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OBJECTIVE Spinal robotics for thoracolumbar procedures, predominantly employed for the insertion of pedicle screws, is currently an emerging topic in the literature. The use of robotics in instrumentation of the cervical spine has not been broadly explored. In this review, the authors aimed to coherently synthesize the existing literature of intraoperative robotic use in the cervical spine and explore considerations for future directions and developments in cervical spinal robotics. METHODS A literature search in the Web of Science, Scopus, and PubMed databases was performed for the purpose of retrieving all articles reporting on cervical spine surgery with the use of robotics. For the purposes of this study, randomized controlled trials, nonrandomized controlled trials, retrospective case series, and individual case reports were included. The Newcastle-Ottawa Scale was utilized to assess risk of bias of the studies included in the review. To present and synthesize results, data were extracted from the included articles and analyzed using the PyMARE library for effect-size meta-analysis. RESULTS On careful review, 6 articles published between 2016 and 2022 met the inclusion/exclusion criteria, including 1 randomized controlled trial, 1 nonrandomized controlled trial, 2 case series, and 2 case reports. These studies featured a total of 110 patients meeting the inclusion criteria (mean age 53.9 years, range 29–77 years; 64.5% males). A total of 482 cervical screws were placed with the use of a surgical robot, which yielded an average screw deviation of 0.95 mm. Cervical pedicle screws were the primary screw type used, at a rate of 78.6%. According to the Gertzbein-Robbins classification, 97.7% of screws in this review achieved a clinically acceptable grade. The average duration of surgery, blood loss, and postoperative length of stay were all decreased in minimally invasive robotic surgery relative to open procedures. Only 1 (0.9%) postoperative complication was reported, which was a surgical site infection, and the mean length of follow-up was 2.7 months. No mortality was reported. CONCLUSIONS Robot-assisted cervical screw placement is associated with acceptable rates of clinical grading, operative time, blood loss, and postoperative complications—all of which are equal to or improved relative to the metrics seen in the conventional use of fluoroscopy or computer-assisted navigation for cervical screw placement.

Background: Supraorbital keyhole craniotomy is a minimally invasive approach used to access the parasellar region with advantages of decreased cortical exposure, simple closure, and decreased risk of postoperative cerebrospinal fluid leak. The incision of this approach, however, has raised cosmetic concerns, especially for pediatric patients. The aim of this study is to assess postoperative complications and cosmeses of the supraorbital keyhole approach for resection of intracranial lesions in pediatric patients. Methods: A literature search of PubMed, Scopus, and Web of Science databases was performed on June 1, 2021, searching for all studies of pediatric patients undergoing supraorbital keyhole craniotomy for surgical resection of lesions in the anterior fossa/sellar region. Results: Of 729 unique hits, 15 supraorbital keyhole studies reporting on 177 pediatric cases were included in the final review. Quality of all included studies was moderate. Overall, the surgery was well tolerated with a low number of severe adverse events. A wide variety of pathologies were treated with this approach. Complications of surgery included changes in vision, epidural hematoma, subdural hematoma, cerebrospinal fluid leak, and wound infection. At 6 weeks of follow-up, surgical scars in most patients were noted to be minimally detectable. At 3–6 months of follow-up, scars were no longer visible. Cosmetic complications included 5 bone defects, 1 split eyebrow, and 1 case of ptosis. Conclusions: This study suggests that supraorbital keyhole craniotomy is a safe and effective approach to access the parasellar region in pediatric patients with excellent cosmetic outcomes reported across multiple institutions.

To (1) measure surgical outcomes associated with stereotactic radiosurgery treatment of cerebellopontine angle meningiomas, and (2) determine if differences in radiation dosages or preoperative tumor volumes affect surgical outcomes.A systematic search was performed on the PubMed, Medline, Embase and Cochrane Library databases searching for patients under stereotactic radiosurgery for meningiomas of the cerebellopontine angle. After data extraction and Newcastle-Ottawa scale quality assessment, meta-analysis of the data was performed with Review Manager 3.4.5.In total, 6 studies including 406 patients were included. Postprocedure, patients had minimal cranial nerve complications while having an overall tumor control rate of 95.6%. Complications were minimal with facial nerve deficits occurring in 2.4%, sensation deficits of the trigeminal nerve in 4.0%, hearing loss in 5.9%, hydrocephalus in 2.0% and diplopia in 2.6% of all patients. Individuals with tumors extending into the internal auditory canal extension did not have significantly increases in hearing loss. There was a higher likelihood of tumor regression on postprocedure imaging in studies with a median prescription dose of13 Gy (RR 1.27 [95% CI 1.04-1.56,Radiosurgery is an effective modality for offering excellent tumor control of CPA meningiomas while allowing for only minimal complications postprocedure. A higher prescription dose may achieve higher tumor regression at follow up. Future studies should aim at establishing and optimizing accurate dosimetric guidelines for this patient population.

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

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

Objectives Responsive neurostimulation is an innovative modality in the treatment of medication-refractory epilepsy for patients who are not suitable candidates for surgical intervention. While being a potentially life-changing treatment option for many individuals with epilepsy, little is known about the system's complications aside from its performance in initial clinical trials. Therefore, the goal of this study was to characterize all reported complications of the RNS system made to the Food & Drug Administration since its approval. Materials and methods The Manufacturer and User Facility Device Experience (MAUDE) database was queried for entries reported under "implanted brain stimulator for epilepsy" through the dates of November 1, 2013 to March 1, 2020. After correction of duplicate entries, each was sorted into complication types based on the entries' narrative descriptions. Results The searched yielded 241 unique complication events. The most common complications were attributed to infections (40%) and lead breaks (12%). Other reported complications included poor wound healing (10%) and intrinsic device failure (7%). Focal neurological deficits were found in 2%. Over half (67%) of the reported complications required return to the operating room for revision or explant. The remainder of the adverse events were self-resolved or treated with either medication or software adjustment. Conclusions Future research endeavors should attempt to optimize the implantable device for preventing infections. The data of complications provided by this review will also aid physicians in providing the most accurate informed consent for patients when deciding to undergo implantation with the responsive neurostimulation system.

Introduction Meningiomas—the most common extra-axial tumors—are benign, slow-growing dural-based lesions that can involve multiple cranial fossae and can progress insidiously for years until coming to clinical attention secondary to compression of adjacent neurovascular structures. For complex, multicompartmental lesions, multistaged surgeries have been increasingly shown to enhance maximal safe resection while minimizing adverse sequela. Here, we systematically review the extant literature to highlight the merits of staged resection. Methods PubMed, Scopus, and Web of Science databases were queried to identify articles reporting resections of intracranial meningiomas using a multistaged approach, and articles were screened for possible inclusion in a systematic process performed by two authors. Results Of 118 identified studies, 36 describing 169 patients (mean age 42.6 ± 21.3 years) met inclusion/exclusion criteria. Petroclival lesions comprised 57% of cases, with the most common indications for a multistaged approach being large size, close approximation of critical neurovascular structures, minimization of brain retraction, identification and ligation of deep vessels feeding the tumor, and resection of residual tumor found on postoperative imaging. Most second-stage surgeries occurred within 3 months of the index surgery. Few complications were reported and multistaged resections appeared to be well tolerated overall. Conclusions Current literature suggests multistaged approaches for meningioma resection are well-tolerated. However, there is insufficient comparative evidence to draw definitive conclusions about its advantages over an unstaged approach. There are similarly insufficient data to generate an evidence-based decision-making framework for when a staged approach should be employed. This highlights the need for collaborative efforts among skull base surgeons to establish an evidentiary to support the use of staged approaches and to outline those indications that merit such an approach.

Chronic back pain (CBP) is a condition that places a considerable burden on society, with several million people affected in the United States alone. Treatment options to address this problem and relieve CBP are constantly evolving, and one of the most promising treatment modalities for CBP that is refractory to conservative treatment options is endoscopic rhizotomy (ER).A thorough search of the PubMed (MEDLINE) database was conducted to assess the full progression of ER from its earliest uses to present day in a historical narrative review of ER, with treatment of facetogenic pain as a model pathology.ER allows for direct visualization and ablation of sensory branches of the dorsal ramus to provide pain relief in up to 80% of patients faced with refractory CBP. This technique has been built upon since the early 20th century, and the novel endoscopic approach continues to gain popularity among physicians. Benefits of ER include superior postoperative median pain-free duration compared with traditional percutaneous radiofrequency ablation, as well as direct visualization of regional anatomy. Patient selection criteria for the procedure and a modest list of contraindications allow the use of ER as a viable treatment option for a significant population of patients suffering from CBP. Potential barriers to ER include high cost of the procedure, longer intraoperative time, and expensive proprietary equipment.ER is an effective treatment for refractory CBP with notable advantages. As the technology and popularity of this procedure progress, improvements in the cost, training, and intraoperative time may make it a favorable alternative to the current standard of care.

YouTube is one of the most widely accessed platforms for patients seeking information across all medical specialties. More than 50% of patients engage with online information before seeing a physician. There has been no qualitative analysis of neuromodulation content on YouTube.By evaluating the search interest of neuromodulation terms via Google Trends, the authors selected 3 search terms to assess on YouTube. For each term, the top 20 videos were selected, 10 sorting by view count and 10 by relevance. DISCERN criteria were used to evaluate each video. Statistical analysis was performed with R software to discover associations among video characteristics and DISCERN scores (DSs).Neuromodulation, deep brain stimulation, and spinal cord stimulation terms were searched. There were 52 unique and 8 duplicate videos, which were excluded. The videos received 6,984,743 combined views (134,321 average). Neurosurgeons were the most common authors, producing 22 videos, followed by anesthesiologists with 10 videos. Statistical analysis showed that videos that were sponsored (DS 44.79 vs. 34.53; P0.011), had board-certified physicians (DS 42.88 vs. 31.25; P0.004), and had credentials of the video producer (DS 41.82 vs. 34.42; P0.044) were more likely to have higher DSs. Spinal cord stimulation videos had the lowest quality of the search terms (DS 30.9 vs. 39.2, 42.6; P0.043).Certain characteristics of YouTube videos are associated with higher quality. Video producers should aim to use these characteristics and follow DISCERN criteria when preparing online videos.

Cerebral palsy (CP) is a chronic congenital disorder as the result of abnormal brain development. Children suffering from CP often battle debilitating chronic spasticity, which has been the focus of recent academic literature. In this systematic review, the authors aim to update the current neuromodulation procedures for the treatment of spasticity associated with CP in all age groups. A systematic review following was conducted using PubMed from inception to 2020. After initial title and abstract screening, 489 articles were identified, and 48 studies met the inclusion criteria for this review. In total, a majority of the published articles of treatments for CP were reporting the use of selective dorsal rhizotomy (SDR) (54%), and the remainder were of intrathecal baclofen (ITB) pumps (29%) and extracorporeal shockwave therapy (ESWT) (17%). Each method was found to have improvement of spasticity at a rate that achieved statistical significance. ITB pump therapy is an all-encompassing method of treating spasticity in children from CP, as it allows for a less invasive treatment that can be titrated to individual patient needs; however, its disadvantages include its long-term maintenance requirements. SDR appears to be an effective method for permanent spasticity relief in young patients. ESWT is a more recent and innovative technique for offering relief of spasticity while being minimally invasiveness. Further studies are needed to establish optimal frequencies and sites of application for ESWT.

Tumors of the central nervous system are the most common solid malignancies diagnosed in children. While common, they are also found to have some of the lowest survival rates of all malignancies. Treatment of childhood brain tumors often consists of operative gross total resection with adjuvant chemotherapy or radiotherapy. The current body of literature is largely inconclusive regarding the overall benefit of adjuvant chemo- or radiotherapy. However, it is known that both are associated with conditions that lower the quality of life in children who undergo those treatments. Chemotherapy is often associated with nausea, emesis, significant fatigue, immunosuppression, and alopecia. While radiotherapy can be effective for achieving local control, it is associated with late effects such as endocrine dysfunction, secondary malignancy, and neurocognitive decline. Advancements in radiotherapy grant both an increase in lifetime survival and an increased lifetime for survivors to contend with these late effects. In this review, the authors examined all the published literature, analyzing the results of clinical trials, case series, and technical notes on patients undergoing radiotherapy for the treatment of tumors of the central nervous system with a focus on neurocognitive decline and survival outcomes.

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

Extraction of a bullet fragment seated in deep brain parenchyma utilizing a neuroendoscope has not been previously reported in the literature. The authors report the case of a 4-year-old patient who presented after a pellet gun injury with a projectile located 6 cm intracranially and lodged within the posterior thalamus and near the posterior limb of the internal capsule. Initial operative repair included repair of a CSF leak with duraplasty, minimal brain debridement, and elevation of a depressed skull fracture. Subsequent CT at 2 months postoperatively revealed migration of the deep intracranial pellet. This finding correlated with intermittent worsening neurological symptoms and signs. A rigid 3-mm neuroendoscope with CT stereotactic navigation was then used to remove the pellet fragment from the thalamus. The patient returned home with alleviation of clinical symptoms and an uneventful postoperative recovery. This case demonstrates that navigation-guided neuroendoscopy can be successfully used to remove projectile fragments from deep brain structures, especially when the migration is along the initial path of the bullet. This technique represents another low-risk curative option in the management of retained bullet fragments in gunshot wound injuries to the head.

Background Intrathecal baclofen (ITB) is an effective treatment for spasticity, and therapeutic levels may be optimized using surgically implanted pumps. Though these devices are effective, complications can pose significant challenges to patients, decreasing the therapeutic effect and potentially requiring reoperation. As such, it is critical that complications associated with ITB be effectively characterized. Methods We queried the Manufacturer and User Facility Device Experience (MAUDE) database for cases reported during the past 3 years documenting adverse events specifically related to ITB pumps. We identified 1935 adverse events that were individually analyzed and categorized by type of complication. Results Out of the 1935 unique adverse events identified from the MAUDE database, 25.7% were device-related complications (n = 497). Of those, 50.3% were catheter-specific (n = 250), 21.3% (n = 106) were pump-specific, and 28.3% (n = 141) were included, more generally, in catheter or device erosion. Conclusions The MAUDE database may be a useful resource for evaluating ITB pump complications across a larger data set. By characterizing the complications and providing values for their total occurrences, patients and physicians may have more realistic expectations for the outcomes and morbidity of this device.

This was a national database study.To examine the role of comorbidities and demographics on inpatient complications in patients with lumbar degenerative conditions.Degenerative conditions of the lumbar spine account for the most common indication for spine surgery in the elderly population in the United States. Significant studies investigating demographic as predictors of surgical rates and health outcomes for degenerative lumbar conditions are lacking.Data were obtained from the National Inpatient Sample from 2010 to 2014 and International Classification of Diseases, 9th revision, Clinical Modification codes were used to identify patients with a primary diagnosis of degenerative lumbar condition. Patients were stratified based on demographic variables and comorbidity status. Multivariate regression analyses were used to determine whether any individual demographic variables, such as race, sex, insurance, and hospital status predicted postoperative complications.A total of 256,859 patients were identified for analysis. The rate of overall complications was found to be 16.1% with a mortality rate of 0.10%. Female, Black, Hispanic, and Asian/Pacific Islander patients had lower odds of receiving surgical treatment compared to White patients (P.001). Medicare and Medicaid patients were less likely to be surgically managed than patients with private insurance (OR = 0.75, 0.37; P.001, respectively). Urban hospitals were more likely to provide surgery when compared to rural hospitals (P.001). Patients undergoing fusion had more complications than decompression alone (P.001). Females, Medicare insurance status, Medicaid insurance status, urban hospital locations, and certain geographical locations were found to predict postoperative complications (P.001).There were substantial differences in surgical management and postoperative complications among individuals of different sex, races, and insurance status. Further investigation evaluating the effect of demographics in spine surgery is warranted to fully understand their influence on patient complications.

BACKGROUND Chordomas are rare malignant neoplasms that develop from the primitive notochord with < 5% of the tumors occurring in pediatric patients younger than the age of 20. Of these pediatric chordomas, those affecting the craniocervical junction (C1–C2) are even more rare; therefore, parameters for surgical management of these pediatric tumors are not well characterized. OBSERVATIONS In this case, a 3-year-old male was found to have a clival chordoma on imaging with extension to the craniocervical junction resulting in spinal cord compression. Endoscopic-assisted transoral transclival approach for clival tumor resection was performed first. As a second stage, the patient underwent a left-sided far lateral craniotomy and cervical laminectomy for resection of the skull base chordoma and instrumented fusion of the occiput to C3. He made excellent improvements in strength and dexterity during rehab and was discharged after 3 weeks. LESSONS In pediatric patients with chordoma with extension to the craniocervical junction and spinal cord compression, decompression with additional occipito-cervical fusion appears to offer a good clinical outcome. Fusion performed as a separate surgery before or at the same time as the initial tumor resection surgery may lead to better outcomes.

To examine the role of demographics on surgical management and inpatient complications in patients with spinal deformity between 2010 and 2014 via retrospective analysis.Data were obtained from the National Inpatient Sample (NIS). International Classification of Diseases 9th revision codes were used to identify patients with a primary diagnosis of adult spinal deformity (ASD). Multivariable Poisson regression analyses were used to determine whether any individual demographic variables were predictive of surgical management, surgical complexity, postoperative complications and revision operations.17,433 patients were identified for analysis. Surgical intervention was performed for 94.5% of patients with a primary diagnosis of ASD. Patients at urban teaching hospitals were the most likely to receive surgery (OR= 2.13; 95% CI 1.51-2.95; p 0.001) relative to rural patients. Female patients were the majority undergoing surgery and were more likely to receive a complication or require a revision when controlling for surgical complexity. Medicare patients were the least likely to undergo surgery and the most likely to receive complex fusion when undergoing an operation. Medicare patients were the least likely to experience complications (OR=0.89; 95% CI 0.80-0.98; p = 0.022) after adjusting for surgical complexity. With regards to race and ethnicity, Hispanics had a decreased likelihood of receiving a revision surgery.There were substantial differences in rates of surgical management, postoperative complications, and revisions among individuals of different demographics including sex, insurance status, ethnicity and hospital teaching status. Further research evaluating the effect of demographics in spine surgery is warranted to fully understand their influence on patient outcomes.

Introduction Neuromodulation is an evolving and increasingly popular therapy for chronic pain management. Recent data suggest that novel waveforms have demonstrated greater benefit over traditional spinal cord stimulation (SCS). The authors conducted a retrospective review of patients undergoing high-frequency 10 kHz SCS at a single tertiary medical center for the purpose of contributing further evidence to this growing body of data. The literature of high-frequency SCS published to date was also reviewed. Methods A retrospective chart review was performed for patients with chronic pain syndrome, including failed back surgery syndrome and sciatica alone, who underwent high-frequency SCS at 10 kHz. This data was analyzed using R software (R Foundation for Statistical Computing, Vienna, Austria) for statistical analysis. The PubMed database was searched for relevant articles using the search terms "high frequency," "10 kHz," and "spinal cord stimulation." All relevant studies conducted to date were included in this literature review. Results Twenty-one patients had complete follow-up data and were included in this study. Of the 21 patients, 85.7% subjectively reported post-operative pain relief while 71.4% of the total patients reported pain relief by ≥ 50%. There was a statistically significant decrease in mean VAS scores from pre-operative to 12-months post-operative (8.52 vs 4.37, p < 0.001). Additionally, 76.5% of patients subjectively reported improvements in sleep and activities of daily living. Recent studies indicate that high-frequency SCS appears to be a viable option for delivering quality pain relief in patients for chronic regional pain syndrome, failed back surgery syndrome, sciatica, and also pain in the upper cervical region of the spine. Conclusion This article provides evidence both with the authors' own institutional data and from the currently published literature for the efficacy of using high-frequency SCS at 10 kHz as a first-line programming option for patients undergoing SCS.

Study Design: Systemic review and meta-analysis. Objectives: To review and compare surgical outcomes for patients undergoing stand-alone anterior cervical discectomy and fusion (ACDF) versus cervical disc arthroplasty (CDA) for the treatment of cervical spine disease. Methods: A systematic search was performed on PubMed, Medline, and the Cochrane Library. Comparative trials measuring outcomes of patients undergoing CDA and stand-alone ACDF for degenerative spine disease in the last 10 years were selected for inclusion. After data extraction and quality assessment, statistical analysis was performed with R software metafor package. The random-effects model was used if there was heterogeneity between studies; otherwise, the fixed-effects model was used. Results: In total, 12 studies including 859 patients were selected for inclusion in the meta-analysis. Patients undergoing stand-alone ACDF had a statistically significant increase in postoperative segmental angles (mean difference 0.85° [95% confidence interval = 0.35° to 1.35°], P = .0008). Patients undergoing CDA had a decreased rate of developing adjacent segmental degeneration (risk ratio = 0.56 [95% confidence interval = −0.06 to 1.18], P = .0745). Neck Disability Index, Japanese Orthopedic Association score, Visual Analogue Scale of the arm and neck, as well as postoperative cervical angles were similar between the 2 treatments. Conclusions: When compared with CDA, stand-alone ACDF offers similar clinical outcomes for patients and leads to increased postoperative segmental angles. We encourage further blinded randomized trials to compare rates of adjacent segmental degeneration and other postoperative outcomes between these 2 treatments options.

Robot-assisted spine surgery has recently emerged as a viable tool to enable less invasive and higher precision surgery. The first-ever spine robot, the SpineAssist (Mazor Robotics Ltd., Caesarea, Israel), gained FDA approval in 2004. With its ability to provide real-time intraoperative navigation and rigid stereotaxy, robotic-assisted surgery has the potential to increase accuracy while decreasing radiation exposure, complication rates, operative time, and recovery time. Currently, robotic assistance is mainly restricted to spinal fusion and instrumentation procedures, but recent studies have demonstrated its use in increasingly complex procedures such as spinal tumor resections and ablations, vertebroplasties, and deformity correction. However, robots do require high initial costs and training, and thus, require justification for their incorporation into common practice. In this review, we discuss the history of spinal robots along as well as currently available systems. We then examine the literature to evaluate accuracy, operative time, complications, radiation exposure, and costs - comparing robotic-assisted to traditional fluoroscopy-assisted freehand approaches. Finally, we consider future applications for robots in spine surgery.

Mercer University School of Medicine utilizes a problem-based learning (PBL) curriculum for educating medical students in the basic clinical sciences. In 2014, an adjustment was piloted that enabled PBL cases to align with their corresponding cadaver dissection that reviewed the content of anatomy contained in the PBL cases. Faculty had the option of giving PBL cases in sequence with the cadaveric dissection schedule (sequential group) or maintaining PBL cases out of sequence with dissections (traditional group). During this adjustment, students' academic performances were compared. Students' perception of their own preparedness for cadaveric dissection, their perceived utility of the cadaver dissections, and free-response comments were solicited via an online survey. There were no statistically significant differences when comparing student mean examination score values between the sequential and traditional groups on both multidisciplinary examinations (79.39 ± 7.63 vs. 79.88 ± 7.31, P = 0.738) and gross anatomy questions alone (78.15 ± 10.31 vs. 79.98 ± 9.31, P = 0.314). A statistically significant difference was found between the sequential group's and traditional group's (63% vs. 29%; P = 0.005) self-perceived preparedness for cadaveric dissections in the 2017 class. Analysis of free-response comments found that students in the traditional group believed their performance in PBL group, participation in PBL group and examination performance was adversely affected when compared to students with the sequential schedule. This study provides evidence that cadaveric dissections scheduled in sequence with PBL cases can lead to increased student self-confidence with learning anatomy but may not lead to improved examination scores.

Hereditary multiple exostoses (HME) are an autosomal dominant skeletal disorder characterized by the development of multiple benign osteochondromas (exostoses) that frequently involve long bones of the body. Less commonly, the ribs are a site of involvement, and long-term friction between an exostosis and pleura can produce a hemothorax or pneumothorax. The purpose of this study is to provide a comprehensive review of existing literature on pneumothorax or hemothorax secondary to costal exostosis in HME patients. We reviewed the databases of PubMed and Embase and included data as current as of February 15, 2021. All case reports included cases of hemothorax or pneumothorax in patients with a known personal or family history of HME. After evaluation for inclusion based on eligibility criteria, 18 cases were included. The average age at presentation was 11.7 years (range: 3-32), and most patients were male (83%). Hemothoraces occurred in 15 cases, while pneumothoraces occurred in three cases. All cases were evaluated using chest X-ray and CT scan, and the majority of the cases were treated with surgical resection of the exostosis, either with video-assisted thoracoscopic surgery (VATS; 61%) or thoracotomy (22%). Outcomes were successful with no cases of recurrence after surgical intervention. Although rare, costal exostosis should be considered as a differential in patients presenting with pneumothorax or hemothorax and past medical history or physical exam findings suggestive of HME. Immediate evaluation and surgical intervention to resect costal exostosis are essential to reduce the risk of recurrent life-threatening injury.

Introduction Cranioplasty is performed by placing an artificial plate in place of a patient's native skull bones to repair post-craniectomy defects after trauma. Implanted materials can range from titanium to synthetic polyether derivatives and are produced by multiple manufacturers. There are few studies characterizing complications associated with these cranioplasty plates to date. We aimed to quantify and categorize complications of these devices using a national federal database. Methods The Manufacturer and User Facility Device Experience (MAUDE) database was queried for all entries reported under the category "plate, cranioplasty, preformed, non-alterable" with the additional product code GXN between the time range from September 1, 2010, to September 1, 2020. After data extraction, each of the entries was screened for duplicates and tabulated into different categories of complications. Additionally, product information such as the plate manufacturer was extracted from each entry. Results The search yielded 329 unique event reports. The most frequent complications were infection (39%), followed by incorrectly fitting implants (30%) and implant breaks (6%). Other major complications included cerebrospinal fluid leakage and cerebral edema (5%), wound dehiscence (5%), and migration of hardware (3%). The brands associated with the most entries in the database were the Synthes (DePuy Synthes Companies, Massachusetts, United States) polyetheretherketone (PEEK) patient-specific implants (PSI) (57%), the Biomet (Zimmer Biome, Indiana, United States) hard tissue replacement-polyetherketoneketone (HTR-PEKK) patient-matched implant (PMI) (23%), and the AccuShape PEEK PSI (MedCAD, Dallas, USA) (5%). Conclusions Infection and improperly fitting implants appear to be the two most frequent complications of cranioplasty plates. The goals of future research should include the prevention of plate infections as well as improving techniques to custom-fit implantable devices.

Introduction Deep brain stimulation (DBS) is a modality of treatment for medication refractory Parkinson's disease (PD) in patients with debilitating motor symptoms. While potentially life-changing for individuals with Parkinson's disease, characterization of adverse events for these DBS devices have not yet been systematically organized. Therefore, the goal of this study was to characterize reported complications of DBS devices reported to the Food & Drug Administration over the last 10 years. Methods The Manufacturer and User Facility Device Experience (MAUDE) database was utilized to retrieve entries reported under "Stimulator, Electrical, Implanted, For Parkinsonian Symptoms" between July 31, 2010 and August 1, 2020. After removing duplicate entries, each unique adverse event reported was sorted into complication categories based on the entries' provided narrative description. A final tabulation of complications was generated. Results The search query revealed 221 unique adverse events. The most common DBS devices were the Vercise Gevia, Vercise Cartesia and Vercise PC produced by Boston Scientific (Brian Walker, Boston Scientific, Marlborough, MA, USA). The most commonly reported complications were infection (16.2%) follow by lead migrations (8.6%). Other common causes of complications were circuit-related impedance (6.5%), cerebral bleeds (6.3%), device failure (6.3%) and device-related trauma (4.5%). Over a third (40%) of all devices reported with adverse events required returning to the operating room for explant or revision. Conclusion The most common complications of DBS systems are infections followed by lead migrations. Further research is needed to minimize infection rates associated with DBS systems and to reduce intrinsic device malfunctions for patients in the future.

Cerebral palsy (CP) is a chronic congenital disorder as the result of abnormal brain development. Children suffering from CP often battle debilitating chronic spasticity, which has been the focus of recent academic literature. In this systematic review, the authors aim to update the current neuromodulation procedures for the treatment of spasticity associated with CP in all age groups. A systematic review following was conducted using PubMed from inception to 2020. After initial title and abstract screening, 489 articles were identified, and 48 studies met the inclusion criteria for this review. In total, a majority of the published articles of treatments for CP were reporting the use of selective dorsal rhizotomy (SDR) (54%), and the remainder were of intrathecal baclofen (ITB) pumps (29%) and extracorporeal shockwave therapy (ESWT) (17%). Each method was found to have improvement of spasticity at a rate that achieved statistical significance. ITB pump therapy is an all-encompassing method of treating spasticity in children from CP, as it allows for a less invasive treatment that can be titrated to individual patient needs; however, its disadvantages include its long-term maintenance requirements. SDR appears to be an effective method for permanent spasticity relief in young patients. ESWT is a more recent and innovative technique for offering relief of spasticity while being minimally invasiveness. Further studies are needed to establish optimal frequencies and sites of application for ESWT.

Background and objective Novel surgical advancements have introduced endoscopic operative techniques for low back surgery, including transforaminal lumbar interbody fusion (TLIF), which theoretically allows for improved decompression with minimal invasiveness. In addition, endoscopically performed TLIF has allowed for the use of local anesthesia as an alternative method to general anesthesia for patients. We aimed to evaluate the clinical outcomes in patients undergoing endoscopic TLIF and also compare the outcomes in patients undergoing general versus local anesthesia. Methods The databases of PubMed, Medline, Embase, and the Cochrane Library were queried for all studies involving patients undergoing endoscopic TLIF. After the extraction of the data and assessment of study quality via the Newcastle-Ottawa Scale, statistical analysis was performed with the R software (The R Foundation, Vienna, Austria) metafor package. The random-effects model was used as the data was largely heterogeneous (I2 >50%). Results In total, 15 studies involving a total of 441 patients were selected for the final quantitative meta-analysis. The overall mean difference between the postoperative visual analog scale (VAS) leg scores and preoperative VAS scores was 3.45 (95% CI: 4.93-1.97, p

Introduction Hydrocephalus is a significant public health concern estimated to affect 380,000 new individuals annually. In addition, it exhibits an increasingly high financial burden for the healthcare industry. Clinical trials are the gold standard for evaluating preventative and therapeutic strategies to bring potential treatments to the forefront of clinical practice. Methods A study of the ClinicalTrials.gov was conducted in April 2019 to examine all current and previously reported clinical trials studying hydrocephalus. Studies were reviewed to extrapolate information to characterize the current state of research being conducted for hydrocephalus. Results In total, 80 clinical trials met inclusion criteria and were analyzed: 48.8% were observation and 51.2% were interventional. Of those, 55% have been completed while 30.0% are still recruiting, and 15.0% are not yet recruiting. The United States has the most clinical trials (42.0%) and a plurality of trials has a sample size of 0-50 participants. The majority of studies included only adults (53.8%). Of those studies, 54.0% were cohort and the majority were prospective (74.0%). Of the different types of hydrocephalus, normal pressure hydrocephalus and pediatric hydrocephalus have generated the most interest for research comprising a majority of the clinical trial registry. While 44 of the trials are complete, only 20 have published results in peer-reviewed literature highlighting the need for improvement in publishing study results even if the results of the trials are null. Conclusion Most clinical trials to date have pertained to the treatment of normal pressure hydrocephalus and pediatric hydrocephalus. While great advancements have been made for the treatment of hydrocephalus, there remains much room for improvements in therapeutic interventional modalities as well as ensuring the reporting of all undertaken clinical trials.

Objective Medulloblastoma is the most common malignant brain tumor in children younger than four years of age. Children diagnosed with desmoplastic nodular medulloblastoma (DNMB) have more favorable survival outcomes when compared to other subtypes of this disease and, to date, the demographics of DNMB have only been characterized by a few small clinical case series. Additionally, the current effort is being made at reducing radiotherapeutic modalities in this patient population to avoid the adverse effects associated with radiotherapy in children. Therefore, the goal of this study was to characterize the demographics, treatments, and survival outcomes of patients with DNMB using a large federal database. Methods The Surveillance, Epidemiology, and End Results database was queried to retrieve demographical, treatment, and survival data for patients diagnosed with DNMB. Statistical testing was performed with the R software stats package (R Foundation for Statistical Computing, Vienna, Austria). Student's t tests and analysis of variance tests were used to measure differences among survival rates. Results Data from 360 patients with DNMB were retrieved from 1975-2016. There was a higher prevalence of DNMB in children younger than four years of age (33% of all cases). Males had a higher prevalence than females (57%). There was a preponderance of diagnoses in white individuals (82% of all cases) and more diagnoses in the Pacific Coast region (49% of all cases). Distant metastases were present at initial diagnosis in 8.7%. Surgery was performed in almost all patients, and gross total resection was achieved in 77%. The overall rate of survival was 77.8% at five years; age, sex, race, and geographical region of diagnosis were not associated with differences in survival outcomes. Patients with no radiotherapy had a lower rate of survival compared to patients with postoperative radiotherapy (mean difference = 19.7%; [95% CI 1.4%-38.0%], p = 0.0314). However, radiotherapy did not improve survival outcomes in patients undergoing chemotherapeutic treatment to a degree with any statistical significance. There was no statistically significant improvement in survival for patients undergoing radiotherapy prior to procedure when compared to patients with no radiotherapy. Conclusions In patients undergoing chemotherapeutic treatment for the DNMB subtype of medulloblastoma specifically, additional radiotherapy may offer only minimal benefit to the survival outcome. It is essential continued clinical trials be performed for the purpose of devising alternate treatments to radiotherapy.

STUDY DESIGN This was a systematic review and meta-analysis. OBJECTIVE The objective was (1) to measure rates of successful resolution of dysphagia in patients after undergoing surgical intervention for diffuse idiopathic skeletal hyperostosis (DISH); and (2) to determine if older age, longer duration of preoperative symptoms, or increased severity of disease was correlated with unsuccessful surgical intervention. SUMMARY OF BACKGROUND DATA DISH, also known as Forestier disease, is an enthesopathy affecting up to 35% of the elderly population. Many patients develop osteophytes of the anterior cervical spine, which contribute to chronic symptoms of dysphagia causing debilitating weight loss and possibly resulting in the placement of a permanent gastrostomy feeding tube. For patients that fail conservative medical management, an increase in surgical interventions have been reported in the literature in the last 2 decades. MATERIALS AND METHODS A systematic search was performed on PubMed, Medline, Cochrane Library, and Embase. Studies measuring outcomes after surgical intervention for patients with dysphagia from DISH were selected for inclusion. Two independent reviewers screened and assessed all literature in accordance with Cochrane systematic reviewing standards. RESULTS In total, 22 studies reporting 119 patients were selected for inclusion. Successful relief of dysphagia was obtained in 89% of patients after surgical intervention. Failure to relieve dysphagia was associated with increased length of symptoms preoperatively (P

Molecular therapeutics for use in neurodegenerative disease and traumatic injury to the central nervous system have been implemented widely in preclinical studies and clinical trials. These strategies have broadly employed both pharmacologic and vector-driven gene-therapy approaches targeting different pathophysiologic mechanisms. As such, we have selected several representative indications that can serve as examples of traumatic, autoimmune, and mixed pathophysiologic mechanisms. The aim of this chapter is to provide an overview of molecular therapeutic options in preclinical and clinical development in several representative indications of neurodegenerative disease and injury. Here we will discuss molecular therapies in development for amyotrophic lateral sclerosis, multiple sclerosis, Alzheimer’s disease, Parkinson’s disease, traumatic brain injury, and traumatic spinal cord injury.

Although research involving traumatic brain injury (TBI) has traditionally focused on the acute clinical manifestations, new studies provide evidence for chronic and progressive neurological sequelae associated with TBI, highlighting the risk of persistent, and sometimes life-long, consequences for affected patients. Several treatment modalities to date have demonstrated efficacy in experimental models. However, there is currently no effective treatment to improve neural structure repair and functional recovery of TBI patients. Optogenetics represents a potential molecular tool for neuromodulation and monitoring cellular activity with unprecedented spatial resolution and millisecond temporal precision. In this review, we discuss the conceptual background and preclinical evidence of optogenetics for neuromodulation, and translational applications for TBI treatment are considered.

While CDD directly to the CSF can provide a constant delivery of the dopaminergic drug resulting in a more stable treatment effect without the limitations of traditional oral therapy without peripheral effects, it is still young and longitudinal data is lacking. These experimental therapies show promise and further investigation into their efficacy and safety could extend the frontiers for management of PD.

As our ability to use quality reporting systems has progressively improved, the Center for Medicare and Medicaid Services (CMS) is moving from a fee-for-service to a value-based incentive program for physician compensation. Programs such as Hospital Compare, Physician Compare, and Open Payments have also recently been launched by CMS to improve public reporting and healthcare transparency in the United States. These programs are all relatively new and are currently undergoing improvements to increase the accuracy and reliability of the data they provide.

To facilitate high-quality inpatient care for stroke patients, we built a system within our electronic health record (EHR) to identify stroke patients while they are in the hospital; capture necessary data in the EHR to minimize the burden of manual abstraction for stroke performance measures, decreasing daily time requirement from 2 hours to 15 minutes; generate reports using an automated process; and electronically transmit data to third parties. Provider champions and support from the EHR development team ensured that we balanced the needs of the hospital with those of frontline providers. This work summarizes the development and implementation of our stroke quality system.