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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.

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Nataly Raviv, Ami Amin, Tyler J. Kenning, Carlos D. Pinheiro-Neto, David Jones, Vibhavasu Sharma, and Maria Peris-Celda

In this report, the authors demonstrated that idiopathic pituitary hyperplasia (PH) can cause complete bitemporal hemianopia and amenorrhea, even in the setting of mild anatomical compression of the optic chiasm and normal pituitary function. Furthermore, complete resolution of symptoms can be achieved with surgical decompression.

PH can occur in the setting of pregnancy or end-organ insufficiency, as well as with medications such as oral contraceptives and antipsychotics, or it can be idiopathic. It is often found incidentally, and surgical intervention is usually unnecessary, as the disorder rarely progresses and can be managed by treating the underlying etiology. Here, the authors present the case of a 24-year-old woman with no significant prior medical history, who presented with bitemporal hemianopia and amenorrhea. Imaging revealed an enlarged pituitary gland that was contacting, but not compressing, the optic chiasm, and pituitary hormone tests were all within normal limits. The patient underwent surgical decompression of the sella turcica and exploration of the gland through an endoscopic endonasal transsphenoidal approach. Pathology results demonstrated PH. A postoperative visual field examination revealed complete resolution of the bitemporal hemianopia, and menstruation resumed 3 days later. The patient remains asymptomatic with no hormonal deficits.

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Abigail Hellman, Teresa Maietta, Alicia Clum, Kanakaharini Byraju, Nataly Raviv, Michael D. Staudt, Erin Jeannotte, Julia Nalwalk, Sophie Belin, Yannick Poitelon, and Julie G. Pilitsis

OBJECTIVE

To date, muscular and bone pain have been studied in domestic swine models, but the only neuropathic pain model described in swine is a mixed neuritis model. Common peroneal nerve injury (CPNI) neuropathic pain models have been utilized in both mice and rats.

METHODS

The authors developed a swine surgical CPNI model of neuropathic pain. Behavioral outcomes were validated with von Frey filament testing, thermal sensitivity assessments, and social and motor scoring. Demyelination of the nerve was confirmed through standard histological assessment. The contralateral nerve served as the control.

RESULTS

CPNI induced mechanical and thermal allodynia (p < 0.001 [n = 10] and p < 0.05 [n = 4], respectively) and increased pain behavior, i.e., guarding of the painful leg (n = 12). Myelin protein zero (P0) staining revealed demyelination of the ligated nerve upstream of the ligation site.

CONCLUSIONS

In a neuropathic pain model in domestic swine, the authors demonstrated that CPNI induces demyelination of the common peroneal nerve, which the authors hypothesize is responsible for the resulting allodynic pain behavior. As the anatomical features of domestic swine resemble those of humans more closely than previously used rat and mouse models, utilizing this swine model, which is to the authors’ knowledge the first of its kind, will aid in the translation of experimental treatments to clinical trials.

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Abigail Hellman, Teresa Maietta, Alicia Clum, Kanakaharini Byraju, Nataly Raviv, Michael D. Staudt, Erin Jeannotte, Goutam Ghoshal, Damian Shin, Paul Neubauer, Emery Williams, Tamas Heffter, Clif Burdette, Jiang Qian, Julia Nalwalk, and Julie G. Pilitsis

OBJECTIVE

The authors’ laboratory has previously demonstrated beneficial effects of noninvasive low intensity focused ultrasound (liFUS), targeted at the dorsal root ganglion (DRG), for reducing allodynia in rodent neuropathic pain models. However, in rats the DRG is 5 mm below the skin when approached laterally, while in humans the DRG is typically 5–8 cm deep. Here, using a modified liFUS probe, the authors demonstrated the feasibility of using external liFUS for modulation of antinociceptive responses in neuropathic swine.

METHODS

Two cohorts of swine underwent a common peroneal nerve injury (CPNI) to induce neuropathic pain. In the first cohort, pigs (14 kg) were iteratively tested to determine treatment parameters. liFUS penetration to the L5 DRG was verified by using a thermocouple to monitor tissue temperature changes and by measuring nerve conduction velocity (NCV) at the corresponding common peroneal nerve (CPN). Pain behaviors were monitored before and after treatment. DRG was evaluated for tissue damage postmortem. Based on data from the first cohort, a treatment algorithm was developed, parameter predictions were verified, and neuropathic pain was significantly modified in a second cohort of larger swine (20 kg).

RESULTS

The authors performed a dose-response curve analysis in 14-kg CPNI swine. Specifically, after confirming that the liFUS probe could reach 5 cm in ex vivo tissue experiments, the authors tested liFUS in 14-kg CPNI swine. The mean ± SEM DRG depth was 3.79 ± 0.09 cm in this initial cohort. The parameters were determined and then extrapolated to larger animals (20 kg), and predictions were verified. Tissue temperature elevations at the treatment site did not exceed 2°C, and the expected increases in the CPN NCV were observed. liFUS treatment eliminated pain guarding in all animals for the duration of follow-up (up to 1 month) and improved allodynia for 5 days postprocedure. No evidence of histological damage was seen using Fluoro-Jade and H&E staining.

CONCLUSIONS

The results demonstrate that a 5-cm depth can be reached with external liFUS and alters pain behavior and allodynia in a large-animal model of neuropathic pain.