Cooled radiofrequency ablation of the sacroiliac joint a retrospective case series.

BACKGROUND: Sacroiliac (SI) joint dysfunction is a common source of back pain. Recent evidence from different parts of the world suggest that cooled radiofrequency ablation of sacral nerves supplying the SI joints has superior pain alleviating properties than currently available treatment options for SI joint dysfunction. PATIENTS AND METHODS: After obtaining institutional review board approval, the medical records of 81 patients who underwent cooled radiofrequency ablation in a single institution and by a single surgeon were analyzed retrospectively. The recurrence of pain, progression to fusion and functional outcomes were noted. The patients were operated on between June 2020 and December 2021, they include 59 females and 22 males, the average age was 55.4 ± 17.3. Follow up was at least 6 months postoperative. RESULTS: 22 of the patients had previously underwent lumbar fusions. Follow up period ranged from 6 to 18 months. After radiofrequency ablation, 7 patients progressed to fusions, and 6 patients had to have the procedure done again to relieve their pain. Student t-test was used to compare between preoperative and postoperative values of NPRS (numerical pain rating score) and ODI (Oswestry disability index). It showed significance with P-value < 0.001 in both. CONCLUSIONS: Sacroiliac joint radiofrequency ablation is a good option in the treatment of SI joint pain showing good results in the short term follow up period. It is a simple procedure that can be done in less than 30 min and is capable of providing significant pain relief for patients with sacroiliac joint dysfunction.

Reference values of four measures of craniocervical stability using upright dynamic magnetic resonance imaging.

PURPOSE: To establish reference ranges for four most commonly used diagnostic measures of craniocervical instability (CCI) in three cervical sagittal positions. This necessitated development of a reliable measurement protocol using upright, dynamic MRI (udMRI), to determine differences in the extent of motion between positions, and whether age and sex correlate with these measures. MATERIALS AND METHODS: Deidentified udMRIs of 50 adults, referred for reasons other than CCI, were captured at three positions (maximal flexion, maximal extension and neutral). Images were analyzed, providing measures of basion-axial interval, basion-axial angle, basion-dens interval (BDI) and the Grabb-Oakes line (GOL) for all three positions (12 measures per participant). All measures were independently recorded by a radiologist and neurosurgeon to determine their reliability. Descriptive statistics, correlations, paired and independent t-tests were used. Mean (± 2 SD) identified the reference range for all four measures at each craniocervical position. RESULTS: The revised measurement protocol produced inter-rater reliability indices of 0.69-0.97 (moderate-excellent). Fifty adults' (50% male; mean age 41.2 years (± 9.7)) reference ranges for all twelve measures were reported. Except for the BDI and GOL when moving between neutral and full flexion, significant extents of movement were identified between the three craniocervical positions for all four measures (p ≤ 0.005). Only a minor effect of age was found. CONCLUSIONS: This is the first study to provide a rigorous standardized protocol for four diagnostic measures of CCI. Reference ranges are established at mid and ends of sagittal cervical range corresponding to where exacerbations of signs and symptoms are commonly reported.

Minilaparoscopic CLIPLESS Cholecystectomy: Tips, Tricks and Advanced Maneuvers.

As the world sought the 'Holy Grail' of scarless surgery, minimizing access seemed to be the natural path to follow, and minilaparoscopy (MINI) was considered to be a natural advancement of standard laparoscopy. It aims at minimizing surgical trauma by further reducing the diameter of standard instruments, without compromising range of motion, triangulation or safety. Several different terms have been coined to address this sophisticated reduced-port technique, which is characterized by the use of instruments 3 mm or less in diameter: acuscopic surgery, minilaparoscopy, needlescopic surgery and microlaparoscopy. The early adoption of MINI was mostly inhibited by the limitations of first-generation instruments, especially with respect to functionality, cost and durability. Furthermore, mini cholecystectomy demanded the use of mini optics, which suffered from poor imaging quality and a short lifetime of the scopes. Newer-generation mini instruments have mitigated these issues through the use of improved effector tips, better insulation, strength and durability, and superior optics. During the early MINI years, surgeons clipped most structures, but sturdy mini clip appliers were either unavailable or did not hold the requisite-size clips. Clipping with MINI required the use of a standard clip applier and the scope had to be changed several times during a procedure, making MINI not only more complicated but also boring and time-consuming. The development and popularization of the clipless technique allowed the surgeon to get free from the expensive and cumbersome minilaparoscopic clip appliers, and replace clips with knots. The marked improvements in instrumentation and the development of the clipless technique have occurred simultaneously with the development of NOTES, LESS and Robotic surgery, which may have contributed to a greater push towards MINI. MINI has been proven to offer more than just better cosmesis. Other advantages include better visualization of the surgical field and, with the development of precisely engineered low-friction trocars, which enhance surgical precision during dynamic and delicate tasks (knotting and suturing small structures), less stress and higher efficiency, which makes the procedure easier to perform. Furthermore, transmission of electro cautery through mini instruments has led to less lateral spread of electric current and subsequent less tissue trauma. For more than 20 years, our team has successfully used minilaparoscopy. Even with the rising popularity of robotic surgery, which still uses 8 mm instruments, minilaparoscopy remains an attractive option that is far from becoming obsolete.

Dulucq's technique for laparoscopic totally extraperitoneal hernioplasty.

BACKGROUND: Inguinal hernia repair has been a controversial area in surgical practice. Its complexity is reflected by the fact that numerous different procedures including both open and laparoscopic techniques are in use today. Laparoscopic totally extraperitoneal (TEP) repair is preferred over transabdominal pre-peritoneal repair as the peritoneum is not breached and also due to fewer intra-abdominal complications. This is the most elegant technique but rather difficult to perform. AIM: The purpose of this study was to describe Dulucq's technique for inguinal hernia repair and the use of three-dimensional mesh without fixation in laparoscopic TEP inguinal hernioplasty. METHODS: Surgical technique of laparoscopic TEP inguinal hernia repair is detailed in the text. RESULTS: A total of 945 hernia repairs were included in the study. The hernias were repaired by Dulucq's technique. Mean operative time was 45 min in unilateral hernia and 65 min in bilateral hernia. There were no serious complications. CONCLUSION: The laparoscopic TEP hernioplasty by Dulucq's technique is feasible with fewer intra-abdominal complications. The dissection must always be done with the same stages with minimal monopolar diathermy and patient in a slight Trendelenburg position.

Should all paediatric patients with presumed idiopathic scoliosis undergo MRI screening for neuro-axial disease?

BACKGROUND: Idiopathic scoliosis is a relatively common childhood condition affecting 0.47-5.2% of the population. Traditional interventions focus on orthopaedic correction of the curve angle. There is a spectrum of patients with scoliosis who are found to have neuro-axial abnormality on full MRI of the spine, but not all surgeons request imaging in the absence of neurological symptoms. There is evidence to suggest that treatment of neuro-axial disease may improve scoliosis curve outcome. We therefore sought to estimate what proportion of patients with normal neurology and scoliosis are found to have neuro-axial abnormality on full MRI imaging of the spine, in particular Chiari malformation and syringomyelia. RESULTS: Out of 11 identified studies consisting of 3372 paediatric patients (age < 18 years), mean weighted proportion demonstrates that 14.7% of patients with scoliosis (Cobb angle > 20°) and normal neurological examination will demonstrate a neuro-axial abnormality on full MRI imaging of the spine. Of patients, 8.3 and 8.4% were found to have Chiari malformation and syringomyelia, respectively. CONCLUSIONS: Up to one in seven paediatric patients with scoliosis and normal neurological examination will demonstrate neuro-axial disease on MRI imaging of the spine. Given that younger age and earlier age of decompression is associated with improvement in curve angle, it seems important that MRI screening be considered in all patients regardless of neurological examination findings. There is a potentially long-term benefit in these patients. Multi-cross institutional prospective studies are encouraged to further investigate effect on curve angle.

Treating multi-level cervical disc disease with hybrid surgery compared to anterior cervical discectomy and fusion: a systematic review and meta-analysis.

PURPOSE: The traditional surgical approach to treat multi-level cervical disc disease (mCDD) has been anterior cervical discectomy and fusion (ACDF). There has been recent development of other surgical approaches to further improve clinical outcomes. Collectively, when elements of these different approaches are combined in surgery, it is known as hybrid surgery (HS) which remains a novel treatment option. A systematic review and meta-analysis was conducted to compare the outcomes of HS versus ACDF for the treatment of mCDD. METHODS: Relevant articles were identified from six electronic databases from their inception to January 2016. RESULTS: From 8 relevant studies identified, 169 patients undergoing HS were compared with 193 ACDF procedures. Operative time was greater after HS by 42 min (p < 0.00001), with less intraoperative blood loss by 26 mL (p < 0.00001) and shorter return to work by 32 days (p < 0.00001). In terms of clinical outcomes, HS was associated with greater C2-C7 range of motion (ROM) preservation (p < 0.00001) and less functional impairment (p = 0.008) after surgery compared to ACDF. There was no significant difference between HS and ACDF with respect to postoperative pain (p = 0.12). The postoperative course following HS was not significantly different to ACDF in terms of length of stay (p = 0.24) and postoperative complication rates (p = 0.18). CONCLUSIONS: HS is a novel surgical approach to treat mCDD, associated with a greater operative time, less intraoperative blood loss and comparable if not superior clinical outcomes compared to ACDF. While it remains a viable consideration, there is a lack of robust clinical evidence in the literature. Future large prospective registries and randomised trials are warranted to validate the findings of this study.

Minimally invasive versus open transforaminal lumbar interbody fusion for treatment of degenerative lumbar disease: systematic review and meta-analysis.

PURPOSE: While open TLIF (O-TLIF) remains the mainstay approach, minimally invasive TLIF (MI-TLIF) may offer potential advantages of reduced trauma to paraspinal muscles, minimized perioperative blood loss, quicker recovery and reduced risk of infection at surgical sites. This meta-analysis was conducted to provide an updated assessment of the relative benefits and risks of MI-TLIF versus O-TLIF. METHODS: Electronic searches were performed using six databases from their inception to December 2014. Relevant studies comparing MI-TLIF and O-TLIF were included. Data were extracted and analysed according to predefined clinical end points. RESULTS: There was no significant difference in operation time noted between MI-TLIF and O-TLIF cohorts. The median intraoperative blood loss for MI-TLIF was significantly lower than O-TLIF (median: 177 vs 461 mL; (weighted mean difference) WMD, -256.23; 95% CI -351.35, -161.1; P < 0.00001). Infection rates were significantly lower in the minimally invasive cohort (1.2 vs 4.6%; relative risk (RR), 0.27; 95%, 0.14, 0.53; I2) = 0%; P = 0.0001). VAS back pain scores were significantly lower in the MI-TLIF group compared to O-TLIF (WMD, -0.41; 95% CI -0.76, -0.06; I2 = 96%; P < 0.00001). Postoperative ODI scores were also significantly lower in the minimally invasive cohort (WMD, -2.21; 95% CI -4.26, -0.15; I2 = 93%; P = 0.04). CONCLUSIONS: In summary, the present systematic review and meta-analysis demonstrated that MI-TLIF appears to be a safe and efficacious approach compared to O-TLIF. MI-TLIF is associated with lower blood loss and infection rates in patients, albeit at the risk of higher radiation exposure for the surgical team. The long-term relative merits require further validation in prospective, randomized studies.

Does preoperative imaging for scalp non-melanocytic skin cancer accurately predict invasion of the cranial vault? A systematic review and meta-analysis.

PURPOSE: This study aimed to determine the diagnostic accuracy of CT and MRI in the preoperative detection of bone involvement for non-melanoma skin cancers (NMSCs) located on the scalp. This study further aimed to evaluate the predictive value of these imaging modalities in determining the need for craniectomy and to identify gaps in the existing literature. METHODS: Electronic searches of the MEDLINE, Embase, Cochrane and Google Scholar databases were performed for English language studies of any type. Studies reporting detection or exclusion of histopathologically confirmed bone involvement through preoperative imaging were identified according to PRISMA guidelines. Studies reporting dural involvement, non-scalp tumours, and lacking tumour type(s) or outcome data were excluded. Outcomes were preoperative imaging result and histopathologically confirmed bone invasion. Meta-analysis was performed and sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated (excluding case report and MRI data due to insufficient quality and quantity respectively). RESULTS: Four studies with a total of 69 patients were included in the final review, of which two studies totalling 66 patients were included in the meta-analysis. Preoperative CT had a sensitivity of 38%, specificity of 98%, PPV of 90% and NPV of 73%. CONCLUSIONS: The available data suggests that a preoperative CT finding of calvarial involvement by a scalp NMSC is likely to be real, but the absence of such a finding is unreliable. Current evidence suggests that preoperative imaging cannot exclude the necessity for craniectomy and future research is needed, particularly on the role of MRI.

Validation of a novel range of motion assessment tool for the cervical spine: the HALO© digital goniometer.

Background: Cervical spine range of motion (ROM) assessment has long been carried out via use of the universal goniometer (UG) as an objective tool in the evaluation of patient rehabilitation pre- and post-operatively. The advent of novel ROM assessment technology, such as HALO digital goniometer (DG), presents an avenue for research and potential application within clinical and surgical settings. The objective of this study was to examine the reliability and validity of the HALO DG in the assessment of the active ROM of the cervical spine. Methods: One hundred healthy subjects were recruited for the study and were split into two groups to be assessed by either physiotherapists or medical students. The methodology for cervical spine ROM assessment was carried out per the American Association of Orthopaedic Surgeons (AAOS) guidelines. The reliability analysis was completed using IBM SPSS Statistics 25, calculating the intraclass correlation coefficients (ICC) to determine both the intra- and inter-rater reliability of the device. Results: Inter-rater reliability within the physiotherapist cohort with the DG (ICCr =0.477, 0.718, 0.551) was higher compared to the UG (ICCr =0.380, 0.510, 0.255) for active cervical flexion, lateral flexion, and rotation, respectively. The UG (ICCr =0.819) showed better reliability versus the DG (ICCr =0.780) when assessing cervical extension. Similarly, in the medical student cohort, the DG outperformed the UG in all movement except cervical lateral flexion. When assessing for intra-rater reliability, the DG (ICCm =0.507, 0.773, 0.728, 0.691) performed better than the UG (ICCm =0.487, 0.529, 0.532, 0.585) in cervical flexion, extension, lateral flexion, and rotation, respectively. Conclusions: The present validation study identified the DG as a reliable substitute for the UG.

Gender Bias in the News: A Scalable Topic Modelling and Visualization Framework.

We present a topic modelling and data visualization methodology to examine gender-based disparities in news articles by topic. Existing research in topic modelling is largely focused on the text mining of closed corpora, i.e., those that include a fixed collection of composite texts. We showcase a methodology to discover topics via Latent Dirichlet Allocation, which can reliably produce human-interpretable topics over an open news corpus that continually grows with time. Our system generates topics, or distributions of keywords, for news articles on a monthly basis, to consistently detect key events and trends aligned with events in the real world. Findings from 2 years worth of news articles in mainstream English-language Canadian media indicate that certain topics feature either women or men more prominently and exhibit different types of language. Perhaps unsurprisingly, topics such as lifestyle, entertainment, and healthcare tend to be prominent in articles that quote more women than men. Topics such as sports, politics, and business are characteristic of articles that quote more men than women. The data shows a self-reinforcing gendered division of duties and representation in society. Quoting female sources more frequently in a caregiving role and quoting male sources more frequently in political and business roles enshrines women's status as caregivers and men's status as leaders and breadwinners. Our results can help journalists and policy makers better understand the unequal gender representation of those quoted in the news and facilitate news organizations' efforts to achieve gender parity in their sources. The proposed methodology is robust, reproducible, and scalable to very large corpora, and can be used for similar studies involving unsupervised topic modelling and language analyses.

Adjacent-Level Ossification Development in Single-Level Standalone Anterior Cervical Discectomy and Fusion Versus Anterior Cervical Discectomy and Fusion With Plate.

STUDY DESIGN: Retrospective case control study. OBJECTIVES: Adjacent-level ossification development (ALOD) is a distinct form of adjacent segmental degeneration that has been recognized to occur after anterior cervical discectomy and fusion (ACDF). It is unclear whether ACDF with plate versus standalone has an effect on rates of ALOD. This retrospective case-control study aims to assess the rate of ALOD in a large series of patients undergoing ACDF with and without plate and factors causing ALOD. METHODS: Data was collected for patients undergoing ACDF from January 2009 to July 2016. Data collected was from multiple centers and included demographic data, surgical data, radiological imaging at time of surgery, and serial follow-up imaging. The radiology for ALOD was independently reviewed. Cohorts were divided into ACDF with plate (Group P = plate) and ACDF without plate (Groups S = standalone) and outcomes were compared. RESULTS: There were 260 patients with 138 (53%) in Group P and 122 (47%) in Group S. ALOD was observed in 15.3% of patients overall, 29% in group P and 2.8% in group S (P < .001). Following multivariate adjustment, statistically significant association was found between use of plate and ALOD (odds ratio = 12.8, 95% confidence interval = 3.52-45.45, P < .001). Plate-to-disc distance <5 mm was significantly associated with ALOD (odds ratio = 13.5, 95% confidence interval = 3.83-47.62, P < .001). CONCLUSION: The use of anterior plate with ACDF was associated with ALOD. Plate-to-disc distance <5 mm was significantly associated with ALOD even after adjustment for confounding factors. We conclude utilization of standalone cages or cages with plate with more than 5 mm distance from adjacent disc to minimize ALOD.

The Gender Gap Tracker: Using Natural Language Processing to measure gender bias in media.

We examine gender bias in media by tallying the number of men and women quoted in news text, using the Gender Gap Tracker, a software system we developed specifically for this purpose. The Gender Gap Tracker downloads and analyzes the online daily publication of seven English-language Canadian news outlets and enhances the data with multiple layers of linguistic information. We describe the Natural Language Processing technology behind this system, the curation of off-the-shelf tools and resources that we used to build it, and the parts that we developed. We evaluate the system in each language processing task and report errors using real-world examples. Finally, by applying the Tracker to the data, we provide valuable insights about the proportion of people mentioned and quoted, by gender, news organization, and author gender. Data collected between October 1, 2018 and September 30, 2020 shows that, in general, men are quoted about three times as frequently as women. While this proportion varies across news outlets and time intervals, the general pattern is consistent. We believe that, in a world with about 50% women, this should not be the case. Although journalists naturally need to quote newsmakers who are men, they also have a certain amount of control over who they approach as sources. The Gender Gap Tracker relies on the same principles as fitness or goal-setting trackers: By quantifying and measuring regular progress, we hope to motivate news organizations to provide a more diverse set of voices in their reporting.

The Incidence of Pars Interarticularis Defects in Athletes.

STUDY DESIGN: Literature review. OBJECTIVE: To conduct a literature review of studies reporting the incidence of pars interarticularis defects in athletes of specific sports, in order to allow more targeted prevention and treatment strategies to be implemented for the groups at highest risk. METHODS: Electronic searches were performed using PubMed, Ovid Medline, EMBASE, Google Scholar, Cochrane Database of Systematic Reviews, and Cochrane Database of Controlled Trials from their dates of inception to September 2017, with the following keywords: "spondylolysis," "sports," "low back pain," and "pars defects." RESULTS: A total of 509 total articles were retrieved, of which 114 were used in the final review. The incidence of pars interarticularis defects was found to be highest in diving (35.38%), cricket (31.97%), baseball/softball (26.91%), rugby (22.22%), weightlifting (19.49%), sailing (17.18%), table tennis (15.63%), and wrestling (14.74%). Only 5 studies reported the management instituted for their participants, and these were all case reports. Of 74 players with spondylolysis in these studies, 70 (94.59%) underwent conservative treatment and 4 (5.41%) underwent surgical treatment. 61 (82.43%) returned to their previous level of play, 6 (8.11%) retired, and the disposition of the final 7 was not reported. CONCLUSION: The current medical literature provides good evidence that the incidence of pars interarticularis defects is higher in the athletic population, with the highest incidence in diving. There remains no gold standard protocol for the management of pars interarticularis defects. Further research is required to compare conservative therapy to surgical therapy and to compare the various surgical techniques to each other.

Degenerate-disc infection study with contaminant control (DISC): a multicenter prospective case-control trial.

BACKGROUND: A bacterial cause of disc degeneration has evoked several controversies and, if true, would lead to a major shift in treatment paradigm. Earlier studies analyzing the relationship of bacterial disc infection within a degenerative cohort featured prolonged cultures susceptible to contamination. The degenerate-disc infection study with contaminant control (DISC) trial aims to investigate this theory further by examining infection rates using a non-degenerative control cohort in comparison to a degenerative internal control cohort and a sham cohort (sampling only sterile paraspinal tissue). To our knowledge, the current study is the largest evaluating the growth of organisms (or possible contamination rate) in paraspinal tissue if prolonged cultures are performed. Protocols on methodology have been previously published. PURPOSE: (1) To investigate the infection rates across cohorts (degenerative vs. nondegenerative control; paraspinal and/or disc controls vs. combined sampling cohorts) using stringent standardized aseptic surgical technique and laboratory processing. (2) To compare our findings to that of the literature and make a statement in support and/or against a possible contamination theory to positive cultures. STUDY DESIGN: Multicenter, multisurgeon case-control trial. PATIENT SAMPLE: In all, 812 surgical samples were retrieved across a 3.5-year period (2013-2016) including 25 trauma controls (nondegenerative), 550 "disc and paraspinal" samples (degenerative cases with internal control), 190 disc-only samples (degenerative cases without internal control), and 46 paraspinal only controls (sham group). OUTCOME MEASURES: Growth and/or Contamination rate (%) per cohort. Chi-square of growth in disc versus paraspinal samples as a means of examining the distribution of false positive and contaminant growth. The impact of previous injections and/or surgery on positive disc or paraspinal growth. Correlation of Modic changes with positive growth rates analyzed with the Kruskal-Wallis Test. The distribution of species in positive samples were also analyzed. METHODS: The DISC trial is registered under Australian and New Zealand clinical trials registry-ACTRN12616000541404. Institutional ethics review was obtained (HREC northern sector 13/218) at the primary center and further centers (n=6) were recruited. Patients undergoing spinal surgery with discectomy were eligible for trial entry with tissue specimens obtained using strict aseptic technique for microbiological examination. All specimens were handled with sterile instruments only and by a fresh instrument to a sterile pot that was closed immediately. Separate pots were used for the disc and paraspinal tissue respectively with similar stringent processing during microbiological assessment. A cohort of the degenerative cases at one single institution also underwent an additional histopathological examination. RESULTS: There was an expected significant difference in gender and age associated with the non-degenerative control group (due to trauma patients) compared with other cohorts. There was a higher percentage of positive-growth in the control group in comparison to the disc and paraspinal and disc only groups across positive disc growth (48% vs. 27% vs. 17%, p<.001). A similar infection rate was observed in the paraspinal samples across the equivalent controls (44% vs. 36% vs. 37%, p=.739). There was a significant difference in the proportions of positive growth with a large proportion of false positives (growth in both disc and paraspinal samples; p<.001). There was no difference in true positive growth between the case and control groups (16.0 vs. 7.7%, p=.112). These trends were preserved across all cohorts and when stratifying by spinal segment (cervical or lumbar). There was no correlation between Modic changes and positive disc culture growth (p=.398, n=144 samples). Cutibacterium (formerly Propionibacterium) acnes was the most dominant pathogen isolated, representing between 50% and 70% of positive disc and paraspinal specimens, followed by staphylococcal species. CONCLUSIONS: Our study failed to find a difference in true infection rates between the nondegenerative and degenerative disc populations. These findings are suggestive of a contamination theory and against a common infective etiology in the setting of discogenic back and neck pain. We believe the rationale for antibiotic therapy in the management of discogenic back pain warrants further evidence to establish efficacy.

Novel magnetically guided intra-abdominal camera to facilitate laparoendoscopic single-site surgery: initial human experience.

BACKGROUND: Magnetic anchoring guidance systems (MAGS) are composed of an internal surgical instrument controlled by an external handheld magnet and do not require a dedicated surgical port. Therefore, this system may help to reduce internal and external collision of instruments associated with laparoendoscopic single-site (LESS) surgery. Herein, we describe the initial clinical experience with a magnetically anchored camera system used during laparoscopic nephrectomy and appendectomy in two human patients. METHODS: Two separate cases were performed using a single-incision working port with the addition of a magnetically anchored camera that was controlled externally with a magnet. RESULTS: Surgery was successful in both cases. Nephrectomy was completed in 120 min with 150 ml estimated blood loss (EBL) and the patient was discharged home on postoperative day 2. Appendectomy was successfully completed in 55 min with EBL of 10 ml and the patient was discharged home the following morning. CONCLUSIONS: Use of a MAGS camera results in fewer instrument collisions, improves surgical working space, and provides an image comparable to that in standard laparoscopy.

Dabigatran reversal by idarucizumab in the setting of intracranial hemorrhage: A systematic review of the literature.

Idarucizumab is the first Food and Drugs Administration (FDA) approved reversal agent for anticoagulant dabigatran, a direct thrombin inhibitor. Emerging evidence suggests idarucizumab can improve clinical outcome following dabigatran-associated hemorrhage, however, its specific use in intracranial hemorrhage has been poorly described. The aim of this study was to systematically review the available literature of idarucizumab in the setting of dabigatran-associated ICH to evaluate its efficacy in the stabilizing/resolving of the primary hemorrhage. A systematic search of 7 electronic databases from their earliest records to August 2018 was conducted following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. There were 864 articles identified for screening against selection criteria. The search identified 9 articles to be included in our analysis, describing hemorrhage outcomes in 23 dabigatran-associated cases of ICH managed by idarucizumab. Mean overall age was 76.2 years, with 43% females, and bleeding was subdural, subarachnoid and intracerebral in 43%, 13% and 43% cases respectively. Surgical intervention was pursued in 48% of cases. During the course of the hospitalization, the hemorrhages stabilized/resolved in 87% of patients, and worsened in 13%. In-hospital complications occurred in 4% of cases, and mortality occurred in 4% of cases as well. The available literature suggests that idarucizumab can be applied in the setting of ICH, for its therapeutic effect in patients presenting with dabigatran-associated ICH appears acceptable with no compromise to clinical safety. However, currently there is a paucity of data about various aspects that are involved in other aspects of ICH treatment, including recovery, that limits the significance of the current literature. As more evidence is published relating specifically to long-term ICH outcomes that have been treated by idarucizumab, we will be better placed to establish the optimal role of idarucizumab in the setting of dabigatran-associated ICH.

Degenerate-disc infection study with contaminant control (DISC): Application of a proposed histological scoring system.

Recent evidence into an infectious etiology of discogenic back pain/leg pain are ongoing with contradictory data in literature. We sought to validate the clinical relevance of histopathological evidence of inflammation through a previously proposed histological grading system. In this prospective cohort study, 124 consecutive patients undergoing an elective spinal decompression and/or fusion procedure involving discectomy were selected with intraoperative tissue sampling of intervertebral disc and paraspinal tissue at a single institution. The histological domains were correlated with positive disc cultures to assist in identifying relevant positive infections. Inter-observer analysis of the scoring system was also performed. There were 124 samples (36 cervical and 88 lumbar) obtained. 29 (23.4%) disc specimens and 37 (29.8%) of ligament samples demonstrated growth of C. acnes. In total, 38/124 (30.6%) of disc specimens were positive for growth of any species. There was poor association between positive disc culture and the presence of neutrophilia (p = 0.123) or chronic inflammatory changes (p = 0.092) on histopathological assessment. There was no statistical significance noted across all histological domains examined within the finalised scoring system and positive culture across disc specimens. There was moderate agreement in between observers (kappa range: 0.41-0.60) in the assessment of inflammatory changes using the proposed scoring system. The current study suggests poor correlation between histopathological evidence of chronic or acute inflammation and positive disc cultures questioning the idea that disc infection is the root cause of acute or chronic back pain/leg pain.

Outcomes of direct lateral interbody fusion (DLIF) in an Australian cohort.

BACKGROUND: Direct lateral interbody fusion (DLIF) mitigates many of the vascular complications and bony resections associated with other interbody fusion techniques. However, there are concerns regarding postoperative neural complications and that indirect decompression of the foramen has not been consistently demonstrated. This study prospectively assessed the clinical and radiological outcomes and the complication rates of the DLIF approach. METHODS: A prospective review was conducted of the first 50 consecutive DLIF cases of a single neurosurgeon between 2010 and 2014. Clinical outcomes were assessed using Visual Analogue Scale (VAS), Oswestry Disability Index (ODI) and Roland Morris Disability Questionnaire (RMDQ) surveys. Radiological outcomes, including spondylolisthesis, disc height, local disc angle, lumbar lordosis and foraminal height and width, were measured using Surgimap Spine software at the preoperative, 6 weeks, 6 months, and 12 months postoperative follow-up. Complication rates were also reported. RESULTS: A total of 50 patients (84 levels) were treated with DLIF. The mean patient age was 68.2±9.8 years and 62.0% were female. At latest follow-up, mean VAS pain score improved from 7.7±1.5 to 1.9±0.9 (P<0.0001), mean ODI improved from 42.1±14.5 to 16.9±6.7 (P<0.0001) and mean RMDQ score improved from 12.1±5.2 to 6.2±4.7 (P<0.0001). Mean spondylolisthesis reduced from 7.5%±6.5% to 1.3%±1.1% at 6 weeks (P<0.0001), 0.95%±0.74% at 6 months (P<0.0001) and recurred to 1.9%±1.7% at 12 months postoperatively (P=0.0006). Mean anterior disc height improved from 7.3±3.2 to 11.6±2.5 mm at 6 weeks (P<0.0001), 12.2±3.3 mm at 6 months (P<0.0001) and 9.8±2.1 mm at 12 months (P=0.0032) postoperatively. Mean posterior disc height improved from 4.4±2.0 to 6.8±2.1 mm at 6 weeks (P<0.0001), 6.6±2.5 mm at 6 months (P=0.0003), and 5.9±1.4 mm at 12 months (P=0.0039) postoperatively. Mean local disc angle improved from 7.0°±3.7° to 9.2°±3.3° at 6 weeks (P=0.0072), 10.4°±3.9° at 6 months (P=0.0013) and 8.2°±2.9° at 12 months (P=0.2487) postoperatively. No significant postoperative changes in lumbar lordosis were observed. Mean foraminal height improved from 18.3±3.5 to 21.5±3.9 mm at 6 weeks (P=0.0004), 20.6±3.4 mm at 6 months (P=0.0266), and 18.7±1.9 mm at 12 months (P=0.8021) postoperatively. Mean foraminal width improved from 7.9±2.0 to 10.2±2.8 mm at 6 weeks (P=0.0001), 9.4±2.6 mm at 6 months (P=0.0219) and 8.3±1.6 mm at 12 months (P=0.5734) postoperatively. Fusion rate at 6 and 12 months was 62.2% and 89.2%, respectively. A total of 6 patients (12%) had postoperative complications. Three patients (6%) had pain-related psoas muscle weakness and 3 patients (6%) had sensory neural complications that had resolved entirely by 8 and 16 weeks postoperatively, respectively. CONCLUSIONS: The study provides encouraging short and medium-term clinical and radiological results for DLIF. In this patient series, there was a low complication rate with no permanent neural injury reported.