Publications by authors named "Michael Karsy"

137 Publications

Work relative value units and perioperative outcomes in patients undergoing brain tumor surgery.

Neurosurg Rev 2021 Jul 8. Epub 2021 Jul 8.

Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 North Medical Drive East, Salt Lake City, UT, 84132, USA.

The work relative value unit (wRVU) is a commonly cited surrogate for surgical complexity; however, it is highly susceptible to subjective interpretation and external forces. Our objective was to evaluate whether wRVU is associated with perioperative outcomes, including complications, after brain tumor surgery. The 2006-2014 American College of Surgeons National Surgical Quality Improvement Program database was queried to identify patients ≥ 18 years who underwent brain tumor resection. Patients were categorized into approximate quintiles based on total wRVU. The relationship between wRVU and several perioperative outcomes was assessed with univariate and multivariate analyses. Subgroup analyses were performed using a Current Procedural Terminology code common to all wRVU groups. The 16,884 patients were categorized into wRVU ranges 0-30.83 (4664 patients), 30.84-34.58 (2548 patients), 34.59-38.04 (3147 patients), 38.05-45.38 (3173 patients), and ≥ 45.39 (3352 patients). In multivariate logistic regression analysis, increasing wRVU did not predict more 30-day postoperative complications, except respiratory complications and need for blood transfusion. Linear regression analysis showed that wRVU was poorly correlated with operative duration and length of stay. On multivariate analysis of the craniectomy subgroup, wRVU was not associated with overall or respiratory complications. The highest wRVU group was still associated with greater risk of requiring blood transfusion (OR 3.01, p < 0.001). Increasing wRVU generally did not correlate with 30 days postoperative complications in patients undergoing any surgery for brain tumor resection; however, the highest wRVU groups may be associated with greater risk of respiratory complications and need for transfusion. These finding suggests that wRVU may be a poor surrogate for case complexity.
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http://dx.doi.org/10.1007/s10143-021-01601-6DOI Listing
July 2021

Prediction of Readmission and Complications After Pituitary Adenoma Resection via the National Surgical Quality Improvement Program (NSQIP) Database.

Cureus 2021 May 2;13(5):e14809. Epub 2021 May 2.

Neurological Surgery, University of Utah, Salt Lake City, USA.

Introduction Pituitary adenomas are common intracranial tumors (incidence 4:100,000 people) with good surgical outcomes; however, a subset of patients show higher rates of perioperative morbidity. Our goal was to identify risk factors for postoperative complications or readmission after pituitary adenoma resection. Methods We undertook a retrospective cohort study of patients who underwent surgery for pituitary adenoma in 2006-2018 by using the National Surgical Quality Improvement Program database. The main outcome measures were patient complications and the 30-day readmission rate. Results Among the 2,292 patients (mean age 53.3±15.9 years), there were 491 complications in 188 patients (8.2%). Complications and 30-day readmission have remained stable over time rather than declined. Unplanned readmission was seen in 141 patients (6.2%). Multivariable analysis demonstrated that hypertension (OR=1.6; 95% CI= 1.1, 2.1; p=0.005) and high white blood cell count (OR=1.08; 95% CI=1.03, 1.1; p=0.0001) were independent predictors of complications. Return to the operating room (OR=5.9, 95% CI=1.7, 20.2, p=0.0005); complications (OR=4.1, 95% CI=1.6, 10.6, p=0.004); and blood urea nitrogen (OR=1.08, 95% CI=1.02, 1.2, p=0.02) were independent predictors of 30-day readmission. Conclusion Using one of the largest datasets of pituitary adenoma patients, we identified perioperative factors most critical for patient outcome. One strength of this study is adjusting for cofactors that predict outcomes, which has not been done previously. Several patient biomarkers, namely white blood cell count and blood urea nitrogen, may serve as preoperative markers that might identify patients at higher risk. Control of blood pressure and renal disease may be perioperative management strategies that can impact the outcome.
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http://dx.doi.org/10.7759/cureus.14809DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8191857PMC
May 2021

Use of a Surgical Stepdown Protocol for Cost Reduction After Transsphenoidal Pituitary Adenoma Resection: A Case Series.

World Neurosurg 2021 Aug 16;152:e476-e483. Epub 2021 Jun 16.

Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA. Electronic address:

Objective: No established standard of care currently exists for the postoperative management of patients with surgically resected pituitary adenomas. Our objective was to quantify the efficacy of a postoperative stepdown unit protocol for reducing patient cost.

Methods: In 2018-2020, consecutive patients undergoing transsphenoidal microsurgical resection of sellar lesions were managed postoperatively in the full intensive care unit (ICU) or an ICU-based surgical stepdown unit based on preset criteria. Demographic variables, surgical outcomes, and patient costs were evaluated.

Results: Fifty-four patients (27 stepdown, 27 full ICU; no difference in age or sex) were identified. Stepdown patients were also compared with 634 historical control patients. The total hospital length of stay was no different among stepdown, ICU, and historical patients (4.8 ± 1.0 vs. 5.9 ± 2.8 vs. 4.4 ± 4.3 days, respectively, P = 0.1). Overall costs were 12.5% less for stepdown patients (P = 0.01), a difference mainly driven by reduced facility utilization costs of -8.9% (P = 0.02). The morbidity and complication rates were similar in the stepdown and full ICU groups. Extrapolation of findings to historical patients suggested that ∼$225,000 could have been saved from 2011 to 2016.

Conclusions: These results suggest that use of a postoperative stepdown unit could result in a 12.5% savings for eligible patients undergoing treatment of pituitary tumors by shifting patients to a less acute unit without worsened surgical outcomes. Historical controls indicate that over half of all pituitary patients would be eligible. Further refinement of patient selection for less costly perioperative management may reduce cost burden for the health care system and patients.
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http://dx.doi.org/10.1016/j.wneu.2021.05.126DOI Listing
August 2021

Impact of Hospital Volume on Outcome After Surgical Treatment for Hydrocephalus: A U.S. Population Study From the National Inpatient Sample.

Cureus 2021 Feb 28;13(2):e13617. Epub 2021 Feb 28.

Department of Neurosurgery, University of Utah, Salt Lake City, USA.

Introduction Hydrocephalus remains a common condition with significant patient morbidity; however, accurate accounting of the incidence of this disease as well as of the impact of hospital volume on outcome remains limited. Methods The National Inpatient Sample was used to evaluate patients who underwent surgical treatment of hydrocephalus from 2009-2013. Patient demographics (e.g., length of stay, disposition, charges), and the impact of hospital volume on outcomes were evaluated. Results A total of 156,205 patients were identified. Ventriculoperitoneal (VP) shunting the most common type of device (35.8%) followed by shunt replacement (23.9%). Treatment charges for hydrocephalus were $332 million in 2009 and $418 million in 2013 nationally. High-volume hospitals had more routine discharges compared with lower-volume hospitals (65.7% vs. 50.9%, p<0.0001), which was a trend that improved over time. Multivariate analysis confirmed that hospital volume was independently associated with routine disposition after adjusting for other factors such as patient age, length of stay, and shunt type. However, hospital volume showed a small association with length of stay (β = -0.05, p = 0.0001) and did not impact hospital charges on multivariate analysis. Conclusion This analysis provides a recent update of hydrocephalus epidemiology, trends, and outcomes nationally. Estimates from this study suggest that hydrocephalus is a common and costly problem. Hospital volume was for the first time to be associated with important differences in patient outcomes.
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http://dx.doi.org/10.7759/cureus.13617DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8009768PMC
February 2021

Granulomatosis with polyangiitis masquerading as pituitary adenoma with apoplexy.

Mod Rheumatol Case Rep 2021 Jul 15;5(2):342-346. Epub 2021 Apr 15.

Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.

Granulomatosis with polyangiitis (GPA), formerly known as Wegener's granulomatosis, is a small- and medium-vessel autoimmune vasculitis. Rare presentations of GPA can manifest as ophthalmologic and endocrinological deficits with sellar enhancement on imaging. While GPA typically presents distinct in appearance from other sellar pathologies, such as pituitary adenoma, we report the case of a 41-year-old woman with GPA of the pituitary that was initially diagnosed as pituitary macroadenoma with apoplexy and treated with two surgical resections without improvement of clinical symptoms. Pathology analysis of the second resection specimen revealed an inflammatory process consistent with GPA. After the pathologic and clinical diagnosis of GPA was established, treatment with steroid and steroid-sparing immunosuppressants resulted in improvements both on imaging and symptomatically. We discuss important aspects of the diagnosis and treatment of this rare presentation of GPA.
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http://dx.doi.org/10.1080/24725625.2021.1909222DOI Listing
July 2021

Glioma Stem Cells as Immunotherapeutic Targets: Advancements and Challenges.

Front Oncol 2021 24;11:615704. Epub 2021 Feb 24.

Ben & Catherine Ivy Center for Advanced Brain Tumor Treatment, Swedish Neuroscience Institute, Seattle, WA, United States.

Glioblastoma is the most common and lethal primary brain malignancy. Despite major investments in research into glioblastoma biology and drug development, treatment remains limited and survival has not substantially improved beyond 1-2 years. Cancer stem cells (CSC) or glioma stem cells (GSC) refer to a population of tumor originating cells capable of self-renewal and differentiation. While controversial and challenging to study, evidence suggests that GCSs may result in glioblastoma tumor recurrence and resistance to treatment. Multiple treatment strategies have been suggested at targeting GCSs, including immunotherapy, posttranscriptional regulation, modulation of the tumor microenvironment, and epigenetic modulation. In this review, we discuss recent advances in glioblastoma treatment specifically focused on targeting of GCSs as well as their potential integration into current clinical pathways and trials.
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http://dx.doi.org/10.3389/fonc.2021.615704DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7945033PMC
February 2021

Developmentally anomalous cerebellar encephalocele arising within the cerebellopontine angle and extending into the adjacent skull base in a pediatric patient.

Childs Nerv Syst 2021 Feb 10. Epub 2021 Feb 10.

Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Utah, 100 N. Mario Capecchi Drive, Salt Lake City, UT, 84113, USA.

Lesions of the cerebellopontine angle (CPA) in young children are rare, with the most common being arachnoid cysts and epidermoid inclusion cysts. The authors report a case of an encephalocele containing heterotopic cerebellar tissue arising from the right middle cerebellar peduncle and filling the right internal acoustic canal in a 2-year-old female patient. Her initial presentation included a focal left 6th nerve palsy. Magnetic resonance imaging was suggestive of a high-grade tumor of the right CPA. The lesion was removed via a retrosigmoid approach, and histopathologic analysis revealed heterotopic atrophic cerebellar tissue. This report is the first description of a heterotopic cerebellar encephalocele within the CPA and temporal skull base of a pediatric patient.
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http://dx.doi.org/10.1007/s00381-020-05020-8DOI Listing
February 2021

Higher Admission D-Dimer Values Are Associated With an Increased Risk of Nonroutine Discharge in Neurosurgery Patients.

Cureus 2020 Jul 27;12(7):e9425. Epub 2020 Jul 27.

Neurosurgery, University of Utah, Salt Lake City, USA.

Background D-dimers are serum acute-phase proteins with a role in mediating inflammation that may be used as biomarkers for the prediction of deep vein thrombosis. Recent studies have shown that D-dimers can be used to predict prognosis and stratify risk in neurosurgical patients; however, a comparative analysis across diagnostic subtypes has yet to be performed. Methods A bioinformatics analysis evaluated neurosurgical patients with admission D-dimer levels between 2008 and 2017. Nonroutine disposition (e.g., skilled nursing facility, rehabilitation, other hospital, mortality) was primarily evaluated. Results A total of 1,854 patients (mean age 55.1±18.2 years, 55.4% male; mean admission D-dimer 4.83±7.78 μg/ml) were identified. Patient diagnoses included vascular (27.1%), trauma (16.4%), multiple diagnoses (15.7%), spine (15.6%), tumor (13.0%), and other (12.2%) causes. Univariate analysis showed that older age (p=0.0001), higher American Society of Anesthesiologists (ASA) score (p=0.0001), lower Glasgow Coma Scale (GCS) score (p=0.0001), diagnosis type (p=0.0001), longer length of stay (LOS) (p=0.0001), higher infection rate (p=0.0001), surgery in the past year (p=0.02), and higher D-dimer levels (3.4±4.9 vs. 5.4±8.7 μg/ml, p=0.0001) were associated with nonroutine disposition. Multivariate logistic regression showed that elevated D-dimers were independently associated with a greater relative risk of nonroutine disposition (relative risk [RR] 1.026, 95% CI 1.02-1.033, p=0.0001). Conclusions Elevated admission D-dimer values were independently associated with a 3% increased risk of nonroutine disposition per D-dimer unit after accounting for other factors. These results suggest that D-dimer values may help in stratifying patient risk models despite clinical heterogeneity. Further refinement of neurosurgical patient risk models using clinical variables and biomarkers may aid in resource allocation and early warning.
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http://dx.doi.org/10.7759/cureus.9425DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7450899PMC
July 2020

Surgical Management of Multifocal Trigeminal Schwannomas.

Oper Neurosurg (Hagerstown) 2020 Jul 27. Epub 2020 Jul 27.

Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah.

Background: Isolated trigeminal schwannomas occur in 0.07% to 0.3% of intracranial tumors and account for 0.8% to 8% of intracranial schwannomas and 1/3 of Meckel cave tumors. The presence of multisegmental schwannoma is rare, resulting in a limited understanding of its optimal management.

Objective: To describe potential surgical options to manage this rare entity.

Methods: A 2-institution retrospective review of all patients with pathologically confirmed trigeminal schwannoma managed with resection from January 2009 through January 2019 was conducted. A manual chart review was performed to verify patients' inclusion and collect data about age, sex, tumor size, tumor site, treatment modality, surgical approach, complications, and follow-up duration and status.

Results: A total of 4 patients (age range 12-50 yr) who underwent a variety of cranial and orbitocranial approaches for tumor resection were identified. Patients achieved good outcomes with improvement of visual outcomes. One case of infection and 1 case of partial tumor recurrence requiring reresection were identified.

Conclusion: Multisegmental trigeminal schwannoma is a rare and unique entity, often associated with trigeminal schwannomatosis. Interdisciplinary management has been shown to be the most effective method for improving patient outcomes with these complex and poorly understood diseases.
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http://dx.doi.org/10.1093/ons/opaa227DOI Listing
July 2020

Reduced 2-year aneurysm retreatment and costs among patients treated with flow diversion versus non-flow diversion embolization: A Premier Healthcare Database retrospective cohort study.

PLoS One 2020 18;15(6):e0234478. Epub 2020 Jun 18.

Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut, United States of America.

Introduction: The use of endovascular treatments, including Pipeline embolization devices (PEDs) and coiling approaches (non-PEDs), has played an increasingly important role in the treatment of intracranial aneurysms. Despite multiple studies evaluating PEDs, a real-world evaluation of follow-up outcomes and costs remains to be completed.

Methods: The Premier Healthcare Database (PHD), 2010-2017, was queried to identify patients with unruptured intracranial aneurysms treated endovascularly. Rates of readmission, retreatment, and cost at the same hospital were compared between patients who underwent PED and non-PED endovascular treatments of their aneurysms. One-to-three (PED-to-non-PED) propensity score (PS) matching was performed to adjust for potential case selection bias into the PED cohort, with covariates including age group, sex, Charlson Comorbidity Index (CCI) group, payor, region, and randomized hospital identifier.

Results: A total of 679 patients underwent PED placement and 8432 had non-PED treatments. Prior to PS matching, there were significant but minor differences in age (56.7±12.8 vs. 58.2±12.6 years, p = 0.004) and sex (male 16.6% vs. 24.4%, p<0.0001) for PED and non-PED, respectively, but no differences in CCI (p = 0.08), length of stay (p = 0.88), or rate of routine discharge (p = 0.21). All-cause readmission/emergency department reevaluation rates in the two cohorts were similar at 30, 90, and 180 days and 1 and 2 years. Our results identified a significantly lower retreatment rate for PEDs at all follow-up time points over a 2-year period (range: 0.9-8.1%) compared with non-PED treatments (range: 1.7-11.6%). These findings remained consistent after PS matching: all-cause readmission/reevaluation rates were significantly lower in patients treated with PED at 90 days, 180 days, 1 year, and 2 years (p<0.001). Although the initial treatment costs were higher for PED at time of treatment (p<0.001), cumulative follow-up emergency department visit and readmission costs (inclusive of patients with no readmission and/or no retreatment) were significantly lower for patients with initial PED relative to non-PED treatment at 2 years (p = 0.021).

Conclusions: These results suggest that PEDs may potentially reduce downstream retreatment rates and costs. Further work is required to improve identification of patient subgroups that could benefit from PED over non-PED treatments both initially and during follow-up.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0234478PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7302520PMC
August 2020

Hemorrhagic Fibrous Dysplasia with Acute Neurological Decline: Case Report and Review of the Literature.

World Neurosurg 2020 08 11;140:71-75. Epub 2020 May 11.

Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA.

Background: Fibrous dysplasia is a rare, benign fibro-osseous malformation whose occurrence in the craniofacial area can result in optic nerve compression, a cerebral mass effect, and cosmetic deformity. Most lesions will progress slowly, and the risk of malignant progression is rare.

Case Description: We present the case of a 21-year-old woman who had presented with acute worsening visual loss secondary to hemorrhagic fibrous dysplasia with ensuing optic nerve compression. Emergent surgical decompression resulted in rapid improvement of her visual dysfunction. The pathological features demonstrated a mixed pattern of woven bone in a fibrous background and secondary aneurysmal bone cyst-like changes.

Conclusions: Hemorrhagic transformation of craniofacial FD remains rare but can present with acute neurologic deterioration. Rapid diagnosis and treatment can allow reversal of patient morbidity. We have also included Supplementary Video 1 to illustrate the surgical principles, and we review the reported data of similar cases.
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http://dx.doi.org/10.1016/j.wneu.2020.04.249DOI Listing
August 2020

Prolonged Length of Stay and Risk of Unplanned 30-Day Readmission After Elective Spine Surgery: Propensity Score-Matched Analysis of 33,840 Patients.

Spine (Phila Pa 1976) 2020 Sep;45(18):1260-1268

Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah.

Study Design: Retrospective database study.

Objective: To assess the association between prolonged length of hospital stay (pLOS) (≥4 d) and unplanned readmission in patients undergoing elective spine surgery by controlling the clinical and statistical confounders.

Summary Of Background Data: pLOS has previously been cited as a risk factor for unplanned hospital readmission. This potentially modifiable risk factor has not been distinguished as an independent risk factor in a large-scale, multi-institutional, risk-adjusted study.

Methods: Data were collected from the American College of Surgeons National Surgical Quality Improvement Program database. A retrospective propensity score-matched analysis was used to reduce baseline differences between the cohorts. Univariate and multivariate analyses were performed to assess the degree of association between pLOS and unplanned readmission.

Results: From the 99,575 patients that fit the inclusion criteria, propensity score matching yielded 16,920 well-matched pairs (mean standard propensity score difference = 0.017). The overall 30-day unplanned readmission rate of these 33,840 patients was 5.5%. The mean length of stay was 2.0 ± 0.9 days and 6.0 ± 4.5 days (P ≤ 0.001) for the control and pLOS groups, respectively. In our univariate analysis, pLOS was associated with postoperative complications, especially medical complications (22.7% vs. 8.3%, P < 0.001). Multivariate analysis of the propensity score-matched population, which adjusted identified confounders (P < 0.02 and ≥10 occurrences), showed pLOS was associated with an increased risk of 30-day unplanned readmission (odds ratio [OR] 1.423, 95% confidence interval [CI] 1.290-1.570, P < 0.001).

Conclusion: Patients who undergo elective spine procedures who have any-cause pLOS (≥4 d) are at greater risk of having unplanned 30-day readmission compared with patients with shorter hospital stays.

Level Of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000003520DOI Listing
September 2020

A Survey of Applicant Views Regarding the Neurosurgical Fellowship Application Process.

World Neurosurg 2020 07 17;139:e373-e382. Epub 2020 Apr 17.

Department of Neurosurgery, Louisiana State University, Shreveport, Louisiana, USA.

Objective: The process of fellowship selection remains unclear and heterogeneous among subspecialties in neurosurgery. We surveyed neurosurgical residents applying for subspecialty fellowships about their experiences to evaluate the process and find areas for improvement.

Methods: We distributed an online, nationwide survey to 153 U.S. neurosurgical residents (postgraduate years 5-7) identified via the American Association of Neurological Surgeons resident database.

Results: Sixty-nine residents responded to the survey, representing a variety of subspecialties. Most residents applied for 2-5 programs (45%) and completed 2-5 interviews (45%). The primary methods of finding fellowships were via word of mouth (68%) and faculty mentors (67%), followed by Web sites and reaching out to fellowship directors (54%) and online database searching (46%). Although many residents applied for fellowships in postgraduate year 5 of training (39%), there was significant variability in times for interviews and offer letters. Most residents accepted their first offer (75%). Most respondents (93%) believed that national neurosurgical societies should help improve the fellowship application process, with reasons including a common application and due dates (29%), fellowship database with program details (29%), and improved coordination of interviews (23%). Regarding a nationalized match system, residents were roughly split among opposed (38.6%), neutral (26.3%), and supportive (35.1%).

Conclusions: These survey results suggested that the neurosurgical fellowship application process could be improved by a common application, public listing of programs, standardized dates for application, and improved coordination of interviews. Residents are generally supportive of having an improved organization of the match and/or a national fellowship match.
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http://dx.doi.org/10.1016/j.wneu.2020.03.224DOI Listing
July 2020

Stereotactic laser interstitial thermal therapy for brainstem cavernous malformations: two preliminary cases.

Acta Neurochir (Wien) 2020 07 12;162(7):1771-1775. Epub 2020 Apr 12.

Department of Neurosurgery, Clinical Neurosciences Center, 175 North Medical Drive East, Salt Lake City, UT, 84132, USA.

Brainstem cavernous malformations (CMs) often have high hemorrhage rates and significant posthemorrhage morbidity. The authors present two cases in which magnetic resonance thermography-guided laser interstitial therapy was used for treatment of pontine CMs after recurrent hemorrhage. Both patients showed significant symptomatic improvement and were hemorrhage-free at 12- and 6-month follow-up, respectively. Each had radiographic evidence of lesion involution on serial follow-up imaging. These early results demonstrate this treatment modality may be technically safe; however, larger case numbers and longer follow-up are needed to demonstrate efficacy.
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http://dx.doi.org/10.1007/s00701-020-04316-7DOI Listing
July 2020

Cranio-Orbital and Orbitocranial Approaches to Orbital and Intracranial Disease: Eye-Opening Approaches for Neurosurgeons.

Front Surg 2020 7;7. Epub 2020 Feb 7.

Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, United States.

Orbital approaches for targeting intracranial, orbital, and infratemporal disease have evolved over the years in an effort to discover safe, reliable, effective, and cosmetically satisfying surgical corridors. The surgical goals of these approaches balance important factors such as proximity of the lesion to the optic nerve, the degree of anticipated manipulation and required space for surgical maneuverability, and the type of disease. The authors provide a comprehensive review of the most commonly used periorbital approaches in the management of intra- and extracranial disease, with emphasis on the advantages and limitations of each approach.
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http://dx.doi.org/10.3389/fsurg.2020.00001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7025513PMC
February 2020

Outcomes and Complications With Age in Spondylolisthesis: An Evaluation of the Elderly From the Quality Outcomes Database.

Spine (Phila Pa 1976) 2020 Jul;45(14):1000-1008

Department of Neurological Surgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT.

Study Design: Prospective database analysis.

Objective: To assess the effect of age on patient-reported outcomes (PROs) and complication rates after surgical treatment for spondylolisthesis SUMMARY OF BACKGROUND DATA.: Degenerative lumbar spondylolisthesis affects 3% to 20% of the population and up to 30% of the elderly. There is not yet consensus on whether age is a contraindication for surgical treatment of elderly patients.

Methods: The Quality Outcomes Database lumbar registry was used to evaluate patients from 12 US academic and private centers who underwent surgical treatment for grade 1 lumbar spondylolisthesis between July 2014 and June 2016.

Results: A total of 608 patients who fit the inclusion criteria were categorized by age into the following groups: less than 60 (n = 239), 60 to 70 (n = 209), 71 to 80 (n = 128), and more than 80 (n = 32) years. Older patients showed lower mean body mass index (P < 0.001) and higher rates of diabetes (P = 0.007), coronary artery disease (P = 0.0001), and osteoporosis (P = 0.005). A lower likelihood for home disposition was seen with higher age (89.1% in <60-year-old vs. 75% in >80-year-old patients; P = 0.002). There were no baseline differences in PROs (Oswestry Disability Index, EuroQol health survey [EQ-5D], Numeric Rating Scale for leg pain and back pain) among age categories. A significant improvement for all PROs was seen regardless of age (P < 0.05), and most patients met minimal clinically important differences (MCIDs) for improvement in postoperative PROs. No differences in hospital readmissions or reoperations were seen among age groups (P < 0.05). Multivariate analysis demonstrated that, after controlling other variables, a higher age did not decrease the odds of achieving MCID at 12 months for the PROs.

Conclusion: Our results indicate that well-selected elderly patients undergoing surgical treatment of grade 1 spondylolisthesis can achieve meaningful outcomes. This modern, multicenter US study reflects the current use and limitations of spondylolisthesis treatment in the elderly, which may be informative to patients and providers.

Level Of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000003441DOI Listing
July 2020

Internal Auditory Canal Variability: Anatomic Variation Affects Cisternal Facial Nerve Visualization.

Oper Neurosurg (Hagerstown) 2020 09;19(3):E251-E258

Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah.

Background: The internal auditory canal (IAC) is an important landmark during surgery for lesions of the cerebellopontine angle. There is significant variability in the position and orientation of the IAC radiographically, and the authors have noted differences in surgical exposure depending on the individual anatomy of the IAC.

Objective: To test the hypothesis that IAC position and orientation affects the surgical exposure of the IAC and facial nerve, especially when performing the translabyrinthine approach.

Methods: The authors retrospectively reviewed magnetic resonance imaging studies of 50 randomly selected patients with pathologically confirmed vestibular schwannomas. Measurements, including the anterior (APD) and posterior (PPD) petrous distances, the anterior (APA) and posterior (PPA) petro-auditory angles, and the internal auditory angle (IAA), were obtained to quantify the position and orientation of the IAC within the petrous temporal bone.

Results: The results quantitatively demonstrate tremendous variability of the position and orientation of the IAC in the petrous temporal bone. The measurement ranges were APD 10.2 to 26.1 mm, PPD 15.1 to 37.2 mm, APA 104 to 157°, PPA 30 to 96°, and IAA -5 to 40°.

Conclusion: IAC variability can have a substantial effect on the surgical exposure of the IAC and facial and vestibulocochlear nerves. Specifically, a horizontally oriented IAC with a small IAA may have significant impact on visualization of the facial nerve within its cisternal segment with the translabyrinthine approach. The retrosigmoid approach is less affected with IAC variability in position and angle.
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http://dx.doi.org/10.1093/ons/opz410DOI Listing
September 2020

Liquid biopsies for the diagnosis and surveillance of primary pediatric central nervous system tumors: a review for practicing neurosurgeons.

Neurosurg Focus 2020 01;48(1):E8

2Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah.

Objective: Primary brain tumors are the most common cause of cancer-related deaths in children and pose difficult questions for the treating physician regarding issues such as the risk/benefit of performing a biopsy, the accuracy of monitoring methods, and the availability of prognostic indicators. It has been recently shown that tumor-specific DNA and proteins can be successfully isolated in liquid biopsies, and it may be possible to exploit this potential as a particularly useful tool for the clinician in addressing these issues.

Methods: A review of the current literature was conducted by searching PubMed and Scopus. MeSH terms for the search included "liquid biopsy," "brain," "tumor," and "pediatrics" in all fields. Articles were reviewed to identify the type of brain tumor involved, the method of tumor DNA/protein analysis, and the potential clinical utility. All articles involving primary studies of pediatric brain tumors were included, but reviews were excluded.

Results: The successful isolation of circulating tumor DNA (ctDNA), extracellular vesicles, and tumor-specific proteins from liquid biopsies has been consistently demonstrated. This most commonly occurs through CSF analysis, but it has also been successfully demonstrated using plasma and urine samples. Tumor-related gene mutations and alterations in protein expression are identifiable and, in some cases, have been correlated to specific neoplasms. The quantity of ctDNA isolated also appears to have a direct relationship with tumor progression and response to treatment.

Conclusions: The use of liquid biopsies for the diagnosis and monitoring of primary pediatric brain tumors is a foreseeable possibility, as the requisite developmental steps have largely been demonstrated. Increasingly advanced molecular methods are being developed to improve the identification of tumor subtypes and tumor grades, and they may offer a method for monitoring treatment response. These minimally invasive markers will likely be used in the clinical treatment of pediatric brain tumors in the future.
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http://dx.doi.org/10.3171/2019.9.FOCUS19712DOI Listing
January 2020

A Case of Ventral Spinal Cord Herniation from a Chronic Dural-pleural Fistula Resulting in Thoracic Myelopathy.

Cureus 2019 Nov 11;11(11):e6123. Epub 2019 Nov 11.

Neurological Surgery, University of Utah School of Medicine, Salt Lake City, USA.

Formation of a dural-pleural fistula is uncommon after anterior thoracic spine surgery, tumor, or trauma. The goal of surgical management is to terminate the connection between the pleura and subarachnoid space. We describe a case of chronic dural-pleural fistula in a 70-year-old woman and present a unique surgical treatment option. The patient presented 25 years after an anterior thoracic surgery she had undergone for a thoracic disc herniation, with a dural-pleural fistula and ventral herniation of the spinal cord into the defect. She was treated with a bovine pericardium sling patch to cover the defect. This case highlights the identification of a chronic thoracic dural-pleural fistula and surgical treatment with double intradural and extradural layering of bovine pericardium sling patch, which has not been described previously for chronic thoracic dural-pleural fistula.
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http://dx.doi.org/10.7759/cureus.6123DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6903874PMC
November 2019

Evaluation of disease severity and treatment intensity as cost drivers for ruptured intracranial aneurysms.

Acta Neurochir (Wien) 2020 01 6;162(1):157-167. Epub 2019 Dec 6.

Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA.

Background: Previous studies have not evaluated the impact of illness severity and postrupture procedures in the cost of care for intracranial aneurysms. We hypothesize that the severity of aneurysm rupture and the aggressiveness of postrupture interventions play a role in cost.

Methods: The Value Driven Outcomes database was used to assess direct patient cost during the treatment of ruptured intracranial aneurysm with clipping, coiling, and Pipeline flow diverters.

Results: One hundred ninety-eight patients (mean age 52.8 ± 14.1 years; 40.0% male) underwent craniotomy (64.6%), coiling (26.7%), or flow diversion (8.6%). Coiling was 1.4× more expensive than clipping (p = .005) and flow diversion was 1.7× more expensive than clipping (p < .001). More severe illness as measured by American Society of Anesthesia, Hunt/Hess, and Fisher scales incurred higher costs than less severe illness (p < .05). Use of a lumbar drain protocol to reduce subarachnoid hemorrhage and use of an external ventricular drain to manage intracranial pressure were associated with reduced (p = .05) and increased (p < .001) total costs, respectively. Patients with severe vasospasm (p < .005), those that received shunts (p < .001), and those who had complications (p < .001) had higher costs. Multivariate analysis showed that procedure type, length of stay, number of angiograms, vasospasm severity, disposition, and year of treatment were independent predictors of cost.

Conclusions: These results show for the first time that disease and vasospasm severity and intensity of treatment directly impact the cost of care for patients with aneurysms in the USA. Strategies to alter these variables may prove important for cost reduction.
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http://dx.doi.org/10.1007/s00701-019-04153-3DOI Listing
January 2020

Resection of Pituitary Tumor with Lateral Extension to the Temporal Fossa: The Toothpaste Extrusion Technique.

Cureus 2019 Oct 21;11(10):e5953. Epub 2019 Oct 21.

Neurosurgery, University of Utah School of Medicine, Huntsman Cancer Institute, Salt Lake City, USA.

Transsphenoidal resection of the sellar and suprasellar lesions, whether microscopic or endoscopic, has been traditionally limited by tumors extending laterally to the carotid artery and cavernous sinus. Extended endoscopic or transmaxillary approaches may be warranted depending on these tumor extensions. We describe the use of an intraoperative Valsalva maneuver as a surgical adjunct to the transsphenoidal approach to improve the extent of resection for a favorable outcome. The patient was a 65-year-old woman who underwent resection of a giant pituitary tumor that extended laterally to the cavernous sinus to occupy a volume within the middle fossa. It was the senior author's impression that the lateral cavernous wall was intact at the time of surgery although this is difficult to determine definitively. After a transsphenoidal intrasellar resection of the intrasellar tumor, side-angled endoscopic visualization enabled identification of the breach in the medial cavernous wall where the tumor had invaded the cavernous sinus and ultimately grown into the middle fossa. A Valsalva maneuver was then applied, and the tumor was extruded from the cavernous sinus lateral to the carotid. The significant tumor was removed under direct visualization of the abducens nerve, which was well preserved. Postoperative imaging showed a sufficient extent of resection, and there were no postoperative complications. An intraoperative Valsalva maneuver can be a potentially useful technique for extending tumor resection in cases with a soft tumor and visualization of the opening within the cavernous sinus wall.
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http://dx.doi.org/10.7759/cureus.5953DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6863590PMC
October 2019

Restabilization of the Occipitocervical Junction After a Complete Unilateral Condylectomy: A Biomechanical Comparison of Unilateral and Bilateral Fixation Techniques.

Oper Neurosurg (Hagerstown) 2020 08;19(2):157-164

Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah.

Background: Occipitocervical instability may result from transcondylar resection of the occipital condyle. Initially, patients may be able to maintain a neutral alignment but severe occipitoatlantal subluxation may subsequently occur, with cranial settling, spinal cord kinking, and neurological injury.

Objective: To evaluate the ability of posterior fixation constructs to prevent progression to severe deformity after radical unilateral condylectomy.

Methods: Eight human cadaveric specimens (Oc-C2) underwent biomechanical testing to compare stiffness under physiological loads (1.5 N m). A complete unilateral condylectomy was performed to destabilize one Oc-C1 joint, and the contralateral joint was left intact. Unilateral Oc-C1 or Oc-C2 constructs on the resected side and bilateral Oc-C1 or Oc-C2 constructs were tested.

Results: The bilateral Oc-C2 construct provided the greatest stiffness, but the difference was only statistically significant in certain planes of motion. The unilateral constructs had similar stiffness in lateral bending, but the unilateral Oc-C1 construct was less stiff in axial rotation and flexion-extension than the unilateral Oc-C2 construct. The bilateral Oc-C2 construct was stiffer than the unilateral Oc-C2 construct in axial rotation and lateral bending, but there was no difference between these constructs in flexion-extension.

Conclusion: Patients who undergo a complete unilateral condylectomy require close surveillance for occipitocervical instability. A bilateral Oc-C2 construct provides suitable biomechanical strength, which is superior to other constructs. A unilateral construct decreases abnormal motion but lacks the stiffness of a bilateral construct. However, given that most patients undergo a partial condylectomy and only a small proportion of patients develop instability, there may be scenarios in which a unilateral construct may be appropriate, such as for temporary internal stabilization.
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http://dx.doi.org/10.1093/ons/opz341DOI Listing
August 2020

Improved Surgical Safety via Intraoperative Navigation for Transnasal Transsphenoidal Resection of Pituitary Adenomas.

J Neurol Surg B Skull Base 2019 Dec 21;80(6):626-631. Epub 2019 Jan 21.

Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, United States.

 Intraoperative navigation during neurosurgery can aid in the detection of critical structures and target lesions. The safety and efficacy of intraoperative, stereotactic computed tomography (CT) in the transnasal transsphenoidal resection of pituitary adenomas were explored.  Retrospective chart review  Tertiary care hospital  Patients who underwent transsphenoidal resection of pituitary adenomas from February 2002 to May 2017. Intraoperative stereotactic CT navigation was used for all patients after mid-October 2013.  Operative time, estimated blood loss, gross total resection rate.  Of 634 patients included, 175 underwent surgery with intraoperative navigation and 444 had no intraoperative navigation during surgery. There was no difference in mean age, sex, tumor type, or tumor size between the two groups. Operative time, endoscope use, cerebrospinal fluid diversion, and estimated blood loss were also similar. Two patients showed intraoperative, iatrogenic misdirection in the absence of stereotactic CT navigation (  = 0.99) but similar numbers of patients having navigated and non-navigated surgery returned to the operating room, underwent gross total resection, and showed endocrinological normalization.  These results suggest that intraoperative navigation can reduce injury without resulting in increased operative time, estimated blood loss, or reduction in gross total resection.
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http://dx.doi.org/10.1055/s-0039-1677677DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6868505PMC
December 2019

Cost Analysis of Inpatient Rehabilitation after Spinal Injury: A Retrospective Cohort Analysis.

Cureus 2019 Sep 24;11(9):e5747. Epub 2019 Sep 24.

Neurosurgery, University of Utah School of Medicine, Salt Lake City, USA.

Objective The lifetime direct and indirect costs of spinal injury and spinal cord injury (SCI) increase as the severity of injury worsens. Despite the potential for substantial improvement in function with acute rehabilitation, the factors affecting its cost have not yet been evaluated. We used a proprietary hospital database to evaluate the direct costs of rehabilitation after spine injury. Methods A single-center, retrospective cohort cost analysis of patients with acute, traumatic spine injury treated at a tertiary facility from 2011 to 2017 was performed. Results In the 190 patients (mean age 46.1 ± 18.6 years, 76.3% males) identified, American Spinal Injury Association impairment scores on admission were 32.1% A, 14.7% B, 14.7% C, 33.2% D, and 1.1% E. Surgical treatment was performed in 179 (94.2%) cases. Most injuries were in the cervical spine (53.2%). A mean improvement of Functional Impairment Score of 30.7 ± 16.2 was seen after acute rehabilitation. Costs for care comprised facility (86.5%), pharmacy (9.2%), supplies (2.0%), laboratory (1.5%), and imaging (0.8%) categories. Injury level, injury severity, and prior inpatient surgical treatment did not affect the cost of rehabilitation. Higher injury severity (p = 0.0001, one-way ANOVA) and spinal level of injury (p = 0.001, one-way ANOVA) were associated with higher length of rehabilitation stay in univariate analysis. However, length of rehabilitation stay was the strongest independent predictor of higher-than-median cost (risk ratio = 1.56, 95% CI 1.21-2.0, p = 0.001) after adjusting for other factors. Conclusions Spine injury has a high upfront cost of care, with greater need for rehabilitation substantially affecting cost. Improving the efficacy of rehabilitation to reduce length of stay may be effective in reducing cost.
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http://dx.doi.org/10.7759/cureus.5747DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6825436PMC
September 2019

Initial Treatment for Unruptured Intracranial Aneurysm and Its Follow-up: A Cost Analysis of Pipeline Flow Diverters versus Coiling.

Cureus 2019 Sep 18;11(9):e5692. Epub 2019 Sep 18.

Neurosurgery, University of Utah School of Medicine, Salt Lake City, USA.

Purpose Intracranial aneurysms are relatively common epidemiological problems for which the surveillance, treatment, and follow-up are costly. Although multiple studies have evaluated the treatment cost of aneurysms, the follow-up costs are often not examined. In our study, we analyzed how follow-up costs after treatment affected the overall cost of different endovascular techniques for treating aneurysms. Materials and methods An institutional database was used to evaluate the upfront and follow-up costs incurred by patients who underwent elective coiling or placement of a pipeline embolization device (PED) for the treatment of unruptured intracranial aneurysms from July 2011 to December 2017. Results A total of 114 patients (coiling, n = 37; PED, n = 77 ) were included in the study. There was no significant difference among patients in mean age [61.3 (±12.8 years) vs. 57.0 (±14.5 years); probability value (p) = 0.2], sex (male: 32.4% vs. 22.1%; p = 0.2), American Society of Anesthesiologists (ASA) grade (p = 0.5), discharge disposition (p = 0.1), mean length of stay [3.1 days (±5.5) vs. 2.4 days (±2.6); p = 0.2) or follow-up period [22.7 months (±18.5) vs. 18.6 months (±14.9); p = 0.2). There were no differences in costs during admission (p = 0.5) or in follow-up (p = 0.3) between coiling and PED treatments. Initial costs were predominantly related to supplies/implants (56.1% vs. 63.7%) for both treatments. Follow-up costs mostly comprised facility costs (68.2% vs. 67.5%), and there were no differences in costs of subgroups such as supplies/implants (10.5% vs. 9.4%), imaging (17.0% vs. 17.8%), or facilties between coiling and PED. Conclusion These results suggest that the upfront and follow-up costs are mostly similar for the treatment of intracranial aneurysms irrespective of whether the providers used coiling or PED endovascular techniques. Hence, we conclude that follow-up costs should not be a deciding factor when considering these treatments.
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http://dx.doi.org/10.7759/cureus.5692DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6823005PMC
September 2019

Pathologic remodeling in human neuromas: insights from clinical specimens.

Acta Neurochir (Wien) 2019 12 14;161(12):2453-2466. Epub 2019 Oct 14.

Department of Pathology, University of Utah, Salt Lake City, UT, USA.

Background: Neuroma pathology is commonly described as lacking a clear internal structure, but we observed evidence that there are consistent architectural elements. Using human neuroma samples, we sought to identify molecular features that characterize neuroma pathophysiology.

Methods: Thirty specimens-12 neuromas-in-continuity (NICs), 11 stump neuromas, two brachial plexus avulsions, and five controls-were immunohistochemically analyzed with antibodies against various components of normal nerve substructures.

Results: There were no substantial histopathologic differences between stump neuromas and NICs, except that NICs had intact fascicle(s) in the specimen. These intact fascicles showed evidence of injury and fibrosis. On immunohistochemical analysis of the neuromas, laminin demonstrated a consistent double-lumen configuration. The outer lumen stained with GLUT1 antibodies, consistent with perineurium and microfascicle formation. Antibodies to NF200 revealed small clusters of small-diameter axons within the inner lumen, and the anti-S100 antibody showed a relatively regular pattern of non-myelinating Schwann cells. CD68+ cells were only seen in a limited temporal window after injury. T-cells were seen in neuroma specimens, with both a temporal evolution as well as persistence long after injury. Avulsion injury specimens had similar architecture to control nerves. Seven pediatric specimens were not qualitatively different from adult specimens. NICs demonstrated intact but abnormal fascicles that may account for the neurologically impoverished outcomes from untreated NICs.

Conclusions: We propose that there is consistent pathophysiologic remodeling after fascicle disruption. Particular features, such as predominance of small caliber axons and persistence of numerous T-cells long after injury, suggest a potential role in chronic pain associated with neuromas.
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http://dx.doi.org/10.1007/s00701-019-04052-7DOI Listing
December 2019

Evaluation of a D-Dimer Protocol for Detection of Venous Thromboembolism.

World Neurosurg 2020 Jan 9;133:e774-e783. Epub 2019 Oct 9.

Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA. Electronic address:

Background: The use of venous duplex ultrasonography (VDU) for confirmation of deep venous thrombosis in neurosurgical patients is costly and requires experienced personnel. We evaluated a protocol using D-dimer levels to screen for venous thromboembolism (VTE), defined as deep venous thrombosis and asymptomatic pulmonary embolism.

Methods: We used a retrospective bioinformatics analysis to identify neurosurgical inpatients who had undergone a protocol assessing the serum D-dimer levels and had undergone a VDU study to evaluate for the presence of VTE from March 2008 through July 2017. The clinical risk factors and D-dimer levels were evaluated for the prediction of VTE.

Results: In the 1918 patient encounters identified, the overall VTE detection rate was 28.7%. Using a receiver operating characteristic curve, an area under the curve of 0.58 was identified for all D-dimer values (P = 0.0001). A D-dimer level of ≥2.5 μg/mL on admission conferred a 30% greater relative risk of VTE (sensitivity, 0.43; specificity, 0.67; positive predictive value, 0.27; negative predictive value, 0.8). A D-dimer value of ≥3.5 μg/mL during hospitalization yielded a 28% greater relative risk of VTE (sensitivity, 0.73; specificity, 0.32; positive predictive value, 0.24; negative predictive value, 0.81). Multivariable logistic regression showed that age, male sex, length of stay, tumor or other neurological disease diagnosis, and D-dimer level ≥3.5 μg/mL during hospitalization were independent predictors of VTE.

Conclusions: The D-dimer protocol was beneficial in identifying VTE in a heterogeneous group of neurosurgical patients by prompting VDU evaluation for patients with a D-dimer values of ≥3.5 μg/mL during hospitalization. Refinement of this screening model is necessary to improve the identification of VTE in a practical and cost-effective manner.
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http://dx.doi.org/10.1016/j.wneu.2019.09.160DOI Listing
January 2020

Spinal cord stimulation failure: evaluation of factors underlying hardware explantation.

J Neurosurg Spine 2019 Oct 4:1-6. Epub 2019 Oct 4.

2Mayfield Clinic, Cincinnati, Ohio; and.

Objective: Spinal cord stimulation has been shown to improve pain relief and reduce narcotic analgesic use in cases of complex refractory pain syndromes. However, a subset of patients ultimately undergoes removal of the spinal cord stimulator (SCS) system, presumably because of surgical complications or poor efficacy. This retrospective study addresses the paucity of evidence regarding risk factors and underlying causes of spinal cord stimulation failures that necessitate this explantation.

Methods: In this retrospective single-center review, 129 patients underwent explantation of SCS hardware during a 9-year period (2005-2013) following initial placement at the authors' institution or elsewhere. Medical history, including indication of implantation, device characteristics, revision history, and reported reasons for removal of hardware, were reviewed.

Results: The 74 (57%) women and 55 (43%) men were a median of 49 years old (IQR 41-61 years) at explantation; the median time to explantation was 20 months (IQR 7.5-45.5 months). Thoracic or upper lumbar leads were placed in 89.9% of patients primarily for the diagnosis of postsurgical failed-back surgery syndrome (70.5%), chronic regional pain syndrome (14.7%), and neuropathic pain (8.5%). More than half of patients were legally disabled. Initial postoperative reduction in pain was reported in 81% of patients, and 37.8% returned to work. Among 15 patients with acute postsurgical complications (12 infections, 2 hemorrhages, 1 immediate paraplegia), the median time to removal was 2 months. Primary reasons for hardware removal were lack of stimulation efficacy (81%), electrode failure due to migration (14%), and allergic reactions to implanted hardware in 2 patients. The 72 patients who underwent formal psychiatric evaluation before implantation were affected by high rates of major depression (64%), anxiety (34%), posttraumatic stress disorder (PTSD) (12%), drug or alcohol abuse (12%), and physical or sexual abuse (22%).

Conclusions: The authors' findings provide insight regarding the mechanisms of spinal cord stimulation failure that resulted in total removal of the implanted system. The relationship between spinal cord stimulation failure and certain psychiatric disorders, such as PTSD, depression, and anxiety, is highlighted. Ultimately, this work may shed light on potential avenues to reduce morbidity and improve patient outcomes.
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http://dx.doi.org/10.3171/2019.6.SPINE181099DOI Listing
October 2019

The Effect of Hospital Transfer on Patient Outcomes After Rehabilitation for Spinal Injury.

World Neurosurg 2020 Jan 12;133:e76-e83. Epub 2019 Sep 12.

Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA.

Objective: Spine fractures, including associated spinal cord injury, account for 3%-6% of all skeletal fractures annually in the United States. Patients who undergo interhospital transfer after injury may have a greater likelihood of nonroutine disposition, longer hospital stay, and higher cost. We evaluated the effects of patient transfer on functional outcomes after spine trauma.

Methods: Patients were treated after acute traumatic spine injury at a rehabilitation hospital in 2011-2017. Compared patients were those directly admitted to the tertiary hospital or transferred from a community hospital.

Results: A total of 188 patients (mean age 46.1 ± 18.6 years, 77.1% men) were evaluated, including 130 (69.1%) directly admitted and 58 (30.9%) transferred patients. The most common levels of injury were at C5 (19.1%) and C6 (12.2%), and most injuries were American Spinal Injury Association injury severity score grade D (33.2%) or grade A (32.1%). No statistical difference in age, injury pattern, timing from injury to surgery, or rehabilitation length of stay was seen between admitted and transferred patients. A significant improvement in ambulation distances was seen at discharge for directly admitted compared with transferred patients (447.7 ± 724.9 vs. 159.9 ± 359.5 feet; P = 0.005). However, no significant difference primary outcomes, namely American Spinal Injury Association injury severity score distribution (P = 0.2) or Functional Independence Measures (Δ30.9 ± 15.9 vs. 30.1 ± 17.1; P = 0.7), were seen between admitted and transferred patients at time of rehabilitation discharge.

Conclusions: Interhospital transfer status did not diminish time to rehabilitation after injury or reduce functional recovery, suggesting early surgical treatment in community settings may have merit prior to transfer.
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http://dx.doi.org/10.1016/j.wneu.2019.08.091DOI Listing
January 2020
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