Connor Wathen

BACKGROUND AND OBJECTIVES: The purpose of the present work was to review our series of patients with far lateral disk herniations treated by the intertransverse approach. METHODS: Patients undergoing intertransverse approach to treat far-lateral disk herniation by a single surgeon over a 10-year period were identified through the electronic medical record. Additional variables regarding the intraoperative and postoperative course were also collected. Response to treatment was assessed using Odom criteria at the patient's postoperative follow-up. RESULTS: Sixty patients met inclusion criteria. The most frequently treated levels were L3-4 and L4-5 (41.7% and 36.7%, respectively), and 11.7% at L5-S1. The mean age was 56.8 years (SD = 12.6y). Isolated radicular pain was the most common presenting symptom (66%). Two-thirds of patients had mild systemic disease as determined by the American Society of Anesthesiologists score (II). Estimated blood loss ranged from <50 to 600 mL, with a median of 50 mL (IQR 30-120 mL). The mean length of stay was 48h (SD = 46 hours), with 35% of patients (22) undergoing outpatient surgery. The median length of latest postoperative follow-up was 78 days (IQR 34-19 days). Per Odom criteria, most patients had good-to-excellent improvement of preoperative symptoms (80%, N = 48). 8.3% of patients required revision surgery with fusion (N = 5). CONCLUSION: Most patients had good-to-excellent improvement of preoperative symptoms. The paucity of revision procedures in this cohort suggests that the intertransverse approach is durable as it enables direct decompression of the nerve root without destabilizing the motion segment. Further studies are required to compare the efficacy of the intertransverse approach with other approaches.

Background: Adult spinal deformity (ASD) is a prevalent condition often treated with circumferential spinal fusion (CF), which can be performed as staged or same-day procedures. However, evidence guiding the choice between these approaches is lacking. Objective: This study aims to compare patient outcomes following staged and same-day CF for ASD. Methods: Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a comprehensive literature search was conducted in PubMed, MEDLINE, Embase, Cochrane CENTRAL, Web of Science, and Scopus. Eligibility criteria included studies comparing outcomes following staged and same-day CF in adults with ASD. Searches were exported to Covidence, and records were deduplicated automatically. Title and abstract screening, full-text review, and data extraction were performed by two independent reviewers, with all conflicts being resolved by a third reviewer. A meta-analysis was conducted for outcomes reported in 3 or more studies. Results: Seven studies with 741 patients undergoing CF for ASD were included in the review (staged: n=331, 44.7% and same-day: n=410, 55.3%). Four studies that had comparable outcomes were merged for the quantitative meta-analysis and split based on observed measures. The meta-analysis revealed significantly shorter hospital length of stay (mean difference 3.98, 95% CI 2.23-5.72 days; P<.001) for same-day CF. Three studies compared the operative time between staged and same-day CF, with all reporting a lower mean operative time for same-day CF (mean between 291-479, SD 129 minutes) compared to staged CF (mean between 426-541, SD 124 minutes); however, inconsistent reporting of mean and SD made quantitative analyses unattainable. Of the 4 studies that compared estimated blood loss (EBL) in the relevant groups, 3 presented a lower EBL (mean between 412-1127, SD 954 mL) in same-day surgery compared to staged surgery (mean between 642, SD 550 to 1351, SD 869 mL). Both studies that reported intra- and postoperative adverse events showed more intraoperative adverse events in staged CF (10.9% and 13.6%, respectively) compared to same-day CF (9.1% and 3.6%, respectively). Four studies measuring any perioperative adverse events showed a higher incidence of adverse events in staged CF than all studies combined. However, quantitative analysis of EBL, intraoperative adverse events, and perioperative adverse events found no statistically significant difference. Postoperative adverse events, reoperation, infection rates, and readmission rates showed inconsistent findings between studies. Data quality assessment revealed a moderate degree of bias for all included studies. Conclusions: Same-day CF may offer shorter operating time and hospital stay compared to staged CF for ASD. However, there was marked heterogeneity in perioperative outcomes reporting, and continuous variables were inconsistently presented. This underscored the need for standardized reporting of clinical variables and patient-reported outcomes and higher evidence of randomized controlled trials to elucidate the clinical superiority of either approach. Trial Registration: PROSPERO CRD42022339764; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=339764 International Registered Report Identifier (IRRID): RR2-10.2196/42331

Purpose: This study aimed to investigate the relationship of preoperative hemoglobin levels as an independent prognostic factor for hospital and intensive care unit (ICU) length of stay (LOS) in patients undergoing surgery for adult spinal deformity (ASD), with the intent of determining whether there exists a correlation and enhancing patient preoperative optimization protocols. Methods: The authors reviewed consecutive patients who underwent elective thoracolumbosacral posterior spinal fusion (PSF) involving six or more vertebrae for ASD from January 1, 2013, to December 13, 2021, with a minimum follow-up period of two years. This study primarily investigated the association of preoperative hemoglobin levels with hospital and ICU LOS. To analyze the data, both unadjusted and adjusted generalized linear models (GLM), incorporating cubic splines for non-linear variables, were applied. Results: A total of 598 patients were included. GLMs for hospital and ICU LOS demonstrated nonlinear relationships with preoperative hemoglobin levels. Specifically, hospital LOS decreased with increasing preoperative hemoglobin until a significance threshold of 13.5 g/dl. Similarly, ICU LOS significantly decreased with increasing preoperative hemoglobin until 13.0 g/dl. Lower preoperative hemoglobin was associated with more perioperative transfusions, less likely discharge to home, and greater risk of reoperation. Conclusions: Preoperative anemia is an independent non-linear risk factor that significantly affects LOS, disposition, and outcomes after surgery for ASD. These findings advocate for a systemic preoperative approach and highlight the need for future research to improve postoperative outcomes and reduce hospital resource utilization. Level of evidence: IV.

BACKGROUND Adult spinal deformity (ASD) is a prevalent condition often treated with circumferential spinal fusion (CF), which can be performed as staged or same-day procedures. However, evidence guiding the choice between these approaches is lacking. OBJECTIVE This study aims to compare patient outcomes following staged and same-day CF for ASD. METHODS Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a comprehensive literature search was conducted in PubMed, MEDLINE, Embase, Cochrane CENTRAL, Web of Science, and Scopus. Eligibility criteria included studies comparing outcomes following staged and same-day CF in adults with ASD. Searches were exported to Covidence, and records were deduplicated automatically. Title and abstract screening, full-text review, and data extraction were performed by two independent reviewers, with all conflicts being resolved by a third reviewer. A meta-analysis was conducted for outcomes reported in 3 or more studies. RESULTS Seven studies with 741 patients undergoing CF for ASD were included in the review (staged: n=331, 44.7% and same-day: n=410, 55.3%). Four studies that had comparable outcomes were merged for the quantitative meta-analysis and split based on observed measures. The meta-analysis revealed significantly shorter hospital length of stay (mean difference 3.98, 95% CI 2.23-5.72 days; P<.001) for same-day CF. Three studies compared the operative time between staged and same-day CF, with all reporting a lower mean operative time for same-day CF (mean between 291-479, SD 129 minutes) compared to staged CF (mean between 426-541, SD 124 minutes); however, inconsistent reporting of mean and SD made quantitative analyses unattainable. Of the 4 studies that compared estimated blood loss (EBL) in the relevant groups, 3 presented a lower EBL (mean between 412-1127, SD 954 mL) in same-day surgery compared to staged surgery (mean between 642, SD 550 to 1351, SD 869 mL). Both studies that reported intra- and postoperative adverse events showed more intraoperative adverse events in staged CF (10.9% and 13.6%, respectively) compared to same-day CF (9.1% and 3.6%, respectively). Four studies measuring any perioperative adverse events showed a higher incidence of adverse events in staged CF than all studies combined. However, quantitative analysis of EBL, intraoperative adverse events, and perioperative adverse events found no statistically significant difference. Postoperative adverse events, reoperation, infection rates, and readmission rates showed inconsistent findings between studies. Data quality assessment revealed a moderate degree of bias for all included studies. CONCLUSIONS Same-day CF may offer shorter operating time and hospital stay compared to staged CF for ASD. However, there was marked heterogeneity in perioperative outcomes reporting, and continuous variables were inconsistently presented. This underscored the need for standardized reporting of clinical variables and patient-reported outcomes and higher evidence of randomized controlled trials to elucidate the clinical superiority of either approach. CLINICALTRIAL PROSPERO CRD42022339764; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=339764 INTERNATIONAL REGISTERED REPORT RR2-10.2196/42331

BACKGROUND AND OBJECTIVES: With advances in surgical techniques over the past 40 years, single-level lumbar hemilaminectomy and microdiscectomy (HLMD) has become a standard outpatient surgery. Incidental durotomy is a common complication of lumbar decompression surgeries and often precludes same-day discharge based on preexisting paradigms, involving bedrest that have no empirical support, but often lead to increased complications in available evidence-based studies. Limited data exist regarding the safety of same-day discharge after lumbar decompression involving an incidental durotomy. The objective of this study was to establish the safety of same-day discharge after repair of incidental durotomy after single-level lumbar HLMD. METHODS: This study involved a retrospective review of the electronic medical record for all adult patients undergoing single-level lumbar hemilaminectomy and microdiscectomy by a single surgeon at our institution from 2013 through 2021. Descriptive statistics were used for data analysis. RESULTS: 346 lumbar single-level HLMD were performed during this time frame by a single surgeon. There were 17 incidental durotomies (4.9%), all primarily repaired. Of the 17 patients with incidental durotomy, all but 5 returned home on postoperative day 0, with the 5 who remained inpatient staying for reasons unrelated to the dural tear. Patients had no durotomy-associated complications, readmissions, or reoperations regardless of same-day discharge home. CONCLUSION: Same-day discharge after primary repair of incidental durotomy in single-level lumbar HLMD seems to be safe and may significantly improve health care costs associated with HLMD. This investigation should be expanded to other one-level to two-level lumbar decompression surgeries and minimally invasive and endoscopic approaches.

Traumatic brain injury (TBI) remains a pervasive clinical problem associated with significant morbidity and mortality. However, TBI remains clinically and biophysically ill-defined, and prognosis remains difficult even with the standardization of clinical guidelines and advent of multimodality monitoring. Here we leverage a unique data set from TBI patients implanted with either intracranial strip electrodes during craniotomy or quad-lumen intracranial bolts with depth electrodes as part of routine clinical practice. By extracting spectral profiles of this data, we found that the presence of narrow-band oscillatory activity in the beta band (12-30 Hz) closely corresponds with the neurological exam as quantified with the standard Glasgow Coma Scale (GCS). Further, beta oscillations were distributed over the cortical surface as traveling waves, and the evolution of these waves corresponded to recovery from coma, consistent with the putative role of waves in perception and cognitive activity. We consequently propose that beta oscillations and traveling waves are potential biomarkers of recovery from TBI. In a broader sense, our findings suggest that emergence from coma results from recovery of thalamo-cortical interactions that coordinate cortical beta rhythms.