Outcomes Following 2-Level Cervical Interventions with Cage-and-Plate, Zero-Profile, or Arthroplasty Constructs.

BACKGROUND: Though cage-and-plate constructs are widely used for disk height restoration in surgery for cervical disc disease, concerns over range of motion limitations and adjacent disc space violations have fueled the development of artificial disc and zero-profile constructs. This study investigated the outcomes of patients undergoing two-level cervical interventions via arthroplasty, cage-and-plate, or zero-profile constructs. METHODS: Patients undergoing two-level anterior cervical procedures between 2010 and 2020 were identified using an all-payer claims database. Logistic regression models were utilized to develop criteria for a 1:1:1-exact match procedure. The primary outcome was the need for additional surgery within 30 months, and the secondary outcomes included medical and surgical complications observed within 30 days of index intervention. P values < 0.05 were considered statistically significant. RESULTS: 133,831 patients were identified as undergoing two-level anterior cervical interventions. Seven thousand three hundred seventy-one records were analyzed through a 1:1:1 match. Patients who received zero-profile versus cage-and-plate constructs had significantly decreased odds of requiring additional surgery within 30 months (Odds Ratio [OR] 0.64; 95% Confidence Interval [CI] 0.51-0.81). However, postoperative medical complications were increased among patients who received zero-profile constructs compared to cage-and-plate (OR 1.59; 95%CI 1.07-2.37). Patients who underwent arthroplasty also had decreased odds for additional surgery versus cage-and-plate (OR 0.75; 95%CI 0.60-0.93). There was no significant difference between arthroplasty and cage-and-plate constructs in developing postoperative surgical or medical complications. CONCLUSIONS: Among patients undergoing two-level interventions, cage-and-plate constructs were associated with increased odds of additional surgery within 30 months following index procedures when compared to zero-profile constructs or arthroplasty.

Gastrostomy Sequence With Ventriculoperitoneal Shunting-Does It Matter?

BACKGROUND: Neurological injury requiring ventriculoperitoneal shunt (VPS) placement often necessitates gastrostomy for nutritional support. The sequence of these procedures is debated over concerns for shunt infection and displacement requiring revisional surgery as a consequence of gastrostomy. OBJECTIVE: To determine the optimal sequence of VPS shunt and gastrostomy tube placement in adults. METHODS: In an all-payer database, adult patients undergoing gastrostomy and VPS placement were identified within 15 days between January 2010 and October 2021. Patients were categorized as receiving gastrostomy before, on the same day as, or after shunt placement. The primary outcomes of this study were rates of revision and infection. All outcomes were evaluated within 30 months after index shunting. RESULTS: In total, 3015 patients were identified as undergoing VPS and gastrostomy procedures within 15 days. After a 1:1:1 match, 1080 patient records were analyzed. Revision rates at 30 months were significantly lower among patients who received VPS and gastrostomy procedures on the same day compared with gastrostomy after VPS (odds ratio [OR] 0.61, 95% CI 0.39-0.96). In addition, patients who received gastrostomy before VPS compared with those after had lower revision rates (OR 0.61, 95% CI 0.39-0.96) and infection (OR 0.46, 95% CI 0.21-0.99). No significant differences were noted in mechanical complication or shunt displacement rates. CONCLUSION: Patients requiring VPS and gastrostomy may benefit from undergoing both procedures concurrently or with gastrostomy before VPS placement, secondary to lower revision rates. Patients undergoing gastrostomy before VPS have the added benefit of decreased infection rates.

Racial Disparities in Time to Decompression in Central Cord Syndrome: A National Trauma Database Analysis.

OBJECTIVE: Cervical cord syndrome (CCS) is the most common type of incomplete spinal cord injury. Prompt surgical decompression within 24 hours increases neurologic function and rates of home discharge. Racial disparities exist in spinal cord injury, with Black patients experiencing longer lengths of stay and higher rates of complications than in White patients. This study aims to investigate potential racial disparities in time to surgical decompression in patients with CCS. METHODS: The National Trauma Data Bank (NTDB) was queried from 2017 to 2019 for patients who underwent surgery for CCS. The primary outcome was time from hospital admission to surgery. Student's t-test and Pearson's chi-squared test were used to evaluate differences in categorical and continuous variables, respectively. An uncensored Cox proportional hazards regression model was developed to assess the effect of race on surgical timing while adjusting for potential confounders. RESULTS: 1,076 patients with CCS resulting in cervical spinal cord surgery were included in the analysis. Regression analysis results showed that Black patients (HR=0.85, P = 0.03), female patients (HR=0.81, P < 0.01), and patients treated at community hospitals (HR=0.82, P = 0.01) were less likely to receive early surgery. CONCLUSIONS: Though the advantages of early surgical decompression in the setting of CCS have been detailed in medical literature, Black, and female patients experience lower rates of prompt surgery following hospital admission and higher rates of adverse outcomes. This disproportionately increased time to intervention exemplifies demographic disparities in the timely provision of treatment to patients with spinal cord injuries.

Postoperative Opioid Use Among Opioid-Naive Cannabis Users Following Single-Level Lumbar Fusions.

BACKGROUND: As the literature grows on opioid use, the impact of simultaneous cannabis use has hitherto been mostly unexplored. In this study, we assessed the effects of cannabis use on postoperative opioid utilization in opioid-naive patients undergoing single level fusions of the lumbar spine. METHODS: Using an all-payer claims database, the medical records of 91 million patients were analyzed to identify patients who had undergone single level lumbar fusions between January 2010 and October 2020. Rates of opioid utilization at 6 months following index procedure (morphine milligram equivalents/day), the development of opioid use disorder (OUD), and the rates of opioid overuse were assessed. RESULTS: Following examination of 87,958 patient records, 454 patients were matched and distributed equally into cannabis user and noncannabis user cohorts. At 6 months following index procedure, cannabis users were equal to nonusers in their rates of prescribed opioid utilization (49.78%, P > 0.99). Cannabis users used smaller daily dosages compared to nonusers (51.1 ± 35.05 vs. 59.72 ± 41, P = 0.003). On the other hand, the proportion of patients diagnosed with OUD was found to be significantly higher among patients using cannabis (18.94% vs. 3.96%, P < 0.0001). CONCLUSIONS: Compared to noncannabis users, opioid-naive patients who are cannabis users undergoing lumbar spinal fusions are at a higher risk of developing opioid dependence following surgery, despite having decreased daily dosages of opioids overall. Further studies should explore the factors associated with the development of OUD and the details of concurrent marijuana use to effectively treat pain while limiting the potential for abuse.

Outcomes Following Endoscopic versus Open Carpal Tunnel Release-A Matched Study.

OBJECTIVE: Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy in the world. Surgical treatment can be performed in an open or endoscopic fashion. To date, similar rates of complications for both approaches have been described. We sought to compare the results of endoscopic carpal tunnel release (ECTR) with open carpal tunnel release (OCTR) in patients with CTS. METHODS: Patients with a diagnosis of CTS undergoing open or endoscopic surgical management were identified between January 2010 and October 2020. The primary outcome of the study was nerve injury within 30 days of the procedure. Secondary outcomes included readmission, wound-related complications, hematoma, seroma formation, and cost. RESULTS: A total of 735,631 patients were identified as undergoing CTR. Following a 1:1 match procedure, 292,626 patient records were analyzed. Patients undergoing OCTR versus ECTR had an increased odds of readmission at 30 days (odds ratio [OR] 1.89, 95% confidence interval [CI] 1.73-2.06), developing an infection (OR 1.59, 95% CI 1.41-1.80), and experiencing wound complications (OR 1.97, 95% CI 1.74-2.23). No significant difference in odds of developing a seroma (OR 1.17, 95% CI 0.83-1.65), hematoma (OR 1.15, 95% CI 0.95-1.39), or nerve injury (OR 1.18, 95% CI 0.98-1.43) was noted. The reimbursement cost of ECTR was significantly greater than OCTR ($310.60 ± $1639.57 vs. $237.69 ± $1488.93, P < 0.001). CONCLUSIONS: In the largest study to date on the surgical management of CTR, OCTR was seen to be associated with an increased odds of readmission, infection, and wound complications, but reduced costs for the procedure alone.

The neural basis for mental state attribution: A voxel-based lesion mapping study.

The ability to infer other persons' mental states, "Theory of Mind" (ToM), is a key function of social cognition and is needed when interpreting the intention of others. ToM is associated with a network of functionally related regions, with reportedly key prominent hubs located in the dorsolateral prefrontal cortex (dlPFC) and the temporoparietal junction (TPJ). The involvement of (mainly the right) TPJ in ToM is based primarily on functional imaging studies that provide correlational evidence for brain-behavior associations. In this lesion study, we test whether certain brain areas are necessary for intact ToM performance. We investigated individuals with penetrating traumatic brain injury (n = 170) and healthy matched controls (n = 30) using voxel-based lesion-symptom mapping (VLSM) and by measuring the impact of a given lesion on white matter disconnections. ToM performance was compared between five patient groups based on lesion location: right TPJ, left TPJ, right dlPFC, left dlPFC, and other lesion, as well as healthy controls. The only group to present with lower ToM abilities was the one with lesions in the right dlPFC. Similarly, VLSM analysis revealed a main cluster in the right frontal middle gyrus and a secondary cluster in the left inferior parietal gyrus. Last, we found that disconnection of the left inferior longitudinal fasciculus and right superior longitudinal fasciculus were associated with poor ToM performance. This study highlights the importance of lesion studies in complementing functional neuroimaging findings and supports the assertion that the right dlPFC is a key region mediating mental state attribution.