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Comparison of minimally invasive decompression alone versus minimally invasive short-segment fusion in the setting of adult degenerative lumbar scoliosis: a propensity score–matched analysis

Murray Echt, Adewale A. Bakare, Jesus R. Varela, Andrew Platt, Mohammed Abdul Sami, Joseph Molenda, Mena Kerolus, and Richard G. Fessler

OBJECTIVE

Patients with degenerative lumbar scoliosis (DLS) and neurogenic pain may be candidates for decompression alone or short-segment fusion. In this study, minimally invasive surgery (MIS) decompression (MIS-D) and MIS short-segment fusion (MIS-SF) in patients with DLS were compared in a propensity score–matched analysis.

METHODS

The propensity score was calculated using 13 variables: sex, age, BMI, Charlson Comorbidity Index, smoking status, leg pain, back pain, grade 1 spondylolisthesis, lateral spondylolisthesis, multilevel spondylolisthesis, lumbar Cobb angle, pelvic incidence minus lumbar lordosis, and pelvic tilt in a logistic regression model. One-to-one matching was performed to compare perioperative morbidity and patient-reported outcome measures (PROMs). The minimal clinically important difference (MCID) for patients was calculated based on cutoffs of percentage change from baseline: 42.4% for Oswestry Disability Index (ODI), 25.0% for visual analog scale (VAS) low-back pain, and 55.6% for VAS leg pain.

RESULTS

A total of 113 patients were included in the propensity score calculation, resulting in 31 matched pairs. Perioperative morbidity was significantly reduced for the MIS-D group, including shorter operative duration (91 vs 204 minutes, p < 0.0001), decreased blood loss (22 vs 116 mL, p = 0.0005), and reduced length of stay (2.6 vs 5.1 days, p = 0.0004). Discharge status (home vs rehabilitation), complications, and reoperation rates were similar. Preoperative PROMs were similar, but after 3 months, improvement was significantly higher for the MIS-SF group in the VAS back pain score (−3.4 vs −1.2, p = 0.044) and Veterans RAND 12-Item Health Survey (VR-12) Mental Component Summary (MCS) score (+10.3 vs +1.9, p = 0.009), and after 1 year the MIS-SF group continued to have significantly greater improvement in the VAS back pain score (−3.9 vs −1.2, p = 0.026), ODI score (−23.1 vs −7.4, p = 0.037), 12-Item Short-Form Health Survey MCS score (+6.5 vs −6.5, p = 0.0374), and VR-12 MCS score (+7.6 vs −5.1, p = 0.047). MCID did not differ significantly between the matched groups for VAS back pain, VAS leg pain, or ODI scores (p = 0.38, 0.055, and 0.072, respectively).

CONCLUSIONS

Patients with DLS undergoing surgery had similar rates of significant improvement after both MIS-D and MIS-SF. For matched patients, tradeoffs were seen for reduced perioperative morbidity for MIS-D versus greater magnitudes of improvement in back pain, disability, and mental health for patients 1 year after MIS-SF. However, rates of MCID were similar, and the small sample size among the matched patients may be subject to patient outliers, limiting generalizability of these results.

In Journal of Neurosurgery: Spine Publish Before Print

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Comparison of outcomes in the management of abdominal pseudocyst in children with shunted hydrocephalus: a Hydrocephalus Clinical Research Network study

Vijay M. Ravindra, Hailey Jensen, Jay Riva-Cambrin, John C. Wellons III, David D. Limbrick Jr., Jonathan Pindrik, Eric M. Jackson, Ian F. Pollack, Todd C. Hankinson, Jason S. Hauptman, Mandeep S. Tamber, Abhaya V. Kulkarni, Brandon G. Rocque, Curtis Rozzelle, William E. Whitehead, Jason Chu, Mark D. Krieger, Tamara D. Simon, Ron Reeder, Patrick J. McDonald, Nichol Nunn, John R. W. Kestle, and

OBJECTIVE

Abdominal pseudocyst (APC) can cause distal site failure in children with ventriculoperitoneal shunts and is specifically designated as an infection in Hydrocephalus Clinical Research Network (HCRN) protocols. Specific management and outcomes of children with APCs have not been reported in a multicenter study. In this study, the authors investigated the management and outcomes of APC in children with shunted hydrocephalus who were treated at centers in the HCRN.

METHODS

The HCRN Registry was queried to identify children < 18 years old with shunts who were diagnosed with an APC (i.e., a loculated abdominal fluid collection containing the peritoneal catheter with abdominal distention and/or displacement of peritoneal contents). The primary outcome was shunt failure after APC treatment. The primary variable was reimplantation of the distal catheter after pseudocyst treatment back into the peritoneum versus implantation in a nonperitoneal site. Other risk factors for shunt failure after APC treatment and variability in APC management were investigated.

RESULTS

Among 141 children from 14 centers who underwent first-time management of an APC over a 14-year period, the median time from previous shunt surgery to APC diagnosis was 3.8 months. Overall, 17.7% of children had a positive culture: APC cultures were positive in 14.2% and CSF cultures in 15.6%. Six other children underwent shunt revision without removal; all underwent reoperation within 1 month. There was no difference in shunt survival (log-rank test, p = 0.42) or number of subsequent revisions within 6, 12, or 24 months for shunts reimplanted in the abdomen versus those implanted in a nonperitoneal location. Nonperitoneal implantation was associated with more noninfectious revisions (42.3% vs 22.9%, p = 0.019), whereas infection was more common after reimplantation in the abdomen (25.7% vs 7.0%, p = 0.003). Univariable analysis demonstrated that younger age at APC diagnosis (8.3 vs 12.2 years, p = 0.006) and prior shunt procedure within 12 weeks of APC diagnosis (59.5% vs 40.5%, p = 0.012) were associated with shunt failure after APC treatment. Multivariable modeling confirmed that prior shunt surgery within 12 weeks of APC diagnosis was independently associated with failure (HR 1.79 [95% CI 1.04–3.07], p = 0.035).

CONCLUSIONS

In the HCRN, APCs in the setting of CSF shunts are usually managed with externalization. Shunt surgery within 12 weeks of APC diagnosis was associated with risk of failure after APC treatment. Although no differences were found in overall shunt failure rate, noninfectious shunt revisions were more common in the nonperitoneal distal catheter sites, and infection was a more common reason for failure after reimplantation of the shunt in the abdomen.

In Journal of Neurosurgery: Pediatrics Publish Before Print

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Erratum. Tethered spinal cord among individuals with myelomeningocele: an analysis of the National Spina Bifida Patient Registry

Mark S. Dias

In Journal of Neurosurgery: Pediatrics Publish Before Print

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Expression of Concern

James T. Rutka

In Journal of Neurosurgery Publish Before Print

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Failure of nonoperative care in adult symptomatic lumbar scoliosis: incidence, timing, and risk factors for conversion from nonoperative to operative treatment

John C. F. Clohisy, Justin S. Smith, Michael P. Kelly, Elizabeth L. Yanik, Christine R. Baldus, Shay Bess, Christopher I. Shaffrey, Han Jo Kim, Adam LaBore, Vy Pham, and Keith H. Bridwell

OBJECTIVE

The Adult Symptomatic Lumbar Scoliosis (ASLS) study is a prospective multicenter trial with randomized and observational cohorts comparing operative and nonoperative treatment for ASLS. The objective of the present study was to perform a post hoc analysis of the ASLS trial to examine factors related to failure of nonoperative treatment in ASLS.

METHODS

Patients from the ASLS trial who initially received at least 6 months of nonoperative treatment were followed for up to 8 years after trial enrollment. Baseline patient-reported outcome measures (Scoliosis Research Society-22 [SRS-22] questionnaire and Oswestry Disability Index), radiographic data, and other clinical characteristics were compared between patients who did and did not convert to operative treatment during follow-up. The incidence of operative treatment was calculated and independent predictors of operative treatment were identified using multivariate regression.

RESULTS

Of 135 nonoperative patients, 42 (31%) crossed over to operative treatment after 6 months and 93 (69%) received only nonoperative treatment. In the observational cohort, 23 (22%) of 106 nonoperative patients crossed over to surgery. In the randomized cohort, 19 (66%) of 29 patients randomized to nonoperative treatment crossed over to surgery. The most impactful factors associated with crossover from nonoperative to operative treatment were enrollment in the randomized cohort and baseline SRS-22 subscore < 3.0 at the 2-year follow-up, closer to 3.4 at 8 years. In addition, baseline lumbar lordosis (LL) < 50° was associated with crossover to operative treatment. Each 1-point decrease in baseline SRS-22 subscore was associated with a 233% higher risk of conversion to surgery (hazard ratio [HR] 2.33, 95% confidence interval [CI] 1.14–4.76, p = 0.0212). Each 10° decrease in LL was associated with a 24% increased risk of conversion to operative treatment (HR 1.24, 95% CI 1.03–1.49, p = 0.0232). Enrollment in the randomized cohort was associated with a 337% higher probability of proceeding with operative treatment (HR 3.37, 95% CI 1.54–7.35, p = 0.0024).

CONCLUSIONS

Enrollment in the randomized cohort, a lower baseline SRS-22 subscore, and lower LL were associated with conversion from nonoperative treatment to surgery in patients (observational and randomized) who were initially managed nonoperatively in the ASLS trial.

In Journal of Neurosurgery: Spine Publish Before Print

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Letter to the Editor. Endovascular treatment: a first-line approach for anterior cranial fossa DAVFs?

Xin Su, Zhenzhong Gao, Yongjie Ma, Zihao Song, Hongqi Zhang, Peng Zhang, and Ming Ye

In Journal of Neurosurgery Publish Before Print

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Measurement of interspinous motion in dynamic cervical radiographs using a deep learning–based segmentation model

Dae-Woong Ham, Yang-seon Choi, Yisack Yoo, Sang-Min Park, and Kwang-Sup Song

OBJECTIVE

Interspinous motion (ISM) is a representative method for evaluating the functional fusion status following anterior cervical discectomy and fusion (ACDF) surgery, but the associated measuring difficulty and potential errors in the clinical setting remain concerns. The aim of this study was to investigate the feasibility of a deep learning–based segmentation model for measuring ISM in patients who underwent ACDF surgery.

METHODS

This study is a retrospective analysis of flexion-extension dynamic cervical radiographs from a single institution and a validation of a convolutional neural network (CNN)–based artificial intelligence (AI) algorithm for measuring ISM. Data from 150 lateral cervical radiographs from the normal adult population were used to train the AI algorithm. A total of 106 pairs of dynamic flexion-extension radiographs from patients who underwent ACDF at a single institution were analyzed and validated for measuring ISM. To evaluate the agreement power between human experts and the AI algorithm, the authors assessed the interrater reliability using the intraclass correlation coefficient and root mean square error (RMSE) and performed a Bland-Altman plot analysis. They processed 106 pairs of radiographs from ACDF patients into the AI algorithm for autosegmenting the spinous process created using 150 normal population radiographs. The algorithm automatically segmented the spinous process and converted it to a binary large object (BLOB) image. The rightmost coordinate value of each spinous process from the BLOB image was extracted, and the pixel distance between the upper and lower spinous process coordinate value was calculated. The AI-measured ISM was calculated by multiplying the pixel distance by the pixel spacing value included in the DICOM tag of each radiograph.

RESULTS

The AI algorithm showed a favorable prediction power for detecting spinous processes with an accuracy of 99.2% in the test set radiographs. The interrater reliability between the human and AI algorithm of ISM was 0.88 (95% CI 0.83–0.91), and its RMSE was 0.68. In the Bland-Altman plot analysis, the 95% limit of interrater differences ranged from 0.11 to 1.36 mm, and a few observations were outside the 95% limit. The mean difference between observers was 0.02 ± 0.68 mm.

CONCLUSIONS

This novel CNN-based autosegmentation algorithm for measuring ISM in dynamic cervical radiographs showed strong agreement power to expert human raters and could help clinicians to evaluate segmental motion following ACDF surgery in clinical settings.

In Journal of Neurosurgery: Spine Publish Before Print

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Pediatric patients with malignant brain tumor treated at children’s hospitals: association with fewer unplanned readmissions

Kristie Q. Liu, Shivani D. Rangwala, Talia A. Wenger, Mmerobasi U. Kanu, Jane S. Han, Li Ding, William J. Mack, Mark D. Krieger, and Frank J. Attenello

OBJECTIVE

Pediatric primary brain tumors are the leading cause of death among childhood cancers. Guidelines recommend specialized care with a multidisciplinary team and focused treatment protocols to optimize outcomes in this patient population. Furthermore, readmission is a key metric of patient outcomes and has been used to inform reimbursement. However, no prior study has analyzed national database–level records to evaluate the role of care in a designated children’s hospital following pediatric tumor resection and its impact on readmission rates. The goal of this study was to investigate whether treatment at a children’s hospital rather than a nonchildren’s hospital has a significant effect on outcome.

METHODS

The Nationwide Readmissions Database records from 2010 to 2018 were analyzed retrospectively to evaluate the effect of hospital designation on patient outcomes after craniotomy for brain tumor resection, and results are reported as national estimates. Univariate and multivariate regression analyses of patient and hospital characteristics were conducted to evaluate if craniotomy for tumor resection at a designated children’s hospital was independently associated with 30-day readmissions, mortality rate, and length of stay.

RESULTS

A total of 4003 patients who underwent craniotomy for tumor resection were identified using the Nationwide Readmissions Database, with 1258 of these cases (31.4%) treated at children’s hospitals. Patients treated at children’s hospitals were associated with decreased likelihood of 30-day hospital readmission (OR 0.68, 95% CI 0.48–0.97, p = 0.036) compared to patients treated at nonchildren’s hospitals. There was no significant difference in index mortality between patients treated at children’s hospitals and those treated at nonchildren’s hospitals.

CONCLUSIONS

The authors found that patients undergoing craniotomy for tumor resection at children’s hospitals were associated with decreased rates of 30-day readmission, with no significant difference in index mortality. Future prospective studies may be warranted to confirm this association and identify components contributing to improved outcomes in care at children’s hospitals.

In Journal of Neurosurgery: Pediatrics Publish Before Print

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Predicting traumatic brain injury outcomes using a posterior dominant rhythm

Nathaniel A. Cleri, Jordan R. Saadon, Xuwen Zheng, Sujith A. Swarna, Jason Zhang, Vaibhav Vagal, Cassie Wang, Robert S. Kleyner, Charles B. Mikell, and Sima Mofakham

OBJECTIVE

Predicting severe traumatic brain injury (sTBI) outcomes is challenging, and existing models have limited applicability to individual patients. This study aimed to identify metrics that could predict recovery following sTBI. The researchers strived to demonstrate that a posterior dominant rhythm on electroencephalography is strongly associated with positive outcomes and to develop a novel machine learning–based model that accurately forecasts the return of consciousness.

METHODS

In this retrospective study, the authors assessed all intubated adults admitted with sTBI (Glasgow Coma Scale [GCS] score ≤ 8) from 2010 to 2021, who underwent EEG recording < 30 days from sTBI (n = 195). Seventy-three clinical, radiographic, and EEG variables were collected. Based on the presence of a PDR within 30 days of injury, two cohorts were created—those with a PDR (PDR[+] cohort, n = 51) and those without (PDR[−] cohort, n = 144)—to assess differences in presentation and four outcomes: in-hospital survival, recovery of command following, Glasgow Outcome Scale–Extended (GOS-E) score at discharge, and GOS-E score at 6 months post discharge. AutoScore, a machine learning–based clinical score generator that selects and assigns weights to important predictive variables, was used to create a prognostic model that predicts in-hospital survival and recovery of command following. Lastly, the MRC-CRASH and IMPACT traumatic brain injury predictive models were used to compare expected patient outcomes with true outcomes.

RESULTS

At presentation, the PDR(−) cohort had a lower mean GCS motor subscore (1.97 vs 2.45, p = 0.048). Despite no difference in predicted outcomes (via MRC-CRASH and IMPACT), the PDR(+) cohort had superior rates of in-hospital survival (84.3% vs 63.9%, p = 0.007), recovery of command following (76.5% vs 53.5%, p = 0.004), and mean discharge GOS-E score (3.00 vs 2.39, p = 0.006). There was no difference in the 6-month GOS-E score. AutoScore was then used to identify the 7 following variables that were highly predictive of in-hospital survival and recovery of command: age, body mass index, systolic blood pressure, pupil reactivity, blood glucose, and hemoglobin (all at presentation), and a PDR on EEG. This model had excellent discrimination for predicting in-hospital survival (area under the curve [AUC] 0.815) and recovery of command following (AUC 0.700).

CONCLUSIONS

A PDR on EEG in sTBI patients predicts favorable outcomes. The authors’ prognostic model has strong accuracy in predicting these outcomes, and performed better than previously reported models. The authors’ model can be valuable in clinical decision-making as well as counseling families following these types of injuries.

In Journal of Neurosurgery Publish Before Print

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Radiotherapy after gross-total resection and subtotal resection of spinal chordoma: a SEER database analysis of overall survival outcomes

Julian Gendreau, Cathleen C. Kuo, Yusuf Mehkri, Sachiv Chakravarti, Brian Lu, Daniel Lubelski, Kristin J. Redmond, Chetan Bettegowda, and Debraj Mukherjee

OBJECTIVE

Chordomas are most frequently found in the sacrum, vertebral column, and skull base. Achieving gross-total resection (GTR) has been shown to optimize overall survival (OS); however, the efficacy of radiotherapy (RT) for patients with GTR is currently not well understood. Given that RT may negatively impact patient quality of life, the aim of this study was to evaluate the utility of RT for improving OS in patients who have undergone GTR of spinal chordoma through analysis of the national Surveillance, Epidemiology, and End Results (SEER) database.

METHODS

The SEER database (1975–2018) was queried for all adult patients (≥ 21 years) who underwent GTR for spinal chordoma. Bivariate analysis was conducted using chi-square testing for categorical variables, and the log-rank test was performed to find the associations of clinical variables with OS. Cox proportional hazards models were generated for multivariate analyses of the associations among clinical variables and OS.

RESULTS

A total of 263 spinal chordomas that underwent GTR were identified. The mean age of all included patients was 58.72 years, and 63.9% of patients were male. In addition, 0.4% had dedifferentiated histology. The mean follow-up was 75.54 months. Of all patients, 152 (57.8%) received no RT and 111 (42.2%) received RT. Patients with sacral tumor location (80.9% vs 51.4%, p < 0.001) were more likely not to undergo RT when compared to patients with vertebral column location. In multivariate analysis, only age ≥ 65 years was associated with poorer OS (HR 3.16, CI 1.54–5.61, p < 0.001). RT did not have a statistically significant association with OS.

CONCLUSIONS

RT after GTR of chordoma did not improve OS among SEER chordoma patients to a value that achieved statistical significance. Additional multicenter prospective studies are needed to determine the true efficacy of RT after GTR of spinal chordoma.

In Journal of Neurosurgery: Spine Publish Before Print