Nimodipine-associated standard dose reductions and neurologic outcomes after aneurysmal subarachnoid hemorrhage: the era of pharmacogenomics.

Nimodipine, an L-type cerebroselective calcium channel antagonist, is the only drug approved by the US Food and Drug Administration for the neuroprotection of patients with aneurysmal subarachnoid hemorrhage (aSAH). Four randomized, placebo-controlled trials of nimodipine demonstrated clinical improvement over placebo; however, these occurred before precision medicine with pharmacogenomics was readily available. The standard enteral dose of nimodipine recommended after aSAH is 60 mg every 4 h. However, up to 78% of patients with aSAH develop systemic arterial hypotension after taking the drug at the recommended dose, which could theoretically limit its neuroprotective role and worsen cerebral perfusion pressure and cerebral blood flow, particularly when concomitant vasospasm is present. We investigated the association between nimodipine dose changes and clinical outcomes in a consecutive series of 150 patients (mean age, 56 years; 70.7% women) with acute aSAH. We describe the pharmacogenomic relationship of nimodipine dose reduction with clinical outcomes. These results have major implications for future individualized dosing of nimodipine in the era of precision medicine.

Use of Recombinant Human Bone Morphogenetic Protein-2 After Anterior Cervical Corpectomy and Fusion for the Treatment of Vertebral Osteomyelitis.

OBJECTIVE: To report the operative outcomes after treating vertebral osteomyelitis patients with an anterior cervical corpectomy and fusion procedure using recombinant human bone morphogenetic protein-2 (rhBMP-2) as graft material. METHODS: A retrospective review of electronic medical records of 26 adult patients who underwent an anterior cervical corpectomy and fusion procedure for cervical osteomyelitis using rhBMP-2 at the University of Puerto Rico University District Hospital was performed. Indication, preoperative laboratory results, levels of corpectomy, preoperative American Spinal Injury Association Impairment Scale (ASIA) score, complications, fusion evaluation at 12 months, and ASIA score at 12 months were reviewed. RESULTS: For the cohort of patients, mean age was 47 ± 13 years and 65% were male. Spinal instability was present in 54%. The levels of corpectomy were: 1 level in 2 cases, 2 levels in 15 cases, 3 levels in 8 cases, and 5 levels in 1 case. Four patients had complications and, of these, 2 experienced dysphagia. The fusion rate was 100% and no reoperations were performed. An improvement in ASIA score was seen for 54% patients at 12-month follow-up. CONCLUSIONS: This study demonstrates a fusion rate of 100% with no reoperations reported. Recombinant human bone morphogenetic protein-2 could be considered and further researched as grafting material for anterior cervical corpectomy and fusion procedures in cervical osteomyelitis patients.

Neurosurgery Morbidity and Mortality: A Prospective Surgical and Medical Analysis.

OBJECTIVE: The analysis of morbidity and mortality is fundamental for improving the quality of patient care. The objective of this study was to evaluate the combined medical and surgical morbidity and mortality of neurosurgical patients. METHODS: We performed a daily prospective compilation of morbidities and mortalities during a consecutive 4-month period in all the patients who were 18 years of age or older and had been admitted to the neurosurgery service at the Puerto Rico Medical Center. For each patient, any surgical or medical complication, adverse event, or death within 30 days was included. The patients' comorbidities were analyzed for their influence on mortality. RESULTS: Fifty-seven percent of the patients presented at least 1 complication. The most frequent complications were hypertensive episodes, mechanical ventilation for more than 48 hours, sodium disturbances, and bronchopneumonia. Twenty-one patients died, for an overall 30-day mortality of 8.2%. Mechanical ventilation for more than 48 hours, sodium disturbances, bronchopneumonia, unplanned intubation, acute kidney injury, blood transfusion, shock, urinary tract infection, cardiac arrest, arrhythmia, bacteremia, ventriculitis, sepsis, elevated intracranial pressure, vasospasm, stroke, and hydrocephalus were significant factors for mortality. None of the analyzed patients' comorbidities were significant for mortality or longer length of stay. The type of surgical procedure did not influence the length of stay. CONCLUSION: The mortality and morbidity analysis provided valuable neurosurgical information that may influence future treatment management and corrective recommendations. Indication and judgment errors were significantly associated with mortality. In our study, the patients' comorbidities were not significant for mortality or increased length of stay.

Spine Trauma Secondary to Diving Accidents: A Seven-year Retrospective Study in Puerto Rico.

OBJECTIVE: Review the profile of patients with spinal trauma after diving accidents referred to the Puerto Rico Medical Center. This study intended to develop more awareness of the risks of spinal cord injury after diving. METHODS: The patient's records for diving accident cases referred to our center during January 2014 until December 2020 were assessed retrospectively. The cases were evaluated according to sex, age, vertebral level, and neurological deficit. The Puerto Rico Medical Center is the only level 1 trauma center in Puerto Rico; therefore, this study likely included all the cases of diving injury on the island. RESULTS: Sixty five patients with a median age of 29 years were identified consisting primarily of males (94%). The regions affected included the cervical (96%), thoracic (2%), and lumbar (2%) spine. Twenty-seven patients (42%) developed a spinal cord injury secondary to a diving accident. Involvement of the C4, C5, or C6 vertebral level, was significant for the development of a spinal cord injury. Diving accidents occurring at beaches were the most common cause. CONCLUSION: In Puerto Rico, there is a yearly incidence of 9.3 diving accidents causing spinal trauma; these accidents most frequently affect the C6 vertebra. These diving accidents mainly occur in young individuals, predominantly at beaches. Most of our patients were neurologically intact after their diving accident, although 42% sustained a spinal cord injury. This study provided a better understanding of this traumatic event and determined its most affected levels, accident sites, and population involved.

Prognosis and Outcome of Cervical Primary Extraosseous Intradural Extramedullary Ewing Sarcoma: A Systematic Review.

Primary spinal extraosseous Ewing sarcoma (ES) is a rare mesenchymal tumor characterized by high malignancy, occurring in a few patients with ES. The occurrence of this tumor in the intradural extramedullary spinal region is infrequent. This systematic review examines primary extraosseous intradural extramedullary ES in the cervical region to provide specific outcomes and evaluate the role of adjuvant chemoradiation in overall prognosis. A systematic review was conducted to identify all cervical primary extraosseous intradural extramedullary ES reported in the literature. The search included the databases of PubMed, Google Scholar, Medline, Embase, and Scopus from inception to June 2021. Inclusion criteria include a reported death outcome or a minimum one-year follow-up. Our search retrieved 21 articles that involved the cervical spine, but only 11 cases met the inclusion criteria. Of the nine patients who demonstrated disease progression, six experienced local failure, two had distant craniospinal axis failure, and one had systemic metastases. Five patients died of the disease at a median of 11 months after diagnosis. Our analysis showed a one-, two-, and five-year progression-free survival (PFS) of 36.4%, 36.4%, and 12.1%, respectively. The one-, two-, and five-year overall survival rates were 72.7%, 62.3%, and 46.8%, respectively. Three of the five (60%) patients who died received craniospinal radiotherapy. Of the six patients who survived, two received craniospinal radiotherapy (33%), and one received whole spine radiotherapy (17%). This review showed that patients with cervical primary extraosseous intradural extramedullary ES had poor progression-free survival and overall survival rates. The addition of adjunct craniospinal radiotherapy did not improve the prognosis of these patients.

90-Day Return Visit to the Emergency Department After an Initial Neurosurgical Evaluation.

OBJECTIVE: This study evaluated emergency department (ED) neurosurgical reevaluation rates and their causes. Identifying the most significant reasons that make patients return to the ED for a neurosurgical reevaluation can help implement changes to reduce the economic and medical burden of patient turnover. METHODS: All patients undergoing neurosurgical reevaluation at our institution's ED after an initial neurosurgical evaluation were enrolled in a prospective 3-month longitudinal registry. Inclusion criteria were all adult patients 21 years of age or older previously evaluated by neurosurgery at our institution's ED who return within 90 days for a neurosurgical reevaluation. RESULTS: We found an overall 90-day ED neurosurgical return visit rate of 2.1%. During the study, 34 patients returned to the ED for a neurosurgical reevaluation. Patients returned for a neurosurgical reevaluation at a median of 23.5 days after the initial neurosurgery evaluation. The principal causes for a return visit were altered mental status, headache, and wound infections. Among the returning patients, 59% required hospitalization and 50% required an operation. CONCLUSIONS: To our knowledge, this is the first study to prospectively collect data to estimate the 90-day ED return visit rate for a neurosurgical reevaluation following an initial ED neurosurgical evaluation. Some patients still use the ED to get continued care of their condition despite having access to their primary care physician. Better communication, social worker coordination, and prompt follow-up appointments at the neurosurgical outpatient clinic may reduce return visits.

Prevention of Surgical Site Infection in Lumbar Instrumented Fusion Using a Sterile Povidone-Iodine Solution.

BACKGROUND: Surgical site infection (SSI) is a well-documented complication in patients who undergo posterior spine instrumentation with most studies reporting an incidence of 1%-12%. Some studies have documented that a diluted sterile povidone-iodine (PVI) solution can be safely used in posterior spinal fusion surgeries as an antiseptic; in this study, we analyzed its effectiveness in reducing SSI. METHODS: This retrospective study consisted of consecutive patients who underwent elective posterior lumbar instrumentation performed by a single surgeon from 2016 to 2019. In the first 134 patients, wounds were irrigated before arthrodesis and closure with 1 L of 0.9% normal saline solution; in the subsequent 144 patients, wound irrigation was with a solution of 35 mL of sterile 10% PVI. Both groups were analyzed to determine if wound irrigation with sterile PVI solution decreased SSIs. RESULTS: There were 9 (6.7%) SSIs in the 0.9% normal saline solution group versus 1 (0.7%) SSI in the PVI group (P = 0.008). PVI solution had a relative risk for SSI of 0.093 (P = 0.008) and an adjusted odds ratio of 0.113 (P = 0.05). Increased body mass index and posterolateral spine fusion with laminectomy were significant risk factors for SSI (P = 0.04 and P = 0.030, respectively). CONCLUSIONS: Wound irrigation with PVI solution significantly reduced SSI in elective posterior lumbar instrumentation cases. Subgroup analysis provided significant results to recommend use of PVI solution for SSI prevention, particularly in overweight and obese patients. We also recommend its use in patients with risk factors for SSI, such as longer operative time and unintended durotomy.

Eating Habits Associated with Nutrition-Related Knowledge among University Students Enrolled in Academic Programs Related to Nutrition and Culinary Arts in Puerto Rico.

University students frequently develop unhealthy eating habits. However, it is unknown if students enrolled in academic programs related to nutrition and culinary arts have healthier eating habits. We evaluated the relationship of eating habits and nutritional status of students in academic programs with knowledge on nutrition, as well as cooking methods and techniques. A descriptive cross-sectional study was conducted in spring of 2019, while we completed a survey measuring eating habits and knowledge on nutrition, as well as cooking methods and techniques. Anthropometric measurements were collected for nutritional status estimation. The non-probabilistic convenience sample comprised 93 students pursuing degrees at Universidad Ana G. Mendez, Puerto Rico. Inadequate body mass index (BMI) was observed in 59% of the students. Eating habits, knowledge on nutrition, and knowledge on cooking methods and techniques were inadequate in 86%, 68%, and 41% of the population, respectively. Eating habits were associated with knowledge on nutrition and academic program, but not with knowledge on cooking methods and techniques. Most students reported having inadequate eating habits and BMI. Nutrition and dietetics students had the best knowledge on nutrition compared to culinary management students, a majority of whom had inadequate knowledge. We can conclude that there are other factors inherent to students' life that may have a stronger influence on eating habits.

Posttraumatic Hydrocephalus in Pediatric Patients After Decompressive Craniectomy.

OBJECTIVE: The risk for developing posttraumatic hydrocephalus (PTH) is higher when patients undergo decompressive craniectomy as part of their treatment. The purpose of this study is to determine the prevalence of PTH after decompressive craniectomy in pediatric patients and determine associated risk factors that may lead to PTH. METHODS: A retrospective analysis was conducted by searching the Puerto Rico neurologic surgery database from 2010 to 2019. All pediatric patients (1-18 years old) at the University Pediatric Hospital of the Puerto Rico Medical Center who had traumatic brain injury and had a decompressive craniectomy were included in the study. Data were reviewed to determine if time to decompressive craniectomy, side of decompressive craniectomy, gender, mechanism of trauma, amount of subarachnoid hemorrhage, and time to cranioplasty were risk factors for the development of PTH. RESULTS: Incidence of PTH after decompressive craniectomy was 21%. Neither gender, side of decompressive craniectomy, mechanism of trauma, amount of subarachnoid hemorrhage, time from trauma to decompressive craniectomy, nor cranioplasty intervention had statistical significance for developing PTH. Time from decompressive craniectomy to cranioplasty was significant for development of PTH. CONCLUSIONS: Longer time to cranioplasty was associated with an increased likelihood of PTH. We recommend performing cranioplasty as soon as possible to reduce hydrocephalus development.

Mechanical Thrombectomy for Middle Cerebral Artery Division Occlusions: A Systematic Review and Meta-Analysis.

BACKGROUND: Middle cerebral artery division (M2) occlusion was significantly underrepresented in recent mechanical thrombectomy (MT) randomized controlled trials, and the approach to this disease remains heterogeneous. OBJECTIVE: To conduct a systematic review and meta-analysis of outcomes at 90 days among patients undergoing MT for M2 middle cerebral artery (MCA) occlusions. METHODS: Five clinical databases were searched from inception through September 2016. Observational studies reporting 90-day modified Rankin Scale scores for patients undergoing MT for M2 MCA occlusions with an M1 MCA control group were selected. The primary outcome of interest was good clinical outcome 90 days after MT of an M1 or M2 MCA occlusion. Secondary outcomes of interest included mortality and excellent clinical outcome, recanalization rates, significant intracerebral hemorrhage, and procedural complications. RESULTS: A total of 323 publications were identified, and 237 potentially relevant articles were screened. Six studies were included in the analysis (M1 = 1,203, M2 = 258; total n = 1,461). We found no significant differences in good clinical outcomes (1.10 [95% CI, 0.83-1.44]), excellent clinical outcomes (1.07 [0.65-1.79]), mortality at 3 months (0.85 [0.58-1.24]), recanalization rates (1.06 [0.32-3.48]), and significant intracranial hemorrhage (1.19 [0.61-2.30]). CONCLUSIONS: MT of M2 MCA occlusions is as safe as that of main trunk MCA occlusions, and comparable in terms of clinical outcomes and hemorrhagic complications. Randomized clinical trials are needed to assess the impact of MT in patients with M2 occlusions, given that M1 MCA occlusions have different natural histories than M2 occlusions.