Outcomes of Mechanical Thrombectomy in Patients With Neurological Disorders: A National Inpatient Sample Database Analysis.

INTRODUCTION: Mechanical thrombectomy (MT) has changed the standard of care for patients presenting with acute ischemic stroke (AIS). The window of treatment has significantly increased the number of patients who would benefit from intervention and operators may be confronted with patients harboring preexistent neurological disorders. Still, the epidemiology of patients with AIS and neurological disorders has not been established. METHODS: This is a retrospective study, which utilizes data from the National Inpatient Sample (NIS) between 2012 and 2016. Patients with the major neurological comorbidities in the study were included: Alzheimer's dementia (AD), Parkinson's disease (PD), amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), and myasthenia gravis (MG). These patients were divided into groups and analyzed based on discharged home status, length of hospital stay (LOS), and inpatient mortality. These outcomes were also compared between patients who underwent MT versus those who did not. RESULTS: In this study, 460,070 patients with AIS were identified and included. MT was performed less often when the patient had a neurological diagnosis compared to those without a neurological disease (p<0.0001). However, patients with AIS who have underlying neurological disorders such as AD, PD, and MS have shown similar outcomes after MT to those who do not have these disorders. CONCLUSION: Patients with preexisting neurological disorders were less likely to undergo MT. Further studies are required to elucidate the implications of having a neurological disorder in the setting of an AIS.

Managing Disease-Modifying Antirheumatic Drugs (DMARDs) for Patients Undergoing Elective Spine Surgery: A Pilot Survey.

Introduction: Patients affected by autoimmune pathologies such as rheumatoid arthritis require surgery for various reasons. However, the systemic inflammatory nature of these disease processes often necessitates therapy with disease-modifying antirheumatic drugs (DMARDs). Alteration of these agents in the perioperative period for surgery requires a careful risk-benefit analysis to limit disease flares, infection rates, and secondary revisions. We therefore queried North and South American practices for perioperative management of DMARDs in patients undergoing elective spine surgery. Methods: An institutional review board-approved pilot survey was disseminated to spine surgeons regarding how they managed DMARDs before, during, and after spine surgery. Results: A total of 47 spine surgeons responded to the survey, 37 of whom were neurosurgeons (78.7%) and 10 orthopedic surgeons (21.3%). Of the respondents, 80.9% were from North America, 72.3% were board-certified, 51.1% practiced in academic institutions, and 66.0% performed 50-150 spine surgeries per year. Most respondents consulted a rheumatologist before continuing or withholding a DMARD in the perioperative period (70.2%). As such, a majority of the spine surgeons in this survey withheld DMARDs at an average of 13.8 days before and 19.6 days after spine surgery. Of the spine surgeons who withheld DMARDs before and after spine surgery, the responses were variable with a trend toward no increased risk of postoperative complications. Conclusions: Based on the results of this pilot survey, we found a consensus among spine surgeons to withhold DMARDs before and after elective spine surgery.

Evaluation of the Thoracolumbar Injury Classification and Severity (TLICS) Score Over a Two-Year Period at a Level One Trauma Center.

Introduction The use of the Thoracolumbar Injury Classification and Severity Score (TLICS) and other classification systems for guiding the management of traumatic spinal injuries remains controversial. TLICS is one of the few classifications that provides treatment recommendations.We sought to analyze intervention modality selection based on the TLICS scoring system. Methods A retrospective review of patients presenting with traumatic thoracolumbar fractures at a level 1 trauma center over a two-year period was performed. Primary endpoints for comparison analysis included visual analog scale (VAS) scores and Cobb angles during follow-up. Results There were 272 patients with thoracolumbar fractures, of whom 212 had TLICS of ≤3, six with TLICS of 4, and 54 with TLICS of ≥5. Of the 272 total patients, 59 were treated via surgery and 213 via non-surgical conservative methods. The VAS scores significantly decreased from presentation to last follow-up in both surgically treated and conservative groups (p<0.0001). This remained consistent in subgroup analyses of TLICS ≤ 3, TLICS = 4, and TLICS ≥ 5 (p<0.0001). Burst fractures treated conservatively had larger fracture Cobb angles versus those treated via surgery at the last follow-up, although this was not significantly associated (p=0.07). The only significant relationship with Cobb angles was in distraction fractures of the TLICS > 4 conservative group, who had significantly lower Cobb angles at the last follow-up than the TLICS > 4 surgical group (p<0.04). The "surgeon's choice" for TLICS = 4 was surgical intervention (4/6 patients, 66.7%). Conclusion Using the TLICS score, thoracolumbar injuries in a level 1 trauma center are more commonly TLICS ≤ 3. For patients with TLICS = 4, the surgeon's choice was most commonly surgical repair. VAS scores decreased over time from presentation between surgically and conservatively managed patients (as well as within-group analyses). The data concerning Cobb angles were more ambiguous, as larger Cobb angles in burst fractures treated conservatively did not show statistically significant differences with surgery.

Outcomes following therapeutic intervention of post-traumatic vasospasm: A systematic review and meta-analysis.

BACKGROUND: Vasospasm occurrence following traumatic brain injury may impact neurologic and functional recovery of patients, yet treatment of post-traumatic vasospasm (PTV) has not been well documented. This systematic review and meta-analysis aims to assess the current evidence regarding favorable outcome as measured by Glasgow Outcome Scale (GOS) scores following treatment of PTV. METHODS: A systematic review of PubMed, Ovid MEDLINE, and Ovid EMBASE was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Included manuscripts were methodically scrutinized for quality; occurrence of PTV; rate of favorable outcome following each treatment modality; and follow-up duration. Treatments evaluated were calcium channel blockers (CCBs), endovascular intervention, and dopamine-induced hypertension. Outcomes were compared via the random-effects analysis. RESULTS: Fourteen studies with 1885 PTV patients were quantitatively analyzed: 982 patients who received tailored therapeutic intervention and 903 patients who did not receive tailored therapy. For patients undergoing treatment, the rate of favorable outcome was 57.3 % (500/872 patients; 95 % CI 54.1 - 60.6 %) following administration of CCBs, 94.1 % (16/17 patients; 95 % CI 82.9 - 100.0 %) following endovascular intervention, and 54.8 % (51/93 patients; 95 % CI 44.7 - 65.0 %) following dopamine-induced hypertension. Of note, the endovascular group had the highest rate of favorable outcome but was also the smallest sample size (n = 17). Patients who received tailored therapeutic intervention for PTV had a higher rate of favorable outcome than patients who did not receive tailored therapy: 57.7 % (567/982 patients; 95 % CI 54.1 - 60.8 %) versus 52.0 % (470/903 patients; 95 % CI 48.8 - 55.3 %), respectively. CONCLUSIONS: The available data suggests that tailored therapeutic intervention of PTV results in a favorable outcome. While endovascular intervention of PTV had the highest rate of favorable outcome, both CCB administration and dopamine-induced hypertension had similar lower rates of favorable outcome.

Predictors of revision surgery after bedside subdural drain placement for chronic subdural hematomas.

BACKGROUND AND OBJECTIVE: For chronic subdural hematoma (cSDH), bedside subdural drains (SDD) provide a useful alternative to more invasive neurosurgical techniques, including evacuation through multiple burr holes or formal craniotomy. However, no scale currently exists adequately predicting SDD candidacy or treatment response. The present study sought to characterize predictors of revision surgery after initial treatment with bedside SDD for cSDH. METHODS: We conducted a retrospective case control study of cSDH patients treated with bedside SDD at a level one trauma center between 2018 and 2022. Binomial regression was used to compare SDD patients and generate odds ratios associated with revision surgery, which were compared using a binary random effects model. RESULTS: Ninety six cSDH patients were included, of whom 13 (13.5%) required a revision surgery after initial treatment failure with bedside SDD. Patients requiring revision surgery demonstrated an increased male predominance (84.6% vs. 69.9% of SDD patients not requiring revision surgery), tended to be younger (67.8 vs. 70.5 years) with a greater body mass index (28.7 vs. 25.6 kg/m2), and have a lower Glasgow Coma Scale (GCS) score on presentation of 12.5 (versus 14). Patients with an initial GCS score less than 13 (OR 11.0 95% CI 2.8 - 43.3), midline shift greater than 10 mm on CT (OR 6.5 95% CI 1.7 - 25.7), or duration of SDD placement longer than 3 days (OR 10.5 95% CI 2.6 - 41.9) demonstrated a greater likelihood of needing a revision surgery after initial treatment with bedside SDD. CONCLUSION: Among patients treated with SDD, we identified 3 independent factors predicting the need for revision surgery: GCS score, midline shift, and duration of drain placement. Craniotomy may be favored over bedside SDD in patients presenting with a GCS score less than 13 or midline shift greater than 10 mm and for SDD patients demonstrating inadequate clinical response after 3 days.

Recurrence Rates Following Treatment of Spinal Vascular Malformations: A Systematic Review and Meta-Analysis.

BACKGROUND: Spinal vascular malformations (SVMs), including arteriovenous malformations (AVMs) and arteriovenous fistulas (AVFs), are a varied group of vascular lesions that can be subclassified according to localization, vascular structure, and hemodynamics. Early intervention is necessary to halt progression of disease and minimize irreversible dysfunction. We sought to characterize initial treatment success and recurrence rates following interventional treatment of various types of SVMs. METHODS: A systematic review and meta-analysis were performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. SVMs were categorized into 4 groups: dural AVFs, perimedullary AVFs, intramedullary AVMs, and extradural-intradural AVMs (e.g., epidural, paraspinal). Initial occlusion, recurrence, and complication rates were compared using random-effects analysis. RESULTS: There were 112 manuscripts included, with a total of 5626 patients with SVM. For treatment, 2735 patients underwent endovascular embolization, 2854 underwent surgical resection, and 37 underwent stereotactic radiosurgery. The initial treatment success and overall recurrence rates following surgical resection of all SVMs were 89.5% (95% CI: 80.5%-98.5%) and 2.3% (95% CI: 0.9%-3.7%), respectively. Those rates following endovascular embolization were 55.9% (95% CI: 30.3%-81.5%) and 27.7% (95% CI: 11.2%-44.2%), respectively. Higher rates of initial treatment success and lower rates of recurrence with surgery were observed in all subtypes compared to embolization. Overall complication rates were higher after embolization for each of the SVM categories. CONCLUSIONS: Surgical resection of SVMs provided higher rates of initial complete occlusion and lower rates of recurrence than endovascular techniques. Attaining technical success through obliteration must still be weighed against clinical impact and natural history of the specific vascular malformation.

Evolution of open surgery for unruptured intracranial aneurysms over a fifteen year period-increased difficulty and morbidity.

OBJECTIVE: The approach to intervention for unruptured intracranial aneurysms (UIAs) remains controversial. Utilization of endovascular techniques for aneurysm repair increased dramatically during the last decade. We sought to analyze recent national trends for electively treated (open and endovascular) UIAs focusing on pre-existing patient disease burden and intervention modality selection. METHODS: The Nationwide Inpatient Sample (NIS) national database was used to identify patients with primary diagnosis codes of unruptured intracranial aneurysm between 1999 and 2014. Patients were dichotomized by intervention into endovascular or open surgical treatment. Analysis of pre-existing disease severity were calculated using the Elixhauser comorbidity index. Complications of combined peri-procedural stroke or death during admission and hospital length of stay were used as primary endpoints for comparison. RESULTS: The percent of total UIAs treated electively with open approach decreased from more than 95 % of cases in 1999 to less than 25 % in 2014. Patients undergoing clipping were 3 years younger than those in the endovascular group (p < 0.001). The rate of primary endpoint complications (stroke and death) and length of stay for open cases saw a decrease throughout the study but remained statistically higher when compared to the endovascular group over the study period (p < 0.001). Additionally, non-neurologic complications increased over the time period for open cases. The average preoperative co-morbid disease severity for all groups treated increased over this interval. Conversely, the relative volume of endovascular cases increased but the rate of complications and average group disease remained statistically lower than the surgical clipping group (p < 0.05). CONCLUSION: The percent of UIAs treated electively with open approach has decreased since 1999 with a concomitant increase in complication rate in particular compared to endovascular cases. However, the health characteristics of patients treated with surgical clipping show an increase in severity of pre-existing co-morbidities. Further research into factors contributing to this finding, including potential socioeconomic differences and changes in surgeon experience are needed.

Spinal cord stimulation for genitofemoral neuropathy: A case report and review of the literature.

Background: Chronic testicular pain due to genitofemoral neuropathy often becomes refractory to conservative medical therapy. Neurostimulation is a potentially useful treatment option, should the neuropathic pain remain refractory to more invasive procedures such as orchiectomy. We provide a case report of spinal cord stimulation (SCS) for successful treatment of genitofemoral neuropathy and have also reviewed the literature to find similar cases which required a similar treatment paradigm. Case Description: A 42-year-old male underwent SCS for refractory testicular and groin pain. SCS through a four-column, 2 × 8 contact neurostimulator paddle lead, was implanted in the mid-thoracic-9 (T9) vertebral level, providing > 50% testicular pain relief with a decrease in visual analog scale scores from 8-10/10 to 3-4/10. The patient required one adjustment to the stimulation parameters at the time of the 6 weeks follow-up visit due to over-stimulation. He then continued to experience >50% resolution in pain 9 months later. A review of the literature yielded only two similar cases that successfully utilized SCS for treatment of chronic testicular pain. Conclusion: SCS should be considered as a possible treatment option for patients with chronic testicular pain localized to the genitofemoral nerve distribution.

Combined Responsive Neurostimulation and Focal Resection for Super Refractory Status Epilepticus: A Systematic Review and Illustrative Case Report.

OBJECTIVE: Super-refractory status epilepticus (SRSE) is a neurologic emergency with high mortality and morbidity. Although medical algorithms typically are effective, when they do fail, options may be limited, and neurosurgical intervention should be considered. METHODS: We report a case of SRSE treated acutely with responsive neurostimulation (RNS) and focal surgical resection after intracranial monitoring. We also conducted a systematic review of the literature for neurosurgical treatment of SRSE (e.g., neurostimulation). Only published manuscripts were considered. RESULTS: Our patient's seizure semiology consisted of left facial twitching with frequent evolution to bilateral tonic-clonic convulsions. Stereoelectroencephalography and grid monitoring identified multiple seizure foci. The patient underwent right RNS placement with cortical strip leads over the lateral primary motor and premotor cortex as well as simultaneous right superior temporal and frontopolar resection. Status epilepticus resolved 21 days after surgical resection and placement of the RNS. The systematic review revealed 15 case reports describing 17 patients with SRSE who underwent acute neurosurgical intervention. There were 3 patients with SRSE with RNS placement as a single modality, all of whom experienced cessation of SE. Four patients with SRSE received vagus nerve stimulation (3 as a single modality and 1 with combined corpus callosotomy), of whom 1 had SE recurrence at 2weeks. Two patients with SRSE received deep brain stimulation, and the remaining 8 underwent surgical resection; none had recurrence of SE. CONCLUSIONS: RNS System placement with or without resection can be a viable treatment option for select patients with SRSE. Early neurosurgical intervention may improve seizure outcomes and reduce complications.

Is the routine use of systemic antibiotics after spine surgery warranted? A systematic review and meta-analysis.

PURPOSE: To determine whether the published literature supports the current practice of utilizing antibiotics postoperatively in spine surgery. METHODS: A systematic review from PubMed and Cochrane Central Register of Controlled trials databases was performed. Search terms used: "Antibiotic Prophylaxis"[Mesh], antibiotic*, antibacterial*, "Spine"[Mesh], "Surgical Procedures, Operative"[Mesh]. Only comparative, clinical studies were included. Those studies with surgical site infection (SSI) criteria that were not similar to the CDC definition were excluded. A meta-analysis for overall SSI was performed. A subgroup analysis was also performed to analyze the outcomes specifically on instrumented groups of patients. A random-effects model was used to calculate risk ratios (RR). Forest plots were used to display RR and 95% confidence intervals (CI). RESULTS: Thirteen studies were included (four Randomized-Controlled Trials, three prospective cohorts, and six retrospective). Three different perioperative strategies were used in the selected studies: Group 1: preoperative antibiotic administration (PreopAbx) versus PreopAbx and any type of postoperative antibiotic administration (Pre + postopAbx) (n = 6 studies; 7849 patients); Group 2: Pre + postopAbx ≤ 24 h versus Pre + postopAbx > 24 h (n = 6; 1982); and Group 3: Pre + postopAbx ≤ 48 h versus. Pre + postopAbx ≤ 72 h (n = 1; 502). The meta-analysis performed on Groups 1 and 2 did not show significant effects (RR = 1.27, 95% CI = 0.77, 2.09, and RR = 0.97, 95% CI = 0.64, 1.46, respectively). CONCLUSION: A meta-analysis and comprehensive review of the literature show that the routine use of postoperative antibiotics in spine surgery may not be effective in preventing surgical site infections.

National trends in endovascular thrombectomy and decompressive craniectomy for acute ischemic stroke: A study using National Inpatient Sample data from 2006 to 2016.

BACKGROUND: Ischemic stroke is a frequently encountered neurologic process with wide-spanning impact. A dreaded complication is "malignant" cerebral edema, necessitating decompression to reduce herniation risk. Following the publication of several landmark trials in 2015, endovascular thrombectomy (EVT) with novel clot-removal devices has emerged as an effective treatment for proximal large vessel disease. Herein, we examine recent national trends in EVT and decompressive craniectomy (DC) rates for acute stroke. METHODS: National Inpatient Sample data were abstracted from 2006 to 2016. Primary outcomes were EVT and DC rates, compared using Cochrane-Armitage test of trend. Chi-square test was also used to compare data from 2015 to 2016. Secondary outcomes included inpatient mortality and home discharge rates. RESULTS: EVT rates steadily increased from 2006 to 2016, with most change occurring from 2014 to 2016 (1.36% in 2014, 2.29% in 2016). DC rates similarly increased from 2006 to 2015, though a sharp decline was observed in 2016 (0.42% in 2015, 0.22% in 2016). Test of trend from 2006 to 2016 for both variables was found to be statistically significant (p = 0.001); DC rate change from 2015 to 2016 was also statistically significant (p < 0.01). Mortality rate and home discharge rate steadily improved over the study period. CONCLUSIONS: Recent innovation in stroke treatment has led to increased EVTs. While DC rate initially followed this same trend, a significant decline was noted in 2016, around the time that wider adoption of novel EVT technologies were instituted in clinical practice.

Current status of augmented reality in cerebrovascular surgery: a systematic review.

Augmented reality (AR) is an adjuvant tool in neuronavigation to improve spatial and anatomic understanding. The present review aims to describe the current status of intraoperative AR for the treatment of cerebrovascular pathology. A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The following databases were searched: PubMed, Science Direct, Web of Science, and EMBASE up to December, 2020. The search strategy consisted of "augmented reality," "AR," "cerebrovascular," "navigation," "neurovascular," "neurosurgery," and "endovascular" in both AND and OR combinations. Studies included were original research articles with intraoperative application. The manuscripts were thoroughly examined for study design, outcomes, and results. Sixteen studies were identified describing the use of intraoperative AR in the treatment of cerebrovascular pathology. A total of 172 patients were treated for 190 cerebrovascular lesions using intraoperative AR. The most common treated pathology was intracranial aneurysms. Most studies were cases and there was only a case-control study. A head-up display system in the microscope was the most common AR display. AR was found to be useful for tailoring the craniotomy, dura opening, and proper identification of donor and recipient vessels in vascular bypass. Most AR systems were unable to account for tissue deformation. This systematic review suggests that intraoperative AR is becoming a promising and feasible adjunct in the treatment of cerebrovascular pathology. It has been found to be a useful tool in the preoperative planning and intraoperative guidance. However, its clinical benefits remain to be seen.

Perioperative management of disease-modifying antirheumatic drugs for patients undergoing elective spine surgery: a systematic review.

BACKGROUND: In preparation for surgery, patients being treated with disease-modifying antirheumatic drugs (DMARDs) are recommended to either continue or withhold therapy perioperatively. Some of these drugs have known effects against bone healing, hence the importance of adequately managing them before and after surgery. OBJECTIVE: We aim to assess the current evidence for managing conventional synthetic and/or biologic DMARDs in the perioperative period for elective spine surgery. METHODS: A systematic review of four databases was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The included manuscripts were methodically scrutinized for quality, postoperative infections, wound healing characteristics, bone fusion rates, and clinical outcomes. RESULTS: Six studies were identified describing the management of conventional synthetic and/or biologic DMARDs. There were 294 DMARD-treated patients described undergoing various spine surgeries such as craniovertebral junction fusions. Three of the studies involved exclusive continuation of DMARDs in the perioperative window; one study involved exclusive discontinuation of DMARDs in the perioperative window; and two studies involved continuation or discontinuation of DMARDs perioperatively. Of patients that continued DMARDs in the perioperative period, 13/50 patients (26.0%) had postoperative surgical site infections or wound dehiscence, 2/19 patients (10.5%) had delayed wound healing, and 32/213 patients (15.0%) had secondary revision surgeries. A fusion rate of 14/19 (73.6%) was described in only one study for patients continuing DMARDs perioperatively. CONCLUSIONS: The available published data may suggest a higher risk of wound healing concerns and lower than average bone fusion, although this may be under-reported given the current state of the literature.

Complete seizure-free rates following interventional treatment of intracranial arteriovenous malformations: a systematic review and meta-analysis.

Seizures are common presenting symptoms of intracranial arteriovenous malformations (AVMs). This systematic review and meta-analysis aims to assess the current evidence regarding complete seizure freedom rates following surgical resection, stereotactic radiosurgery (SRS), and/or endovascular embolization of intracranial AVMs. A systematic review of PubMed, Ovid MEDLINE, and Ovid EMBASE was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Included manuscripts were methodically scrutinized for quality, spontaneous AVM-associated or hemorrhage-associated seizures, complete seizure-free rates following each interventional treatment, follow-up duration; determination methods of seizure outcomes, and average time-to-onset of recurrent seizures after each treatment. Manuscripts that described patients with nondisabling seizures or reduced seizure frequency in their seizure-free calculations were excluded. Seizure freedom rates following surgical resection, SRS, and endovascular embolization were compared via random-effect analysis. Thirty-four studies with a total of 1765 intracranial AVM patients presenting with spontaneous AVM-associated seizures and 408 patients presenting with hemorrhage-associated seizures were qualitatively analyzed. For patients presenting with AVM-associated seizures, the complete seizure-free rates were 73.0% (321/440 patients; 95% CI 68.8-77.1%) following surgical resection, 60.5% (376/622 patients; 95% CI 56.6-64.3%) following SRS, and 44.6% (29/65 patients; 95% CI 32.5-56.7%) following endovascular embolization alone. For patients presenting with either AVM-associated or hemorrhage-associated seizures, the complete seizure-free rates were 73.0% (584/800 patients; 95% CI 69.9-76.1%) following surgical resection, 46.4% (572/1233 patients; 95% CI 43.6-49.2%) following SRS, and 44.6% (29/65 patients; 95% CI 32.5-56.7%) following embolization. For patients presenting with either AVM-associated or hemorrhage-associated seizures, the overall improvements in seizure outcomes regardless of complete seizure freedom were 82.6% (661/800 patients; 95% CI 80.0-85.3%), 70.6% (870/1233 patients; 95% CI 68.0-73.1%), and 70.8% (46/65 patients; 95% CI 59.7-81.1%) following surgical resection, SRS, and embolization, respectively. No study reported information about the time-to-onset for recurrent seizures in any patient following treatment, as seizure outcomes were only described at the last follow-up visit. The available data suggests that surgical resection results in the highest rate of complete seizure freedom. The rate of seizure improvement following surgery increased further to 82.3% when including patients who had improved seizure frequency without achieving true seizure freedom. Complete seizure-free rates following SRS or embolization were more ambiguous and lower when compared to surgical resection. There is a need for high quality studies evaluating AVM treatment modalities and clearly defined seizure outcomes, as the current literature consists mostly of heterogenous patient populations.

Utility of Augmented Reality and Virtual Reality in Spine Surgery: A Systematic Review of the Literature.

BACKGROUND: Augmented reality (AR), virtual reality (VR), and mixed reality (MR) are emerging technologies that are starting to be translated into clinical practice. Limited data are available regarding these tools in use during live surgery of the spine. Our objective was to systematically collect, analyze, and interpret the existing data regarding AR, VR, and MR use in spine surgery on living people. METHODS: A systematic review was conducted using the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. The PubMed, PubMed Central, Cochrane Reviews, and Embase databases were searched. Combinations and variations of the phrases "augmented reality," "virtual reality," and spine surgery using both "AND" and "OR" configurations were used to find relevant studies. The references of the included reports from the systematic review were also screened for possible inclusion as a part of a manual review. The included studies were full-text publications written in English that had included any spine surgery on live persons with the use of VR or AR. RESULTS: A total of 1566 unique reports were found, and 15 full-text publications met the criteria for the present study. The total number of patients from all studies was 241, with a weighted average age of 50.37 years. Surgical procedures using AR, VR, and/or MR were diverse and spanned from simple discectomy to intradural spinal tumor resection. All patients experienced improvement in their symptoms present at clinical presentation. The highest complication rate reported in the studies was 6.1% and was for suboptimal pedicle screw placement. No complications led to clinical sequelae. CONCLUSIONS: The systematically collected, analyzed, and interpreted data of existing peer-reviewed full-text articles showed favorable metrics regarding surgical efficacy, pedicle screw target accuracy, radiation exposure, clinical outcomes, and disability and pain for patients with spinal pathology treated with the help of AR, VR, and/or MR.

Parkinson Disease, Dysphagia, and Cervical Spine Surgery.

STUDY DESIGN: An analysis of a National Database. OBJECTIVE: The objective of this study was to evaluate the rate of dysphagia for Parkinson disease (PD) patients undergoing cervical spine surgery for cervical myelopathy. SUMMARY OF BACKGROUND DATA: Cervical spondylotic myelopathy (CSM) is an increasingly common problem in the aging population. Several surgical options exist to treat this condition including anterior, posterior and combined surgical approaches. Each approach carries its own set of postoperative complications. Little is known of the of outcomes after cervical spine surgery in PD. MATERIALS AND METHODS: The National Inpatient sample was queried 1998 to 2016, all elective admissions with CSM were identified. Surgical treatments were identified as either: anterior cervical discectomy and fusion (ACDF), posterior laminectomies, posterior cervical fusion or combined anterior/posterior surgery. Preexisting PD was identified. Endpoints included mortality, length of stay (LOS), swallowing dysfunction measured by placement of feeding tube (NGT), and postprocedure pneumonia. RESULTS: A total of 73,088 patients underwent surgical procedures for CSM during the study period. Of those, 552 patients (7.5%) had concomitant PD. The most common procedure was ACDF. Patients with PD had a higher rate of dysphagia (NGT placement) after surgery compared with those without PD (P<0.001). Multiple regression analysis showed that PD patients had a higher risk of having NGT placement or developing pneumonia [odds ratio 2.98 (1.7-5.2), P<0.001] after surgery.Patients with PD who underwent ACDF, posterior laminectomies or posterior cervical fusion had a longer LOS compared with those who did not have PD (P<0.001). There was no difference in LOS for patients who underwent combined anterior/posterior surgery. Inpatient mortality was higher in patients with PD who underwent ACDF or combined surgery (P<0.001). CONCLUSIONS: While ACDF is the most commonly performed procedure for CSM in patients with PD, it is associated with longer LOS, higher incidence of postoperative dysphagia, and postprocedural pneumonia, as well as higher inpatient mortality compared with posterior cervical procedures. LEVEL OF EVIDENCE: Level III.

Carotid Cavernous Fistula Treatment via Flow Diversion: A Systematic Review of the Literature.

BACKGROUND: Carotid cavernous fistulas (CCFs) are pathologic connections between the carotid arteries and the cavernous sinus and have been classically treated with endovascular coil embolization, although flow diverters have been used for treatment successfully multiple times. The aim of this study is to systematically review the literature for efficacy of flow diverters in treating CCFs. METHODS: A systematic review was conducted using the PRISMA guidelines. PubMed, PubMed Central, Cochrane Library, and Embase databases were searched. Combinations and variations of "carotid cavernous fistula," "flow diversion," "pipeline embolization device," "Surpass," "Silk," "p64," "FRED," and "flow redirection endoluminal device" in both AND and OR configurations were used to gather relevant articles. Citations of included articles from the systematic review were also screened for possible inclusion as a part of manual review. Included studies were full-text publications written in English that had patients with diagnosed CCFs and treatment with flow diversion. RESULTS: Eighteen full-text publications were relevant to this systematic review. A total of 41 patients underwent flow-diverting therapy alone or in conjunction with coil embolization, liquid embolization, and/or stenting for treatment of a diagnosed CCF. Twenty-nine patients (70.7%) needed 1 procedure alone, 11 patients (26.8%) required a second procedure, and 1 patient (2.4%) required a third procedure. Six patients (14.6%) had lasting symptoms despite intervention; however, all 41 patients had clinical improvement compared with initial presentation. Flow diversion was a useful solitary treatment or adjunctive treatment in all patients. CONCLUSIONS: Flow diversion is a useful adjunct in combination with coil embolization for the treatment of CCFs but long-term outcomes remain to be seen.

The use of cangrelor in neurovascular interventions: a multicenter experience.

PURPOSE: Thromboembolic events represent the most common procedure-related complication associated with neurointerventions. Cangrelor is a potent, intravenous (IV), P2Y12-receptor antagonist with a rapid onset and offset presented as an alternative antiplatelet agent. We aim to evaluate the safety and effectiveness of IV cangrelor in neurovascular intervention. METHODS: This is a retrospective analysis of data from four cerebrovascular interventional centers. We identified patients who underwent acute neurovascular intervention and received cangrelor as part of their optimum care. Patients were divided into 2 groups: ischemic and aneurysm. Periprocedural thromboembolic events, hemorrhagic complications, and outcomes were analyzed. RESULTS: Sixty-six patients were included, 42 allocated into the ischemic group (IG), and 24 into aneurysm group (AG). The IG periprocedural symptomatic complication rate was 9.5%, represented by 3 postoperative intracranial hemorrhages and 1 retroperitoneal hematoma. At discharge, 47.6% had a favorable outcome and the mortality rate was 2.4%, related to clinical deterioration of a large infarct. In the AG, 4.2% had a periprocedural complication during or after cangrelor infusion, represented by an intracranial hemorrhage in an initially ruptured aneurysm. Favorable clinical outcome was seen in 56.2% and 87.7% of ruptured and unruptured aneurysms, respectively, upon discharge. CONCLUSIONS: Cangrelor may be a feasible alternative for patients requiring immediate intervention with the use of endoluminal devices. It allows the possibility for a secure transition to long-term ticagrelor and progression to surgery in the setting of unexpected complications.