Arachnoid webs with spinal cord compression: insights from three cases.

Spinal arachnoid webs are intradural bands of abnormally formed arachnoid tissue, located within the subarachnoid space and causing compression of the dorsal aspect of the spinal cord. Arachnoid webs are uncommon and can be difficult to treat. We report 3 patients presenting with a spinal arachnoid web within a 6-month period. All of them exhibited signs of thoracic myelopathy and the MRI showed the pathognomonic 'scalpel sign'. Two of the patients underwent surgery for removal of their spinal arachnoid web, whereas the third patient case is currently being managed conservatively. We also present our 2D intraoperative video for arachnoid web removal and spinal cord decompression.

Decompression and Interlaminar Stabilization for Lumbar Spinal Stenosis: A Cohort Study and Two-Dimensional Operative Video.

Background and Objectives: Lumbar spinal stenosis is one of the most common causes of disability in the elderly and often necessitates surgical intervention in patients over the age of 65. Our study aimed to evaluate the clinical efficacy of interlaminar stabilization following decompressive laminectomy in patients with lumbar stenosis without instability. Materials and Methods: Twenty patients with lumbar stenosis underwent decompressive laminectomy and interlaminar stabilization at our academic institution. Clinical outcomes were measured using the visual analog scale (VAS) and Oswestry disability index (ODI) at the 2-month, 6-month, and 1-year postoperative visits, and these outcomes were compared to the preoperative scores. Results: The average VAS scores for low back pain significantly improved from 8.8 preoperatively to 4.0, 3.7, and 3.9 at 2 months, 6 months, and 1 year postoperatively, respectively (p < 0.001). The average VAS scores for lower extremity pain significantly improved from 9.0 preoperatively to 2.7, 2.5, and 2.5 at 2 months, 6 months, and 1 year postoperatively, respectively (p < 0.001). The average ODI scores significantly improved from 66.6 preoperatively to 23.8, 23.3, and 24.5 at 2 months, 6 months, and 1 year postoperatively, respectively (p < 0.001). There was no statistical significance for difference in VAS or ODI scores between 2 months, 6 months, and 1 year. One patient had an intraoperative durotomy that was successfully treated with local repair and lumbar drainage. Another patient had progression of stenosis and had to undergo bilateral facetectomy and fusion. Conclusions: Decompressive laminectomy and interlaminar stabilization in patients with spinal claudication and low back pain is a good surgical option in the absence of instability and may provide significant clinical improvement of pain and functional disability.

A Retrospective Review of the Timing of Glasgow Coma Scale Documentation in a Trauma Database: Implications for Patient Care, Research, and Performance Metrics.

BACKGROUND: The Glasgow Coma Scale (GCS) is intended to be an objective, reliable measure of a patient's mental status. It is included as a metric for trauma registries, having implications for performance metrics and research. Our study compared the GCS recorded in the trauma registry (GCS-1) with that recorded in the neurosurgery consultation (GCS-2). METHODS: This retrospective review compared GCS-1 with GCS-2. The Trauma Injury Severity Score (TRISS) method was used to calculate probability of survival (POS) for patients using both GCS-1 and GCS-2. RESULTS: GCS-1 score significantly differed from GCS-2 score (6.69 vs. 7.84, ± 2.553; P < 0.001). There were 172 patients (37.55%) with a GCS-1 score of 3 and 87 (19.00%) with a GCS-2 score of 3 (χ2P < 0.001). The POS calculated using TRISS methodology with GCS-1 (POS-1) was 74.7% ± 26.6% compared with GCS-2 (POS-2), which was 79.3% ± 24.4%. There was a statistically significant difference in the means of POS-2 and POS-2 (P < 0.001). The actual observed survival for the cohort was 71.0% (325/458). CONCLUSIONS: The immediate GCS score recorded on patient arrival after trauma differs significantly from the GCS score recorded at later times. This finding significantly altered the probability of survival as calculated by the TRISS methodology. This situation could have profound effects on risk-adjusted benchmarking, assessments of quality of care, and injury severity stratification for research. More studies into the optimal timing of GCS score recording or changes in GCS score and their impact on survival are warranted.

Rupture of a superficial temporal artery pseudoaneurysm following craniotomy.

Pseudoaneurysm of the superficial temporal artery (STA) is a rare entity that has been reported in the literature after trauma or iatrogenic injuries. We describe a unique case of STA pseudoaneurysm rupture and the clinical sequelae associated with its rupture. We report a case of pseudoaneurysm rupture of the STA that occurred 14 days after craniotomy for cerebrospinal fluid leak repair. We also review the literature, diagnosis and treatment of external carotid artery aneurysms. Rupture of a STA pseudoaneurysm is a previously unreported and serious complication that must be quickly recognized in order to control hemorrhage that may have life threatening complications.

Prospective Trial of Sacroiliac Joint Fusion Using 3D-Printed Triangular Titanium Implants: 24-Month Follow-Up.

BACKGROUND: Strong evidence supports minimally invasive sacroiliac joint (SIJ) fusion using triangular titanium implants (TTI) for chronic SIJ dysfunction. OBJECTIVE: To report safety and effectiveness of SIJF using a 3D-printed TTI at 24 months. METHODS: SIJF with TTI was performed in 51 subjects. Structured follow-up occurred at 3, 6, 12 and 24 months. Both quality of life questionnaires and functional tests were performed at all study visits. RESULTS: 84% of subjects were available for 24-month follow-up. Observed were rapid and persistent improvements in dysfunction due to pain (Oswestry Disability Index [ODI], mean 52.8 at baseline and 28.3 at 24 months, p<0.0001) and SIJ pain ratings (mean 78.5 at baseline [0-100 scale] to 21.5 at 24 months). Opioid use for SIJ pain decreased markedly from baseline. Physical function tests impaired by SIJ pain showed persistent improvements compared to baseline. There was no evidence of device breakage, migration or subsidence and few late adverse events occurred attributable to the device. CONCLUSION: In this prospective study, SIJF using 3D-printed TTI resulted in immediate, marked and persistent improvements in pain and quality of life, with improved physical function, reduced opioid use and a low rate of late device-related adverse events. LEVEL OF EVIDENCE: Level II.

Management of cerebrospinal fluid leak from cervical gunshot wounds with external ventricular drainage: a small case series.

Historically, the surgical management of gunshot wounds to the spine has been controversial. Repair of a persistent cerebrospinal fluid (CSF) leak is a generally agreed upon indication. The management of such CSF leaks typically involves lumbar drainage or direct surgical repair. Here, the authors report two cases of CSF diversion with an external ventricular drain (EVD) in patients with cervical gunshot wounds. Both patients had spinal canal obliteration or physiologic myelographic block at or below the level of injury. To the best of the author's knowledge, these are the first two reports of successful EVD treatment of persistent CSF leaks related cervical gunshot wounds. The authors also propose a CSF treatment algorithm for cervical gunshot wounds that includes EVD.

Minimally invasive lateral corpectomy for thoracolumbar traumatic burst fractures.

OBJECTIVE: The need for anterior column reconstruction after thoracolumbar burst fractures remains controversial. Here, the authors present their experience with minimally invasive lateral thoracolumbar corpectomies for traumatic fractures. METHODS: Between 2012 and 2019, 59 patients with 65 thoracolumbar fractures underwent 65 minimally invasive lateral corpectomies (MIS group). This group was compared to 16 patients with single-level thoracolumbar fractures who had undergone open lateral corpectomies with the assistance of general surgery between 2007 and 2011 (open control group). Comparisons of the two groups were made with regard to operative time, estimated blood loss, time to ambulation, and fusion rates at 1 year postoperatively. The authors further analyzed the MIS group with regard to injury mechanism, fracture characteristics, neurological outcome, and complications. RESULTS: Patients in the MIS group had a significantly shorter mean operative time (228.3 ± 27.9 vs 255.6 ± 34.1 minutes, p = 0.001) and significantly shorter mean time to ambulation after surgery (1.8 ± 1.1 vs 5.0 ± 0.8 days, p < 0.001) than the open corpectomy group. Mean estimated blood loss did not differ significantly between the two groups, though the MIS group did trend toward a lower mean blood loss. There was no significant difference in fusion status at 1 year between the MIS and open groups; however, this comparison was limited by poor follow-up, with only 32 of 59 patients (54.2%) in the MIS group and 8 of 16 (50%) in the open group having available imaging at 1 year. Complications in the MIS group included 1 screw misplacement requiring revision, 2 postoperative femoral neuropathies (one of which improved), 1 return to surgery for inadequate posterior decompression, 4 pneumothoraces requiring chest tube placement, and 1 posterior wound infection. The rate of revision surgery for the failure of fusion in the MIS group was 1.7% (1 of 59 patients). CONCLUSIONS: The minimally invasive lateral thoracolumbar corpectomy approach for traumatic fractures appears to be relatively safe and may result in shorter operative times and quicker mobilization as compared to those with open techniques. This should be considered as a treatment option for thoracolumbar spine fractures.

Prospective Trial of Sacroiliac Joint Fusion Using 3D-Printed Triangular Titanium Implants.

BACKGROUND: Prior trials provide strong evidence supporting minimally invasive sacroiliac joint (SIJ) fusion using triangular titanium implants (TTI) for chronic SIJ dysfunction. OBJECTIVE: To assess the safety and effectiveness of SIJF using a 3D-printed TTI. METHODS: Fifty-one subjects with carefully diagnosed SIJ dysfunction underwent SIJF with 3D TTI. Subjects completed pain, disability and quality of life questionnaires at baseline and 3, 6 and 12 months postoperatively. Functional tests were performed in the clinic at each visit. Pelvic CT scans were independently evaluated for radiolucency, bridging bone and other endpoints. RESULTS: Ninety percent had 12-month follow-up. Dysfunction due to pain (Oswestry Disability Index [ODI]) decreased from 52.8 at baseline to 27.9 at 12 months (p<.0001 for change, p=.004 for non-inferiority primary hypothesis). SIJ pain scores improved from 78 preoperatively to 21 at 12-month follow-up (P<.0001). Ninety-six percent experienced an improvement of 20 points or more in VAS SIJ pain by month 12. The percentage of subjects reporting minimal difficulty performing physical activities typically impaired by back/SIJ pain improved significantly for all activities. The proportion of subjects taking opioids for SIJ pain decreased from 57% to 22%. Three physical function tests improved markedly from baseline to 1 year. Positive radiographic findings were observed, including a 70% and 77% rate of bone bridging observed at 6 and 12 months, respectively. There was no evidence of device breakage, migration or subsidence. CONCLUSION: In this prospective multicenter trial, SIJF with 3D-printed TTI markedly improved pain, disability and quality of life. Results are consistent with 3 prior prospective multicenter trials of a milled implant but suggest accelerated bony fusion with the newer implant. Physical function improved, and high rates of opioid cessation were observed. LEVEL OF EVIDENCE: Level II.

Minimally Invasive Management of Civilian Gunshot Wounds to the Lumbar Spine: A Case Series and Technical Report.

BACKGROUND: Treatment of penetrating gunshot wounds (GSW) to the spine remains controversial. The decision to operate is often based on surgeon preference and experience. We present a case series of 7 patients who underwent minimally invasive thoracolumbar/sacral decompression and bullet removal at a level 1 trauma center. OBJECTIVE: To describe the use of minimally invasive techniques to achieve decompression and bullet removal for GSW to the spine. METHODS: From 2010 to 2017, 7 patients with spinal GSW underwent minimally invasive decompression and bullet removal at an academic level 1 trauma center. RESULTS: Patient ages ranged from 20 to 55 yr (mean: 31 yr). The mechanisms of injury were GSW to the abdomen/pelvis (n = 6) and direct GSW to the spine (n = 1). Based on the neurological examination, the injuries were characterized as complete (n = 1) or incomplete (n = 6). Decompression and bullet removal were performed using a tubular retractor system. All patients with incomplete injuries who had postdischarge follow-up demonstrated some neurologic recovery. There were no postoperative wound infections, cerebrospinal fluid (CSF) fistulas, or other complications related to the procedure. CONCLUSION: Minimally invasive decompression and bullet removal is a safe technique that may help reduce the risk of postoperative infections and CSF fistulas in patients with GSW to the lumbar spine compared to the standard open technique. This approach appears to be particularly beneficial in patients with incomplete injuries and neuropathic pain refractory to medical treatment.

The Impact of Drug and Alcohol Intoxication on Glasgow Coma Scale Assessment in Patients with Traumatic Brain Injury.

BACKGROUND: The effect of intoxicating substances on assessment of Glasgow Coma Scale (GCS) in the trauma setting has not been completely elucidated. METHODS: A trauma registry was queried for patients with blunt head trauma in 2013-2017. Initial GCS score and toxicology screening from the database were reviewed. Next recorded GCS score from the neurosurgery evaluation and change in GCS score (ΔGCS) were compared. RESULTS: We reviewed 468 patients. In 217 (46.4%) patients, no toxic substances were found, whereas >1 toxic substance was found in 104 (22.2%) patients. Alcohol level above the legal limit was found in 109 (23.3%) patients, marijuana was found in 105 (22.4%) patients, benzodiazepines were found in 94 (20.1%) patients, opiates were found in 48 (10.3%) patients, and cocaine was found in 41 (8.8%) patients. Mean change in GCS score was significantly higher in impaired patients compared with patients with a negative screening test (1.74 ± 2.4 vs. 0.75 ± 2.7, P < 0.001); this is despite both groups having a similar initial GCS score (6.23 ± 3.86 in impaired group vs. 6.47 ± 3.52 in sober group, P = 0.677). Initial GCS score was 3 in 187 patients, of whom 150 had a positive toxicology screen. Change in GCS score was significantly higher in the impaired group (2.75 ± 2.7 vs. 1.19 ± 1.8, P < 0.001). CONCLUSIONS: Intoxicating substances can confound GCS assessment in trauma patients. This can have effects on patient care as well as performance metrics and predictive analytics. These patients should be screened, and intoxicating substances should be reversed or allowed to wear off before GCS score is recorded for benchmarking or quality reporting.

Primary pain generator identification by CT-SPECT in patients with degenerative spinal disease.

OBJECTIVE: Axial spinal pain generators are difficult to identify using current diagnostic modalities. Merging CT with SPECT (CT-SPECT) scans allows for accurate identification of areas with increased osteoblastic activity, which may reflect pain generators. In this study, the authors aimed to evaluate the degree of pain improvement in patients who underwent surgery, addressing primary pain generators identified by CT-SPECT. METHODS: The authors retrospectively reviewed all patients with chronic axial spine pain who underwent diagnostic CT-SPECT at their institution and analyzed pain improvement in those who underwent surgical treatment in order to determine whether CT-SPECT correctly identified the primary pain generator. RESULTS: A total of 315 patients underwent diagnostic CT-SPECT between January 2014 and August 2018. Forty-eight patients underwent either cervical or lumbar fusion; there were 26 women (16 cervical, 10 lumbar) and 22 men (9 cervical, 13 lumbar). The overall axial spinal pain, as assessed through self-reporting of visual analog scale scores at 6 months postoperatively, improved from 9.04 ± 1.4 to 4.34 ± 2.3 (p = 0.026), with cervical fusion patients improving from 8.8 ± 1.8 to 3.92 ± 2.2 (p = 0.019) and lumbar fusion patients improving from 9.35 ± 0.7 to 4.87 ± 2.3 (p = 0.008). CONCLUSIONS: CT-SPECT may offer a diagnostic advantage over current imaging modalities in identifying the primary pain generator in patients with axial spinal pain.

Traumatic cervical spine injury during sexual activity.

Sexual activity is unlikely to result in spinal injuries. We present the first case of a cervical fracture-subluxation and spinal cord injury following sexual activity. This 31-year-old female presented to the emergency room with neck pain and quadriparesis, following sexual activity in an extreme position. Imaging revealed a hyperflexion cervical fracture-subluxation injury, requiring reduction by traction, followed by circumferential surgical fixation. At 6 months postoperatively, she reported baseline return of function. This case demonstrates that sex-induced spinal injuries are possible and may require urgent surgical treatment.

Minimally invasive lateral transiliac sacroiliac joint fusion using 3D-printed triangular titanium implants.

Background: Minimally invasive sacroiliac joint (SIJ) fusion (SIJF) has become an increasingly accepted surgical option for chronic SI joint dysfunction, a prevalent cause of chronic low back/buttock pain. Objective: To report clinical and functional outcomes of SIJF using 3D-printed triangular titanium implants (TTI) for patients with chronic SI joint dysfunction. Methods: A total of 28 subjects with SIJ dysfunction at 8 centers underwent SIJF with 3D TTI and had scheduled follow-up to 6 months (NCT03122899). Results: Mean preoperative SIJ pain score was 79.1 and mean preoperative Oswestry Disability Index (ODI) was 49.9. At 6 months, pain scores decreased by 51 points and ODI decreased by 23.6 points (both p<0.0001). The proportion of subjects able to perform various back/pelvis-related physical functions with minimal difficulty improved significantly for nearly all activities. Opioid use decreased and physical function, as assessed with three objective tests, improved. Conclusion: Early results from this prospective multicenter trial confirm that clinical responses to a 3D triangular titanium implant for SIJF are similar to those from prior trials, with improved physical function and decreased opioid use. Level of evidence: Level II.

Outcomes of posterior cervical fusion and decompression: a systematic review and meta-analysis.

BACKGROUND CONTEXT: Posterior cervical fusion (PCF) with decompression is a treatment option for patients with conditions such as spondylosis, spinal stenosis, and degenerative disc disorders that result in myelopathy or radiculopathy. The annual rate, number, and cost of PCF in the United States has increased. Far fewer studies have been published on PCF outcomes than on anterior cervical fusion (ACF) outcomes, most likely because far fewer PCFs than ACFs are performed. PURPOSE: To evaluate the patient-reported and clinical outcomes of adult patients who underwent subaxial posterior cervical fusion with decompression. STUDY DESIGN/SETTING: Systematic review and meta-analysis. PATIENT SAMPLE: The total number of patients in the 31 articles reviewed and included in the meta-analysis was 1,238 (range 7-166). OUTCOME MEASURES: Preoperative to postoperative change in patient-reported outcomes (visual analog scales for arm pain and neck pain, Neck Disability Index, Japanese Orthopaedic Association [JOA] score, modified JOA score, and Nurick pain scale) and rates of fusion, revision, and complications or adverse events. METHODS: This study was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and a preapproved protocol. PubMed and Embase databases were searched for articles published from January 2001 through July 2018. Statistical analyses for patient-reported outcomes were performed on the outcomes' raw mean differences, calculated as postoperative value minus preoperative value from each study. Pooled rates of successful fusion, revision surgery, and complications or adverse events, and their 95% confidence intervals, were also calculated. Two subgroup analyses were performed: one for studies in which only myelopathy or radiculopathy (or both) were stated as surgical indications and the other for studies in which only myelopathy or ossification of the posterior longitudinal ligament (or both) were stated as surgical indications. This study was funded by Providence Medical Technology, Inc. ($32,000). RESULTS: Thirty-three articles were included in the systematic review, and 31 articles were included in the meta-analysis. For all surgical indications and for the 2 subgroup analyses, every cumulative change in patient-reported outcome improved. Many of the reported changes in patient-reported outcome also exceeded the minimal clinically important differences. Pooled outcome rates with all surgical indications were 98.25% for successful fusion, 1.09% for revision, and 9.02% for complications or adverse events. Commonly reported complications or adverse events were axial pain, C5 palsy, transient neurological worsening, and wound infection. CONCLUSIONS: Posterior cervical fusion with decompression resulted in significant clinical improvement, as indicated by the changes in patient-reported outcomes. Additionally, high fusion rates and low rates of revision and of complications and adverse events were found.

A case series of penetrating spinal trauma: comparisons to blunt trauma, surgical indications, and outcomes.

OBJECTIVEWhile blunt spinal trauma accounts for the majority of spine trauma, penetrating injuries affect a substantial number of patients. The goal of this study was to examine the epidemiology of penetrating spine injuries compared with blunt injuries and review the operative interventions and outcomes in the penetrating spine injury group.METHODSThe prospectively maintained trauma database was queried for spinal fractures from 2012 to 2018. Charts from patients with penetrating spine trauma were reviewed.RESULTSA total of 1130 patients were evaluated for traumatic spinal fractures; 154 injuries (13.6%) were secondary to penetrating injuries. Patients with penetrating injuries were significantly younger (29.2 years vs 44.1 years, p < 0.001), more likely male (87.7% vs 69.2%, p < 0.001), and more commonly African American (80.5% vs 33.3%, p < 0.05). When comparing primary insurers, the penetrating group had a significantly higher percentage of patients covered by Medicaid (60.4% vs 32.6%, p < 0.05) or prison (3.9% vs 0.1%, p < 0.05) or being uninsured (17.5% vs 10.3%, p < 0.05). The penetrating group had a higher Injury Severity Score on admission (20.2 vs 15.6, p < 0.001) and longer hospital length of stay (20.1 days vs 10.3 days, p < 0.001) and were less likely to be discharged home (51.3% vs 65.1%, p < 0.05). Of the penetrating injuries, 142 (92.2%) were due to firearms. Sixty-three patients (40.9%) with penetrating injuries had a concomitant spinal cord or cauda equina injury. Of those, 44 (69.8%) had an American Spinal Injury Association Impairment Scale (AIS) grade of A. Ten patients (15.9%) improved at least 1 AIS grade, while 2 patients (3.2%) declined at least 1 AIS grade. Nine patients with penetrating injuries underwent neurosurgical intervention: 5 for spinal instability, 4 for compressive lesions with declining neurological examination results, and 2 for infectious concerns, with some patients having multiple indications. Patients undergoing neurosurgical intervention did not show a significantly greater change in AIS grade than those who did not. No patient experienced a complication directly related to neurosurgical intervention.CONCLUSIONSPenetrating spinal trauma affects a younger, more publicly funded cohort than blunt spinal trauma. These patients utilize more healthcare resources and are more severely injured. Surgery is undertaken for limiting progression of neurological deficit, stabilization, or infection control.

Change in Policy Allowing Overlapping Surgery Decreases Length of Stay in an Academic, Safety-Net Hospital.

BACKGROUND: The practice of surgeons running overlapping operating rooms has recently come under scrutiny. OBJECTIVE: To examine the impact of hospital policy allowing overlapping rooms in the case of patients admitted to a tertiary care, safety-net hospital for urgent neurosurgical procedures. METHODS: The neurosurgery service at the hospital being studied transitioned from routinely allowing 1 room per day (period 1) to overlapping rooms (period 2), with the second room being staffed by the same attending surgeon. Patients undergoing neurosurgical intervention in each period were retrospectively compared. Demographics, indication, case type, complications, outcomes, and total charges were tracked. RESULTS: There were 59 urgent cases in period 1 and 63 in period 2. In the case of these patients, the length of stay was significantly decreased in period 2 (13.09 d vs 19.52; P = .006). The time from admission to surgery (wait time) was also significantly decreased in period 2 (5.12 d vs 7.00; P = .04). Total charges also trended towards less in period 2 (${\$}$150 942 vs ${\$}$200 075; P = .05). Surgical complications were no different between the groups (16.9% vs 14.3%; P = .59), but medical complications were significantly decreased in period 2 (14.3% vs 30.5%; P = .009). Significantly more patients were discharged to home in period 2 (69.8% vs 42.4%; P = .003). CONCLUSION: As a matter of policy, allowing overlapping rooms significantly reduces the length of stay in the case of a vulnerable population in need of urgent surgery at a single safety-net academic institution. This may be due to a reduction in medical complications in these patients.

The increasing frequency of intravenous drug abuse-associated spinal epidural abscesses: a case series.

OBJECTIVEFew studies have been published specifically examining intravenous drug abuse (IVDA)-associated spinal epidural abscesses (SEAs), an unfortunate sequela of the opioid crisis in the United States. Here, the authors examined a series of patients with IVDA-associated SEAs in order to shed light on this challenging disease entity.METHODSThis study is a retrospective chart review of patients presenting with IVDA-associated SEAs at the authors' institution from 2013 to 2018, spanning the statewide implementation of opioid-prescribing restrictions.RESULTSA total of 45 patients presented with IVDA-associated SEAs; 46.5% presented with a neurological deficit. Thirty-one patients underwent surgery for neurological deficit, failure of medical therapy, or both. Nineteen surgical patients underwent a fusion procedure along with decompression. The complication rate was 41.9%, and the mortality rate was 6.7%. The average length of stay was 27.6 days. Patients who underwent surgery within 24 hours of onset of neurological symptoms trended toward more improvement in their American Spinal Cord Association Impairment Scale grade than those who did not (0.5 vs -0.2, p = 0.068). Methicillin-resistant Staphylococcus aureus was isolated as the causative pathogen in 57.8% of patients. Twenty-three patients (51.5%) kept their scheduled clinic follow-up appointments. Of the fusion patients with adequate follow-up, 5 showed bony arthrodesis and 3 had pseudarthrosis. The rate of IVDA-associated SEAs increased after opioid-prescribing restrictions were put in place, from 0.54 cases per month to 1.15 cases per month (p = 0.017).CONCLUSIONSPatients with IVDA-associated SEAs are challenging to treat, with high complication rates and poor follow-up. This disease is increasing in frequency, and opioid-prescribing restrictions did not slow that rise. Community outreach to promote prevention, early medical attention, and medication compliance would benefit this largely publicly funded patient population.

Peroneal Nerve Repair of a 9 Year Old: Return of Motor Function after 2 Years.

Major factors that influence functional nerve recovery, postrepair, are length of the nerve defect, type of injury, operative technique, time until treatment, and age of the patient. We present a severe motor nerve defect in a complicated peroneal nerve injury in a 9-year-old that showed functional return after a delayed period of 23 months with sural nerve cable grafting. This case revealed the increased resiliency and regenerative capacity of motor end plates in young patients. In conclusion, autograft for a deep peroneal nerve repair, by means of sural nerve graft, proved to be an acceptable option in children.

The Effects of Agrin Isoforms on Diabetic Neuropathic Pain in a Rat Streptozotocin Model.

BACKGROUND: Diabetes mellitus affects 9.3% of the US population and increases risks of surgery and complications. Diabetic neuropathic pain (DNP), one of the main consequences of diabetes mellitus, is extremely difficult to treat. Current medications yield limited benefits and/or have severe adverse effects. Therefore, new, effective treatment is needed. METHODS: Streptozotocin at 55 mg/kg was injected intraperitoneally in rats to induce diabetes mellitus. Diabetic rats exhibiting neuropathic pain underwent intrathecal injection of purified agrin proteins at various doses and were then tested for tactile allodynia to evaluate whether DNP was inhibited. The agrin effects were also analyzed with patch-clamp recording on spinal cord slices. RESULTS: Fifty-kilo Dalton agrin (Agr50) at 0.2 and 2 ng suppressed DNP when given intrathecally, while 25- and 75-kDa agrin (Agr25, Agr75) had little effect. The suppressive effect of Agr50 lasted 4 hours after a single bolus injection. The difference in effects of Agr50 on mean withdrawal threshold (4.6 ± 2.2 g before treatment to 26 ± 0 g after treatment) compared with that of Agr25 (4.9 ± 2.0 g to 4.9 ± 2.0 g) and Agr75 (5.3 ± 2.3 g to 9.2 ± 2.5 g) was highly significant (P < .01). On spinal cord slices, Agr50 increased spontaneous GABAergic current activities, suggesting increased spontaneous inhibitory postsynaptic currents and action potential firing rate from GABA neurons, whereas Agr25 and Agr75 had no such effect. CONCLUSIONS: Agr50 had a potent suppressive effect on DNP and increased spontaneous inhibitory postsynaptic currents and action potential firing rate from GABA neurons. Therefore, Agr50 may provide a potential therapy for DNP.