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## A broad and variable lumbosacral myotome map uncovered by foraminal nerve root stimulation

### OBJECTIVE

The human myotome is fundamental to the diagnosis and treatment of neurological disorders. However, this map was largely constructed decades ago, and its breadth, variability, and reliability remain poorly described, limiting its practical use.

### METHODS

The authors used a novel method to reconstruct the myotome map in patients (n = 42) undergoing placement of dorsal root ganglion electrodes for the treatment of chronic pain. They electrically stimulated nerve roots (n = 79) in the intervertebral foramina at T12–S1 and measured triggered electromyography responses.

### RESULTS

L4 and L5 stimulation resulted in quadriceps muscle (62% and 33% of stimulations, respectively) and tibialis anterior (TA) muscle (25% and 67%, respectively) activation, while S1 stimulation resulted in gastrocnemius muscle activation (46%). However, L5 and S1 both resulted in abductor hallucis (AH) muscle activation (17% and 31%), L5 stimulation resulted in gastrocnemius muscle stimulation (42%), and S1 stimulation in TA muscle activation (38%). The authors also mapped the breadth of the myotome in individual patients, finding coactivation of adductor and quadriceps, quadriceps and TA, and TA and gastrocnemius muscles under L3, L4, and both L5 and S1 stimulation, respectively. While the AH muscle was commonly activated by S1 stimulation, this rarely occurred together with TA or gastrocnemius muscle activation. Other less common coactivations were also observed throughout T12–S1 stimulation.

### CONCLUSIONS

The muscular innervation of the lumbosacral nerve roots varies significantly from the classic myotome map and between patients. Furthermore, in individual patients, each nerve root may innervate a broader range of muscles than is commonly assumed. This finding is important to prevent misdiagnosis of radicular pathologies.

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## Dr. Ruth Jackson: the legacy of the first female spine surgeon

Dr. Ruth Jackson, born in 1902, was the first female spine surgeon on record. Her story of remarkable resilience and sacrifice is even more relevant given the stark gender disparities in orthopedic surgery and neurosurgery that remain today. Dr. Jackson entered the field during the Great Depression and overcame significant barriers at each step along the process. In 1937, she became the first woman to pass the American Board of Orthopedic Surgery examination and join the American Academy of Orthopedic Surgeons as a full member. Her work in the cervical spine led to a notable lecture record and the publication of several articles, as well as a book, The Cervical Syndrome, in which she discussed the anatomy, etiology, and treatment of cervical pathologies. Additionally, Dr. Jackson developed the Jackson CerviPillo, a neck support that is still in use today. She left a legacy that continues to resonate through the work of the Ruth Jackson Orthopedic Society, which supports women at all levels of practice and training. From the story of Dr. Jackson’s life, we can appreciate her single-minded determination that blazed a path for women in spine surgery, as well as consider the progress that remains to be made.

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## Erratum. A survival analysis of ventricular access devices for delivery of cerliponase alfa

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## Evaluating caregiver stress in craniosynostosis patients

### OBJECTIVE

Caregiver stress from a child’s diagnosis can impact a caregiver’s ability to participate in treatment decisions, comply, and manage long-term illness. The aim of this study was to compare caregiver stress in children with craniosynostosis at diagnosis and postoperatively.

### METHODS

This prospective study included caregivers of pediatric patients with craniosynostosis receiving operative intervention. Demographics and Parenting Stress Index, Short Form (PSI-SF) and Pediatric Inventory for Parents (PIP) surveys at baseline (preoperatively) and 3 and 6 months postoperatively were completed. PSI-SF scores between 15 and 80 are considered normal, with > 85 being clinically significant and requiring follow-up. Higher PIP scores represent increased frequency and difficulty of stressful events due to the child’s illness. Pairwise comparisons were performed using the Wilcoxon signed-rank test. Multivariate analysis was performed to assess for PSI-SF and PIP predictors.

### RESULTS

Of 106 caregivers (84% Caucasian), there were 62 mothers and 40 fathers. There were 68 and 45 responses at 3 and 6 months postoperatively, respectively. Regarding the baseline group, more than 80% were between 20 and 40 years of age and 58% had less than 2 years of college education. The median household income fell in the $45,001–$60,000 bracket. There was no significant difference between median baseline PSI-SF score (65, IQR 51–80) and those at 3 months (p = 0.45) and 6 months (p = 0.82) postoperatively. Both median PIP frequency (89 vs 74, p < 0.01) and difficulty (79 vs 71, p < 0.01) scores were lower at 3 months, although no significant difference was observed at 6 months (frequency: 95 vs 91, p = 0.67; difficulty: 82 vs 80, p = 0.34). Female sex, uninsured status, and open surgery type were all risk factors for higher parental stress.

### CONCLUSIONS

Stress levels ranged from normal to clinically significant in the caregivers, with sex, uninsured status, and open repair predicting higher stress. Stress decreased at 3 months postoperatively before increasing at 6 months. Intervention targeting caregiver stress should be explored to maintain lower stress observed at 3 months after surgery.

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## High intratumoral susceptibility signal grade on susceptibility-weighted imaging: a risk factor for hemorrhage after stereotactic biopsy

### OBJECTIVE

This study aimed to examine the association of preoperative intratumoral susceptibility signal (ITSS) grade with hemorrhage after stereotactic biopsy (STB).

### METHODS

The authors retrospectively reviewed 66 patients who underwent STB in their institution. Preoperative factors including age, sex, platelet count, prothrombin time–international normalized ratio, activated thromboplastin time, antiplatelet agent use, history of diabetes mellitus and hypertension, target location, anesthesia type, and ITSS data were recorded. ITSS was defined as a dot-like or fine linear low signal within a tumor on susceptibility-weighted imaging (SWI) and was graded using a 3-point scale: grade 1, no ITSS within the lesion; grade 2, 1–10 ITSSs; and grade 3, ≥ 11 ITSSs. Postoperative final tumor pathology was also reviewed. The association between preoperative variables and the size of postoperative hemorrhage was examined.

### CONCLUSIONS

ITSS grade on SWI is associated with size of postoperative hemorrhage after STB.

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## Long-term functional independence after minimally invasive endoscopic intracerebral hemorrhage evacuation

### OBJECTIVE

Intracerebral hemorrhage (ICH) is a devastating form of stroke with no proven treatment. However, minimally invasive endoscopic evacuation is a promising potential therapeutic option for ICH. Herein, the authors examine factors associated with long-term functional independence (modified Rankin Scale [mRS] score ≤ 2) in patients with spontaneous ICH who underwent minimally invasive endoscopic evacuation.

### METHODS

Patients with spontaneous supratentorial ICH who had presented to a large urban healthcare system from December 2015 to October 2018 were triaged to a central hospital for minimally invasive endoscopic evacuation. Inclusion criteria for this study included age ≥ 18 years, hematoma volume ≥ 15 ml, National Institutes of Health Stroke Scale (NIHSS) score ≥ 6, premorbid mRS score ≤ 3, and time from ictus ≤ 72 hours. Demographic, clinical, and radiographic factors previously shown to impact functional outcome in ICH were included in a retrospective univariate analysis with patients dichotomized into independent (mRS score ≤ 2) and dependent (mRS score ≥ 3) outcome groups, according to 6-month mRS scores. Factors that reached a threshold of p < 0.05 in a univariate analysis were included in a multivariate logistic regression.

### RESULTS

A total of 90 patients met the study inclusion criteria. The median preoperative hematoma volume was 41 (IQR 27–65) ml and the median postoperative volume was 1.2 (0.3–7.5) ml, resulting in a median evacuation percentage of 97% (85%–99%). The median hospital length of stay was 17 (IQR 9–25) days, and 8 (9%) patients died within 30 days of surgery. Twenty-four (27%) patients had attained functional independence by 6 months. Factors independently associated with long-term functional independence included lower NIHSS score at presentation (OR per point 0.78, 95% CI 0.67–0.91, p = 0.002), lack of intraventricular hemorrhage (IVH; OR 0.20, 95% CI 0.05–0.77, p = 0.02), and shorter time to evacuation (OR per hour 0.95, 95% CI 0.91–0.99, p = 0.007). Specifically, patients who had undergone evacuation within 24 hours of ictus demonstrated an mRS score ≤ 2 rate of 36% and were associated with an increased likelihood of long-term independence (OR 17.7, 95% CI 1.90–164, p = 0.01) as compared to those who had undergone evacuation after 48 hours.

### CONCLUSIONS

In a single-center minimally invasive endoscopic ICH evacuation cohort, NIHSS score on presentation, lack of IVH, and shorter time to evacuation were independently associated with functional independence at 6 months. Factors associated with functional independence may help to better predict populations suitable for minimally invasive endoscopic evacuation and guide protocols for future clinical trials.

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## Not a trifecta: complementary use of carotid artery revascularization techniques in the era of hybrid neurosurgery

### OBJECTIVE

Carotid stenosis is currently treated by carotid endarterectomy (CEA), carotid artery stenting (CAS), or transcarotid artery revascularization (TCAR). This study sought to add to the literature by providing real-world data comparing the safety and effectiveness associated with the performance of these carotid revascularization techniques by dual-trained neurosurgeons.

### METHODS

The authors performed a retrospective review of carotid stenosis databases at two US centers. Patients treated by CEA, transfemoral CAS, or TCAR for atherosclerotic carotid artery disease were included. Clinical outcomes were compared at 30 days after the procedure.

### RESULTS

Seven hundred eighty patients were included (583 with CAS, 165 with CEA, and 32 with TCAR). Overall, 486 patients (62.3%) were men, and 393 (50.4%) had left-sided carotid stenosis. Most patients (n = 617, 79.1%) had symptomatic disease. Among the three treatment groups, there were no statistically significant differences with respect to 30-day ischemic events (CAS 3.8%, CEA 1.8%, TCAR 6.3%; p = 0.267) or 30-day mortality rates (CAS 3.6%, CEA 2.4%, TCAR 3.1%; p = 0.857). Male sex had significantly lower odds of 30-day transient ischemic attack (TIA) or stroke in both univariable (p = 0.024) and multivariable (p = 0.023) regression models. Increasing age had significantly higher odds of 30-day mortality on univariable (p = 0.006) and multivariable (p = 0.003) regression. Patients with the occurrence of 30-day TIA or stroke also had significantly higher odds of 30-day mortality on univariable (p < 0.001) and multivariable (p < 0.001) regression.

### CONCLUSIONS

This real-world experience reflects the current practice of hybrid neurosurgery at two high-volume tertiary care centers and suggests that all three treatment modalities have comparable safety and effectiveness if patients are properly selected.

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## Novel MRI-based vertebral bone quality score as a predictor of cage subsidence following transforaminal lumbar interbody fusion

### OBJECTIVE

Decreased bone mineral density as measured by dual-energy x-ray absorptiometry (DEXA) has been reported to be associated with cage subsidence following transforaminal lumbar interbody fusion (TLIF). However, DEXA is not often available or routinely performed before surgery. A novel MRI-based vertebral bone quality (VBQ) score has been developed and reported to be correlated with DEXA T-scores. The authors investigated the ability of the VBQ score to predict cage subsidence and other risk factors associated with this complication.

### METHODS

In this retrospective study, the authors reviewed the records of patients who had undergone single-level TLIF from March 2014 to October 2015 and had a follow-up of more than 2 years. Cage subsidence was measured as postoperative disc height loss and was graded according to the system proposed by Marchi et al. The MRI-based VBQ score was measured on T1-weighted images. Univariable analysis and multivariable binary logistic regression analysis were performed. Ad hoc analysis with receiver operating characteristic curve analysis was performed to assess the predictive ability of the significant continuous variables. Additional analyses were used to determine the correlations between the VBQ score and T-scores and between the significant continuous variables and the amount of cage subsidence.

### RESULTS

Among 242 patients eligible for study inclusion, 111 (45.87%) had cage subsidence after the index operation. Multivariable logistic regression analyses demonstrated that an increased VBQ score (OR 14.615 ± 0.377, p < 0.001), decreased depth ratio (OR 0.011 ± 1.796, p = 0.013), and the use of kidney-shaped cages instead of bullet-shaped cages (OR 2.766 ± 0.358, p = 0.008) were associated with increased cage subsidence. The VBQ score was shown to significantly predict cage subsidence with an accuracy of 85.6%. The VBQ score was found to be moderately correlated with DEXA T-scores of the total hip (r = −0.540, p < 0.001) and the lumbar spine (r = −0.546, p < 0.001). The amount of cage subsidence was moderately correlated with the VBQ score (r = 0.512, p < 0.001).

### CONCLUSIONS

Increased VBQ scores, posteriorly placed cages, and kidney-shaped cages were risk factors for cage subsidence. The VBQ score was shown to be a good predictor of cage subsidence, was moderately correlated with DEXA T-scores for the total hip and lumbar spine, and also had a moderate correlation with the amount of cage subsidence.

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## Surgical morbidity of the extradural anterior petrosal approach: the Lariboisière experience

### OBJECTIVE

Concerns about the approach-related morbidity of the extradural anterior petrosal approach (EAPA) have been raised, especially regarding temporal lobe and venous injuries, hearing impairment, facial nerve palsy, cerebrospinal fluid fistula, and seizures. There is lack in the literature of studies with detailed analysis of surgical complications. The authors have presented a large series of patients who were treated with EAPA, focusing on complications and their avoidance.

### METHODS

The authors carried out a retrospective review of patients who underwent EAPA at their institution between 2012 and 2021. They collected preoperative clinical characteristics, operative reports, operative videos, findings on neuroimaging, histological diagnosis, postoperative course, and clinical status at last follow-up. For pathologies without petrous bone invasion, the amount of petrous apex drilling was calculated and classified as low (< 70% of the volume) or high (≥ 70%). Complications were dichotomized as approach related and resection related.

### RESULTS

This study included 49 patients: 26 with meningiomas, 10 brainstem cavernomas, 4 chondrosarcomas, 4 chordomas, 2 schwannomas, 1 epidermoid cyst, 1 cholesterol granuloma, and 1 osteoblastoma. The most common approach-related complications were temporal lobe injury (6.1% of patients), seizures (6.1%), pseudomeningocele (6.1%), hearing impairment (4.1%), and dry eye (4.1%). Approach-related complications occurred most commonly in patients with a meningioma (p = 0.02) and Meckel’s cave invasion (p = 0.02). Gross-total or near-total resection was correlated with a higher rate of tumor resection–related complications (p = 0.02) but not approach-related complications (p = 0.76). Inferior, lateral, and superior tumoral extension were not correlated with a higher rate of tumor resection–related complications. No correlation was found between high amount of petrous bone drilling and approach- or resection-related complications.

### CONCLUSIONS

EAPA is a challenging approach that deals with critical neurovascular structures and demands specific skills to be safely performed. Contrary to general belief, its approach-related morbidity seems to be acceptable at dedicated skull base centers. Morbidity can be lowered with careful examination of the preoperative neuroradiological workup, appropriate patient selection, and attention to technical details.

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## Anterior cranial fossa osseous arteriovenous fistula of the crista galli with bone erosion: patient series

### BACKGROUND

Although an anterior cranial fossa dural arteriovenous fistula (ACFdAVF) is thought to have a fistula on the dura near the olfactory groove, the detailed angioarchitecture remains unreported.

### OBSERVATIONS

In case 1, a 65-year-old man was found to have an asymptomatic ACFAVF. His computed tomography angiography (CTA)-maximum intensity projection (MIP) showed the shunt point in the crista galli (CG), with the intradural drainer penetrating the destroyed bone of the CG. In case 2, a 78-year-old man had a past history of intracerebral hemorrhage and was found to have an ACFAVF. The rotational angiography (RA)-MIP showed the intraosseous fistula in the CG with the drainer passing through a tiny bone defect of the CG. In case 3, a 35-year-old man was investigated for epilepsy. The RA-MIP showed an osseous arteriovenous fistula (AVF) in the anterior cranial base, with the drainer penetrating the skull osteolytic site. In case 4, a 73-year-old woman was found to have an asymptomatic ACFAVF. Her RA-MIP showed the osseous AVF with the drainer penetrating the CG with bone erosion.

### LESSSONS

All patients were diagnosed with anterior cranial fossa osseous AVF rather than dAVF, with bone erosion in the CG. These findings should be noted at the time of diagnosis and treatment.