Citations

Background/Objectives: To identify predictors of successful fusion and adjacent segment disease (ASD) following ALIF. Methods: Records of patients undergoing one- or two-level ALIF were queried for baseline and postoperative radiographic data, demographics, operative notes, and implant characteristics. All had ≥1 year of follow-up with CT, and multivariable Cox regression was used to identify predictors of radiographic fusion through the interbody, ASD, and ASD requiring reoperation. Results: In total, 177 patients (median 59 yr; 52.5% male) were treated at 245 unique levels, of which 193 fused (81.3% with posterior fixation and 59.6% with standalone), 43 had ASD (17.6%), and 14 had ASD requiring reoperation (5.7%). Fusion was predicted by anterior cage placement (HR 0.94/mm; 95% CI [0.90, 0.98]; p = 0.003) and BMP use (HR 1.92; [1.15, 3.18]; p = 0.012). Radiographic ASD was predicted by older age (HR 1.08 per year; [1.03, 1.14]; p < 0.001), undergoing a revision [vs. index] fusion operation (HR 3.51; [1.44; 8.59]; p = 0.006), lower preoperative disc height (HR 0.83/mm; [0.74, 0.94]; p = 0.003), and preoperative facet vacuum phenomenon (HR 2.46; [1.18, 5.15]; p = 0.017). None of the extracted variables predicted reoperation for ASD. Conclusions: BMP use along with anterior cage placement and posterior fixation may improve the odds of fusion through the interbody following one- or two-level ALIF. Adjacent segment pathology is more common in patients with greater preoperative degenerative pathology (vacuum sign; more collapsed disc) and advanced age. Pelvic fixation did not improve fusion odds, but the data highlight the benefits of supplementary posterior fixation vs. standalone ALIF.

Purpose: To determine the clinical utility of the assessment of preoperative orbital compliance in predicting the amount of postoperative proptosis reduction in patients with stable-phase thyroid eye disease who undergo orbital fat decompression surgery. Methods: A retrospective chart review was conducted of stable-phase thyroid eye disease patients who underwent orbital fat decompression by a single surgeon. Orbital compliance was measured preoperatively as axial globe displacement (in millimeters) using a Hertel exophthalmometer. Displacement ≥2.5 mm was classified as high compliance and <2.5 mm as low compliance. Radiographic thyroid eye disease type, preoperative proptosis, and intraoperative fat volume removed were recorded. Linear regression analysis determined whether orbital compliance independently predicted postoperative proptosis reduction. Levene’s test assessed variability between groups. Results: Forty-six orbits from 24 patients were included, 15 orbits with low compliance and 31 with high orbital compliance. Patients with high orbital compliance had a mean postoperative proptosis reduction of 3.19 mm (range 0.5–6.0 mm) while patients with low orbital compliance had a mean proptosis reduction of 2.67 mm (range 2.0–3.5 mm). On average, higher preoperative orbital compliance led to 0.959 mm greater proptosis reduction compared with low orbital compliance, when accounting for radiographic thyroid eye disease type and volume of fat removed intraoperatively ( p = 0.048). Variability in proptosis reduction was higher among the high orbital compliance group ( p = 0.00085). Conclusions: Higher preoperative orbital compliance results in greater proptosis reduction. However, patients with high orbital compliance have greater variability in proptosis reduction, suggesting that surgical outcomes are less predictable among these patients.

BACKGROUND Differential awakening is a well-known, yet poorly understood phenomenon seen in patients with intracranial pathologies. Because acute postoperative neurological decline has many potentially reversible causes, distinguishing differential awakening from other etiologies is critical. To the authors’ knowledge, differential awakening has not been reported following peripheral nerve procedures. OBSERVATIONS A 40-year-old man presented with a 1.5-year history of painful bilateral cervical and right lumbosacral radiculoplexus neuropathy recently associated with bilateral facial and vestibulocochlear neuropathy. He had not responded to treatment trials. A sciatic nerve lesion in the sciatic notch was identified on imaging and an open biopsy of the posterior femoral cutaneous nerve was pursued. Immediately after emergence from anesthesia, he demonstrated a complete inability to dorsiflex or plantar flex the right foot, despite minimal intraoperative manipulation of the sciatic nerve. Over the ensuing hour, motor function progressively returned to baseline. The transient postoperative motor deficit was attributed to differential awakening of the sciatic nerve. Pathological analysis confirmed high-grade B-cell lymphoma. LESSONS Differential awakening may be an underrecognized cause of transient neurological worsening during emergence from anesthesia following peripheral nerve surgery. Further investigation is needed to clarify the underlying mechanisms and define its incidence and risk factors. https://thejns.org/doi/10.3171/CASE251028

Importance Current risk prediction guidelines for hypertrophic cardiomyopathy predict only sudden cardiac death and are imperfect, leading to avoidable deaths and unnecessary implantable cardioverter defibrillators. Objective To combine prospectively collected clinical history, imaging, genetic, and biomarker data to improve risk prediction of adverse events in hypertrophic cardiomyopathy. Design, Setting, and Participants A total of 2750 patients with hypertrophic cardiomyopathy were prospectively enrolled in the registry-based study from 44 sites in North America and Europe with expertise in hypertrophic cardiomyopathy and cardiac magnetic resonance (CMR) imaging. Participants were enrolled from April 1, 2014, to April 7, 2017. Exposures Patients underwent a health history questionnaire, blood sampling for biomarkers and genotyping, and contrast-enhanced CMR. Patients were followed up yearly by telephone and through records review regarding event documentation. Main Outcomes and Measures The predefined composite adjudicated primary end point was time to first event for hypertrophic cardiomyopathy–related deaths; nonfatal sustained ventricular arrhythmias (VAs) requiring cardioversion or defibrillation; and left ventricular (LV) assist device implant or heart transplant. A secondary end point was a composite of sudden cardiac death and nonfatal VA events. The elastic-net method identified the most important predictors. Cox proportional hazards regression assessed associations with time to the first end point. Results Of the 2750 prospectively enrolled patients, 2698 (98%) had analyzable data after 9 were excluded because they had hypertrophic cardiomyopathy phenocopies and 43 withdrew. Of these remaining patients, 1919 (71%) were male, mean age was 50 years (SD, 11 years), and 423 (16%) were from underrepresented racial and minority groups. The mean follow-up was 6.9 years (SD, 2.1 years). The primary event model in 104 patients included LV scar as a percentage of LV mass by late gadolinium enhancement (LGE%; hazard ratio [HR], 1.86; 95% CI, 1.58-2.20; P &amp;lt; .001), LV mass index (HR, 1.09; 95% CI, 1.01-1.17; P = .03), LV end-systolic volume index (HR, 1.28; 95% CI, 1.12-1.46; P &amp;lt; .001 ), all per 10-unit increase, history of heart failure at study entry (HR, 2.89; 95% CI, 1.75-4.77; P &amp;lt; .001), and log N-terminal pro–B-type natriuretic peptide (NT-proBNP; HR, 1.41; 95% CI, 1.17-1.70; P &amp;lt; .001) level per log unit, (C index for all, 0.77). An LGE percentage of the LV mass of 9% or higher substantially increased the primary composite event rate ( P = .001). The secondary sudden cardiac death and VA risk factor model (in 69 patients) included LGE%, LV mass index, LV ejection fraction, and log(NT-proBNP) (C index, 0.76). Conclusions and Relevance These results provide prospective evidence for incorporating cardiac magnetic resonance and NT-proBNP in the evaluation of patients with hypertrophic cardiomyopathy. Trial Registration ClinicalTrials.gov Identifier: NCT01915615

This secondary analysis of a nonrandomized clinical trial identifies which participant characteristics were associated with selection of centralized or remote trial engagement.

Background/Objectives: Primary spinal sarcomas, encompassing both bone and soft tissue histotypes, demand individualized reconstruction due to heterogeneous tumor biology, anatomic complexity, and host environments compromised by radiation, systemic therapy, or prior surgery. This narrative review reframes post-resection spinal reconstruction through a precision-medicine lens. Methods: A structured literature review was performed using PubMed and Scopus, targeting articles published between 2000 and 2026. Searches encompassed spinal sarcoma reconstruction, radiation and fusion, biologic reconstruction, and emerging technologies. Results: Tumor grade, radiation exposure, and systemic therapy timing emerge as multiplicative determinants of reconstructive environment quality, with drug-class-specific perioperative effects warranting stratified management. Vascularized bone grafts achieve reliable fusion in compromised hosts where avascular constructs fail. A precision-oriented reconstructive ladder is proposed as a conceptual, hypothesis-generating framework to guide strategy selection. Hybrid PSI-VBG constructs may further expand reconstructive possibilities. The evidence base remains largely composed of small, retrospective series. Conclusions: Individualized strategies anchored in tumor biology and host environment are the cornerstone of durable spinal sarcoma reconstructions. The proposed framework requires prospective, multi-institutional validation. Standardized outcome definitions, prospective registries, and histotype-stratified analyses are needed to advance the field.

BACKGROUND: Free fibula flaps have been widely used for bony reconstruction in pediatric patients. While donor site complications have been well studied in adults, data in the pediatric population remains limited. This study exclusively reports donor-site morbidity following fibula flap harvests in the pediatric and adolescent population. METHODS: We reviewed all patients younger than 18 years with open physes who underwent fibula flap harvests at a single academic institution from 1997 to 2024. Demographics, clinical and surgical characteristics, and donor-site complications were recorded. RESULTS: Fifty-seven free fibula flaps were harvested from 55 pediatric patients (mean age 12 years; 29 female) with a mean follow-up of 6 years. Flaps were most commonly used for lower extremity reconstruction (52%) and following tumor resection (74%). Osteoarticular flaps (n=8) were associated with transient deep peroneal nerve palsy in four cases, all of which recovered antigravity dorsiflexion by 6 months. In standard segmental harvests (n=49), donor-site complications occurred in 38%, most frequently valgus ankle deformity (9%) and neuropathic pain (6%). Valgus deformity was more likely in patients with shorter distal residual fibula and an age–residual fibula index (A-RFI) <16. CONCLUSIONS: Vascularized fibula flaps are safe and versatile for pediatric skeletal reconstruction. Donor-site complications are common but generally manageable, with full recovery of nerve function. Osteoarticular harvests carry the highest risk of peroneal nerve injury, and valgus ankle deformity may occur, particularly with an age–residual fibula index <16. Careful planning and age-adjusted fibular preservation are essential to optimize outcomes.

Abstract Medial meniscus root tears are among the most painful and disabling injuries in knee preservation practice, frequently presenting with substantial functional decline, particularly in female patients. Recent research associates increased posterior tibial slope with both root tears and worse pain scores. Although biomechanically plausible, posterior tibial slope should be interpreted as an association rather than a primary causal driver, as small variations in slope alone are unlikely to fully account for symptom burden or structural progression. Pain and functional decline in this population more likely reflects a multifactorial mechanical environment, in which posterior tibial slope interacts with other determinants of joint loading, including meniscal extrusion, limb alignment, cartilage health, body mass index, subchondral bone response, and degenerative meniscal changes. In our view, posterior tibial slope is one contributor within a broader mechanical environment rather than the primary driver. However, the key clinical message is clear: root tears represent a critical joint‐failure event that demands early recognition and treatment.

BACKGROUND: Hemorrhagic risk in dural arteriovenous fistulas (dAVFs) is largely determined by venous anatomy, but the contribution of systemic cardiovascular factors and their medical therapy remains poorly defined. This study examined associations between cardiovascular risk factors and antithrombotic use and hemorrhagic presentation, angiographic obliteration, and early functional outcomes after treatment. METHODS: We analyzed 1350 adults with intracranial dAVFs from the international Consortium for Dural Arteriovenous Fistula Outcomes Research registry, which retrospectively accrued cases across 14 centers in 4 countries between 1990 and 2017. Demographics, cardiovascular comorbidities, antithrombotic use, angioarchitectural features, treatment strategies, and follow-up outcomes were collected from prospectively maintained databases. Primary end points were hemorrhagic presentation, angiographic obliteration, and 90-day functional status after treatment. Univariable and multivariable logistic regressions were performed with model-specific adjustments. RESULTS: Hemorrhage occurred in 375 patients (27.8%) and was most strongly associated with high-grade dAVF classification and male sex; antithrombotic therapy was associated with lower odds of hemorrhagic presentation. Other cardiovascular risk factors showed no independent relationship with bleeding. Angiographic obliteration was achieved in 621 of 845 patients (73.5%). Hemorrhagic onset, high dAVF grade, and surgical treatment were independently associated with angiographic obliteration, whereas smoking and embolization demonstrated only nonsignificant trends after adjustment. At 90 days, 934 patients (88.9%) were functionally independent. Baseline modified Rankin Scale score was the strongest factor associated with 90-day functional outcome, while neither cardiovascular comorbidities nor treatment modality independently influenced functional status. CONCLUSIONS: In this large multicenter dAVF cohort, hemorrhagic presentation was most strongly associated with venous angioarchitecture. Male sex and antithrombotic therapy were also independently associated with hemorrhagic presentation. Angiographic obliteration was common, particularly among surgically treated lesions, and 90-day functional outcome was most strongly associated with baseline functional status.

ABSTRACT Understanding how fish navigate complex natural environments requires bridging fine-scale biomechanics with ecological behavior. We investigated the volitional movement and energetics of wild red drum (Sciaenops ocellatus) across laboratory, mesocosm and field settings. Using flow-respirometry, we quantified metabolic costs and swimming kinematics under ecologically relevant flow conditions shaped by bluff bodies mimicking mangrove roots and oyster mounds. Fish swimming in turbulent wakes exhibited reduced oxygen consumption and altered tailbeat dynamics, especially at high flow speeds. In a large outdoor mesocosm, dual accelerometers revealed a rich behavioral repertoire, including maneuvering and rest, which is not easily observable in confined lab settings. Spectral analysis and clustering identified eight distinct locomotory states, highlighting the limitations of summed acceleration metrics. Field telemetry tracked wild red drum across a 54 km estuarine corridor for a 3 year period through an array of 36 acoustic receivers, revealing movement patterns shaped by tidal flow and physical habitats. Hydrodynamic modeling showed that although laboratory trials demonstrated substantial energetic savings at high flows (approaching 100 cm s−1), wild fish were detected predominantly in low-velocity microhabitats (&lt;30 cm s−1) near structurally complex features. This mismatch suggests that habitat selection is an adaptive strategy driven by ecological factors such as foraging opportunities, predation refuge and site fidelity, rather than hydrodynamic efficiency alone. Our multi-scalar approach demonstrates that whereas flow–structure interactions can reduce locomotor costs for fish, habitat use in the wild reflects broader ecological constraints, offering a framework for integrating biomechanics, physiology and ecology in conservation-relevant contexts.