Patterns of Acute Ischemic Stroke Treatment from 2010 to 2020: An Evolving Landscape in Stroke Management Following Thrombectomy Trials.

Background and Objectives: Population-based studies on stroke can help guide the care of patients with acute ischemic stroke (AIS) by providing health care communities with information regarding the current usage of stroke treatments. It remains unclear how rapidly new techniques, particularly endovascular stroke treatment (EST), are being adopted and whether there is any disparity in their availability. Although studies using the National Inpatient Sample (NIS) have been conducted, updated studies over a longer period may provide further insights. This study aimed to understand patterns of AIS treatment, discharge disposition, in-hospital mortality, and mean length of stay (LOS) for each modality from 2010 to 2020 using the NIS database. Methods: This retrospective longitudinal study was conducted using NIS data from 2010 to 2020. Patients were categorized into groups based on whether they received intravenous recombinant tissue plasminogen activator (rt-PA), EST, both rt-PA and EST (combined therapy), or supportive care alone. Demographic, socioeconomic, regional, insurance, and hospital data were also obtained. The primary outcome was the proportion of patients receiving each modality, whereas the secondary outcomes were in-hospital mortality, mean LOS, and discharge disposition. Results: The usage rates increased (p < 0.001) in all groups between 2010 and 2020 (rt-PA: 5.09% to 8.39%, EST: 0.31% to 4.40%, and rt-PA+EST: 0.46% to 1.09%). The highest increase in usage was observed for EST, with a thirteen-fold increase. Mortality decreased from 2010 to 2020 in all groups (rt-PA: 8.45% to 3.54%, EST: 25.22% to 12.50%, and rt-PA+EST: 21.12% in 2010 to 9.30%) (p < 0.001). Combination therapy demonstrated the greatest improvement, with an 11.2% reduction in absolute mortality. Mean LOS was reduced for patients who received rt-PA (6.8 to 4.8 days), EST (9.3 to 8.9 days), and combined therapy (10.0 to 8.3 days) (p < 0.001) over the study period. The proportion of patients discharged to home increased for rt-PA (29.01% to 41.85%), EST (14.13% to 17.70%), and combined therapy (12.89% to 24.29%) (p < 0.001). Overall, stroke treatment usage was higher among the higher income groups, regardless of race. Higher usage was also observed for Whites in the West and Hispanic ethnicities in the South and West. Regardless of income or treatment method, utilization rates were lower for Black patients. Utilization rates were lower for Black patients with Medicare, Medicaid, or self-pay than for White patients. Discussion: Our study demonstrated that endovascular stroke treatment continues to expand, leading to better outcomes for mortality, LOS, and home discharge. Despite these positive patterns, there are visible inequities across regions, income status, and races.

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.

Intraoperative cortical stimulation mapping with laryngeal electromyography for the localization of human laryngeal motor cortex.

OBJECTIVE: The objectives of this study were to describe the authors' clinical methodology and outcomes for mapping the laryngeal motor cortex (LMC) and define localization of the LMC in a cohort of neurosurgical patients undergoing intraoperative brain mapping. Because of mapping variability across patients, the authors aimed to define the probabilistic distribution of cortical sites that evoke laryngeal movement, as well as adjacent cortical somatotopic representations for the face (mouth), tongue, and hand. METHODS: Thirty-six patients underwent left (n = 18) or right (n = 18) craniotomy with asleep motor mapping. For each patient, electromyography (EMG) electrodes were placed in the face, tongue, and hand; a nerve integrity monitor (NIM) endotracheal tube with surface electrodes detected EMG activity from the bilateral vocal folds. After dense cortical stimulation was delivered throughout the sensorimotor cortex, motor responses were then mapped onto a three-dimensional reconstruction of the patient's cortical surfaces for location characterization of the evoked responses. Finally, stimulation sites were transformed into a two-dimensional coordinate system for probabilistic mapping of the stimulation site relative to the central sulcus and sylvian fissure. RESULTS: The authors found that the LMC was predominantly localized to a mid precentral gyrus region, dorsal to face representation and surrounding a transverse sulcus ventral to the hand knob. In 14 of 36 patients, the authors identified additional laryngeal responses located ventral to all orofacial representations, providing evidence for dual LMC representations. CONCLUSIONS: The authors determined the probabilistic distribution of the LMC. Cortical stimulation mapping with an NIM endotracheal tube is an easy and effective method for mapping the LMC and is simply integrated into the current neuromonitoring methods for brain mapping.

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.

The Re-Evaluation of Frailty in Predicting Complications after Long-Segment Spinal Fusion for Adult Spinal Deformity.

OBJECTIVE: To evaluate on a national scale how frailty status (stratified using the 5-item Modified Frailty Index (mFI-5)) affects the operative characteristics of and complications after long-segment spinal fusion (LSF) for adult spinal deformity (ASD). METHODS: Adults undergoing LSF of ≥3 vertebrae in the National Surgical Quality Improvement Program database years 2015-2020 were split into 2 cohorts: nonfrail with mFI = 0 or 1; frail with mFI ≥2. Demographics, operative characteristics, and 30-day complications were contrasted between the cohorts using the Student's t-test, the Fisher's exact test, or a multivariate analysis when appropriate. RESULTS: In the 340 LSF cases collected, 268 fell into the nonfrail cohort and 72 into the frail cohort. The frail cohort constituted a high rate of geriatric age (65.3% vs. 38.1%; P < 0.001), higher body mass index (32.9 ± 0.86 vs. 30.2 ± 0.39; P = 0.005), and more comorbidities in 9 of 14 measures. After surgery, the frail cohort experienced more urinary tract infections (odds ratio [OR], 3.33; confidence interval [CI], 1.01-10.94; P = 0.04). However, the frail cohort shared similarities with the nonfrail cohort in terms of length of stay (5.11 ± 0.51 vs. 6.01 ± 1.62 days; P = 0.60), home discharge (OR, 0.76; CI, 0.42-1.39; P = 0.38), readmission (OR, 2.45; CI, 0.87-6.89; P = 0.09), and overall rate of complications (OR, 0.89; CI, 0.50-1.59; P = 0.70). CONCLUSIONS: Despite trends found in past studies of ASD, this analysis showed that the frailty status of mFI ≥2 is a poor predictor of surgical and hospitalization course and overall complications in LSF when examined up to 30 days postoperatively.

Peroneal Nerve Repair with Cross-Bridge Ladder Technique: Parallel End-to-Side Neurorrhaphies.

Background Multiple nerve transfer techniques are used to treat patients with nerve injuries when a primary repair is not possible. These techniques are categorized to end-to-end, end-to-side, and side-to-side neurorrhaphy. Our study aims to explore the utility of the cross-bridge ladder technique (H-shaped), which has shown promising results in animal models and probably underutilized clinically. Methods Four patients with significant loss of ankle dorsiflexion were seen in the clinic and underwent evaluation, including electrodiagnostic studies. A cross-bridge ladder repair technique was used between the tibial nerve as the donor and the common peroneal nerve as the recipient via one or two nerve grafts coapted in parallel with end-to-side neurorrhaphies. Dorsiflexion strength was measured preoperatively using the Medical Research Council (MRC) grading system and at each postoperative follow-up appointment. Results All four patients had suffered persistent and severe foot drop (MRC of 0) following trauma that had occurred between 6 and 15 months preoperatively. Three of the four patients improved to an MRC of 2 several months postoperatively. The last patient had an immediate improvement to an MRC of 2 by his first month and had a complete recovery of ankle dorsiflexion within 4 months from surgery. Conclusion We demonstrate the utility and clinical outcomes of the cross-bridge ladder technique in patients with persistent and prolonged foot drop following trauma. Both early and late recovery were seen while all patients regained motor function, with some patients continuing to improve up to the most recent follow-up. IRB Approval: Obtained 2013-1411-CP005.

Variant Sciatic Nerve Anatomy in Relation to the Piriformis Muscle on Magnetic Resonance Neurography: A Potential Etiology for Extraspinal Sciatica.

OBJECTIVE: To assess the prevalence and clinical implications of variant sciatic nerve anatomy in relation to the piriformis muscle on magnetic resonance neurography (MRN), in patients with lumbosacral neuropathic symptoms. MATERIALS AND METHODS: In this retrospective single-center study, 254 sciatic nerves, from 127 patients with clinical and imaging findings compatible with extra-spinal sciatica on MRN between 2003 and 2013, were evaluated for the presence and type of variant sciatic nerves, split sciatic nerve, abnormal T2-signal hyperintensity, asymmetric piriformis size and increased nerve caliber, and summarized using descriptive statistics. Two-tailed chi-square tests were performed to compare the anatomical variant type and clinical symptoms between imaging and clinical characteristics. RESULTS: Sixty-four variant sciatic nerves were identified with an equal number of right and left variants. Bilateral variants were noted in 15 cases. Abnormal T2-signal hyperintensity was seen significantly more often in variant compared to conventional anatomy (40/64 vs. 82/190; p = 0.01). A sciatic nerve split was seen significantly more often in variant compared to conventional anatomy (56/64 vs. 20/190; p < 0.0001). Increased nerve caliber, abnormal T2-signal hyperintensity, and asymmetric piriformis size were significantly associated with the clinically symptomatic side compared to the asymptomatic side (98:2, 98:2, and 97:3, respectively; p < 0.0001 for all). Clinical symptoms were correlated with variant compared to conventional sciatic nerve anatomy (64% vs. 46%; p = 0.01). CONCLUSION: Variant sciatic nerve anatomy, in relation to the piriformis muscle, is frequently identified with MRN and is more likely to be associated with nerve signal changes and symptomatology.

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.

Interactive Effects of Molecular, Therapeutic, and Patient Factors on Outcome of Diffuse Low-Grade Glioma.

PURPOSE: In patients with diffuse low-grade glioma (LGG), the extent of surgical tumor resection (EOR) has a controversial role, in part because a randomized clinical trial with different levels of EOR is not feasible. METHODS: In a 20-year retrospective cohort of 392 patients with IDH-mutant grade 2 glioma, we analyzed the combined effects of volumetric EOR and molecular and clinical factors on overall survival (OS) and progression-free survival by recursive partitioning analysis. The OS results were validated in two external cohorts (n = 365). Propensity score analysis of the combined cohorts (n = 757) was used to mimic a randomized clinical trial with varying levels of EOR. RESULTS: Recursive partitioning analysis identified three survival risk groups. Median OS was shortest in two subsets of patients with astrocytoma: those with postoperative tumor volume (TV) > 4.6 mL and those with preoperative TV > 43.1 mL and postoperative TV ≤ 4.6 mL. Intermediate OS was seen in patients with astrocytoma who had chemotherapy with preoperative TV ≤ 43.1 mL and postoperative TV ≤ 4.6 mL in addition to oligodendroglioma patients with either preoperative TV > 43.1 mL and residual TV ≤ 4.6 mL or postoperative residual volume > 4.6 mL. Longest OS was seen in astrocytoma patients with preoperative TV ≤ 43.1 mL and postoperative TV ≤ 4.6 mL who received no chemotherapy and oligodendroglioma patients with preoperative TV ≤ 43.1 mL and postoperative TV ≤ 4.6 mL. EOR ≥ 75% improved survival outcomes, as shown by propensity score analysis. CONCLUSION: Across both subtypes of LGG, EOR beginning at 75% improves OS while beginning at 80% improves progression-free survival. Nonetheless, maximal resection with preservation of neurological function remains the treatment goal. Our findings have implications for surgical strategies for LGGs, particularly oligodendroglioma.

Short segment rib resection to mitigate risk of pleural violation during retropleural lateral thoracic interbody fusion.

It can be difficult to avoid violating the pleura during the retropleural approach to the thoracolumbar spine. In this video, the authors resect a short segment of rib to allow more room for pleural dissection during a minimally invasive (MIS) lateral retropleural approach. After a lateral MIS skin incision, the rib is dissected and removed, clearly identifying the retropleural space. The curvature of the rib can then be followed, decreasing the risk of pleural violation. The pleura can then be mobilized ventrally until the spine is accessed. Managing the diaphragm is also illustrated by separating the fibers without a traditional cut through the muscle. The video can be found here: https://stream.cadmore.media/r10.3171/2022.3.FOCVID21138.

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.

Machine learning for predicting hemorrhage in pediatric patients with brain arteriovenous malformation.

OBJECTIVE: Ruptured brain arteriovenous malformations (bAVMs) in a child are associated with substantial morbidity and mortality. Prior studies investigating predictors of hemorrhagic presentation of a bAVM during childhood are limited. Machine learning (ML), which has high predictive accuracy when applied to large data sets, can be a useful adjunct for predicting hemorrhagic presentation. The goal of this study was to use ML in conjunction with a traditional regression approach to identify predictors of hemorrhagic presentation in pediatric patients based on a retrospective cohort study design. METHODS: Using data obtained from 186 pediatric patients over a 19-year study period, the authors implemented three ML algorithms (random forest models, gradient boosted decision trees, and AdaBoost) to identify features that were most important for predicting hemorrhagic presentation. Additionally, logistic regression analysis was used to ascertain significant predictors of hemorrhagic presentation as a comparison. RESULTS: All three ML models were consistent in identifying bAVM size and patient age at presentation as the two most important factors for predicting hemorrhagic presentation. Age at presentation was not identified as a significant predictor of hemorrhagic presentation in multivariable logistic regression. Gradient boosted decision trees/AdaBoost and random forest models identified bAVM location and a concurrent arterial aneurysm as the third most important factors, respectively. Finally, logistic regression identified a left-sided bAVM, small bAVM size, and the presence of a concurrent arterial aneurysm as significant risk factors for hemorrhagic presentation. CONCLUSIONS: By using an ML approach, the authors found predictors of hemorrhagic presentation that were not identified using a conventional regression approach.

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.

Sexual dimorphism of the immune system predicts clinical outcomes in glioblastoma immunotherapy: A systematic review and meta-analysis.

Background: Biological differences based on sex have been documented throughout the scientific literature. Glioblastoma (GBM), the most common primary malignant brain tumor in adults, has a male sex incidence bias, however, no clinical trial data examining differential effects of treatment between sexes currently exists. Method: We analyzed genomic data, as well as clinical trials, to delineate the effect of sex on the immune system and GBM outcome following immunotherapy. Results: We found that in general females possess enriched immunological signatures on gene set enrichment analysis, which also stratified patient survival when delineated by sex. Female GBM patients treated with immunotherapy had a statistically significant survival advantage at the 1-year compared to males (relative risk [RR] = 1.15; P = .0241). This effect was even more pronounced in vaccine-based immunotherapy (RR = 1.29; P = .0158). Conclusions: Our study shows a meaningful difference in the immunobiology between males and females that also influences the overall response to immunotherapy in the setting of GBM.

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.

External Review and Validation of a Spinal Epidural Abscess Predictive Score for Clinical Failure.

BACKGROUND: Spinal epidural abscess (SEA) is a rare but serious pathology that may result in delayed neurologic injury despite treatment with antibiotic therapy or surgery. Given this, the development of predictive scores for risk stratification has value in clinical decision making; however, external validation is necessary to understand their generalizability and reliability. METHODS: A retrospective review was conducted of all patients presenting with SEA at a single institution. Patients were reviewed and graded according to the proposed SEA predictive score by Baum et al. Clinical failure was defined as documented laboratory or radiographic progression requiring surgical intervention, increased deformity requiring surgical intervention, or repeat surgical intervention if prior surgical intervention was undertaken as the initial treatment strategy. Brier score and receiver operating characteristic were used to calculate reliability. RESULTS: There were 224 patients presenting with primary spinal infections with associated SEA. Of these, 209 patients had no history of intravenous drug abuse. Clinical failure was demonstrated in 52 of 209 patients (24.9%). Antibiotic treatment alone compared with antibiotic therapy and surgical treatment on initial presentation was found to have a significantly greater chance of clinical failure (odds ratio = 3.0930, P = 0.01). The proposed epidural abscess prediction score did not correlate with clinical outcomes with a Brier score of 0.229 and receiver operating characteristic area under the curve of 0.5944. CONCLUSIONS: The proposed risk stratification scale for patients was not correlated with risk of clinical failure. Additionally, patients treated with antibiotics and surgical intervention on initial presentation had a significantly lower clinical failure rate.