (NPH) patients to CSF diversion. However, it remains unknown whether the predictors of passing an LD trial match the predictors of improvement after ventriculoperitoneal shunting. The aim of this study was to examine outcomes, complication rates, and associations between predictors and outcomes after an LD trial in patients with NPH. METHODS: The authors retrospectively reviewed the records of 254 patients with probable NPH who underwent an LD trial between March 2008 and September 2017. Multivariate regression models were constructed to examine predictors of passing the LD trial. Complications associated with the LD trial procedure were recorded. RESULTS: The mean patient age was 77 years and 56.7% were male. The mean durations of gait disturbance, cognitive decline, and urinary incontinence were 29 months, 32 months, and 28 months, respectively. Of the 254 patients, 30% and 16% reported objective and subjective improvement after the LD trial, respectively. Complications included a sheared LD catheter, meningitis, lumbar epidural abscess, CSF leak at insertion site, transient lower extremity numbness, slurred speech, refractory headaches, and hyponatremia. Multivariate analyses using MAX-R revealed that a prior history of stroke predicted worse outcomes, while disproportionate subarachnoid spaces (uneven enlargement of supratentorial spaces) predicted better outcomes after the LD trial (r2 = 0.12, p < 0.05). CONCLUSIONS: The LD trial is generally safe and well tolerated. The best predictors of passing the LD trial include a negative history of stroke and having disproportionate subarachnoid spaces.

Isolated Dorsal Thoracic Neuroenteric Cyst with Spinal Cord Compression: Case Reports in Pediatrics.

BACKGROUND: Neuroenteric cysts are rare developmental anomalies of the central nervous system that account for approximately 0.7%-1.3% of all spinal cord lesions. The majority of spinal neuroenteric cysts are located ventral to the spinal cord. Dorsally located neuroenteric cysts are rare and are almost always associated with other spinal anomalies. Isolated dorsal spinal neuroenteric cysts, without other associated spinal anomalies, are extremely rare. These lesions can be mistaken for the more commonly encountered spinal cysts (e.g., arachnoid cysts, ependymal cysts, cystic teratomas). CASE DESCRIPTION: We present the first pediatric case of a 9-month-old boy with an isolated dorsal thoracic neuroenteric cyst and cord compression that underwent surgical resection. The patient tolerated the procedure well and remained neurologically stable after surgery. Pathology was consistent with a neuroenteric cyst. Complete resection was not achieved at the time of surgery. In retrospect, knowing the lesion is a neuroenteric cyst, a more aggressive approach aiming for a complete surgical resection should have been undertaken. To our knowledge, only 2 adult cases of isolated dorsal spinal neuroenteric cysts have been reported in the literature. CONCLUSIONS: Neuroenteric cysts can occur dorsal to the spinal cord without any associated spinal anomalies. The gold standard treatment for neuroenteric cysts is surgical resection, and the goal of surgery is complete resection.

Milrinone-Associated Cardiomyopathy and Arrhythmia in Cerebral Vasospasm.

BACKGROUND: Milrinone is an inotropic and vasodilatory drug proven safe for use in treatment of cerebral vasospasm. Despite its reported safety profile, its use is not free of side effects. Milrinone-associated cardiomyopathy and arrhythmia can occur in patients with cerebral vasospasm. CASE DESCRIPTION: This is a retrospective chart review of a patient who presented with aneurysmal subarachnoid hemorrhage and developed clinical vasospasm twice over a period of 2 weeks. Sustained intravenous milrinone infusion was used in association with norepinephrine infusion during this period. The patient developed R-on-T triggered torsades de pointes and cardiogenic shock requiring resuscitation. Follow-up echocardiogram showed decreased ejection fraction from 64% to 43% consistent with cardiac remodeling. Systemic complications such as cardiotoxicity and arrhythmias with the use of intravenous milrinone can be seen particularly when used in combination with catecholamines. CONCLUSIONS: With increased combined milrinone and catecholamine use for the treatment of cerebral vasospasm, physicians should be aware of the potential cardiac complications of these agents. Close monitoring with daily electrocardiograms may be helpful to detect changes that suggest cardiotoxicity. If changes are noted, an echocardiogram and cardiology consultation may be warranted.