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Hiroyuki Aono, Shota Takenaka, Hidekazu Tobimatsu, Yukitaka Nagamoto, Masayuki Furuya, Tomoya Yamashita, Hiroyuki Ishiguro and Motoki Iwasaki

OBJECTIVE

Posterior lumbar interbody fusion (PLIF) is a widely accepted procedure for degenerative lumbar diseases, and there have been many reports concerning adjacent-segment disease (ASD) after PLIF. In the reports of ASD in which the fusion level was limited to 1 segment, all reports describe ASD of the L3–4 segment after L4–5 PLIF. On the basis of these reports, it is thought that ASD mainly occurs at the cranial segment. However, no report has covered ASD after L3–4 PLIF. Therefore, the authors investigated ASD after L3–4 PLIF.

METHODS

In conducting a retrospective case series analysis, the authors reviewed a surgical database providing details of all spine operations performed between 2006 and 2017 at a single institution. During that period, PLIF was performed to treat 632 consecutive patients with degenerative lumbar diseases. Of these patients, 71 were treated with L3–4 PLIF alone, and 67 who were monitored for at least 2 years (mean 5.8 years; follow-up rate 94%) after surgery were enrolled in this study. Radiological ASD (R-ASD), symptomatic ASD (S-ASD), and operative ASD (O-ASD) were evaluated. These types of ASD were defined as follows: R-ASD refers to radiological degeneration adjacent to the fusion segment as shown on plain radiographs; S-ASD is a symptomatic condition due to neurological deterioration at the adjacent-segment degeneration; and O-ASD refers to S-ASD requiring revision surgery.

RESULTS

All patients had initial improvement of neurological symptoms after primary PLIF. R-ASD was observed in 32 (48%) of 67 patients. It occurred at the cranial segment in 12 patients and at the caudal segment in 24; R-ASD at both adjacent segments was observed in 4 patients. Thus, the occurrence of R-ASD was more significant in the caudal segment than in the cranial segment. S-ASD was observed in 10 patients (15%), occurring at the cranial segment in 3 patients and at the caudal segment in 7. O-ASD was observed in 6 patients (9%): at the cranial segment in 1 patient and at the caudal segment in 5. Thus, the rate of involvement of the caudal segment was 67% in R-ASD, 70% in S-ASD, and 83% in O-ASD.

CONCLUSIONS

The incidences of R-ASD, S-ASD, and O-ASD were 48%, 15%, and 9%, respectively, after L3–4 PLIF for degenerative lumbar diseases. In contrast to ASD after L4–5 PLIF, ASD after L3–4 PLIF was more frequently observed at the caudal segment than at the cranial segment. In follow-up for patients with L3–4 PLIF, surgeons should pay attention to ASD in the caudal segment.

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Alexandra Cutillo, Kathrin Zimmerman, Susan Davies, Avi Madan-Swain, Wendy Landier, Anastasia Arynchyna and Brandon G. Rocque

OBJECTIVE

Because caregivers are a crucial part of a child’s medical care, it is important to understand how to best communicate with them during hospitalization. Qualitative research can elucidate the best strategies for effective parent–provider communication. This study aims to reveal communication styles of neurosurgery team members, and to identify areas for improvement in the future.

METHODS

Caregivers of children with a newly diagnosed brain tumor requiring neurosurgery were enrolled during their child’s hospitalization. During routine follow-up clinic visits within 3 months after diagnosis and tumor resection, caregivers participated in a semistructured interview, which assessed the quality of communication with the neurosurgery and oncology teams during hospitalization. Interviews were audio-recorded, transcribed, and coded for common themes until thematic saturation was reached.

RESULTS

During caregiver interviews (N = 22), several domains were discussed including communicating the diagnosis to the patient and siblings, to the rest of the family/support network, and with the neurosurgery team. Regarding parent–neurosurgeon communication, 82% of caregivers identified at least one positive aspect and 55% identified at least one negative aspect of communication. Caregivers who provided positive feedback appreciated that their neurosurgeon was thorough (73%), direct (27%), or compassionate (14%). They also valued when providers would speak “on my level” (18%) and would speak directly to the patient (27%). In terms of negative feedback, caregivers identified miscommunications (32%), discussing the diagnosis in front of the child before feeling prepared to do so (14%), and a lack of clarity about expectations, medications, or treatment (32%).

CONCLUSIONS

These data provide specific ways in which neurosurgery providers have communicated effectively with caregivers and identify areas for improvement. Results have been used to develop a navigator-led intervention geared toward improving parent–provider communication during hospitalization for resection of a brain tumor.

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Fu-Lin He, Shuai Qiu, Jian-Long Zou, Fan-Bin Gu, Zhi Yao, Zhe-Hui Tu, Yuan-Yuan Wang, Xiao-Lin Liu, Li-Hua Zhou and Qing-Tang Zhu

OBJECTIVE

Neuropathic pain caused by traumatic neuromas is an extremely intractable clinical problem. Disorderly scar tissue accumulation and irregular and immature axon regeneration around the injury site mainly contribute to traumatic painful neuroma formation. Therefore, successfully preventing traumatic painful neuroma formation requires the effective inhibition of irregular axon regeneration and disorderly accumulation of scar tissue. Considering that chondroitin sulfate proteoglycans (CSPGs) can act on the growth cone and effectively inhibit axon regeneration, the authors designed and manufactured a CSPG-gelatin blocker to regulate the CSPGs’ spatial distribution artificially and applied it in a rat model after sciatic nerve neurectomy to evaluate its effects in preventing traumatic painful neuroma formation.

METHODS

Sixty female Sprague Dawley rats were randomly divided into three groups (positive group: no covering; blank group: covering with gelatin blocker; and CSPG group: covering with the CSPG-gelatin blocker). Pain-related factors were evaluated 2 and 8 weeks postoperatively (n = 30). Neuroma growth, autotomy behavior, and histological features of the neuromas were assessed 8 weeks postoperatively (n = 30).

RESULTS

Eight weeks postoperatively, typical bulb-shaped neuromas did not form in the CSPG group, and autotomy behavior was obviously better in the CSPG group (p < 0.01) than in the other two groups. Also, in the CSPG group the regenerated axons showed a lower density and more regular and improved myelination (p < 0.01). Additionally, the distribution and density of collagenous fibers and the expression of α–smooth muscle actin were significantly lower in the CSPG group than in the positive group (p < 0.01). Regarding pain-related factors, c-fos, substance P, interleukin (IL)–17, and IL-1β levels were significantly lower in the CSPG group than those in the positive and blank groups 2 weeks postoperatively (p < 0.05), while substance P and IL-17 remained lower in the CSPG group 8 weeks postoperatively (p < 0.05).

CONCLUSIONS

The authors found that CSPGs loaded in a gelatin blocker can prevent traumatic neuroma formation and effectively relieve pain symptoms after sciatic nerve neurotomy by blocking irregular axon regeneration and disorderly collagenous fiber accumulation in the proximal nerve stump. These results indicate that covering the proximal nerve stump with CSPGs may be a new and promising strategy to prevent traumatic painful neuroma formation in the clinical setting.

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Alex Soroceanu, Justin S. Smith, Darryl Lau, Michael P. Kelly, Peter G. Passias, Themistocles S. Protopsaltis, Jeffrey L. Gum, Virginie Lafage, Han-Jo Kim, Justin K. Scheer, Munish Gupta, Gregory M. Mundis Jr., Eric O. Klineberg, Douglas Burton, Shay Bess, Christopher P. Ames and the International Spine Study Group

OBJECTIVE

It is being increasingly recognized that adult cervical deformity (ACD) is correlated with significant pain, myelopathy, and disability, and that patients who undergo deformity correction gain significant benefit. However, there are no defined thresholds of minimum clinically important difference (MCID) in Neck Disability Index (NDI) and modified Japanese Orthopaedic Association (mJOA) scores.

METHODS

Patients of interest were consecutive patients with ACD who underwent cervical deformity correction. ACD was defined as C2–7 sagittal Cobb angle ≥ 10° (kyphosis), C2–7 coronal Cobb angle ≥ 10° (cervical scoliosis), C2–7 sagittal vertical axis ≥ 4 cm, and/or chin-brow vertical angle ≥ 25°. Data were obtained from a consecutive cohort of patients from a multiinstitutional prospective database maintained across 13 sites. Distribution-based MCID, anchor-based MCID, and minimally detectable measurement difference (MDMD) were calculated.

RESULTS

A total of 73 patients met inclusion criteria and had sufficient 1-year follow-up. In the cohort, 42 patients (57.5%) were female. The mean age at the time of surgery was 62.23 years, and average body mass index was 29.28. The mean preoperative NDI was 46.49 and mJOA was 13.17. There was significant improvement in NDI at 1 year (46.49 vs 37.04; p = 0.0001). There was no significant difference in preoperative and 1-year mJOA (13.17 vs 13.7; p = 0.12). Using multiple techniques to yield MCID thresholds specific to the ACD population, the authors obtained values of 5.42 to 7.48 for the NDI, and 1.00 to 1.39 for the mJOA. The MDMD was 6.4 for the NDI, and 1.8 for the mJOA. Therefore, based on their results, the authors recommend using an MCID threshold of 1.8 for the mJOA, and 7.0 for the NDI in patients with ACD.

CONCLUSIONS

The ACD-specific MCID thresholds for NDI and mJOA are similar to the reported MCID following surgery for degenerative cervical disease. Additional studies are needed to verify these findings. Nonetheless, the findings here will be useful for future studies evaluating the success of surgery for patients with ACD undergoing deformity correction.

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Joel Haakon Borgstedt-Bakke, Thea Overgaard Wichmann, Gudrun Gudmundsdottir and Mikkel Mylius Rasmussen

OBJECTIVE

The goal of this study was to establish an incidence and assess the effect of tethered cord release for tethered cord syndrome in patients with myelomeningocele.

METHODS

The study population was based on the Western Denmark Myelomeningocele Database, which contains all patients born with myelomeningocele in western Denmark since 1970. The study population was cross-referenced in 2015 with a database for surgical procedures containing all surgical procedures performed in the central Denmark region since 1996. Patients alive between 1996 and 2015 were identified. Incidences was calculated and presented for year of age. File reviews were conducted for all patients who underwent the procedure. Follow-up was divided into short-term and long-term follow-up.

RESULTS

One hundred sixty-six patients were alive during various time periods between 1996 and 2015. Of these, 45 patients underwent the procedure. Seven underwent reoperation. The median age for the procedure was 12 years and the highest incidence was found at 15 years of age. Incidence was bimodal with highest incidence in children and adolescents. The most common indications were progressive spine deformity (40%), deteriorating ambulation (38%), and deteriorating neurogenic bladder and/or bowel dysfunction (32%). The mean short-term follow-up was 4.7 months and the mean long-term follow-up was 72.6 months. Postoperatively, the majority had improved (27%) or stabilized (27%) at short-term follow-up. At long-term follow-up, most patients were stable (27%) or had deteriorated (24%). For both follow-up terms there was a loss of approximately one-third of all patients. Complications occurred in 17% of the procedures.

CONCLUSIONS

In this population-based study, tethered cord release has the highest incidence in children and adolescents. The beneficial effect of the procedure seems to be short term. Due to the uncertainty of a long-term effect of the procedure in patients with myelomeningocele and the registered complications, the authors suggest that this surgical indication should be reserved for well-selected patients.

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Ina Bährend, Max R. Muench, Heike Schneider, Rabih Moshourab, Felix R. Dreyer, Peter Vajkoczy, Thomas Picht and Katharina Faust

OBJECTIVE

Given the interindividual variance of functional language anatomy, risk prediction based merely on anatomical data is insufficient in language area–related brain tumor surgery, suggesting the need for direct cortical and subcortical mapping during awake surgery. Reliable, noninvasive preoperative methods of language localization hold the potential for reducing the necessity for awake procedures and may improve patient counseling and surgical planning. Repetitive navigated transcranial magnetic stimulation (rnTMS) is an evolving tool for localizing language-eloquent areas. The aim of this study was to investigate the reliability of rnTMS in locating cortical language sites.

METHODS

Twenty-five patients with brain tumors in speech-related areas were prospectively evaluated with preoperative rnTMS (5 Hz, train of five, average 105% resting motor threshold) and navigated direct cortical stimulation (DCS; bipolar, 50 Hz, 6–8 mA, 200-μsec pulse width) during awake surgeries employing a picture-naming task. Positive and negative stimulation spots within the craniotomy were documented in the same MRI data set. TMS and DCS language-positive areas were compared with regard to their spatial overlap, their allocation in a cortical parcellation system, and their linguistic qualities.

RESULTS

There were over twofold more positive language spots within the exposed area on rnTMS than on DCS. The comparison of positive rnTMS and DCS (ground truth) overlaps revealed low sensitivity (35%) and low positive predictive value (16%) but high specificity (90%) and high negative predictive value (96%). Within the overlaps, there was no correlation in error quality. On DCS, 73% of language-positive spots were located in the pars opercularis and pars triangularis of the frontal operculum and 24% within the supramarginal gyrus and dorsal portion of the superior temporal gyrus, while on rnTMS language positivity was distributed more evenly over a large number of gyri.

CONCLUSIONS

The current protocol for rnTMS for language mapping identified language-negative sites with good dependability but was unable to reliably detect language-positive spots. Further refinements of the technique will be needed to establish rnTMS language mapping as a useful clinical tool.