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Which supervised machine learning algorithm can best predict achievement of minimum clinically important difference in neck pain after surgery in patients with cervical myelopathy? A QOD study

Christine Park, Praveen V. Mummaneni, Oren N. Gottfried, Christopher I. Shaffrey, Anthony J. Tang, Erica F. Bisson, Anthony L. Asher, Domagoj Coric, Eric A. Potts, Kevin T. Foley, Michael Y. Wang, Kai-Ming Fu, Michael S. Virk, John J. Knightly, Scott Meyer, Paul Park, Cheerag Upadhyaya, Mark E. Shaffrey, Avery L. Buchholz, Luis M. Tumialán, Jay D. Turner, Brandon A. Sherrod, Nitin Agarwal, Dean Chou, Regis W. Haid Jr., Mohamad Bydon, and Andrew K. Chan

OBJECTIVE

The purpose of this study was to evaluate the performance of different supervised machine learning algorithms to predict achievement of minimum clinically important difference (MCID) in neck pain after surgery in patients with cervical spondylotic myelopathy (CSM).

METHODS

This was a retrospective analysis of the prospective Quality Outcomes Database CSM cohort. The data set was divided into an 80% training and a 20% test set. Various supervised learning algorithms (including logistic regression, support vector machine, decision tree, random forest, extra trees, gaussian naïve Bayes, k–nearest neighbors, multilayer perceptron, and extreme gradient boosted trees) were evaluated on their performance to predict achievement of MCID in neck pain at 3 and 24 months after surgery, given a set of predicting baseline features. Model performance was assessed with accuracy, F1 score, area under the receiver operating characteristic curve, precision, recall/sensitivity, and specificity.

RESULTS

In total, 535 patients (46.9%) achieved MCID for neck pain at 3 months and 569 patients (49.9%) achieved it at 24 months. In each follow-up cohort, 501 patients (93.6%) were satisfied at 3 months after surgery and 569 patients (100%) were satisfied at 24 months after surgery. Of the supervised machine learning algorithms tested, logistic regression demonstrated the best accuracy (3 months: 0.76 ± 0.031, 24 months: 0.773 ± 0.044), followed by F1 score (3 months: 0.759 ± 0.019, 24 months: 0.777 ± 0.039) and area under the receiver operating characteristic curve (3 months: 0.762 ± 0.027, 24 months: 0.773 ± 0.043) at predicting achievement of MCID for neck pain at both follow-up time points, with fair performance. The best precision was also demonstrated by logistic regression at 3 (0.724 ± 0.058) and 24 (0.780 ± 0.097) months. The best recall/sensitivity was demonstrated by multilayer perceptron at 3 months (0.841 ± 0.094) and by extra trees at 24 months (0.817 ± 0.115). Highest specificity was shown by support vector machine at 3 months (0.952 ± 0.013) and by logistic regression at 24 months (0.747 ± 0.18).

CONCLUSIONS

Appropriate selection of models for studies should be based on the strengths of each model and the aims of the studies. For maximally predicting true achievement of MCID in neck pain, of all the predictions in this balanced data set the appropriate metric for the authors’ study was precision. For both short- and long-term follow-ups, logistic regression demonstrated the highest precision of all models tested. Logistic regression performed consistently the best of all models tested and remains a powerful model for clinical classification tasks.

In Neurosurgical Focus Volume 54 (2023): Issue 6 (Jun 2023): Machine Learning in Neurosurgery

Open access

Contralateral lower limb radiculopathy by extraforaminal disc herniation following oblique lumbar interbody fusion in degenerative lumbar disorder: illustrative cases

Satoshi Hattori and Toru Maeda

BACKGROUND

Contralateral lower limb radiculopathy is a potential early complication of oblique lumbar interbody fusion (OLIF) in degenerative lumbar disorders. Among several pathologies related to contralateral radiculopathy following OLIF, extraforaminal disc herniation during the OLIF procedure is very rare.

OBSERVATIONS

Case 1 is a 68-year-old male underwent L4–5 and L5–6 OLIF for recurrent lumbar canal stenosis–expressed right leg pain and muscle weakness after surgery. Case 2 is a 76-year-old female on whom L4–5 OLIF was performed for L4 degenerative spondylolisthesis and who presented right leg pain and numbness postoperatively. In both patients, OLIF cages were inserted into the posterior part of the disc space or obliquely and the extraforaminal extruded disc compressed opposite exiting nerve roots (L5 root in case 1 and L4 root in case 2) as shown on magnetic resonance imaging (MRI). Surgical decompression with discectomy was required for pain relief and neurological improvement in both cases.

LESSONS

When emerging from new-onset opposite limb radiculopathy attributed to the OLIF procedure, extraforaminal disc herniation should be considered a potential pathology and MRI is useful for early diagnosis and selecting a subsequent management, including surgery.

In Journal of Neurosurgery: Case Lessons Volume 5 (2023): Issue 22 (May 2023)

Open access

Hemorrhagic cervical juxta-facet cyst presenting with Brown-Séquard syndrome: illustrative case

Shigeyoshi Shimura, Ryu Saito, Takashi Yagi, Hideyuki Yoshioka, and Hiroyuki Kinouchi

BACKGROUND

Intraspinal juxta-facet cysts of the spine are known to predominate at the lumbar level and is relatively rare at the cervical level. Most cervical spinal lesions are found incidentally, but they sometimes cause myelopathy or radiculopathy in a chronic course.

OBSERVATIONS

The authors present a rare case of hemorrhagic cervical juxta-facet cyst presenting with Brown-Séquard syndrome. An 86-year-old woman presented with acute-onset right hemiparesis following neck pain and was admitted to the local hospital. She was started on antithrombotic therapy with a suspected diagnosis of cerebral infarction, but quadriplegia progressed 2 days later. Cervical magnetic resonance imaging revealed an intraspinal mass at the C4–5 level and she was referred to the authors’ hospital. Her neurological findings on admission revealed right Brown-Séquard syndrome. In emergency surgery, the mass was resected with a posterior approach. Pathological findings showed hemosiderin deposition and fibroblast proliferation, consistent with a juxta-facet cyst with intracystic hemorrhage. The patient recovered well and returned to an independent daily life.

LESSONS

Rarely, juxta-facet cyst of the cervical spine can cause acute Brown-Séquard syndrome due to intraspinal hemorrhage. In a case of hemiparesis that develops following neck pain, hemorrhagic cervical juxta-facet cyst should be taken into consideration as a differentiation.

In Journal of Neurosurgery: Case Lessons Volume 5 (2023): Issue 22 (May 2023)

Open access

Pediatric internal auditory canal cavernous hemangioma with rapid progression of sensorineural hearing loss: illustrative case

Hiroshi Hyakusoku, Yoshihide Tanaka, Yusuke Tsuchiya, and Meijin Nakayama

BACKGROUND

Cavernous hemangioma of the internal auditory canal is extremely rare and is characterized by symptoms such as vertigo, sensorineural hearing loss, and facial nerve dysfunction.

OBSERVATIONS

A health examination on an 11-year-old female in the fifth grade revealed hearing loss in the left ear. She also had dizziness that had persisted for approximately 1 year. Pure-tone audiometry revealed sensorineural hearing loss in her left ear. Rightward horizontal and rotatory nystagmus was detected. Facial paralysis was not present. Magnetic resonance imaging showed a lesion that was suspected to be hemangioma. The authors selected a left suboccipital retrosigmoid approach. The tumor showed a berry-tufted appearance throughout the cerebellopontine angle. The seventh cranial nerve penetrated the tumor and partly circulated outside the tumor with marked adhesion. The authors partially resected the tumor to avoid damaging the facial nerve. A histological examination identified cavernous hemangioma.

LESSONS

The fundamental treatment for cavernous hemangioma of the internal auditory canal is complete surgical removal; however, any surgical intervention may result in hearing loss and facial paralysis. The extent of surgery needs to be decided intraoperatively based on the balance between preoperative symptoms and postoperative complications.

In Journal of Neurosurgery: Case Lessons Volume 5 (2023): Issue 22 (May 2023)

Open access

Superficial siderosis: comparison of two cases indicates two distinct diagnostic entities. Illustrative cases

Asha Krishnakumar, Ashwin Ghadiyaram, Vishal C. Patel, Charles F. Opalak, Neel Dixit, and William C. Broaddus

BACKGROUND

Superficial siderosis is the deposition of hemosiderin in the superficial layers of the central nervous system. It has been described in patients with chronic leakage of blood into the cerebrospinal fluid or with amyloid angiopathy, often associated with Alzheimer’s disease (AD).

OBSERVATIONS

We present two cases of superficial siderosis with vastly different symptomatologies and treatment courses. The patient in case 1 had diffuse superficial siderosis demonstrated on T2-weighted magnetic resonance imaging (MRI), appearing mostly in the inferior cerebellum and extending throughout the neuraxis. He presented with hearing loss, spasticity, gait abnormalities, and urinary incontinence. Ultimately, surgical exploration of the thoracic spinal dura revealed an arteriovenous fistula, which was obliterated. His clinical course stabilized but with persistent deficits. The patient in case 2 had a family history of AD and underwent MRI to evaluate for memory impairment, which demonstrated superficial siderosis of the left occipital lobe. Lumbar puncture demonstrated only traumatic contamination by red blood cells, but tau protein analysis was consistent with the diagnosis of AD.

LESSONS

Superficial siderosis is a diagnostic term prompted by findings on MRI that can arise due to two different pathological entities. The diagnosis in case 1 should be termed diffuse superficial siderosis and in case 2 should be termed lobar cortical siderosis.

In Journal of Neurosurgery: Case Lessons Volume 5 (2023): Issue 22 (May 2023)

Open access

Uniportal full endoscopic spinous process–preserving laminectomy for bilateral decompression in cervical stenotic myelopathy: patient series

Hyun-Jin Ma, Sang-Ho Lee, and Chan Hong Park

BACKGROUND

Endoscopic decompression for cervical stenotic myelopathy has several advantages over conventional open surgery. However, sometimes performing bilateral decompression, especially contralateral decompression, can be dangerous. The cervical spine has specific characteristics, including a shallower lamina angle and thinner lamina than the lumbar or thoracic lamina. These characteristics may cause cord compression when instruments approach the contralateral side of the lamina. This article introduces a novel surgical technique that can overcome the specificities of the cervical spine and discusses the efficacy and safety of uniportal full endoscopy for cervical decompression.

OBSERVATIONS

Fourteen patients underwent uniportal full endoscopic spinous process–preserving laminectomy (ESP-L) for bilateral decompression of multilevel cervical stenotic myelopathy. The mean follow-up period was 13.44 months (range: 4–17 months). The preoperative and postoperative cervical spine angle and cervical range of motion did not differ significantly. The Japanese Orthopaedic Association score significantly improved postoperatively. The numeric rating scale scores significantly improved postoperatively. The mean duration of postoperative hospitalization was 2.3 days.

LESSONS

ESP-L is a new, safe, effective, and noninvasive technique that can achieve complete decompression of multilevel cervical stenotic myelopathy.

In Journal of Neurosurgery: Case Lessons Volume 5 (2023): Issue 22 (May 2023)

Open access

Vasospasm secondary to responsive neurostimulator placement: a previously unreported complication. Illustrative case

Brandon Rogowski, Aaron Miller, Brian F. Saway, Jeffrey Wessell, Nathan C. Rowland, Jonathan Ross Lena, and William A. Vandergrift

BACKGROUND

The Responsive Neurostimulation (RNS) system is an implantable device for patients with drug-resistant epilepsy who are not candidates for resection of a seizure focus. As a relatively new therapeutic, the full spectrum of adverse effects has yet to be determined. A literature review revealed no previous reports of cerebral vasospasm following RNS implantation.

OBSERVATIONS

A 35-year-old man developed severe angiographic and clinical vasospasm following bilateral mesial temporal lobe RNS implantation. He initially presented with concerns for status epilepticus 8 days after implantation. On hospital day 3, a decline in his clinical examination prompted imaging studies that revealed a left middle cerebral artery (MCA) stroke with angiographic evidence of severe vasospasm of the left internal carotid artery (ICA), MCA, anterior cerebral artery (ACA), and right ICA and ACA. Despite improvements in angiographic vasospasm after appropriate treatment, a thrombus developed in the posterior M2 branch, requiring mechanical thrombectomy. Ultimately, the patient was stabilized and discharged to a rehabilitation facility with residual cognitive and motor deficits.

LESSONS

Cerebral vasospasm as a cause of ischemic stroke after uneventful RNS implantation is exceedingly rare, yet demands particular attention given the potential for severe consequences and the growing number of patients receiving RNS devices.

In Journal of Neurosurgery: Case Lessons Volume 5 (2023): Issue 22 (May 2023)

Open access

"Are we recording this?" Surgeons deserve next-generation analytics

Dhiraj J. Pangal and Daniel A. Donoho

In Journal of Neurosurgery Publish Before Print

Restricted access

Association of upper-limb neurological recovery with functional outcomes in high cervical spinal cord injury

Saad Javeed, Jacob K. Greenberg, Justin K. Zhang, Benjamin Plog, Christopher F. Dibble, Braeden Benedict, Kathleen Botterbush, Jawad M. Khalifeh, Huacong Wen, Yuying Chen, Yikyung Park, Allan J. Belzberg, Sami Tuffaha, Stephen S. Burks, Allan D. Levi, Eric L. Zager, Amir H. Faraji, Mark A. Mahan, Rajiv Midha, Thomas J. Wilson, Neringa Juknis, and Wilson Z. Ray

OBJECTIVE

High cervical spinal cord injury (SCI) results in complete loss of upper-limb function, resulting in debilitating tetraplegia and permanent disability. Spontaneous motor recovery occurs to varying degrees in some patients, particularly in the 1st year postinjury. However, the impact of this upper-limb motor recovery on long-term functional outcomes remains unknown. The objective of this study was to characterize the impact of upper-limb motor recovery on the degree of long-term functional outcomes in order to inform priorities for research interventions that restore upper-limb function in patients with high cervical SCI.

METHODS

A prospective cohort of high cervical SCI (C1–4) patients with American Spinal Injury Association Impairment Scale (AIS) grade A–D injury and enrolled in the Spinal Cord Injury Model Systems Database was included. Baseline neurological examinations and functional independence measures (FIMs) in feeding, bladder management, and transfers (bed/wheelchair/chair) were evaluated. Independence was defined as score ≥ 4 in each of the FIM domains at 1-year follow-up. At 1-year follow-up, functional independence was compared among patients who gained recovery (motor grade ≥ 3) in elbow flexors (C5), wrist extensors (C6), elbow extensors (C7), and finger flexors (C8). Multivariable logistic regression evaluated the impact of motor recovery on functional independence in feeding, bladder management, and transfers.

RESULTS

Between 1992 and 2016, 405 high cervical SCI patients were included. At baseline, 97% of patients had impaired upper-limb function with total dependence in eating, bladder management, and transfers. At 1 year of follow-up, the largest proportion of patients who gained independence in eating, bladder management, and transfers had recovery in finger flexion (C8) and wrist extension (C6). Elbow flexion (C5) recovery had the lowest translation to functional independence. Patients who achieved elbow extension (C7) were able to transfer independently. On multivariable analysis, patients who gained elbow extension (C7) and finger flexion (C8) were 11 times more likely to gain functional independence (OR 11, 95% CI 2.8–47, p < 0.001) and patients who gained wrist extension (C6) were 7 times more likely to gain functional independence (OR 7.1, 95% CI 1.2–56, p = 0.04). Older age (≥ 60 years) and motor complete SCI (AIS grade A–B) reduced the likelihood of gaining independence.

CONCLUSIONS

After high cervical SCI, patients who gained elbow extension (C7) and finger flexion (C8) had significantly greater independence in feeding, bladder management, and transfers than those with recovery in elbow flexion (C5) and wrist extension (C6). Recovery of elbow extension (C7) also increased the capability for independent transfers. This information can be used to set patient expectations and prioritize interventions that restore these upper-limb functions in patients with high cervical SCI.

In Journal of Neurosurgery: Spine Publish Before Print

Restricted access

Changes in the epidemiology of pediatric sinogenic and otogenic intracranial infections during the COVID-19 pandemic: a single-institution study

Sophia J. Angelo, Megan G. Anderson, Pearl A. Sutter, Patrick J. Halloran, Katherine R. Kavanagh, Mitch R. Paro, Jonathan E. Martin, Markus J. Bookland, Ian C. Michelow, and David S. Hersh

OBJECTIVE

Focal intracranial infections (epidural abscesses, subdural empyemas, and intraparenchymal abscesses) are uncommon complications of sinusitis and otitis media but can be associated with significant morbidity. Treatment typically requires neurosurgical and otolaryngological interventions in combination with antibiotic treatment. Historically, children have presented to the authors’ pediatric referral center with sinusitis- or otitis media–related intracranial infections in low numbers. However, since the onset of the COVID-19 pandemic, the incidence of intracranial pyogenic complications has increased at this center. The objective of this study was to compare the epidemiology, severity, microbial causes, and management of pediatric sinusitis- and otitis–related intracranial infections in the periods before and during the COVID-19 pandemic.

METHODS

All patients 21 years of age or younger who presented with an intracranial infection in the setting of sinusitis or otitis media and who underwent neurosurgical treatment at Connecticut Children’s from January 2012 to December 2022 were retrospectively reviewed. Demographic, clinical, laboratory, and radiological data were systematically collated, and variables before and during COVID-19 were compared statistically.

RESULTS

Overall, 18 patients were treated for sinusitis-related (n = 16) or otitis media–related (n = 2) intracranial infections during the study period. Ten patients (56%) presented from January 2012 to February 2020, none from March 2020 to June 2021, and 8 (44%) from July 2021 to December 2022. There were no significant demographic differences between the pre-COVID-19 and COVID-19 cohorts. The 10 patients in the pre-COVID-19 cohort underwent a total of 15 neurosurgical and 10 otolaryngological procedures, while the 8 patients in the COVID-19 cohort underwent a total of 12 neurosurgical and 10 otolaryngological procedures. Surgically obtained wound cultures yielded a variety of organisms; Streptococcus constellatus/S. anginosus/S. intermedius were more prevalent in the COVID-19 cohort (87.5% vs 0%, p < 0.001) as was Parvimonas micra (62.5% vs 0%, p = 0.007).

CONCLUSIONS

At an institutional level, there has been an approximately threefold increase in cases of sinusitis- and otitis media–related intracranial infections during the COVID-19 pandemic. Multicenter studies are needed to confirm this observation and to investigate whether the mechanisms of infection are related directly to SARS-CoV-2, changes in the respiratory flora, or delayed care. The next steps will include expansion of this study to other pediatric centers throughout the United States and Canada.

In Journal of Neurosurgery: Pediatrics Publish Before Print