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OBJECTIVE External ventricular drain (EVD) placement is a common neurosurgical procedure. While this procedure is simple and effective, infection is a major limiting factor. Factors predictive of infection reported in the literature are not conclusive. The aim of this retrospective, single-center large series was to assess the rate and independent predictors of ventriculostomy-associated infection (VAI). METHODS The authors performed a retrospective chart review of consecutive patients who underwent EVD placement between January 2012 and January 2018. RESULTS A total of 389 patients were included in the study. The infection rate was 3.1% (n = 12). Variables that were significantly associated with VAI were EVD replacement (OR 10, p = 0.001), bilateral EVDs (OR 9.2, p = 0.009), duration of EVD placement (OR 1.1, p = 0.011), increased CSF output/day (OR 1.0, p = 0.001), CSF leak (OR 12.9, p = 0.001), and increased length of hospital stay (OR 1.1, p = 0.002). Using multivariate logistic regression, independent predictors of VAI were female sex (OR 7.1, 95% CI 1.1–47.4; p = 0.043), EVD replacement (OR 8.5, 95% CI 1.44–50.72; p = 0.027), increased CSF output/day (OR 1.01, 95% CI 1.0–1.02; p = 0.023), and CSF leak (OR 15.1, 95% CI 2.6–87.1; p = 0.003). CONCLUSIONS The rate of VAI was 3.1%. Routine CSF collection (every other day or every 3 days) and CSF collection when needed were not associated with VAI. The authors recommend CSF collection when clinically needed rather than routinely.

Study Design: Literature review. Objectives: Paraspinal muscle integrity is believed to play a critical role in low back pain (LBP) and numerous spinal deformity diseases and other pain pathologies. The influence of paraspinal muscle atrophy (PMA) on the clinical and radiographic success of spinal surgery has not been established. We aim to survey the literature in order to evaluate the impact of paraspinal muscle atrophy on low back pain, spine pathologies, and postoperative outcomes of spinal surgery. Methods: A review of the literature was conducted using a total of 267 articles identified from a search of the PubMed database and additional resources. A full-text review was conducted of 180 articles, which were assessed based on criteria that included an objective assessment of PMA in addition to measuring its relationship to LBP, thoracolumbar pathology, or surgical outcomes. Results: A total of 34 studies were included in this review. The literature on PMA illustrates an association between LBP and both decreased cross-sectional area and increased fatty infiltration of paraspinal musculature. Atrophy of the erector spinae and psoas muscles have been associated with spinal stenosis, isthmic spondylolisthesis, facet arthropathy, degenerative lumbar kyphosis. A number of studies have also demonstrated an association between PMA and worse postoperative outcomes. Conclusions: PMA is linked to several spinal pathologies and some studies demonstrate an association with worse postoperative outcomes following spinal surgery. There is a need for further research to establish a relationship between preoperative paraspinal muscle integrity and postoperative success, with the potential for guiding surgical decision making.

IntroductionTrigeminal neuralgia remains a challenging disease with significant debilitating symptoms and variable efficacy in terms of treatment options, namely microvascular decompression (MVD), stereotactic radiosurgery (SRS), and percutaneous rhizotomy. Internal neurolysis (IN) is an alternative treatment that may be provide patient benefit but has limited understanding. We performed a systematic review of IN treatment of trigeminal neuralgia.MethodsStudies from 2000 to 2021 that assessed IN in trigeminal neuralgia were aggregated and independently reviewed. Weighted averages for demographics, outcomes and complications were generated.ResultsA total of 520 patients in 12 studies were identified with 384 who underwent IN (mean age 53.8 years, range 46-61.4 years). A mean follow-up time of 36.5 months (range 12-90 months) was seen. Preoperative symptoms were present for about 55.0 months before treatment and pain was predominantly in V2/3 (26.8%) followed by other distributions. An excellent to good outcome (Barrow Neurological Institute Pain Score [BNI-PS] I-III) was seen in 83.7% of patients (range 72-93.8%). Pain outcomes at 1 year were excellent in 58-78.4%, good or better in 77-93.75% and fair or better in 80-93.75% of patients. On average facial numbness following IN was seen in 96% of patients however at follow-up remained in only 1.75-10%. The vast majority of remaining numbness was not significantly distressing to patients. Subgroup comparisons of IN vs. recurrent MVD, IN vs. radiofrequency ablation, the impact of IN during the absence of vascular compression as well as IN with and without MVD were also evaluated.ConclusionsIN represents a promising approach for surgical treatment of trigeminal neuralgia in the absence of vascular compression or in potential cases of recurrence. Complications were limited in general. Further study is required to evaluate the impact of IN via higher quality prospective studies.

Ossification of the posterior longitudinal ligament (OPLL) is a rare but potentially devastating cause of degenerative cervical myelopathy (DCM). Decompressive surgery is the standard of care for OPLL and can be achieved through anterior, posterior, or combined approaches to the cervical spine. Surgical correction of OPLL via any approach is associated with higher rates of complications and the presence of OPLL is considered a significant risk factor for perioperative complications in DCM surgeries. Potential complications include dural tear (DT) and subsequent cerebrospinal fluid leak, C5 palsy, hematoma, hardware failure, surgical site infections, and other neurological deficits. Anterior approaches are technically more demanding and associated with higher rates of DT but offer greater access to ventral OPLL pathology. Posterior approaches are associated with lower rates of complications but may allow for continued disease progression. Therefore, the decision to pursue either an anterior or posterior approach to surgical decompression may be critically influenced by complications associated with each procedure. The authors critically review anterior and posterior approaches to surgical decompression of OPLL with particular focus on the complications associated with each approach. We also review the recent work in developing new surgical treatments for OPLL that aim to reduce complication incidence.

Background and importance Pivotal trials have shown the tremendous efficacy of mechanical thrombectomy in proximal occlusions (PO). However distal occlusions (DO) involving M2 and beyond, distal ACA (A2) and posterior cerebral arteries were not represented. The thoughts are that distal vessels supply a smaller brain area, however, with significant symptoms paired with accessible occlusions, the concept may need to be revisited. In this study, we investigated the efficacy and safety of distal circulation mechanical thrombectomies compared to proximal circulation mechanical thrombectomies. Methods A retrospective review of patients presenting with distal circulation acute ischemic stroke (AIS) who underwent mechanical thrombectomy at a tertiary referral center between 2010 and 2018. Results Out of 453 patients who underwent mechanical thrombectomy for AIS, 73 patients had a DO (average age 72 years, 59% female). The mean NIHSS upon admission was 12 (95% CI: 11–14). The mean procedure time was 45 minutes (95% CI: 38–52) and mean time to revascularization, from symptom onset to finishing the thrombectomy procedure, was 522 minutes (95% CI: 438–5607). 45% (n=34) of subjects received tPA. Vessels involved included M2 (89%, n=68), A2 (3%, n=2), PCA (3%, n=2), and M3/4 (5%, n=4). A stentreiver alone was used in 11% of the cases (n=8), aspiration alone in 8% (n=6), and both stentreiver and aspiration in 72% (n=55), with failed attempts in 9% (n=7) of cases. Most procedures required one pass to recanalize the vessel (55%, n=42). TICI > 2b was achieved in 88% (n=67) of the subjects. Mean length of stay was eight days (95% CI: 6–10). Mortality was noted in 8% (n=6) of patients and independent functional outcome of mRS 2b) was not significantly different between DO and PO. However, procedure time was significantly shorter in the DO group (45 min vs. 52 min, p=0.05) and the mean number of passes were lower in the DO group (1.5 vs. 1.8, p=0.01). Mortality rate and good functional outcome was not significantly different between both groups. On multivariate analysis, DO group had a significantly shorter length of stay by about two days, compared to PO, when controlling for confounders (coef: -2 days, 95%CI: -4 to 0 days, p=0.05). Subjects with PO were over five times more likely to have a good TICI score compared to DO group (OR: 5.69, 95% CI: 1.22–26.5, p Conclusion Mechanical thrombectomy procedure for distal circulation strokes is as effective and safe as a proximal group. Though distal vessels supply smaller brain area, however when symptoms are pronounced the benefit of the procedure outweighs the risks. Disclosures A. Sweid: None. J. Head: None. S. Tjoumakaris: None. V. Xu: None. K. Shivashankar: None. T. Alexander: None. M. Gooch: None. N. Herial: None. R. Rosenwasser: None. P. Jabbour: None.

Background External ventricular drain (EVD) placement is a common neurosurgical procedure. While this procedure is simple and effective, infection is a major limiting factor. Factors predictive of infection reported in the literature are not conclusive. Objective The aim of this retrospective single-center large sample was to assess the rate and factors predictive of infection. Methods We performed a retrospective review of patients who underwent EVD placement between January 2012 and January 2018. Results A total of 714 patients were included in the study. The infection rate was 3.6% (26/714). In 45% of the cases, the indication for ventriculostomy placement was for acute subarachnoid hemorrhage (aSAH) or intracerebral hemorrhage (ICH). Of the factors that were an independently significant predictor of ventriculostomy-associated infection (VAI) was the placement of a second EVD; the likelihood was eight times higher than if only a single EVD was placed (OR: 7.95, 95% CI: 1.01–62.9, p 1060, p Conclusion Our study shows that the rate of VAI was 3.6%. Only three variables were significant independent predictors of VAI; these were the replacement of the EVD, routine CSF aspiration, and intrathecal drug delivery. Disclosures A. Sweid: None. S. Tjoumakaris: None. C. Wamsley: None. E. Mann: None. C. Neely: None. J. Head: None. M. Gooch: None. N. Herial: None. T. Alexander: None. S. Missios: None. N. Chalouhi: None. R. Rosenwasser: None. P. Jabbour: None.

Introduction Pivotal trials have shown the tremendous efficacy of mechanical thrombectomy in proximal occlusions. However distal occlusions involving second-order branches of the middle cerebral artery and beyond, anterior cerebral and posterior cerebral arteries were not represented. In this study, we investigated the feasibility and safety of distal circulation mechanical thrombectomy. Methods A retrospective review of patients presenting with distal circulation acute ischemic stroke who underwent mechanical thrombectomy 2010 and 2018. Results Of 453 patients who underwent mechanical thrombectomy for acute ischemic stroke, 76 had a distal occlusion. The mean National Institute Health Stroke Scale on admission was 12. Vessels involved included second-order branches of the middle cerebral artery (89%), third- and fourth-order branches of the middle cerebral artery (5%), second-order branch of the anterior cerebral artery (3%), and posterior cerebral artery (3%). Most procedures required 1 pass to recanalize the vessel (55%, n = 42). Thrombolysis in Cerebral Infarction score ≥IIb was achieved in 89% of subjects. Mortality rate was 8% and independent functional outcome of m Rankin score ≤2 at 3 months was seen in 64.7% with clinical follow-up. On multivariate analysis, distal circulation had a significantly shorter length of stay by about 2 days, compared with proximal circulation. Subjects with proximal occlusion were more than 5 times more likely to have a good Thrombolysis in Cerebral Infarction score compared with the distal group. There was no significant difference in periprocedural and postprocedural complications, good functional outcome at 3 months, and mortality between both groups. Conclusions Mechanical thrombectomy procedure for distal circulation strokes is as effective and safe as a proximal group. Though distal vessels supply smaller brain area; however, when symptoms are pronounced, the benefit of the procedure outweighs the risks.

In the United States, chronic low back pain affects up to 37% of adults and is a multibillion dollar health care expenditure. Spinal cord simulation (SCS) has been established as an effective treatment alternative for chronic neuropathic low back and leg pain, especially for patients with failed back surgery syndrome or chronic regional pain syndrome. The field of SCS has rapidly advanced such that analgesia can now be achieved through numerous different waveforms, each claiming to offer improved outcomes. These waveforms include traditional paresthesia-based SCS (