Event-related brain potentials were examined in 32 adolescents (50% female) from a high-risk sample, who were exposed to cocaine and other drugs prenatally. Adolescents were selected for extreme high- or low-risk behavior on the Balloon Analog Risk Task, a measure of real-world risk-taking propensity. The feedback error-related negativity (fERN), an event-related potential (ERP) that occurs when an expected reward does not occur, was examined in a game in which choices lead to monetary gains and losses with feedback delayed 1 or 2 s. The fERN was clearly visible in the fronto-central scalp region in this adolescent sample. Feedback type, feedback delay, risk status, and sex were all associated with fERN variability. Monetary feedback also elicited a P300-like component, moderated by delay and sex. Delaying reward feedback may provide a means for studying complementary functioning of dopamine and norepinephrine systems.

OBJECTIVEFew studies have been published specifically examining intravenous drug abuse (IVDA)–associated spinal epidural abscesses (SEAs), an unfortunate sequela of the opioid crisis in the United States. Here, the authors examined a series of patients with IVDA-associated SEAs in order to shed light on this challenging disease entity.METHODSThis study is a retrospective chart review of patients presenting with IVDA-associated SEAs at the authors’ institution from 2013 to 2018, spanning the statewide implementation of opioid-prescribing restrictions.RESULTSA total of 45 patients presented with IVDA-associated SEAs; 46.5% presented with a neurological deficit. Thirty-one patients underwent surgery for neurological deficit, failure of medical therapy, or both. Nineteen surgical patients underwent a fusion procedure along with decompression. The complication rate was 41.9%, and the mortality rate was 6.7%. The average length of stay was 27.6 days. Patients who underwent surgery within 24 hours of onset of neurological symptoms trended toward more improvement in their American Spinal Cord Association Impairment Scale grade than those who did not (0.5 vs −0.2, p = 0.068). Methicillin-resistant Staphylococcus aureus was isolated as the causative pathogen in 57.8% of patients. Twenty-three patients (51.5%) kept their scheduled clinic follow-up appointments. Of the fusion patients with adequate follow-up, 5 showed bony arthrodesis and 3 had pseudarthrosis. The rate of IVDA-associated SEAs increased after opioid-prescribing restrictions were put in place, from 0.54 cases per month to 1.15 cases per month (p = 0.017).CONCLUSIONSPatients with IVDA-associated SEAs are challenging to treat, with high complication rates and poor follow-up. This disease is increasing in frequency, and opioid-prescribing restrictions did not slow that rise. Community outreach to promote prevention, early medical attention, and medication compliance would benefit this largely publicly funded patient population.

This study reports that there are racial disparities between assault GSW and self-inflicted GSW. However, neither race nor intent is a predictor of survival outcome. Targeted efforts are needed to reduce occurrence of cranial GSW events in order to decrease associated morbidity and mortality.

OBJECTIVEWhile blunt spinal trauma accounts for the majority of spine trauma, penetrating injuries affect a substantial number of patients. The goal of this study was to examine the epidemiology of penetrating spine injuries compared with blunt injuries and review the operative interventions and outcomes in the penetrating spine injury group.METHODSThe prospectively maintained trauma database was queried for spinal fractures from 2012 to 2018. Charts from patients with penetrating spine trauma were reviewed.RESULTSA total of 1130 patients were evaluated for traumatic spinal fractures; 154 injuries (13.6%) were secondary to penetrating injuries. Patients with penetrating injuries were significantly younger (29.2 years vs 44.1 years, p < 0.001), more likely male (87.7% vs 69.2%, p < 0.001), and more commonly African American (80.5% vs 33.3%, p < 0.05). When comparing primary insurers, the penetrating group had a significantly higher percentage of patients covered by Medicaid (60.4% vs 32.6%, p < 0.05) or prison (3.9% vs 0.1%, p < 0.05) or being uninsured (17.5% vs 10.3%, p < 0.05). The penetrating group had a higher Injury Severity Score on admission (20.2 vs 15.6, p < 0.001) and longer hospital length of stay (20.1 days vs 10.3 days, p < 0.001) and were less likely to be discharged home (51.3% vs 65.1%, p < 0.05). Of the penetrating injuries, 142 (92.2%) were due to firearms. Sixty-three patients (40.9%) with penetrating injuries had a concomitant spinal cord or cauda equina injury. Of those, 44 (69.8%) had an American Spinal Injury Association Impairment Scale (AIS) grade of A. Ten patients (15.9%) improved at least 1 AIS grade, while 2 patients (3.2%) declined at least 1 AIS grade. Nine patients with penetrating injuries underwent neurosurgical intervention: 5 for spinal instability, 4 for compressive lesions with declining neurological examination results, and 2 for infectious concerns, with some patients having multiple indications. Patients undergoing neurosurgical intervention did not show a significantly greater change in AIS grade than those who did not. No patient experienced a complication directly related to neurosurgical intervention.CONCLUSIONSPenetrating spinal trauma affects a younger, more publicly funded cohort than blunt spinal trauma. These patients utilize more healthcare resources and are more severely injured. Surgery is undertaken for limiting progression of neurological deficit, stabilization, or infection control.

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There are sparse data regarding the impact of alcohol on in-hospital complications associated with traumatic spinal cord injuries (TSCIs). We set out to quantify the impact of alcohol on TSCI outcomes and its influence on health care cost and utilization. The National Trauma Data Bank (NTDB) Research Data Set version 7.2 (2000-2006) was utilized to gather data between 2007 and 2009. We extracted cases of TSCI (International Classification of Diseases, Ninth Revision, Clinical Modification codes 806.xx) without concurrent traumatic brain injury. Outcomes of interest were mortality, length of stay (LOS), intensive care unit (ICU) days, ventilator days, and complications. Continuous outcomes such as LOS, ICU days, and ventilator days were analyzed using linear regression. Risk-adjusted analysis of risk factors for mortality and complication rates were performed using multiple logistic regression. Of the 10,611 persons identified in the NTDB, alcohol was present in approximately one fifth of all cases (20.76%). A majority of TSCI patients were young (mean age, 39 years) Caucasian (65.07%) males (75.93%). Blunt injury was the most common mechanism of injury. The presence of alcohol did not significantly affect mortality or neurological complications. Alcohol in the blood was associated with extended LOS, longer ICU stays, more days spent ventilated, and increased risk of all-type complications. Further, there was a statistically significant association with the presence alcohol and increased risk for pulmonary, pneumonia, deep vein thrombosis and pulmonary embolism, urinary tract infection, and ulcer/skin complications. Alcohol intoxication is associated with increased in-hospital morbidity. The significant association with in-hospital complications increases health resource utilization after spinal cord injury.

The traditional posterior subscapular approach offers excellent exposure of the lower brachial plexus and has been successfully used in patients with recurrent thoracic outlet syndrome after an anterior operation, brachial plexus tumors involving the proximal roots, and postirradiation brachial plexopathy, among others. However, this approach also carries some morbidity, mostly related to the extensive muscle dissection of the trapezius, rhomboids, and levator scapulae. In this article, the authors present the surgical technique and video illustration of a modified, less invasive posterior subscapular approach, using a small, self-retaining retractor and only a partial trapezius and rhomboid minor muscle dissection. This approach is likely to result in decreased postoperative morbidity and a shorter hospital stay.

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