Percutaneous pedicle screw placement into a spinal segment previously treated with vertebroplasty: technical note

Vertebral augmentation with cement has become a common procedure for the treatment of compression fractures, leading to a growing population who have had this procedure and are now in need of another spinal surgery. This technical note reports an undescribed method for placing pedicle screws through a previously cemented level

Machine learning to predict passenger mortality and hospital length of stay following motor vehicle collision

Motor vehicle collisions (MVCs) account for 1.35 million deaths and cost $518 billion US dollars each year worldwide, disproportionately affecting young patients and low-income nations. The ability to successfully anticipate clinical outcomes will help physicians form effective management strategies and counsel families with greater accuracy. The authors aimed to train several classifiers, including a neural network model, to accurately predict MVC outcomes. A prospectively maintained database at a single institution's level I trauma center was queried to identify all patients involved in MVCs over a 20-year period, generating a final study sample of 16,287 patients from 1998 to 2017. Patients were categorized by in-hospital mortality (during admission) and length of stay (LOS), if admitted. All models included age (years), Glasgow Coma Scale (GCS) score, and Injury Severity Score (ISS). The in-hospital mortality and hospital LOS models further included time to admission. After comparing a variety of machine learning classifiers, a neural network most effectively predicted the target features. In isolated testing phases, the neural network models returned reliable, highly accurate predictions: the in-hospital mortality model performed with 92% sensitivity, 90% specificity, and a 0.98 area under the receiver operating characteristic curve (AUROC), and the LOS model performed with 2.23 days mean absolute error after optimization. The neural network models in this study predicted mortality and hospital LOS with high accuracy from the relatively few clinical variables available in real time. Multicenter prospective validation is ultimately required to assess the generalizability of these findings. These next steps are currently in preparation

Chapter 55 - Overview of CNS Vaccines—Pediatrics

Vaccine immunotherapy for pediatric CNS malignancy is a new and developing field, primarily aimed at glial tumors. Vaccines typically must be found safe and effective in adults before being tested in children. There are three major types of tumor vaccines: dendritic cell (DC), peptide, and vector-based. All vaccines directed at pediatric CNS tumors currently remain in pilot or Phase I trials, evaluating feasibility and safety, respectively. Immune response and improved clinical outcomes have been documented as secondary measures in some cases. In this chapter, we will present a thorough review of vaccine therapy for pediatric CNS tumors

Who Needs Sleep? An Analysis of Patient Tolerance in Awake Craniotomy

Awake craniotomy (AC) is generally a safe and effective procedure; however, a small but not insignificant portion of cases are aborted due to patient intolerance of the awake portion of surgery. There is not yet a firm understanding of what characteristics indicate patient tolerance or failure of AC. We retrospectively reviewed a single-surgeon database of patients treated by AC over a 5-year period. Charts were reviewed for demographic, clinical, and operative characteristics, including anesthetic administration during the awake portion of surgery. Statistical analysis was performed to determine which factors predicted patient tolerance or failure. Our study cohort comprised 120 patients with an average age of 56.0 ± 15.2 years. A majority of patients were male (55.8%). The most common surgical indication was tumor (95.8%), with gliobastoma as the most common diagnosis (43.3%). Male sex predicted surgical tolerance on univariate analysis (P = 0.015). Remifentanil administration was associated with surgical failure on univariate analysis (P = 0.068), and also predicted failure on multivariate analysis (P = 0.030). Preoperative seizure, ketamine administration, and right-sided surgery each predicted patient tolerance, but did not achieve statistical significance. Similarly, respiratory comorbidity was associated with surgical failure, but did not achieve significance. AC remains an effective treatment option; the majority of patients tolerate the procedure without issue. Male patients have lower rates of surgical failure, whereas remifentanil administration may increase failure rate. •Male sex and right-side surgery were associated with patient tolerance.•Ketamine administration was associated with patient tolerance.•Remifentanil administration was associated with patient intolerance

Frontal Sinus Osteoma Presenting with Meningitis and Epilepsy

Osteomas are benign lesions of bone, most frequently seen in the paranasal sinuses; however, they are typically asymptomatic and without complication. We report a rare case of large frontal sinus osteoma with intracranial extension, associated with meningitis and the development of seizures. The patient is a 38-year-old man with a prolonged history of headache and seizures, who was seen by multiple specialists previously, all of whom deferred treatment. After years of worsening seizure activity, he finally underwent surgical resection of the lesion at our institution in a joint operation with neurosurgery and otolaryngology. We examine his course, presentation, and management, and examine the literature for cases of complicated sinus osteomas. This represents the fourth reported case of frontal sinus osteoma associated with meningitis. We believe this case demonstrates the value of a robust differential and a multidisciplinary approach

Central Neurocytoma: Rare Presentation in Fourth Ventricle and Review of Literature

Central neurocytomas are rare tumors, typically found in the third ventricle. We present the unusual case of a fourth ventricular central neurocytoma in a 70-year-old female presenting with imbalance and headaches, with an enhancing fourth ventricular mass on imaging. We examine the details of her clinical presentation, imaging characteristics, histopathologic analysis, and postoperative course. We performed a critical literature review of fourth ventricular central neurocytoma, identifying 6 previously reported cases. In contrast to our patient, the majority of these cases were in young males. The 2 females with fourth ventricular neurocytoma developed it at a much later age (mean 63.5 years) than their male counterparts (mean 22.8 years; P = 0.005). Despite being a rare cause for a fourth ventricular lesion, given the appropriate clinical context and radiographic findings, this should remain part of the differential diagnosis

Predictors of Successful Discharge of Patients on Postoperative Day 1 After Craniotomy for Brain Tumor

Shorter hospital stays have been associated with decreased complication rates, fewer hospital-acquired infections, and lower costs. We evaluated an optimized treatment paradigm for patients undergoing craniotomy allowing for postoperative day 1 (POD1) discharge if the criteria were met. We compared the complication and readmission rates between the POD1 patients and those with longer stays, and examined the patient and surgical variables for predictors of POD1 discharge. We performed a retrospective review of craniotomies performed for tumor from 2011 to 2015. Craniotomies for tumors were included, and laser ablations and biopsies were excluded. A total 424 of patients were included, 132 (31%) of whom had been discharged on POD1. The mean length of stay was 6 days. The POD1 patients had had significantly better preoperative Karnofsky performance scale scores (P 1 day, 4.4% and 2.7% developed DVT or PE (P = 0.0119) and urinary tract infections (P = 0.0202), respectively. Multivariate regression identified patient factors (male gender, low preoperative modified Rankin scale score), tumor factors (right-sided, supratentorial, smaller size), lower modified frailty index score, and operative factors (lack of a cerebrospinal fluid drain, awake surgery) as independent predictors of successful early discharge. Patients with good functional status can be safely discharged on POD1 after tumor craniotomy if the appropriate postoperative criteria have been met. Patients with early discharge had lower 30-day readmission and DVT/PE rates, likely owing to better baseline health status