Baseline Cognitive Performance and Treatment Outcomes From Cognitive-Behavioral Therapies for Posttraumatic Stress Disorder: A Naturalistic Study.

OBJECTIVE: Approximately 5%-20% of U.S. troops returning from Iraq and Afghanistan have posttraumatic stress disorder (PTSD), and another 11%-23% have traumatic brain injury (TBI). Cognitive-behavioral therapies (CBTs) are empirically validated treatment strategies for PTSD. However, cognitive limitations may interfere with an individual's ability to adhere to as well as benefit from such therapies. Comorbid TBI has not been systematically taken into consideration in PTSD outcome research or in treatment planning guidance. The authors hypothesized that poorer pretreatment cognitive abilities would be associated with poorer treatment outcomes from CBTs for PTSD. METHODS: This study was designed as a naturalistic examination of treatment as usual in an outpatient clinic that provides manualized CBTs for PTSD to military service members and veterans. Participants were 23 veterans, aged 18-50 years, with combat-related PTSD and a symptom duration of more than 1 year. Of these, 16 participants had mild TBI (mTBI). Predictor variables were well-normed objective tests of cognitive ability measured at baseline. Outcome variables were individual slopes of change of the PTSD Checklist for DSM-5 (PCL-5) and the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) over weeks of treatment, and of pretreatment-to-posttreatment change in PCL-5 and CAPS-5 (ΔPCL-5 and ΔCAPS-5, respectively). RESULTS: Contrary to prediction, neither pretreatment cognitive performance nor the presence of comorbid mTBI predicted poorer response to CBTs for PTSD. CONCLUSIONS: These results discourage any notion of excluding patients with PTSD and poorer cognitive ability from CBTs.

Pilot Study of Neurological Soft Signs and Depressive and Postconcussive Symptoms During Recovery From Mild Traumatic Brain Injury (mTBI).

Neurological soft signs (NSSs) tap into a variety of perceptual, motor, and cognitive functions. The authors administered a battery of NSSs serially to a group of 14 pilot patients recruited from an emergency room after they experienced a mild traumatic brain injury. Patients were seen within 96 hours after injury, and again 30 and 90 days later. Measures of balance, mood, and postconcussive symptoms and impairment were also obtained. NSSs and balance improved across visits. Across visits, NSSs and balance were not significantly associated with any postconcussive outcome measures, although depressive symptoms were. Initial neurological impairment appeared to predict subsequent residual postconcussive symptoms and impairment, but this result requires replication.

Stress, PTSD, and dementia.

The physiological consequences of acute and chronic stress on a range of organ systems have been well documented after the pioneering work of Hans Selye more than 70 years ago. More recently, an association between exposure to stressful life events and the development of later-life cognitive dysfunction has been proposed. Several plausible neurohormonal pathways and genetic mechanisms exist to support such an association. However, many logistical and methodological barriers must be overcome before a defined causal linkage can be firmly established. Here the authors review recent studies of the long-term cognitive consequences of exposures to cumulative ordinary life stressors as well as extraordinary traumatic events leading to posttraumatic stress disorder. Suggestive effects have been demonstrated for the role of life stress in general, and posttraumatic stress disorder in particular, on a range of negative cognitive outcomes, including worse than normal changes with aging, Alzheimer's disease, and vascular dementia. However, given the magnitude of the issue, well-controlled studies are relatively few in number, and the effects they have revealed are modest in size. Moreover, the effects have typically only been demonstrated on a selective subset of measures and outcomes. Potentially confounding factors abound and complicate causal relationships despite efforts to contain them. More well-controlled, carefully executed longitudinal studies are needed to confirm the apparent association between stress and dementia, clarify causal relationships, develop reliable antemortem markers, and delineate distinct patterns of risk in subsets of individuals.

Sacroiliac joint arthropathy in adult spinal deformity patients with long constructs to the pelvis.

OBJECTIVE: Sacroiliac joint (SIJ) arthropathy is an increasingly recognized problem in adult spinal deformity patients undergoing long construct surgery. S2-alar-iliac (S2AI) screw instrumentation is thought to reduce morbidity from pelvic fixation in these patients. The goal of this study is to assess the overall incidence of SIJ arthropathy in patients with long constructs to the pelvis as well as compare SIJ outcomes of partially threaded (PT) versus fully threaded (FT) S2AI screws. METHODS: Data of eligible patients were collected from a prospectively maintained database with retrospective review of electronic records at an academic institution between 2016 and 2019. RESULTS: 65 consecutive patients who underwent S2AI screw instrumentation (40 in PT group, 25 in FT group) were enrolled. The rate of postoperative SIJ pain was higher in the PT (52.5 %) compared to FT (32 %) group. There was a significantly shorter time-to-pain development in the PT compared to FT group (11.8 versus 20.1 months, respectively). Of those who developed SIJ pain in the PT group, the pain worsened in 80.9 % versus only 25 % of those in the FT group despite conservative treatment. Cox regression found the PT group more likely to develop SIJ pain at any point during follow-up compared to the FT group (Hazard Ratio = 7.308). SIJ fusion was not detected on imaging of any patient during follow-up. CONCLUSION: FT S2AI screws are associated with better SIJ outcomes compared to PT screws. However, our data suggest that S2AI screw instrumentation is not sufficient to achieve fusion or prevent development of SIJ pain. Concurrent SIJ fusion may be necessary in patients with long constructs to prevent SIJ arthropathy.

Minimally Invasive Lateral Retropleural Approach to the Thoracic Spine for Salvage of a Subsided Expandable Interbody Cage.

BACKGROUND: Cylindrical expandable cages are commonly used as interbody grafts after cervical, thoracic, or lumbar corpectomy in patients with osteomyelitis. Unfortunately, there is a high incidence of hardware subsidence due to small-diameter footplates. Newer expandable intervertebral cages with large rectangular endcaps use the anatomic strength of the vertebral epiphyseal ring to prevent subsidence. CASE DESCRIPTION: A 67-year-old man with medically refractory thoracic osteomyelitis and discitis presented to our service for further management of debilitating back pain secondary to a persistent infection and associated progressive spinal kyphotic deformity. He underwent a transpedicular T9-10 corpectomy, placement of an expandable interbody cage, and posterior instrumented spinal fusion from T7 to T12. On postoperative day 2, upright thoracic radiographs demonstrated cage subsidence of >50% into the T8 vertebral body. The patient was returned to the operating room for hardware revision and placement of an expandable intervertebral cage with rectangular endcaps through a minimally invasive lateral retropleural approach to the thoracic spine. The patient tolerated the procedure well, and no evidence of subsidence occurred after the revision after 2 years of follow-up. CONCLUSIONS: Expandable intervertebral cages with rectangular endcaps can be used to prevent and/or correct preexisting cage subsidence in patients in need of anterior column instrumentation, especially in those with bone-weakening pathologies. Prospective studies should be entertained to evaluate subsidence rates in cages with cylindrical versus rectangular endcaps.

Minimally Invasive Lateral Retropleural and Retroperitoneal Approaches in Patients with Thoracic and Lumbar Osteomyelitis: Description of the Techniques and a Series of 14 Patients.

BACKGROUND: The growing interest in minimally invasive approaches to the thoracic and lumbar spine is mostly secondary to the high surgical morbidity and complication rates associated with conventional open approaches. The objective was to report the largest series of patients with thoracic and lumbar vertebral osteomyelitis who underwent multilevel corpectomies using the minimally invasive lateral (MIL) retropleural and retroperitoneal approaches. METHODS: The surgical techniques of the MIL approaches are illustrated and described in detail. The MIL retropleural approach was performed in 9 patients, MIL retroperitoneal approach in 3 patients, and combined MIL retropleural/retroperitoneal approach in 2 patients with thoracic, lumbar and thoracolumbar vertebral osteomyelitis, respectively. RESULTS: Multilevel corpectomies were successfully accomplished in all 14 patients using the MIL approaches (11 patients with 2-level corpectomy, 2 patients with 3-level corpectomy, and 1 patient with extension of a 3-level corpectomy to 6 levels). Correction of kyphotic deformity was achieved postoperatively in all 14 patients and remained stable with no proximal junctional kyphosis for a median of 10 months of follow-up on 10 patients; 4 patients were lost to follow-up after discharge from the hospital. Posterior instrumentation was performed in 12 patients to further support the spinal alignment. CONCLUSIONS: The MIL retropleural and retroperitoneal approaches described in this manuscript are feasible and safe in achieving multilevel corpectomies, anterior column reconstruction, and spinal deformity correction in patients with thoracic, lumbar, and thoracolumbar vertebral osteomyelitis.

Impact of the COVID-19 Pandemic on Neurosurgical Practice at an Academic Tertiary Referral Center: A Comparative Study.

BACKGROUND: Neurosurgical services have been affected by the 2019 novel coronavirus disease (COVID-19) pandemic, and several departments have reported their experiences and responses to the COVID-19 crisis in an attempt to provide insights from which other impacted departments can benefit. The goals of this study were to report the load and variety of emergent/urgent neurosurgical cases after implementing the "Battle Plan" at an academic tertiary referral center during the COVID-19 pandemic and to compare these variables with previous practice at the same institution. METHODS: The clinical data of all patients who underwent a neurosurgical intervention between March 23, 2020, and April 20, 2020, were obtained from a prospectively maintained database. Data of the control group were retrospectively collected from the medical records to compare the types of surgeries/interventions performed by the same neurosurgical service before the COVID-19 pandemic started. RESULTS: Over a 4-week period during the COVID-19 pandemic, 91 patients underwent emergent, urgent, and essential neurosurgical interventions. Patient screening at teleclinics identified 11 urgent surgical cases. The implementation of the Battle Plan led to a significant decrease in the caseload, and the variation of cases by subspecialty was evident when compared with a control group comprising 214 patients. CONCLUSIONS: Delivery of optimal care and safe practice and education at an academic neurosurgical department can be well maintained with proper execution of crisis protocols. Teleclinics proved to be efficient in screening patients for urgent neurosurgical conditions, but in-person clinic visits may still be necessary for some cases in the immediate postoperative period.

Management of Thoracic Disc Herniation Using the Mini-Open Retropleural Approach: Technique Illustration and Clinical Outcomes of 33 Patients From a Single Academic Center.

BACKGROUND: Conventional surgical approaches used in the management of thoracic disc herniation (TDH) are associated with high morbidity. The development of minimally invasive and mini-open approaches has consistently improved patient outcomes. OBJECTIVE: To report our experience and outcomes of patients with symptomatic TDHs who underwent discectomy and partial corpectomy using the mini-open retropleural (MORP) approach as well as provide a detailed and illustrated technical description of the approach. METHODS: Retrospective chart review was performed on all patients with symptomatic TDHs who underwent a MORP approach at a tertiary academic center between 2011 and 2019. Patient demographic, clinical, and imaging data were examined (n = 33). The surgical technique is illustrated and described in detail. RESULTS: Discectomy of the herniated thoracic discs was successfully achieved in all patients using the MORP approach. Calcified discs were present in 63.6% (n = 21) of patients. Immediate instrumentation and fusion were performed in 30.3% (n = 10) of patients, which were among the earlier cases in this series. Symptomatic pleural effusions and cerebrospinal fluid leakage occurred in 6.1% (n = 2) and 9.1% (n = 3), respectively. No patient required chest tube placement. CONCLUSION: The MORP approach described in this manuscript is feasible and safe in achieving discectomy in patients with symptomatic TDHs. Compared to conventional open and other minimally invasive approaches, patients undergoing the MORP approach may have better outcomes with lower complication rates.

The Return Back to Typical Practice from the "Battle Plan" of the Coronavirus Disease 2019 (COVID-19) Pandemic: A Comparative Study.

BACKGROUND: Every aspect of the medical field has been heavily affected by the coronavirus disease 2019 (COVID-19) pandemic, and neurosurgical services are no exception. Several departments have reported their experiences and protocols to provide insights for others impacted. The goals of this study are to report the load and variety of neurosurgical cases and clinic visits after discontinuing the COVID-19 Battle Plan at an academic tertiary care referral center to provide insights for other departments going through the same transition. METHODS: The clinical data of all patients who underwent a neurosurgical intervention between May 4, 2020, and June 4, 2020 were obtained from a prospectively maintained database. Data of the control group were retrospectively collected from the medical records to compare the types of surgeries/interventions and clinic visits performed by the same neurosurgical service before the COVID-19 pandemic started. RESULTS: One hundred sixty-one patients underwent neurosurgical interventions, and seven-hundred one patients were seen in clinic appointments, in the 4-week period following easing back from our COVID-19 "Battle Plan." Discontinuing the "Battle Plan" resulted in increases in case load to above-average practice after a week but a continued decrease in clinic appointments throughout the 4 weeks compared with average practice. CONCLUSIONS: As policy-shaping crises like pandemics abate, easing back to "typical" practice can be completed effectively by appropriately allocating resources. This can be accomplished by anticipating increases in neurosurgical volume, specifically in the functional/epilepsy and brain tumor subspecialties, as well as continued decreases in neurosurgical clinic volume, specifically in elective spine.

Can mHealth Technology Help Mitigate the Effects of the COVID-19 Pandemic?

Goal: The aim of the study herein reported was to review mobile health (mHealth) technologies and explore their use to monitor and mitigate the effects of the COVID-19 pandemic. Methods: A Task Force was assembled by recruiting individuals with expertise in electronic Patient-Reported Outcomes (ePRO), wearable sensors, and digital contact tracing technologies. Its members collected and discussed available information and summarized it in a series of reports. Results: The Task Force identified technologies that could be deployed in response to the COVID-19 pandemic and would likely be suitable for future pandemics. Criteria for their evaluation were agreed upon and applied to these systems. Conclusions: mHealth technologies are viable options to monitor COVID-19 patients and be used to predict symptom escalation for earlier intervention. These technologies could also be utilized to monitor individuals who are presumed non-infected and enable prediction of exposure to SARS-CoV-2, thus facilitating the prioritization of diagnostic testing.