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Sameer A. Kitab, Andrew E. Wakefield, and Edward C. Benzel

OBJECTIVE

Roussouly lumbopelvic sagittal profiles are associated with distinct pathologies or distinct natural histories and prognoses. The associations between developmental lumbar spinal stenosis (DLSS) and native lumbopelvic sagittal profiles are unknown. Moreover, the relative effects of multilevel decompression on lumbar sagittal alignment, geometrical parameters of the pelvis, and compensatory mechanisms for each of the Roussouly subtypes are unknown. This study aimed to explore the association between DLSS and native lumbar lordosis (LL) subtypes. It also attempts to understand the natural history of postlaminectomy lumbopelvic sagittal changes and compensatory mechanisms for each of the Roussouly subtypes and to define the critical lumbar segment or specific lordosis arc that is recruited after relief of the stenosis effect.

METHODS

A total of 418 patients with multilevel DLSS were grouped into various Roussouly subtypes, and lumbopelvic sagittal parameters were prospectively compared at follow-up intervals of preoperative to < 2 years, 2 to < 5 years, and 5 to ≥ 10 years after laminectomy. The variables analyzed included LL, upper lordosis arc from L1 to L4, lower lordosis arc from L4 to S1, and segmental lordosis from L1 to S1. Pelvic parameters included pelvic incidence, sacral slope, pelvic tilt, and pelvic incidence minus LL values.

RESULTS

Of the 329 patients who were followed up throughout this study, 33.7% had Roussouly type 1 native lordosis, whereas the incidence rates of types 2, 3, and 4 were 33.4%, 21.9%, and 10.9%, respectively. LL was not reduced in any of the Roussouly subtypes after multilevel decompressions. Instead, LL increased by 4.5° (SD 11.9°—from 27.3° [SD 11.5°] to 31.8° [SD 9.8°]) in Roussouly type 1 and by 3.1° (SD 11.6°—from 41.3° [SD 9.5°] to 44.4° [SD = 9.7°]) in Roussouly type 2. The other Roussouly types showed no significant changes. Pelvic tilt decreased significantly—by 2.8°, whereas sacral slope increased significantly—by 2.9° in Roussouly type 1 and by 1.7° in Roussouly type 2. The critical lumbar segment that recruits LL differs between Roussouly subtypes. Increments and changes were sustained until the final follow-up.

CONCLUSIONS

The study findings are important in predicting patient prognosis, LL evolution, and the need for prophylactic or corrective deformity surgery. Multilevel involvement in DLSS and the high prevalence of Roussouly types 1 and 2 suggest that spinal canal dimensions are closely linked to the developmental evolution of LL.

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Amir Hadanny, Zachary T. Olmsted, Anthony M. Marchese, Kyle Kroll, Christopher Figueroa, Thomas Tagney, Jennifer Tram, Marisa DiMarzio, Olga Khazen, Dorothy Mitchell, Theodore Cangero, Vishad Sukul, and Julie G. Pilitsis

OBJECTIVE

The incidence of hemorrhage in patients who undergo deep brain stimulation (DBS) and spinal cord stimulation (SCS) is between 0.5% and 2.5%. Coagulation status is one of the factors that can predispose patients to the development of these complications. As a routine part of preoperative assessment, the authors obtain prothrombin time (PT), partial thromboplastin time (PTT), and platelet count. However, insurers often cover only PT/PTT laboratory tests if the patient is receiving warfarin/heparin. The authors aimed to examine their experience with abnormal coagulation parameters in patients who underwent neuromodulation.

METHODS

Patients who underwent neuromodulation (SCS, DBS, or intrathecal pump implantation) over a 9-year period and had preoperative laboratory values available were included. The authors determined abnormal values on the basis of a clinical protocol utilized at their practice, which combined the normal ranges of the laboratory tests and clinical relevance. This protocol had cutoff values of 12 seconds and 39 seconds for PT and PTT, respectively, and < 120,000 platelets/μl. The authors identified risk factors for these abnormalities and described interventions.

RESULTS

Of the 1767 patients who met the inclusion criteria, 136 had abnormal preoperative laboratory values. Five of these 136 patients had values that were misclassified as abnormal because they were within the normal ranges at the outside facility where they were tested. Fifty-one patients had laboratory values outside the ranges of our protocol, but the surgeons reviewed and approved these patients without further intervention. Of the remaining 80 patients, 8 had known coagulopathies and 24 were receiving warfarin/heparin. The remaining 48 patients were receiving other anticoagulant/antiplatelet medications. These included apixaban/rivaroxaban/dabigatran anticoagulants (n = 22; mean ± SD PT 13.7 ± 2.5 seconds) and aspirin/clopidogrel/other antiplatelet medications (n = 26; mean ± SD PT 14.4 ± 5.8 seconds). Eight new coagulopathies were identified and further investigated with hematological analysis.

CONCLUSIONS

New anticoagulants and antiplatelet medications are not monitored with PT/PTT, but they affect coagulation status and laboratory values. Although platelet function tests aid in a subset of medications, it is more difficult to assess the coagulation status of patients receiving novel anticoagulants. PT/PTT may provide value preoperatively.

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Joshua S. Catapano, Mohamed A. Labib, Visish M. Srinivasan, Candice L. Nguyen, Kavelin Rumalla, Redi Rahmani, Tyler S. Cole, Jacob F. Baranoski, Caleb Rutledge, Kristina M. Chapple, Andrew F. Ducruet, Felipe C. Albuquerque, Joseph M. Zabramski, and Michael T. Lawton

OBJECTIVE

The Barrow Ruptured Aneurysm Trial (BRAT) was a single-center trial that compared endovascular coiling to microsurgical clipping in patients treated for aneurysmal subarachnoid hemorrhage (aSAH). However, because patients in the BRAT were treated more than 15 years ago, and because there have been advances since then—particularly in endovascular techniques—the relevance of the BRAT today remains controversial. Some hypothesize that these technical advances may reduce retreatment rates for endovascular intervention. In this study, the authors analyzed data for the post-BRAT (PBRAT) era to compare microsurgical clipping with endovascular embolization (coiling and flow diverters) in the two time periods and to examine how the results of the original BRAT have influenced the practice of neurosurgeons at the study institution.

METHODS

In this retrospective cohort study, the authors evaluated patients with saccular aSAHs who were treated at a single quaternary center from August 1, 2007, to July 31, 2019. The saccular aSAH diagnoses were confirmed by cerebrovascular experts. Patients were separated into two cohorts for comparison on the basis of having undergone microsurgery or endovascular intervention. The primary outcome analyzed for comparison was poor neurological outcome, defined as a modified Rankin Scale (mRS) score > 2. The secondary outcomes that were compared included retreatment rates for both therapies.

RESULTS

Of the 1014 patients with aSAH during the study period, 798 (79%) were confirmed to have saccular aneurysms. Neurological outcomes at ≥ 1-year follow-up did not differ between patients treated with microsurgery (n = 451) and those who received endovascular (n = 347) treatment (p = 0.51). The number of retreatments was significantly higher among patients treated endovascularly (32/347, 9%) than among patients treated microsurgically (6/451, 1%) (p < 0.001). The retreatment rate after endovascular treatment was lower in the PBRAT era (9%) than in the BRAT (18%).

CONCLUSIONS

Similar to results from the BRAT, results from the PBRAT era showed equivalent neurological outcomes and increased rates of retreatment among patients undergoing endovascular embolization compared with those undergoing microsurgery. However, the rate of retreatment after endovascular intervention was much lower in the PBRAT era than in the BRAT.

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Brian J. Park, Colin J. Gold, Royce W. Woodroffe, and Satoshi Yamaguchi

OBJECTIVE

The ability to utilize the T1 slope is often limited by poor visibility on cervical radiographs. The C7 slope has been proposed as a reliable substitute but may have similar limitations of visibility. Herein, the authors propose a novel method that takes advantage of the superior visibility on CT to accurately substitute for the radiographic T1 slope and compare the accuracy of this method with previously reported substitutes.

METHODS

Lateral neutral standing cervical radiographs and cervical CT scans were examined. When the T1 slope was clearly visible on radiographs, the C3–7 slopes and T1 slope were measured. In CT method 1, a direct method, the T1 slope was measured from the upper endplate of T1 to the bottom edge of the CT image, assuming the edge was parallel to the horizontal plane. In CT method 2, an overlaying method, the T1 slope was calculated by superimposing the C7 slope angle measured on a radiograph onto the CT scan and measuring the angle formed by the upper endplate of T1 and the superimposed horizontal line of the C7 slope. A Pearson correlation with linear regression modeling was performed for potential substitutes for the actual T1 slope.

RESULTS

Among 160 patients with available noninstrumented lateral neutral cervical radiographs, the T1 slope was visible in only 54 patients (33.8%). A total of 52 patients met the inclusion criteria for final analysis. The Pearson correlation coefficients between the T1 slope and the C3–7 slopes, CT method 1, and CT method 2 were 0.243 (p = 0.083), 0.292 (p = 0.035), 0.609 (p < 0.001), 0.806 (p < 0.001), 0.898 (p < 0.001), 0.426 (p = 0.002), and 0.942 (p < 0.001), respectively. Linear regression modeling showed R2 = 0.807 for the correlation between C7 slope and T1 slope and R2 = 0.888 for the correlation between T1 slope with the CT method 2 and actual T1 slope.

CONCLUSIONS

The C7 slope can be a reliable predictor of the T1 slope and is more accurate than more rostral cervical slopes. However, this study disclosed that the novel CT method 2, an overlaying method, was the most reliable estimate of true T1 slope with a greater positive correlation than C7 slope. When CT studies are available in patients with an invisible T1 slope on cervical radiographs, CT method 2 should be used as a substitute for the T1 slope.

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Albert Antar, James Feghali, Elizabeth E. Wicks, Shahab Aldin Sattari, Sean Li, Timothy F. Witham, Henry Brem, and Judy Huang

OBJECTIVE

In this study, the authors sought to determine which US medical schools have produced the most neurosurgery residents and to evaluate potential associations between recruitment and medical school characteristics.

METHODS

Demographic and bibliometric characteristics were collected for 1572 residents in US-based and Accreditation Council for Graduate Medical Education (ACGME)–accredited neurosurgery programs over the 2014 to 2020 match period using publicly available websites. US medical school characteristics were collected, including class size, presence of a home neurosurgery program, number of clinical neurosurgery faculty, research funding, presence of a neurosurgery interest group, and a top 10 ranking via U.S. News & World Report or Doximity. Correlations and associations were then evaluated using Pearson’s correlation coefficient (PCC), independent-samples t-test, and univariable or stepwise multivariable linear regression, as appropriate.

RESULTS

Vanderbilt University produced the most neurosurgery residents as a percentage of medical graduates at 3.799%. Case Western Reserve University produced the greatest absolute number of neurosurgery residents (n = 40). The following factors were shown to be associated with a higher mean percentage of graduates entering neurosurgery: number of clinical neurosurgery faculty (PCC 0.509, p < 0.001), presence of a neurosurgery interest group (1.022% ± 0.737% vs 0.351% ± 0.327%, p < 0.001) or home neurosurgery program (1.169% ± 0.766% vs 0.428% ± 0.327%, p < 0.001), allopathic compared with osteopathic school (0.976% ± 0.719% vs 0.232% ± 0.272%, p < 0.001), U.S. News top 10 ranking for neurology and neurosurgery (1.923% ± 0.924% vs 0.757% ± 0.607%, p < 0.001), Doximity top 10 residency program ranking (1.715% ± 0.803% vs 0.814% ± 0.688%, p < 0.001), and amount of NIH funding (PCC 0.528, p < 0.001).

CONCLUSIONS

The results of this study have delineated which medical schools produced the most neurosurgery residents currently in training, and the most important independent factors predicting the percentage of graduates entering neurosurgery and the preresidency h-index.

Open access

Jordan Xu, Gira Morchi, and Suresh N. Magge

BACKGROUND

Displacement of a distal catheter of a ventriculoatrial (VA) shunt is a rare complication and can lead to a challenging extraction requiring endovascular retrieval of the distal catheter.

OBSERVATIONS

The authors describe a patient in whom the distal catheter of the VA shunt had become displaced and traveled through the tricuspid valve into the right ventricular outflow tract.

LESSONS

In this case report, the authors present a multidisciplinary approach to retrieving a displaced distal catheter from a VA shunt.

Open access

Izumi Koyanagi, Yasuhiro Chiba, Hiroyuki Imamura, and Toshiya Osanai

BACKGROUND

Intradural radicular arteriovenous malformation (AVM) of the cauda equina is a rare entity of spinal AVMs. Because of the specific arterial supply of the conus medullaris and cauda equina, AVMs in this area sometimes present with confusing radiological features.

OBSERVATIONS

The authors reported a rare case of intradural radicular AVM arising from the lumbar posterior root. The patient presented with urinary symptoms with multiple flow void around the conus medullaris, as shown on magnetic resonance imaging. Digital subtraction angiography demonstrated arteriovenous shunt at the left side of the conus medullaris fed by the anterior spinal artery via anastomotic channel to the posterior spinal artery and rich perimedullary drainers. There was another arteriovenous shunt at the L3 level from the left L4 radicular artery. Preoperative diagnosis was perimedullary AVM with radicular arteriovenous fistula. Direct surgery with indocyanine green angiography revealed that the actual arteriovenous shunt was located at the left L4 posterior root. The AVM was successfully treated by coagulation of feeding branches.

LESSONS

Unilateral arteriovenous shunt fed by either posterior or anterior spinal artery at the conus medullaris may include AVM of the cauda equina despite abundant perimedullary venous drainage. Careful pre- and intraoperative diagnostic imaging is necessary for appropriate treatment.

Open access

Matthew A. Liu, Julian L. Gendreau, Joshua J. Loya, Nolan J. Brown, Amber Keith, Ronald Sahyouni, Mickey E. Abraham, David Gonda, and Michael L. Levy

BACKGROUND

Chordomas are rare malignant neoplasms that develop from the primitive notochord with < 5% of the tumors occurring in pediatric patients younger than the age of 20. Of these pediatric chordomas, those affecting the craniocervical junction (C1–C2) are even more rare; therefore, parameters for surgical management of these pediatric tumors are not well characterized.

OBSERVATIONS

In this case, a 3-year-old male was found to have a clival chordoma on imaging with extension to the craniocervical junction resulting in spinal cord compression. Endoscopic-assisted transoral transclival approach for clival tumor resection was performed first. As a second stage, the patient underwent a left-sided far lateral craniotomy and cervical laminectomy for resection of the skull base chordoma and instrumented fusion of the occiput to C3. He made excellent improvements in strength and dexterity during rehab and was discharged after 3 weeks.

LESSONS

In pediatric patients with chordoma with extension to the craniocervical junction and spinal cord compression, decompression with additional occipito-cervical fusion appears to offer a good clinical outcome. Fusion performed as a separate surgery before or at the same time as the initial tumor resection surgery may lead to better outcomes.

Open access

Florian Wilhelmy, Tim Wende, Johannes Kasper, Maxime Ablefoni, Lena Marie Bode, Jürgen Meixensberger, and Ulf Nestler

BACKGROUND

Posterior fossa epidural hematoma rarely occurs in children after traumatic head injury. There is ongoing discussion about appropriate treatment, yet the radiological features regarding the time to resorption of the hematoma or required follow-up imaging are rarely discussed.

OBSERVATIONS

The authors presented the case of a 3-year-old child who was under clinical observation and receiving analgetic and antiemetic treatment in whom near-complete hematoma resorption was shown by magnetic resonance imaging as soon as 60 hours after diagnosis. The child was neurologically stable at all times and showed no deficit after observational treatment. Hematoma resorption was much faster than expected. The authors discussed hematoma drainage via the sigmoid sinus.

LESSONS

Epidural hematomas in children can be treated conservatively and are resorbed in a timely manner.

Open access

Reilly L. Kidwell, Lauren E. Stone, Vanessa Goodwill, and Joseph D. Ciacci

BACKGROUND

Thoracic epidural capillary hemangioma is exceedingly rare, with only a few reported cases. The typical presentation usually includes chronic, progressive symptoms of spinal cord compression in middle-aged adults. To the authors’ knowledge, this case is the first report in the literature of acute traumatic capillary hemangioma rupture.

OBSERVATIONS

A 22-year-old male presented with worsening lower extremity weakness and paresthesias after a fall onto his spine. Imaging showed no evidence of spinal fracture but revealed an expanding hematoma over 24 hours. Removal of the lesion demonstrated a ruptured capillary hemangioma.

LESSONS

This unique case highlights a rare occurrence of traumatic rupture of a previously unknown asymptomatic thoracic capillary hemangioma in a young adult.