Hypotension secondary to autonomic dysfunction is a common complication of acute spinal cord injury (SCI) that may worsen neurologic outcomes. Midodrine, an enteral α-1 agonist, is often used to facilitate weaning intravenous (IV) vasopressors, but its use can be limited by reflex bradycardia. Alternative enteral agents to facilitate this wean in the acute post-SCI setting have not been described. We aim to describe novel application of droxidopa, an enteral precursor of norepinephrine that is approved to treat neurogenic orthostatic hypotension, in the acute post-SCI setting. Droxidopa may be an alternative enteral therapy for those intolerant of midodrine due to reflex bradycardia. We describe two patients suffering traumatic cervical SCI who were successfully weaned off IV vasopressors with droxidopa after failing with midodrine. The first patient was a 64-year-old male who underwent C3–6 laminectomies and fusion after a ten-foot fall resulting in quadriparesis. Post-operatively, the addition of midodrine in an attempt to wean off IV vasopressors resulted in significant reflexive bradycardia. Treatment with droxidopa facilitated rapidly weaning IV vasopressors and transfer to a lower level of care within 72 hours of treatment initiation. The second patient was a 73-year-old male who underwent C3–5 laminectomies and fusion for a traumatic hyperflexion injury causing paraplegia. The addition of midodrine resulted in severe bradycardia, prompting consideration of pacemaker placement. However, with the addition of droxidopa, this was avoided, and the patient was weaned off IV vasopressors on dual oral therapy with midodrine and droxidopa. Droxidopa may be a viable enteral therapy to treat hypotension in patients after acute SCI who are otherwise not tolerating midodrine in order to wean off IV vasopressors. This strategy may avoid pacemaker placement and facilitate shorter stays in the intensive care unit, particularly for patients who are stable but require continued intensive care unit admission for IV vasopressors, which can be cost ineffective and human resource depleting.

Objective: Traditional open discectomy has long been the standard treatment for lumbar disc herniation, but minimally invasive endoscopic approaches are increasingly being adopted. However, comprehensive comparative analyses of these techniques in terms of clinical outcomes remain limited. This study aimed to compare the short-term clinical outcomes of endoscopic versus open single-level lumbar discectomy, with the hypothesis that the endoscopic approach reduces postoperative complications within 1 month of surgery. Methods: This retrospective cohort study used data from the MARINER database, covering January 2017 to October 2022. Adult patients aged 18 to 74 years who underwent single-level lumbar discectomy were included. A total of 243,684 patients were identified (1,470 endoscopic and 242,214 open surgical procedures). A 1:3 propensity score matching was performed based on age, sex, Charlson Comorbidity Index, and selected comorbidities, yielding a balanced cohort of 5,640 patients (1,416 endoscopic; 4,224 open). Results: After matching, the demographic and comorbidity profiles of the 2 groups were well balanced. The endoscopic group demonstrated significantly lower rates of surgical site infections (0.35% vs. 0.95%, p<0.05; odds ratio [OR], 2.69; 95% confidence interval [CI], 1.06–6.85), surgical complications (0.71% vs. 1.52%, p<0.05; OR, 2.16; 95% CI, 1.11–4.17), and 30-day readmissions (2.47% vs. 7.65%, p<0.05; OR, 3.09; 95% CI, 2.19–4.36). Kaplan-Meier survival analysis over 18 months revealed no significant difference in the probability of subsequent lumbar fusion between groups (log-rank test p=0.8). Conclusion Endoscopic single-level lumbar discectomy is associated with fewer short-term complications compared with open surgery. These findings support the consideration of endoscopic techniques as a lower-risk alternative for appropriately selected patients. Further studies are needed to evaluate long-term outcomes.

Methods: In this database study, medical coding was used to identify patients who had undergone one- to three-level lumbar fusions between 2012 and 2021. Propensity score matching was used to create two equal cohorts with respect to cannabis use history. Opioid utilization rates (morphine milligram equivalents [MME]/day) and overuse rates at 6 months post-index procedure were assessed. All pvalues <0.05 were considered statistically significant. Results: Following examination of 153,500 patient records, 1,216 patients were matched into cannabis user and non-cannabis user cohorts. Cannabis users had lower rates of opioid utilization compared to non-cannabis users as early as 2 months after fusion (47.7% vs. 41.1%, p <0.05), a relationship which persisted at 6 months (46.2% vs. 37.7%, p <0.01). Additionally, cannabis users had lower rates of high-dose opioid utilization (≥100 MME per day) during the initial 14–30 days following surgery (6.91% vs. 3.79%, p <0.05). Conclusions Patients with a history of cannabis use were less likely to be using opioids as early as 2 months postoperatively and had lower rates of high-dose opioid utilization in the immediate postoperative period. Physicians operating on these patients should consider their cannabis use patterns to provide appropriate titration of pain medication over time.