Spinal fractures in the setting of diffuse idiopathic skeletal hyperostosis conservatively treated via orthosis: illustrative cases.

BACKGROUND: Fractures in patients with diffuse idiopathic skeletal hyperostosis (DISH) are considered highly unstable injuries with high risk for neurological injury. Surgical intervention is the standard of care for these patients to avoid secondary spinal cord injuries. Despite this, certain cases may necessitate a nonoperative approach. Herein within, the authors describe three cases of cervical, thoracic, and lumbar fractures in the setting of DISH that were successfully treated via orthosis. OBSERVATIONS: The authors present three cases of fractures in patients with DISH. A 74-year-old female diagnosed with an acute fracture of a flowing anterior osteophyte at C6-C7 treated with a cervical orthosis. A 78-year-old male with an anterior fracture of the ankylosed T7-T8 vertebrae managed with a Jewett hyperextension brace. Finally, a 57-year-old male with an L1-L2 disc space fracture treated with a thoraco-lumbo-sacral orthosis. All patients recovered successfully. LESSONS: In certain cases, conservative treatment may be more appropriate for fractures in the setting of DISH as an alternative to the surgical standard of care. Most fractures in the setting of DISH are unstable, therefore it is necessary to manage these patients on a case-by-case basis.

Academics versus the Internet: Evaluating the readability of patient education materials for cerebrovascular conditions from major academic centers.

Background: Health literacy profoundly impacts patient outcomes as patients with decreased health literacy are less likely to understand their illness and adhere to treatment regimens. Patient education materials supplement in-person patient education, especially in cerebrovascular diseases that may require a multidisciplinary care team. This study aims to assess the readability of online patient education materials related to cerebrovascular diseases and to contrast the readability of those materials produced by academic institutions with those of non-academic sources. Methods: The readability of online patient education materials was analyzed using Flesch-Kincaid Grade Level (FKGL) and Flesch Reading Ease (FRE) assessments. Readability of academic-based online patient education materials was compared to nonacademic online patient education materials. Online patient education materials from 20 academic institutions and five sources from the web were included in the analysis. Results: Overall median FKGL for neurovascular-related patient online education documents was 11.9 (95% CI: 10.8-13.1), reflecting that they are written at a 12th grade level, while the median FRE was 40.6 (95% CI: 34.1-47.1), indicating a rating as "difficult" to read. When comparing academic-based online patient education materials to other internet sources, there was no significant difference in FRE and FKGL scores (P = 0.63 and P = 0.26 for FKGL and FRE, respectively). Conclusion: This study demonstrates that online patient education materials pertaining to cerebrovascular diseases from major academic centers and other nonacademic internet sites are difficult to understand and written at levels significantly higher than that recommended by national agencies. Both academic and nonacademic sources reflect this finding equally. Further study and implementation are warranted to investigate how improvements can be made.

Comparison of the Safety, Efficacy, and Procedural Characteristics Associated with Proximal and Distal Radial Access for Diagnostic Cerebral Angiography.

OBJECTIVES: Radial access is an increasingly popular approach for performing cerebral angiography. There are two sites for radial artery puncture: proximal transradial access (pTRA) in the wrist and distal transradial access (dTRA) in the snuffbox. These approaches have not been directly compared. MATERIALS AND METHODS: Consecutive diagnostic cerebral angiograms performed at a single institution were retrospectively reviewed. Outcomes included fluoroscopy time, radiation dose, contrast volume, time to obtain access, procedure duration, and time to discharge home. Success rates as well as minor and major complication rates associated with each approach were also compared. Multivariate linear regression models were used to determine the relationship between access site and outcomes while adjusting for covariates. RESULTS: A total of 287 angiograms on 244 patients met the inclusion criteria. pTRA was associated with shorter fluoroscopy time (ß -2.54, 95% CI -4.18 - -0.9, p = 0.003) and lower radiation dose (ß -242.89, 95% CI -351.55 - -134.24, p < 0.001), but not contrast volume. Time to obtain access, procedure duration, and time to discharge home were similar between approaches. A total of 10 minor complications occurred with similar rates for each approach (8 for dTRA, 2 for pTRA, p = 0.168) and there were no major complications. The conversion rate to femoral access was low (1.05% overall) and did not differ with approach. CONCLUSION: dTRA and pTRA are associated with similarly high rates of safety and efficacy. Procedure duration, time to obtain access, and time to discharge did not differ between approaches.

Outcomes associated with brain tissue oxygen monitoring in patients with severe traumatic brain injury undergoing intracranial pressure monitoring.

OBJECTIVE: Brain tissue oxygen monitoring combined with intracranial pressure (ICP) monitoring in patients with severe traumatic brain injury (sTBI) may confer better outcomes than ICP monitoring alone. The authors sought to investigate this using a national database. METHODS: The National Trauma Data Bank from 2013 to 2017 was queried to identify patients with sTBI who had an external ventricular drain or intraparenchymal ICP monitor placed. Patients were stratified according to the placement of an intraparenchymal brain tissue oxygen tension (PbtO2) monitor, and a 2:1 propensity score matching pair was used to compare outcomes in patients with and those without PbtO2 monitoring. Sensitivity analyses were performed using the entire cohort, and each model was adjusted for age, sex, Glasgow Coma Scale score, Injury Severity Score, presence of hypotension, insurance, race, and hospital teaching status. The primary outcome of interest was in-hospital mortality, and secondary outcomes included ICU length of stay (LOS) and overall LOS. RESULTS: A total of 3421 patients with sTBI who underwent ICP monitoring were identified. Of these, 155 (4.5%) patients had a PbtO2 monitor placed. Among the propensity score-matched patients, mortality occurred in 35.4% of patients without oxygen monitoring and 23.4% of patients with oxygen monitoring (OR 0.53, 95% CI 0.33-0.85; p = 0.007). The unfavorable discharge rates were 56.3% and 47.4%, respectively, in patients with and those without oxygen monitoring (OR 1.41, 95% CI 0.87-2.30; p = 0.168). There was no difference in overall LOS, but patients with PbtO2 monitoring had a significantly longer ICU LOS and duration of mechanical ventilation. In the sensitivity analysis, PbtO2 monitoring was associated with decreased odds of mortality (OR 0.56, 95% CI 0.37-0.84) but higher odds of unfavorable discharge (OR 1.59, 95% CI 1.06-2.40). CONCLUSIONS: When combined with ICP monitoring, PbtO2 monitoring was associated with lower inpatient mortality for patients with sTBI. This supports the findings of the recent Brain Oxygen Optimization in Severe Traumatic Brain Injury phase 2 (BOOST 2) trial and highlights the importance of the ongoing BOOST3 trial.

Comparison of Pericranial Autograft and AlloDerm for Duraplasty in Patients With Type I Chiari Malformation: Retrospective Cohort Analysis.

BACKGROUND: Pericranial autograft is a popular option for duraplasty during Chiari decompression with several theoretical advantages, but comparisons to other materials have yielded mixed results. OBJECTIVE: To compare outcomes between pericranial autograft and AlloDerm (BioHorizons). METHODS: Consecutive suboccipital craniectomies for patients with type I Chiari malformation (CM-I) over an 8-yr period at a single institution were identified. Exclusion criteria included revision surgeries and suboccipital decompressions without duraplasty. Outcomes included incisional cerebrospinal fluid (CSF) leakage, length of stay (LOS), wound complication, aseptic meningitis, syrinx improvement, and symptomatic improvement. RESULTS: A total of 101 patients (70 females and 31 males) with a median (interquartile range) age of 17 yr (11-32) met the inclusion criteria. There were 51 (50%) patients who underwent duraplasty with pericranial autograft, and the remainder underwent duraplasty with AlloDerm. There were 9 (9%) patients who experienced a postoperative CSF leak. After adjusting for confounding factors, obesity (odds ratio [OR]: 4.69, 95% CI: 1.03-25.6) and use of AlloDerm (OR: 10.54, 95% CI: 1.7-206.12) were associated with CSF leak. Wound complication occurred in 8 (8%) patients but was not associated with graft type (P = .8). Graft type was not associated with LOS, syrinx improvement, or symptom improvement. Reoperations occurred in 10 patients with 4 in the autograft group and 6 in the AlloDerm group (P = .71). CONCLUSION: In patients with CM-I, expansile duraplasty with AlloDerm was associated with greater odds of CSF leakage than pericranial autograft. Obesity was also associated with increased odds of CSF leakage.

Transition from Proximal to Distal Radial Access for Diagnostic Cerebral Angiography: Learning Curve Analysis.

BACKGROUND: Distal transradial access (dTRA) has several advantages compared with proximal transradial access (pTRA) for cerebral angiography. The learning curve for transitioning from pTRA to dTRA has not been described. METHODS: Retrospective analysis of the first 75 diagnostic cerebral angiograms performed with dTRA by a single operator was performed. Outcomes included time for sheath insertion, sheath to first vessel time, procedure duration, fluoroscopy time, radiation dose, and contrast volume. Their associations with procedure number were evaluated with multivariate linear regressions, segmented linear regression, and locally weighted regression (LOESS). RESULTS: The mean age of patients was 56.1 years and 61.3% were female. Seventy-four of 75 angiograms were successfully completed with dTRA. There were 3 minor and no major complications. After adjusting for covariates, sheath to first vessel time (ß = -0.50, P < 0.001) and procedure duration (ß = -0.26, P = 0.002) were associated with procedure number. Time for sheath insertion, fluoroscopy time, radiation dose, and contrast volume were not associated with procedure number. Segmented linear regression identified break-points of 33 for sheath to first vessel time and 11 for procedure duration, which corresponded to the procedure number after which these outcomes trended down. LOESS models for time to sheath placement, procedure duration, fluoroscopy time, and radiation dose predicted minimum values between procedures 40-50. CONCLUSIONS: Transitioning from pTRA to dTRA for diagnostic cerebral angiography is feasible and safe. The learning curve is overcome between procedures 11 and 33, and further refinement in performance occurs through procedures 40-50.

Management of chronic subdural hematoma with the subdural evacuating port system: Systematic review and meta-analysis.

The subdural evacuating port system (SEPS) is a minimally invasive option for treating chronic subdural hematoma (cSDH). Individual case series have shown it to be safe and effective, but outcomes have not been systematically reviewed. We sought to review the literature in order to determine the safety and efficacy of SEPS as a first line treatment for cSDH. A comprehensive literature search for outcomes following SEPS placement as a primary treatment for cSDH was performed. The primary outcome was treatment success, which was defined as a composite of improvement in presenting symptoms and no need for further treatment in the operating room. Additional outcomes included discharge disposition, length of stay (LOS), hematoma recurrence, and complications. A total of 12 studies comprising 953 patients who underwent SEPS placement met the inclusion criteria. The pooled rate of a successful outcome was 0.79 (95% CI 0.75-0.83). Frequency of delayed hematoma recurrence was 0.15 (95% CI 0.10-0.21). The pooled inpatient mortality rate was 0.02 (95% CI 0.01-0.03). Complications rates included 0.02 (95% CI 0.00-0.03) for any acute hemorrhage, 0.01 (95% CI 0.00-0.01) for acute hemorrhage requiring surgery, and 0.02 (95% CI 0.01-0.03) for seizure. SEPS placement is associated with a success rate of 79% and very low rates of acute hemorrhage and seizure. This data supports its use as a first-line management strategy, although prospective randomized studies are needed.

The Effect of Timing of Intracranial Pressure Monitor Placement in Patients with Severe Traumatic Brain Injury.

BACKGROUND/OBJECTIVE: Intracranial pressure (ICP) monitor placement is indicated for patients with severe traumatic brain injury (sTBI) to minimize secondary brain injury. There is little evidence to guide the optimal timing of ICP monitor placement. METHODS: A retrospective cohort study using the National Trauma Data Bank (NTDB) from 2013 to 2017 was performed. The NTDB was queried to identify patients with sTBI who underwent external ventricular drain or intraparenchymal ICP monitor placement. Propensity score matching was used to create matched pairs of patients who underwent early compared to late ICP monitor placement using 6-h and 12-h cutoffs. The outcomes of interest were in-hospital mortality, non-routine discharge disposition, total length of stay (LOS), intensive care unit (ICU) LOS, and number of days mechanically ventilated. RESULTS: A total of 5057 patients with sTBI were included in the study. In-hospital mortality for patients with early compared to late ICP monitor placement was 33.6% and 30.4%, respectively (p = 0.049). The incidence of non-routine disposition was 92.6% in the within 6 h group and 94.4% in the late placement group (p = 0.037). Hospital LOS, ICU LOS, and number of days mechanically ventilated were significantly greater in the late ICP monitoring group. Similar results were seen when using a 12-h cutoff for late ICP monitor placement. In the Cox proportional hazards model, craniotomy (HR 1.097, 95% CI 1.037-1.160) and isolated intracranial injury (HR 1.128, 95% CI 1.055-1.207) were associated with early ICP monitor placement. Hypotension was negatively associated with early ICP monitor placement (HR 0.801, 95% CI 0.725-0.884). CONCLUSION: Despite a statistically marginal association between mortality and early ICP monitor placement, most outcomes were superior when ICP monitors were placed within 6 or 12 h of arrival. This may be due to earlier identification and treatment of intracranial hypertension.

Risk Factors and Outcomes Associated with Blunt Cerebrovascular Injury in Patients with Mild or Moderate Traumatic Brain Injury.

BACKGROUND: Blunt cerebrovascular injury (BCVI) represents a spectrum of traumatic injuries to the carotid and vertebral arteries that is an often-overlooked source of morbidity and mortality. Its incidence, risk factors, and effect on outcomes in patients with mild or moderate traumatic brain injury (mTBI) have not been studied independently. METHODS: The National Trauma Data Bank from 2013 to 2017 was queried to identify patients with mTBI who suffered blunt injuries. BCVI was identified using abbreviated injury scores and included blunt carotid artery injury (BCAI) and blunt vertebral artery injury (BVAI). A binary logistic regression was used to identify patient-related and injury-related factors associated with BCVI. Binary logistic regressions were also performed to evaluate the effect of BCVI on stroke, in-hospital mortality, nonroutine discharge disposition, total length of stay (LOS), intensive care unit LOS, and number of days mechanically ventilated. RESULTS: Of 485,880 patients with mTBI, there were 4,382 (0.9%) with BCVI. Cervical spine fracture was the strongest factor associated with BCAI (odds ratio [OR], 1.97; 95% confidence interval [95% CI], 1.77-2.19), followed by mandible fracture and basilar skull fracture. Cervical spine fracture also had the strongest association with BVAI (OR, 18.28; 95% CI, 16.47-20.28), followed by spinal cord injury and neck contusion. Stroke was more common in patients with BCAI (OR, 5.50; 95% CI, 4.19-7.21) and BVAI (OR, 7.238; 95% CI, 5.929-8.836). BVAI increased the odds of mortality, but BCAI did not. Both were associated with nonroutine discharge and increased LOS, intensive care unit LOS, and number of days mechanically ventilated. CONCLUSIONS: The incidence of BCVI in patients with mTBI is low, and it usually does not require invasive treatment. However, it is associated with greater odds of stroke and negative outcomes. Knowledge of risk factors for BCVI may tailor further investigation to aid prompt diagnosis.

Use of Intracranial Pressure Monitoring in Patients with Severe Traumatic Brain Injury.

OBJECTIVE: The Brain Trauma Foundation (BTF) recommends intracranial pressure (ICP) monitoring for all salvageable patients with an abnormal computed tomography (CT) scan and a Glasgow Coma Scale <9. Studies have shown that compliance with this recommendation is low. We sought to obtain contemporary national rates of ICP monitor placement in patients with severe traumatic brain injury (TBI). METHODS: Patients from the National Trauma Data Bank from 2013 to 2017 who met BTF criteria for ICP monitoring were included. Placement of an intraparenchymal ICP monitor or an external ventricular drain was queried. Binary logistic regression was used to determine factors that influenced the placement of an ICP monitor. RESULTS: A total of 21,374 patients with severe TBI and an abnormal CT scan were included in the study. An ICP monitor was placed in 6543 patients (30.6%). ICP monitor placement increased modestly from 28.6% in 2013 to 32.8% in 2017. The pooled odds of ICP monitor placement between 2014 and 2017 were not different from 2013 (odds ratio, 1.04; 95% confidence interval, 0.99-1.09), but the adjusted odds of ICP monitor placement in 2017 were significantly greater (odds ratio, 1.18; 95% confidence interval, 1.06-1.30). Treatment at a teaching hospital, subdural hematoma, multiple intracranial abnormalities on CT, and greater Injury Severity Score were associated with ICP monitor placement, whereas older age was negatively associated with ICP monitor placement. CONCLUSIONS: The rate of ICP monitoring in patients with severe TBI who meet BTF criteria is low and increased only slightly from 2013 to 2017.