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Objective Surgical techniques to achieve complete resection of mesial–basal temporal tumors should be pursued by neurosurgical oncologists. We describe the anatomical subpial amygdalohippocampectomy (SpAH) technique for tumor resection. Methods The key anatomical landmarks and critical steps of the SpAH technique were outlined and emphasized with medical illustrations and intraoperative photographs. The senior author's 90-day surgical outcomes with this approach were reviewed. Results Twenty-five patients (men, 17 [68%]; women, 8 [32%]; median [range] age, 59 [23–80] years) with temporal tumors involving the amygdalohippocampal region were included. SpAH was performed selectively in 8 [32%] patients, whereas 17 [68%] patients underwent SpAH in conjunction with an anterior temporal lobectomy due to tumor involvement of the anterolateral temporal cortex. The subpial resection of the amygdala protected the critical structures of the suprasellar cistern and sylvian fissure. Identifying the choroidal fissure as the superior-most aspect of hippocampal resection protected the optic tract and the thalamus. Subpial resection of the parahippocampal gyrus inferiorly protected the brainstem and critical structures of the ambient cistern. Tumors in the amygdalohippocampal region were anatomically and completely resected in all 25 patients. Of the 15 patients who presented with seizures, 13 (87%) were seizure-free at the 90-day postsurgical follow-up. Permanent neurologic deficits occurred in 3 patients (12%). Conclusions The SpAH technique permits complete resection of mesial–basal temporal tumors with an acceptable morbidity profile. An in-depth understanding of temporal lobe anatomy combined with a refined microsurgical technique allows for reproducible resection of tumor in the amygdalohippocampal region while protecting critical neurovascular structures.

Objective Patients undergoing frontal lobectomy demonstrate lower seizure-freedom rates than patients undergoing temporal lobectomy and several other resective interventions. We attempted to utilize automated preoperative quantitative analysis of focal and global cortical volume loss to develop predictive volumetric indicators of seizure outcome after frontal lobectomy. Methods Ninety patients who underwent frontal lobectomy were stratified based on seizure freedom at a mean follow-up time of 3.5 (standard deviation [SD] 2.5) years. Automated quantitative analysis of cortical volume loss organized by distinct brain region and laterality was performed on preoperative T1-weighted magnetic resonance imaging (MRI) studies. Univariate statistical analysis was used to select potential predictors of seizure freedom. Backward variable selection and multivariate logistical regression were used to develop models to predict seizure freedom. Results Forty-eight of 90 (53.3%) patients were seizure-free at the last follow-up. Several frontal and extrafrontal brain regions demonstrated statistically significant differences in both volumetric cortical volume loss and volumetric asymmetry between the left and right sides in the seizure-free and non-seizure-free cohorts. A final multivariate logistic model utilizing only preoperative quantitative MRI data to predict seizure outcome was developed with a c-statistic of 0.846. Using both preoperative quantitative MRI data and previously validated clinical predictors of seizure outcomes, we developed a model with a c-statistic of 0.897. Significance This study demonstrates that preoperative cortical volume loss in both frontal and extrafrontal regions can be predictive of seizure outcome after frontal lobectomy, and models can be developed with excellent predictive capabilities using preoperative MRI data. Automated quantitative MRI analysis can be quickly and reliably performed in patients with frontal lobe epilepsy, and further studies may be developed for integration into preoperative risk stratification.

BACKGROUND: The COVID-19 pandemic has significantly affected patient care across specialties. Ramifications for neurosurgery include substantial disruptions to surgical training and changes in nonurgent patient presentations to the emergency department. This study quantifies the effects of the COVID-19 pandemic on the number of emergency department patients who were referred to the neurosurgery department for further consultation and treatment and identifies and describes trends in the characteristics of these visits. METHODS: A retrospective review was performed of neurosurgical consultations at a single high-volume institution for 28 call-day periods before and after the official announcement of the pandemic. Primary outcomes included consultations per call-day, patient presentation category, and patient admission. RESULTS: The neurosurgical service was consulted regarding 629 patients (367 male patients) during the study period, with 471 (75%) and 158 (25%) patients presenting before and after the announcement of the COVID-19 pandemic, respectively. The mean number of neurosurgical consultations per call-day was significantly lower in the COVID-19 period (5.6 consultations) compared with the pre-COVID-19 period (16.8 consultations) (P < 0.001). After adjusting for patient demographics, the rate of presentation for general nonurgent concerns, such as back pain, headaches, and other general weaknesses, significantly decreased (odds ratio [95% confidence interval], 0.60 [0.47-0.77], P < 0.001). CONCLUSIONS: Neurosurgical consultations significantly decreased after the onset of the COVID-19 pandemic, with a substantially lower overall number of consultations necessitating operative interventions. Furthermore, the relative number of patients with nonemergent neurological conditions significantly decreased during the pandemic.

Treatment of small ruptured aneurysms (SRAs) remains controversial, with literature reporting difficulty with endovascular versus microsurgical approaches. This paper analyzes outcomes after endovascular coiling and microsurgical clipping among patients with SRAs prospectively enrolled in the Barrow Ruptured Aneurysm Trial (BRAT). All BRAT patients were included in this study. Patient demographics, aneurysm size, aneurysm characteristics, procedure-related complications, and outcomes at discharge and at 1-year and 6-year follow-up were evaluated. A modified Rankin scale (mRS) score > 2 was considered a poor outcome. Of 73 patients with SRAs, 40 were initially randomly assigned to endovascular coiling and 33 to microsurgical clipping. The rate of treatment crossover was significantly different between coiling and clipping; 25 patients who were assigned to coiling crossed over to clipping, and no clipping patients crossed over to coiling (P 2) at discharge and 1-year and 6-year follow-up (P = 0.48 and 0.73, respectively). Most SRA patients in the BRAT underwent surgical clipping, with a high rate of crossover from endovascular approaches. Endovascular treatment was equivalent to surgical clipping with regard to procedure-related complications and neurologic outcomes.

Skull base paragangliomas are highly vascular tumors that are often embolized before surgical resection; however, the safety and efficacy of preoperative embolization using an ethylene vinyl alcohol copolymer (Onyx; Medtronic, Dublin, Republic of Ireland) in these tumors is unknown. This retrospective cohort study evaluated patient outcomes after preoperative embolization of skull base paragangliomas using Onyx. We retrospectively analyzed data from all patients with skull base paragangliomas who underwent preoperative Onyx embolization at our institution (January 01, 2005–December 31, 2017). Patient, tumor, embolization, and outcomes data were extracted by reviewing inpatient and outpatient clinical and imaging records. Seven patients were studied (5/7 [71%] female), 6 with glomus jugulares and 1 with a glomus vagale. The median age was 52 years, and the most common presenting symptom was cranial neuropathy (6/7 [86%]). The tumor vascular supply was from the ascending pharyngeal artery in all 7 cases (100%) with additional feeders including the occipital artery in 5 (71%); internal carotid artery in 3 (43%); middle meningeal, vertebral, and internal maxillary artery each in 2 (29%); and posterior auricular artery in 1 (14%). The median postembolization tumor devascularization was 80% (range, 64–95%). The only postembolization complication was a facial palsy in 1 patient. Preoperative embolization with Onyx affords excellent devascularization for the majority of skull base paragangliomas, and it may facilitate resection of these hypervascular lesions. The advantages provided by Onyx with respect to penetration of intratumoral vessels must be weighed against the risk of cranial neuropathy.

Traumatic brain injury (TBI) is associated with one-third of all deaths from trauma. Preinjury exposure to cardiovascular drugs may affect TBI outcomes. Angiotensin-converting enzyme inhibitors (ACEIs) exacerbate brain cell damage and worsen functional outcomes in the laboratory setting. β-blockers (BBs), however, appear to be associated with reduced mortality among patients with isolated TBI. Examine the association between preinjury ACEI and BB use and clinical outcome among patients with isolated TBI. A retrospective cohort study of patients age ≥ 40 years admitted to an academic level 1 trauma center with isolated TBI between January 2010 and December 2014 was performed. Isolated TBI was defined as a head Abbreviated Injury Scale (AIS) score ≥ 3, with chest, abdomen, and extremity AIS scores ≤ 2. Preinjury medication use was determined through chart review. All patients with concurrent BB use were initially excluded. In-hospital mortality was the primary measured outcome. Over the 5-year study period, 600 patients were identified with isolated TBI who were naive to BB use. There was significantly higher mortality (P = .04) among patients who received ACEI before injury (10 of 96; 10%) than among those who did not (25 of 504; 5%). A multivariate stepwise logistic regression analysis revealed a threefold increased risk of mortality in the ACEI cohort (P

External ventricular drains (EVDs) are often placed emergently for patients with hydrocephalus, which carries a risk of hemorrhage. Rarely, rupture of a pseudoaneurysm originating from an EVD placement precipitates such a hemorrhage. An EVD was placed in a patient with a ruptured left posterior communicating artery aneurysm who later underwent endovascular coil embolization. On post-bleed day 20, a distal right anterior cerebral artery pseudoaneurysm along the EVD tract ruptured, which was successfully treated via clip-wrapping. Although EVD-associated pseudoaneurysms are rare, they have a high propensity for rupture. Early treatment of these lesions should be considered to prevent neurologic deterioration.

Microsurgical clipping of large paraclinoid aneurysms is challenging because of the complex anatomy of the dural rings, lack of easy proximal control, and wide aneurysm necks. Proximal retrograde suction decompression, or the Dallas technique, can reduce aneurysm turgor and, with aspiration of the trapped cervical and supraclinoid internal carotid arteries (ICAs), can collapse the aneurysm to aid microsurgical clipping.(1-5) A woman in her late 30s presented with decreased right-eye visual acuity. Informed written consent was obtained for microsurgical management and publication. Upon cervical exposure of the carotid bifurcation, we performed a standard pterional craniotomy, trans-sylvian exposure, and intradural anterior clinoidectomy. After burst suppression and cross-clamping of the carotid, we inserted an angiocatheter at the common carotid artery (CCA). Distal temporary clips were placed on the posterior communicating artery and C7 ICA. With the cervical ICA unclamped, retrograde suction was continuously applied to deflate the aneurysm. We applied 2 pairs of fenestrated-booster clips to the aneurysm dome and a fifth clip to the aneurysm neck. After restoration of flow, indocyanine green angiography and Doppler assessments were performed. The proximal clip was converted into a curved clip to optimize ICA flow. Postoperative angiography confirmed complete occlusion of the aneurysm. The patient was discharged on postoperative day 3, with stable visual acuity.(6) This video demonstrates that retrograde suction decompression via the cervical CCA can be safely performed to facilitate clipping of complex paraclinoid ICA aneurysms. Comprehensive planning of temporary aneurysm trapping for suction decompression and permanent clip construct for aneurysm occlusion are needed for effective aneurysm repair.

Treatment of small ruptured aneurysms (SRAs) remains controversial, with literature reporting difficulty with endovascular versus microsurgical approaches. This paper analyzes outcomes after endovascular coiling and microsurgical clipping among patients with SRAs prospectively enrolled in the Barrow Ruptured Aneurysm Trial (BRAT).All BRAT patients were included in this study. Patient demographics, aneurysm size, aneurysm characteristics, procedure-related complications, and outcomes at discharge and at 1-year and 6-year follow-up were evaluated. A modified Rankin scale (mRS) score 2 was considered a poor outcome.Of 73 patients with SRAs, 40 were initially randomly assigned to endovascular coiling and 33 to microsurgical clipping. The rate of treatment crossover was significantly different between coiling and clipping; 25 patients who were assigned to coiling crossed over to clipping, and no clipping patients crossed over to coiling (P 0.001). Among SRA patients, 15 underwent coiling and 58 underwent clipping; groups did not differ significantly in demographic characteristics or aneurysm type (P ≥ 0.11). Mean aneurysm diameter was significantly greater in the endovascular group (3.0 ± 0.3 vs 2.6 ± 0.6; P = 0.02). The incidence of procedure-related complications was similar for endovascular and microsurgical treatments (odds ratio [95% confidence interval], 1.0 [0.1-10.0], P = 0.98). Both groups had comparable overall outcome (mRS score 2) at discharge and 1-year and 6-year follow-up (P = 0.48 and 0.73, respectively).Most SRA patients in the BRAT underwent surgical clipping, with a high rate of crossover from endovascular approaches. Endovascular treatment was equivalent to surgical clipping with regard to procedure-related complications and neurologic outcomes.

Background Stereoelectroencephalography (SEEG) is used to identify the epileptogenic zone (EZ) in patients with epilepsy for potential surgical intervention. Occasionally, the EZ is difficult to localize even after an SEEG implantation. Objective To demonstrate a safe technique for placing additional electrodes in ongoing SEEG evaluations. Describe efficacy, complications, and surgical outcomes. Methods An operative technique which involves maintaining previously placed electrodes and sterilely placing new electrodes was developed and implemented. All patients who underwent placement of additional SEEG electrodes during the same admission were retrospectively reviewed. Results A total of 14 patients met criteria and had undergone SEEG evaluation with 198 electrodes implanted. A total 93% of patients (13/14) had nonlesional epilepsy. After unsuccessful localization of the EZ after a mean of 9.6 d of monitoring, each patient underwent additional placement of electrodes (5.5 average electrodes per patient) to augment the original implantation. At no point did any patients develop new hemorrhage, infection, wound breakdown, or require any kind of additional antimicrobial treatment. A total 64% (9/14) of patients were able to undergo surgery aimed at removing the EZ guided by the additional SEEG electrodes. A total 44% (4/9) of surgical patients had Engel class I outcomes at an average follow-up time of 11 mo. Conclusion Placing additional SEEG electrodes, while maintaining the previously placed electrodes, appears to be safe, effective, and had no infectious complications. When confronted with difficult-to-localize epilepsy even after invasive monitoring, it appears to be safe and potentially clinically effective to place additional electrodes during the same admission.

Background Spetzler Martin (SM) grade 3 arteriovenous malformations (AVMs) are challenging lesions, often treated with preoperative embolization before definitive microsurgical resection. However, no significant difference in outcomes has been reported in patients with preoperative embolization for these lesions. Objective To compare neurological outcomes of microsurgically treated SM grade 3 AVMs with vs without preoperative resection. Methods A retrospective analysis of prospectively collected AVM databases from two large tertiary centers for all microsurgically treated SM grade 3 AVMs during 2011–2018 was performed. Comparison of neurological outcome (modified Rankin Scale score [mRS] >2 and change in mRS on last follow-up) between patients with vs without preoperative embolization was performed. Results Of 102 patients with microsurgically treated SM grade 3 AVMs, 57 (56%) underwent preoperative embolization. Significant differences between patients with vs without embolization were found for eloquence (75% vs 93%, p=0.02), diameter ≥3 cm (53% vs 27%, p=0.01), diffuseness (7% vs 22%, p=0.04), and mean follow-up mRS (1.1 vs 2.0, p=0.005). A higher percentage of patients without embolization (38%) than with embolization (7%) had an mRS >2 on follow-up (p 2. Conclusion Lack of preoperative embolization in SM grade 3 AVMs may be associated with increased risk of poor outcome following microsurgical resection. Hence, evaluation for preoperative embolization is essential for all intermediate-grade lesions. Disclosures J. Catapano: None. F. Frisoli: None. C. Nguyen: None. D. Wilkinson: None. N. Majmundar: None. T. Cole: None. J. Baranoski: None. A. Whiting: None. H. Kim: None. R. Spetzler: None. A. Ducruet: None. F. Albuquerque: None. M. Lawton: None.

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.

OBJECTIVETakotsubo cardiomyopathy (TC) in patients with aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity and mortality. Previous studies have shown that female patients presenting with a poor clinical grade are at the greatest risk for developing TC. Intra-aortic balloon pumps (IABPs) are known to support cardiac function in severe cases of TC, and they may aid in the treatment of vasospasm in these patients. In this study, the authors investigated risk factors for developing TC in the setting of aSAH and outcomes among patients requiring IABPs.METHODSThe authors retrospectively reviewed the records of 1096 patients who had presented to their institution with aSAH. Four hundred five of these patients were originally enrolled in the Barrow Ruptured Aneurysm Trial, and an additional 691 patients from a subsequent prospectively maintained aSAH database were analyzed. Medical records were reviewed for the presence of TC according to the modified Mayo Clinic criteria. Outcomes were determined at the last follow-up, with a poor outcome defined as a modified Rankin Scale (mRS) score > 2.RESULTSTC was identified in 26 patients with aSAH. Stepwise multivariate logistic regression analysis identified female sex (OR 8.2, p = 0.005), Hunt and Hess grade > III (OR 7.6, p < 0.001), aneurysm size > 7 mm (OR 3, p = 0.011), and clinical vasospasm (OR 2.9, p = 0.037) as risk factors for developing TC in the setting of aSAH. TC patients, even with IABP placement, had higher rates of poor outcomes (77% vs 47% with an mRS score > 2, p = 0.004) and mortality at the last follow-up (27% vs 11%, p = 0.018) than the non-TC patients. However, aggressive intra-arterial endovascular treatment for vasospasm was associated with good outcomes in the TC patients versus nonaggressive treatment (100% with mRS ≤ 2 at last follow-up vs 53% with mRS > 2, p = 0.040).CONCLUSIONSTC after aSAH tends to occur in female patients with large aneurysms, poor clinical grades, and clinical vasospasm. These patients have significantly higher rates of poor neurological outcomes, even with the placement of an IABP. However, aggressive intra-arterial endovascular therapy in select patients with vasospasm may improve outcome.

Invasive neuromonitoring is an important component of presurgical workup and seizure onset zone localization in patients with epilepsy being considered for surgical resection. In the United States, intraparenchymal stereoelectroencephalography (SEEG) electrodes have been replacing subdural grid electrodes for most cases, following a trend that has already matured in Europe. The use of robotic assistance has been shown to improve operative times and accuracy in SEEG electrode placement, as users benefit from the embedded planning software as well as the efficiency and accuracy of the robotic arm. The greatest barriers to implementation of this technology are the upfront cost and learning curve. This case-based surgeon's perspective operative video could benefit those considering incorporating robotic assistance for SEEG electrode placement. Those considering robotic assistance for pedicle screw placement and other budding applications may also benefit, as well as innovators looking for new applications. The patient consented for the procedure, video recording, and inclusion in subsequent publications.

OBJECTIVE Debate continues over proper surgical treatment for mesial temporal lobe epilepsy (MTLE). Few large comprehensive studies exist that have examined outcomes for the subtemporal selective amygdalohippocampectomy (sSAH) approach. This study describes a minimally invasive technique for sSAH and examines seizure and neuropsychological outcomes in a large series of patients who underwent sSAH for MTLE. METHODS Data for 152 patients (94 women, 61.8%; 58 men, 38.2%) who underwent sSAH performed by a single surgeon were retrospectively reviewed. The sSAH technique involves a small, minimally invasive opening and preserves the anterolateral temporal lobe and the temporal stem. RESULTS All patients in the study had at least 1 year of follow-up (mean [SD] 4.52 [2.57] years), of whom 57.9% (88/152) had Engel class I seizure outcomes. Of the patients with at least 2 years of follow-up (mean [SD] 5.2 [2.36] years), 56.5% (70/124) had Engel class I seizure outcomes. Preoperative and postoperative neuropsychological test results indicated no significant change in intelligence, verbal comprehension, perceptual reasoning, attention and processing, cognitive flexibility, visuospatial memory, or mood. There was a significant change in word retrieval regardless of the side of surgery and a significant change in verbal memory in patients who underwent dominant-side resection (p < 0.05). Complication rates were low, with a 1.3% (2/152) permanent morbidity rate and 0.0% mortality rate. CONCLUSIONS This study reports a large series of patients who have undergone sSAH, with a comprehensive presentation of a minimally invasive technique. The sSAH approach described in this study appears to be a safe, effective, minimally invasive technique for the treatment of MTLE.

Skull base paragangliomas are highly vascular tumors that are often embolized before surgical resection; however, the safety and efficacy of preoperative embolization using an ethylene vinyl alcohol copolymer (Onyx; Medtronic, Dublin, Republic of Ireland) in these tumors is unknown. This retrospective cohort study evaluated patient outcomes after preoperative embolization of skull base paragangliomas using Onyx.We retrospectively analyzed data from all patients with skull base paragangliomas who underwent preoperative Onyx embolization at our institution (January 01, 2005-December 31, 2017). Patient, tumor, embolization, and outcomes data were extracted by reviewing inpatient and outpatient clinical and imaging records.Seven patients were studied (5/7 [71%] female), 6 with glomus jugulares and 1 with a glomus vagale. The median age was 52 years, and the most common presenting symptom was cranial neuropathy (6/7 [86%]). The tumor vascular supply was from the ascending pharyngeal artery in all 7 cases (100%) with additional feeders including the occipital artery in 5 (71%); internal carotid artery in 3 (43%); middle meningeal, vertebral, and internal maxillary artery each in 2 (29%); and posterior auricular artery in 1 (14%). The median postembolization tumor devascularization was 80% (range, 64-95%). The only postembolization complication was a facial palsy in 1 patient.Preoperative embolization with Onyx affords excellent devascularization for the majority of skull base paragangliomas, and it may facilitate resection of these hypervascular lesions. The advantages provided by Onyx with respect to penetration of intratumoral vessels must be weighed against the risk of cranial neuropathy.

OBJECTIVELateral lumbar interbody fusion (LLIF) is a useful minimally invasive technique for achieving anterior interbody fusion and preserving or restoring lumbar lordosis. However, achieving circumferential fusion via posterior instrumentation after an LLIF can be challenging, requiring either repositioning the patient or placing pedicle screws in the lateral position. Here, the authors explore an alternative single-position approach: LLIF in the prone lateral (PL) position.METHODSA cadaveric feasibility study was performed using 2 human cadaveric specimens. A retrospective 2-center early clinical series was performed for patients who had undergone a minimally invasive lateral procedure in the prone position between August 2019 and March 2020. Case duration, retractor time, electrophysiological thresholds, implant size, screw accuracy, and complications were recorded. Early postoperative radiographic outcomes were reported.RESULTSA PL LLIF was successfully performed in 2 cadavers without causing injury to a vessel or the bowel. No intraoperative subsidence was observed. In the clinical series, 12 patients underwent attempted PL surgery, although 1 case was converted to standard lateral positioning. Thus, 11 patients successfully underwent PL LLIF (89%) across 14 levels: L2–3 (2 of 14 [14%]), L3–4 (6 of 14 [43%]), and L4–5 (6 of 14 [43%]). For the 11 PL patients, the mean (± SD) age was 61 ± 16 years, mean BMI was 25.8 ± 4.8, and mean retractor time per level was 15 ± 6 minutes with the longest retractor time at L2–3 and the shortest at L4–5. No intraoperative subsidence was noted on routine postoperative imaging.CONCLUSIONSPerforming single-position lateral transpsoas interbody fusion with the patient prone is anatomically feasible, and in an early clinical experience, it appeared safe and reproducible. Prone positioning for a lateral approach presents an exciting opportunity for streamlining surgical access to the lumbar spine and facilitating more efficient surgical solutions with potential clinical and economic advantages.

Anterior column realignment (ACR) with anterior longitudinal ligament (ALL) release from a lateral transpsoas approach is increasingly being used as a minimally invasive technique to restore lordosis. Safe execution requires a plane between the ALL and the anterior vasculature. An unfavorable plane on preoperative imaging is a contraindication to using the technique. We describe a patient undergoing multistage minimally invasive correction of a flat-back deformity who had an unfavorable plane between the ALL and vasculature at L4-5. Patient consent was provided, and Institutional Review Board approval was not required. To safely complete the ALL release and ACR, we elected to sharply incise the lateral aspect of the ligament at L4-5 with direct control of the vessels during the anterior approach for an L5-S1 anterior lumbar interbody fusion. We then moved to the lateral transpsoas approach and used controlled distraction techniques to complete the ALL release and then to complete the ACR in a standard fashion. We ultimately achieved excellent realignment with correction of the patient's flat-back deformity using minimally invasive surgical techniques while minimizing vascular risk. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

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

The mechanisms of appetite disorders, such as refractory obesity and anorexia nervosa, have been vigorously studied over the last century, and these studies have shown that the central nervous system has significant involvement with, and responsibility for, the pathology associated with these diseases. Because deep brain stimulation has been shown to be a safe, efficacious, and adjustable treatment modality for a variety of other neurological disorders, it has also been studied as a possible treatment for appetite disorders. In studies of refractory obesity in animal models, the ventromedial hypothalamus, the lateral hypothalamus, and the nucleus accumbens have all demonstrated elements of success as deep brain stimulation targets. Multiple targets for deep brain stimulation have been proposed for anorexia nervosa, with research predominantly focusing on the subcallosal cingulate, the nucleus accumbens, and the stria terminalis and medial forebrain bundle. Human deep brain stimulation studies that focus specifically on refractory obesity and anorexia nervosa have been performed but with limited numbers of patients. In these studies, the target for refractory obesity has been the lateral hypothalamus, ventromedial hypothalamus, and nucleus accumbens, and the target for anorexia nervosa has been the subcallosal cingulate. These studies have shown promising findings, but further research is needed to elucidate the long-term efficacy of deep brain stimulation for the treatment of appetite disorders.

Objective Obesity has become a worldwide epidemic, with very few long-term successful treatment options for refractory disease. Deep brain stimulation (DBS) of the bilateral lateral hypothalamus (LH) in refractory obesity has been performed safely. However, questions remain regarding the optimal settings and its effects on metabolic rate. The goals of our experiment were to determine the optimal DBS settings and the actual effect of optimal stimulation on energy expenditure. Methods After bilateral LH DBS implantation, 2 subjects with treatment refractory obesity underwent 4 days of metabolic testing. The subjects slept overnight in a respiratory chamber to measure their baseline sleep energy expenditure, followed by 4 consecutive days of resting metabolic rate (RMR) testing at different stimulation settings. On day 4, the optimized DBS settings were used, and sleep energy expenditure was measured again overnight in the room calorimeter. Results During daily testing, the RMR fluctuated acutely with changes in stimulation settings and returned to baseline immediately after turning off the stimulation. Optimal stimulation settings selected for participants showed a 20% and 16% increase in RMR for the 2 participants. Overnight sleep energy expenditure measurements at these optimized settings on day 4 yielded a 10.4% and 4.8% increase over the baseline measurements for the 2 participants. Conclusions These findings have demonstrated the efficacy of optimized DBS of the LH on increasing the RMR acutely and maintaining this increase during overnight sleep. These promising preliminary findings have laid the groundwork for the possible treatment of refractory obesity with DBS.

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.

Although the epilepsy refractory to medical therapy can potentially be cured by the resection of epileptogenic tissue, many patients do not qualify for surgery, because epileptogenic tissue can arise from eloquent areas of the brain, where surgical resection would result in severe neurological deficits. Palliative surgical treatments currently used in these situations include deep brain stimulation, responsive neurostimulation, and vagal nerve stimulation.1 A previously developed technique, multiple subpial transections (MSTs), although used infrequently, is another effective tool.2 Our patient, a 34-yr-old man, had epilepsy that was refractory to medical management. His preoperative work-up demonstrated a potential seizure focus in the left pars opercularis and left superior temporal gyrus, which was verified using invasive stereoelectroencephalography. Functional magnetic resonance imaging demonstrated a significant verbal and motor function in this region. After informed consent was obtained, the patient underwent a left-sided craniotomy. The central portion of the seizure focus was resected using the subpial technique. The surrounding presumed epileptogenic cortex, which was considered functionally eloquent, was then horizontally disconnected with MSTs. For each transection, a small puncture incision was made in the pia, and a vertical cut was completed using Morrell dissectors.2 MSTs were performed circumferentially around the entire resection cavity in 5-mm increments. All hemostasis was achieved with irrigation instead of electrocautery, although noncauterizing hemostatic agents are also acceptable. The patient was neurologically intact after the operation and was discharged home on postoperative day 2. He was free of seizures at 11-month follow-up. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.