Incidence of medical and surgical complications after elective lumbar spine surgery.

INTRODUCTION: The demographic change results in an ever increasing number of older patients with pre-existing medical conditions who require spinal surgery, and recovery is often severely impaired by procedure-related complications. The purpose of this retrospective study was to determine patients at risk of medical and surgical complications. METHOD: Using our database, we reviewed 1244 patients with lumbar degenerative disk disease, spinal stenosis, and instability, who had undergone surgery at our department between 2009 and 2014. We screened for medical complications (thromboembolic and cardiac events, pneumonia, and sepsis) and surgical complications (hemorrhage, wound infection, and CSF fistula). Furthermore, a matched 1:1 control group consisted of 103 patients without any surgical and medical complications in the randomly selected period of May 2009 to October 2014. RESULTS: 93 patients (46 women, 47 men), mean age 70 years (range 33-86 years, median 67.4 years), with complications were identified (overall morbidity 7.6 %): 22.6 % (n = 26) had medical complications and 77.4 % (n = 89) surgical complications. In 93 patients (46 females, 47 males), mean age 70 years (range 33-86 years, median 67.4 years), a total of 115 complications were noted (overall morbidity of the 93 patients 7.6 %): 22.6 % (n = 26) medical complications and 77.4 % (n = 89) surgical complications. Age and pre-existing conditions were independently associated with medical complications (p < 0.001). Infections (pneumonia and sepsis) were correlated with multi-segmental interventions (p = 0.009), duration of surgery (p = 0.009), and pre-existing conditions (p = 0.014). Surgical complications were significantly correlated with age (p = 0.016) and duration of surgery (p = 0.014) and occurred significantly more often in patients with instability (p < 0.001). Wound healing disorders were associated with coagulopathy (p = 0.013) and transfusion (p < 0.001). CONCLUSIONS: We identified predictors that help identify patients at risk of medical and surgical complications. These correlations should be taken into account when advising older patients with pre-existing conditions on lumbar spine surgery.

Urgent discectomy: Clinical features and neurological outcome.

BACKGROUND: To evaluate the clinical features and outcome of patients with progressive neurological deficits due to disc herniation who were treated surgically within 24 h. METHODS: We conducted a retrospective analysis of consecutive patients who were admitted between 2004 and 2013 via the Emergency Department. Records were screened for presenting symptoms, neurological status at admission, discharge, and 6-week follow-up. RESULTS: About 72 of 526 patients underwent surgery within 24 h. Magnetic resonance imaging showed lumbar disc herniation in 72 patients. The most common presenting symptoms included radiculopathy (n = 69), the Lasègue sign (n = 60), sensory deficits (n = 57), or motor deficits (n = 47). In addition, 11 patients experienced perineal numbness and 12 had bowel and bladder dysfunction. At discharge, motor and sensory deficits and bowel and bladder dysfunction had improved significantly (P < 0.001, P = 0.029, and P = 0.015, respectively). CONCLUSION: Motor deficits, sensory deficits, and cauda equina dysfunction were significantly improved immediately after urgent surgery. After 6 weeks, motor and sensory deficits were also significantly improved compared to the neurological status at discharge. Thus, we advocate immediate surgery of disc herniation in patients with acute onset of motor deficits, perineal numbness, or bladder or bowel dysfunction indicative of cauda equina syndrome.

A single neurosurgical center's experience of the resolution of cervical radiculopathy after dorsal foraminotomy and ventral discectomy.

Monosegmental cervical disc herniation can be removed either by dorsal foraminotomy and sequesterectomy (Frykholm's method) or by a ventral approach with extensive removal of the affected disc with subsequent segmental fusion (modified Cloward's method). The choice of method largely depends on the surgeon's individual preference and experience. We evaluated the neurological outcomes of both surgical methods in a retrospective series of 100 consecutive patients (50 male, 50 female; mean age=47.7 years) who underwent surgery within a 3-year period. Fifty-one patients (30 male, 21 female; mean age=50.1 years) underwent a dorsal foraminotomy and 49 patients (20 male, 29 female; mean age=45.3 years) underwent surgery by the ventral approach with consecutive segmental fusion. We identified demographic data and analysed the postoperative neurological performance (motor and sensory activity) and the resolution of the radiating and local pain during the in-hospital stay. Patients in the Cloward Group recovered significantly better from cervicobrachialgia (p=0.02), neck pain (p=0.01) and sensory deficits (p=0.003). Furthermore, the Cloward Group showed a trend towards better outcomes for paresis. Complete removal of the affected cervical disc via a ventral approach and segmental fusion results in a superior neurological performance in the short-term compared to a dorsal foraminotomy and nerve root decompression by sequestrectomy. However, assessment of the long-term outcome is required and further studies are required to confirm our results.

Effects of temporary clipping during aneurysm surgery.

OBJECTIVE: Intraoperative aneurysm rupture is associated with a high morbidity and mortality. Temporary vessel occlusion is an integral part of aneurysm clipping to avoid intraoperative hemorrhage. The information concerning the role of temporary occlusion regarding the development of cerebral vasospasm is sparse. The aim of this study was to provide more information in this field. METHODS: We operated on 292 patients suffering from cerebral aneurysms. The data were reviewed from a prospectively collected databank, which includes information about the severity of subarachnoid hemorrhage, as well as transcranial Doppler data and surgical data such as temporary occlusion. RESULTS: In 50% of our patients, temporary occlusion was performed during surgery. Twenty-nine percent showed an ischemic lesion in the CCT post-operatively, and in 58% of these patients, temporary occlusion was performed (versus 47% without temporary occlusion, p = 0.09). The mean occlusion time was longer in patients with radiologic signs of infarction. Furthermore, patients having unfavorable outcome showed a longer temporary occlusion time. Thirty-four percent of patients who underwent temporary vessel occlusion developed vasospasm postoperatively (versus 20% without temporary occlusion, p < 0.006). Temporary occlusion time correlated to the development of vasospasm as defined by transcranial Doppler flow velocity. Forty-eight percent of the patients treated using temporary occlusion suffered from middle cerebral artery aneurysm (versus 22% without temporary occlusion, p < 0.0001). An increased blood flow velocity was mostly seen in this region (p < 0.003). CONCLUSION: According to our results, it seems to be the possible that temporary vessel occlusion is an additional factor in aggravating vasospasm after aneurysmatic subarachnoid hemorrhage.

Comparison of craniotomy and craniectomy in patients with acute subdural haematoma.

Despite the increasing acceptance of craniectomy in patients with traumatic brain injury, the value of early decompressive craniectomy in patients with acute subdural haematoma is still under debate. In this retrospective study, we reviewed 180 patients with traumatic acute subdural haematoma, 111 of whom were treated with haematoma evacuation via craniotomy and 69 of whom were treated with early decompressive craniectomy. Due to the higher incidence of signs of herniation for patients in the craniectomy group, the mortality rate in this group was higher than that in the craniotomy group (53% vs. 32.3%). However, overall there was no significant difference in outcome between the two groups. Age and clinical signs of herniation were significantly associated with an unfavourable outcome, regardless of the type of surgery. Decompressive craniectomy did not seem to have a therapeutic advantage over craniotomy in traumatic acute subdural haematoma.

Ventricular tapping seems to have no influence on S-100B and NSE serum concentrations.

Serum markers, e.show $132#g., the protein S-100B and neuron-specific enolase (NSE), are recognized to give additional information about the extension and prognosis of brain damage. In some of these patients it is necessary to insert a ventricular drain. Whether the cannulation of the ventricle falsifies the serum concentrations of these markers is unknown. The aim of this study was to get further information in this field. In this prospective study we included 19 patients. All patients underwent ventricular tapping and insertion of a ventricular drain. Serum samples for estimation of S-100B and NSE were collected before, directly after and 6 h after insertion. In addition we investigated the cerebrospinal fluid (CSF) directly after and 6 h after insertion. All patients but one showed no significantly increased S-100B or NSE serum concentration after insertion of the drainage. The concentrations in the CSF were significantly higher. One patient showed increasing concentrations of the markers in all samples reflecting ongoing brain damage. The serum values of S-100B and NSE seem not to be falsified by insertion of a ventricular drain. Therefore the prognostic value of these serum markers seems to be preserved despite the surgical manipulation.