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Objectives. The aim of this study was to examine the current scientific literature on deep brain stimulation (DBS) targeting the habenula for the treatment of neuropsychiatric disorders including schizophrenia, major depressive disorder, and obsessive-compulsive disorder (OCD). Materials and Methods. Two authors performed independent data base searches using the PubMed, Cochrane, PsycINFO, and Web of Science search engines. The data bases were searched for the query (“deep brain stimulation” and “habenula”). The inclusion criteria involved screening for human clinical trials written in English and published from 2007 to 2020. From the eligible studies, data were collected on the mean age, sex, number of patients included, and disorder treated. Patient outcomes of each study were summarized. Results. The search yielded six studies, which included 11 patients in the final analysis. Treated conditions included refractory depression, bipolar disorder, OCD, schizophrenia, and major depressive disorder. Patients with bipolar disorder unmedicated for at least two months had smaller habenula volumes than healthy controls. High-frequency stimulation of the lateral habenula attenuated the rise of serotonin in the dorsal raphe nucleus for treating depression. Bilateral habenula DBS and patient OCD symptoms were reduced and maintained at one-year follow up. Low- and high-frequency stimulation DBS can simulate input paths to the lateral habenula to treat addiction, including cocaine addiction. More data are needed to draw conclusions as to the impact of DBS for schizophrenia and obesity. Conclusions. The habenula is a novel target that could aid in reducing neuropsychiatric symptoms and should be considered in circuit-specific investigation of neuromodulation for psychiatric disorders. More information needs to be gathered and assessed before this treatment is fully approved for treatment of neuropsychiatric conditions.

Introduction. Anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis is a form of encephalitis previously associated with dermoid tumors. However, most studies in the literature evaluating the disease are case reports and small patient cohorts, limiting robust statistical analysis. Here, we demonstrate predictors of anti-NMDAR encephalitis in a large cohort of US patients. Methods. We used the 2016 National Inpatient Sample (NIS) to identify a cohort of 24,270 admitted for an ovarian dermoid tumor. Of these patients, 50 (0.21%) were diagnosed with anti-NMDAR encephalitis. Patient demographics, hospital characteristics, length of stay (LOS), and complications were collected. Statistical analysis consisted of odds ratios with chi-square testing to compare categorical variables. Results. The mean age of all patients with dermoid tumors was 45.5 ± 18.0 years, and the mean age of patients with diagnosed anti-NMDAR encephalitis was 27.4 ± 4.9 years. The mean LOS in the dermoid tumor cohort was 3.5 ± 4.9 days, while the mean LOS in the anti-NMDAR encephalitis cohort was 31.9 ± 25.9 days (p < 0.001). The mean cost in the dermoid tumor cohort was $44,813.18±$54,305.90, while the mean cost in the anti-NMDAR encephalitis cohort was $445,628.60±$665,423.40 (p < 0.001). Patients with age above 30 years with dermoid tumors had significantly lower odds of developing anti-NMDAR encephalitis compared to patients younger than 30 years (OR: 0.19; 95%CI: 0.045–0.67; p-value: 0.003). White patients had significantly lower odds of developing anti-NMDAR encephalitis (OR: 0.19; 95%CI: 0.026–0.77; p-value: 0.013), and Black patients had significantly higher odds of developing anti-NMDAR encephalitis (OR: 3.45; 95%CI: 1.00–12.46; p-value: 0.044). Conclusion. Patient predictors of developing anti-NMDAR encephalitis include age, race, ethnicity and patients who go on to develop anti-NMDAR encephalitis have a significantly increased hospital LOS and cost compared to those who do not. Future research, including multi-center clinical trials and longitudinal data, is necessary to fully cement the findings of this manuscript.

Background. As an established antifibrinolytic agent, tranexamic acid (TXA) has garnered widespread use during surgery to limit intraoperative blood loss. In the field of neurosurgery, TXA is often introduced in cases of traumatic brain injury or elective spine surgeries; however, its role during elective cranial surgeries is not well established. We report a systematic review of the use of TXA in elective surgical resection of intracranial neoplasms. Methods. We performed this systematic review following PRISMA guidelines to identify studies investigating the use of TXA in elective neurosurgical resection of intracranial neoplasms. Variables extracted included patient demographics, surgical indications, type of surgery performed, TXA dose and route of administration, operative duration, blood loss, transfusion rate, postoperative hemoglobin level, and complications. Results. After careful screening, 4 articles (consisting of 682 patients) met our inclusion/exclusion criteria. The studies included 2 prospective cohort studies, 1 retrospective cohort study, and 1 case series. A χ2 test of pooled data demonstrated that patients administered TXA had a significantly decreased need for blood transfusions during surgery (odds ratio, 0.6273; 95% confidence interval, 0.4254–0.9251; P = 0.018). Mean total blood loss was 821.9 mL in the TXA group and 1099.0 mL in the control group across the studies. There was no significant difference in postoperative hemoglobin levels, with a mean of 11.4 g/dL in both the TXA and control groups. Conclusions. These results support the use of intraoperative TXA in tumor resection. However, its role in tumor resection has been less well investigated compared with its use in other areas of neurosurgery.

OBJECTIVE Tranexamic acid (TXA) is an antifibrinolytic agent associated with reduced blood loss and mortality in a wide range of procedures, including spine surgery, traumatic brain injury, and craniosynostosis. Despite this wide use, the safety and efficacy of TXA in spine surgery has been considered controversial due to a relative scarcity of literature and lack of statistical power in reported studies. However, if TXA can be shown to reduce blood loss in laminectomy with fusion and posterior instrumentation, more surgeons may include it in their armamentarium. The authors aimed to conduct an up-to-date systematic review and meta-analysis of the efficacy of TXA in reducing blood loss in laminectomy and fusion with posterior instrumentation. METHODS A systematic review and meta-analysis, abiding by PRISMA guidelines, was performed by searching the databases of PubMed, Web of Science, and Cochrane. These platforms were queried for all studies reporting the use of TXA in laminectomy and fusion with posterior instrumentation. Variables retrieved included patient demographics, surgical indications, involved spinal levels, type of laminectomy performed, TXA administration dose, TXA route of administration, operative duration, blood loss, blood transfusion rate, postoperative hemoglobin level, and perioperative complications. Heterogeneity across studies was evaluated using a chi-square test, Cochran’s Q test, and I2 test performed with R statistical programming software. RESULTS A total of 7 articles were included in the qualitative study, while 6 articles featuring 411 patients underwent statistical analysis. The most common route of administration for TXA was intravenous with 15 mg/kg administered preoperatively. After the beginning of surgery, TXA administration patterns were varied among studies. Blood transfusions were increased in non-TXA cohorts compared to TXA cohorts. Patients administered TXA demonstrated a significant reduction in blood loss (mean difference −218.44 mL; 95% CI −379.34 to −57.53; p = 0.018). TXA administration was not associated with statistically significant reductions in operative durations. There were no adverse events reported in either the TXA or non-TXA patient cohorts. CONCLUSIONS TXA can significantly reduce perioperative blood loss in cervical, thoracic, and lumbar laminectomy and fusion procedures, while demonstrating a minimal complication profile.

Introduction Vertebrobasilar aneurysms carry a high risk of operative morbidity and high mortality risk with rupture. Treatment with flow diversion embolization has gained popularity. While adjunctive coiling may lower the risk of delayed aneurysm rupture (DAR), DAR can occur during stent endothelialization. describe a case of DAR following flow diversion with adjunctive coil embolization of a giant vertebrobasilar aneurysm and review the literature to further characterize this phenomenon. Methods PubMed was queried using search terms: “delayed,” “aneurysm,” “rupture,” “flow diverter,” “flow diversion,” and “flow diverting stent” yielding 220 results. There were 47 studies describing 89 patients with DAR after flow diversion. Results A forty‐five‐year‐old male presented with posterior fossa compression symptoms secondary to a 30‐mm fusiform basilar artery aneurysm, which grew during short‐interval follow‐up to 35 mm. The patient consented to endovascular embolization. Tri‐axial catheter access system was used to deploy seven telescoping flow diverters from the basilar tip to the intradural left vertebral artery, and nine coils were subsequently deployed in the aneurysm dome. The right vertebral artery was coil embolized. The procedure was uncomplicated and the patient was continued on dual‐antiplatelet therapy. Four weeks later, the patient became unresponsive with absent brainstem reflexes, workup revealed diffuse subarachnoid hemorrhage with intraventricular hemorrhage. Digital subtraction angiography demonstrated contrast extravasation at the aneurysm neck. He succumbed to his neurological injury two days later. Out of 89 patients with DAR after flow diversion, only 3 occurred in fusiform basilar aneurysms treated with adjunctive coil embolization. Only one case, a 37.1‐mm aneurysm treated with 3 flow diverters with adjunctive embolization, occurred at greater than 30 days post‐intervention. Conclusions This case highlights the need to better characterize the role of adjunctive coiling with flow diversion for large or giant aneurysms, and to better understand risk factors related to delayed aneurysm rupture.

Dural closure is an important part of any pediatric spinal procedure with intradural pathology to prevent post-operative cerebrospinal fluid (CSF) egress and associated complications. Utilization of nonpenetrating titanium clips is one closure option that may have technical advantages such as ease of use and amenability to a narrow surgical corridor. No data exist on the efficacy of these clips for pediatric spinal dural closure.A single surgeon case series of 152 pediatric patients underwent procedures involving lumbar durotomy with subsequent dural closure using the AnastoClip® nonpenetrating titanium clip closure system. Rates of infection and cerebrospinal fluid leak were measured during the follow-up period.A total of 152 pediatric patients (mean age: 6.25 ± 5.85 years, 50.7 % female) underwent intradural surgery with clip closure. The mean follow-up time was 57.0 ± 28.5 months. All patients were initially indicated for procedures involving spinal durotomy, with a majority being isolated tethered cord release (84.2 %). Others required tethered cord release and excision of a lipomyelomeningocele, spinal meningioma or arachnoid cyst (15.8 %). Post operative CSF leak occurred in two (1.32 %) patients at 11 and 18 days. Only one (0.66 %) patient was diagnosed with an infection, which was in a separate patient from those that had CSF leaks.The remarkably low incidence of post-operative CSF leak and infection with nonpenetrating titanium clips suggests a strong safety and efficacy profile for this form of dural closure in a pediatric cohort. Further research evaluating this technique is required to fully demonstrate its acceptability as a cost-effective alternative to traditional suture-based closure.

Objective A specialty with high value on reliability and accountability, aspiring neurosurgical residents have classically excelled in demonstrating these attributes through in-person engagements. Sub-internship rotations, leadership in extracurriculars, and longitudinal research endeavors have traditionally shed light on uniquely responsible and self-driven candidates. As the COVID-19 pandemic altered the paradigm for medical student engagements, our team investigated whether neurosurgical residency programs would be able to gauge candidates’ favorable attributes with the same accuracy as prior to the pandemic. Design/Setting/Participants: The PubMed/MEDLINE database was queried from inception to 2021 to determine the factors that contribute to a successful American neurosurgery residency match. Inclusion and exclusion criteria were predetermined to ensure comprehensiveness and relevance. Data from the National Residency Matching Program were also reviewed to determine significant trends in the American neurosurgery residency match. These data were then interpreted in the context of the COVID-19 pandemic to gain insight into the present-day neurosurgery match experience. Results A total of 32 studies were included in the review. Factors relevant to current neurosurgery residency match rates include the number of applicants to neurosurgery programs, quantity of research publications, quality of mentorship, interviews, letters of recommendation, standardized academic metrics, and residency program outreach. While current neurosurgery residency program directors are generally satisfied with recent match cycles, survey respondents expressed support for a more objective application review process. The transition to virtual interviews and suspension of away rotations required by the COVID-19 pandemic has raised significant student concerns related to the pandemic’s impact on the current residency recruitment process. Conclusion The neurosurgery match is influenced by multiple dynamic, varied factors that are currently impacted dramatically by the COVID-19 pandemic. While more studies focusing on refining applicant selection processes are warranted, it is imperative for neurosurgical programs to seek new surrogates for assessing favorable neurosurgery residency applicant attributes.

Background: The costs of cervical spine surgery have steadily increased. We performed a 5-year propensity scoring-matched analysis of 276 patients undergoing anterior versus posterior cervical surgery at one institution. Methods: We performed propensity score matching on financial data from 276 patients undergoing 1–3 level anterior versus posterior cervical fusions for degenerative disease (2015–2019). Results: We found no significant difference between anterior versus posterior approaches for hospital costs ($42,529.63 vs. $45,110.52), net revenue ($40,877.25 vs. $34,036.01), or contribution margins ($14,230.19 vs. $6,312.54). Multivariate regression analysis showed variables significantly associated with the lower contribution margins included age (β = −392.3) and length of stay (LOS; β = −1151). Removing age/LOS from the analysis, contribution margins were significantly higher for the anterior versus posterior approach ($17,824.16 vs. $6,312.54, P = 0.01). Conclusion: Anterior cervical surgery produced higher contribution margins compared to posterior approaches, most likely because posterior surgery was typically performed in older patients requiring longer LOS.

External ventricular drainage is a common and invaluable neurosurgical procedure and is one of the first procedures learned and performed independently by neurosurgical residents. As accuracy and precision are paramount to EVD placement, attention to technique is paid early in a resident's training. With the advancement of virtual technology, it has become increasingly possible to move away from traditional training situations and human error, and towards automated assistance and superior cyber learning environments. Although there is significant room for improvement, there are promising results with computerized placement guides and virtually augmented practice. Here, we provide a review of the updates on EVD placement techniques, technology and training, all of which serve to improve the precision, accuracy and efficiency of EVD placement.

Accurate spinal screw placement in spinal instrumentation is of utmost importance to avoid injury to surrounding neurovascular structures. This study was performed to investigate differences in accuracy, operating room time, length of stay, and operative blood loss across studies involving all types of spinal fixation.PubMed, EMBASE, and Scopus were systematically queried to identify articles that fit the inclusion and exclusion criteria. Meta-analysis was performed using R software, and odds ratios and 95% CIs were calculated.Sixty-nine articles were included in qualitative synthesis, and 35 studies in the meta-analysis, for a total of 8,174 robotically placed screws in 1,492 patients compared to 9,791 conventionally placed screws in 1,638 patients. A total of 9 screw trajectories were studied in the literature, although only 4 had enough evidence to be included in the meta-analysis. Robotic screw placement was more accurate than conventional screw placement (OR 2.24; 95% CI, 1.71-2.94). Robotic placement was not associated with significantly different postoperative length of stay (SMD -0.32; 95% CI, -1.20, 0.51), operative blood loss (SMD -0.25; 95% CI, -0.79, 0.19), or operative duration (SMD 0.08; 95% CI -1.00, 1.39). A total of 8 robotic platforms were found in the literature with accuracy rates above 93%.Robotic spinal fixation is associated with increased screw placement accuracy and similar operative blood loss, length of stay, and operative duration. These findings support the safety and cost-effectiveness of robotic spinal surgery across the spectrum of robotic systems and screw types.

Background Chronic subdural hematoma (cSDH) is predicted to become the most common intracranial neurosurgical condition by 2030. Recurrence is estimated between 5-15%, and the use of a surgical drain is associated with lower recurrence rates. The authors present their experience with six patients undergoing cSDH evacuation with an irrigating drainage system, comprising the largest single-institution group in the United States (US). Methods IRB-approved, retrospective chart review was performed for six patients who underwent irrigating surgical drain placement during cSDH evacuation. Outcome measures included device settings and duration of the irrigating drain, postoperative length of stay, neurological status at follow-up, and hematoma recurrence. Results There were no recurrences noted within this group at last follow-up, with an average follow-up length over three months. The average postoperative length of stay was 2.67 ± 0.51 days. Patients were drained on average for 1.41 ± 0.49 days at 0cm water, irrigating at 55.25 ± 46.44cc/hr. On postoperative day one, average hematoma size and midline shift (MLS) reduction were respectively 13.43 ± 3.31mm and 5.71 ± 1.33mm. No device-related complications were noted. Conclusion The authors' early experience with this irrigating drainage device demonstrates that it is safe and effective for this population. Although this is a preliminary study on a small sample size, the excellent results warrant further investigation and establishment of a standard protocol to compare against current treatment regimens.

There are numerous emergency department visits in the United States for all types of marine animal injuries each year. These injuries may result in significant morbidity or mortality if not managed appropriately. Accurate identification of the offending species, thorough wound hygiene, and judicious use of antibiotics are important for preventing infections. This review aims to describe management strategies and antimicrobial considerations for nonmammalian marine vertebrate penetrating trauma in North America, the Caribbean, and Hawaii. A literature search was performed to identify studies on this subject. This literature consisted of clinical case reports and case series. Reports extracted included those on sharks, barracuda, eels, catfish, stingrays, lionfish, stonefish, and scorpionfish. The majority of reported trauma occurred to beachgoers, fishermen, or commercial aquarium employees who routinely handle these animals. Injury patterns depended on the species but most commonly affected the lower extremities. Infections were seen from saltwater bacteria, human skin flora, or marine animal oral flora. After thorough wound irrigation and exploration, most authors recommended prophylactic antimicrobials to cover Vibrio species, in addition to other gram-negative and gram-positive species. The literature is notable for the lack of controlled studies. Some authors recommended radiographic and/or ultrasonographic imaging to identify retained foreign bodies, such as spines, sand, or teeth.

Sacroiliac (SI) joint pathology is a newly appreciated contributor to lower back pain. Sacroiliac joint fusion (SIJF) has grown rapidly in popularity in association with the advent of minimally-invasive surgical techniques. This has led to an explosion of new medical devices used for SIJF. The objective of this article is to outline clinical trends, summarize the current data, and categorize novel devices for SIJF.Trends in SI joint pathology and fusion were obtained via the Healthcare Cost and Utilization Project's (HCUP) National Inpatient Sample (NIS) database and Web of Science. To review literature on devices for SIJF, PubMed was searched using the Boolean phrase "sacroiliac joint AND (fusion OR arthrodesis)" since 2010. To establish a list of SIJF devices not represented in the literature, searches were performed on the FDA 510(k), premarket approval, and de novo databases, as well as Google and LinkedIn. Literature review yielded 11 FDA-approved devices for minimally invasive SIJF. Database query yielded an additional 22 devices for a total of 33 devices. Twenty-one devices used the lateral transiliac approach, six posterior allograft approach, three posterolateral approach, and three combined the lateral transiliac and posterolateral approaches. The evidence for the lateral transiliac approach is the most robust. Many novel devices have been developed for minimally invasive SIJF over the past 10 years. Further randomized comparative trials are warranted to evaluate different surgical approaches and novel devices at this time.

At the time of writing of this article, there have been over 110 million cases and 2.4 million deaths worldwide since the start of the Coronavirus Disease 2019 (COVID-19) pandemic, postponing millions of non-urgent surgeries. Existing literature explores the complexities of rationing medical care. However, implications of non-urgent surgery postponement during the COVID-19 pandemic have not yet been analyzed within the context of the four pillars of medical ethics. The objective of this review is to discuss the ethics of elective surgery cancellation during the COVID-19 pandemic in relation to beneficence, non-maleficence, justice, and autonomy. This review hypothesizes that a more equitable decision-making algorithm can be formulated by analyzing the ethical dilemmas of elective surgical care during the pandemic through the lens of these four pillars. This paper’s analysis shows that non-urgent surgeries treat conditions that can become urgent if left untreated. Postponement of these surgeries can cause cumulative harm downstream. An improved algorithm can address these issues of beneficence by weighing local pandemic stressors within predictive algorithms to appropriately increase surgeries. Additionally, the potential harms of performing non-urgent surgeries extend beyond the patient. Non-maleficence is maintained through using enhanced screening protocols and modifying surgical techniques to reduce risks to patients and clinicians. This model proposes a system to transfer patients from areas of high to low burden, addressing the challenge of justice by considering facility burden rather than value judgments concerning the nature of a particular surgery, such as cosmetic surgeries. Autonomy can be respected by giving patients the option to cancel or postpone non-urgent surgeries. However, in the context of limited resources in a global pandemic, autonomy is not absolute. Non-urgent surgeries can ethically be postponed in opposition to the patient’s preference. The proposed algorithm attempts to uphold the four principles of medical ethics in rationing non-urgent surgical care by building upon existing decision models, using additional measures of resource burden and surgical safety to increase health care access and decrease long-term harm as much as possible. The next global health crisis will undoubtedly present its own unique challenges. This model may serve as a comprehensive starting point in determining future guidelines for non-urgent surgical care.

Background The oblique lateral interbody fusion (OLIF) procedure is an important component of the surgeon's armamentarium for the treatment of degenerative spinal conditions. OLIF with posterior spinal fixation frequently is performed and requires additional time because the patient is flipped to a prone position and redraped. We report a series of cases in which robotic-assistance was used for a 2-surgeon workflow in which OLIF and single lateral position posterior spinal fixation were performed at the same time, termed simultaneous robotic single position surgery (SR-SPS). Methods Data were collected retrospectively from medical records of 13 consecutive patients who underwent SR-SPS by a single surgeon at an academic center between June and December 2020. Instrumentation accuracy, total operating room time, estimated blood loss, length of stay, and complications were assessed. Results A total of 13 patients whose mean age was 64.1 years (range 46–84 years) underwent SR-SPS over a 6-month period. Average follow-up was 10.3 months. All patients were treated for degenerative spine disease. The average operative duration was 111.2 ± 25.2 minutes. A total of 60 pedicle screws were placed bilaterally in the lateral position with an accuracy rate of 95.0%. Complications included 1 postoperative seroma, and 1 patient required reoperation 3 months postoperatively due to a fall. Conclusions We report the first case series describing SR-SPS. Our study shows that this method can reduce operative time while ensuring accurate and timely screw placement with minimal complications.

Background and importance Chronic subdural hematoma (cSDH) is a common neurosurgical pathology with a projected increase in prevalence as the elderly population grows. Traditional treatment for cSDH involves burr hole drainage or craniotomy with or without a subdural drain. This case describes a novel irrigation and drainage protocol using IRRAflow dual-lumen catheter system that utilizes early irrigation and measurement of the net fluid output to improve postoperative outcomes. Clinical presentation A 75-yr-old male presented to the emergency department with 2 wk of progressive dizziness, headache, confusion, and left-sided weakness over the past week. Computed tomography (CT) of the head showed 25-mm-thick, right-sided cSDH with 7 mm of right-to-left midline shift. The patient was taken to the operating room for right-sided craniotomy for subdural hematoma evacuation with placement of IRRAflow irrigating drain in the subdural space. The IRRAflow drain irrigated at 100 cc/h for 23 h with net output consistently greater than irrigation rate. Head CT the following day showed a progressive decrease in subdural collection. The patient was discharged on postoperative day 2 and had complete resolution of his neurological symptoms by postoperative day 11. Conclusion As cSDHs become more prevalent in the aging population, development of improved management strategies is imperative. This report describes the use of an IRRAflow dual-lumen catheter with a novel protocol consisting of a high rate of irrigation but net fluid output, which led to rapid recovery and resolution of neurological deficits in a patient with a cSDH.

Background: Ependymomas are rare tumors originating from neuroepithelial cells lining the wall of the ventricles or central canal of the spinal cord. While these tumors mainly occur within the central nervous system (CNS), there are occasional reports in children and young adult patients with a primary tumor occurrence outside of the CNS. Ependymomas of the sacrococcygeal region have been infrequently described in the literature with no standard of care established. We present a case report and review of the literature regarding this rare entity. Case Description: A 24-year-old woman presented with right gluteal pain worsened by sitting and a palpable soft tissue mass of the sacrococcygeal region. Magnetic resonance imaging revealed a 3.7 cm cystic mass centered in the right gluteal region. She underwent a biopsy at an outside institution, with histology revealing myxopapillary ependymoma. The patient was referred to our hospital and underwent an interdisciplinary neurosurgical and orthopedic oncology en bloc resection of the ependymoma, which intraoperatively appeared to originate from the coccygeal nerve. Conclusion: In the present report, the authors demonstrate that a myxopapillary ependymoma may present as an isolated gluteal mass attached to the coccygeal nerve, without frank CNS involvement. Furthermore, an interdisciplinary approach to surgical resection of this lesion appears to represent an effective treatment modality.