Providencia rettgeri infection complicating cranial surgery: illustrative cases.

BACKGROUND: Providencia rettgeri is a rare cause of nosocomial infection in humans. These organisms are capable of biofilm production and are intrinsically resistant to commonly used antibiotics, leading to high rates of morbidity and mortality. P. rettgeri may very rarely cause postneurosurgical infection. OBSERVATIONS: In this report, the authors describe two patients in whom P. rettgeri infection complicated the postoperative course. Both the patients underwent craniotomy at approximately the same time under similar environments. The organism isolated was resistant to most of the commonly used antibiotics, and therapy tailored to the results of susceptibility testing led to resolution of infection in both cases. LESSONS: P. rettgeri is a rare cause of postneurosurgical nosocomial infection. Timely identification and early tailoring of antibiotic therapy based on susceptibility testing is the key to treatment. Every effort should be made to identify the source of infection and rectify it so that mortality, morbidity, and financial burden are reduced. Contact isolation and use of sterile gloves after each patient contact are effective in preventing its spread, as in most cases of nosocomial infection.

Intraoperative MRI for the microsurgical resection of meningiomas close to eloquent areas or dural sinuses: patient series.

BACKGROUND: Meningiomas are the most commonly encountered nonglial primary intracranial tumors. The authors report on the usefulness of intraoperative magnetic resonance imaging (iMRI) during microsurgical resection of meningiomas located close to eloquent areas or dural sinuses and on the feasibility of further radiation therapy. OBSERVATIONS: Six patients benefited from this approach. The mean follow-up period after surgery was 3.3 (median 3.2, range 2.1-4.6) years. Five patients had no postoperative neurological deficit, of whom two with preoperative motor deficit completely recovered. One patient with preoperative left inferior limb deficit partially recovered. The mean interval between surgery and radiation therapy was 15.8 (median 16.9, range 1.4-40.5) months. Additional radiation therapy was required in five cases after surgery. The mean preoperative tumor volume was 38.7 (median 27.5, range 8.6-75.6) mL. The mean postoperative tumor volume was 1.2 (median 0.8, range 0-4.3) mL. At the last follow-up, all tumors were controlled. LESSONS: The use of iMRI was particularly helpful to (1) decide on additional tumor resection according to iMRI findings during the surgical procedure; (2) evaluate the residual tumor volume at the end of the surgery; and (3) judge the need for further radiation and, in particular, the feasibility of single-fraction radiosurgery.

Patient-specific virtual reality technology for complex neurosurgical cases: illustrative cases.

BACKGROUND: Virtual reality (VR) offers an interactive environment for visualizing the intimate three-dimensional (3D) relationship between a patient's pathology and surrounding anatomy. The authors present a model for using personalized VR technology, applied across the neurosurgical treatment continuum from the initial consultation to preoperative surgical planning, then to intraoperative navigation, and finally to postoperative visits, for various tumor and vascular pathologies. OBSERVATIONS: Five adult patients undergoing procedures for spinal cord cavernoma, clinoidal meningioma, anaplastic oligodendroglioma, giant aneurysm, and arteriovenous malformation were included. For each case, 360-degree VR (360°VR) environments developed using Surgical Theater were used for patient consultation, preoperative planning, and/or intraoperative 3D navigation. The custom 360°VR model was rendered from the patient's preoperative imaging. For two cases, the plan changed after reviewing the patient's 360°VR model from one based on conventional Digital Imaging and Communications in Medicine imaging. LESSONS: Live 360° visualization with Surgical Theater in conjunction with surgical navigation helped validate the decisions made intraoperatively. The 360°VR models provided visualization to better understand the lesion's 3D anatomy, as well as to plan and execute the safest patient-specific approach, rather than a less detailed, more standardized one. In all cases, preoperative planning using the patient's 360°VR model had a significant impact on the surgical approach.

Primary spinal melanoma: illustrative case.

BACKGROUND: Primary spinal melanoma is extremely rare, accounting for ∼1% of all primary melanomas. Typically presenting insidiously in the thoracic spinal cord, primary spinal melanomas can have an acute presentation due to their propensity to hemorrhage. OBSERVATIONS: Despite its rarity, primary spinal melanoma should be included in the differential diagnosis when a hemorrhagic pattern of T1 and T2 intensities is seen on magnetic resonance imaging. Furthermore, the complete diagnosis is crucial because the prognosis of a primary spinal melanoma is considerably more favorable than that of a primary cutaneous melanoma with metastatic spread. LESSONS: Resection is the treatment of choice, with some authors advocating for postoperative chemotherapy, immunotherapy, and/or radiation. We describe a case of acute quadriplegia from hemorrhagic primary spinal melanoma requiring resection.

Surgical management of atlantoaxial dislocation and cervical spinal cord injury in craniopagus twins.

A case of cervical spinal cord injury in 12-year-old angular craniopagus twins is presented, with a description of the planning and execution of surgical treatment along with subsequent clinical outcome. The injury occurred following a fall from a standing position, resulting in quadriparesis in one of the twins. Imaging revealed severe craniocervical stenosis resulting from a C1-2 dislocation, and T2-weighted hyperintensity of the cervical spinal cord. After custom halo fixation was obtained, a posterior approach was utilized to decompress and instrument the occiput, cervical, and upper thoracic spine with intraoperative reduction of the dislocation. Early neurological improvement was noted during the acute postoperative phase, and 27 months of follow-up demonstrated intact instrumentation with continued neurological improvement to near baseline. The complexity of managing such an injury, inclusive of the surgical, anesthetic, biomechanical, and ethical considerations, is described in detail.

A high-definition 3D exoscope as an alternative to the operating microscope in spinal microsurgery.

OBJECTIVE: Since the 1970s, the operating microscope (OM) has been a standard for visualization and illumination of the surgical field in spinal microsurgery. However, due to its limitations (e.g., size, costliness, and the limited movability of the binocular lenses, in addition to discomfort experienced by surgeons due to the posture required), there are efforts to replace the OM with exoscopic video telescopes. The authors evaluated the feasibility of a new 3D exoscope as an alternative to the OM in spine surgeries. METHODS: Patients with degenerative pathologies scheduled for single-level lumbar or cervical spinal surgery with use of a high-definition 3D exoscope were enrolled in a prospective cohort study between January 2019 and September 2019. Age-, sex-, body mass index-, and procedure-matched patients surgically treated with the assistance of the OM served as the control group. Operative baseline and postoperative outcome parameters were assessed. Periprocedural handling, visualization, and illumination by the exoscope, as well as surgeons' comfort level in terms of posture, were scored using a questionnaire. RESULTS: A 3D exoscope was used in 40 patients undergoing lumbar posterior decompression (LPD) and 20 patients undergoing anterior cervical discectomy and fusion (ACDF); an equal number of controls in whom an OM was used were studied. Compared with controls, there were no significant differences for mean operative time (ACDF: 132 vs 116 minutes; LPD: 112 vs 113 minutes) and blood loss (ACDF: 97 vs 93 ml; LPD: 109 vs 55 ml) as well as postoperative improvement of symptoms (ACDF/Neck Disability Index: p = 0.43; LPD/Oswestry Disability Index: p = 0.76). No intraoperative complications occurred in either group. According to the attending surgeon, the intraoperative handling of instruments was rated to be comparable to that of the OM, while the comfort level of the surgeon's posture intraoperatively (especially during "undercutting" procedures) was rated as superior. In cases of ACDF procedures and long approaches, depth perception, image quality, and illumination were rated as inferior when compared with the OM. By contrast, for operating room nursing staff participating in 3D exoscope procedures, the visualization of intraoperative process flow and surgical situs was rated to be superior to the OM, especially for ACDF procedures. CONCLUSIONS: A 3D exoscope seems to be a safe alternative for common spinal procedures with the unique advantage of excellent comfort for the surgical team, but the drawback is the still slightly inferior visualization/illumination quality compared with the OM.

Initial blood pressure is important for long-term outcome after traumatic spinal cord injury.

OBJECTIVE: Patients with traumatic spinal cord injury (TSCI) are at risk of developing neurogenic shock that causes hypotension and thereby secondary injury to the spinal cord due to ischemia. Hemodynamic treatment of patients with acute TSCI remains inadequately elucidated. Guidelines for management are divergent and based on limited evidence. To this end, the authors evaluated whether mean arterial blood pressure (MABP) during the prehospital and initial hospital phases of TSCI treatment is correlated with long-term neurological outcome. METHODS: The authors performed a retrospective cohort study based on a chart review of MABP data collected during the prehospital transport, in the operating room (OR), and in the neurointensive care unit (NICU) during the first 7 days after trauma. Data from the NICU were divided into two periods: days 1-2 and days 3-7. Data were analyzed using Spearman's rank correlation to evaluate for any correlation between MABP and changes in the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) score 1 year postinjury. In the analysis, the MABP target value was 80 mm Hg. Hypotension was treated with metaoxedrin or norepinephrine. Statistically significant differences were evaluated using Spearman's rank correlation coefficient. RESULTS: The chart review yielded 129 patients treated for TSCI. The inclusion period was 2010-2017. For the prehospital transport measurements of MABP, the Spearman's rank correlation coefficient was a rho of 0.5662 (p < 0.001), for OR measurements it was a rho of 0.6818 (p < 0.001), and for the NICU measurements it was a rho of 0.4611 (p < 0.001); for NICU unit days 1-2 and days 3-7, the Spearman's rank correlation coefficient was a rho of 0.2209 (p = 0.0681). CONCLUSIONS: Continuous MABP levels exceeding 80 mm Hg have a significant impact on neurological outcome-from earliest possible stabilization in the prehospital care, through hospital admission, the surgical phase, and into the first 2 days in the NICU.

Protocol-driven prevention of perioperative hypothermia in the pediatric neurosurgical population.

OBJECTIVE: Perioperative hypothermia (PH) is a preventable, pathological, and iatrogenic state that has been shown to result in increased surgical blood loss, increased surgical site infections, increased hospital length of stay, and patient discomfort. Maintenance of normothermia is recommended by multiple surgical quality organizations; however, no group yet provides an ergonomic, evidence-based protocol to reduce PH for pediatric neurosurgery patients. The authors' aim was to evaluate the efficacy of a PH prevention protocol in the pediatric neurosurgery population. METHODS: A prospective, nonrandomized study of 120 pediatric neurosurgery patients was performed. Thirty-eight patients received targeted warming interventions throughout their perioperative phases of care (warming group-WG). The remaining 82 patients received no extra warming care during their perioperative period (control group-CG). Patients were well matched for age, sex, and preparation time intraoperatively. Hypothermia was defined as < 36°C. The primary outcome of the study was maintenance of normothermia preoperatively, intraoperatively, and postoperatively. RESULTS: WG patients were significantly warmer on arrival to the operating room (OR) and were 60% less likely to develop PH (p < 0.001). Preoperative forced air warmer use both reduced the risk of PH at time 0 intraoperatively and significantly reduced the risk of any PH intraoperatively (p < 0.001). All patients, regardless of group, experienced a drop in core temperature until a nadir occurred at 30 minutes intraoperatively for the WG and 45 minutes for the CG. At every time interval, from preoperatively to 120 minutes intraoperatively, CG patients were between 2 and 3 times more likely to experience PH (p < 0.001). All patients were warm on arrival to the postanesthesia care unit regardless of patient group. CONCLUSIONS: Preoperative forced air warmer use significantly increases the average intraoperative time 0 temperature, helping to prevent a fall into PH at the intraoperative nadir. Intraoperatively, a strictly and consistently applied warming protocol made intraoperative hypothermia significantly less likely as well as less severe when it did occur. Implementation of a warming protocol necessitated only limited resources and an OR culture change, and was well tolerated by OR staff.

Index episode-of-care propensity-matched comparison of transforaminal lumbar interbody fusion (TLIF) techniques: open traditional TLIF versus midline lumbar interbody fusion (MIDLIF) versus robot-assisted MIDLIF.

OBJECTIVE: Posterior fixation with interbody cage placement can be accomplished via numerous techniques. In an attempt to expedite recovery by limiting muscle dissection, midline lumbar interbody fusion (MIDLIF) has been described. More recently, the authors have developed a robot-assisted MIDLIF (RA-MIDLIF) technique. The purpose of this study was to compare the index episode-of-care (iEOC) parameters between patients undergoing traditional open transforaminal lumbar interbody fusion (tTLIF), MIDLIF, and RA-MIDLIF. METHODS: A retrospective review of a prospective, multisurgeon surgical database was performed. Consecutive patients undergoing 1- or 2-level tTLIF, MIDLIF, or RA-MIDLIF for degenerative lumbar conditions were identified. Patients in each cohort were propensity matched based on age, sex, smoking status, BMI, diagnosis, American Society of Anesthesiologists (ASA) class, and number of levels fused. Index EOC parameters such as length of stay (LOS), estimated blood loss (EBL), operating room (OR) time, and actual, direct hospital costs for the index surgical visit were analyzed. RESULTS: Of 281 and 249 patients undergoing tTLIF and MIDLIF, respectively, 52 cases in each cohort were successfully propensity matched to the authors' first 55 RA-MIDLIF cases. Consistent with propensity matching, there was no significant difference in age, sex, BMI, diagnosis, ASA class, or levels fused. Spondylolisthesis was the most common indication for surgery in all cohorts. The mean total iEOC was similar across all cohorts. Patients undergoing RA-MIDLIF had a shorter average LOS (1.53 days) than those undergoing either MIDLIF (2.71 days) or tTLIF (3.58 days). Both MIDLIF and RA-MIDLIF were associated with lower EBL and less OR time compared with tTLIF. CONCLUSIONS: Despite concerns for additional cost and time while introducing navigation or robotic technology, a propensity-matched comparison of the authors' first 52 RA-MIDLIF surgeries with tTLIF and MIDLIF showed promising results for reducing OR time, EBL, and LOS without increasing cost.

Incidence of intraoperative hypotension in acute traumatic spinal cord injury and associated factors.

OBJECTIVE: The importance of maintaining mean arterial pressure (MAP) > 85 mm Hg for patients with acute spinal cord injury (SCI) is well documented, because systemic hypotension greatly increases the risk of secondary SCI. Current literature focuses on the ICU setting; however, there is a paucity of data describing the changes in MAP in the operating room (OR). In the present study, the authors investigated the incidence of intraoperative hypotension for patients with acute traumatic SCI as well as any associated factors that may have impacted these findings. METHODS: This retrospective study was performed at a level 1 trauma center from 2015 to 2016. All patients with American Spinal Injury Association (ASIA) score A-D acute traumatic SCIs from C1 to L1 were identified. Those included underwent spinal instrumentation and/or laminectomy decompression. Associated factors investigated include the following: age, body mass index, trauma mechanism of injury, Injury Severity Score, level of SCI, ASIA score, hospital day of surgery, total OR time, need for laminectomy decompression, use of spinal fixation, surgical positioning, blood loss, use of blood products, length of hospital stay, length of ICU stay, and discharge disposition. Intraoperative minute-by-minute MAP recordings were used to determine time spent in various MAP ranges. RESULTS: Thirty-two patients underwent a total of 33 operations. Relative to the total OR time, patients spent an average of 51.9% of their cumulative time with an MAP < 85 mm Hg. Furthermore, 100% of the study population recorded at least one MAP measurement < 85 mm Hg. These hypotensive episodes lasted a mean of 103 cumulative minutes per operative case. Analysis of associated factors demonstrated that fall mechanisms of injury led to a statistically significant increase in intraoperative hypotension compared to motor vehicle collisions/motorcycle collisions (p = 0.033). There were no significant differences in MAP recordings when analyzed according to all other associated factors studied. CONCLUSIONS: This is the first study reporting the incidence of intraoperative hypotension for patients with acute traumatic SCIs, and the results demonstrated higher proportions of relative hypotension than previously reported in the ICU setting. Furthermore, the authors identified that every patient experienced at least one MAP below the target value, which was much greater than the initial hypothesis of 50%. Given the findings of this study, adherence to the MAP protocol intraoperatively needs to be improved to minimize the risk of secondary SCI and associated deleterious neurological outcomes.

Jean Talairach: a cerebral cartographer.

Although French psychiatrist-turned-neurosurgeon Jean Talairach (1911-2007) is perhaps best known for the stereotaxic atlas he produced with Pierre Tournoux and Gábor Szikla, he has left his mark on most aspects of modern stereotactic and functional neurosurgery. In the field of psychosurgery, he expressed critique of the practice of prefrontal lobotomy and subsequently was the first to describe the more selective approach using stereotactic bilateral anterior capsulotomy. Turning his attention to stereotaxy, Talairach spearheaded the team at Hôpital Sainte-Anne in the construction of novel stereotaxic apparatus. Cadaveric investigation using these tools and methods resulted in the first human stereotaxic atlas where the use of the anterior and posterior commissures as intracranial reference points was established. This work revolutionized the approach to cerebral localization as well as leading to the development of numerous novel stereotactic interventions by the Sainte-Anne team, including tumor biopsy, interstitial irradiation, thermal ablation, and endonasal procedures. Together with epileptologist Jean Bancaud, Talairach invented the field of stereo-electroencephalography and developed a robust scientific methodology for the assessment and treatment of epilepsy. In this article the authors review Talairach's career trajectory in its historical context and in view of its impact on modern stereotactic and functional neurosurgery.

Reduction of ventriculostomy-associated CSF infection with antibiotic-impregnated catheters in pediatric patients: a single-institution study.

OBJECTIVE: External ventricular drains (EVDs) are commonly used in the neurosurgical population. However, very few pediatric neurosurgery studies are available regarding EVD-associated infection rates with antibiotic-impregnated EVD catheters. The authors previously published a large pediatric cohort study analyzing nonantibiotic-impregnated EVD catheters and risk factors associated with infections. In this study, they aimed to analyze the EVD-associated infection rate after implementation of antibiotic-impregnated EVD catheters. METHODS: A retrospective observational cohort of pediatric patients (younger than 18 years of age) who underwent a burr hole for antibiotic-impregnated EVD placement and who were admitted to a quaternary care ICU between January 2011 and January 2019 were reviewed. The ventriculostomy-associated infection rate in patients with antibiotic-impregnated EVD catheters was compared to the authors' historical control of patients with nonantibiotic-impregnated EVD catheters. RESULTS: Two hundred twenty-nine patients with antibiotic-impregnated EVD catheters were identified. Neurological diagnostic categories included externalization of an existing shunt (externalized shunt) in 34 patients (14.9%); brain tumor (tumor) in 77 patients (33.6%); intracranial hemorrhage (ICH) in 27 patients (11.8%); traumatic brain injury (TBI) in 6 patients (2.6%); and 85 patients (37.1%) were captured in an "other" category. Two of 229 patients (0.9% of all patients) had CSF infections associated with EVD management, totaling an infection rate of 0.99 per 1000 catheter days. This is a significantly lower infection rate than was reported in the authors' previously published analysis of the use of nonantibiotic-impregnated EVD catheters (0.9% vs 6%, p = 0.00128). CONCLUSIONS: In their large pediatric cohort, the authors demonstrated a significant decline in ventriculostomy-associated CSF infection rate after implementation of antibiotic-impregnated EVD catheters at their institution.

Insurance type impacts the economic burden and survival of patients with newly diagnosed glioblastoma.

OBJECTIVE: Glioblastoma (GBM) carries a high economic burden for patients and caregivers, much of which is associated with initial surgery. The authors investigated the impact of insurance status on the inpatient hospital costs of surgery for patients with GBM. METHODS: The authors conducted a retrospective review of patients with GBM (2010-2015) undergoing their first resection at the University of California, San Francisco, and corresponding inpatient hospital costs. RESULTS: Of 227 patients with GBM (median age 62 years, 37.9% females), 31 (13.7%) had Medicaid, 94 (41.4%) had Medicare, and 102 (44.9%) had private insurance. Medicaid patients had 30% higher overall hospital costs for surgery compared to non-Medicaid patients ($50,285 vs $38,779, p = 0.01). Medicaid patients had higher intensive care unit (ICU; p < 0.01), operating room (p < 0.03), imaging (p < 0.001), room and board (p < 0001), and pharmacy (p < 0.02) costs versus non-Medicaid patients. Medicaid patients had significantly longer overall and ICU lengths of stay (6.9 and 2.6 days) versus Medicare (4.0 and 1.5 days) and privately insured patients (3.9 and 1.8 days, p < 0.01). Medicaid patients had similar comorbidity rates to Medicare patients (67.8% vs 68.1%), and both groups had higher comorbidity rates than privately insured patients (37.3%, p < 0.0001). Only 67.7% of Medicaid patients had primary care providers (PCPs) versus 91.5% of Medicare and 86.3% of privately insured patients (p = 0.009) at the time of presentation. Tumor diameter at diagnosis was largest for Medicaid (4.7 cm) versus Medicare (4.1 cm) and privately insured patients (4.2 cm, p = 0.03). Preoperative (70 vs 90, p = 0.02) and postoperative (80 vs 90, p = 0.03) Karnofsky Performance Scale (KPS) scores were lowest for Medicaid versus non-Medicaid patients, while in subgroup analysis, postoperative KPS score was lowest for Medicaid patients (80, vs 90 for Medicare and 90 for private insurance; p = 0.03). Medicaid patients had significantly shorter median overall survival (10.7 months vs 12.8 months for Medicare and 15.8 months for private insurance; p = 0.02). Quality-adjusted life year (QALY) scores were 0.66 and 1.05 for Medicaid and non-Medicaid patients, respectively (p = 0.036). The incremental cost per QALY was $29,963 lower for the non-Medicaid cohort. CONCLUSIONS: Patients with GBMs and Medicaid have higher surgical costs, longer lengths of stay, poorer survival, and lower QALY scores. This study indicates that these patients lack PCPs, have more comorbidities, and present later in the disease course with larger tumors; these factors may drive the poorer postoperative function and greater consumption of hospital resources that were identified. Given limited resources and rising healthcare costs, factors such as access to PCPs, equitable adjuvant therapy, and early screening/diagnosis of disease need to be improved in order to improve prognosis and reduce hospital costs for patients with GBM.

Machine learning for automated 3-dimensional segmentation of the spine and suggested placement of pedicle screws based on intraoperative cone-beam computer tomography.

OBJECTIVE: The goal of this study was to develop and validate a system for automatic segmentation of the spine, pedicle identification, and screw path suggestion for use with an intraoperative 3D surgical navigation system. METHODS: Cone-beam CT (CBCT) images of the spines of 21 cadavers were obtained. An automated model-based approach was used for segmentation. Using machine learning methodology, the algorithm was trained and validated on the image data sets. For measuring accuracy, surface area errors of the automatic segmentation were compared to the manually outlined reference surface on CBCT. To further test both technical and clinical accuracy, the algorithm was applied to a set of 20 clinical cases. The authors evaluated the system's accuracy in pedicle identification by measuring the distance between the user-defined midpoint of each pedicle and the automatically segmented midpoint. Finally, 2 independent surgeons performed a qualitative evaluation of the segmentation to judge whether it was adequate to guide surgical navigation and whether it would have resulted in a clinically acceptable pedicle screw placement. RESULTS: The clinically relevant pedicle identification and automatic pedicle screw planning accuracy was 86.1%. By excluding patients with severe spinal deformities (i.e., Cobb angle > 75° and severe spinal degeneration) and previous surgeries, a success rate of 95.4% was achieved. The mean time (± SD) for automatic segmentation and screw planning in 5 vertebrae was 11 ± 4 seconds. CONCLUSIONS: The technology investigated has the potential to aid surgeons in navigational planning and improve surgical navigation workflow while maintaining patient safety.

Combined use of minimal access craniotomy, intraoperative magnetic resonance imaging, and awake functional mapping for the resection of gliomas in 61 patients.

OBJECTIVECurrent management of gliomas involves a multidisciplinary approach, including a combination of maximal safe resection, radiotherapy, and chemotherapy. The use of intraoperative MRI (iMRI) helps to maximize extent of resection (EOR), and use of awake functional mapping supports preservation of eloquent areas of the brain. This study reports on the combined use of these surgical adjuncts.METHODSThe authors performed a retrospective review of patients with gliomas who underwent minimal access craniotomy in their iMRI suite (IMRIS) with awake functional mapping between 2010 and 2017. Patient demographics, tumor characteristics, intraoperative and postoperative adverse events, and treatment details were obtained. Volumetric analysis of preoperative tumor volume as well as intraoperative and postoperative residual volumes was performed.RESULTSA total of 61 patients requiring 62 tumor resections met the inclusion criteria. Of the tumors resected, 45.9% were WHO grade I or II and 54.1% were WHO grade III or IV. Intraoperative neurophysiological monitoring modalities included speech alone in 23 cases (37.1%), motor alone in 24 (38.7%), and both speech and motor in 15 (24.2%). Intraoperative MRI demonstrated residual tumor in 48 cases (77.4%), 41 (85.4%) of whom underwent further resection. Median EOR on iMRI and postoperative MRI was 86.0% and 98.5%, respectively, with a mean difference of 10% and a median difference of 10.5% (p < 0.001). Seventeen of 62 cases achieved an increased EOR > 15% related to use of iMRI. Seventeen (60.7%) of 28 low-grade gliomas and 10 (30.3%) of 33 high-grade gliomas achieved complete resection. Significant intraoperative events included at least temporary new or worsened speech alteration in 7 of 38 cases who underwent speech mapping (18.4%), new or worsened weakness in 7 of 39 cases who underwent motor mapping (18.0%), numbness in 2 cases (3.2%), agitation in 2 (3.2%), and seizures in 2 (3.2%). Among the patients with new intraoperative deficits, 2 had residual speech difficulty, and 2 had weakness postoperatively, which improved to baseline strength by 6 months.CONCLUSIONSIn this retrospective case series, the combined use of iMRI and awake functional mapping was demonstrated to be safe and feasible. This combined approach allows one to achieve the dual goals of maximal tumor removal and minimal functional consequences in patients undergoing glioma resection.

A modified endovascular treatment protocol for iatrogenic internal carotid artery injuries following endoscopic endonasal surgery.

OBJECTIVE: Internal carotid artery (ICA) injuries during endoscopic endonasal surgery (EES) are catastrophic complications. Alongside the advancements in medical instrumentation and material, there is a need to modify previous treatment modalities and principles. METHODS: A retrospective review of 3658 patients who underwent EES performed at the authors' institution between January 2012 and December 2017 was conducted. Ultimately, 20 patients (0.55%) with ICA injury following EES were enrolled for analysis. Data collection included demographic data, preoperative diagnosis, injury setting, repair method, and immediate and follow-up angiographic and clinical outcomes. RESULTS: Among the 20 patients, 11 received immediate endovascular therapy and 9 were treated only with packing. Of the 11 patients who received endovascular treatment, 6 were treated by covered stent and 5 by parent artery occlusion (PAO). The preservation rate of injured ICA increased from 20.0% (1 of 5) to 83.3% (5 of 6) after the Willis covered stent graft became available in January 2016. Of the 20 patients in the study, 19 recovered well and 1 patient-who had a pseudoaneurysm and was treated by PAO with a detachable balloon-suffered epistaxis after the hemostat in her nasal cavity was removed in ward, and she died later that day. The authors speculated that the detachable balloon had shifted to the distal part of ICA, although the patient could not undergo a repeat angiogram because she quickly suffered shock and could not be transferred to the catheter room. After the introduction of a hybrid operating room (OR), one patient whose first angiogram showed no ICA injury was found to have a pseudoaneurysm. He received endovascular treatment when he was brought for a repeat angiogram 5 days later in the hybrid OR after removing the hemostat in his nasal cavity. Of the 4 surviving patients treated with PAO, no external carotid artery-ICA bypass was required. The authors propose a modified endovascular treatment protocol for ICA injuries suffered during EES that exploits the advantage of the covered stent graft and the hybrid OR. CONCLUSIONS: The endovascular treatment protocol used in this study for ICA injuries during EES was helpful in the management of this rare complication. Willis stent placement improved the preservation rate of injured ICA during EES. It would be highly advantageous to manage this complication in a hybrid OR or by a mobile C-arm to get a clear intraoperative angiogram.

Corpus callosotomy via laser interstitial thermal therapy: a case series.

Corpus callosotomy has been used as a form of surgical palliation for patients suffering from medically refractory generalized seizures, including drop attacks. Callosotomy has traditionally been described as involving a craniotomy with microdissection. MR-guided laser interstitial thermal therapy (MRg-LITT) has recently been used as a minimally invasive method for performing surgical ablation of epileptogenic foci and corpus callosotomy. The authors present 3 cases in which MRg-LITT was used to perform a corpus callosotomy as part of a staged surgical procedure for a patient with multiple seizure types and in instances when further ablation of residual corpus callosum is necessary after a prior open surgical procedure. To the authors' knowledge, this is the first case series of corpus callosotomy performed using the MRg-LITT system with a 3.3-year average follow-up. Although MRg-LITT is not expected to replace the traditional corpus callosotomy in all cases, it is a safe, effective, and durable alternative to the traditional open corpus callosotomy, particularly in the setting of a prior craniotomy.

Elective neurosurgical humanitarian care in a deployed setting.

OBJECTIVEActive-duty neurosurgical coverage has been provided at Bagram Air Force Base in Afghanistan since 2007. Early operative logs were reflective of a large number of surgical procedures performed to treat battlefield injuries. However, with maturation of the war effort, the number of operations for battlefield injuries has decreased with time. Consequently, procedures performed for elective neurosurgical humanitarian care (NHC) increased in number and complexity prior to closure of the Korean Hospital in 2015, which resulted in effective termination of NHC at Bagram. Monthly neurosurgical caseloads for deployed personnel have dropped precipitously since this time, renewing a debate as to whether the benefits of providing elective NHC in Afghanistan outweigh the costs of such a strategy. To date, there is a paucity of information in the literature discussing the overall context of such a determination.METHODSThe author retrospectively reviewed his personal database of all patients who underwent neurosurgical procedures at Bagram during his deployment there from April 17 to October 29, 2014. Standardized clinical parameters had been recorded in the ABNS NeuroLog system. All cases of nonelective surgical care for battlefield injuries were identified and excluded. Records of all other procedures, which represented elective NHC delivered during this period, were accessed to extract salient clinical and radiological data.RESULTSDuring the 6-month deployment, 49 patients (29 male and 20 female, age range 18 months to 63 years) were treated by the author in elective NHC. Procedures were performed for spinal degenerative disease (n = 28), cranial tumors (n = 11), pediatric conditions (n = 6), Pott's disease (n = 2), peripheral nerve impingement (n = 1), and adult hydrocephalus (n = 1). The duration of follow-up ranged from 3 to 23 weeks. Complications referable to surgery included asymptomatic, unilateral lumbar screw fracture detected 3 months postoperatively and treated with revision of hardware (n = 1); wound infection requiring cranial flap explantation and staged cranioplasty (n = 1); and unanticipated return to the operating room for resection of residual tumor in a patient with a solitary metastatic lesion involving the mesial temporal lobe/ambient cistern (n = 1). There were no instances of postoperative neurological decline.CONCLUSIONSElective NHC can be safely and effectively implemented in the deployed setting. Benefits of a military strategy that supports humanitarian care include strengthening of the bond between the US/Afghan military communities and the local civilian population as well as maintenance of skills of the neurosurgical team during the sometimes-lengthy intervals between cases in which emergent neurosurgical care is provided for treatment of battlefield injuries.

Implications of anesthetic approach, spinal versus general, for the treatment of spinal disc herniation.

OBJECTIVEHealthcare costs continue to escalate. Approaches to care that have comparable outcomes and complications are increasingly assessed for quality improvement and, when possible, cost containment. Efforts to identify components of care to reduce length of stay (LOS) have been ongoing. Spinal anesthesia (SA), for select lumbar spine procedures, has garnered interest as an alternative to general anesthesia (GA) that might reduce cost and in-hospital LOS and accelerate recovery. While clinical outcomes with SA or GA have been studied extensively, few authors have looked at the cost-analysis in relation to clinical outcomes. The authors' objectives were to compare the clinical perioperative outcomes of patients who received SA and GA, as well as the direct costs associated with each modality of care, and to determine which, in a retrospective analysis, can serve as a dominant procedural approach.METHODSThe authors retrospectively analyzed a homogeneous surgical population of 550 patients who underwent hemilaminotomy for disc herniation and who received either SA (n = 91) or GA (n = 459). All clinical and billing data were obtained via each patient's chart and the hospital's billing database, respectively. Additionally, the authors prospectively assessed patient-reported outcome measures for a subgroup of consecutively treated patients (n = 75) and compared quality-adjusted life year (QALY) gains between the two cohorts. Furthermore, the authors performed a propensity score-matching analysis to compare the two cohorts (n = 180).RESULTSDirect hospital costs for patients receiving SA were 40% higher, in the hundreds of dollars, than for patients who received GA (p < 0.0001). Furthermore, there was a significant difference with regard to LOS (p < 0.0001), where patients receiving SA had a considerably longer hospital LOS (27.6% increase in hours). Patients undergoing SA had more comorbidities (p = 0.0053), specifically diabetes and hypertension. However, metrics of complications, including readmission (p = 0.3038) and emergency department (ED) visits at 30 days (p = 1.0), were no different. Furthermore, in a small pilot group, QALY gains were statistically no different (n = 75, p = 0.6708). Propensity score-matching analysis demonstrated similar results as the univariate analysis: there was no difference between the cohorts regarding 30-day readmission (p = 1.0000); ED within 30 days could not be analyzed as there were no patients in the SA group; and total direct costs and LOS were significantly different between the two cohorts (p < 0.0001 and p = 0.0126, respectively).CONCLUSIONSBoth SA and GA exhibit the qualities of a good anesthetic, and the utilization of these modalities for lumbar spine surgery is safe and effective. However, this work suggests that SA is associated with increased LOS and higher direct costs, although these differences may not be clinically or fiscally meaningful.

Surgeon specialty and patient outcomes in carotid endarterectomy.

OBJECTIVE: The goal of this study was to compare outcomes of carotid endarterectomy performed by neurological, general, and vascular surgeons. METHODS: The authors identified 80,475 patients who underwent carotid endarterectomy between 2006 and 2015 in the National Surgical Quality Improvement Program, a prospectively collected, national clinical database with established reproducibility and validity. Nine hundred forty-three patients were operated on by a neurosurgeon; 75,649 by a vascular surgeon; and 3734 by a general surgeon. Preoperative and intraoperative characteristics and 30-day outcomes were stratified by the surgeon's primary specialty. Using propensity scores, comprising pre- and intraoperative characteristics as well as procedure and diagnostic codes, the authors matched 203 neurosurgery (NS) patients to 203 vascular surgery (VS) patients and 203 NS patients to 203 general surgery (GS) patients. No pre- or intraoperative factors were significantly different between specialties in the matched sample. Regular logistic regression and conditional logistic regression were used to predict postoperative complications in the full sample and in the matched sample. RESULTS: In the complete population sample, NS patients, when compared to patients of general and vascular surgeons, were less likely to be admitted from home and more likely to have carotid artery occlusion or stenosis with cerebral infarction, to be a current smoker, to have had recent chemo- or radiotherapy, to have surgery under general anesthesia, to undergo multiple procedures, and to have longer surgery times. In unadjusted analyses, NS patients were more likely to experience major complications (NS vs VS: odds ratio 1.3, 95% CI 1.1-1.6; NS vs GS: odds ratio 1.3, 95% CI 1.0-1.7); minor complications (NS vs VS: odds ratio 2.9, 95% CI 2.0-4.1; NS vs GS: odds ratio 2.7, 95% CI 1.7-4.2); intra- or postoperative transfusions (NS vs VS: odds ratio 1.6, 95% CI 1.4-1.9; NS vs GS: odds ratio 1.9, 95% CI 1.6-2.3); prolonged hospitalization (NS vs VS: odds ratio 3.0, 95% CI 2.6-3.5; NS vs GS: odds ratio 2.6, 95% CI 2.2-3.0); and discharge to skilled care facilities (NS vs VS: odds ratio 2.8, 95% CI 2.3-3.4; NS vs GS: odds ratio 3.1, 95% CI 2.4-4.1). In adjusted, propensity-matched analyses, however, patients' outcome with carotid endarterectomy performed by NS was comparable with those completed by GS and VS. CONCLUSIONS: Patients who undergo carotid endarterectomy performed by a neurosurgeon tend to have a greater preoperative disease burden than do those treated by a general or vascular surgeon, which contributes significantly to more morbid postoperative courses. In patients matched carefully on the basis of health status at the time of surgery and intraoperative variables that affect results, patients' outcomes after carotid endarterectomy do not appear to depend on the attending surgeon's primary specialty.