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Calibration of a comprehensive predictive model for the development of proximal junctional kyphosis and failure in adult spinal deformity patients with consideration of contemporary goals and techniques

Peter S. Tretiakov, Renaud Lafage, Justin S. Smith, Breton G. Line, Bassel G. Diebo, Alan H. Daniels, Jeffrey Gum, Themistocles Protopsaltis, D. Kojo Hamilton, Alex Soroceanu, Justin K. Scheer, Robert K. Eastlack, Gregory Mundis Jr., Pierce D. Nunley, Eric O. Klineberg, Khaled Kebaish, Stephen Lewis, Lawrence Lenke, Richard Hostin, Munish C. Gupta, Christopher P. Ames, Robert A. Hart, Douglas Burton, Christopher I. Shaffrey, Frank Schwab, Shay Bess, Han Jo Kim, Virginie Lafage, and Peter G. Passias

OBJECTIVE

The objective of this study was to calibrate an updated predictive model incorporating novel clinical, radiographic, and prophylactic measures to assess the risk of proximal junctional kyphosis (PJK) and failure (PJF).

METHODS

Operative patients with adult spinal deformity (ASD) and baseline and 2-year postoperative data were included. PJK was defined as ≥ 10° in sagittal Cobb angle between the inferior uppermost instrumented vertebra (UIV) endplate and superior endplate of the UIV + 2 vertebrae. PJF was radiographically defined as a proximal junctional sagittal Cobb angle ≥ 15° with the presence of structural failure and/or mechanical instability, or PJK with reoperation. Backstep conditional binary supervised learning models assessed baseline demographic, clinical, and surgical information to predict the occurrence of PJK and PJF. Internal cross validation of the model was performed via a 70%/30% cohort split. Conditional inference tree analysis determined thresholds at an alpha level of 0.05.

RESULTS

Seven hundred seventy-nine patients with ASD (mean 59.87 ± 14.24 years, 78% female, mean BMI 27.78 ± 6.02 kg/m2, mean Charlson Comorbidity Index 1.74 ± 1.71) were included. PJK developed in 50.2% of patients, and 10.5% developed PJF by their last recorded visit. The six most significant demographic, radiographic, surgical, and postoperative predictors of PJK/PJF were baseline age ≥ 74 years, baseline sagittal age-adjusted score (SAAS) T1 pelvic angle modifier > 1, baseline SAAS pelvic tilt modifier > 0, levels fused > 10, nonuse of prophylaxis measures, and 6-week SAAS pelvic incidence minus lumbar lordosis modifier > 1 (all p < 0.015). Overall, the model was deemed significant (p < 0.001), and internally validated receiver operating characteristic analysis returned an area under the curve of 0.923, indicating robust model fit.

CONCLUSIONS

PJK and PJF remain critical concerns in ASD surgery, and efforts to reduce the occurrence of PJK and PJF have resulted in the development of novel prophylactic techniques and enhanced clinical and radiographic selection criteria. This study demonstrates a validated model incorporating such techniques that may allow for the prediction of clinically significant PJK and PJF, and thus assist in optimizing patient selection, enhancing intraoperative decision making, and reducing postoperative complications in ASD surgery.

In Journal of Neurosurgery: Spine Publish Before Print

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Clinical outcomes of pediatric hemispherectomy following unsuccessful subhemispheric resection for refractory epilepsy: a case review study

Lisa F. Akiyama, Emma A. Roberts, Hillary A. Shurtleff, Dwight Barry, Russell P. Saneto, Edward J. Novotny, Christopher C. Young, Molly H. Warner, Jason S. Hauptman, Jeffrey G. Ojemann, and Ahmad Marashly

OBJECTIVE

Epilepsy surgery remains one of the most underutilized procedures in epilepsy despite its proven superiority to other available therapies. This underutilization is greater in patients in whom initial surgery fails. This case series examined the clinical characteristics, reasons for initial surgery failure, and outcomes in a cohort of patients who underwent hemispherectomy following unsuccessful smaller resections for intractable epilepsy (subhemispheric group [SHG]) and compared them to those of a cohort of patients who underwent hemispherectomy as the first surgery (hemispheric group [HG]). The objective of this paper was to determine the clinical characteristics of patients in whom a small, subhemispheric resection failed, who went on to become seizure free after undergoing a hemispherectomy.

METHODS

Patients who underwent hemispherectomy at Seattle Children’s Hospital between 1996 and 2020 were identified. Inclusion criteria for SHG were as follows: 1) patients ≤ 18 years of age at the time of hemispheric surgery; 2) initial subhemispheric epilepsy surgery that did not produce seizure freedom; 3) hemispherectomy or hemispherotomy after the subhemispheric surgery; and 4) follow-up for at least 12 months after hemispheric surgery. Data collected included the following: patient demographics; seizure etiology; comorbidities; prior neurosurgeries; neurophysiological studies; imaging studies; and surgical details—plus surgical, seizure, and functional outcomes. Seizure etiology was classified as follows: 1) developmental, 2) acquired, or 3) progressive. The authors compared SHG to HG in terms of demographics, seizure etiology, and seizure and neuropsychological outcomes.

RESULTS

There were 14 patients in the SHG and 51 patients in the HG. All patients in the SHG had Engel class IV scores after their initial resective surgery. Overall, 86% (n = 12) of the patients in the SHG had good posthemispherectomy seizure outcomes (Engel class I or II). All patients in the SHG who had progressive etiology (n = 3) had favorable seizure outcomes, with eventual hemispherectomy (1 each with Engel classes I, II, and III). Engel classifications posthemispherectomy between the groups were similar. There were no statistical differences in postsurgical Vineland Adaptive Behavior Scales Adaptive Behavior Composite scores or postsurgical full-scale IQ scores between groups when accounting for presurgical scores.

CONCLUSIONS

Hemispherectomy as a repeat surgery after unsuccessful subhemispheric epilepsy surgery has a favorable seizure outcome, with stable or improved intelligence and adaptive functioning. Findings in these patients are similar to those in patients who had hemispherectomy as their first surgery. This can be explained by the relatively small number of patients in the SHG and the higher likelihood of hemispheric surgeries to resect or disconnect the entire epileptogenic lesion compared to smaller resections.

In Journal of Neurosurgery: Pediatrics Publish Before Print

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Clinical outcomes of solitary fibrous tumors and hemangiopericytomas and risk factors related to recurrence and survival based on the 2021 WHO classification of central nervous system tumors

Yingxi Wu, Tianzhi Zhao, Yaning Cai, Min Zheng, Yunze Zhang, Yan Qu, and Qing Cai

OBJECTIVE

The authors aimed to explore the clinical outcomes and risk factors related to recurrence of and survival from solitary fibrous tumors (SFTs) and hemangiopericytomas (HPCs) that were reclassified according to the 2021 WHO classification of central nervous system (CNS) tumors.

METHODS

The authors retrospectively collected and analyzed the clinical and pathological data of SFTs and HPCs recorded from January 2007 to December 2021. Two neuropathologists reassessed pathological slides and regraded specimens on the basis of the 2021 WHO classification. The prognostic factors related to progression-free survival (PFS) and overall survival (OS) were statistically assessed with univariate and multivariate Cox regression analyses.

RESULTS

A total of 146 patients (74 men and 72 women, mean ± SD [range] age 46.1 ± 14.3 [3–78] years) were reviewed, and 86, 35, and 25 patients were reclassified as having grade 1, 2, and 3 SFTs on the basis of the 2021 WHO classification, respectively. The median PFS and OS of the patients with WHO grade 1 SFT were 105 months and 199 months after initial diagnosis; for patients with WHO grade 2 SFT, 77 months and 145 months; and for patients with WHO grade 3 SFT, 44 months and 112 months, respectively. Of the entire cohort, 61 patients experienced local recurrence and 31 died, of whom 27 (87.1%) died of SFT and relevant complications. Ten patients had extracranial metastasis. In multivariate Cox regression analysis, subtotal resection (STR) (HR 4.648, 95% CI 2.601–8.304, p < 0.001), tumor located in the parasagittal or parafalx region (HR 2.105, 95% CI 1.099–4.033, p = 0.025), tumor in the vertebrae (HR 3.352, 95% CI 1.228–9.148, p = 0.018), WHO grade 2 SFT (HR 2.579, 95% CI 1.343–4.953, p = 0.004), and WHO grade 3 SFT (HR 5.814, 95% CI 2.887–11.712, p < 0.001) were significantly associated with shortened PFS, whereas STR (HR 3.217, 95% CI 1.435–7.210, p = 0.005) and WHO grade 3 SFT (HR 3.433, 95% CI 1.324–8.901, p = 0.011) were significantly associated with shortened OS. In univariate analyses, patients who received adjuvant radiotherapy (RT) after STR had longer PFS than patients who did not receive RT.

CONCLUSIONS

The 2021 WHO classification of CNS tumors better predicted malignancy with different pathological grades, and in particular WHO grade 3 SFT had worse prognosis. Gross-total resection (GTR) can significantly prolong PFS and OS and should serve as the most important treatment method. Adjuvant RT was helpful for patients who underwent STR but not for patients who underwent GTR.

In Journal of Neurosurgery Publish Before Print

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Complications associated with single-position prone lateral lumbar interbody fusion: a systematic review and pooled analysis

S. Harrison Farber, Bayron Valenzuela Cecchi, Luke K. O’Neill, Kristina M. Chapple, James J. Zhou, Nima Alan, Timothy C. Gooldy, Joseph D. DiDomenico, Laura A. Snyder, Jay D. Turner, and Juan S. Uribe

OBJECTIVE

Lateral lumbar interbody fusion (LLIF) is a workhorse surgical approach for lumbar arthrodesis. There is growing interest in techniques for performing single-position surgery in which LLIF and pedicle screw fixation are performed with the patient in the prone position. Most studies of prone LLIF are of poor quality and without long-term follow-up; therefore, the complication profile related to this novel approach is not well known. The objective of this study was to perform a systematic review and pooled analysis to understand the safety profile of prone LLIF.

METHODS

A systematic review of the literature and a pooled analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All studies reporting prone LLIF were assessed for inclusion. Studies not reporting complication rates were excluded.

RESULTS

Ten studies meeting the inclusion criteria were analyzed. Overall, 286 patients were treated with prone LLIF across these studies, and a mean (SD) of 1.3 (0.2) levels per patient were treated. The 18 intraoperative complications reported included cage subsidence (3.8% [3/78]), anterior longitudinal ligament rupture (2.3% [5/215]), cage repositioning (2.1% [2/95]), segmental artery injury (2.0% [5/244]), aborted prone interbody placement (0.8% [2/244]), and durotomy (0.6% [1/156]). No major vascular or peritoneal injuries were reported. Sixty-eight postoperative complications occurred, including hip flexor weakness (17.8% [21/118]), thigh and groin sensory symptoms (13.3% [31/233]), revision surgery (3.8% [3/78]), wound infection (1.9% [3/156]), psoas hematoma (1.3% [2/156]), and motor neural injury (1.2% [2/166]).

CONCLUSIONS

Single-position LLIF in the prone position appears to be a safe surgical approach with a low complication profile. Longer-term follow-up and prospective studies are needed to better characterize the long-term complication rates related to this approach.

In Journal of Neurosurgery: Spine Publish Before Print

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Does disc distraction after cervical total disc arthroplasty impact range of motion and patient-reported outcomes?

Vincent P. Federico, Athan G. Zavras, James W. Nie, Alexander J. Butler, Mohammed A. Munim, Michael T. Nolte, Gregory D. Lopez, Howard S. An, Matthew W. Colman, and Frank M. Phillips

OBJECTIVE

Total disc arthroplasty (TDA) has been established as a safe and effective alternative to anterior cervical discectomy and fusion for the treatment of cervical spine pathology. However, there remains a paucity of studies in the literature regarding the amount of disc height distraction that can be tolerated, as well as its impact on kinematic and clinical outcomes.

METHODS

Patients who underwent 1- or 2-level cervical TDA with a minimum follow-up of 1 year with lateral flexion/extension and patient-reported outcome measures (PROMs) were included. Middle disc space height was measured on preoperative and 6-week postoperative lateral radiographs to quantify the magnitude of disc space distraction, and patients were grouped into < 2-mm distraction and > 2-mm distraction groups. Radiographic outcomes included operative segment lordosis, segmental range of motion (ROM) on flexion/extension, cervical (C2–7) ROM on flexion/extension, and heterotopic ossification (HO). General health and disease-specific PROMs were compared at the preoperative, 6-week, and final postoperative time points. The independent-samples t-test and chi-square test were used to compare outcomes between groups, while multivariate linear regression was used to adjust for baseline differences.

RESULTS

Fifty patients who underwent cervical TDA at 59 levels were included in the analysis. Distraction < 2 mm was seen at 30 levels (50.85%), while distraction > 2 mm was observed at 29 levels (49.15%). Radiographically, after adjustment for baseline differences, C2–7 ROM was significantly greater in the patients who underwent TDA with < 2-mm disc space distraction at final follow-up (51.35° ± 13.76° vs 39.19° ± 10.52°, p = 0.002), with a trend toward significance in the early postoperative period. There were no significant postoperative differences in segmental lordosis, segmental ROM, or HO grades. After the authors controlled for baseline differences, < 2-mm distraction of the disc space led to significantly greater improvement in visual analog scale (VAS)–neck scores at 6 weeks (−3.68 ± 3.12 vs −2.24 ± 2.70, p = 0.031) and final follow-up (−4.59 ± 2.74 vs −1.70 ± 3.03, p = 0.008).

CONCLUSIONS

Patients with < 2-mm disc height difference had increased C2–7 ROM at final follow-up and significantly greater improvement in neck pain after controlling for baseline differences. Limiting differences in disc space height to < 2 mm affected C2–7 ROM but not segmental ROM, suggesting that less distraction may result in more harmonious kinematics between all cervical levels.

In Journal of Neurosurgery: Spine Publish Before Print

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Effect of collateral status on the outcomes of endovascular treatment of acute basilar artery occlusion due to large-artery atherosclerosis

Xingyun Yuan, Haojin Zhao, Yuanjun Shan, Jiacheng Huang, Jinrong Hu, Jie Yang, Zhouzhou Peng, Weilin Kong, Changwei Guo, Wenjie Zi, and Nizhen Yu

OBJECTIVE

Authors of this study aimed to evaluate the effects of collateral status on the prognostic value of endovascular treatment (EVT) in patients with basilar artery occlusion (BAO) due to large-artery atherosclerosis (LAA).

METHODS

The study included 312 patients from the BASILAR (Endovascular Treatment for Acute Basilar Artery Occlusion Study) registry who had undergone EVT for acute BAO due to LAA and whose composite collateral scores were available. The effects of collateral status on EVT were assessed based on the composite collateral score (0–2 vs 3–5). The primary outcome was a favorable outcome (modified Rankin Scale score of 0–3) at 90 days.

RESULTS

The composite collateral score was 0–2 in 130 patients and 3–5 in 182. A good collateral status (composite collateral score 3–5) was associated with a favorable outcome (66/182 [36.3%] vs 31/130 [23.8%], adjusted odds ratio [aOR] 2.21, 95% CI 1.18–4.14, p = 0.014). A lower baseline National Institutes of Health Stroke Scale (NIHSS) score was an independent predictor of a favorable outcome in the poor collateral status group (aOR 0.91, 95% CI 0.87–0.96, p = 0.001). In the good collateral status group, there was a significant correlation between favorable outcomes and a younger age (aOR 0.96, 95% CI 0.92–0.99, p = 0.016), lower baseline NIHSS score (aOR 0.89, 95% CI 0.85–0.93, p < 0.001), lower proportion of diabetes mellitus (aOR 0.31, 95% CI 0.13–0.75, p = 0.009), and shorter procedure time (aOR 0.99, 95% CI 0.98–1.00, p = 0.003).

CONCLUSIONS

A good collateral status was a strong prognostic factor after EVT in patients with BAO underlying LAA. A shorter procedure time was associated with favorable outcomes in patients with a good collateral status.

In Journal of Neurosurgery Publish Before Print

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Ethical challenges of travel for experimental therapy in malignant brain tumor patients

Manuela Vooijs, Faith C. Robertson, Gail Rosseau, Anastasia Tasiou, Ana Rodríguez-Hernández, Stiliana I. Mihaylova, Mary Murphy, and Marike L. D. Broekman

In Journal of Neurosurgery Publish Before Print

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Hydrocephalus in the emergency department: descriptive nationwide data and analysis of transfer

Joseph Piatt

OBJECTIVE

Hydrocephalus is a chronic, treatable, but in most cases incurable condition characterized by long periods of stability punctuated by crises. Patients in crisis usually seek care in an emergency department (ED). How patients with hydrocephalus use EDs has received almost no epidemiological study.

METHODS

Data were taken from the National Emergency Department Survey for 2018. Visits by patients with hydrocephalus were identified by diagnostic codes. Neurosurgical visits were identified by codes for imaging of the brain or skull or by neurosurgical procedure codes. Visits and dispositions were characterized by demographic factors for neurosurgical and unspecified visits by using methods for analysis of complex survey designs. Associations among demographic factors were assessed using latent class analysis.

RESULTS

There were an estimated 204,785 ED visits by patients with hydrocephalus in the United States in 2018. Roughly 80% of patients with hydrocephalus who visited EDs were adults or elders. By a ratio of 2:1, patients with hydrocephalus visited EDs much more often for unspecified reasons than for neurosurgical reasons. Patients with neurosurgical complaints had more costly ED visits, and if they were admitted they had longer and more costly hospitalizations than did patients with unspecified complaints. Only 1 in 3 patients with hydrocephalus who visited an ED was sent home regardless of whether the complaint was neurosurgical. Neurosurgical visits ended in transfer to another acute care facility more than 3 times as often as unspecified visits. Odds of transfer were more strongly associated with geography and, specifically, with proximity to a teaching hospital than with personal or community wealth.

CONCLUSIONS

Patients with hydrocephalus make heavy use of EDs, and they make more visits for reasons unrelated to their hydrocephalus than for neurosurgical reasons. Transfer to another acute care facility is an adverse clinical outcome that is much more common after neurosurgical visits. It is a system inefficiency that might be minimized by proactive case management and coordination of care.

In Journal of Neurosurgery Publish Before Print

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The ivy sign as a radiological marker for follow-up of postoperative cerebral perfusion status in adult moyamoya disease

Sung Ho Lee, Won-Sang Cho, Hee Chang Lee, Hansan Oh, Jin Woo Bae, Young Hoon Choi, Jin Chul Paeng, Joonhyung Gil, Kangmin Kim, Hyun-Seung Kang, and Jeong Eun Kim

OBJECTIVE

Little is known about the relationship between postoperative changes in cerebral perfusion and the ivy sign representing leptomeningeal collateral burden in moyamoya disease (MMD). This study aimed to investigate the usefulness of the ivy sign in evaluating cerebral perfusion status following bypass surgery in patients with adult MMD.

METHODS

Two hundred thirty-three hemispheres in 192 patients with adult MMD undergoing combined bypass between 2010 and 2018 were retrospectively enrolled. The ivy sign was represented as the ivy score on FLAIR MRI in each territory of the anterior, middle, and posterior cerebral arteries. Ivy scores, as well as clinical and hemodynamic states on SPECT, were semiquantitatively compared both preoperatively and at 6 months after surgery.

RESULTS

Clinical status improved at 6 months after surgery (p < 0.01). On average, ivy scores in whole and individual territories were decreased at 6 months (all p values < 0.01). Cerebral blood flow (CBF) postoperatively improved in three individual vascular territories (all p values ≤ 0.03) except for the posterior cerebral artery territory (PCAt), and cerebrovascular reserve (CVR) improved in those areas (all p values ≤ 0.04) except for the PCAt. Postoperative changes in ivy scores and CBF were inversely correlated in all territories (p ≤ 0.02), except for the PCAt. Furthermore, changes in ivy scores and CVR were only correlated in the posterior half of the middle cerebral artery territory (p = 0.01).

CONCLUSIONS

The ivy sign was significantly decreased after bypass surgery, which was well correlated with postoperative hemodynamic improvement in the anterior circulation territories. The ivy sign is believed to be a useful radiological marker for postoperative follow-up of cerebral perfusion status.

In Journal of Neurosurgery Publish Before Print

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Letter to the Editor. Dynamic pedicle-based stabilization: a true blessing?

Vishwa Bharathi Gaonkar, Manbachan Singh, Sanjeev Srivastava, Pawan Goyal, Sanjay K. Rajan, and Aditya Gupta

In Journal of Neurosurgery: Spine Publish Before Print