Early elective delivery for fetal ventriculomegaly: are neurosurgical and medical complications mitigated by this practice?

PURPOSE: Antenatally diagnosed ventriculomegaly (VM) requires the balance of risks of neurological injury with premature delivery. The purpose of this study was to evaluate outcomes related to early elective delivery due to fetal VM at our institution. METHODS: We retrospectively assessed 120 babies (2008-2012) with antenatally diagnosed fetal VM. Inclusion criteria for ("early") cohort were (1) elective delivery occurred for expedited neurosurgical intervention between 32 and 36 weeks EGA and (2) fetal VM noted on official antenatal ultrasound. The comparative "near term" cohort differed only in that delivery occurred at 37+ weeks EGA. Statistical significance for comparative analyses set a priori at p < 0.05. RESULTS: Babies electively delivered early had a lower birthweight (p < 0.0001), greater ventricle width (p < 0.0001), and underwent initial CSF diversion sooner (p = 0.014). The early cohort (n = 22), compared to near term (n = 50), had a lower birthweight (p < 0.0001), greater ventricle width (p < 0.0001), and underwent initial CSF diversion sooner (p = 0.014). The early cohort required more repeat procedures: (45 vs. 22% p = 0.021), and VPS removals after VPS infections (41 vs. 12%, p = 0.010). Additionally, newborn respiratory failure (32 vs. 6%, p = 0.037) was more common. Finally, of four babies who died in the early cohort, 2/4 died for prematurity-associated pulmonary hypoplasia. CONCLUSIONS: While early elective delivery for fetal VM expedites intervention for rapidly expanding ventricles, few benefits were identified. Our study concluded those infants that were delivered earlier had increased VPS infections, repeat neurosurgical procedures, and medical co-morbidities. A multi-institutional prospective observational study would be needed in order to confirm the clinical implications of such practice.

Cutibacterium acnes in spine surgery: pathophysiology, diagnosis, and treatment.

Cutibacterium acnes (C. acnes) previously named Propionibacterium acnes (P. acnes) has been increasingly recognized by spine surgeons as a cause of indolent post-surgical spinal infection. Patients infected with C. acnes may present with pseudarthrosis or nonspecific back pain. Currently, microbiological tissue cultures remain the gold standard in diagnosing C. acnes infection. Ongoing research into using genetic sequencing as a diagnostic method shows promising results and may be another future way of diagnosis. Optimized prophylaxis involves the use of targeted antibiotics, longer duration of antibiotic prophylaxis, antibacterial-coated spinal implants, and evidence-based sterile surgical techniques all of which decrease contamination. Antibiotics and implant replacement remain the mainstay of treatment, with longer durations of antibiotics proving to be more efficacious. Local guidelines must consider the surge of antimicrobial resistance worldwide when treating C. acnes.

Value Proposition to a Hospital of Obtaining 36-inch Standing Scoliosis Film Technology.

Introduction Some hospitals do not have the technological capabilities of obtaining full 36-inch long-standing films to evaluate patients via proper sagittal balance spinal imaging protocol. Resistance from hospital administration for the purchase of proper hardware and software remains frustrating for spinal surgeons at both community and academic hospitals. Materials and methods Recurring transaction-based revenue streams were applied comparing cost with the different income generation at the hospital level. Cost is fixed cost, attributed to purchasing both the physical radiograph machine as well as the necessary software capabilities. Marginal cost was negligible as both materials and human capital are largely fungible and trivial at the margin. Revenue generation is largely identical to marginal revenue. Income was linked to the Hospital Outpatient Prospective Payment System for radiographic interpretation of films (Current Procedural Terminology (CPT) 72069). Income was also estimated from surgical volume calculation. Results The listed prospective outpatient radiographic reimbursement for the hospital was $24.36 per film. Medicare-defined reimbursements for a complex spinal fusion except cervical with spinal curvature, malignancy or 9+ fusions with a Major Complication or Comorbidity (MCC) was listed at $55,228, and with a Complication or Comorbidity (CC) was noted to be $40,566. Complex spinal fusion except cervical with spinal curvature, malignancy or 9+ fusions without CC/MCC was listed as $30,913. Lumbar spinal fusion except cervical with MCC was $39,164 and with CC was $23,490. University Neurosurgery at Louisiana State University (LSU) Health Sciences Center in Shreveport, LA performed 1,013 thoracolumbar procedures in fiscal year (FY) 2015 with 557 (54.9%) being instrumented procedures. At a minimum, all instrumented procedures could benefit from proper spinal axis imaging, representing $13,568.52 of transaction-based annual gross revenue from radiographs alone. Hypothetical revenue generation of $491,696.42 was calculated. Conclusion There is a significant value proposition to the hospital in obtaining the proper technology for formal standing 36-inch scoliosis imaging. Marginal cost is negligible, while there are significant opportunities for marginal revenue per image obtained through transaction-based gross revenue, as well an immense hypothetical revenue stream from surgery-related gains. More importantly, it ensures a proper and complete delivery of spinal health to the hospital's healthcare population.