A review of Big Data analytics and potential for implementation in the delivery of global neurosurgery.

Global access to neurosurgical care is still a work in progress, with many patients in low-income countries not able to access potentially lifesaving neurosurgical procedures. "Big Data" is an increasingly popular data collection and analytical technique predicated on collecting large amounts of data across multiple data sources and types for future analysis. The potential applications of Big Data to global outreach neurosurgery are myriad: from assessing the overall burden of neurosurgical disease to planning cost-effective improvements in access to neurosurgical care, and collecting data on conditions which are rare in developed countries. Although some global neurosurgical outreach programs have intelligently implemented Big Data principles in their global neurosurgery initiatives already, there is still significant progress that remains to be made. Big Data has the potential to drive the efficient improvement of access to neurosurgical care across low- and medium-income countries.

Novel placement of cortical bone trajectory screws in previously instrumented pedicles for adjacent-segment lumbar disease using CT image-guided navigation.

OBJECT: Symptomatic adjacent-segment lumbar disease (ASLD) after lumbar fusion often requires subsequent surgical intervention. The authors report utilizing cortical bone trajectory (CBT) pedicle screw fixation with intraoperative CT (O-arm) image-guided navigation to stabilize spinal levels in patients with symptomatic ASLD. This unique technique results in the placement of 2 screws in the same pedicle (1 traditional pedicle trajectory and 1 CBT) and obviates the need to remove preexisting instrumentation. METHODS: The records of 5 consecutive patients who underwent lumbar spinal fusion with CBT and posterior interbody grafting for ASLD were retrospectively reviewed. All patients underwent screw trajectory planning with the O-arm in conjunction with the StealthStation navigation system. Basic demographics, operative details, and radiographic and clinical outcomes were obtained. RESULTS: The average patient age was 69.4 years (range 58-82 years). Four of the 5 surgeries were performed with the Minimal Access Spinal Technologies (MAST) Midline Lumbar Fusion (MIDLF) system. The average operative duration was 218 minutes (range 175-315 minutes). In the entire cohort, 5.5-mm cortical screws were placed in previously instrumented pedicles. The average hospital stay was 2.8 days (range 2-3 days) and there were no surgical complications. All patients had more than 6 months of radiographic and clinical follow-up (range 10-15 months). At last follow-up, all patients reported improved symptoms from their preoperative state. Radiographic follow-up showed Lenke fusion grades of A or B. CONCLUSIONS: The authors present a novel fusion technique that uses CBT pedicle screw fixation in a previously instrumented pedicle with intraoperative O-arm guided navigation. This method obviates the need for hardware removal. This cohort of patients experienced good clinical results. Computed tomography navigation was critical for accurate CBT screw placement at levels where previous traditional pedicle screws were already placed for symptomatic ASLD.

Neurosurgery residency and fellowship education in the United States: 2 decades of system development by the One Neurosurgery Summit organizations.

The purpose of this report is to chronicle a 2-decade period of educational innovation and improvement, as well as governance reform, across the specialty of neurological surgery. Neurological surgery educational and professional governance systems have evolved substantially over the past 2 decades with the goal of improving training outcomes, patient safety, and the quality of US neurosurgical care. Innovations during this period have included the following: creating a consensus national curriculum; standardizing the length and structure of neurosurgical training; introducing educational outcomes milestones and required case minimums; establishing national skills, safety, and professionalism courses; systematically accrediting subspecialty fellowships; expanding professional development for educators; promoting training in research; and coordinating policy and strategy through the cooperation of national stakeholder organizations. A series of education summits held between 2007 and 2009 restructured some aspects of neurosurgical residency training. Since 2010, ongoing meetings of the One Neurosurgery Summit have provided strategic coordination for specialty definition, neurosurgical education, public policy, and governance. The Summit now includes leadership representatives from the Society of Neurological Surgeons, the American Association of Neurological Surgeons, the Congress of Neurological Surgeons, the American Board of Neurological Surgery, the Review Committee for Neurological Surgery of the Accreditation Council for Graduate Medical Education, the American Academy of Neurological Surgery, and the AANS/CNS Joint Washington Committee. Together, these organizations have increased the effectiveness and efficiency of the specialty of neurosurgery in advancing educational best practices, aligning policymaking, and coordinating strategic planning in order to meet the highest standards of professionalism and promote public health.

Cannabinoids in the Treatment of Back Pain.

Marijuana is increasingly utilized for the treatment of multiple medical problems, including back pain, in the United States. Although there is strong preclinical evidence supporting the promise of cannabinoids in the treatment of back pain, there is a paucity of clinical data supporting their use in clinical practice. Opioids are an important medication for the treatment of acute and chronic back pain, but utilization of opioid-based regimens have likely contributed to the growing opioid epidemic. The significant risk of morbidity, mortality, and dependence secondary to opioid medications have increased the interest in nonopioid medications, including cannabinoid-based pain regimens, in treating back pain. This review will provide an overview on the pharmacology, drug delivery methods, clinical evidence, and safety considerations critical to understanding the potential role of cannabinoids in the treatment of back pain.

Chronicling the philanthropic arm of neurological surgery: a review of the growth and development of the Neurosurgery Research & Education Foundation.

OBJECTIVE: The Neurosurgery Research & Education Foundation (NREF), previously known as the Research Foundation of the American Association of Neurological Surgeons (AANS), was established in 1980 to encourage and facilitate innovation through financial support to young neurosurgeons in the process of honing their competencies in neurosciences and neurological surgery. This article provides a historical overview of NREF, its mission, and charitable contributions and the ever-expanding avenues for neurosurgeons, neurosurgical residents and fellows, and medical students to supplement clinical training and to further neurosurgical research advances. METHODS: Data were collected from the historical archives of the AANS and NREF website. Available data included tabulated revenue, geographic and institutional records of funding, changes in funding for fellowships and awards, advertising methods, and sources of funding. RESULTS: Since 1984, NREF has invested more than $23 million into the future of neurosurgery. To date, NREF has provided more than 500 fellowship opportunities which have funded neurosurgeons' education and research efforts at all stages of training and practice. CONCLUSIONS: NREF is designed to serve as the vehicle through which the neurosurgical community fosters the continued excellence in the care of patients with neurosurgical diseases.

Occipital Condyle Fractures and Concomitant Cervical Spine Fractures: Implications for Management.

BACKGROUND: Occipital condyle fractures (OCFs) have traditionally been described based on anatomic characteristics; however, recent literature has proposed management based on biomechanical stability and neural element compression. The treatment of biomechanically stable fractures varies between observation and cervical immobilization. Before determining the best management approach, an understanding of concomitant cervical spine fractures in the presence of OCFs is important. The primary aim of this pilot study was to determine the rate of occurrence of biomechanically significant cervical spine fractures with OCFs. METHODS: A retrospective chart review was performed of 13,363 patients presenting to a level 1 trauma center between 2013 and 2017 with a diagnosis of OCF. RESULTS: Forty-six patients presented with OCFs, with an average Glasgow Coma Scale score of 12 on presentation and an average Injury Severity Score of 23. The average patient age was 42.1 years, and 4 patients had bilateral OCFs. Approximately 30% of these patients had associated intracranial injuries and 59% had an associated cervical spine injury. The overall rate of associated potentially biomechanically significant cervical spine fracture was 43.5%. Treatment of OCFs included collar immobilization (83%) and observation (17%). The average duration of follow-up was 3.37 months. CONCLUSIONS: This study characterizes cervical spine fractures that occur concomitantly with OCFs. The results indicate that more than one-half of patients with OCFs do not have biomechanically significant fractures elsewhere in the cervical spine. This subset of patients will be the cohort for a prospective study to assess whether collar immobilization is necessary.

Applications of a resorbable interbody spacer in posterior lumbar interbody fusion.

Polyhydroxy acids are a promising class of resorbable materials with potential applications in spinal surgery. One such polymer, MacroPore (MacroPore Biosurgery, Inc.), offers a balance of strength, predictable degradation, lack of stimulus of foreign body reaction, and biocompatibility with neural tissue. MacroPore can be formed into an array of shapes and can be manufactured, sterilized, and stored using conventional techniques. Limited clinical experience has been gained with resorbable implants used as load-sharing devices in a posterior lumbar interbody fusion construct.

Posterior lumbar interbody fusion using recombinant human bone morphogenetic protein type 2 with cylindrical interbody cages.

BACKGROUND CONTEXT: In a large series of human patients undergoing open anterior lumbar interbody fusion with a tapered titanium fusion cage, recombinant human bone morphogenetic protein type 2 (rhBMP-2) on an absorbable collagen sponge carrier has been shown to decrease operative time and blood loss, to promote osteoinduction and fusion and to be a safe and effective substitute for iliac crest harvesting. PURPOSE: The purpose of the study was to determine the clinical and radiographic outcomes in patients treated for single-level degenerative lumbar disc disease with a posterior interbody fusion, using stand-alone cylindrical threaded titanium fusion cages with either autogenous bone graft or rhBMP-2 and an absorbable collagen sponge carrier. STUDY DESIGN/SETTING: A prospective, randomized, nonblinded, 2-year pilot study at 14 investigational sites. PATIENT SAMPLE: Between March 1999 and December 1999, 67 patients with symptomatic, single-level degenerative lumbar disc disease of at least 6 months' duration underwent a single-level posterior lumbar interbody fusion using two paired cylindrical threaded titanium fusion devices. Patients were randomly assigned to one of two groups: one (n=34 patients) received rhBMP-2 on a collagen sponge carrier; the other (n=33 patients) autogenous iliac crest bone graft. OUTCOME MEASURES: Clinical outcomes were measured using low back and leg pain numerical rating scales, the Short Form (SF)-36, Oswestry Low Back Pain Disability Questionnaire and work status. Plain radiographs and computed tomographic scans were used to evaluate fusion at 6, 12 and 24 months after surgery. METHODS: In this prospective nonblinded study, 67 patients were randomly assigned to one of two groups who underwent interbody fusion using two cylindrical threaded fusion cages: the investigational group (34 patients), who received rhBMP-2 on an absorbable collagen sponge, and a control group (33 patients), who received autogenous iliac crest bone graft. Clinical data were collected and analyzed by a commercial entity. RESULTS: The mean operative time and blood loss for the investigational rhBMP-2 group was 2.6 hours and 322.8 ml, respectively. For the autograft control group, these values were 3.0 hours and 372.7 ml. The differences were not significant. Although not statistically different, at 24 months, the investigational group's fusion rate of 92.3% was higher than the control's at 77.8%. At all postoperative intervals, the mean Oswestry, back and leg pain scores and physical components of the SF-36 improved in both treatment groups compared with preoperative scores, but no significant differences were found between groups. A statistically significant difference in the change in back pain was found at 24 months for the investigational group. In the control group, two adverse events related to harvesting of the iliac crest graft occurred in two patients (6.1%). CONCLUSIONS: This small multicenter, randomized, nonblinded trial showed few statistically significant differences between the study groups. Both groups showed comparable improvements on outcome scores. Overall results show that the use of rhBMP-2 can eliminate the need for harvesting iliac crest graft and may be an equivalent replacement for autograft for use in successful posterior lumbar interbody fusions. Further studies of the use of rhBMP-2 in posterior lumbar interbody fusion cage procedures are needed.

Posterior lumbar interbody fusion with bioabsorbable spacers and local autograft in a series of 27 patients.

OBJECT: The goal of this prospective study was to review a series of 27 patients who underwent bilateral posterior lumbar interbody fusion with instrumented pedicle fixation and two HYDROSORB (known generically as 70:30 poly[L-lactide-co-D,L-lactide]) rectangular cages packed with locally harvested autograft at a total of 48 levels, and to assess the safety and efficacy of this novel technique. This analysis, conducted at a mean of 26 months of follow up, is the first report of a long-term evaluation of this technique. Fusion rates and clinical outcomes are presented. METHODS: A prospective clinical and radiographic review of findings in 27 consecutive patients was performed. Fusion rates and clinical outcome were assessed at 6-month intervals up to the 32-month follow-up end point. Two patients with four corresponding fusion levels were lost to follow up. Radiographic evidence of satisfactory fusion was achieved in 42 (95.5%) of 44 levels fused. Satisfactory fusion at all levels was achieved in 23 (92%) of 25 patients. Two patients required repeated operations for treatment of symptomatic pseudarthrosis during the study period. The likelihood of all levels attaining fusion in a given patient decreased as the number of levels treated increased, which is consistent with previously published studies. Nonetheless, fusion rates per treated level were similar for patients in whom one to three levels were treated. No significant surgical complication occurred. CONCLUSIONS: Posterior lumbar interbody fusion in which the HYDROSORB bioabsorbable implant packed with locally harvested autograft and segmental internal fixation are used appears to be an interbody fusion alternative whose efficacy is comparable with previously reported procedures.

Spinal pseudomeningoceles and cerebrospinal fluid fistulas.

Spinal pseudomeningoceles and cerebrospinal fluid (CSF) fistulas are rare extradural collections of CSF that result following a breach in the dural-arachnoid layer. They may occur due to an incidental durotomy, during intradural surgery, or from trauma or congenital abnormality. The majority are iatrogenic and occur in the posterior lumbar region following surgery. Although they are often asymptomatic, they may cause low-back pain, headaches, and even nerve root entrapment. Leakage of CSF from the wound may cause a fistulous tract, which is a conduit for infection and should be repaired immediately. Diagnosis can be confirmed on clinical examination or imaging studies including magnetic resonance imaging, computerized tomography myelography, and radionuclide myelography. Treatment must be specific to each patient because the timing, size, symptoms, and location of the dural breach all affect the choice of therapy. Nonsurgical methods may be used, but more frequently operative repair is required. In this article, the authors review the diagnosis and treatment of spinal pseudomeningoceles and CSF fistulas.

Postoperative Level 1 anticoagulation therapy and spinal surgery: practical guidelines for management.

OBJECT: The authors conducted a review of the literature to establish reasonable practical guidelines for the management of complications in patients who have undergone recent spinal surgery and who require Level 1 anticoagulation therapy. METHODS: A MEDLINE (PubMed) literature search was performed using the key words "postoperative anticoagulation," "spinal surgery," and "postoperative epidural hematoma," for articles published between 1990 and 2004. The search yielded 148 articles, which were then further screened for relevance and classified according to level-of-evidence guidelines established by the American Association of Neurological Surgeons/Congress of Neurological Surgeons joint committee for spinal cord injury. A total of 12 relevant articles were reviewed. There were no relevant articles meeting Class 1 standards of evidence, two met Class 2 evidence standards (one was a nonrandomized cohort study, the other was case-controlled), and the remaining 10 articles contained Class 3 evidence. CONCLUSIONS: There are insufficient data to establish evidence-based guidelines for the use of Level 1 heparin or an equivalent anticoagulation protocol in patients who have recently undergone spinal surgery. Nevertheless, a search of the limited peer-reviewed literature on the subject indicates that there is an anecdotally high risk of complications in patients who have undergone spinal surgery and in whom a Level 1 or equivalent heparin protocol is administered. It therefore seems most prudent to arrange for placement of a vena cava filter in patients who have undergone spinal surgery and in whom a pulmonary embolus is found postoperatively. In patients who undergo spinal surgery and who require heparinization therapy for myocardial ischemia or infarction, the use of frequent neurological examinations in conjunction with anticoagulation therapy seems to be the only reasonable option.

Cervical osteomyelitis: a brief review.

OBJECT: The authors conducted a literature-based review of the etiology, diagnosis, and treatment of cervical vertebral osteomyelitis (CVO). METHODS: A Medline (PubMed) search using the key words "cervical vertebral osteomyelitis" yielded 256 articles. These were further screened for relevance, yielding 15 articles. Each publication was reviewed, and several others not identified in the PubMed search were screened and included in the review according to relevance. Each article was identified as involving either the epidemiology/etiology, diagnosis, or treatment of CVO. Separate categories were created for case reports and general reviews. CONCLUSIONS: Cervical vertebral osteomyelitis has a spectrum of origins, which include spontaneous, postoperative, traumatic, and hematogenously spread causes. The majority of patients have medical risk factors and comorbidities that include diabetes, trauma, drug abuse, and infectious processes in extraspinal areas. The diagnosis of CVO can be accomplished in most cases by using plain x-ray films and computerized tomography scans. Nevertheless, preferential use of magnetic resonance imaging in cases in which there is a neurological deficit is helpful in identifying epidural compressive processes. Treatment for CVO can be successfully initiated with intravenous antibiotic therapy. Nevertheless, in cases in which there is a neurological deficit, spinal deformity and/or progressive lysis, or intractable pain, the earliest feasible surgical intervention with debridement and fusion is warranted.

Novel bioabsorbable interbody fusion spacer-assisted fusion for correction of spinal deformity.

OBJECT: The authors report the cases of 12 patients with medically refractory mechanical low-back pain and intermittent radicular symptoms in whom radiography demonstrated evidence of multilevel lumbosacral degenerative kyphotic and scoliotic deformity and spondylolisthesis. METHODS: These patients underwent multilevel posterior lumbar interbody fusion in which Macropore bioabsorbable spacers were placed. Each patient underwent at least 1 year of clinical and radiographic follow up. CONCLUSIONS: This series illustrates the novel use of bioabsorbable interbody spacers and fusion technique for correction of spinal deformity due to advanced degenerative kyphoscoliosis and spondylolisthesis.

Applications of a resorbable interbody spacer via a posterior lumbar interbody fusion technique.

Polyhydroxyacids are a promising class of bioresorbable materials withpotential applications in spinal surgery. One such polymer, MacroPore (MacroPore Biosurgery Inc, San Diego, Calif), offers a balance of strength, predictable degradation, lack of stimulus of foreign body reaction, and biocompatibility with neural tissue. MacroPore can be formed into an array of shapes and can be manufactured, sterilized, and stored with conventional techniques. Limited clinical experience has been gained with bioresorbable implants that are used as load-sharing devices in a posterior lumbar interbody fusion construct.

The subdural evacuation port system: outcomes from a single institution experience and predictors of success.

INTRODUCTION: Numerous surgical options for treatment of chronic subdural hematomas (cSDH) exist. Several reports have examined the Subdural Evacuating Port System (SEPS), a variation of the twist drill craniotomy (TDC) technique. Although high success rates have been reported, a significant portion of patients treated with SEPS fail and require additional procedures. This report examines the largest single institution experience with the SEPS and explores patient and imaging characteristics associated with successful procedures. METHODS: A retrospective chart review was performed to identify all patients who have undergone SEPS drainage of cSDH. Demographic and radiographic characteristics were evaluated. Demographic data included patient's age, sex, presenting symptoms, pre-procedural GCS score, and use of anticoagulation or antiplatelet agents. The volume of drainage per procedure and radiographic data including laterality, density, and maximal diameter of the collection, presence of septations, midline shift, resolution of the collection 3 weeks post procedure, and measurements to assess atrophy were collected. Total length of stay and time in the intensive care unit was also recorded. Results were classified as a success or failure based on the need for additional procedures including craniotomy or burr hole craniotomy in the operating room. Patients treated with two SEPS procedures during the same hospitalization and no other procedures were included in the success group for statistical analyses. RESULTS: 171 subdural collections were treated in 159 patients (147 unilateral and 12 bilateral). One hundred thirty three collections (77.8%) were successfully drained. In a comparison of the success and failure groups, there were no statistically significant differences (p<0.05) in the patients' mean age, sex, presenting Glasgow Coma Scale score, coagulation profile, presenting symptoms (except altered mental status and language disturbance), subdural diameter or laterality, midline shift, presence of atrophy, density of most acute portion, or time in hospital. In the success group, there was a shorter mean stay in the intensive care unit (S: 4.1±4.5 days vs F: 5.4±4.6 days; p=0.03) and a larger output drained (S: 131.1±71.2ml vs F: 99.0±84.2ml; p=0.04). Success was less likely with mixed density collections (S: 38.2% vs F: 64.3%; p=0.02) and with collections containing greater than 2 intrahematomal septations (S: 17.1% vs F: 40.7%; p=0.007). In successful cases, mean volumes for collections prior to SEPS, immediately after SEPS, and on delayed scans (≥30 days since SEPS placement) the respective volumes were 83.1±35.1ml, 41.5±23.2ml, and 37.9±26.5ml. Both post-SEPS volumes were less than the pre-SEPS volume (p<0.0001). 76.0% of patients with delayed scans had complete resolution of cSDH or minimal residual cSDH with no local mass effect on the most recent imaging. The mean period of follow-up imaging was 95.6±196.2 days. Only one patient in our series required an emergent craniotomy following immediate complications from SEPS placement. CONCLUSIONS: The SEPS is an effective, safe, and durable treatment for cSDH. Although we consider the SEPS a first-line treatment for the majority of patients with cSDH, management of cSDH must be tailored to each patient. In mixed density collections with large proportions of acute hemorrhage and in collections with numerous intrahematomal septations, alternative surgical techniques should be considered as first-line therapies.