Experience with the utilization of new-generation shared-control robotic system for spinal instrumentation.

BACKGROUND: Robotic assistance in spine surgery is emerging as an accurate, effective and enabling technology utilized in the treatment of patients with surgical spinal pathology. The safety and reproducibility of robotic assistance in the placement of pedicle screw instrumentation is still being investigated. The objective of this study was to present our experience of instrumented spinal fusion utilizing an intraoperative robotic guidance system. METHODS: We retrospectively reviewed all cases of spinal instrumentation of the thoracic and lumbo-sacral spine using the Mazor X robotic system (Medtronic Inc, Minneapolis, MN, USA), performed at our institution by one surgeon between July 2017 and June 2020. Wilcoxon Rank test was used to compare time taken to place each screw during the first 20 cases and the cases thereafter. RESULTS: A total of 28 patients were included. A total of 159 screws were placed using the Mazor X robotic system. The overall mean time for screw placement was 7.8±2.3 minutes and there was a significant reduction in the mean time for screw placement after the 20th case or 120 screws (8.70 vs. 5.42 min, P=0.008). No postoperative neurologic deficit or new radiculopathy was noted to occur secondary to hardware placement. No revision surgery was required for replacement or removal of a mispositioned screw. CONCLUSIONS: From this single-center, single-surgeon series we conclude that robot-assisted spine surgery can be safely and efficiently integrated into the operating room workflow, which improves after a learning curve of approximately 20 operative interventions. We found robot-assisted spinal instrumentation to be reliable, safe, effective and highly precise.

Misplaced intraspinal venous stent causing cauda equina syndrome: illustrative case.

BACKGROUND: Endovenous stents for deep venous thrombosis treatment can be unintentionally placed in the spinal canal, resulting in neurological deficit. OBSERVATIONS: The authors report the case of a patient presenting to our institution with intraspinal misplacement of an endovenous stent, resulting in cauda equina syndrome. The authors also performed a systematic literature review, evaluating the few previously reported cases. This review was performed according to the updated Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. In four of five cases describing stent misplacement into the spinal canal, the authors report that only anteroposterior monoplanar imaging modalities were utilized for venous localization and stent deployment. The anteroposterior plane cannot assess the relative depth of structures, nor can it distinguish between superimposed structures well. Therefore, the use of biplanar imaging should at least be considered before stent deployment, as intraspinal stent placement can lead to disastrous consequences. LESSONS: This report should serve as an impetus for the use of biplanar or three-dimensional imaging modalities for iliac venous stent placement. Additionally, this work should increase spine surgeons' awareness about management and operative techniques when faced with this complication.

Machine Learning in Neurosurgery: Toward Complex Inputs, Actionable Predictions, and Generalizable Translations.

Machine learning can predict neurosurgical diagnosis and outcomes, power imaging analysis, and perform robotic navigation and tumor labeling. State-of-the-art models can reconstruct and generate images, predict surgical events from video, and assist in intraoperative decision-making. In this review, we will detail the neurosurgical applications of machine learning, ranging from simple to advanced models, and their potential to transform patient care. As machine learning techniques, outputs, and methods become increasingly complex, their performance is often more impactful yet increasingly difficult to evaluate. We aim to introduce these advancements to the neurosurgical audience while suggesting major potential roadblocks to their safe and effective translation. Unlike the previous generation of machine learning in neurosurgery, the safe translation of recent advancements will be contingent on neurosurgeons' involvement in model development and validation.

Evaluating Computer Vision, Large Language, and Genome-Wide Association Models in a Limited Sized Patient Cohort for Pre-Operative Risk Stratification in Adult Spinal Deformity Surgery.

Background: Adult spinal deformities (ASD) are varied spinal abnormalities, often necessitating surgical intervention when associated with pain, worsening deformity, or worsening function. Predicting post-operative complications and revision surgery is critical for surgical planning and patient counseling. Due to the relatively small number of cases of ASD surgery, machine learning applications have been limited to traditional models (e.g., logistic regression or standard neural networks) and coarse clinical variables. We present the novel application of advanced models (CNN, LLM, GWAS) using complex data types (radiographs, clinical notes, genomics) for ASD outcome prediction. Methods: We developed a CNN trained on 209 ASD patients (1549 radiographs) from the Stanford Research Repository, a CNN pre-trained on VinDr-SpineXR (10,468 spine radiographs), and an LLM using free-text clinical notes from the same 209 patients, trained via Gatortron. Additionally, we conducted a GWAS using the UK Biobank, contrasting 540 surgical ASD patients with 7355 non-surgical ASD patients. Results: The LLM notably outperformed the CNN in predicting pulmonary complications (F1: 0.545 vs. 0.2881), neurological complications (F1: 0.250 vs. 0.224), and sepsis (F1: 0.382 vs. 0.132). The pre-trained CNN showed improved sepsis prediction (AUC: 0.638 vs. 0.534) but reduced performance for neurological complication prediction (AUC: 0.545 vs. 0.619). The LLM demonstrated high specificity (0.946) and positive predictive value (0.467) for neurological complications. The GWAS identified 21 significant (p < 10-5) SNPs associated with ASD surgery risk (OR: mean: 3.17, SD: 1.92, median: 2.78), with the highest odds ratio (8.06) for the LDB2 gene, which is implicated in ectoderm differentiation. Conclusions: This study exemplifies the innovative application of cutting-edge models to forecast outcomes in ASD, underscoring the utility of complex data in outcome prediction for neurosurgical conditions. It demonstrates the promise of genetic models when identifying surgical risks and supports the integration of complex machine learning tools for informed surgical decision-making in ASD.

Navigated Simultaneous Lateral Minimally Invasive Tubular and Posterior Mini-Open Access for Removal and Revision of Triangular Sacroiliac Joint Implants: A Technical Note.

BACKGROUND: Sacroiliac joint (SIJ) fusion, to treat back pain caused by SIJ dysfunction, can employ open or minimally invasive surgery (MIS) techniques and either cylindrical (screw-shaped) or triangular (wedge-shaped) implants. Fusion nonunion sometimes explains recurrent SIJ pain following fusion and occasionally requires hardware revision. MIS revision minimizes patient pain, infection, and disability, but due to the triangular implant size and form factor, implant removal can present challenges for MIS access during the explantation and achieving good bony purchase for reinstrumentation. Here, we report a prone single-position lateral MIS/posterior mini-open procedure for triangular-implant SIJ fusion revision. METHODS: The patient is a 72-year-old female who underwent right SIJ fusion for lower back and leg pain sustained after a fall 2 years prior but experienced recurrent pain over the subsequent 2 years, with imaging findings of right SIJ peri-hardware lucencies and diagnostic injections confirming persistent right-sided sacroiliitis. RESULTS: The patient underwent hardware removal using the lateral MIS incision with table-mounted tubular access and image-guided navigation to maintain exposure, plus simultaneous reinstrumentation using a navigated S2-alar-iliac screw and iliac bolt construct with connecting rod through the posterior mini-open incision made for the navigation reference frame spinous process clamp. CONCLUSIONS: The use of navigation and MIS access can significantly decrease the complexity of lateral hardware removal, and mini-open navigated screw-and-rod constructs offer reinstrumentation options accessible to surgeons unfamiliar with specialized posterior SIJ systems.

Type II odontoid fractures in the elderly presenting to the emergency department: an assessment of factors affecting in-hospital mortality and discharge to skilled nursing facilities.

BACKGROUND CONTEXT: Type II odontoid fractures (OF) are among the most common cervical spine injuries in the geriatric population. However, there is a paucity of literature regarding their epidemiology. Additionally, the optimal management of these injuries remains controversial, and no study has evaluated the short-term outcomes of geriatric patients presenting to emergency departments (ED). PURPOSE: This study aims to document the epidemiology of geriatric patients presenting to EDs with type II OFs and determine whether surgical management was associated with early adverse outcomes such as in-hospital mortality and discharge to skilled nursing facilities (SNF). STUDY DESIGN: This is a retrospective cohort study. PATIENT SAMPLE: Data was used from the 2016-2020 Nationwide Emergency Department Sample. Patient encounters corresponding to type II OFs were identified. Patients younger than 65 at the time of presentation to the ED and those with concomitant spinal pathology were excluded. OUTCOME MEASURES: The association between the surgical management of geriatric type II OFs and outcomes such as in-hospital mortality and discharge to SNFs. METHODS: Patient, fracture, and surgical management characteristics were recorded. A propensity score matched cohort was constructed to reduce differences in age, comorbidities, and injury severity between patients undergoing operative and nonoperative management. Additionally, to develop a positive control for the analysis of geriatric patients with type II OFs and no other concomitant spinal pathology, a cohort of patients that had been excluded due to the presence of a concomitant spinal cord injury (SCI) was also constructed. Multivariate regressions were then performed on both the matched and unmatched cohorts to ascertain the associations between surgical treatment and in-hospital mortality, inpatient length of stay, encounter charges, and discharge to SNFs. RESULTS: A total of 11,325 encounters were included. The mean total charge per encounter was $60,221. 634 (5.6%) patients passed away during their encounters. In total, 1,005 (8.9%) patients were managed surgically. Surgical management of type II OFs was associated with a 316% increase in visit charge (95% CI: 291%-341%, p<.001), increased inpatient length of stay (IRR: 2.87, 95% CI: 2.62-3.12, p<.001), and increased likelihood of discharge to SNFs (OR=2.62, 95% CI: 2.26-3.05, p<.001), but decreased in-hospital mortality (OR=0.32, CI: 0.21-0.45, p<.001). The propensity score matched cohort consisted of 2,010 patients, matching each of the 1,005 that underwent surgery to 1,005 that did not. These cohorts were well balanced across age (78.24 vs 77.91 years), Elixhauser Comorbidity Index (3.68 vs 3.71), and Injury Severity Score (30.15 vs 28.93). This matching did not meaningfully alter the associations determined between surgical management and in-hospital mortality (OR=0.34, CI=0.21-0.55, p<.001) or SNF discharge (OR=2.59, CI=2.13-3.16, p<.001). Lastly, the positive control cohort of patients with concurrent SCI had higher rates of SNF discharge (50.0% vs 42.6%, p<.001), surgical management (32.3% vs 9.7%, p<.001), and in-hospital mortality (28.9% vs 5.6%, p<.001). CONCLUSIONS: This study lends insight into the epidemiology of geriatric type II OFs and quantifies risk factors influencing adverse outcomes. Patient informed consent should include a discussion of the protective association between definitive surgical management and in-hospital mortality against potential operative morbidity, increased lengths of hospital stay, and increased likelihood of discharge to SNFs. This information may impact patient treatment selection and decision making.

Accuracy of predicted postoperative segmental lumbar lordosis in spinal fusion using an intraoperative robotic planning and guidance system.

BACKGROUND: Restoring lumbar lordosis is one of the main goals in lumbar spinal fusion surgery. The Mazor X-AlignTM software allows for the prediction of postoperative segmental lumbar lordosis based on preoperative imaging. There is limited data on the accuracy of this preoperative prediction, especially in patients undergoing short segment lumbar fusion. The objective of our study was to determine the accuracy of predicted postoperative segmental lumbar lordosis using the Mazor X-AlignTM software in patients requiring short segmental fusion. METHODS: Retrospective analysis of adult patients undergoing pedicle screw spinal instrumentation of not more than four levels using the Mazor XTM Robot (Medtronic Inc., Minneapolis, MN, USA) between July 2017 to June 2020. The robotic guidance software, Mazor X-AlignTM (Medtronic Inc., Minneapolis, MN, USA) was used to calculate the predicted segmental lumbar lordosis based on preoperative CT-imaging and the plan was executed under intraoperative robotic guidance. Predicted segmental lumbar lordosis was compared to achieved segmental lumbar lordosis on 1-month postoperative x-rays using the Cobb angle methodology. RESULTS: A total of 15 patients (46.6% female) with a mean age of 61.5±10.9 years were included. All patients underwent posterior lumbo-sacral spinal fusion with the Mazor XTM robotic system with 11 patients (73.3%) undergoing anterior column reconstruction prior to posterior fixation. Instrumentation was performed across a mean of 2.6 levels per case. Preoperative, the mean segmental lumbar lordosis was 30.2±13.6 degrees. The mean planned segmental lumbar lordosis was 35.5±17.0 degrees while the mean achieved segmental lumbar lordosis was 35.8±16.7 degrees. There was no significant mean difference between the planned and achieved segmental lumbar lordosis (P=0.334). CONCLUSIONS: The Mazor XTM intraoperative robotic planning and guidance is accurate in predicting postoperative segmental lumbar lordosis after short segmental fusion. Our findings may assure surgical decision making and planning.

Socio-economic disparities influence likelihood of post-operative radiation to resection cavities of metastatic brain tumors.

PURPOSE: Irradiating the surgical bed of resected brain metastases improves local and distant disease control. Over time, stereotactic radiosurgery (SRS) has replaced whole brain radiotherapy (WBRT) as the treatment standard of care because it minimizes long-term damage to neuro-cognition. Despite this data and growing adoption, socio-economic disparities in clinical access can result in sub-standard care for some patient populations. We aimed to analyze the clinical and socio-economic characteristics of patients who did not receive radiation after surgical resection of brain metastasis. METHODS: Our sample was obtained from Clinformatics® Data Mart Database and included all patients from 2004 to 2021 who did or did not receive radiation treatment within sixty days after resection of tumors metastatic to the brain. Regression analysis was done to identify factors responsible for loss to adjuvant radiation treatment. RESULTS: Of 8362 patients identified who had undergone craniotomy for resection of metastatic brain tumors, 3430 (41%) patients did not receive any radiation treatment. Compared to patients who did receive some form of radiation treatment (SRS or WBRT), patients who did not get any form of radiation were more likely to be older (p = 0.0189) and non-white (p = 0.008). Patients with Elixhauser Comorbidity Index ≥3 were less likely to receive radiation treatment (p < 0.01). Fewer patients with household income ≥ $75,000 did not receive radiation treatment (p < 0.01). CONCLUSION: Age, race, household income, and comorbidity status were associated with differential likelihood to receive post-operative radiation treatment.

Sigma-1 receptor expression in a subpopulation of lumbar spinal cord microglia in response to peripheral nerve injury.

Sigma-1 Receptor has been shown to localize to sites of peripheral nerve injury and back pain. Radioligand probes have been developed to localize Sigma-1 Receptor and thus image pain source. However, in non-pain conditions, Sigma-1 Receptor expression has also been demonstrated in the central nervous system and dorsal root ganglion. This work aimed to study Sigma-1 Receptor expression in a microglial cell population in the lumbar spine following peripheral nerve injury. A publicly available transcriptomic dataset of 102,691 L4/5 mouse microglial cells from a sciatic-sural nerve spared nerve injury model and 93,027 age and sex matched cells from a sham model was used. At each of three time points-postoperative day 3, postoperative day 14, and postoperative month 5-gene expression data was recorded for both spared nerve injury and Sham cell groups. For all cells, 27,998 genes were sequenced. All cells were clustered into 12 distinct subclusters and gene set enrichment pathway analysis was performed. For both the spared nerve injury and Sham groups, Sigma-1 Receptor expression significantly decreased at each time point following surgery. At the 5-month postoperative time point, only one of twelve subclusters showed significantly increased Sigma-1 Receptor expression in spared nerve injury cells as compared to Sham cells (p = 0.0064). Pathway analysis of this cluster showed a significantly increased expression of the inflammatory response pathway in the spared nerve injury cells relative to Sham cells at the 5-month time point (p = 6.74e-05). A distinct subcluster of L4/5 microglia was identified which overexpress Sigma-1 Receptor following peripheral nerve injury consistent with neuropathic pain inflammatory response functioning. This indicates that upregulated Sigma-1 Receptor in the central nervous system characterizes post-acute peripheral nerve injury and may be further developed for clinical use in the differentiation between low back pain secondary to peripheral nerve injury and low back pain not associated with peripheral nerve injury in cases where the pain cannot be localized.

Progression to fusion after lumbar laminectomy for degenerative lumbar spondylolisthesis: Rate and risk-factors. A national database study.

OBJECTIVE: Lumbar laminectomy is often utilized in the treatment of degenerative lumbar spondylolisthesis. Risk factors that contribute to reoperation rates, in particular to progression to fusion, are poorly understood. We aimed to identify rate and risk factors of lumbar fusion surgery following lumbar laminectomy for the treatment of degenerative lumbar spinal spondylolisthesis. METHODS: Our sample was obtained from the national MarketScan Commercial Claims and Encounters Database. We reviewed patients undergoing lumbar laminectomy for stable degenerative lumbar spondylolisthesis (Grade-1) at one or two levels between January 2007 and December 2016. RESULTS: A total of 33,681 patients were included. By 2 years after the index operation, 2.48 % of patients had required lumbar fusion surgery. Female sex was associated with lower odds (OR 0.8, 95 %CI 0.7-0.9) of reoperation for fusion. Diabetes (OR 1.2, 95 %CI 1.1-1.4), rheumatoid arthritis (OR 1.5, 95 %CI 1.2-1.7) and clinical presentation with LBP (OR 2.1, 95 %CI 1.6-2.9), lower extremity weakness (OR 1.4, 95 %CI 1.1-1.5), as well as occurrence of a postoperative neurological complications (OR 2.0, 95 %CI 1.1-3.4) increased the odds ratio for requiring fusion surgery within two years after lumbar laminectomy. CONCLUSION: In this large cross-sectional sample of a national claims database consisting of lumbar laminectomy patients for the treatment of spondylolisthesis, approximately 2.5 % required subsequent lumbar fusion. Several modifiable risk factors for fusion progression were identified, which may guide clinicians in shared decision-making and to help identify patients with elevated post-operative risk providing potential leverage point for prevention.

Cyberknife Radiosurgery for Synovial Sarcoma Metastasizing to the Spine: Illustrative Case Reports.

Synovial sarcoma (SS) is a rare and aggressive type of soft tissue sarcoma that commonly affects young adults. Metastasis in the spine is a rare complication, and the management of these lesions is challenging. Radiosurgery is an increasingly popular treatment option for spinal metastasis due to its ability to deliver high doses of radiation to the target volume with minimal exposure to surrounding healthy tissues. In this paper, we present two cases of SS with spinal metastasis that were treated with CyberKnife radiosurgery (CKRS). The first case was a 52-year-old female with a history of multiple thoracotomies and lobectomies for lung metastases, who was diagnosed with T6-T8 and T4 spinal metastasis. The second case was a 53-year-old female with Down syndrome, who was diagnosed with T12-L1 spinal metastasis. Both patients experienced an improvement in their symptoms following CKRS treatment and showed stable or decreasing lesion sizes on follow-up imaging. The progression-free survival (PFS) in the first case was 37 months and overall survival (OS) was 79 months. In the second case, the PFS was 12 months and OS was 18 months. These cases highlight the potential benefits of CKRS as a treatment option for SS with spinal metastasis and support its use in the management of this challenging condition.

Clinical Outcomes and Cost Differences Between Patients Undergoing Primary Anterior Cervical Discectomy and Fusion Procedures with Private or Medicare Insurance: A Propensity Score-Matched Study.

OBJECTIVE: We assessed whether the insurance type reflects a patient's quality of care after an anterior discectomy and fusion (ACDF) procedure by comparing differences in the postoperative complications, readmission rates, reoperation rates, lengths of hospital stay, and cost of treatment between patients with Medicare versus private insurance. METHODS: Propensity score matching was used to match patient cohorts insured by Medicare and private insurance in the MarketScan Commercial Claims and Encounters Database (2007-2016). Age, sex, year of operation, geographic region, comorbidities, and operative factors were used to match cohorts of patients who had undergone an ACDF procedure. RESULTS: A total of 110,911 patients met the inclusion criteria. Of these patients, 97,543 patients (87.9%) were privately insured and 13,368 patients (12.1%) were insured by Medicare. The propensity score matching algorithm matched 7026 privately insured patients to 7026 Medicare patients. After matching, no significant differences were found in the 90-day postoperative complication rates, lengths of stay, or reoperation rates between the Medicare and privately insured cohorts. The Medicare group had had lower postoperative readmission rates for all time points: 30 days (1.8% vs. 4.6%; P < 0.001), 60 days (2.5% vs. 6.3%; P < 0.001), and 90 days (4.2% vs. 7.7%; P < 0.001). The median payment to physicians was significantly lower for the Medicare group ($3885 vs. $5601; P < 0.001). CONCLUSIONS: In the present study, propensity score matched patients covered by Medicare and private insurance who had undergone an ACDF procedure had had similar treatment outcomes.

Utilization of lateral anterior lumbar interbody fusion for revision of failed prior TLIF: illustrative case.

BACKGROUND: The use of the lateral decubitus approach for L5-S1 anterior lumbar interbody fusion (LALIF) is a recent advancement capable of facilitating single-position surgery, revision operations, and anterior column reconstruction. To the authors' knowledge, this is the first description of the use of LALIF at L5-S1 for failed prior transforaminal lumbar interbody fusion (TLIF) and anterior column reconstruction. Using an illustrative case, the authors discuss their experience using LALIF at L5-S1 for the revision of pseudoarthrosis and TLIF failure. OBSERVATIONS: The patient had prior attempted L2 to S1 fusion with TLIF but suffered from hardware failure and pseudoarthrosis at the L5-S1 level. LALIF was used to facilitate same-position revision at L5-S1 in addition to further anterior column revision and reconstruction by lateral lumbar interbody fusion at the L1-2 level. Robotic posterior T10-S2 fusion was then added to provide stability to the construct and address the patient's scoliotic deformity. No complications were noted, and the patient was followed until 1 year after the operation with a favorable clinical and radiological result. LESSONS: Revision of a prior failed L5-S1 TLIF with an LALIF approach has technical challenges but may be advantageous for single position anterior column reconstruction under certain conditions.

Impact of socio-economic factors on radiation treatment after resection of metastatic brain tumors: trends from a private insurance database.

BACKGROUND: Stereotactic radiosurgery (SRS) to the surgical bed of resected brain metastases is now considered the standard of care due to its advantages over whole brain radiation therapy (WBRT). Despite the upward trend in SRS adoption since the 2000s, disparities have been reported suggesting that socio-economic factors can influence SRS utilization. OBJECTIVE: To analyze recent trends in SRS use and identify factors that influence treatment. METHODS: We conducted a retrospective cohort study with the Optum Commercial Claims and Encounters Database and included all patients from 2004 to 2021 who received SRS or WBRT within 60 days after resection of tumors metastatic to the brain. RESULTS: A total of 3495 patients met the inclusion and exclusion criteria. There were 1998 patients in the SRS group and 1497 patients in the WBRT group. SRS use now supersedes WBRT by a wide margin. Lung, breast and colon were the most common sites of primary tumor. Although we found no significant differences based on race among the treatment groups, patients with annual household income greater than $75,000 and those with some college or higher education are significantly more likely to receive SRS (OR 1.44 and 1.30; 95% CI 1.18-1.76 and 1.08-1.56; P = 0.001 and 0.005, respective). Patients with Elixhauser Comorbidity Index of three or more were significantly more likely to receive SRS treatment. CONCLUSION: The use of post-surgical SRS for brain metastasis has increased significantly over time, however education and income were associated with differential SRS utilization.

Intracranial Hypertension Following Gunshot Wound to the Torcula: Case Report and Literature Review.

BACKGROUND: Elevation of bone for the treatment of depressed skull fractures overlying venous sinuses is rarely required or performed. The neurosurgical literature only describes a handful of cases of surgical intervention in which the posterior two-thirds of the superior sagittal sinus was involved. Clinical course is variable, signs and symptoms suggest increased intracranial pressure, and all conservative measures should be exhausted before proceeding with the surgical route. CASE DESCRIPTION: A 27-year-old man presented with a self-inflicted gunshot wound to posterior head. On presentation, there were no neurologic complaints. On imaging, the bullet fragment was associated with a comminuted anteriorly displaced fracture over the torcula. Vessel imaging showed tapering of the superior sagittal sinus and transverse sinuses near the torcula, suggesting narrowing due to mass effect. The patient did not respond to initial conservative management and developed worsening diplopia and papilledema concerning for increased intracranial pressure. Occipital/suboccipital craniectomy was performed with elevation of depressed skull fracture, decompression of dural venous sinus, removal of bullet, and mesh cranioplasty. Repeat ophthalmology examination postoperatively showed improvement in optic disc edema and diplopia. CONSLUSIONS: This case confirms that the approach of surgical management of superior sagittal venous sinus injuries associated with skull fractures described in the literature also can be used successfully for injuries over the torcula if conservative management does not help alleviate the symptoms and results in good outcome. It was felt that delayed surgery also plays an important role, as it gives time for scar tissue to form, which may help to protect the sinus from injury during surgery.

Pre-operative Voriconazole in patients undergoing surgery for Central Nervous System fungal infections: Special Report.

Fungal infections of the central nervous system (CNS) are uncommon. Despite several advancements in diagnosis and treatment of these infections, the mortality rates remain high. The current retrospective study was planned to define the demographic and clinical features of patients with CNS fungal infections. Conducted at Aga Khan University Hospital, Karachi, and comprising CNS fungal infections operated between January 2000 and December 2015. The study analysed whether a short course of pre-operative anti-fungal therapy may improve outcomes in these patients. There were 47 cases confirmed on histopathology and/or microbiology. Outcome measures used were Glasgow coma score (GCS), Glasgow outcome score (GOS) and Karnofsky performance score (KPS). The overall 30-day mortality was 20(42.5%). Fungal infections of the CNS can occur in both immune-compromised and immune-competent patients. Early diagnosis, radical surgery, pre-operative anti-fungal therapy for at least 2 weeks, pre- and postoperative Voriconazole therapy results in more favourable outcomes.

Choosing between endoscopic or microscopic removal of third ventricle colloid cysts.

Colloid cysts are benign lesions, found in the anterior part of the roof of the third ventricle. A PubMED search of literature was performed to identify the evidence on different treatment options and surgical approaches for removal of colloid cysts. Evidence on endoscopic versus microsurgical resection of colloid cysts showed that microsurgical approach had significantly higher rates of gross total resection, lower recurrence rate and lower re-operation rate. No significant difference with respect to the mortality rate or the need for a shunt was found between the two groups. However, the overall morbidity rate was lower for the endoscopic group. .

Outcomes of post-neurosurgical ventriculostomy-associated infections.

BACKGROUND: Ventriculostomy-associated infection (VAI) is a major concern to physicians. Limited studies have looked at the outcomes of external ventricular drain (EVD) infection and predictors of unfavorable outcomes. In this study, we assessed the outcomes of EVD infection and predictors of unfavorable outcomes. METHODS: This was a retrospective medical chart review, conducted at the Aga Khan University Hospital. All the patients irrespective of age and gender, fulfilling the diagnostic criteria of VAI were included. Patients with preexisting bacterial meningitis or ventriculitis were excluded from the study. Outcome assessment was based on Glasgow outcome scale (GOS) at 1 and 3 months after procedure. Other outcomes included 30-day mortality and total length of hospital stay. RESULTS: We included 256 patients in the study. 66 patients (25.8%) developed VAI. EVD was the primary procedure in 21 (31.8%) cases. Most patients, 24 (36.4%), had EVD as a secondary procedure for tumor surgery. Median interval between EVD placement and diagnosis of infection was 3 days. Mean length of stay in VAI patients was 31.85 ± 20.53 days. Seven patients required ICU care. Ten patients (15.2%) expired during hospital stay or within 30 days of discharge and further four had GOS of 2 or 3. A total of 52 patients had a favorable outcome after 6 months. CONCLUSIONS: Rate of VAI in this cohort was high. VAI is associated with increased morbidity, mortality, and prolonged hospital stay.