Outcomes After Minimally Invasive Sacroiliac Joint Fusion: A Scoping Review.

BACKGROUND: Sacroiliac joint (SIJ) dysfunction is a significant contributor to lower back pain. Although open surgical treatment for persistent pain has long been the standard, it is associated with significant surgical morbidity, high complication rates, and variable patient satisfaction. Minimally invasive SIJ fusion (MISJF) is a promising and effective approach. This scoping review was carried out to map the available evidence on outcomes after MISJF. METHODS: This review was conducted in accordance with the PRISMA guidelines. Inclusion criteria were all full-text articles reporting on functional, clinical, and quality-of-life outcomes after MISJF. Exclusion criteria consisted of studies including patients with traumatic sacroiliac injuries or congenital spinal abnormalities, and procedures involving multiple spinal fusions or an open approach to SIJ fusion. RESULTS: A total of 1305 studies were identified across 6 databases. After duplicate removal and further screening, 33 independent studies were included in our review. Regarding pain management, 21 studies reported visual analog scale scores, and all showed significant (>50%) reductions in pain at multiple time points postoperatively. Six studies reported on quality-of-life outcomes and showed significant increases, especially compared with nonsurgical treatment. CONCLUSIONS: This study highlights the existing literature regarding outcomes after MISJF. MISJF provides favorable responses in quality-of-life metrics, pain scores, and overall postoperative outcomes in select patients. Although outcomes have been widely studied, more studies, especially prospectively designed and those without industry influence, should be performed to elucidate the optimal management of patients with intractable SIJ pain.

Innovation-Oriented Medical School Curricula: Review of the Literature.

Innovation and entrepreneurship (I&E) programs in medical education have become available as medical schools recognize the need to train forward-thinking physicians. There is considerable diversity in the design and implementation of these curricula, which represents a challenge and possibly serves as a deterrent for the development of additional I&E programs. A comprehensive search of medical school I&E programs and review of all Association of American Medical Colleges member websites (n = 171) were conducted. This review sought to (1) identify all American and Canadian allopathic medical schools with I&E curricula, (2) evaluate their structure/integration in the context of medical education, (3) outline core learning themes, and (4) describe the evaluative metrics. Information was collected through published or publicly available websites and through a questionnaire sent to identified I&E program leaders. Twenty-eight I&E-oriented medical education programs were identified from 26 schools; all of the programs integrated faculty leadership with backgrounds in medicine, engineering, and/or business/entrepreneurship. Of the programs, 57% (16/28) had been launched within the past four years and 75% (21/28) based program enrollment on a selective application process. Nearly all (27/28) incorporated lecture series and/or hands-on modules as a teaching technique. The most prevalent metric was completion of a capstone project (22/28; 79%). At least 15.2% (26/171) of American and Canadian allopathic medical schools include the option for students to participate in an I&E curriculum-based program. This review can be used to help medical school faculty with developing I&E curricula.

Halo vest immobilization - an institutional review of safety in acute cervical spine injury from 2013 to 2017.

Objective: Halo vest immobilization (HVI) remains an important treatment option for occipital-cervical injuries. It provides the surgeon with a safe and effective medical treatment options for challenging patients. The aim of this study was to evaluate the safety of HVI in these patients.Methods: This retrospective study identified adult patients treated with Halo vests immobilization (HVI) for acute cervical spine injury at our metropolitan level 1 trauma center from 2013 to 2017. This heterogenous cohort included 67 consecutive patients with acute cervical spine injury secondary to trauma or iatrogenic injury following surgical intervention with a mean age of 52 and a mean injury severity score (ISS) of 18. Forty-six percent of patients were treated with HVI as an adjunct therapy to surgical fixation (both short- and long-term immobilization), 45% of patients were treated with HVI as a primary medical treatment, and 9% of patients were treated with HVI instead of failed conservative medical treatment, such as cervical braces. Results: Pneumonia during the initial hospital stay was the most common complication (25%), followed by the correction of loose pins (22%) and pin site infections (18%). Overall, 51% of patients experienced at least one of these complications. There were significant associations between low initial GCS scores and the development of pneumonia (p < 0.001), high ISS scores and the development of pneumonia (p < 0.01), and duration of HVI and the occurrence of loose pins (p < 0.05). Four patients initially treated with HVI as primary medical treatment was converted to surgical treatment due to an intolerance of HVI or non-healing injuries.Conclusions:The HVI is a safe and effective treatment modality in a subset of patients with complex cervical junction and subaxial cervical spine pathology.

Microglial Calcium Waves During the Hyperacute Phase of Ischemic Stroke.

BACKGROUND AND PURPOSE: Ischemic injury triggers multiple pathological responses in the brain tissue, including spreading depolarizations across the cerebral cortex (cortical spreading depolarizations [CSD]). Microglia have been recently shown to play a significant role in the propagation of CSD. However, the intracellular responses of myeloid cells during ischemic stroke have not been investigated. METHODS: We have studied intracellular calcium activity in cortical microglia in the stroke model of the middle cerebral artery occlusion, using the murine Polr2a-based and Cre-dependent GCaMP5 and tdTomato reporter (PC::G5-tdT). High-speed 2-photon microscopy through cranial windows was employed to record signals from genetically encoded indicators of calcium. Inflammatory stimuli and pharmacological inhibition were used to modulate microglial calcium responses in the somatosensory cortex. RESULTS: In vivo imaging revealed periodical calcium activity in microglia during the hyperacute phase of ischemic stroke. This activity was more frequent during the first 6 hours after occlusion, but the amplitudes of calcium transients became larger at later time points. Consistent with CSD nature of these events, we reproducibly triggered comparable calcium transients with microinjections of potassium chloride (KCl) into adjacent cortical areas. Furthermore, lipopolysaccharide-induced peripheral inflammation, mimicking sterile inflammation during ischemic stroke, produced significantly greater microglial calcium transients during CSD. Finally, in vivo pharmacological analysis with CRAC (calcium release-activated channel) inhibitor CM-EX-137 demonstrated that CSD-associated microglial calcium transients after KCl microinjections are mediated at least in part by the CRAC mechanism. CONCLUSIONS: Our findings demonstrate that microglia participate in ischemic brain injury via previously undetected mechanisms, which may provide new avenues for therapeutic interventions.

Combined Posterior-Anterior Interbody Fusion in the Management of Traumatic Lumbosacral Dissociation: A Case Report and Review of Literature.

Traumatic lumbosacral dissociation is a unique, but well-documented, phenomenon that generally stems from high-energy impact injuries to the lower lumbar spine. Patients typically present with complicated and multisystem injuries with wide-ranging neurological deficits below the level of trauma. This presents stark challenges regarding the diagnosis, management, and surgical correction technique utilized. In this study, we present the case of a 21-year-old, morbidly obese, male patient that presented after a traumatic motor vehicle accident with L5-S1 lumbosacroiliac dissociation, cauda equina syndrome, and left lower extremity monoplegia. The degree of disruption warranted a 360° approach, we opted for an anterior lumbar interbody fusion followed by a posterior, lumbar interbody, short segment fusion. We review the case and relevant literature of similar lumbosacral dissociation studies with their management options and outcomes. Due to the rare nature of these devastating injuries, there remains wide variability in their management, with a combination of open anterior and posterior approaches resulting in variable long-term outcomes. The management of these rare injuries will require appropriate consideration of the patient's unique etiology, coexisting injuries, and radiological imaging in deciding surgical stabilization techniques.

Does Surgical Intervention Help with Neurological Recovery in a Lumbar Spinal Gun Shot Wound? A Case Report and Literature Review.

The third leading cause of spinal injuries are gunshot wounds to the spine, accounting for 15.2% of all spinal cord injuries. Treatment for gunshot wound spinal cord injuries (GSWSCI) remains variable, with indications for surgery being controversial. There is no clear evidence or guidelines that can help spine surgeons decide and direct surgical intervention. With the paucity of available literature, we report an interesting case of a gunshot injury to the lumbar spine at L1-L2, discuss the presentation and outcome, and evaluate relevant literature. A 27-year-old incarcerated male patient presented with a conus cauda equina asymmetrical injury involving the lower extremities and required initial medical stabilization in the intensive care unit (ICU). He subsequently underwent delayed surgical treatment with decompression and fragment resection at L1-L2. The patient improved neurologically to the American Spinal Injury Association (ASIA) Classification D and eventually regained nearly all lower extremity neurological function. Despite considerable evidence favoring the conservative management of GSWSCI and the absence of guidelines or recommendations on surgical interventions, our case report demonstrates that surgical intervention in appropriately selected patients can yield good recovery of neurological function and improvement in the quality of life. The key remains careful patient selection, the appropriate location of the retained fragment, and the extent of neurological injury that occurred. We feel surgical decompression and fragment removal, along with debridement, can result in good neurological recovery and long-term outcomes.

Reimbursement patterns for neurosurgery: Analysis of the NERVES survey results from 2011-2016.

OBJECTIVE: In response to rising national health expenditures, the Patient Protection and Affordable Care Act (ACA) was passed in 2010, with major provisions implemented in 2014. Due to increasing concerns about workload and compensation among neurosurgeons, we evaluated trends in neurosurgical reimbursement, productivity and compensation before and after the implementation of the major provisions of the ACA. PATIENTS AND METHODS: Results from Neurosurgery Executives' Resource Value and Education Society (NERVES) annual surveys were collected, representing data from 2011 to 2016. Responses from different practice settings across the six years were categorized into groups, and inverse variance-weighted averaging was performed within the frameworks of a one-way ANOVA model with year. Data from 2011 to 2013 and 2014-2016 were analyzed similarly for differences among practice setting and region. RESULTS: The NERVES survey response rates ranged from 20% to 36%. Median values for compensation decreased by 3.66%, 6.42%, and 10.34% within private, hospital, and academic practices respectively after 2014 although these trends did not reach statistical significance. Median work RVUs had a trend to decrease by 5.67%, 13.08%, and 19.44% within private, hospital, and academic practices respectively after 2014. Academic practices showed statistically significant decreases in annual total RVUs, total gross charges and collections. CONCLUSION: These data demonstrate neurosurgical reimbursement and productivity have trended down during a time that increases in productivity and reimbursement were predicted. This phenomenon is most notable in academic practices compared to private or hospital based practices. Prospective analyses of the impact of healthcare policy reform on neurosurgical productivity are urgently needed.