BACKGROUND AND OBJECTIVES:In recent years, there has been an outpouring of scoring systems that were built to predict outcomes after various surgical procedures; however, research validating these studies in spinal surgery is quite limited. In this study, we evaluated the predictability of the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator (ACS NSQIP SRC) for various postoperative outcomes after spinal deformity surgery. METHODS:A retrospective chart review was conducted to identify patients who underwent spinal deformity surgery at our hospital between January 1, 2014, and December 31, 2022. Demographic and clinical data necessary to use the ACS NSQIP SRC and postoperative outcomes were collected for these patients. Predictability was analyzed using the area under the curve (AUC) of receiver operating characteristic curves and Brier scores. RESULTS:Among the 159 study patients, the mean age was 64.5 ± 9.5 years, mean body mass index was 31.9 ± 6.6, and 95 (59.7%) patients were women. The outcome most accurately predicted by the ACS NSQIP SRC was postoperative pneumonia (observed = 5.0% vs predicted = 3.2%, AUC = 0.75, Brier score = 0.05), but its predictability still fell below the acceptable threshold. Other outcomes that were underpredicted by the ACS NSQIP SRC were readmission within 30 days (observed = 13.8% vs predicted = 9.0%, AUC = 0.63, Brier score = 0.12), rate of discharge to nursing home or rehabilitation facilities (observed = 56.0% vs predicted = 46.6%, AUC = 0.59, Brier = 0.26), reoperation (observed 11.9% vs predicted 5.4%, AUC = 0.60, Brier = 0.11), surgical site infection (observed 9.4% vs predicted 3.5%, AUC = 0.61, Brier = 0.05), and any complication (observed 33.3% vs 19%, AUC = 0.65, Brier = 0.23). Predicted and observed length of stay were not significantly associated (β = 0.132, P = .47). CONCLUSION:The ACS NSQIP SRC is a poor predictor of outcomes after spinal deformity surgery.

BACKGROUND:Spontaneous intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) may present with intraventricular hemorrhage (IVH). Prior studies show IVH correlates with increased mortality and morbidity. Neuroinflammation from blood organization in cerebrospinal fluid (CSF) contributes to poor outcomes. OBJECTIVE:We hypothesized that active external ventricular drainage (EVD) would accelerate blood removal, reducing adverse events. Study sites used double-lumen EVDs with active irrigation and intracranial pressure control via passive drainage. MATERIAL AND METHODS:Data from 6 centers in the EU and USA were analyzed. Forty patients in total were included: 21 with SAH, 13 with spontaneous ICH-related IVH, and 6 with vascular anomaly-related hemorrhage. Blood removal was assessed via CT imaging. Shunt dependency in SAH patients was calculated using CHESS scores. RESULTS:Blood removal via active EVD was safely achieved. Removal pace correlated with irrigation volume. All 13 ICH patients had median IVH clearance of 91.3% (range: 0.7%-100%) over 7.6 days. SAH patients showed lower shunt dependency (2) than expected (11) per CHESS scores and literature. The vascular anomaly group had median IVH clearance of 91.3% over 8 days. No CSF exchange-related infections occurred. CONCLUSIONS:Accelerated blood removal from the CSF system via active EVD is safe and feasible. Active irrigation reduced adverse events. Blood clearance is strongly linked to irrigation rate. Prospective trials are needed to identify the patient population most likely to benefit from CSF exchange during hemorrhagic stroke treatment.

INTRODUCTION: Optic nerve sheath diameter (ONSD) can be used as a noninvasive measurement of intercranial pressure. Few studies have evaluated the value of ONSD in predicting the need for ventriculoperitoneal shunt (VPS) placement after development of post-hemorrhagic hydrocephalus (PHH) in adults. METHODS: Adult patients 18 years or older, admitted with intracranial hemorrhage and hydrocephalus requiring EVD placement were included in the study. Demographics were recorded. CT imaging of ONSD was measured (mm) upon initial ED visit before EVD placement (pre-EVD), immediately after successful EVD removal (post-EVD), and if applicable, after EVD removal but immediately before VPS placement. Change in ONSD was calculated and groups were stratified by EVD only patients and EVD+VPS patients. RESULTS: Imaging for 30 patients were successfully retrieved and analyzed for bilateral ONSD values at all timepoints. A statistically significant convergence to a normally distributed mean ONSD was found for both groups (EVD and EVD+VPS). Additionally, a statistically significant increase was found in ONSD between the EVD+VPS group compared to the EVD only group. The EVD only group showed a mean EVD placement time of only 14 days (2 weeks) with an average decrease in ONSD (-0.905mm) compared with the EVD+VPS group who had an increase in ONSD at 14-days (+1.089 mm). CONCLUSIONS: Patients with hydrocephalus due to intracranial hemorrhage who went on to require VPS developed an increase in ONSD despite EVD use while patients who were successfully weaned from the EVD developed a decrease in ONSD. ONSD may be a useful adjunct tool to aid in the process of EVD weaning in this patient population.

INTRODUCTION: Cerebral ventriculitis remains one of the most challenging neurosurgical conditions, with poor outcome and a long course of treatment and duration of hospital stay. Despite the current conventional management plans, i.e., using antibiotics in addition to CSF drainage, the outcome remains unsatisfactory in some cases, with no definitive therapeutic guidelines. METHODS: We conducted a multicenter, international, retrospective study of ventriculitis patients treated with a novel automated active irrigation, and drainage system. Data collected included patients’ demographics, comorbidities, admission Glasgow Coma Scale (GCS) score, and pre-hospital modified Rankin Scale (mRS). Catheter occlusions, infections, and shunt placement was recorded for outcome assessment, along with discharge mRS, and in-hospital mortality. RESULTS: Four centers (3 from U.S and 1 from Finland) contributed data for a total of 21 ventriculitis patients who had IRRAflow placement. Thirteen (61.9%) were males (mean age = 49.8 ± 14.87 years). The baseline median mRS was 1 and the median GCS at time of ventriculitis diagnosis was 13. Etiology of ventriculitis was iatrogenic in 12 (57.4%), and secondary to abscess in 9 (42.6%). No cases reported hemorrhage, or failure of IRRAflow placement. Antibiotics were administered in through the IRRAflow in 13 (61.9%) cases in addition to systemic dosing. Sixteen (76.19%) patients had significant clinical improvement and resolution of ventriculitis. Seven (33.33%) patients required shunt placement after resolution. There were 6 (28.6%) in-hospital mortalities reported. CONCLUSIONS: Use of active and continuous irrigation with drainage for continuous delivery of intraventricular irrigation fluid with antibiotics led to dramatically lower mortality when compared to literature (mortality approx. 70%). In our case series, it led to marked improvement in neurologic status, imaging findings, and CSF profiles making it technically feasible and safe treatment for ventriculitis.

- OBJECTIVE: Spinal fusion procedures are used to treat a wide variety of spinal pathologies. Diabetes mellitus (DM) has been shown to be a significant risk factor for several complications following these procedures in previous studies. To the authors ' knowledge, this is the first systematic review and meta-analysis elucidating the relationship between DM and complications occurring after spinal fusion procedures. - METHODS: Systematic literature searches of PubMed and EMBASE were performed from their inception to October 1, 2022, to identify studies that directly compared postfusion complications in patients with and without DM. Studies met the prespecified inclusion criteria if they reported the following data for patients with and without DM: (1) demographics; (2) postspinal fusion complication rates; and (3) postoperative clinical outcomes. The included studies were then pooled and analyzed. - RESULTS: Twenty-eight studies, with a cumulative total of 18,853 patients (2695 diabetic patients), were identified that met the inclusion criteria. Analysis showed that diabetic patients had significantly higher rates of total number of postoperative complications (odds ratio [OR] = 1.33; 95% confidence interval [CI] = 1.12-1.58; P = 0.001), postoperative pulmonary complications (OR = 2.01; 95%CI = 1.31-3.08; P = 0.001), postoperative renal complications (OR = 2.20; 95%CI = 1.27-3.80; P = 0.005), surgical site infection (OR = 2.65; 95%CI = 2.19-3.20; P < 0.001), and prolonged hospital stay (OR = 1.67; 95%CI = 1.47-1.90; P < 0.001). - CONCLUSIONS: Patients with DM had a significantly higher risk of developing complications after spinal fusion, particularly pulmonary and renal complications, in addition to surgical site infections and had a longer length of stay. These findings are important for informed discussions of surgical risks with patients and families before surgery.

One of the most common complications of lumbar fusions is cage subsidence, which leads to collapse of disc height and reappearance of the presenting symptomology. However, definitions of cage subsidence are inconsistent, leading to a variety of subsidence calculation methodologies and thresholds. To review previously published literature on cage subsidence in order to present the most common methods for calculating and defining subsidence in the anterior lumbar interbody fusion (ALIF), oblique lateral interbody fusion (OLIF), and lateral lumbar interbody fusion (LLIF) approaches. A search was completed in PubMed and Embase with inclusion criteria focused on identifying any study that provided descriptions of the method, imaging modality, or subsidence threshold used to calculate the presence of cage subsidence. A total of 69 articles were included in the final analysis, of which 18 (26.1

BACKGROUND AND OBJECTIVE:Posterior cervical fusion is the surgery of choice when fusing long segments of the cervical spine. However, because of the limited presence of this pathology, there is a paucity of data in the literature about the postoperative complications of distal junctional kyphosis (DJK). We aimed to identify and report potential associations between the preoperative cervical vertebral bone quality (C-VBQ) score and the occurrence of DJK after posterior cervical fusion.METHODS:The authors retrospectively reviewed records of patients who underwent posterior cervical fusion at a single hospital between June 1, 2010, and May 31, 2020. Patient data were screened to include patients who were >18 years old, had baseline MRI, had baseline standing cervical X-ray, had immediate postoperative standing cervical X-ray, and had clinical and radiographic follow-ups of >1 year, including a standing cervical X-ray at least 1 year postoperatively. Univariate analysis was completed between DJK and non-DJK groups, with multivariate regression completed for relevant clinical variables. Simple linear regression was completed to analyze correlation between the C-VBQ score and total degrees of kyphosis angle change.RESULTS:Ninety-three patients were identified, of whom 19 (20.4%) had DJK and 74 (79.6%) did not. The DJK group had a significantly higher C-VBQ score than the non-DJK group (2.97 ± 0.40 vs 2.26 ± 0.46; P < .001). A significant, positive correlation was found between the C-VBQ score and the total degrees of kyphosis angle change (r 2 = 0.26; P < .001). On multivariate analysis, the C-VBQ score independently predicted DJK (odds ratio, 1.46; 95% CI, 1.27-1.67; P < .001).CONCLUSION:We found that the C-VBQ score was an independent predictive factor of DJK after posterior cervical fusion.

INTRODUCTION: Intraventricular hemorrhage (IVH) is a common neurosurgical pathological conditon that can occur in isolation or along with intraparenchymal and subarachnoid hemorrhage and is associated with poor outcome. Hydrocephalus associated with IVH is often treated with external ventricular drain (EVD) placement, although occlusion and replacement of the drain are common. METHODS: A prospectively maintained database was retrospectively searched for consecutive patients who presented with IVH between September 2020 and Febuary 2023 who were treated with an EVD or the IRRAflow. Pretreatment and posttreatment noncontrast computed tomography scans were segmented to determine IVH volumes. Change in hematoma volume, catheter related conversion and infections, in-hospital mortality, shunt dependency, and symptom resolution or improvement were recorded for outcome assessment. RESULTS: A total of 51 patients were included (21 in the active irrigation and drainage [IRRAflow] group vs. 30 in the passive EVD group. Demographic, disease severity, and presenting variables betweeen the groups were statistically similar. Mean hematoma volume change (8.8 ± 11.3 vs. 17.7 ± 19.4 mL, p = 0.0459) of IVH was significantly lower in the EVD group than the IRRAflow group. No. of days catheter was put in was longer in the EVD group compared to IRRAflow (15.2 ± 10.0 vs. 9.4 ± 4.5; p = 0.0019). On multivaritate logistic regression, shunt dependency on follow-up was higher in the passive EVD group compared to active irrigation and drainage group (p = 0.0215). CONCLUSIONS: Active irrigation with drainage along with CSF exchange for IVH patients appears to be superor to passive drainage alone using EVD.

Introduction Glioblastoma (GBM) is the most common central nervous system malignancy in adults. Despite decades of developments in surgical management, radiation treatment, chemotherapy, and tumor treating field therapy, GBM remains an ultimately fatal disease. There is currently no definitive standard of care for patients with recurrent glioblastoma (rGBM) following failure of initial management. Objective In this retrospective cohort study, we set out to examine the relative effects of bevacizumab and Gamma Knife radiosurgery on progression-free survival (PFS) and overall survival (OS) in patients with GBM at first-recurrence. Methods We conducted a retrospective review of all patients with rGBM who underwent treatment with bevacizumab and/or Gamma Knife radiosurgery at Roswell Park Comprehensive Cancer Center between 2012 and 2022. Mean PFS and OS were determined for each of our three treatment groups: Bevacizumab Only, Bevacizumab Plus Gamma Knife, and Gamma Knife Only. Results Patients in the combined treatment group demonstrated longer post-recurrence median PFS (7.7 months) and median OS (11.5 months) compared to glioblastoma patients previously reported in the literature, and showed improvements in total PFS (p=0.015), total OS (p=0.0050), post-recurrence PFS (p=0.018), and post-recurrence OS (p=0.0082) compared to patients who received either bevacizumab or Gamma Knife as monotherapy. Conclusion This study demonstrates that the combined use of bevacizumab with concurrent stereotactic radiosurgery can have improve survival in patients with rGBM.

BACKGROUND AND OBJECTIVES:Cerebral ventriculitis remains a challenging neurosurgical condition because of poor outcomes including mortality rates of nearly 80% and a prolonged course of treatment in survivors. Despite current conventional management, outcomes in some cases remain unsatisfactory, with no definitive therapeutic guidelines. This feasibility study aims to explore the use of a novel active, continuous irrigation and drainage system (IRRA flow [IRRAS AB]) combined with intraventricular drug delivery for patients with cerebral ventriculitis. METHODS:We conducted a multicenter, international, retrospective study of patients with ventriculitis who were treated with use of the IRRA flow system. Data collected included patient demographics, comorbidities, admission Glasgow Coma Scale score, baseline modified Rankin Scale (mRS) score, and imaging findings. Catheter occlusions, infections, and shunt placement were recorded for outcome assessment, along with discharge mRS scores and in-hospital deaths. RESULTS:Four centers contributed data for a total of 21 patients who had IRRA flow placement for treatment of ventriculitis. Thirteen (61.9%) were men (mean age = 49.8 ± 14.87 years). The median baseline mRS score was 1. The median Glasgow Coma Scale score at admission was 13. The etiology of ventriculitis was iatrogenic in 12 (57.1%) patients and secondary to an abscess in 9 (42.9%). No cases reported hemorrhage or failure of IRRA flow placement. Antibiotics were administered through the IRRA flow system in 13 (61.9%) cases in addition to systemic dosing. Sixteen (76.2%) patients had significant clinical improvement and resolution of ventriculitis. Seven (33.3%) patients required shunt placement after resolution because of persistent hydrocephalus. There were 6 (28.6%) in-hospital deaths. CONCLUSION:The use of active irrigation with drainage for continuous delivery of intraventricular irrigation fluid with antibiotics led to dramatically low mortality. In our case series, it led to a marked improvement in neurological status, imaging findings, and cerebrospinal fluid profiles, making it a technically feasible and safe treatment for ventriculitis.

INTRODUCTION: Passive drainage post-surgical evacuation of symptomatic chronic subdural hematoma (cSDH) is currently standard of care. High rates of infection, drain occlusion, and recurrence are associated complications. METHODS: A prospectively maintained database was retrospectively searched for consecutive patients presenting with cSDH. One-to-one PSM of covariates (including baseline comorbidities and presentation hematoma volume) in active and passive irrigation groups was performed to adjust for treatment selection bias. Rates of hematoma clearance, catheter-related occlusion, and infection; number of revisions; and length of hospital stay were recorded. RESULTS: This study included 55 patients: active continuous irrigation-drainage-21 (21 post-PSM); passive drainage-34 (21 post-PSM). For PSM groups, a significantly higher rate of hematoma clearance was obtained in the active irrigation-drainage group (0.5±0.4 vs. 0.4±0.5 ml/day in the passive drainage group; odds ratio [OR] = 1.291 (confidence interval [CI]:1.062-1.570, P = 0.002) and a significantly lower rate of catheter-related infections (OR = 0.051; CI: 0.004-0.697, P = 0.039). A non-significantly lower hematoma expansion rate at discharge was noted in the active irrigation-drainage group (4.8% vs. 23.8%; OR = 0.127; P = 0.186). No statistical difference in all-cause in-hospital mortality or discharge GCS score was observed between groups. CONCLUSIONS: Active and automated continuous irrigation plus drainage following cSDH surgical evacuation results in faster hematoma clearance and led to favorable clinical outcomes and low complication and revision rates compared to passive irrigation.

INTRODUCTION: Spontaneous Intracerebral hemorrhage (ICH) and subarachnoidal hemorrhages (SAH) can represent with intraventricular hemorrhage (IVH). Previous studies have demonstrated, patients with IVH have higher mortality and morbidity. Neuroinflammation due to organization of blood in cerebrospinal fluid (CSF) is one of the key contributing factors to poor outcome. METHODS: Data utilizing the new active EVD system were collected from six leading centers in the EU and USA. 40 patients were analyzed, 21 patients had SAH, 13 patients had spontaneous ICH related IVH, and six patient had vascular anomaly related hemorrhage. Blood removal from ventricular system was calculated utilizing daily CT imaging. Actual and expected shunt dependency were calculated for SAH patients with CHESS score. RESULTS: Removal of blood from CSF system with the active EVD was achieved safely. Pace of blood removal was highly related to irrigation volume used during treatment. All the 13 spontaneous ICH patients had IVH clearance of median 91.3% (0.7-100%) in average 7.6 days. Additionally, in the SAH patients, there was lower shunt (2) dependency compared to those observed in literature and to expected (11) calculated based on CHESS score. Vascular anomaly cohort had median IVH clearance 91.3% in average 8.0 days. CONCLUSIONS: It is safe and feasible to remove blood from CSF system in an accelerated fashion via active EVD. Active removal of blood reduced adverse events in this patient population. Removal of blood is highly related to irrigation rate. Prospective trials are needed to demonstrate the target population who will benefit the most from CSF exchange during hemorrhagic stroke treatment.

INTRODUCTION: Posterior cervical fusion is the surgery of choice when fusing long segments of the cervical spine. However, due to the limited presence of this pathology, there is a paucity of data in the literature about the postoperative complication of distal junctional kyphosis (DJK). METHODS: A retrospective analysis of consecutive set of patients who underwent posterior cervical fusion at a single hospital between June 1, 2010 and May 31, 2020. Univariate analysis was completed between DJK and non-DJK groups, with multivariate regression completed for relevant clinical variables. Simple linear regression was completed to analyze correlation between the C-VBQ score and total degrees of kyphosis angle change. RESULTS: Ninety-three patients were identified, of whom 19 (20.4%) had DJK and 74 (79.6%) did not. The DJK group had a significantly greater number of patients with anemia than the non-DJK group (15.8% vs. 1.4%; P = .03). The DJK group had a significantly higher C-VBQ score than the non-DJK group (2.97 ± 0.40 vs. 2.26 ± 0.46; P < .001). A significant, positive correlation was found between the C-VBQ score and the total degrees of kyphosis angle change (r2 = 0.26, P < .001). On multivariate analysis, the C-VBQ score independently predicted DJK (OR, 1.50; 95% CI, 1.28-1.76; P < .001). CONCLUSIONS: We found that the C-VBQ score was an independent predictive factor of DJK after posterior cervical fusion.

The COVID-19 pandemic has resulted in a delay in cancer diagnosis and treatment during this time. A potential cause of delayed diagnosis that may be underrecognized is a patient misinterpretation of symptoms. To illustrate this point, we present the case of a patient with a delayed diagnosis of olfactory neuroblastoma 2 years after the onset of anosmia.

-OBJECTIVE: Interbody cages for spinal fusions are pri-marily constructed from polyetheretherketone or titanium compositions. However, these crude macroscopic mate-rials pose limitations for improving the rates of bony fu-sions. The authors aimed to compare the fusion rates and postoperative complications in patients who underwent 2-level or 3-or 4-level anterior cervical discectomy and fusion (ACDF) performed with the use of a novel biomimetic surface titanium cage.-METHODS: A retrospective multicenter study was con-ducted that included all patients who underwent multilevel ACDF with this cage between January 2017 and April 2021. Patient demographics and procedure-related, radiographic, and postoperative complication data were collected.-RESULTS: A total of 124 patients were identified; 69 (55.6%) had a 3-or 4-level fusion and 55 (44.4%) had a 2-level fusion. The demographics of the 2 groups differed significantly only in terms of age (P = 0.01). At 3 months, a significantly higher solid fusion rate was found for 2-level fusions than 3-or 4-level fusions (83.7% vs. 56.3%, P = 0.004); however, significance was lost at 6-months (98.2% vs. 88.4%, respectively; P = 0.08). No patients required posterior supplemental fixation. Transient dysphagia was the only postoperative complication that was significantly increased in the 3-or 4-level fusion group compared to the 2-level group (27.5% vs. 9.1%, P = 0.02)-CONCLUSIONS: Radiographic and clinical outcomes were equivalent in 3-or 4-level and 2-level ACDFs in which these biomimetic surface titanium cages were used. Furthermore, the use of this technology led to high fusion rates with no requirement for posterior supplemental fusions.

Abstract Glioblastoma is the most common central nervous system malignancy in adults and remains a uniformly fatal disease despite two decades of developments in surgical management, radiation treatment, chemotherapy, and immunotherapy. There is currently no established standard of care for patients with recurrent glioblastoma following failure of initial Stupp protocol management. In this retrospective cohort study, we set out to determine if the use of bevacizumab and/or Gamma Knife radiosurgery in patients with recurrent disease could have an effect on prolonging progression-free survival (PFS) or overall survival (OS). Patients in the combined treatment group demonstrated longer post-recurrence mean PFS (9.1 ± 6.0 months) and OS (13.5 ± 8.6 months) compared to glioblastoma patients previously reported in the literature, and showed improvements in total OS (p=0.021), total PFS (p=0.057), post-recurrence PFS (p=0.034), and post-recurrence OS (p=0.017) compared to patients who received standalone bevacizumab or Gamma Knife treatment. This study demonstrates that the combined use of an antiangiogenic agent with stereotactic radiosurgery can have significant effects on improving patient survival in recurrent glioblastoma.

BACKGROUND: Passive drainage post-surgical evacuation of symptomatic chronic subdural hematoma (cSDH) is currently standard of care. High rates of infection, drain occlusion, and recurrence are associated complications. OBJECTIVE: To explore the use of a novel double-lumen active automated irrigation and aspiration system, IRRAflow (IRRAS), for patients with cSDH and compared procedural and clinical outcomes against passive drainage alone with propensity score matching (PSM) and volumetric analysis. METHODS: A prospectively maintained database was retrospectively searched for consecutive patients presenting with cSDH. One-to-one PSM of covariates (including baseline comorbidities and presentation hematoma volume) in active and passive irrigation groups was performed to adjust for treatment selection bias. Rates of hematoma clearance, catheter-related occlusion, and infection; number of revisions; and length of hospital stay were recorded. RESULTS: This study included 55 patients: active continuous irrigation-drainage-21 (21 post-PSM) and passive drainage-34 (21 post-PSM). For PSM groups, a significantly higher rate of hematoma clearance was obtained in the active irrigation-drainage group (0.5 ± 0.4 vs 0.4 ± 0.5 mL/day) and in the passive drainage group; odds ratio (OR) = 1.291 (CI: 1.062-1.570, P = .002) and a significantly lower rate of catheter-related infections (OR = 0.051; CI: 0.004-0.697, P = .039). A nonsignificantly lower hematoma expansion rate at discharge was noted in the active irrigation-drainage group (4.8% vs 23.8%; OR = 0.127; P = .186). No statistical difference in all-cause in-hospital mortality or discharge Glasgow Coma Scale score was observed between groups. CONCLUSION: Active and automated continuous irrigation plus drainage after cSDH surgical evacuation resulted in faster hematoma clearance and led to favorable clinical outcomes and low complication and revision rates compared with passive irrigation.

To determine risk factors increasing susceptibility to early complications (intraoperative and postoperative within 6 weeks) associated with surgery to correct thoracic and lumbar spinal deformity. We systematically searched the PubMed and EMBASE databases for studies published between January 1990 and September 2021. Observational studies evaluating predictors of early complications of thoracic and lumbar spinal deformity surgery were included. Pooled odds ratio (OR) or standardized mean difference (SMD) with 95