From Operating Room to Courtroom: Analyzing Malpractice Trajectories in Cranial Neurosurgery.

BACKGROUND AND OBJECTIVES: Nearly all neurosurgeons in the United States will be named defendants in a malpractice claim before retirement. We perform an assessment of national malpractice trends in cranial neurosurgery to inform neurosurgeons on current outcomes, trends over time, benchmarks for malpractice coverage needs, and ways to mitigate lawsuits. METHODS: The Westlaw Edge and LexisNexis databases were searched to identify medical malpractice cases relating to open cranial surgery between 1987 and 2023. Extracted data included date of verdict, jurisdiction, outcome, details of sustained injuries, and any associated award/settlement figures. RESULTS: Of 1550 cases analyzed, 252 were identified as malpractice claims arising from open cranial surgery. The median settlement amount was $950 000 and the average plaintiff ruling was $2 750 000. The highest plaintiff ruling resulted in an award of $28.1 million. Linear regression revealed no significant relationship between year and defendant win (P-value = .43). After adjusting for inflation, award value increased with time (P-value = .01). The most common cranial subspecialties were tumor (67 cases, 26.6%), vascular (54 cases, 21.4%), infection (23 cases, 9.1%), and trauma (23 cases, 9.1%). Perioperative complications was the most common litigation category (96 cases, 38.1%), followed by delayed treatment (40 cases, 15.9%), failure to diagnose (38 cases, 15.1%), and incorrect choice of procedure (29 cases, 11.5%). The states with most claims were New York (40 cases, 15.9%), California (24 cases, 9.5%), Florida (21 cases, 8.3%), and Pennsylvania (20 cases, 7.9%). CONCLUSION: Although a stable number of cases were won by neurosurgeons, an increase in award sizes was observed in the 37-year period assessed. Perioperative complications and delayed treatment/diagnosis were key drivers of malpractice claims.

Benign Natural Progression of Small Cavernous Carotid Aneurysms Suggests Limited Clinical Utility of Serial Longitudinal Follow-up.

BACKGROUND AND OBJECTIVES: Aneurysms in the cavernous segment of the internal carotid artery (ICA) often present in an indolent fashion with limited morbidity. However, their growth progression and possible rupture over time remains poorly defined, thereby limiting optimization of serial follow-up. Thus, we aim to describe the progression of cavernous ICA aneurysms over time, as well as the patient and aneurysm characteristics associated with possible growth and rupture status. METHODS: We identified a consecutive cohort of 157 patients from 2007 to 2021 with cavernous ICA aneurysms. Patient demographic data, possible risk factors, presenting symptoms, radiographic features of aneurysms, size progression, rupture status, and concomitant noncavernous aneurysm rupture data were manually extracted. RESULTS: One hundred and fifty-seven patients (mean age at diagnosis 57.2 ± 15.6 years; 85.4% females) with 174 cavernous carotid aneurysms (CCAs) were followed for an average of 7.1 ± 4.8 years. 76.4% of aneurysms were identified incidentally, with predominantly ocular palsies as the presenting symptoms in remaining primary cases. Most aneurysms were small, and of the 168 aneurysms that were followed, 98.2% did not demonstrate appreciable growth. Of the aneurysms that grew, it took an average of 6.0 years to grow 1.6 ± 0.2 mm. Demographic data, hypertension, and smoking status were not associated with aneurysm growth. Most radiographic features also were not associated with growth, except long-axis diameter, which had an odds ratio of 1.4 (CI: 1.2, 1.8) on multivariable analysis. Presenting clinical symptoms were not associated with growth. No CCAs ruptured during follow-up. CONCLUSION: Cavernous ICA aneurysms in our series demonstrate no rupture and limited growth over years of clinical follow-up. No radiographic or patient risk factors were associated with growth except initial aneurysm size. Hence, small CCAs may not require close follow-up over time.

Elevated risk of recurrence and retreatment for silent pituitary adenomas.

PURPOSE: Pituitary adenomas are the most common tumor of the pituitary gland and comprise nearly 15% of all intracranial masses. These tumors are stratified into functional or silent categories based on their pattern of hormone expression and secretion. Preliminary evidence supports differential clinical outcomes between some functional pituitary adenoma (FPA) subtypes and silent pituitary adenoma (SPA) subtypes. METHODS: We collected and analyzed the medical records of all patients undergoing resection of SPAs or FPAs from a single high-volume neurosurgeon between 2007 and 2018 at Brigham and Women's Hospital. Descriptive statistics and the Mantel-Cox log-rank test were used to identify differences in outcomes between these cohorts, and multivariate logistic regression was used to identify predictors of radiographic recurrence for SPAs. RESULTS: Our cohort included 88 SPAs and 200 FPAs. The majority of patients in both cohorts were female (48.9% of SPAs and 63.5% of FPAs). SPAs were larger in median diameter than FPAs (2.1 cm vs. 1.2 cm, p < 0.001). The most frequent subtypes of SPA were gonadotrophs (55.7%) and corticotrophs (30.7%). Gross total resection (GTR) was achieved in 70.1% of SPA resections and 86.0% of FPA resections (p < 0.001). SPAs had a higher likelihood of recurring (hazard ratio [HR] 3.2, 95% confidence interval [95%CI] 1.6-7.2) and a higher likelihood of requiring retreatment for recurrence (HR 2.5; 95%CI 1.0-6.1). Subset analyses revealed that recurrence and retreatment were more both likely for subtotally resected SPAs than subtotally resected FPAs, but this pattern was not observed in SPAs and FPAs after GTR. Among SPAs, recurrence was associated with STR (odds ratio [OR] 9.3; 95%CI 1.4-64.0) and younger age (OR 0.92 per year; 95%CI 0.88-0.98) in multivariable analysis. Of SPAs that recurred, 12 of 19 (63.2%) were retreated with repeat surgery (n = 11) or radiosurgery (n = 1), while the remainder were observed (n = 7).There were similar rates of recurrence across different SPA subtypes. CONCLUSION: Patients undergoing resection of SPAs should be closely monitored for disease recurrence through more frequent clinical follow-up and diagnostic imaging than other adenomas, particularly among patients with STR and younger patients. Several patients can be observed after radiographic recurrence, and the decision to retreat should be individualized. Longitudinal clinical follow-up of SPAs, including an assessment of symptoms, endocrine function, and imaging remains critical.

Does minimally invasive spine surgery improve outcomes in the obese population? A retrospective review of 1442 degenerative lumbar spine surgeries.

OBJECTIVE: The effect of obesity on outcomes in minimally invasive surgery (MIS) approaches to posterior lumbar surgery is not well characterized. The authors aimed to determine if there was a difference in operative variables and complication rates in obese patients who underwent MIS versus open approaches in posterior spinal surgery, as well as between obese and nonobese patients undergoing MIS approaches. METHODS: A retrospective review of all consecutive patients who underwent posterior lumbar surgery from 2013 to 2016 at a single institution was performed. The primary outcome measure was postoperative complications. Secondary outcome measures included estimated blood loss (EBL), operative time, the need for revision, and hospital length of stay (LOS); readmission and disposition were also reviewed. Obese patients who underwent MIS were compared with those who underwent an open approach. Additionally, obese patients who underwent an MIS approach were compared with nonobese patients. Bivariate and multivariate analyses were carried out between the groups. RESULTS: In total, 423 obese patients (57.0% decompression and 43.0% fusion) underwent posterior lumbar MIS. When compared with 229 obese patients (56.8% decompression and 43.2% fusion) who underwent an open approach, patients in both the obese and nonobese groups who underwent MIS experienced significantly decreased EBL, LOS, operative time, and surgical site infections (SSIs). Of the nonobese patients, 538 (58.4% decompression and 41.6% fusion) underwent MIS procedures. When compared with nonobese patients, obese patients who underwent MIS procedures had significantly increased LOS, EBL, operative time, revision rates, complications, and readmissions in the decompression group. In the fusion group, only LOS and disposition were significantly different. CONCLUSIONS: Obese patients have poorer outcomes after posterior lumbar MIS when compared with nonobese patients. The use of an MIS technique can be of benefit, as it decreased EBL, operative time, LOS, and SSIs for posterior decompression with or without instrumented fusion in obese patients.

Comparison of Clinical and Radiographic Outcomes After Standalone Versus Cage and Plate Constructs for Anterior Cervical Discectomy and Fusion.

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) has conventionally been performed using an allograft cage with a plate-and-screw construct. Recently, standalone cages have gained popularity due to theorized decreases in operative time and postoperative dysphagia. Few studies have compared these outcomes. Here, we directly compare the outcomes of plated versus standalone ACDF constructs. METHODS: A single-center retrospective review of patients undergoing ACDF after June 2011 with at least 6 months of follow up was conducted. Clinical outcomes were analyzed and compared between standalone and plated constructs. Multivariate regression analysis of the primary outcome, need for revision surgery, as well as several secondary outcomes, procedure duration, estimated blood loss (EBL), length of hospital stay, disposition, and incidence of dysphagia, hoarseness, or surgical site infection, was completed. RESULTS: A total of 321 patients underwent ACDF and met inclusion-exclusion criteria, with mean follow-up duration of 20 months. Forty-six (14.3%) patients received standalone constructs, while 275 (85.7%) received plated constructs. Fourteen (4.4%) total revisions were necessary, 4 in the standalone group and 10 in the plated group, yielding revision rates of 8.7% and 3.6%, respectively (P = .125). Mean EBL was 98 mL in the standalone group and 63 mL in the plated group (P = .001). Mean procedure duration was 147 minutes in the standalone group and 151 minutes in the plated group (P = .800). Mean hospital stay was 3.6 days in the standalone group and 2.5 days in the plated group (P = .270). There was no significant difference in incidence of dysphagia (P = .700) or hoarseness (P = .700). CONCLUSIONS: Standalone ACDF demonstrates higher, but not statistically significant, revision rates than plate-and-screw constructs, without the hypothesized decreased incidence of dysphagia or hoarseness and without decreased procedure duration or EBL. Surgeons may consider limiting use of these constructs to cases of adjacent segment disease. Larger studies with longer follow up are necessary to make more definitive conclusions. LEVEL OF EVIDENCE: 4. CLINICAL RELEVANCE: This study will help spine surgeons decide between using standalone or cage-and-plate constructs for ACDF.

Does minimally invasive spine surgery reduce the rate of perioperative medical complications? A retrospective single-center experience of 1435 degenerative lumbar spine surgeries.

PURPOSE: It is unclear if minimally invasive techniques reduce the rate of perioperative complications when compared to traditional open approaches to the lumbar spine. Our aim was to evaluate perioperative complications in patients that underwent MIS and conventional open techniques for degenerative lumbar pathology. METHODS: A retrospective review of a prospectively collected database identified 1435 patients that underwent surgery for degenerative lumbar pathology from January 2013-2016. We evaluated the rates of deep vein thrombosis, pulmonary embolism, urinary tract infection, and pneumonia. Groups were analyzed based on decompression alone as compared with decompression and fusion for both MIS and traditional open techniques. RESULTS: Patients that underwent traditional open lumbar decompression surgery were more likely to develop a DVT (P = .01) than those undergoing MIS decompression. There was no significant difference in rates of PE (P = .99), UTI (P = .24), or pneumonia (P = .56). Patients that underwent traditional open lumbar fusion surgery compared to MIS fusion were also more likely to have a PE (P = .03). There was no significant difference in rates of DVT (P = .22), UTI (P = .43), or pneumonia (P = .24). CONCLUSION: Minimally invasive spinal surgery was found to reduce the rate of DVT for decompression surgeries and reduce the rate of PE for fusion surgeries.

Spontaneous Occlusion of a Complex Brain Arteriovenous Malformation Following Partial Embolization.

BACKGROUND: Curative embolization for cerebral arteriovenous malformation (AVM) cannot always be achieved. Rather, embolization plays a role in AVM treatment as an adjuvant therapy before radiosurgery and microsurgery. Curative embolization for large, complex AVMs is not commonly seen. CASE DESCRIPTION: A man in his 30s with an unruptured left cerebral AVM underwent radiosurgery in 2014 and was lost to follow-up. He presented with intracerebral hemorrhage in 2019, and diagnostic cerebral angiography demonstrated a large, complex AVM. The patient was scheduled for 2-stage embolization in preparation for microsurgical resection. Initial embolization targeted and occluded 20% of the AVM nidus involving primarily the anteroinferior portion. A cerebral angiogram obtained 5 weeks following initial embolization revealed spontaneous occlusion of the remaining AVM. CONCLUSIONS: There are few reported cases of spontaneous occlusion of a large, complex AVM following embolization with previous radiation therapy. The spontaneous occlusion in this case suggests that at least some AVMs that receive embolization after radiation, rather than before, may have a potential for spontaneous, curative thrombosis.

Reoperation, Readmission, and Discharge Disposition for Patients With Degenerative Lumbar Pathology Treated With Either Open or Minimally Invasive Techniques: A Single-Center Retrospective Review of 1435 Cases.

BACKGROUND: Spine surgery has been transformed by the growth of minimally invasive surgery (MIS) procedures. Previous studies agree that MIS has shorter hospitalization and faster recovery time when compared to conventional open surgery. However, the reoperation and readmission rates between the 2 techniques have yet to be well characterized. OBJECTIVE: To evaluate the rate of subsequent revision between MIS and open techniques for degenerative lumbar pathology. METHODS: A total of 1435 adult patients who underwent lumbar spine surgery between 2013 and 2016 were included in this retrospective analysis. The rates of need for subsequent reoperation, 30- and 90-d readmission, and discharge to rehabilitation were recorded for both MIS and traditional open techniques. Groups were divided into decompression alone and decompression with fusion. RESULTS: The rates of subsequent reoperation following MIS and open surgery were 10.4% and 12.2%, respectively (P = .32), which were maintained when subdivided into decompression and decompression with fusion. MIS and open 30-d readmission rates were 7.9% and 7.2% (P = .67), while 90-d readmission rates were 4.3% and 3.6% (P = .57), respectively. Discharge to rehabilitation was significantly lower for patients under 60 yr of age undergoing MIS (1.64% vs 5.63%, P = .04). CONCLUSION: The use of minimally invasive techniques for the treatment of lumbar spine pathology does not result in increased reoperation or 30- and 90-d readmission rates when compared to open approaches. Patients under the age of 60 yr undergoing MIS procedures were less likely to be discharged to rehab.

The incidence of symptomatic postoperative epidural hematoma after minimally invasive lumbar decompression: A single institution retrospective review.

OBJECTIVE: Postoperative epidural hematoma (PEDH) after minimally invasive lumbar laminectomy (MILL) can lead to significant morbidity and healthcare cost. The incidence is not well characterized in the literature as compared with traditional open techniques. Our aim was to define the incidence of PEDH after MIS lumbar decompression procedures and evaluate strategies for reduction of PEDH. PATIENTS AND METHODS: A retrospective review of a prospectively collected database was queried from January 2013 to September 2018 for all patients that underwent a minimally invasive lumbar laminectomy or laminotomy, with or without discectomy, for which the goal was decompression alone. Charts were reviewed to see the operation type and whether the patient developed a postoperative epidural hematoma. RESULTS: 1004 cases were identified and reviewed. The overall PEDH rate was 1.4 % (14/1004). 78.5 % (11/14) of cases involved at least a single level laminectomy. 21.4 % (3/14) involved a laminotomy alone or with discectomy. 64.3 % (9/14) of patients presented with a neurological deficit. CONCLUSIONS: The rate of PEDH after MIS lumbar decompression procedures is 1.4 %. A majority of patients presented with a neurological deficit.

Partial loss of ATP13A2 causes selective gliosis independent of robust lipofuscinosis.

Loss-of-function mutations in ATP13A2 are associated with three neurodegenerative diseases: a rare form of Parkinson's disease termed Kufor-Rakeb syndrome (KRS), a lysosomal storage disorder termed neuronal ceroid lipofuscinosis (NCL), and a form of hereditary spastic paraplegia (HSP). Furthermore, recent data suggests that heterozygous carriers of mutations in ATP13A2 may confer risk for the development of Parkinson's disease, similar to the association of mutations in glucocerebrosidase (GBA) with both Parkinson's disease and Gaucher's disease, a lysosomal storage disorder. Mutations in ATP13A2 are generally thought to be loss of function; however, the lack of human autopsy tissue has prevented the field from determining the pathological consequences of losing functional ATP13A2. We and others have previously neuropathologically characterized mice completely lacking murine Atp13a2, demonstrating the presence of lipofuscinosis within the brain - a key feature of NCL, one of the diseases to which ATP13A2 mutations have been linked. To determine if loss of one functional Atp13a2 allele can serve as a risk factor for disease, we have now assessed heterozygous Atp13a2 knockout mice for key features of NCL. In this report, we demonstrate that loss of one functional Atp13a2 allele leads to both microgliosis and astrocytosis in multiple brain regions compared to age-matched controls; however, levels of lipofuscin were only modestly elevated in the cortex of heterozygous Atp13a2 knockout mice over controls. This data suggests the possibility that partial loss of ATP13A2 causes inflammatory changes within the brain which appear to be independent of robust lipofuscinosis. This study suggests that heterozygous loss-of-function mutations in ATP13A2 are likely harmful and indicates that glial involvement in the disease process may be an early event that positions the CNS for subsequent disease development.