Technical Challenges in Endovascular Treatment of Ruptured Aneurysm in a Patient with Body Mass Index >100.

BACKGROUND: Morbid obesity can pose unique challenges in the endovascular treatment of cerebrovascular diseases, particularly in the management of ruptured aneurysms. CASE DESCRIPTION: This technical report discusses the challenges faced during the treatment of a ruptured aneurysm in a morbidly obese patient with a body mass index of 101. The technical adaptations used included the utilization of Dyna CT for routine imaging, vacuum assist devices for patient transfer, and a transradial approach to avoid groin complications. The technical adaptations used in the management of the ruptured aneurysm in the morbidly obese patient were effective in overcoming the challenges posed by the patient's obesity. CONCLUSION: This technical report and literature review can serve as a guide for physicians treating morbidly obese patients with cerebrovascular diseases. Utilization of advanced technology and innovative approaches can aid in overcoming the challenges posed by obesity and improving patient outcomes.

The Scope and Impact of the COVID-19 Pandemic on Neuroemergent Patient Transfers, Clinical Care and Patient Outcomes.

Introduction: The SARS-CoV-2 (COVID-19) pandemic continues to substantially alter previously established clinical practice patterns and has transformed patient care in American healthcare. However, studies to evaluate the impact of COVID-19 on neuroemergent patient care and associated clinical outcomes are limited. Herein, we describe the impact of COVID-19 on the Neuroemergency Transfer Program (NTP) - a novel, urban, high volume interhospital patient transfer program. Objective: To evaluate and describe the clinical impact of the COVID-19 pandemic on the NTP. Study Design: A single-center retrospective study of prospectively collected consecutive neuroemergent patient transfer data between 2018-2021 was analyzed. Adult patients were divided based upon transfer date into a Pre-COVID (PCOV) or COVID cohort. Patient demographics, transfer characteristics and clinical data and outcomes were analyzed. Results: 3,096 patients were included for analysis. Mean age at transfer in the PCOV and COVID cohorts were 62.4 ± 0.36 and 61.1 ± 0.6 years. A significant decrease in mean transfers per month was observed between cohorts (PCOV = 97.8 vs. COV = 68.2 transfers/month, p < 0.01). Total transfer time in the PCOV cohort was 155.1 ± 3.4 min which increased to 169.3 ± 12.8 min in the COVID cohort (p = 0.13). Overall mean transfer distance was significantly longer in the PCOV cohort at 22.0 ± 0.4 miles vs. 20.3 ± 0.67 miles in the COV cohort (p = 0.03). The relative frequency of transfer diagnoses was unchanged between cohorts. A significant increase in mean inpatient length of stay was noted, 7.9 ± 0.15 days to 9.6 ± 0.33 days in the PCOV vs. COVID cohorts (p < 0.01). Ultimately, no difference in the frequency of good vs. poor clinical outcome were noted between the PCOV (79.8% and 19.4%) vs. COV (78.8% and 20.4%) cohorts. Conclusion: The impact of COVID-19 on current healthcare dynamics are far reaching. Here, we show a significant decrease in interhospital patient transfers and increased length of stay between a Pre-COVID and COVID cohort. Further work to better elucidate the specific interplay of clinical contributors to account for these changes is indicated.

Expandable versus Static Transforaminal Lumbar Interbody Fusion Cages: 1-year Radiographic Parameters and Patient-Reported Outcomes.

OBJECTIVE: Expandable transforaminal lumbar interbody fusion (TLIF) cages capable of multidirectional in situ expansion have gained popularity as they increase axial surface area for fusion and may enhance lordotic correction through a traditional minimally invasive surgery (MIS) surgical corridor. We evaluated and compared the radiographic and clinical outcomes between a novel expandable versus static minimally invasive surgery TLIF cage for the treatment of degenerative disk disease. METHODS: A single-center retrospective review of 120 consecutive adult patients undergoing 1- or 2-level MIS TLIF with an expandable (n = 60) or static cage was performed between 2015 and 2019. Preoperative and 1-year postoperative radiographic and clinical outcomes were assessed by upright flexion/extension radiographs and serial confidential surveys. RESULTS: One-hundred twenty patients (mean age 63.5 years, 60.0% female) undergoing 1- and 2-level MIS TLIF met inclusion criteria. A statistically significant reduction of spondylolisthesis, restoration of foraminal height as well as anterior and posterior disk height was achieved in both cohorts, however was greater in the expandable cage cohort (ECC) (all P < 0.05). Comparable rates of fusion, 93% and 91%, were observed in the ECC and static cage cohort. A significant reduction in Numeric Pain Rating Scale back and Oswestry Disability Index scores were observed in both cohorts but were more pronounced in the ECC (5.9 ± 2.4 to 2.2 ± 1.9 and 37.3 ± 16.2 to 17.1 ± 15.2) versus static cage cohort (6.2 ± 2.8 to 3.2 ± 2.5 and 41.8 ± 16.1 to 24.3 ± 17.5) (P < 0.05). One instance of cage migration requiring reoperation occurred in the ECC. CONCLUSIONS: Taken together, these radiographic and clinical findings suggest an expandable cage placed through an MIS corridor represents a safe, equitable, and efficacious alternative to a static TLIF in adults with degenerative lumbar pathology.

Nonunion Rates After Anterior Cervical Discectomy and Fusion: Comparison of Polyetheretherketone vs Structural Allograft Implants.

BACKGROUND: Although advances in implant materials, such as polyetheretherketone (PEEK), have been developed aimed to improve outcome after anterior cervical discectomy and fusion (ACDF), it is essential to confirm whether these changes translate into clinically important sustained benefits. OBJECTIVE: To compare the radiographic and clinical outcomes of patients undergoing up to 3-level ACDF with PEEK vs structural allograft implants. METHODS: In this cohort study, radiographic and symptomatic nonunion rates were compared in consecutive patients who underwent 1 to 3 level ACDF with allograft or PEEK implant. Prospectively collected clinical data and patient-reported outcome (PRO) scores were compared between the allograft and PEEK groups. Regression analysis was performed to determine the predictors of nonunion. RESULTS: In total, 194 of 404 patients met the inclusion criteria (79% allograft vs 21% PEEK). Preoperative demographic variables were comparable between the 2 groups except for age. The rate of radiographic nonunion was higher with PEEK implants (39% vs 27%, P = .0035). However, a higher proportion of nonunion in the allograft cohort required posterior instrumentation (14% vs 3%, P = .039). Patients with multilevel procedures and PEEK implants had up to 5.8 times the risk of radiographic nonunion, whereas younger patients, active smokers, and multilevel procedures were at higher risk of symptomatic nonunion. CONCLUSION: Along with implant material, factors such as younger age, active smoking status, and the number of operated levels were independent predictors of fusion failure. Given the impact of nonunion on PRO, perioperative optimization of modifiable factors and surgical planning are essential to ensure a successful outcome.

Gout in the thoracic spine causing acute paraplegia: illustrative case.

BACKGROUND: Although spinal involvement by gout is not uncommon, spinal gout leading to symptomatic spinal cord compression in the thoracic spine is very rare and poses a diagnostic challenge by mimicking symptoms of more common diagnoses such as epidural abscess and malignancy. An even more unique presentation is spinal gout causing thoracic cord compression leading to acute paraplegia. OBSERVATIONS: The authors present an illustrative case of a 35-year-old man with thoracic spinal compression by tophaceous gout who developed rapid progression to complete paraplegia over a 5-day period. Magnetic resonance imaging of the thoracic spine revealed a cystic-appearing lesion within the dorsal extradural space of the lower thoracic spine extending from T8 to T10 accompanied by compression of the spinal cord. An emergent T9-10 laminectomy was performed, and the occupying lesion in the thoracic spine was resected. The diagnosis of spinal tophaceous gout was made by pathological examination. LESSONS: Although varying clinical manifestations of spinal gout have been reported in the literature, the patient's age and the rapid progression to complete paraplegia over a 5-day period reveals a unique presentation that broadens understanding of the manner in which this condition can present and allow more rapid diagnosis and treatment.