Nathani, Karim Rizwan

Abstract Background Hydrocephalus, the abnormal buildup of cerebrospinal fluid (CSF) in the brain’s ventricles, makes pediatric neurosurgery difficult. Endoscopic Third Ventriculostomy (ETV) and Ventriculoperitoneal Shunting (VPS) are the basic treatments, however unsuccessful ETV management is disputed. This study aims to compare RE-ETV with VPS in pediatric hydrocephalus patients after unsuccessful ETV. Methods A comprehensive literature review was performed using PubMed, Embase, and Cochrane Library. The review covered pediatric RE-ETV or VPS trials following ETV failure. Success rates, complications, failure timings, and reoperation rates were extracted. The Cochrane Collaboration’s risk of bias instrument (RoB 2.0) and Critical Appraisal Skills Programme (CASP) were utilized to assess quality of studies. Results 40 articles were chosen for comprehensive full-text evaluation. Nine publications specifically addressing the topic of Re-ETV and/or VPS placement after the failure of original ETV were identified as acceptable for the review. A data set of 663 patients was assessed. Re-ETV was carried out in 220 patients (33.18%) and VPS Placement was done in 443 patients (66.81%). The primary ETV failure rates ranged from 16.6% to 60.89%. There was a larger failure rate of Re-ETV (74.98%) compared to VPS (22.26%) showing that VPS is often more effective as a secondary intervention. The presence of bleeding during primary ETV suggested more benefit from VPS placement rather than Re-ETV (p < 0.05). Conclusions VPS is more commonly employed than RE-ETV in pediatric patients after unsuccessful ETV. Although RE-ETV provides a less invasive technique, it has a greater failure rate. However, owing to inadequate evidence on VPS failure post-ETV, additional research is recommended. Future research should concentrate on enhancing the evidence foundation to aid clinical decision-making in treating hydrocephalus post-ETV failure.

OBJECTIVE Isthmic spondylolisthesis impacts up to 11.5% of the general population. For patients who have failed conservative therapy, decompression and fusion or decompression alone are options for surgical management. However, there remains debate as to whether reduction of mobile spondylolisthesis is integral to good patient outcomes. The present systematic review and meta-analysis aimed to address this by comparing clinical and radiological outcomes between patients treated with fusion in situ and those undergoing fusion with reduction of isthmic spondylolisthesis. METHODS The Scopus, EMBASE, Medline, and Cochrane databases were systematically queried on the basis of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies comparing treatment outcomes in patients with isthmic spondylolisthesis after in situ fusion or fusion with spondylolisthesis reduction. Endpoints of interest included Oswestry Disability Index (ODI) score, hospitalization duration, operative morbidity, and rates of surgical revision. Data from individual studies were aggregated using random-effects models to assess combined effects. RESULTS Of 277 identified studies, 7 studies were included with an aggregate 308 patients (143 underwent fusion in situ and 165 underwent reduction). Patients who underwent reduction for isthmic lumbar spondylolisthesis had significantly lower rates of pseudarthrosis at last follow-up (OR 0.22, p = 0.03). Estimated blood loss, operative time, hospitalization duration, change in ODI score, change in back pain (visual analog scale [VAS]), and reoperation rate did not differ significantly between groups. CONCLUSIONS For patients with isthmic spondylolisthesis, the present data suggest that fusion with reduction of spondylolisthesis may lower rates of pseudarthrosis as compared to in situ fusion. However, operative morbidity and improvement in patient-reported outcomes were similar between strategies.

OBJECTIVE Hundreds of thousands of Americans undergo decompression for lumbar spinal stenosis annually. The mild (minimally invasive lumbar decompression) procedure was developed as a potentially less invasive alternative to open decompression; however, much of the evidence has been gathered from industry-sponsored studies. The present study sought to compare real-world clinical outcomes between the mild procedure and open decompression for lumbar spinal stenosis. METHODS All patients who underwent the mild procedure at a single-institution, multisite, tertiary care center from 2005 to October 2024 were included. One-to-one propensity score matching was used to identify patients who underwent open decompression at the same institution, with age, sex, smoking, and comorbidities as covariates. Primary outcomes were change in pain on the numeric rating scale (NRS), surgical reoperation, and perioperative complications. For pain, the minimal clinically important difference (MCID) was defined as a 30% improvement in NRS score. RESULTS A total of 175 patients who underwent the mild procedure (mean age 76.3 ± 8.7 years; 44.6% female) were matched to 175 patients treated with open decompression (mean age 75.4 ± 8.7 years; 44.0% female). Among patients with at least 60 days of follow-up, those treated with open decompression were more likely to achieve the MCID for pain (43.1% vs 22.2%, p < 0.001). Patients treated with mild were more likely to require reoperation (46.2% vs 29.3%, p = 0.008). Those who underwent the mild procedure experienced lower rates of durotomies (0% vs 2.9%, p = 0.024) but had higher rates of neurological deficits (6.3% vs 0.6%, p = 0.003). CONCLUSIONS For patients with symptomatic lumbar stenosis, those who underwent open decompression were more likely to achieve pain improvement and less likely to require reoperation compared with those who underwent the mild procedure.

OBJECTIVE Surgical site infection (SSI) is a leading cause of morbidity following posterior spine surgery. The optimal choice of skin closure technique depending on patient- and procedure-specific characteristics remains to be elucidated. METHODS The Neurosurgery Enterprise Registry (NER) at Mayo Clinic was queried for patients who underwent posterior spine surgery from 2017 to 2023. Propensity matching was performed to match patients on the basis of the development of SSI and baseline characteristics, including age, sex, race, and comorbidities. Perioperative outcomes were analyzed using data from the NER and medical records. RESULTS A total of 18,842 cases of posterior spine surgery were identified in the NER, and SSI was observed in 154 cases (0.8%). Of these patients, 308 patients were included in the 1:1 propensity score–matched cohort analysis, with 154 patients included in each group. Sutures were used in 224 patients (72.7%) and staples in 84 patients (27.3%) (p < 0.01). Female patients comprised 45.1% of the sutures group and 46.4% of the staples group (p = 0.8). The mean ± SD age was 59.8 ± 15.4 years in the sutures group and 60.8 ± 11.9 years in the staples group (p = 0.6). Fusion was performed in 27.2% of patients in the sutures group and 44% in the staples group (p < 0.01). Multilevel fusion comprised 68.9% of fusion cases in the sutures group and 67.6% in the staples group (p = 0.8). Comorbidities, such as diabetes (p = 0.6), hypertension (p = 0.1), and the use of disease-modifying antirheumatic drugs (DMARDs) (p = 0.5) and immunosuppressants (p = 0.2), did not differ between groups. Univariate analysis performed in the propensity score–matched cohort showed that SSI was observed in 53.6% of patients in the sutures group and 40.5% in the staples group (p = 0.04). No significant differences were noted regarding 30-day (p = 0.3), 90-day (p = 0.2), and 1-year (p = 0.3) readmissions and 30-day (p = 0.7), 90-day (p = 0.8), and 1-year (p = 0.8) reoperations. On multivariable logistic regression, SSI was not significantly associated with the choice of skin closure technique (p = 0.3). CONCLUSIONS After adjustment for spinal fusion, number of fused levels, the use of immunosuppressants, and other risk factors, SSI development was not significantly associated with the use of sutures versus staples following posterior spine surgery in our institution. Additionally, no significant differences were observed regarding baseline characteristics and other perioperative outcomes. The authors’ analysis shows that skin closure technique did not significantly affect SSI rates and other outcomes in these patients.

Abstract INTRODUCTION Hydrocephalus in pediatric patients is commonly treated with endoscopic third ventriculostomy (ETV) or ventriculoperitoneal shunting (VPS). When primary ETV fails, clinicians must decide between repeat ETV (Re-ETV) and VPS placement. However, the optimal secondary intervention remains debated. Objective: To compare the efficacy and outcomes of Re-ETV versus VPS placement following failed primary ETV in pediatric hydrocephalus. METHODS We conducted a systematic review following PRISMA guidelines. Searches of PubMed, Embase, and the Cochrane Library identified English-language studies (2001–2023) reporting on Re-ETV or VPS after failed primary ETV in patients aged 0–18 years. Comparative studies, including randomized controlled trials, cohort studies, and prospective designs were eligible. Two independent reviewers screened titles, abstracts, and full texts; extracted data on sample size, intervention rates, failure rates, and complications; and assessed study quality using RoB 2.0 and CASP tools. Pooled descriptive statistics and odds ratios (OR) were calculated for secondary intervention failure. RESULTS Nine studies (n = 663) met inclusion criteria. Re-ETV was performed in 220 patients (33.2%) and VPS in 443 (66.8%). Primary ETV failure rates ranged from 16.6% to 60.9% (mean 40.6%). Re-ETV exhibited a pooled failure rate of 74.98%, whereas VPS failure was 22.26% (OR 4.86; 95% CI 3.21–7.38; p &lt; 0.05). Hemorrhagic etiology during primary ETV significantly favored VPS over Re-ETV (p &lt; 0.05). Time to secondary failure averaged 15.8 ± 21.7 months, with broad inter-study variability. CONCLUSION VPS placement demonstrates a substantially lower failure rate than Re-ETV as a secondary intervention after primary ETV failure in pediatric hydrocephalus. Nevertheless, variability in patient age, etiology, and follow-up underscores the necessity of individualized decision-making. Prospective trials with standardized outcome measures are warranted to refine secondary treatment guidelines.

Study Design: Retrospective cohort analysis. Objective: To determine the effect of long-segment posterior cervical decompression and fusion (PCDF) on perioperative changes in vertebral Hounsfield Units (HUs) and the impact of these changes on radiographic outcomes and fusion status. Summary of Background Data: Low preoperative CT HUs have been associated with adverse outcomes after spinal fusion, including hardware complications and reoperation. No existing studies have investigated the preoperative to postoperative change in HUs after cervical spinal fusion. Stress shielding may decrease bone quality within the fusion construct. Whereas, altered junctional loading and increased segmental mobility may precipitate bony hypertrophy in the terminal and adjacent levels. Methods: All adult patients who underwent C2-T2 PCDF for myelopathy/ myeloradiculopathy at an academic center between 2013 and 2020 were retrospectively identified. Preoperative and postoperative HUs were assessed on axial CT images in the cranial, middle, and caudal C2, C6, T2, and T3 vertebral bodies, outside of the region of instrumentation and artifact by 2 independent reviewers. Paired t test compared preoperative to postoperative changes in HUs. Preoperative and long-term postoperative cervical alignment, fusion, and revision rates were assessed. Univariate and regression analysis compared patient factors and outcomes between groups with perioperative increase versus decrease in vertebral HUs. Results: One hundred patients were included. The average preoperative to postoperative change in HUs in the C2, C6, T2, and T3 vertebral bodies were −19.80 (P=0.008), −52.63 (P<0.001), 15.15 (P=0.014), and 9.41 (P=0.346), respectively. Perioperative increase in C2 HUs was predictive of increased postoperative distal junctional angle (β=3.41, P=0.048) and increased T1–T4 kyphosis (β=6.50, P=0.003). Perioperative increase in C6 HU predicted pseudoarthrosis (fusion odds ratio: 0.19, P=0.007). Conclusions: Significant perioperative decreases in C6 HUs within a long-fused construct may demonstrate stress shielding. The significant association between greater distal kyphosis and an increase in C2 HUs may be attributed to a stress riser effect. Level of Evidence: Level III.

Background: Estimating operative time with low accuracy and precision leads to suboptimal scheduling of available operating rooms (ORs) and waste of healthcare resources. We aimed to develop a predictive machine learning (ML) model for operative time using our institutional data to improve the scheduling of neurosurgical ORs, minimize waste, and maximize resource utilization. Methods: We developed a predictive model using our institution’s multicenter registry, which included diverse neurosurgical cases across three tertiary hospitals. We applied multiple ML techniques, including linear regression, support vector regression, deep neural networks, and extreme gradient boosting regression (XGBR). The best model was combined with the first fit decreasing bin-packing algorithm to create a practical OR scheduling system based on prior data. Results: The XGBR model exhibited the best performance, with lower mean absolute errors (MAEs) (root mean squared error: 52.24, MAE: 37.25) and higher R2 (0.76) values than other models. Implementing this model in a simulated OR scheduling scenario using institutional data, we successfully scheduled 30 random procedures with minimal residual time, such that the model ran out of procedures for the week with 86 and 171 min remaining in the cranial and spinal ORs, respectively, demonstrating potential efficiency gains. The cranial procedures were scheduled over 4 days and spinal procedures over 6 days, optimizing available OR time. Conclusion: Integrating ML models into operative time prediction can significantly improve the accuracy and efficiency of surgical schedules. This approach minimizes wasted OR time and enhances resource allocation, potentially improving patient outcomes and satisfaction by reducing waiting times.

OBJECTIVE Artificial intelligence (AI) is increasingly capable of academic writing, with large language models such as ChatGPT showing potential to assist or even generate scientific manuscripts. However, concerns remain regarding the quality, reliability, and interpretive capabilities of AI-generated content. The authors’ study aimed to compare the quality of a human-written versus an AI-generated scientific manuscript to evaluate the strengths and limitations of AI in the context of academic publishing. METHODS Two manuscripts were developed using identical titles, abstracts, and tables of a simulated analysis: one authored by a physician with multiple publications, and the other generated by ChatGPT-4o. Three independent and blinded reviewers—two human and one AI—assessed each manuscript across five domains: clarity and readability, coherence and flow, technical accuracy, depth, and conciseness and precision. Each category was scored on a 10-point scale, and qualitative feedback was collected to highlight specific strengths and weaknesses. Additionally, all reviewers were asked to deduce authorship of the manuscripts. RESULTS The AI-generated manuscript scored higher in clarity and readability (mean 9.0 vs 7.2), but lower in technical accuracy (mean 6.3 vs 9.3) and depth (mean 5.5 vs 7.5). However, reviewers noted that the AI version lacked depth, critical analysis, and contextual interpretation. All reviewers accurately identified the authorship of each manuscript and tended to rate the version more favorably when it aligned with their own origin (human or AI); i.e., human reviewers assigned higher scores to the human-written manuscript, while the AI reviewer scored the AI-generated manuscript higher. CONCLUSIONS Although AI models can improve some aspects of scientific writing, particularly clarity and readability, they fall short in critical reasoning and contextual understanding. This reinforces the importance of human authorship and oversight in maintaining the critical analysis and scientific accuracy essential for academic publishing. AI may be used as a complementary tool to support, rather than replace, human-led scientific writing.

Study design: Cohort study. Objective: This study aimed to evaluate influence of facet cysts on outcomes in patients undergoing lumbar decompression, and the influence of spinal fusion in patients undergoing decompression for facet cysts. Summary of Background Data: The impact of facet cysts on outcomes following lumbar spine surgery for degenerative spine disease remains unclear. Methods: Our multicenter institutional Neurosurgery Enterprise Registry was queried for patients who underwent lumbar decompression for degenerative spine conditions. Patients were divided into 2 cohorts: those with lumbar spine facet cysts and those without. Retrospective propensity-score matching was performed using 13 baseline variables to adjust for potential confounding factors, including age, sex, race, body mass index, and comorbidities. Secondary analysis comparing outcomes in patients with facet cysts cases undergoing decompression only versus those undergoing decompression and fusion was conducted. Results: A total of 6768 patients were reviewed, of which 188 (2.8%) had facet cysts, which underwent lumbar decompression during 2019–2023. After 3:1 matching, patients with facet cysts were compared with 564 patients without it. We found no significant differences in LOS, nonroutine discharge, postoperative complications, readmissions, and reoperations. In addition, in cases with facet cysts, decompression reported no increased risk for discharge opioids, readmissions, and reoperations, whereas fusion (in a separate cohort of 127 patients with facet cysts) was associated with an increased risk for nonroutine discharge (3.7% vs. 10.2%, P=0.021), complications (2.1% vs. 7.1%, P=0.042), and longer LOS (0.89±1.69 vs. 3.74±2.03 d, P<0.001) and operative time (138.78±62.99 vs. 273.07±111.51 min, P <0.001). Conclusions: The presence of facet cysts does not significantly affect outcomes of lumbar decompression for degenerative spine disease. Decompression alone for facet cysts can have better outcomes than decompression and fusion. The need for fusion should be weighted with its higher risks of complications, longer hospital stays, and nonroutine discharges.

BACKGROUND AND OBJECTIVES: Cervical spinal cord injury (SCI) can occur in the absence of easily identifiable osseoligamentous abnormalities, such as fractures and dislocations. The role of surgery in the management of this condition remains to be elucidated. METHODS: A comprehensive literature search was conducted to identify studies investigating outcomes after surgical management of cervical SCI without fracture and dislocation. Random-effects model meta-analysis was performed, with neurological improvement and time to surgery as primary end points. Subgroup analysis by time to surgery was performed to assess neurological improvement between patients undergoing surgery within 72 hours of injury vs later than 72 hours after injury. RESULTS: A total of 16 studies yielding 398 surgically treated patients with this condition were analyzed. The mean age at the time of injury was 52 ± 33.8 years, and male patients comprised 86.4% (95% CI: 76.6%-94.4%). The mean number of spinal cord segments affected was 2.5 ± 4. Injury was most commonly inflicted by falls (58.4%, 95% CI: 46.6%-69.9%), followed by motor vehicle accidents (30.5%, 95% CI: 23.4%-38%). Preoperatively, abnormal magnetic resonance imaging findings were observed in 125 patients (31.4%), and included: Intervertebral disk injury in 33 patients (26.4%); Cord edema in 23 patients (18.4%); Cord contusion in 22 patients (17.6%); Ligamentous injury in 6 patients (4.8%); and MRI abnormalities not specified in 41 patients (32.8%). Postoperatively, neurological improvement was noted in 62% (95% CI: 21.4%-95.2%) of patients who underwent surgery within 72 hours after injury, and in 71.1% (95% CI: 33%-98.1%) of the patients who underwent surgery later than 72 hours after injury ( P = .8). CONCLUSION: This meta-analysis demonstrated high rates of neurological improvement in patients treated surgically for cervical SCI without fracture and dislocation. No significant differences were noted between patients undergoing surgery acutely, within 72 hours after injury, and patients being treated surgically later in the course of cervical SCI without fracture and dislocation.