Management of Symptomatic Hemorrhage From a Developmental Venous Anomaly.

Developmental venous anomalies (DVAs) are clinically benign, low-flow vascular malformations that classically hemorrhage only when associated with a cerebral cavernous malformation. It is very rare for an isolated DVA to hemorrhage. Resection of the DVA is generally contraindicated because of the high risk of venous infarct. We present the case of a large symptomatic hemorrhage stemming from an isolated DVA. The hematoma was evacuated and the hemorrhagic portion of the DVA was resected. This case demonstrates that in rare circumstances, careful resection can successfully treat hemorrhagic DVAs.

Subtemporal Approach for the Treatment of Ruptured and Unruptured Distal Basilar Artery Aneurysms: Is There a Contemporary Use?

BACKGROUND AND OBJECTIVES: Distal basilar artery aneurysms (DBAs) are high-risk lesions for which endovascular treatment is preferred because of their deep location, yet indications for open clipping nonetheless remain. The subtemporal approach allows for early proximal control and direct visualization of critical posterior perforating arteries, especially for posterior-projecting aneurysms. Our objective was to describe our clinical experience with the subtemporal approach for clipping DBAs in the evolving endovascular era. METHODS: This was a retrospective, single-institution case series of patients with DBAs treated with microsurgery over a 21-year period (2002-2023). Demographic, clinical, and surgical data were collected for analysis. RESULTS: Twenty-seven patients underwent clipping of 11 ruptured and 16 unruptured DBAs with a subtemporal approach (24 female; mean age 53 years). Ten patients had expanded craniotomies for treatment of additional aneurysms. The aneurysm occlusion rate was 100%. Good neurological outcomes as defined by the modified Rankin Scale score ≤2 and Glasgow Outcome Scale score ≥4 were achieved in 21/27 patients (78%). Two patients died before hospital discharge, one from vasospasm-induced strokes and another from an intraoperative myocardial infarction. CONCLUSION: These results demonstrate that microsurgical clip ligation of DBAs using the subtemporal approach remains a viable option for complex lesions not amenable to endovascular management.

Hospital cost differences between open and endoscopic lumbar spine decompression surgery.

OBJECTIVE: In recent years, fully endoscopic decompression surgery for degenerative spine disease has become increasingly popular in the US. Although an endoscopic approach has demonstrated some benefits compared with open procedures in randomized controlled trials, the cost of advanced technologies remains contested. The authors evaluated the differences in costs and cost drivers between open and endoscopic decompression surgical procedures performed at a single institution. METHODS: Using associated Current Procedural Terminology codes, the authors identified all open and endoscopic decompression lumbar surgical procedures performed from January 1, 2016, through December 31, 2022. Preoperative comorbidities, surgical characteristics, and postoperative outcomes were captured. The costs of index surgery-related readmission for revision, washout, or other complications were included in the index surgery expenses. Associated in-hospital costs were collected; these were reported in comparative percentages with open surgical procedures as the baseline because of an institutional agreement. Univariate and multivariate analyses were performed. RESULTS: The retrospective search identified 633 open surgical procedures and 195 endoscopic surgical procedures for inclusion. The two patient cohorts were similar, with clinically nonrelevant but statistically significant differences in mean age (open 55.7 years vs endoscopic 59.4 years, p = 0.01) and mean American Society of Anesthesiologists physical status class (open 2.3 vs endoscopic 2.4, p = 0.03). Postoperatively, patients who underwent open surgical procedures had significantly longer mean hospital stays (open 1.4 days vs endoscopic 0.7, p < 0.01) and more perioperative complications (open 7.9% of patients vs endoscopic 3.1%, p = 0.02), and they required washout surgical procedures in some cases (open 1.3% vs endoscopic 0%, p = 0.12). The largest cost difference between open and endoscopic surgical procedures was the significantly greater cost of disposable supplies for endoscopic cases (10.1% vs 31.7% of the total cost of open procedures, p < 0.01), and open surgical procedures were generally less costly in total (100.0% vs 115.1%, p < 0.01). In multivariate linear regression, endoscopic surgery was independently associated with greater total costs (standardized beta 15.9%, p < 0.01), although length of hospital stay (standardized beta 34.0%) and readmissions (standardized beta 30.0%, p < 0.01) had larger effects on cost. CONCLUSIONS: The endoscopic approach was associated with greater total in-hospital costs compared with open procedures. The findings of further cost evaluations, including those of patient-reported outcomes, social cost, and capital costs per procedure type, need to be included in operational and clinical decisions.

Are There Racial and Ethnic Health Disparities Among Outcomes After Anterior Cranial Fossa Surgery? A Propensity Score-Matched American College of Surgeons National Surgical Quality Improvement Program Study.

BACKGROUND: Race-based health care outcomes remain to be described in anterior cranial fossa (ACF) surgery. OBJECTIVE: To determine whether race predicts worse outcomes after ACF surgery. METHODS: A retrospective cohort study was performed using the American College of Surgeons National Surgical Quality Improvement Program data for 2005 to 2020. Current Procedural Terminology and International Classification of Diseases-9 codes were used to identify ACF tumor cases. Propensity score matching was performed to compare White and minority patients to assess the robustness of unmatched findings. A subanalysis of pituitary adenoma (PA) resections was also performed. RESULTS: In an unmatched analysis of 1370 patients who underwent ACF surgery (67.9% White, 17.4% Black, 6.6% Asian/Pacific Islander, and 6.3% Hispanic), minority groups had higher rates of comorbidities. Unmatched multivariate analysis found Hispanic patients bore a 1.86 odds ratio (OR) of minor complications, Black and Asian and Pacific Islander patients bore 1.49 and 1.71 ORs, respectively, for extended length of stay, and Black patients bore a 3.78 OR for urinary tract infection (UTI). Matched analysis found that minority patients had higher UTI rates ( P = .02) and a 4.11 OR of UTI. In PA cases specifically, minority groups had higher comorbidities and length of stay in addition to extended length of stay odds (1.84 OR). CONCLUSION: Although most ACF surgery outcomes were unaffected by race, minority groups had more minor postoperative complications than White patients, particularly UTI. Similar disparities were observed among PA cases. Higher rates of comorbidities may also have led to longer hospital stays. Further study is needed to understand what actions might be necessary to address any race-associated health disparities in ACF surgery.

High Failure Rates in Prisoners Undergoing Spine Fusion Surgery.

OBJECTIVE: The medical literature on prisoner health care is limited, despite data showing that prisoners experience high rates of physical and mental health challenges. We compared clinical outcomes for prisoners undergoing spine fusion with comparable nonincarcerated patients and determined what factors were implicated in differences in outcomes. METHODS: Prisoners who underwent spinal fusion in 2011-2021 were retrospectively compared with an age-, sex-, and procedure-matched 3:1 control group of nonincarcerated spinal fusion patients. Fusion failure was confirmed by lack of bridging bone between vertebrae on CT or radiographic images >1 year postoperatively or evidence of instrumentation failure with resultant >2 mm of translation on flexion/extension radiographs. RESULTS: Twenty-seven identified prisoners were compared with 81 nonincarcerated controls. Ten prisoners and 6 controls experienced nonunion (37% vs. 7%, P < 0.01). Rates of risk factors for nonunion, such as smoking history, elevated body mass index, chronic steroid use, diabetes mellitus, previous spine surgery, and levels fused, were not significantly different between prisoners and controls. Among prisoners, those with nonunion were younger (45 vs. 53 years, P = 0.03), had greater body mass index (34 vs. 29, P = 0.02), and were more likely to undergo reoperation (30% vs. 0%, P = 0.02). Multivariate analysis revealed that prisoners carry a 9.62 increased odds of nonunion compared with controls. CONCLUSIONS: This is one of few studies investigating health care outcomes in prisoners. We found they had a significantly higher rate of nonunion than matched control patients from the general population treated at the same hospital, suggesting additional measures may be necessary postoperatively to support fusion in prisoners.

Dual Dural Patch Graft With AlloDerm and DuraGen Underlay for Duraplasty in Chiari Malformation Results in Significantly Decreased Cerebrospinal Fluid Leak Complications.

BACKGROUND: Grafts available for posterior fossa dural reconstruction after Chiari decompression surgery include synthetic, xenograft, allograft, and autograft materials. The reported rates of postoperative pseudomeningocele and cerebrospinal fluid leak vary, but so far, no dural patch material or technique has sufficiently eliminated these problems. OBJECTIVE: To compare the incidence of graft-related complications after posterior fossa surgery using AlloDerm alone vs AlloDerm with a DuraGen underlay. METHODS: We performed a retrospective single-center study of a cohort of 106 patients who underwent Chiari decompression surgery by a single surgeon from 2014 through 2021. Age, sex, body mass index, tonsillar descent, syrinx formation, type of dural graft, and follow-up data were analyzed using univariate and χ2 statistical tests. RESULTS: The AlloDerm-only group had a percutaneous cerebrospinal fluid (CSF) leak rate of 8.6% vs a 0% rate in the dual graft group (P = .037). At initial follow-up, there was a 15.5% combined rate of pseudomeningocele formation plus CSF leak in the AlloDerm-only group vs 18.8% in the AlloDerm + DuraGen group (P = .659). However, the pseudomeningoceles were larger in the AlloDerm-only cohort (45.5 vs 22.4 mm anteroposterior plane, P = .004), and 5 patients in this group required operative repair (56%). All pseudomeningoceles resolved without reoperation in the AlloDerm + DuraGen group (P = .003). CONCLUSION: The use of a DuraGen underlay with a sutured AlloDerm dural patch resulted in significantly fewer CSF-related complications and eliminated the need for reoperation compared with AlloDerm alone. This single-center study provides evidence that buttressing posterior fossa dural grafts with a DuraGen underlay may decrease the risk of postoperative complications.

Identification of an Operative Time Threshold for Substantially Increased Postoperative Complications Among Elderly Spine Surgery Patients.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To identify whether thresholds exist beyond which operative duration or age increases risks for complications among patients ≥65 years undergoing elective spine surgery. METHODS: Elective inpatient spine procedures unrelated to infection/trauma/tumor diagnoses in patients <65 years recorded in the 2006-2019 American College of Surgeons National Surgical Quality Improvement database were identified. Univariate analyses was used to compare 30 day complication rates among 5 operative duration and age-stratified groups. To quantify the risk of prolonged operative duration on complications, multivariate analyses were performed controlling for confounders. A generalized linear model was used to assess the individual and combined effect strength of age and operative duration on complication rates. RESULTS: Among 87,705 patients stratified by operative duration, 30 day complication rates rose nonlinearly as operative duration increased, with a sharp rise after 4.0-4.9 hours (28.3% at 4.0-4.9 hours, 51.7% at ≥5 hours, P < .001). Multivariate analysis found operative duration was independently associated with increased risk of overall complications (odds ratio 1.10→1.69, P < .001) and medical complications (odds ratio 1.19→1.98, P < .001). Although complication rates rose by age (all P < .001), age was not independently predictive of overall complications within any operative duration group on multivariate analysis. Operative duration had a greater effect (η2P = .067) than age (η2P = .003) on overall complication rates. CONCLUSIONS: Increased operative duration was strongly associated with 30 day complication rates, particularly beyond a threshold of 5 hours. Furthermore, operative duration had a notably larger effect on overall complication rates than age.

Full-endoscopic spine surgery diminishes surgical site infections - a propensity score-matched analysis.

BACKGROUND CONTEXT: Surgical site infections (SSI) are one the most frequent and costly complications following spinal surgery. The SSI rates of different surgical approaches need to be analyzed to successfully minimize SSI occurrence. PURPOSE: The purpose of this study was to define the rate of SSIs in patients undergoing full-endoscopic spine surgery (FESS) and then to compare this rate against a propensity score-matched cohort from the National Surgical Quality Improvement Program (NSQIP) database. DESIGN: This is a retrospective multicenter cohort study using a propensity score-matched analysis of prospectively maintained databases. PATIENT SAMPLE: A total of 1277 noninstrumented FESS cases between 2015 and 2021 were selected for analysis. In the nonendoscopic NSQIP cohort we selected data of 55,882 patients. OUTCOME MEASURES: The occurrence of any SSI was the primary outcome. We also collected any other perioperative complications, demographic data, comorbidities, operative details, history of smoking, and chronic steroid intake. METHODS: All FESS cases from a multi-institutional group that underwent surgery from 2015 to 2021 were identified for analysis. A cohort of cases for comparison was identified from the NSQIP database using Current Procedural Terminology of nonendoscopic cervical, thoracic, and lumbar procedures from 2015 to 2019. Trauma cases as well as arthrodesis procedures, surgeries to treat pathologies affecting more than 4 levels or spine tumors that required surgical treatment were excluded. In addition, nonelective cases, and patients with wounds worse than class 1 were also not included. Patient demographics, comorbidities, and operative details were analyzed for propensity matching. RESULTS: In the nonpropensity-matched dataset, the endoscopic cohort had a significantly higher incidence of medical comorbidities. The SSI rates for nonendoscopic and endoscopic patients were 1.2% and 0.001%, respectively, in the nonpropensity match cohort (p-value <.011). Propensity score matching yielded 5936 nonendoscopic patients with excellent matching (standard mean difference of 0.007). The SSI rate in the matched population was 1.1%, compared to 0.001% in endoscopic patients with an odds ratio 0.063 (95% confidence interval (CI) 0.009-0.461, p=.006) favoring FESS. CONCLUSIONS: FESS compares favorably for risk reduction in SSI following spinal decompression surgeries with similar operative characteristics. As a consequence, FESS may be considered the optimal strategy for minimizing SSI morbidity.

Optimal Donor Nerve to Restore Elbow Flexion After Traumatic Brachial Plexus Injury: A Systematic Review and Meta-Analysis.

BACKGROUND: Traumatic brachial plexus injuries (BPIs) often lead to devastating upper extremity deficits. Treatment frequently prioritizes restoring elbow flexion through transfer of various donor nerves; however, no consensus identifies optimal donor nerve sources. OBJECTIVE: To complete a meta-analysis to assess donor nerves for restoring elbow flexion after partial and total BPI (TBPI). METHODS: Original English language articles on nerve transfers to restore elbow flexion after BPI were included. Using a random-effects model, we calculated pooled, weighted effect size of the patients achieving a composite motor score of ≥M3, with subgroup analyses for patients achieving M4 strength and with TBPI. Meta-regression was performed to assess comparative efficacy of each donor nerve for these outcomes. RESULTS: Comparison of the overall effect size of the 61 included articles demonstrated that intercostal nerves and phrenic nerves were statistically superior to contralateral C7 (cC7; P = .025, <.001, respectively) in achieving ≥M3 strength. After stratification by TBPI, the phrenic nerve was still superior to cC7 in achieving ≥M3 strength (P = .009). There were no statistical differences among ulnar, double fascicle, or medial pectoral nerves in achieving ≥M3 strength. Regarding M4 strength, the phrenic nerve was superior to cC7 (P = .01) in patients with TBPI and the ulnar nerve was superior to the medial pectoral nerve (P = .036) for partial BPI. CONCLUSION: Neurotization of partial BPI or TBPI through the intercostal nerve or phrenic nerve may result in functional advantage over cC7. In patients with upper trunk injuries, neurotization using ulnar, median, or double fascicle nerve transfers has similarly excellent functional recovery.

Work relative value units and perioperative outcomes in patients undergoing brain tumor surgery.

The work relative value unit (wRVU) is a commonly cited surrogate for surgical complexity; however, it is highly susceptible to subjective interpretation and external forces. Our objective was to evaluate whether wRVU is associated with perioperative outcomes, including complications, after brain tumor surgery. The 2006-2014 American College of Surgeons National Surgical Quality Improvement Program database was queried to identify patients ≥ 18 years who underwent brain tumor resection. Patients were categorized into approximate quintiles based on total wRVU. The relationship between wRVU and several perioperative outcomes was assessed with univariate and multivariate analyses. Subgroup analyses were performed using a Current Procedural Terminology code common to all wRVU groups. The 16,884 patients were categorized into wRVU ranges 0-30.83 (4664 patients), 30.84-34.58 (2548 patients), 34.59-38.04 (3147 patients), 38.05-45.38 (3173 patients), and ≥ 45.39 (3352 patients). In multivariate logistic regression analysis, increasing wRVU did not predict more 30-day postoperative complications, except respiratory complications and need for blood transfusion. Linear regression analysis showed that wRVU was poorly correlated with operative duration and length of stay. On multivariate analysis of the craniectomy subgroup, wRVU was not associated with overall or respiratory complications. The highest wRVU group was still associated with greater risk of requiring blood transfusion (OR 3.01, p < 0.001). Increasing wRVU generally did not correlate with 30 days postoperative complications in patients undergoing any surgery for brain tumor resection; however, the highest wRVU groups may be associated with greater risk of respiratory complications and need for transfusion. These finding suggests that wRVU may be a poor surrogate for case complexity.

Visual Outcomes in Spheno-Orbital Meningioma: A 10-Year Experience.

BACKGROUND: Spheno-orbital meningiomas (SOMs) present distinct surgical challenges because they involve important neurovascular structures, such as the orbit, cavernous sinus, superior orbital fissure, and optic canal. Resection thus focuses on maximum safe resection while preserving these neurovascular structures. Our objective was to describe our method of surgical management of SOMs and summarize visual outcomes. METHODS: A retrospective chart review was performed to identify patients who underwent surgery for SOM in 2011-2021. Demographics, preoperative visual summary, operative details, visual outcomes, and recurrence data were collected. RESULTS: The 33 patients (10 male, 23 female) had a mean age of 56 years (range 27-74 years). The mean tumor volume was 39 mL (range 4.7-220 mL). The mean follow-up period was 18 months (range 1-120 months). Thirty-two patients had preoperative radiographic evidence of proptosis (based on exophthalmos index), 23 (70%) presented with diminished visual acuity, and 10 (30%) had a concomitant visual field deficit. At last postoperative follow-up, vision was stable for 25 patients (83.3%), improved for 1 (3.3%), and worsened for 3 (10%; 2 occurring after tumor recurrence beyond 2 years). Proptosis was stable or improved in all patients. One patient had an enucleated eye. A total of 7 patients (21%) had recurrence of the tumor at 19-72 months from the operation. CONCLUSIONS: In this study, maximum safe resection, including periorbital resection, provided adequate visual and cosmetic outcomes, as well as reasonable tumor control in the long term. Rigid orbital reconstruction was not required to prevent pulsatile enophthalmos.

Impact of modified Frailty Index-11 (mFI-11) on postoperative complications in patients undergoing transsphenoidal resection of pituitary tumors: Analysis of 2006-2014 ACS-NSQIP database.

INTRODUCTION: Frailty is a measure of physiologic reserve that is frequently cited as a predictor of postoperative complications. However, the effect of frailty on patients undergoing a relatively common procedure such as transsphenoidal resection of pituitary tumors (TSRPT) is unknown. Therefore, we sought to explore this relationship using a large, national database. METHODS: The 2006-2014 American College of Surgeons National Surgical Quality Improvement Program database was retrospectively reviewed to identify all patients who underwent TSRPT. Frailty scores were assigned using the established 11-factor modified Frailty Index (mFI-11). Patients were divided into low-frailty and high-frailty groups, based on mFI comorbidities of ≤ 1 and ≥ 2, respectively. Univariable and multivariable analyses were performed to evaluate the impact of frailty on postoperative outcomes and mortality. RESULTS: A total of 993 patients were included in the analysis. The low-frailty group consisted of 825 patients; the high-frailty group comprised 168 patients. In univariable analysis, there were no significant differences in medical (low-frailty 4.8%, high-frailty 8.3%; p = 0.069) and surgical (low-frailty 1.1%, high-frailty 1.2%; p = 1.000) complications; however, the high-frailty group had a higher rate of mortality (3%) when compared with the low-frailty group (0.6%; p = 0.016, OR 4.07, p = 0.044) and longer hospitalization (4.5 ±â€¯7.4 vs. 5.8 ±â€¯6.8 days; p = 0.023). In multivariable analysis, frailty was a predictor of mortality but not complications or reoperation. CONCLUSIONS: Our study shows that frailty, as measured by the mFI-11, does not predict postoperative complications in patients who undergo TSRPT, but greater frailty is correlated with higher mortality and increased hospital length of stay.

Endoscopic Posterior Approach for Cervicothoracic and Upper Thoracic Foraminotomies: 2-Dimensional Operative Video.

Lower cervical and cervicothoracic radiculopathies can be challenging to treat through an anterior approach in patients with short-statured necks. With unilateral pathology, a posterior foraminotomy affords preservation of motion and avoids risks to anterior structures; yet, traditional open or even tubular retractor-based open systems are associated with postoperative muscle pain. Endoscopic approaches reduce muscle retraction and resection and are associated with shorter recovery time. This video demonstrates the endoscopic technique for performing cervicothoracic and thoracic foraminotomies. We present the case of a patient with severe left-hand weakness, particularly in grasp and hand intrinsic muscles. The differential diagnosis included a combined median and ulnar neuropathy, lower trunk plexopathy, medial cord plexopathy, thoracic outlet syndrome, and combined C8 and T1 radiculopathies. Imaging did not show brachial plexus pathology; instead, severe foraminal narrowing at the C8 and T1 roots was noted. We performed a fully endoscopic approach to decompress 2 levels of foraminal stenosis on the left side. Because the levels were adjacent, we operated through a single incision. Recovery of motor-evoked potentials to the abductor pollicis brevis was identified intraoperatively. The patient consented to the procedure and publication.

Prolonged Length of Stay and Risk of Unplanned 30-Day Readmission After Elective Spine Surgery: Propensity Score-Matched Analysis of 33,840 Patients.

STUDY DESIGN: Retrospective database study. OBJECTIVE: To assess the association between prolonged length of hospital stay (pLOS) (≥4 d) and unplanned readmission in patients undergoing elective spine surgery by controlling the clinical and statistical confounders. SUMMARY OF BACKGROUND DATA: pLOS has previously been cited as a risk factor for unplanned hospital readmission. This potentially modifiable risk factor has not been distinguished as an independent risk factor in a large-scale, multi-institutional, risk-adjusted study. METHODS: Data were collected from the American College of Surgeons National Surgical Quality Improvement Program database. A retrospective propensity score-matched analysis was used to reduce baseline differences between the cohorts. Univariate and multivariate analyses were performed to assess the degree of association between pLOS and unplanned readmission. RESULTS: From the 99,575 patients that fit the inclusion criteria, propensity score matching yielded 16,920 well-matched pairs (mean standard propensity score difference = 0.017). The overall 30-day unplanned readmission rate of these 33,840 patients was 5.5%. The mean length of stay was 2.0 ±â€Š0.9 days and 6.0 ±â€Š4.5 days (P ≤ 0.001) for the control and pLOS groups, respectively. In our univariate analysis, pLOS was associated with postoperative complications, especially medical complications (22.7% vs. 8.3%, P < 0.001). Multivariate analysis of the propensity score-matched population, which adjusted identified confounders (P < 0.02 and ≥10 occurrences), showed pLOS was associated with an increased risk of 30-day unplanned readmission (odds ratio [OR] 1.423, 95% confidence interval [CI] 1.290-1.570, P < 0.001). CONCLUSION: Patients who undergo elective spine procedures who have any-cause pLOS (≥4 d) are at greater risk of having unplanned 30-day readmission compared with patients with shorter hospital stays. LEVEL OF EVIDENCE: 4.

Currarino syndrome presenting as a cerebrospinal fluid leak from the dermal sinus tract: case report.

Currarino syndrome is an autosomal dominant condition with variable expressivity and penetrance that is associated with several classic features: sacral dysgenesis, presacral mass, and/or anorectal anomalies. The authors present a unique case in which the patient's initial presentation was a CSF leak from a sinus tract. The sinus tract was identified and disconnected from the thecal sac, obliterating the anterior sacral meningocele. This case represents a unique scenario in which Currarino syndrome manifested as a CSF leak from a dermal sinus tract.

Postoperative Posterior Ischemic Optic Neuropathy After Left Far-Lateral Craniectomy for Resection of Craniocervical Meningioma.

BACKGROUND: Postoperative posterior ischemic optic neuropathy (PION) is a rare cause of postoperative vision loss, most often seen when surgical patients are placed in the prone position for a prolonged period of time. We report a case of bilateral PION after far-lateral craniectomy in the lateral position. CASE DESCRIPTION: A 36-year-old man presented with a history of right extremity numbness, weakness, and muscle atrophy, and a craniocervical meningioma was diagnosed. Surgery in the lateral position lasted 9 hours, 52 minutes; the patient had 2 L of blood loss. On postoperative day 1, the patient had bilateral vision loss, which prompted further work-up. Diffusion-weighted imaging of the orbits demonstrated restricted diffusion within the bilateral optic nerves. The clinical presentation of painless vision loss after surgery with these imaging findings led to a diagnosis of PION. At the time of discharge, he had not recovered any visual function. CONCLUSIONS: This case suggests that PION can occur in the lateral position where there is no direct pressure on the orbits. PION is often not discussed as a potential complication during the preoperative consent process. This case suggests it may be prudent to discuss PION in similar neurosurgical cases. Intraoperative blood transfusion should be considered in prolonged surgeries in the lateral position, where slow blood loss over a long period could be a contributing factor to development of PION.

Comparing Short-term Complications of Inpatient Versus Outpatient Single-level Anterior Cervical Discectomy and Fusion: An Analysis of 6940 Patients Using the ACS-NSQIP Database.

STUDY DESIGN: Multicenter propensity score-adjusted retrospective cohort study. OBJECTIVE: To determine baseline 30-day complication rates for anterior cervical discectomy and fusion (ACDF) and compare clinical complications for patients undergoing single-level ACDFs between inpatient and outpatient settings. SUMMARY OF BACKGROUND DATA: ACDF remains the most common procedure in the treatment of a variety of cervical disc pathologies, making it a focus of quality improvement initiatives. Outpatient single-level ACDFs are becoming more common and offer advantages including reducing nosocomial infections and costs, as well as improved patient satisfaction. MATERIALS AND METHODS: The 2011-2013 NSQIP datasets were queried to identify all patients who underwent single-level ACDF procedures using current procedural terminology codes. Outpatient and inpatient cohorts were matched 1:1 using propensity score analysis to assess short-term outcomes. The outcomes assessed included 30-day medical and surgical complications, reoperation, readmission, and mortality. RESULTS: In total, 6940 patients underwent a single-level ACDF with an overall complication rate of 4.2%. A total of 5162 patients (74.4%) had an inpatient hospital stay after surgery, whereas 1778 patients (25.6%) had outpatient surgery. After matching based on preoperative and operative characteristics to account for potential confounders, the overall complication rate was higher in the inpatient arm compared with the outpatient arm (2.5% vs. 1.2%; P=0.003). The 30-day readmission rate was also higher but not significant in the inpatient group than the outpatient group (2.2% vs. 1.8%; P=0.355). Mortality was the same with 0.1% in both groups (P=0.564). CONCLUSIONS: Patients undergoing outpatient single-level ACDF had a lower 30-day complication rates than those undergoing it in the inpatient setting. Outpatient surgery for single-level ACDF is safe and a favorable option for suitable patients. LEVEL OF EVIDENCE: Level 3.

Risk Factors for Medical and Surgical Complications Following Single-Level ALIF.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The objective of the study was to determine rates of medical and surgical postoperative complications following anterior lumbar interbody fusion (ALIF) along with their associated predictors. METHODS: Using the American College of Surgeons National Surgical Quality Improvement database, patients who underwent single-level ALIF surgery from 2006 to 2013 were identified. The 30-day rate of postoperative medical and surgical complications along with associated risk factors were evaluated by multivariable logistic regression. RESULTS: In total, 1474 patients were included in the analysis. The overall rate of complications was 14.5%. The medical complication rate was 12.7%, while the surgical complication rate was 2.8%. Predictors of surgical complications were diabetes (odds ratio [OR] = 2.79, 95% CI = 1.20-6.01, P = .009), corticosteroid dependence (OR = 4.94, 95% CI = 1.73-14.08, P = .003), and preoperative transfusion of >4 units (OR = 7.12, 95% CI = 1.43-35.37, P = .016). Predictors of medical complications were longer operative times (OR = 4.25, 95% CI = 2.90-6.24, P < .001), preoperative anemia (OR = 2.29, 95% CI = 1.50-3.50, P < .001), >10% weight loss prior to surgery (OR = 6.79, 95% CI = 1.01-45.93, P = .049), and more severe American Society of Anesthesiologists classification (OR = 2.18, 95% CI = 1.54-3.11, P < .001). CONCLUSIONS: The present study determines postoperative medical and surgical complications among patients undergoing ALIF. The risk factors elucidated in this study indicate that clinical practices to curtail complications should be targeted toward patients with preoperative anemia, weight loss, corticosteroid dependence, and toward those at risk for perioperative transfusions.

Evaluation of American Society of Anesthesiologists classification as 30-day morbidity predictor after single-level elective anterior cervical discectomy and fusion.

BACKGROUND CONTEXT: Higher American Society of Anesthesiologists (ASA) classification is a known predictor of postoperative complication in diverse surgical settings. However, its predictive value is not established in single-level elective anterior cervical discectomy and fusion (SLE-ACDF). PURPOSE: This study aimed to evaluate the predictive value of ASA classification system on 30-day morbidity following SLE-ACDF. DESIGN/SETTING: Patients who underwent SLE-ACDF between 2011 and 2013 were selected from the American College of Surgeons National Surgical Quality Improvement Program database. PATIENT SAMPLE: A total of 6,148 patients were selected from the 2011-2013 American College of Surgeons National Surgical Quality Improvement Program database. OUTCOME MEASURES: All outcomes are self-report measures as tracked by dedicated clinical reviewers via prospective review of inpatient charts, outpatient clinic visits, and direct contact with the surgical team. METHODS: Propensity score matching and multiple logistic regression analyses were performed to evaluate ASA classification as 30-day morbidity predictor. This study has no financial conflict and has no potential conflict of interest to disclose. RESULTS: A total of 6,148 patients were analyzed in this study. Patients in the ASA >II cohort had higher incidence of comorbidities and postoperative complications (overall complication, pneumonia, unplanned intubation, ventilator dependent >48 hours, cerebrovascular accident or stroke, catastrophic outcome, and airway complication). Propensity score matching yielded 1,628 pairs of well-matched patients. Multivariable analyses with the propensity score matched dataset revealed the following associations between ASA class >II and 30-day outcomes: any complication (odds ratio [OR] 0.82, 95% confidence interval [CI] 0.48-1.41), pneumonia (OR 1.22, 95% CI 0.33-4.56), unplanned intubation (OR 1.49, 95% CI 0.41-5.36), ventilator >48 hours (OR 5.92, 95% CI 0.69-50.96), catastrophic outcome (OR 1.02, 95% CI 0.39-2.71), and airway complication (OR 2.21, 95% CI 0.67-7.29). CONCLUSIONS: Although we did not detect associations between ASA class >II and adverse 30-day outcomes following SLE-ACDF, imprecision of estimates precludes definitive inferences. Although ASA classification allows simple assessment of patients' physiological status, their overall perioperativerisk factors need to be considered collectively for adequate optimization and improved outcomes in SLE-ACDF.