Primary anterior lumbar interbody fusion, with and without posterior instrumentation: a 1,377-patient cohort from a multicenter spine registry.

BACKGROUND CONTEXT: Lumbar interbody instrumentation techniques are common and effective surgical options for a variety of lumbar degenerative pathologies. Anterior lumbar interbody fusion (ALIF) has become a versatile and powerful means of decompression, stabilization, and reconstruction. As an anterior only technique, the integrity of the posterior muscle and ligaments remain intact. Adding posterior instrumentation to ALIF is common and may confer benefits in terms of higher fusion rate but could contribute to adjacent segment degeneration due to additional rigidity. Large clinical studies comparing stand-alone ALIF with and without posterior supplementary fixation (ALIF+PSF) are lacking. PURPOSE: To compare rates of operative nonunion and adjacent segment disease (ASD) in ALIF with or without posterior instrumentation. STUDY DESIGN: Retrospective cohort study. PATIENT SAMPLE: Adult patients (≥18 years old) who underwent primary ALIF for lumbar degenerative pathology between levels L4 to S1 over a 12-year period. Exclusion criteria included trauma, cancer, infection, supplemental decompression, noncontiguous fusions, prior lumbar fusions, and other interbody devices. OUTCOME MEASURES: Reoperation for nonunion and ASD compared between ALIF only and ALIF+PSF. METHODS: Reoperations were modeled as time-to-events where the follow-up time was defined as the difference between the primary ALIF procedure and the date of the outcome of interest. Crude cumulative reoperation probabilities were reported at 5-years follow-up. Multivariable Cox proportional hazard regression was used to evaluate risk of operative nonunion and for ASD adjusting for patient characteristics. RESULTS: The study consisted of 1,377 cases; 307 ALIF only and 1070 ALIF+PSF. Mean follow-up time was 5.6 years. The 5-year crude nonunion incidence was 2.4% for ALIF only and 0.5% for ALIF+PSF; after adjustment for covariates, a lower operative nonunion risk was observed for ALIF+PSF (HR=0.22, 95% CI=0.06-0.76). Of the patients who are deemed potentially suitable for ALIF alone, one would need to add posterior instrumentation in 53 patients to prevent one case of operative nonunion at a 5-year follow-up (number needed to treat). Five-year operative ASD incidence was 4.3% for ALIF only and 6.2% for ALIF+PSF; with adjustments, no difference was observed between the cohorts (HR=0.96, 95% CI=0.54-1.71). CONCLUSIONS: While the addition of posterior instrumentation in ALIFs is associated with lower risk of operative nonunion compared with ALIF alone, operative nonunion is rare in both techniques (<5%). Accordingly, surgeons should evaluate the added risks associated with the addition of posterior instrumentation and reserve the supplemental posterior fixation for patients that might be at higher risk for operative nonunion. Rates of operative ASD were not statistically higher with the addition of posterior instrumentation suggesting concern regarding future risk of ASD perhaps should not play a role in considering supplemental posterior instrumentation in ALIF.

Brain and lung metastasis of uterine leiomyosarcoma: illustrative case.

BACKGROUND: Uterine leiomyosarcoma is a rare, extremely aggressive tumor with a high rate of metastasis. Five-year survival for individuals with metastatic disease is only 10%-15%. Metastases to the brain are exceptionally rare and are associated with poor survival. OBSERVATIONS: The authors report a case of uterine leiomyosarcoma that metastasized to the brain in a 51-year-old woman. A single lesion on magnetic resonance imaging was discovered in the right posterior temporo-occipital region 44 months after resection of the primary uterine tumor. The patient underwent a right occipital craniotomy with gross-total resection of the tumor and is receiving adjuvant stereotactic radiosurgery and chemotherapy with gemcitabine and docetaxel. At 8 months postresection, the patient remains alive and asymptomatic with no sign of recurrence. A literature review of prior reported cases was conducted to analyze patterns of approach to patient treatment and survival. LESSONS: The authors found an apparent survival benefit in patients receiving adjuvant radiation therapy.

Control of Charge Carrier Relaxation at the Au/WSe2 Interface by Ti and TiO2 Adhesion Layers: Ab Initio Quantum Dynamics.

Phonon-mediated charge relaxation plays a vital role in controlling thermal transport across an interface for efficient functioning of two-dimensional (2D) nanostructured devices. Using a combination of nonadiabatic molecular dynamics with real-time time-dependent density functional theory, we demonstrate a strong influence of adhesion layers at the Au/WSe2 interface on nonequilibrium charge relaxation, rationalizing recent ultrafast time-resolved experiments. Ti oxide layers (TiOx) create a barrier to the interaction between Au and WSe2 and extend hot carrier lifetimes, creating benefits for photovoltaic and photocatalytic applications. In contrast, a metallic Ti layer accelerates the energy flow, as needed for efficient heat dissipation in electronic devices. The interaction of metallic Ti with WSe2 causes W-Se bond scissoring and pins the Fermi level. The Ti adhesion layer enhances the electron-phonon coupling due to an increased density of states and the light mass of the Ti atom. The conclusions are robust to presence of typical point defects. The atomic-scale ab initio analysis of carrier relaxation at the interfaces advances our knowledge in fabricating nanodevices with optimized electronic and thermal properties.

Do PEEK Rods for Posterior Instrumented Fusion in the Lumbar Spine Reduce the Risk of Adjacent Segment Disease?

BACKGROUND: Polyetheretherketone (PEEK) rods were clinically introduced in the mid-2000s as an alternative to titanium (Ti) rods for posterior instrumented lumbar spine fusion, theorized to reduce the risk of adjacent segment disease (ASD). However, few studies have follow-up beyond 2 years. Consequently, we conducted a matched cohort study using data from Kaiser Permanente's spine registry to compare the 2 rod systems and risk for outcomes. METHODS: Patients aged ≥18 undergoing first posterior lumbar fusion for a degenerative diagnosis from 2009 to 2018 using either a PEEK or a Ti rod were identified. Fusions using Ti rods were 2:1 propensity score matched to PEEK rods on the following factors: patient age, body mass index, smoking, American Society of Anesthesiologists classification, diagnosis, interbody use, bone morphogenic protein use, number of levels fused, fusion levels, and operative year. The matched sample included 154 PEEK and 308 Ti fusions. We used Cox regression to evaluate ASD and nonunion, and logistic regression to evaluate 90-day emergency department (ED) visit, readmission, and complication. RESULTS: We did not observe a difference in risk for ASD (hazard ratio = 1.02, 95% confidence interval [CI] = 0.66-1.59) or ED visit (odds ratio [OR] = 0.88, 95% CI = 0.48-1.59). A lower likelihood of readmission (OR = 0.34, 95% CI = 0.13-0.94) was observed following PEEK fusion compared with Ti. No nonunions or 90-day complications were observed for the PEEK group; 5 (2-year cumulative incidence = 0.7%) nonunions and 4 (1.3%) complications were observed for the Ti group. CONCLUSIONS: Our multicenter study did not support the hypothesis that PEEK rods are associated with a lower ASD risk. Reasons for readmission need to be identified to better understand the differences observed here. Further study of patients with TLIF using Ti and PEEK rods and posterolateral fusion with Ti and PEEK rods is needed. CLINICAL RELEVANCE: The present study adds to the literature supporting their midterm effectiveness of PEEK rods compared with Ti rods for both their safety and their effectiveness at the 5-7-year follow-up. LEVEL OF EVIDENCE: 3.

Minimally invasive surgery for lumbar synovial cysts with coexisting degenerative spondylolisthesis.

BACKGROUND: About one third of lumbar synovial cysts are associated with degenerative spondylolisthesis. Segmental instability is thought to contribute to the pathogenesis and recurrence of synovial cysts and lumbar fusion has been advocated as a treatment of choice in the presence of spondylolisthesis. In patients with spondylolisthesis, minimally invasive resection of lumbar synovial cysts, without fusion, could minimize surgically induced segmental instability while providing good pain relief. METHODS: Clinical and radiological outcomes of lumbar synovial cyst patients with and without spondylolisthesis were retrospectively compared. Pain outcomes were assessed with modified Macnab criteria. RESULTS: Fifty-three patients (18 with grade 1 spondylolisthesis) underwent minimally invasive synovial cyst resection and all had either excellent or good pain outcome at ≤ 8 post- operative weeks (P = 1.000, n = 53). At > 8 post-operative weeks (mean (SD) follow-up of 200 (175) weeks), excellent or good outcomes were noted in 89% of patients without spondylolisthesis and in 75% of patients with spondylolisthesis (P = 0.425, n = 40). Four patients developed a new grade 1 spondylolisthesis at a mean follow-up of 2.6 ± 2.1 years. Nine patients were assessed for spondylolisthesis measurements at 1.2 ± 1.3 years of follow up and no significant difference was observed (5 ± 0 vs 5 ± 1 mm; P = 0.791). Two patients without spondylolisthesis and none of the patients with spondylolisthesis had a synovial cyst recurrence. CONCLUSION: Patients with concomitant lumbar degenerative spondylolisthesis and synovial cyst can have good short- and long-term clinical outcomes with minimally invasive surgery without fusion. Post-operative segmental instability does not appear to be significant in patients with spondylolisthesis. All patients included in this article signed an informed consent for the use of their medical information for research.

Role of Metabolomics in Traumatic Brain Injury Research.

Metabolomics is an important member of the omics community in that it defines which small molecules may be responsible for disease states. This article reviews the essential principles of metabolomics from specimen preparation, chemical analysis, to advanced statistical methods. Metabolomics in traumatic brain injury has so far been underutilized. Future metabolomics-based studies focused on the diagnoses, prognoses, and treatment effects need to be conducted across all types of traumatic brain injury.

Clinical outcomes of middle fossa craniotomy for superior semicircular canal dehiscence repair.

OBJECTIVE Superior semicircular canal dehiscence (SSCD) is a rare disorder characterized by the formation of a third opening in the inner ear between the superior semicircular canal and the middle cranial fossa. Aberrant communication through this opening causes a syndrome of hearing loss, pulsatile tinnitus, disequilibrium, and autophony. This study analyzed the clinical outcomes of a single-institution series of patients with SSCD undergoing surgical repair by the same otolaryngologist and neurosurgeon. METHODS All patients who underwent SSCD repair at the University of California, Los Angeles, between March 2011 and November 2014 were included. All patients had their SSCD repaired via middle fossa craniotomy by the same otolaryngologist and neurosurgeon. Outcomes were analyzed with Fisher's exact test. RESULTS A total of 18 patients with a mean age of 56.2 years (range 27-84 years) and an average follow-up of 5.0 months (range 0.2-21.8 months) underwent 21 cases of SSCD repair. Following treatment, all patients (100%) reported resolution in ≥ 1 symptom associated with SSCD. Autophony (p = 0.0005), tinnitus (p = 0.0059), and sound- and/or pressure-induced dizziness (p = 0.0437) showed significant symptomatic resolution. Following treatment, 29% (2/7) of patients developed imbalance, 20% (1/5) of patients developed sound- and/or pressure-induced dizziness, and 18% (2/11) of patients developed aural fullness. Among patients with improved symptoms following surgical repair, none reported recurrence of symptoms at subsequent follow-up visits. CONCLUSIONS SSCD remains an underdiagnosed and undertreated condition. Surgical repair of SSCD using a middle fossa craniotomy is associated with a high rate of symptom resolution. Continued investigation using a larger patient cohort and longer-term follow-up could further demonstrate the effectiveness of using middle fossa craniotomy for SSCD repair.

Metabolomic analysis of cerebral spinal fluid from patients with severe brain injury.

Proton nuclear magnetic resonance (H-NMR) spectroscopic analysis of cerebral spinal fluid provides a quick, non-invasive modality for evaluating the metabolic activity of brain-injured patients. In a prospective study, we compared the CSF of 44 TBI patients and 13 non-injured control subjects. CSF was screened for ten parameters: ß-glucose (Glu), lactate (Lac), propylene glycol (PG), glutamine (Gln), alanine (Ala), α-glucose (A-Glu), pyruvate (PYR), creatine (Cr), creatinine (Crt), and acetate (Ace). Using mixed effects measures, we discovered statistically significant differences between control and trauma concentrations (mM). TBI patients had significantly higher concentrations of PG, while statistical trends existed for lactate, glutamine, and creatine. TBI patients had a significantly decreased concentration of total creatinine. There were no significant differences between TBI patients and non-injured controls regarding ß- or α-glucose, alanine, pyruvate or acetate. Correlational analysis between metabolites revealed that the strongest significant correlations in non-injured subjects were between ß- and α-glucose (r = 0.74), creatinine and pyruvate (r = 0.74), alanine and creatine (r = 0.62), and glutamine and α-glucose (r = 0.60). For TBI patients, the strongest significant correlations were between lactate and α-glucose (r = 0.54), lactate and alanine (r = 0.53), and α-glucose and alanine (r = 0.48). The GLM and multimodel inference indicated that the combined metabolites of PG, glutamine, α-glucose, and creatinine were the strongest predictors for CMRO2, ICP, and GOSe. By analyzing the CSF of patients with TBI, our goal was to create a metabolomic fingerprint for brain injury.

Nonconvulsive electrographic seizures after traumatic brain injury result in a delayed, prolonged increase in intracranial pressure and metabolic crisis.

OBJECTIVE: To determine whether nonconvulsive electrographic post-traumatic seizures result in increases in intracranial pressure and microdialysis lactate/pyruvate ratio. DESIGN: Prospective monitoring with retrospective data analysis. SETTING: Single center academic neurologic intensive care unit. PATIENTS: Twenty moderate to severe traumatic brain injury patients (Glasgow Coma Score 3-13). MEASUREMENTS AND MAIN RESULTS: Continuous electroencephalography and cerebral microdialysis were performed for 7 days after injury. Ten patients had seizures and were compared with a matched cohort of traumatic brain injury patients without seizures. The seizures were repetitive and constituted status epilepticus in seven of ten patients. Using a within-subject design, post-traumatic seizures resulted in episodic increases in intracranial pressure (22.4 +/- 7 vs. 12.8 +/- 4.3 mm Hg; p < .001) and an episodic increase in lactate/pyruvate ratio (49.4 +/- 16 vs. 23.8 +/- 7.6; p < .001) in the seizure group. Using a between-subjects comparison, the seizure group demonstrated a higher mean intracranial pressure (17.6 +/- 6.5 vs. 12.2 +/- 4.2 mm Hg; p < .001), a higher mean lactate/pyruvate ratio (38.6 +/- 18 vs. 27 +/- 9; p < .001) compared with nonseizure patients. The intracranial pressure and lactate/pyruvate ratio remained elevated beyond postinjury hour 100 in the seizure group but not the nonseizure group (p < .02). CONCLUSION: Post-traumatic seizures result in episodic as well as long-lasting increases in intracranial pressure and microdialysis lactate/pyruvate ratio. These data suggest that post-traumatic seizures represent a therapeutic target for patients with traumatic brain injury.

Pericontusional brain tissue exhibits persistent elevation of lactate/pyruvate ratio independent of cerebral perfusion pressure.

OBJECTIVE: To determine whether pericontusional tissue exhibits neurochemical responsiveness to changes in cerebral perfusion pressure as measured by microdialysis lactate/pyruvate ratio. DESIGN: Prospective monitoring with retrospective data analysis. SETTING: Single-center academic neurologic intensive care unit. PATIENTS: Twenty-one patients with severe traumatic brain injury (Glasgow Coma Scale score 3-8). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Cerebral microdialysis was performed for the initial 7 days after traumatic brain injury. Thirteen patients had microdialysis probes in normal tissue and eight had two probes, one of which was located in pericontusional tissue. Retrospective analysis was performed to determine if microdialysis levels in pericontusional tissue demonstrates higher levels of lactate/pyruvate ratio than normal tissue and if lactate/pyruvate ratio increased with reductions in cerebral perfusion pressure. Univariate analysis revealed higher values for glutamate and lactate/pyruvate ratio in pericontusional tissue compared with normal tissue. However, based on the mixed-effects model analysis, the percent time of elevated lactate/pyruvate ratio was significantly higher in pericontusional tissue (40 +/- 59% vs. 17 +/- 37%, p < .05), and the mean lactate/pyruvate ratio values showed only a trend relationship (62 +/- 134 vs. 34 +/- 78, p < .06). When examined by cerebral perfusion pressure threshold, cerebral perfusion pressure <60 mm Hg was not associated with higher lactate/pyruvate ratio values in normal or pericontusional tissue. In addition, no single cerebral perfusion pressure threshold was associated with a significant reduction in lactate/pyruvate ratio in either pericontusional or normal tissue (p < .08). CONCLUSIONS: Sustained increases in lactate/pyruvate ratio occurred more frequently in pericontusional tissue compared with normal brain tissue. The lactate/pyruvate ratio was not related to cerebral perfusion pressure, nor was the percent time-burden of elevated lactate/pyruvate ratio related to any particular sustained cerebral perfusion pressure threshold. Lactate/pyruvate ratio values appear to be elevated despite cerebral perfusion pressure values customarily considered to be adequate.

Frameless stereotactic aspiration and thrombolysis of deep intracerebral hemorrhage is associated with reduced levels of extracellular cerebral glutamate and unchanged lactate pyruvate ratios.

INTRODUCTION: Intracerebral hemorrhage (ICH) is a devastating form of stroke commonly resulting in severe morbidity and high mortality. Secondary brain injury often occurs in the days following the initial hemorrhage and is associated with significant neurological deterioration. The neurochemistry associated with secondary injury is poorly understood. The purpose of this study is to characterize the neurochemical changes in perihematomal tissue during frameless minimally invasive evacuation of spontaneous hematomas. METHODS: This is a nonrandomized prospective microdialysis study of 12 consecutive patients undergoing Frameless Stereotactic Aspiration and Thrombolysis (FAST) of deep ICHs. Hourly glucose, lactate, pyruvate, and glutamate were measured in the perihematomal tissue of patients undergoing minimally invasive hematoma evacuation. Analyte concentrations were compared to evaluate the natural history of perihematomal neurochemistry and to identify changes potentially related to secondary injury. RESULTS: Brain hematoma volumes were reduced 87% during FAST and National Institute of Health Stroke Scale (NIHSS) scores were improved from an average of 19 at admission to 12.6 at time of discharge from the intensive care unit. Glutamate average values decreased from the first 24 hours of measurement (12 mmol/L +/- 6) to the final 24-hour epoch (5 mmol/L +/- 6). Glutamate reduction showed a significant linear (p = 0.0007) and quadratic (p <0.05) trend during hematoma drainage. Lactate pyruvate ratios (LPR), a common marker of ischemia, were unchanged. CONCLUSIONS: This study reports that elevated levels of glutamate are found in the perihematomal region after ICH and are decreased during hematoma drainage. Conversely, ischemic LPRs are not found in perihematomal regions and were unchanged during hematoma drainage. These data suggest that excitotoxicity related to glutamate may have an important impact on secondary injury. The data failed to support the role of ischemia in secondary perihematomal damage.