Clinical impact of craniectomy on shunt-dependent hydrocephalus after intracerebral hemorrhage: A propensity score-matched analysis.

PURPOSE: A consensus on decompressive craniectomy for intracerebral hemorrhage (ICH) has not yet been established. We aimed to investigate the development of shunt-dependent hydrocephalus based on the method of ICH surgery, with a focus on craniectomy. METHODS: We retrospectively enrolled 458 patients with supratentorial ICH who underwent surgical hematoma evacuation between April 2005 and December 2021 at two independent stroke centers. Multivariate analyses were performed to characterize risk factors for postoperative shunt-dependent hydrocephalus. Propensity score matching (1:2) was undertaken to compensate for group-wise imbalances based on probable factors that were suspected to affect the development of hydrocephalus, and the clinical impact of craniectomy on shunt-dependent hydrocephalus was evaluated by the matched analysis. RESULTS: Overall, 43 of the 458 participants (9.4%) underwent shunt procedures as part of the management of hydrocephalus after ICH. Multivariate analysis revealed that intraventricular hemorrhage (IVH) and craniectomy were associated with shunt-dependent hydrocephalus after surgery for ICH. After propensity score matching, there were no statistically significant intergroup differences in participant age, sex, hypertension status, diabetes mellitus status, lesion location, ICH volume, IVH occurrence, or IVH severity. The craniectomy group had a significantly higher incidence of shunt-dependent hydrocephalus than the non-craniectomy group (28.9% vs. 4.3%, p < 0.001; OR 9.1, 95% CI 3.7-22.7), craniotomy group (23.2% vs. 4.3%, p < 0.001; OR 6.6, 95% CI 2.5-17.1), and catheterization group (20.0% vs. 4.0%, p = 0.012; OR 6.0, 95% CI 1.7-21.3). CONCLUSION: Decompressive craniectomy seems to increase shunt-dependent hydrocephalus among patients undergoing surgical ICH evacuation. The decision to perform a craniectomy for patients with ICH should be carefully individualized while considering the risk of hydrocephalus.

Integrated proteogenomic characterization of glioblastoma evolution.

The evolutionary trajectory of glioblastoma (GBM) is a multifaceted biological process that extends beyond genetic alterations alone. Here, we perform an integrative proteogenomic analysis of 123 longitudinal glioblastoma pairs and identify a highly proliferative cellular state at diagnosis and replacement by activation of neuronal transition and synaptogenic pathways in recurrent tumors. Proteomic and phosphoproteomic analyses reveal that the molecular transition to neuronal state at recurrence is marked by post-translational activation of the wingless-related integration site (WNT)/ planar cell polarity (PCP) signaling pathway and BRAF protein kinase. Consistently, multi-omic analysis of patient-derived xenograft (PDX) models mirror similar patterns of evolutionary trajectory. Inhibition of B-raf proto-oncogene (BRAF) kinase impairs both neuronal transition and migration capability of recurrent tumor cells, phenotypic hallmarks of post-therapy progression. Combinatorial treatment of temozolomide (TMZ) with BRAF inhibitor, vemurafenib, significantly extends the survival of PDX models. This study provides comprehensive insights into the biological mechanisms of glioblastoma evolution and treatment resistance, highlighting promising therapeutic strategies for clinical intervention.

Effect of Bevacizumab Treatment in Cerebral Radiation Necrosis : Investigation of Response Predictors in a Single-Center Experience.

OBJECTIVE: Bevacizumab is a feasible option for treating cerebral radiation necrosis (RN). We investigated the clinical outcome of RN after treatment with bevacizumab and factors related to the initial response and the sustained effect. METHODS: Clinical data of 45 patients treated for symptomatic RN between September 2019 and February 2021 were retrospectively collected. Bevacizumab (7.5 mg/kg) was administered at 3-week intervals with a maximum four-cycle schedule. Changes in the lesions magnetic resonance image (MRI) scans were examined for the response evaluation. The subgroup analysis was performed based on the initial response and the long-term maintenance of the effect. RESULTS: Of the 45 patients, 36 patients (80.0%) showed an initial response, and eight patients (17.8%) showed delayed worsening of the corresponding lesion. The non-responders showed a significantly higher incidence of diffusion restriction on MRI than the responders (100.0% vs. 25.0%, p<0.001). The delayed worsening group showed a significantly higher proportion of glioma pathology than the maintenance group (87.5% vs. 28.6%, p=0.005). Cumulative survival rates with sustained effect were significantly higher in the groups with non-glioma pathology (p=0.019) and the absence of diffusion restriction (p<0.001). Pathology of glioma and diffusion restriction in MRI were the independent risk factors for non-response or delayed worsening after initial response. CONCLUSION: The initial response of RN to bevacizumab was favorable, with improvement in four-fifths of the patients. However, a certain proportion of patients showed non-responsiveness or delayed exacerbations. Bevacizumab may be more effective in treating RN in patients with non-glioma pathology and without diffusion restriction in the MRI.

Safety and Efficacy of Low-dose Prasugrel in the Endovascular Treatment of Unruptured Aneurysms in the Elders (≥ 75 Years).

PURPOSE: The effectiveness and safety of low-dose prasugrel (PSG) premedication for endovascular treatment of unruptured intracranial aneurysms (UIAs) have been widely reported. In this study, we evaluated the clinical outcomes of elders patients (≥ 75 years) treated with PSG. METHODS: A total of 200 patients with 209 UIAs who were administered PSG as premedication (20 mg loading and 5 mg maintenance with 100 mg aspirin) between March 2018 and December 2021 were retrospectively enrolled. Among them, 39 patients were aged 75 years or over (elders group), and 161 patients were aged under 75 years (control group). Patients' clinical data were collected, and outcomes were compared between the two groups. RESULTS: Of the 200 patients with PSG, 9 cases (4.5%) had overall complications (7 ischemic, 2 hemorrhagic). In the comparison between the elders group and the control group, no significant differences were observed in the overall complication rates (elders group vs. control group; 2.6% vs. 5.0%, P = 1.00). Moreover, the rates of poor clinical outcome were comparable (2.6% vs. 1.2%, P = 0.48). The subgroup analysis of patients with stent-assisted procedures revealed no significant differences in complication rates (0% vs. 1.6%, P = 1.00) or poor clinical outcomes (0% vs. 0%, P = 1.00) during maintenance with aspirin 100 mg or PSG 5 mg. CONCLUSION: The complication rates in the elders treated with low-dose PSG premedication were similar to those in the control. Low-dose PSG premedication could be prescribed without any additional risk for the endovascular treatment of UIAs in elders patients.

Clinical Impact of Hydroxyapatite on the Outcome of Skull Base Reconstruction for Intraoperative High-Flow CSF Leak: A Propensity Score Matching Analysis.

Background: Despite recent advances in skull base reconstructive techniques, including the multilayer technique during the last decade, complete reconstruction of grade 3 intraoperative high-flow cerebrospinal fluid (CSF) leak remains challenging. This study was designed to investigate the role of injectable hydroxyapatite (HXA) used in the multilayer technique on the clinical outcome of skull base reconstruction for intraoperative high-flow CSF leak. Materials and Methods: This study enrolled 187 patients who experienced intraoperative high-flow CSF leak after endoscopic endonasal surgery for anterior skull base or suprasellar pathologies between January 2014 and July 2021. All skull base defects were reconstructed using the conventional multilayer technique including a vascularized naso-septal flap (NSF, n = 141) and the combined use of HXA with the conventional multilayer technique (HXA group, n = 46). We retrospectively evaluated the efficacy of the HXA group by 1:2 propensity score matching analysis. Results: Overall, 17 of 187 patients (9.1%) showed postoperative CSF leaks, resulting in second reconstruction surgery. There were no statistical differences in patient age, sex, body mass index, tumor location, tumor type, and degree of resection, except for the follow-up period between the two groups. The HXA group showed a significantly lower incidence of postoperative CSF leak than the control group (0% vs. 12.1%, p < 0.05). Postoperative lumbar drain (LD) was performed in 8.7% of the HXA group compared to 46.1% of the control group (p < 0.01). CSF leak-related infection rates showed a decreasing tendency in the HXA group compared to the control group (0 vs. 7.1%, p = 0.06). A total of 46 patients in the HXA group were well matched with the control group (92 patients) at a 1:2 ratio. In the propensity score-matched control group, there were higher rates of postoperative CSF leaks than in the HXA group. Conclusion: The use of HXA combined with the conventional multilayer technique completely reduced postoperative CSF leaks in this study. This technique resulted in reduced CSF leakage, even without postoperative LD, and decreased infection rates. Further randomized comparative studies are required to confirm our findings.

Comparison of Postoperative Complications between Simultaneous and Staged Surgery in Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy.

OBJECTIVE: Cranioplasty (CP) and ventriculoperitoneal shunt (VPS) are required procedures following decompressive craniectomy (DC) for craniofacial protection and to prevent hydrocephalus. This study assessed the safety and efficacy of simultaneous operation with CP and VPS after DC, and determined the preoperative risk factors for postoperative complications. METHODS: Between January 2009 and December 2019, 81 patients underwent CP and VPS in simultaneous or staged operations following DC. Cumulative medical records and radiologic data were analyzed using univariate analysis to identify factors predisposing patients to complications after CP and VPS. RESULTS: CP and VPS were performed as simultaneous or staged operations in 18 (22.2%) and 63 (77.8%) patients, respectively. The overall postoperative complication rate was 16.0% (13/81). Patients who underwent simultaneous CP and VPS were significantly more likely to experience complications when compared with patients who underwent staged operations (33.3% vs. 9.6%, p<0.01). Univariate analysis revealed that simultaneous CP and VPS surgery was the only significant predictor of postoperative complications (p=0.031). CONCLUSION: This study provided detailed data on surgical timing and complications for CP and VPS after DC. We showed that simultaneous procedures were a significant risk factor for postoperative complications.

Macrophage migration inhibitory factor (MIF) inhibitor 4-IPP downregulates stemness phenotype and mesenchymal trans-differentiation after irradiation in glioblastoma multiforme.

Radiation therapy is among the most essential treatment methods for glioblastoma multiforme (GBM). Radio-resistance and cancer stem cell properties can cause therapeutic resistance, cancer heterogeneity, and poor prognoses in association with GBM. Furthermore, the GBM subtype transition from proneural to the most malignant mesenchymal subtype after radiation therapy also accounts for high resistance to conventional treatments. Here, we demonstrate that the inhibition of macrophage migration inhibitory factor (MIF) and D-dopachrome tautomerase (DDT) by 4-iodo-6-phenylpyrimidine (4-IPP), a dual inhibitor targeting MIF and DDT, downregulates stemness phenotype, intracellular signaling cascades, mesenchymal trans-differentiation, and induces apoptosis in proneural glioma stem cells (GSCs). In an analysis of The Cancer Genome Atlas, high MIF and DDT expression were associated with poor prognosis. GSC growth was effectively inhibited by 4-IPP in a time- and dose-dependent manner, and 4-IPP combined with radiation therapy led to significantly reduced proliferation compared with radiation therapy alone. The expression of stemness factors, such as Olig2 and SOX2, and the expression of pAKT, indicating PI3K signaling pathway activation, were decreased in association with both 4-IPP monotherapy and combination treatment. The expression of mesenchymal markers, TGM2 and NF-κB, and expression of pERK (indicating MAPK signaling pathway activation) increased in association with radiation therapy alone but not with 4-IPP monotherapy and combination therapy. In addition, the combination of 4-IPP and radiation therapy significantly induced apoptosis compared to the monotherapy of 4-IPP or radiation. In vivo results demonstrated a significant tumor-suppressing effect of 4-IPP when combined with radiation therapy. Collectively, our results showed that the targeted inhibition of MIF and DDT has the potential to strengthen current clinical strategies by enhancing the anticancer effects of radiation therapy.

Clinical Pathway for Emergency Brain Surgery during COVID-19 Pandemic and Its Impact on Clinical Outcomes.

BACKGROUND: One of the challenges neurosurgeons are facing in the global public health crisis caused by the coronavirus disease 2019 (COVID-19) pandemic is to balance COVID-19 screening with timely surgery. We described a clinical pathway for patients who needed emergency brain surgery and determined whether differences in the surgery preparation process caused by COVID-19 screening affected clinical outcomes. METHODS: During the COVID-19 period, patients in need of emergency brain surgery in our institution were managed using a novel standardized pathway designed for COVID-19 screening. We conducted a retrospective review of patients who were hospitalized through the emergency room and underwent emergency brain surgery. A total of 32 patients who underwent emergency brain surgery from February 1 to June 30, 2020 were included in the COVID-19 group, and 65 patients who underwent surgery from February 1 to June 30, 2019 were included in the pre-COVID-19 group. The baseline characteristics, disease severity indicators, time intervals of emergency processes, and clinical outcomes of the two groups were compared. Subgroup analysis was performed between the immediate surgery group and the semi-elective surgery group during the COVID-19 period. RESULTS: There were no significant differences in baseline characteristics and severity indicators between the pre-COVID-19 group and COVID-19 group. The time interval to skin incision was significantly increased in the COVID-19 group (P = 0.027). However, there were no significant differences in the clinical outcomes between the two groups. In subgroup comparison, the time interval to skin incision was shorter in the immediate surgery group during the COVID-19 period compared with the pre-COVID-19 group (P = 0.040). The screening process did not significantly increase the time interval to classification and admission for immediate surgery. The time interval to surgery initiation was longer in the COVID-19 period due to the increased time interval in the semi-elective surgery group (P < 0.001). CONCLUSION: We proposed a clinical pathway for the preoperative screening of COVID-19 in patients requiring emergency brain surgery. No significant differences were observed in the clinical outcomes before and after the COVID-19 pandemic. The protocol we described showed acceptable results during this pandemic.

Growth profile assessment of young adults with tethered cord syndrome: a retrospective cohort analysis of Korean conscription data.

PURPOSE: Tethered cord syndrome (TCS) is characterized by progressive spinal cord degeneration secondary to congenital spinal dysraphism. The associated accompanying physical inactivity and musculoskeletal deformities have raised interest in the growth profile of adult TCS patients. However, few previous studies have investigated the growth profile of adult TCS patients. METHODS: We retrospectively reviewed the demographic data and medical records of 20-year-old Korean conscription examinees who were registered between April 2004 and September 2019. In total, 151 examinees with a diagnosis of TCS were enrolled. The height, weight, and body mass index (BMI) of 300 randomly selected examinees were compared to the TCS group. Obesity was defined by the World Health Organization and Asian-Pacific criteria for BMI and compared between the groups. Growth profile differences according to tethering location and musculoskeletal deformities were analyzed in both groups. RESULTS: The mean height, weight, and BMI values of the TCS group were lower than those of the control group. The TCS group had a lower proportion of obese and overweight individuals, and a higher proportion of underweight individuals, according to both BMI criteria. The tethering level was not associated with the degree of obesity in the tethered group. The mean height, weight, and BMI were lower in the tethered group regardless of the existence of musculoskeletal deformity. CONCLUSION: Enrollees with a history of TCS were smaller than controls of the same age. Monitoring of health behaviors, including nutrition, diet, and exercise, is warranted for TCS patients.

Impact of adolescent complex regional pain syndrome on the psychopathology of young men ahead of military service: a retrospective cohort analysis of Korean conscription data.

BACKGROUND: The relationship between physical and psychopathological features in complex regional pain syndrome (CRPS) has been a subject of constant interest, but no data are available in adolescents. Therefore, we aimed to identify the factors associated with psychopathology in adolescents with CRPS ahead of military service. METHODS: We retrospectively reviewed all conscription examinees who had completed a Military Personality Inventory (MPI) during a period between February 2013 and December 2016. A total of 63 persons with a history of CRPS (19-years of age for all) were enrolled. Basic demographic and pain-related data were analyzed to examine their association with MPI results. The mean FGR score as well as the 8 subdomain scores were compared between those with pain duration at < 15 months (n = 30) versus ≥15 months (n = 33). Binary MPI results (normal-abnormal) were also compared between the two groups. RESULTS: In multivariate analysis, abnormal MPI was associated with pain duration, with an odds ratio (OR) at 1.05 for every 1-month increase (95% confidence interval (CI) 1.02-1.08; P = 0.002). Subjects with pain duration at ≥15 months have lower faking good response score (P < 0.001 vs. those with pain duration at < 15 months), and higher abnormal MPI result rate, faking bad response, inconsistency, anxiety, depression, somatization, paranoid, personality disorder cluster A, and personality disorder cluster B scores (P < 0.05). Pain duration was significantly associated with the MPI variables. CONCLUSIONS: Pain duration is associated with psychopathology in adolescents with CRPS. Psychopathologic features increased as the disease duration increased. A comprehensive understanding of time-dependent psychopathological factors could support the planning of multimodal approaches for managing adolescent CRPS.

Psychopathological Influence of Middle Fossa Arachnoid Cysts in Young Men: Analysis of Korean Conscription Data.

BACKGROUND: A few reported studies have documented psychotic syndromes secondary to a middle fossa arachnoid cyst (AC). However, the association between middle fossa ACs and psychopathological symptoms remains to be determined. The present study investigated the psychopathological effects of middle fossa ACs in young men. METHODS: We reviewed military personal inventory test profiles and baseline demographic data of 19-year-old conscription examinees from February 2013 to December 2016. In total, 132 examinees with middle fossa ACs and 350 examinees with normal findings were enrolled in the present study. Two separate comparisons were performed. First, we compared the middle fossa AC group with the control group. Second, the middle fossa AC group was divided into 2 groups according to cyst size and compared with the control group. RESULTS: Faking bad response behavior, infrequency, inconsistency, depression, schizophrenia, paranoia, and personality disorder cluster A scales were significantly associated with the presence of a middle fossa AC. Abnormal responses to the military personal inventory were significantly and positively correlated with cyst size. The prediction rate to show abnormal psychological results with the presence of an AC was estimated to be 60.7%-68.8%. CONCLUSIONS: The presence of ACs and cyst size were associated with psychopathology in this select group of young men. The size-dependent psychopathological effects of ACs appear to result from a local mass effect on the brain.

What Effects Does Necrotic Area of Contrast-Enhanced MRI in Osteoporotic Vertebral Fracture Have on Further Compression and Clinical Outcome?

OBJECTIVE: The objective of this study was to analyze the correlation between further compression and necrotic area in osteoporotic vertebral fracture (OVF) patients with contrast-enhanced magnetic resonance imaging (CEMRI). In addition, we investigated the radiological and clinical outcome according to the range of the necrotic area. METHODS: Between 2012 and 2014, the study subjects were 82 OVF patients who did not undergo vertebroplasty or surgical treatment. The fracture areas examined on CEMRI at admission were defined as edematous if enhancement was seen and as necrotic if no enhancement was seen. The correlation between further compression and the necrotic and edematous areas of CEMRI, age, and bone mineral density was examined. Also, necrotic areas were classified into those with less than 25% (non-necrosis group) and those with more than 25% (necrosis group) according to the percentages of the entire vertebral body. For both groups, further compression and the changes in wedge and kyphotic angles were examined at admission and at 1 week, 3 months, and 6 months after admission, while the clinical outcomes were compared using the visual analog scale (VAS) and Eastern Cooperative Oncology Group (ECOG) performance status grade. RESULTS: Further compression was 14.78±11.11% at 1 month and 21.75±14.43% at 6 months. There was a very strong correlation between the necrotic lesion of CEMRI and further compression (r=0.690, p<0.001). The compression of the necrosis group was 33.52±12.96%, which was higher than that of the non-necrosis group, 14.96±10.34% (p<0.005). Also, there was a statistically significantly higher number of intervertebral cleft development and surgical treatments being performed in the necrosis group than in the non-necrosis group (p<0.005). Moreover, there was a statistical difference in the decrease in the height of the vertebral body, and an increase was observed in the kyphotic change of wedge angle progression. There was also a difference in the VAS and ECOG performance scales. CONCLUSION: The necrotic area of CEMRI in OVF had a strong correlation with further compression over time. In addition, with increasing necrosis, intervertebral clefts occurred more frequently, which induced kyphotic changes and resulted in poor clinical outcomes. Therefore, identifying necrotic areas by performing CEMRI on OVF patients would be helpful in determining their prognosis and treatment course.

The fatty degeneration of lumbar paraspinal muscles on computed tomography scan according to age and disc level.

BACKGROUND CONTEXT: Spinal degeneration can occur not only in the bone and disc but also in muscles. Fatty infiltration (FI) and decreased volume have been described as characteristic changes that occur in muscle degeneration. Many studies about the lumbar paraspinal muscles have been conducted on patients with spine problems. However, the natural changes of age-dependent degeneration in the paraspinal muscles have not been studied properly. PURPOSE: The purpose of this study is to investigate age- and level-dependent changes of the lumbar paraspinal muscles in the population without lumbar spinal symptoms. STUDY DESIGN: This study is a retrospective case-control study. PATIENT SAMPLE: A total of 887 patients who underwent computed tomography scan for abdomen and pelvis (APCT) between January 2013 and December 2013 were enrolled. After excluding 237 patients with medical history of spine surgery, low back pain, myopathy, muscular dystrophy, infectious disease, vertebral fracture, and deformity, 650 patients were finally subjected to this study. OUTCOME MEASURE: The patients were divided into three age groups: young (20-39 years old), middle (40-59 years old), and old (60-89 years old). The degree of FI was checked twice for multifidus muscle (MF), erector spinae muscle (ES), and psoas muscle (PS) at each disc level from L1 to S1 on APCT by two investigators. The FI was measured as the Hounsfield unit, a mean density (MD) on CT. METHODS: The age differences were compared with the data of the young group, and the level differences were compared with the data of the L1-L2 level. Student t test and intraclass correlation coefficient were checked for statistical analysis. RESULTS: The gender ratio was not significantly different among the groups. Comparing with the young group, the MD of MF significantly decreased at L5-S1 in the middle group (p<.05), and at L3-L4-L5-S1 in the old group (p<.05). The MD of ES was significantly decreased at all levels in the old group (p<.05) but not significant in the middle group. Comparing with the L1-L2 level, the MD of MF significantly decreased at L5-S1 in the middle group (p<.05) and at L4-L5-S1 in the old group (p<.05). The MD of ES was significantly decreased at L5-S1 in the young and middle groups (p<.05) and at L4-L5-S1 in the old group (p<.01) compared with those at L1-L2. According to the age- and level-dependent changes of MD in the MF and ES, there was a tendency of progressive increase of FI in the muscles with age, which seemed to start from L5-S1 and spread to the upper levels. The age-dependent fatty degeneration appeared wider in the ES than the MF. The level-dependent FI of the ES showed a similar pattern with the MF, but the change of the ES seemed to start earlier in age than the MF at the L5-S1. There was no significant MD change in the PS according to age and level. Intraobserver and interobserver reliabilities were both high across all of the muscles (0.86-0.94 and 0.83-0.92). CONCLUSIONS: As a result, the degree of intramuscular fat infiltration seems to be affected by age, disc level, and muscle type. It seems to be more prominent in the extensor muscles, extending from lower to upper levels.

A Case of Traumatic Unilateral Internuclear Ophthalmoplegia: Clinical Significance of Susceptibility-Weighted Imaging.

A 43-year-old man was admitted for head trauma after falling backward. The patient complained of diplopia. Unilateral internuclear ophthalmoplegia (INO) was diagnosed during the neurologic examination. Initially, no specific finding was shown on T2-weighted, T1-weighted, and fluid attenuated inversion recovery brain magnetic resonance image (MRI) or brain computed tomography (CT). However, susceptibility-weighted imaging (SWI) definitively demonstrated a tiny hemorrhage at the midline of the pontomesencephalic junction. The patient's symptom improved after 12 weeks. We discuss the clinical significance of SWI when traumatic INO due to a tiny hemorrhage is suspected.

The Prevalence of Undiagnosed Presurgical Cognitive Impairment and Its Postsurgical Clinical Impact in Older Patients Undergoing Lumbar Spine Surgery.

OBJECTIVE: Because elderly patients are undergoing more surgeries, the importance of postoperative cognitive impairment (CI) evaluations is rising, especially for spine surgery, which is related to subjective pain. We investigated the prevalence of undiagnosed CI among elderly patients who underwent spine surgery and the impact of CI on postoperative outcomes. METHODS: The preoperative cognitive statuses of 129 patients over 65 who underwent lumbar spine surgery from 2012 to 2014 were determined with the Mini-Mental State Examination, and patients with scores under 24 were diagnosed with CI. The patients were then divided into a CI group (n=49) and non-cognitive impairment (NCI) group (n=80). RESULTS: Among the 129 patients, 49 (38.0%) were diagnosed with CI, and 9 (7.0%) had severe CI. The age of the CI group (72.88±6.20 years) was significantly greater than that of the NCI group (69.96±4.53 years). In contrast, the postoperative visual analog scale scores and performance statuses did not differ significantly. However, postoperative delirium was more frequent and the hospital stay length was longer in the CI group compared with the NCI group (p<0.05). CONCLUSION: A high prevalence of undiagnosed CI was discovered among elderly patients undergoing spine surgery. The existence of CI was associated with higher rates of postoperative delirium and prolonged hospital stays, which affected clinical outcomes. Thus, CI assessments should be included in preoperative evaluations of elderly patients prior to spine surgery.