Does Impaired Glymphatic Drainage Cause Glymphedema? A Review Tailored to Neurocritical Care and Neurosurgery.

Research into the glymphatic system reached an inflection point with steep trajectory in 2012 when it was formally recognized and named, but the historical roots for it are solid and deep, dating back to pioneers such as Cushing, Weed, and Dandy. We provide an overview of key discoveries of the glymphatic system, which promotes bulk flow of fluid and solutes throughout the brain parenchyma. We also discuss the lymphatic drainage of the central nervous system. Evidence is building that failure of the glymphatic system causes glymphedema in patients commonly managed by neurocritical care and neurosurgery specialists. We review research supporting this for decompressive craniectomy, subarachnoid hemorrhage, and normal-pressure hydrocephalus. We argue that it is time for a paradigm shift from the traditional model of cerebrospinal fluid circulation to a revised model that incorporates the glymphatic pathway and lymphatic clearance. These recent breakthroughs will inspire new therapeutic approaches to recognize, reverse, and restore glymphatic dysfunction and to leverage this pathway to deliver brain-wide therapeutics.

Does the use of preoperative bisphosphonates in patients with osteopenia and osteoporosis affect lumbar fusion rates? Analysis from a national spine registry.

OBJECTIVE: Bisphosphonates are used to increase bone strength in treating osteopenia and osteoporosis, but their use for increasing lumbar fusion rates has been controversial. The objective of this study was to determine if preoperative treatment with bisphosphonates affects the reoperation rates for nonunions (operative nonunion rates) following lumbar fusions in patients with osteopenia or osteoporosis. METHODS: The authors conducted a cohort study using data from the Kaiser Permanente Spine Registry. Patients (aged ≥ 50 years) with a diagnosis of osteopenia or osteoporosis who underwent primary elective lumbar fusions for degenerative disc disease, deformity, or spondylolisthesis were included in the cohort. Repeated spinal procedures at the index lumbar levels were noted through chart review. Reoperations for symptomatic nonunions (operative nonunions), time to nonunion, and the nonunion spine level(s) were also identified. The crude 2-year cumulative incidence of operative nonunions was calculated as 1 minus the Kaplan-Meier estimator. Cox proportional hazard regression was used to evaluate the association between preoperative bisphosphonate use and operative nonunion after adjustment for covariates. Analysis was stratified by osteopenia and osteoporosis diagnosis. RESULTS: The cohort comprised 1040 primary elective lumbar fusion patients, 408 with osteopenia and 632 with osteoporosis. Ninety-seven (23.8%) patients with osteopenia and 370 (58.5%) patients with osteoporosis were preoperative bisphosphonate users. For the osteopenia group, no operative nonunions were observed in patients with preoperative bisphosphonate, while the crude 2-year incidence was 2.44% (95% CI 0.63-4.22) in the nonuser group. For the osteoporotic group, after adjustment for covariates, no difference was observed in risk for operative nonunions between the preoperative bisphosphonate users and nonusers (HR 0.96, 95% CI 0.20-4.55, p = 0.964). CONCLUSIONS: To the authors' knowledge, this study presents one of the largest series of patients with the diagnosis of osteopenia or osteoporosis in whom the effects of preoperative bisphosphonates on lumbar fusions were evaluated using operative nonunion rates as an outcome measure. The results indicate that preoperative bisphosphonate use had no effect on the operative nonunion rates for patients with osteoporosis. Similar indications were not confirmed in osteopenia patients because of the low nonunion frequency. Further studies are warranted to the determine if preoperative and postoperative timing of bisphosphonate use has any effect on lumbar fusion rates.

Lumbar Spine Fusion Patients See Similar Improvements in Physical Activity Level to Non-Spine Fusion Patients Following Total Hip Arthroplasty.

BACKGROUND: The impact of prior lumbar spinal fusion on the change in physical activity level following total hip arthroplasty (THA) has not been thoroughly examined. Therefore, we sought to compare the change in physical activity level following THA for patients with and without a history of lumbar spine fusion. METHODS: Patients who underwent primary elective THA were identified using an integrated healthcare system's Total Joint Replacement Registry (2010-2013). Prior lumbar spine fusion was identified using the healthcare system's Spine Registry. Physical activity was self-reported by patients and measured in min/wk. Generalized linear models were used to evaluate the association between prior spine fusion and the change in physical activity from 1 year pre-THA to 1-2 years post-THA. RESULTS: Of 11,416 THAs, 90 (0.8%) had a history of lumbar spinal fusion. Patients with a prior lumbar fusion had a median physical activity level of 28 min/wk prior to THA compared to 45 min/wk in the patients with no history of lumbar spinal fusion. One year after THA, patients with a history of lumbar spinal fusion reported a median of 120 min/wk of physical activity compared to 150 min/wk for patients without a history of lumbar spinal fusion. The difference in physical activity level change between groups was not statistically significant (estimate = -23.1, 95% confidence interval -62.1 to 15.9, P = .246). CONCLUSION: Patients with prior lumbar fusion were found to have lower self-reported physical activity levels than patients without spine fusion both before and after THA surgery. However, both groups saw the same degree of improvement in physical activity level following THA. These findings may help in counseling patients who have had a prior lumbar spine fusion and in setting appropriate expectations prior to THA.

Initial Conservative Management of Severe Hemispheric Stroke Reduces Decompressive Craniectomy Rates.

BACKGROUND: Pooled European trial results of early decompressive craniectomy (DC) for severe hemispheric stroke did not require radiographic mass effect as an inclusion criterion. Early surgery for supratentorial cerebral hemorrhage does not improve functional status or survival compared to initial conservative medical management. Early versus delayed DC for hemispheric stroke has not been investigated. METHODS AND RESULTS: A prospective inpatient neurosurgical database from October 2007 to March 2015 was queried for neurocritical care admissions for hemispheric ischemic stroke in patients aged 18-60 under IRB approval. A retrospective chart review was conducted using a structured questionnaire and the electronic medical record. We identified 30 patients who met the inclusion criteria for the pooled European early DC stroke trial. The mean age was 46, and the median NIH stroke score was 19. All hemispheric stroke patients were monitored in the neurocritical care unit with hourly neurochecks and daily CT scans for a minimum of 3 days. Eighteen patients (60 %) were managed with medical treatment only (MTO) with an average maximal septal shift of 5.2 mm and a pineal shift of 3.1 mm. Twelve patients (40 %) underwent DC with an average maximal septal shift of 6.8 mm and a pineal shift of 4.1 mm. Modified Rankin (MR) outcomes at 3 months for the overall group, MTO, and DC were as follows: MR 0-3 60 % versus 67 % versus 50 %; MR 4-5 27 % versus 17 % versus 42 %; and death 13 % versus 17 % versus 8 %, respectively. Four patients in the MTO group declined DC; 3 died and one survived with an MR of 4. No patients developed brainstem herniation prior to referral for DC. Surgical complications occurred in 4/12 (33 %) patients. CONCLUSIONS: Delayed DC for hemispheric stroke patients managed under protocol in the neurocritical care unit is a safe alternative to early, prophylactic DC for adults with severe hemispheric stroke. This strategy reduced DC rates by 60 % without an excess of death or survival with severe disabilities.

The use of intraoperative navigation for complex upper cervical spine surgery.

Imaging guidance using intraoperative CT (O-arm surgical imaging system) combined with a navigation system has been shown to increase accuracy in the placement of spinal instrumentation. The authors describe 4 complex upper cervical spine cases in which the O-arm combined with the StealthStation surgical navigation system was used to accurately place occipital screws, C-1 screws anteriorly and posteriorly, C-2 lateral mass screws, and pedicle screws in C-6. This combination was also used to navigate through complex bony anatomy altered by tumor growth and bony overgrowth. The 4 cases presented are: 1) a developmental deformity case in which the C-1 lateral mass was in the center of the cervical canal causing cord compression; 2) a case of odontoid compression of the spinal cord requiring an odontoidectomy in a patient with cerebral palsy; 3) a case of an en bloc resection of a C2-3 chordoma with instrumentation from the occiput to C-6 and placement of C-1 lateral mass screws anteriorly and posteriorly; and 4) a case of repeat surgery for a non-union at C1-2 with distortion of the anatomy and overgrowth of the bony structure at C-2.

Are there differences in the reoperation rates for operative adjacent-segment disease between ALIF+PS, PLIF+PS, TLIF+PS, and LLIF+PS? An analysis of a cohort of 5291 patients.

OBJECTIVE: Biomechanical factors in lumbar fusions accelerate the development of adjacent-segment disease (ASD). Stiffness in the fused segment increases motion in the adjacent levels, resulting in ASD. The objective of this study was to determine if there are differences in the reoperation rates for symptomatic ASD (operative ASD) between anterior lumbar interbody fusion plus pedicle screws (ALIF+PS), posterior lumbar interbody fusion plus pedicle screws (PLIF+PS), transforaminal lumbar interbody fusion plus pedicle screws (TLIF+PS), and lateral lumbar interbody fusion plus pedicle screws (LLIF+PS). METHODS: A retrospective study using data from the Kaiser Permanente Spine Registry identified an adult cohort (≥ 18 years old) with degenerative disc disease who underwent primary lumbar interbody fusions with pedicle screws between L3 to S1. Demographic and operative data were obtained from the registry, and chart review was used to document operative ASD. Patients were followed until operative ASD, membership termination, the end of study (March 31, 2022), or death. Operative ASD was analyzed using Cox proportional hazards models. RESULTS: The final study population included 5291 patients with a mean ± SD age of 60.1 ± 12.1 years and a follow-up of 6.3 ± 3.8 years. There was a total of 443 operative ASD cases, with an overall incidence rate of reoperation for ASD of 8.37% (95% CI 7.6-9.2). The crude incidence of operative ASD at 5 years was the lowest in the ALIF+PS cohort (7.7%, 95% CI 6.3-9.4). In the adjusted models, the authors failed to detect a statistical difference in operative ASD between ALIF+PS (reference) versus PLIF+PS (HR 1.06 [0.79-1.44], p = 0.69) versus TLIF+PS (HR 1.03 [0.81-1.31], p = 0.83) versus LLIF+PS (HR 1.38 [0.77-2.46], p = 0.28). CONCLUSIONS: In a large cohort of over 5000 patients with an average follow-up of > 6 years, the authors found no differences in the reoperation rates for symptomatic ASD (operative ASD) between ALIF+PS and PLIF+PS, TLIF+PS, or LLIF+PS.

Improvements in Quality, Safety and Costs Associated with Use of Implant Registries Within a Health System.

BACKGROUND: Clinical quality registries (CQRs) are intended to enhance quality, safety, and cost reduction using real-world data for a self-improving health system. Starting in 2001, Kaiser Permanente established several medical device CQRs as a quality improvement initiative. This report examines the contributions of these CQRs on improvement in health outcomes, changes in clinical practice, and cost-effectiveness over the past 20 years. METHODS: Eight implant registries were instituted with standardized collection from the electronic health record and other institutional data sources of patient characteristics, medical comorbidities, implant attributes, procedure details, surgical techniques, and outcomes (including complications, revisions, reoperations, hospital readmissions, and other utilization measures). A rigorous quality control system is in place to improve and maintain the quality of data. Data from the Implant Registries form the basis for multiple quality improvement and patient safety initiatives to minimize variation in care, promote clinical best practices, facilitate recalls, perform benchmarking, identify patients at risk, and construct reports about individual surgeons. RESULTS: Following the inception of the Implant Registries, there was an observed (1) reduction in opioid utilization following orthopedic procedures, (2) reduction in use of bone morphogenic protein during lumbar fusion allowing for cost savings, (3) reduction in allograft for anterior cruciate ligament reconstruction and subsequent decrease in organizationwide revision rates, (4) cost savings through expansion of same-day discharge programs for joint arthroplasty, (5) increase in the use of cement fixation in the hemiarthroplasty treatment of hip fracture, and (6) organizationwide discontinuation of an endograft device associated with a higher risk for adverse outcomes following endovascular aortic aneurysm repair. CONCLUSION: The use of Implant Registries within our health system, along with clinical leadership and organizational commitment to a learning health system, was associated with improved quality and safety outcomes and reduced costs. The exact mechanisms by which such registries affect health outcomes and costs require further study.

Lateral Mass Screws Versus Pedicle Screws at C7: Reoperation Rates for Operative Adjacent Segment Disease and Nonunion in Posterior Cervical Fusion.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: To determine if there is a difference in reoperation rates for symptomatic adjacent segment disease (operative ASD) and symptomatic nonunions (operative nonunions) in posterior cervical fusions (PCFs) stopping at C7 using either lateral mass screws (LMS) or cervical pedicle screws (CPS) at C7. SUMMARY OF BACKGROUND DATA: Stopping PCFs at C7 has been controversial because of the risks of adjacent segment disease or nonunions. The two commonly used fixation techniques at the C7 level are LMS and CPS. MATERIALS AND METHODS: A retrospective analysis from the Kaiser Permanente Spine Registry identified a cohort of patients with cervical degenerative disk disease who underwent primary PCFs stopping at C7 with either LMS or CPS at C7. Demographic and operative data were extracted from the registry, and operative ASD and operative nonunions were adjudicated through chart review. Patients were followed until validated operative ASD or nonunion, membership termination, death, or end of study (March 31, 2022). Descriptive statistics and multivariable Cox proportional hazards models were calculated for operative ASDs and operative nonunions. RESULTS: We found 481 patients with PCFs stopping at C7 with either LMS (n=347) or CPS (n=134) at C7 with an average follow-up time of 5.6 (±3.8) years, time to operative ASD of 3.0 (±2.8) years, and to operative nonunion of 1.2 (±0.7) years. There were 11 operative ASDs (LMS=8, CPS=3) and eight operative nonunions (LMS=4, CPS=4). There was no statistical difference between patients stopping at C7 with LMS versus CPS for operative ASDs (HR: 0.68, 95% CI=0.17-2.77, P =0.60) or operative nonunions (HR: 2.09, 95% CI=0.45-8.58, P =0.37). CONCLUSION: A large cohort of patients with PCFs stopping at C7 with an average follow-up of > 5 years found no statistical difference in reoperation rates for symptomatic ASD (operative ASD) or operative nonunion using either LMS or CPS at C7.

Increased risks of vertebral fracture and reoperation in primary spinal fusion patients who test positive for osteoporosis by Biomechanical Computed Tomography analysis.

BACKGROUND CONTEXT: While osteoporosis is a risk factor for adverse outcomes in spinal fusion patients, diagnosing osteoporosis reliably in this population has been challenging due to degenerative changes and spinal deformities. Addressing that challenge, biomechanical computed tomography analysis (BCT) is a CT-based diagnostic test for osteoporosis that measures both bone mineral density and bone strength (using finite element analysis) at the spine; CT scans taken for spinal evaluation or previous care can be repurposed for the analysis. PURPOSE: Assess the effectiveness of BCT for preoperatively identifying spinal fusion patients with osteoporosis who are at high risk of reoperation or vertebral fracture. STUDY DESIGN: Observational cohort study in a multi-center integrated managed care system using existing data from patient medical records and imaging archives. PATIENT SAMPLE: We studied a randomly sampled subset of all adult patients who had any type of primary thoracic (T4 or below) or lumbar fusion between 2005 and 2018. For inclusion, patients with accessible study data needed a preop CT scan without intravenous contrast that contained images (before any instrumentation) of the upper instrumented vertebral level. OUTCOME MEASURES: Reoperation for any reason (primary outcome) or a newly documented vertebral fracture (secondary outcome) occurring up to 5 years after the primary surgery. METHODS: All study data were extracted using available coded information and CT scans from the medical records. BCT was performed at a centralized lab blinded to the clinical outcomes; patients could test positive for osteoporosis based on either low values of bone strength (vertebral strength ≤ 4,500 N women or 6,500 N men) and/or bone mineral density (vertebral trabecular bone mineral density ≤ 80 mg/cm3 both sexes). Cox proportional hazard ratios were adjusted by age, presence of obesity, and whether the fusion was long (four or more levels fused) or short (3 or fewer levels fused); Kaplan-Meier survival was compared by the log rank test. This project was funded by NIH (R44AR064613) and all physician co-authors and author 1 received salary support from their respective departments. Author 6 is employed by, and author 1 has equity in and consults for, the company that provides the BCT test; the other authors declare no conflicts of interest. RESULTS: For the 469 patients analyzed (298 women, 171 men), median follow-up time was 44.4 months, 11.1% had a reoperation (median time 14.5 months), and 7.7% had a vertebral fracture (median time 2.0 months). Overall, 25.8% of patients tested positive for osteoporosis and no patients under age 50 tested positive. Compared to patients without osteoporosis, those testing positive were at almost five-fold higher risk for vertebral fracture (adjusted hazard ratio 4.7, 95% confidence interval = 2.2-9.7; p<.0001 Kaplan-Meier survival). Of those positive-testing patients, those who tested positive concurrently for low values of both bone strength and bone mineral density (12.6% of patients overall) were at almost four-fold higher risk for reoperation (3.7, 1.9-7.2; Kaplan-Meier survival p<.0001); the remaining positive-testing patients (those who tested positive for low values of either bone strength or bone mineral density but not both) were not at significantly higher risk for reoperation (1.6, 0.7-3.7) but were for vertebral fracture (4.3, 1.9-10.2). For both clinical outcomes, risk remained high for patients who underwent short or long fusion. CONCLUSION: In a real-world clinical setting, BCT was effective in identifying primary spinal fusion patients aged 50 or older with osteoporosis who were at elevated risks of reoperation and vertebral fracture.

Bilateral papilledema with vision loss due to post-COVID-19-induced thiamine deficiency: illustrative case.

BACKGROUND: Bilateral papilledema with vision loss is considered a neurosurgical emergency due to high intracranial pressure. However, it may not be the only cause of papilledema. The authors reported an association among coronavirus disease 2019 (COVID-19), bilateral papilledema, blindness, and Wernicke's encephalopathy (WE). OBSERVATIONS: An 18-year-old woman presented to the neurosurgery service with rapid profound vision loss and bilateral papilledema. She had COVID-19 3 months earlier with subsequent loss of smell (anosmia) and taste (ageusia), which resulted in hyperemesis and a 43-lb weight loss. Examination revealed ataxia, horizontal nystagmus, and blindness. Magnetic resonance imaging and magnetic resonance venography of her brain were normal. Presumptive diagnosis of WE was made, and she was treated with intravenous thiamine with restoration of vision within 48 hours. Patient's thiamine level was less than half the normal value. LESSONS: Neurosurgeons should be aware of this unique correlation between papilledema and vision loss and its association with WE due to post-COVID-19 hyperemesis and weight loss from anosmia and ageusia.

Are Octogenarians at Higher Risk of Complications After Elective Lumbar Spinal Fusion Surgery? Analysis of a Cohort of 7880 Patients From the Kaiser Permanente Spine Registry.

STUDY DESIGN: A retrospective cohort study with chart review. OBJECTIVE: To determine if there is a difference in risk of adverse outcomes following elective posterior instrumented lumbar spinal fusions for patients aged 80 years and above compared with patients aged 50 to 79 years. SUMMARY OF BACKGROUND DATA: Patients aged 80 years and above are undergoing elective lumbar spinal fusion surgery in increasing numbers. There are conflicting data on the risks of intraoperative and postoperative complications in these patients. MATERIALS AND METHODS: Patients aged 80 years and above were compared with 50 to 79 years (reference group) using time-dependent multivariable Cox proportional hazards regression with a competing risk of death for longitudinal outcomes and multivariable logistic regression for binary outcomes. Outcome measures used were: (1) intraoperative complications (durotomy), (2) postoperative complications: 30-day outcomes (pneumonia); 90-day outcomes (deep vein thrombosis, pulmonary embolism, emergency room visits, readmission, reoperations, and mortality); and two-year outcomes (reoperations and mortality). RESULTS: The cohort consisted of 7880 patients who underwent primary elective posterior instrumented lumbar spinal fusion (L1-S1) for degenerative disk disease or spondylolisthesis. This was subdivided into 596 patients were aged 80 years and above and 7284 patients aged 50 to 79. After adjustment, patients aged 80 years and above had a higher likelihood of durotomy [odds ratio (OR)=1.43, 95% confidence interval (CI)=1.02-2.02] and 30-day pneumonia (OR=1.81, 95% CI=1.01-3.23). However, there was a lower risk of reoperation within two years of the index procedure (hazard ratio=0.69, 95% CI=0.48-0.99). No differences were observed for mortality, readmissions, emergency room visits, pulmonary embolism, or deep vein thrombosis. CONCLUSIONS: In a cohort of 7880 elective posterior instrumented lumbar fusion patients for degenerative disk disease or spondylolisthesis, we did not observe any significant risks of adverse events between patients aged 80 years and above and those aged 50 to 79 except for higher durotomies and 30-day pneumonia in the former. We believe octogenarians can safely undergo lumbar fusions, but proper preoperative screening is necessary to reduce the risks of 30-day pneumonia.

No difference in reoperation rates for nonunions (operative nonunions) in posterior cervical fusions stopping at C7 versus T1/2: a cohort of 875 patients.

OBJECTIVE: The challenges of posterior cervical fusions (PCFs) at the cervicothoracic junction (CTJ) are widely known, including the development of adjacent-segment disease by stopping fusions at C7. One solution has been to cross the CTJ (T1/T2) rather than stopping at C7. This approach may have undue consequences, including increased reoperations for symptomatic nonunion (operative nonunion). The authors sought to investigate if there is a difference in operative nonunion in PCFs that stop at C7 versus T1/T2. METHODS: A retrospective analysis identified patients from the authors' spine registry (Kaiser Permanente) who underwent PCFs with caudal fusion levels at C7 and T1/T2. Demographics, diagnoses, operative times, lengths of stay, and reoperations were extracted from the registry. Operative nonunion was adjudicated via chart review. Patients were followed until validated operative nonunion, membership termination, death, or end of study (March 31, 2020). Descriptive statistics and 2-year crude incidence rates and 95% confidence intervals for operative nonunion for PCFs stopping at C7 or T1/T2 were reported. Time-dependent crude and adjusted multivariable Cox proportional hazards models were used to evaluate operative nonunion rates. RESULTS: The authors identified 875 patients with PCFs (beginning at C3, C4, C5, or C6) stopping at either C7 (n = 470) or T1/T2 (n = 405) with a mean follow-up time of 4.6 ± 3.3 years and a mean time to operative nonunion of 0.9 ± 0.6 years. There were 17 operative nonunions, and, after adjustment for age at surgery and smoking status, the cumulative incidence rates were similar between constructs stopping at C7 and those that extended to T1/T2 (C7: 1.91% [95% CI 0.88%-3.60%]; T1/T2: 1.98% [95% CI 0.86%-3.85%]). In the crude model and model adjusted for age at surgery and smoking status, no difference in risk for constructs extended to T1/T2 compared to those stopping at C7 was found (adjusted HR 1.09 [95% CI 0.42-2.84], p = 0.86). CONCLUSIONS: In one of the largest cohort of patients with PCFs stopping at C7 or T1/T2 with an average follow-up of > 4 years, the authors found no statistically significant difference in reoperation rates for symptomatic nonunion (operative nonunion). This finding shows that there is no added risk of operative nonunion by extending PCFs to T1/T2 or stopping at C7.

No Difference in Reoperation Rates for Adjacent Segment Disease (Operative Adjacent Segment Disease) in Posterior Cervical Fusions Stopping at C7 Versus T1/T2: A Cohort of 875 Patients-Part 1.

STUDY DESIGN: A retrospective cohort study with chart review. OBJECTIVE: To determine whether there is a difference in reoperation rates for adjacent segment disease ([ASD] operative ASD) in posterior cervical fusions (PCFs) that stop at -C7 versus -T1/T2. SUMMARY OF BACKGROUND DATA: There are surgical treatment challenges to the anatomical complexities of the cervicothoracic junction. Current posterior cervical spine surgery is based on the belief that ASD occurs if fusions are stopped at C7 although there is varying evidence to support this assumption. METHODS: Patients were followed until validated reoperations for ASD, membership termination, death, or March 31, 2020. Descriptive statistics and 5-year crude incidence rates and 95% confidence intervals for operative ASD for PCF ending at -C7 or -T1/T2 were reported. Time-dependent crude and adjusted multivariable Cox-Proportional Hazards models were used to evaluate operative ASD rates with adjustment for covariates or risk change estimates more than 10%. RESULTS: We identified 875 patients with PCFs (beginning at C3 or C4 or C5 or C6) stopping at either -C7 (n = 470) or -T1/T2 (n = 405) with average follow-up time of 4.6 (±3.3) years and average time to operative ASD of 2.7 (±2.8) years. Crude overall incidence rates for stopping at -C7 (2.12% [1.02%-3.86%]) and -T1/T2 (2.48% [1.25%-4.40%]) were comparable with no statistical difference in risk (adjusted hazard ratio = 1.47, 95% confidence interval = 0.61-3.53, P = 0.39). In addition, we observed no differences in the probability of operative ASD in competing risk time-dependent models (Grey test P  = 0.448). CONCLUSION: A large cohort of 875 patients with PCFs stopping at -C7 or -T1/T2 with an average follow-up of more than 4 years found no statistical difference in reoperation rates for ASD (operative ASD).Level of Evidence: 3.

The genesis of low pressure hydrocephalus.

BACKGROUND: Low pressure hydrocephalus (LPH) is an uncommon entity. Recognition of this treatable condition is important when clinicians are faced with the paradox of symptomatic hydrocephalus despite low intracranial pressures (ICP). Its etiology remains enigmatic. METHODS: We identified patients with LPH from the prospective, inpatient neuro-intensive care database over a 4-year period (2006-2010). RESULTS: Nine patients with LPH were identified over a 4-year period. The time from diagnosis of the initial neurosurgical condition to development of LPH varied from 7 days to 5 years. The sub-zero drainage method of Pang and Altschuler was successful in all cases. LPH was accompanied by transependymal edema in five patients despite low ICP. Four patients developed LPH during their initial admission for intracranial bleeding. As patients entered the LPH state, the ICP remained in a normal range yet daily CSF output from the external ventricular drain was reduced. When LPH patients were drained at sub-zero levels, daily CSF output exceeded baseline values for several days and then receded to baseline. Long-term management was achieved with low pressure shunt systems: six programmable shunts; one valveless ventriculoperitoneal shunt; two ventriculopleural shunts. Conditions most commonly associated with LPH are: subarachnoid hemorrhage, chronic hydrocephalus, brain tumors, and chronic CNS infections. CONCLUSIONS: Low pressure hydrocephalus is a challenging diagnosis. The genesis of LPH was associated with a drop in EVD output, symptomatic ventriculomegaly, and a remarkable absence of intracranial hypertension. When LPH was treated with the sub-zero method, a 'diuresis' of CSF ensued. These observations support a Darcy's flux of brain interstitial fluid due to altered brain poroelastance; in simpler terms, a boggy brain state.

PLF Versus PLIF and the Fate of L5-S1: Analysis of Operative Nonunion Rates Among 3065 Patients with Lumbar Fusions from a Regional Spine Registry.

STUDY DESIGN: A retrospective cohort study with chart review. OBJECTIVE: The aim of this study was to compare the reoperation rates for symptomatic nonunions (operative nonunion rates) between posterolateral fusions with pedicle screws (PLFs) and posterior interbody fusion with pedicle screws (PLIFs). SUMMARY OF BACKGROUND DATA: Although radiographic nonunions in PLFs and PLIFs are well documented in the literature, there is no consensus on which technique has lower nonunions. Since some radiographic nonunions may be asymptomatic, a more clinically useful measure is operative nonunions, of which there is minimal research. METHODS: A retrospective cohort study, using data from the Kaiser Permanente Spine Registry, identified adult patients (≥18 years' old) who had elective single and multilevel PLFs and PLIFs. Descriptive statistics and 2-year incidence rates for operative nonunions were calculated by fusion-level (1-3), fusion type (PLF vs. PLIF), and levels fused (L3 to S1). Time-dependent multivariable Cox-Proportional Hazards regression was used to evaluate nonunion reoperation rates with adjustment for covariates. RESULTS: The cohort consisted of 3065 patients with PLFs (71.6%) and PLIFs (28.4%). Average age was 65.0 ±â€Š11.7, average follow-up time was 4.8 ±â€Š3.1 years, and average time to operative nonunion was 1.6 (±1.3) years. Single and multilevel incidence rates for nonunions after PLF versus PLIF were similar except for three-level fusions (2.9% [95% confidence interval, CI = 1.0-6.7] vs. 7.1% [95% CI = 0.2-33.9]). In adjusted models, there was no difference in risk of operative nonunions in PLIF compared to PLF (hazard ratio [HR]: 0.8, 95% CI = 0.4-1.6); however, patients with L5-S1 constructs with PLFs had 2.8 times the risk of operative nonunion compared to PLIFs (PLF: HR = 2.8, 95% CI = 1.3-6.2; PLIF: HR = 1.5, 95% CI = 0.4-5.1). CONCLUSION: In a large cohort of patients with >4 years of follow-up, we found no difference in operative nonunions between PLF and PLIF except for constructs that included L5-S1 in which the risk of nonunion was limited to PLF patients.Level of Evidence: 3.

PLF+PS or ALIF+PS: which has a lower operative nonunion rate? Analysis of a cohort of 2,061 patients from a National Spine Registry.

BACKGROUND CONTEXT: Although fusion rates in posterolateral lumbar fusions with pedicle screws (PLF+PS) and anterior lumbar interbody fusions with pedicle screws (ALIF+PS) have been reported, there has been no consensus on superiority with respect to clinical outcome and nonunion rates. Most studies determine nonunion rates based on radiographic studies; however, many of these nonunions are asymptomatic and may not require reoperations. Hence, a potentially more clinically useful measure is the reoperation rate for symptomatic nonunions, which we term the operative nonunion rate. PURPOSE: To determine if there is a difference in operative nonunion rates between PLF+PS versus ALIF+PS. STUDY DESIGN: Retrospective cohort study. PATIENT SAMPLE: Adult patients (≥18 years old) with the diagnosis of lumbar spondylolisthesis or lumbar spinal stenosis who underwent primary elective PLF+PS and ALIF+PS for 1-level and 2-level fusions (L4-S1) between 2009 and 2018. OUTCOME MEASURES: Reoperation rates for symptomatic nonunions (ie, operative nonunion rates). METHODS: Patients were followed until validated operative nonunions, membership termination, death, or 03/31/2019. Descriptive statistics and 2-year incidence rates for operative nonunions were calculated by fusion-level, fusion type, and levels fused. Time-dependent multivariable Cox-Proportional Hazards regression was used to evaluate operative nonunion rates with adjustment for covariates or risk change estimates more than 10%. RESULTS: We identified 2,061 patients (PLF+PS:1,491, ALIF+PS:570) with average follow-up time of 4.8 (±3.1) years and average time to operative nonunion of 1.3 (±1.2) yrs. Comparatively, unadjusted 1-level and 2-level incidence rates for operative nonunions were higher in PLF+PS versus ALIF+PS. For 1-level procedures these were 0.9% (95% CI=0.4-1.6) versus 0.6% (95% CI=0.1-2.1); 2-level, 2.0% (95% CI=0.8-4.0) versus 0.9% (95% CI=0.1-3.3). However, there were no observed significant differences in risks for operative nonunions in multivariable models comparing PLF+PS versus ALIF+PS (HR=0.3, 95% CI=0.1-1.1), 1-level versus 2-level fusions (HR=1.8, 95% CI=0.8-4.3), or by fusion level (L4-L5: HR=1.0, 95% CI=0.4-2.7; L5-S1: HR=2.0, 95% CI=0.7-5.4). CONCLUSIONS: A large cohort of patients with lumbar fusions between L4 to S1 and an average follow-up of >4 years found that although there was a trend for higher operative nonunions in PLF+PS compared with ALIF+PS, this was not statistically significant. The role of spinal alignment was not investigated.

Operative Nonunion Rates in Posterolateral Lumbar Fusions: Analysis of a Cohort of 2591 Patients from a National Spine Registry.

OBJECTIVE: Radiographic nonunion rates in the literature for posterolateral lumbar fusions with pedicle screws (PLFs) range from 8.1% to 43.3% but may not represent nonunion rates. A few small studies have reported reoperations for symptomatic nonunions (operative nonunions) to range from 3.2% to 13.9%. The objective of this study is to determine operative nonunion rates for 1-level, 2-level, 3-level, and ≥4-level PLFs and to determine the risks for these nonunions. METHODS: A retrospective cohort study, using data from the Kaiser Permanente Spine Registry, identified adult patients (≥18 years old) who underwent PLFs for degenerative disc disease. Multivariable Cox proportional hazards regression and Kaplan-Meier survival estimates using the log-rank statistic were used to evaluate operative nonunion rates. RESULTS: The cohort consisted of 2591 patients with single-level and multilevel PLFs with mean follow-up of 4.6 years, time to operative nonunion of 1.52 years, and 2-year operative nonunion rate of 1.08%. Compared with single-level fusions, patients with 3-level and ≥4-level fusion had 2.8 and 3.7 times higher risk of operative nonunions. Patients with PLFs involving L5-S1 had 2.5 times the risk of an operative nonunion compared with those without. CONCLUSIONS: Our study reports results from one of the largest cohort of patients for the first time with single-level and multilevel instrumented PLFs and found a 2-year operative nonunion rate of 1.08% with increased risk of nonunion for constructs that included L5-S1 and ≥3-level fusions. Operative nonunion combines clinical and radiographic data and provides an alternative measure of fusion rates.

Slippery platelet syndromes in subdural hematoma.

BACKGROUND: This study investigates platelet dysfunction in patients with subdural hematomas (SDH) using platelet function analysis (PFA). METHODS: PFA using the PFA-100 (Dade International Inc., Miami, FL) was performed at admission using the collagen-epinephrine and collagen-ADP assays in 58 SDH patients. Clinical and radiologic information was collected. RESULTS: Normal PFA results were present in 36 patients (62%; PFA collagen:epinephrine assay (s) 118 ave; PFA collagen:adenosine diphosphate assay (s) ave 75) and abnormal platelet function in 22 patients (38%; PFA collagen:epinephrine assay (s) 231 average; PFA collagen:adenosine diphosphate assay (s) 124 average). Compared to patients with normal PFA results, patients with abnormal PFA results were more likely to have hypertension (22 vs. 55%; P = 0.01), take clopidogrel (3 vs. 32%; P = 0.001), and use anti-platelet medications and non-steroidal anti-inflammatory agents (22 vs. 59%; P = 0.004). Measurements of baseline CT for midline shift, maximum thickness, presence of blood/fluid levels in the hematoma, and presence of additional sites of intracranial bleeding did not reveal significant differences based on PFA testing. Platelet dysfunction improved after platelet transfusions (PFA collagen:epinephrine assay: baseline 270 s, CI 61 s; after transfusion 124 s, CI 50 s, P < 0.001). CONCLUSION: Platelet dysfunction was found in 38% of SDH patients. This finding adds to our understanding of the pathophysiology of SDH. Since platelet transfusions are indicated for platelet dysfunction accompanied by major bleeding or need for surgery, these results impact peri-operative management.

Impact of Chronic DMARD Therapy in Patients With Rheumatoid Arthritis Undergoing Surgery of the Craniovertebral Junction: A Multi-center Retrospective Study.

STUDY DESIGN: A multi-centered retrospective review from five institutions. OBJECTIVE: The aim of this study was to determine whether continuing or withholding disease-modifying antirheumatoid drugs (DMARDs) in the perioperative period affect outcomes in rheumatoid arthritis (RA) patients undergoing arthrodesis at the craniovertebral junction SUMMARY OF BACKGROUND DATA.: RA is a chronic systemic inflammatory disease that affects the cervical spine and is treated with DMARDs. Some advocate withholding DMARDs in the perioperative period due to concern for the cytotoxic effects of these medications. However, the impact of DMARDs in the perioperative period is not well understood. METHODS: A multicenter retrospective study from five affiliated institutions was performed. Adult patients with RA on chronic DMARDs undergoing posterior arthrodesis of the craniovertebral junction (occipital-cervical or atlanto-axial arthrodesis) were identified. Patients were stratified based on whether DMARD therapy was continued (C group) or discontinued (DC group) in the perioperative period. The primary outcome was the need for reoperation and reason for reoperation. RESULTS: Thirty-nine patients met inclusion criteria, 19 in C group and 20 in DC group. Average follow-up time was 42 months. Four patients (three in DC group and one in C group) required reoperation. Two patients from the DC group required readmission secondary to RA flare-up. CONCLUSION: Our cohort of RA patients who underwent occipital-cervical and C1/C2 posterior arthrodesis showed no significant differences in surgical complications when DMARD therapy was continued or discontinued in the perioperative period. The decision to continue or discontinue DMARD therapy in the perioperative period is at the discretion of the treating physician, but we encourage physicians to counsel patients regarding this theoretical risk and their tolerance of the medications as well as the risk of RA flare-up. Factors such as overall health, disease burden, nutrition, bone quality, smoking status, and other comorbid conditions are likely to have a larger influence on perioperative complications. LEVEL OF EVIDENCE: 3.

The use of flexion-extension magnetic resonance imaging for evaluating signal intensity changes of the cervical spinal cord.

The authors present 2 cases involving patients who presented with myelopathy. Magnetic resonance imaging of the cervical spine showed spinal cord signal changes on T2-weighted images without any spinal cord compression. Flexion-extension plain radiographs of the spine showed no instability. Dynamic MR imaging of the cervical spine, however, showed spinal cord compression on extension. Compression of the spinal cord was caused by dynamic anulus bulging and ligamentum flavum buckling. This report emphasizes the need for dynamic MR imaging of the cervical spine for evaluating spinal cord changes on neutral position MR imaging before further workup for other causes such as demyelinating disease.