Thirty- and 90-day Readmissions After Spinal Surgery for Spine Metastases: A National Trend Analysis of 4423 Patients.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim of this study was to investigate differences in 30- and 90-day readmissions for spine metastases treated with decompression and/or fusion spine surgery in a nationwide readmission database. SUMMARY OF BACKGROUND DATA: Patients with metastases to the spine represent a particularly vulnerable patient group that may encounter frequent readmissions. However, the 30- and 90-day rates for readmission following surgery for spine metastases have not been well described. METHODS: The Nationwide Readmission Database years 2013 to 2015 was queried. Patients were grouped by no readmission (non-R), readmission within 30 days (30-R), and readmission within 31 to 90 days (90-R). Weighted multivariate analysis assessed impact of treatment approach and clinical factors associated with 30- and 90-day readmissions. RESULTS: There were a total of 4423 patients with a diagnosis of spine metastases identified who underwent spine surgery, of which 1657 (37.5%) encountered either a 30-or 90-day unplanned readmission (30-R: n = 1068 [24-.1%]; 90-R: n = 589 [13.3%]; non-R: n = 2766). The most prevalent inpatient complications observed were postoperative infection (30-R: 16.3%, 90-R: 14.3%, non-R: 11.5%), acute post-hemorrhagic anemia (30-R: 13.4%, 90-R: 14.2%, non-R: 14.5%), and genitourinary complication (30-R: 5.7%, 90-R: 2.9%, non-R: 6.2%). The most prevalent 30-day and 90-day reasons for admission were sepsis (30-R: 10.2%, 90-R: 10.8%), postoperative infection (30-R: 13.7%, 90-R: 6.5%), and genitourinary complication (30-R: 3.9%, 90-R: 4.1%). On multivariate regression analysis, surgery type, age, hypertension, and renal failure were independently associated with 30-day readmission; rheumatoid arthritis/collagen vascular diseases, and coagulopathy were independently associated with 90-day readmission. CONCLUSION: In this study, we demonstrate several patient-level factors independently associated with unplanned hospital readmissions after surgical treatment intervention for spine metastases. Furthermore, we find that the most common reasons for readmission are sepsis, postoperative infection, and genitourinary complications.Level of Evidence: 3.

Patient Risk Factors Associated With 30- and 90-Day Readmission After Cervical Discectomy: A Nationwide Readmission Database Study.

STUDY DESIGN: This is a retrospective cohort study. OBJECTIVE: The aim of this study was to assess the patient-level risk factors associated with 30- and 90-day unplanned readmissions following elective anterior cervical decompression and fusion (ACDF) or cervical disk arthroplasty (CDA). SUMMARY OF BACKGROUND DATA: For cervical disk pathology, both ACDF and CDA are increasingly performed nationwide. However, relatively little is known about the adverse complications and rates of readmission for ACDF and CDA. METHODS: A retrospective cohort study was performed using the Nationwide Readmission Database from the years 2013 to 2015. All patients undergoing either CDA or ACDF were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. Unique patient linkage numbers were used to follow patients and to identify 30- and 31-90-day readmission rates. Patients were grouped by no readmission (Non-R), readmission within 30 days (30-R), and readmission within 31-90 days (90-R). RESULTS: There were a total of 13,093 index admissions with 856 (6.5%) readmissions [30-R: n=532 (4.0%); 90-R: n=324 (2.5%)]. Both overall length of stay and total cost were greater in the 30-R cohort compared with 90-R and Non-R cohorts. The most prevalent 30- and 90-day complications seen among the readmitted cohorts were infection, genitourinary complication, and device complication. On multivariate regression analysis, age, Medicaid status, medium and large hospital bed size, deficiency anemia, and any complication during index admission were independently associated with increased 30-day readmission. Whereas age, large hospital bed size, coagulopathy, and any complication during the initial hospitalization were independently associated with increased 90-day readmission. CONCLUSION: Our nationwide study identifies the 30- and 90-day readmission rates and several patient-related risk factors associated with unplanned readmission after common anterior cervical spine procedures. LEVEL OF EVIDENCE: Level III.

Influence of gender on discharge disposition after spinal fusion for adult spine deformity correction.

OBJECTIVES: Gender has been shown to impact several aspects of spine surgical care. However, the influence of gender disparities on discharge disposition after adult spine deformity correction (ASD) is relatively understudied. The aim of this study was to investigate the influence of gender on discharge disposition after elective spinal fusion involving ≥4 levels for ASD correction. PATIENTS AND METHODS: The Nationwide Inpatient Sample database (2011-2014) was queried for patients with ASD (≥26 years-old) and elective spine fusion surgery involving ≥4 levels using ICD-9 codes. Patients were stratified by gender: Male or Female. Multivariate linear and logistic regressions were used to assess the impact of gender on length of hospital stay and discharge disposition. RESULTS: A total of 4972 patients were identified of which 3282 (66.0%) were Female and 1690 (34.0%) were Male. The Male cohort had a higher prevalence of comorbidities than the Female cohort. There was a difference in the number of levels operated on between cohorts, with the Female cohort having fewer 4-8-level fusions (77.6% vs. 86.8%) and more 9+-level fusions (23.0% vs. 13.6%) compared to Males. The Female cohort had greater rates of postoperative UTI (5.5% vs. 2.5%) and surgical site hematomas (2.6% vs. 1.3%), while the Male cohort had more postoperative MI (5.4% vs. 1.5%). The Female cohort spent slightly more time in the hospital than Male cohort (6.2 days vs. 5.9 days, P = 0.035). Female patients had a significantly greater proportion of non-routine discharge disposition (F: 48.5% vs. M: 40.3%, P < 0.001) compared to Male patients. However, in a multivariate analysis including patient and hospital factors, gender was not an independent predictor of discharge disposition (OR: 0.976, CI: 0.865-1.101, P = 0.688), but was independently associated with increased LOS [female (RR: 0.331, CI: 0.106-0.556, P = 0.004)]. CONCLUSION: Our study suggests gender disparities may not have a significant impact on discharge disposition after spinal fusion for ASD involving four levels or greater. Further studies are necessary to understand risk factors for non-routine discharges in ASD patients to improve quality of patient care and reduced healthcare costs.

Independent Association Between Type of Intraoperative Blood Transfusion and Postoperative Delirium After Complex Spinal Fusion for Adult Deformity Correction.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To determine whether type of intraoperative blood transfusion used is associated with increased incidence of postoperative delirium after complex spine fusion involving five levels or greater. SUMMARY OF BACKGROUND DATA: Postoperative delirium after spine surgery has been associated with age, cognitive status, and several comorbidities. Intraoperative allogenic blood transfusions have previously been linked to greater complication risks and length of hospital stay. However, whether type of intraoperative blood transfusion used increases the risk for postoperative delirium after complex spinal fusion remains relatively unknown. METHODS: The medical records of 130 adult (≥18 years old) spine deformity patients undergoing elective, primary complex spinal fusion (more than or equal to five levels) for deformity correction at a major academic institution from 2010 to 2015 were reviewed. We identified 104 patients who encountered an intraoperative blood transfusion. Of the 104, 15 (11.5%) had Allogenic-only, 23 (17.7%) had Autologous-only, and 66 (50.8%) had Combined transfusions. The primary outcome investigated was the rate of postoperative delirium. RESULTS: There were significant differences in estimated blood loss (Combined: 2155.5 ±â€Š1900.7 mL vs. Autologous: 1396.5 ±â€Š790.0 mL vs. Allogenic: 1071.3 ±â€Š577.8 mL vs. None: 506.9 ±â€Š427.3 mL, P < 0.0001) and amount transfused (Combined: 1739.7 ±â€Š1127.6 mL vs. Autologous: 465.7 ±â€Š289.7 mL vs. Allogenic: 986.9 ±â€Š512.9 mL, P < 0.0001). The Allogenic cohort had a significantly higher proportion of patients experiencing delirium (Combined: 7.6% vs. Autologous: 17.4% vs. Allogenic: 46.7% vs. None: 11.5%, P = 0.002). In multivariate nominal-logistic regression analysis, Allogenic (odds ratio [OR]: 24.81, 95% confidence interval [CI] [3.930, 156.702], P = 0.0002) and Autologous (OR: 6.43, 95% CI [1.156, 35.772], P = 0.0335) transfusions were independently associated with postoperative delirium. CONCLUSION: Our study suggests that there may be an independent association between intraoperative autologous and allogenic blood transfusions and postoperative delirium after complex spinal fusion. Further studies are necessary to identify the physiological effect of blood transfusions to better overall patient care and reduce healthcare expenditures. LEVEL OF EVIDENCE: 3.

Cost-effectiveness of Magnetic Resonance Imaging in Cervical Clearance of Obtunded Blunt Trauma After a Normal Computed Tomographic Finding.

Importance: Magnetic resonance imaging (MRI) continues to be performed for cervical clearance of obtunded blunt trauma, despite poor evidence regarding its utility after a normal computed tomographic (CT) finding. Objective: To evaluate the utility and cost-effectiveness of MRI vs no follow-up after a normal cervical CT finding in patients with obtunded blunt trauma. Design, Setting and Participants: This cost-effectiveness analysis evaluated an average patient aged 40 years with blunt trauma from an institutional practice. The analysis used a Markov decision model over a lifetime horizon from a societal perspective with variables from systematic reviews and meta-analyses and reimbursement rates from the Centers for Medicare & Medicaid Services, National Spinal Cord Injury Database, and other large published studies. Data were collected from the most recent literature available. Interventions: No follow-up vs MRI follow-up after a normal cervical CT finding. Results: In the base case of a 40-year-old patient, the cost of MRI follow-up was $14 185 with a health benefit of 24.02 quality-adjusted life-years (QALY); the cost of no follow-up was $1059 with a health benefit of 24.11 QALY, and thus no follow-up was the dominant strategy. Probabilistic sensitivity analysis showed no follow-up to be the better strategy in all 10 000 iterations. No follow-up was the better strategy when the negative predictive value of the initial CT was relatively high (>98%) or the risk of an injury treated with a cervical collar turning into a permanent neurologic deficit was higher than 25% or when the risk of a missed injury turning into a neurologic deficit was less than 58%. The sensitivity and specificity of MRI were varied simultaneously in a 2-way sensitivity analysis, and no follow-up remained the optimal strategy. Conclusions and Relevance: Magnetic resonance imaging had a lower health benefit and a higher cost compared with no follow-up after a normal CT finding in patients with obtunded blunt trauma to the cervical spine, a finding that does not support the use of MRI in this group of patients. The conclusion is robust in sensitivity analyses varying key variables in the model. More literature on these key variables is needed before MRI can be considered to be beneficial in the evaluation of obtunded blunt trauma.

"White Cord Syndrome" of Acute Hemiparesis After Posterior Cervical Decompression and Fusion for Chronic Cervical Stenosis.

BACKGROUND: "White cord syndrome" is a very rare condition thought to be due to acute reperfusion of chronically ischemic areas of the spinal cord. Its hallmark is the presence of intramedullary hyperintense signal on T2-weighted magnetic resonance imaging sequences in a patient with unexplained neurologic deficits following spinal cord decompression surgery. The syndrome is rare and has been reported previously in 2 patients following anterior cervical decompression and fusion. We report an additional case of this complication. CASE DESCRIPTION: A 68-year-old man developed acute left-sided hemiparesis after posterior cervical decompression and fusion for cervical spondylotic myelopathy. The patient improved with high-dose steroid therapy. CONCLUSIONS: The rare white cord syndrome following either anterior cervical decompression and fusion or posterior cervical decompression and fusion may be due to ischemic-reperfusion injury sustained by chronically compressed parts of the spinal cord. In previous reports, patients have improved following steroid therapy and acute rehabilitation.

Imaging of lumbar spinal surgery complications.

UNLABELLED: Lumbar spine surgery for spinal stenosis is a frequently performed procedure and was the fastest growing type of surgery in the US from 1980 to 2000. With increasing surgical invasiveness, postoperative complications also tend to be higher. Cross-sectional imaging techniques (CT and MRI) are more sensitive than radiographs and play an increasingly important role in evaluation of patients with lumbar spine surgery. Their use in patients with metallic implants is somewhat limited by artefacts, which can obscure pathology and decrease accuracy and reader confidence. Metal artefact reduction techniques have been developed, which can significantly improve image quality and enable early detection of postoperative complications. Complications can occur throughout postoperative course. Early complications include hardware displacement, incidental durotomy, postoperative collections-most commonly seroma, and less likely haematoma and/or infection. Incidental durotomy with CSF leak causing intracranial hypotension has characteristic MR brain findings and diagnosis of occult leak sites have been improved with use of dynamic CT myelography. Haematomas, even when compressing the thecal sac, are usually asymptomatic. Early infection, with nonspecific MR findings, can be diagnosed accurately using dual radiotracer studies. Delayed complications include loosening, hardware failure, symptomatic new or recurrent disc herniation, peri-/epidural fibrosis, arachnoiditis, and radiculitis. TEACHING POINTS: • CT and MRI play an increasingly important role in evaluation of patients with lumbar spine surgery • Complications can occur throughout the postoperative course and early detection is critical • Artefact reduction techniques can improve image quality for early and improved detection of complications.

Management of acute traumatic spinal cord injury.

OPINION STATEMENT: Spinal cord injury (SCI) causes significant morbidity and mortality. Clinical management in the acute setting needs to occur in the intensive care unit in order to identify, prevent, and treat secondary insults from local ischemia, hypotension, hypoxia, and inflammation. Maintenance of adequate perfusion and oxygenation is quintessential and a mean arterial pressure >85-90 mm Hg should be kept for at least 1 week. A cervical collar and full spinal precautions (log-roll, flat, holding C-spine) should be maintained until the spinal column has been fully evaluated by a spine surgeon. In patients with SCI, there is a high incidence of other bodily injuries, and there should be a low threshold to assess for visceral, pelvic, and long bone injuries. Computed tomography of the spine is superior to plain films, as the former rarely misses fractures, though caution needs to be exerted as occipitocervical dislocation can still be missed. To reliably assess the spinal neural elements, soft tissues, and ligamentous structures, magnetic resonance imaging is indicated and should be obtained within 48-72 h from the time of injury. All patients should be graded daily using the American Spinal Injury Association classification, with the first prognostic score at 72 h postinjury. Patients with high cervical cord (C4 or higher) injury should be intubated immediately, and those with lower cord injuries should be evaluated on a case-by-case basis. However, in the acute setting, respiratory mechanics will be disrupted with any spinal cord lesion above T11. Steroids have become extremely controversial, and the professional societies for neurosurgery in the United States have given a level 1 statement against their use in all patients. We, therefore, do not advocate for them at this time. With every SCI, a spine surgeon must be consulted to discuss operative vs nonoperative management strategies. Indications for surgery include a partial or progressive neurologic deficit, instability of the spine not allowing for mobilization, correction of a deformity, and prevention of potential neurologic compromise. Measures to prevent pulmonary emboli from deep venous thromboembolisms are necessary: IVC filters are recommended in bedbound patients and low-molecular weight heparins are superior to unfractionated heparin. Robust prevention of pressure ulcers as well as nutritional support should be a mainstay of treatment. Lastly, it is important to note that neurologic recovery is a several-year process. The most recovery occurs in the first year following injury, and therefore aggressive rehabilitation is crucial.

Cost-effectiveness of lumbar discectomy and single-level fusion for spondylolisthesis: experience with the NeuroPoint-SD registry.

OBJECT: There is significant practice variation and uncertainty as to the value of surgical treatments for lumbar spine disorders. The authors' aim was to establish a multicenter registry to assess the efficacy and costs of common lumbar spinal procedures by using prospectively collected outcomes. METHODS: An observational prospective cohort study was completed at 13 academic and community sites. Patients undergoing single-level fusion for spondylolisthesis or single-level lumbar discectomy were included. The 36-Item Short Form Health Survey (SF-36) and Oswestry Disability Index (ODI) data were obtained preoperatively and at 1, 3, 6, and 12 months postoperatively. Power analysis estimated a sample size of 160 patients: lumbar disc (125 patients) and lumbar listhesis (35 patients). The quality-adjusted life year (QALY) data were calculated using 6-dimension utility index scores. Direct costs and complication costs were estimated using Medicare reimbursement values from 2011, and indirect costs were estimated using the human capital approach with the 2011 US national wage index. Total costs equaled $14,980 for lumbar discectomy and $43,852 for surgery for lumbar spondylolisthesis. RESULTS: There were 198 patients enrolled over 1 year. The mean age was 46 years (49% female) for lumbar discectomy (n = 148) and 58.1 years (60% female) for lumbar spondylolisthesis (n = 50). Ten patients with disc herniation (6.8%) and 1 with listhesis (2%) required repeat operation at 1 year. The overall 1-year follow-up rate was 88%. At 30 days, both lumbar discectomy and single-level fusion procedures were associated with significant improvements in ODI, visual analog scale, and SF-36 scores (p = 0.0002), which persisted at the 1-year evaluation (p < 0.0001). By 1 year, more than 80% of patients in each cohort who were working preoperatively had returned to work. Lumbar discectomy was associated with a gain of 0.225 QALYs over the 1-year study period ($66,578/QALY gained). Lumbar spinal fusion for Grade I listhesis was associated with a gain of 0.195 QALYs over the 1-year study period ($224,420/QALY gained). CONCLUSIONS: This national spine registry demonstrated successful collection of high-quality outcomes data for spinal procedures in actual practice. These data are useful for demonstrating return to work and cost-effectiveness following surgical treatment of single-level lumbar disc herniation or spondylolisthesis. One-year cost per QALY was obtained, and this cost per QALY is expected to improve further by 2 years. This work sets the stage for real-world analysis of the value of health interventions.

The efficacy of lumbar discectomy and single-level fusion for spondylolisthesis: results from the NeuroPoint-SD registry: clinical article.

OBJECT: There is significant practice variation and considerable uncertainty among payers and other major stakeholders as to whether many surgical treatments are effective in actual US spine practice. The aim of this study was to establish a multicenter cooperative research group and demonstrate the feasibility of developing a registry to assess the efficacy of common lumbar spinal procedures using prospectively collected patient-reported outcome measures. METHODS: An observational prospective cohort study was conducted at 13 US academic and community sites. Unselected patients undergoing lumbar discectomy or single-level fusion for spondylolisthesis were included. Patients completed the 36-item Short-Form Survey Instrument (SF-36), Oswestry Disability Index (ODI), and visual analog scale (VAS) questionnaires preoperatively and at 1, 3, 6, and 12 months postoperatively. Power analysis estimated a sample size of 160 patients: 125 patients with lumbar disc herniation, and 35 with lumbar spondylolisthesis. All patient data were entered into a secure Internet-based data management platform. RESULTS: Of 249 patients screened, there were 198 enrolled over 1 year. The median age of the patients was 45.0 years (49% female) for lumbar discectomy (n = 148), and 58.0 years (58% female) for lumbar spondylolisthesis (n = 50). At 30 days, 12 complications (6.1% of study population) were identified. Ten patients (6.8%) with disc herniation and 1 (2%) with spondylolisthesis required reoperation. The overall follow-up rate for the collection of patient-reported outcome data over 1 year was 88.3%. At 30 days, both lumbar discectomy and single-level fusion procedures were associated with significant improvements in ODI, VAS, and SF-36 scores (p ≤ 0.0002), which persisted over the 1-year follow-up period (p < 0.0001). By the 1-year follow-up evaluation, more than 80% of patients in each cohort who were working preoperatively had returned to work. CONCLUSIONS: It is feasible to build a national spine registry for the collection of high-quality prospective data to demonstrate the effectiveness of spinal procedures in actual practice. Clinical trial registration no.: 01220921 (ClinicalTrials.gov).

Extraction of fronto-orbital metallic radio antenna through Stallard orbitotomy.

A 39-year-old man presented after falling on a radio antenna while in his yard. Computed tomography revealed that the antenna entered the right superolateral orbit, penetrating through the right orbital roof and extending into the right frontal lobe. A Stallard orbitotomy was performed to remove the antenna resulting in blepharoptosis.

Two-level thoracic pedicle subtraction osteotomy for progressive post-laminectomy kyphotic deformity following resection of an unusual thoracolumbar intradural extramedullary tumor.

The authors report a case in which multilevel thoracic pedicle subtraction osteotomy (PSO) was performed to correct post-laminectomy kyphotic deformity in a 9-year-old boy presenting with worsening lower-extremity neurological deficits. Five years prior to presentation, the patient underwent multilevel thoracolumbar laminectomies for resection of an atypical teratoid/rhabdoid tumor (AT/RT), a rare lesion that typically occurs intracranially and has a poor prognosis, making this particular presentation unusual and the patient's subsequent postoperative course remarkable. No fusion was undertaken at the time of resection, given the patient's age and presumptive poor prognosis. Over the next 5 years, the patient developed progressive thoracolumbar kyphotic deformity, with a Cobb angle greater than 110°, despite bracing, and bilateral lower-extremity weakness requiring ankle-foot orthotics for continued ambulation due to progressive foot drop. Worsening gait and the onset of respiratory issues prompted surgical intervention. Multilevel thoracic PSO and thoracolumbar fusion were performed, resulting in improved lower-extremity function and correction of the kyphotic deformity to approximately 65°. This report outlines an unusual AT/RT presentation and postoperative course and also discusses literature related to PSO within the context of pediatric kyphotic deformity. The authors' experience supports the use of multilevel PSO with fusion as a potential treatment option for significant pediatric thoracolumbar kyphotic deformity requiring surgical correction.

Primary central nervous system vasculitis presenting as spinal subdural hematoma.

BACKGROUND: Primary central nervous system vasculitis (PCNSV) is a rare and poorly described vascular inflammatory condition confined within the central nervous system (CNS). Typical presentations of PCNSV include headache, hemiparesis, cerebral edema, and altered cognition. Vasculitic processes in the spinal cord are exceedingly rare. Although intracranial vasculitis has been associated with certain systemic inflammatory disorders and lymphomas, the etiology of spinal cord vasculitis is unclear. We report the first case of a patient in whom spinal subdural hematomas were the first presenting signs of PCNSV. CASE DESCRIPTION: A 69-year-old woman presented with sudden-onset severe back pain and paraplegia following an acute hypertensive event. Multiple spinal subdural hematomas were noted on magnetic resonance imaging, and emergent laminectomies were performed for evacuation. Vasculitic abnormalities confined to the CNS were noted intraoperatively and on imaging, leading to the unique diagnosis. CONCLUSIONS: This previously unreported etiology of nontraumatic acute spinal subdural hematomas suggests that spinal cord vasculitis as part of PCNSV should be included in the differential diagnosis.

Comparative effectiveness of ventral vs dorsal surgery for cervical spondylotic myelopathy.

BACKGROUND: Cervical spondylotic myelopathy (CSM) is the most common cause of spinal cord dysfunction. OBJECTIVE: To determine the feasibility of a randomized clinical trial comparing the clinical effectiveness and costs of ventral vs dorsal decompression with fusion surgery for treating CSM. METHODS: A nonrandomized, prospective, clinical pilot trial was conducted. Patients ages 40 to 85 years with degenerative CSM were enrolled at 7 sites over 2 years (2007-2009). Outcome assessments were obtained preoperatively and at 3 months, 6 months, and 1 year postoperatively. A hospital-based economic analysis used costs derived from hospital charges and Medicare cost-to-charge ratios. RESULTS: The pilot study enrolled 50 patients. Twenty-eight were treated with ventral fusion surgery and 22 with dorsal fusion surgery. The average age was 61.6 years. Baseline demographics and health-related quality of life (HR-QOL) scores were comparable between groups; however, dorsal surgery patients had significantly more severe myelopathy (P<.01). Comprehensive 1-year follow-up was obtained in 46 of 50 patients (92%). Greater HR-QOL improvement (Short-Form 36 Physical Component Summary) was observed after ventral surgery (P=.05). The complication rate (16.6% overall) was comparable between groups. Significant improvement in the modified Japanese Orthopedic Association scale score was observed in both groups (P<.01). Dorsal fusion surgery had significantly greater mean hospital costs ($29 465 vs $19 245; P<.01) and longer average length of hospital stay (4.0 vs 2.6 days; P<.01) compared with ventral fusion surgery. CONCLUSION: Surgery for treating CSM was followed by significant improvement in disease-specific symptoms and in HR-QOL. Greater improvement in HR-QOL was observed after ventral surgery. Dorsal fusion surgery was associated with longer length of hospital stay and higher hospital costs. The pilot study demonstrated feasibility for a larger randomized clinical trial.

Cervical spine reoperation rates and hospital resource utilization after initial surgery for degenerative cervical spine disease in 12,338 patients in Washington State.

OBJECTIVE: Patients undergoing surgery for degenerative cervical spine disease may require future surgery for disease progression. We investigated factors related to the rate of additional cervical spine surgery, the associated length of stay, and hospital charges. METHODS: The was a longitudinal retrospective cohort study using Washington state's 1998 to 2002 state inpatient databases and International Classification of Diseases-Ninth Revision-Clinical Modification (ICD-9) codes to analyze patients undergoing degenerative cervical spine surgery. Multivariate Poisson regression to identify patient and surgical factors associated with reoperation for degenerative cervical spine disease was used. Multivariate linear regressions to identify factors associated with length of stay and hospital charges adjusted for age, sex, year of surgery, primary diagnosis, payment type, discharge status, and comorbidities were also used. RESULTS: A total of 12,338 patients underwent initial cervical spine surgeries from 1998 to 2002; the mean follow-up duration was 2.3 years, and 688 patients (5.6%) underwent a reoperation (2.5% per year). Higher reoperation rates were independently associated with younger patients (P < 0.001) and a primary diagnosis of disc herniation with myelopathy (P = 0.011). Ventral surgery (P < 0.001) and fusion (P < 0.001) were both associated with lower rates of reoperation; however, a high correlation (Spearman's rho = 0.82; P < 0.001) made it impossible to determine which factor was dominant. Longer length of stay was independently associated with nonventral approaches (+1.0 day; P < 0.001) and fusion surgery (+0.8 day; P < 0.001). Greater hospital charges were independently associated with nonventral approaches (+$2900; P < 0.001) and fusion surgery (+$9600; P < 0.001). CONCLUSION: Patients undergoing surgery for degenerative cervical spine disease undergo reoperations at the rate of 2.5% per year. An initial ventral approach and/or fusion seem to be associated with lower reoperation rates. An initial nonventral approach and fusion were more expensive.

Decompressive hemicraniectomy in a 19-month-old female after malignant cerebral infarction.

Malignant cerebral infarction is a life-threatening condition with case fatality rates of approximately 80% in adults with malignant infarction of the middle cerebral artery. No medical treatment has been proven effective for this condition. Decompressive hemicraniectomy within 48 h of massive cerebral infarction significantly reduces mortality and improves outcome in adults 18-60 years of age. However, there is very limited data available about the role of decompressive hemicraniectomy in children with acute malignant cerebral infarction. We present the case of a 19-month-old female who presented with progressive encephalopathy and right hemiparesis. Computed tomography and magnetic resonance imaging of the brain showed massive cerebral infarction in the distribution of the left carotid artery with midline shift and impeding brain stem herniation. She underwent emergent decompressive hemicraniectomy with duraplasty and placement of an intracranial pressure monitor. Intracranial pressure was controlled with sedation and the patient was extubated on postoperative day 4. Extensive stroke workup was negative. Cranioplasty was performed at 3 months post-op. At the 6-month follow-up, she had an excellent recovery (modified Rankin scale of 1). Decompressive hemicraniectomy should be considered for the treatment of cerebral edema in children with malignant cerebral infarction. This may improve mortality and functional outcome compared to medical therapy alone. Due to the rare occurrence of stroke in children, more reports of decompressive hemicraniectomy are encouraged.

A phase I open-label, dose-escalation, multi-institutional trial of injection with an E1B-Attenuated adenovirus, ONYX-015, into the peritumoral region of recurrent malignant gliomas, in the adjuvant setting.

ONYX-015 is an oncolytic virus untested as a treatment for malignant glioma. The NABTT CNS Consortium conducted a dose-escalation trial of intracerebral injections of ONYX-015. Cohorts of six patients at each dose level received doses of vector from 10(7) plaque-forming units (pfu) to 10(10) pfu into a total of 10 sites within the resected glioma cavity. Adverse events were identified on physical exams and testing of hematologic, renal, and liver functions. Efficacy data were obtained from serial MRI scans. None of the 24 patients experienced serious adverse events related to ONYX-015. The maximum tolerated dose was not reached at 10(10) pfu. The median time to progression after treatment with ONYX-015 was 46 days (range 13 to 452 + days). The median survival time was 6.2 months (range 1.3 to 28.0 + months). One patient has not progressed and 1 patient showed regression of interval-increased enhancement. With more than 19 months of follow-up, 1/6 recipients at a dose of 10(9) and 2/6 at a dose of 10(10) pfu remain alive. In 2 patients who underwent a second resection 3 months after ONYX-015 injection, a lymphocytic and plasmacytoid cell infiltrate was observed. Injection of ONYX-015 into glioma cavities is well tolerated at doses up to 10(10) pfu.