Patients undergoing surgery for cervical spine metastases are at risk for unplanned readmission due to comorbidities and chemotherapy/radiation. Our objectives were to: 1) report the incidence of ...unplanned readmission, 2) identify risk factors associated with unplanned readmission, and 3) determine the impact of an unplanned readmission on long-term outcomes.
A single-center, retrospective, case-control study was undertaken of patients undergoing cervical spine surgery for metastatic disease between 02/2010 and 01/2021. The primary outcome of interest was unplanned readmission within 6 months. Survival analysis was performed for overall survival (OS) and local recurrence (LR).
A total of 61 patients underwent cervical spine surgery for metastatic disease with the following approaches: 11 (18.0%) anterior, 28 (45.9%) posterior, and 22 (36.1%) combined. Mean age was 60.9 ± 11.2 years and 38 (62.3%) were males. A total of 9/61 (14.8%) patients had an unplanned readmission, 3 for surgical reasons and 6 for medical reasons. No difference was found in demographics, preoperative Karnofsky Performance Scale (P = 0.992), motor strength (P = 0.477), or comorbidities (P = 0.213) between readmitted patients versus not. Readmitted patients had a higher rate of preoperative radiation (P = 0.009). No statistical differences were found in operative time (P = 0.893), estimated blood loss (P = 0.676), length of stay (P = 0.720), discharge disposition (P = 0.279), and operative approach (P = 0.450). Furthermore, no difference was found regarding complications (P = 0.463), postoperative Karnofsky Performance Scale (P = 0.535), and postoperative Modified McCormick Scale (P = 0.586). Lastly, unplanned readmissions were not associated with OS (log-rank; P = 0.094) or LR (log-rank; P = 0.110).
In patients undergoing cervical spine metastasis surgery, readmission occurred in 15% of patients, 33% for surgical reasons, and 67% for medical reasons. Preoperative radiotherapy was associated with an increased rate of unplanned readmissions, yet readmission had no association with OS or LR.
Pre-operative psychological assessment is commonly used to assess patients for spinal cord stimulation (SCS). Though often times mandated by insurance, its value is frequently questioned.
We review ...the literature on the predictive value of psychological testing prior to SCS and retrospectively examine our prospective database of SCS patients. We examine associations of Minnesota Multiphasic Personality Inventory (MMPI), Beck Depression Inventory (BDI), and Pain Catastrophizing Scale (PCS) findings and outcomes on the visual analog scale (VAS), McGill Pain Questionnaire - Short Form (MPQ), and Oswestry Disability Index (ODI) at 6 and 12 months post-implantation.
The nine studies examining psychological predictors of SCS outcomes collectively showed that substance abuse or feelings of demoralization or less joy correlated with worse outcomes. Though not statistically significant, our data show that at one year follow-up, patients without psychiatric disorders improved 1.5 times as much on ODI and 2.4 times as much on PCS as compared to patients with psychiatric disorders. Further, depressed patients concurrently treated with anti-depressants had greater improvement in BDI than non-medicated depressed patients (p = 0.009). We develop a tool for pain psychologists based on the existing literature to aid in identifying possible concerns and treating these patients peri-operatively.
The predictive value of psychological testing depends on which psychiatric factors are used and which outcomes are measured. The predictive capacity of psychological indications can be used to holistically treat patients, specifically to recommend psychiatric medication and consulting to supplement SCS treatment as needed.
Narrative review.
To review indications and strategies for revision of cervical disc arthroplasty (CDA).
No data were generated as part of this review.
A narrative review of the literature was ...performed.
No results were generated as part of this review.
CDA is a proven, motion-sparing surgical option for the treatment of myelopathy or radiculopathy secondary to cervical degenerative disc disease. As is the case with any operation, a small percentage of CDA will require revision, which can be a technically demanding endeavor. Here we review available revision strategies and associated indications, a thorough understanding of which will aid the surgeon in finely tailoring their approach to varying presentations.
Accurate lead placement is critical for spinal cord stimulation (SCS) efficacy. The traditional gold standard of awake placement is often technically difficult. While there is retrospective evidence ...supporting the use of intraoperative neurophysiological monitoring (IOM) as an alternative, a prospective assessment has not yet been performed.
To prospectively evaluate pain and functionality outcomes for IOM-guided SCS, validate two IOM modalities as a means to lateralize lead placement and assess whether IOM can be useful for postoperative programming.
A total of 73 patients were implanted with SCS using electromyography (EMG) and somatosensory-evoked potential collision studies (SSEP-CS) to verify lead placement. Patient pain and function were assessed through serial administration of several validated questionnaires. Stimulation parameters at 6 months were documented.
Statistically significant (p < 0.05) improvements were observed in the McGill Pain Questionnaire, Oswestry Disability Index, Pain Catastrophizing Scale, and Visual Analog Scale. EMG and SSEP-CS appropriately lateralized leads in 65/73 (89.0%) and 40/58 (69.0%) cases, respectively. EMG predicted active contacts in use at follow-up with 82.7% sensitivity.
We provide prospective evidence that IOM can be used to verify SCS placement. Additionally, EMG may help to streamline device programming and thereby improve outcomes by predicting the ideal stimulation contacts in many cases.
Cerebrovascular injury (CVI) is a potentially devastating complication of gunshot wounds to the head (GSWH), with yet unclear incidence and prognostic implications. Few studies have also attempted to ...define CVI risk factors and their role in patient outcomes. We aimed to describe 10 years of CVI from GSWH and characterize these injury patterns.
Single-institution data from 2009 to 2019 were queried to identify patients presenting with dural-penetrating GSWH. Patient records were reviewed for GSWH characteristics, CVI patterns, management, and follow-up.
Overall, 63 of 297 patients with GSWH underwent computed tomography angiography (CTA) with 44.4% showing CVI. The middle cerebral artery (22.2%), dural venous sinuses (15.9%), and internal carotid artery (14.3%) were most frequently injured. Arterial occlusion was the most prominent injury type (22.2%) followed by sinus thrombosis (15.9%). One fifth of patients underwent delayed repeat CTA, with 20.1% showing new/previously unrecognized CVI. Bihemispheric bullet tracts were associated with CVI occurrence (P = 0.001) and mortality (P = 0.034). Dissection injuries (P = 0.013), injuries to the vertebrobasilar system (P = 0.036), or the presence of ≥2 concurrent CVIs (P = 0.024) were associated with increased risk of mortality. Of patients with CVI on initial CTA, 30% died within the first 24 hours.
CVI was found in 44.4% of patients who underwent CTA. Dissection and vertebrobasilar injuries are associated with the highest mortality. CTA should be considered in any potentially survivable GSWH. Longitudinal study with consistent CTA use is necessary to determine the true prevalence of CVI and optimize the use of imaging modalities.
(a) Describe the time course of each mechanical complication, and (b) compare radiographic measurements and preoperative patient-reported outcome measures (PROMs) among each mechanical complication ...type.
A single-institution case-control study was undertaken of patients undergoing adult spinal deformity (ASD) surgery from 2009-2017. Exposure variables included patient demographics, operative variables, radiographic measurements, and preoperative PROMs, including Oswestry Disability Index (ODI), Numeric Rating Scale Back/Leg-pain scores (NRS-Back/Leg), and EuroQol-5D (EQ-5D). The primary outcomes were occurrence of a mechanical complication and time to complication. Due to overlapping occurrence, rod fracture and pseudarthrosis were grouped into one composite category.
145 patients underwent ASD surgery and were followed for at least 2 years. 30/47 (63.8%) patients with proximal junctional kyphosis (PJK) required reoperation, whereas 27/31 (87.1%) patients with pseudarthrosis/rod fracture required reoperation (63.8% vs. 87.1%, Χ
= -0.23, 95% CI -0.41, -0.05, p = 0.023). Cox regression showed no significant difference in time to reoperation between PJK and rod fracture/pseudarthrosis (HR = 0.97, 95% CI 0.85-1.11, p = 0.686). Distal junctional kyphosis (DJK) (N = 3; 2 reoperation) and implant failures (N = 4; 0 reoperations) were rare. Patients with PJK had significantly lower Hounsfield Units preoperatively compared to those with pseudarthrosis/rod fracture (138.2 ± 43.8 vs. 160.3 ± 41.0, mean difference (MD) = -22.1, 95% CI -41.8, -2.4, p = 0.028), more prior fusions (51.1% vs. 25.8%, Χ
= 0.253, 95% CI 0.41, 0.46, p = 0.026), fewer instrumented vertebrae (9.2 ± 2.6 vs. 10.7 ± 2.5, MD = -1.5, 95% CI -2.7, -0.31, p = 0.013), and higher postoperative thoracic kyphosis (TK) (46.3 ± 12.7 vs. 34.9 ± 10.6, MD = 11.4, 95% CI 5.9, 16.9, p < 0.001). Higher postoperative C7 sagittal vertical axis (SVA) did not achieve a significant difference (80.7 ± 72.1 vs. 51.9 ± 57.3, MD = 28.8, 95% CI -1.9, 59.5, p = 0.066). No differences were seen in preoperative PROMs.
Patients with pseudarthrosis/rod fracture had a higher reoperation rate compared to those with PJK with similar time to reoperation. Moreover, patients with PJK had higher postoperative TK, lower Hounsfield Units, more prior fusions, and fewer instrumented levels compared to those with pseudarthrosis/rod fracture. The results of this single-institution study suggest that even though mechanical complications are often analyzed as a single group, important differences may exist between them.
III.
Whether a combined anterior-posterior (AP) approach offers additional benefits over the posterior-only (P) approach in adult spinal deformity (ASD) surgery remains unknown. In a cohort of patients ...undergoing ASD surgery, we compared the combined AP vs. the P-only approach in: (1) preoperative/perioperative variables, (2) radiographic measurements, and (3) postoperative outcomes.
A single-institution, retrospective cohort study was performed for patients undergoing ASD surgery from 2009 to 2021. Inclusion criteria were ≥5-level fusion, sagittal/coronal deformity, and 2-year follow-up. The primary exposure was the operative approach: a combined AP approach or P alone. Postoperative outcomes included mechanical complications, reoperation, and minimal clinically important difference (MCID), defined as 30% of patient-reported outcome measures (PROMs). Multivariable linear regression was controlled for age, BMI, and previous fusion.
Among 238 patients undergoing ASD surgery, 34 (14.3%) patients underwent the AP approach and 204 (85.7%) underwent the P-only approach. The AP group consisted mostly of anterior lumbar interbody fusion (ALIF) at L5/S1 (73.5%) and/or L4/L5 (38.0%). Preoperatively, the AP group had more previous fusions (64.7% vs. 28.9%,
< 0.001), higher pelvic tilt (PT) (29.6 ± 11.6° vs. 24.6 ± 11.4°,
= 0.037), higher T1 pelvic angle (T1PA) (31.8 ± 12.7° vs. 24.0 ± 13.9°,
= 0.003), less L1-S1 lordosis (-14.7 ± 28.4° vs. -24.3 ± 33.4°,
< 0.039), less L4-S1 lordosis (-25.4 ± 14.7° vs. 31.6 ± 15.5°,
= 0.042), and higher sagittal vertical axis (SVA) (102.6 ± 51.9 vs. 66.4 ± 71.2 mm,
= 0.005). Perioperatively, the AP approach had longer operative time (553.9 ± 177.4 vs. 397.4 ± 129.0 min,
< 0.001), more interbodies placed (100% vs. 17.6%,
< 0.001), and longer length of stay (8.4 ± 10.7 vs. 7.0 ± 9.6 days,
= 0.026). Radiographically, the AP group had more improvement in T1PA (13.4 ± 8.7° vs. 9.5 ± 8.6°,
= 0.005), L1-S1 lordosis (-14.3 ± 25.6° vs. -3.2 ± 20.2°,
< 0.001), L4-S1 lordosis (-4.7 ± 16.4° vs. 3.2 ± 13.7°,
= 0.008), and SVA (65.3 ± 44.8 vs. 44.8 ± 47.7 mm,
= 0.007). These outcomes remained statistically significant in the multivariable analysis controlling for age, BMI, and previous fusion. Postoperatively, no significant differences were found in mechanical complications, reoperations, or MCID of PROMs.
Preoperatively, patients undergoing the combined anterior-posterior approach had higher PT, T1PA, and SVA and lower L1-S1 and L4-S1 lordosis than the posterior-only approach. Despite increased operative time and length of stay, the anterior-posterior approach provided greater sagittal correction without any difference in mechanical complications or PROMs.
Post-mechanical thrombectomy (MT) intracranial hemorrhage (ICH) is a major source of morbidity in treated acute ischemic stroke patients with large vessel occlusion. ICH expansion may further ...contribute to morbidity. We sought to identify factors associated with ICH expansion on imaging evaluation post-MT.
We performed a retrospective cohort study of patients undergoing MT at a single comprehensive stroke center. Per protocol, patients underwent dual-energy head CT (DEHCT) post-MT followed by a 24-h interval non-contrast enhanced MRI. ICH expansion was defined as any increase in blood volume between the two studies if identified on the DEHCT. Univariate and multivariable analyses were performed to identify risk factors for ICH expansion.
ICH was identified on DEHCT in 13% of patients (
= 35/262), with 20% (7/35) demonstrating expansion on interval MRI. The average increase in blood volume was 11.4 ml (SD 6.9). Univariate analysis identified anticoagulant usage (57% vs 14%,
= 0.03), petechial hemorrhage inside the infarct margins or intraparenchymal hematoma on DEHCT (ECASS-II HI2/PH1/PH2) (71% vs 14%,
< 0.01), basal ganglia hemorrhage (71% vs 21%,
= 0.02), and basal ganglia infarction (86% vs 32%,
= 0.03) as factors associated with ICH expansion. Multivariate regression demonstrated that anticoagulant usage (OR 20.3, 95% C.I. 2.43-446,
< 0.05) and ECASS II scores of HI2/PH1/PH2 (OR 11.7, 95% C.I. 1.24-264,
< 0.05) were significantly predictive of ICH expansion.
Expansion of post-MT ICH on 24-h interval MRI relative to immediate post-thrombectomy DEHCT is significantly associated with baseline anticoagulant usage and petechial hemorrhage inside the infarct margins or presence of intraparenchymal hematoma (ECASS-II HI2/PH1/PH2).
Embolism, hyperglycemia, high intraocular pressure-induced increased reactive oxygen species (ROS) production, and microglial activation result in endothelial/retinal ganglion cell death. Here, we ...conducted in vitro and in vivo ischemia/reperfusion (I/R) efficacy studies of a hybrid antioxidant-nitric oxide donor small molecule,
to assess its therapeutic potential for ocular stroke.
To induce I/R injury and inflammation, we subjected R28 and primary microglial cells to oxygen glucose deprivation (OGD) for 6 h in vitro or treated these cells with a cocktail of TNF-α, IL-1β and IFN-γ for 1 h, followed by the addition of
(10 µM). Inhibition of microglial activation, ROS scavenging, cytoprotective and anti-inflammatory activities were measured. In vivo I/R-injured mouse retinas were treated with either PBS or
(2%) intravitreally, and pattern electroretinogram (ERG), spectral-domain optical coherence tomography, flash ERG and retinal immunocytochemistry were performed.
significantly inhibited microglial activation and inflammation in vitro. Compared to the control, the compound
significantly attenuated cell death in both microglia (43% vs. 13%) and R28 cells (52% vs. 17%), decreased ROS (38% vs. 68%) production in retinal microglia cells, preserved neural retinal function and increased SOD1 in mouse eyes.
is protective to retinal neurons by decreasing oxidative stress and inflammatory cytokines.
PDF
