Epidemiology of Gunshot-Related Spinal Injuries and Related Risk Factors for In-Hospital Mortality in the United States from 2015-2019: A National Trauma Data Bank Analysis.

Firearm injuries in the U.S. pose a significant public health burden, but data on gunshot wounds (GSWs) specifically involving the spine are scarce. We examined epidemiological trends in GSWs to the spine and associated spinal cord injury (SCI) and mortality rates. This was a cross-sectional study of data from level I-III trauma centers in the U.S. participating in the American College of Surgeons National Trauma Data Bank (ACS NTDB) in 2015-2019. We identified adult and pediatric patients presenting with GSW and evaluated those with Abbreviated Injury Scale codes indicating spinal involvement and SCI. We assessed in-hospital mortality and GSW-related SCI. A total of 5,021,316 patients were enrolled in the ACS NTDB. Of the 107,233 patients (2.1% of total) presenting with GSW, 9023 (8.4%) patients had spine involvement. Overall rates of GSW and spinal GSW were similar across years. The most common cause of spinal GSW injury was assault (86.7%). The cervical spine was involved in 24.2% of patients, thoracic spine in 42.8%, and lumbar spine in 39.7%. Cervical SCI was present in 8.7% of all spinal GSW (35.7% of cervical GSW), thoracic SCI in 17.4% (40.6% of thoracic GSW), and lumbar SCI in 8.1% (20.3% of lumbar GSW). The mean patient age was 29.0 ± 12.2 years, 88.5% were male, 62.4% were black, 23.7% were white, and 13.9% were another race. Blood alcohol content was ≥0.08 in 12.1%, and illicit drugs were positive in 24.4%. In-hospital mortality was high in patients with spinal GSWs (8.1%), and mortality was significantly higher with cervical involvement (18.1%), cervical SCI (30.7%), or thoracic incomplete SCI (13.6%) on univariate analysis. On multi-variate analysis of age (excluding patients <16 years of age), sex, Injury Severity Score (ISS), complete SCI, and spinal area of involvement, only greater patient age (age 40-65 years: adjusted odds ratio [aOR] 1.52, 95% confidence interval [CI] 1.09-2.11, p = 0.014; age >65 years: aOR 3.90, 95% CI 2.10-7.27, p < 0.001) and higher ISS (ISS 9-15: aOR 6.65, 95% CI 2.38-18.54, p < 0.001; ISS 16-24: aOR 18.13, 95% CI 6.65-49.44, p < 0.001; ISS >24: aOR 68.44, 95% CI 25.39-184.46, p < 0.001) were independently associated with in-hospital mortality risk after spinal GSW. These results demonstrate that spinal GSW is not uncommon and that older patients with more severe systemic injuries have higher in-hospital mortality risk.

Natural history of pituitary carcinoma with metastasis to the cervical spine: illustrative case.

BACKGROUND: Pituitary carcinoma is a rare tumor of the adenohypophysis with noncontiguous craniospinal dissemination and/or systemic metastases. Given the rarity of this malignancy, there is limited knowledge and consensus regarding its natural history, prognosis, and optimal treatment. OBSERVATIONS: The authors present the case of a 46-year-old woman initially treated with invasive prolactin-secreting pituitary macroadenoma who developed metastatic disease of the cervical spine 6 years later. The patient presented with acutely worsening compressive cervical myelopathy and required posterior cervical decompression, tumor resection, and instrumented arthrodesis for posterolateral fusion. LESSONS: This case underscores the importance of long-term monitoring of hormone levels and having a high clinical suspicion for metastatic disease to the spine in patients presenting with acute myelopathy or radiculopathy in the setting of previously treated invasive secreting pituitary adenoma.

Neurosurgery at Pearl Harbor: Ralph Cloward's legacy.

Ralph B. Cloward (1908-2000) was the sole neurosurgeon present during the Japanese attack on Pearl Harbor on December 7, 1941. Cloward operated on 42 patients in a span of 4 days during the attacks and was awarded a commendation signed by President Franklin D. Roosevelt in 1945 for his wartime efforts. During the attacks, he primarily treated depressed skull fractures and penetrating shrapnel wounds, but he also treated peripheral nerve and spine injuries in the aftermath. His techniques included innovative advancements such as tantalum cranioplasty plates, electromagnets for intracranial metallic fragment removal, and the application of sulfonamide antibiotic powder within cranial wounds, which had been introduced by military medics for gangrene prevention in 1939 and described for penetrating cranial wounds in 1940. Despite the severity of injuries encountered, only 2 soldiers died in the course of Cloward's interventions. As the sole neurosurgeon in the Pacific Theater until 1944, he remained in Honolulu through World War II's duration and gained immense operative experience through his wartime service. Here, the authors review the history of Cloward's remarkable efforts, techniques, injury patterns treated, and legacy.

Differences in Patient-Reported Outcomes Between Anterior and Posterior Approaches for Treatment of Cervical Spondylotic Myelopathy: A Quality Outcomes Database Analysis.

OBJECTIVE: Surgery for cervical spondylotic myelopathy (CSM) may use anterior or posterior approaches. Our objective was to compare baseline differences and validated postoperative patient-reported outcome measures between anterior and posterior approaches. METHODS: The NeuroPoint Quality Outcomes Database was queried retrospectively to identify patients with symptomatic CSM treated at 14 high-volume sites. Demographic, comorbidity, socioeconomic, and outcome measures were compared between treatment groups at baseline and 3 and 12 months postoperatively. RESULTS: Of the 1151 patients with CSM in the cervical registry, 791 (68.7%) underwent anterior surgery and 360 (31.3%) underwent posterior surgery. Significant baseline differences were observed in age, comorbidities, myelopathy severity, unemployment, and length of hospital stay. After adjusting for these differences, anterior surgery patients had significantly lower Neck Disability Index score (NDI) and a higher proportion reaching a minimal clinically important difference (MCID) in NDI (P = 0.005 at 3 months; P = 0.003 at 12 months). Although modified Japanese Orthopaedic Association scores were lower in anterior surgery patients at 3 and 12 months (P < 0.001 and P = 0.022, respectively), no differences were seen in MCID or change from baseline. Greater EuroQol-5D improvement at 3 months after anterior versus posterior surgery (P = 0.024) was not sustained at 12 months and was insignificant on multivariate analysis. CONCLUSIONS: In the largest analysis to date of CSM surgery data, significant baseline differences existed for patients undergoing anterior versus posterior surgery for CSM. After adjusting for these differences, patients undergoing anterior surgery were more likely to achieve clinically significant improvement in NDI at short- and long-term follow-up.

Spinal Cord Injury Management on the Front Line: ABCs of Spinal Cord Injury Treatment Based on American Association of Neurological Surgeons/Congress of Neurological Surgeons Guidelines and Common Sense.

Spinal cord injury (SCI) affects approximately 54 per 1 million people annually in the United States. Treatment strategies for this patient population focus on initial stabilization and early intervention. The cornerstones of early management are clinical assessment, characterization of the injury, medical optimization, and definitive surgical treatment, including surgical stabilization and/or decompression. This article discusses the important strategies in caring for patients with SCI that are supported with significant literature.

Finite element modeling to compare craniocervical motion in two age-matched pediatric patients without or with Down syndrome: implications for the role of bony geometry in craniocervical junction instability.

OBJECTIVE: Instability of the craniocervical junction (CCJ) is a well-known finding in patients with Down syndrome (DS); however, the relative contributions of bony morphology versus ligamentous laxity responsible for abnormal CCJ motion are unknown. Using finite element modeling, the authors of this study attempted to quantify those relative differences. METHODS: Two CCJ finite element models were created for age-matched pediatric patients, a patient with DS and a control without DS. Soft tissues and ligamentous structures were added based on bony landmarks from the CT scans. Ligament stiffness values were assigned using published adult ligament stiffness properties. Range of motion (ROM) testing determined that model behavior most closely matched pediatric cadaveric data when ligament stiffness values were scaled down to 25% of those found in adults. These values, along with those assigned to the other soft-tissue materials, were identical for each model to ensure that the only variable between the two was the bone morphology. The finite element models were then subjected to three types of simulations to assess ROM, anterior-posterior (AP) translation displacement, and axial tension. RESULTS: The DS model exhibited more laxity than the normal model at all levels for all of the cardinal ROMs and AP translation. For the CCJ, the flexion-extension, lateral bending, axial rotation, and AP translation values predicted by the DS model were 40.7%, 52.1%, 26.1%, and 39.8% higher, respectively, than those for the normal model. When simulating axial tension, the soft-tissue structural stiffness values predicted by the DS and normal models were nearly identical. CONCLUSIONS: The increased laxity exhibited by the DS model in the cardinal ROMs and AP translation, along with the nearly identical soft-tissue structural stiffness values exhibited in axial tension, calls into question the previously held notion that ligamentous laxity is the sole explanation for craniocervical instability in DS.

Prolonged Length of Stay and Risk of Unplanned 30-Day Readmission After Elective Spine Surgery: Propensity Score-Matched Analysis of 33,840 Patients.

STUDY DESIGN: Retrospective database study. OBJECTIVE: To assess the association between prolonged length of hospital stay (pLOS) (≥4 d) and unplanned readmission in patients undergoing elective spine surgery by controlling the clinical and statistical confounders. SUMMARY OF BACKGROUND DATA: pLOS has previously been cited as a risk factor for unplanned hospital readmission. This potentially modifiable risk factor has not been distinguished as an independent risk factor in a large-scale, multi-institutional, risk-adjusted study. METHODS: Data were collected from the American College of Surgeons National Surgical Quality Improvement Program database. A retrospective propensity score-matched analysis was used to reduce baseline differences between the cohorts. Univariate and multivariate analyses were performed to assess the degree of association between pLOS and unplanned readmission. RESULTS: From the 99,575 patients that fit the inclusion criteria, propensity score matching yielded 16,920 well-matched pairs (mean standard propensity score difference = 0.017). The overall 30-day unplanned readmission rate of these 33,840 patients was 5.5%. The mean length of stay was 2.0 ±â€Š0.9 days and 6.0 ±â€Š4.5 days (P ≤ 0.001) for the control and pLOS groups, respectively. In our univariate analysis, pLOS was associated with postoperative complications, especially medical complications (22.7% vs. 8.3%, P < 0.001). Multivariate analysis of the propensity score-matched population, which adjusted identified confounders (P < 0.02 and ≥10 occurrences), showed pLOS was associated with an increased risk of 30-day unplanned readmission (odds ratio [OR] 1.423, 95% confidence interval [CI] 1.290-1.570, P < 0.001). CONCLUSION: Patients who undergo elective spine procedures who have any-cause pLOS (≥4 d) are at greater risk of having unplanned 30-day readmission compared with patients with shorter hospital stays. LEVEL OF EVIDENCE: 4.

Minimally invasive oblique interbody fusion for correction of iatrogenic lumbar deformity.

Spinal instability may arise as a consequence of decompressive lumbar surgery. An oblique lumbar interbody fusion combined with pedicle screw fixation can provide indirect decompression on neural elements, stabilization of mobile spondylolisthesis, and restoration of segmental lordosis. Minimally invasive techniques may facilitate a shorter hospitalization and faster recovery than a traditional open revision operation. The authors describe the use of an anterior interbody fusion via an oblique retroperitoneal approach and posterior pedicle screw fixation to treat a 67-year-old woman who developed L3-4 and L4-5 unstable spondylolisthesis after a lumbar laminectomy. The video can be found here: https://youtu.be/KWwGMIoDrmU.

Effect of patient age on glioblastoma perioperative treatment costs: a value driven outcome database analysis.

INTRODUCTION: Identification of groups of patients or interventions with higher associated treatment costs may be beneficial in efforts to decrease the overall financial burden of glioblastoma (GBM) treatment. The authors' objective was to evaluate perioperative surgical treatment cost differences between elderly and nonelderly patients with GBM using the Value Driven Outcome (VDO) database. METHODS: The authors obtained data from a retrospective cohort of GBM patients treated surgically (resection or biopsy) at their institution from August 2011 to February 2018. Data were compiled using medical records and the VDO database. RESULTS: A total of 181 patients with GBM were included. Patients were grouped into age < 70 years at time of surgery (nonelderly; n = 121) and ≥ 70 years (elderly; n = 60). Costs were approximately 38% higher in the elderly group on average (each patient was mean 0.68% of total cohort cost vs. 0.49%, p = 0.044). Higher age significantly, but weakly, correlated with higher treatment cost on linear regression analysis (p = 0.007; R2 = 0.04). Length of stay was significantly associated with increased cost on linear regression (p < 0.001, R2 = 0.84) and was significantly longer in the elderly group (8.7 ± 11.3 vs. 5.2 ± 4.3 days, p = 0.025). The cost breakdown by facility, pharmacy, supply/implants, imaging, and laboratory costs was not significantly different between age groups. Elderly patients with any postoperative complication had 2.1 times greater total costs than those without complication (p = 0.094), 2.9 times greater total costs than nonelderly patients with complication (p = 0.013), and 2.3 times greater total costs than nonelderly patients without complication (p = 0.022). CONCLUSIONS: GBM surgical treatment costs are higher in older patients, particularly those who experience postoperative complications.

Use of Anticoagulation Agents After Traumatic Intracranial Hemorrhage.

OBJECTIVE: Anticoagulant therapy (ACT) after traumatic intracranial hemorrhage may lead to progression of hemorrhage, but in the presence of thromboembolic events, the clinician must decide if the benefits outweigh the risks. Currently, no data exist to guide therapy in the acute setting. METHODS: We retrospectively identified all patients admitted to our institution with traumatic intracranial hemorrhage that received intravenous heparin, full-dose enoxaparin, or warfarin during their initial hospitalization over a 3-year period. We reviewed their demographics, hospital course, clinical indication and timing for initiation of ACT, and complications. RESULTS: A total of 112 patients were identified. The median age and Glasgow Coma Scale score of these patients was 50.5 years and 9.5, respectively. Twenty-two patients required neurosurgical procedures for their presenting injury, including intracranial pressure monitors and/or open surgeries. Fifty-four patients had deep vein thrombosis or pulmonary embolism prior to initiation, and the remaining 20 patients had preexisting conditions or other indications for initiating ACT. The median time from injury to starting ACT was 8 days. Immediate complications occurred in 6 patients; however, none of these patients required a neurosurgical intervention. Delayed complications included progression of acute to chronic subdural hematoma that required intervention in 2 patients. One patient died from delayed hemorrhage. CONCLUSIONS: For this patient population, the risk of immediate and delayed intracranial hemorrhages from initiating ACT therapy in intracranial injury must be weighed against the morbidity of delaying treatment. Although further studies are needed, our review provides the first rates of complications for this patient population.

Subdural Empyema in the Setting of Multimodal Intracranial Monitoring.

BACKGROUND: Multimodal intracranial monitoring is becoming an increasingly common tool in the management of patients with traumatic brain injury. Although numerous reports detailing the benefits of such advanced monitoring exist in the literature, there is minimal discussion of the possible complications that may arise in this patient population. CASE DESCRIPTION: We report the case of a 32-year-old patient who had been assaulted and presented initially at an outside facility with a Glasgow Coma Scale score of 8. After transfer to our hospital, his Glasgow Coma Scale score was noted at 7T and multimodal monitoring with the Integra Licox brain tissue oxygen monitor and the Hemedex Bowman perfusion monitor was implemented, along with an external ventricular drain when a standard intracranial pressure monitor indicated increasing intracranial pressure. The patient's intracranial pressure normalized but he did require a course of antibiotics during this time for a fever and methicillin-resistant Staphylococcus aureus. The patient subsequently developed multifocal subdural empyemas requiring surgical evacuation. Postoperatively, the patient's intraoperative cultures remained without bacterial growth, likely related to the 2-week broad-spectrum antibiotic use. CONCLUSIONS: To our knowledge, this is the first reported incidence of a subdural empyema developing in this setting. Although the safety profile of multimodal intracranial modeling is excellent, with increasing numbers of invasive bedside procedures, neurosurgeons must remain acutely vigilant for the development of infectious complications.

Use of anti-platelet agents after traumatic intracranial hemorrhage.

OBJECTIVE: To evaluate the risk of hemorrhagic complications associated with starting anti-platelet therapy (APT) after acute traumatic intracranial hemorrhage (tICH) and to examine the frequency of thrombotic complications. PATIENTS AND METHODS: We retrospectively identified all patients admitted to our institution with tICH that received APT during their initial hospitalization over a three-year period. We reviewed their demographics, hospital course, clinical indication and timing for initiation of APT, and complications. RESULTS: A total of 222 patients were identified. The median age and Injury Severity Score (ISS) was 61 and 21, respectively. Fifty (23%) patients required neurosurgical procedures. APTs were initiated due to a history of APT use in 91 patients (41%) and blunt cerebrovascular injury in 86 patients (38.6%). The median time from injury to starting APT was 4 days. Immediate complications including new or worsening hemorrhage occurred in 1 (<1%) patient. Delayed hemorrhagic complications occurred in 6 (4.7%) patients. Thrombotic events occurred in 21 (9.4%) patients prior to starting APT. Thirteen (5.8%) of these were potentially preventable. CONCLUSION: The risk of immediate and delayed intracranial hemorrhages from initiating APT after tICH must be weighed against the morbidity of delaying indicated thrombotic prophylaxis. Our initial data indicates that hemorrhagic complications are infrequent, and thrombotic complications can have significant clinical consequences. Our retrospective review provides the first rates of complications for this patient population.