Citations

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.

OBJECTIVE Lordotic devices have garnered increased attention for improving the segmental lordosis (SL) achieved with transforaminal lumbar interbody fusion (TLIF). However, it is unclear the degree to which surgeons maximize the "ideal" or listed lordosis of the interbody device. METHODS Patients undergoing one- or two-level TLIF for degenerative pathologies were identified and data were extracted on demographics, baseline lumbopelvic radiographic parameters, and TLIF details. The primary outcome of interest was the degree to which postoperative SL approximated the listed cage lordosis (Δtarget). Change in SL was a secondary outcome. Linear mixed-effects modeling was used to identify significant predictors of the percentage of ideal lordosis achieved. RESULTS A total of 239 treated levels were included (median patient age 66.6 years; 56.9% female); 151 levels were part of single-level TLIF constructs. The median segmental corrections were a 2.8° increase in SL and 2.8 mm in disc height. The median difference between listed cage lordosis and postoperative SL (Δtarget) was 0.5°. However, only 56.1% of levels achieved at least the listed cage lordosis. Linear mixed-effects modeling found that independent predictors of Δtarget were lower implant lordosis (estimate −1.01° [95% CI −1.15° to −0.87°] per degree, p < 0.001), greater preoperative SL (estimate 0.38° [95% CI 0.28°–0.48°] per degree, p < 0.001), greater preoperative PI (estimate 0.06° [95% CI 0.02°–0.11°] per degree, p = 0.007), and closer approximation of the anterior apophyseal ring of the caudal vertebrae (estimate −0.27° [95% CI −0.39° to −0.15°] per mm, p < 0.001). Similarly, independent predictors of postoperative SL were larger implant lordosis (estimate 0.16° [95% CI 0.05°–0.27°] per degree, p = 0.004), lower preoperative SL (estimate −0.70° [95% CI −0.79° to −0.62°] per degree, p < 0.001), greater preoperative PI (estimate 0.08° [95% CI 0.04°–0.12°] per degree, p < 0.001), and closer approximation of the anterior apophyseal ring of the cranial vertebrae (estimate −0.15° [95% CI −0.28° to −0.03°] per mm, p = 0.014). CONCLUSIONS The present results suggest that while lordosing, only 56% TLIF operations obtain the listed interbody lordosis ("target" lordosis). Anterior placement within the disc space is the only modifiable intraoperative technical factor for maximizing lordosis for a given interbody, highlighting the importance of effective disc space exenteration.

Abstract Background DNA methylation profiling can be used to robustly predict postsurgical outcomes and response to radiotherapy (RT) for meningioma patients. To allow for seamless integration of these complementary models into clinical practice, a practical framework is needed. Methods We leveraged a cohort of nearly 2000 surgically-treated meningiomas with DNA methylation profiling and clinical outcomes data. Existing methylation-based prediction models were dichotomized to yield four risk groups: low and high recurrent risk, each with RT sensitive and resistant subgroups. Risk groups were correlated with progression-free survival in the context of existing biomarkers including extent of resection and WHO grade. Results We first demonstrated that all risk groups benefit from gross total resection. All “high-risk, RT sensitive” tumors (n = 306, 15.7%) also benefited from adjuvant RT: after GTR, median PFS increased from 4.68 (4.13-9.48) years to not reached (P = .003); after subtotal resection (STR), from 2.12 (1.59-3.02) to 4.09 (3.41-not reached) years (P = .004). “Low-risk, RT sensitive cases” (n = 1207, 61.8%) also benefited from RT after STR (median PFS 7.39 (6.66-12.8) vs. 16.53 (10.35-not reached) years, P = .03), suggesting that RT be considered in these patients. Neither “low-risk RT resistant” (n = 84, 4.3%) nor “high-risk RT resistant” (n = 356, 18.2%) cases benefited from RT, and the latter group was associated with universally poor outcomes. Conclusions We identify methylation-defined risk groups of meningioma for which additional benefit is gained from adjuvant RT, leading to a clinical decision-making framework for straightforward integration of molecular models into clinical practice.

Hyperkalemia is a common and potentially life-threatening electrolyte abnormality in patients with heart failure, particularly among those with diabetes or chronic kidney disease. It often results from the use of renin–angiotensin–aldosterone system inhibitors, which, while improving survival, increase serum potassium levels. Elevated potassium produces cardiotoxic effects, often recognized by characteristic electrocardiographic changes. Acute management focuses on stabilizing cardiac membranes with intravenous calcium and shifting potassium intracellularly through insulin-dextrose, β₂-agonists, or sodium bicarbonate, with caution to avoid fluid overload. Potassium elimination may be achieved using diuretics or hemodialysis when refractory. For chronic management, newer potassium-binding agents such as patiromer and sodium zirconium cyclosilicate offer improved safety and efficacy compared with traditional resins, enabling the continuation and up-titration of renin–angiotensin–aldosterone system inhibitors. These therapies support optimal neurohormonal blockade, improve adherence, and reduce morbidity and mortality in heart failure.

Abstract BACKGROUND Awake craniotomy with speech mapping remains a gold standard for achieving maximal safe resection of diffuse gliomas located in eloquent cortex. Significant practice variability exists with regards to patient selection, speech mapping paradigms, aggressiveness of resection, and use of other adjuncts. We report our experience with speech mapping procedures for patients with diffuse gliomas, comparing cases performed with and without intraoperative MRI. METHODS A single-surgeon retrospective review of 148 consecutive awake craniotomy procedures, from 2008-2024, was performed. We recorded baseline patient characteristics, speech mapping findings, post-operative course, and volumetric extents of resection. Multivariate regression analyses were performed for factors predictive of permanent aphasia and residual tumor volume. RESULTS Speech mapping was performed in 95% of cases, with positive speech areas found in 49% of cases. Intraoperative MRI cases (75% of total) had significantly greater extent of resection (87.4% vs. 78.6%, p=0.03) despite equivalent pre-operative volumes. Post-operative new/worsened aphasia was 15% for mild and 5% for moderate symptoms, and this was associated with reduced rates of return to work (54% vs 78%, p=0.04). Predictors of recovery from aphasia were extent of resection (OR 1.1, p=0.006) and 90-day disease progression (OR 0.06, p=0.04). Predictors of residual tumor volume were pre-operative tumor volume (β 0.3, p&lt;0.001), identification of after-discharge potentials during speech mapping (β -9.7, p&lt;0.001), and pre-operative functional status (β -0.3, p=0.02). Overall survival was impacted by presence of contrast enhancement (p=0.0002), tissue diagnosis (p&lt;0.0001), and WHO grade (p&lt;0.0001). CONCLUSIONS Awake craniotomy with speech mapping remains a valuable strategy for achieving maximal safe resection of diffuse gliomas, with the majority of patients returning to baseline level of functioning. New/worsened aphasia is the biggest risk of surgery, which significantly impacts patient quality of life. Intraoperative MRI can be considered as an adjunctive tool for awake speech mapping during glioma surgery.