Coronal Deformity is Associated With Uptake on Single Photon Emission Computed Tomography in Patients With Low Back Pain.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVE: Single Photon Emission Computed Tomography/Computed Tomography (SPECT/CT) is emerging as a valuable imaging test for identifying pain generators within the lumbar spine. The relationship between radiotracer uptake on SPECT/CT and anatomic biomechanical parameters has not been previously studied. METHODS: We performed a retrospective review of all patients seen at our institution between 2021-2023 who obtained SPECT/CT scans for workup of thoracolumbar back pain. Patient data including demographic, clinical symptoms, and surgical history were collected. Radiology reports were reviewed for evidence of pathologic degeneration and increased bone metabolism on SPECT/CT. Biomechanical parameters were measured from standing scoliosis plain radiographs. Patients were stratified into two cohorts by either presence or absence of asymmetric coronal uptake on SPECT/CT. RESULTS: 160 patients met inclusion criteria. Patients were primarily male (55%) with average age 55 ± 15 years. 87 (54%) patients demonstrated asymmetric uptake on SPECT/CT. These patients were older (P < 0.001), but with similar gender, prior fusion history, sacroiliitis, adjacent segment degeneration, and pseudoarthrosis (P > 0.05). This cohort had more disc disease, facet arthropathy, and greater degree of coronal scoliosis and coronal imbalance (P < 0.001). There were significantly more sites of uptake in the asymmetric cohort, and uptake was preferentially observed in the concavity of the lumbar curve (P < 0.001). There were no significant differences in sagittal balance or spinopelvic mismatch between cohorts (P > 0.05). CONCLUSION: Asymmetric uptake on SPECT/CT was associated with coronal deformity in patients with low back pain. Further prospective studies are warranted to assess the effect of coronal deformity on pain generation.

Biomechanical Predictors of Sacroiliac Joint Uptake on Single-Photon Emission Computed Tomography/Computed Tomography.

OBJECTIVE: Single-photon emission computed tomography/computed tomography (SPECT/CT) is an emerging imaging modality that identifies sites of heightened bone metabolism in response to increased stresses. The relationship between sacroiliac (SI) joint radiotracer uptake and anatomic biomechanical parameters is poorly understood. METHODS: Adult patients with SPECT/CT scans performed at our institution between 2021 and 2023 for the workup of low back pain were included. Patient charts were reviewed for demographic factors including age, gender, and prior thoracolumbar fusion history. Biomechanical spinopelvic parameters were measured from standing scoliosis radiographs. SPECT/CT scans were reviewed for uptake at the SI joint. Patients were stratified into 2 cohorts; patients with SI uptake greater than iliac crest uptake were designated "hot," whereas those with less or equal uptake were labeled "cold." RESULTS: One-hundred and sixty patients met inclusion criteria. Patients were slightly more male (55%) with average age 55 ± 14.9 years. Sixty-eight patients (43%) had evidence of increased SI activity. Interrater reliability showed substantial agreement (kappa = 0.62). The hot cohort demonstrated greater pelvic incidence (54.8 ± 14.0 degrees vs. 51.0 ± 11.0 degrees, P = 0.031) and pelvic tilt (20.8 ± 9.5 degrees vs. 18.4 ± 8.6 degrees, P =0.047) compared with the cold cohort. Patients were otherwise similar between cohorts (P > 0.05). CONCLUSIONS: Increased pelvic incidence and pelvic tilt angles are associated with SPECT/CT uptake at the SI joint, which may reflect altered biomechanics at the spinopelvic junction. SPECT/CT may be a valuable tool to assess SI degeneration. Future studies are warranted to better characterize the clinical applications of these findings.

Glasgow Coma Scale Motor Score Predicts Need for Tracheostomy After Decompressive Craniectomy for Traumatic Brain Injury.

Objective: Many patients with severe traumatic brain injury (TBI) require a tracheostomy after decompressive craniectomy. Determining which patients will require tracheostomy is often challenging. The existing methods for predicting which patients will require tracheostomy are more applicable to stroke and spontaneous intracranial hemorrhage. The aim of this study was to investigate whether the Glasgow Coma Scale (GCS) motor score can be used as a screening method for predicting which patients who undergo decompressive craniectomy for severe TBI are likely to require tracheostomy. Methods: The neurosurgery census at the University of Kansas Medical Center was retrospectively reviewed to identify adult patients aged over 18 years who underwent decompressive craniectomy for TBI. Eighty patients met the inclusion criteria for the study. There were no exclusion criteria. The primary outcome of interest was the need for tracheostomy. The secondary outcome was the comparison of the total length of stay (LOS) and intensive care unit LOS between the early and late tracheostomy patient groups. Results: All patients (100%) with a GCS motor score of 4 or less on post operative (POD) 5 required tracheostomy. Setting the threshold at GCS motor score of 5 on POD 5 for recommending tracheostomy resulted in 86.7% sensitivity, 91.7% specificity, and 90.5% positive predictive value, with an area under the receiver operator curve of 0.9101. Conclusion: GCS motor score of 5 or less on POD 5 of decompressive craniectomy is a useful screening threshold for selecting patients who may benefit from tracheostomy, or may be potential candidates for extubation.

Postponed depth electrode placement due to seborrheic dermatitis of the scalp: illustrative case.

BACKGROUND: Seborrheic dermatitis is a common fungal infection of the scalp that may potentially affect depth electrode placement for intracranial seizure monitoring. No cases documenting the safety of proceeding with depth electrode placement in the setting of seborrheic dermatitis have been reported. OBSERVATIONS: A 19-year-old man with a history of drug-resistant epilepsy was taken to the operating room for placement of depth electrodes for long-term seizure monitoring. Annular patches of erythema with trailing scales were discovered after shaving the patient's head. Dermatology service was consulted, and surgery was cancelled because of the uncertainty of his diagnosis and possible intracranial spreading. He was diagnosed with severe seborrheic dermatitis and treated with topical ketoconazole. Surgery was rescheduled, and the patient received successful placement and removal of depth electrodes without any complications. LESSONS: Seborrheic dermatitis is a common skin infection that, in the authors' experience, is unlikely to lead to any intracranial spread after treatment. However, surgeons should use clinical judgment and engage dermatology colleagues regarding any uncertain skin lesions.

Intracranial tuberculoma: a rare complication of extrapulmonary tuberculosis. Illustrative case.

BACKGROUND: Intracranial tuberculomas are rare entities commonly seen only in low- to middle-income countries where tuberculosis remains endemic. Furthermore, following adequate treatment, the development of intracranial spread is uncommon in the absence of immunosuppression. OBSERVATIONS: A 22-year-old man with no history of immunosuppression presented with new-onset seizures in the setting of miliary tuberculosis status post 9 months of antitubercular therapy. Following a 2-month period of remission, he presented with new-onset tonic-clonic seizures. Magnetic resonance imaging demonstrated interval development of a mass concerning for an intracranial tuberculoma. After resection, pathological analysis of the mass revealed caseating granulomas within the multinodular lesion, consistent with intracranial tuberculoma. The patient was discharged after the reinitiation of antitubercular medications along with a steroid taper. LESSONS: To the best of the authors' knowledge, this case represents the first instance of intracranial tuberculoma occurring after the initial resolution of a systemic tuberculosis infection. The importance of retaining a high level of suspicion when evaluating these patients for seizure etiology is crucial because symptoms are rapidly responsive to resection of intracranial tuberculoma masses. Furthermore, it is imperative for surgeons to recognize the isolation steps necessary when managing these patients within the operating theater and inpatient settings.

A systematic review and meta-analysis of traumatic intracranial hemorrhage in patients taking prehospital antiplatelet therapy: Is there a role for platelet transfusions?

BACKGROUND: Platelet transfusion has been utilized to reverse platelet dysfunction in patients on preinjury antiplatelets who have sustained a traumatic intracranial hemorrhage (tICH); however, there is little evidence to substantiate this practice. The objective of this study was to perform a systematic review on the impact of platelet transfusion on survival, hemorrhage progression and need for neurosurgical intervention in patients with tICH on prehospital antiplatelet medication. METHODS: Controlled, observational and randomized, prospective and retrospective studies describing tICH, preinjury antiplatelet use, and platelet transfusion reported in PubMed, Embase, Cochrane Reviews, Cochrane Trials and Cochrane DARE databases between January 1987 and March 2019 were included. Investigations of concomitant anticoagulant use were excluded. Risk of bias was assessed using the Newcastle-Ottawa scale. We calculated pooled estimates of relative effect of platelet transfusion on the risk of death, hemorrhage progression and need for neurosurgical intervention using the methods of Dersimonian-Laird random-effects meta-analysis. Sensitivity analysis established whether study size contributed to heterogeneity. Subgroup analyses determined whether antiplatelet type, additional blood products/reversal agents, or platelet function assays impacted effect size using meta-regression. RESULTS: Twelve of 18,609 screened references were applicable to our questions and were qualitatively and quantitatively analyzed. We found no association between platelet transfusion and the risk of death in patients with tICH taking prehospital antiplatelets (odds ratio [OR], 1.29; 95% confidence interval [CI], 0.76-2.18; p = 0.346; I = 32.5%). There was no significant reduction in hemorrhage progression (OR, 0.88; 95% CI, 0.34-2.28; p = 0.788; I = 78.1%). There was no significant reduction in the need for neurosurgical intervention (OR, 1.00; 95% CI, 0.53-1.90, p = 0.996; I = 59.1%; p = 0.032). CONCLUSION: Current evidence does not support the use of platelet transfusion in patients with tICH on prehospital antiplatelets, highlighting the need for a prospective evaluation of this practice. LEVEL OF EVIDENCE: Systematic Reviews and Meta-Analyses, Level III.

Effects of platelet dysfunction and platelet transfusion on outcomes in traumatic brain injury patients.

OBJECTIVE: Platelet inhibition in traumatic brain injury (TBI) may be due to injury or antiplatelet medication use pre-injury. This study aims to identify factors associated with increased platelet arachidonic acid (AA) and adenosine diphosphate (ADP) inhibition and determine if platelet transfusion reduces platelet dysfunction and affects outcome. METHODS: Prospective thromboelastography (TEG) assays were collected on adult patients with TBI with intracranial injuries detected by computed tomography (CT). Outcomes included in-hospital mortality, and CT lesion expansion. RESULTS: Of 153 patients, ADP inhibition was increased in moderate and severe TBI compared to mild TBI (p = 0.0011). P2Y12 inhibiting medications had increased ADP inhibition (p = 0.0077). Admission ADP inhibition was not associated with in-hospital mortality (p = 0.24) or CT lesion expansion (p = 0.94). Mean reduction of ADP inhibition from platelet transfusion (-15.1%) relative to no transfusion (+ 11.7%) was not statistically different (p = 0.0472). CONCLUSIONS: Mild TBI results in less ADP inhibition compared to moderate and severe TBI, suggesting a dose response relationship between TBI severity and degree of platelet dysfunction. Further, study is warranted to determine efficacy and parameters for platelet transfusion in patients with TBI.

Coagulopathy in the Setting of Mild Traumatic Brain Injury: Truths and Consequences.

Mild traumatic brain injury (mTBI) is a common, although poorly-defined clinical entity. Despite its initially mild presentation, patients with mTBI can rapidly deteriorate, often due to significant expansion of intracranial hemorrhage. TBI-associated coagulopathy is the topic of significant clinical and basic science research. Unlike trauma-induced coagulopathy (TIC), TBI-associated coagulopathy does not generally follow widespread injury or global hypoperfusion, suggesting a distinct pathogenesis. Although the fundamental mechanisms of TBI-associated coagulopathy are far from clearly elucidated, several candidate molecules (tissue plasminogen activator (tPA), urokinase plasminogen activator (uPA), tissue factor (TF), and brain-derived microparticles (BDMP)) have been proposed which might explain how even minor brain injury can induce local and systemic coagulopathy. Here, we review the incidence, proposed mechanisms, and common clinical tests relevant to mTBI-associated coagulopathy and briefly summarize our own institutional experience in addition to identifying areas for further research.