Introduction Paraspinal muscle robustness is an area of growing interest in spinal deformity that may impact biomechanical integrity and patient quality-of-life after reconstructive surgery. Changes in paraspinal musculature after circumferential minimally-invasive (cMIS) deformity correction have not yet been investigated. Methods We identified patients who underwent cMIS deformity correction and had lumbar spine MRIs at baseline and at minimum 1-year postoperatively. Using T2-weighted MRI, we measured total muscular volume of the psoas major, erector spinae, and multifidus muscles. We used the threshold method to determine fatty infiltration as percent fat area (PFA) along the length of these scanned regions, encompassing the final surgical construct. Results We identified 10 patients who met inclusion criteria. On average, patients underwent interbody fusion at 3.8±0.9 disc levels and posterior instrumentation at 4.6±1.7 vertebral levels. All constructs included lateral interbody fusion (average 2.7±0.8 levels); 6 were from a right-sided approach. Postoperative MRIs were obtained at 28±14.2 months.There were no significant changes in pre- and postoperative volumes or PFA in any muscle group. There were no significant differences in left/right psoas volume or PFA in patients when stratified by side of lateral approach, nor did the number of lateral interbody fusion levels correlate with psoas volume or PFA. Change in posterior paraspinal musculature characteristics did not correlate with increasing number of fixated levels, nor significantly differ in patients who underwent posterior decompression. Preoperative muscle volumes were strongly correlated with postoperative volumes. Conclusions In this pilot series, paraspinal and psoas muscle volumes were preserved after circumferential MIS deformity correction. Fatty infiltration was not increased in paraspinal muscles after multi-level percutaneous instrumentation, nor in the psoas after multi-level trans-psoas approaches. These findings call for more in-depth investigation in a larger cohort of patients with comparison to open deformity correction patients to determine the impact of muscle volume changes on clinical outcomes.

Background The incidence of intracerebral hemorrhage (ICH) and its effect on the outcomes after endovascular thrombectomy (EVT) for patients with large core infarcts have not been well-characterized. Methods SELECT2 trial follow-up imaging was evaluated using the Heidelberg Bleeding Classification (HBC) to define hemorrhage grade. The association of ICH with clinical outcomes and treatment effect was examined. Results Of 351 included patients, 194 (55%) and 189 (54%) demonstrated intracranial and intracerebral hemorrhage, respectively, with a higher incidence in EVT (134 (75%) and 130 (73%)) versus medical management (MM) (60 (35%) and 59 (34%), both P<0.001). Hemorrhagic infarction type 1 (HBC=1a) and type 2 (HBC=1b) accounted for 93% of all hemorrhages. Parenchymal hematoma (PH) type 1 (HBC=1c) and type 2 (HBC=2) were observed in 1 (0.6%) EVT-treated and 4 (2.2%) MM patients. Symptomatic ICH (sICH) (SITS-MOST definition) was seen in 0.6% EVT patients and 1.2% MM patients. No trend for ICH with core volumes (P=0.10) or Alberta Stroke Program Early CT Score (ASPECTS) (P=0.74) was observed. Among EVT patients, the presence of any ICH did not worsen clinical outcome (modified Rankin Scale (mRS) at 90 days: 4 (3-6) vs 4 (3-6); adjusted generalized OR 1.00, 95% CI 0.68 to 1.47, P>0.99) or modify EVT treatment effect (P-interaction=0.77). Conclusions ICH was present in 75% of the EVT population, but PH or sICH were infrequent. The presence of any ICH did not worsen functional outcomes or modify EVT treatment effect at 90-day follow-up. The high rate of hemorrhages overall still represents an opportunity for adjunctive therapies in EVT patients with a large ischemic core.

OBJECTIVE:Erector spinae plane block (ESPB) is a relatively new regional analgesic technique used during spine surgery. Its role in anterior lumbar surgery remains unknown. The aim of this study was to evaluate the effectiveness of ESPB in reducing perioperative pain, opioid use (OU), and hospital length of stay (LOS) in patients undergoing anterior-only lumbar surgery. METHODS:This is a retrospective study of consecutive patients who underwent spine surgery from January 2020 to December 2024 at a single center. Patients were grouped based on ESPB administration. Outcomes included the in-hospital self-reported pain score, OU measured in morphine milligram equivalents (MMEs), time to ambulation, LOS, and opioid-related complications. RESULTS:Overall, 179 patients (mean age 55.9 years) who underwent spine surgery with or without ESPB were included in the analysis. Both groups were similar at baseline except for lower preoperative OU in the ESPB group (23.0% vs 36.7%, p = 0.045). The multivariable analysis showed that ESPB was associated with a lower pain score on the day of surgery (β = -0.56, p = 0.035), as well as early ambulation (β = -4.44, p = 0.015) and LOS (β = -0.61, p = 0.022). Older age and preoperative OU were associated with lower OU overall; older age and multilevel surgery were associated with a longer time to ambulation; and female sex and multilevel surgery were associated with a higher pain score on the day of surgery. A subset of patients in the ESPB group with a shorter LOS (< 2 days) had earlier ambulation, a lower MME and pain score on POD 1, and a lower inpatient MME (p < 0.0001). In another ESPB subgroup, baseline OU was associated with higher incidence of urinary retention and high inpatient OU, including the total daily MME (p = 0.001), in-hospital total MME (p = 0.034), and POD 1 total and average MME (p = 0.003, p = 0.021, respectively). CONCLUSIONS:These findings suggest that ESPB is a valuable adjunct to anterior-only lumbar surgery, demonstrating its effectiveness in reducing pain scores on the day of surgery while also facilitating early ambulation and shortened LOS. Patients who received ESPB and had shorter hospital stays were found to have reduced OU and early ambulation. In the ESPB group, baseline OU was associated with higher inpatient OU and urinary retention.

Introduction Surgical treatment of skull base pathologies is frequently discussed in the context of endoscopic endonasal or transcranial approaches. Combined endoscopic and open approaches have been utilized in a staged or sequential fashion, with the goal of reducing the risk of postoperative cerebrospinal fluid leak, morbidity, wound infection/complication, and failure to achieve adequate reconstruction. However, few studies have described the concurrent use of endoscopic endonasal and transcranial approaches to safely address complex skull base pathologies. Methods We treated 13 patients with primary skull base tumors (sinonasal undifferentiated carcinoma/esthesioneuroblastoma), recurrent tumors, infection, and skull base defect/encephalocele. Out of the thirteen patients, eight had undergone prior endoscopic and/or open transcranial approaches for resection of their pathologies. Additionally, 3/13 patients underwent radiation or chemotherapy radiation prior to the combined approach. Results The desired clinical outcome (i.e., gross total tumor resection, resolution of infection, and skull base resection/repair) was achieved in 12/13 cases. One case had subtotal resection (Simpson grade III) of an olfactory groove meningioma. Postoperatively, there was one 30-day mortality due to pulmonary infarction, one case with hydrocephalus requiring ventriculoperitoneal shunt placement, and one flap infection due to postoperative cocaine use resulting in revisions and hospice. Importantly, no patients experienced postoperative CSF leaks, including those who underwent postoperative chemotherapy/radiation. Conclusion This case series suggests that a concurrent combined endoscopic transcranial approach, in carefully selected patients, can treat a wide range of complex and recurrent skull base pathologies resistant to previous treatment, with a reasonable rate of postoperative wound/leak complications.

BACKGROUND Several recent reports of CorPath GRX vascular robot (Cordinus Vascular Robotics, Natick, MA) use intracranially suggest feasibility of neuroendovascular application. Further use and development is likely. During this progression it is important to understand endovascular robot feasibility principles established in cardiac and peripheral vascular literature which enabled extension intracranially. Identification and discussion of robotic proof of concept principals from sister disciplines may help guide safe and accountable neuroendovascular application. OBJECTIVE Summarize endovascular robotic feasibility principals established in cardiac and peripheral vascular literature relevant to neuroendovascular application. METHODS Searches of PubMed, Scopus and Google Scholar were conducted under PRISMA guidelines1 using MeSH search terms. Abstracts were uploaded to Covidence citation review (Covidence, Melbourne, AUS) using RIS format. Pertinent articles underwent full text review and findings are presented in narrative and tabular format. RESULTS Search terms generated 1642 articles; 177, 265 and 1200 results for PubMed, Scopus and Google Scholar respectively. With duplicates removed, title review identified 176 abstracts. 55 articles were included, 45 from primary review and 10 identified during literature review. As it pertained to endovascular robotic feasibility proof of concept 12 cardiac, 3 peripheral vascular and 5 neuroendovascular studies were identified. CONCLUSIONS Cardiac and peripheral vascular literature established endovascular robot feasibility and efficacy with equivalent to superior outcomes after short learning curves while reducing radiation exposure >95% for the primary operator. Limitations of cost, lack of haptic integration and coaxial system control continue, but as it stands neuroendovascular robotic implementation is worth continued investigation.

INTRODUCTION: Surgical decision-making for decompressive hemicraniectomy (DHC) is challenging because of the heterogeneity of health status and the paucity of tools for predicting the operative risk of DHC for malignant edema following acute infarction. METHODS: The 2008–2018 National Surgical Quality Improvement Program (NSQIP) data set was accessed for patients undergoing DHC for Acute ischemic stroke (AIS) based on Current Procedural Terminology (CPT) codes. We used a modified frailty index (mFI) based on eleven preoperative clinical NSQIP variables. The outcomes assessed were 30-day occurrences of adverse events. RESULTS: A total of 394 patients were identified in the database, there were 55 (14%) patients with mFI 0, 118 patients (30%) with mFI 0.09, 115(29.2 %) with mFI 0.18 and 106 (27%) patients with mFI = 0.27. The rate of return to the operating room for a second procedure significantly increased from 4/55 (7.3%) in patients with mFI 0 to 23/106 (31.1%) in patients with mFI = 0.27. The discharge disposition was significantly different in patients with higher mFI (mFI > 0.27), with only 6/106 (5.7%) discharged to home versus 8/55 (14.5%) with mFI 0. Multivariate logistic regression analysis showed that compared to age, gender, ASA class, and pre albumin levels, mFI was a better predictor of the development of pneumonia (OR 6.278, 95 % CI 1.8, 22.0, p = 0.004) and return to the operating room (OR 4.0, 95 % CI 1.2 ,13.4, p = 0.02). CONCLUSIONS: A higher mFI was associated with an increased risk of return to the operating room and worse discharge disposition. The mFI is based on easily identifiable patient characteristics and can be an additional tool to improve perioperative risk stratification in elderly patients considered for DHC after AIS.

OBJECTIVE Traditional pain management pathways following craniotomy are predicated on opioids. However, narcotics can confound critical neurological examination, contribute to respiratory depression, lower the seizure threshold, and lead to medication habituation, dependence, and/or abuse. Alternative medications to better address postoperative pain while mitigating opioid-related adverse effects remain insufficiently studied. Preliminary studies suggest sumatriptan, a 5-HT (1B/1D) receptor agonist known to regulate dural vasoactivity and inflammation, may moderate pain following trigeminal microvascular decompression and chronic postcraniotomy headache. In this study, the authors evaluated the efficacy of sumatriptan to modulate pain and opioid requirements following craniotomy surgery. METHODS This was a single academic center, retrospective cohort study of 300 consecutive adult patients who underwent elective craniotomy surgery between 2015 and 2022. Patients were equally divided between a control and a sumatriptan cohort contingent upon administration of 6 mg of subcutaneous sumatriptan within 1 hour of surgery completion and prior to opioid administration. Postoperative opioid consumption at 6, 12, and 24 hours, as well as admission total, inpatient length of stay, and 30-day global reevaluation, were assessed. RESULTS Three hundred patients were included for analysis. Significant differences were seen in baseline hypertension (p < 0.01), hyperlipemia (p < 0.01), anxiety (p = 0.04), and operative time (p = 0.02). A significant reduction of mean postoperative pain scores at 12 (p = 0.03) and 24 (p < 0.01) hours and total opioid consumption (p = 0.04) was observed in the sumatriptan cohort. Subgroup analysis revealed significantly lower postoperative pain scores at 6 (p = 0.05), 12 (p < 0.01), and 24 (p < 0.01) hours in patients who underwent burr hole placement in the sumatriptan cohort as compared with controls; however, no significant difference in opioid consumption was noted. No adverse events related to sumatriptan administration were noted throughout the study. CONCLUSIONS Postoperative single-dose subcutaneous sumatriptan following elective craniotomy may reduce pain scores and opioid requirements. Additional studies are needed to better understand nuanced differences in opioid modulation and optimal patient selection.

BACKGROUND AND OBJECTIVES:The management of giant pituitary adenomas (GPAs) is challenging due to associated endocrinopathies and the close proximity of these tumors to critical structures, such as the optic nerves, structures of the cavernous sinus, and hypothalamus. The objective of this review article was to summarize the current management strategies for giant pituitary adenomas, including the role of open and endoscopic surgical approaches and the role of medical and radiation therapy in conjunction with surgery.METHODS:We conducted a retrospective review of GPAs operated at our institute between January 2010 and March 2023. Surgical approaches, extent of resection, and associated complications were documented. Furthermore, we conducted a thorough literature review to identify relevant studies published in the past decade, which were incorporated along with insights gained from our institutional case series of GPAs to analyze and integrate both the existing knowledge base and our institution's firsthand experience in the management of GPAs.RESULTS:A total of 46 giant pituitary adenomas (GPAs) were operated on, using various surgical approaches. Transsphenoidal approach was used in 25 cases and a staged approach using transsphenoidal and pterional was used in 15 cases. Other approaches included transcortical-transventricular, transcallosal, pterional/orbitozygomatic, and subfrontal approaches. Complications and technical nuances were reported.CONCLUSION:The management of giant pituitary adenomas remains complex, often involving several modalities-open or endoscopic resection, radiosurgery, and medical management of both the tumor and associated endocrinopathies. Surgical resections are often challenging procedures that require careful consideration of several factors, including patient characteristics, tumor location, and size, and the experience and skill of the surgical team.

BACKGROUND:Femoral access (TFA) for neuroendovascular procedures may present a challenge in very high body mass index (BMI) individuals. Whether radial access (TRA) confers a comparative benefit in this specific population has not been studied. METHODS:We retrospectively identified all patients undergoing neuroendovascular procedures at our center between 2017 and 2021 with BMI ≥35 kg/m2. A total of 335 patients met our inclusion criteria, with 224 undergoing femoral access and 111 undergoing radial access. Electronic medical records were reviewed for baseline clinical and angiographic characteristics and procedural outcomes. RESULTS:The primary outcome of any bleeding complication occurred in 7% of the femoral group and 2% of the radial group (odds ratio 4.2, 95% confidence interval 1.0-18.6, P = 0.0421). Radial access was also associated with significantly shorter mean procedure times (median 43 minutes for radial, median 58 minutes for femoral, P = 0.0009) and mean fluoroscopy exposure times (median 15 minutes for radial, median 20 minutes for femoral, P = 0.0003). There were no significant differences in nonaccess site complications, procedural failure, length of stay, or deaths during hospitalization. CONCLUSIONS:When compared to TRA, TFA was associated with a significantly greater rate of bleeding complications in very high BMI patients undergoing neuroendovascular procedures. Procedure time and fluoroscopy time were both significantly longer when using TFA compared to TRA in this patient population.

BACKGROUND:Multimodal monitoring to guide medical intervention in high-grade aneurysmal subarachnoid hemorrhage (aSAH) is well described. Multimodal monitoring to guide surgical intervention in high-grade aSAH has been less studied.OBSERVATIONS:Intracranial pressure (ICP), brain lactate to pyruvate ratio (L/P ratio), and brain parenchymal oxygen tension (pO2) were used as surrogates for clinical status in a comatose man after high-grade aSAH. Acute changes in ICP, L/P ratio, and pO2 were used to identify brain injury from both malignant cerebral edema and delayed cerebral ischemia, respectively, and decompressive hemicraniectomy with clot evacuation and intraarterial nimodipine were used to treat these conditions. The patient showed marked improvement in multimodal parameters following each intervention and eventually recovered to a modified Rankin score of 2.LESSONS:In patients with a limited neurological examination due to severe acute brain injury in the setting of aSAH, multimodal monitoring can be used to guide surgical treatment. With prompt, aggressive, maximal medical and surgical interventions, otherwise healthy individuals may retain the capacity for close to full recovery from seemingly catastrophic aSAH.

This observational study uses citation rates to measure the influence of National Institutes of Health R01 grants issued to department of surgery investigators and compared them according to whether the investigator was a surgeon-scientist or a research-scientist.

Potential complications from lateral transpsoas approaches to the lumbar spine include injury to the bowel, vasculature, and most commonly, the lumbar plexus. In the open and extreme lumber interbody fusion approaches (OLIF and XLIF, respectively), further subtle anatomical differences affect the complication profile. Broadly, these complications can be classed as retroperitoneal and peritoneal. Herein, complications related to lateral approaches are discussed.

Background: Carotid blowout syndrome is a surgical emergency caused by structural compromise of the extracranial carotid artery either due to local invasion from head and neck malignancies or to secondary effects from radiotherapy, resulting in uncontrolled hemorrhage. Patients with newly diagnosed nonresectable head and neck cancers with involvement of the carotid artery may benefit from prophylactic stenting to prevent carotid blowout. Prophylactic carotid stenting may also benefit patients already treated for advanced head and neck cancer presenting with newly observed disease progression or threatened carotid blowout.

The lateral lumbar interbody fusion technique for lumbar arthrodesis is gaining popularity and being added as an option to traditional posterior and anterior approaches. In light of this, we analyzed the literature to identify the 25 most cited articles regarding lateral lumbar interbody fusion. The Thomson Reuters Web of Science was systematically searched to identify papers pertaining to lateral lumbar interbody fusion. The results were sorted in order to identify the top cited 25 articles. Statistical analysis was applied to determine metrics of interest, and observational studies were further classified. A search of all databases in the Thomson Reuters Web of Science identified 379 articles pertaining to lateral lumbar interbody fusion, with a total of 3800 citations. Of the 25 most cited articles, all were case series, reporting on a total of 2981 patients. These 25 articles were cited 2232 times in the literature and total citations per article ranged from 29 to 433. The oldest article was published in 2006, whereas the most recent article was published in 2015. The most cited article, by Ozgar et al., was cited 433 times, and the journal Spine published 7 of the 25 most cited articles. Herein, we report and analyze the 25 most cited articles on lateral lumbar interbody fusion, which include 25 cases series reporting a variety of data on a total of 2513 patients. Such data might assist in the design and interpretation of future studies pertaining to this topic.

Animal models have played a key role in elucidating the mechanisms underlying the occurrence, recurrence, and therapeutic treatment of primary brain tumors. In this chapter, we review the various types of human primary brain tumors, describe the general properties of the dominantly used animal model systems, and propose general guidelines to help optimize animal model creation. We also discuss the history and current uses of rodent models in the study of the pathologenesis and treatment of various important types of primary brain tumors, including adult and pediatric glioma, meningioma, medulloblastoma, and CNS lymphoma. Included is an analysis of the role of rodent models in the development of immune-based therapies for brain tumors. Lastly, we summarize the tradeoffs and limitations of currently existing animal models of primary brain tumors and discuss the current outlook for future developments.

OBJECTIVE Steno-occlusive diseases of the cerebral vasculature have been associated with cognitive decline. The authors performed a systematic review of the existing literature on intracranial steno-occlusive disease, including intracranial atherosclerosis and moyamoya disease (MMD), to determine the extent and quality of evidence for the effect of revascularization on cognitive performance. METHODS A systematic search of PubMed/MEDLINE, the Thomson Reuters Web of Science Core Collection, and the KCI Korean Journal Database was performed to identify randomized controlled trials (RCTs) in the English-language literature and observational studies that compared cognitive outcomes before and after revascularization in patients with steno-occlusive disease of the intracranial vasculature, from which data were extracted and analyzed. RESULTS Nine papers were included, consisting of 2 RCTs and 7 observational cohort studies. Results from 2 randomized trials including 142 patients with symptomatic intracranial atherosclerotic steno-occlusion found no additional benefit to revascularization when added to maximal medical therapy. The certainty in the results of these trials was limited by concerns for bias and indirectness. Results from 7 observational trials including 282 patients found some cognitive benefit for revascularization for symptomatic atherosclerotic steno-occlusion and for steno-occlusion related to MMD in children. The certainty of these conclusions was low to very low, due to both inherent limitations in observational studies for inferring causality and concerns for added risk of bias and indirectness in some studies. CONCLUSIONS The effects of revascularization on cognitive performance in intracranial steno-occlusive disease remain uncertain due to limitations in existing studies. More well-designed randomized trials and observational studies are needed to determine if revascularization can arrest or reverse cognitive decline in these patients.

Lumbar spinal stenosis is defined as narrowing of the lumbar spinal canal, which causes compression of the spinal cord and nerves. Spinal stenosis can cause leg pain and potentially back pain that can affect the quality of life. Ultimately, surgical decompression is required to alleviate the symptoms. In this review, we first utilize several important studies to compare lumbar laminectomy alone versus lumbar laminectomy and fusion. We also compare the effectiveness of more novel surgical approaches, stand-alone anterior lumbar interbody fusion (ALIF), and stand-alone lateral lumbar interbody fusion (LLIF). These techniques have their own advantages and disadvantages in which many factors must be taken into account before choosing a surgical approach. In addition, the patient’s anatomy and pathology, lifestyle, and desires should be analyzed to help determine the ideal surgical strategy