Citations

Background: Emerging neuromodulation approaches, including epidural electrical stimulation (EES), offer hope for restoration of function following chronic spinal cord injury (SCI). However, integrating neuromodulation therapies into clinical procedures is challenging due to the unique needs of the SCI population. Objectives: The purpose of this study was to understand the experiences of participants during a first-in-human trial of perilesional EES aimed at restoring sensorimotor function. Methods: We report participants’ experiences by describing their clinical care, experiences during experimental neuromodulation sessions, and perspectives on the utility of a perilesional EES system. Three participants with chronic thoracic SCI participated in semistructured interviews after completing a 14-day inpatient experimental protocol, which included stimulation mapping, lower extremity motor control experiments, and treadmill stepping. Interview data were analyzed using an applied thematic analysis approach. Nine key themes addressed 4 major topic areas: clinical experiences, experiences during laboratory experiments, experiences as a research participant, and perceived value of perilesional EES. Results: All participants noted the potential for EES to enhance functional recovery, though their postoperative experiences related to clinical care, postoperative pain, and disruptions to routine care differed. Insights gained from qualitative analyses highlighted challenges and opportunities for improving postsurgical care and refining application of EES technology. Further, these results inform recommendations for neuromodulation trials in the SCI community to help mitigate postoperative complications and improve study participant experiences. Conclusion: Key recommendations include being proactive regarding potential postsurgical complications, educating clinical staff regarding common SCI comorbidities, and customizing experimental protocols to align with the priorities and clinical needs of each participant.

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 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.

Purpose of the review With the widespread integration of spinal cord stimulation (SCS) into clinical practice, understanding its ethical, economic, and patient-centered implications has become increasingly important. This review critically examines recent evidence across these domains to illuminate challenges and opportunities for advancing transparent, ethical, patient-centered, and value-based neuromodulation practice. Recent findings Recent analyses reveal persistent challenges with bias, conflicts of interest, and selective outcome reporting in neuromodulation research. Studies demonstrate significant disparities in access to SCS across racial and socioeconomic groups and highlight new ethical considerations associated with artificial intelligence–enabled and informed treatment in neuromodulation. Contemporary randomized trials support clinically meaningful improvements in pain, functionality, psychological outcomes, and other patient-centered outcomes, although durability remains inconsistent because of the potential for therapy habituation or adverse events. Despite high initial upfront costs, evaluations of SCS cost-effectiveness across healthcare systems generally favor SCS over conventional medical management when assessed over multiyear periods, with differential economic benefits observed based on the type of waveform and type of national healthcare system. Summary While current evidence supports the clinical and long-term economic benefits of SCS in defined clinical contexts and indications, gaps in research transparency, equitable access to care, economic considerations, and durability of effectiveness persist.

Achieving optimal unloading in patients with left ventricular assist devices (LVADs) is associated with improved outcomes but remains unattainable in some cases. We retrospectively reviewed 33 patients with a HeartMate 3 LVAD who underwent speed optimization with concomitant echocardiography and right heart catheterization for inadequate left ventricular (LV) unloading between January 2016 and December 2023. Patients were stratified based on left ventricular transmural pressure (LVTMP) into two groups: LVTMP ⩽7 mmHg and LVTMP >7 mmHg using a median split approach. Pulmonary capillary wedge pressure (PCWP) decreased in both groups with increased LVAD speed; however, the mean PCWP change per 100 rpm was significantly smaller in patients with LVTMP ⩽7 mmHg (−0.50 vs −0.99 mmHg per 100 rpm, p = 0.003). Comparative analysis demonstrated LVTMP’s superiority over established RV markers, with the strongest interaction effect for predicting speed optimization response. Changes in cardiac output were similar between the two groups. In univariate analysis, multiple hemodynamic parameters were significantly associated with reduced LVTMP, including right atrial pressure (OR = 1.27, p = 0.036), TPG (OR = 1.25, p = 0.037), DPG (OR = 1.69, p = 0.012), and PAPi (OR = 0.35, p = 0.019).LVTMP, as a surrogate for true LV preload, particularly in the context of RV failure, may offer predictive value for the success or failure of LV unloading with LVAD speed optimization.

Abstract Glioblastoma (GBM) and Alzheimer’s disease (AD) are devastating, age associated disorders with no cure. Epidemiologic data has established an inverse comorbidity between AD and cancer, including GBM, with up to a 50% reduction of cancer incidence in AD patients. While the underlying biology remains unclear, myeloid cells, which are central players in both neurodegeneration and tumor immunity, may serve as a mechanistic link. We hypothesize that myeloid cells activated by pre-existing AD pathology suppress tumor growth more effectively than homeostatic microglia. In this study, age-matched APPNL-G-F/MAPT double knock-in (henceforth “AD”) and wildtype (WT) mice received orthotopic xenografts of syngeneic GBM cell lines (GL261, SB28) (n=15/sex/genotype). We observed a significant survival difference, with AD mice living an average of 20% longer than WT mice (p&lt;0.0001). In vivo luciferase imaging revealed impaired engraftment of tumor cells in AD mice compared to WT a week post-engraftment (p&lt;0.05). At the microscopic level, tumors in AD mice were found to have nearly 2-fold the amount of tumor-infiltrating myeloid cells (p&lt;0.01), with the proportion of anti-tumoral “activated” myeloid cells also being greater (p&lt;0.05). Tumors in AD mice were found to have markedly higher immune infiltrate at the tumor rim and margin (p&lt;0.001). We also observed striking astrogliosis (GFAP+) and microgliosis (P2RY12+) in both the tumor rim (p&lt;0.05) and margin (p&lt;0.01) in AD animals. This robust glial response was significantly higher in AD mice bearing tumor compared to both WT mice bearing tumor and sham AD mice. Lastly, we utilized a luciferase stain to visualize tumor cells that invaded beyond the bulk tumor. We found that both the quantity (p&lt;0.01) and invasion distance of tumor cells (p&lt;0.05) was lower in AD mice. We demonstrate that an AD-induced inflammatory microenvironment antagonizes glioma growth, providing a foundation for novel GBM treatment strategies that potentially exploit these immune signals.