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Neuromonitoring has been utilized during spinal surgery to assess the function of the spinal cord in an effort to prevent intraoperative injury. Although its use is widespread, no clear benefit has been demonstrated. Our goal in this study was to interrogate the value of intraoperative neuromonitoring in decreasing the severity and rate of neurological injury during and after spinal surgery. Here we describe our experience of 121 patients who underwent spinal cord procedures with the combination of intraoperative neuromonitoring, to determine its ability to detect neurological changes and the specificity and sensitivity in this setting. The data for the 121 patients who underwent neurophysiological monitoring during various spinal procedures was collected retrospectively. The patients were classified into one of four groups according to the findings of intraoperative monitoring and the clinical outcomes on postoperative neurological exam. Intraoperative monitoring was evaluated for its specificity, sensitivity, and predictive value. In our cohort of 121 patients, the use of intraoperative neuromonitoring had a low sensitivity, which may produce an excessive number of false negatives. Based on these findings, neuromonitoring seems to have a poor positive predictive value and is thus an inappropriate test to prevent harm to patients., Competing Interests: The authors have declared that no competing interests exist.

Background:  Urinary tract infections (UTIs) in ischemic stroke patients are a common occurrence and the frequent focus of quality improvement initiatives. However, many UTIs are community-acquired and the impact of such infections on patient outcomes remains controversial., Methods:  We conducted a retrospective analysis of our Stroke Center Database and electronic medical records to determine the incidence of both community-acquired UTI (CA-UTI) and hospital-acquired UTI (HA-UTI) in hospitalized ischemic stroke patients. We assessed risk factors for UTI, as well as clinical outcome, the length of stay (LOS), and hospital charges., Results:  In our study sample of 395 patients, UTIs were found in 11.7% and the majority of these (65%) were found on admission. Patients admitted from another hospital were more likely to be diagnosed with a UTI of any type compared to those arriving from home (odds ratio (OR) 2.42 95%, confidence interval (CI) 1.18, 4.95) and were considerably more likely to have an HA-UTI than a CA-UTI (OR 12.06 95% CI 2.14, 95.32). Those with a Foley catheter were also more likely to have a UTI (OR 2.65 95% CI 1.41, 4.98). In the multivariable analysis, we did not find a statistically significant relationship between any UTI or a specific UTI subtype and discharge modified Rankin Score (mRS), LOS, or hospital charges. Admission stroke severity remained associated with higher odds of discharge in poor condition (adjusted odds ratio (aOR) 6.23 95% CI2.33, 16.62), an extended LOS (6.84 vs 5.07, p = 0.006), and higher hospital charges ($18,305 vs $12,162, p = 0.001).  Conclusions: Urinary tract infections remain a common occurrence in stroke patients. However, the majority of UTIs are present on admission and may have little impact on discharge clinical condition, LOS, or hospital charges. These results may have implications for quality improvement (QI) initiatives that focus on the prevention and treatment of hospital-acquired UTIs., Competing Interests: The authors have declared that no competing interests exist.

Background: Case reports and case control studies have suggested an association between chiropractic neck manipulation and cervical artery dissection (CAD), but a causal relationship has not been established. We evaluated the evidence related to this topic by performing a systematic review and meta-analysis of published data on chiropractic manipulation and CAD., Methods: Search terms were entered into standard search engines in a systematic fashion. The articles were reviewed by study authors, graded independently for class of evidence, and combined in a meta-analysis. The total body of evidence was evaluated according to GRADE criteria., Results: Our search yielded 253 articles. We identified two class II and four class III studies. There were no discrepancies among article ratings (i.e., kappa=1). The meta-analysis revealed a small association between chiropractic care and dissection (OR 1.74, 95% CI 1.26-2.41). The quality of the body of evidence according to GRADE criteria was "very low.", Conclusions: The quality of the published literature on the relationship between chiropractic manipulation and CAD is very low. Our analysis shows a small association between chiropractic neck manipulation and cervical artery dissection. This relationship may be explained by the high risk of bias and confounding in the available studies, and in particular by the known association of neck pain with CAD and with chiropractic manipulation. There is no convincing evidence to support a causal link between chiropractic manipulation and CAD. Belief in a causal link may have significant negative consequences such as numerous episodes of litigation.