Faculty Bibliography

High-riding vertebral artery (HRVA) is an important anatomical variant of the vertebral artery that poses significant challenges during cervical spine surgery, particularly at the C1-C2 level, where it reduces the safe corridor for pedicle screw placement and increases the risk of arterial injury. This narrative review summarizes current evidence regarding the definition, prevalence, imaging identification, and surgical implications of HRVA, along with risk mitigation strategies. Radiographically, HRVA is most commonly defined by reduced C2 isthmus height (C2IsH) (≤5 mm) and/or internal height (C2InH) (≤2 mm) on computed tomography (CT) scans. Reported prevalence varies widely across populations, typically ranging from 10% to 25%, with higher rates observed in selected patient cohorts. The presence of HRVA necessitates careful perioperative planning, including comprehensive imaging and modification of surgical techniques, such as the use of alternative fixation strategies, including pars screws, laminar screws, navigation-assisted instrumentation, and artery mobilization. Advances in CT angiography (CTA), alternative fixation strategies, surgical navigation, and emerging predictive models may further improve risk stratification and operative safety. Recognition of HRVA and tailored surgical planning are essential to minimize the risk of vertebral artery injury (VAI) and to optimize patient outcomes in cervical spine surgery and instrumentation.

INTRODUCTION/BACKGROUND:Hemispherotomy is an effective treatment for children with drug-resistant epilepsy (DRE). While hemispherotomy techniques and indications have evolved, access remains predominantly constrained to high-resource settings. METHODS:We performed a retrospective analysis of children who underwent hemispherotomy from 2011 to 2023 by a hybrid team, including local Panamanian and US neurologists, neurosurgeons, and EEG technicians and analyzed surgical, epilepsy, and quality of life (QoL) parameters. Follow-up data were collected according to the International Consortium for Health Outcomes Measurement (ICHOM) guidelines for children with epilepsy. RESULTS:Twenty-three children underwent hemispherotomy. The median age at surgery was 10 years (range 2-20). The median follow-up time was 6 years (range 1-13). The etiology of DRE included malformations of cortical development in 14 children (60.8%), including 8 (34.8%) with schizencephaly, and secondary causes in 9 children (39.1%). Seizure frequency improved for all 23 children (100%): Engel I was achieved in 15 children (65.2%), Engel II (26.1%) in six children, and Engel III (8.7%) in two children. Patients with seizure freedom had significantly fewer preoperative seizures per day than patients with seizure recurrence. Complications occurred in six children (26.1%): 2 wound infections, 2 meningitis, 1 femoral vein thrombosis, and 1 wound hematoma with return to OR. There were no perioperative mortality and no postoperative hydrocephalus or CSF diversion. QoL-related outcomes were available for 16 children: 16/16 (100%) reported that the surgery was a worthwhile and repeatable choice, 14 (87.5%) reported improved cognitive function, the median QOLCE-16 score was 62.5 ± 21. CONCLUSION/CONCLUSIONS:Hemispherotomy for DRE in selected children is a safe and effective surgery in a public children's hospital in a low-resource setting. At last follow-up, the majority of children were seizure-free, and all children had decreased seizure frequency. Families reported improved cognitive function, improved QoL and high satisfaction with their decision to pursue this surgery.

BACKGROUND:Despite a high incidence of tracheostomy-related airway complications with potentially life-threatening implications, nonsurgical tracheostomy first-responders receive limited formal education on the management of tracheostomy emergencies. While the U.K. has developed multidisciplinary guidelines and education for tracheostomy emergencies, such programs have not been widely implemented in the United States. OBJECTIVE:We evaluated the feasibility and effectiveness of an immersive virtual reality (VR) simulation training as a potential generalizable and scalable approach to tracheostomy-related emergency training. METHODS:Over the academic year 2023-2024, critical care fellows were randomized to participate in tracheostomy emergency training either via immersive VR simulation or via small group discussion sessions facilitated by expert faculty. After each case-based educational intervention, participants were asked to manage four simulated tracheostomy-related emergencies involving common tracheostomy complications. Fellow performance was evaluated using a purpose-built task trainer. Three independent and blinded graders completed fellow scoring using a checklist assessment for which validation evidence was also collected. Fellows received pre- and post-intervention surveys to measure attitudes towards VR training. RESULTS:Nineteen out of 27 eligible fellows participated in the study, managing a total of 76 simulated tracheostomy emergencies. There were 10 fellows in the VR arm and 9 fellows in the Small Group arm. Out of a total possible 26 points on the checklist assessment, fellows in the VR group scored an average of 18.03 ± 3.39 compared to the Small Group score of 16.96 ± 4.41 (P = .558). Surveys indicated improvements in fellow confidence after the training and high levels of acceptance of the VR curriculum. CONCLUSIONS:An immersive VR educational intervention for the management of tracheostomy-related emergencies was feasible and well-received by learners. There was no significant difference in post-training checklist assessment scores between the VR and Small Group participants, suggesting non-inferiority of the VR intervention, and contributing validation evidence to our task trainer simulation assessment. FUNDING/BACKGROUND:This study was funded via the APCCMPD, CHEST, and ATS Education Research Award.

OBJECTIVE:The aim of the study was to evaluate the safety and efficacy of initiating physical therapy (PT) on the day of surgery (i.e., postoperative day 0 [POD0]) in patients undergoing single-level lumbar fusion surgery, with a focus on hospital length of stay (LOS) and early postoperative outcomes. METHODS:The authors conducted a retrospective review of prospectively collected data from a single institution. Patients undergoing single-level lumbar fusion between August 2022 and December 2024 were included. Those with revision surgery, tumors, or infections were excluded. POD0 PT was implemented in January 2024. Patients treated prior to this date received POD1 PT. Demographic, surgical, and postoperative data were compared between the POD0 and POD1 PT groups. RESULTS:A total of 586 patients were analyzed (POD0, n = 84; POD1, n = 502). Baseline demographics and surgical characteristics were similar between the groups. The POD0 group had a significantly shorter LOS (mean 3.4 ± 1.6 vs 4.0 ± 2.7 days, p = 0.016), and the patients were more likely to be discharged home. No significant differences were found in postoperative complications, including cardiac, pulmonary, neurological, gastrointestinal, urinary, infectious, or mechanical issues. Rates of 30- and 90-day emergency department visits, readmissions, or reoperations were also comparable between the groups. CONCLUSIONS:Initiating PT on the day of surgery is associated with reduced LOS and an increased likelihood of home discharge, without increasing complications or worsening clinical outcomes. These findings support the safety and potential benefits of POD0 PT in enhancing early recovery following single-level lumbar fusion surgery.

PURPOSE/OBJECTIVE:To evaluate the impact of thoracic spine degeneration in adult spinal deformity (ASD) patients on radiographic outcomes. METHODS:Primary ASD patients undergoing thoracolumbar fusion with T9-L1 upper instrumented vertebra (UIV) and S1/ilium lower instrumented vertebra were included. Thoracic spine degeneration was assessed radiographically using Kellgren-Lawrence (KL) grading and segmented into T1-T5, T5-T9, and T9-L1 arcs per Lafage criteria. Arc degeneration was defined as ≥ 2 levels with KL grade 3 + in an arc and thoracic spine degeneration as ≥ 1 degenerated arc. Proximal zone degeneration was KL grade 3 + in the two levels above the UIV and distal zone degeneration was KL grade 3 + in unfused thoracic levels outside the proximal zone. Patients with no degenerated levels served as controls. RESULTS:Among 272 patients (mean age 65.1years, 74% female, mean Charlson Comorbidity Index 1.9), 19, 81, and 100 patients had T1-T5, T5-T9, and T9-L1 arc degeneration, respectively, corresponding to 151 degenerated and 72 control patients. Degenerated patients exhibited higher thoracic kyphosis (36.1° vs. 27.6°), reduced expected thoracic compensation via hypokyphosis (- 0.7° vs. 8.8°), and higher lumbar lordosis (38.6° vs. 32.3°) (p < 0.05). At six weeks, degenerated patients had smaller reciprocal kyphotic changes (1.6° vs. 5.8°). At two years, they had higher proximal junctional kyphosis (PJK)-Normative rates (38% vs. 24%) (p < 0.05). Proximal zone sub-analysis showed that two-year PJK-Normative rates (43% vs. 32% vs. 24%) decreased incrementally from proximal to distal zone degeneration to controls (p < 0.05). CONCLUSION/CONCLUSIONS:Over half of ASD patients exhibited thoracic spine degeneration, predominantly in the lower arcs (T5-L1). This was associated with reduced thoracic hypokyphosis, smaller six-week reciprocal kyphotic changes, and higher two-year PJK rates. Proximal zone degeneration predicted junctional failure. Surgical planning should consider thoracic degeneration and compensatory mechanisms, with careful UIV selection to ensure sustained correction. LEVEL OF EVIDENCE/METHODS:IV.

PURPOSE/OBJECTIVE:This multicenter, multi-surgeon retrospective study aimed to identify risk factors for postoperative cerebrospinal fluid (CSF) leak following endonasal resection of craniopharyngioma, while evaluating the "perception gap" through a surgeon survey. METHODS:A retrospective review was conducted on 416 patients who underwent endoscopic transsphenoidal surgery (ETS) for craniopharyngioma from 20 institutions. Factors were compared between patients with and without postoperative CSF leak, and between Early (2007-2015) and Late (2016-2025) Epochs. Complementing the clinical data, a survey of 19 neurosurgeons captured expert perspectives on risk stratification and management strategies. RESULTS:Overall postoperative CSF leak rate was 13.5% (56/416 patients). Univariate analysis identified predominantly cystic tumors (34% vs. 21%, p = 0.034) and intraoperative lumbar drain (LD) use (p < 0.028) as associated with postoperative CSF leak. BMI (p = 0.587), prior surgery (p = 0.576), and tumor size (p = 0.363) were not significant. In the multivariable analysis, LD use was associated with a higher postoperative CSF leak rate (OR 1.91, 95% CI 1.06-3.46; p = 0.030). Between Epochs, nasoseptal flap (NSF) utilization increased from 70.7% to 87.6% (p < 0.001). NSF was protective (OR 0.28, 95% CI 0.07-0.92; p = 0.037) in the Early Epoch; no factors were significant in the Late Epoch. The surgeons' survey identified prior surgery and intraoperative high flow leaks as primary risks; however, their LD protocols diverged from clinical data. CONCLUSION/CONCLUSIONS:Postoperative CSF leak in Craniopharyngioma has evolved. The study highlights a significant divergence between expert perception and clinical data regarding lumbar drains.

OBJECTIVE:To describe intraoperative fluoroscopic and transimpedance matrix (TIM) findings during cochlear implantation in a patient with bilateral cochlear malformations, highlighting the dynamic relationship between electrode position and evolving TIM heatmap patterns. STUDY DESIGN/METHODS:Case report. METHODS:Retrospective review of patient medical and radiographic records, intraoperative fluoroscopy, and TIM data. RESULTS:Initial insertion produced a previously characterized TIM skip heat pattern seen in patients with incomplete partition type II and deficient interscalar septal width. This prompted partial electrode withdrawal under fluoroscopy, which subsequently resulted in a TIM central heat pattern, representing a symmetric voltage concentration around the mid-array region. Advancing the array slightly resulted in a skip heat pattern with a more defined current delineation and a more favorable x-ray profile. Interestingly, SmartNav analysis interpreted the TIM data as a tip fold over, despite good positioning. CONCLUSION/CONCLUSIONS:This case visually demonstrates which small positional changes of electrodes within malformed cochleae can transform TIM morphology, helping to elucidate why certain patterns occur, and the next steps to study clinical relevance.

Persons with disorders of consciousness (DoC) occupy an ethically charged space in modern medicine and biomedical research. Their decisional capacity is characteristically absent or limited or unpredictably fluctuates, requiring clinicians and investigators to rely on surrogates. Although there is general guidance for informed consent (IC) for research studies, there is no specific guidance for research involving persons with DoC. There are inconsistencies in IC forms for these studies related to explanation of a DoC, evaluation of capacity, description of risks/benefits, and sharing investigational results. This is problematic for persons with DoC, their surrogates, researchers, and institutional review boards (IRBs)/research ethics boards (REBs). To address these issues, the Curing Coma Campaign (CCC) Ethics Workgroup developed the Common Consent Elements for Research Involving Persons with Disorders of Consciousness (CCE-DoC). This practical framework aims to clarify and standardize consent processes in this complex and ethically sensitive research area. Through this structured, adaptable approach, CCE-DoC may have the potential to enhance participant protections, strengthen trust, help families and decision-makers understand studies, reduce duplicative efforts across research groups, and guide investigators and IRBs/REBs in navigating the complex ethical terrain of consent in DoC research. In so doing, CCE-DoC seeks to extend respect for autonomy and trust and promote responsible research urgently needed to advance paradigms of diagnosis, prognosis, and treatment for individuals with disorders of consciousness. The framework offers example language to encourage standardization, while allowing teams flexibility to customize to local needs.

OBJECTIVE:The objective was to evaluate the trajectories of hematoma resolution and functional improvement after middle meningeal artery embolization (MMAE) for chronic subdural hematoma (cSDH), model the temporal pattern of cSDH resolution, and identify factors associated with favorable outcomes. METHODS:This real-world multicenter retrospective study included cSDH patients treated with MMAE at 24 centers between 2019 and 2024. Hematoma thickness was measured at baseline and at follow-up intervals (1-4 weeks, 1-3 months, 3-6 months, 6-12 months, and > 12 months after embolization). Resolution patterns were modeled using exponential decay functions. Modified Rankin Scale (mRS) scores assessed functional outcomes. Good functional outcome was defined as mRS score ≤ 2. Resolution patterns were modeled using exponential decay functions to estimate time to 50% and 80% reduction. Patients were categorized as complete resolution (≥ 99%) or by quartile of the remaining distribution (substantial [73%-98%], moderate [53%-73%], partial [27%-53%], minimal [< 27%]). The primary outcome was good functional status (mRS score ≤ 2). RESULTS:The authors analyzed a total of 1781 patients with 2295 cSDHs who underwent MMAE. The mean ± SD age was 72.8 ± 12.4 years and 68.1% of patients were male. The initial mean hematoma thickness was 15.31 ± 6.53 mm, decreasing to 5.24 ± 5.91 mm at final follow-up (mean reduction 64.3% ± 42.1%). Resolution followed an exponential decay pattern, with an estimated time to 50% reduction of 1.8 months and to 80% reduction of 8.9 months. Complete resolution occurred in 1031 of 2224 patients (46.4%) with complete follow-up. The median (IQR) mRS score improved from 1 (0-3) at baseline to 0 (0-2) at > 12 months. Good functional outcomes were more common in patients with complete versus minimal resolution (68.9% vs 35.0%, p < 0.001). Achieving ≥ 73% resolution within 90 days was associated with better outcomes (good outcome in 76.9% of those with ≥ 73% resolution vs 67.3% in those without, p < 0.001). Neurological deterioration was the strongest predictor of lack of good outcome (23.7% in patients with neurological deterioration vs 82.4% without, p < 0.001). CONCLUSIONS:After MMAE for cSDH, reduction in hematoma thickness follows a predictable exponential decay pattern. Greater extent (≥ 80%) and faster timing (within 90 days) of resolution are valuable prognostic indicators. Functional outcomes improve progressively through 6-12 months after the procedure. The relationship between resolution extent and functional outcomes provides quantitative benchmarks for evaluating treatment response.