The association of preoperative TNF-alpha inhibitor use and reoperation rates in spinal fusion surgery.

BACKGROUND CONTEXT: Preoperative TNF-AI use has been associated with increased rate of postoperative infections and complications in a variety of orthopedic procedures. However, the association between TNF-AI use and complications following spine surgery has not yet been studied. PURPOSE: The purpose of the present study was to assess the risk of reoperation in patients prescribed TNF-AI undergoing spinal fusion surgery. STUDY DESIGN: This is a retrospective review. PATIENT SAMPLE: A total of 427 patients who underwent spinal fusion surgery at a large healthcare system from 1/1/2009 to 12/31/2018. OUTCOME MEASURE: Reoperation within 1 year. METHODS: We retrospectively reviewed the records of patients who underwent spinal fusion surgery at a large healthcare system from 1/1/2009 to 12/31/2018. There were three distinct cohorts of spine surgery patients under study: patients with TNF-AI use in 90 days before surgery, patients with non-TNF-AI DMARD medications use in the 90 days before surgery, and patients taking neither TNF-AI nor other DMARD medications in 90 days before surgery. The primary outcome of interest was reoperation for any reason within 1 year following surgery. RESULTS: Our study included 90 TNF-AI, 90 DMARD, and 123 control patients. Reoperation up to 1-year postsurgery occurred in 19% (n=17) of the TNF-AI group, 11% (n=10) of the DMARD group, and 6% (n=7) of the control group. The reasons for reoperation for TNF-AI group were 47% (n=8) infection and 53% (n=9) other causes which included failure to fuse and adjacent segment disease. Reasons for reoperation at 1 year were 40% (n=4) infection and 60% (n=6) other causes for DMARD patients and 14% (n=1) infection with 86% (n=6) other causes for control patients. The cox-proportional hazard model of reoperation within 1 year indicated that the odds of reoperation were 3.1 (95% CI:1.4-7.0) and 2.2 (95% CI 0.96-5.3) times higher in the TNF-AI and DMARD groups, respectively, compared to the control group. CONCLUSIONS: Patients taking TNF-AIs before surgery were found to have a significantly higher rate of reoperation in the 1 year following surgery compared to controls. The higher rate of reoperation associated with TNF-AI use before spinal fusion surgery represents the potential for higher morbidity and costs for patient which is important to consider for both surgeon and patient in preoperative decision making.

An Endovascular Surgery Experience in Far-Forward Military Healthcare-A Case Series.

INTRODUCTION: The advancement of interventional neuroradiology has drastically altered the treatment of stroke and trauma patients. These advancements in first-world hospitals, however, have rarely reached far forward military hospitals due to limitations in expertise and equipment. In an established role III military hospital though, these life-saving procedures can become an important tool in trauma care. MATERIALS AND METHODS: We report a retrospective series of far-forward endovascular cases performed by 2 deployed dual-trained neurosurgeons at the role III hospital in Kandahar, Afghanistan during 2013 and 2017 as part of Operations Resolute Support and Enduring Freedom. RESULTS: A total of 15 patients were identified with ages ranging from 5 to 42 years old. Cases included 13 diagnostic cerebral angiograms, 2 extremity angiograms and interventions, 1 aortogram and pelvic angiogram, 1 bilateral embolization of internal iliac arteries, 1 lingual artery embolization, 1 administration of intra-arterial thrombolytic, and 2 mechanical thrombectomies for acute ischemic stroke. There were no complications from the procedures. Both embolizations resulted in hemorrhage control, and 1 of 2 stroke interventions resulted in the improvement of the NIH stroke scale. CONCLUSIONS: Interventional neuroradiology can fill an important role in military far forward care as these providers can treat both traumatic and atraumatic cerebral and extracranial vascular injuries. In addition, knowledge and skill with vascular access and general interventional radiology principles can be used to aid in other lifesaving interventions. As interventional equipment becomes more available and portable, this relatively young specialty can alter the treatment for servicemen and women who are injured downrange.

A Comparison of Ventriculoperitoneal and Ventriculoatrial Shunts in a Population of 544 Consecutive Pediatric Patients.

BACKGROUND: Although ventriculoperitoneal shunts (VPS) remain the first-line option in most instances of pediatric hydrocephalus, the long-term efficacy of ventriculoatrial shunts (VAS) remains unknown. OBJECTIVE: To characterize the long-term outcomes and adverse occurrences associated with both VPS and VAS at our institution. METHODS: The authors retrospectively analyzed all cerebrospinal fluid (CSF) shunting procedures performed over a 13-yr period at a single institution. A total of 544 pediatric shunt patients were followed for at least 90 d (VPS: 5.9 yr; VAS: 5.3 yr). RESULTS: A total of 54% of VPS and 60% of VAS required at least 1 revision. VPS demonstrated superior survival overall; however, if electively scheduled VAS lengthening procedures are not considered true "failures," no statistical difference is noted in overall survival (P = .08). VPS demonstrated significantly greater survival in patients less than 7 yr of age (P = .001), but showed no difference in older children (P = .4). VAS had a significantly lower rate of infection (P < .05) and proximal failure (P < .001). CONCLUSION: VAS can be a useful alternative to VPS when the abdomen is unsuitable, particularly in older children. Although VPS demonstrates superior overall survival, it should be understood that elective VAS lengthening procedures are often necessary, especially in younger patients. If elective lengthening procedures are not considered true failures, then the devices show similar survival.

The Silver Lining: Advances in the Surgical Management of Brain Trauma Attributable to War.

Within the text we elaborate on the relationship between war and medicine, particularly as it pertains to neurosurgery and the management of brain trauma, and emphasize neurosurgical advancements in the treatment of brain trauma gleaned from U.S.-involved conflicts of the 21st century.

Development and implementation of a comprehensive spine surgery enhanced recovery after surgery protocol: the Cleveland Clinic experience.

Enhanced recovery after surgery (ERAS) protocols have been shown to be effective at reducing perioperative morbidity and costs while improving outcomes. To date, spine surgery protocols have been limited in scope, focusing only on specific types of procedures or specific parts of the surgical episode. The authors describe the creation and implementation of one of the first comprehensive ERAS protocols for spine surgery. The protocol is unique in that it has a comprehensive perioperative paradigm encompassing the entire surgical period that is tailored based on the complexity of each individual spine patient.

Inadequate Decompressive Craniectomy Following a Wartime Traumatic Brain Injury - An Illustrative Case of Why Size Matters.

Traumatic brain injury has been called the "signature injury" of the wars in Iraq and Afghanistan, and the management of severe and penetrating brain injury has evolved considerably based on the experiences of military neurosurgeons. Current guidelines recommend that decompressive hemicraniectomy be performed with large, frontotemporoparietal bone flaps, but practice patterns vary markedly. The following case is illustrative of potential clinical courses, complications, and efforts to salvage inadequately-sized decompressive craniectomies performed for combat-related severe and penetrating brain injury. The authors follow this with a review of the current literature pertaining to decompressive craniectomy, and finally provide their recommendations for some of the technical nuances of performing decompressive hemicraniectomy after severe or penetrating brain injury.

Return-to-active-duty rates after anterior cervical spine surgery in military pilots.

OBJECTIVESymptomatic cervical spondylosis with or without radiculopathy can ground an active-duty military pilot if left untreated. Surgically treated cervical spondylosis may be a waiverable condition and allow return to flying status, but a waiver is based on expert opinion and not on recent published data. Previous studies on rates of return to active duty status following anterior cervical spine surgery have not differentiated these rates among military specialty occupations. No studies to date have documented the successful return of US military active-duty pilots who have undergone anterior cervical spine surgery with cervical fusion, disc replacement, or a combination of the two. The aim of this study was to identify the rate of return to an active duty flight status among US military pilots who had undergone anterior cervical discectomy and fusion (ACDF) or total disc replacement (TDR) for symptomatic cervical spondylosis.METHODSThe authors performed a single-center retrospective review of all active duty pilots who had undergone either ACDF or TDR at a military hospital between January 2010 and June 2017. Descriptive statistics were calculated for both groups to evaluate demographics with specific attention to preoperative flight stats, days to recommended clearance by neurosurgery, and days to return to active duty flight status.RESULTSAuthors identified a total of 812 cases of anterior cervical surgery performed between January 1, 2010, and June 1, 2017, among active duty, reserves, dependents, and Department of Defense/Veterans Affairs patients. There were 581 ACDFs and 231 TDRs. After screening for military occupation and active duty status, there were a total of 22 active duty pilots, among whom were 4 ACDFs, 17 TDRs, and 2 hybrid constructs. One patient required a second surgery. Six (27.3%) of the 22 pilots were nearing the end of their career and electively retired within a year of surgery. Of the remaining 16 pilots, 11 (68.8%) returned to active duty flying status. The average time to be released by the neurosurgeon was 128 days, and the time to return to flying was 287 days. The average follow-up period was 12.3 months.CONCLUSIONSAdhering to military service-specific waiver guidelines, military pilots may return to active duty flight status after undergoing ACDF or TDR for symptomatic cervical spondylosis.

Treatment of Moyamoya Disease and Unruptured Intracranial Aneurysm in Floating-Harbor Syndrome.

BACKGROUND: This is the first report of the successful treatment of moyamoya disease and an unruptured intracranial aneurysm in a patient with Floating-Harbor syndrome. CASE DESCRIPTION: A 35-year-old, phenotypically syndromic woman presented with signs and symptoms consistent with ischemic stroke. Magnetic resonance imaging and catheter angiography confirmed diagnosis of moyamoya and a 6-mm basilar apex artery aneurysm (BAA). She underwent right-sided craniotomy for direct and indirect revascularization by means of superficial temporal artery-middle cerebral artery bypass and encephalo-duro-arterio-synangiosis. Three months later, she underwent stent-assisted coiling of the BAA. At 9 months, the patient remains without her preoperative neurological deficits. Interval catheter angiography confirms revascularization of her right hemisphere and obliteration of her BAA. CONCLUSIONS: We present the first case of diagnosis and treatment of moyamoya disease and BAA in a patient with Floating-Harbor syndrome. Due to a paucity of literature on this rare disorder, there has not been an associated link between Floating-Harbor syndrome and cerebrovascular disease. Our report and literature review suggest that these patients may be prone to cerebrovascular disorders and should be followed closely with neurovascular imaging.

Noncalcified Hypertrophic Ligamentum Flavum Causing Severe Cervical Stenosis and Myelopathy: Case Report and Review of the Literature.

BACKGROUND: Calcified hypertrophic ligamentum flavum is a known entity that causes myeloradiculopathy of the cervical, thoracic, and lumbar spine and is seen more commonly in Asian populations. Noncalcified hypertrophic changes are less common and may mimic other epidural space-occupying lesions. CASE DESCRIPTION: A 59-year-old woman presented with progressive myelopathy, and imaging studies were consistent with an epidural space-occupying lesion from C4-T3. The patient underwent posterior cervical decompression and fusion with instrumentation. Pathology specimens revealed noncalcified hypertrophic ligamentum flavum. CONCLUSIONS: To our knowledge, noncalcified hypertrophic ligamentum flavum causing progressive cervical myelopathy has never been reported in the English literature. This entity should be considered in cases with epidural masses causing progressive myelopathy.

Prediction and verification of mouse tRNA gene families.

BACKGROUND: Transfer RNA (tRNA) gene predictions are complicated by challenges such as structural variation, limited sequence conservation and the presence of highly reiterated short interspersed sequences (SINEs) that originally derived from tRNA genes or tRNA-like transcription units. Annotation of "tRNA genes" in sequenced genomes generally have not been accompanied by experimental verification of the expression status of predicted sequences. RESULTS: To address this for mouse tRNA genes, we have employed two programs, tRNAScan-SE and ARAGORN, to predict the tRNA genes in the nuclear genome, resulting in diverse but overlapping predicted gene sets. From these, we removed known SINE repeats and sorted the genes into predicted families and single-copy genes. In particular, four families of intron-containing tRNA genes were predicted for the first time in mouse, with introns in positions and structures similar to the well characterized intron-containing tRNA genes in yeast. We verified the expression of the predicted tRNA genes by microarray analysis. We then confirmed the expression of appropriately sized RNA for the four intron-containing tRNA gene families, as well as the other 30 tRNA gene families creating an index of expression-verified mouse tRNAs. CONCLUSIONS: These confirmed tRNA genes represent all anticodons and all known mammalian tRNA structural groups, as well as a variety of predicted "rogue" tRNA genes within families with altered anticodon identities.

Genome-wide search for yeast RNase P substrates reveals role in maturation of intron-encoded box C/D small nucleolar RNAs.

Ribonuclease P (RNase P) is an essential endonuclease responsible for the 5'-end maturation of precursor tRNAs. Bacterial RNase P also processes precursor 4.5S RNA, tmRNA, 30S preribosomal RNA, and several reported protein-coding RNAs. Eukaryotic nuclear RNase P is far more complex than in the bacterial form, employing multiple essential protein subunits in addition to the catalytic RNA subunit. RNomic studies have shown that RNase P binds other RNAs in addition to tRNAs, but no non-tRNA substrates have previously been identified. Additional substrates were identified by using a multipronged approach in the budding yeast Saccharomyces cerevisiae. First, RNase P-dependant changes in RNA abundance were examined on whole-genome microarrays by using strains containing temperature sensitive (TS) mutations in two of the essential RNase P subunits, Pop1p and Rpr1r. Second, RNase P was rapidly affinity-purified, and copurified RNAs were identified by using a genome-wide microarray. Third, to identify RNAs that do not change abundance when RNase P is depleted but accumulate as larger precursors, >80 potential small RNA substrates were probed directly by Northern blot analysis with RNA from the RNase P TS mutants. Numerous potential substrates were identified, of which we characterized the box C/D intron-encoded small nucleolar RNAs (snoRNAs), because these both copurify with RNase P and accumulate larger forms in the RNase P temperature-sensitive mutants. It was previously known that two pathways existed for excising these snoRNAs, one using the pre-mRNA splicing path and the other that was independent of splicing. RNase P appears to participate in the splicing-independent path for the box C/D intron-encoded snoRNAs.

Functional characterization of the conserved amino acids in Pop1p, the largest common protein subunit of yeast RNases P and MRP.

RNase P and RNase MRP are ribonucleoprotein enzymes required for 5'-end maturation of precursor tRNAs (pre-tRNAs) and processing of precursor ribosomal RNAs, respectively. In yeast, RNase P and MRP holoenzymes have eight protein subunits in common, with Pop1p being the largest at >100 kDa. Little is known about the functions of Pop1p, beyond the fact that it binds specifically to the RNase P RNA subunit, RPR1 RNA. In this study, we refined the previous Pop1 phylogenetic sequence alignment and found four conserved regions. Highly conserved amino acids in yeast Pop1p were mutagenized by randomization and conditionally defective mutations were obtained. Effects of the Pop1p mutations on pre-tRNA processing, pre-rRNA processing, and stability of the RNA subunits of RNase P and MRP were examined. In most cases, functional defects in RNase P and RNase MRP in vivo were consistent with assembly defects of the holoenzymes, although moderate kinetic defects in RNase P were also observed. Most mutations affected both pre-tRNA and pre-rRNA processing, but a few mutations preferentially interfered with only RNase P or only RNase MRP. In addition, one temperature-sensitive mutation had no effect on either tRNA or rRNA processing, consistent with an additional role for RNase P, RNase MRP, or Pop1p in some other form. This study shows that the Pop1p subunit plays multiple roles in the assembly and function of of RNases P and MRP, and that the functions can be differentiated through the mutations in conserved residues.

Ethanol- and Fe(+2)-induced membrane lipid oxidation is not additive in developing chick brains.

In order to study the effects of exogenous EtOH and/or Fe(+2) on membrane lipid peroxidation, exogenous EtOH, FeCl(2), FeCl(2) & EtOH, NaCl and NaCl & EtOH were injected into fertile chicken eggs. Controls were either shams or injected with saline. These injections were made at 0 days or 0-2 days of development and tissue removed at stage 37 (11 days of development). Embryonic exposure to exogenous EtOH and/or Fe(+2) promoted decreased brain mass, decreased levels of brain membrane polyunsaturated fatty acids, elevated levels of brain lipid hydroperoxides, and elevated levels of Fe(+2) within embryonic brain and liver. These alterations were more severe in triple-injected embryos (E0-2/E11) as compared to single-injected embryos (E0/E11). While exogenous treatments of either EtOH and/or FeCl(2) promoted increased levels of endogenous brain Fe(+2), the effects were not additive. These observations are consistent with the hypothesis that embryonic exposure to exogenous EtOH and/or Fe(+2) promotes brain membrane lipid peroxidation.