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Tyler S. Cole and Robert F. Spetzler

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Joseph R. Linzey, Craig Williamson, Venkatakrishna Rajajee, Kyle Sheehan, B. Gregory Thompson, and Aditya S. Pandey

OBJECTIVE

Recent observational data suggest that ultra-early treatment of ruptured aneurysms prevents rebleeding, thus improving clinical outcomes. However, advances in critical care management of patients with ruptured aneurysms may reduce the rate of rebleeding in comparison with earlier trials, such as the International Cooperative Study on the Timing of Aneurysm Surgery. The objective of the present study was to determine if an ultra-early aneurysm repair protocol will or will not significantly reduce the number of incidents of rebleeding following aneurysmal subarachnoid hemorrhage (SAH).

METHODS

A retrospective analysis of data from a prospectively collected cohort of patients with SAH was performed. Rebleeding was diagnosed as new or expanded hemorrhage on CT, which was determined by independent review conducted by multiple physicians. Preventability of rebleeding by ultra-early aneurysm clipping or coiling was also independently reviewed. Standard statistics were used to determine statistically significant differences between the demographic characteristics of those with rebleeding compared with those without.

RESULTS

Of 317 patients with aneurysmal SAH, 24 (7.6%, 95% CI 4.7–10.5) experienced rebleeding at any time point following initial aneurysm rupture. Only 1/24 (4.2%, 95% CI −3.8 to 12.2) incidents of rebleeding could have been prevented by a 24-hour ultra-early aneurysm repair protocol. The other 23 incidents could not have been prevented for the following reasons: rebleeding prior to admission to the authors’ institution (14/23, 60.9%); initial diagnostic angiography negative for aneurysm (4/23, 17.4%); postoperative rebleeding (2/23, 8.7%); patient unable to undergo operation due to medical instability (2/23, 8.7%); intraoperative rebleeding (1/23, 4.3%).

CONCLUSIONS

At a single tertiary academic center, the overall rebleeding rate was 7.6% (95% CI 4.7–10.5) for those presenting with ruptured aneurysms. Implementation of a 24-hour ultra-early aneurysm repair protocol would only result in, at most, a 0.3% (95% CI −0.3 to 0.9) reduction in the incidence of rebleeding.

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Joseph R. Linzey, Kevin S. Chen, Luis Savastano, B. Gregory Thompson, and Aditya S. Pandey

Brain shifts following microsurgical clip ligation of anterior communicating artery (ACoA) aneurysms can lead to mechanical compression of the optic nerve by the clip. Recognition of this condition and early repositioning of clips can lead to reversal of vision loss.

The authors identified 3 patients with an afferent pupillary defect following microsurgical clipping of ACoA aneurysms. Different treatment options were used for each patient. All patients underwent reexploration, and the aneurysm clips were repositioned to prevent clip-related compression of the optic nerve. Near-complete restoration of vision was achieved at the last clinic follow-up visit in all 3 patients.

Clip ligation of ACoA aneurysms has the potential to cause clip-related compression of the optic nerve. Postoperative visual examination is of utmost importance, and if any changes are discovered, reexploration should be considered as repositioning of the clips may lead to resolution of visual deterioration.

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Joseph R. Linzey, Christopher S. Graffeo, Justin Z. Wang, Ali S. Haider, and Naif M. Alotaibi

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Joseph R. Linzey, James F. Burke, Jeffrey L. Nadel, Craig A. Williamson, Luis E. Savastano, D. Andrew Wilkinson, and Aditya S. Pandey

OBJECTIVE

It is unknown what proportion of patients who undergo emergent neurosurgical procedures initiate comfort care (CC) measures shortly after the operation. The purpose of the present study was to analyze the proportion and predictive factors of patients who initiated CC measures within the same hospital admission after undergoing emergent neurosurgery.

METHODS

This retrospective cohort study included all adult patients who underwent emergent neurosurgical and endovascular procedures at a single center between 2009 and 2014. Primary and secondary outcomes were initiation of CC measures during the initial hospitalization and determination of predictive factors, respectively.

RESULTS

Of the 1295 operations, comfort care was initiated in 111 (8.6%) during the initial admission. On average, CC was initiated 9.3 ± 10.0 days postoperatively. One-third of the patients switched to CC within 3 days. In multivariate analysis, patients > 70 years of age were significantly more likely to undergo CC than those < 50 years (70–79 years, p = 0.004; > 80 years, p = 0.0001). Two-thirds of CC patients had been admitted with a cerebrovascular pathology (p < 0.001). Admission diagnosis of cerebrovascular pathology was a significant predictor of initiating CC (p < 0.0001). A high Hunt and Hess grade of IV or V in patients with subarachnoid hemorrhage was significantly associated with initiation of CC compared to a low grade (27.1% vs 2.9%, p < 0.001). Surgery starting between 15:01 and 06:59 hours had a 1.70 times greater odds of initiating CC compared to surgery between 07:00 and 15:00.

CONCLUSIONS

Initiation of CC after emergent neurosurgical and endovascular procedures is relatively common, particularly when an elderly patient presents with a cerebrovascular pathology after typical operating hours.

Open access

Michael J. Strong, Joseph R. Linzey, Mark M. Zaki, Rushikesh S. Joshi, Ayobami Ward, Timothy J. Yee, Siri Sahib S. Khalsa, Yamaan S. Saadeh, and Paul Park

Retropleural, retrodiaphragmatic, and retroperitoneal approaches are utilized to access difficult thoracolumbar junction (T10–L2) pathology. The authors present a 58-year-old man with chronic low-back pain who failed years of conservative therapy. Preoperative radiographs demonstrated significant levoconvex scoliosis with coronal and sagittal imbalance. He underwent a retrodiaphragmatic/retroperitoneal approach for T12–L1, L1–2, L2–3, and L3–4 interbody release and fusion in conjunction with second-stage facet osteotomies, L4–5 TLIF, and T10–iliac posterior instrumented fusion. This video focuses on the retrodiaphragmatic approach assisted by 3D navigation.

The video can be found here: https://stream.cadmore.media/r10.3171/2022.3.FOCVID2215

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René Post, Jantien Hoogmoed, Dagmar Verbaan, and W. Peter Vandertop

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Nachiket Deshpande, Moustafa S. Hadi, Jock C. Lillard, Peter G. Passias, Joseph R. Linzey, Yamaan S. Saadeh, Michael LaBagnara, and Paul Park

OBJECTIVE

Osteoporosis has significant implications in spine fusion surgery, for which reduced spinal bone mineral density (BMD) can result in complications and poorer outcomes. Currently, dual-energy x-ray absorptiometry (DEXA) is the gold standard for radiographic diagnosis of osteoporosis, although DEXA accuracy may be limited by the presence of degenerative spinal pathology. In recent years, there has been an evolving interest in using alternative imaging, including CT and MRI, to assess BMD. In this systematic review of the literature, the authors assessed the use and effectiveness of MRI, opportunistic CT (oCT), and quantitative CT (qCT) to measure BMD.

METHODS

In accordance with the PRISMA guidelines, the authors conducted a systematic search for articles posted on PubMed between the years 2000 and 2022 by using the keywords "opportunistic CT, quantitative CT, MRI" AND "bone density" AND "spine." Inclusion criteria consisted of articles written in English that reported studies pertaining to human or cadaveric subjects, and studies including a measure of spinal BMD. Articles not related to spinal BMD, osteoporosis, or spinal surgery or reports of studies that did not include the use of spinal MRI or CT were excluded. Key study outcomes were extracted from included articles, and qualitative analysis was subsequently performed.

RESULTS

The literature search yielded 302 articles. Forty-two articles reported studies that met the final inclusion criteria. Eighteen studies utilized MRI protocols to correlate spinal BMD with vertebral bone quality scores, M-scores, and quantitative perfusion markers. Eight studies correlated oCT with spinal BMD, and 16 studies correlated qCT with spinal BMD. With oCT and qCT imaging, there was consensus that Hounsfield unit (HU) values > 160 demonstrated significant reduction in risk of osteoporosis, whereas HU values < 110 were significantly correlated with osteoporosis.

CONCLUSIONS

Osteoporosis is increasingly recognized as a significant risk factor for complications after spinal fusion surgery. Consequently, preoperative assessment of BMD is a critical factor to consider in planning surgical treatment. Although DEXA has been the gold standard for BMD measurement, other imaging modalities, including MRI, oCT, and qCT, appear to be viable alternatives and may offer cost and time savings.

Free access

Zoe E. Teton, Rachel S. Freedman, Samuel B. Tomlinson, Joseph R. Linzey, Alvin Onyewuenyi, Anadjeet S. Khahera, Benjamin K. Hendricks, and Aaron A. Cohen-Gadol

OBJECTIVE

The advent of the internet and the popularity of e-learning resources has promoted a shift in medical and surgical education today. The Neurosurgical Atlas has sought to capitalize on this shift by providing easily accessible video and online education to its users on an international scale. The rising popularity of social media has provided new avenues for expanding that global reach, and the Atlas has sought to do just that. In this study, the authors analyzed user demographics and web traffic patterns to quantify the international reach of the Atlas and examined the potential impact of social media platforms on the expansion of that reach.

METHODS

Twitter, Facebook, and Instagram metrics were extracted using each respective service’s analytics tool from the date of their creation through October 2019. Google Analytics was used to extract website traffic data from September 2018 to September 2019 and app data from January 2019 to October 2019. The metrics extracted included the number of platform users/followers, user demographic information, percentage of new versus returning visitors, and a number of platform-specific values.

RESULTS

Since the authors’ previous publication in 2017, annual website viewership has more than doubled to greater than 500,000 viewing sessions in the past year alone; international users accounted for more than 60% of the visits. The Atlas Twitter account, established in August 2012, has more than 12,000 followers, primarily hailing from the United States, the United Kingdom, Canada, and Saudi Arabia. The Atlas Facebook account, established in 2013, has just over 13,000 followers, primarily from India, Egypt, and Mexico. The Atlas Instagram account (established most recently, in December 2018) has more than 16,000 followers and the highest percentage (31%) of younger users (aged 18–24 years). The Atlas app was officially launched in May 2019, largely via promotion on the Atlas social media platforms, and has since recorded more than 60,000 viewing sessions, 80% of which were from users outside the United States.

CONCLUSIONS

The Neurosurgical Atlas has attempted to leverage the many e-learning resources at its disposal to assist in spreading neurosurgical best practice on an international scale in a novel and comprehensive way. By incorporating multiple social media platforms into its repertoire, the Atlas is able to ensure awareness of and access to these resources regardless of the user’s location or platform of preference. In so doing, the Atlas represents a novel way of advancing access to neurosurgical educational resources in the digital age.