Laser interstitial thermal therapy (LITT) for intracranial lesions: a single-institutional series, outcomes, and review of the literature.

INTRODUCTION: Laser interstitial thermal therapy (LITT) is a minimally invasive treatment method in managing primary brain neoplasms, brain metastases, radiation necrosis, and epileptogenic lesions, many of which are located in operative corridors that would be difficult to address. Although the use of lasers is not a new concept in neurosurgery, advances in technology have enabled surgeons to perform laser treatment with the aid of real-time MRI thermography as a guide. In this report, we present our institutional series and outcomes of patients treated with LITT. METHODS: We retrospectively evaluated 19 patients (age range, 28-77 years) who underwent LITT at one or more targets from 2015 to 2019. Primary endpoint observed was mean progression free survival (PFS) and overall survival (OS). RESULTS: Seven patients with glial neoplasms and 12 patients with metastatic disease were reviewed. Average hospitalization was 2.4 days. Median PFS was 7 and 4 months in the metastatic group and primary glial neoplasm group, respectively (p = 0.01). Median OS from time of diagnosis was 41 and 32 months (p = 0.02) and median OS after LITT therapy was 25 and 24 months (p = 0.02) for the metastatic and primary glial neoplasm groups, respectively. One patient experienced immediate post-procedural morbidity secondary to increased intracerebral edema peri-lesionally while one patient experienced post-operative mortality and expired secondary to hemorrhage 1-month post-procedure. Median follow-up was 10 months. CONCLUSION: Laser interstitial thermal therapy (LITT) is a safe, minimally invasive treatment method that provides surgeons with cytoreductive techniques to treat neurosurgical conditions. Both PFS and OS appear to be more favorable after LITT in patients with metastatic disease. In properly selected patients, this modality offers improved survival outcomes in conjunction with other salvage therapies.

Cationic Hyperbranched Polymers with Biocompatible Shells for siRNA Delivery.

Cationic hyperbranched polymers (HBP) were prepared by self-condensing vinyl polymerization of an atom transfer radical polymerization (ATRP) inimer containing a quaternary ammonium group. Two types of biocompatible shells, poly(oligoethylene glycol) methacrylate (polyOEGMA) and poly(2-(methylsulfinyl) ethyl methacrylate) (polyDMSO), were grafted respectively from HBP core to form core-shell structures with low molecular weight dispersity and high biocompatibility, polyOEGMA-HBP and polyDMSO-HBP. Both of the structures showed low cytotoxicity and good siRNA complexing ability. The efficacy of gene silencing against Runt-related transcription factor 2 ( Runx2) expression and the long-term assessment of mineralized nodule formation in osteoblast cultures were evaluated. The biocompatible core-shell structures were crucial to minimizing undesired cytotoxicity and nonspecific gene suppression. polyDMSO-HBP showed higher efficacy of forming polyplexes than polyOEGMA-HBP due to shell with lower steric hindrance. Overall, the gene silencing efficiency of both core-shell structures was comparable to commercial agent Lipofectamine, indicating long-term potential for gene silencing to treat heterotopic ossification (HO).

Factor Eight Inhibitor Bypassing Agent (FEIBA) for Reversal of Target-Specific Oral Anticoagulants in Life-Threatening Intracranial Bleeding.

INTRODUCTION: As increasing number of patients present to emergency departments with life threatening hemorrhages, particularly intracranial hemorrhage on anticoagulation physicians must be cognizant of the limitations of the available reversal options. Based upon the available literature, our institution formulated a reversal algorithm for patients with life-threatening bleeding on factor Xa inhibitors by administering factor eight inhibitor bypassing agent (FEIBA) 20 units/kg. METHODS: A retrospective chart review was performed to include all patients who received FEIBA per institutional protocol. This case series excluded patients who received FEIBA for reversal of dabigatran. Pre and post FEIBA CT scans were compared for changes. Finally, patients were stratified by estimated mortality rates calculated based on pre-intervention characteristics via published risk models. RESULTS: Thirteen patients were initially included in this study yet two patients were excluded because they were on dabigatran. Fifty-five percent of patients demonstrated stable ICH on CT scan after FEIBA administration while thirty-six percent showed worsening scans. Two patients developed thrombotic events after FEIBA administration. DISCUSSION: FEIBA is a treatment option in patients on a TSOA with acute intracranial hemorrhage with evidence of at least partial pharmacologic reversal of their anticoagulation status. There does not appear to be any major risk of thromboembolic complications associated with FEIBA. Much larger study sizes will be necessary to establish statically significant clinical efficacy for FEIBA use in this patient population. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency medicine physicians are first-line caretakers for patients with life threatening intracranial hemorrhages whether spontaneous or traumatic. FEIBA is a potentially safe option to reverse TSOA in this patient population.

Spinal brachytherapy.

Brachytherapy remains an underrecognized and underutilized radiation therapy modality for the treatment of spinal tumors. This article summarizes the existing body of medical literature on the usage, indications, techniques, and outcomes of brachytherapy for the treatment of spine tumors. The disease pathology most commonly treated with brachytherapy is metastatic spine cancer, rather than primary bone tumors of the spine. Brachytherapy can be used alone, as percutaneous needle injections; however, it is more often used in conjunction with open surgery or cement vertebral body augmentation. Although the data are still relatively sparse, studies show consistent benefit from brachytherapy in terms of improvements in pain, function, local recurrence rate, and overall survival. Brachytherapy is also associated with a favorable complication profile.

Endoscope-Assisted Retroperitoneal Prepsoas Approach to Lumbar Intervertebral Disk Decompression. Technical Note.

BACKGROUND: Increasingly there is an impetus on the part of surgeons to find more minimally invasive approaches to treat spinal pathologies. Retroperitoneal prepsoas and transpsoas approaches to the lumbar spine are one such example gaining increased attention. Endoscope-assisted approaches may help further reduce soft tissue dissection. OBJECTIVE: To describe an endoscope-assisted lateral retroperitoneal prepsoas approach for lumbar diskectomy. METHODS: Two fresh-frozen thoracolumbar cadaveric specimens were obtained and placed in the right lateral decubitus position. Using a left-sided, retroperitoneal prepsoas approach to the lumbar spine and under endoscopic visualization, diskectomies were performed at the L2/3, L3/4, L4/5, and L5/S1 intervertebral spaces. Qualitative assessment of the extent of central and contralateral foraminal decompression was performed. RESULTS: The endoscope was found to provide effective visualization at all disk spaces and combined with the anterior retroperitoneal prepsoas approach allowed for effective decompression of all explored disk spaces. Both operators noted difficulty obtaining visualization of the ipsilateral foramen, but adequate central and contralateral foraminal decompression was achievable for central, paracentral, and contralateral far lateral disk protrusions. CONCLUSION: Endoscope assistance may improve visualization of the lumbar intervertebral disk spaces during retroperitoneal prepsoas approaches and thereby help to expand the surgical indication for anterior and oblique lumbar interbody fusion.

Fifty years later: the "rule of Spence" is finally ready for retirement.

Determination of the optimal approach to traumatic atlas fractures with or without transverse atlantal ligament (TAL) injury requires a nuanced understanding of the biomechanics of the atlantoaxial complex. The "rule of Spence" (ROS) was created in 1970 in a landmark effort to streamline management of burst-type atlas fractures. The ROS states that radiographic evidence of lateral mass displacement (LMD) (i.e., the distance that the C1 lateral masses extend beyond the C2 superior articular processes) greater than 6.9 mm may indicate both a torn TAL and need for surgical management. Since then, the ROS has become ubiquitous in the spine literature about atlas injuries. However, in the decades since the original paper by Spence et al., modern research efforts and imaging advancements have revealed that the ROS is inaccurate on both fronts: it neither accurately predicts a TAL injury nor does it inform surgical decision-making. The purpose of this review was to delineate the history of the ROS, demonstrate its limitations, present findings in the existing literature on ROS and LMD thresholds, and discuss the current landscape of management techniques for TAL injuries, including parameters such as the atlantodental interval and type of injury according to the Dickman classification system and AO Spine upper cervical injury classification system. The ROS was revolutionary for initially investigating and later propelling the biomechanical and clinical understanding of atlas fractures and TAL injuries; however, it is time to retire its legacy as a rule.

Case Series of Skull Base Meningioma Resection in the Octogenarian Population.

Introduction The geriatric population is the fastest growing segment of the American population, and octogenarians are increasingly seen by neurosurgeons for relatively common lesions such as meningiomas. Unfortunately, providers do not have clear data to guide decision-making regarding these lesions, particularly if they involve the skull base. Current research in outcomes among the elderly looks at a wide range of ages, often anyone older than 65. Previous studies in octogenarians report a wide-range of mortality rates and do not focus on skull base lesions. This paper strives to clarify the experiences and outcomes of octogenarians. Patients and Methods This retrospective series reviews skull base tumor surgeries performed at a single academic institution over the past 15 years in octogenarian patients. Primary endpoint was 30-day mortality; however, potential risk factors, perioperative morbidity, postdischarge disposition, and longer term follow-up were also captured. Multivariate logistic regression was performed to identify relevant perioperative and medical characteristics that increases the risk of adverse events. Results Fourteen patients underwent craniotomies for skull base procedures with an average age of 84.5, with a 14% 30-day mortality rate. One patient required a tracheostomy on discharge and approximately half were able to either go home or rehabilitation after their procedure. On statistical analysis, there were no noted characteristics that predisposed any of the patients to a poorer outcome. Conclusion Octogenarian patients were able to tolerate surgery for skull base meningiomas resection. This outcome data may be used to inform surgical decision and guide conversation with patients and their families.

Craniocervical instability in patients with Ehlers-Danlos syndrome: controversies in diagnosis and management.

Ehlers-Danlos syndrome (EDS) is a rare hereditary condition that can result in ligamentous laxity and hypermobility of the cervical spine. A subset of patients can develop clinical instability of the craniocervical junction associated with pain and neurological dysfunction, potentially warranting treatment with occipitocervical fixation (OCF). Surgical decision-making in patients with EDS can be complicated by difficulty distinguishing from hypermobility inherent in the disease and true pathological instability necessitating intervention. Here we comprehensively review the available medical literature to critically appraise the evidence behind various proposed definitions of instability in the EDS population, and summarize the available outcomes data after OCF. Several radiographic parameters have been used, including the clivo-axial angle, basion-axial interval, and pB-C2 measurement. Despite increasing recognition of EDS by spine surgeons, there remains a paucity of data supporting proposed radiographic parameters for spinal instability among EDS patients. Furthermore, there is a lack of high-quality evidence concerning the efficacy of surgical treatments for chronic debilitating pain prevalent in this population. More standardized clinical measures and rigorous study methodologies are needed to elucidate the role of surgical intervention in this complex patient population.

Vascular Myelopathy Secondary to Compression of the Artery of Adamkiewicz From an Intrathecal Catheter: A Technical Case Report.

BACKGROUND AND IMPORTANCE: Although catheter-related complications in intrathecal drug delivery systems are relatively common, vascular myelopathy secondary to occlusion of the artery of Adamkiewicz (AoA) from an abutting intrathecal catheter has not yet been reported. In this study, we present a case of this extremely rare presentation, which resolved after decompression of the artery. CLINICAL PRESENTATION: A 39-year-old woman presented with lower extremity weakness and paresthesia. She had a 20-year history of severe chronic back pain and stable sensory disturbances below T8 as sequelae of multiple injuries after a motor vehicle accident. Three years before presentation in our clinic, she underwent baclofen pump placement because of neuropathic pain refractory to oral medication. After pump placement, she gradually developed myelopathic symptoms and dysautonomia. All medications through the pump were discontinued, but her symptoms continued to progress. Workup included a spinal angiogram that showed that her intrathecal catheter was abutting the left side of the AoA at the T12 level. After interdisciplinary evaluation, it was believed that her clinical presentation was attributable to vascular compression, and she underwent surgical removal of the catheter. Three years later, her symptoms have improved and her neurological examination returned to baseline before the catheter placement. CONCLUSION: Meticulous, multidisciplinary neurological and radiological evaluations were essential to diagnose the compression of the AoA as the cause of this patient's myelopathy. Although exceedingly rare, direct compression of the AoA by an intrathecal catheter should be on the differential diagnosis when evaluating for causes of vascular myelopathy.

The clinical impact and safety profile of high-dose intra-arterial verapamil treatment for cerebral vasospasm following aneurysmal subarachnoid hemorrhage.

BACKGROUND: Cerebral vasospasm (CVS) leads to delayed cerebral ischemia (DCI) and cerebral infarction, a potential cause of morbidity and mortality following aneurysmal subarachnoid hemorrhage (aSAH). The objective of this study was to evaluate the clinical efficacy and safety profile of high-dose IA verapamil for aSAH in a large series of patients. METHODS: Between 2011-2019, a retrospective cohort of 188 consecutive patients presenting with aSAH were reviewed. High-dose IA verapamil (> 20 mg per vascular territory on each side) was intermittently used for appropriate patients to manage symptomatic CVS. Of the 188 patients reviewed, 86 were treated with high-dose IA verapamil. The clinical efficacy and safety profile of our ruptured aneurysm patient cohort were compared to historical literature controls. The primary endpoints studied included radiographic stroke corresponding to cerebral vasospasm, clinical outcome at discharge and subsequent follow-up, and overall functional status as defined by the modified Rankin scale (mRS). The safety profile of high dose IA verapamil was a secondary endpoint. RESULTS: IA verapamil was delivered between 2-16 days after ictus (median post-bleed day 6) and 74 % of patients had documented clinical improvement after therapy, with 61.5 % achieving good functional outcomes (mRS < 2). 25.5 % of all patients had evidence of vasospasm-related DCI. 3 patients sustained transient hemodynamic changes after verapamil treatment and 10 patients developed post-procedural seizures successfully managed with intravenous lorazepam. CONCLUSION: High-dose IA verapamil treatment is well-tolerated in the high-risk aneurysmal subarachnoid hemorrhage population that experience severe, symptomatic CVS with good functional outcomes at follow-up.

Neurologic Complications in Monitored versus Unmonitored Image-Guidance Assisted Posterior Lumbar Instrumentation.

BACKGROUND: Intraoperative neurophysiologic monitoring (IOM) has been used clinically since the 1970s and is a reliable tool for detecting impending neurologic compromise. However, there are mixed data as to whether long-term neurologic outcomes are improved with its use. We investigated whether IOM used in conjunction with image guidance produces different patient outcomes than with image guidance alone. METHODS: We reviewed 163 consecutive cases between January 2015 and December 2018 and compared patients undergoing posterior lumbar instrumentation with image guidance using and not using multimodal IOM. Monitored and unmonitored surgeries were performed by the same surgeons, ruling out variability in intersurgeon technique. Surgical and neurologic complication rates were compared between these 2 cohorts. RESULTS: A total of 163 patients were selected (110 in the nonmonitored cohort vs. 53 in the IOM cohort). Nineteen signal changes were noted. Only 3 of the 19 patients with signal changes had associated neurologic deficits postoperatively (positive predictive value 15.7%). There were 5 neurologic deficits that were observed in the nonmonitored cohort and 8 deficits observed in the monitored cohort. Transient neurologic deficit was significantly higher in the monitored cohort per case (P < 0.0198) and per screw (P < 0.0238); however, there was no difference observed between the 2 cohorts when considering permanent neurologic morbidity per case (P < 0.441) and per screw (P < 0.459). CONCLUSIONS: The addition of IOM to cases using image guidance does not appear to decrease long-term postoperative neurologic morbidity and may have a reduced diagnostic role given availability of intraoperative image-guidance systems.

Transcranial Dopplers Revisited: Development of Novel Markers for Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage.

Background Cerebral vasospasm has been monitored by conventional angiography or transcranial Doppler (TCD). While angiography is the most accurate and reliable method for detection, TCDs are a noninvasive alternative to monitor onset and resolution of vasospasm. We aim to determine whether alternative TCD parameters rather than Lindegaard ratio lead to an improved method to diagnose and potentially prevent cerebral vasospasm. Methods A total of 103 consecutive patients with subarachnoid hemorrhage (SAH) were retrospectively reviewed and TCD studies were performed during the first 14 days post-bleed or longer if indicated. Multivariate logistic regression models were developed using significant univariate characteristics. Receiver operating characteristic (ROC) curves evaluated the mean middle cerebral artery (MCA), peak systolic MCA (PSV MCA), and end diastolic MCA (EDV MCA) velocities as well as ratios when compared to the ipsilateral extracranial internal carotid artery (ICA). The area under the curve was calculated to compare accuracy for symptomatic vasospasm. Results Thirteen patients (12.6%) were observed to develop cerebral vasospasm. Aneurysm location (p = 0.51), Hunt and Hess grade (p = 0.44), Fischer grade (p = 0.87), comorbidities, age (p = 0.67), or gender (p = 0.41) did not appear to have any effect in predicting the presence of vasospasm. ROC curves demonstrated that MCA EDV appeared to be slightly better compared to MCA velocity in predicting symptomatic vasospasm. PSV MCA/extracranial ICA and the EDV MCA/extracranial ICA ratios appeared to be an improvement to the Lindegaard ratio in the prediction of symptomatic vasospasm. Conclusion The utility of peak systolic and end diastolic velocities, instead of the classically referenced mean velocities and Lindegaard ratio, may improve diagnostic sensitivity of cerebral vasospasm after subarachnoid hemorrhage.

The transpalpebral approach "eyelid incision" for surgical management of intracranial tumors: A 10-years' experience.

BACKGROUND: The minimally invasive approaches to the anterior skull base region through fronto-orbital craniotomy remain a highly accepted option that gains countenance and predilection over time. The transpalpebral "eyelid" incision is an under-utilized and more recent technique that offers a safe efficient corridor to manage a wide variety of lesions. METHODS: We carried a retrospective study of 44 patients operated on by the fronto-orbital craniotomy through transpalpebral "eyelid" incision for intracranial tumors, in the time period from March 2007 to July 2016. The results from surgeries were analyzed; extent of tumor resection, length of hospital stay, cosmetic outcome, and complications. RESULTS: Out of the 44 intracranial tumor cases, we had 16 male and 28 female patients with median age 54 years. We had 19 anterior skull base lesions, 8 middle skull base lesions and 8 parasellar lesions. We also operated on four frontal intraparenchymal lesions and four other various lesions. Total resection was achieved in 32 cases (72.7%), with excellent cosmetic outcome in 43 cases (97.7%). Average hospital stay was 6 days. No major complications recorded. Three cases (6.8%) had complications that varied between pseudomeningocele, wound infections, and facial pain. Follow-up average period was 23.6 months. CONCLUSION: The fronto-orbital approach through eyelid incision remains a reliable approach to the skull base. It provides natural anatomical dissection planes through the eyelid incision and a fronto-orbital craniotomy, creating a wide surgical corridor to manage specific lesions with consistent surgical and cosmetic outcome.

The use of hospital consumer assessment of healthcare services and the Press Ganey medical practice surveys in guiding surgical patient care practices.

BACKGROUND: Patient satisfaction questionaries have become popular in the past decade after the institution of the Patient Care and Affordable Care Act of 2010. This study evaluated whether the Hospital Consumer Assessment of Healthcare Services (H-CAHPS) and Press Ganey scores improved after institutional changes to the rounding system. METHODS: In the summer of 2017, utilizing H-CAHPS and Press Ganey scores, we asked whether switching from mid-level rounding providers to resident physicians improved patient care. Pre- and post-intervention groups, each lasting four quarters, were divided into care provided by mid-level personnel versus residents. For these periods, H-CAHPS respondent data were compared by a Chi-squared test (P < 0.05), while Press Ganey responses were analyzed with an independent samples t-test (P < 0.05). RESULTS: Significant improvement was noted in patients answering "Definitely yes" in recommending our institution in both H-CAHPS and Press Ganey satisfaction surveys. Significant improvement regarding the speed of discharge, instructions for post-hospital care, and the overall rating of care given was observed in the Press Ganey responses alone. CONCLUSION: Significant improvement in satisfaction was noted in the Press Ganey responses regarding the discharge process and speed of discharge. The quality of this last encounter likely contributed to+ the significant improvement observed in both the H-CAPHS and Press Ganey Scores for an overall hospital stay and the percentage of those definitely recommending our institution.

Transpalpebral Approach "Eyelid Incision" for Surgical Treatment of Intracerebral Aneurysms: Lessons Learned During a 10-Year Experience.

BACKGROUND: The classic pterional, pretemporal, and orbitozygomatic approaches achieve large areas of exposure with easy maneuverability. In select cases (eg, some anterior circulation aneurysms), the minimally invasive fronto-orbital craniotomy can yield adequate exposure that must be balanced with its risk of frontalis injury. OBJECTIVE: To detail a 10-yr experience using the transpalpebral approach, characterized by an incision whose camouflage is the natural eyelid crease, notably the effectiveness and outcomes of this exposure for anterior circulation aneurysms. METHODS: In this retrospective review, 82 patients with 88 aneurysms underwent a supraorbital frontal minicraniotomy via the eyelid incision performed by a single neurosurgeon and closure by an oculoplastic surgeon (2007-2016). Incision of the orbiculi oculi developed a plane between the muscle and orbital septum superiorly. Outcomes recorded included aneurysm occlusion or residual, treatment modality (clipping/wrapping), postoperative hemorrhage or stroke, postoperative wound healing, and overall cosmesis. RESULTS: Of 85 (97%) aneurysms treated by clipping, postoperative and follow-up imaging showed complete obliteration in 81 (95%) aneurysms and residuals in 4 (5%). Cosmetic outcomes for the eyelid incision were excellent: 81 (99%) patients noted excellent wound healing at follow-up and no scarring; 1 patient developed significant temporalis wasting and upper eyelid scarring after posterior communicating artery aneurysm clipping. Overall, 13 minor and 8 major complications affected 19 patients. CONCLUSION: Our findings confirm the versatility of the eyelid supraorbital frontal minicraniotomy for common anterior circulation aneurysms. This large series found that postoperative complication risks were similar to traditional techniques and cosmetic results were excellent.

Single-Surgeon Direct Comparison of O-arm Neuronavigation versus Mazor X Robotic-Guided Posterior Spinal Instrumentation.

OBJECTIVE: We sought to compare intraoperative surgical instrumentation techniques with image-guidance versus robotic-guided procedures for posterior spinal fusion. METHODS: A retrospective review of institutional data collected from a single surgeon was used to compare surgical outcomes between O-arm neuronavigation and the Mazor X robotic-assistance system for placement of posterior spinal instrumentation in a consecutive series of patients. Univariate statistical significance testing compared time spent in the operating room, blood loss, screw accuracy, and wound healing. RESULTS: Between January 2017 and February 2019, 46 O-arm cases (mean age 59.6 years ± 13.7 years) and 39 Mazor X cases (mean age 59.5 years ± 12.4 years) were conducted. Cases were classified as degenerative, infectious, oncologic, and trauma with a mean of 4.57 and 5.43 levels operated on using O-arm neuronavigation and Mazor X, respectively. Mean operative times (P = 0.124), estimated blood loss (P = 0.212), wound revision rates (P = 0.560), and clinically acceptable instrumentation placement (P = 0.076) did not demonstrate significance between the 2 groups. However, screw placement was significantly more accurate and precise (P = 1 × 10-9) with robotic assistance when considering Gertzbein-Robbins A placement. CONCLUSIONS: Although a trend toward greater accuracy was noticed with robotic technology when determining clinically acceptable screws, there was not a significant difference when compared with O-arm neuronavigation. However, robotic technology has a significant effect on both precision and accuracy in Gertzbein-Robbins A screw placement. Robotics does not have a clear advantage when discussing infection rates, intraoperative blood loss, or operative time.

Long-term outcomes of pediatric arteriovenous malformations: the 30-year Pittsburgh experience.

OBJECTIVE: The study of pediatric arteriovenous malformations (pAVMs) is complicated by the rarity of the entity. Treatment choice has often been affected by the availability of different modalities and the experience of the providers present. The University of Pittsburgh experience of multimodality treatment of pAVMs is presented. METHODS: The authors conducted a retrospective cohort study examining 212 patients with pAVM presenting to the University of Pittsburgh between 1988 and 2018, during which patients had access to surgical, endovascular, and radiosurgical options. Univariate analysis was performed comparing good and poor outcomes. A poor outcome was defined as a modified Rankin Scale (mRS) score of ≥ 3. Multivariate analysis via logistic regression was performed on appropriate variables with a p value of ≤ 0.2. Seventy-five percent of the cohort had at least 3 years of follow-up. RESULTS: Five patients (2.4%) did not receive any intervention, 131 (61.8%) had GKRS alone, 14 (6.6%) had craniotomies alone, and 2 (0.9%) had embolization alone. Twenty-two (10.4%) had embolization and Gamma Knife radiosurgery (GKRS); 20 (9.4%) had craniotomies and GKRS; 8 (3.8%) had embolization and craniotomies; and 10 (4.7%) had embolization, craniotomies, and GKRS. Thirty-one patients (14.6%) were found to have poor outcome on follow-up. The multivariate analysis performed in patients with poor outcomes was notable for associations with no treatment (OR 18.9, p = 0.02), hemorrhage requiring craniotomy for decompression alone (OR 6, p = 0.03), preoperative mRS score (OR 2.1, p = 0.004), and Spetzler-Martin score (OR 1.8, p = 0.0005). The mean follow-up was 79.7 ± 62.1 months. The confirmed radiographic obliteration rate was 79.4% and there were 5 recurrences found on average 9.5 years after treatment. CONCLUSIONS: High rates of long-term functional independence (mRS score of ≤ 2) can be achieved with comprehensive multimodality treatment of pAVMs. At this center there was no difference in outcome based on treatment choice when accounting for factors such as Spetzler-Martin grade and presenting morbidity. Recurrences are rare but frequently occur years after treatment, emphasizing the need for long-term screening after obliteration.

Clinical Outcomes After Spine Surgery for Traumatic Injury in the Octogenarian Population.

OBJECTIVE: To review the surgical outcomes of the octogenarian population at a single institution after spinal traumatic injury. METHODS: Patients with both radiographic and clinical evidence of acute traumatic spine injury were reviewed using an institutional trauma survey to determine patient demographics and outcome data in a population of patients aged 80 years and older. RESULTS: Thirty-nine patients aged 80 years and older underwent surgical intervention for acute spinal trauma. There were 25 cases of cervical spine and 14 cases of thoracolumbar spine surgical intervention. Falls were the number one cause of acute spinal injury (31/39, 71%). Major respiratory disorders were the most common postoperative adverse event (12/39, 31%). Five patients experienced superficial wound dehiscence, fascial dehiscence, superficial infection, or delayed wound erosion. Patients were either discharged to home (10.5%), inpatient rehabilitation, (38.5%), skilled nursing facilities (17.9%), or long-term care facilities (17.9%). The postoperative mortality was 10.3%. CONCLUSIONS: Although the octogenarian population has increased risk for postoperative events after acute spinal injuries, surgical intervention may be worthwhile in the elderly population. Although direct surgical complication rates are not higher, medical risks are significantly higher after surgery.

Covalent Attachment of P15 Peptide to Ti Alloy Surface Modified with Polymer to Enhance Osseointegration of Implants.

Titanium (Ti) and its alloys are used in orthopedic and dental implants due to their excellent physical properties and biocompatibility. Although Ti exhibits superior osteoconductive properties compared to those of polymer-based implants, improved bone-on growth properties are required for enhanced surgical outcomes and improved recovery surgical interventions. Herein, we demonstrate a novel surface modification strategy to enhance the osteoconductivity of Ti surfaces through the grafting-from procedure of a reactive copolymer via surface-initiated atom transfer radical polymerization (SI-ATRP). Then, postpolymerization conjugation of the P15 peptide, an osteoblast binding motif, was successfully carried out. Subsequent in vitro studies revealed that the surface modification promoted osteoblast attachment on the Ti discs at 6 and 24 h. Moreover, mineral matrix deposition by osteoblasts was greater for the surface-modified Ti than for plain Ti and P15 randomly absorbed onto the Ti surface. These results suggest that the strategy for postpolymerization incorporation of P15 onto a Ti surface with a polymer interface may provide improved osseointegration outcomes, leading to enhanced quality of life for patients.

Vagal Nerve Stimulation: Indications for Revision in Adult Refractory Epilepsy.

OBJECTIVE: The goal of this study was to assess the indications of revision for vagal nerve stimulation at a single institution in an adult population with drug-resistant epilepsy. METHODS: This was a retrospective review of a prospectively collected database who underwent vagal nerve stimulator implantation for drug-resistant epilepsy during 1992-2017. Patients receiving vagal nerve stimulation (VNS) implants were monitored throughout their perioperative and postoperative course and were classified according to type of seizure at the time of diagnosis and indications for VNS revision. In addition, response to dysfunctional VNS devices or adverse effects were noted. RESULTS: Most patients receiving VNS implants were given a diagnosis of complex partial seizures (CPSs) before implantation (95.1%). Other epileptic conditions identified requiring implantation included generalized seizures, generalized-atonic seizures, Lennox-Gastaut syndrome, CPS or generalized seizures, and tuberous sclerosis (with generalized characteristics). High lead impedance was the most common indication for revision (5.6%), whereas device ineffectiveness leading to continued seizures was the most common indication for removal (2.3%). Infection, lead fracture, and dual- to single-pin lead battery changes occurred at an incidence of 1.9%, requiring either implant removal or revision. Other events that occurred, albeit rarely, included skin extrusion (0.5%), postoperative hematoma (0.5%), and implant rejection (0.5%) necessitating removal. CONCLUSIONS: VNS implantation in adults was shown to be a well-tolerated procedure. In addition, indications for revision or removal of the VNS device was low in this population with lead fracture rates lower than the incidence reported in pediatric population literature.