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BackgroundSpetzler-Martin (SM) grade III arteriovenous malformations (AVMs) are at the boundary of safe operability, and preoperative embolization may reduce surgical risks.ObjectiveTo evaluate the benefits of preoperative AVM embolization by comparing neurological outcomes in patients with grade III AVMs treated with or without preoperative embolization.MethodsAll microsurgically treated grade III AVMs were identified from 2011 to 2018 at 2 medical centers. Neurological outcomes, measured as final modified Rankin Scale scores (mRS) and changes in mRS from preoperative baseline to last follow-up evaluation, were compared in patients with and without preoperative embolization.ResultsOf the 102 patients with grade III AVMs who were treated microsurgically, 57 (56%) underwent preoperative embolization. Significant differences were found between the patients with and without embolization in AVM eloquence (74% vs 93%, P=.02), size≥3cm (47% vs 73%, P=.01), diffuseness (7% vs 22%, P=.04), and mean final mRS (1.1 vs 2.0, P=.005). Poor outcomes were more frequent in patients without embolization (38%) than with embolization (7%) (final mRS>2; P2; odds ratio, 4.2; 95% CI, 1.1-16; P=.03).ConclusionNonembolization of SM grade III AVMs is associated with an increased risk of poor neurological outcomes after microsurgical resection. Preoperative embolization of intermediate-grade AVMs selected because of large AVM size, surgical inaccessibility of feeding arteries, and high flow should be employed more often than anticipated, even in the context of increasing microsurgical experience with AVMs.

BACKGROUND AND IMPORTANCE Acute spinal cord injury (SCI) is managed by avoiding hypotension and elevating mean arterial pressure (MAP) to attain optimal perfusion of the spinal cord. Few studies have been published regarding complications related to this treatment paradigm. CLINICAL PRESENTATION Three patients with SCI developed posterior reversible encephalopathic syndrome (PRES) during treatment with intravenous fluids and vasopressors administered to maintain elevated MAPs. All of them experienced temporary elevations well above the standard blood pressure goals for acute SCI and deterioration of neurological status. CONCLUSION PRES is a potential complication of elevated MAPs in patients with SCI, particularly if the blood pressure rises above the goals of standard treatment paradigms. The neurosurgical staff should be suspicious of possible PRES early in the course of acute SCI in patients with unexplained neurological decline. This case series is the first report of PRES in patients with acute SCI.

BACKGROUND Multimodal analgesia regimens have been suggested to improve pain control and reduce opioid consumption after surgery. OBJECTIVE To institutionally implement an evidence-based quality improvement initiative to standardize and optimize pain treatment following neurosurgical procedures. Our goal was to objectively evaluate efficacy of this multimodal protocol. METHODS A retrospective cohort analysis of pain-related outcomes after posterior lumbar fusion procedures was performed. We compared patients treated in the 6 mo preceding (PRE) and 6 mo following (POST) protocol execution. RESULTS A total of 102 PRE and 118 POST patients were included. The cohorts were well-matched regarding sex, age, surgical duration, number of segments fused, preoperative opioid consumption, and baseline physical status (all P > .05). Average patient-reported numerical rating scale pain scores significantly improved in the first 24 hr postoperatively (5.6 vs 4.5, P

Background Tethering after spinal surgery is caused by adhesions that arise from intradural tissue manipulation. Microsurgical detethering is the only treatment for symptomatic patients, but retethering occurs commonly and no treatment is widely available to prevent this complication. Objective To apply human amniotic membrane (HAM) grafts, which are immune-privileged and known to possess antifibrogenic properties, in patients requiring microsurgical detethering. For this first-in-human use, we evaluated the safety and potential efficacy of these grafts for preventing retethering. Methods We retrospectively reviewed the medical records of all patients who required detethering surgery and received an HAM graft between 2013 and 2016 at our institution after various previous intradural spinal surgeries. In all 14 cases, intradural lysis of adhesions was achieved, an HAM graft was sewn in place intradurally, and a dural patch was closed in a watertight fashion over the graft. Results Fourteen patients had received HAM grafts to prevent retethering. All patients had at least 6 mo of follow-up (mean follow-up, 14 mo). Retethering was noted in only 1 patient. Surgical re-exploration showed that the retethering occurred caudal to the edge of the HAM graft, with no tethering underneath the original graft. No complications were attributed specifically to the HAM graft placement. Conclusion This first-in-human series provides evidence that HAM grafts are a safe and potentially efficacious method for preventing retethering after microsurgical intradural lysis of adhesions. These results lay the groundwork for further prospective controlled trials in patients with this difficult-to-treat pathology.