Laser interstitial thermal therapy for first-line treatment of insular glioma.

OBJECTIVE: Insular gliomas pose a significant surgical challenge due to the complex surrounding functional and vascular anatomy. The authors report their experience using a novel framework for the treatment of insular gliomas with laser interstitial thermal therapy (LITT) and provide representative case examples emphasizing indications, rationale, and technical pearls. METHODS: A prospectively gathered institutional database was used to identify patients with newly diagnosed insular gliomas who underwent LITT between 2015 and 2023. The proposed framework of insular glioma management is guided by tumor size and extent of extra-insular tumor involvement. Patients with tumors localized to the insula (insula-only) were treated with single-session or staged LITT. Patients with insular tumors with frontotemporal involvement (insular+) were treated with insular LITT and standard frontotemporal resection of extra-insular tumor. Clinical and volumetric lesional characteristics were analyzed, with particular emphasis on extent of cytoreductive treatment and safety. RESULTS: Of the 261 patients treated at the authors' institution with LITT between 2015 and 2023, 33 LITT procedures were identified involving 22 unique patients with treatment-naive insular gliomas. Of the 22 patients, 12 had insular-only tumors and were treated with LITT alone, while 10 patients had insular+ lesions and were treated with LITT and resection. The median tumor volume for insular-only tumors was 13.4 cm3 (IQR 10.6, 26.3 cm3), with a median extent of treatment of 100% (IQR 92.1%, 100%). Insular+ lesions were significantly larger, with a median volume of 81.2 cm3 (IQR 51.9, 97 cm3) and median extent of treatment of 96.6% (IQR 93.7%, 100%). All patients with insular-only tumors were discharged the day after ablation, while insular+ patients had significantly longer hospital stays, with 50% staying more than 3 days. Overall, 8% of insular-only patients had permanent neurological deficits compared with 33% of insular+ patients. Two patients' tumors progressed during follow-up: one patient with WHO grade 4 astrocytoma and the other with diffuse glioma not otherwise specified. Patients with grade 4 tumors had the highest rate of permanent neurological deficit (43%) and a larger decline in postoperative Karnofsky Performance Status score (p = 0.046). CONCLUSIONS: The authors present their experience using a novel insular glioma treatment paradigm that incorporates LITT into the broader framework of insular glioma surgery. Their findings suggest that insular LITT is feasible and may allow for high rates of cytoreduction while potentially ameliorating the risks of conventional insular glioma surgery.

Radiological features of patients with headache as a presenting symptom of neurosarcoidosis.

OBJECTIVE: To describe the radiological features of patients with headache as a presenting symptom of neurosarcoidosis. BACKGROUND: Neurologic complications occur in approximately 5%-10% of patients with sarcoidosis, and approximately 50% of these patients have neurologic deficits at the time sarcoidosis is first diagnosed. A wide spectrum of central and peripheral nervous system clinical manifestations may be observed, including cranial nerve palsies, sensory and/or motor deficits, and headache. Magnetic resonance imaging (MRI) results in patients with neurosarcoidosis may include abnormal contrast enhancement, structural masses, and demyelinating lesions. METHODS: This single-center retrospective cohort study assessed patients who were diagnosed with neurosarcoidosis in an urban tertiary care center between 1995 and 2016. We included patients who had MRI results at the time of diagnosis. Patients were divided into two groups based on the presence or absence of headache as a presenting symptom. The MRI result of meningeal contrast enhancement was reviewed. RESULTS: Of the 110 patients analyzed, 30 (27.3%) had an initial presenting symptom of headache while 80 (72.7%) did not. Patients with headache had a higher proportion of meningeal contrast enhancement on MRI (66.7% [20/30] vs. 25.0% [20/80]; p < 0.001) and leptomeningeal involvement (53.3% [16/30] vs. 7.5% [6/80], p < 0.001) compared to patients with no headache. However, those with headache had a lower proportion of spinal cord localization (13.8% [4/29] vs. 34.2% [26/76], p = 0.038) and intraparenchymal central nervous system involvement (16.7% [5/30] vs. 51.3% [41/80], p = 0.001) compared to patients with no headache. CONCLUSION: Patients with neurosarcoidosis who presented with headache as an initial symptom had a higher proportion of meningeal contrast enhancement seen by MRI than patients who presented with other neurological symptoms. This suggests a clinico-radiologic link between headache and meningeal disruption in patients with neurosarcoidosis.

Early vs late anticoagulation in acute ischemic stroke with indications outside atrial fibrillation.

BACKGROUND: Current literature lacks guidance on the safety of administering anticoagulation in acute ischemic stroke with emergent indications that require anticoagulation other than atrial fibrillation. Therefore, we tend to rely on studies investigating acute ischemic stroke in atrial fibrillation for anticoagulation recommendations. METHODS: We retrospectively reviewed data for patients with acute ischemic stroke who had a non-atrial fibrillation emergent indication for anticoagulation (e.g., intra-arterial thrombus, intracardiac thrombus, acute coronary syndrome, acute limb ischemia, deep vein thrombosis and pulmonary embolism) diagnosed within 3 days of acute ischemic stroke. Patients who received anticoagulation ≤ 3 days of stroke onset (Group A) were compared to those who either received it afterwards or did not receive it at all (Group B). RESULTS: Out of the 558 patients, only 88 patients met our inclusion criteria. Of the total cohort, 55.7 % patients were males, and basic demographics were similar in both groups except for milder strokes in Group A (national institute of health stroke scale 6 vs. 12.5, p = 0.03). Only 2 patients in Group A and 1 patient in Group B developed intracranial hemorrhage, which was not statistically significant. Group A patients had a lower incidence of both new diagnosis (2 % vs. 34.2 % %, p < 0.001) and propagation of an established venous thromboembolism. They also had a lower rate of any thromboembolic complication (2 % vs. 42 %, p < 0.001). CONCLUSION: Early anticoagulation (i.e., ≤ 3 days) in non-atrial fibrillation ischemic stroke patients with an emergent indication may be safe and carry a lower risk of thromboembolic complications than later anticoagulation.

The impact of anxiety and depression on lumbar spine surgical outcomes: a Michigan Spine Surgery Improvement Collaborative study.

OBJECTIVE: The presence of depression and anxiety has been associated with negative outcomes in spine surgery patients. While it seems evident that a history of depression or anxiety can negatively influence outcome, the exact additive effect of both has not been extensively studied in a multicenter trial. The purpose of this study was to investigate the relationship between a patient's history of anxiety and depression and their patient-reported outcomes (PROs) after lumbar surgery. METHODS: Patients in the Michigan Spine Surgery Improvement Collaborative registry undergoing lumbar spine surgery between July 2016 and December 2021 were grouped into four cohorts: those with a history of anxiety only, those with a history of depression only, those with both, and those with neither. Primary outcomes were achieving the minimal clinically important difference (MCID) for the Patient-Reported Outcomes Measurement Information System Physical Function 4-item Short Form (PROMIS PF), EQ-5D, and numeric rating scale (NRS) back pain and leg pain, and North American Spine Society patient satisfaction. Secondary outcomes included surgical site infection, hospital readmission, and return to the operating room. Multivariate Poisson generalized estimating equation models were used to report incidence rate ratios (IRRs) from patient baseline variables. RESULTS: Of the 45,565 patients identified, 3941 reported a history of anxiety, 5017 reported a history of depression, 9570 reported both, and 27,037 reported neither. Compared with those who reported having neither, patients with both anxiety and depression had lower patient satisfaction at 90 days (p = 0.002) and 1 year (p = 0.021); PROMIS PF MCID at 90 days (p < 0.001), 1 year (p < 0.001), and 2 years (p = 0.006); EQ-5D MCID at 90 days (p < 0.001), 1 year (p < 0.001), and 2 years (p < 0.001); NRS back pain MCID at 90 days (p < 0.001) and 1 year (p < 0.001); and NRS leg pain MCID at 90 days (p < 0.001), 1 year (p = 0.024), and 2 years (p = 0.027). Patients with anxiety only (p < 0.001), depression only (p < 0.001), or both (p < 0.001) were more likely to be readmitted within 90 days. Additionally, patients with anxiety only (p = 0.015) and both anxiety and depression (p = 0.015) had higher rates of surgical site infection. Patients with anxiety only (p = 0.006) and depression only (p = 0.021) also had higher rates of return to the operating room. CONCLUSIONS: The authors observed an association between a history of anxiety and depression and negative outcome after lumbar spine surgery. In addition, they found an additive effect of a history of both anxiety and depression with an increased risk of negative outcome when compared with either anxiety or depression alone.

Risk factors of emergency department visits following elective cervical and lumbar surgical procedures: a multi-institution analysis from the Michigan Spine Surgery Improvement Collaborative.

OBJECTIVE: Emergency department visits 90 days after elective spinal surgery are relatively common, with rates ranging from 9% to 29%. Emergency visits are very costly, so their reduction is of importance. This study's objective was to evaluate the reasons for emergency department visits and determine potentially modifiable risk factors. METHODS: This study retrospectively reviewed data queried from the Michigan Spine Surgery Improvement Collaborative (MSSIC) registry from July 2020 to November 2021. MSSIC is a multicenter (28-hospital) registry of patients undergoing cervical and lumbar degenerative spinal surgery. Adult patients treated for elective cervical and/or lumbar spine surgery for degenerative pathology (spondylosis, intervertebral disc disease, low-grade spondylolisthesis) were included. Emergency department visits within 90 days of surgery (outcome measure) were analyzed utilizing univariate and multivariate regression analyses. RESULTS: Of 16,224 patients, 2024 (12.5%) presented to the emergency department during the study period, most commonly for pain related to spinal surgery (31.5%), abdominal problems (15.8%), and pain unrelated to the spinal surgery (12.8%). On multivariate analysis, age (per 5-year increase) (relative risk [RR] 0.94, 95% CI 0.92-0.95), college education (RR 0.82, 95% CI 0.69-0.96), private insurance (RR 0.79, 95% CI 0.70-0.89), and preoperative ambulation status (RR 0.88, 95% CI 0.79-0.97) were associated with decreased emergency visits. Conversely, Black race (RR 1.30, 95% CI 1.13-1.51), current diabetes (RR 1.13, 95% CI 1.01-1.26), history of deep venous thromboembolism (RR 1.28, 95% CI 1.16-1.43), history of depression (RR 1.13, 95% CI 1.03-1.25), history of anxiety (RR 1.32, 95% CI 1.19-1.46), history of osteoporosis (RR 1.21, 95% CI 1.09-1.34), history of chronic obstructive pulmonary disease (RR 1.19, 95% CI 1.06-1.34), American Society of Anesthesiologists class > II (RR 1.18, 95% CI 1.08-1.29), and length of stay > 3 days (RR 1.29, 95% CI 1.16-1.44) were associated with increased emergency visits. CONCLUSIONS: The most common reasons for emergency department visits were surgical pain, abdominal dysfunction, and pain unrelated to index spinal surgery. Increased focus on postoperative pain management and bowel regimen can potentially reduce emergency visits. The risks of diabetes, history of osteoporosis, depression, and anxiety are areas for additional preoperative screening.

New-onset as opposed to established atrial fibrillation as a risk factor for incident stroke.

BACKGROUND: Atrial fibrillation (AF) is an established risk factor for acute ischemic stroke (AIS). It remains unclear if new-onset AF confers a higher risk of AIS than longer-standing AF. METHODS: We retrospectively analyzed all stroke-free patients who underwent transthoracic echocardiography (TTE) in the Henry Ford Health System between March 6 and September 6, 2016. Incident AIS and new-onset AF were ascertained by the presence of new diagnostic codes in the electronic medical record over a follow-up period of up to 5 years. Cox proportional hazards regression was used to identify risk factors for new-onset AF or AIS. RESULTS: Of 7310 patients who underwent baseline TTE the mean age was 65 years, 54% were female, 51% were Caucasian, and 46% had left atrial enlargement (LAE). Of at-risk patients, 10.9% developed new-onset AF and 2.9% experienced incident AIS. The risk of new-onset AF among at-risk patients was 3.1 times higher among patients with any degree of LAE compared to those with normal LA size (95% CI 2.6-3.6, P < 0.0001). New-onset AF, more than established AF, in turn had a powerful association with incident AIS. The cumulative 5-year risk of AIS was 3.5% in those without AF, 5.9% in those with established AF prior to TTE, and 20.1% in those with new-onset AF (P < 0.0001). In multivariable analysis new-onset AF had the strongest association with incident AIS (P < 0.0001), followed by increasing age (P = 0.0025), black race (P = 0.0032), and smoking (P = 0.0063). CONCLUSIONS: New-onset AF has a strong relationship with incident AIS. LAE was present in nearly half of stroke-free patients undergoing TTE, and was associated with a significantly higher likelihood of new-onset AF during follow-up. Vigilant cardiac monitoring for AF in individuals with LAE, coupled with the timely initiation of anticoagulation, may be an important strategy for the primary prevention of AF-related stroke.

Does Tighter Glycemic Control Beyond Hemoglobin A1c of 8% Improve Outcome for Lumbar Spine Surgery? A MSSIC Study.

BACKGROUND AND OBJECTIVES: Diabetes mellitus is associated with increased risk of postoperative adverse outcomes. Previous studies have emphasized the role of glycemic control in postoperative complications. This study aims to ascertain whether controlling hemoglobin A1c (HbA1c) lower than 8% preoperatively results in meaningful risk reduction or improved outcomes. METHODS: We used patient-level data from the Michigan Spine Surgery Improvement Collaborative registry, focusing on patients who underwent elective lumbar spine surgery between 2018 and 2021. The primary outcomes were length of stay and the occurrence of postoperative adverse events. Secondary outcomes included patient satisfaction, achievement of a minimum clinically important difference (MCID) of Patient-Reported Outcomes Measurement Information System-Physical Function, the EuroQol-5D and NRS of leg and back pain, and return to work. RESULTS: A total of 11 348 patients were included in this analysis. Patients with HbA1c above the thresholds before surgery had significantly higher risks of urinary retention for all 3 possible threshold values (incidence rate ratio [IRR] = 1.30, P = .015; IRR = 1.35, P = .001; IRR = 1.25, P = .011 for the HbA1c cutoffs of 8%, 7.5%, and 7%, respectively). They also had longer hospital stay (IRR = 1.04, P = .002; IRR = 1.03, P = .001; IRR = 1.03, P < .001 for the HbA1c cutoffs of 8%, 7.5%, and 7%, respectively) and had higher risks of developing any complication with HbA1c cutoff of 7.5% (IRR = 1.09, P = .010) and 7% (IRR = 1.12, P = .001). Diabetics with preoperative HbA1c above all 3 thresholds were less likely to achieve Patient-Reported Outcomes Measurement Information System MCID at the 90-day follow-up (IRR = .81, P < .001; IRR = .86, P < .001; IRR = .90, P = .007 for the HbA1c cutoffs of 8%, 7.5%, and 7%, respectively) and less likely to achieve EuroQol-5D MCID at the 2-year follow-up (IRR = .87, P = .027; IRR = .84, P = .005 for the HbA1c cutoffs of 7.5% and 7%, respectively). CONCLUSION: Our study suggests that reducing HbA1c below 8% may have diminishing returns regarding reducing complications after spine surgery.

Risk factors for not reaching minimal clinically important difference at 90 days and 1 year after elective lumbar spine surgery: a cohort study.

OBJECTIVE: Patient-perceived functional improvement is a core metric in lumbar surgery for degenerative disease. It is important to identify both modifiable and nonmodifiable risk factors that can be evaluated and possibly optimized prior to elective surgery. This case-control study was designed to study risk factors for not achieving the minimal clinically important difference (MCID) in Patient-Reported Outcomes Measurement Information System Function 4-item Short Form (PROMIS PF) score. METHODS: The authors queried the Michigan Spine Surgery Improvement Collaborative database to identify patients who underwent elective lumbar surgical procedures with PROMIS PF scores. Cases were divided into two cohorts based on whether patients achieved MCID at 90 days and 1 year after surgery. Patient characteristics and operative details were analyzed as potential risk factors. RESULTS: The authors captured 10,922 patients for 90-day follow-up and 4453 patients (40.8%) did not reach MCID. At the 1-year follow-up period, 7780 patients were identified and 2941 patients (37.8%) did not achieve MCID. The significant demographic characteristic-adjusted relative risks (RRs) for both groups (RR 90 day, RR 1 year) included the following: symptom duration > 1 year (1.34, 1.41); previous spine surgery (1.25, 1.30); African American descent (1.25, 1.20); chronic opiate use (1.23, 1.25); and less than high school education (1.20, 1.34). Independent ambulatory status (0.83, 0.88) and private insurance (0.91, 0.85) were associated with higher likelihood of reaching MCID at 90 days and 1 year, respectively. CONCLUSIONS: Several key unique demographic risk factors were identified in this cohort study that precluded optimal postoperative functional outcomes after elective lumbar spine surgery. With this information, appropriate preoperative counseling can be administered to assist in shaping patient expectations.

Cervical disc arthroplasty versus anterior cervical discectomy and fusion: an analysis of the Michigan Spine Surgery Improvement Collaborative Database.

BACKGROUND CONTEXT: Anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) are established surgical options for the treatment of cervical radiculopathy, myelopathy, and cervical degenerative disc disease. However, current literature does not demonstrate a clear superiority between ACDF and CDA. PURPOSE: To investigate procedural and patient-reported outcomes of ACDF and CDA among patients included in the Michigan Spine Surgery Improvement Collaborative (MSSIC) database. DESIGN: Retrospective study of prospectively collected outcomes registry data. PATIENT SAMPLE: Individuals within the MSSIC database presenting with radiculopathy, myelopathy, or cervical spondylosis refractory to typical conservative care undergoing primary ACDF or CDA from January 4, 2016, to November 5, 2021. OUTCOME MEASURES: Perioperative measures (including surgery length, length of stay, return to OR, any complications), patient-reported functional outcomes at 2-year follow-up (including return to work, patient satisfaction, PROMIS, EQ-5D, mJOA). METHODS: Patients undergoing ACDF were matched 4:1 with those undergoing CDA; propensity analysis performed on operative levels (1- and 2- level procedures), presenting condition, demographics, and comorbidities. Initial comparisons performed with univariate testing and multivariate analysis performed with Poisson generalized estimating equation models clustering on hospital. RESULTS: A total of 2,208 patients with ACDF and 552 patients with CDA were included. Baseline demographics were similar, with younger patients undergoing CDA (45.6 vs 48.6 years; p<.001). Myelopathy was more frequent in ACDF patients (30% vs 25%; p=.015). CDA was more frequently planned as an outpatient procedure. Length of stay was increased in ACDF (1.3 vs 1.0 days; p<.001). Functional outcomes were similar, with comparable proportions of patients meeting minimal clinically important difference thresholds in neck pain, arm pain, PROMIS, EQ-5D, and mJOA score. After multivariate regression, no significant differences were seen in surgical or functional outcomes. CONCLUSIONS: This study demonstrates similar outcomes for those undergoing ACDF and CDA at 2 years. Previous meta-analyses of CDA clinical trial data adhere to strict inclusion and exclusion criteria required by clinical studies; this registry data provides "real world" clinical outcomes reflecting current practices for ACDF and CDA patient selection.

Association of prolonged symptom duration with poor outcomes in lumbar spine surgery: a Michigan Spine Surgery Improvement Collaborative study.

OBJECTIVE: There is a scarcity of large multicenter data on how preoperative lumbar symptom duration relates to postoperative patient-reported outcomes (PROs). The objective of this study was to determine the effect of preoperative and baseline symptom duration on PROs at 90 days, 1 year, and 2 years after lumbar spine surgery. METHODS: The Michigan Spine Surgery Improvement Collaborative registry was queried for all lumbar spine operations between January 1, 2017, to December 31, 2021, with a follow-up of 2 years. Patients were stratified into three subgroups based on symptom duration: < 3 months, 3 months to < 1 year, and ≥ 1 year. The primary outcomes were reaching the minimal clinically important difference (MCID) for the PROs (i.e., leg pain, Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF), EQ-5D, North American Spine Society satisfaction, and return to work). The EQ-5D score was also analyzed as a continuous variable to calculate quality-adjusted life years. Multivariable Poisson generalized estimating equation models were used to report adjusted risk ratios, with the < 3-month cohort used as the reference. RESULTS: There were 37,223 patients (4670 with < 3-month duration, 9356 with 3-month to < 1-year duration, and 23,197 with ≥ 1-year duration) available for analysis. Compared with patients with a symptom duration of < 1 year, patients with a symptom duration of ≥ 1 year were significantly less likely to achieve an MCID in PROMIS PF, EQ-5D, back pain relief, and leg pain relief at 90 days, 1 year, and 2 years postoperatively. Similar trends were observed for patient satisfaction and return to work. With the EQ-5D score as a continuous variable, a symptom duration of ≥ 1 year was associated with 0.04, 0.05, and 0.03 (p < 0.001) decreases in EQ-5D score at 90 days, 1 year, and 2 years after surgery, respectively. CONCLUSIONS: A symptom duration of ≥ 1 year was associated with poorer outcomes on several outcome metrics. This suggests that timely referral and surgery for degenerative lumbar pathology may optimize patient outcome.

Clinical Outcome in Patients With Early-Stage Small Cell Lung Cancer Treated With Surgery or Radiation in the Absence of Prophylactic Cranial Irradiation: A Single-Center Retrospective Study.

Purpose: As screening chest computed tomography for patients at high risk for cancer has become more widely accepted, increasing numbers of patients with early-stage small cell lung cancer (SCLC) are being diagnosed. Although surgery is an accepted option for patients with early-stage SCLC, for patients who decline or cannot undergo surgery, stereotactic body radiation treatment (SBRT) is an alternative. Although prophylactic cranial irradiation (PCI) improves survival in patients with limited-stage SCLC, PCI for early-stage SCLC (stage T1-T2) has not been explored. This study defines survival and recurrence patterns in patients with early-stage SCLC who were treated with surgery or SBRT in the absence of PCI. Methods and Materials: In this single-institution retrospective study, 14 patients diagnosed with early-stage SCLC (stage T1-T2) between July 2015 and May 2021 at a single tertiary care hospital were treated with SBRT or surgery with no PCI. Primary outcomes were locoregional cancer recurrence, distant recurrence, recurrence-free survival, and overall survival. The secondary outcome was development of brain metastasis. Analyses included Cox regression, Kaplan-Meier survival, and log-rank tests. Results: A total of 14 patients (5 women and 9 men) were included in the study: 9 with stage T1 and 5 with stage T2 SCLC. Six patients (43%) received SBRT and 8 (57%) had surgical treatment. All patients except 1 received adjuvant chemotherapy. Median follow-up was 14.3 months (range, 2.4-64.4 months), and the median age at diagnosis was 71.5 years (range, 54-81 years). Cox regression and log-rank tests showed no significant differences in any outcomes between the surgery and SBRT groups, and no patients developed brain metastases during the study period. Conclusions: Data are lacking regarding the benefit of PCI in early-stage SCLC. Although the sample size in this study was too small to draw any conclusions, the findings add to the ongoing dialogue regarding the importance of PCI in this patient population. No difference was identified in survival and cancer recurrence in patients who received either surgery or SBRT in the absence of PCI.

Comparison of Oropharyngeal Dysphagia Before and After Botulinum Toxin Injection in Cervical Dystonia.

Cervical dystonia (CD) is the most common form of focal dystonia with Botulinum neurotoxin (BoNT) being a frequent method of treatment. Dysphagia is a common side effect of BoNT treatment for CD. Instrumental evaluation of swallowing in CD using standardized scoring for the videofluoroscopic swallowing study (VFSS) and validated and reliable patient-reported outcomes measures is lacking in the literature. (1) to determine if BoNT injections change instrumental findings of swallowing function using the Modified Barium Swallow Impairment Profile (MBSImP) in individuals with CD; (2) to determine if BoNT injections change self-perception of the psychosocial handicapping effects of dysphagia in individuals with CD, using the Dysphagia Handicap Index (DHI); (3) to determine the effect of BoNT dosage on instrumental swallowing evaluation and self-reported swallowing outcomes measures. 18 subjects with CD completed a VFSS and the DHI before and after BoNT injection. There was a significant increase in pharyngeal residue for pudding consistency after BoNT injection, p = 0.015. There were significant positive associations between BoNT dosage and self-perception of the physical attributes of the handicapping effect of dysphagia, the grand total score and patient self-reported severity of dysphagia on the DHI; p = 0.022; p = 0.037; p = 0.035 respectively. There were several significant associations between changes in MBSImP scores and BoNT dose. Pharyngeal efficiency of swallowing may be affected by BoNT for thicker consistencies. Individuals with CD perceive greater physical handicapping effects of dysphagia with increased amounts of BoNT units and have greater self-perceptions of dysphagia severity with increased amounts of BoNT units.

A Multicenter Allelic Analysis of Diffuse Idiopathic Skeletal Hyperostosis: Nature Versus Nurture?

BACKGROUND: Diffuse idiopathic skeletal hyperostosis (DISH) is an incompletely defined disease process with no known unifying pathophysiological mechanism. OBJECTIVE: To our knowledge, no genetic studies have been performed in a North American population. To summarize genetic findings from previous studies and to comprehensively test for these associations in a novel and diverse, multi-institutional population. METHODS: Cross-sectional, single nucleotide polymorphism (SNP) analysis was performed in 55 of 121 enrolled patients with DISH. Baseline demographic data were available on 100 patients. Based on allele selection from previous studies and related disease conditions, sequencing was performed on COL11A2, COL6A6, fibroblast growth factor 2 gene, LEMD3, TGFB1, and TLR1 genes and compared with global haplotype rates. RESULTS: Consistent with previous studies, older age (mean 71 years), male sex predominance (80%), a high frequency of type 2 diabetes (54%), and renal disease (17%) were observed. Unique findings included high rates of tobacco use (11% currently smoking, 55% former smoker), a higher predominance of cervical DISH (70%) relative to other locations (30%), and an especially high rate of type 2 diabetes in patients with DISH and ossification of the posterior longitudinal ligament (100%) relative to DISH alone (100% vs 47%, P < .001). Compared with global allele rates, we found higher rates of SNPs in 5 of 9 tested genes ( P < .05). CONCLUSION: We identified 5 SNPs in patients with DISH that occurred more frequently than a global reference. We also identified novel environmental associations. We hypothesize that DISH represents a heterogeneous condition with both multiple genetic and environmental influences.

Community health workers as change agents in improving equity in birth outcomes in Detroit.

We examined whether pairing pregnant women with community health workers improved pregnancy outcomes among 254 Black women with singleton pregnancies participating in the Women-Inspired Neighborhood (WIN) Network: Detroit using a case-control design. A subset (N = 63) of women were recontacted and asked about program satisfaction, opportunities, and health behaviors. Michigan Vital Statistics records were used to ascertain controls (N = 12,030) and pregnancy and infant health outcomes. Logistic and linear regression were used to examine the association between WIN Network participation and pregnancy and infant health outcomes. The WIN Network participants were less likely than controls to be admitted to the neonatal intensive care unit (odds ratio = 0.55, 95% CI 0.33-0.93) and had a longer gestational length (mean difference = 0.42, 95% CI 0.02-0.81). Community health workers also shaped participants' view of opportunities to thrive. This study demonstrates that community health workers can improve pregnancy outcomes for Black women.

The Potential Negative Effects of Smoking on Cervical and Lumbar Surgery Beyond Pseudarthrosis: A Michigan Spine Surgery Improvement Collaborative Study.

OBJECTIVE: To review the Michigan Spine Surgery Improvement Collaborative registry to investigate the long-term associations between current smoking status and outcomes after elective cervical and lumbar spine surgery. METHODS: Using the Michigan Spine Surgery Improvement Collaborative, we captured all cases from January 1, 2017, to November 21, 2020, with outcomes data available; 19,251 lumbar cases and 7936 cervical cases were included. Multivariate regression analyses were performed to assess the relationship of smoking with the clinical outcomes. RESULTS: Current smoking status was associated with lower urinary retention and satisfaction for patients after lumbar surgery and was associated with less likelihood of achieving minimal clinically important difference in primary outcome measures including Patient-Reported Outcomes Measurement Information System, back pain, leg pain, and EuroQol-5D at 90 days and 1 year after surgery. Current smokers were also less likely to return to work at 90 days and 1 year after surgery. Among patients who underwent cervical surgery, current smokers were less likely to have urinary retention and dysphagia postoperatively. They were less likely to be satisfied with the surgery outcome at 1 year. Current smoking was associated with lower likelihood of achieving minimal clinically important difference in Patient-Reported Outcomes Measurement Information System, neck pain, arm pain, and EuroQol-5D at various time points. There was no difference in return-to-work status. CONCLUSIONS: Our analysis suggests that smoking is negatively associated with functional improvement, patient satisfaction, and return-to-work after elective spine surgery.

Correlation of mJOA, PROMIS physical function, and patient satisfaction in patients with cervical myelopathy: an analysis of the Michigan Spine Surgery Improvement Collaborative (MSSIC) database.

BACKGROUND CONTEXT: Patient-reported outcomes (PROs) are increasingly utilized to evaluate the efficacy and value of spinal procedures. Among patients with cervical myelopathy, the modified Japanese Orthopaedic Association (mJOA) remains the standard instrument, with Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and patient satisfaction also frequently assessed. These outcomes have not all been directly compared using a large spine registry at 2 years follow-up for cervical myelopathic patients undergoing surgery. PURPOSE: To determine the correlation and association of PROMIS PF, mJOA, and patient satisfaction outcomes in patients undergoing surgery for cervical myelopathy. STUDY DESIGN/SETTING: Retrospective review of a multicenter spine registry database. PATIENT SAMPLE: Adult patients with cervical myelopathy who underwent cervical spine surgery between 2/26/2018 and 4/17/2021. OUTCOME MEASURES: PROMIS PF, mJOA, and North American Spine Society (NASS) patient satisfaction index. METHODS: The MSSIC database was accessed to gather pre- and postoperative outcome data on patients with cervical myelopathy. Spearman's correlation coefficients relating mJOA and PROMIS PF were quantified up to 2 years postoperatively. The correlations between patient satisfaction with mJOA and PROMIS were determined. Kappa statistics were used to evaluate for agreement between those reaching the minimum clinically important difference (MCID) for mJOA and PROMIS PF. Odds ratios were calculated to determine the association between patient satisfaction and those reaching MCID for mJOA and PROMIS PF. Support for MSSIC is provided by BCBSM and Blue Care Network as part of the BCBSM Value Partnerships program. RESULTS: Data from 2,023 patients were included. Moderate to strong correlations were found between mJOA and PROMIS PF at all time points (p<.001). These outcomes had fair agreement at all postoperative time points when comparing those who reached MCID. Satisfaction was strongly related to changes from baseline for both mJOA and PROMIS PF at all time points (p<.001). Odds ratios associating satisfaction with PROMIS PF MCID were higher at all time points compared with mJOA, although the differences were not significant. CONCLUSIONS: PROMIS PF has a strong positive correlation with mJOA up to 2 years postoperatively in patients undergoing surgery for cervical myelopathy, with similar odds of achieving MCID with both instruments. Patient satisfaction is predicted similarly by these outcome measures by 2 years postoperatively. These results affirm the validity of PROMIS PF in the cervical myelopathic population. Given its generalizability and ease of use, PROMIS PF may be a more practical outcome measure for clinical use compared with mJOA.

Rates and reasons for reoperation within 30 and 90 days following cervical spine surgery: a retrospective cohort analysis of the Michigan Spine Surgery Improvement Collaborative (MSSIC) registry.

BACKGROUND CONTEXT: Reoperation following cervical spinal surgery negatively impacts patient outcomes and increases health care system burden. To date, most studies have evaluated reoperations within 30 days after spine surgery and have been limited in scope and focus. Evaluation within the 90-day period, however, allows a more comprehensive assessment of factors associated with reoperation. PURPOSE: The purpose of this study is to assess the rates and reasons for reoperations after cervical spine surgery within 30 and 90 days. DESIGN: We performed a retrospective analysis of a state-wide prospective, multi-center, spine-specific database of patients surgically treated for degenerative disease. PATIENT SAMPLE: Patients 18 years of age or older who underwent cervical spine surgery for degenerative pathologies from February 2014 to May 2019. Operative criteria included all degenerative cervical spine procedures, including those with cervical fusions with contiguous extension down to T3. OUTCOME MEASURES: We determined causes for reoperation and independent surgical and demographic risk factors impacting reoperation. METHODS: Patient-specific and surgery-specific data was extracted from the registry using ICD-10-DM codes. Reoperations data was obtained through abstraction of medical records through 90 days. Univariate analysis was done using chi-square tests for categorical variables, t-tests for normally distributed variables, and Wilcoxon rank-sum tests for variables with skewed distributions. Odds ratios for return to the operating room (OR) were evaluated in multivariate analysis. RESULTS: A total of 13,435 and 13,440 patients underwent cervical spine surgery and were included in the 30 and 90-day analysis, respectively. The overall reoperation rate was 1.24% and 3.30% within 30 and 90 days, respectively. Multivariate analysis showed within 30 days, procedures involving four or more levels, posterior only approach, and longer length of stay had increased odds of returning to the OR (p<.05), whereas private insurance had a decreased odds of return to OR (p<.05). Within 90 days, male sex, coronary artery disease (CAD), previous spine surgery, procedures with 4 or more levels, and longer length of stay had significantly increased odds of returning to the OR (p<.05). Non-white race, independent ambulatory status pre-operatively, and having private insurance had decreased odds of return to the OR (p<.05). The most common specified reasons for return to the OR within 30 days was hematoma (19%), infection (17%), and wound dehiscence (11%). Within 90 days, reoperation reasons were pain (10%), infection (9%), and hematoma (8%). CONCLUSION: Reoperation rates after elective cervical spine surgery are 1.24% and 3.30% within 30 and 90 days, respectively. Within 30 days, four or more levels, posterior approach, and longer length of stay were risk factors for reoperation. Within 90 days, male sex, CAD, four or more levels, and longer length of hospital stay were risk factors for reoperation. Non-white demographic and independent preoperative ambulatory status were associated with decreased reoperation rates.

Postoperative opioid prescription and patient-reported outcomes after elective spine surgery: a Michigan Spine Surgery Improvement Collaborative study.

OBJECTIVE: This study was designed to assess how postoperative opioid prescription dosage could affect patient-reported outcomes after elective spine surgery. METHODS: Patients enrolled in the Michigan Spine Surgery Improvement Collaborative (MSSIC) from January 2020 to September 2021 were included in this study. Opioid prescriptions at discharge were converted to total morphine milligram equivalents (MME). A reference value of 225 MME per week was used as a cutoff. Patients were divided into two cohorts based on prescribed total MME: ≤ 225 MME and > 225 MME. Primary outcomes included patient satisfaction, return to work status after surgery, and whether improvement of the minimal clinically important difference (MCID) of the Patient-Reported Outcomes Measurement Information System 4-question short form for physical function (PROMIS PF) and EQ-5D was met. Generalized estimated equations were used for multivariate analysis. RESULTS: Regression analysis revealed that patients who had postoperative opioids prescribed with > 225 MME were less likely to be satisfied with surgery (adjusted OR [aOR] 0.81) and achieve PROMIS PF MCID (aOR 0.88). They were also more likely to be opioid dependent at 90 days after elective spine surgery (aOR 1.56). CONCLUSIONS: The opioid epidemic is a serious threat to national public health, and spine surgeons must practice conscientious postoperative opioid prescribing to achieve adequate pain control. The authors' analysis illustrates that a postoperative opioid prescription of 225 MME or less is associated with improved patient satisfaction, greater improvement in physical function, and decreased opioid dependence compared with those who had > 225 MME prescribed.

Non-stenosing carotid artery plaques in embolic stroke of undetermined source: a retrospective analysis.

BACKGROUND: We aim to identify the association between high-risk carotid plaques and their laterality to stroke in ESUS patient population. We also discuss recurrent stroke events and their laterality to the index stroke. METHODS: This was a retrospective study. We reviewed data for patients with ESUS between June 20, 2016, and June 20, 2021. Using computed tomography angiography, we analyzed plaque features that are associated with ESUS, and then, we identified the recurrent stroke events and characterized lateralization to the index stroke. RESULTS: Out of 1779 patients with cryptogenic ischemic stroke, we included 152 patients who met the criteria for ESUS. High-risk plaque features were found more often ipsilateral to the stroke side when compared contralaterally: plaque ulceration (19.08% vs 5.26%, p < .0001), plaque thickness > 3 mm (19.08% vs 7.24%, p = 0.001), and plaque length > 1 cm (13.16% vs 5.92%, p = 0.0218). There was also a significant difference in plaque component in which both components (soft and calcified) and only soft plaques were more prevalent ipsilaterally (42.76% vs 23.68% and 17.76% vs 9.21%, respectively, p < .0001). Of the 152 patients, 17 patients were found to have a recurrent stroke event, and 47% (n = 8) had an ipsilateral stroke to the index event. Moreover, stroke was bilateral in 41% of the patients (n = 7), and contralateral in 12% (n = 2). CONCLUSION: High-risk plaque features studied here were more prevalent ipsilaterally to the stroke side in ESUS than contralaterally. Multicenter studies are needed to form precise prediction models and scoring systems to help guide treatment, i.e., choice of medical therapy and/or revascularization.

Laser Interstitial Thermal Therapy for First-Line Treatment of Surgically Accessible Recurrent Glioblastoma: Outcomes Compared With a Surgical Cohort.

BACKGROUND: Laser interstitial thermal therapy (LITT) for glioblastoma (GBM) has been reserved for poor surgical candidates and deep "inoperable" lesions. We present the first reported series of LITT for surgically accessible recurrent GBM (rGBM) that would otherwise be treated with surgical resection. OBJECTIVE: To evaluate the use of LITT for unifocal, lobar, first-time rGBM compared with a similar surgical cohort. METHODS: A retrospective institutional database was used to identify patients with unifocal, lobar, first-time rGBM who underwent LITT or resection between 2013 and 2020. Clinical and volumetric lesional characteristics were compared between cohorts. Subgroup analysis of patients with lesions ≤20 cm 3 was also completed. Primary outcomes were overall survival and progression-free survival. RESULTS: Of the 744 patients with rGBM treated from 2013 to 2020, a LITT cohort of 17 patients were compared with 23 similar surgical patients. There were no differences in baseline characteristics, although lesions were larger in the surgical cohort (7.54 vs 4.37 cm 3 , P = .017). Despite differences in lesion size, both cohorts had similar extents of ablation/resection (90.7% vs 95.1%, P = .739). Overall survival (14.1 vs 13.8 months, P = .578) and progression-free survival (3.7 vs 3.3 months, P = 0. 495) were similar. LITT patients had significantly shorter hospital stays (2.2 vs 3.0 days, P = .004). Subgroup analysis of patients with lesions ≤20 cm 3 showed similar outcomes, with LITT allowing for significantly shorter hospital stays. CONCLUSION: We found no difference in survival outcomes or morbidity between LITT and repeat surgery for surgically accessible rGBM while LITT resulted in shorter hospital stays and more efficient postoperative care.