Faculty Bibliography

OBJECTIVES/OBJECTIVE:The gut microbiome plays a crucial role in regulating systemic immunity and has been implicated in several chronic inflammatory diseases. Intestinal expansions of Ruminococcus gnavus (RG), a dominant gut commensal, correlate with disease flares in lupus nephritis (LN), but the underlying mechanism remains unknown. METHODS:In a Pilot cohort of patients with biopsy-proven LN, subsetted by gut microbiota community, immune status was characterised using bulk-blood RNA sequencing libraries, serum levels of representative host proteins, and levels of immunoglobulin (Ig)G antibodies to the novel lipoglycan (LG) produced by pathogenic RG strains. A Validation LN cohort was evaluated for blood transcriptomic profiles and levels of anti-LG antibodies. In murine models, mechanistic hypotheses were tested after RG gut colonisation or after intraperitoneal injection with an LG preparation, with outcomes determined by transcriptomic analyses, platelet functional readouts, and tissue histology. RESULTS:In a Pilot cohort of patients with LN, RG gut expansions were associated with high-level platelet, neutrophil, and monocyte activation. Serum levels of platelet factor 4 and release of neutrophil extracellular traps (NETs) were significantly higher in patients with high serum IgG antibody against the novel RG-specific LG, a marker of in vivo immune exposure. An LN Validation cohort confirmed these correlates and showed that anti-LG antibodies serve as a surrogate for thromboinflammatory profile in this LN-associated endotype. In mice, gut colonisation with LG-producing RG strains or a single LG injection caused megakaryocytosis and platelet activation; RG colonisation with LG-producing strains induced tubulointerstitial injury with NETosis. In vivo responses to LG toxin were Toll-like receptor 2-dependent. CONCLUSIONS:Gut expansions of the RG pathobiont may contribute to autoimmune pathogenesis through the LG toxin and cause LN flares through thromboinflammatory mechanisms in this previously unrecognised LN endotype.

BACKGROUND:Lateral lumbar interbody fusion is a widely used technique to address degenerative lumbar conditions but can be associated with injury to the psoas, lumbar plexus, and abdominal wall owing to retractor usage. We describe a minimally invasive endoscopic lateral lumbar interbody fusion (ELLIF) procedure that aims to reduce these complications by avoiding prolonged muscle retraction, preparing the disc space under direct endoscopic vision, and shortening the surgical time. METHODS:Between 2019 and 2024, 35 patients underwent ELLIF at a single center. Discectomy, endplate preparation, and iliac crest harvest were done via a working-channel endoscope without expandable retractors. Neurophysiological monitoring was used to minimize nerve injury. Outcomes included complications, visual analog scale scores for pain, and Oswestry Disability Index (ODI). RESULTS:< 0.001). By the 3-year follow-up in 9 patients, ODI scores remained near normal, and visual analog scale was reduced by 93% from baseline. CLINICAL RELEVANCE/CONCLUSIONS:We present a minimally invasive, ELLIF, and decompression technique that provides patients with minimal complications and excellent functional recovery. CONCLUSION/CONCLUSIONS:ELLIF offers a safe, minimally invasive alternative for patients with lumbar degenerative disease. This technique minimizes direct retraction on the psoas and lumbar plexus, resulting in a low complication rate and substantial functional recovery at short- and medium-term follow-up.

BACKGROUND:Thoracic disc herniations (TDHs) are rare, comprising <1% of all disc herniations, but when symptomatic can cause severe neurological dysfunction. Traditional open and mini-open approaches allow for ventral canal decompression but are associated with high morbidity, including pulmonary complications, chest tube placement, and frequent need for fusion. Full-endoscopic thoracic discectomy has emerged as an ultra-minimally invasive alternative with reduced complications and faster recovery, but its application to midline or calcified thoracic discs remains technically demanding. CASE PRESENTATION/METHODS:We report the case of a 54-year-old man with progressive chest wall pain and lower-extremity hyperreflexia who was found to have a T6 to T7 central disc herniation with mild calcification and spinal cord signal change. The patient underwent an outpatient right-sided full-endoscopic transforaminal discectomy. Complete decompression was achieved without spinal cord retraction or manipulation. The patient had complete resolution of his preoperative pain and was discharged home within 2 hours. DISCUSSION/CONCLUSIONS:Compared with open thoracic discectomy, endoscopic approaches significantly lower complication rates, blood loss, hospital stay, and cost while preserving motion segments. Our case highlights strategies for addressing technically challenging central TDHs, including lateralized access, controlled bony resection, and angled instrumentation. These methods align with growing evidence demonstrating the safety and efficacy of endoscopy in thoracic pathology, though the technique requires advanced endoscopic expertise and careful patient selection. CONCLUSION/CONCLUSIONS:Full-endoscopic transforaminal discectomy provides a safe, effective, and minimally invasive option for central TDHs in selected cases. With proper planning and advanced technical execution, endoscopic surgery can achieve decompression comparable to open surgery while minimizing morbidity and expediting recovery.

BACKGROUND:Implementation of guideline-recommended strategies to prevent acute ischemic stroke (AIS) in type 2 diabetes (T2D) remains suboptimal. OBJECTIVES:We evaluated and compared the health impact and cost-effectiveness of improved implementation of guideline-recommended strategies for AIS prevention in patients with T2D in the United States. DESIGN:We compared scenarios with enhanced implementation of these prevention strategies to the status-quo using a microsimulation model. PARTICIPANTS:National Health and Nutrition Examination Survey (NHANES) 2015-2018 participants ≥ 45 years of age with T2D and no stroke history. MAIN MEASURES:We evaluated stroke-related events, costs, stroke-related quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios, and net health benefit (NHB) from a health system perspective over a 10-year time horizon. A discount rate of 3% per year was applied to costs and QALYs. Costs were expressed in 2022 U.S. dollars. KEY RESULTS:Full implementation of guideline-recommended blood pressure (BP), statin, and aspirin therapies, and smoking cessation would each be cost-saving or highly cost-effective (< $50,000 per QALY-gained). Over 10 years, full implementation of all four of the strategies would prevent 151,000 stroke events, 61,900 deaths from stroke, save $13.4 billion, and produce a nationwide increase of 1,552,000 QALYs (NHB). CONCLUSIONS:Recent attention has focused on the treatment of AIS. We demonstrate that substantial opportunities exist to improve the primary prevention of AIS in Americans with T2D. Providers and payers should prioritize adherence to guidelines for BP, statin and aspirin therapy, and smoking cessation for stroke prevention.

OBJECTIVE:The role of prophylactic musculocutaneous flap closure following posterior spine surgery remains under-characterized. This study presents a single-institution experience with paraspinous-only musculocutaneous flap reconstruction among high-risk patients following spine surgery. Associations between risk factors, surgical indication, intraoperative characteristics, and postoperative wound complications are explored. METHODS:A retrospective chart review identified all cases of prophylactic paraspinous flap reconstruction following posterior spine over an 11-year period. Patients who had uncomplicated postoperative courses were compared to those who developed wound complications. Multivariate logistic regression characterized associations among risk factors, surgical indication, and wound complications. RESULTS:Two hundred fifty-seven patients underwent primary prophylactic closure using paraspinous musculocutaneous flaps only. 49.4% female, with a mean age of 60.7±13.9 years. Surgical indications included degenerative disease (n=124, 48.2%), tumor (n=78, 30.4%), deformity (n=22, 8.6%), congenital anomaly (n=18, 7.0%), and trauma (n=15, 5.8%). This population exhibited high-risk features, including diabetes (19.5%), history of smoking (53.3%), prior spine surgery (58.8%); mean body mass index was 30.1±6.9. Wound complications occurred in 37 patients (14.4%). Postoperative complications coincided with greater number of incised levels, higher degree of instrumentation, and longer closure length. CONCLUSIONS:Prophylactic flap closure was associated with wound complication rates consistent with the literature in cohorts with substantial comorbidity burden. Outcomes were predominantly influenced by procedural factors rather than baseline patient characteristics. The findings support the feasibility of prophylactic flap closure in high-risk patients across the spectrum of spinal indications. Controlled studies are necessary to evaluate effectiveness.

Cerebrospinal fluid (CSF) leaks of spinal origin present unique diagnostic and therapeutic challenges. Ventral leaks in particular are technically demanding due to limited exposure, proximity to the spinal cord, and the need for precise dural repair. Traditional management strategies, ranging from laminectomy-based approaches to thoracotomy, carry significant morbidity. Recent advances in full endoscopic spine surgery provide a minimally invasive alternative that allows surgeons to access ventral pathology, remove osteophytes, and perform direct dural closure under continuous irrigation. This article reviews treatment challenges, highlights conventional and emerging strategies, and discusses the role of full endoscopic repair of spinal CSF leaks. Technical considerations unique to endoscopic repair of Type 1 CSF leaks in the thoracic spine are described.

BACKGROUND:Travel distance can serve as an objective, behavioral measure of patient preference in health care. Endoscopic spine surgery is the least invasive surgical option for treating spinal pathology, yet access is limited due to the relatively small number of trained surgeons. This study evaluates travel patterns of patients seeking care at the Endoscopic Spine Institute of New York, a specialized center staffed by 3 fellowship-trained endoscopic spine surgeons. METHODS:We conducted a retrospective analysis of the first 100 consecutive patients undergoing endoscopic spine surgery at Endoscopic Spine Institute of New York. The primary objective was to quantify patient travel distance as a behavioral proxy for preference for specialized, minimally invasive care. Secondary objectives were to characterize spinal pathology, determine revision surgery frequency, and compare travel distances by pathology type and revision status. Travel distances were calculated as straight-line distances from the patient's city of residence to the institute. Descriptive and comparative statistics were performed. RESULTS:< 0.05). Lumbar pathology cases were associated with slightly longer travel distances compared with cervical and thoracic cases, though differences were not statistically significant. CONCLUSIONS:Patients are willing to travel substantial distances to access specialized, minimally invasive spine surgery. Travel distance serves as a behavioral measure of patient preference, distinct from conventional quality metrics, providing insight into patient priorities in health care utilization and informing the centralization of specialized surgical services. CLINICAL RELEVANCE/CONCLUSIONS:Understanding how far patients will travel for endoscopic spine surgery provides insight into the growing demand for minimally invasive approaches and the regionalization of specialized spine care. This information can help guide resource allocation, referral patterns, and the develpment of centers of excellence. LEVEL OF EVIDIENCE/UNASSIGNED:4.