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Opioids are commonly prescribed for chronic pain prior to spinal surgery and research has shown an increased rate of post-operative adverse events in these patients.This study compared the incidence of two-year subsequent surgical procedures and post-operative adverse events in patients undergoing lumbar fusion with or without 90-day pre-operative opioid use. We hypothesized that patients using preoperative opioids to have a higher incidence of subsequent surgery and adverse outcomes.A retrospective cohort study was performed using Optum Pan-Therapeutic Electronic Health Records database including adult patients who had their first lumbar fusion between 2015 and 2018. The daily average preoperative opioid dosage 90 days prior to fusion was determined as morphine equivalent dose (MED) and further categorized into high-dose (MED100mg/day) and low-dose (1-100mg/day). Clinical outcomes were compared after adjusting for confounders.A total of 23,275 patients were included, with 2,112 (10%) patients using opioids preoperatively. There was a significantly higher incidence of infection compared to non-users (12.3% versus 10.1%; P=0.01). There was no association between subsequent fusion surgery (7.9% versus 7.5%, P=0.52) and subsequent decompression surgery (4.1% versus 3.6%; P=0.3) between opioid users and non-users. Regarding post-operative infection risk, low-dose users showed significantly higher incidence (12.7% versus 10.1%; P0.01), but high-dose users did not demonstrate higher incidence than nonusers (7.5% versus 10.1%; P=0.23).Consistent with prior publications, opioid use was significantly associated with a higher incidence of two-year post-operative infection compared to non-use. Low-dose opioid users had higher post-operative infection rates than non-users.

Cervical pseudarthrosis is a postoperative adverse event that occurs when a surgically induced fusion fails to establish bone growth connecting the 2 regions. It has both clinical and financial implications and may result in significant patient morbidity; it continues to be one of the leading causes of pain after surgery.A retrospective longitudinal cohort study was performed. Patients in the IBM MarketScan Commercial Claims and Encounters (CCAE) database, 18-64 years old, who underwent elective cervical fusions during 2015-2019 were included. Patients with trauma, infection, or neoplasm were excluded. Patients were followed for 2 years from surgical fusion for occurrence of pseudarthrosis. After pseudarthrosis, subsequent surgery was documented, and cumulative incidence curves, adjusted for patient/procedure characteristics, with 95% confidence intervals (CIs) were generated. Risk factors were evaluated with multivariable Cox regression analysis.The cohort included 45,584 patients. The 1-year and 2-year incidence of pseudarthrosis was 2.0% (95% CI, 1.9%-2.2%) and 3.3% (95% CI, 3.1%-3.5%), respectively. Factors significantly associated with increased risk of pseudarthrosis were female gender, current/previous substance abuse, previous spinal pain in the cervical/thoracic/lumbar spine, and Elixhauser score ≥5. Factors significantly associated with decreased risk of pseudarthrosis were anterior cervical approach, use of an interbody cage, and 2-level or 3-level anterior instrumentation. The 1-year and 2-year incidence of subsequent surgery in patients with pseudarthrosis was 11.7% (95% CI, 9.6%-13.7%) and 13.8% (95% CI, 11.5%-16.2%), respectively.Cervical pseudarthrosis and subsequent surgery still occur at a low rate. Surgical factors such as anterior approach, interbody cage use, and anterior instrumentation may reduce pseudarthrosis risk.

The present study design was that of a single center, retrospective cohort study to evaluate the influence of surgeon-specific factors on patient functional outcomes at 6 months following lumbar fusion. Retrospective review of a prospectively maintained database of patients who underwent neurosurgical lumbar instrumented arthrodesis identified the present study population.This study seeks to evaluate surgeon-specific variable effects on patient-reported outcomes such as Oswestry Disability Index (ODI) and the effect of North American Spine Society (NASS) concordance on outcomes in the setting of variable surgeon characteristics.Lumbar fusion is one of the fastest growing procedures performed in the United States. Although the impact of surgeon-specific factors on patient-reported outcomes has been contested, studies examining these effects are limited.This is a single center, retrospective cohort study analyzing a prospectively maintained database of patients who underwent neurosurgical lumbar instrumented arthrodesis by 1 of 5 neurosurgery fellowship trained spine surgeons. The primary outcome was improvement of ODI at 6 months postoperative follow-up compared with preoperative ODI.A total of 307 patients were identified for analysis. Overall, 62% of the study population achieved minimum clinically important difference (MCID) in ODI score at 6 months. Years in practice and volume of lumbar fusions were statistically significant independent predictors of MCID ODI on multivariable logistic regression (P=0.0340 and P=0.0343, respectively). Concordance with evidence-based criteria conferred a 3.16 (95% CI: 1.03, 9.65) times greater odds of achieving MCID.This study demonstrates that traditional surgeon-specific variables predicting surgical morbidity such as experience and procedural volume are also predictors of achieving MCID 6 months postoperatively from lumbar fusion. Independent of surgeon factors, however, adhering to evidence-based guidelines can lead to improved outcomes.

With this manuscript the authors sought to write a succinct review of the origins, as well as the latest advancements in endoscopic spine surgery to serve as a reference frame for physicians looking to learn this approach.At its infancy, the indications for posterolateral and transforaminal endoscopic decompression remained narrow, which prevented the procedure from gaining rapid traction during those days. However, more recently the tides have turned and an increasing number of surgeons are starting to adopt this technique given all its advantages. With the advent of higher quality camera systems and instruments, indications to use a minimally invasive option have gotten significantly broader. The most basic indication for the use of this technology is a soft disc herniation causing compromise of a neural structure that has failed to be managed successfully with non-surgical therapies. The use of endoscopic techniques provides significant advantages to patient outcomes and patient recovery. Endoscopic procedures should not be used as a blanket approach to nerve root decompression, as they certainly have limitations. Most contraindications to this procedure are relative and serve mostly as points to consider when selecting the methods to address neural compression. As these techniques become more widely accepted, we expect its reach and indications to continue to broaden and diversify. The full integration of navigation technologies will likely leapfrog this procedure into the mainstream use.

Intensive care units (ICUs) lack both standardized performance indicators to better understand the effectiveness of interventions and uniform platforms to present these indicators. The goal of this study was to identify ICU metrics meaningful to stakeholders to help guide the development of a local visualization dashboard. Individual ICU directors were interviewed to collate their input on metrics important to their units. These qualitative data were used to develop a dashboard draft, after which the authors surveyed 20 stakeholders from different hospital departments for feedback on its content and structure. The varied survey results reinforced the inherent difficulties of adapting previously developed measurement tools while also selecting ICU performance measures that are simultaneously widely accepted yet relevant to local practice. These results also call attention to the importance of interdisciplinary input in quality dashboard development, thereby enabling more successful implementation and utilization for ICU quality improvement.

Introduction The American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) 2014 lumbar fusion guidelines for stenosis with degenerative spondylolisthesis (DS) support surgical decompression and fusion as an effective treatment option for symptomatic stenosis associated with DS. The association between the number of levels decompressed in patients with single-level fusion and clinical outcomes has never been published. Methods A retrospective analysis of a single-center, prospectively collected database was performed on 77 patients to compare the effect of the number of decompression levels in patients that received single-level fusion surgery. A total of 77 patients met the criteria. Group one had one level decompressed, group two had two levels decompressed, and group three had three or four levels decompressed. All patients received lumbar fusion surgery at a single spinal level. Outcomes at six months included: Substantial Clinical Benefit (SCB) (ΔODI ≥ 10 points); Minimal Clinically Important Difference (MCID) (ΔODI ≥ 5); no MCID (ΔODI5 points). Student's t-tests, one-way analysis of variance (ANOVA), and post hoc comparison using unpaired two-tailed student's t-test with Holm-Bonferroni correction were performed.

BACKGROUND United States (U.S.) healthcare is a volume-based inefficient delivery system. Value requires the consideration of quality, which is lacking in most healthcare disciplines. OBJECTIVE To assess whether patients who met specific evidence-based medicine (EBM)-based criteria preoperatively for lumbar fusion would achieve higher rates of achieving the minimal clinical important difference (MCID) than those who did not meet the EBM indications. METHODS All elective lumbar fusion cases, March 2018 to August 2019, were prospectively evaluated and categorized based on EBM guidelines for surgical indications. The MCID was defined as a reduction of ≥5 points in Oswestry Disability Index (ODI). Multiple logistic regression identified multivariable-adjusted odds ratio of EBM concordance. RESULTS A total of 325 lumbar fusion patients were entered with 6-mo follow-up data available for 309 patients (95%). The median preoperative ODI score was 24.4 with median 6-mo improvement of 7.0 points (P

Background: Coronavirus disease 2019 (COVID-19) mortality has waned significantly over time; however, factors contributing towards this reduction largely remain unidentified. The purpose of this study was to evaluate the trend in mortality at our large tertiary academic health system and factors contributing to this trend. Methods: This is a retrospective cohort study of intensive care unit (ICU) patients diagnosed with COVID-19 between March and August 2020 admitted across 14 hospitals in the Philadelphia area. Collected data included demographics, comorbidities, admission risk of mortality score, laboratory values, medical interventions, survival outcomes, hospital and ICU length of stay (LOS) and discharge disposition. Chi-square (? 2 ) test, Fisher exact test, Cochran-Mantel-Haenszel method, multinomial logistic regression models, independent sample t -test, Mann-Whitney U test and one-way analysis of variance (ANOVA) were used. Results: A total of 1,204 patients were included. Overall mortality was 39%. Mortality declined significantly from 46% in March to 14% in August 2020 (P < 0.05). The most common underlying comorbidities were hypertension (60.2%), diabetes mellitus (44.7%), dyslipidemia (31.6%) and congestive heart failure (14.7%). Hydroxychloroquine (HCQ) use was more commonly associated with the patients who died, while the use of remdesivir, tocilizumab, steroids and duration of these medications were not significantly different. Peak values of ferritin, lactate dehydrogenase (LDH), C-reactive protein (CRP) and D-dimer levels were significantly higher in patients who died (P < 0.05). The mean hospital LOS was significantly longer in the patients who survived compared to the patients who died (18 vs. 12, P < 0.05). Conclusions: The mortality of patients admitted to our ICU system significantly decreased over time. Factors that may have contributed to this may be the result of a better understanding of COVID-19 pathophysiology and treatments. Further research is needed to elucidate the factors contributing to a reduction in the mortality rate for this patient population. J Clin Med Res. 2021;13(3):184-190 doi: https://doi.org/10.14740/jocmr4452

Herein, the authors present the case of a 54-year-old male diagnosed with coronavirus disease 2019 (COVID-19) during a screening test. The patient was asked to self-isolate at home and report with any exacerbations of symptoms. He presented later with pneumonia complicated by encephalopathy at days 14 and 15 from initial diagnosis, respectively. MRI of the brain showed bithalamic and gangliocapsular FLAIR signal abnormality with mild right-sided thalamic and periventricular diffusion restriction. A CT venogram was obtained given the distribution of edema and demonstrated deep venous thrombosis involving the bilateral internal cerebral veins and the vein of Galen. CSF workup was negative for encephalitis, as the COVID-19 polymerase chain reaction (PCR) test and bacterial cultures were negative. A complete hypercoagulable workup was negative, and the venous thrombosis was attributed to a hypercoagulable state induced by COVID-19. The mental decline was attributed to bithalamic and gangliocapsular venous infarction secondary to deep venous thrombosis. Unfortunately, the patient’s condition continued to decline, and care was withdrawn.

BACKGROUND Decompressive hemicraniectomy (DHC) is well established as an effective life-saving intervention. Although literature documents a correlation between mortality and hemicraniectomy flap size, no literature exists demonstrating whether a larger flap may be achieved with 3-pin fixation devices versus nonfixed positioning (e.g., occipital headrest, gel donut). Therefore, positioning for DHC remains the preference of the institution and attending physician. METHODS Patients undergoing DHC during 2005-2016 were identified using Current Procedural Terminology codes. Inclusion criteria were: operative note available in the electronic medical record and postoperative head computed tomography (hCT). Exclusion criteria were: age

Study Design Retrospective Cohort Study. Objectives To determine the ability of early vital sign abnormalities to predict functional independence in patients with SCI that required surgery. Methods A retrospective analysis of data extracted from the Pennsylvania Trauma Outcome Study database. Inclusion criteria were patients >18 years with a diagnosis of SCI who required urgent spine surgery in Pennsylvania from 1/1/2010-12/31/2020 and had complete records available. Results A total of 644 patients met the inclusion criteria. The mean age was 47.1 ± 14.9 years old and the mean injury severity score (ISS) was 22.3 ± 12.7 with the SCI occurring in the cervical, thoracic, and lumbar spine in 61.8%, 19.6% and 18.0%, respectively. Multivariable logistic regression analyses for predictors of functional independence at discharge showed that higher HR at the scene (OR 1.016, 95% CI 1.006-1.027, P = .002) and lower ISS score (OR .894, 95% CI .870-.920, P < .001) were significant predictors of functional independence. Similarly, higher admission HR (OR 1.015, 95% CI 1.004-1.027, P = .008) and lower ISS score (OR .880, 95% CI 0.864-.914, P < .001) were significant predictors of functional independence. Peak Youden indices showed that patients with HR at scene >70 and admission HR ≥83 were more likely to achieve functional independence. Conclusions Early heart rate is a strong predictor of functional independence in patients with SCI. HR at scene >70 and admission HR ≥83 is associated with improved outcomes, suggesting lack of neurogenic shock.

Patients with a history of surgically treated cervical myelopathy and lumbar pathology requiring fusion present complex challenges, and literature describing patient-reported outcomes in this cohort beyond patients with tandem spinal stenosis is sparse. This has led to unclear guidelines in the literature. We present the first dataset comparing patient-reported outcomes for lumbar fusion in patients with isolated lumbar pathology versus patients with a history of surgically treated cervical myelopathy.In this retrospective cohort study of a prospectively collected lumbar fusion database, variables of interest included demographics, comorbidities, type and levels of fusion, Oswestry Disability Index (ODI), and minimal clinically important difference.Of 325 patients identified, 309 met inclusion criteria. Of these, 29 patients had previous cervical surgery to address cervical myelopathy. Median time between cervical and lumbar surgery was 4.0 years (range, 0.3-19.7). There was no statistical difference in preoperative ODI score (24.8 vs. 25.6, P = 0.687), 6-month postoperative ODI score (17.3 vs. 18.7, P = 0.459), change in ODI score (7.5 vs. 6.9, P = 0.673), or minimal clinically important difference for ODI score (62.1% vs. 58.6%, P = 0.710) in patients who had undergone cervical surgery versus patients who had not.Patients with a history of previously treated cervical myelopathy have a similar rate of clinically relevant improvement after lumbar fusion compared with patients without such history. As such, these patients appear to benefit from lumbar fusion surgery to the same degree as patients without a history of surgically treated cervical myelopathy.

BACKGROUND There is a paucity of information regarding treatment strategies and variables affecting outcomes of revision lumbar fusions. OBJECTIVE To evaluate the influence of primary vs different surgeon on functional outcomes of revisions. METHODS All elective lumbar fusion revisions, March 2018 to August 2019, were retrospectively categorized as performed by the same or different surgeon who performed the primary surgery. Oswestry Disability Index (ODI) and clinical variables were collected. Multiple logistic regression identified multivariable-adjusted odds ratio (OR) of independent variables analyzed. RESULTS Of the 130 cases, 117 (90%) had complete data. There was a slight difference in age in the same (median: 59; interquartile range [IQR], 54-66) and different surgeon (median: 67; IQR, 56-72) groups (P = .02); all other demographic variables were not significantly different (P > .05). Revision surgery with a different surgeon had an ODI improvement (median: 8; IQR, 2-14) greater than revisions performed by the same surgeon (median: 1.5; IQR, -3 to 10) (P

Instrumented fusion procedures are essential in the treatment of degenerative lumbar spine disease to alleviate pain and improve neurological function, but they are being performed with increasing incidence and variability. We implemented a training module for neurosurgery residents that is based on evidence-based criteria for lumbar fusion surgery and measured its effectiveness in residents' decision making regarding whether patients should or should not undergo instrumented fusion.The study design was a pretest versus posttest experiment conducted from September 2019 until July 2020 to measure improvement after formalized instruction on evidence-based guidelines. Neurosurgery residents of all training levels at our institution participated. A test was administered at the beginning of each academic year. The highest possible score was 18 points in each pretest and posttest.There was a general trend of test score improvement across all levels of training with a greater degree of change for participants with lower compared with higher pretest scores, indicating a possible ceiling effect. Paired t test demonstrated an overall mean score increase of 2 points (P0.0001), equivalent to an 11.11% increase (P 0.0001). Stratified by training group, mean absolute change in test score was 2 (P = 0.0217), 1.67 (P = 0.0108), and 2.25 (P = 0.0173) points for junior, midlevel, and senior training groups, respectively.Incorporating a targeted evidence-based learning module for lumbar spine fusion surgery can improve neurosurgery residents' clinical decision making toward a more uniform practice supported by published data.

Intracranial pressure (ICP)-guided therapy has been the mainstay of treatment of patients with severe traumatic brain injury (TBI), but recent data have questioned its efficacy. The aim of this study was to demonstrate trends in compliance to TBI guidelines and use of ICP-guided care in a mature trauma system.A retrospective analysis was conducted of 36,915 patients with severe TBI collected by the Pennsylvania Trauma Systems Foundation. The registry includes all patients18 years old with a diagnosis of TBI with a Glasgow Coma Scale score ≤8 who were admitted from January 2000 to December 2017.Of 36,915 patients, 73.6% were men with a median age of 43.0 ± 21.3 years. An ICP monitor was placed in 16.3% of all patients. The rate of ICP monitoring ranged from 17.8% of patients in 2000-2004 to 16.7% in 2005-2009, 16.4% in 2010-2014, and 12.8% in 2015-2017 (P 0.001). The most statistically significant decrease was noted from 2014 (16.4%) to 2015 (14.1%, P = 0.042). The percent decrease in ICP monitoring from 2000-2014 to 2015-2017 was equivalent for patients with Glasgow Coma Scale scores of 3-5 (-4.0%) and 6-8 (-4.5%).As studies emerged that demonstrated unclear benefit of ICP monitoring in improving care in patients with severe TBI, there was a significant statewide decline in the use of ICP monitoring after 2014 among all TBI subpopulations despite noteworthy limitations in the aforementioned studies and clear recommendations from the Brain Trauma Foundation guidelines.

Background Minimally invasive surgery procedures, including stereotactic catheter aspiration and clearance of intracerebral hemorrhage (ICH) with recombinant tissue plasminogen activator hold a promise to improve outcome of supratentorial brain hemorrhage, a morbid and disabling type of stroke. A recently completed Phase III randomized trial showed improved mortality but was neutral on the primary outcome (modified Rankin scale score 0 to 3 at 1 yr). Objective To assess surgical performance and its impact on the extent of ICH evacuation and functional outcomes. Methods Univariate and multivariate models were used to assess the extent of hematoma evacuation efficacy in relation to mRS 0 to 3 outcome and postulated factors related to patient, disease, and protocol adherence in the surgical arm (n = 242) of the MISTIE trial. Results Greater ICH reduction has a higher likelihood of achieving mRS of 0 to 3 with a minimum evacuation threshold of ≤15 mL end of treatment ICH volume or ≥70% volume reduction when controlling for disease severity factors. Mortality benefit was achieved at ≤30 mL end of treatment ICH volume, or >53% volume reduction. Initial hematoma volume, history of hypertension, irregular-shaped hematoma, number of alteplase doses given, surgical protocol deviations, and catheter manipulation problems were significant factors in failing to achieve ≤15 mL goal evacuation. Greater surgeon/site experiences were associated with avoiding poor hematoma evacuation. Conclusion This is the first surgical trial reporting thresholds for reduction of ICH volume correlating with improved mortality and functional outcomes. To realize the benefit of surgery, protocol objectives, surgeon education, technical enhancements, and case selection should be focused on this goal.

Background Idiopathic spinal cord herniation (ISCH) is a rare pathology characterized by extravasation of the spinal cord through a dural defect. The optimal algorithm for choosing operative or nonoperative management is not well elucidated, partially because of the rarity of this pathology. We present the largest single-center series of ISCH and compare operative treatment to conservative management. Methods A retrospective case series of all patients evaluated for treatment of ISCH at our institution between 2010 and 2019 was conducted. Demographic variables, presenting symptoms, and imaging characteristics were assessed for all patients. For patients who underwent operative treatment, surgical approach, postoperative course, and discharge outcomes were recorded. Follow-up notes were reviewed for status of symptoms and functional capabilities, which were synthesized into Odom’s criteria score. Results Sixteen patients met the inclusion criteria for this study, 8 of whom underwent operative treatment. No significant differences were found between operative and nonoperative groups with regard to demographic variables or pathology characteristics. Odom’s criteria scores for the operative cohort were 12.5% (1 of 8) Excellent, 62.5% (5 of 8) Good, 12.5% (1 of 8) Fair, and 12.5% (1 of 8) Poor. Odom’s criteria scores for the nonoperative cohort were 16.7% (1 of 6) Excellent, 33.3% (2 of 6) Good, 16.7% (1 of 6) Fair, and 33.3% (2 of 6) Poor. There was no significant difference between Odom’s criteria score distribution between the operative and nonoperative groups at latest follow up (P = 0.715). Conclusions Conservative management of spinal cord herniation is an option that does not preclude symptomatic improvement in patients with idiopathic spinal cord herniation.

INTRODUCTION: Cervical spontaneous epidural hematoma is a serious neurosurgical pathology that often requires prompt surgical intervention. While a variety of causes may contribute, the authors present the first case in the literature of cervical disc extrusion provoking epidural hemorrhage and acute neurological deterioration. CASE PRESENTATION: A 65 year old male presented with six months of worsening signs and symptoms of cervical myelopathy. He had progressive deterioration over the course of two weeks leading to ambulatory dysfunction requiring a cane for assistance. While undergoing his medical workup in the emergency department, the patient became acutely plegic in the right lower extremity prompting emergent surgical decompression and stabilization. DISCUSSION: Based on imaging, pathology, and intraoperative findings, it was concluded that the patient had an extruded disc segment that may have precipitated venous bleeding in the epidural space and findings of acute cervical cord compression. Cervical disc extrusion may lead to venous damage, epidural hematoma, and spinal cord compression. If this unique presentation is recognized and addressed in a timely manner, patient outcomes may still be largely positive as this case demonstrates.

Errors in communication are a major source of preventable medical errors. Neurosurgical patients frequently present to the neuro-intensive care unit (NICU) postoperatively, where handoffs occur to coordinate care within a large multidisciplinary team. A multidisciplinary working group at our institution started an initiative to improve postoperative neurosurgical handoffs using validated quality improvement methodology. Baseline handoff practices were evaluated through staff surveys and serial observations. A formalized handoff protocol was implemented using the evidence based IPASS format (Illness severity, Patient summary, Action list, Situational awareness and contingency planning, Synthesis by receiver). Cycles of objective observations and surveys were employed to track practice improvements and guide iterative process changes over one year. Surveys demonstrated improved perceptions of handoffs as organized (17.1% vs 69.7%, p 0.001), efficient (27.0% vs. 72.7%, p 0.001), comprehensive (17.1% vs. 66.7%, p 0.001), and safe (18.0% vs. 66.7%, p 0.001), noting improved teamwork (31.5% vs. 69.7%, p 0.001). Direct observations demonstrated improved communication of airway concerns (47.1% observed vs. 92.3% observed, p 0.001), hemodynamic concerns (70.6% vs. 97.1%, p = 0.001), intraoperative events (52.9% vs. 100%, p 0.001), neurological examination (76.5% vs. 100%, p 0.001), vital sign goals (70.6% vs. 100%, p 0.001), and required postoperative studies (76.5% vs. 100%, p 0.001). Receiving teams demonstrating improved rates of summarization (47.1% vs. 94.2%, p = 0.005) and asking questions (76.5% vs 98.1%, p = 0.004). The mean handoff time during long-term follow-up was 4.4 min (95% confidence interval = 3.9-5.0 min). Standardization of handoff practices yields improvements in communication practices for postoperative neurosurgical patients.

Study Design: Retrospective observational case series. Objective: To assess the outcome of patients with diffuse idiopathic skeletal hyperostosis (DISH) with dysphagia who underwent cricopharyngeal myotomy (CPM) in conjunction with anterior osteophytectomy (OP). Methods: This is a retrospective observational study of 9 patients that received combined intervention by neurosurgeons and otolaryngologists. Inclusion criteria for surgery consisted of patients who failed to respond to conservative treatments for dysphagia and had evidence of both upper esophageal dysfunction and osteophyte compression. We present the largest series in literature to date including patients undergoing combined OP and CPM. Results: A total of 88.9% (8/9) of the patients who underwent OP and CPM showed improvement in their symptoms. Of the aforementioned group, 22.2% of these patients had complete resolution of their symptoms, 11.1% did not improve, and only 2 patients showed recurrence of their symptoms. None of the patients in whom surgery was performed required reoperation or suffered serious complication related to the surgical procedures. Conclusion: Based on the literature results, high rate of improvements in dysphagia, and low rate of complications, combined OP and CPM procedures may be beneficial to a carefully selected group of patients.

IMPORTANCE: Pneumonia due to COVID-19 can lead to respiratory failure and death due to the development of the acute respiratory distress syndrome. Tocilizumab, a monoclonal antibody targeting the interleukin-6 receptor, is being administered off-label to some patients with COVID-19, and although early small studies suggested a benefit, there are no conclusive data proving its usefulness. OBJECTIVE: To evaluate outcomes in hospitalized patients with COVID-19 with or without treatment with Tocilizumab. DESIGN, SETTING, PARTICIPANTS: Retrospective study of 1938 patients with confirmed COVID-19 pneumonia admitted to hospitals within the Jefferson Health system in Philadelphia, Pennsylvania, between March 25, 2020 and June 17, 2020, of which 307 received Tocilizumab. EXPOSURES: Confirmed COVID-19 pneumonia. MAIN OUTCOMES AND MEASURES: Outcomes data related to length of stay, admission to intensive care unit (ICU), requirement of mechanical ventilation, and mortality were collected and analyzed. RESULTS: The average age was 65.2, with 47% women; 36.4% were African-American. The average length of stay was 22 days with 26.3% of patients requiring admission to the ICU and 14.9% requiring mechanical ventilation. The overall mortality was 15.3%. Older age, admission to an ICU, and requirement for mechanical ventilation were associated with higher mortality. Treatment with Tocilizumab was also associated with higher mortality, which was mainly observed in subjects not requiring care in an ICU with estimated odds ratio (OR) of 2.9 (p = 0.0004). Tocilizumab treatment was also associated with higher likelihood of admission to an ICU (OR = 4.8, p

OBJECTIVE The authors compared primary lumbar spine fusions with revision fusions by using patient Oswestry Disability Index (ODI) scores to evaluate the impact of the North American Spine Society (NASS) evidence-based medicine (EBM) lumbar fusion indications on patient-reported outcome measures of revision surgeries. METHODS This study was a retrospective analysis of a prospective observational cohort of patients who underwent elective lumbar fusion between January 2018 and December 2019 at a single quaternary spine surgery service and had a minimum of 6 months of follow-up. A prospective quality improvement database was constructed that included the data from all elective lumbar spine surgeries, which were categorized prospectively as primary or revision surgeries and EBM-concordant or EBM-discordant revision surgeries based on the NASS coverage EBM policy. In total, 309 patients who met the inclusion criteria were included in the study. The ODIs of all groups (primary, revision, revision EBM concordant, and revision EBM discordant) were statistically compared. Differences in frequencies between cohorts were evaluated using chi-square and Fisher’s exact tests. The unpaired 2-tailed Student t-test and the Mann-Whitney U-test for nonparametric data were used to compare continuous variables. Logistic regression was performed to determine the associations between independent variables (surgery status and NASS criteria indications) and functional outcomes. RESULTS Primary lumbar fusions were significantly associated with improved functional outcomes compared with revisions, as evidenced by ODI scores (OR 1.85, 95% CI 1.16–2.95 to achieve a minimal clinically important difference, p = 0.01). The percentage of patients whose functional status had declined at the 6-month postoperative evaluation was significantly higher in patients who had undergone a revision surgery than in those who underwent a primary surgery (23% vs 12.3%, respectively). An increase in ODI score, indicating worse clinical outcome after surgery, was greater in patients who underwent revision procedures (OR 2.14, 95% CI 1.17–3.91, p = 0.0014). Patients who underwent EBM-concordant revision surgery had significantly improved mean ODI scores compared with those who underwent EBM-discordant revision surgery (7.02 ± 5.57 vs −4.6 ± 6.54, p < 0.01). CONCLUSIONS The results of this prospective quality improvement program investigation illustrate that outcomes of primary lumbar fusions were superior to outcomes of revisions. However, revision procedures that met EBM guidelines were associated with greater improvements in ODI scores, which indicates that the use of defined EBM guideline criteria for reoperation can improve clinical outcomes of revision lumbar fusions.

Background: Euvolemic hyponatremia is prevalent in patients with aneurysmal subarachnoid hemorrhages (aSAH) and is associated with poor outcome, gait imbalance, cognitive impairment, and prolonged length of stay. We sought to determine the effect of 3% hypertonic saline (HTS3%) on sodium (Na) trends in an interim analysis of the HS3 clinical trial. Methods: The “Safety and Feasibility of HTS3% after aSAH Hemorrhage (HS3)” Clinical Trial (ClinicalTrials.gov NCT02432157) is a randomized, safety and efficacy, single center, single blinded clinical trial designed to evaluate if a protocol of volume expansion with HTS3% is safe and effective in patients with aSAH for the prevention of hyponatremia. Within 72 hours of index hemorrhage, aSAH patients were randomized to receive prophylactic intravenous HTS3% bolus injections at a dose of 250ml via central line every 6 hours for 7 days vs. routine fluid management with isotonic fluids as pre-specified by our local management protocol, which is based on multi-professional guidelines for the management of aSAH. We followed serum Na levels from day of admission (D0) to hospital day 10 (D10) and compared them using the Mann-U-Whitney test for non-parametric data. Results: In total, 22 patients participated in the study. Half of the patients (11) were randomized to the treatment group and 11 were part of the control arm. Mean age was 53±12years, 68.2% (n=15) were female, 54.5% (n=12) were white, and median (Md) Hunt and Hess was 3 (IQR=1), Md-modified-Fisher was 3 (IQR=1). Mean GCS on admission was 10 (SD 4) and mean ICP was 13 (SD 5). There was no significant difference in the demographics between the groups. Md-Na levels from D0-D10 did not differ between the groups and hyponatremia did not occur in either group. Conclusion: Data from an interim analysis of HS3 clinical trial indicate that both fluid strategies were associated with similar profile in Na balance and no incidence of hyponatremia. Further data is needed to investigate association between HTS3% and mortality, clinical outcome, delayed cerebral ischemia and vasospasms.

Severe traumatic brain injury (TBI) remains a major cause of morbidity and mortality with mortality rates reaching 35%. Intracranial pressure (ICP) monitoring is used to prevent secondary brain injury and death. However, while the association of elevated ICP and worsened outcomes is accepted, routine ICP monitoring has been questioned after the publication of several studies including the Benchmark Evidence from South American Trials: Treatment of Intracranial Pressure trial. We examined whether severe TBI patients in the trauma system of Pennsylvania fared better with or without ICP monitoring.We conducted a statewide retrospective analysis and included all TBI patients18 years with an admission Glasgow Coma Scale (GCS)9 from January 2000 through December 2017. The primary outcome was mortality. Secondary outcomes examined were intensive care unit length of stay (LOS) and discharge functional independence measure (FIM).A total of 36,929 patients matched our inclusion criteria and were included in the analysis. Of those, 6025 (16.3%) had ICP monitor placement. Mean ICU LOS was significantly higher in ICP-monitored patients (13.1 ± 11.6 days vs. 6.0 ± 10.8 days, P0.0001). Increasing age was a significant predictor of death (P0.0001). Mean FIM scores at discharge were significantly higher in patients without an ICP monitor (16.21 ± 4.91 vs. 9.53 ± 5.07, P0.0001). When controlling for injury severity score, GCS, age, and craniotomy, ICP monitoring conferred a hazard ratio of 0.85 (χWe found that ICP-monitored patients had a lower risk of in-hospital mortality. Our findings support the use of ICP monitors in eligible patients.

The utilization of robotics has been gaining increased popularity in spine surgery. It can be used to assist in pedicle screw insertion when anatomy is complex in deformity surgery, but is also helpful in degenerative spine as it can minimize tissue dissection and fluoroscopy use.1-6 We present an operative video that demonstrates the use of a robotic system (Globus Excelsius GPS, Audubon, Pennsylvania) for thoracic instrumentation in an unstable fracture. The patient we present is a 64-yr-old male who sustained a T8-9 distraction extension fracture after falling down a flight of stairs. His computed tomography (CT) scan showed ossification of the anterior longitudinal ligament making ankylosing spondylitis the likely underlying condition.7,8 His magnetic resonance imaging showed an epidural hematoma extending from T7 to T11. Due to the unstable nature of this fracture and the presence of the hematoma, informed consent was obtained and the patient underwent thoracic pedicle screw fixation from T7 to T11 and laminectomy for hematoma evacuation. A preoperative CT was done for screw trajectory planning. Paraspinal muscle dissection was limited to the hematoma level to allow for laminectomy and evacuation. After registration of the patient to the robotic system using C-arm fluoroscopy, pilot burr holes are drilled using a rigid robotic arm and with optical tracking in real time. This reduces the degrees of freedom and allows for higher precision of screw placement. To the authors' knowledge, this video is the first one to show the utilization of robotics for thoracic instrumentation in an acute fracture.

Elevated intracranial pressure (ICP) may be a sequelae of head trauma, as well as cerebral infarcts and spontaneous intracranial hemorrhages. It is a commonly seen conundrum in neurosurgical practice. Management of elevated ICP is guided by etiology, patient factors, and guidelines for medical and operative treatment. The Brain Trauma Foundation guidelines recommend ICP monitoring in patients with a Glasgow Coma Scale score of less than 8 and an abnormal head CT, or in patients with a normal head CT who meet other inclusion criteria. Once ICP monitoring is begun, multiple strategies for maintaining a goal below 20 are recognized and may be added in a stepwise fashion and continued concurrently. Failure of medical therapy to control ICP may require operative intervention. At the time of initial consultation and throughout medical management of ICP, frank discussions with patient families is essential to accurately communicate prognosis and set expectations for clinical outcomes.

Occipital condyle fractures are a rare entity most commonly associated with traumatic injuries. Head CT is the most sensitive method for detecting such fractures, and follow-up MRI to identify ligamentous injury is necessary to determine if the fracture is unstable or if there is compression of neural elements. Surgical intervention with either a Halo device or internal fixation is only necessary in the setting of unstable fractures or when there is evidence of bilateral fractures or avulsed fragments causing neural compression. Most patients recover with little to no lasting symptoms, though it is important to watch for a delayed presentation of lower cranial nerve deficits.

Acute stroke due to supratentorial intracerebral haemorrhage is associated with high morbidity and mortality. Open craniotomy haematoma evacuation has not been found to have any benefit in large randomised trials. We assessed whether minimally invasive catheter evacuation followed by thrombolysis (MISTIE), with the aim of decreasing clot size to 15 mL or less, would improve functional outcome in patients with intracerebral haemorrhage. MISTIE III was an open-label, blinded endpoint, phase 3 trial done at 78 hospitals in the USA, Canada, Europe, Australia, and Asia. We enrolled patients aged 18 years or older with spontaneous, non-traumatic, supratentorial intracerebral haemorrhage of 30 mL or more. We used a computer-generated number sequence with a block size of four or six to centrally randomise patients to image-guided MISTIE treatment (1·0 mg alteplase every 8 h for up to nine doses) or standard medical care. Primary outcome was good functional outcome, defined as the proportion of patients who achieved a modified Rankin Scale (mRS) score of 0-3 at 365 days, adjusted for group differences in prespecified baseline covariates (stability intracerebral haemorrhage size, age, Glasgow Coma Scale, stability intraventricular haemorrhage size, and clot location). Analysis of the primary efficacy outcome was done in the modified intention-to-treat (mITT) population, which included all eligible, randomly assigned patients who were exposed to treatment. All randomly assigned patients were included in the safety analysis. This study is registered with ClinicalTrials.gov, number NCT01827046. Between Dec 30, 2013, and Aug 15, 2017, 506 patients were randomly allocated: 255 (50%) to the MISTIE group and 251 (50%) to standard medical care. 499 patients (n=250 in the MISTIE group; n=249 in the standard medical care group) received treatment and were included in the mITT analysis set. The mITT primary adjusted efficacy analysis estimated that 45% of patients in the MISTIE group and 41% patients in the standard medical care group had achieved an mRS score of 0-3 at 365 days (adjusted risk difference 4% [95% CI -4 to 12]; p=0·33). Sensitivity analyses of 365-day mRS using generalised ordered logistic regression models adjusted for baseline variables showed that the estimated odds ratios comparing MISTIE with standard medical care for mRS scores higher than 5 versus 5 or less, higher than 4 versus 4 or less, higher than 3 versus 3 or less, and higher than 2 versus 2 or less were 0·60 (p=0·03), 0·84 (p=0·42), 0·87 (p=0·49), and 0·82 (p=0·44), respectively. At 7 days, two (1%) of 255 patients in the MISTIE group and ten (4%) of 251 patients in the standard medical care group had died (p=0·02) and at 30 days, 24 (9%) patients in the MISTIE group and 37 (15%) patients in the standard medical care group had died (p=0·07). The number of patients with symptomatic bleeding and brain bacterial infections was similar between the MISTIE and standard medical care groups (six [2%] of 255 patients vs three [1%] of 251 patients; p=0·33 for symptomatic bleeding; two [1%] of 255 patients vs 0 [0%] of 251 patients; p=0·16 for brain bacterial infections). At 30 days, 76 (30%) of 255 patients in the MISTIE group and 84 (33%) of 251 patients in the standard medical care group had one or more serious adverse event, and the difference in number of serious adverse events between the groups was statistically significant (p=0·012). For moderate to large intracerebral haemorrhage, MISTIE did not improve the proportion of patients who achieved a good response 365 days after intracerebral haemorrhage. The procedure was safely adopted by our sample of surgeons. National Institute of Neurological Disorders and Stroke and Genentech. [Abstract copyright: Copyright © 2019 Elsevier Ltd. All rights reserved.]

Study Design: Systematic analysis and review. Objective: Evaluation of the presentation, etiology, management strategies (including both surgical and nonsurgical options), and neurological functional outcomes in patients with cervical spinal epidural abscess (SEA). Methods: The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria were used to create a framework based on which articles pertaining to cervical SEA were chosen for review following a search of the Ovid and PubMed databases using the search terms “epidural abscess” and “cervical.” Included studies needed to have at least 4 patients aged 18 years or older, and to have been published within the past 20 years. Results: Database searches yielded 521 potential articles in PubMed and 974 potential articles in Ovid. After review, 11 studies were ultimately identified for inclusion in this systematic review. Surgery appears to be a well-tolerated management strategy with limited complications for patients with cervical SEA. However, the quantity of data comparing medical and surgical treatment of cervical SEA is limited and the bulk of the data is derived from low quality studies. Conclusion: Data reporting was heterogeneous among studies making it difficult to draw discrete conclusions. Early surgical intervention may be appropriate in selected patients with cervical epidural abscess, but it is not clear what distinguishes these patients from those who are successfully managed nonoperatively.

BACKGROUND Traumatic brain injury (TBI) carries a devastatingly high rate of morbidity and mortality. OBJECTIVE To assess whether patients undergoing craniotomy/craniectomy for severe TBI fare better at level I than level II trauma centers in a mature trauma system. METHODS The data were extracted from the Pennsylvania Trauma Outcome Study database. Inclusion criteria were patients > 18 yr with severe TBI (Glasgow Coma Scale [GCS] score less than 9) undergoing craniotomy or craniectomy in the state of Pennsylvania from January 1, 2002 through September 30, 2017. RESULTS Of 3980 patients, 2568 (64.5%) were treated at level I trauma centers and 1412 (35.5%) at level II centers. Baseline characteristics were similar between the 2 groups except for significantly worse GCS scores at admission in level I centers (P = .002). The rate of in-hospital mortality was 37.6% in level I centers vs 40.4% in level II centers (P = .08). Mean Functional Independence Measure (FIM) scores at discharge were significantly higher in level I (10.9 ± 5.5) than level II centers (9.8 ± 5.3; P