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OBJECTIVE: The influence of social determinants of health on health disparities is substantial. However, their impact on postsurgical outcomes in spine can be challenging to ascertain at the community level. This study aims to explore the interplay between presurgical attitudes, area deprivation index (ADI), income, employment status, and body mass index (BMI) on postsurgical outcomes at 3, 6, 9, and 12 months after elective spine surgery. METHODS: The study involved 127 patients who underwent elective spine surgery between August 2021 and August 2022 at a large academic institution. The main objective involved a prospective analysis of presurgical attitudes, coupled with a retrospective assessment of ADI, income, employment status, and BMI over 3, 6, 9, and 12 months following elective spine surgery using a univariate analysis. RESULTS: Utilizing the univariate analyses, ADI displayed a significant correlation with increased Patient-Reported Outcomes Measurement Information System and Visual Analog Scale scores both before surgery and at the 3-, 6-, and 9-month postsurgical intervals (P < 0.05). One year after surgery, patients in the lowest income group (annual income under $25,000) consistently demonstrated the highest Patient-Reported Outcomes Measurement Information System pain (8.00, P = 0.022). Patients who were not employed had significantly lower levels of social support (P = 0.042) and confidence in the health care system (P = 0.009). Individuals who were unemployed were most likely to be readmitted six weeks after surgery (P < 0.001). CONCLUSIONS: Presurgical attitudes, ADI, income, employment status, and BMI were important factors associated with improved surgical outcome measurements, indicating potential focal points for combating health disparities in spinal surgery patients.
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OBJECTIVE: Basilar impression (BI) is a rare yet debilitating abnormality of the craniovertebral junction, known to cause life-threatening medullary brainstem compression. Our study analyzes surgical approaches for BI and related outcomes. METHODS: A systematic review was conducted using PubMed, Google Scholar, and Web of Science electronic databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to critically assess primary articles examining BI. RESULTS: We analyzed 87 patients from 65 articles, mostly female (55.17%) with a mean age of 46.31 ± 17.94 years, commonly presenting with motor (59.77%) and sensory deficits (55.17%). Commonly employed procedures included posterior occipitocervical fusion (24.14%), anterior decompression (20.69%), and combined anterior decompression with posterior fusion (21.84%). Patients who underwent anterior approaches were found to be older (55.38 ± 17.67 vs. 45.49 ± 18.78 years, P < 0.05) and had a longer duration from symptom onset to surgery (57.39 ± 64.33 vs. 26.02 ± 29.60 months, P < 0.05) compared to posterior approaches. Our analysis revealed a significant association between a longer duration from symptom onset to surgery and an increased likelihood of undergoing odontoidectomy and decompression (odds ratio: 1.02, 95% confidence interval: 1.00-1.03, P < 0.05). Furthermore, after adjusting for all other covariates, a history of rheumatoid arthritis and the use of a posterior approach were significantly associated with an elevated risk of postoperative complications (P < 0.05). CONCLUSIONS: The treatment approach to complex craniovertebral junction disease should be tailored to the surgeon's experience and the nature of the compressive pathology.
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OBJECTIVE: Anterior cervical spine operations are commonly performed on cervical spine pathologies and to a large extent are safe and successful. However, these surgical procedures expose the vertebral artery, posing a risk of harm to it. METHODS: A systematic review was conducted using PubMed, Google Scholar, and Web of Science electronic databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to critically assess primary articles discussing treatment strategies "vertebral artery injury" AND "anterior cervical spine" and develop a management strategy based on our experience and meta-analysis of the literature. In addition, we present an illustrative case of iatrogenic vertebral artery injury presenting with 6 to 7 months' history of progressive dysphagia was transferred to our care from an outside institution. RESULTS: Included and analyzed were 43 articles that detailed 75 cases involving vertebral artery injury (VAI) in anterior cervical spine operations. Preoperatively, frequent clinical findings reported were sensory deficit (26 patients [63.41%]), motor deficit (20 patients [48.78%]), and pain (17 patients [41.46%]). In total, 32 patients (50.00%) endured injury of their left VA, and 30 patients had a right VAI. The 2 common causes of VAI were drilling (24 patients [40.00%]) and instrumentation (8 patients [13.33%]). CONCLUSIONS: Altogether, our review recommends repair or tamponade packing with a hemostatic agent for primary management. Should tamponade packing with a hemostatic agent be used for primary management, secondary management should entail either repair, stenting occlusion, embolization, anticoagulants, or ligation. Further examination of this treatment strategy based on a larger cohort is necessary.
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Embolización Terapéutica , Procedimientos Ortopédicos , Humanos , Vértebras Cervicales/diagnóstico por imagen , Vértebras Cervicales/cirugía , Procedimientos Ortopédicos/efectos adversos , Factores de Riesgo , Arteria Vertebral/diagnóstico por imagen , Arteria Vertebral/cirugía , Arteria Vertebral/lesionesRESUMEN
Oxytocin (OT) is essential for successful reproduction, particularly during parturition and lactation. During the postpartum period, OT also influences maternal behavior to promote bonding between mothers and their newborns, and increases stress resilience. However, the mechanism by which stress influences OT neuron activity and OT release has remained unclear. Here, we provide evidence that a subpopulation of OT neurons initiate expression of the receptor for the stress neuropeptide Corticotropin Releasing Factor (CRF), CRFR1, in reproductive females. OT neuron expression of CRFR1 begins at the first parturition and increases during the postpartum period until weaning. The percentage of OT neurons that express CRFR1 increases with successive breeding cycles until it reaches a plateau of 20-25% of OT neurons. OT neuron expression of CRFR1 in reproductive females is maintained after they are no longer actively breeding. CRFR1 expression leads to activation of OT neurons when animals are stressed. We propose a model in which direct CRF signaling to OT neurons selectively in reproductive females potentiates OT release to promote stress resilience in mothers.
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Hormona Liberadora de Corticotropina , Oxitocina , Animales , Hormona Liberadora de Corticotropina/metabolismo , Femenino , Neuronas/metabolismo , Oxitocina/metabolismo , Parto , Embarazo , Receptores de Hormona Liberadora de Corticotropina/genética , Receptores de Hormona Liberadora de Corticotropina/metabolismoRESUMEN
OBJECTIVE: Red blood cell (RBC) transfusion is commonly indicated in brain tumor surgery due to risk of blood loss. Current transfusion guidelines are based on evidence derived from critically ill patients and may not be optimal for brain tumor surgeries. Our study is the first to synthesize available evidence to suggest RBC transfusion thresholds in brain tumor patients undergoing surgery. METHODS: A systematic review was conducted using PubMed, EMBASE, and Google Scholar databases in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines to critically assess RBC transfusion thresholds in adult patients with brain tumors and complications secondary to transfusion following blood loss in the operating room or perioperative period. RESULTS: Seven articles meeting our search criteria were reviewed. Brain tumor patients who received blood transfusions were older, had greater rates of American Society of Anesthesiologists class 3 or 4, and presented with increased number of comorbidities including diabetes, hypertension, and cardiovascular diseases. In addition, transfused patients had a prolonged surgical time. Transfusions were associated with multiple postoperative major and minor complications, including longer hospital length of stay, increased return to the operating room, and elevated 30-day mortality. Analysis of transfusion thresholds showed that a restrictive hemoglobin threshold of 8 g/dL is safe in patients, as evidenced by a reduction in length of stay, mortality, and complications (level C class IIa). CONCLUSIONS: A restrictive Hb threshold of 8 g/dL appears to be safe and minimizes potential complications of transfusion in brain tumor patients.
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Neoplasias Encefálicas , Transfusión de Eritrocitos , Adulto , Transfusión Sanguínea , Neoplasias Encefálicas/etiología , Neoplasias Encefálicas/cirugía , Enfermedad Crítica , Transfusión de Eritrocitos/efectos adversos , Hemoglobinas , HumanosRESUMEN
Our study aims to provide a synthesis of the best available evidence on the hemoglobin (hgb) red blood cell (RBC) transfusion thresholds in adult traumatic brain injury (TBI) patients, as well as describing the risk factors and outcomes associated with RBC transfusion in this population. A systematic review and meta-analysis was conducted using PubMed, Google Scholar, and Web of Science electronic databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to assess articles discussing RBC transfusion thresholds and describe complications secondary to transfusion in adult TBI patients in the perioperative period. Fifteen articles met search criteria and were reviewed for analysis. Compared to non-transfused, TBI patients who received transfusion tended to be primarily male patients with worse Injury Severity Score (ISS) and Glasgow Coma Scale. Further, the meta-analysis corroborated that transfused TBI patients are older (p = 0.04), have worse ISS scores (p = 0.001), receive more units of RBCs (p = 0.02), and have both higher mortality (p < 0.001) and complication rates (p < 0.0001). There were no differences identified in rates of hypertension, diabetes mellitus, and Abbreviated Injury Scale scores. Additionally, whereas many studies support restrictive (hgb <7 g/dL) transfusion thresholds over liberal (hgb <10 g/dL), our meta-analysis revealed no significant difference in mortality between those thresholds (p = 0.79). Current Class B/C level III evidence predominantly recommends against a liberal transfusion threshold of 10 g/dL for TBI patients (Class B/C level III), but our meta-analysis found no difference in survival between groups. There is evidence suggesting that an intermediate threshold between 7 and 9 g/dL, reflecting the physiological oxygen needs of cerebral tissue, may be worth exploring.
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OBJECTIVE: Surgical management of aneurysmal subarachnoid hemorrhage (SAH) often involves red blood cell (RBC) transfusion, which increases the risk of postoperative complications. RBC transfusion guidelines report on chronically critically ill patients and may not apply to patients with SAH. Our study aims to synthesize the evidence to recommend RBC transfusion thresholds among adult patients with SAH undergoing surgery. METHODS: A systematic review was conducted using PubMed, Google Scholar, and Web of Science electronic databases according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to critically assess primary articles discussing RBC transfusion thresholds and describe complications secondary to RBC transfusion in adult patients with SAH in the perioperative period. RESULTS: Sixteen articles meeting our search strategy were reviewed. Patients with SAH who received blood transfusion were older, female, had World Federation of Neurosurgical Societies grade IV-V and modified Fisher grade 3-4 scores, and presented with more comorbidities such as hypertension, diabetes, and cardiovascular and pulmonary diseases. In addition, transfusion was associated with multiple postoperative complications, including higher rates of vasospasms, surgical site infections, cardiovascular and respiratory complications, increased postoperative length of stay, and 30-day mortality. Analysis of transfused patients showed that a higher hemoglobin (>10 g/dL) goal after SAH was safe and that patients may benefit from a higher whole hospital stay hemoglobin nadir, as shown by a reduction in risk of cerebral vasospasm and improvement in clinical outcomes (level B class II). CONCLUSIONS: Among patients with SAH, the benefits of reducing cerebral ischemia and anemia are shown to outweigh the risks of transfusion-related complications.