Healthcare disparities in pediatric neurosurgery: a scoping review.

OBJECTIVE: The aim of this scoping review was to identify relevant articles that have contributed to the body of knowledge describing pediatric neurosurgical healthcare disparities. Identifying healthcare disparities in pediatric neurosurgery is essential to understanding how to best provide care for this unique patient population. Although it is undoubtedly important to increase the knowledge of pediatric neurosurgical healthcare disparities, it is also important to understand the current state of the literature. METHODS: This scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. The search terms "pediatric neurosurgical disparities" and "pediatric neurosurgical inequities" were entered into the following databases: PubMed, Scopus, and Embase. RESULTS: The initial database search returned a total of 366 results from the PubMed, Embase, and Scopus databases. One hundred thirty-seven duplicates were removed, and the remaining articles were screened by title and abstract. Articles were excluded on the basis of the inclusion and exclusion criteria. Of the remaining 229 articles, 168 were excluded. Sixty-one full-text articles were then examined for eligibility, and 28 did not reach the specified inclusion and exclusion criteria. The remaining 33 articles were included for final review. The results of the reviewed studies were stratified on the basis of disparity type. CONCLUSIONS: Although there has been an increase in the number of publications discussing pediatric neurosurgical healthcare disparities within the last decade, there still remains a scarcity of information regarding healthcare disparities in neurosurgery. Furthermore, less information exists that specifically addresses healthcare disparities in the pediatric population.

A Novel Construct to Treat Destructive Osteomyelitis of the Lumbar Spine in a Patient With Pre-existing Paraplegia.

Treatment for vertebral osteomyelitis varies depending on the extent of pathology and includes both medical and surgical approaches. Pathogen-directed antibiotic therapy is often the first-line treatment, however, refractory cases or those with sepsis, segmental instability, or epidural abscess may be candidates for surgical treatment. Patients with extensive bony destruction often require a corpectomy with the placement of a cage for anterior column reconstruction. In this case report, we describe a patient with a complex past medical history, including paraplegia secondary to a spinal cord infarct, chronic urinary tract infections (UTIs), acute myeloid leukemia (AML), and decubitus ulcers who presented with increasing back pain and imaging demonstrating vertebral osteomyelitis and diskitis with associated epidural abscess extending from L1-L4 vertebral bodies and significant osseous destruction of the L3 and L5 vertebral bodies. A multistage surgical approach was performed involving an initial laminectomy, wound wash-out, and bony debridement followed by an additional wound wash-out and then a posterior approach for corpectomy and graft placement accomplished by tying off the thecal sac. In rare cases where patients present with complete neurologic injury and extensive destructive osteomyelitis, a posterior approach for corpectomy and stabilization may be an option.

Robotic guidance platform for laser interstitial thermal ablation and stereotactic needle biopsies: a single center experience.

While laser ablation has become an increasingly important tool in the neurosurgical oncologist's armamentarium, deep seated lesions, and those located near critical structures require utmost accuracy during stereotactic laser catheter placement. Robotic devices have evolved significantly over the past two decades becoming an accurate and safe tool for stereotactic neurosurgery. Here, we present our single center experience with the MedTech ROSA ONE Brain robot for robotic guidance in laser interstitial thermal therapy (LITT) and stereotactic biopsies. We retrospectively analyzed the first 70 consecutive patients treated with ROSA device at a single academic medical center. Forty-three patients received needle biopsy immediately followed by LITT with the catheter placed with robotic guidance and 27 received stereotactic needle biopsy alone. All the procedures were performed frameless with skull bone fiducials for registration. We report data regarding intraoperative details, mortality and morbidity, diagnostic yield and lesion characteristics on MRI. Also, we describe the surgical workflow for both procedures. The mean age was 60.3 ± 15 years. The diagnostic yield was positive in 98.5% (n = 69). Sixty-three biopsies (90%) were supratentorial and seven (10%) were infratentorial. Gliomas represented 54.3% of the patients (n = 38). There were two postoperative deaths (2.8%). No permanent morbidity related to surgery were observed. We did not find intraoperative technical problems with the device. There was no need to reposition the needle after the initial placement. Stereotactic robotic guided placement of laser ablation catheters and biopsy needles is safe, accurate, and can be implemented into a neurosurgical workflow.

Ninety-day complication, revision, and readmission rates for current-generation robot-assisted thoracolumbar spinal fusion surgery: results of a multicenter case series.

OBJECTIVE: Robotics is a major area for research and development in spine surgery. The high accuracy of robot-assisted placement of thoracolumbar pedicle screws is documented in the literature. The authors present the largest case series to date evaluating 90-day complication, revision, and readmission rates for robot-assisted spine surgery using the current generation of robotic guidance systems. METHODS: An analysis of a retrospective, multicenter database of open and minimally invasive thoracolumbar instrumented fusion surgeries using the Mazor X or Mazor X Stealth Edition robotic guidance systems was performed. Patients 18 years of age or older and undergoing primary or revision surgery for degenerative spinal conditions were included. Descriptive statistics were used to calculate rates of malpositioned screws requiring revision, as well as overall complication, revision, and readmission rates within 90 days. RESULTS: In total, 799 surgical cases (Mazor X: 48.81%; Mazor X Stealth Edition: 51.19%) were evaluated, involving robot-assisted placement of 4838 pedicle screws. The overall intraoperative complication rate was 3.13%. No intraoperative implant-related complications were encountered. Postoperatively, 129 patients suffered a total of 146 complications by 90 days, representing an incidence of 16.1%. The rate of an unrecognized malpositioned screw resulting in a new postoperative radiculopathy requiring revision surgery was 0.63% (5 cases). Medical and pain-related complications unrelated to hardware placement accounted for the bulk of postoperative complications within 90 days. The overall surgical revision rate at 90 days was 6.63% with 7 implant-related revisions, representing an implant-related revision rate of 0.88%. The 90-day readmission rate was 7.13% with 2 implant-related readmissions, representing an implant-related readmission rate of 0.25% of cases. CONCLUSIONS: The results of this multicenter case series and literature review suggest current-generation robotic guidance systems are associated with low rates of intraoperative and postoperative implant-related complications, revisions, and readmissions at 90 days. Future outcomes-based studies are necessary to evaluate complication, revision, and readmission rates compared to conventional surgery.

Using smartphone-based accelerometers to gauge postoperative outcomes in patients with NPH: Implications for ambulatory monitoring.

BACKGROUND: The surgical treatment of normal pressure hydrocephalus (NPH) with shunting remains controversial due to the difficulty in distinguishing such pathology from other neurological conditions that can present similarly. Thus, patients with suspected NPH should be carefully selected for surgical intervention. Historically, clinical improvement has been measured by the use of functional grades, alleviation of symptoms, and/or patient/family-member reported surveys. Such outcome analysis can be subjective, and there is difficulty in quantifying cognition. Thus, a push for a more quantifiable and objective investigation is warranted, especially for patients with idiopathic NPH (INPH), for which the final diagnosis is confirmed with postoperative clinical improvement. We aimed to use Apple Health (Apple Inc., Cupertino, CA) data to approximate physical activity levels before and after shunt placement for NPH as an objective outcome measurement. The patients were contacted and verbally consented to export Apple Health activity data. The patient's physical activity data were then analyzed. A chart review from the patient's EMR was performed to understand and better correlate recovery. CASE DESCRIPTION: Our first patient had short-term improvements in activity levels when compared to his preoperative activity. The patient's activity level subsequently decreased at 6 months and onward. This decline was simultaneous to new-onset lumbar pain. Our second patient experienced sustained improvements in activity levels for 12 months after his operation. His mobility data were in congruence with his subjectively reported improvement in clinical symptoms. He subsequently experienced a late-decline that began at 48-months. His late deterioration was likely confounded by exogenous factors such as further neurodegenerative diseases coupled with old age. CONCLUSION: The use of objective activity data offers a number of key benefits in the analysis of shunted patients with NPH/INPH. In this distinctive patient population, detailed functional outcome analysis is imperative because the long-term prognosis can be affected by comorbid factors or life expectancy. The benefits from using smartphone-based accelerometers for objective outcome metrics are abundant and such an application can serve as a clinical aid to better optimize surgical and recovery care.

Using Smartphone-Based Accelerometer Data to Objectively Assess Outcomes in Spine Surgery.

BACKGROUND: In order to deliver optimal patient care, spine surgeons must integrate technological changes to arrive at novel measures of functional outcomes. Historically, subjective patient-reported outcome (PRO) surveys have been used to determine the relative benefit of surgical treatments. Using smartphone-based accelerometers, surgeons now have the ability to arrive at objective outcome metrics. OBJECTIVE: To use Apple Health (Apple Inc, Cupertino, California) data to approximate physical activity levels before and after spinal fusion as an objective outcome measurement. METHODS: Personal activity data were acquired retrospectively from the cellphones of consenting patients. These data were used to measure changes in activity level (daily steps, flights climbed, and distance traveled) before and after patients underwent spine surgery at a single institution by a single surgeon. After data collection, we investigated the demographic information and daily physical activity pre- and postoperatively of participating patients. RESULTS: Twenty-three patients were included in the study. On average, patients first exceeded their daily 1-yr average distance walked, flights climbed, and steps taken at 10.3 ± 14, 7.6 ± 21.1, and 8 ± 9.9 wk, respectively. Mean flights climbed, distance traveled, and steps taken decreased significantly from 6 mo prior to surgery to 2 wk postoperatively. Distance traveled and steps taken significantly increased from 6 mo prior to surgery to 7 to 12 mo postoperatively. CONCLUSION: We demonstrated a valuable supplement to traditional PROs by using smartphone-based activity data. This methodology yields a rich data set that has the potential to augment our understanding of patient recovery.