Osteoporosis as a Risk Factor for Intraoperative Complications and Long-term Instrumentation Failure in Patients With Scoliotic Spinal Deformity.

STUDY DESIGN: A retrospective review study. OBJECTIVE: This study aims to determine the effect of osteoporosis on spine instrumentation. SUMMARY OF BACKGROUND DATA: Osteoporosis is a common skeletal pathology that affects systemic cortical bone maintenance and remodeling. This disease accelerates the degeneration of the spine, often necessitating spinal surgery for progressive vertebral deformity, pathologic fracture, bony canal stenosis, and/or neural element decompression. There is a paucity of literature describing the role of osteoporosis as it relates to both perioperative complications and outcomes after spine fusion surgery. MATERIALS AND METHODS: A retrospective review was conducted of a prospectively maintained database for patients undergoing spine surgery between January 1, 2006 and October 3, 2017. Inclusion criteria included age 18 years and above and surgery performed for the correction of thoracolumbar scoliosis. Data collected included various demographic, clinical, and operative variables. RESULTS: A total of 532 patients met inclusion criteria, including 144 (27%) patients with a diagnosis of osteoporosis. Osteoporosis was significantly associated with increased blood volume loss (P=0.003). Postoperatively, osteoporosis was associated with increased rates of instrumentation failure (19% vs. 10%; P=0.008) and the need for revision surgery (33% vs. 16%; P<0.001). Multivariate analysis confirmed osteoporosis to be an independent risk factor for increased mean number of spinal segments fused (P<0.05), mean blood volume loss (P<0.05), rate of postoperative deep venous thrombosis/pulmonary embolism (P<0.05), rate of instrumentation failure (P<0.05), and need for revision surgery (P<0.05). CONCLUSION: Osteoporosis is a significant risk factor for instrumentation failure and need for revision surgery following arthrodesis for scoliosis correction. Furthermore, patients with osteoporosis have a significantly higher risk of intraoperative blood volume loss and postoperative thromboembolic events.

Headache and Other Symptoms in Chiari Malformation Type I Are Associated with Cerebrospinal Fluid Flow Improvement After Decompression: A Two-Institutional Study.

OBJECTIVE: Chiari malformation type I (CMI) is a common neurologic condition and surgery is the standard treatment. We aim to establish the cerebrospinal fluid (CSF) flow change as a potential objective indicator of surgical efficacy to improve symptoms. METHODS: We performed a retrospective 2-center analysis of surgically treated patients with CMI. Qualitative CSF flow studies obtained preoperatively and postoperatively were analyzed by the neuroradiologist, seeking improvement in CSF flow. Symptom status, including headache and neck pain, were recorded. RESULTS: Forty-nine patients were identified between 2010 and 2017. The average age was 36 years, with 47 females. After decompression, CSF flow was improved in 41 patients (group A) and unchanged in 8 (group B). Group A and B had a mean age of 34 and 42 years (P < 0.05) and an average tonsillar herniation of 8.3 and 8.5 mm (P = 0.40), respectively. Group A had improved clinical outcomes, compared with group B (P = 0.024), more specifically, in headache (50% vs. 37%), neck pain (66% vs. 33%), dizziness (78% vs. 50%), vision symptoms (84% vs. 80%), and weakness (100% vs. 66%), respectively. Group B had the only patient who did worse on clinical follow-up. CONCLUSIONS: Patients with CMI often present with a constellation of symptoms. We showed a significant association between improved CSF flow after decompression and symptom alleviation. Further, our study suggests that the presence of improved CSF flow postoperatively could represent an objective indicator for improved patient outcomes.

A Population-Based Study of Patients with Sleep-Wake Disorders Undergoing Elective Instrumented Spinal Surgery.

BACKGROUND: Sleep-wake disorders (SWDs) are associated with multiple systemic pathologies; however, the clinical risk that such disorders carry for spinal surgery patients is not well understood. In the present population-based study, we comprehensively evaluated the significance of sleep-related risk factors on instrumented spinal surgery outcomes. METHODS: National Inpatient Sample data for the hospitalization of patients who had undergone elective instrumented spine surgery from 2008 to 2014 were analyzed using national estimates. The cohorts were defined as those admissions with or without a coexisting SWD diagnosis identified by International Classification of Diseases, ninth revision, codes. Postoperative complications, mortality rate, length of stay, discharge status, and the total cost of admission were compared between the groups using bivariate and multivariate analyses. RESULTS: A coexisting SWD was present in 234,640 of 2,171,167 instrumented spinal surgery hospitalizations (10.8%). Multivariate binary logistic regression accounting for these variables confirmed that a SWD is a significant risk factor for postoperative complications (odds ratio [OR], 1.160; 95% confidence interval [CI], 1.140-1.179; P < 0.0001), length of stay greater than the 75th percentile (OR, 1.303; 95% CI, 1.288-1.320; P < 0.0001), nonroutine discharge (OR, 1.147; 95% CI, 1.131-1.163; P < 0.0001), and death (OR, 1.533; 95% CI, 1.131-2.078; P < 0.01), but not for total charges greater than the 75th percentile (OR, 0.975; 95% CI, 0.962-0.989; P < 0.001). CONCLUSIONS: SWDs confer an increased risk of morbidity and mortality for elective instrumented spine surgery. Understanding the specific contributions of SWDs to postoperative morbidity and mortality will help physicians implement prophylactic measures to reduce complications and improve postoperative patient recovery.

Recrudescent infection after deep brain stimulator reimplantation.

OBJECTIVE: The efficacy of deep brain stimulation (DBS) in treating the symptoms of movement disorders can be life changing for patients. Thus, the 5%-15% incidence of stimulator-related infection requiring removal of the device can be particularly disheartening. Although DBS system reimplantation is generally successful, this is not always the case. The literature is replete with publications describing the incidence of infection and the associated features. However, the literature is sparse in terms of information on the incidence of recurrent or recrudescent infection after system reimplantation. The goal of this paper was to evaluate factors leading to unsuccessful reimplantation of a DBS system following initial infection. METHODS: Data were reviewed for all DBS procedures performed by one surgeon (K.L.H.) over 19 years including the infectious agent, location of infection, treatment regimen, and subsequent reimplantation of a DBS system and long-term outcome. RESULTS: In this series of 558 patients who had undergone DBS surgery, 37 (6.6%) subsequently developed an infection. Infections with methicillin-sensitive Staphylococcus aureus, Enterobacter species, or coagulase-negative staphylococci were predominant. Four patients had cerebritis, one had meningitis, and the rest had soft tissue infections of the pocket or scalp. All had their entire DBS system explanted, followed by 4-6 weeks of intravenous antibiotics and surveillance for recrudescence for an additional period of at least 30 days. Twenty-five patients subsequently underwent DBS system reimplantation, and the procedure was successful in 22. Three of the 4 patients with cerebritis developed a subsequent wound infection after system reimplantation. None of the other 22 patients developed a recurrence. The odds ratio for developing a recurrent infection after cerebritis was 28.5 (95% CI 1.931-420.5, p = 0.007). CONCLUSIONS: This study, the largest series of DBS system reimplantations following infection, demonstrated that most patients can have successful reimplantations without recurrent infection. However, patients who have had DBS-related cerebritis have a nearly 30-fold increased risk of developing reinfection after reimplantation. Alternative strategies for these patients are discussed.

Usefulness and Impact of Intraoperative Imaging for Glioma Resection on Patient Outcome and Extent of Resection: A Systematic Review and Meta-Analysis.

BACKGROUND: Diffusion tensor imaging (DTI), functional magnetic resonance imaging (fMRI), and intraoperative magnetic resonance imaging (iMRI) permit greater visualization and more accurate presurgical planning. Meta-analysis of these techniques for maximizing resection, postoperative functionality, and survival may further validate purported strengths of these techniques compared with standard neuronavigation. METHODS: A systematic search of the PubMed database was conducted in line with the PRISMA guidelines for meta-analysis with the following keywords: "Diffusion tensor imaging" OR "intraoperative MRI" OR "functional MRI" AND "glioma surgery resection outcome." Articles found to meet inclusion criteria were segregated and analyzed and resulting data were compared with standard neuronavigation (control cohort). RESULTS: A total of 435 articles were identified, with 29 distinct studies meeting inclusion criteria, including DTI (n = 3), fMRI (n = 5), and iMRI (n = 21). Nine studies directly compared results with standard navigation. Mean gross total resection (GTR) rates were not different among cases using DTI, fMRI, iMRI, or traditional neuronavigation (P = 0.136). On controlling for covariates, more patients received GTR in the advanced imaging cohort, although statistically insignificant (46.5% [95% confidence interval, 38.0%-55.0%] vs. 30.4% [95% confidence interval, 11.6%-49.1%]; P = 0.127; partial η2 = 0.217). Patients undergoing advanced imaging showed attenuated incidence of postsurgical permanent neurologic deficits, although also statistically insignificant (11.3% vs. 13.8%; P = 0.838). CONCLUSIONS: Current data are overall insufficient to support the notion that advanced imaging techniques are superior, either as a combined cohort or individually, in achieving GTR, improved symptom resolution, or survival compared with traditional neuronavigation.

Patients with Parkinson Disease Experience Increased Perioperative Complications Following Cervical Decompression and Fusion: A Retrospective Review of the National Inpatient Sample.

BACKGROUND: Despite improved medical management, the incidence of spinal pathology remains high in patients with Parkinson disease (PD). Several studies have investigated lumbar spine surgery in this population, but data regarding costs and perioperative complications for patients undergoing cervical decompression/fusion on a nationwide scale are lacking. METHODS: Cases of cervical spinal decompression, fusion, or exploration in years 2008-2014 were collected via the Healthcare Cost and Utilization Project National Inpatient Sample. Demographics, complications, outcome, and total charges were compared in patients with and without PD (NPD). Confounding variables were identified for multivariate analysis. RESULTS: Data were available for 195,341 cervical spine cases, of which PD was prevalent in 779 cases (0.4%). Cases with PD experienced greater overall complication rates (12.5 vs. 7.6%; P < 0.001). Multivariate analysis revealed longer lengths of stay for the PD cohort (mean = 1.21 days longer; P < 0.001) and decreased routine discharge (odds ratio = 0.308; P < 0.001). There was no significant difference in mean total charges between PD and NPD (-$1532; P = 0.337). Mortality rates did not significantly differ for either group. CONCLUSIONS: Although patients with PD experience greater complication rates and non-home discharges following cervical spine surgery compared with NPD patients, the overall clinical impact of these results may be minimal relative to surgery at other spinal levels in this population.