Extraocular muscle electromyographic recordings for intraoperative monitoring of cranial nerves III, IV, and VI: a single-center experience with intraorbital electrodes.

OBJECTIVE: The objective of this study was to describe the quantitative features of intraoperative electromyographic recordings obtained from cranial nerve III, IV, and VI neuromonitoring using 25-mm intraorbital electrodes, in the larger context of demonstrating the practicality of this technique during neurosurgical cases. METHODS: A 25-mm-long shaft-insulated intraorbital needle electrode is routinely used at the authors' institution for extraocular muscle (EOM) electromyographic monitoring of the inferior rectus, superior oblique, and/or lateral rectus muscles when their function is at risk. Cases monitored between January 1, 2021, and December 31, 2022, were reviewed for patient demographics, tumor location and pathology, EOMs monitored, pre- and postoperative examination, and complications from electrode placement. Compound muscle action potentials on triggered electromyography, as well as neurotonic discharges on free-run electromyography, were described quantitatively. RESULTS: There were 141 cases in 139 patients reviewed during the 24-month time span, with 278 EOMs monitored (inferior rectus/superior oblique/lateral rectus muscles 68/68/142). Triggered electromyography yielded biphasic or triphasic compound muscle action potentials from EOMs with a mean onset latency of 1.51 msec (range 0.94-3.22 msec), mean maximal peak-to-trough amplitude of 1073.93 µV (range 76.75-7796.29 µV), and high specificity for the channel in nearly all cases. Neurotonic discharges were recorded in 30 of the 278 EOMs (with all 3 muscles represented) and associated with a greater incidence of new or worsened ophthalmoparesis (OR 4.62, 95% CI 1.3-16.4). There were 2 cases of small periorbital ecchymosis attributed to needle placement; additionally, 1 case of needle-related intraorbital hematoma occurred after the review period. CONCLUSIONS: The 25-mm shaft-insulated intraorbital electrode facilitates robust and consistent electromyographic recordings of EOMs that are advantageous over existing techniques. Combined with the relative ease of needle placement and low rate of complications, the technique is practical for neuromonitoring during craniotomies.

Assessment of minimum target dose as a predictor of local failure after spine SBRT.

OBJECTIVES: Metastasis-directed stereotactic body radiation therapy (SBRT) has demonstrated robust clinical benefits in carefully selected patients, improving local control and even overall survival (OS). We assess a large database to determine clinical and dosimetric predictors of local failure after spine SBRT. METHODS: Spine SBRT treatments with imaging follow-up were identified. Patients were treated with a simultaneous integrated boost technique using 1 or 3 fractions, delivering 20-24 Gy in 1 fraction to the gross tumor volume (GTV) and 16 Gy to the low dose volume (or 27-36 Gy and 21-24 Gy for 3 fraction treatments). Exclusions included: lack of imaging follow-up, proton therapy, and benign primary histologies. RESULTS: 522 eligible spine SBRT treatments (68 % single fraction) were identified in 377 unique patients. Patients had a median OS of 43.7 months (95 % confidence interval: 34.3-54.4). The cumulative incidence of local failure was 10.5 % (7.4-13.4) at 1 year and 16.3 % (12.6-19.9) at 2 years. Local control was maximized at 15.3 Gy minimum dose for single-fraction treatment (HR = 0.31, 95 % CI: 0.17 - 0.56, p < 0.0001) and confirmed via multivariable analyses. Cumulative incidence of local failure was 6.1 % (2.6-9.4) vs. 14.2 % (8.3-19.8) at 1 year using this cut-off, with comparable findings for minimum 14 Gy. Additionally, epidural and soft tissue involvement were predictive of local failure (HR = 1.77 and 2.30). CONCLUSIONS: Spine SBRT offers favorable local control; however, minimum dose to the GTV has a strong association with local control. Achieving GTV minimum dose of 14-15.3 Gy with single fraction SBRT is recommended whenever possible.

Inhibition of CERS1 in skeletal muscle exacerbates age-related muscle dysfunction.

Age-related muscle wasting and dysfunction render the elderly population vulnerable and incapacitated, while underlying mechanisms are poorly understood. Here, we implicate the CERS1 enzyme of the de novo sphingolipid synthesis pathway in the pathogenesis of age-related skeletal muscle impairment. In humans, CERS1 abundance declines with aging in skeletal muscle cells and, correlates with biological pathways involved in muscle function and myogenesis. Furthermore, CERS1 is upregulated during myogenic differentiation. Pharmacological or genetic inhibition of CERS1 in aged mice blunts myogenesis and deteriorates aged skeletal muscle mass and function, which is associated with the occurrence of morphological features typical of inflammation and fibrosis. Ablation of the CERS1 orthologue lagr-1 in Caenorhabditis elegans similarly exacerbates the age-associated decline in muscle function and integrity. We discover genetic variants reducing CERS1 expression in human skeletal muscle and Mendelian randomization analysis in the UK biobank cohort shows that these variants reduce muscle grip strength and overall health. In summary, our findings link age-related impairments in muscle function to a reduction in CERS1, thereby underlining the importance of the sphingolipid biosynthesis pathway in age-related muscle homeostasis.

Safety and histopathologic yield of percutaneous CT-guided biopsies of the skull base, orbit, and calvarium.

PURPOSE: Although CT-guided biopsies of the calvarium, skull base, and orbit are commonly performed, the best approaches, efficacy, and safety of such procedures remain scantly described in the literature. This retrospective review of percutaneous biopsies illustrates several approaches to challenging biopsy targets and provides a review of procedural planning considerations and histopathologic yield. METHODS: A retrospective review of CT-guided biopsies of the skull base, calvarium, and orbit between 1/1/2010 and 10/30/2020 was conducted. Patient demographics and procedural factors were recorded, including lesion size and location, biopsy approach, and needle gauge. Outcomes were also noted, including CT dose length product, complications, and histopathologic yield. RESULTS: Sixty-one CT-guided biopsies were included in the final analysis: 34 skull base, 23 calvarial, and 4 orbital lesions. The initial diagnostic yield was 32/34 (94%) for skull base lesions, with one false-negative and one non-diagnostic sample. Twenty-one of twenty-three (91%) biopsies in the calvarium were initially diagnostic, with one false-negative and one non-diagnostic sample. In the orbit, 4/4 biopsies were diagnostic. The total complication rate for the cohort was 4/61 (6.6%). Three complications were reported in skull base procedures (2 immediate and 1 delayed). A single complication was reported in a calvarial biopsy, and no complications were reported in orbital biopsies. CONCLUSION: Percutaneous CT-guided core needle biopsies can be performed safely and with a high diagnostic yield for lesions in the skull base, calvarium, and orbit.

MR Lymphangiography in Lymphatic Disorders: Clinical Applications, Institutional Experience, and Practice Development.

Lymphatic flow and anatomy can be challenging to study, owing to variable lymphatic anatomy in patients with diverse primary or secondary lymphatic pathologic conditions and the fact that lymphatic imaging is rarely performed in healthy individuals. The primary components of the lymphatic system outside the head and neck are the peripheral, retroperitoneal, mesenteric, hepatic, and pulmonary lymphatic systems and the thoracic duct. Multiple techniques have been developed for imaging components of the lymphatic system over the past century, with trade-offs in spatial, temporal, and contrast resolution; invasiveness; exposure to ionizing radiation; and the ability to obtain information on dynamic lymphatic flow. More recently, dynamic contrast-enhanced (DCE) MR lymphangiography (MRL) has emerged as a valuable tool for imaging both lymphatic flow and anatomy in a variety of congenital and acquired primary or secondary lymphatic disorders. The authors provide a brief overview of lymphatic physiology, anatomy, and imaging techniques. Next, an overview of DCE MRL and the development of an MRL practice and workflow in a hybrid interventional MRI suite incorporating cart-based in-room US is provided, with an emphasis on multidisciplinary collaboration. The spectrum of congenital and acquired lymphatic disorders encountered early in an MRL practice is provided, with emphasis on the diversity of imaging findings and how DCE MRL can aid in diagnosis and treatment of these patients. Methods such as DCE MRL for assessing the hepatic and mesenteric lymphatic systems and emerging technologies that may further expand DCE MRL use such as three-dimensional printing are introduced. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Projection of realistic three-dimensional photogrammetry models using stereoscopic display: A technical note.

The 3D stereoscopic technique consists in providing the illusional perception of depth of a given object using two different images mimicking how the right and left eyes capture the object. Both images are slightly different and when overlapped gives a three-dimensional (3D) experience. Considering the limitations for establishing surgical laboratories and dissections courses in some educational institutions, techniques such as stereoscopy and photogrammetry seem to play an important role in neuroanatomy and neurosurgical education. The aim of this study was to describe how to combine and set up realistic models acquired with photogrammetry scans in 3D stereoscopic projections. Three donors, one dry skull, embalmed brain and head, were scanned using photogrammetry. The software used for displaying the final realistic 3D models (Blender, Amsterdam, the Netherlands) is a free software and allows stereoscopic projection without compromising the interactivity of each model. By default, the model was exported and immediately displayed as a red cyan 3D mode. The 3D projector used in the manuscript required a side-by-side 3D mode which was set up with simple commands on the software. The final stereoscopy projection offered depth perception and a visualization in 360° of each donor; this perception was noted especially when visualizing donors with different cavities and fossae. The combination of 3D techniques is of paramount importance for neuroanatomy education. Stereoscopic projections could provide a valuable tool for neuroanatomy instruction directed at clinical trainees and could be especially useful when access to laboratory-based learning is limited.

Intrapartum fetal heart rate monitoring: Rationalise, refine or replace?

Monitoring the fetal heartbeat underpins assessment of fetal wellbeing in labour. Although commonly employed in clinical practice, shortcomings remain. A recent review of clinical practice guidelines highlights the variation in definitions of the fetal heart rate that will lead to differences in interpretation. Will intrapartum care be improved by greater consensus around clinical practice guidelines through rationalisation or refinement of guidelines, or will the future see this technique replaced by more accurate forms of fetal monitoring?

Perspectives on implementing Individual Placement and Support (IPS) within primary health care settings for adults living in British Columbia, Canada.

BACKGROUND: Individual placement and support (IPS) is an evidence-based practice (EBP) designed to help people with severe mental illness re-enter the labour market. Implementing an IPS program within a new context (e.g., primary health care setting) to support populations that are complex and multi-barriered presents a set of unique challenges and considerations. This paper provides community-based perspectives that identify implementation strengths and challenges and highlights potential strategies aimed at addressing emergent barriers. METHODS: A case study was conducted across three community health centres in British Columbia (BC), Canada, where a novel IPS program was embedded within primary care services. Data collection consisted of open-ended surveys and focus groups with service providers directly involved in program implementation and their associated clinical and managerial support teams (n = 15). Using the updated Consolidated Framework for Implementation Research (CFIR) as a guide, we performed deductive thematic analysis to identify key areas impacting IPS implementation. RESULTS: Integration with existing health care systems and primary health care teams and support from leadership across all levels were identified as both key facilitators and barriers to implementation. Facilitators and barriers were identified across all domains, with those within innovation and process most easily addressed. Four cross-cutting themes emerged for promoting more integrated and sustainable program implementation: investing in pre-implementation activities, supporting a dynamic and flexible program, building from community experiences, and developing a system for shared knowledge. CONCLUSIONS: Implementing an IPS program embedded within primary health care settings is complex and requires extensive planning and consultation with community-based service providers and decision-makers to achieve full integration. Future practice and policy decisions aimed at supporting employment and well-being should be made in collaboration with communities.

Resection of a Solitary Right Ventricular Metastasis in Oligorecurrent Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC), constituting the predominant manifestation of liver cancer, stands as a formidable medical challenge. The prognosis subsequent to surgical intervention, particularly for individuals presenting with a solitary tumor, relies heavily on the degree of invasiveness. The decision-making process surrounding therapeutic modalities in such cases assumes paramount importance. This case report illuminates a rather unusual clinical scenario. Here, we encounter a patient who, following a disease-free interval, manifested an atypical presentation of HCC, specifically, a solitary cardiac metastasis. The temporal interval of remission adds an additional layer of complexity to the case. Through a multidisciplinary planning process, the decision was made for surgical removal of the metastatic tumor.

Mitochondrial electron transport chain, ceramide, and coenzyme Q are linked in a pathway that drives insulin resistance in skeletal muscle.

Insulin resistance (IR) is a complex metabolic disorder that underlies several human diseases, including type 2 diabetes and cardiovascular disease. Despite extensive research, the precise mechanisms underlying IR development remain poorly understood. Previously we showed that deficiency of coenzyme Q (CoQ) is necessary and sufficient for IR in adipocytes and skeletal muscle (Fazakerley et al., 2018). Here, we provide new insights into the mechanistic connections between cellular alterations associated with IR, including increased ceramides, CoQ deficiency, mitochondrial dysfunction, and oxidative stress. We demonstrate that elevated levels of ceramide in the mitochondria of skeletal muscle cells result in CoQ depletion and loss of mitochondrial respiratory chain components, leading to mitochondrial dysfunction and IR. Further, decreasing mitochondrial ceramide levels in vitro and in animal models (mice, C57BL/6J) (under chow and high-fat diet) increased CoQ levels and was protective against IR. CoQ supplementation also rescued ceramide-associated IR. Examination of the mitochondrial proteome from human muscle biopsies revealed a strong correlation between the respirasome system and mitochondrial ceramide as key determinants of insulin sensitivity. Our findings highlight the mitochondrial ceramide-CoQ-respiratory chain nexus as a potential foundation of an IR pathway that may also play a critical role in other conditions associated with ceramide accumulation and mitochondrial dysfunction, such as heart failure, cancer, and aging. These insights may have important clinical implications for the development of novel therapeutic strategies for the treatment of IR and related metabolic disorders.

Naturally Occurring Vegetation Connectivity Facilitates Ant-Mediated Coffee Berry Borer Removal.

Vegetation connectivity is an essential aspect of the habitat complexity that impacts species interactions at local scales. However, agricultural intensification reduces connectivity in agroforestry systems, including coffee agroecosystems, which may hinder the movement of natural enemies and reduce the ecosystem services that they provide. Ants play an important role in regulating the coffee berry borer (CBB), which is the most damaging coffee pest. For arboreal ant communities, the connections between trees are important structures that facilitate ant mobility, resource recruitment, foraging success, and pest control ability. To better understand how connectivity impacts arboreal ants in coffee agroecosystems, we conducted an experiment to assess the impact of artificial (string) and naturally occurring vegetation (vines, leaves, branches) connectivity on Azteca sericeasur behavior on coffee plants. We compared ant activity, resource recruitment, and CBB removal rates across three connectivity treatments connecting coffee plants to A. sericeasur nest trees: vegetation connectivity, string, and control (not connected) treatments. We found higher rates of ant activity, resource recruitment, and CBB removal on plants with naturally occurring vegetation connections to A. sericeasur nest trees. Artificial connectivity (string) increased the rates of resource recruitment and CBB removal but to a lesser extent than vegetation connectivity. Moreover, vegetation connectivity buffered reductions in ant activity with distance from the ant nest tree. These results reinforce how habitat complexity in the form of vegetation connectivity impacts interspecific interactions at the local scale. Our results also suggest that leaving some degree of vegetation connectivity between coffee plants and shade trees can promote ant-mediated biological pest control in coffee systems.

Targeting alternative splicing as a new cancer immunotherapy-phosphorylation of serine arginine-rich splicing factor (SRSF1) by SR protein kinase 1 (SRPK1) regulates alternative splicing of PD1 to generate a soluble antagonistic isoform that prevents T cell exhaustion.

BACKGROUND: Regulation of alternative splicing is a new therapeutic approach in cancer. The programmed cell death receptor 1 (PD-1) is an immunoinhibitory receptor expressed on immune cells that binds to its ligands, PD-L1 and PD-L2 expressed by cancer cells forming a dominant immune checkpoint pathway in the tumour microenvironment. Targeting this pathway using blocking antibodies (nivolumab and pembrolizumab) is the mainstay of anti-cancer immunotherapies, restoring the function of exhausted T cells. PD-1 is alternatively spliced to form isoforms that are either transmembrane signalling receptors (flPD1) that mediate T cell death by binding to the ligand, PD-L1 or an alternatively spliced, soluble, variant that lacks the transmembrane domain. METHODS: We used PCR and western blotting on primary peripheral blood mononuclear cells (PBMCs) and Jurkat T cells, IL-2 ELISA, flow cytometry, co-culture of melanoma and cholangiocarcinoma cells, and bioinformatics analysis and molecular cloning to examine the mechanism of splicing of PD1 and its consequence. RESULTS: The soluble form of PD-1, generated by skipping exon 3 (∆Ex3PD1), was endogenously expressed in PBMCs and T cells and prevents cancer cell-mediated T cell repression. Multiple binding sites of SRSF1 are adjacent to PD-1 exon 3 splicing sites. Overexpression of phosphomimic SRSF1 resulted in preferential expression of flPD1. Inhibition of SRSF1 phosphorylation both by SRPK1 shRNA knockdown and by a selective inhibitor, SPHINX31, resulted in a switch in splicing to ∆Ex3PD1. Cholangiocarcinoma cell-mediated repression of T cell IL-2 expression was reversed by SPHINX31 (equivalent to pembrolizumab). CONCLUSIONS: These results indicate that switching of the splicing decision from flPD1 to ∆Ex3PD1 by targeting SRPK1 could represent a potential novel mechanism of immune checkpoint inhibition in cancer.

Clinical situations for which 3D printing is considered an appropriate representation or extension of data contained in a medical imaging examination: neurosurgical and otolaryngologic conditions.

BACKGROUND: Medical three dimensional (3D) printing is performed for neurosurgical and otolaryngologic conditions, but without evidence-based guidance on clinical appropriateness. A writing group composed of the Radiological Society of North America (RSNA) Special Interest Group on 3D Printing (SIG) provides appropriateness recommendations for neurologic 3D printing conditions. METHODS: A structured literature search was conducted to identify all relevant articles using 3D printing technology associated with neurologic and otolaryngologic conditions. Each study was vetted by the authors and strength of evidence was assessed according to published guidelines. RESULTS: Evidence-based recommendations for when 3D printing is appropriate are provided for diseases of the calvaria and skull base, brain tumors and cerebrovascular disease. Recommendations are provided in accordance with strength of evidence of publications corresponding to each neurologic condition combined with expert opinion from members of the 3D printing SIG. CONCLUSIONS: This consensus guidance document, created by the members of the 3D printing SIG, provides a reference for clinical standards of 3D printing for neurologic conditions.

Pre-eclampsia in a first pregnancy and subsequent pregnancy outcomes: a nationwide cohort study.

BACKGROUND: For women whose first pregnancy was complicated by pre-eclampsia (PE), particularly if severe and requiring early birth, the risk of recurrence and maternal and neonatal outcomes at subsequent birth are important considerations. METHODS: In this observational cohort study, all primiparous women who gave birth in Denmark between 1997 and 2016 were identified using nationwide registries. Women were stratified by whether they developed PE and followed from date of birth until subsequent birth, emigration, death or end of study (December 2016). The cumulative incidences of subsequent birth among women with versus without PE were assessed using the Aalen-Johansen estimator. Subsequent outcomes including PE recurrence and maternal and neonatal morbidity and mortality were also examined. Factors associated with subsequent birth and recurrent PE were examined using multivariable Cox regression models. RESULTS: Among 510 615 primiparous women with singleton pregnancies, 21 683 (4.2%) developed PE, with 1819 (0.4%) being early-onset PE (birth <34 weeks). Women with PE had a lower subsequent birth rate (57.4%) compared with women without PE (61.2%), and it was considerably lower among women with early-onset PE (49.4%). Among women with PE who had a subsequent birth, the overall recurrence rate of PE was 15.8% and higher among those with early-onset PE (31.5%). The gestational age increased with a median of 3 days (IQR -5 to 14) overall and 50 days (IQR 35-67) among those with early-onset PE. Moreover, neonatal and maternal morbidity and mortality were substantially improved in a subsequent pregnancy. CONCLUSIONS: Primiparous women with PE have a significantly lower rate of a subsequent birth than women without PE, yet the absolute difference was modest. Although the overall risk of recurrent PE is 1 in 6, maternal and neonatal morbidity and mortality at subsequent birth are substantially improved.

Vascular endothelial growth factor isoforms differentially protect neurons against neurotoxic events associated with Alzheimer's disease.

Alzheimer's disease (AD) is the most common cause of dementia, the chronic and progressive deterioration of memory and cognitive abilities. AD can be pathologically characterised by neuritic plaques and neurofibrillary tangles, formed by the aberrant aggregation of ß-amyloid and tau proteins, respectively. We tested the hypothesis that VEGF isoforms VEGF-A165a and VEGF-A165b, produced by differential splice site selection in exon 8, could differentially protect neurons from neurotoxicities induced by ß-amyloid and tau proteins, and that controlling expression of splicing factor kinase activity could have protective effects on AD-related neurotoxicity in vitro. Using oxidative stress, ß-amyloid, and tau hyperphosphorylation models, we investigated the effect of VEGF-A splicing isoforms, previously established to be neurotrophic agents, as well as small molecule kinase inhibitors, which selectively inhibit SRPK1, the major regulator of VEGF splicing. While both VEGF-A165a and VEGF-A165b isoforms were protective against AD-related neurotoxicity, measured by increased metabolic activity and neurite outgrowth, VEGF-A165a was able to enhance neurite outgrowth but VEGF-A165b did not. In contrast, VEGF-A165b was more effective than VEGF-A165a in preventing neurite "dieback" in a tau hyperphosphorylation model. SRPK1 inhibition was found to significantly protect against neurite "dieback" through shifting AS of VEGFA towards the VEGF-A165b isoform. These results indicate that controlling the activities of the two different isoforms could have therapeutic potential in Alzheimer's disease, but their effect may depend on the predominant mechanism of the neurotoxicity-tau or ß-amyloid.

That which is unseen: 3D printing for pediatric cerebrovascular education.

INTRODUCTION: Pediatric cerebrovascular lesions are very rare and include aneurysms, arteriovenous malformations (AVM), and vein of Galen malformations (VOGM). OBJECTIVE: To describe and disseminate a validated, reproducible set of 3D models for optimization of neurosurgical training with respect to pediatric cerebrovascular diseases METHODS: All pediatric cerebrovascular lesions treated at our institution with adequate imaging studies during the study period 2015-2020 were reviewed by the study team. Three major diagnostic groups were identified: aneurysm, AVM, and VOGM. For each group, a case deemed highly illustrative of the core diagnostic and therapeutic principles was selected by the lead and senior investigators for printing (CSG/JM). Files for model reproduction and free distribution were prepared for inclusion as Supplemental Materials. RESULTS: Representative cases included a 7-month-old female with a giant left MCA aneurysm; a 3-day-old male with a large, complex, high-flow, choroidal-type VOGM, supplied from bilateral thalamic, choroidal, and pericallosal perforators, with drainage into a large prosencephalic vein; and a 7-year-old male with a left frontal AVM with one feeding arterial vessel from the anterior cerebral artery and one single draining vein into the superior sagittal sinus CONCLUSION: Pediatric cerebrovascular lesions are representative of rare but important neurosurgical diseases that require creative approaches for training optimization. As these lesions are quite rare, 3D-printed models and open source educational materials may provide a meaningful avenue for impactful clinical teaching with respect to a wide swath of uncommon or unusual neurosurgical diseases.

3D Printed Models of Trochlear Dysplasia and Trochleoplasty Simulation for Trainee Education.

Trochlear dysplasia is a major contributor to patellofemoral instability and subsequent failure of isolated soft tissue reconstruction procedures in the treatment of recurrent patellar dislocation and/or subluxation. Trochleoplasty procedures aim to address abnormal osseous trochlear morphologic factors that contribute to patellar maltracking. However, teaching these techniques is limited by the lack of reliable training models for trochlear dysplasia and trochleoplasty simulation. Although a cadaveric knee model of trochlear dysplasia for trochleoplasty simulation has been recently described, cadaveric knees are less amenable for use in trochleoplasty planning and surgeon training because of the absence of reliable, natural dysplastic anatomic relationships, such as suprapatellar spurs due to the rarity of dysplastic cadavers and the high cost of cadaveric specimens. Furthermore, readily available sawbone models represent "normal" osseous trochlear morphology and are difficult to modify and bend due to their material composition. Given this, we have developed a cost-effective, reliable, and anatomically accurate three-dimensional (3D) knee model of trochlear dysplasia for trochleoplasty simulation and trainee education.

The Role of 3D Printing in Treatment Planning of Spine and Sacral Tumors.

Three-dimensional (3D) printing technology has proven to have many advantages in spine and sacrum surgery. 3D printing allows the manufacturing of life-size patient-specific anatomic and pathologic models to improve preoperative understanding of patient anatomy and pathology. Additionally, virtual surgical planning using medical computer-aided design software has enabled surgeons to create patient-specific surgical plans and simulate procedures in a virtual environment. This has resulted in reduced operative times, decreased complications, and improved patient outcomes. Combined with new surgical techniques, 3D-printed custom medical devices and instruments using titanium and biocompatible resins and polyamides have allowed innovative reconstructions.

Incremental diagnostic yield and clinical outcomes of lateral decubitus CT myelogram immediately following negative lateral decubitus digital subtraction myelogram.

INTRODUCTION: Spontaneous intracranial hypotension (SIH) caused by a spinal cerebrospinal fluid (CSF) leak classically presents with orthostatic headache. Digital subtraction myelography (DSM) has a well-established diagnostic yield in the absence of extradural spinal collection. At our institution, DSM is followed by lateral decubitus CT myelogram (LDCTM) in the same decubitus position to increase diagnostic yield of the combined study. We evaluated the incremental diagnostic yield of LDCTM following negative DSM and reviewed patient outcomes. METHODS: Retrospective review of consecutive DSMs with subsequent LDCTM from April 2019 to March 2021 was performed. Combined reports were reviewed, and studies with positive DSMs were excluded. Of the exams with negative DSM, only studies with LDCTM reports identifying potential leak site were included. Interventions and follow-up clinical notes were reviewed to assess symptoms improvement following treatment. RESULTS: Of the 83 patients with negative DSMs, 11 (13.2%) had positive leak findings on LDCTMs, and 21 (25.3%) were equivocal. Of 11 positive LDCTMs, 6 leaks were nerve sheath tears (NSTs) and 5 were CSF-venous fistulas (CVFs). 10/11 (90.9%) had intervention and follow-up, with 9/10 (90%) having positive clinical outcome. Of the 21 equivocal LDCTM patients (19 CVFs and 2 NSTs), 15 (71.4%) had interventions and follow-up, with 3/15 (20.0%) with positive clinical outcomes. CONCLUSION: LDCTM following negative DSM has an incremental diagnostic yield up to 38.6%, with up to 14.5% of positive patient outcomes following treatment. LDCTM should be considered after DSM to maximize diagnostic yield of the combined exam.