"Mail-slot" technique for minimally-invasive placement of subdural grid electrodes: a single-institution experience.

BACKGROUND: In the management of multi-drug-resistant focal epilepsies, intracranial electrode implantation is employed for precise localization of the ictal onset zone. In select patients, subdural grid electrode implantation is utilized. Subdural grid placement traditionally requires large craniotomies to visualize the cortex prior to mapping. However, smaller craniotomies may enable shorter operations and reduced risks. We aimed to compare surgical outcomes between patients undergoing traditional large craniotomies with those undergoing tailored 'mini' craniotomies (the "Mail-Slot" technique) for subdural grid placement. METHODS: This retrospective cohort study included 23 patients who underwent subdural electrode implantation for epilepsy monitoring between 2014 and 2020. Patients were categorized into mini craniotomies (N=9) and traditional large craniotomies (N=14) groups. Demographics, operative details, and outcomes were reviewed. Craniotomy size and number of electrodes were determined via post-hoc radiographs. RESULTS: Of the 23 patients studied, the mini group had smaller craniotomy sizes (mean=22.71 cm2 vs. 65.17 cm2, p<0.001) and higher electrode-to-size ratios (mean=4.25 vs. 1.71, p<0.0001). The mini group had slightly fewer total electrodes (mean=88.67 vs. 107.43, p=0.047). No significant differences were found in operative duration, blood loss, invasive EEG duration, complications, or Engel scores between the groups. One patient per group required further invasive epilepsy monitoring for localization; all patients underwent therapeutic surgery. CONCLUSION: Our findings suggest that mini craniotomies for subdural grid placement in epilepsy monitoring offer significant advantages, including smaller craniotomy sizes and shorter operation durations, without compromising safety or efficacy. These results support the trend towards minimally invasive, patient-tailored surgical approaches in epilepsy treatment.

The NUTRIENT Trial (NUTRitional Intervention among myEloproliferative Neoplasms): Results from a Randomized Phase I Pilot Study for Feasibility and Adherence.

PURPOSE: Chronic inflammation is integral to myeloproliferative neoplasm (MPN) pathogenesis. JAK inhibitors reduce cytokine levels, but not without significant side effects. Nutrition is a low-risk approach to reduce inflammation and ameliorate symptoms in MPN. We performed a randomized, parallel-arm study to determine the feasibility of an education-focused Mediterranean diet intervention among patients with MPN. EXPERIMENTAL DESIGN: We randomly assigned patients with MPN to either a Mediterranean diet or standard U.S. Dietary Guidelines for Americans (USDA). Groups received equal but separate education with registered dietician counseling and written dietary resources. Patients were prospectively followed for feasibility, adherence, and symptom burden assessments. Biological samples were collected at four timepoints during the 15-week study to explore changes in inflammatory biomarkers and gut microbiome. RESULTS: The Mediterranean diet was as easy to follow for patients with MPN as the standard USDA diet. Approximately 80% of the patients in the Mediterranean diet group achieved a Mediterranean Diet Adherence Score of ≥8 throughout the entire active intervention period, whereas less than 50% of the USDA group achieved a score of ≥8 at any timepoint. Improvement in symptom burden was observed in both diet groups. No significant changes were observed in inflammatory cytokines. The diversity and composition of the gut microbiome remained stable throughout the duration of the intervention. CONCLUSIONS: With dietician counseling and written education, patients with MPN can adhere to a Mediterranean eating pattern. Diet interventions may be further developed as a component of MPN care, and potentially incorporated into the management of other hematologic conditions. SIGNIFICANCE: Diet is a central tenant of management of chronic conditions characterized by subclinical inflammation, such as cardiovascular disease, but has not entered the treatment algorithm for clonal hematologic disorders. Here, we establish that a Mediterranean diet intervention is feasible in the MPN patient population and can improve symptom burden. These findings warrant large dietary interventions in patients with hematologic disorders to test the impact of diet on clinical outcomes.

Developing Predictive Models to Anticipate Shunt Complications in 33,248 Pediatric Patients with Shunted Hydrocephalus Utilizing Machine Learning.

INTRODUCTION: Hydrocephalus is a common pediatric neurosurgical pathology, typically treated with a ventricular shunt, yet approximately 30% of patients experience shunt failure within the first year after surgery. As a result, the objective of the present study was to validate a predictive model of pediatric shunt complications with data retrieved from the Healthcare Cost and Utilization Project (HCUP) National Readmissions Database (NRD). METHODS: The HCUP NRD was queried from 2016 to 2017 for pediatric patients undergoing shunt placement using ICD-10 codes. Comorbidities present upon initial admission resulting in shunt placement, Johns Hopkins Adjusted Clinical Groups (JHACG) frailty-defining criteria, and Major Diagnostic Category (MDC) at admission classifications were obtained. The database was divided into training (n = 19,948), validation (n = 6,650), and testing (n = 6,650) datasets. Multivariable analysis was performed to identify significant predictors of shunt complications which were used to develop logistic regression models. Post hoc receiver operating characteristic (ROC) curves were created. RESULTS: A total of 33,248 pediatric patients aged 6.9 ± 5.7 years were included. Number of diagnoses during primary admission (OR: 1.05, 95% CI: 1.04-1.07) and initial neurological admission diagnoses (OR: 3.83, 95% CI: 3.33-4.42) positively correlated with shunt complications. Female sex (OR: 0.87, 95% CI: 0.76-0.99) and elective admissions (OR: 0.62, 95% CI: 0.53-0.72) negatively correlated with shunt complications. ROC curve for the regression model utilizing all significant predictors of readmission demonstrated area under the curve of 0.733, suggesting these factors are possible predictors of shunt complications in pediatric hydrocephalus. CONCLUSION: Efficacious and safe treatment of pediatric hydrocephalus is of paramount importance. Our machine learning algorithm delineated possible variables predictive of shunt complications with good predictive value.

Safety and Efficacy of High-Dose Tranexamic Acid in Spine Surgery: A Retrospective Single-Institution Series.

OBJECTIVE: Currently, tranexamic acid (TXA) is the most widely used antifibrinolytic agent in spine surgery and has been proven to reduce perioperative blood loss. However, the safety of high-dose regimens remains in established. METHODS: A retrospective chart review was performed to identify all adult patients who underwent spine surgery with high-dose TXA (50 mg/kg loading dose, mg/kg/h maintenance dose) between September 2019 and March 2020. RESULTS: Thirty-six patients were treated with intraoperative high-dose TXA during the study period. The mean age was 56.6 (range: 22-82). Average body mass index was 27.2 (5.1) kg/m2. Average preoperative Charlson Comorbidity Index was 3.0 (2.7). The mean number of spinal levels operated on was 6.9 (4.3). Seven cases (19.4%) were revision surgeries. The mean intraoperative blood loss was 587.1 (900.0) mL, and total blood loss was 623.8 (991.9) mL. Postoperatively, time to ambulation was on average 1.7 (1.7) days. The mean total length of stay was 9.8 days (7.9, range 2-41). The most common indication for surgery was tumor (n = 9, 25%), followed by fracture (n = 8, 22.2%), deformity (n = 7, 19.4%), pseudarthrosis (n = 6, 16.7%), and symptomatic lumbar disc herniation (n = 2, 5.6%). There were no thromboembolic or other significant complications among the 36 patients. CONCLUSIONS: This retrospective case series demonstrates that the use of high-dose TXA provides is potentially safe and efficacious in adult patients undergoing complex spine surgeries. However, further investigations are required before the true safety and optimal dosing can be determined for high-dose TXA.

The NUTRIENT Trial (NUTRitional Intervention among myEloproliferative Neoplasms): Feasibility Phase.

Purpose: Chronic inflammation is integral to Myeloproliferative Neoplasm (MPN) pathogenesis. JAK inhibitors reduce cytokine levels, but not without significant side effects. Nutrition is a low-risk approach to reduce inflammation and ameliorate symptoms in MPN. We performed a randomized, parallel-arm study to determine the feasibility of an education-focused Mediterranean diet intervention among MPN patients. Experimental Design: We randomly assigned participants to either a Mediterranean diet or standard US Dietary Guidelines for Americans (USDA). Groups received equal but separate education with registered dietician counseling and written dietary resources. Patients were prospectively followed for feasibility, adherence, and symptom burden assessments. Biological samples were collected at four time points during the 15-week study to explore changes in inflammatory biomarkers and gut microbiome. Results: The Mediterranean diet was as easy to follow for MPN patients as the standard USDA diet. Over 80% of the patients in the Mediterranean diet group achieved a Mediterranean Diet Adherence Score of ≥8 throughout the entire active intervention period, whereas less than 50% of the USDA group achieved a score of ≥8 at any time point. Improvement in symptom burden was observed in both diet groups. No significant changes were observed in inflammatory cytokines. The diversity and composition of the gut microbiome remained stable throughout the duration of the intervention. Conclusions: With dietician counseling and written education MPN patients can adhere to a Mediterranean eating pattern. Diet interventions may be further developed as a component of MPN care, and potentially even be incorporated into the management of other chronic clonal hematologic conditions.

Characteristics and Outcomes in Pediatric Versus Adult Craniopharyngiomas: A Systematic Review and Meta-Analysis.

BACKGROUND: Craniopharyngiomas account for 1.2% to 4.6% of all intracranial tumors. Although age at presentation is distributed bimodally, with a pediatric peak occurring between 5 and 15 years and an adult peak between 50 and 70 years, presentation, treatment, and outcome differences between these two craniopharyngioma populations have not been thoroughly characterized. OBJECTIVE: To compare treatments and outcomes between adult and pediatric craniopharyngiomas. METHODS: This is a systematic review and meta-analysis. Web of Science, MEDLINE, and Scopus databases were searched for primary studies reporting postoperative complications, functional outcomes, recurrence, and overall survival in patients with craniopharyngioma undergoing surgery. RESULTS: The search yielded 1,202 unique articles, of which 106 (n=4,202 patients) met criteria for qualitative synthesis and 23 (n=735 patients) met criteria for meta-analysis. Compared with adult, pediatric craniopharyngiomas were less likely to present with visual defects (odds ratio [OR] 0.54, 95% CI 0.36-0.80) or cognitive impairment (OR 0.29, 95% CI 0.12-0.71) and more likely with headaches (OR 2.08, 95% CI 1.16-3.73). Children presented with significantly larger tumors compared with adults (standardized mean difference 0.68, 95% CI 0.38-0.97). Comparing functional outcomes, pediatric patients sustained higher rates of permanent diabetes insipidus (OR 1.70, 95% CI 1.13-2.56), obesity (OR 3.15, 95% CI 1.19-8.31), and cranial nerve and/or neurological defects (OR 4.87, 95% CI 1.78-13.31) than adults. No significant differences were found in rates of postoperative cerebrospinal fluid leak, overall or progression-free survival, or recurrence. CONCLUSION: Adult and pediatric craniopharyngiomas seem to have fundamental differences in clinical presentation and functional outcomes. These patients frequently require multimodality treatment and are best managed with a multidisciplinary team and an individualized approach.

Novel use of nonpenetrating titanium clips for pediatric primary spinal dural closure: A technical note.

BACKGROUND: Dural closure is an important part of any pediatric spinal procedure with intradural pathology to prevent post-operative cerebrospinal fluid (CSF) egress and associated complications. Utilization of nonpenetrating titanium clips is one closure option that may have technical advantages such as ease of use and amenability to a narrow surgical corridor. No data exist on the efficacy of these clips for pediatric spinal dural closure. METHODS: A single surgeon case series of 152 pediatric patients underwent procedures involving lumbar durotomy with subsequent dural closure using the AnastoClip® nonpenetrating titanium clip closure system. Rates of infection and cerebrospinal fluid leak were measured during the follow-up period. RESULTS: A total of 152 pediatric patients (mean age: 6.25 ± 5.85 years, 50.7 % female) underwent intradural surgery with clip closure. The mean follow-up time was 57.0 ± 28.5 months. All patients were initially indicated for procedures involving spinal durotomy, with a majority being isolated tethered cord release (84.2 %). Others required tethered cord release and excision of a lipomyelomeningocele, spinal meningioma or arachnoid cyst (15.8 %). Post operative CSF leak occurred in two (1.32 %) patients at 11 and 18 days. Only one (0.66 %) patient was diagnosed with an infection, which was in a separate patient from those that had CSF leaks. CONCLUSION: The remarkably low incidence of post-operative CSF leak and infection with nonpenetrating titanium clips suggests a strong safety and efficacy profile for this form of dural closure in a pediatric cohort. Further research evaluating this technique is required to fully demonstrate its acceptability as a cost-effective alternative to traditional suture-based closure.

Demographic predictors of treatment and complications for adult spinal deformity: An analysis of the national inpatient sample.

PURPOSE: To examine the role of demographics on surgical management and inpatient complications in patients with spinal deformity between 2010 and 2014 via retrospective analysis. METHODS: Data were obtained from the National Inpatient Sample (NIS). International Classification of Diseases 9th revision codes were used to identify patients with a primary diagnosis of adult spinal deformity (ASD). Multivariable Poisson regression analyses were used to determine whether any individual demographic variables were predictive of surgical management, surgical complexity, postoperative complications and revision operations. RESULTS: 17,433 patients were identified for analysis. Surgical intervention was performed for 94.5% of patients with a primary diagnosis of ASD. Patients at urban teaching hospitals were the most likely to receive surgery (OR= 2.13; 95% CI 1.51-2.95; p < 0.001) relative to rural patients. Female patients were the majority undergoing surgery and were more likely to receive a complication or require a revision when controlling for surgical complexity. Medicare patients were the least likely to undergo surgery and the most likely to receive complex fusion when undergoing an operation. Medicare patients were the least likely to experience complications (OR=0.89; 95% CI 0.80-0.98; p = 0.022) after adjusting for surgical complexity. With regards to race and ethnicity, Hispanics had a decreased likelihood of receiving a revision surgery. CONCLUSION: There were substantial differences in rates of surgical management, postoperative complications, and revisions among individuals of different demographics including sex, insurance status, ethnicity and hospital teaching status. Further research evaluating the effect of demographics in spine surgery is warranted to fully understand their influence on patient outcomes.

Cost analysis comparison between anterior and posterior cervical spine approaches.

Background: The costs of cervical spine surgery have steadily increased. We performed a 5-year propensity scoring-matched analysis of 276 patients undergoing anterior versus posterior cervical surgery at one institution. Methods: We performed propensity score matching on financial data from 276 patients undergoing 1-3 level anterior versus posterior cervical fusions for degenerative disease (2015-2019). Results: We found no significant difference between anterior versus posterior approaches for hospital costs ($42,529.63 vs. $45,110.52), net revenue ($40,877.25 vs. $34,036.01), or contribution margins ($14,230.19 vs. $6,312.54). Multivariate regression analysis showed variables significantly associated with the lower contribution margins included age (ß = -392.3) and length of stay (LOS; ß = -1151). Removing age/LOS from the analysis, contribution margins were significantly higher for the anterior versus posterior approach ($17,824.16 vs. $6,312.54, P = 0.01). Conclusion: Anterior cervical surgery produced higher contribution margins compared to posterior approaches, most likely because posterior surgery was typically performed in older patients requiring longer LOS.

Evaluating the incidence and predictors of anti-NMDAR encephalitis in a contemporary cohort of patients diagnosed with dermoid tumors: A national inpatient sample analysis.

INTRODUCTION: Anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis is a form of encephalitis previously associated with dermoid tumors. However, most studies in the literature evaluating the disease are case reports and small patient cohorts, limiting robust statistical analysis. Here, we demonstrate predictors of anti-NMDAR encephalitis in a large cohort of US patients. METHODS: We used the 2016 National Inpatient Sample (NIS) to identify a cohort of 24,270 admitted for an ovarian dermoid tumor. Of these patients, 50 (0.21%) were diagnosed with anti-NMDAR encephalitis. Patient demographics, hospital characteristics, length of stay (LOS), and complications were collected. Statistical analysis consisted of odds ratios with chi-square testing to compare categorical variables. RESULTS: The mean age of all patients with dermoid tumors was 45.5 ± 18.0 years, and the mean age of patients with diagnosed anti-NMDAR encephalitis was 27.4 ± 4.9 years. The mean LOS in the dermoid tumor cohort was 3.5 ± 4.9 days, while the mean LOS in the anti-NMDAR encephalitis cohort was 31.9 ± 25.9 days (p < 0.001). The mean cost in the dermoid tumor cohort was $44,813.18±$54,305.90, while the mean cost in the anti-NMDAR encephalitis cohort was $445,628.60±$665,423.40 (p < 0.001). Patients with age above 30 years with dermoid tumors had significantly lower odds of developing anti-NMDAR encephalitis compared to patients younger than 30 years (OR: 0.19; 95%CI: 0.045-0.67; p-value: 0.003). White patients had significantly lower odds of developing anti-NMDAR encephalitis (OR: 0.19; 95%CI: 0.026-0.77; p-value: 0.013), and Black patients had significantly higher odds of developing anti-NMDAR encephalitis (OR: 3.45; 95%CI: 1.00-12.46; p-value: 0.044). CONCLUSION: Patient predictors of developing anti-NMDAR encephalitis include age, race, ethnicity and patients who go on to develop anti-NMDAR encephalitis have a significantly increased hospital LOS and cost compared to those who do not. Future research, including multi-center clinical trials and longitudinal data, is necessary to fully cement the findings of this manuscript.

Bony fixation in the era of spinal robotics: A systematic review and meta-analysis.

BACKGROUND: Accurate spinal screw placement in spinal instrumentation is of utmost importance to avoid injury to surrounding neurovascular structures. This study was performed to investigate differences in accuracy, operating room time, length of stay, and operative blood loss across studies involving all types of spinal fixation. METHODS: PubMed, EMBASE, and Scopus were systematically queried to identify articles that fit the inclusion and exclusion criteria. Meta-analysis was performed using R software, and odds ratios and 95% CIs were calculated. RESULTS: Sixty-nine articles were included in qualitative synthesis, and 35 studies in the meta-analysis, for a total of 8,174 robotically placed screws in 1,492 patients compared to 9,791 conventionally placed screws in 1,638 patients. A total of 9 screw trajectories were studied in the literature, although only 4 had enough evidence to be included in the meta-analysis. Robotic screw placement was more accurate than conventional screw placement (OR 2.24; 95% CI, 1.71-2.94). Robotic placement was not associated with significantly different postoperative length of stay (SMD -0.32; 95% CI, -1.20, 0.51), operative blood loss (SMD -0.25; 95% CI, -0.79, 0.19), or operative duration (SMD 0.08; 95% CI -1.00, 1.39). A total of 8 robotic platforms were found in the literature with accuracy rates above 93%. CONCLUSION: Robotic spinal fixation is associated with increased screw placement accuracy and similar operative blood loss, length of stay, and operative duration. These findings support the safety and cost-effectiveness of robotic spinal surgery across the spectrum of robotic systems and screw types.

Use of Tranexamic Acid for Elective Resection of Intracranial Neoplasms: A Systematic Review.

BACKGROUND: As an established antifibrinolytic agent, tranexamic acid (TXA) has garnered widespread use during surgery to limit intraoperative blood loss. In the field of neurosurgery, TXA is often introduced in cases of traumatic brain injury or elective spine surgeries; however, its role during elective cranial surgeries is not well established. We report a systematic review of the use of TXA in elective surgical resection of intracranial neoplasms. METHODS: We performed this systematic review following PRISMA guidelines to identify studies investigating the use of TXA in elective neurosurgical resection of intracranial neoplasms. Variables extracted included patient demographics, surgical indications, type of surgery performed, TXA dose and route of administration, operative duration, blood loss, transfusion rate, postoperative hemoglobin level, and complications. RESULTS: After careful screening, 4 articles (consisting of 682 patients) met our inclusion/exclusion criteria. The studies included 2 prospective cohort studies, 1 retrospective cohort study, and 1 case series. A χ2 test of pooled data demonstrated that patients administered TXA had a significantly decreased need for blood transfusions during surgery (odds ratio, 0.6273; 95% confidence interval, 0.4254-0.9251; P = 0.018). Mean total blood loss was 821.9 mL in the TXA group and 1099.0 mL in the control group across the studies. There was no significant difference in postoperative hemoglobin levels, with a mean of 11.4 g/dL in both the TXA and control groups. CONCLUSIONS: These results support the use of intraoperative TXA in tumor resection. However, its role in tumor resection has been less well investigated compared with its use in other areas of neurosurgery.

Association of tranexamic acid with decreased blood loss in patients undergoing laminectomy and fusion with posterior instrumentation: a systematic review and meta-analysis.

OBJECTIVE: Tranexamic acid (TXA) is an antifibrinolytic agent associated with reduced blood loss and mortality in a wide range of procedures, including spine surgery, traumatic brain injury, and craniosynostosis. Despite this wide use, the safety and efficacy of TXA in spine surgery has been considered controversial due to a relative scarcity of literature and lack of statistical power in reported studies. However, if TXA can be shown to reduce blood loss in laminectomy with fusion and posterior instrumentation, more surgeons may include it in their armamentarium. The authors aimed to conduct an up-to-date systematic review and meta-analysis of the efficacy of TXA in reducing blood loss in laminectomy and fusion with posterior instrumentation. METHODS: A systematic review and meta-analysis, abiding by PRISMA guidelines, was performed by searching the databases of PubMed, Web of Science, and Cochrane. These platforms were queried for all studies reporting the use of TXA in laminectomy and fusion with posterior instrumentation. Variables retrieved included patient demographics, surgical indications, involved spinal levels, type of laminectomy performed, TXA administration dose, TXA route of administration, operative duration, blood loss, blood transfusion rate, postoperative hemoglobin level, and perioperative complications. Heterogeneity across studies was evaluated using a chi-square test, Cochran's Q test, and I2 test performed with R statistical programming software. RESULTS: A total of 7 articles were included in the qualitative study, while 6 articles featuring 411 patients underwent statistical analysis. The most common route of administration for TXA was intravenous with 15 mg/kg administered preoperatively. After the beginning of surgery, TXA administration patterns were varied among studies. Blood transfusions were increased in non-TXA cohorts compared to TXA cohorts. Patients administered TXA demonstrated a significant reduction in blood loss (mean difference -218.44 mL; 95% CI -379.34 to -57.53; p = 0.018). TXA administration was not associated with statistically significant reductions in operative durations. There were no adverse events reported in either the TXA or non-TXA patient cohorts. CONCLUSIONS: TXA can significantly reduce perioperative blood loss in cervical, thoracic, and lumbar laminectomy and fusion procedures, while demonstrating a minimal complication profile.

Citation analysis of the most influential ependymoma research articles illustrates improved knowledge of the molecular biology of ependymoma.

The history of academic research on ependymoma is expansive. This review summarizes its history with a bibliometric analysis of the 100 most cited articles on ependymoma. In March 2020, we queried the Web of Science database to identify the most cited articles on ependymoma using the terms "ependymoma" or "ependymal tumors," yielding 3145 publications. Results were arranged by the number of times each article was cited in descending order. The top 100 articles spanned across nearly a century; the oldest article was published in 1924, while the most recent was in 2017. These articles were published in 35 unique journals, including a mix of basic science and clinical journals. The three institutions with the most papers in the top 100 were St. Jude Children's Research Hospital (16%), the University of Texas MD Anderson Cancer Center (6%), and the German Cancer Research Center (5%). We analyzed the publications that may be considered the most influential in the understanding and treatment management of ependymoma. Studies focused on the molecular classification of ependymomas were well-represented among the most cited articles, reflecting the field's current area of focus and its future directions. Additionally, this article also offers a reference for further studies in the ependymoma field.

Pigmented ependymoma, a tumor with predilection for the middle-aged adult: case report with methylation classification and review of 16 literature cases.

Ependymomas have rarely been described to contain pigment other than melanin, neuromelanin, lipofuscin or a combination. In this case report, we present a pigmented ependymoma in the fourth ventricle of an adult patient and review 16 additional cases of pigmented ependymoma from the literature. A 46-year-old female showed up with hearing loss, headaches, and nausea. Magnetic resonance imaging revealed a 2.5 cm contrast-enhancing cystic mass in the fourth ventricle, which was resected. Intraoperatively, the tumor appeared grey-brown, cystic, and was adherent to the brainstem. Routine histology revealed a tumor with true rosettes, perivascular pseudorosettes and ependymal canals consistent with ependymoma, but also showed chronic inflammation and abundant distended pigmented tumor cells that mimicked macrophages in frozen and permanent sections. The pigmented cells were positive for GFAP and negative for CD163 consonant with glial tumor cells. The pigment was negative for Fontana-Masson, positive for Periodic-acid Schiff and autofluorescent, which coincide with characteristics of lipofuscin. Proliferation indices were low and H3K27me3 showed partial loss. H3K27me 3 is an epigenetic modification to the DNA packaging protein Histone H3 that indicates the tri-methylation of lysine 27 on histone H3 protein. This methylation classification was compatible with a posterior fossa group B ependymoma (EPN_PFB). The patient was clinically well without recurrence at three-month post-operative follow-up appointment. Our analysis of all 17 cases, including the one presented, shows that pigmented ependymomas are most common in the middle-aged with a median age of 42 years and most have a favorable outcome. However, one patient that also developed secondary leptomeningeal melanin accumulations died. Most (58.8%) arise in the 4th ventricle, while spinal cord (17.6%) and supratentorial locations (17.6%) were less common. The age of presentation and generally good prognosis raise the question of whether most other posterior fossa pigmented ependymomas may also fall into the EPN_PFB group, but additional study is required to address that question.

Trends in Diagnosis and Treatment of Sacroiliac Joint Pathology Over the Past 10 Years: Review of Scientific Evidence for New Devices for Sacroiliac Joint Fusion.

Sacroiliac (SI) joint pathology is a newly appreciated contributor to lower back pain. Sacroiliac joint fusion (SIJF) has grown rapidly in popularity in association with the advent of minimally-invasive surgical techniques. This has led to an explosion of new medical devices used for SIJF. The objective of this article is to outline clinical trends, summarize the current data, and categorize novel devices for SIJF. Trends in SI joint pathology and fusion were obtained via the Healthcare Cost and Utilization Project's (HCUP) National Inpatient Sample (NIS) database and Web of Science. To review literature on devices for SIJF, PubMed was searched using the Boolean phrase "sacroiliac joint AND (fusion OR arthrodesis)" since 2010. To establish a list of SIJF devices not represented in the literature, searches were performed on the FDA 510(k), premarket approval, and de novo databases, as well as Google and LinkedIn. Literature review yielded 11 FDA-approved devices for minimally invasive SIJF. Database query yielded an additional 22 devices for a total of 33 devices. Twenty-one devices used the lateral transiliac approach, six posterior allograft approach, three posterolateral approach, and three combined the lateral transiliac and posterolateral approaches. The evidence for the lateral transiliac approach is the most robust. Many novel devices have been developed for minimally invasive SIJF over the past 10 years. Further randomized comparative trials are warranted to evaluate different surgical approaches and novel devices at this time.

Simultaneous Robotic Single-Position Surgery (SR-SPS) with Oblique Lumbar Interbody Fusion: A Case Series.

BACKGROUND: The oblique lateral interbody fusion (OLIF) procedure is an important component of the surgeon's armamentarium for the treatment of degenerative spinal conditions. OLIF with posterior spinal fixation frequently is performed and requires additional time because the patient is flipped to a prone position and redraped. We report a series of cases in which robotic-assistance was used for a 2-surgeon workflow in which OLIF and single lateral position posterior spinal fixation were performed at the same time, termed simultaneous robotic single position surgery (SR-SPS). METHODS: Data were collected retrospectively from medical records of 13 consecutive patients who underwent SR-SPS by a single surgeon at an academic center between June and December 2020. Instrumentation accuracy, total operating room time, estimated blood loss, length of stay, and complications were assessed. RESULTS: A total of 13 patients whose mean age was 64.1 years (range 46-84 years) underwent SR-SPS over a 6-month period. Average follow-up was 10.3 months. All patients were treated for degenerative spine disease. The average operative duration was 111.2 ± 25.2 minutes. A total of 60 pedicle screws were placed bilaterally in the lateral position with an accuracy rate of 95.0%. Complications included 1 postoperative seroma, and 1 patient required reoperation 3 months postoperatively due to a fall. CONCLUSIONS: We report the first case series describing SR-SPS. Our study shows that this method can reduce operative time while ensuring accurate and timely screw placement with minimal complications.

Surgical management of a rare myxopapillary ependymoma of the gluteal region: A case report.

BACKGROUND: Ependymomas are rare tumors originating from neuroepithelial cells lining the wall of the ventricles or central canal of the spinal cord. While these tumors mainly occur within the central nervous system (CNS), there are occasional reports in children and young adult patients with a primary tumor occurrence outside of the CNS. Ependymomas of the sacrococcygeal region have been infrequently described in the literature with no standard of care established. We present a case report and review of the literature regarding this rare entity. CASE DESCRIPTION: A 24-year-old woman presented with right gluteal pain worsened by sitting and a palpable soft tissue mass of the sacrococcygeal region. Magnetic resonance imaging revealed a 3.7 cm cystic mass centered in the right gluteal region. She underwent a biopsy at an outside institution, with histology revealing myxopapillary ependymoma. The patient was referred to our hospital and underwent an interdisciplinary neurosurgical and orthopedic oncology en bloc resection of the ependymoma, which intraoperatively appeared to originate from the coccygeal nerve. CONCLUSION: In the present report, the authors demonstrate that a myxopapillary ependymoma may present as an isolated gluteal mass attached to the coccygeal nerve, without frank CNS involvement. Furthermore, an interdisciplinary approach to surgical resection of this lesion appears to represent an effective treatment modality.

Ethical considerations and patient safety concerns for cancelling non-urgent surgeries during the COVID-19 pandemic: a review.

At the time of writing of this article, there have been over 110 million cases and 2.4 million deaths worldwide since the start of the Coronavirus Disease 2019 (COVID-19) pandemic, postponing millions of non-urgent surgeries. Existing literature explores the complexities of rationing medical care. However, implications of non-urgent surgery postponement during the COVID-19 pandemic have not yet been analyzed within the context of the four pillars of medical ethics. The objective of this review is to discuss the ethics of elective surgery cancellation during the COVID-19 pandemic in relation to beneficence, non-maleficence, justice, and autonomy. This review hypothesizes that a more equitable decision-making algorithm can be formulated by analyzing the ethical dilemmas of elective surgical care during the pandemic through the lens of these four pillars. This paper's analysis shows that non-urgent surgeries treat conditions that can become urgent if left untreated. Postponement of these surgeries can cause cumulative harm downstream. An improved algorithm can address these issues of beneficence by weighing local pandemic stressors within predictive algorithms to appropriately increase surgeries. Additionally, the potential harms of performing non-urgent surgeries extend beyond the patient. Non-maleficence is maintained through using enhanced screening protocols and modifying surgical techniques to reduce risks to patients and clinicians. This model proposes a system to transfer patients from areas of high to low burden, addressing the challenge of justice by considering facility burden rather than value judgments concerning the nature of a particular surgery, such as cosmetic surgeries. Autonomy can be respected by giving patients the option to cancel or postpone non-urgent surgeries. However, in the context of limited resources in a global pandemic, autonomy is not absolute. Non-urgent surgeries can ethically be postponed in opposition to the patient's preference. The proposed algorithm attempts to uphold the four principles of medical ethics in rationing non-urgent surgical care by building upon existing decision models, using additional measures of resource burden and surgical safety to increase health care access and decrease long-term harm as much as possible. The next global health crisis will undoubtedly present its own unique challenges. This model may serve as a comprehensive starting point in determining future guidelines for non-urgent surgical care.