Advancing glenohumeral dysplasia treatment in brachial plexus birth injury: the end-to-side spinal accessory to suprascapular nerve transfer technique.

PURPOSE: Brachial plexus birth injury (BPBI) is a common injury with the spectrum of disease prognosis ranging from spontaneous recovery to lifelong debilitating disability. A common sequela of BPBI is glenohumeral dysplasia (GHD) which, if not addressed early on, can lead to shoulder dysfunction as the child matures. However, there are no clear criteria for when to employ various surgical procedures for the correction of GHD. METHODS: We describe our approach to correcting GDH in infants with BPBIs using a reverse end-to-side (ETS) transfer from the spinal accessory to the suprascapular nerve. This technique is employed in infants that present with GHD with poor external rotation (ER) function who would not necessitate a complete end-to-end transfer and are still too young for a tendon transfer. In this study, we present our outcomes in seven patients. RESULTS: At presentation, all patients had persistent weakness of the upper trunk and functional limitations of the shoulder. Point-of-care ultrasounds confirmed GHD in each case. Five patients were male, and two patients were female, with a mean age of 3.3 months age (4 days-7 months) at presentation. Surgery was performed on average at 5.8 months of age (3-8.6 months). All seven patients treated with a reverse ETS approach had full recovery of ER according to active movement scores at the latest follow-up. Additionally, ultrasounds at the latest follow-up showed a complete resolution of GHD. CONCLUSION: In infants with BPBI and evidence of GHD with poor ER, end-to-end nerve transfers, which initially downgrade function, or tendon transfers, that are not age-appropriate for the patient, are not recommended. Instead, we report seven successful cases of infants who underwent ETS spinal accessory to suprascapular nerve transfer for the treatment of GHD following BPBI.

Novel surface biochemical modifications of urinary catheters to prevent catheter-associated urinary tract infections.

More than 70% of hospital-acquired urinary tract infections are related to urinary catheters, which are commonly used for the treatment of about 20% of hospitalized patients. Urinary catheters are used to drain the bladder if there is an obstruction in the tube that carries urine out of the bladder (urethra). During catheter-associated urinary tract infections, microorganisms rise up in the urinary tract and reach the bladder, and cause infections. Various materials are used to fabricate urinary catheters such as silicone, polyurethane, and latex. These materials allow bacteria and fungi to develop colonies on their inner and outer surfaces, leading to bacteriuria or other infections. Urinary catheters could be modified to exert antibacterial and antifungal effects. Although so many research have been conducted over the past years on the fabrication of antibacterial and antifouling catheters, an ideal catheter needs to be developed for long-term catheterization of more than a month. In this review, we are going to introduce the recent advances in fabricating antibacterial materials to prevent catheter-associated urinary tract infections, such as nanoparticles, antibiotics, chemical compounds, antimicrobial peptides, bacteriophages, and plant extracts.

A Case Report of Infant-Type Hemispheric Glioma with a Novel GAB1-ABL2 Kinase Fusion Treated with Dasatinib.

INTRODUCTION: Infant-type hemispheric glioma (IHG) is a rare form of cancer that affects newborns and infants. It is classified as a pediatric-type high-grade glioma and typically harbors receptor tyrosine kinase (RTK) gene fusions. Here, we present the finding of a novel gene fusion IHG treated with a targeted therapy that has yet to be implemented for any other IHG case to date. CASE PRESENTATION: We report the case of a 12-month-old boy with IHG who presented with obstructive hydrocephalus due to a large mass in the right frontal lobe. The patient initially underwent mass resection, but subsequent imaging showed rapid interval progression of the residual tumor. Comprehensive molecular analysis of the tumor tissue revealed a novel GAB1-ABL2 gene fusion, and the patient was started on dasatinib, an ABL kinase inhibitor. Shortly after initiation of dasatinib treatment, there was a significant reduction in tumor size and enhancement, followed by stabilization of disease. DISCUSSION: The patient's robust response to treatment suggests that dasatinib is an effective targeted therapy for IHG harboring a GAB1-ABL2 gene fusion. This finding may inform future investigations into the disease processes of IHG and help guide the diagnosis and treatment of IHG in the absence of previously identified gene fusions, improving clinical management of this vulnerable patient population.

Pediatric brain aneurysms: a review of 1458 brain MR angiograms.

PURPOSE: To evaluate clinical and imaging characteristics of pediatric brain aneurysms. MATERIALS AND METHODS: A retrospective review of 1458 MR angiograms of pediatric patients (≤18 years old) obtained between 2006 and 2021 was performed. A non-infundibular arterial luminal outpouching larger than 1mm in size was identified as an "Intracranial aneurysm." Patient demographics, clinical presentations, and predisposing risk factors, including family history and underlying medical conditions, were reviewed. MRA images were analyzed for aneurysm location, number, maximum diameter, and interval changes on follow-up. RESULTS: Forty-nine (3.3%) patients (30 females, 19 males) with 64 intracranial aneurysms were identified with an average age of 13.71 ± 3.67 years. Eleven (22.4%) patients had multiple aneurysms. An underlying systemic illness was observed in 81.6% (40/49) cases, with sickle cell disease as the most frequent (25/49, 51%) diagnosis. A first-degree family history of intracranial aneurysms was recognized in 36/1458 (2.5%) patients. However, no intracranial aneurysm was found in this group. While 02/49 (4%) patients presented with acute SAH, headache was the most common (16/49, 32.7%) symptom at presentation in unruptured cases. The majority (47/64, 73.4%) of the aneurysms were located in the anterior circulation, with the ICA ophthalmic segment being most frequently (24/47, 51%) involved. Most (54/64, 84.4%) aneurysms were smaller than 4mm in size at the time of diagnosis. At least one follow-up MRA was obtained in 72.3% (34/47) of the unruptured aneurysms cohort. There was no change in the aneurysm size and morphology in 31/34 (91.2 %) patients over an average imaging follow-up of 39.6 months. Three (6%) patients demonstrated an interval increase in the aneurysm size. SAH patients (n=2) and two unruptured aneurysm patients with an interval increase in size were successfully treated with endovascular techniques. CONCLUSION: Female predominance with a higher frequency of small and unruptured intracranial aneurysms was recognized in our cohort. A higher incidence of an underlying systemic illness, especially sickle cell disease, was also noted. Most intracranial aneurysms in children appear to remain stable. However, there seems to be the risk of an aneurysm size increase which warrants regular clinical and imaging follow-up.

Ventriculopleural shunt outcomes for pediatric hydrocephalus: a single-institution experience.

PURPOSE: The aim of this study is to analyze rates of ventriculopleural (VPL) shunt failure and complications among patients with pediatric hydrocephalus, and to analyze which factors may predict early (< 1 year) or late (> 1 year) VPL shunt failure in this sample. METHODS: A retrospective chart review was conducted of all consecutive VPL shunt placements from 2000 to 2019 at our institution. Data was collected on patient characteristics, shunt history, and shunt type. Primary endpoints include rates of VPL shunt survival and rates of symptomatic pleural effusion. The Kaplan-Meier method was used to calculate shunt survival, and Fisher's exact test and t-test were used to compare differences between categorical variables and means, respectively (p < 0.05). RESULTS: Thirty-one patients with pediatric hydrocephalus underwent VPL shunt placement (mean age 14.2 years). Of the 27 patients with long-term follow-up (mean 46 months), VPL shunt revision was required in 19, seven of which were due to pleural effusion. Overall shunt survival rates at 1, 3, 5, and 7 years were 76%, 62%, 55%, and 46%, respectively. Mean duration of shunt survival was 26.74 months. Overall pleural effusion rate was 26%. No patient-specific factors, including shunt valve type, were significantly associated with shunt survival, risk of early revision, or risk of pleural effusion. CONCLUSIONS: Our results are comparable to those reported in the literature and represent one of the largest case series on the topic. VPL shunts are a viable second-line option when ventriculoperitoneal (VP) shunt placement is not possible or desirable, though there are high rates of shunt revision and pleural effusion.

An adolescent case of sellar osteochondromyxoma in the setting of spondyloepiphyseal dysplasia.

PURPOSE: Osteochondromyxomas (OMX) are rare congenital bone tumors that have only been described in the context of Carney complex syndrome (CNC). Data on OMX as a separate entity and in association with other disorders remain limited, making both diagnosis and treatment difficult. METHODS: A case report of a 17-year-old female diagnosed with sellar OMX is presented in the setting of spondyloepiphyseal dysplasia (SED). We discuss the radiographic and histopathological interpretations in addition to reviewing the current literature on OMX. RESULTS: A successful gross total resection of the tumor was achieved via an endonasal endoscopic transsphenoidal approach. A diagnosis was established radiographically and pathologically. CONCLUSION: The diagnosis and treatment of OMX are best achieved via tissue biopsy. Following confirmed osteochondromyxoma cases long term for recurrence and outcomes will be essential in understanding its natural tumor history and in establishing standard treatments.

Pediatric Endoscopic Endonasal Skull Base Surgery: A Retrospective Review Over 11 Years.

OBJECTIVE: To show the safety and efficacy of the endoscopic endonasal approach (EEA) for skull base surgery in pediatric patients through descriptive analysis of cases over an 11-year period. METHODS: The study comprised 94 patients undergoing EEA for skull base surgery, between January 2007 and June 2018, at 2 tertiary pediatric hospitals. Descriptive statistics are presented regarding the presentation, intraoperative details, and complications. RESULTS: Over the study period, 130 surgeries were performed in 94 patients: 94 primary surgeries and 36 reoperations. The mean patient age was 13.8 years and 48.9% of patients were female. Presenting signs/symptoms included endocrinopathies (56.4%), vision abnormalities (37.2%), and cranial nerve deficits (20.2%). EEA alone was used in 95.7% of primary surgeries and 91.7% of reoperations. Diseases treated included craniopharyngioma (18.1%), pituitary adenoma (17.0%), Rathke cleft cyst (13.8%), chordoma (9.6%), osteosarcoma (5.3%), juvenile nasopharyngeal angiofibroma (4.3%), skull base fracture (4.3%), and encephalocele (3.2%). A lumbar drain was used in 20.2% of primary surgeries and 25% of reoperations. A nasoseptal flap was used in 36.2% of primary surgeries and 25% of reoperations. Postoperative complications included cerebrospinal fluid leak (12.8%), sinusitis (7.4%), bacterial meningitis (3.2%), and carotid artery injury in 1 reoperation. CONCLUSIONS: EEA for anterior cranial base disease is safe and efficacious in pediatric patients and can be used to treat many of the rare and heterogenous diseases that arise in this anatomic location. Management strategies and rates of sinonasal and intracranial complications including cerebrospinal fluid leak rate are similar to those reported in adult cohorts.

Endoscopic endonasal optic nerve decompression: treatment of fibrous dysplasia in a pediatric population.

OBJECTIVE: Patients with fibrous dysplasia (FD) of the anterior skull base can experience progressive visual loss and impairment. The authors reviewed their experience with endonasal decompression of the optic nerve (ON) in this patient population. Endoscopic ON decompression (EOND) is a feasible surgical approach for children with FD and visual deficit due to structural ON compression. METHODS: Electronic medical records of children between 1 and 17 years of age with unilateral FD of the anterior skull base and concomitant ON compression, who required EOND between 2017 and 2022 (n = 4), were reviewed for demographic data, both pre- and postoperative imaging, and evaluations by an otolaryngologist, neurosurgeon, and ophthalmologist in a multidisciplinary fashion. RESULTS: EOND was found to be a safe and effective surgery for children with FD. Visual acuity was stable in 80% of the eyes postoperatively. Visual fields improved in 40% of the eyes and remained stable in the rest. CONCLUSIONS: EOND is beneficial for progressive optic neuropathy that is unresponsive to steroid therapy and can prevent permanent disability if performed prior to irreversible damage to the nerve. EOND can decompress the edematous ON with proper exposure of the optic canal and orbital apex, without any major complications.

Investigating the anti-streptococcal biofilm effect of ssDNA aptamer-silver nanoparticles complex on a titanium-based substrate.

Streptococcus mutans is a commensal and opportunistic pathogen that causes several diseases by forming a biofilm in humans and animals in many areas such as nasopharyngeal, cardiac valves, lungs, and oral cavity. Biofilms are very important in prosthetic infections associated with medical implants. The use of nanoparticles is one of the evolving fields in biofilm targeting. Silver nanoparticles can be used for biofilm targeting due to their inherent antimicrobial properties. Hybridization of nanoparticles with small molecules increases their biological properties and makes them multifunctional. The present investigation aimed to design an appropriate silver nanoparticles-aptamer complex that binds to the surface receptors of streptococcal strains. For this reason, silver nanoparticles with particle sizes in a range of 50 to 70 nm were synthesized and connected to a designed aptamer with a streptavidin-biotin linker. Then, the effect of the complex was investigated on the S. mutans biofilm formed on the surface of a medical-grade titanium substrate. The silver nanoparticles-aptamer complex at a concentration of 100 µg mL-1 after 48 h inhibited 43% of the biofilm formation and degraded 63% of the formed biofilm. Also, the cell availability reached 96% and the complex was stable in cell medium culture for 360 min. It was concluded that this complex could be a good candidate for removing the formed biofilms on the surface of titanium implants.

Isolation, characterization, and functional study of extracellular vesicles derived from Leishmania tarentolae.

Leishmania (L.) species are protozoan parasites with a complex life cycle consisting of a number of developmental forms that alternate between the sand fly vector and their host. The non-pathogenic species L. tarentolae is not able to induce an active infection in a human host. It has been observed that, in pathogenic species, extracellular vesicles (EVs) could exacerbate the infection. However, so far, there is no report on the identification, isolation, and characterization of L. tarentolae EVs. In this study, we have isolated and characterized EVs from L. tarentolae GFP+ (tEVs) along with L. major GFP+ as a reference and positive control. The EVs secreted by these two species demonstrated similar particle size distribution (approximately 200 nm) in scanning electron microscopy and nanoparticle tracking analysis. Moreover, the said EVs showed similar protein content, and GFP and GP63 proteins were detected in both using dot blot analysis. Furthermore, we could detect Leishmania-derived GP63 protein in THP-1 cells treated with tEVs. Interestingly, we observed a significant increase in the production of IFN-γ, TNF-α, and IL-1ß, while there were no significant differences in IL-6 levels in THP-1 cells treated with tEVs following an infection with L. major compared with another group of macrophages that were treated with L. major EVs prior to the infection. Another exciting observation of this study was a significant decrease in parasite load in tEV-treated Leishmania-infected macrophages. In addition, in comparison with another group of Leishmania-infected macrophages which was not exposed to any EVs, tEV managed to increase IFN-γ and decrease IL-6 and the parasite burden. In conclusion, we report for the first time that L. tarentolae can release EVs and provide evidence that tEVs are able to control the infection in human macrophages, making them a great potential platform for drug delivery, at least for parasitic infections.

Pediatric benign triton tumor of trigeminal nerve: a case report and literature review.

PURPOSE: Benign triton tumors (BTTs) in the pediatric population are extremely rare occurrences. Paucity of data on BTTs poses both diagnostic and therapeutic challenges, particularly when found intracranially. METHODS: A case report of a 10-year-old male diagnosed with incidental maxillary trigeminal (V2) BTT is presented. We discuss radiographic and histopathological interpretations. Furthermore, we provide a brief review of current literature and historical background on pediatric trigeminal BTT diagnosis, histopathology, and management. RESULTS: Successful gross total resection of the tumor was achieved via Dolenc approach to the cavernous sinus. Management options with consideration of outcomes from the few prior cases reported in the literature are presented. CONCLUSION: Treatment of trigeminal nerve tumors requires a broad differential diagnosis and understanding rare tumors is essential in the diagnosis and treatment algorithm.

Presentation, management and outcome of surgically managed pediatric thoracic outlet syndrome.

PURPOSE: Thoracic outlet syndrome (TOS) is a rare disorder involving compression of the brachial plexus, subclavian artery, and subclavian vein. There is a paucity of data for this pathology's surgical treatment within pediatrics. The objective of this study is to explore the presentation, management, and outcome of pediatric TOS. METHODS: A retrospective chart review was conducted for 44 patients at a single institution undergoing surgery for TOS. Data was collected on demographics, pre- and postoperative factors, and outcomes. RESULTS: Forty-four patients underwent 50 surgeries (8 bilaterally). The average age was 15.5 years with 72% female. The most common symptoms were numbness (72%) and pain (66%), with a normal exam in 58%. The average symptom duration prior to surgery was 35.2 months. A supraclavicular approach was performed in all patients, with anterior scalene section (90%), rib resection (72%), neurolysis (92%), and intraoperative EMG (84%) commonly used. Two patients had a lymphatic leak. All patients reported subjective improvement of preoperative symptoms of numbness (26%), pain (22%), and weakness (6%). Differences between vTOS (n = 9) and nTOS (n = 35) included higher preop swelling (p < 0.012), decreased symptom duration (p < 0.022), higher venogram usage (p < 0.0030), and higher preoperative thrombolytics/angioplasty (p < 0.001) in vTOS compared to nTOS. A comparison of soft tissue and soft tissue with bone decompression did not reveal any outcome differences. CONCLUSION: Pediatric TOS benefits from a multidisciplinary approach, showing good outcomes in postoperative symptom resolution. In our cohort, a supraclavicular approach provided an effective window for decompression with a low complication rate.

Middle meningeal artery embolization in pediatric patient.

PURPOSE: There is paucity of data in management of recurrent and expanding subdural hematomas (SDH) within the pediatric population, who are otherwise not surgical candidates. Middle meningeal artery (MMA) embolization has been utilized minimally in this population and here, we explore the utility of this procedure in a 15-month-old-child, along with review of the literature. METHODS: A case report of a 15-month-old child who underwent MMA embolization for recurrent and expanding SDH in the setting of anticoagulation for cardiac condition. A literature review of MMA embolization in pediatric patients was conducted. RESULTS: Initially stabilization of SDH was noted on serial imaging; however, recurrent hemorrhages were noted with subsequent boluses of antiplatelet and anticoagulating agents. There are only 5 total reported cases, included ours, of MMA embolization in pediatrics with an overall success rate of 80%. CONCLUSION: Treatment of chronic or recurrent subdural hematoma by MMA embolization in the pediatric population is understudied. Our case notes limitation of this procedure and impact on long-term success, specifically in patients with systemic illness and ongoing anticoagulation.

Current Trends and Socioeconomic Disparities in the Utilization of Spine Augmentation for Patients With Osteoporotic Vertebral Compression Fracture: A Nationwide Inpatient Sample Analysis From 2012 to 2016.

INTRODUCTION: Osteoporotic vertebral compression fracture (OVCF) is a growing health care problem in today's aging population. Since the advent of kyphoplasty and vertebroplasty, these interventions have been commonly utilized in the treatment of symptomatic OVCF. However, the use of these interventions varies because there is not a standard of care for the management of OVCF. There remain disparities in the use of these procedures as treatment for OVCFs in the United States. METHODS: The 2012 to 2016 Nationwide Inpatient Sample was queried for all patients admitted for OVCF. These patients were then grouped based on whether they received conservative vs surgical (kyphoplasty/vertebroplasty) management and compared with respect to various socioeconomic factors including race, insurance coverage, income quartile, hospital control, and geography. Propensity score matching was utilized to control for potential baseline confounders as well as the influence of other endpoints. RESULTS: The search criteria identified 35,199 patients admitted with OVCF, of whom 7900 (22.4%) received spine augmentation. Blacks/African Americans (risk ratios [RR] = 0.79, P < 0.001), Hispanics/Latinos (RR = 0.82, P < 0.001), Asians/Pacific Islanders (RR = 0.81, P = 0.048), and unknown/other races (RR = 0.88, P = 0.037) were less likely to receive surgical management than whites/Caucasians. When compared with Medicare patients, those with Medicaid (RR = 0.76, P < 0.001) were less likely to receive surgery while privately insured patients were more likely (RR = 1.06, P = 0.42). Patients in the West (RR = 0.90, P < 0.001) were less likely to receive surgery for OVCF than those in the Northeast. CONCLUSIONS: A wide variety of socioeconomic disparities exists in the use of spinal augmentation for the management of OVCF in the United States, limiting patient access to a potentially beneficial procedure. CLINICAL RELEVANCE: Retrospective Analysis.

Gender Disparities in Outpatient Management of Postlaminectomy Syndrome.

INTRODUCTION: Postlaminectomy syndrome (PLS), also known as failed back surgery syndrome, is the persistence of radicular pain in the face of surgical intervention. Despite its prevalence in 10 to 40% of spine surgery patients, outpatient pharmacologic and interventional management remains poorly characterized. METHODS: The 2007 to 2016 National Ambulatory Medical Care Survey (NAMCS) was utilized to include all outpatients diagnosed with PLS. For each visit, documented pain medications (opioids, nonsteroidal anti-inflammatory drugs [NSAIDs], neuropathic agents, etc) as well as patient demographics and comorbidities (sex, age, race, insurance coverage, and medical history) were recorded. The association between medication class and rate of prescription relative to sex was assessed in the population-weighted cohort, using propensity score matching to control for potential confounders. RESULTS: A total of 70,343 PLS patients were identified, including 36,313 (51.6%) women. After accounting for baseline demographics and comorbidity differences between male and female patients, men were 2 to 3 times more likely to be prescribed opioids (OR: 2.38; 95%CI: 2.30-2.46) and procedural interventions for PLS compared to the female cohort, while women utilized neuropathic agents (OR: 0.53; 95%CI: 0.51-0.55) and NSAIDs (OR: 0.68; 95%CI: 0.65-0.70) more frequently. CONCLUSION: Pain management in outpatients presenting with PLS-related pain consisted of higher opioid utilization for men and higher neuropathic agents and NSAIDs utilization for the female patients. CLINICAL RELEVANCE: This article is the first to shed light on disparities in pain management among patients with post-laminectomy syndrome.

Surgical management of myelocystocele: a single-center experience with long-term functional outcomes.

OBJECTIVE: Myelocystocele (MCC) is an uncommon form of skin-covered spinal dysraphism. The authors aimed to present long-term functional outcomes of patients treated for MCC with and without associated abnormalities of cloacal development (ACD). METHODS: All patients with MCC and at least one tethered cord release (TCR) treated at a single institution between 1982 and 2019 were retrospectively reviewed. Demographic, operative, and functional outcome data were analyzed. RESULTS: Of 51 children with MCC, 30 (58.8%) had MCC only and 21 (41.2%) had associated ACD (MCC/ACD). Thirty-two patients (62.7%) had undergone one TCR, while 19 patients (37.3%) had multiple TCRs. Urinary continence assessment was possible in 41 patients (80.4%), and bowel continence assessment was possible in 43 patients (84.3%) who were either older than 6 years or toilet trained. Although patients with MCC only were more likely to void volitionally (p = 0.0001), there was no difference in overall bladder continence based on the presence of ACD (p = 0.15) or the need for additional untethering procedures (p = 0.15). Those with MCC only were more likely to have overall bowel continence (p = 0.0001) and not require any management (p = 0.002), while those with MCC/ACD were more likely to have an ileostomy (p = 0.01). Of the 30 patients with MCC only, 29 (96.7%) were able to ambulate in the community. Of 21 patients with MCC/ACD, 14 (66.7%) were able to ambulate in the community, 5 (23.8%) were not ambulating, and 2 (9.5%) were therapeutic ambulators. A greater proportion of children in the MCC cohort were ambulating in the community (p = 0.01). There was no difference in community ambulation based on the number of TCRs (p > 0.99), but those with multiple TCRs were more likely to use braces (p = 0.01) and require lower-extremity orthopedic surgery (p = 0.01). CONCLUSIONS: Patients born with an MCC, with or without an associated ACD, attained long-term favorable outcomes in bladder and bowel continence and ambulation.

Anterior Cervical Discectomy and Fusion Versus Cervical Disc Arthroplasty: A Comparison of National Trends and Outcomes.

OBJECTIVE: Anterior cervical discectomy and fusion (ACDF) has been considered the standard treatment for degenerative cervical disc disease; however, recent trials have shown comparable outcomes with cervical disc arthroplasty (CDA). This study aimed to observe disparities in treatment paradigms of single-level cervical disc diseases and compare inpatient outcomes between procedures. METHODS: A retrospective cohort of patients treated for single-level cervical disc herniation or degeneration without myelopathy was queried from the Nationwide Inpatient Sample spanning 2012-2015. Multivariate logistic regression was performed to assess the effects of demographics, temporality of admission, and hospital characteristics on odds of receiving CDA versus ACDF. Propensity-score matching was performed to compare cost, length of stay (LOS), non-home discharge, and inpatient complications. RESULTS: In total, 1028 CDAs and 44,374 ACDFs were performed for single-level cervical disc disease during 2012-2015. Matched comparison showed that while non-home discharges were not different between CDA and ACDF (P = 0.248), patients who received CDA had a 0.19-day shorter LOS (P < 0.001) and $4694 greater total cost (P < 0.001). There were no statistically significant differences in inpatient complication rates. Multivariate analysis showed that patients in the 26th-50th percentile, 51st-75th percentile, and 76th-100th percentile of median household income had greater odds of CDA compared with patients in the 0-25th percentile (odds ratio [OR] 1.35, P = 0.003; OR 1.31, P = 0.013; OR 1.34, P = 0.011, respectively). Patients with private insurance had greater odds of receiving CDA compared with patients on Medicare (OR 1.91, P < 0.001). CONCLUSIONS: CDA was associated with shorter LOS but greater costs compared with ACDF. Patients with greater median income and private insurance were more likely to receive CDA.

Disparities in Rates of Fusions in Lumbar Disc Pathologies.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To identify disparities in surgical decision making for lumbar disc pathologies based on patient demographics, hospital characteristics, and temporal characteristics of admission. METHODS: A retrospective analysis of patients admitted for surgical intervention of disc herniation or degeneration was performed to observe the effect of demographic, hospital, and admission-related factors on the decision to perform an isolated decompression or decompression with single level fusion using the National Inpatient Sample. RESULTS: Of 84 953 patients with lumbar disc pathologies, 69 975 patients were treated electively, and 14 978 patients were treated nonelectively. Hispanic and Asian/Pacific Islander patients were less likely to receive a fusion for elective cases compared with White patients (odds ratio [OR] 0.88, P = .004; OR 0.70, P < .001, respectively). In elective cases, privately insured and self-paying patients were less likely to receive a fusion compared with Medicare patients (OR 0.83, P < .001; OR 0.66, P < .001, respectively), while this effect was limited to self-pay patients in nonelective cases (OR 0.44, P < .001). Urban teaching and nonteaching hospitals were less likely to perform fusions compared with rural hospitals in nonelective cases (OR 0.47, P < .001; OR 0.58, P < .001, respectively). Private for-profit hospitals were associated with higher rates of fusion in both elective and nonelective cases (OR 1.16, P = .003; OR 1.94, P < .001). CONCLUSION: This study illustrates disparities in the modality of surgical intervention for lumbar disc pathologies in terms of demographics, hospital characteristics, and temporal characteristics of admission. The development of more evidence-based guidelines is warranted to reduce variability seen in treatment regimens for these conditions.

Feasibility of Full Neuromuscular Blockade During Transcranial Motor Evoked Potential Monitoring of Neurosurgical Procedures.

BACKGROUND: Transcranial motor evoked potential (TcMEP) monitoring is conventionally performed during surgical procedures without or with minimal neuromuscular blockade (NMB) because of its potential interference with signal interpretation. However, full blockade offers increased anesthetic management options and facilitates surgery. Here, the feasibility of TcMEP interpretation was assessed during full NMB in adult neurosurgical patients. METHODS: Patients undergoing cervical or lumbar decompression received a rocuronium bolus producing 95% or greater blockade by qualitative train-of-four at the ulnar nerve. TcMEPs were recorded in bilateral thenar-hypothenar and abductor hallucis muscles. Adequacy of response for reliable signal interpretation was determined on the basis of repeatability and clarity, assessed by coefficient of variation and signal-to-noise ratio, respectively. RESULTS: All patients had at least 3 of 4 measurable TcMEP limb responses present during full NMB, and 70.8% of patients had measurable responses in all 4 limbs. In total, 82.2% of thenar-hypothenar responses and 62.8% of abductor hallucis responses were robust enough for reliable signal interpretation on the basis of clarity. In addition, 97.8% of thenar-hypothenar responses and 79.1% of abductor hallucis responses met the criteria for reliable signal interpretation on the basis of consistency. Patient demographics, medical comorbidities, and preoperative weakness were not predictive of absent responses during full NMB. CONCLUSIONS: TcMEP interpretation may be feasible under greater levels of NMB than previously considered, allowing for monitoring with greater degrees of muscle relaxation. Consideration for monitoring TcMEP during full NMB should be made on a case-by-case basis, and baseline responses without blockade may predict which patients will have adequate responses for interpretation.