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Ping Zhu, Xianglin L. Du, Jay-Jiguang Zhu and Yoshua Esquenazi

OBJECTIVE

The present study was designed to explore the association between facility type (academic center [AC] vs non-AC), facility volume (high-volume facility [HVF] vs low-volume facility [LVF]), and outcomes of glioblastoma (GBM) treatment.

METHODS

Based on the National Cancer Database (NCDB), GBM patients were categorized by treatment facility type (non-AC vs AC) and volume [4 categories (G1–G4): < 5.0, 5.0–14.9, 15.0–24.9, and ≥ 25.0, cases/year]. HVF was defined based on the 90th percentile of annual GBM cases (≥ 15.0 cases/year). Outcomes include overall survival (OS), the receipt of surgery and adjuvant therapies, 30-day readmission/mortality, 90-day mortality, and prolonged length of inpatient hospital stay (LOS). Kaplan-Meier methods and accelerated failure time (AFT) models were applied for survival analysis, and multivariable logistic regression models were performed to compare differences in the receipt of treatment and related short-term outcomes by facility type and volume.

RESULTS

A total of 40,256 GBM patients diagnosed between 2004 and 2014 were included. Patients treated at an AC & HVF experienced the longest survival (median OS: 13.3, 11.8, 11.1, and 10.3 months; time ratio [TR]: 1.00 [Ref.], 0.96, 0.92, and 0.89; for AC & HVF, AC & LVF, non-AC & HVF, and non-AC & LVF, respectively), regardless of care transition/treatment referral. Tumor resection, radiotherapy, and chemotherapy were most frequently utilized in AC & HVF. Prolonged LOS, 30-day readmission, and 90-day mortality were decreased by 20%, 22%, and 16% (p ≤ 0.001), respectively, at AC & HVF.

CONCLUSIONS

This study provides evidence of superior outcomes when GBM patients are treated at AC and HVF. Standardization of health care across facility type and/or volume and comprehensive neuro-oncological care should be a potential goal in the management of GBM patients.

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Bang-ping Qian, Ji-chen Huang, Yong Qiu, Bin Wang, Yang Yu, Ze-zhang Zhu, Sai-hu Mao and Jun Jiang

OBJECTIVE

To describe the incidence of complications in spinal osteotomy for thoracolumbar kyphosis caused by ankylosing spondylitis (AS) and to investigate the risk factors for these complications.

METHODS

From April 2000 to July 2017, 342 consecutive AS patients with a mean age (± SD) of 35.4 ± 9.8 years (range 17–71 years) undergoing spinal osteotomy were enrolled. Patients with complications within the 1st postoperative year were identified. Demographic, radiological, and surgical data were compared between patients with and without complications. The complications were classified into intraoperative and postoperative complications.

RESULTS

A total of 310 consecutive pedicle subtraction osteotomy (PSO) and 37 multiple Smith-Petersen osteotomy (SPO) procedures were performed in 342 patients. Overall, 47 complications were identified in 47 patients (13.7%), including 31 intraoperative complications and 16 postoperative complications. Patients with complications were older than those without (p = 0.006). A significant difference was observed in preoperative global kyphosis (GK), lumbar lordosis (LL), sagittal vertical axis (SVA), and the correction of these radiographic parameters between patients with and without complications (p < 0.05). Two-level PSO (p = 0.022) and an increased number of instrumented vertebrae (p = 0.019) were significantly associated with an increased risk of complications.

CONCLUSIONS

The overall incidence of complications was 13.7%. Age; preoperative GK, LL, and SVA; the correction of GK, LL, and SVA; 2-level PSO; and number of instrumented vertebrae were risk factors. Therefore, the potential risk of extensive surgeries with large correction and long fusion in older AS patients with severe GK should be seriously considered in surgical decision-making.

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Chuanjiang Dong, Ping Zhu, Zonglan Xie, Zheqi Fan and Ziqiang Dong

OBJECTIVE

The purpose of this study was to determine the feasibility of rectum reinnervation with transfer of a primarily genitofemoral nerve to the pelvic nerve in the rat.

METHODS

Thirty-six male rats were randomly divided into 3 groups: rats in the nerve transfer group (n = 12) were subjected to rectal denervation and then bilateral genitofemoral nerve–pelvic nerve transfer; rats in the nerve resection group (n = 12) underwent rectum denervation without nerve transfer; and rats in the control group (n = 12) underwent sham surgery. Rectum denervation was achieved by transection of the L-6 spinal nerves, the spinal nerves below L-6, and the pelvic nerve. Four months postoperatively, retrograde nerve tracing, regenerative nerve morphological examination, and rectal manometry assessment were performed.

RESULTS

Regenerative nerve morphological examination showed good axonal regeneration after genitofemoral nerve transfer. Nerve stimulation induced increased rectal pressures in 10 of 12 rats in the nerve transfer group. The mean rectal pressure in this group was 54.9 ± 7.1 mm Hg, which is higher than the mean value in the nerve resection group (5.5 ± 2.0 mm Hg) but lower than that in the control group (70.6 ± 8.5 mm Hg) (p < 0.05). The appearance of FluoroGold-labeled neurons in the L-1 and L-2 spinal cord segments in the nerve transfer group confirmed the formation of new neural pathways.

CONCLUSIONS

The results have demonstrated that genitofemoral nerve–pelvic nerve transfer can achieve nerve regeneration. In this animal model, the authors were able to reinnervate the rectum by nerve transfer.

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Patrick S. Rollo, Matthew J. Rollo, Ping Zhu, Oscar Woolnough and Nitin Tandon

OBJECTIVE

Traditional stereo-electroencephalography (sEEG) entails the use of orthogonal trajectories guided by seizure semiology and arteriography. Advances in robotic stereotaxy and computerized neuronavigation have made oblique trajectories more feasible and easier to implement without formal arteriography. Such trajectories provide access to components of seizure networks not readily sampled using orthogonal trajectories. However, the dogma regarding the relative safety and predictability of orthogonal and azimuth-based trajectories persists, given the absence of data regarding the safety and efficacy of oblique sEEG trajectories. In this study, the authors evaluated the relative accuracy and efficacy of both orthogonal and oblique trajectories during robotic implantation of sEEG electrodes to sample seizure networks.

METHODS

The authors performed a retrospective analysis of 150 consecutive procedures in 134 patients, accounting for 2040 electrode implantations. Of these, 837 (41%) were implanted via oblique trajectories (defined as an entry angle > 30°). Accuracy was calculated by comparing the deviation of each electrode at the entry and the target point from the planned trajectory using postimplantation imaging.

RESULTS

The mean entry and target deviations were 1.57 mm and 1.89 mm for oblique trajectories compared with 1.38 mm and 1.69 mm for orthogonal trajectories, respectively. Entry point deviation was significantly associated with entry angle, but the impact of this relationship was negligible (−0.015-mm deviation per degree). Deviation at the target point was not significantly affected by the entry angle. No hemorrhagic or infectious complications were observed in the entire cohort, further suggesting that these differences were not meaningful in a clinical context. Of the patients who then underwent definitive procedures after sEEG, 69 patients had a minimum of 12 months of follow-up, of whom 58 (84%) achieved an Engel class I or II outcome during a median follow-up of 27 months.

CONCLUSIONS

The magnitude of stereotactic errors in this study falls squarely within the range reported in the sEEG literature, which primarily features orthogonal trajectories. The patient outcomes reported in this study suggest that seizure foci are well localized using oblique trajectories. Thus, the selective use of oblique trajectories in the authors’ cohort was associated with excellent safety and efficacy, with no patient incidents, and the findings support the use of oblique trajectories as an effective and safe means of investigating seizure networks.

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Qing-shuang Zhou, MM, Xu Sun, Xi Chen, Liang Xu, Bang-ping Qian, Ze-zhang Zhu, Bin Wang and Yong Qiu

OBJECTIVE

The aim of this study was to investigate sagittal alignment and compensatory mechanisms in patients with monosegmental spondylolysis (mono_lysis) and multisegmental spondylolysis (multi_lysis).

METHODS

A total of 453 adult patients treated for symptomatic low-grade spondylolytic spondylolisthesis were retrospectively studied at a single center. Patients were divided into 2 subgroups, the mono_lysis group and the multi_lysis group, based on the number of spondylolysis segments. A total of 158 asymptomatic healthy volunteers were enrolled in this study as the control group. Radiographic parameters measured on standing sagittal radiographs and the ratios of L4–S1 segmental lordosis (SL) to lumbar lordosis (L4–S1 SL/LL) and pelvic tilt to pelvic incidence (PT/PI) were compared between all experimental groups.

RESULTS

There were 51 patients (11.3%) with a diagnosis of multi_lysis in the spondylolysis group. When compared with the control group, the spondylolysis group exhibited larger PI (p < 0.001), PT (p < 0.001), LL (p < 0.001), and L4–S1 SL (p = 0.025) and a smaller L4–S1 SL/LL ratio (p < 0.001). When analyzing the specific spondylolysis subgroups, there were no significant differences in PI, but the multi_lysis group had a higher L5 incidence (p = 0.004), PT (p = 0.018), and PT/PI ratio (p = 0.039). The multi_lysis group also had a smaller L4–S1 SL/LL ratio (p = 0.012) and greater sagittal vertical axis (p < 0.001).

CONCLUSIONS

A high-PI spinopelvic pattern was involved in the development of spondylolytic spondylolisthesis, and a larger L5 incidence might be associated with the occurrence of consecutive multi_lysis. Unlike patients with mono_lysis, individuals with multi_lysis were characterized by an anterior trunk, insufficiency of L4–S1 SL, and pelvic retroversion.

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Ping Zhu, Xianglin L. Du, Angel I. Blanco, Leomar Y. Ballester, Nitin Tandon, Mitchel S. Berger, Jay-Jiguang Zhu and Yoshua Esquenazi

OBJECTIVE

The object of this study was to investigate the impact of facility type (academic center [AC] vs non-AC) and facility volume (high-volume facility [HVF] vs low-volume facility [LVF]) on low-grade glioma (LGG) outcomes.

METHODS

This retrospective cohort study included 5539 LGG patients (2004–2014) from the National Cancer Database. Patients were categorized by facility type and volume (non-AC vs AC, HVF vs LVF). An HVF was defined as the top 1% of facilities according to the number of annual cases. Outcomes included overall survival, treatment receipt, and postoperative outcomes. Kaplan-Meier and Cox proportional-hazards models were applied. The Heller explained relative risk was computed to assess the relative importance of each survival predictor.

RESULTS

Significant survival advantages were observed at HVFs (HR 0.67, 95% CI 0.55–0.82, p < 0.001) and ACs (HR 0.84, 95% CI 0.73–0.97, p = 0.015), both prior to and after adjusting for all covariates. Tumor resection was 41% and 26% more likely to be performed at HVFs vs LVFs and ACs vs non-ACs, respectively. Chemotherapy was 40% and 88% more frequently to be utilized at HVFs vs LVFs and ACs vs non-ACs, respectively. Prolonged length of stay (LOS) was decreased by 42% and 24% at HVFs and ACs, respectively. After tumor histology, tumor pattern, and codeletion of 1p19q, facility type and surgical procedure were the most important contributors to survival variance. The main findings remained consistent using propensity score matching and multiple imputation.

CONCLUSIONS

This study provides evidence of survival benefits among LGG patients treated at HVFs and ACs. An increased likelihood of undergoing resections, receiving adjuvant therapies, having shorter LOSs, and the multidisciplinary environment typically found at ACs and HVFs are important contributors to the authors’ finding.