The prognostic role of neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and systemic immune-inflammation index on short- and long-term outcome following surgery for spinal metastases.

OBJECTIVE: Inflammatory markers such as neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII) have shown promise in predicting mortality in various types of cancer. The purpose of this study was to assess NLR, PLR, and SII in predicting 30-day mortality and overall survival (OS) among surgically treated patients with spinal metastasis. METHODS: This was a retrospective study including 153 patients who underwent surgery for spinal metastasis between 2012 and 2022. Electronic medical records were manually reviewed, and NLR, PLR, and SII were calculated from preoperative neutrophil, platelet, and lymphocyte counts. Receiver operating characteristic curves with areas under the curve were generated to determine cutoff values. Logistic regression was used to determine the odds ratios (ORs) for 30-day mortality. The Kaplan-Meier method and Cox regression were used to determine the hazard ratio (HR) for OS limited to 5 years postoperatively. RESULTS: Preoperative cutoff values were as follows: NLR > 10.2, PLR > 260, and SII > 2900. Overall, 35.9% (55/153) of patients had elevated NLR, 45.7% (70/153) had elevated PLR, and 30.7% (47/153) had elevated SII. The overall 30-day mortality was 8.5% (13/153). After controlling for confounders such as performance status and primary tumor type, high NLR (OR 5.20, 95% CI 1.21-22.28; p = 0.026) and SII (OR 4.92, 95% CI 1.17-20.63; p = 0.029) were associated with increased odds of 30-day postoperative mortality. The median OS time in the study population was 26 months (95% CI 12-40 months). After controlling for confounders such as Eastern Cooperative Oncology Group status, primary tumor, and hypoalbuminemia, high NLR was associated with shorter OS (HR 2.23, 95% CI 1.48-3.97; p = 0.003). CONCLUSIONS: High preoperative NLR and SII were independently associated with 30-day postoperative mortality in this study. Elevated NLR was also found to be associated with shorter OS. The prognostic role of these metrics warrants further investigation.

The prognostic nutritional index (PNI) is independently associated with 90-day and 12-month mortality after metastatic spinal tumor surgery.

INTRODUCTION: Estimated postoperative survival is an important consideration during the decision-making process for patients with spinal metastases. Nutritional status has been associated with poor outcomes and limited survival in the general cancer population. The objective of this study was to evaluate the predictive utility of the prognostic nutritional index (PNI) for postoperative mortality after spinal metastasis surgery. METHODS: A total of 139 patients who underwent oncologic surgery for spinal metastases between April 2012 and August 2022 and had a minimum 90-day follow-up were included. PNI was calculated using preoperative serum albumin and total lymphocyte count, with PNI < 40 defined as low. The mean PNI of our cohort was 43 (standard deviation: 7.7). The primary endpoint was 90-day mortality, and the secondary endpoint was 12-month mortality. Multivariate logistic regression analyses were performed. RESULTS: The 90-day mortality was 27% (37/139), and the 12-month mortality was 56% (51/91). After controlling for age, ECOG performance status, total psoas muscle cross-sectional area (TPA), and primary cancer site, the PNI was associated with 90-day mortality [odds ratio 0.86 (95% confidence interval 0.79-0.94); p = 0.001]. After controlling for ECOG performance status and primary cancer site, the PNI was associated with 12-month mortality [OR 0.89 (95% CI 0.82-0.97); p = 0.008]. Patients with a low PNI had a 50% mortality rate at 90 days and an 84% mortality rate at 12 months. CONCLUSION: The PNI was independently associated with 90-day and 12-month mortality after metastatic spinal tumor surgery, independent of performance status, TPA, and primary cancer site.

Predictive value of six nutrition biomarkers in oncological spine surgery: a performance assessment for prediction of mortality and wound infection.

OBJECTIVE: Assessment of nutritional status is fundamental in cancer patients. The objective of this study was to assess the predictive ability of 6 nutritional biomarkers for postoperative mortality and wound infection after metastatic spinal tumor surgery. METHODS: A total of 139 patients who underwent oncological surgery for metastatic spine disease between April 2012 and August 2022 and had a minimum follow-up of 90 days were included. Six unique nutritional biomarkers were assessed: Prognostic Nutritional Index (PNI), Nutritional Risk Index (NRI), Controlling Nutritional Status Score (CONUT), total psoas cross-sectional area (TPA), body mass index (BMI), and body weight. Study endpoints were 90-day mortality rate, 12-month mortality rate, and wound infection. The discriminative ability of each of these markers was assessed with the c-statistic. A multivariate analysis was done for each of the biomarkers after a univariate analysis was first performed. RESULTS: The 90-day mortality rate was 27% (37 of 139). The biomarkers and respective c-statistics were as follows: PNI (0.74), NRI (0.75), CONUT (0.71), TPA (0.64), BMI (0.59), and body weight (0.60). The 12-month mortality rate was 56% (51 of 91). The biomarkers and respective c-statistics were as follows: PNI (0.72), NRI (0.73), CONUT (0.70), TPA (0.63), BMI (0.59), and body weight (0.60). The wound infection rate was 8% (11 of 139). The biomarkers and respective c-statistics were as follows: PNI (0.57), NRI (0.53), CONUT (0.55), TPA (0.57), BMI (0.48), and body weight (0.52). The PNI, NRI, and CONUT all predicted 90-day and 12-month mortality after multivariate regression analysis. No association between nutrition and wound infection was found. CONCLUSIONS: In this study, nutritional status was associated with postoperative mortality following oncological spine surgery. Three biomarkers predicted outcome independent of variables such as performance status or primary cancer. Future validation of these metrics is needed.

Evaluation of lymphopenia as a predictor of postoperative mortality and major complications in patients undergoing surgery for metastatic spine tumors.

OBJECTIVE: Lymphopenia is often seen in advanced metastatic disease and has been associated with poor postoperative outcomes. Limited research has been done to validate this metric in patients with spinal metastases. The objective of this study was to evaluate the capability of preoperative lymphopenia to predict 30-day mortality, overall survival (OS), and major complications in patients undergoing surgery for metastatic spine tumors. METHODS: A total of 153 patients who underwent surgery for metastatic spine tumor between 2012 and 2022 and met the inclusion criteria were examined. Electronic medical record chart review was conducted to obtain patient demographics, comorbidities, preoperative laboratory values, survival time, and postoperative complications. Preoperative lymphopenia was defined as < 1.0 K/µL based on the institution's laboratory cutoff value and within 30 days prior to surgery. The primary outcome was 30-day mortality. Secondary outcomes were OS up to 2 years and 30-day postoperative major complications. Outcomes were assessed with logistic regression. Survival analyses were done using the Kaplan-Meier method with log-rank test and Cox regression. Receiver operating characteristic curves were plotted to classify the predictive ability of lymphocyte count as a continuous variable on outcome measures. RESULTS: Lymphopenia was identified in 47% of patients (72 of 153). The overall 30-day mortality rate was 9% (13 of 153). In logistic regression analysis, lymphopenia was not associated with 30-day mortality (OR 1.35, 95% CI 0.43-4.21; p = 0.609). The mean OS in this sample was 15.6 months (95% CI 13.9-17.3 months), with no significant difference between patients with lymphopenia and those with no lymphopenia (p = 0.157). Cox regression analysis did not show an association between lymphopenia and survival (HR 1.44, 95% CI 0.87-2.39; p = 0.161). The major complication rate was 26% (39 of 153). In univariable logistic regression analysis, lymphopenia was not associated with the development of a major complication (OR 1.44, 95% CI 0.70-3.00; p = 0.326). Finally, receiver operating characteristic curves generated poor discrimination between lymphocyte count and all outcomes, including 30-day mortality (area under the curve 0.600, p = 0.232). CONCLUSIONS: This study does not support prior research that had shown an independent association between low preoperative lymphocyte level and poor postoperative outcomes following surgery for metastatic spine tumors. Although lymphopenia may be used to predict outcomes in other tumor-related surgeries, this metric may not hold a similar predictive capability in the population undergoing surgery for metastatic spine tumors. Further research into reliable prognostic tools is needed.

Performance Assessment of the American College of Surgeons Risk Calculator in Metastatic Spinal Tumor Surgery.

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: The objective of this study was to assess the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator performance in patients undergoing surgery for metastatic spine disease. SUMMARY OF BACKGROUND DATA: Patients with spinal metastases may require surgical intervention for cord compression or mechanical instability. The ACS-NSQIP calculator was developed to assist surgeons with estimating 30-day postoperative complications based on patient-specific risk factors and has been validated within several surgical patient populations. MATERIALS AND METHODS: We included 148 consecutive patients at our institution who underwent surgery for metastatic spine disease between 2012 and 2022. Our outcomes were 30-day mortality, 30-day major complications, and length of hospital stay (LOS). Predicted risk, determined by the calculator, was compared with observed outcomes using receiver operating characteristic curves with area under the curve (AUC) and Wilcoxon signed-rank tests. Analyses were repeated using individual corpectomy and laminectomy Current Procedural Terminology (CPT) codes to determine procedure-specific accuracy. RESULTS: Based on the ACS-NSQIP calculator, there was good discrimination between observed and predicted 30-day mortality incidence overall (AUC=0.749), as well as in corpectomy cases (AUC=0.745) and laminectomy cases (AUC=0.788). Poor 30-day major complication discrimination was seen in all procedural cohorts, including overall (AUC=0.570), corpectomy (AUC=0.555), and laminectomy (AUC=0.623). The overall median observed LOS was similar to predicted LOS (9 vs. 8.5 d, P =0.125). Observed and predicted LOS were also similar in corpectomy cases (8 vs. 9 d; P =0.937) but not in laminectomy cases (10 vs. 7 d, P =0.012). CONCLUSIONS: The ACS-NSQIP risk calculator was found to accurately predict 30-day postoperative mortality but not 30-day major complications. The calculator was also accurate in predicting LOS following corpectomy but not laminectomy. While this tool may be utilized to predict risk short-term mortality in this population, its clinical value for other outcomes is limited.

The role of venous anatomy in guiding treatment approach for dural arteriovenous fistulas of the craniocervical junction; case series & systematic review.

BACKGROUND: Dural arteriovenous fistulas (DAVF) of the craniocervical junction (CCF) are an uncommon entity with the following venous drainage pattern: inferior, superior and mixed. Patients may present with subarachnoid hemorrhage, myelopathy or brainstem dysfunction. CCJ DAVF can be treated with microsurgery or with transarterial and transvenous embolization, depending on the venous drainage pattern. We present our institutional experience of treating CCJ DAVFs along with a systematic review of the literature. METHODS: Six patients with CCJ DAVF were treated at our institution over five years. Data was collected using electronic medical record review. Systematic review was performed on CCJ DAVF using the PubMed database from 1990 to 2021. We characterized venous drainage patterns, treatment choices, and outcomes to create a classification system. RESULTS: 50 case reports, consisting of 115 patients, were included in our review. 61 (53.0 %) patients had inferior drainage while 32 (27.8 %) patients had superior drainage and 22 (19.2 %) patients had mixed venous drainage. Patients with inferior drainage had the fistulous connection at the foramen magnum while patients with superior drainage had a fistulous connection at C1-C2 (p value = 0.026). Patients with inferior drainage were more likely to present with myelopathy while patients with superior drainage presented with hemorrhage (p value = 0.000). CONCLUSIONS: Classifying the venous drainage pattern is essential in making treatment decision. Transvenous embolization works best with large superior venous drainage. If endovascular treatment is not an option, then surgical clipping can achieve successful cure. Transarterial embolization is a reasonable option in cases with a large arterial feeder.

Performance assessment and external validation of specific thresholds of total psoas muscle cross-sectional area as predictors of mortality in oncologic spine surgery for spinal metastases.

PURPOSE: The purpose of this study was to assess the utility of low muscle mass (LMM) in predicting 90-day and 12-month mortality after spinal tumor surgery. METHODS: We identified 115 patients operated on for spinal metastases between April 2012 and August 2022 who had available perioperative abdominal or lumbar spine CT scans and minimum 90-day follow-up. LMM was defined as a total psoas muscle cross-sectional area (TPA) at the L4 pedicle level less than 10.5 cm2 for men and less than 7.2 cm2 for women based on previously reported thresholds. A secondary analysis was performed by analyzing TPA as a continuous variable. The primary endpoint was 90-day mortality, and the secondary endpoint was 12-month mortality. Multivariate logistic regression analyses were performed. RESULTS: The 90-day mortality was 19% for patients without and 42% for patients with LMM (p = 0.010). After multivariate analysis, LMM was not independently associated with increased odds of 90-day mortality (odds ratio 2.16 [95% confidence interval 0.62 to 7.50]; p = 0.223). The 12-month mortality was 45% for patients without and 71% for patients with LMM (p = 0.024). After multivariate analysis, LMM was not independently associated with increased odds of 12-month mortality (OR 1.64 [95% CI 0.46 to 5.86]; p = 0.442). The secondary analysis showed no independent association between TPA and 90-day or 12-month mortality. CONCLUSION: Patients with LMM had higher rates of 90-day and 12-month mortality in our study, but this was not independent of other parameters such as performance status, hypoalbuminemia, or primary cancer type.

Cochlear Implants: What the Neurosurgeon Needs to Know.

Patients with cochlear implants (CIs) commonly undergo neurosurgical interventions for concurrent pathologies. The neurosurgeon must be aware of the limitations these devices place on treating these patients and all pertinent interactions CIs have with common neurosurgical instruments and procedures. A literature search was performed utilizing the terms "cochlear implant" and "neurosurgery" or "neurosurgical" and all associated iterations. We reviewed the abstracts of 146 generated reports and eight published papers discussing the interaction and limitations of CI use in different neurosurgical procedures. Five realms were identified in which a CI may potentially interfere with standard neurosurgical care: Magnetic resonance imaging (MRI), radiotherapy, deep brain stimulation (DBS), intraventricular shunt placement, and intraoperative neuromonitoring (IONM). First, MRI use with CIs is limited due to thermal injury risk, imaging disruption, and implant damage. Secondly, high-dose >50 Gy single-fraction linear accelerator-based radiosurgery has been demonstrated to result in a loss of radio frequency link range in CIs, interfering with their function. Next, during surgery for DBS, the need for MRI and microelectrode recording requires CI magnet removal by neurotology and the surgeon must communicate with a non-hearing patient. Tunneling of shunts must accommodate CI position retroauricularly, if ipsilateral, and programmable valves must be placed >2 cm from the CI to prevent interference. Intraoperative neuromonitoring may produce voltages that interfere with CIs, and while monopolar cautery may pose the same risk, no study has proven this to date. Generally, bipolar cautery is safe and favored >1 cm from CIs. MRI use is limited in CI patients, although MRI-safer devices are in production. DBS electrodes may be successfully placed after CI magnet removal. Programmable shunt valves may be placed >2 cm away from CIs and radiosurgery <50 Gy has not demonstrated harm to these devices. IONM and monopolar cautery have not been demonstrated to directly affect CIs; however, more research is needed.

Advancements and Updates on Operative Techniques in Spinal Deformity.

Spinal deformity involves a spectrum of abnormal spinal curvatures deviating from normal alignment [...].

Cement Augmentation of Two-Level Lumbar Corpectomy Cage After Malposition: A Novel Salvage Procedure Technical Note.

Intervertebral cage mispositioning is an uncommon complication of a posterior lumbar corpectomy. Most frequently, cages are placed obliquely, laterally, or protruding. However, there are few reports of implanted cages that fail to contact the adjacent vertebral endplate and thus no descriptions of successful revisions. The objective of this case report is to report a unique case of minimally invasive rescue vertebroplasty with cement augmentation following a lumbar corpectomy that resulted in graft-endplate noncontact in a medically complicated patient A 60-year-old male with a history of active intravenous (IV) drug use, untreated hepatitis C virus (HCV) infection, and chronic malnourishment presented with low back pain. He had a history of vertebral osteomyelitis managed with intravenous antibiotics, although he was noncompliant with infusions. The diagnosis of L2-L3 discitis-osteomyelitis with intradiscal abscess causing cord compression was made using inpatient lumbar imaging. The initial intervention was accomplished with L2 and L3 vertebral corpectomy with decompression and expandable cage placement as well as a T10-pelvis posterior fixation. Despite the resolution of presenting symptoms, routine postoperative radiographs identified noncontact between the inferior surface of the cage and the superior endplate of the L4 vertebral body. Salvage therapy was pursued via fluoroscopy-guided vertebroplasty with cement augmentation to correct cage malposition. Secondary surgical intervention was successful in bringing the intervertebral cage into contact with the adjacent vertebral body. Lower extremity strength improved, and back pain was resolved. The postoperative motor examination remained unchanged after the rescue procedure. Accurate intraoperative cage placement can be difficult in patients with poor bone quality, especially in the setting of ongoing infection and cachexia. For this reason, routine postoperative imaging is crucial to assessing graft complications. In patients who are poor candidates for revision surgery, we demonstrate that an interventional radiology-based approach may be successful in correcting cage mispositioning and preventing further changes during healing and fusion.

An Artificial Neural Network Model for the Prediction of Perioperative Blood Transfusion in Adult Spinal Deformity Surgery.

Prediction of blood transfusion after adult spinal deformity (ASD) surgery can identify at-risk patients and potentially reduce its utilization and the complications associated with it. The use of artificial neural networks (ANNs) offers the potential for high predictive capability. A total of 1173 patients who underwent surgery for ASD were identified in the 2017-2019 NSQIP databases. The data were split into 70% training and 30% testing cohorts. Eighteen patient and operative variables were used. The outcome variable was receiving RBC transfusion intraoperatively or within 72 h after surgery. The model was assessed by its sensitivity, positive predictive value, F1-score, accuracy (ACC), and area under the curve (AUROC). Average patient age was 56 years and 63% were female. Pelvic fixation was performed in 21.3% of patients and three-column osteotomies in 19.5% of cases. The transfusion rate was 50.0% (586/1173 patients). The best model showed an overall ACC of 81% and 77% on the training and testing data, respectively. On the testing data, the sensitivity was 80%, the positive predictive value 76%, and the F1-score was 78%. The AUROC was 0.84. ANNs may allow the identification of at-risk patients, potentially decrease the risk of transfusion via strategic planning, and improve resource allocation.

Successful Treatment of Pediatric Holo-Spinal Epidural Abscess With Percutaneous Drainage.

Spinal epidural abscess (SEA) is a rare and potentially devastating neurologic disease that is commonly treated with neurosurgical decompression and evacuation. We describe the case of an 11-month-old immunocompetent infant who presented with a large multiloculated methicillin-resistant Staphylococcus aureus abscess in the left lung apex with likely mediastinal involvement, extending into the epidural space from C7 down to L2 causing cord compression which was successfully treated with percutaneous placement of an epidural drainage catheter and antibiotic therapy. Although there are rare reports of percutaneous drainage of SEAs, to our knowledge, there are no reports of successful use of percutaneous indwelling catheters resulting in the complete resolution of an SEA. Holo-spinal epidural abscess in an infant is an extremely rare disease with limited literature available regarding the best practice for its treatment. Multiple considerations must be taken into account when weighing the different treatment options ranging from surgical decompression to conservative management with antibiotic therapy. We present a unique case of successful treatment with percutaneous epidural drain placement. This provides a reasonable alternative for management in children for whom surgical decompression carries multiple risks for complications both acutely and delayed.

The Use of a Transforaminal Lumbar Interbody Fusion (TLIF) Cage Following Inadequate Access to the Disc Space During an Anterior Lumbar Interbody Fusion Procedure.

Non-specific lower back pain caused by degenerative lumbar disease, such as disc and facet joint degeneration or spondylolisthesis, significantly impairs quality of life of patients and is associated with higher pain scores and reduced function. Patients that fail to respond to conservative treatment may require surgical intervention, such as lumbar interbody fusion (LIF). Compared to other approaches, an anterior approach to lumbar interbody fusion (ALIF) has advantages regarding efficacy of fusion, visualization of relevant anatomy, and a larger allowable size of the interbody fusion device. An anterior approach's main biomechanical advantage includes the ability to restore sagittal alignment, achieve indirect decompression, and provide increased anterior column support. Complications of anterior interbody fusion are mostly approach related and include vascular injury or visceral injury. However, the anterior anatomy can make the placement of an interbody device challenging. In the case reported here, an ALIF procedure was complicated by immobile iliac vessels leaving a small window to place the interbody cage. Continuing with the anterior approach was opted, but with the oblique placement of a cage traditionally used in transforaminal lumbar interbody fusion (TLIF) procedures.

Use of the Image Guided Minimally Invasive BrainPath System to Evacuate Spontaneous Cerebellar Hemorrhages.

BrainPath (NICO, Indianapolis, Indiana) is a tool that can be used to evacuate supratentorial hematomas due to spontaneous intracerebral hemorrhage (ICH). However, when ICH occurs in the posterior fossa, an open approach is often undertaken to evacuate the hematoma. The application of minimally invasive technology, while available, has not been well established. Our objective was to describe the use of the image-guided, minimally invasive BrainPath system to evacuate a spontaneous cerebellar hemorrhage. We present the case of a sixty-four-year-old male patient with a cerebellar hematoma due to hypertensive hemorrhage. The patient's medical record, including the history and physical, progress notes, operative notes, discharge summary, and imaging studies were reviewed to document the clinical presentation as well as the details of the operative technique and postoperative outcomes in this paper. We discuss the technical nuances of the operative points in detail. In our example case, the BrainPath system was successfully used to evacuate the cerebellar hematoma and no procedural-related complications occurred. The patient's recovery remained uncomplicated at three months of follow-up. In summary, the BrainPath system offers a less invasive alternative to open evacuation for cerebellar bleeds.

A Novel Clinical Scoring System for Perioperative Morbidity in Metastatic Spinal Tumor Surgery: The Spine Oncology Morbidity Assessment Score.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To evaluate a scoring system to predict morbidity for patients undergoing metastatic spinal tumor surgery (MSTS). SUMMARY OF BACKGROUND DATA: Multiple scoring systems exist to predict survival for patients with spinal metastasis. The potential benefits and risks of surgery need to be evaluated for patients with disseminated cancer and limited life expectancy. Few scoring systems exist to predict perioperative morbidity after MSTS. METHODS: We reviewed records of patients who underwent MSTS at our institution between 2013 and 2019. All perioperative complications occurring within 30 days were recorded. A clinical scoring system consisting of five variables (age ≥ 70 yr, hypoalbuminemia, poor preoperative functional status [Karnofsky ≤ 40], Frankel Grade A-C, and multilevel disease ≥2 continuous vertebral bodies) was evaluated as a predictive tool for morbidity; every parameter was assigned a value of 0 if absent or 1 if present (total possible score = 5). The effect of the scoring system on morbidity was evaluated using stepwise multiple logistic regression. Model accuracy was calculated by receiver operating characteristic analysis. RESULTS: One hundred and five patients were identified, with a male prevalence of 58.1% and average age at surgery of 61 years. The overall 30-day complication rate was 36.2%. The perioperative morbidity was 4.6%, 30.0%, 53.9%, and 64.7% for patients with scores of 0, 1, 2, and ≥3 points, respectively (P < 0.001). On multiple logistic regression analysis controlling for covariates not present in the model, the scoring system was significantly associated with 30-day morbidity (OR 3.11; 95% CI, 1.72-5.59; P < 0.001). The model's accuracy was estimated at 0.75. CONCLUSION: Our proposed model was found to accurately predict perioperative morbidity after MSTS. The Spine Oncology Morbidity Assessment (SOMA) score may prove useful for risk stratification and possibly decision-making, though further validation is needed.Level of Evidence: 4.

A Retrospective Quality Analysis of External Ventricular Drain Infection Rates Following Stroke Diagnoses and Other Brain Injuries: Comparison of Emergency Room and ICU/OR Setting.

Objective The purpose of this study was to analyze the incidence of infections in patients following placement of External Ventricular Drain (EVD) in either the Emergency Room (ER) or the Intensive Care Unit (ICU)/ Operating Room (OR) at a single Comprehensive Stroke Center. Methods Retrospective analysis of post-procedure infection rates in 710 patients with EVDs placed on site between 2010 and 2018 was performed. We analyzed cases between sex, age, stroke and non-stroke related and further requirement of conversion of the EVD to a ventriculoperitoneal (VP) shunt. Results Significant decrease in EVD related infection (ERIs) rates following the shift in EVD placement from ER to ICU/OR (from 13% to 7.7%, p=.03) among all ages, sex and type of brain injury was observed. Furthermore, our data also shows that the rate of conversion of EVDs to VP shunts is independent of the setting where EVD was placed, but increases in patients who develop ERIs. 23.1% of stroke patients that developed an ERI required a conversion to VP shunt while 67.3% of non-stroke patients that developed an ERI required further VP shunt (p<.001) showing that non-stroke EVD patients with infections are more likely to require VP shunt. Conclusion This is one of the larger retrospective studies conducted on EVD related infections. ERIs were significantly higher when EVDs were placed in the ER. Moreover, our results highlight the relation between ERIs and further requirement of conversion EVD to VP shunt. These figures highlight the importance of focusing on infection rates, and the implications CSF infection has on the long-term care of patients.

Potential Uses of Isolated Toxin Peptides in Neuropathic Pain Relief: A Literature Review.

Neuropathic pain is a subset of chronic pain that is caused by neurons that are damaged or firing aberrantly in the peripheral or central nervous systems. The treatment guidelines for neuropathic pain include antidepressants, calcium channel α2 delta ligands, topical therapy, and opioids as a second-line option. Pharmacotherapy has not been effective in the treatment of neuropathic pain except in the treatment of trigeminal neuralgia with carbamazepine. The inability to properly treat neuropathic pain causes frustration in both the patients and their treating physicians. Venoms, which are classically believed to be causes of pain and death, have peptide components that have been implicated in pain relief. Although some venoms are efficacious and have shown benefits in patients, their side-effect profile precludes their more widespread use. This review identifies and explores the use of venoms in neuropathic pain relief. This treatment can open doors to potential therapeutic targets. We believe that further research into the mechanisms of action of these receptors as well as their functions in nature will provide alternative therapies as well as a window into how they affect neuropathic pain.