Patel, Naresh P.

BACKGROUND Hirayama disease (HD), also known as juvenile spinal muscular atrophy, is a rare condition in which flexion of the cervical neck causes compression and ischemic changes to the anterior horns of the spinal cord. Here the authors presented the first reported case of HD in North America that was successfully treated via surgical intervention. OBSERVATIONS The patient was a 15-year boy with insidious onset upper limb weakness and atrophy. His findings were a classic presentation of HD although his complex history and relative rarity of the disease caused him to remain undiagnosed for months. After conservative management via cervical collar failed, the patient was successfully treated via C5-C7 anterior cervical discectomy and fusion. The patient’s symptoms stabilized by the 3-month follow-up. LESSONS The diagnosis of HD is easy to miss because of the lack of reporting and widespread knowledge of this condition in North America. Thus, when presented with a case of insidious onset limb weakness in a juvenile patient, HD should be placed on the differential list and verified with cervical flexion magnetic resonance imaging. Additionally, surgical intervention should be considered a safe and effective option for HD when conservative methods have failed.

OBJECTIVE Spinal cord stimulation (SCS) at 10 kHz (10-kHz SCS) is a safe and effective therapy for treatment of chronic low-back pain. However, it is unclear from existing evidence whether these findings can be generalized to patients with chronic back pain that is refractory to conventional medical management (CMM) and who have no history of spine surgery and are not acceptable candidates for spine surgery. The authors have termed this condition "nonsurgical refractory back pain" (NSRBP) and conducted a multicenter, randomized controlled trial to compare CMM with and without 10-kHz SCS in this population. METHODS Patients with NSRBP, as defined above and with a spine surgeon consultation required for confirmation, were randomized 1:1 to patients undergoing CMM with and without 10-kHz SCS. CMM included nonsurgical treatment for back pain, according to physicians’ best practices and clinical guidelines. Primary and secondary endpoints included the responder rate (≥ 50% pain relief), disability (Oswestry Disability Index [ODI]), global impression of change, quality of life (EQ-5D-5L), and change in daily opioid use and were analyzed 3 and 6 months after randomization. The protocol allowed for an optional crossover at 6 months for both arms, with observational follow-up over 12 months. RESULTS In total, 159 patients were randomized; 76 received CMM, and 69 (83.1%) of the 83 patients who were assigned to the 10-kHz SCS group received a permanent implant. At the 3-month follow-up, 80.9% of patients who received stimulation and 1.3% of those who received CMM were found to be study responders (primary outcome, ≥ 50% pain relief; p < 0.001). There was also a significant difference between the treatment groups in all secondary outcomes at 6 months (p < 0.001). In the 10-kHz SCS arm, outcomes were sustained, including a mean 10-cm visual analog scale score of 2.1 ± 2.3 and 2.1 ± 2.2 and mean ODI score of 24.1 ± 16.1 and 24.0 ± 17.0 at 6 and 12 months, respectively (p = 0.9). In the CMM arm, 74.7% (56/75) of patients met the criteria for crossover and received an implant. The crossover arm obtained a 78.2% responder rate 6 months postimplantation. Five serious adverse events occurred (procedure-related, of 125 total permanent implants), all of which resolved without sequelae. CONCLUSIONS The study results, which included follow-up over 12 months, provide important insights into the durability of 10-kHz SCS therapy with respect to chronic refractory back pain, physical function, quality of life, and opioid use, informing the current clinical practice for pain management in patients with NSRBP.

Injections of local anesthetic in the fascial planes around the quadratus lumborum muscle (QL blocks) are performed for postoperative pain control after abdominal surgeries. Multiple approaches of injecting anesthetic in and around the QL have been reported (anterior, posterior, transmuscular, intramuscular and lateral QL blocks). These techniques vary in terms of ease of administration and extent of analgesia. The extent of the anesthetic spread from this ultrasound‐guided procedure is influenced by the fascial layers surrounding the QL. A limited number of studies on small samples using varying amounts of anesthetic have left open questions regarding the extent of spread of local anesthetic and the best approach. This study evaluates the local anesthetic spread of two ultrasound‐guided lateral QL block approaches that have proven effective in controlling postoperative pain. A methylene blue‐dyed saline solution (40mL per QL block) is injected into fresh frozen cadavers (n=10). With the patient in supine position, the needle tip is placed at either (1) the anterolateral border of the QL deep to the transversalis fascia or (2) anterior to the transversus abdominus muscle superficial to its aponeurosis. Anatomic dissection of the injection plane is then performed to determine the extent of spread of the dyed saline. We hypothesize that the continuity between the transversalis fascia and the anterior layer of the thoracolumbar fascia (anterior to the QL) facilitates the cranial spread of the anesthetic under the lateral arcuate ligament to the endothoracic fascia. This would explain our observed analgesic effect past the umbilical region to dermatomes in the epigastric region (T7–T8). Understanding how QL fascial planes facilitate anesthetic spread will enable intraoperative administration of these blocks to be tailored to specific procedures and facilitate post‐operative recovery after abdominal operations. Improved methods of intraoperative pain management may reduce post‐operative opioid use and support the medical community in addressing the opioid epidemic in the United States. This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal .

Retro-odontoid cysts are a rare cause of cervicomedullary compression. The etiology of these lesions is not completely understood. Previous trauma and instability at the cervicomedullary junction may be the precipitating event in the development of retro-odontoid cysts in rare cases. We discussed the neurosurgical evaluation of a patient who presented with progressive and rapid neurological deterioration secondary to cervicomedullary compression. Posterior occipitocervical fusion was performed. The patient made an excellent neurological recovery, and postoperative imaging studies demonstrated resolution of the compression and intramedullary cyst.

OBJECTIVE The authors aimed to demonstrate the feasibility and advantages of carbon fiber–reinforced PEEK (CFRP) composite implants in patients with both primary and secondary osseous spinal tumors. METHODS Twenty-eight spinal tumor patients who underwent fixation with CFRP hardware were retrospectively identified in a Spine Tumor Quality Database at a single institution. Demographic, procedural, and follow-up data were retrospectively collected. RESULTS The study population included 14 females and 14 males with a mean age of 60 years (range 30–86 years). Five patients had primary bone tumors, and the remaining patients had metastatic tumors. Breast cancer was the most common metastatic tumor. The most common presenting symptom was axial spine pain (25 patients, 89%), and the most common Spine Instability Neoplastic Score was 7 (range 6–14). Two patients in this series had anterior cervical procedures. The remaining patients underwent posterior thoracolumbar fixation. The average fusion length included 4.6 vertebral segments (range 3–8). The mean clinical follow-up time with surgical or oncology teams was 6.5 months (range 1–23 months), and the mean interval for last follow-up imaging (CT or MRI) was 6.5 months (range 1–22 months). Eighteen patients received postoperative radiation at the authors’ institution (16 with photon therapy, 2 with proton therapy). Eleven of the patients (39%) in this series died. At the last clinical follow-up, 26 patients (93%) had stable or improved neurological function compared with their preoperative status. At the last imaging follow-up, local disease control was observed in 25 patients (89%). Two patients required reoperation in the immediate postoperative period, one for surgical site infection and the other for compressive epidural hematoma. One patient was noted to have lucencies around the most cephalad screws 3 months after surgery. No hardware fracture or malfunction occurred intraoperatively. No patients required delayed surgery for hardware loosening, fracture, or other failure. Early tumor recurrence was detected in 3 patients. Early detection was attributed to the imaging characteristics of the CFRP hardware. CONCLUSIONS CFRP spinal implants appear to be safe and comparable to conventional titanium implants in terms of functionality. The imaging characteristics of CFRP hardware facilitate radiation planning and assessment of surveillance imaging. CFRP hardware may enhance safety and efficacy, particularly with particle therapy dosimetry. Larger patient populations with longer-term follow-up are needed to confirm the various valuable aspects of CFRP spinal implants.

Abstract BACKGROUND Trends in Medicare billing and procedural reimbursement for outpatient office visits remain unclear within the field of neurosurgery. OBJECTIVE To analyze financial trends of neurosurgeon reimbursement for Medicare office visits in 2010 compared to 2018. METHODS The 2010 and 2018 physician/supplier files from the Centers for Medicare and Medicaid Services website were utilized. All payments submitted by neurosurgeons (provider ID 14) were included. Trends in office visit Current Procedural Terminology codes 99201 to 99205 and 99211 to 99215 were analyzed. RESULTS Neurosurgeons billed for 1 109 979 office visits (463 611 h) in 2010 and Medicare denied 63 704 payments (totaling $11 205 283). Neurosurgeons billed for 1 189 046 office visits (508 526 h) in 2018 and Medicare denied 57 048 payments (totaling $15 103 879). This is a 7.1% increase in total neurosurgery office visits billed to Medicare, 9.7% increase in total office hours, and 34.8% increase in the payment amounts denied over 8 yr. Furthermore, after adjusting for inflation, the average amount paid to physicians by Medicare decreased by 8.3% per office visit. Additionally, Medicare paid 36.1% of the total neurosurgeon submitted charge amount for all office visits in 2010 but paid only 27.8% in 2018 (−8.3%). CONCLUSION Neurosurgeons are performing more office visits and billing for more time with patients. Meanwhile, Medicare has been paying physicians less per office visit, denying higher amounts of payments and reimbursing a decreasing percentage of submitted charges for office visits. An understanding of these trends is necessary to ensure continued equity and quality access to neurosurgical care in the United States.

Abstract BACKGROUND Trigeminal neuralgia (TN) refractory to medical management is often treated with microvascular decompression (MVD) involving the intracranial placement of Teflon. The placement of Teflon is an effective treatment, but does apply distributed pressure to the nerve and has been associated with pain recurrence. OBJECTIVE To report the rate of postoperative pain recurrence in TN patients who underwent MVD surgery using a transposition technique with fibrin glue without Teflon. METHODS Patients were eligible for our study if they were diagnosed with TN, did not have multiple sclerosis, and had an offending vessel that was identified and transposed with fibrin glue at our institution. All eligible patients were given a follow-up survey. We used a Kaplan-Meier (KM) model to estimate overall pain recurrence. RESULTS A total of 102 patients met inclusion criteria, of which 85 (83%) responded to our survey. Overall, 76 (89.4%) participants responded as having no pain recurrence. Approximately 1-yr pain-free KM estimates were 94.1% (n = 83), 5-yr pain-free KM estimates were 94.1% (n = 53), and 10-yr pain-free KM estimates were 83.0% (n = 23). CONCLUSION Treatment for TN with an MVD transposition technique using fibrin glue may avoid some cases of pain recurrence. The percentage of patients in our cohort who remained pain free at a maximum of 17 yr follow-up is on the high end of pain-free rates reported by MVD studies using Teflon. These results indicate that a transposition technique that emphasizes removing any compression near the trigeminal nerve root provides long-term pain-free rates for patients with TN.

Background:Among the elderly, chronic subdural hematoma is a relatively common neurosurgical condition. Presenting symptoms range from headache and focal neurological deficits to seizure and coma depending on location and extent of brain compression. Functional recovery following surgery for chronic subdural hematoma is central to quality of life and ongoing health for elderly patients; however, there is a paucity of data regarding functional recovery in this population.Methods:In this study, the physical activity of patients who underwent surgical evacuation of chronic subdural hematoma was surveyed, as well as participation in physical therapy following surgery. In total, 38 patients completed the survey.Results:Of the 30 patients who exercised regularly before surgery, 28 (90.3%) returned to exercise within 1 year after surgery. Of 13 patients who reported playing hobby sports before surgery, 9 (69.2%) returned to those sports. 17/38 (44.7%) patients participated in physical therapy after surgery. 35/38 (92.1%) of patients reported that the surgery improved their quality of life.Conclusion:The majority of patients who underwent surgery for chronic subdural hematoma were able to return to exercise within 1 year. Participation in physical therapy was associated with return to exercise and sports. Further study is needed to determine which factors contribute to a return to baseline levels of physical activity following surgery for chronic subdural hematoma.

Case Report. Spine surgery in patients with Parkinson’s disease (PD) involves increased risk. We describe a case of cervical myelopathy in a patient with PD, multiple fractures involving the atlas and axis vertebrae, and spasmodic torticollis. The patient was successfully treated with an upper cervical decompression and occipital-cervical (OC) fusion surgery. Strategies for torticollis reduction and successful surgical outcome are discussed. Risks and benefits must be carefully weighed when considering occipital cervical fusion in PD patients. Conclusion. Intraoperative manual reduction of laterocollis is possible after general endotracheal anesthesia, and continuous neuromonitoring is established. Use of optimizing strategies such as perioperative botulinum injections and intraoperative O-arm navigation should be considered.