Evaluation and Treatment of Primary Spinal Epidural Lymphoma Presenting as Acute Myelopathy in a Young Adult: A Case Report.

CASE: Primary spinal epidural lymphoma (PSEL) presenting as myelopathy is extremely rare, particularly within young, healthy adults. This case report describes a 26-year-old man presenting with progressive thoracic myelopathy. Magnetic resonance imaging revealed spinal epidural masses spanning T5-T10 and T12-L2 with multilevel cord compression and edema. After evaluation, the patient underwent emergent posterior decompression to prevent progressive neurological decline. Histology was consistent with diffuse large B-cell lymphoma, germinal center type. At 3 months postoperatively, the patient regained full neurologic function. CONCLUSION: Although rare, PSELs should be considered in patients presenting with myelopathy to facilitate timely diagnosis and treatment.

Impact of radiocapitellar interposition arthroplasty on ulnohumeral joint biomechanics.

BACKGROUND: Radial head excision (RHE) has been shown to increase contact pressures within the ulnohumeral joint. Radiocapitellar interposition arthroplasty (RCIA) with the use of a soft tissue graft is an alternative for the treatment of isolated radiocapitellar arthritis or with failure of radial head replacement. We investigated contact pressures and contact area within the ulnohumeral joint after RHE compared to RCIA with dermal autograft. METHODS: Six fresh-frozen cadaver elbows were tested on a custom dynamic elbow frame. A pressure sensor was inserted into the intact elbow joint, and mean contact pressure, peak contact pressure, contact area, and force within the ulnohumeral joint were recorded at 0°, 30°, 60°, 90°, and 120° of flexion as a valgus load was applied to the elbow. The radial head was then excised and specimens were retested. Finally, a dermal graft matched to the size of the resected radial head was inserted in the radiocapitellar space and the specimens were tested a third time. RESULTS: At 90° of flexion, contact pressure within the ulnohumeral joint was significantly lower with RCIA compared with RHE (110.8 kPa vs 216.8 kPa; P = .013). The mean peak contact pressure was also significantly lower with RCIA compared with RHE at 90° (279.4 vs 626.7 kPa; P = .025). No statistically significant differences were seen in mean contact area or force between the 3 testing conditions at any flexion position. CONCLUSION: RCIA with a dermal graft reduced contact pressures within the ulnohumeral joint compared to RHE at 90° of flexion without a significant change in contact area or contact force.

Rimegepant for the treatment of migraine.

Migraine is a common form of primary headache, affecting up to 1 in every 6 Americans. The pathophysiology is an intricate interplay of genetic factors and environmental influence and is still being elucidated in ongoing studies. The trigeminovascular system is now known to have a significant role in the initiation of migraines, including the release of pain mediators such as CGRP and substance P. Traditional treatment of migraine is usually divided into acute and preventive treatment. Acute therapy includes non-specific therapy, such as NSAIDs and other analgesics, which may provide relief in mild to moderate migraines. 5-HT1 agonists may provide relief in severe migraine, but are not universally effective and carry a significant side-effect profile with frequent redosing requirement. Prophylactic therapy may reduce the occurrence of acute migraine attacks in selected patients, but does not completely eliminate it. More recently, CGRP antagonism has been studied and shown to be effective in both abortion and prevention of migraine. Novel medications, targeting CGRP, divide into CGRP antibodies and receptor antagonists (gepants). Rimegepant, a second-generation gepant, has shown efficacy in several clinical trials in treating acute migraine. Ongoing trials are also evaluating its role in migraine prophylaxis, and results are promising. It is also generally safer for use than existing options, does not appear to increase the chance of developing chronic migraines, and carries a very tolerable side effects profile. It is a part of a growing arsenal in migraine treatment, and may present the silver bullet for treatment of this disease.

The Ramifications of Opioid Utilization and Outcomes of Alternative Pain Control Strategies for Total Knee Arthroplasties.

Morbidity and mortality related to opioid use has generated a public health crisis in the United States. Total knee arthroplasty (TKA) is an increasingly common procedure and is often accompanied by post-operative opioid utilization. Unfortunately, post-operative opioid usage after TKA has been shown to lead to higher rates of complications, longer hospital stays, increased costs, and more frequent need for revision surgery. Pre-operative opioid utilization has been shown to be one of the most important predictors of post-operative opioid usage. Additional risk factors for continued post-operative opioid utilization after TKA include pre-operative substance and tobacco use as well as higher post-operative prescription dosages, younger age, female gender, and Medicaid insurance. One method for mitigating excessive post-operative opioid utilization are Enhanced Recovery After Surgery (ERAS) protocols, which include a multidisciplinary approach that focuses on perioperative factors to optimize patient recovery and function after surgery. Additional strategies include multimodal pain regimens with epidural anesthetics, extended duration local anesthetics and adjuvants, and ultrasound guided peripheral nerve blocks. In recent years, opioid prescribing duration limitations have also been put into place by state and federal government, hospital systems, and ambulatory surgery centers making effective acute pain management imperative for all stakeholders. In this regard, as rates of TKA continue to increase across the United States, multidisciplinary efforts by all stakeholders are needed to ensure adequate pain control while preventing the negative sequalae of opioid medications.

Opioid Use Consequences, Governmental Strategies, and Alternative Pain Control Techniques Following Total Hip Arthroplasties.

Over the last several decades, rates of opioid use and associated problems have dramatically increased in the United States leading to laws limiting prescription duration for acute pain management. As a result, orthopedic surgeons who perform total hip arthroplasty (THA), a procedure that often leads to significant postoperative pain, have been faced with substantial challenges to adequately mitigate patient pain while also reducing opioid intake. Current strategies include identifying and correcting modifiable risk factors associated with postoperative opioid use such as preoperative opioid use, alcohol and tobacco abuse, and untreated psychiatric illness. Additionally, recent evidence has emerged in the form of Enhanced Recovery After Surgery (ERAS) protocols suggesting that a multidisciplinary focus on patient factors perioperatively can lead to reduced postoperative opioid administration and decreased hospital stays. A cornerstone of ERAS protocols includes multimodal pain regimens with opioid rescue only as needed, which often includes multiple systemic pain therapies such as acetaminophen, gabapentin, non-steroidal anti-inflammatory drugs, as well as targeted pain therapies that include epidural catheters and ultrasound-guided nerve blocks. Many hospital systems and states have also implemented opioid prescribing limitations with mixed success. As the opioid epidemic continues in the United States, while contributing to poor outcomes following elective surgeries, further research is warranted to identify multidisciplinary strategies that mitigate opioid use while also allowing for adequate pain control and rehabilitation.

Fragility of randomized controlled trials on treatment of proximal humeral fracture.

BACKGROUND: Proximal humeral fracture represents an increasingly common pathology with evaluation and treatment often guided by evidence from randomized controlled trials (RCTs), but the strength of an RCT must be considered in this process. The purpose of this study was to evaluate the strength of outcomes in RCTs on the management of proximal humeral fractures using the fragility index (FI), a method used with statistically significant dichotomous outcomes to assess the number of patients that would change an outcome measure from significant (P ≤ .05) to nonsignificant if the patient outcome changed. We also aimed to correlate the FI with other measures of study strength. METHODS: A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines to evaluate RCTs on the management of proximal humeral fractures. The PubMed, Ovid MEDLINE, Web of Science, and Embase databases were searched from database inception to May 2021. RCTs with at least 1 statistically significant (P ≤ .05) dichotomous outcome were included. The FI was calculated for each included trial using the Fisher exact test. The FI was correlated with the study sample size and journal impact factor. RESULTS: Ten RCTs reporting on 656 patients and published between 2011 and 2020 were included. The median patient sample size was 67 (mean, 65.6; range, 40-86). Complications were the most commonly reported dichotomous statistically significant outcome. The median FI was 1 (mean, 2.6; range, 0-18), with 4 studies having an FI of 0. A median FI of 1 indicates that 1 patient experiencing an alternative outcome or having not been lost to follow-up could have changed the pertinent conclusions of the trial for a given outcome. The median number of patients lost to follow-up was 3 (mean, 4.9; range, 0-16) and exceeded the FI in 50% of studies. There was no correlation between the FI and sample size (Spearman coefficient = 0.0592, P = .865) or between the FI and journal impact factor (Spearman coefficient = -0.0229, P = .522). CONCLUSION: In most studies of proximal humeral fractures, only 1 or 2 patients experiencing an alternative outcome or lost to follow-up would change the conclusions for the dichotomous outcome studied. Although the FI cannot be used to assess continuous variables, which are often the primary outcome variables of RCTs, it does offer an additional unique measure of study strength that surgeons should consider when evaluating RCTs.

Diagnostic Evaluation and Cervical Spine Surgery in the Setting of a Cardiac Left Ventricular Assist Device: Challenges and a Case Illustration.

Due to incompatibility with magnetic resonance imaging, patients with left ventricular assist devices (LVADs) presenting with pathologies of the spinal soft tissues or neural elements represent diagnostically complex cases. We present a case of a patient undergoing a CT (computed tomography) myelogram and subsequent successful cervical posterior laminectomy. A C1-C2 lateral puncture approach CT myelogram revealed nearly a complete block of contrast movement at the level of the C2-C3 vertebrae concerning a compressive etiology. The cervical lateral approach was chosen based on patient symptomology and concern that contrast dye injected in the lumbar spine would not travel to the region of interest due to altered CSF pulsatility caused by the LVAD device. A C3-C7 posterior laminectomy was then successfully performed. Intra-operatively, however, there was no sign of a compressive lesion, and ultrasound confirmed a decompressed spinal cord. This case highlights the diagnostic challenges of pre-operative evaluation in patients with LVADs in which the efficacy of performing CT myelograms is also questionable due to potential alterations in cerebrospinal fluid movement due to variations in arterial pulsatility due to LVAD physiology.

An Update on Postoperative Opioid Use and Alternative Pain Control Following Spine Surgery.

Opioids are commonly prescribed postoperatively for pain control, especially in spine surgery. Not only does this pose concerns for potential abuse, but it also has been shown to worsen certain outcomes. Risk factors for increased use include preoperative opioid use, female sex, psychiatric diagnoses, and drug and alcohol use. Over the past few decades, there have been increasing efforts mostly spearheaded by governmental agencies to decrease postoperative opioid use via opioid prescription limitation laws regulating the number of days and amounts of analgesics prescribed and promotion of the use of enhanced recovery after surgery (ERAS) protocols, multimodal pain regimens, epidural catheters, and ultrasound-guided peripheral nerve blocks. These strategies collectively have been efficacious in decreasing overall opioid use and better controlling patients' postoperative pain while simultaneously improving other outcomes such as postoperative nausea, vomiting, and length of stay. With an aging population undergoing an increasing number of spinal surgeries each year, it is now more important than ever to continue these efforts to improve the quality and safety of pain control methods after spinal surgery and limit the transition of acute management to the development of opioid dependence and addiction long-term.

Does minimally invasive spine surgery improve outcomes in the obese population? A retrospective review of 1442 degenerative lumbar spine surgeries.

OBJECTIVE: The effect of obesity on outcomes in minimally invasive surgery (MIS) approaches to posterior lumbar surgery is not well characterized. The authors aimed to determine if there was a difference in operative variables and complication rates in obese patients who underwent MIS versus open approaches in posterior spinal surgery, as well as between obese and nonobese patients undergoing MIS approaches. METHODS: A retrospective review of all consecutive patients who underwent posterior lumbar surgery from 2013 to 2016 at a single institution was performed. The primary outcome measure was postoperative complications. Secondary outcome measures included estimated blood loss (EBL), operative time, the need for revision, and hospital length of stay (LOS); readmission and disposition were also reviewed. Obese patients who underwent MIS were compared with those who underwent an open approach. Additionally, obese patients who underwent an MIS approach were compared with nonobese patients. Bivariate and multivariate analyses were carried out between the groups. RESULTS: In total, 423 obese patients (57.0% decompression and 43.0% fusion) underwent posterior lumbar MIS. When compared with 229 obese patients (56.8% decompression and 43.2% fusion) who underwent an open approach, patients in both the obese and nonobese groups who underwent MIS experienced significantly decreased EBL, LOS, operative time, and surgical site infections (SSIs). Of the nonobese patients, 538 (58.4% decompression and 41.6% fusion) underwent MIS procedures. When compared with nonobese patients, obese patients who underwent MIS procedures had significantly increased LOS, EBL, operative time, revision rates, complications, and readmissions in the decompression group. In the fusion group, only LOS and disposition were significantly different. CONCLUSIONS: Obese patients have poorer outcomes after posterior lumbar MIS when compared with nonobese patients. The use of an MIS technique can be of benefit, as it decreased EBL, operative time, LOS, and SSIs for posterior decompression with or without instrumented fusion in obese patients.

Minimally invasive posterior lumbar surgery in the morbidly obese, obese and non-obese populations: A single institution retrospective review.

BACKGROUND: There is a paucity of information regarding outcomes in minimally invasive surgical (MIS) approaches to posterior lumbar surgery in morbidly obese patients. We seek to determine if there are differences in operative variables and early complication rates in morbidly obese patients undergoing MIS posterior lumbar surgery compared to obese and non-obese patients. METHODS: A single institution retrospective review of patients undergoing MIS posterior lumbar surgery (decompression and/or fusion) between 2013 and 2016 was performed. Morbidly obese patients (BMI ≥ 40) were compared to obese (BMI 30-39.9) and non-obese (BMI < 30) cohorts. Postoperative complication rates and perioperative variables including estimated blood loss, operative time, and outcome measures including length of stay (LOS), in-hospital complications, readmission, and disposition were assessed. RESULTS: 47 morbidly obese, 135 obese and 224 non-obese patients underwent posterior MIS instrumented fusion. 59 morbidly obese, 182 obese and 314 non-obese patients underwent posterior MIS decompression. The morbidly obese group experienced a greater rate of deep vein thrombosis and had an increased hospital LOS (p < 0.05). Morbidly obese patients who underwent MIS decompression experienced increased postoperative complications (p < 0.01), and increased LOS (p < 0.0001) compared to obese and non-obese patients. There were no differences in revision rates, readmissions, and other complications including surgical site infection. Morbid obesity was an independent predictor of overall complications and increased LOS on multivariate analysis. CONCLUSION: Morbidly obese patients undergoing posterior MIS fusion had a higher rate of complications and increased LOS. While weight loss should be encouraged, complication rates remains acceptably low in morbidly obese patients and MIS posterior lumbar surgery should still be offered.

Abnormal neurological pupil index is associated with malignant cerebral edema after mechanical thrombectomy in large vessel occlusion patients.

BACKGROUND AND OBJECTIVES: Malignant cerebral edema (MCE) is a feared complication in patients suffering from large vessel occlusion. Variables associated with the development of MCE have not been clearly elucidated. Use of pupillometry and the neurological pupil index (NPi) as an objective measure in patients undergoing mechanical thrombectomy (MT) has not been explored. We aim to evaluate variables significantly associated with MCE in patients that undergo MT and hypothesize that abnormal NPi is associated with MCE in this population. METHODS: A retrospective analysis of patients with acute ischemic stroke who had undergone MT at our institution between 2017 and 2020 was performed. Baseline and outcome variables were collected, including NPi values from pupillometry readings of patients within 72 h after the MT. Patients were divided into two groups: MCE versus non-MCE group. A univariate and multivariate analysis was performed. RESULTS: Of 284 acute ischemic stroke patients, 64 (22.5%) developed MCE. Mean admission glucose (137 vs. 173; p < 0.0001), NIHSS on admission (17 vs. 24; p < 0.01), infarct core volume (27.9 vs. 17.9 mL; p = 0.0036), TICI score (p = 0.001), and number of passes (2.9 vs. 1.8; p < 0.0001) were significantly different between the groups. Pupillometry data was present for 64 patients (22.5%). Upon multivariate analysis, abnormal ipsilateral NPi (OR 21.80 95% CI 3.32-286.4; p = 0.007) and hemorrhagic conversion were independently associated with MCE. CONCLUSION: Abnormal NPi and hemorrhagic conversion are significantly associated with MCE in patients following MT. Further investigation is warranted to better define an association between NPi and patient outcomes in this patient population.

Management of Intracranial Hemorrhage in Patients with a Left Ventricular Assist Device: A Systematic Review and Meta-Analysis.

BACKGROUND: Intracranial hemorrhage (ICH) has been reported to occur in up to 23% of patients with left ventricular assist devices (LVADs). Currently, limited data exists to guide neurosurgical management strategies to optimize outcomes in patients with an LVAD who develop ICH. METHODS: A systematic review and meta-analysis of the literature was performed to evaluate the mortality rate in these patients following medical and/or surgical management and to evaluate antithrombotic reversal and resumption strategies after hemorrhage. RESULTS: 17 studies reporting on 3869 LVAD patients and 545 intracranial hemorrhages spanning investigative periods from 1996 to 2019 were included. The rate of ICH in LVAD patients was 10.6% (411/3869) with 58.6% (231/394) being intraparenchymal hemorrhage (IPH), 23.6% (93/394) subarachnoid hemorrhage (SAH), and 15.5% (61/394) subdural hemorrhage (SDH). Total mortality rates for surgical management 65.6% (40/61) differed from medical management at 45.2% (109/241). There was an increased relative risk of mortality (RR=1.45, 95% CI: 1.10-1.91, p = 0.01) for ICH patients undergoing surgical intervention. The hemorrhage subtype most frequently managed with anticoagulation reversal was IPH 81.8% (63/77), followed by SDH 52.2% (12/23), and SAH 39.1% (18/46). Mean number of days until antithrombotic resumption ranged from 6 to 10.5 days. CONCLUSION: Outcomes remain poor, specifically for those undergoing surgery. As experience with this population increases, prospective studies are warranted to contribute to management and prognostication .

General surgery involvement with ventriculoperitoneal shunt insertions reduces revision rates.

BACKGROUND: Ventriculoperitoneal shunts (VPS) are placed for a variety of etiologies. It is common for general surgery to assist with insertion of the distal portion in the peritoneum. OBJECTIVE: To determine if there is a difference in revision rates in patients undergoing VPS placement with general surgery as well as those undergoing laparoscopic insertion. METHODS: A retrospective review of all consecutive patients undergoing VPS placements was performed in a three-year period (2017-2019). Those that underwent placement with general surgery were compared to those without general surgery. Additionally, patients undergoing distal placement via mini-laparotomy versus laparoscopy were compared. Multivariable logistic regression was used to examine risk factors for distal VPS failure. RESULTS: 331 patients were included. 202 (61.0 %) underwent VPS placement with general surgery. 121 (36.6 %) patients underwent insertion via laparoscopic technique. General surgery involvement reduced operative times, decreased length of stay, and lowered overall revision rates with distal revision rates being most significant (1.5 % vs 8.5 %; p = 0.0034). Patients undergoing VPS placement via laparoscopic technique had decreased operative time, length of stay, in-hospital complications and revision rates, with significant decrease in shunt infection (1.7 % vs 7.1 %; p = 0.0366). A history of prior shunt or abdominal surgery (OR 3.826; p = 0.0282) and lack of general surgery involvement (OR 20.98; p = 0.0314) are independent risk factors for distal shunt revision in our cohort. CONCLUSION: The use of general surgeons in VPS insertion can be of benefit by decreasing operative time, length of stay, total revisions, and distal revision rates. Further prospective studies are warranted to determine true benefit.