An International, Multicenter Feasibility Study on Active and Continuous Irrigation With Cerebrospinal Fluid Exchange for Improving Outcomes in Cerebral Ventriculitis.

BACKGROUND AND OBJECTIVES: Cerebral ventriculitis remains a challenging neurosurgical condition because of poor outcomes including mortality rates of nearly 80% and a prolonged course of treatment in survivors. Despite current conventional management, outcomes in some cases remain unsatisfactory, with no definitive therapeutic guidelines. This feasibility study aims to explore the use of a novel active, continuous irrigation and drainage system (IRRAflow [IRRAS AB]) combined with intraventricular drug delivery for patients with cerebral ventriculitis. METHODS: We conducted a multicenter, international, retrospective study of patients with ventriculitis who were treated with use of the IRRAflow system. Data collected included patient demographics, comorbidities, admission Glasgow Coma Scale score, baseline modified Rankin Scale (mRS) score, and imaging findings. Catheter occlusions, infections, and shunt placement were recorded for outcome assessment, along with discharge mRS scores and in-hospital deaths. RESULTS: Four centers contributed data for a total of 21 patients who had IRRAflow placement for treatment of ventriculitis. Thirteen (61.9%) were men (mean age = 49.8 ± 14.87 years). The median baseline mRS score was 1. The median Glasgow Coma Scale score at admission was 13. The etiology of ventriculitis was iatrogenic in 12 (57.1%) patients and secondary to an abscess in 9 (42.9%). No cases reported hemorrhage or failure of IRRAflow placement. Antibiotics were administered through the IRRAflow system in 13 (61.9%) cases in addition to systemic dosing. Sixteen (76.2%) patients had significant clinical improvement and resolution of ventriculitis. Seven (33.3%) patients required shunt placement after resolution because of persistent hydrocephalus. There were 6 (28.6%) in-hospital deaths. CONCLUSION: The use of active irrigation with drainage for continuous delivery of intraventricular irrigation fluid with antibiotics led to dramatically low mortality. In our case series, it led to a marked improvement in neurological status, imaging findings, and cerebrospinal fluid profiles, making it a technically feasible and safe treatment for ventriculitis.

Frailty predicts readmission, reoperation, and infection after posterior spinal fusion: An institutional series of 3965 patients.

OBJECTIVE: Frailty is a measure of physiologic vulnerability conceptualized as the accumulation of deficits with aging, and may be useful for predicting risk of adverse events following posterior spinal fusion. Our objective was to investigate the utility of the Canadian Study on Health and Aging (CHSA) Modified Frailty Index (mFI) in patients undergoing posterior spinal fusion (PSF) as a predictor of several surgical quality metrics including readmission, reoperation, and surgical site infection. METHODS: We examined 3965 consecutive PSF patients treated at our institution between 2000 and 2015, and collected demographic, clinical, and frailty and comorbid disease burden measures using the mFI and Charlson Comorbidity Index (CCI). We examined trends and changes in these clinical and demographic characteristics over the course of the study period. We performed multivariable regression to identify independent predictors of readmission, reoperation, and surgical site infection. RESULTS: Over the course of the study period, the mean patient age increased linearly year-over-year (ß=0.60 [0.48, 0.72], p < 0.0001, R=0.94), while the SSI rate decreased linearly (ß=-0.14 [-0.27, -0.02], p = 0.0249, R=0.56), and frailty scores did not change significantly (p = 0.8124, R=0.065). Among all patients undergoing PSF, postoperative wound infection was independently associated with number of levels fused (OR=1.104 p < 0.001), frailty as measured by mFI (OR=1.150 p = 0.006), and BMI (OR=1.041 p = 0.008). Frailty was also independently associated with postoperative ICU admission (OR=1.1080 p = 0.005), 30-day readmission (OR=1.181 p < 0.001), and 30-day reoperation (OR=1.128 p < 0.001). Among all patients, rate of postoperative wound infection increased with increasing frailty (p = 0.0002) and increasing comorbid disease burden (chi-square p = 0.0012). CONCLUSION: The mFI predicts adverse events among patients undergoing PSF, including readmission, reoperation, and surgical site infection. When controlling for frailty, age was not an independent predictor of adverse events.

Using smartphone-based accelerometers to gauge postoperative outcomes in patients with NPH: Implications for ambulatory monitoring.

BACKGROUND: The surgical treatment of normal pressure hydrocephalus (NPH) with shunting remains controversial due to the difficulty in distinguishing such pathology from other neurological conditions that can present similarly. Thus, patients with suspected NPH should be carefully selected for surgical intervention. Historically, clinical improvement has been measured by the use of functional grades, alleviation of symptoms, and/or patient/family-member reported surveys. Such outcome analysis can be subjective, and there is difficulty in quantifying cognition. Thus, a push for a more quantifiable and objective investigation is warranted, especially for patients with idiopathic NPH (INPH), for which the final diagnosis is confirmed with postoperative clinical improvement. We aimed to use Apple Health (Apple Inc., Cupertino, CA) data to approximate physical activity levels before and after shunt placement for NPH as an objective outcome measurement. The patients were contacted and verbally consented to export Apple Health activity data. The patient's physical activity data were then analyzed. A chart review from the patient's EMR was performed to understand and better correlate recovery. CASE DESCRIPTION: Our first patient had short-term improvements in activity levels when compared to his preoperative activity. The patient's activity level subsequently decreased at 6 months and onward. This decline was simultaneous to new-onset lumbar pain. Our second patient experienced sustained improvements in activity levels for 12 months after his operation. His mobility data were in congruence with his subjectively reported improvement in clinical symptoms. He subsequently experienced a late-decline that began at 48-months. His late deterioration was likely confounded by exogenous factors such as further neurodegenerative diseases coupled with old age. CONCLUSION: The use of objective activity data offers a number of key benefits in the analysis of shunted patients with NPH/INPH. In this distinctive patient population, detailed functional outcome analysis is imperative because the long-term prognosis can be affected by comorbid factors or life expectancy. The benefits from using smartphone-based accelerometers for objective outcome metrics are abundant and such an application can serve as a clinical aid to better optimize surgical and recovery care.

Intracranial arachnoid cysts in an infant: A technical note on the innovative use of navigation and flexible endoscopy for cyst fenestration.

BACKGROUND: Intracranial arachnoid cysts (ACs) are a cerebral spinal fluid (CSF) collection within the meninges. They typically arise during embryologic development. Some are stable overtime with little consequence, but large or growing cysts may require surgical intervention. The optimal surgical technique is debated and may be more technically challenging in the infant age group. CASE DESCRIPTION: Our unique case report details a 10-month-old (6 months corrected age) infant who presented with a drastic increase in head circumference and was found to have midline shift and three cysts - one large and two smaller ones. He was treated with an innovative surgical approach combining stereotactic introduction of a catheter to facilitate subsequent flexible endoscopy allowing three separate cysts to be treated through one small surgical incision with no complications and a stable examination on 2-year follow-up. CONCLUSION: Symptomatic ACs in the infant population that require treatment can be addressed with open surgery to fenestrate the cyst, endoscopic cyst fenestration, or cystoperitoneal shunting. Typically, surgeons must choose between a rigid endoscope which allows stereotactic navigation or a flexible endoscope which allows multiple trajectories but precludes navigation. Our case demonstrates that combining stereotactic ventricular placement before flexible endoscopy provides the benefit of both approaches and allows for successful endoscopic treatment in a young patient with durable results.

Heads Up Play: Acute Assessment and Management of Basketball-Related Craniofacial Injuries by On-Court Personnel.

INTRODUCTION: With a following of over 825 million people, basketball currently ranks amongst the world's most popular sports. Despite a number of concussion awareness and player safety protocols that have been implemented at the professional level of organized play, a standardized, layperson-friendly algorithm for the acute management of basketball-related craniofacial injuries does not appear to presently exist. METHODS: This 10-year retrospective cohort study was conducted using the National Electronic Injury Surveillance System database to examine basketball-related craniofacial injuries from 2010 to 2019. Within the National Electronic Injury Surveillance System dataset, factors including patient age, gender, diagnosis, injury type, and injury location were included in our analysis. RESULTS: Overall, 22,529 basketball-related craniofacial injuries occurred between 2010 and 2019 in players ages 5 to 49 years old. Adolescent (12-18-year-old) and young adult (19-34-year-old) age groups had the highest incidence of craniofacial injuries. The adolescent cohort experienced a significantly greater proportion of concussions and lower proportion of both facial lacerations and fractures compared with the within group null hypothesis of equal proportions (P < 0.05). The young adult cohort experienced a significantly greater proportion of facial lacerations and fractures and lower proportion of concussions, contusions/abrasions, hematomas, and internal injuries compared to this cohort's null hypothesis (P < 0.05). Males experienced a significantly greater proportion of fractures, lacerations, and dental injuries and lower proportion of concussions, contusions/abrasions, and internal injuries compared to the hypothesized equality of proportions (P < 0.05). Females experienced a significantly greater proportion of concussions, contusions/abrasions, and internal injuries and lower proportion of fractures, lacerations, and dental injuries compared to the hypothesized equality of proportions (P < 0.05). CONCLUSIONS: Although several steps have already been taken at the professional level to try to promote player safety, particularly with concussion protocols and prevention of lower extremity injuries, there remains a paucity of resources to guide management of other types of acute craniofacial injury. The role of layperson-friendly educational interventions remains intriguing as a potential means of improving outcomes regardless of socioeconomic status or health literacy. Additional studies still need to be completed to determine efficacy and best future direction.

Using Smartphone-Based Accelerometer Data to Objectively Assess Outcomes in Spine Surgery.

BACKGROUND: In order to deliver optimal patient care, spine surgeons must integrate technological changes to arrive at novel measures of functional outcomes. Historically, subjective patient-reported outcome (PRO) surveys have been used to determine the relative benefit of surgical treatments. Using smartphone-based accelerometers, surgeons now have the ability to arrive at objective outcome metrics. OBJECTIVE: To use Apple Health (Apple Inc, Cupertino, California) data to approximate physical activity levels before and after spinal fusion as an objective outcome measurement. METHODS: Personal activity data were acquired retrospectively from the cellphones of consenting patients. These data were used to measure changes in activity level (daily steps, flights climbed, and distance traveled) before and after patients underwent spine surgery at a single institution by a single surgeon. After data collection, we investigated the demographic information and daily physical activity pre- and postoperatively of participating patients. RESULTS: Twenty-three patients were included in the study. On average, patients first exceeded their daily 1-yr average distance walked, flights climbed, and steps taken at 10.3 ± 14, 7.6 ± 21.1, and 8 ± 9.9 wk, respectively. Mean flights climbed, distance traveled, and steps taken decreased significantly from 6 mo prior to surgery to 2 wk postoperatively. Distance traveled and steps taken significantly increased from 6 mo prior to surgery to 7 to 12 mo postoperatively. CONCLUSION: We demonstrated a valuable supplement to traditional PROs by using smartphone-based activity data. This methodology yields a rich data set that has the potential to augment our understanding of patient recovery.

Large prevertebral hematoma and carotid pseudoaneurysm following percutaneous anterior cervical discectomy: illustrative case.

BACKGROUND: The percutaneous, endoscope-assisted anterior cervical discectomy is a relatively new procedure, and because of its novelty, complications are minimal and pertinent literature is scarce. This approach relies on a sufficient anatomical understanding of the vital neurovascular structures in the operating workspace. Although complications are rare, they can be significant. OBSERVATIONS: The patient presented with difficulty breathing following an anterior percutaneous cervical discectomy performed at an outpatient surgical center. Imaging revealed a prevertebral hematoma and multiple carotid pseudoaneurysms. Given the large prevertebral hematoma and concern for imminent airway collapse, the authors proceeded with emergent intubation and surgical evacuation of the clot. LESSONS: The authors propose managing complications in a fashion similar to those for comparable injuries after classic anterior approaches. Definitive management of our patient's carotid injury would require stenting and, therefore, dual antiplatelet agents. Thus, the authors proceeded with the hematoma evacuation first. Additionally, careful dissection was needed to decrease further carotid damage. Thus, the authors made a more rostral incision to maintain the given stability of the carotid insult before the angiographic intervention to follow. It is the authors' hope that the technical pearls from this two-staged open hematoma evacuation and endovascular stenting may guide future presurgical and intraoperative planning and management of complications, should they arise.

Safe at the Plate: Acute Assessment and Management of Baseball-Related Craniofacial Injuries by On-Field Personnel.

INTRODUCTION: Long regarded as "America's Past Time", over 8.6 million children partake in organized and recreational baseball. Although improved equipment has reduced contemporary injury rates, nearly half of pediatric baseball injuries requiring hospitalization are due to craniofacial trauma. Sideline personnel at the youth levels, often without advanced medical training, frequently act as first-responders in instances of acute craniofacial injury. METHODS: An IRB-approved survey was distributed nationally to target field personnel working at youth, high school, collegiate, and professional baseball levels. Survey items included: comfort in assessing subtypes of acute craniofacial trauma (loss of consciousness (LOC), skull injury, orbital injury, nasal injury, and dental injury) via Likert scale, years of medical training, presence of an emergency action plan (EAP), and access to higher level care from emergency medical services (EMS) or a nearby hospital. RESULTS: When comparing the amateur and professional cohorts, the respondents from professional teams were significantly more confident in assessing LOC (P = 0.001), skull injury (P < 0.001), orbital injury (P < 0.001), nasal injury (P < 0.001), and dental injury (P < 0.001). The professional teams had significantly more years of first aid training (P < 0.0001) and were significantly more likely to have an EAP (P < 0.0001). Professional teams also had a significantly higher average of reported craniofacial incidents (P = 0.0279). CONCLUSION: The authors identified a significant disparity in comfort level between amateur and professional baseball field personnel for identifying and managing acute craniofacial trauma. Based on these findings, the authors were able to develop a rudimentary tool for on-field personnel to effectively assess and manage craniofacial injuries.

Patient Participation With a Mobile Phone Application for Objective Activity Assessment Before and After Spinal Fusion.

Background  Evolution within spine surgery is driven by a surgeon's desire for expertise and significant improvement in their patients' quality of life. As surgeons move away from using subjective patient-reported outcome (PRO) surveys, there must be an alternative objective metric in its place. Modern iPhone (Apple Inc., Cupertino, CA) technology can be used to capture daily activity in a simple, non-user biased manner. These health data can be used to analyze objective functional status in conjunction with PRO surveys to measure surgical outcomes. Methods  Patients who underwent an awake transforaminal lumbar interbody fusion (TLIF) between 2014 and 2018 at our institution were identified. Patients were consented and instructed to download the application "QS Access" (Quantified Self Labs, San Francisco, CA). Following data collection, we analyzed the demographic information of patients who were reached to gauge participation and feasibility of data exportation. Results A total of 177 patients who underwent an awake TLIF at our institution were contacted. Of those who answered, 41 (44.6%) agreed to participate and 51 (55.4%) declined to participate. When comparing those who either participated or declined, there were no significant differences in age (p=0.145), sex (p=0.589), or ethnicity (p=0.686). Conclusion  Our pilot study examined the patient participation in the novel usage of Apple "Health" data, queried from "QS Access" (Quantified Self Labs), to objectively measure relative patient functional status surrounding spinal fusion. We demonstrated that a smartphone-based application was mostly well received by our patient cohort and has the potential to be used as an objective operative metric moving forward.

Rathke's cleft cyst with xanthogranulomatous change: A case report and review of the literature.

BACKGROUND: Rathke's cleft cysts (RCCs) are benign, typically asymptomatic sellar lesions found incidentally in adults, with a dramatically lower incidence in pediatric patients (<18 years). We present a case of RCC with xanthogranulomatous change (XGC) - an even less common subtype of RCC - treated by endoscopic endonasal surgical resection. This is the second reported instance of an RCC with XGC occurring in a pediatric patient. CASE DESCRIPTION: The patient is a 17-year-old male with delayed puberty who presented with bitemporal hemianopsia and was found to have a 2.6 cm lesion, initially thought to be a craniopharyngioma. He subsequently underwent uncomplicated transsphenoidal endoscopic endonasal resection. Histology confirmed the diagnosis of RCC and demonstrated marked degenerative XGCs with squamous metaplasia. The patient tolerated the procedure well with improvement in visual symptoms. CONCLUSION: RCC with XGC is a very rare pathology, particularly in the pediatric population. These lesions, while benign, can manifest clinically with significant symptoms. While treatment paradigms are not fully established with a small cohort of cases, endoscopic endonasal approaches have made surgical resection of these lesions a safe and effective treatment strategy, even in the pediatric population.

Transsphenoidal Approach for Pituitary Adenomas in Elderly Patients.

INTRODUCTION: With a rapidly expanding elderly population in the United States, the incidence of pituitary adenomas in elderly will continue to rise. In this study, we aim to evaluate the safety and efficacy of transsphenoidal endoscopic endonasal resection for pituitary adenomas in the elderly population. METHODS: A retrospective review of 131 consecutive patients who underwent transsphenoidal endoscopic endonasal resection for pituitary adenomas at the University of Miami Hospital between 2012 and 2016 was performed. Preoperative, intraoperative, and surgical outcomes were analyzed in elderly (>70 years) versus nonelderly (<70 years) patients. RESULTS: Of the 131 patients, 23 of them were >70 years (18%), of which 14 were septuagenarians and 9 were octogenarians. Elderly patients were more likely to present with vision loss (80.8% vs. 56.6%; P = 0.013) and larger tumors on imaging (2.7 ± 1.0 cm vs. 2.4 ± 1.3 cm; P = 0.042). Overall surgical and endocrinologic outcomes between the 2 groups were similar. However, patients <70 years old were more likely to have a gross total resection (86.7% vs. 65.4%; P = 0.011), as well as transient diabetes insipidus (54.3% vs. 26.9% P = 0.012) and intraoperative cerebrospinal fluid leak (83.5% vs. 58.5%; P = 0.013). However, permanent postoperative complication rates were similar including rate of permanent diabetes insipidus (4.3% elderly vs. 12.1% adult), cerebrospinal fluid leak (8.7% elderly vs. 8.4% adult), and meningitis (4.3% elderly vs. 2.8% adult). There were no medical complications or deaths in our cohort. CONCLUSION: The transsphenoidal endoscopic endonasal approach can be a safe and effective technique for resection of pituitary adenomas in patients >70 years old with appropriate patient selection.