2-Level Anterior Cervical Arthrodesis With Integrated Spacer and Plate vs Traditional Anterior Spacer and Plate System.

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) is a common surgery to treat cervical degenerative disc disease. Use of an anterior spacer and plate system (ASPS) results in increased disc height, higher fusion rate, lower subsidence rate, and lower complication rate than a spacer alone.1,2 However, anterior cervical plating is associated with complications, such as dysphagia, plate-screw dislodgment, soft tissue injury, neural injury, and esophageal perforation.3-9 To potentially reduce these drawbacks, integrated spacer and plate (ISP) systems have gained popularity. METHODS: From November 2009 to October 2013, a total of 84 consecutive patients who underwent 2-level ACDF using ISP or ASPS were reviewed for clinical and radiographic outcomes. Patient-reported visual analog scale (VAS) and Neck Disability Index (NDI) scores, fusion rates, and hardware failure were determined at 1, 3, 6, 12, and 24 months after surgery. RESULTS: Forty-three patients received ISP and 41 patients received ASPS. There were no significant differences in patient demographics between the 2 groups. Perioperative characteristics were similar, except for operative time. Postoperatively, no significant differences in VAS or NDI scores or fusion status were found. At the proximal surgical level only, there was a trend toward an earlier observed radiographic fusion rate in ASPS vs ISP, but this finding was not statistically significant (P = 0.092). One case of long-term dysphagia was reported in each group. Neither group had implant failures up to 2 years. CONCLUSIONS: The ISP system for 2-level ACDF compared to traditional ASPS has comparable clinical and radiographic outcomes up to 2 years postoperatively. There may be a trend toward an earlier observed radiographic fusion in the ASPS group, but there was no difference in long-term dysphagia rate. CLINICAL RELAVANCE: Integrated spacer and traditional anterior spacer for 2-level ACDF has similar clinical and radiographical outcome.

Continuous Electroencephalographic Training for Neuroscience Intensive Care Unit Nurses: A Feasibility Study.

BACKGROUND: Use of continuous electroencephalographic (cEEG) monitoring has more than doubled at our institution for the last 4 years. Although intensive care unit cEEG is reviewed remotely by board-certified epileptologists every 4 to 6 hours, there are inherent delays between occurrence, recognition, and treatment of epileptiform activity. Neuroscience intensive care unit (NSICU) nurses are uniquely positioned to monitor cEEG in real time yet do not receive formal training. The purpose of this study was to evaluate the effectiveness of an education program to teach nurses to monitor cEEG, identify a burst suppression pattern, and measure the duration of suppression. METHODS: We performed a retrospective analysis of pretest and posttest data. All NSICU nurses (40) were invited to complete the pretest (PT-0), with 25 participating. Learning style/preference, demographics, comfort with cEEG, and knowledge of EEG fundamentals were assessed. A convenience cohort of NSICU nurses (13) were selected to undergo EEG training. Posttests evaluating EEG fundamental knowledge were completed immediately after training (PT-1), at 3 months (PT-3), and at 6 months (PT-6). The cohort also completed a burst suppression module after the training, which assessed ability to quantify the duration of suppression. RESULTS: Mean cohort test scores significantly improved after the training (P < .001). All nurses showed improvement in test scores, and 76.9% passed PT-1 (a score of 80% or higher). Reported mean comfort level with EEG also significantly improved after the training (P = .001). There was no significant difference between mean cohort scores between PT-1, PT-3, and PT-6 (all 88.6%; P = 1.000). Mean cohort score from the bust suppression module was 73%, with test scores ranging from 31% to 93%. CONCLUSIONS: NSICU nurses can be taught fundamentals of cEEG, to identify a burst suppression pattern, and to quantify the duration of suppression. Further research is needed to determine whether this knowledge can be translated into clinical competency and affect patient care.

Headache Relief Is Maintained 7 Years After Anterior Cervical Spine Surgery: Post Hoc Analysis From a Multicenter Randomized Clinical Trial and Cervicogenic Headache Hypothesis.

OBJECTIVE: To evaluate whether anterior cervical spine surgery offers sustained (7 years) relief in patients with cervicogenic headaches (CGHs), and evaluate the difference between cervical disc arthroplasty (CDA) and anterior cervical discectomy and fusion (ACDF) for 1 and 2-level surgeries from a multicenter randomized clinical trial. METHODS: A post hoc analysis was performed of 575 patients who underwent one or 2-level CDA or ACDF for symptomatic cervical spondylosis as part of a prospective randomized clinical trial. Assessment of pain and functional outcome was done with the Neck Disability Index (NDI) in the trial. We used the NDI headache component to assess headache outcome. RESULTS: For both 1- and 2-level CDA and ACDF groups, there was significant headache improvement from preoperative baseline out to 7 years (p < 0.0001). For 1-level surgeries, headache improvement was similar for both groups at the 7-year point. For 2-level treatment, CDA patients had significantly improved headache scores versus ACDF patients at the 7-year point (p = 0.016). CONCLUSION: The headache improvement noted at early follow-up was sustained over the long-term period with ACDF and CDA populations. In the case of 2-level operations, CDA patients demonstrated significantly greater benefit compared to ACDF patients over the long-term. Sinuvertebral nerve irritation at the unco-vasculo-radicular junction and anterior dura may be the cause of CGH. Therefore, it is possible that improved cervical kinematics and preservation of range of motion at adjacent uncovertebral joints in CDA may contribute to the observed difference between the groups.

De Novo Blister Aneurysm Formation in 16 Days Associated with Mucorales Fungi.

Although blister aneurysms represent a small percentage of all intracranial aneurysms, they are generally considered to be a more morbid and challenging entity than the more common saccular intracranial aneurysms. Despite this, the etiology of blister aneurysms is still unknown, though there are several theories. We present the case of a 54-year-old man who initially presented with vision loss and normal intracranial computed tomography angiography imaging. Only 16 days thereafter, he underwent rapidly progressive clinical decline, which was found to be due to the development and rupture of a de novo supraclinoidal blister aneurysm. Autopsy results showed fungal infection of the arterial wall by Mucorales fungi at the site of the aneurysm. Our case report supports the theory that blister aneurysms can be caused by fungal infection of the wall of the internal carotid artery.

The C7 pedicle as a superior fixation point in spinal stabilization for spinal metastatic disease.

Spinal metastatic disease (SMD) often requires spinal stabilization; however, the cervicothoracic junction can be a challenging area to instrument. An anterior approach may require division of the sternum. A posterior or posterolateral approach may rely on cervical lateral mass screws for superior construct fixation that are more prone to pullout than screws placed in a pedicle. The C7 pedicle is able to support pedicle screw fixation in most instances based on morphological features of the vertebra. When the C7 pedicle is used as a superior fixation point, it aligns with the thoracic pedicles below to create a streamlined posterior construct. In this study, patients undergoing posterior stabilization with C7 pedicle superior fixation were examined. One hundred and thirty-nine consecutive spinal operations at a National Cancer Institute designated cancer center were retrospectively reviewed to identify patients who underwent spinal stabilization for SMD with a C7 pedicle screw placed as the superior fixation point of a posterior construct. Patient age, the primary disease, and clinical and radiographic information were identified. Follow-up duration was noted, and follow-up outcomes were recorded on the basis of the clinical history and the findings on computed tomography (CT) spinal imaging. Three patients were identified who underwent separation surgery for SMD that included posterior spinal stabilization with C7 pedicle screws as the superior fixation point. The average patient age was 70 years and one patient was a woman. The average follow-up time was 20.7 months. There were no occurrences of hardware failure, neurologic deterioration, or protracted pain in the cases analyzed. Overall, there were good surgical outcomes with improvement in pain without neurovascular injury or evidence of hardware failure during follow-up evaluation. These findings add to a small but notable number of studies showing the effectiveness of C7 pedicle screws as a superior fixation point in spinal oncology, specifically in metastatic lesions. In our experience the C7 pedicle has provided a useful superior fixation point solution for the posterior stabilization of high thoracic vertebral body metastases. This surgical option may help spinal surgeons address the stabilization of SMD in the cervicothoracic region.

Primary Stenting for Acute Ischemic Stroke Using the Enterprise Intracranial Stent: 2-Year Results of a Phase-I Trial.

BACKGROUND: The preliminary results of a prospective consecutive series of 20 patients who underwent Enterprise-assisted recanalization for acute ischemic stroke were recently reported. Recanalization to thrombolysis in myocardial infarction (TIMI) grade 2 (n = 6) or 3 (n = 12) flow was achieved in 18 patients (90% revascularization rate). Good outcome (modified Rankin Scale [mRS] score of ≤2) was obtained in 10 patients (50%) at 30 days. Here, we report the 2-year clinical follow-up data for patients enrolled in that prospective study. METHODS: Study patients were scheduled for examinations 2 years postprocedure at which time mRS and Barthel indices were obtained. RESULTS: Among 12 survivors at 2 years, 11 of the 20 (55%) study patients improved to mRS score ≤2 and 1 (5%) patient was disabled with an mRS 4. Of the 11 patients with mRS 0-2 scores, 10 patients had a Barthel index of 100, and the 11th had a Barthel index of 95. One patient improved from mRS 3 to 2 during the interval between the 6- and 12-month postintervention evaluations after intervention. Eight of 13 (62%) survivors underwent follow-up imaging at 6 months without evidence of instent stenosis or thrombosis. CONCLUSION: At 2 years of follow-up, improvement in quality of life after acute stroke intervention was sustained; and 11 of 12 (92%) survivors had an excellent functional outcome. Improvement in functional status can occur even up to 1 year after stroke intervention. These results 2 years after acute stroke intervention demonstrate sustained benefit from acute intervention. ABBREVIATIONS: AISacute ischemic strokeCTcomputed tomographicFDAFood and Drug AdministrationIVintravenousMCAmiddle cerebral arterymRSmodified Rankin ScaleNIHSSNational Institutes of Health Stroke Scale ScoreSWIFTSolitaire FR With the Intention For Thrombectomy (SWIFT)TIMIthrombolysis in myocardial infarctiontPAtissue plasminogen activatorTREVOThrombectomy REvascularization of large Vessel Occlusions.

The role of microscope-integrated near-infrared indocyanine green videoangiography in the surgical treatment of intracranial dural arteriovenous fistulas.

OBJECT: The successful treatment of an intracranial dural arteriovenous fistula (dAVF) requires complete obliteration of blood flow through the fistulous point. Surgical ligation is often used along with endovascular techniques. Digital subtraction angiography (DSA) can be used to confirm fistula obliteration; however, this technique can be cumbersome intraoperatively and difficult to correlate anatomically with the surgical field. Near-infrared indocyanine green (ICG) videoangiography has been described as a complementary tool for this purpose. METHODS: The authors examined intracranial dAVF cases in which microscope-integrated intraoperative ICG videoangiography was used to identify and/or confirm obliteration of the dAVF during surgery. Retrospective evaluation of all intracranial dAVF cases treated with surgical ligation over a 10-year period at the Barrow Neurological Institute (n = 47) revealed 28 cases in which ICG videoangiography was used. The results were compared with findings on preoperative and intraoperative or postoperative DSA. RESULTS: ICG videoangiography successfully confirmed the fistulous point intraoperatively in 96% (22/23) of the cases. It also revealed complete obliteration of fistulas, comparable to intraoperative or postoperative DSA, in 91% (21/23) of the cases. The false-negative rate of ICG was 8.7% (2/23), which is similar to the false-negative rate of intraoperative DSA alone (10.5% [2/19]). CONCLUSIONS: Microscope-based ICG videoangiography provides real-time information about the intraoperative anatomy of dAVFs. In addition, it can confirm complete obliteration of a fistula. This technique may be useful during dAVF surgery as an independent form of angiography or as an adjunct to intraoperative or postoperative DSA.

Spondylolysis outcomes in adolescents after direct screw repair of the pars interarticularis.

OBJECT: Isthmic spondylolysis can significantly decrease functional abilities, especially in adolescent athletes. Although treatment can range from observation to surgery, direct screw placement through the fractured pars, or Buck's procedure, may be a more minimally invasive procedure than the more common pedicle screw-hook construct. METHODS: Review of surgical databases identified 16 consecutive patients treated with Buck's procedure from 2004 to 2010. Twelve patients were treated at Miami Children's Hospital and 4 at Barrow Neurological Institute. Demographics and clinical and radiographic outcomes were recorded and analyzed retrospectively. RESULTS: The 16 patients had a median age of 16 years, and 14 were 20 years or younger at the time of treatment. Symptoms included axial back pain in 100% of patients with concomitant radiculopathy in 38%. Pars defects were bilateral in 81% and unilateral in 19% for a total of 29 pars defects treated using Buck's procedure. Autograft or allograft augmented with recombinant human bone morphogenetic protein as well as postoperative bracing was used in all cases. Postoperatively, symptoms resolved completely or partially in 15 patients (94%). Of 29 pars defects, healing was observed in 26 (89.6%) prior to 1 revision surgery, and an overall fusion rate of 97% was observed at last radiological follow-up. There were no implant failures. All 8 athletes in this group had returned to play at last follow-up. CONCLUSIONS: Direct screw repair of the pars interarticularis defect as described in this series may provide a more minimally invasive treatment of adolescent patients with satisfactory clinical and radiological outcomes, including return to play of adolescent athletes.

Safety, efficacy, and cost of intraoperative indocyanine green angiography compared to intraoperative catheter angiography in cerebral aneurysm surgery.

Intraoperative angiography in cerebrovascular neurosurgery can drive the repositioning or addition of aneurysm clips. Our institution has switched from a strategy of intraoperative digital subtraction angiography (DSA) universally, to a strategy of indocyanine green (ICG) videoangiography with DSA on an as-needed basis. We retrospectively evaluated whether the rates of perioperative stroke, unexpected postoperative aneurysm residual, or parent vessel stenosis differed in 100 patients from each era (2002, "DSA era"; 2007, "ICG era"). The clip repositioning rate for neck residual or parent vessel stenosis did not differ significantly between the two eras. There were no differences in the rate of perioperative stroke or rate of false-negative studies. The per-patient cost of intraoperative imaging within the DSA era was significantly higher than in the ICG era. The replacement of routine intraoperative DSA with ICG videoangiography and selective intraoperative DSA in cerebrovascular aneurysm surgery is safe and effective.