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Tumoral calcinosis of the cervical spine in an infant

Case illustration

James F. Mooney III and Steven S. Glazier

InJournal of Neurosurgery Volume 86: Issue 1 (Jan 1997)

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Effects of prior concussion on symptom severity and recovery time in acute youth concussion

詹姆斯•穆尼詹姆斯脑袋,伊恩·康明斯m·钱德勒McLeod, and Sara Gould

OBJECTIVE

Many studies have identified factors associated with increased symptom burden and prolonged recovery after pediatric and adolescent concussion. Few have systematically examined the effects of prior concussion on these outcomes in patients with concussion due to any mechanism. An improved understanding of the short- and long-term effects of a multiple concussion history will improve counseling and management of this subgroup of patients.

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A retrospective review of adolescent and young adult acute concussion patients presenting to the multidisciplinary concussion clinic between 2018 and 2019 was conducted at a single center. Patient demographic data, medical history including prior concussion, initial symptom severity score (SSS), injury mechanisms, and recovery times were collected. Univariate and multivariable analyses were conducted to identify associations of history of prior concussion and patient and injury characteristics with symptom score and recovery time.

RESULTS

共有266名患者平均年龄为15岁。4 years (age range 13–27 years) were included. Prior concussion was reported in 35% of patients. The number of prior concussions per patient was not significantly associated with presenting symptom severity, recovery time, or recovery within 28 days. Male sex and sports-related concussion (SRC) were associated with lower presenting SSS and shorter recovery time on univariate but not multivariable analysis. However, compared to non–sport concussion mechanisms, SRC was associated with 2.3 times higher odds of recovery within 28 days (p = 0.04). A history of psychiatric disorders was associated with higher SSS in univariate analysis and longer recovery time in univariate and multivariable analyses. Multivariable log-linear regression also demonstrated 5 times lower odds of recovery within 28 days for those with a psychiatric history.

CONCLUSIONS

The results of this study demonstrated that an increasing number of prior concussions was associated with a trend toward higher presenting SSS after youth acute concussion but did not show a significant association with recovery time or delayed (> 28 days) recovery. Presence of psychiatric history was found to be significantly associated with longer recovery and lower odds of early (≤ 28 days) recovery. Future prospective, long-term, and systematic study is necessary to determine the optimal counseling and management of adolescent and young adult patients with a history of multiple concussions.

InJournal of Neurosurgery: Pediatrics Volume 30: Issue 3 (Sep 2022)

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Molecular and cellular intratumoral heterogeneity in primary glioblastoma: clinical and translational implications

Joshua D. Bernstock, James H. Mooney, Adeel Ilyas, Gustavo Chagoya, Dagoberto Estevez-Ordonez, Ahmed Ibrahim, and Ichiro Nakano

Glioblastoma (GBM), the most common primary malignant brain tumor in adults, is associated with significant morbidity and mortality despite maximal safe resection followed by chemo- and radiotherapy. GBMs contain self-renewing, tumorigenic glioma stem cells that contribute to tumor initiation, heterogeneity, therapeutic resistance, and recurrence. Intratumoral heterogeneity (ITH) of GBMs is also a major contributing factor to poor clinical outcomes associated with these high-grade glial tumors. Herein, the authors summarize recent discoveries and advances in the molecular and phenotypic characterization of GBMs with particular focus on ITH. In so doing, they attempt to highlight recent advances in molecular signatures/properties and metabolic alterations in an effort to clarify translational implications that may ultimately improve clinical outcomes.

InJournal of Neurosurgery Volume 133: Issue 3 (Sep 2020)

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Comparison of aesthetic outcomes between open and endoscopically treated sagittal craniosynostosis

Jacob Lepard, S. Hassan A. Akbari, James Mooney, Anastasia Arynchyna, Samuel G. McClugage III, René P. Myers, John Grant, and James M. Johnston Jr.

OBJECTIVE

In the last several decades, there has been much debate regarding the ideal treatment for sagittal synostosis. The purpose of this study was to compare perioperative, anthropometric, and subjective assessments of cosmetic outcomes between open and endoscopic management of isolated sagittal synostosis.

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At their routine postoperative follow-up, pediatric patients with sagittal craniosynostosis were recruited to undergo digital cranial measurement and standardized photography for objective and subjective assessments of perioperative outcomes. Age-normalized z-scores for cephalic index, head circumference, euryon-euryon diameter (Eu-Eu), and glabella-opisthocranion diameter (G-Op) were calculated for each patient. Faculty surgeons, surgical trainees, nurses, and laypersons were asked to rate the normalcy of craniofacial appearances using a 5-point Likert scale. Outcomes were compared between patients treated with endoscopic correction and those treated with open repair.

RESULTS

A total of 50 patients were included in the study. Thirty-one had undergone open surgical correction, and 19 had undergone endoscopic treatment. Endoscopic repair involved significantly lower operative time, blood loss, transfusion rate, and hospital length of stay than those with open repair (p < 0.001). There was no significant difference between groups in terms of z-scores for head circumference (p = 0.22), cephalic index (p = 0.25), or Eu-Eu (p = 0.38). Endoscopic treatment was associated with a significantly lower G-Op (p = 0.009). Additionally, the average subjective rating of head shape was higher for endoscopic treatment when corrected for age, gender, and ethnicity (p = 0.02).

CONCLUSIONS

The study findings suggest that patients who are treated endoscopically may have an overall more normal appearance in skull morphology and cosmesis, although these results are limited by poor reliability.

InJournal of Neurosurgery: Pediatrics Volume 28: Issue 4 (Oct 2021)

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Racial differences in the care of pediatric sagittal craniosynostosis: a single-institution cohort study affecting state Medicaid policy

S. Hassan A. Akbari, James Mooney, Jacob Lepard, Anastasia Arynchyna-Smith, Samuel McClugage, Rene Myers, John Grant, Curtis Rozzelle, and James M. Johnston

OBJECTIVE

Although research has shown the cost-effectiveness of endoscopic versus open repair of sagittal synostosis, few studies have shown how race, insurance status, and area deprivation impact care for these patients. The authors analyzed data from children evaluated for sagittal synostosis at a single institution to assess how socioeconomic factors, race, and insurance status affect the surgical treatment of this population. They hypothesized that race and indicators of disadvantage negatively impact workup and surgical timing for craniosynostosis surgery.

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Medical records of patients treated for sagittal synostosis between 2010 and 2019 were reviewed. Area deprivation index (ADI) and rural-urban commuting area codes, as well as median income by zip code, were used to measure neighborhood disadvantage. Black and White patients were compared as well as patients using Medicaid versus private insurance.

RESULTS

Fifty patients were prospectively included in the study. Thirty-one underwent open repair; 19 had endoscopic repair. All 8 (100%) Black patients had open repair, compared to 54.8% of White patients (p = 0.018). Black patients were more likely to use Medicaid compared to White patients (75.0% vs 28.6%, p = 0.019). White patients were younger at surgery (5.5 vs 10.0 months, p = 0.001), and Black patients had longer surgeries (147.5 minutes vs 110.0 minutes, p = 0.021). The median household income by zip code was similar for the two groups. Black patients were generally from areas of greater disadvantage compared to White patients, based on both state and national ADI scores (state: 7.5 vs 4.0, p = 0.013; national: 83.5 vs 60.0, p = 0.013). All (94.7%) but 1 patient undergoing endoscopic repair used private insurance compared to 14 (45.2%) patients in the open repair group (p = 0.001). Patients using Medicaid were from areas of greater disadvantage compared to those using private insurance by both state and national ADI scores (state: 6.0 vs 3.0, p = 0.001; national: 75.0 vs 52.0, p = 0.001).

CONCLUSIONS

Because Medicaid in the geographic region of this study did not cover helmeting after endoscopic repair of sagittal synostosis, these patients usually had open repair, resulting in significant racial and socioeconomic disparities in treatment of sagittal synostosis. This research has led to a change in Alabama Medicaid policy to now cover the cost of postoperative helmeting.

InJournal of Neurosurgery: Pediatrics Publish Before Print

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Whole blood aggregometry prior to Pipeline embolization device treatment of intracranial aneurysms: defining an optimal platelet inhibition cutoff value for clopidogrel

Paul M. Foreman, Alejandro Enriquez-Marulanda, James H. Mooney, Philip G. R. Schmalz, Christoph J. Griessenauer, John P. Deveikis, and Mark R. Harrigan

OBJECTIVE

Dual antiplatelet therapy is required for the treatment of intracranial aneurysms with the Pipeline embolization device (PED). Platelet function testing (PFT) is often used to assess the efficacy of the antiplatelet regimen prior to PED placement. The optimal impedance values for whole blood aggregometry in this setting have not been defined.

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A retrospective review of a prospectively maintained database was performed for the years 2011–2015 to identify patients with intracranial aneurysms treated with the PED who underwent pretreatment PFT using whole blood aggregometry. Antiplatelet therapy was not altered based on PFT results; all patients remained on standard doses of aspirin and clopidogrel. Clinical, radiographic, and laboratory data were analyzed to identify the optimal cutoff impedance value for clopidogrel responsiveness using the receiver operating characteristic curve and Youden’s index.

RESULTS

Forty-nine patients underwent 53 endovascular procedures for the treatment of 76 aneurysms using the PED. The majority of these aneurysms were located in the anterior circulation (90.8%) and affected the internal carotid artery (89.5%). Patients in 30 procedures (56.6%) were identified as clopidogrel responders based on the manufacturer cutoff value (< 6 Ω). Thromboembolic complications occurred in 13 (24.5%) procedures; patients in 6 (11.3%) cases were symptomatic and those in 3 (5.7%) cases had ischemic strokes. Eleven of the 13 (84.6%) thromboembolic complications occurred in clopidogrel nonresponders. An impedance value of ≥ 6 Ω was independently associated with thromboembolic complications. The optimal electrical impedance value was identified as ≥ 6 Ω (sensitivity 84.6%, specificity 70.0%, area under the curve 0.77) for identifying clopidogrel nonresponders.

CONCLUSIONS

Thromboembolic complications are more common following PED placement in patients who do not respond adequately to clopidogrel. Clopidogrel nonresponders can be identified using pretreatment whole blood aggregometry. The optimal cutoff value to categorize a patient as a clopidogrel nonresponder when using whole blood aggregometry is ≥ 6 Ω.

InJournal of Neurosurgery Volume 131: Issue 5 (Nov 2019)

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Targeting glioma-initiating cells via the tyrosine metabolic pathway

Daisuke Yamashita, Joshua D. Bernstock, Galal Elsayed, Hirokazu Sadahiro, Ahmed Mohyeldin, Gustavo Chagoya, Adeel Ilyas, James Mooney, Dagoberto Estevez-Ordonez, Shinobu Yamaguchi, Victoria L. Flanary, James R. Hackney, Krishna P. Bhat, Harley I. Kornblum, Nicola Zamboni, Sung-Hak Kim, E. Antonio Chiocca, and Ichiro Nakano

OBJECTIVE

Despite an aggressive multimodal therapeutic regimen, glioblastoma (GBM) continues to portend a grave prognosis, which is driven in part by tumor heterogeneity at both the molecular and cellular levels. Accordingly, herein the authors sought to identify metabolic differences between GBM tumor core cells and edge cells and, in so doing, elucidate novel actionable therapeutic targets centered on tumor metabolism.

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Comprehensive metabolic analyses were performed on 20 high-grade glioma (HGG) tissues and 30 glioma-initiating cell (GIC) sphere culture models. The results of the metabolic analyses were combined with the Ivy GBM data set. Differences in tumor metabolism between GBM tumor tissue derived from within the contrast-enhancing region (i.e., tumor core) and that from the peritumoral brain lesions (i.e., tumor edge) were sought and explored. Such changes were ultimately confirmed at the protein level via immunohistochemistry.

RESULTS

Metabolic heterogeneity in both HGG tumor tissues and GBM sphere culture models was identified, and analyses suggested that tyrosine metabolism may serve as a possible therapeutic target in GBM, particularly in the tumor core. Furthermore, activation of the enzyme tyrosine aminotransferase (TAT) within the tyrosine metabolic pathway influenced the noted therapeutic resistance of the GBM core.

CONCLUSIONS

Selective inhibition of the tyrosine metabolism pathway may prove highly beneficial as an adjuvant to multimodal GBM therapies.

InJournal of Neurosurgery Volume 134: Issue 3 (Mar 2021)

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Outpatient versus inpatient lumbar decompression surgery: a matched noninferiority study investigating clinical and patient-reported outcomes

James Mooney, Giorgos D. Michalopoulos, Daniel Zeitouni, Sally El Sammak, Mohammed Ali Alvi, Michael Y. Wang, Domagoj Coric, Andrew K. Chan, Praveen V. Mummaneni, Erica F. Bisson, Brandon Sherrod, Regis W. Haid Jr., John J. Knightly, Clinton J. Devin, Brenton H. Pennicooke, Anthony L. Asher, and Mohamad Bydon

OBJECTIVE

Spine surgery represents an ideal target for healthcare cost reduction efforts, with outpatient surgery resulting in significant cost savings. With an increased focus on value-based healthcare delivery, lumbar decompression surgery has been increasingly performed in the outpatient setting when appropriate. The aim of this study was to compare clinical and patient-reported outcomes following outpatient and inpatient lumbar decompression surgery.

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The Quality Outcomes Database (QOD) was queried for patients undergoing elective one- or two-level lumbar decompression (laminectomy or laminotomy with or without discectomy) for degenerative spine disease. Patients were grouped as outpatient if they had a length of stay (LOS) < 24 hours and as inpatient if they stayed in the hospital ≥ 24 hours. Patients with ≥ 72-hour stay were excluded from the comparative analysis to increase baseline comparability between the two groups. To create two highly homogeneous groups, optimal matching was performed at a 1:1 ratio between the two groups on 38 baseline variables, including demographics, comorbidities, symptoms, patient-reported scores, indications, and operative details. Outcomes of interest were readmissions and reoperations at 30 days and 3 months after surgery, overall satisfaction, and decrease in Oswestry Disability Index (ODI), back pain, and leg pain at 3 months after surgery. Satisfaction was defined as a score of 1 or 2 in the North American Spine Society patient satisfaction index. Noninferiority of outpatient compared with inpatient surgery was defined as risk difference of < 1.5% at a one-sided 97.5% confidence interval.

RESULTS

共有18689个符合条件的一个,二级装饰mpression surgeries were identified. The matched study cohorts consisted of 5016 patients in each group. Nonroutine discharge was slightly less common in the outpatient group (0.6% vs 0.3%, p = 0.01). The 30-day readmission rates were 4.4% and 4.3% for the outpatient and inpatient groups, respectively, while the 30-day reoperation rates were 1.4% and 1.5%. The 3-month readmission rates were 6.3% for both groups, and the 3-month reoperation rates were 3.1% for the outpatient cases and 2.9% for the inpatient cases. Overall satisfaction at 3 months was 88.8% for the outpatient group and 88.4% for the inpatient group. Noninferiority of outpatient surgery was documented for readmissions, reoperations, and patient-reported satisfaction from surgery.

CONCLUSIONS

朱元璋门诊腰椎减压手术ed slightly lower nonroutine discharge rates in comparison with inpatient surgery. Noninferiority in clinical outcomes at 30 days and 3 months after surgery was documented for outpatient compared with inpatient decompression surgery. Additionally, outpatient decompression surgery performed noninferiorly to inpatient surgery in achieving patient satisfaction from surgery.

InJournal of Neurosurgery: Spine Volume 37: Issue 4 (Oct 2022)

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Minimally invasive versus open lumbar spinal fusion: a matched study investigating patient-reported and surgical outcomes

James Mooney, Giorgos D. Michalopoulos, Mohammed Ali Alvi, Daniel Zeitouni, Andrew K. Chan, Praveen V. Mummaneni, Erica F. Bisson, Brandon A. Sherrod, Regis W. Haid, John J. Knightly, Clinton J. Devin, Brenton Pennicooke, Anthony L. Asher, and Mohamad Bydon

OBJECTIVE

With the expanding indications for and increasing popularity of minimally invasive surgery (MIS) for lumbar spinal fusion, large-scale outcomes analysis to compare MIS approaches with open procedures is warranted.

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The authors queried the Quality Outcomes Database for patients who underwent elective lumbar fusion for degenerative spine disease. They performed optimal matching, at a 1:2 ratio between patients who underwent MIS and those who underwent open lumbar fusion, to create two highly homogeneous groups in terms of 33 baseline variables (including demographic characteristics, comorbidities, symptoms, patient-reported scores, indications, and operative details). The outcomes of interest were overall satisfaction, decrease in Oswestry Disability Index (ODI), and back and leg pain, as well as hospital length of stay (LOS), operative time, reoperations, and incidental durotomy rate. Satisfaction was defined as a score of 1 or 2 on the North American Spine Society scale. Minimal clinically important difference (MCID) in ODI was defined as ≥ 30% decrease from baseline. Outcomes were assessed at the 3- and 12-month follow-up evaluations.

RESULTS

After the groups were matched, the MIS and open groups consisted of 1483 and 2966 patients, respectively. Patients who underwent MIS fusion had higher odds of satisfaction at 3 months (OR 1.4, p = 0.004); no difference was demonstrated at 12 months (OR 1.04, p = 0.67). Lumbar stenosis, single-level fusion, higher American Society of Anesthesiologists Physical Status Classification System grade, and absence of spondylolisthesis were most prominently associated with higher odds of satisfaction with MIS compared with open surgery. Patients in the MIS group had slightly lower ODI scores at 3 months (mean difference 1.61, p = 0.006; MCID OR 1.14, p = 0.0495) and 12 months (mean difference 2.35, p < 0.001; MCID OR 1.29, p < 0.001). MIS was also associated with a greater decrease in leg and back pain at both follow-up time points. The two groups did not differ in operative time and incidental durotomy rate; however, LOS was shorter for the MIS group. Revision surgery at 12 months was less likely for patients who underwent MIS (4.1% vs 5.6%, p = 0.032).

CONCLUSIONS

In patients who underwent lumbar fusion for degenerative spinal disease, MIS was associated with higher odds of satisfaction at 3 months postoperatively. No difference was demonstrated at the 12-month follow-up. MIS maintained a small, yet consistent, superiority in decreasing ODI and back and leg pain, and MIS was associated with a lower reoperation rate.

InJournal of Neurosurgery: Spine Volume 36: Issue 5 (May 2022)

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