BACKGROUND AND OBJECTIVES: The unfused lumbar curve (ULC) distal to a thoracolumbar fusion may respond differently in pediatric vs adult scoliosis patients because of age-related differences in flexibility and compensatory capacity. However, no previous study has directly compared age-related postoperative ULC behavior between these cohorts to better understand differences in coronal balance restoration. METHODS: Four hundred fifty-one patients undergoing thoracolumbar fusion for idiopathic scoliosis with a thoracic upper instrumented vertebra and lower instrumented vertebra between L1-L4 were included: pediatric aged 8 to 17 years (n = 346), and adults aged 18 years and older (n = 105). Pediatric ULC (pULC) and adult ULC (aULC) were defined as coronal Cobb angle between lower instrumented vertebra and S1, if >10°. Radiographic parameters and outcomes (Scoliosis Research Society-22, mechanical complications) were assessed preoperatively, 6 weeks (early), and 2 years (late). Global coronal malalignment (GCM) was central sacral vertical line distance. RESULTS: Pediatric (14.9 ± 2.2 yo) and adult (34.5 ± 15.1 yo) patients had similar major curve magnitude and correction (pediatric: preop 57.7° ± 12.8° vs 55.3° ± 17.6°, 6-week 20.3° ± 7.5° vs 19.9° ± 12.4°; P > .2). Preoperative pULCs were larger (22.8° ± 6.5° vs 19.9° ± 7.3°; P < .001) and experienced greater correction at 6 weeks (Δ18.2° vs Δ12.9°; P < .001). pULC and GCM changed significantly at 6 weeks and remained stable at 2 years, whereas adult GCM changed over 2 years ( P < .001). Age was associated with lower preoperative ULC and higher residual ULC at 6 weeks and 2 years (all P < .001). pULC remodeled directionally to improve GCM early postoperatively ( P = .03), whereas aULCs remodeled to improve GCM late postoperatively ( P = .037). Larger residual pULC was associated with lower Scoliosis Research Society-22 pain and function; residual pULC and aULC were not associated with mechanical complications ( P = .21) or reoperations ( P = .06). There were few caudal extension fusions (3 adults, 0 children) in this cohort. CONCLUSION: Pediatric patients experience greater magnitude correction of the ULC compared with adults after thoracolumbar fusion for scoliosis. ULC remodels to improve GCM early in children and late in adults. Residual ULC magnitude was not associated with mechanical complications.
BACKGROUND AND OBJECTIVES: Spontaneous cerebrospinal fluid (sCSF) leaks are frequently linked to underlying intracranial hypertension. Intraoperative opening pressure (OP) is used to assess intracranial pressure during repair. However, active leakage can act as a physiological release valve, underestimating true pressure. This study evaluates postoperative OP changes after surgical closure of spontaneous skull base leaks and identifies predictors of substantial pressure increase. METHODS: A retrospective review analyzed patients undergoing surgical repair for anterior or lateral sCSF leaks at our institution between 2009 and 2025. Included patients had prerepair and postoperative OP measurements within 6 weeks of surgery. Patients were stratified by a ≥25% OP increase after repair. RESULTS: A total of 46 patients met inclusion criteria. The mean prerepair OP was 18.92 ± 5.20 cm H 2 O, significantly increasing to 23.57 ± 9.04 cm H 2 O postoperatively (mean increase +4.64 cm H 2 O; 95% CI, 1.58-7.70; P = .004). Eighteen patients (39.1%) demonstrated a ≥25% OP increase, with the mean OP rising 89.6% from 16.75 to 31.75 cm H 2 O. Active leak at surgery was strongly associated with postoperative pressure rise (100% vs 28.6%, P < .001). Prerepair OP was significantly lower in the ≥25% increase subgroup ( P = .021). No recurrences occurred during a mean follow-up of 24.9 months. CONCLUSION: OPs may significantly increase after closure of sCSF leaks, especially in patients with active leakage. Normal intraoperative OP does not rule out underlying intracranial hypertension. These findings support the concept of masked intracranial hypertension, emphasizing the need for careful postoperative pressure reassessment.
BACKGROUND AND OBJECTIVES: Decisional regret (DR) measures perception of an event relative to one's own expectations, for example, the choice to undergo or perform adult spinal deformity (ASD) surgery. It is unclear how patient and surgeon DR evolves after ASD surgery and what drives asymmetry. METHODS: Nine hundred and twelve patients who underwent ASD surgery and their surgeons were asked at 6 weeks, 1 year, and 2 years postoperatively: “Would you have/perform the same surgery again?” (patient/surgeon SS). Responses were on a Likert scale (5 = Definitely yes, 4 = Probably yes, 3 = Unsure, 2 = Probably no, 1 = Definitely no). Patient-surgeon disagreement (D) was quantified as D = patient SS–surgeon SS; distributional symmetry was tested using the Wilcoxon signed-rank test. Multivariable ordinal regression evaluated factors associated with SS and disagreement. RESULTS: At 6 weeks, DR was low for both patients and surgeons. Over 2 years, patient same-surgery (SS) scores improved (odds ratios [OR] = 1.35-1.51, P = .02), whereas surgeon SS score remained stable ( P > .1). Patient-surgeon disagreement was small (<0.5 Likert points) but favored greater patient regret at 6 weeks (D = −0.26, P < .001) and 1 year (D = −0.19, P = .002), resolving by 2 years ( P = .09). Baseline disability was associated with greater early surgeon regret relative to patients (OR = 0.43–0.53, P < .02), whereas baseline opioid use was associated with greater long-term patient regret (OR = 1.77, P = .04). After revision surgery, patients were more likely to report improved SS score (39.7% vs 18.5%, P < .001), whereas surgeons were more likely to report worsening SS score (17.2% vs 11.1%, P = .003). Early patient SS score was associated with 2-year ODI (r = −0.241, P < .001) and Scoliosis Research Society-22 total score (r = 0.339, P < .001) and outperformed Scoliosis Research Society-22 satisfaction in predicting long-term outcomes ( P < .05). CONCLUSION: Patients and surgeons have low DR after ASD surgery, and when there is asymmetry, it is small and within the 1-year postoperative period. After revision, patients are more likely to have decreased regret, whereas surgeon regret does not improve. These findings have implications for patient counseling and expectations.
BACKGROUND AND OBJECTIVES: The benefit of thrombectomy in general for patients with large core strokes has been established across multiple trials, although inclusion criteria for the procedure seem quite broad across heterogeneous groups. Understanding subgroups that benefit optimally vs those in which thrombectomy may fall in the realm of futility is lacking. METHODS: A prospectively maintained database was queried for thrombectomy for acute ischemic stroke with Alberta Stroke Program Early Computed Tomography Score of ≤5 from 2021 to 2025. Study outcomes at 90 days included functional independence (modified Rankin Scale [mRS] 0-2), independent ambulation (mRS 0-3), and mortality. Stratified results classified patients into potential categories, based on probability curves and heatmaps across age, last-known-well (LKW), and National Institute of Health Stroke Scale (NIHSS) score. Impact of the category was adjusted in logistic regression models. RESULTS: Of 1458 patients who underwent thrombectomy, 80 (5.5%) were for acute ischemic stroke of Alberta Stroke Program Early Computed Tomography Score ≤5, with a modified Treatment in Cerebral Infarction ≥2b in 89%. The symptomatic hemorrhage rate was 6.3%. At 90 days, 10% of patients were mRS 0 to 2, 30% mRS 0 to 3, and mortality was 34%. Patients were classified into 3 categories. Category 1 (57% of cases) were aged 75 years and younger with NIHSS <20 or LKW ≤12 hours. Ninety days after thrombectomy, 18% of these patients were mRS 0 to 2, 47% mRS 0% to 3%, and 18% died. Category 2 (27% of cases) were aged 75 years and younger with NIHSS ≥20 and LKW >12 hours, or older than 75 with LKW ≤12 hours. There was a 0% mRS 0 to 2 rate in this subgroup; 14% were mRS 3%, and 52% died. Category 3 patients (16% of patients) were aged older than 75 years with LKW >12 hours. No patient was mRS 0 to 3 at follow-up, and 62% had died. A higher risk category was associated with a decreased probability of mRS 0 to 3 (adjusted odds ratio 0.14, P = .01) and higher mortality (adjusted odds ratio 2.7, P = .03) in multiple regression models. CONCLUSION: Patient age, presenting NIHSS and last known well time are significant determinants of outcome after thrombectomy for patients with large core stroke.
BACKGROUND AND OBJECTIVES: The role of blood-based biomarkers in guiding the acute management of patients with established traumatic brain injury is unclear. We sought to determine whether concentrations of glial fibrillary acid protein (GFAP) or ubiquitin C-terminal hydrolase L1 (UCH-L1) on hospital day 1 are associated with intracranial pressure (ICP) and therapeutic intensity level (TIL). METHODS: We conducted a retrospective cohort study using the Transforming Research and Clinical Knowledge in Traumatic Brain Injury data set, including patients age 17 years and older with traumatic brain injury and invasive ICP monitoring, excluding those undergoing decompressive craniectomy on admission. Patients were stratified into biomarker quartiles, and the relationships with ICP and TIL were analyzed descriptively. Multivariable linear regressions were performed to test the hypothesis that GFAP and UCH-L1 concentrations were independently associated with ICP and TIL after adjusting for a priori defined covariates. RESULTS: Two hundred twenty-nine patients with a median age of 39 years (IQR 26-56) were included. Geometric mean concentrations for GFAP and UCH-L1 were 4423 and 989 pg/mL, respectively. Patients in the lowest GFAP quartile had a median of 7.3% of ICP readings >22 mm Hg vs 23.2% in the highest quartile ( P < .001); secondary decompressive craniectomy was performed in 16% of the lowest quartile, compared with 39% of the highest quartile ( P = .008). After adjusting for covariates, GFAP was significantly associated with ICP burden (B = 8.05, P = .014) and median TIL over 5 days (B = 1.65, P = .009). No significant relationship was seen for UCH-L1. CONCLUSION: Day 1 blood concentration of GFAP is associated with elevated ICP and may be a useful adjunct when risk-stratifying patients for intracranial hypertension.
