The Effect of Antithrombotics on Hematoma Expansion in Small- to Moderate-Sized Traumatic Intraparenchymal Hemorrhages.

BACKGROUND: Although pre-injury antithrombotic agents, including antiplatelets and anticoagulants, are historically associated with expansion of traumatic intraparenchymal hemorrhage (tIPH), the literature has poorly elucidated the actual risk of hematoma expansion on repeat computed tomography (CT). The objective was to determine the effect of antithrombotic agents on hematoma expansion in tIPH by comparing patients with and without pre-injury antithrombotic medication. METHODS: The volume of all tIPHs over a 5-year period at an academic Level 1 trauma center was measured retrospectively. The initial tIPH was divided into 3 equally sized quantiles. The third tercile, representing the largest subset of tIPH, was then removed from the study population because these patients reflect a different pathophysiologic mechanism that may require a more acute and aggressive level of care with reversal agents and/or operative management. Per institutional policy, all patients with small- to moderate-sized hemorrhages received a 24-hour stability CT scan. Patients who received reversal agents were excluded. RESULTS: Of the 105 patients with a tIPH on the initial head CT scan, small- to moderate-sized hemorrhages were <5 cm3. The size of tIPH on initial imaging did not statistically significantly differ between the antithrombotic cohort (0.7 ± 0.1 cm3) and the non-antithrombotic cohort (0.5 ± 0.1 cm3) (P = 0.091). Similarly, the volume of tIPH failed to differ on 24-hour repeat imaging (1.0 ± 0.2 cm3 vs. 0.6 ± 0.1 cm3, respectively, P = 0.172). Following a multiple linear regression, only history of stroke, not antithrombotic medications, predicted increased tIPH on 24-hour repeat imaging. CONCLUSIONS: In small- to moderate-sized tIPH, withholding antithrombotic agents without reversal may be sufficient.

The Effect of Physical Therapy on Time to Discharge After Lumbar Interbody Fusion.

BACKGROUND: With a lesser degree of tissue destruction, patients undergoing minimally-invasive spine surgery are primed to benefit from early mobilization, which can further enhance recovery and hasten rehabilitation. We aimed to determine the role of physical therapy on earlier discharge after minimally-invasive transforaminal lumbar interbody fusion (TLIF). METHODS: Michigan Spine Surgery Improvement Collaborative (MSSIC) provided patients undergoing one- and two-level minimally-invasive TLIF for degenerative lumbar disease. The study population was divided into patients with a one-day length of stay (LOS 1), two days (LOS 2), and three or more days (LOS ≥ 3) to maintain three equal-time cohorts. On POD 0, physical therapy (or, in very rare circumstances, a spine-care-specialized nurse in patients arriving to the in-patient floors late after hours) must evaluate capacity to ambulate. RESULTS: Of the 101 patients, the median day of first ambulation statistically significantly increased from the LOS 1 to LOS ≥ 3 cohort (P = 0.007). Mean distance ambulated decreased from 156.5 ±â€¯123.1 feet in the LOS 1 group, 108.9 ±â€¯83.9 feet in the LOS 2 group, to 69.2 ±â€¯58.3 feet in the LOS ≥ 3 group (P = 0.002). Patient-reported outcomes did not differ among the three cohorts. Following a multivariable ordinal logistical regression controlling for disposition to rehab over home (ORadj = 5.47, P = 0.045), the odds of longer LOS decreased by 39% for every 50-feet ambulated (P = 0.002). CONCLUSIONS: Time to first ambulation independently increases the odds of earlier discharge, regardless of comorbidity burden and surgical determinants.

Prevalence of Alternative Diagnoses and Implications for Management in Idiopathic Normal Pressure Hydrocephalus Patients.

BACKGROUND: Following Bayes theorem, ventriculomegaly and ataxia confer only a 30% chance of idiopathic Normal Pressure Hydrocephalus (NPH). When coupled with positive responses to best diagnostic testing (extended lumbar drainage), 70% of patients recommended for shunting will not actually have NPH. This is inadequate clinical care. OBJECTIVE: To determine the proportion of alternative and treatable diagnoses in patients referred to a multidisciplinary NPH clinic. METHODS: Patients without previously diagnosed NPH were queried from prospectively collected data. At least 1 neurosurgeon, cognitive neurologist, and neuropsychologist jointly formulated best treatment plans. RESULTS: Of 328 total patients, 45% had an alternative diagnosis; 11% of all patients improved with treatment of an alternative diagnosis. Of 87 patients with treatable conditions, the highest frequency of pathologies included sleep disorders, and cervical stenosis, followed by Parkinson disease. Anti-cholinergic burden was a contributor for multiple patients. Of 142 patients undergoing lumbar puncture, 71% had positive responses and referred to surgery. Compared to NPH patients, mimickers were statistically significantly older with lower Montreal Cognitive Assessment (MoCA) score and worse gait parameters. Overall, 26% of the original patients underwent shunting. Pre-post testing revealed a statistically significant improved MoCA score and gait parameters in those patients who underwent surgery with follow-up. CONCLUSION: Because the Multidisciplinary NPH Clinic selected only 26% for surgery (corroborating 30% in Bayes theorem), an overwhelming majority of patients with suspected NPH will harbor alternative diagnoses. Identification of contributing/confounding conditions will support the meticulous work-up necessary to appropriately manage patients without NPH while optimizing clinical responses to shunting in correctly diagnosed patients.

A Survey of Chemoprophylaxis Techniques in Spine Surgery Among American Neurosurgery Training Programs.

BACKGROUND: A paucity of randomized trials have compared prophylactic dose of unfractionated heparin (UFH) versus low-molecular-weight heparin (LMWH) for the prevention of venous thromboembolic events in spinal surgery. Our objective was to determine the most prevalent chemoprophylactic techniques in spine surgery. METHODS: The Accreditation Council for Graduate Medical Education was queried for all neurosurgical residency programs, which were subsequently sent an electronic survey about prophylactic UFH versus LMWH in spine surgery for (1) degenerative/deformity, (2) traumatic, and (3) neoplastic pathologies. RESULTS: Of 69 unique responding residencies, the first dose of chemoprophylaxis for degenerative/deformity spinal disease started most commonly on postoperative day (POD) 1 in 75.3% of neurosurgery programs, followed by POD 2 in 10.1% of programs, POD 0 (same day of surgery) in 8.7% of programs, POD 3 in 1.4% of programs, and morning of surgery in 1.4% of programs. Choice of postoperative chemoprophylaxis did not differ statistically significantly between UFH versus LMWH: 56.5% versus 36.2% in degenerative/deformity pathologies (P = 0.080) and 50.7% versus 43.4% in traumatic pathologies (P = 0.535). Three programs (4.3%) in both the degenerative/deformity and trauma groups documented no chemoprophylaxis. Neoplastic pathologies saw a statistically significantly higher proportion of prophylactic UFH (60.8%) compared with prophylactic LMWH (36.2%) (P = 0.037). One program (1.4%) in the neoplastic group did not utilize chemoprophylaxis. Two institutions (2.8%) in the degenerative/deformity cohort and 1 institution (1.4%) in the trauma and cancer cohorts reported "other". CONCLUSIONS: Prophylactic UFH was statistically more common than LMWH in neoplastic spinal surgery, but not in the degenerative/deformity and trauma groups (cohorts). Further trials are warranted.

Trends in the Abscopal Effect After Radiation to Spinal Metastases: A Systematic Review.

While the abscopal effect has been previously described, the phenomenon has been poorly defined in the case of spinal metastases. This article is unique in that we present the first systematic review of the abscopal effect after radiation therapy to metastatic spinal cancer, especially since the spinal column represents one of the most common metastatic locations. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) resources, a systematic review identified relevant studies via a computer-aided search of MEDLINE and Embase. Ten publications that met the inclusion and exclusion criteria from the PRISMA flow diagram described a total of 13 patients, 76.9% of whom demonstrated image findings of the abscopal effect. In summary, important trends in the nine patients who experienced the abscopal effect in this review include higher doses of radiation and treatment with immunomodulators, both of which may help guide treatment paradigms for spinal metastases superimposed on diffuse metastatic disease. These trends, however, still warrant further investigations with experimental and clinical studies for a mechanistic understanding of the abscopal effect.

A direct comparison of prophylactic low-molecular-weight heparin versus unfractionated heparin in neurosurgery: A meta-analysis.

BACKGROUND: Several studies have confirmed the role of prophylactic low-molecular-weight heparin (LMWH) for venous thromboembolism (VTE) in neurosurgery; however, a paucity of literature has assessed its safety and efficacy versus prophylactic unfractionated heparin (UFH). The objective is to present a meta-analysis directly comparing prophylactic LMWH to UFH for the prevention of VTE in neurosurgery. MATERIALS AND METHODS: Relevant studies that directly compared LMWH to UFH for prophylaxis of VTE in neurosurgery and/or spine surgery were identified by MEDLINE and EMBASE searches plus a scrutiny of references from the original articles and reviews. Three randomized trials were included in the meta-analysis. Efficacy and safety were ascertained per three primary outcome measures: VTE, minor complications (decline in hemoglobin/hematocrit), and major complications. Forest plot analysis provided odds ratio (OR), 95% confidence intervals (CIs), and P-values. RESULTS: Of the 429 patients in the pooled analysis, the postoperative VTE rate of 5.6% (12/213) after LMWH chemoprophylaxis was equivalent to 3.7% (8/216) after UFH chemoprophylaxis (OR = 1.42, 95% CI 0.62-3.75, P = 0.308). Minor complications of 4.7% versus 4.6%, respectively, were nearly equal (OR = 1.01, 95% CI 0.41- 2.50, P = 0.929). All four major complications included intracranial hemorrhages: three after LMWH (1.4%) and one after UFH (0.5%) (OR = 2.32, 95% CI 0.34-16.01, P = 0.831). Tests for heterogeneity were nonsignificant in all three outcome measures. CONCLUSION: Rates of VTE, minor complications, and major complications were equivalent between prophylactic LMWH and UFH in neurosurgery. Further, randomized clinical trials comparing the two heparin products are required to elucidate superior safety and efficacy in neurosurgical patients.

The Impact of Different Postgraduate Year Training in Neurosurgery Residency on 30-Day Postoperative Outcomes.

BACKGROUND: Previous studies have failed to demonstrate statistically significant differences in postsurgical outcomes between operative cases featuring resident participation compared to attending only; however, the effects of level of postgraduate year (PGY) training have not been explored. OBJECTIVE: To correlate different PGYs in neurosurgery with 30-d postoperative outcomes. METHODS: Using National Surgical Quality Improvement Program 2005-2014, adult neurosurgical cases were divided into subspecialties: spine, open-vascular, cranial, and functional in teaching institutions. Comparison groups: cases involving junior residents (PGY 1-PGY 3), mid-level residents (PGY 4 + PGY 5), and senior residents (PGY 6 + PGY 7). Primary outcome measures included any wound disruption (surgical site infections and/or wound dehiscence), Clavien-Dindo grade IV (life-threatening) complications, and death. RESULTS: Compared to junior residents (n = 3729) and mid-level residents (n = 2779), senior residents (n = 3692) operated on patients with a greater comorbidity burden, as reflected by higher American Society of Anesthesiology classifications and decreased level of functional status. Cases with senior resident participation experienced the highest percentages of postoperative wound complications (P = .005), Clavien-Dindo grade IV complications (P = .001), and death (P = .035). However, following multivariable regression, level of residency training in neurosurgery did not predict any of the 3 primary outcome measures. Compared to spinal cases, cranial cases predicted a higher incidence of life-threatening complications (odds ratio 1.84, P < .001). CONCLUSION: Cases in the senior resident cohort were more technically challenging and exhibited a higher comorbidity burden preoperatively; however, level of neurosurgical training did not predict any wound disruption, life-threatening complications, or death. Residents still provide safe and effective assistance to attending neurosurgeons.

Clinching the cause: A review of foot drop secondary to lumbar degenerative diseases.

Foot drop is defined as weakness on dorsiflexion of the foot. The top two most common etiologies for foot drop include lumbar degenerative disease and common peroneal nerve injury. This review provides "updates" on understanding the lumbar etiologies of foot drop. Since the publication of "Preoperative motor strength and time to surgery are the most important predictors of improvement in foot drop due to degenerative lumbar disease" in the Journal of Neurological Sciences, three cohort studies have been published on spinal causes of foot drop. Classification, clinical features, diagnosis, and pathogenesis that may 'clinch' the cause of foot drop are discussed in the context of these recent publications.

The Impact of Different Postgraduate Year Training in Neurosurgery Residency on 30-Day Return to Operating Room: A National Surgical Quality Improvement Program Study.

OBJECTIVE: Because of the health care initiative on quality improvement projects in academic medicine, this study explores the impact of different postgraduate years (PGYs) on unexpected re-operation rates. METHODS: Using the National Surgical Quality Improvement Program 2005-2014, adult neurosurgical cases were divided into subspecialties: spine, open vascular, cranial, and functional. Comparison groups were cases involving junior residents (PGY 1-PGY 3), mid-level residents (PGY 4 + PGY 5), and senior residents (PGY 6 + PGY 7). Comorbidity disease burden was measured by frailty index. The primary outcome measure was 30-day unintended return to the operating room. RESULTS: Of the 9782 cases, re-operations were higher for those cases featuring a senior resident (5.6%) compared with mid-level resident (4.1%) and junior resident (3.8%) (P = 0.001). Although senior residents operated on patients with a statistically significantly higher neurologic disease burden, greater relative value units, longer operative times, and more 30-day postoperative adverse events, the level of resident training did not have an impact on revision surgery after multivariable logistical regression. The strongest predictors of return to the operating room included the frailty index (adjusted odds ratio [ORadj] = 5.18, P < 0.001), functional subspecialty (ORadj = 2.65, P < 0.001), and Wound Class 4 - dirty/infected wound (ORadj = 2.33, P = 0.016). CONCLUSIONS: Resident participation in neurosurgical cases does not affect 30-day unplanned re-operation rates, which were affected by frailty index, functional subspecialty, and wound class.