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Risheng Xu, Joshua Materi, Divyaansh Raj, Safwan Alomari, Yuanxuan Xia, Sumil K. Nair, Pavan P. Shah, Nivedha Kannapadi, Timothy Kim, Judy Huang, Chetan Bettegowda, and Michael Lim

OBJECTIVE

Internal neurolysis (IN) and intraoperative glycerin rhizotomy (ioGR) are emerging surgical options for patients with trigeminal neuralgia without neurovascular contact. The objective of this study was to compare the neurological outcomes of patients who underwent IN with those of patients who underwent ioGR.

METHODS

The authors retrospectively reviewed all patients who underwent IN or ioGR for trigeminal neuralgia at our institution. Patient demographic characteristics and immediate postoperative outcomes, as well as long-term neurological outcomes, were compared.

RESULTS

Of 1044 patients who underwent open surgical treatment for trigeminal neuralgia, 56 patients underwent IN and 91 underwent ioGR. Of these 147 patients, 37 had no evidence of intraoperative neurovascular conflict. All patients who underwent IN and 96.7% of patients who underwent ioGR had immediate postoperative pain relief. At last follow-up, patients who underwent IN had lower Barrow Neurological Institute (BNI) pain intensity scores (p = 0.05), better BNI facial numbness scores (p < 0.01), and a greater degree of pain improvement (p = 0.05) compared with those who underwent ioGR. Patients who underwent IN also had significantly lower rates of symptomatic pain recurrence (p < 0.01) at last follow-up over an average of 9.5 months.

CONCLUSIONS

IN appears to provide patients with a greater degree of pain relief, lower rates of facial numbness, and lower rates of pain recurrence compared with ioGR. Future prospective studies will better characterize long-term pain recurrence and outcomes.

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Langston T. Holly, William W. Ashley Jr., Edjah K. Nduom, Brenton Pennicooke, Caple A. Spence, and Babu G. Welch

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Adriana Vázquez-Medina, Grazia Diano, Manthia A. Papageorgakopoulou, and Andrea Otamendi-Lopez

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Alexander Ramos, Joseph A. Carnevale, Kashif Majeed, Gary Kocharian, Ibrahim Hussain, Jacob L. Goldberg, Justin Schwarz, David I. Kutler, Jared Knopman, and Philip Stieg

OBJECTIVE

Carotid body tumors (CBTs) are rare, slow-growing neoplasms derived from the parasympathetic paraganglia of the carotid bodies. Although inherently vascular lesions, the role of preoperative embolization prior to resection remains controversial. In this report, the authors describe an institutional series of patients with CBT successfully treated via resection following preoperative embolization and compare the results in this series to previously reported outcomes in the treatment of CBT.

METHODS

All CBTs resected between 2013 and 2019 at a single institution were retrospectively identified. All patients had undergone preoperative embolization performed by interventional neuroradiologists, and all had been operated on by a combined team of cerebrovascular neurosurgeons and otolaryngology–head and neck surgeons. The clinical, radiographic, endovascular, and perioperative data were collected. All procedural complications were recorded.

RESULTS

Among 22 patients with CBT, 63.6% were female and the median age was 55.5 years at the time of surgery. The most common presenting symptoms included a palpable neck mass (59.1%) and voice changes (22.7%). The average tumor volume was 15.01 ± 14.41 cm3. Most of the CBTs were Shamblin group 2 (95.5%). Blood was predominantly supplied from branches of the ascending pharyngeal artery, with an average of 2 vascular pedicles (range 1–4). Fifty percent of the tumors were embolized with more than one material: polyvinyl alcohol, 95.5%; Onyx, 50.0%; and N-butyl cyanoacrylate glue, 9.1%. The average reduction in tumor blush following embolization was 83% (range 40%–95%). No embolization procedural complications occurred. All resections were performed within 30 hours of embolization. The average operative time was 173.9 minutes, average estimated blood loss was 151.8 ml, and median length of hospital stay was 4 days. The rate of permanent postoperative complications was 0%; 2 patients experienced transient hoarseness, and 1 patient had medical complications related to alcohol withdrawal.

CONCLUSIONS

This series reveals that endovascular embolization of CBT is a safe and effective technique for tumor devascularization, making preoperative angiography and embolization an important consideration in the management of CBT. Moreover, the successful management of CBT at the authors’ institution rests on a multidisciplinary approach whereby endovascular surgeons, neurosurgeons, and ear, nose, and throat–head and neck surgeons work together to optimally manage each patient with CBT.

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Andy Y. Wang, Vaishnavi Sharma, Wenya Linda Bi, William T. Curry, Jeffrey E. Florman, Michael W. Groff, Carl B. Heilman, Jennifer Hong, James Kryzanski, S. Scott Lollis, Gerald T. McGillicuddy, Jennifer Moliterno, Christopher S. Ogilvy, Dennis S. Oh, Adetokunbo A. Oyelese, Mark R. Proctor, Perry A. Shear, Andrew E. Wakefield, Robert G. Whitmore, and Ron I. Riesenburger

The New England Neurosurgical Society (NENS) was founded in 1951 under the leadership of its first President (Dr. William Beecher Scoville) and Secretary-Treasurer (Dr. Henry Thomas Ballantine). The purpose of creating the NENS was to unite local neurosurgeons in the New England area; it was one of the first regional neurosurgical societies in America. Although regional neurosurgical societies are important supplements to national organizations, they have often been overshadowed in the available literature. Now in its 70th year, the NENS continues to serve as a platform to represent the needs of New England neurosurgeons, foster connections and networks with colleagues, and provide research and educational opportunities for trainees. Additionally, regional societies enable discussion of issues uniquely relevant to the region, improve referral patterns, and allow for easier attendance with geographic proximity. In this paper, the authors describe the history of the NENS and provide a roadmap for its future. The first section portrays the founders who led the first meetings and establishment of the NENS. The second section describes the early years of the NENS and profiles key leaders. The third section discusses subsequent neurosurgeons who steered the NENS and partnerships with other societies. In the fourth section, the modern era of the NENS and its current activities are highlighted.

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James Mooney, Giorgos D. Michalopoulos, Daniel Zeitouni, Sally El Sammak, Mohammed Ali Alvi, Michael Y. Wang, Domagoj Coric, Andrew K. Chan, Praveen V. Mummaneni, Erica F. Bisson, Brandon Sherrod, Regis W. Haid Jr., John J. Knightly, Clinton J. Devin, Brenton H. Pennicooke, Anthony L. Asher, and Mohamad Bydon

OBJECTIVE

Spine surgery represents an ideal target for healthcare cost reduction efforts, with outpatient surgery resulting in significant cost savings. With an increased focus on value-based healthcare delivery, lumbar decompression surgery has been increasingly performed in the outpatient setting when appropriate. The aim of this study was to compare clinical and patient-reported outcomes following outpatient and inpatient lumbar decompression surgery.

METHODS

The Quality Outcomes Database (QOD) was queried for patients undergoing elective one- or two-level lumbar decompression (laminectomy or laminotomy with or without discectomy) for degenerative spine disease. Patients were grouped as outpatient if they had a length of stay (LOS) < 24 hours and as inpatient if they stayed in the hospital ≥ 24 hours. Patients with ≥ 72-hour stay were excluded from the comparative analysis to increase baseline comparability between the two groups. To create two highly homogeneous groups, optimal matching was performed at a 1:1 ratio between the two groups on 38 baseline variables, including demographics, comorbidities, symptoms, patient-reported scores, indications, and operative details. Outcomes of interest were readmissions and reoperations at 30 days and 3 months after surgery, overall satisfaction, and decrease in Oswestry Disability Index (ODI), back pain, and leg pain at 3 months after surgery. Satisfaction was defined as a score of 1 or 2 in the North American Spine Society patient satisfaction index. Noninferiority of outpatient compared with inpatient surgery was defined as risk difference of < 1.5% at a one-sided 97.5% confidence interval.

RESULTS

A total of 18,689 eligible one- and two-level decompression surgeries were identified. The matched study cohorts consisted of 5016 patients in each group. Nonroutine discharge was slightly less common in the outpatient group (0.6% vs 0.3%, p = 0.01). The 30-day readmission rates were 4.4% and 4.3% for the outpatient and inpatient groups, respectively, while the 30-day reoperation rates were 1.4% and 1.5%. The 3-month readmission rates were 6.3% for both groups, and the 3-month reoperation rates were 3.1% for the outpatient cases and 2.9% for the inpatient cases. Overall satisfaction at 3 months was 88.8% for the outpatient group and 88.4% for the inpatient group. Noninferiority of outpatient surgery was documented for readmissions, reoperations, and patient-reported satisfaction from surgery.

CONCLUSIONS

Outpatient lumbar decompression surgery demonstrated slightly lower nonroutine discharge rates in comparison with inpatient surgery. Noninferiority in clinical outcomes at 30 days and 3 months after surgery was documented for outpatient compared with inpatient decompression surgery. Additionally, outpatient decompression surgery performed noninferiorly to inpatient surgery in achieving patient satisfaction from surgery.

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Annick Kronenburg, Pieter T. Deckers, Esther van den Berg, Monique M. van Schooneveld, Evert-Jan Vonken, Albert van der Zwan, Bart N. M. van Berckel, Maqsood Yaqub, Willem Otte, Catharina J. M. Klijn, and Kees P. J. Braun

OBJECTIVE

Patients with moyamoya vasculopathy often experience cognitive impairments. In this prospective single-center study, the authors investigated the profile of neurocognitive impairment and its relation with the severity of ischemic brain lesions and hemodynamic compromise.

METHODS

Patients treated in a Dutch tertiary referral center were prospectively included. All patients underwent standardized neuropsychological evaluation, MRI, digital subtraction angiography, and [O]H2O-PET (to measure cerebrovascular reactivity [CVR]). The authors determined z-scores for 7 cognitive domains and the proportion of patients with cognitive impairment (z-score < −1.5 SD in at least one domain). The authors explored associations between patient characteristics, imaging and CVR findings, and cognitive scores per domain by using multivariable linear regression and Bayesian regression analysis.

RESULTS

A total of 40 patients (22 children; 75% females) were included. The median age for children was 9 years (range 1–16 years); for adults it was 39 years (range 19–53 years). Thirty patients (75%) had an infarction, and 31 patients (78%) had impaired CVR (steal phenomenon). Six of 7 cognitive domains scored below the population norm. Twenty-nine patients (73%) had cognitive impairment. Adults performed better than children in the cognitive domain visuospatial functioning (p = 0.033, Bayes factor = 4.0), and children performed better in processing speed (p = 0.041, Bayes factor = 3.5). The authors did not find an association between infarction, white matter disease, or CVR and cognitive domains.

CONCLUSIONS

In this Western cohort, cognitive functioning in patients with moyamoya vasculopathy was below the population norm, and 73% had cognitive impairment in at least one domain. The cognitive profile differed between adults and children. The authors could not find an association with imaging findings.

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Renaud Lafage, Justin S. Smith, Alex Moy Fong, Basel Sheikh Alshabab, Themistocles Protopsaltis, Eric O. Klineberg, Gregory Mundis Jr., Peter G. Passias, Munish Gupta, Christopher I. Shaffrey, Han Jo Kim, Shay Bess, Frank Schwab, Christopher P. Ames, Virginie Lafage, and

OBJECTIVE

Hyperextension of C0–2 is a debilitating compensatory mechanism used to maintain horizontal gaze, analogous to high pelvic tilt in the lumbopelvic complex to maintain an upright posture. This study aims to investigate the impact of cervical deformity (CD) correction on this hyperextension. The authors hypothesize that correction of cervical sagittal malalignment allows for relaxation of C0–2 hyperextension and improved clinical outcomes.

METHODS

A retrospective review was conducted of a multicenter database of patients with CD undergoing spinal realignment and fusion caudal to C2 and cephalad to the pelvis. Range of motion (ROM) and reserve of extension (ROE) were calculated across C2–7 and C0–2. The association between C2–7 correction and change in C0–2 ROE was investigated while controlling for horizontal gaze, followed by stratification into ΔC2–7 percentiles.

RESULTS

Sixty-five patients were included (mean age 61.8 ± 9.6 years, 68% female). At baseline, patients had cervical kyphosis (C2–7, −11.7° ± 18.2°; T1 slope–cervical lordosis mismatch, 38.6° ± 18.6°), negative global alignment (sagittal vertical axis [SVA] −12.8 ± 71.2 mm), and hyperlordosis at C0–2 (mean 33.2° ± 11.8°). The mean ROM was 25.7° ± 17.7° and 21.3° ± 9.9° at C2–7 and C0–2, respectively, with an ROE of approximately 9° for each segment. Limited C0–2 ROM and ROE correlated with the Neck Disability Index (r = −0.371 and −0.394, p < 0.01). The mean number of levels fused was 7.0 ± 3.1 (24.6% anterior, 43.1% posterior), with 87.7% undergoing at least an osteotomy. At 1 year, mean C2–7 increased to 5.5° ± 13.4°, SVA became neutral (11.5 ± 54.8 mm), C0–2 hyperlordosis decreased to 27.8° ± 11.7°, and thoracic kyphosis (TK) increased to −49.4° ± 18.1° (all p < 0.001). Concurrently, mean C0–2 ROM increased to 27.6° ± 8.1° and C2–7 ROM decreased significantly to 9.0° ± 12.3° without a change in ROE. Controlling for horizontal gaze, change in C2–7 lordosis significantly correlated with increased TK (r = −0.617, p < 0.001), decreased C0–2 (r = −0.747, p < 0.001), and increased C0–2 ROE (r = 0.550, p = 0.002).

CONCLUSIONS

CD correction can significantly impact cephalad and caudal compensation in the upper cervical and thoracic spine. Restoration of cervical alignment resulted in increased C0–2 ROE and TK and was also associated with improved clinical outcome.

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Daniel Mandel, Scott Moody, Kelly Pan, Thanujaa Subramaniam, Bradford B. Thompson, Linda C. Wendell, Michael E. Reznik, Karen L. Furie, and Ali Mahta

OBJECTIVE

Nonaneurysmal perimesencephalic subarachnoid hemorrhage (pmSAH) is considered to have a lower-risk pattern than other types of subarachnoid hemorrhage (SAH). However, a minority of patients with pmSAH may harbor a causative posterior circulation aneurysm. To exclude this possibility, many institutions pursue exhaustive imaging. In this study the authors aimed to develop a novel predictive model based on initial noncontrast head CT (NCHCT) features to differentiate pmSAH from aneurysmal causes.

METHODS

The authors retrospectively reviewed patients admitted to an academic center for treatment of a suspected aneurysmal SAH (aSAH) during the period from 2016 to 2021. Patients with a final diagnosis of pmSAH or posterior circulation aSAH were included. Using NCHCT, the thickness (continuous variable) and location of blood in basal cisterns and sylvian fissures (categorical variables) were compared between groups. A scoring system was created using features that were significantly different between groups. Receiver operating characteristic curve analysis was used to measure the accuracy of this model in predicting aneurysmal etiology. A separate patient cohort was used for external validation of this model.

RESULTS

Of 420 SAH cases, 48 patients with pmSAH and 37 with posterior circulation aSAH were identified. Blood thickness measurements in the crural and ambient cisterns and interhemispheric and sylvian fissures and degree of extension into the sylvian fissure were all significantly different between groups (all p < 0.001). The authors developed a 10-point scoring model to predict aneurysmal causes with high accuracy (area under the curve [AUC] 0.99; 95% CI 0.98–1.00; OR per point increase 10; 95% CI 2.18–46.4). External validation resulted in persistently high accuracy (AUC 0.97; 95% CI 0.92–1.00) of this model.

CONCLUSIONS

A risk stratification score using initial blood clot burden may accurately differentiate between aneurysmal and nonaneurysmal pmSAH. Larger prospective studies are encouraged to further validate this quantitative tool.