Predictors of Early Mortality Following Surgical or Non-surgical Treatment of Subaxial Cervical Spine Fractures: A Retrospective Nationwide Registry Study.

BACKGROUND: Traumatic subaxial cervical spine fractures are a significant public health concern due to their association with spinal cord injuries (SCI). Despite being mostly caused by low-energy trauma, these fractures significantly contribute to morbidity and mortality. Currently, research regarding early mortality based on the choice of treatment following these fractures is limited. Identifying predictors of early mortality may aid in postoperative patient monitoring and improve outcomes. PURPOSE: This study aimed to identify predictors of 30-days, 90-days, and one-year mortality in adults treated for subaxial fractures. STUDY DESIGN: A retrospective review of the nationwide Swedish Fracture Register (SFR). PATIENT SAMPLE: All adult patients in the SFR who underwent treatment for a subaxial cervical fracture (n = 1,963). OUTCOME MEASURES: Analyzed variables included age, sex, injury mechanism, neurological function, fracture characteristics, and treatment type. The primary endpoints were 30-days, 90-days, and one-year mortality. METHODS: 1,963 patients in the SFR, treated for subaxial cervical fractures between 2013 to 2021, were analyzed. Surgical procedures included anterior, posterior, or anteroposterior approaches. Non-surgical treatment included collar treatment or medical examinations without intervention. Stepwise regression and Cox regression analysis were used to determine predictors. Model performance was tested using the area under the receiver operating characteristic curve (AUC). RESULTS: 620 patients underwent surgery and 1,343 received non-surgical treatment. Surgical cases had primarily translation fractures, with 323 (52%) displaying no neurological deficits. Mortality rates at 30 days, 90 days, and one year were 22/620 (3.5%), 35/620 (5.6%), and 53/620 (8.5%), respectively. Age and SCI were predictors of mortality. Non-surgically treated patients mostly had compression fracture, with 1,214 (90%) experiencing no neurological deficits. Mortality rates at 30 days, 90 days, and one year were 41/1,343 (3.1%), 71/1,343 (5.3%), and 118/1,343 (8.7%). Age, male sex, SCI and fractures occurring at the C3 or C6 levels were predictors of mortality. An intact neurological function was a positive predictor of survival among non-surgically treated patients (AUC > 0.78). CONCLUSIONS: Age and SCI emerged as significant predictors of early mortality in both surgically and non-surgically treated patients. An intact neurological function served as a protective factor against early mortality in non-surgically treated patients. Fractures at C3 or C6 vertebrae may impact mortality.

Navigating the Neurosurgery Match Process: Insights from the National Resident Matching Program - Program Director Surveys.

OBJECTIVE: Neurosurgery is one of the most competitive specialties and navigating the match process is often challenging for aspiring applicants. Here, we analyze insights from the National Resident Matching Program (NRMP) Program Director Surveys, illustrating evolving trends in applicant selection for interviews and for the ranking process, and providing a comparison with other specialties. METHODS: We evaluated seven surveys administered from 2012 to 2022. Six biennial surveys reported on factors influencing interview and ranking processes, while all seven surveys included data about the program director (PD)'s attitude towards USMLE test scores. RESULTS: The response rate of PDs decreased over the years. The most cited for interviews included specialty-specific recommendation letters (95%), USMLE Step 1 scores (91%), and interest in research (78%). A recent decline in emphasis on USMLE Step 1 scores coincided with a growing reliance on USMLE Step 2 scores. Award in basic science held significant esteem to a subset of programs. Personal characteristics dominated for ranking, with faculty interaction (89%), interpersonal skills (89%), and house staff interaction (85%) being the most important. Yet, PDs reported a difficulty in assessing interpersonal skills through virtual interviews. CONCLUSION: Our analysis revealed the pervasive importance of specialized endorsements and academic achievements when screening applicants for the interview process. A shift in emphasis towards the USMLE step 2 became apparent. Personal characteristics, on the other hand, seemed crucial to make a match and rank high among the pool of interviewed applicants. We uncovered difficulties in assessing these characteristics through virtual interviews.

Optical Methods for Brain Tumor Detection: A Systematic Review.

Background: In brain tumor surgery, maximal tumor resection is typically desired. This is complicated by infiltrative tumor cells which cannot be visually distinguished from healthy brain tissue. Optical methods are an emerging field that can potentially revolutionize brain tumor surgery through intraoperative differentiation between healthy and tumor tissues. Methods: This study aimed to systematically explore and summarize the existing literature on the use of Raman Spectroscopy (RS), Hyperspectral Imaging (HSI), Optical Coherence Tomography (OCT), and Diffuse Reflectance Spectroscopy (DRS) for brain tumor detection. MEDLINE, Embase, and Web of Science were searched for studies evaluating the accuracy of these systems for brain tumor detection. Outcome measures included accuracy, sensitivity, and specificity. Results: In total, 44 studies were included, covering a range of tumor types and technologies. Accuracy metrics in the studies ranged between 54 and 100% for RS, 69 and 99% for HSI, 82 and 99% for OCT, and 42 and 100% for DRS. Conclusions: This review provides insightful evidence on the use of optical methods in distinguishing tumor from healthy brain tissue.

Proton versus photon adjuvant radiotherapy: a multicenter comparative evaluation of recurrence following spinal chordoma resection.

OBJECTIVE: Chordomas are rare tumors of the skull base and spine believed to arise from the vestiges of the embryonic notochord. These tumors are locally aggressive and frequently recur following resection and adjuvant radiotherapy. Proton therapy has been introduced as a tissue-sparing option because of the higher level of precision that proton-beam techniques offer compared with traditional photon radiotherapy. This study aimed to compare recurrence in patients with chordomas receiving proton versus photon radiotherapy following resection by applying tree-based machine learning models. METHODS: The clinical records of all patients treated with resection followed by adjuvant proton or photon radiotherapy for chordoma at Mayo Clinic were reviewed. Patient demographics, type of surgery and radiotherapy, tumor recurrence, and other variables were extracted. Decision tree classifiers were trained and tested to predict long-term recurrence based on unseen data using an 80/20 split. RESULTS: Fifty-three patients with a mean ± SD age of 55.2 ± 13.4 years receiving surgery and adjuvant proton or photon therapy to treat chordoma were identified; most patients were male. Gross-total resection was achieved in 54.7% of cases. Proton therapy was the most common adjuvant radiotherapy (84.9%), followed by conventional or external-beam radiation therapy (9.4%) and stereotactic radiosurgery (5.7%). Patients receiving proton therapy exhibited a 40% likelihood of having recurrence, significantly lower than the 88% likelihood observed in those treated with nonproton therapy. This was confirmed on logistic regression analysis adjusted for extent of tumor resection and tumor location, which revealed that proton adjuvant radiotherapy was associated with a decreased risk of recurrence (OR 0.1, 95% CI 0.01-0.71; p = 0.047) compared with photon therapy. The decision tree algorithm predicted recurrence with an accuracy of 90% (95% CI 55.5%-99.8%), with the lowest risk of recurrence observed in patients receiving gross-total resection with adjuvant proton therapy (23%). CONCLUSIONS: Following resection, adjuvant proton therapy was associated with a lower risk of chordoma recurrence compared with photon therapy. The described machine learning models were able to predict tumor progression based on the extent of tumor resection and adjuvant radiotherapy modality used.

Long-term outcomes after surgery for subaxial cervical spine injuries in octogenarians, a matched population-based cohort study.

PURPOSE: We aimed to investigate surgical outcomes in octogenarians with subaxial cervical spine injuries and determine the predictors of complications and mortality. METHODS: Eligible for inclusion were all patients surgically treated between 2006 and 2018, with either anterior or posterior fixation for subaxial spine injuries. A cohort of octogenarians was identified and matched 1:1 to a corresponding cohort of younger adults. Primary outcomes were perioperative complications and mortality. RESULTS: Fifty-four patients were included in each of the octogenarian and younger groups (median age: 84.0 vs. 38.5). While the risks for surgical complications, including dural tears and wound infections, were similar between groups, the risks of postoperative medical complications, including respiratory or urinary tract infections, were significantly higher among the elderly (p < 0.05). Additionally, there were no differences in operative time (p = 0.625) or estimated blood loss (p = 0.403) between groups. The 30 and 90-day mortality rates were significantly higher among the elderly (p = 0.004 and p < 0.001). These differences were due to comorbidities in the octogenarian cohort as they were revoked when propensity score matching was performed to account for the differences in American Society of Anesthesiology (ASA) grade. Multivariable logistic regression revealed age and ASA score to be independent predictors of complications and the 90-day mortality, respectively. CONCLUSIONS: Octogenarians with comorbidities were more susceptible to postoperative complications, explaining the increased short-term mortality in this group. However, octogenarians without comorbidities had similar outcomes compared to the younger patients, indicating that overall health, including comorbidities, rather than chronological age should be considered in surgical decision-making.

Spontaneous spinal cord infarction: a systematic review.

Background and objectives: Spontaneous spinal cord infarction (SCInf) is a rare condition resulting in acute neurological impairment. Consensus on diagnostic criteria is lacking, which may present a challenge for the physician. This review aims to analyse the current literature on spontaneous SCInf, focusing on epidemiology, the diagnostic process, treatment strategies and neurological outcomes. Methods: The study was performed in accordance with a previously published protocol. PubMed, Web of Science and Embase were searched using the keywords 'spontaneous', 'spinal cord', 'infarction' and 'ischaemic'. The eligibility of studies was evaluated in two steps by multiple reviewers. Data from eligible studies were extracted and systematically analysed. Results: 440 patients from 33 studies were included in this systematic review. Analysis of vascular risk factors showed that hypertension was present in 40%, followed by smoking in 30%, dyslipidaemia in 29% and diabetes in 16%. The severity of symptoms at admission according to the American Spinal Injury Association (ASIA) Impairment Scale was score A 19%, score B14%, score C36% and score D32%. The mean follow-up period was 34.8 (±12.2) months. ASIA score at follow-up showed score A 11%, score B 3%, score C 16%, score D 67% and score E 2%. The overall mortality during the follow-up period was 5%. When used, MRI with diffusion-weighted imaging (DWI) supported the diagnosis in 81% of cases. At follow-up, 71% of the patients were able to walk with or without walking aids. Conclusion: The findings suggest a significant role for vascular risk factors in the pathophysiology of spontaneous SCInf. In the diagnostic workup, the use of DWI along with an MRI may help in confirming the diagnosis. The findings at follow-up suggest that neurological recovery is to be expected, with the majority of patients regaining ambulation. This systematic review highlights gaps in the literature and underscores the necessity for further research to establish diagnostic criteria and treatment guidelines.

Health-Related Quality of Life and Return to Work after Surgery for Spinal Schwannoma: A Population-Based Cohort Study.

Spinal schwannomas are the second most common primary intradural spinal tumor. This study aimed to assess health-related quality of life (HRQoL) and the frequency of return to work after the surgical treatment of spinal schwannomas. HRQoL was compared to a sample of the general population. Patients operated for spinal schwannomas between 2006 and 2020 were identified in a previous study and those alive at follow-up (171 of 180) were asked to participate. Ninety-four (56%) responded and were included in this study. Data were compared to the Stockholm Public Health Survey 2006, a cross-sectional survey of a representative sample of the general population. An analysis for any potential non-response bias was performed and showed no significant differences between the groups. HRQoL was equal between the spinal schwannoma sample and the general population sample in all but one dimension; men in the spinal schwannoma sample reported more moderate problems in the usual activities dimension than men in the general population (p = 0.020). In the schwannoma sample, there were no significant differences between men and women in either of the dimensions EQ-5Dindex or EQVAS. Before surgery, a total of 71 (76%) were working full-time and after surgery almost all (94%) returned to work, most of them within 3 months of surgery. Eighty-nine (95%) of the patients responded that they would accept the surgery for their spinal schwannoma if asked again today. To conclude, surgical treatment of spinal schwannomas is associated with good HRQoL and with a high frequency of return to work.

Predictors of failure after primary anterior cervical discectomy and fusion for subaxial traumatic spine injuries.

INTRODUCTION: Traumatic subaxial fractures account for more than half of all cervical spine injuries. The optimal surgical approach is a matter of debate and may include anterior, posterior or a combined anteroposterior (360º) approach. Analyzing a cohort of patients initially treated with anterior cervical discectomy and fusion (ACDF) for traumatic subaxial injuries, the study aimed to identify predictors for treatment failure and the subsequent need for supplementary posterior fusion (PF). METHODS: A retrospective, single center, consecutive cohort study of all adult patients undergoing primary ACDF for traumatic subaxial cervical spine fractures between 2006 and 2018 was undertaken and 341 patients were included. Baseline clinical and radiological data for all included patients were analyzed and 11 cases of supplementary posterior fixation were identified. RESULTS: Patients were operated at a median of 2.0 days from the trauma, undergoing 1-level (78%), 2-levels (16%) and ≥ 3-levels (6.2%) ACDF. A delayed supplementary PF was performed in 11 cases, due to ACDF failure. On univariable regression analysis, older age (p = 0.017), shorter stature (p = 0.031), posterior longitudinal ligament (PLL) injury (p = 0.004), injury to ligamentum flavum (p = 0.005), bilateral facet joint dislocation (p < 0.001) and traumatic cervical spondylolisthesis (p = 0.003) predicted ACDF failure. On the multivariable regression model, older age (p = 0.015), PLL injury (p = 0.048), and bilateral facet joint dislocation (p = 0.010) remained as independent predictors of ACDF failure. CONCLUSIONS: ACDF is safe and effective for the treatment of subaxial cervical spine fractures. High age, bilateral facet joint dislocation and traumatic PLL disruption are independent predictors of failure. We suggest increased vigilance regarding these cases.

Clinical course and predictors of outcome following surgical treatment of benign peripheral nerve sheath tumors, a single center retrospective study.

INTRODUCTION: Peripheral nerve sheath tumors are the most common tumor of the peripheral nerves. In general, surgery has a favorable outcome and is the treatment of choice. However, postoperative neurologic deficits are not uncommon, and predictors of outcome are poorly defined. OBJECTIVE: To evaluate clinical outcomes after surgical treatment of benign peripheral nerve sheath tumors and identify outcome predictors that may affect preoperative decision making and improve surgical outcomes. METHOD: In this single center retrospective study, all patients surgically treated for a benign peripheral nerve sheath tumor between 2005 and 2020 were eligible for inclusion. Medical records and imaging data were reviewed. Studied outcomes were changes in neurological symptoms, pain, and tumor recurrence. Logistic regression was performed to identify possible outcome predictors. RESULTS: In total, 81 patients undergoing 85 separate surgeries for benign peripheral nerve sheath tumors were included. The most common preoperative symptoms were local pain (90%) followed by a noticeable mass (78%), radiating pain (72%), sensory deficit (18%), and motor deficit (16%). A postoperative improvement of symptoms was seen in 94% of those with pain, 48% of those with sensory deficits and 78% of those with motor deficits. However, 35% and 9% developed new postoperative sensory and motor deficits, respectively. Multivariable analysis showed complete tumor removal as a predictor of reduced pain (p = 0.033), and younger age and larger tumors were risk factors for persistent or increased sensory deficits (p = 0.002 and p = 0.005, respectively). There were no significant predictors of motor deficits. Neurocutaneous syndromes were associated with increased odds of tumor recurrence on univariable analysis (p = 0.008). CONCLUSION: Surgery of benign peripheral nerve sheath tumors is a safe procedure with a favorable outcome in most cases. Younger age and larger tumors were risk factors for persistent or increased sensory deficits, while complete tumor removal was associated with reduced pain. Patients with neurocutaneous syndromes had a higher rate of tumor recurrence. To further evaluate outcome predictors, we recommend future studies to focus on longer follow-up periods to assess the natural course of postoperative neurological deficits.

Extended reality in cranial and spinal neurosurgery - a bibliometric analysis.

PURPOSE: This bibliometric analysis of the top 100 cited articles on extended reality (XR) in neurosurgery aimed to reveal trends in this research field. Gender differences in authorship and global distribution of the most-cited articles were also addressed. METHODS: A Web of Science electronic database search was conducted. The top 100 most-cited articles related to the scope of this review were retrieved and analyzed for trends in publications, journal characteristics, authorship, global distribution, study design, and focus areas. After a brief description of the top 100 publications, a comparative analysis between spinal and cranial publications was performed. RESULTS: From 2005, there was a significant increase in spinal neurosurgery publications with a focus on pedicle screw placement. Most articles were original research studies, with an emphasis on augmented reality (AR). In cranial neurosurgery, there was no notable increase in publications. There was an increase in studies assessing both AR and virtual reality (VR) research, with a notable emphasis on VR compared to AR. Education, surgical skills assessment, and surgical planning were more common themes in cranial studies compared to spinal studies. Female authorship was notably low in both groups, with no significant increase over time. The USA and Canada contributed most of the publications in the research field. CONCLUSIONS: Research regarding the use of XR in neurosurgery increased significantly from 2005. Cranial research focused on VR and resident education while spinal research focused on AR and neuronavigation. Female authorship was underrepresented. North America provides most of the high-impact research in this area.

Machine learning for enhanced prognostication: predicting 30-day outcomes following posterior fossa decompression surgery for Chiari malformation type I in a pediatric cohort.

OBJECTIVE: Chiari malformation type I (CM-I) is a congenital disorder occurring in 0.1% of the population. In symptomatic cases, surgery with posterior fossa decompression (PFD) is the treatment of choice. Surgery is, however, associated with peri- and postoperative complications that may require readmission or renewed surgical intervention. Given the associated financial costs and the impact on patients' well-being, there is a need for predictive tools that can assess the likelihood of such adverse events. The aim of this study was therefore to leverage machine learning algorithms to develop a predictive model for 30-day readmissions and reoperations after PFD in pediatric patients with CM-I. METHODS: This was a retrospective study based on data from the National Surgical Quality Improvement Program-Pediatric database. Eligible patients were those undergoing PFD (Current Procedural Terminology code 61343) for CM-I between 2012 and 2021. Patients undergoing surgery for tumors or vascular lesions were excluded. Unplanned 30-day readmission and unplanned 30-day reoperation were the main study outcomes. Additional outcome data considered included the length of hospital stay, 30-day complications, discharge disposition, and 30-day mortality. Training and testing samples were randomly generated (80:20) to study the 30-day readmission and reoperation using logistic regression, decision tree, random forest (RF), K-nearest neighbors, and Gaussian naive Bayes algorithms. RESULTS: A total of 7106 pediatric patients undergoing PFD were included. The median age was 9.2 years (IQR 4.7, 14.2 years). Most of the patients were female (56%). The 30-day readmission and reoperation rates were 7.5% and 3.4%, respectively. Headaches (32%) and wound-related complications (30%) were the most common reasons for 30-day readmission, while wound revisions and evacuation of fluid or blood (62%), followed by CSF diversion-related procedures (28%), were the most common reasons for 30-day reoperation. RF classifiers had the highest predictive accuracy for both 30-day readmissions (area under the curve [AUC] 0.960) and reoperations (AUC 0.990) compared with the other models. On feature importance analysis, sex, developmental delay, ethnicity, respiratory disease, premature birth, hydrocephalus, and congenital/genetic anomaly were some of the variables contributing the most to both RF models. CONCLUSIONS: Using a large-scale nationwide dataset, machine learning models for the prediction of both 30-day readmissions and reoperations were developed and achieved high accuracy. This highlights the utility of machine learning in risk stratification and surgical decision-making for pediatric CM-I.

The negative impact of treatment delays on the long-term neurological outcomes of spinal dural arteriovenous fistulas: a longitudinal cohort study.

OBJECTIVE: Dural arteriovenous fistulas are rare vascular malformations that affect the brain and spinal cord. Spinal dural arteriovenous fistulas (sdAVFs) are the most frequently encountered vascular malformation affecting the spinal cord. The object of this study was to evaluate the impact of treatment delays on the long-term neurological outcomes of either open surgical or interventional treatment of sdAVFs. METHODS: In this retrospective, population-based cohort study, the authors examined consecutive patients with diagnosed sdAVFs at a tertiary care center between 2005 and 2020. Patients were assessed using the Aminoff-Logue disability scale (ALS) at various time points including symptom onset, primary care visit, first specialist outpatient visit, as well as both short and long-term follow-ups. The postoperative long-term ALS gait and bladder grades constituted the primary outcomes of the study. RESULTS: Among the 34 patients included in the study, the median age was 65 years, and there was a male predominance (71%). Most lesions were in the lumbar region (47%). Significant worsening in ALS gait and bladder grades was observed preoperatively, followed by postoperative improvements (p < 0.05). There was no difference in outcomes between surgical and endovascular treatments. Older age (OR 1.10, 95% CI 1.03-1.17, p = 0.007), worse preoperative ALS gait grades (OR 5.12, 95% CI 2.18-12.4, p < 0.001), and longer time from first specialist outpatient visit to first treatment (OR 1.00, 95% CI 1.00-1.01, p = 0.040) were independently associated with worse long-term gait outcomes. Only the preoperative ALS bladder score was a predictor of worse long-term bladder function (OR 92.7, 95% CI 28.0-306.7, p < 0.001). CONCLUSIONS: Both surgical and endovascular treatments for sdAVFs led to significant neurological improvements. However, treatment delays were associated with less favorable long-term outcomes. Prompt diagnosis and early intervention prior to symptom progression may enhance recovery and help to preserve neurological function.

The Effect of Concomitant Spinal Cord Injury on Postoperative Health-related Quality of Life After Traumatic Subaxial Cervical Spine Injuries: A Nationwide Registry Study.

OBJECTIVE: To evaluate the effect of spinal cord injury (SCI) on the health-related quality of life (HRQoL) in patients surgically treated for traumatic subaxial cervical spine injuries and investigate the agreement between objective neurologic outcomes and patient reported outcome measures (PROMs) in that context. STUDY DESIGN: Observational study on prospectively collected multi-institutional registry data. SETTING: Sweden. PARTICIPANTS: Patients with traumatic subaxial spine injuries identified in the Swedish Spine Registry (Swespine) between 2006 and 2016. INTERVENTIONS: Anterior, posterior, or anteroposterior cervical fixation surgery. MAIN OUTCOMES: Patient-reported outcome measures (PROMs) consisting of EQ-5D-3Lindex and Neck Disability Index (NDI). RESULTS: Among the 418 identified patients, 93 (22%) had a concomitant SCI. In this group, 30 (32%) had a complete SCI (Frankel A), and the remainder had incomplete SCIs (17%) Frankel B; 25 (27%) Frankel C; 22 (24%) Frankel D. PROMs significantly correlated with the Frankel grade (P<.001). However, post hoc analysis revealed that the differences between adjacent Frankel grades failed to reach both statistical and clinical significance. On univariable linear regression, the Frankel grade was a significant predictor of a specific index derived from the EQ-5D-3L questionnaire (EQ-5D-3Lindex) at 1, 2, and 5 years postoperatively as well as the NDI at 1 and 2 years postoperatively (P<.001). Changes of PROMs over time from 1, to 2, and 5 years postoperatively did not reach statistical significance, regardless of the presence and degree of SCI (P>.05). CONCLUSION: Overall, the Frankel grade significantly correlated with the EQ-5D-3Lindex and NDI and was a significant predictor of PROMs at 1, 2, and 5 years. PROMs were stable beyond 1 year postoperatively regardless of the severity of the SCI.

Long-Term Functional Outcomes Following Surgical Treatment of Spinal Schwannomas: A Population-Based Cohort Study.

Spinal schwannomas are the second most common form of primary intradural spinal tumor. Despite being benign, they may cause spinal cord compression and subsequently acute or chronic neurological dysfunction. The primary treatment is surgical resection. The aim of this study was to identify pre- and postoperative predictors of favorable outcomes after surgical treatment for spinal schwannoma. All adult patients surgically treated for spinal schwannoma between 2006 and 2020 were eligible for inclusion. Medical records and imaging data were retrospectively reviewed. The primary outcome measures were neurological improvement according to the modified McCormick Scale (mMC) and changes in motor deficit, sensory deficit, gait disturbance, bladder dysfunction, and pain at long-term follow-up. In total, 180 patients with a median follow-up time of 4.4 years were included. Pain was the most common presenting symptom (87%). The median time between symptom presentation and surgery was 12 months, while the median time between diagnosis (first MRI) and surgery was 3 months. Gross total resection (GTR) was achieved in 150 (83%) patients and the nerve root could be preserved in 133 (74%) patients. A postoperative complication occurred in 10 patients (5.6%). There were significant postoperative improvements in terms of motor, sensory, gait, and bladder functions, as well as pain (p < 0.001). Of these symptoms, bladder dysfunction was the one most often improved, with complete symptom resolution in all cases. However, no other predictors of improvement could be identified. There were three cases of recurrence after GTR and nine cases of regrowth after STR. Reoperation was performed in six (3.3%) cases. GTR was associated with a significant improvement in neurological status at long-term follow-up and increased the chance of progression-free survival.

Automatic image registration on intraoperative CBCT compared to Surface Matching registration on preoperative CT for spinal navigation: accuracy and workflow.

INTRODUCTION: Spinal navigation solutions have been slower to develop compared to cranial ones. To facilitate greater adoption and use of spinal navigation, the relatively cumbersome registration processes need to be improved upon. This study aims to validate a new solution for automatic image registration and compare it to a traditional Surface Matching method. METHOD: Adult patients undergoing spinal surgery requiring navigation were enrolled after providing consent. A registration matrix-Universal AIR (= Automatic Image Registration)-was placed in the surgical field and used for automatic registration based on intraoperative 3D imaging. A standard Surface Matching method was used for comparison. Accuracy measurements were obtained by comparing planned and acquired coordinates on the vertebrae. RESULTS: Thirty-nine patients with 42 datasets were included. The mean accuracy of Universal AIR registration was 1.20 ± 0.42 mm, while the mean accuracy of Surface Matching registration was 1.94 ± 0.64 mm. Universal AIR registration was non-inferior to Surface Matching registration. Post hoc analysis showed a significantly greater accuracy for Universal AIR registration. In Surface Matching, but not automatic registration, user-related errors such as incorrect identification of the vertebral level were seen. CONCLUSION: Automatic image registration for spinal navigation using Universal AIR and intraoperative 3D imaging provided improved accuracy compared to Surface Matching registration. In addition, it minimizes user errors and offers a standardized workflow, making it a reliable registration method for navigated spinal procedures.

General Versus Nongeneral Anesthesia for Carotid Endarterectomy: A Prospective Multicenter Registry-Based Study on 25 000 Patients.

BACKGROUND AND OBJECTIVES: Carotid endarterectomy (CEA) is a well-established treatment option for carotid stenosis. The choice between general anesthesia (GA) and nongeneral anesthesia (non-GA) during CEA remains a subject of debate, with concerns regarding perioperative complications, particularly myocardial infarctions. This study aimed to evaluate the outcomes associated with GA vs non-GA CEA using a large, nationwide database. METHODS: The National Surgical Quality Improvement Project database was queried for patients undergoing CEA between 2013 and 2020. Primary outcome measures including surgical outcomes and 30-day postoperative complications were compared between the 2 anesthesia methods, after 2:1 propensity score matching. RESULTS: After propensity score matching, a total of 25 356 patients (16 904 in the GA and 8452 in the non-GA group) were included. Non-GA compared with GA CEA was associated with significantly shorter operative times (101.9, 95% CI: 100.5-103.3 vs 115.8 95% CI: 114.4-117.2 minutes, P < .001), reduced length of hospital stays (2.3, 95% CI: 2.15-2.4 vs 2.5, 95% CI: 2.4-2.6 days, P < .001), and lower rates of 30-day postoperative complications, including myocardial infarctions (0.8% vs 1.2%, P = .003), unplanned intubations (0.8% vs 1.1%, P = .016), pneumonia (0.5% vs 1%, P < .001), and urinary tract infections (0.4% vs 0.7%, P = .003). These outcomes were notably more pronounced in the younger (≤70 years) and high morbidity (American Society of Anesthesiologists 3-5) cohorts. CONCLUSION: In this nationwide registry-based study, non-GA CEA was associated with better short-term outcomes in terms of perioperative complications, compared with GA CEA. The findings suggest that non-GA CEA may be a safer alternative, especially in younger patients and those with more comorbidities.

Impact of the pandemic and concomitant COVID-19 on the management and outcomes of middle cerebral artery strokes: a nationwide registry-based study.

OBJECTIVES: To investigate the impact of the COVID-19 pandemic as well as concomitant COVID-19 itself on stroke care, focusing on middle cerebral artery (MCA) territory infarctions. DESIGN: Registry-based study. SETTING: We used the National Inpatient Sample (NIS) database, which covers a wide range of hospitals within the USA. PARTICIPANTS: The NIS was queried for patients with MCA strokes between 2016 and 2020. In total, 35 231 patients were included. OUTCOME MEASURES: Outcome measures were postprocedural complications, length of stays (LOSs), in-hospital mortality and non-routine discharge. Propensity score matching using all available baseline variables was performed to reduce confounders when comparing patients with and without concomitant COVID-19. RESULTS: Mechanical thrombectomy (MT) was performed in 48.4%, intravenous thrombolysis (IVT) in 38.2%, and both MT and IVT (MT+IVT) in 13.4% of patients. A gradual increase in the use of MT and an opposite decrease in the use of IVT (p<0.001) was detected during the study period. Overall, 25.0% of all patients were admitted for MCA strokes during the pandemic period (2020), of these 209 (2.4%) were concomitantly diagnosed with COVID-19. Patients with MCA strokes and concomitant COVID-19 were significantly younger (64.9 vs 70.0; p<0.001), had significantly worse NIH Stroke Severity scores, and worse outcomes in terms of LOS (12.3 vs 8.2; p<0.001), in-hospital mortality (26.3% vs 9.8%; p<0.001) and non-routine discharge (84.2% vs 76.9%; p=0.013), as compared with those without COVID-19. After matching, only in-hospital mortality rates remained significantly higher in patients with COVID-19 (26.7% vs 8.5%; p<0.001). Additionally, patients with COVID-19 had higher rates of thromboembolic (12.3% vs 7.6%; p=0.035) and respiratory (11.3% vs 6.6%; p=0.029) complications. CONCLUSIONS: Among patients with MCA stroke, those with concomitant COVID-19 were significantly younger and had higher stroke severity scores. They were more likely to experience thromboembolic and respiratory complications and in-hospital mortality compared with matched controls.

Detection and Management of Elevated Intracranial Pressure in the Treatment of Acute Community-Acquired Bacterial Meningitis: A Systematic Review.

Acute bacterial meningitis (ABM) is associated with severe morbidity and mortality. The most prevalent pathogens in community-acquired ABM are Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae. Other pathogens may affect specific patient groups, such as newborns, older patients, or immunocompromised patients. It is well established that ABM is associated with elevated intracranial pressure (ICP). However, the role of ICP monitoring and management in the treatment of ABM has been poorly described.An electronic search was performed in four electronic databases: PubMed, Web of Science, Embase, and the Cochrane Library. The search strategy chosen for this review used the following terms: Intracranial Pressure AND (management OR monitoring) AND bacterial meningitis. The search yielded a total of 403 studies, of which 18 were selected for inclusion. Eighteen studies were finally included in this review. Only one study was a randomized controlled trial. All studies employed invasive ICP monitoring techniques, whereas some also relied on assessment of ICP-based on clinical and/or radiological observations. The most commonly used invasive tools were external ventricular drains, which were used both to monitor and treat elevated ICP. Results from the included studies revealed a clear association between elevated ICP and mortality, and possibly improved outcomes when invasive ICP monitoring and management were used. Finally, the review highlights the absence of clear standardized protocols for the monitoring and management of ICP in patients with ABM. This review provides an insight into the role of invasive ICP monitoring and ICP-based management in the treatment of ABM. Despite weak evidence certainty, the present literature points toward enhanced patient outcomes in ABM with the use of treatment strategies aiming to normalize ICP using continuous invasive monitoring and cerebrospinal fluid diversion techniques. Continued research is needed to define when and how to employ these strategies to best improve outcomes in ABM.

Two years of neurosurgical intraoperative MRI in Sweden - evaluation of use and costs.

BACKGROUND: The current shortage of radiology staff in healthcare provides a challenge for departments all over the world. This leads to more evaluation of how the radiology resources are used and a demand to use them in the most efficient way. Intraoperative MRI is one of many recent advancements in radiological practice. If radiology staff is performing intraoperative MRI at the operation ward, they may be impeded from performing other examinations at the radiology department, creating costs in terms of exams not being performed. Since this is a kind of cost whose importance is likely to increase, we have studied the practice of intraoperative MRI in Sweden. METHODS: The study includes data from the first four hospitals in Sweden that installed MRI scanners adjacent to the operating theaters. In addition, we included data from Karolinska University Hospital in Solna where intraoperative MRI is carried out at the radiology department. RESULTS: Scanners that were moved into the operation theater and doing no or few other scans were used 11-12% of the days. Stationary scanners adjacent to the operation room were used 35-41% of the days. For scanners situated at the radiology department doing intraoperative scans interspersed among all other scans, the proportion was 92%. CONCLUSION: Our study suggests that performing exams at the radiology department rather than at several locations throughout the hospital may be an efficient approach to tackle the simultaneous trends of increasing demands for imaging and increasing staff shortages at radiology departments.

Dysphagia, health-related quality of life, and return to work after occipitocervical fixation.

PURPOSE: The purpose of this study was to evaluate patient-reported outcome measures (PROMS) on dysphagia, health-related quality of life (HRQoL) and return to work after occipitocervical fixation (OCF). Postoperative radiographic measurements were evaluated to identify possible predictors of dysphagia. METHODS: All individuals (≥ 18 years) who underwent an OCF at the study center or were registered in the Swedish spine registry (Swespine) between 2005 and 2019, and were still alive when the study was conducted, were eligible for inclusion. There was no overlap between the cohorts. Prospectively collected data on dysphagia (Dysphagia Short Questionnaire DSQ), HRQoL (EQ5D-3L) and return to work were used. Radiological and baseline patient data were retrospectively collected. In addition, HRQoL data of a matched sample of individuals was elicited from the Stockholm Public Health Survey 2006. RESULTS: In total, 54 individuals were included. At long-term follow-up, 26 individuals (51%) had no dysphagia, and 25 (49%) reported some degree of dysphagia: 11 (22%) had mild dysphagia, and 14 (27%) had moderate to severe dysphagia. On a group level, the OCF sample scored significantly lower EQVAS and EQ-5Dindex values compared to the general population (60.0 vs. 80.0, p = 0.016; 0.43 vs. 0.80, p < 0.001). Individuals working preoperatively returned to work after surgery. Of those responding, 88% stated that they would undergo the OCF operation if it was offered today. No predictors of dysphagia based on radiographic measurements were identified. CONCLUSION: Occipitocervical fixation results in a high frequency of long-term dysphagia. The HRQoL of OCF patients is significantly reduced compared to matched controls. However, most patients are satisfied with their surgery. No radiographic predictors of long-term dysphagia could be identified. Future prospective and systematic studies with larger samples and more objective outcome measures are needed to elucidate the causes of dysphagia in OCF.