Durable responses at 24 months with high-frequency spinal cord stimulation for nonsurgical refractory back pain.

OBJECTIVE: The objective of this study was to evaluate the 24-month durability of pain relief, function, quality of life, and safety outcomes for patients with nonsurgical refractory back pain (NSRBP) treated with high-frequency spinal cord stimulation (SCS) within a large, national, multicenter randomized controlled trial (RCT). METHODS: Following the completion of an RCT comparing high-frequency SCS plus CMM with CMM alone for the treatment of NSRBP, patients gave additional consent for a follow-up extension to 24 months. Presented is the cohort analysis of all patients treated with high-frequency SCS following the optional crossover at 6 months. The outcomes assessed to 24 months included responder rate of ≥ 50% pain relief measured according to the visual analog scale [VAS]), disability (Oswestry Disability Index [ODI]), quality of life (EQ-5D 5-level [EQ-5D-5L]), opioid reduction. RESULTS: Of the 125 patients who received a permanent implant, 121 completed the 12-month follow-up, 101 gave additional consent for extended follow-up, and 98 completed the 24-month follow-up. At 24 months after implantation, the mean back pain VAS score was reduced by 73% and the responder rate was 82%. ODI and EQ-5D-5L both improved by at least double the minimal clinically important difference for each measure. No unexpected adverse events were observed, and the rates of serious adverse events (3.4%) and device explantations (4.8%) were low. CONCLUSIONS: The addition of high-frequency SCS to CMM in patients with NSRBP offers profound improvements at 24 months in pain, function, quality of life, and reduced opioid use. This study provides much-needed evidence to inform current clinical practice for managing patients with NSRBP.

Effect of STN/GPi DBS on swallowing function in Parkinson's disease as assessed by Video fluoroscopy: A retrospective study.

INTRODUCTION: The goal of the study is to objectively assess changes in swallowing (using "gold standard" video fluoroscopy (VFS)) following Deep Brain Stimulation (DBS) surgery in Parkinson's disease (PD) patients. There are few studies on the effect of DBS on swallowing in PD. We use VFS to assess swallowing function pre- and post-DBS. METHODS: Our study participants underwent pre- and post-DBS VFS (6 months later) in the practically defined on state. We converted VFS reports into an objective numerical scale. Higher scores denote more severe dysphagia. We used non-parametric test (Wilcoxon signed rank test) to test if the difference between pre- and post-DBS swallow score is significantly different from 0. RESULTS: Fifty-four PD patients completed pre- and post-DBS evaluations. Twenty-five patients had bilateral GPi DBS (46.3%) and 29 had bilateral STN DBS (53.7%). The mean (SD) post-DBS swallow score is 1.9 (2.0) and pre-DBS swallow score is 1.6 (1.3). The difference is not significantly different from 0 (p = 0.16). In our study, swallow scores for majority of the patients (39 out of 54) did not change after DBS regardless of lead location. Six (11.1%) PD patients had post-DBS swallow score decrease on average by 1 (SD: 0) points. 9 (16.7%) patients had post-DBS swallow score increase on average by 2.7 (SD: 2.3) points. CONCLUSION: There was no statistically significant change in the swallow scores pre-and 6 months post-DBS with VFS when assessed in the practically defined on state, regardless of the site of bilateral lead implantation. Hence, we believe that DBS does not improve or reduce swallow function in a clinically meaningful way in PD.

Factors associated with greater patient satisfaction in outpatient neurosurgical clinics: Recommendation for surgery, older age, cranial chief complaint, and public health insurance.

OBJECTIVE: Patient satisfaction has increasingly played a role in determining care quality. Surveys are used to gauge patient experience, satisfaction of care, and likelihood to recommend providers and facilities. The aim of the study is to evaluate whether clinical and demographic data predict greater patient satisfaction with providers in the outpatient neurosurgery clinic. METHODS: Press-Ganey (Press Ganey Associates, South Bend, IL) evaluations of 1521 patients were reviewed in an academic neurosurgical clinic from January 1, 2019 through February 1, 2021. We analyzed associations between Press-Ganey ratings and patient demographics, chief complaint, psychiatric comorbidities, number of orders placed, medication prescriptions, surgical recommendation, payor status, and referral source. We used univariate logistic regression to assess for associations between independent variables and Press-Ganey ratings. Multivariable logistic regression was used for associated factors. RESULTS: For the Likelihood to Recommend question, older age (p = 0.003), cranial chief complaint (p = 0.046), and recommendations for surgery (p < 0.001) were significantly associated with "good" ratings. For the rating of Care Received, older age (p = 0.002), cranial chief complaint (p = 0.05), and recommendations for surgery (p = 0.002) were significantly associated with "good" ratings. For Confidence in Care Provider question, recommendations for surgery (p = <0.001) and government insurance type (p = 0.002) were significantly associated with "good" ratings. CONCLUSIONS: Patients with older age, cranial pathologies, a recommendation for surgery, and government health insurance were significantly associated with favorable patient satisfaction with providers in the outpatient neurosurgery clinic. Prospective studies should target patient populations who are younger, have spinal complaints, have non-surgical needs, and have commercial insurance to improve satisfaction.

Multispecialty perspective on intradural disc herniation: diagnosis and management - A case report.

BACKGROUND: Intradural disc herniation (IDH) is a very rare and challenging diagnosis, with an estimated incidence of less than 1.5%. The pathogenesis of IDH remains uncertain. Definitive management remains surgical; however, some cases may initially be managed non-surgically. CASE: A middle-aged male with presented with acute right-sided lumbar radiculopathy following heavy lifting. History was significant for prior lumbar disc herniation managed non-surgically. Lumbar MRI demonstrated a large disc herniation. The patient was initially treated non-surgically with epidural steroid injections. At 4-months, he re-injured and follow-up images demonstrated the herniated disc penetrating the dura and the diagnosis of intradural disc herniation. CONCLUSIONS: The present case is rare because the IDH occurred at the L3-4 level and resulted in unilateral radiculopathy without cauda-equina symptoms and occurred in the absence of prior surgery. This patient was initially treated non-surgically with satisfactory relief, however, reinjury led to progression of IDH with new neurological deficits necessitating surgery.

Treatment of nonsurgical refractory back pain with high-frequency spinal cord stimulation at 10 kHz: 12-month results of a pragmatic, multicenter, randomized controlled trial.

OBJECTIVE: Spinal cord stimulation (SCS) at 10 kHz (10-kHz SCS) is a safe and effective therapy for treatment of chronic low-back pain. However, it is unclear from existing evidence whether these findings can be generalized to patients with chronic back pain that is refractory to conventional medical management (CMM) and who have no history of spine surgery and are not acceptable candidates for spine surgery. The authors have termed this condition "nonsurgical refractory back pain" (NSRBP) and conducted a multicenter, randomized controlled trial to compare CMM with and without 10-kHz SCS in this population. METHODS: Patients with NSRBP, as defined above and with a spine surgeon consultation required for confirmation, were randomized 1:1 to patients undergoing CMM with and without 10-kHz SCS. CMM included nonsurgical treatment for back pain, according to physicians' best practices and clinical guidelines. Primary and secondary endpoints included the responder rate (≥ 50% pain relief), disability (Oswestry Disability Index [ODI]), global impression of change, quality of life (EQ-5D-5L), and change in daily opioid use and were analyzed 3 and 6 months after randomization. The protocol allowed for an optional crossover at 6 months for both arms, with observational follow-up over 12 months. RESULTS: In total, 159 patients were randomized; 76 received CMM, and 69 (83.1%) of the 83 patients who were assigned to the 10-kHz SCS group received a permanent implant. At the 3-month follow-up, 80.9% of patients who received stimulation and 1.3% of those who received CMM were found to be study responders (primary outcome, ≥ 50% pain relief; p < 0.001). There was also a significant difference between the treatment groups in all secondary outcomes at 6 months (p < 0.001). In the 10-kHz SCS arm, outcomes were sustained, including a mean 10-cm visual analog scale score of 2.1 ± 2.3 and 2.1 ± 2.2 and mean ODI score of 24.1 ± 16.1 and 24.0 ± 17.0 at 6 and 12 months, respectively (p = 0.9). In the CMM arm, 74.7% (56/75) of patients met the criteria for crossover and received an implant. The crossover arm obtained a 78.2% responder rate 6 months postimplantation. Five serious adverse events occurred (procedure-related, of 125 total permanent implants), all of which resolved without sequelae. CONCLUSIONS: The study results, which included follow-up over 12 months, provide important insights into the durability of 10-kHz SCS therapy with respect to chronic refractory back pain, physical function, quality of life, and opioid use, informing the current clinical practice for pain management in patients with NSRBP.

Atlantoaxial Osteoarthritis: A Well-Established Entity that Remains Frequently Overlooked.

Painful atlantoaxial (C1-2) osteoarthritis (AAOA) has been described over 40 years ago. The condition may cause severe pain symptoms and disability related to the unilateral suboccipital pain and, in some cases, occipital neuralgia. One of the greatest challenges with AAOA is making the diagnosis. Diagnosis is commonly missed or delayed when headaches are treated in isolation or when pain is attributed to subaxial spondylosis. Here we present an illustrative case involving a 67-year-old male presenting with classic painful AAOA. After failing conservative treatments, he was evaluated with morphologic, radiological studies and a diagnostic injection. He was successfully treated with bilateral, navigation guided C1 lateral mass and C2 pedicle screw fixation and fusion. To conclude, when there is clinical suspicion for painful AAOA, providers have numerous diagnostic modalities, including newer hybrid techniques, that can be used to solidify the diagnosis. When conservative efforts fail, C1-2 fusion is an effective and enduring treatment for most patients.

Burnout and Emotional Intelligence in Neurosurgical Advanced Practice Providers Across the United States: A Cross-Sectional Analysis.

OBJECTIVE: Although much research has examined nursing and physician burnout, the advanced practice provider (APP) population has not yet been studied. The goal of the present study was to survey APPs in neurosurgery to determine whether greater emotional intelligence (EI) is protective against burnout. METHODS: An 80-item survey was created that incorporated the Maslach Burnout Inventory Human Services Survey for Medical Personnel, the Trait Emotional Intelligence Questionnaire-short form, and original questions developed by us. The collective survey was distributed, administered, and collected using the web-based REDCap (Research Electronic Data Capture) platform. Statistical analyses were completed using a comparison between participants with and without burnout. RESULTS: A total of 106 neurosurgical APPs (26 men, 80 women) completed the survey, of whom, 57 (54%) reported current burnout. High average scores for personal accomplishment and global EI were inversely related to burnout (P = 0.034 and P = 0.003, respectively). In addition, the following factors were associated with burnout: inadequate support staff in the work place (P = 0.008), inadequate time off work (P < 0.001), inadequate administrative time (P = 0.009), not experiencing support from one's supervisor (P = 0.017), insufficient time for continuing medical education (P < 0.001), an inability to separate work from personal time (P < 0.001), and an inability to advance within one's professional field (P = 0.043). CONCLUSIONS: For neurosurgical APPs, EI is protective against burnout. Many opportunities exist at the individual and organizational level to alleviate burnout among neurosurgical APPs. Targeted strategies to improve work-life balance, EI, support systems, and opportunities for career development among neurosurgical APPs might enhance employment satisfaction and reduce burnout.

Surgical Management of Retro-Odontoid Cystic Mass with Cervicomedullary Compression.

Retro-odontoid cysts are a rare cause of cervicomedullary compression. The etiology of these lesions is not completely understood. Previous trauma and instability at the cervicomedullary junction may be the precipitating event in the development of retro-odontoid cysts in rare cases. We discussed the neurosurgical evaluation of a patient who presented with progressive and rapid neurological deterioration secondary to cervicomedullary compression. Posterior occipitocervical fusion was performed. The patient made an excellent neurological recovery, and postoperative imaging studies demonstrated resolution of the compression and intramedullary cyst.

A Technical Nuance to Avoid Lumbar Five Radiculopathy with Anterior Lumbar Fusion and Posterior Instrumentation.

The anterior lumbar interbody fusion (ALIF) is a well-established procedure used to treat a multitude of spinal pathologies. When performed at the L5-S1 level, the ALIF is often supplemented with posterior pedicle screw and rod fixation. Because the interbody device can restore disk and foraminal height, one benefit of the ALIF procedure is indirect neural decompression in the spinal canal and neural foramina. If the contour of the posterior rod is not matched to the exact position of the tulip heads on the pedicle screws, spondylolisthesis can be introduced, leading to foraminal stenosis and nerve compression. This concern is particularly germane when the posterior instrumentation is placed percutaneously without any direct foraminal decompression. In this report, we describe a patient who had an L4-S1 ALIF, resulting in new L5-S1 retrolisthesis and worsening L5 radiculopathy. Technical nuances and avoidance strategies are discussed.

Leveraging social media and digital technology to market and meet the needs of neurosurgery patients.

The digital era has arrived in healthcare. Health-care consumers, including neurosurgery patients, are increasingly using social media and other digital technologies to meet their health-care needs. In this work, we describe an illustrative case from Mayo Clinic where interlacing social media strategies are leveraged to educate and engage patients. These strategies not only provide a valuable service to patients but they also reinforce the brand and serve as a marketing tool. Other digital technologies such as health-care apps and telemedicine are also adaptations that help meet the needs of the current neurosurgical patient. Similar to consumer trends in other service industries, these technologies provide patients with greater autonomy, convenience, and personalization. The digital era in health care presents an exciting opportunity for health-care organizations and providers to innovate, evolve, and improve the health of our patients.

Empowering qualities and skills for leaders in neurosurgery.

Neurosurgeons may have multiple roles including clinician, educator, researcher, and administrator. Leaders in neurosurgery have the added responsibilities of setting a vision, communicating the vision, implementing a plan to achieve it, and gaining commitment from the team and other stakeholders. For success in the current era of U.S. health care, neurosurgical leaders must deliver despite challenges such as reduced resources, increased protocolized care, automation, and depersonalization. In this work, we describe five empowering strategies that can help leaders perform best. The steps include deepening self-awareness, leading with honesty, developing emotional intelligence, improving coaching skills, and becoming a better influencer. Leaders that take these steps to invest in their leadership skills will reap broad benefits.

Surgical management of thoracic myelopathy from long-segment epidural lipomatosis with skip hemilaminotomies: illustrative case.

BACKGROUND: Thoracic spinal epidural lipomatosis (SEL) involves the pathological overgrowth of histologically normal, unencapsulated adipose tissue that can compress the spinal cord and cause myelopathy. SEL has been associated with multiple medical conditions, including Scheuermann kyphosis (SK). Optimal treatment strategies for SEL, especially in the setting of a sagittal spinal deformity, remain unclear. OBSERVATIONS: In this report, the authors discussed surgical management of a patient with thoracic SEL and SK using skip hemilaminotomies for resection of the epidural adipose tissue. To the authors' knowledge, only one other report described a similar surgical technique in a patient who did not have a spinal deformity. LESSONS: When conservative efforts fail, thoracic SEL may require surgical treatment. Surgical planning must account for co-medical conditions such as SK. The described approach involving skip laminotomies, which minimizes spine destabilization, is a viable option to treat SEL spanning multiple spinal segments. Prognosis after surgical treatment varies and is impacted by multiple factors, including severity of preoperative neurological deficits.

An unusual case of a persistent, infected retroperitoneal fluid collection 5 years after anterior lumbar fusion surgery: illustrative case.

BACKGROUND: Anterior lumbar fusion procedures have many benefits and continue to grow in popularity. The technique has many potential approach- and procedure-related complications. Symptomatic retroperitoneal fluid collections are uncommon but potentially serious complications after anterior lumbar procedures. Collection types include hematomas, urinomas, chyloperitoneum, cerebrospinal fluid collections, and deep infections. OBSERVATIONS: The authors present an unusual case of a patient with persistent symptoms related to a retroperitoneal collection over a 5-year period following anterior lumbar fusion surgery. To the authors' knowledge, no similar case with such extensive symptom duration has been described. The patient had an infected encapsulated fluid collection. The collection was presumed to be a postoperative lymphocele that was secondarily infected after serial percutaneous drainage procedures. LESSONS: When retroperitoneal collections occur after anterior retroperitoneal approaches, clinical clues, such as timing of symptoms, hypotension, acute anemia, urinary tract infection, hydronephrosis, elevated serum creatinine and blood urea nitrogen, low-pressure headaches, anorexia, or systemic signs of infection, can help narrow the differential. Retroperitoneal collections may continue to be symptomatic many years after anterior lumbar surgery. The collections may become infected after serial percutaneous drainage or prolonged continuous drainage. Encapsulated, infected fluid collections typically require surgical debridement of the capsule and its contents.

Spinal intramedullary hemangioblastoma and schwannoma collision tumor: illustrative case.

BACKGROUND: Intramedullary spinal cord tumors represent a minority of intradural tumors. Among intramedullary spinal cord tumors, hemangioblastomas are uncommon, and schwannomas are extremely rare. Collision tumors are histologically distinct tumors that are intermingled and growing together. OBSERVATIONS: In this report, the authors describe a patient with a cervical intramedullary collision tumor involving a hemangioblastoma and schwannoma. To the authors' knowledge, no prior spinal intramedullary collision tumor involving multiple neoplasms has been described. The patient's presentation and management are described. LESSONS: Clinicians should consider the possibility of collision tumors when evaluating intramedullary spinal cord tumors, especially when patient presentation and radiographic findings are atypical. When tumors with similar radiographic characteristics form collision tumors, distinction using preoperative imaging can be extremely challenging. In addition, surgical management of intramedullary collision tumors, like that for all intramedullary spinal cord tumors, should involve meticulous perioperative care and a methodical surgical technique. Maximal safe resection will depend upon histopathological diagnosis, anatomical location of the tumor, presence of distinct dissection planes, and stability of neuromonitoring. Finally, ongoing research on the genetics of intramedullary spinal cord tumors may identify underlying genetic links for intramedullary hemangioblastomas and schwannomas.

Linear accelerator-based single-fraction stereotactic body radiotherapy for symptomatic vertebral body hemangiomas: The Mayo Clinic experience.

Symptomatic vertebral hemangiomas (SVHs) are rare benign tumors that when symptomatic require procedural intervention or radiotherapy (RT). Although conventionally-fractionated RT has been an alternative to surgical resection, there is very little data on stereotactic body radiotherapy (SBRT) for SVHs. Six consecutively treated patients with SVHs underwent definitive single-fraction SBRT from 2010 to 2018 at our institution. The RT planning parameters, treatment, outcome, and toxicities are reported for 6 patients with 6 total SVHs treated with single-fraction SBRT. Each patient presented with back pain and received single-fraction SBRT to a thoracic vertebral body hemangioma. One patient had received radiofrequency ablation prior to SBRT. The median SBRT dose was 18 Gy (range, 13-20). Following SBRT, 4 (67%) patients reported improvement in presenting symptoms and 2 patients (33%) were refractory. There were no acute or chronic toxicities associated with SBRT including esophagitis, vertebral compression fractures, or myelopathy. To date, this is the largest series of single-fraction SBRT for SVHs. Single fraction SBRT appears to be a feasible option for SVHs. Further studies are needed to confirm our preliminary findings and optimize dose fractionation.

Surgical Management of Thoracic Osteomyelitis due to Escherichia Coli Sepsis.

Case Report. Escherichia coli is a rare cause of vertebral osteomyelitis. It is more common in adults and males. We present a case of an immunocompetent adult male presenting with a several month history of progressive systemic symptoms and subsequent neurologic compromise. We discuss the neurosurgical evaluation of a patient with a progressive vertebral osteomyelitis and treatment options. Surgical debridement and spinal stabilization were performed and confirmed the diagnosis. The patient successfully completed a prolonged antimicrobial therapy course. The patient made a complete neurologic recovery. We discuss the presentation of a patient with Escherichia coli vertebral osteomyelitis and the successful surgical management.

Acute Spinal Cord Contusion in a Patient with Multiple Upper Cervical Fractures, Parkinson's Disease, and Torticollis: Surgical Management.

Case Report. Spine surgery in patients with Parkinson's disease (PD) involves increased risk. We describe a case of cervical myelopathy in a patient with PD, multiple fractures involving the atlas and axis vertebrae, and spasmodic torticollis. The patient was successfully treated with an upper cervical decompression and occipital-cervical (OC) fusion surgery. Strategies for torticollis reduction and successful surgical outcome are discussed. Risks and benefits must be carefully weighed when considering occipital cervical fusion in PD patients. Conclusion. Intraoperative manual reduction of laterocollis is possible after general endotracheal anesthesia, and continuous neuromonitoring is established. Use of optimizing strategies such as perioperative botulinum injections and intraoperative O-arm navigation should be considered.

Burnout and work-life balance in neurosurgery: Current state and opportunities.

BACKGROUND: Burnout is a syndrome characterized by emotional exhaustion, depersonalization, and reduced sense of personal accomplishment. The syndrome has been recognized as a pandemic among physicians. The demanding nature of neurosurgery makes neurosurgeons, particularly prone to burnout. In recent years, pioneering work has shed light on burnout in the field of neurosurgery. METHODS: We have reviewed the literature in PUBMED on burnout in physicians, focusing on neurosurgical publications. RESULTS: In this manuscript, we explore the topic of burnout in neurosurgery by reviewing definitions, magnitude, etiologies, sequelae, and mitigation strategies. CONCLUSION: Ongoing education, recognition, and targeted interventions for neurosurgeons at different career stages are needed to manage burnout proactively and ensure a resilient neurosurgery workforce.

Retrospective radiographic analysis of anterior lumbar fusion for high grade lumbar spondylolisthesis.

BACKGROUND: High-grade spondylolisthesis (>50% slippage) is infrequently encountered in adults and frequently requires surgical treatment. The optimal surgical treatment is controversial with limited literature guidance as to optimal approach to treatment. An observational study to examine the technique and radiographic outcomes of adult patients treated with anterior lumbar interbody fusion (ALIF) and posterior percutaneous instrumentation for high-grade spondylolisthesis. METHODS: ALIF was performed in 5 consecutive patients (3/5 female, 2/5 male) aged 29-67 years old who presented with low back pain and L5 radiculopathy. All patients failed conservative treatment and were treated with L4-5 and L5-S1 ALIF followed by posterior percutaneous L4-S1 pedicle screw and rod fixation. Pre- and postoperative clinical data was collected including L5-S1 posterior disk height in millimeters, millimeters of spondylolisthesis at L5-S1, degrees of segmental lordosis (L4-S1), lumbar lordosis (L1-S1), and lumbar lordosis pelvic incidence (LL-PI) mismatch. RESULTS: Six weeks following surgery, no patient reported residual L5 radicular symptoms. At last follow up, patient satisfaction, according to Modified Macnab Criteria, was excellent in 4/5 patients and good in 1/5 patient. In the 4 patients with greater than 1 year radiographic follow up, fusion rate was 100% on computed tomography (CT). Mean increase in posterior disk height was 12.5 mm (range, 11.4-13.5 mm). Mean reduction in spondylolisthesis was 58.7% (range, 20.2-100%). Mean segmental (L4-S1) and overall (L1-S1) lumbar lordosis increased by 23.6% (range, 6.5-41.7%) and 16.6% (2.5-31.5%), respectively. Following surgery, LL-PI mismatch decreased from a mean of 16.4 to 10.2 degrees. CONCLUSIONS: ALIF with posterior percutaneous instrumentation is a safe and effective treatment for high-grade lumbosacral spondylolisthesis in properly selected adults. This technique improves lumbar sagittal parameters and reduces spondylolisthesis. The indirect neural decompression from simultaneous disk height restoration and spondylolisthesis reduction may be associated with lower neurological injury rate compared to posterior-only. Future prospective study is needed to validate this hypothesis.

Utility of Augmented Reality Imaging (GLOW800) in Resection of Hemangioblastoma.

This is a surgical video that sheds light on the utility of a new imaging modality GLOW800 (Leica Microsystems, Wetzlar, Germany) in resection of vascular tumors. We describe the surgical resection of posterior fossa hemangioblastoma in 2 different patients after informed consent was obtained. In the first case no intraoperative angiographic imaging was used, while in the second case GLOW800 was used. Because of its ability to overlay the augmented reality view on the surgical field, it allowed for localization of highly vascular tumors as seen in the second patient. In addition, it helped in the confirmation of complete resection of the lesion. Another advantage of GLOW800 was that it allowed safe resection of the lesion in and around highly eloquent areas with a narrow surgical corridor (Video 1).