Outcomes of laparoscopic and open ventriculoperitoneal shunt placement.

OBJECTIVE: Ventriculoperitoneal (VP) shunt placement requires a concurrent abdominal procedure. For peritoneal access laparoscopic or open approach may be utilized. Our aim was to compare patient/procedure characteristics and outcomes by peritoneal approach for VP shunts in children. METHODS: NSQIP-Pediatric procedure targeted cerebral spinal fluid shunt Participant Use Data Files from 2016 to 2020 were queried. Patients were grouped into laparoscopic vs open abdominal approach. Patient demographics, procedure characteristics and 30-day outcomes were compared. RESULTS: 7742 NSQIP-Pediatric patients underwent VP shunt placement. Patients undergoing laparoscopic approach were older and required less preoperative support. Mean operative time was longer with laparoscopy (mean(SD): 74.2(48.1) vs. 64.6(39) minutes, p â€‹< â€‹0.0001) but had shorter hospital LOS. There was no difference in SSI, readmissions, or reoperation rates. CONCLUSION: Patients undergoing laparoscopy for distal VP shunts are older with less support needs preoperatively. While laparoscopic approach had a shorter hospital LOS, there was no demonstratable difference in SSI, readmissions or reoperations between approaches. Further studies are needed to assess long-term outcomes.

Development of new postoperative neck pain at 12 and 24 months after surgery for cervical spondylotic myelopathy: a Quality Outcomes Database study.

OBJECTIVE: Patients who undergo surgery for cervical spondylotic myelopathy (CSM) will occasionally develop postoperative neck pain that was not present preoperatively, yet the incidence of this phenomenon is unclear. The authors aimed to elucidate patient and surgical factors associated with new-onset sustained pain after CSM surgery. METHODS: The authors reviewed data from the Quality Outcomes Database (QOD) CSM module. The presence of neck pain was defined using the neck pain numeric rating scale (NRS). Patients with no neck pain at baseline (neck NRS score ≤ 1) were then stratified based on the presence of new postoperative pain development (neck NRS score ≥ 2) at 12 and 24 months postoperatively. RESULTS: Of 1141 patients in the CSM QOD, 224 (19.6%) reported no neck pain at baseline. Among 170 patients with no baseline neck pain and available 12-month follow-up, 46 (27.1%) reported new postoperative pain. Among 184 patients with no baseline neck pain and available 24-month follow-up, 53 (28.8%) reported new postoperative pain. The mean differences in neck NRS scores were 4.3 for those with new postoperative pain compared with those without at 12 months (4.4 ± 2.2 vs 0.1 ± 0.3, p < 0.001) and 3.9 at 24 months (4.1 ± 2.4 vs 0.2 ± 0.4, p < 0.001). The majority of patients reporting new-onset neck pain reported being satisfied with surgery, but their satisfaction was significantly lower compared with patients without pain at the 12-month (66.7% vs 94.3%, p < 0.001) and 24-month (65.4% vs 90.8%, p < 0.001) follow-ups. The baseline Neck Disability Index (NDI) was an independent predictor of new postoperative neck pain at both the 12-month and 24-month time points (adjusted OR [aOR] 1.04, 95% CI 1.01-1.06; p = 0.002; and aOR 1.03, 95% CI 1.01-1.05; p = 0.026, respectively). The total number of levels treated was associated with new-onset neck pain at 12 months (aOR 1.34, 95% CI 1.09-1.64; p = 0.005), and duration of symptoms more than 3 months was a predictor of 24-month neck pain (aOR 3.22, 95% CI 1.01-10.22; p = 0.048). CONCLUSIONS: Increased NDI at baseline, number of levels treated surgically, and duration of symptoms longer than 3 months preoperatively correlate positively with the risk of new-onset neck pain following CSM surgery. The majority of patients with new-onset neck pain still report satisfaction from surgery, suggesting that the risk of new-onset neck pain should not hinder indicated operations from being performed.

Review: Patent Bibliometrics in Cranial Neurosurgery: The First Bibliometric Analysis of Neurosurgery's Technological Literature.

BACKGROUND: Bibliometric analyses of the scientific literature have grown increasingly popular in the past few decades. However, patent bibliometric studies, evaluation of technological literature, have not yet been applied in neurosurgery. OBJECTIVE: To perform a pilot patent bibliometric analysis of the top 100 most cited patents in cranial neurosurgery. METHODS: The Lens was used to query multiple databases, to select the top 100 cranial neurosurgical patents based upon forward patent citations. These were organized into 9 categories based on technological descriptors and were evaluated based on the earliest priority date, year issued, and expiration status, among others. RESULTS: The top 100 most cited patents included technology underlying 3D navigation (n = 31), pharmacology and implants (n = 20), vascular occlusion (n = 5), craniotomy closure (n = 9), focal lesioning and tissue resection (n = 8), brain and systemic cooling (n = 5), neuroendoscopy (n = 8), neuromonitoring and stimulation (6), and technologies improving surgeon performance (n = 8). Ninety-six patents were filed in the United States, 72 were expired, 19 are still active, and 9 were listed as inactive. The highest number of patents was applied for from the mid-1990s to the mid-2000s. Demonstrated trends showed no meaningful correlation between patent rank and earliest priority date (linear trendline y = 0.7107 x -1367.5; R2 = 0.0671), while a very strong correlation was found between patent rank and citations per year (power trendline y = 127.93 x -1.094; R2 = 0.8579). CONCLUSIONS: Patent bibliometrics allow evaluation of neurosurgical advancements from the past and enable subsequent development of cutting-edge technology in the future. The described method is a reproducible and reliable technique for evaluating our field's patent literature.

Laparoscopic Co-surgeon Ventriculoperitoneal Shunt Placement Versus Single Surgeon Mini Laparotomy.

INTRODUCTION: Ventriculoperitoneal (VP) shunt placement is one of the most common treatments for pediatric hydrocephalus. However, device failures often occur, requiring operative revision of either the intraventricular or intraperitoneal shunt catheters. Historically, shunt placement was performed via laparotomy, but there has been a trend towards laparoscopic-assisted placement of the intraperitoneal portion of the shunt. We examined the outcomes of laparoscopic-assisted versus open VP shunt placement utilizing a local institutional retrospective review. METHODS: Single institution 2012-2017 retrospective review of all cases was performed. Patients were divided into two groups - laparoscopic and open. Thirty-day outcomes, patient age, surgery performed, surgical control time (SCT), length of stay (LOS), and readmission were analyzed.  Results: Cohort analysis inclusion criteria included 188 patients. The cohort analysis showed both decreased laparoscopic-assisted SCT (56.4 vs 32.1 min, p<0.0001) and postop complications (16.7% vs 7.1%, p<0.07). There was no significant difference in surgical site infection or readmission rates.  Conclusion: Local analysis show advantages for laparoscopic-assisted VP shunt placement over open single surgeon techniques with decreased SCT, LOS, and unplanned interventions.

Mild and Severe Obesity Reduce the Effectiveness of Lumbar Fusions: 1-Year Patient-Reported Outcomes in 8171 Patients.

BACKGROUND: Elevated body mass index (BMI) is a well-known risk factor for surgical complications in lumbar surgery. However, its effect on surgical effectiveness independent of surgical complications is unclear. OBJECTIVE: To determine increasing BMI's effect on functional outcomes following lumbar fusion surgery, independent of surgical complications. METHODS: We retrospectively analyzed a prospectively built, patient-reported, quality of life registry representing 75 hospital systems. We evaluated 1- to 3-level elective lumbar fusions. Patients who experienced surgical complications were excluded. A stepwise multivariate regression model assessed factors independently associated with 1-yr Oswestry Disability Index (ODI), preop to 1-yr ODI change, and achievement of minimal clinically important difference (MCID). RESULTS: A total of 8171 patients met inclusion criteria: 2435 with class I obesity (BMI 30-35 kg/m2), 1328 with class II (35-40 kg/m2), and 760 with class III (≥40 kg/m2). Increasing BMI was independently associated with worse 12-mo ODI (t = 8.005, P < .001) and decreased likelihood of achieving MCID (odds ratio [OR] = 0.977, P < .001). One year after surgery, mean ODI, ODI change, and percentage achieving MCID worsened with class I, class II, and class III vs nonobese cohorts (P < .001) in stepwise fashion. CONCLUSION: Increasing BMI is associated with decreased effectiveness of 1- to 3-level elective lumbar fusion, despite absence of surgical complications. BMI ≥ 30 kg/m2 is, therefore, a risk factor for both surgical complication and reduced benefit from lumbar fusion.

Expandable Interbody Spacers: A Two-Year Study Evaluating Radiologic and Clinical Outcomes With Patient-Reported Outcomes.

BACKGROUND: Posterior and transforaminal lumbar interbody fusion (PLIF and TLIF) have gained significant popularity for management of lumbar degenerative spine over the last 3 decades. Expandable interbody spacers are a newer technology that can increase in size after placement, theoretically minimizing the operative risks of static spacers without sacrificing radiographic correction. The goal of this study is to further evaluate the radiographic and clinical outcomes of expandable spacers. METHODS: This was a retrospective analysis of a prospective cohort that underwent elective 1- to 3-level PLIF/TLIF with expandable interbody spacers from 2014 to 2020 at a single institution. Patient-reported outcome measures (PROMs) Oswestry Disability Index and Visual Analog Scale were collected at 6 weeks, 3 months, 6 months, and 12 months. Imaging was performed at 12 months, with follow up at 24 months in case of nonunion. Retrospective outcomes were computer tomography (CT) based and Bridwell-Lenke classification of fusion, radiographic parameters, and adverse events. RESULTS: A total of 50/53 (94.3%) otherwise eligible patients had 12-month PROMs and CT imaging for analysis. Here, 50% were obese (body mass index > 30), 58% had a smoking history, and 24% had a prior lumbar procedure. Also, 46/50 (92%) patients fused by CT criteria. Significant decrease in PROMs was seen as early as 6 weeks postoperatively. The mean change in preoperative-to-postoperative global lordosis values was 3.8° ± 15.6°. There were 4 (8%) intraoperative durotomies and 5 (10%) patients requiring reoperation for nonunion. CONCLUSIONS: Our study demonstrates the use of expandable spacers in a high comorbidity cohort with low complications, excellent improvement in PROMs despite minimal lordotic improvement, and high rates of fusion without recombinant human bone morphogenetic protein-2 (rhBMP-2) or iliac crest bone graft. LEVEL OF EVIDENCE: 4. CLINICAL RELEVANCE: Expandable interbody fusion can significantly improve outcomes for degenerative lumbar spondylosis, with good safety profile, and high fusion rates.

Thirty-day medical and surgical readmission following prenatal versus postnatal myelomeningocele repair.

OBJECTIVE: Hospital readmission is an important quality metric that has not been evaluated in prenatal versus postnatal myelomeningocele (MMC) repair. This study compares hospital readmission outcomes between these two groups as well as their etiologies. METHODS: The medical records of patients who had undergone MMC repair in the period from 2011 to 2017 at a single academic medical center were retrospectively reviewed. Collected clinical data included surgery and defect details, neonatal intensive care unit (NICU) stay, and any readmissions or surgical procedures up to 1 year after surgery. Patient and defect characteristics, readmission outcomes at 30 and 60 days and 1 year after discharge from the NICU, and cerebrospinal fluid (CSF) diversion surgery rates were analyzed with the two-tailed t-test and/or k-sample test on the equality of medians. RESULTS: A total of 24 prenatal and 34 postnatal MMC repairs were completed during the study period. Prenatally repaired patients were born more prematurely (p < 0.001) and with lower birth weights (p < 0.001), although the NICU stay was similar between the two groups (p = 0.59). Fewer prenatally repaired patients were readmitted at 30 days (p = 0.005), 90 days (p = 0.004), and 1 year (p = 0.007) than the postnatal repair group. Hydrocephalus was the most common readmission etiology, and 29% of prenatal repair patients required CSF diversion at 1 year versus 81% of the postnatal repair group (p < 0.01). Prenatal patients who required CSF diversion had a higher body weight (p = 0.02) and an older age (p = 0.01) at the time of CSF diversion surgery than the postnatal group. CONCLUSIONS: Patients with prenatal MMC repair had fewer hospital readmissions at 30 days, 60 days, and 1 year than the postnatal repair group, despite similar NICU lengths of stay. The prenatal repair group had lower requirements for CSF diversion at 1 year and was older with greater body weights at the time of CSF diversion surgery, compared to those of the postnatal repair group. Future study of hospital quality metrics such as readmissions should be performed to better understand outcomes of these two procedures.

Nocardial clival osteomyelitis secondary to sphenoid sinusitis: an atypical skull base infection.

Clival osteomyelitis is a life-threatening complication of untreated malignant otitis externa or paranasal sinus infection. Although various pathogens have been implicated, to our knowledge, primary nocardial clival osteomyelitis has never been reported. We describe a 74-year-old woman who presented with headaches, abducens and hypoglossal nerve palsies, facial numbness, photophobia, and neck stiffness. Imaging revealed a heterogeneous mass within the sphenoid sinus with clival extension. The lesion was extirpated via a binostril endoscopic endonasal transsphenoidal approach. Histopathological and microbiological examination revealed a nocardial source. Clival osteomyelitis associated with sphenoid sinusitis should be included in the differential diagnosis of progressive skull base lesions in the setting of an underlying infection. Early recognition and intervention with antibiotics and surgical debridement is essential in the management of this rare entity.