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Leonardo A. Frizon, Sean J. Nagel, Francis J. May, Jianning Shao, Andres L. Maldonado-Naranjo, Hubert H. Fernandez, and Andre G. Machado

OBJECTIVE

The number of patients who benefit from deep brain stimulation (DBS) for Parkinson’s disease (PD) has increased significantly since the therapy was first approved by the FDA. Suboptimal outcomes, infection, or device failure are risks of the procedure and may require lead removal or repositioning. The authors present here the results of their series of revision and reimplantation surgeries.

METHODS

The data were reviewed from all DBS intracranial lead removals, revisions, or reimplantations among patients with PD over a 6-year period at the authors’ institution. The indications for these procedures were categorized as infection, suboptimal outcome, and device failure. Motor outcomes as well as lead location were analyzed before removal and after reimplant or revision.

RESULTS

The final sample included 25 patients who underwent 34 lead removals. Thirteen patients had 18 leads reimplanted after removal. There was significant improvement in the motor scores after revision surgery among the patients who had the lead revised for a suboptimal outcome (p = 0.025). The mean vector distance of the new lead location compared to the previous location was 2.16 mm (SD 1.17), measured on an axial plane 3.5 mm below the anterior commissure–posterior commissure line. When these leads were analyzed by subgroup, the mean distance was 1.67 mm (SD 0.83 mm) among patients treated for infection and 2.73 mm (SD 1.31 mm) for those with suboptimal outcomes.

CONCLUSIONS

Patients with PD who undergo reimplantation surgery due to suboptimal outcome may experience significant benefits. Reimplantation after surgical infection seems feasible and overall safe.

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The efficacy of intraoperative multimodal monitoring in pedicle subtraction osteotomies of the lumbar spine

Presented at the 2019 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves

Jianning Shao, Maxwell Y. Lee, Shreya Louis, Konrad Knusel, Bryan S. Lee, Dominic W. Pelle, Jason Savage, Joseph E. Tanenbaum, Thomas E. Mroz, and Michael P. Steinmetz

OBJECTIVE

Iatrogenic spine injury remains one of the most dreaded complications of pedicle subtraction osteotomies (PSOs) and spine deformity surgeries. Thus, intraoperative multimodal monitoring (IOM), which has the potential to provide real-time feedback on spinal cord signal transmission, has become the gold standard in such operations. However, while the benefits of IOM are well established in PSOs of the thoracic spine and scoliosis surgery, its utility in PSOs of the lumbar spine has not been robustly documented. The authors’ aim was to determine the impact of IOM on outcomes in patients undergoing PSO of the lumbar spine.

METHODS

All patients older than 18 years who underwent lumbar PSOs at the authors’ institution from 2007 to 2017 were analyzed via retrospective chart review and categorized into one of two groups: those who had IOM guidance and those who did not. Perioperative complications were designated as the primary outcome measure and postoperative quality of life (QOL) scores, specifically the Parkinson’s Disease Questionnaire–39 (PDQ-39) and Patient Health Questionnaire–9 (PHQ-9), were designated as secondary outcome measures. Data on patient demographics, surgical and monitoring parameters, and outcomes were gathered, and statistical analysis was performed to compare the development of perioperative complications and QOL scores between the two cohorts. In addition, the proportion of patients who reached minimal clinically important difference (MCID), defined as an increase of 4.72 points in the PDQ-39 score or a decrease of 5 points in the PHQ-9 score, in the two cohorts was also determined.

RESULTS

A total of 95 patients were included in the final analysis. IOM was not found to significantly impact the development of new postoperative deficits (p = 0.107). However, the presence of preoperative neurological comorbidities was found to significantly correlate with postoperative neurological complications (p = 0.009). Univariate analysis showed that age was positively correlated with MCID achievement 3 months after surgery (p = 0.018), but this significance disappeared at the 12-month postoperative time point (p = 0.858). IOM was not found to significantly impact MCID achievement at either the 3- or 12-month postoperative period as measured by PDQ-39 (p = 0.398 and p = 0.156, respectively). Similarly, IOM was not found to significantly impact MCID achievement at either the 3- or 12-month postoperative period, as measured by PHQ-9 (p = 0.230 and p = 0.542, respectively). Multivariate analysis showed that female sex was significantly correlated with MCID achievement (p = 0.024), but this significance disappeared at the 12-month postoperative time point (p = 0.064). IOM was not found to independently correlate with MCID achievement in PDQ-39 scores at either the 3- or 12-month postoperative time points (p = 0.220 and p = 0.097, respectively).

CONCLUSIONS

In this particular cohort, IOM did not lead to statistically significant improvement in outcomes in patients undergoing PSOs of the lumbar spine (p = 0.220). The existing clinical equipoise, however, indicates that future studies in this arena are necessary to achieve systematic guidelines on IOM usage in PSOs of the lumbar spine.

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Jianning Shao, Jaes Jones, Patrick Ellsworth, Ghaith Habboub, Gino Cioffi, Nirav Patil, Quinn T. Ostrom, Carol Kruchko, Jill S. Barnholtz-Sloan, Varun R. Kshettry, and Pablo F. Recinos

OBJECTIVE

Spinal cord astrocytoma (SCA) is a rare tumor whose epidemiology has not been well defined. The authors utilized the Central Brain Tumor Registry of the United States (CBTRUS) to provide comprehensive up-to-date epidemiological data for this disease.

METHODS

The CBTRUS was queried for SCAs on ICD-O-3 (International Classification of Diseases for Oncology, 3rd edition) histological and topographical codes. The age-adjusted incidence (AAI) per 100,000 persons was calculated and stratified by race, sex, age, and ethnicity. Joinpoint was used to calculate the annual percentage change (APC) in incidence.

RESULTS

Two thousand nine hundred sixty-nine SCAs were diagnosed in the US between 1995 and 2016, resulting in an average of approximately 136 SCAs annually. The overall AAI was 0.047 (95% CI 0.045–0.049), and there was a statistically significant increase from 0.051 in 1995 to 0.043 in 2016. The peak incidence of 0.064 (95% CI 0.060–0.067) was found in the 0- to 19-year age group. The incidence in males was 0.053 (95% CI 0.050–0.055), which was significantly greater than the incidence in females (0.041, 95% CI 0.039–0.044). SCA incidence was significantly lower both in patients of Asian/Pacific Islander race (AAI = 0.034, 95% CI 0.028–0.042, p = 0.00015) and in patients of Hispanic ethnicity (AAI = 0.035, 95% CI 0.031–0.039, p < 0.001). The incidence of WHO grade I SCAs was significantly higher than those of WHO grade II, III, or IV SCAs (p < 0.001).

CONCLUSIONS

The overall AAI of SCA from 1995 to 2016 was 0.047 per 100,000. The incidence peaked early in life for both sexes, reached a nadir between 20 and 34 years of age for males and between 35 and 44 years of age for females, and then slowly increased throughout adulthood, with a greater incidence in males. Pilocytic astrocytomas were the most common SCA in the study cohort. This study presents the most comprehensive epidemiological study of SCA incidence in the US to date.

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Joshua L. Golubovsky, Hong Li, Arbaz Momin, Jianning Shao, Maxwell Y. Lee, Leonardo A. Frizon, Olivia Hogue, Benjamin Walter, André G. Machado, and Sean J. Nagel

OBJECTIVE

Parkinson’s disease (PD) is a progressive neurological movement disorder that is commonly treated with deep brain stimulation (DBS) surgery in advanced stages. The purpose of this study was to investigate factors that affect time to placement of a second-sided DBS lead for PD when a unilateral lead is initially placed for asymmetrical presentation. The decision whether to initially perform unilateral or bilateral DBS is largely based on physician and/or patient preference.

METHODS

This study was a retrospective cohort analysis of patients with PD undergoing initial unilateral DBS for asymmetrical disease between January 1999 and December 2017 at the authors’ institution. Patients treated with DBS for essential tremor or other conditions were excluded. Variables collected included demographics at surgery, time since diagnosis, Unified Parkinson’s Disease Rating Scale motor scores (UPDRS-III), patient-reported quality-of-life outcomes, side of operation, DBS target, intraoperative complications, and date of follow-up. Paired t-tests were used to assess mean changes in UPDRS-III. Cox proportional hazards analysis and the Kaplan-Meier method were used to determine factors associated with time to second lead insertion over 5 years.

RESULTS

The final cohort included 105 patients who underwent initial unilateral DBS for asymmetrical PD; 59% of patients had a second-sided lead placed within 5 years with a median time of 34 months. Factors found to be significantly associated with early second-sided DBS included patient age 65 years or younger, globus pallidus internus (GPi) target, and greater off-medication reduction in UPDRS-III score following initial surgery. Older age was also found to be associated with a smaller preoperative UPDRS-III levodopa responsiveness score and with a smaller preoperative to postoperative medication-off UPDRS-III change.

CONCLUSIONS

Younger patients, those undergoing GPi-targeted unilateral DBS, and patients who responded better to the initial DBS were more likely to undergo early second-sided lead placement. Therefore, these patients, and patients who are more responsive to medication preoperatively (as a proxy for DBS responsiveness), may benefit from consideration of initial bilateral DBS.