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.

The Medical Legal Environment in Neurosurgery: An Informative Overview of the Stages of Litigation and Distinct Challenges.

Medical malpractice litigation is something that every neurosurgeon encounters in his or her career and causes significant strife to amateur physicians attempting to navigate the medicolegal process. Neurosurgery in particular is one of the highest risk specialties for litigation. This calls to order the importance of a clear understanding of the medicolegal proceedings that may follow after a complaint has been filed. This report describes the steps to be taken by the physician in the instance that litigation is expected or considered a possibility. We describe the elements that comprise a medical malpractice claim, details of the lawsuit process including hospital peer review and expert witness selection, and how to communicate appropriately with the patients and their families in an empathetic way. It is imperative to gain an appropriate understanding of the entirety of the malpractice claim process to ease the anxiety of litigation for the physician and decrease the amount of avoidable complications.

Pediatric Suprasellar Germ Cell Tumors: A Clinical and Radiographic Review of Solitary vs. Bifocal Tumors and Its Therapeutic Implications.

Suprasellar germ cell tumors (S-GCTs) are rare, presenting in either solitary or multifocal fashion. In this study, we retrospectively examine 22 solitary S-GCTs and 20 bifocal germ cell tumors (GCTs) over a 30-year period and demonstrate clinical, radiographic, and prognostic differences between the two groups with therapeutic implications. Compared to S-GCTs, bifocal tumors were almost exclusively male, exhibited higher rate of metastasis, and had worse rates of progression free and overall survival trending toward significance. We also introduce a novel magnetic resonance (MR) imaging classification of suprasellar GCT into five types: a IIIrd ventricle floor tumor extending dorsally with or without an identifiable pituitary stalk (Type Ia, Ib), ventrally (Type III), in both directions (Type II), small lesions at the IIIrd ventricle floor extending to the stalk (Type IV), and tumor localized in the stalk (Type V). S-GCTs almost uniformly presented as Type I-III, while most bifocal GCTs were Type IV with a larger pineal mass. These differences are significant as bifocal GCTs representing concurrent primaries or subependymal extension may be treated with whole ventricle radiation, while cerebrospinal fluid (CSF)-borne metastases warrant craniospinal irradiation (CSI). Although further study is necessary, we recommend CSI for bifocal GCTs exhibiting high-risk features such as metastasis or non-germinomatous germ cell tumor histology.

Contract Negotiation for Neurosurgeons: A Practical Guide.

Contract negotiation is a reality in the career of any neurosurgeon. However, little formal training exists for physicians - including neurosurgeons - on potential techniques and strategies for conducting meaningful contract negotiation. Increasing numbers of neurosurgeons seek hospital employment for which an employment contract will be provided. During contract negotiation, it is likely that a young neurosurgeon will be in discussion with an experienced negotiator acting on behalf of a hospital, practice, or department. Understanding and adapting to this imbalance in experience and using basic negotiating techniques as a means of approaching and resolving key contract issues is critical for the neurosurgeon to maximize his or her value in the course of contract negotiation. Even without formal training in negotiation in residency, negotiation skills can be taught, practiced, and improved. In affiliation with the Medical Director's Ad-Hoc Representational Section of Council of State Neurosurgical Societies (CSNS) this article is intended to serve as a practical guide for contract negotiation. Contract basics, negotiation terms, strategies, unique neurosurgical issues, and value creation are explored.

Pediatric tethered cord release: an epidemiological and postoperative complication analysis.

BACKGROUND: Tethered cord release (TCR) is a common procedure in pediatric neurosurgery. Despite a reputation for being relatively safe, the risk factors for postoperative complications are poorly understood. METHODS: In this study, the American College of Surgeons-National Surgical Quality Improvement Program Pediatric Database (ACS-NSQIP-P) was reviewed to identify the demographics, risk factors, and 30-day postoperative complications for tethered cord release using univariate and multivariate analysis. A detailed analysis of reasons for readmission and reoperation was also performed. RESULTS: Three thousand and six hundred eighty-two pediatric patients were studied. Males undergoing TCR were younger (5.6 vs. 6.1 years) and had a higher rate of pre-operative comorbidities but lower 30-day complication rate versus females. Patients who later developed complications were more likely to require a microscope intraoperatively, had longer operative times, and worse preoperative American Society of Anesthesiologists (ASA) class. CONCLUSIONS: Despite being a relatively safe procedure, TCR in the pediatric population carries a finite risk of complications. In this large, international database study, males were found to have a greater number of risk factors prior to TCR, while females exhibit a higher risk of developing postoperative complications. This paper provides a large sample size of multi institutional pediatric patients undergoing TCR and may serve as a contemporary "snapshot" for future studies.

Supratentorial and Infratentorial Approaches to Pineal Surgery: A Database Analysis.

Objectives Neoplasms involving the pineal gland are rare. When they do occur, tumor resection is anatomically challenging and is traditionally addressed by either a supratentorial or an infratentorial approach. To date, no large, multicenter studies have been performed that systematically analyze outcomes comparing these two approaches. This study aimed to evaluate outcomes for patients undergoing pineal neoplasm resection, comparing supratentorial and infratentorial approaches. Design Retrospective database review. Setting Multi-institutional database. Participants From 2005 to 2016, 60 patients were identified, with 13 undergoing a supratentorial approach and 47 undergoing an infratentorial approach. Main Outcome Measures Patient demographics, comorbidities, and 30-day postoperative outcomes were investigated using the American College of Surgeons National Surgical Quality Improvement Program database. Demographics, readmission, reoperation, and complication rates were analyzed and compared with previous studies. Results Patient demographics were similar between these two groups. The overall complication rates for the supratentorial and infratentorial approaches were 30.8 and 17%, respectively, and the difference was not statistically significant. The most common medical complications encountered were respiratory and hematological. Conclusion As the first multi-institutional database analysis of approaches to the pineal gland, this study provides an analysis of patient demographics, comorbidities, and postoperative complications. After controlling for preoperative risk factors and demographic characteristics, no statistically significant differences in postoperative outcomes were found between infratentorial and supratentorial approaches. The mean readmission, reoperation, and complication rates were found to be 2.1, 8.3, and 20%, respectively. The lack of significant difference between approaches suggests that clinical decision-making should depend upon anatomical considerations and physician preference, although the complications illustrated here may provide some preoperative guidance.

Mycobacterium fortuitum Meningitis: Approach to Lumboperitoneal Shunt Infection.

Mycobacterium fortuitum is a rare, opportunistic pathogen most frequently contracted through contact with a contaminated source. An immunocompetent 26-year-old female patient presented to our institution with an infected lumboperitoneal (LP) shunt presenting as continued nonhealing wounds. After multiple debridements, shunt revisions, and wound closure failures, infectious disease specialists were consulted. The wound cultures returned positive for M. fortuitum and the shunt was removed. Cerebrospinal fluid studies revealed significant pleocytosis with normal opening pressure, and the patient was diagnosed as having secondary meningitis. After shunt removal, the patient was treated with intravenous and oral antibiotics, resulting in infection resolution. Five months later, a new LP shunt was placed without infection recurrence. Although M. fortuitum was previously reported in neurosurgical patients with ventriculoperitoneal shunts, which are summarized here, to date this is the first case in the literature of M. fortuitum meningitis from an LP shunt. This case demonstrates the importance of clinicians considering uncommon and slow-growing pathogens, as well as consulting infectious disease specialists for patients with persistent, unexplained infections.

Intracranial Electrode Placement for Seizures Before Temporal Lobectomy: A Risk-Benefit Analysis.

BACKGROUND AND OBJECTIVE: Anterior temporal lobectomy (ATL) is the most common surgical procedure for refractory temporal lobe epilepsy. When scalp electroencephalography cannot adequately identify an epileptogenic site, electrode implantation may be used to monitor epileptic activity and localize a target focus before surgical resection. Whether the advantage of improved seizure localization justifies the added risk of electrode placement remains unclear. : The present study uses an international surgical database to explore whether a 2wo-stage approach, electrode implant followed by ATL, has a reasonable safety profile and is clinically worthwhile versus ATL alone. METHODS: Data from the American College of Surgeons National Surgical Quality Improvement Program for 2005 to 2016 were queried to identify patients undergoing ATL or electrode implant for epilepsy. The 30-day postoperative outcomes were analyzed for the electrode implant and ATL groups, and individual and combined risk profiles were determined. RESULTS: Patients undergoing electrode implant followed by ATL had a predicted reoperation rate of 7.6%, readmission rate of 14.6%, and a 30-day mortality rate of 1.2%. The combined rate of patients having ≥1 medical complication for 2-staged procedures was higher, at 14.7%. The most common complications encountered were urinary tract infection (2.7%) and sepsis (2.7%). CONCLUSIONS: Intracranial electrode placement increases the risk of complications when added to ATL. The severity of complications from electrode placement are mild, however, and as intracranial electrode recording provides a potentially large reduction in the surgical failure risk, electrode placement may be advisable for all but the most convincing seizure foci.

Vagal Nerve Stimulation for Epilepsy in Adults: A Database Risk Analysis and Review of the Literature.

BACKGROUND: Epilepsy is one of the most common neurologic disorders and often remains refractory despite pharmacologic treatment. In patients who are not amenable to surgical resection of seizure foci, vagal nerve stimulation (VNS) may be beneficial. Multiple case series have attempted to construct a risk profile for VNS, but they are largely confined to pediatric or single-center populations. We aimed to compile a risk profile for adults undergoing VNS, using multicenter patient data from an international database. METHODS: The 30-day outcomes of adults undergoing VNS from 2005 to 2016 were collected from the American College of Surgeons National Surgical Quality Improvement Program database. Readmission rates, reoperation rates, length of hospital stay, operative time, and complications were assessed. A comprehensive literature search was performed to identify historically reported complication rates. RESULTS: Inclusion and exclusion criteria were met by 77 patients. A 30-day risk profile revealed low readmission (6.2%), reoperation (1.3%), and postoperative infection (1.3%) rates. Mean operative time was 81.7 minutes, and average length of stay was 0.27 days. Most (87.0%) patients were discharged on the day of operation. CONCLUSIONS: This study provides a current snapshot of risks and outcomes in VNS, revealing a safe 30-day risk profile. Greater use of VNS may be beneficial in this fragile population.

C1-C2 Fusion Versus Occipito-Cervical Fusion for High Cervical Fractures: A Multi-Institutional Database Analysis and Review of the Literature.

OBJECTIVE: Type II odontoid fractures of the axis (C2) account for more than 20% of all cervical fractures. If an odontoid screw is contraindicated, the treatment approach for type II C2 fractures typically involves C1-C2 posterior fusion or occipito-cervical (O-C) fusion, each of which has distinct advantages and disadvantages. In this study, postoperative outcomes of C1-C2 fusion and O-C fusion for high cervical fractures were compared. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried to determine 30-day surgical outcomes of posterior C1-C2 fusion versus O-C fusion for adult patients with C2 fractures between 2005 and 2016. Demographics, operative factors, and postoperative events were analyzed, including returns to the operating room, readmission, and death. RESULTS: In total, 165 patients were identified. A majority of the patients (142, 86.1%) had independent functional status, although 133 (80.6%) had an American Society of Anesthesiologists classification ranging from 3 to 5, representing poor preoperative health. A significantly greater proportion of O-C (9.1%) versus C1-C2 fusion (1.7%) returned to the operating room (odds ratio 6.465, confidence interval 1.079-38.719, P = 0.041). The length of operation approached statistical significance (P = 0.053) between the 2 groups, with O-C fusion group having a longer average length of operation (196.4 minutes) versus the C1-C2 group (164.0 minutes). CONCLUSIONS: This study provides a snapshot of the risk profiles of C1-C2 and O-C fusion for C2 fracture, demonstrating a statistically higher risk of reoperation in O-C fusion versus C1-C2 fusion. Future randomized trials are needed to identify the preferred technique to improve patient outcomes.

Magnetic Drug Targeting: A Novel Treatment for Intramedullary Spinal Cord Tumors.

Most applications of nanotechnology in cancer have focused on systemic delivery of cytotoxic drugs. Systemic delivery relies on accumulation of nanoparticles in a target tissue through enhanced permeability of leaky vasculature and retention effect of poor lymphatic drainage to increase the therapeutic index. Systemic delivery is limited, however, by toxicity and difficulty crossing natural obstructions, like the blood spine barrier. Magnetic drug targeting (MDT) is a new technique to reach tumors of the central nervous system. Here, we describe a novel therapeutic approach for high-grade intramedullary spinal cord tumors using magnetic nanoparticles (MNP). Using biocompatible compounds to form a superparamagnetic carrier and magnetism as a physical stimulus, MNP-conjugated with doxorubicin were successfully localized to a xenografted tumor in a rat model. This study demonstrates proof-of-concept that MDT may provide a novel technique for effective, concentrated delivery of chemotherapeutic agents to intramedullary spinal cord tumors without the toxicity of systemic administration.

Cost-Effectiveness of Quantitative Magnetic Resonance Angiography Screening and Submaximal Angioplasty for Symptomatic Vertebrobasilar Disease.

Background and Purpose- The VERiTAS (Vertebrobasilar Flow Evaluation and Risk of Transient Ischemic Attack and Stroke) study demonstrated posterior circulation distal flow status, determined by quantitative magnetic resonance angiography, is a robust predictor of vertebrobasilar stroke risk in patients with symptomatic atherosclerotic vertebrobasilar disease. Flow-compromised high-risk patients may benefit from flow-restoring endovascular procedures, such as submaximal angioplasty. In this study, we examine the cost-effectiveness of quantitative magnetic resonance angiography screening to identify patients who may benefit from submaximal angioplasty to restore vertebrobasilar flow. Methods- A Markov model was created comparing a no screening strategy with standard medical management alone and a screening strategy involving quantitative magnetic resonance angiography imaging and submaximal angioplasty for treatable patients with low vertebrobasilar flow for a 30-year time horizon. Outcomes included quality-adjusted life years (QALY) and lifetime costs. Rates of stroke and death were obtained from VERiTAS data, and disability rates and costs were derived from VERiTAS and the literature. A sensitivity analysis was performed with periprocedural stroke rate from angioplasty the primary variable of interest. Results- At a 6% periprocedural stroke risk, the screening strategy saved an average of 0.364 QALYs per patient and a lifetime cost savings of $7312 versus the no screening strategy. Among patients with low flow suitable for intervention, the benefit was substantially higher, averaging 1.485 QALYs saved and lifetime cost savings of $21 294. Across the entire cohort, QALY savings were observed at the end of the first year and economic savings at year 6. The benefit of screening declined at higher periprocedural risk. Conclusions- Quantitative magnetic resonance angiography screening and submaximal angioplasty with 6% periprocedural risk in suitable patients are cost effective both in terms of QALY and lifetime costs for patients with symptomatic vertebrobasilar occlusive disease. With potential health and economic savings, a clinical trial examining the periprocedural risk of submaximal angioplasty is warranted. Clinical Trial Registration- URL: http://www.clinicaltrials.gov . Unique identifier: NCT00590980.

Lumbar Discectomy Outcomes by Specialty: A Propensity-Matched Analysis of 7464 Patients from the ACS-NSQIP Database.

OBJECTIVE: To investigate the influence of surgeon specialty on 30-day postoperative complication rates for single-level lumbar discectomies. METHODS: All patients who underwent single-level lumbar discectomy between 2005 and 2014 were reviewed from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Propensity score matching and univariate binary regression was used to determine whether surgeon subspecialty had an influence on 30-day postoperative complications. RESULTS: Of the 28,863 patients who underwent single-level lumbar discectomies during 2005-2014, 12,659 patients met inclusion criteria. Orthopedic surgeons performed 3733 operations (29.4%), and neurosurgeons performed 8926 operations (70.6%). A propensity-score matched sample of 7464 total cases (3732 orthopedic surgeon, 3732 neurosurgeon) was analyzed for the effect of surgeon specialty on 30-day outcomes. After propensity matching, orthopedic surgeons and neurosurgeons were similar in all postoperative outcomes, except for a slightly higher frequency of blood transfusions (0.3%, n = 11) in orthopedic versus neurosurgery patients (0.1%, n = 3; P = 0.032), although this did not remain significant after Bonferroni adjustment. Mean operative time was slightly longer for neurosurgeons (83.7 minutes) versus orthopedic surgeons (72.5 minutes; P < 0.001). There were no significant differences in mortality, readmission, or reoperation rates. CONCLUSIONS: Single-level lumbar discectomies hold a low complication profile and show equivalent outcomes for both orthopedic and neurological surgeons, although neurosurgeons may exhibit a slightly longer mean operative time. In propensity score-matched cohorts, orthopedic surgeons had slightly higher rates of blood transfusions, although the number was small and did not remain significant after Bonferroni adjustment.

Epidural Abscess: A Propensity Analysis of Surgical Treatment Strategies.

STUDY DESIGN: Observational analysis of retrospectively collected data. OBJECTIVE: A retrospective study was performed in order to compare the surgical profile of risk factors and perioperative complications for laminectomy and laminectomy with fusion procedures in the treatment of spinal epidural abscess (SEA). SUMMARY OF BACKGROUND DATA: SEA is a highly morbid condition typically presenting with back pain, fever, and neurologic deficits. Posterior fusion has been used to supplement traditional laminectomy of SEA to improve spinal stability. At present, the ideal surgical strategy-laminectomy with or without fusion-remains elusive. METHODS: Thirty-day outcomes such as reoperation and readmission following laminectomy and laminectomy with fusion in patients with SEA were investigated utilizing the American College of Surgeons National Quality Improvement Program database. Demographics and clinical risk factors were collected, and propensity matching was performed to account for differences in risk profiles between the groups. RESULTS: Seven hundred thirty-eight patients were studied (608 laminectomy alone, 130 fusion). The fusion population was in worse health. The fusion population experienced significantly greater rate of return to the operating room (odds ratio [OR] 1.892), with the difference primarily accounted for by cervical spine operations. Additionally, fusion patients had significantly greater rates of blood transfusion. Infection was the most common reason for reoperation in both populations. CONCLUSION: Both laminectomy and laminectomy with fusion effectively treat SEA, but addition of fusion is associated with significantly higher rates of transfusion and perioperative return to the operating room. In operative situations where either procedure is reasonable, surgeons should consider that fusion nearly doubles the odds of reoperation in the short-term, and weigh this risk against the benefit of added stability. LEVEL OF EVIDENCE: 3.

Surgical Complications in Intradural Extramedullary Spinal Cord Tumors - An ACS-NSQIP Analysis of Spinal Cord Level and Malignancy.

BACKGROUND: Intradural extramedullary (IDEM) spinal cord tumors account for two-thirds of all intraspinal neoplasms. Surgery for IDEM tumors carries risks for many different complications, which to date have been poorly described and quantified. In this study, we better characterize risk factors and complications for IDEM tumors, stratifying patients by spinal cord level and malignancy. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried to determine 30-day outcomes following surgery for IDEM tumors between 2005 and 2016. Patients with cervical, thoracic, and lumbar tumors were compared in terms of demographics, comorbidities, and postoperative complications. A similar analysis was performed comparing patients with benign and malignant tumors. RESULTS: A total of 991 patients with IDEM tumors were identified in the cohort. The majority of tumors were thoracic (44.3%), followed by lumbar (35.4%) and cervical (20.3%). Only 6.3% of patients were readmitted within 30 days, 4.2% returned to the operating room, and 1.0% died. Significant associations were noted between spinal cord level and patient sex, age, functional status, American Society of Anesthesiologists (ASA) classification, prevalence of diabetes and hypertension, and risk of developing pneumonia. Benign and malignant tumors differed by patient sex, baseline ASA class, risk of return to the operating room, mortality, and likelihood of transfusion. CONCLUSIONS: IDEM tumors are common and carry surgical risks, with different complication profiles for tumors at different spinal levels and degrees of malignancy. With definitive risk factors and outcomes, the ACS-NSQIP cohort provides a snapshot of national neurosurgery trends and outcomes in contemporary IDEM surgery.

Location of Thalamic Hemorrhage Impacts Prognosis.

OBJECTIVE: Approximately 12% of intracerebral hemorrhages (ICHs) occur in the thalamus. Understanding the anatomic regions involved with thalamic hemorrhages is potentially useful, offering the physician a more accurate prognosis for patient outcomes. This study was performed to determine if thalamic hemorrhage location observed on a computed tomography (CT) scan was predictive of neurologic outcomes. METHODS: A sample of 168 thalamic hemorrhage patients admitted to a tertiary care center were analyzed. Axial CT scans of thalamic hemorrhages were classified into 1 of 6 possible categories based on thalamic nuclei anatomy: anterior, posterior, medial, lateral, central, or global. For each classification, patient clinical characteristics were collected to identify variables indicative of clinical outcome. Outcome measures used in this study included mortality, hospital length of stay, readmission within 30 days, ICH score, Glasgow Coma Scale score, neurologic deterioration (calculated as a change in modified Rankin scale score from admission to discharge), and discharge disposition. RESULTS: On multivariable analysis, patients with posterior and lateral thalamic hemorrhages demonstrated a decreased likelihood of mortality; patients with posterior hemorrhages were less likely to have neurologic deterioration relative to global thalamic hemorrhages when controlling for hemorrhage volume and ventriculomegaly. Ventriculomegaly and hemorrhage volume were also predictive of both mortality and neurologic deterioration. CONCLUSIONS: In thalamic hemorrhages, patient prognosis may be influenced by hemorrhage location, with posterior and lateral hemorrhages demonstrating better clinical outcome versus hemorrhages in other locations. This is potentially valuable because hemorrhage location affords the treating physician a readily available prognostic factor when assessing intracranial hemorrhages.

Anterior Versus Posterior Approach for Thoracic Corpectomy: An Analysis of Risk Factors, Outcomes, and Complications.

BACKGROUND: Thoracic corpectomies are performed for various reasons, including spinal deformity, trauma, neoplasms, and infection. Regardless of indication, both anterior and posterior approaches are surgical options, selected based on pathology, anatomy, patient characteristics, and surgical experience. Risk profiles and outcomes for these procedures are poorly characterized, however, and the choice between the 2 approaches remains inconclusive. OBJECTIVE: To compare risk factors and complications for adult patients undergoing anterior and posterior thoracic corpectomies. METHODS: A review of the American College of Surgeons National Quality Improvement Program database was performed, with 30-day patient outcomes after anterior or posterior thoracic corpectomy queried from 2005 to 2016. Preoperative risk factors and postoperative outcomes (e.g., deaths, reoperations, readmissions) were identified and compared. RESULTS: In total, 1327 corpectomies were studied, 861 (64.9%) by an anterior approach and 465 (35.1%) by a posterior approach. Patients undergoing a posterior approach were generally male, older, and had a greater American Association of Anesthesiologists class, whereas those subject to anterior approaches had a greater average body mass index. After we controlled for these baseline characteristics, no significant difference in postoperative events was observed, with 9.3% of anterior approach patients and 7.1% of posterior approach patients returning to the operating room within 30 days. CONCLUSIONS: No significant difference in rates of reoperation, readmission, death, average length of stay, or medical complications exists between anterior and posterior thoracic corpectomy approaches. Both have relatively low-risk profiles and, in situations in which either strategy is reasonable, each can be selected at the surgeon's discretion with comparable risk.

Preoperative steroids do not improve outcomes for intramedullary spinal tumors: a NSQIP analysis of 30-day reoperation and readmission rates.

BACKGROUND: Intramedullary spinal cord tumors (IMSCTs) account for 8-10% of all spinal cord tumors and affect patients of all ages. Although uncommon, IMSCTs carry risk of neurological morbidity and mortality, with 5-year survival rates ranging from 50% to 80%. In this study, we utilize the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to determine the effect of steroid administration on 30-day outcomes following surgery for IMSCTs. METHODS: ACS-NSQIP data for patients undergoing surgery for intramedullary tumors from 2005 to 2015 was reviewed. Patients were selected based on current procedural terminology (CPT) codes 63285 (Laminectomy, intradural, intramedullary, cervical), 63286 (Laminectomy, intradural, intramedullary, thoracic), and 63287 (Laminectomy, intradural, intramedullary, thoracolumbar). ICD-9 and ICD-10 codes were chosen based on the diagnosis of a tumor. The 30-day clinical outcome data, including reoperations and readmission rates, were collected and compared. RESULTS: A total of 259 patients were reviewed. One hundred eighty-one patients had benign intramedullary tumors and 78 had malignant intramedullary tumors. The majority of IMSCTs were at the thoracic level (n=100), followed by the cervical (n=99), and thoracolumbar (n=39) levels. Thirty-one patients were on corticosteroid therapy prior to surgery. Patients with preoperative steroid administration had no significant difference in reoperation and readmission rates. No significant differences were noted between steroid vs. non-steroid therapy for discharge destination, length of hospital stay, or other postoperative complications. CONCLUSIONS: Contrary to previous reports, corticosteroid use prior to surgery for IMSCTs does not have a significant impact on 30-day risk of readmission, reoperation, and risk of postoperative complications.

Motor Cortex Stimulation for Deafferentation Pain.

PURPOSE OF REVIEW: Since the early 1990s, motor cortex stimulation (MCS) has been a unique treatment modality for patients with drug-resistant deafferentation pain. While underpowered studies and case reports have limited definitive, data-driven analysis of MCS in the past, recent research has brought new clarity to the MCS literature and has helped identify appropriate indications for MCS and its long-term efficacy. RECENT FINDINGS: In this review, new research in MCS, repetitive transcranial magnetic stimulation (rTMS), and transcranial direct current stimulation (tDCS) are analyzed and compared with historical landmark papers. Currently, MCS is effective in providing relief to 40-64% of patients, with decreasing analgesic effect over time addressed by altering stimulation settings. rTMS and tDCS, two historic, non-invasive stimulation techniques, are providing new alternatives for the treatment of deafferentation pain, with rTMS finding utility in identifying MCS responders. Future advances in electrode arrays, neuro-navigation, and high-definition tDCS hold promise in providing pain relief to growing numbers of patients. Deafferentation pain is severe, disabling, and remains a challenge for patients and providers alike. Over the last several years, the MCS literature has been revitalized with studies and meta-analyses demonstrating MCS effectiveness and providing guidance in identifying responders. At the same time, rTMS and tDCS, two time-honored non-invasive stimulation techniques, are finding new utility in managing deafferentation pain and identifying good MCS candidates. As the number of potential therapies grow, the clinician's role is shifting to personalizing treatment to the unique pain of each patient. With new treatment modalities, this form of personalized medicine is more possible than ever before.