Radiology Reports Do Not Accurately Portray the Severity of Cervical Neural Foraminal Stenosis

STUDY DESIGN

Retrospective study.

OBJECTIVE

(1) To compare cervical magnetic resonance imaging (MRI) radiology reports to a validated grading system for cervical foraminal stenosis (FS) and (2) to evaluate whether the severity of cervical neural FS on MRI correlates to motor weakness or patient-reported outcomes.

BACKGROUND

Radiology reports of cervical spine MRI are often reviewed to assess the degree of neural FS. However, research looking at the association between these reports and objective MRI findings, as well as clinical symptoms, is lacking.

PATIENTS AND METHODS

We retrospectively identified all adult patients undergoing primary 1 or 2-level anterior cervical discectomy and fusion at a single academic center for an indication of cervical radiculopathy. Preoperative MRI was assessed for neural FS severity using the grading system described by Kim and colleagues for each level of fusion, as well as adjacent levels. Neural FS severity was recorded from diagnostic radiologist MRI reports. Motor weakness was defined as an examination grade <4/5 on the final preoperative encounter. Regression analysis was conducted to evaluate whether the degree of FS by either classification was related to patient-reported outcome measure severity.

RESULTS

A total of 283 patients were included in the study, and 998 total levels were assessed. There were significant differences between the MRI grading system and the assessment by radio-logists (P< 0.001). In levels with moderate stenosis, 28.9% were classified as having no stenosis by radiology. In levels with severe stenosis, 29.7% were classified as having mild-moderate stenosis or less. Motor weakness was found similarly often in levels of moderate or severe stenosis (6.9% and 9.2%, respectively). On regression analysis, no associations were found between baseline patient-reported outcome measures and stenosis severity assessed by radiologists or MRI grading systems.

CONCLUSION

Radiology reports on the severity of cervical neural FS are not consistent with a validated MRI grading system. These radiology reports underestimated the severity of neural foraminal compression and may be inappropriate when used for clinical decision-making.

LEVEL OF EVIDENCE

Level III.

Impact of postoperative stereotactic body radiation therapy on survival of patients with spinal metastases in the context of additional systemic adjuvant therapy

BACKGROUND

Stereotactic body radiotherapy (SBRT) has been established as a safe and effective treatment modality for control of long-term pain and tumor growth. However, few studies have investigated the efficacy of postoperative SBRT versus conventional external beam radiation therapy (EBRT) in extending survival within the context of systemic therapy.

METHODS

A retrospective chart review of patients who underwent surgery for spinal metastasis at our institution was conducted. Demographic, treatment and outcome data were collected. SBRT was compared with EBRT and non-SBRT, and analyses were stratified by whether or not patients received systemic therapy. Survival analysis was conducted using propensity score matching.

RESULTS

Bivariate analysis in the non-systemic therapy group revealed longer survival with SBRT compared to EBRT and non-SBRT. Further analysis also showed that primary cancer type and preoperative mRS significantly affected survival. Within patients who received systemic therapy, overall median survival for SBRT patients was 22.7 months (95% CI: 12.1 - 52.3) versus 16.1 months (95% CI: 12.7 - 44.0; p = 0.28) for EBRT patients and 16.1 months (95% CI: 12.2 - 21.9; p = 0.07) for non-SBRT patients. Within patients who did not receive systemic therapy, overall median survival for SBRT patients was 62.1 months (95% CI: 18.1 - unknown) versus 5.3 months (95% CI: 2.8 - unknown; p = 0.08) for EBRT patients and 6.9 months (95% CI: 5.0 - 45.6; p = 0.02) for non-SBRT patients.

CONCLUSION

In patients who do not receive systemic therapy, treatment with postoperative SBRT may increase survival time compared to patients not receiving SBRT.

Analysis of socioeconomic and demographic factors on post-treatment outcomes for metastatic spinal tumors

OBJECTIVE

Sociodemographic factors may play a role in incidence and treatment of metastatic spinal tumors, as there is a delay in diagnosis and increased incidence of relevant primaries. There has yet to be a detailed analysis of the impact of sociodemographic factors on surgical outcomes for spinal metastases. We sought to examine the influence of socioeconomic factors on outcomes for patients with metastatic spinal tumors.

METHODS

Two hundred and sixty-three patients who underwent surgery for metastatic spinal tumors were identified. Sociodemographic characteristics were then collected and assigned to patients based on their ZIP code. The Chi-square test and the Mann-Whitney-U test were used for binary and continuous variables, respectively. Multivariate regression models were also used to control for age, smoking status, body mass index, and Charlson Comorbidity Index.

RESULTS

Males had significantly lower rates of post-treatment complication compared to females (22.7 % vs 39.3 %, p = 0.0052), and those in high educational attainment ZIP codes had significantly shorter length of stay (LOS) compared to low educational attainment ZIP codes (9.3 days vs 12.2 days, p = 0.0058). Multivariate regression revealed that living in a high percentage white ZIP code and being male significantly decreased risk of post-treatment complication by 19 % (p = 0.042) and 14 % (p = 0.032), respectively. Living in a high educational attainment ZIP code decreased LOS by 3 days (p = 0.019).

CONCLUSIONS

Males had significantly lower rates of post-treatment complication. Patients in high percentage white areas also had decreased rate of post-treatment complications. Patients living in areas with high educational attainment had shorter length of stay.

Impact of intraoperative direct cortical stimulation dynamics on perioperative seizures and afterdischarge frequency in patients undergoing awake craniotomy

OBJECTIVE

Intraoperative stimulation is used as a crucial adjunct in neurosurgical oncology, allowing for greater extent of resection while minimizing morbidity. However, limited data exist regarding the impact of cortical stimulation on the frequency of perioperative seizures in these patients.

METHODS

A retrospective chart review of patients undergoing awake craniotomy with electrocorticography data by a single surgeon at the authors' institution between 2013 and 2020 was conducted. Eighty-three patients were identified, and electrocorticography, stimulation, and afterdischarge (AD)/seizure data were collected and analyzed. Stimulation characteristics (number, amplitude, density [stimulations per minute], composite score [amplitude × density], total and average stimulation duration, and number of positive stimulation sites) were analyzed for association with intraoperative seizures (ISs), ADs, and postoperative clinical seizures.

RESULTS

Total stimulation duration (p = 0.005), average stimulation duration (p = 0.010), and number of stimulations (p = 0.020) were found to significantly impact AD incidence. A total stimulation duration of more than 145 seconds (p = 0.04) and more than 60 total stimulations (p = 0.03) resulted in significantly higher rates of ADs. The total number of positive stimulation sites was associated with increased IS (p = 0.048). Lesions located within the insula (p = 0.027) were associated with increased incidence of ADs. Patients undergoing repeat awake craniotomy were more likely to experience IS (p = 0.013). Preoperative antiepileptic drug use, seizure history, and number of prior resections of any type showed no impact on the outcomes considered. The charge transferred to the cortex per second during mapping was significantly higher in the 10 seconds leading to AD than at any other time point examined in patients experiencing ADs, and was significantly higher than any time point in patients not experiencing ADs or ISs. Although the rate of transfer for patients experiencing ISs was highest in the 10 seconds prior to the seizure, it was not significantly different from those who did not experience an AD or IS.

CONCLUSIONS

The data suggest that intraoperative cortical stimulation is a safe and effective technique in maximizing extent of resection while minimizing neurological morbidity in patients undergoing awake craniotomies, and that surgeons may avoid ADs and ISs by minimizing duration and total number of stimulations and by decreasing the overall charge transferred to the cortex during mapping procedures.

Neurologic, functional, and survival outcomes following surgical management of metastatic breast cancer to the spine

OBJECTIVE

Metastatic spinal tumors commonly arise from primary breast cancer. We assessed outcomes and identified associated variables for patients who underwent surgical management for spinal metastases of breast cancer.

METHODS

We retrospectively reviewed patients surgically treated for spinal metastases of breast cancer. Neurologic and functional outcomes were analyzed via Frankel scale and Karnofksy Performance Status (KPS) scores, respectively. Variables associated with Frankel and KPS scores after surgery were identified. Multivariable analysis was used to assess predictors for postoperative survival.

RESULTS

Forty-nine patients were identified. There was no significant difference in Frankel scores postoperatively and at last follow-up. KPS scores (P = 0.002) significantly improved at last follow-up. Preoperative non-ambulation and postprocedural complications were associated with non-ambulation postoperatively. Postprocedural complications and disease-free interval (DFI) < 24 and < 60 months were associated with functional impairment at last follow-up. Current smoking status at the time of surgery (P = 0.021) and triple negative (negative immunohistochemistry for estrogen receptor, progesterone receptor, and HER2) breast cancer (P = 0.038) were significantly associated with shortened postoperative survival.

CONCLUSION

When indicated, surgery for spinal metastases of breast cancer leads to preservation of neurologic status and long-term functional improvement. Preoperative ambulatory status and postprocedural complications were associated with ambulatory status after surgery, while postprocedural complications and shortened DFI were associated with functional status after surgery.Current smoking status at the time of surgery and triple negative breast cancer are negative predictors for postoperative survival after metastatic breast cancer to the spine.

Myeloid Cell Classification and Therapeutic Opportunities Within the Glioblastoma Tumor Microenvironment in the Single Cell-Omics Era

The glioma tumor microenvironment (TME) is complex and heterogeneous, and multiple emerging and current technologies are being utilized for an improved comprehension and understanding of these tumors. Single cell analysis techniques such as single cell genomic and transcriptomic sequencing analysis are on the rise and play an important role in elucidating the glioma TME. These large datasets will prove useful for patient tumor characterization, including immune configuration that will ultimately influence therapeutic choices and especially immune therapies. In this review we discuss the advantages and drawbacks of these techniques while debating their role in the domain of glioma-infiltrating myeloid cells characterization and function.

Predictors of an academic career among fellowship-trained spinal neurosurgeons

OBJECTIVE

Although fellowship training is becoming increasingly common in neurosurgery, it is unclear which factors predict an academic career trajectory among spinal neurosurgeons. In this study, the authors sought to identify predictors associated with academic career placement among fellowship-trained neurological spinal surgeons.

METHODS

Demographic data and bibliometric information on neurosurgeons who completed a residency program accredited by the Accreditation Council for Graduate Medical Education between 1983 and 2019 were gathered, and those who completed a spine fellowship were identified. Employment was denoted as academic if the hospital where a neurosurgeon worked was affiliated with a neurosurgical residency program; all other positions were denoted as nonacademic. A logistic regression model was used for multivariate statistical analysis.

RESULTS

A total of 376 fellowship-trained spinal neurosurgeons were identified, of whom 140 (37.2%) held academic positions. The top 5 programs that graduated the most fellows in the cohort were Cleveland Clinic, The Johns Hopkins Hospital, University of Miami, Barrow Neurological Institute, and Northwestern University. On multivariate analysis, increased protected research time during residency (OR 1.03, p = 0.044), a higher h-index during residency (OR 1.12, p < 0.001), completing more than one clinical fellowship (OR 2.16, p = 0.024), and attending any of the top 5 programs that graduated the most fellows (OR 2.01, p = 0.0069) were independently associated with an academic career trajectory.

CONCLUSIONS

Increased protected research time during residency, a higher h-index during residency, completing more than one clinical fellowship, and attending one of the 5 programs graduating the most fellowship-trained neurosurgical spinal surgeons independently predicted an academic career. These results may be useful in identifying and advising trainees interested in academic spine neurosurgery.

Lumboperitoneal shunts for the treatment of idiopathic normal pressure hydrocephalus

The standard of care for idiopathic normal pressure hydrocephalus (iNPH) is placement of a ventriculoperitoneal (VP) shunt. However, VP shunts require intracranial intervention and are associated with notable postoperative complications, with some groups reporting complication rates for VP shunts ranging from 17 to 33%, along with failure rates up to 17.7%. Lumboperitoneal (LP) shunts are an alternative for cerebrospinal fluid diversion that do not require intracranial surgery, thus providing utility in patients where intracranial surgery is not possible or preferred. Here we retrospectively reviewed our 25 patients with LP horizontal-vertical (LP-HV) shunts placement for initial treatment for iNPH from 2014 to 2019. All patients had preoperative gait dysfunction, 16 (64%) had urinary incontinence, and 21 (84%) exhibited cognitive insufficiency. Two weeks post-shunt placement, 23/25 (92%) patients demonstrated improvement in gait, 11/16 (68%) had improvement in incontinence, and 14/21 (66%) had improvement cognitive insufficiency. At six months or greater follow up 13/20 (65%) had improvement in gait, 7/15 (47%) showed improvement in incontinence, and 11/15 (73%) demonstrated improvement in cognitive function. Six patients (24%) required at least one revision of the LP shunt. Shunt malfunctions resulted from CSF leak in one patient, shunt catheter migration in two patients, peritoneal catheter pain in one patient, and clinical symptoms for overdrainage in two patients. Thus, we demonstrate that LP-HV shunt placement is safe and efficacious alternative to VP shunting for iNPH, resulting in notable symptomatic improvement and low risk of overdrainage, and may be considered for patients where cranial approaches should be avoided.

Overview of medical malpractice in neurosurgery

Annually, 20% of all practicing neurosurgeons in the United States are faced with medical malpractice litigation. The average indemnity paid in a closed neurosurgical civil claim is $439,146, the highest of all medical specialties. The majority of claims result from dissatisfaction following spinal surgery, although claims after cranial surgery tend to be costlier. On a societal scale, the increasing prevalence of medical malpractice claims is a catalyst for the practice of defensive medicine, resulting in record-level healthcare costs. Outside of the obvious financial strains, malpractice claims have also been linked to professional disenchantment and career changes for afflicted physicians. Unfortunately, neurosurgical residents receive minimal practical education regarding these matters and are often unprepared and vulnerable to these setbacks in the earlier stages of their careers. In this article, the authors aim to provide neurosurgical residents and junior attendings with an introductory guide to the fundamentals of medical malpractice lawsuits and the implications for neurosurgeons as an adjunct to more formal residency education.

Gastric corpus atrophy following eradication of Helicobacter pylori

BACKGROUND

Atrophic gastritis can develop in patients with Helicobacter pylori infection leading to a reduction in basal acid output. Whether the atrophy that develops is reversible is controversial.

OBJECTIVE

To investigate the effect of H. pylori eradication in infected subjects who had developed atrophy of the corpus mucosa.

METHOD

Ten H. pylori positive patients with corpus atrophy were identified at oesophagogastroduodenoscopy (OGD). They received eradication therapy with amoxicillin, clarithromycin and omeprazole. Repeat OGD with biopsy was performed at least 3 months later. Fasting plasma gastrin was measured at baseline and at re-endoscopy. H. pylori eradication was confirmed by 13C urea breath testing.

RESULTS

Median time to re-endoscopy was 5 months. There was improvement in corpus atrophy in 50% of patients after H. pylori eradication, and a significant reduction in plasma gastrin (P = 0.03). The index patients had a significant diminution of basal acid output compared to controls.

CONCLUSION

Corpus atrophy as defined by the Sydney System is reversible in some patients after H. pylori eradication. Improvement in atrophy is associated with a fall in fasting plasma gastrin levels. This may have implications in the prevention of gastric carcinoma.

Precut sphincterotomy: indications, pitfalls, and complications

Precut sphincterotomy is a technique employed to gain access to the common bile duct (CBD) when standard methods using catheters, cannulatomes, and guidewires have failed. It is particularly useful in cases of distal biliary strictures or distal impacted stones and in patients with Billroth II gastrectomies who require papillotomy. It significantly improves the overall success rate of CBD access. This technique should only be used, however, when a therapeutic maneuver is anticipated, and it has no place in diagnostic imaging. In the hands of experienced, skillful endoscopists, the complication rate is comparable with that of standard sphincterotomy.

Radiation doses to patients during ERCP

BACKGROUND

There is a scarcity of data regarding the radiation dose and associated risks to patients during ERCP. Dose area product (DAP) measurements can be used to estimate an effective dose (ED) to patients undergoing ERCP. This measure allows radiation risk associated with such procedures to be quantified. The aim of this study was to evaluate the ED to patients undergoing ERCP.

METHODS

A DAP meter was fitted to the x-ray tube before each ERCP. DAP reading (Gy-cm(2)), fluoroscopy time, average screening kVp, number of films, and kVp per film were recorded. Mean ED was estimated by using DAP readings and Monte Carlo computer software to model radiation exposure conditions.

RESULTS

Data were recorded on 20 subjects. Average DAP was 13.5 Gy-cm(2) (6.8-23.9) for diagnostic and 66.8 Gy-cm(2) (28.7-108.5) for therapeutic ERCP (p < 0.05). Average fluoroscopy time was 2.3 minutes (1.1-5.3) for diagnostic and 10.5 minutes (5.9-16.6) for therapeutic ERCP (p < 0.05). DAP showed a linear relationship with fluoroscopy time (R(2) = 0.928). Mean number of diagnostic and therapeutic films was 2.8 and 3.7, respectively. Fluoroscopic exposure represented 69% of the DAP for diagnostic ERCP and 90% of the DAP for therapeutic ERCP. Average ED was 3.1 mSv for diagnostic and 12.4 mSv for therapeutic ERCP.

CONCLUSIONS

Therapeutic ERCP is associated with significantly higher radiation exposure than diagnostic ERCP. ED in therapeutic ERCP is a result largely of fluoroscopy time as opposed to number of films.

Distribution of atrophy in Helicobacter pylori-infected subjects taking proton pump inhibitors

BACKGROUND

Gastric atrophy is associated with Helicobacter pylori infection. Conflicting results have been obtained as to whether acid suppressant therapy hastens the development or changes the distribution of atrophy in the stomach. The aim of this study was to investigate whether concomitant proton pump inhibitor (PPI) therapy in H. pylori-infected individuals resulted in an increase or an alteration in atrophy distribution and whether this was reflected by the plasma gastrin.

METHODS

Multiple gastric biopsy specimens were taken from the antrum and corpus from 46 H. pylori-infected subjects, 18 of whom were taking PPIs, and assessed histologically by the updated Sydney System. The control group was age- and sex-matched to the index group. Fasting gastrin levels were measured.

RESULTS

In the control group there was no significant tendency for either antral or corpus atrophy to predominate (P = 0.44). In the treatment group there was a significant tendency for corpus as opposed to antral atrophy to develop (P < 0.001). There was no significant difference in the overall atrophy score between the treated and untreated groups (P = 0.76). Fasting gastrin levels were significantly higher in the treated group (P < 0.001).

CONCLUSIONS

Treatment with PPIs in H. pylori-infected subjects does not lead to an overall increase in gastric atrophy. It does, however, result in an increased prevalence of corpus as opposed to antral atrophy. This is associated with a significantly higher gastrin level.

Autoantibodies to gastrin in patients with pernicious anaemia--a novel antibody

Autoantibodies arise when there is a breakdown in immunological tolerance. Autoantibodies to parietal cells and intrinsic factor are found in autoimmune atrophic gastritis (AAG) and are associated with elevated plasma gastrin. Endogenous gastrin autoantibodies have not been described to date. The aim of this study was to investigate the occurrence of autoantibodies to gastrin. Plasma from 50,000 patients, including more than 2000 with AAG, was tested. Gastrin was measured by radioimmunoassay (RIA) in whole plasma and the presence of autoantibody determined by using a control which omitted assay antibody. The quantity and affinity of gastrin autoantibodies was assessed. Three patients had autoantibodies to gastrin. All three had AAG and pernicious anaemia (PA). The antibodies were of low titre and relatively high affinity. Free circulating plasma gastrin levels were within the normal range, but total gastrin levels were elevated. This is the first description of autoantibodies to endogenous gastrin. The incidence of antibodies to gastrin is low, they are found in association with PA, and they may lead to falsely low measurements of plasma gastrin.

Gastrinomas and the change in their presentation and management in Northern Ireland, UK, from 1970 to 1996

Thirty-five new cases of gastrinomas were diagnosed in N. Ireland between 1970 and 1996. Over this period, patient care has improved, with advances in imaging techniques and therapeutic regimens. Patients are now no longer presenting in the classical way with severe ulcer diathesis. Diarrhoea is often a major feature, occurring in 46% of patients. Thirty-one percent of patients presented with mixed amine precursor, uptake and decarboxylation (APUD) tumours. Survival has improved, most likely as a result of better detection of tumours, as well as treatment that is aimed at resection and removal of the gastrinoma. The advent of proton pump inhibitors has ensured symptom control in those for whom total tumour removal is impossible. Owing to improved survival, metastatic complications are often associated with patient mortality.