Characterization of cerebral radiation necrosis following the treatment of sinonasal malignancies.

Objectives: Our study aims to determine the incidence and potential risk factors for cerebral radiation necrosis (CRN) following treatment of sinonasal malignancies. Methods: One hundred thirty-two patients diagnosed with sinonasal malignancies over an 18-year period were identified at two institutions. Forty-six patients meeting inclusion criteria and treated with radiation therapy were included for analysis. Demographic and clinical-pathologic characteristics were collected and reviewed. Post-treatment magnetic resonance imaging (MRI) at least 1 year following treatment was reviewed to determine presence or absence of CRN. Results: CRN was identified on MRI in 8 of 46 patients (17.4%) following radiation treatment. Patients with a history of reirradiation were more likely to develop CRN (50% vs. 10.5%, p < .05). The BEDs of radiation were also higher in CRN patients compared to non-CRN patients, but this difference was not significant (p > .05). CRN patients had a higher proportion of tumors with skull base involvement than non-CRN patients (100% vs. 57.9%, p = .037). Demographics, comorbidities, pathology, primary tumor subsite, chemotherapy use, and stage of disease demonstrated no significant increase in risk of CRN. Conclusions: Reirradiation and tumor skull base involvement were significant risk factors associated with CRN. Higher average total prescribed and BEDs of radiation were seen in the CRN groups, but these differences were not statistically significant. Gender, comorbidities, tumor subsite, tumor location, and treatment type were not significantly different between groups. Level of evidence: Level 3.

Comparison of Clinical and Radiographic Outcomes After Standalone Versus Cage and Plate Constructs for Anterior Cervical Discectomy and Fusion.

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) has conventionally been performed using an allograft cage with a plate-and-screw construct. Recently, standalone cages have gained popularity due to theorized decreases in operative time and postoperative dysphagia. Few studies have compared these outcomes. Here, we directly compare the outcomes of plated versus standalone ACDF constructs. METHODS: A single-center retrospective review of patients undergoing ACDF after June 2011 with at least 6 months of follow up was conducted. Clinical outcomes were analyzed and compared between standalone and plated constructs. Multivariate regression analysis of the primary outcome, need for revision surgery, as well as several secondary outcomes, procedure duration, estimated blood loss (EBL), length of hospital stay, disposition, and incidence of dysphagia, hoarseness, or surgical site infection, was completed. RESULTS: A total of 321 patients underwent ACDF and met inclusion-exclusion criteria, with mean follow-up duration of 20 months. Forty-six (14.3%) patients received standalone constructs, while 275 (85.7%) received plated constructs. Fourteen (4.4%) total revisions were necessary, 4 in the standalone group and 10 in the plated group, yielding revision rates of 8.7% and 3.6%, respectively (P = .125). Mean EBL was 98 mL in the standalone group and 63 mL in the plated group (P = .001). Mean procedure duration was 147 minutes in the standalone group and 151 minutes in the plated group (P = .800). Mean hospital stay was 3.6 days in the standalone group and 2.5 days in the plated group (P = .270). There was no significant difference in incidence of dysphagia (P = .700) or hoarseness (P = .700). CONCLUSIONS: Standalone ACDF demonstrates higher, but not statistically significant, revision rates than plate-and-screw constructs, without the hypothesized decreased incidence of dysphagia or hoarseness and without decreased procedure duration or EBL. Surgeons may consider limiting use of these constructs to cases of adjacent segment disease. Larger studies with longer follow up are necessary to make more definitive conclusions. LEVEL OF EVIDENCE: 4. CLINICAL RELEVANCE: This study will help spine surgeons decide between using standalone or cage-and-plate constructs for ACDF.

Volume of Disease as a Predictor for Clinical Outcomes in Patients With Melanoma Brain Metastases Treated With Stereotactic Radiosurgery and Immune Checkpoint Therapy.

PURPOSE/OBJECTIVES: Clinical trials of anti-Programmed cell death protein 1 (PD-1) and cytotoxic T-lymphocyte-associated protein (CTLA-4) therapies have demonstrated a clinical benefit with low rates of neurologic adverse events in patients with melanoma brain metastases (MBMs). While the combined effect of these immunotherapies (ITs) and stereotactic radiosurgery (SRS) has yielded impressive results with regard to local control (LC) and overall survival (OS), it has also been associated with increased rates of radiation necrosis (RN) compared to historical series of SRS alone. We retrospectively reviewed patients treated with IT in combination with SRS to report on predictors of clinical outcomes. MATERIALS AND METHODS: Patients were included if they had MBMs treated with SRS within 1 year of receiving anti-PD-1 and/or CTLA-4 therapy. Clinical outcomes including OS, LC, intracranial death (ID), and RN were correlated with type and timing of IT with SRS, radiation dose, total volume, and size and number of lesions treated. RESULTS: Twenty-nine patients with 171 MBMs were treated between May 2012 and May 2018. Patients had a median of 5 lesions treated (median volume of 6.5 cm3) over a median of 2 courses of SRS. The median dose was 21 Gy. Most patients were treated with ipilimumab (n = 13) or nivolumab-ipilimumab (n = 10). Most patients underwent SRS concurrently or within 3 months of receiving immunotherapy (n = 21). Two-year OS and LC were 54.4% and 85.5%, respectively. In addition, 14% of patients developed RN; however, only 4.7% of the total treated lesions developed RN. The median time to development of RN was 9.5 months. Patients with an aggregate tumor volume >6.5 cm3 were found to be at increased risk of ID (p = 0.05) and RN (p = 0.03). There was no difference in OS, ID, or RN with regard to type of IT, timing of SRS and IT, number of SRS courses, SRS dose, or number of cumulative lesions treated. CONCLUSIONS: In our series, patients treated with SRS and IT for MBMs had excellent rates of OS and LC; however, patients with an aggregate tumor volume >6.5 cm3 were found to be at increased risk of ID and RN. Given the efficacy of combined anti-PD-1/CTLA-4 therapy for MBM management, further study of optimal selection criteria for the addition of SRS is warranted.

General surgery involvement with ventriculoperitoneal shunt insertions reduces revision rates.

BACKGROUND: Ventriculoperitoneal shunts (VPS) are placed for a variety of etiologies. It is common for general surgery to assist with insertion of the distal portion in the peritoneum. OBJECTIVE: To determine if there is a difference in revision rates in patients undergoing VPS placement with general surgery as well as those undergoing laparoscopic insertion. METHODS: A retrospective review of all consecutive patients undergoing VPS placements was performed in a three-year period (2017-2019). Those that underwent placement with general surgery were compared to those without general surgery. Additionally, patients undergoing distal placement via mini-laparotomy versus laparoscopy were compared. Multivariable logistic regression was used to examine risk factors for distal VPS failure. RESULTS: 331 patients were included. 202 (61.0 %) underwent VPS placement with general surgery. 121 (36.6 %) patients underwent insertion via laparoscopic technique. General surgery involvement reduced operative times, decreased length of stay, and lowered overall revision rates with distal revision rates being most significant (1.5 % vs 8.5 %; p = 0.0034). Patients undergoing VPS placement via laparoscopic technique had decreased operative time, length of stay, in-hospital complications and revision rates, with significant decrease in shunt infection (1.7 % vs 7.1 %; p = 0.0366). A history of prior shunt or abdominal surgery (OR 3.826; p = 0.0282) and lack of general surgery involvement (OR 20.98; p = 0.0314) are independent risk factors for distal shunt revision in our cohort. CONCLUSION: The use of general surgeons in VPS insertion can be of benefit by decreasing operative time, length of stay, total revisions, and distal revision rates. Further prospective studies are warranted to determine true benefit.

Outcomes of Surgical Evacuation of Chronic Subdural Hematoma in the Aged: Institutional Experience and Systematic Review.

BACKGROUND: Surgical intervention for chronic subdural hematoma (cSDH) in the elderly population remains a clinical challenge given that associated morbidity and outcomes do not always equate radiographic success with clinical success. Our objective was to compare outcome measures of 2 age groups of patients undergoing surgical intervention for cSDH evacuation and to perform a systematic review of the literature related to this topic. METHODS: A retrospective analysis of adult patients undergoing surgical evacuation of cSDH at our institution was performed. Primary outcome measures of modified Rankin Scale (mRS) score at discharge and 3 months were assessed. In addition, a systematic search was performed to collect all relevant studies addressing outcomes after surgical intervention in aged patients with cSDH. RESULTS: There were 72 patients in the younger cohort (<70 years) and 113 patients in the aged cohort (≥70 years). Multivariate analysis showed significant association between age and higher mRS score at discharge and 3 months follow-up. There were also significant differences in length of stay and disposition between the 2 groups. Twenty-one studies were reviewed, and 11 studies were included in a meta-analysis of recurrence rates between studied age groups. CONCLUSIONS: The aged cohort had worse outcomes than the younger cohort as determined by mRS score at discharge and 3 months. A systematic review of outcomes is provided with limited meta-analysis because of the heterogenous nature of outcome reporting and the observational design of previous studies. Further studies with standardized reporting and long-term follow-up are warranted to further study outcomes in this increasing population.

Crossing the Cervicothoracic Junction During Posterior Cervical Decompression and Fusion: Is It Necessary?

BACKGROUND: Posterior cervical fusion (PCF) is performed to treat cervical myelopathy, radiculopathy, and/or deformity. Constructs ending at the cervicothoracic junction (CTJ) may lead to higher rates of adjacent segment disease, and much debate exists regarding crossing the CTJ due to paucity of data in the literature. OBJECTIVE: To determine whether extension of PCF constructs across the CTJ decreases incidence of adjacent segment disease and need for revision surgery. METHODS: A single-center retrospective case series of patients undergoing multilevel PCFs since 2011 with at least 6-mo follow-up was conducted. Outcomes were analyzed and compared based on caudal extent of instrumentation via multivariate regression. RESULTS: A total of 149 patients underwent PCF, with a mean follow-up of 18.9 mo. A total of 15 (10.1%) revisions were performed, 7 (4.7%) of which were related to the construct. Five (8.3%) revisions were performed for constructs ending at C6, 1 (5.3%) at C7, 1 (2.6%) at T1, and none (0%) at T2 (P = .035). Mean procedure duration was 215 min at C6, 214 min at C7, 239 min at T1, and 343 min at T2 (P = .001). Mean estimated blood loss was 224 mL at C6, 178 mL at C7, 308 mL at T1, and 575 mL at T2 (P = .001). There was no difference in length of stay, disposition, surgical site infection, or radiographic parameters. CONCLUSION: Extension of PCFs across the CTJ leads to lower early revision rates, but also to increased procedure duration and estimated blood loss. As such, decisions regarding caudal extent of instrumentation must weigh the risk of pseudarthrosis against that of longer procedures with higher blood loss.

Implementation and Evaluation of a Smartphone Application for the Perioperative Care of Neurosurgery Patients at an Academic Medical Center: Implications for Patient Satisfaction, Surgery Cancelations, and Readmissions.

BACKGROUND: Smartphone applications (apps) in the health care arena are being increasingly developed with the aim of benefiting both patients and their physicians. The delivery of adequate instructions both before and after a procedure or surgery is of paramount importance in ensuring the best possible outcome for patients. OBJECTIVE: To demonstrate that app-based instructions with built-in reminders may improve patient understanding and compliance and contribute to reducing the number of surgery cancellations and postoperative complications and readmissions. METHODS: We prospectively accrued 56 patients undergoing routine neurosurgery procedures who subsequently downloaded the app. The median age was 54 (range 27-79). Patients were followed for successful registration and use of the app, compliance with reading instructions before and after surgery, and sending pain scores and/or wound images. The number of surgeries cancelled, postoperative complications, 30-d readmissions, and phone calls for surgery-related questions were examined. RESULTS: Fifty-four of the 56 patients successfully registered, downloaded, and used the app and read and complied with instructions both before and after surgery. There were no cancelled surgeries. There was 1 postoperative complication. There were no readmissions. Eight of the 54 patients (14.8%) called the office on a single occasion for a surgery related question. CONCLUSION: We demonstrate the utility of a smartphone application in the perioperative neurosurgical care setting with regard to patient compliance and satisfaction as well as surgery cancellations and readmissions. Further study of a larger number of patients with a control group is warranted.

Bilateral Subaxial Rotational Vertebral Artery Occlusion in a Setting of a Prior Cervical Construct.

BACKGROUND: Rotational vertebral artery occlusion, or bow hunter's syndrome, most commonly affects the C1-2 level because of its importance in regulating rotational movement. CASE DESCRIPTION: A 50-year-old man with increasing neck pain and severe symptoms of vertebrobasilar insufficiency with bidirectional head rotation had undergone several prior subaxial cervical spine operations. Dynamic cerebral angiography demonstrated complete occlusion of the left vertebral artery during head rotation to the right and complete occlusion of the right vertebral artery during head rotation to the left. Occlusions occurred at the level of and rostral to his prior construct, with immediate recurrence of debilitating vertigo and near syncope. Successful radiographic and clinical resolution of symptoms was achieved by posterior instrumentation and fusion from C2, connecting to his prior hardware. CONCLUSIONS: A brief literature review and treatment options are discussed for this unusual presentation of a rare clinical entity.

Small Vestibular Schwannomas: Does Surgery Remain a Viable Treatment Option?

Background Surgery for small vestibular schwannomas (Koos grade I and II) has been increasingly rejected as the optimal primary treatment, instead favoring radiosurgery and observation that offer lower morbidity and potentially equal efficacy. Our study assesses the outcomes of contemporary surgical strategies including tumor control, functional preservation, and implications of pathologic findings. Design Retrospective review. Setting/Participants Eighty consecutive patients (45 women, 35 men; mean: 47 years of age). Main Outcomes Measures Approaches included retrosigmoid approach (52%), translabyrinthine (40%), and middle fossa (8%). Operated on by the same surgical team, we analyzed presentation, radiographic imaging, surgical data, and outcomes. Results At last follow-up (mean: 34 months), 95% had good facial nerve function (House-Brackmann grade I or II); 36% who presented with serviceable hearing retained it; and 93% who presented with vestibular dysfunction reported resolution. Pathology identified two grade I meningiomas. Conclusions As one of the largest contemporary surgical series of small vestibular schwannomas, we discuss some nuances to help refine treatment algorithms. Although observation and radiosurgery have established roles, our results reinforce microsurgery as a viable, safe option for a subgroup of patients.

Prospective evaluation of 1-year outcomes in single-level percutaneous lumbar transfacet screw fixation in the lateral decubitus position following lateral transpsoas interbody fusion.

PURPOSE: Lateral transpsoas lumbar interbody fusion (LTIF) is an accepted treatment for degenerative lumbar disc disease. Bilateral percutaneous transfacet (TF) fixation is a promising option for stabilization following LTIF. Here, we describe our experience with this technique and assess the clinical outcomes and efficacy. METHODS: Thirty-eight consecutive patients were identified who underwent LTIF followed by bilateral percutaneous transfacet fixation in the lateral position. Preoperative and 1-year postoperative VAS scores, and operative data were prospectively recorded. One-year outcomes were also assessed according to the MacNab criteria. Fusion was assessed at 1 year via computed tomography and dynamic radiography. Two-tailed Student's t test was used to compare VAS scores. RESULTS: Twenty-six patients underwent fusion at L4-5, 11 at L3-4, and one at L2-3; two patients were lost to follow-up. Mean operative time was 148.0 ± 47.9 min; mean blood loss was 33.0 ± 26.1 ml; mean hospital stay was 53.5 ± 51.2 h. Mean preoperative VAS scores for back and leg pain were 7.4 ± 3.0 and 7.0 ± 2.9, respectively; mean postoperative VAS scores for back and leg pain were 1.9 ± 2.4 (p < 0.0001) and 2.0 ± 3.0 (p < 0.0001), respectively. Most (89 %) patients had some relief, 72 % good to excellent and 17 % fair outcomes; eleven percent had little to no relief. There was one postoperative complication (pulmonary embolus). All patients had evidence of solid bony fusion. CONCLUSIONS: Percutaneous transfacet fixation in the lateral position is a safe and effective alternative for fixation after LTIF and may be associated with shorter operative time and less blood loss than other posterior fixation techniques.

Facial nerve preservation surgery for koos grade 3 and 4 vestibular schwannomas.

BACKGROUND: Facial nerve preservation surgery for large vestibular schwannomas is a novel strategy for maintaining normal nerve function by allowing residual tumor adherent to this nerve or root-entry zone. OBJECTIVE: To report, in a retrospective study, outcomes for large Koos grade 3 and 4 vestibular schwannomas. METHODS: After surgical treatment for vestibular schwannomas in 52 patients (2004-2013), outcomes included extent of resection, postoperative hearing, and facial nerve function. Extent of resection defined as gross total, near total, or subtotal were 7 (39%), 3 (17%), and 8 (44%) in 18 patients after retrosigmoid approaches, respectively, and 10 (29.5%), 9 (26.5%), and 15 (44%) for 34 patients after translabyrinthine approaches, respectively. RESULTS: Hearing was preserved in 1 (20%) of 5 gross total, 0 of 2 near-total, and 1 (33%) of 3 subtotal resections. Good long-term facial nerve function (House-Brackmann grades of I and II) was achieved in 16 of 17 gross total (94%), 11 of 12 near-total (92%), and 21 of 23 subtotal (91%) resections. Long-term tumor control was 100% for gross total, 92% for near-total, and 83% for subtotal resections. Postoperative radiation therapy was delivered to 9 subtotal resection patients and 1 near-total resection patient. Follow-up averaged 33 months. CONCLUSION: Our findings support facial nerve preservation surgery in becoming the new standard for acoustic neuroma treatment. Maximizing resection and close postoperative radiographic follow-up enable early identification of tumors that will progress to radiosurgical treatment. This sequential approach can lead to combined optimal facial nerve function and effective tumor control rates.