Spontaneous intramedullary abscesses caused by Streptococcus anginosus: two case reports and review of the literature.

BACKGROUND: Intramedullary abscesses are rare infections of the spinal cord. Intramedullary abscesses often have a complex presentation, making a high index of suspicion essential for prompt diagnosis and management. CASE PRESENTATION: We present two cases of intramedullary abscesses referred to and ultimately managed at our institution. Delayed diagnosis occurred in both instances due to the rarity of intramedullary abscesses and their propensity to mimic other pathologies. For both patients, prompt surgical management and the rapid institution of broad-spectrum antibiotics were critical in preventing further neurological decline. CONCLUSIONS: Although rare, it is critical to consider intramedullary abscesses on the differential for any MRI lesions that are hyperintense on T2 and peripherally enhancing on T1 post-contrast sequences, as even short delays in treatment can lead to severe neurological damage.

Incidence and Outcomes of Registry-Based Acute Myocardial Infarction After Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: Acute myocardial infarction (AMI) is the rarest and least studied cardiac complication of aneurysmal subarachnoid hemorrhage (aSAH). Precise estimates of the incidence of AMI after aSAH are unavailable. Our goal was to estimate the incidence of registry-based AMI (rb-AMI) after aSAH and determine its association with clinical outcomes. METHODS: Adult patients with aSAH in the National Inpatient Samples from 2002 to 2014 were included in the study. We evaluated risk factors for rb-AMI using univariate and multivariate regression models. Clinical outcomes that were assessed included functional status at discharge, in-patient mortality, length of stay, and total hospitalization cost, adjusting for patient demographics and cardiovascular risk factors through an inverse probability weighted analysis. Subgroup analyses were further performed stratified by rb-AMI type (ST-segment elevation myocardial infarction [STEMI] vs. non-STEMI [NSTEMI]). RESULTS: A total of 139,734 patients with aSAH were identified, 3.6% of whom had rb-AMI. NSTEMI was the most common type of rb-AMI occurring after aSAH (71% vs. 29% for NSTEMI vs. STEMI, respectively). Patient characteristics associated with higher odds of rb-AMI included age, female sex, poor aSAH grade, and various cardiovascular risk factors. Rb-AMI was also associated with poor functional status at discharge, higher in-hospital mortality, and a longer and more costly hospital stay. CONCLUSIONS: Rb-AMI occurs in 3.6% of patients with aSAH and is associated with poor functional status at discharge, higher in-patient mortality, and a longer and more costly hospitalization. Differentiating between different types of rb-AMI would be important in optimizing the management of patients with aSAH. Our definition of rb-AMI likely includes patients with neurogenic stress cardiomyopathy, which may confound the results.

Minimally invasive versus open surgery for the correction of adult degenerative scoliosis: a systematic review.

While open surgery has been the primary surgical approach for adult degenerative scoliosis, minimally invasive surgery (MIS) represents an alternative option and appears to be associated with reduced morbidity. Given the lack of consensus, we aimed to conduct a systematic review on available literature comparing MIS versus open surgery for adult degenerative scoliosis. PubMed, Embase, and Cochrane databases were searched through December 16, 2019, for studies that compared both MIS and open surgery in patients with degenerative scoliosis. Four cohort studies reporting on 350 patients met the inclusion criteria. In two studies, patients undergoing open surgery were younger and had more severe disease at baseline as compared with MIS. Patients who underwent MIS had less blood loss, shorter length of stay, and a reduced rate of complications and infections. Both MIS and open surgery resulted in a significant change in pain and disability scores and both approaches provided significant correction of deformity in all studies, although open surgery was associated with a greater change in pelvic incidence-lumbar lordosis mismatch (PI-LL) and sagittal vertical axis (SVA) in two and three studies, respectively. In patients with adult degenerative scoliosis undergoing surgery, both MIS and open approaches appeared to offer comparable improvements in pain and function. However, MIS was associated with better safety outcomes, while open surgery provided greater correction of spinal deformity. Further studies are needed to identify specific subset of patients who may benefit from one approach versus the other.

Seizure Outcomes After Interventional Treatment in Cerebral Arteriovenous Malformation-Associated Epilepsy: A Systematic Review and Meta-Analysis.

BACKGROUND: Seizures are the second most common presenting symptom of cerebral arteriovenous malformations (AVMs). Evidence supporting different treatment modalities is continuously evolving and it remains unclear which modality offers better seizure outcomes. OBJECTIVE: To compare various interventional treatment modalities (i.e., microsurgery, radiosurgery, endovascular embolization, or multimodality treatment), regarding outcomes in AVM-associated epilepsy. METHODS: PubMed, Embase, and Web of Science were searched on December 31, 2020 for studies that evaluated outcomes in patients with AVM-associated epilepsy after undergoing different treatment modalities. Pooled analysis was performed using a random-effects model and stratified by different modalities. RESULTS: Forty-nine studies including 2668 patients were included. Interventional management was associated with a 56.0% probability of seizure freedom and a 73.0% probability of seizure improvement. The probability of discontinuing antiepileptic drugs was estimated at 38.0%. The stratified analysis showed that microsurgery was associated with a higher probability of seizure freedom and seizure improvement than was radiosurgery, endovascular, or multimodality treatment. The probability of antiepileptic drug cessation was also higher after microsurgery compared with radiation therapy; however, only clinical but not statistical significance could be inferred because of the lack of comparative analyses. CONCLUSIONS: Interventional management of AVM-related epilepsy was associated with seizure freedom and seizure improvement in 56% and 73% of cases. Microsurgery seemed to be associated with a higher incidence of seizure freedom and seizure improvement than did other modalities. Future well-designed comparative studies are needed to draw definitive conclusions regarding each modality.

Therapeutic cancer vaccines for pediatric malignancies: advances, challenges, and emerging technologies.

Though outcomes for pediatric cancer patients have significantly improved over the past several decades, too many children still experience poor outcomes and survivors suffer lifelong, debilitating late effects after conventional chemotherapy, radiation, and surgical treatment. Consequently, there has been a renewed focus on developing novel targeted therapies to improve survival outcomes. Cancer vaccines are a promising type of immunotherapy that leverage the immune system to mediate targeted, tumor-specific killing through recognition of tumor antigens, thereby minimizing off-target toxicity. As such, cancer vaccines are orthogonal to conventional cancer treatments and can therefore be used alone or in combination with other therapeutic modalities to maximize efficacy. To date, cancer vaccination has remained largely understudied in the pediatric population. In this review, we discuss the different types of tumor antigens and vaccine technologies (dendritic cells, peptides, nucleic acids, and viral vectors) evaluated in clinical trials, with a focus on those used in children. We conclude with perspectives on how advances in combination therapies, tumor antigen (eg, neoantigen) selection, and vaccine platform optimization can be translated into clinical practice to improve outcomes for children with cancer.

Expandable Versus Static Cages in Minimally Invasive Lumbar Interbody Fusion: A Systematic Review and Meta-Analysis.

BACKGROUND: Expandable cages for interbody fusion allow for in situ expansion optimizing fit while mitigating endplate damage. Studies comparing outcomes after using expandable or static cages have been conflicting. METHODS: This was a meta-analysis A systematic search was performed in accordance with the Preferred Reporting Items for Systemic Reviews and Meta-Analyses (PRISMA) guidelines identifying studies reporting outcomes among patients who underwent minimally invasive lumbar interbody fusion (MIS-LIF). RESULTS: Fourteen articles with 1129 patients met inclusion criteria. Compared with MIS-LIFs performed with static cages, those with expandable cages had a significantly lower incidence of graft subsidence (expandable: incidence 0.03, I2 22.50%; static: incidence 0.27, I2 51.03%, P interaction <0.001), length of hospital stay (expandable: mean difference [MD] 3.55 days, I2 97%; static: MD 7.1 days, I2 97%, P interaction <0.01), and a greater increase in disc height (expandable: MD -4.41 mm, I2 99.56%; static: MD -0.79 mm, I2 99.17%, P interaction = 0.02). There was no statistically significant difference among Oswestry Disability Index (expandable: MD -22.75, I2 98.17%; static: MD -17.11, I2 95.26%, P interaction = 0.15), fusion rate (expandable: incidence 0.94, I2 0%; static incidence 0.92, I2 0%, P interaction = 0.44), overall change in lumbar lordosis (expandable: MD 3.48 degrees, I2 59.29%; static: MD 3.67 degrees, I2 0.00%, P interaction 0.88), blood loss (expandable: MD 228.9 mL, I2 100%; static: MD 261.1 mL, I2 94%, P interaction = 0.69) and operative time (expandable: MD 184 minutes, I2 95.32%; static: MD 150.4 minutes, I2 91%, P interaction = 0.56). CONCLUSIONS: Expandable interbody cages in MIS-LIF were associated with a decrease in subsidence rate, operative time and greater in increase in disc height.

Insulin in the Management of Acute Ischemic Stroke: A Systematic Review and Meta-Analysis.

OBJECTIVE: The role of tight glycemic control in the management of acute ischemic stroke remains uncertain. Our goal is to evaluate the effects of tight glucose control with insulin therapy after acute ischemic stroke. METHODS: We searched PubMed, CENTRAL, and Embase for randomized controlled trials (RCTs) that evaluated the effects of tight glycemic control (70-135 mg/dL) in acute ischemic stroke. Analysis was performed using fixed-effects and random-effects models. Outcomes were death, independence, and modified Rankin Scale (mRS) score at ≥90 days follow-up, and symptomatic or severe hypoglycemia during treatment. RESULTS: Twelve RCTs including 2734 patients were included. Compared with conventional therapy or placebo, tight glycemic control was associated with similar rates of mortality at ≥90 days follow-up (pooled odds ratio [pOR], 0.99; 95% confidence interval [CI], 0.79-1.22]; I2 = 0%), independence at ≥90 days follow-up (pOR, 0.95; 95% CI, 0.79-1.14; I2 = 0%) and mRS scores at ≥90 days follow-up (standardized mean difference, 0.014; 95% CI, -0.15 to 0.17; I2 = 0%). In contrast, tight glycemic control was associated with increased rates of symptomatic or severe hypoglycemia during treatment (pOR, 5.2; 95% CI, 1.7-15.9; I2 = 28%). CONCLUSIONS: Tight glucose control after acute ischemic stroke is not associated with improvements in mortality, independence, or mRS score and leads to higher rates of symptomatic or severe hypoglycemia.

Surgical management of ossification of the posterior longitudinal ligament in the cervical spine.

OPLL is a progressive process that can result in spinal cord compression and myelopathy. Various surgical approaches for the management of OPLL in the cervical spine exist. Our goal is to present our institution's experience in the management of OPLL over the last 20 years. Sixty-eight patients underwent surgery for cervical OPLL. Mean age at surgery was 56.9 years. No differences between demographic characteristics and surgical approach were identified. There were no significant differences between the approaches regarding the mean estimated blood loss, occurrence of durotomy, reoperation rate, positive K-line and preoperative cervical spine sagittal balance. Number of levels operated on was significantly different (anterior approach 2 ± 0.8 levels, posterior approach 4.3 ± 1.3 levels, combined approach 3.3 ± 0.9 levels, p-value <0.01), but postoperative sagittal balance was not (anterior approach Cobb angle 11.9 ± 5.8 degrees, posterior approach Cobb angle 7 ± 3.5 degrees, combined approach Cobb angle 16.7 ± 7.3 degrees, p-value = 0.09). Functional outcomes were good for 70% of patients and did not significantly differ across approaches (anterior approach 28%, posterior approach 33%, combined approach 9%, p-value = 0.46). Good functional outcomes were more commonly observed in patients with a positive K-line (OR 0.2, 95% CI 0.04-0.9, p-value 0.05) while poor outcomes were most commonly observed in patients with an occupational ratio >0.6 (OR 6.9, 95% CI 1.35-42.7, p-value 0.02). OPLL is a rare disease for which prompt referral for surgical decompression may lead to good clinical outcomes.

The safety and efficacy of steroid treatment for acute spinal cord injury: A Systematic Review and meta-analysis.

INTRODUCTION: The role for steroids in acute spinal cord injury (ASCI) remains unclear; while some studies have demonstrated the risks of steroids outweigh the benefits,a meta-analyses conducted on heterogeneous patient populations have shown significant motor improvement at short-term but not at long-term follow-up. Given the heterogeneity of the patient population in previous meta-analyses and the publication of a recent trial not included in these meta-analyses, we sought to re-assess and update the safety and short-term and long-term efficacy of steroid treatment following ASCI in a more homogeneous patient population. MATERIALS AND METHODS: A literature search was conducted on PubMed, EMBASE and Cochrane Library through June 2019 for studies evaluating the utility of steroids within the first 8 h following ASCI. Neurological and safety outcomes were extracted for patients treated and not treated with steroids. Pooled effect estimates were calculated using the random-effects model. RESULTS: Twelve studies, including five randomized controlled trials (RCTs) and seven observational studies (OBSs), were meta-analyzed. Overall, methylprednisolone was not associated with significant short-term or long-term improvements in motor or neurological scores based on RCTs or OBSs. An increased risk of hyperglycemia was shown in both RCTs (RR: 13.7; 95% CI: 1.93, 97.4; 1 study) and OBSs (RR: 2.9; 95% CI: 1.55, 5.41; 1 study). Risk for pneumonia was increased with steroids; while this increase was not statistically significant in the RCTs (pooled RR: 1.16; 95% C.I: 0.59, 2.29; 3 studies), it reached statistical significance in the OBSs (pooled RR: 2.00; 95% C.I: 1.32, 3.02; 6 studies). There was no statistically significant increased risk of gastrointestinal bleeding, decubitus ulcers, surgical site infections, sepsis, atelectasis, venous thromboembolism, urinary tract infections, or mortality among steroid-treated ASCI patients compared to untreated controls in either RCTs or OBSs. CONCLUSIONS: Methylprednisolone therapy within the first 8 h following ASCI failed to show a statistically significant short-term or long-term improvement in patients' overall motor or neurological scores compared to controls who were not administered steroids. For the same comparison, there was an increased risk of pneumonia and hyperglycemia compared to controls. Routine use of methylprednisone following ASCI should be carefully considered in the context of these results.

Bilateral Synovial Cysts as a Rare Cause of Myelopathy in a 38-year-old Woman.

Synovial cysts are rare, and they occur even more rarely bilaterally or in the cervical spine. A 38-year-old previously healthy female presented with acute onset of numbness and tingling down her arms and weakness in her legs, which progressed steadily over 2-3 weeks to include significant gait disturbance. She denied bowel or bladder symptoms, saddle anesthesia, night sweats, weight loss, fever, or chills. MRI spine revealed a C7-T1 extradural mass consistent with bilateral synovial cysts emanating from bilateral neuroforamina resulting in critical spinal cord compression with T2 signal change in the cord. There was questionable patch enhancement after gadolinium contrast. The patient underwent C7-T1 laminectomies and partial bilateral medial facetectomies with excision of the cysts. Intraoperative cultures unexpectedly grew Staphylococcus aureus, suggesting superinfection of cysts. The patient recovered neurologic function postoperatively and was discharged on a 6-week course of IV antibiotics. We report and discuss the clinical presentation, pathogenesis, and neuroradiological findings in an adult case of bilateral synovial cysts at the C-T-spine junction. Immediate resection at symptom onset is indicated due to the good clinical outcome following resection and the real risk of paralysis if cysts are not excised in a timely fashion.

The Safety and Efficacy of Tranexamic Acid in Adult Spinal Deformity Surgery: A Systematic Review and Meta-Analysis.

OBJECTIVES: Major spinal corrective surgeries can be associated with critical intra-operative blood loss. The objective of this systematic review and meta-analysis was to assess the safety and efficacy of tranexamic acid (TXA), a commonly used antifibrinolytic agent, in adult spinal deformity (ASD) surgery, defined as fusion of five or more levels. METHODS: Articles from PubMed, Embase, Cochrane, and clinicaltrials.gov were screened using PRISMA guidelines through December 2018. Thromboembolic events, blood loss, and transfusion levels were primary outcomes of interest. Randomized controlled trials (RCTs) and observational studies (OBSs) with adult patients (≥ 18 years) were included. Continuous variables were analyzed using mean difference (MD) and categorical variables were analyzed using Peto odds ratio (OR), via random effects models. RESULTS: Of the 604 articles screened, seven studies (two RCTs and five cohort studies) were included. Incidence of thromboembolic events was not statistically significantly different between TXA (1 event/19) and placebo (0 events/13) in the RCT (Peto OR = 1.41, 95% CI 0.05-37.2; 32 patients; 1 study) and in the OBSs (TXA [2 events/135] vs control [0 events/72]; Peto OR = 1.09, 95% CI 0.16-7.61; p-heterogeneity = 0.85; 207 patients; 3 studies). Data from OBSs showed that the pooled MD was statistically significantly lower in the TXA group compared with the control group for intraoperative blood loss (MD: - 620.2 mL, 95% CI - 1066.6 to - 173.7; p-heterogeneity = 0.14; 228 patients; 4 studies) and total transfusion volume (MD: - 958.2 mL, 95% CI - 1867.5 to - 49.0; p-heterogeneity = 0.23; 93 patients; 2 studies). CONCLUSION: In this meta-analysis, TXA was not significantly associated with increased risk of thromboembolic events but was associated with lower intraoperative blood loss and lower total transfusion volumes in ASD surgery.

Insulin-associated neuroinflammatory pathways as therapeutic targets for traumatic brain injury.

Traumatic brain injury (TBI) is characterized by an abrupt blow or exchange of force against the head and can be categorized as mild, moderate, and severe. The secondary cell death after TBI displays ischemic-like patterns including neuroinflammation. The scavenger receptor cluster of differentiation (CD) 36 is a lipid-associated protein capable of transducing intracellular signals to promote inflammatory mechanisms within different cell types. Expression and activation of CD36 is closely related to dyslipidemia secondary to diabetes. Diabetes mellitus (DM) has been documented as a co-morbidity factor in TBI, in that patients with a history of diabetes present with more severe brain damage and slower recovery from TBI than non-diabetic patients. Indeed, a strict regulation of blood serum glucose by the use of insulin promotes a better outcome for TBI patients. Based on these recent findings, we now advance the hypothesis that CD36 via DM insulin-associated pathways is closely involved in TBI chronic pathology.