Effect of perioperative anticoagulant prophylaxis in patients with traumatic subdural hematoma and a history of anticoagulant use: a propensity-matched National Trauma Data Bank analysis.

OBJECTIVE: The use of anticoagulation to prevent venous thromboembolism (VTE) is controversial in the setting of neurosurgical decompression for traumatic subdural hematoma (SDH). In these patients, there is concern that anticoagulation may cause secondary hemorrhage, increasing the risk of death and other complications. Patients with a history of anticoagulant use are at further risk of VTE, but the effect of VTE prophylaxis (VTEP) following neurosurgery for SDH has not been thoroughly investigated in this population. This study aims to investigate the differences in in-hospital outcomes in patients with SDH and preexisting anticoagulant use who received VTEP following neurosurgical intervention compared with those who did not. METHODS: The National Trauma Data Bank was queried from 2017 to 2019 for all patients with preexisting anticoagulant use presenting with an SDH who subsequently underwent neurosurgical intervention. Patients who received VTEP were propensity score matched with patients who did not based on demographics, insurance type, injury severity, and comorbidities. Paired Student t-tests, Pearson's chi-square tests, and Benjamini-Hochberg multiple comparisons correction were used to compare differences in in-hospital complications, length of stay (LOS), and mortality rate between the two groups. A logistic regression model was developed to identify risk factors for in-hospital mortality. RESULTS: Two thousand seven hundred ninety-four patients matching the inclusion criteria were identified, of whom 950 received VTEP. Following one-to-one matching and multiple comparisons correction, the VTEP group had a lower mortality rate (18.53% vs 34.53%, p < 0.001) but longer LOS (14.09 vs 8.57 days, p < 0.001) and higher rates of pressure ulcers (2.11% vs 0.53%, p = 0.01), unplanned intensive care unit admission (9.05% vs 3.47%, p < 0.001), and unplanned intubation (9.47% vs 6.11%, p = 0.021). The multivariable logistic regression showed that use of unfractionated heparin (UH; OR 0.36, p < 0.001) and low-molecular-weight heparin (LMWH; OR 0.3, p < 0.001) were associated with lower odds of in-hospital mortality. CONCLUSIONS: In patients with traumatic SDH and a history of anticoagulant use, perioperative VTEP was associated with increased LOS but provided a mortality benefit. LMWH and UH use were the strongest predictors of survival.

Racial disparities in incidence, treatment, and survival in adult brain metastases: a 10-year national database analysis.

OBJECTIVE: The aim of this study was to assess demographic and racial disparities in incidence, treatment, and survival of adults with metastatic malignancy to the brain. METHODS: Using the Surveillance, Epidemiology, and End Results (SEER) Program database, the authors identified adults with nonprimary brain metastases between 2010 and 2019. Incidence was calculated for all 10 years while data from 2010 to 2014 were used for survival analysis. The primary outcome measure was all-cause mortality within 5 years, assessed by 6-month, 1-year, 2-year, and 5-year survival rates. Chi-square tests of independence and one-way ANOVA were used to compare categorical and continuous measures, respectively, between non-Hispanic White (NHW), Hispanic White (HW), Black, and Asian/Pacific Islander (API) patients. A multivariable Cox proportional hazards model was developed to evaluate the risk of death within 5 years. RESULTS: A total of 64,690 patient records were identified and analyzed following exclusion based on age (patients > 84 years or < 18 years were excluded), missing race data, and missing survival data. Incidences are reported per 100,000 adults. The incidence of brain metastases increased from 2.59 in 2010 to 2.78 in 2019, with an average 10-year incidence of 2.72. API patients had the highest population-adjusted incidence (3.52), followed by NHW (2.99), Black (2.32), and HW (1.59) patients. Black patients were the most likely to have low income and single status, while API patients were the most likely to have high income and married status. Subsequently, Black patients had the shortest survival time (9.05 months vs 9.19 months for NHW vs 12.93 months for HW vs 15.89 months for API patients, p < 0.001). After controlling for the effect of socioeconomic factors on survival, the multivariable analysis showed that Black (HR 0.91, 95% CI 0.88-0.94), HW (HR 0.73, 95% CI 0.69-0.76), and API (HR 0.69, 95% CI 0.66-0.73) patients all had a survival advantage compared with NHW patients. Surgery also conferred a strong survival advantage (HR 0.47, 95% CI 0.44-0.49). CONCLUSIONS: The incidence of brain metastases has increased slightly between 2010 and 2019, with the highest rate in API patients. Black patients had the lowest survival, potentially due to poor socioeconomic status and lower rates of surgery and chemotherapy. Black patients were the most likely to not be recommended surgery, suggesting a discrepancy in services offered to these patients. More research is warranted to understand the underlying causes of these disparities.

Characteristics of work-related spine injury in the USA: a National Trauma Data Bank analysis.

PURPOSE: Workplace injury is a commonplace occurrence in the USA. Spine injuries are especially devastating as they can cause chronic pain and limit mobility which prevents patients from returning to work. Gaining a better understanding of the patients, mechanisms, and treatments associated with these injuries can aid in improving outcomes. The purpose of this study is to characterize the nature of work-related spine injuries. METHODS: The National Trauma Data Bank was queried from 2017 to 2019 for all diagnoses involving the cervical, thoracic, lumbar, and sacral spine. Patient demographics, comorbidities, injury characteristics, spinal diagnoses, and procedures were identified for each occupation. Occupational industries, patient demographics, mechanisms of injury, diagnoses, and spinal procedures were characterized. RESULTS: A total of 100,842 work-related injuries were identified between 2017 and 2019. Of those, 19,002 (19%) were spine injuries, and subsequently, 3963 (21%) required spinal surgery. Eight thousand twenty-nine (42%) cases were seen among construction workers, which had the highest proportion of Hispanic patients (36%). Smoking was prevalent in labor-intensive occupations with high rates of spine injury such as building and grounds maintenance. The most common mechanism of injury was a fall from a roof. The most common injury diagnoses were L1, L2, and L3 fractures, and the most common procedures were T12-L1 fusion, multilevel thoracic fusion, and multilevel lumbar fusion. CONCLUSION: Spine injuries represent a significant portion of work-related injuries in the USA and a considerable portion require neurosurgical intervention. Initial efforts should focus on the prevention and management of lumbar spine injuries in the construction industry.

A comparison of outcomes for above-knee-amputation and arthrodesis for the chronically infected total knee arthroplasty: a systematic review.

INTRODUCTION: Several strategies have been shown to have some efficacy in the chronically infected total knee arthroplasty (TKA): chronic antibiotic suppression, a second two-stage revision, arthrodesis, and above-the-knee amputation (AKA). We conducted a systematic review to determine the efficacy of these treatments in patients who had previously received a two-stage revision. METHODS: A systematic review of the literature was performed which investigated PubMed, Embase, Scopus, and Web of Science Databases. Chronic infection was defined as a persistent infection of a TKA after a previous two-stage revision. Studies were independently evaluated by two reviewers. Quality appraisal was performed using MINORS Criteria. RESULTS: 14 studies were included for the final review. For chronically infected TKA, a second two-stage revision was often sufficient to control infection. If revision failed, the most common next procedure was either a repeat revision or AKA. AKA patients had less pain and higher quality of life scores compared to arthrodesis, but a higher five-year mortality rate. DISCUSSION AND CONCLUSION: Chronic infection in TKA offers a multitude of challenges for orthopedic surgeons. We found that arthrodesis and AKA were not significantly different in rates of infection eradication or quality of life. We recommend clinicians to actively discuss options with patients to find a procedure most suitable for them.

Cemented total knee arthroplasty provides greater knee range of motion at 2 years than cementless technique.

INTRODUCTION: Optimal fixation method between cemented, cementless, and hybrid techniques for total knee arthroplasty (TKA) is still debated. The purpose of this study is to evaluate the clinical outcomes of patients undergoing cemented versus cementless TKA. METHODS: We reviewed 168 patients who underwent a primary TKA at a single academic institution between January 2015 and June 2017. Patients were categorized into cemented (n = 80) or cementless (n = 88) groups. Only patients with greater than or equal to 2-year follow-up were included in the study. Multivariate regressions were performed to analyze the relationship between the surgical fixation technique and the clinical outcomes. RESULTS: There were no differences in demographics or baseline operative characteristics between the two groups. The cemented group had fewer manipulations under anesthesia (MUA) (4 vs. 15, p = 0.01), longer intraoperative tourniquet times (101.30 vs. 93.55 min, p = 0.02), and increased knee range of motion (ROM) at final follow-up (111.48 vs. 103.75°, p = 0.02) compared to the cementless group. DISCUSSION AND CONCLUSION: Both cemented and cementless component fixation are viable options for (TKA). This study found that patients who underwent a cemented TKA required fewer MUA's and had greater final ROM compared to patients undergoing cementless TKA. Additional research is required regarding cementless and cemented fixation. We believe that the choice of which fixation technique to use ultimately comes down to patient characteristics and surgeon preference.

Exceptionally high-affinity Ras binders that remodel its effector domain.

The Ras proteins are aberrantly activated in a wide range of human cancers, often endowing tumors with aggressive properties and resistance to therapy. Decades of effort to develop direct Ras inhibitors for clinical use have thus far failed, largely because of a lack of adequate small-molecule-binding pockets on the Ras surface. Here, we report the discovery of Ras-binding miniproteins from a naïve library and their evolution to afford versions with midpicomolar affinity to Ras. A series of biochemical experiments indicated that these miniproteins bind to the Ras effector domain as dimers, and high-resolution crystal structures revealed that these miniprotein dimers bind Ras in an unprecedented mode in which the Ras effector domain is remodeled to expose an extended pocket that connects two isolated pockets previously found to engage small-molecule ligands. We also report a Ras point mutant that stabilizes the protein in the open conformation trapped by these miniproteins. These findings provide new tools for studying Ras structure and function and present opportunities for the development of both miniprotein and small-molecule inhibitors that directly target the Ras proteins.

Is Elective Soft Tissue Hand Surgery Associated with Periprosthetic Joint Infection after Total Joint Arthroplasty?

BACKGROUND: Although current guidelines do not recommend the routine use of surgical antibiotic prophylaxis to reduce the risk of surgical site infection following clean, soft tissue hand surgery, antibiotics are nevertheless often used in patients with an existing joint prosthesis to prevent periprosthetic joint infection (PJI), despite little data to support this practice. QUESTIONS/PURPOSES: (1) Is clean, soft tissue hand surgery after THA or TKA associated with PJI risk? (2) Does surgical antibiotic prophylaxis before hand surgery decrease PJI risk in patients with recent THA or TKA? METHODS: We assessed all patients who underwent THA or TKA between January 2007 and December 2015 by retrospective analysis of the IBM® MarketScan® Databases, which provide a longitudinal view of all healthcare services used by a nationwide sample of millions of patients under commercial and supplemental Medicare insurance coverage-particularly advantageous given the relatively low frequency of hand surgery after THA/TKA and of subsequent PJI. The initial search yielded 940,861 patients, from which 509,896 were excluded for not meeting continuous enrollment criteria, having a diagnosis of PJI before the observation period, or having another arthroplasty procedure before or during the observation period; the final study cohort consisted of 430,965 patients of which 147,398 underwent THA and 283,567 underwent TKA. In the treated cohort, 8489 patients underwent carpal tunnel release, trigger finger release, ganglion or retinacular cyst excision, de Quervain's release, or soft-tissue mass excision within 2 years of THA or TKA. The control cohort was comprised of 422,476 patients who underwent THA or TKA but did not have subsequent hand surgery. The primary outcome was diagnosis or surgical management of a PJI within 90 days of the index hand surgery for the treated cohort, or within a randomly assigned 90-day observation period for each patient in the control group. Propensity score matching was used to match treated and control cohorts by patient and treatment characteristics and previously-reported risk factors for PJI. Logistic regression before and after propensity score matching was used to assess the association of hand surgery with PJI risk and the association of surgical antibiotic prophylaxis before hand surgery with PJI risk in the treated cohort. Other possible PJI risk factors were also explored in multivariable logistic regression. Statistical significance was assessed at α = 0.01. RESULTS: Hand surgery was not associated with PJI risk after propensity score matching of treated and control cohorts (OR, 1.39; 99% CI, 0.60-3.22; p = 0.310). Among patients who underwent hand surgery after arthroplasty, surgical antibiotic prophylaxis before hand surgery was not associated with decreased PJI risk (OR 0.42; 99% CI, 0.03-6.08; p = 0.400). CONCLUSIONS: Clean, soft-tissue hand surgery was not found to be associated with PJI risk in patients who had undergone primary THA or TKA within 2 years before their hand procedure. While the effect of PJIs can be devastating, we do not find increased risk of infection with hand surgery nor data supporting routine use of surgical antibiotic prophylaxis in this setting. LEVEL OF EVIDENCE: Level III, therapeutic study.

Prophylactic Fixation Can Be Cost-effective in Preventing a Contralateral Bisphosphonate-associated Femur Fracture.

BACKGROUND: Bisphosphonates reduce the risk of fractures associated with osteoporosis but increase the risk of atypical subtrochanteric femur fractures. After unilateral atypical femur fracture, there is risk of contralateral fracture, but the indications for prophylactic fixation are controversial. QUESTIONS/PURPOSES: The purpose of this study is to use Markov modeling to determine whether contralateral prophylactic femur fracture fixation is cost-effective after a bisphosphonate-associated atypical femur fracture and, if so, what patient-related factors may influence that determination. METHODS: Markov modeling was used to determine the cost-effectiveness of contralateral prophylactic fixation after an initial atypical femur fracture. Simulated patients aged 60 to 90 years were included and separated into standard and high fracture risk cohorts. Patients with standard fracture risk were defined as those presenting with one atypical femur fracture but without symptoms or findings in the contralateral femur, whereas patients with high fracture risk were typified as those with more than one risk factor, including Asian ethnicity, prodromal pain, femoral geometry changes, or radiographic findings in the contralateral femur. Outcome probabilities and utilities were derived from studies matching to patient characteristics, and fragility fracture literature was used when atypical femur fracture data were not available. Associated costs were largely derived from Medicare 2015 reimbursement rates. Sensitivity analysis was performed on all model parameters within defined ranges. RESULTS: Prophylactic fixation for a 70-year-old patient with standard risk for fracture costs USD 131,300/quality-adjusted life-year (QALY) and for high-risk patients costs USD 22,400/QALY. Sensitivity analysis revealed that prophylaxis for high-risk patients is cost-effective at USD 100,000/QALY when the cost of prophylaxis was less than USD 29,400, the probability of prophylaxis complications was less than 21%, or if the patient was younger than 89 years old. The parameters to which the model was most sensitive were the cost of prophylaxis, patient age, and probability of prophylaxis-related complications. CONCLUSIONS: Prophylactic fixation of the contralateral side after unilateral atypical femur fracture is not cost-effective for standard-risk patients but is cost-effective among high-risk patients between 60 and 89 years of age with a high risk for an atypical femur fracture defined by patients with more than one risk factor such as Asian ethnicity, prodromal pain, varus proximal femur geometry, femoral bowing, or radiographic changes such as periosteal beaking and a transverse radiolucent line. However, our findings are based on several key assumptions for modeling such as the probability of fractures and complications, the costs associated for each health state, and the risks of surgical treatment. Future research should prospectively evaluate the degree of risk contributed by known radiographic and demographic parameters to guide management of the contralateral femur after a patient presents with an atypical femur fracture. LEVEL OF EVIDENCE: Level III, economic and decision analyses.

Diagnostic staging laparoscopy in gastric cancer treatment: A cost-effectiveness analysis.

BACKGROUND AND OBJECTIVES: Accurate preoperative staging helps avert morbidity, mortality, and cost associated with non-therapeutic laparotomy in gastric cancer (GC) patients. Diagnostic staging laparoscopy (DSL) can detect metastases with high sensitivity, but its cost-effectiveness has not been previously studied. We developed a decision analysis model to assess the cost-effectiveness of preoperative DSL in GC workup. METHODS: Analysis was based on a hypothetical cohort of GC patients in the U.S. for whom initial imaging shows no metastases. The cost-effectiveness of DSL was measured as cost per quality-adjusted life-year (QALY) gained. Drivers of cost-effectiveness were assessed in sensitivity analysis. RESULTS: Preoperative DSL required an investment of $107 012 per QALY. In sensitivity analysis, DSL became cost-effective at a threshold of $100 000/QALY when the probability of occult metastases exceeded 31.5% or when test sensitivity for metastases exceeded 86.3%. The likelihood of cost-effectiveness increased from 46% to 93% when both parameters were set at maximum reported values. CONCLUSIONS: The cost-effectiveness of DSL for GC patients is highly dependent on patient and test characteristics, and is more likely when DSL is used selectively where procedure yield is high, such as for locally advanced disease or in detecting peritoneal and superficial versus deep liver lesions.

Effectiveness of Preoperative Antibiotics in Preventing Surgical Site Infection After Common Soft Tissue Procedures of the Hand.

BACKGROUND: Antibiotic prophylaxis is a common but controversial practice for clean soft tissue procedures of the hand, such as carpal tunnel release or trigger finger release. Previous studies report no substantial reduction in the risk of surgical site infection (SSI) after antibiotic prophylaxis, yet are limited in power by low sample sizes and low overall rates of postoperative infection. QUESTIONS/PURPOSES: Is there evidence that antibiotic prophylaxis decreases the risk of SSI after soft tissue hand surgery when using propensity score matching to control for potential confounding variables such as demographics, procedure type, medication use, existing comorbidities, and postoperative events? METHODS: This retrospective analysis used the Truven Health MarketScan databases, large, multistate commercial insurance claims databases corresponding to inpatient and outpatient services and outpatient drug claims made between January 2007 and December 2014. The database includes records for patients enrolled in health insurance plans from self-insured employers and other private payers. Current Procedural Terminology codes were used to identify patients who underwent carpal tunnel release, trigger finger release, ganglion and retinacular cyst excision, de Quervain's release, or soft tissue mass excision, and to assign patients to one of two cohorts based on whether they had received preoperative antibiotic prophylaxis. We identified 943,741 patients, of whom 426,755 (45%) were excluded after meeting one or more exclusion criteria: 357,500 (38%) did not have 12 months of consecutive insurance enrollment before surgery or 1 month of enrollment after surgery; 60,693 (6%) had concomitant bony, implant, or incision and drainage or débridement procedures; and 94,141 (10%) did not have complete data. In all, our initial cohort consisted of 516,986 patients, among whom 58,201 (11%) received antibiotic prophylaxis. Propensity scores were calculated and used to create cohorts matched on potential risk factors for SSI, including age, procedure type, recent use of steroids and immunosuppressive agents, diabetes, HIV/AIDs, tobacco use, obesity, rheumatoid arthritis, alcohol abuse, malnutrition, history of prior SSI, and local procedure volume. Multivariable logistic regression before and after propensity score matching was used to test whether antibiotic prophylaxis was associated with a decrease in the risk of SSI within 30 days after surgery. RESULTS: After controlling for patient demographics, hand procedure type, medication use, existing comorbidities (eg, diabetes, HIV/AIDs, tobacco use, obesity), and postoperative events through propensity score matching, we found that the risk of postoperative SSI was no different between patients who had received antibiotic prophylaxis and those who had not (odds ratio, 1.03; 95% CI, 0.93-1.13; p = 0.585). CONCLUSIONS: Antibiotic prophylaxis for common soft tissue procedures of the hand is not associated with reduction in postoperative infection risk. While our analysis cannot account for factors that are not captured in the billing process, this study nevertheless provides strong evidence against unnecessary use of antibiotics before these procedures, especially given the difficulty of conducting a randomized prospective study with a sample size large enough to detect the effect of prophylaxis on the low baseline risk of infection. LEVEL OF EVIDENCE: Level III, therapeutic study.

Women in Neurosurgery: Trends in the United States.

OBJECTIVE: We sought to identify trends in the number of female neurosurgeons across each state and identify state characteristics that affect such values. METHODS: The Physician Compare National Downloadable File was queried from the Center for Medicare & Medicaid Services for 2017 and 2023. Physicians indicating "neurosurgery" as their primary specialty were extracted and duplicates were removed. States were ranked based on the number of female neurosurgeons. The percent growth in the number of female neurosurgeons from 2017 to 2023 was calculated for each state. Univariable and multivariable regressions were used to identify the association between state characteristics and the number of female neurosurgeons. RESULTS: The number of female neurosurgeons was higher in urban states while rural states saw a greater increase compared to five years ago. Univariable regression showed significant differences in the number of neurosurgery residency programs, neurosurgery hospitals ranked in U.S. News & World Report, paid parental leave law, number and percentage of female physicians, and diversity index score (P < 0.05). The diversity index score independently affected the number of female neurosurgeons (P < 0.05). CONCLUSIONS: States with more training programs, female physicians, and paid parental leave policies saw a large number of female neurosurgeons. Diversity in the general population is also crucial to improving the equity in gender representation of neurosurgeons in each state. The increase in female neurosurgery representation in rural states shows that the shortage of neurosurgeons in underserved areas is creating a unique niche for female neurosurgeons to excel.

Comparison of In-Hospital Mortality and Neurosurgical Intervention Between Intracranial Gunshot Wounds Arising From Long Guns and Handguns: A Propensity Score Matched Study.

BACKGROUND AND OBJECTIVES: Patients with intracranial gunshot wounds (IC-GSWs) often present with severe neurological injuries requiring prompt neurological evaluation. Neurosurgical intervention is reserved for those with reasonable chances of survival. Handguns and long guns, such as shotguns and rifles, have differing mechanisms of injury which may influence surgical candidacy and outcomes. This study aims to compare rates and types of neurosurgical intervention and inpatient outcomes in patients with IC-GSWs handguns and long guns. METHODS: The National Trauma Data Bank was retrospectively queried for patients with IC-GSWs from 2017 to 2019. Patients with long gun IC-GSWs were propensity score matched with those with handgun IC-GSWs based on patient demographics, comorbidities, insurance status, injury extent and severity, and hospital trauma level. Group differences were compared using Student's t-tests and Pearson's χ2 tests, and multivariable logistic regression was used to identify predictors of in-hospital mortality. RESULTS: Overall, patients in the long gun group were more likely to undergo neurosurgical intervention (21% vs 17%, P = .02). Following propensity score matching, the long gun group had lower rates of in-hospital mortality (35% vs 43%, P < .01), lower rates of cardiac arrest (5% vs 8%, P = .02), and lower rates of reoperation (0% vs 2%, P = .02) than the handgun group. In multivariable regression, independent predictors of survival included long gun IC-GSWs (odds ratio [OR] 0.65, CI 0.52-0.83), neurosurgical foreign body removal (OR 0.44, CI 0.33-0.58), intracranial debridement (OR 0.47, 0.33-0.67), and craniectomy (OR 0.46, CI 0.34-0.63). CONCLUSION: Patients with IC-GSWs present to the hospital with severe neurological injury. Neurosurgical intervention was independently associated with decreased mortality. After matching, patients with long gun IC-GSWs experienced lower in-hospital mortality rates compared with those from handguns. This study suggests that patients suffering from long gun IC-GSW may respond particularly well to neurosurgical intervention and firearm type should be considered when determining neurosurgical candidacy.

In-hospital outcomes following surgery versus conservative therapy in elderly patients with C2 fractures: a propensity score-matched analysis.

OBJECTIVE: Second cervical vertebrae (C2) fractures are a common traumatic spinal injury in the elderly population. Surgical fusion and nonoperative bracing are two primary treatments for cervical instability, but the former is often withheld in the elderly due to concerns for poor postoperative outcomes arising from patient frailty. This study sought to evaluate the in-hospital differences in mortality, outcomes, and discharge disposition in elderly patients with C2 fractures undergoing surgical intervention compared with conservative therapy. METHODS: The National Trauma Data Bank was queried from 2017 to 2019 for all patients aged ≥ 65 years with C2 fractures undergoing either surgical stabilization or conservative therapy. Propensity score matching was performed using k-nearest neighbors with replacement based on patient demographics, comorbidities, insurance type, injury severity, and fracture type. Group differences were compared using Student t-tests and Pearson's chi-square tests with Benjamini-Hochberg multiple comparisons correction. Subgroup analyses were performed in the 65-74, 75-79, and 80+ year age subgroups. RESULTS: Six thousand forty-nine patients were identified, of whom 2156 underwent surgery and 3893 received conservative treatment. Following matching, the surgery group had significantly lower mortality rates (5.52% vs 9.6%, p < 0.001), a longer mean hospital length of stay (LOS; 12.64 vs 7.49 days p < 0.001), and slightly higher rates of several complications (< 3% difference), as well as lower rates of discharge home (14.56% vs 23.52%, p < 0.001) and to hospice (1.07% vs 2.09%, p = 0.02) and a higher rate of discharge to intermediate care (68.83% vs 48.28%, p < 0.001). Similar trends in mortality and LOS were noted in all 3 subgroups. CONCLUSIONS: In elderly patients with C2 fractures, surgical stabilization confers a small survival advantage with a slightly higher in-hospital complication rate compared to conservative therapy. The increased rate of discharge to rehabilitation may represent better long-term prognosis following surgery. The increased risk of short-term complications is present but relatively small, thus surgery should not be withheld in patients with good long-term prognosis.

Neurometabolic alterations in children and adolescents with functional neurological disorder.

OBJECTIVES: In vivo magnetic resonance spectroscopy (MRS) was used to investigate neurometabolic homeostasis in children with functional neurological disorder (FND) in three regions of interest: supplementary motor area (SMA), anterior default mode network (aDMN), and posterior default mode network (dDMN). Metabolites assessed included N-acetyl aspartate (NAA), a marker of neuron function; myo-inositol (mI), a glial-cell marker; choline (Cho), a membrane marker; glutamate plus glutamine (Glx), a marker of excitatory neurotransmission; γ-aminobutyric acid (GABA), a marker of inhibitor neurotransmission; and creatine (Cr), an energy marker. The relationship between excitatory (glutamate and glutamine) and inhibitory (GABA) neurotransmitter (E/I) balance was also examined. METHODS: MRS data were acquired for 32 children with mixed FND (25 girls, 7 boys, aged 10.00 to 16.08 years) and 41 healthy controls of similar age using both short echo point-resolved spectroscopy (PRESS) and Mescher-Garwood point-resolved spectroscopy (MEGAPRESS) sequences in the three regions of interest. RESULTS: In the SMA, children with FND had lower NAA/Cr, mI/Cr (trend level), and GABA/Cr ratios. In the aDMN, no group differences in metabolite ratios were found. In the pDMN, children with FND had lower NAA/Cr and mI/Cr (trend level) ratios. While no group differences in E/I balance were found (FND vs. controls), E/I balance in the aDMN was lower in children with functional seizures-a subgroup within the FND group. Pearson correlations found that increased arousal (indexed by higher heart rate) was associated with lower mI/Cr in the SMA and pDMN. CONCLUSIONS: Our findings of multiple differences in neurometabolites in children with FND suggest dysfunction on multiple levels of the biological system: the neuron (lower NAA), the glial cell (lower mI), and inhibitory neurotransmission (lower GABA), as well as dysfunction in energy regulation in the subgroup with functional seizures.

Discharge within 1 day following elective single-level transforaminal lumbar interbody fusion: a propensityscore-matched analysis of predictors, complications, and readmission.

STUDY DESIGN: This was a retrospective case-control study using 8 years of data from a nationwide database of surgical outcomes in the United States. PURPOSE: This study aimed to improve our understanding of the risk factors associated with a length of stay (LOS) >1 day and aid in reducing postoperative hospitalization and complications. OVERVIEW OF LITERATURE: Despite the proven safety of transforaminal lumbar interbody fusion (TLIF), some patients face prolonged postoperative hospitalization. METHODS: Data were collected from the American College of Surgeons National Surgical Quality Improvement Program dataset from 2011 to 2018. The cohort was divided into patients with LOS up to 1 day (LOS ≤1 day), defined as same day or next-morning discharge, and patients with LOS >1 day (LOS >1 day). Univariable and multivariable regression analyses were performed to evaluate predictors of LOS >1 day. Propensity-score matching was performed to compare pre- and postdischarge complication rates. RESULTS: A total of 12,664 eligible patients with TLIF were identified, of which 14.8% had LOS ≤1 day and 85.2% had LOS >1 day. LOS >1 day was positively associated with female sex, Hispanic ethnicity, diagnosis of spondylolisthesis, American Society of Anesthesiologists classification 3, and operation length of >150 minutes. Patients with LOS >1 day were more likely to undergo intraoperative/postoperative blood transfusion (0.3% vs. 4.5%, p<0.001) and reoperation (0.1% vs. 0.6%, p=0.004). No significant differences in the rates of postdischarge complications were found between the matched groups. CONCLUSIONS: Patients with worsened preoperative status, preoperative diagnosis of spondylolisthesis, and prolonged operative time are more likely to require prolonged hospitalization and blood transfusions and undergo unplanned reoperation. To reduce the risk of prolonged hospitalization and associated complications, patients indicated for TLIF should be carefully selected.

Surgical Outcomes in Octogenarians with Central Cord Syndrome: A Propensity-Score Matched Analysis.

OBJECTIVE: Central cord syndrome (CCS) is a traumatic cervical spine injury that is treated with surgical decompression. In octogenarians (80-89), surgeons often opt for conservative management instead due to fears of postoperative complications and prolonged recovery times. This study aims to assess the in-hospital complications and outcomes in octogenarians undergoing surgery compared to those undergoing nonsurgical management for CCS. METHODS: The National Trauma Data Bank was queried from 2017 to 2019 for octogenarians with CCS. Patients who received surgical fusion or decompression were divided into the surgery group and the remaining into the nonsurgical group. The surgery group was sampled and propensity score matched with the non-surgery group. Student t tests and Pearson χ2 tests were used to test for group differences. RESULTS: A total of 759 octogenarians with CCS were identified. Following sampling and propensity score matching, 225 patients were identified in each group. The surgery group experienced longer intensive care unit (6.8 days vs. 3.21 days, P < 0.001) and hospital (13.79 days vs. 7.8 days, P < 0.001) lengths of stay and higher rates of deep vein thrombosis (4.89% vs. 0.44%, P = 0.02) and ventilator-associated pneumonia (4% vs. 0%, P = 0.02). Patients did not otherwise differ in mortality rate, other hospital complications, and discharge disposition. CONCLUSIONS: Octogenarians undergoing surgery for CCS experience longer length of stay and complications consistent with prolonged hospitalization but otherwise have similar mortality, hospital complications, and discharge disposition compared to non-surgical treatment. Given the relative lack of short-term drawbacks, surgery should be considered first-line management when the long-term benefits are substantive.

Postoperative Opioid Use Among Opioid-Naive Cannabis Users Following Single-Level Lumbar Fusions.

BACKGROUND: As the literature grows on opioid use, the impact of simultaneous cannabis use has hitherto been mostly unexplored. In this study, we assessed the effects of cannabis use on postoperative opioid utilization in opioid-naive patients undergoing single level fusions of the lumbar spine. METHODS: Using an all-payer claims database, the medical records of 91 million patients were analyzed to identify patients who had undergone single level lumbar fusions between January 2010 and October 2020. Rates of opioid utilization at 6 months following index procedure (morphine milligram equivalents/day), the development of opioid use disorder (OUD), and the rates of opioid overuse were assessed. RESULTS: Following examination of 87,958 patient records, 454 patients were matched and distributed equally into cannabis user and noncannabis user cohorts. At 6 months following index procedure, cannabis users were equal to nonusers in their rates of prescribed opioid utilization (49.78%, P > 0.99). Cannabis users used smaller daily dosages compared to nonusers (51.1 ± 35.05 vs. 59.72 ± 41, P = 0.003). On the other hand, the proportion of patients diagnosed with OUD was found to be significantly higher among patients using cannabis (18.94% vs. 3.96%, P < 0.0001). CONCLUSIONS: Compared to noncannabis users, opioid-naive patients who are cannabis users undergoing lumbar spinal fusions are at a higher risk of developing opioid dependence following surgery, despite having decreased daily dosages of opioids overall. Further studies should explore the factors associated with the development of OUD and the details of concurrent marijuana use to effectively treat pain while limiting the potential for abuse.

Racial Disparities in Time to Decompression in Central Cord Syndrome: A National Trauma Database Analysis.

OBJECTIVE: Cervical cord syndrome (CCS) is the most common type of incomplete spinal cord injury. Prompt surgical decompression within 24 hours increases neurologic function and rates of home discharge. Racial disparities exist in spinal cord injury, with Black patients experiencing longer lengths of stay and higher rates of complications than in White patients. This study aims to investigate potential racial disparities in time to surgical decompression in patients with CCS. METHODS: The National Trauma Data Bank (NTDB) was queried from 2017 to 2019 for patients who underwent surgery for CCS. The primary outcome was time from hospital admission to surgery. Student's t-test and Pearson's chi-squared test were used to evaluate differences in categorical and continuous variables, respectively. An uncensored Cox proportional hazards regression model was developed to assess the effect of race on surgical timing while adjusting for potential confounders. RESULTS: 1,076 patients with CCS resulting in cervical spinal cord surgery were included in the analysis. Regression analysis results showed that Black patients (HR=0.85, P = 0.03), female patients (HR=0.81, P < 0.01), and patients treated at community hospitals (HR=0.82, P = 0.01) were less likely to receive early surgery. CONCLUSIONS: Though the advantages of early surgical decompression in the setting of CCS have been detailed in medical literature, Black, and female patients experience lower rates of prompt surgery following hospital admission and higher rates of adverse outcomes. This disproportionately increased time to intervention exemplifies demographic disparities in the timely provision of treatment to patients with spinal cord injuries.

The Revised Baux Score as a Predictor of Burn Mortality: A Systematic Review and Meta-Analysis.

Mortality following a severe burn is influenced by both patient- and injury-factors, and a number of predictive models have been developed or applied. As there is no consensus on the optimal formula to use, we aimed to investigate the predictive value of the revised Baux score in comparison to other models when determining mortality risk in patients with burn injuries. A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The review yielded 21 relevant studies. The Prediction model Risk Of Bias ASsessment Tool quality appraisal checklist was used with many studies classified as "high" quality. All studies assessed the utility of the revised Baux score in comparison to other scoring systems such as the original Baux, Belgian Outcome in Burn Injury, Abbreviated Burn Severity Index, Acute Physiology and Chronic Health Evaluation II, Sequential Organ Failure Assessment, Boston Group/Ryan scores, the Fatality by Longevity, APACHE II score, Measured Extent of burn, and Sex model, and the Prognostic Burn Index. There was a range of 48 to 15975 participants per study, with a mean age range of 16 to 52 years old. The area under the curve (AUC) values of the rBaux score ranged from 0.682 to 0.99, with a summary AUC of 0.93 for all included studies (CI 0.91-0.95). This summary value demonstrates that the rBaux equation is a reliable predictor for mortality risk in heterogeneous populations. However, this study also identified that the rBaux equation has a diminished ability to predict mortality risk when applied to patients at both extremes of age, highlighting an important area for future research. Overall, the rBaux equation offers a relatively easy means to quickly assess the mortality risk from burn injury in a broad range of patient populations.

Short-term neurochemical effects of transcutaneous trigeminal nerve stimulation using 7T magnetic resonance spectroscopy.

BACKGROUND AND PURPOSE: The purpose was to explore the effects of transcutaneous trigeminal nerve stimulation (TNS) on neurochemical concentrations (brainstem, anterior cingulate cortex [ACC], dorsolateral prefrontal cortex [DLPFC], ventromedial prefrontal cortex [VMPFC], and the posterior cingulate cortex [PCC]) using ultrahigh-field magnetic resonance spectroscopy. METHODS: This double-blinded study tested 32 healthy males (age: 25.4 ± 7.3 years) on two separate occasions where participants received either a 20-minute TNS or sham session. Participants were scanned at baseline and twice post-TNS/sham administration. RESULTS: There were no group differences in concentration changes of glutamate, gamma-aminobutyric acid, glutamine, myoinositol (mI), total N-acetylaspartate, total creatine (tCr), and total choline between the baseline scan and the first post-TNS/sham scan and between the first and second post-TNS/sham scan in the brainstem, ACC, DLPFC, VMPFC, and PCC. Between the baseline scan and the second post-TNS/sham scan, changes in tCr (mean difference = 0.280 mM [0.075 to 0.485], p = .026) and mI (mean difference = 0.662 mM [0.203 to 1.122], p = .026) in the DLPFC differed between groups. Post hoc analyses indicated that there was a decrease in tCr (mean change = -0.201 mM [-0.335 to -0.067], p = .003) and no change in mI (mean change = -0.327 mM [-0.737 to 0.083], p = .118) in the TNS group; conversely, there was no change in tCr (mean change = -0.100 mM [-0.074 to 0.274], p = .259) and an increase in mI (mean change = 0.347 mM [0.106 to 0.588], p = .005) in the sham group. CONCLUSION: These data demonstrate that a single session of unilateral TNS slightly decreased tCr concentrations in the DLPFC region.