The role of endoscopic endonasal surgery in the management of prolactinomas based on their invasiveness into the cavernous sinus.

PURPOSE: To review our institutional experience with the surgical management of prolactinomas through the endoscopic endonasal approach with specific focus on cavernous sinus invasion. METHODS: Clinical and radiographic data were collected retrospectively from the electronic medical record of 78 consecutive patients with prolactinomas undergoing endoscopic endonasal resection from 2002 to 2019. Immediate and late post-operative remission were defined as prolactin < 20 ng/mL within 14 days and 1-year of surgery without adjuvant therapy, respectively. Cavernous sinus invasion was quantified by Knosp score. RESULTS: A total of 78 patients with prolactinoma, 59% being male, underwent surgical resection with a mean age of 37 ± 13 years. Indications for surgery were medication resistance in 38 patients (48.7%), medication intolerance in 11 (14.1%), and patient preference in 29 (37.2%). Patients with Knosp 0-2 achieved higher immediate remission rates (83.8%) compared to patients with Knosp 3 (58.8%) and Knosp 4 (41.7%) patients (p = 0.003). Long-term remission rates were 48.7% and increased to 71.8% when combined with adjuvant treatments. Knosp 4 prolactinomas had significantly higher tumor volumes, higher preoperative prolactin levels, higher recurrence rates, higher rates of adjuvant therapy utilization, and were more likely to have failed dopamine agonist therapy compared to other tumor grades (p < 0.05). We encountered 18 complications in our series, and no cerebrospinal fluid leaks. CONCLUSION: The endoscopic endonasal approach is a safe and effective modality that can be employed in properly selected patients with invasive prolactinomas. It is associated with improved control and remission rates despite cavernous sinus invasion, though at a lower rate than without invasion.

Blood supply to the corticospinal tract: A pictorial review with application to cranial surgery and stroke.

The corticospinal tract (CST) is the main neural pathway responsible for conducting voluntary motor function in the central nervous system. The CST condenses into fiber bundles as it descends from the frontoparietal cortex, traveling down to terminate at the anterior horn of the spinal cord. The CST is at risk of injury from vascular insult from strokes and during neurosurgical procedures. The aim of this article is to identify and describe the vasculature associated with the CST from the cortex to the medulla. Dissection of cadaveric specimens was carried out in a manner, which exposed and preserved the fiber tracts of the CST, as well as the arterial systems that supply them. At the level of the motor cortex, the CST is supplied by terminal branches of the anterior cerebral artery and middle cerebral artery. The white matter tracts of the corona radiata and internal capsule are supplied by small perforators including the lenticulostriate arteries and branches of the anterior choroidal artery. In the brainstem, the CST is supplied by anterior perforating branches from the basilar and vertebral arteries. The caudal portions of the CST in the medulla are supplied by the anterior spinal artery, which branches from the vertebral arteries. The non-anastomotic nature of the vessel systems of the CST highlights the importance of their preservation during neurosurgical procedures. Anatomical knowledge of the CST is paramount to clinical diagnosis and treatment of heterogeneity of neurodegenerative, neuroinflammatory, cerebrovascular, and skull base tumors.

Long term results of primary radiosurgery for vestibular schwannomas.

BACKGROUND: Stereotactic radiosurgery (SRS) has become a primary option for management for both newly diagnosed vestibular schwannomas (VS), as well as VS that enlarge after initial observation. METHODS: A retrospective review of our prospectively maintained data base found 871 patients who underwent Gamma knife® SRS as their initial (primary) management between 1987 and 2008. Follow-up ranged from 1-25 years (median = 5.2 years) Median tumor volume was 0.9 cc (0.02-36) and median margin dose was 13 Gy (12-25). RESULTS: Progression free survival (PFS) after SRS was 97% at 3 years, 95% at 5 years, and 94% at 10 years. Freedom from delayed surgical resection was found in 98.7% of patients. Smaller tumor volume was significantly associated with improved PFS. There were 326 patients with serviceable hearing (Gardner-Robertson 1 or 2) at the time of SRS with audiological follow-up of ≥ 1 year. Serviceable hearing preservation rates after SRS were 89.8% at 1 year, 76.9% at 3 years, 68.4% at 5 years, 62.5% at 7 years, and 51.4% at 10 years. Factors associated with improved serviceable hearing preservation included younger age, Gardner-Robertson grade 1 at SRS, and absence of subjective complaints of dysequilibrium or vertigo (vestibulopathy). Fifty-one patients (5.8%) developed trigeminal neuropathy. Fourteen (1.6%) developed a transient House-Brackmann grade 2 or 3 facial neuropathy. CONCLUSIONS: In this report with extended follow-up, primary SRS achieved tumor growth control in 94% of patients. Optimization of long- term cranial nerve outcomes remains an important achievement of this management strategy for VS.

Isolated Traumatic Diastasis of the Clival Synchondroses without Clival Fracture.

Traumatic clival fractures in the pediatric population are associated with high mortality rates. In our previously reported series, a subset of clival fractures were associated with traumatic diastasis of the surrounding clival synchondroses. Herein, we describe a pediatric case of an isolated traumatic diastasis of the clival synchondroses without clival fracture with significant injury to neurovascular structures. To our knowledge this is the first report to describe this entity. Careful radiological attention should be made towards the clival synchondroses in crushing head injuries to best tailor screening for cerebrovascular injury even in the absence of clival fractures.

Stereotactic Radiosurgery as Initial Surgical Management for Elderly Patients with Trigeminal Neuralgia.

BACKGROUND: Management of older patients with medically refractory trigeminal neuralgia (TN) is yet a matter of debate. OBJECTIVE: We sought to determine the benefit of stereotactic radiosurgery (SRS) as the sole surgical management in older patients (≥70 years). METHODS: One hundred and twenty-seven patients (≥70 years) with typical TN underwent SRS as initial surgical management. The median maximum dose for the first procedure was 80 Gy. Repeat SRS was performed in 46 patients who developed recurrent pain. RESULTS: After the first SRS, the initial pain control was achieved in 91% of patients. Complete pain relief (Barrow Neurological Institute [BNI] score I) developed in 75 patients (59%) and was maintained in 59, 39, and 22% of patients at 1, 3, and 5 years. Following repeat SRS, the rate of complete pain relief was 79, 55, and 41% at 1, 3, and 5 years. The chance of BNI I preservation was greater after repeat SRS compared to initial SRS (hazards ratio: 2.02, p < 0.0001). The incidence of trigeminal sensory loss was 17% after initial SRS but increased to 39% after repeat SRS. CONCLUSIONS: SRS alone was used effectively in older TN patients to achieve pain control. Recurrent pain responded to retreatment but was associated with an increased risk of sensory dysfunction.

Electrospinography for non-invasively recording spinal sensorimotor networks in humans.

Objective. Currently, few non-invasive measures exist for directly measuring spinal sensorimotor networks. Electrospinography (ESG) is one non-invasive method but is primarily used to measure evoked responses or for monitoring the spinal cord during surgery. Our objectives were to evaluate the feasibility of ESG to measure spinal sensorimotor networks by determining spatiotemporal and functional connectivity changes during single-joint movements at the spinal and cortical levels.Approach. We synchronously recorded electroencephalography (EEG), electromyography, and ESG in ten neurologically intact adults while performing one of three lower-limb tasks (no movement, plantar-flexion and knee flexion) in the prone position. A multi-pronged approach was applied for removing artifacts usingH∞filtering, artifact subspace reconstruction and independent component (IC) analysis. Next, data were segmented by task and ICs of EEG were clustered across participants. Within-participant analysis of ICs and ESG data was conducted, and ESG was characterized in the time and frequency domains. Generalized partial directed coherence analysis was performed within ICs and between ICs and ESG data by participant and task.Results.K-means clustering resulted in five clusters of ICs at Brodmann areas (BAs) 9, BA 8, BA 39, BA 4, and BA 22. Areas associated with motor planning, working memory, visual processing, movement, and attention, respectively. Time-frequency analysis of ESG data found localized changes during movement execution when compared to no movement. Lastly, we found bi-directional changes in functional connectivity (p < 0.05, adjusted for multiple comparisons) within IC's and between IC's and ESG sensors during movement when compared to the no movement condition.Significance. To our knowledge this is the first report using high density ESG for characterizing single joint lower limb movements. Our findings provide support that ESG contains information about efferent and afferent signaling in neurologically intact adults and suggests that we can utilize ESG to directly study the spinal cord.

Synergistic implications of combinatorial rehabilitation approaches using spinal stimulation on therapeutic outcomes in spinal cord injury.

OBJECTIVE: The objective of this narrative review was to locate and assess recent articles employing a combinatorial approach of transcutaneous spinal cord stimulation or epidural spinal cord stimulation with additional modalities. We sought to provide relevant knowledge of recent literature and advance understanding on outcomes reported, to better equip those working in neurorehabilitation and neuromodulation. METHODS: Articles were selected and analyzed based on study approach, stimulation parameters, outcome measures, and presence of neurophysiological data to support findings. RESULTS: This narrative review analyzed 44 recent articles employing a combinatorial approach of transcutaneous spinal cord stimulation or epidural spinal cord stimulation with additional modalities. Our findings showed that limited research exists regarding such combinatorial approaches, particularly when considering modalities beyond activity-based training. There is also limited consistency in neurophysiological and quality of life outcomes. CONCLUSION: Articles involving transcutaneous spinal cord stimulation or epidural spinal cord stimulation with other modalities are limited in the current body of literature. Authors noted variety in approach, sample size, and use of participant perspective. Opportunities are present to add high quality research to this body of literature. SIGNIFICANCE: Transcutaneous spinal cord stimulation and epidural spinal cord stimulation are emerging in research as viable avenues for targeting improvement of function after traumatic spinal cord injury, particularly when combined with activity-based training. This body of literature demonstrates viable areas for growth from both neurophysiological and functional perspectives. Further, exploration of novel combinatorial approaches holds potential to offer enhanced contributions to clinical and neurophysiological rehabilitation and research.

Response to Letter Regarding "Predictive Value of Preoperative Serum Albumin in Patients With Metastatic Spine Diseases: A Statistical Comment".

We thank the authors for their interest in and commentary on "Preoperative Serum Albumin Level Predicts Length of Stay and Perioperative Adverse Events Following Vertebral Corpectomy and Posterior Stabilization for Metastatic Spine Disease." We appreciate the opportunity to respond to their comments herein.

Racial Disparities in Outcomes Following Surgical Fixation of Traumatic Thoracolumbar Fractures: A National Database Analysis.

OBJECTIVE: This study aims to assess race as an independent risk factor for postoperative complications after surgical fixation of traumatic thoracolumbar fractures for African American and Asian American patients compared with White patients. METHODS: The 2011-2021 American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) dataset was used to identify patients undergoing fusion surgeries for thoracolumbar spine fractures. Patient comorbidity burden was assessed using a modified 5-item frailty index score (mFI-5). Chi-squared and ANOVA tests were used to compare baseline clinical characteristics between groups. Multivariate analysis was performed to compare African American and Asian American patients with White patients controlling for age, BMI, and American Society of Anesthesiologists (ASA) score. RESULTS: African American patients experienced longer operative times compared to Asian American and White patients (3.74 ± 1.87 hours vs. 3.04 ± 1.71 hours and 3.48 ± 1.81 hours, P < 0.001). African American and Asian American patients demonstrated higher comorbidity burden with mFI-5>2 compared to White patients (30.7% and 25.6% vs. 19.9%, P < 0.001). African American and Asian American patients had a higher risk of postoperative complications than White patients (22.4% and 20% vs. 19.7%, P < 0.001). African American race was an independent risk factor of postoperative 30-day morbidity (OR 1.19, CI 1.11-1.28, P < 0.001). CONCLUSIONS: African American and Asian American patients undergoing thoracolumbar fusion surgeries exhibit disproportionate comorbidity burden, longer LOS, and greater postoperative complications compared with White patients. Furthermore, the African American race was associated with an increased rate of 30-day postoperative complications.

Restoration of respiration in high cervical spinal cord injury via phrenic nerve reinnervation: illustrative case.

BACKGROUND: Traumatic high cervical spinal cord injury (SCI) can result in a devastating loss of functional respiration, leaving patients permanently dependent on mechanical ventilation. Nerve transfer is a promising reinnervation strategy that has the potential to restore connectivity in paralyzed distal muscles. The spinal accessory nerve (SAN) remains functional in most cases after high cervical SCI and can serve as a donor to reinnervate the phrenic nerve (PN), thereby improving diaphragmatic function. OBSERVATIONS: Information regarding thorough physical, electrodiagnostic, and pulmonary assessments to establish candidacy for nerve transfer, as well as the surgical procedure, was summarized with an illustrative case. The patient demonstrated improvement in pulmonary function testing but did not achieve independent respiration. A systematic literature review identified 3 studies with 9 additional patients who had undergone SAN-to-PN transfer. The nerve transfer meaningfully restored diaphragmatic function, improving pulmonary function tests and reducing ventilator dependency. LESSONS: Respiratory dependency significantly impacts the quality of life of patients with a high cervical SCI. The use of the lower SAN motor branch for PN transfer is safe and does not result in a meaningful downgrade in trapezius function. Outcomes following this procedure are promising but heterogeneous, indicating a need for significant innovation and improvement for future therapies. https://thejns.org/doi/10.3171/CASE24236.

Treatment of Intrathecal Drug Pump Flipping Using Fascial Flaps: A Technical Description and Case Series.

BACKGROUND AND OBJECTIVES: Intrathecal drug therapy is a common treatment for dystonia, pain, and spasticity using implanted pump and catheter systems. Standardized management of intrathecal drug pump (ITDP) migration and flipping has not been well established in the literature. This study reports the use of soft tissue to address less common pump complications such as pump flipping, migration, and difficulty in medication refill. METHODS: A retrospective chart review of intrathecal pump cases performed by two surgeons between February 2020 and August 2022 was conducted. Patients with complications such as pump flipping, migration, or challenges in medication refill treated with soft tissue flaps were included. Patient demographics, comorbidities, and perioperative data were collected. RESULTS: A total of five patients with ITDP complicated by pump flipping, migration, malposition, or difficulty in medication refill that were treated using fascial flaps were included in the study. Three technical considerations when revising ITDP complications are secure pump anchoring, reliable wound closure, and ease of pump medication refill. Cases 1 and 2 demonstrate the technique of secure pump anchoring with a rectus fascial flap. Cases 3 and 4 show a technique to achieve reliable vascularized wound closure, and case 5 describes a technique to solve an uncommon problem of a thick subcutaneous abdominal tissue preventing the refill of the ITDP medication. CONCLUSION: Soft tissue flaps may serve as a treatment option for patients with uncommon ITDP complications. De-epithelialized dermal fasciocutaneous or fascial flaps may be developed to anchor the pump more securely. Cross-discipline collaboration may further delineate the technique, benefits, and outcomes of this approach.

Clinical outcomes of peripheral nerve interfaces for rehabilitation in paralysis and amputation: a literature review.

Peripheral nerve interfaces (PNIs) are electrical systems designed to integrate with peripheral nerves in patients, such as following central nervous system (CNS) injuries to augment or replace CNS control and restore function. We review the literature for clinical trials and studies containing clinical outcome measures to explore the utility of human applications of PNIs. We discuss the various types of electrodes currently used for PNI systems and their functionalities and limitations. We discuss important design characteristics of PNI systems, including biocompatibility, resolution and specificity, efficacy, and longevity, to highlight their importance in the current and future development of PNIs. The clinical outcomes of PNI systems are also discussed. Finally, we review relevant PNI clinical trials that were conducted, up to the present date, to restore the sensory and motor function of upper or lower limbs in amputees, spinal cord injury patients, or intact individuals and describe their significant findings. This review highlights the current progress in the field of PNIs and serves as a foundation for future development and application of PNI systems.

Electrokinetic convection-enhanced delivery for infusion into the brain from a hydrogel reservoir.

Electrokinetic convection-enhanced delivery (ECED) utilizes an external electric field to drive the delivery of molecules and bioactive substances to local regions of the brain through electroosmosis and electrophoresis, without the need for an applied pressure. We characterize the implementation of ECED to direct a neutrally charged fluorophore (3 kDa) from a doped biocompatible acrylic acid/acrylamide hydrogel placed on the cortical surface. We compare fluorophore infusion profiles using ECED (time = 30 min, current = 50 µA) and diffusion-only control trials, for ex vivo (N = 18) and in vivo (N = 12) experiments. The linear intensity profile of infusion to the brain is significantly higher in ECED compared to control trials, both for in vivo and ex vivo. The linear distance of infusion, area of infusion, and the displacement of peak fluorescence intensity along the direction of infusion in ECED trials compared to control trials are significantly larger for in vivo trials, but not for ex vivo trials. These results demonstrate the effectiveness of ECED to direct a solute from a surface hydrogel towards inside the brain parenchyma based predominantly on the electroosmotic vector.

Modified 5-Item Frailty Index: A Useful Tool for Assessing the Impact of Frailty on Postoperative Morbidity and Mortality Following Surgical Fixation of Thoracolumbar Fractures.

OBJECTIVES: The modified 5-item frailty index (mFI-5) is a comorbidity-based risk stratification tool to predict adverse events following various neurologic surgeries. This study aims to quantify the association between increased mFI-5 and postoperative complications and mortality following surgical fixation of traumatic thoracolumbar fractures. METHODS: The 2011-2021 American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) dataset was used to identify patients undergoing fusion surgeries for thoracolumbar spine fractures. The mFI-5 score was calculated based on the presence of 5 major comorbidities: congestive heart failure within 30 days before surgery, insulin-dependent or noninsulin-dependent diabetes mellitus, chronic obstructive pulmonary disease, partially dependent or totally dependent functional health status at the time of surgery, and hypertension requiring medication. Multivariate analysis assessed the independent impact of increasing mFI-5 scores on postoperative 30-day morbidity and mortality while controlling for baseline clinical characteristics. RESULTS: A total of 66,904 patients were included in our analysis (54.2% female, mean age 62.27 ± 12.93 years). On univariate analysis, higher mFI-5 score was significantly associated with increased risks of superficial surgical site infection, deep surgical site infection, wound dehiscence, unplanned reoperation, pneumonia, unplanned intubation, postoperative ventilator use, progressive renal insufficiency, acute renal failure, urinary tract infection, stroke, myocardial infarction, cardiac arrest, pulmonary embolism, deep vein thrombosis, bleeding requiring transfusion, sepsis, septic shock, and longer hospital length of stay (LOS). On multivariate logistic regression, increasing mFI-5 score versus a mFI-5 score of zero was associated with higher odds of overall complications (mFI-5 ≥2: odds ratio [OR] 1.38 CI: 1.24-1.54, P < 0.001; mFI-5 = 1: OR 1.18 CI: 1.11-1.24, P < 0.001) and 30-day mortality (mFI-5 ≥2: OR 2.33 CI: 1.60-3.38, P < 0.001). CONCLUSION: This study demonstrates that frailty, when measured using the mFI-5, independently predicts postoperative complications, hospital LOS, and 30-day mortality after surgical repair of thoracolumbar fractures. These findings are important for risk stratification in patients undergoing thoracolumbar fusion surgery and for standardization in reporting outcomes after those procedures.

Influence of Hospital Transfer Status on Surgical Outcomes for Traumatic Thoracolumbar Spine Fractures: Insights from a Multicenter Investigation.

OBJECTIVES: Surgical intervention for unstable thoracolumbar spine fractures is common, but delayed management and complications can impact outcomes. This study compares perioperative outcomes between patients directly admitted and those transferred from another facility for thoracolumbar spine surgery, aiming to identify predictors of complications and mortality. METHODS: A multicenter retrospective cohort study used the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2011 to 2021 identified 61,626 patients undergoing fusion surgeries for thoracolumbar spine fractures, excluding spinal cord injury or pathological fractures. Patients were categorized as Direct (admitted from the emergency department) and Transfer (transferred from another facility). Perioperative outcomes, including operative time, length of stay (LOS), 30-day mortality, and complications were compared. RESULTS: Our patient population (54.3% female, mean age 62.4 ± 12.9 years) comprised 12.2% Transfer and 87.8% Direct patients. Following propensity score matching, Transfer patients had a longer hospital LOS (5.1±5.7 days vs 4.5±4.6 days, p<0.001). Transfer exhibited higher rates of superficial incisional surgical site infection (1.7% vs 1.1%, p=0.003), sepsis (1.7% vs 1.3%, p=0.038), pneumonia (1.7% vs 1.2%, p=0.019), postoperative reintubation (0.9% vs 0.6%, p=0.036), and failure to wean off ventilator >48 hours post-surgery (0.7% vs 0.3%, p=0.005) compared to Direct admissions. Direct group had higher rate of perioperative transfusion (16.5% vs 13.4%, p<0.001). Transfer patients also had higher 30-day mortality rate compared to Direct admissions (1.1% vs 0.6%, p=0.002). CONCLUSIONS: Interhospital transfers significantly affect hospital LOS, postoperative morbidity, and mortality in thoracolumbar spine surgery. Enhancing postoperative monitoring for transfer patients is crucial.

Transabdominal motor evoked potential neuromonitoring of lumbosacral spine surgery.

BACKGROUND CONTEXT: Transcranial Motor Evoked Potentials (TcMEPs) can improve intraoperative detection of femoral plexus and nerve root injury during lumbosacral spine surgery. However, even under ideal conditions, TcMEPs are not completely free of false-positive alerts due to the immobilizing effect of general anesthetics, especially in the proximal musculature. The application of transcutaneous stimulation to activate ventral nerve roots directly at the level of the conus medularis (bypassing the brain and spinal cord) has emerged as a method to potentially monitor the motor component of the femoral plexus and lumbosacral nerves free from the blunting effects of general anesthesia. PURPOSE: To evaluate the reliability and efficacy of transabdominal motor evoked potentials (TaMEPs) compared to TcMEPs during lumbosacral spine procedures. DESIGN: We present the findings of a single-center 12-month retrospective experience of all lumbosacral spine surgeries utilizing multimodality intraoperative neuromonitoring (IONM) consisting of TcMEPs, TaMEPs, somatosensory evoked potentials (SSEPs), electromyography (EMG), and electroencephalography. PATIENT SAMPLE: Two hundred and twenty patients having one, or a combination of lumbosacral spine procedures, including anterior lumbar interbody fusion (ALIF), lateral lumbar interbody fusion (LLIF), posterior spinal fusion (PSF), and/or transforaminal lumbar interbody fusion (TLIF). OUTCOME MEASURES: Intraoperative neuromonitoring data was correlated to immediate postoperative neurologic examinations and chart review. METHODS: Baseline reliability, false positive rate, true positive rate, false negative rate, area under the curve at baseline and at alerts, and detection of preoperative deficits of TcMEPs and TaMEPs were compared and analyzed for statistical significance. The relationship between transcutaneous stimulation voltage level and patient BMI was also examined. RESULTS: TaMEPs were significantly more reliable than TcMEPs in all muscles except abductor hallucis. Of the 27 false positive alerts, 24 were TcMEPs alone, and 3 were TaMEPs alone. Of the 19 true positives, none were detected by TcMEPs alone, 3 were detected by TaMEPs alone (TcMEPs were not present), and the remaining 16 true positives involved TaMEPs and TcMEPs. TaMEPs had a significantly larger area under the curve (AUC) at baseline than TcMEPs in all muscles except abductor hallucis. The percent decrease in TcMEP and TaMEP AUC during LLIF alerts was not significantly different. Both TcMEPs and TaMEPs reflected three preexisting motor deficits. Patient BMI and TaMEP stimulation intensity were found to be moderately positively correlated. CONCLUSIONS: These findings demonstrate the high reliability and predictability of TaMEPs and the potential added value when TaMEPs are incorporated into multimodality IONM during lumbosacral spine surgery.

Impact of Upper Limb Motor Recovery on Functional Independence After Traumatic Low Cervical Spinal Cord Injury.

Cervical spinal cord injury (SCI) causes devastating loss of upper limb function and independence. Restoration of upper limb function can have a profound impact on independence and quality of life. In low-cervical SCI (level C5-C8), upper limb function can be restored via reinnervation strategies such as nerve transfer surgery. The translation of recovered upper limb motor function into functional independence in activities of daily living (ADLs), however, remains unknown in low cervical SCI (i.e., tetraplegia). The objective of this study was to evaluate the association of patterns in upper limb motor recovery with functional independence in ADLs. This will then inform prioritization of reinnervation strategies focused to maximize function in patients with tetraplegia. This retrospective study performed a secondary analysis of patients with low cervical (C5-C8) enrolled in the SCI Model Systems (SCIMS) database. Baseline neurological examinations and their association with functional independence in major ADLs-i.e., eating, bladder management, and transfers (bed/wheelchair/chair)-were evaluated. Motor functional recovery was defined as achieving motor strength, in modified research council (MRC) grade, of ≥ 3 /5 at one year from ≤ 2/5 at baseline. The association of motor function recovery with functional independence at one-year follow-up was compared in patients with recovered elbow flexion (C5), wrist extension (C6), elbow extension (C7), and finger flexion (C8). A multi-variable logistic regression analysis, adjusting for known factors influencing recovery after SCI, was performed to evaluate the impact of motor function at one year on a composite outcome of functional independence in major ADLs. Composite outcome was defined as functional independence measure score of 6 or higher (complete independence) in at least two domains among eating, bladder management, and transfers. Between 1992 and 2016, 1090 patients with low cervical SCI and complete neurological/functional measures were included. At baseline, 67% of patients had complete SCI and 33% had incomplete SCI. The majority of patients were dependent in eating, bladder management, and transfers. At one-year follow-up, the largest proportion of patients who recovered motor function in finger flexion (C8) and elbow extension (C7) gained independence in eating, bladder management, and transfers. In multi-variable analysis, patients who had recovered finger flexion (C8) or elbow extension (C7) had higher odds of gaining independence in a composite of major ADLs (odds ratio [OR] = 3.13 and OR = 2.87, respectively, p < 0.001). Age 60 years (OR = 0.44, p = 0.01), and complete SCI (OR = 0.43, p = 0.002) were associated with reduced odds of gaining independence in ADLs. After cervical SCI, finger flexion (C8) and elbow extension (C7) recovery translate into greater independence in eating, bladder management, and transfers. These results can be used to design individualized reinnervation plans to reanimate upper limb function and maximize independence in patients with low cervical SCI.

Leukoencephalopathy after whole-brain radiation therapy plus radiosurgery versus radiosurgery alone for metastatic lung cancer.

BACKGROUND: As systemic therapies improve and patients live longer, concerns mount about the toxicity of whole-brain radiation therapy (WBRT) for treatment of brain metastases. Development of delayed white matter abnormalities indicative of leukoencephalopathy have been correlated with cognitive dysfunction. This study assesses the risk of imaging-defined leukoencephalopathy in patients whose management included WBRT in addition to stereotactic radiosurgery (SRS). This risk is compared to patients who only underwent SRS. METHODS: We retrospectively compared 37 patients with non-small cell lung cancer who underwent WBRT plus SRS to 31 patients who underwent only SRS. All patients survived at least 1 year after treatment. We graded the development of delayed white matter changes on magnetic resonance imaging using a scale to evaluate T(2) /FLAIR (fluid attenuated image recovery) images: grade 1 = little or no white matter hyperintensity; grade 2 = limited periventricular hyperintensity; and grade 3 = diffuse white matter hyperintensity. RESULTS: Patients treated with WBRT and SRS had a significantly greater incidence of delayed white matter leukoencephalopathy compared to patients who underwent SRS alone (P < .001). On final imaging, 36 of 37 patients (97.3%) treated by WBRT developed leukoencephalopathy (25% with grade 2; 70.8% with grade 3). Only 1 patient treated with SRS alone developed leukoencephalopathy. CONCLUSIONS: Risk of leukoencephalopathy in patients treated with SRS alone for brain metastases was significantly lower than that for patients treated with WBRT plus SRS. A prospective study is necessary to correlate these findings with neurocognition and quality of life. These data supplement existing reports regarding the differential effects of WBRT and SRS on normal brain structure and function.

Operative Technique and Nuances for the Stereoelectroencephalographic (SEEG) Methodology Utilizing a Robotic Stereotactic Guidance System.

The SEEG methodology has gained favor in North America over the last decade as a means of localizing the epileptogenic zone (EZ) prior to epilepsy surgery. Recently, the application of a robotic stereotactic guidance system for implantation of SEEG electrodes has become more popular in many epilepsy centers. The technique for the use of the robot requires extreme precision in the pre-surgical planning phase and then the technique is streamlined during the operative portion of the methodology, as the robot and surgeon work in concert to implant the electrodes. Herein is detailed precise operative methodology of using the robot to guide implantation of SEEG electrodes. A major limitation of the procedure, namely its heavy reliance on the ability to register the patient to a preoperative volumetric magnetic resonance image (MRI), is also discussed. Overall, this procedure has been shown to have a low morbidity rate and an extremely low mortality rate. The use of a robotic stereotactic guidance system for the implantation of SEEG electrodes is an efficient, fast, safe, and accurate alternative to conventional manual implantation strategies.

Implantation accuracy and operative variables in robot-assisted stereoelectroencephalography.

OBJECTIVE: The stereoelectroencephalography (SEEG) procedure provides a unique 3D overview of the seizure-onset zone. Although the success of SEEG relies on the accuracy of depth electrode implantation, few studies have investigated how different implantation techniques and operative variables affect accuracy. This study examined the effect of two different electrode implantation techniques (external vs internal stylet) on implantation accuracy while controlling for other operative variables. METHODS: The implantation accuracy of 508 depth electrodes from 39 SEEG cases was measured after coregistration of postimplantation CT or MR images with planned trajectories. Two different implantation techniques were compared: preset length with internal stylet use and measured length with external stylet use. Correlations between implantation accuracy and technique type, entry angle, intended implantation depth, and other operative variables were determined statistically using multiple regression analysis. RESULTS: Multiple regression analysis showed that the internal stylet technique exhibited a larger target radial error (p = 0.046) and angular deviation (p = 0.039) with a smaller depth error (p < 0.001) than the external stylet technique. Entry angle and implantation depth were positively correlated with target radial error (p = 0.007 and < 0.001, respectively) only for the internal stylet technique. CONCLUSIONS: Better target radial accuracy was achieved when an external stylet was used to open the intraparenchymal pathway for the depth electrode. In addition, more oblique trajectories were equally accurate to orthogonal ones with the usage of an external stylet, while more oblique trajectories were associated with larger target radial errors with the usage of an internal stylet (without an external stylet).