Protocolization of Post-Transforaminal Lumbar Interbody Fusion Pain Control with Elimination of Benzodiazepines and Long-Acting Opioids.

BACKGROUND: The opioid epidemic continues to worsen with a concomitant increase in opioid-related mortality. In response, the Department of Defense and Veterans Health Agency recommended against the use of long-acting opioids (LAOs) and concurrent use of opioids with benzodiazepines. Subsequently, we eliminated benzodiazepines and LAOs from our postoperative pain control regimen. OBJECTIVE: To evaluate the impact of removing benzodiazepines and LAOs on postoperative pain in single-level transforaminal lumbar interbody fusion (TLIF) patients. METHODS: A retrospective cohort study of single-level TLIF patients from February 2016-March 2018 was performed. Postoperative pain control in the + benzodiazepine cohort included scheduled diazepam with or without LAOs. These medications were replaced with nonbenzodiazepine, opioid-sparing adjuncts in the -benzodiazepine cohort. Pain scores, length of hospitalization, trigger medication use, and opioid use and duration were compared. RESULTS: Among 77 patients, there was no difference between inpatient pain scores, but the -benzodiazepine cohort experienced a faster rate of morphine equivalent reduction (-18.7%, 95% CI [-1.22%, -36.10%]), used less trigger medications (-1.55, 95% CI [-0.43, -2.67]), and discharged earlier (0.6 d; 95% CI [0.01, 1.11 d]). As outpatients, the -benzodiazepine cohort was less likely to receive opioid refills at 2 wk (29.2% vs 55.8%, P = .021) and 6 mo postoperatively (0% vs 13.2%, P = .039), and was less likely to be using opioids by 3 mo postoperatively (13.3% vs 34.2%, P = .048). CONCLUSION: Replacement of benzodiazepines and LAOs in the pain control regimen for single-level TLIFs did not affect pain scores and was associated with decreased opioid use, a reduction in trigger medications, and shorter hospitalizations.

Dual Invasive Fungal Infection Presenting with Cervical Myelopathy.

Disseminated fungal infections are often seen in immunocompromised patients. Here we present a case of a previously healthy woman presenting with cervical myeloradiculopathy found to have two separate fungal infections in the setting of depressed CD4 cell counts and a genetic mutation predisposing to invasive fungal infections.

Two-year mortality and functional outcomes in combat-related penetrating brain injury: battlefield through rehabilitation.

OBJECTIVEThere are limited data concerning the long-term functional outcomes of patients with penetrating brain injury. Reports from civilian cohorts are small because of the high reported mortality rates (as high as 90%). Data from military populations suggest a better prognosis for penetrating brain injury, but previous reports are hampered by analyses that exclude the point of injury. The purpose of this study was to provide a description of the long-term functional outcomes of those who sustain a combat-related penetrating brain injury (from the initial point of injury to 24 months afterward).METHODSThis study is a retrospective review of cases of penetrating brain injury in patients who presented to the Role 3 Multinational Medical Unit at Kandahar Airfield, Afghanistan, from January 2010 to March 2013. The primary outcome of interest was Glasgow Outcome Scale (GOS) score at 6, 12, and 24 months from date of injury.RESULTSA total of 908 cases required neurosurgical consultation during the study period, and 80 of these cases involved US service members with penetrating brain injury. The mean admission Glasgow Coma Scale (GCS) score was 8.5 (SD 5.56), and the mean admission Injury Severity Score (ISS) was 26.6 (SD 10.2). The GOS score for the cohort trended toward improvement at each time point (3.6 at 6 months, 3.96 at 24 months, p > 0.05). In subgroup analysis, admission GCS score ≤ 5, gunshot wound as the injury mechanism, admission ISS ≥ 26, and brain herniation on admission CT head were all associated with worse GOS scores at all time points. Excluding those who died, functional improvement occurred regardless of admission GCS score (p < 0.05). The overall mortality rate for the cohort was 21%.CONCLUSIONSGood functional outcomes were achieved in this population of severe penetrating brain injury in those who survived their initial resuscitation. The mortality rate was lower than observed in civilian cohorts.

Cost-effectiveness of adult spinal deformity surgery in a military healthcare system.

OBJECTIVEAdult spinal deformity surgery is an effective way of treating pain and disability, but little research has been done to evaluate the costs associated with changes in health outcome measures. This study determined the change in quality-adjusted life years (QALYs) and the cost per QALY in patients undergoing spinal deformity surgery in the unique environment of a military healthcare system (MHS).METHODSPatients were enrolled between 2011 and 2017. Patients were eligible to participate if they were undergoing a thoracolumbar spinal fusion spanning more than 6 levels to treat an underlying deformity. Patients completed the 36-Item Short Form Health Survey (SF-36) prior to surgery and 6 and 12 months after surgery. The authors used paired t-tests to compare SF-36 Physical Component Summary (PCS) scores between baseline and postsurgery. To estimate the cost per QALY of complex spine surgery in this population, the authors extended the change in health-related quality of life (HRQOL) between baseline and follow-up over 5 years. Data on the cost of surgery were obtained from the MHS and include all facility and physician costs.RESULTSHRQOL and surgical data were available for 49 of 91 eligible patients. Thirty-one patients met additional criteria allowing for cost-effectiveness analysis. Over 12 months, patients demonstrated significant improvement (p < 0.01) in SF-36 PCS scores. A majority of patients met the minimum clinically important difference (MCID; 83.7%) and substantive clinical benefit threshold (SCBT; 83.7%). The average change in QALY was an increase of 0.08. Extended across 5 years, including the 3.5% discounting per year, study participants increased their QALYs by 0.39, resulting in an average cost per QALY of $181,649.20. Nineteen percent of patients met the < $100,000/QALY threshold with half of the patients meeting the < $100,000/QALY mark by 10 years. A sensitivity analysis showed that patients who scored below 60 on their preoperative SF-36 PCS had an average increase in QALYs of 0.10 per year or 0.47 over 5 years.CONCLUSIONSWith a 5-year extended analysis, patients who receive spinal deformity surgery in the MHS increased their QALYs by 0.39, with 19% of patients meeting the $100,000/QALY threshold. The majority of patients met the threshold for MCID and SCBT at 1 year postoperatively. Consideration of preoperative functional status (SF-36 PCS score < 60) may be an important factor in determining which patients benefit the most from spinal deformity surgery.

Balloon-augmented Onyx embolization of cerebral arteriovenous malformations using a dual-lumen balloon: a multicenter experience.

INTRODUCTION: Conventional Onyx embolization of cerebral arteriovenous malformations (AVMs) requires lengthy procedure and fluoroscopy times to form an adequate 'proximal plug' which allows forward nidal penetration while preventing reflux and non-targeted embolization. We review our experience with balloon-augmented Onyx embolization of cerebral AVMs using a dual-lumen balloon catheter technique designed to minimize these challenges. METHODS: Retrospectively acquired data for all balloon-augmented cerebral AVM embolizations performed between 2011 and 2014 were obtained from four tertiary care centers. For each procedure, at least one Scepter C balloon catheter was advanced into the AVM arterial pedicle of interest and Onyx embolization was performed through the inner lumen after balloon inflation via the outer lumen. RESULTS: Twenty patients underwent embolization with the balloon-augmented technique over 24 discreet treatment episodes. There were 37 total arterial pedicles embolized with the balloon-augmented technique, a mean of 1.9 per patient (range 1-5). The treated AVMs were heterogeneous in their location and size (mean 3.3±1.6 cm). Mean fluoroscopy time for each procedure was 48±26 min (28 min per embolized pedicle). Two Scepter C balloon catheter-related complications (8.3% of embolization sessions, 5.4% of pedicles embolized) were observed: an intraprocedural rupture of a feeding pedicle and fracture and retention of a catheter fragment. CONCLUSIONS: This multicenter experience represents the largest reported series of balloon-augmented Onyx embolization of cerebral AVMs. The technique appears safe and effective in the treatment of AVMs, allowing more efficient and controlled injection of Onyx with a decreased risk of reflux and decreased fluoroscopy times.

Analysis of occupational radiation exposure during cerebral angiography utilizing a new real time radiation dose monitoring system.

BACKGROUND: Thermoluminescent dosimeter badges currently utilized to monitor occupational radiation exposures are limited in their ability to provide timely feedback, restricting workers' ability to identify unnecessary exposure. New real time radiation monitoring systems provide an opportunity for workers to immediately identify and alter problematic behaviors in the neuroangiography suite, decreasing unnecessary exposures, lowering risk, and maximizing safety efforts. METHODS: Real time radiation monitoring was performed for 120 diagnostic cerebral angiography procedures. Data were collected in two phases, for procedures performed by two physician participants (30 procedures per physician per phase). Workers were blinded to their real time dose in phase I, and unblinded in phase II. Individual exposures (Sv) and the incidence of red events (exposure rates ≥2.0 mSv/h) were collected for each assigned participating role (physician A, physician B, nurse, scrubbed technologist, and circulating technologist). The dose area product was collected for each procedure to standardize against variations in procedure duration or intensity. RESULTS: In phase II, significant decreased radiation exposure was observed for all roles except physician A. Physician B decreased most from 24.3×10(-8) to 6.9×10(-8) Sv/Gy-cm(2) (p<0.0001). Rates of red events decreased similarly for all roles except physician A, and were significant for all roles except the nurse role. CONCLUSIONS: Real time radiation dose monitoring during diagnostic cerebral angiography may help to reduce occupational radiation exposures for healthcare workers.

Burn-injured patients in a disaster: September 11th revisited.

We sought to review the steps taken by the New York Presbyterian Healthcare System to address disaster preparedness in the wake of the terrorist attacks of September 11, 2001. We reviewed the institutional records of emergency preparedness efforts, including improvements in infrastructure, employee education and training, and participation in intramural and extramural disaster response initiatives. We used a state discharge database to review burn injury triage within New York State (1995-2004). Since September 11, 2001, significant resources have been devoted to emergency preparedness: expansion of emergency services training, education, response, equipment, and communications; participation in regional disaster response exercises; revision of hospital preparedness plans; and development of municipal and regional responses to a burn mass casualty incident. A review of state and city burn triage patterns during the period of 1995 to 2004 revealed a decline in the number of burn cases treated in New York State-based hospitals by an average of 81 +/- 24 (mean +/- SEM) fewer cases/year (P = .01), occurring primarily in hospitals outside of New York City. Additionally, there was a steady increase in the proportion of New York City burn patients treated at burn center hospitals by 1.8 +/- 0.1 % per year (P < .0001). In response to the events of September 11, 2001, this health care system and this hospital has taken many steps to enhance its disaster response capabilities.