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Jan-Karl Burkhardt, Omar Tanweer, Miguel Litao, Pankaj Sharma, Eytan Raz, Maksim Shapiro, Peter Kim Nelson and Howard A. Riina

OBJECTIVE

A systematic analysis on the utility of prophylactic antibiotics for neuroendovascular procedures has not been performed. At the authors’ institution there is a unique setup to address this question, with some attending physicians using prophylactic antibiotics (cefazolin or vancomycin) for all of their neurointerventions while others generally do not.

METHODS

The authors performed a retrospective review of the last 549 neurointerventional procedures in 484 patients at Tisch Hospital, NYU Langone Medical Center. Clinical and radiological data were collected for analysis, including presence of prophylactic antibiotic use, local or systemic infection, infection laboratory values, and treatment. Overall, 306 aneurysms, 117 arteriovenous malformations/arteriovenous fistulas, 86 tumors, and 40 vessel stenosis/dissections were treated with coiling (n = 109), Pipeline embolization device (n = 197), embolization (n = 203), or stenting (n = 40).

RESULTS

Antibiotic prophylaxis was used in 265 of 549 cases (48%). There was no significant difference between patients with or without antibiotic prophylaxis in sex (p = 0.48), presence of multiple interventions (p = 0.67), diseases treated (p = 0.11), or intervention device placed (p = 0.55). The mean age of patients in the antibiotic prophylaxis group (53.4 years) was significantly lower than that of the patients without prophylaxis (57.1 years; p = 0.014). Two mild local groin infections (0.36%) and no systemic infections (0%) were identified in this cohort, with one case in each group (1/265 [0.38%] vs 1/284 [0.35%]). Both patients recovered completely with local drainage (n = 1) and oral antibiotic treatment (n = 1).

CONCLUSIONS

The risk of infection associated with endovascular neurointerventions with or without prophylactic antibiotic use was very low in this cohort. The data suggest that the routine use of antibiotic prophylaxis seems unnecessary and that to prevent antibiotic resistance and reduce costs antibiotic prophylaxis should be reserved for selected patients deemed to be at increased infection risk.

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Giulia Cossu, Mahmoud Messerer and Roy Thomas Daniel

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R. Michael Scott and Edward R. Smith

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Vincenzo Levi, Nicola Ernesto Di Laurenzio, Andrea Franzini, Irene Tramacere, Alessandra Erbetta, Luisa Chiapparini, Domenico D’Amico, Angelo Franzini and Giuseppe Messina

OBJECTIVE

Although epidural blood patch (EBP) is considered the gold-standard treatment for drug-resistant orthostatic headache in spontaneous intracranial hypotension (SIH), no clear evidence exists regarding the best administration method of this technique (blind vs target procedures). The aim of this study was to assess the long-term efficacy of blind lumbar EBP and predictors on preoperative MRI of good outcome.

METHODS

Lumbar EBP was performed by injecting 10 ml of autologous venous blood, fibrin glue, and contrast medium in 101 consecutive patients affected by SIH and orthostatic headache. Visual analog scale (VAS) scores for headache were recorded preoperatively, at 48 hours and 6 months after the procedure, and by telephone interview in July 2017. Patients were defined as good responders if a VAS score reduction of at least 50% was achieved within 48 hours of the procedure and lasted for at least 6 months. Finally, common radiological SIH findings were correlated with clinical outcomes.

RESULTS

The median follow-up was 60 months (range 8–135 months); 140 lumbar EBPs were performed without complications. The baseline VAS score was 8.7 ± 1.3, while the mean VAS score after the first EBP procedure was 3.5 ± 2.2 (p < 0.001). The overall response rate at the 6-month follow-up was 68.3% (mean VAS score 2.5 ± 2.4, p < 0.001). Symptoms recurred in 32 patients (31.7%). These patients underwent a second procedure, with a response rate at the 6-month follow-up of 78.1%. Seven patients (6.9%) did not improve after a third procedure and remained symptomatic. The overall response rate at the last follow-up was 89.1% with a mean VAS score of 2.7 ± 2.3 (p < 0.001). The only MRI predictors of good outcome were location of the iter > 2 mm below the incisural line (p < 0.05) and a pontomesencephalic angle (PMA) < 40° (p < 0.05).

CONCLUSIONS

Lumbar EBP may be considered safe and effective in cases of drug-refractory SIH. The presence of a preprocedural PMA < 40° and location of the iter > 2 mm below the incisural line were the most significant predictors of good outcome. Randomized prospective clinical trials comparing lumbar with targeted EBP are warranted to validate these results.

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Aziz S. Alali, Nancy Temkin, Monica S. Vavilala, Abhijit V. Lele, Jason Barber, Sureyya Dikmen and Randall M. Chesnut

OBJECTIVE

The aim of this study was to examine the relationship between early arterial oxygenation thresholds and long-term outcome after severe traumatic brain injury (TBI).

METHODS

In a post hoc analysis of a randomized trial, adults with severe TBI were classified based on exposure to different levels of arterial oxygenation as measured using the average of arterial partial pressure of oxygen (PaO2) values obtained within 24 hours of admission. Potentially important PaO2 thresholds were defined a priori. The primary outcome was Glasgow Outcome Scale–Extended (GOSE) score at 6 months. Secondary outcomes were cognitive outcomes measured using a battery of 9 neuropsychological tests administered at 6 months, and 6-month mortality.

RESULTS

In adjusted analyses, oxygenation thresholds of 150 and 200 mm Hg were associated with better functional outcome at 6 months (adjusted OR for better functional outcome on GOSE 1.82 [95% CI 1.12–2.94] and 1.59 [95% CI 1.06–2.37], respectively) and improved cognitive outcome at 6 months (adjusted beta coefficients for better cognitive percentile across 9 neuropsychological tests: 6.9 [95% CI 1.3–12.5] and 6.8 [95% CI 2.4–11.3], respectively). There was no significant association between oxygenation level and 6-month mortality except at a PaO2 threshold of 200 mm Hg (OR for death 0.36, 95% CI 0.18–0.71). Higher or lower oxygenation thresholds were not associated with functional or cognitive outcome.

CONCLUSIONS

In this observational study, the relationship between early arterial oxygenation and long-term functional and cognitive TBI outcomes appears to be U-shaped. Mild levels of hyperoxemia within the first 24 hours after injury were associated with better long-term functional and cognitive outcomes. These findings highlight the importance of examining balanced oxygen supplementation as a potential strategy to improve TBI outcomes in future research.

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Claudia L. Craven, Roshini Ramkumar, Linda D’Antona, Simon D. Thompson, Lewis Thorne, Laurence D. Watkins and Ahmed K. Toma

OBJECTIVE

Chronic ventriculomegaly in the absence of raised intracranial pressure (ICP) is a known entity in adult hydrocephalus practice. The natural history and indication for treatment is, however, poorly defined. A highly heterogeneous group, some adults with ventriculomegaly are asymptomatic, while others have life-threatening deteriorations. The authors hypothesized that the various presentations can be subtyped and represent different stages of decompensation. A cluster analysis was performed on a cohort of patients with chronic ventriculomegaly with the aim of elucidating typical clinical characteristics and outcomes in chronic ventriculomegaly in adults.

METHODS

Data were collected from 79 patients with chronic ventriculomegaly referred to a single center, including demographics, presenting symptoms, and 24-hour ICP monitoring (ICPM). A statistical cluster analysis was performed to determine the presence of subgroups.

RESULTS

Four main subgroups and one highly dissimilar group were identified. Patients with ventriculomegaly commonly have a perinatal event followed by one of four main presentations: 1) incidental ventriculomegaly with or without headache; 2) highly symptomatic presentation (including reduced consciousness) and raised ICP; 3) early presenting with symptoms of headache and nausea (with abnormal pulsatility); and 4) late presenting with features common to normal pressure hydrocephalus. Each symptomatic group has characteristic radiological features, ICPM, and responses to treatment.

CONCLUSIONS

Cluster analysis has identified subgroups of adult patients with ventriculomegaly. Such groups may represent various degrees of decompensation. Surgical interventions may not be equally effective across the subgroups, presenting an avenue for further research. The identified subtypes provide further insight into the natural history of this lesser studied form of hydrocephalus.

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Ema Onode, Takuya Uemura, Kiyohito Takamatsu, Kosuke Shintani, Takuya Yokoi, Mitsuhiro Okada and Hiroaki Nakamura

OBJECTIVE

Treatment of painful neuroma remains difficult, despite the availability of numerous surgical procedures. Recently, nerve capping treatment for painful neuroma using artificial nerve conduits has been introduced in clinical and basic research. However, the appropriate length of the nerve conduit and the pain relief mechanism have not been determined. In this study the authors aimed to investigate nerve capping treatment with a bioabsorbable nerve conduit using the rat sciatic nerve amputation model. Using histological analysis, the authors focused on the nerve conduit length and pain relief mechanism.

METHODS

Sixteen Sprague Dawley rats were evaluated for neuropathic pain using an autotomy (self-amputation) score and gross and histological changes of the nerve stump 2, 4, 8, and 12 weeks after sciatic nerve neurectomy without capping. Forty-five rats were divided into 3 experimental groups, no capping (control; n = 15), capping with a 3-mm nerve conduit (n = 15), and capping with a 6-mm nerve conduit (n = 15). All rats were evaluated using an autotomy score and nerve stump histology 12 weeks after neurectomy. The nerve conduit was approximately 0.5 mm larger than the 1.5-mm diameter of the rat sciatic nerves to prevent nerve constriction.

RESULTS

The autotomy scores gradually exacerbated with time. Without capping, a typical bulbous neuroma was formed due to random axonal regeneration 2 weeks after neurectomy. Subsequently, the adhesion surrounding the neuroma expanded over time for 12 weeks, and at the 12-week time point, the highest average autotomy scores were observed in the no-capping (control) group, followed by the 3- and the 6-mm nerve conduit groups. Histologically, the distal axonal fibers became thinner and terminated within the 6-mm nerve conduit, whereas they were elongated and protruded across the 3-mm nerve conduit. Minimal perineural scar formation was present around the terminated axonal fibers in the 6-mm nerve conduit group. Expressions of anti–α smooth muscle actin and anti–sigma-1 receptor antibodies in the nerve stump significantly decreased in the 6-mm nerve conduit group.

CONCLUSIONS

In the rat sciatic nerve amputation model, nerve capping treatment with a bioabsorbable nerve conduit provided relief from neuroma-induced neuropathic pain and prevented perineural scar formation and neuroinflammation around the nerve stump. The appropriate nerve conduit length was determined to be more than 4 times the diameter of the original nerve.

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Tryggve Lundar, Bernt Johan Due-Tønnessen, Radek Frič, Bård Krossnes, Petter Brandal, Einar Stensvold and Paulina Due-Tønnessen

OBJECTIVE

The authors conducted a study to delineate the long-term results of the surgical treatment of pediatric pleomorphic xanthoastrocytomas (PXAs).

METHODS

All consecutive children and adolescents (0–20 years) who underwent primary tumor resection for a PXA during the years 1972–2015 were included in this retrospective study on surgical morbidity, mortality rate, academic achievement, and/or work participation. Gross motor function and activities of daily living were scored according to the Barthel Index.

RESULTS

Of the 12 patients, 8 patients were in the 1st decade of life and 4 in the 2nd. The male/female ratio was 6:6. No patient was lost to follow-up. One patient presented with severe progressive tumor disease and died within 3 months after repeated resection. Another child died 3 days following a second surgical procedure involving gross-total resection (GTR) 8 years after the initial operation. The other 10 patients were alive at the latest follow-up when they reached the median age of 34 years (range 11–60 years). The median follow-up duration was 22 years (range 2–41 years). Barthel Index score was 100 in all 10 survivors. A total 18 tumor resections were performed. Five patients underwent a second tumor resection after MRI/CT confirmed recurrent tumor disease, from 6 months up to 17 years after the initial operation. Only one of our patients received adjuvant therapy: a 19-year-old male who underwent resection (GTR) for a right-sided temporal tumor in 1976. This particular tumor was originally classified as astrocytoma WHO grade IV, and postoperative radiotherapy (54 Gy) was given. The histology was reclassified to that of a PXA. Seven of 8 children whose primary tumor resection was performed more than 20 years ago are alive as of this writing—i.e., 88% observed 20-year survival. These are long-term survivors with good clinical function and all are in full- or part-time work.

CONCLUSIONS

Pediatric patients with PXA can be treated with resection alone with rewarding results. Recurrences are not uncommon, but repeated surgery is well tolerated and should be considered in low-grade cases before adjuvant therapy is implemented. Follow-up including repeated MRI is important during the first postoperative years, since individual patients may have a more aggressive tumor course.

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Thomas J. Buell, Shay Bess, Ming Xu, Frank J. Schwab, Virginie Lafage, Christopher P. Ames, Christopher I. Shaffrey and Justin S. Smith

OBJECTIVE

Proximal junctional kyphosis (PJK) is, in part, due to altered segmental biomechanics at the junction of rigid instrumented spine and relatively hypermobile non-instrumented adjacent segments. Proper application of posteriorly anchored polyethylene tethers (i.e., optimal configuration and tension) may mitigate adjacent-segment stress and help prevent PJK. The purpose of this study was to investigate the impact of different tether configurations and tensioning (preloading) on junctional range-of-motion (ROM) and other biomechanical indices for PJK in long instrumented spine constructs.

METHODS

Using a validated finite element model of a T7–L5 spine segment, testing was performed on intact spine, a multilevel posterior screw-rod construct (PS construct; T11–L5) without tether, and 15 PS constructs with different tether configurations that varied according to 1) proximal tether fixation of upper instrumented vertebra +1 (UIV+1) and/or UIV+2; 2) distal tether fixation to UIV, to UIV−1, or to rods; and 3) use of a loop (single proximal fixation) or weave (UIV and/or UIV+1 fixation in addition to UIV+1 and/or UIV+2 proximal attachment) of the tether. Segmental ROM, intradiscal pressure (IDP), inter- and supraspinous ligament (ISL/SSL) forces, and screw loads were assessed under variable tether preload.

RESULTS

PS construct junctional ROM increased abruptly from 10% (T11–12) to 99% (T10–11) of baseline. After tethers were grouped by most cranial proximal fixation (UIV+1 vs UIV+2) and use of loop versus weave, UIV+2 Loop and/or Weave most effectively dampened junctional ROM and adjacent-segment stress. Different distal fixation and use of loop versus weave had minimal effect. The mean segmental ROM at T11–12, T10–11, and T9–10, respectively, was 6%, 40%, and 99% for UIV+1 Loop; 6%, 44%, and 99% for UIV+1 Weave; 5%, 23%, and 26% for UIV+2 Loop; and 5%, 24%, and 31% for UIV+2 Weave.

Tethers shared loads with posterior ligaments; consequently, increasing tether preload tension reduced ISL/SSL forces, but screw loads increased. Further attenuation of junctional ROM and IDP reversed above approximately 100 N tether preload, suggesting diminished benefit for biomechanical PJK prophylaxis at higher preload tensioning.

CONCLUSIONS

In this study, finite element analysis demonstrated UIV+2 Loop and/or Weave tether configurations most effectively mitigated adjacent-segment stress in long instrumented spine constructs. Tether preload dampened ligament forces at the expense of screw loads, and an inflection point (approximately 100 N) was demonstrated above which junctional ROM and IDP worsened (i.e., avoid over-tightening tethers). Results suggest tether configuration and tension influence PJK biomechanics and further clinical research is warranted.

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Christopher Wilson, Alan P. Yaacoub, Adewale Bakare, Na Bo, Abdul Aasar and Nicholas M. Barbaro

OBJECTIVE

A common cause of peroneal neuropathy is compression near the fibular head. Studies demonstrate excellent outcomes after decompression but include few cases (range 15–60 patients). Consequently, attempts to define predictors of good outcomes are limited. Here, the authors combine their institutional outcomes with those in the literature to identify predictors of good outcomes after peroneal nerve decompression.

METHODS

The authors searched their institutional electronic medical records to identify all peroneal nerve decompressions performed in the period between December 1, 2012, and September 30, 2016, and created an IRB-approved database. They also conducted a MEDLINE and literature search to identify articles discussing surgical decompression. All data were combined by meta-analysis to identify the factors associated with a favorable outcome, which was defined as improvement in preoperative symptoms. Patients were analyzed in the aggregate and by presentation (pain, paresthesias, weakness, foot drop). The factors evaluated included age, sex, body mass index, diabetes, smoking status, previous knee or lumbar spine surgery, preoperative symptom duration, and etiology. A meta-analysis was completed for any factor evaluated in at least three data sets.

RESULTS

Twenty-one institutional cases had sufficient data for review. The follow-up among this group was long: median 29 months, range 12–52 months. On aggregate analysis of the data, only diabetes was significantly associated with unfavorable outcomes after decompression (p = 0.05). A trend toward worse outcomes was seen in smokers presenting with pain (p = 0.06). Outcomes were not affected by presentation.

An additional 115 cases in the literature had extractable data for meta-analysis, and other associations were seen. Preoperative symptom duration longer than 12 months was associated with unfavorable outcomes (OR 0.23, 95% CI 0.08–0.65). Patients presenting with paresthesias or hypesthesia demonstrated a trend toward more unfavorable outcomes when operated on more than 6 months after symptom onset (OR 0.37, 95% CI 0.13–1.06). Even after the meta-analysis, outcomes did not vary with an advanced age (OR 0.70, 95% CI 0.24–1.98) or with patient sex (OR 1.13, 95% CI 0.42–3.06).

CONCLUSIONS

The authors provide their institutional data in combination with published data regarding outcomes after peroneal nerve decompression. Outcomes are typically favorable and generally unaffected by the type of symptoms preoperatively, especially if the patient is nondiabetic and preoperative symptom duration is less than 12 months. Patients with paresthesias may benefit from surgery within 6 months after onset. Smoking may adversely affect surgical outcomes. Finally, an advanced age does not adversely affect outcomes, and older patients should be considered for surgery.