The roles of early surgery and comorbid conditions on outcomes of severe necrotizing soft-tissue infections.

PURPOSE: Severe necrotizing soft-tissue infections (NSTIs) require immediate early surgical treatment to avoid adverse outcomes. This study aims to determine the impact of early surgery and comorbid conditions on the outcomes of NSTIs. METHODS: A retrospective cohort study was performed on all subjects presenting with NSTI at an academic medical center between 2005 and 2016. Patients were identified based on ICD codes. Those under the age of 18 or with intraoperative findings not consistent with NSTI diagnosis were excluded. RESULTS: There were 115 patients with a confirmed diagnosis of NSTI with a mean age of 55 ± 18 years; 41% were females and 55% were diabetics. Thirty percent of patients underwent early surgery (< 6 h). There were no significant differences between groups in baseline characteristics. The late group (≥ 6 h) had prolonged hospital stay (38 vs. 23 days, p < 0.008) in comparison to the early group (< 6 h). With every 1 h delay in time to surgery, there is a 0.268 day increase in length of stay, adjusted for these other variables: alcohol abuse, number of debridements, peripheral vascular disease, previous infection and clinical necrosis. Mortality was 16.5%. Multivariable analysis revealed that alcohol abuse, peripheral vascular disease, diabetes, obesity, hypothyroidism, and presence of COPD were associated with an increase in mortality. CONCLUSIONS: Early surgical intervention in patients with severe necrotizing soft-tissue infections reduces length of hospital stay. Presence of comorbid conditions such as alcohol abuse, peripheral vascular disease, diabetes, obesity and hypothyroidism were associated with increased mortality.

Soluble Fms-Like Tyrosine Kinase 1 (sFlt-1) and Risk of Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: The molecular mechanisms underlying cerebral vasospasm and delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH) are incompletely understood. We hypothesized that circulating antiangiogenic factors, such as soluble Fms-like tyrosine kinase 1 (sFlt-1) and soluble transforming growth factor ß coreceptor, soluble endoglin (sEng), are important markers of their pathophysiology. METHODS: We performed a prospective study in patients with aSAH and measured cerebrospinal fluid and serum levels of sFlt-1 and sEng on postbleed day 1 and 6 and correlated levels with incidence and severity of cerebral vasospasm and DCI. RESULTS: Twenty-seven patients with aSAH were enrolled in the study. Severe angiographic vasospasm was present in 14.8% of patients and DCI occurred in 33.3%. Serum sFlt1 levels were increased on postbleed day 6 in patients who developed vasospasm. However, on postbleed day 1, there were no differences in patients who developed vasospasm. Increased serum sFlt-1 levels on postbleed day 1 were found to predict the development of severe angiographic vasospasm with an area under the curve of 0.818 with an optimal cutoff value of 95 pg/mL. Alterations in sFlt1 were not associated with DCI. Serum and cerebrospinal fluid sEng levels did not correlate with vasospasm or DCI. CONCLUSIONS: Serum levels of sFlt-1 are increased in patients with aSAH who are at risk for severe vasospasm. Further studies with larger sample sizes are needed to evaluate whether sFlt-1 levels may predict onset of severe vasospasm and DCI.

Instability in Thoracolumbar Trauma: Is a New Definition Warranted?

STUDY DESIGN: Review of the articles. OBJECTIVE: The objective of this study was to review all articles related to spinal instability to determine a consensus statement for a contemporary, practical definition applicable to thoracolumbar injuries. SUMMARY OF BACKGROUND DATA: Traumatic fractures of the thoracolumbar spine are common. These injuries can result in neurological deficits, disability, deformity, pain, and represent a great economic burden to society. The determination of spinal instability is an important task for spine surgeons, as treatment strategies rely heavily on this assessment. However, a clinically applicable definition of spinal stability remains elusive. MATERIALS AND METHODS: A review of the Medline database between 1930 and 2014 was performed limited to papers in English. Spinal instability, thoracolumbar, and spinal stability were used as search terms. Case reports were excluded. We reviewed listed references from pertinent search results and located relevant manuscripts from these lists as well. RESULTS: The search produced a total of 694 published articles. Twenty-five articles were eligible after abstract screening and underwent full review. A definition for spinal instability was described in only 4 of them. Definitions were primarily based on biomechanical and classification studies. No definitive parameters were outlined to define stability. CONCLUSIONS: Thirty-six years after White and Panjabi's original definition of instability, and many classification schemes later, there remains no practical and meaningful definition for spinal instability in thoracolumbar trauma. Surgeon expertise and experience remains an important factor in stability determination. We propose that, at an initial assessment, a distinction should be made between immediate and delayed instability. This designation should better guide surgeons in decision making and patient counseling.

A Multicenter Cohort Comparison Study of the Safety, Efficacy, and Cost of Ticagrelor Compared to Clopidogrel in Aneurysm Flow Diverter Procedures.

BACKGROUND: Thromboembolic and hemorrhagic complications are among the most feared adverse events in the endovascular treatment of aneurysms, and this is particularly the case for flow diverter devices. Dual antiplatelet therapy has become standard of care; however, the safety, efficacy, and cost profiles of newer antiplatelet agents are not well characterized in the neurovascular context. OBJECTIVE: To compare the safety, efficacy, and cost of one of these newer agents, ticagrelor, to the most frequently used agent, clopidogrel. METHODS: A multicenter, retrospective, cohort comparison study design of consecutively treated aneurysms with flow diverter embolization device and treated with either ticagrelor or clopidogrel was performed. Data were collected on patient demographics and risk factors, procedural details, antiplatelet treatment regime, complications, and angiographic and functional outcomes. RESULTS: Fifty patients undergoing flow diverter device deployment and treatment with ticagrelor were compared to 53 patients undergoing flow diversion and treatment with clopidogrel. The patients' age, sex, smoking status, aneurismal morphology and size, and procedural details did not differ between the 2 groups; neither did the rate of thromboembolic and hemorrhagic complications, angiographical, and functional outcomes. Ticagrelor was more expensive when compared to clopidogrel. CONCLUSION: Ticagrelor is a safe and effective agent for prevention of thromboembolic complications following flow diverter deployment when compared to clopidogrel. However, ticagrelor remains significantly more expensive than clopidogrel, and, thus, we would advise ticagrelor be reserved for patients who are hyporesponsive to clopidogrel.

Clinical presentation, progression, and treatment outcomes of moyamoya disease in the elderly.

BACKGROUND: Moyamoya disease is a vascular disorder characterized by progressive stenosis of the internal carotid artery. The presentation, progression, treatment options, and post-operative clinical outcomes for elderly (60 and older) Moyamoya patients have never been reported. METHODS: A retrospective analysis of all patients who were diagnosed with Moyamoya disease by the senior authors between 1991 and 2016 was performed. Patients who were 60 years or older at the time of surgery or last follow-up were further evaluated. RESULTS: Seventy patients were diagnosed with probable or definite Moyamoya disease during the study period (1991-2016). Eight patients (11.4 %; six females: two males; median age 63; range, 60-71 years) were found to be 60 years or older at the time of surgery or last follow-up and were included in the study. All patients had a modified Rankin scale (mRS) of either one or two (median 1) pre-operatively. Six patients (75 %) underwent surgical treatment on a total on seven hemispheres. Post-surgery, one patient had an improved mRS score, three had no changes, and two had worsening in their mRS scores. Both patients who did not undergo surgical interventions suffered from intra-parenchymal hemorrhages post-diagnosis. CONCLUSIONS: Moyamoya disease is most commonly seen in young and middle-aged patients. Presentation in the elderly (defined as 60 years and older in this study) is rare, and has never been reported in the literature. In this study, both direct and indirect revascularization procedures demonstrated potential benefit in some of these patients, with stabilization of progressive symptoms.

Removal of symptomatic titanium fixation plates after craniotomy.

INTRODUCTION: Titanium fixation plates are routinely used for rigid fixation of bone flaps after craniotomy. In craniofacial surgery or after craniotomy involving orbitozygomatic osteotomies, these plates are occasionally removed because of infection, pain, protrusion, soft tissue erosion, and plate malfunction. However, plate removal because of pain and protrusion after craniotomy without orbitozygomatic osteotomy has rarely been reported. METHODS: A retrospective analysis of all patients who underwent removal of cranial fixation plates after craniotomy, performed by the senior authors at one institution between 2014 and 2016, was conducted. RESULTS: A total of 319 patients underwent bone flap fixation after craniotomy using cranial fixation plates between 2014 and 2016. Five of those patients (1.6 %) had their cranial plates removed because of pain and protrusion. An additional four patients had a cranial fixation plate removed during that time frame with the original craniotomy performed before 2014. All nine patients had immediate resolution of symptoms after plate removal. CONCLUSION: We report our experience with cranial fixation plate removal because of pain and protrusion in patients who underwent craniotomy without orbitozygomatic osteotomy, particularly frontotemporal craniotomy. In an attempt to reduce this complication, we recently stopped placing a full-size burr hole in the keyhole area of a frontotemporal craniotomy, eliminating the need for a titanium burr hole cover plate.

Residual neurological function after sacral root resection during en-bloc sacrectomy: a systematic review.

PURPOSE: Sacrectomy is a highly demanding surgery representing the main treatment for primary tumors arising in the sacrum and pelvis. Unfortunately, it is correlated with loss of important function depending on the resection level and nerve roots sacrificed. The current literature regarding residual function after sacral resection comes from several small case series. The goal of this review is to appraise residual motor function and gait, sensitivity, bladder, bowel, and sexual function after sacrectomies, with consideration to the specific roots sacrificed. METHODS: An exhaustive literature search was conducted. All manuscripts published before May 2015 regarding residual function after sacrectomy were considered; if a clear correlation between root level and functioning was not present, the paper was excluded. The review identified 15 retrospective case series, totaling 244 patients; 42 patients underwent sacrectomies sparing L4/L4, L4/L5 and L5/L5; 45 sparing both L5 and one or both S1 roots; 8 sparing both S1 and one S2; 48 sparing both S2; 11 sparing both S2 and one S3, 54 sparing both S3, 9 sparing both S3 and one or both S4, and 27 underwent unilateral variable resection. RESULTS: Patients who underwent a sacrectomy maintained functionally normal ambulation in 56.2 % of cases when both S2 roots were spared, 94.1 % when both S3 were spared, and in 100 % of more distal resections. Normal bladder and bowel function were not present when both S2 were cut. When one S2 root was spared, normal bladder function was present in 25 % of cases; when both S2 were spared, 39.9 %; when one S3 was spared, 72.7 %; and when both S3 were spared, 83.3 %. Abnormal bowel function was present in 12.5 % of cases when both S1 and one S2 were spared; in 50.0 % of cases when both S2 were spared; and in 70 % of cases when one S3 was spared; if both S3 were spared, bowel function was normal in 94 % of cases. When even one S4 root was spared, normal bladder and bowel function were present in 100 % of cases. Unilateral sacral nerve root resection preserved normal bladder function in 75 % of cases and normal bowel function in 82.6 % of cases. Motor function depended on S1 root involvement. CONCLUSION: Total sacrectomy is associated with compromising important motor, bladder, bowel, sensitivity, and sexual function. Residual motor function is dependent on sparing L5 and S1 nerve roots. Bladder and bowel function is consistently compromised in higher sacrectomies; nevertheless, the probability of maintaining sufficient function increases progressively with the roots spared, especially when S3 nerve roots are spared. Unilateral resection is usually associated with more normal function. To the best of our knowledge, this is the first comprehensive literature review to analyze published reports of residual sacral nerve root function after sacrectomy.

The Surgical Anatomy of the Lumbosacroiliac Triangle: A Cadaveric Study.

OBJECTIVE: The anatomic area delineated medially by the lateral part of the L4-L5 vertebral bodies, distally by the anterior-superior surface of the sacral wing, and laterally by an imaginary line joining the base of the L4 transverse process to the proximal part of the sacroiliac joint, is of particular interest to spine surgeons. We are referring to this area as the lumbo-sacro-iliac triangle (LSIT). Knowledge of LSIT anatomy is necessary during approaches for L5 vertebral and sacral fractures, sacral and iliac tumors, and extraforaminal decompression of the L5 nerve roots. METHODS: We performed an anatomic dissection of the LSIT in 3 embalmed cadavers (6 triangles), using an anterior and posterior approach. RESULTS: We identified 3 key tissue planes: the neurological plexus plane, constituted by L4 and L5 nerve roots; an intermediate level constituted by the ileosacral tunnel; and posteriorly, by the lumbosacral ligament, and the posterior muscular plane. CONCLUSIONS: Improving anatomic knowledge of the LSIT may help surgeons decrease the risk of possible complications. When LSIT pathology is present, a lateral approach corresponding to the tip of the L4 transverse process, medially, is suggested to decrease the risk of vessel and nerve root damage.

The surgical vascular anatomy of the minimally invasive lateral lumbar interbody approach: a cadaveric and radiographic analysis.

PURPOSE: The minimally invasive (MI) lateral lumbar interbody fusion (LLIF) approach has become increasingly popular for the treatment of degenerative lumbar spine disease. The neural anatomy of the lumbar plexus has been studied; however, the pertinent surgical vascular anatomy has not been examined in detail. The goal of this study is to examine the vascular structures that are relevant in relation to the MI-LLIF approach. METHODS: Anatomic dissection of the lumbar spines and associated vasculature was performed in three embalmed, adult cadavers. Right and left surgeon perspective views during LLIF were for a total of six approaches. During the dissection, all vascular elements were noted and photographed, and anatomical relationships to the vertebral bodies and disc spaces were analyzed. In addition, several axial and sagittal MRI images of the lumbar spine were analyzed to complement the cadaveric analysis. RESULTS: The aorta descends along the left anterior aspect of lumbar vertebra with an average distance of 2.1 cm (range 1.9-2.3 cm) to the center of each intervertebral disc. The vena cava descends along the right anterior aspect of lumbar vertebrates with average distance of 1.4 cm (range 1.3-1.6 cm) to the center of the intervertebral disc. Each vertebral body has two lumbar arteries (direct branches from the aorta); one exits to the left and one to the right side of the vertebral body. The lumbar arteries pass underneath the sympathetic trunk, run in the superior margin of the vertebral body and extend all the way across it, with average length of 3.8 cm (range 2.5-5 cm). The mean distance between the arteries and the inferior plate of the superior disc space is 4.2 mm (range 2-5 mm) and mean distance of 3.1 cm (range 2.8-3.8 cm) between two arteries in adjacent vertebrae. One of the cadavers had an expected normal anatomical variation where the left arteries at L3-L4 anastomosed dorsally of the vertebral bodies at the middle of the intervertebral disc. CONCLUSIONS: Understanding the vascular anatomy of the lateral and anterior lumbar spine is paramount for successfully and safely executing the LLIF procedure. It is imperative to identify anatomical variations in lumbar arteries and veins with careful assessment of the preoperative imaging.

Fusion after intradural spine tumor resection in adults: A review of evidence and practices.

There is ample evidence supporting concomitant fusion after intradural spinal tumor resection in select pediatric patients. Unfortunately, the data are scarcer in adults. The objective of this work is to review the published literature and analyze practice patterns for stabilization and fusion after intradural tumor resection in adults. We performed a literature review via PubMed for information available regarding fusion in adults with intradural spine tumors. Additionally, we manually searched the references of selected articles to add relevant articles. Finally, we retrieved the criteria for fusion (if any) in the selected studies. A total of 639 articles were found and 35 were finally selected for analysis. Of those, three were literature reviews and 32 were retrospective case series. There were a total of 1288 patients on the series with 104 of them requiring fusion (8.1%). The median follow up of all the series was 24 months (range 1.5-180).The criteria for fusion that were common in most cases series were: previous deformity (i.e. kyphosis in the cervical spine), 3 or more levels of laminectomy, laminectomy encompassing a spinal junction, "young adults" (33 ± 4.2 years), facetectomy ≥ 50% (unilateral or bilateral), persistence of deformity after 1 year of the surgery and, C2 laminectomy. There appears to be some consistent practices for fusion after intradural tumor resection in adults, but this is based on retrospective analyses of case series. Prospective or randomized trials will likely provide more evidence based support for this practice.

Peribrachiocephalic approaches to the anterior cervicothoracic spine.

This cadaveric study aims to reexamine the corridors to the anterior cervicothoracic junction, relative to the left brachiocephalic vein, and to present these working corridors as either supra- or infra-brachiocephalic. The anterior cervicothoracic junction incorporates the seventh cervical vertebrae through the fourth thoracic vertebrae (C7-T4) and involves critical anatomical structures. Operative approaches to this area are well described in the literature, with the predominant implementation of three surgical corridors. We used three embalmed, human, cadaveric specimens for this study. No pathology involving the cervicothoracic junction was noted. While dissecting, we tried to imitate the actual surgery. For each surgical step, photographs were taken, drawing attention to the critical structures and highlighting the different corridors to the spine relative to the left brachiocephalic vein. It is possible to access the cervicothoracic junction relative to the brachiocephalic vein from the left. The supra-brachiocephalic approach gives access to the C7-T4 vertebrae, whereas if T4-T5 is the goal, the infra-brachiocephalic approach may be utilized. In the supra-brachiocephalic approach, the brachiocephalic artery can be either medialized or lateralized as needed. A re-examination of the anterior cervicothoracic junction anatomy has allowed us to classify approaches relative to the left brachiocephalic vein. Identifying and understanding the approaches relative to this structure will assist in safe and effective spinal surgery in this area.

Anatomic considerations of the anterior upper cervical spine during decompression and instrumentation: a cadaveric based study.

We evaluated the anatomical considerations specific to the high anterior retropharyngeal approach to the cervical spine. Surgical exposure of the anterior upper cervical spine can sometimes be challenging due to the surrounding neurovascular structures. Using three adult cadavers, we performed high anterior retropharyngeal cervical dissection of the left and right side for a total of six approaches (six sides). During the dissection, all important neurovascular elements were noted and photographed, and anatomical relationships to the spinal vertebral bodies and disc spaces were analyzed. There are certain anatomic considerations that are unique to the high anterior cervical spine. The unique structures include the hypoglossal nerve and the superior thyroid artery/nerve. Only the superior thyroid artery in this region has numerous anatomical variations. Awareness of other structures, including the carotid artery, recurrent laryngeal nerve, and esophagus also remains important. Awareness of the anatomical structures in the anterior upper cervical spine is essential for performing safe anterior upper cervical spinal surgery, avoiding serious complications.