bluuebunny/crossref_metadata_2025 huggingface dataset:
564 The Influence of Presenting Glucose and Glycated Hemoglobin on Outcomes Following Mechanical Thrombectomy for Anterior Circulation Large Vessel Occlusion
Authors: Hoffman Haydn , Wood Jacob , Cote John , Jalal Muhammad Safwan , Otite Fadar , Masoud Hesham , Gould Grahame C.D.
Published: March 2023

INTRODUCTION:

Elevated presenting glucose and glycated hemoglobin (HbA1C) values may be associated with worse outcomes following mechanical thrombectomy (MT) for anterior circulation large vessel occlusion (ACLVO).

METHODS:

All patients who underwent MT for ACLVO between 2015 – 2021 at a single institution were reviewed. The outcomes included favorable functional status (modified Rankin Scale [mRS] 0 – 2) at 90 days, any intracranial hemorrhage (ICH), parenchymal hemorrhage, and malignant middle cerebral artery infarction (MMI). Multivariate logistic regression analyses adjusting for age, premorbid mRS, admission NIHSS, ASPECTS, collateral score, tPA administration, onset to reperfusion time, and TICI grade were performed. Youden’s index was used to identify thresholds for glucose and HbA1C that optimized area under the receiving operator characteristic curve for predicting outcomes.

RESULTS:

A total of 332 patients were included. The mean (SD) age was 70.9 years (15.1), 50.3% of patients were female, and 26.9% of patients had a history of diabetes. The median (IQR) presenting glucose, SGR, and HbA1C values were 118 mg/dL (40), 1.0 (0.35), and 5.7% (1.0), respectively. Presenting glucose was associated with any ICH (OR 1.38, 95% 1.08 – 1.80) and MMI (OR 1.48, 95% CI 1.06 – 2.03), but not functional status. SGR was not associated with any outcome. Presenting HbA1C was associated with MMI (OR 1.43, 95% 1.02 – 2.02) but not functional status or ICH. The optimal threshold among glucose values for predicting ICH and MMI were 167 mg/dL and 128 mg/dL, respectively. For HbA1c, the threshold for predicting MMI was 6.0.

CONCLUSIONS:

Presenting glucose and HbA1C were associated with MMI, and glucose was associated with ICH after MT for ACLVO. Improved glucose control prior to admission could decrease the odds of these events.
566 Role of STA-MCA Bypass in Recurrent Ischemic Stroke
Authors: Ferrarez Carlos Eduardo , Bertani Raphael , Batista Sávio , Perret Caio , Koester Stefan Wolfgang , Carvalho Tamires , Landeiro Jose Alberto
Published: March 2023

INTRODUCTION:

In the recurrent scenario of ischemic strokes, clinicians are faced with the options of switching to a new antiplatelet medication or using a combination of antiplatelet medications in the acute setting and for long-term secondary stroke prevention, balancing future protective benefits and increased hemorrhagic risks.

METHODS:

Patients presenting recurrent ischemic stroke that were surgically treated with STA-MCA bypass at our hospital between 2016 and 2021. Criteria inclusion were patients diagnosed with a minor ischemic stroke or TIA in MCA or ICA territory, submitted or not to thrombolysis, without indication for mechanical thrombectomy, presenting with hypoperfusion > 10% in the affected vascular territory. Were excluded patients presenting malignant ischemic stroke >1/3 of the MCA territory, cardiogenic causes, or atherosclerotic disease in cervical carotid arteries.

RESULTS:

STA-MCA bypass was performed in 10 patients presenting recurrent ischemic stroke. There were 6 males and 4 female patients with an age ranging from 40 to 75 years and a mean age of 59.6 (SD 10.59). Presented initial etiologies were ICA occlusion (40%), MCA occlusion (30%), TIA (10%), Moyamoya disease (10%), and Vertebral Artery occlusion (10%). Middle Cerebral Artery (MCA) was the most common site affected (90%), and the mean initial NIHSS was 11.1 (SD 4.57). 1 Day after surgery, the NIHSS average was 11.1 (SD 4.57), followed by 8.3 (SD 4.98), and 6.7 (SD 5.92) average on days 3 and 14, respectively. When comparing pre-op NIHSS and post-op NIHSS, a significant improvement after STA-MCA Bypass (p = 0.0085) was found.

CONCLUSIONS:

STA-MCA Bypass can be a feasible option in recurrent ischemic strokes and can be indicated in some cases.
624 Economic Development and Trends of Cerebrovascular Disease Mortality in Eastern Europe: 1992-2019
Authors: Stonnington Henry Owen , Singh Rohin , Nguyen Brandon , Rangel India , Brown Nolan James , Shahrestani Shane , Patel Naresh P.
Published: March 2023

INTRODUCTION:

Several studies have shown that a country's overall mortality rates are inversely related to it's gross domestic product (GDP). Eastern Europe experienced rapid economic growth after the fall of communism, and as such its public health sector swiftly improved. How this economic growth has affected mortality rates due to cerebrovascular disease has never been studied.

METHODS:

Eight countries were included in this study, representing the Warsaw Pact founding members: Albania, Bulgaria, Poland, Romania, Hungary, and Czechia, with Russia and Ukraine representing the former Soviet Union. As East Germany joined West Germany in 1990, it was excluded. Age standardized death rates from cerebrovascular disease per 100,000 people from 1992-2019 were taken from the World Health Organization (WHO) Mortality Database using the ICD-10 (International Classification of Disease) codes 160-169. Each country’s GDP per capita (inflation adjusted to 2015 dollar amount) during those years was taken from the World Bank World Development Indicators Database.

RESULTS:

Cerebrovascular disease mortality decreased from 1992-2019 in every country, despite divergent trends in economic development. Indeed, Ukraine’s cerebrovascular disease mortality rate decreased by 42.9% even though its GDP per capita decreased by 4.8%. The countries with the largest decreases in mortality are Czechia (-78.9%), Hungary (-62.7%), and Russia (-49.3%) while Albania had the smallest decrease (-29.4%).

CONCLUSIONS:

Rates of cerebrovascular disease mortality among the Warsaw Pact’s founding members decreased after the fall of communism, despite differing rates of economic development. Further research is warranted regarding these countries’ healthcare practices during this period. Hopefully, lessons can be gleaned to improve public health and neurosurgical care in other developing nations.
626 From the Stroke Belt to San Francisco: Racial Disparities in Stroke Persist
Authors: Collins Malie Kawila , Billingsley Angel , Amoah Dadey David Yaw , Dodd Robert L.
Published: March 2023

INTRODUCTION:

Racial disparities in stroke are classically observed in geographical areas carrying the greatest stroke burden and mortality, namely the Stroke Belt region of the Southeastern U.S. In these territories, African Americans experience a substantially greater stroke incidence than Caucasians, however there is a paucity of in-depth analyses for regions of vastly different demographic variation and socioeconomic profile. The authors seek to determine if the same disparity exists in the surrounding counties of the San Francisco Bay Area.

METHODS:

A county-specific search of the CDC Interactive Atlas of Heart Disease and Stroke was conducted for seventeen Bay Area counties (2017-2019) using stroke hospitalization rates by race, population counts, race distribution, and percent aged ≥65. Percent estimates of the racial distribution of IS and HS hospitalizations were calculated. The probability of Black racial identity and IS was estimated to observe the relationship between population distribution across counties and the likelihood of IS hospitalization among Blacks.

RESULTS:

Stroke hospitalization rates among Blacks/African Americans averaged 10.67 per 1000 for IS (95% CI [10.01, 11.32]), 2.19 for HS (95% CI [1.96, 2.42]); average rates among whites/Caucasians were 7.04 (95% CI [6.64, 7.45]) and 1.37 (95% CI [1.30, 1.43]), respectively. While the probability of Black racial identity and IS hospitalization was expectedly higher in counties with a larger Black population, it was disproportionate in counties like Alameda and Sacramento.

CONCLUSIONS:

Examination of CDC data revealed a 1.5-fold greater disparity in stroke hospitalization rates among African Americans in the San Francisco Bay Area, indicating a persistence of established racial disparities in other parts of the country. Further analysis of socioeconomic data by county and regional comparisons are necessary to uncover the mechanisms of racial disparity in stroke.
658 Pseudarthrosis and Reoperation Rates in Minimally Invasive Adult Spinal Deformity Correction
Authors: Kalavacherla Sandhya , Stone Lauren , Pham Martin H.
Published: March 2023

INTRODUCTION:

Adult spinal deformity (ASD) has historically been corrected via open surgery (OS). Recent developments in minimally invasive surgery (MIS) have made ASD correction possible with less blood loss, shorter hospital stays, and fewer complications. However, it has been proposed that inherent exposure constraints in MIS approaches limit proximal construct fusion, resulting in pseudarthrosis and potentially proximal junctional kyphosis and failure.

METHODS:

We initially screened 66 abstracts in PubMed. Manuscripts were initially included if they described outcomes from an MIS to correct ASD, including those comparing outcomes between MIS and OS or hybrid open-MIS. Exclusion criteria included failure to mention pseudarthrosis and surgeries performed on 2 levels or fewer. After independent review by two authors, 10 papers were selected. Patient demographics, perioperative and postoperative characteristics were calculated.

RESULTS:

Within the 10 articles, 509 MIS patients were reviewed. The average age was 65.5 years; 64.8% were female. An average of 6 levels (4.2 - 11) were fused per patient. Perioperative characteristics include mean follow-up time of 26.9 months, mean estimated blood loss (EBL) of 527 mL, mean operating time (OT) of 297.9 minutes, and mean length of stay (LOS) of 7.7 days. Among manuscripts comparing MIS to OS, all reported a statistically significant lower EBL in MIS patients. Conversely, OT and LOS were less consistently reported as lower in MIS compared to OS. The overall proximal pseudarthrosis rate among MIS patients was 6.2%. Among patients with pseudarthrosis, 88.2% underwent revision.

CONCLUSIONS:

The results of this analysis demonstrate a measurable risk of pseudarthrosis when using MIS to treat ASD, overwhelmingly requiring reoperation. Considering this risk of pseudarthrosis and subsequent revision surgery against the benefits of MIS is crucial to evaluate surgical treatment options for patients with ASD.
661 Six-Month Spinal Surgery Outcomes in Marijuana and Opiate Users as Determined by Preoperative Urine Toxicology
Authors: Singh Manjot , Bajaj Ankush , Shlimak Anna , Kanekar Samika , Leary Owen P. , Gokaslan Ziya L. , Scarfo Keith-Austin , Guglielmo Maria
Published: March 2023

INTRODUCTION:

Despite their limited utility, diagnostic codes for substance use disorders and self-reported patient histories are often used to assess the impact of marijuana and opiate use on spinal surgery outcomes in the pre-operative setting.

METHODS:

Adult patients undergoing elective spinal surgery between August 2020 and May 2022 with a single neurosurgical provider were offered enrollment into the study. Participants completed urine toxicology screenings at preoperative baseline visits and reported Oswetry Disability Index (ODI), Neck Disability Index (NDI), and Visual Analogue Scale (VAS) at baseline and postoperative follow-up visits over a six-month period. Outcome measures for the marijuana and opiate use groups were analyzed using group-wise linear regression analyses (P<0.05).

RESULTS:

67 participants (mean age 59 years, 66% female, 96% white) were included in this study. Participants commonly underwent lumbar decompression with laminectomy (47%), lumbar fusion (24%), and cervical fusion (12%). Preoperative urine toxicology screenings demonstrated that marijuana (28%) and opiate (19%) use were variably consistent with patient-reported frequencies (18% and 19%, respectively). Regression analyses revealed a statistically significant increase in NDI (P = 0.042) and VAS (P = 0.034) among marijuana users relative to non-users over a six-month period after spinal surgery. However, no significant changes were observed in ODI (P = 0.065) among marijuana users or ODI (P = 0.105), NDI (P = 0.241), and VAS (P = 0.125) among opiate users over the same time period.

CONCLUSIONS:

Preoperative marijuana use, as determined by urine toxicology, was associated with poorer postoperative neck disability and subjective pain outcomes, potentially due to decreased pain tolerance. The same effect was not seen with preoperative opiate use. Future analyses will evaluate marijuana and other substance use within a larger cohort.
662 Navigation in Cervical Spine Surgery: A Review of Past and Current Uses
Authors: Avila Mauricio J. , Farhadi Dara , Cavagnaro María José , Orenday Jose , Fellow Research , Hussein Amna , Reyes Angelica Alvarez , Bauer Isabel , Khan Naushaba , Strouse Isabel Martha , Baaj Ali A.
Published: March 2023

INTRODUCTION:

The last two decades in spine surgery have resulted in an expansion of innovation and new enabling technologies. Within those new developments, spinal navigation has been adopted widely. Nonetheless, the use in the cervical spine remains a less explored

METHODS:

A scoping review of the literature was performed via PubMed. Limited to English and no date limit. Different search queries with MesH terms such as “Surgical Navigation Systems" "Spatial Navigation”, "Surgery, Computer-Assisted”, "Cervical Vertebrae", “cervical spine” with combination of OR and AND. Inclusion criteria: articles discussing the use of any navigation platform in the cervical spine.

RESULTS:

A total of 365 articles were found. After title and abstract selection, a total of 87 articles were reviewed. All the articles were retrospective. A total of 2101 patients underwent cervical procedures with spinal navigation, 54% were male. Average age of the cohort was 53.6 years. The Stealth navigation system (Medtronic) was the most commonly used followed by BrainLab and the large majority used CT based navigation. Degenerative conditions were the most common followed by trauma. There were 1872 total screws placed under navigation. Most common use for navigation was placement of cervical pedicle screws with a range of pedicle screw accuracy from 76.5-97.1%. The most common level for misplacement was C4. Additional uses include occipital and C1-2 fusion, corpectomies, transoral, transnasal approaches, and tumor localization. Direct complications from screw placement: C5 palsy, vertebral artery injury and dural tears. Mean follow up was 22.6 months.

CONCLUSIONS:

Spinal navigation in the cervical spine remains an understudied field. The current reports show good accuracy for placement of cervical pedicle screws, with minimal complications but other uses within the cervical spine remain somewhat limited. Given our evolving understanding of cervical pathology
667 Trends and Patterns of Robotic Assistance in Lumbar Fusion Surgery
Authors: Pando Alejandro , Hanna Gabriel , Goldstein Ira M.
Published: March 2023

INTRODUCTION:

Robotic-assisted spine surgery is an emerging field that is growing in utilization. Intraoperative robotic surgical units cost upwards of $600,000 for medical facilities to purchase. Despite significant cost barriers, these devices are highly marketable for hospitals and physicians.

METHODS:

The Nationwide Inpatient Sample database from 2016 to 2019 was investigated. Inclusion criteria were patients ≥ 18-years-old who underwent elective lumbar spinal fusion surgery. Trends of robotic-assisted lumbar fusion were examined over time, as well as stratified based on patient and surgical characteristics.

RESULTS:

A total of 176,377 patients met the inclusion criteria. The overall rate of robotic-assisted lumbar fusion was 1.2% (2,131/174,246). Patients with private insurance were more likely to receive robotic-assisted lumbar fusion (40.3% vs. 37.5%; p < 0.05). Stratifying by race, whites were more likely to receive robotic-assisted lumbar fusion (84.1% vs. 79.5%; p < 0.05). Patients who underwent robotic-assisted lumbar fusion were significantly more likely to have a diagnosis of spondylolisthesis compared to those that underwent traditional lumbar fusion (25.9% vs. 22.0%; p < 0.05). Patients with lumbar fusion done via the anterior approach were more likely to have robotic-assisted surgery compared to other approaches (25.2% vs. 21.3; p < 0.05). Overall, there was a steady increase in its use over time, with patients who underwent lumbar fusion procedures four times more likely to receive robotic-assistance in 2019 compared to 2016 (OR: 4.0; 95% CI: 3.5-4.6; p < 0.0001). Robotic-assisted lumbar fusion was associated with higher inpatient costs ($170,036.40 vs. $139,026.10; p < 0.0001) despite having equivalent length of stay (3.31 ± 2.6 vs. 3.37 ± 2.6; p = 0.06).

CONCLUSIONS:

Robotic-assisted lumbar fusion is on the rise. Patients who had private insurance, were diagnosed with spondylolisthesis, and who had lumbar fusion via the anterior approach were more likely to undergo lumbar fusion using robotic-assistance.
670 Learning Curve Associated With Thoracoscopic Anterior Vertebral Body Tether for Idiopathic Scoliosis: Analysis of Three Independent Surgeons
Authors: Lau Darryl , Kurland David B. , Neifert Sean N. , Wei-Hung Hwang Steven , Pahys Josh , Samdani Amer F.
Published: March 2023

INTRODUCTION:

Anterior vertebral body tethering (VBT) is a fusionless surgery that harnesses growth to correct idiopathic scoliosis. More surgeons are beginning to implement VBT.

METHODS:

A single-institution retrospective review of three surgeons' experiences of their first 40 single thoracic VBT and 20 double thoracolumbar VBT cases was performed. Patients had skeletally-immature, idiopathic scoliosis and underwent thoracoscopic VBT. Primary outcomes were intraoperative measures and radiographic correction. A pooled and individual surgeon analysis was performed with multivariable modeling.

RESULTS:

A total of 126 single and 60 double VBT patients were included. Mean age was 12.7 years and 13.4% were male. Mean segments tethered was 8.8 in single and 11.0 in double VBT. Mean preoperative thoracic scoliosis was 50.6°: single (49.3°) and double (53.3°). Mean lumbar scoliosis was 35.9°: single (20.9°) and double (49.0°) (p < 0.001). Average OR time was 273.7 minutes with double VBT taking significantly longer (216.4 vs. 394.0 minutes, p<0.001). Mean blood loss was 194.5 ml and fluoroscopy dose 73.6 mGy with no differences between single and double VBT. For single VBT, there was a significant decrease in operative time per 10 cases performed (287.9 to 174.1. minutes). This trend was present for all surgeons. A nonsignificant decrease in fluoroscopy dosing was evident (70.1 to 53.5 mGy, p=0.154). Single and double VBT achieved 41.1% and 47.3% thoracic curve correction, respectively. Double VBT achieved 51.5% lumbar curve correction. Increased experience was not associated with absolute or percentage curve correction for single and double VBT.

CONCLUSIONS:

VBT is an exciting fusionless surgical option for scoliosis. Increased experience resulted in shorter operative time but curve correction was adequate even at the start of the learning curve. Additional studies of long-term results of initial case experiences are needed.
673 Utility of Diffusion Basis Spectrum Imaging in Quantifying Baseline Disease Severity and Prognosis of Cervical Spondylotic Myelopathy
Authors: Zhang Justin , Javeed Saad , Greenberg Jacob K. , Jayasekera Dinal , Sun Peng , Blum Jacob , Dibble Christopher , Song Chunyu , Song Sheng-Kwei , Ray Wilson Zachary
Published: March 2023

INTRODUCTION:

Despite advancements in diffusion-weighted imaging, few studies have examined associations between diffusion MRI markers and CSM-specific clinical domains at baseline and long-term follow-up.

METHODS:

A single-center prospective cohort study enrolled fifty CSM patients who underwent surgical decompression and twenty controls from 2018-2020. At initial evaluation, all patients underwent diffusion-weighted MRI acquisition, followed by DTI and DBSI analyses. Diffusion-weighted MRI metrics assessed white matter integrity by fractional anisotropy, axial diffusivity, radial diffusivity, and fiber fraction. To improve estimations of intra-axonal anisotropic diffusion, DBSI measures intra-/extra-axonal fraction, and intra-axonal axial diffusivity. DBSI also evaluates extra-axonal isotropic diffusion by restricted and non-restricted fraction. Clinical assessments were performed at baseline and two-year follow-up and included the mJOA, SF-36 PCS, SF-36 MCS, NDI, MDI, and DASH. Pearson’s correlation coefficients were computed to compare associations between DTI/DBSI and clinical measures. A False Discovery Rate correction was applied for multiple comparisons testing.

RESULTS:

At baseline presentation, of 36 correlations analyzed between DTI metrics and CSM clinical measures, only DTI fractional anisotropy showed a positive correlation with SF-36 PCS (r = 0.36, p = 0.02). In comparison, there were 30/81 (37%) significant correlations among DBSI and clinical measures. Increased DBSI axial diffusivity, intra-axonal axial diffusivity, intra-axonal fraction, restricted fraction, and extra-axonal anisotropic fraction were associated with worse clinical presentation (decreased mJOA, SF-36 PCS/MCS, and increased NDI, MDI, DASH). At latest follow-up, increased preoperative DBSI intra-axonal axial diffusivity and extra-axonal anisotropic fraction were significantly correlated with improved mJOA.

CONCLUSIONS:

Our findings demonstrate that DBSI measures may reflect baseline disease burden and long-term prognosis of CSM as compared to DTI. With further validation, DBSI may serve as a non-invasive biomarker following decompressive surgery.
674 Diffusion Basis Spectrum Imaging Predicts Comprehensive Clinical Outcomes Following Surgery for Cervical Spondylotic Myelopathy
Authors: Zhang Justin , Javeed Saad , Jayasekera Dinal , Greenberg Jacob K. , Dibble Christopher , Blum Jacob , Sun Peng , Song Sheng-Kwei , Ray Wilson Zachary
Published: March 2023

INTRODUCTION:

A major shortcoming in improving care for cervical spondylotic myelopathy (CSM) patients is the lack of robust quantitative imaging tools to guide surgical decision-making.

METHODS:

A prospective cohort study enrolled fifty CSM patients who underwent cervical decompressive surgery. DBSI metrics assessed white matter tract integrity by fractional anisotropy, axial diffusivity, radial diffusivity, and fiber fraction. To evaluate extra-axonal diffusion, DBSI measures restricted and non-restricted fractions. Neurofunctional status was assessed by the mJOA, MDI, and DASH. Quality of life was measured by the SF-36 PCS and MCS. The NDI was used to measure self-reported neck pain. Patient satisfaction was assessed by the NASS satisfaction index. Support vector machine classification algorithms were used to predict surgical outcomes. Specifically, three models were built for each clinical outcome measure (e.g., mJOA), including clinical, DBSI, and combined models.

RESULTS:

Twenty-seven mild (mJOA 15-17), 12 moderate (12-14) and 11 severe (0-11) CSM patients were enrolled. Twenty-four (60%) underwent anterior surgery compared to 16 (40%) posterior surgery. The mean (SD) follow-up was 23.2 (5.6, range 6.1-32.8) months. The best performing model was for the prediction of the NASS satisfaction index, with an accuracy [95% CI] of 94.4 [94.3, 94.8]. Conversely, the worst performing model was for the NDI, with an accuracy of 73.8 [73.6, 74.5]. When predicting improvement in the mJOA, the clinically-driven model had an accuracy of 61.9 [61.6, 62.5], compared to 78.6 [78.4, 79.2] in the DBSI model, and 90.5 [90.2, 90.8] in the combined model.

CONCLUSIONS:

When combined with key clinical covariates, DBSI metrics predicted improvement after surgical decompression with high accuracy. These results suggest that DBSI may serve as a non-invasive imaging biomarker for CSM.
676 Anatomic Assessment of L1-S1 Neural Foraminal Dimensions Using Computed Tomography
Authors: Razzouk Jacob , Harianja Gideon , Urbina Bryan , Cabrera Andrew , Ramos Omar , Wycliffe Nathaniel D. , Cheng Wayne K. , Danisa Olumide A.
Published: March 2023

INTRODUCTION:

While radiographic parameters for diagnosis of central lumbar canal stenosis are well known, parameters for diagnosis of neural foraminal stenosis are less well defined. Previous research has used magnetic resonance imaging (MRI) to describe neural foraminal dimensions. However, the blooming artifact on MRI may distort these measurements. There is limited research using computed tomography (CT) to investigate normal neuroforamina dimensions.

METHODS:

We evaluated CT imaging of 55 female and 55 male subjects between 18 and 35 years of age. Those with history of degenerative disc disease, spondylolisthesis, fracture, neoplasm, trauma, existing spinal hardware, CT imaging performed due to back pain, or previous spinal surgery were excluded from review. Three independent reviewers were trained by a board-certified neuroradiologist to measure L1-S1 neural foraminal dimensions bilaterally. Intraclass correlation coefficient (ICC) two-way mixed model on absolute agreement was used to analyze interrater reliability. Pearson’s correlation was used to evaluate associations among variables. Differences between sexes were analyzed using independent sample t-tests. Measurement differences between disc levels and left- and right-sided measurements were analyzed using paired sample t-tests and one-way analysis of variance.

RESULTS:

Mean subject age, height, weight, and BMI were 27.16 years, 1.71 m, 88.1 kg, and 29.63 kg/m2, respectively. No moderate or strong correlations were found between measurements and age, height, weight, or BMI for all levels L1-S1. No sex differences were found for measurements at all levels L1-S1.

CONCLUSIONS:

This study describes CT-based L1-S1 neural foraminal dimensions in patients without pathology affecting the neuroforamina. Dimensions were not strongly influenced by demographic or anthropometric factors.
679 Epidural Hypertension Theory in Patients With Lumbar Spinal Stenosis
Authors: Vargas Jimenez Andres Camilo , Granada Angela Carrascosa , Barcia Albacar Juan Antonio
Published: March 2023

INTRODUCTION:

Laminectomy is the standard of treatment in Lumbar Spinal Stenosis(LSS). Multiple studies (Mariconda;Boden;Schonstrom;Matsumoto;Herno;Webber.) have not found relationship between spinal canal widening and symptoms improvement in LSS. Neurogenic compression and rootlets hypoxia theories try to explain pathophysiology of LSS. We propose Epidural Hypertension (EH) as a new paradigm that explains dynamic stress of neural structures involved in LSS.

METHODS:

Group A: single-segment LSS diagnosed by magnetic resonance (n = 4). Group B: Patients without LSS requiring surgery for another diagnosis (spinal cord stimulation, foraminotomy) (n = 3). Laminectomy was performed, previously, flavum ligament was meticulously dissected and a pressure microsensor was inserted in epidural space in stenotic segment. EP was measured in 0 and 50° extension in order to extrapolate EP in standing position.

RESULTS:

EP in LSS patients was 18,5 mmHg at 0° (IQR 16.5-37.5 mmHg) and 26 mmHg at 50° (IQR 20-34.5 mmHg). In patients without LSS, EP was 8mmHg at 0° (IQR 1-8 mmHg) and 3 mmHg at 50° (IQR 1-12 mmHg). We found differences using Wilcoxon's test. EP was greater in patients with LSS at 0° (p = 0.031) y 50° (p = 0.034).

CONCLUSIONS:

EH may play a foundamental role in pathophysiology of LSS. In Patients without LSS we found a drop in EP at 50° possibly secondary to caudal CSF displacement. In LSS patients we found a raise in EP at 50° possibly secondary to spinal canal narrowing impeding normal CSF flow increasing hydrostatic pressure in the stenotic segment. This results might be the first step to consider EH as a treatment target in LSS and determine its relationship with LSS symptoms.
681 Postoperative Muscle Relaxant Use Associated With Increased Risk of Delirium Following Lumbar Spinal Fusion
Authors: Piscopo Anthony , Perez Eli , Woodroffe Royce
Published: March 2023

INTRODUCTION:

Muscle relaxants including cyclobenzaprine and baclofen are frequently utilized in pain management following spine surgery as part of enhanced recovery after surgery (ERAS) protocols. These medications are associated with anticholinergic and central nervous system side effects and are used with caution in outpatient treatment for those at high-risk of delirium, especially the elderly. Literature investigating their association with delirium in the postoperative setting has not been described.

METHODS:

Patients over age 65 undergoing elective posterior lumbar fusion between 2017 and 2021 at the senior author’s institution were retrospectively reviewed. Variables collected included patient demographics as well as whether subjects received postoperative administration of baclofen and/or cyclobenzaprine on postoperative day 1 as part of a multimodal analgesia regimen. Doubly-robust inverse probability weighting (IPW) with cox-regression was used to evaluate the incidence of postoperative delirium between groups.

RESULTS:

Five-hundred and thirty-one patients were included in the analysis. Incidence of delirium in those who received postoperative muscle relaxants was 17.6% (44/250) compared to 11.4% (32/281) in the control group who did not (p = 0.001). Doubly-robust IPW analysis found patients who received muscle relaxants were at a 2.07 (95% CI: 1.18-3.63) times increased risk of delirium compared to controls (p = 0.015). Postoperative time to delirium onset was similar between groups (3.0 vs 3.1 days; p = 0.916) while the average duration of delirium was significantly longer in those who received postoperative muscle relaxants (2.5 vs 1.6 days; p = 0.008).

CONCLUSIONS:

Postoperative muscle relaxant use was associated with a higher risk of delirium in elderly adults following lumbar spinal fusion. Although muscle relaxants may assist with postoperative pain control as part of ERAS protocols while minimizing opioid administration, their side effect profile should be considered in patients at high risk of postoperative delirium.
747 Operative Objectives—A Pilot Study
Authors: Khalid Syed Ibad , Kwasnicki Amanda M. , Charbel Fady T.
Published: March 2023

INTRODUCTION:

Surgical graduate medical education requires residents to learn a wide array of skills and apply them practically in a progressively independent manner, ultimately allowing them to practice independently. We devised "Operative-Objectives" as a tool to define the learning goals for each resident at a particular epoch of their training. This approach is operationalized, measurable, and consistently carried over time.

METHODS:

The Residents at a neurosurgical training program set their "Operative-Objectives" at the beginning of each 3-month rotation. These goals were then reviewed by the Program Director (PD) and faculty and appropriately tailored and finalized--forming a compact between residents and faculty whereby their commitment to the learning and teaching objectives are defined. The outcomes are reviewed with the PD following each rotation and scored. Residents and faculty were provided a pre-and post-implementation survey that sought to understand the impact of implementing "Operative-Objectives" on resident preparedness, objectives for improvement, resident satisfaction with, and objective improvement in resident's surgical skills.

RESULTS:

A total of eight residents and five faculty completed both a pre-and post-implementation survey. Residents reported significantly increased case preparedness (p = .048), ability to track improvement (p = .044), clear objectives for improvement (p = .021), and satisfaction with improvement in surgical skill (p = .044). The faculty reported a significant increase in resident preparedness for surgery (p = .049), ability to track improvement (p=.044), focus for improvement (p=.033), and goals for improvement (p = .033).

CONCLUSIONS:

"Operative Objectives" provide a focused delineation and tracking of a resident's surgical learning at the intersection of three vectors: level of training, location, and ability. The deliverables are measurable. They can be followed over time and allow for an organized and focused framework for improvement and feedback. As such, they can significantly improve the learning skills of the residents as well as the teaching abilities of the faculty.
767 Electrophysiological Analysis of Traumatic Optic Neuropathy in Patients with Suspected Traumatic Brain Injury: A Prospective Cohort Study
Authors: Lucke-Wold Brandon , Carter Lea , Zwerling Charles
Published: March 2023

INTRODUCTION:

Traumatic optic neuropathy (TON) can cause persistent visual deficits and is a known sequala of traumatic brain injury (TBI). Little is known regarding appropriate diagnosis, management, and treatment.

METHODS:

We performed a prospective cohort study with 356 active military personnel using electrophysiological visual evoked potential (VEP) testing for TON in the context of known or suspected TBI. We utilized a new VEP protocol that included kinetic and static visual field testing to uncover occult cases of TON previously missed in the current disability examination. This was done to incorporate patients with borderline concussive cases that do not meet current diagnosis of mild, moderate, or severe TBI by the Veteran’s Disability Exam.

RESULTS:

80 patients were diagnosed with TON. Average age of TON patients was 37.4 years, with most patients being male. Of those patients with TON, 45% had reported TBI, whereas an additional 54% had suspected history of concussion. Patients presented with bilateral TON (65.8%, n = 52), while unilateral TON cases occurred less frequently (35.4%, n=28). Visual field defects were apparent in both static and kinetic visual field testing in 54% of cases. VEP sensitivity in our study was 88%. Military parachute jumpers (paratroopers) represented the highest risk group for undiagnosed TBI and TON.

CONCLUSIONS:

We recommend periodic static and kinetic visual field testing in high-risk individuals working in fields with high concussion rates. This allows implementation of treatment early to avoid decrements in visual acuity. By instituting our protocol, we can detect visual deficits early in our TBI patients and direct to appropriate treatment centers.
769 In Vivo Evaluation of Spinal Cord Perfusion Using Contrast-Enhanced Transcutaneous Ultrasound
Authors: Shaaya Elias , Leary Owen P. , Sastry Rahul , Zhu Michelle , Persad-Paisley Elijah , Seidler Michael , Beland Michael , Fridley Jared
Published: March 2023

INTRODUCTION:

Ultrasound (US) imaging is cheap, portable, and widely available. It has been used in multiple medical disciplines, both as a means of diagnosis and therapy. Developing US as a platform for spinal cord perfusion monitoring in patients with spinal cord injury (SCI) would provide a cheap, accessible, and real-time platform for managing spinal cord perfusion in the acute setting.

METHODS:

Four patients with previous cervical decompression and instrumentation were evaluated at a single center with transcutaneous US. We included adult patients with at least 2 levels of continuous cervical laminectomies greater than 3 months prior to US and no history of SCI. The first two patients underwent US imaging without contrast and the second two patients underwent contrast-enhanced US imaging with Lumason, a microbubble agent. Imaging was performed by a board-certified radiologist with US expertise using a General Electric (GE) Logiq E10 ultrasound scanner ans a high frequency linear transducer. The study was approved by the institutional ethics committee.

RESULTS:

In the non-contrast study (n = 2), the dura, spinal cord, and vertebral body were apparent on US. Application of Doppler was insufficient to discern intramedullary perfusion, so contrast-enhanced ultrasound was pursued (n = 2). With contrast, anatomic structures were again visible, and we were able to quantify differential spinal cord perfusion within and between cross-sectional sections of the cord. We demonstrated spinal cord hemodynamic perfusion by measuring peak signal intensity and the time to peak signal intensity after microbubble contrast injection. Then, a time-intensity curve was created and the area under the curve was calculated as a surrogate of spinal cord perfusion.

CONCLUSIONS:

Contrast-enhanced US is a viable platform for monitoring spinal cord perfusion in patients who have undergone prior cervical laminectomies.
770 Gastrostomy Sequence With Ventriculoperitoneal Shunting—Does it Matter?
Authors: Khalid Syed Ibad , Maynard Marquis , Mehta Ankit Indravadan
Published: March 2023

INTRODUCTION:

Patients who suffer neurologic injury that require ventriculoperitoneal shunt(VPS) placement often also require gastrostomy procedures for feeding access and nutritional support. The timing of these procedures in relation to each other has been debated in the literature, largely steaming from a proposed risk of infection and displacement resulting in a need for revision related to the presence of a gastrostomy.

METHODS:

In an all-payor database, patients undergoing index gastrostomy procedures and VPS placement between 1/2010-10/2020 were identified. Patients were stratified as undergoing gastrostomy placement before, on the same day as, and following the placement of a shunt. The primary outcome of the study was rates of revision All outcomes were evaluated within 30-months following index-shunting. Patients were matched based upon logistic-regression models that evaluated the independent effects of patient and procedural factors on the primary-outcome.

RESULTS:

A total of 4,290-patients were identified as undergoing VPS and gastrostomy procedures. Following a 1:1:1-match procedure, 852-patient records were analyzed. Patients undergoing gastrostomy and VPS on the same day or gastrostomy procedures before VPS (Odds Ratio [OR] 0.55, 95% Confidence Interval [CI] 0.33-0.91 vs. OR 0.60, 95% CI 0.36-0.97, respectively) were observed to have significantly lower rates of revision at 30-months following index shunting when compared to those patients who underwent gastrostomy placement after VPS. No significant differences were noted in rates of infection, mechanical complications, g-tube infections, or shunt displacement between the three approaches.

CONCLUSIONS:

Patients undergoing shunting and gastrostomy tube placement procedures may benefit from undergoing the procedures at the same time as patients undergoing these procedures at the same time are at a decreased risk of repeat requirement for anesthesia reduced rates of VPS revision following observed in comparison to patients undergoing gastrostomy placement after VPS.
772 Re-examining the Role of Post-Operative ICU Admission for Patients Undergoing Elective Craniotomy: A Systematic Review
Authors: Azad Tej D. , Shah Pavan P. , Kannapadi Nivedha , Rincon Torroella Jordina N. , Xia Yuanxuan , Bernhardt Lydia , Hansen Landon John , Materi Joshua , Raj Divyaansh , Jackson Christopher Mitchell , Mukherjee Raj , Gallia Gary L. , Weingart Jon , Suarez Jose , Brem Henry , Bettegowda Chetan
Published: March 2023

INTRODUCTION:

The standard-of-care for post-operative care following elective craniotomy has historically been intensive care unit (ICU) admission. However, recent literature interrogating complications and interventions during this post-operative ICU stay suggests that all patients may not require this level of care. Thus, hospitals began implementing non-ICU post-operative care pathways for elective craniotomy.

METHODS:

A systematic review of the PubMed database was performed following PRISMA guidelines from database inception through August 2021. Included studies were published in peer-reviewed journals, in English, and described outcomes for patients undergoing elective craniotomies without post-operative ICU care. Data regarding study design, patient characteristics, and post-operative care pathways was extracted independently by two authors. Quality and risk of bias were evaluated using the Oxford Centre for Evidence-Based Medicine Levels of Evidence tool and Risk Of Bias In Non-Randomized Studies—of Interventions tool, respectively.

RESULTS:

In total, 1,131 unique papers were identified through the database search, with 27 meeting inclusion criteria. Included articles were published from 2001-2021 and included non-ICU inpatient care and same-day discharge pathways. Overall, the studies demonstrated that post-operative non-ICU care for elective craniotomies led to length of stay reduction ranging from 6 hours to 4 days and notable cost reductions. Across 13 studies, 53 of the 2,469 (2.1%) patients intended for post-operative management in a non-ICU setting required subsequent care escalation.

CONCLUSIONS:

Overall, these studies suggest that non-ICU care pathways for appropriately selected post-craniotomy patients may represent a meaningful opportunity to improve care value. However, included studies varied greatly in patient selection, post-operative care protocol, and outcomes reporting. Standardization and multi-institutional collaboration are needed to draw definitive conclusions regarding non-ICU post-operative care for elective craniotomy.
774 Prognostication of Civilian Gunshot Wounds to the Head: Internal Validation of the Baylor Score
Authors: Gopakumar Sricharan , Anand Adrish , McDonald Malcolm F. , Cruz-Navarro Jovany , Karas Patrick J. , Gopinath Shankar Prakash
Published: March 2023

INTRODUCTION:

Early prognostication of patients with gunshot wounds to the head (GSWH) can identify patients who may benefit from aggressive management. The Baylor score uses patient age, pupil reactivity, Glasgow Coma Scale, and bullet trajectory at initial presentation to predict mortality and functional status at six months and performed well when recently assessed at a separate level 1 trauma center demonstrating external validation of the score.

METHODS:

Retrospective chart review of patients with GSWH treated at an academic level 1 trauma center between 2008 and 2022 was performed with Baylor score calculated for each patient. Accuracy of the Baylor score in predicting mortality and good functional outcome (Glasgow Outcome Scale score of 4 or 5) was assessed using receiver operating characteristic (ROC) curves and area under the curve (AUC) as measures of performance.

RESULTS:

A total of 405 patients with GSWH were identified over the 14-year study period (mean age 31.5 years, 88.9% male, 19.5% white). 225 (55.6%) patients died, while 145 (35.8%) had favorable functional outcomes. Mortality rates ranged from 8% for Baylor score 0 to 97% for Baylor score 5, and good functional outcomes ranged from 15% for Baylor score 3 to 87% for Baylor score 0. Baylor score demonstrated good accuracy in prognosticating both mortality (AUC = 0.85) and good functional outcome (AUC = 0.90), though scores 0-2 underestimated favorable outcomes and scores 3-5 underestimated mortality.

CONCLUSIONS:

The Baylor score is a valuable tool for prognosticating GSWH survival and functional outcome and may aid in guiding treatment and family-centered discussions regarding patient prognosis earlier in the hospital course.
775 The Effect of Anti-Seizure Medication Administration on Mortality and Early Post Traumatic Seizures In Critically Ill Older Adults With Traumatic Brain Injury
Authors: Glaser Adam , Kanter John , Martinez-Camblor Pablo , Buhl Lauren , Anderson Matthew , Pannu Ameeka , Shaefi Shahzad , Taenzer Andreas , Boone Myles Dustin
Published: March 2023

INTRODUCTION:

Older adults (≥65-years) are an understudied and growing TBI population. Guidelines support prophylactic antiseizure medication (ASM) to reduce early posttraumatic seizures (ePTS) (within 7-days of injury) in severe TBI. Whether ASM decreases mortality or ePTS in this population remains unclear. This study assesses association between ASM administration, mortality, and seizure in older TBI patients.

METHODS:

This retrospective cohort study utilized data from the Massachusetts Institute of Technology, Medical Information Mart for Intensive Care-III (MIMIC). Our cohort included patients 65-years or older. Primary exposure was early ASM administration in TBI patients admitted to an ICU at a Level 1 trauma center from 2001-2012. A double-robust inverse propensity scale weighted model based on proportional hazard and logistic regression models assessed the association between ASM administration and risk of death within 7-days of admission.

RESULTS:

Of 1,145 patients, 783 (68.4%) received ASM within the first 24 hours. TBI severity, classified by Glasgow Coma Score (GCS), was predominantly mild (71.2%) followed by moderate (16.8%), and severe (11.3%). Patients who received ASM were less likely to have died at 7-days (adjusted Death HR = 0.48 [95% CI 0.28–0.88] P = 0.005), at 30 days (adjusted HR 0.67 [0.45–0.99] P = 0.045) and at one year (adjusted HR 0.72 [0.54–0.97] P = 0.029). There was no difference in seizure (adjusted Seizure OR 1.18 [0.61–2.26] compared with those who did not receive ASM.

CONCLUSIONS:

Early ASM administration was associated with reduced mortality at 7-days, 30-days, and one-year, but did not affect early seizure risk. This observed benefit in older adults with all TBI severity suggest broader recommendations for ASM use.
793 Sole Arterial Versus Venous Compression in Trigeminal Neuralgia
Authors: Xu Risheng , Nair Sumil , Materi Joshua , So Raymond , Huang Judy , Lim Michael , Bettegowda Chetan
Published: March 2023

INTRODUCTION:

The majority of trigeminal neuralgia (TN) patients present with trigeminal nerve compression from the superior cerebellar artery. However, pain outcomes in patients with sole venous compression are not well understood.

METHODS:

We retrospectively reviewed 1020 patients undergoing microvascular decompression at our institution, identifying patients with either sole arterial or venous trigeminal nerve compression. We dichotomized patients into arterial or venous compression groups and obtained presenting characteristics, length of stay, and postoperative complications for each case. Pain outcomes were collected for each patient preoperatively and immediately postoperatively, in addition at 3-month, 6-month, 1 year, and >1 year follow up for each case via Barrow Neurological Index (BNI) pain scores. Statistical differences were calculated via Chi-squared tests and t-tests.

RESULTS:

Of 1020 patients, 648 (63.5%) had either sole arterial or venous compression of the trigeminal nerve. 514 of these cases demonstrated arterial compression, as opposed to 134 with only venous compression. Patients in the venous compression group were significantly younger than those in the arterial group. There were no significant differences in presenting comorbidities, ICU admission, length of stay, and postoperative complications between groups. Compared to the arterial compression group, patients with sole venous compression demonstrated significantly worse preoperative (p < 0.001), 3-month follow-up (p = 0.001), 6-month follow-up (p < 0.001), 1-year follow-up (p =< 0.001), and >1-year follow-up BNI scores (p = 0.001). Patients with venous compression were more likely to have recurrent pain (p = 0.047) and demonstrated significantly lower time to recurrence than the arterial compression group (p = 0.001).

CONCLUSIONS:

Patients with sole venous compression of the trigeminal nerve are more likely to have worse pain outcomes following MVD compared to those with only arterial compression, including both likelihood of pain recurrence, and time to recurrence