Spine Surgeon Assessments of Patient Psychological Distress are Inaccurate and Bias Treatment Recommendations.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: This study determined (1) the surgeon accuracy of psychological assessment in patients in spine clinic, (2) the impact of psychological distress on surgical recommendation, and (3) the correlation between patient-reported disability and psychological distress. SUMMARY OF BACKGROUND DATA: Psychological distress is common among patients presenting for spine surgery. Surgeon estimations of patients' distress may influence treatment recommendations, but little is known as to whether these assessments accurately mirror patient-perceived psychological distress. MATERIALS AND METHODS: A sample of new patients was recruited from an academic spine center. Prior to their initial consultation, patients completed the Modified Somatic Perception Questionnaire and Zung Depression Index to assess mental and physical manifestations of distress, which generated a Distress and Risk Assessment Method (DRAM) score of N (normal), R (at risk), or D (distressed). The Oswestry Disability Index and Neck Disability Index scores were also collected. Surgeons provided their estimates of the DRAM score after the visit and indicated their surgery recommendation. RESULTS: Of 296 patients, 40.5% reported some level of psychological distress (DRAM=R) and 15.9% had a high level of distress (DRAM=D). All three surgeons' ability to accurately assess the participant DRAM score was poor, with an overall kappa of 0.13 (0.08-0.18), biased toward underestimating the patient's true level of psychological distress. Patients rated as normal (N) by the surgeon were 3.78 times more likely to be recommended for surgery compared to those assessed as distressed (D) ( P =0.007). Patients with higher DRAM scores had higher Oswestry Disability Index ( P =0.008) and Neck Disability Index ( P =0.005) scores compared to those with lower DRAM scores. CONCLUSIONS: Spine surgeons have limited ability to detect psychological profiles in patients, with a tendency to underestimate levels of distress. The finding that these inaccurate assessments influence surgical recommendations underscores the importance of limiting surgeon bias in the decision-making process. LEVEL OF EVIDENCE: Diagnostic Level 2.

Lumbar epidural hematoma associated with spondylolyses.

This report describes 3 young male patients with multiple lumbar spondylolyses in combination with a symptomatic epidural hematoma. The records of all 3 patients were reviewed for clinical details. All patients were successfully treated without surgical intervention. Initial neuroimaging results for all patients revealed epidural hematomas, and follow-up imaging confirmed resolution of the hematomas. The relevant literature is briefly reviewed to examine the rarity of this combination. Spontaneous epidural hematomas may occur in the setting of spondylolysis, and this diagnosis should be considered when imaging reveals an unusual epidural lesion in a young active patient.

Occipitocondylar hyperplasia: an unusual craniovertebral junction anomaly causing myelopathy. Case report.

The authors of this brief case report describe a previously unreported developmental variant of the craniovertebral junction. A 10-year-old girl who presented with cervical myelopathy was found to have cervicomedullary compression by hypertrophic occipital condyles. Decompression was achieved via a midline dorsal approach with no complications. The embryology of this area is briefly reviewed to attempt to explain the origin of this anomaly.

Frameless stereotaxy as an alternative to fluoroscopy for transsphenoidal surgery: use of the InstaTrak-3000 and a novel headset.

Our aim was to evaluate the applicability of an electromagnetic-based frameless stereotactic system for use in transsphenoidal surgery. The system utilizes a novel headset that acts as a replaceable fiducial frame as well as a fixation point for the system's transmitter. It can replace the fluoroscope as a guide to navigation in the sphenoid sinus and sella. The system was used in a consecutive series of 11 patients undergoing transsphenoidal surgery. It was used in conjunction with intraoperative fluoroscopy. We found the Instatrak-3000 to correlate well with lateral fluoroscopic images, and provide additional information in the axial and coronal planes. The InstaTrak-3000 frameless stereotactic system is accurate and obviates the need for intraoperative fluoroscopy during transsphenoidal surgery. Compared to other frameless systems, it avoids the use of fiducial skin markers and head fixation. In common with other frameless stereotactic systems, it provides additional information important for safely approaching the sella and avoids intraoperative radiation exposure for the patient and operating room staff.

Immediate titanium mesh cranioplasty for treatment of postcraniotomy infections.

OBJECTIVE: Postcraniotomy infections have generally been treated by debridement of infected tissues, disposal of the bone flap, and delayed cranioplasty several months later to repair the resulting skull defect. Debridement followed by retention of the bone flap has also been advocated. Here we propose an alternative operative strategy for the treatment of postcraniotomy infections. METHODS: Two patients presenting with clinical and radiographic signs and symptoms of postcraniotomy infections were treated by debridement, bone flap disposal, and immediate titanium mesh cranioplasty. The patients were subsequently administered antibiotics, and their clinical courses were followed. RESULTS: The patients treated in this fashion did not have recurrence of their infections during 3-year follow-up periods. CONCLUSIONS: Surgical debridement, bone flap disposal, and immediate titanium mesh cranioplasty may be a suitable option for the treatment of postcraniotomy infections. This treatment strategy facilitates the eradication of infectious sources and obviates the risks and costs associated with a second surgical procedure.

Multiple successful revisions of a ventriculoureteral shunt without nephrectomy for the treatment of hydrocephalus: case report.

OBJECTIVE: Ventriculoureteral shunts have been described occasionally for patients with complicated hydrocephalus. Repeated successful revision of the distal end of such a shunt has not been reported previously. We report a case in which this was achieved. CLINICAL PRESENTATION: A 21-year-old woman with long-standing hydrocephalus, numerous prior shunt revisions and failures, and several distal shunt sites was shunted successfully into her right ureter. INTERVENTION: On two occasions, proximal shunt infections required shunt externalization, and the distal end was reinserted successfully into the same distal ureter both times. The patient recovered well from surgery with no clinical evidence of shunt malfunction. CONCLUSION: Multiple distal target failures are an unusual but difficult problem in patients with hydrocephalus. Ventriculoureteral shunts without nephrectomy should be considered, and they can be reused successfully if necessary.