Telemedicine in a spine clinic setting: a large survey of patient preferences and experiences.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has greatly disturbed healthcare and the practice of neurosurgery. As healthcare systems evolve in the face of COVID-19, the use of telehealth platforms has expanded. We presented the results of a large survey of patient perspectives on the role of telehealth in the care of spine clinic patients. METHODS: All patients at the spine clinic of a large, tertiary, academic medical center were surveyed at their clinic visit from May 30, 2020-June 30, 2020. All responses were anonymous, and results were analyzed with standard statistical techniques. RESULTS: One hundred and seventy-six surveys were returned and 164 were entirely completed. 56.8% of patients were new while 24.4% were postoperative follow-up visits: 54.9% had lumbar symptoms. 85% had pain while more than half also reported weakness; 58% traveled greater than twenty-five miles for their appointment; 96% had transportation readily available. Of all respondents, only 15.3% preferred the appointment via video telehealth while 4% had no preference between in-person appointment or virtual visit. Preference for telehealth appointment was not associated with factors such as new or established in the practice, spinal region of symptoms, pain, weakness, comfort with technology, age, or duration of symptoms. There was a significant difference between how far the patient traveled for the clinic appointment and their preference for a telehealth appointment, with patients traveling further distances favoring telehealth (P=0.04). This effect remained significant when stratifying based on 25 miles (P=0.03) or 50 miles (P=0.03) but not when stratifying based on 100 miles (P=0.32). However, the sample size of patients traveling >100 miles was small, limiting any inference regarding that subgroup. Access to transportation was associated with preference for telehealth (88.89% vs. 97.18%, P=0.08) but did not reach statistical significance. CONCLUSIONS: Most spine patients prefer in-person clinic appointments to virtual appointments. These preferences should be considered when arranging patient encounters.

Rare septic arthritis of the wrist and carpus primary osteoarticular manifestation of Mycobacterium tuberculosis: A case report.

Mycobacterium tuberculosis is one of the oldest and most studied infections, yet it remains one of the most common causes of infection-related death worldwide. The majority concern pulmonary tuberculosis. Therefore, extrapulmonary cases are rare and are often neglected in the differential diagnosis, especially in chronic musculoskeletal complaints. Nevertheless, osteoarticular manifestation of tuberculosis can cause disabling destruction of bone, cartilage, and surrounding soft tissues which may be exacerbated by a delay in diagnosis. This case report documents a case of primary osteoarticular tuberculosis causing septic arthritis of the wrist and carpus. In our case, the patient had no pulmonary burden of tuberculosis, which further delayed diagnosis and lead to irreversible damage to the wrist as well as carpus. This case illustrates the need to consider this diagnosis in at risk populations in order to prevent a delay in diagnosis and treatment.

Major complications of dural venous sinus stenting for idiopathic intracranial hypertension: case series and management considerations.

BACKGROUND: Venous sinus stenting (VSS) is a safe, effective, and increasingly popular treatment option for selected patients with idiopathic intracranial hypertension (IIH). Serious complications associated with VSS are rarely reported. METHODS: Serious complications after VSS were identified retrospectively from multicenter databases. The cases are presented and management strategies are discussed. RESULTS: Six major acute and chronic complications after VSS were selected from a total of 811 VSS procedures and 1466 venograms for IIH. These included an acute subdural hematoma from venous extravasation, cases of both intraprocedural and delayed stent thrombosis, an ultimately fatal cerebellar hemorrhage resulting in acute obstructive hydrocephalus, venous microcatheter perforation during venography and manometry, and a patient who developed subarachnoid hemorrhage and subdural hematoma after cerebellar cortical vein perforation. The six cases are reviewed and learning points regarding complication avoidance and management are presented. CONCLUSION: We report on six rare, major complications after VSS for IIH. Familiarity with these potential complications and appropriate timely management may allow for good clinical outcomes.

Mental health disorders in newly diagnosed non-functional pitutary adenoma under initial observation: an observational cohort study using the nationwide MarketScan database.

PURPOSE: Nonfunctioning pituitary adenomas account for 15-30% of pituitary tumors. Studies exploring the role of an intracranial tumor diagnosis, specifically nonfunctioning pituitary adenomas, on mental health disorders (MHDs) in patients have been limited. We characterize the incidence and factors affecting the development of MHDs in untreated pituitary adenomas. METHODS: Utilizing a large-scale private payor database, MarketScan, we performed a retrospective study of patients with an untreated pituitary adenomas and corresponding MHD. RESULTS: We found that in patients diagnosed with an untreated pituitary adenomas, approximately 15% were newly diagnosed with a MHD within 1 year of the pituitary adenoma diagnosis. Independent risk factors included female gender and substance abuse. Headaches, visual symptoms, and higher Charlson Co-morbidity indexes were also independently associated with a subsequent diagnosis of MHD. On multivariable analysis, patients in the pituitary tumor cohort were more likely to be diagnosed with a MHD than those in the matched cohort (aOR: 1.31, CI: 1.19-1.44). CONCLUSION: By identifying risk factors, advanced screening can focus on non-operative pituitary adenoma patients at high-risk for the development of MHD.

Delayed Anterior Cervical Screw Migration Causing Swallowing Difficulty.

Cervical disc disease is a common pathology that may require surgical intervention. A common surgical intervention for cervical disc disease is anterior discectomy and fusion. A number of complications are associated with this technique, including hoarseness, dysphagia, pseudoarthrosis, adjacent segment disease, and hardware failure. Here, we present a case detailing a unique complication of delayed migration of an anterior cervical screw which resulted in swallowing difficulties. Subsequently, we discuss the related reports and highlight the literature on the topic. We conclude with a brief discussion on the principle of patient autonomy.

Dural venous sinus stenting for treatment of pediatric idiopathic intracranial hypertension.

BACKGROUND: Dural venous sinus stenting (VSS) is an effective treatment for idiopathic intracranial hypertension (IIH) in adult patients. There are no published series to date evaluating safety and efficacy of VSS in pediatric patients. OBJECTIVE: To report on procedural device selection and technique as well as safety and efficacy of VSS for pediatric patients with medically refractory IIH due to underlying venous sinus stenosis. METHODS: A multi-institutional retrospective case series identified patients with medically refractory IIH aged less than 18 years who underwent VSS. RESULTS: 14 patients were identified at four participating centers. Patient ages ranged from 10 to 17 years, and 10 patients (71.4%) were female. Mean body mass index was 25.7 kg/m2 (range 15.8-34.6 kg/m2). Stenting was performed under general endotracheal anesthesia in all except two patients. The average trans-stenotic gradient during diagnostic venography was 10.6 mm Hg. Patients had stents placed in the superior sagittal sinus, transverse sinus, sigmoid sinus, occipital sinus, and a combination. Average follow-up was 1.7 years after stenting. Six patients out of 10 (60%) had reduced medication dosing, 12 of 14 patients (85.7%) had improvements in headaches, two patients (100%) with pre-stent tinnitus had resolution of symptoms, and four (80%) of five patients with papilledema had improvement on follow-up ophthalmological examinations. Two patients (14.3%) developed postprocedural groin hematomas, one patient (7.1%) developed a groin pseudoaneurysm, and one patient (7.1%) had postprocedural groin bleeding. No other procedural complications occurred. Four patients (28.6%) required further surgical treatment (cerebrospinal shunting and/or stenting) after their first stenting procedure. CONCLUSIONS: This series suggests that VSS is feasible in a pediatric population with IIH and has a low complication rate and good clinical outcomes.

Mental health disorders in patients with untreated meningiomas: an observational cohort study using the nationwide MarketScan database.

BACKGROUND: Meningiomas are the most common primary tumor of the CNS. Studies investigating the impact of a brain tumor diagnosis on mental health disorders (MHDs) in patients have been limited. The objective of this work is to characterize the incidence and factors affecting the presence of MHDs in untreated meningiomas. METHODS: Using a large-scale private payer database, MarketScan, we performed a retrospective study of patients with an untreated meningioma and corresponding MHD. RESULTS: We found that in patients diagnosed with an untreated meningioma, approximately 16% were diagnosed with an MHD within 1 year of the diagnosis of the meningioma. CONCLUSION: By identifying risk factors, appropriate screening can focus on patients at high-risk for the development of MHD.

Non-Union After Multiple Lumbar Fusion Surgeries in a Patient With Facioscapulohumeral Muscular Dystrophy: A Case Report and Review of the Literature.

BACKGROUND: Facioscapulohumeral muscular dystrophy (FSHD) is a rare condition affecting 1/20,000 persons and the third most common muscular dystrophy condition, with an autosomal dominant pattern of inheritance characterized by progressive muscular weakness primarily involving the face, shoulder girdle, and upper arm. The condition is associated with atrophic musculature of the trunk and core leading to difficulties with gait, posture, and function. FSHD leaves as many as 20% of patients wheelchair-bound and most commonly presents with low back, neck, and shoulder pain. CASE DESCRIPTION: We present the case of a patient with FSHD who underwent multiple spinal fusion surgeries without relief in her back pain. Imaging studies serve to highlight the extent of paraspinal muscle atrophy and provides the basis for a discussion on the preoperative factors that may predict patients most likely to benefit from surgery. We then provide a brief review of the literature on the role of paraspinal muscle atrophy in back pain. CONCLUSIONS: This case adds to our understanding of the surgical management of patients with FSHD and patients with atrophic core musculature as a whole.

The Role of Anesthesia during Intra-Arterial Mechanical Thrombectomy for theTreatment of Acute Ischemic Stroke.

Background Type of sedation (conscious sedation (CS) or general anesthesia (GA)) during Intra-arterial mechanical thrombectomy (IAMT) for treatment of acute ischemic stroke may affect patient outcomes. Previous studies suggested that CS cohorts have a higher probability of good outcome than GA cohorts. However, CS cohorts had lower initial NIH stroke scores (NIHSS). This study offers an investigation into outcomes after IAMT based on sedation type. Methods Patients at our institution who underwent IAMT for treatment of acute ischemic stroke caused by anterior circulation occlusion between 2013-2015 were included in the study. Primary endpoint was functional outcome on the modified Rankin Scale (mRS) at 90 days post-IAMT. Secondary endpoints included NIHSS at 48 hours post-IAMT, time from CT scan to puncture and from puncture to initial recanalization, recanalization as defined by the Thrombolysis in Cerebral Ischemia (TICI) score, intensive care and hospital length of stay, and all-cause in-hospital mortality. Results Thirty nine patients were included in analysis; 17 received GA and 22 received CS. Cohorts were similar in baseline characteristics, including NIHSS. The 90-day mRS was not significantly different between cohorts, as was the case for most secondary endpoints. Successful recanalization was higher in both groups than previously reported and a significantly higher TICI 3 recanalization rate was achieved in the GA cohort. Conclusions We show that equal outcomes are possible with either CS or GA if initial NIHSS is comparable. It seems reasonable for neuro-interventionalists to continue practicing using their personal preference for sedation. However, prospective randomized trials are still needed.

Idiopathic Intracranial Hypertension Masking as Obstructive Hydrocephalus: A Case Report.

Idiopathic intracranial hypertension (IIH) is a poorly understood phenomenon and its presentation can both mimic and co-exist with other intra-cranial processes. Accurate diagnosis is imperative as ongoing advancements in treatment can yield dramatic positive results. Here we present the case of an individual with signs and symptoms of obstructive hydrocephalus who was ultimately found to have IIH secondary to venous sinus stenosis. After correction of the venous sinus stenosis, resolution in the patient's symptoms was noted. The case highlights some of the unique considerations in approaching patients with IIH and provides a framework for review of current literature related to IIH and venous sinus stenosis.

Heavily Calcified Esthesioneuroblastoma in a 72-year-old.

A 72-year-old female presented with the complaint of declining vision. Workup included magnetic resonance imaging (MRI) which revealed a large enhancing mass extending into the nasal cavity, nasopharynx, and anterior cranial fossa. Computed tomography (CT) imaging revealed extensive calcification. Subsequent endonasal biopsy revealed the tumor to be an unusually calcified esthesioneuroblastoma (ENB). The patient elected for palliative measures. The case provides a basis for a discussion on rare esthesioneuroblastomas and highlights the possibility of extensive calcification on such tumors.

Mice Lacking M1 and M3 Muscarinic Acetylcholine Receptors Have Impaired Odor Discrimination and Learning.

The cholinergic system has extensive projections to the olfactory bulb (OB) where it produces a state-dependent regulation of sensory gating. Previous work has shown a prominent role of muscarinic acetylcholine (ACh) receptors (mAChRs) in regulating the excitability of OB neurons, in particular the M1 receptor. Here, we examined the contribution of M1 and M3 mAChR subtypes to olfactory processing using mice with a genetic deletion of these receptors, the M1-/- and the M1/M3-/- knockout (KO) mice. Genetic ablation of the M1 and M3 mAChRs resulted in a significant deficit in odor discrimination of closely related molecules, including stereoisomers. However, the discrimination of dissimilar molecules, social odors (e.g., urine) and novel object recognition was not affected. In addition the KO mice showed impaired learning in an associative odor-learning task, learning to discriminate odors at a slower rate, indicating that both short and long-term memory is disrupted by mAChR dysfunction. Interestingly, the KO mice exhibited decreased olfactory neurogenesis at younger ages, a deficit that was not maintained in older animals. In older animals, the olfactory deficit could be restored by increasing the number of new born neurons integrated into the OB after exposing them to an olfactory enriched environment, suggesting that muscarinic modulation and adult neurogenesis could be two different mechanism used by the olfactory system to improve olfactory processing.

Disruption of centrifugal inhibition to olfactory bulb granule cells impairs olfactory discrimination.

Granule cells (GCs) are the most abundant inhibitory neuronal type in the olfactory bulb and play a critical role in olfactory processing. GCs regulate the activity of principal neurons, the mitral cells, through dendrodendritic synapses, shaping the olfactory bulb output to other brain regions. GC excitability is regulated precisely by intrinsic and extrinsic inputs, and this regulation is fundamental for odor discrimination. Here, we used channelrhodopsin to stimulate GABAergic axons from the basal forebrain selectively and show that this stimulation generates reliable inhibitory responses in GCs. Furthermore, selective in vivo inhibition of GABAergic neurons in the basal forebrain by targeted expression of designer receptors exclusively activated by designer drugs produced a reversible impairment in the discrimination of structurally similar odors, indicating an important role of these inhibitory afferents in olfactory processing.

Subcutaneous anterior transposition versus decompression and medial epicondylectomy for the treatment of cubital tunnel syndrome.

A review of the literature often fails to uncover the best procedure for the treatment of cubital tunnel syndrome. This article compares 2 frequently used methods (subcutaneous anterior transposition vs decompression and medial epicondylectomy) for their effectiveness in relieving both subjective and objective symptoms of cubital tunnel syndrome. Between August 1991 and October 1993, nineteen patients underwent surgical decompression by a single surgeon for ulnar neuropathy at the elbow. Factors evaluated included upper extremity range of motion, elbow valgus stress, grip strength, pinch, 2-point discrimination, and pre- and postoperative nerve conduction. A standardized questionnaire was administered to assess subjective relief of symptoms.In the transposition group, grip strength averaged 71.2% of normal and pinch strength 86.6% of normal, and 2-point discrimination averaged 8.0 mm. The derived subjective assessment score was 23.2 of a possible 40. The average ulnar motor conduction velocity across the elbow was 50.1 m/sec preoperatively and 56.3 m/sec postoperatively. In the medial epicondylectomy group, grip strength averaged 79.5% of normal and pinch strength 81.7% of normal, and 2-point discrimination averaged 8.0 mm. The average ulnar motor conduction velocity across the elbow was 45.7 m/sec preoperatively and 55.7 m/sec postoperatively. No statistically significant difference existed between the 2 groups for the aforementioned indexes. These results do not indicate a difference between the outcomes of the patients undergoing either of the procedures. Because epicondylectomy is less technically demanding, with less soft tissue dissection of the nerve, it may be preferred over ulnar transposition.

Laboratory evaluation of a new lateral-flow-based point-of-care rapid test for assessment of chronic systemic inflammation.

The determination of C-reactive protein (CRP) by means of a highly sensitive laboratory method as an independent biomarker for assessment of chronic systemic vascular inflammation and cardiovascular risk is recommended by therapeutic guidelines for diabetes and cardiovascular disease in the United States and in Europe. The purpose of this investigation was to investigate the specificity and sensitivity of a newly developed lateral-flow-based point-of-care (POC) rapid test with semi-quantitative visual reading in comparison with a laboratory reference standard method. The high-sensitivity CRP concentrations of 66 samples were determined by means of turbidimetry and the POC test (5 microl serum/10 microl capillary whole blood, 10 minutes) was independently performed by three investigators blinded to each other's results. The visual readings were classified, as recommended by the American Heart Association, to represent a low risk (0-1 mg/liter), moderate risk (>1-3 mg/liter), or high risk (>3-10 mg/liter) or to indicate an unspecific inflammation (>10 mg/liter). According to the reference method, there were 17 samples in the low-risk group, 19 samples in the moderate-risk group, and 26 samples in the high-risk group, and 4 samples showed an unspecific inflammation. All three investigators reached very conclusive results. The range of agreement between the visual readings of the investigators and the laboratory method ranged between 94% and 97%. The sensitivity for assessment of moderate-to-high cardiovascular risk was 100% (45/45 were detected), and the specificity ranged between 90% and 95%. The newly developed lateral-flow-based POC rapid test showed an excellent agreement between individual visual reading and the laboratory reference method. It may therefore be suitable for a fast and convenient screening, which, after laboratory test confirmation, may help to identify patients with elevated risk of macrovascular disease.

Tungsten-rhenium suture needles with improved properties for coronary artery bypass graft surgery.

Suture needles are essential instruments for performing blood vessel anastomosis in coronary artery bypass graft (CABG) surgeries. Exceptional needle performance is needed now as never before because of the increasing prevalence of elderly patients with advanced stages of coronary disease and calcified tissue. The various properties that affect the performance of suture needles used in CABG surgery are reviewed and recent progress towards improving needle performance through the use of tungsten-rhenium alloys and novel lubricous needle coatings is presented. Substantial enhancement of properties beyond those exhibited by commercially available stainless steel suture needles has been made, including an approximate 40% increase in strength, 100% increase in stiffness, and superior multiple pass penetration performance in both synthetic rubber media and human cadaver carotid arteries (p < 0.01).

External fixation of distal radius fractures: effect of distraction and duration.

PURPOSE: To assess the effects of the amount of distraction across the wrist and the duration of fixator placement on the clinical outcome of patients with distal radius fractures treated with external fixation. METHODS: A total of 42 patients with closed distal radius fractures were treated with a spanning external fixator plus supplementary percutaneous K-wires over a 6-year period. All fractures were extra-articular (A type) or simple intra-articular (C type). Twenty-four of these patients were evaluated retrospectively for clinical and radiographic outcomes at an average follow-up time of 22 months (range, 4-49 months). The amount of distraction attained by the fixator was determined by measuring the carpal height ratio on plain radiographs. Wrist and forearm range of motion were recorded, as well as grip and pinch strength. Standard radiographs were taken to evaluate healing and bony alignment. RESULTS: Using the Gartland Werley classification, there were 11 excellent, 10 good, and 3 fair results. Statistical analysis indicated that a higher carpal height ratio at the initial reduction positively correlated (p = .041) with an excellent outcome. Duration of external fixation did not have a significant impact on the final outcome within the parameters studied (p = .891). Average wrist range of motion at follow-up was as follows: flexion, 54.1 degrees (75% of the contralateral side); extension, 59.0 degrees (78%); radial deviation, 18.0 degrees (85%); ulnar deviation, 22 degrees (73%); pronation, 79.0 degrees (95%); and supination, 76.6 degrees (93%). None of the individual components of range of motion were negatively correlated with higher carpal height ratio at fixator application or duration of fixation, within the parameters studied. CONCLUSIONS: Moderately increased distraction of the carpus at the initial fracture reduction is correlated with improved clinical outcome and does not have an adverse affect on subsequent wrist range of motion. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Lack of protein expression of the Simian virus 40 large T antigen in human lymphomas.

Several studies have detected Simian virus 40 (SV40) deoxyribonucleic acid sequences in human tumor tissues, including lymphomas, mainly by the polymerase chain reaction, but these data were not confirmed by subsequent investigations. Regional differences in the distribution of the SV40 and/or technical difficulties have been taken into account to explain these divergent results, but because only a few such studies dealt with the expression of SV40 proteins in tumor tissues, we investigated the expression of the SV40 large T antigen in human lymphomas by immunohistochemistry. Tissue microarrays containing Non-Hodgkin's-lymphomas and Hodgkin's-lymphomas were constructed utilizing archival samples encompassing the years 1974--2001 from Italian, Swiss and Austrian patients. Expression of the SV40 large T antigen was analysed by highly specific and sensitive immunohistochemistry using a mouse monoclonal antibody. Protein expression of the large T antigen was not detected in 655 Non-Hodgkin's-lymphomas or in 337 Hodgkin's- lymphomas. The results suggest the absence of an association between SV40 large T antigen and human lymphomas.