The influence of emotional faces on the spatial allocation of attention.

OBJECTIVES: Studies suggest that the right hemisphere is dominant for emotional facial recognition. In addition, whereas some studies suggest the right hemisphere mediates the processing of all emotions (dominance hypothesis), other studies suggest that the left hemisphere mediates positive emotions the right mediates negative emotions (valence hypothesis). Since each hemisphere primarily attends to contralateral space, the goals of this study was to learn if emotional faces would induce a leftward deviation of attention and if the valence of facial emotional stimuli can influence the normal viewer's spatial direction of attention. METHODS: Seventeen normal right handed participants were asked to bisect horizontal lines that had all combinations of sad, happy or neutral faces at ends of these lines. During this task the subjects were never requested to look at these faces and there were no task demands that depended on viewing these faces. RESULTS: Presentation of emotional faces induced a greater leftward deviation compared to neutral faces, independent of where (spatial position) these faces were presented. However, faces portraying negative emotions tended to induce a greater leftward bias than positive emotions. CONCLUSIONS: Independent of location, the presence of emotional faces influenced the spatial allocation of attention, such that normal subjects shift the direction of their attention toward left hemispace and this attentional shift appears to be greater for negative (sad) than positive faces (happy).

Superior Laryngeal Nerve Palsy in Revision Anterior Cervical Surgery.

Most spine surgeons routinely obtain preoperative ENT evaluation of recurrent laryngeal nerve function when contemplating revision anterior approaches to the cervical spine to avoid the potentially catastrophic consequences of bilateral vocal cord palsy. By contrast, there is less awareness of the potential for superior laryngeal nerve (SLN) injury-although a bilateral injury can, like bilateral injuries of the recurrent laryngeal nerve, have serious clinical consequences. This case report describes a 74-year-old man who, after a contralateral revision anterior approach to the upper cervical spine, developed bilateral SLN injury causing aspiration pneumonia and respiratory failure. We discuss risk factors associated with subclinical SLN injury and define at-risk patients who would benefit from preoperative SLN screening before revision anterior cervical surgery.

Variations in treatment of C1 fractures by time, age, and geographic region in the United States: An analysis of 985 patients.

The purpose of this investigation was to evaluate the variations in the treatment of C1 fractures over time, by age group, and by geographic region using a nationwide database. The Nationwide Emergency Department Sample (NEDS) database was queried to identify patients ≥18 years who sustained C1 fracture from 2006-2012. Patients were filtered based on the intervention they received: collar, halo, or surgery. Regions of hospital used in analysis were defined as Northeast, Midwest, South, and West. Surgical intervention for C1 fracture increased from 27.1% of cases in 2006 to 55.4% of cases in 2012 (P<0.001). The rate of collar treatment increased with increasing age. In contrast, rate of halo use decreased with increasing age. A greater proportion of patients in the Northeast were treated by collar compared to all other regions (P<0.001). We can conclude that there is considerable variation in the treatment of C1 fractures with regards to age and geographic region. Surgical treatment of these fractures is increasing over time. Future considerations should be given to developing treatment guidelines to decrease variation and potentially create cost-savings.

Variations in Treatment of C2 Fractures by Time, Age, and Geographic Region in the United States: An Analysis of 4818 Patients.

BACKGROUND: The optimal form of treatment for C2 spine fractures is controversial. This investigation analyzed the variations in treatment of C2 fractures over time, by age group, and by geographic location. METHODS: The Nationwide Emergency Department Sample database was queried to identify patients 18 years and older who sustained C2 fracture without neurologic injury from 2006 to 2012. Subsequently, patients were further filtered based on the intervention they received: collar, halo, and surgery. Regions of hospital used in analysis were defined as Northeast, Midwest, South, and West. Linear regression models were used to analyze trends for C2 incidence rates and treatment type. Analysis of variance tests were used to determine differences among procedure groups when stratified by regions and age groups. RESULTS: Surgical intervention for C2 fracture increased from 36.5% in 2006 to 55.7% in 2012 (r = 0.116, P < 0.001). In contrast, the rate of halo use decreased from 57.8% in 2006 to 37.1% in 2012 (r = -0.139, P < 0.001). Surgery displayed increasing trend across all age groups. A greater proportion of patients in the Northeast were treated by collar compared with all other regions (P < 0.001). In contrast, halo use was significantly lower in the Northeast than the other 3 regions (P < 0.001). CONCLUSIONS: This investigation demonstrated that surgical management of C2 fractures is increasing in frequency over time and at all age groups. Furthermore, the treatment of these fractures varies by region-the Northeast had the highest incidence of collar use and lowest rate of halo use.

Testosterone therapy in men with Parkinson disease: results of the TEST-PD Study.

BACKGROUND: Testosterone deficiency has been reported in patients with Parkinson disease (PD), Alzheimer disease, and Huntington disease. It is not known whether testosterone therapy (TT) in men with borderline hypogonadism and neurodegenerative diseases will be of substantial benefit. Previously, we reported that testosterone deficiency is more common in patients with PD compared with age-matched control subjects, and we also reported in 2 small open-label studies that some nonmotor symptoms responded favorably to TT. OBJECTIVE: To define the effects of TT on nonmotor and motor symptoms in men with PD and probable testosterone deficiency. DESIGN: Double-masked, placebo-controlled, parallel-group, single-center trial. PATIENTS: Two experimental groups: patients with PD who were receiving either TT or placebo. INTERVENTIONS: Participants received either the study drug by intramuscular injection (200 mg/mL of testosterone enanthate every 2 weeks for 8 weeks) or placebo (isotonic sodium chloride solution injections). In patients in each group, the testosterone serum concentration was obtained at each study visit. During 2 study visits, testosterone levels were blindly evaluated and the intramuscular testosterone dose was increased by 200 mg/mL if the free testosterone value failed to double from the baseline value. MAIN OUTCOME MEASURES: The primary outcome variable was the St Louis Testosterone Deficiency Questionnaire, and secondary outcome measures included measures of mood, cognition, fatigue, motor function, and frequency of adverse events. At the end of the double-blind phase, all patients were offered open-label TT and were followed up after 3 and 6 months. RESULTS: Fifteen patients in the placebo group (mean age, 69.9 years), receiving a mean total levodopa equivalent dose of 924 mg/d, had a baseline free testosterone level of 47.91 pg/mL, compared with 15 patients in the TT group (mean age, 66.7 years), receiving an average total levodopa equivalent dose of 734 mg/d, who had a baseline free testosterone level of 63.49 pg/mL. Testosterone was generally well tolerated. More subjects in the TT group experienced lower extremity edema (40% vs 20%). In 2 patients, 1 in each group, prostate-specific antigen levels were elevated from baseline. The improvement in the TT group compared with the placebo group (1.7 vs 1.1) on the St Louis Testosterone Deficiency Scale was not statistically significant. In addition, there were no significant differences in motor and nonmotor features of PD between the 2 groups, although a few subscales showed improvements (Hopkins Verbal Learning Test, P<.04; and Backward Visual Span subtrial, P<.03). However, long-term open-label TT resulted in delayed but sustained improvement in subjects in the TT group who continued to receive treatment (n = 6) compared with subjects in the placebo group who elected not to receive TT (n = 3). CONCLUSIONS: Testosterone therapy was generally well tolerated in elderly men with PD and probable testosterone deficiency. While there was no significant difference in the motor and nonmotor scales between the TT and placebo groups at the end of 8 weeks compared with baseline, this may be due to several study limitations, including small sample size, a strong placebo effect with intramuscular therapy, and short follow-up that did not allow measurement of delayed effects of TT in some subjects. Until more definitive studies are reported, practitioners should be particularly cautious in treatment of low testosterone concentrations in men with PD and borderline testosterone deficiency, and careful consideration should be given to the risks vs the benefits of TT.

Is more lordosis associated with improved outcomes in cervical laminectomy and fusion when baseline alignment is lordotic?

BACKGROUND CONTEXT: In cervical spondylotic myelopathy (CSM), cervical sagittal alignment (CSA) is associated with disease severity. Increased kyphosis and C2-C7 sagittal vertical axis (SVA) correlate with worse myelopathy and poor outcomes. However, when alignment is lordotic, it is unknown whether these associations persist. PURPOSE: The study aimed to investigate the associations between CSA parameters and patient-reported outcomes (PROs) following posterior decompression and fusion for CSM when baseline lordosis is maintained. STUDY DESIGN/SETTING: This is an analysis of a prospective surgical cohort at a single academic institution. PATIENT SAMPLE: The sample includes adult patients undergoing primary cervical laminectomy and fusion for CSM over a 3-year period. OUTCOME MEASURES: The PROs included EuroQol-5D, Short-Form-12 (SF-12) physical composite (PCS) and mental composite scales (MCS), Neck Disability Index, and the modified Japanese Orthopaedic Association scores. Radiographic CSA parameters measured included C1-C2 Cobb, C2-C7 Cobb, C1-C7 Cobb, C2-C7 SVA, C1-C7 SVA, and T1 slope. METHODS: The PROs were recorded at baseline and at 3 and 12 months postoperatively. The CSA parameters were measured on standing radiographs in the neutral position at baseline and 3 months. Wilcoxon rank test was used to test for changes in PROs and CSA parameters, and Pearson correlation coefficients were calculated for CSA parameters and PROs preoperatively and at 12 months. No external sources of funding were used for this work. RESULTS: There were 45 patients included with an average age of 63 years who underwent posterior decompression and fusion of 3.7±1.3 levels. Significant improvements were found in all PROs except SF-12 MCS (p=.06). Small but statistically significant changes were found in C2-C7 Cobb (mean change: +3.6°; p=.03) and C2-C7 SVA (mean change: +3 mm; p=.01). At baseline, only C2-C7 SVA associated with worse SF-12 PCS scores (r=-0.34, p=.02). Postoperatively, there were no associations found between PROs and any CSA parameters. Similarly, no CSA parameters were associated with changes in PROs. CONCLUSIONS: Although creating more lordosis and decreasing SVA are associated with improved myelopathy and outcomes in patients with kyphosis, our study did not find such associationsin patients with lordosis undergoing posterior laminectomy and fusion for CSM. This suggests that any amount of lordosis may be sufficient.

Diabetes Is Related to Worse Patient-Reported Outcomes at Two Years Following Spine Surgery.

BACKGROUND: Diabetes has been associated with poor outcomes following elective spine surgery. The purpose of our study was to determine if diabetes predicts worse patient-reported outcomes at two years postoperatively and to evaluate the effect of perioperative blood glucose levels and control on patient-reported outcomes in patients with diabetes. METHODS: One thousand and five patients undergoing elective spine surgery were included in this prospective cohort study. The presence of diabetes and baseline and one and two-year patient-reported outcomes (Short Form-12 [SF-12], EuroQol-5D [EQ-5D], Oswestry Disability Index [ODI] or Neck Disability Index [NDI], and Numeric Rating Scale [NRS] pain scores) were recorded. The mean blood glucose measurements in patients with diabetes were collected during the postoperative period. Multivariable linear regression analyses were performed to determine predictors of one and two-year outcomes as well as the relationship between perioperative blood glucose and patient-reported outcomes in patients with diabetes. RESULTS: Four hundred and thirty-four patients (43%) had diabetes. When compared with patients without diabetes at two years, patients with diabetes had lower SF-12 Physical Component Summary scores (34.4 points for the diabetic group compared with 38.6 points for the non-diabetic group), lower EQ-5D scores (0.67 for the diabetic group compared with 0.74 for the non-diabetic group), higher ODI or NDI scores (32.1 points for the diabetic group compared with 26.8 points for the non-diabetic group), and higher NRS scores (5.1 points for the diabetic group compared with 4.3 points for the non-diabetic group) (p < 0.05 for all). Although patients with diabetes improved significantly over time, they did not improve to the extent that patients without diabetes did in the ODI or NDI and EQ-5D scores (p < 0.05). Diabetes and preoperative opioid use were independent predictors of decreased SF-12 scores, decreased EQ-5D scores, increased ODI or NDI scores, and increased NRS scores (p < 0.05). Diabetes was associated with increased ODI or NDI (by 6.6 points) and decreased EQ-5D (by 0.1) at two years. Perioperative blood glucose control did not predict outcomes at either one or two years in patients with diabetes. CONCLUSIONS: Diabetes was associated with worse patient-reported outcomes when patients with diabetes were compared with patients without diabetes at two years following elective spine surgery. Although patients with diabetes improved when compared from baseline to the time following elective spine surgery, they did not improve to the same extent as patients without diabetes in the ODI or NDI and EQ-5D scores. Providers may use this information to counsel patients with diabetes on expectations following spine surgery.

The Evaluation of Donor Site Pain After Harvest of Tricortical Anterior Iliac Crest Bone Graft for Spinal Surgery: A Prospective Study.

STUDY DESIGN: A prospective cohort. OBJECTIVE: The aim of this study was to prospectively observe donor site pain, health-related quality-of-life outcomes, and complications following harvest of tricortical anterior iliac crest bone graft (AICBG) for anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: Persistent donor site pain from the anterior iliac crest has been reported to range between 2% and 40%. This morbidity has led surgeons to consider interbody alternatives for ACDF, which carry additional costs. METHODS: We prospectively enrolled 50 patients from 2 tertiary care centers over the course of 1 year observing complications and patient-reported outcomes. Patients filled out SF-12 and numeric rating scale (NRS) for pain in the arm, neck, and donor site pre-operatively and at 1 week, 2 weeks, 6 weeks, 3 to 6 months, and 1 year postoperatively. Outcomes were compared with a control group undergoing ACDF with allograft or Polyether ether ketone cages at 1 year. RESULTS: The mean ±â€ŠSD donor site pain at 1 week was 5.6 ±â€Š2.8 but decreased to 2.2 ±â€Š2.4 at 6 weeks and 1.1 ±â€Š1.8 at 1 year (P < 0.001). Including the 3 patients who were lost to follow-up, 10% of patients may have experienced persistent moderate or worse pain at 1 year. Linear regression analysis demonstrated that preoperative opioid use was an independent risk factor for increased donor site pain at 1 and 2 weeks (P < 0.05). There were no differences in outcomes at 1 year compared with the nonautograft group. There were 2 (4%) minor wound complications, both treated successfully with oral antibiotics. CONCLUSION: Tricortical AICBG for ACDF is not associated with major complications and only 4% of patients (potentially, maximum of 10%) experienced moderate, persistent donor site pain at 1 year. There is no difference in health-related outcomes between patients who have autograft with those who did not at 1 year. Preoperative opioid use is associated with increased donor site pain within the first 2 weeks postoperatively but not in the long term. At 6 weeks postoperatively, patients can expect the majority of their donor site pain to be resolved. LEVEL OF EVIDENCE: 2.

Increased Preoperative Narcotic Use and Its Association With Postoperative Complications and Length of Hospital Stay in Patients Undergoing Spine Surgery.

STUDY DESIGN: Prospective cohort analysis. OBJECTIVE: To assess the effect of preoperative narcotic use on the incidence of 30- and 90-day postoperative complications, as well as length of hospital stay (LOS) in patients undergoing spine surgery. SUMMARY OF BACKGROUND DATA: Previous work has associated an increased incidence of complications and length of stay following surgery in patients with increased preoperative narcotic use. Despite this and recent national attention highlighting the negative effects of narcotics, they remain commonly used for the management of pain in patients undergoing spine surgery. MATERIALS AND METHODS: A total of 583 patients undergoing spine surgery for a structural lesion were evaluated. Self-reported preoperative narcotic consumption was obtained and converted to morphine equivalents at the initial preoperative visit. LOS was recorded upon discharge and presence/type of a postoperative complication within 30/90 days was obtained. A multivariable logistic and linear regression analysis was performed for the incidence of complications and length of stay controlling for clinically important covariates. RESULTS: Narcotic use was not associated with 30- or 90-day complications; however, smoking status was significantly associated with 30-day complications. Increased preoperative narcotic use was significantly associated with increased LOS, as was age, type of surgery, and depression. CONCLUSIONS: Increased preoperative narcotic use and depression are associated with increased LOS in patients undergoing spine surgery. We calculated that for every 100 morphine equivalents a patient is taking preoperatively; their stay is extended 1.1 days. Narcotic use was not associated with 30- or 90-day postoperative complications. As reimbursement is bundled before surgery, providing interventions for patients with treatable causes for increased length of stay can save cost overall.

Safety of topical vancomycin for pediatric spinal deformity: nontoxic serum levels with supratherapeutic drain levels.

STUDY DESIGN: Retrospective cohort analysis. OBJECTIVE: To establish if drain levels exceed the minimum inhibitory concentrations for common pathogens (methicillin-resistant Staphylococcus aureus, methicillin-sensitive Staphylococcus aureus, and Propionibacterium acnes-2 µg/mL; Staphylococcus epidermidis, Enterococcus faecalis-4 µg/mL). Evaluate the safety of topical vancomycin in pediatric patients undergoing spinal deformity surgery and determine if postoperative serum levels approach toxicity (25 µg/mL). SUMMARY OF BACKGROUND DATA: The application of topical vancomycin powder has decreased postoperative wound infections in retrospective analyses in the adult population with minimal local and systemic risks. The safety and efficacy of vancomycin powder has not been completely evaluated in the pediatric population after deformity surgery. METHODS: Topical vancomycin powder (1 g) was applied during wound closure after instrumented posterior spinal fusion. All patients received intravenous perioperative antibiotics and a subfascial drain was used. Serum and drain vancomycin levels were collected immediately postoperatively and during the first 2 postoperative days (PODs). Complications were recorded. RESULTS: The study population consisted of 25 patients with a mean age of 13.5 years (9.5-17.1 yr) and mean ± standard deviation body weight of 44.5 ± 18 kg. Underlying diagnoses included: adolescent idiopathic scoliosis (12), neuromuscular scoliosis (10), and kyphosis (3). Mean serum vancomycin levels trended downward from 2.5 µg/mL (POD 0) to 1.9 µg/mL (POD 1) to 1.1 µg/mL (POD 2). Mean drain levels also trended downward from 403 µg/mL (POD 0) to 251 µg/mL (POD 1) to 115 µg/mL (POD 2). No vancomycin toxicity or deep wound infections were observed. One patient with neuromuscular scoliosis developed a superficial wound dehiscence that was managed with dressing changes. CONCLUSION: Topical application of vancomycin powder in pediatric spinal deformity surgery produced local levels well above the minimum inhibitory concentration for common pathogens and serum levels below the toxicity threshold (25 µg/mL). There were no deep wound or antibiotic related complications. LEVEL OF EVIDENCE: 3.

Preoperative opioid use and its association with perioperative opioid demand and postoperative opioid independence in patients undergoing spine surgery.

STUDY DESIGN: Prospective cohort. OBJECTIVE: To assess whether preoperative opioid use is associated with increased perioperative opioid demand and postoperative opioid independence in patients undergoing spine surgery. SUMMARY OF BACKGROUND DATA: Previous work has demonstrated increased opioid requirements during the intraoperative and immediate postoperative period in patients with high levels of preoperative opioid use. Despite this, they remain a common agent class used for the management of pain in patients prior to spine surgery. METHODS: A total of 583 patients were included. Self-reported daily opioid consumption was obtained preoperatively and converted into morphine equivalent amounts and opioid use was recorded at the 12-month postoperative time. Intraoperative and immediate postoperative opioid demand was calculated. Linear regression analyses for intraoperative and immediate postoperative opioid demand while logistic regression analyses for opioid independence at 12 months including relevant covariates such as depression and anxiety were performed. RESULTS: The median preoperative morphine equivalent amount for the cohort was 8.75 mg, with 55% of patients reporting some degree of opioid use. Younger age, more invasive surgery, anxiety, and primary surgery were significantly associated with increased intraoperative opioid demand (P < 0.05). Younger age, anxiety, and greater preoperative opioid use were significantly associated with increased immediate postoperative opioid demand (P < 0.05). More invasive surgery, anxiety, revision surgery, and greater preoperative opioid use were significantly associated with a decreased incidence of opioid independence at 12 months postoperatively (P < 0.01). CONCLUSION: Greater preoperative opioid use prior to undergoing spine surgery predicts increased immediate postoperative opioid demand and decreased incidence of postoperative opioid independence. Psychiatric diagnoses in those using preoperative opioids were predictors of continued opioid use at 12 months. Patients may benefit from preoperative counseling that emphasizes minimizing opioid use prior to undergoing spine surgery. LEVEL OF EVIDENCE: 2.

Dopamine does not appear to affect mental rotation in Parkinson's disease.

OBJECTIVE: Patients with Parkinson's disease (PD) often have deficits with mental rotation (MR). The neuropathological factors underlying these deficits, however, remain to be elucidated. One hypothesis suggests that dopamine depletion in nigro-striatal systems adversely influences MR. Another hypothesis suggests that deterioration of cortical (fronto-temporo-parietal basal ganglia) networks that mediate this function are responsible for this deficit. The goal of this study was to test the dopamine hypothesis by determining if dopamine abstinence negatively influences MR performance. METHODS: Thirty three non-demented right-handed individuals with PD were assess for their ability to perform a pencil and paper MR test while "on" and "off" dopaminergic medications. Dopamine abstinence followed the typical overnight withdrawal procedures. RESULTS: No differences in mental rotation abilities were found between "on" and "off" dopaminergic medications. CONCLUSIONS: These results suggest that other neuropathological factors, such as cortical-basal ganglia neurodegeneration, or dysfunction of other neurotransmitters systems, might account for these cognitive deficits and future research will have to test these alternative hypotheses.

Approach to pain management in chronic opioid users undergoing orthopaedic surgery.

Opioids are commonly used for the management of pain in patients with musculoskeletal disorders; however, national attention has highlighted the potential adverse effects of the use of opioid analgesia in this and other nonmalignant pain settings. Chronic opioid users undergoing orthopaedic surgery represent a particularly challenging patient population in regard to their perioperative pain control and outcomes. Preoperative evaluation provides an opportunity to estimate a patient's preoperative opioid intake, discuss pain-related fears, and identify potential psychiatric comorbidities. Patients using high levels of opioids may also require referral to an addiction specialist. Various regional blockade and pharmaceutical options are available to help control perioperative pain, and a multimodal pain management approach may be of particular benefit in chronic opioid users undergoing orthopaedic surgery.

Utility of Postoperative Radiographs for Pediatric Scoliosis: Association Between History and Physical Examination Findings and Radiographic Findings.

BACKGROUND: Postoperative radiographs are routinely obtained following surgery for the correction of scoliosis in pediatric patients. The purpose of this study was to comprehensively evaluate the utility of obtaining routine postoperative radiographs in the management of these patients. METHODS: A total of 1969 clinic notes and corresponding radiographs regarding 451 consecutive patients with scoliosis (age range, ten to eighteen years) who had surgical correction over a ten-year period at a single institution were retrospectively reviewed. Curve etiology, preoperative curve characteristics, and surgical procedures performed were recorded. All postoperative clinic notes and radiographs were reviewed for abnormalities and changes in treatment course. It was then determined whether clinical signs and symptoms and/or abnormal radiographic findings led to a change in treatment course, which was defined as a therapeutic intervention or further diagnostic testing. RESULTS: Of the 451 patients in this study (average age [and standard deviation], 14.7 ± 2.4 years), 72.5% had adolescent idiopathic scoliosis, 23.3% had neuromuscular scoliosis, and 4.2% had other underlying causes of scoliosis. A change in treatment course occurred in the cases of forty-two patients, all of whom had symptomatic findings on postoperative history and physical examination and only fifteen of whom had supportive abnormal findings on postoperative radiographs. Curve etiology and surgical procedures performed had no impact on radiographic utility. A significant increase in utility was seen for radiographs obtained at visits one year or more following surgery compared with those obtained at visits less than one year following surgery (1.7% compared with 0.3%, p = 0.001). The overall sensitivity, specificity, positive predictive value, and negative predictive value of routine postoperative radiographs in guiding treatment course were 35.7%, 98.1%, 28.8%, and 98.6%, respectively. CONCLUSIONS: Routine radiographs provide low utility in guiding the course of treatment for asymptomatic pediatric patients following surgery for scoliosis. The results of this study suggest that patient or caregiver complaints, comorbidities, and clinical suspicion should be considered before obtaining radiographs at postoperative visits in order to minimize radiation exposure in pediatric patients and reduce medical costs without compromising care. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Preoperative Opioid Use as a Predictor of Adverse Postoperative Self-Reported Outcomes in Patients Undergoing Spine Surgery.

BACKGROUND: Opioids are commonly used for preoperative pain management in patients undergoing spine surgery. The objective of this investigation was to assess whether preoperative opioid use predicts worse self-reported outcomes in patients undergoing spine surgery. METHODS: Five hundred and eighty-three patients undergoing lumbar, thoracolumbar, or cervical spine surgery to treat a structural lesion were included in this prospective cohort study. Self-reported preoperative opioid consumption data were obtained at the preoperative visit and were converted to the corresponding daily morphine equivalent amount. Patient-reported outcome measures were assessed at three and twelve months postoperatively via the 12-Item Short-Form Health Survey and the EuroQol-5D questionnaire, as well as, when appropriate, the Oswestry Disability Index and the Neck Disability Index. Separate multivariable linear regression analyses were then performed. RESULTS: At the preoperative evaluation, of the 583 patients, 56% (326 patients) reported some degree of opioid use. Multivariable analyses controlling for age, sex, diabetes, smoking, surgery invasiveness, revision surgery, preoperative Modified Somatic Perception Questionnaire score, preoperative Zung Depression Scale score, and baseline outcome score found that increased preoperative opioid use was a significant predictor (p < 0.05) of decreased 12-Item Short-Form Health Survey and EuroQol-5D scores, as well as of increased Oswestry Disability Index and Neck Disability Index scores at three and twelve months postoperatively. Every 10-mg increase in daily morphine equivalent amount taken preoperatively was associated with a 0.03 decrease in the 12-Item Short-Form Health Survey physical component summary and mental component summary scores, a 0.01 decrease in the EuroQol-5D score, and a 0.5 increase in the Oswestry Disability Index and Neck Disability Index score at twelve months postoperatively. Higher preoperative Modified Somatic Perception Questionnaire and Zung Depression Scale scores were also significant negative predictors (p < 0.05). CONCLUSIONS: Increased preoperative opioid consumption, Modified Somatic Perception Questionnaire score, and Zung Depression Scale score prior to undergoing spine surgery predicted worse patient-reported outcomes. This suggests the potential benefit of psychological and opioid screening with a multidisciplinary approach that includes weaning of opioid use in the preoperative period and close opioid monitoring postoperatively. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Preoperative narcotic use and its relation to depression and anxiety in patients undergoing spine surgery.

STUDY DESIGN: Prospective review of registry data at a single institution from October 2010 to June 2012. OBJECTIVE: To assess whether the amount of preoperative narcotic use is associated with preoperative depression and anxiety in patients undergoing spine surgery for a structural lesion. SUMMARY OF BACKGROUND DATA: Previous work suggests that narcotic use and psychiatric comorbidities are significantly related. Among other psychological considerations, depression and anxiety may be associated with the amount of preoperative narcotic use in patients undergoing spine surgery. METHODS: Five hundred eighty-three patients undergoing lumbar (60%), thoracolumbar (11%), or cervical spine (29%) were included. Self-reported preoperative narcotic consumption was obtained at the initial preoperative visit and converted to daily morphine equivalent amounts. Preoperative Zung Depression Scale (ZDS) and Modified Somatic Perception Questionnaire (MSPQ) scores were also obtained at the initial preoperative visit and recorded as measures of depression and anxiety, respectively. Resistant and robust bootstrapped multivariable linear regression analysis was performed to determine the association between ZDS and MSPQ scores and preoperative narcotics, controlling for clinically important covariates. Mann-Whitney U tests examined preoperative narcotic use in patients who were categorized as depressed (ZDS ≥ 33) or anxious (MSPQ ≥ 12). RESULTS: Multivariable analysis controlling for age, sex, smoking status, preoperative employment status, and prior spinal surgery demonstrated that preoperative ZDS (P = 0.006), prior spine surgery (P = 0.007), and preoperative pain (0.014) were independent risk factors for preoperative narcotic use. Preoperative MSPQ (P = 0.083) was nearly a statistically significant risk factor. Patients who were categorized as depressed or anxious on the basis of ZDS and MSPQ scores also showed higher preoperative narcotic use than those who were not (P < 0.0001). CONCLUSION: Depression and anxiety as assessed by ZDS and MSPQ scores were significantly associated with increased preoperative narcotic use, underscoring the importance of thorough psychological and substance use evaluation in patients being evaluated for spine surgery.

Visual-spatial disembedding in Parkinson's disease.

Visual-spatial disembedding requires a person to visually scan the stimulus and allocate spatial selective attention to the locations of relevant stimuli. Parkinson's disease (PD) is often associated with visual-spatial deficits, but the influence of PD on disembedding is not entirely known. The goal of this study is to learn whether participants with PD have defective visuospatial disembedding and whether this defect responds to dopaminergic treatment. We also wanted to examine the relationship of disembedding with other cognitive processes and the different parkinsonian clinical symptoms. Participants were PD patients and matched controls. PD participants were tested "on" and "off" medications on the Hidden Patterns Test (HPT) and tests of frontal-executive functions. PD patients had difficulties in visual-spatial disembedding that were not related to medication status, illness duration or severity, or symptom presentation, but were related to other tasks requiring visual scanning in response to alterations in spatial allocation of attention. Lack of improvement with dopaminergic treatment suggests deficits in other neurotransmitter-neuromodulatory systems or degenerative processes in the frontal-striatal networks, cortex, or basal ganglia.