Faculty Bibliography

BACKGROUND/UNASSIGNED:Most patients with cervical synovial cysts (CSC) present with radiculopathy and/or myelopathy. MR studies are the gold standard for diagnosing CSC, and typically show hypointense T1/hyperintense T2 lesions, with occasional cyst-wall enhancement and additional cyst-wall calcification. Surgery typically warrants focal cyst resection/ decompression with/without an instrumented fusion. Here, we reviewed the diagnosis/treatment of a 76-year-old male with a CSC, and C5-C6/C6-C7 , and C7-T1 stenosis. We further provided a select review of the literature. METHODS/UNASSIGNED:For 3 months, a 76-year-old-male experienced progressive bilateral/arm pain (i.e., radiculopathy), and one week of increased right upper/right lower extremity weakness with loss of balance (i.e., myelopathy). The MR with/without contrast and non contrast CT studies documented moderate C5-C6/C6-C7 stenosis and a large, likely synovial cyst filling the right-side of the spinal canal at the C7-T1 level (i.e, 12 mm x 9 mmx 19 mm). RESULTS/UNASSIGNED:The patient urgently underwent excision of the large right C7-T1 synovial cyst, along with a C6-T2 laminectomy for stenosis, and a C4-T4 instrumented fusion. At 4-postoperative months, the patient was neurologically intact. The repeated X-rays performed at 2, 6, and 12 weeks postoperatively documented maintained alignment, while the MR scan confirmed adequate cord decompression without myelomalacia. CONCLUSION/UNASSIGNED:A 76-year-old male with increased right-sided myeloradiculopathy, successfully underwent resection of a right-sided C7-T1 synovial cyst filling the spinal canal, a C6-T2 laminectomy for stenosis, and a C4-T4 instrumented fusion. Four months postoperatively, the patient was neurologically intact, with postoperative X-rays showing stable alignment. Further, the follow-up MR documented no residual cord/root compression, or myelomalacia. Here, we have provided a review of this case and select literature regarding the diagnosis and surgery for CSC.

BACKGROUND/UNASSIGNED:In this short review/perspective, we asked what the frequencies would be for both postoperative spinal epidural hematomas (SpEH) and postoperative surgical site infections (SSI) in predominantly posterior lumbar procedures performed with or without the placement of wound drains? METHODS/UNASSIGNED:Many spine surgeons are trained to use wound drains to decrease the risk of postoperative SpEH, despite the potential increased risk of SSI. Alternatively, avoiding drains may increase the risk of SpEH but likely decrease the potential for SSI. RESULTS/UNASSIGNED:Performing predominantly posterior lumbar procedures with or without wound drains resulted in largely comparable frequencies of postoperative spinal epidural hematomas (SpEH; range of 0.10%-0.69%) and postoperative surgical site infections (SSI: range of 0.75%-7.3%). Notably, however, two studies documented that drains increased transfusion requirements, with one study showing a prolongation of the in-hospital length of stay. Critically, these series emphasized the importance of early/emergent diagnosis (i.e., with MR) and surgical treatment of SpEH to minimize residual neurological deficits. CONCLUSION/UNASSIGNED:Here, we showed that patients undergoing predominantly lumbar spine surgery performed with or without wound drains demonstrated comparable frequencies of postoperative SpEH and SSI. Nevertheless, spine surgeons must assess on a case-by-case basis whether, based on their education, training, and experience, placing a wound drain is appropriate for their particular patient.

INTRODUCTION/UNASSIGNED:Recent investigations have identified patients of African ancestry (AA) with Multiple Sclerosis (MS), who display more rapid B-cell repopulation after standard semi-annual infusions with an anti-CD20 monoclonal antibody for B cell depletion. In this study, we explored the immunologic and genetic factors, with, serum drug monitoring that may contribute to a faster rate of B-cell repletion that follows during recovery from treatment with anti-CD20 antibody. METHODS/UNASSIGNED:In AA MS patients treated with an anti-CD20 antibody that had early repopulation of peripheral blood B cells, we assessed for extrinsic factors, including the presence of anti-drug antibodies against ocrelizumab, which may contribute to early repletion. We also documented the associated serum drug levels. In addition, we examined for inheritance of intrinsic gene polymorphisms associated with B cell survival and immune function. RESULTS/UNASSIGNED:Our findings identified a subset of AA patients with early B cell repletion after anti-CD20 treatment associated with anti-drug antibodies and an absence of detectable drug. Furthermore, a separate set of AA patients with the early B cell repletion phenotype without anti-drug antibodies had significant over-representation of genetic polymorphisms that map to genes for the B cell survival factor, BAFF, to antibody-dependent cytotoxicity, and to pathways involved in inflammation, leukocyte activation and B cell differentiation. DISCUSSION/UNASSIGNED:In AA patients with MS, after anti-CD20 antibody treatment we found an unexpected high occurrence of early B cell replenishment. This was associated with the presence of anti-drug antibodies and/or specific genetic polymorphisms. Larger studies are now needed to determine whether these factors may lead to impaired therapeutic benefits of B cell targeted therapy and clinical progression, and these findings may be useful to guide future optimized personalized therapeutic strategies.

BACKGROUND/UNASSIGNED:Early treatment of cerebrospinal fluid (CSF) infections, including meningitis and/or ventriculitis (MV) is critical to minimize morbidity/mortality. Infections/MV are typically attributed to; recurrent postoperative lumbar CSF fistulas with drainage through the skin (12.2-33.3%), lumbar drains, and/or various intracranial devices (i.e. external ventricular drains, intracranial pressure monitors). METHODS/UNASSIGNED:Lumbar MR examinations best document recurrent postoperative dural fistulas with subcutaneous extension leading to leaking wounds; the longer these leaks persist, the greater the risk of CSF infection and MV. Classical cranial MR findings of MV due to prior lumbar surgery, lumbar drains or multiple intracranial devices include; ventricular debris, ependymal enhancement, hydrocephalus, extra-axial fluid collections, infarcts (arteritis/ventriculitis), abscesses, and granulomas. RESULTS/UNASSIGNED:Surgery for recurrent postoperative lumbar CSF leaks typically warrant wound reexploration with direct sutured-dural repairs, use of muscle patch grafts (avoid fat - it resorbs), fibrin sealants/fibrin glues (FS/FG), lumbar drains, lumboperitoneal and/or pseudomeningocele-peritoneal shunts. For patients who additionally develop meningitis/ventriculitis, one should consider adding intraventricular (IVT) or lumbar intrathecal (IT) antibiotic therapy to routine intravenous antibiotics. Notably, all efforts should be made to avoid the high mortality rates associated with VM (i.e., 13% to 60%). CONCLUSION/UNASSIGNED:Recurrent postoperative lumbar CSF leaks (i.e., especially after CSF breaches the skin), lumbar drains, and/or intracranial devices/implants may cause infections including meningitis and ventriculitis (MV). It is critical to recognize and treat these infections/MV early to avoid high morbidity and mortality rates.

Repetitive head impacts are associated with structural brain changes and an increased risk for chronic traumatic encephalopathy, a progressive neurodegenerative disease that can only be diagnosed after death. Chronic traumatic encephalopathy is defined by the abnormal accumulation of phosphorylated tau protein, particularly at the depths of the superior frontal sulci, suggesting that sulcal morphology may serve as a relevant structural biomarker. Contact sport athletes, such as former football players, are at elevated risk due to their prolonged exposure to repetitive head impacts. Cortical atrophy linked to underlying tau accumulation may result in shallower and wider sulci, potentially making sulcal morphology an imaging marker for identifying individuals at risk for this disease. This study investigated sulcal morphological differences in former football players and examined associations with age, football-related exposure, clinical diagnosis of traumatic encephalopathy syndrome, levels of certainty for chronic traumatic encephalopathy pathology, neuropsychological performance, and positron emission tomography imaging using flortaucipir. We analysed structural magnetic resonance imaging data from 169 male former football players (mean age 57.2 (8.2) years, range 45-74) and 54 age-matched, unexposed asymptomatic male controls (mean age 59.4 (8.5) years, range 45-74). Sulcal depth and width were quantified using the CalcSulc, focusing on two regions in each hemisphere commonly affected by chronic traumatic encephalopathy pathology: the superior frontal and occipitotemporal sulci. Generalized least squares models were used to assess group differences and interactions with age and football exposure variables, including age of first exposure, total years played, and cumulative head impact exposure. An analysis of covariance evaluated relationships between sulcal morphology, clinical measures, and flortaucipir uptake, adjusting for age, race, body mass index, education, imaging site, apolipoprotein E4 status, and total intracranial volume. Former football players demonstrated significantly shallower sulcal depth in the left superior frontal sulcus compared to unexposed controls. Earlier age of first exposure and longer football careers were associated with greater widening of the left occipitotemporal sulcus. Higher cumulative head impact exposure was linked to reduced sulcal depth in the left superior frontal region. However, sulcal morphology was not associated with clinical diagnosis, levels of certainty, neuropsychological test performance, or flortaucipir imaging. These findings suggest that sulcal morphology may reflect cumulative exposure to repetitive head impacts, particularly in brain regions vulnerable to chronic traumatic encephalopathy pathology. Future ante- and post-mortem validation studies are needed to determine whether sulcal morphology can serve as a reliable in vivo biomarker of risk.

BACKGROUND/UNASSIGNED:Posttraumatic stress disorder (PTSD) symptoms are common in people with cocaine use disorder (CUD), and even sub-threshold PSTD symptoms result in worse treatment outcomes. Difficulties with reward functioning may drive this comorbidity. Impairments in reward functioning are prominent in both PTSD and CUD and contribute to development of substance use problems after trauma. There are three distinct reward processes that may be involved in the PTSD/CUD overlap: consummatory reward (ability to experience pleasure), motivational reward (willingness to exert effort for rewards), and reward learning (adapting behavior based on reward history). Here we test whether impairments in these reward functions account for the relationship between PTSD and CUD symptoms. METHODS/UNASSIGNED:This is a secondary analysis of data from a clinical trial (NCT02773212) that measured of PTSD symptoms, CUD severity, consummatory reward, motivational reward, and reward learning in 53 treatment-seeking people with CUD. RESULTS/UNASSIGNED:Greater PTSD symptoms related to (1) more severe CUD and (2) less ability to learn from reward; however, impaired reward learning did not significantly account for the overlap in PTSD and CUD symptom severity. CONCLUSIONS/UNASSIGNED:The observed relationship between PTSD and CUD symptoms was not accounted for by reduced ability to experience pleasure from rewards, reduced motivation for rewards, or reduced ability to learn from rewards. Thus, treatments that attempt to enhance reward functioning seem unlikely to address this complex comorbidity.

BACKGROUND/UNASSIGNED:that requires emergent postoperative MR confirmation of the classical "white cord" (i.e., high intrinsic T2W MR cord signal reflecting edema/swelling). METHODS/UNASSIGNED:Most frequently, postoperative MR studies in newly paretic/injured patients following cervical operations will show evidence of direct intraoperative ("iatrogenic") spinal cord injury. Less frequently, findings may include new non-operative vs. operative pathology (i.e., hematomas/hematomyelia, graft extrusions/malpositioning, new/residual/recurrent disc/stenosis/Ossification of the Posterior Longitudinal Ligament (OPLL), and other pathology). RESULTS/UNASSIGNED:WCS/RI after cervical spine surgery is extremely rare, being reported in only 17 cases as of 2020, and cannot be diagnosed based on "clinical judgment" alone; rather, it requires a STAT corroborate postoperative MR to demonstrate the classical "white cord". However, most likely postoperative MR studies document "iatrogenic" cord injuries, and less likely show new non-surgical and/or new surgical compressive pathology warranting reoperations to remediate the extent/severity of neurological injuries. CONCLUSION/UNASSIGNED:that requires STAT postoperative MR documentation of the classical swollen/edematous "white cord".

[This corrects the article DOI: 10.3389/fimmu.2025.1590165.].

BACKGROUND/UNASSIGNED:Can we document that posterior cervical surgery (i.e., Laminoforaminotomy (LF) and Laminectomy (L) with Posterior Fusion (PF)) exposes patients to fewer adverse events (i.e., including negligence, multiple risks, negligence, errors, and mistakes) vs. anterior cervical surgery (i.e., Anterior Cervical Diskectomy/Fusion (ACDF) or Anterior Corpectomy/Fusion (ACF))? METHODS/UNASSIGNED:Posterior cervical surgery avoids many of the adverse events uniquely attributed to anterior cervical operations. These include; avoiding fusions with LF vs. ACDF for disc herniations, a lower rate of pseudarthrosis, the avoidance of direct laceration/indirect traction-related carotid/jugular vascular and/or dysphagia/esophageal injuries, fewer neural/cord injuries, vertebral artery injuries, and cerebrospinal fluid (CSF) leaks/dural tears (i.e., particularly with Ossification of the Posterior Longitudinal Ligament (OPLL)). RESULTS/UNASSIGNED:Posterior cervical surgery also poses no direct risks to the following anteriorly-located nerves: recurrent laryngeal nerve (i.e., vocal cord paralysis), phrenic nerve (i.e., diaphragmatic paralysis), the Vagus nerve (i.e., hypotension, reflux, arrhythmias), and sympathetic trunk (i.e., Horner's Syndrome). However, posterior cervical surgery is generally associated with a higher risk of infection (i.e., 2-10%) vs. anterior surgery (i.e., > 1%), more posterior muscle pain, and a higher risk of kyphosis. CONCLUSIONS/UNASSIGNED:Posterior cervical surgery exposes patients to many fewer adverse events vs. anterior cervical surgery. We therefore recommend that in appropriately chosen patients, posterior cervical surgical approaches should be chosen over anterior surgery.