The Impact of Peri-operative Enhanced Recovery After Surgery Protocols on Outcomes Following Adult Cervical Deformity Surgery.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To assess the impact of Enhanced recovery after surgery (ERAS) protocols on peri-operative course in adult cervical deformity (ACD) corrective surgery. METHODS: Patients ≥18 yrs with complete pre-(BL) and up to 2-year (2Y) radiographic and clinical outcome data were stratified by enrollment in an ERAS protocol that commenced in 2020. Differences in demographics, clinical outcomes, radiographic alignment targets, peri-operative factors and complication rates were assessed via means comparison analysis. Logistic regression analysed differences while controlling for baseline disability and deformity. RESULTS: We included 220 patients (average age 58.1 ± 11.9 years, 48% female). 20% were treated using the ERAS protocol (ERAS+). Disability was similar between both groups at baseline. When controlling for baseline disability and myelopathy, ERAS- patients were more likely to utilize opioids than ERAS+ (OR 1.79, 95% CI: 1.45-2.50, P = .016). Peri-operatively, ERAS+ had significantly lower operative time (P < .021), lower EBL (583.48 vs 246.51, P < .001), and required significantly lower doses of propofol intra-operatively than ERAS- patients (P = .020). ERAS+ patients also reported lower mean LOS overall (4.33 vs 5.84, P = .393), and were more likely to be discharged directly to home (χ2(1) = 4.974, P = .028). ERAS+ patients were less likely to require steroids after surgery (P = .045), were less likely to develop neuromuscular complications overall (P = .025), and less likely experience venous complications or be diagnosed with venous disease post-operatively (P = .025). CONCLUSIONS: Enhanced recovery after surgery programs in ACD surgery demonstrate significant benefit in terms of peri-operative outcomes for patients.

Impact of congestive heart failure on patients undergoing lumbar spine fusion for adult spine deformity.

Background: With the increasing amount of elective spine fusion patients presenting with cardiac disease and congestive heart failure, it is becoming difficult to assess when it is safe to proceed with surgery. Assessing the severity of heart failure (HF) through ejection fraction may provide insight into patients' short- and long-term risks. Purpose: The purpose of this study was to assess the severity of HF on perioperative outcomes of spine fusion surgery patients. Study Design/Setting: This was a retrospective cohort study of the PearlDiver database. Patient Sample: We enrolled 670,526 patients undergoing spine fusion surgery. Outcome Measures: Thirty-day and 90-day complication rates, discharge destination, length of stay (LOS), physician reimbursement, and hospital costs. Methods: Patients undergoing elective spine fusion surgery were isolated and stratified by preoperative HF with preserved ejection fraction (P-EF) or reduced ejection fraction (R-EF) (International Classification of Diseases-9: 428.32 [chronic diastolic HF] and 428.22 [chronic systolic HF]). Means comparison tests (Chi-squared and independent samples t-tests, as appropriate) compared differences in demographics, diagnoses, comorbidities, procedural characteristics, LOS, 30-day and 90-day complication outcomes, and total hospital charges between those diagnosed with P-EF and those not R-EF. Binary logistic regression assessed the odds of complication associated with HF, controlling for levels fused (odds ratio [OR] [95% confidence interval]). Statistical significance was set at P < 0.05. Results: Totally 670,526 elective spine fusion patients were included. Four thousand and seventy-seven were diagnosed with P-EF and 2758 R-EF. Overall, P-EF patients presented with higher rates of morbid obesity, chronic kidney disease, chronic obstructive pulmonary disease, diabetes mellitus, and hypertension (all P < 0.001). In relation to No-HF, P-EF patients had higher rates of 30-day major complications including pulmonary embolism, pneumonia, cerebrovascular accident (CVA), myocardial infarctions (MI), sepsis, and death (all P < 0.001). Furthermore, P-EF was associated significantly with increased odds of pneumonia (OR: 2.07 [1.64-2.56], P < 0.001) and sepsis (OR: 2.09 [1.62-2.66], P < 0.001). Relative to No-HF, R-EF was associated with significantly higher odds of MI (OR: 3.66 [2.34-5.47]), CVA (OR: 2.70 [1.67-4.15]), and pneumonia (OR: 1.85 [1.40-2.40]) (all P < 0.001) postoperative within 30 days. Adjusting for prior history of MI, CAD, and the presence of a pacemaker R-EF was a significant predictor of an MI 30 days postoperatively (OR: 2.2 [1.14-4.32], P = 0.021). Further adjusting for history of CABG or stent placement, R-EF was associated with higher odds of CVA (OR: 2.11 [1.09-4.19], P = 0.028) and MI (OR: 2.27 [1.20-4.43], P = 0.013). Conclusions: When evaluating the severity of HF before spine surgery, R-EF was associated with a higher risk of major complications, especially the occurrence of a myocardial infarction 30 days postoperatively. During preoperative risk assessment, congestive HF should be considered thoroughly when thinking of postoperative outcomes with emphasis on R-EF.

The Evolution of Enhanced Recovery After Surgery: Assessing the Clinical Benefits of Developments Within Enhanced Recovery After Surgery Protocols in Adult Cervical Deformity Surgery.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: To investigate the impact of evolving Enhanced Recovery After Surgery (ERAS) protocols on outcomes after cervical deformity (CD) surgery. BACKGROUND: ERAS can help accelerate patient recovery and assist hospitals in maximizing the incentives of bundled payment models while maintaining high-quality patient care. However, there remains a paucity of literature assessing how developments have impacted outcomes after adult CD surgery. METHODS: Patients with operative CD 18 years or older with pre-baseline and 2 years (2Y) postoperative data, who underwent ERAS protocols, were stratified by increasing implantation of ERAS components: (1) early (multimodal pain program), (2) intermediate (early protocol + paraspinal blocks, early ambulation), and (3) late (early/intermediate protocols + comprehensive prehabilitation). Differences in demographics, clinical outcomes, radiographic alignment targets, perioperative factors, and complication rates were assessed through Bonferroni-adjusted means comparison analysis. RESULTS: A total of 131 patients were included (59.4 ± 11.7 y, 45% females, 28.8 ± 6.0 kg/m 2 ). Of these patients, 38.9% were considered "early," 36.6% were "intermediate," and 24.4% were "late." Perioperatively, rates of intraoperative complications were lower in the late group ( P = 0.036). Postoperatively, discharge disposition differed significantly between cohorts, with late patients more likely to be discharged to home versus early or intermediate cohorts [χ 2 (2) = 37.973, P < 0.001]. In terms of postoperative disability recovery, intermediate and late patients demonstrated incrementally improved 6 W modified Japanese Orthopedic Association scores ( P = 0.004), and late patients maintained significantly higher mean Euro-QOL 5-Dimension Questionnaire and modified Japanese Orthopedic Association scores by 1 year ( P < 0.001, P = 0.026). By 2Y, cohorts demonstrated incrementally increasing SWAL-QOL scores (all domains P < 0.028) domain scores versus early or intermediate cohorts. By 2Y, incrementally decreasing reoperation was observed in early versus intermediate versus late cohorts ( P = 0.034). CONCLUSIONS: The present study demonstrates that patients enrolled in an evolving ERAS program demonstrate incremental improvement in preoperative optimization and candidate selection, greater likelihood of discharge to home, decreased postoperative disability and dysphasia burden, and decreased likelihood of intraoperative complications and reoperation rates.

Assessing the Economic Benefits of Enhanced Recovery After Surgery (ERAS) Protocols in Adult Cervical Deformity Patients: Is the Initial Additive Cost of Protocols Offset by Clinical Gains?

OBJECTIVE: To assess the financial impact of Enhanced Recovery After Surgery (ERAS) protocols and cost-effectiveness in cervical deformity corrective surgery. STUDY DESIGN: Retrospective review of prospective CD database. BACKGROUND: Enhanced Recovery After Surgery (ERAS) can help accelerate patient recovery and assist hospitals in maximizing the incentives of bundled payment models while maintaining high-quality patient care. However, the economic benefit of ERAS protocols, nor the heterogeneous components that make up such protocols, has not been established. METHODS: Operative CD patients ≥18 y with complete pre-(BL) and up to 2-year(2Y) postop radiographic/HRQL data were stratified by enrollment in Standard-of-Care ERAS beginning in 2020. Differences in demographics, clinical outcomes, radiographic alignment targets, perioperative factors, and complication rates were assessed through means comparison analysis. Costs were calculated using PearlDiver database estimates from Medicare pay scales. QALY was calculated using NDI mapped to SF6D using validated methodology with a 3% discount rate to account for a residual decline in life expectancy. RESULTS: In all, 127 patients were included (59.07±11.16 y, 54% female, 29.08±6.43 kg/m 2 ) in the analysis. Of these patients, 54 (20.0%) received the ERAS protocol. Per cost analysis, ERAS+ patients reported a lower mean total 2Y cost of 35049 USD compared with ERAS- patients at 37553 ( P <0.001). Furthermore, ERAS+ patients demonstrated lower cost of reoperation by 2Y ( P <0.001). Controlling for age, surgical invasiveness, and deformity per BL TS-CL, ERAS+ patients below 70 years old were significantly more likely to achieve a cost-effective outcome by 2Y compared with their ERAS- counterparts (OR: 1.011 [1.001-1.999, P =0.048]. CONCLUSIONS: Patients undergoing ERAS protocols experience improved cost-effectiveness and reduced total cost by 2Y post-operatively. Due to the potential economic benefit of ERAS for patients incorporation of ERAS into practice for eligible patients should be considered.

Assessing the effects of prehabilitation protocols on post-operative outcomes in adult cervical deformity surgery: does early optimization lead to optimal clinical outcomes?

PURPOSE: To investigate the effect of a prehabilitation program on peri- and post-operative outcomes in adult cervical deformity (CD) surgery. METHODS: Operative CD patients ≥ 18 years with complete baseline (BL) and 2-year (2Y) data were stratified by enrollment in a prehabilitation program beginning in 2019. Patients were stratified as having undergone prehabilitation (Prehab+) or not (Prehab-). Differences in pre and post-op factors were assessed via means comparison analysis. Costs were calculated using PearlDiver database estimates from Medicare pay-scales. RESULTS: 115 patients were included (age: 61 years, 70% female, BMI: 28 kg/m2). Of these patients, 57 (49%) were classified as Prehab+. At baseline, groups were comparable in age, gender, BMI, CCI, and frailty. Surgically, Prehab+ were able to undergo longer procedures (p = 0.017) with equivalent EBL (p = 0.627), and shorter SICU stay (p < 0.001). Post-operatively, Prehab+ patients reported greater reduction in pain scores and greater improvement in quality of life metrics at both 1Y and 2Y than Prehab- patients (all p < 0.05). Prehab+ patients reported significantly less complications overall, as well as less need for reoperation (all p < 0.05). CONCLUSION: Introducing prehabilitation protocols in adult cervical deformity surgery may aid in improving patient physiological status, enabling patients to undergo longer surgeries with lessened risk of peri- and post-operative complications.

Advances in Imaging (Intraop Cone-Beam Computed Tomography, Synthetic Computed Tomography, Bone Scan, Low-Dose Protocols).

Spine surgery has seen a rapid advance in the refinement and development of 3-dimensional and nuclear imaging modalities in recent years. Cone-beam CT has proven to be a valuable tool for improving the accuracy of pedicle screw placement. The use of synthetic CT and low-dose CT have also emerged as modalities which allow for little to no radiation while streamlining imaging workflows. Bone scans also serve to provide functional information about bone metabolism in both the preoperative and postoperative monitoring phases.

Contribution of MRI and imaging exams in the diagnosis of lumbar pseudarthrosis.

INTRODUCTION: The diagnosis of pseudoarthrosis is based on imaging and clinical exam findings. The standard for pseudarthrosis diagnosis remains postoperative observation through computer tomography (CT) and patient's symptoms. This can be further augmented by dynamic X-ray imaging or nuclear positron emission tomography (PET) CT to demonstrate an absence of fusion by showing a persistence of mobility. However, there is not a uniform diagnostic approach that is a standard of care amongst spine practioners. The aim of this study is to describe the timeline and diagnostic analysis for pseudoarthrosis between the initial surgery and follow-up procedure. METHODS: This is a single-center retrospective observational study. The aim was to enroll patients reoperated for pseudarthrosis after 1 or 2 level lumbar fusions, between August 1st, 2008 and August 1st, 2018. The exams were reviewed by one surgeon and one radiologist, defining a status either in favor of pseudarthrosis, or against it, or inconclusive, based on the radiological criteria mentioned below. We then investigated different combinations of exams and their specific chronology before a diagnosis was established. RESULTS: Forty-four patients were included, 70.5% male and with a mean age of 47.3 years. The median time between the 2 surgeries was 23.7 months. Plain X-rays supported the diagnosis in 38.7% of cases, dynamic X-rays showed hypermobility in 50% of cases. The CT-scan demonstrated pseudarthrosis in 94,4% of cases. A MODIC 1 signal was observed in 87,2% of cases on MRI. SPECT-CT showed a tracer uptake in 70% of cases. CONCLUSION: Reducing the time to reintervention is a key objective for improving the management and clinical outcomes of these patients. We suggest that MRI is an additional tool in combination with CT in the assessment of suspected mechanical pseudarthrosis, in order to optimize the diagnosis and shorten the time to revision surgery. LEVEL OF EVIDENCE: IV.

Does the presence of cervical deformity in patients with baseline mild myelopathy increase operative urgency in adult cervical spinal surgery? A retrospective analysis.

OBJECTIVE: The objective of this study was to assess whether delaying surgical management of cervical deformity (CD) in patients with concomitant mild myelopathy increases the risk of suboptimal outcomes. METHODS: Patients aged ≥ 18 years who had a baseline diagnosis of mild myelopathy with baseline and up to 2 years of postoperative data were assessed. Patients were categorized as having CD (CD+) or not (CD-) at baseline. Patients with symptoms of myelopathy for more than 1 year after the initial visit prior to surgery were considered delayed. Clinical and radiographic data were assessed using means comparison analyses. Multivariate regression analysis assessed correlations between increasing time to surgery and peri- and postoperative outcomes adjusted for baseline age and frailty score. Backstep logistic regression analysis assessed the risk of complications or reoperation, while controlling for baseline T1 slope minus cervical lordosis (TS-CL). RESULTS: One hundred six patients were included (mean age 58.11 ± 11.97 years, 48% female, mean BMI 29.13 ± 6.89). Of the patients with baseline mild myelopathy, 22 (20.8%) were CD- while 84 (79.2%) were CD+. Overall, 9.5% of patients were considered to have delayed surgery. Linear regression revealed that both CD- and CD+ patients were more likely to require reoperation when there was more time between the initial visit and surgical admission (p < 0.001). Additionally, an adjusted logistic regression indicated that CD+ patients who had a greater length of time to surgery had a higher likelihood for major complications (p < 0.001). Conversely, CD+ patients who were operated on within 30 days of the initial visit had a significantly lower risk for a major complication (OR 0.901, 95% CI 0.889-1.105, p = 0.043), and a lower risk for reoperation (OR 0.954, 95% CI 0.877-1.090, p = 0.043), while controlling for the severity of deformity based on baseline TS-CL. CONCLUSIONS: The findings of this study demonstrate that a delay in surgery after the initial visit significantly increases the risk for major complications and reoperation in patients with CD with associated mild baseline myelopathy. Early operative treatment in this patient population may lower the risk of postoperative complications.

Predictors of Complication Severity Following Adult Spinal Deformity Surgery: Smoking Rate, Diabetes, and Osteotomy Increase Risk of Severe Adverse Events.

BACKGROUND: Given the physical and economic burden of complications in spine surgery, reducing the prevalence of perioperative adverse events is a primary concern of both patients and health care professionals. This study aims to identify specific perioperative factors predictive of developing varying grades of postoperative complications in adult spinal deformity (ASD) patients, as assessed by the Clavien-Dindo complication classification (Cc) system. METHODS: Surgical ASD patients ≥18 years were identified in the American College of Surgeons' National Surgical Quality Improvement Program from 2005 to 2015. Postoperative complications were stratified by Cc grade severity: minor (I, II, and III) and severe (IV and V). Stepwise regression models generated dataset-specific predictive models for Cc groups. Model internal validation was achieved by bootstrapping and calculating the area under the curve (AUC) of the model. Significance was set at P < 0.05. RESULTS: Included were 3936 patients (59 ± 16 years, 63% women, 29 ± 7 kg/m2) undergoing surgery for ASD (4.4 ± 4.7 levels, 71% posterior approach, 11% anterior, and 18% combined). Overall, 1% of cases were revisions, 39% of procedures involved decompression, 27% osteotomy, and 15% iliac fixation. Additionally, 66% of patients experienced at least 1 complication, 0% of which were Cc grade I, 51% II, 5% III, 43% IV, and 1% V. The final model predicting severe Cc (IV-V) complications yielded an AUC of 75.6% and included male sex, diabetes, increased operative time, central nervous system tumor, osteotomy, cigarette pack-years, anterior decompression, and anterior lumbar interbody fusion. Final models predicting specific Cc grades were created. CONCLUSIONS: Specific predictors of adverse events following ASD-corrective surgery varied for complications of different severities. Multivariate modeling showed smoking rate, osteotomy, diabetes, anterior lumbar interbody fusion, and higher operative time, among other factors, as predictive of severe complications, as classified by the Clavien-Dindo Cc system. These factors can help in the identification of high-risk patients and, consequently, improve preoperative patient counseling. CLINICAL RELEVANCE: The findings of this study provide a foundation for identifying ASD patients at high risk of postoperative complications .

Progressive decline in pulmonary function 5 years post-operatively in patients who underwent anterior instrumentation for surgical correction of adolescent idiopathic scoliosis.

PURPOSE: To evaluate changes in pulmonary function tests (PFT) at 5 years post-operatively in patients with adolescent idiopathic scoliosis (AIS) and to determine whether these changes are progressive or static after 2 years. METHODS: AIS surgical patients with pre-operative and 5 year post-operative forced expiratory volume (FEV) and forced vital capacity (FVC) were included. The percentage of patients with pulmonary impairment at 5 years was calculated. Repeated measures ANOVA was used to evaluate changes between pre-operative PFT and 5 years post-operative PFT and to determine whether the changes differed between curve types and approach. A sub-analysis of patients with 2 year data was performed to determine whether PFT changes were static or progressive. RESULTS: Two hundred and sixty-two patients had undergone pre-operative and 5 year post-operative PFTs. At 5 years, 42% were normal, 41% had mild impairment, and 17% had moderate-severe impairment. Overall, there was a decline in % predicted FVC (p < 0.05); FEV remained stable. There was no difference based on major curve type (p > 0.05). Anterior instrumentation cases declined significantly between pre-operative PFT and 5 years post-operative PFT (FEV: - 10% open, - 6% thoracoscopic; FVC: - 13% open, - 8% thoracoscopic) (p ≤ 0.02). The posterior cases remained stable (2% FEV, p = 0.7; - 0.6% FVC, p = 0.06). A subgroup of 90 patients with 2 year post-operative PFTs demonstrated that changes were progressive between 2 and 5 years post-operatively. The average change in FVC from 2 to 5 years was significantly different between the anterior open (- 9%) and posterior-only (0.7%) groups (p = 0.015). CONCLUSION: In patients who underwent anterior instrumentation, PFTs declined from the pre-operative to the 5 years post-operative time point. There was a progressive decline of 4-10% beyond 2 years post-operatively. Patients who underwent posterior instrumentation remained stable. These slides can be retrieved under Electronic Supplementary Material.

Alcoholism as a predictor for pseudarthrosis in primary spine fusion: An analysis of risk factors and 30-day outcomes for 52,402 patients from 2005 to 2013.

INTRODUCTION: This study assessed the incidence and risk factors for pseudarthrosis among primary spine fusion patients. METHODS: Retrospective review of ACS-NSQIP (2005-2013). Differences in comorbidities between spine fusion patients with and without pseudarthrosis (Pseud, N-Pseud) were assessed using chi-squared tests and Independent Samples t-tests. Binary logistic regression assessed patient-related and procedure-related predictors for pseudarthrosis. RESULTS: 52,402 patients (57yrs, 53%F, 0.4% w/pseudarthrosis). Alcohol consumption (OR:2.6[1.2-5.7]) and prior history of surgical revision (OR:1.6[1.4-1.8]) were risk factors for pseudarthrosis operation. Pseud patients at higher risk for deep incisional SSI (at 30-days:OR:6.6[2.0-21.8]). Pseud patients had more perioperative complications (avg:0.24 ±â€¯0.43v0.18 ±â€¯0.39,p=0.026). CONCLUSIONS: Alcoholism and surgical revision are major risk factors for pseudarthrosis in patients undergoing spine fusion.

Decreased rates of 30-day perioperative complications following ASD-corrective surgery: A modified Clavien analysis of 3300 patients from 2010 to 2014.

The Clavien-Dindo grading allows for broad comparison of perioperative surgical complications, and a temporal analysis of complications following ASD-corrective surgery. NSQIP database was utilized from 2010 to 2014 to isolate patients. Complications were stratified by Clavien complication (Cc) grade, and patients grouped by highest Cc grade: I, II, III, IV, V. Secondary analysis grouped by minor (I, II, III) and severe (IV, V). Comorbidity burden was assessed with a NSQIP-modified Charlson Comorbidity Index (CCI) and frailty was measured with a 5-factor modified frailty index (mFI). From 2010 to 2014, 2971 patients (57 yrs, 58% F) underwent surgery for ASD (3.4 ±â€¯4.1 levels; surgical approach: 46% anterior, 44% posterior, 10% combined), the rate of which increased 0.01% to 0.13. 32% suffered >1 complication. Patient breakdown by Cc grade: 0% I, 25% II, 3% III, 4% IV, 1% V. Severe Cc patients were more comorbid than minor Cc (CCI 2.8 vs 1.8), had longer operative times (394 min vs 251), and higher rates of osteotomy (29% vs 13%) and iliac fixation (16% vs 5%). Overall CCI (2.1-1.7) and perioperative complication rates (55-29%) decreased, despite increasing surgical invasiveness (2.8-4.5) and increasing frailty score (0.14 ±â€¯0.15 vs 0.16 ±â€¯0.16). Rates of Clavien grade II (39.80-22.20%) and IV (9.40-3.50%) complications also decreased, indicative of surgical improvements and effective preoperative patient selection. The decrease in CCI and increase in the modified frailty score may show that we are becoming more cognizant of discerning of comorbidities, but likely to not to have taken into account frailty, which may have an impact on future health socioeconomics.

The Relationship Between Apical Vertebral Rotation and Truncal Rotation in Adolescent Idiopathic Scoliosis Using 3D Reconstructions.

STUDY DESIGN: Retrospective review of prospective data. OBJECTIVES: To evaluate the relationship between absolute apical vertebral rotation (AVR) evaluated with upright 3D imaging and angle of trunk rotation (ATR) before and after surgery for thoracic and lumbar curves in adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: New imaging technology allows for improved radiographic assessment of the degree of AVR pre- and postoperatively through 3D spine models created from biplanar, simultaneous spine radiographs. METHODS: A prospective registry was queried and identified 55 AIS patients with major thoracic or major thoracolumbar/lumbar curves who underwent posterior spinal fusion. All patients had biplanar upright imaging of their spine and ATR measurements assessed via scoliometer pre- and postoperatively. RESULTS: There were 33 major thoracic and 22 major lumbar curves. The mean Cobb angles for thoracic and thoracolumbar/lumbar curves were 54° ± 10° and 47° ± 8° preoperatively, and 11 ± 6° and 12 ± 7° postoperatively. The differences in the mean preoperative ATR measurements for both major curve types was not statistically significant; however, the difference in AVR between thoracic curves (13 ± 6°) and lumbar curves (22 ± 7°) was significant (p < .001). There was a significant decrease in the ATR and AVR for both thoracic and thoracolumbar/lumbar curves (p < .001) postoperatively. A significant correlation between ATR and AVR was found only for the major thoracolumbar/lumbar curves (p < .001). The relationship between ATR and AVR changes for both curves was not statistically significant. CONCLUSION: ATR measured via scoliometer strongly correlates with 3D measurements of AVR in both thoracic and lumbar curves before and after surgery for AIS. No significant relationship was found between the changes in ATR and AVR due to surgery. Postoperatively, greater clinical rotational deformity remains in the thoracic spine compared to the lumbar spine, despite greater apical vertebra axial plane correction in thoracic curves. LEVEL OF EVIDENCE: Level II, diagnostic.

Intraspinal Pathology Associated With Pediatric Scoliosis: A Ten-year Review Analyzing the Effect of Neurosurgery on Scoliosis Curve Progression.

STUDY DESIGN: This was a retrospective study of patients with Chiari I (CM I) and Chiari II (CM II) malformations, tethered cord syndrome, and syringomyelia examining the effect of neurosurgery on scoliosis. OBJECTIVE: The aim of this study was to determine the factors affecting spinal deformity progression in patients with diseases of the neural axis following neurosurgical management. SUMMARY OF BACKGROUND DATA: There have been attempts to explain which factors influence the spinal deformity in diseases of the neural axis with varying results. Debate still exists as to the effectiveness of neurosurgery in curve stabilization. METHODS: The medical records for patients treated over the past 10 years were reviewed. The spinal deformity surgical group consisted of patients who received surgery or progressed to surgical range (50°) and the nonsurgical group those who did not undergo fusion. RESULTS: Fifteen patients (eight females and seven males) with scoliosis who underwent neurosurgical intervention were identified. Ten had tethered cord, six CM II, four CM I, and 11 syrinx. Average age at the time of neurosurgery was 7 ±â€Š4 years (range 0.7-14 yrs). Following neurosurgery, no patients experienced improvement in their curves (defined as >10° decrease in Cobb angle), eight patients experienced stabilization (<10° decrease), and seven experienced worsening (>10° increase). The group that went on to spinal deformity surgery possessed larger curves before neurosurgery (mean 42°, range 20°-63°) than the nonsurgical group (19°, range 15°-26°; P = 0.004). CM II patients had the greatest magnitude of curve progression, mean of 49°, compared with patients with CM I (6°) or tether cord without CM I or II (11°, P = 0.01). CONCLUSION: Neurosurgical intervention may prevent curve progression in patients with scoliosis and Cobb angles < 30° if they do not have a complex CM II malformation. Patients with CM II are at a higher risk of curve progression and undergoing spinal fusion than patients with CM I, tethered cord syndrome, or syringomyelia. LEVEL OF EVIDENCE: 4.

Pituitary tumor apoplexy in adolescents.

OBJECTIVE: The aim of this study was to determine whether there are differences in pituitary apoplexy and subclinical apoplexy secondary to adenoma hemorrhage in the adolescent population with regard to symptomatology, neuroimaging features, pathology, and outcomes compared with adults. METHODS: A retrospective series of 9 consecutive patients with a diagnosis of pituitary hemorrhage who were surgically treated at Rady's Children's Hospital San Diego, between 2008 and 2013 were evaluated for clinical, endocrine, neuroradiographic, and pathologic features in association with clinical outcomes. RESULTS: Nine patients (6 girls, age 14-21 years) presented to our institution with headache (9/9), nausea (3/9), dizziness (4/9), and visual disturbances (6/9) in the setting of a sellar hemorrhagic tumor on magnetic resonance imaging (MRI). Three patients presented with apoplexy and 6 with subclinical apoplexy. Duration of symptoms ranged from 3 days to 1 year. MRI revealed hemorrhage (9/9), rim enhancement (6/9), sphenoid sinus mucosal thickening (2/9), mass effect on the optic chiasm (8/9), and sellar remodeling (9/9). The percentage of hemorrhage preoperatively observed on MRI ranged from 50% to greater than 95%. On presentation, hyperprolactinemia was recorded in 7 patients, 6 of whom had galactorrhea and/or amenorrhea. Open transsphenoidal decompression was performed in 8/9 patients; 7 of 9 were diagnosed with prolactinoma. Biopsy specimens revealed 10%-90% hemorrhage and no infarction in any of the cases. All patients treated showed improvement of symptoms after surgery (average follow-up, 28.2 months). Postoperative complications included transient diabetes insipidus (n = 5), persistent cerebrospinal fluid rhinorrhea (n = 3), and meningitis (n = 1). Five patients had long-term endocrine sequelae of hyperprolactinemia requiring ongoing medical treatment. CONCLUSIONS: Pituitary hemorrhage resulting in apoplexy or subclinical apoplexy in adolescents may represent a distinct entity with a more indolent symptomatology and more favorable neurologic and endocrine outcome compared with adults that is worthy of further validation in a multi-institutional cohort.

Post-traumatic basal ganglia haemorrhage in a child with primary central nervous system lymphoma.

Primary central nervous system lymphoma (PCNSL) is a rare tumour of childhood with 15-20 cases reported yearly in North America. We present a case of a 13-year-old boy diagnosed with PCNSL who presented more than one-and-a-half years post-treatment with high dose cytosine arabinoside and methotrexate with a right-sided basal ganglia haemorrhage on MRI following a concussion while playing organised football against medical advice. There was no evidence of an underlying vascular malformation or recurrent disease by MRI, cerebrospinal fluid analysis or positron emission tomography computed tomography (PET-CT). However, 6 months post-injury he presented with asymptomatic disease recurrence of the frontal lobe. Our case reports an unusual MRI pattern of post-traumatic injury in a child previously treated for PCNSL that would support a recommendation for the avoidance of contact sports in this population.

Delayed cerebritis after bilateral stereotactic implantation of globus pallidus interna electrodes for treatment of dystonia.

Deep brain stimulation (DBS) is being used to treat an increasing number of movement and psychiatric disorders. However, the risk of infection remains as a problem that can hinder the usefulness of this technology. We report a case of a patient with dystonia who underwent bilateral globus pallidus interna electrode and impulse generator (IPG) placement, developed an infection of his IPG, and later cerebritis. The patient was initially treated with antibiotics and partial hardware removal. Follow-up cranial imaging showed an area concerning for cerebritis around one of the intracranial electrodes. The patient was then treated with complete hardware removal followed by a course of intravenous antibiotics. Four-month follow-up imaging showed resolution of the infection. This case demonstrates the importance of following cranial imaging in DBS patients with delayed infection, continued vigilance for infection in implanted patients and that partial hardware removal may not be successful in the setting of methicillin-sensitive Staphylococcus aureus infections.

A single spinal lesion arising from an intradural meningioma contiguous with an extradural lymphoma.

The authors describe here a unique case of contiguous, synchronous meningioma and lymphoma in the spinal column. Both tumors were present at the same vertebral level, one intradural and the other extradural. A patient presented with bilateral leg pain, acute weakness, and sensory loss in the lower extremities. Magnetic resonance imaging revealed an intradural mass at T6-7 with ambiguous boundaries relative to the thecal sac and compressing the spinal cord. The patient underwent resection of the epidural and intradural mass at T6-7. Histopathology revealed the epidural specimen to be a double-hit B-cell lymphoma and the intradural mass to be a transitional meningioma. Postoperatively, the patient did well, with an immediate return of strength and sensation. A postoperative MR image showed complete resection of the intradural mass. The authors suggest that biopsy may be prudent in patients with known systemic lymphoma presenting with a spinal lesion that has unclear boundaries relative to the thecal sac prior to commencing radiation and chemotherapy.

Apurinic/apyrimidinic endonuclease is inversely associated with response to radiotherapy in pediatric ependymoma.

Apurinic/apyrimidinic endonuclease (Ap endo) is a key DNA repair activity that confers radiation resistance in human cells. Here we examined the association between Ap endo activity and response to radiotherapy in pediatric ependymomas, tumors for which treatment options are limited and survival rates are only about 50%. We assayed Ap endo activity in 36 ependymomas and expression of Ape1/Ref-1, the predominant Ap endo activity in humans, in 44 tumors by immunostaining. Cox proportional hazards regression models were used to analyze the association of activity or expression with progression-free survival or with overall survival. Activity varied 13-fold and was not associated with tumor or patient characteristics. In univariate models with Ap endo activity entered as a continuous variable, the hazard ratio for progression increased by a factor of 2.18 for every 0.01 unit increase in activity (p ≤ 0.003) in 24 grade II ependymomas. Risk for death increased by a factor of 1.89 (p ≤ 0.02) in the same population. The fraction of Ape1/Ref-1 immunopositive cells varied widely within individual tumors and was not associated with either progression-free or with overall survival. Suppressing Ap endo activity in pediatric ependymoma cells significantly increased radiation sensitivity, suggesting that the association of activity with radiation response reflected, at least in part, repair of radiation-induced DNA lesions. Our data indicate that Ap endo activity is predictive of outcome following radiotherapy, and suggest that Ape1/Ref-1 promotes radiation resistance in pediatric ependymomas. Our findings support the use of inhibitors of Ap endo activity to overcome resistance.