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Analysis of combined clinical and diffusion basis spectrum imaging metrics to predict the outcome of chronic cervical spondylotic myelopathy following cervical decompression surgery

Dinal Jayasekera, Justin K. Zhang, Jacob Blum, Rachel Jakes, Peng Sun, Saad Javeed, Jacob K. Greenberg, Sheng-Kwei Song, and Wilson Z. Ray

OBJECTIVE

Cervical spondylotic myelopathy (CSM) is the most common cause of chronic spinal cord injury, a significant public health problem. Diffusion tensor imaging (DTI) is a neuroimaging technique widely used to assess CNS tissue pathology and is increasingly used in CSM. However, DTI lacks the needed accuracy, precision, and recall to image pathologies of spinal cord injury as the disease progresses. Thus, the authors used diffusion basis spectrum imaging (DBSI) to delineate white matter injury more accurately in the setting of spinal cord compression. It was hypothesized that the profiles of multiple DBSI metrics can serve as imaging outcome predictors to accurately predict a patient’s response to therapy and his or her long-term prognosis. This hypothesis was tested by using DBSI metrics as input features in a support vector machine (SVM) algorithm.

METHODS

Fifty patients with CSM and 20 healthy controls were recruited to receive diffusion-weighted MRI examinations. All spinal cord white matter was identified as the region of interest (ROI). DBSI and DTI metrics were extracted from all voxels in the ROI and the median value of each patient was used in analyses. An SVM with optimized hyperparameters was trained using clinical and imaging metrics separately and collectively to predict patient outcomes. Patient outcomes were determined by calculating changes between pre- and postoperative modified Japanese Orthopaedic Association (mJOA) scale scores.

RESULTS

Accuracy, precision, recall, and F1 score were reported for each SVM iteration. The highest performance was observed when a combination of clinical and DBSI metrics was used to train an SVM. When assessing patient outcomes using mJOA scale scores, the SVM trained with clinical and DBSI metrics achieved accuracy and an area under the curve of 88.1% and 0.95, compared with 66.7% and 0.65, respectively, when clinical and DTI metrics were used together.

CONCLUSIONS

The accuracy and efficacy of the SVM incorporating clinical and DBSI metrics show promise for clinical applications in predicting patient outcomes. These results suggest that DBSI metrics, along with the clinical presentation, could serve as a surrogate in prognosticating outcomes of patients with CSM.

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Patient perception of scoliosis correction surgery on Instagram

Nitin Agarwal, Amaan Rahman, Rachel Jacobs, Tavis Taylor, Nallammai Muthiah, Nima Alan, Alp Ozpinar, Daryl Fields, and David Kojo Hamilton

OBJECTIVE

Patient feedback surveys provide important insight into patient outcomes, satisfaction, and perioperative needs. Recent critiques have questioned provider-initiated surveys and their capacity to accurately gauge patient perspectives due to intrinsic biases created by question framing. In this study, the authors sought to evaluate provider-independent, patient-controlled social media Instagram posts in order to better understand the patient experience following scoliosis correction surgery.

METHODS

Twitter and Instagram were queried for posts with two tagged indicators, #scoliosissurgery or @scoliosissurgery, resulting in no relevant Twitter posts and 25,000 Instagram posts. Of the initial search, 24,500 Instagram posts that did not directly involve the patient’s own experience were eliminated. Posts were analyzed and coded for the following criteria: the gender of the patient, preoperative or postoperative timing discussed in the post, and classified themes related to the patient’s experiences with scoliosis correction surgery.

RESULTS

Females made 87.6% of the Instagram posts about their experience following scoliosis correction surgery. The initial postoperative stage of surgery was mentioned in 7.6% of Instagram posts. The most common theme on Instagram involved offering or seeking online support from other patients, which constituted 85.2% of all posts. Other common themes included concern about the surgical scar (31.8%), discussing the results of treatment (28.8%), and relief regarding results (21.2%).

CONCLUSIONS

Social media provided a platform to analyze unprompted feedback from patients. Patients were most concerned with their scoliosis correction surgery in the period of time 2 weeks or more after surgery. Themes that were most commonly found on Instagram posts were offering or seeking online support from other patients and concern about the surgical scar. Patient-controlled social media platforms, like Instagram, may provide a useful mechanism for healthcare providers to understand the patient experience following scoliosis correction surgery. Such platforms may help in evaluating postoperative satisfaction and improving postoperative quality of care.

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Long-term outcomes of deep pediatric arteriovenous malformations

Prateek Agarwal, Nikhil Sharma, Gautam Nayar, Rachel C. Jacobs, Alhamza Al-Bayati, L. Dade Lunsford, Michael M. McDowell, and Stephanie Greene

OBJECTIVE

Multimodality treatment has been shown to be the optimal management strategy for pediatric arteriovenous malformations (AVMs). Deep AVMs represent a subset of AVMs for which optimal management may be achieved with a combination of radiosurgery and highly selective embolization, in the absence of compelling features requiring operative intervention. The objective of this study was to identify predictors of good functional outcomes in pediatric patients with deep AVMs.

METHODS

A retrospective cohort study of the outcomes of 79 patients with deep AVMs from January 1988 through December 2021 was performed. Deep AVMs were defined as those with the majority of the nidus centered in the basal ganglia, thalamus, or brainstem. Collected data included patient demographics and presenting symptoms, presenting modified Rankin Scale (mRS) score, radiographic findings and outcomes, management strategy, complications, and clinical outcomes as indicated by follow-up mRS score. A good outcome was defined as a follow-up mRS score ≤ 2, while a poor outcome was defined as a follow-up mRS score ≥ 3. Statistical analysis was performed to identify factors associated with functional outcomes.

RESULTS

With a mean follow-up duration of 85.6 months, there was a 72.2% angiographic obliteration rate, with 75.9% of patients having a good clinical outcome (mRS score ≤ 2). Presenting symptoms and radiographic characteristics were not significantly associated with long-term functional outcomes. There was a significantly higher rate of posttreatment hemorrhage in patients with a poor versus good outcome (11.8% vs 0%, p = 0.010). On multivariate logistic regression analysis, poor long-term functional outcome was only associated with poor presenting mRS score (p = 0.002).

CONCLUSIONS

Satisfactory angiographic obliteration rates and good long-term functional outcomes can be achieved for deep AVMs, with stereotactic radiosurgery as the cornerstone of multimodality treatment.

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How to improve obliteration rates during volume-staged stereotactic radiosurgery for large arteriovenous malformations

Hideyuki Kano, John C. Flickinger, Aya Nakamura, Rachel C. Jacobs, Daniel A. Tonetti, Craig Lehocky, Kyung-Jae Park, Huai-che Yang, Ajay Niranjan, and L. Dade Lunsford

OBJECTIVE

The management of large-volume arteriovenous malformations (AVMs) with stereotactic radiosurgery (SRS) remains challenging. The authors retrospectively tested the hypothesis that AVM obliteration rates can be improved by increasing the percentage volume of an AVM that receives a minimal threshold dose of radiation.

METHODS

In 1992, the authors prospectively began to stage anatomical components in order to deliver higher single doses to AVMs > 15 cm3 in volume. Since that time 60 patients with large AVMs have undergone volume-staged SRS (VS-SRS). The median interval between the first stage and the second stage was 4.5 months (2.8–13.8 months). The median target volume was 11.6 cm3 (range 4.3–26 cm3) in the first-stage SRS and 10.6 cm3 (range 2.8–33.7 cm3) in the second-stage SRS. The median margin dose was 16 Gy (range 13–18 Gy) for both SRS stages.

RESULTS

AVM obliteration after the initial two staged volumetric SRS treatments was confirmed by MRI alone in 4 patients and by angiography in 11 patients at a median follow-up of 82 months (range 0.4–206 months) after VS-SRS. The post–VS-SRS obliteration rates on angiography were 4% at 3 years, 13% at 4 years, 23% at 5 years, and 27% at 10 years. In multivariate analysis, only ≥ 20-Gy volume coverage was significantly associated with higher total obliteration rates confirmed by angiography. When the margin dose is ≥ 17 Gy and the 20-Gy SRS volume included ≥ 63% of the total target volume, the angiographically confirmed obliteration rates increased to 61% at 5 years and 70% at 10 years.

CONCLUSIONS

The outcomes of prospective VS-SRS for large AVMs can be improved by prescribing an AVM margin dose of ≥ 17 Gy and adding additional isocenters so that ≥ 63% of the internal AVM dose receives more than 20 Gy.

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Does waiting for surgery matter? How time from diagnostic MRI to resection affects outcomes in newly diagnosed glioblastoma

Jacob S. Young, Nadeem N. Al-Adli, Rachel Muster, Ankush Chandra, Ramin A. Morshed, Matheus P. Pereira, Eric J. Chalif, Shawn L. Hervey-Jumper, Philip V. Theodosopoulos, Michael W. McDermott, Mitchel S. Berger, and Manish K. Aghi

OBJECTIVE

Maximal safe resection is the standard of care for patients presenting with lesions concerning for glioblastoma (GBM) on magnetic resonance imaging (MRI). Currently, there is no consensus on surgical urgency for patients with an excellent performance status, which complicates patient counseling and may increase patient anxiety. This study aims to assess the impact of time to surgery (TTS) on clinical and survival outcomes in patients with GBM.

METHODS

This is a retrospective study of 145 consecutive patients with newly diagnosed IDH–wild-type GBM who underwent initial resection at the University of California, San Francisco, between 2014 and 2016. Patients were grouped according to the time from diagnostic MRI to surgery (i.e., TTS): ≤ 7, > 7–21, and > 21 days. Contrast-enhancing tumor volumes (CETVs) were measured using software. Initial CETV (CETV1) and preoperative CETV (CETV2) were used to evaluate tumor growth represented as percent change (ΔCETV) and specific growth rate (SPGR; % growth/day). Overall survival (OS) and progression-free survival (PFS) were measured from the date of resection and were analyzed using the Kaplan-Meier method and Cox regression analyses.

RESULTS

Of the 145 patients (median TTS 10 days), 56 (39%), 53 (37%), and 36 (25%) underwent surgery ≤ 7, > 7–21, and > 21 days from initial imaging, respectively. Median OS and PFS among the study cohort were 15.5 and 10.3 months, respectively, and did not differ among the TTS groups (p = 0.81 and 0.17, respectively). Median CETV1 was 35.9, 15.7, and 10.2 cm3 across the TTS groups, respectively (p < 0.001). Preoperative biopsy and presenting to an outside hospital emergency department were associated with an average 12.79-day increase and 9.09-day decrease in TTS, respectively. Distance from the treating facility (median 57.19 miles) did not affect TTS. In the growth cohort, TTS was associated with an average 2.21% increase in ΔCETV per day; however, there was no effect of TTS on SPGR, Karnofsky Performance Status (KPS), postoperative deficits, survival, discharge location, or hospital length of stay. Subgroup analyses did not identify any high-risk groups for which a shorter TTS may be beneficial.

CONCLUSIONS

An increased TTS for patients with imaging concerning for GBM did not impact clinical outcomes, and while there was a significant association with ΔCETV, SPGR remained unaffected. However, SPGR was associated with a worse preoperative KPS, which highlights the importance of tumor growth speed over TTS. Therefore, while it is ill advised to wait an unnecessarily long time after initial imaging studies, these patients do not require urgent/emergency surgery and can seek tertiary care opinions and/or arrange for additional preoperative support/resources. Future studies are needed to explore subgroups for whom TTS may impact clinical outcomes.

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Adverse radiation effects in volume-staged radiosurgery for large arteriovenous malformations: a multiinstitutional study

Zachary A. Seymour, Jason W. Chan, Michael W. McDermott, Inga Grills, Hong Ye, Hideyuki Kano, Craig A. Lehocky, Rachel C. Jacobs, L. Dade Lunsford, Tomas Chytka, Roman Liščák, Cheng-Chia Lee, Huai-che Yang, Dale Ding, Jason P. Sheehan, Caleb E. Feliciano, Rafael Rodriguez-Mercado, Veronica L. Chiang, Judith A. Hess, Samuel Sommaruga, Brendan McShane, John Y. K. Lee, Lucas T. Vasas, Anthony M. Kaufmann, and Penny K. Sneed

OBJECTIVE

The optimal treatment paradigm for large arteriovenous malformations (AVMs) is controversial. One approach is volume-staged stereotactic radiosurgery (VS-SRS). The authors previously reported efficacy of VS-SRS for large AVMs in a multiinstitutional cohort; here they focus on risk of symptomatic adverse radiation effects (AREs).

METHODS

This is a multicentered retrospective review of patients treated with a planned prospective volume staging approach to stereotactically treat the entire nidus of an AVM, with volume stages separated by intervals of 3–6 months. A total of 9 radiosurgical centers treated 257 patients with VS-SRS between 1991 and 2016. The authors evaluated permanent, transient, and total ARE events that were symptomatic.

RESULTS

Patients received 2–4 total volume stages. The median age was 33 years at the time of the first SRS volume stage, and the median follow-up was 5.7 years after VS-SRS. The median total AVM nidus volume was 23.25 cm3 (range 7.7–94.4 cm3), with a median margin dose per stage of 17 Gy (range 12–20 Gy). A total of 64 patients (25%) experienced an ARE, of which 19 were permanent. Rather than volume, maximal linear dimension in the Z (craniocaudal) dimension was associated with toxicity; a threshold length of 3.28 cm was associated with an ARE, with a 72.5% sensitivity and a 58.3% specificity. In addition, parietal lobe involvement for superficial lesions and temporal lobe involvement for deep lesions were associated with an ARE.

CONCLUSIONS

Size remains the dominant predictor of toxicity following SRS, but overall rates of AREs were lower than anticipated based on baseline features, suggesting that dose and size were relatively dissociated through volume staging. Further techniques need to be assessed to optimize outcomes.

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Abstracts of the 2012 Meeting of the Lumbar Spine Research Society April 26–27, 2012

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Abstracts of the 10th Annual Meeting of the Lumbar Spine Research Society Chicago, Illinois • April 6 & 7, 2017

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Abstracts of the Eighth Annual Meeting of the Lumbar Spine Research Society Chicago, Illinois • April 9–10, 2015

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Abstracts of the 2013 Annual Meeting of the AANS/CNS Section on Disorders of the Spine and Peripheral Nerves

Phoenix, Arizona • March 6–9, 2013