Direct withdrawal of a retained foreign body bisecting the thoracic spinal canal in a neurologically intact pediatric patient: illustrative case.

BACKGROUND: Nonmissile penetrating spinal cord injury (NMPSCI) with a retained foreign body (RFB) is rare and usually results in permanent neurological deficits. In extremely rare cases, patients can present without significant neurological deficits despite an RFB that traverses the spinal canal. Given the rarity of these cases, a consensus has not yet been reached on optimal management. In a patient with an RFB and a neurologically normal clinical examination, the risk of open surgical exploration may outweigh the benefit and direct withdrawal may be a better option. OBSERVATIONS: A 10-year-old female suffered an NMPSCI to the thoracic spine with an RFB that bisected the spinal canal but remained neurologically intact. Direct withdrawal of the RFB was chosen instead of open surgical exploration, leading to an excellent clinical outcome. The literature was reviewed to find other examples of thoracic NMPSCI with RFB and neurologically normal examinations. Management strategies were compared. LESSONS: For NMPSCI with RFB and without significant neurological deficits, direct withdrawal is a viable and possibly the best treatment option. The use of fast-acting anesthesia without intubation minimizes patient manipulation, speeds up recovery, and allows early assessment of neurological status after removal.

Occipital interhemispheric transtentorial approach in pediatric patients for lesions of the superomedial cerebellum: operative findings and results.

BACKGROUND: The occipital interhemispheric transtentorial (OITT) approach is frequently used for accessing the pineal region. There are scarce reports of using the OITT to access superior cerebellar lesions. This approach affords the patient several advantages over traditional posterior fossa approaches. PURPOSE: This study is to describe and evaluate clinical outcomes in a single surgeon case series of the OITT approach for pediatric patients with lesions of the superior cerebellum. METHODS: All pediatric patients who underwent an OITT craniotomy for a superior cerebellar lesion by a single surgeon over a 5-year period were included in this retrospective analysis. Patient demographics and clinical data were collected. RESULTS: Thirteen pediatric patients were identified. Cases included twelve tumors and one arteriovenous malformation. Gross total resection was achieved in 92% of cases. No patients developed posterior fossa syndrome. Two patients had transient homonymous hemianopsia that resolved by 1 month post-operatively. There were no permanent neurological deficits. CONCLUSION: For superomedial cerebellar lesions presenting to the tentorial surface of the superior cerebellum in patients with normal to steep tentorial angles, the OITT approach is effective and safe. This approach has a low risk of posterior fossa syndrome and permanent visual deficits when applied appropriately. Patient selection is critical for maximizing the advantages of the OITT for superior cerebellar lesions.

Predictors of Above Average 6-Year Citation Rates in Leading Spine-Specific Medical Journals.

STUDY DESIGN: Cross-sectional. OBJECTIVE: To identify predictors of manuscripts achieving 6-year citation rates higher than the mean in spine-specific literature. SUMMARY OF BACKGROUND DATA: An article's citation rate demonstrates its contribution to academia and its quality. Predictors of citation rates have not yet been studied in spine-specific medical literature. METHODS: Three leading spine-specific journals were identified by a weighted scoring system comparing various journal metrics. Research articles published in 2014 were evaluated from the following journals: Spine, European Spine Journal, and Journal of Neurosurgery: Spine. Article features analyzed included journal of origin, number of words in article title, author count, degree of first author, conflicts of interest, quantity of contributing academic institutions, country of origin, study topic, study design, level of evidence, sample size, reference count, and citation rate. Multivariate logistic regression was used to determine predictors of above average citation rate at 6 years following publication. RESULTS: The final analysis included 1091 articles. Spine had a significantly higher citation rate than European Spine Journal (P = 0.0008); however, no significant differences were observed between Spine and Journal of Neurosurgery: Spine. Regression analysis demonstrated that studies originating in North America (OR:1.44, 95% CI:1.01-2.01, P = 0.04), those with 6 ≥ authors (OR:1.72, 95% CI:1.29-2.30, P < 0.001), sample size >100 (P < 0.001), prospective case series (OR: 2.67, 95% CI: 1.24-5.76), and retrospective case series (OR: 1.99, 95% CI: 1.07-3.73) were independent predictors of achieving above average 6-year citation rates. CONCLUSION: Spine, European Spine Journal, and Journal of Neurosurgery: Spine had the highest 6-year citation rates of the top 10 orthopedic spine journals, with Spine being significantly higher than European Spine Journal. Studies originating in North America, those with six or more authors, sample sizes > 100, and those that are retrospective or prospective case series are independent predictors of greater citation rates at 6 years in orthopedic spine-specific medical literature.Level of Evidence: 4.

Neuromuscular Ultrasound in the Pediatric Population.

The diagnosis and evaluation of neuromuscular disorders traditionally involves electrodiagnostic (EDx) testing, including nerve conduction studies (NCSs) and electromyography (EMG). These tools can cause pain and discomfort, an important consideration when performed on children. Neuromuscular ultrasound is noninvasive, cost-effective, and increasingly utilized for the detection of neuromuscular pathology. Studies investigating the performance and clinical implementation of ultrasound have primarily been performed in adult populations. Ultrasound in children has the potential to guide EDx testing and ultimately improve diagnostic efficiency and accuracy. This review aims to describe key features of neuromuscular ultrasound in the pediatric population based on the available studies, including our own institutional experience.

Defining a Minimum Clinically Important Difference in Patient-Reported Outcome Measures in Lumbar Tubular Microdecompression Patients.

BACKGROUND: Patient-reported outcome measures (PROMs) are critical tools used in the assessment and reporting of surgical outcomes. However, significant differences in PROM scores have not been shown to consistently correlate with clinical improvement from the physician or patient perspective. Defining a minimum clinically important difference (MCID) for PROMs offers interpretation of surgical outcomes with an emphasis on patient-centered feedback. The goal of this study was to define a MCID for the following PROMs in lumbar tubular microdecompression (LTMD) patients: the EuroQol-Five Dimensions (EQ-5D) index, Oswestry Disability Index (ODI), leg pain visual analog scale (VAS), and low back pain VAS. METHODS: This study examined 235 index LTMD patients with PROMs collected at preoperative evaluation and 1-year follow-up. Using an anchor-based approach with patient satisfaction index, a receiver operating characteristic analysis was performed to define a MCID in the EQ-5D index, ODI, leg pain VAS, and low back pain VAS. RESULTS: The patients had a mean age of 65.18 ± 12.81 years, and 47.7% were male. The MCID values for the EQ-5D, ODI, leg pain VAS, and low back pain VAS are 0.219, 15.0-16.5, 0.5, and 2.5-3.5, respectively. CONCLUSIONS: This study helps define a MCID for the EQ-5D index in LTMD patients. Given its ease of administration and economic relevance, further characterization of the EQ-5D index may warrant its use as a potential alternative or adjunct to the routinely collected PROMs following spine surgery. LEVEL OF EVIDENCE: 3.

Hip Joint Pathology Among Men Referred to Urology for Chronic Orchialgia: A Source for Misdiagnosis and Opportunity for Quality Improvement.

OBJECTIVE: To evaluate the findings of magnetic resonance imaging (MRI) of the ipsilateral hip(s) as part of the workup of men with chronic orchialgia (CO). METHODS: Following IRB approval, a retrospective chart review was performed from a single surgeon database of all men with a diagnosis of CO from June 2018 to October 2019 who underwent subsequent hip MRI evaluation. RESULTS: Ten men were identified. Median age was 51 years and median duration of pain was 10 months. MRI was obtained after testis pathology was ruled out. Pain was noted in the groin (100%) and hip (50%). Hip MRI identified overt labral tears in 8 men (10/12 hips evaluated, 83%) and labral fraying in the remaining 2 (16.7%). Standard plain film radiography was performed in 6 men prior to MRI, all of which were negative. Following MRI, 5 men underwent hip injection with steroid and local analgesic with lasting resolution (2 men) or significant improvement in pain (2 men; 80%, follow-up 3-15 months). Two men had complete resolution of pain with 8 weeks of physical therapy. CONCLUSION: Hip MRI has a high rate of diagnosis of labral tear in appropriately selected men referred to the urologist for CO. Identification of orthopedic pathology may avoid unnecessary antibiotics, opiates, or urological surgery. Referrals to orthopedics and/or physical therapy for intervention may lead to resolution of pain.

Should the EuroQol-Five Dimensions Replace the Oswestry Disability Index When Tracking Lumbar Tubular Microdecompression Outcomes?

OBJECTIVE: Patient-reported outcomes measures (PROMs) are critical in evaluating the effectiveness of surgical spine interventions. The Oswestry Disability Index (ODI) is commonly used but tedious to administer routinely. The EuroQol-5 Dimensions (EQ-5D) questionnaire is easier to administer but not traditionally used to measure spine surgical results. This study aimed to investigate the correlation of commonly administered PROMs in lumbar tubular microdecompression patients, and to consider whether ODI could be predicted from remaining PROMs. METHODS: This study examined 304 index lumbar tubular microdecompression patients with PROMs collected at routine intervals. Spearman correlation coefficients were calculated for each pairwise combination of the following PROMs: ODI, EQ-5D index, leg pain visual analog scale (VAS), low back pain VAS, health state item. Linear regression modeling was conducted to predict ODI from the remaining four PROMs. RESULTS: The patients had a mean age of 65.55 ± 12.97 years and 46.4% were male. Each combination of PROMs demonstrated a statistically significant pairwise correlation (P < 0.001). ODI showed strong correlation with EQ-5D index (r = -0.77), leg pain VAS (r = 0.73), and back pain VAS (r = 0.65), but weak correlation with health state item (r = -0.33). Forwards stepwise model selection yielded a multiple linear regression model including all four PROMs predictors, with an adjusted R2 of 0.690. There was strong correlation between predicted and observed ODI (r = 0.83, P < 0.001). CONCLUSIONS: ODI can be predicted from EQ-5D, leg and low back pain VAS, and health state items with moderate accuracy. The added utility of capturing ODI routinely may not out-weigh the challenges in doing so.