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William L Pridgen,1 Carol Duffy,2 Judy F Gendreau,3 R Michael Gendreau3 1Innovative Med Concepts, LLC, 2Department of Biological Sciences, University of Alabama, Tuscaloosa, AL, 3Gendreau Consulting, LLC, Poway, CA, USA Objective: Infections and other stressors have been implicated in the development of fibromyalgia. We hypothesized that these stressors could result in recurrent reactivations of latent herpes virus infections, which could lead to the development of fibromyalgia. This study evaluated a famciclovir + celecoxib drug combination (IMC-1), active against suspected herpes virus reactivation and infection, for the treatment of fibromyalgia.Methods: A total of 143 fibromyalgia patients were enrolled at 12 sites in a 16-week, double-blinded, placebo-controlled proof-of-concept trial. Randomized patients received either IMC-1 or placebo in a 1:1 ratio. Outcome measures included a 24-hour recall pain Numerical Rating Scale, the Revised Fibromyalgia Impact Questionnaire (FIQ-R), the Patient’s Global Impression of Change (PGIC) questionnaire, the Multidimensional Fatigue Inventory, the NIH Patient-Reported Outcomes Measurement Information System (PROMIS), and the Beck Depression Inventory-II conducted at baseline and weeks 6, 12, and 16 of the study.Results: A significant decrease in fibromyalgia-related pain was observed for patients on IMC-1 treatment versus placebo. PGIC response rates were significantly improved with IMC-1 treatment. Overall, patient self-reported functioning, as measured by the FIQ-R, was significantly improved. Fatigue was also significantly improved as measured by the PROMIS fatigue inventory. The safety profile was encouraging. Despite the celecoxib component of IMC-1, gastrointestinal and nervous system treatment emergent adverse events were reported less frequently in the IMC-1 group, and study completion rates favored IMC-1 treatment.Conclusion: IMC-1 was efficacious and safe in treating symptoms of fibromyalgia, supporting the hypothesis that herpes virus infections may contribute to this syndrome. Improved retention rates, decreased adverse event rates, and evidence of efficacy on a broad spectrum of outcome measures are suggestive that IMC-1 may represent an effective, novel treatment for fibromyalgia. Keywords: fibromyalgia, famciclovir, celecoxib, antiviral, herpes virus

Introduction: Pituitary apoplexy has historically been considered an emergent condition that necessitates surgical intervention when there is acute symptomatic onset. This potentially serious condition often occurs in the setting of an underlying adenoma, cystic lesion, or other sellar mass. When these mass lesions hemorrhage within the confined space of the sella turcica, the pituitary gland is subjected to hemorrhagic ischemia. Furthermore, critical neurovasculature in close proximity to the sella can sustain collateral damage. In the present study, we investigate whether early versus delayed surgical intervention (in terms of three timelines: before versus after 48 h, 72 h, and 7 days, respectively) results in differences in visual outcomes for patients experiencing pituitary apoplexy with acute onset neurological and/or neuro-opthalmic symptoms. Furthermore, we compare the efficacy of surgical decompression versus expectant management of this condition., Methods: Accordingly, we queried the PubMed, Scopus, and Embase databases in adherence to PRISMA guidelines. Quantitative meta-analysis was performed according to the Mantel-Haenszel method and forest plots were generated using Review Manager v5.4. P-values < 0.05 were defined as the threshold for statistical significance., Results: Twenty-nine studies remained eligible for review following initial search and screen, including 16 studies describing the role of intervention timing and 15 studies comparing intervention modality. Most patients presented with a visual deficit, and all patients underwent surgery - most commonly via the endoscopic endonasal (EEA) approach. Two hundred and twenty patients were included in the sub-analysis for the 7-day cutoff point. Furthermore, 81 patients underwent surgical decompression of the sella prior to 48 h, and 32 patients underwent surgical decompression between 48-72 h following presentation. Almost all patients exhibited improved vision post-decompression, including 19/19 patients (100%) in the post-72-h cohort. On meta-analysis using the Mantel-Haenszel method, there was a significant difference in vision outcomes in favor of patients who underwent surgical decompression before 7 days as compared to after seven days (OR 5.88, 95% CI [1.77, 19.60], I 2  = 0%, p < 0.01). In a separate sub-analysis, there was a total of 288 patients across 15 studies comparing surgical versus conservative management of pituitary apoplexy. These management options proved equivocal on meta-analysis (p > 0.05)., Conclusion: In the present study, timing of surgical intervention for pituitary apoplexy was predictive of visual function recovery only at the 7-day timepoint, as has been reported by previous studies. Ultimately, this suggests that pituitary apoplexy involving severe visual deficits or altered mental status is best addressed within the first seven days post-presentation, and that both surgery and conservative management can offer similar outcomes. When apoplexy is suspected, IV corticosteroids should be administered independent of acuity or severity to prevent secondary adrenal crisis. Subsequently, for patients presenting without severe visual or other neurological deficits, expectant management is recommended. Management should be patient-specific and dependent upon the severity of symptoms present at onset., (© 2024. The Author(s).)

Introduction: Professional society awards can substantially impact career trajectory of awardees in neurosurgery. Past studies have discussed the demographics of neurosurgery conference awardees in terms of gender and professional experience; however, a full assessment of awardee qualities and characteristics has yet to be studied., Objective: The goal of this study is to provide a comprehensive evaluation of neurosurgical society winners that focuses on gender, race, academic degrees, and institutional/geographic affiliation., Methods: Data of awardees across 14 neurosurgical societies from 2019 to 2022 was recorded. Variables recorded include professional society, award classification, year won, age, gender, race and ethnicity, board certification status, MD graduation year, degrees obtained, awardee home institution location, h-index, and NIH-funding. Statistical analysis was performed using IBM SPSS., Results: A total of 102 unique awards from 14 different societies between 2019 and 2022 were identified. Significantly more men (83 %) as compared to women (17 %) were awardees (p < 0.001). Awardees were significantly more likely to be Caucasian as compared to any other race (p < 0.001), and Caucasian awardees were more likely to be board certified and receive NIH funding. A higher proportion of male awardees had a PhD; however, the majority of all awardees were significantly more likely to not have a PhD or be board certified (p < 0.001). The majority of awardees were based in the Northeastern United States., Conclusions: Among winners of neurosurgical society awards, significant differences exist with respect to gender, race, ethnicity, degree type, and geographic location. Future research endeavors are needed to explore the reason for why these differences exist to ultimately develop strategies that promote equal opportunities for all neurosurgeons., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Objective: Patients with glioblastoma (GBM) often undergo surgery to prolong survival. However, the use of surgery, and more specifically achieving gross total resection (GTR), in patients >80 years old has yet to be fully assessed. Using the Surveillance, Epidemiology, and End Results (SEER) database, we aim to assess the efficacy of surgical resection, radiotherapy (RT) and chemotherapy (CT) on overall survival (OS) in very elderly GBM patients compared to elderly counterparts (age 65-79 years)., Methods: The SEER database was queried for all patients >65 years old with GBM (2000-2020). Patients not undergoing surgery or biopsy were excluded. Patients were stratified by age, and demographic relationships were assessed with chi-squared testing for categorical variables. Bivariable models were created using Kaplan-Meier survival estimates. All significant variables from bivariable analysis were included on multivariable Cox survival regression models to determine independent associations between clinical variables and OS., Results: A total of 27,090 operative GBM patients were identified; 1868 patients (15.92 %) were very elderly and 10,092 patients (84.38 %) were elderly. Very elderly patients were less likely to undergo GTR (28 % vs 35 %, p<0.001), RT (59 % vs 78 %, p<0.001) and CT (40 % vs 66 %, p<0.001). In multivariable Cox regression analysis, very elderly patients who achieved GTR (HR=.696, p<0.001), received RT (HR=0.583, p<0.001) and underwent CT (HR=0.4197, p<0.001) had significantly improved OS compared to very elderly patients that did not undergo these treatment options., Conclusion: Currently, very elderly GBM patients undergo lower rates of aggressive surgery, RT and CT. However, very elderly patients that undergo surgery, RT and CT may have a survival advantage. These treatments should be considered as potential options for this patient population., Competing Interests: Declaration of Competing Interest The authors declare no conflict of interest., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Pediatric spinal fusion surgery is a complex procedure that poses challenges in perioperative management. The enhanced recovery after surgery (ERAS) approach is an evidence-based, multidisciplinary strategy to optimize patient care in an individualized, multidisciplinary way. Despite the benefits of ERAS protocol implementation, the role of ERAS in pediatric spine surgery remains understudied. This systematic review and meta-analysis aims to evaluate the current literature regarding pediatric spinal surgery ERAS protocols and their ability to decrease the length of stay, pain, time-to-stand, and complications., Methods: A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Statistical analyses were performed using Cochrane's RevMan (version 5.4)., Results: Seventeen studies totaling 2733 patients were included in this analysis. Patients treated in an ERAS protocol had significant reductions in length of stay (P < 0.001), time-to-stand (P < 0.001), total complications (P = 0.02), and estimated blood loss (P = 0.001)., Conclusions: ERAS protocol implementation can significantly enhance outcomes for pediatric patients receiving spinal surgery. Consequently, ERAS protocols have the potential to lower healthcare expenses, increase access, and set a new standard of care. Future research should be conducted to expand pediatric ERAS protocols to a diverse range of spinal pathologies and assess the long-term advantages of this practice., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Spinal cord injury (SCI) affects around 18,000 individuals annually, representing nearly one-third of all paralysis cases. Stem cell therapy, a focal point in contemporary neuroregeneration research for SCI treatment, holds potential in leveraging undifferentiated stem cells to regenerate damaged tissues. This study seeks to comprehensively analyze current clinical trials exploring the potential use of stem cells in treating spinal cord injuries., Methods: A data retrieval approach examined the ClinicalTrials.gov database using the terms "spinal cord injury" and "stem cells." Exclusion criteria eliminated studies not recruiting, terminated prematurely, suspended, withdrawn, or of unknown status. Data for each trial, including ClinicalTrial.gov NCT identifier, title, intervention details, initiation/completion dates, and sample size, were systematically collected. Literature searches on PubMed.gov were conducted for completed trials with results., Results: Thirty clinical trials were analyzed, with 20 completed and six with published results on PubMed.gov. Interventions included 20 biological (66.7%), 6 procedural (20%), and 4 drug interventions (13.3%). Stem cell sources varied, including bone marrow (46.7%), umbilical cells (20%), adipose tissue (20%), embryonic cells (6.7%), and neural cells (6.7%). Trials spanned 2005 to 2022, with 11 (36.7%) commencing in or after 2017. Among six trials with results, 50% used bone marrow-derived stem cells., Conclusions: The promising potential of stem cells in neuroregenerative SCI treatment necessitates further exploration through large-scale, multicenter clinical trials to enhance understanding and guide wider adoption of this emerging treatment paradigm., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Endovascular treatment with the woven endobridge (WEB) device has been widely utilized for managing intracranial aneurysms. However, predicting the probability of achieving adequate occlusion (Raymond-Roy classification 1 or 2) remains challenging., Objective: Our study sought to develop and validate a predictive calculator for adequate occlusion using the WEB device via data from a large multi-institutional retrospective cohort., Methods: We used data from the WorldWide WEB Consortium, encompassing 356 patients from 30 centers across North America, South America, and Europe. Bivariate and multivariate regression analyses were performed on a variety of demographic and clinical factors, from which predictive factors were selected. Calibration and validation were conducted, with variance inflation factor (VIF) parameters checked for collinearity., Results: A total of 356 patients were included: 124 (34.8%) were male, 108 (30.3%) were elderly (≥65 years), and 118 (33.1%) were current smokers. Mean maximum aneurysm diameter was 7.09 mm (SD 2.71), with 112 (31.5%) having a daughter sac. In the multivariate regression, increasing aneurysm neck size (OR 0.706 [95% CI: 0.535-0.929], p  = 0.13) and partial aneurysm thrombosis (OR 0.135 [95% CI: 0.024-0.681], p  = 0.016) were found to be the only statistically significant variables associated with poorer likelihood of achieving occlusion. The predictive calculator shows a c -statistic of 0.744. Hosmer-Lemeshow goodness-of-fit test indicated a satisfactory model fit with a p -value of 0.431. The calculator is available at: https://neurodx.shinyapps.io/WEBDEVICE/., Conclusion: The predictive calculator offers a substantial contribution to the clinical toolkit for estimating the likelihood of adequate intracranial aneurysm occlusion by WEB device embolization., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Axel Perneczky is responsible for conceptualizing the "keyhole" philosophy as a new paradigm of minimal invasiveness within cranial neurosurgery. Keyhole neurosurgery aims to limit approach-related traumatization and minimize brain retraction while still enabling the neurosurgeon to achieve operative goals. The supraorbital keyhole craniotomy (SOKC) and minipterional (pterional keyhole, PKC) approaches have become mainstays for clipping intracranial aneurysms. While studies have compared these approaches to the traditional pterional craniotomy for clipping cerebral aneurysms, head-to-head comparisons of these workhorse keyhole approaches remain limited., Methods: The authors queried three databases per PRISMA guidelines to identify all studies comparing the SOKC to the PKC for microsurgical clipping of cerebral aneurysms. Of 148 unique studies returned on initial query, a total of 5 studies published between 2013 and 2019 met inclusion criteria. Where applicable, quantitative meta-analysis was performed via the Mantel-Haenszel method using Review Manager v5.4 (Nordic Cochrane Centre, Cochrane Collaboration, Copenhagen, Denmark). Risk of bias (ROB) was assessed using the Cochrane ROBINS-I tool, and all studies were assigned a Level of Evidence (I-V)., Results: Across all five studies, the mean age ranged from 53.0 to 57.5 years old, and the cohort consisted of more females (n = 403, 60.6%) than males. The proportion of patients presenting with ruptured aneurysmal SAH was comparable between the SOKC and PKC cohorts (p = 0.43). Clipping rate [defined as the rate of successful aneurysm clip deployment with successful intraoperative occlusion] (OR 1.52 [0.49, 4.71], I 2  = 0%, p = 0.47), final occlusion rates (OR 1.27 [0.37, 4.32], p = 0.70), and operative durations (SMD 0.33 [-0.83. 1.49], I 2  = 97%, p = 0.58) were comparable regardless of approach used. Furthermore, rates of intraoperative rupture (OR 1.51 [0.64, 3.55], I 2  = 0, p = 0.34), postoperative hemorrhage (OR 1.49 [0.74, 3.01], I 2  = 0, p = 0.26), postoperative vasospasm (OR 0.94 [0.49, 1.80], I 2  = 63, p = 0.86), and postoperative infection (OR 0.70 [0.16, 2.99], I 2  = 0%, p = 0.63) were equivocal across SOKC and PKC cohorts., Conclusion: The PKC and SOKC approaches appear to afford comparable outcomes when used for open microsurgical clipping of cerebral aneurysms in select patients with both ruptured and unruptured aneurysms. Both are associated with excellent clipping and occlusion rates, minimal perioperative complication profiles, and favorable postoperative neurologic outcomes. Further investigations are merited so clinicians can further parse out the indications and contraindications for each keyhole approach., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

The acute and long-term consequences of mild traumatic brain injury (mTBI) are far reaching. Though it may often be overlooked due to the now expansive field of research dedicated to understanding the consequences of mTBI on the brain, recent work has revealed that substantial changes in the vestibulo-auditory system can also occur due to mTBI. These changes, termed "labyrinthine" or "cochlear concussion," include hearing loss, vertigo, and tinnitus that develop after mTBI in the setting of an intact bony labyrinthine capsule (as detected on imaging). In the review that follows, we focus our discussion on the effects of mTBI on the peripheral structures and pathways of the auditory and vestibular systems. Although the effects of indirect trauma (e.g., noise and blast trauma) have been well-investigated, there exists a profound need to improve our understanding of the effects of direct head injury (such as mTBI) on the auditory and vestibular systems. Our aim is to summarize the current evidentiary foundation upon which labyrinthine and/or cochlear concussion are based to shed light on the ways in which clinicians can refine the existing modalities used to diagnose and treat patients experiencing mTBI as it relates to hearing and balance.

Background and Objectives: Surgery for the very elderly is a progressively important paradigm as life expectancy continues to rise. Patients with glioblastoma multiforme often undergo surgery, radiotherapy (RT), and chemotherapy (CT) to prolong overall survival (OS). However, the efficacy of these treatment modalities in patients aged 80 years and older has yet to be fully assessed in the literature., Methods: The National Cancer Database was used to retrospectively identify patients aged 65 years and older with glioblastoma multiforme (1989-2016). All available patient demographic characteristics, disease characteristics, and clinical outcomes were collected. To study OS, bivariable survival models were created using Kaplan-Meier estimates. A Cox proportional-hazards model was used for final adjusted analyses., Results: A total of 578 very elderly patients (aged 80 years and older) and 2836 elderly patients (aged 65-79 years) were identified. Compared with elderly patients, very elderly patients were more likely to have Medicare (odds ratio [OR] 1.899 [95% CI: 1.417-2.544], P < .001) while less likely to have private insurance status (OR 0.544 [95% CI: 0.401-0.739], P < .001). In addition, very elderly patients were more likely to travel the least distance for treatment and have multiple tumors (P < .001). When controlling for demographic and disease characteristics, very elderly patients were less likely to receive gross total resection (GTR) (OR 0.822 [95% CI: 0.681-0.991], P < .041), RT (OR 0.385 [95% CI: 0.319-0.466], P < .001), or postoperative CT (OR 0.298 [95% CI: 0.219-0.359], P < .001) relative to elderly counterparts. Within very elderly patients, GTR, RT, and CT all independently and significantly predicted improved OS (P < .001 for all). These predictive models were deployed in an online calculator (https://spine.shinyapps.io/GBM&#95;elderly)., Conclusion: Very elderly patients are less likely to receive GTR, RT, or CT when compared with elderly counterparts despite use of these therapies conferring improved OS. Selected very elderly patients may benefit from more aggressive attempts at surgical and adjuvant treatment., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Background and Objective: As incidence of operative spinal pathology continues to grow, so do the rates of lumbar spinal fusion procedures. Comorbidity indices can be used preoperatively to predict potential complications. However, there is a paucity of research defining the optimal comorbidity indices in patients undergoing spinal fusion surgery. We aimed to use modeling strategies to evaluate the predictive validity of various comorbidity indices and combinations thereof., Methods: Patients who underwent spinal fusion were queried using data from the Nationwide Readmissions Database for the years 2016 through 2019. Using comorbidity indices as predictor variables, receiver operating characteristic curves were developed for pertinent complications such as mortality, nonroutine discharge, top-quartile cost, top-quartile length of stay, and 30-day readmission., Results: A total of 750 183 patients were included. Nonroutine discharges occurred in 161 077 (21.5%) patients. The adjusted all-payer cost for the procedure was $37 616.97 ± $27 408.86 (top quartile: $45 409.20), and the length of stay was 4.1 ± 4.4 days (top quartile: 8.1 days). By comparing receiver operating characteristics of various models, it was found that models using Frailty + Elixhauser Comorbidity Index (ECI) as the primary predictor performed better than other models with statistically significant P -values on post hoc testing. However, for prediction of mortality, the model using Frailty + ECI was not better than the model using ECI alone ( P = .23), and for prediction of all-payer cost, the ECI model outperformed the models using frailty alone ( P < .0001) and the model using Frailty + ECI ( P < .0001)., Conclusion: This investigation is the first to use big data and modeling strategies to delineate the relative predictive utility of the ECI and Johns Hopkins Adjusted Clinical Groups comorbidity indices for the prognostication of patients undergoing lumbar fusion surgery. With the knowledge gained from our models, spine surgeons, payers, and hospitals may be able to identify vulnerable patients more effectively within their practice who may require a higher degree of resource utilization., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Objective: Factors that may drive recommendations for operative intervention for patients with intramedullary spinal cord tumors (ISCTs) have yet to be extensively studied. The authors investigated racial and socioeconomic disparities in the management of patients with primary spinal cord ependymomas and nonependymal gliomas, with the aim of determining the associations between socioeconomic patient characteristics, survival, and recommendations for the resection of primary ISCTs., Methods: The Surveillance, Epidemiology, and End Results registry was queried to identify all patients > 18 years of age with ISCTs diagnosed between 2000 and 2019. Univariable and multivariable logistic regression analyses were used to calculate odds ratios for variables associated with receiving a surgical recommendation. Log-rank tests and multivariable Cox proportional hazards models were used to investigate overall survival (OS) and disease-specific survival (DSS)., Results: The authors identified 2325 patients (mean age 49 [SD 16] years; 48.8% female; 67.4% non-Hispanic White, 7.8% non-Hispanic Black, 16.2% Hispanic, 6.5% Asian/Pacific Islander, 0.6% Native American; 56.7% married; 64.4% with household income < $75,000; 73.8% with spinal ependymoma; and 26.2% with nonependymal spinal glioma). Eighty-seven percent of patients received a surgical recommendation. In multivariable models, marriage was associated with higher odds of receiving a surgical recommendation for ependymomas (OR 1.80, p = 0.005). In multivariable models for nonependymal spinal gliomas, older age (OR 0.98, p = 0.001) and increased number of tumors (OR 0.62, p = 0.015) were associated with decreased odds of receiving surgical recommendations. Among ependymomas, marriage (HR 0.59, p = 0.001), younger age (HR 0.93, p < 0.001), female sex (HR 0.43, p = 0.006), and decreased number of tumors (HR 0.56, p < 0.001) were associated with improved OS. Among nonependymal spinal gliomas, median household income ≥ $75,000 (HR 0.69, p = 0.020) and younger age (HR 0.98, p < 0.001) were associated with improved DSS, while Black race (HR 4.65, p = 0.027) and older age (HR 1.05, p < 0.001) were associated with worse OS., Conclusions: In patients with spinal ependymomas and nonependymal spinal gliomas, recommendations for surgery appear to be unaffected by patient sex, race, or income. Survival disparities appear to exist among unmarried, male, Black, and lower-income cohorts. Continued initiatives to identify drivers of disparities while improving health equity in this patient population are needed.

Background: The cautionary stance normally taken towards tranexamic acid (TXA) is rooted in concerns regarding its complication profile, namely its purported risk for venous thromboembolic events (VTEs). In the present review, we intend to bring increased attention to TXA as a remarkably valuable tool that does not appear to increase the risk for VTE when used as indicated in select patients., Methods: We queried three databases to identify reporting use of TXA during nontraumatic cranial neurosurgery procedures (excluded traumatic brain injury). Data gathered included VTE complications, deep venous thrombosis, use of allogeneic blood transfusions, estimated blood loss, and operative duration., Results: Twenty-eight studies were deemed eligible for inclusion in the present meta-analysis, including nine studies on surgical resection of intracranial neoplasms, ten studies on aneurysmal subarachnoid hemorrhage, and nine studies on craniosynostosis. In brain tumor surgery, TXA appears to successfully reduce blood loss without predisposing patients to VTE or seizure (P < 0.01). However, it does not appear to reduce rates of vasospasm in aneurysmal subarachnoid hemorrhage (P = 0.27), and its administration is not associated with clinically meaningful differences in long term neurological outcomes. For pediatric patients undergoing craniosynostosis procedures, TXA similarly reduces blood loss (P < 0.01). Nonetheless, low dosing protocols should be used because they appear effective and the effects of high dose TXA in children have not been studied., Conclusions: TXA is an effective hemostatic agent that can be administered to reduce blood loss and transfusion requirements for a wide range of neurosurgical applications in a broad spectrum of patient populations., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Decompressive hemicraniectomy (DHC) is a critical procedure used to alleviate elevated intracranial pressure (ICP) in emergent situations. It is typically performed to create space for the swelling brain and to prevent dangerous and potentially fatal increases in ICP. DHC is indicated for pathologies ranging from MCA stroke to traumatic subarachnoid hemorrhage-essentially any cause of refractory brain swelling and elevated ICPs. Scalp incisions for opening and closing the soft tissues during DHC are crucial to achieve optimal outcomes by promoting proper wound healing and minimizing surgical site infections (SSIs). Though the reverse question mark (RQM) scalp incision has gained significant traction within neurosurgical practice, alternatives-including the retroauricular (RA) and Kempe incisions-have been proposed. As choice of technique can impact postoperative outcomes and complications, we sought to compare outcomes associated with different scalp incision techniques used during DHC. We queried three databases according to PRISMA guidelines in order to identify studies comparing outcomes between the RQM versus "alternative" scalp incision techniques for DHC. Our primary outcome of interest in the present study was postoperative wound infection rates according to scalp incision type. Secondary outcomes included estimated blood loss (EBL) and operative duration. We identified seven studies eligible for inclusion in the formal meta-analysis. The traditional RQM technique shortened operative times by 36.56 min, on average. Additionally, mean EBL was significantly lower when the RQM scalp incision was used. Postoperatively, there was no significant association between DHC incision type and mean intensive care unit (ICU) length of stay (LOS), nor was there a significant difference in predisposition to developing wound complications or infections between the RQM and retroauricular/Kempe incision cohorts. Superficial temporal artery (STA) preservation and reoperation rates were collected but could not be analyzed due to insufficient number of studies reporting these outcomes. Our meta-analysis suggests that there is no significant difference between scalp incision techniques as they relate to surgical site infection and wound complications. At present, it appears that outcomes following DHC can be improved by ensuring that the bone flap is large enough to enable sufficient cerebral expansion and decompression of the temporal lobe, the latter of which is of particular importance. Although previous studies have suggested that there are several advantages to performing alternative scalp incision techniques during DHC, the present study (which is to our knowledge the first to meta-analyze the literature on outcomes in DHC by scalp incision type) does not support these findings. As such, further investigations in the form of prospective trials with high statistical power are merited., (© 2024. The Author(s).)

Genetically modified organisms or GMOs offer significant advantages in food production, including increased yield, decreased pesticide usage, and better disease resistance. However, adoption and public sentiment toward GMOs is highly variable. Without positive sentiment toward GMOs, consumption of GMO-based foods may not have an adequate market for further investment. In order to better understand overall public sentiment toward GMO-based foods, a Boolean search was created using a commercial web-crawling service to collect and analyze public sentiment of GMOs across multiple social media and web-based services from May 1, 2019, to May 31, 2021. The Boolean query identified 2 million mentions of GMOs during the study period. Using the commercial software's sentiment analysis (i.e. classifying mentions as either neutral, negative, or positive), 54% of the mentions were categorized as having a neutral sentiment, 32% as having a negative sentiment, and 14% as having a positive sentiment. Further emotional analysis (classifying posts by the emotion expressed, e.g., disgust, joy, sadness, anger, fear, surprise) produced by the software shows that the majority of the mentions were categorized as expressing a negative emotion: 31% of mentions expressed disgust, 28% joy, 18% sadness, 16% anger, 7% fear, and 1% surprise. Among the various social media sources collected, Twitter was the main source of data, providing 62% of the total 2 million mentions, followed by 14% from news sources and 12% from Reddit. These types of data can be used to better understand trends in sentiment toward GMOs and ultimately play an important role in combating mis-information.

Laparoscopic anterior lumbar interbody fusion (L-ALIF), which employs laparoscopic cameras to facilitate a less invasive approach, originally gained traction during the 1990s but has subsequently fallen out of favor. As the envelope for endoscopic approaches continues to be pushed, a recurrence of interest in laparoscopic and/or endoscopic anterior approaches seems possible. Therefore, evaluating the current evidence base in regard to this approach is of much clinical relevance. To this end, a systematic literature search was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using the following keywords: "(laparoscopic OR endoscopic) AND (anterior AND lumbar)." Out of the 441 articles retrieved, 22 were selected for quantitative analysis. The primary outcome of interest was the radiographic fusion rate. The secondary outcome was the incidence of perioperative complications. Meta-analysis was performed using RStudio's "metafor" package. Of the 1,079 included patients (mean age, 41.8±2.9 years), 481 were males (44.6%). The most common indication for L-ALIF surgery was degenerative disk disease (reported by 18 studies, 81.8%). The mean follow-up duration was 18.8±11.2 months (range, 6-43 months). The pooled fusion rate was 78.9% (95% confidence interval [CI], 68.9-90.4). Complications occurred in 19.2% (95% CI, 13.4-27.4) of L-ALIF cases. Additionally, 7.2% (95% CI, 4.6-11.4) of patients required conversion from L-ALIF to open surgery. Although L-ALIF does not appear to be supported by studies available in the literature, it is important to consider the context from which these results have been obtained. Even if these results are taken at face value, the failure of endoscopy to have a role in the ALIF approach does not mean that it should not be incorporated in posterior approaches.

Background: Deep inferior epigastric perforator (DIEP) surgery is one of the most difficult breast reconstruction techniques available, both in terms of operating complexity and patient recovery. Enhanced recovery after surgery (ERAS) pathways were recently introduced in numerous subspecialties to reduce recovery time, patient pain, and cost by providing multimodal perioperative care. Plastic surgery has yet to widely integrate ERAS with DIEP reconstruction, mostly due to insufficient data on patient outcomes with this combined approach., Methods: Five major medical databases were queried using predetermined search criteria according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Statistical analysis was performed using Cochrane's RevMan (v5.4)., Results: A total of 466 articles were identified. A total of 14 studies were included in the review with a combined sample of 2102 patients. Eight studies were included in the meta-analysis with a combined sample of 1679 patients. On average, the included studies utilized 11.69 of 18 suggested protocols for ERAS with breast reconstruction. Our primary outcome, length of stay, was reduced by a mean of 1.12 (95% confidence interval [CI] [-1.30, -0.94], n = 1627, p < 0.001) days in the ERAS group. Postoperative oral morphine equivalents (OME) were also reduced in the ERAS group by 104.02 (95% CI [-181.43, -26.61], n = 545, p = 0.008) OME. The ERAS group saw a significant 3.54 (95% CI [-4.43, -2.65], n = 527, p < 0.001) standardized mean difference cost reduction relative to the control groups. The surgery time was reduced by 60.46 (95% CI [-125, 4.29], n = 624, p < 0.07) min, although this was not statistically significant., Conclusions: The ERAS pathway in DIEP breast reconstruction is consistently associated with reduced hospital stay, opioid use, and patient cost. Moreover, there appears to be no evidence of serious adverse outcomes associated with the application of the ERAS protocol., Competing Interests: Declaration of Competing Inrerest The authors have no personal or institutional interest with regards to the authorship and/or publication of this manuscript., (Copyright © 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Introduction  The American Association of Neurological Surgeons (AANS), North American Skull Base Society (NASBS), American Rhinologic Society (ARS), and American Neurotology Society (ANS) fellowship directories are important information repositories for skull base surgical fellowship programs. However, there is limited research on the amount and depth of information available through these resources. The objective of the present study is to assess Web site accessibility and information availability for individual fellowship programs listed within the AANS, NASBS, ARS, and ANS fellowship directories. Methods  Lists of all accredited skull base surgical programs were obtained from the AANS and NASBS fellowship directories. Duplications in listed programs were removed, and systematic queries via an online search engine were conducted to identify fellowship Web sites. From each available Web site, information pertaining to 24 different variables was collected and organized into two categories-recruitment and education. Differences in the availability of information on recruitment and education were then compared across Web sites and contextualized relative to other surgical specialties. Results  After excluding duplicates, 113 fellowship programs were identified, of which 99 (87.6%) had accessible Web sites. Of the 48 listed by the NASBS, direct Web site links were available for 33 (68.8%), email contacts were accessible for 32 (66.7%), and phone numbers were listed for 6 (12.5%). Of the 39 programs listed by the AANS, none included Web site links, 38 (97.4%) provided an email contact, and 39 (100%) listed a departmental contact telephone number. All 28 (100%) programs listed by the ANS provided a phone and email contact in addition to a Web site link to each institutional Web site. Of the 33 programs listed by the ARS, 29 (88%) had a departmental contact telephone number, 31 (94%) had an email contact available, and 4 (12%) had a program Web site link directly available from the database Web site. Of the 99 total programs, fellowship Web sites displayed an average of 5.46 (42.0%) of the 13 recruitment features and 4.80 (42.6%) of the 11 education features. Programs in the geographic Northeast were significantly less likely to present information pertaining to recruitment ( p  = 0.023). Furthermore, programs in geographic Northeast and West were significantly less likely to present information focused on surgical training and/or education ( p  = 0.006). Conclusion  Although many skull base fellowship programs have maintained comprehensive program Web sites, certain critical aspects remain deficient, and some programs provide little to no information. Providing more detailed information about programs can prove mutually beneficial for fellowship program directors and candidates., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

Objective: The American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons (CNS) Joint Cerebrovascular (CV) Section serves as a centralized entity for the dissemination of information related to CV neurosurgery. The quality of scientific conferences, such as the CV Section's Society of NeuroInterventional Surgery Annual Meeting, can be gauged by the number of poster and oral presentations that are published in peer-reviewed journals. However, publication rates from the CV Section's meetings are unknown. The objective of this study was to assess the rate at which abstracts presented at the AANS/CNS CV Section Annual Meeting from 2014 to 2018 were subsequently published in peer-reviewed journals., Methods: The abstract titles for all accepted poster and oral podium presentation abstracts from the 2014-2018 Annual Joint AANS/CNS CV Section Meetings were searched using PubMed. A match was defined as sufficient similarity between the abstract and its corresponding journal publication with regard to title, authors, methods, and results. Five-year impact factors (IFs) from Journal Citation Reports (JCR), the country of the corresponding author, and the number of citations in the Scopus database were obtained using the articles' digital object identifier when available, or the exact article title, journal, and year of publication., Results: Of the 607 total poster and oral presentations from the 2014-2018 Annual Meetings of the AANS/CNS Joint CV Section, 46.29% (n = 281) have been published. Published articles received 3233 total citations for an average number of citations per article (± SD) of 10.89 ± 16.37. The average 5-year JCR IF of published studies was 4.64 ± 3.13. Additionally, 98.22% of published abstracts were in publication within 4 years from the time the abstract was presented. The most common peer-reviewed neurosurgical journals featuring these publications were the Journal of Neurosurgery, World Neurosurgery, the Journal of NeuroInterventional Surgery, Neurosurgery, and the Journal of Clinical Neuroscience., Conclusions: Nearly half of all poster and oral presentations at the annual meetings of the AANS/CNS Joint CV Section from 2014 to 2018 have been published in PubMed-indexed, peer-reviewed journals. The average number of citations per publication (10.89 ± 16.37) reflects the high quality of abstracts accepted for presentation. It is important to continuously assess the quality of research presented at national conferences to ensure that standards are being maintained for the advancement of clinical practice in a given area of medicine. Conference abstract publication rates in peer-reviewed journals represent a way in which research quality can be gauged, and the authors encourage others to conduct similar investigations in their subspecialty area of interest and/or practice.

Introduction: Medical Students applying to neurosurgery residency programs incur substantial costs associated with interviews, away rotations, and application fees. However, few studies have compared expenses prior to and during the COVID-19 pandemic. This study evaluates the financial impact of COVID-19 on the neurosurgery residency application and identifies strategies that may alleviate the financial burden of prospective neurosurgery residents., Methods: The TEXAS STAR database was surveyed for applicants of neurosurgical residency programs during the COVID-19 pandemic (2021) and post-pandemic (2022). 66 applicants for the 2021 application cycle and 50 applicants for the 2022 application cycle completed the survey. We compared application fees, away rotations cost, interview cost, and total expenses as reported by the neurosurgery applicants of the 2021 and 2022 application cycle. A Shapiro-Wilk test was used to test for data normality, and a Mann-Whitney U-Test was used to compare costs during the 2021 and 2022 neurosurgery application cycle., Results: There was a statistically significant reduction in total expenses in 2021 vs 2022 ($3,934 vs $9,860). Interview and away rotation expenses decreased in 2021 vs 2022 (interview expenses $786 vs $4511, away rotation $1,083 vs $3,000, p < 0.001). Application fee expenses were not different between 2021 and 2022. The greatest reduction in application cost ($11,908) was seen in the South for 2021., Conclusions: The COVID-19 pandemic significantly reduced total fees associated with the neurosurgical residency application. Virtual platforms in place of in-person interviews could lessen the financial burden on applicants and alleviate socioeconomic barriers in the neurosurgical application process after COVID-19., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Published by Elsevier Ltd.)

Objective: Antifibrinolytics, such as tranexamic acid (TXA), have been shown to decrease intraoperative blood loss across multiple surgical disciplines. However, they carry the theoretical risk of thromboembolic events secondary to induced hypercoagulability. Therefore, the aim of this study was to systematically review the available literature and perform a meta-analysis on the use of TXA in meningioma resection to assess thromboembolic risks., Methods: The PubMed, Web of Science, and Google Scholar databases were reviewed for all randomized controlled trials presenting primary data on TXA use during resection of intracranial meningiomas. Data were gathered on operative duration, venous thromboembolic complications, deep venous thrombosis, use of allogeneic blood transfusion, estimated blood loss (EBL), and postoperative hemoglobin. Patients who received TXA were compared with controls who did not receive TXA intraoperatively using random-effects models., Results: A total of 508 unique articles were identified, of which 493 underwent full-text review. Ultimately, 6 studies with 381 total patients (190 receiving TXA) were included in the final analysis. All 6 trials were randomized, blinded, and placebo controlled with a TXA administration rate of a 20-mg/kg load followed by a 1-mg/kg/hr infusion. All studies were performed in lower-middle-income countries. There were no reported instances of venous thromboembolism (VTE) in the TXA and non-TXA cohorts. Patients receiving TXA exhibited fewer allogeneic transfusions (21.5% vs 41.6% [OR 0.26, 95% CI 0.09-0.77], p = 0.02) and lower EBL (MD -282.48 mL [95% CI -367.77 to -197.20 mL], p < 0.001) compared with patients who did not receive TXA, and they also had lower rates of perioperative complications (10.7% vs 19.9% [OR 0.47, 95% CI 0.2-0.95], p = 0.04)., Conclusions: Current literature suggests that TXA is not associated with increased risk for VTE when administered during resection of intracranial meningioma. TXA appears to decrease intraoperative blood loss and allogeneic transfusion requirements during meningioma resection and thus may improve the safety of surgical management of this pathology.

Meningiomas are neoplasms derived from the arachnoid cap cells of the leptomeninges and are the most common intracranial tumor. In the present historical vignette, the evolution of the management and diagnosis of meningioma is described. We begin with studies of skulls from the prehistoric record, such as the Steinheim skull, which demonstrate morphologic changes (e.g., hyperostosis) now known to occur with meningioma growth. We then continue with the earliest formal descriptions of meningiomas, including that by Platter, who published the first report of meningioma, along with early histopathologic descriptions by Cushing, who divined the cytological origins of the tumor and was the first to use the term meningioma. We conclude with a description of current management of meningiomas and potential avenues for further discovery. This article is effectively a lifetime biography of a tumor known and loved by neurosurgeons, the simple and yet complex meningioma., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Despite their precarious behavioral classification (benign and low grade on histopathology yet behaviorally malignant), great strides have been taken to improve prognostication and treatment paradigms for patients with skull base chordoma. With respect to surgical techniques, lateral transcranial (TC) approaches have traditionally been used, however endoscopic endonasal approaches (EEA) have been advocated for midline lesions. Nonetheless, due to the rarity of this pathology (0.2% of all intracranial neoplasms), investigations within the literature remain limited to small retrospective series. Furthermore, radiotherapeutic treatments investigated to date have proven largely ineffective., Methods: Accordingly, we performed a systematic review in order to profile surgical and survival outcomes for skull base chordoma. Fixed and random-effect meta-analyses were performed for categorical variables including GTR, STR, 5-year OS, 10-year OS, 5-year PFS, and 10-year PFS. Additionally, we pooled eligible studies for formal meta-analysis to compare outcomes by surgical approach (lateral versus midline). Statistical analyses were performed using R Studio 'metafor' package or Cochrane Review Manager. Furthermore, meta-analysis of pooled mortality rates and sub-analyses of operative margin and surgical complications were used to compare midline versus lateral approaches via the Mantel-Haenszel method. We considered all p-values < 0.05 to be statistically significant., Results: Following the systematic search and screen, 55 studies published between 1993 and 2022 reporting data for 2453 patients remained eligible for analysis. Sex distribution was comparable between males and females, with a slight predominance of male-identifying patients (0.5625 [95% CI: 0.5418; 0.3909]). Average age at diagnosis was 42.4 ± 12.5 years, while average age of treatment initiation was 43.0 ± 10.6 years. Overall, I 2 value indicated notable heterogeneity across the 55 studies [I 2  = 56.3% (95%CI: 44.0%; 65.9%)]. With respect to operative margins, the rate of GTR was 0.3323 [95% CI: 0.2824; 0.3909], I 2  = 91.9% [95% CI: 90.2%; 93.4%], while the rate of STR was significantly higher at 0.5167 [95% CI: 0.4596; 0.5808], I 2  = 93.1% [95% CI: 91.6%; 94.4%]. The most common complication was CSF leak (5.4%). In terms of survival outcomes, 5-year OS rate was 0.7113 [95% CI: 0.6685; 0.7568], I 2  = 91.9% [95% CI: 90.0%; 93.5%]. 10-year OS rate was 0.4957 [95% CI: 0.4230; 0.5809], I 2  = 92.3% [95% CI: 89.2%; 94.4%], which was comparable to the 5-year PFS rate of 0.5054 [95% CI: 0.4394; 0.5813], I 2  = 84.2% [95% CI: 77.6%; 88.8%] and 10-yr PFS rate of 0.4949 [95% CI: 0.4075; 0.6010], I 2  = 14.9% [95% CI: 0.0%; 87.0%]. There were 55 reported deaths for a perioperative mortality rate of 2.5%. The relative risk for mortality in the midline group versus the lateral approach group did not indicate any substantial difference in survival according to laterality of approach (-0.93 [95% CI: -1.03, -0.97], I 2  = 95%, (p < 0.001)., Conclusion: Overall, these results indicate good 5-year survival outcomes for patients with skull base chordoma; however, 10-year prognosis for skull base chordoma remains poor due to its radiotherapeutic resistance and high recurrence rate. Furthermore, mortality rates among patients undergoing midline versus lateral skull base approaches appear to be equivocal., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Despite more than six decades of extensive research, the etiology of moyamoya disease (MMD) remains unknown. Inflammatory or autoimmune (AI) processes have been suggested to instigate or exacerbate the condition, but the data remains mixed. The objective of the present systematic review was to summarize the available literature investigating the association of MMD and AI conditions as a means of highlighting potential treatment strategies for this subset of moyamoya patients. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, the PubMed, Embase, Scopus, Web of Science, and Cochrane databases were queried to identify studies describing patients with concurrent diagnoses of MMD and AI disease. Data were extracted on patient demographics, clinical outcomes, and treatment. Stable or improved symptoms were considered favorable outcomes, while worsening symptoms and death were considered unfavorable. Quantitative pooled analysis was performed with individual patient-level data. Of 739 unique studies identified, 103 comprising 205 unique patients (80.2% female) were included in the pooled analysis. Most patients (75.8%) identified as Asian/Pacific Islanders, and the most commonly reported AI condition was Graves' disease (57.6%), with 55.9% of these patients presenting in a thyrotoxic state. Of the 148 patients who presented with stroke, 88.5% of cases (n = 131) were ischemic. Outcomes data was available in 152 cases. There were no significant baseline differences between patients treated with supportive therapy alone and those receiving targeted immunosuppressant therapy. Univariable logistic regression showed that surgery plus medical therapy was more likely than medical therapy alone to result in a favorable outcome. On subanalysis of operated patients, 94.1% of patients who underwent combined direct and indirect bypass reported favorable outcomes, relative to 76.2% of patients who underwent indirect bypass and 82% who underwent direct bypass (p < 0.05). On univariable analysis, the presence of multiple AI disorders was associated with worse outcomes relative to having a single AI disorder. Autoimmune diseases have been uncommonly reported in patients with MMD, but the presence of multiple AI comorbidities portends poorer prognosis. The addition of surgical intervention appears to improve outcomes and for patients deemed surgical candidates, combined direct and indirect bypass appears to offer better outcomes that direct or indirect bypass alone., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Objective: There is a growing body of evidence demonstrating improved outcomes for patients with CNS neoplasms treated at academic centers (ACs) versus nonacademic centers (non-ACs), which represents a potential healthcare disparity within neurosurgery. In this paper, the authors sought to investigate the relationship between facility type and surgical outcomes in meningioma patients., Methods: The National Cancer Database was queried for adult patients diagnosed with intracranial meningioma between 2004 and 2019. Patients were stratified by facility type, and the Mann-Whitney U-test and Fisher exact test were used for bivariate comparisons of continuous and categorical variables, respectively. Multivariate logistic regression was used to assess whether demographic variables were associated with treatment at ACs. Furthermore, multivariate Cox proportional hazards models were used to determine whether facility type was associated with overall survival (OS) outcomes., Results: Data on 139,304 patients (74% male, 84% White) were retrieved. Patients were stratified by facility type, with 50,349 patients (36%) treated at ACs and 88,955 patients (64%) treated at non-ACs. Patients treated at ACs were more likely to have private insurance (41% vs 34%, p < 0.001) and less likely to have Medicare (46% vs 57%, p < 0.001). Patients treated at ACs were more likely to have larger tumors (36.91 mm vs 33.57 mm, p < 0.001) and more likely to undergo surgery (47% vs 34%, p < 0.001). Interestingly, patients treated at ACs had decreased comorbidities (Charlson Comorbidity Index rating 0: 74% vs 69%) and similar income levels (income ≥ $46,000: 44% vs 43%). With respect to survival outcomes, patients treated at ACs demonstrated a higher median OS at 10 years than patients treated at non-ACs (65.2% vs 54.1%). The association of improved OS in patients treated at ACs continued to be true when adjusting for all other clinical and demographic variables (HR 0.900, 95% CI 0.882-0.918; p < 0.001)., Conclusions: The results of this study indicate that facility type is associated with disparate survival outcomes in the treatment of intracranial meningiomas. Namely, patients treated at non-ACs appear to have a survival disadvantage even when controlling for additional comorbidities.

Introduction: Spine surgery has undergone significant changes in approach and technique. With the adoption of intraoperative navigation, minimally invasive spinal surgery (MISS) has arguably become the gold standard. Augmented reality (AR) has now emerged as a front-runner in anatomical visualization and narrower operative corridors. In effect, AR is poised to revolutionize surgical training and operative outcomes. Our study examines the current literature on AR-assisted MISS, synthesizes findings, and creates a narrative highlighting the history and future of AR in spine surgery., Material and Methods: Relevant literature was gathered using the PubMed (Medline) database from 1975 to 2023. Pedicle screw placement models were the primary intervention in AR. These were compared to the outcomes of traditional MISS RESULTS: We found that AR devices on the market show promising clinical outcomes in preoperative training and intraoperative use. Three prominent systems were as follows: XVision, HoloLens, and ImmersiveTouch. In the studies, surgeons, residents, and medical students had opportunities to operate AR systems, showcasing their educational potential across each phase of learning. Specifically, one facet described training with cadaver models to gauge accuracy in pedicle screw placement. AR-MISS exceeded free-hand methods without unique complications or contraindications., Conclusions: While still in its infancy, AR has already proven beneficial for educational training and intraoperative MISS applications. We believe that with continued research and advancement of this technology, AR is poised to become a dominant player within the fundamentals of surgical education and MISS operative technique., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: Lateral lumbar interbody fusion including anterior-to-psoas oblique lumbar interbody fusion has conventionally relied on pedicle screw placement (PSP) for construct stabilization. Single-position surgery with lumbar interbody fusion in the lateral decubitus position with concomitant PSP has been associated with increased operative efficiency. What remains unclear is the accuracy of PSP with robotic guidance when compared with the more familiar prone patient positioning. The present study aimed to compare robot-assisted screw placement accuracy between patients with instrumentation placed in the prone and lateral positions., Methods: The authors identified all consecutive patients treated with interbody fusion and PSP in the prone or lateral position by a single surgeon between January 2019 and October 2022. All pedicle screws placed were analyzed using CT scans to determine appropriate positioning according to the Gertzbein-Robbins classification grading system (grade C or worse was considered as a radiographically significant breach). Multivariate logistic regression models were constructed to identify risk factors for the occurrence of a radiographically significant breach., Results: Eighty-nine consecutive patients (690 screws) were included, of whom 46 (477 screws) were treated in the prone position and 43 (213 screws) in the lateral decubitus position. There were fewer breaches in the prone (n = 13, 2.7%) than the lateral decubitus (n = 15, 7.0%) group (p = 0.012). Nine (1.9%) radiographically significant breaches occurred in the prone group compared with 10 (4.7%) in the lateral decubitus group (p = 0.019), for a prone versus lateral decubitus PSP accuracy rate of 98.1% versus 95.3%. There were no significant differences in BMI between prone versus lateral decubitus cohorts (30.1 vs 29.6) or patients with screw breach versus those without (31.2 vs 29.5). In multivariate models, the prone position was the only significant protective factor for screw accuracy; no other significant risk factors for screw breach were identified., Conclusions: The present data suggest that pedicle screws placed with robotic assistance have higher placement accuracy in the prone position. Further studies will be needed to validate the accuracy of PSP in the lateral position as single-position surgery becomes more commonplace in the treatment of spinal disorders.

Introduction: Staphylococcus aureus (S aureus) is the foremost bacterial cause of surgical-site infection (SSI) and is a common source of neuromodulation SSI. Endogenous colonization is an independent risk factor for SSI; however, this risk has been shown to diminish with screening and decolonization., Materials and Methods: A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the PubMed, Cochrane Library, and Embase data bases from inception to January 1, 2022, for the purposes of identifying all studies reporting on the use of S aureus swabbing and/or decolonization before neuromodulation procedures. A random-effects meta-analysis was performed using the metaphor package in R to calculate odds ratios (OR)., Results: Five observational cohort studies were included after applying the inclusion and exclusion criteria. The average study duration was 6.6 ± 3.8 years. Three studies included nasal screening as a prerequisite for subsequent decolonization. Type of neuromodulation included spinal cord stimulation in two studies, deep brain stimulation in two studies, intrathecal baclofen in one study, and sacral neuromodulation in one study. Overall, 860 and 1054 patients were included in a control or intervention (ie, screening and/or decolonization) group, respectively. A combination of nasal mupirocin ointment and a body wash, most commonly chlorhexidine gluconate soap, was used to decolonize throughout. Overall infection rates were observed at 59 of 860 (6.86%) and ten of 1054 (0.95%) in the control and intervention groups, respectively. Four studies reported a significant difference. The OR for intervention (screen and/or decolonization) vs no intervention was 0.19 (95% CI, 0.09-0.37; p < 0.001). Heterogeneity between studies was nonsignificant (I 2  = 0.43%, τ 2  = 0.00)., Conclusions: Preoperative S aureus swabbing and decolonization resulted in significantly decreased odds of infection in neuromodulation procedures. This measure may represent a worthwhile tool to reduce neuromodulation SSI, warranting further investigation., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)