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Emrah Celtikci, Fatih Yakar, Pinar Celtikci and Yusuf Izci

OBJECTIVE

The aim of this study was to investigate the relationship between lumbar spondylolysis and payload weight between different combat units of Turkish land forces (TLF).

METHOD

The authors reviewed clinical and radiological data of the military personnel with low-back pain (LBP) admitted to their clinic between July 2017 and July 2018. Age, BMI, average payload weight, and military service unit were recorded. CT scans were evaluated for pars interarticularis fractures and spondylolisthesis, whereas MRI studies were evaluated for spondylolisthesis, Modic-type endplate changes, or signal loss on T2-weighted images compatible with disc degeneration.

RESULT

Following exclusion, a total of 642 all-male military personnel were included. Of these personnel, 122 were commandos, 435 were infantry, and 85 were serving in the artillery units. Bilateral pars interarticularis fracture was noted in 42 commandos (34.42%) and 2 infantrymen (0.45%). There was no spondylolysis in the artillery units. There was no multiple-level spondylolysis and the most common level of spondylolysis was L5. Commandos had a significantly higher incidence of spondylolysis and more average payload weight (p < 0.001). Twelve patients (27.2%) with spondylolysis had accompanying MRI pathologies at the same level, whereas 32 patients (72.7%) had no accompanying MRI pathologies.

CONCLUSIONS

Increased payload weight in military personnel is associated with spondylolysis, and commandos in the TLF have significantly heavier payloads, which causes an increased rate of spondylolysis compared to other units. Additionally, spondylolysis without adjacent-level changes on MRI could be undiagnosed. LBP in active military personnel who have a history of carrying heavy payloads should be evaluated extensively with both MRI and CT scans.

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Daniel B. Herrick, Joseph E. Tanenbaum, Marc Mankarious, Sagar Vallabh, Eitan Fleischman, Swamy Kurra, Shane M. Burke, Marie Roguski, Thomas E. Mroz, William F. Lavelle, Jeffrey E. Florman and Ron I. Riesenburger

OBJECTIVE

Use of surgical site drains following posterior cervical spine surgery is variable, and its impact on outcomes remains controversial. Studies of drain use in the lumbar spine have suggested that drains are not associated with reduction of reoperations for wound infection or hematoma. There is a paucity of studies examining this relationship in the cervical spine, where hematomas and infections can have severe consequences. This study aims to examine the relationship between surgical site drains and reoperation for wound-related complications following posterior cervical spine surgery.

METHODS

This study is a multicenter retrospective review of 1799 consecutive patients who underwent posterior cervical decompression with instrumentation at 4 tertiary care centers between 2004 and 2016. Demographic and perioperative data were analyzed for associations with drain placement and return to the operating room.

RESULTS

Of 1799 patients, 1180 (65.6%) had a drain placed. Multivariate logistic regression analysis identified history of diabetes (OR 1.37, p = 0.03) and total number of levels operated (OR 1.32, p < 0.001) as independent predictors of drain placement. Rates of reoperation for any surgical site complication were not different between the drain and no-drain groups (4.07% vs 3.88%, p = 0.85). Similarly, rates of reoperation for surgical site infection (1.61% vs 2.58%, p = 0.16) and hematoma (0.68% vs 0.48%, p = 0.62) were not different between the drain and no-drain groups. However, after adjusting for history of diabetes and the number of operative levels, patients with drains had significantly lower odds of returning to the operating room for surgical site infection (OR 0.48, p = 0.04) but not for hematoma (OR 1.22, p = 0.77).

CONCLUSIONS

This large study characterizes current practice patterns in the utilization of surgical site drains during posterior cervical decompression and instrumentation. Patients with drains placed did not have lower odds of returning to the operating room for postoperative hematoma. However, the authors’ data suggest that patients with drains may be less likely to return to the operating room for surgical site infection, although the absolute number of infections in the entire population was small, limiting the analysis.

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Abhijeet S. Barath, Osmond C. Wu, Mohit Patel and Manish K. Kasliwal

Ossification of the ligamentum flavum (OLF) is a well-recognized but rare cause of thoracic myelopathy. Its subtle and variable clinical presentation often makes the diagnosis challenging. The treatment of symptomatic OLF requires surgical intervention, with the most common surgical procedure being a posterior decompression with or without instrumentation. Recurrence of ossification and stenosis after surgery is rare and usually occurs at the same intervertebral level. Multiple recurrences of ossification and stenosis are exceptionally rare. The authors report the case of OLF in a 60-year-old man who experienced recurrence of ossification and stenosis twice after posterior decompression surgeries alone. The patient was ultimately treated with revision decompression and instrumented fusion. The authors also present a pertinent review of the literature.

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Charles A. Miller, Jason H. Boulter, Daniel J. Coughlin, Michael K. Rosner, Chris J. Neal and Michael S. Dirks

OBJECTIVE

Symptomatic cervical spondylosis with or without radiculopathy can ground an active-duty military pilot if left untreated. Surgically treated cervical spondylosis may be a waiverable condition and allow return to flying status, but a waiver is based on expert opinion and not on recent published data. Previous studies on rates of return to active duty status following anterior cervical spine surgery have not differentiated these rates among military specialty occupations. No studies to date have documented the successful return of US military active-duty pilots who have undergone anterior cervical spine surgery with cervical fusion, disc replacement, or a combination of the two. The aim of this study was to identify the rate of return to an active duty flight status among US military pilots who had undergone anterior cervical discectomy and fusion (ACDF) or total disc replacement (TDR) for symptomatic cervical spondylosis.

METHODS

The authors performed a single-center retrospective review of all active duty pilots who had undergone either ACDF or TDR at a military hospital between January 2010 and June 2017. Descriptive statistics were calculated for both groups to evaluate demographics with specific attention to preoperative flight stats, days to recommended clearance by neurosurgery, and days to return to active duty flight status.

RESULTS

Authors identified a total of 812 cases of anterior cervical surgery performed between January 1, 2010, and June 1, 2017, among active duty, reserves, dependents, and Department of Defense/Veterans Affairs patients. There were 581 ACDFs and 231 TDRs. After screening for military occupation and active duty status, there were a total of 22 active duty pilots, among whom were 4 ACDFs, 17 TDRs, and 2 hybrid constructs. One patient required a second surgery. Six (27.3%) of the 22 pilots were nearing the end of their career and electively retired within a year of surgery. Of the remaining 16 pilots, 11 (68.8%) returned to active duty flying status. The average time to be released by the neurosurgeon was 128 days, and the time to return to flying was 287 days. The average follow-up period was 12.3 months.

CONCLUSIONS

Adhering to military service-specific waiver guidelines, military pilots may return to active duty flight status after undergoing ACDF or TDR for symptomatic cervical spondylosis.

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Mohamad A. Hussain, Aziz S. Alali, Muhammad Mamdani, Jack V. Tu, Gustavo Saposnik, Konard Salata, Avery B. Nathens, Charles de Mestral, Deepak L. Bhatt, Subodh Verma and Mohammed Al-Omran

OBJECTIVE

Intracranial hemorrhage (ICH) associated with cerebral hyperperfusion syndrome is a rare but major complication of carotid artery revascularization. The objective of this study was to compare the rate of ICH after carotid artery stenting (CAS) with that after endarterectomy (CEA).

METHODS

The authors performed a retrospective population-based cohort study of patients who underwent carotid artery revascularization in the province of Ontario, Canada, between 2002 and 2015. The primary outcome was the rate of ICH that occurred within 90 days after carotid artery intervention among patients who underwent CAS versus that of those who underwent CEA. The authors used inverse probability of treatment weighting and propensity scores to account for selection bias. In sensitivity analyses, patients who had postprocedure ischemic stroke were excluded, and the following subgroups were examined: patients with symptomatic and asymptomatic carotid artery stenosis, patients treated between 2010 and 2015, and patients aged ≥ 66 years (to account for antiplatelet and anticoagulant use).

RESULTS

A total of 16,688 patients underwent carotid artery revascularization (14% CAS, 86% CEA). Patients with more comorbid illnesses, symptomatic carotid artery stenosis, or cardiac disease and those who were taking antiplatelet agents or warfarin before surgery were more likely to undergo CAS. Among the overall cohort, 80 (0.48%) patients developed ICH within 90 days (0.85% after CAS, 0.42% after CEA). The 180-day mortality rate after ICH in the overall cohort was 2.7%, whereas the 180-day mortality rate among patients who suffered ICH was 42.5% (40% for CAS-treated patients, 43.3% for CEA-treated patients). In the adjusted analysis, patients who underwent CAS were significantly more likely to have ICH than those who underwent CEA (adjusted OR 1.77; 95% CI 1.32–2.36; p < 0.001). These results were consistent after excluding patients who developed postprocedure ischemic stroke (adjusted OR 1.90; 95% CI 1.41–2.56) and consistent among symptomatic (adjusted OR 1.74; 95% CI 1.16–2.63) and asymptomatic (adjusted OR 1.75; 95% CI 1.16–2.63) patients with carotid artery stenosis, among patients treated between 2010 and 2015 (adjusted OR 2.21; 95% CI 1.45–3.38), and among the subgroup of patients aged ≥ 66 years (adjusted OR 1.53; 95% CI 1.05–2.24) after adjusting for medication use.

CONCLUSIONS

CAS is associated with a rare but higher risk of ICH relative to CEA. Future research is needed to devise strategies that minimize the risk of this serious complication after carotid artery revascularization.

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Robert A. McGovern, Elia Pestana Knight, Ajay Gupta, Ahsan N. V. Moosa, Elaine Wyllie, William E. Bingaman and Jorge Gonzalez-Martinez

OBJECTIVE

The goal in the study was to describe the clinical outcomes associated with robot-assisted stereoelectroencephalography (SEEG) in children.

METHODS

The authors performed a retrospective, single-center study in consecutive children with medically refractory epilepsy who were undergoing robot-assisted SEEG. Kaplan-Meier survival analysis was used to calculate the probability of seizure freedom. Both univariate and multivariate methods were used to analyze the preoperative and operative factors associated with seizure freedom.

RESULTS

Fifty-seven children underwent a total of 64 robot-assisted procedures. The patients’ mean age was 12 years, an average of 6.4 antiepileptic drugs (AEDs) per patient had failed prior to implantation, and in 56% of the patients the disease was considered nonlesional. On average, children had 12.4 electrodes placed per implantation, with an implantation time of 9.6 minutes per electrode and a 10-day postoperative stay. SEEG analysis yielded a definable epileptogenic zone in 51 (89%) patients; 42 (74%) patients underwent surgery, half of whom were seizure free at last follow-up, 19.6 months from resection. In a multivariate generalized linear model, resective surgery, older age, and shorter SEEG-related hospital length of stay were associated with seizure freedom. In a Cox proportional hazards model including only the children who underwent resective surgery, older age was the only significant factor associated with seizure freedom. Complications related to bleeding were the major contributors to morbidity. One patient (1.5%) had a symptomatic hemorrhage resulting in a permanent neurological deficit.

CONCLUSIONS

The authors report one of the largest pediatric-specific SEEG series demonstrating that the modern surgical management of medically refractory epilepsy in children can lead to seizure freedom in many patients, while also highlighting the challenges posed by this difficult patient population.

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Joshua Chiu, Steve Braunstein, Jean Nakamura, Philip Theodosopoulos, Penny Sneed, Michael McDermott and Lijun Ma

OBJECTIVE

Interfractional residual patient shifts are often observed during the delivery of hypofractionated brain radiosurgery. In this study, the authors developed a robustness treatment planning check procedure to assess the dosimetric effects of residual target shifts on hypofractionated Gamma Knife radiosurgery (GKRS).

METHODS

The residual patient shifts were determined during the simulation process immediately after patient immobilization. To mimic incorporation of residual target shifts during treatment delivery, a quality assurance procedure was developed to sample and shift individual shots according to the residual uncertainties in the prescribed treatment plan. This procedure was tested and demonstrated for 10 hypofractionated GKRS cases.

RESULTS

The maximum residual target shifts were less than 1 mm for the studied cases. When incorporating such shifts, the target coverage varied by 1.9% ± 2.2% (range 0.0%–7.1%) and selectivity varied by 3.6% ± 2.5% (range 1.1%–9.3%). Furthermore, when incorporating extra random shifts on the order of 0.5 mm, the target coverage decreased by as much as 7%, and nonisocentric variation in the dose distributions was noted for the studied cases.

CONCLUSIONS

A pretreatment robustness check procedure was developed and demonstrated for hypofractionated GKRS. Further studies are underway to implement this procedure to assess maximum tolerance levels for individual patient cases.

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Neena I. Marupudi, Carolyn Harris, Tanya Pavri, Brenna Mell, Rasanjeet Singh, Steven D. Ham and Sandeep Sood

OBJECTIVE

Lumboperitoneal (LP) shunts have a role not only in pseudotumor cerebri, but also in patients with slit-like ventricles who are treated with CSF shunting on a chronic basis. Hesitation to utilize LP shunts is based on previous conventional beliefs including the tendency for overdrainage, difficulties accessing the shunt to tap or revise, and risk of progressive cerebellar tonsillar herniation. The authors hypothesized that the use of horizontal-vertical (HV) valves may reduce the risk of these complications, particularly overdrainage and development of Chiari malformation.

METHODS

All pediatric cases involving patients treated with an LP shunt at the Children’s Hospital of Michigan were reviewed in this retrospective case series. A total of 143 patients with hydrocephalus were treated with LP shunts from 1997–2015 (follow-up range 8 months–8 years, median 4.2 years). Patients with pseudotumor cerebri underwent placement of an LP shunt as a primary procedure. In patients with slit ventricles from chronically treated hydrocephalus or repeated shunt malfunctions from proximal catheter obstruction, a lumbar drain was inserted to assess candidacy for conversion to an LP shunt. In patients who tolerated the lumbar drain and demonstrated communication of the ventricles with the spinal cisterns, treatment was converted to an LP shunt. All patients included in the series had undergone initial shunt placement between birth and age 16 years.

RESULTS

In 30% of patients (n = 43), LP shunts were placed as the initial shunt treatment; in 70% (n = 100), treatment was converted to LP shunts from ventriculoperitoneal (VP) shunts. The patients’ age at insertion of or conversion to an LP shunt ranged from 1 to 43 years (median 8.5 years). Of the patients with clear pre-LP and post-LP shunt follow-up imaging, none were found to develop an acquired Chiari malformation. In patients with pre-existing tonsillar ectopia, no progression was noted on follow-up MRIs of the brain in these patients after LP shunt insertion. In our LP shunt case series, no patient presented with acute deterioration from shunt malfunction.

CONCLUSIONS

Conversion to an LP shunt may minimize acute deterioration from shunt malfunction and decrease morbidity of repeated procedures in patients with chronically shunt-treated hydrocephalus and small ventricles. In comparison to previously published case series of LP shunt treatment, the use of LP shunts in conjunction with HV valves may decrease the overall risk of cerebellar tonsillar herniation. The use of an LP shunt may be an alternative in the management of slit ventricles when VP shunting repeatedly fails.

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Masayuki Nitta, Yoshihiro Muragaki, Takashi Maruyama, Hiroshi Iseki, Takashi Komori, Soko Ikuta, Taiichi Saito, Takayuki Yasuda, Junji Hosono, Saori Okamoto, Shunichi Koriyama and Takakazu Kawamata

OBJECTIVE

In this study on the effectiveness and safety of photodynamic therapy (PDT) using talaporfin sodium and a semiconductor laser, the long-term follow-up results of 11 patients with glioblastoma enrolled in the authors’ previous phase II clinical trial (March 2009–2012) and the clinical results of 19 consecutive patients with newly diagnosed glioblastoma prospectively enrolled in a postmarket surveillance (March 2014–December 2016) were analyzed and compared with those of 164 patients treated without PDT during the same period.

METHODS

The main outcome measures were the median overall survival (OS) and progression-free survival (PFS) times. Moreover, the adverse events and radiological changes after PDT, as well as the patterns of recurrence, were analyzed and compared between the groups. Kaplan-Meier curves were created to assess the differences in OS and PFS between the groups. Univariate and multivariate analyses were performed to identify the prognostic factors, including PDT, among patients with newly diagnosed glioblastoma.

RESULTS

The median PFS times of the PDT and control groups were 19.6 and 9.0 months, with 6-month PFS rates of 86.3% and 64.9%, respectively (p = 0.016). The median OS times were 27.4 and 22.1 months, with 1-year OS rates of 95.7% and 72.5%, respectively (p = 0.0327). Multivariate analyses found PDT, preoperative Karnofsky Performance Scale score, and IDH mutation to be significant independent prognostic factors for both OS and PFS. Eighteen of 30 patients in the PDT group experienced tumor recurrence, including local recurrence, distant recurrence, and dissemination in 10, 3, and 4 patients, respectively. Conversely, 141 of 164 patients in the control group experienced tumor recurrence, including 101 cases of local recurrence. The rate of local recurrence tended to be lower in the PDT group (p = 0.06).

CONCLUSIONS

The results of the present study suggest that PDT with talaporfin sodium and a semiconductor laser provides excellent local control, with few adverse effects even in cases of multiple laser irradiations, as well as potential survival benefits for patients with newly diagnosed glioblastoma.