Influence of instrumentation type on outcomes after surgical management of spondylodiscitis: a systematic review and meta-analysis.

OBJECTIVE: Spondylodiscitis refers to infection of the intervertebral disk and neighboring structures. Outcomes based on instrumentation type are not well reported in the literature, but are important in establishing guidelines for surgical management of spondylodiscitis. This study aims to clarify the effect of instrumentation material selection on clinical and radiographic outcomes in patients with spondylodiscitis. METHODS: Studies that evaluated the use of polyetheretherketone (PEEK), titanium, allograft, and/or autologous bone grafts for spondylodiscitis were identified in the literature. Radiographic and clinical data were analyzed using a meta-analysis of proportions, with estimated risk and confidence intervals reported for our primary study outcomes. RESULTS: Thirty-two retrospective studies totaling 1088 patients undergoing surgical management of spondylodiscitis with PEEK, TTN, allograft, and autologous bone graft instrumentation were included. There were no differences in fusion rates (p-interaction = 0.55) with rates of fusion of 93.4% with TTN, 98.6% with allograft, 84.2% with autologous bone graft, and 93.9% with PEEK. There were no differences in screw loosening (p-interaction = 0.52) with rates of 0.33% with TTN, 0% with allograft, 1.3% with autologous bone graft, and 8.2% with PEEK. There were no differences in reoperation (p-interaction = 0.59) with rates of 2.64% with TTN, 0% with allograft, 1.69% with autologous bone graft, and 3.3% with PEEK. CONCLUSIONS: This meta-analysis demonstrates that the choice of instrumentation type in the surgical management of spondylodiscitis resulted in no significant differences in rate of radiographic fusion, screw loosening, or reoperation. Future comparative studies to optimize guidelines for the management of spondylodiscitis are needed.

Awake Craniotomy in Pediatric Patients: A Meta-analysis of Operative Outcomes.

BACKGROUND: Awake craniotomy allows neurosurgeons to make critical decisions when operating in eloquent regions of the brain. The phenomenon of "waking up" during surgery is underexplored in pediatric patients, and the operative outcomes following awake craniotomy are not well understood. Correspondingly, the aim of this study was to quantitatively aggregate the contemporary metadata regarding the operative outcomes of awake craniotomy when used in the pediatric setting. METHODS: Multiple electronic databases from inception to June 2023 were searched following PRISMA guidelines. Respective cohort-level outcomes were then abstracted and pooled by means of meta-analysis utilizing random-effects modeling, and trends evaluated by meta-regression analysis. RESULTS: There were 4 observational studies that satisfied all selection criteria, describing a total cohort of 57 pediatric patients undergoing awake craniotomy. There were 34 (60%) male patients with a median age of 14 years old, with lesions on the left side in 80% of cases when reported. Meta-analysis demonstrated pooled incidences of intraoperative complication to be 17% (95% CI 4%-37%), the need to convert cases to general anesthesia to be 2% (95% CI 0%-9%), immediate postoperative complication to be 18% (95% CI 6%-33%), and long-term complications to be 6% (95% CI 0%-15%). The most common intraoperative complication reported was seizure. Certainty of these estimates were very low due to limited metadata. Meta-regression did not indicate any trend bias due to study and cohort parameters. CONCLUSIONS: Multiple studies have demonstrated the feasibility of the awake craniotomy approach in pediatric patients. The risks for intraoperative and postoperative complications are non-zero, with their incidences trending towards incidences seen in the adult demographic. It is likely formal neuropsychologic preparation and follow-up will increase the candidacy and success of this approach in the future.

Risk factors for vascular injuries in anterior lumbar interbody fusion: a single-institution retrospective study.

OBJECTIVE: Vascular injuries in anterior lumbar interbody fusion (ALIF) occur due to the vascular manipulation needed to achieve optimal disc space exposure. In this study, the authors aimed to evaluate intraoperative vascular injuries in patients undergoing single- and multilevel ALIF at a large tertiary academic center. METHODS: Prospectively collected data specifically addressing postoperative complications in patients who underwent ALIF by neurosurgery spine faculty working with a specialized vascular surgeon were retrospectively reviewed. Demographic characteristics and intraoperative data were collected. Patients were split into vascular injury and non-vascular injury groups. Outcome comparisons were conducted using the chi-square exact and Wilcoxon rank-sum tests for categorical and continuous data, respectively. Logistic regression was used to investigate associations with vascular injury, with univariate analysis first conducted to identify candidate associations. Based on these results, variables demonstrating a between-groups test statistic of p < 0.10 were included in the multivariate analysis to determine the independent predictors of vascular injuries. RESULTS: In total, 323 patients who underwent ALIF procedures were identified: 51% were male (n = 166) and 49% were female (n = 157). The mean age was 57.1 years, with 56% (n = 182) having undergone prior lumbar surgery. Vascular injuries were encountered intraoperatively in 7.1% (n = 23) of patients, and the majority (91% [n = 21]) involved the left common iliac vein. Patients with vascular injuries were statistically older (mean 63.6 vs 56.6 years), had greater incidence rates of coronary artery disease, opioid use, multilevel ALIF surgery involving the L2-3 level, and surgery involving multiple disc spaces, had more multilevel anterior instrumentation, and experienced greater blood loss during surgery and longer length of stay (all p < 0.05). Overall, there was 1 death (0.3%) secondary to aortic artery injury. Multivariate analysis identified opioid use, multilevel ALIF involving L2-3, and multiple interbodies as statistically independent predictors of vascular injury (all p < 0.05). CONCLUSIONS: Identifying patient risk factors can reduce the risk of vascular injuries in ALIF. Opioid use, multilevel ALIF involving L2-3, and multiple interbodies were independent predictors of vascular injuries in ALIF.

Infrasellar Nasopharyngeal Craniopharyngiomas: An Individual Participant Data Meta-Analysis and Review of the Literature.

BACKGROUND: Craniopharyngiomas are benign tumors of the anterior skull base arising from epithelial remnants of Rathke pouch. They mainly occur in the suprasellar space, can be incredibly debilitating, and remain difficult to resect as they frequently involve critical neurovascular structures. Although it is embryologically possible for craniopharyngiomas to arise extracranially along the entire migrational path of Rathke pouch, these remain exceedingly rare, especially among adults, and can be mistaken for nasopharyngeal cancer. As such, minimal data exist evaluating the management and outcomes of such lesions. We evaluated our institutional experience with purely infrasellar nasopharyngeal craniopharyngiomas and obtained individual patient data reported in the contemporary literature to better characterize the demographics, presentation, surgical management, and long-term outcomes of these lesions. METHODS: A systematic review of the literature was performed to identify previously published cases of purely infrasellar nasopharyngeal craniopharyngioma in 3 electronic databases: MEDLINE (PubMed), Embase, and Scopus. Search terms were "infrasellar craniopharyngioma" and "nasopharyngeal craniopharyngioma." RESULTS: We identified 25 cases, in which 72% of patients presented with symptoms of nasal obstruction, epistaxis, or headache. An endoscopic approach was performed in 40% of cases; 83.3% of all patients had gross total resection, with 60% having no recurrence at a median follow-up of 13 months. No postoperative complications were reported. Tumor location involving the cavernous sinus was associated with incomplete resection (100%) compared with tumors not involving the cavernous sinus (87%) (P = 0.033). CONCLUSIONS: While uncommon, infrasellar nasopharyngeal craniopharyngiomas appear to have better perioperative and long-term surgical outcomes than their suprasellar counterparts.

A Comparison of Clinical Outcomes Between Anterior Cervical Discectomy and Fusion Versus Posterior Cervical Laminoplasty for Multilevel Cervical Myelopathy.

STUDY DESIGN: Retrospective Cohort. OBJECTIVE: To compare patient-reported outcomes and surgical outcomes after anterior cervical discectomy and fusion (ACDF) versus cervical laminoplasty for multilevel cervical spondylotic myelopathy. BACKGROUND: Treatment options for multilevel cervical spondylotic myelopathy include ACDF and cervical laminoplasty. Given that the literature has been mixed regarding the optimal approach, especially in patients without kyphosis, there is a need for additional studies investigating outcomes between ACDF and cervical laminoplasty. METHODS: A retrospective review was conducted of adult patients undergoing 3 or 4-level surgery. Patients with preoperative kyphosis based on C2-C7 Cobb angles were excluded. The electronic medical record and institutional databases were reviewed for baseline characteristics, surgical outcomes, and patient-reported outcomes. RESULTS: A total of 101 patients who underwent ACDF and 52 patients who underwent laminoplasty were included in the study. The laminoplasty cohort had a higher overall Charlson Comorbidity Index (3.10 ± 1.43 vs 2.39 ± 1.57, P = 0.011). Both groups had a comparable number of levels decompressed, C2-C7 lordosis, and diagnosis of myelopathy versus myeloradiculopathy. Patients who underwent laminoplasty had a longer length of stay (2.04 ± 1.15 vs 1.48 ± 0.70, P = 0.003) but readmission, complication, and revision rates were similar. Both groups had similar improvement in myelopathy scores (∆modified Japanese Orthopedic Association: 1.11 ± 3.09 vs 1.06 ± 3.37, P = 0.639). ACDF had greater improvement in Neck Disability Index (∆Neck Disability Index: -11.66 ± 19.2 vs -1.13 ± 11.2, P < 0.001), neck pain (∆Visual Analog Scale-neck: -2.69 ± 2.78 vs -0.83 ± 2.55, P = 0.003), and arm pain (∆Visual Analog Scale-arm: -2.47 ± 3.15 vs -0.48 ± 3.19, P = 0.010). These findings persisted in multivariate analysis except for Neck Disability Index. CONCLUSION: ACDF and cervical laminoplasty appear equally efficacious at halting myelopathic progression. However, patients who underwent ACDF had greater improvements in arm pain at 1 year postoperatively. Longitudinal studies evaluating the efficacy of laminoplasty to mitigate adjacent segment disease are indicated to establish a robust risk-benefit assessment for these 2 procedures. LEVEL OF EVIDENCE: III.

Impact of Preoperative Intervertebral Disc Degeneration on Patient-Reported Outcome Measures After Lumbar Fusion.

OBJECTIVE: The Pfirrmann scoring system classifies lumbosacral disc degeneration based on magnetic resonance imaging signal intensity. The relationship between pre-existing disc degeneration and patient-reported outcome measures (PROMs) after one-level lumbar fusion is not well documented. The purpose of this study was to investigate the relationship between the severity of preoperative intervertebral disc degeneration and preoperative and postoperative PROMs in patients undergoing one-level lumbar fusion. METHODS: All adult patients who underwent posterior lumbar decompression and fusion or transforaminal lumbar interbody fusion between 2014 and 2022 were included. Patient demographics and comorbidities were extracted from medical records. Lumbar intervertebral discs on sagittal magnetic resonance imaging T2-weighted images were assessed by 2 independent graders utilizing Pfirrmann criteria. Grades I-III were categorized as low-grade disc degeneration, while IV-V were considered high grade. Multivariable linear regression assessed the impact of disc degeneration on PROMs. RESULTS: A total of 150 patients were included, of which 69 (46%) had low-grade disc degeneration, while 81 (54%) had high-grade degeneration. Patients with high-grade degeneration had increased preoperative visual analog scale (VAS)-Leg scores (6.10 vs. 4.54, P = 0.005) and displayed greater 1-year postoperative improvements in VAS-Back scores (-2.11 vs. -0.66, P = 0.002). Multivariable regression demonstrated Pfirrmann scores as independent predictors for both preoperative VAS-Leg scores (P = 0.004) and postoperative VAS-Back improvement (P = 0.005). CONCLUSIONS: In patients undergoing one-level lumbar fusion, higher Pfirmann scores were associated with increased preoperative leg pain and greater 1-year postoperative improvement in back pain. Further studies into the relationship of preoperative disc degeneration and their impact on postoperative outcomes may help guide clinical decision-making and patient expectations.

Algorithm for evaluating ophthalmic artery pseudo-occlusion during intra-arterial chemotherapy for retinoblastoma.

BACKGROUND AND IMPORTANCE: Intra-arterial chemotherapy infusion for retinoblastoma is typically performed via selective catheterization of the ophthalmic artery. Anastomoses between the external carotid and the ophthalmic arteries have also been utilized when the ophthalmic artery cannot be catheterized directly. However, these are not present in every patient. CLINICAL PRESENTATION: A 10-month-old boy presented with bilateral retinoblastoma and underwent one round of intra-arterial chemotherapy (IAC) via direct catheterization of the ophthalmic arteries. Combined with adjuvant laser therapy, they experienced symptomatic improvement and tumour regression. However, during subsequent treatment sessions both ophthalmic arteries did not have anterograde flow and attempts to catheterize their origin were unsuccessful. Unfortunately, no targetable anastomoses between the external carotid and ophthalmic arteries were identified for drug delivery. Due to the patient's anatomy, balloon occlusion of the ECA was felt to be unsafe. As a salvage technique, a balloon was inflated in the left internal carotid artery (ICA) distal to the ophthalmic take-off to redirect flow into the ophthalmic. Repeat angiography with the distal ICA occluded showed improved flow into the ipsilateral ophthalmic artery. IAC was then successfully delivered through the left ICA. CONCLUSION: This case illustrates the importance of utilizing creative endovascular techniques for targeted intra-arterial drug delivery when other conventional measures fail as these patients often have limited, and potentially higher risk, therapeutic alternatives.

Spinal Epidermoid Tumor: A Case Report.

Spinal epidermoid tumors are rare tumors with typical symptoms including low back pain, radiculopathy, weakness, sensory disturbances, and bowel/bladder dysfunction. Here we present a rare case of a spinal epidermoid tumor in a 44-year-old female patient with a previous surgical history of epidural anesthesia with two cesarean sections. Our report aims to highlight the rare development of this type of tumor following epidural anesthesia, a routine part of labor management.

An updated review on the genetics of arteriovenous malformations.

Arteriovenous malformations (AVM) are congenital malformations of the cerebral vasculature resulting in pathological shunting of blood through dilated arteries and veins. The most common clinical manifestations of AVM are intracerebral hemorrhage, due to rupture of these lesions as they continue to expand, which can have devastating neurological consequences and residual deficits. The genetic underpinnings of AVM have been explored for their role in the angiogenesis of these lesions in both its sporadic and inherited forms. In recent times, our understanding of the genetic variation involved in the pathogenesis AVM has advanced in both the preclinical and clinical realms. The current review highlights in detail these advancements, namely, the genetic underpinnings of diagnostic testing and profiling of AVM, and the preclinical epigenetic and genetic data on AVM pathogenesis and growth. In addition, we review the current candidate genes implicated in AVM pathogenesis in the literature. Finally, we provide a discussion on the genetic conditions associated with AVM and the advancements in treatment paradigms influenced by the genetic profiles of these lesions.

Differentiating Lumbar Spinal Etiology from Peripheral Plexopathies.

Clinicians have managed and treated lower back pain since the earliest days of practice. Historically, lower back pain and its accompanying symptoms of radiating leg pain and muscle weakness have been recognized to be due to any of the various lumbar spine pathologies that lead to the compression of the lumbar nerves at the root, the most common of which is the radiculopathy known as sciatica. More recently, however, with the increased rise in chronic diseases, the importance of differentially diagnosing a similarly presenting pathology, known as lumbosacral plexopathy, cannot be understated. Given the similar clinical presentation of lumbar spine pathologies and lumbosacral plexopathies, it can be difficult to differentiate these two diagnoses in the clinical setting. Resultingly, the inappropriate diagnosis of either pathology can result in ineffective clinical management. Thus, this review aims to aid in the clinical differentiation between lumbar spine pathology and lumbosacral plexopathy. Specifically, this paper delves into spine and plexus anatomy, delineates the clinical assessment of both pathologies, and highlights powerful diagnostic tools in the hopes of bolstering appropriate diagnosis and treatment. Lastly, this review will describe emerging treatment options for both pathologies in the preclinical and clinical realms, with a special emphasis on regenerative nerve therapies.

Spinal tumor embolization: benefit for surgical resection.

The embolization of hypervascular spinal tumors preoperatively has shown to be a worthwhile adjunctive procedure to minimize the elevated risks associated with surgical resection, such as intraoperative blood loss and its associated complications. Resection of these hypervascular tumors is necessary for local tumor control, reduction in patient-reported pain, improved neurological functioning, and spinal stability. This adjunctive procedure has been associated with improved surgical outcomes and easier facilitation of surgical resection. As such, we provide a review of the current literature examining the employment of this technique. Specifically, this article (a) reviews the techniques of embolization, with anatomical considerations of the arterial framework of the spinal network; (b) relativizes and outlines the post-embolization management of spinal tumor resection; (c) provides a critical outlook on the reported benefit of preoperative embolization before surgical resection with support from clinical studies in the literature; and (d) discusses the efficacy and reliability of provocative testing and post-procedural management and follow-up. Ultimately, a thorough and updated review of preoperative spinal tumor embolization and its clinical benefits will summarize the current fund of knowledge and encourage future research toward continued improvements in patient outcomes for those needing to undergo surgical resection of spinal lesions.

Recurrent Peroneal Intraneural Ganglion Cyst: Management and Review of the Literature.

Intraneural ganglion cysts have been reported to affect the common peroneal nerve. Peroneal intraneural ganglion cysts are managed through surgical intervention. Despite surgical intervention, intraneural ganglion cysts can recur. Common intraneural ganglion cyst recurrence patterns have been proposed based on the initial surgical management of the cyst. These patterns all emphasize the importance of treatment of the proximal tibiofibular (TF) joint to reduce the risk of cyst recurrence. Although joint resection is the favored intervention in the literature, joint arthrodesis is an option for certain patients. Here, we present a case of a peroneal intraneural ganglion cyst and its recurrence in a 36-year-old male who had previously undergone surgical removal of the cyst three months prior, as well as a review of the current literature that aims to add to our current understanding of intraneural cysts.

Healthcare disparities in pediatric neurosurgery: a scoping review.

OBJECTIVE: The aim of this scoping review was to identify relevant articles that have contributed to the body of knowledge describing pediatric neurosurgical healthcare disparities. Identifying healthcare disparities in pediatric neurosurgery is essential to understanding how to best provide care for this unique patient population. Although it is undoubtedly important to increase the knowledge of pediatric neurosurgical healthcare disparities, it is also important to understand the current state of the literature. METHODS: This scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. The search terms "pediatric neurosurgical disparities" and "pediatric neurosurgical inequities" were entered into the following databases: PubMed, Scopus, and Embase. RESULTS: The initial database search returned a total of 366 results from the PubMed, Embase, and Scopus databases. One hundred thirty-seven duplicates were removed, and the remaining articles were screened by title and abstract. Articles were excluded on the basis of the inclusion and exclusion criteria. Of the remaining 229 articles, 168 were excluded. Sixty-one full-text articles were then examined for eligibility, and 28 did not reach the specified inclusion and exclusion criteria. The remaining 33 articles were included for final review. The results of the reviewed studies were stratified on the basis of disparity type. CONCLUSIONS: Although there has been an increase in the number of publications discussing pediatric neurosurgical healthcare disparities within the last decade, there still remains a scarcity of information regarding healthcare disparities in neurosurgery. Furthermore, less information exists that specifically addresses healthcare disparities in the pediatric population.

Rathke's cleft cysts causing Cushing's disease: Two unique cases and review of the literature.

Background: The presentation of isolated Rathke's cleft cysts (RCC) without any associated pituitary adenoma in patients with symptoms consistent with Cushing's disease (CD) remains exceedingly rare. As such, we aim to present two cases of RCC presenting with CD with a resultant resolution of their CD following surgical resection. Case Description: Here, we present two cases of RCCs presenting with symptoms suggestive of CD. A functional pituitary microadenoma was the presumed diagnosis based on initial clinical presentation and diagnostic imaging suggesting a pituitary lesion. However, pathology results demonstrated no evidence of adenoma but cysts lined with columnar epithelia consistent with RCC. Complete surgical resection was achieved in both patients through endoscopic endonasal pituitary resection with postoperative symptomatic resolution and normalization of cortisol levels. In addition, we discuss the literature on this rare presentation and suggest a pathological mechanism for this unique presentation of RCC-causing CD. Conclusion: Surgical resection of RCC may provide a "biochemical cure" for patients presenting with CD, as demonstrated by these two unique cases. The clinical features, histological findings, and possible pathological mechanisms for this unique presentation of RCC causing CD discussed lay the groundwork for future studies into the pathophysiology of RCC and CD.

Surgical Management of a Spinal Dural Arteriovenous Fistula.

Spinal dural arteriovenous fistulas (SDAVFs) may have subtle clinical presentations and are often misdiagnosed. Clinical status gradually deteriorates following symptom onset making prompt identification and management essential. Here we present a case of a 67-year-old patient with rapidly progressing motor and sensory deficits to eventual right hemiplegia. Following imaging and surgical intervention, a thoracic SDAVF was identified and resected. This case report highlights a unique SDAVF with a stroke-like presentation. For patients with such presentation, without a clear source of intracranial pathology, spinal causes such as SDAVF could be considered.

Effects of Obesity on Cervical Disc Arthroplasty Complications.

OBJECTIVE: High body mass index is a well-established modifiable comorbidity that is known to increase postoperative complications in all types of surgery, including spine surgery. Obesity is increasing in prevalence amongst the general population. As this growing population of obese patients ages, understanding how they faire undergoing cervical disc arthroplasty (CDA) is important for providing safe and effective evidence-based care for cervical degenerative pathology. METHODS: Our study used the Healthcare Cost and Utilization Project's National Inpatient Sample to assess patients undergoing CDA comparing patient characteristics and outcomes in nonobese patients to obese patients from 2004 to 2014. RESULTS: Our study found a significant increase in the overall utilization of CDA as a treatment modality (p = 0.012) and a statistically significant increase in obese patients undergoing CDA (p < 0.0001) from 2004 to 2014. Obesity was identified as an independent risk factor associated with increased rates of inpatient neurologic complications (odds ratio [OR], 6.99; p = 0.03), pulmonary embolus (OR, 5.41; p = 0.05), and wound infection (OR, 6.97; p < 0.001) in patients undergoing CDA from 2004 to 2014. CONCLUSION: In patients undergoing CDA, from 2004 to 2014, obesity was identified as an independent risk factor with significantly increased rates of inpatient neurologic complications, pulmonary embolus and wound infection. Large prospective trials are needed to validate these findings.

Bon Sante (Good Health): Factors Influencing PrEP Use Among Haitians/Haitian Americans.

BACKGROUND: The HIV/AIDS epidemic has disproportionately affected Black individuals in the USA, and this health disparity has increased over time. Despite the effectiveness of pre-exposure prophylaxis (PrEP) as a prevention tool for HIV, there are disparities in its use, and uptake of this intervention remains low among racial and ethnic minorities, including Haitians/Haitian Americans. In this study, factors influencing PrEP use among Haitians/Haitian Americans in Miami, FL, are explored to provide necessary data to address disparities. METHODS: The research team collaborated with local organizations to recruit 30 individuals (Haitians/Haitian Americans) between February 4 and October 1, 2021, and conducted semi-structured interviews. All interviews were audio-recorded and transcribed, and NVivo® was used to analyze the transcripts for emergent themes. RESULTS: The study sample comprised 30 adults of Haitian descent in Miami, FL (50% female, approximately 67% with a high school education or more, mean age = 43.7 ± 13 years, and 74.2% born in Haiti). Four primary themes emerged from the analysis: (1) limited PrEP awareness, (2) underutilization of PrEP, (3) inadequate discussion of HIV prevention strategies, and (4) PrEP delivery encompassing barriers and facilitators for PrEP delivery and promotion strategies. CONCLUSION: This study indicated that there is a critical need to increase Haitians/Haitian Americans' knowledge regarding PrEP. Health communication interventions tailored specifically for Haitians/Haitian Americans that target stigma, attitudes toward HIV, and risk perception may be significant in increasing PrEP in this population.