Intramedullary spinal cord tumors: a review of current and future treatment strategies.

Intramedullary spinal cord tumors have low incidence rates but are associated with difficult treatment options. The majority of patients with these tumors can be initially treated with an attempted resection. Unfortunately, those patients who cannot undergo gross-total resection or have subtotal resection are left with few treatment options, such as radiotherapy and chemotherapy. These adjuvant treatments, however, are associated with the potential for significant adverse side effects and still leave patients with a poor prognosis. To successfully manage these patients and improve both their quality of life and prognosis, novel treatment options must be developed to supplement subtotal resection. New research is underway investigating alternative therapeutic approaches for these patients, including directed, localized drug delivery and nanomedicine techniques. These and other future investigations will hopefully lead to promising new therapies for these devastating diseases.

Treatment of intramedullary spinal cord tumors: a modified Delphi technique of the North American Spine Society Section of Spine Oncology.

OBJECTIVE: Intramedullary spinal cord tumors (IMSCTs) are rare tumors with heterogeneous presentations and natural histories that complicate their management. Standardized guidelines are lacking on when to surgically intervene and the appropriate aggressiveness of resection, especially given the risk of new neurological deficits following resection of infiltrative tumors. Here, the authors present the results of a modified Delphi method using input from surgeons experienced with IMSCT removal to construct a framework for the operative management of IMSCTs based on the clinical, radiographic, and tumor-specific characteristics. METHODS: A modified Delphi technique was conducted using a group of 14 neurosurgeons experienced in IMSCT resection. Three rounds of written correspondence, surveys, and videoconferencing were carried out. Participants were queried about clinical and radiographic criteria used to determine operative candidacy and guide decision-making. Members then completed a final survey indicating their choice of observation or surgery, choice of resection strategy, and decision to perform duraplasty, in response to a set of patient- and tumor-specific characteristics. Consensus was defined as ≥ 80% agreement, while responses with 70%-79% agreement were defined as agreement. RESULTS: Thirty-six total characteristics were assessed. There was consensus favoring surgical intervention for patients with new-onset myelopathy (86% agreement), chronic myelopathy (86%), or progression from mild to disabling numbness (86%), but disagreement for patients with mild numbness or chronic paraplegia. Age was not a determinant of operative candidacy except among frail patients, who were deemed more suitable for observation (93%). Well-circumscribed (93%) or posteriorly located tumors reaching the surface (86%) were consensus surgical lesions, and participants agreed that the presence of syringomyelia (71%) and peritumoral T2 signal change (79%) were favorable indications for surgery. There was consensus that complete loss of transcranial motor evoked potentials with a 50% decrease in the D-wave amplitude should halt further resection (93%). Preoperative symptoms seldom influenced choice of resection strategy, while a distinct cleavage plane (100%) or visible tumor-cord margins (100%) strongly favored gross-total resection. CONCLUSIONS: The authors present a modified Delphi technique highlighting areas of consensus and agreement regarding surgical management of IMSCTs. Although not intended as a substitute for individual clinical decision-making, the results can help guide care of these patients. Additionally, areas of controversy meriting further investigation are highlighted.

Outcomes Following 2-Level Cervical Interventions with Cage-and-Plate, Zero-Profile, or Arthroplasty Constructs.

BACKGROUND: Though cage-and-plate constructs are widely used for disk height restoration in surgery for cervical disc disease, concerns over range of motion limitations and adjacent disc space violations have fueled the development of artificial disc and zero-profile constructs. This study investigated the outcomes of patients undergoing two-level cervical interventions via arthroplasty, cage-and-plate, or zero-profile constructs. METHODS: Patients undergoing two-level anterior cervical procedures between 2010 and 2020 were identified using an all-payer claims database. Logistic regression models were utilized to develop criteria for a 1:1:1-exact match procedure. The primary outcome was the need for additional surgery within 30 months, and the secondary outcomes included medical and surgical complications observed within 30 days of index intervention. P values < 0.05 were considered statistically significant. RESULTS: 133,831 patients were identified as undergoing two-level anterior cervical interventions. Seven thousand three hundred seventy-one records were analyzed through a 1:1:1 match. Patients who received zero-profile versus cage-and-plate constructs had significantly decreased odds of requiring additional surgery within 30 months (Odds Ratio [OR] 0.64; 95% Confidence Interval [CI] 0.51-0.81). However, postoperative medical complications were increased among patients who received zero-profile constructs compared to cage-and-plate (OR 1.59; 95%CI 1.07-2.37). Patients who underwent arthroplasty also had decreased odds for additional surgery versus cage-and-plate (OR 0.75; 95%CI 0.60-0.93). There was no significant difference between arthroplasty and cage-and-plate constructs in developing postoperative surgical or medical complications. CONCLUSIONS: Among patients undergoing two-level interventions, cage-and-plate constructs were associated with increased odds of additional surgery within 30 months following index procedures when compared to zero-profile constructs or arthroplasty.

Life-saving hemicraniectomy for fulminant acute disseminated encephalomyelitis.

Fulminant acute disseminated encephalomyelitis (ADEM) is a rare demyelinating disorder, which most often occurs after an infection or vaccination. It frequently presents with focal neurologic signs and an altered sensorium. Patients often require critical care for airway management but are typically treated with medical therapy alone, including intravenous steroids and other immunotherapies. We present a case of dominant hemisphere fulminant ADEM in a patient who required neurosurgical intervention and a life-saving hemicraniectomy despite maximum medical therapy.

Effect of Magnetic Resonance Imaging on Surgical Approach and Outcomes in the Management of Subaxial Cervical Fractures.

BACKGROUND: In the initial evaluation of suspected cervical fracture, computed tomography (CT) is the gold standard for assessing bony anatomy and fracture morphology with high sensitivity and specificity. However, CT is relatively insensitive to ligamentous, discogenic, and myelopathic injury, leading to supplementary use of MRI, which is more sensitive and specific to these diseases. Here, we assess whether preoperative cervical spine magnetic resonance imaging (MRI) affects surgical management of subaxial cervical fractures. METHODS: The National (Nationwide) Inpatient Sample (NIS) was queried for MRI use, surgical approach, rate of operative intervention, all-cause mortality, days from admission to surgery, discharge disposition, length of hospital stay, and total hospital charges among those with closed subaxial cervical spine fractures from 2012 to 2015. The effect of MRI on these End points was evaluated, controlling for significant baseline differences in demographics, comorbidities, and presentation. RESULTS: A total of 820 patients met inclusion and exclusion criteria; 255 (31.1%) were assessed with MRI and CT, 565 (68.9%) were evaluated with CT alone. After 1:1 propensity score matching based on severity of presentation, preoperative MRI was not significantly associated with surgical approach, in-hospital mortality, discharge disposition, length of stay, or total hospital charges. Segregating patients by functional status group shows MRI use among patients presenting with moderate loss of function associated with a shorter length of time between admission and surgery (1.50 vs. 2.59 days; P = 0.027). CONCLUSIONS: The addition of MRI to CT in the evaluation of subaxial cervical spine fractures does not seem to affect surgical management.

Locum Tenens Neurosurgery in the United States: A Medicare Claims Analysis of Outcomes, Complications, and Cost of Care.

BACKGROUND: The utilization of locum tenens physicians in the United States has risen significantly as a stopgap for clinical practice needs, particularly in rural and other underserved areas. The difficulty in hiring new physicians to remote hospitals has resulted in the dependence of these institutions on locum tenens coverage. Here, we assess the quality and cost of neurosurgical care between locum and non-locum neurosurgeons in the United States, the first study in our knowledge to do so. METHODS: A 5% random sample of the Medicare claims limited data set was queried for 2005-2011 for neurosurgical cases using International Classification of Diseases, Clinical Modification, 9th edition (ICD-9-CM) procedure codes for common cranial and spine procedures. Cases were divided into locum and non-locum groups using ICD modifier Q6. The association between locum care and 30-day surgical complications, disposition, and cost of care was evaluated. RESULTS: A total of 112,397 patients met inclusion criteria, with locum tenens practitioners involved in 164 (0.15%) cases. Locum and non-locum cohorts were statistically and clinically similar at baseline, with respect to comorbidity and case type. Mortality (0.00% vs. 0.19%; P=0.739), discharge disposition (P=0.739), surgical complication rates, and length of stay (8.74 ± 12.24 vs. 10.54 ± 15.51 days; P = 0.117) did not appear to differ significantly between the 2 groups. Hospitalization costs were also similar (158,780.20 ± 223,735.50 vs. 168,104.40 ± 308,074.90 USD; P = 0.698), as were amounts paid by patients (39,197.70 ± 14,144.75 vs. 39,234.36 ± 15,467.63 USD, P = 0.976). CONCLUSIONS: Among Medicare beneficiaries, there exists no difference in short-term complication rates, lengths of hospitalization, or costs between locum and non-locum neurosurgeons.

Early versus late surgical intervention for central cord syndrome: A nationwide all-payer inpatient analysis of length of stay, discharge destination and cost of care.

OBJECTIVE: Central cord syndrome (CCS) is the most common incomplete spinal cord injury (SCI), resulting in various degrees of neurologic compromise below the level of the affected cervical cord. The management of CCS is controversial regarding not only whether to surgically intervene, but also when surgery should occur. In this study, we conduct the largest multi-center study to date examining differences in inpatient outcomes, general discharge disposition, length of stay, and cost associated with early versus late surgical intervention for CCS. PATIENTS AND METHODS: The National Inpatient Sample (NIS) was queried for years 2012-2015 for patients who underwent surgery with a primary diagnosis of CCS. The median interval between admission and intervention was noted. Patients operated upon prior to this timepoint were placed in the early surgery group, and others into the later surgery group. The groups were then compared, while using 1:1 propensity score matching to control for baseline presentation, with respect to mortality, discharge disposition, length of stay, and total charges. RESULTS: A total of 422 patients met inclusion and exclusion criteria. The median time from admission to intervention was 2 days. Patients with higher initial severity of injury were more likely to undergo early surgery. Upon controlling for severity of initial presentation, earlier intervention did not appear to affect mortality or post-operative length of stay. However, patients operated upon earlier had more favorable discharge destinations (p = 0.025) and a lower associated cost of care ($198,050.70 vs. $243,048.10, p = 0.009). CONCLUSION: Earlier surgical intervention for CCS may result in better patient disposition and less total charges. LEVEL OF EVIDENCE: III.

Dorsal thoracic spinal cord herniation: report of an unusual case and review of the literature.

BACKGROUND CONTEXT: Spinal cord herniation is a rare but well-documented condition that has been associated with tethering through the dural defect. Both spinal cord herniation and cord tethering result in progressive myelopathy that can be improved or stabilized with surgical intervention. Most cases of herniation are caused by dural defects in the ventral or ventrolateral thoracic spine, rarely occurring through the dorsal dura. This is the first reported case of a spontaneous dorsal herniation. PURPOSE: To describe a unique case of thoracic tethered cord resulting from a dorsal dural defect through which there is spinal cord herniation. STUDY DESIGN: A case report and review of the literature. METHODS: A 55-year-old man presented with progressive low back pain, paresthesias, and weakness in his left lower extremity that was exacerbated by walking. Imaging revealed a dorsal dural defect with tethering and herniation of the spinal cord at T7. RESULTS: The patient underwent a T6-T7 laminoplasty to release the tethered cord and repair the dural defect. At 1-year follow-up, the patient noted improvement in strength and back spasticity. CONCLUSIONS: Spinal cord herniation through a dural defect is an uncommon but important cause of symptomatic tethered cord in adults. Surgical intervention can significantly alter the course and prevent further disability.

Handoffs in the era of duty hours reform: a focused review and strategy to address changes in the Accreditation Council for Graduate Medical Education Common Program Requirements.

With changes in the Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements related to transitions in care effective July 1, 2011, sponsoring institutions and training programs must develop a common structure for transitions in care as well as comprehensive curricula to teach and evaluate patient handoffs. In response to these changes, within the Duke University Health System, the resident-led Graduate Medical Education Patient Safety and Quality Council performed a focused review of the handoffs literature and developed a plan for comprehensive handoff education and evaluation for residents and fellows at Duke. The authors present the results of their focused review, concentrating on the three areas of new ACGME expectations--structure, education, and evaluation--and describe how their findings informed the broader initiative to comprehensively address transitions in care managed by residents and fellows. The process of developing both institution-level and program-level initiatives is reviewed, including the development of an interdisciplinary minimal data set for handoff core content, training and education programs, and an evaluation strategy. The authors believe the final plan fully addresses both Duke's internal goals and the revised ACGME Common Program Requirements and may serve as a model for other institutions to comprehensively address transitions in care and to incorporate resident and fellow leadership into a broad, health-system-level quality improvement initiative.