Genetic Biomarkers in Astrocytoma: Diagnostic, Prognostic, and Therapeutic Potential.

Astrocytoma are the most common adult brain tumor, with Glioblastoma being the deadliest neuro-related malignancy. Despite advances in oncology, the prognosis for Astrocytoma, especially Glioblastoma, remains poor, and tracking disease progression is challenging due to a lack of robust biomarkers. Genetic biomarkers, including microRNAs, cell-free DNA, circulating tumor DNA, circular RNA, and long non-coding RNA (lncRNA), can serve as potential diagnostic and therapeutic targets. In this review, we examine the existing literature, analyzing the various less established liquid and tumor genetic biomarkers and their potential to act as diagnostic, prognostic, and therapeutic targets. We highlight the clinical challenges and limitations in implementing liquid biopsy strategies in clinical practice. The article discusses the potential of liquid biopsies as valuable tools for personalized Astrocytoma management while emphasizing the need for standardized protocols and further advancements to establish their clinical utility and therapeutic application.

Early Celecoxib Use in Spontaneous Intracerebral Hemorrhage is Associated with Reduced Mortality.

BACKGROUND: Hemorrhagic strokes constitute 10-15% of all strokes and have the worst mortality and morbidity of all subtypes. Mortality and morbidity of spontaneous intracerebral hemorrhage (sICH) are often secondary to the effects of inflammation, brain edema, and swelling. Studies have shown that celecoxib, a selective cyclooxygenase 2 (COX-2) inhibitor, reduces perihematomal edema formation and inflammation. This study aimed to examine the impact of celecoxib on sICH outcomes. METHODS: TriNetX, a multi-institutional research database, was retrospectively queried to identify patients with sICH. Outcomes in patients who received celecoxib within 5 days (cohort 1) were analyzed and compared to those in patients who did not receive celecoxib (cohort 2). The primary end point was mortality within 1 year of sICH. Secondary end points included ventilator dependence, tracheostomy, percutaneous endoscopic gastrostomy tube placement, craniotomy, deep venous thrombosis, pulmonary embolism, ischemic stroke, transient ischemia attack, myocardial infarction, and seizures. Further analysis was performed to assess these outcomes for patients treated with ibuprofen, a nonselective COX inhibitor. RESULTS: After propensity score matching, 833 patients were identified in each cohort based on celecoxib use. Mortality at 1 year was significantly reduced in patients with sICH receiving celecoxib compared to those who did not (13.33% vs. 17.77%; p = 0.0124). Risks of ventilator dependence, tracheostomy, percutaneous endoscopic gastrostomy tube placement, craniotomy, deep venous thrombosis, pulmonary embolism, ischemic stroke, transient ischemia attack, myocardial infarction, and seizures were not significantly increased in patients who received celecoxib within 5 days of sICH compared to those who did not receive celecoxib. There was no significant difference in mortality between patients based on ibuprofen administration. CONCLUSIONS: There exists a growing interest in using COX-2 as a potential target strategy for neuroprotection in patients with sICH, with some evidence of a mortality benefit in small cohort studies. This study shows that early celecoxib use is associated with decreased mortality in patients with sICH.

Effects of Preoperative Glucocorticoid Use on Patients Undergoing Single-Level Lumbar Fusions: A Retrospective Propensity Score-Matched Registry Study.

Objective Spinal fusions are gaining popularity as a means of treating spinal deformity and instability from a range of pathologies. The prevalence of glucocorticoid use has also increased in recent decades, and their systemic effects are well-documented. Although commonly used in the preoperative period, the effects of steroids on outcomes among patients undergoing spinal fusions are inadequately described. This study compares the odds of developing complications among patients who underwent single-level lumbar fusions with and without preoperative glucocorticoid use in hopes of establishing more evidence-based parameters for guiding preoperative steroid use. Methods The TriNetX multi-institutional electronic health record database was used to perform a retrospective, propensity score-matched analysis of clinical outcomes of two cohorts of patients who underwent posterior or posterolateral single-level lumbar fusions with and without interbody fusion, those who used glucocorticoids for at least one week within a year of fusion and those who did not. The outcomes of interest were examined within 30 days of the operation and included death, reoperation, deep or superficial surgical site infection (SSI), pneumonia, reintubation, ventilator dependence, tracheostomy, acute kidney injury (AKI), renal insufficiency, pulmonary embolism (PE) or deep venous thrombosis (DVT), urinary tract infection (UTI), emergency department (ED) visit, sepsis, and myocardial infarction (MI). Results The odds of developing pneumonia within 30 days of spinal fusion in the cohort that used glucocorticoids within one year of operation compared to the cohort without glucocorticoid use was 0.67 (p≤0.001, 95% CI: 0.59-0.69). The odds of requiring a tracheostomy within 30 days of spinal fusion in the cohort that used glucocorticoids within one year of operation compared to the cohort without glucocorticoid use was 0.39 (p≤0.001, 95% CI: 0.26-0.60). The odds of reoperation, deep and superficial SSI, and ED visits within 30 days of operation were significantly higher for the same glucocorticoid-receiving cohort, with odds ratios of 1.4 (p=0.003, 95% CI: 1.11-1.65), 1.86 (p≤0.001, 95% CI: 1.31-2.63), 2.28 (p≤0.001, 95% CI: 1.57-3.31), and 1.25 (p≤0.001, 95% CI: 1.17-1.33), respectively. After propensity score-matching, there was no significant difference between the odds of death, DVT, PE, MI, UTI, AKI, sepsis, reintubation, and ventilator dependence between the two cohorts. Conclusion In support of much of the current literature regarding preoperative glucocorticoid use and rates of complications, patients who underwent a single-level lumbar fusion and have used glucocorticoids for at least a week within a year of operation experienced significantly higher odds of reoperation, deep and superficial SSI, and ED visits. However, these patients using glucocorticoids were also found to have lower odds of developing pneumonia, renal insufficiency, and tracheostomy requirement than those who did not use steroids within a year of surgery.

Incidence of tethered cord syndrome in neurofibromatosis types 1 and 2 pediatric patients: a population-level analysis.

PURPOSE: Tethered spinal cord syndrome (TCS) is characterized by cutaneous attachments on the filum terminale that stretch the spinal cord, leading to musculoskeletal and urogenital sequelae. While the neurocutaneous associations with TCS remain undefined, a recent study reports a high incidence of TCS among a pediatric neurofibromatosis (NF) cohort. This present study utilizes a population-level database to estimate TCS incidence among pediatric patients with neurofibromatosis types 1 and 2 (NF1, NF2). METHODS: The TriNetX Research Network was queried to identify patients diagnosed with NF and/or TCS before the age of 21. Symptomatic TCS requiring surgical intervention was identified using corresponding procedural codes within 12 months following TCS diagnosis. Odds ratios (OR) were calculated to measure the associations of NF1/NF2 with TCS. RESULTS: 19,426 pediatric NF patients were evaluated (NF1: 18,383, NF2: 1042). The average ages of TCS diagnosis among NF1, NF2, and non-NF patients were 12, 16, and 9 years, respectively. The incidence of TCS was 1.2% in NF1 patients and 7.3% in NF2 patients, compared to 0.074% in the general population. The associations of NF incidence with TCS were significantly increased in both NF1 (OR 16.42; 14.38-18.76) and NF2 (OR 105.58; 83.56-133.40) patients compared to the general population. Symptomatic TCS requiring surgical intervention was not significantly associated with NF1/NF2 patients compared to the general TCS population. CONCLUSION: This analysis demonstrates a high incidence of TCS but delayed intervention in pediatric NF patients. Considering TCS counseling, spinal MRI, and earlier intervention may be warranted for NF patients experiencing musculoskeletal symptomatology.

Numerical Study on the Impact of Central Venous Catheter Placement on Blood Flow in the Cavo-Atrial Junction.

An in silico study is performed to investigate fluid dynamic effects of central venous catheter (CVC) placement within patient-specific cavo-atrial junctions. Prior studies show the CVC infusing a liquid, but this study focuses on the placement without any liquid emerging from the CVC. A 7 or 15-French double-lumen CVC is placed virtually in two patient-specific models; the CVC tip location is altered to understand its effect on the venous flow field. Results show that the CVC impact is trivial on flow in the superior vena cava when the catheter-to-vein ratio ranges from 0.15 to 0.33. Results further demonstrate that when the CVC tip is directly in the right atrium, flow vortices in the right atrium result in elevated wall shear stress near the tip hole. A recirculation region characterizes a spatially variable flow field inside the CVC side hole. Furthermore, flow stagnation is present near the internal side hole corners but an elevated wall shear stress near the curvature of the side hole's exit. These results suggest that optimal CVC tip location is within the superior vena cava, so as to lower the potential for platelet activation due to elevated shear stresses and that CVC geometry and location depth in the central vein significantly influences the local CVC fluid dynamics. A thrombosis model also shows thrombus formation at the side hole and tip hole. After modifying the catheter design, the hemodynamics change, which alter thrombus formation. Future studies are warranted to study CVC design and placement location in an effort to minimize CVC-induced thrombosis incidence.

Pediatric Traumatic Injuries Due to Agrarian Hay-Hole Falls.

Hay-holes are a design feature in many traditionally built barns that serve as a portal through which stored hay is passed to the lower level where animals are fed. Unfortunately, children sometimes fall through the hay-hole to the concrete or packed earth below. Available data on the frequency and types of hay-hole injuries is limited. The purpose of this study was to better characterize the resultant injuries and identify prognostic factors that predict outcomes from them. We performed a retrospective review of 53 children admitted to the Penn State Hershey Children's Hospital at the Penn State Hershey Medical Center with injuries due to a fall through a hay-hole over 15 years. Compared to urban trauma, hay-hole falls more frequently involve younger children and craniofacial injuries. Although they may result in significant injuries, they are rarely fatal. Greater fall height is associated with longer length of stay (LOS) but not with a greater frequency of intubation, intracranial hemorrhage, or skull fracture. A re-examination of barn design may help to reduce the frequency of this injury type.

Core outcomes in nerve surgery: development of a core outcome set for brachial plexus and upper extremity nerve injuries.

OBJECTIVE: When considering traumatic brachial plexus and upper extremity nerve injuries, iatrogenic nerve injuries, and nontraumatic nerve injuries, brachial plexus and upper extremity nerve injuries are commonly encountered in clinical practice. Despite this, data synthesis and comparison of available studies are difficult. This is at least in part due to the lack of standardization in reporting and a lack of a core outcome set (COS). Thus, there is a need for a COS for adult brachial plexus and upper extremity nerve injuries (COS-BPUE). The objective of this study was to develop a COS-BPUE using a modified Delphi approach. METHODS: A 5-stage approach was used to develop the COS-BPUE: 1) consortium development, 2) literature review to identify potential outcome measures, 3) Delphi survey to develop consensus on outcomes for inclusion, 4) Delphi survey to develop definitions, and 5) consensus meeting to finalize the COS and definitions. The study followed the Core Outcome Set-STAndards for Development (COS-STAD) recommendations. RESULTS: The Core Outcomes in Nerve Surgery (COINS) Consortium comprised 23 participants, all neurological surgeons, representing 13 countries. The final COS-BPUE consisted of 36 data points/outcomes covering demographic, diagnostic, patient-reported outcome, motor/sensory outcome, and complication domains. Appropriate instruments, methods of testing, and definitions were set. The consensus minimum duration of follow-up was 24 months, with the consensus optimal time points for assessment being preoperatively and 3, 6, 12, and 24 months postoperatively. CONCLUSIONS: The COINS Consortium developed a consensus COS and provided definitions, methods of implementation, and time points for assessment. The COS-BPUE should serve as a minimum set of data that should be collected in all future neurosurgical studies on adult brachial plexus and upper extremity nerve injuries. Incorporation of this COS should help improve consistency in reporting, data synthesis, and comparability, and should minimize outcome reporting bias.

Congenital Pediatric Hydrocephalus in the Brazilian Public Health System: The Reality of a Middle-Income Country in the Past 13 Years.

BACKGROUND: Congenital hydrocephalus is a significant challenge in neurosurgery, particularly in resource-limited settings. This study focuses on the congenital hydrocephalus in Brazil, a developing country, over the past 13 years. METHODS: This study is a retrospective analysis of congenital hydrocephalus treatment and outcomes using data records on DATASUS from January 2008 to July 2021. Demographics, cost of hospitalizations, amount paid to professionals, mortality, and mean length of stay (LOS) were analyzed. Statistical analysis was conducted to determine significant associations between these indicators and pediatric hydrocephalus. RESULTS: DATASUS recorded 8493 cases of congenital hydrocephalus in the studied period, with a prevalence of 24.28 per 100,000 newborns, mostly linked to spina bifida. Congenital hydrocephalus caused 60.83 ± 13.98 neonatal deaths per year, with the highest rate among 32-36 weeks gestational age. Acquired hydrocephalus led to 1063 infant deaths, whereas congenital hydrocephalus resulted in 3122 deaths, with no clear trend by the years. White infants had the highest mortality. A total of 33,184 shunt procedures were performed, with an average cost of $715.37 per procedure. The mortality model showed no significant effects of cost or professionals' salary, but a significant effect of LOS on hospitalization costs was observed. CONCLUSIONS: Pediatric hydrocephalus in Brazil's public health system is a significant burden. Congenital hydrocephalus prevalence and mortality emphasize the need for early diagnosis and treatment. Early diagnosis, prenatal care, and adequate resources are crucial. This study offers insights into congenital hydrocephalus, highlighting challenges and future directions for improved care.

Core outcomes in nerve surgery: development of a core outcome set for ulnar neuropathy at the elbow.

OBJECTIVE: Ulnar neuropathy at the elbow (UNE) is common, affecting 1%-6% of the population. Despite this, there remains a lack of consensus regarding optimal treatment. This is primarily due to the difficulty one encounters when trying to assess the literature. Outcomes are inconsistently reported, which makes comparing studies or developing meta-analyses difficult or even impossible. Thus, there is a need for a core outcome set (COS) for UNE (COS-UNE) to help address this problem. The objective of this study was to utilize a modified Delphi method to develop COS-UNE. METHODS: A 5-stage approach was utilized to develop COS-UNE: stage 1, consortium development; 2, literature review to identify potential outcome measures; 3, Delphi survey to develop consensus on outcomes for inclusion; 4, Delphi survey to develop definitions; and 5, consensus meeting to finalize the COS and definitions. The study followed the Core Outcome Set-STAndards for Development (COS-STAD) recommendations. RESULTS: The Core Outcomes in Nerve Surgery (COINS) Consortium comprised 21 participants, all neurological surgeons representing 11 countries. The final COS-UNE consisted of 22 data points/outcomes covering the domains of demographic characteristics, diagnostics, patient-reported outcomes, motor/sensory outcomes, and complications. Appropriate instruments, methods of testing, and definitions were set. The consensus minimum duration of follow-up was 6 months, with the consensus optimal timepoints for assessment identified as preoperatively and 3, 6, and 12 months postoperatively. CONCLUSIONS: The authors identified consensus data points/outcomes and also provided definitions and specific scales to be utilized to help ensure that clinicians are consistent in their reporting across studies on UNE. This COS should serve as a minimum set of data to be collected in all future neurosurgical studies on UNE. The authors hope that clinicians evaluating ulnar neuropathy will incorporate this COS into routine practice and that future studies will consider this COS in the design phase.

Simultaneous versus staged bilateral carpal tunnel release via open and endoscopic surgeries: a retrospective propensity score-matched patient comorbidity analysis.

OBJECTIVE: Carpal tunnel syndrome (CTS) presents bilaterally in nearly 60%-70% of affected patients. Bilateral carpal tunnel release (CTR) can be performed in a staged or simultaneous fashion. There remains a limited understanding of the optimal preoperative factors to use for patient selection when determining simultaneous versus staged bilateral CTR. Moreover, it is unclear how these factors influence postoperative outcomes. In this study, the authors aimed to identify and compare preoperative comorbidities and postoperative outcomes in patients who had undergone simultaneous versus staged open and endoscopic bilateral CTR. METHODS: The authors performed a retrospective analysis of data collected from the TriNetX database. Patients with bilateral CTS who had been treated from February 1, 2002, to February 1, 2022, were dichotomized by their bilateral release approach: simultaneous or staged within 3 months. The resulting groups were analyzed separately by open versus endoscopic techniques. Next, cohorts were analyzed for preoperative comorbidities to identify possible factors for surgical determination. Then, they were propensity score matched on demographics and comorbidities. Postoperative outcomes within 6 months of surgery were measured with and without matching. RESULTS: After matching, 9286 and 3709 patients remained in the open and endoscopic groups, respectively. Those who had undergone staged surgeries via an open or endoscopic approach had more preoperative comorbidities. After matching, staged open release was associated with significantly higher rates of postprocedural care, hand/joint pain, limb pain, trigger finger, and upper respiratory tract infections. Simultaneous open release was associated with higher rates of emergency room visits. Staged endoscopic release was associated with significantly higher rates of postprocedural care, limb pain, and trigger finger. No significant outcomes were favored in the simultaneous endoscopic group. CONCLUSIONS: Before matching, patients who had undergone staged CTR had significantly higher rates of preoperative medical comorbidities compared with patients in the simultaneous CTR group. Moreover, staged CTR was significantly associated with higher rates of postoperative complications. After matching on demographics and comorbidities, staged CTR was still associated with higher rates of postoperative complications, suggesting that preoperative comorbidities do not influence postoperative outcome. Further prospective studies could be used to validate these results and provide new findings for the management and treatment of these groups.

Epidural Steroid Injection Prior to Spinal Surgery: A Step-Wise and Wise Approach.

BACKGROUND: An epidural steroid injection (ESI) is used to treat a number of morbid central nervous system pathologies and is considered a reasonably safe procedure. This study aimed to determine the relative infection risk after spinal surgery by comparing outcomes in spinal surgery patients who received an ESI shortly prior to the surgery against those who did not receive an ESI shortly prior to the surgery. METHODS: The present study is a retrospective cohort study using a multi-institutional healthcare database, TriNetX, to collect data on patients who received spinal surgery with and without having had ESIs six months before surgery. Two cohorts were generated: Cohort 1 included patients who had received an ESI in the six months prior to spinal surgery, and cohort 2 included patients who did not have an ESI in the six months prior to spinal surgery. The patients in cohort 2 had propensity scores matched 1:1 to those in cohort 1 using common baseline demographics, comorbidities and spinal procedure indications. The spinal procedures and surgeries considered for the analysis included open procedures for any purpose, including exploration, decompression, resection, revision or biopsy. Multiple outcomes were compared across these two cohorts in the three months following the spinal procedure/surgery, including the occurrence of death, surgical site infection, epidural and/or spinal abscess, and dural tear. RESULTS: An ESI in the six months prior to spinal surgery was associated with a significant decrease in the likelihood epidural/spinal abscess in the three months after surgery. There was no change in mortality, wound infection or identification of dural tear in the three months after spinal surgery for those who received an ESI six months before spinal surgery. CONCLUSION: This data suggests that epidural steroid injections' anti-inflammatory effects provide benefits before surgery beyond symptomatic relief. Given that the degeneration of spinal pathologies is typically advanced rather than corrected by the body's inflammatory response, it is likely that preventing hyperactivation of the body's immune system in the months preceding surgical intervention, a traumatic insult, is protective compared to no intervention and, importantly, without major adverse effects.

Early Celecoxib use in Patients with Traumatic Brain Injury.

BACKGROUND: Traumatic brain injury (TBI) can cause rapid brain inflammation. There is debate over the safety and efficacy of anti-inflammatory agents in its treatment. With a particular focus on cyclooxygenase 2 (COX2) selective inhibition, we sought to determine the impact of celecoxib versus no celecoxib treatment on outcomes in patients with TBI and compare these with outcomes associated with nonselective COX inhibition (ibuprofen) and corticosteroid (dexamethasone) treatment. METHODS: This retrospective cohort study used TriNetX, a large publicly available global health research network, to gather clinical data extracted from the electronic medical records. Using International Classification of Diseases, Tenth Revision and pharmacy codes, we identified patients with TBI who were and were not treated with celecoxib, ibuprofen, and dexamethasone. Analysis was performed on propensity-matched and unmatched cohorts, which were matched on demographics, comorbidities, and neurological injuries. Our primary end point was 1-year survival. Secondary end points were ventilator and tracheostomy dependence, gastrostomy tube placement, seizures, and craniotomy. RESULTS: After propensity score matching, a total of 1443 patients were identified in both the celecoxib and no celecoxib cohorts. Ninety-two (6.4%) patients in the celecoxib cohort died within 1 year following TBI versus 145 (10.0%) in the no celecoxib cohort (odds ratio 0.61; 95% confidence interval 0.46-0.80; p = 0.0003). The 1-year survival rate was 96.1% in the celecoxib cohort versus 93.1% in the no celecoxib cohort (p < 0.0001). At the end of the 1-year period, celecoxib was associated with significantly lower gastrostomy tube dependence (p = 0.017), seizure activity (p = 0.027), and myocardial infarction (p = 0.021) compared with the control cohort. Ibuprofen was also associated with higher 1-year survival probability and lower rates of post-TBI complications. Dexamethasone was broadly associated with higher morbidity but was associated with higher 1-year survival probability compared with the no dexamethasone cohort. CONCLUSIONS: Early celecoxib and ibuprofen use within 5 days post TBI was associated with higher 1-year survival probabilities and fewer complications. With emerging yet controversial preclinical evidence to suggest that COX inhibition improves TBI outcomes, this population-level study offers suggestive support for these drugs' clinical benefit, which should be pursued in prospective clinical studies.

Lumbar Puncture in Thrombocytopenia: The Floor Is Not Firm.

Objective Lumbar puncture (LP) is a diagnostic procedure that accesses the spinal subarachnoid space to measure the opening pressure of the cerebrospinal fluid (CSF) and obtain samples of CSF for analysis. Although commonly performed, LPs are associated with the risk of morbidity and mortality. In addition, thrombocytopenia is thought to increase the risk of LP complications, particularly spinal bleeds. This study compares rates of complications among patients who received LPs with and without thrombocytopenia in hopes of establishing more evidence-based platelet thresholds for an LP. Methods The TriNetX multi-institutional electronic health record database was used to perform a retrospective propensity score-matched analysis of clinical outcomes of two cohorts of patients who underwent LPs - those with thrombocytopenia (defined as a platelet level of 10,000-50,000 platelets {plts}/µL) and those without thrombocytopenia. The outcomes of interest were the new occurrence of subdural hematoma, epidural hematoma, subarachnoid hemorrhage, receipt of a blood patch, new onset of paralysis, and requirement of spinal decompression. Results The risk of developing a spinal bleed following an LP was 1.496% (42 of 2,808) for the cohort with thrombocytopenia versus 1.09% (31 of 2,843) for the cohort without thrombocytopenia. The risk difference, risk ratio, and odds ratio of patients from these two cohorts experiencing a spinal bleed following an LP were insignificant at 0.05. The risk of receiving a blood patch following an LP was 7.844% for those with thrombocytopenia compared to 1.421% for those without thrombocytopenia. The odds ratio of receiving a blood patch between the two cohorts was 5.906, significant to the 0.05 level (95% CI: 4.213-8.279). There was no significant difference in the cohorts' risk of developing paralysis or requiring spinal decompression following an LP. Conclusion In support of recent findings against conventional platelet count thresholds prior to LP, it was observed in the present study that the incidence of post-LP spinal bleeding in the 30 days after LP is not associated with platelet counts below the guideline threshold of 50,000 plts/µL. Patients with thrombocytopenia are also not significantly more likely to require spinal decompression or develop new onset paralysis. However, thrombocytopenia is associated with a significantly increased likelihood of receiving a blood patch following an LP.

Awake craniotomies in the pediatric population: a systematic review.

OBJECTIVE: Awake craniotomy (AC) is employed to maximize tumor resection while preserving neurological function in eloquent brain tissue. This technique is used frequently in adults but remains poorly established in children. Its use has been limited due to concern for children's neuropsychological differences compared with adults and how these differences may interfere with the safety and feasibility of the procedure. Among studies that have reported pediatric ACs, complication rates and anesthetic management vary. This systematic review was performed to comprehensively analyze outcomes and synthesize anesthetic protocols of pediatric ACs. METHODS: The authors followed PRISMA guidelines to extract studies that reported AC in children with intracranial pathologies. The Medline/PubMed, Ovid, and Embase databases were searched from database inception to 2021, using the terms ("awake") AND ("Pediatric*" OR "child*") AND (("brain" AND "surgery") OR "craniotomy"). Data extracted included patient age, pathology, and anesthetic protocol. Primary outcomes assessed were premature conversion to general anesthesia, intraoperative seizures, completion of monitoring tasks, and postoperative complications. RESULTS: Thirty eligible studies published from 1997 to 2020 were included that described a total of 130 children ranging in age from 7 to 17 years who had undergone AC. Of all patients reported, 59% were male and 70% had left-sided lesions. Procedure indications included the following etiologies: tumors (77.6%), epilepsy (20%), and vascular disorders (2.4%). Four (4.1%) of 98 patients required conversion to general anesthesia due to complications or discomfort during AC. In addition, 8 (7.8%) of 103 patients experienced intraoperative seizures. Furthermore, 19 (20.6%) of 92 patients had difficulty completing monitoring tasks. Postoperative complications occurred in 19 (19.4%) of 98 patients and included aphasia (n = 4), hemiparesis (n = 2), sensory deficit (n = 3), motor deficit (n = 4), or others (n = 6). The most commonly reported anesthetic techniques were asleep-awake-asleep protocols using propofol, remifentanil or fentanyl, a local scalp nerve block, and with or without dexmedetomidine. CONCLUSIONS: The findings of this systematic review suggest the tolerability and safety of ACs in the pediatric population. Although pediatric intracranial pathologies pose etiologies that certainly may benefit from AC, there is a need for surgeons and anesthesiologists to perform individualized risk-benefit analyses due to the risks associated with awake procedures in children. Age-specific, standardized guidelines for preoperative planning, intraoperative mapping, monitoring tasks, and anesthesia protocols will help to continue minimizing complications, while improving tolerability, and streamlining workflow in the treatment of this patient population.

Intravascular fasciitis of the scalp as a complication of ICP monitor placement: a case report and review of the literature.

BACKGROUND/IMPORTANCE: There are only 56 documented cases of intravascular fasciitis, a rare variant of nodular fasciitis. Of these cases, only 2 involved the scalp. This lesion is amenable to surgical resection, making it important to differentiate it from soft tissue malignancies of the scalp. CLINICAL PRESENTATION: We report an unusual case of intravascular fasciitis involving the scalp at the site of an intracranial pressure (ICP) monitor of a 13-year-old male patient. The lesion was surgically excised with no recurrence upon 1-month follow-up. CONCLUSION: Intravascular fasciitis is a benign, reactive proliferation of soft tissue that may arise at sites of prior trauma. It appears as a soft, painless, mobile lesion, and immunohistochemical studies are required to differentiate it from malignant lesions. The standard of care is surgical resection of the lesion.

First-time tethered cord release among adults with myelomeningocele: an analysis of people in the National Spina Bifida Patient Registry.

OBJECTIVE: The authors analyzed the National Spina Bifida Patient Registry (NSBPR), a national registry that tracks the outcomes for people with various forms of spinal dysraphism, to determine the ongoing longitudinal risk for tethered cord release (TCR) among adults with myelomeningocele who had not previously undergone TCR during childhood. The authors also sought to identify the impact of lesion level, ambulation status, and prior treatments for hydrocephalus or Chiari malformations on TCR rates. METHODS: Adults in the registry who had not previously undergone TCR during childhood were studied. This group was compared with the remaining adults in the registry. The frequency of first-time TCR and time to TCR (using Kaplan-Meier analysis) were determined independently for males and females. Cox proportional hazards analysis identified correlations between sex, best lesion level and ambulation status prior to TCR, and previous treatments for hydrocephalus and Chiari decompression. RESULTS: Among 967 adults in the NSBPR (422 [43.6%] males and 545 [56.4%] females) who had not undergone TCR during childhood, the authors identified 47 people (4.9%) who underwent their first TCR during adulthood. This study cohort had significantly better mean functional motor levels and ambulation compared with the remaining adult cohort (both p < 0.001). The study group included 35 females (74.5%) and 12 males (25.5%); this sex distribution was significantly different in comparison with the remaining adult cohort (p = 0.016). The Kaplan-Meier curves for first TCR for females and males were significantly different (p = 0.01, log-rank test). TCR rates were correlated with sex (males had decreased risk; OR 0.31, 95% CI 0.16-0.62, p < 0.001), prior treatment for hydrocephalus (those who underwent prior treatment had decreased risk; OR 0.21, 95% CI 0.20-0.42, p < 0.001), and prior treatment for Chiari malformation (those who underwent prior treatment had greater risk; OR 3.84, 95% CI 1.50-9.88, p = 0.005). CONCLUSIONS: Adults with myelomeningocele who escape childhood without undergoing TCR have an ongoing, albeit decreased, risk for spinal cord tethering requiring TCR. This risk is obviously not due to spinal column growth and therefore must reflect other factors such as dynamic changes in spinal cord health over time. Among people with MMC who underwent their first TCR as adults, females seemed to be overrepresented. Similar to the authors' prior childhood study, people who underwent previous Chiari decompression seemed to be overrepresented, whereas those who underwent previous treatment for hydrocephalus seem to be underrepresented. These novel findings deserve further study.

Minimally Invasive Image-Guided Transgluteal Approach for Resection of a Sciatic Nerve Tumor: A Technical Note.

There are a variety of surgical approaches to lesions around the sciatic notch. Historically, peripheral nerve surgeons prefer an infragluteal approach involving a large incision with reflection of the gluteus maximus to better visualize the operative field. This approach was imperative when lesion localization was imprecise. Comparatively, orthopedic surgeons prefer a muscle-splitting, transgluteal approach to operate on the static structures of the posterior hip. The transgluteal approach is significantly less morbid, allowing for same-day discharge and less extensive rehab given preservation of the gluteal muscle. In this article we describe the use of dynamic ultrasound imaging to localize and aid in the resection of three unique tumors around the sciatic notch using a minimally invasive, tissue-sparing, transgluteal technique. We offer a comprehensive description of the benefits, anatomic considerations, and nuances of using a transgluteal approach for the resection of lesions at the sciatic notch.

Mental health and substance use disorders in young adults with spina bifida.

OBJECTIVE: Although medical advances have allowed most patients with spina bifida (SB) to survive into adulthood, these patients may have physical impairments, urological complications, infections, and neurocognitive deficits. These factors can cause psychological distress and impact the transition from pediatric to adult care. There remains limited research on mental health disorders (MHDs) and substance use disorders (SUDs) in SB patients during this vulnerable transition period. This study aimed to investigate the 10-year incidence of MHDs and SUDs in 18- to 25-year-old patients with SB. METHODS: TriNetX, a federated de-identified database, was retrospectively queried to identify 18- to 25-year-old patients with SB. The presence of MHDs and SUDs based on ICD-10 codes in SB patients (cohort 1) was analyzed and compared with those of patients without SB (cohort 2). Subgroup analysis was performed on SB patients with hydrocephalus and neurogenic bladder (NB). SB patients were further compared to patients with a spinal cord injury (SCI). RESULTS: After propensity score matching, the authors identified 1494 patients in each cohort. SB patients were more likely to have depression (OR 1.949, 95% CI 1.64-2.317), anxiety (OR 1.603, 95% CI 1.359-1.891), somatoform disorders (OR 2.102, 95% CI 1.052-4.199), and suicidal ideations or attempts and self-harm (OR 1.424, 95% CI 1.014-1.999). The prevalence of attention-deficit/hyperactivity disorder (ADHD) and eating disorders were comparable between cohorts. SB patients also had increased rates of nicotine dependence (OR 1.546, 95% CI 1.22-1.959) but not of alcohol or opioid disorders. In SB patients, the presence of hydrocephalus and NB was not associated with significantly increased rates of any measured MHDs or SUDs. When compared with SCI patients, SB patients were more likely to have anxiety (OR 1.377, 95% CI 1.028-1.845) and ADHD (OR 1.875, 95% CI 1.084-3.242). However, SB patients had lower rates of nicotine dependence (OR 0.682, 95% CI 0.482-0.963) and opioid-related disorders (OR 0.434, 95% CI 0.223-0.845). SB and SCI patients shared similar rates of depression, suicidal ideations or attempts and self-harm, and alcohol-related disorders. CONCLUSIONS: Young adults with SB have higher prevalence rates of MHDs and SUDs compared with the general population. Therefore, incorporation of mental health and substance use management is critical to facilitate transition to adulthood.

Transgenerational epigenetic inheritance of axonal regeneration after spinal cord injury.

Human epidemiological studies reveal that dietary and environmental alterations influence the health of the offspring and that the effect is not limited to the F1 or F2 generations. Non-Mendelian transgenerational inheritance of traits in response to environmental stimuli has been confirmed in non-mammalian organisms including plants and worms and are shown to be epigenetically mediated. However, transgenerational inheritance beyond the F2 generation remains controversial in mammals. Our lab previously discovered that the treatment of rodents (rats and mice) with folic acid significantly enhances the regeneration of injured axons following spinal cord injury in vivo and in vitro, and the effect is mediated by DNA methylation. The potential heritability of DNA methylation prompted us to investigate the following question: Is the enhanced axonal regeneration phenotype inherited transgenerationally without exposure to folic acid supplementation in the intervening generations? In the present review, we condense our findings showing that a beneficial trait (i.e., enhanced axonal regeneration after spinal cord injury) and accompanying molecular alterations (i.e., DNA methylation), triggered by an environmental exposure (i.e., folic acid supplementation) to F0 animals only, are inherited transgenerationally and beyond the F3 generation.