Cannabis Use is Associated With Higher Rates of Pseudarthrosis Following TLIF: A Multi-Institutional Matched-Cohort Study.

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: To compare the rates of pseudarthrosis in patients undergoing 1 to 3 level transforaminal lumbar interbody fusion (TLIF) procedures between cannabis users and noncannabis users. SUMMARY OF BACKGROUND DATA: Recreational use of cannabis is common, though it remains poorly studied and legally ambiguous in the United States. Patients with back pain may turn to adjunctive use of cannabis to manage their pain. However, the implications of cannabis use on the achievement of bony fusion are not well-characterized. METHODS: Patients who underwent 1 to 3 level TLIF for degenerative disc disease or degenerative spondylolisthesis between 2010 and 2022 were identified using the PearlDiver Mariner all-claims insurance database. Cannabis users were identified with ICD 10 code F12.90. Patients undergoing surgery for nondegenerative pathologies such as tumors, trauma, or infection were excluded. 1:1 exact matching was performed using demographic factors, medical comorbidities, and surgical factors which were significantly associated with pseudarthrosis in a linear regression model. The primary outcome measure was development of pseudarthrosis within 24 months after 1 to 3 level TLIF. The secondary outcomes were the development of all-cause surgical complications as well as all-cause medical complications. RESULTS: A 1:1 exact matching resulted in two equal groups of 1593 patients who did or did not use cannabis and underwent 1 to 3 level TLIF. Patients who used cannabis were 80% more likely to experience pseudarthrosis compared with patients who do not [relative risk (RR): 1.816, 95% CI: 1.291-2.556, P <0.001]. Similarly, cannabis use was associated with significantly higher rates of all-cause surgical complications (RR: 2.350, 95% CI: 1.399-3.947, P =0.001) and all-cause medical complications (RR: 1.934, 95% CI: 1.516-2.467, P <0.001). CONCLUSION: After 1:1 exact matching to control for confounding variables, the findings of this study suggest that cannabis use is associated with higher rates of pseudarthrosis, as well as higher rates of all-cause surgical and all-cause medical complications. Further studies are needed to corroborate our findings.

TLIF is Associated With Lower Rates of Adjacent Segment Disease and Complications Compared to ALIF: A Matched-Cohort Analysis.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: To compare the rate of adjacent segment disease (ASD) in patients undergoing anterior lumbar interbody fusion (ALIF) versus transforaminal lumbar interbody fusion (TLIF) for the treatment of degenerative stenosis and spondylolisthesis. SUMMARY OF BACKGROUND DATA: ALIF and TLIF are frequently used to treat Lumbar stenosis and spondylolisthesis. While both approaches have distinct advantages, it is unclear whether there are any differences in rates of ASD and postoperative complications. METHODS: A retrospective cohort study of patients who underwent index 1-3 levels ALIF or TLIF between 2010 and 2022, using the PearlDiver Mariner Database, an all-claims insurance database (120 million patients). Patients with a history of prior lumbar surgery and those undergoing surgery for cancer, trauma, or infection were excluded. Exact 1:1 matching was performed using demographic factors, medical comorbidities, and surgical factors found to be significantly associated with ASD in a linear regression model. The primary outcome was a new diagnosis of ASD within 36 months of index surgery, and secondary outcomes were all-cause medical and surgical complications. RESULTS: Exact 1:1 matching resulted in 2 equal groups of 106,451 patients undergoing TLIF and ALIF. The TLIF approach was associated with a lower risk of ASD (RR 0.58, 95% CI 0.56-0.59, P < 0.001) and all-cause medical complications (RR 0.94, 95% CI 0.91-0.98, P =0.002). All-cause surgical complications were not significantly different between both groups. CONCLUSION: After 1:1 exact matching to control for confounding variables, this study suggests that for patients with symptomatic degenerative stenosis and spondylolisthesis, a TLIF procedure (compared to ALIF) is associated with a decreased risk of developing ASD within 36 months of index surgery. Future prospective studies are needed to corroborate these findings. LEVEL OF EVIDENCE: Level-3.

2D versus 3D Endoscopy: Head-to-Head Comparison in a Simulated Model of Endoscopic Endonasal Dural Suturing.

Objective Endonasal dural suturing (EDS) has been reported to decrease the incidence of cerebrospinal fluid fistula. This technique requires handling of single-shaft instrumentation in the narrow endonasal corridor. It has been proposed that three-dimensional (3D) endoscopes were associated with improved depth perception. In this study, we sought to perform a comparison of two-dimensional (2D) versus 3D endoscopy by assessing surgical proficiency in a simulated model of EDS. Materials and Methods Twenty-six participants subdivided into groups based on previous endoscopic experience were asked to pass barbed sutures through preset targets with either 2D (Storz Hopkins II) or 3D (Storz TIPCAM) endoscopes on 3D-printed simulation model. Surgical precision and procedural time were measured. All participants completed a Likert scale questionnaire. Results Novice, intermediate, and expert groups took 11.0, 8.7, and 5.7 minutes with 2D endoscopy and 10.9, 9.0, and 7.6 minutes with 3D endoscopy, respectively. The average deviation for novice, intermediate, and expert groups (mm) was 5.5, 4.4, and 4.3 with 2D and 6.6, 4.6, and 3.0 with 3D, respectively. No significant difference in procedural time or accuracy was found in 2D versus 3D endoscopy. 2D endoscopic visualization was preferred by the majority of expert/intermediate participants, while 3D endoscopic visualization by the novice group. Conclusion In this pilot study, there was no statistical difference in procedural time or accuracy when utilizing 2D versus 3D endoscopes. While it is possible that widespread familiarity with 2D endoscopic equipment has biased this study, preliminary analysis suggests that 3D endoscopy offers no definitive advantage over 2D endoscopy in this simulated model of EDS.

Noninvasive electrical stimulation as an adjunct to fusion procedures: a systematic review and meta-analysis.

OBJECTIVE: Noninvasive electrical stimulation represents a distinct group of devices used to augment fusion rates. However, data regarding outcomes of noninvasive electrical stimulation have come from a small number of studies. The goal of this systematic review and meta-analysis was to determine outcomes of noninvasive electrical stimulation used as an adjunct to fusion procedures to improve rates of successful fusion. METHODS: PubMed, Embase, and the Cochrane Clinical Trials database were searched according to search strategy and PRISMA guidelines. Random-effects meta-analyses of fusion rates with the three main modalities of noninvasive electrical stimulation, capacitively coupled stimulation (CCS), pulsed electromagnetic fields (PEMFs), and combined magnetic fields (CMFs), were conducted using R version 4.1.0 (The R Foundation for Statistical Computing). Both retrospective studies and clinical trials were included. Animal studies were excluded. Risk-of-bias analysis was performed with the Risk of Bias 2 (RoB 2) and Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) tools. RESULTS: Searches of PubMed, Embase, and the Cochrane Clinical Trials database identified 8 articles with 1216 participants meeting criteria from 213 initial results. There was a high overall risk of bias identified for the majority of randomized studies. No meta-analysis could be performed for CCS as only 1 study was identified. Meta-analysis of 6 studies of fusion rates in PEMF did not find any difference between treatment and control groups (OR 1.89, 95% CI 0.36-9.80, p = 0.449). Meta-analysis of 2 studies of CMF found no difference in fusion rates between control and treatment groups (OR 0.90, 95% CI 0.07-11.93, p = 0.939). Subgroup analysis of PEMF was limited given the small number of studies and patients, although significantly increased fusion rates were seen in some subgroups. CONCLUSIONS: This meta-analysis of clinical outcomes and fusion rates in noninvasive electrical stimulation compared to no stimulation did not identify any increases in fusion rates for any modality. A high degree of heterogeneity between studies was noted. Although subgroup analysis identified significant differences in fusion rates in certain groups, these findings were based on a small number of studies and further research is needed. This analysis does not support routine use of these devices to augment fusion rates, although the data are limited by a high risk of bias and a small number of available studies.

Stenting in High-Grade Internal Carotid Artery Stenosis: 2-Dimensional Operative Video.

Carotid artery stenosis is implicated in up to 40% of all ischemic strokes. Accordingly, symptomatic, high-grade carotid artery stenosis portends an especially high risk of future stroke. Intervention via open or endovascular approaches drastically reduces this risk. Under the appropriate conditions, carotid artery stenting serves as a safe and effective alternative to carotid endarterectomy. We present the case of a 57-yr-old male with symptomatic, high-grade stenosis of his right internal carotid artery, for whom a history of radiation to the head and neck represented a relative contraindication to carotid endarterectomy, and thus endovascular treatment with angioplasty and stenting was performed. Informed consent was obtained prior to the procedure. Intraprocedurally, stent delivery past the area of stenosis proved somewhat challenging. However, by employing several nuanced maneuvers, we utilized our guiding catheter in a nonconventional manner in order to successfully perform the procedure. As the field of neuroendovascular surgery evolves, each case provides us unique lessons, which in turn expands our interventional capabilities and adds to the armamentarium of neuroendovascular techniques. We present this surgical video both as a means to provide a general overview of carotid artery stenting, and to share a lesson learned through the implementation of an interesting technical nuance.

Super-Pedicle Osteotomy for Correction of Focal Thoracolumbar Kyphosis.

BACKGROUND: Focal thoracolumbar kyphotic deformities require operative correction through osteotomies to restore normal spinal balance. Traditional osteotomies, such as the pedicle subtraction osteotomy, that are often used in the lumbar spine are less useful in the thoracolumbar region. The super-pedicle osteotomy is a pedicle-sparing wedge osteotomy that can be used for correction of kyphosis in patients with thoracolumbar deformities. METHODS: A retrospective review was conducted of 9 consecutive cases using the super-pedicle technique. Clinical data regarding patient age at presentation, etiology of deformity, symptoms, neurological status at presentation, American Society of Anesthesiologists class, type of surgery performed, estimated blood loss during surgery, and complications up to last follow-up were recorded. The primary parameter of interest was the angle at the planned osteotomy site before and after correction. RESULTS: Nine patients with an average age of 64 years were included. All 9 patients had focal thoracic kyphosis either at T11-T12 or T12-L1. All patients underwent thoracolumbar operations with super-pedicle osteotomies at their main level of kyphosis. Estimated blood loss was 600 mL. Average correction at the osteotomy site as measured on preoperative and postoperative radiographs was 31°. At an average follow-up of 338 days, no patients experienced rod fracture, but 1 patient required extension of fusion for proximal junctional kyphosis. CONCLUSIONS: In this small series of patients with thoracolumbar kyphosis, the super-pedicle osteotomy technique was clinically useful. More robust examination is required to determine the safety, utility, and durability of this osteotomy technique.

The History of Anterior and Lateral Approaches to the Lumbar Spine.

Anterior and lateral approaches to the lumbar spine are commonly used today for a variety of indications. These approaches can ultimately be traced back to early attempts to treat Pott's disease. Evidence of Mycobacterium tuberculosis infection of the spine dates as far back as 2400 BCE, with ancient Egyptian mummies exhibiting lesions consistent with Pott's disease. For many centuries, Pott's disease was treated conservatively, and surgery came to be used when conservative therapy was ineffective, as medical therapy had yet to become available. In 1779, Percivall Pott recommended that peripheral paraspinal tuberculous abscesses be drained after noticing that patients' lower limb function improved after the formation of spontaneous draining sinuses. Building on Pott's ideas, Ménard described the first lateral approach to the spine via a costotransversectomy approximately 1 century after Pott's theory. Most importantly, the surge in understanding anatomy with respect to developing safe corridors to the deeper structures of the human body brought together advances in technology, instrumentation, and visualization. Surgeons were thus emboldened to explore more complex anterior approaches to the spine. In 1906, Müller reported the first successful anterior approach to the spine in a patient with Pott's disease. Over the next several decades, the efforts of surgeons such as Ito, Capener, Burns, and Mercer would lead to the development of the anterior lumbar interbody fusion. The costotransversectomy later evolved into the lateral rhachotomy and lateral extracavitary approach, which along with advances in the anterior lumbar interbody fusion paved the way for the oblique lumbar interbody fusion and lateral lumbar interbody fusion.

Sacral Rheumatoid Nodule: An Unusual Indication for Coccygectomy.

Here, we present a case report of a woman who presented with a large sacral rheumatoid nodule. This patient failed conservative treatment and presented in search of a surgical solution. We successfully removed her rheumatoid nodule using a surgical approach typically reserved for traumatic coccydynia. We show how coccygectomy, although a rare surgical procedure, was effective in treatment of a large rheumatoid nodule.

Moyamoya and Inflammation.

BACKGROUND: More than 50 years have elapsed since moyamoya disease was initially described; however, the disease etiology remains unknown. Although certain genetic loci and immunologic characteristics are associated with moyamoya disease, this does not fully explain its pathophysiology. An association with inflammatory disease has been postulated but not rigorously explored. We sought to examine the epidemiologic association of moyamoya and inflammatory diseases by analyzing data from a large administrative database. METHODS: The National Inpatient Sample database for 2009-2012 was obtained. The diagnoses of moyamoya disease and inflammatory diseases were made using the International Classification of Disease, 9th revision. Sample prevalence, sex, age, and admission type were recorded. Patients were grouped into inflammatory disease clusters on the basis of the presence of diagnosis codes for atherosclerotic, adult-onset autoimmune, and juvenile-onset autoimmune diseases. RESULTS: There were 2633 total admissions for moyamoya disease. Atherosclerotic (P < 0.05) and juvenile-onset autoimmune disease (P < 0.05) were associated with moyamoya disease in both pediatric and adult patient groups. Adult-onset autoimmune disease was associated with moyamoya disease in pediatric (P < 0.05) but not adult groups. CONCLUSION: Moyamoya is associated with inflammatory disease clusters in both pediatric and adult populations. Further studies are warranted to investigate the pathophysiologic association between moyamoya disease and inflammatory disease processes.

Staged laser interstitial thermal therapy and topectomy for complete obliteration of complex focal cortical dysplasias.

Anatomically complex focal cortical dysplasias may present significant challenges to safe and complete surgical resection via standard operative corridors. Laser interstitial thermal therapy (LITT) is an emerging minimally invasive technique that may address some of these challenges, enabling stereotactic ablation of deep and/or surgically inaccessible regions. However, complete ablation may not be feasible in all cases. To address this dilemma, we have designed a protocol utilizing staged LITT followed by topectomy to effect complete obliteration of a complex focal cortical dysplasia. The approach presented demonstrates the feasibility, safety, and clinical utility of combining laser ablation and open surgery for the definitive management of this lesion.

Arteriovenous malformations and headache.

Brain arteriovenous malformations (AVM) are complex vascular lesions commonly associated with chronic headache. An occipital location appears to increase the risk of concurrent migraine-like headaches in AVM patients. We have experienced great success in treating these headaches through a multidisciplinary approach to eradicate cerebral AVM. However, the specific clinical characteristics of AVM-associated headaches and the most effective treatment strategies for these patients remain unclear. Here, we provide a comprehensive review of the literature on AVM-associated headaches. We detail the history, classification, epidemiology, presentation, pathophysiology, treatment options, and outcomes for this poorly described condition. Additionally, we illustrate our approach to the management of patients with occipital AVM and associated intractable headaches.

Determination of sinus pericranii resectability by external compression during angiography: technical note.

Sinus pericranii is an uncommon congenital cranial venous malformation that may become symptomatic in the pediatric population. Both dominant and accessory sinus pericranii, as determined by the intracranial venous drainage pattern, have been described. The dominant variety drain a significant proportion of the intracranial venous outflow while the accessory variety have minimal or no role in this. Classic teachings hold that dominant sinus pericranii should never be treated while accessory sinus pericranii may be safely obliterated. This determination of dominance is solely based on a qualitative assessment of standard venous phase catheter cerebral angiography, leaving some doubt regarding the actual safety of obliteration. In this paper the authors describe a simple and unique method for determining whether intracranial venous outflow may be compromised by sinus pericranii treatment. This involves performing catheter angiography while the lesion is temporarily obliterated by external compression. Analysis of intracranial venous outflow in this setting allows visualization of angiographic changes that will occur once the sinus pericranii is permanently obliterated. Thus, the safety of surgical intervention can be more fully appraised using this technique.

Trigeminal branch stimulation for the treatment of intractable craniofacial pain.

OBJECT Trigeminal branch stimulation has been used in the treatment of craniofacial pain syndromes. The risks and benefits of such an approach have not been clearly delineated in large studies, however. The authors report their experience in treating craniofacial pain with trigeminal branch stimulation and share the lessons they have learned after 93 consecutive electrode placements. METHODS A retrospective review of all patients who underwent trigeminal branch electrode placement by the senior author (C.J.W.) for the treatment of craniofacial pain was performed. RESULTS Thirty-five patients underwent implantation of a total of 93 trial and permanent electrodes between 2006 and 2013. Fifteen patients who experienced improved pain control after trial stimulation underwent implantation of permanent stimulators and were followed for an average of 15 months. At last follow-up 73% of patients had improvement in pain control, whereas only 27% of patients had no pain improvement. No serious complications were seen during the course of this study. CONCLUSIONS Trigeminal branch stimulation is a safe and effective treatment for a subset of patients with intractable craniofacial pain.