Lumbar Drain Use during Middle Fossa Approaches for Nonneoplastic Pathology of the Skull Base.

Introduction The middle fossa craniotomy (MFCs) is commonly utilized for spontaneous cerebrospinal fluid (CSF) leaks, encephaloceles, and superior semicircular canal dehiscence (SSCD). This study compares postoperative outcomes of MFCs with and without LD use. Methods A retrospective cohort study of adults over the age of 18 years presenting for the repair of nonneoplastic CSF leak, encephalocele, or SSCD via MFC from 2009 to 2021 was conducted. The main exposure of interest was the placement of an LD. The primary outcome was the presence of postoperative complications (acute/delayed neurologic deficit, meningitis, intracranial hemorrhage, and stroke). Secondary outcomes included operating room (OR) time, length of stay, recurrence, and need for reoperation. Results In total, 172 patients were included, 96 of whom received an LD and 76 who did not. Patients not receiving an LD were more likely to receive intraoperative mannitol ( n = 24, 31.6% vs. n = 16, 16.7%, p = 0.02). On univariate logistic regression, LD placement did not influence overall postoperative complications (OR: 0.38, 95% confidence interval [CI]: 0.05-2.02, p = 0.28), CSF leak recurrence (OR: 0.75, 95% CI: 0.25-2.29, p = 0.61), or need for reoperation (OR: 1.47, 95% CI: 0.48-4.96, p = 0.51). While OR time was shorter for patients not receiving LD (349 ± 71 vs. 372 ± 85 minutes), this difference was not statistically significant ( p = 0.07). Conclusion No difference in postoperative outcomes was observed in patients who had an intraoperative LD placed compared to those without LD. Operative times were increased in the LD cohort, but this difference was not statistically significant. Given the similar outcomes, we conclude that LD is not necessary to facilitate safe MCF for nonneoplastic skull base pathologies.

Preresidency research output among US neurological surgery residents.

OBJECTIVE: Research productivity is often used to evaluate candidates for neurosurgery residency. Official annual reports describe the mean total number of research products of successful applicants for each match cycle; however, the average number of indexed publications, the highest-valued research product, is not reported separately from other research products. The primary objectives of this study were to describe the distribution of preresidency indexed publication quantity among successful neurosurgery applicants from 2017 to 2021 and determine whether any change in publication quantity across application cycles existed. Secondary objectives included determining the rate at which the average publication quantity is increasing across application cycles, whether this increase is driven by high-output applicants alone, and if a performance ceiling has been reached. METHODS: US doctor of medicine seniors applying to the senior author's institution between 2017 and 2021 and who successfully matched into any US neurosurgery program were included. Publication quantities were extracted using Scopus. Additional variables were extracted from residency applications. Mean (SD) and median (IQR) publication quantities were used to describe the distribution and compare across years. Applicants were ranked by descending publication count and divided into quartiles. Averages within each quartile were compared with respective quartiles across years. Averages of the top 10% most productive applicants were compared across years to determine if a performance ceiling existed. RESULTS: Overall, 93.2% of matched applicants were captured. The mean and median total numbers of publications for applicants who matched from 2017 to 2021 were 5.6 ± 8.3 and 3.0 (1.0, 7.0), respectively. The mean and median numbers of publications increased from 3.7 ± 5.3 and 2.0 (0.0, 5.0) in 2016-2017 to 8.1 ± 10.0 and 5.0 (2.0, 11.0) in 2020-2021 (p < 0.001). The distribution of publication quantity was right-skewed. Multivariable analysis determined the application year to be independently and positively correlated with publication quantity (ß 1.07 [95% CI 0.71-1.42], p < 0.001). All quartiles observed an increased average number of publications across years (p < 0.001). The mean and median numbers for the top 10% increased from 15.8 ± 8.7 and 13.0 (10.8, 15.5) in 2016-2017, respectively, to 31.3 ± 16.0 and 25.0 (21.0, 35.5) in 2020-2021 (p < 0.001). CONCLUSIONS: Indexed publications account for a small portion of the total research products that successful neurosurgery candidates list on applications. A high number of publications is not necessary for candidates to match, with approximately 50% of all applicants who successfully matched having ≤ 5 publications and 25% having ≤ 2 publications. The average preresidency publication quantity has been increasing yearly among neurosurgery applicants. This increase was present across the applicant pool. Additionally, no performance ceiling was observed.

The incidence of reoperation for pseudarthrosis after cervical spine surgery.

INTRODUCTION: Pseudarthrosis after cervical spine surgery represents an underreported and challenging complication. Using a large multi-center surgical database, we sought to: (1) report the incidence of cervical pseudarthrosis, (2) evaluate changes in rates of cervical pseudarthrosis, and (3) describe risk factors for suboptimal outcomes after cervical pseudarthrosis surgery. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2019 was used. The primary outcome was occurrence of a cervical fusion procedure with a prior diagnosis of pseudarthrosis. Fusion for pseudarthrosis was divided into anterior and posterior approaches. Post-operative complications were classified as major or minor. Prolonged LOS was defined as exceeding the 75th percentile for total hospital stay. RESULTS: A total of 780 patients underwent cervical fusion for pseudarthrosis, and a significant increase in rates of surgery for pseudarthrosis was seen (0.25-1.2%, p < 0.001). The majority of cervical pseudarthrosis was treated with a posterior approach (66.5%). Postoperatively, 38 (4.9%) patients suffered a complication and 247 (31.7%) had a prolonged LOS. The three strongest risk factors for complications and extended LOS were > 10% weight loss preoperatively, congestive heart failure, and pre-operative bleeding disorder. CONCLUSION: Results from a large multi-center national database revealed that surgery to treat cervical pseudarthrosis has increased from 2012 to 2019. Most pseudarthrosis was treated with a posterior approach. Reoperation to treat cervical pseudarthrosis carried risk, with 5% having complications and 32% having an extended LOS. These results lay the groundwork for a future prospective study to discern the true incidence of cervical pseudarthrosis and how to best avoid its occurrence.

Risk of Two Sport-Related Concussions in the Same Year: Is the Second Concussion Worse?

OBJECTIVES: 1) Evaluate the frequency of same-year, repeat concussions; (2) assess predictors of sustaining a repeat concussion; and (3) compare outcomes of athletes with repeat concussions with athletes with single concussion. DESIGN: A retrospective, case-control study. SETTING: Regional sports concussion center. PATIENTS: Adolescents sustaining a sport-related concussions (SRC) from November 2017 to October 2020. INDEPENDENT VARIABLES: Participants were dichotomized into 2 groups: (1) athletes with a single concussion; and (2) athletes with repeat concussions. MAIN OUTCOME MEASURES: Between group and within group analyses were completed to look for differences in demographics, personal and family history, concussion history, and recovery metrics between the 2 groups. RESULTS: Of 834 athletes with an SRC, 56 (6.7%) sustained a repeat concussion and 778 (93.3%) had a single concussion. Between group: Personal history of migraines (19.6% vs 9.5%, χ 2 = 5.795, P = 0.02), family history of migraines (37.5% vs 24.5%, χ 2 = 4.621, P = 0.03), and family history of psychiatric disorders (25% vs 13.1%, χ 2 = 6.224, P = 0.01) were significant predictors of sustaining a repeat concussion. Within group: Among those with a repeat concussion, initial symptom severity was greater (Z = -2.422; P = 0.02) during the repeat concussion and amnesia was more common (χ 2 = 4.775, P = 0.03) after the initial concussion. CONCLUSIONS: In a single-center study of 834 athletes, 6.7% suffered a same-year, repeat concussion. Risk factors included personal/family migraine history and family psychiatric history. For athletes with repeat concussions, initial symptom score was higher after the second concussion, yet amnesia was more common after the initial concussion.

Modern treatment of tibial shaft fractures: Is there a role today for closed treatment?

PURPOSE: The decision to attempt closed treatment on tibial shaft fractures can be challenging. At our institution, we attempt treatment of nearly all closed, isolated tibial shaft fractures. The purpose of this study was to report the results of 10 years of experience to develop a tool to identify patients for whom non-operative treatment of tibial shaft fractures may be a viable option METHOD: This was a retrospective review of patients with tibial shaft fracture seen at a level 1 trauma center over 10 years. Patients with closed, isolated injuries underwent sedation, closed reduction, long-leg casting, and outpatient follow-up. Patients were converted to surgery for inability to obtain or maintain acceptable alignment or patient intolerance. Radiographic characteristics and patient demographics were extracted. Logistic regression analysis was used to develop a model to predict which patient and injury characteristics determined success of nonoperative treatment. RESULTS: 334 patients were identified with isolated, closed tibial shaft fractures, who were reduced and treated in a long leg cast. 234 patients (70%) converted to surgical treatment due to inability to maintain alignment, patient intolerance, and nonunion. In a regression model, coronal/sagittal translation, sagittal angulation, fracture morphology, and smoking status were shown to be significant predictors of success of nonoperative treatment (p < 0.05). We developed a Tibial Operative Outcome Likelihood (TOOL) score designed to help predict success or failure of closed treatment. The TOOL score can be used to identify a subsegment of patients with injuries amenable to closed treatment (38% of injuries) with a nonoperative success rate over 60%. CONCLUSION: Non-operative treatment of tibial shaft fractures is feasible, although there is a relatively high conversion rate to operative treatment. However, it is possible to use injury characteristics to identify a cohort of patients with a higher chance of success with closed treatment, which is potentially useful in a resource-constrained setting or for patients who wish to avoid surgery. LEVEL OF EVIDENCE: Prognostic Level 3.

Can we predict failure of percutaneous fixation of femoral neck fractures?

PURPOSE: This study evaluated a series of geriatric femoral neck fracture treated with closed reduction percutaneous pinning (CRPP) at a single level-1 trauma center to determine if there are any simple, reliable, radiographic characteristics that can be used to predict increased risk of post-operative failure in nondisplaced and valgus impacted fracture patterns. METHODS: We conducted a retrospective cohort study of all patients with femoral neck fractures (AO/OTA 31B) who underwent CRPP over a 12-year period at a single Level 1 trauma center. Failure was defined as radiographic failure within the first year after the index operation requiring revision surgery. Common patterns identified on initial review were the presence of a visible medial transcervical line (MTL) felt to indicate a tension-sided failure, a straight inferior calcar (SIC) indicating severe valgus impaction, and quality of intra-operative screw positioning. X-rays of patients were then reviewed for these characteristics in a blinded manner by three different trauma-fellowship trained orthopedic surgeons. Inter-rater reliability was calculated using Fleiss' Kappa Coefficient. Comparisons of failure rates between groups were made using a Fisher's Exact test. RESULTS: 139 patients who underwent CRPP for a femoral neck fracture and follow-up for at least 90 days were identified and reviewed. There were a total of 19 failures (13.6%) within one year. The patients with a varus fracture had a failure rate of 9/24 (37.5%). Of the valgus/nondisplaced fractures, MTL was identified in 42/115 (36%) patients. Inter-rater agreement was high for the presence of an MTL (84%, Kappa 0.69). Patients with an MTL had a fourfold increase in risk of failure (7/42=17% with an MTL vs. 3/73=4% without, p  0.03). The presence of a SIC and quality of screw placement were not predictive of failure. CONCLUSION: Varus femoral neck fractures fixed with CRPP have a high rate of failure (37.5%). Nondisplaced or valgus impacted fractures with the presence of a visible medial transcervical line on pre-operative radiographic imaging resulted in a fourfold increase in the risk of failure after CRPP. Identification of the MTL will help treating surgeons better council patients when making pre-operative decisions between arthroplasty and CRPP.

"Found Down" Compartment Syndrome: Experience from the Front Lines of the Opioid Epidemic.

BACKGROUND: With the worsening of the opioid epidemic, there has been an increasing number of cases in which patients are "found down" following a drug overdose and develop a crush injury resulting in muscle necrosis, rhabdomyolysis, and elevated compartment pressures in a unique presentation of compartment syndrome. The purpose of the present study is to summarize our experience at a trauma center in a region with a high endemic rate of opiate abuse to provide guidance for the management of patients with "found down" compartment syndrome. METHODS: We performed a retrospective review of the records of patients who had been found unconscious as the result of overdose, with findings that were concerning for compartment syndrome, and had been managed with fasciotomy or observation at the discretion of the surgeon. The patients were divided into 3 groups based on presentation (partial deficits, complete deficits, or unexaminable), and the operative findings, hospital course, laboratory values, and functional status were compared between the groups. RESULTS: Over 12 years, we identified 30 "found down" patients who had an examination that was concerning for compartment syndrome. Twenty-five patients were managed with fasciotomy; this group required an average of 4.2 operations and had a 20% infection rate and a 12% amputation rate. Lactate, creatine phosphokinase, and creatinine levels typically were elevated but did not correspond with muscle viability or return of function. At the time of initial debridement, 56% of patients had muscle that appeared nonviable, although muscle function returned in 28% of the patients who had questionable viability. Four patients had no motor or neurological function on initial examination, and none had meaningful return of function at the time of the latest follow-up. Of the 10 patients who had partial neurological deficits at the time of presentation and underwent fasciotomy, over half (70%) had some improvement in ultimate function. CONCLUSIONS: Patients who are "found down" following an opiate overdose with crush injuries resulting in compartment syndrome have a high surgical complication rate and poor recovery of function. The limited data from the present study suggest that those with absent function at the time of presentation are unlikely to gain function after fasciotomy, and the risk-benefit ratio of fasciotomy in this patient population may be different from that for patients with traumatic compartment syndrome. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.