The AANS Harvey Cushing Medal: a demographic and academic analysis of its recipients.

Background: The Harvey Cushing Medal, awarded by the American Association of Neurological Surgeons, is the premier accolade in neurosurgery. The study's purpose was to examine the qualities and accomplishments of previous winners, emphasizing potential selection biases, with the aim to promote social justice and guide young neurosurgeons in their career paths. Results: Predominantly, recipients graduated from top-ranked United States News and World Report institutions and specialized in cerebrovascular and neuro-oncologic/skull base neurosurgery. A significant proportion held roles as department or division chairs and led neurosurgical organizations. All awardees were male, and there was a notable trend of increasing publication counts among more recent recipients. Conclusions: Commonalities among Harvey Cushing Medal winners include graduating from top institutions, holding significant leadership roles, and having an extensive publication history. However, the absence of female and underrepresented minority awardees underscores an urgent need for greater diversity in the selection process.

The Enhanced Recovery After Surgery pathway for posterior cervical surgery: a retrospective propensity-matched cohort study.

OBJECTIVE: The Enhanced Recovery After Surgery (ERAS) protocol is a comprehensive, multifaceted approach aimed at improving postoperative outcomes. It incorporates a range of strategies to promote early and more effective recovery, including reducing pain, complications, and length of stay, without increasing readmission rate. To date, ERAS for spine surgery patients has been primarily limited to lumbar surgery and anterior cervical decompression and fusion (ACDF). ERAS has not been previously studied for posterior cervical surgery, which may present a greater opportunity for improvement in patient outcomes with ERAS than ACDF. This single-institution, multi-surgeon study assessed the impact of an ERAS protocol in patients undergoing posterior cervical decompression surgery. METHODS: This study included a retrospective consecutive patient cohort with controls that were propensity matched for age, body mass index, sex, home opioid use, surgical levels, Nurick grade, and smoking status. In addition, consecutive patients who underwent posterior cervical decompression surgery for degenerative disease from December 2014 to December 2021 were included. ERAS was implemented in December 2018. Demographic, perioperative, clinical, and radiographic information was gathered. Regression models were created to evaluate length of stay, physiological function, pain levels, and opioid use. The primary focus was length of stay, with secondary outcomes including timing of ambulation, bowel movement, and voiding; daily pain scores; opioid consumption; discharge status; 30-day readmission rates; and reoperation rates. RESULTS: There were 366 patients included in the study, all of whom were included in multivariate models, and 254 (127 in each cohort) were included on the basis of matching. After propensity matching, patient characteristics, operative procedures, and operative duration were similar between groups. The ERAS cohort had a significantly improved length of stay (3.2 vs 4.7 days, p < 0.0001) and home discharge rate (80% vs 50%, p < 0.001) without an increase in readmission rate. The ERAS cohort had an earlier day of the first ambulation (p = 0.003), bowel movement (p = 0.014), and voiding (p = 0.001). ERAS demonstrated a significantly lower composite complication rate (1.1 vs 1.8, p < 0.0001). ERAS resulted in better maximum pain scores (p = 0.043) and trended toward improved mean pain scores (p = 0.072), although total opioid use was similar. CONCLUSIONS: Implementing a novel ERAS protocol significantly improved length of stay, return of physiological function, home discharge, complications, and maximum pain score after posterior cervical surgery.

Enhanced recovery after surgery (ERAS) improves return of physiological function in frail patients undergoing one- to two-level TLIFs: an observational retrospective cohort study.

BACKGROUND CONTEXT: The enhanced recovery after surgery (ERAS) protocol is a multimodal approach which has been shown to facilitate recovery of physiological function, and reduce early post-operative pain, complications, and length of stay (LOS) in open one- to two-level TLIF. The benefit of ERAS in specifically frail patients undergoing TLIF has not been demonstrated. Frailty is clinically defined as a syndrome of physiological decline that can predispose patients undergoing surgery to poor outcomes. PURPOSE: This study primarily evaluated the benefit of an ERAS protocol in frail patients undergoing one- or two-level open TLIF compared to frail patients without ERAS. Secondarily, we assessed whether outcomes in frail patients with ERAS approximated those seen in nonfrail patients with ERAS. STUDY DESIGN: Retrospective consecutive patient cohort with controls propensity-matched for age, body mass index, sex, and smoking status. PATIENT SAMPLE: Consecutive patients that underwent one- or two-level open TLIF for degenerative disease from August, 2015 to July, 2021 by a single surgeon. ERAS was implemented in December 2018. OUTCOME MEASURES: Primary outcome measure was return of postoperative physiological function defined as the summation of first day to ambulate, first day to bowel movement, and first day to void. Additional outcome measures included LOS, daily average pain scores, opioid use, discharge disposition, 30-day readmission rate, and reoperation. METHODS: A retrospective analysis of frail patients > 65 years of age undergoing one- to two-level open TLIF post-ERAS were compared to propensity matched frail pre-ERAS patients. Frailty was assessed using the Fried phenotype classification (score >1). Patient demographics, LOS, first-day-to-ambulate (A1), first-day-to-bowel movement (B1), first-day-to-void (V1) were collected. Return of physiological function was defined as A1+B1+V1. Primary analysis was a comparison of frail patients pre-ERAS versus post-ERAS to determine effect of ERAS on return of physiologic function with frailty. Secondary analysis was a comparison of post-ERAS frail versus post-ERAS nonfrail patients to determine if return of physiologic function in frail patients with ERAS approximates that of nonfrail patients. RESULTS: In the primary analysis, 32 frail patients were included with mean age ± standard deviation of 72.8±4.4 years, mean BMI 28.8±5.5, 65.6% were male, 15 pre-ERAS and 17 post-ERAS. Patient characteristics were similar between groups. After ERAS implementation, return of physiological function improved by a mean 3.2 days overall (post-ERAS 3.4 vs. pre-ERAS 6.7 days) (p<.0001), indicating a positive effect of ERAS in frail patients. Additionally, length of stay improved by 1 day (4.8±1.6 vs. 3.8±1.9 days, p<.0001). Total daily intravenous morphine milligram equivalent (MME) as well as average daily pain scores were similar between groups. Secondarily, 26 nonfrail patients post ERAS were used as a comparison group with the 17 post-ERAS frail cohort. Mean age of this cohort was 73.4±4.6 years, mean BMI 27.4±4.9, and 61.9% were male. Return of physiologic function was similar between cohorts (post-ERAS nonfrail 3.5 vs. post-ERAS frail 3.4 days) (p=.938), indicating the benefit with ERAS in frail patients approximates that of nonfrail patients. CONCLUSIONS: ERAS significantly improves return of physiologic function and length of stay in patients with frailty after one- to two-level TLIF, and approximates improved outcomes seen in non-frail patients.

Enhanced recovery after surgery (ERAS) for open transforaminal lumbar interbody fusion: a retrospective propensity-matched cohort study.

BACKGROUND: The enhanced recovery after surgery (ERAS) protocol is a multidisciplinary, multimodal approach which has been shown to facilitate recovery of physiological function, and reduce postoperative pain, complication rates, and length of stay without adversely affecting readmission rates. Design and implementation of ERAS protocols in the recent spine surgery literature has primarily focused on patients undergoing minimally invasive lumbar surgery. However, conventional open transforaminal lumbar interbody fusion (TLIF) remains a common procedure and to date there are no studies assessing an ERAS protocol in this patient population. PURPOSE: This study presents a single surgeon experience implementing an ERAS protocol in patients undergoing 1- or 2-level open TLIF. STUDY DESIGN/SETTING: Retrospective consecutive patient cohort with controls propensity-matched for age, body mass index, sex, and smoking status. PATIENT SAMPLE: Consecutive patients that underwent 1- or 2-level open TLIF for degenerative disease from 12/2018 - 02/2021 and controls from 12/2011-12/2017 by a single surgeon. ERAS was implemented in December 2018. OUTCOME MEASURES: Primary: length of stay; Secondary: first day to ambulate, first day to bowel movement, first day to void, daily average and maximum pain scores, opioid use, discharge disposition, 30-day readmission rate, and re-operations. METHODS: Demographic, perioperative, clinical, radiographic data were collected. Multivariate mixed-linear regression models were developed for length of stay, physiological function, pain scales, and opiate use. RESULTS: There were 114 patients included with 57 in each cohort. After propensity matching, patient characteristics were similar between groups. Operative time decreased significantly after institution of ERAS (170±44 vs. 141±37 minutes, p <.0001) as did length of stay (4.6±1.7 vs. 3.6±1.6 days, p<.0001). First day of ambulation, bowel movement, and bladder voiding improved by 0.8 (p<.0001), 0.7 (p=.008), and 0.8 (p<.0001) days, respectively, in the ERAS cohort. Total daily intravenous morphine milligram equivalent (MME) (8±9 vs. 36±38, p<0.0001) and total 72-hour MME consumption (53±33 vs. 68±48, p<.0001) was significantly lower in the ERAS cohort; however, 72-hour MME consumption was not found to be significantly different in a sensitivity analysis controlling for preoperative MME. Average daily pain scores were similar between groups. CONCLUSIONS: Consistent with other studies demonstrating benefit of an ERAS protocol for minimally invasive spine procedures, ERAS was associated with decreased operative time, reduced length of stay, decrease in IV opioid consumption, and improved physiological outcomes for open 1- and 2-level TLIF. ERAS can be a potentially effective strategy for improving patient outcome and efficiency of healthcare resources for common conventional spinal surgeries such as open TLIF.

Trends in mechanical thrombectomy and decompressive hemicraniectomy for stroke: A multicenter study.

BACKGROUND AND PURPOSE: Acute ischemic stroke has increasingly become a procedural disease following the demonstrated benefit of mechanical thrombectomy (MT) for emergent large vessel occlusion (ELVO) on clinical outcomes and tissue salvage in randomized trials. Given these data and anecdotal experience of decreased numbers of decompressive hemicraniectomies (DHCs) performed for malignant cerebral edema, we sought to correlate the numbers of strokes, thrombectomies, and DHCs performed over the timeline of the 2013 failed thrombolysis/thrombectomy trials, to the 2015 modern randomized MT trials, to post-DAWN and DEFUSE 3. MATERIALS AND METHODS: This is a multicenter retrospective compilation of patients who presented with ELVO in 11 US high-volume comprehensive stroke centers. Rates of tissue plasminogen activator (tPA), thrombectomy, and DHC were determined by current procedural terminology code, and specificity to acute ischemic stroke confirmed by each institution. Endpoints included the incidence of stroke, thrombectomy, and DHC and rates of change over time. RESULTS: Between 2013 and 2018, there were 55,247 stroke admissions across 11 participating centers. Of these, 6145 received tPA, 4122 underwent thrombectomy, and 662 patients underwent hemicraniectomy. The trajectories of procedure rates over time were modeled and there was a significant change in MT rate (p = 0.002) without a concomitant change in the total number of stroke admissions, tPA administration rate, or rate of DHC. CONCLUSIONS: This real-world study confirms an increase in thrombectomy performed for ELVO while demonstrating stable rates of stroke admission, tPA administration and DHC. Unlike prior studies, increasing thrombectomy rates were not associated with decreased utilization of hemicraniectomy.

Patient-Reported Outcomes: Quality of Care on a Neurosurgical Ward.

BACKGROUND AND OBJECTIVES: Patient experience has become a quality measure in hospitals across the United States. To improve our understanding of our neurosurgical patient population's satisfaction needs, we undertook a detailed survey to identify areas of needed improvement. METHODS: Upon institutional review board approval, a detailed survey adopted from the Swedish quality-of-care patient questionnaire was distributed to all patients being discharged from the neurosurgical ward over a month period. From June 2014 to July 2014, all patients admitted to the neurosurgery service through the emergency department, clinic, or other facilities were enrolled. There were no specific inclusion criteria except for age older than 18 years, intact cognition to complete the survey, and return of a completed survey. Data were collected in 6 major categories, including information availability, patient accessibility, treatment received, caring perception, hospital environment, and overall satisfaction. Patients were evaluated by age, gender, surgery, and admission type. RESULTS: Our analysis demonstrated an improved overall satisfaction in those patients being admitted electively from the clinic as compared with emergency department admissions or hospital transfers. In addition, patients admitted on an emergent basis reported a lower satisfaction pertaining to receiving information, specifically test results. CONCLUSIONS: Emergent admissions represent a subpopulation that may require additional strategies to improve patient satisfaction survey scores.

Race and socioeconomic disparity in treatment and outcome of traumatic cervical spinal cord injury with fracture: Nationwide Inpatient Sample database, 1998-2009.

STUDY DESIGN: A retrospective national administrative database study. OBJECTIVE: Advances in treatment of traumatic cervical spinal cord injury with fracture (TCSCIF) have led to significant improvements in clinical outcomes; however, progress in healthcare is seldom ubiquitous across demographic groups. Therefore, we explored if disparities in treatment and outcome after TCSCIF exist across race and socioeconomic status. SETTING: USA. METHODS: We queried the Nationwide Inpatient Sample database from 1998 to 2009 for TCSCIF hospitalizations. Multivariate analysis was used to identify the correlation between socioeconomic status and race to injury, treatment type, and outcome. RESULTS: There were 21,985 admissions for TCSCIF, 66.9% of whom had a favorable discharge disposition. In-hospital mortality rate was 12.5%. A total of 43.7% underwent surgery. Overall, surgery was associated with lower in-hospital mortality (OR 0.30, 95% CI 0.27-0.34, p < 0.01) and better discharge disposition (OR 0.68, 95% CI 0.62-0.74, p < 0.01) versus nonsurgical or no intervention. African-American (AA) race and low socioeconomic status (LSES) were significant predictors of lower odds to undergo surgery and unfavorable discharge disposition, respectively; potentially explained by a higher odds of increased New Injury Severity Score classification at presentation. Surgical and favorable discharge rates for LSES and non-Caucasian races, however, have been steadily improving over the study period. CONCLUSIONS: Despite trending improved outcomes after TCSCIF, LSES, or AA race were more likely to have worse outcomes compared to their counterparts. In addition, LSES, AA, and Hispanic groups were less likely to undergo surgical treatment, suggesting disparities in management and outcome effect.

The effects of new or worsened postoperative neurological deficits on survival of patients with glioblastoma.

OBJECTIVE An increased extent of resection (EOR) has been shown to improve overall survival of patients with glioblastoma (GBM) but has the potential for causing a new postoperative neurological deficit. To investigate the impact of surgical neurological morbidity on survival, the authors performed a retrospective analysis of the clinical data from patients with GBM to quantify the impact of a new neurological deficit on the survival benefit achieved with an increased EOR. METHODS The data from all GBM patients who underwent resection at the University of Florida from 2010 to 2015 with postoperative imaging within 72 hours of surgery were included in the study. Retrospective analysis was performed on clinical outcomes and tumor volumes determined on postoperative and follow-up imaging examinations. RESULTS Overall, 115 patients met the inclusion criteria for the study. Tumor volume at the time of presentation was a median of 59 cm3 (enhanced on T1-weighted MRI scans). The mean EOR (± SD) was 94.2% ± 8.7% (range 59.9%-100%). Almost 30% of patients had a new postoperative neurological deficit, including motor weakness, sensory deficits, language difficulty, visual deficits, confusion, and ataxia. The neurological deficits had resolved in 41% of these patients on subsequent follow-up examinations. The median overall survival was 13.1 months (95% CI 10.9-15.2 months). Using a multipredictor Cox model, the authors observed that increased EOR was associated with improved survival except for patients with smaller tumor volumes (≤ 15 cm3). A residual volume of 2.5 cm3 or less predicted a favorable overall survival. Developing a postoperative neurological deficit significantly affected survival (9.2 months compared with 14.7 months, p = 0.02), even if the neurological deficit had resolved by the first follow-up. However, there was a trend of improved survival among patients with resolution of a neurological deficit by the first follow-up compared with patients with a permanent neurological deficit. Any survival benefit from achieving a 95% EOR was abrogated by the development of a new neurological deficit postoperatively. CONCLUSIONS Developing a new neurological deficit after resection of GBM is associated with a decrease in overall survival. A careful balance between EOR and neurological compromise needs to be taken into account to reduce the likelihood of neurological morbidity from surgery.

Prophylactic Antiepileptic Drug Use in Patients with Brain Tumors Undergoing Craniotomy.

BACKGROUND: Prophylactic use of antiepileptic drugs (AEDs) for patients undergoing brain tumor surgery is common practice despite lack of clear evidence. We hypothesized that prophylactic AED (pAED) use did not affect seizure rates in patients with brain tumor who underwent craniotomy for tumor resection. METHODS: A retrospective review was performed of 606 patients who underwent surgery for brain tumors from 2006 to 2013 at the University of Florida, excluding patients with preexisting seizure condition before tumor diagnosis. Data were analyzed to determine seizure incidence, AED use, and AED toxicities. RESULTS: Most patients (81%) had no seizure on presentation. Eight patients did not present with seizure but had seizure postoperatively, and 9 patients did not present with seizure or have seizure postoperatively but did have seizure on follow-up. Despite not presenting with a seizure preoperatively, 208 patients (43%) were placed on pAED preoperatively, 313 patients (64%) were on AED in the postoperative period, and 274 patients (56%) remained on AED at discharge. The pAED use odds ratio for seizures was 1.3 (95% confidence interval, 0.5-3.4; P = 0.599). At last follow-up, 34% of patients with no seizure on presentation remained on pAEDs. CONCLUSIONS: pAEDs did not significantly reduce postoperative seizures in patients with brain tumor in this analysis. In addition, pAED was often continued once prescribed even if the patient remained seizure free.

Complications After In Vivo and Ex Vivo Autologous Bone Flap Storage for Cranioplasty: A Comparative Analysis of the Literature.

INTRODUCTION: The most common bone flap storage strategies after decompressive hemicraniectomy for malignant intracranial hypertension include freezer cryopreservation (CP) and subcutaneous abdominal implantation (AP). Numerous series have reported on patient outcomes after cranioplasty in terms of infection, cosmesis, and resorption. This meta-analysis compares published outcomes of bone flap CP and subcutaneous storage with respect to efficacy and complication risk in patients undergoing cranioplasty after hemicraniectomy. METHODS: A systematic review was performed using PubMed-searchable studies that included bone flap storage methods and outcome data for cranioplasties performed between 1975 and 2015. RESULTS: A total of 48 studies including 5346 patients were identified that met the inclusion criteria. Of these patients, 4096 underwent cranioplasty with an autologous flap. Mean bone flap storage times for CP and AP flaps were 69.9 and 69.7 days. Mean follow-up time for CP and AP flaps was 16.9 and 16.5 months. No statistically significant differences were found when comparing CP with subcutaneous storage of bone flaps with respect to percentage of patients developing infection (7.3% vs. 7.1%), percentage of patients needing revision surgery (15.9% vs. 7.6%), and percentage of patients experiencing resorption (9.7% vs. 7.7%). CONCLUSIONS: This is the largest and most robust review comparing published outcomes of CP and subcutaneous storage of bone flaps in patients who have undergone decompressive hemicraniectomy. This review found no statistically significant differences in clinical outcomes (infection, resorption, reoperation) when comparing storage methods for bone flap preservation. This study suggests that both strategies may be used safely and successfully.

Neutrophilic dermatosis of the dorsal hands in an elderly man.

recently diagnosed with stage II lung adenocarcinoma, who presented to the clinic with a 14-day history of painful macules that progressed to bullae on the dorsal surface of his hands; decreased range of motion was noted. Examination revealed bilateral small, tender violaceous vesicopustules admixed with larger tense hemorrhagic pus-filled bullae on the dorsal aspect of his hands. Biopsy demonstrated changes consistent with neutrophilic dermatosis of the dorsal hands. The patient had been diagnosed with ulcerative colitis in the 1970s, although the condition was asymptomatic at the time of presentation. Treatment with prednisone 60 mg daily resulted in significant improvement by the next day. This regimen was continued for two weeks and was followed by a 6-week steroid taper. After a review of the approximate 75 cases currently reported, we also discuss the recurrence rate of NDDH of approximately 10%.

Clinical and angiographic outcomes after stent-assisted coiling of cerebral aneurysms with Enterprise and Neuroform stents: a comparative analysis of the literature.

INTRODUCTION: The most widely used intracranial stents for stent-assisted coiling are Neuroform (NEU) and Enterprise stents (ENT). This study compares published outcomes between the ENT and NEU coil-assist systems and comments on the published safety and efficacy of stent-assisted coiling in general. METHODS: A literature search was performed through PubMed for all published series of ENT or NEU stent-assisted coiling of cerebral aneurysms from 2004 to 2014. All studies including 10 or more published cases of stent-assisted coiling with ENT or NEU were included. RESULTS: 47 studies met the inclusion criteria, containing 4238 aneurysms in 4039 patients. 2111 aneurysms were treated with NEU and 2127 were treated with ENT. Mean follow-up was 14.1 months. Overall, thromboembolic events occurred in 6.4% of aneurysms, intracranial hemorrhage (ICH) in 2.6%, permanent morbidity in 3.9%, and mortality in 2.3%. Initial and final 100% angiographic occlusion was seen in 53% and 69% of patients, respectively. Deployment failures (p<0.001), ICH (p=0.001), mortality among all patients (p=0.03), and recanalization (p=0.02) were more commonly reported in NEU treated aneurysms. The ENT system was also associated with higher reported complete occlusion at follow-up (p<0.001). CONCLUSIONS: This literature review represents the largest and most robust comparison of stent-assisted coiling devices to date, containing over 4200 aneurysms in more than 4000 patients. Comparative analyses demonstrate that both devices are reported to be safe and effective with comparable permanent morbidity.

Indirect basal ganglia pathway mediation of repetitive behavior: attenuation by adenosine receptor agonists.

Repetitive behaviors are diagnostic for autism and common in related neurodevelopmental disorders. Despite their clinical importance, underlying mechanisms associated with the expression of these behaviors remain poorly understood. Our lab has previously shown that the rates of spontaneous stereotypy in deer mice (Peromyscus maniculatus) were negatively correlated with enkephalin content, a marker of striatopallidal but not striatonigral neurons. To investigate further the role of the indirect basal ganglia pathway, we examined neuronal activation of the subthalamic nucleus (STN) using cytochrome oxidase (CO) histochemistry in high- and low-stereotypy mice. CO activity in STN was significantly lower in high-stereotypy mice and negatively correlated with the frequency of stereotypy. In addition, exposure to environmental enrichment, which attenuated stereotypy, normalized the activity of STN. Co-administration of the adenosine A(2A) receptor agonist CGS21680 and the A(1) receptor agonist CPA attenuated stereotypy dose-dependently. The significant reduction associated with the lowest dose of the drug combination tested was due to its effects on mice with lower baseline levels of stereotypy. Higher doses of the drug combination were required to show robust behavioral effects, and presumably requisite activation of the indirect pathway, in high-stereotypy mice. These findings support that decreased indirect pathway activity is linked to the expression of high levels of stereotypy in deer mice and that striatal A(1) and A(2A) receptors may provide promising therapeutic targets for the treatment of repetitive behaviors in neurodevelopmental disorders.