Surgical site infection rates in open versus endoscopic lumbar spinal decompression surgery: A retrospective cohort study.

Background: Lumbar decompression is a commonly performed procedure for the operative management of several degenerative lumbar spinal pathologies. Although open approaches are considered the traditional method, endoscopic techniques represent a relatively novel, less-invasive option to achieve neural element decompression. Here within, we examine if the use of endoscopic techniques decreases the risk of post operative infections. Methods: We performed a retrospective cohort analysis to directly compare patients who underwent either open or endoscopic lumbar decompression at a single institution. Rates of postoperative outcomes such as surgical site infection, hospital length of stay, estimated blood loss, and others were compared between the two treatment groups. A multivariate logistic regression model was constructed using patient comorbidities and procedural characteristics to identify the risk factors for surgical site infection. Results: 150 patients were identified as undergoing lumbar spine decompression surgeries that met inclusion criteria for the study, of whom 108 (72.0%) underwent open and 61 (28.0%) underwent endoscopic approaches. Unpaired analysis revealed positive associations between operative duration, estimated blood loss, drain placement rates. Multivariate logistic regression did not reveal an association between surgical approach (open versus endoscopic) and the development of surgical site infection. Conclusions: Surgical site infections following endoscopic lumbar spine decompression are relatively uncommon, however, after adjusting for baseline differences between patient populations, surgical approach does not independently predict the development of postoperative infection.

Development of a Predictive Model for Persistent Instability Following Conservative Management of Type II Odontoid Fractures.

BACKGROUND: Odontoid fractures are common cervical spine fractures; however, significant controversy exists regarding their treatment. Risk factors for failure of conservative therapy have been identified, although no predictive risk score has been developed to aid in decision-making. METHODS: A retrospective review was conducted of all patients evaluated at a level 1 trauma center. Patients identified with type II odontoid fractures as classified by the D'Alonzo Classification system who were treated with external orthosis were included in analysis. Patients were considered to have failed conservative therapy if they were offered surgical intervention. A machine learning method (Risk-SLIM) was then utilized to create a risk stratification score based on risk factors to identify patients at high risk for requiring surgical intervention due to persistent instability. RESULTS: A total of 138 patients were identified as presenting with type II odontoid fractures that were treated conservatively; 38 patients were offered surgery for persistent instability. The Odontoid Fracture Predictive Model (OFPM) was created using a machine learning algorithm with a 5-fold cross validation area under the curve of 0.7389 (95% CI: 0.671 to 0.808). Predictive factors were found to include fracture displacement, displacement greater than 5 mm, comminution at the fracture base, and history of smoking. The probability of persistent instability was <5% with a score of 0 and 88% with a score of 5. CONCLUSIONS: The OFPM model is a unique, quick, and accurate tool to assist in clinical decision-making in patients with type II odontoid fractures. External validation is necessary to evaluate the validity of these findings.

Radiographic Outcomes Following Various Treatment Options of Thoracolumbar Burst Fractures.

BACKGROUND: Thoracolumbar burst fractures include a spectrum of treatment options ranging from conservative management to multilevel fusion with or without corpectomy. Given the variability of treatment options, consideration of radiographic outcomes with different treatment modalities should be a critical consideration in management. METHODS: A retrospective review was conducted evaluating all patients presenting with spine fractures over a 7-year period. Inclusion criteria were limited to adults with acute, traumatic burst fractures of the thoracolumbar joint levels T11-L2. Patients were categorized by nonoperative management, short-segment fusion, multilevel fusion without anterior column reconstruction, and corpectomy. Radiographic information collected included kyphotic angle (KA), Cobb angle (CA), and Gardner angle (GA). RESULTS: In total, 117 patients (70.5%) were successfully treated nonoperatively, 4 (2.4%) underwent short-segment fusion, 28 (16.9%) underwent multilevel fusion, and 12 (7.2%) underwent corpectomy. All nonoperative patients demonstrated significantly worse kyphosis at 1-year follow-up as measured by KA, CA, and GA (P < 0.001). Patients undergoing corpectomy had the largest improvement in kyphosis with an average improvement of 14.1° on KA, 8.1° on CA, and 11.0° on GA (P < 0.001, P = 0.098, and P = 0.004, respectively). In comparison, patients undergoing multilevel fusion showed an average improvement of 2.6°, 2.7°, and 3.3° of correction on GA, CA, and KA, respectively (P > 0.05). CONCLUSIONS: Nonoperative and short-segment fusion burst fracture patients demonstrated significantly worse kyphosis at 1-year follow-up. Patients undergoing corpectomy demonstrated a superior improvement in kyphotic correction compared with those undergoing multilevel fusion and short-segment fusion.

Socioeconomic Disparities in Outcomes Following Conservative Treatment of Spinal Epidural Abscesses.

BACKGROUND: Primary spinal epidural abscess (SEA) is a rare but serious pathology that may result in severe neurologic injury. While certain literature has identified medical risk factors for failure of conservative therapy, no current evidence has been published regarding socioeconomic risk factors associated with failure of medical therapy. METHODS: A retrospective review was conducted of patients presenting with SEA from primary spinal infections. Patients presenting with magnetic resonance imaging evidence of SEA treated conservatively in the absence of neurologic deficits were included. Baseline clinical and socioeconomic characteristics were collected. Failure of medical management was defined as requiring surgical intervention despite maximal medical therapy due to the development of neurologic deficits or clinically significant deformity. RESULTS: A total of 150 patients were identified as presenting with magnetic resonance imaging evidence of SEAs without evidence of neurologic deficit. Of these patients, 42 required surgical intervention compared with 108 whose infection was successfully treated with medical therapy alone. Estimated average annual income was $64,746 vs $62,615 in those who successfully cleared their infection with medical management without requiring surgery, which was not statistically significant (P = 0.5). Insured patients were 5 times more likely to be successfully treated with antibiotics alone compared with uninsured patients (OR = 5.83, P = 0.008). Payer type, employment status, and incarceration status were not associated with failure of conservative therapy. CONCLUSIONS: In the treatment of primary SEA, absence of medical insurance is associated with failure of medical management. Payer status, employment status, average salary, and incarceration are not significant risk factors for failure of conservative management.

Lateral femoral cutaneous nerve transposition.

Lateral femoral cutaneous neuropathy, also known as meralgia paresthetica, is a pathology commonly encountered by neurosurgeons. Symptoms include numbness, tingling, and burning pain over the anterolateral thigh due to impingement on the lateral femoral cutaneous nerve (LFCN). Surgical treatment has traditionally involved nerve release or neurectomy. LFCN transposition is a relatively new approach that can provide excellent symptomatic relief. In this video, the authors highlight key operative techniques to ensure easy identification, adequate decompression, and transposition of the nerve. Key steps include ultrasound-guided wire localization, superficial decompression, opening of the inguinal ligament, deep decompression, and medial transposition. The video can be found here: https://stream.cadmore.media/r10.3171/2022.10.FOCVID2289.

Transient internuclear ophthalmoplegia following anterior cervical discectomy and fusion.

Background: Internuclear ophthalmoplegia (INO), characterized by impaired horizontal eye movement, occurred following an anterior cervical discectomy/fusions (ACDF). Case Description: A 48-year-old female with recurrent C5-6 foraminal stenosis presented with right C6 radiculopathy. She underwent a C5-6 ACDF, but postoperatively, complained of diplopia. Her examination revealed left-eye INO. Notably, the brain magnetic resonance imaging showed no significant radiological findings. The patient's diplopia and INO resolved spontaneously on postoperative day 2 and never recurred. Conclusion: Ocular complications following anterior cervical spine procedures are rare. Here, a 48-year-old female developed left eye INO following an ACDF that spontaneously resolved on postoperative day 2.

Spinal fractures in the setting of diffuse idiopathic skeletal hyperostosis conservatively treated via orthosis: illustrative cases.

BACKGROUND: Fractures in patients with diffuse idiopathic skeletal hyperostosis (DISH) are considered highly unstable injuries with high risk for neurological injury. Surgical intervention is the standard of care for these patients to avoid secondary spinal cord injuries. Despite this, certain cases may necessitate a nonoperative approach. Herein within, the authors describe three cases of cervical, thoracic, and lumbar fractures in the setting of DISH that were successfully treated via orthosis. OBSERVATIONS: The authors present three cases of fractures in patients with DISH. A 74-year-old female diagnosed with an acute fracture of a flowing anterior osteophyte at C6-C7 treated with a cervical orthosis. A 78-year-old male with an anterior fracture of the ankylosed T7-T8 vertebrae managed with a Jewett hyperextension brace. Finally, a 57-year-old male with an L1-L2 disc space fracture treated with a thoraco-lumbo-sacral orthosis. All patients recovered successfully. LESSONS: In certain cases, conservative treatment may be more appropriate for fractures in the setting of DISH as an alternative to the surgical standard of care. Most fractures in the setting of DISH are unstable, therefore it is necessary to manage these patients on a case-by-case basis.

Academics versus the Internet: Evaluating the readability of patient education materials for cerebrovascular conditions from major academic centers.

Background: Health literacy profoundly impacts patient outcomes as patients with decreased health literacy are less likely to understand their illness and adhere to treatment regimens. Patient education materials supplement in-person patient education, especially in cerebrovascular diseases that may require a multidisciplinary care team. This study aims to assess the readability of online patient education materials related to cerebrovascular diseases and to contrast the readability of those materials produced by academic institutions with those of non-academic sources. Methods: The readability of online patient education materials was analyzed using Flesch-Kincaid Grade Level (FKGL) and Flesch Reading Ease (FRE) assessments. Readability of academic-based online patient education materials was compared to nonacademic online patient education materials. Online patient education materials from 20 academic institutions and five sources from the web were included in the analysis. Results: Overall median FKGL for neurovascular-related patient online education documents was 11.9 (95% CI: 10.8-13.1), reflecting that they are written at a 12th grade level, while the median FRE was 40.6 (95% CI: 34.1-47.1), indicating a rating as "difficult" to read. When comparing academic-based online patient education materials to other internet sources, there was no significant difference in FRE and FKGL scores (P = 0.63 and P = 0.26 for FKGL and FRE, respectively). Conclusion: This study demonstrates that online patient education materials pertaining to cerebrovascular diseases from major academic centers and other nonacademic internet sites are difficult to understand and written at levels significantly higher than that recommended by national agencies. Both academic and nonacademic sources reflect this finding equally. Further study and implementation are warranted to investigate how improvements can be made.

Management of failed Chiari decompression and intrasyringeal hemorrhage in Noonan syndrome: illustrative cases.

BACKGROUND: Noonan syndrome (NS) is a rare genetic RASopathy with multisystem implications. The disorder is typically characterized by short stature, distinctive facial features, intellectual disability, developmental delay, chest deformity, and congenital heart disease. NS may be inherited or arise secondary to spontaneous mutations of genes in the Ras/mitogen activated protein kinase signaling pathways. OBSERVATIONS: Numerous case reports exist detailing the association between NS and Chiari I malformation (CM-I), although this relationship has not been fully established. Patients with NS who present with CM-I requiring operation have shown high rates reoperation for failed decompression. The authors reported two patients with NS, CM-I, and syringomyelia who had prior posterior fossa decompressions without syrinx improvement. Both patients received reoperation with successful outcomes. LESSONS: The authors highlighted the association between NS and CM-I and raised awareness that patients with these disorders may be at higher risk for failed posterior fossa decompression, necessitating reoperation.

Outcomes following conservative treatment of extension fractures in the setting of diffuse idiopathic skeletal hyperostosis: is external orthosis alone a reasonable option?

OBJECTIVE: Extension fractures in the setting of diffuse idiopathic skeletal hyperostosis (DISH) represent highly unstable injuries. As a result, these fractures are most frequently treated with immediate surgical fixation to limit any potential risk of associated neurological injury. Although this represents the standard of care, patients with significant comorbidities, advanced age, or medical instability may not be surgical candidates. In this paper, the authors evaluated a series of patients with extension DISH fractures who were treated with orthosis alone and evaluated their outcomes. METHODS: A retrospective review from 2015 to 2022 was conducted at a large level 1 trauma center. Patients with extension-type DISH fractures without neurological deficits were identified. All patients were treated conservatively with orthosis alone. Baseline patient characteristics and adverse outcomes are reported. RESULTS: Twenty-seven patients were identified as presenting with extension fractures associated with DISH without neurological deficit. Of these, 22 patients had complete follow-up on final chart review. Of these 22 patients, 21 (95.5%) were treated successfully with external orthosis. One patient (4.5%) who was noncompliant with the brace had an acute spinal cord injury 1 month after presentation, requiring immediate surgical fixation and decompression. No other complications, including skin breakdown or pressure ulcers related to bracing, were reported. CONCLUSIONS: Treatment of extension-type DISH fractures may be a reasonable option for patients who are not candidates for safe surgical intervention; however, a risk of neurological injury secondary to delayed instability remains, particularly if patients are noncompliant with the bracing regimen. This risk should be balanced against the high complication rate and potential mortality associated with surgical intervention in this patient population.

Management of Craniocervical Instability in Spondyloepiphyseal Dysplasia Congenita: Assessment of Literature and Presentation of Two Cases.

Spondyloepiphyseal dysplasia congenita (SEDC) is a rare autosomal dominant skeletal dysplasia resulting in impairment of type II collagen function. Phenotypically, this results in various skeletal, ligamentous, ocular, and otologic abnormalities. Platyspondyly, scoliosis, ligamental laxity, and odontoid hypoplasia are common, resulting in myelopathy in a high number of patients due to atlantoaxial instability. Despite patients undergoing surgical fixation, complication rates such as nonunion have been reported to be high. Here within, we present two patients treated with occipitocervical fusion for atlantoaxial instability and early symptoms of progressive myelopathy. We additionally provide a detailed review of the literature to inform practitioners of the spinal manifestations and clinical considerations in SEDC.

Creation and validation of a predictive model for lumbar synovial cyst recurrence following decompression without fusion.

OBJECTIVE: Lumbar synovial cysts (LSCs) represent a relatively rare clinical pathology that may result in radiculopathy or neurogenic claudication. Because of the potential for recurrence of these cysts, some authors advocate for segmental fusion, as opposed to decompression alone, as a way to eliminate the risk for recurrence. The objective of this study was to create a predictive score for synovial cyst recurrence following decompression without fusion. METHODS: A retrospective chart review was completed of all patients evaluated at a single center over 20 years who were found to have symptomatic LSCs requiring intervention. Only patients undergoing decompression without fusion were included in the analysis. Following this review, baseline characteristics were obtained as well as radiological information. A machine learning method (risk-calibrated supersparse linear integer model) was then used to create a risk stratification score to identify patients at high risk for symptomatic cyst recurrence requiring repeat surgical intervention. Following the creation of this model, a fivefold cross-validation was completed. RESULTS: In total, 89 patients were identified who had complete radiological information. Of these 89 patients, 11 developed cyst recurrence requiring reoperation. The Lumbar Synovial Cyst Score was then created with an area under the curve of 0.83 and calibration error of 11.0%. Factors predictive of recurrence were found to include facet inclination angle > 45°, canal stenosis > 50%, T2 joint space hyperintensity, and presence of grade I spondylolisthesis. The probability of cyst recurrence ranged from < 5% for a score of 2 or less to > 88% for a score of 7. CONCLUSIONS: The Lumbar Synovial Cyst Score model is a quick and accurate tool to assist in clinical decision-making in the treatment of LSCs.

Evaluation of Endoscopic Versus Open Lumbar Discectomy: A Multi-Center Retrospective Review Utilizing the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) Database.

INTRODUCTION: Endoscopic techniques in spine surgery continue to gain popularity due to their potential for decreased blood loss and post-operative pain. However, limited studies have evaluated these techniques within the United States. Additionally, given the limited number of practitioners with experience in endoscopy, most current studies are limited by a lack of heterogeneity. METHODS: The American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) database was queried to evaluate the effect of endoscopic surgery on adverse events. Current Procedural Terminology (CPT) codes for open discectomy were compared with the relevant CPT codes for endoscopic lumbar discectomy. Baseline patient characteristics and adverse outcomes were then compared.  Results: A total of 38,497 single-level lumbar discectomies were identified and included. Of these, 175 patients undergoing endoscopic discectomy were compared with 38,322 patients undergoing open discectomy. Endoscopic discectomy demonstrated a shorter operative time of 88.6 minutes than 92.1 minutes in the open group. However, this was not significant (p=0.08). Patients in the endoscopic group demonstrated a shorter total length of stay of 0.81 days vs 1.15 days (p=0.014). Total adverse events were lower in the endoscopic group at 0.6% vs 3.4% in the open group (p=0.03). CONCLUSION:  Endoscopic discectomy demonstrated a significantly lower rate of adverse events and shorter total length of stay than open discectomy. Further research is necessary over time to evaluate larger patient populations as this technology is more rapidly incorporated.

Candida Shunt Infection Causing Arachnoiditis and Hydrocephalus: A Case Report.

Arachnoiditis is a relatively rare condition and can result in long-term chronic and debilitating complications if not diagnosed early and treated properly. However, diagnosis of arachnoiditis is rare and knowledge of potential causes of this condition is still sparse. Current known causes of arachnoiditis include infections, trauma, spinal tumors, and iatrogenic causes induced via neurological interventions. Here, we present a case of a 65-year-old female who presented with arachnoiditis caused by Candida albicans infection from a contaminated ventriculoperitoneal (VP) shunt, placed following the development of hydrocephalus from subarachnoid hemorrhage. During her initial assessment, the possibility of arachnoiditis was raised after spinal magnetic resonance imaging (MRI) due to leg weakness and spasms with bladder dysfunction. However, further workup was not pursued after a normal spinal angiogram and lack of constitutional symptoms. She presented six months later with symptoms of fever and lower abdominal pain. She was diagnosed with fungal arachnoiditis after a computerized tomography (CT) of the abdomen showed thickening of the fascia around the shunt catheter and fluid collections near the tip of the shunt in the abdominal cavity after hospitalization. The diagnosis was made after an ultrasound-guided tap of the same area revealed budding yeast and cerebrospinal fluid (CSF) showed growths of Candida albicans. Her shunt was removed, and she received intravenous (IV) antifungals and recovered. MRI should be considered with clinical presentations that are characteristic of arachnoiditis. Symptoms from fungal infections are usually dramatic; however, in some instances as in this case, they may follow a more progressive course. The patient should be extensively evaluated for infection, especially fungal, in interventions involving device placement even when minimally, but persistently, symptomatic.

Development and Validation of a Predictive Model for Failure of Medical Management in Spinal Epidural Abscesses.

BACKGROUND: The optimal management of spinal epidural abscesses (SEA) secondary to primary spinal infections has demonstrated large variability in the literature. Although some literature suggests a high rate of neurological deterioration, others suggest failure of medical management is uncommon. OBJECTIVE: To develop a predictive model to evaluate the likelihood of failure of medical therapy in the setting of SEA. METHODS: A retrospective review was conducted of all patients presenting with SEA from primary spinal infections. Patients presenting with MRI evidence of SEA without neurological deficits were included. Failure of medical management was defined as requiring surgical intervention over 72 hours after the initiation of antibiotics. A machine learning method (Risk-Calibrated Supersparse Linear Integer Model) was used to create a risk stratification score to identify patients at high risk for requiring surgical intervention. RESULTS: In total, 159 patients were identified as presenting with MRI findings of SEA without evidence of neurological deficit. Of these patients, 50 required delayed surgery compared with 109 whose infection were successfully treated with surgical intervention. The Spinal Epidural Abscess Predictive Score was created using a machine learning model with an area under the curve of 0.8043 with calibration error of 14.7%. Factors included active malignancy, spondylodiscitis, organism identification, blood cultures, and sex. The probability of failure of medical management ranged from <5% for a score of 2 or less and >95% for a score of 7 or more. CONCLUSION: The Spinal Epidural Abscess Predictive Score model is a quick and accurate tool to assist in clinical decision-making in SEA.

Radiographic Outcomes of Thoracolumbar AOSpine A3 and A4 Fractures Treated With External Bracing.

Background The treatment of AOSpine A3 and A4 fractures is controversial with no consensus regarding their management in the absence of neurologic deficits. While conservative management with spinal orthosis is a reasonable treatment option, it is believed to run the risk of progressive segmental kyphosis. Methodology A retrospective chart review was conducted of all patients undergoing treatment for thoracolumbar burst fractures from T11 to L2. Patients treated with conservative management with lumbar orthosis were included. Upright radiographs at the time of presentation and the one-year follow-up were compared. Results In total, 112 patients were evaluated as being treated with thoracolumbar orthosis. Of these, 61 patients presented with A3 fractures compared with 51 who presented with A4 fractures. Of these, two patients in each group failed conservative management and required surgical intervention. At the one-year follow-up, A3 fractures demonstrated an average change in Cobb angle of 4.1 degrees compared with 6.1 degrees in A4 fractures (p = 0.021). In addition, A4 fractures demonstrated a significantly worse kyphotic angle and Gardner angle at the one-year follow-up (p = 0.05 and p = 0.026, respectively). Conclusions A3 and A4 fractures can be safely treated with orthosis with overall low rates for failure; however, A4 fractures result in significantly worse segmental kyphosis at the one-year follow-up.