Does the presence of cervical deformity in patients with baseline mild myelopathy increase operative urgency in adult cervical spinal surgery? A retrospective analysis.

OBJECTIVE: The objective of this study was to assess whether delaying surgical management of cervical deformity (CD) in patients with concomitant mild myelopathy increases the risk of suboptimal outcomes. METHODS: Patients aged ≥ 18 years who had a baseline diagnosis of mild myelopathy with baseline and up to 2 years of postoperative data were assessed. Patients were categorized as having CD (CD+) or not (CD-) at baseline. Patients with symptoms of myelopathy for more than 1 year after the initial visit prior to surgery were considered delayed. Clinical and radiographic data were assessed using means comparison analyses. Multivariate regression analysis assessed correlations between increasing time to surgery and peri- and postoperative outcomes adjusted for baseline age and frailty score. Backstep logistic regression analysis assessed the risk of complications or reoperation, while controlling for baseline T1 slope minus cervical lordosis (TS-CL). RESULTS: One hundred six patients were included (mean age 58.11 ± 11.97 years, 48% female, mean BMI 29.13 ± 6.89). Of the patients with baseline mild myelopathy, 22 (20.8%) were CD- while 84 (79.2%) were CD+. Overall, 9.5% of patients were considered to have delayed surgery. Linear regression revealed that both CD- and CD+ patients were more likely to require reoperation when there was more time between the initial visit and surgical admission (p < 0.001). Additionally, an adjusted logistic regression indicated that CD+ patients who had a greater length of time to surgery had a higher likelihood for major complications (p < 0.001). Conversely, CD+ patients who were operated on within 30 days of the initial visit had a significantly lower risk for a major complication (OR 0.901, 95% CI 0.889-1.105, p = 0.043), and a lower risk for reoperation (OR 0.954, 95% CI 0.877-1.090, p = 0.043), while controlling for the severity of deformity based on baseline TS-CL. CONCLUSIONS: The findings of this study demonstrate that a delay in surgery after the initial visit significantly increases the risk for major complications and reoperation in patients with CD with associated mild baseline myelopathy. Early operative treatment in this patient population may lower the risk of postoperative complications.

Instrumented arthrodesis for non-traumatic craniocervical instability in very young children.

PURPOSE: Occipitocervical instrumentation is infrequently required for stabilization of the axial and subaxial cervical spine in very young children. However, when it is necessary, unique surgical considerations arise in children when compared with similar procedures in adults. METHODS: The authors reviewed literature describing fusion of the occipitocervical junction (OCJ) in toddlers and share their experience with eight cases of young children (age less than or equal to 4 years) receiving occiput to axial or subaxial spine instrumentation and fixation. Diagnoses and indications included severe or secondary Chiari malformation, skeletal dysplastic syndromes, Klippel-Feil syndrome, Pierre Robin syndrome, Gordon syndrome, hemivertebra and atlantal occipitalization, basilar impression, and iatrogenic causes. RESULTS: All patients underwent occipital bone to cervical spine instrumentation and fixation at different levels. Constructs extended from the occiput to C2 and T1 utilizing various permutations of titanium rods, autologous rib autografts, Mersilene sutures, and combinations of autografts with bone matrix materials. All patients were placed in rigid cervical bracing or halo fixation postoperatively. No postoperative neurological deficits or intraoperative vascular injuries occurred. CONCLUSION: Instrumented arthrodesis can be a treatment option in very young children to address the non-traumatic craniocervical instability while reducing the need for prolonged external halo vest immobilization. Factors affecting fusion are addressed with respect to preoperative, intraoperative, and postoperative decision-making that may be unique to the toddler population.

Risk Factors for Wound Infections after Deformity Correction Surgery in Neuromuscular Scoliosis.

OBJECTIVE: This study aims to elucidate surgical risk factors in neuromuscular scoliosis (NMS) with respect to wound site infection after spinal fusion. METHODS: A retrospective review was performed of all patients treated surgically for NMS between January 2008 and December 2016 (minimum 6 months' follow-up). A sub-cohort of 60 patients with minimum 2 years of follow-up data was also analyzed. RESULTS: In 102 patients (53 boys and 49 girls), the mean age at surgery was 14.0 years (SD ±2.7). Mean follow-up was 2.53 years (±1.66), and mean time to presentation of infection was 2.14 months (±4.95). The overall perioperative complication rate was 26.5%, with 14.7% of patients developing deep wound infection. Gram-negative bacteria were responsible for 60% of infections; 20% were Gram positive, and 20% involved both types. Pulmonary comorbidities (p = 0.007), pre- to postoperative increase in weight (p = 0.010), exaggerated lumbar lordosis at follow-up (p = 0.008), history of seizures (p = 0.046), previous myelomeningocele repair (p = 0.046), and previous operations (p = 0.013) were significant risk factors for infection. CONCLUSION: Our data suggest that in the pediatric population treated surgically for NMS, wound infection is strongly associated with postoperative increase in body weight, residual lumbar lordosis, pulmonary comorbidity, history of myelomeningocele repair, seizures, and previous operations.

Increased tolerance to stress in cardiac expressed gain-of-function of adenosine triphosphate-sensitive potassium channel subunit Kir6.1.

BACKGROUND: The adenosine triphosphate-sensitive potassium (KATP) channel opener diazoxide (DZX) prevents myocyte volume derangement and reduced contractility secondary to stress. KATP channels are composed of pore-forming (Kir6.1 or Kir6.2) and regulatory (sulfonylurea receptor, SUR1 or SUR2) subunits. Gain of function (GOF) of Kir6.1 subunits has been implicated in cardiac pathology in Cantu syndrome in humans (cardiomegaly, lymphedema, and pericardial effusions). We hypothesized that GOF of Kir6.1 subunits would result in altered myocyte response to stress. MATERIALS AND METHODS: Isolated cardiac myocytes from wild type (WT) and transgenic Kir6.1GOF mice were exposed to Tyrode's physiologic solution for 20 min, test solution (Tyrode's or stress [hyperkalemic cardioplegia {CPG, known myocyte stress}] +/- KATP channel opener DZX), followed by Tyrode's for 20 min. Myocyte volume and contractility were measured and compared. RESULTS: WT myocytes demonstrated significant swelling in response to stress, but significantly less swelling was seen in Kir6.1GOF myocytes. DZX prevented swelling secondary to CPG in WT but resulted in a nonsignificant reduction in swelling in Kir6.1GOF myocytes. Both WT and Kir6.1GOF myocytes demonstrated a reduction in contractility during stress, although this was only significant in Kir6.1GOF myocytes. DZX was not associated with an improvement in contractility in Kir6.1GOF myocytes following stress. CONCLUSIONS: Similar to previous results in Kir6.1(-/-) myocytes, Kir6.1GOF myocytes demonstrate resistance (less volume derangement) to stress of cardioplegia. Understanding the role of Kir6.1 in myocyte response to stress may aid in the treatment of patients with Cantu syndrome and warrants further investigation.

Metastasectomy for extracalvarial renal cell carcinoma.

Key Clinical Message: Palliative surgical resection of extra-calvarial metastatic lesions from renal cell tumors is crucial for controlling metastatic spread, improving quality of life, and preventing associated morbidity. Careful surgical planning, including selective preoperative embolization and controlled resection around critical structures such as the sagittal sinus, is essential for successful outcomes. Cranioplasty with Titanium mesh and bone cement post-resection can provide symptomatic relief, better cosmesis, and overall improved quality of life. Abstract: Renal cell carcinomas are aggressive tumors with distant systemic disease. The calvarium appears to be an unusual and rare site for distant metastasis. The treatment modalities are challenging and out of the normal realm for the management of these tumors. We report a case of a 63-year-old woman with a previous history of nephrectomy who presented with symptoms of severe headaches, and swelling of bi-frontal and bi-parietal scalp regions due to multifocal extracalvarial disease. Preoperative bilateral superficial temporal artery embolization was performed to control the intraoperative bleeding. Surgical technique has been described with the critical steps involved, and a literature review has been conducted. Palliative tumor resection surgery was performed to improve the patient's quality of life as well as to confirm the histopathological diagnosis. Gross total resection of the extracalvarial metastatic tumor was achieved. Biopsy confirmed renal cell tumor with the clear cell subtype. The patient recovered well from her surgery with slow healing of the scalp wound. At 6-month follow-up, no recurrence of the extracalvarial disease was observed on serial imaging. Extracalvarial metastasis is a rare presentation in renal cell carcinoma. Considering the inherent radioresistant nature of the tumor, palliative surgical resection can be offered to control the metastatic spread, relieve agonizing pain symptoms, and to improve the quality of life. Preoperative embolization helps to decrease intraoperative blood loss. Moreover, palliative surgical resection of extracalvarial diseases helps to treat the metastasis as well as avoiding the associated morbidity that may occur if left untreated.

Mapping the geographic migration of United States neurosurgeons across training and current practice regions: associations with academic productivity.

OBJECTIVE: Characterizing changes in the geographic distribution of neurosurgeons in the United States (US) may inform efforts to provide a more equitable distribution of neurosurgical care. Herein, the authors performed a comprehensive analysis of the geographic movement and distribution of the neurosurgical workforce. METHODS: A list containing all board-certified neurosurgeons practicing in the US in 2019 was obtained from the American Association of Neurological Surgeons membership database. Chi-square analysis and a post hoc comparison with Bonferroni correction were performed to assess differences in demographics and geographic movement throughout neurosurgeon careers. Three multinomial logistic regression models were performed to further evaluate relationships among training location, current practice location, neurosurgeon characteristics, and academic productivity. RESULTS: The study cohort included 4075 (3830 male, 245 female) neurosurgeons practicing in the US. Seven hundred eighty-one neurosurgeons practice in the Northeast, 810 in the Midwest, 1562 in the South, 906 in the West, and 16 in a US territory. States with the lowest density of neurosurgeons included Vermont and Rhode Island in the Northeast; Arkansas, Hawaii, and Wyoming in the West; North Dakota in the Midwest; and Delaware in the South. Overall, the effect size, as measured by Cramér's V statistic, between training stage and training region is relatively modest at 0.27 (1.0 is complete dependence); this finding was reflected in the similarly modest pseudo R2 values of the multinomial logit models, which ranged from 0.197 to 0.246. Multinomial logistic regression with L1 regularization revealed significant associations between current practice region and residency region, medical school region, age, academic status, sex, or race (p < 0.05). On subanalysis of the academic neurosurgeons, the region of residency training correlated with an advanced degree type in the overall neurosurgeon cohort, with more neurosurgeons than expected holding Doctor of Medicine and Doctor of Philosophy degrees in the West (p = 0.021). CONCLUSIONS: Female neurosurgeons were less likely to practice in the South, and neurosurgeons in the South and West had reduced odds of holding academic rather than private positions. The Northeast was the most likely region to contain neurosurgeons who had completed their training in the same locality, particularly among academic neurosurgeons who did their residency in the Northeast.

Long-term Morbidity in Patients After Surgical Correction of Adult Spinal Deformity: Results From a Cohort With Minimum 5-year Follow-up.

STUDY DESIGN: Retrospective. OBJECTIVE: The objective of this study is to describe the rate of postoperative morbidity before and after two-year (2Y) follow-up for patients undergoing surgical correction of adult spinal deformity (ASD). SUMMARY OF BACKGROUND DATA: Advances in modern surgical techniques for deformity surgery have shown promising short-term clinical results. However, the permanence of radiographic correction, mechanical complications, and revision surgery in ASD surgery remains a clinical challenge. Little information exists on the incidence of long-term morbidity beyond the acute postoperative window. METHODS: ASD patients with complete baseline and five-year (5Y) health-related quality of life and radiographic data were included. The rates of adverse events, including proximal junctional kyphosis (PJK), proximal junctional failure (PJF), and reoperations up to 5Y were documented. Primary and revision surgeries were compared. We used logistic regression analysis to adjust for demographic and surgical confounders. RESULTS: Of 118 patients eligible for 5Y follow-up, 99(83.9%) had complete follow-up data. The majority were female (83%), mean age 54.1 years and 10.4 levels fused and 14 undergoing three-column osteotomy. Thirty-three patients had a prior fusion and 66 were primary cases. By 5Y postop, the cohort had an adverse event rate of 70.7% with 25 (25.3%) sustaining a major complication and 26 (26.3%) receiving reoperation. Thirty-eight (38.4%) developed PJK by 5Y and 3 (4.0%) developed PJF. The cohort had a significantly higher rate of complications (63.6% vs. 19.2%), PJK (34.3% vs. 4.0%), and reoperations (21.2% vs. 5.1%) before 2Y, all P <0.01. The most common complications beyond 2Y were mechanical complications. CONCLUSIONS: Although the incidence of adverse events was high before 2Y, there was a substantial reduction in longer follow-up indicating complications after 2Y are less common. Complications beyond 2Y consisted mostly of mechanical issues.

Natural history of adult spinal deformity: how do patients with suboptimal surgical outcomes fare relative to nonoperative counterparts?

OBJECTIVE: Management of adult spinal deformity (ASD) has increasingly favored operative intervention; however, the incidence of complications and reoperations is high, and patients may fail to achieve idealized postsurgical results. This study compared health-related quality of life (HRQOL) metrics between patients with suboptimal surgical outcomes and those who underwent nonoperative management as a proxy for the natural history (NH) of ASD. METHODS: ASD patients with 2-year data were included. Patients who were offered surgery but declined were considered nonoperative (i.e., NH) patients. Operative patients with suboptimal outcome (SOp)-defined as any reoperation, major complication, or ≥ 2 severe Scoliosis Research Society (SRS)-Schwab modifiers at follow-up-were selected for comparison. Propensity score matching (PSM) on the basis of baseline age, deformity, SRS-22 Total, and Charlson Comorbidity Index score was used to match the groups. ANCOVA and stepwise logistic regression analysis were used to assess outcomes between groups at 2 years. RESULTS: In total, 441 patients were included (267 SOp and 174 NH patients). After PSM, 142 patients remained (71 SOp 71 and 71 NH patients). At baseline, the SOp and NH groups had similar demographic characteristics, HRQOL, and deformity (all p > 0.05). At 2 years, ANCOVA determined that NH patients had worse deformity as measured with sagittal vertical axis (36.7 mm vs 21.3 mm, p = 0.025), mismatch between pelvic incidence and lumbar lordosis (11.9° vs 2.9°, p < 0.001), and pelvic tilt (PT) (23.1° vs 20.7°, p = 0.019). The adjusted regression analysis found that SOp patients had higher odds of reaching the minimal clinically important differences in Oswestry Disability Index score (OR [95% CI] 4.5 [1.7-11.5], p = 0.002), SRS-22 Activity (OR [95% CI] 3.2 [1.5-6.8], p = 0.002), SRS-22 Pain (OR [95% CI] 2.8 [1.4-5.9], p = 0.005), and SRS-22 Total (OR [95% CI] 11.0 [3.5-34.4], p < 0.001). CONCLUSIONS: Operative patients with SOp still experience greater improvements in deformity and HRQOL relative to the progressive radiographic and functional deterioration associated with the NH of ASD. The NH of nonoperative management should be accounted for when weighing the risks and benefits of operative intervention for ASD.

Retrospective analysis of open surgical versus laser interstitial thermal therapy callosotomy in pediatric patients with refractory epilepsy.

OBJECTIVE: Corpus callosotomy remains an established surgical treatment for certain types of medically refractory epilepsy in pediatric patients. While the traditional surgical approach is often well tolerated, the advent of MR-guided laser interstitial thermal therapy (LITT) provides a new opportunity to ablate the callosal body in a minimally invasive fashion and minimize the risks associated with an open interhemispheric approach. However, the literature is sparse regarding the comparative efficacy and safety profiles of open corpus callosotomy (OCC) and LITT callosotomy. To this end, the authors present a novel retrospective analysis comparing the efficacy and safety of these methods. METHODS: Patients who underwent OCC and LITT callosotomy during the period from 2005 to 2018 were included in a single-center retrospective analysis. Patient demographic and procedural variables were collected, including length of stay, procedural blood loss, corticosteroid requirements, postsurgical complications, and postoperative disposition. Pre- and postoperative seizure frequency (according to seizure type) were recorded. RESULTS: In total, 19 patients, who underwent 24 interventions (16 OCC and 8 LITT), were included in the analysis. The mean follow-up durations for the OCC and LITT cohorts were 83.5 months and 12.3 months, respectively. Both groups experienced reduced frequencies of seizure and drop attack frequency postoperatively. Additionally, LITT callosotomy was associated with a significant decrease in estimated blood loss and decreased length of pediatric ICU stay, with a trend of shorter length of hospitalization. CONCLUSIONS: Longer-term follow-up and a larger population are required to further delineate the comparative efficacies of LITT callosotomy and OCC for the treatment of pediatric medically refractory epilepsy. However, the authors' data demonstrate that LITT shows promise as a safe and effective alternative to OCC.

Soft Landing technique as a possible prevention strategy for proximal junctional failure following adult spinal deformity surgery.

BACKGROUND: This cross sectional study describes a "Soft Landing" strategy utilizing hooks for minimizing proximal junctional kyphosis (PJK) and proximal junctional failure (PJF). The technique creates a gradual transition from a rigid segmental construct to unilateral hooks at the upper instrumented level and preservation of the soft tissue attachments on the contralateral side of the hooks. Authors devise a novel classification system for better grading of PJK severity. METHODS: Thirty-nine consecutive adult spinal deformity (ASD) patients at a single institution received the "Soft Landing" technique. The proximal junctional angle was measured preoperatively and at last follow-up using standing 36-inch spinal radiographs. Changes in proximal junctional angle and rates of PJK and PJF were measured and used to create a novel classification system for evaluating and categorizing ASD patients postoperatively. RESULTS: The mean age of the cohort was 61.4 years, and 90% of patients were women. Average follow up was 2.2 years. The mean change in proximal junctional angle was 8° (SD 7.4°) with the majority of patients (53%) experiencing less than 10° and only 1 patients with proximal junctional angle over 20°. Four patients (10%) needed additional surgery for proximal extension of the uppermost instrumented vertebra (UIV) secondary to PJF. CONCLUSIONS: Soft Landing technique is a possibly effective treatment strategy to prevent PJK and PJF following ASD that requires further evaluation. The described classification system provides management framework for better grading of PJK. The "Soft Landing" technique warrants further comparison to other techniques currently used to prevent both PJK and failure.

Risk Factors for Proximal Junctional Kyphosis Following Surgical Deformity Correction in Pediatric Neuromuscular Scoliosis.

STUDY DESIGN: Single-center retrospective cohort analysis. OBJECTIVE: The aim of this study was to evaluate risk factors associated with the development of proximal junctional kyphosis (PJK) in pediatric neuromuscular scoliosis (NMS). SUMMARY OF BACKGROUND DATA: PJK is a common cause of reoperation in adult deformity but has been less well reported in pediatric NMS. METHODS: Sixty consecutive pediatric patients underwent spinal fusion for NMS with a minimum 2-year follow-up. PJK was defined as >10° increase between the inferior end plate of the upper instrumented vertebra (UIV) and the superior end plate of the vertebra two segments above. Regression analyses as well as binary correlational models and Student t tests were employed for further statistical analysis assessing variables of primary and compensatory curve magnitudes, thoracic kyphosis, proximal kyphosis, lumbar lordosis, pelvic obliquity, shoulder imbalance, Risser classification, and sagittal profile. RESULTS: The present cohort consisted of 29 boys and 31 girls with a mean age at surgery of 14 ±â€Š2.7 years. The most prevalent diagnoses were spinal cord injury (23%) and cerebral palsy (20%). Analysis reflected an overall radiographic PJK rate of 27% (n = 16) and a proximal junctional failure rate of 7% (n = 4). No significant association was identified with previously suggested risk factors such as extent of rostral fixation (P = 0.750), rod metal type (P = 0.776), laminar hooks (P = 0.654), implant density (P = 0.386), nonambulatory functional status (P = 0.254), or pelvic fixation (P = 0.746). Significant risk factors for development of PJK included perioperative use of halo gravity traction (38%, P = 0.029), greater postoperative C2 sagittal translation (P = 0.030), decreased proximal kyphosis preoperatively (P = 0.002), and loss of correction of primary curve magnitude at follow-up (P = 0.047). Increase in lumbar lordosis from post-op to last follow-up trended toward significance (P = 0.055). CONCLUSION: Twenty-seven percent of patients with NMS developed PJK, and 7% had revision surgery. Those treated with halo gravity traction or with greater postoperative C2 sagittal translation, loss of primary curve correction, and smaller preoperative proximal kyphosis had the greatest risk of developing PJK.Level of Evidence: 4.

Impact of Myelopathy Severity and Degree of Deformity on Postoperative Outcomes in Cervical Spinal Deformity Patients.

OBJECTIVE: Malalignment of the cervical spine can result in cord compression, leading to a myelopathy diagnosis. Whether deformity or myelopathy severity is stronger predictors of surgical outcomes is understudied. METHODS: Surgical cervical deformity (CD) patients with baseline (BL) and up to 1-year data were included. Modified Japanese Orthopaedic Association (mJOA) score categorized BL myelopathy (mJOA = 18 excluded), with moderate myelopathy mJOA being 12 to 17 and severe myelopathy being less than 12. BL deformity severity was categorized using the mismatch between T1 slope and cervical lordosis (TS-CL), with CL being the angle between the lower endplates of C2 and C7. Moderate deformity was TS-CL less than or equal to 25° and severe deformity was greater than 25°. Categorizations were combined into 4 groups: group 1 (G1), severe myelopathy and severe deformity; group 2 (G2), severe myelopathy and moderate deformity; group 3 (G3), moderate myelopathy and moderate deformity; group 4 (G4), moderate myelopathy and severe deformity. Univariate analyses determined whether myelopathy or deformity had greater impact on outcomes. RESULTS: One hundred twenty-eight CD patients were included (mean age, 56.5 years; 46% female; body mass index, 30.4 kg/m2) with a BL mJOA score of 12.8 ± 2.7 and mean TS-CL of 25.9° ± 16.1°. G1 consisted of 11.1% of our CD population, with 21% in G2, 34.6% in G3, and 33.3% in G4. At BL, Neck Disability Index (NDI) was greatest in G2 (p = 0.011). G4 had the lowest EuroQol-5D (EQ-5D) (p < 0.001). Neurologic exam factors were greater in severe myelopathy (p < 0.050). At 1-year, severe deformity met minimum clinically important differences (MCIDs) for NDI more than moderate deformity (p = 0.002). G2 had significantly worse outcomes compared to G4 by 1-year NDI (p = 0.004), EQ-5D (p = 0.028), Numerical Rating Scale neck (p = 0.046), and MCID for NDI (p = 0.001). CONCLUSION: Addressing severe deformity had increased clinical weight in improving patient-reported outcomes compared to addressing severe myelopathy.

Photogrammetric analysis: An objective measure to assess the craniocervical range of motion after cervical laminoplasty surgeries.

Surgical decompression using laminoplasty is commonly performed for multilevel stenosis with cervical spondylotic myelopathy. However, the long-term effects on the craniocervical range of motion (ROM) after surgery are not well understood. This study represents the first entry into the literature of photogrammetric analysis for clinical measurement of craniocervical ROM. All patients underwent a French-door laminoplasty from 1995 to 2016 and were evaluated radiologically and with postoperative photographs (photogrammetric analysis) to measure craniocervical ROM and axial rotation. Radiographic parameters were occiput to C2 angle, C1-2 angle, C2-7 angle/cervical lordosis (CL), T1-slope (T1S), and TS-CL were measured. Chin-brow vertical angle (CBVA) was utilized for flexion and extension, while nose-turn angle (NTA) was used to assess axial rotation. Forty-four patients (mean age: 65.7 years, 50% female) had a mean follow-up of 37.9 months. Mean values in neutral, flexion, and extension were occiput to C2 = 30°, 15°, and 43°; C1-C2 = -32°, -25°, -32°; and C2-C7 = -4°, 11°, -20°, respectively. Mean CL was within 1 SD of the established -17° (±13.86°). Mean T1S and TS-CL were 33° and 30° in the neutral position, respectively. Mean radiographic full range of motion from flexion to extension was 53°. NTA towards patients' left was 48° and the right side was 45°. Mean CBVA, was -4°, mean flexion 37°, and extension -45°; full range was 81°. Global craniocervical ROM has proven to be well preserved for many years following cervical laminoplasty. Photogrammetric analysis is a cost-effective and radiation-free method, accurate for quantitative assessment of craniocervical and cervical ROM.

Complication rates following Chiari malformation surgical management for Arnold-Chiari type I based on surgical variables: A national perspective.

INTRODUCTION: This study aimed to identify complication trends of Chiari Malformation Type 1 patients (CM-1) for certain procedures and concomitant diagnoses on a national level. MATERIALS: The Kids' Inpatient Database was queried for diagnoses of operative CM-1 by International Classification of Disease-9 codes (348.4). Differences in preoperative demographics and perioperative complication rates between patient cohorts were assessed using Pearson's Chi-squared test and t-test when necessary. Binary logistic regression was utilized to find significant factors associated with complication rate. Certain surgical procedures were analyzed for their relationship with postoperative outcomes. RESULTS: Thirteen thousand eight hundred and twelve CM-1 patients were identified with 8.2% suffering from a complication. From 2003 to 2012, the rate of complications for CM-1 pts decreased significantly (9.6%-5.1%) along with surgical rate (33.3%-28.6%), despite the increase in CM-1 diagnosis (36.3%-42.3%; all P < 0.05). CM-1 pts who had a complication were younger and had a lower invasiveness score; however, they had a larger Charlson Comorbidity Index than those who did not have a complication (all P < 0.05). CM-1 pts who experienced complications had a concurrent diagnosis of syringomyelia (7.1%), and also scoliosis (3.2%; all P < 0.05). CM-1 pts who did not have a complication had a greater rate of operation than those that had a complication (76.4% vs. 23.6% P < 0.05). The most common complications were nervous system related (2.8%), anemia (2.4%), and acute respiratory distress (2.1%). CM-1 pts that underwent an instrumented fusion (3.4% vs. 2.1%) had a greater complication rate as well as compared to those who underwent a craniotomy (23.2% vs. 19.1%; all P < 0.05). However, CM-1 pts that underwent a decompression had lower postoperative complications (21.3% vs. 28.9%; all P < 0.05). CONCLUSIONS: Chiari patients undergoing craniectomies as well as instrumented fusions are at a higher risk of postoperative complications especially when the instrumented fusions were performed on >4 levels.

Surgical Treatment of Flat Back Syndrome With Anterior Hyperlordotic Cages.

BACKGROUND: Traditional correction for flat back syndrome is performed with a posterior-based surgery or combined approaches in revision cases. OBJECTIVE: To evaluate outcome from anterior surgery with the use of hyperlordotic cages (HLCs) in patients with flat back syndrome. METHODS: All patients operated with or without prior posterior lumbar surgery were studied. Pre- to postoperative sagittal alignment was analyzed. Radiographic parameters were analyzed including T1 pelvic angle (T1PA), sagittal vertical axis (SVA), pelvic tilt (PT), pelvic incidence (PI), lumbar lordosis (LL), sacral slope (SS), pelvic incidence and lumbar lordosis (PI-LL), and T4-12TK. RESULTS: All 50 patients (mean age of 58 yr, 72% female with mean body mass index of 28) demonstrated significant radiographic alignment difference in their spinopelvic and global parameters from pre- to postoperative standing: LL (-37.04° vs -59.55°, P < .001), SS (35.12 vs 41.13, P < .001), PI-LL (23.55 vs 6.46), T4-12 TK (30.59 vs 41.67), PT (28.22 vs 22.13), SVA in mm (80.94 vs 37.39), and T1PA (28.70° vs 18.43°, P < .001). Using linear regression analysis, predicted pre- to postoperative change in standing LL corresponded to a pre- to postoperative changes in standing PI-LL mismatch, T1PA, TK, SS, PT, and SVA (R2 = 0.59, 0.38, 0.25, 0.16, 0.12, and 0.17, respectively). Five degrees of pre- to postoperative change in T1PA translates to -4.15° change in LL. CONCLUSION: Anterior surgery with HLCs followed by posterior instrumentation is an effective technique to treat flat back syndrome. HLCs are effective to maximize LL up to 30°, which is equivalent in magnitude to a pedicle subtraction osteotomy, but associated with less blood loss, quicker recovery, lower complications, and good surgical outcome.

Determinants of Chiari I progression in pregnancy.

Chiari Malformation type 1 (CM-I) is congenital or an acquired anomaly of the hind brain; develops when the cerebellar tonsils recede downwards below the foramen magnum. Recurrent post tussive suboccipital headache is the common presentation in a pregnant woman and the diagnosis is usually missed or delayed due to lack of formal understanding of this neurological pathology. Much has been written regarding presentation, morphology and the treatment of CM-I; however, little is known when the etiology is acquired or an iatrogenic in its evolution. Similarly, unknown is the progression of CM-I (diagnosed or undiagnosed) in pregnancy. The objective of this study is to elucidate the causes of progression of CM-I in pregnancy, and how this can be avoided. A detailed literature review has been conducted to find the case reports or case studies on association of CM-I in pregnancy; therefore, the risk factors regarding the progression have been sought. There is a lack of literature on timing, mode of anesthesia, and the management of CM-I. Moreover, authors have sought a questionnaire to screen these patients at pre-conception, intrapartum visits if, the initial diagnosis is delayed. Crucial points of concern including but not limited to the diagnosis, pre-conception counseling, timing of intervention during pregnancy, and mode of anesthesia, have been discussed in detail. In summary, a formal management algorithm has been proposed to avoid the rapid progression of this complex neurological pathology especially, in women of child bearing age and/or during pregnancy.

Diffuse intrinsic pontine gliomas: Diagnostic approach and treatment strategies.

Diffuse intrinsic pontine gliomas (DIPG) are high grade gliomas of the brainstem with fatal outcomes. Radiation is known to be partially effective to control the immediate flare but relapse is frequent. There has been ongoing research to study the role of molecular subgroups and identification of specific targets but this is not possible with histopathological diagnosis alone. The authors' objective is to highlight the need for and discuss ongoing molecular research. There is an inherent need for the availability of tumor tissue to be able to conduct research studies. The authors advocate the use of neuronavigation assisted stereotactic technique for tumor biopsy. The technique is feasible with a predefined surgical trajectory. After obtaining tissue diagnosis further work can be performed to isolate and identify histone protein genetic mutations and methylation changes responsible for DIPG molecular subgrouping. Moreover, convection enhanced delivery of therapeutic agents is being developed for better instillation of future drug agents. Despite identification of genetic/epigenetic mutations, growth factors, receptors, and tissue biomarkers, the oncogenesis of DIPG remains elusive. The authors' effort to provide a comprehensive review on DIPG to better understand the disease, need for tissue diagnosis, described surgical technique, and need for pre-clinical and clinical future research is novel.

Occipital neuralgia: A neurosurgical perspective.

Occipital neuralgia typically arises in the setting of nerve compression by fibrosis, surrounding anatomic structures, or osseous pathology, such as bone spurs or hypertrophic atlanto-epistropic ligament. It generally presents as paroxysmal bouts of sharp pain in the sensory distribution of the first three occipital nerves. Due to the long course of the greater occipital nerve (GON), and its peculiar anatomy, and location in a mobile region of the neck, it is unsurprising that the GON is at high risk for compression. Little is known how to diagnose or treat this neuropathic pain syndrome. The objective of this paper is to isolate the etiology involved, and treat this condition promptly. After all nonoperative efforts are exhausted, surgical transection of the nerve is the treatment of choice in these cases. An isolated C2 neurectomy or ganglionectomy is performed for an optimal pain relief. C1-2 instrumented fusion can be considered if, extensive facet arthropathy with instability is identified. Authors review the spectrum of treatment options for this debilitating condition, and discuss the case example of a patient who required conversion to a C1-C2 instrumented fusion following C2 ganglionectomy due to an underlying extensive degenerative disease and intraoperative findings suggestive of atlantoaxial instability.

Thirty-day readmission risk after intracranial tumor resection surgeries in children.

OBJECTIVE: The risk of readmission after brain tumor resection among pediatric patients has not been defined. The authors' objective was to evaluate the readmission rates and predictors of readmission after pediatric brain tumor resection. METHODS: Nationwide Readmissions Database (NRD) data sets from 2010 to 2014 were searched for unplanned readmissions within 30 days of the discharge date after pediatric brain tumor resection. Patient demographic variables included sex, age, expected payment source (Medicaid or private insurance), and median annual household income. Readmission events for chemotherapy, radiation therapy, or further tumor resection were not included. RESULTS: Of 282 patients (12.7%) readmitted within 30 days of the index event, the median time to readmission was 10 days (IQR 5-19 days). The most common reason for readmission was hydrocephalus, which accounted for 19% of readmission events. Other CNS-related complications (24%), surgical site infections or septicemia (14%), seizures (7%), and hematological disorders (7%) accounted for other major readmission events. The median charge for readmission events was $35,431, and the median length of readmission stay was 4 days. In multivariate regression, factors associated with a significant increase in readmission risk included Medicaid as the primary payor, discharge from the index event with home health services, and fluid and electrolyte disorders during the index event. CONCLUSIONS: More than 10% of pediatric brain tumor patients have unplanned readmission events within 30 days of discharge after tumor resection. Medicaid patients and those with preoperative or early postoperative fluid and electrolyte disturbances may benefit from early or frequent outpatient visits after tumor resection.

Association of spinal instability due to metastatic disease with increased mortality and a proposed clinical pathway for treatment.

OBJECTIVE: Multidisciplinary treatment including medical oncology, radiation oncology, and surgical consultation is necessary to provide comprehensive therapy for patients with spinal metastases. The goal of this study was to review the use of radiation therapy and/or surgical intervention and their impact on patient outcomes. METHODS: In this retrospective series, the authors identified at their institution those patients with spinal metastases who had received radiation therapy alone or had undergone surgery with or without radiation therapy within a 6-year period. Data on patient age, chemotherapy, surgical procedure, radiation therapy, Karnofsky Performance Status (KPS), primary tumor pathology, Spinal Instability Neoplastic Score (SINS), and survival after treatment were collected from the patient electronic medical records. N - 1 chi-square testing was used for comparisons of proportions. The Student t-test was used for comparisons of means. A p value < 0.05 was considered statistically significant. A survival analysis was completed using a multivariate Cox proportional hazards model. RESULTS: Two hundred thirty patients with spinal metastases were identified, 109 of whom had undergone surgery with or without radiation therapy. Among the 104 patients for whom the surgical details were reviewed, 34 (33%) had a history of preoperative radiation to the surgical site but ultimately required surgical intervention. In this surgical group, a significantly increased frequency of death within 30 days was noted for the SINS unstable patients (23.5%) as compared to that for the SINS stable patients (2.3%; p < 0.001). The SINS was a significant predictor of time to death among surgical patients (HR 1.11, p = 0.037). Preoperative KPS was not independently associated with decreased survival (p > 0.5) on univariate analysis. One hundred twenty-six patients met the criteria for inclusion in the radiation-only analysis. Ninety-eight of these patients (78%) met the criteria for potential instability (PI) at the time of treatment, according to the SINS system. Five patients (5%) with PI in the radiation therapy group had a documented neurosurgical or orthopedic surgery consultation prior to radiation therapy. CONCLUSIONS: At the authors' institution, patients with gross mechanical instability per the SINS system had an increased rate of 30-day postoperative mortality, which remained significant when controlling for other factors. Surgical consultation for metastatic spine patients receiving radiation oncology consultation with PI is low. The authors describe an institutional pathway to encourage multidisciplinary treatment from the initial encounter in the emergency department to expedite surgical evaluation and collaboration.