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Bernardo de Andrada Pereira, Piyanat Wangsawatwong, Jennifer N. Lehrman, Anna G. U. Sawa, S. Harrison Farber, Jakub Godzik, Luke K. O’Neill, Juan S. Uribe, Brian P. Kelly, and Jay D. Turner

OBJECTIVE

Changes to segmental lordosis at a single level may affect adjacent-level biomechanics and overall spinal alignment with an iatrogenic domino effect commonly seen in adult spinal deformity. This study investigated the effects of different segmental angles of single-level lumbar fixation on stability and principal strain across the surface of the adjacent-level disc.

METHODS

Seven human cadaveric L3–S1 specimens were instrumented at L4–5 and tested in 3 conditions: 1) neutral native angle ("neutral"), 2) increasing angle by 5° of lordosis ("lordosis"), and 3) decreasing angle by 5° of kyphosis ("kyphosis"). Pure moment loads (7.5 Nm) were applied in flexion, extension, lateral bending, and axial rotation, followed by 400 N of axial compression alone and together with pure moments. Range of motion (ROM), principal maximum strain (E1), and principal minimum strain (E2) across different surface subregions of the upper adjacent-level disc (L3–4) were optically assessed. Larger magnitudes of either E1 or E2 indicate larger tissue deformations and represent indirect measures of increased stress.

RESULTS

At the superior adjacent level, a significant increase in ROM was observed in kyphosis and lordosis versus neutral in flexion (p ≤ 0.001) and extension (p ≤ 0.02). ROM was increased in lordosis versus neutral (p = 0.03) and kyphosis (p = 0.004) during compression. ROM increased in kyphosis versus neutral and lordosis (both p = 0.03) in compression plus extension. Lordosis resulted in increased E1 across the midposterior subregion of the disc (Q3) versus neutral during right lateral bending (p = 0.04); lordosis and kyphosis resulted in decreased E1 in Q3 versus neutral with compression (p ≤ 0.03). Lordosis decreased E1 in Q3 versus neutral during compression plus flexion (p = 0.01), whereas kyphosis increased E1 in all quartiles and increased E2 in the midanterior subregion versus lordosis in compression plus flexion (p ≤ 0.047). Kyphosis decreased E1 in Q3 (p = 0.02) and E2 in the anterior-most subregion of the disc (Q1) (p = 0.006) versus neutral, whereas lordosis decreased E1 in Q3 (p = 0.008) versus neutral in compression plus extension.

CONCLUSIONS

Lumbar spine monosegmental fixation with 5° offset from the neutral individual segmental angle altered the motion and principal strain magnitudes at the upper adjacent disc, with induced kyphosis resulting in larger principal strains compared with lordosis. Segmental alignment of single-level fusion influences adjacent-segment biomechanics, and suboptimal alignment may play a role in the clinical development of adjacent-segment disease.

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Josue M. Avecillas-Chasin, Christopher R. Honey, Manraj K. S. Heran, and Marie T. Krüger

OBJECTIVE

In patients with essential tremor (ET) treated with standard deep brain stimulation (sDBS) whose ET had progressed and who no longer received optimal benefit from sDBS, directional deep brain stimulation (dDBS) may provide better tremor control. Current steering may provide better coverage of subcortical structures related to tremor control in patients with ET and significant progression without optimal response to sDBS.

METHODS

This study included 6 patients with ET initially treated with sDBS whose tremor later progressed and who then underwent reimplantation with dDBS to optimize their tremor control. To investigate the differences in the local effects of sDBS and dDBS, the authors generated the volume of tissue activation (VTA) to calculate the sweet spots associated with the best possible tremor control with no side effects. Then, to investigate the anatomical structures associated with maximal tremor control, the white matter pathways of the posterior subthalamic areas (PSAs) were generated and their involvement with the sDBS and dDBS sweet spots was calculated.

RESULTS

Tremor improvement was significantly better with dDBS (68.4%) than with sDBS (48.7%) (p = 0.017). The sDBS sweet spot was located within the ventral intermediate nucleus, whereas the sweet spot of the dDBS was mainly located within the PSA. The sweet spots of both sDBS and dDBS involved a similar portion of the cerebellothalamic pathway. However, the dDBS had greater involvement of the pallidofugal pathways than the sDBS.

CONCLUSIONS

In patients with ET treated with sDBS who later had ET progression, dDBS provided better tremor control, which was related to directionality and a more ventral position. The involvement of both the cerebellothalamic and pallidofugal pathways obtained with dDBS is associated with additional improvement over the sDBS.

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Joseph Schaefer, Elias Atallah, Eric Tecce, Sara Thalheimer, James Harrop, and Joshua E. Heller

OBJECTIVE

There is currently a lack of consensus on the utility of intraoperative neuromonitoring (IONM) for decompression of Chiari type I malformation (CM-I). Commonly used monitoring modalities include somatosensory evoked potentials (SSEPs), motor evoked potentials (MEPs), and brainstem auditory evoked potentials (BAEPs). The purpose of this study was to evaluate the utility of IONM in preventing neurological injury for CM-I decompression.

METHODS

The authors conducted a retrospective study of a population of adult patients (ages 17–76 years) diagnosed with CM-I between 2013 and 2021. IONM modalities included SSEPs, MEPs, and/or BAEPs. Prepositioning baseline signals and operative alerts of significant signal attenuation were recorded.

RESULTS

Ninety-three patients (average age 38.4 ± 14.6 years) underwent a suboccipital craniectomy for CM-I decompression. Eighty-two (88.2%) of 93 patients underwent C1 laminectomy, 8 (8.6%) underwent C1 and C2 laminectomy, and 4 (4.3%) underwent suboccipital craniectomy with concomitant cervical decompression and fusion in the setting of degenerative cervical spondylosis. Radiographically, the average cerebellar tonsillar ectopia/descent was 1.1 ± 0.5 cm and 53 (57.0%) of 93 patients presented with a syrinx. The average number of vertebral levels traversed by the syrinx was 5.3 ± 3.5, and the average maximum width of the syrinx was 5.8 ± 3.3 mm. There was one instance (1/93, 1.1%) of an MEP alert, which resolved spontaneously after 10 minutes in a patient who had concomitant stenosis due to pannus formation at C1–2. No patient developed a permanent neurological complication.

CONCLUSIONS

There were no permanent complications related to intraoperative neurological injury. Transient fluctuations in IONM signals can be detected without clinical significance. The authors suggest that CM-I suboccipital decompression surgery may be performed safely without IONM. The use of IONM in patients with additional occipitocervical pathology should be left as an option to the performing surgeon on a case-by-case basis.

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Kareem El Naamani, Ching-Jen Chen, Rawad Abbas, Ahmad Sweid, Georgios S. Sioutas, Khodr Badih, Sunidhi Ramesh, Stavropoula I. Tjoumakaris, M. Reid Gooch, Nabeel A. Herial, Hekmat Zarzour, Richard F. Schmidt, Robert H. Rosenwasser, and Pascal M. Jabbour

OBJECTIVE

Stent-assisted coil (SAC) embolization has been the mainstay endovascular treatment for bifurcation aneurysms. The recent introduction of the Woven EndoBridge (WEB) device has presented an alternative endovascular treatment modality for these aneurysms. Direct comparisons of outcomes between these two modalities are limited in the literature. Here, the authors compared the outcomes of bifurcation aneurysms treated with SAC and WEB devices.

METHODS

This retrospective single-center study comprised 148 bifurcation aneurysms that were treated endovascularly with SAC or WEB devices between 2011 and 2019. The primary outcome was complete occlusion of the aneurysm at 6 months on catheter angiography.

RESULTS

The SAC and WEB cohorts comprised 85 and 63 aneurysms, respectively. The baseline characteristics were well balanced after inverse probability weight (IPW) adjustment, except for smoking status. The 6-month complete occlusion rate was higher in the WEB cohort than the SAC cohort (67.4% vs 40.6%; unadjusted OR [95% CI] 3.014 [1.385–6.563], p = 0.005). However, this difference in complete occlusion rates did not remain significant after IPW adjustment and multiple imputations. The neck remnant rate was lower in the WEB cohort than the SAC cohort (20% vs 50%; OR [95% CI] 0.250 [0.107–0.584], p = 0.001), and this difference remained significant after IPW adjustment (OR [95% CI] 0.304 [0.116–0.795], p = 0.015) and multiple imputations.

CONCLUSIONS

Use of SAC and WEB demonstrated comparable 6-month complete occlusion rates for bifurcation aneurysms. WEB appeared to be associated with a lower rate of neck remnant at 6 and 12 months compared with SAC. WEB was also associated with fewer complications and decreased retreatment rates compared with SAC.

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Koichi Hagiwara, Takashi Kamada, Satoshi O. Suzuki, Ayako Miyoshi, Hideaki Tanaka, Hiroshi Shigeto, Shinji Ohara, and Naoki Akamatsu

BACKGROUND

Polymorphous low-grade neuroepithelial tumor of the young (PLNTY) is a newly identified low-grade brain tumor with frequent epileptic presentation. Despite the facilitated use of invasive electroencephalography owing to the growing availability of stereo-electroencephalography (SEEG), intracranial features of tumor-related seizures are still scarcely described. This report provides the first description of SEEG-recorded seizures in PLNTY to provide an insight into its surgical strategy.

OBSERVATIONS

Spontaneous clinical seizures were recorded with SEEG in a young adult patient with drug-resistant epilepsy associated with a PLNTY in the left lateral temporal cortex. The seizure onset was characterized by low-voltage fast activity (LVFA) and showed eccentric localization with respect to the tumor: LVFA was localized in the anterior portion of the tumor and spread toward the adjacent polar cortex. The language risks associated with the resection of the posterior temporal cortex could thus be minimized.

LESSONS

PLNTY can show a focal and eccentric seizure-onset zone around the tumor. The present findings serve to improve the functional and seizure outcomes using the staged invasive approach in PLNTY.

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Atiq ur Rehman Bhatti, Joseph Cesare, Waseem Wahood, Mohammed Ali Alvi, Chiduziem E. Onyedimma, Abdul Karim Ghaith, Oluwatoyin Akinnusotu, Sally El Sammak, Brett A. Freedman, Arjun S. Sebastian, and Mohamad Bydon

OBJECTIVE

Anterior-to-psoas lumbar interbody fusion (ATP-LIF), more commonly referred to as oblique lateral interbody fusion, and lateral transpsoas lumbar interbody fusion (LTP-LIF), also known as extreme lateral interbody fusion, are the two commonly used lateral approaches for performing a lumbar fusion procedure. These approaches help overcome some of the technical challenges associated with traditional approaches for lumbar fusion. In this systematic review and indirect meta-analysis, the authors compared operative and patient-reported outcomes between these two select approaches using available studies.

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) approach, the authors conducted an electronic search using the PubMed, EMBASE, and Scopus databases for studies published before May 1, 2019. Indirect meta-analysis was conducted on fusion rate, cage movement (subsidence plus migration), permanent deficits, and transient deficits; results were depicted as forest plots of proportions (effect size [ES]).

RESULTS

A total of 63 studies were included in this review after applying the exclusion criteria, of which 26 studies investigated the outcomes of ATP-LIF, while 37 studied the outcomes of LTP-LIF. The average fusion rate was found to be similar between the two groups (ES 0.97, 95% CI 0.84–1.00 vs ES 0.94, 95% CI 0.91–0.97; p = 0.561). The mean incidence of cage movement was significantly higher in the ATP-LIF group compared with the LTP-LIF group (stand-alone: ES 0.15, 95% CI 0.06–0.27 vs ES 0.09, 95% CI 0.04–0.16 [p = 0.317]; combined: ES 0.18, 95% CI 0.07–0.32 vs ES 0.02, 95% CI 0.00–0.05 [p = 0.002]). The mean incidence of reoperations was significantly higher in patients undergoing ATP-LIF than in those undergoing LTP-LIF (ES 0.02, 95% CI 0.01–0.03 vs ES 0.04, 95% CI 0.02–0.07; p = 0.012). The mean incidence of permanent deficits was similar between the two groups (stand-alone: ES 0.03, 95% CI 0.01–0.06 vs ES 0.05, 95% CI 0.01–0.12 [p = 0.204]; combined: ES 0.03, 95% CI 0.01–0.06 vs ES 0.03, 95% CI 0.00–0.08 [p = 0.595]). The postoperative changes in visual analog scale (VAS) and Oswestry Disability Index (ODI) scores were both found to be higher for ATP-LIF relative to LTP-LIF (VAS: weighted average 4.11 [SD 2.03] vs weighted average 3.75 [SD 1.94] [p = 0.004]; ODI: weighted average 28.3 [SD 5.33] vs weighted average 24.3 [SD 4.94] [p < 0.001]).

CONCLUSIONS

These analyses indicate that while both approaches are associated with similar fusion rates, ATP-LIF may be related to higher odds of cage movement and reoperations as compared with LTP-LIF. Furthermore, there is no difference in rates of permanent deficits between the two procedures.

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Shawn R. Eagle, Lisa Manderino, Michael Collins, Nathan Kegel, Vanessa Fazio-Sumrok, Anne Mucha, and Anthony P. Kontos

OBJECTIVE

The aim of this study was to analyze the best combination of clinical variables associated with concussion subtypes using a multidomain assessment comprising medical history; symptoms; and cognitive, ocular, and vestibular impairment in a cohort of patients presenting to a concussion specialty clinic.

METHODS

Adolescent patients (n = 293) completed demographics and medical history, Concussion Clinical Profiles Screening, Immediate Post-Concussion Assessment and Cognitive Testing, and vestibular ocular motor screening at their first visit (mean 7.6 ± 7.8 days postinjury) to a concussion specialty clinic. Each participant was adjudicated to have one or more subtype (anxiety/mood, cognitive, migraine, ocular, and vestibular) by a healthcare professional based on previously published criteria. A series of backward, stepwise logistic regressions were used to identify significant predictors of concussion subtypes, and predictive probabilities from the logistic regression models were entered into area under the receiver operating characteristic curve (AUC) models.

RESULTS

Each of 5 logistic regression models predicting primary subtypes accounted for 28%–50% of the variance (R2 = 0.28–0.50, p < 0.001) and included 2–8 significant predictors per model. Each of the models significantly differentiated the primary subtype from all other subtypes (AUC = 0.76–0.94, p < 0.001).

CONCLUSIONS

These findings suggest that each concussion subtype can be identified using specific outcomes from a multidomain assessment. Clinicians can employ such an approach to better identify and monitor recovery from subtypes as well as guide interventions.

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Chao-Jui Chang, Yuan-Fu Liu, Yu-Meng Hsiao, Yi-Hung Huang, Keng-Chang Liu, Ruey-Mo Lin, and Cheng-Li Lin

OBJECTIVE

Anterior cervical discectomy and fusion (ACDF) has long been regarded as a gold standard in the treatment of cervical myelopathy. Subsequently, cervical artificial disc replacement (c-ADR) was developed and provides the advantage of motion preservation at the level of the intervertebral disc surgical site, which may also reduce stress at adjacent levels. The goal of this study was to compare clinical and functional outcomes in patients undergoing ACDF with those in patients undergoing c-ADR for cervical spondylotic myelopathy (CSM).

METHODS

A systematic literature review and meta-analysis were performed using the Embase, PubMed, and Cochrane Central Register of Controlled Trials databases from database inception to November 21, 2021. The authors compared Neck Disability Index (NDI), SF-36, and Japanese Orthopaedic Association (JOA) scores; complication rates; and reoperation rates for these two surgical procedures in CSM patients. The Mantel-Haenszel method and variance-weighted means were used to analyze outcomes after identifying articles that met study inclusion criteria.

RESULTS

More surgical time was consumed in the c-ADR surgery (p = 0.04). Shorter hospital stays were noted in patients who had undergone c-ADR (p = 0.04). Patients who had undergone c-ADR tended to have better NDI scores (p = 0.02) and SF-36 scores (p = 0.001). Comparable outcomes in terms of JOA scores (p = 0.24) and neurological success rate (p = 0.12) were noted after the surgery. There was no significant between-group difference in the overall complication rates (c-ADR: 18% vs ACDF: 25%, p = 0.17). However, patients in the ACDF group had a higher reoperation rate than patients in the c-ADR group (4.6% vs 1.5%, p = 0.02).

CONCLUSIONS

At the midterm follow-up after treatment of CSM, better functional outcomes as reflected by NDI and SF-36 scores were noted in the c-ADR group than those in the ACDF group. c-ADR had the advantage of retaining range of motion at the level of the intervertebral disc surgical site without causing more complications. A large sample size with long-term follow-up studies may be required to confirm these findings in the future.

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Kamlesh B. Patel, Cihat Eldeniz, Gary B. Skolnick, Paul K. Commean, Parna Eshraghi Boroojeni, Udayabhanu Jammalamadaka, Corinne Merrill, Matthew D. Smyth, Manu S. Goyal, and Hongyu An

OBJECTIVE

Head trauma is the most common indication for a CT scan. In this pilot study, the authors assess the feasibility of a 5-minute high-resolution 3D golden-angle (GA) stack-of-stars radial volumetric interpolated breath-hold examination (VIBE) MRI sequence (GA-VIBE) to obtain clinically acceptable cranial bone images and identify cranial vault fractures compared to CT.

METHODS

Patients younger than 18 years of age presenting after head trauma were eligible for the study. Three clinicians reviewed and assessed 1) slice-by-slice volumetric CT and inverted MR images, and 2) 3D reconstructions obtained from inverted MR images and the gold standard (CT). For each image set, reviewers noted on 5-point Likert scales whether they recommended that a repeat scan be performed and the presence or absence of cranial vault fractures.

RESULTS

Thirty-one patients completed MRI after a clinical head CT scan was performed. Based on CT imaging, 8 of 31 patients had cranial fractures. Two of 31 patients were sedated as part of their clinical MRI scan. In 30 (97%) of 31 MRI reviews, clinicians agreed (or strongly agreed) that the image quality was acceptable for clinical diagnosis. Overall, comparing MRI to acceptable gold-standard CT, sensitivity and specificity of fracture detection were 100%. Furthermore, there were no discrepancies between CT and MRI in classification of fracture type or location.

CONCLUSIONS

When compared with the gold standard (CT), the volumetric and 3D reconstructed images using the GA-VIBE sequence were able to produce clinically acceptable cranial images with excellent ability to detect cranial vault fractures.

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Per K. Eide, Angelika Sorteberg, Terje Nome, Pål A. Rønning, and Wilhelm Sorteberg

OBJECTIVE

Early repair of ruptured blood-blister aneurysms (BBAs) of the internal carotid artery (ICA) remains challenging. Although both surgical and endovascular therapies have been established, their relative superiority remains debated. The authors assessed their single-center experience and compared early deconstructive versus reconstructive repair and early reconstructive surgical versus endovascular repair of ruptured BBAs of the ICA.

METHODS

The study included patients who underwent repair of ruptured BBAs of the ICA within 1 week after the ictus during a 20-year period. Multiple variables were recorded, including clinical state, severity of subarachnoid hemorrhage (SAH), characteristics of the BBA, treatment details, complication profile, need for secondary treatment, and clinical outcome.

RESULTS

In total, 27 patients underwent early surgical (n = 16) or endovascular (n = 11) repair of BBAs at a median of 24 hours (range 9–120 hours) after the ictus during the period from September 2000 to June 2021 (20.4 years). Primary deconstructive repair (n = 6) without bypass was accompanied by middle cerebral artery (MCA) territory infarction in 5 of 6 (83%) patients and a high mortality rate (4/6 [67%]). Among the 21 patients who underwent early reconstructive repair, surgery was performed in 11 patients (clipping in 6 and clip-wrapping in 5 patients) and endovascular repair in 10 patients (flow diversion in 7 and stent/stent-assisted coiling in 3 patients). No differences were found in complication profiles or clinical outcomes between the surgical and endovascular groups. The mortality rate was low (2/21 [9.5%]), with 1 fatality in each group.

CONCLUSIONS

From the authors’ experience, both surgical and endovascular approaches permitted reconstructive repair of ruptured BBAs of the ICA, with no modality proving superior. Reconstructive treatment is preferable to ICA sacrifice, and if sacrifice is chosen, it should be accompanied with bypass surgery or delayed to the phase when cerebral vasospasm has resumed. The rare occurrence of this disease calls for prospective multicenter studies to improve treatment and delineate which modality is preferable in individual cases.