Perioperative Neurological Deficits Research Articles

Diagnostic Accuracy of Somatosensory Evoked Potential monitoring during Scoliosis correction surgery in the pediatric population: A Systematic Review (P7-4.002)

<h3>Objective:</h3> To evaluate the diagnostic accuracy of intraoperative somatosensory evoked potential (SSEP) monitoring in predicting the risk of perioperative neurological outcomes during scoliosis fusion surgery for idiopathic scoliosis (IS) in the pediatric age group (≤ 21 years). <h3>Background:</h3> Scoliosis correction surgery is the most effective treatment for pediatric IS. However, new neurological deficits during the surgery can potentially affect the outcomes of this surgery. Intraoperative neuromonitoring techniques like SSEP provide real-time information about the spinal cord and nerve roots and can be used as a reliable indicator to predict perioperative neurological deficits. <h3>Design/Methods:</h3> A systematic review of various databases to find literature on pediatric IS patients who underwent scoliosis correction with intraoperative neuromonitoring. Data collection included study design, patient demographics, procedure, neuromonitoring modalities, SSEP alarm criteria, SSEP changes (including reversible and irreversible changes), and perioperative neurological deficit. We calculated the sensitivity, specificity, and diagnostic odds ratio (DOR) of SSEP changes (total, transient, and persistent) and SSEP loss for predicting perioperative neurological deficits. <h3>Results:</h3> We included eighteen studies for our final analysis, with a total cohort of 4674 children. The incidence of a significant SSEP change was 3.1% (145/4674), while the incidence of a new neurological deficit was 1.01% (47/4674). The incidence of new neurological deficits in children with an intraoperative SSEP change was 28.28% (41/145), while it was 0.13% (6/4529) in children without an SSEP change. SSEP changes had a sensitivity of 72%, specificity of 97%, and DOR of 98.64, while SSEP loss had a sensitivity of 42%, specificity of 99.3%, and a DOR of 143.76 for predicting new neurologic deficit. Transient and Persistent SSEP changes had sensitivities of 37% and 39%, specificities of 97% and 99.2%, and DORs of 18.09 and 75.43, respectively. <h3>Conclusions:</h3> Intraoperative SSEP monitoring can predict perioperative neurological injury and help improve the surgical outcomes in pediatric scoliosis fusion surgery. <b>Disclosure:</b> Dr. Gorijala has nothing to disclose. Dr. Shaik has nothing to disclose. The institution of Dr. Thirumala has received research support from University of Pittsburgh. Dr. Anetakis has nothing to disclose. Jeffery Balzer has nothing to disclose. Donald Crammond has nothing to disclose. Dr. Shandal has nothing to disclose. Dr. Lee has nothing to disclose. The institution of Dr. Shaw has received research support from LSRS. The institution of Dr. Shaw has received research support from CSRS. The institution of Dr. Shaw has received research support from AO Spine. Dr. Shaw has received intellectual property interests from a discovery or technology relating to health care. Mr. Reddy has nothing to disclose.

Unilateral versus bilateral antegrade cerebral perfusion during surgical repair for patients with acute type A aortic dissection

ObjectivesTo compare unilateral versus bilateral antegrade cerebral perfusion (ACP) techniques on cerebral protection during acute type A aortic dissection repair. MethodsUsing an institutional database, we retrospectively reviewed patients who underwent acute type A aortic dissection repair with selective ACP techniques from October 2008 to December 2019. Primary end point was the detection of neurologic dysfunctions. The secondary end point was mortality. For baseline adjustment, the propensity score matching method was used. Multivariable logistic regression analysis was performed to determine the predictor of neurologic events. ResultsAmong 522 patients (aged 62.0 ± 14.9 years; 45.7% women), unilateral and bilateral ACP techniques were used in 357 (64.7%) and 165 (35.3%) patients, respectively. Transient (19.6% vs 21.2%; P = .65) and permanent (7.0% vs 10.3%; P = .70) neurologic dysfunction rates were not significantly different in patients with unilateral versus bilateral ACP, respectively. Observed mortality rate was higher in the patients with bilateral ACP (hazard ratio, 2.05; 95% CI, 1.33-3.14; P = .001). Propensity-score matching yielded 94 pairs of patients. In matched analysis, bilateral ACP did not significantly lower the risks for transient (odds ratio, 0.87; 95% CI, 0.42-1.81; P = .71) and permanent (odds ratio, 1.42; 95% CI, 0.55-3.85; P = .47) neurologic dysfunction or death (hazard ratio, 1.65; 95% CI, 0.87-3.15; P = .13). In the multivariable analysis, the ACP technique was not significantly associated with perioperative neurologic deficit. ConclusionsDespite additional supply, the patients undergoing bilateral ACP during acute type A aortic dissection repair did not have superior outcomes in neurologic and death events compared with the patients undergoing unilateral ACP.

131. Risk factors that decrease complete recovery in idiopathic scoliosis surgery associated neurological injuries

<h3>BACKGROUND CONTEXT</h3> Neurological injuries (NI) are devastating complications of idiopathic scoliosis (IS) surgeries. The risk factors for these injuries have been well studied in the literature. However, the prognosis and the factors that impact the prognosis of NIs have been poorly studied. <h3>PURPOSE</h3> The purpose of this study was to summarize the prognosis of the documented 8-year NIs associated with IS surgeries from the Scoliosis Research Society Morbidity and Mortality (SRS M&M) database. <h3>STUDY DESIGN/SETTING</h3> Retrospective study conducted querying the SRS M&M database between 2009 and 2017 for idiopathic scoliosis population who had perioperative neurological deficits from scoliosis surgery. <h3>PATIENT SAMPLE</h3> n= 418; males (n=93; 22.4%), females (n=322, 77.6%), 3 unknown. <h3>OUTCOME MEASURES</h3> To determine the risk factors that decrease the complete recovery of neurological injuries. <h3>Methods</h3> Analyses were made to compare the correlation between the extent of neurological recovery (complete, partial and no change) and time of event occurrence (intraoperative, acute postoperative (<24hrs) and delayed postoperative >24hrs), intraoperative neurophysiological monitoring (IONM) used (yes/no), intra- and postoperative hypotension (yes/no), type of neurological injury (cord, root or both), type of cord injury (complete or incomplete). Chi-square and ANOVA tests were used for analyses. <h3>Results</h3> Data showed: EOIS (n=30), adolescent IS (n=244) and adult IS (n=144); average estimated blood loss, 1.9L; and average follow-up: 180 days. Intraoperative neuromonitoring (IONM) was used in 351 (84%), intraoperative hypotension observed in 73 (18%), and postoperative hypotension observed in 32 (8%). The majority of the NIs were intraoperative 168 (40.2%); postoperative (<24hrs.) 159 (38%); delayed (> 24 hrs) 91 (21.8%). Incomplete cord injuries were 178 (47.7%), complete cord injuries 53 (14.2%), root injuries 142 (38.1%) and no information for 45 patients. Injury level noticed at: cervical=20 (4.8%); thoracic=181 (43.3%), lumbar=187 (44.7%), sacrum=5 (1.2%) and unknown in 25 (6.0%) patients. Complete recovery was noticed in 269 patients (64.4%), partial recovery in 125 patients (29.9%), no recovery in 24 patients (5.7%). Average follow-up length was no different among recovery types: complete=190 days; partial=174 days; and no change=174 days, p=0.35. Complete NI recovery rate was significantly lower for adult IS patients (n= 67, 46.5%) vs EOIS (n=24, 80%) and AIS (n=178, 73%), (p<0.001). There was a significant increase in no recovery NIs status rates for complete cord injuries (n=13, 24.5%) vs incomplete cord (n=4, 2.2%) and root injuries (n=4, 2.8%), p<0.001), IONM abnormalities decreased complete recovery rates for intraoperative NIs (n=4, 33% vs n=109, (76.8%), p=0.001. There was a trend toward lower complete recovery rates in patients who did not use IONM for intraoperative NIs (p=0.06). <h3>Conclusions</h3> Lower complete NI recovery rates were observed in adult IS patients. Complete cord injuries reduced NIs complete recovery rate. IONM signal abnormalities have a potential effect on intraoperative NI prognosis, but not on postoperative or delayed NI prognosis. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Optimizing the methodology for saphenous nerve somatosensory evoked potentials for monitoring upper lumbar roots and femoral nerve during lumbar spine surgery: technical note.

The demand for intraoperative monitoring (IOM) of lumbar spine surgeries has escalated to accommodate more challenging surgical approaches to prevent perioperative neurologic deficits. Identifying impending injury of individual lumbar roots can be done by assessing free-running EMG and by monitoring the integrity of sensory and motor fibers within the roots by eliciting somatosensory (SEP), and motor evoked potentials. However, the common nerves for eliciting lower limb SEP do not monitor the entire lumbar plexus, excluding fibers from L1 to L4 roots. We aimed to technically optimize the methodology for saphenous nerve SEP (Sap-SEP) proposed for monitoring upper lumbar roots in the operating room. In the first group, the saphenous nerve was consecutively stimulated in two different locations: proximal in the thigh and distal close to the tibia. In the second group, three different recording derivations (10-20 International system) to distal saphenous stimulation were tested. Distal stimulation yielded a higher Sap-SEP amplitude (mean ± SD) than proximal: 1.36 ± 0.9µV versus 0.62 ± 0.6µV, (p < 0.0001). Distal stimulation evoked either higher (73%) or similar (12%) Sap-SEP amplitude compared to proximal in most of the nerves. The recording derivation CPz-cCP showed the highest amplitude in 65% of the nerves, followed by CPz-Fz (24%). Distal stimulation for Sap-SEP has advantages over proximal stimulation, including simplicity, lack of movement and higher amplitude responses. The use of two derivations (CPz-cCP, CPz-Fz) optimizes Sap-SEP recording.

Treatments for unruptured intracranial aneurysms

Unruptured intracranial aneurysms are relatively common lesions in the general population, with a prevalence of 3.2%, and are being diagnosed with greater frequency as non-invasive techniques for imaging of intracranial vessels have become increasingly available and used. If not treated, an intracranial aneurysm can be catastrophic. Morbidity and mortality in aneurysmal subarachnoid hemorrhage are substantial: in people with subarachnoid hemorrhage, 12% die immediately, more than 30% die within one month, 25% to 50% die within six months, and 30% of survivors remain dependent. However, most intracranial aneurysms do not bleed, and the best treatment approach is still a matter of debate. To assess the risks and benefits of interventions for people with unruptured intracranial aneurysms. We searched CENTRAL(Cochrane Library 2020, Issue 5),MEDLINE Ovid, Embase Ovid, and Latin American and Caribbean Health Science Information database (LILACS). We alsosearched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform from inception to 25 May 2020. There were no language restrictions. We contacted experts in the field to identify further studies and unpublished trials. Unconfounded, truly randomized trials comparing conservative treatment versus interventional treatments (microsurgical clipping or endovascular coiling) and microsurgical clipping versus endovascular coiling for individuals with unruptured intracranial aneurysms. Two review authors independently selected trials for inclusion according to the above criteria, assessed trial quality and risk of bias, performed data extraction, and applied the GRADE approach to the evidence. We used an intention-to-treat analysis strategy. We included two trials in the review: one prospective randomized trial involving 80 participants that compared conservative treatment toendovascular coiling, and one randomized controlled trial involving 136 participants that compared microsurgical clipping toendovascular coiling for unruptured intracranial aneurysms. There wasno difference in outcome events between conservative treatment and endovascular coiling groups. New perioperative neurological deficits were more common in participants treated surgically (16/65, 24.6%; 15.8% to 36.3%) versus 7/69 (10.1%; 5.0% to 19.5%); odds ratio (OR) 2.87 (95% confidence interval (CI) 1.02 to 8.93; P = 0.038). Hospitalizationfor more than five days was more common in surgical participants(30/65, 46.2%; 34.6% to 58.1%) versus 6/69 (8.7%; 4.0% to 17.7%); OR 8.85 (95% CI 3.22 to 28.59; P < 0.001). Clinical follow-up to one year showed 1/48 clipped versus 1/58 coiled participants haddied, and 1/48 clipped versus 1/58 coiled participants had become disabled (modified Rankin Scale > 2). All the evidence is of very low quality. There is currently insufficient good-quality evidence to support either conservative treatment or interventional treatments (microsurgical clipping or endovascular coiling) for individuals with unruptured intracranial aneurysms. Further randomized trials are required to establish if surgery is a better option than conservative management, and if so, which surgical approach is preferred for which patients. Future studies should include consideration of important characteristics such as participant age, gender, aneurysm size, aneurysm location (anterior circulation and posterior circulation), grade of ischemia (major stroke), and duration of hospitalizations.

P44 Direct and Combined Revascularization Versus Indirect Revascularization in the Treatment of Moyamoya Disease: A Systematic Review and Meta-Analysis

IntroductionThere is currently no definite consensus regarding the surgical treatment of moyamoya disease (MMD). This study aimed to compare direct and combined versus indirect bypasses with regard to perioperative complications in pediatric and adult patients with MMD.MethodsSystematic searches of Medline, Embase and Cochrane Central were undertaken. Primary outcome measures analyzed included perioperative complications defined as any major adverse events within 30 days after bypass surgery.Results2490 studies were identified. 20 reporting 2982 patients were eventually included in our meta-analysis. Pooled mean age was 37.5 years (95%CI:33.5–41.5) and 7.4 years (95%CI:4.1–10.7) in adult and pediatric patients respectively. For adult patients, perioperative stroke rate was comparable between direct/combined bypass and indirect bypass (OR = 1.26 [95%CI:0.81–1.96], p = 0.300 for indirect bypass). For pediatric patients, perioperative stroke rate was comparable between direct/combined bypass and indirect bypass (OR = 2.43[95%CI:0.74–7.94], p = 0.143 for indirect bypass). No difference was found in perioperative mortality between direct/combined bypass and indirect bypass for adult patients (OR = 1.16[95%CI:0.07–19.00], p = 0.915 for indirect bypass). There was no difference in perioperative mortality between direct/combined bypass and indirect bypass (OR = 1.39 [95%CI:0 –Inf], p = 1.00 for indirect bypass) in pediatric patients. There was no significant difference in perioperative neurological deficit rates between direct/combined bypass and indirect bypass (OR = 1.27[95%CI:0.68–2.39], p = 0.451 for indirect bypass).Discussions/ConclusionsOur meta-analysis provides statistical evidence suggesting that both direct and indirect bypasses can be equally effective in preventing stroke, with similar rates of perioperative complications in pediatric and adult patients.

Somatosensory Evoked Potentials as a Useful Tool to Limit the Temporary Clipping Time during Aneurysm Clipping

Perioperative neurological deficit is one of the known complications of cerebral aneurysm clipping procedures, leading to significant morbidity and mortality of the patients.[1] Neurological deficits noticed immediately in the postoperative period are often due to prolonged temporary or permanent clipping on adjacent vessels. Intraoperative somatosensory evoked potentials (SSEPs) have been in use to predict postoperative neurological deficits.[2]

Initial intraoperative experience with robotic-assisted pedicle screw placement with stealth navigation in pediatric spine deformity: an evaluation of the first 40 cases.

Pedicle screw fixation in pediatric spine surgery has become common practice given the fixation stability and improved curve correction. However, due to proximity to vital structures, accuracy is paramount. Literature has reported accuracy rates from 87.5 to 90% using traditional freehand techniques. This study presents our initial experience with pedicle screw placement using the newest generation of spinal robotics for treatment of pediatric spinal deformity. A cohort of patients, aged 8-21years, undergoing spinal fusion surgery using robotic-assisted technology was reviewed. Diagnoses, Cobb angles, surgical time, robot time, number of screws placed, and complications were recorded. Accuracy of screw placement was assessed based on analysis of successful screw execution, evaluation screw position using intraoperative fluoroscopy and post-operative radiographs, and clinical evaluation. The average age was 14.5years. Prevalent diagnoses included idiopathic (65%) and neuromuscular scoliosis (13%). Mean preoperative curve measured 66.8°. The median time for operation was 235 minutes with medians of 8 levels fused and 5 screws placed per patient. Of the 314 screws placed, we recorded a 98.7% accuracy rate. Lateral deviation was the most common cause of malpositioning. Post-operative plain films revealed no grossly misplaced screws. There were no perioperative neurologic deficits or malpositioned screws requiring reoperation. This is the first reported series of navigated spinal robotics used for pedicle screw placement in children. Our clinical success rate was 98.7% and there were no clinically relevant screw related complications. The study shows promising initial results of combined robotic-navigation techniques in pediatric patients.

Acute Neurological Deficits in Instrumented Pediatric Cervical Spine Fusions

Recipient: Bram Verhofste, MD Acute Neurological Deficits in Instrumented Pediatric Cervical Spine Fusions Bram P. Verhofste, MD1; Michael P. Glotzbecker, MD2; M Timothy Hresko, MD2; Patricia Miller, MS1; Craig M. Birch, MD1; Michael Troy, BS1; Nora P. O'Neill, BA1; Lawrence I. Karlin, MD2; John B. Emans, MD2; Mark R. Proctor, MD2; Daniel J. Hedequist, MD2, (1) Boston Children's Hospital, Boston, MA, (2) Boston Children's Hospital, Harvard Medical School, Boston, MA Introduction: Pediatric cervical deformity is a complex disorder often associated with neurological deterioration requiring cervical spine fusion. However, little literature exists on new perioperative neurologic deficits in children. This study describes new perioperative neurologic deficits in pediatric cervical spine instrumentation and fusion. Methods: A single-center review of pediatric cervical spine instrumentation and fusion during 2002-2018 was performed. Demographics, surgical characteristics, and neurological complications were recorded. Perioperative neurologic deficits were defined as the deterioration of preexisting neurologic function or the appearance of new neurologic symptoms. Results: A total of 184 cases (160 patients, 57% male) with an average age of 12.6 ±5.30 years were included. Instability (n=63) and deformity (n=41) were the most frequent indications. Syndromes were present in 39% (n=71). Eighty-seven (48%) children presented with preoperative neurologic deficits (16 sensory, 16 motor, and 55 combined deficits). A total of 178 (96.7%) cases improved or remained neurologically stable. New neurologic deficits occurred in six (3.3%) cases: three hemiparesis, one hemiplegia, one quadriplegia, and one quadriparesis (Table 1, Figure 1). Preoperative neurologic compromise was seen in four (67%) of these new deficits (three myelopathy, one sensory deficit) and five had complex syndromes. Three new deficits were anticipated with intraoperative neuromonitoring changes (p=0.025). Three (50.0%) patients recovered within six months and the child with quadriparesis is expected to make a complete recovery. Hemiplegia persisted in one patient and one child died due a complication related to the tracheostomy. No association was found between etiology (p=0.46), preoperative neurological symptoms (p=0.65), age (p=0.56), halo (p=0.41), EBL (p=0.09), levels fused (p=0.09), approach (p=0.07), or fusion location (p=0.37). Conclusion: An improvement of the preexisting neurologic deficit or stabilization of neurologic function was seen in 96.7% of children after cervical spine fusion. New or progressive neurologic deficits occurred in 3.3% of the patients and occurred more frequently in children with preoperative neurologic symptoms. Patients with syndromic diagnoses are at higher risk to develop a deficit, likely due to the severity of deformity and the degree of cervical instability. Long-term outcomes of new neurologic deficits are favorable and 50% experienced complete neurologic recovery within six months.

Perioperative neurological deficits following anterior lumbar interbody fusion: Risk factors and clinical impact

IntroductionAnterior lumbar interbody fusion is a common and well-utilized approach to treatment of lower lumbosacral spondylolisthesis. The authors aim to assess the impact of perioperative neurological deficits on the in-hospital morbidity and mortality. As such, the clinical risk factors leading to perioperative neurological deficits in patients undergoing anterior lumbar interbody fusion are assessed in a large cohort sample from the national inpatient sample (NIS). MethodsData was collected fromtheNIS-HCUP, a stratified sample of 20% ofallcommunity hospitaldischargesfrom the years 1999–2011 was analyzed. Patients who underwentanterior lumbar interbody fusion(ALIF) as their primary procedure were included. ResultsThe study cohort consisted of 67,900 patients with a mean age of 49.37 years. Approximately54.96% of thepatients were female, 83.60% were white,and 92.62% of the patients were operated on electively. The incidence of perioperative neurological deficit following ALIF was 1.02%. Perioperative neurological deficits were found to independently predict morbidityfollowing ALIFin our multivariable analysis (OR 2.07; CI 1.688 – 2.541) but were not an independent predictor of mortality. Patients with increasing age (OR 1.034; CI 1.027–1.041) andhigh vWR5–14 (OR 1.456; CI 1.065–1.990) had an increased risk of having perioperative neurological deficits. ConclusionOverall, perioperative neurological deficits following ALIF are rare (1.02%), and mortality is extraordinarily rare (0.15%). Patients with older age and higher comorbidities are at increased risk for of perioperative neurological deficit and consequently in hospital morbidity. As such, these results serve to further illuminate the importance of preoperative screening and proper patient stratification.

Neurophysiological Characteristics of Cranial Nerves V- and VII-Triggered EMG in Endoscopic Endonasal Approach Skull Base Surgery.

Objective This study proposes to present reference parameters for trigeminal (V) and facial (VII) cranial nerves (CNs)-triggered electromyography (tEMG) during endoscopic endonasal approach (EEA) skull base surgeries to allow more precise and accurate mapping of these CNs. Study Design We retrospectively reviewed EEA procedures performed at the University of Pittsburgh Medical Center between 2009 and 2015. tEMG recorded in response to stimulation of CN V and VII was analyzed. Analysis of tEMG waveforms included latencies and amplitudes. Medical records were reviewed to determine the presence of perioperative neurologic deficits. Results A total of 28 patients were included. tEMG from 34 CNs (22 V and 12 VII) were analyzed. For CN V, the average onset latency was 2.9 ± 1.1 ms and peak-to-peak amplitude was 525 ± 436.94 μV ( n = 22). For CN VII, the average onset latency and peak-to-peak amplitude were 5.1 ± 1.43 ms and 315 ± 352.58 μV for the orbicularis oculi distribution ( n = 09), 5.9 ± 0.67 ms and 517 ± 489.07 μV on orbicularis oris ( n = 08), and 5.3 ± 0.98 ms 303.1 ± 215.3 μV on mentalis ( n = 07), respectively. Conclusion Our data support the notion that onset latency may be a feasible parameter in the differentiation between the CN V and VII during the crosstalk phenomenon in EEA surgeries but the particularities of this type of procedure should be taken into consideration. A prospective analysis with a larger data set is necessary.

Perioperative acute neurological deficits in instrumented pediatric cervical spine fusions.

Pediatric cervical deformity is a complex disorder often associated with neurological deterioration requiring cervical spine fusion. However, limited literature exists on new perioperative neurological deficits in children. This study describes new perioperative neurological deficits in pediatric cervical spine instrumentation and fusion. A single-center review of pediatric cervical spine instrumentation and fusion during 2002-2018 was performed. Demographics, surgical characteristics, and neurological complications were recorded. Perioperative neurological deficits were defined as the deterioration of preexisting neurological function or the appearance of new neurological symptoms. A total of 184 cases (160 patients, 57% male) with an average age of 12.6 ± 5.30 years (range 0.2-24.9 years) were included. Deformity (n = 39) and instability (n = 36) were the most frequent indications. Syndromes were present in 39% (n = 71), with Down syndrome (n = 20) and neurofibromatosis (n = 12) the most prevalent. Eighty-seven (48%) children presented with preoperative neurological deficits (16 sensory, 16 motor, and 55 combined deficits).A total of 178 (96.7%) cases improved or remained neurologically stable. New neurological deficits occurred in 6 (3.3%) cases: 3 hemiparesis, 1 hemiplegia, 1 quadriplegia, and 1 quadriparesis. Preoperative neurological compromise was seen in 4 (67%) of these new deficits (3 myelopathy, 1 sensory deficit) and 5 had complex syndromes. Three new deficits were anticipated with intraoperative neuromonitoring changes (p = 0.025).Three (50.0%) patients with new neurological deficits recovered within 6 months and the child with quadriparesis was regaining neurological function at the latest follow-up. Hemiplegia persisted in 1 patient, and 1 child died due a complication related to the tracheostomy. No association was found between neurological deficits and indication (p = 0.96), etiology (p = 0.46), preoperative neurological symptoms (p = 0.65), age (p = 0.56), use of halo vest (p = 0.41), estimated blood loss (p = 0.09), levels fused (p = 0.09), approach (p = 0.07), or fusion location (p = 0.07). An improvement of the preexisting neurological deficit or stabilization of neurological function was seen in 96.7% of children after cervical spine fusion. New or progressive neurological deficits occurred in 3.3% of the patients and occurred more frequently in children with preoperative neurological symptoms. Patients with syndromic diagnoses are at higher risk to develop a deficit, probably due to the severity of deformity and the degree of cervical instability. Long-term outcomes of new neurological deficits are favorable, and 50% of patients experienced complete neurological recovery within 6 months.

Impact of contralateral carotid stenosis on brain tissue oxygenation during carotid endarterectomy

Background: Cerebral oximetry (rSO(2)) seems to be a promising technique for assessment the adequacy of cerebral oxygen delivery during carotid endarterectomy (CEA). The purpose of this study was to evaluate the association of the severity of contralateral (non-operated) carotid artery stenosis and the magnitude of rSO(2) changes during CEA. Methods: rSO(2) was monitored in 38 patients undergoing CEA under regional anesthesia. Patients were retrospectively assigned to one of two groups: with (Gdef) or without (Gnodef) change in neurological status. Baseline rSO(2) values (rSO(2) base), average (rSO(2)avg) and minimal (rSO(2)min) values during 3 minutes after clamping, and rSO(2) change after clamping (Delta rSO(2)avg and Delta rSO(2)min) were compared between both groups. The influence of contralateral carotid artery stenosis on rSO(2) was assessed by correlation. Data are presented as median (IQR). Results: Neurologic deterioration has developed in 4 patients. We did not find any statistical difference in rSO(2) values between Gdef a Gnodef on operated side - rSO(2) base was 79 (75-87) in Gnodef and 79 (64-90) in Gdef (p = 0.84), rSO(2) min 74 (65-81) in Gnodef and 75 (59-90) in Gdef (p = 0.70), and Delta rSO(2) min 6 (2-13) in Gnodef and 2 (0-6) in Gdef (p = 0.15). Similarly, there was not any difference between groups if rSO(2) was measured on contralateral side. We showed that non-operated ACI stenosis was a risk factor for developing of perioperative neurological deficit, but we did not demonstrate any influence of non-operated ACI stenosis severity on rSO(2) values. Conclusion: We did not prove any association between the severity of contralateral carotid artery stenosis and the magnitude of rSO(2) changes during CEA. Cerebral oximetry was not able to predict the development of neurologic deficit during CEA.

Dl-3-n-butylphthalide for alleviation of neurological deficit after combined extracranial-intracranial revascularization for moyamoya disease: a propensity score-matched analysis.

Postoperative neurological deficits impair the overall outcome of revascularization surgery for patients with moyamoya disease (MMD). dl-3-n-butylphthalide (NBP) is approved for the treatment of ischemic stroke in China. This pilot study evaluated the effect of NBP on perioperative stroke and neurological deficits in patients with MMD. The authors studied cases in which patients underwent combined revascularization surgery for MMD at their institution, with or without NBP administration. The overall study group included 164 patients (213 surgically treated hemispheres), including 49 patients who received NBP (25 mg twice daily) for 7 postoperative days. The incidence of perioperative stroke and transient neurological deficit (TND) and the severity of neurological deficits were compared between 49 propensity score-matched case pairs with or without NBP treatment. Subgroup analyses by type of onset and preoperative neurological status were also performed to determine specific characteristics of patients who might benefit from NBP administration. In the overall cohort, baseline characteristics differed with respect to preoperative stroke and modified Rankin Scale (mRS) score between patients who received NBP and those who did not receive it. In the 49 propensity score-matched pairs, postoperative stroke was observed in 11 patients and TND occurred in 21 patients, with no significant difference in incidence between the 2 groups. However, the TND was less severe in the NBP-treated group (p = 0.01). At 1 month after surgery, the neurological outcome was more favorable (p = 0.001) and the disability-free recovery rate was higher in patients with NBP treatment (p < 0.001). The number of patients who experienced an improved neurological function, compared to preoperative function, as measured by mRS, was greater in the NBP group than in the no-NBP group (p < 0.001). Multivariable analysis revealed that NBP administration was associated with decreased severity of TND (OR 0.28, p = 0.02), improved neurological function (OR 65.29, p = 0.04), and lower postoperative mRS score (OR 0.06, p < 0.001). These beneficial effects of NBP remained significant in ischemic type MMD and patients with preoperative mRS scores of 2 or greater. Postoperative administration of NBP may alleviate perioperative neurological deficits after revascularization surgery for MMD, especially in patients with ischemic MMD and unfavorable preoperative status. The results of this study suggest that randomized controlled trials to assess the potential benefit of NBP in patients with MMD may be warranted.

Treatments for unruptured intracranial aneurysms

BACKGROUND Unruptured intracranial aneurysms are relatively common lesions in the general population, with a prevalence of 3.2%, and are being diagnosed with greater frequency as non-invasive techniques for imaging of intracranial vessels have become increasingly available and used. If not treated, an intracranial aneurysm can be catastrophic. Morbidity and mortality in aneurysmal subarachnoid hemorrhage are substantial: in people with subarachnoid hemorrhage, 12% die immediately, more than 30% die within one month, 25% to 50% die within six months, and 30% of survivors remain dependent. However, most intracranial aneurysms do not bleed, and the best treatment approach is still a matter of debate. OBJECTIVES To assess the risks and benefits of interventions for people with unruptured intracranial aneurysms. SEARCH METHODS We searched CENTRAL (Cochrane Library 2020, Issue 5), MEDLINE Ovid, Embase Ovid, and Latin American and Caribbean Health Science Information database (LILACS). We also searched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform from inception to 25 May 2020. There were no language restrictions. We contacted experts in the field to identify further studies and unpublished trials. SELECTION CRITERIA Unconfounded, truly randomized trials comparing conservative treatment versus interventional treatments (microsurgical clipping or endovascular coiling) and microsurgical clipping versus endovascular coiling for individuals with unruptured intracranial aneurysms. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion according to the above criteria, assessed trial quality and risk of bias, performed data extraction, and applied the GRADE approach to the evidence. We used an intention-to-treat analysis strategy. MAIN RESULTS We included two trials in the review: one prospective randomized trial involving 80 participants that compared conservative treatment to endovascular coiling, and one randomized controlled trial involving 136 participants that compared microsurgical clipping to endovascular coiling for unruptured intracranial aneurysms. There was no difference in outcome events between conservative treatment and endovascular coiling groups. New perioperative neurological deficits were more common in participants treated surgically (16/65, 24.6%; 15.8% to 36.3%) versus 7/69 (10.1%; 5.0% to 19.5%); odds ratio (OR) 2.87 (95% confidence interval (CI) 1.02 to 8.93; P = 0.038). Hospitalization for more than five days was more common in surgical participants (30/65, 46.2%; 34.6% to 58.1%) versus 6/69 (8.7%; 4.0% to 17.7%); OR 8.85 (95% CI 3.22 to 28.59; P 2). All the evidence is of very low quality. AUTHORS' CONCLUSIONS There is currently insufficient good-quality evidence to support either conservative treatment or interventional treatments (microsurgical clipping or endovascular coiling) for individuals with unruptured intracranial aneurysms. Further randomized trials are required to establish if surgery is a better option than conservative management, and if so, which surgical approach is preferred for which patients. Future studies should include consideration of important characteristics such as participant age, gender, aneurysm size, aneurysm location (anterior circulation and posterior circulation), grade of ischemia (major stroke), and duration of hospitalizations.

Frameless Stereotactic Navigation during Insular Glioma Resection using Fusion of Three-Dimensional Rotational Angiography and Magnetic Resonance Imaging

Perioperative cerebral infarction is a potential complication of glioma resection, of which insular tumors are at higher risk because of the proximity of middle cerebral artery branches, including the lateral lenticulostriates and long insular arteries. In this study, 3 patients received three-dimensional rotational angiography, which was fused with magnetic resonance imaging (MRI) for frameless stereotactic navigation during dominant-hemisphere insular glioma resection. All patients obtained a preoperative catheter angiogram with a three-dimensional rotational acquisition of the ipsilateral internal carotid artery. The pixel-based axial three-dimensional angiography data, thin-cut structural MRI, tractography from diffusion tensor imaging, and expressive language activation from functional MRI were uploaded into the iPlan software (Brainlab, Heimstetten, Germany) and fused. The target tumor, regional blood vessels, adjacent functional areas, and their associated fiber tracts were segmented and overlaid on the appropriate MRI sequence. This image fusion was used preoperatively to visualize the relationship of the mass with the adjacent vasculature and intraoperatively for frameless stereotactic navigation to optimize preservation of arterial structures. Three patients aged 27-60 years with excellent baseline functional status presented with seizures and were found to have a large dominant-hemisphere T2 hyperintense nonenhancing insular mass. Surgical resection was performed using multimodality neuronavigation. None sustained a postoperative arterial infarction or a perioperative neurologic deficit. Neuronavigation using a fusion of three-dimensional rotational angiography with MRI is a technique that can be used for preoperative planning and during resection of insular gliomas to optimize preservation of adjacent arteries.

Instrumentation complication rates following spine surgery: a report from the Scoliosis Research Society (SRS) morbidity and mortality database.

Objective of this study is to evaluate demographics, risk factors, and incidence of instrumentation related complications (IRC) in spinal surgeries from 2009-2012. The Scoliosis Research Society (SRS) morbidity and mortality (M&M) database has tremendous value in orthopaedic surgery. SRS gathers surgeon-reported complications, including instrumentation failure, visual complications, neurological deficits, infections, and death. Limited literature exists on the incidence of perioperative instrumentation complications in deformity surgery. We utilized the SRS database to evaluate demographics, risk factors, and incidence of IRC in spinal surgeries from 2009-2012. The SRS M&M database was queried for IRC in patients undergoing surgery for scoliosis, spondylolisthesis, and kyphosis from 2009-2012. Demographics, comorbidities, diagnoses, curve magnitude, and intraoperative characteristics were analyzed. Intraoperative characteristics included surgical approach, performance of fusion or osteotomy, operative times, blood loss, instrumentation used, and documented instrumentation complication. A total of 167,972 patients were identified, including 311 IRC. The overall IRC rate was 0.19% (18.5 per 10,000 patients), which decreased significantly from 2009-2012 (0.37% vs. 0.19%, P<0.001). The mean age of patients with IRC was 38.5±25.5 years. Most common comorbidities included hypertension (23.5%), pulmonary disease (13.5%), diabetes (10.6%), smoking (8.7%), and vascular disease (7.1%). IRC occurred in 206 (66.2%) patients with scoliosis, 58 (18.6%) with spondylolisthesis, and 45 (14.5%) with kyphosis. Compared to patients with spondylolisthesis, patients with kyphosis (0.27% vs. 0.11%, P<0.001) and scoliosis (0.21% vs. 0.11%, P<0.001), experienced significantly more IRC. IRC included implant failure (23.3%), migration (28.3%), and malpositioned implants (48.6%). New perioperative neurologic deficits were reported in 146 (46.9%) patients, and 84 (27%) of these implants were removed. IRC occur in approximately 18.5 per 10,000 deformity patients, with a rate significantly higher in patients with kyphosis. The potentially avoidable occurrence of implant malpositioning represents nearly 50% of these complications. Closer attention to posterior bony anatomy, improved intraoperative imaging with utilization of navigation or robotic guidance may decrease these complications.

The diagnostic accuracy of somatosensory evoked potentials in evaluating neurological deficits during 1057 lumbar interbody fusions

BackgroundLumbar interbody spinal fusion (LIF) surgeries are performed to treat or prevent back pain in patients with degenerated intervertebral discs and a variety of spinal diseases. However, post-operative neurological complications may ensue. Intraoperative monitoring techniques have been used to predict and potentially reduce the risk of complications. MethodsThis study examined the diagnostic accuracy of significant changes of somatosensory evoked potentials (SSEPs) to evaluate and predict post-operative neurological deficits after LIF. All patients underwent LIF at UPMC from 2010 to 2012. One thousand fifty-seven patients had pre-operative baseline and continuous intraoperative SSEP monitoring. Statistical analysis was completed using SPSS version 22. No relevant disclosure. ResultsPatient outcomes were not significantly affected by age over 65, gender, obesity, and abnormal baselines. Lower extremity (LE) significant changes in SSEPs and LE loss of responses resulted in a sensitivity/specificity of 0.03/0.99 and 0.03/0.99; they had an AUC of 0.54/0.73 with a 95% confidence interval (CI) of [0.34, 0.74]/[0.29, 1.00]. ConclusionsSignificant SSEP changes during LIF are a very specific but poorly sensitive indicator of perioperative neurological deficits. The odds ratio for LE loss of responses was 29.14 with a 95% CI of 1.79-475.5, so LE SSEP loss of responses can serve as a biomarker of perioperative neurological deficits after LIF.

Unruptured Intracranial Aneurysms.

Unruptured Intracranial Aneurysms.

Impact of Perioperative Neurologic Deficits on Clinical Outcomes After Posterior Cervical Fusion

In the United States, the number of posterior cervical fusions has increased substantially. Perioperative neurologic complications associated with this procedure, such as spinal cord and peripheral nerve injuries, can have significant effects on patient health. We examined the impact of perioperative neurologic deficits on mortality in patients undergoing posterior cervical fusion. The secondary aim was to understand the risk factors for perioperative neurologic complications. Data were collected from the National Inpatient Sample (NIS) Health Cost Utilization Project (HCUP) between 1999 and 2011. Patients younger than 18 years and older than 80 years were excluded, as were patients who underwent posterior cervical fusion caused by trauma. Patient demographics and comorbidities were compiled as well as variables that have been associated with increased risk of perioperative neurologic deficits. We used the van Walraven score, a weighted numeric surrogate for the Elixhauser comorbidity index, as a covariate to assess comorbidities that have been associated with in-hospital mortality and morbidity after posterior cervical fusion. In addition, we performed univariate comparisons between covariates and surgical outcomes. We conducted a multivariable logistic regression, adjusting for many of the covariates, as well as trend analyses. An analysis of 33,644 patients yielded an overall rate of perioperative neurologic deficits, morbidity, and mortality of 1.08%, 40.44%, and 1.00%, respectively. Perioperative neurologic deficits were independent risk factors predictors of in-hospital mortality (odds ratio, 5.270; P < 0.0001) and morbidity (odds ratio, 2.579; P < 0.0001). Other statistically significant predictors of mortality included increasing van Walraven score, myocardial infarction, metastatic cancer, and weight loss. These were also independent predictors of morbidity along with but not limited to age, device complications, congestive heart failure, paralysis, diabetes with chronic complications, deficiency anemias, device complications, and intraspinal abscess. Perioperative neurologic deficits are serious complications of posterior cervical fusion and can independently predict in-hospital mortality and morbidity. As this procedure continues to be used increasingly, attention should be directed toward preventing these complications and intervening earlier in patients who have a neurologic deficit. Future efforts should be geared toward screening for at-risk patients with the initiation of surgical prehabilitation.