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1.
J Neurosurg ; : 1-9, 2022 Apr 29.
Artigo em Inglês | MEDLINE | ID: mdl-35535844

RESUMO

OBJECTIVE: Intraoperative stimulation is used as a crucial adjunct in neurosurgical oncology, allowing for greater extent of resection while minimizing morbidity. However, limited data exist regarding the impact of cortical stimulation on the frequency of perioperative seizures in these patients. METHODS: A retrospective chart review of patients undergoing awake craniotomy with electrocorticography data by a single surgeon at the authors' institution between 2013 and 2020 was conducted. Eighty-three patients were identified, and electrocorticography, stimulation, and afterdischarge (AD)/seizure data were collected and analyzed. Stimulation characteristics (number, amplitude, density [stimulations per minute], composite score [amplitude × density], total and average stimulation duration, and number of positive stimulation sites) were analyzed for association with intraoperative seizures (ISs), ADs, and postoperative clinical seizures. RESULTS: Total stimulation duration (p = 0.005), average stimulation duration (p = 0.010), and number of stimulations (p = 0.020) were found to significantly impact AD incidence. A total stimulation duration of more than 145 seconds (p = 0.04) and more than 60 total stimulations (p = 0.03) resulted in significantly higher rates of ADs. The total number of positive stimulation sites was associated with increased IS (p = 0.048). Lesions located within the insula (p = 0.027) were associated with increased incidence of ADs. Patients undergoing repeat awake craniotomy were more likely to experience IS (p = 0.013). Preoperative antiepileptic drug use, seizure history, and number of prior resections of any type showed no impact on the outcomes considered. The charge transferred to the cortex per second during mapping was significantly higher in the 10 seconds leading to AD than at any other time point examined in patients experiencing ADs, and was significantly higher than any time point in patients not experiencing ADs or ISs. Although the rate of transfer for patients experiencing ISs was highest in the 10 seconds prior to the seizure, it was not significantly different from those who did not experience an AD or IS. CONCLUSIONS: The data suggest that intraoperative cortical stimulation is a safe and effective technique in maximizing extent of resection while minimizing neurological morbidity in patients undergoing awake craniotomies, and that surgeons may avoid ADs and ISs by minimizing duration and total number of stimulations and by decreasing the overall charge transferred to the cortex during mapping procedures.

2.
Radiol Artif Intell ; 3(6): e200232, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-34870211

RESUMO

PURPOSE: To investigate if a deep learning convolutional neural network (CNN) could enable low-dose fluorine 18 (18F) fluorodeoxyglucose (FDG) PET/MRI for correct treatment response assessment of children and young adults with lymphoma. MATERIALS AND METHODS: In this secondary analysis of prospectively collected data (ClinicalTrials.gov identifier: NCT01542879), 20 patients with lymphoma (mean age, 16.4 years ± 6.4 [standard deviation]) underwent 18F-FDG PET/MRI between July 2015 and August 2019 at baseline and after induction chemotherapy. Full-dose 18F-FDG PET data (3 MBq/kg) were simulated to lower 18F-FDG doses based on the percentage of coincidence events (representing simulated 75%, 50%, 25%, 12.5%, and 6.25% 18F-FDG dose [hereafter referred to as 75%Sim, 50%Sim, 25%Sim, 12.5%Sim, and 6.25%Sim, respectively]). A U.S. Food and Drug Administration-approved CNN was used to augment input simulated low-dose scans to full-dose scans. For each follow-up scan after induction chemotherapy, the standardized uptake value (SUV) response score was calculated as the maximum SUV (SUVmax) of the tumor normalized to the mean liver SUV; tumor response was classified as adequate or inadequate. Sensitivity and specificity in the detection of correct response status were computed using full-dose PET as the reference standard. RESULTS: With decreasing simulated radiotracer doses, tumor SUVmax increased. A dose below 75%Sim of the full dose led to erroneous upstaging of adequate responders to inadequate responders (43% [six of 14 patients] for 75%Sim; 93% [13 of 14 patients] for 50%Sim; and 100% [14 of 14 patients] below 50%Sim; P < .05 for all). CNN-enhanced low-dose PET/MRI scans at 75%Sim and 50%Sim enabled correct response assessments for all patients. Use of the CNN augmentation for assessing adequate and inadequate responses resulted in identical sensitivities (100%) and specificities (100%) between the assessment of 100% full-dose PET, augmented 75%Sim, and augmented 50%Sim images. CONCLUSION: CNN enhancement of PET/MRI scans may enable 50% 18F-FDG dose reduction with correct treatment response assessment of children and young adults with lymphoma.Keywords: Pediatrics, PET/MRI, Computer Applications Detection/Diagnosis, Lymphoma, Tumor Response, Whole-Body Imaging, Technology AssessmentClinical trial registration no: NCT01542879 Supplemental material is available for this article. © RSNA, 2021.

3.
Plast Reconstr Surg Glob Open ; 9(5): e3529, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-34881139

RESUMO

Bioabsorbable meshes have seen increasing clinical use to reinforce soft tissue, and exist on a spectrum of strength loss versus absorption: several retain their strength for months, but remain in situ for years. Others lose strength fully by 6 weeks. An intermediate profile, with some strength for 3 -4 months, but consistent absorption in less than a year, may be an optimal balance of near-term support and long-term safety. In this large animal study, we evaluate such a mesh (DuraSorb, SIA), assessing its utility in a porcine model of abdominal wall repair. METHODS: Two full-thickness defects were created in the abdominal walls of nine Yucatan swine via midline approach and repaired preperitoneally with either DuraSorb or long-lasting control mesh (TIGR, Novus Scientific). At 30 days, 3 months, and 1 year, the implantations were assessed by clinical pathology, post-necropsy histopathology, and burst strength testing. RESULTS: No device-associated complications were found in vivo, at necropsy, or histologically. DuraSorb was well-integrated and vascularized by 30 days. DuraSorb demonstrated minimal/mild inflammation and fibroplasia, and lower inflammatory scores when compared with TIGR at all time points (P < 0.05). Burst strength of the repair sites was higher than adjacent abdominal wall at all time points (P < 0.05). CONCLUSIONS: DuraSorb provided durable long-term support, minimal inflammation, and consistent absorption in this porcine model of abdominal wall repair, as compared to a long-term control. Clinical data is needed, but these results suggest that this mesh provides adequate structural support while potentially reducing long-term device reactions.

4.
World Neurosurg ; 153: e147-e152, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34166830

RESUMO

BACKGROUND: Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), and intracranial hemorrhage (ICH) may complicate the post-operative course of patients undergoing craniotomy. While prophylaxis with unfractionated heparin (UFH) has been shown to reduce VTE rates, twice-daily (BID) and three-times-daily (TID) UFH dosing regimens have not been compared in neurosurgical procedures. The objective of this study was to explore the association between UFH dosing regimen and rates of VTE and ICH in craniotomy patients. METHODS: A retrospective chart review was conducted for 159 patients at Northwestern University receiving 5000 units/0.5 mL UFH injections either BID (n = 132) or TID (n = 27). General linear regression models were run to predict rates of DVT, PE, and reoperation due to bleeding from UFH dosing regimen while controlling for age at surgery, sex, VTE history, craniotomy for tumor resection, surgery duration, length of stay, reoperation, infections, and IDH/MGMT mutations. RESULTS: Receiving UFH TID was significantly associated with a lower rate of PE when compared with receiving UFH BID (ß = -0.121, P = 0.044; TID rate = 0%, BID rate = 10.6%). UFH TID also showed a trend toward lower rates of DVT (ß = -0.0893, P = 0.295; TID rate = 18.5%, BID rate = 21.2%) when compared with UFH BID. UFH TID showed no significant difference in rate of reoperation for bleeding when compared to UFH BID (ß = -0.00623, P = 0.725; TID rate = 0%, BID rate = 0.8%). CONCLUSIONS: UFH TID dosing is associated with lower rates of PE when compared with BID dosing in patients undergoing craniotomy.


Assuntos
Anticoagulantes/administração & dosagem , Craniotomia , Heparina/administração & dosagem , Hemorragias Intracranianas/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Hemorragia Pós-Operatória/epidemiologia , Embolia Pulmonar/prevenção & controle , Trombose Venosa/prevenção & controle , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias Encefálicas/cirurgia , Esquema de Medicação , Feminino , Glioblastoma/cirurgia , Hematoma/cirurgia , Humanos , Hemorragias Intracranianas/induzido quimicamente , Modelos Lineares , Masculino , Neoplasias Meníngeas/cirurgia , Meningioma/cirurgia , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Hemorragia Pós-Operatória/induzido quimicamente , Embolia Pulmonar/epidemiologia , Reoperação , Estudos Retrospectivos , Trombose Venosa/epidemiologia , Adulto Jovem
5.
J Clin Neurosci ; 86: 1-5, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33775310

RESUMO

The standard of care for idiopathic normal pressure hydrocephalus (iNPH) is placement of a ventriculoperitoneal (VP) shunt. However, VP shunts require intracranial intervention and are associated with notable postoperative complications, with some groups reporting complication rates for VP shunts ranging from 17 to 33%, along with failure rates up to 17.7%. Lumboperitoneal (LP) shunts are an alternative for cerebrospinal fluid diversion that do not require intracranial surgery, thus providing utility in patients where intracranial surgery is not possible or preferred. Here we retrospectively reviewed our 25 patients with LP horizontal-vertical (LP-HV) shunts placement for initial treatment for iNPH from 2014 to 2019. All patients had preoperative gait dysfunction, 16 (64%) had urinary incontinence, and 21 (84%) exhibited cognitive insufficiency. Two weeks post-shunt placement, 23/25 (92%) patients demonstrated improvement in gait, 11/16 (68%) had improvement in incontinence, and 14/21 (66%) had improvement cognitive insufficiency. At six months or greater follow up 13/20 (65%) had improvement in gait, 7/15 (47%) showed improvement in incontinence, and 11/15 (73%) demonstrated improvement in cognitive function. Six patients (24%) required at least one revision of the LP shunt. Shunt malfunctions resulted from CSF leak in one patient, shunt catheter migration in two patients, peritoneal catheter pain in one patient, and clinical symptoms for overdrainage in two patients. Thus, we demonstrate that LP-HV shunt placement is safe and efficacious alternative to VP shunting for iNPH, resulting in notable symptomatic improvement and low risk of overdrainage, and may be considered for patients where cranial approaches should be avoided.


Assuntos
Derivações do Líquido Cefalorraquidiano/métodos , Hidrocefalia de Pressão Normal/cirurgia , Resultado do Tratamento , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Complicações Pós-Operatórias/cirurgia , Estudos Retrospectivos
6.
Neurosurgery ; 88(3): 648-657, 2021 02 16.
Artigo em Inglês | MEDLINE | ID: mdl-33469652

RESUMO

BACKGROUND: Opioid requirements in the perioperative period in patients undergoing lumbar spine fusion surgery remain problematic. Although minimally invasive surgery (MIS) techniques have been developed, there still remain substantial challenges to reducing length of hospital stay (LOS) because of postoperative opioid requirements. OBJECTIVE: To study the effect of implementing an enhanced recovery after surgery (ERAS) pathway in patients undergoing a 1-level MIS transforaminal lumbar interbody fusion (MIS TLIF) at our institution. METHODS: We implemented an ERAS pathway in patients undergoing an elective single-level MIS TLIF for degenerative changes at a single institution. Consecutive patients were enrolled over a 20-mo period and compared with a pre-ERAS group prior to the implementation of the ERAS protocol. The primary outcome was LOS. Secondary outcomes included reduction in morphine milligram equivalent units (MME), pain scores, postoperative urinary retention (POUR), and incidence of postoperative delirium. Patients were compared using the chi-square and Welch's 2-sample t-tests. RESULTS: A total of 299 patients were evaluated in this study: 87 in the ERAS group and 212 in the pre-ERAS group. In the ERAS group, there was a significant reduction in LOS (3.13 ± 1.53 vs 3.71 ± 2.07 d, P = .019), total admission MME (252.74 ± 317.38 vs 455.91 ± 498.78 MME, P = .001), and the number of patients with POUR (48.3% vs 65.6%, P = .008). There were no differences in pain scores. CONCLUSION: This is the largest ERAS MIS fusion cohort published to date evaluating a single cohort of patients in a generalizable manner. This ERAS pathway has shown a substantial decrease in LOS and opioid requirements in the immediate perioperative and postoperative period. There is further work to be done to evaluate patients undergoing other complex spine surgical interventions.


Assuntos
Analgésicos Opioides/administração & dosagem , Recuperação Pós-Cirúrgica Melhorada , Tempo de Internação/tendências , Vértebras Lombares/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/tendências , Fusão Vertebral/tendências , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Fusão Vertebral/métodos , Resultado do Tratamento
7.
Neurosurg Focus ; 49(5): E2, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33130621

RESUMO

Annually, 20% of all practicing neurosurgeons in the United States are faced with medical malpractice litigation. The average indemnity paid in a closed neurosurgical civil claim is $439,146, the highest of all medical specialties. The majority of claims result from dissatisfaction following spinal surgery, although claims after cranial surgery tend to be costlier. On a societal scale, the increasing prevalence of medical malpractice claims is a catalyst for the practice of defensive medicine, resulting in record-level healthcare costs. Outside of the obvious financial strains, malpractice claims have also been linked to professional disenchantment and career changes for afflicted physicians. Unfortunately, neurosurgical residents receive minimal practical education regarding these matters and are often unprepared and vulnerable to these setbacks in the earlier stages of their careers. In this article, the authors aim to provide neurosurgical residents and junior attendings with an introductory guide to the fundamentals of medical malpractice lawsuits and the implications for neurosurgeons as an adjunct to more formal residency education.


Assuntos
Imperícia , Neurocirurgia , Médicos , Humanos , Neurocirurgiões , Estados Unidos
8.
Clin Neurol Neurosurg ; 199: 106280, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33080428

RESUMO

BACKGROUND AND OBJECTIVE: Unilateral subaxial non-subluxed facet fractures (USNSFF) are a pathology seen in traumatic events such as motor vehicle accidents. Management involves either rigid collar bracing or surgical intervention. There currently is no consensus on the treatment of these injuries; this review aims to examine the extant data for recommendations as to which treatment is more effective. METHODS: MEDLINE, Scopus, and the Cochrane trial register were all searched on January 16, 2020, comparing outcomes for surgical and conservative therapy for USNSFF. The meta-analysis examined rates of treatment failure (need for subsequent operative management) in conservative versus surgical management. The meta-analysis was performed using a random effects model, with visualization in forest and L'Abbé plots. RESULTS: We identified six retrospective studies describing 270 patients, with three studies describing 137 patients used in the meta-analysis. Overall, a surgical success rate of 97.7 % and a non-operative success rate of 79.7 % was observed. A random effects model risk ratio of 1.66 (95 % CI: 0.61-4.52) was obtained, suggesting efficacy of surgical management over conservative management. CONCLUSION: The need for surgical intervention subsequent to initial management in the treatment of USNSFF was found to be lower in surgical treatment in contrast to conservative management. However, the studies that were included in the meta-analysis had patient cohorts with much higher rates of neurological deficit and ligamentous injury on presentation, indicating that these may be prognostic indicators of conservative management failure. Furthermore, those that did fail conservative management did not develop severely debilitating conditions. Accordingly, conservative treatment is generally sufficient as a first step in a majority of cases of USNSFF lacking neurological deficit or ligamentous involvement.


Assuntos
Tratamento Conservador/métodos , Fixação de Fratura/métodos , Fraturas da Coluna Vertebral/cirurgia , Articulação Zigapofisária/cirurgia , Tratamento Conservador/tendências , Fixação de Fratura/tendências , Humanos , Estudos Retrospectivos , Fraturas da Coluna Vertebral/diagnóstico por imagem , Fraturas da Coluna Vertebral/terapia , Articulação Zigapofisária/diagnóstico por imagem
9.
World Neurosurg ; 143: e574-e580, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32791230

RESUMO

BACKGROUND: Neurosurgical spine specialists receive considerable amounts of industry support that may impact the cost of care. The aim of this study was to evaluate the association between industry payments received by spine surgeons and the total hospital and operating room (OR) costs of an anterior cervical discectomy and fusion (ACDF) procedure among Medicare beneficiaries. METHODS: All ACDF cases were identified among the Medicare carrier files from January 1, 2013, to December 31, 2014, and matched to the Medicare inpatient baseline file. The total hospital and OR charges were obtained for these cases. Charges were converted to cost using year-specific cost-to-charge ratios. Surgeons were identified among the Open Payments database, which is used to quantify industry support. Analyses were performed to examine the association between industry payments received and ACDF costs. RESULTS: Matching resulting in the inclusion of 2209 ACDF claims from 2013-2014. In 2013 and 2014, the mean total cost for an ACDF was $21,798 and $21,008, respectively; mean OR cost was $5878 and $6064, respectively. Mann-Whitney U test demonstrated no significant differences in the mean total or OR cost for an ACDF based on quartile of general industry payment received (P = 0.21 and P = 0.54), and linear regression found no association between industry general payments, research support, or investments on the total hospital cost (P = 0.41, P = 0.13, and P = 0.25, respectively), or OR cost for an ACDF (P = 0.35, P = 0.24, and P = 0.40, respectively). CONCLUSIONS: This study suggests that spine surgeons performing ACDF surgeries may receive industry support without impacting the cost of care.


Assuntos
Vértebras Cervicais/cirurgia , Discotomia/economia , Custos Hospitalares , Medicare/economia , Médicos/economia , Fusão Vertebral/economia , Idoso , Idoso de 80 Anos ou mais , Discotomia/tendências , Feminino , Custos Hospitalares/tendências , Humanos , Indústrias/economia , Indústrias/tendências , Benefícios do Seguro/economia , Benefícios do Seguro/tendências , Masculino , Medicare/tendências , Médicos/tendências , Fusão Vertebral/tendências , Estados Unidos
10.
Surg Neurol Int ; 11: 202, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32754373

RESUMO

BACKGROUND: Neurocysticercosis (NCC) is the most common parasitic infection of the central nervous system worldwide and is caused by the larval form of the tapeworm Taenia solium. In general, T. solium larval form may be located in the neuraxis, resulting in pathology. Here, we report a rare case of female with a history of adult onset seizures presenting with adult form T. solium in the fourth ventricle, causing hydrocephalus. CASE DESCRIPTION: A 36-year-old female patient with a known history of adult onset seizures presented with a 1-year history of progressively worsening bilateral headaches with vertigo and intermittent nausea. A computerized tomography scan revealed ventriculomegaly and transependymal flow, with an obstruction at the level of the fourth ventricle. Outpatient magnetic resonance imaging demonstrated obstructive hydrocephalus secondary to a lobulated cystic mass within the fourth ventricle, demonstrating a gross appearance consistent with racemose NCC. The patient underwent endoscopic third ventriculostomy, and gross examination of the resected cyst revealed a mature T. solium larvae encased in a cystic membrane. Given that our patient was born and raised in Mexico but had not returned since the age of 8, NCC was an unexpected finding. CONCLUSION: The present case highlights the importance of maintaining high suspicion for NCC in all patients presenting with seizures or hydrocephalus of unknown cause. Even in patients with a very remote history of residence in an endemic country, NCC can be an overlooked, underlying cause of both chronic neurologic symptoms, as well as acute, life-threatening neurologic emergencies.

11.
J Neurosurg ; 134(5): 1610-1617, 2020 May 22.
Artigo em Inglês | MEDLINE | ID: mdl-32442979

RESUMO

OBJECTIVE: Intraoperative stimulation has emerged as a crucial adjunct in neurosurgical oncology, aiding maximal tumor resection while preserving sensorimotor and language function. Despite increasing use in clinical practice of this stimulation, there are limited data on both intraoperative seizure (IS) frequency and the presence of afterdischarges (ADs) in patients undergoing such procedures. The objective of this study was to determine risk factors for IS or ADs, and to determine the clinical consequences of these intraoperative events. METHODS: A retrospective chart review was performed for patients undergoing awake craniotomy (both first time and repeat) at a single institution from 2013 to 2018. Hypothesized risk factors for ADs/ISs in patients were evaluated for their effect on ADs and ISs, including tumor location, tumor grade (I-IV), genetic markers (isocitrate dehydrogenase 1/2, O 6-methylguanine-DNA methyltransferase [MGMT] promoter methylation, chromosome 1p/19q codeletion), tumor volume, preoperative seizure status (yes/no), and dosage of preoperative antiepileptic drugs for each patient. Clinical outcomes assessed in patients with IS or ADs were duration of surgery, length of stay, presence of perioperative deficits, and postoperative seizures. Chi-square analysis was performed for binary categorical variables, and a Student t-test was used to assess continuous variables. RESULTS: A total of 229 consecutive patients were included in the analysis. Thirty-five patients (15%) experienced ISs. Thirteen (37%) of these 35 patients had experienced seizures that were appreciated clinically and noted on electrocorticography simultaneously, while 8 patients (23%) experienced ISs that were electrographic alone (no obvious clinical change). MGMT promoter methylation was associated with an increased prevalence of ISs (OR 3.3, 95% CI 1.2-7.8, p = 0.02). Forty patients (18%) experienced ADs. Twenty-three percent of patients (9/40) with ISs had ADs prior to their seizure, although ISs and ADs were not statistically associated (p = 0.16). The presence of ADs appeared to be correlated with a shorter length of stay (5.1 ± 2.6 vs 6.1 ± 3.7 days, p = 0.037). Of the clinical features assessed, none were found to be predictive of ADs. Neither IS nor AD, or the presence of either IS or AD (65/229 patients), was a predictor for increased length of stay, presence of perioperative deficits, or postoperative seizures. CONCLUSIONS: ISs and ADs, while commonly observed during intraoperative stimulation for brain mapping, do not negatively affect patient outcomes.


Assuntos
Mapeamento Encefálico/efeitos adversos , Craniotomia , Eletrocorticografia/efeitos adversos , Complicações Intraoperatórias/etiologia , Monitorização Intraoperatória/efeitos adversos , Convulsões/etiologia , Adulto , Biomarcadores Tumorais , Mapeamento Encefálico/métodos , Neoplasias Encefálicas/genética , Neoplasias Encefálicas/fisiopatologia , Neoplasias Encefálicas/cirurgia , Metilação de DNA , Metilases de Modificação do DNA/genética , Enzimas Reparadoras do DNA/genética , Feminino , Humanos , Complicações Intraoperatórias/fisiopatologia , Isocitrato Desidrogenase/genética , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/métodos , Regiões Promotoras Genéticas , Estudos Retrospectivos , Fatores de Risco , Convulsões/fisiopatologia , Carga Tumoral , Proteínas Supressoras de Tumor/genética , Vigília
12.
Neurosurgery ; 86(6): E490-E507, 2020 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-32271911

RESUMO

BACKGROUND: Prescription opioid use and opioid-related deaths have become an epidemic in the United States, leading to devastating economic and health ramifications. Opioids are the most commonly prescribed drug class to treat low back pain, despite the limited body of evidence supporting their efficacy. Furthermore, preoperative opioid use prior to spine surgery has been reported to range from 20% to over 70%, with nearly 20% of this population being opioid dependent. OBJECTIVE: To review the medical literature on the effect of preoperative opioid use in outcomes in spine surgery. METHODS: We reviewed manuscripts published prior to February 1, 2019, exploring the effect of preoperative opioid use on outcomes in spine surgery. We identified 45 articles that analyzed independently the effect of preoperative opioid use on outcomes (n = 32 lumbar surgery, n = 19 cervical surgery, n = 7 spinal deformity, n = 5 "other"). RESULTS: Preoperative opioid use is overwhelmingly associated with negative surgical and functional outcomes, including postoperative opioid use, hospitalization duration, healthcare costs, risk of surgical revision, and several other negative outcomes. CONCLUSION: There is an urgent and unmet need to find and apply extensive perioperative solutions to combat opioid use, particularly in patients undergoing spine surgery. Further investigations are necessary to determine the optimal method to treat such patients and to develop opioid-combative strategies in patients undergoing spine surgery.


Assuntos
Analgésicos Opioides/efeitos adversos , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Dor Pós-Operatória/epidemiologia , Cuidados Pré-Operatórios/efeitos adversos , Doenças da Coluna Vertebral/cirurgia , Analgésicos Opioides/administração & dosagem , Humanos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Dor Pós-Operatória/prevenção & controle , Cuidados Pré-Operatórios/métodos , Reoperação , Doenças da Coluna Vertebral/tratamento farmacológico , Resultado do Tratamento
13.
J Spine Surg ; 6(1): 205-209, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32309658

RESUMO

Cervical radiculopathy is a common spinal condition associated with pain, sensory disturbances, and motor weakness. Symptoms often can be attributable to either disc herniation and/or bony foraminal stenosis due to uncinate hypertrophy. Posterior cervical foraminotomy and conventional anterior cervical discectomy and fusion (ACDF) represent the mainstay of treatment. In patients with severe bony foraminal stenosis, posterior foraminotomy and standard ACDF without complete resection of uncinate process may result in incomplete decompression. ACDF with uncinectomy allows for complete and direct decompression of the exiting nerve root, and may lead to improved clinical outcome in appropriately selected patients. We describe the technique for ACDF with uncinectomy and report the clinical outcome in a consecutive series of patients.

14.
World Neurosurg X ; 5: 100068, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31956859

RESUMO

OBJECTIVE: More than 5 billion individuals lack access to essential surgical care. Neurosurgical care is especially limited in low-income countries (LICs). Studies describing neurosurgical care in LICs are critical for understanding global disparities in access to neurosurgical procedures. To better understand these disparities, we conducted a systematic review of the literature identifying neurosurgical patients in LICs. METHODS: MEDLINE (PubMed), Embase (embase.com), and Cochrane Library (Wiley) databases were systematically searched to retrieve studies describing neurosurgical care in LICs as defined by the World Bank Country and Lending Groups income classification. All databases were searched from their inception; no date or language limits were applied. All the articles were blindly reviewed by 2 individuals. Data from eligible studies were extracted and summarized. RESULTS: Of the 4377 citations screened, 154 studies met inclusion criteria. The number of publications substantially increased over the study period, with 49% (n = 76) of studies published in the last 5 years. Twenty-six percent (n = 40) of studies had a first author, and 30% (n = 46) had a senior author, affiliated with a country different from the LIC of study. The most common neurosurgical diagnosis was traumatic brain injury (24%, n = 37), followed by hydrocephalus (26%, n = 40), and neoplastic intracranial mass (10%, n = 16). Of LICs, 43% (n = 15/35) had no published neurosurgical literature. CONCLUSIONS: There is a significant deficit in the literature on neurosurgical care in LICs. Efforts must focus on supporting research initiatives in LICs to improve publication bias and understand disparities in access to neurosurgical care in the lowest-resource countries.

15.
Mol Imaging Biol ; 22(3): 722-729, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-31325083

RESUMO

PURPOSE: Tumor response assessments on positron emission tomography (PET)/magnetic resonance imaging (MRI) scans require correct quantification of radiotracer uptake in tumors and normal organs. Historically, MRI scans have been enhanced with gadolinium (Gd)-based contrast agents, which are now controversial due to brain deposition. Recently, ferumoxytol nanoparticles have been identified as an alternative to Gd-based contrast agents because they provide strong tissue enhancement on MR images but are not deposited in the brain. However, it is not known if the strong T1- and T2-contrast obtained with iron oxide nanoparticles such as ferumoxytol could affect MR-based attenuation correction of PET data. The purpose of our study was to investigate if ferumoxytol administration prior to a 2-deoxy-2-[18F]fluoro-D-glucose [18F]FDG PET/MR scan would change standardized uptake values (SUV) of normal organs. PROCEDURES: Thirty pediatric patients (6-18 years) with malignant tumors underwent [18F]FDG-PET/MR scans (dose 3 MBq/kg). Fifteen patients received an intravenous ferumoxytol injection (5 mg Fe/kg) prior to the [18F]FDG-PET/MR scans (group 1). Fifteen additional age- and sex-matched patients received unenhanced [18F]FDG-PET/MR scans (group 2). For attenuation correction of PET data, we used a Dixon-based gradient echo sequence (TR 4.2 ms, TE 1.1, 2.3 ms, FA 5), which accounted for soft tissue, lung, fat, and background air. We used a mixed linear effects model to compare the tissue MRI enhancement, quantified as the signal-to-noise ratio (SNR), as well as tissue radiotracer signal, quantified as SUVmean and SUVmax, between group 1 and group 2. Alpha was assumed at 0.05. RESULTS: The MRI enhancement of the blood and solid extra-cerebral organs, quantified as SNR, was significantly higher on ferumoxytol-enhanced MRI scans compared to unenhanced scans (p < 0.001). However, SUVmean and SUVmax values, corrected based on the patients' body weight or body surface area, were not significantly different between the two groups (p > 0.05). CONCLUSION: Ferumoxytol administration prior to a [18F]FDG PET/MR scan did not change standardized uptake values (SUV) of solid extra-cerebral organs. This is important, because it allows injection of ferumoxytol contrast prior to a PET/MRI procedure and, thereby, significantly accelerates image acquisition times.


Assuntos
Óxido Ferroso-Férrico/farmacologia , Imageamento por Ressonância Magnética/métodos , Neoplasias/diagnóstico por imagem , Tomografia por Emissão de Pósitrons/métodos , Compostos Radiofarmacêuticos/farmacocinética , Adolescente , Criança , Ensaios Clínicos como Assunto , Meios de Contraste/química , Meios de Contraste/metabolismo , Interações Medicamentosas , Feminino , Óxido Ferroso-Férrico/química , Óxido Ferroso-Férrico/farmacocinética , Fluordesoxiglucose F18/química , Humanos , Masculino , Imagem Multimodal/métodos , Neoplasias/metabolismo , Neoplasias/patologia , Neoplasias/terapia , Compostos Radiofarmacêuticos/química , Resultado do Tratamento , Imagem Corporal Total/métodos
16.
Neurosurgery ; 86(1): 30-45, 2020 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30690479

RESUMO

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) is being increasingly offered on an outpatient basis. However, the safety profile of outpatient ACDF remains poorly defined. OBJECTIVE: To review the medical literature on the safety of outpatient ACDF. METHODS: We systematically reviewed the literature for articles published before April 1, 2018, describing outpatient ACDF and associated complications, including incidence of reoperation, stroke, thrombolytic events, dysphagia, hematoma, and mortality. A random-effects analysis was performed comparing complications between the inpatient and outpatient groups. RESULTS: We identified 21 articles that satisfied the selection criteria, of which 15 were comparative studies. Most of the existing studies were retrospective, with a lack of level I or II studies on this topic. We found no statistically significant difference between inpatient and outpatient ACDF in overall complications, incidence of stroke, thrombolytic events, dysphagia, and hematoma development. However, patients undergoing outpatient ACDF had lower reported reoperation rates (P < .001), mortality (P < .001), and hospitalization duration (P < .001). CONCLUSION: Our meta-analysis indicates that there is a lack of high level of evidence studies regarding the safety of outpatient ACDF. However, the existing literature suggests that outpatient ACDF can be safe, with low complication rates comparable to inpatient ACDF in well-selected patients. Patients with advanced age and comorbidities such as obesity and significant myelopathy are likely not suitable for outpatient ACDF. Spine surgeons must carefully evaluate each patient to decide whether outpatient ACDF is a safe option. Higher quality, large prospective randomized control trials are needed to accurately demonstrate the safety profile of outpatient ACDF.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/métodos , Vértebras Cervicais/cirurgia , Discotomia/métodos , Segurança do Paciente , Fusão Vertebral/métodos , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Procedimentos Cirúrgicos Ambulatórios/tendências , Vértebras Cervicais/patologia , Discotomia/efeitos adversos , Discotomia/tendências , Hospitalização/tendências , Humanos , Segurança do Paciente/normas , Estudos Prospectivos , Reoperação/efeitos adversos , Reoperação/métodos , Reoperação/tendências , Estudos Retrospectivos , Doenças da Medula Espinal/diagnóstico , Doenças da Medula Espinal/cirurgia , Fusão Vertebral/efeitos adversos , Fusão Vertebral/tendências
17.
J Clin Neurosci ; 69: 143-148, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31427233

RESUMO

Medical student (MS) observation and assistance in the operating room (OR) is a critical component of medical education. Though participation in the operating room has many benefits to the medical student, the potential cost of these experiences to the patients must be taken into account. Other studies have shown differences in outcomes with resident involvement, but the effect of medical students in the OR has been poorly understood. The objective of this study was to understand how medical students and residents impacted surgical outcomes in posterior spinal fusions, anterior cervical discectomy and fusions (ACDFs), and lumbar discectomies. We conducted a retrospective study of patients undergoing posterior spinal fusions, ACDFs, and lumbar discectomies over 15 years. There were 6485 patients met the inclusion criteria of either undergoing a posterior fusion, ACDF or lumbar discectomy (1250 posterior fusion, 1381 ACDF, 3854 lumbar discectomies). Overall, little difference was observed when a medical student was present for surgical outcomes including length of stay, infection, and readmission. For ACDFs, having a medical student present had a significantly longer procedure durations (OR = 1.612, p = 0.001) than cases without. Besides slightly longer operative time (in posterior fusions), there were no major differences in outcomes when a medical student was present in the OR.


Assuntos
Discotomia/educação , Educação Médica , Duração da Cirurgia , Fusão Vertebral/educação , Adulto , Vértebras Cervicais/cirurgia , Discotomia/métodos , Educação Médica/economia , Educação Médica/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fusão Vertebral/métodos , Estudantes de Medicina , Resultado do Tratamento , Adulto Jovem
18.
Mol Oncol ; 13(10): 2049-2061, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31376208

RESUMO

The long-term survival of osteosarcoma patients with metastatic or recurrent disease remains dismal, and new therapeutic options are urgently needed. The purpose of our study was to compare the efficacy of CD47 mAb plus doxorubicin combination therapy in mouse models of osteosarcoma with CD47 mAb and doxorubicin monotherapy. Forty-eight NOD scid gamma (NSG) mice with intratibial MNNG/HOS tumors received CD47 mAb, doxorubicin, combination therapy, or control IgG treatment. Twenty-four mice (n = 6 per group) underwent pre- and post-treatment magnetic resonance imaging (MRI) scans with the macrophage marker ferumoxytol, bioluminescence imaging, and histological analysis. Tumor ferumoxytol enhancement, tumor flux, and tumor-associated macrophages (TAM) density were compared between different groups using a one-way ANOVA. Twenty-four additional NSG mice underwent survival analyses with Kaplan-Meier curves and a log-rank (Mantel-Cox) test. Intratibial osteosarcomas demonstrated significantly stronger ferumoxytol enhancement and significantly increased TAM quantities after CD47 mAb plus doxorubicin combination therapy compared to CD47 mAb (P = 0.02) and doxorubicin monotherapy (P = 0.001). Tumor-bearing mice treated with CD47 mAb plus doxorubicin combination therapy demonstrated significantly reduced tumor size and prolonged survival compared to control groups that received CD47 mAb (P = 0.03), doxorubicin monotherapy (P = 0.01), and control IgG (P = 0.001). In conclusion, CD47 mAb plus doxorubicin therapy demonstrates an additive therapeutic effect in mouse models of osteosarcomas, which can be monitored with an immediately clinically applicable MRI technique.


Assuntos
Anticorpos Monoclonais/uso terapêutico , Antineoplásicos/uso terapêutico , Neoplasias Ósseas/tratamento farmacológico , Antígeno CD47/imunologia , Doxorrubicina/uso terapêutico , Osteossarcoma/tratamento farmacológico , Animais , Neoplasias Ósseas/diagnóstico por imagem , Neoplasias Ósseas/imunologia , Linhagem Celular Tumoral , Óxido Ferroso-Férrico/análise , Humanos , Luminescência , Macrófagos/efeitos dos fármacos , Macrófagos/imunologia , Imageamento por Ressonância Magnética , Camundongos Endogâmicos NOD , Imagem Óptica , Osteossarcoma/diagnóstico por imagem , Osteossarcoma/imunologia , Fagocitose/efeitos dos fármacos
19.
Radiology ; 292(1): 129-137, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31063081

RESUMO

Background Cartilage repair outcomes of matrix-associated stem cell implants (MASIs) in patients have been highly variable. Conventional MRI cannot help distinguish between grafts that will and grafts that will not repair the underlying cartilage defect until many months after the repair. Purpose To determine if ferumoxytol nanoparticle labeling could be used to depict successful or failed MASIs compared with conventional MRI in a large-animal model. Materials and Methods Between January 2016 and December 2017, 10 Göttingen minipigs (n = 5 male; n = 5 female; mean age, 6 months ± 5.1; age range, 4-20 months) received implants of unlabeled (n = 12) or ferumoxytol-labeled (n = 20) viable and apoptotic MASIs in cartilage defects of the distal femur. All MASIs were serially imaged with MRI on a 3.0-T imaging unit at week 1 and weeks 2, 4, 8, 12, and 24, with calculation of T2 relaxation times. Cartilage regeneration outcomes were assessed by using the MR observation of cartilage repair tissue (MOCART) score (scale, 0-100), the Pineda score, and histopathologic quantification of collagen 2 production in the cartilage defect. Findings were compared by using the unpaired Wilcoxon rank sum test, a linear regression model, the Fisher exact test, and Pearson correlation. Results Ferumoxytol-labeled MASIs showed significant T2 shortening (22.2 msec ± 3.2 vs 27.9 msec ± 1.8; P < .001) and no difference in cartilage repair outcomes compared with unlabeled control MASIs (P > .05). At week 2 after implantation, ferumoxytol-labeled apoptotic MASIs showed a loss of iron signal and higher T2 relaxation times compared with ferumoxytol-labeled viable MASIs (26.6 msec ± 4.9 vs 20.8 msec ± 5.3; P = .001). Standard MRI showed incomplete cartilage defect repair of apoptotic MASIs at 24 weeks. Iron signal loss at 2 weeks correlated with incomplete cartilage repair, diagnosed at histopathologic examination at 12-24 weeks. Conclusion Ferumoxytol nanoparticle labeling can accelerate the diagnosis of successful and failed matrix-associated stem cell implants at MRI in a large-animal model. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Sneag and Potter in this issue.


Assuntos
Doenças das Cartilagens/diagnóstico por imagem , Doenças das Cartilagens/cirurgia , Meios de Contraste , Óxido Ferroso-Férrico , Imageamento por Ressonância Magnética/métodos , Transplante de Células-Tronco/métodos , Animais , Cartilagem Articular/diagnóstico por imagem , Cartilagem Articular/cirurgia , Modelos Animais de Doenças , Suínos , Resultado do Tratamento
20.
J Clin Neurosci ; 65: 77-82, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31014906

RESUMO

Multiple sclerosis (MS) and cervical stenosis (CS) are two unique pathologies that can present with overlapping symptoms. In patients with concurrent MS and CS, the exact cause for worsening of symptoms is often difficult to decipher. In this study, we aimed to review the medical literature on the benefits of surgical decompression surgery in patients with coexisting CS and MS. We systematically reviewed the literature for articles published prior to December 1st, 2018 describing outcomes (improvement of symptoms of radiculopathy, myelopathy, and neck pain) in patients with coexisting MS and CS undergoing cervical decompression surgery. Effect sizes were calculated demonstrating the effect of surgical decompression on improving symptoms. We identified eight articles that satisfied our selection criteria, of which six provided data regarding symptoms after surgery. Our meta-analysis indicates that cervical decompression surgery in patients with coexisting MS and CS is beneficial in improving symptoms of myelopathy (ES 0.74, 95% CI 0.38-1.10, p < 0.0001), radiculopathy (ES 1.29, 95% CI 0.15-2.42, p < 0.001), and neck pain (ES 1.66, 95% CI 1.02-2.31, p < 0.0001). Our meta-analysis indicates that there is paucity of high level of evidence studies regarding the benefit of cervical decompression surgery in patients with concomitant CS and MS. However, the literature suggests that cervical decompression may be beneficial to such patients, providing stabilization or improvement in symptoms of myelopathy, radiculopathy, and neck pain. Spine surgeons must carefully delineate the cause of symptoms in patients to decide whether this is the optimal treatment for each individual patient.


Assuntos
Constrição Patológica/cirurgia , Esclerose Múltipla/cirurgia , Adulto , Vértebras Cervicais/cirurgia , Constrição Patológica/complicações , Descompressão Cirúrgica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Esclerose Múltipla/complicações , Cervicalgia/complicações , Radiculopatia/cirurgia , Estudos Retrospectivos , Doenças da Medula Espinal/cirurgia , Resultado do Tratamento
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