Standard Orbitozygomatic Craniotomy versus Mini Orbitozygomatic Craniotomy via an Eyebrow Incision for Microsurgical Treatment of Anterior Communicating Artery Aneurysms.

Background Skull base approaches are utilized to improve microsurgical treatment of cerebral aneurysms. Advantages include early proximal and distal control, increased visualization, and minimal brain retraction. Orbitozygomatic (OZ) craniotomies via pterional incision are commonly used for the treatment of anterior communicating artery (ACoA) aneurysms. A smaller, less invasive OZ craniotomy performed through an eyebrow incision may provide several advantages over a standard OZ approach. Objective We compare surgical outcomes of the standard and eyebrow OZ for the treatment of ACoA aneurysms. Design All patients who underwent microsurgical treatment for ACoA aneurysms by a single surgeon over an 8-year period were included in this retrospective analysis. Patient demographics and clinical data were collected. Participants Thirty-seven consecutive patients were identified, with 15 receiving eyebrow OZ and 22 receiving standard OZ. Main Outcome Measures Data were collected on patient demographics, pathology, intraoperative and perioperative data, and 30-day morbidity. Results A total of 100% of the eyebrow OZ group and 95.5% of the standard OZ group had complete aneurysmal occlusion. Four eyebrow OZ and six standard OZ patients had an intraoperative rupture. All were managed without complication. Two eyebrow OZ and one standard OZ patient died within 30 days of surgery. No patients in either group had aneurysm recurrence, required retreatment, or were limited intraoperatively by exposure. Conclusions The OZ approach via an eyebrow incision has similar outcomes to a standard OZ approach and is a safe option for the treatment of ACoA aneurysms.

Mental health comorbidities in workers' compensation patients and the effect on pain, disability, quality of life, and return to work after lumbar spine surgery.

OBJECTIVE: The impact of mental health comorbidities on outcomes after lumbar spine surgery in workers' compensation (WC) patients has not been robustly explored. The goal of this study was to examine the impact of mental health comorbidities on pain, disability, quality of life, and return to work after lumbar spine surgery in WC patients. METHODS: A nationwide, prospective surgical outcomes registry (National Neurosurgery Quality Outcomes Database [N2QOD]) was queried for all patients who underwent 1- to 4-level lumbar decompression and/or fusion from 2012 to 2021. Patients were stratified on the basis of compensation status into non-WC (25,507) and WC (1018) cohorts. Baseline demographic data, perioperative safety data, and patient-reported outcome measures were compared between groups. The WC cohort was further subdivided on the basis of mental health status into patients with anxiety and depression (n = 107) and those without anxiety and depression (n = 911). Propensity matching was used to generate parity between these subgroups, generating 214 patients (107 pairs) for analysis. Perioperative safety, facility utilization, 1-year patient-reported outcomes (back and leg pain, disability, and quality of life), and return to work were measured as a function of WC and mental health comorbidity status. RESULTS: A total of 26,525 patients (25,507 non-WC and 1018 WC) who underwent 1- to 4-level lumbar spine surgery were reviewed. WC patients were younger, healthier (lower American Society of Anesthesiologists class), more likely to be minorities, less educated, and more likely to smoke and had greater baseline back pain, disability, and quality of life compared to non-WC patients. The prevalence of anxiety and depression was similar between groups (11%). WC patients had worse outcomes for all measures and lower rates of return to work compared to non-WC patients. WC patients with anxiety and depression demonstrated even greater disparities in all outcomes. After propensity matching, WC patients with anxiety and depression continued to demonstrate significantly worse outcomes in comparison to WC patients without anxiety and depression. CONCLUSIONS: Disparities in outcomes after lumbar spine surgery in WC patients are exacerbated in patients with anxiety and depression. WC patients with mental health comorbidities receive the least benefit from lumbar spine surgery and may represent the most vulnerable subset of patients with spine pathology. Addressing mental health comorbidities preoperatively may represent an opportunity for valuable resource allocation and surgical optimization in the WC population.

Microendoscopic Posterior Cervical Laminoforaminotomy for C4 Radiculopathy.

OBJECTIVE: Cervical microendoscopic laminoforaminotomy (MELF) has been proven to be an effective, motion preserving procedure for the surgical treatment of cervical radiculopathy. Cervical 4 (C4) radiculopathies are often unrecognized by the initial evaluating physician and may be misdiagnosed as axial neck pain. In this study, we compare MELF to anterior cervical disk fusion (ACDF) for C4 radiculopathy in the largest series of minimally invasive foraminotomy for C4 radiculopathy to date. METHODS: This is a single-institution retrospective chart review of 42 cases for C4 radiculopathy, 21 MELF and 21 ACDF. Primary outcome measures were length of surgery, length of hospital stay, and time to return to work. Secondary outcome measures were visual analog scale (VAS) neck pain and reoperation rate. RESULTS: All patients were diagnosed with a unilateral C4 radiculopathy using magnetic resonance imaging or steroid injections. The length of surgery and length of hospital stay were significantly decreased in the MELF group compared with ACDF. VAS neck pain significantly decreased for patients in both groups, but the difference between MELF and ACDF was not statistically significant. There were no major complications. No patient underwent revision at the index level or adjacent levels in the MELF group. CONCLUSIONS: We demonstrate that C4 radiculopathy can be identified with appropriate history, physical examination, and targeted nerve root injections. When identified, these radiculopathies that fail conservative therapy can be effectively treated with cervical microendoscopic laminoforaminotomy, with comparable outcomes to ACDF. The length of surgery and length of stay are reduced when compared with ACDF.

Effect of workers' compensation status on pain, disability, quality of life, and return to work after anterior cervical discectomy and fusion: a 1-year propensity score-matched analysis.

OBJECTIVE: Patients with workers' compensation (WC) claims are reported to demonstrate poorer surgical outcomes after lumbar spine surgery. However, outcomes after anterior cervical discectomy and fusion (ACDF) in WC patients remain debatable. The authors aimed to compare outcomes between a propensity score-matched population of WC and non-WC patients who underwent ACDF. METHODS: Patients who underwent 1- to 4-level ACDF were retrospectively reviewed from the prospectively maintained Quality Outcomes Database (QOD). After propensity score matching, 1-year patient satisfaction, physical disability (Neck Disability Index [NDI]), pain (visual analog scale [VAS]), EQ-5D, and return to work were compared between WC and non-WC cohorts. RESULTS: A total of 9957 patients were included (9610 non-WC and 347 WC patients). Patients in the WC cohort were significantly younger (50 ± 9.1 vs 56 ± 11.4 years, p < 0.001), less educated, and were more frequently male, non-Caucasian, and active smokers (29.1% vs 18.1%, p < 0.001), with greater baseline VAS and NDI scores and poorer quality of life (p < 0.001). One-year postoperative improvements in VAS, NDI, EQ-5D, and return-to-work rates and satisfaction were all significantly worse for WC compared with non-WC patients. After adjusting for baseline differences via propensity score matching, WC versus non-WC patients continued to demonstrate worse 3- and 12-month VAS neck pain and NDI (p = 0.010), satisfaction (χ2 = 4.03, p = 0.045), and delayed return to work (9.3 vs 5.7 weeks, p < 0.001). CONCLUSIONS: WC status was associated with greater 1-year residual disability and axial pain along with delayed return to work, without any difference in quality of life despite having fewer comorbidities and being a younger population. Further studies are needed to determine the societal impact that WC claims have on healthcare delivery in the setting of ACDF.

Surgical treatment for chronic subdural hematoma in the elderly: A retrospective analysis.

Background: Chronic subdural hematoma (CSDH) is primarily a disease of the elderly. Less invasive interventions are often offered for elderly (> 80 years) patients due to concerns for elevated surgical risk, although data suggesting a clear outcome benefit is lacking. Methods: All patients aged 65 years or older who underwent surgical treatment for CSDH at a single institution over a 4-year period were evaluated in this retrospective analysis. Surgical options included twist drill craniostomy (TDC), burr hole craniotomy (BHC), or standard craniotomy (SC). Outcomes, demographics, and clinical data were collected. Practice patterns and outcomes for patients older than 80 years old were compared to the age 65-80 cohort. Results: 110 patients received TDC, 35 received BHC, and 54 received SC. There was no significant difference in post-operative complications, outcomes, or late recurrence (30-90 days). Recurrence at 30 days was significantly higher for TDC (37.3% vs. 2.9% vs 16.7%, p 80 group, SC had higher risk of stroke and increased length of stay. Conclusion: Twist drill craniostomy, burr hole craniostomy, and standard craniotomy have similar neurologic outcomes in elderly patients. Presence of thick membranes is a relative contra-indication for TDC due to high 30-day recurrence. Patients > 80 have higher risk of stroke and increased length of stay with SC.

Minimally Invasive Transforaminal Lumbar Interbody Fusion in the Ambulatory Surgery Center Versus Inpatient Setting: A 1-Year Comparative Effectiveness Analysis.

BACKGROUND: Ambulatory surgery centers (ASCs) have emerged as an alternative setting for surgical care as part of the national effort to lower health care costs. The literature regarding the safety of minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) in the ASC setting is limited to few small case series. OBJECTIVE: To assess the safety and efficacy of MIS TLIF performed in the ASC vs inpatient hospital setting. METHODS: A total of 775 patients prospectively enrolled in the Quality Outcomes Database undergoing single-level MIS TLIF at a single ASC (100) or the inpatient hospital setting (675) were compared. Propensity matching generated 200 patients for analysis (100 per cohort). Demographic data, resource utilization, patient-reported outcome measures (PROMs), and patient satisfaction were assessed. RESULTS: There were no significant differences regarding baseline demographic data, clinical history, or comorbidities after propensity matching. Only 1 patient required inpatient transfer from the ASC because of intractable pain. All other patients were discharged home within 23 hours of surgery. The rates of 90-day readmission (2.0%) and reoperation (0%) were equivalent between groups. Both groups experienced significant improvements in all PROMs (Oswestry Disability Index, EuroQol-5D, back pain, and leg pain) at 3 months that were maintained at 1 year. PROMs did not differ between groups at any time point. Patient satisfaction was similar between groups at 3 and 12 months after surgery. CONCLUSION: In carefully selected patients, MIS TLIF may be performed safely in the ASC setting with no statistically significant difference in safety or efficacy in comparison with the inpatient setting.

Anterior Cervical Discectomy and Fusion Versus Microendoscopic Posterior Cervical Foraminotomy for Unilateral Cervical Radiculopathy: A 1-Year Cost-Utility Analysis.

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) and posterior cervical foraminotomy (PCF) are the most common surgical approaches for medically refractory cervical radiculopathy. Rigorous cost-effectiveness studies comparing ACDF and PCF are lacking. OBJECTIVE: To assess the cost-utility of ACDF vs PCF performed in the ambulatory surgery center setting for Medicare and privately insured patients at 1-year follow-up. METHODS: A total of 323 patients who underwent 1-level ACDF (201) or PCF (122) at a single ambulatory surgery center were compared. Propensity matching generated 110 pairs (220 patients) for analysis. Demographic data, resource utilization, patient-reported outcome measures, and quality-adjusted life-years were assessed. Direct costs (1-year resource use × unit costs based on Medicare national allowable payment amounts) and indirect costs (missed workdays × average US daily wage) were recorded. Incremental cost-effectiveness ratios were calculated. RESULTS: Perioperative safety, 90-day readmission, and 1-year reoperation rates were similar between groups. Both groups experienced significant improvements in all patient-reported outcome measures at 3 months that was maintained at 12 months. The ACDF cohort had a significantly higher preoperative Neck Disability Index and a significantly greater improvement in health-state utility (ie, quality-adjusted life-years gained) at 12 months. ACDF was associated with significantly higher total costs at 1 year for both Medicare ($11 744) and privately insured ($21 228) patients. The incremental cost-effectiveness ratio for ACDF was $184 654 and $333 774 for Medicare and privately insured patients, respectively, reflecting poor cost-utility. CONCLUSION: Single-level ACDF may not be cost-effective in comparison with PCF for surgical management of unilateral cervical radiculopathy.

Effect of workers' compensation status on pain, disability, quality of life, and return to work after lumbar spine surgery: a 1-year propensity-matched analysis.

OBJECTIVE: Workers' compensation (WC) and litigation have been shown to adversely impact prognoses in a vast range of health conditions. Low-back pain is currently the most frequent reason for WC claims. The objective of this study was to conduct the largest propensity-matched comparison of outcomes between patients with WC and non-WC status who underwent lumbar spinal decompression with and without fusion. METHODS: Complete data sets for patients who underwent 1- to 4-level lumbar spinal fusion or decompression alone were retrospectively retrieved from the Quality Outcomes Database (QOD), which included 1-year patient-reported outcomes from more than 200 hospital systems collected from 2012 to 2021. Population demographics, perioperative safety, facility utilization, patient satisfaction, disability, pain, EQ-5D quality of life, and return to work (RTW) rates were compared between cohorts for both subgroups. Statistical significance was set at p < 0.05. RESULTS: There were 29,652 patients included in the study. Laminectomy was performed in 16,939 with non-WC status and in 615 with WC, whereas fusion was performed in 11,767 with non-WC status and in 331 with WC. WC patients were more frequently male, a minority race, younger, less educated, more frequently a smoker, had a healthier American Society of Anesthesiologists grade, and with greater baseline visual analog scale (VAS) and Oswestry Disability Index (ODI) scores (p < 0.001). One-year postoperative improvements in VAS, ODI, quality-adjusted life years (QALYs), RTW rates, and satisfaction were all significantly worse for WC versus non-WC patients for both procedures. After adjusting for baseline differences via propensity matching, WC versus non-WC patients continued to demonstrate worse 3- and 12-month VAS and ODI scores, reduced 12-month QALY gain, and delayed RTW after both procedure types. CONCLUSIONS: WC status was associated with significantly greater residual disability and pain postoperatively, a lower quality of life, and delayed RTW. Utilizing resources to identify the negative influences on outcomes for WC patients may be valuable in preoperative optimization and could yield better outcomes in these patients.

Feasibility and Safety of Microendoscopic Posterior Cervical Foraminotomy in an Ambulatory Surgery Center: A Longitudinal Experience with 1000 Cases.

OBJECTIVE: Ambulatory surgery centers (ASCs) have become an increasingly attractive setting for spine surgery in recent decades. Although posterior cervical foraminotomy (PCF) is widely performed in ASCs, there are no studies supporting the safety of this practice. We aimed to demonstrate the feasibility and safety of microendoscopic (MED)-PCF in a large cohort of patients at a freestanding ASC. METHODS: Consecutive patients undergoing MED-PCF for unilateral cervical radiculopathy at a single freestanding ASC from January 2013 to December 2020 were queried. Standard demographic and perioperative data were collected. Outcomes included need for inpatient transfer, perioperative complications, 30-day readmission, 30-day reoperation, and clinical improvement according to the Odom criteria. RESULTS: A total of 1106 patients underwent MED-PCF during the study period. Mean age was 53.3 ± 10.3 years. Most patients underwent decompression at C5-6 (31.4%) or C6-7 (51.9%). Approximately 10% underwent surgery at multiple levels. Mean operative time was 40.0 ± 16.4 minutes. There were no intraoperative or immediate postoperative complications. All patients were discharged home within a few hours of surgery. The rates of 30-day readmission (0.81%) and reoperation (0.36%) were exceedingly low. Nearly 3 quarters of patients (73.7%) achieved a good or excellent clinical outcome (73.7%) according to the Odom criteria. CONCLUSIONS: MED-PCF can be performed in a freestanding ASC with exceedingly low rates of perioperative complications and short-term readmission or reoperation. Our findings support the ongoing migration of PCF from the hospital to the ambulatory setting. Future studies assessing patient-reported outcomes and long-term reoperation rates are necessary.

Ten-Year Experience of Skip Anterior Cervical Corpectomy and Fusion.

BACKGROUND: Anterior cervical corpectomy and fusion (ACCF) is often required to adequately decompress the spinal cord in patients with multilevel cervical spondylosis. Unfortunately, multilevel corpectomy constructs have high rates of early failure and frequently require supplemental posterior fixation. First described in 2003, skip ACCF (sACCF) is defined by corpectomies above and below an intervening vertebral body, which serves as an additional fixation point to augment biomechanical stability. Subsequent studies report high fusion rates and low construct failure rates secondary to superior biomechanical stability. OBJECTIVE: The goal of this study was to demonstrate the safety and efficacy of sACCF in the largest series published to date. METHODS: This study was a retrospective case series of all patients who underwent sACCF at a single institution over a 10-year period. Standard demographic and perioperative data were collected. Outcome data included immediate postoperative complications, long-term reoperation, and pre- and postoperative radiographic parameters. RESULTS: Forty-five patients underwent sACCF: 42 at C4-C6 and 3 at C5-C7. Mean age was 57.5 years. More than half (64.4%) of patients were smokers. Almost all patients were discharged home, the vast majority (82.2%) within 3 days of surgery. Five patients (11.1%) developed complications during the index hospitalization: 2 C5 palsies and 3 medical complications. Three patients (6.7%) developed instrumentation failure requiring anterior revision and supplemental posterior fixation. There were statistically significant increases in C1-C7 (47.8 vs 41.1, P < 0.001) and C2-C7 lordosis (11.1 vs 5.0, P < 0.001) on postoperative radiographs compared with preoperative imaging. Average follow-up was 21.1 months. CONCLUSION: sACCF can be performed safely with complication rates similar to those reported for multilevel anterior cervical discectomy and fusion or adjacent segment ACCF. It should be considered for patients with multilevel cervical pathology for whom an anterior approach is favored. CLINICAL RELEVANCE: sACCF is an effective surgical technique for multilevel cervical decompression and correction of cervical alignment.

Anterior Cervical Discectomy and Fusion in the Ambulatory Surgery Center Versus Inpatient Setting: One-Year Cost-Utility Analysis.

STUDY DESIGN: Retrospective analysis of prospectively collected data. OBJECTIVE: Assess the cost-utility of anterior cervical discectomy and fusion (ACDF) performed in the ambulatory surgery center (ASC) versus inpatient hospital setting for Medicare and privately insured patients at one-year follow-up. SUMMARY OF BACKGROUND DATA: Outpatient ACDF has gained popularity due to improved safety and reduced costs. Formal cost-utility studies for ambulatory versus inpatient ACDF are lacking, precluding an accurate assessment of cost-effectiveness. MATERIALS AND METHODS: A total of 6504 patients enrolled in the Quality Outcomes Database (QOD) undergoing one-level to two-level ACDF at a single ASC (520) or the inpatient hospital setting (5984) were compared. Propensity matching generated 748 patients for analysis (374 per cohort). Demographic data, resource utilization, patient-reported outcome measures, and quality-adjusted life-years (QALYs) were assessed. Direct costs (1-year resource use×unit costs based on Medicare national allowable payment amounts) and indirect costs (missed workdays×average US daily wage) were recorded. Incremental cost-effectiveness ratios were calculated. RESULTS: Complication rates and improvements in patient-reported outcome measures and QALYs were similar between groups. Ambulatory ACDF was associated with significantly lower total costs at 1 year for Medicare ($5879.46) and privately insured ($12,873.97) patients, respectively. The incremental cost-effectiveness ratios for inpatient ACDF was $3,674,662 and $8,046,231 for Medicare and privately insured patients, respectively, reflecting unacceptably poor cost-utility. CONCLUSION: Inpatient ACDF is associated with significant increases in total costs compared to the ASC setting without a safety, outcome, or QALY benefit. The ASC setting is a dominant option from a health economy perspective for first-time one-l to two-level ACDF in select patients compared to the inpatient hospital setting.

Minimally Invasive Transforaminal Lumbar Interbody Fusion in the Ambulatory Setting with an Enhanced Recovery After Surgery Protocol.

OBJECTIVE: Enhanced Recovery After Surgery (ERAS) is a multidisciplinary approach to surgical care that aims to improve outcomes and reduce costs. Its application to spine surgery has been increasing in recent years, with a notable focus on lumbar fusion. This study describes the development, implementation, and outcomes of the first ERAS pathway for ambulatory spine surgery and the largest ambulatory minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) series to date. METHODS: A comprehensive protocol for ambulatory lumbar fusion is described, including patient selection criteria, a multimodal analgesia regimen, and discharge assessment. Consecutive patients undergoing 1- or 2-level MIS TLIF using the described protocol at a single ambulatory surgery center (ASC) over a five-year period were queried. RESULTS: A total of 215 patients underwent ambulatory MIS TLIF over the study period. There were no intraoperative or immediate postoperative complications. All but one patient (99.5%) were discharged home from the ASC. Almost three-quarters (71.2%) were discharged on the day of surgery. Thirty- and 90-day readmission rates were 1.4% and 2.8%, respectively. Only one readmission (0.5%) was for intractable back pain. There were no reoperations or mortalities within 90 days of surgery. CONCLUSIONS: MIS TLIF can be performed safely in a freestanding ambulatory surgery center with minimal perioperative and short-term morbidity. The addition of comprehensive ERAS protocols to the ambulatory setting can promote the transition of fusion procedures to this lower cost environment in an effort to provide higher value care.

Is Thoracic Paddle Lead Spinal Cord Stimulator Implantation Safe in an Ambulatory Surgery Center?

OBJECTIVE: Spinal cord stimulation is an effective treatment modality for chronic pain. Although percutaneous leads are commonly placed in the outpatient setting, paddle leads are typically implanted in the inpatient setting. Given the substantial cost savings associated with the ambulatory setting, we aimed to demonstrate the feasibility and safety of thoracic paddle lead implantation in a freestanding ambulatory surgery center (ASC). METHODS: Consecutive patients undergoing thoracic paddle lead implantation at a single freestanding ASC from January 2015 to December 2020 were queried. Demographic, perioperative, and outcome data were collected. Primary outcomes were incidence of intraoperative or immediate postoperative complications and need for inpatient transfer. Secondary outcomes included readmission at 30 and 90 days and reoperation at 30 days, 90 days, and 1 year. RESULTS: A total of 46 patients underwent ambulatory thoracic paddle lead implantation over the study period. Two patients (4.3%) suffered an immediate postoperative complication requiring return to surgery at the ASC-one for an epidural hematoma, and one for a flank hematoma. All but one patient (97.8%) were discharged home on the day of surgery. The overall 30- and 90-day readmission rates were 4.3% and 6.5%, respectively. One patient (2.2%) required reoperation for a mechanical complication. No device-related infections were noted during the follow-up period. CONCLUSIONS: Thoracic laminotomy for paddle lead spinal cord stimulator implantation can be performed in a freestanding ASC with complication rates comparable to the hospital setting. Future comparative studies that assess clinical outcomes and cost are necessary to determine the cost-effectiveness of the ambulatory setting.

Child participation in collision sports and football: what influences parental decisions?

OBJECTIVE: Sport participation promotes health benefits for children. Current media and scientific coverage of sport-related head injury may influence a parent's decision on sports participation. Physicians must understand what influences these decisions to effectively counsel patients and families. This study sought to better understand and quantify the parental decisions to allow/disallow collision sports, including football participation. METHODS: A 31-question survey related to child/parent demographics, sports history, and influences to allow/disallow sport participation was available to parents in the United States through a national volunteer registry, between November 2016 and September 2019. Pearson's chi-squared and Wilcoxon's signed-rank test were used to analyze categorical and continuous variables, respectively. Multivariate logistic regression was performed to identify the most powerful factors associated with the decision. RESULTS: Of the 884 responses, 430 (49%) parents would disallow collision sport participation and 334 (38%) would disallow football. Parents who would allow collision sports more commonly cited child desire, while those parents who would disallow cited safety concern as the greatest influence to generally disallow a sport. Those who would disallow reported doctors (35.1% vs 25.3%; P = 0.002), media (12.8% vs 7.3%; P = 0.006) and other parents (11.2% vs 7.3%; P = 0.045) as influences. A child's age (OR 1.039, 95%CI 1.007-1.073; P = 0.018) was independently associated with their parent responding that they would allow collision sports. Parent educational status showed that those with higher than a bachelor's degree would be less likely to allow football participation (OR 0.635, 95%CI 0.443-0.910; P = 0.013). CONCLUSIONS: Parents incorporate many sources of information into the decision to allow or disallow their child to participate in collision sports. A child's desire to play a sport and child safety are driving factors for parents faced with the decision of whether to allow participation in collision sports. Physician input is more frequently influential to parents than the media, underscoring the responsibility of physicians to engage families on the risks, benefits, and resources available for sport participation.

Expandable Interbody Spacers: A Two-Year Study Evaluating Radiologic and Clinical Outcomes With Patient-Reported Outcomes.

BACKGROUND: Posterior and transforaminal lumbar interbody fusion (PLIF and TLIF) have gained significant popularity for management of lumbar degenerative spine over the last 3 decades. Expandable interbody spacers are a newer technology that can increase in size after placement, theoretically minimizing the operative risks of static spacers without sacrificing radiographic correction. The goal of this study is to further evaluate the radiographic and clinical outcomes of expandable spacers. METHODS: This was a retrospective analysis of a prospective cohort that underwent elective 1- to 3-level PLIF/TLIF with expandable interbody spacers from 2014 to 2020 at a single institution. Patient-reported outcome measures (PROMs) Oswestry Disability Index and Visual Analog Scale were collected at 6 weeks, 3 months, 6 months, and 12 months. Imaging was performed at 12 months, with follow up at 24 months in case of nonunion. Retrospective outcomes were computer tomography (CT) based and Bridwell-Lenke classification of fusion, radiographic parameters, and adverse events. RESULTS: A total of 50/53 (94.3%) otherwise eligible patients had 12-month PROMs and CT imaging for analysis. Here, 50% were obese (body mass index > 30), 58% had a smoking history, and 24% had a prior lumbar procedure. Also, 46/50 (92%) patients fused by CT criteria. Significant decrease in PROMs was seen as early as 6 weeks postoperatively. The mean change in preoperative-to-postoperative global lordosis values was 3.8° ± 15.6°. There were 4 (8%) intraoperative durotomies and 5 (10%) patients requiring reoperation for nonunion. CONCLUSIONS: Our study demonstrates the use of expandable spacers in a high comorbidity cohort with low complications, excellent improvement in PROMs despite minimal lordotic improvement, and high rates of fusion without recombinant human bone morphogenetic protein-2 (rhBMP-2) or iliac crest bone graft. LEVEL OF EVIDENCE: 4. CLINICAL RELEVANCE: Expandable interbody fusion can significantly improve outcomes for degenerative lumbar spondylosis, with good safety profile, and high fusion rates.

Imaging findings after acute sport-related concussion in American football players: A systematic review.

Sport-related concussion (SRC) has emerged as a major public health problem. The results of brain imaging studies following SRC have raised questions about long-term neurologic health, but the clinical implications of these findings remain unknown. A systematic review of brain imaging findings after SRC was performed utilizing the following inclusion criteria: football players, brain imaging within 6 months of SRC, and sample size >5. Studies were assessed for: 1) methodology, 2) imaging outcomes, and 3) number of positive statistical comparisons. Imaging was classified as immediate (≤1 week post-injury) or subacute (>1 week to 6 months post-injury). Eleven studies met inclusion criteria. Eight of the 11 studies conducted a total of 809 comparisons of brain function, of which 149 (18%) were statistically significant. Nine of the 11 studies (82%) reported positive immediate findings, but were more likely to be subject to recall bias (86% vs. 0%) and to lack baseline advanced brain imaging (78% vs. 50%) than negative studies. Only 3 of 9 studies that reported subacute findings (33%) reported positive results, and these positive studies were also more likely to be subject to recall bias (100% vs. 40%) and to lack baseline advanced brain imaging (100% vs. 67%) than negative studies. The results of the study demonstrate the transitory nature of positive imaging findings and methodological limitations that complicate study interpretation. Further research is required to correlate imaging findings with clinical outcomes.

Long-Term Neuroimaging Findings in American Football Players: Systematic Review.

BACKGROUND: Lasting neuroimaging changes after participation in American football are an increasing public health concern. The clinical relevance of imaging findings remains unknown. METHODS: A systematic review was performed with the following inclusion criteria: football players, brain imaging ≥2 years from previous concussion or retirement, and sample size ≥5. Studies were assessed for 1) methodology (control selection, type I error, and recall bias), 2) imaging outcomes, and 3) number of significant statistical comparisons. RESULTS: Sixteen studies (all cross-sectional studies) met the inclusion criteria. Highest level of play included high school (n = 1), college (n = 3), and professional (n = 12). Thirteen of the 16 studies made a total 456 comparisons of brain activity, of which 171 were statistically significant (38%). Nine of 16 studies (56%) had appropriate controls, and 5 of 16 studies (31%) appropriately accounted for type I error. To obtain player concussion history, all studies (16/16) had recall bias or unclear methodology. Imaging outcome measures included structural magnetic resonance imaging (MRI) (29.2%), diffusion tensor imaging (25%), radioactive tracer uptake on positron emission tomography (16.7%), patterns of connectivity on functional MRI (fMRI) (12.5%), transcranial magnetic stimulation (8.3%), arterial spin labeling MRI (4.2%), and metabolic changes on 1H-magnetic resonance spectroscopy (4.2%). CONCLUSIONS: Long-term neuroimaging findings in American football players are heterogeneous in both methodology and findings. Understanding the clinical importance of statistically significant findings is complicated by methodological limitations and study design. Further research is required to correlate imaging findings with clinical outcomes.

Identifying Characteristics in Abusive Head Trauma: A Single-Institution Experience.

Abusive head trauma (AHT) is a significant cause of childhood morbidity and mortality. The purpose of this study was to better understand the trends centered on AHT patients treated at Vanderbilt Children's Hospital. A retrospective study of 139 children undergoing treatment and management for traumatic brain injury due to abuse between January 2006 and April 2013 at Vanderbilt Children's Hospital was conducted. Caucasian males made up 61% and the youngest sibling represented 86.3% of our cohort. The median age was 5 months with injuries occurring during summertime and on weekdays, 31 and 63%, respectively. Seventy-nine percent were diagnosed with subdural hematomas, and 42% had a Glasgow Coma Scale (GCS) of 8 or less. A total of 25 patients, median age 8.6 months, died during our study period. The results of this study describe the AHT population at Vanderbilt Children's Hospital. Future studies should prospectively assess this population to better understand social factors involved in AHT.

Development of high-resolution real-time sub-ppb ethane spectroscopy and some pilot studies in life science.

We describe a high-resolution real-time spectroscopy system targeted to ethane gas with sensitivity > or = 70 ppt and response time from > or = 0.7 s. The measurement technique is based on a mid-IR lead-salt laser passing through a Herriott cell through which a gas sample flows. We compare wavelength scanning and locked configurations and discuss their relative merits. The technology has been motivated by clinical breath testing applications, ethane being widely regarded as the most important breath biomarker for cell damage via free-radical-mediated oxidative attack. We discuss preliminary human and animal studies in which ultrasensitive real-time ethane detection offers new diagnostic and monitoring potential.