Sternotomy for Hemorrhage Control in Trauma.

BACKGROUND: Little is known about the injuries, mechanisms, and outcomes in trauma patients undergoing sternotomy for hemorrhage control (SHC). The purpose of this study was to identify predictors of mortality for SHC and provide a descriptive analysis of the use of SHC in trauma. We hypothesize blunt trauma is associated with higher mortality compared with penetrating trauma among trauma patients requiring SHC. METHODS: The Trauma Quality Improvement Program (2013-2016) database was queried for adult patients undergoing SHC within 24 h of admission. Patients with blunt and penetrating trauma were compared using chi-square and Mann-Whitney U-test. A multivariable logistic regression model was used to determine the risk of mortality. RESULTS: Of 584 patients undergoing SHC, 322 (55.1%) were involved in penetrating trauma, and 69 (11.8%) were involved in blunt. The blunt trauma group had a higher median injury severity score (31.5 versus 25.0; P < 0.001) compared with the penetrating group. The median time to hemorrhage control was longer in those with blunt compared with penetrating trauma (84.6 versus 49.8 min; P < 0.001). The mortality rate was higher in patients with blunt compared with penetrating trauma (29.0% versus 12.7%; P < 0.001). However, after adjusting for covariates, there was no difference in risk of mortality between blunt and penetrating trauma (P = 0.06). CONCLUSIONS: Trauma patients requiring SHC after blunt trauma had a higher mortality rate than those in penetrating trauma. After adjusting for predictors of mortality, there was no difference in risk of mortality despite nearly double the time to hemorrhage control in patients presenting after blunt trauma.

Decreased incidence of venous thromboembolism found in trauma patients with positive blood alcohol concentration on admission.

BACKGROUND: The reported incidence of venous thromboembolism (VTE) disease in trauma is 1-58% and is considered a preventable cause of mortality. Positive blood alcohol concentration (BAC) is found in 8-45% of trauma admissions; however, its association with VTE is controversial. OBJECTIVES: We hypothesized that a positive BAC on admission would be associated with a lower rate of VTE in a large national database of trauma patients. METHODS: We queried the largest United States trauma registry, National Trauma Data Bank (2007-2015), for any patient with positive BAC on admission. The primary outcome was VTE and the secondary outcome was mortality. A multivariable logistic regression model was used for analysis. RESULTS: From 2,725,032 patients (70.1% male, 29.9% female), 1,800,216 (66.1%) had a negative BAC while 924,816 (33.9%) had a positive BAC. A positive BAC was associated with lower rates of VTE (OR = 0.88, CI = 0.86-0.90, p < 0.001) and mortality (OR = 0.91, CI = 0.90-0.93, p < 0.001). CONCLUSION: In a large national database, trauma patients with a positive BAC were associated with a lower rate of VTE compared to those with negative BAC. Additionally, trauma patients with positive BAC had a lower association with mortality. These findings remained after adjustment of well-known risk factors for VTE and mortality, respectively.

Image-guided resection of aggressive sacral tumors.

OBJECTIVE The aim of this study was to identify and discuss operative nuances utilizing image guidance in the surgical management of aggressive sacral tumors. METHODS The authors report on their single-institution, multi-surgeon, retrospective case series involving patients with pathology-proven aggressive sacral tumors treated between 2009 and 2016. They also reviewed the literature to identify articles related to aggressive sacral tumors, their diagnosis, and their surgical treatment and discuss the results together with their own experience. Information, including background, imaging, treatment, and surgical pearls, is organized by tumor type. RESULTS Review of the institutional records identified 6 patients with sacral tumors who underwent surgery between 2009 and 2016. All 6 patients were treated with image-guided surgery using cone-beam CT technology (O-arm). The surgical technique used is described in detail, and 2 illustrative cases are presented. From the literature, the authors compiled information about chordomas, chondrosarcomas, giant cell tumors, and osteosarcomas and organized it by tumor type, providing a detailed discussion of background, imaging, and treatment as well as surgical pearls for each tumor type. CONCLUSIONS Aggressive sacral tumors can be an extremely difficult challenge for both the patient and the treating physician. The selected surgical intervention varies depending on the type of tumor, size, and location. Surgery can have profound risks including neural compression, lumbopelvic instability, and suboptimal oncological resection. Focusing on the operative nuances for each type can help prevent many of these complications. Anecdotal evidence is provided that utilization of image-guided surgery to aid in tumor resection at our institution has helped reduce blood loss and the local recurrence rate while preserving function in both malignant and aggressive benign tumors affecting the sacrum.

Resection of spinal column tumors utilizing image-guided navigation: a multicenter analysis.

OBJECTIVE The use of intraoperative stereotactic navigation has become more available in spine surgery. The authors undertook this study to assess the utility of intraoperative CT navigation in the localization of spinal lesions and as an intraoperative tool to guide resection in patients with spinal lesions. METHODS This was a retrospective multicenter study including 50 patients from 2 different institutions who underwent biopsy and/or resection of spinal column tumors using image-guided navigation. Of the 50 cases reviewed, 4 illustrative cases are presented. In addition, the authors provide a description of surgical technique with image guidance. RESULTS The patient group included 27 male patients and 23 female patients. Their average age was 61 ± 17 years (range 14-87 years). The average operative time (incision to closure) was 311 ± 188 minutes (range 62-865 minutes). The average intraoperative blood loss was 882 ± 1194 ml (range 5-7000 ml). The average length of hospitalization was 10 ± 8.9 days (range 1-36 days). The postoperative complications included 2 deaths (4.0%) and 4 radiculopathies (8%) secondary to tumor burden. CONCLUSIONS O-arm 3D imaging with stereotactic navigation may be used to localize lesions intraoperatively with real-time dynamic feedback of tumor resection. Stereotactic guidance may augment resection or biopsy of primary and metastatic spinal tumors. It offers reduced radiation exposure to operating room personnel and the ability to use minimally invasive approaches that limit tissue injury. In addition, acquisition of intraoperative CT scans with real-time tracking allows for precise targeting of spinal lesions with minimal dissection.

Cost-effectiveness analysis in minimally invasive spine surgery.

OBJECT: Medical care has been evolving with the increased influence of a value-based health care system. As a result, more emphasis is being placed on ensuring cost-effectiveness and utility in the services provided to patients. This study looks at this development in respect to minimally invasive spine surgery (MISS) costs. METHODS: A literature review using PubMed, the Cost-Effectiveness Analysis (CEA) Registry, and the National Health Service Economic Evaluation Database (NHS EED) was performed. Papers were included in the study if they reported costs associated with minimally invasive spine surgery (MISS). If there was no mention of cost, CEA, cost-utility analysis (CUA), quality-adjusted life year (QALY), quality, or outcomes mentioned, then the article was excluded. RESULTS: Fourteen studies reporting costs associated with MISS in 12,425 patients (3675 undergoing minimally invasive procedures and 8750 undergoing open procedures) were identified through PubMed, the CEA Registry, and NHS EED. The percent cost difference between minimally invasive and open approaches ranged from 2.54% to 33.68%-all indicating cost saving with a minimally invasive surgical approach. Average length of stay (LOS) for minimally invasive surgery ranged from 0.93 days to 5.1 days compared with 1.53 days to 12 days for an open approach. All studies reporting EBL reported lower volume loss in an MISS approach (range 10-392.5 ml) than in an open approach (range 55-535.5 ml). CONCLUSIONS: There are currently an insufficient number of studies published reporting the costs of MISS. Of the studies published, none have followed a standardized method of reporting and analyzing cost data. Preliminary findings analyzing the 14 studies showed both cost saving and better outcomes in MISS compared with an open approach. However, more Level I CEA/CUA studies including cost/QALY evaluations with specifics of the techniques utilized need to be reported in a standardized manner to make more accurate conclusions on the cost effectiveness of minimally invasive spine surgery.

The Effects of the 80-hour Workweek on Occupational Hazards.

BACKGROUND : The most recent work-hour restrictions were implemented in July 2011 for training physicians. The impact of these regulations on workplace injuries is not yet fully understood. Our goal is to determine the effect of the work-hour limitation on the rates of needlestick and eyesplash injuries. METHODS : Approximately 1200 neurosurgery residents and fellows in the United States were emailed a survey, several times, Sept 2013-February 2014. There were 212 responses across postgraduate years 1-7 and fellowship regarding the rate of needlestick and eyesplash injuries experienced or witnessed before and after July 2011. RESULTS : Regarding witnessing a needlestick/eyesplash accident: 89.33% of respondents claimed witnessing an injury. Specifically regarding percutaneous injuries (PCIs): before July 2011, 21.77% claimed never witnessing; after July 2011, only 8.9% indicated never witnessing. Specifically regarding eyesplash injuries: comparing the injuries (40.94%) before July 2011 to those (51.94%) after July 2011, the survey indicated an increase in eyesplash injuries. CONCLUSION : The results of this survey document that neurosurgery residents/fellows observed (or personally sustained) an increased number of needlestick and eyesplash injuries after implementation of the July 2011 work-hour limitations. Although the last set of reduced-hour regulations have been in place for more than three years, there does not therefore seem to be a safety advantage associated with them regarding a reduction in PCI or eyesplash accidents. This may be due to other confounding factors, not yet affirmatively identified, which warrant additional investigation and identification, directed at preventing future injuries.

Long-term Remission Over Six Years for a Patient with Recurrent Glioblastoma Treated with Cediranib/Lomustine.

Cediranib is an orally available, pan-VEGFR tyrosine kinase inhibitor. A previous Phase III study of patients with recurrent glioblastoma treated with this drug did not meet the primary end of progressive-free survival (PFS). We identified one patient, a 57-year-old Caucasian female who, following surgery in October 2008 and concurrent temozolomide and radiation therapy from November 8, 2008, to January 6, 2009, developed a tumor progression of the left posterior frontal measuring 1.2 x 1.5 cm in February 2009. She was enrolled in a randomized, Phase III, placebo-controlled, partially-blinded clinical trial of cediranib as either monotherapy or in combination with lomustine (CCNU) versus CCNU. She was randomized to receive a combination therapy with 1st cycle CCNU 190 mg and cediranib 20 mg per day on April 15, 2009. However, she developed nephrotic syndrome and uncontrolled hypertension and was taken off this study in May 2010. Her six-week MRI showed a 50% tumor regression and a complete response at twenty-four weeks. With no enhancement seen on MRI on June 4, 2015, she has been off therapy and in clinical remission over five years with high functional level and good quality of life (KPS-90%). This is a case report of successful therapy for recurrent glioblastoma with long-term remission despite termination of therapy greater than six years from cediranib and limited CCNU dosage.

Treatment of Recurrent Disc Herniation: A Systematic Review.

Intervertebral disc herniation is one of the most common causes of back and extremity pain. The most commonly used surgical treatment is lumbar discectomy. About 0.5-25% go on to develop recurrent disc herniation (rDH) after a successful first discectomy. Currently, there aren't any guidelines to assist surgeons in determining which approach is most appropriate to treat rDH. A recent survey showed significant heterogeneity among surgeons regarding treatment options for rDH. It remains unclear which methods lead to better outcomes, as there are no comparative studies with a sufficient level of evidence. In this study, we aimed to perform a systematic review to compare treatment options for rDH and determine if one intervention provides better outcomes than the other; more specifically, whether outcome differences exist between discectomy alone and discectomy with fusion. We applied the PICOS (participants, intervention, comparison, outcome, study design) format to develop this systematic review through PubMed. Twenty-seven papers from 1978-2014 met our inclusion criteria and were included in the analysis. Nine papers reported outcomes after discectomy and seven of them showed good or excellent outcomes (70.60%-89%). Ten papers reported on minimally invasive discectomy. The percent change in visual analog scale (VAS) ranged from -50.77% to -86.57%, indicating an overall pain reduction. Four studies out of the ten reported good or excellent outcomes (81% to 90.2%). Three studies looked at posterolateral fusion. Three studies analyzed posterior lumbar interbody fusion. For one study, we found the VAS percentage change to be -46.02%. All reported good to excellent outcomes. Six studies evaluated the transforaminal lumbar interbody fusion. All reported improvement in pain. Four used VAS, and we found the percent change to be -54% to -86.5%. The other two used the Japanese Orthopedic Association (JOA) score, and we found the percent change to be 68.3% to 93.3%. We did not find enough evidence to support any significant difference in outcomes between discectomy alone and discectomy with fusion. The limitation of our study includes the lack of standardized outcomes reporting in the literature. However, reviewing the selected articles shows that fusion may have a greater improvement in pain compared to reoperation without fusion. Nonetheless, our study shows that further and more in-depth investigation is needed on the of treatment of rDH.

Scoliosis surgery in the elderly: Complications, readmissions, reoperations and mortality.

The operative management of scoliosis in the elderly remains controversial. The authors of this study sought to evaluate outcomes in elderly patients with scoliosis undergoing deformity correction. Patient data was obtained from a 5% sample of the Medicare Provided Analysis and Review database (MEDPAR). Patients over 65years of age with scoliosis undergoing corrective surgery were identified between the years 2005 to 2011. A total of 453 patients were analyzed: 262 (57%) between ages 66 to 74years, and 191 (42%) over the age of 75years. Female predominance (78%) was observed in this sample. Pre-diagnosis follow-up averaged 118months. Post-surgery follow-up averaged 33months. Patients between 66 and 74years old were mostly discharged home, while patients over the age of 75years were discharged to skilled nursing facilities (SNFs) (38.55% versus 34.04%, p value=0.0011). Readmission rates were lower in patients between 66 and 74years old when compared to patients over the age of 75years (9.92% versus 17.28%, p value=0.0217). Complication rates 30-days after discharge were less in patients between 66 and 74years, compared to those over 75years (21% versus 26.6%, respectively), but this was not statistically significant. These findings suggest varying outcomes following scoliosis surgery in the elderly, but interpretation of these results is weakened by the inherent limitations of database utilization. Future prospective studies are needed to understand risk factors and other confounding variables, such as discharge disposition, that may influence outcomes.

Routine intraoperative cholangiography is unnecessary in patients with mild gallstone pancreatitis and normalizing bilirubin levels.

BACKGROUND: The benefit of intraoperative cholangiography (IOC) is controversial in patients with gallstone pancreatitis whose bilirubin levels are normalizing. IOC with subsequent endoscopic retrograde cholangiopancreatography may lengthen duration of surgery and length of stay, whereas failure to clear the common bile duct may result in recurrent pancreatitis. METHODS: We performed a 6-year retrospective cohort analysis of consecutive adult patients with mild gallstone pancreatitis undergoing same-admission cholecystectomy at 2 university-affiliated medical centers. Institution A routinely performed IOC, whereas institution B did not. The primary outcome was readmission within 30 days for recurrent pancreatitis. RESULTS: Of 520 patients evaluated, 246 (47%) were managed at institution A (routine IOC) and 274 (53%) were managed at institution B (restricted IOC). Patients at institution B had a shorter duration of surgery (1.0 vs 1.6 hours, P < .001), shorter length of stay (4 vs 5 days, P < .001), and fewer postoperative endoscopic retrograde cholangiopancreatographies performed (1.8% vs 21%, P < .001), without a difference in readmissions (1.5% vs 0%, P = .12). CONCLUSIONS: Routine IOC is not necessary in the setting of mild gallstone pancreatitis with normalizing bilirubin values.

Disparities in clinical and economic outcomes in children and adolescents following surgery for tethered cord syndrome in the United States.

OBJECT: Tethered cord syndrome (TCS) is a common spinal abnormality. In this study, the authors analyzed demographics, complications, and outcomes in children and adolescents who underwent surgery for TCS. METHODS: Using the national Kids' Inpatient Database (KID), the authors retrospectively identified patients with a primary diagnosis of TCS who were treated with spinal laminectomy and discharged in 2000, 2003, 2006, and 2009. Descriptive analysis was provided for patient- and hospital-level characteristics. Mortality, complications, non-routine discharges, in-hospital length of stay (LOS), and total charges were documented for the entire cohort and age-specific cohorts (0-5, 6-10, 11-15, and 16-20 years). Comparisons by complications and age groups were conducted. RESULTS: A total of 7397 children and adolescents met the criteria in the 4 studied years. The mean age was 5.7 years; 55.3% of patients were younger than 5 years, 21.5% were 6-10 years, and 16.2% were 11-15 years. Most surgeries were performed in patients who were female (55.0%) and white (64.4%) and were performed at large (49.8%), teaching (94.2%), and urban (99.1%) children's (89.3%) hospitals. The trend showed an increase in prevalence from 2000 (19.9%) to 2009 (29.6%). Common comorbidities included anomalies in spinal curvature (16.7%), urinary or bladder dysfunction (14.3%), and spinal stenosis/spondylosis (1.4%). Non-routine discharges (3.3%) were significantly higher with advancing age, increasing from 2.2% in those younger than 5 years to 9.0% in those older than 15 years (p < 0.0001). There was a similar increasing trend for complications (6.8% to 13.9%, respectively, p < 0.0001) and average LOS (3.5 to 5.1 days, respectively, p < 0.0001). Hospital charges increased with age from an average of $28,521 in those younger than 5 years to $36,855 in those older than 15 years (p < 0.0001). CONCLUSIONS: There was a steady trend of increasing operative treatment for TCS over the more recent years. The nationwide analysis was also indicative of an existing disparity, based on age, in complications, outcomes, and charges following TCS surgical correction. Older children tended to have more complications, longer LOS, more non-routine discharges, and higher hospital costs. The results are highly supportive of surgery at a younger age for this condition. Future research should investigate this correlation, especially considering the efforts to control and reduce health care costs.

Economics of image guidance and navigation in spine surgery.

BACKGROUND: Image-guidance and navigation in spinal surgery is becoming more widely utilized. Several studies have shown the use of this technology to increase accuracy of pedicle screw placement, decrease the rates of revision surgery, and minimize radiation exposure. In this paper, the authors analyze the economics of image-guided surgery (IGS) and navigation in spine surgery. METHODS: A literature review was performed using PubMed, the CEA Registry, and the National Health Service Economic Evaluation Database. Each article was screened for inclusion and exclusion criteria, including costs, reoperation, readmission rates, operating room time, and length of stay. RESULTS: Thirteen studies were included in the analysis. Six studies were identified to meet the inclusion criteria for reporting costs and seven met the criteria for analysis of efficacy. Average costs ranged from $17,650 to $39,643. Pedicle screw misplacement rates using IGS ranged from 1.20% to 15.07% while reoperation rates ranged from 0% to 7.42%. CONCLUSION: There is currently an insufficient amount of studies reporting on the economics of spinal navigation to accurately conclude on its cost-effectiveness in clinical practice. Although a few of these studies showed less costs associated with intraoperative imaging, none were able to establish a statistically significant difference. Preliminary findings drawn from this study indicate a possible cost-effectiveness advantage with IGS, but more comprehensive data on costs need to be reported in order to validate its utilization.