Minimally Destabilizing Corridor for Resection of Dumbbell Nerve Sheath Tumors: A Novel Surgical Technique.

BACKGROUND AND OBJECTIVES: Current surgical strategies for dumbbell nerve sheath tumors (DNSTs) with cord compression have primarily involved wide spinal exposures with total laminectomy and unilateral facetectomy, often leading to spinal destabilization and requiring fusion, or staged procedures separately addressing the intraspinal and extraforaminal tumor components. This study highlights technical nuances of a novel approach for DNST resection to minimize spinal destabilization and avoid fusion while facilitating safe, single-stage complete resection. METHODS: A retrospective chart review was conducted on patients undergoing DNST resection. Using unilateral subperiosteal dissection, hemilaminotomy and medial facetectomy procedures are performed. The extradural tumor component is resected, followed by internal decompression of the intradural tumor. A small horizontal incision at the origin of the nerve root sleeve releases the underlying dural stricture, facilitating delivery of the remaining intradural tumor and allowing section of the nerve root of origin. Ultrasonography confirms complete tumor resection and return of cord pulsation, and excludes intradural hemorrhagic complications. The dura is reconstructed using a dural substitute bolstered with fat graft and sealant. RESULTS: Twelve consecutive patients undergoing this approach from 2014 to 2021 were included. Mean patient age was 53.5 years, and 58.3% were male. Nine tumors were cervical and 3 were lumbar. Five patients presented with myelopathy, 4 with radiculopathy, and 4 with axial pain. Two cases had transient intraoperative neuromonitoring signal changes. Eleven tumors were diagnosed as schwannomas and 1 as neurofibroma. All patients had complete resection of the intraspinal component; 2 had far distal extraforaminal residual. No patient has had recurrence, progression of residual, or signs of spinal instability during follow-up (median 28.5 months, range 6-66 months). CONCLUSION: This study highlights technical considerations for DNST resection, focusing the approach at the center of the tumor, with minimal bone removal and ligamentous disruption. Intraoperative ultrasound is instrumental in the safety of this approach.

Increased Time to Fixation After Traumatic Spinal Cord Injury Influenced by Race and Insurance Status.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVES: Although the optimal timing of surgical intervention for traumatic spinal cord injury (TSCI) is controversial, early intervention has been recognized as being beneficial in several studies. The objective of this study was to evaluate the socioeconomic factors that may delay time to surgical fixation in the management of TSCI. METHODS: The present study utilized the Trauma Quality Improvement Program (TQIP) dataset to identify patients aged greater than 18 undergoing spinal fusion for TSCI from 2007-2016. Patients were divided into subgroups based on race and insurance types. Multivariable linear regression was used to compare time to procedure based on race and payer type while adjusting for demographic and injury-specific factors. Significance was set at P < .05. RESULTS: Using multivariable analysis, Hispanic and Black patients were associated with significantly increased time to fixation of 12.1 h (95% CI 5.5-18.7, P < .001), and 20.1 h (95% CI 12.1-28.1, P < .001), respectively compared to White patients. Other cohorts based on racial status did not have significantly different times to fixation (P > .05). Medicaid was associated with an increased time to fixation compared to private insurance (11.6 h, 95% CI 3.9-19.2, P = .003). CONCLUSIONS: Black and Hispanic race and Medicaid were associated with statistically significant increases in time to fixation following TSCI, potentially compromising quality of patient care and resulting in poorer outcomes. More research is needed to elucidate this relationship and ensure equitable care is being delivered.

Embodying performance excellence in medicine: Can The Six Viewpoints help?

Performance excellence in healthcare relies on skilled situational awareness, but there is no comprehensive framework articulating what within a situation requires awareness. Envisioning medicine as a performing artform, we introduce Mary Overlie's The Six Viewpoints-a comprehensive, yet flexible, conceptual framework used in the performing arts world, for teaching, learning, and creating, for over 50 years. We imagine The Viewpoints could serve as a framework to help improve verbal and non-verbal communication and collaboration on medical teams and between providers and their patients. We call on health professions educators to experiment with The Viewpoints to determine how they could be adapted to support performance excellence in the medical arena.

Neurosurgery Influences and X: A Social Media Analysis.

BACKGROUND: There exists a complex and ever-evolving relationship between social media and medicine. This study investigates the usage of X (formerly Twitter) among neurosurgeons and explores how virtual engagement potentially impacts this specialty. METHODS: The researchers examined X posts from the top fifty influential neurosurgeons over 6 months. Demographics and practice information were collected. Posts were categorized into 9 predetermined coding definitions. Descriptive statistics were used to summarize user characteristics. χ2 tests and two-tailed T-tests were employed to examine patterns of posting behavior. RESULTS: Most influencers practiced in an academic setting (89%) and 43% of them were age fifty or older. Only 15% identified as female. Cerebrovascular subspecialists accounted for 39% of the cohort. Reposting was the most popular type of posting, constituting 61% of all posts. The most common postcategory observed was "Professional Events" (31%), while "Patient Education" was the least common (0.8%). Private practice and general neurosurgeons infrequently posted about "Professional Events" (5.1%, P < 0.01 and 3.2%, P < 0.01, respectively). "Personal Thoughts" constituted the second most common category, with a notable increase among users younger than 50 (25%, P < 0.01), individuals who identified as female (62%, P < 0.01), those in private practice (69%, P < 0.01), and general neurosurgeons (86%, P < 0.01). CONCLUSIONS: Neurosurgeons of all ages use X to advance their careers and stay updated. However, the utilization of this influential platform likely varies depending on the current practice setting and individual career goals. Neurosurgeons on X appear to have the greatest influence within an academic context, particularly when promoting professional events.

The Impact of Mental Illness on Postoperative Adverse Outcomes After Outpatient Joint Surgery.

BACKGROUND: The effect of pre-existing mental illness on outpatient surgical outcomes is not well characterized. The objective of this study was to evaluate the association between pre-existing mental illness diagnosis and postoperative complications after outpatient total knee (TKA) and total hip arthroplasty (THA) and 2) compare with inpatient total joint arthroplasty (TJA). METHODS: The Mariner Claims Database was used to capture patients undergoing outpatient TJA from 2010 to 2017. Patients were grouped into three categories: those with an existing history of anxiety and/or depression, those with severe mental illness, and those without history of mental illness. Additional subgroup analysis compared those with severe mental illness undergoing outpatient vs inpatient TJA. Outcomes were analyzed using multivariable logistic regression (P < .05). RESULTS: Patients undergoing outpatient TJA with prior history of anxiety and/or depression or severe mental illness had an increased risk of emergency department (ED) visits (TKA, P < .001; THA, P = .014) within 90 days compared with those without history of mental illness. Severe mental illness was also associated with increased risk of medical complications at 90 days (TKA, P < .001; THA, P = .006). When compared with those undergoing inpatient surgery, patients undergoing outpatient TKA with severe mental illness were at increased risk of periprosthetic infection (P = .005) and ED visit (P = .003) within 90 days of surgery. CONCLUSION: Anxiety/depression and severe mental illness are associated with higher rates of ED visits after outpatient TJA. Patients with severe mental illness also experienced more adverse events, whereas those with anxiety and/or depression had similar rates compared with control. A higher rate of adverse outcomes was seen after TKA in patients with severe mental illness when surgery was performed in the outpatient setting vs those that had surgery as an inpatient. LEVEL OF EVIDENCE: III.