Effectiveness of a multimodal strategy to reduce external ventricular drain-associated infection: A quasi-experimental study.

BACKGROUND: Infection is a serious complication in neurosurgical patients who undergo external ventricular drain (EVD) insertion. METHODS: We conducted a quasi-experimental study in patients who underwent EVD insertion to evaluate the impact of a multi-modal strategy to reduce the incidence of external ventricular drain associated infections (EVDAIs). The study was divided into 2 periods; (1) the pre-intervention period when techniques for EVD insertion and maintenance were up to the discretion of the neurosurgeons and (2) the post-intervention after implementation of a multi-modal strategy (cefazolin antibiotic prophylaxis, preoperative chlorhexidine showers, application of postoperative chlorhexidine-impregnated dressing, limited manipulation of the EVD, and meticulous EVD management). The primary outcome was the incidence rate of EVDAIs; secondary outcomes included in-hospital mortality rate, the hospital length of stay. RESULTS: In total, 135 patients were included. The incidence rate of EVDAIs was significantly reduced in the post-intervention period (5.6 cases/1,000 EVD-days) compared with the pre-intervention period (18.2 cases/1,000 EVD-days; P=0.026). There were no differences in all secondary outcomes analyzed. This multi-modal strategy was associated with high satisfaction among health care personnel. CONCLUSIONS: Implementation of a multi-modal strategy was associated with a reduction in the incidence of EVDAIs. This was in line with our goal of promoting a new culture of safety despite being in a resource-limited setting.

Comparative Analysis of Three Posterior-Only Surgical Techniques for Isthmic L5-S1 Spondylolisthesis.

OBJECTIVE: To compare adults with isthmic L5-S1 spondylolisthesis who were treated with three different surgical techniques: PS-only, TS, and transforaminal lumbar interbody fusion/posterior lumbar interbody fusion (TLIF/PLIF). METHODS: This is a retrospective analysis of adults with L5-S1 isthmic spondylolisthesis (grade ≥2) who underwent primary all-posterior operations with pedicle screws. Patients were excluded if they had <1 year follow-up, anterior approaches, and trans-sacral fibular grafts. Patient demographics and surgical, radiographic, and clinical data were compared between groups based on the method of anterior column support: none (PS-only), TS, and TLIF/PLIF. RESULTS: Sixty patients met inclusion criteria (male patients 21, female patients 39, average age 47 ± 15 years, PS-only 16; TS 20; TLIF/PLIF 24). TS patients more commonly had high-grade slips and markedly greater slip percentage, lumbosacral kyphosis, and pelvic incidence. The three groups were similar for smoking status, visual analog scores/Oswestry Disability Index scores (VAS/ODI), surgical data, and average follow-up (40.1 ± 31.2 months). All groups had similarly notable improvements in Meyerding grade and lumbosacral angle. Slip reduction percentage was similar between groups. While there was a markedly higher overall complication rate for PS-only constructs, all groups had similarly notable improvements in ODI and VAS back scores. CONCLUSIONS: All-posterior techniques for L5-S1 isthmic spondylolisthesis resulted in excellent improvement in preoperative symptoms and HRQoL scores and similar radiographic alignment. Trans-sacral screws were more commonly used for high-grade slips. The use of anterior column support resulted in fewer overall complications than posterior-only instrumentation.

Bleeding pediatric AVM with negative pre-operative angiography: the first case report.

INTRODUCTION: Pediatric arteriovenous malformation (pAVM) is one of the most common vascular entities in non-traumatic intracerebral hemorrhage (ICH) in children. To diagnose arteriovenous malformation (AVM), digital subtraction angiography (DSA) is the gold standard investigation because it can provide sufficient dynamic information about the AVM. In extremely rare occasions, angiography is unable to detect an AVM because the AVM is spontaneously occluded. All reported cases found by authors in the literature had already been diagnosed with AVM by angiography or other vascular studies before the AVM occlusion. CASE PRESENTATION: We present a case of a 4-year-old girl who presented with left occipital ICH with atypical calcification. Based on history and investigation, pAVM was the most likely diagnosis. However, preoperative angiography was negative for pAVM and for shunting. Bleeding tumor was then suspected instead. After resection, pathological diagnosis confirmed pAVM. CONCLUSION: Our case demonstrates that DSA, despite being considered the gold standard, cannot always diagnose pAVM. The mechanism of spontaneous AVM occlusion remains unknown.

Clinical Outcome in Cerebral Vasospasm Patients Treated with and without Intra-Arterial Nimodipine Infusion.

BACKGROUND: Cerebral vasospasm (CV) after aneurysmal subarachnoid hemorrhage (aSAH) is still a problem. Hypertension, hypervolemia, and hemodilution (triple-H) therapy and oral nimodipine only a modest effect on patients. Intra-arterial treatment, including nimodipine, has been studied, but only as retrospective and single-arm prospective studies. We compared the outcomes between CV patients who received an adjunct intra-arterial nimodipine infusion (IANI) and those who received the standard medical treatment alone in a prospective randomized controlled trial. METHODS: In this study, patients between the age of 18 and 80 years, who underwent angiography within 14 days after aneurysm obliteration, were recruited and randomized to receive adjunct IANI or not, if they were identified with angiographic vasospasm. All the angiographic and neurologic data were recorded and analyzed during their admission, at the discharge date, and during the 6-month follow-up period. RESULTS: From June 2016 to December 2018, we enrolled 68 patients who were randomized into two groups, 36 in the intervention group and 32 in the control group. The patients' characteristics, aneurysm data, and modalities of treatment were similar between the two groups. Within 24 hours after IANI, Glasgow Coma Scale (GCS) score and motor strength revealed a significant improvement of 33.33 and 38.89%, respectively, in the intervention group versus 12.5 and 9.38%, respectively, in the control group. At discharge, the intervention group still had significant motor improvement (58.33 vs. 21.88%; p = 0.002). CONCLUSION: IANI could be considered an effective treatment for CV without significant complications. This is the first RCT demonstrating statistically significant motor strength improvement within 24 hours and at discharge.

Relationship of the character of rod fractures on outcomes following long thoracolumbar fusion to the sacrum for adult spinal deformity.

BACKGROUND CONTEXT: Rod fractures (RF) and pseudarthrosis are a frequent occurrence after adult spinal deformity (ASD) surgery and may be problematic. However, not all RF signal nonunion and cause clinical concern. An improved understanding of the sequelae after RF occurrence is valuable for further management. PURPOSE: To characterize the radiographic findings, clinical outcomes, and revision rates between patients who developed unilateral RF (URF) and bilateral RF (BRF) following thoracolumbar posterior spinal fusions to the sacrum for ASD and identify patient characteristics associated with clinically significant RF that lead to subsequent revision surgeries and detection of nonunion. STUDY DESIGN/SETTING: A retrospective single-center cohort study was performed. PATIENT SAMPLE: Patients undergoing long-construct posterior spinal fusions to the sacrum performed at a single institution from 2004 to 2014 and developed a RF postoperatively were included. OUTCOME MEASURES: Patient demographics, radiographic parameters, surgical data, Oswestry Disability Index (ODI), Scoliosis Research Society-22 (SRS-22), and revision rates. METHODS: Inclusion criteria were ASD patients age >18 who had ≥5 vertebrae instrumented and fused posteriorly to the sacrum and development of RF. Data were compared among patients: who developed unilateral-nondisplaced RF (UNRF), unilateral-displaced RF (UDRF), bilateral-nondisplaced RF and bilateral-displaced RF (BDRF) at baseline and follow-up. ODI and SRS-22 scores were assessed at baseline, 1 year postoperatively, the time of RF occurrence, and latest follow-up. RESULTS: Of 526 patients who met inclusion criteria, 96 (18.3%) developed RF (URF n=70 [73%]; BRF n=26 [27%]). Preoperative demographics and surgical parameters were similar between the groups. BRF patients had substantial loss of sagittal correction from 1-year postoperatively to the time of RF, including loss of sagittal vertical axis (4.8 cm vs. 2.2 cm; p<.001), loss of lumbar lordosis (14.8° vs. 4.9°; p=.010) and loss of pelvic incidence minus lumbar lordosis mismatch (PI-LL) mismatch (5.0° vs. 14.6°; p=.020) compared with those of URF patients. The BDRF group had more loss of ODI scores (13.4 vs. 4.2; p=.013), SRS pain score (0.8 vs. 0.2; p=.024), SRS function score (0.3 vs. 0; p=.020) and SRS subscore (0.4 vs. 0.1; p=.148) from 1-year postoperatively to the time of RF and underwent revision surgery more often than the UNRF group (87.5% vs. 4.8%; p<.0001). At final follow-up (median 2.8 years, range 1-10.3 years after RF detection), URF patients who did not undergo revision surgeries still maintained equivalent sagittal alignment correction (sagittal vertical axis, LL and PI-LL; all p>.05) and had similar, not worse, mean ODI scores, SRS Subscore and SRS pain compared with the time at RF and 1-year follow-up. CONCLUSIONS: RF are not uncommon after ASD operations. Asymptomatic, UNRF in our study did not jeopardize clinical outcomes or radiographic alignment parameters and, in most cases, did not represent a nonunion, as opposed to BRF. BRF patients exhibited loss of sagittal correction, loss of clinical outcome improvements, as measured by ODI, SRS pain and SRS Subscore at the time of RF, and were revised more often than URF patients.

Rod fracture in adult spinal deformity surgery fused to the sacrum: prevalence, risk factors, and impact on health-related quality of life in 526 patients.

BACKGROUND CONTEXT: Risk factors associated with rod fracture (RF) following adult spinal deformity (ASD) surgery fused to the sacrum remain debatable, and the impact of RF on patient-reported outcomes (PROs) after ASD surgery has not been investigated. PURPOSE: We aimed to evaluate the prevalence of and risk factors for RF and determine PROs changes associated with RF after ASD surgery fused to the sacrum. STUDY DESIGN/SETTING: A retrospective single-center cohort study was performed. PATIENT SAMPLE: Patients undergoing long-construct posterior spinal fusions to the sacrum performed at a single institution by two senior spine surgeons from 2004 to 2014 were included. OUTCOME MEASURES: Patient demographics, radiographic parameters, and surgical factors were assessed for risk factors associated with RF. Oswestry Disability Index (ODI) and Scoliosis Research Society-30 (SRS-30) scores were assessed at baseline, 1 year postoperatively, and latest follow-up. METHODS: Inclusion criteria were ASD patients age >18 who had ≥5 vertebrae instrumented and fused posteriorly to the sacrum and either development of RF or no development of RF with minimum 2-year follow-up. Patient characteristics, operative data, radiographic parameters, and PROs were analyzed at baseline and follow-up. Separate Cox proportional hazard models based on rod material and diameter were used to determine factors associated with RF. RESULTS: Five hundred twenty-six patients (80%) were available for analysis. RF occurred in 97 (18.4%) patients (unilateral RF n=61 [63%]; bilateral RF n=36 [37%]). Risk factors for fracture of 5.5 mm cobalt chromium (CC) instrumentation (CC 5.5 model) included preoperative sagittal vertical axis (hazard ratio [HR] 1.07, 95% confidence interval [95% CI] 1.02-1.14 per 1-cm increase), preoperative thoracolumbar kyphosis (HR 1.02, 95% CI 1.01-1.04 per 1-degree increase), and number of levels fused for patients who received rhBMP-2 <12 mg per level fused (HR 1.48, 95% CI 1.20-1.82 per 1-level increase). Implants that were 5.5-mm CC constructs were at a higher risk for fracture than 6.35-mm stainless steel (SS) constructs (HR 8.49, 95% CI 4.26-16.89). The RF group had less overall improvement in SRS Satisfaction (0.93 vs. 1.32; p=.007) and SRS Self-image domain scores (0.72 vs. 1.02; p=.01). The bilateral RF group had less overall improvement in ODI (8.1 vs. 15.8; p=.02), SRS Subscore (0.51 vs. 0.85; p=.03), and SRS Pain domain scores (0.48 vs. 0.95; p=.02) compared with the non-RF group at final follow-up. CONCLUSIONS: The prevalence of all RF after index procedures was 18.4%, 37% for bilateral RF. Greater preoperative sagittal vertical axis, greater preoperative thoracolumbar kyphosis, increased number of vertebrae fused for patients who received rhBMP-2 <12 mg per level fused, and CC 5.5-mm rod were associated with RF. Less improvement in patient satisfaction and self-image was noted in the RF group. Furthermore, bilateral RF significantly affected PROs as measured by ODI and SRS Subscore at final follow-up.

Freehand technique for C2 pedicle and pars screw placement: is it safe?

BACKGROUND CONTEXT: During placement of C2 pedicle and pars screws, intraoperative fluoroscopy is used so that neurovascular complications can be avoided, and screws can be placed in the proper position. However, this method is time consuming and increases radiation exposure. Furthermore, it does not guarantee a completely safe and accurate screw placement. PURPOSE: The objective of this study was to evaluate the safety of the C2 pedicle and pars screw placement without fluoroscopic or other guidance methods. STUDY DESIGN: This is a retrospective comparative study. PATIENT SAMPLE: One hundred ninety-eight patients who underwent placement of C2 pedicle or pars screws without any intraoperative radiographic guidance were included in the study. OUTCOME MEASURES: Medical records and postoperative computed tomography (CT) scans were evaluated. MATERIALS AND METHODS: Clinical data were reviewed for intraoperative and postoperative complications. The accuracy of screw placement was evaluated with postop CT scans using a previously published cortical-breach grading system (described by the location and the percentage of the screw diameter over the cortical edge [0=none, Grade I≤25% of the screw diameter, Grade II=26%-50%, Grade III=51%-75%, and Grade IV=76%-100%]). RESULTS: A total of 148 pedicle screws and 219 pars screws were inserted by two experienced surgeons. There were no cases of cerebral spinal fluid leakage and no neurovascular complications during screw placement. Postoperative CT scans were available for 76 patients, which included 52 pedicle screws and 87 pars screws. For cases with C2 pedicle screws, there were 12 breaches (23%); these included 10 screws with a Grade I breach (19%), 1 screw with a Grade II breach (2%), and 1 screw with a Grade IV breach (2%). Lateral breaches occurred in seven screws (13%), inferior breaches occurred in three screws (6%), and superior breaches occurred in two screws (4%). For cases with C2 pars screws, there were 10 breaches (11%); these included 6 screws with a Grade I breach (7%), 2 screws with a Grade II breach (2%), and 2 screws with a Grade IV breach (2%). Medial breaches were found in four (5%), lateral breaches in two (2%), inferior breaches in two (2%), and superior breaches in two (2%). Two of the cases with superior breaches (one for pedicle and one for pars) experienced occipital neuralgia months after surgery. There was no statistically significant difference in the incidence of overall and high-grade breaches between the groups (p=.07 and 1.0, respectively). CONCLUSIONS: Although even in experienced hands up to 23% of C2 pedicle screws and 11% of C2 pars screws placed using a freehand technique without guidance may be malpositioned, a clear majority of malpositioned screws demonstrated a low-grade breach, and only 2 of 198 patients (1%) experienced complications related to screw placement.