Is young adult idiopathic scoliosis a distinct clinical entity from adolescent idiopathic scoliosis? a Systematic Review and Meta-analysis comparing pre-operative characteristics and operative outcomes.

PURPOSE: This study aims to conduct a systematic review of the literature comparing pre-operative, intraoperative, and post-operative characteristics between adolescent idiopathic scoliosis (AIS) and young adult idiopathic scoliosis (YAdIS) patients. METHODS: Following PRISMA guidelines, we conducted a search of the PubMed/Medline, EMBASE, and Cochrane Central databases to identify full-text articles in the English-language literature. Our inclusion criteria were studies that compared preoperative, intraoperative, and postoperative characteristics between AIS and YAdIS patients. We performed a meta-analysis reporting mean difference (MD) for continuous variables and Odds ratios (ORs) to assess differences in postoperative complications. RESULTS: Seven studies consisting of 1562 patients were included in the meta-analysis. The AIS group exhibited less intraoperative bleeding and shorter surgical procedures, with a mean difference between groups of 122.3 ml (95% CI 46.2-198.4, p = 0.002) and 28.7 min (95% CI 6.5-50.8, p = 0.01), respectively. Although the preoperative Cobb angle did not differ between groups (p = 0.65), patients with AIS achieved superior postoperative deformity correction, with a mean difference of 7.3% between groups, MD - 7.3 (95% CI - 9.7, - 4.8, p < 0.00001), and lower postoperative Cobb angles of the major curve, MD 4.2 (95% CI 3.1, 5.3, p < 0.00001). YAdIS patients were fused, on average, 0.2 more vertebral levels than AIS patients, MD 0.2 (95% CI 0.01, 0.5, p = 0.04). AIS patients experienced a significantly shorter length of stay after the surgical procedure, with an MD of 0.8 days (95% CI 0.1, 1.6, p = 0.02). No significant difference was found between groups in terms of complications (p = 0.19). CONCLUSIONS: YAdIS should be regarded as a distinct surgical entity, characterized by increased bleeding, longer surgical duration, greater deformity correction challenges, and the need for fusion of additional vertebral levels compared to AIS. Surgeons should be mindful of these differences and discuss them with patients and their families, especially in cases where the correction of the AIS deformity is delayed and there is a high risk of progression after skeletal maturity. Further research is needed to explore alternative surgical techniques and enhance outcomes for YAdIS patients.

Clinical Outcomes and Complication Profile of Spine Surgery in Septuagenarians and Octogenarians: Case Series.

OBJECTIVE: The aging global population presents an increasing challenge for spine surgeons. Advancements in spine surgery, including minimally invasive techniques, have broadened treatment options, potentially benefiting older patients. This study aims to explore the clinical outcomes of spine surgery in septuagenarians and octogenarians. METHODS: This retrospective analysis, conducted at a US tertiary center, included patients aged 70 and older who underwent elective spine surgery for degenerative conditions. Data included the Charlson Comorbidity Index (CCI), ASA classification, surgical procedures, intraoperative and postoperative complications, and reoperation rates. The objective of this study was to describe the outcomes of our cohort of older patients and discern whether differences existed between septuagenarians and octogenarians. RESULTS: Among the 120 patients meeting the inclusion criteria, there were no significant differences in preoperative factors between the age groups (P > 0.05). Notably, the septuagenarian group had a higher average number of fused levels (2.36 vs. 0.38, P = 0.001), while the octogenarian group underwent a higher proportion of minimally invasive procedures (P = 0.012), resulting in lower overall bleeding in the oldest group(P < 0.001). Mobility outcomes were more favorable in septuagenarians, whereas octogenarians tended to maintain or experience a decline in mobility(P = 0.012). A total of 6 (5%) intraoperative complications and 12 (10%) postoperative complications were documented, with no statistically significant differences observed between the groups. CONCLUSIONS: This case series demonstrates that septuagenarians and octogenarians can achieve favorable clinical outcomes with elective spine surgery. Spine surgeons should be well-versed in the clinical and surgical care of older adults, providing optimal management that considers their increased comorbidity burden and heightened fragility.

Subfascial drains are safe and effective in preventing postoperative cerebrospinal fluid leaks after intradural spine tumor surgery.

Background: Delayed cerebrospinal fluid (CSF) leaks are a known complication following intradural spinal tumor surgery. The placement of subfascial drains in these patients undergoing requisite intradural surgery is controversial. Here, we demonstrated that placing a subfascial drain on partial suction for 48 h, with early ambulation, proved to be safe and effective in preventing early/delayed recurrent CSF fistulas. Methods: Medical records of 17 patients undergoing surgery for intradural spinal tumors over a 30-month were reviewed. All patients underwent intradural tumor resection followed by primary dural closure, placement of Gelfoam in a non-compressive fashion, application of fibrin sealant, and utilization of a subfascial drain placed on partial suction for 48 h postoperatively. Patients are mobilized the morning following surgery. We tracked the incidence of postoperative recurrent CSF leaks, over drainage, infection, wound dehiscence, pseudo meningocele formation, and the reoperation rate. Results: For the 17 patients, our programmed average utilization of subfascial drains was 48 h. Moreover, the average drain output was 165 mL. Over the 1-year follow-up period, no patient developed a recurrent early/ delayed CSF leak, there were no wound complications, nor need for revision surgery. Conclusion: Utilizing subfascial drains on partial suction following the resection of intradural spinal tumors with primary dural closure proved to be safe and effective.

Resection of an Intradural Intramedullary C7-T1 Tumor: Technical Nuances and Complication Management.

Primary spinal cord tumors are relatively rare, comprising approximately 4%-16% of all tumors originating from the central nervous system. These tumors are anatomically separable into 2 broad categories: intradural intramedullary and intradural extramedullary. Intramedullary tumors are composed predominantly of gliomas (infiltrative astrocytoma) and ependymomas.1-4 The primary treatment approach for these tumors is surgical resection, aiming to preserve neurologic function.5-9 In Video 1, the authors showcase a step-by-step approach for microsurgical resection of a primary spinal ependymoma, with emphasis on microsurgical technique and utility of adjunct equipment, such as intraoperative ultrasound and neuromonitoring.10,11 The patient consented to the procedure.

C2 versus C3 or C4 as the upper instrumented vertebra for long-segment cervical fusions: a systematic review and meta-analysis.

OBJECTIVE: Selecting C2 versus C3 or C4 (i.e., C3/C4) as the rostral anchoring level in long-segment cervical fusions is a common clinical conundrum. The data regarding proximal failure in long constructs of the cervical spine is scarce. The objective of this study was to systematically review the published literature and perform a meta-analysis of the incidence for proximal adjacent-segment disease (ASD) in the context of long cervical fusions and cervicothoracic fusions ending in C2 versus those ending in the subaxial spine (C3 or C4). METHODS: Using the PRISMA guidelines, the authors performed a search of the PubMed/MEDLINE, Embase/Ovid, and Cochrane Central databases to identify all full-text articles in the English-language literature with the following inclusion criteria: 1) studies including patients with the upper instrumented vertebra (UIV) at C2 versus C3/C4; 2) patients undergoing ≥ 3-level posterior cervical fusion; and 3) indication for surgery of degenerative disc disease, cervical spondylotic myelopathy, or cervical deformity. Studies that were not published in the English language, case reports, review articles, letters to the editor, and meeting abstracts were excluded. A meta-analysis was conducted using a fixed-effects model when I2 values were below 70%. Conversely, when I2 values were equal to or greater than 70%, a random-effects model was used. A funnel plot was used to assess the presence of publication bias. RESULTS: Seven studies consisting of 1215 patients were included in the meta-analysis. There were 403 (32.8%) patients in the C2 UIV group and 812 (67.2%) patients in the C3/C4 UIV group. When the 7 studies were analyzed, the overall rate of reoperation was comparable between the C2 (9.2%) and C3/C4 (9.4%) UIV groups (p = 0.93) but the rate of surgical ASD due to proximal pathology was 1.2% and 3%, respectively (OR 0.36, 95% CI 0.15-0.86; p = 0.02). When comparing between groups, no statistical difference was found regarding the rate of reoperation due to distal pathology or surgical infection. CONCLUSIONS: Long-segment cervical or cervicothoracic constructs that anchor into C2 may have similar complication rates but lower revision rates for proximal ASD than constructs that anchor into the subaxial spine.

Trends in Spinal Orthosis Utilization Among Patients Insured through Medicare Part B.

STUDY DESIGN: Retrospective population-based database analysis from the Physician/Supplier Procedure Summary Medicare/Medicaid Dataset. OBJECTIVE: To provide a comprehensive analysis of trends in spinal orthosis utilization over a 12-year period. SUMMARY OF BACKGROUND DATA: Widespread prescription of spinal orthosis persists, despite evidence suggesting equivocal efficacy in many spinal conditions. The utilization of spinal orthosis on a national level, including prescribing specialty data, has not been previously analyzed. METHODS: Healthcare common procedure coding system (HCPCS) codes for cervical (CO), thoracic-lumbar-sacral (TLSO), lumbar (LO), lumbar-sacral (LSO), and cervical-thoracic-lumbar-sacral (CTLSO) orthosis were used to determine spinal orthosis utilization from 2010 to 2021. Provider specialty codes were utilized to compare trends between select specialties. Additionally, a neurosurgical CO analysis, based on subclassifications of cervical bracing, was performed. Linear trendlines were implemented to elucidate and present trends by slope (ß). RESULTS: Among 332,241 claims, decreases in CO (ß=-0.3387), TLSO (ß=-0.0942), LO (ß=-0.3485), and LSO (ß=-0.1545) per 100,000 Medicare Part B enrollees and CTLSO (ß=-0.052) per 1,000,000 Medicare Part B enrollees were observed. Decreases among neurosurgery (ß=-7.9208), family medicine (ß=-1.0097), emergency medicine (ß=-2.1958), internal medicine (ß=-1.1151), interventional pain management (ß=-5.0945), and chiropractic medicine (ß=-49.012), and increases among orthopedic surgery (ß=5.5891), pain management (ß=30.416), physical medicine and rehabilitation (ß=4.6524), general practice (ß=79.111), and osteopathic manipulative medicine (ß=45.303) in total spinal orthosis use per 100,000 specialty claims were observed. Analysis on subclassifications of cervical orthosis among neurosurgeons revealed decreases in flexible (ß=-1.7641), semi-rigid (ß=-0.6157), and collar bracing (ß=-2.7603), and an increase in multi-post collar bracing (ß=2.2032) per 100 neurosurgical cervical orthosis claims. CONCLUSIONS: While utilization of spinal orthosis decreased between 2010-2021, increased utilization was observed among a subset of specialties. Identifying these specialties allows for focused research and educational efforts to minimize unnecessary durable medical equipment use for effective healthcare spending.

Indications for Fusion With Intradural Spine Tumor Resection in Adults: A Systematic Review and Meta-analysis.

BACKGROUND: The evidence for instrumented fusion in the setting of degenerative, traumatic, or congenital deformity is well established. Data on fusion indications in intradural spinal tumors (IDST) are scarce and reduced to retrospective studies. The objective of this work is to systematically review the published literature since 2015 and analyze the change of practice patterns for stabilization and fusion after intradural tumor resection in adults. METHODS: A systematic literature review was performed via PubMed with the terms: "intradural spinal tumors", "intramedullary spinal tumors", and "intraspinal tumors". The analysis was limited to adult patients with IDST and studies with more than 10 patients. Data on the proportion of patients who underwent instrumentation and had postoperative deformity was pooled in a meta-analysis. RESULTS: A total of 1073 articles were identified and 47 papers were selected. All the studies were retrospective series and a total of 2473 patients were included. The follow-up ranged from 1 to 96 months, the pooled spinal fixation rate was 6% (95% CI 4.5%-7.6%), the pooled laminoplasty rate was 14.4% (95% CI 5.9%-23%), the pooled rate of postoperative deformity or malalignment in patients with a follow up of at least 6 months was 2.1% (95% CI 1.2%-3%) and just 7 patients were reoperated due to progressive deformity. CONCLUSIONS: Based on existing evidence, the rate of fusion during resection of intradural spinal tumors is low. Prophylactic fixation is often unnecessary and only indicated in unique cases that require extensive bony resection.

Sinusitis complicated by intracranial abscess in 3 patients with coronavirus disease 2019: illustrative cases.

BACKGROUND: The novel coronavirus disease 2019 (COVID-19) can be associated with various neurological manifestations, including cerebrovascular disease, seizures, peripheral nerve disease, and encephalitis. Intracranial abscess related to COVID-19 is rare but illustrates a serious complication in the studied cases. OBSERVATIONS: The authors report 3 cases of patients presenting with COVID-19 complicated by sinusitis with associated intracranial abscesses. Each patient underwent craniotomy with washout and sinus debridement during their hospital stay. All 3 patients improved to their baseline following treatment. Similar outcomes have been observed in other cases of intracranial abscess associated with COVID-19 infections. LESSONS: Patients achieved significant improvement following evacuation of the abscess and intravenous antibiotics. Further investigation is needed to determine treatment in relation to COVID-19, and the authors recommend following the standard treatment of intracranial abscess at this time.

Pseudoaneurysm as a differential for the computed tomography angiography "spot sign" in atypical presentations of intracerebral hemorrhage: illustrative case.

BACKGROUND: The computed tomography angiography (CTA) "spot sign" is a well-recognized radiographic marker in primary intracerebral hemorrhage (ICH). Although it has been demonstrated to represent an area of active hemorrhage or contrast extravasation, the exact pathophysiology remains unclear. Vascular mimics of the spot sign have been identified; however, those representing pseudoaneurysm and small vessel aneurysm have rarely been reported. OBSERVATIONS: A 57-year-old female with a past medical history of hypertension and diabetes mellitus presented with 2 weeks of acute-onset, worsening headache. Computed tomography scanning showed a right interior frontal lobe intraparenchymal hemorrhage. CTA demonstrated a punctate focus of hyperattenuation within the hematoma, consistent with a spot sign, which corresponded to a distal anterior cerebral artery pseudoaneurysm on a cerebral angiogram. The patient subsequently underwent emergent resection of the pseudoaneurysm and hematoma evacuation without complications. Her postoperative course was unremarkable without acute concerns or residual symptoms at the 4-month follow-up. LESSONS: The authors present a unique case of a distal anterior cerebral artery pseudoaneurysm presenting as a spot sign in a relatively young patient without underlying vascular disease. Given the need for emergent intervention, intracranial pseudoaneurysm is an important diagnosis to consider in the presence of a spot sign in atypical clinical presentations of primary ICH.

Intracranial metastasis from a malignant peripheral nerve sheath tumor in a patient with neurofibromatosis type 1: A case study and literature review.

INTRODUCTION: Malignant Peripheral Nerve Sheath Tumors (MPNSTs) are a rare type of soft tissue sarcoma. While these tumors often metastasize, intracranial metastases of MPNSTs have only been rarely noted. METHODS: Using Pubmed, Google Scholar, and Science Direct we conducted a systematic review of the literature to identify all reported cases of MPNSTs with metastases to the brain since the inception of these databases through January 2020. Data were extracted and data analysis was completed using python statistical packages. RESULTS: Only 26 cases (including present study) of MPNSTs resulting in intracranial metastases have been reported in the literature. Eight of these 26 cases occurred in patients who were previously diagnosed with Neurofibromatosis Type 1 (NF1). Additionally, one patient had been previously diagnosed with Neurofibromatosis Type 2 (NF2). The average reported time from diagnosis of a MPNST to the time of diagnosis with intracranial metastasis was 36 months, with a median time of 14 months. The average reported survival time for patients after being diagnosed with intracranial metastasis was 5.9 months. The cases that utilized a combination of therapeutic intervention including surgical resection, radiotherapy and chemotherapy saw the greatest improvement of survival times. CONCLUSION: MPNSTs with brain metastases are extremely rare and have a poor prognosis with a 6 months median survival after metastasis. While combination therapy is indicated, further studies on treatment are needed to determine survival benefits. Early and effective initial diagnosis of MPNST before brain metastases occurs is likely to give the best chance of increased overall survival.

Cervical Disc Arthroplasty Migration Following Mechanical Intubation: A Case Presentation and Review of the Literature.

BACKGROUND: Cervical arthroplasty has established itself as a safe and efficacious alternative to fusion in management of symptomatic cervical degenerative disease. Recent literature has indicated a trend toward decreased risk of reoperation with cervical arthroplasty, and reoperation in this subset commonly occurs secondary to recurrent pain and device-related complications. The instance of cervical arthroplasty migration, particularly in the setting of trauma, is particularly rare. Here, we report the first case of implant migration secondary to iatrogenic trauma following neck manipulation during direct laryngoscopy for mechanical intubation. CASE DESCRIPTION: A 53-year-old smoker with cervical spondylosis underwent a cervical 3/4 arthroplasty with a ProDisc-C implant. About a month postoperatively, he was intubated via direct laryngoscopy for community acquired pneumonia and began experiencing new dysphonia and dysphagia after extubation. Delayed imaging revealed anterior migration of the implant. The patient immediately underwent removal of the implant and conversion to anterior cervical discectomy and fusion. CONCLUSIONS: Supraphysiologic forces exerted through neck manipulation in mechanical intubation mimicked low-energy trauma, and in the setting of ligamentous resection necessary for cervical arthroplasty and inadequate osseous integration, led to migration of the implant. We recommend the integration of fiberoptic technique or video laryngoscopy with manual in line stabilization for intubation of post cervical arthroplasty patients when airway management is necessary within 10 months after cervical arthroplasty. Clinicians and anesthesiologists should have a high clinical suspicion for prompt and early workup with spine imaging in the setting of persistent postintubation symptoms such as dysphonia and/or dysphagia.

Minimally Invasive Evacuation of Severe Intraventricular Hemorrhage Using the BrainPath Endoport-Assisted Microsurgical System.

OBJECTIVE: We present the application of the BrainPath endoport-assisted microsurgical device (EAMD) as a treatment modality for patients with severe intraventricular hemorrhage (IVH) secondary to spontaneous supratentorial intracerebral hemorrhage (sICH). METHODS: Patients with severe secondary IVH (defined as Graeb score [GS] >6) who presented to Saint Louis University Hospital, St. Louis, Missouri, United States, from 2017 to 2019 were treated with the minimally invasive approach for IVH evacuation using the atraumatic BrainPath aspiration system. RESULTS: Three patients (2 men and 1 woman) with a mean age of 54 years were included in this study. The mean preoperative GS was 10.0 with a modified GS of 23.3. The mean postoperative GS was 4.0 (P = 0.001) with a modified GS of 10.67 (P = 0.001). There were no complications related to the surgery itself in any of the reported cases. CONCLUSIONS: BrainPath EAMD evacuation of severe IVH secondary to sICH appears to be a safe and effective treatment modality that significantly increases the extent of IVH clearance, which could also lead to improved long-term patient outcomes.

Awake High-Flow Extracranial to Intracranial Bypass for Complex Cerebral Aneurysms: Institutional Clinical Trial Results.

OBJECTIVE: Assess the potential added benefit to patient outcomes of "awake" neurological testing when compared with standard neurophysiologic testing performed under general endotracheal anesthesia. METHODS: Prospective study of 30 consecutive adult patients who underwent awake high flow extracranial to intracranial (HFEC-IC) bypass. Clinical neurological and neurophysiologic findings were recorded. Primary outcome measures were the incidence of stroke/cerebrovascular accident (CVA), length of stay, discharge to rehabilitation, 30-day modified Rankin scale score, and death. An analysis was also performed of a retrospective control cohort (n = 110 patients who underwent HFEC-IC for internal carotid artery (ICA) aneurysms under standard general endotracheal anesthesia). RESULTS: Five patients (16.6%) developed clinical awake neurological changes (4, contralateral hemiparesis; 1, ipsilateral visual changes) during the 10-minute ICA occlusion test. These patients had 2 kinks in the graft, 1 vasospasm, 1 requiring reconstruction of the distal anastomosis, and 1 developed blurring of vision that reversed after the removal of the distal permanent clip on the ICA. Three of these 5 patients had asynchronous clinical "awake" neurological and neurophysiologic changes. Two patients (7%) developed CVA. Median length of stay was 4 days. Twenty-eight of 30 patients were discharged to home. Median modified Rankin scale score was 1. There were no deaths in this series. Absolute risk reduction in the awake craniotomy group (n = 30) relative to control retrospective group (n = 110) was 7% for CVA, 9% for discharge to rehabilitation, and 10% for graft patency. CONCLUSIONS: Temporary ICA occlusion during HFEC-IC bypass for ICA aneurysms in conjunction with awake intraoperative clinical testing was effective in detecting a subset of patients (n = 3, 10%) in whom neurological deficit was not detected by neurophysiologic monitoring alone.