Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 14 de 14
Filtrar
1.
World Neurosurg ; 170: e236-e241, 2023 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-36334713

RESUMO

BACKGROUND: Increasing evidence supports the effectiveness of venous sinus stenting (VSS) with favorable outcomes, safety, and expenses compared with shunting for idiopathic intracranial hypertension. Yet, no evidence is available regarding optimal postoperative recovery, which has increasing importance with the burdens on health care imposed by the coronavirus disease 2019 pandemic. We examined adverse events and costs after VSS and propose an optimal recovery pathway to maximize patient safety and reduce stress on health care resources. METHODS: A retrospective review was undertaken of elective VSS operations performed from May 2008 to August 2021 at a single institution. Primary data included hospital length of stay, intensive care unit (ICU) length of stay, adverse events, need for ICU interventions, and hospital costs. RESULTS: Fifty-three patients (98.1% female) met the inclusion criteria. Of these patients, 51 (96.2%) were discharged on postoperative day (POD) 1 and 2 patients were discharged on POD 2. Both patients discharged on POD 2 remained because of groin hematomas from femoral artery access. There were no major complications or care that required an ICU. Eight patients (15.1%) were lateralized to other ICUs or remained in a postanesthesia care unit because the neurosciences ICU was above capacity. Total estimated cost for initial recovery day in a neurosciences ICU room was $2361 versus $882 for a neurosurgery/neurology ward room. In our cohort, ward convalescence would save an estimated $79,866 for bed placement alone and increase ICU bed availability. CONCLUSIONS: Our findings reaffirm the safety of VSS. These patients should recover on a neurosurgery/neurology ward, which would save health care costs and increase ICU bed availability.


Assuntos
COVID-19 , Pseudotumor Cerebral , Humanos , Feminino , Masculino , Pseudotumor Cerebral/cirurgia , Procedimentos Neurocirúrgicos/efeitos adversos , Unidades de Terapia Intensiva , Atenção à Saúde , Estudos Retrospectivos
2.
Neurospine ; 20(4): 1132-1139, 2023 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-38171283

RESUMO

OBJECTIVE: The purpose of this study is to examine the utilization of kyphoplasty/vertebroplasty procedures in the management of compression fractures. With the growing elderly population and the associated increase in rates of osteoporosis, vertebral compression fractures have become a daily encounter for spine surgeons. However, there remains a lack of consensus on the optimal management of this patient population. METHODS: A retrospective analysis of 91 million longitudinally followed patients from 2016 to 2019 was performed using the PearlDiver Patient Claims Database. Patients with compression fractures were identified using International Classification of Disease, 10th Revision codes, and a subset of patients who received kyphoplasty/vertebroplasty were identified using Common Procedural Terminology codes. Baseline demographic and clinical data between groups were acquired. Multivariable regression analysis was performed to determine predictors of receiving kyphoplasty/vertebroplasty. RESULTS: A total of 348,457 patients with compression fractures were identified with 9.2% of patients receiving kyphoplasty/vertebroplasty as their initial treatment. Of these patients, 43.5% underwent additional kyphoplasty/vertebroplasty 30 days after initial intervention. Patients receiving kyphoplasty/vertebroplasty were significantly older (72.2 vs. 67.9, p < 0.05), female, obese, had active smoking status and had higher Elixhauser Comorbidity Index scores. Multivariable analysis demonstrated that female sex, smoking status, and obesity were the 3 strongest predictors of receiving kyphoplasty/vertebroplasty (odds ratio, 1.27, 1.24, and 1.14, respectively). The annual rate of kyphoplasty/vertebroplasty did not change significantly (range, 8%-11%). CONCLUSION: The majority of vertebral compression fractures are managed nonoperatively. However, certain patient factors such as smoking status, obesity, female sex, older age, osteoporosis, and greater comorbidities are predictors of undergoing kyphoplasty/vertebroplasty.

3.
J Cerebrovasc Endovasc Neurosurg ; 24(3): 297-302, 2022 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-36068675

RESUMO

Vascular compression of neural tissue causing neurological symptoms is a wellknown phenomenon. This is commonly seen in trigeminal neuralgia and, less commonly, in hemifacial spasm by small arteries, which can be treated by microvascular decompression. Rarely, larger arteries, such as the vertebral arteries, may compress the brainstem. This can lead to symptoms of pontine or medullary distress like hemiparesis, dysphagia, or respiratory distress. This is treated by macrovascular decompression. Due to the rare and heterogenous nature of this disease, there is no standardized approach. We describe a novel technique whereby the vertebrobasilar system is mobilized anterolaterally towards the occipital condyle with a sling to decompress the brainstem.
We report two cases of vertebrobasilar dolichoectasia causing brainstem compression. A carotid patch graft sling with anterolateral mobilization to the occipital condyle is described as a surgical nuance to macrovascular decompressive surgery. Briefly, the vertebral artery was identified and dissected away from the brainstem and the bulbar cranial nerves. Bovine pericardium graft was used to create a sling around the artery by suturing the two ends together. The sling was then fixed either to the occipital condyle using cranial plating screws or suturing to the dura of the occipital condyle.
A novel surgical technique for management of vertebrobasilar dolichoectasia causing brainstem compression with progressive neurological deterioration is reported. Anatomical location and the offending vessel should guide neurosurgeons to select the best surgical option to achieve complete decompression of the involved neural structures.

4.
J Neurol Surg Rep ; 83(3): e110-e118, 2022 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-36148089

RESUMO

Objective We describe the first jugular foramen angiomatoid fibrous histiocytoma (AFH) case and the first treatment with preoperative endovascular embolization. AFH is a rare intracranial neoplasm, primarily found in pediatric patient extremities. With an increase in AFH awareness and a well-described genetic profile, intracranial prevalence has also subsequently increased. Study Design We compare this case to previously reported cases using PubMed/Medline literature search, which was performed using the algorithm ["intracranial" AND "angiomatoid fibrous histiocytoma"] through December 2020 (23 manuscripts with 46 unique cases). Patient An 8-year-old female presented with failure to thrive and right-sided hearing loss. Work-up revealed an absence of right-sided serviceable hearing and a large jugular foramen mass. Angiogram revealed primary arterial supply from the posterior branch of the ascending pharyngeal artery, which was preoperatively embolized. Intervention Gross total resection was performed via a translabyrinthine approach. Conclusion The case presented is unique; the first reported AFH at the jugular foramen and the first reported case utilizing preoperative embolization. Preoperative embolization is a relatively safe technique that can improve the surgeon's ability to perform a maximally safe resection, which may decrease the need for adjuvant radiation in rare skull base tumors in young patients.

5.
Neurooncol Adv ; 4(1): vdac104, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35892048

RESUMO

Background: Intra-arterial administration of chemotherapy with or without osmotic blood-brain barrier disruption enhances delivery of therapeutic agents to brain tumors. The aim of this study is to evaluate the safety of these procedures. Methods: Retrospectively collected data from a prospective database of consecutive patients with primary and metastatic brain tumors who received intra-arterial chemotherapy without osmotic blood-brain barrier disruption (IA) or intra-arterial chemotherapy with osmotic blood-brain barrier disruption (IA/OBBBD) at Oregon Health and Science University (OHSU) between December 1997 and November 2018 is reported. Chemotherapy-related complications are detailed per Common Terminology Criteria for Adverse Events (CTCAE) guidelines. Procedure-related complications are grouped as major and minor. Results: 4939 procedures (1102 IA; 3837 IA/OBBBD) were performed on 436 patients with various pathologies (primary central nervous system lymphoma [26.4%], glioblastoma [18.1%], and oligodendroglioma [14.7%]). Major procedure-related complications (IA: 12, 1%; IA/OBBBD: 27, 0.7%; P = .292) occurred in 39 procedures including 3 arterial dissections requiring intervention, 21 symptomatic strokes, 3 myocardial infarctions, 6 cervical cord injuries, and 6 deaths within 3 days. Minor procedure-related complications occurred in 330 procedures (IA: 41, 3.7%; IA/OBBBD: 289, 7.5%; P = .001). Chemotherapy-related complications with a CTCAE attribution and grade higher than 3 was seen in 359 (82.3%) patients. Conclusions: We provide safety and tolerability data from the largest cohort of consecutive patients who received IA or IA/OBBBD. Our data demonstrate that IA or IA/OBBBD safely enhance drug delivery to brain tumors and brain around the tumor.

6.
Oper Neurosurg (Hagerstown) ; 15(3): 332-340, 2018 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-29554354

RESUMO

BACKGROUND: Delivery of higher value healthcare is an ultimate government and public goal. Improving efficiency by standardization of surgical steps can improve patient outcomes, reduce costs, and lead to higher value healthcare. Lean principles and methodology have improved timeliness in perioperative medicine; however, process mapping of surgery itself has not been performed. OBJECTIVE: To apply Plan/Do/Study/Act (PDSA) cycles methodology to lumbar posterior instrumented fusion (PIF) using lean principles to create a standard work flow, identify waste, remove intraoperative variability, and examine feasibility among pilot cases. METHODS: Process maps for 5 PIF procedures were created by a PDSA cycle from 1 faculty neurosurgeon at 1 institution. Plan, modularize PIF into basic components; Do, map and time components; Study, analyze results; and Act, identify waste. Waste inventories, spaghetti diagrams, and chartings of time spent per step were created. Procedural steps were broadly defined in order to compare steps despite the variability in PIF and were analyzed with box and whisker plots to evaluate variability. RESULTS: Temporal variabilities in duration of decompression vs closure and hardware vs closure were significantly different (P = .003). Variability in procedural step duration was smallest for closure and largest for exposure. Wastes including waiting and instrument defects accounted for 15% and 66% of all waste, respectively. CONCLUSION: This pilot series demonstrates that lean principles can standardize surgical workflows and identify waste. Though time and labor intensive, lean principles and PDSA methodology can be applied to operative steps, not just the perioperative period.


Assuntos
Eficiência , Vértebras Lombares/cirurgia , Fusão Vertebral/métodos , Fluxo de Trabalho , Humanos , Melhoria de Qualidade
7.
Oper Neurosurg (Hagerstown) ; 14(2): 178-187, 2018 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-29351677

RESUMO

BACKGROUND: Quality improvement projects increasingly emphasize standardization of surgical work flow to optimize operative room efficiency. Removing special cause variability resulting from nonsurgical waste is an obvious target; however, resident surgical education must be maintained, even in the setting of process improvement. OBJECTIVE: To describe the impact of resident-identified "risky" or "uncomfortable" procedural steps on operative time during transforaminal lumbar interbody fusion (TLIF). METHODS: TLIF procedure steps were defined. An 8 2-part questions survey regarding comfort level and perceived risk assessment at each step was developed and completed by junior (17) and senior residents (10), and by faculty (6) from orthopedic, and neurological surgery. A risk matrix was constructed defining 2 zones: a "danger zone"; responses were high risk (3-5) and low comfort (1-3), and a "safe zone"; responses were low risk (1-2) and high comfort (4-5). One-tailed Chi-square with Yates correction was performed. RESULTS: Risk matrix analysis showed a statistical difference among "danger zone" respondents between junior resident and faculty groups for exposure, pedicle screw placement, neural decompression, interbody placement, posterolateral fusion, and hemostasis. A radar graph identifies percent of respondents who fall within the "danger zone". CONCLUSION: Resident perception of surgical complexity can be evaluated for procedural steps using a risk matrix survey. For TLIF, residents may assign more risk and may be less comfortable performing steps in a training-level-dependent manner. Identification of particular high-risk or uncomfortable steps should prompt strict faculty oversight to improve patient safety, monitor resident education, and reduce operative time.


Assuntos
Internato e Residência , Vértebras Lombares/cirurgia , Neurocirurgiões/educação , Cirurgiões Ortopédicos/educação , Medição de Risco , Fusão Vertebral , Antecipação Psicológica , Atitude do Pessoal de Saúde , Competência Clínica , Docentes , Humanos , Modelos Teóricos , Neurocirurgiões/psicologia , Duração da Cirurgia , Cirurgiões Ortopédicos/psicologia , Percepção , Projetos Piloto , Estudo de Prova de Conceito , Medição de Risco/métodos , Fusão Vertebral/educação , Fusão Vertebral/métodos
8.
J Surg Educ ; 75(1): 147-155, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-28647393

RESUMO

OBJECTIVES: The purpose of this study was to determine the effect of the Accreditation Council for Graduate Medical Education Milestones on the assessment of neurological surgery residents. The authors sought to determine the feasibility, acceptability, and utility of this new framework in making judgments of progressive competence, its implementation within programs, and the influence on curricula. Residents were also surveyed to elicit the effect of Milestones on their educational experience and professional development. DESIGN, SETTING, AND PARTICIPANTS: In 2015, program leadership and residents from 21 neurological surgery residency programs participated in an online survey and telephone interview in which they reflected on their experiences with the Milestones. Survey data were analyzed using descriptive statistics. Interview transcripts were analyzed using grounded theory. RESULTS: Response themes were categorized into 2 groups: outcomes of the Milestones implementation process, and facilitators and barriers. Because of Milestones implementation, participants reported changes to the quality of the assessment process, including the ability to identify struggling residents earlier and design individualized improvement plans. Some programs revised their curricula based on training gaps identified using the Milestones. Barriers to implementation included limitations to the adoption of a developmental progression model in the context of rotation block schedules and misalignment between progression targets and clinical experience. The shift from time-based to competency-based evaluation presented an ongoing adjustment for many programs. Organized preparation before clinical competency committee meetings and diverse clinical competency committee composition led to more productive meetings and perceived improvement in promotion decisions. CONCLUSIONS: The results of this study can be used by program leadership to help guide further implementation of the Milestones and program improvement. These results also help to guide the evolution of Milestones language and their implementation across specialties.


Assuntos
Acreditação , Competência Clínica , Educação de Pós-Graduação em Medicina/organização & administração , Internato e Residência/organização & administração , Neurocirurgia/educação , Adulto , Educação Baseada em Competências , Currículo , Feminino , Humanos , Entrevistas como Assunto , Masculino , Avaliação de Programas e Projetos de Saúde , Inquéritos e Questionários , Estados Unidos
9.
World Neurosurg ; 93: 490.e1-6, 2016 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-27353558

RESUMO

OBJECTIVE: Operatively, video-assisted thoracoscopic sympathectomy (VATS) involves pleural entry and poses risk in small children and patients with pulmonary disease. A conventional posterior sympathectomy is more invasive than VATS. We investigated a cadaveric feasibility study of a minimal access posterior approach for endoscopic extrapleural sympathectomy and discuss this minimal approach in children with cardiac sympathectomy. METHODS: A posterior endoscopic extrapleural approach for thoracic sympathectomy was performed using lightly embalmed cadavers; surgical corridor depth, width, and associated pleural violation were recorded. Two pediatric cases undergoing secondary prevention for breakthrough cardiac dysrhythmias using this approach are discussed: case 1, a 9-year-old girl with refractory long QT syndrome; and case 2, a 13-year-old boy with hypertrophic cardiomyopathy. RESULTS: The cadaveric study supported 100% identification of a craniocaudal-oriented sympathetic chain using an 18-mm tubular retractor, and a 10% pleural violation rate. There were no clinically significant pneumothoracies in either proof of concept cases. CONCLUSIONS: Minimal access posterior extrapleural sympathectomy is feasible to expose the sympathetic chain in the thoracic region with good visualization using either endoscopic or microscopic magnification. Single-position bilateral thoracic sympathectomy can be performed in pediatric patients with life-threatening ventricular arrhythmias. Based on the cadaveric study and the 2 preliminary cases, we believe that a posterior minimal access approach allows safe and effective access to the thoracic sympathetic chain for causes requiring sympathectomy using single positioning, with minimal risk of pneumothorax or Horner syndrome.


Assuntos
Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Neuroendoscopia/métodos , Simpatectomia/métodos , Nervos Torácicos/patologia , Nervos Torácicos/cirurgia , Cirurgia Torácica Vídeoassistida/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Cadáver , Criança , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Vértebras Torácicas/patologia , Vértebras Torácicas/cirurgia , Resultado do Tratamento , Adulto Jovem
10.
Surg Neurol Int ; 7: 47, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27168950

RESUMO

BACKGROUND: Intracranial pressure (ICP) monitoring is not routinely used during complex spinal deformity correction surgery. The authors report a 66-year-old male who during thoracolumbar deformity surgery required the placement of an ICP monitor due to the underlying history of a superior vena cava syndrome (e.g., s/p right jugular stent). CASE DESCRIPTION: A 66-year-old male with multiple prior lumbar spinal procedures presented with lower back and bilateral lower extremity pain, paresthesias, and weakness. He had a history of chronic left internal jugular and brachiocephalic venous occlusion (e.g., he had a right internal jugular stent). During deformity surgery, a frontal intraparenchymal ICP monitor was placed. During the early portion of the operation, bed adjustments (increasing reverse trendelenburg position) were required to compensate for ICP elevations as high as 30 mm Hg. A subsequent inadvertent durotomy during decompression lowered the ICP to <5 mm Hg; no further ICP spikes occurred. His postoperative course was uneventful, and 14-month later, he was dramatically improved. CONCLUSION: ICP monitoring may be a useful adjunct for patient safety in selected patients who are at risk for developing intracranial hypertension during extensive spinal deformity surgery.

11.
World Neurosurg ; 90: 372-379, 2016 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-26968445

RESUMO

INTRODUCTION: En bloc resection of high-cervical chordomas is a technically challenging procedure associated with significant morbidity. Two key components of this procedure include the approach and the method of spinal reconstruction. A limited number of reported cases of en bloc resection of high-cervical chordomas have been reported in the literature. CASE PRESENTATION: We report a novel case using an expandable cage to reconstruct the anterior spinal column above C2 with fixation to the clivus. We also report a novel anterior approach to the high-cervical spine via a midline labiomandibular glossotomy. We detail the management of complications related to 2 instances of wound dehiscence and hardware exposure requiring two additional operations. The final surgical procedure involved explantation of the anterior cervical plate and use of a vascularized radial graft to close the posterior pharyngeal defect and protect the hardware. At 26-month follow-up, the patient remained disease free without any neurologic deficit. DISCUSSION: We report the novel use of the midline labiomandibular glossotomy for surgical approach and reconstruction of the anterior column to the clivus with an expandable cage. The unique features of this operative strategy allowed the surgical team to tailor the construct intraoperatively, resulting in solid arthrodesis without significant neurologic sequelae. CONCLUSIONS: Labiomandibular glossotomy for approach to high anterior cervical chordomas followed by craniospinal reconstruction to the clivus with an expandable cage represents a novel technique for managing high cervical chordomas.


Assuntos
Vértebras Cervicais/cirurgia , Cordoma/cirurgia , Fossa Craniana Posterior/cirurgia , Fixadores Internos , Procedimentos de Cirurgia Plástica , Neoplasias da Coluna Vertebral/cirurgia , Vértebras Cervicais/diagnóstico por imagem , Cordoma/diagnóstico por imagem , Fossa Craniana Posterior/diagnóstico por imagem , Feminino , Humanos , Lábio/cirurgia , Mandíbula/cirurgia , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/patologia , Complicações Pós-Operatórias/terapia , Procedimentos de Cirurgia Plástica/instrumentação , Procedimentos de Cirurgia Plástica/métodos , Neoplasias da Coluna Vertebral/diagnóstico por imagem , Língua/cirurgia
13.
J Neurosurg Spine ; 23(6): 780-3, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26296191

RESUMO

Complex neurocristopathy, a disorder resulting from the aberrant proliferation of tissues derived from neural crest cells, has been previously reported in 2 patients, both involving ophthalmic melanoma and other tumors. One patient had a periorbital neurofibroma, sphenoid wing meningioma, and choroid juxtapapillary meningioma. The other patient had a choroidal melanoma and an optic nerve sheath meningioma. The authors describe clinical and pathological findings in a patient who underwent resection of 2 distinct lesions: primary CNS melanoma at T-12 and an L-5 schwannoma. Clinical and histopathological findings of the case are reviewed. To the authors' knowledge, this is the first patient to present with complex neurocristopathy involving both a spinal melanoma and schwannoma.


Assuntos
Vértebras Lombares , Melanoma/diagnóstico , Neoplasias Primárias Múltiplas/diagnóstico , Neurilemoma/diagnóstico , Neoplasias da Medula Espinal/diagnóstico , Neoplasias da Coluna Vertebral/diagnóstico , Humanos , Masculino , Melanoma/terapia , Pessoa de Meia-Idade , Neoplasias Primárias Múltiplas/terapia , Neurilemoma/terapia , Neoplasias da Medula Espinal/terapia , Neoplasias da Coluna Vertebral/terapia , Vértebras Torácicas
14.
J Neurosurg Spine ; 22(1): 47-51, 2015 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-25360531

RESUMO

Intrathecal catheter placement into the lumbar cistern has varied indications, including drug delivery and CSF diversion. These Silastic catheters are elastic and durable; however, catheter-associated malfunctions are well reported in the literature. Fractured catheters are managed with some variability, but entirely intradural retained fragments are often managed conservatively with observation. The authors describe a case of a 70-year-old man with an implanted intrathecal morphine pump for failed back surgery syndrome who presented to an outside hospital with a history of headache, neck pain, nausea, and photophobia of 3 days' duration. He also described mild weakness and intermittent numbness of both legs. Unenhanced head CT demonstrated subarachnoid hemorrhage (SAH). A right C-5 hemilaminectomy was performed. This case is unique in that there was no indication that the lumbar intrathecal catheter had fractured prior to the patient's presentation with SAH. This case demonstrates that intrathecal catheter fragments are mobile and can precipitate intracranial morbidity. Extrication of known fragments is safe and should be attempted to prevent further neurosurgical morbidity.


Assuntos
Síndrome Pós-Laminectomia/tratamento farmacológico , Migração de Corpo Estranho/diagnóstico por imagem , Migração de Corpo Estranho/etiologia , Bombas de Infusão Implantáveis/efeitos adversos , Morfina/administração & dosagem , Hemorragia Subaracnóidea/etiologia , Idoso , Analgésicos Opioides/administração & dosagem , Catéteres/efeitos adversos , Forame Magno/diagnóstico por imagem , Humanos , Injeções Espinhais , Vértebras Lombares/diagnóstico por imagem , Masculino , Hemorragia Subaracnóidea/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Insuficiência Vertebrobasilar/diagnóstico por imagem , Insuficiência Vertebrobasilar/etiologia
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA