American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator as a Predictor of Postoperative Outcomes After Adult Spinal Deformity Surgery: A Retrospective Cohort Analysis.

BACKGROUND AND OBJECTIVES: In recent years, there has been an outpouring of scoring systems that were built to predict outcomes after various surgical procedures; however, research validating these studies in spinal surgery is quite limited. In this study, we evaluated the predictability of the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator (ACS NSQIP SRC) for various postoperative outcomes after spinal deformity surgery. METHODS: A retrospective chart review was conducted to identify patients who underwent spinal deformity surgery at our hospital between January 1, 2014, and December 31, 2022. Demographic and clinical data necessary to use the ACS NSQIP SRC and postoperative outcomes were collected for these patients. Predictability was analyzed using the area under the curve (AUC) of receiver operating characteristic curves and Brier scores. RESULTS: Among the 159 study patients, the mean age was 64.5 ± 9.5 years, mean body mass index was 31.9 ± 6.6, and 95 (59.7%) patients were women. The outcome most accurately predicted by the ACS NSQIP SRC was postoperative pneumonia (observed = 5.0% vs predicted = 3.2%, AUC = 0.75, Brier score = 0.05), but its predictability still fell below the acceptable threshold. Other outcomes that were underpredicted by the ACS NSQIP SRC were readmission within 30 days (observed = 13.8% vs predicted = 9.0%, AUC = 0.63, Brier score = 0.12), rate of discharge to nursing home or rehabilitation facilities (observed = 56.0% vs predicted = 46.6%, AUC = 0.59, Brier = 0.26), reoperation (observed 11.9% vs predicted 5.4%, AUC = 0.60, Brier = 0.11), surgical site infection (observed 9.4% vs predicted 3.5%, AUC = 0.61, Brier = 0.05), and any complication (observed 33.3% vs 19%, AUC = 0.65, Brier = 0.23). Predicted and observed length of stay were not significantly associated (ß = 0.132, P = .47). CONCLUSION: The ACS NSQIP SRC is a poor predictor of outcomes after spinal deformity surgery.

The Effect of Diabetes on Complications after Spinal Fusion: A Systematic Review and Meta-Analysis.

OBJECTIVE: Spinal fusion procedures are used to treat a wide variety of spinal pathologies. Diabetes mellitus (DM) has been shown to be a significant risk factor for several complications following these procedures in previous studies. To the authors' knowledge, this is the first systematic review and meta-analysis elucidating the relationship between DM and complications occurring after spinal fusion procedures. METHODS: Systematic literature searches of PubMed and EMBASE were performed from their inception to October 1, 2022, to identify studies that directly compared postfusion complications in patients with and without DM. Studies met the prespecified inclusion criteria if they reported the following data for patients with and without DM: (1) demographics; (2) postspinal fusion complication rates; and (3) postoperative clinical outcomes. The included studies were then pooled and analyzed. RESULTS: Twenty-eight studies, with a cumulative total of 18,853 patients (2695 diabetic patients), were identified that met the inclusion criteria. Analysis showed that diabetic patients had significantly higher rates of total number of postoperative complications (odds ratio [OR] = 1.33; 95% confidence interval [CI] = 1.12-1.58; P = 0.001), postoperative pulmonary complications (OR=2.01; 95%CI=1.31-3.08; P = 0.001), postoperative renal complications (OR=2.20; 95%CI=1.27-3.80; P = 0.005), surgical site infection (OR=2.65; 95%CI=2.19-3.20; P < 0.001), and prolonged hospital stay (OR=1.67; 95%CI=1.47-1.90; P < 0.001). CONCLUSIONS: Patients with DM had a significantly higher risk of developing complications after spinal fusion, particularly pulmonary and renal complications, in addition to surgical site infections and had a longer length of stay. These findings are important for informed discussions of surgical risks with patients and families before surgery.

Bevacizumab and gamma knife radiosurgery for first-recurrence glioblastoma.

INTRODUCTION: Glioblastoma (GBM) is the most common central nervous system malignancy in adults. Despite decades of developments in surgical management, radiation treatment, chemotherapy, and tumor treating field therapy, GBM remains an ultimately fatal disease. There is currently no definitive standard of care for patients with recurrent glioblastoma (rGBM) following failure of initial management. OBJECTIVE: In this retrospective cohort study, we set out to examine the relative effects of bevacizumab and Gamma Knife radiosurgery on progression-free survival (PFS) and overall survival (OS) in patients with GBM at first-recurrence. METHODS: We conducted a retrospective review of all patients with rGBM who underwent treatment with bevacizumab and/or Gamma Knife radiosurgery at Roswell Park Comprehensive Cancer Center between 2012 and 2022. Mean PFS and OS were determined for each of our three treatment groups: Bevacizumab Only, Bevacizumab Plus Gamma Knife, and Gamma Knife Only. RESULTS: Patients in the combined treatment group demonstrated longer post-recurrence median PFS (7.7 months) and median OS (11.5 months) compared to glioblastoma patients previously reported in the literature, and showed improvements in total PFS (p=0.015), total OS (p=0.0050), post-recurrence PFS (p=0.018), and post-recurrence OS (p=0.0082) compared to patients who received either bevacizumab or Gamma Knife as monotherapy. CONCLUSION: This study demonstrates that the combined use of bevacizumab with concurrent stereotactic radiosurgery can have improve survival in patients with rGBM.

Cervical Vertebral Bone Quality Score Independently Predicts Distal Junctional Kyphosis After Posterior Cervical Fusion.

BACKGROUND AND OBJECTIVE: Posterior cervical fusion is the surgery of choice when fusing long segments of the cervical spine. However, because of the limited presence of this pathology, there is a paucity of data in the literature about the postoperative complications of distal junctional kyphosis (DJK). We aimed to identify and report potential associations between the preoperative cervical vertebral bone quality (C-VBQ) score and the occurrence of DJK after posterior cervical fusion. METHODS: The authors retrospectively reviewed records of patients who underwent posterior cervical fusion at a single hospital between June 1, 2010, and May 31, 2020. Patient data were screened to include patients who were >18 years old, had baseline MRI, had baseline standing cervical X-ray, had immediate postoperative standing cervical X-ray, and had clinical and radiographic follow-ups of >1 year, including a standing cervical X-ray at least 1 year postoperatively. Univariate analysis was completed between DJK and non-DJK groups, with multivariate regression completed for relevant clinical variables. Simple linear regression was completed to analyze correlation between the C-VBQ score and total degrees of kyphosis angle change. RESULTS: Ninety-three patients were identified, of whom 19 (20.4%) had DJK and 74 (79.6%) did not. The DJK group had a significantly higher C-VBQ score than the non-DJK group (2.97 ± 0.40 vs 2.26 ± 0.46; P < .001). A significant, positive correlation was found between the C-VBQ score and the total degrees of kyphosis angle change (r 2 = 0.26; P < .001). On multivariate analysis, the C-VBQ score independently predicted DJK (odds ratio, 1.46; 95% CI, 1.27-1.67; P < .001). CONCLUSION: We found that the C-VBQ score was an independent predictive factor of DJK after posterior cervical fusion.

Outcomes of 2-Level Versus 3- or 4-Level Anterior Cervical Discectomy and Fusion Using a Biomimetic Surface Titanium Cage: Multicenter Experience.

OBJECTIVE: Interbody cages for spinal fusions are primarily constructed from polyetheretherketone or titanium compositions. However, these crude macroscopic materials pose limitations for improving the rates of bony fusions. The authors aimed to compare the fusion rates and postoperative complications in patients who underwent 2-level or 3-or 4-level anterior cervical discectomy and fusion (ACDF) performed with the use of a novel biomimetic surface titanium cage. METHODS: A retrospective multicenter study was conducted that included all patients who underwent multilevel ACDF with this cage between January 2017 and April 2021. Patient demographics and procedure-related, radiographic, and postoperative complication data were collected. RESULTS: A total of 124 patients were identified; 69 (55.6%) had a 3-or 4-level fusion and 55 (44.4%) had a 2-level fusion. The demographics of the 2 groups differed significantly only in terms of age (P = 0.01). At 3 months, a significantly higher solid fusion rate was found for 2-level fusions than 3-or 4-level fusions (83.7% vs. 56.3%, P = 0.004); however, significance was lost at 6-months (98.2% vs. 88.4%, respectively; P = 0.08). No patients required posterior supplemental fixation. Transient dysphagia was the only postoperative complication that was significantly increased in the 3-or 4-level fusion group compared to the 2-level group (27.5% vs. 9.1%, P = 0.02). CONCLUSIONS: Radiographic and clinical outcomes were equivalent in 3-or 4-level and 2-level ACDFs in which these biomimetic surface titanium cages were used. Furthermore, the use of this technology led to high fusion rates with no requirement for posterior supplemental fusions.

Strong Correlation Between the Vertebral Bone Quality Score and the Cervical-Vertebral Bone Quality Score in Spine Surgery Patients.

OBJECTIVE: Osteoporosis is a burgeoning public health problem for over 44 million people in the United States. The magnetic resonance imaging-based vertebral bone quality (VBQ) score and cervical VBQ (C-VBQ) score are two novel approaches that use data routinely gathered during preoperative evaluation to assess bone quality. The goal of this study was to investigate the relationship between the VBQ and C-VBQ scores. METHODS: We performed a retrospective review of chart data for patients who underwent spine surgery for degenerative conditions between 2015 and 2022. Patients eligible for study inclusion had preoperative T1-weighted magnetic resonance imaging of the lumbar and cervical spine available for review. Demographics of each patient were collected. The VBQ score was determined by dividing the median signal intensity (SI) of the L1-L4 vertebral bodies by the SI of the cerebrospinal fluid at L3. The C-VBQ score was calculated by dividing the median SI of the C3-C6 vertebral bodies by the SI of the C2 cerebrospinal fluid space. Pearson's correlation test was utilized to evaluate the association between the scores. RESULTS: We identified 171 patients, with a mean age of 57.44 ± 11.79 years. The interrater reliability of the VBQ and C-VBQ measurements was excellent (intraclass correlation-coefficients were 0.89 and 0.84, respectively). A statistically significant, positive correlation was found between the VBQ score and the C-VBQ score (r = 0.757,P < 0.001). CONCLUSIONS: This is the first study, to our knowledge, to assess the degree to which the newly developed C-VBQ score correlates with the VBQ score. We found a strong positive correlation between the scores.

Use of Novel Automated Active Irrigation With Drainage Versus Passive Drainage Alone for Chronic Subdural Hematoma-A Propensity Score-Matched Comparative Study With Volumetric Analysis.

BACKGROUND: Passive drainage post-surgical evacuation of symptomatic chronic subdural hematoma (cSDH) is currently standard of care. High rates of infection, drain occlusion, and recurrence are associated complications. OBJECTIVE: To explore the use of a novel double-lumen active automated irrigation and aspiration system, IRRAflow (IRRAS), for patients with cSDH and compared procedural and clinical outcomes against passive drainage alone with propensity score matching (PSM) and volumetric analysis. METHODS: A prospectively maintained database was retrospectively searched for consecutive patients presenting with cSDH. One-to-one PSM of covariates (including baseline comorbidities and presentation hematoma volume) in active and passive irrigation groups was performed to adjust for treatment selection bias. Rates of hematoma clearance, catheter-related occlusion, and infection; number of revisions; and length of hospital stay were recorded. RESULTS: This study included 55 patients: active continuous irrigation-drainage-21 (21 post-PSM) and passive drainage-34 (21 post-PSM). For PSM groups, a significantly higher rate of hematoma clearance was obtained in the active irrigation-drainage group (0.5 ± 0.4 vs 0.4 ± 0.5 mL/day) and in the passive drainage group; odds ratio (OR) = 1.291 (CI: 1.062-1.570, P = .002) and a significantly lower rate of catheter-related infections (OR = 0.051; CI: 0.004-0.697, P = .039). A nonsignificantly lower hematoma expansion rate at discharge was noted in the active irrigation-drainage group (4.8% vs 23.8%; OR = 0.127; P = .186). No statistical difference in all-cause in-hospital mortality or discharge Glasgow Coma Scale score was observed between groups. CONCLUSION: Active and automated continuous irrigation plus drainage after cSDH surgical evacuation resulted in faster hematoma clearance and led to favorable clinical outcomes and low complication and revision rates compared with passive irrigation.

Risk factors of early complications after thoracic and lumbar spinal deformity surgery: a systematic review and meta-analysis.

PURPOSE: To determine risk factors increasing susceptibility to early complications (intraoperative and postoperative within 6 weeks) associated with surgery to correct thoracic and lumbar spinal deformity. METHODS: We systematically searched the PubMed and EMBASE databases for studies published between January 1990 and September 2021. Observational studies evaluating predictors of early complications of thoracic and lumbar spinal deformity surgery were included. Pooled odds ratio (OR) or standardized mean difference (SMD) with 95% confidence intervals (CI) was calculated via the random effects model. RESULTS: Fifty-two studies representing 102,432 patients met the inclusion criteria. Statistically significant patient-related risk factors for early complications included neurological comorbidity (OR = 3.45, 95% CI 1.83-6.50), non-ambulatory status (OR = 3.37, 95% CI 1.96-5.77), kidney disease (OR = 2.80, 95% CI 1.80-4.36), American Society of Anesthesiologists score > 2 (OR = 2.23, 95% CI 1.76-2.84), previous spine surgery (OR = 1.98, 95% CI 1.41-2.77), pulmonary comorbidity (OR = 1.94, 95% CI 1.21-3.09), osteoporosis (OR = 1.60, 95% CI 1.17-2.20), cardiovascular diseases (OR = 1.46, 95% CI 1.20-1.78), hypertension (OR = 1.37, 95% CI 1.23-1.52), diabetes mellitus (OR = 1.84, 95% CI 1.30-2.60), preoperative Cobb angle (SMD = 0.43, 95% CI 0.29, 0.57), number of comorbidities (SMD = 0.41, 95% CI 0.12, 0.70), and preoperative lumbar lordotic angle (SMD = - 0.20, 95% CI - 0.35, - 0.06). Statistically significant procedure-related factors were fusion extending to the sacrum or pelvis (OR = 2.53, 95% CI 1.53-4.16), use of osteotomy (OR = 1.60, 95% CI 1.12-2.29), longer operation duration (SMD = 0.72, 95% CI 0.05, 1.40), estimated blood loss (SMD = 0.46, 95% CI 0.07, 0.85), and number of levels fused (SMD = 0.37, 95% CI 0.03, 0.70). CONCLUSION: These data may contribute to development of a systematic approach aimed at improving quality-of-life and reducing complications in high-risk patients.

Meta-analysis of overall survival and postoperative neurologic deficits after resection or biopsy of butterfly glioblastoma.

Butterfly glioblastoma (bGBM) is a grade 4 glioma with a poor prognosis. Surgical treatment of these cancers has been reviewed in the literature with some recent studies supporting resection as a safe and effective treatment instead of biopsy and adjuvant therapy. This meta-analysis was designed to determine whether there are significant differences in overall survival (OS) and postoperative neurologic deficits (motor, speech, and cranial nerve) following intervention in patients who underwent tumor resection as part of their treatment, compared to patients who underwent biopsy without surgical resection. A literature search was conducted using PubMed (National Library of Medicine) and Embase (Elsevier) to identify articles from each database's earliest records to May 25, 2021, that directly compared the outcomes of biopsy and resection in bGBM patients and met predetermined inclusion criteria. A meta-analysis was conducted to compare the effects of the two management strategies on OS and postoperative neurologic deficits. Six articles met our study inclusion criteria. OS was found to be significantly longer for the resection group at 6 months (odds ratio [OR] 2.94, 95% confidence interval [CI] 1.23-7.05) and 12 months (OR 3.75, 95% CI 1.10-12.76) than for the biopsy group. No statistically significant differences were found in OS at 18 and 24 months. Resection was associated with an increased rate of postoperative neurologic deficit (OR 2.05, 95% CI 1.02-4.09). Resection offers greater OS up to 1 year postintervention than biopsy alone; however, this comes at the cost of higher rates of postoperative neurologic deficits.

Predicting prolonged length of stay in patients undergoing transforaminal lumbar interbody fusion.

BACKGROUND: With growing emphasis on high-value care, many institutions have been working on improving surgical efficiency, quality, and complication reduction. Unfortunately, data are limited regarding perioperative factors that may influence length of stay (LOS) following transforaminal lumbar interbody fusion (TLIF). We sought to design a predictive algorithm that determined patients at risk of prolonged LOS after TLIF. The goal was to identify patients who would benefit from preoperative intervention aimed to reduce LOS. METHODS: We conducted a review of perioperative data for patients who underwent TLIF between 2014 and 2019. Univariate and multivariate stepwise regression models were used to analyze risk factor effects on postoperative LOS. RESULTS: Two hundred and sixty-nine patients were identified (57.2% women). Mean age at surgery was 61.7 ± 12.3 years. Mean postoperative LOS was 3.08 ± 1.54 days. In multivariate analysis, American Society of Anesthesiologists class (odds ratio [OR] = 1.441, 95% confidence interval [CI] 1.321-1.571), preoperative functional status (OR = 1.237, 95% CI 1.122-1.364), Oswestry Disability Index (OR = 1.010, 95% CI 1.004-1.016), and estimated blood loss (OR = 1.050, 95% CI 1.003-1.101) were independent risk factors for postoperative LOS ≥ 5 days. The final model had an area under the curve of 0.948 with good discrimination and was implemented in the form of an online calculator ( https://spine.shinyapps.io/TLIF_LOS/ ). CONCLUSION: The prediction tool derived can be useful for assessing likelihood of prolonged LOS in patients undergoing TLIF. With external validation, this calculator may ultimately assist healthcare providers in identifying patients at risk for prolonged hospitalization so preoperative interventions can be undertaken to reduce LOS, thus reducing resource utilization.

Cerebral Proliferative Angiopathy Presenting as Subdural Hematoma: A Case Report and Systematic Literature Review.

Cerebral proliferative angiopathy (CPA) is a rare cerebrovascular pathology that presents with unique clinical features due to distinct histologic, angiographic, and pathophysiologic characteristics that separate it from classical arteriovenous malformation. The disorder is characterized by uncontrolled angiogenesis in which functional brain parenchyma is interspersed with abnormal vascular channels without a distinct nidus. Common presenting symptoms include headache, seizures, and stroke-like symptoms. Hemorrhagic presentations are rare in contrast to the typical presentations of classical arteriovenous malformation. Here, we report a young woman with a history of a suspected connective tissue disorder who presented to the emergency department with worsening headaches in a delayed fashion after experiencing minor head trauma and was found to have a left-sided subdural hematoma. Angiography confirmed a diagnosis of CPA after abnormal cortical vasculature was noted during the patient's craniotomy. A systematic review of CPA cases described in the literature was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, with the findings discussed.

Continuous Antibiotic Administration Using IRRAflow® Catheter for Treatment of Intracranial Abscess.

Intracranial abscesses are rare lesions with an incidence of approximately 4 per 1 million people. The optimal surgical management of these lesions is still unclear. We present the case of a patient who was discovered to have an intracranial abscess after presenting with right-sided weakness. He was treated via a combination of open craniotomy and continuous antibiotic irrigation using an IRRAflow® catheter (IRRAS, Stockholm, Sweden). Use of the IRRAflow® in this fashion has not yet been described in the literature. This novel approach appears to be safe and resulted in continued decrease in the abscess burden following surgical drainage.

Effectiveness and Safety of Continuous Infusion Regional Anesthesia Pumps for Pain After Thoracopelvic Fusion Surgery for Persistent Spinal Pain Syndrome.

BACKGROUND: Postoperative pain after complex revision spine surgery, especially for the treatment of persistent spinal pain syndrome (PSPS), is frequently severe and can be debilitating, requiring the use of intravenous and oral opioids. To the best of our knowledge, the present study is the first to evaluate the effectiveness and safety of a continuous infusion regional anesthesia pump placed after thoracopelvic fusion for the treatment of PSPS. METHODS: We performed a retrospective comparative study of consecutive patients who had undergone thoracopelvic fusion for PSPS. The patients included in the present study had either had a continuous infusion regional anesthesia pump placed during surgery or had not (control). Demographics, use of preoperative and postoperative opioids, postoperative adverse events, length of hospital stay, and 90-day readmission were recorded. RESULTS: The patients in the pump group (n = 14) had used fewer opioids during their hospital stay compared with the control group (n = 12; P = 0.6). This difference was greater for postoperative days 1 and 2 (P = 0.3 and P = 0.2, respectively). No significant difference was found in opioid usage during the first 14 days after surgery (P = 0.8) or at the 3-month postoperative follow-up evaluation (P = 0.8). Furthermore, no significant difference was found between the 2 groups in terms of postoperative complications. The pump group had a 1.4-day shorter hospital stay (P = 0.7). The control group had more 90-day readmissions than did the pump group (P = 0.2). CONCLUSIONS: Despite showing a trend toward less usage of opioids during the first 2 days after surgery and a shorter hospital stay with no increased complications in the pump group, the study data failed to demonstrate a statistically significant difference between the two groups.

Factors Affecting Postoperative Length of Stay in Patients Undergoing Anterior Lumbar Interbody Fusion.

BACKGROUND: With hospital leaders and policy makers increasingly seeking ways to improve resource use, there has been heightened interest in reducing hospital length of stay (LOS) and performing spine procedures on an outpatient basis. We aimed to determine which risk factors correlated with prolonged LOS after anterior lumbar interbody fusion (ALIF). METHODS: Medical records for patients who underwent ALIF were retrospectively reviewed. Patients were divided into those who had extended (≥3 days) versus nonextended (<3 days) LOS, and patient demographics, medical comorbidities, and preoperative medications were analyzed. Univariate and multivariate regression were then used to determine preoperative risk factors for extended LOS. RESULTS: A total of 166 patients were included (mean age, 48.7 years). Medical comorbidities included hypertension (31.9%), diabetes (8.4%), and obesity (body mass index >30 kg/m2) (48.8%). LOS was not extended in 121 patients and extended in 45. Mean LOS was 2.2 days (95% confidence interval, 1.9-2.5). On multivariate logistic analysis, age ≥65 years (P = 0.001), preoperative benzodiazepine use (P = 0.014), 12-item Short Form mental component score (P = 0.008), estimated blood loss (P = 0.015), time to mobilization (P < 0.001), and total operative time (P = 0.020) were independent predictors for extended LOS. CONCLUSIONS: As attempts are made to perform more spine procedure in ambulatory surgical centers, strict patient selection criteria are all critical in making this possible. Our results suggest that age, preoperative benzodiazepine use, higher intraoperative blood loss, delayed mobilization, and lower 12-item Short Form mental component score were correlated with increased LOS. Therefore, inpatient ALIF may be more suitable for patients with these risk factors.

The effect of COVID-19 on trainee operative experience at a multihospital academic neurosurgical practice: A first look at case numbers.

BACKGROUND: COVID-19 has had a significant impact on the economy, health care, and society as a whole. To prevent the spread of infection, local governments across the United States issued mandatory lockdowns and stay-at-home orders. In the surgical world, elective cases ceased to help "flatten the curve" and prevent the infection from spreading to hospital staff and patients. We explored the effect of the cancellation of these procedures on trainee operative experience at our high-volume, multihospital neurosurgical practice. METHODS: Our department cancelled all elective cases starting March 16, 2020, and resumed elective surgical and endovascular procedures on May 11, 2020. We retrospectively reviewed case volumes for 54 days prelockdown and 54 days postlockdown to evaluate the extent of the decrease in surgical volume at our institution. Procedure data were collected and then divided into cranial, spine, functional, peripheral nerve, pediatrics, and endovascular categories. RESULTS: Mean total cases per day in the prelockdown group were 12.26 ± 7.7, whereas in the postlockdown group, this dropped to 7.78 ± 5.5 (P = 0.01). In the spine category, mean cases per day in the prelockdown group were 3.13 ± 2.63; in the postlockdown group, this dropped to 0.96 ± 1.36 (P < 0.001). In the functional category, mean cases per day in the prelockdown group were 1.31 ± 1.51, whereas in the postlockdown group, this dropped to 0.11 ± 0.42 (P < 0.001). For cranial (P = 0.245), peripheral nerve (P = 0.16), pediatrics (P = 0.34), and endovascular (P = 0.48) cases, the volumes dropped but were not statistically significant decreases. CONCLUSION: The impact of this outbreak on operative training does appear to be significant based solely on statistics. Although the drop in case volumes during this time can be accounted for by the pandemic, it is important to understand that this is a multifactorial effect. Further studies are needed for these results to be generalizable and to fully understand the effect this pandemic has had on trainee operative experience.

Drainage, Irrigation, and Fibrinolytic Therapy (DRIFT) for Adult Intraventricular Hemorrhage Using IRRAflow® Self-Irrigating Catheter.

Intraventricular hemorrhage (IVH) is a devastating neurosurgical condition associated with high rates of morbidity and mortality. It can occur as the result of several pathologies and typically presents with mental status changes, neurologic deficits, seizures, headaches, and decreased Glasgow Coma Scale score. These patients are often treated with placement of an external ventricular drain, which helps decrease the clot burden; however, they commonly clot off leading to multiple exchanges. We present a case in which drainage, irrigation, and fibrinolytic (DRIFT) therapy using IRRAflow® (IRRAS) irrigating catheter was used to treat a patient with severe IVH secondary to aneurysmal subarachnoid hemorrhage.

Minimally Invasive Approach to Subdural Hematoma Treatment Using IRRAflow Catheter and Middle Meningeal Artery Embolization.

Chronic subdural hematoma (cSDH) is a common neurosurgical pathology that usually occurs in the seventh decade of life. Patients can present with mental status changes, focal neurologic deficits, seizures, headaches, or may be asymptomatic. Recurrence is common. In order to address this problem with the treatment of cSDH, many studies exist that compare the effectiveness of various treatment modalities. Two recently developed treatment options of cSDH include middle meningeal artery (MMA) embolization and use of self-irrigating catheter systems. To our knowledge there have been no reported cases of combining the use of these new treatments. What follows is a case report of a 72-year-old patient with recurrent cSDH following MMA embolization who underwent minimally invasive surgical drainage of his hematoma using an IRRAflow catheter (IRRAS, San Diego, CA, USA).

Use of the Scan-and-Plan Workflow in Next-Generation Robot-Assisted Pedicle Screw Insertion: Retrospective Cohort Study and Literature Review.

OBJECTIVE: To report our experience using the scan-and-plan workflow and review current literature on surgical efficiency, safety, and accuracy of next-generation robot-assisted (RA) spine surgery. METHODS: The records of patients who underwent RA pedicle screw fixation were reviewed. The accuracy of pedicle screw placement was determined based on the Ravi classification system. To evaluate workflow efficiency, 3 demographically matched cohorts were created to analyze differences in time per screw placement (defined as operating room [OR] time divided by number of screws placed). Group A had <4 screws placed, Group B had 4 screws placed, and Group C had >4 screws placed. Intraoperative errors and postoperative complications were collected to elucidate safety. RESULTS: Eighty-four RA cases (306 pedicle screws) were included for analysis. The mean number of screws placed was 2.1 ± 0.3 in Group A and 6.4 ± 1.2 in Group C; 4 screws were placed in Group B patients. The accuracy rate (Ravi grade I) was 98.4%. Screw placement time was significantly longer in Group A (101 ± 37.7 minutes) than Group B (50.5 ± 25.4 minutes) or C (43.6 ± 14.7 minutes). There were no intraoperative complications, robot failures, or in-hospital complications requiring a return to the OR. CONCLUSIONS: The scan-and-plan workflow allowed for a high degree of accuracy. It was a safe method that provided a smooth and efficient OR workflow without registration errors or robotic failures. After the placement of 4 pedicle screws, the per-screw time remained constant. Further studies regarding efficiency and utility in multilevel procedures are necessary.

Technologic Evolution of Navigation and Robotics in Spine Surgery: A Historical Perspective.

Spine surgery is continuously evolving. The synergy between medical imaging and advances in computation has allowed for stereotactic neuronavigation and its integration with robotic technology to assist in spine surgery. The discovery of x-rays in 1895, the development of image intensifiers in 1940, and then advancements in computational science and integration have allowed for the development of computed tomography. In combination with the advancements of stereotaxy in the late 1980s, and manipulation of volumetric and special data for 3-dimensional reconstruction in 1998, computed tomography has revolutionized neuronavigational systems. Integrating all these technologies, robotics in spine surgery was introduced in 2004. Since then, it has become a safe modality that can reproducibly place accurate pedicle screws. Robotics may have the added benefits of improving the surgical workflow and optimizing surgeon ergonomics. Growing at a rapid rate, the second-generation spinal robotics have overcome preliminary limitations and errors. However, comparatively, robotics in spine surgery remains in its infancy. By leveraging technologic advancements in medical imaging, computation, and stereotactic navigation, robotics in spine surgery will continue to mature and expand in utility.