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Giant ruptured distal anterior cerebral artery aneurysms are rare, challenging pathologies that may require a combination of microsurgical and endovascular techniques for optimal treatment [1-9]. We describe the case of a female in her 40 s who presented with a Hunt-Hess 4, Fisher 4 subarachnoid hemorrhage from a multiply ruptured, giant distal anterior cerebral artery aneurysm. The patient underwent coil and n-BCA glue embolization of the aneurysm and its feeding A2 anterior cerebral artery. She subsequently underwent decompressive craniectomy, intracerebral hematoma evacuation, and microsurgical trapping and resection of the aneurysm. Postoperative imaging demonstrated no further aneurysm filling, complete hematoma evacuation, and good decompression. The technical considerations and literature for the combined treatment of large and giant ruptured aneurysms are reviewed. The case presentation, operative nuances, and postoperative course with imaging are reviewed with detailed anatomical diagrams to orient the viewer. The patient consented to the procedure and to the publication of her imaging., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Objective. Highly comparative time series analysis (HCTSA) is a novel approach involving massive feature extraction using publicly available code from many disciplines. The Prematurity-Related Ventilatory Control (Pre-Vent) observational multicenter prospective study collected bedside monitor data from>700extremely preterm infants to identify physiologic features that predict respiratory outcomes. Approach . We calculated a subset of 33 HCTSA features on>7 M 10 min windows of oxygen saturation (SPO2) and heart rate (HR) from the Pre-Vent cohort to quantify predictive performance. This subset included representatives previously identified using unsupervised clustering on>3500HCTSA algorithms. We hypothesized that the best HCTSA algorithms would compare favorably to optimal PreVent physiologic predictor IH90_DPE (duration per event of intermittent hypoxemia events below 90%). Main Results. The top HCTSA features were from a cluster of algorithms associated with the autocorrelation of SPO2 time series and identified low frequency patterns of desaturation as high risk. These features had comparable performance to and were highly correlated with IH90_DPE but perhaps measure the physiologic status of an infant in a more robust way that warrants further investigation. The top HR HCTSA features were symbolic transformation measures that had previously been identified as strong predictors of neonatal mortality. HR metrics were only important predictors at early days of life which was likely due to the larger proportion of infants whose outcome was death by any cause. A simple HCTSA model using 3 top features outperformed IH90_DPE at day of life 7 (.778 versus .729) but was essentially equivalent at day of life 28 (.849 versus .850). Significance . These results validated the utility of a representative HCTSA approach but also provides additional evidence supporting IH90_DPE as an optimal predictor of respiratory outcomes., (Creative Commons Attribution license.)

Background: Venous sinus stenosis has been implicated in intracranial hypertension and can lead to papilledema and blindness. The authors report the unique case of a cerebellar transtentorial lesion resulting in venous sinus stenosis in the torcula and bilateral transverse sinuses that underwent resection., Observations: A 5-year-old male presented with subacute vision loss and bilateral papilledema. Imaging demonstrated a lesion causing mass effect on the torcula/transverse sinuses and findings of increased intracranial pressure (ICP). A lumbar puncture confirmed elevated pressure, and the patient underwent bilateral optic nerve sheath fenestration. Cerebral angiography and venous manometry showed elevated venous sinus pressures suggestive of venous hypertension. The patient underwent a craniotomy and supracerebellar/infratentorial approach. A stalk emanating from the cerebellum through the tentorium was identified and divided. Postoperative magnetic resonance imaging showed decreased lesion size and improved sinus patency. Papilledema resolved and other findings of elevated ICP improved. Pathology was consistent with atrophic cerebellar cortex. Serial imaging over 6 months demonstrated progressive decrease in the lesion with concurrent improvements in sinus patency., Lessons: Although uncommon, symptoms of intracranial hypertension in patients with venous sinus lesions should prompt additional workup ranging from dedicated venous imaging to assessments of ICP and venous manometry.

Background: Artificial intelligence (AI) and machine learning have transformed health care with applications in various specialized fields. Neurosurgery can benefit from artificial intelligence in surgical planning, predicting patient outcomes, and analyzing neuroimaging data. GPT-4, an updated language model with additional training parameters, has exhibited exceptional performance on standardized exams. This study examines GPT-4's competence on neurosurgical board-style questions, comparing its performance with medical students and residents, to explore its potential in medical education and clinical decision-making., Methods: GPT-4's performance was examined on 643 Congress of Neurological Surgeons Self-Assessment Neurosurgery Exam (SANS) board-style questions from various neurosurgery subspecialties. Of these, 477 were text-based and 166 contained images. GPT-4 refused to answer 52 questions that contained no text. The remaining 591 questions were inputted into GPT-4, and its performance was evaluated based on first-time responses. Raw scores were analyzed across subspecialties and question types, and then compared to previous findings on Chat Generative pre-trained transformer performance against SANS users, medical students, and neurosurgery residents., Results: GPT-4 attempted 91.9% of Congress of Neurological Surgeons SANS questions and achieved 76.6% accuracy. The model's accuracy increased to 79.0% for text-only questions. GPT-4 outperformed Chat Generative pre-trained transformer (P < 0.001) and scored highest in pain/peripheral nerve (84%) and lowest in spine (73%) categories. It exceeded the performance of medical students (26.3%), neurosurgery residents (61.5%), and the national average of SANS users (69.3%) across all categories., Conclusions: GPT-4 significantly outperformed medical students, neurosurgery residents, and the national average of SANS users. The mode's accuracy suggests potential applications in educational settings and clinical decision-making, enhancing provider efficiency, and improving patient care., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objectives: Multiple prior studies have shown a relationship between COVID-19 and strokes; further, COVID-19 has been shown to influence both time-to-thrombectomy and overall thrombectomy rates. Using large-scale, recently released national data, we assessed the association between COVID-19 diagnosis and patient outcomes following mechanical thrombectomy., Materials and Methods: Patients in this study were identified from the 2020 National Inpatient Sample. All patients with arterial strokes undergoing mechanical thrombectomy were identified using ICD-10 coding criteria. Patients were further stratified by COVID diagnosis (positive vs. negative). Other covariates, including patient/hospital demographics, disease severity, and comorbidities were collected. Multivariable analysis was used to determine the independent effect of COVID-19 on in-hospital mortality and unfavorable discharge., Results: 5078 patients were identified in this study; 166 (3.3%) were COVID-19 positive. COVID-19 patients had a significantly higher mortality rate (30.1% vs. 12.4%, p < 0.001). When controlling for patient/hospital characteristics, APR-DRG disease severity, and Elixhauser Comorbidity Index, COVID-19 was an independent predictor of increased mortality (OR 1.13, p = 0.002). COVID-19 was not significantly related to discharge disposition (p = 0.480). Older age and increased APR-DRG disease severity were also correlated with increase morality., Conclusions: Overall, this study indicates that COVID-19 is a predictor of mortality among mechanical thrombectomy. This finding is likely multifactorial but may be related to multisystem inflammation, hypercoagulability, and re-occlusion seen in COVID-19 patients. Further research would be needed to clarify these relationships., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: Venous thromboembolic event (VTE) after spine surgery is a rare but potentially devastating complication. With the advent of machine learning, an opportunity exists for more accurate prediction of such events to aid in prevention and treatment., Methods: Seven models were screened using 108 database variables and 62 preoperative variables. These models included deep neural network (DNN), DNN with synthetic minority oversampling technique (SMOTE), logistic regression, ridge regression, lasso regression, simple linear regression, and gradient boosting classifier. Relevant metrics were compared between each model. The top four models were selected based on area under the receiver operator curve; these models included DNN with SMOTE, linear regression, lasso regression, and ridge regression. Separate random sampling of each model was performed 1000 additional independent times using a randomly generated training/testing distribution. Variable weights and magnitudes were analyzed after sampling., Results: Using all patient-related variables, DNN using SMOTE was the top-performing model in predicting postoperative VTE after spinal surgery (area under the curve [AUC] =0.904), followed by lasso regression (AUC = 0.894), ridge regression (AUC = 0.873), and linear regression (AUC = 0.864). When analyzing a subset of only preoperative variables, the top-performing models were lasso regression (AUC = 0.865) and DNN with SMOTE (AUC = 0.864), both of which outperform any currently published models. Main model contributions relied heavily on variables associated with history of thromboembolic events, length of surgical/anesthetic time, and use of postoperative chemoprophylaxis., Conclusions: The current study provides promise toward machine learning methods geared toward predicting postoperative complications after spine surgery. Further study is needed in order to best quantify and model real-world risk for such events., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Journal of Craniovertebral Junction and Spine.)

Objective: The coronavirus disease 2019 (COVID-19) pandemic has necessitated the use of telehealth visits (THVs). The effects on neurosurgical practice have not been well characterized, especially concerning new-patient THVs. Therefore, the authors of this study reviewed their institution's experience with outpatient clinic visits and THVs from before the COVID-19 pandemic to the present to focus on clinical metrics, rates of surgery, and the effects of implementing THVs in order to better understand their implications for clinical practice as more data emerge over time., Methods: The authors reviewed 15,677 consecutive new outpatient in-person visits (IPVs), THVs, and neurosurgical procedures/cases proceeding from their institution between 2018 and 2022 for trends and associations related to THVs., Results: Among spine patients, there was no difference in the proportion of encounters that led to surgery (surgical conversion rate) between THVs and IPVs (p = 0.49). Among cranial patients, THVs were negatively associated with conversion (OR 0.73, p = 0.03). On average, patients using THVs lived further from the hospital (p < 0.001); however, the patient catchment area appeared unchanged. The median distance to the hospital among THV patients was counterbalanced by a decreased distance for spine patients pursing IPVs (p < 0.001), with no significant change to case volume. There was no change in distance to the hospital among cranial patients. For both cranial and spine patients, surgical conversion was more likely among those who lived a great distance from the hospital if their initial encounter was an IPV (p = 0.007 and < 0.001, respectively). However, there was no relationship between distance from the hospital and surgical conversion among THV patients (p = 0.565). The availability of THVs did not significantly affect follow-up time (p = 0.837). For new patients at IPVs, there was no difference in time to the operating room between cranial and spine cases; for new patients at THVs, however, time to the operating room was significantly faster for cranial cases than for spine cases (p = 0.0018)., Conclusions: Compared to IPVs, THVs lead to decreased surgical conversion for cranial patients but not spine patients. THVs do not appear to increase the catchment area. For patients who live far from the hospital, an IPV is associated with surgical conversion. Surgical conversion is faster following cranial THVs than after spine THVs. THVs did not increase the duration of follow-up.

Background: Traumatic vertebral artery dissections (tVADs) occur in up to 20% of patients with head trauma, yet data on their presentation and associated sequelae are limited., Aims and Objectives: To characterize the tVAD population and identify factors associated with clinical outcomes., Materials and Methods: We retrospectively analyzed all cases of tVAD at our institution from January 2004 to December 2018 with respect to mechanism of injury, clinical presentation, anatomic factors, associated pathologies, and relevant outcomes., Results: Of the 123 patients with tVAD, the most common presenting symptoms were neck pain (n=76, 67.3%), headache (57.5%), and visual changes (29.6%). 101 cases (82.1%) were unilateral, and 22 cases (17.9%) were bilateral. V2 was the most involved anatomic segment (83 cases, 70.3). 30 cases (25.4%) led to stroke, and 39 cases (31.7%) had a concomitant cervical fracture. The anatomic segment and number of segments involved, and baseline clinical and demographic characteristics were not associated with risk of stroke. Patients with associated fractures were older (50.3 years v. 36.4 years, p=0.0233), had a higher comorbid disease burden (CCI 1 vs. CCI 1, p<0.0007), were more likely to smoke (OR 3.0 [1.2178, 7.4028], p=0.0202), be male (OR 7.125 [3.0181, 16.8236], p<0.0001), and have mRS≥3 at discharge (OR 3.0545 [1.0937, 8.5752], p=0.0449). On multivariable regression, only fracture independently predicted mRS≥3 at discharge (OR 5.6898 [1.5067, 21.4876], p=0.010)., Conclusion: tVADs may be associated with stroke and/or cervical fracture. Presenting symptoms predict stroke, but baseline demographic and clinical characteristics do not. Comorbid cervical fractures, not stroke, drive negative outcomes., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Journal of Craniovertebral Junction and Spine.)

Objective: To investigate perspectives of patients, family members, caregivers (PFC), and healthcare professionals (HCP) on tracheostomy care during the COVID-19 pandemic., Methods: The cross-sectional survey investigating barriers and facilitators to tracheostomy care was collaboratively developed by patients, family members, nurses, speech-language pathologists, respiratory care practitioners, physicians, and surgeons. The survey was distributed to the Global Tracheostomy Collaborative's learning community, and responses were analyzed., Results: Survey respondents (n = 191) from 17 countries included individuals with a tracheostomy (85 [45 %]), families/caregivers (43 [22 %]), and diverse HCP (63 [33.0 %]). Overall, 94 % of respondents reported concern that patients with tracheostomy were at increased risk of critical illness from SARS-CoV-2 infection and COVID-19; 93 % reported fear or anxiety. With respect to prioritization of care, 38 % of PFC versus 16 % of HCP reported concern that patients with tracheostomies might not be valued or prioritized (p = 0.002). Respondents also differed in fear of contracting COVID-19 (69 % PFC vs. 49 % HCP group, p = 0.009); concern for hospitalization (55.5 % PFC vs. 27 % HCP, p < 0.001); access to medical personnel (34 % PFC vs. 14 % HCP, p = 0.005); and concern about canceled appointments (62 % PFC vs. 41 % HCP, p = 0.01). Respondents from both groups reported severe stress and fatigue, sleep deprivation, lack of breaks, and lack of support (70 % PFC vs. 65 % HCP, p = 0.54). Virtual telecare seldom met perceived needs., Conclusion: PFC with a tracheostomy perceived most risks more acutely than HCP in this global sample. Broad stakeholder engagement is necessary to achieve creative, patient-driven solutions to maintain connection, communication, and access for patients with a tracheostomy., Competing Interests: Declaration of competing interest Other authors report nothing to disclose., (Copyright © 2021. Published by Elsevier Inc.)

Background: One strategy to reduce extensive intraoperative bleeding for patients undergoing surgery for metastatic renal cell carcinoma (RCC) to the spine is preoperative embolization. Prior studies have shown mixed results. The objective of this study is to evaluate the efficacy of preoperative embolization in patients undergoing spine surgery for metastatic RCC with consideration of multiple confounders. We aim to assess blood loss and other outcomes reflective of functional status and postoperative complications., Methods: A retrospective chart review was conducted for 43 patients that underwent surgery for metastatic spinal RCC and either received preoperative embolization (n = 29) or did not (n = 14). Mann Whitney tests were run for initial analyses. Multivariate regression models were then used to predict outcomes while controlling for multiple demographic and preoperative variables., Results: Mann Whitney tests revealed a significant difference between the mean age of patients undergoing preoperative embolization in comparison to those that did not (59.2 years versus 52.4 years; p = 0.044). We found that preoperative embolization was not significantly associated with decreased blood loss (2257 mL versus 2000 mL; p = 0.97). There were also no significant differences between groups in post-procedural complications (34.5% versus 14.3%; p = 0.097), last follow-up Nurick score (β = 0.72, p = 0.18; 2.1 versus 1.6) or operative duration (β = 28, p = 0.66; 408 min versus 353 min). The female gender was found to be significantly associated with higher last follow-up Nurick scores (β = 1.24, p = 0.033)., Conclusion: We observed no differences in blood loss or other outcomes between patients undergoing preoperative embolization and those that did not., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: Intracranial hemorrhage (ICH) is considered an emergency that requires rapid medical or surgical management. Previous studies have used artificial intelligence to attempt to expedite the diagnosis of this pathology on neuroimaging. However, these studies have used local, institution-specific data for training of networks that limit deployment of across broader hospital networks or regions because of data biases., Objective: To demonstrate the creation of a neural network based on an openly available imaging data tested on data from our institution demonstrating a high-efficacy, institution-agnostic network., Methods: A data set was created from publicly available noncontrast computed tomography images of known ICH. These data were used to train a neural network using distinct windowing and augmentation. This network was then validated in 2 phases using cohort-based (phase 1) and longitudinal (phase 2) approaches., Results: Our convolutional neural network was trained on 752 807 openly available slices, which included 112 762 slices containing intracranial hemorrhage. In phase 1, the final network performance for intracranial hemorrhage showed a receiver operating characteristic curve (AUC) of 0.99. At the inflection point, our model showed a sensitivity of 98% at a threshold specificity of 99%. In phase 2, we obtained an AUC of 0.98 after analysis of 726 scans with a negative predictive value of 99.70% (n = 726)., Conclusion: We demonstrate an effective neural network trained on completely open data for screening ICH at an unrelated institution. This study demonstrates a proof of concept for screening networks for multiple sites while maintaining high efficacy., (Copyright © Congress of Neurological Surgeons 2022. All rights reserved.)

Abstract: Few interventions have targeted resilience resources in people living with HIV (PLWH). We tested the acceptability of an existing resilience intervention in middle-age and older PLWH. Fourteen PLWH attended one 3-hr group session, which included videos, quizzes, and written activities. Participants provided quantitative and qualitative feedback. The mean acceptability rating was 8.71 (1.27) on a 10-point scale. A majority of participants reported that the intervention was an appropriate length; that it improved their resilience, mood, and ability to manage HIV; and that they would likely continue using the tools. Average content retention accuracy was 75% (12.66). Qualitative feedback suggested addressing HIV-specific stressors, including disclosure concerns, stigma, health concerns, and treatment adherence. The resilience intervention was deemed highly acceptable among older PLWH. Uptake may increase by addressing HIV-specific stressors and improving comprehensibility. Future research should further refine and test the efficacy of a modified version of the intervention., (Copyright © 2020 Association of Nurses in AIDS Care.)

Background: Postpartum vertebral artery dissections (ppVADs) are rare but potentially morbid conditions that occur in otherwise healthy patients., Objective: To evaluate clinical characteristics of ppVADs., Methods: Demographic, clinical, treatment, and outcome data were collected on ppVADs and are presented in a case series of 12 patients and compared to the general cohort., Results: In total, 12 patients had ppVADs in our cohort of 310 patients with vertebral artery dissections (VADs). They occurred 11.27 days (95% CI, -0.85 to 23.39) postdelivery. Of these, there were 5 (42%) with a hypertensive disorder of pregnancy, and 4 (33%) who had migraines. A total of 3 (25%) had ischemic strokes and 1 (8%) had a subarachnoid hemorrhage. In total, 2 patients (17%) had unfavorable modified Rankin Scale (mRS, 2-6) at discharge from hospital. Patients with ppVADs more often had bilateral VADs (42% vs 17%, P = .03), had pseudoaneurysms (50% vs 18%, P = .0068), were younger (33.83 years vs 44.32 years, P = .018), and had lower Charlson Comorbidity Index (CCI = 0 vs 0.99, P = .0038). Anticoagulant treatment was used in a similar percentage of patients. Multivariate analysis revealed 3 factors were predictive of change in mRS: CCI (OR = 1.09, 95% CI, 1.02-1.15), stroke (OR = 0.78, 95% CI, 0.65-0.95), and mRS at hospital discharge (OR = 0.80, 95% CI, 0.74-0.87)., Conclusion: There are only 15 isolated ppVADs reported in the literature; this study adds 12 patients with 17 ppVADs. Postpartum VADs occur in younger, healthier patients than in the general cohort, raising questions about mechanism of injury. The majority of ppVADs have good neurological outcomes., (© Congress of Neurological Surgeons 2021.)

Background: Vertebral artery dissections (VADs) are rare yet potentially devastating events. While the etiology of these events is either traumatic or spontaneous, there is a paucity of quantitative literature comparing the two., Objective: To identify differences in predisposing factors, event characteristics, and clinical outcomes between traumatic VADs (tVADs) and spontaneous VADs (sVADs)., Methods: We retrospectively identified patients with VADs presenting to our institution at VAD onset with at least a 3-mo follow-up. Demographics, event characteristics, treatment details, and neurological outcomes as modified Rankin scale (mRS) scores were collected., Results: Of the 310 patients sustaining 366 VADs total, 187 (60.3%) patients experienced a total of 221 (60.4%) sVADs and 123 (39.7%) patients experienced a total of 145 (39.6%) tVADs. sVADs were more likely to occur in the intracranial course of the artery (P = .042) and have a lower mRS at discharge, 3-month, and last clinical follow-up (P = 003, .002, and .001, respectively). tVADs were more likely associated with concomitant fractures (P < .001)., Conclusion: Despite similar patient populations, tVADs are associated with higher mRS scores at all time points. Although further study is needed, this may suggest other concomitant trauma rather than the VAD itself is contributing to worse neurological status in patients with tVADs., (© Congress of Neurological Surgeons 2021.)

Robust literature supports the positive effects of kangaroo mother care (KMC) on infant physiologic stability and parent-infant bonding in the Neonatal Intensive Care Unit (NICU). Comparatively little is known about kangaroo father care (KFC) in the NICU, and KFC implementation has been limited. Our pilot feasibility study objective was to examine KFC effects on premature infants and fathers as compared to KMC. Parents of preterm NICU infants independently completed a 90-min Kangaroo Care (KC) session on consecutive days. Infant heart rate variability (HRV) and apnea/periodicity measures were compared (pre-KC to KC; KFC to KMC). Additionally, we assessed the feasibility of administering three psychosocial questionnaires to fathers and mothers in the NICU and after discharge. Ten preterm infants completed 20 KC sessions (33 4/7 -37 4/7  weeks post-menstrual age). Results demonstrated similar infant physiologic responses between KMC and KFC, including significant differences in measures of HRV (p < .05) between KC and non-KC periods. Eighty-eight percentage of questionnaires administered were completed, supporting the utilization of these instruments in future research of this population. If confirmed, these preliminary results identify an opportunity to objectively assess KFC effects, supporting the development of empirically based KFC programs benefitting NICU families., (© 2021 Wiley Periodicals LLC.)

Background: Vertebral artery dissections (VAD) are a rare but important cause of ischemic stroke, especially in younger patients. Many etiologies have been identified, including MVAs, cervical fractures, falls, physical exercise, and cervical chiropractic manipulation. The goal of this study was to investigate the subgroup of patients who suffered a chiropractor-associated injury and determine how their prognosis compared to other-cause VAD., Methods: We conducted a retrospective chart review of 310 patients with vertebral artery dissections who presented at our institution between January 2004 and December 2018. Variables included demographic data, event characteristics, treatment, radiographic outcomes, and clinical outcomes measured using the modified Rankin Scale., Findings: Overall, 34 out of our 310 patients suffered a chiropractor-associated injury. These patients tended to be younger (p = 0.01), female (p = 0.003), and have fewer comorbidities (p = 0.005) compared to patients with other-cause VADs. The characteristics of the injuries were similar, but chiropractor-associated injuries appeared to be milder at discharge and at follow-up. A higher proportion of the chiropractor-associated group had injuries in the 0-2 mRS range at discharge and at 3 months (p = 0.05, p = 0.04) and no patients suffered severe long-term neurologic consequences or death (0% vs. 9.8%, p = 0.05). However, when a multivariate binomial regression was performed, these effects dissipated and the only independent predictor of a worse injury at discharge was the presence of a cervical spine fracture (p < 0.001)., Interpretation: Chiropractor-associated injuries are similar to VADs of other causes, and apparent differences in the severity of the injury are likely due to demographic differences between the two populations., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objective: Social media has been used increasingly in neurosurgery by individuals. We aimed to identify demographics and preferences of social media use, describe the scope of social media use, and characterize its utility., Methods: A systematic review was conducted using PubMed, Embase, and Scopus databases. Titles and abstracts from articles identified in the search were read and selected for full-text review. Studies meeting prespecified inclusion criteria were reviewed in full and analyzed for relevant data., Results: Of 431 resultant articles, 29 were included. Patients and caregivers most commonly used Facebook and Twitter, whereas nearly 50% of neurosurgeons used LinkedIn and Doximity. Patient and caregiver users of social media tended to be <35 years old. Content of posts varied from requesting/providing information (∼40%) to seeking emotional support/forming connections (∼30%). A total of 20.6% of videos were irrelevant to clinical neurosurgery. Factual accuracy of most videos was poor to inadequate. Social media use was associated with greater academic impact for neurosurgical departments and journals. Posts with photos and videos and weekend posts generated 1.2-2 times greater engagement., Conclusions: Patients and caregivers who use social media are typically younger than 35 years old and commonly use Facebook or Twitter. Neurosurgeons prefer Doximity and LinkedIn. Social media yields information regarding common symptoms and uncovers novel symptoms. Videos are poor-to-inadequate quality and often irrelevant to clinical neurosurgery. Optimizing social media use will augment the exchange of ideas regarding clinical practice and research and empower patients and caregivers., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Study Design: Retrospective case series., Objective: We sought to identify risk factors associated with surgical site infection (SSI) after posterior long segment spinal fusion (PLSF)., Summary of Background Data: Patients who undergo PLSF may be at elevated risk of SSI. Identifying factors associated with SSI in these operations can help risk stratify patients and tailor management., Methods: We analyzed PLSFs-seven or more levels-at our institution from 2000 to 2015. Data on patients' clinical characteristics, procedural factors, and antimicrobial management were collected. Multivariable analysis identified factors independently associated with outcomes of interest., Results: In 628 cases, SSI was associated with steroid use (P = 0.024, odds ratio [OR] = 2.54) and using cefazolin (P < 0.001, OR = 4.37) or bacitracin (P = 0.010, OR 3.49) irrigation, as opposed to gentamicin or other irrigation. Gram-positive infections were more likely with staged procedures (P = 0.021, OR 4.91) and bacitracin irrigation (P < 0.001, OR = 17.98), and less likely with vancomycin powder (P = 0.050, OR 0.20). Gram-negative infections were more likely with a history of peripheral arterial disease (P = 0.034, OR = 3.21) or cefazolin irrigation (P < 0.001, OR 25.47). Readmission was more likely after staged procedures (P = 0.003, OR = 3.31), cervical spine surgery (P = 0.023, OR = 2.28), or cefazolin irrigation (P = 0.039, OR = 1.85). Reoperation was more common with more comorbidities (P = 0.022, OR 1.09), staged procedures (P < 0.001, OR = 4.72), cervical surgeries (P = 0.013, OR = 2.36), more participants in the surgery (P = 0.011, OR = 1.06), using cefazolin (P < 0.001, OR = 3.12) or bacitracin (P = 0.009, OR = 3.15) irrigation, and higher erythrocyte sedimentation rate at readmission (P = 0.009, OR = 1.04). Washouts were more likely among patients with more comorbidities (P = 0.013, OR = 1.16), or who used steroids (P = 0.022, OR = 2.92), and less likely after cervical surgery (P = 0.028, OR = 0.24). Instrumentation removal was more common with bacitracin irrigation (p = 0.013, OR = 31.76)., Conclusion: Patient factors, whether a procedure is staged, and choice of antibiotic irrigation affect the risk of SSI and ensuing management required.Level of Evidence: 4., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Vertebral artery dissections (VADs) are a common cause of stroke in young patients and can result in various secondary effects, including pseudoaneurysm formation., Objective: To identify differences in predisposing factors and outcomes for VADs with and without concomitant pseudoaneurysms., Methods: We retrospective chart reviewed patients who presented to our institution at the time of VAD with at least a 3-mo clinical follow-up. Demographics, VAD characteristics, treatment, and outcomes represented as modified Rankin scale (mRS) scores were collected., Results: Of 310 patients with a VAD included in this study, 301 patients had an identified pseudoaneurysm status, with 54 pseudoaneurysm-associated VADs and 247 VADs not associated with pseudoaneurysm. VAD patients with associated pseudoaneurysms were more likely to be female (P < .004), have bilateral VADs (P < .001), and have fewer vertebral artery segments affected (P = .018), and less likely to have stroke (P < .008) or occlusion of the vertebral artery (P < .001). There was no difference in the proportion of patients treated with antiplatelet agents (P = .12) or anticoagulants (P = .27) between the groups. VAD patients with associated pseudoaneurysms were more likely to have a higher mRS at 3-mo follow-up (P = .044) but not discharge (P = .18) or last follow-up (P = .05). VAD patients with pseudoaneurysms were equally likely to have resolution of occlusion (P = .40) and stenosis (P = .19)., Conclusion: Demographics and clinical and radiological characteristics of VADs associated with pseudoaneurysms are different from those without associated pseudoaneurysms. Vertebral artery dissections with concomitant pseudoaneurysms are neither associated with worse functional nor radiographic outcomes., (© Congress of Neurological Surgeons 2021.)

Background: Patient education has become increasingly important in neurosurgery. However, little is known regarding how to comprehensively educate neurosurgical patients. In the first part of a 2-part systematic review, we identify baseline patient understanding and educational needs, examine existing patient education materials, and characterize shortcomings in neurosurgical patient education practices. Our findings may guide neurosurgeons, departments, and professional associations in improving communication with patients., Methods: A 2-part systematic review was conducted using the PubMed, Embase, and Scopus databases. Titles and abstracts were read and selected for full text review. Studies meeting prespecified inclusion criteria were reviewed in full and analyzed for study design, aim, population, interventions, and outcomes., Results: Of 1617 resultant articles, 41 were included. Patient comprehension was low. Patient informational needs differed across patients and between patients and neurosurgeons. Patient informational needs were often unmet, promoting dissatisfaction. Written educational materials from government agencies, professional associations, neurosurgery departments, neurosurgeons, or widely read Web sites were written at a reading level above the recommended reading level, with complex topics written at a higher level. Information found on hospital and university Web sites was poor quality because of self-marketing and lack of reference to peer-reviewed literature. Educational videos created by universities and hospitals were poor quality., Conclusions: Current in-clinic discussions and education materials show shortcomings, promoting poor comprehension. Neurosurgeons, departments, and professional organizations can act to improve the effectiveness of patient education initiatives. This policy will better inform patients, increase rapport between neurosurgeons and patients, and improve patient decision making and satisfaction., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Increasing focus has been placed on patient education to optimize care. In the second part of a 2-part systematic review, we characterize the scope of interventions specifically created to improve neurosurgery patient education, assess the effectiveness of these interventions, and extract features of existing interventions that may be incorporated into future patient education interventions. Our findings may help promote the creation of effective, patient-centered educational interventions., Methods: A 2-part systematic review was conducted using the PubMed, Embase, and Scopus databases. Titles and abstracts were read and selected for full text review. Studies meeting prespecified inclusion criteria were reviewed in full and analyzed for study design, aim, population, interventions, and outcomes., Results: Of 1617 resultant articles, 33 were included. Print materials, electronic materials, models, and interventions using multiple modalities improved patient knowledge, decreased anxiety, and increased satisfaction. Electronic materials were preferred. Interventions using multiple modalities engaging multiple sensory systems were reported most beneficial. Video was rated the most effective medium for reinforcing spoken conversation between neurosurgeons and patients. Three-dimensional models decreased the time required for preoperative patient conversation but could be perceived as emotionally confronting. Virtual reality was preferred to patient models., Conclusions: Electronic interventions using multiple modalities in concert with each other may be most effective. Interventions should incorporate baseline knowledge and health literacy and address patient concerns and needs in a manner that is valid cross-contextually, uses clear communication, and is continuous. These interventions will improve the patient-friendliness of discussions with patients., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: We assessed the prognostic value of the preoperative magnetization transfer ratio (MTR) and morphometrics of the spinal cord in patients with degenerative cervical myelopathy (DCM) in a longitudinal cohort study., Methods: Thirteen subjects with DCM underwent 3T magnetization transfer imaging. The MTR was calculated for the spinal cord regions and specific white matter tracts. Morphometric measures were extracted. Clinical (modified Japanese Orthopaedics Association [mJOA] and Nurick scale scores) and health-related quality of life scores were assessed before and after cervical decompression surgery. The association between the magnetic resonance imaging (MRI) metrics and postoperative recovery was assessed (Spearman's correlation). Receiver operating characteristics were used to assess the accuracy of MRI metrics in identifying ≥50% recovery in function., Results: Preoperative anterior cord MTRs were associated with recovery in mJOA scores (ρ = 0.608; P = 0.036; area under the curve [AUC], 0.66). Preoperative lateral cord MTR correlated with the neck disability index (ρ = 0.699; P = 0.011) and pain interference scale (ρ = 0.732; P = 0.007). Preoperative rubrospinal tract MTR was associated with mJOA score recovery (ρ = 0.573; P = 0.041; AUC, 0.86). Preoperative corticospinal tract and reticulospinal MTRs were related to recovery in pain interference scores (ρ = 0.591; P = 0.033; and ρ = 0.583; P = 0.035, respectively). Eccentricity of the cord was associated with Nurick scores (ρ = 0.606; P = 0.028) and mJOA scores (ρ = 0.651; P = 0.025; AUC, 0.92)., Conclusions: Preoperative MTR and eccentricity measurements of the spinal cord have prognostic value in assessing the response to surgery and recovery in patients with DCM. Advanced MRI and atlas-based postprocessing techniques can inform interventions and advance the healthcare received by patients with DCM., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: Vertebral artery dissections occur when tears in the intimal layer of the vertebral artery and are associated with trauma, infection, and spontaneous etiologies. We aimed to identify differences in predisposing factors and outcomes in vertebral artery dissections associated with cervical spine fractures compared to those not associated with cervical spine fractures., Patients and Methods: We conducted a retrospective chart review of patients with vertebral artery dissections who presented to our institution at the time of dissection and had a minimum of 3 month follow-up and collected data on demographics, event characteristics, treatments, and outcomes in the form of modified Rankin scale scores., Results: In total, 291 patients with VAD were included in this study. Thirty-nine patients with VADs had associated fracture, while 252 patients had VADs without fracture. VAD patients with associated cervical fractures were more likely to be male (p < 0.001), have a greater number of comorbid conditions (p < 0.01), be smokers (p = 0.045), or have violence (p < 0.001) or motor vehicle accidents (p < 0.001) as the cause of their VADs. VAD patients with associated cervical fractures were less likely to have associated aneurysms or pseudoaneurysms (p = 0.002). VAD patients with associated cervical fractures were more likely to have higher mRS at discharge from the hospital (p < 0.001), 3 month follow-up (p < 0.001), and last follow-up (p < 0.001)., Conclusion: Cervical spine fracture is likely the primary driver of poor neurological outcomes following vertebral artery dissection with associated cervical spine fracture., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Dermatomal maps are a mainstay of clinical practice and provide information on the spatial distribution of the cutaneous innervation of spinal nerves. Dermatomal deficits can help isolate the level of spinal nerve root involvement in spinal conditions and guide clinicians in diagnosis and treatment. Dermatomal maps, however, have limitations, and the spatial distribution of spinal cord sensory activity in humans remains to be quantitatively assessed. Here we used spinal cord functional MRI to map and quantitatively compare the spatial distribution of sensory spinal cord activity during tactile stimulation of the left and right lateral shoulders (i.e. C5 dermatome) and dorsal third digits of the hands (i.e., C7 dermatome) in healthy humans (n ​= ​24, age ​= ​36.8 ​± ​11.8 years). Based on the central sites for processing of innocuous tactile sensory information, we hypothesized that the activity would be localized more to the ipsilateral dorsal spinal cord with the lateral shoulder stimulation activity being localized more superiorly than the dorsal third digit. The findings demonstrate lateralization of the activity with the left- and right-sided stimuli having more activation in the ipsilateral hemicord. Contradictory to our hypotheses, the activity for both stimulation sites was spread across the dorsal and ventral hemicords and did not demonstrate a clear superior-inferior localization. Instead, the activity for both stimuli had a broader than expected distribution, extending across the C5, C6, and C7 spinal cord segments. We highlight the complexity of the human spinal cord neuroanatomy and several sources of variability that may explain the observed patterns of activity. While the findings were not completely consistent with our a priori hypotheses, this study provides a foundation for continued work and is an important step towards developing normative quantitative spinal cord measures of sensory function, which may become useful objective MRI-based biomarkers of neurological injury and improve the management of spinal disorders., (Copyright © 2020 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objectives: Machine Learning and Artificial Intelligence (AI) are rapidly growing in capability and increasingly applied to model outcomes and complications within medicine. In spinal surgery, post-operative surgical site infections (SSIs) are a rare, yet morbid complication. This paper applied AI to predict SSIs after posterior spinal fusions., Patients and Methods: 4046 posterior spinal fusions were identified at a single academic center. A Deep Neural Network DNN classification model was trained using 35 unique input variables The model was trained and tested using cross-validation, in which the data were randomly partitioned into training n = 3034 and testing n = 1012 datasets. Stepwise multivariate regression was further used to identify actual model weights based on predictions from our trained model., Results: The overall rate of infection was 1.5 %. The mean area under the curve (AUC), representing the accuracy of the model, across all 300 iterations was 0.775 (95 % CI [0.767,0.782]) with a median AUC of 0.787. The positive predictive value (PPV), representing how well the model predicted SSI when a patient had SSI, over all predictions was 92.56 % with a negative predictive value (NPV), representing how well the model predicted absence of SSI when a patient did not have SSI, of 98.45 %. In analyzing relative model weights, the five highest weighted variables were Congestive Heart Failure, Chronic Pulmonary Failure, Hemiplegia/Paraplegia, Multilevel Fusion and Cerebrovascular Disease respectively. Notable factors that were protective against infection were ICU Admission, Increasing Charlson Comorbidity Score, Race (White), and being male. Minimally invasive surgery (MIS) was also determined to be mildly protective., Conclusion: Machine learning and artificial intelligence are relevant and impressive tools that should be employed in the clinical decision making for patients. The variables with the largest model weights were primarily comorbidity related with the exception of multilevel fusion. Further study is needed, however, in order to draw any definitive conclusions., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: White matter volume loss may be an anatomic driver in the development of clinical symptoms in cervical spondylotic myelopathy (CSM). Considerably less attention has been devoted to gray matter (GM) injury. Newly developed atlas-based mapping techniques may allow evaluation of GM cord volume alterations in CSM., Methods: There were 29 subjects evaluated: 15 patients with CSM (61.1 ± 8.7 years old) and 14 age-matched control subjects (56.1 ± 5.3 years old). All subjects underwent 3T magnetic resonance imaging of the cervical spine. Post-processing with the Spinal Cord Toolbox (v3.0) provided GM volumetric analysis. Clinical scores collected included modified Japanese Orthopaedic Association, neck and arm numeric rating scales, Nurick Scale, and Neck Disability Index. All volumes were normalized to account for anatomic variability., Results: Normalized mean ventral GM volume in the compression region was significantly lower in patients compared with control subjects (1.103 ± 0.21 vs. 1.35 ± 0.32, P = 0.027). Normalized mean dorsal volume in the compression region was decreased in patients compared with control subjects (0.90 ± 0.17 vs. 1.04 ± 0.15, P = 0.049). GM volumes were associated with clinical scores, including Neck Disability Index, arm numeric rating scale, modified Japanese Orthopaedic Association, and Nurick Scale scores (P = 0.022, P = 0.004, P = 0.027, and P = 0.016)., Conclusions: GM volume loss may be evaluated through atlas-based post-processing techniques and may correlate with clinical symptoms in CSM., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: Unplanned preventable hospital readmissions within 30 days are a great burden to patients and the healthcare system. With an estimated $41.3 billion spent yearly, reducing such readmission rates is of the utmost importance. With the widespread adoption of big data and machine learning, clinicians can use these analytical tools to understand these complex relationships and find predictive factors that can be generalized to future patients. The object of this study was to assess the efficacy of a machine learning algorithm in the prediction of 30-day hospital readmission after posterior spinal fusion surgery., Methods: The authors analyzed the distribution of National Surgical Quality Improvement Program (NSQIP) posterior lumbar fusions from 2011 to 2016 by using machine learning techniques to create a model predictive of hospital readmissions. A deep neural network was trained using 177 unique input variables. The model was trained and tested using cross-validation, in which the data were randomly partitioned into training (n = 17,448 [75%]) and testing (n = 5816 [25%]) data sets. In training, the 17,448 training cases were fed through a series of 7 layers, each with varying degrees of forward and backward communicating nodes (neurons)., Results: Mean and median positive predictive values were 78.5% and 78.0%, respectively. Mean and median negative predictive values were both 97%, respectively. Mean and median areas under the curve for the model were 0.812 and 0.810, respectively. The five most heavily weighted inputs were (in order of importance) return to the operating room, septic shock, superficial surgical site infection, sepsis, and being on a ventilator for > 48 hours., Conclusions: Machine learning and artificial intelligence are powerful tools with the ability to improve understanding of predictive metrics in clinical spine surgery. The authors' model was able to predict those patients who would not require readmission. Similarly, the majority of predicted readmissions (up to 60%) were predicted by the model while retaining a 0% false-positive rate. Such findings suggest a possible need for reevaluation of the current Hospital Readmissions Reduction Program penalties in spine surgery.

Introduction: Exercise-related injuries (ERIs) are a common cause of nonfatal emergency department and hospital visits. CrossFit is a high-intensity workout regimen whose popularity has grown rapidly. However, ERIs due to CrossFit remained under investigated., Methods: All patients who presented to the main hospital at a major academic center complaining of an injury sustained performing CrossFit between June 2010 and June 2016 were identified. Injuries were classified by anatomical location (eg, knee, spine). For patients with spinal injuries, data were collected including age, sex, body mass index (BMI), CrossFit experience level, symptom duration, type of symptoms, type of clinic presentation, cause of injury, objective neurological examination findings, imaging type, number of clinic visits, and treatments prescribed., Results: Four hundred ninety-eight patients with 523 CrossFit-related injuries were identified. Spine injuries were the most common injuries identified, accounting for 20.9%. Among spine injuries, the most common location of injury was the lumbar spine (83.1%). Average symptom duration was 6.4 months ± 15.1, and radicular complaints were the most common symptom (53%). A total of 30 (32%) patients had positive findings on neurologic examination. Six patients (6.7%) required surgical intervention for treatment after failing an average of 9.66 months of conservative treatment. There was no difference in age, sex, BMI, or duration of symptoms of patients requiring surgery with those who did not., Conclusions: CrossFit is a popular, high-intensity style workout with the potential to injure its participants. Spine injuries were the most common type of injury observed and frequently required surgical intervention.

Methods: Twenty patients with CSM and 17 controls were recruited. Clinical scores of modified Japanese Orthopedic Association (mJOA) and Nurick were collected. MRI based compression grades such as cord distortion were assessed. Hand dysfunction was tested using a custom motorized apparatus. Subject's forearm was placed in a cast and positioned such that their metacarpophalangeal (MCP) joint was vertically aligned with the motor shaft. Surface electromyographic sensors were placed on flexor digitorum superficialis (FDS) and extensor digitorum communis muscles. Hyperreflexia was measured as the FDS muscle activation during reflex when the MCP joint was moved from flexion to extension at 300°/sec. Proprioception was quantified as the angle of detection in absence of visual or auditory cues (subjects were blindfolded and given noise-cancelling headphones). Strength was measured as the maximum isometric force at the MCP joint. 2-sample t-test (p<0.05) were performed to assess significant differences in reflexes, proprioception and strength among patients and controls (SPSS software version 24)., Results: Patients reported higher Nurick (1.90±1.0 vs 0±0, p<0.001) and lower mJOA scores (14.3±1.9 vs 18.0±0, p<0.001) as compared to controls. Similarly, patients with CSM had increased reflexes (peak FDS EMG) (0.073±0.096 vs. 0.014±0.010, p = 0.019). Patient proprioception was significantly worse; mean angle of detection was greater than twice as high in patients (9.6± 9.43°) compared to controls (4.0± 2.3°), p = 0.022. MRI based compression ratio (CR) was a significant predictor of hyperreflexia, CR<0.44 resulted in steep increase in reflex activity. Fifteen of the 20 patients who completed follow up testing at 6 months after surgery show substantial clinical improvement in reflexes and proprioceptive angle, while repeated testing in controls were unchanged., Conclusion: In conclusion, hyperreflexia and decline in proprioception are the main drivers of hand disability in patients with CSM. Of multiple scales, only a select few MRI scales (such as compression ratio) were predictive of increased reflexes. The study describes a pre-clinical testing apparatus to quantitatively and objectively assess primary presenting symptoms in CSM. This pilot apparatus has the potential to evaluate treatment efficacy through repeated testing. Objective testing of hand dysfunction can help inform the design of clinically feasible devices, guide MRI biomarker analysis, and improve our understanding of the progression of neurological injury in this patient population., Competing Interests: The authors have declared that no competing interests exist.

Objective: The economic pressures widely discussed in health care have a large impact on spine practices. This current study is the first to look at characteristics associated with revenues from an outpatient spine clinic., Methods: All clinic visits to spine providers were identified at a single academic institution spanning the dates June 1, 2014, to June 1, 2018. All payment information was calculated using Medicare reimbursement values for Current Procedural Terminology codes. Relevant clinical, surgical, and cost structure data was collected for each patient., Results: On average, providers had 21.9 average appointments over the course of 7.6 hours per clinic day. The average ratio of new to follow-up patients was 39.3%, with an average new patient to surgery conversion rate of 15.0%. The adjusted average total procedural revenue per new patient, controlled for scheduled appointment length and actual appointment length, was $686.02. The adjusted average procedural revenue per surgery was $3444.64 and average procedural revenue per hour in spine clinic was $552.40. With a 1% and 5% increase in new patient visits, total procedural revenue increases 2.7% and 13.5%, respectively. With a 1% and 5% increase in conversion rate, total procedural revenue increases 6.7% and 33.3%, respectively. With a decrease in new patient appointment length from 30 minutes to 25 minutes, the opportunity for 1.7 new patient appointments per day was created resulting in a net increase in procedural revenue per clinic day of $837.57., Conclusions: Incremental changes in practice structure can significantly affect procedural revenue. Significant heterogeneity also exists among spine providers., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Cervical spondylotic myelopathy (CSM) severity and presence of symptoms are often difficult to predict based simply on clinical imaging alone. Similarly, improved machine learning techniques provide new tools with immense clinical potential., Methods: A total of 14 patients with CSM and 14 controls underwent imaging of the cervical spine. Two different artificial neural network models were trained; 1) to predict CSM diagnosis; and 2) to predict CSM severity. Model 1 consisted of 6 inputs including 3 common imaging scales for the evaluation of cord compression, alongside 3 objective magnetic resonance imaging measurements. The outcome for model 1 was binary to predict CSM diagnosis. Model 2 consisted of 23 input variables derived from probabilistic volume mapping measurements of white matter tracts in the region of compression. The outcome of model 2 was linear, to predict the modified Japanese Orthopedic Association (mJOA) score., Results: Model 1 was used in predicting CSM. The mean cross-validated accuracy of the trained model was 86.50% (95% confidence interval, 85.16%-87.83%) with a median accuracy of 90.00%. Area under the curve (AUC) was calculated for each repetition. Average AUC for each repetition was 0.947 with a median AUC of 1.0. Average sensitivity, specificity, positive predictive value, and negative predictive value were 90.25%, 85.05%, 81.58%, and 91.94%, respectively. Model 2 was used in modeling mJOA. The mJOA model predicted scores, with a mean and median error of -0.29 mJOA points and -0.08 mJOA points, respectively, mean error per batch was 0.714 mJOA points., Conclusions: Machine learning provides a promising method for prediction, diagnosis, and even prognosis in patients with CSM., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: CrossFit is an increasingly popular high intensity work out program geared towards high repetition and intensity done in short intervals. Recently, documented cases of rhabdomyolysis (muscle necrosis and extreme muscle breakdown) after CrossFit participation have become increasingly concerning to physicians and participants alike., Design: Retrospective cohort study., Methods: All patients who presented to the main hospital at a major academic center complaining of an injury sustained performing CrossFit between June 2010 and June 2016 were identified by the key phrases 'CrossFit', 'crossfit', 'Crossfit' or 'cross fit'., Results: 523 patients incurred injuries associated with CrossFit activities. 11 patients presented to our institution ultimately received a diagnosis of rhabdomyolysis (2.1%). The average age of Rhabdomyolysis patient was 34.9 years, with 81.9% of patients being male. The average BMI was 24.2, and the average experience level was beginner (54.5%). The most common presenting symptom was dark urine (90.9%), followed by upper extremity pain (54.5%). Average symptom duration was 2.9days with 81.8% of patients presenting initially to the ED. The average hospital stay was roughly 2.9 days, and patients had an average of 1.44 clinical follow up visits., Conclusion: CrossFit participation poses significant risks to participants including exercise induced rhabdomyolysis. Further study is needed in order to raise awareness of this issue and further quantify risk factors that may promote injury during participation., (Copyright © 2019 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.)

OBJECTIVEPatient satisfaction is a new and important metric in the American healthcare system. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a common modality used to assess patient satisfaction in inpatient settings. Despite the existence of data, neurosurgical literature on patient satisfaction following spinal surgery is scarce.METHODSA total of 17,853 patients who underwent spinal procedures at the authors' institution were analyzed retrospectively for HCAHPS survey participation. Appropriate demographic, surgical, comorbidity, and complication data were collected; 1118 patients had patient satisfaction survey data, and further survey metrics were collected for this subset of patients.RESULTSMale patients, patients with urgent/emergency procedures, and patients with a longer length of stay were less likely to complete an HCAHPS survey (OR 0.820, p < 0.001; OR 0.818, p = 0.042; and OR 0.983, p < 0.001, respectively). Posterior approach was negatively associated with HCAHPS survey participation (OR 0.868, p = 0.007). Patients undergoing fusion procedures were more likely to participate in HCAHPS surveys (OR 1.440, p < 0.001). Of the completed HCAHPS surveys, there were no positive predictors associated with perfect scores. High Charlson Comorbidity Index (OR 0.931, p = 0.007), increasing elapsed time since surgery or discharge (OR 0.992, p = 0.004), and increasing length of stay (OR 0.928, p < 0.001) were all negatively associated with a perfect score. Finally, patient sex and race did not influence the likelihood of a perfect or low survey score.CONCLUSIONSParticipation in HCAHPS surveys was correlated with preoperative and postoperative factors. Among these, procedure approach and type, length of stay, and complications seemed to influence participation the most. No factors were associated with an increased likelihood of receiving a perfect score. Similarly, length of stay and time elapsed since surgery to survey completion were significant negative predictors of receiving perfect HCAHPS survey scores. Increasing comorbid burden was also found to be a negative predictor for high scores. Further study on predictors of inpatient satisfaction within spine surgery is needed.

OBJECTIVEPress Ganey surveys are common modalities used to assess patient satisfaction scores in an outpatient setting. Despite the existence of data, neurosurgical and orthopedic literature on patient satisfaction following spinal surgery is scarce.METHODSA total of 17,853 patients who underwent spinal procedures at the authors' institution were analyzed retrospectively for Press Ganey survey participation. Appropriate demographic, surgical, comorbidity, and complication data were collected; 1936 patients had patient satisfaction survey data, and further survey metrics were collected for this subset of patients.RESULTSMale patients, patients with urgent/emergency procedures, and patients with longer length of stay (LOS) were less likely to fill out Press Ganey surveys (OR 0.822, p < 0.001; OR 0.781, p = 0.010; and OR 0.983, p < 0.001, respectively). Posterior approach was negatively associated with Press Ganey participation (OR 0.907, p = 0.055). Patients undergoing fusion procedures were more likely to participate in Press Ganey surveys (OR 1.419, p < 0.001). Of the patients who filled out surveys, there were no positive predictors associated with receiving perfect scores on Press Ganey surveys. High Charlson Comorbidity Index (OR 0.959, p = 0.02), increasing elapsed time since surgery or discharge (OR 0.996, p = 0.03), and increasing LOS (OR 0.965, p = 0.009) were all negatively associated with receiving a perfect score. Patients who underwent a posterior-approach procedure compared with other approaches were less likely to report a low Press Ganey score (OR 0.297, p = 0.046). Patient sex and race did not influence the likelihood of receiving perfect or low Press Ganey scores. Finally, the perceived skill of the surgeon was not a significant predictor for perfect (p > 0.99) or low (p = 0.828) Press Ganey scores.CONCLUSIONSPatient participation in Press Ganey surveys strongly correlated with preoperative factors such as procedure approach and type, as well as postoperative factors such as LOS and complications. No factors were associated with an increased likelihood of receiving a perfect Press Ganey score. Similarly, LOS and time elapsed since surgery to survey completion were significant negative predictors of perfect Press Ganey scores. Skill of surgeon, sex, and race did not correlate with a predictive value for Press Ganey outcomes. In addition, overall comorbid disease burden was found to be a significant negative predictor for high patient satisfaction scores. Further study on predictors of patient satisfaction within spine surgery is needed to better assist physicians in improving the surgical experience for patients.

Study Design: Case-control., Objective: The aim of this study was to understand the role of high-resolution magnetic resonance (MR) in identifying regional cord volume loss in cervical spondylotic myelopathy (CSM)., Summary of Background Data: Preliminary studies suggest that compression of the ventral region of the cord may contribute disproportionately to CSM symptomology; however, tract-specific data are lacking in the CSM population. The current study is the first to use 3T MR imaging (MRI) images of CSM patients to determine specific volume loss at the level of detail of individual descending white matter tracts., Methods: Twelve patients with CSM and 14 age-matched were enrolled prospectively and underwent 3-Tesla MRI of the cervical spine. Using the high-resolution images of the spinal cord, straightening and alignment with a template was performed and specific spinal cord tract volumes were measured using Spinal Cord Tool-box version 3.0.7. Modified Japanese orthopedic association (mJOA) and Nurick disability scores were collected in a prospective manner and were analyzed in relation to descending spinal tract volumes., Results: Having CSM was predicted by anterior/posterior diameter, eccentricity of the cord [odds ratio (OR) 0.000000621, P = 0.004], ventral reticulospinal tract volume (OR 1.167, P = 0.063), lateral corticospinal tract volume (OR 1.034, P = 0.046), rubrospinal tract volume (OR 1.072, P = 0.011), and ventrolateral reticulospinal tract volume (OR 1.474, P = 0.005) on single variable logistic regression. Single variable linear regression showed decreases in anterior/posterior spinal cord diameter (P = 0.022), ventral reticulospinal tract volumes (P = 0.007), and ventrolateral reticulospinal tract volumes (P = 0.017) to significantly predict worsening mJOA scores. Similarly, decreases in ventral reticulospinal tract volumes significantly predicted increasing Nurick scores (P = 0.039)., Conclusion: High-resolution 3T MRI can detect tract-specific volume loss in descending spinal cord tracts in CSM patients. Anterior/posterior spinal cord diameter, ventral reticulospinal tract, ventrolateral reticulospinal tract, lateral corticospinal tract, and rubrospinal tract volume loss are associated with CSM symptoms., Level of Evidence: 2.

In BriefIn a retrospective study the authors examined 1269 patients who underwent spinal surgery and were admitted to the intensive care unit (ICU) and identified factors that are associated with venous thromboembolic events (VTEs) in this "high risk" group. Amongst these high-risk factors were: surgeries longer than 4 hours, comorbid disease, patients needing an osteotomy, and patients undergoing spinal stabilization for fractures. Identification of factors that can be optimized prior to surgery will decrease the rates of VTE.

Introduction: Objective of the study is to define rates of successful completion of components of pediatric vestibular testing (VT)., Methods: Retrospective review of VT performed on patients less than 18 years of age from 2004 to 2015., Results: 188 pediatric patients (mean age: 13.9 ± 3.56 years old, range 2-17 years) underwent testing. Thirty-five (18.6%) had abnormal test results. Pediatric patients unable to complete all aspects of VT could still complete an average of 7.9 ± 4.0 of 12 test components. The optokinetic tracking test was the most commonly omitted component of the vestibular tests. In a multivariate analysis, failure to perform Nylen-Barany positional testing (χ 2 27.5, p < 0.0001) or Dix-Hallpike (5.66, p = 0.0174) testing was associated with inability to obtain final diagnosis on VT., Conclusions: Interpretable VT may be obtained in most children, even in those that do not tolerate the full testing protocol. Spontaneous and gaze-evoked nystagmus testing maybe considered as part of initial testing protocol before attempting less well-tolerated components such as bithermal calorics or components that require VNG goggles., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Six cases of bacterial tracheitis (BT) occurring early in the 2009 flu season have been isolated in conjunction with the H1N1 strain of influenza A (H1N1). No previous H1N1 cases have presented as BT in the literature to date. We would like to discuss viral coinfection in BT patients and how this new strain may affect the rate and type of presentation encountered. The life-threatening potential of BT and the pandemic proportion of H1N1 highlight a possibly dangerous combination that should be recognized by the otolaryngology community. In hospitalized patients with presumed BT, consideration should be given to routine H1N1 testing and the addition of antiviral medication when indicated as this entity is further investigated., (Copyright 2010 American Academy of Otolaryngology-Head and Neck Surgery Foundation. Published by Mosby, Inc. All rights reserved.)

A historical review is presented of a number of aspects of early animal experiments and clinical trials dealing with the i.v. infusion of whole blood and milk; the nutritional use of i.v. erythrocytes, plasma proteins, protein hydrolysates, amino acids, and glucose; and development and use of i.v. fat emulsions. A brief description of the experience with the nutritional use of i.v. ethyl alcohol is also presented. The important studies beginning in the 1960's by Dudrick, Rhoads, Vars, and Wilmore are described elsewhere by them.

Heterotrophic bacteria were enumerated from the Seattle drinking water catchment basins and distribution system. The highest bacterial recoveries were obtained by using a very dilute medium containing 0.01% peptone as the primary carbon source. Other factors favoring high recovery were the use of incubation temperatures close to that of the habitat and an extended incubation (28 days or longer provided the highest counts). Total bacterial counts were determined by using acridine orange staining. With one exception, all acridine orange counts in chlorinated samples were lower than those in prechlorinated reservoir water, indicating that chlorination often reduces the number of acridine orange-detectable bacteria. Source waters had higher diversity index values than did samples examined following chlorination and storage in reservoirs. Shannon index values based upon colony morphology were in excess of 4.0 for prechlorinated source waters, whereas the values for final chlorinated tap waters were lower than 2.9. It is not known whether the reduction in diversity was due solely to chlorination or in part to other factors in the water treatment and distribution system. Based upon the results of this investigation, we provide a list of recommendations for changes in the procedures used for the enumeration of heterotrophic bacteria from drinking waters.

The clinical course of 24 patients with insulin-requiring diabetes mellitus who had received total parenteral nutrition (TPN) was retrospectively analyzed. Routine nutritional assessment disclosed significant depression of anthropometric indices and secretory protein levels in patients with chronic renal failure complicating juvenile onset diabetes mellitus (JODM). Biochemical complications including hypo- or hyperglycemia were significantly more frequent (p less than 0.001) in JODM than in maturity-onset diabetes and found to a lesser degree in patients with renal failure. The catheter infection rate was substantially higher (17%) than usually encountered in TPN therapy. Positive nitrogen balance was achieved in the majority of patients with an average 84% and 92% of estimated protein and caloric requirements being provided. Close monitoring and a protocol of infusion plus supplemental subcutaneous regular insulin was useful in providing adequate TPN safely to these high-risk patients.

The charts of all patients with the acquired immune deficiency syndrome (AIDS) who underwent emergency intra-abdominal surgery between January 1981 and July 1987 were reviewed. Eleven AIDS patients underwent 13 emergency laparotomies. Seven of these patients (64 percent) had cytomegalovirus (CMV) ileocolitis as the pathologic process requiring emergent surgical intervention. Four patients had hemorrhagic CMV proctocolitis and three had perforations of CMV ulcers of the ileum or rectosigmoid. The operations performed included three subtotal colectomies, two segmental resections, and two diverting stomas. The postoperative mortality rate in the CMV group was 28 percent at one day, 71 percent at one month, and 86 percent at six months. Furthermore, CMV ileocolonic pathology was directly responsible for 70 percent of the deaths in AIDS patients who underwent emergent exploratory laparotomy.