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Purpose: Despite the introduction of "standardized counting" methods, errors in counting spinal levels and subsequent wrong-level surgery (WLS) remain critically important patient safety concerns. Previous work by our group has documented inconsistency in the identification of T12 despite the use of these systems including the Spinal Deformity Study Group (SDSG) conventions. To assist with consistent and repeatable identification of proposed preoperative surgical levels, the current study investigates a new strategy: utilization of a "landmark vertebra". It was hypothesized that individuals using a "landmark vertebra" strategy will achieve high concordance with target level identification between distinct time points as compared to conventional methods defining T12., Methods: Survey participants analyzed 99 pre-op radiographs, identifying and naming a "landmark vertebra" with concise descriptions like "last bilaterally ribbed vertebra." They then noted the proposed lowest instrumented vertebra's (LIV) distance relative to landmark (i.e., one below landmark). After a waiting period, participants used their written descriptions of the landmark and distance to LIV to reidentify these vertebrae. Cohen's Kappa (k) was used to measure intra-rater agreeability. The landmark strategy was compared to our previous work evaluating consistency in defining T12 based on the SDSG system., Results: All raters showed perfect to near-perfect agreement when re-identifying the landmark and target vertebrae (k = 0.819-1.00; Table 1A). Raters at all training levels had higher agreeability in naming the landmark vertebra and target when compared to raters at similar training levels defining T12 (k = 0.34-0.91; Table 1B). This high agreement across training demonstrates the strategy's versatility and generalizability., Conclusion: Utilization of a landmark strategy proved to be highly effective in reducing intra-rater variability, with perfect to near-perfect agreement among all raters and consistently higher agreeability when compared to defining T12., Level of Evidence: Level II-prospective survey., Competing Interests: Declarations. Conflict of interest: RRG has no conflicts of interest to disclose. MSM has no conflicts of interest to disclose. KL has no conflicts of interest to disclose. AM has no conflicts of interest to disclose. NB has no conflicts of interest to disclose. TMZ has no conflicts of interest to disclose. BDR has received grants from the Pediatric Orthopaedic Society of North America, Scoliosis Research Society, and Orthopedic Science Research Foundation. LGL has received royalties from Medtronic and Acuity Surgical and is a consultant for Medtronic and Acuity Surgical. He has received grants from the Setting Scoliosis Straight (SSS) Foundation, International Spine Study Group (ISSG) Foundation, and AOSpine. LGL has served on the board of the National Spine Health Foundation (NSHF), Global Spine Outreach (GSO), and Setting Scoliosis Straight Foundation (SSSF). He has also received funding/support from the Fox Family (Prospective Pediatric Spinal Deformity study), AOSpine, Scoliosis Research Society (SRS) and BroadWater. MGV has received grants from the Pediatric Orthopaedic Society of North America, Orthopedic Science Research Foundation, Pediatric Spine Foundation, and Setting Scoliosis Straight Foundation and royalties from Biomet. He is a paid consultant for Stryker, Biomet, and NuVasive. MGV is on the Board of Directors of Pediatric Spine Foundation, Pediatric Spine Study Group, and C4K. He is former president of Pediatric Orthopaedic Society of North America and is a Board Member, Chair Emeritus of the International Pediatric Orthopaedic Symposium. Ethical approval: This study was approved by the Columbia University Institutional Review Board under protocol AAAU3144. It was performed in accordance with the ethical standards of the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Consent for publication: No patient identifying information is included in the article. Not applicable., (© 2024. The Author(s), under exclusive licence to Scoliosis Research Society.)

Purpose: Teamwork and communication are important components of any surgical team. This study uses a simple, reproducible, and quantitative "team consistency score" and a nodal-based model for examining prior interactions amongst team members to represent and quantify the regularity of an OR team for a specific surgical case., Methods: The electronic medical record (EMR) at our institution was queried for pediatric patients undergoing spinal surgery from January 2021 through December 2023. The number of prior interactions between individuals filling distinct roles in the OR for each case was recorded. A metric coined the consistency score was developed representing the sum total of these prior interactions standardized to a reference case. Spearman's Correlation as well as the Mann-Whitney comparison test were used to analyze the associations between case team consistency score and efficiency measures., Results: 154 cases were included for analysis. There was a statistically significant negative correlation between case consistency score and both anesthesia time (rho = -0.159; p < 0.05) and patient preparation time (rho = -0.218; p < 0.01). When looking at the consistent (above median consistency score of 0.46) vs. inconsistent cohorts, the inconsistent cohort had a higher mean patient preparation time (53.3 ± 14.0 min vs. 49.0 ± 9.3 min; p < 0.05), as well as a higher overall mean case length (336.6 ± 47.4 min vs. 321.9 ± 42.4 min; p < 0.05)., Conclusion: The findings suggest that increased team consistency, as measured by a "team consistency score" metric, is related to heightened efficiency and reduced intraoperative times., (© 2024. The Author(s), under exclusive licence to Scoliosis Research Society.)

Case: Spinal deformity associated with Guillain-Barre syndrome (GBS) is not commonly reported. We present a 6-year-old girl who developed kyphoscoliosis after being diagnosed GBS. She had extensive motor deficits requiring 2 hospitalizations and treatment with IV immunoglobulin therapy. Five months after diagnosis, she presented to our clinic with a 15° coronal scoliosis and a 65° thoracic kyphosis. At 6-month follow-up, kyphosis progressed to 77° with no significant change in the coronal curve. At 1 year, sagittal alignment was within normal limits and the coronal curve had completely resolved., Conclusion: Spinal deformity in GBS can resolve spontaneously., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C409)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Diffuse idiopathic skeletal hyperostosis (DISH) is an incompletely defined disease process with no known unifying pathophysiological mechanism., Objective: To our knowledge, no genetic studies have been performed in a North American population. To summarize genetic findings from previous studies and to comprehensively test for these associations in a novel and diverse, multi-institutional population., Methods: Cross-sectional, single nucleotide polymorphism (SNP) analysis was performed in 55 of 121 enrolled patients with DISH. Baseline demographic data were available on 100 patients. Based on allele selection from previous studies and related disease conditions, sequencing was performed on COL11A2, COL6A6, fibroblast growth factor 2 gene, LEMD3, TGFB1, and TLR1 genes and compared with global haplotype rates., Results: Consistent with previous studies, older age (mean 71 years), male sex predominance (80%), a high frequency of type 2 diabetes (54%), and renal disease (17%) were observed. Unique findings included high rates of tobacco use (11% currently smoking, 55% former smoker), a higher predominance of cervical DISH (70%) relative to other locations (30%), and an especially high rate of type 2 diabetes in patients with DISH and ossification of the posterior longitudinal ligament (100%) relative to DISH alone (100% vs 47%, P < .001). Compared with global allele rates, we found higher rates of SNPs in 5 of 9 tested genes ( P < .05)., Conclusion: We identified 5 SNPs in patients with DISH that occurred more frequently than a global reference. We also identified novel environmental associations. We hypothesize that DISH represents a heterogeneous condition with both multiple genetic and environmental influences., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Background: Despite the well-documented utility of responsive neurostimulation (RNS, NeuroPace) in adult epilepsy patients, literature on the use of RNS in children is limited., Objective: To determine the real-world efficacy and safety of RNS in pediatric epilepsy patients., Methods: Patients with childhood-onset drug-resistant epilepsy treated with RNS were retrospectively identified at 5 pediatric centers. Reduction of disabling seizures and complications were evaluated for children (<18 yr) and young adults (>18 yr) and compared with prior literature pertaining to adult patients., Results: Of 35 patients identified, 17 were <18 yr at the time of RNS implantation, including a 3-yr-old patient. Four patients (11%) had concurrent resection. Three complications, requiring additional surgical interventions, were noted in young adults (2 infections [6%] and 1 lead fracture [3%]). No complications were noted in children. Among the 32 patients with continued therapy, 2 (6%) achieved seizure freedom, 4 (13%) achieved ≥90% seizure reduction, 13 (41%) had ≥50% reduction, 8 (25%) had <50% reduction, and 5 (16%) experienced no improvement. The average follow-up duration was 1.7 yr (median 1.8 yr, range 0.3-4.8 yr). There was no statistically significant difference for seizure reduction and complications between children and young adults in our cohort or between our cohort and the adult literature., Conclusion: These preliminary data suggest that RNS is well tolerated and an effective off-label surgical treatment of drug-resistant epilepsy in carefully selected pediatric patients as young as 3 yr of age. Data regarding long-term efficacy and safety in children will be critical to optimize patient selection., (© Congress of Neurological Surgeons 2021.)

Minimally invasive posterior cervical microdiscectomy is an appropriate surgical approach for patients with foraminal stenosis from herniated disc with radicular symptoms that is not responsive to conservative management. While anterior cervical discectomy and fusion (ACDF) or arthroplasty is increasingly utilized to treat herniated disc, a posterior approach eliminates the risk of potential approach related injuries to the esophagus, carotid artery, or recurrent laryngeal nerve. Additional benefits of posterior decompression include avoidance of instrumentation, which represents an increased healthcare cost, as well as potential long-term risks of adjacent-level pathologies or device failures.  A traditional open posterior cervical approach has the potential to cause significant postoperative pain due to dissection of the paraspinal musculature and the potential for disrupting the posterior tension band with inadvertent injury to the interspinous ligaments. Such disadvantages are reduced by utilizing the minimally invasive technique where a small tubular working channel is placed through a muscle splitting technique via a paramedian approach. This technique minimizes the need for muscle stripping, and thus decreases postoperative functional and structural disturbance. Discectomy in this case can also be safely performed with minimal retraction at the axilla of the nerve root. Additionally, this approach can be utilized in an ambulatory setting, which coupled with the lack of any additional instrumentation helps contribute to the overall healthcare cost savings of such a procedure.  This video describes how the minimally invasive posterior cervical discectomy can be effectively and safely performed in this illustrative case. The patient consented to the procedure and publication., (© Congress of Neurological Surgeons 2021.)

Background: Minimal clinically important difference (MCID) is determined when a patient or physician defines the minimal change that outweighs the costs and untoward effects of a treatment. These measurements are "anchored" to validated quality-of-life instruments or physician-rated, disease-activity indices. To capture the subjective clinical experience in a measurable way, there is an increasing use of MCID., Objective: To review the overall concept, method of calculation, strengths, and weaknesses of MCID and its application in the neurosurgical literature., Methods: Recent articles were reviewed based on PubMed query. To illustrate the strengths and limitations of MCID, studies regarding the measurement of pain are emphasized and their impact on subsequent publications queried., Results: MCID varies by population baseline characteristics and calculation method. In the context of pain, MCID varied based on the quality of pain, chronicity, and treatment options., Conclusion: MCID evaluates outcomes relative to whether they provide a meaningful change to patients, incorporating the risks and benefits of a treatment. Using MCID in the process of evaluating outcomes helps to avoid the error of interpreting a small but statistically significant outcome difference as being clinically important., (© Congress of Neurological Surgeons 2020.)

As the popularity of minimally invasive surgery (MIS) continues to grow, novel techniques are needed to meet the demands of multisegment fixation for advanced spinal diseases. In one such example, iliac bolts are often required to anchor large fusion constructs, but MIS technical notes are missing from the literature.  A 67-yr-old female presented with a symptomatic coronal deformity: preoperative pelvic incidence = 47°, pelvic tilt = 19°, and lumbar lordosis = 29°, sagittal vertical axis = +5.4 cm with 30° of scoliosis. The operative plan included T10-ilium fusion with transforaminal interbody grafts at L2-3, L3-4, L4-5, and L5-S1. The intraoperative video is of minimally invasive placement of iliac bolts using the O-Arm Surgical Imaging System (Medtronic®). The patient consented to the procedure.  A mini-open exposure that remains above the fascial planes allows for multilevel instrumentation with appropriate decompression at the interbody segments. After the placement of the pedicle screws under image-guidance, the direction is turned to the minimally invasive iliac bolts. Following the trajectory described in the standard open approach,1 the posterior superior iliac spine (PSIS) is identified with the navigation probe, which will guide the Bovie cautery through the fascia. This opening assists in the trajectory of the navigated-awl tap toward the anterior superior iliac spine (ASIS). Next, 8.5 mm x 90 mm iliac screws were placed in the cannulated bone under navigation. After intraoperative image confirmation of screw placement, the contoured rods are threaded under the fascia. The setscrews lock the rod in position. MIS approaches obviate cross-linking the rods, rendering pelvic fixation more facile.  This technique allows for minimal dissection of the posterior pelvic soft tissue while maintaining adequate fixation., (© Congress of Neurological Surgeons 2021.)

Background: Few studies provide insight into risk factors (RFs) associated with postoperative deep vein thrombosis (DVT) following elective spinal surgery. DVTs are detrimental in this population because of the risk of pulmonary embolization or surgical site hemorrhage with treatment., Objective: Elective spine surgery patients have a low incidence of DVT, thus a case-control study was selected to investigate RFs associated with postoperative, symptomatic DVT., Methods: Cases were matched to controls in a 1:2 ratio based on surgery type. Risk of having a prior DVT and choice of subcutaneous heparin dosing following surgery was analyzed in a multivariate regression model with other potentially confounding variables., Results: A total of 195 patients were included in this study. Independent of patient age, history of DVT was associated with postoperative symptomatic DVT (odds ratio [OR], 4.09; 95% confidence interval [CI], 1.22-13.78). Two versus 3 times daily postoperative heparin dosing (OR, 1.56; 95% CI, 0.32-7.56), surgery length (OR, 1.32; 95% CI, 0.98-1.79), and patient age (OR, 1.04; 95% CI, 1.0-1.08) were not statistically significant, independent RFs. Older age and longer length of surgery trended toward association with DVT without reaching significance. Length of stay was increased from 3-5 days (P < 0.001) in DVT patients compared with controls., Conclusions: These results suggest that patients with a history of DVT undergoing elective spinal surgery are at higher risk of developing symptomatic DVT postoperatively resulting in significantly increased length of stay. Further studies on additional preoperative screening and medical optimization in elective spine surgery patients may help reduce the rate of symptomatic, postoperative DVT., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: New techniques of intraoperative magnetic resonance imaging (MRI)-guided stereotaxy enable minimally invasive approaches to intracranial pathology. Laser interstitial thermal therapy (LITT), convection-enhanced drug delivery, and stereotactic biopsy can be performed with a real-time confirmation of location and the ability to adjust for intracranial shift during the procedure. However, these procedures are constrained by patient positioning and the need for trajectories that avoid collision between stereotactic elements and the small MRI bore. To our knowledge, this is the first report to outline the technical details of safe intraoperative MRI (iMRI)-guided stereotaxy, performed with prone positioning., Objective: To present technical pearls to guide the safe conduction of iMRI-guided stereotaxy and LITT while in the prone position., Methods: The details of the positioning and trajectories for a series of patients who underwent Clearpoint® (MRI Interventions Inc) frameless real-time MRI-guided stereotaxis using a posterior approach were reviewed., Results: In this series, 5 patients underwent selective amygdalohippocampectomy, and 2 underwent tumor biopsy/ablation while in the prone position without any complications., Conclusion: Prone iMRI procedures can be performed safely even in a 60-cm MRI bore., (Copyright © 2019 by the Congress of Neurological Surgeons.)

Background: Anterior ethmoid aneurysms are rare with 5 cases of intracranial rupture and 3 cases of life-threatening epistaxis described in recent literature. We present a case of an intracranial ruptured anterior ethmoid aneurysm treated surgically with a favorable outcome., Case Description: A 64-year-old male presenting with a headache was found to have a right frontal intracranial hemorrhage with an associated 1.5 cm length × 1.8 cm maximal width anterior ethmoidal artery aneurysm. No definitive etiology of the aneurysm was identified. The aneurysm was treated using a bifrontal craniotomy with interhemispheric microdissection, clip ligation, and resection of the aneurysm dome for pathologic analysis, which ruled out a mycotic etiology. He recovered uneventfully and returned to work with no identifiable neurologic deficit., Conclusions: Consistent with prior reports, an intracranial, anterior ethmoidal artery aneurysm can occur in isolation without an associated vascular malformation. On the basis of a literature review and this case, surgical ligation is considered effective and possibly superior over endovascular treatment due to the risk of injury to the orbital vascular supply with transarterial treatment., (Copyright © 2020 Elsevier Inc. All rights reserved.)

First reported in 1988, Staphylococcus lugdunensis is a virulent coagulase-negative Staphylococcus species often associated with endocarditis. This is the first case report describing this infection in the cervical spine. A 58-year-old, left-handed Caucasian woman with no significant medical history presented with neck and left arm pain. Neurological examination revealed mild left deltoid 4/5 weakness and myelopathy. She was found to have an epidural cervical spinal cord mass that was causing severe cord compression and underwent partial anterior cervical decompression of the mass. On entering what was believed to be the mass, yellow-tinged fluid was encountered. An abscess was immediately suspected, so the dura was not entered. The specimen sent for culture was identified a day later as S. lugdunensis A two-dimensional echocardiogram was negative for vegetations. A peripherally inserted central catheter line was placed and the patient discharged on 6 weeks of physical therapy and 6-8 weeks of intravenous cefazolin., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The effect of time and temperature on beta-2 transferrin stability in cerebrospinal fluid (CSF) is not well established. After collecting nasal CSF for testing, beta-2 transferrin has been found to be stable and detectable for 1 week, whether being refrigerated or stored at room temperature. The purpose of this study was to determine if beta-2 transferrin remained detectable longer than 1 week and whether refrigeration improved its detectability., Methods: In patients undergoing therapeutic CSF diversion, 2-mL CSF samples were collected from 18 patients. The samples were divided and stored either at room temperature, or at 4°C, and tested for beta-2 transferrin at 7 and 14 days. CSF was collected from external ventricular drains (EVDs) (n = 15), lumbar drains (n = 2), and subdural drains (n = 1)., Results: Of the 18 CSF samples originally testing positive for beta-2 transferrin, none turned negative at 7 or 14 days, in both the refrigerated and room temperature groups (95% confidence interval [CI], 0% to 18.5%)., Conclusion: Beta-2 transferrin remained detectable for 14 days in all CSF samples, regardless of being stored at 4°C or room temperature., (© 2018 ARS-AAOA, LLC.)

Since there is no cure for glioblastoma multiforme (GBM), the goal of treatment becomes prolonging the survival through cytoreduction while minimising neurological deficits. In this case report, laser interstitial thermal therapy (LITT) was used once the tumour progressed into the isthmus of the cingulate gyrus. One year after temporal lobectomy, disorders of memory, emotion, personality and navigation, likely related to limbic system involvement along with hallucinations and fluctuating cognition occurred as the tumour progressed. After ablation of the posterior cingulum, worsening of topographical disorientation was observed.Per literature review, delirium has been noted in patients with strokes involving the right-sided temporo-parieto-occipital junction, and topographical disorientation has been associated with lesions of the right posterior cingulum. Alternative causes of these deficits were ruled out, leaving structural changes as the primary explanation. This is the first report of the neurological deficits associated with tumour progression and vasogenic oedema in this region., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2018. No commercial re-use. See rights and permissions. Published by BMJ.)

Neurogenesis is associated with functional recovery after stroke. However, the underlying molecular mechanisms have not been fully investigated. Using an Ago2-based RNA immunoprecipitation to immunoprecipated Ago2-RNA complexes followed by RNA sequencing (Ago2 RIP-seq) approach, we profiled the miRNomes in neural progenitor cells (NPCs) harvested from the subventricular zone (SVZ) of the lateral ventricles of young adult rats. We identified more than 7 and 15 million reads in normal and ischemic NPC libraries, respectively. We found that stroke substantially changed Ago2-associated miRNA profiles in NPCs compared to those in non-ischemic NPCs. We also discovered a new complex repertoire of isomiRs and multiple miRNA-miRNA* pairs and numerous novel miRNAs in the non-ischemic and ischemic NPCs. Among them, pc-3p-17172 significantly regulated NPC proliferation and neuronal differentiation. Collectively, the present study reveals profiles of Ago2-associated miRNomes in non-ischemic and ischemic NPCs, which provide a molecular basis to further investigate the role of miRNAs in mediating adult neurogenesis under physiological and ischemic conditions.

The majority of Plasmodium falciparum field isolates are defined as complex infections because they contain multiple genetically distinct clones. Studying interactions between clones in complex infections in vivo and in vitro could elucidate important phenomena in malaria infection, transmission and treatment. Using quantitative PCR (qPCR) of the P. falciparum merozoite surface protein 1, block 2 (PfMSP1-B2), we provide a sensitive and efficient genotyping method. This is important for epidemiological studies because it makes it possible to study genotype-specific growth dynamics. We compared 3 PfMSP1-B2 genotyping methods by analysing 79 field isolates from the Peruvian Amazon. In vivo observations from other studies using these techniques led to the hypothesis that clones within complex infections interact. By co-culturing clones with different PfMSP1-B2 genotypes, and measuring parasitaemia using qPCR, we found that suppression of clonal expansion was a factor of the collective density of all clones present in a culture. PfMSP1-B2 qPCR enabled us to find in vitro evidence for parasite-parasite interactions and could facilitate future investigations of growth trends in naturally occurring complex infections.