Racial Disparities in Outcomes After Spine Surgery: A Systematic Review and Meta-Analysis.

OBJECTIVE: Racial disparities are a major issue in health care but the overall extent of the issue in spinal surgery outcomes is unclear. We conducted a systematic review/meta-analysis of disparities in outcomes among patients belonging to different racial groups who had undergone surgery for degenerative spine disease. METHODS: We searched Ovid MEDLINE, Scopus, Cochrane Review Database, and ClinicalTrials.gov from inception to January 20, 2021 for relevant articles assessing outcomes after spine surgery stratified by race. We included studies that compared outcomes after spine surgery for degenerative disease among different racial groups. RESULTS: We found 30 studies that met our inclusion criteria (28 articles and 2 published abstracts). We included data from 20 cohort studies in our meta-analysis (3,501,830 patients), which were assessed to have a high risk of observation/selection bias. Black patients had a 55% higher risk of dying after spine surgery compared with white patients (relative risk [RR], 1.55, 95% confidence interval [CI], 1.28-1.87; I2 = 70%). Similarly, black patients had a longer length of stay (mean difference, 0.93 days; 95% CI, 0.75-1.10; I2 = 73%), and higher risk of nonhome discharge (RR, 1.63; 95% CI, 1.47-1.81; I2 = 89%), and 30-day readmission (RR, 1.45; 95% CI, 1.03-2.04; I2 = 96%). No significant difference was noted in the pooled analyses for complication or reoperation rates. CONCLUSIONS: Black patients have a significantly higher risk of unfavorable outcomes after spine surgery compared with white patients. Further work in understanding the reasons for these disparities will help develop strategies to narrow the gap among the racial groups.

False Localization of Ruptured Intracranial Dermoid Secondary to Subarachnoid Spread of Cyst Contents.

A 34-year-old right-handed female presented to the emergency department with a worsening headache, neck stiffness, intermittent abnormal sensation, and right arm weakness. Shortly after arrival, she had a generalized tonic-clonic seizure. A noncontrast head computed tomography scan revealed a right-sided, low-attenuating, lobulated mass ipsilateral to her arm symptoms. Magnetic resonance imaging revealed an abnormal signal throughout the subarachnoid space and increased fluid-attenuated inversion recovery sequence signal contralateral to the mass. This presentation suggested a false localization sign of sensory and motor disturbance ipsilateral to the mass likely caused by cyst rupture and sebum spread contralateral, causing cortical irritation (evidenced by increased fluid-attenuated inversion recovery sequence signal). During mass resection, sebum was visible throughout the subarachnoid space. The patient had an uneventful recovery from surgery and has been seizure free since the resection with steady improvement of symptoms. This case highlights the importance of avoiding cyst rupture of dermoid cysts.

Treatment of intracerebral hemorrhage: a selective review and future directions.

Intracerebral hemorrhage (ICH) is a devastating disease. Sixty percent of survivors do not function independently at one year. Treatment of ICH costs approximately US$ 12.7 billion annually. To date no intervention has demonstrated clear efficacy in improving outcomes. The goal of this selective review is to provide an understanding of current treatment and discuss future directions. After a discussion of pathophysiology and societal impact, a synopsis of treatment options is reviewed, including: 1) open craniotomy; 2) catheter-based thrombolytic therapy; 3) endoscopic evacuation; and 4) ultrasonic lysis. Amongst other studies, we will discuss the results of STICH (International Surgical Trial in ICH) and MISTIE (Minimally Invasive Surgery plus Recombinant Tissue-type Plasminogen Activator for ICH Evacuation). We hope to provide a succinct, pragmatic review for the neurosurgical community on the current state of therapy and encourage novel ways to aggressively treat this burdensome disease.

Point-of-View Recording Devices for Intraoperative Neurosurgical Video Capture.

INTRODUCTION: The ability to record and stream neurosurgery is an unprecedented opportunity to further research, medical education, and quality improvement. Here, we appraise the ease of implementation of existing point-of-view devices when capturing and sharing procedures from the neurosurgical operating room and detail their potential utility in this context. METHODS: Our neurosurgical team tested and critically evaluated features of the Google Glass and Panasonic HX-A500 cameras, including ergonomics, media quality, and media sharing in both the operating theater and the angiography suite. RESULTS: Existing devices boast several features that facilitate live recording and streaming of neurosurgical procedures. Given that their primary application is not intended for the surgical environment, we identified a number of concrete, yet improvable, limitations. CONCLUSION: The present study suggests that neurosurgical video capture and live streaming represents an opportunity to contribute to research, education, and quality improvement. Despite this promise, shortcomings render existing devices impractical for serious consideration. We describe the features that future recording platforms should possess to improve upon existing technology.

Intracerebral Hemorrhage: A Common and Devastating Disease in Need of Better Treatment.

OBJECTIVE: To review the poor natural history of intracerebral hemorrhage (ICH), current treatment options for ICH, discuss ongoing trials evaluating minimally invasive techniques for clot evacuation, and offer future directions of investigation for the management of this devastating disease. METHODS: A selective review of recent trials regarding treatment of ICH was performed. RESULTS: Completed trials of medical and surgical management are reviewed. The supportive research for clot evacuation to limit secondary injury is surveyed. We also provide a comprehensive discussion of current data evaluating minimally invasive techniques to achieve clot removal, including Minimally Invasive Surgery plus tPA for ICH Evacuation (MISTIE), Clot Lysis: Evaluating Accelerated Resolution (CLEAR), and endoscopic evacuation. CONCLUSION: We encourage the neurosurgical community to pursue improved therapies for ICH. PRACTICE: New minimally invasive treatments for ICH are being developed. IMPLICATIONS: Treatment of ICH is an important area of research and should continue to be aggressively pursued because of the significant societal burden and poor outcomes associated with ICH.

Surgical management of large scalp infantile hemangiomas.

BACKGROUND: Infantile Hemangiomas (IH) are the most common benign tumor of infancy, occurring in over 10% of newborns. While most IHs involute and never require intervention, some scalp IHs may cause severe cosmetic deformity and threaten tissue integrity that requires surgical excision. CASE DESCRIPTION: We present our experience with two infants who presented with large scalp IH. After vascular imaging, the patients underwent surgical resection of the IH and primary wound closure with excellent cosmetic outcome. We detail the surgical management of these cases and review the relevant literature. CONCLUSION: In some cases the IHs leave behind fibro-fatty residuum causing contour deformity. Surgery is often required for very large lesions causing extensive anatomical and/or functional disruption. The goal of surgical intervention is to restore normal anatomic contour and shape while minimizing the size of the permanent scar.

Resolution of trigeminal neuralgia by coil embolization of a persistent primitive trigeminal artery aneurysm.

The persistent primitive trigeminal artery (PTA) is a rare anastomosis between the carotid artery and basilar artery. While most PTAs are asymptomatic, lateral variants can occasionally compress the trigeminal nerve and precipitate trigeminal neuralgia. Aneurysms of the PTA are exceptionally rare in the literature and have not previously been associated with trigeminal neuralgia. We present the first case of an aneurysm of the PTA causing trigeminal neuralgia. The patient underwent coil embolization of the aneurysm which relieved her symptoms. We propose embolization as a viable therapeutic option for the resolution of trigeminal neuralgia when the condition is secondary to irritation by the high velocity pulsatile flow of an aneurysm.

The role of the CXCR4 cell surface chemokine receptor in glioma biology.

CXCR4, a cell surface chemokine receptor, mediates cellular dissemination, invasion, and proliferation in a wide range of cancers including gliomas. It is over-expressed in glioma progenitor cells, and its protein ligand, CXCL12, has been shown to mediate a specific proliferative response in these cells thereby implicating a role for CXCR4 in glioma initiation and renewal. Given the failure of currently employed therapies to meaningfully impact prognosis in patients with high-grade gliomas, the CXCR4-CXCL12 axis represents a novel biologically relevant mechanism that could be specifically targeted for therapy. From this perspective, this review summarizes the biological effects of CXCR4 activity and its implications for glioma pathogenesis. Ultimately, the development of effective treatment approaches for malignant glioma must be based on a rational mechanistic understanding of tumor cell biology. As such, this article presents such a framework with regard to the CXCR4 pathway in glioma thereby supporting the further investigation of CXCR4 as a therapeutic target in patients with this disease.

Primary calvarial angiosarcoma: A case report and review of the literature.

BACKGROUND: Angiosarcomas are high-grade endothelial tumors remarkable for their rarity and malignant behavior. Primary calvarial angiosarcoma is an extremely rare entity and its behavior usually sets it apart from other angiosarcoma types. We highlight the successful management of cranial angiosarcoma using a multidisciplinary approach. CASE DESCRIPTION: We present a 16-year-old male who was first noted to have a right-sided parietal cranial mass that was biopsied in 2008. Pathology was initially thought to be Kaposiform hemangioendothelioma. The patient subsequently underwent chemotherapy with vincristine. The patient did well until early 2010, when he suffered a right-sided intraparenchymal intratumoral hemorrhage. At this time, the original pathologic diagnosis was revisited and the diagnosis was upgraded to an angiosarcoma. The patient underwent a second round of chemotherapy using vincristine, cyclophosphamide, and actinomycin. The tumor continued to progress despite this treatment and he developed extensive skull deformity. At this point more definitive surgical intervention was reconsidered. Preoperative embolization of the mass was performed followed by aggressive surgical resection of the bony disease. The patient tolerated the procedure well and was discharged 6 days postoperatively without any new deficits. The patient is currently in the process of completing radiation therapy to entire tumor bed. He has clinically done well with no neurologic deterioration and has demonstrated long-term survival (>3 years). CONCLUSION: With the combined efforts of pediatric oncology, radiation oncology, interventional neuroradiology, and neurosurgery, a survival of greater than 3 years is possible with this aggressive pathology.