Impact of extent of resection and adjuvant therapy in diffuse gliomas of the spine.

BACKGROUND CONTENT: Diffuse gliomas of the spine (DGS)-consisting of intradural intramedullary glioblastoma, astrocytoma, and oligodendroglioma-are exceedingly rare tumors that account for about 2% of primary spinal cord tumors. Much is unknown about their optimal treatment regimen due to a relative lack of clinical outcome data. PURPOSE: To provide an updated analysis on treatment and outcomes in DGS. STUDY DESIGN/SETTING: Observational cohort study using The National Cancer Database (NCDB), a multicenter prospectively collected oncology outcomes database. A systematic literature review was also performed to compare the resulting data to previous series. PATIENT SAMPLE: Patients with histologically confirmed DGS from 2004 to 2018. OUTCOME MEASURES: Long-term overall survival and short-term 30/90-day postsurgical mortality, 30-day readmission, and prolonged hospital length of stay. METHODS: Impact of extent of resection and adjuvant therapy on overall survival was evaluated using Kaplan-Meier estimates and multivariable Cox proportional hazards regression. Univariate and multivariate logistic regression was used to analyze covariables and their prognostic impact on short-term surgical outcomes. RESULTS: Of the 747 cases that met inclusion criteria, there were 439 astrocytomas, 14 oligodendrogliomas, and 208 glioblastomas. Sixty percent (n=442) of patients received radiation, and 45% (n=324) received chemotherapy. Tumor histology significantly impacted survival; glioblastoma had the poorest survival (median survival time [MS]: 12.3 months), followed by astrocytoma (MS: 70.8 months) and oligodendroglioma (MS: 71.6 months) (p<.001). Gross total resection (GTR) independently conferred a survival benefit in patients with glioblastoma (hazard ratio [HR]: 0.194, p<0.001) and other WHO grade four tumors (HR: 0.223, p=.003). Adjuvant chemotherapy also improved survival in patients with glioblastoma (HR: 0.244, p=.007) and WHO grade four tumors (HR: 0.252, p<.001). Systematic literature review identified 14 prior studies with a combined DGS mortality rate of 1.3%, which is lower than the 4% real-world outcomes calculated from the NCDB. This difference may be explained by selection biases in previously published literature in which only centers with favorable outcomes publish their results. CONCLUSIONS: There remains a paucity of data regarding treatment paradigms and outcomes for DGS. Our analysis, the largest to date, demonstrates that GTR and adjuvant therapy independently improve survival for certain high-grade subgroups of DGS. This best-available data informs optimal management for such patients.

Augmented-reality template guided transorbital approach for intradural tumors.

For "minimally invasive" approaches to a deep-lying skull base lesion, the bone opening must be precisely placed and adequately wide to accomplish the surgical goal. Surgical rehearsal in virtual reality (VR) can generate navigation-integrated augmented reality (AR) templates to ensure precise surgical openings. In this video, the authors used AR templates for the transpalpebral, transorbital approach for intradural tumors. VR renderings of patient-specific anatomy were used in surgical rehearsal. The optimal openings were saved and, at surgery, projected into the eyepiece of the navigation-tracked microscope. The template enhanced the planning of the incision and soft-tissue exposure and guided the drill toward the target. The video can be found here: https://stream.cadmore.media/r10.3171/2021.10.FOCVID21172.

Neurosurgery Subspecialty Practice During a Pandemic: A Multicenter Analysis of Operative Practice in 7 U.S. Neurosurgery Departments During Coronavirus Disease 2019.

OBJECTIVE: Changes to neurosurgical practices during the coronavirus disease 2019 (COVID-19) pandemic have not been thoroughly analyzed. We report the effects of operative restrictions imposed under variable local COVID-19 infection rates and health care policies using a retrospective multicenter cohort study and highlight shifts in operative volumes and subspecialty practice. METHODS: Seven academic neurosurgery departments' neurosurgical case logs were collected; procedures in April 2020 (COVID-19 surge) and April 2019 (historical control) were analyzed overall and by 6 subspecialties. Patient acuity, surgical scheduling policies, and local surge levels were assessed. RESULTS: Operative volume during the COVID-19 surge decreased 58.5% from the previous year (602 vs. 1449, P = 0.001). COVID-19 infection rates within departments' counties correlated with decreased operative volume (r = 0.695, P = 0.04) and increased patient categorical acuity (P = 0.001). Spine procedure volume decreased by 63.9% (220 vs. 609, P = 0.002), for a significantly smaller proportion of overall practice during the COVID-19 surge (36.5%) versus the control period (42.0%) (P = 0.02). Vascular volume decreased by 39.5% (72 vs. 119, P = 0.01) but increased as a percentage of caseload (8.2% in 2019 vs. 12.0% in 2020, P = 0.04). Neuro-oncology procedure volume decreased by 45.5% (174 vs. 318, P = 0.04) but maintained a consistent proportion of all neurosurgeries (28.9% in 2020 vs. 21.9% in 2019, P = 0.09). Functional neurosurgery volume, which declined by 81.4% (41 vs. 220, P = 0.008), represented only 6.8% of cases during the pandemic versus 15.2% in 2019 (P = 0.02). CONCLUSIONS: Operative restrictions during the COVID-19 surge led to distinct shifts in neurosurgical practice, and local infective burden played a significant role in operative volume and patient acuity.

Coagulation Profile as a Significant Risk Factor for Short-Term Complications and Mortality after Anterior Cervical Discectomy and Fusion.

BACKGROUND: Cervical degenerative disc disease is the most common indication for anterior cervical discectomy and fusion. Given the possible complications, patients are stratified before anterior cervical discectomy and fusion by preoperative risk factors to optimize treatment. One preoperative factor is a patient's coagulation profile. METHODS: The American College of Surgeons-National Surgical Quality Improvement Database was used to identify patient preoperative coagulation profile and postoperative complications. By generating binary logistic regression models, each of the 4 abnormal coagulation categories (bleeding disorder, low platelet count, high partial thromboplastin time, and high international normalized ratio [INR]) were analyzed for their independent impact on increased risk for complications compared with the control cohort. RESULTS: A total of 61,977 patients were assessed. The most common abnormal coagulation was abnormal platelet count (n = 2149). The most common postoperative outcome was an extended length of hospital stay among patients with an abnormal coagulation profile relative to the control cohort. After multivariate analysis, patients with an abnormal INR (odds ratio, 2.2 [1.3-3.8]; P = 0.003) or abnormal platelet count (odds ratio, 1.5 [1.2-2.1]; P = 0.003) had a higher chance of having an extended length of hospital stay relative to patients having a normal coagulation profile. Having an abnormal INR was found to be associated with an increased risk for having "Any complication." CONCLUSIONS: Our results show significant differences in the incidence rates of a multitude of complications among the 5 groups based on univariate analysis. Patients with any abnormal coagulation disorder had increased rates of developing any complication or having an extended length of hospital stay.

The impact of COVID-19 on neurosurgeons and the strategy for triaging non-emergent operations: a global neurosurgery study.

OBJECT: The COVID-19 pandemic has disrupted all aspects of society globally. As healthcare resources had to be preserved for infected patients, and the risk of in-hospital procedures escalated for uninfected patients and staff, neurosurgeons around the world have had to postpone non-emergent procedures. Under these unprecedented conditions, the decision to defer cases became increasingly difficult as COVID-19 cases skyrocketed. METHODS: Data was collected by self-reporting surveys during two discrete periods: the principal survey accrued responses during 2 weeks at the peak of the global pandemic, and the supplemental survey accrued responses after that to detect changes in opinions and circumstances. Nine hypothetical surgical scenarios were used to query neurosurgeons' opinion on the risk of postponement and the urgency to re-schedule the procedures. An acuity index was generated for each scenario, and this was used to rank the nine cases. RESULTS: There were 494 respondents to the principal survey from 60 countries. 258 (52.5%) reported that all elective cases and clinics have been shut down by their main hospital. A total of 226 respondents (46.1%) reported that their operative volume had dropped more than 50%. For the countries most affected by COVID-19, this proportion was 54.7%. There was a high degree of agreement among our respondents that fast-evolving neuro-oncological cases are non-emergent cases that nonetheless have the highest risk in postponement, and selected vascular cases may have high acuity as well. CONCLUSION: We report on the impact of COVID-19 on neurosurgeons around the world. From their ranking of the nine case scenarios, we deduced a strategic scheme that can serve as a guideline to triage non-emergent neurosurgical procedures during the pandemic. With it, hopefully, neurosurgeons can continue to serve their patients without endangering them either neurologically or risking their exposure to the deadly virus.

The Benefits of Limited Orbitotomy on the Supraorbital Approach: An Anatomic and Morphometric Study in Virtual Reality.

BACKGROUND: Cadaveric studies on surgical anatomy and approaches are hampered by the limited number of specimens. Virtual reality (VR) technology can overcome this limitation, allowing for more in-depth statistical analysis of the data. OBJECTIVE: To determine the benefit of a supraorbital ridge osteotomy in a supraorbital craniotomy targeting (1) the anterior communicating artery complex (ACOM), and (2) a lesion 25 mm above tuberculum sellae, using a large dataset generated by VR. METHODS: Computed tomography scans of 30 subjects without cranial osseous pathology were identified for use with VR technology. After correlating VR and DICOM datasets, supraorbital craniotomies were simulated without and with removal of supraorbital ridge, bilaterally (n = 60). Area of freedom (AOF) from the outer table to the targets and the vertical center angle (VCA) to targets were calculated, before and after the orbitotomy. RESULTS: For the ACOM, AOF averaged 496 mm2 (range: 322-805) and increased 8.9% to an average of 547 mm2 with the removal of the supraorbital ridge (P < .001). VCA increased from 18.5 to 20.3 degrees. For the suprasellar target, AOF averaged 507 mm2 (range 324-772) and increased 42.5% to 722 mm2 after orbitotomy (P < .001). VCA increased from 22.1 to 30.8 degrees. CONCLUSION: VR technology is an emerging tool to study neurosurgical approaches. Here, we demonstrate with VR that the removal of the supraorbital ridge in a supraorbital craniotomy affords greater access to superiorly located lesions of the anterior fossa floor; however, deeper and lower lesions require a more aggressive orbital roof osteotomy to widen the exposure.

Perioperative Complications Associated with Severity of Anemia in Geriatric Patients Undergoing Spinal Procedures.

OBJECTIVE: To investigate preoperative baseline anemia, stratified by severity as a function of hematocrit level, as a risk factor for perioperative complications in geriatric patients undergoing spinal procedures. BACKGROUND: Previous literature has examined the impact of anemia on risk for complications and adverse outcomes in patients undergoing elective spinal procedures. However, there is a paucity of literature analyzing the impact of anemia in the geriatric population, specifically. METHODS: The American College of Surgeons-National Surgical Quality Improvement Database was used to identify patients older than 65 years who had undergone elective spinal procedures and were subsequently stratified into 3 separate cohorts based on hematocrit levels: severe/moderate (hematocrit level <30%), mild (30%-37%), and no anemia (>38%). These patient samples were then analyzed using multivariate analyses to assess severity of anemia as a risk factor for complications in elderly patients undergoing spinal procedures. RESULTS: When anemia classes were analyzed as separate independent risk factors for complications, mild anemia (class II) was a significant risk factor for the same complications as moderate/severe anemia (class III/IV), with the exception of 2 complications, compared with nonanemic patients. Mild anemia was independently associated with wound dehiscence (odds ratio, 1.521; 95% confidence interval, 1.126-2.054; P = 0.006), whereas moderate/severe anemia did not show an increased risk for wound dehiscence. However, moderate/severe anemia independently increased the risk for deep venous thromboembolism (odds ratio, 1.437; 95% confidence interval, 1.028-2.011; P = 0.034), compared with mild anemia. Both categories of anemia independently increased the risk for additional complications such as deep incisional surgical site infection, organ/space surgical site infection, pneumonia, unplanned intubation, ventilator dependence, progressive renal insufficiency, acute renal failure, urinary tract infections, cardiac arrest, myocardial infarctions, blood transfusions, systemic sepsis, reoperation, extended length of stay of ≥5 days, unplanned readmission, and mortality. CONCLUSIONS: This study indicated that patients with preoperative baseline anemia were at risk for requiring transfusions, renal failure, and infectious complications. Physicians should be cognizant of anemia as a risk factor affecting numerous perioperative complications and adverse outcomes to work toward improving health-related quality of life.

Early Experience with Electric Scooter Injuries Requiring Neurosurgical Evaluation in District of Columbia: A Case Series.

BACKGROUND: To decrease vehicular traffic in major metropolitan cities throughout the United States, multiple ridesharing companies have launched dockless electric scooters and bicycles throughout cities. From September 2017 through November 2018, Washington, DC, launched a 15-month dockless vehicle pilot program to allow for the rapid entry and growth of electric scooters within the metropolitan area. This rapid growth resulted in a number of minor and significant injuries. CASE DESCRIPTION: We reviewed the electronic medical record of The George Washington University Hospital to investigate and characterize the types of electric scooter-related injuries resulting in neurosurgical consultation in the 15-month period of the Washington, DC, scooter pilot program. Thirteen patients sustained injuries serious enough to merit neurosurgical consultation, including 1 patient whose symptoms required procedural intervention by a neurointerventional radiologist and another patient who was pronounced dead soon after arrival to the hospital. CONCLUSIONS: In this case series, we highlight more severe injuries that resulted in hospitalization or intervention, including skull fracture, central cord syndrome, and vertebral compression fracture. This case series aims to illustrate the potential severity of injuries related to electric scooters, raise awareness on the issues of safety and public health, and call for further investigation into injuries relating to electric scooters.

Cold Atmospheric Plasma as an Adjunct to Immunotherapy for Glioblastoma Multiforme.

Glioblastoma multiforme (GBM) is the most common and aggressive form of brain cancer in adults. GBM carries a dismal prognosis because of its proliferative, invasive, and angiogenic capabilities and because of its ability to downregulate the immune system. Immune-based therapies under investigation for GBM have been unsuccessful in vivo because of this downregulation. Cold atmospheric plasma (CAP) is a high-energy state of matter that can be applied directly or indirectly to tumor tissue to serve as an adjunct to immunotherapy in the treatment of GBM because it upregulates the immune system by the induction of reactive oxygen species. CAP has the potential to improve the efficacy of existing and investigative immunotherapies for GBM.

Primary Sjögren's syndrome as a systemic disease: a study of participants enrolled in an international Sjögren's syndrome registry.

OBJECTIVE: To study the prevalence of extraglandular manifestations in primary Sjögren's syndrome (SS) among participants enrolled in the Sjögren's International Collaborative Clinical Alliance (SICCA) Registry. METHODS: A total of 1,927 participants in the SICCA registry were studied, including 886 participants who met the 2002 American-European Consensus Group (AECG) criteria for primary SS, 830 "intermediate" cases who had some objective findings of primary SS but did not meet AECG criteria, and 211 control individuals. We studied the prevalence of immunologic and hematologic laboratory abnormalities, specific rheumatologic examination findings, and physician-confirmed thyroid, liver, and kidney disease, as well as lymphoma among SICCA participants. RESULTS: Laboratory abnormalities, including hematologic abnormalities, hypergammaglobulinemia, and hypocomplementemia, frequently occurred among primary SS cases and were more common among the intermediate cases than among control participants. Cutaneous vasculitis and lymphadenopathy were also more common among primary SS cases. In contrast, the frequency of physician-confirmed diagnoses of thyroid, liver, and kidney disease and lymphoma was low and only primary biliary cirrhosis was associated with primary SS case status. Rheumatologic and neurologic symptoms were common among all SICCA participants, regardless of case status. CONCLUSION: Data from the international SICCA registry support the systemic nature of primary SS, manifested primarily in terms of specific immunologic and hematologic abnormalities. The occurrence of other systemic disorders among this cohort is relatively uncommon. Previously reported associations may be more specific to select patient subgroups, such as those referred for evaluation of certain neurologic, rheumatologic, or other systemic manifestations.

Osteoarthritis. What therapies for this disease of many causes?

Osteoarthritis is a common and sometimes disabling disease. New directions in therapy include inhibitors of selective proteins and transplantation of cultured chondrocytes. At the present time, treatment continues to be in response to a patient's symptoms. Thus, the challenge to physicians is to devise individual treatment plans that safely maximize relief and preservation of joint function.

Treatment of ankylosing spondylitis by inhibition of tumor necrosis factor alpha.

BACKGROUND: There are few effective treatments for ankylosing spondylitis, which causes substantial morbidity. Because of the central role of tumor necrosis factor alpha in the spondyloarthritides, we performed a randomized, double-blind, placebo-controlled trial of etanercept, a recombinant human tumor necrosis factor receptor (p75):Fc fusion protein, in patients with ankylosing spondylitis. METHODS: Forty patients with active, inflammatory ankylosing spondylitis were randomly assigned to receive twice-weekly subcutaneous injections of etanercept (25 mg) or placebo for four months. The primary end point was a composite of improvements in measures of morning stiffness, spinal pain, functioning, the patient's global assessment of disease activity, and joint swelling. Patients were allowed to continue taking nonsteroidal antiinflammatory drugs, oral corticosteriods (< or =10 mg per day), and disease-modifying antirheumatic drugs at stable doses during the trial. RESULTS: Treatment with etanercept resulted in significant and sustained improvement. At four months, 80 percent of the patients in the etanercept group had a treatment response, as compared with 30 percent of those in the placebo group (P=0.004). Improvements over base-line values for various measures of disease activity, including morning stiffness, spinal pain, functioning, quality of life, enthesitis, chest expansion, erythrocyte sedimentation rate, and C-reactive protein, were significantly greater in the etanercept group. Longitudinal analysis showed that the treatment response was rapid and did not diminish over time. Etanercept was well tolerated, with no significant differences in rates of adverse events between the two groups. CONCLUSIONS: Treatment with etanercept for four months resulted in rapid, significant, and sustained improvement in patients with ankylosing spondylitis.