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OBJECTIVE High cervical spinal cord injury (SCI) results in complete loss of upper-limb function, resulting in debilitating tetraplegia and permanent disability. Spontaneous motor recovery occurs to varying degrees in some patients, particularly in the 1st year postinjury. However, the impact of this upper-limb motor recovery on long-term functional outcomes remains unknown. The objective of this study was to characterize the impact of upper-limb motor recovery on the degree of long-term functional outcomes in order to inform priorities for research interventions that restore upper-limb function in patients with high cervical SCI. METHODS A prospective cohort of high cervical SCI (C1–4) patients with American Spinal Injury Association Impairment Scale (AIS) grade A–D injury and enrolled in the Spinal Cord Injury Model Systems Database was included. Baseline neurological examinations and functional independence measures (FIMs) in feeding, bladder management, and transfers (bed/wheelchair/chair) were evaluated. Independence was defined as score ≥ 4 in each of the FIM domains at 1-year follow-up. At 1-year follow-up, functional independence was compared among patients who gained recovery (motor grade ≥ 3) in elbow flexors (C5), wrist extensors (C6), elbow extensors (C7), and finger flexors (C8). Multivariable logistic regression evaluated the impact of motor recovery on functional independence in feeding, bladder management, and transfers. RESULTS Between 1992 and 2016, 405 high cervical SCI patients were included. At baseline, 97% of patients had impaired upper-limb function with total dependence in eating, bladder management, and transfers. At 1 year of follow-up, the largest proportion of patients who gained independence in eating, bladder management, and transfers had recovery in finger flexion (C8) and wrist extension (C6). Elbow flexion (C5) recovery had the lowest translation to functional independence. Patients who achieved elbow extension (C7) were able to transfer independently. On multivariable analysis, patients who gained elbow extension (C7) and finger flexion (C8) were 11 times more likely to gain functional independence (OR 11, 95% CI 2.8–47, p < 0.001) and patients who gained wrist extension (C6) were 7 times more likely to gain functional independence (OR 7.1, 95% CI 1.2–56, p = 0.04). Older age (≥ 60 years) and motor complete SCI (AIS grade A–B) reduced the likelihood of gaining independence. CONCLUSIONS After high cervical SCI, patients who gained elbow extension (C7) and finger flexion (C8) had significantly greater independence in feeding, bladder management, and transfers than those with recovery in elbow flexion (C5) and wrist extension (C6). Recovery of elbow extension (C7) also increased the capability for independent transfers. This information can be used to set patient expectations and prioritize interventions that restore these upper-limb functions in patients with high cervical SCI.

Despite an increased understanding of the impact of socioeconomic status on neurosurgical outcomes, the impact of neighborhood-level social determinants on lumbar spine surgery patient-reported outcomes remains unknown.To evaluate the impact of geographic social deprivation on physical and mental health of lumbar surgery patients.A single-center retrospective cohort study analyzing patients undergoing lumbar surgery for degenerative disease from 2015 to 2018 was performed. Surgeries were categorized as decompression only or decompression with fusion. The area deprivation index was used to define social deprivation. Study outcomes included preoperative and change in Patient-Reported Outcomes Measurement (PROMIS) physical function (PF), pain interference (PI), depression, and anxiety (mean follow-up: 43.3 weeks). Multivariable imputation was performed for missing data. One-way analysis of variance and multivariable linear regression were used to evaluate the association between area deprivation index and PROMIS scores.In our cohort of 2010 patients, those with the greatest social deprivation had significantly worse mean preoperative PROMIS scores compared with the least-deprived cohort (mean difference [95% CI]-PF: -2.5 [-3.7 to -1.4]; PI: 3.0 [2.0-4.1]; depression: 5.5 [3.4-7.5]; anxiety: 6.0 [3.8-8.2], all P.001), without significant differences in change in these domains at latest follow-up (PF: +0.5 [-1.2 to 2.2]; PI: -0.2 [-1.7 to 2.1]; depression: -2 [-4.0 to 0.1]; anxiety: -2.6 [-4.9 to 0.4], all P.05).Lumbar spine surgery patients with greater social deprivation present with worse preoperative physical and mental health but experience comparable benefit from surgery than patients with less deprivation, emphasizing the need to further understand social and health factors that may affect both disease severity and access to care.

Study design This was a retrospective clinical series. Objective The objective of this study was to evaluate radiologic changes in central spinal canal dimensions following minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) with placement of a static or an expandable interbody device. Summary of background data MIS-TLIF is used to treat lumbar degenerative diseases and low-grade spondylolisthesis. MIS-TLIF enables direct and indirect decompression of lumbar spinal stenosis, with patients experiencing relief from radiculopathy and neurogenic claudication. However, the effects of MIS-TLIF on the central spinal canal are not well-characterized. Materials and methods We identified patients who underwent MIS-TLIF for degenerative lumbar spondylolisthesis and concurrent moderate to severe spinal stenosis. We selected patients who had both preoperative and postoperative magnetic resonance imaging (MRI) and upright lateral radiographs of the lumbar spine. Measurements on axial T2-weighted MRI scans include anteroposterior and transverse dimensions of the dural sac and osseous spinal canal. Measurements on radiographs include disk height, neural foraminal height, segmental lordosis, and spondylolisthesis. We made pairwise comparisons between each of the central canal dimensions and lumbar sagittal segmental radiologic outcome measures relative to their corresponding preoperative values. Correlation coefficients were used to quantify the association between changes in lumbar sagittal segmental parameters relative to changes in radiologic outcomes of central canal dimensions. Statistical analysis was performed for "all patients" and further stratified by interbody device subgroups (static and expandable). Results Fifty-one patients (age 60.4 y, 68.6% female) who underwent MIS-TLIF at 55 levels (65.5% at L4-L5) were included in the analysis. Expandable interbody devices were used in 45/55 (81.8%) levels. Mean duration from surgery to postoperative MRI scan was 16.5 months (SD 11.9). MIS-TLIF was associated with significant improvements in dural sac dimensions (anteroposterior +0.31 cm, transverse +0.38 cm) and osseous spinal canal dimensions (anteroposterior +0.16 cm, transverse +0.32 cm). Sagittal lumbar segmental parameters of disk height (+0.56 cm), neural foraminal height (+0.35 cm), segmental lordosis (+4.26 degrees), and spondylolisthesis (-7.5%) were also improved following MIS-TLIF. We did not find meaningful associations between the changes in central canal dimensions relative to the corresponding changes in any of the sagittal lumbar segmental parameters. Stratified analysis by interbody device type (static and expandable) revealed similar within-group changes as in the overall cohort and minimal between-group differences. Conclusions MIS-TLIF is associated with radiologic decompression of neural foraminal and central spinal canal stenosis. The mechanism for neural foraminal and central canal decompression is likely driven by a combination of direct and indirect corrective techniques.

BACKGROUND Advances in operative techniques and instrumentation technology have evolved to maximize patient outcomes following minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). The transfacet MIS-TLIF is a modified approach to the standard MIS-TLIF that leverages a bony working corridor to access the disc space for discectomy and interbody device placement. OBJECTIVE To evaluate clinical and radiographic results following transfacet MIS-TLIF using an expandable interbody device. METHODS We performed a retrospective review of consecutive patients who underwent transfacet MIS-TLIF for degenerative lumbar spondylolisthesis. Patient-reported outcome measures for pain and disability were assessed. Sagittal lumbar segmental parameters and regional lumbopelvic parameters were assessed on upright lateral radiographs obtained preoperatively and during follow-up. RESULTS A total of 68 patients (61.8% male) underwent transfacet MIS-TLIF at 74 levels. The mean age was 63.4 yr and the mean follow-up 15.2 mo. Patients experienced significant short- and long-term postoperative improvements on the numeric rating scale for low back pain (-2.3/10) and Oswestry Disability Index (-12.0/50). Transfacet MIS-TLIF was associated with an immediate and sustained reduction of spondylolisthesis, and an increase in index-level disc height (+0.71 cm), foraminal height (+0.28 cm), and segmental lordosis (+6.83°). Patients with preoperative hypolordosis (

Awake spine surgery is growing in popularity, and may facilitate earlier postoperative recovery, reduced cost, and fewer complications than spine surgery conducted under general anesthesia (GA). However, trends in the adoption of awake (ie, non-GA) spine surgery have not been previously studied.To investigate temporal trends in non-GA spine surgery utilization and outcomes in the United States.A retrospective observational study.Patients undergoing cervical or lumbar decompression or/and fusion from the American College of Surgeons National Surgical Quality Improvement Program database records dated 2005-2019.The primary outcome was the adoption trends of awake cervical and lumbar spine operations from 2005 to 2019. The secondary outcomes included the outcomes trends of 30-day complications, readmission rates, and length of stay in cervical and lumbar spine operations from 2005 to 2019.Patients were stratified into two groups: GA and non-GA (regional, epidural, spinal, monitored anesthesia care/intravenous sedation). Pearson chi-square or Fisher exact test and independent-sample t test were used to compare demographics between groups. Jonckheere-Terpstra test was used to determine whether trends and outcomes of non-GA operations from 2005 to 2019 were statistically significant. No non-GA spine operations were reported in the database from 2005 to 2006.We included 301,521 patients who underwent cervical or lumbar spine operations from 2005 to 2019. GA was used in 294,903 (97.8%) operations; 6,618 (2.2%) operations were non-GA. Patients in the non-GA cohort were more likely to be younger (50.1 vs 57.2 years; p.001), less likely to have American Society of Anesthesiologists classification ≥3 (39.7% vs 48.3%; p.001), and to have lower BMI (27.8 vs 31.5 kg/mOur trends analysis revealed increasing utilization and improved outcomes of non-GA spine surgery from 2005 to 2019; however, the proportion of non-GA spine operations remains small. Future research should investigate the barriers to adoption of non-GA spine surgery.

BACKGROUND Intracranial deposits of fat droplets are an unusual presentation of a spinal dermoid cyst after spontaneous rupture and are even more uncommon after trauma. Here, the authors present a case with this rare clinical presentation, along with a systematic review of the literature to guide decision making in these patients. OBSERVATIONS A 54-year-old woman with Lynch syndrome presented with severe headache and sacrococcygeal pain after a traumatic fall. Computed tomography of the head revealed multifocal intraventricular and intracisternal fat deposits, which were confirmed by magnetic resonance imaging (MRI) of the neuroaxis; in addition, a ruptured multiloculated cyst was identified within the sacral canal with proteinaceous/hemorrhagic debris, most consistent with a sacral dermoid cyst with rupture into the cerebrospinal fluid (CSF) space. An unruptured sacral cyst was later noted on numerous previous MRI scans. In our systematic review, we identified 20 similar cases, most of which favored surgical treatment. LESSONS Rupture of an intraspinal dermoid cyst must be considered when intracranial fat deposits are found in the context of cauda equina syndrome, meningism, or hydrocephalus. Complete tumor removal with close postoperative follow-up is recommended to decrease the risk of complications. CSF diversion must be prioritized if life-threatening hydrocephalus is present.

OBJECTIVE Local and regional radiographic outcomes following minimally invasive (MI) transforaminal lumbar interbody fusion (TLIF) versus open TLIF remain unclear. The purpose of this study was to provide a comprehensive assessment of local and regional radiographic parameters following MI-TLIF and open TLIF. The authors hypothesized that open TLIF provides greater segmental and global lordosis correction than MI-TLIF. METHODS A single-center retrospective cohort study of consecutive patients undergoing MI- or open TLIF for grade I degenerative spondylolisthesis was performed. One-to-one nearest-neighbor propensity score matching (PSM) was used to match patients who underwent open TLIF to those who underwent MI-TLIF. Sagittal segmental radiographic measures included segmental lordosis (SL), anterior disc height (ADH), posterior disc height (PDH), foraminal height (FH), percent spondylolisthesis, and cage position. Lumbopelvic radiographic parameters included overall lumbar lordosis (LL), pelvic incidence (PI)–lumbar lordosis (PI-LL) mismatch, sacral slope (SS), and pelvic tilt (PT). Change in segmental or overall lordosis after surgery was considered "lordosing" if the change was > 0° and "kyphosing" if it was ≤ 0°. Student t-tests or Wilcoxon rank-sum tests were used to compare outcomes between MI-TLIF and open-TLIF groups. RESULTS A total of 267 patients were included in the study, 114 (43%) who underwent MI-TLIF and 153 (57%) who underwent open TLIF, with an average follow-up of 56.6 weeks (SD 23.5 weeks). After PSM, there were 75 patients in each group. At the latest follow-up both MI- and open-TLIF patients experienced significant improvements in assessment scores obtained with the Oswestry Disability Index (ODI) and the numeric rating scale for low-back pain (NRS-BP), without significant differences between groups (p > 0.05). Both MI- and open-TLIF patients experienced significant improvements in SL, ADH, and percent corrected spondylolisthesis compared to baseline (p < 0.001). However, the MI-TLIF group experienced significantly larger magnitudes of correction with respect to these metrics (ΔSL 4.14° ± 4.35° vs 1.15° ± 3.88°, p < 0.001; ΔADH 4.25 ± 3.68 vs 1.41 ± 3.77 mm, p < 0.001; percent corrected spondylolisthesis: −10.82% ± 6.47% vs −5.87% ± 8.32%, p < 0.001). In the MI-TLIF group, LL improved in 44% (0.3° ± 8.5°) of the cases, compared to 48% (0.9° ± 6.4°) of the cases in the open-TLIF group (p > 0.05). Stratification by operative technique (unilateral vs bilateral facetectomy) and by interbody device (static vs expandable) did not yield statistically significant differences (p > 0.05). CONCLUSIONS Both MI- and open-TLIF patients experienced significant improvements in patient-reported outcome (PRO) measures and local radiographic parameters, with neutral effects on regional alignment. Surprisingly, in our cohort, change in SL was significantly greater in MI-TLIF patients, perhaps reflecting the effect of operative techniques, technological innovations, and the preservation of the posterior tension band. Taking these results together, no significant overall differences in LL between groups were demonstrated, which suggests that MI-TLIF is comparable to open approaches in providing radiographic correction after surgery. These findings suggest that alignment targets can be achieved by either MI- or open-TLIF approaches, highlighting the importance of surgeon attention to these variables.

ImportanceCervical spinal cord injury (SCI) causes devastating loss of upper extremity function and independence. Nerve transfers are a promising approach to reanimate upper limbs; however, there remains a paucity of high-quality evidence supporting a clinical benefit for patients with tetraplegia.ObjectiveTo evaluate the clinical utility of nerve transfers for reanimation of upper limb function in tetraplegia.Design, Setting, and ParticipantsIn this prospective case series, adults with cervical SCI and upper extremity paralysis whose recovery plateaued were enrolled between September 1, 2015, and January 31, 2019. Data analysis was performed from August 2021 to February 2022.InterventionsNerve transfers to reanimate upper extremity motor function with target reinnervation of elbow extension and hand grasp, pinch, and/or release.Main Outcomes and MeasuresThe primary outcome was motor strength measured by Medical Research Council (MRC) grades 0 to 5. Secondary outcomes included Sollerman Hand Function Test (SHFT); Michigan Hand Outcome Questionnaire (MHQ); Disabilities of Arm, Shoulder, and Hand (DASH); and 36-Item Short Form Health Survey (SF-36) physical component summary (PCS) and mental component summary (MCS) scores. Outcomes were assessed up to 48 months postoperatively.ResultsTwenty-two patients with tetraplegia (median age, 36 years [range, 18-76 years]; 21 male [95%]) underwent 60 nerve transfers on 35 upper limbs at a median time of 21 months (range, 6-142 months) after SCI. At final follow-up, upper limb motor strength improved significantly: median MRC grades were 3 (IQR, 2.5-4; P = .01) for triceps, with 70% of upper limbs gaining an MRC grade of 3 or higher for elbow extension; 4 (IQR, 2-4; P P Conclusions and RelevanceIn this prospective case series, nerve transfer surgery was associated with improvement of upper limb motor strength and functional independence in patients with tetraplegia. Nerve transfer is a promising intervention feasible in both subacute and chronic SCI.

OBJECTIVEPatients with cervical spinal cord injury (SCI)/tetraplegia consistently rank restoring arm and hand function as their top functional priority to improve quality of life. Motor nerve transfers traditionally used to treat peripheral nerve injuries are increasingly used to treat patients with cervical SCIs. In this article, the authors present early results of a prospective clinical trial using nerve transfers to restore upper-extremity function in tetraplegia.METHODSParticipants with American Spinal Injury Association (ASIA) grade A–C cervical SCI/tetraplegia were prospectively enrolled at a single institution, and nerve transfer(s) was performed to improve upper-extremity function. Functional recovery and strength outcomes were independently assessed and prospectively tracked.RESULTSSeventeen participants (94.1% males) with a median age of 28.4 years (range 18.2–76.3 years) who underwent nerve transfers at a median of 18.2 months (range 5.2–130.8 months) after injury were included in the analysis. Preoperative SCI levels ranged from C2 to C7, most commonly at C4 (35.3%). The median postoperative follow-up duration was 24.9 months (range 12.0–29.1 months). Patients who underwent transfers to median nerve motor branches and completed 18- and 24-month follow-ups achieved finger flexion strength Medical Research Council (MRC) grade ≥ 3/5 in 4 of 15 (26.7%) and 3 of 12 (25.0%) treated upper limbs, respectively. Similarly, patients achieved MRC grade ≥ 3/5 wrist flexion strength in 5 of 15 (33.3%) and 3 of 12 (25.0%) upper limbs. Among patients who underwent transfers to the posterior interosseous nerve (PIN) for wrist/finger extension, MRC grade ≥ 3/5 strength was demonstrated in 5 of 9 (55.6%) and 4 of 7 (57.1%) upper limbs 18 and 24 months postoperatively, respectively. Similarly, grade ≥ 3/5 strength was demonstrated in 5 of 9 (55.6%) and 4 of 7 (57.1%) cases for thumb extension. No meaningful donor site deficits were observed. Patients reported significant postoperative improvements from baseline on upper-extremity–specific self-reported outcome measures.CONCLUSIONSMotor nerve transfers are a promising treatment option to restore upper-extremity function after SCI. In the authors’ experience, nerve transfers for the reinnervation of hand and finger flexors showed variable functional recovery; however, transfers for the reinnervation of arm, hand, and finger extensors showed a more consistent and meaningful return of strength and function.

OBJECTIVEThe Patient-Reported Outcomes Measurement Information System (PROMIS) is an adaptive, self-reported outcomes assessment tool that utilizes item response theory and computer adaptive testing to efficiently and precisely evaluate symptoms and perceived health status. Efforts to implement and report PROMIS outcomes in spine clinical practice remain limited. The objective of this retrospective cohort study is to evaluate the performance and psychometric properties of PROMIS physical function (PF) and pain interference (PI) among patients undergoing spine surgery.METHODSThe authors identified all patients who underwent spine surgery at their institution between 2016 and 2018, and for whom there was retrievable PROMIS data. Descriptive statistics were calculated to summarize demographics, operative characteristics, and patient-reported outcomes. Assessments were evaluated preoperatively, and postoperatively within 2 months (early), 6 months (intermediate), and up to 2 years (late). Pairwise change scores were calculated to evaluate within-subjects differences and construct responsiveness over time. Pearson’s correlation coefficients were used to evaluate the association between PROMIS PF and PI domains. Subgroup analysis was performed based on the primary diagnoses of cervical radiculopathy, cervical myelopathy, or lumbar degenerative disease.RESULTSA total of 2770 patients (1395 males, 50.4%) were included in the analysis. The mean age at the time of surgery was 57.3 ± 14.4 years. Mean postoperative follow-up duration was 7.6 ± 6.2 months. Preoperatively, patients scored an average 15.1 ± 7.4 points below the normative population (mean 50 ± 10 points) in PF, and 15.8 ± 6.8 points above the mean in PI. PROMIS PF required a mean of 4.1 ± 0.6 questions and median 40 seconds (interquartile range [IQR] 29–58 seconds) to be completed, which was similar to PI (median 4.3 ± 1.1 questions and 38 seconds [IQR 27–59 seconds]). Patients experienced clinically meaningful improvements in PF and PI, which were sustained throughout the postoperative course. PROMIS instruments were able to capture anticipated changes in PF and PI, although to a lesser degree in PF early postoperatively. There was a strong negative correlation between PROMIS PF and PI scores at baseline (Pearson’s r = −0.72) and during follow-up appointments (early, intermediate, and late |r| > 0.6, each). Subgroup analysis demonstrated similar results within diagnostic groups compared to the overall cohort. However, the burden of PF limitations and PI was greater within the lumbar spine disease subgroup, compared to patients with cervical radiculopathy and myelopathy.CONCLUSIONSPatients receiving care at a tertiary spine surgery outpatient clinic experience significant overall disability and PI, as measured by PROMIS PF and PI computer adaptive tests. PROMIS PF and PI health domains are strongly correlated, responsive to changes over time, and facilitate time-efficient evaluations of perceived health status outcomes in patients undergoing spine surgery.

Objective We sought to perform a systematic, comprehensive, and nationwide cross-sectional analysis of surgical capacity in Lebanon. Background Providing surgical care in refugee areas is increasingly recognized as a global health priority. The surgical capacity of Lebanon where at least 1 in 6 inhabitants is currently a refugee remains unknown. Methods The Surgical Capacity in Areas with Refugees cross-sectional study included 3 steps: (1) geographically mapping all hospitals providing surgical care in Lebanon, (2) systematically assessing each hospital's surgical capacity, and (3) identifying surgical care gaps/disparities. First, a list of hospitals in Lebanon and their locations was generated combining data from the Lebanese Ministry of Health and Syndicate of Hospitals. Specialty, rehabilitation, and maternity facilities were excluded. Second, the validated 5 domain Personnel, Infrastructure, Procedures, Equipment, and Supplies (PIPES) tool was administered in each hospital through a face-to-face or phone interview. Hospitals' PIPES indices were computed; data were aggregated and analyzed for geographic and private/public disparities. Results A total of 129 hospitals were geographically mapped; 20% were public. The PIPES tool was administered in all hospitals (100%). The mean PIPES index was 10.98 (Personnel = 14.91, Infrastructure = 15.36, Procedures = 37.47, Equipment = 21.63, Supplies = 24.78). The number of hospital beds, operating rooms, surgeons, and anesthesiologists per 100,000 people were 217, 8, 16, and 9, respectively. Deficiencies in infrastructure were significant, whereby 62%, 36%, 16%, and 5% of hospitals lack incinerators, pretested blood, intensive care units, and computed tomography, respectively. Continuous external electricity was lacking in 16 hospitals (12%). Compared to private hospitals, public hospitals had a lower PIPES index (10.48 vs 11.1, P = 0.022), including lower Personnel and Infrastructure scores (12.31 vs 15.57, P = 0.03; 14.04 vs 15.7, P = 0.003, respectively). Geographically, the administrative governorates with highest refugee concentrations had the lowest PIPES indices. Conclusions Evaluating surgical capacity in Lebanon reveals significant deficiencies, most pronounced in public hospitals in which refugee care is provided and in areas with the highest refugee concentration.

OBJECTIVE Nerve transfers are increasingly being utilized in the treatment of chronic tetraplegia, with increasing literature describing significant improvements in sensorimotor function up to years after injury. However, despite technical advances, clinical outcomes remain heterogenous. Preoperative electrodiagnostic testing is the most direct measure of nerve health and may provide prognostic information that can optimize preoperative patient selection. The objective of this study in patients with spinal cord injury (SCI) was to determine various zones of injury (ZOIs) via electrodiagnostic assessment (EDX) to predict motor outcomes after nerve transfers in tetraplegia. METHODS This retrospective review of prospectively collected data included all patients with tetraplegia from cervical SCI who underwent nerve transfer at the authors’ institution between 2013 and 2020. Preoperative demographic data, results of EDX, operative details, and postoperative motor outcomes were extracted. EDX was standardized into grades that describe donor and recipient nerves. Five zones of SCI were defined. Motor outcomes were then compared based on various zones of innervation. RESULTS Nineteen tetraplegic patients were identified who underwent 52 nerve transfers targeting hand function, and 75% of these nerve transfers were performed more than 1 year postinjury, with a median interval to surgery following SCI of 24 (range 8–142) months. Normal recipient compound muscle action potential and isolated upper motor neuron injury on electromyography (EMG) were associated with greater motor recovery. When nerve transfers were stratified based on donor EMG, greater motor gains were associated with normal than with abnormal donor EMG motor unit recruitment patterns. When nerve transfers were separated based on donor and recipient nerves, normal flexor donors were more crucial than normal extensor donors in powering their respective flexor recipients. CONCLUSIONS This study elucidates the relationship of the preoperative innervation zones in SCI patients to final motor outcomes. EDX studies can be used to tailor surgical therapies for nerve transfers in patients with tetraplegia. The authors propose an algorithm for optimizing nerve transfer strategies in tetraplegia, whereby understanding the ZOI and grade of the donor/recipient nerve is critical to predicting motor outcomes.

Background and objective High-frequency alternating current (HFAC) can yield a rapid-acting and reversible nerve conduction block. The present study aimed to demonstrate the successful implementation of HFAC block delivery via regenerative macro-sieve electrodes (MSEs). Methods Dual-electrode assemblies in two configurations [dual macro-sieve electrode-1 (DMSE-I), DMSE-II] were fabricated from pairs of MSEs and implanted in the transected and subsequently repaired sciatic nerves of two male Lewis rats. After four months of postoperative nerve regeneration through the MSEs' transit zones, the efficacy of acute HFAC block was tested for both configurations. Frequencies ranging from 10 kHz to 42 kHz, and stimulus amplitudes with peak-to-peak voltages ranging from 2 V to 20 V were tested. Evoked muscle force measurement was used to quantify the nerve conduction block. Results HFAC stimulation delivered via DMSE assemblies obtained a complete block at frequencies of 14 to 26 kHz and stimulus amplitudes of 12 to 20 V p-p. The threshold voltage for the complete block showed an approximately linear dependence on frequency. The threshold voltage for the partial conduction block was also approximately linear. For those frequencies that displayed both partial and complete block, the partial block thresholds were consistently lower. Conclusion This study provides a proof of concept that regenerative MSEs can achieve complete and reversible conduction block via HFAC stimulation of regenerated nerve tissue. A chronically interfaced DMSE assembly may thereby facilitate the inactivation of targeted nerves in cases wherein pathologic neuronal hyperactivity is involved.

This was a systematic review of the literature.The aim was to examine the contemporary demographics, etiological factors, treatment options and outcomes of spinal epidural lipomatosis (SEL) in adults.SEL is primarily seen in obese patients as well as those on steroid therapy. Much regarding the etiology and treatment outcomes of SEL is unknown.We reviewed Ovid MEDLINE, PubMed, SCOPUS, and Google Scholars databases from 1990 through August 2020 to identify cases of SEL. Data collected included patient characteristics, disease associations, level of pathology, treatment, and clinical outcomes.Ninety articles (145 individual cases) were included in the analysis. The median age was 54 years and 79% were males. Obesity-associated SEL constituted the largest proportion (52%) of our cohort. 22% of SEL cases were related to steroid use, while 26% cases were considered to be idiopathic. Lumbosacral SEL was the most frequently reported level of disease (68.9%), followed by the thoracic level (26.2%). The mean age of cases who underwent surgical intervention was 55 years, as compared with 48 years in those who received conservative management ( P =0.03). 95% of patients reported some degree of symptomatic improvement regardless of the treatment modality. Logistic regression suggested a possible superior outcome associated with those undergoing surgical treatment.In contrast to historical comparisons, contemporary articles support that obesity has become the major contributing factor for SEL. Logistic regression of the existing cases suggests that there may be a role for surgical intervention in select patients.

Indications and procedural techniques for successful transvenous embolization of cerebral dural arteriovenous fistulas (dAVFs) are reviewed. A brief historic context for transvenous embolization is presented. We discuss important anatomical considerations and present illustrative cases for ideal scenarios and more challenging transvenous approaches.

Bioresorbable drug release platforms offer advanced treatment for hormone imbalances, malignant cancers, and diabetic conditions., Implantable drug release platforms that offer wirelessly programmable control over pharmacokinetics have potential in advanced treatment protocols for hormone imbalances, malignant cancers, diabetic conditions, and others. We present a system with this type of functionality in which the constituent materials undergo complete bioresorption to eliminate device load from the patient after completing the final stage of the release process. Here, bioresorbable polyanhydride reservoirs store drugs in defined reservoirs without leakage until wirelessly triggered valve structures open to allow release. These valves operate through an electrochemical mechanism of geometrically accelerated corrosion induced by passage of electrical current from a wireless, bioresorbable power-harvesting unit. Evaluations in cell cultures demonstrate the efficacy of this technology for the treatment of cancerous tissues by release of the drug doxorubicin. Complete in vivo studies of platforms with multiple, independently controlled release events in live-animal models illustrate capabilities for control of blood glucose levels by timed delivery of insulin.

Pseudarthrosis is an exceedingly common, costly, and morbid complication in the treatment of long bone fractures and after spinal fusion surgery. Electrical bone growth stimulation (EBGS) presents a unique approach to accelerate healing and promote fusion success rates. Over the past three decades, increased experience and widespread use of EBGS devices has led to significant improvements in stimulation paradigms and clinical outcomes. In this paper, we comprehensively review the literature and examine the history, scientific evidence, available technology, and clinical applications for EBGS. We summarize indications, limitations, and provide an overview of cost-effectiveness and future directions of EBGS technology. Various models of electrical stimulation have been proposed and marketed as adjuncts for spinal fusions and long bone fractures. Clinical studies show variable safety and efficacy of EBGS under different conditions and clinical scenarios. While the results of clinical trials do not support indiscriminate EBGS utilization for any bone injury, the evidence does suggest that EBGS is desirable and cost efficient for certain orthopedic indications, especially when used in combination with standard, first-line treatments. This review should serve as a reference to inform practicing clinicians of available treatment options, facilitate evidence-based decision making, and provide a platform for further research.

Background Advances in operative techniques and minimally invasive technologies have evolved to maximize patient outcomes and radiographic results, while reducing morbidity and recovery time. Objective To describe the operative technique for a transfacet minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) as a proposed modification to the standard approach MIS-TLIF. Methods We present the case of a 72-yr-old man with left-sided lumbar radiculopathy. Preoperative imaging demonstrated degenerative lumbar anterolisthesis at L4-5, with associated canal and neuroforaminal stenosis. The patient underwent transfacet MIS-TLIF at L4-L5. We describe the preoperative planning, patient positioning, incision and dissection, pedicle screw insertion, transfacet approach to the working access corridor, discectomy, interbody device placement, fixation, and closure. Results The transfacet MIS-TLIF utilizes 3 key techniques to safely maximize surgical correction: (1) a limited bony resection based on the superior articular process, leaving the medial inferior articular process, lateral superior articular process, and rostral pars intact, providing a working bony corridor that protects the traversing and exiting nerve roots; (2) decortication and release of the contralateral facet joint to provide additional capacity for indirect decompression and provide the first point of osseous fusion; and (3) placement of an expandable interbody device that provides additional indirect decompression to the working side and contralateral foramen. Conclusion The transfacet MIS-TLIF uniquely leverages a bony working corridor to access the disc space for discectomy and interbody placement. Transfacet MIS-TLIF is a feasible solution for lumbar spinal reconstruction to maximize direct and indirect decompression of the neuroforamina and central spinal canal in patients with lumbar degenerative diseases and low-grade spondylolisthesis.

Retrospective cohort study.To evaluate the performance and convergent validity of the disabilities of the arm, shoulder, and hand (DASH) in comparison with the visual analog scale (VAS) for pain, and neck disability index (NDI) in patients undergoing cervical spine surgery.Neck-specific disability scales do not adequately assess concurrent upper extremity involvement in patients with cervical spine disorders. The DASH is a patient-reported outcomes (PRO) instrument designed to measure functional disability due to upper extremity conditions but has additionally been shown to perform well in patients with neck disorders.We identified patients who underwent cervical spine surgery at our institution between 2013 and 2016. We collected demographic information, clinical characteristics, and PRO measures-DASH, VAS, NDI-preoperatively, as well as early and late postoperatively. We calculated descriptive statistics and changes from baseline in PROs. Correlation coefficients were used to quantify the association between PRO measures. The analysis was stratified by radiculopathy and myelopathy diagnoses.A total of 1046 patients (52.8% male) with PROs data at baseline were included in the analysis. The mean age at surgery ± SD was 57.2 ± 11.3 years, and postoperative follow-up duration 12.7 ± 10.7 months. The most common surgical procedure was anterior cervical discectomy and fusion (71.1%). Patients experienced clinically meaningful postoperative improvements in all PRO measures. The DASH showed moderate positive correlations with VAS preoperatively (Spearman rho = 0.43), as well as early (rho = 0.48) and late postoperatively (rho = 0.60). DASH and NDI scores were strongly positively correlated across operative states (Preoperative rho = 0.74, Early Postoperative rho = 0.78, Late Postoperative rho = 0.82). Stratified analysis by preoperative diagnosis showed similar within-groups trends and pairwise correlations. However, radiculopathy patients experienced larger magnitude early and late change scores.The DASH is a valid and responsive PRO measure to evaluate disabling upper extremity involvement in patients undergoing cervical spine surgery.3.

OBJECTIVEPatients with cervical spinal cord injury (SCI)/tetraplegia consistently rank restoring arm and hand function as their top functional priority to improve quality of life. Motor nerve transfers traditionally used to treat peripheral nerve injuries are increasingly being used to treat patients with cervical SCIs. In this study, the authors performed a systematic review summarizing the published literature on nerve transfers to restore upper-extremity function in tetraplegia.METHODSA systematic literature search was conducted using Ovid MEDLINE 1946–, Embase 1947–, Scopus 1960–, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and clinicaltrials.gov to identify relevant literature published through January 2019. The authors included studies that provided original patient-level data and extracted information on clinical characteristics, operative details, and strength outcomes after nerve transfer procedures. Critical review and synthesis of the articles were performed.RESULTSTwenty-two unique studies, reporting on 158 nerve transfers in 118 upper limbs of 92 patients (87 males, 94.6%) were included in the systematic review. The mean duration from SCI to nerve transfer surgery was 18.7 months (range 4 months–13 years) and mean postoperative follow-up duration was 19.5 months (range 1 month–4 years). The main goals of reinnervation were the restoration of thumb and finger flexion, elbow extension, and wrist and finger extension. Significant heterogeneity in transfer strategy and postoperative outcomes were noted among the reports. All but one case report demonstrated recovery of at least Medical Research Council grade 3/5 strength in recipient muscle groups; however, there was greater variation in the results of larger case series. The best, most consistent outcomes were demonstrated for restoration of wrist/finger extension and elbow extension.CONCLUSIONSMotor nerve transfers are a promising treatment option to restore upper-extremity function after SCI. Flexor reinnervation strategies show variable treatment effect sizes; however, extensor reinnervation may provide more consistent, meaningful recovery. Despite numerous published case reports describing good patient outcomes with nerve transfers, there remains a paucity in the literature regarding optimal timing and long-term clinical outcomes with these procedures.

Background Red blood cell transfusion after coronary artery bypass graft surgery has been associated with increased late all-cause death. Yet, whether this association is, first, independent of the packed red blood cells and perioperative morbidity association, and second, of a cardiac versus noncardiac etiology remains unknown. Methods We analyzed patients undergoing coronary artery bypass graft surgery at two Ohio hospitals (n = 6,947) from 1994 to 2007. Salvage operations and patients with preoperative renal failure were excluded. Long-term outcomes and leading cause of death (cardiac, noncardiac, all cause) were derived from the US Social Security Death Index and later from Ohio Department of Health Death Index. Fifteen-year mortality cumulative incidence functions were compared for transfusion groups (yes, n = 2,540; no, n = 4,806) overall, and then stratified based on perioperative complications status (yes, n = 2,638; no, n = 4,708). Comprehensive, 32 covariates, risk-adjusted transfusion effects were estimated by competing risk regression. Results were confirmed by propensity score adjusted analysis. Results Perioperative transfusions and complications occurred in 33.9% and 35.2% of patients, respectively. In all, 3,108 deaths (48.1%) have been documented (median time to death, 7.43 years). Both transfusion rates (25.6% versus 49.1%, p p Conclusions Perioperative red blood cells transfusion is associated with significant adverse late death effects among both complicated patients and noncomplicated patients, principally seen between 0 and 5 years postoperatively, and is driven by both increased cardiovascular and noncardiovascular mortality. Further studies are needed to elucidate the mechanisms behind these findings, including their potential dose dependence.

Background Lebanon hosts an estimated one million Syrian refugees registered with the United Nations High Commissioner for Refugees (UNHCR). The UNHCR contracts with select Lebanese hospitals to provide affordable primary and emergency care to refugees. We aimed to assess the surgical capabilities of UNHCR-affiliated hospitals in Lebanon. Methods Cross-sectional data from the Surgical Capacity in Areas with Refugees study were combined with hospital affiliation data obtained from the UNHCR. The Surgical Capacity in Areas with Refugees study evaluated surgical capacity in Lebanon by mapping all acute care hospitals and administering the five domain Personnel, Infrastructure, Procedures, Equipment, and Supplies (PIPES) tool to each hospital. Mean PIPES indices and mean numbers of hospital beds, surgeons, and anesthesiologists were compared between UNHCR-affiliated and nonaffiliated hospitals. Geographically, the distribution of UNHCR-affiliated hospitals was cross-referenced with refugee population distributions. Results One hundred and twenty nine hospitals were included, 35 (27.1%) of which were affiliated with the UNHCR. The PIPES tool was administered across all hospitals. Mean PIPES indices and mean number of hospital beds, general surgeons, and anesthesiologists were similar between UNHCR-affiliated and nonaffiliated hospitals. Geographical mapping of hospitals and refugee populations across Lebanon revealed a disparity in the Northeastern region of the country: that region had the highest number of refugees but lacked sufficient UNHCR coverage. Conclusions Hospitals covered by the UNHCR performed similarly to nonaffiliated hospitals with respect to all aspects of the PIPES surgical capacity tool. However, there is a concerning geographic mismatch between UNHCR coverage and refugee density, specifically in the governorates of Akkar, Bekaa, and Baalbek-Hermel.

Peripheral nerve injuries represent a significant problem in public health, constituting 2-5% of all trauma cases1. For severe nerve injuries, even advanced forms of clinical intervention often lead to incomplete and unsatisfactory motor and/or sensory function2. Numerous studies report the potential of pharmacological approaches (for example, growth factors, immunosuppressants) to accelerate and enhance nerve regeneration in rodent models3-10. Unfortunately, few have had a positive impact in clinical practice. Direct intraoperative electrical stimulation of injured nerve tissue proximal to the site of repair has been demonstrated to enhance and accelerate functional recovery11,12, suggesting a novel nonpharmacological, bioelectric form of therapy that could complement existing surgical approaches. A significant limitation of this technique is that existing protocols are constrained to intraoperative use and limited therapeutic benefits13. Herein we introduce (i) a platform for wireless, programmable electrical peripheral nerve stimulation, built with a collection of circuit elements and substrates that are entirely bioresorbable and biocompatible, and (ii) the first reported demonstration of enhanced neuroregeneration and functional recovery in rodent models as a result of multiple episodes of electrical stimulation of injured nervous tissue.

BACKGROUND Restoration of shoulder function is an important treatment goal in upper brachial plexus injury (UBPI). Combined dual motor nerve transfer (CDNT) of spinal accessory to suprascapular and radial to axillary nerves demonstrates good functional recovery with minimal risk of perioperative complications. OBJECTIVE To evaluate the cost-effectiveness of CDNT vs alternative operative and nonoperative treatments for UBPI. METHODS A decision model was constructed to evaluate costs ($, third-party payer) and effectiveness (quality-adjusted life years [QALYs]) of CDNT compared to glenohumeral arthrodesis (GA), conservative management, and nontreatment strategies. Estimates for branch probabilities, costs, and QALYs were derived from published studies. Incremental cost-effectiveness ratios (ICER, $/QALY) were calculated to compare the competing strategies. One-way, 2-way, and probabilistic sensitivity analyses with 100 000 iterations were performed to account for effects of uncertainty in model inputs. RESULTS Base case model demonstrated CDNT effectiveness, yielding an expected 21.04 lifetime QALYs, compared to 20.89 QALYs with GA, 19.68 QALYs with conservative management, and 19.15 QALYs with no treatment. The ICERs for CDNT, GA, and conservative management vs nontreatment were $5776.73/QALY, $10 483.52/QALY, and $882.47/QALY, respectively. Adjusting for potential income associated with increased likelihood of returning to work after clinical recovery demonstrated CDNT as the dominant strategy, with ICER = -$56 459.54/QALY relative to nontreatment. Probabilistic sensitivity analysis showed CDNT cost-effectiveness at a willingness-to-pay threshold of $50 000/QALY in 78.47% and 81.97% of trials with and without income adjustment, respectively. Conservative management dominated in

Background Tetraplegia caused by cervical spinal cord injury is devastating for patients and represents a significant public health problem in both developed and developing countries. Improved functional outcomes after nerve transfers are increasingly reported in the literature, but thus far, no options exist for injuries above the C5 level. Case Description We report the cases of 2 patients with C4 spinal cord injury, American Spinal Injury Association A, who underwent successful bilateral spinal accessory nerve transfers, on 1 side to the triceps nerve with long intervening sural graft and on the other side direct transfer to the motor fascicles of the middle trunk. Patients improved from Medical Research Council 0 to 4 on the side of the nerve graft and 0 to 2 or 3 on the side of the direct transfer. Both patients also underwent transfer of the greater auricular nerve to sensory fascicles of the middle trunk, and they experienced sensory recovery in the C6 distribution. Notably, both patients were far removed from the traditional window of nerve transfer surgery at 4 years and almost 11 years out from injury. Conclusions We describe 2 successful cases of the first and to date only option for motor and sensory reinnervation in high cervical spinal cord injuries. These procedures provide a robust nerve transfer option capable of improving quality of life in tetraplegic patients. There may be a significant undertreated population of patients with cervical spinal cord injury patients in the United States who were previously considered outside the window for benefiting from nerve transfers but who would benefit from these techniques.

OBJECTIVEMinimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) has been adopted as an alternative technique to hasten recovery and minimize postoperative morbidity. Advances in instrumentation technologies and operative techniques have evolved to maximize patient outcomes as well as radiographic results. The development of expandable interbody devices allows a surgeon to perform MIS-TLIF with minimal tissue disruption. However, sagittal segmental and pelvic radiographic outcomes after MIS-TLIF with expandable interbody devices are not well characterized. The object of this study is to evaluate the radiographic sagittal lumbar segmental and pelvic parameter outcomes of MIS-TLIF performed using an expandable interbody device.METHODSA retrospective review of MIS-TLIFs performed between 2014 and 2016 at a high-volume center was performed. Radiographic measurements were performed on lateral radiographs before and after MIS-TLIF with static or expandable interbody devices. Radiographic measurements included disc height, foraminal height, fused disc angle, lumbar lordosis, pelvic incidence, sacral slope, and pelvic tilt. Mismatch between pelvic incidence and lumbar lordosis were calculated for each radiograph.RESULTSA total of 48 MIS-TLIFs were performed, predominantly at the L4–5 level, in 44 patients. MIS-TLIF with an expandable interbody device led to a greater and more sustained increase in disc height when compared with static interbody devices. Foraminal height increased after MIS-TLIF with expandable but not with static interbody devices. MIS-TLIF with expandable interbody devices increased index-level segmental lordosis more than with static interbody devices. The increase in segmental lordosis was sustained in the patients with expandable interbody devices but not in patients with static interbody devices. For patients with a collapsed disc space, MIS-TLIF with an expandable interbody device provided superior and longer-lasting increases in disc height, foraminal height, and index-level segmental lordosis than in comparison with patients with static interbody devices. Using an expandable interbody device improved the Oswestry Disability Index scores more than using a static interbody device, and both disc height and segmental lordosis were correlated with improved clinical outcome. Lumbar MIS-TLIF with expandable or static interbody devices had no effect on overall lumbar lordosis, pelvic parameters, or pelvic incidence–lumbar lordosis mismatch.CONCLUSIONSPerforming MIS-TLIF with an expandable interbody device led to a greater and longer-lasting restoration of disc height, foraminal height, and index-level segmental lordosis than MIS-TLIF with a static interbody device, especially for patients with a collapsed disc space. However, neither technique had any effect on radiographic pelvic parameters.

Context and Aims: The evolving influence of social media in trauma, acute, and critical care surgery (TACCS) cannot be ignored. We sought to investigate the extent and patterns of use of social networks by major regional, national and international TACCS societies. Materials and Methods: The two leading social networking sites, Facebook (FB) and Twitter (TW), were thoroughly examined for the presence of official accounts for each of the major TACCS societies. An official FB or TW account was defined as one which has a blue verified badge and/or is linked the society's official website. For societies with confirmed official accounts, the extent and patterns of use of the two platforms were systematically examined over a 2-week period through: (1) manual inspection of the societies' FB and TW pages, (2) the SQLite database containing downloaded samples of posts, and (3) the TW analytics database, symplur.com. Standardized social media metrics were calculated for each society. Posted content was categorized as being: (1) society news updates, (2) event announcements, or (3) general medical information. Results: From a total of 64 TACCS societies, only 27 (42%) had FB and/or TW accounts. Ten out of the 12 American societies had accounts compared to 13/39 of European, 2/9 of Australasian, and 0/2 of international societies. For the societies with social media presence, the mean numbers of monthly tweets and FB posts per society were 22 and 8, respectively. We summarize the FB and TW activity of the studied TACCS societies. Most tweets/posts were society news updates and event announcements intended to the society's constituents not the general public. A text cloud was constructed to summarize the major featured topics. Conclusion: Less than half of the TACCS societies are currently using social media; those that do are arguably underutilizing its potential. Non-American societies in particular lag behind in their use of social networking.