Emerging Outlook on Personalized Neuromodulation for Depression: Insights From Tractography-Based Targeting.

BACKGROUND: Deep brain stimulation has shown promise in treating individual patients with treatment-resistant depression, but larger-scale trials have been less successful. Here, we created what is, to our knowledge, the largest meta-analysis with individual patient data to date to explore whether the use of tractography enhances the efficacy of deep brain stimulation for treatment-resistant depression. METHODS: We systematically reviewed 1823 articles, selecting 32 that contributed data from 366 patients. We stratified the individual patient data based on stimulation target and use of tractography. Using 2-way type III analysis of variance, Welch's 2-sample t tests, and mixed-effects linear regression models, we evaluated changes in depression severity 1 year (9-15 months) postoperatively and at last follow-up (4 weeks to 8 years) as assessed by depression scales. RESULTS: Tractography was used for medial forebrain bundle (MFB) (n = 17 tractography/32 total), subcallosal cingulate (SCC) (n = 39 tractography/241 total), and ventral capsule/ventral striatum (n = 3 tractography/41 total) targets; it was not used for bed nucleus of stria terminalis (n = 11), lateral habenula (n = 10), and inferior thalamic peduncle (n = 1). Across all patients, tractography significantly improved mean depression scores at 1 year (p < .001) and last follow-up (p = .009). Within the target cohorts, tractography improved depression scores at 1 year for both MFB and SCC, though significance was met only at the α = 0.1 level (SCC: ß = 15.8%, p = .09; MFB: ß = 52.4%, p = .10). Within the tractography cohort, patients with MFB tractography showed greater improvement than patients with SCC tractography (72.42 ± 7.17% vs. 54.78 ± 4.08%) at 1 year (p = .044). CONCLUSIONS: Our findings underscore the promise of tractography in deep brain stimulation for treatment-resistant depression as a method for personalization of therapy, supporting its inclusion in future trials.

Neurosurgical management of vertebral lesions in pediatric chronic recurrent multifocal osteomyelitis: patient series.

BACKGROUND: Chronic recurrent multifocal osteomyelitis (CRMO) is a rare pediatric autoinflammatory disorder involving 2 or more inflammatory bone lesions separated in time and space associated with pathological vertebral fractures. There are no current guidelines for the role of pediatric spine surgeons in the management of this condition. The authors demonstrate the importance of close and early involvement of neurosurgeons in caring for patients with CRMO with vertebral involvement. OBSERVATIONS: Fifty-six pediatric patients with clinical and radiographic evidence of CRMO were identified and clinical, radiographic, laboratory, and histopathological data were reviewed. All were evaluated via Jansson and Bristol CRMO diagnostic criteria. Ten had radiographic evidence of vertebral involvement (17.9%). Nine of these had multifocal disease. Five patients had multiple vertebrae affected. Six patients were evaluated for possible surgical intervention and one required intervention due to vertebra plana leading to a progressive kyphotic deformity and significant spinal canal stenosis. LESSONS: In conjunction with management by the primary pediatric rheumatology team using nonsteroidal anti-inflammatory drugs, disease-modifying anti-rheumatic drugs, immunotherapies, and bisphosphonates, given the risk of pathological fractures and potential resulting long-term neurological deficits, the authors recommend close monitoring and management by pediatric spine surgeons for any patient with CRMO with vertebral lesions.

Pituitary macroadenoma causing vision loss in Wyburn-Mason syndrome: illustrative case.

BACKGROUND: Wyburn-Mason syndrome (WMS) is a neurocutaneous disorder consisting of vascular malformations of the brain, eye, and skin. These include characteristically high-flow intracranial and intraorbital arteriovenous malformations (AVMs) that present commonly with visual deterioration, headache, and hemiplegia. Complete removal of these lesions is challenging. Most patients are followed closely, and intervention occurs only in the setting of worsening symptoms secondary to AVM growth or hemorrhage. Here the authors present the first known case of a patient with WMS and a pituitary macroadenoma. OBSERVATIONS: A 62-year-old man with a 30-year history of WMS with right basal ganglia and orbital AVMs and right eye blindness presented for new-onset left-sided vision loss. A pituitary adenoma was identified compressing the optic chiasm and left optic nerve. Magnetic resonance imaging and digital subtraction angiography studies were obtained for surgical planning, and the patient underwent an endoscopic transnasal transsphenoidal resection, with significant postoperative vision improvement. LESSONS: Given the variable presentation and poor characterization of this rare syndrome, patients with WMS presenting with new symptoms must undergo evaluation for growth and hemorrhage of known AVMs, as well as new lesions. Further, in patients undergoing intracranial surgery, extensive preoperative imaging and planning are crucial for safe and successful procedures.

Magnetic resonance imaging-guided laser interstitial thermal therapy for refractory focal epilepsy in a patient with a fully implanted RNS system: illustrative case.

BACKGROUND: The resective surgery plus responsive neurostimulation (RNS) system is an effective treatment for patients with refractory focal epilepsy. Furthermore, the long-term intracranial electroencephalography data provided by the system can inform a future resection or ablation procedure. RNS patients may undergo 1.5-T magnetic resonance imaging (MRI) under the conditions specified in the RNS system MRI guidelines; however, it was unknown if the MRI artifact would limit intraoperative laser interstitial thermal therapy (LITT) in a patient with a fully implanted RNS system. OBSERVATIONS: The authors were able to complete a successful awake LITT of epileptogenic tissue in a 1.5-T MRI scanner on the ipsilateral side to an implanted RNS system. LESSONS: If a future LITT procedure is probable, the neurostimulator should be placed contralateral to the side of the potential ablation. Using twist drill holes versus burr holes for depth lead placement may assist in future laser bone anchor seating. Before a LITT procedure in a patient with the neurostimulator ipsilateral to the ablation, 1.5-T MRI thermography scanning should be scheduled preoperatively to assess artifact in the proposed ablation zone. Per the RNS system MRI guidelines, the patient must be positioned supine and awake, with no more than 30 minutes of active scan time before a 30-minute pause.

Research reporting in cubital tunnel syndrome studies: an analysis of the literature.

PURPOSE: There is a strong need for a set of consensus outcomes to be utilized for future studies on cubital tunnel syndrome. The goal was to assess the outcome measures utilized in the cubital tunnel syndrome literature as a way of measuring popularity/acceptability and then to perform a literature review for the most commonly used outcomes. METHODS: A literature search was performed using the pubmed.gov database and Medical Subject Headings (MeSH). For each article, the following data were abstracted: study type, motor outcome(s), sensory outcome(s), composite outcome(s), patient-reported outcome (PRO) metric(s), pain outcome(s), psychological outcome(s), electrodiagnostic outcome(s), and any other outcomes that were used. RESULTS: A composite outcome was reported in 52/85 (61%) studies, with the modified Bishop score (27/85; 32%) most common. A motor outcome was reported in 44/85 (52%) studies, with dynamometry (38/85; 45%) most common. The majority of studies (55%) did not report a sensory outcome. The majority of studies (52%) did not report a PRO. A specific pain outcome was reported in the minority (23/85; 27%), with the visual analogue scale (VAS) (22/85; 26%) most common. Pre- and postoperative electrodiagnostic results were presented in 22/85 studies (26%). DISCUSSION: Understanding current clinical practice and historical outcomes reporting provides a foundation for discussion regarding the development of a core outcome set for cubital tunnel syndrome. We hope that the data provided in the current study will stoke a discussion that will culminate in a consensus statement for research reporting in cubital tunnel syndrome studies.

Assessment of variability in motor grading and patient-reported outcome reporting: a multi-specialty, multi-national survey.

BACKGROUND: The goal of this survey-based study was to evaluate the current practice patterns of clinicians who assess patients with peripheral nerve pathologies and to assess variance in motor grading on the Medical Research Council (MRC) scale using example case vignettes. METHODS: An electronic survey was distributed to clinicians who regularly assess patients with peripheral nerve pathology. Survey sections included (1) demographic data, (2) vignettes where respondents were asked to assess on the MRC scale, and (3) assessment of practice patterns regarding the use of patient-reported outcome measures. Inter-rater reliability statistics were calculated for the application of the MRC scale on example vignettes. RESULTS: There were 109 respondents. There was significant dispersion in motor grading seen on the example vignettes. For the raw responses grading the example vignettes on the MRC scale, Krippendorff's alpha was 0.788 (95% CI 0.604, 0.991); Gwet's AC2 was 0.808 (95% CI 0.683, 0.932); Fleiss' kappa was 0.416 (95% CI 0.413, 0.419). Most respondents reported not utilizing any patient-reported outcome measures across peripheral nerve pathologies. DISCUSSION: Our data show that there is significant disagreement among providers when applying the MRC scale. It is important for us to reassess our current tools for patient evaluation in order to improve upon both clinical evaluation and outcomes reporting. Consensus guidelines for outcomes reporting are needed, and domains outside of manual muscle testing should be included.

Extraforaminal Vertebral Artery Anomalies and Their Associated Surgical Implications: An Epidemiologic and Anatomic Report on 1000 Patients.

OBJECTIVE: Extraforaminal vertebral anomalies involve entry at cervical transverse foramina other than at C6 and can appear with other anatomic variations along the V2 segment. Such unexpected vessel courses can have implications on surgical planning. We sought to evaluate the incidence of anomalous V2 segment entries, as well as their associations with vessel dominance, medialization, and C7 pedicle width. METHODS: We conducted a retrospective study on 1000 consecutive computed tomography angiograms, documenting level and laterality of vessel of entry, as well as vertebral dominance patterns. Patients with rostral C4 anomalies were assessed for medialization. The pedicle widths ipsilateral to caudal C7 anomalies were compared with those of contralateral and matched controls. RESULTS: A total of 157 patients were identified with extraforaminal entries, with 25 having bilateral findings. The most common alternative entry was at C5 (70.3%), followed by C4 (17.6%) and C7 (11.5%). Among patients with unilateral anomalies, there was an increased representation of contralateral vertebral dominance, relative to ipsilateral dominance (79.6% vs 20.4%, P < 0.0001). Among anomalous C4 entries, vertebral medialization was seen along the right (35%) and left sides (23.1%) spanning C6-T1. Among C7 anomalous entries there was no statistical difference in pedicle width. CONCLUSIONS: Extraforaminal anomalies may be more frequent than previously reported and are important considerations during subaxial cervical spine surgery planning. Particular attention should be paid to the contralateral dominance pattern within this subgroup. In patients with anomalous V2 segment entries, adherence to the standard, anatomic landmarks remains desirable.

Deep Brain Stimulation Results in Greater Symptomatic Improvement in Tourette Syndrome than Conservative Measures: A Meta-Analysis.

INTRODUCTION: Deep brain stimulation (DBS) has emerged as a safe and effective therapy for refractory Tourette syndrome (TS). Recent studies have identified several neural targets as effective in reducing TS symptoms with DBS, but, to our knowledge, none has compared the effectiveness of DBS with conservative therapy. METHODS: A literature review was performed to identify studies investigating adult patient outcomes reported as Yale Global Tic Severity Scale (YGTSS) scores after DBS surgery, pharmacotherapy, and psychotherapy. Data were pooled using a random-effects model of inverse variance-weighted meta-analysis (n = 168 for DBS, n = 131 for medications, and n = 154 for behavioral therapy). RESULTS: DBS resulted in a significantly greater reduction in YGTSS total score (49.9 ± 17.5%) than pharmacotherapy (22.5 ± 15.2%, p = 0.001) or psychotherapy (20.0 ± 11.3%, p < 0.001), with a complication (adverse effect) rate of 0.15/case, 1.13/case, and 0.60/case, respectively. CONCLUSION: Our data suggest that adult patients with refractory TS undergoing DBS experience greater symptomatic improvement with surprisingly low morbidity than can be obtained with pharmacotherapy or psychotherapy.

Imaging of Damaged Nerves.

Nerve imaging is an important component in the assessment of patients presenting with suspected peripheral nerve pathology. Although magnetic resonance neurography and ultrasound are the most commonly utilized techniques, several promising new modalities are on the horizon. Nerve imaging is useful in localizing the nerve injury, determining the severity, providing prognostic information, helping establish the diagnosis, and helping guide surgical decision making. The focus of this article is imaging of damaged nerves, focusing on nerve injuries and entrapment neuropathies.

Analysis of Outcomes and Cost of Inpatient and Ambulatory Anterior Cervical Disk Replacement Using a State-level Database.

BACKGROUND: Outpatient cervical artificial disk replacement (ADR) is a promising candidate for cost reduction. Several studies have demonstrated low overall complications and minimal readmission in anterior cervical procedures. OBJECTIVE: The objective of this study was to compare clinical outcomes and cost associated between inpatient and ambulatory setting ADR. MATERIALS AND METHODS: Outcomes and cost were retrospectively analyzed for patients undergoing elective ADR in California, Florida, and New York from 2009 to 2011 in State Inpatient and Ambulatory Databases. RESULTS: A total of 1789 index ADR procedures were identified in the inpatient database (State Inpatient Databases) compared with 370 procedures in the ambulatory cohort (State Ambulatory Surgery and Services Databases). Ambulatory patients presented to the emergency department 19 times (5.14%) within 30 days of the index procedure compared with 4.2% of inpatients. Four unique patients underwent readmission within 30 days in the ambulatory ADR cohort (1% total) compared with 2.2% in the inpatient ADR group. No ambulatory ADR patients underwent a reoperation within 30 days. Of the inpatient ADR group, 6 unique patients underwent reoperation within 30 days (0.34%, Charlson Comorbidity Index zero=0.28%, Charlson Comorbidity Index>0=0.6%). There was no significant difference in emergency department visit rate, inpatient readmission rate, or reoperation rates within 30 days of the index procedure between outpatient or inpatient ADR. Outpatient ADR is noninferior to inpatient ADR in all clinical outcomes. The direct cost was significantly lower in the outpatient ADR group ($11,059 vs. 17,033; P<0.001). The 90-day cumulative charges were significantly lower in the outpatient ADR group (mean $46,404.03 vs. $80,055; P<0.0001). CONCLUSIONS: ADR can be performed in an ambulatory setting with comparable morbidity, readmission rates, and lower costs, to inpatient ADR.

Outpatient vs Inpatient Anterior Cervical Discectomy and Fusion: A Population-Level Analysis of Outcomes and Cost.

BACKGROUND: Outpatient anterior cervical discectomy and fusion (ACDF) is a promising candidate for US healthcare cost reduction as several studies have demonstrated that overall complications are relatively low and early discharge can preserve high patient satisfaction, low morbidity, and minimal readmission. OBJECTIVE: To compare clinical outcomes and associated costs between inpatient and ambulatory setting ACDF. METHODS: Demographics, comorbidities, emergency department (ED) visits, readmissions, reoperation rates, and 90-d charges were retrospectively analyzed for patients undergoing elective ACDF in California, Florida, and New York from 2009 to 2011 in State Inpatient and Ambulatory Databases. RESULTS: A total of 3135 ambulatory and 46 996 inpatient ACDFs were performed. Mean Charlson comorbidity index, length of stay, and mortality were 0.2, 0.4 d, and 0% in the ambulatory cohort and 0.4, 1.8 d, and 0.04% for inpatients (P < .0001). Ambulatory patients were younger (48.0 vs 53.1) and more likely to be Caucasian. One hundred sixty-eight ambulatory patients (5.4%) presented to the ED within 30 d (mean 11.3 d), 51 (1.6%) were readmitted, and 5 (0.2%) underwent reoperation. Among inpatient surgeries, 2607 patients (5.5%) presented to the ED within 30 d (mean 9.7 d), 1778 (3.8%) were readmitted (mean 6.3 d), and 200 (0.4%) underwent reoperation. Higher Charlson comorbidity index increased rate of ED visits (ambulatory operating room [OR] 1.285, P < .05; inpatient OR 1.289, P < .0001) and readmission (ambulatory OR 1.746, P < .0001; inpatient OR 1.685, P < .0001). Overall charges were significantly lower for ambulatory ACDFs ($33 362.51 vs $74 667.04; P < .0001). CONCLUSION: ACDF can be performed in an ambulatory setting with comparable morbidity and readmission rates, and lower costs, to those performed in an inpatient setting.