A comparison of prolonged nonoperative management strategies in cervical stenosis patients: Successes versus failures

A paucity of evidence exists regarding the optimal composition of conservative therapies to best treat patients diagnosed with cervical stenosis prior to consideration of surgery. The purpose of this study was to compare the nonoperative therapy utilization strategies in cervical stenosis patients successfully managed with conservative treatments versus those that failed medical management and opted for an anterior cervical discectomy and fusion (ACDF) surgery. Medical records from adult patients with a diagnosis of cervical stenosis from 2007 to 2017 were collected retrospectively from a large insurance database. Patients were divided into two cohorts: patients treated successfully with nonoperative therapies and patients that failed conservative management and opted for ACDF surgery. Nonoperative therapies utilized by the two cohorts were collected over a 2-year surveillance window. A total of 90,037 adult patients with cervical stenosis comprised the base population. There were 83,384 patients (92.6%) successfully treated with nonoperative therapies alone, while 6,653 patients (7.4%) ultimately failed conservative management and received an ACDF. Failure rates of non-operative therapies were higher in smokers (11.2%), patients receiving cervical epidural steroid injections (11.2%), and male patients (8.1%). A greater percentage of patients who failed conservative management utilized opioid medications (p < 0.001), muscle relaxants (p < 0.001), and CESIs (p < 0.001). The costs of treating patients that failed conservative management was double the amount of the successfully treated group (failed cohort: $1,215.73 per patient; successful cohort: $659.58 per patient). A logistic regression analysis demonstrated that male patients, smokers, opioid utilization, and obesity were independent predictors of conservative treatment failure.     

Gender differences in the 3-month utilization of nonoperative therapies prior to primary lumbar microdiscectomy

Patients with lumbar intervertebral disc herniation classically trial a brief course of conservative management prior to microdiscectomy surgery. Gender differences have previously been identified in the selection and symptomatic response to commonly-utilized nonoperative treatments. However, whether gender differences exist in the degree and cost of nonoperative therapy in this cohort remains unknown. Therefore, the purpose of this study was to assess for gender differences in the utilization and costs of nonoperative therapy in patients diagnosed with symptomatic lumbar intervertebral disc herniation 3-months prior to undergoing microdiscectomy. Medical records from adult patients diagnosed with a lumbar intervertebral disc herniation undergoing index microdiscectomy procedures from 2007 to 2017 were collected retrospectively from a large insurance database. The utilization of nonoperative therapy within 3-months after initial lumbar herniation diagnosis was determined. A total of 13,106 patients (55.4% Males) underwent index microdiscectomy. Male patients were more likely to fail conservative management and opt for surgery (Males: 2.9% vs. Females: 1.8%, p < 0.0001). A greater percentage of female patients utilized muscle relaxants (p = 0.0049), lumbar epidural steroid injections (p = 0.0007), and emergency department services (p = 0.001). The total direct cost of conservative treatment prior to microdiscectomy was $13,205,924, with males accountable for $7,457,023 (56.5%). When normalized by number of patients utilizing the respective therapy, males used fewer units of NSAIDs (males: 84.2 pills/patient; females: 97.3 pills/patient) and muscle relaxants (males: 77.5 pills/patient; females: 89.0 pills/patient). These results suggest that gender differences exist in the utilization of nonoperative therapies for the management of a lumbar intervertebral herniated disc prior to microdiscectomy surgery.     

Duration of indwelling drain following instrumented posterolateral fusion of the lumbar spine does not predict surgical site infection requiring reoperation

The objective of this study was to determine the incidence and predictors of reoperation for surgical site infections (SSI) among patients whose lumbar, closed wound suction drains were removed in the inpatient setting prior to hospital discharge (pre-discharge cohort) versus after inpatient discharge during the first follow up visit (post-discharge cohort). All patients who were admitted for first-time, posterolateral decompression and fusion for degenerative lumbar spine disease were retrospectively reviewed at a single institution. In order to eliminate biases, neither the pre-discharge nor post-discharge cohorts experienced any intra-/postoperative sentinel events other than the primary outcome measure: reoperation for SSI. Of 209 patients in the pre-discharge (n = 130) and post-discharge (n = 79) cohorts, 15 patients required reoperation for SSI. Although time to drain discontinuation was significantly longer in the post-discharge (8.28 days) than the pre-discharge (4.65 days) cohorts (p < 0.001), the incidences of reoperation for SSI did not significantly differ (6.33 vs 7.69%, respectively, p = 0.711). In a multivariable regression, only smoking (OR = 5.75, p = 0.007) and depression (OR = 4.11, p = 0.040) predicted reoperation for SSI. Neither time to drain removal nor setting of drain removal was a predictor of reoperation for SSI. Although time to drain discontinuation was expectedly longer in the post-discharge versus pre-discharge cohorts, the incidences of reoperation for SSI did not significantly differ. Neither time to drain removal nor setting of drain removal predicted reoperation for SSI. These results suggest that patients may be safely discharged from the hospital with the surgical drain in place.     

A meta-analysis comparing ALIF,PLIF, TLIF and LLIF

IntroductionLumbar interbody fusions have been widely used to treat degenerative lumbar disease that fails to respond to conservative treatment. This procedure is divided according to its approach: anterior lumbar interbody fusion (ALIF), posterior lumbar interbody fusion (PLIF), transforaminal lumbar interbody fusion (TLIF) and lateral lumbar interbody fusion (LLIF). Each approach has its own theoretical advantages and disadvantages; however, there have been no studies that compared these.MethodsVarious full-text databases were systematically searched through December 2015. Data regarding the radiological, operative and clinical outcomes of each lumbar interbody fusion were extracted. All outcomes were pooled using random effects meta-analysis, with the relative risk (RR) and/or weighted mean difference (WMD) as the summary statistic.ResultsThirty studies met the inclusion criteria. The ALIF procedure has been studied most intensively, followed by PLIF, TLIF and LLIF respectively. All four approaches had similar fusion rates (p = 0.320 & 0.703). ALIF has superior radiological outcome, achieving better postoperative disc height (p = 0.002 & 0.005) and postoperative segmental lordosis (p = 0.013 & 0.000). TLIF had better Oswestry Disability Index scores (p = 0.025 & 0.000) while PLIF had the greatest blood loss (p = 0.032 & 0.006). Complication rates were similar between approaches. Other comparisons were either inconclusive or lacked data. There was marked less studies comparing against LLIF.ConclusionsEach approach has their own risks and benefits but similar fusion rates. Despite the large number of studies, there is little data overall when comparing specific aspects of lumbar interbody fusions. More studies, especially RCTs are needed to further explore this topic.     

Indirect decompression and reduction of lumbar spondylolisthesis does not result in higher rates of immediate and long term complications

Nerve root decompression and spondylolisthesis reduction is typically reserved for open surgery. MIS techniques have been thought to be associated with higher rates of neurological complications. This study aims to report acute and chronic neurologic complications encountered with MIS surgery for spondylolisthesis, specifically, the incidence of nerve root injury and clinical and radiographic outcomes. A retrospective review of 269 patients who underwent MIS LIF or ALIF treatment for lumbar degenerative or isthmic grade 1 or 2 spondylolisthesis was conducted. Immediate and long-term complication rates were the primary outcome. Only patients who had symptomatic anterolisthesis and 2-year outcome data were included in the study. 52 patients met inclusion criteria with 54 lumbar spondylolisthesis levels treated. Five patients (9.6%) experienced postoperative anterior thigh numbness, which completely resolved within 3 months. There were no permanent neurologic deficits; however, 2 patients (3.8%) suffered a transient foot weakness that resolved with physical therapy by 3 months follow-up. There was one incidence of wound breakdown that required revision and one incidence of L5/S1 endplate/sacral promontory fracture and relisthesis 3 months postoperatively. Overall fusion rate was 98% at 6 months. Indirect decompression and closed anatomical reduction for treatment of low-grade spondylolisthesis using ALIF and LIF with posterior percutaneous fixation was not associated with an increased risk of neurologic deficit. This study suggests that this technique is safe, reproducible, durable, and provides adequate fusion rates.     

Percutaneous bipolar radiofrequency thermocoagulation for the treatment of lumbar disc herniation

Lumbar disc herniation is usually managed with conservative treatment or surgery. However, conservative therapy seldom yields good results, and surgery is associated with multiple complications. This study aimed to assess bipolar radiofrequency thermocoagulation for the treatment of lumbar disc herniation. A total of 168 patients with lumbar disc herniation suitable for radiofrequency thermocoagulation were enrolled and randomized to monopolar radiofrequency thermocoagulation (control group, n = 84) or bipolar radiofrequency thermocoagulation (experimental group, n = 84) treatment groups. Ablation sites were targeted under CT scan guidance, and consecutive radiofrequency therapy was used. One and two probes were used for monopolar and bipolar thermocoagulation, respectively. Thermocoagulation was achieved at 50°C, 60°C, and 70°C for 60 s each, 80°C for 90 s, and 92°C for 100 s. Symptoms and complications were evaluated using the modified Macnab criteria and Visual Analog Scale at 7, 30, and 180 days postoperatively. At 180 days, a significantly higher efficacy rate was obtained in the experimental group compared with control patients (91.6% versus 79.7%, P < 0.05). No severe complications were occurred in either group. Targeted ablation via bipolar radiofrequency thermocoagulation is efficient for lumbar disc herniation treatment, and should be further explored for broad clinical application.     

A systematic review and meta-analysis of outcomes in hybrid constructs for multi-level lumbar degenerative disc disease

A systematic review and meta-analysis was performed to assess the effect of hybrid constructs which involve a total disc arthroplasty (TDA) with stand-alone anterior lumbar interbody fusion (ALIF) versus non-hybrid constructs including multi-level TDA, multi-level transforaminal lumbar interbody fusion (TLIF) with posterior transpedicular fixation or multi-level stand-alone ALIF as a surgical intervention for degenerative disc disease (DDD) in the lumbar spine. Primary outcomes analysed included the Oswestry Disability Index (ODI) and the Visual Analogue Scale (VAS) for back pain. A systematic search of Medline, Embase, Pubmed, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and Google Scholar was undertaken by two separate reviewers and a meta-analysis of the outcomes was performed. Three studies met our search criteria. When comparing hybrid constructs to multi-level TDA or lumbar fusion (LF) improvements in back pain were found with a VAS back pain score reduction of 1.38 (P < 0.00001) postoperatively and a VAS back pain score reduction of 0.99 points (P = 0.0006) at 2-years follow-up. Results so far slightly favour clinically significant improved VAS back pain score outcomes postoperatively and at 2-years follow-up for hybrid constructs in multi-level lumbar DDD of the spine when compared with non-hybrid multi-level LF or TDA. It cannot however be concluded that a hybrid construct is superior to multi-level LF or TDA based on this meta-analysis. The results highlight the need for further prospective studies to delineate best practice in the management of degenerative disc disease of the lumbar spine.     

Pelvic parameters of sagittal balance in extreme lateral interbody fusion for degenerative lumbar disc disease

There is increasing interest in the use of pelvic indices to evaluate sagittal balance and predict outcomes in patients with spinal disease. Conventional posterior lumbar fusion techniques may adversely affect lumbar lordosis and spinal balance. Minimally invasive fusion of the lumbar spine is rapidly becoming a mainstay of treatment of lumbar degenerative disc disease. To our knowledge there are no studies evaluating the effect of extreme lateral interbody fusion (XLIF) on pelvic indices. Hence, our aim was to study the effect of XLIF on pelvic indices related to sagittal balance, and report the results of a prospective longitudinal clinical study and retrospective radiographic analyses of patients undergoing XLIF in a single centre between January 2009 and July 2011. Clinical outcomes are reported for 30 patients and the retrospective analyses of radiographic data is reported for 22 of these patients to assess global and segmental lumbar lordosis and pelvic indices. Effect of XLIF on the correction of scoliotic deformity was assessed in 15 patients in this series. A significant improvement was seen in the visual analogue scale score, the Oswestry Disability Index and the Short Form-36 at 2 months and 6 months (p < 0.0001). The mean pelvic index was 48.6° ± 11.9° (± standard deviation, SD) with corresponding mean sacral slopes and pelvic tilt of 32.0° ± 10.6° (SD) and 18.0° ± 9.5 (SD), respectively. XLIF did not significantly affect sacral slope or pelvic tilt (p > 0.2). Global lumbar lordosis was not affected by XLIF (p > 0.4). XLIF significantly increased segmental lumbar lordosis by 3.3° (p < 0.0001) and significantly decreased the scoliotic Cobb angle by 5.9° (p = 0.01). We found that XLIF improved scoliosis and segmental lordosis and was associated with significant clinical improvement in patients with lumbar degenerative disc disease. However, XLIF did not change overall lumbar lordosis or significantly alter pelvic indices associated with sagittal balance. Long-term follow-up with a larger cohort will be required to further evaluate the effects of XLIF on sagittal balance.     

Impact of surgical site infection and surgical debridement on lumbar arthrodesis: A single-institution analysis of incidence and risk factors

This study identifies the rate of pseudarthrosis following surgical debridement for deep lumbar spine surgical site infection and identify associated risk factors. Patients who underwent index lumbar fusion surgery from 2013 to 2014 were included if they met the following criteria: 1) age >18 years, 2) had debridement of deep lumbar SSI, and had 3) lumbar spine AP, lateral and flexion/extension X-rays and computed tomography (CT) at 12 months or greater postoperatively. Criteria for fusion included 1) solid posterolateral, facet, or disk space bridging bone, 2) no translational or angular motion on flexion/extension X-rays, and 3) intact posterior hardware without evidence of screw lucency or breakage. Twenty-five patients (age 63.2 ± 12.6 years, 10 male) involving 58 spinal levels met inclusion criteria. They underwent fusion at a mean of 2.32 [range 1–4] spinal levels. Sixteen (64.0%) patients received interbody grafts at a total of 34 (58.6%) spinal levels. All underwent surgical debridement with removal of all non-incorporated posterior bone graft and devascularized tissue. At one-year postoperatively, (56%) patients and 30 (52%) spinal levels demonstrated radiographic evidence of successful fusion. Interbody cage during initial fusion was significantly associated with successful arthrodesis at follow-up (p = 0.017). There is a high rate of pseudoarthrosis in 44% of patients (48% of levels) undergoing lumbar fusion surgery complicated by SSI requiring debridement. Use of interbody cage during initial fusion was significantly associated with higher rate of arthrodesis.     

Effect of steerable cage placement during minimally invasive transforaminal lumbar interbody fusion on lumbar lordosis

Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is commonly used for the treatment of a variety of degenerative spine disorders. Recently, steerable interbody cages have been developed which potentially allow for greater restoration of lumbar lordosis. Here we describe a technique and radiographic results following minimally invasive placement of steerable cages through a bilateral approach. A retrospective review was conducted of the charts and radiographs of 15 consecutive patients who underwent 19 levels of bilateral MIS-TLIF with the placement of steerable cages. These were compared to 10 patients who underwent 16 levels of unilateral MIS-TLIF with the placement of bullet cages. The average age, body mass index, distribution of the levels operated and follow-up were similar in both groups. The average height of the steerable cage placed was 10.9 mm compared to 8.5 mm for bullet cages. The preoperative focal Cobb’s angle per level was similar between both groups with a mean of −5.3 degrees for the steerable cage group and −4.8 degrees for the bullet cage group. There was a significant improvement in postoperative Cobb’s angle after placement of a steerable cage with a mean of −13.7 (p < 0.01) and this persisted at the last follow-up with −13 degrees (p < 0.01). There was no significant change in Cobb’s angle after bullet cage placement with −5.7 degrees postoperatively and a return to the baseline preoperative Cobb’s angle of −4.8 at the last follow-up. Steerable cage placement for MIS-TLIF improves focal lordosis compared to bullet cage placement.     

Comparison of the clinical profile of Parkinson's disease between Spanish and Cameroonian Cohorts

BackgroundThere are limited data in terms of the clinical profile of Parkinson's disease in sub-Saharan African patients.ObjectiveTo compare the clinical profile and access to standard antiparkinsonian therapies of a Cameroonian cohort of patients with an age, sex, and disease duration-matched Spanish cohort (Longitudinal Study of Parkinson's disease, ELEP).MethodsObservational, cross-sectional design. Demographic data were collected and the following ELEP assessments were applied: Scales for Outcomes in Parkinson's disease (SCOPA) Motor, Autonomic, Cognition, Sleep and Psychosocial; Hoehn and Yahr staging; modified Parkinson Psychosis Rating Scale; Cumulative Illness Rating Scale-Geriatrics; Hospital Anxiety and Depression Scale; pain and fatigue visual analog scales; Zarit, and EuroQoL.Results74 patients with idiopathic Parkinson's disease were included (37 from each country) with a mean age of 64.4 ± 10.5 years old, 70.3% males, and mean disease duration of 5.6 ± 5.9 years. Compared to the Spanish cohort, Cameroonians were intermittently treated, less frequently received dopaminergic agonists (p < 0.001), had a trend for taking lower doses of levodopa (p = 0.06), and were more frequently on anticholinergics (p < 0.0005). Cameroonians were more severely impaired in terms of motor (Hoehn Yahr stage, p = 0.03; SCOPA-Motor, p < 0.001), cognitive status (p < 0.001), anxiety and depression (p < 0.001), psychosis (p = 0.008), somnolence, fatigue and pain (p < 0.001, respectively), caregiver burden (p < 0.0001), and quality of life (p = 0.002). Instead, autonomic, comorbidity, and nocturnal sleep problems were similarly found.ConclusionsLimited and intermittent access to dopaminergic drugs has a negative impact on motor symptoms, nonmotor symptoms and quality of life in patients with Parkinson's disease and their caregivers.     

Endoscopy-assisted posterior lumbar interbody fusion in a single segment

Posterior lumbar interbody fusion (PLIF) has been routinely performed for the treatment of lumbar segmental lesions. However, traditional PLIF procedures can result in a variety of approach-related morbidities. The purpose of this study was to determine the efficacy of endoscopy-assisted PLIF in lumbar arthrodesis. From July 2005 to May 2007, a total of 56 patients underwent PLIF, including 24 endoscopy-assisted operations (endoscopic group) and 32 traditional open operations (open group). The perioperative data, clinical outcomes and radiographic results were compared. The intraoperative bleeding volume, postoperative drainage volume, intraoperative and postoperative allogeneic blood transfusion volumes, values for C-reactive protein and erythrocyte sedimentation rate on postoperative day 3 and postoperative hospitalization days were decreased in the endoscopic group (p < 0.05), while the operative time was longer than that of the open group (p = 0.026). According to the Visual Analog Scale for pain, the postoperative low back pain score in the endoscopic group was lower than that observed in the open group (p < 0.05). In the endoscopic group, the excellent and good outcome rate was 87.5%, the incidence of complications was 8.3%, and the intervertebral fusion rate was 100%. There were no significant differences for these outcomes when compared with the open group (p > 0.05). Endoscopy-assisted PLIF can achieve a clinical efficacy similar to that of traditional open operations while minimizing destruction to adjacent tissues. This technique is safe and is characterized by less bleeding, less tissue trauma, decreased postoperative pain, rapid recovery, and a shorter postoperative hospital stay.     

Risk of symptomatic radiation necrosis in patients treated with stereotactic radiosurgery for brain metastases

IntroductioStereotactic radiosurgery (SRS) is a treatment option in the initial management of patients with brain metastases. While its efficacy has been demonstrated in several prior studies, treatment-related complications, particularly symptomatic radiation necrosis (RN), remains as an obstacle for wider implementation of this treatment modality. We thus examined risk factors associated with the development of symptomatic RN in patients treated with SRS for brain metastases.Patients and methodsWe performed a retrospective review of our institutional database to identify patients with brain metastases treated with SRS. Diagnosis of symptomatic RN was determined by appearance on serial MRIs, MR spectroscopy, requirement of therapy, and the development of new neurological complaints without evidence of disease progression.ResultsWe identified 323 brain metastases treated with SRS in 170 patients from 2009 to 2018. Thirteen patients (4%) experienced symptomatic RN after treatment of 23 (7%) lesions. After SRS, the median time to symptomatic RN was 8.3 months. Patients with symptomatic RN had a larger mean target volume (p < 0.0001), and thus larger V100% (p < 0.0001), V50% (p < 0.0001), V12 Gy (p < 0.0001), and V10 Gy (p = 0.0002), compared to the rest of the cohort. Single-fraction treatment (p = 0.0025) and diabetes (p = 0.019) were also significantly associated with symptomatic RN.ConclusionSRS is an effective treatment option for patients with brain metastases; however, a subset of patients may develop symptomatic RN. We found that patients with larger tumor size, larger plan V100%, V50%, V12 Gy, or V10 Gy, who received single-fraction SRS, or who had diabetes were all at higher risk of symptomatic RN.     

Long term results of lumbar sequestrectomy versus aggressive microdiscectomy

It remains unknown whether aggressive microdiscectomy (AD) provides a better outcome than simple sequestrectomy (S) with little disc disruption for the treatment of lumbar disc herniation with radiculopathy. We compared the long term results for patients with lumbar disc herniation who underwent either AD or S. The patients were split into two groups: 85 patients who underwent AD in Group A and 40 patients who underwent S in Group B. The patients were chosen from a cohort operated on by the same surgeon using either of the two techniques between 2003 and 2008. The demographic characteristics were similar. The difference in complication rates between the two groups was not statistically significant. During the first 10 days post-operatively, the Visual Analog Scale score for back pain was 4.1 in Group A and 2.1 in Group B, and the difference was statistically significant (p < 0.005). The Oswestry Disability Index score was 11% in Group A and 19% in Group B at the last examination. The reherniation rate was 1.5% in Group A and 4.1% in Group B (p < 0.005). We argue that reherniation rates are much lower over the long term when AD is used with microdiscectomy. AD increases back pain for a short time but does not change the long term quality of life. To our knowledge this is the first study with a very long term follow-up showing that reherniation is three times less likely after AD than S.     

Surgical management of recurrent lumbar disc herniation and the role of fusion

This systematic review was performed to evaluate the various operative management strategies for recurrent lumbar disc herniation (RLDH), including the efficacy of instrumented spinal fusion (ISF) at repeat discectomy, and whether the operative approach for repeat discectomy, minimally invasive (MID) or conventional open discectomy (CD), affected the outcomes. RLDH is one of the most common complications of lumbar discectomies. Whilst repeat discectomy is the standard procedure performed, the routine addition of ISF has been advocated to improve outcomes and prevent reherniation. A comprehensive search of the MEDLINE, EMBASE, CINAHL and Cochrane databases was performed. The measured outcomes included the rate of satisfactory clinical outcome, improvement in leg and back pain, Japanese Orthopaedic Association (JOA) recovery score, and complication rates. In total, 37 studies met our inclusion criteria, with 1483 patients. The rate of satisfactory outcomes was found to be statistically similar between the patients undergoing a discectomy with or without fusion (77.8% with ISF versus 79.5% without ISF; p = 0.665). Back pain and JOA scores showed greater improvements in the patients undergoing discectomy and fusion, compared to discectomy alone. The rate of satisfactory outcomes was marginally higher in the patients undergoing MID compared to CD (MID 81.2% versus CD 77.5%; p = 0.248). However, the leg pain improvement was similar. The postoperative back pain improvement was greater in the MID group (52.5% MID versus 36.3% CD), but with lower complication rates, specifically durotomies (MID 5.2% versus CD 15.3%; p < 0.001). There is no evidence to recommend the routine addition of ISF in the management of RLDH. The data suggest that MID has lower complication rates than CD in the setting of RLDH, yet unequivocal evidence is lacking.     

Cortical processing during smartphone text messaging

ObjectiveThe objective of this study was to report the EEG features of text messaging using smartphones.MethodsOne hundred twenty-nine patients were prospectively evaluated during video-EEG monitoring (VEM) over 16 months. A reproducible texting rhythm (TR) present during active text messaging with a smartphone was compared with passive and forced audio telephone use, thumb/finger movements, cognitive testing/calculation, scanning eye movements, and speech/language tasks in patients with and without epilepsy. Statistical significance was set at p < 0.05.ResultsTwenty-seven patients with a TR were identified from a cohort of 129 (93 female, mean age: 36; range: 18–71) unselected VEM patients. Fifty-three out of 129 patients had epileptic seizures (ES), 74/129 had nonepileptic seizures (NES), and 2/129 were dual-diagnosed. A reproducible TR was present in 27/129 (20.9%) specific to text messaging (p < 0.0001) and present in 28% of patients with ES and 16% of patients with NES (p = NS). The TR was absent during independent tasks and audio cellular telephone use (p < 0.0001). Age, gender, epilepsy type, MRI results, and EEG lateralization in patients with focal seizures were unrelated (p = NS).ConclusionsOur results suggest that the TR on scalp EEG represents a novel technology-specific neurophysiological alteration of brain networks. We propose that cortical processing in the contemporary brain is uniquely activated by the use of PEDs.SignificanceThese findings have practical implications that could impact industry and research in nonverbal communication.     

Mortality in patients with refractory temporal lobe epilepsy at a tertiary center in Cuba

ObjectivesWe aimed to investigate the prevalence and risk of mortality in patients with refractory temporal lobe epilepsy.MethodsEligible patients included all adults referred to the National Institute of Neurology (NIN) in Havana, Cuba. All patients were followed up for 9 years. All analyses were made with the data available at the last follow-up. The frequency of death related to refractory TLE was analyzed taking into account the total number of patients included in the study. We analyzed the causes of death for each case. Multivariate analysis was made to determine the specific variables related to the death. All values were statistically significant if p < 0.05.ResultsSix out of 117 patients died during follow-up. Fifty percent of patients died because of suicide. Only the presence of aura, specifically experiential psychic auras, and prodromal depressive disorders were associated significantly with the deaths (p < 0.05). Patients who died had a higher concern about their seizures than patients who were still alive at last follow-up (p < 0.01); they also had a poor perception of the overall QOL (p < 0.01); and they were more concerned about the possible medication side effects than patients who did not die (p < 0.05). Logistic regression provided only one variable related to the deaths in our cohort in multivariate analysis: presence of prodromal depressive disorder.ConclusionThe causes of death in patients with refractory temporal lobe epilepsy were similar to those documented in the general population of patients with epilepsy.     

Patient-reported and radiographic outcomes of minimally invasive transforaminal lumbar interbody fusion for degenerative spondylolisthesis with or without reduction: A comparative study

This retrospective study aimed to compare the patient-reported outcomes and radiographic assessment of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) for degenerative spondylolisthesis with reduction versus in situ fusion. Patients receiving MI-TLIF with reduction were assigned as Group A, and those without reduction were assigned as Group B. Radiographic fusion was assessed using Bridwell’s grading criteria. Preoperative and postoperative patient-reported outcomes including visual analogue score (VAS), Oswestry Disability Index (ODI), Japanese Orthopedic Association (JOA) scale and improvement rate were analyzed. There were 41 patients in Group A and 37 patients in Group B. The mean follow-up was 30.78 ± 14.15 months in Group A and 28.95 ± 10.75 months in Group B (p = 0.525). There were no significant differences in hospital stay (p = 0.261), estimated blood loss (p = 0.639), blood transfusion (p = 0.336), operation time (p = 0.762) and complications (p = 1.00) between the two groups. Radiographic fusion rate was 92.68% (38/41) in Group A, and 81.08% (30/37) in Group B (p = 0.110). Significant differences were observed in either 3-month or last follow-up JOA, VAS, and ODI compared with preoperative JOA, VAS, and ODI, respectively (p < 0.05). However, there were no significant differences in JOA, VAS, and ODI between the two groups whenever preoperatively, or 3-month postoperatively, or at the last follow-up (p > 0.05). According to MacNab criteria, the excellent and good rate was 85.37% in Group A and 86.49% in Group B (p = 0.983). MI-TLIF is an effective and satisfactory surgical technique to manage degenerative spondylolisthesis regardless of reduction or not, so routine reduction may not be a requirement in MI-TLIF for degenerative spondylolisthesis.     

Psychosocial and sociodemographic associates of felt stigma in epilepsy

BackgroundLack of a sufficient range in socioeconomic status (SES) in most prior studies of felt stigma and epilepsy has hampered the ability to better understand this association.MethodsWe assessed the burden and associates of felt stigma in 238 individuals with prevalent epilepsy aged 18 and older, comparing low SES with high SES.ResultsReported levels of stigma were higher in low SES than in high SES (p < 0.0001), and all psychosocial variables were associated with stigma, including depression severity (p < 0.0001), knowledge of epilepsy (p = 0.006), quality of life (p < 0.0001), social support (p < 0.0001), and self-efficacy (p = 0.0009). Stigma was statistically significantly associated with quality of life in the low SES group and with depression severity and social support in the high SES group.ConclusionsLow SES alone did not account for felt stigma; rather, we found that quality of life, depressive symptoms, and social support have the greatest impact on reported felt stigma in individuals with prevalent epilepsy.