The Effect of Cervical and Lumbar Decompression Surgery for Spinal Stenosis on Erectile Dysfunction.

STUDY DESIGN: Observational study. OBJECTIVES: To evaluate the prevalence of erectile dysfunction and evaluate the effects of decompressive surgery on erectile dysfunction in cervical spinal stenosis and lumbar canal stenosis patients. METHODS: This observational, prospective analysis enrolled patients aged 18-80 with cervical spinal stenosis and/or lumbar canal stenosis that underwent respective decompressive surgery. The IIEF-5 questionnaire was administered preoperatively, and at 6- and 12-months postoperatively to assess erectile dysfunction severity. The EPIC database was queried to determine any postoperative complications and document prominent erectile dysfunction risk factors. RESULTS: Of 79 patients included in the analysis, 42 (53.2%) completed the IIEF-5 at 6 months, and 62 (78.5%) completed it at 12 months. Eighteen had cervical stenosis only, 54 had lumbar stenosis only, and 7 had both. 72% (18/25) of cervical stenosis patients and 83.6% (51/61) of lumbar stenosis patients had erectile dysfunction preoperatively according to IIEF-5 responses. The average preoperative IIEF-5 score indicated significant presence of erectile dysfunction for both the cervical and lumbar stenosis groups. No significant differences were identified in IIEF-5 score deltas from pre- to both postoperative periods. The presence of erectile dysfunction in both the cervical and lumbar stenosis groups was not significantly associated with the presence of any documented risk factors. CONCLUSIONS: Our results suggest no significant improvement in overall erectile function postoperatively for patients with preoperative erectile dysfunction. This is important to address during patient counseling for decompression surgery candidates with cervical spinal stenosis and/or lumbar canal stenosis to manage expectations.

Detection of Wandering Behaviors Using a Body-Worn Inertial Sensor in Patients With Cognitive Impairment: A Feasibility Study.

Patients with Alzheimer's disease (AD) and AD related dementias (ADRD) often experience spatial disorientation that can lead to wandering behavior, characterized by aimless or purposeless movement. Wandering behavior has been associated with falls, caregiver burden, and nursing home placement. Despite the substantial clinical consequences of wandering, there is currently no standardized approach to objectively quantify wandering behavior. In this pilot feasibility study, we used a lightweight inertial sensor to examine mobility characteristics of a small group of 12 older adults with ADRD and mild cognitive impairment in their homes. Specifically, we evaluated their compliance with wearing a sensor for a minimum of 4 days. We also examined the ability of the sensor to measure turning frequency and direction changes, given that frequent turns and direction changes during walking have been observed in patients who wander. We found that all patients were able to wear the sensor yielding quantitative turn data including number of turns over time, mean turn duration, mean peak turn speed, and mean turn angle. We found that wanderers make more frequent, quicker turns compared to non-wanderers, which is consistent with pacing or lapping behavior. This study provides preliminary evidence that continuous monitoring in patients with dementia is feasible using a wearable sensor. More studies are needed to explore if objective measures of turning behaviors collected using inertial sensors can be used to identify wandering behavior.

Diagnostic Accuracy of Fine-Needle Biopsy for Salivary Gland Neoplasms in a Community Otolaryngology Practice.

OBJECTIVE: To assess the diagnostic accuracy of fine-needle biopsy (FNB) of salivary gland neoplasms via ultrasound (US) or palpation guidance by an otolaryngologist in a community practice. STUDY DESIGN: Retrospective chart review. SETTING: Community otolaryngology practice. METHODS: Retrospective analysis was conducted for all office-based salivary gland FNBs from a community practice from 2005 through 2018. There were 433 FNBs performed among 370 patients. The likelihood of achieving a diagnostic result based on method (US vs palpation guidance) was calculated. Of this cohort, 196 cases had surgical follow-up (parotid gland, n = 168; submandibular gland, n = 28). Correlation of preoperative FNB results to final surgical pathology was performed and measures of diagnostic accuracy computed. RESULTS: US-guided FNBs were more likely to achieve a diagnostic result than FNBs obtained via palpation guidance (P = .00002). Parotid gland FNBs demonstrated a sensitivity and specificity of 78.57% and 92.44%, respectively. Submandibular FNBs demonstrated a sensitivity and specificity of 57.14% and 93.74%. CONCLUSION: FNBs performed under US guidance are more likely to achieve a diagnostic specimen than those performed under palpation guidance. FNBs of parotid gland tumors may be assessed with diagnostic accuracy in the community setting that is similar to that achieved at tertiary care centers. Further research is needed to ascertain whether this finding extends to FNBs of submandibular gland tumors. Offering this procedure at point of care in the community may improve compliance and reduce wait time.

"Text It" program to track falls in patients with Alzheimer's disease and dementia.

INTRODUCTION: Falls are a significant problem among older adults with Alzheimer's disease, leading to high rates of fracture, hospitalization, and death. Tracking falls in older adults, particularly those with cognitive impairment, is a clinical and research challenge. METHODS: This prospective pilot study evaluated the feasibility of a text message program to track falls among patients with dementia. We also compared this technique with the calendar method of fall data collection. RESULTS: There was a 96% completion rate of text messaging and 100% of calendars; however, the text-gathered data were more accurate. DISCUSSION: A text-messaging platform to track falls shows promise in cognitively impaired individuals.

Nonalcoholic fatty liver disease in spinal and bulbar muscular atrophy.

OBJECTIVE: To determine the prevalence and features of fatty liver disease in spinal and bulbar muscular atrophy (SBMA). METHODS: Two groups of participants with SBMA were evaluated. In the first group, 22 participants with SBMA underwent laboratory analysis and liver imaging. In the second group, 14 participants with SBMA were compared to 13 female carriers and 23 controls. Liver biopsies were done in 4 participants with SBMA. RESULTS: Evidence of fatty liver disease was detected by magnetic resonance spectroscopy in all participants with SBMA in the first group, with an average dome intrahepatic triacylglycerol of 27% (range 6%-66%, ref ≤5.5%). Liver dome magnetic resonance spectroscopy measurements were significantly increased in participants with SBMA in the second group relative to age- and sex-matched controls, with average disease and male control measurements of 17% and 3%, respectively. Liver biopsies were consistent with simple steatosis in 2 participants and nonalcoholic steatohepatitis in 2 others. CONCLUSIONS: We observed evidence of nonalcoholic liver disease in nearly all of the participants with SBMA evaluated. These observations expand the phenotypic spectrum of the disease and provide a potential biomarker that can be monitored in future studies.

Sexual Reassignment Fails to Prevent Kennedy's Disease.

Spinal and bulbar muscular atrophy is caused by polyglutamine expansion in the androgen receptor. As an X-linked disease dependent on androgens, symptoms and findings are only fully manifest in males. Here we describe a 40-year-old male-to-female transgender SBMA patient who developed full disease manifestations despite undetectable levels of androgens. We used cell culture and animal models to show that spironolactone, the anti-androgen she had taken for 15 years, promotes nuclear localization and toxicity of the mutant protein, which may explain the disease manifestations in this patient.

Decompression surgery for spinal metastases: a systematic review.

OBJECTIVE The aim of this study was to systematically review the literature on reported outcomes following decompression surgery for spinal metastases. METHODS The authors conducted MEDLINE, Scopus, and Web of Science database searches for studies reporting clinical outcomes and complications associated with decompression surgery for metastatic spinal tumors. Both retrospective and prospective studies were included. After meeting inclusion criteria, articles were categorized based on the following reported outcomes: survival, ambulation, surgical technique, neurological function, primary tumor histology, and miscellaneous outcomes. RESULTS Of the 4148 articles retrieved from databases, 36 met inclusion criteria. Of those included, 8 were prospective studies and 28 were retrospective studies. The year of publication ranged from 1992 to 2015. Study size ranged from 21 to 711 patients. Three studies found that good preoperative Karnofsky Performance Status (KPS ≥ 80%) was a significant predictor of survival. No study reported a significant effect of time-to-surgery following the onset of spinal cord compression symptoms on survival. Three studies reported improvement in neurological function following surgery. The most commonly cited complication was wound infection or dehiscence (22 studies). Eight studies reported that preoperative ambulatory or preoperative motor status was a significant predictor of postoperative ambulatory status. A wide variety of surgical techniques were reported: posterior decompression and stabilization, posterior decompression without stabilization, and posterior decompression with total or subtotal tumor resection. Although a wide range of functional scales were used to assess neurological outcomes, four studies used the American Spinal Injury Association (ASIA) Impairment Scale to assess neurological function. Four studies reported the effects of radiation therapy and local disease control for spinal metastases. Two studies reported that the type of treatment was not significantly associated with the rate of local control. The most commonly reported primary tumor types included lung cancer, prostate cancer, breast cancer, renal cancer, and gastrointestinal cancer. CONCLUSIONS This study reports a systematic review of the literature on decompression surgery for spinal metastases. The results of this study can help educate surgeons on the previously published predictors of outcomes following decompression surgery for metastatic spinal disease. However, the authors also identify significant gaps in the literature and the need for future studies investigating the optimal practice with regard to decompression surgery for spinal metastases.

Divalent cation-responsive myotonia and muscle paralysis in skeletal muscle sodium channelopathy.

We report a patient with paramyotonia congenita/hyperkalemic periodic paralysis due to Nav1.4 I693T mutation who had worsening of myotonia and muscle weakness in the setting of hypomagnesemia and hypocalcemia with marked recovery after magnesium administration. Computer simulations of the effects of the I693T mutation were introduced in the muscle fiber model by both hyperpolarizing shifts in the Nav1.4 channel activation and a faster recovery from slow channel inactivation. A further shift in the Nav1.4 channel activation in the hyperpolarizing direction as expected with low divalent cations resulted in myotonia that progressed to membrane inexcitability. Shifting the channel activation in the depolarizing direction as would be anticipated from magnesium supplementation abolished the myotonia. These observations provide clinical and biophysical evidence that the muscle symptoms in sodium channelopathy are sensitive to divalent cations. Exploration of the role of magnesium administration in therapy or prophylaxis is warranted with a randomized clinical trial.

Utility of delayed surgical repair of neonatal brachial plexus palsy.

OBJECT: Neonatal brachial plexus palsy (NBPP) represents a significant health problem with potentially devastating consequences. The most common form of NBPP involves the upper trunk roots. Currently, primary surgical repair is performed if clinical improvement is lacking. There has been increasing interest in "early" surgical repair of NBPPs, occurring within 3-6 months of life. However, early treatment recommendations ignore spontaneous recovery in cases of Erb's palsy. This study was undertaken to evaluate the optimal timing of surgical repair in this group with respect to quality of life. METHODS: The authors formulated a decision analytical model to compare 4 treatment strategies (no repair or repair at 3, 6, or 12 months of life) for infants with persistent NBPPs. The model derives data from a critical review of published studies and projects health-related quality of life and quality-adjusted life years over a lifetime. RESULTS: When evaluating the quality of life of infants with NBPP, improved outcomes are seen with delayed surgical repair at 12 months, compared with no repair or repair at early and intermediate time points, at 3 and 6 months, respectively. ANOVA showed that the differences among the 4 groups are highly significant (F = 8369; p < 0.0001). Pairwise post hoc comparisons revealed that there are highly significant differences between each pair of strategies (p < 0.0001). Meta-regression showed no evidence of improved outcomes with more recent treatment dates, compared with older ones, for either nonsurgical or for surgical treatment (p = 0.767 and p = 0.865, respectively). CONCLUSIONS: These data support a delayed approach of primary surgical reconstruction to optimize quality of life. Early surgery for NBPPs may be an overly aggressive strategy for infants who would otherwise demonstrate spontaneous recovery of function by 12 months. A randomized, controlled trial would be necessary to fully elucidate the natural history of NBPP and determine the optimal time point for surgical intervention.

Wilbrand knee.

Wilbrand and Saenger(1) studied optic chiasms after unilateral enucleation, noting inferonasal crossing fibers curved anteriorly into the contralateral optic nerve (Wilbrand knee; figure, A). This explains contralateral superotemporal visual field defects (junctional scotomas) with optic nerve lesions at the chiasmal junction. However, Wilbrand knee may be an enucleation artifact.(2) The anisotropic light-reflecting properties of myelinated axons permitted imaging of normal human chiasms. Thin sections (25 µm) were illuminated and digitally imaged from 3 incident angles. Each of the images was pseudocolored (red, green, or blue) and merged, revealing an anomalously oriented fiber tract (appearing white) that reversed direction at the optic nerve-chiasm junction, found in inferior (figure, C) but not in superior sections (figure, B), consistent with Wilbrand and Saenger's original description.

Pediatric intracranial arachnoid cysts: comparative effectiveness of surgical treatment options.

PURPOSE: A variety of surgical approaches for the treatment of pediatric intracranial arachnoid cysts exist. In an effort to identify the optimal surgical treatment for this disorder, we developed a decision analytic model to evaluate outcomes of four surgical approaches in children. These included open craniotomy for cyst excision, open craniotomy for cyst fenestration, endoscopic cyst fenestration, and cystoperitoneal shunting. METHODS: Pooled data were used to create evidence tables, from which we calculated incidence, relative risks, and summary outcomes in quality-adjusted life years (QALYs) for the four surgical treatments. Our study incorporated data up to 5 years postsurgery. RESULTS: We analyzed 1,324 cases from 36 case series. There were no significant differences in outcome among the four surgical strategies. The QALYs (maximum of 5) for surgical approaches resulted in a range from 4.79 (for open craniotomy and excision) to 4.92 (for endoscopic fenestration). CONCLUSIONS: Overall quality of life is comparable between patients undergoing open craniotomy for cyst excision or fenestration, endoscopic fenestration, and cystoperitoneal shunting up to 5 years after surgery. While each approach offers unique advantages and disadvantages, an individualized treatment strategy should be employed in the setting of surgical outcome equipoise.