TLIF is Associated With Lower Rates of Adjacent Segment Disease and Complications Compared to ALIF: A Matched-Cohort Analysis.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: To compare the rate of adjacent segment disease (ASD) in patients undergoing anterior lumbar interbody fusion (ALIF) versus transforaminal lumbar interbody fusion (TLIF) for the treatment of degenerative stenosis and spondylolisthesis. SUMMARY OF BACKGROUND DATA: ALIF and TLIF are frequently used to treat Lumbar stenosis and spondylolisthesis. While both approaches have distinct advantages, it is unclear whether there are any differences in rates of ASD and postoperative complications. METHODS: A retrospective cohort study of patients who underwent index 1-3 levels ALIF or TLIF between 2010 and 2022, using the PearlDiver Mariner Database, an all-claims insurance database (120 million patients). Patients with a history of prior lumbar surgery and those undergoing surgery for cancer, trauma, or infection were excluded. Exact 1:1 matching was performed using demographic factors, medical comorbidities, and surgical factors found to be significantly associated with ASD in a linear regression model. The primary outcome was a new diagnosis of ASD within 36 months of index surgery, and secondary outcomes were all-cause medical and surgical complications. RESULTS: Exact 1:1 matching resulted in 2 equal groups of 106,451 patients undergoing TLIF and ALIF. The TLIF approach was associated with a lower risk of ASD (RR 0.58, 95% CI 0.56-0.59, P < 0.001) and all-cause medical complications (RR 0.94, 95% CI 0.91-0.98, P =0.002). All-cause surgical complications were not significantly different between both groups. CONCLUSION: After 1:1 exact matching to control for confounding variables, this study suggests that for patients with symptomatic degenerative stenosis and spondylolisthesis, a TLIF procedure (compared to ALIF) is associated with a decreased risk of developing ASD within 36 months of index surgery. Future prospective studies are needed to corroborate these findings. LEVEL OF EVIDENCE: Level-3.

Lumbar Arthroplasty Is Associated With a Lower Incidence of Adjacent Segment Disease Compared With ALIF: A Propensity-matched Analysis.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVE: The objective of this study was to compare the rate of adjacent segment disease (ASD) between lumbar disk arthroplasty (LDA) and anterior lumbar interbody fusion (ALIF). SUMMARY OF BACKGROUND DATA: LDA and ALIF are alternative surgical approaches used to treat lumbar degenerative disk disease. However, there is a paucity of studies comparing the risk of ASD after these procedures. METHODS: Patients who underwent 1- to 2-level LDA or ALIF between 2010 and 2022 were identified in the PearlDiver Mariner insurance all-claims database. Exclusion criteria included the history of prior lumbar spine surgery or surgery for tumors, trauma, or infection. 1:1 propensity matching was performed using demographic factors, medical comorbidities, and surgical factors, which were significantly associated with ASD. RESULTS: 1:1 propensity matching created two equal groups of 1625 patients without baseline differences who underwent LDA or ALIF. LDA was significantly associated with a lower risk of ASD (relative risk: 0.932, 95% CI, 0.899-0.967, P <0.001) and need for revision within 30 days (relative risk: 0.235, 95% CI, 0.079-0.698, P =0.007). There were no differences in all-cause surgical and medical complications between both groups. CONCLUSIONS: After risk adjustment for demographic and clinical characteristics, the results suggest that LDA is associated with a lower risk of ASD compared with ALIF. LDA was also associated with lower hospital cost and shorter length of stay.

Pyoderma Gangrenosum Masquerading as Wound Infection in the Early Postoperative Period After Lumbar Spine Deformity Correction Surgery.

The development of pyoderma gangrenosum (PG) after surgical site trauma is a rare, poorly understood immunologic phenomenon. PG is an immunologic disorder characterized by lymphocytic infiltration of the dermis that can manifest with skin necrosis and ulceration. This rare phenomenon can mimic surgical site infection (SSI) when it occurs in the perioperative period and in the region of surgical wounds. Within the neurosurgical literature, only two cases of postoperative PG have been reported to our knowledge. We describe the clinical features and treatment of PG in the case of a 65-year-old man who underwent a three-stage surgical approach for intractable mechanical low back pain on hospital days (HDs) 1 and 2, and who subsequently developed PG around all three surgical sites in the immediate postoperative period (HD 8). The physical and laboratory findings and surgical and pharmacologic treatments are detailed. The patient was initially treated for presumed SSI, started on broad-spectrum antibiotics, and underwent surgical wound debridement twice, without resolution of symptoms. The diagnosis of PG was ultimately made by a consulting dermatologist on HD 17. The patient was started on systemic immunosuppression with steroids during his initial hospitalization; symptoms resolved within two weeks of the index surgery. Although PG is a rare entity, we suggest that it be considered in the differential diagnosis of nonhealing surgical wounds. Familiarity with PG may help mitigate unnecessary surgical morbidity and reduce the length of hospital stays and unnecessary use of antibiotics.

Cerebral Autoregulation Correlation With Outcomes and Spreading Depolarization in Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: Delayed cerebral ischemia remains one of the principal therapeutic targets after aneurysmal subarachnoid hemorrhage. While large vessel vasospasm may contribute to ischemia, increasing evidence suggests that physiological impairment through disrupted impaired cerebral autoregulation (CA) and spreading depolarizations (SDs) also contribute to delayed cerebral ischemia and poor neurological outcome. This study seeks to explore the intermeasure correlation of different measures of CA, as well as correlation with SD and neurological outcome. METHODS: Simultaneous measurement of 7 continuous indices of CA was calculated in 19 subjects entered in a prospective study of SD in aneurysmal subarachnoid hemorrhage undergoing surgical aneurysm clipping. Intermeasure agreement was assessed, and the association of each index with modified Rankin Scale score at 90 days and occurrence of SD was assessed. RESULTS: There were 4102 hours of total monitoring time across the 19 subjects. In time-resolved assessment, no CA measures demonstrated significant correlation; however, most demonstrate significant correlation averaged over 1 hour. Pressure reactivity (PRx), oxygen reactivity, and oxygen saturation reactivity were significantly correlated with modified Rankin Scale score at 90 days. PRx and oxygen reactivity also were correlated with the occurrence of SD events. Across multiple CA measure reactivity indices, a threshold between 0.3 and 0.5 was most associated with intervals containing SD. CONCLUSIONS: Different continuous CA indices do not correlate well with each other on a highly time-resolved basis, so should not be viewed as interchangeable. PRx and oxygen reactivity are the most reliable indices in identifying risk of worse outcome in patients with aneurysmal subarachnoid hemorrhage undergoing surgical treatment. SD occurrence is correlated with impaired CA across multiple CA measurement techniques and may represent the pathological mechanism of delayed cerebral ischemia in patients with impaired CA. Optimization of CA in patients with aneurysmal subarachnoid hemorrhage may lead to decreased incidence of SD and improved neurological outcomes. Future studies are needed to evaluate these hypotheses and approaches.

Protocolized Whole-Body Computed Tomography Imaging After Extracorporeal Membrane Oxygenation (ECMO) Cannulation for Cardiac Arrest.

Evaluate the utility of whole-body computed tomography (WBCT) imaging in detecting clinically significant findings in patients who have undergone extracorporeal membrane oxygenation (ECMO) cannulation for cardiac arrest (extracorporeal cardiopulmonary resuscitation or "eCPR"). Single-center retrospective review of 52 consecutive patients from 2017 to 2019 who underwent eCPR and received concomitant WBCT imaging. WBCT images were reviewed for clinically significant findings (compression-related injuries, cannulation-related complications, etiology of cardiac arrest, incidental findings, and evidence of hypoxic brain injury) as well as the frequency of interventions performed as a direct result of such findings. Thirty-eight patients met inclusion criteria for analysis. Clinically significant WBCT findings were present in 37/38 (97%) of patients with 3.3 ± 1.7 findings per patient. An intervention as a direct result of WBCT findings was performed in 54% (20/37) of patients with such findings. Evidence of hypoxic brain injury on WBCT was associated with clinical brain death as compared with those without such findings (10/15 [67%] vs 1/22 [4%], P < 0.001), respectively. WBCT scan after eCPR frequently detects clinically significant findings which commonly prompt an intervention directly affecting the patient's clinical course. We advocate for protocolized use of WBCT imaging in all eCPR patients.

Incidence and outcomes of intracerebral haemorrhage with mechanical compression hydrocephalus.

INTRODUCTION: Intracerebral haemorrhage (ICH) within deep structures adjacent to the third ventricle is associated with worse outcomes when compared with lobar ICH due to the critical role of deep nuclei in normal neurological functioning. New evidence suggests another contributing factor to poor outcome is obstruction of cerebrospinal fluid outflow by clot burden causing mechanical compression of the third ventricle. The authors reviewed the incidence and outcomes of mechanical compression ICH in order to identify this high-risk group which may potentially benefit from minimally invasive evacuation. METHODS: Patients with spontaneous, non-traumatic, supratentorial ICH were identified retrospectively over a 30-month period. CT imaging was reviewed to assess location of the ICH, volume of the ICH, presence of hydrocephalus requiring external ventricular drain (EVD) placement, and time to clearing of the third ventricle. Hydrocephalus was then categorised as due to 'primarily intraventricular haemorrhage (IVH)', 'primarily mechanical compression' or 'mixed'. Functional outcomes at discharge were assessed using the modified Rankin Score (mRS). RESULTS: 287 patients met inclusion criteria, of which 39 (13.5%) patients developed hydrocephalus that required EVD. EVD patients had significantly higher mRS at discharge (p≤0.001) when compared with the non-EVD group. Lobar location was associated with lower odds of poor outcome compared with thalamic location (OR 0.107-0.560). Mechanical compression hydrocephalus was associated with poor outcome when compared with the primary IVH hydrocephalus subgroup (p=0.037) as well as longer time to clearing of the third ventricle (p=0.006). CONCLUSIONS: Mechanical obstruction requiring EVD occurs in approximately (21/287) 7.3% of all patients with spontaneous supratentorial ICH. It is unknown if the worse morbidity in these subjects is purely related to damage to deep structures surrounding the third ventricle or if secondary damage from hydrocephalus could be mitigated with targeted minimally invasive clot evacuation.

Melanotic neuroectodermal tumor of infancy: A rare pediatric head and neck lesion.

Melanotic neuroectodermal tumors of infancy are rare tumors arising from the neural crest and typically present during the first 12 months of life. The majority involve the facial bones, although melanotic neuroectodermal tumors of infancy of the skull and extremities have been observed with less frequency, as in the present case. This entity may initially be presented to the dermatologist as a scalp mass and should be considered in the differential diagnosis of infants with rapidly growing head and neck lesions.