Evidence-based interventions to reduce shunt infections: a systematic review.

PURPOSE: Cerebrospinal fluid shunt infection is associated with patient morbidity and high cost. We conducted a systematic review of the current evidence of comprehensive surgical protocols or individual interventions designed to reduce shunt infection incidence. METHODS: A systematic review using PubMed and SCOPUS identified studies evaluating the effect of a particular intervention on shunt infection risk. Systemic prophylactic antibiotic or antibiotic-impregnated shunt efficacy studies were excluded. A total of 7429 articles were screened and 23 articles were included. RESULTS: Eight studies evaluated the effect of comprehensive surgical protocols. Shunt infection was reduced in all studies (absolute risk reduction 2.2-12.3 %). Level of evidence was low (level 4 in seven studies) due to the use of historical controls. Compliance ranged from 24.6 to 74.5 %. Surgical scrub with antiseptic foam and omission of a 5 % chlorhexidine gluconate preoperative hair wash were both associated with increased shunt infection. Twelve studies evaluated the effect of a single intervention. Only antibiotic-impregnated suture, a no-shave policy, and double gloving with glove change prior to shunt handling, were associated with a significant reduction in shunt infection. In a hospital with high methicillin-resistant staphylococcus aureus (MRSA) prevalence, a randomized controlled trial found that perioperative vancomycin rather than cefazolin significantly reduced shunt infection rates. CONCLUSION: Despite wide variation in compliance rates, the implementation of comprehensive surgical protocols reduced shunt infection in all published studies. Antibiotic-impregnated suture, a no-shave policy, double gloving with glove change prior to device manipulation, and 5 % chlorhexidine hair wash were associated with significant reductions in shunt infection.

Lumbar spine surgery positioning complications: a systematic review.

OBJECT There are a variety of surgical positions that provide optimal exposure of the dorsal lumbar spine. These include the prone, kneeling, knee-chest, knee-elbow, and lateral decubitus positions. All are positions that facilitate exposure of the spine. Each position, however, is associated with an array of unique complications that result from excessive pressure applied to the torso or extremities. The authors reviewed clinical studies reporting complications that arose from positioning of the patient during dorsal exposures of the lumbar spine. METHODS MEDLINE, Scopus, and Web of Science database searches were performed to find clinical studies reporting complications associated with positioning during lumbar spine surgery. For articles meeting inclusion criteria, the following information was obtained: publication year, study design, sample size, age, operative time, type of surgery, surgical position, frame or table type, complications associated with positioning, time to first observed complication, long-term outcomes, and evidence-based recommendations for complication avoidance. RESULTS Of 3898 articles retrieved from MEDLINE, Scopus, and Web of Science, 34 met inclusion criteria. Twenty-four studies reported complications associated with use of the prone position, and 7 studies investigated complications after knee-chest positioning. Complications associated with the knee-elbow, lateral decubitus, and supine positions were each reported by a single study. Vision loss was the most commonly reported complication for both prone and knee-chest positioning. Several other complications were reported, including conjunctival swelling, Ischemic orbital compartment syndrome, nerve palsies, thromboembolic complications, pressure sores, lower extremity compartment syndrome, and shoulder dislocation, highlighting the assortment of possible complications following different surgical positions. For prone-position studies, there was a relationship between increased operation time and position complications. Only 3 prone-position studies reported complications following procedures of less than 120 minutes, 7 studies reported complications following mean operative times of 121-240 minutes, and 9 additional studies reported complications following mean operative times greater than 240 minutes. This relationship was not observed for knee-chest and other surgical positions. CONCLUSIONS This work presents a systematic review of positioning-related complications following prone, knee-chest, and other positions used for lumbar spine surgery. Numerous evidence-based recommendations for avoidance of these potentially severe complications associated with intraoperative positioning are discussed. This investigation may serve as a framework to educate the surgical team and decrease rates of intraoperative positioning complications.

Lumbar microdiscectomy complication rates: a systematic review and meta-analysis.

OBJECT Lumbar microdiscectomy and its various minimally invasive surgical techniques are seeing increasing popularity, but a systematic review of their associated complications has yet to be performed. The authors sought to identify all prospective clinical studies reporting complications associated with lumbar open microdiscectomy, microendoscopic discectomy (MED), and percutaneous microdiscectomy. METHODS The authors conducted MEDLINE, Scopus, Web of Science, and Embase database searches for randomized controlled trials and prospective cohort studies reporting complications associated with open, microendoscopic, or percutaneous lumbar microdiscectomy. Studies with fewer than 10 patients and published before 1990 were excluded. Overall and interstudy median complication rates were calculated for each surgical technique. The authors also performed a meta-analysis of the reported complications to assess statistical significance across the various surgical techniques. RESULTS Of 9504 articles retrieved from the databases, 42 met inclusion criteria. Most studies screened were retrospective case series, limiting the number of studies that could be included. A total of 9 complication types were identified in the included studies, and these were analyzed across each of the surgical techniques. The rates of any complication across the included studies were 12.5%, 13.3%, and 10.8% for open, MED, and percutaneous microdiscectomy, respectively. New or worsening neurological deficit arose in 1.3%, 3.0%, and 1.6% of patients, while direct nerve root injury occurred at rates of 2.6%, 0.9%, and 1.1%, respectively. Hematoma was reported at rates of 0.5%, 1.2%, and 0.6%, respectively. Wound complications (infection, dehiscence, orseroma) occurred at rates of 2.1%, 1.2%, and 0.5%, respectively. The rates of recurrent disc complications were 4.4%, 3.1%, and 3.9%, while reoperation was indicated in 7.1%, 3.7%, and 10.2% of operations, respectively. Meta-analysis calculations revealed a statistically significant higher rate of intraoperative nerve root injury following percutaneous procedures relative to MED. No other significant differences were found. CONCLUSIONS This review highlights complication rates among various microdiscectomy techniques, which likely reflect real-world practice and conceptualization of complications among physicians. This investigation sets the framework for further discussions regarding microdiscectomy options and their associated complications during the informed consent process.

Adverse Events Following Cervical Disc Arthroplasty: A Systematic Review.

STUDY DESIGN: Systematic review. OBJECTIVES: Cervical arthroplasty is an increasingly popular treatment of cervical radiculopathy and myelopathy. An understanding of the potential adverse events (AEs) is important to help both clinicians and patients. We sought to provide a comprehensive systematic review of the AEs reported in all randomized controlled trials (RCTs) of cervical disc arthroplasty in an attempt to characterize the quality of reporting. METHODS: We conducted a systematic review of MEDLINE and Web of Science for RCTs of cervical disc arthroplasty reporting AEs. We reported the most frequently mentioned AEs, including dysphagia/dysphonia, vascular compromise, dural injury, and infections. We recorded the presence of industry funding and scored the quality of collection methods and reporting of AEs. RESULTS: Of the 3734 identified articles, 29 articles met full inclusion criteria. The quality of AE reporting varied significantly between studies, and a combined meta-analysis was not feasible. The 29 articles covered separate 19 RCTs. Eight studies were US Food and Drug Administration (FDA) investigational device exemption (IDE) trials. Rates were recorded for the following AEs: dysphagia/dysphonia (range = 1.3% to 27.2%), vascular compromise (range = 1.1% to 2.4%), cervical wound infection (range = 1.2% to 22.5%), and cerebrospinal fluid leak (range = 0.8% to 7.1%). CONCLUSIONS: There is a lack of consistency in reporting of AEs among RCTs of cervical arthroplasty. FDA IDE trials scored better in AE event reporting compared to other studies. Standardized definitions for AEs and standardized data collection methodology are needed to improve future studies.

Dysphagia Rates after Anterior Cervical Diskectomy and Fusion: A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVE: Anterior cervical diskectomy and fusion (ACDF) is an effective surgical option for patients with cervical radiculopathy, myelopathy, or deformity. Although ACDF is generally safe, dysphagia is a common complication. Despite its high incidence, prolonged postoperative dysphagia is poorly understood; its etiology remains relatively unknown, and its risk factors are widely debated. METHODS: We searched MEDLINE, Scopus, Web of Science, and Embase for studies reporting complications for cervical diskectomy with plating. We recorded dysphagia events from all included studies and calculated effect summary values, 95% confidence intervals (CIs), Q values, and I2 values. RESULTS: Of the 7,780 retrieved articles, 14 met inclusion criteria. The overall dysphagia rate was 8.5% (95% CI 5.7 to 11.3%). The rate of moderate or severe dysphagia was 4.4% (0.4 to 8.4%). Follow-up times of <12, 12 to 24, and >24 months reported rates of 19.9% (6.0 to 33.7%), 7.0% (5.2 to 8.7%), and 7.6% (1.4 to 13.8%), respectively. Studies utilizing the Bazaz Dysphagia Score resulted in an increase in dysphagia diagnosis relative to studies with no outlined criteria (19.8%, 5.9 to 33.7% and 6.9%, 3.7 to 10.0%, respectively), indicating that the criteria used for dysphagia identification are critical. There was no difference in dysphagia rate with the use of autograft versus allograft. CONCLUSIONS: This review represents a comprehensive estimation of the actual incidence of dysphagia across a heterogeneous group of surgeons, patients, and criteria. The classification scheme for dysphagia varied significantly within the literature. To ensure its diagnosis and identification, we recommend the use of a standardized, well-outlined method for dysphagia diagnosis.

Transoral and transnasal odontoidectomy complications: A systematic review and meta-analysis.

OBJECT: The craniovertebral junction (CVJ) is a complex region of the spine with unique anatomical and functional relationships. To alleviate symptoms associated with pathological processes involving the odontoid process, decompression is often required, including odontoidectomy. Accurate knowledge of the complication rates following the transoral and transnasal techniques is essential for both patients and surgeons. METHODS: We conducted MEDLINE, Scopus and Web of Science database searches for studies reporting complications associated with the transoral and transnasal techniques for odontoidectomy. Case series presenting data for less than three patients were excluded. Rates of complication and clinical outcomes were calculated and subsequently analyzed using a fixed-effects model to assess statistical significance. RESULTS: Of 1288 articles retrieved from MEDLINE, Scopus, and Web of Science, twenty-six met inclusion criteria. Transoral and transnasal procedures resulted in the following respective complication rates: arterial injury 1.9% and 0.0%, intraoperative CSF leak 0.3% and 30.0%, postoperative CSF leak 0.8% and 5.2%, 30-day mortality 2.9% and 4.4%, medical complications 13.9% and 28.6%, meningitis 1.0% and 4.0%, pharyngeal wound dehiscence 1.7% (transnasal not reported), pneumonia 10.3% (transnasal not reported), prolonged or re-intubation 5.6% and 6.0%, reoperation 2.5% and 5.1%, sepsis 1.9% and 7.7%, tracheostomy 10.8% and 3.4%, velopharyngeal insufficiency 3.3% and 6.4% and wound infection 3.3% and 1.9%. None of these differences were statistically significant, except for postoperative tracheostomy, which was significantly higher after transoral odontoidectomy 8.4% (95% CI 4.9% -11.9%) compared to transnasal odontoidectomy 0.8% (95% CI -1.0% -2.9%). Neurologic outcome was improved in 90.0% and worse in 0.9% of patients after transoral compared to 94.0% and 0.0% after transnasal odontoidectomy (p=0.30). CONCLUSIONS: This work presents a systematic review of complications reported for transoral or transnasal odontoidectomy across a heterogeneous group of surgeons and patients. Due to inconsistent reporting, statistical significance was only achieved for postoperative tracheostomy, which was significantly higher in the transoral group. This investigation sets the framework for further discussions regarding odontoidectomy approach options and their associated complications during the informed consent process.

Adjacent segment degeneration and disease following cervical arthroplasty: a systematic review and meta-analysis.

BACKGROUND CONTEXT: Cervical arthroplasty is an increasingly popular alternative for the treatment of cervical radiculopathy and myelopathy. This technique preserves motion at the index and adjacent disc levels, avoiding the restraints of fusion and potentially minimizing adjacent segment pathology onset during the postoperative period. PURPOSE: This study aimed to identify all prospective studies reporting adjacent segment pathology rates for cervical arthroplasty. STUDY DESIGN/SETTING: Systematic review and meta-analysis were carried out. PATIENT SAMPLE: Studies reporting adjacent segment degeneration (ASDegeneration) and adjacent segment disease (ASDisease) rates in patients who underwent cervical arthroplasty comprised the patient sample. OUTCOME MEASURES: Outcomes of interest included reported ASDegeneration and ASDisease events after cervical arthroplasty. METHODS: We conducted a MEDLINE, SCOPUS, and Web of Science search for studies reporting ASDegeneration or ASDisease following cervical arthroplasty. A meta-analysis was performed to calculate effect summary values, 95% confidence intervals (CIs), Q values, and I(2) values. Forest plots were constructed for each analysis group. RESULTS: Of the 1,891 retrieved articles, 32 met inclusion criteria. The patient incidence of ASDegeneration and ASDisease was 8.3% (95% CI 3.8%-12.7%) and 0.9% (95% CI 0.1%-1.7%), respectively. The rate of ASDegeneration and ASDisease at individual levels was 10.5% (95% CI 6.1%-14.9%) and 0.2% (95% CI -0.1% to 0.5%), respectively. Studies following patients for 12-24 months reported a 5.1% (95% CI 2.1%-8.1%) incidence of ASDegeneration and 0.2% (95% CI 0.1%-0.2%) incidence of ASDisease. Conversely, studies following patients for greater than 24 months reported a 16.6% (5.8%-27.4%) incidence of ASDegeneration and 2.6% (95% CI 1.0%-4.2%) of ASDisease. This identified a statistically significant increase in ASDisease diagnosis with lengthier follow-up. Additionally, 1- and 2-level procedures resulted in a 7.4% (95% CI 3.3%-11.4%) and15.6% (95 CI-9.2% to 40.4%) incidence of ASDegeneration, respectively. Although there was an 8.2% increase in ASDegeneration following 2-level operations (relative to 1-level), it did not reach statistical significance. We were unable to analyze ASDisease incidence following 2-level arthroplasty (too few cases), but 1-level operations resulted in an ASDisease incidence of 0.8% (95% CI 0.1%-1.5%). CONCLUSIONS: This review represents a comprehensive estimation of the actual incidence of ASDegeneration and ASDisease across a heterogeneous group of surgeons, patients, and arthroplasty techniques. Our investigation should serve as a framework for individual surgeons to understand the impact of various cervical arthroplasty techniques, follow-up duration, and surgical levels on the incidence of ASDegeneration and ASDisease during the postoperative period.

Endoscopic Approaches to the Craniovertebral Junction.

The endoscopic endonasal approach provides a direct surgical trajectory to anteriorly located lesions at the craniovertebral junction. The inferior limit of surgical exposure is predicted by the nasopalatine line, and the lateral limit is demarcated by the lower cranial nerves. Endoscopic endonasal odontoidectomy allows preservation of the soft palate, and patients can restart an oral diet on the first postoperative day. Treating the condition at the craniovertebral junction using this approach requires careful preoperative planning and endoscopic endonasal surgical experience with a 2-surgeon 4-handed approach combining expertise in otolaryngology and neurosurgery.

Pseudoarthrosis rates in anterior cervical discectomy and fusion: a meta-analysis.

BACKGROUND CONTEXT: Anterior cervical discectomy and fusion (ACDF) is a commonly performed procedure for patients presenting with cervical radiculopathy, myelopathy, or deformity. A systematic literature review and meta-analysis of pseudoarthrosis rates associated with ACDF with plate fixation have not been previously performed. PURPOSE: The purpose of this study was to identify all prospective studies reporting pseudoarthrosis rates for ACDF with plate fixation. STUDY DESIGN/SETTING: This study is based on a systematic review and meta-analysis. PATIENT SAMPLE: Studies reporting pseudoarthrosis rates in patients who received one-, two-, or three-level ACDF surgeries were included. OUTCOME MEASURES: Outcomes of interest included reported pseudoarthrosis events after ACDF with plate fixation. METHODS: We conducted a MEDLINE, SCOPUS, Web of Science, and EMBASE search for studies reporting complications for ACDF with plate fixation. We recorded pseudoarthrosis events from all included studies. A meta-analysis was performed to calculate effect summary mean values, 95% confidence intervals (CIs), Q statistics, and I(2) values. Forest plots were constructed for each analysis group. RESULTS: Of the 7,130 retrieved articles, 17 met the inclusion criteria. The overall pseudoarthrosis rate was 2.6% (95% CI: 1.3-3.9). Use of autograft fusion (0.9%, 95% CI: -0.4 to 2.1) resulted in a reduced pseudoarthrosis rate compared with allograft fusion procedures (4.8%, 95% CI: 1.7-7.9). Studies were separated based on the length of follow-up: 12 to 24 and greater than 24 months. These groups reported rates of 3.1% (95% CI: 1.2-5.0) and 2.3% (95% CI: 0.1-4.4), respectively. Studies performing single-level ACDF yielded a rate of 3.7% (95% CI: 1.6-5.7). Additionally, there was a large difference in the rate of pseudoarthrosis in randomized controlled trials (4.8%, 95% CI: 2.6-7.0) versus prospective cohort studies (0.2%, 95% CI: -0.1 to 0.5), indicating that the extent of follow-up criteria affects the rate of pseudoarthrosis. CONCLUSIONS: This review represents a comprehensive estimation of the actual incidence of pseudoarthrosis across a heterogeneous group of surgeons, patients, and ACDF techniques. The definition of pseudoarthrosis varied significantly within the literature. To ensure its diagnosis and prevent sequelae, standardized criteria need to be established. This investigation sets the framework for surgeons to understand the impact of surgical techniques on the rate of pseudoarthrosis.