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## Analysis of reasons for medical malpractice litigation due to laminectomy

### OBJECTIVE

The aim of this study was to identify the incidence and characteristics of malpractice lawsuits pertaining to laminectomy performed either as a stand-alone operation or concurrent with another procedure by querying the Westlaw Edge and VerdictSearch databases. Malpractice claims analysis is performed by several medical specialties to provide insight into patient values, methods to improve quality of care, and risk factors for litigation pertaining to specific procedures or treatments.

### METHODS

Westlaw and VerdictSearch were queried using the keywords "laminectomy" and "spine." Claims were reviewed, with the inclusion criteria defined as a case filed between 2000 and 2022 that involved the plaintiff’s basis of litigation resting on a claim of medical malpractice due to laminectomy. Additional collected data included the case date, verdict ruling, state or federal location of the filed claim, sustained injuries, and payment or settlement amount.

### RESULTS

After review of 4732 cases, 201 were identified as malpractice claims due to laminectomy. The most common reasons for litigation were delayed or denied treatment (n = 106), procedural errors (n = 38), inadequate management of postlaminectomy syndrome (n = 26), and incorrect procedural selection (n = 14). Regarding the verdict ruling, 47.3% (n = 95) of cases ruled in favor of the defendant, 9.0% (n = 18) resulted in a mixed ruling, 15.9% (n = 32) ruled in favor of the plaintiff, and 9.5% (n = 19) were resolved with an out-of-court settlement. An average payment of $4,530,277 resulted from the cases that ruled in favor of the plaintiff, while out-of-court settlements yielded an average payment of$1,193,146.

### CONCLUSIONS

This study suggests that there are several well-documented risk factors for malpractice claims attributed to laminectomy. The study findings suggest that prompt and accurate diagnosis, coordination of care, timely referral for surgical intervention, and understanding of the indications versus limitations of conservative therapy may help to mitigate the risk of litigation associated with laminectomy.

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## Clinical outcome in decompression alone versus decompression and instrumented fusion in patients with isthmic spondylolisthesis: a prospective cohort study

### OBJECTIVE

In the surgical treatment of isthmic spondylolisthesis, it is debatable whether instrumented fusion is mandatory in addition to decompression. The objective of this prospective cohort study was to assess the long-term effect of decompression alone compared with decompression and instrumented fusion in patients who underwent the intervention of their own preference. The results were compared with those in patients who underwent randomly assigned treatment.

### METHODS

The authors performed a prospective observational multicenter cohort study, including 91 patients with isthmic spondylolisthesis assigned to undergo either decompression alone (n = 44) or decompression and fusion (n = 47). The main outcomes were the Roland-Morris Disability Questionnaire (RDQ) scores and the patient’s perceived recovery at the 2-year follow-up. Secondary outcomes were visual analog scale (VAS) leg pain and back pain scores and the reoperation rate. A meta-analysis was performed for data from this cohort study (n = 91) and from a randomized controlled trial (RCT) previously reported by the authors (n = 84). Subgroup analyses were performed on these combined data for age, sex, weight, smoking, and Meyerding grade.

### RESULTS

At the 12-week follow-up, improvements of RDQ scores were comparable for the two procedures (decompression alone [D group] 4.4, 95% CI 2.3–6.5; decompression and fusion [DF group] 5.8, 95% CI −4.3 to 1.4; p = 0.31). Likewise, VAS leg pain scores (D group 35.0, 95% CI 24.5–45.6; DF group 47.5, 95% CI 37.4–57.5; p = 0.09) and VAS back pain scores (D group 23.5, 95% CI 13.3–33.7; DF group 34.0, 95% CI 24.1–43.8; p = 0.15) were comparable. At the 2-year follow-up, there were no significant differences between the two groups in terms of scores for RDQ (difference −3.1, 95% CI −6.4 to 0.3, p = 0.07), VAS leg pain (difference −7.4, 95% CI −22.1 to 7.2, p = 0.31), and VAS back pain (difference −11.4, 95% CI −25.7 to 2.9, p = 0.12). In contrast, patient-perceived recovery from leg pain was significantly higher in the DF group (79% vs 51%, p = 0.02). Subgroup analyses did not demonstrate a superior outcome for decompression alone compared with decompression and fusion. Nine patients (20.5%) underwent reoperation in total, all in the D group. The meta-analysis including both the cohort and RCT populations yielded an estimated pooled mean difference in RDQ of −3.7 (95% CI −5.94 to −1.55, p = 0.0008) in favor of decompression and fusion at the 2-year follow-up.

### CONCLUSIONS

In patients with isthmic spondylolisthesis, at the 2-year follow-up, patients who underwent decompression and fusion showed superior functional outcome and perceived recovery compared with those who underwent decompression alone. No subgroups benefited from decompression alone. Therefore, decompression and fusion is recommended over decompression alone as a primary surgical treatment option in isthmic spondylolisthesis.

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## Clinical outcomes of the traditional dual growing rod technique combined with apical pedicle screws in the treatment of early-onset scoliosis: preliminary results from a single center

### OBJECTIVE

Limited control of an apical deformity is a major disadvantage in the traditional dual growing rod (TDGR) technique. Previous literature has reported the results of apical pedicle screw placement (APS) as an apical control technique in patients with early-onset scoliosis (EOS). However, the clinical outcomes, indications, and complications of the TDGR technique combined with APSs have not been well described. The purpose of this study was to evaluate the preliminary clinical outcomes of the TDGR technique combined with APSs in EOS patients.

### METHODS

Clinical data of 12 patients with EOS who were treated with the TDGR technique combined with APSs at the index surgery at the authors’ center from January 2010 to January 2020, with a minimum 2-year follow-up, were retrospectively reviewed. Indications for the use of APSs included 1) no vertebral segmentation failure, fused ribs, or multiple hemivertebrae at the apex; 2) at least 2 normal discs around the apex; and 3) proper development of apical pedicles on the convex side. Etiology, age at index surgery, number of lengthening procedures, follow-up duration, and complications were recorded. Radiographic measurements included Cobb angle, apical vertebral translation (AVT), apical vertebral rotation (AVR), thoracic kyphosis, lumbar lordosis, spine height, and space available for the lung (SAL).

### RESULTS

The mean follow-up period was 4.0 ± 1.4 years, with a mean of 4.8 lengthening procedures per patient. The mean Cobb angle improved from 61.7° ± 10.4° to 19.9° ± 9.0° after the index surgery (19.6° ± 9.4° at the latest follow-up). The mean postindex AVT decreased to 16.8 ± 8.9 mm from a preindex AVT of 56.3 ± 9.7 mm and further improved to 13.6 ± 10.0 mm at the latest follow-up. The mean annual increases in T1–12 and T1–S1 height were 9.0 ± 4.7 mm and 13.9 ± 6.5 mm, respectively. The SAL improved from 0.91 to 1.04 at the latest follow-up. AVR improved significantly after the index surgery (p = 0.013), while minor deterioration was observed after repeat lengthening procedures. Five complications (2 implant related and 3 alignment related) occurred in 4 patients.

### CONCLUSIONS

For EOS patients with good flexibility (without segmentation failure or multiple hemivertebrae at the apex), the TDGR technique combined with APSs can improve primary curve correction, maintain good correction results, and allow continuous spine growth, which may reduce the risks of complications during lengthening treatment. More multicenter prospective studies with larger samples are needed to further validate the findings of this study.

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## Endovascular treatment versus standard medical treatment for basilar artery occlusion: a meta-analysis of randomized controlled trials

### OBJECTIVE

Acute ischemic stroke caused by basilar artery occlusion (BAO) is devastating, but the optimal treatment for patients with BAO remains controversial. In this study, the authors aimed to investigate the safety and efficacy of endovascular treatment (ET) versus standard medical treatment (SMT) in patients with BAO.

### METHODS

The PubMed, Embase, and Cochrane Library databases were searched for randomized controlled trials (RCTs). The primary outcome was good functional outcome, defined as a modified Rankin Scale (mRS) score of 0–3 at 90 days. The secondary efficacy outcome was excellent functional outcome defined as an mRS score of 0–2 at 90 days. The safety outcomes included mortality at 90 days and symptomatic intracranial hemorrhage (sICH). Subgroup analyses were carried out based on race (Asian or non-Asian).

### RESULTS

Four RCTs of 988 patients (556 in the ET group and 432 in the SMT group) were included in this meta-analysis. The proportion of good functional outcome in the ET group was significantly higher than that in the SMT group (45.1% vs 29.6%; number needed to treat 6.45; RR 1.54, 95% CI 1.16–2.06; p = 0.003, I2 = 60%). The subgroup analysis based on race showed a significant difference between Asian and non-Asian race in the primary outcome (p = 0.03, I2 = 78.5%). Patients in the ET group had a higher rate of excellent functional outcome at 90 days than those in the SMT group (34.9% vs 20.6%; RR 1.83, 95% CI 1.07–3.12; p = 0.03, I2 = 80%). Patients in the ET group had a lower mortality at 90 days (35.6% vs 45.4%; RR 0.77, 95% CI 0.66–0.89; p = 0.0007, I2 = 0%) but a higher rate of sICH (5.4% vs 0.5%; RR 8.29, 95% CI 2.49–27.66; p = 0.0006, I2 = 0%) than those in the SMT group.

### CONCLUSIONS

ET may improve the functional outcome and reduce mortality at 90 days but increase the risk of sICH compared with SMT in patients with BAO. This conclusion needs to be confirmed in non-Asian populations in future studies.

Systematic review registration no.: CRD42022357718 (https://www.crd.york.ac.uk/prospero/)

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## Enhanced brain entry of checkpoint-inhibitory therapeutic antibodies facilitated by intraarterial NEO100 in mouse models of brain-localized malignancies

### OBJECTIVE

Immune checkpoint-inhibitory therapeutic antibodies have shown striking activity against several types of cancers but are less effective against brain-localized malignancies, in part due to the protective effect of the blood-brain barrier (BBB). The authors hypothesized that intraarterial (IA) delivery of a novel compound, NEO100, has the potential to safely and reversibly open the BBB to enable brain-targeted therapeutic activity of checkpoint-inhibitory antibodies.

### METHODS

Immunocompetent mice with syngeneic glioblastoma or melanoma cells implanted into their brains were subjected to a single IA injection of NEO100 to open their BBB. One dose of murine anti–PD-1/PD-L1 antibody was either coinjected with NEO100 or separately injected intravenously. Brain penetration of these antibodies and levels of CD8+ T cell infiltrate into the tumor microenvironment were quantitated and animal survival was monitored.

### RESULTS

IA NEO100 enabled the increased accumulation of checkpoint-inhibitory antibodies in the brain, along with greater numbers of T cells. In both malignancy models, a single intervention of IA NEO100 combined with antibody resulted in the long-term survival of animals. Antibody treatment in the absence of NEO100 was far less effective.

### CONCLUSIONS

BBB opening by IA NEO100 facilitates brain tumor access by checkpoint-inhibitory antibodies and enables their therapeutic activity, along with increased levels of T-cell recruitment.

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## Epidemiology and practice variations of shunt surgery for hydrocephalus: a nationwide registry–based study

### OBJECTIVE

Indications for surgical treatment of hydrocephalus (HC) can vary across centers. The authors sought to investigate the frequencies of surgically treated HC disorders and to study variations in the practice of shunt surgery in Norway, a country with universal and free healthcare.

### METHODS

This is a nationwide registry–based study using data from the Norwegian Patient Registry. Four neurosurgical centers serve exclusively in 4 defined geographic regions. All patients who underwent shunt surgery in Norway between January 1, 2008, and December 31, 2021, were included and regional differences and time trends were explored.

### RESULTS

The national annual rate of shunt surgery in the study period was 6.0 per 100,000. A total of 4139 individuals (49.5% male) underwent primary shunt surgeries, and a total of 9262 operations including revision surgeries were performed. There were statistically significant regional differences between the 4 treating centers in Norway in terms of patients’ age (median 61 years, range 53–65 years); mean annual rate of primary shunt surgery (5.1–7.6 per 100,000); annual rate of primary shunt surgery in patients of different age groups (0.9–1.2 in 0–17 years, 1.8–2.7 in 18–64 years, and 1.6–3.9 in ≥ 65 years); annual rate of revision surgeries (2.4–5.7 per 100,000); annual rate of primary surgery for communicating HC (0.7–2.0 per 100,000); annual rate of primary surgery for normal pressure HC (0.5–1.8 per 100,000); and annual rate of primary surgery for HC associated with cerebrovascular disease (0.5–2.0 per 100,000). There was significant variation in overall shunt surgeries during the study period (p = 0.026), and there was an overall decrease in revision surgeries over time (p < 0.001). There appears to be a homogenization of revision surgeries over time.

### CONCLUSIONS

There are significant and large practice variations in the surgical management of HC in Norway. There are significant differences between regions, particularly in terms of rates of shunt surgery for some diagnoses (communicating HC, normal pressure HC, and HC associated with cerebrovascular disease) as well as revision rates.

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## Impact of salvage surgery with or without reirradiation for skull base meningiomas recurring after prior radiotherapy

### OBJECTIVE

Long-term follow-up of meningiomas has demonstrated recurrence rates ranging from 2.5% to 48% after 10 years, depending on histology grade. There are limited data available to guide the management of recurrent and previously irradiated skull base meningiomas, and challenges related to salvage surgery, reirradiation, and lack of clear systemic therapy strategies remain. In this study, the authors analyzed data from their experience with recurrent and previously irradiated meningiomas to assess the impact of salvage surgery and reirradiation on progression-free survival (PFS).

### METHODS

A retrospective cohort study of 48 patients with recurrent and previously irradiated meningiomas who were treated between 1995 and 2021 was conducted. Data were extracted from medical records and included clinical, radiological, and pathologic reports. Patients were clustered according to WHO grades. The authors analyzed the complications related to reirradiation and salvage surgery and the impact of different treatment modalities on PFS using Cox proportional hazard ratios.

### CONCLUSIONS

This study examined the impact of retreatment on PFS in a large cohort of patients with recurrent meningiomas that had been previously irradiated. At the time of recurrence, WHO grade I meningiomas exhibited improved PFS with GTR, subtotally resected WHO grade II meningiomas appeared to have improved PFS when reirradiated, and reirradiation in WHO grade III meningiomas showed improved PFS.

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## Incisional CSF leakage after intradural cranial surgery in children: incidence, risk factors, and complications

### OBJECTIVE

The risk of cerebrospinal fluid (CSF) leakage after cranial surgery and its associated complications in children are unclear because of variable definitions and the lack of multicenter studies. In this study, the authors aimed to establish the incidence of CSF leakage after intradural cranial surgery in the pediatric population. In addition, they evaluated potential risk factors and complications related to CSF leakage in the pediatric population.

### METHODS

The authors performed an international multicenter retrospective cohort study in three tertiary neurosurgical referral centers. Included were all patients aged 18 years or younger who had undergone cranial surgery to reach the subdural space during the period between 2015 and 2021. Patients who died or were lost to follow-up within 6 weeks after surgery were excluded. The primary outcome measure was the incidence of CSF leakage, defined as leakage through the skin, within 6 weeks after surgery. Univariable and multivariable logistic regression analyses were performed to identify risk factors for and complications related to CSF leakage.

### RESULTS

In total, 759 procedures were identified, performed in 687 individual patients. The incidence of CSF leakage was 7.5% (95% CI 5.7%–9.6%). In the multivariate model, independent risk factors for CSF leakage were hydrocephalus (OR 4.5, 95% CI 2.2–8.9) and craniectomy (OR 7.6, 95% CI 3.0–19.5). Patients with CSF leakage had higher odds of pseudomeningocele (5.7, 95% CI 3.0–10.8), meningitis (21.1, 95% CI 9.5–46.8), and surgical site infection (7.4, 95% CI 2.6–20.8) than patients without leakage.

### CONCLUSIONS

CSF leakage risk in children after cranial surgery, which is comparable to the risk reported in adults, is an event of major concern and has a serious clinical impact.

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## Letter to the Editor. Wound complication rates and spine tumors

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## Neurosurgical management of proton beam therapy–induced moyamoya syndrome

### OBJECTIVE

Proton beam therapy (PBT) is an increasingly used treatment modality for pediatric patients with brain tumors. Moyamoya syndrome (MMS) is well recognized as a complication of traditional photon radiotherapy, however its association with PBT is less well described. The authors discuss their initial experience with the neurosurgical management of MMS secondary to PBT in a large-volume pediatric neurovascular service.

### METHODS

The authors performed a retrospective case review of consecutive children referred for neurosurgical management of MMS after PBT between 2009 and 2022. Patient demographic characteristics, oncological history and treatment, interval between PBT and MMS diagnosis, and MMS management were recorded. Clinical outcome at last review was classified as good if the modified Rankin Scale (mRS) score was ≤ 2 and/or the patient attended mainstream education without additional assistance. Poor outcome was defined as mRS score ≥ 3 and/or the patient received additional educational support. The recorded radiological outcomes included angiographic analysis of stenosis, evidence of brain ischemia/infarction on MRI, and postsurgical angiographic revascularization.

### RESULTS

Ten patients were identified. Oncological diagnosis included craniopharyngioma (n = 6), optic pathway glioma (1), ependymoma (1), Ewing sarcoma (1), and rhabdosarcoma (1). The median (interquartile range [IQR]) age at PBT was 5.1 (2.7–7.9) years. The median (IQR) age at MMS diagnosis was 7.8 (5.7–9.3) years. The median time between PBT and diagnosis of MMS was 20 (15–41) months. Six patients had poor functional status after initial oncological treatment and prior to diagnosis of MMS. All 10 patients had endocrine dysfunction, 8 had visual impairment, and 4 had behavioral issues prior to MMS diagnosis. Four patients had a perioperative ischemic event: 2 after tumor surgery, 1 after MMS surgical revascularization, and 1 after receiving a general anesthetic for an MRI scan during oncological surveillance. Seven children were treated with surgical revascularization, whereas 3 were managed medically. The incidence of ischemic events per cerebral hemisphere was reduced after surgical revascularization: only 1 patient of 7 had an ischemic event during the follow-up period after surgery. No children moved from good to poor functional status after MMS diagnosis.

### CONCLUSIONS

MMS can occur after PBT. Magnetic resonance angiography sequences should be included in surveillance MRI scans to screen for MMS, and families should be counseled about this complication. Management at a high-volume pediatric neurovascular center, including selective use of revascularization surgery, appears to maintain functional status in these children.