Perioperative Intravenous Corticosteroids and Radiographic Prevertebral Soft Tissue Swelling in Anterior Cervical Fusion for Degenerative Disease.

OBJECTIVE: Prevertebral soft tissue swelling (PSTS) is a known complication of anterior cervical fusion (ACF). Prior studies have shown that perioperative steroids may reduce PSTS after ACF. We retrospectively evaluated the role of perioperative intravenous (IV) corticosteroid administration in minimizing radiographic PSTS measurements in patients undergoing ACF for degenerative disease. METHODS: Records of 100 consecutive patients undergoing ACF for degenerative disease (Current Procedural Terminology code 63075) from January 2010 through December 2012 by 2 orthopedic spine fellowship-trained surgeons at a single institution were retrospectively reviewed. Patients were included on the basis of specific criteria. They were then separated into comparison and IV steroid groups. Demographic and surgical data were collected. Last, measurements of PSTS, which included PSTS ratio and PSTS index (PSTSI), were obtained from plain radiographs preoperatively and at 3 postoperative time points. RESULTS: Eighty patients were included; 26 received IV steroids at the surgeon's discretion (12 intraoperatively, 11 postoperatively and 3 at both time periods). With the exception of a history of prior anterior cervical spine surgery (3.70% comparison vs. 23.08% IV steroid, P = 0.01), there was no statistically significant demographic characteristic. Furthermore, there was no statistically significant surgical characteristic. Last, there was no statistically significant difference between groups at any time point for either PSTS ratio at any level or PSTSI. CONCLUSIONS: There does not appear to be a role for perioperative IV steroid administration in minimizing radiographic PSTS in patients undergoing ACF for degenerative disease. The relationship between perioperative IV steroid administration and PSTS requires further investigation.

The Impact of Preoperative Mindfulness-Based Stress Reduction on Postoperative Patient-Reported Pain, Disability, Quality of Life, and Prescription Opioid Use in Lumbar Spine Degenerative Disease: A Pilot Study.

BACKGROUND: Prescription opioid medications negatively affect postoperative outcomes after lumbar spine surgery. Furthermore, opioid-related overdose death rates in the United States increased by 200% between 2000 and 2014. Thus, alternatives are imperative. Mindfulness-based stress reduction (MBSR), a mind-body therapy, has been associated with improved activity and mood in opioid-using patients with chronic pain. This study assessed whether preoperative MBSR is an effective adjunct to standard postoperative care in adult patients undergoing lumbar spine surgery for degenerative disease. METHODS: The intervention group underwent a preoperative online MBSR course. The comparison group was matched retrospectively in a 1:1 ratio by age, sex, type of surgery, and preoperative opioid use. Prescription opioid use during hospital admission and at 30 days postoperatively were compared with preoperative use. Thirty-day postoperative patient-reported outcomes for pain, disability, and quality of life were compared with preoperative patient-reported outcomes. Dose-response effect of mindfulness courses was assessed using Mindful Attention Awareness Scale scores. RESULTS: In this pilot study, 24 participants were included in each group. Most intervention patients (70.83%) completed 1 session, and the mean Mindful Attention Awareness Scale score was 4.28 ± 0.71 during hospital admission. At 30 days, mean visual analog scale back pain score was lower in the intervention group (P = 0.004) but other patient-reported outcomes did not differ. CONCLUSIONS: During hospital admission, no significant dose-response effect of mindfulness techniques was found. At 30 days postoperatively, MBSR use was associated with less back pain. Further research is needed to assess the effectiveness of preoperative MBSR on postoperative outcomes in lumbar spine surgery for degenerative disease.

Cauda equina repair in the rat: Part 3. Axonal regeneration across Schwann cell-Seeded collagen foam.

INTRODUCTION: Treatments for patients with cauda equina injury are limited. METHODS: In this study, we first used retrograde labeling to determine the relative contributions of cauda equina motor neurons to intrinsic and extrinsic rat tail muscles. Next, we transected cauda equina ventral roots and proceeded to bridge the proximal and distal stumps with either a type I collagen scaffold coated in laminin (CL) or a collagen-laminin scaffold that was also seeded with Schwann cells (CLSC). Regeneration was assessed by way of serial retrograde labeling. RESULTS: After accounting for the axonal contributions to intrinsic vs. extrinsic tail muscles, we noted a higher degree of double labeling in the CLSC group (58.0 ± 39.6%) as compared with the CL group (27.8 ± 16.0%; P = 0.02), but not the control group (33.5 ± 18.2%; P = 0.10). DISCUSSION: Our findings demonstrate the feasibility of using CLSCs in cauda equina injury repair. Muscle Nerve 57: E78-E84, 2018.

Noninvasive measurement of cerebrospinal fluid flow using an ultrasonic transit time flow sensor: a preliminary study.

OBJECT Mechanical failure-which is the primary cause of CSF shunt malfunction-is not readily diagnosed, and the specific reasons for mechanical failure are not easily discerned. Prior attempts to measure CSF flow noninvasively have lacked the ability to either quantitatively or qualitatively obtain data. To address these needs, this preliminary study evaluates an ultrasonic transit time flow sensor in pediatric and adult patients with external ventricular drains (EVDs). One goal was to confirm the stated accuracy of the sensor in a clinical setting. A second goal was to observe the sensor's capability to record real-time continuous CSF flow. The final goal was to observe recordings during instances of flow blockage or lack of flow in order to determine the sensor's ability to identify these changes. METHODS A total of 5 pediatric and 11 adult patients who had received EVDs for the treatment of hydrocephalus were studied in a hospital setting. The primary EVD was connected to a secondary study EVD that contained a fluid-filled pressure transducer and an in-line transit time flow sensor. Comparisons were made between the weight of the drainage bag and the flow measured via the sensor in order to confirm its accuracy. Data from the pressure transducer and the flow sensor were recorded continuously at 100 Hz for a period of 24 hours by a data acquisition system, while the hourly CSF flow into the drip chamber was recorded manually. Changes in the patient's neurological status and their time points were noted. RESULTS The flow sensor demonstrated a proven accuracy of ± 15% or ± 2 ml/hr. The flow sensor allowed real-time continuous flow waveform data recordings. Dynamic analysis of CSF flow waveforms allowed the calculation of the pressure-volume index. Lastly, the sensor was able to diagnose a blocked catheter and distinguish between the blockage and lack of flow. CONCLUSIONS The Transonic flow sensor accurately measures CSF output within ± 15% or ± 2 ml/hr, diagnoses the blockage or lack of flow, and records real-time continuous flow data in patients with EVDs. Calculations of a wide variety of diagnostic parameters can be made from the waveform recordings, including resistance and compliance of the ventricular catheters and the compliance of the brain. The sensor's clinical applications may be of particular importance to the noninvasive diagnosis of shunt malfunctions with the development of an implantable device.

Innervation and function of rat tail muscles for modeling cauda equina injury and repair.

INTRODUCTION: The rat tail exhibits functional impairment after cauda equina injury. Our goal was to better understand the innervation and roles of muscles that control the tail. METHODS: Adult rats received either: (1) ventral root injury; (2) caudales nerve injury; or (3) mapping of sacrococcygeal myotomes. Activation of small muscles within the tail itself (intrinsics) was compared with that of larger lumbosacral muscles acting on the tail (extrinsics). Behavioral testing of tail movement was done 1 week later. RESULTS: Rats that received ventral root injury exhibited multiple behavioral deficits, whereas rats with injury to caudales nerves maintained more fully preserved tail movement. Mapping studies revealed much broader overlap of myotomes for extrinsic muscles. CONCLUSIONS: Extrinsic tail muscles play a greater role in tail movement in the rat than their intrinsic counterparts and are innervated by multiple neurological segments. These findings have major implications for future research on cauda equina injury.

Coil embolization of an intracranial aneurysm in an infant with tuberous sclerosis complex: A case report and literature review.

BACKGROUND: Tuberous sclerosis (TS) is a multiorgan neurocutaneous syndrome. Vascular manifestations are often extracranial. There is a paucity of cases involving TS combined with intracranial aneurysms reported in the literature. As a result, treatment has not been well described. CASE DESCRIPTION: We report the case of a 13-month-old female infant with a prior diagnosis of TS that was found to have new onset of left eye ptosis, anisocoria, and papillary mydriasis indicative of left third cranial nerve palsy. A magnetic resonance angiogram (MRA) of the brain revealed a left internal carotid artery (ICA) aneurysm. Endovascular embolization was determined to be the best option for treatment. After a successful balloon test occlusion with neuromonitoring, the left internal carotid artery was sacrificed via coil embolization. CONCLUSIONS: This is only the third case report of endovascular coil embolization of an intracranial aneurysm in an infant with TS. We report no complications during the procedure, and the patient was discharged with resolving left third cranial nerve palsy. Neither surgical nor endovascular outcomes have been well described in the literature. Follow-up on this patient will be useful for establishing protocols of treatment.