Developing Predictive Models to Anticipate Shunt Complications in 33,248 Pediatric Patients with Shunted Hydrocephalus Utilizing Machine Learning.

INTRODUCTION: Hydrocephalus is a common pediatric neurosurgical pathology, typically treated with a ventricular shunt, yet approximately 30% of patients experience shunt failure within the first year after surgery. As a result, the objective of the present study was to validate a predictive model of pediatric shunt complications with data retrieved from the Healthcare Cost and Utilization Project (HCUP) National Readmissions Database (NRD). METHODS: The HCUP NRD was queried from 2016 to 2017 for pediatric patients undergoing shunt placement using ICD-10 codes. Comorbidities present upon initial admission resulting in shunt placement, Johns Hopkins Adjusted Clinical Groups (JHACG) frailty-defining criteria, and Major Diagnostic Category (MDC) at admission classifications were obtained. The database was divided into training (n = 19,948), validation (n = 6,650), and testing (n = 6,650) datasets. Multivariable analysis was performed to identify significant predictors of shunt complications which were used to develop logistic regression models. Post hoc receiver operating characteristic (ROC) curves were created. RESULTS: A total of 33,248 pediatric patients aged 6.9 ± 5.7 years were included. Number of diagnoses during primary admission (OR: 1.05, 95% CI: 1.04-1.07) and initial neurological admission diagnoses (OR: 3.83, 95% CI: 3.33-4.42) positively correlated with shunt complications. Female sex (OR: 0.87, 95% CI: 0.76-0.99) and elective admissions (OR: 0.62, 95% CI: 0.53-0.72) negatively correlated with shunt complications. ROC curve for the regression model utilizing all significant predictors of readmission demonstrated area under the curve of 0.733, suggesting these factors are possible predictors of shunt complications in pediatric hydrocephalus. CONCLUSION: Efficacious and safe treatment of pediatric hydrocephalus is of paramount importance. Our machine learning algorithm delineated possible variables predictive of shunt complications with good predictive value.

Intracranial subdural hemorrhage following closed neural tube defect repair: illustrative case.

BACKGROUND: Intracranial subdural hematomas (SDHs) due to intracranial hypotension after pediatric spine surgeries are an uncommon pathology. Such findings have typically been associated with intraoperative durotomies that are complicated by a subsequent cerebrospinal fluid (CSF) leak. OBSERVATIONS: The patient is a 17-year-old boy with a complex past medical history who received an uncomplicated S1-2 laminectomy for repair of his closed neural tube defect (CNTD), cord untethering, and resection of a lipomatous malformation. He returned to the hospital with consistent headaches and a 2-day history of intermittent left-sided weakness. Imaging demonstrated multiple subdural collections without a surgical site pseudomeningocele. LESSONS: The case was unique because there have been no documented cases of acute intracranial SDH after CNTD repair. There was no CSF leak, and spine imaging did not demonstrate any evidence of pseudomeningocele. The authors believed that intraoperative CSF loss may have created enough volume depletion to cause tearing of bridging veins. In younger adolescents, it is possible that an even smaller volume may cause similar effects. Additionally, the authors' case involved resection of the lipomatous malformation and an expansile duraplasty. Hypothetically, both can increase the lumbar cisternal compartment, which can collect a larger amount of CSF with gravity, despite no pseudomeningocele being present.

Relationship of Grit and Resilience to Burnout Among U.S. Neurosurgery Residents.

INTRODUCTION: Studies have begun investigating grit (continued fortitude in the face of hardship) and resilience (ability to recover from a setback) and their relationship to burnout (emotional exhaustion [EE] caused by prolonged stress or frustration) within medicine. We investigated the prevalence of burnout among neurosurgery residents and aimed to determine the relationship among burnout, grit, and resilience. METHODS: We surveyed U.S. neurosurgical residents to perform a discretional analysis of prevalence of burnout. Multivariate analysis was performed to determine which variables were associated with higher and lower levels of EE, depersonalization (DP), personal accomplishment (PA), burnout, grit, and resilience. RESULTS: Of 1385 U.S. neurosurgery residents, 427 (30.8%) responded to our survey. Burnout prevalence was 33.0% (95% confidence interval, 28.6%-37.7%). High grit was associated with U.S. graduates (P = 0.006), married residents (P = 0.025), and fewer social/personal stressors (P = 0.003). Lower resilience was associated with female sex (P = 0.006), whereas higher resilience was associated with international medical graduates (P = 0.017) and fewer social/personal stressors (P = 0.005). High burnout was associated with greater social/personal stressors (P = 0.002), clinical rotations (P = 0.001), and lack of children (P = 0.016). There were positive correlations between EE and DP and among PA, grit, and resilience. There were negative correlations for EE and DP with PA, grit, and resilience and between grit/resilience and burnout. CONCLUSIONS: There is an inverse relationship between grit/resilience and burnout. Increased social/personal stressors are associated with increased levels of burnout and decreased grit and resilience. Grit and resilience are higher when social and personal stressors are decreased, indicating that these characteristics may fluctuate over time.

Balancing Operative Efficiency and Surgical Education: A Functional Neurosurgery Model.

BACKGROUND: Attending surgeons have dual obligations to deliver high-quality health care and train residents. In modern healthcare, lean principles are increasingly applied to processes preceding and following surgery. However, surgeons have limited data regarding variability and waste during any given operation. OBJECTIVE: To measure variability and waste during the following key functional neurosurgery procedures: retrosigmoid craniectomy (microvascular decompression [MVD] and internal neurolysis) and deep brain stimulation (DBS). Additionally, we correlate variability with residents' self-reported readiness for the surgical steps. The aim is to guide surgeons as they balance operative safety and efficiency with training obligations. METHODS: For each operation (retrosigmoid craniectomy and DBS), a standard workflow, segmenting the operation into components, was defined. We observed a representative sample of operations, timing the components, with a focus on variability. To assess perceptions of safety and risk among surgeons of various training levels, a survey was administered. Survey results were correlated with operative variability, attempting to identify areas for increasing value without compromising trainee experience. RESULTS: A sampling of each operation (n = 36) was observed during the study period. For MVD, craniectomy had the highest mean duration and standard deviation, whereas the MVD itself had the lowest mean duration and standard deviation. For DBS, the segments with largest standard deviation in duration were registration and electrode placement. For many steps of both procedures, there was a statistically significant relationship between increasing level of training and increasing perception of safety. CONCLUSION: This proof-of-concept study introduces an educational and process-improvement tool that can be used to aid surgeons in increasing the efficiency of patient care.

Combined Laminoplasty and Posterior Fusion for Cervical Spondylotic Myelopathy Treatment: A Literature Review.

STUDY DESIGN: A literature review. PURPOSE: To explore the utility of laminoplasty in combination with instrumented fusion, with a focus on neurological outcomes and changes in kyphotic deformity. OVERVIEW OF LITERATURE: Management of cervical spondylotic myelopathy (CSM) to reduce morbidity within the neurosurgical population. METHODS: A US National Library of Medicine PubMed search was conducted for manuscripts pertaining to cervical laminoplasty and fusion for the management of CSM. Several relevant studies were shortlisted for review, and the bibliographies of the articles were searched for additional references. The search was limited to human studies, English-language literature, and reports on more than one patient. RESULTS: Combined laminoplasty and fusion was found to provide at least comparable, if not superior, neurological outcomes in specific patient populations with CSM. The Japanese Orthopedic Association scores, local kyphosis, and C2-C7 angle have been reviewed in several manuscripts, and improvement in each of these categories was found with laminoplasty and fusion. CONCLUSIONS: The treatment of CSM necessitates an individualized approach based on the pathoanatomical variation. Laminoplasty and fusion can be appropriately used for patients with CSM in a setting of local kyphotic deformity, ossification of the posterior longitudinal ligament, associated segmental instability, and the need for strong stabilization.

Pseudogout of the cervical and thoracic spine mimicking infection after lumbar fusion: case report.

Pseudogout is a form of acute calcium pyrophosphate deposition (CPPD) disease that typically afflicts the elderly. CPPD commonly involves larger joints, such as the knees, wrists, shoulders, and hips, and has been known to involve the spine. The authors report the case of a 66-year-old woman with a recent history of lumbar laminectomy and fusion who presented 5 weeks postprocedure with a clinical and radiographic picture consistent with multilevel skip lesions involving the cervical and thoracic spine, thoracic discitis, and epidural abscess. Serial blood cultures and repeat biopsy samples were sterile. Subsequent wrist and ankle erythema, pain, and swelling led to synovial fluid analysis, and pseudogout was diagnosed. She was treated with an interleukin-1 inhibitor with immediate symptom relief. To the authors' knowledge, this is only the second report of spinal pseudogout presenting with a clinical and radiographic picture consistent with discitis and epidural abscess. This report is the first to report skip lesions of pseudogout occurring throughout the spine that are uniquely remote from a recent lumbar surgery.

Biphasic bisperoxovanadium administration and Schwann cell transplantation for repair after cervical contusive spinal cord injury.

Schwann cells (SCs) hold promise for spinal cord injury (SCI) repair; however, there are limitations for its use as a lone treatment. We showed that acute inhibition of the phosphatase and tensin homolog deleted on chromosome ten (PTEN) by bisperoxovanadium (bpV) was neuroprotective and enhanced function following cervical hemicontusion SCI. We hypothesized that combining acute bpV therapy and delayed SC engraftment would further improve neuroprotection and recovery after cervical SCI. Adult female Sprague-Dawley (SD) rats were randomly sorted into 5 groups: sham, vehicle, bpV, SC transplantation, and bpV+SC transplantation. SCs were isolated from adult green fluorescent protein (GFP)-expressing SD rats (GFP-SCs). 200 µg/kg bpV(pic) was administered intraperitoneally (IP) twice daily for 7 days post-SCI in bpV-treated groups. GFP-SCs (1×10(6) in 5 µl medium) were transplanted into the lesion epicenter at the 8th day post-SCI. Forelimb function was tested for 10 weeks and histology was assessed. bpV alone significantly reduced lesion (by 40%, p<0.05) and cavitation (by 65%, p<0.05) and improved functional recovery (p<0.05) compared to injury alone. The combination promoted similar neuroprotection (p<0.01 vs. injury); however, GFP-SCs alone did not. Both SC-transplanted groups exhibited remarkable long-term SC survival, SMI-31(+) axon ingrowth and RECA-1(+) vasculature presence in the SC graft; however, bpV+SCs promoted an 89% greater axon-to-lesion ratio than SCs only. We concluded that bpV likely contributed largely to the neuroprotective and functional benefits while SCs facilitated considerable host-tissue interaction and modification. The combination of the two shows promise as an attractive strategy to enhance recovery after SCI.

Risk of radiation-induced malignancies from CT scanning in children who underwent shunt treatment before 6 years of age: a retrospective cohort study with a minimum 10-year follow-up.

OBJECT: A number of mathematical models predict the risk of future cancer from the ionizing radiation exposure of CT scanning. The predictions are alarming. Some models predict 29,000 future cancers and 14,500 deaths in the US will be directly caused by 1 year's worth of CT scanning. However, there are very few clinical data to justify or refute these claims. Young children are theoretically highly susceptible to the damaging effects of radiation. In this study, the authors examined children who underwent CSF shunt placement before 6 years of age. The authors chose to study shunt-treated patients with the assumption that these patients would undergo future imaging, facilitating surveillance. They chose a study period of 1991-2001 to allow more than 10 years of follow-up data. METHODS: The authors studied 104 consecutive children who underwent CSF shunt placement prior to 6 years of age and who had at least 10 years of follow-up data. Sixty-two of these patients underwent shunt placement prior to 1 year of age. The age at the initial scanning session, the number of future CT scanning sessions, diagnosis, and results of any future studies were recorded. The age-specific radiation dose was calculated for children younger than 1 year. Children younger than 1 year at the time of shunt placement were evaluated separately, based on the assumption that they represented the highest risk cohort. The authors examined all data for any evidence of future leukemia or head/neck tumor (benign or malignant). RESULTS: These children underwent a total of 1584 CT scanning sessions over a follow-up period of 1622 person-years. A total of 517 scanning sessions were performed prior to 6 years of age, including 260 in the 1st year of life. Children who underwent shunt placement before 1 year of age underwent an average of 16.3 ± 13.5 CT sessions (range 1-41). Children undergoing placement between 1 and 6 years of age received an average of 14.1 ± 12.5 CT studies (range 5-52). There were no subsequent tumors (benign or malignant) or leukemia detected. CONCLUSIONS: Previously published models predict a significant number of future cancers directly caused by CT scanning. However, there are very few published clinical data. In the authors' study, zero future radiation-induced malignancies were detected after routine CT scanning in a high-risk group. While the authors do not consider their single-institution study adequate to define the actual risk, their data suggest that the overall risk is low. The authors hope this study encourages future collaborative efforts to define the actual risk to patients.

Computed-tomography-based anatomical study to assess feasibility of pedicle screw placement in the lumbar and lower thoracic pediatric spine.

PURPOSE: The anatomy of the pedicle is complex and three-dimensional; however, there are basic dimensions important for possible screw placement. There are relatively few studies examining the pedicle anatomy in children. This study was performed to evaluate the feasibility of pedicle screw placement in children aged 5-16, based on key anatomic dimensions. A case illustration is also provided. METHODS: The CT scans of 102 consecutive children were studied. Patients with abnormal anatomy were excluded. The parameters of the pedicle isthmus width (W), estimation of screw length (L), and axial angle (A) were recorded for 1,632 pedicles from T10 through L5. Patients were divided into four age groups. Statistical analysis was performed evaluating the difference between males and females and of the particular anatomy at the thoracolumbar junction. RESULTS: The pedicles increase in both L and W from T10-T12 and from L1-L5. L1 has a consistently smaller W compared to T12 in both genders over all age ranges. Estimating a W of 4.5 mm necessary for safe screw placement, we calculate that virtually all pedicles of T12 and L3-L5 are large enough for screw placement in both genders after age 8. L4 and L5 are large enough for screw placement in both genders in the youngest age range. CONCLUSIONS: Most of the pedicles of the lower lumbar spine and T12 are large enough to house the smallest commercially available screw. Understanding of the anatomy at the thoracolumbar junction is important, as the W of L1 is consistently smaller than T12.