Complement-dependent neuroinflammation in spinal cord injury: from pathology to therapeutic implications.

ABSTRACT: Spinal cord injury remains a major cause of disability in young adults, and beyond acute decompression and rehabilitation, there are no pharmacological treatments to limit the progression of injury and optimize recovery in this population. Following the thorough investigation of the complement system in triggering and propagating cerebral neuroinflammation, a similar role for complement in spinal neuroinflammation is a focus of ongoing research. In this work, we survey the current literature investigating the role of complement in spinal cord injury including the sources of complement proteins, triggers of complement activation, and role of effector functions in the pathology. We study relevant data demonstrating the different triggers of complement activation after spinal cord injury including direct binding to cellular debris, and or activation via antibody binding to damage-associated molecular patterns. Several effector functions of complement have been implicated in spinal cord injury, and we critically evaluate recent studies on the dual role of complement anaphylatoxins in spinal cord injury while emphasizing the lack of pathophysiological understanding of the role of opsonins in spinal cord injury. Following this pathophysiological review, we systematically review the different translational approaches used in preclinical models of spinal cord injury and discuss the challenges for future translation into human subjects. This review emphasizes the need for future studies to dissect the roles of different complement pathways in the pathology of spinal cord injury, to evaluate the phases of involvement of opsonins and anaphylatoxins, and to study the role of complement in white matter degeneration and regeneration using translational strategies to supplement genetic models.

Surgeon Preference Regarding Wound Dressing Management in Lumbar Fusion Surgery: An AO Spine Global Cross-Sectional Study.

OBJECTIVE: To evaluate the global practice pattern of wound dressing use after lumbar fusion for degenerative conditions. METHODS: A survey issued by AO Spine Knowledge Forums Deformity and Degenerative was sent out to AO Spine members. The type of postoperative dressing employed, timing of initial dressing removal, and type of subsequent dressing applied were investigated. Differences in the type of surgery and regional distribution of surgeons' preferences were analyzed. RESULTS: Right following surgery, 60.6% utilized a dry dressing, 23.2% a plastic occlusive dressing, 5.7% glue, 6% a combination of glue and polyester mesh, 2.6% a wound vacuum, and 1.2% other dressings. The initial dressing was removed on postoperative day 1 (11.6%), 2 (39.2%), 3 (20.3%), 4 (1.7%), 5 (4.3%), 6 (0.4%), 7 or later (12.5%), or depending on drain removal (9.9%). Following initial dressing removal, 75.9% applied a dry dressing, 17.7% a plastic occlusive dressing, and 1.3% glue, while 12.1% used no dressing. The use of no additional coverage after initial dressing removal was significantly associated with a later dressing change (p < 0.001). Significant differences emerged after comparing dressing management among different AO Spine regions (p < 0.001). CONCLUSION: Most spine surgeons utilized a dry or plastic occlusive dressing initially applied after surgery. The first dressing was more frequently changed during the first 3 postoperative days and replaced with the same type of dressing. While dressing policies tended not to vary according to the type of surgery, regional differences suggest that actual practice may be based on personal experience rather than available evidence.

Surgeon Preferences Worldwide in Wound Drain Utilization in Open Lumbar Fusion Surgery for Degenerative Pathologies.

STUDY DESIGN: Cross-sectional survey. OBJECTIVE: Although literature does not recommend routine wound drain utilization, there is a disconnect between the evidence and clinical practice. This study aims to explore into this controversy and analyze the surgeon preferences related to drain utilization, and the factors influencing drain use and criterion for removal. METHODS: A survey was distributed to AO Spine members worldwide. Surgeon demographics and factors related to peri-operative drain use in 1 or 2-level open fusion surgery for lumbar degenerative pathologies were collected. Multivariate analyses by drain utilization, and criterion of removal were conducted. RESULTS: 231 surgeons participated, including 220 males (95.2%), orthopedics (178, 77.1%), and academic/university-affiliated (114, 49.4%). Most surgeons preferred drain use (186, 80.5%) and subfascial drains (169, 73.2%). Drains were removed based on duration by 52.87% of the surgeons, but 27.7% removed drains based on outputs. On multivariable analysis, significant predictors of drain use were surgeon's aged 35-44 (OR = 11.9, 95% CI = 1.2-117.2, P = .034), 45-54 (29.1, 3.1-269.6, P = .003), 55-64 (8.9, 1.4-56.5, .019), and wound closure using coaptive films (6.0, 1.2-29.0, P = .025). Additionally, surgeons from Asia Pacific (OR = 5.19, 95% CI = 1.65-16.38, P = .005), Europe (3.55, 1.22-10.31, P = .020), and Latin America (4.40, 1.09-17.83, .038) were more likely to remove drain based on time duration, but surgeons <5 years of experience (10.23, 1.75-59.71, P = .010) were more likely to remove drains based on outputs. CONCLUSIONS: Most spine surgeons worldwide prefer to place a subfascial wound drain for degenerative open lumbar surgery. The choice for drain placement is associated with the surgeon's age and use of coaptive films for wound closure, while the criterion for drain removal is associated with the surgeons' region of practice and experience.

Comparing Cortical Bone Trajectory and Traditional Pedicle Screws in Transforaminal Lumbar Interbody Fusion: A Retrospective Cohort Study of One-Year Outcomes.

INTRODUCTION: This is a retrospective study of consecutive patients undergoing transforaminal lumbar interbody fusion (TLIF) at a single institution. The objective of this study was to compare the long-term results associated with cortical bone trajectory (CBT) and traditional pedicle screw (TPS) via posterolateral approach in TLIF. METHODS: Consecutive patients treated from November 2014 to March 2019 were included in the CBT TLIF group, while consecutive patients treated from October 2010 to August 2017 were included in the TPS TLIF group. Inclusion criteria comprised single-level or two-level TLIF for degenerative spondylolisthesis with stenosis and at least one year of clinical and radiographic follow-up. Variables of interest included pertinent preoperative, perioperative, and postoperative data. Non-parametric evaluation was performed using the Wilcoxon test. Fisher's exact test was used to assess group differences for nominal data. RESULTS: Overall, 140 patients met the inclusion criteria; 69 patients had CBT instrumentation (mean follow-up 526 days) and 71 patients underwent instrumentation placement via TPS (mean follow-up 825 days). Examination of perioperative and postoperative outcomes demonstrate comparable results between the groups with perioperative complications, length of stay, discharge destination, surgical revision rate, and fusion rates all being similar between groups (p = 0.1; p = 0.53; p = 0.091; p = 0.61; p = 0.665, respectively). CONCLUSIONS: CBT in the setting of TLIF offer equivalent outcomes to TPS with TLIF at both short- and long-term intervals of care.

Telemedicine in Spine Surgery: Outcomes for 138 Patients With Virtual Preoperative Assessment Compared to Historical Controls.

INTRODUCTION: COVID-19 has accelerated the use of telemedicine in all aspects of health care delivery, including initial surgical evaluation. No existing literature investigates the safety and efficacy of telemedicine to preoperatively evaluate spine surgery candidates. Our objectives were: (1) Compare the change in visual analogue scale (VAS) scores between the telemedicine preoperative visit and in-person preoperative visit groups. (2) Compare the average surgical time, estimated blood loss (EBL), length of hospital stay (LOS), rates of intraoperative complications, rates of readmission, and rates of reoperation between the telemedicine preoperative visit and in-person preoperative visit groups. METHODS: The previously stated metrics were collected for 276 patients, 138 who were exclusively evaluated preoperatively with telemedicine and 138 historical controls who were evaluated preoperatively in person. We used χ2 and independent samples t tests to determine significance. RESULTS: There were no significant differences in the mean change in VAS scores (-2.7 ± 3.1 telemedicine vs. -2.2 ± 3.7 in-person, P = 0.317), mean percentage change in VAS scores (-40.5% ± 54.3% vs. -39.5% ± 66.6%, P = 0.811), mean surgical time (2.4 ± 1.4 hours vs. 2.3 ± 1.3 ours, P = 0.527), mean EBL (150.4 ± 173.3 mL vs. 156.7 ± 255.0 mL, P = 0.811), mean LOS (3.3 ± 2.4 days vs. 3.3 ± 2.5 days, P = 0.954), intraoperative complication rates (0.7% vs. 1.4%, P = 0.558), reoperation rates (7.9% vs. 4.3%, P = 0.208), or readmission rates (10.1% vs. 5.1%, P = 0.091) between the telemedicine preoperative visit and in-person preoperative visit groups. CONCLUSIONS: Preoperative evaluation via telemedicine leads to the same short-term surgical outcomes as in-person evaluation with no increased risk of surgical complications.

Spinal Arachnoid Webs: Presentation, Natural History, and Outcomes in 38 Patients.

BACKGROUND: Spinal arachnoid webs are rarely described bands of thickened arachnoid tissue in the dorsal thoracic spine. Much is unknown regarding their origins, risk factors, natural history, and outcomes. OBJECTIVE: To present the single largest case series, detailing presenting symptoms and outcomes amongst operative and nonoperative patients, to better understand the role of intervention. METHODS: This retrospective chart review identified 38 patients with arachnoid webs. Patient demographics, radiologic signs, symptoms, and surgical history data were extracted from the electronic medical record. Symptoms were divided by location and character. 28 patients were successfully contacted for follow up outcome surveys. RESULTS: 26 patients (68%) underwent surgical intervention, 12 (32%) were managed non-operatively. 15 (39%) patients had undergone a previous unsuccessful surgery at a different site for their symptoms prior to arachnoid web diagnosis. Commonly presenting symptoms included myelopathy (68%), focal thoracic back pain (68%), lower extremity weakness (45%), numbness and sensory changes (58%), and lower extremity radicular pain (42%), upper extremity weakness (24%), and radicular pain (37%). Focal thoracic pain was associated with thoracic level (P < .02). Myelopathic symptoms were less common in postoperative patients. Postoperative patients described significantly more upper extremity (P < .01) and thoracic (P < .01) numbness and paresthesias. Surveyed nonoperative patients universally described their symptoms as either stable or worsening. CONCLUSION: Spinal arachnoid webs present with thoracic myelopathy and back pain but can also present with upper extremity symptoms. Surgical intervention stabilizes or improves symptoms and is well received. Nonoperative patients do not spontaneously improve.

Telemedicine in the Evaluation and Management of Neurosurgical Spine Patients: Questionnaire Assessment of 346 Consecutive Patients.

STUDY DESIGN: Retrospective questionnaire study of all patients seen via telemedicine during the COVID-19 pandemic at a large academic institution. OBJECTIVE: This aim of this study was to compare patient satisfaction of telemedicine clinic to in-person visits; to evaluate the preference for telemedicine to in-person visits; to assess patients' willingness to proceed with major surgery and/or a minor procedure based on a telemedicine visit alone. SUMMARY OF BACKGROUND DATA: One study showed promising utility of mobile health applications for spine patients. No studies have investigated telemedicine in the evaluation and management of spine patients. METHODS: An 11-part questionnaire was developed to assess the attitudes toward telemedicine for all patients seen within a 7-week period during the COVID-19 crisis. Patients were called by phone to participate in the survey. χ2 and the Wilcoxon Rank-Sum Test were performed to determine significance. RESULTS: Ninety-five percent were "satisfied" or "very satisfied" with their telemedicine visit, with 62% stating it was "the same" or "better" than previous in-person appointments. Patients saved a median of 105 minutes by using telemedicine compared to in-person visits. Fifty-two percent of patients have to take off work for in-person visits, compared to 7% for telemedicine. Thirty-seven percent preferred telemedicine to in-person visits. Patients who preferred telemedicine had significantly longer patient-reported in-person visit times (score mean of 171) compared to patients who preferred in-person visits (score mean of 137, P = 0.0007). Thirty-seven percent of patients would proceed with surgery and 73% would proceed with a minor procedure based on a telemedicine visit alone. CONCLUSION: Telemedicine can increase access to specialty care for patients with prolonged travel time to in-person visits and decrease the socioeconomic burden for both patients and hospital systems. The high satisfaction with telemedicine and willingness to proceed with surgery suggest that remote visits may be useful for both routine management and initial surgical evaluation for spine surgery candidates.Level of Evidence: 3.

Safety Profile and Radiographic and Clinical Outcomes of Stand-Alone 2-Level Anterior Lumbar Interbody Fusion: A Case Series of 41 Consecutive Patients.

OBJECTIVE: The use of stand-alone 2-level anterior lumbar interbody fusion (ALIF) for degenerative lumbar disease has been increasing as an alternative to routinely augmenting these constructs with posterior fixation or fusion. Despite the potential benefits of a stand-alone approach (decreased cost and operative time, decreased pain and early mobilization), there is a paucity of information regarding these operations in the literature. This investigation aimed to determine the safety profile, radiographic outcomes including fusion rates, improvement in preoperative pain, and spinopelvic parameter modification, for patients undergoing stand-alone 2-level ALIF. METHODS: This retrospective case series involved a chart review of all patients undergoing 2-level stand-alone ALIF at a single tertiary hospital from 2008 to 2018. Data included patient demographics, hospitalization, complications and radiological studies. Visual analog scale (VAS) back and leg scores were measured via patient-administered surveys preoperatively and up to 18 weeks postoperatively. RESULTS: Forty-one patients who underwent L4-S1 stand-alone ALIF were included. Sixteen (39%) of patients had undergone previous posterior lumbar surgery. Length of stay averaged 4.2 days. Complication rates were comparable to 1-level ALIF. Two patients required reoperation. Fusion rates were 100% for L4-5 and 94.4% for L5-S1. There was no significant change in lumbar lordosis (LL) or LL-pelvic incidence (PI), but there was improved segmental lordosis (SL) and disc height at L4-S1 on final follow-up imaging. There was also modest but statistically significant improvement in VAS back and leg scores. CONCLUSIONS: Stand-alone 2-level ALIF is an option for a surgeon to perform in the absence of significant instability, even in the setting of prior posterior surgery. These procedures increase SL and disc height, but do not have the same effect on LL or LL-PI.

Effect of perioperative steroids on dysphagia after anterior cervical spine surgery: A systematic review.

BACKGROUND: Dysphagia following anterior cervical spine surgery is common. Steroids potentially reduce post-operative inflammation that leads to dysphagia; however, the efficacy, optimal dose and route of steroid administration have not been fully elucidated. OBJECTIVE: The purpose of this systematic review is to evaluate the effect of peri-operative steroids on the incidence and severity of dysphagia following anterior cervical spine surgery. METHODS: A PubMed search adherent to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed to include clinical studies reporting use of steroids in adult patients following anterior cervical spine surgery. Data regarding steroid dose, route and timing of administration were abstracted. Incidence and severity of post-operative dysphagia were pooled across studies. RESULTS: Seven of 72 screened articles met inclusion criteria for a total of 246,298 patients that received steroids. Patients that received systemic and local steroids had significant reductions in rate and severity of dysphagia postoperatively. Reduction of dysphagia severity was more pronounced in patients undergoing multilevel procedures in both groups. There was no difference in infectious complications among patients that received steroids compared with controls. There was no difference in fusion rates at long-term follow-up. CONCLUSIONS AND CLINICAL RELEVANCE: Steroids may reduce dysphagia after anterior cervical spinal procedures in the early post-operative period without increasing complications. This may be especially beneficial in patients undergoing multilevel procedures. Future studies should further define the optimal dose and route of steroid administration, and the specific contraindications for use.

Thoracic lateral extracavitary corpectomy for anterior column reconstruction with expandable and static titanium cages: clinical outcomes and surgical considerations in a consecutive case series.

OBJECTIVE: Many surgical interventions have emerged as effective means of restoring mechanical stability of the anterior column of the spine. The lateral extracavitary approach (LECA) allows for broad visualization and circumferential reconstruction of the spinal column. However, early reports demonstrated significant complication rates, protracted operative times, and prolonged hospitalizations. More recent reports have highlighted concerns for subsidence, particularly with expandable cages. Our work seeks to describe a single-surgeon consecutive series of patients undergoing LECA for thoracic corpectomy. Specifically, the objective was to explore the surgical considerations, clinical and radiographic outcomes, and complication profile of this approach. METHODS: A retrospective study examined data from 17 consecutive patients in whom single or multi-level corpectomy was performed via a LECA by a single surgeon. Vertebral body replacement was achieved with either a static or expandable titanium cage. The Karnofsky Performance Scale (KPS) was utilized to assess patient functional status before and after surgery. Radiographic outcomes, particularly footplate-to-body ratio and subsidence, were assessed on CT imaging at 6 weeks after surgery and at follow-up of at least 6 months. RESULTS: The majority of patients had post-operative KPS scores consistent with functional independence (≥70, 12/17 patients, 71%). Fourteen patients had improved or maintained function by last follow-up. In both groups, all patients had a favorable footplate-to-body ratio, and rates of subsidence were similar at both time points. Notably, the overall complication rate (24%) was significantly lower than that published in the literature, and no patient suffered a pneumothorax that required placement of a thoracostomy tube. CONCLUSION: The LECA approach for anterior column reconstruction with static or expandable cages is an important surgical consideration with favorable surgical parameters and complication rates. Further, use of expandable cages may allow for reconstruction over a larger segment without increased risk of subsidence.

Spinal cord infarction following minor trauma in children: fibrocartilaginous embolism as a putative cause.

Spinal cord infarctions following seemingly innocuous trauma in children are rare, devastating events. In the majority of these cases, the pathophysiology is enigmatic. The authors present 3 cases of pediatric spinal cord infarction that followed minor trauma. An analysis of the clinical, radiographic, and laboratory features of these cases suggests that thromboembolism of the nucleus pulposus into the spinal cord microcirculation is the likely mechanism. A review of the human and veterinary literature supports this notion. To the authors' knowledge, this is the largest pediatric series of myelopathy due to thromboembolism of the nucleus pulposus reported to date, and it is the first report of this condition occurring in an infant.

Depressive symptoms in Parkinson disease correlate with impaired global and specific cognitive performance.

Consecutive patients in a Movement Disorders Center with Parkinson disease (PD) were offered to undergo complete neuropsychological testing and to complete the Beck Depression Inventory (BDI), regardless of their cognitive and behavioral status. A total of 82 patients were included in this cross-sectional study and had a mean age of 67.7 years, formal education of 14.8 years, PD duration of 101 months, Unified Parkinson Disease Rating Scale-Motor ''off'' score of 36.96, Mini-Mental State Examination (MMSE) score of 27.8 (range 19-30), and BDI score of 10.23 (SD 8.65). Beck Depression Inventory scores did not correlate with disease duration or motor scores but inversely correlated with the MMSE scores (r = -0.40; P < .001) and total Dementia Rating Scale (DRS) scores (r = -0.33; P < .01). Using a univariate regression analysis controlling for age, gender, education, and total Unified Parkinson Disease Rating Scales (UPDRS) score, the BDI scores had a significant and unique relationship with MMSE scores. However, when the BDI scores were correlated with specific cognitive domains, only the Boston Naming Test and the Hopkins Verbal Learning Test (HVLT) delayed recall remained significant after Bonferroni correction. Similarly, when comparing the cognitive performance of patients with PD who scored >14 on the BDI versus those who scored <14, only the mean score of the Boston Naming Test was different between the 2 groups. Our study shows that while depressive symptoms correlated with global cognitive performance, naming, verbal memory, and language are the most susceptible cognitive domains affected with depressive symptoms.