Publications by authors named "Kevin Swong"

20 Publications

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Impact of Michigan's new opioid prescribing laws on spine surgery patients: analysis of the Michigan Spine Surgery Improvement Collaborative.

J Neurosurg Spine 2020 Dec 11:1-6. Epub 2020 Dec 11.

Departments of1Neurosurgery and.

Objective: In 2017, Michigan passed new legislation designed to reduce opioid abuse. This study evaluated the impact of these new restrictive laws on preoperative narcotic use, short-term outcomes, and readmission rates after spinal surgery.

Methods: Patient data from 1 year before and 1 year after initiation of the new opioid laws (beginning July 1, 2018) were queried from the Michigan Spine Surgery Improvement Collaborative database. Before and after implementation of the major elements of the new laws, 12,325 and 11,988 patients, respectively, were treated.

Results: Patients before and after passage of the opioid laws had generally similar demographic and surgical characteristics. Notably, after passage of the opioid laws, the number of patients taking daily narcotics preoperatively decreased from 3783 (48.7%) to 2698 (39.7%; p < 0.0001). Three months postoperatively, there were no differences in minimum clinically important difference (56.0% vs 58.0%, p = 0.1068), numeric rating scale (NRS) score of back pain (3.5 vs 3.4, p = 0.1156), NRS score of leg pain (2.7 vs 2.7, p = 0.3595), satisfaction (84.4% vs 84.7%, p = 0.6852), or 90-day readmission rate (5.8% vs 6.2%, p = 0.3202) between groups. Although there was no difference in readmission rates, pain as a reason for readmission was marginally more common (0.86% vs 1.22%, p = 0.0323).

Conclusions: There was a meaningful decrease in preoperative narcotic use, but notably there was no apparent negative impact on postoperative recovery, patient satisfaction, or short-term outcomes after spinal surgery despite more restrictive opioid prescribing. Although the readmission rate did not significantly increase, pain as a reason for readmission was marginally more frequently observed.
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http://dx.doi.org/10.3171/2020.7.SPINE20729DOI Listing
December 2020

Three-Dimensional Navigated Lateral Lumbar Interbody Fusion: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2020 12;20(1):E43

Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan.

Spondylolisthesis is a common cause of lower back and leg pain in adults. The initial treatment for patients is typically nonoperative in nature. However, when patients fail conservative management and their back and/or leg pain is recalcitrant, surgical intervention is warranted. Spinal decompression, either directly or indirectly, as well as fusion is often considered at this point. There are numerous approaches to fuse the spine, including anterior, lateral, or posterior, each with their own advantages and disadvantages.   This video illustrates a case of symptomatic spondylolisthesis occurring after laminectomy treated by lateral lumbar interbody fusion for indirect decompression and stabilization. The approach utilizes 3-dimensional navigation rather than traditional fluoroscopy, resulting in markedly decreased radiation exposure for the surgeon and staff while maintaining accuracy. Appropriate patient consent was obtained. This video demonstrates the technique for a lateral lumbar interbody fusion using navigation assistance, which is a minimally invasive technique for the treatment of spondylolisthesis.
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http://dx.doi.org/10.1093/ons/opaa307DOI Listing
December 2020

The feasibility of computer-assisted 3D navigation in multiple-level lateral lumbar interbody fusion in combination with posterior instrumentation for adult spinal deformity.

Neurosurg Focus 2020 09;49(3):E4

Objective: The lateral lumbar interbody fusion (LLIF) technique is used to treat many common spinal degenerative pathologies including kyphoscoliosis. The use of spinal navigation for LLIF has not been broadly adopted, especially in adult spinal deformity. The purpose of this study was to evaluate the feasibility as well as the intraoperative and navigation-related complications of computer-assisted 3D navigation (CaN) during multiple-level LLIF for spinal deformity.

Methods: Retrospective analysis of clinical and operative characteristics was performed for all patients > 18 years of age who underwent multiple-level CaN LLIF combined with posterior instrumentation for adult spinal deformity at the University of Michigan between 2014 and 2020. Intraoperative CaN-related complications, LLIF approach-related postoperative complications, and medical postoperative complications were assessed.

Results: Fifty-nine patients were identified. The mean age was 66.3 years (range 42-83 years) and body mass index was 27.6 kg/m2 (range 18-43 kg/m2). The average coronal Cobb angle was 26.8° (range 3.6°-67.0°) and sagittal vertical axis was 6.3 cm (range -2.3 to 14.7 cm). The average number of LLIF and posterior instrumentation levels were 2.97 cages (range 2-5 cages) and 5.78 levels (range 3-14 levels), respectively. A total of 6 intraoperative complications related to the LLIF stage occurred in 5 patients. Three of these were CaN-related and occurred in 2 patients (3.4%), including 1 misplaced lateral interbody cage (0.6% of 175 total lateral cages placed) requiring intraoperative revision. No patient required a return to the operating room for a misplaced interbody cage. A total of 12 intraoperative complications related to the posterior stage occurred in 11 patients, with 5 being CaN-related and occurring in 4 patients (6.8%). Univariate and multivariate analyses revealed no statistically significant risk factors for intraoperative and CaN-related complications. Transient hip weakness and numbness were found to be in 20.3% and 22.0% of patients, respectively. At the 1-month follow-up, weakness was observed in 3.4% and numbness in 11.9% of patients.

Conclusions: Use of CaN in multiple-level LLIF in the treatment of adult spinal deformity appears to be a safe and effective technique. The incidence of approach-related complications with CaN was 3.4% and cage placement accuracy was high.
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http://dx.doi.org/10.3171/2020.5.FOCUS20353DOI Listing
September 2020

The impact of age on approach-related complications with navigated lateral lumbar interbody fusion.

Neurosurg Focus 2020 09;49(3):E8

Objective: Age is known to be a risk factor for increased complications due to surgery. However, elderly patients can gain significant quality-of-life benefits from surgery. Lateral lumbar interbody fusion (LLIF) is a minimally invasive procedure that is commonly used to treat degenerative spine disease. Recently, 3D navigation has been applied to LLIF. The purpose of this study was to determine whether there is an increased complication risk in the elderly with navigated LLIF.

Methods: Patients who underwent 3D-navigated LLIF for degenerative disease from 2014 to 2019 were included in the analysis. Patients were divided into elderly and nonelderly groups, with those 65 years and older categorized as elderly. Ninety-day medical and surgical complications were recorded. Patient and surgical characteristics were compared between groups, and multivariate regression analysis was used to determine independent risk factors for complication.

Results: Of the 115 patients included, 56 were elderly and 59 were nonelderly. There were 15 complications (25.4%) in the nonelderly group and 10 (17.9%) in the elderly group, which was not significantly different (p = 0.44). On multivariable analysis, age was not a risk factor for complication (p = 0.52). However, multiple-level LLIF was associated with an increased risk of approach-related complication (OR 3.58, p = 0.02).

Conclusions: Elderly patients do not appear to experience higher rates of approach-related complications compared with nonelderly patients undergoing 3D navigated LLIF. Rather, multilevel surgery is a predictor for approach-related complication.
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http://dx.doi.org/10.3171/2020.6.FOCUS20311DOI Listing
September 2020

Surgical management of atlantoaxial dislocation and cervical spinal cord injury in craniopagus twins.

J Neurosurg Spine 2020 Aug 28:1-6. Epub 2020 Aug 28.

Departments of1Neurological Surgery and.

A case of cervical spinal cord injury in 12-year-old angular craniopagus twins is presented, with a description of the planning and execution of surgical treatment along with subsequent clinical outcome. The injury occurred following a fall from a standing position, resulting in quadriparesis in one of the twins. Imaging revealed severe craniocervical stenosis resulting from a C1-2 dislocation, and T2-weighted hyperintensity of the cervical spinal cord. After custom halo fixation was obtained, a posterior approach was utilized to decompress and instrument the occiput, cervical, and upper thoracic spine with intraoperative reduction of the dislocation. Early neurological improvement was noted during the acute postoperative phase, and 27 months of follow-up demonstrated intact instrumentation with continued neurological improvement to near baseline. The complexity of managing such an injury, inclusive of the surgical, anesthetic, biomechanical, and ethical considerations, is described in detail.
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http://dx.doi.org/10.3171/2020.5.SPINE20537DOI Listing
August 2020

Effect of Fenestrated Pedicle Screws with Cement Augmentation in Osteoporotic Patients Undergoing Spinal Fusion.

World Neurosurg 2020 11 7;143:e351-e361. Epub 2020 Aug 7.

Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA. Electronic address:

Objective: Osteoporosis is a well-known risk factor for instrumentation failure and subsequent pseudoarthrosis after spinal fusion. In the present systematic review, we analyzed the biomechanical properties, clinical efficacy, and complications of cement augmentation via fenestrated pedicle screws in spinal fusion.

Methods: We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Reports appearing in the PubMed database up to March 31, 2020 were queried using the key words "cement," "pedicle screw," and "osteoporosis." We excluded non-English language studies, studies reported before 2000, studies that had involved use of cement without fenestrated pedicle screws, nonhuman studies, technical reports, and individual case reports.

Results: Twenty-five studies met the inclusion criteria. Eleven studies had tested the biomechanics of cement-augmented fenestrated pedicle screws. The magnitude of improvement achieved by cement augmentation of pedicle screws increased with the degree of osteoporosis. The cement-augmented fenestrated pedicle screw was superior biomechanically to the alternative "solid-fill" technique. Fourteen studies had evaluated complications. Cement extravasation with fenestrated screw usage was highly variable, ranging from 0% to 79.7%. However, cement extravasation was largely asymptomatic. Thirteen studies had assessed the outcomes. The use of cement-augmented fenestrated pedicles decreased screw pull out and improved fusion rates; however, the clinical outcomes were similar to those with traditional pedicle screw placement.

Conclusions: The use of cement-augmented fenestrated pedicle screws can be an effective strategy for achieving improved pedicle screw fixation in patients with osteoporosis. A potential risk is cement extravasation; however, this complication will typically be asymptomatic. Larger comparative studies are needed to better delineate the clinical efficacy.
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http://dx.doi.org/10.1016/j.wneu.2020.07.154DOI Listing
November 2020

Patients with a depressive and/or anxiety disorder can achieve optimum Long term outcomes after surgery for grade 1 spondylolisthesis: Analysis from the quality outcomes database (QOD).

Clin Neurol Neurosurg 2020 10 17;197:106098. Epub 2020 Jul 17.

Department of Neurologic Surgery, University of Michigan, Ann Arbor, Michigan, United States.

Introduction: In the current study, we sought to compare baseline demographic, clinical, and operative characteristics, as well as baseline and follow-up patient reported outcomes (PROs) of patients with any depressive and/or anxiety disorder undergoing surgery for low-grade spondylolisthesis using a national spine registry.

Patients And Methods: The Quality Outcomes Database (QOD) was queried for patients undergoing surgery for Meyerding grade 1 lumbar spondylolisthesis undergoing 1-2 level decompression or 1 level fusion at 12 sites with the highest number of patients enrolled in QOD with 2-year follow-up data.

Results: Of the 608 patients identified, 25.6 % (n = 156) had any depressive and/or anxiety disorder. Patients with a depressive/anxiety disorder were less likely to be discharged home (p < 0.001). At 3=months, patients with a depressive/anxiety disorder had higher back pain (p < 0.001), lower quality of life (p < 0.001) and higher disability (p = 0.013); at 2 year patients with depression and/or anxiety had lower quality of life compared to those without (p < 0.001). On multivariable regression, depression was associated with significantly lower odds of achieving 20 % or less ODI (OR 0.44, 95 % CI 0.21-0.94,p = 0.03). Presence of an anxiety disorder was not associated with decreased odds of achieving that milestone at 3 months. The presence of depressive-disorder, anxiety-disorder or both did not have an impact on ODI at 2 years. Finally, patient satisfaction at 2-years did not differ between the two groups (79.8 % vs 82.7 %,p = 0.503).

Conclusion: We found that presence of a depressive-disorder may impact short-term outcomes among patients undergoing surgery for low grade spondylolisthesis but longer term outcomes are not affected by either a depressive or anxiety disorder.
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http://dx.doi.org/10.1016/j.clineuro.2020.106098DOI Listing
October 2020

Commentary: Anterior Lumbar Interbody Fusion (ALIF): Technique Video: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2020 09;19(4):E405-E406

Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan.

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http://dx.doi.org/10.1093/ons/opaa161DOI Listing
September 2020

Correlation Between the Oswestry Disability Index and the North American Spine Surgery Patient Satisfaction Index.

World Neurosurg 2020 07 25;139:e724-e729. Epub 2020 Apr 25.

Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA. Electronic address:

Background: The Oswestry Disability Index (ODI) is a widely used patient-reported outcome instrument in lumbar spine surgery, but its relationship to the increasingly scrutinized but still heterogeneous patient satisfaction metrics has not been well described. One popular metric is the North American Spine Society (NASS) patient satisfaction index. This study aimed to determine whether change in ODI predicts patient satisfaction.

Methods: Adult patients at a neurosurgery spine clinic completed the ODI and NASS questionnaires at various times in their care between September 2014 and November 2018. Scores were retrospectively analyzed using ordinal logistic regression.

Results: One thousand thirty-seven patients were identified (mean age 59.3 ± 14.7 years, 54.2% male). At 3, 12, and 24 months postoperatively, 684 (84.5%), 400 (83.3%), and 215 (80.9%) patients, respectively, expressed satisfaction (NASS score 1 or 2). Mean ± standard deviation improvements in ODI at 3, 12, and 24 months postoperatively were 16.8 ± 17.5 (n = 675), 18.4 ± 17.5 (n = 396), and 19.7 ± 17.7 (n = 213). For every unit improvement in ODI, the odds of selecting the next most satisfied NASS score at 3, 12, and 24 months postoperatively increased by 6.8% (95% confidence interval [CI] 5.6%-8.1%), 5.8% (95% CI 4.4%-7.1%), and 6.0% (95% CI 4.2%-7.9%), respectively. Every 10-unit improvement increased the odds, respectively, by 93.8% (95% CI 73.2%-117.0%), 75.0% (95% CI 53.8%-99.1%), and 79.4% (95% CI 50.3%-114.1%).

Conclusions: Improvements in ODI are predictive of increased patient satisfaction as defined by the NASS index. A 10-point improvement in ODI nearly doubled the odds of increased satisfaction 3 months postoperatively.
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http://dx.doi.org/10.1016/j.wneu.2020.04.117DOI Listing
July 2020

Complications of anterior cervical spine surgery: a systematic review of the literature.

J Spine Surg 2020 Mar;6(1):302-322

Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA.

The anterior approach to the cervical spine is commonly utilized for a variety of degenerative, traumatic, neoplastic, and infectious indications. While many potential complications overlap with those of the posterior approach, the distinct anatomy of the anterior neck also presents a unique set of hazards. We performed a systematic review of the literature to assess the etiology, presentation, natural history, and management of these complications. Following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), a PubMed search was conducted to evaluate clinical studies and case reports of patients who suffered a complication of anterior cervical spine surgery. The search specifically included articles concerning adult human subjects, written in the English language, and published from 1989 to 2019. The PubMed search yielded 240 articles meeting our criteria. The overall rates of complications were as follows: dysphagia 5.3%, esophageal perforation 0.2%, recurrent laryngeal nerve palsy 1.3%, infection 1.2%, adjacent segment disease 8.1%, pseudarthrosis 2.0%, graft or hardware failure 2.1%, cerebrospinal fluid leak 0.5%, hematoma 1.0%, Horner syndrome 0.4%, C5 palsy 3.0%, vertebral artery injury 0.4%, and new or worsening neurological deficit 0.5%. Morbidity rates in anterior cervical spine surgery are low. Nevertheless, the unique anatomy of the anterior neck presents a wide variety of potential complications involving vascular, aerodigestive, neural, and osseous structures.
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http://dx.doi.org/10.21037/jss.2020.01.14DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7154369PMC
March 2020

A Novel Instrumentation Approach in a Pediatric Patient with Atlanto-Occipital Dislocation and Cervical Fracture: Case Report.

World Neurosurg 2020 Apr 10;136:70-72. Epub 2020 Jan 10.

Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA. Electronic address:

Background: Although instrumented stabilization of pediatric atlanto-occipital dislocation (AOD) has been described in the literature, there is little evidence regarding instrumentation techniques in pediatric patients presenting with both AOD and a cervical fracture. We present a case of a 2-year-old male involved in a motor vehicle collision with an unstable C2 fracture and AOD, treated with an occiput-C4 posterior arthrodesis using a rod, crosslink, and cable construct.

Case Description: This patient suffered a type III C2 fracture and AOD with 4 mm craniocaudal and 3 mm anterior displacement. In the operating room, 2 cobalt chrome connecting rods (3.5 mm) were connected to 1 another with crosslinks at C2 and C4. These were affixed with suboccipital and sublaminar cables at C1, C2, and C4. At 14 months postoperatively, his spine is clinically and radiographically stable. He has spontaneous movement in all 4 extremities, and remains in a persistent vegetative state because of his underlying central nervous system injury.

Conclusions: Although there is a breadth of literature investigating instrumentation approaches to pediatric AOD, there is minimal evidence on outcomes of patients presenting with both AOD and cervical fracture. The technique we describe has proven safe and effective for this patient.
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http://dx.doi.org/10.1016/j.wneu.2020.01.021DOI Listing
April 2020

Pseudohypoxic Brain Swelling After Uncomplicated Lumbar Decompression and Fusion for Spondylolisthesis.

World Neurosurg 2020 Jan 4;133:155-158. Epub 2019 Sep 4.

Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA. Electronic address:

Background: Pseudohypoxic brain swelling (PHBS), also known as postoperative intracranial hypotension-associated venous congestion, is a rare complication after neurosurgery characterized by rapid and often severe postoperative deterioration in consciousness and distinct imaging findings on brain magnetic resonance imaging. Imaging findings associated with PHBS include computed tomography and magnetic resonance imaging findings that resemble hypoxic changes and intracranial hypotensive changes in basal ganglia and thalamus, telencephalic, and infratentorial regions without notable changes in intracranial vasculature.

Case Description: This report describes the case of an L4-5 microdiskectomy with posterior decompression and fusion complicated by clinical and radiographic findings resembling PHBS without a known intraoperative durotomy.

Conclusions: Spine surgeons should be alerted to the possibility that PHBS may occur in patients even after an operation without known durotomy or cerebrospinal fluid leakage and with spontaneous clinical resolution unrelated to suction drainage changes or epidural blood patches.
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http://dx.doi.org/10.1016/j.wneu.2019.07.228DOI Listing
January 2020

Unintended Consequences After Postoperative Ileus in Spinal Fusion Patients.

World Neurosurg 2019 02 25;122:e512-e515. Epub 2018 Oct 25.

Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA. Electronic address:

Background: Postoperative ileus is not uncommon after spinal surgery. Although previous research has focused on the frequency of ileus formation, little has been done to investigate the clinical sequelae after development. We investigated the effect of postoperative ileus on patients' length of stay and rates of deep vein thrombosis (DVT) formation, myocardial infarction (MI), aspiration pneumonia, sepsis, and death.

Methods: The Healthcare Cost and Utilization Project National Inpatient Sample was queried to identify adult patients who underwent any spinal fusion procedure. Patient characteristics and outcomes for discharges involving spinal fusion surgery were compared between patients with and without postoperative ileus. The Rao-Scott χ test of association was used for categorical variables, and a t test for equality of means was used for continuous variables. Among discharges with postoperative ileus, a multivariate linear regression model was used to assess how fusion approach and fusion length were associated with length of hospital stay, controlling for sex, age, and race.

Results: A total of 250,221 patients were included. The mean length of stay was 3.75 days for patients without postoperative ileus and 9.40 days for patients with postoperative ileus. Patients with postoperative ileus are more likely to have DVT (4.1% vs. 20.8%, P < 0.001), MI (2.5% vs. 7.1%, P < 0.001), aspiration pneumonia (6.6% vs. 34.3%, P < 0.001), sepsis (5.7% vs. 35.7%, P < 0.001), and death (2.6% vs. 11.4%, P < 0.001).

Conclusions: This study demonstrates that patients with postoperative ileus are significantly more likely to have DVT, experience MI, acquire aspiration pneumonia, develop sepsis, and die.
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http://dx.doi.org/10.1016/j.wneu.2018.10.093DOI Listing
February 2019

Spinal Intradural Escherichia coli Abscess Masquerading as a Neoplasm in a Pediatric Patient with History of Neonatal E. coli Meningitis: A Case Report and Literature Review.

World Neurosurg 2019 Jun 21;126:619-623. Epub 2019 Mar 21.

Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA. Electronic address:

Background: Central nervous system abscesses frequently can be seen in the immunocompromised population and most commonly consist of intracranial collections in the adult patient. Spinal intradural abscesses are less commonly encountered, and there are even fewer numbers in the pediatric population with a concordant absence of documentation in the published literature.

Case Description: In this case report, we describe the presentation of a 2-year-old boy with a history of perinatal Escherichia coli meningitis at 2.5 months of age who was found to have an intradural spinal lesion, initially concerning for neoplasm, but later confirmed as an E. coli abscess following biopsy. He was managed with surgical aspiration of the abscess and a long course of intravenous antibiotics. The patient was treated with antibiotics with repeat imaging studies that revealed residual abscess that required re-aspiration at a later date.

Conclusions: Here we present an unusual disease process with an unusual disease pathogenesis in a pediatric patient currently residing in a developed country.
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http://dx.doi.org/10.1016/j.wneu.2019.02.243DOI Listing
June 2019

Risk of Pseudoarthrosis After Spinal Fusion: Analysis From the Healthcare Cost and Utilization Project.

World Neurosurg 2018 Dec 13;120:e194-e202. Epub 2018 Aug 13.

Department of Neurological Surgery, Stritch School of Medicine, Loyola University Medical Center, Maywood, Illinois, USA. Electronic address:

Background: Pseudoarthrosis after spinal fusion is an important cause of pain, neurologic decline, and reoperation.

Methods: The Healthcare Cost and Utilization Project State Inpatient Databases were queried in New York, California, Florida, and Washington for adult patients who had undergone new spinal fusion from 2009 to 2011. In accordance with the Healthcare Cost and Utilization Project methods series and analysis guidelines, generalized linear mixed effects models were used to estimate the odds of experiencing postoperative pseudoarthrosis as a function of multivariable patient characteristics, comorbidities, and surgical approach.

Results: Of the 107,420 patients who had undergone cervical fusion, 1295 (1.2%) developed pseudoarthrosis requiring reoperation. On multivariable analysis, the risk factors included posterior (odds ratio [OR], 4.47; 95% confidence interval [CI], 3.92-5.10) and combined (OR, 1.77; 95% CI, 1.33-2.36) approaches, fusion of ≥9 vertebrae (OR, 2.54; 95% CI, 1.38-4.68), smoking (OR, 1.19; 95% CI, 1.05-1.34), and long-term steroid use (OR, 1.89; 95% CI, 1.18-3.00). Of the 148,081 patients who underwent thoracic or lumbar fusion, 2665 (1.8%) developed pseudoarthrosis. Posterior (OR, 0.58; 95% CI, 0.51-0.56) and combined (OR, 0.46; 95% CI, 0.40-0.54) approaches resulted in reduced rates. Fusion of 4-8 vertebrae (OR, 1.52; 95% CI, 1.39-1.67), ≥9 vertebrae (OR, 1.87; 95% CI, 1.49-2.34), hypertension (OR, 1.18; 95% CI, 1.09-1.28), sleep apnea (OR, 1.48; 95% CI, 1.26-1.72), smoking (OR, 1.22; 95% CI, 1.12-1.33), and long-term steroid use (OR, 1.53, 95% CI, 1.08-2.18) resulted in increased rates.

Conclusions: These findings strongly associate several diagnoses with the development of pseudoarthrosis. However, further prospective studies are warranted to establish causation.
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http://dx.doi.org/10.1016/j.wneu.2018.08.026DOI Listing
December 2018

Clival meningocele causing bilateral hearing loss in a child due to superficial siderosis of the central nervous system: case report.

J Neurosurg Pediatr 2018 05 16;21(5):498-503. Epub 2018 Feb 16.

Departments of1Neurological Surgery and.

Superficial siderosis (SS) of the CNS is a rare and often unrecognized condition. Caused by hemosiderin deposition from chronic, repetitive hemorrhage in the subarachnoid space, it results in parenchymal damage in the subpial layers of the brain and spinal cord. T2-weighted MRI shows the characteristic hypointensity of hemosiderin deposition, classically occurring around the cerebellum, brainstem, and spinal cord. Patients present with progressive gait ataxia and sensorineural hearing impairment. Although there have been several studies, case reports, and review articles over the years, the clear pathophysiology of subarachnoid space hemorrhage remains to be elucidated. The proposed causes include prior intradural surgery, prior trauma, tumors, vascular abnormalities, nerve root avulsion, and dural abnormalities. Surgical repair of a dural defect associated with SS has been shown to be efficacious at preventing symptomatic progression. There have been several reports of dural defects within the spinal canal treated with surgery. Here, the authors present the first known case of a dural defect of the ventral skull base, namely a clival meningocele, presumed to be causing SS. In this case report, a 10-year-old girl with a history of head trauma at the age of 3 years was found to have a clival meningocele 3 years after her original trauma. On follow-up imaging, the patient was found to have radiographic growth of the meningocele along with evidence of SS of the CNS. The patient was treated conservatively until she began to have progressive hearing loss. It was presumed that the growing meningocele was the source of her SS. An endoscopic endonasal transclival approach with a multilayer dural reconstruction was performed to fix the dural defect and repair the meningocele in hopes of mitigating the progression of her symptoms. At her 12-month postoperative follow-up, she was doing well, with audiometry showing a slightly decreased hearing threshold in the left ear but improved speech discrimination bilaterally. Postoperative MRI showed a stable level of hemosiderin deposition and meningocele repair. Long-term follow-up will be necessary to evaluate for continued clinical stabilization or possible improvement.
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http://dx.doi.org/10.3171/2017.11.PEDS17302DOI Listing
May 2018

Surgical Results of Common Peroneal Nerve Neuroplasty at Lateral Fibular Neck.

World Neurosurg 2018 Apr 31;112:e465-e472. Epub 2018 Jan 31.

Department of Neurological Surgery, Loyola University Medical Center - Stritch School of Medicine, Maywood, Illinois, USA. Electronic address:

Background: Common peroneal nerve (CPN) compressive neuropathy is the most common lower-extremity entrapment neuropathy.

Materials And Methods: A retrospective review of a prospectively maintained single-institution database of all patients with CPN palsy who underwent decompression and neuroplasty over a 5-year period was performed.

Results: Thirty patients underwent a neuroplasty of the CPN over a 5-year period (2010-2015) at our institution. The median age was 45 years, and there was a male preponderance. The average time between first onset of symptoms to surgery was 122.9 weeks and between first clinic visit and surgery was 21 weeks. The etiology of the CPN neuropathy was as follows: in 12 patients, it followed a surgical procedure and in 14 patients, it occurred after a trauma to the lower extremity. In 2 patients, it occurred as a result of a mass lesion compromising the nerve and in 1 patient, a local infection predisposed to CPN palsy. Right and left lower extremities were equally involved. The median body mass index was 28.6. The most common presentation was weakness of the tibialis anterior (TA) and extensor hallucis longus (EHL) and loss of sensation in the distribution of the CPN or one of its major branches. Pain was a presenting symptom in 16 patients. Only 12 of the 30 patients had a positive Tinel's sign at the site of compression over the lateral fibular neck. Preoperative electrophysiologic confirmation of CPN neuropathy was available in all patients. Mean follow-up was 52 weeks. Prone positioning and selective use of the operating microscope provided excellent visualization and surgical exposure of the CPN from the lower popliteal region to the peroneal tunnel. Average operating room time was 170 minutes and average skin-to-skin time 91 minutes. Clinical improvement after surgery in terms of motor function was noted in 24 of the 26 patients who presented with a motor deficit. The most consistent improvement was noted in the TA and EHL; a trend toward greater improvement with shorter time to surgery was noted. No complications related to the surgical site or CPN were encountered, and no patient had a decline in their neurologic examination as a consequence of the surgery. One patient developed a positioning-related right upper-extremity brachial plexus neuropraxic injury after surgery that recovered completely.

Conclusions: Common peroneal neuropathy usually presents with weakness of the TA and EHL and decreased sensation or pain in the distribution of the CPN. Microscope-assisted surgical neuroplasty of the CPN at the lateral fibular neck with the patient in a prone position allows decompression of the nerve from the lower popliteal region to the peroneal tunnel. Significant improvement in motor strength after surgery, particularly of the TA and EHL, was observed in this series.
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http://dx.doi.org/10.1016/j.wneu.2018.01.061DOI Listing
April 2018

Antibiotic prophylaxis and infection prevention for endoscopic endonasal skull base surgery: Our protocol, results, and review of the literature.

J Clin Neurosci 2018 Jan 21;47:249-253. Epub 2017 Oct 21.

Department of Neurological Surgery, Loyola University Medical Center, Maywood, IL, USA. Electronic address:

Endoscopic endonasal approaches to the skull base provide minimally invasive corridors to intracranial lesions; however, enthusiasm for this new approach is always tempered by the recognition that this route requires passage through a nonsterile sinonasal corridor. Despite an increasing number of patients undergoing these surgeries, there remains no consensus on the use of perioperative antibiotics. A retrospective review of consecutive patients undergoing endoscopic endonasal skull base surgery (EESBS) at Loyola University Medical Center by the same neurosurgeon and otolaryngologist team between February 2015 and October 2016 was performed. Antibiotic regimens, presence of an intraoperative or postoperative cerebrospinal fluid (CSF) leak, dural reconstruction method, and rates of sinusitis, meningitis, and/or intracranial abscess were analyzed. 39 patients who underwent a total of 41 EESBSs with a mean age of 46 years were identified. A vascularized nasoseptal flap was used for dural reconstruction when high flow CSF leaks were encountered intraoperatively (n = 17); otherwise, reconstruction mostly consisted of allografts and/or free mucosal grafts. There were zero postoperative cases of CSF leaks, meningitis, or intracranial infection. Our current antibiotic prophylaxis protocol coupled with the use of variable dural reconstruction techniques dictated by intraoperative findings has led to low rates of postoperative CSF leaks, intracranial infections, and meningitis. A survey was also distributed to Neurological Surgery Residency Programs to gain a better understanding of the EESBS protocols that are being used nationally. The practice of antibiotic prophylaxis for patients undergoing EESBS is quite variable and this study should provide the impetus for multi-institutional comparison studies.
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http://dx.doi.org/10.1016/j.jocn.2017.10.036DOI Listing
January 2018

Publication Metrics in Neurosurgery.

World Neurosurg 2017 09 20;105:993-996. Epub 2017 Jun 20.

Library, Health Sciences Division, Loyola University, Chicago, Illinois, USA.

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http://dx.doi.org/10.1016/j.wneu.2017.06.081DOI Listing
September 2017

A Stepwise Approach: Decreasing Infection in Deep Brain Stimulation for Childhood Dystonic Cerebral Palsy.

J Child Neurol 2017 Sep 12;32(10):871-875. Epub 2017 Jun 12.

1 Department of Neurological Surgery, Loyola University Medical Center, Maywood, IL, USA.

Dystonia is a movement disorder characterized by involuntary muscle contractions, which cause twisting movements or abnormal postures. Deep brain stimulation has been used to improve the quality of life for secondary dystonia caused by cerebral palsy. Despite being a viable treatment option for childhood dystonic cerebral palsy, deep brain stimulation is associated with a high rate of infection in children. The authors present a small series of patients with dystonic cerebral palsy who underwent a stepwise approach for bilateral globus pallidus interna deep brain stimulation placement in order to decrease the rate of infection. Four children with dystonic cerebral palsy who underwent a total of 13 surgical procedures (electrode and battery placement) were identified via a retrospective review. There were zero postoperative infections. Using a multistaged surgical plan for pediatric patients with dystonic cerebral palsy undergoing deep brain stimulation may help to reduce the risk of infection.
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http://dx.doi.org/10.1177/0883073817713900DOI Listing
September 2017
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