Black faculty members are often expected to engage in diversity initiatives, a drain on their time and resources known as the “minority tax.” But taxes can be reformed, and several strategies could ...help reduce the negative sequelae of the minority tax.
Augmented reality (AR) is increasingly being explored as an adjunct to conventional neuronavigation systems. AR affords the ability to superimpose 3-dimensional images onto the real environment. A ...natural extension of this technology is to help guide neurosurgical planning and a means of stereotactic planning and guidance. Here we review the literature on the use of AR in neurosurgery with a focus on current technologies and limitations. Furthermore, we discuss this technology in the context of neurosurgical training as an educational tool.
PubMed search was performed for “augmented reality and neurosurgery” and “mixed reality and neurosurgery” from 2010. A total of 113 articles written in the last 5 years were retrieved, and 39 were ultimately included in the systematic review.
The most common use of AR in neurosurgery was in cranial surgery (n = 26). Other uses included spine surgery (n = 9) and education (n = 2). Devices used for display of AR images varied as did image-to-patient registration methods and overall system accuracy.
Although various AR systems have been successfully utilized across many neurosurgical disciplines, more research is needed to improve accuracy in registration and to assess whether AR-assisted surgery is safe and effective for widespread adoption.
The incidence of brain metastases is increasing as cancer therapies improve and patients live longer, providing new challenges to the multidisciplinary teams that care for these patients. Brain ...metastatic cancer cells possess unique characteristics that allow them to penetrate the blood-brain barrier, colonize the brain parenchyma, and persist in the intracranial environment. In addition, brain metastases subvert the innate and adaptive immune system, permitting evasion of the antitumor immune response. Better understanding of the above mechanisms will allow for development and delivery of more effective therapies for brain metastases. In this review, we outline the molecular mechanisms underlying development, survival, and immunosuppression of brain metastases. We also discuss current and emerging treatment strategies, including surgery, radiation, disease-specific and mutation-targeted systemic therapy, and immunotherapy.
Glioblastoma (GBM) is the most frequent and aggressive primary brain tumor in adults. Recent research on cancer stroma indicates that the brain microenvironment plays a substantial role in tumor ...malignancy and treatment responses to current antitumor therapy. In this work, we have investigated the effect of alterations in brain tumor extracellular matrix tenascin-C (TNC) on brain tumor growth patterns including proliferation and invasion.
Since intracranial xenografts from patient-derived GBM neurospheres form highly invasive tumors that recapitulate the invasive features demonstrated in human patients diagnosed with GBM, we studied TNC gain-of-function and loss-of function in these GBM neurospheres in vitro and in vivo.
TNC loss-of-function promoted GBM neurosphere cell adhesion and actin cytoskeleton organization. Yet, TNC loss-of-function or exogenous TNC had no effect on GBM neurosphere cell growth in vitro. In animal models, decreased TNC in the tumor microenvironment was accompanied by decreased tumor invasion and increased tumor proliferation, suggesting that TNC regulates the "go-or-grow" phenotypic switch of glioma in vivo. We demonstrated that decreased TNC in the tumor microenvironment modulated behaviors of stromal cells including endothelial cells and microglia, resulting in enlarged tumor blood vessels and activated microglia in tumors. We further demonstrated that tumor cells with decreased TNC expression are sensitive to anti-proliferative treatment in vitro.
Our findings suggest that detailed understanding of how TNC in the tumor microenvironment influences tumor behavior and the interactions between tumor cells and surrounding nontumor cells will benefit novel combinatory antitumor strategies to treat malignant brain tumors.
The incidence of metastatic spine disease (MSD) is increasing among cancer patients. Given the poor outcomes and high rates of morbidity associated with MSD, it is important to determine demographic ...factors that could impact interventions and outcomes for this patient population. The objectives of this study were to compare in-hospital mortality and complication rates, clinical presentation, and interventions between female and male patients diagnosed with MSD.
Patient data were collected from the United States National Inpatient Sample (NIS) database from the years 2012−2014. Descriptive statistics were used to compare data from 51,800 cases; subsequently, multivariable logistic regression analyses were conducted to assess the effect of gender on outcomes.
Males had significantly higher rates of in-hospital mortality (OR 1.30; 95 % CI 1.09–1.56, p = 0.004) and were more likely to have received surgical intervention than females (OR 1.34; 95 % CI 1.16–1.55, p < 0.001). Additionally, female patients were more likely to present with vertebral compression fracture (p < 0.001), while metastatic spinal cord compression (MSCC) and paralysis were more common in male patients (p < 0.001). There was no significant difference in rates of in-hospital complications between female and male patients.
Given the significant differences in mortality, disease course, treatment, and in-hospital complications between female and male patients diagnosed with MSD, additional prospective studies are necessary to understand how to meaningfully incorporate these differences into clinical care and prognostication going forward.
STUDY DESIGN.Retrospective review.
OBJECTIVE.To determine if adjuvant radiation therapy (RT) improves overall survival (OS) following surgical resection of chordomas.
SUMMARY OF BACKGROUND DATA.The ...role of RT for the treatment of chordomas remains incompletely described. Previous studies have not found adjuvant RT to improve OS, but these studies did not group patients based on surgical margin status or radiation dose or modality. We used the National Cancer Database to investigate the role of RT in chordomas following surgical resection.
METHODS.Patients were stratified based on surgical margin status (positive vs. negative). Utilizing the Kaplan–Meier method, OS was compared between treatment modalities (surgical resection alone, therapeutic RT alone, and surgical resection plus therapeutic RT). OS was subsequently compared between patients treated with palliative dose (<40 Gy), low dose (40–65 Gy), and high dose (>65 Gy) RT. Similarly, OS was compared between advanced RT modalities including proton beam therapy (PBT) and intensity-modulated radiation therapy (IMRT), stereotactic radiosurgery (SRS), and external beam radiation therapy (EBRT). A multivariable model was used to determine adjusted variables predictive of mortality.
RESULTS.One thousand four hundred seventy eight chordoma patients were identified; skull base (n = 567), sacral (n = 551), and mobile spine (n = 360). Surgical resection and therapeutic adjuvant RT improved 5-year survival in patients with positive surgical margins (82% vs. 71%, P = 0.03). No clear survival benefit was observed with the addition of adjuvant RT in patients with negative surgical margins. High dose RT was associated with improved OS compared with palliative and low dose RT (P < 0.001). Advanced RT techniques and SRS were associated with improved OS compared with EBRT. In the multivariate analysis high dose advanced RT (>65 Gy) was superior to EBRT.
CONCLUSION.Patients with positive surgical margins benefit from adjuvant RT. Optimal OS is associated with adjuvant RT administered with advanced techniques and cumulative dose more than 65 Gy.Level of Evidence4
Purpose
To report outcomes after total en bloc spondylectomy (TES) for primary aggressive/malignant tumors of the lumbar spine.
Methods
We performed a retrospective review of 23 neurosurgical ...patients operated between 2004 and 2014. Outcomes included perioperative complication rates and reoperation rates for instrumentation failure. The relationship between patient/operative parameters and complication development/instrumentation failure was investigated.
Results
There were 15 men (65.2 %) and eight women (24.8 %), with a median of 47 years. The most common tumor was chordoma in 11 patients (47.8 %), followed by sarcoma in four (17.4 %), and giant cell tumor in three (13.0 %). All patients but one underwent a two-staged operation; median total estimated blood loss was 3200 mL and median total operative time was 18.5 h. Fifteen patients developed at least one perioperative complication (65.2 %), with the most common being wound infection and ileus (26.1 % each). There was one case of intraoperative iliac vein injury (4.4 %). Instrumentation failure occurred in 9 patients (39.1 %) at a median time of 23 months after index spondylectomy. Following logistic regression, there were no factors associated with complication development. On the other hand, postoperative radiation was significantly associated with instrumentation failure (OR 7.49; 95 % CI, 1.02–54.9). Local recurrence and 5-year survival was 8.7 and 84.4 %, respectively. Median follow-up time was 50 months.
Conclusions
Although favorable oncological outcomes after en bloc resection of spinal tumors may be achieved in terms of recurrence and survival, TES in the lumbar spine remains a challenging procedure. Future investigation into complication avoidance and reconstruction techniques is encouraged.
Patients with oncologic spine disease face a high systemic illness burden and often require surgical intervention to alleviate pain and maintain spine stability. Wound healing complications are the ...most common reason for reoperation in this population and are known to impact quality of life and initiation of adjuvant therapy. Prophylactic muscle flap (MF) closure is known to reduce wound healing complications in high-risk patients; however, the efficacy in oncologic spine patients is not well established.
A collaboration at our institution presented an opportunity to study the outcomes of prophylactic MF closure. The authors performed a retrospective cohort study of patients who underwent MF closure versus a cohort who underwent non-MF closure in the preceding time. Demographic and baseline health data were collected, as were postoperative wound complication data.
A total of 166 patients were enrolled, including 83 patients in the MF cohort and 83 control patients. Patients in the MF group were more likely to smoke ( P = 0.005) and had a higher incidence of prior spine irradiation ( P = 0.002). Postoperatively, five patients (6%) in the MF group developed wound complications, compared with 14 patients (17%) in the control group ( P = 0.028). The most common overall complication was wound dehiscence requiring conservative therapy, which occurred in six control patients (7%) and one MF patient (1%) ( P = 0.053).
Prophylactic MF closure during oncologic spine surgery significantly reduces the wound complication rate. Future studies should examine the precise patient population that stands to benefit most from this intervention.
Therapeutic, III.
Abstract Background Context Blood transfusions in spine surgery are shown to be associated with increased patient morbidity. The association between transfusion performed using a liberal hemoglobin ...trigger—defined as an intraoperative hemoglobin level of ≥10 g/dL, a postoperative level of ≥8 g/dL, or a whole hospital nadir between 8-10 g/dL—and perioperative morbidity and cost in spine surgery patients is unknown and thus was investigated in this study. Purpose To describe the perioperative outcomes and economic cost associated with liberal hemoglobin trigger transfusion among spine surgery patients. Study Design/Setting Retrospective study. Patient Sample The surgical billing database at our institution was queried for inpatients discharged between 2008 and 2015 after the following procedures: atlantoaxial fusion, anterior cervical fusion, posterior cervical fusion, anterior lumbar fusion, posterior lumbar fusion, lateral lumbar fusion, other procedures, and tumor-related surgeries. In total, 6931 patients were included for analysis. Outcome Measures The primary outcome was composite morbidity which was comprised of: (1) infection (sepsis, surgical-site infection, Clostridium dificile, or drug-resistant infection), (2) thrombotic event (pulmonary embolus, deep venous thrombosis, or disseminated intravascular coagulation), (3) kidney injury, (4) respiratory event, and/or (5) ischemic event (transient ischemic attack, myocardial infarction, or cerebrovascular accident). Methods Data on intraoperative transfusion were obtained from an automated prospectively collected anesthesia data management system. Data on postoperative hospital transfusion was obtained through a Web-based intelligence portal. Based on previous research, we analyzed the data using three definitions of a liberal transfusion trigger in patients who received an RBC transfusion: a liberal intraoperative Hb trigger as a nadir Hb level of 10 g/dL or greater, a liberal postoperative Hb trigger as a nadir Hb level of 8 g/dL or greater, or a whole hospital nadir Hb level of 8-10 g/dL. Variables analyzed included in-hospital morbidity, mortality, length of stay, and total costs associated with a liberal transfusion strategy. Results Among patients with a whole hospital stay nadir hemoglobin between 8 to 10 g/dL, transfused patients demonstrated a longer in-hospital stay (median IQR, 6 5-9 vs. 4 3-6 days; P<0.0001) and a higher perioperative morbidity (n=145, 11.5% vs. n=74, 6.1%; P<0.0001) than those not transfused. Even after adjusting for age, gender, race, ASA class, CCI score, estimated blood loss, baseline hemoglobin value, number of operated levels, and surgery type, logistic regression analysis revealed that patients with a nadir hemoglobin of 8-10 g/dL who were transfused had an independently higher risk of perioperative morbidity (odds ratio OR = 2.12; 95% confidence interval CI, 1.24-3.64; P=0.006). Estimated additional costs associated with liberal trigger use, defined as a transfusion occurring in patients with a whole hospital stay nadir Hb of 8-10 g/dL, ranged from $202,675 to $700,151 annually. Conclusions Transfusion using a liberal trigger is associated with increased morbidity, even after controlling for possible confounders. Our results suggest that modification of transfusion practice may be a potential area for improving patient outcomes and reducing costs.
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