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Roberto J. Perez-Roman, Vaidya Govindarajan, David J. Levi, Evan Luther, and Allan D. Levi

OBJECTIVE

With an increasing number of disease-modifying drugs available to manage rheumatoid arthritis (RA), spine surgeons have anecdotally noted decreased rates of cervical spine surgical procedures in this population. Although these medications have been shown to mitigate RA progression and its systemic effects on joint destruction, there are currently no large-scale studies of RA patients that suggest the use of these disease-modifying drugs has truly coincided with a decline in cervical spine surgery.

METHODS

Patients with RA who underwent cervical spinal fusion from 1998 to 2021 performed by the senior author were retrospectively reviewed. The cohort was stratified into 3 categories based on procedure level: 1) occipitocervical, 2) atlantoaxial, and 3) subaxial. The number of surgical procedures per year in each subgroup was evaluated to determine treatment trends over time. National (Nationwide) Inpatient Sample (NIS) data on both RA and non-RA patients who underwent cervical fusion were analyzed to assess for surgical trends over time and for differences in likelihood of surgical intervention between RA and non-RA patients over the epoch.

RESULTS

From 1998 to 2021, the number of overall cervical fusions performed in RA patients significantly declined (–0.13 procedures/year, p = 0.01) in this cohort, despite an overall significant increase in cervical fusions in non-RA patients over the same period. NIS analysis of cervical fusions across all patients similarly demonstrated a significant increase in cervical fusions over the same epoch (19,278 cases/year, p < 0.0001). When normalized for changes in population size, the incidence of new surgical procedures was lower in patients with RA regardless of surgical technique. Anterior cervical fusion was the most common approach used over the epoch in both RA and non-RA patients; correspondingly, RA patients were significantly less likely to undergo anterior cervical fusion (OR 0.655, 95% CI −0.4504 to −0.3972, p < 0.0001).

CONCLUSIONS

At the authors’ institution, there was a clear decline in the number of cervical fusions performed to treat the 3 most common forms of cervical spine pathology in RA patients (basilar impression, atlantoaxial instability, and subaxial cervical deformity). Although national trends suggest an increase in total cervical fusions in both RA and non-RA patients, the incidence of new procedures in patients with RA was significantly lower than in patients without RA, which supports the anecdotal results of spine surgeons nationally.

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S. Shelby Burks, David J. Levi, Seth Hayes, and Allan D. Levi

Object

The object of this study was to highlight the challenge of insufficient donor graft material in peripheral nerve surgery, with a specific focus on sciatic nerve transection requiring autologous sural nerve graft.

Methods

The authors performed an anatomical analysis of cadaveric sciatic and sural nerve tissue. To complement this they also present 3 illustrative clinical cases of sciatic nerve injuries with segmental defects. In the anatomical study, the cross-sectional area (CSA), circumference, diameter, percentage of neural tissue, fat content of the sural nerves, as well as the number of fascicles, were measured from cadaveric samples. The percentage of neural tissue was defined as the CSA of fascicles lined by perineurium relative to the CSA of the sural nerve surrounded by epineurium.

Results

Sural nerve samples were obtained from 8 cadaveric specimens. Mean values and standard deviations from sural nerve measurements were as follows: CSA 2.84 ± 0.91 mm2, circumference 6.67 ± 1.60 mm, diameter 2.36 ± 0.43 mm, fat content 0.83 ± 0.91 mm2, and number of fascicles 9.88 ± 3.68. The percentage of neural tissue seen on sural nerve cross-section was 33.17% ± 4.96%. One sciatic nerve was also evaluated. It had a CSA of 37.50 mm2, with 56% of the CSA representing nerve material. The estimated length of sciatic nerve that could be repaired with a bilateral sural nerve harvest (85 cm) varied from as little as 2.5 cm to as much as 8 cm.

Conclusions

Multiple methods have been used in the past to repair sciatic nerve injury but most commonly, when a considerable gap is present, autologous nerve grafting is required, with sural nerve being the foremost source. As evidenced by the anatomical data reported in this study, a considerable degree of variability exists in the diameter of sural nerve harvests. Conversely, the percentage of neural tissue is relatively consistent across specimens. The authors recommend that the peripheral nerve surgeon take these points into consideration during nerve grafting as insufficient graft material may preclude successful recovery.

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Elizabeth A. Vitarbo, Ali Sultan, David Wang, Jacques J. Morcos, and Allan D. Levi

✓ The authors describe the case of a 62-year-old woman with a Type II split cord malformation (SCM). At the initial time of workup, the authors observed an associated Klippel—Feil deformity at the level of the SCM and a low-lying conus medullaris; however, they discovered an associated Type IV perimedullary spinal cord arteriovenous fistula (AVF) only after the patient continued to deteriorate following a spinal cord untethering procedure. Although prominent blood vessels have been reported within the median cleft of SCMs, an angiographically and surgically proven perimedullary AVF has not previously been described. The potential coexistence of SCM and perimedullary AVF has significant clinical implications and its recognition is critically important prior to surgical treatment.

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Victor M. Lu, Shelly Wang, David J. Daniels, Robert J. Spinner, Allan D. Levi, and Toba N. Niazi

OBJECTIVE

Malignant peripheral nerve sheath tumors (MPNSTs) are rare tumors found throughout the body, with their clinical course in children still not completely understood. Correspondingly, this study aimed to determine survival outcomes and specific clinical predictors of survival in this population from a large national database.

METHODS

All patients with MPNSTs aged ≤ 18 years in the US National Cancer Database (NCDB) between 2005 and 2016 were retrospectively reviewed. Data were summarized, and overall survival was modeled using Kaplan-Meier and Cox regression analyses.

RESULTS

A total of 251 pediatric patients with MPNSTs (132 [53%] females and 119 [47%] males) were identified; the mean age at diagnosis was 13.1 years (range 1–18 years). There were 84 (33%) MPNSTs located in the extremities, 127 (51%) were smaller than 1 cm, and 22 (9%) had metastasis at the time of diagnosis. In terms of treatment, surgery was pursued in 187 patients (74%), chemotherapy in 116 patients (46%), and radiation therapy in 129 patients (61%). The 5-year overall survival rate was estimated at 52% (95% CI 45%–59%), with a median survival of 64 months (range 36–136 months). Multivariate regression revealed that older age (HR 1.10, p < 0.01), metastases at the time of diagnosis (HR 2.14, p = 0.01), and undergoing biopsy only (HR 2.98, p < 0.01) significantly and independently predicted a shorter overall survival. Chemotherapy and radiation therapy were not statistically significant.

CONCLUSIONS

In this study, the authors found that older patient age, tumor metastases at the time of diagnosis, and undergoing only biopsy significantly and independently predicted poorer outcomes. Only approximately half of patients survived to 5 years. These results have shown a clear survival benefit in pursuing maximal safe resection in pediatric patients with MPNSTs. As such, judicious workup with meticulous resection by an expert team should be considered the standard of care for these tumors in children.

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Lennart Riemann, Daphne C. Voormolen, Katrin Rauen, Klaus Zweckberger, Andreas Unterberg, Alexander Younsi, and the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) Investigators and Participants

OBJECTIVE

The aim of this paper was to evaluate the prevalence of postconcussive symptoms and their relation to health-related quality of life (HRQOL) in pediatric and adolescent patients with mild traumatic brain injury (mTBI) who received head CT imaging during initial assessment.

METHODS

Patients aged between 5 and 21 years with mTBI (Glasgow Coma Scale scores 13–15) and available Rivermead Post Concussion Questionnaire (RPQ) at 6 months of follow-up in the multicenter, prospectively collected CENTER-TBI (Collaborative European NeuroTrauma Effectiveness Research in TBI) study were included. The prevalence of postconcussive symptoms was assessed, and the occurrence of postconcussive syndrome (PSC) based on the ICD-10 criteria, was analyzed. HRQOL was compared in patients with and without PCS using the Quality of Life after Brain Injury (QOLIBRI) questionnaire.

RESULTS

A total of 196 adolescent or pediatric mTBI patients requiring head CT imaging were included. High-energy trauma was prevalent in more than half of cases (54%), abnormalities on head CT scans were detected in 41%, and admission to the regular ward or intensive care unit was necessary in 78%. Six months postinjury, 36% of included patients had experienced at least one moderate or severe symptom on the RPQ. PCS was present in 13% of adolescents and children when considering symptoms of at least moderate severity, and those patients had significantly lower QOLIBRI total scores, indicating lower HRQOL, compared with young patients without PCS (57 vs 83 points, p < 0.001).

CONCLUSIONS

Adolescent and pediatric mTBI patients requiring head CT imaging show signs of increased trauma severity. Postconcussive symptoms are present in up to one-third of those patients, and PCS can be diagnosed in 13% 6 months after injury. Moreover, PCS is significantly associated with decreased HRQOL.