How a thrombectomy service can reduce hospital deficit: a cost-effectiveness study.

BACKGROUND: There is level 1 evidence for cerebral thrombectomy with thrombolysis in acute large vessel occlusion. Many hospitals are now contemplating setting up this life-saving service. For the hospital, however, the first treatment is associated with an initial high cost to cover the procedure. Whilst the health economic benefit of treating stroke is documented, this is the only study to date performing matched-pair, patient-level costing to determine treatment cost within the first hospital episode and up to 90 days post-event. METHODS: We conducted a retrospective coarsened exact matched-pair analysis of 50 acute stroke patients eligible for thrombectomy. RESULTS: Thrombectomy resulted in significantly more good outcomes (mRS 0-2) compared to matched controls (56% vs 8%, p = 0.001). More patients in the thrombectomy group could be discharged home (60% vs 28%), fewer were discharged to nursing homes (4% vs 16%), residential homes (0% vs 12%) or rehabilitation centres (8% vs 20%). Thrombectomy patients had fewer serious adverse events (n = 30 vs 86) and were, on average, discharged 36 days earlier. They required significantly fewer physiotherapy sessions (18.72 vs 46.49, p = 0.0009) resulting in a median reduction in total rehabilitation cost of £4982 (p = 0.0002) per patient. The total cost of additional investigations was £227 lower (p = 0.0369). Overall, the median cost without thrombectomy was £39,664 per case vs £22,444, resulting in median savings of £17,221 (p = 0.0489). CONCLUSIONS: Mechanical thrombectomy improved patient outcome, reduced length of hospitalisation and, even without procedural reimbursement, significantly reduced cost to the thrombectomy providing hospital.

The surgical management of highly unstable fragility fractures of the sacrum with spinopelvic dissociation: A case series and proposal of a surgical treatment algorithm.

INTRODUCTION: U- and H-shaped fragility fractures of the sacrum (FFP IVb) are unstable fractures. Non-operative treatment may be associated with impaired walking abilities, chronic pain and the potential loss of independency. However, different treatment options are still controversially debated. The aim of surgical treatment includes sufficient fracture stability for immediate full weight bearing and good pain control postoperatively. A new surgical treatment algorithm was developed. This algorithm was evaluated in a cohort of geriatric patients with FFP type IVb regarding surgical complications and patient-related outcome. METHODS: Retrospective case series. Patients ≥65 years, admitted with FFP IVb between 01/2017 and 12/2020 were included. Pelvic CT was performed and the surgical technique was chosen according to the proposed surgical treatment algorithm. For this algorithm, the technique of fracture stabilisation was adapted to sacral anatomy and the specific fracture pattern to minimize the impact of surgery and postoperative complications without compromising a sufficient fracture stability. Pain levels, complications and surgical revisions were recorded. Level of independency, walking abilities and -aids were compared 3- and 12- months postoperatively to the pre-injury situation. RESULTS: Twenty-three patients were included. Outcome parameters could be obtained in 20 patients (85%) after three months and in 18 patients (78%) patients one year postoperatively. All patients were treated according to the algorithm. Sixteen patients received two transilio-transsacral screws (TI-TSS), whereas either lumbopelvic fixation (LPF) combined with a TI-TSS or bilateral ilio-sacral screws (ISS) was performed four times. Three patients underwent bilateral ISS into S1 with one TI-TSS into S2. Three days postoperatively, median pain VAS was 2 (0-8) compared to 7 (4-10) before surgery. One loosened TI-TSS was removed six weeks postoperatively. Three-month mortality was 14% (n=3). At one-year follow-up, all patients regained their pre-injury level of walking abilities. CONCLUSIONS: Restoration of walking abilities, preservation of independency and efficient pain control can be achieved with surgical fixation of FFP type IVb fractures. With the proposed surgical algorithm, the fixation techniques are adapted to the fracture pattern to minimize the surgical burden. LEVEL OF EVIDENCE: IV.

Eponyms of Cranial Neurosurgical Instruments: An International Collaboration to Optimize the Field of Neurosurgery.

The basic set of a cranial instrument tray is filled with eponyms of surgical instruments named after surgeons and physicians from all corners of the medical world. These include pioneers like Castroviejo, Doyen, Frazier, Gigli, Mayfield, Raney, Weitlaner, and Yasargil. These innovators have always strived to enhance and simplify procedures, ultimately shaping the way we perform surgery today. It was a process, which took several generations of surgeons and trials of instruments before its current form could be established. In this paper, the authors provide background information through a historical perspective on the pioneering surgeons and physicians, after whom the instruments were named. Data were collected by searching PubMed, Google Scholar/Books, Google, and the HathiTrust Digital Library. Additional information was obtained via personal contact with American and European medical institutions, libraries, museums, as well as with the surgeons' family members and their perspective foundations. Remembering the life stories of the inventors behind commonly used eponyms in the operating theater reminds us of the long history of even the most rudimentary neurosurgical tool. This unrelenting strive for perfection reminds us, as surgeons, of our duty to continuously assess and improve our surgical tools and processes for the benefit of our patients.

Different factors influence recanalisation rate after coiling in ruptured and unruptured intracranial aneurysms.

BACKGROUND: Most studies evaluating long-term efficacy after coil embolisation of intracranial aneurysms have not differentiated between ruptured and unruptured aneurysms. OBJECTIVES: The aim of this study was to analyse factors that influence recanalisation in ruptured and unruptured aneurysms. METHODS: We performed a retrospective analysis of 182 (98 ruptured, 84 unruptured) aneurysms, treated with coil embolisation alone that received follow-up with digital substraction angiography (DSA). RESULTS: At 6 months 26% of the aneurysms showed recanalisation. Multivariate variance analysis revealed that different factors influenced recanalisation in ruptured and unruptured aneurysms. In ruptured aneurysms patient age was a determinant, with younger patients recanalising more frequently than older ones (p = 0.016). Also, low initial packing density led to higher recanalisation rates (p = 0.015) than higher packing. In the unruptured aneurysm group these factors were not significant. Here, only a larger aneurysm volume led to higher recanalisation rates (p = 0.027). CONCLUSIONS: Our data suggest that in ruptured aneurysms, high packing density is a key factor to prevent recanalisation, while in unruptured aneurysms, aneurysm volume is the main predictor for recanalisation.

Intraoperative CT in spine surgery.

BACKGROUND: In spinal instrumentation the misplacement of screws, cages and rods may cause neurovascular complications. Therefore a large variety of methods have been used in recent years to reduce such complications especially by navigation techniques and intraoperative three-dimensional fluoroscopy. The aim of this study is to answer the question: will intraoperative CT improve the efficiency of the treatment as well as the safety for the patient at the spinal instrumentation? Specific questions were: are the implants placed correctly and has decompression been performed sufficiently? METHODS: This is a prospective study in 100 patients mostly with degenerative diseases, tumours and trauma. 80 patients were treated by spinal instrumentation. A helical CT (Somatom Emotion 2003) was used, which is firmly bound to the OR table by a track system. RESULTS: 569 implants were used: 159 vertebra body screws and plates, 88 cages, 154 pedicle screws, 73 facet joint screws and 95 rods. There was malpositioning in seven patients (8.75%). 18 of 154 pedicle screws were misplaced, 2 of 88 cages, and 4 of 73 facet joint screws, for a total of 24 (7.6%). CONCLUSIONS: Intraoperative CT is a useful tool to check the correct position of the implants used, the extent of decompression and the realignment as early as possible. It therefore reduces second operations. A postoperative CT is no longer necessary.

The ProDisc-C prosthesis: clinical and radiological experience 1 year after surgery.

STUDY DESIGN: This is a prospective randomized and controlled study, approved by the local ethical committee of Saarland (Germany). OBJECTIVE: The aim of the current study was to analyze segmental motion following artificial disc replacement using disc prosthesis over 1 year. A second aim was to compare both segmental motion as well as clinical result to the current gold standard (anterior cervical discectomy and fusion [ACDF]). SUMMARY OF BACKGROUND DATA: ACDF may be considered to be the gold standard for treatment of symptomatic degenerative disc disease within the cervical spine. However, fusion may result in progressive degeneration of the adjacent segments. Therefore, disc arthroplasty has been introduced. Among these, artificial disc replacement seems to be promising. However, segmental motion should be preserved. This, again, is very difficult to judge and has not yet been proven. METHODS: A total of 49 patients with cervical disc herniation were enrolled and assigned to either study group (receiving a disc prosthesis) or control group (receiving ACDF, using a cage with bone graft and an anterior plate). Roentgen stereometric analysis (RSA) was used to quantify intervertebral motion immediately as well as 3, 6, 12, 24, and 52 weeks after surgery. Also, clinical results were judged using visual analog scale and neuro-examination at even RSA follow-up. RESULTS: Cervical spine segmental motion decreased over time in the presence of disc prosthesis or fusion device. However, the loss segmental motion is significantly higher in the fusion group, when looked at 3, 6, 12, 24, and 52 weeks after surgery. We observed significant pain reduction in neck and arm after surgery, without significant difference between both groups. CONCLUSION: Cervical spine disc prosthesis remains cervical spine segmental motion within the first 1 year after surgery. The clinical results are the same when compared with the early results following ACDF.

Sildenafil in the treatment of Raynaud's phenomenon resistant to vasodilatory therapy.

BACKGROUND: Vasodilatory therapy of Raynaud's phenomenon represents a difficult clinical problem because treatment often remains inefficient and may be not tolerated because of side effects. METHODS AND RESULTS: To investigate the effects of sildenafil on symptoms and capillary perfusion in patients with Raynaud's phenomenon, we performed a double-blinded, placebo-controlled, fixed-dose, crossover study in 16 patients with symptomatic secondary Raynaud's phenomenon resistant to vasodilatory therapy. Patients were treated with 50 mg sildenafil or placebo twice daily for 4 weeks. Symptoms were assessed by diary cards including a 10-point Raynaud's Condition Score. Capillary flow velocity was measured in digital nailfold capillaries by means of a laser Doppler anemometer. While taking sildenafil, the mean frequency of Raynaud attacks was significantly lower (35+/-14 versus 52+/-18, P=0.0064), the cumulative attack duration was significantly shorter (581+/-133 versus 1046+/-245 minutes, P=0.0038), and the mean Raynaud's Condition Score was significantly lower (2.2+/-0.4 versus 3.0+/-0.5, P=0.0386). Capillary blood flow velocity increased in each individual patient, and the mean capillary flow velocity of all patients more than quadrupled after treatment with sildenafil (0.53+/-0.09 versus 0.13+/-0.02 mm/s, P=0.0004). Two patients reported side effects leading to discontinuation of the study drug. CONCLUSIONS: Sildenafil is an effective and well-tolerated treatment in patients with Raynaud's phenomenon.