Faculty Bibliography

Residual giant thoracic disc herniations after open decompression are uncommon and present a significant surgical challenge, particularly in the setting of prior instrumentation and distorted anatomy. Here, the authors present a case of salvage full-endoscopic resection of a residual giant, centrally calcified thoracic disc herniation causing persistent spinal cord compression following prior transpedicular decompression and instrumented fusion. A 37-year-old woman presented with persistent thoracic pain, gait disturbance, and myelopathic symptoms after partial improvement from an initial open T6 to T7 transpedicular decompression with T6 to T8 fusion. Magnetic resonance imaging and computed tomography demonstrated a residual giant calcified disc herniation at T6 to T7 with severe spinal cord compression and signal change. The patient underwent revision right-sided full-endoscopic thoracic discectomy using preoperative trajectory planning, docking on preserved osseous landmarks, ventral cavity creation, and controlled disc mobilization. The patient experienced rapid postoperative recovery with immediate resolution of thoracic pain and sustained improvement in gait and balance. This case demonstrates that full-endoscopic thoracic discectomy can be safely and effectively applied as a salvage technique to achieve spinal cord decompression in complex revision settings following failed open thoracic disc surgery.

BACKGROUND/UNASSIGNED:Frailty indices are established tools for estimating long-term survival in oncology, yet their utility for predicting short-term surgical outcomes remains less defined. This study evaluates several frailty, comorbidity, and risk indices for predicting postoperative care needs and other short-term outcomes in patients undergoing spinal metastasis resection. METHODS/UNASSIGNED:A retrospective cohort study was performed on patients undergoing surgery for spinal metastasis at a tertiary spine center. Preoperative risk was assessed using the modified 5-item frailty index (mFI-5), Metastatic Spinal Tumor Frailty Index (MSTFI), modified Charlson Comorbidity Index (CCI), New England Spinal Metastasis Score (NESMS), modified Bauer score (mBauer), and Spinal Instability Neoplastic Score (SINS). Multivariate logistic regression evaluated associations between indices and nonroutine discharge, prolonged length of stay (LOS), and reoperation, as well as other secondary outcomes. RESULTS/UNASSIGNED:Among 114 patients (mean age 65.6±10.7 years; 57.9% male), 57.0% were discharged to nonroutine settings, 16.7% underwent reoperation, and the mean length of stay was 11.1±10.8 days. MSTFI was independently associated with nonroutine discharge (OR=2.81, 95% CI [1.64-4.84], p<.001) but not prolonged LOS (OR=1.51 [0.99-2.30], p=.055). NESMS was also associated with nonroutine discharge (OR=0.49 [0.28-0.87], p=.015). Secondary analyses identified associations of NESMS spine-related complications (OR=0.46 [0.24-0.87], p=.017) and 90-day mortality (OR=0.48 [0.23-0.98], p=.045). No index significantly predicted reoperation. ROC analysis demonstrated that MSTFI and NESMS outperformed other indices for nonroutine discharge and prolonged LOS; DeLong's were equivocal. CONCLUSIONS/UNASSIGNED:In this single-center surgical cohort, MSTFI and NESMS were the most consistent risk-stratification tools for short-term outcomes, particularly discharge disposition and LOS. Secondary analyses suggested additional associations of NESMS with spine-related complications and 90-day mortality, whereas no index reliably predicted reoperation. Incorporating MSTFI and/or NESMS into preoperative assessment may improve risk stratification and perioperative planning.

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.

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: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.

OBJECTIVES:Approximately 20-50% of patients develop biochemical recurrence (BCR) of prostate cancer within 10 years following radical prostatectomy (RP). The accurate identification of recurrent disease is crucial for guiding salvage treatment decisions. While multiparametric MRI (mpMRI) and prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA PET/CT) are both utilized for detecting local recurrence, their combined diagnostic benefits remain unclear. This study seeks to evaluate the diagnostic performance of both modalities alone and in conjunction for detecting local recurrence following RP in patients with BCR. METHODS:A retrospective single-institution analysis included 37 post-RP patients with BCR who received mpMRI and PSMA PET/CT. Five board-certified radiologists reviewed images in three phases: mpMRI only, PSMA PET/CT only, and both modalities combined. Multidisciplinary tumor board consensus served as the reference standard. Diagnostic performance, inter-reader agreement, and radiologist confidence with each modality was examined. RESULTS:MpMRI outperformed PSMA PET/CT, yielding a higher sensitivity (73.0% vs. 65.2%) and specificity (77.1% vs. 75.7%). Interpretation of mpMRI and PSMA PET/CT together achieved the highest diagnostic accuracy (77.8%), representing a statistically-significant increase over PSMA PET/CT (p = 0.026) but a non-statistically-significant increase over mpMRI (p = 0.441). Combined imaging also resulted in greater specificity (90.0%) and inter-rater reliability (κ = 0.622). However, in some cases performance decreased with both modalities due to interpretive pitfalls. CONCLUSION:While mpMRI remains the preferred imaging modality for post-RP local recurrence surveillance, the integration of PSMA PET/CT may lead to improved specificity and inter-rater reliability. However, radiologists must understand each modality's limitations to avoid interpretive pitfalls.

Although BRAF/MEK inhibitor (BRAFi/MEKi) therapy initially shows high efficacy in patients with BRAF ^{V600 E/K} cutaneous melanoma, resistance develops in over 75% of cases. We tested robustness of the umbrella trial strategy in this population by analyzing relationships between genomic status of a gene and associated downstream consequences at the protein level. The results revealed weak relationships among mutations, copy-number amplification, and protein expression and activation. An in vivo compound repurposing screen using 11 clinically relevant agents from an NCI-portfolio with pan-RTK, non-RTK, and/or PI3K-mTOR specificity identified dasatinib as most capable of restoring sensitivity to BRAFi/MEKi in patient-derived xenograft (PDX) models originating from tumors that had progressed on BRAFi ± MEKi. High baseline expression of BRAFi/MEKi resistance-associated proteins (e.g., AXL, YAP, HSP70, and phospho-AKT) was predictive of the response to BRAFi/MEKi + dasatinib combination therapy. These findings suggest that adding dasatinib may help overcome resistance and restore anti-tumor activity in patients with BRAFi/MEKi-refractory cutaneous melanoma.