Evaluation of patients referred to the spine clinic via telemedicine and the impact on diagnosis and surgical decision-making.

OBJECTIVE: Telemedicine encounters are expanding in utility for outpatient care and evaluation, partially as a necessity during the COVID-19 pandemic. It is unclear if telemedicine evaluation is comparable to in-person assessment of patients with spinal pathology undergoing surgical consultation. The objective of this study was to determine if treatment plans change for spine patients evaluated in person following an initial telemedicine consultation. METHODS: Patients referred to the authors' comprehensive spine center were evaluated first via telemedicine and then in clinic. Telemedicine evaluations were conducted via video evaluation with an attending surgeon. Demographic data including age, gender, and distance traveled from the clinic were retrospectively recorded. A chart review retrieved symptoms, radiographic details, and past medical history. The primary outcome was if the treatment plan changed (plan change [PC]) after seeing the patient in the clinic. Chi-square tests and binary logistical regression produced uni- and multivariate analyses. RESULTS: There were 152 new patients seen via telemedicine and in person. Pathology was present in the cervical (28.3%), thoracic (9.9%), and lumbar (61.8%) spine. The most common symptom was pain (72.4%), followed by radiculopathy (66.4%), weakness (26.3%), myelopathy (15.1%), and claudication (12.5%). There were 37 patients (24.3%) for whom there was a PC after clinic evaluation, and of those, only 5 (3.3%) were due to physical examination (PCPE) findings. On univariate analysis, a longer duration between telemedicine and clinic visit (odds ratio [OR] 1.094 per 7 days, p = 0.003), having pathology in the thoracic spine (OR 3.963, p = 0.018) and lack of sufficient imaging (OR 25.455, p < 0.0001) were predictive of a PC. Having pathology in the cervical spine (OR 9.538, p = 0.047) and adjacent-segment disease (OR 11.471, p = 0.010) were predictive of a PCPE. CONCLUSIONS: This study demonstrates that telemedicine may be an effective modality for the initial evaluation of spine surgical patients, without compromising decision-making in the absence of an in-person physical examination.

Surgical Management of Brain Tumors with Focused Ultrasound.

Focused ultrasound is a novel technique for the treatment of aggressive brain tumors that uses both mechanical and thermal mechanisms. This non-invasive technique can allow for both the thermal ablation of inoperable tumors and the delivery of chemotherapy and immunotherapy while minimizing the risk of infection and shortening the time to recovery. With recent advances, focused ultrasound has been increasingly effective for larger tumors without the need for a craniotomy and can be used with minimal surrounding soft tissue damage. Treatment efficacy is dependent on multiple variables, including blood-brain barrier permeability, patient anatomical features, and tumor-specific features. Currently, many clinical trials are currently underway for the treatment of non-neoplastic cranial pathologies and other non-cranial malignancies. In this article, we review the current state of surgical management of brain tumors using focused ultrasound.

The Enhanced Recovery After Surgery pathway for posterior cervical surgery: a retrospective propensity-matched cohort study.

OBJECTIVE: The Enhanced Recovery After Surgery (ERAS) protocol is a comprehensive, multifaceted approach aimed at improving postoperative outcomes. It incorporates a range of strategies to promote early and more effective recovery, including reducing pain, complications, and length of stay, without increasing readmission rate. To date, ERAS for spine surgery patients has been primarily limited to lumbar surgery and anterior cervical decompression and fusion (ACDF). ERAS has not been previously studied for posterior cervical surgery, which may present a greater opportunity for improvement in patient outcomes with ERAS than ACDF. This single-institution, multi-surgeon study assessed the impact of an ERAS protocol in patients undergoing posterior cervical decompression surgery. METHODS: This study included a retrospective consecutive patient cohort with controls that were propensity matched for age, body mass index, sex, home opioid use, surgical levels, Nurick grade, and smoking status. In addition, consecutive patients who underwent posterior cervical decompression surgery for degenerative disease from December 2014 to December 2021 were included. ERAS was implemented in December 2018. Demographic, perioperative, clinical, and radiographic information was gathered. Regression models were created to evaluate length of stay, physiological function, pain levels, and opioid use. The primary focus was length of stay, with secondary outcomes including timing of ambulation, bowel movement, and voiding; daily pain scores; opioid consumption; discharge status; 30-day readmission rates; and reoperation rates. RESULTS: There were 366 patients included in the study, all of whom were included in multivariate models, and 254 (127 in each cohort) were included on the basis of matching. After propensity matching, patient characteristics, operative procedures, and operative duration were similar between groups. The ERAS cohort had a significantly improved length of stay (3.2 vs 4.7 days, p < 0.0001) and home discharge rate (80% vs 50%, p < 0.001) without an increase in readmission rate. The ERAS cohort had an earlier day of the first ambulation (p = 0.003), bowel movement (p = 0.014), and voiding (p = 0.001). ERAS demonstrated a significantly lower composite complication rate (1.1 vs 1.8, p < 0.0001). ERAS resulted in better maximum pain scores (p = 0.043) and trended toward improved mean pain scores (p = 0.072), although total opioid use was similar. CONCLUSIONS: Implementing a novel ERAS protocol significantly improved length of stay, return of physiological function, home discharge, complications, and maximum pain score after posterior cervical surgery.

Update for astrocytomas: medical and surgical management considerations.

Astrocytomas include a wide range of tumors with unique mutations and varying grades of malignancy. These tumors all originate from the astrocyte, a star-shaped glial cell that plays a major role in supporting functions of the central nervous system (CNS), including blood-brain barrier (BBB) development and maintenance, water and ion regulation, influencing neuronal synaptogenesis, and stimulating the immunological response. In terms of epidemiology, glioblastoma (GB), the most common and malignant astrocytoma, generally occur with higher rates in Australia, Western Europe, and Canada, with the lowest rates in Southeast Asia. Additionally, significantly higher rates of GB are observed in males and non-Hispanic whites. It has been suggested that higher levels of testosterone observed in biological males may account for the increased rates of GB. Hereditary syndromes such as Cowden, Lynch, Turcot, Li-Fraumeni, and neurofibromatosis type 1 have been linked to increased rates of astrocytoma development. While there are a number of specific gene mutations that may influence malignancy or be targeted in astrocytoma treatment, O 6-methylguanine-DNA methyltransferase (MGMT) gene function is an important predictor of astrocytoma response to chemotherapeutic agent temozolomide (TMZ). TMZ for primary and bevacizumab in the setting of recurrent tumor formation are two of the main chemotherapeutic agents currently approved in the treatment of astrocytomas. While stereotactic radiosurgery (SRS) has debatable implications for increased survival in comparison to whole-brain radiotherapy (WBRT), SRS demonstrates increased precision with reduced radiation toxicity. When considering surgical resection of astrocytoma, the extent of resection (EoR) is taken into consideration. Subtotal resection (STR) spares the margins of the T1 enhanced magnetic resonance imaging (MRI) region, gross total resection (GTR) includes the margins, and supramaximal resection (SMR) extends beyond the margin of the T1 and into the T2 region. Surgical resection, radiation, and chemotherapy are integral components of astrocytoma treatment.

Electrolyte Imbalance and Neurologic Injury.

Neurologic injury continues to be a debilitating worldwide disease with high morbidity and mortality. The systemic sequelae of a neural insult often lead to prolonged hospital stays and challenging nutritional demands that contribute to poorer prognoses. Clinical management of a given condition should prioritize preserving the homeostatic parameters disrupted by inflammatory response cascades following the primary insult. This focused review examines the reciprocal relationship between electrolyte disturbance and neurologic injury. A prolonged electrolyte imbalance can significantly impact morbidity and mortality in neurologic injuries. A detailed overview of the major electrolytes and their physiologic, iatrogenic, and therapeutic implications are included. The pathophysiology of how dysnatremias, dyskalemias, dyscalcemias, and dysmagnesemias occur and the symptoms they can induce are described. The manifestations in relation to traumatic brain injury, status epilepticus, and acute ischemic stroke are addressed. Each type of injury and the strength of its association with a disruption in either sodium, potassium, calcium, or magnesium is examined. The value of supplementation and replacement is highlighted with an emphasis on the importance of early recognition in this patient population. This review also looks at the current challenges associated with correcting imbalances in the setting of different injuries, including the relevant indications and precautions for some of the available therapeutic interventions. Based on the findings of this review, there may be a need for more distinct clinical guidelines on managing different electrolyte imbalances depending on the specified neurologic injury. Additional research and statistical data on individual associations between insult and imbalance are needed to support this potential future call for context-based protocols.

Proteinopathies and Neurotrauma: Update on Degenerative Cascades.

Neurotrauma, especially repetitive neurotrauma, is associated with the development of progressive neurodegeneration leading to chronic traumatic encephalopathy (CTE). Exposure to neurotrauma regularly occurs during sports and military service, often not requiring medical care. However, exposure to severe and/or repeated sub-clinical neurotrauma has been shown cause physical and psychological disability, leading to reduce life expectancy. Misfolding of proteins, or proteinopathy, is a pathological hallmark of CTE, in which chronic injury leads to local and diffuse protein aggregates. These aggregates are an overlapping feature of many neurodegenerative diseases such as CTE, Alzheimer's Disease, Parkinsons disease. Neurotrauma is also a significant risk factor for the development of these diseases, however the mechanism's underlying this association are not well understood. While phosphorylated tau aggregates are the primary feature of CTE, amyloid-beta, Transactive response DNA-binding protein 43 (TDP-43), and alpha-synuclein (αSyn) are also well documented. Aberrant misfolding of these proteins has been shown to disrupt brain homeostasis leading to neurodegeneration in a disease dependent manor. In CTE, the interaction between proteinopathies and their associated neurodegeneration is a current area of study. Here we provide an update on current literature surrounding the prevalence, characteristics, and pathogenesis of proteinopathies in CTE.

Surgical Management of Synucleinopathies.

Synucleinopathies represent a diverse set of pathologies with significant morbidity and mortality. In this review, we highlight the surgical management of three synucleinopathies: Parkinson's disease (PD), dementia with Lewy bodies (DLB), and multiple system atrophy (MSA). After examining underlying molecular mechanisms and the medical management of these diseases, we explore the role of deep brain stimulation (DBS) in the treatment of synuclein pathophysiology. Further, we examine the utility of focused ultrasound (FUS) in the treatment of synucleinopathies such as PD, including its role in blood-brain barrier (BBB) opening for the delivery of novel drug therapeutics and gene therapy vectors. We also discuss other recent advances in the surgical management of MSA and DLB. Together, we give a diverse overview of current techniques in the neurosurgical management of these pathologies.

Gut microbiome and neurosurgery: Implications for treatment.

Introduction: The aim of this review is to summarize the current understanding of the gut-brain axis (GBA), its impact on neurosurgery, and its implications for future treatment. Background: An abundance of research has established the existence of a collection of pathways between the gut microbiome and the central nervous system (CNS), commonly known as the GBA. Complicating this relationship, the gut microbiome bacterial diversity appears to change with age, antibiotic exposure and a number of external and internal factors. Methods: In this paper, we present the current understanding of the key protective and deleterious roles the gut microbiome plays in the pathogenesis of several common neurosurgical concerns. Results: Specifically, we examine how spinal cord injury, traumatic brain injury and stroke may cause gut microbial dysbiosis. Furthermore, this link appears to be bidirectional as gut dysbiosis contributes to secondary CNS injury in each of these ailment settings. This toxic cycle may be broken, and the future secondary damage rescued by timely, therapeutic, gut microbiome modification. In addition, a robust gut microbiome appears to improve outcomes in brain tumour treatment. There are several primary routes by which microbiome dysbiosis may be ameliorated, including faecal microbiota transplant, oral probiotics, bacteriophages, genetic modification of gut microbiota and vagus nerve stimulation. Conclusion: The GBA represents an important component of patient care in the field of neurosurgery. Future research may illuminate ideal methods of therapeutic microbiome modulation in distinct pathogenic settings.

Advances Research in Traumatic Encephalopathy.

Though there are an abundance of chronic traumatic encephalopathy (CTE) cases worldwide [...].

Neuroinflammation and subarachnoid hemorrhage: a revised look at the literature.

A key topic for aneurysmal subarachnoid hemorrhage is neuroinflammation. Neuroinflammation can predispose to aneurysm formation and rupture. Neuroinflammation can also result from the blood breakdown products after aneurysm rupture. Recent evidence has shown that perpetual neuroinflammation can contribute to vasospasm and hydrocephalus. Targeting neuroinflammation is a novel mechanism for preventing subsequent neurologic sequalae. In this review, we highlight the pathophysiology of aneurysm formation, the neuroinflammatory surge after rupture including the involved cytokines, and ultimately tie in the contributory clinical relevance. In the last sections, we look at the pre-clinical data and novel avenues for further discovery. This paper will be a useful resource to both the clinician and scientific investigator.

Treatment of breast cancer brain metastases: radiotherapy and emerging preclinical approaches.

The breast is one of the common primary sites of brain metastases (BM). Radiotherapy for BM from breast cancer may include whole brain radiation therapy (WBRT), stereotactic radiosurgery (SRS), and stereotactic radiotherapy (SRT), but a consensus is difficult to reach because of the wide and varied protocols, indications, and outcomes of these interventions. Overall, dissemination of disease, patient functional status, and tumor size are all important factors in the decision of treatment with WBRT or SRS. Thus far, previous studies indicate that WBRT can improve tumor control compared to SRS, but increase side effects, however no randomized trials have compared the efficacy of these therapies in BM from breast cancer. Therapies targeting long non-coding RNAs and transcription factors, such as MALAT1, HOTAIR, lnc-BM, TGL1, and ATF3, have the potential to both prevent metastatic spread and treat BM with improved radiosensitivity. Given the propensity for HER2+ breast cancer to develop BM, the above-mentioned cell lines may represent an important target for future investigations, and the development of everolimus and pyrotinib are equally important.

Calcitonin gene-related peptide and neurologic injury: An emerging target for headache management.

Calcitonin gene-related peptide (CGRP) is a 37-amino acid neuropeptide known to be involved in the trigeminovascular system and to function as a potent vasodilator. Although it has emerged as a viable target for headache management with targeted treatments developed for migraine, a highly disabling neurovascular disorder, less is known about CGRP's role in other neurologic conditions such as traumatic brain injury and subarachnoid hemorrhage. The literature has shown that during these injury cascades, CGRP receptors are modulated in varying ways. Therefore, CGRP or its receptors might be viable targets to manage secondary injuries following acute brain injury. In this review, we highlight the pathophysiology of the CGRP pathway and its relation to migraine pathogenesis. Using these same principles, we assess the existing preclinical data for CGRP and its role in acute brain injury. The findings are promising, and set the basis for further work, with specific focus on the therapeutic benefit of CGRP modulation following neurologic injury.

Overview of Neurotrauma and Sensory Loss.

Neurotrauma can cause devastating outcomes for patients both from primary as well as secondary injury. Sensory loss following neurotrauma is often overlooked and undermanaged. To gain awareness about this important topic, we highlight key findings of visual, hearing, taste, and smell disturbances that can occur after injury. The pathways are highlighted as well as significant pathophysiology. Both primary disruption as well as secondary disruptions from ongoing inflammation are addressed. The figures are designed to be user friendly guides for the clinician to help manage these patients. In the final section, we address key management strategies and approaches. The strategies deal with multidisciplinary care as well as multimodality treatments. This review serves as a primer for early recognition of deficits and initiation of appropriate treatments.

Shared pathophysiology: Understanding stroke and Alzheimer's disease.

Alzheimer's disease and stroke share several known vascular risk factors. The pathophysiology and whether one predisposes to the other is a topic of ongoing investigation. In this critical review, we highlight what is known about each pathway and the shared potential mechanisms. We offer insight into topics that warrant further investigation. We address topics of both neurodegeneration and secondary cascades. Furthermore, the concept of targeting secondary mechanisms early might be a viable treatment option for ongoing preventative measures. The review is intended to serve as a catalyst for further scientific inquiry into this important topic.

Recent Treatment Strategies in Alzheimer's Disease and Chronic Traumatic Encephalopathy.

Neurotrauma has been well linked to the progression of neurodegenerative disease. Much work has been done characterizing chronic traumatic encephalopathy, but less has been done regarding the contribution to Alzheimer's Disease. This review focuses on AD and its association with neurotrauma. Emerging clinical trials are discussed as well as novel mechanisms. We then address how some of these mechanisms are shared with CTE and emerging pre-clinical studies. This paper is a user-friendly resource that summarizes the emerging findings and proposes further investigation into key areas of interest. It is intended to serve as a catalyst for both research teams and clinicians in the quest to improve effective treatment and diagnostic options.