Evaluating the Impact of the COVID-19 Pandemic on Late-Canceled and No-Show Appointments at the Department of Neurological Surgery.

The coronavirus disease 2019 (COVID-19) pandemic resulted in unprecedented restrictions on the general public and disturbances to the routines of hospitals worldwide. These restrictions are now being relaxed as the number of vaccinated individuals increases and as the rates of incidence and prevalence decrease; however, they left a lasting impact on healthcare systems that is still being felt today. This retrospective study evaluated the total number of canceled or missed outpatient clinic appointments in a Neurological Surgery department before and after peak COVID-19 restrictions and attempted to assess the impact of these disruptions on neurosurgical clinical attendance. We also attempted to compare our data with the data from another surgical subspecialty department. We evaluated 32,558 scheduled appointments at the Loyola University Medical Center Department of Neurological Surgery, as well as 139,435 scheduled appointments with the Department of Otolaryngology. Appointments before April 2020 were defined as pre-COVID, while appointments during or after April 2020 were defined as post-COVID. Here, we compare no-show and non-attendance rates (no-shows plus late-canceled appointments) within the respective time range. Overall, we observed that before COVID-19 restrictions were put into place, there was an 8.9% no-show rate and a 17.4% non-attendance rate for the Department of Neurological Surgery. After COVID restrictions were implemented, these increased to 10.9% and 18.3%, respectively. Greater no-show and cancellation rates (9.8% in the post-COVID era vs 8.0% in the pre-COVID era) were associated with varying socioeconomic and racial demographics. African-American patients (2.56 times higher), new-visit patients (1.67 times higher), and those with Medicaid/Medicare insurance policies (1.48 times higher) were at the highest risk of no-show in the post-COVID era compared to the pre-COVID era.

Anti-aquaporin-4 immunoglobulin G/anti-myelin oligodendrocyte glycoprotein immunoglobulin G double-positive paraneoplastic neurological syndrome in a patient with triple-negative breast cancer.

We report a rare case of paraneoplastic neurological syndrome with dual seropositivity of anti-aquaporin-4 and myelin oligodendrocyte glycoprotein antibodies in a 40 year-old woman with metastatic triple-negative breast cancer. She received multiple lines of anti-neoplastic treatment, including immunotherapy with pembrolizumab, as well as cytotoxic chemotherapy. Paraneoplastic meningoencephalomyelitis developed 2 years after diagnosis of breast cancer and 1 year after discontinuation of immunotherapy with pembrolizumab. She first developed longitudinally extending transverse myelitis followed by left optic neuritis and meningoencephalitis with new enhancing lesions in the brain and spinal leptomeninges. Cerebrospinal fluid analysis during both episodes showed normal glucose and protein, and elevated white blood cell count. Cytology was negative for malignancy. Cerebrospinal fluid was positive for neuromyelitis optica immunoglobulin G antibody anti-aquaporin-4, and autoimmune myelopathy panel was positive for myelin oligodendrocyte glycoprotein antibody. The patient had significant clinical and radiographic improvement after completion of five cycles of plasmapheresis followed by intravenous immunoglobulin. She did not have recurrence of paraneoplastic syndrome with maintenance rituximab every 6 months and daily low-dose prednisone. She succumbed to progressive systemic metastatic disease 4.5 years after her breast cancer diagnosis. This case shows that these antibodies can occur concurrently and cause clinical features, such as both neuromyelitis optica spectrum disorder and myelin oligodendrocyte glycoprotein antibody disease, in a patient with a singular type of cancer. We highlight the importance of testing for paraneoplastic etiology in cancer patients with radiographic menigoencephalomyelitis or meningitis with atypical symptoms of meningeal carcinomatosis and/or cerebrospinal fluid profile negative for leptomeningeal carcinomatosis.

Cerebral arterial vasospasm complicating supratentorial meningioma resection: illustrative cases.

BACKGROUND: Cerebral arterial vasospasm is a rare complication after supratentorial meningioma resection. The pathophysiology of this condition may be similar to vasospasm after aneurysmal subarachnoid hemorrhage, and treatment options may be similar. OBSERVATIONS: The authors present two cases of cerebral vasospasm after supratentorial meningioma resection and perform a systematic literature review of similar cases. LESSONS: Cerebral arterial vasospasm after supratentorial meningioma resection may be associated with significant morbidity due to cerebral ischemia if not addressed in a timely manner. Treatment paradigms may be adopted from the management of arterial vasospasm associated with subarachnoid hemorrhage.

Impact of a Hands-on Pre-Clinical Neurosurgery Elective Course on Second-Year Medical Student Interest and Attitudes.

INTRODUCTION: Medical student involvement opportunities and educational experiences with surgical residents during medical school have been shown to increase the chance of students deciding to specialize in surgical specialties. This study aims to determine the effect of a neurosurgery elective during the second preclinical year on student interest and opinion of neurosurgery. METHODS: Thirty-nine students completed opinion-based surveys and factual knowledge quizzes during a neurosurgical elective course over 3 iterations, which included lecture and skills lab instruction. Pre- and post-course surveys used the Likert scale, with a score of 1 corresponding to the most negative opinion and a score of 10 corresponding to the most positive opinion, in order to measure various aspects including interest in neurological surgery, understanding of the field, and perception of female inclusion in the field. Weekly pre- and post-lecture quizzes assessed practical knowledge of neurosurgical topics. RESULTS: A higher percentage of students rated neurosurgery highly as a career possibility (⩾8/10 interest level) post-course (58.6%) compared to pre-course (45.7%). Post-course, students reported a significantly increased mean understanding of neurosurgery on the Likert scale compared to pre-course (6.1 ± 1.7 vs 4.4 ± 2.0; P = .001). Knowledge based-content assessment revealed a significant increase in overall correct answers after lectures (meanpre = 3.85, meanpost = 5.05, P = .001). Inclusion of female instructors in the second and third iteration of the course resulted in a significant increase in students' perception of female inclusion in the field of neurosurgery (7.6 compared to 5.6, P = .01). CONCLUSIONS: Early exposure to subspecialties may assist in making important career decisions. The implementation of this neurosurgical elective improved medical students' perception of the field and enhanced knowledge of the lectures and procedures. This study can be used as a framework for implementation of this curriculum at other institutions.

Development and Evaluation of a Preoperative Trigeminal Neuralgia Scoring System to Predict Long-Term Outcome Following Microvascular Decompression.

BACKGROUND: Microvascular decompression (MVD) can be an effective intervention for trigeminal neuralgia (TN); however, an optimal system for patient selection and surgical outcome prediction has not been defined. OBJECTIVE: To develop and validate a preoperative TN grading system for the prediction of long-term pain relief after MVD. METHODS: This retrospective cohort study included consecutive patients suffering unilateral TN who underwent MVD with >18-mo follow-up. A grading system was formulated using 3 previously validated preoperative characteristics. The primary end-point was long-term, pain-free status without use of medication. Ability to predict pain-free status was analyzed by multiple regression and assessed by area under the receiver operating characteristic curve (AUC). Clinical utility to predict MVD success and reduce unnecessary surgeries was assessed by decision-curve analysis. RESULTS: Of 208 patients analyzed, 73% were pain-free without medication at >18-mo follow-up. Pain-free status was predicted by classical TN type, positive response to carbamazepine and/or oxcarbazepine, and presence and nature of neurovascular compression demonstrated on MRI (all P < .01). The TN grading system demonstrated good discriminatory ability for prediction of pain-free status (AUC 0.85, 95% CI 0.80-0.91). Decision-curve analysis demonstrated a net reduction of 20 cases likely to be unsuccessful per 100 patients evaluated with this grading system above a decision threshold of 80%. CONCLUSION: This TN grading system reliably predicts long-term pain-free status without medications following MVD. The use of the TN grading system as part of a comprehensive work-up may reduce the number of unsuccessful operations.

Citation analysis of the most influential articles on traumatic spinal cord injury.

Objective: We conducted a citation analysis in order to catalog and pay tribute to the 100 most influential clinical research articles in traumatic spinal cord injury.Design: The Thomson Reuters Web of Science was searched in a two-step process without time period limitations. Review articles were excluded. In the first stage of data extraction, a Boolean query was used to identify the top 100 most cited clinical papers on traumatic spinal cord injury. One hundred and seven keywords were manually chosen and extracted from titles and abstracts. A second Boolean query used these keywords to broaden search results. The top 100 articles from this second stage search comprised the final list.Outcome Measures: For each article, measures evaluated were number of citations, average number of citations per year, time elapsed before first citation, and time elapsed until the year in which each article received its respective highest number of citations in a one-year period.Results: 119,991 articles were found in the second stage search. The top 100 most cited articles meeting inclusion criteria were identified within the first 2,104 results. Archives of Physical Medicine and Rehabilitation was the most represented journal, with 20 of the top 100 articles. The top 100 list averaged 255 citations per article. The most highly cited article was the NASCIS 2 trial by Bracken et al., cited 1500 times, which investigated the efficacy of methylprednisolone or naloxone for spinal cord injury.Conclusion: Clinical research in traumatic spinal cord injury has grown over time, expanding to encompass rehabilitation and experimental therapies in addition to acute management trials. The list may serve as an archive and reference for further studies in this field.

Significance of degree of neurovascular compression in surgery for trigeminal neuralgia.

OBJECTIVE: The aim of this study was to identify preoperative imaging predictors of surgical success in patients with classic trigeminal neuralgia (cTN) undergoing microvascular decompression (MVD) via retrospective multivariate regression analysis. METHODS: All included patients met criteria for cTN and underwent preoperative MRI prior to MVD. MR images were blindly graded regarding the presence and severity (i.e., mild or severe) of neurovascular compression (NVC). All patients were contacted by telephone to determine their postoperative pain status. RESULTS: A total of 79 patients were included in this study. Sixty-two patients (78.5%) were pain-free without medication following MVD. The following findings were more commonly observed with the symptomatic nerve when compared to the contralateral asymptomatic nerve: NVC (any form), arterial compression alone, NVC along the proximal trigeminal nerve, and severe NVC (p values < 0.0001). The only imaging variable that was a statistically significant predictor of being pain-free without medication following MVD was severe NVC. Patients with severe NVC were 6.36 times more likely to be pain-free following MVD compared to those without severe NVC (p = 0.007). CONCLUSIONS: In patients with cTN undergoing MVD, severe NVC on preoperative MRI is a strong predictor of an excellent surgical outcome.

Trigeminal Nerve Compression Without Trigeminal Neuralgia: Intraoperative vs Imaging Evidence.

BACKGROUND: While high-resolution imaging is increasingly used in guiding decisions about surgical interventions for the treatment of trigeminal neuralgia, direct assessment of the extent of vascular contact of the trigeminal nerve is still considered the gold standard for the determination of whether nerve decompression is warranted. OBJECTIVE: To compare intraoperative and magnetic resonance imaging (MRI) findings of the prevalence and severity of vascular compression of the trigeminal nerve in patients without classical trigeminal neuralgia. METHODS: We prospectively recruited 27 patients without facial pain who were undergoing microvascular decompression for hemifacial spasm and had undergone high-resolution preoperative MRI. Neurovascular contact/compression (NVC/C) by artery or vein was assessed both intraoperatively and by MRI, and was stratified into 3 types: simple contact, compression (indentation of the surface of the nerve), and deformity (deviation or distortion of the nerve). RESULTS: Intraoperative evidence of NVC/C was detected in 23 patients. MRI evidence of NVC/C was detected in 18 patients, all of whom had intraoperative evidence of NVC/C. Thus, there were 5, or 28% more patients in whom NVC/C was detected intraoperatively than with MRI (Kappa = 0.52); contact was observed in 4 of these patients and compression in 1 patient. In patients where NVC/C was observed by both methods, there was agreement regarding the severity of contact/compression in 83% (15/18) of patients (Kappa = 0.47). No patients exhibited deformity of the nerve by imaging or intraoperatively. CONCLUSION: There was moderate agreement between imaging and operative findings with respect to both the presence and severity of NVC/C.

MRI Findings and Outcomes in Patients Undergoing Microvascular Decompression for Glossopharyngeal Neuralgia.

BACKGROUND AND PURPOSE: Glossopharyngeal neuralgia causes extreme paroxysmal pain in the posterior pharynx, tonsillar region, base of tongue, or deep ear, that is, the distribution of the glossopharyngeal nerve. Some cases of glossopharyngeal neuralgia are associated with neurovascular conflict, usually by the posterior inferior cerebellar artery. Such symptomatic compression occurs only in proximal, centrally myelinated portions of the glossopharyngeal nerve near the brainstem. Microvascular decompression provides effective and durable pain relief for properly selected patients with medically refractory glossopharyngeal neuralgia. The purpose of this study is to describe a tailored MRI evaluation of neurovascular conflict in glossopharyngeal neuralgia to improve candidate selection for microvascular decompression. METHODS: Our team developed a glossopharyngeal neuralgia imaging and evaluation protocol including a grading system for neurovascular conflict of the glossopharyngeal nerve and applied it to evaluate candidates for microvascular decompression. RESULTS: Our team grades neurovascular conflict as "contact" (vessel touching nerve without intervening cerebrospinal fluid) versus "deformation" (deviation or distortion of nerve from its normal course by the offending vessel). MRIs of patients with glossopharyngeal neuralgia demonstrate proximal neurovascular conflict. Postoperative MRI demonstrates separation of the glossopharyngeal nerve from the offending vessel. CONCLUSION: A tailored glossopharyngeal neuralgia imaging evaluation protocol is presented. We believe this approach has helped improve microvascular decompression outcomes and reduce unnecessary procedures at our institution. Further research may elucidate whether clinical and imaging features, including neurovascular conflict severity, predict surgical outcome for glossopharyngeal neuralgia.