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Human motor endplate remodeling after traumatic nerve injury

Ranjan Gupta, Justin P. Chan, Jennifer Uong, Winnie A. Palispis, David J. Wright, Sameer B. Shah, Samuel R. Ward, Thay Q. Lee and Oswald Steward

OBJECTIVE

Current management of traumatic peripheral nerve injuries is variable with operative decisions based on assumptions that irreversible degeneration of the human motor endplate (MEP) follows prolonged denervation and precludes reinnervation. However, the mechanism and time course of MEP changes after human peripheral nerve injury have not been investigated. Consequently, there are no objective measures by which to determine the probability of spontaneous recovery and the optimal timing of surgical intervention. To improve guidance for such decisions, the aim of this study was to characterize morphological changes at the human MEP following traumatic nerve injury.

METHODS

A prospective cohort (here analyzed retrospectively) of 18 patients with traumatic brachial plexus and axillary nerve injuries underwent biopsy of denervated muscles from the upper extremity from 3 days to 6 years after injury. Muscle specimens were processed for H & E staining and immunohistochemistry, with visualization via confocal and two-photon excitation microscopy.

RESULTS

Immunohistochemical analysis demonstrated varying degrees of fragmentation and acetylcholine receptor dispersion in denervated muscles. Comparison of denervated muscles at different times postinjury revealed progressively increasing degeneration. Linear regression analysis of 3D reconstructions revealed significant linear decreases in MEP volume (R = −0.92, R2 = 0.85, p = 0.001) and surface area (R = −0.75, R2 = 0.56, p = 0.032) as deltoid muscle denervation time increased. Surprisingly, innervated and structurally intact MEPs persisted in denervated muscle specimens from multiple patients 6 or more months after nerve injury, including 2 patients who had presented > 3 years after nerve injury.

CONCLUSIONS

This study details novel and critically important data about the morphology and temporal sequence of events involved in human MEP degradation after traumatic nerve injuries. Surprisingly, human MEPs not only persisted, but also retained their structures beyond the assumed 6-month window for therapeutic surgical intervention based on previous clinical studies. Preoperative muscle biopsy in patients being considered for nerve transfer may be a useful prognostic tool to determine MEP viability in denervated muscle, with surviving MEPs also being targets for adjuvant therapy.

In Journal of Neurosurgery Publish Before Print

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Letter to the Editor. Alternative to the operating microscope

Kanwaljeet Garg and Manmohan Singh

In Journal of Neurosurgery: Spine Publish Before Print

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Letter to the Editor. An altered posterior question-mark incision

Qingjia Lai and Yuanhong Ge

In Journal of Neurosurgery Publish Before Print

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Postoperative fever workup in pediatric neurosurgery patients

Nataly Raviv, Nicholas Field and Matthew A. Adamo

OBJECTIVE

Fevers are common in the postoperative period, and adult data indicate that workup for an isolated fever is not warranted in the first 4 postoperative days (PODs). Pediatric literature on the subject similarly questions the value of further investigation during the first 2 PODs. The purpose of this study was to determine the incidence of acute fever in the postoperative pediatric neurosurgical population, as well as to assess the utility of performing further workup on these patients.

METHODS

A single-institution retrospective study was performed to assess pediatric neurosurgery patients following surgical intervention for the diagnoses of craniosynostosis, Chiari malformation, and brain tumors from 2009 to 2018. Fevers were identified during the first 4 PODs and were defined as a temperature ≥ 38.0°C. The patient charts were queried for urinalysis and urine culture (UA/Ucx), chest radiographs, blood cultures, CSF culture, respiratory viral panel, white blood cell (WBC) count, transfusion history, development of wound infection, and placement of external ventricular drains (EVDs) or lumbar drains. Thirty-day postoperative microbiology results and readmissions were reviewed. Descriptive statistics were performed using logistic regression analysis.

RESULTS

Two hundred thirty-five patients were evaluated, and 61% had developed fevers within the first 4 PODs. Thirty-eight (26.6%) of the 143 febrile patients underwent further workup, and those with high fevers (> 39.0°C) were more likely to undergo further evaluation, which most commonly included UA/Ucx (21.7%). Approximately 1% (2/235) of the patients were found to have an infection during the first 4 days, and 8 additional patients developed a complication following the initial 4 days and within the first 30 PODs. The development of infectious complications within the first 4 PODs did not correlate with acute postoperative fevers (p = 0.997), nor did the development of complications within the 30 days following surgery (p = 0.776); however, multiple days of acute postoperative fevers (p = 0.034) and the presence of an EVD (p = 0.001) were associated with the development of infectious complications within 30 days. Acute postoperative fevers were associated with EVD placement (p = 0.038), as well as blood product transfusions and an increased WBC count (p < 0.001).

CONCLUSIONS

Isolated fevers manifesting within the first 4 PODs are rarely associated with an infectious etiology. Additional factors should be taken into consideration when deciding to pursue further investigation.

In Journal of Neurosurgery: Pediatrics Publish Before Print

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Quantifying the utility of a multidisciplinary neuro-oncology tumor board

Adham M. Khalafallah, Adrian E. Jimenez, Carlos G. Romo, David Olayinka Kamson, Lawrence Kleinberg, Jon Weingart, Henry Brem, Stuart A. Grossman and Debraj Mukherjee

OBJECTIVE

There has been limited research on the efficacy of multidisciplinary tumor boards (MDTBs) in improving the treatment of patients with tumors affecting the nervous system. The objective of the present study was to quantify the utility of MDTBs in providing alternative diagnostic interpretations and treatment plans for this patient population.

METHODS

The authors performed a prospective study of patients in 4 hospitals whose cases were discussed at MDTBs between July and November 2019. Patient demographic data, diagnoses, treatment plans, and eligibility for clinical trials were recorded, among other variables.

RESULTS

A total of 176 cases met eligibility criteria for study inclusion. The majority (53%) of patients were male, and the mean patient age was 52 years. The most frequent diagnosis was glioblastoma (32.4%). Among the evaluable cases, MDTBs led to 38 (21.6%) changes in image interpretation and 103 (58.2%) changes in patient management. Additionally, patients whose cases were discussed at MDTBs had significantly shorter referral times than patients whose cases were not discussed (p = 0.024).

CONCLUSIONS

MDTB discussions led to significant numbers of diagnostic and treatment plan changes as well as shortened referral times, highlighting the potential clinical impact of multidisciplinary care for patients with nervous system tumors.

In Journal of Neurosurgery Publish Before Print

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Use of fast-sequence spine MRI in pediatric patients

Jordan I. Gewirtz, Alex Skidmore, Matthew D. Smyth, David D. Limbrick Jr., Manu Goyal, Joshua S. Shimony, Robert C. McKinstry, Mari L. Groves and Jennifer M. Strahle

OBJECTIVE

The immediate and long-term risk of anesthesia in the pediatric population is controversial. Traditional spine MRI protocols require the patient to remain still during the examination, and in young children this frequently results in the need for sedation administration. The authors’ goal was to develop an abbreviated spine MRI protocol to reduce sedation administration in young patients undergoing spine MRI.

METHODS

After IRB approval, the medical records of all pediatric patients who underwent a fast spine MRI protocol between 2017 and 2019 were reviewed. The protocol consisted of T2-weighted half-Fourier acquisition single-shot turbo spin echo, T1-weighted turbo spin echo, and T2-weighted STIR sequences acquired in the sagittal plane. The total acquisition time was 2 minutes with no single sequence acquisition longer than 60 seconds. Interpretability of the scans was assessed in accordance with the radiology report in conjunction with the neurosurgeon’s clinical notes.

RESULTS

A total of 47 fast spine MRI sessions were performed in 45 patients. The median age at the time of the MRI was 2.4 years (25th–75th quartile, 1.1–4.3 years; range 0.16–18.58 years). The most common indication for imaging was to rule out or follow a known syrinx (n = 30), followed by the need to rule out or follow known spinal dysraphism (n = 22). There were no uninterpretable or unusable scans. Eight of 47 scans were noted to have moderate motion artifact limitations with respect to the quality of the scan. Seven patients underwent a subsequent MRI with a sedated standard spine protocol within 1 year from the fast scan, which confirmed the findings on the fast MRI protocol with no new findings identified.

CONCLUSIONS

The authors report the first pediatric series of a fast spine MRI protocol for use in young patients. The protocol does not require sedation and is able to identify and monitor syrinx, spinal dysraphism, and potentially other intraspinal anomalies.

In Journal of Neurosurgery: Pediatrics Publish Before Print

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Utility of invasive electroencephalography in children 3 years old and younger with refractory epilepsy

Rafael Uribe-Cardenas, Andre E. Boyke, Justin T. Schwarz, Peter F. Morgenstern, Jeffrey P. Greenfield, Theodore H. Schwartz, James T. Rutka, James Drake and Caitlin E. Hoffman

OBJECTIVE

Early surgical intervention for pediatric refractory epilepsy is increasingly advocated as surgery has become safer and data have demonstrated improved outcomes with early seizure control. There is concern that the risks associated with staged invasive electroencephalography (EEG) in very young children outweigh the potential benefits. Here, the authors present a cohort of children with refractory epilepsy who were referred for invasive monitoring, and they evaluate the role and safety of staged invasive EEG in those 3 years old and younger.

METHODS

The authors conducted a retrospective review of children 3 years and younger with epilepsy, who had been managed surgically at two institutions between 2001 and 2015. A cohort of pediatric patients older than 3 years of age was used for comparison. Demographics, seizure etiology, surgical management, surgical complications, and adverse events were recorded. Statistical analysis was completed using Stata version 13. A p < 0.05 was considered statistically significant. Fisher’s exact test was used to compare proportions.

RESULTS

Ninety-four patients (45 patients aged ≤ 3 [47.9%]) and 208 procedures were included for analysis. Eighty-six procedures (41.3%) were performed in children younger than 3 years versus 122 in the older cohort (58.7%). Forty-two patients underwent grid placement (14 patients aged ≤ 3 [33.3%]); 3 of them developed complications associated with the implant (3/42 [7.14%]), none of whom were among the younger cohort. Across all procedures, 11 complications occurred in the younger cohort versus 5 in the older patients (11/86 [12.8%] vs 5/122 [4.1%], p = 0.032). Two adverse events occurred in the younger group versus 1 in the older group (2/86 [2.32%] vs 1/122 [0.82%], p = 0.571). Following grid placement, 13/14 younger patients underwent guided resections compared to 20/28 older patients (92.9% vs 71.4%, p = 0.23).

CONCLUSIONS

While overall complication rates were higher in the younger cohort, subdural grid placement was not associated with an increased risk of surgical complications in that population. Invasive electrocorticography informs management in very young children with refractory, localization-related epilepsy and should therefore be used when clinically indicated.

In Journal of Neurosurgery: Pediatrics Publish Before Print

Free access

Development and validation of a clinical prediction score for poor postoperative pain control following elective spine surgery

Presented at the 2020 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves

Michael M. H. Yang, Jay Riva-Cambrin, Jonathan Cunningham, Nathalie Jetté, Tolulope T. Sajobi, Alex Soroceanu, Peter Lewkonia, W. Bradley Jacobs and Steven Casha

OBJECTIVE

Thirty percent to sixty-four percent of patients experience poorly controlled pain following spine surgery, leading to patient dissatisfaction and poor outcomes. Identification of at-risk patients before surgery could facilitate patient education and personalized clinical care pathways to improve postoperative pain management. Accordingly, the aim of this study was to develop and internally validate a prediction score for poorly controlled postoperative pain in patients undergoing elective spine surgery.

METHODS

A retrospective cohort study was performed in adult patients (≥ 18 years old) consecutively enrolled in the Canadian Spine Outcomes and Research Network registry. All patients underwent elective cervical or thoracolumbar spine surgery and were admitted to the hospital. Poorly controlled postoperative pain was defined as a mean numeric rating scale score for pain at rest of > 4 during the first 24 hours after surgery. Univariable analysis followed by multivariable logistic regression on 25 candidate variables, selected through a systematic review and expert consensus, was used to develop a prediction model using a random 70% sample of the data. The model was transformed into an eight-tier risk-based score that was further simplified into the three-tier Calgary Postoperative Pain After Spine Surgery (CAPPS) score to maximize clinical utility. The CAPPS score was validated using the remaining 30% of the data.

RESULTS

Overall, 57% of 1300 spine surgery patients experienced poorly controlled pain during the first 24 hours after surgery. Seven significant variables associated with poor pain control were incorporated into a prediction model: younger age, female sex, preoperative daily use of opioid medication, higher preoperative neck or back pain intensity, higher Patient Health Questionnaire–9 depression score, surgery involving ≥ 3 motion segments, and fusion surgery. Notably, minimally invasive surgery, body mass index, and revision surgery were not associated with poorly controlled pain. The model was discriminative (C-statistic 0.74, 95% CI 0.71–0.77) and calibrated (Hosmer-Lemeshow goodness-of-fit, p = 0.99) at predicting the outcome. Low-, high-, and extreme-risk groups stratified using the CAPPS score had 32%, 63%, and 85% predicted probability of experiencing poorly controlled pain, respectively, which was mirrored closely by the observed incidence of 37%, 62%, and 81% in the validation cohort.

CONCLUSIONS

Inadequate pain control is common after spine surgery. The internally validated CAPPS score based on 7 easily acquired variables accurately predicted the probability of experiencing poorly controlled pain after spine surgery.

In Journal of Neurosurgery: Spine Publish Before Print

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Editorial. Postoperative pain control after spinal surgery: an opportunity

Zoher Ghogawala

In Journal of Neurosurgery: Spine Publish Before Print

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The economic value of an on-call neurosurgical resident physician

William E. Gordon, William M. Mangham, L. Madison Michael II and Paul Klimo Jr.

OBJECTIVE

The cost of training neurosurgical residents is especially high considering the duration of training and the technical nature of the specialty. Despite these costs, on-call residents are a source of significant economic value, through both indirectly and directly supervised activities. The authors sought to identify the economic value of on-call services provided by neurosurgical residents.

METHODS

A personal call log kept by a single junior neurosurgical resident over a 2-year period was used to obtain the total number of consultations, admissions, and procedures. Current Procedural Terminology (CPT) codes were used to estimate the resident’s on-call economic value.

RESULTS

A single on-call neurosurgical resident at the authors’ institution produced 8172 work relative value units (wRVUs) over the study period from indirectly and directly supervised activities. Indirectly supervised procedures produced 7052 wRVUs, and directly supervised activities using the CPT modifier 80 yielded an additional 1120 wRVUs. Using the assistant surgeon billing rate for directly supervised activities and the Medical Group Management Association nationwide median neurosurgery reimbursement rate, the on-call activities of a single resident generated a theoretical billing value of $689,514 over the 2-year period, or $344,757 annually. As a program, the on-call residents collectively produced 39,550 wRVUs over the study period, or 19,775 wRVUs annually, which equates to potential reimbursements of $1,668,386 annually.

CONCLUSIONS

Neurosurgery residents at the authors’ institution theoretically produce enough economic value exclusively from on-call activities to far exceed the cost of their education. This information could be used to more precisely estimate the true overall cost of neurosurgical training and determine future graduate medical education funding.

In Journal of Neurosurgery Publish Before Print