The utility of intraoperative neuromonitoring on simple posterior lumbar fusions-analysis of the National Inpatient Sample.

BACKGROUND: Several studies have demonstrated the utility of intraoperative neuromonitoring (IOM) including somatosensory evoked potentials (SSEPs), motor-evoked potentials (MEPs), and electromyography (EMG), in decreasing the risk of neurologic injury in spinal deformity procedures. However, there is limited evidence supporting the routine use of IOM in elective posterolateral lumbar fusion (PLF). METHODS: The National Inpatient Sample (NIS) was analyzed for the years 2012-2015 to identify patients undergoing elective PLF with (n=22,404) or without (n=111,168) IOM use. Statistical analyses were conducted to assess the impact of IOM on length of stay, total charges, and development of neurologic complications. These analyses controlled for age, gender, race, income percentile, primary expected payer, number of reported comorbidities, hospital teaching status, and hospital size. RESULTS: The overall use of IOM in elective PLFs was found to have increased from 14.6% in the year 2012 to 19.3% in 2015. The total charge in hospitalization cost for all patients who received IOM increased from $129,384.72 in 2012 to $146,427.79 in 2015. Overall, the total charge of hospitalization was 11% greater in the IOM group when compared to those patients that did not have IOM (P<0.001). IOM did not have a statistically significant impact on the likelihood of developing a neurological complication. CONCLUSIONS: While there may conceivably be benefits to the use of this technology in complex revision fusions or pathologies, we found no meaningful benefit of its application to single-level index PLF for degenerative spine disease.

Review of wearable technologies and machine learning methodologies for systematic detection of mild traumatic brain injuries.

Mild traumatic brain injuries (mTBIs) are the most common type of brain injury. Timely diagnosis of mTBI is crucial in making 'go/no-go' decision in order to prevent repeated injury, avoid strenuous activities which may prolong recovery, and assure capabilities of high-level performance of the subject. If undiagnosed, mTBI may lead to various short- and long-term abnormalities, which include, but are not limited to impaired cognitive function, fatigue, depression, irritability, and headaches. Existing screening and diagnostic tools to detect acute andearly-stagemTBIs have insufficient sensitivity and specificity. This results in uncertainty in clinical decision-making regarding diagnosis and returning to activity or requiring further medical treatment. Therefore, it is important to identify relevant physiological biomarkers that can be integrated into a mutually complementary set and provide a combination of data modalities for improved on-site diagnostic sensitivity of mTBI. In recent years, the processing power, signal fidelity, and the number of recording channels and modalities of wearable healthcare devices have improved tremendously and generated an enormous amount of data. During the same period, there have been incredible advances in machine learning tools and data processing methodologies. These achievements are enabling clinicians and engineers to develop and implement multiparametric high-precision diagnostic tools for mTBI. In this review, we first assess clinical challenges in the diagnosis of acute mTBI, and then consider recording modalities and hardware implementation of various sensing technologies used to assess physiological biomarkers that may be related to mTBI. Finally, we discuss the state of the art in machine learning-based detection of mTBI and consider how a more diverse list of quantitative physiological biomarker features may improve current data-driven approaches in providing mTBI patients timely diagnosis and treatment.

Is Flow Diversion the Death of Simple Coiling or Stent-assisted Coiling? A Single-center Experience.

BACKGROUND: Since the introduction of endovascular methods to treat cerebral aneurysms, several technical advances have allowed a greater number of aneurysms to be treated endovascularly as opposed to open surgical clipping. These include flow diverting stents, which do not utilize coils and instead treat aneurysms by acting as an "internal bypass." We sought to investigate whether flow diversion is replacing coiling at our institution. METHODS: A retrospective chart review on five years of data was conducted to investigate the possible increasing use of flow diversion devices compared to traditional simple or stent-assisted coiling. RESULTS: Over five years, the population revealed a trend toward an increased proportion of female patients, increased frequency of basilar tip and internal carotid artery (ICA) aneurysm location, increased hospital volume, and increased volume of patients treated by dual-trained neurosurgeons over interventional radiologists. Patients were stratified by aneurysm location and statistically significant differences were observed. Flow diversion devices were used with increasing frequency when treating aneurysms arising from the proximal internal carotid artery (Odds ratio (OR)=1.24, 95% CI: 1.02-1.50; p = 0.03), and middle cerebral artery (OR=2.60, 95% CI: 1.38-4.88; p = 0.003). Distal internal carotid artery aneurysm location came close to achieving statistical significance (OR=1.3, 95% CI: 0.99-1.72; p = 0.063). CONCLUSION: In our single center experience at Houston Methodist Hospital, flow diversion devices are being used more frequently for aneurysms arising from the proximal ICA, MCA, and likely distal ICA (though this third location barely failed to achieve statistical significance.

Symptomatic, left-sided deep brain stimulation lead edema 6 h after bilateral subthalamic nucleus lead placement.

BACKGROUND: Deep brain stimulation (DBS) lead edema can be a serious, although rare, complication in the postoperative period. Of the few cases that have been reported, the range of presentation has been 33 h-120 days after surgery. CASE DESCRIPTION: We report a case of a 75-year-old male with a history of Parkinson's disease who underwent bilateral placement of subthalamic nucleus DBS leads that resulted in symptomatic, left-sided lead edema 6 h after surgery, which is the earliest reported case. CONCLUSIONS: DBS lead edema is noted to be a self-limiting phenomenon. It is critical to recognize the possibility of lead edema as a cause of postoperative encephalopathy even in the acute phase after surgery. Although it is important to rule out other causes of postoperative changes in the patient examination, the recognition of lead edema can help to avoid extraneous diagnostic tests or DBS lead revision or removal.

Immediate Abdominal Pain after Placement of Thoracic Paddle Leads for Spinal Cord Stimulation: A Case Series.

BACKGROUND: Spinal cord stimulation (SCS) is a well-established treatment modality for chronic pain. Thoracic radiculopathy has been reported as a complication of SCS paddle lead implantation by several authors and commonly presents as abdominal pain. METHODS: We performed a search of all patients who underwent either placement of a new epidural paddle lead electrode or revision of an epidural paddle lead electrode for SCS in the thoracic region from January 2017 to January 2018. We then investigated all cases of immediate postoperative abdominal pain. RESULTS: We identified 7 patients who had immediate postoperative abdominal pain among 86 cases of epidural SCS procedures. Most patients were discharged on postoperative days 1-3. No patients required revisions or removals of their SCS for any reason. CONCLUSIONS: We conclude that the etiology of immediate postoperative abdominal pain after thoracic paddle lead implantation for SCS is most likely thoracic radiculopathy. We hypothesize that small, transient epidural hematomas could be the cause of this thoracic radiculopathy. We argue that all patients with immediate postoperative abdominal pain and no other neurologic deficits after thoracic paddle lead implantation for SCS should first be treated conservatively with observation and pain management.