Launching the Quality Outcomes Database Tumor Registry: rationale, development, and pilot data.

OBJECTIVE: Neurosurgeons generate an enormous amount of data daily. Within these data lie rigorous, valid, and reproducible evidence. Such evidence can facilitate healthcare reform and improve quality of care. To measure the quality of care provided objectively, evaluating the safety and efficacy of clinical activities should occur in real time. Registries must be constructed and collected data analyzed with the precision akin to that of randomized clinical trials to accomplish this goal. METHODS: The Quality Outcomes Database (QOD) Tumor Registry was launched in February 2019 with 8 sites in its initial 1-year pilot phase. The Tumor Registry was proposed by the AANS/CNS Tumor Section and approved by the QOD Scientific Committee in the fall of 2018. The initial pilot phase aimed to assess the feasibility of collecting outcomes data from 8 academic practices across the United States; these outcomes included length of stay, discharge disposition, and inpatient complications. RESULTS: As of November 2019, 923 eligible patients have been entered, with the following subsets: intracranial metastasis (17.3%, n = 160), high-grade glioma (18.5%, n = 171), low-grade glioma (6%, n = 55), meningioma (20%, n = 184), pituitary tumor (14.3%, n = 132), and other intracranial tumor (24%, n = 221). CONCLUSIONS: The authors have demonstrated here, as a pilot study, the feasibility of documenting demographic, clinical, operative, and patient-reported outcome characteristics longitudinally for 6 common intracranial tumor types.

Radiographic and clinical outcomes using intraoperative magnetic resonance imaging for transsphenoidal resection of pituitary adenomas.

OBJECTIVE: The utility and safety of intraoperative MRI (iMRI) for resection of pituitary adenomas is not clearly established in the context of advances in endoscopic approaches. The goal in this study was to evaluate the safety and efficacy of iMRI for pituitary adenoma resection, with endoscopic transsphenoidal (ETS) versus microscopic transsphenoidal (MTS) approaches. METHODS: Radiographic and clinical outcomes of all pituitary adenomas resected using iMRI between 2008 and 2017 at a single institution were retrospectively evaluated. RESULTS: Of 212 tumors treated, 131 (62%) underwent further resection based on iMRI findings, resulting in a significant increase in gross-total resection on postoperative MRI compared with iMRI (p = 0.0001) in both ETS and MTS groups. iMRI increased rates of gross-total resection for cavernous sinus invasion Knosp grades 1 and 2, but not in Knosp ≥ 3 across treatment groups (p < 0.0001). The extent of resection on postoperative MRI was significantly correlated with increased progression-free survival (p < 0.0001). Initial hormone remission off medical therapy was achieved in 64%, with a significantly higher rate of remission in tumors resected via the ETS approach (81%) compared with the MTS approach (55%) (p = 0.02). The rate of persistent new hormone deficit was low at 8%, including a 2.8% rate of permanent diabetes insipidus, and 45% of patients had improvement in preoperative hormone deficit following surgery. Serious postoperative complications including CSF leaks requiring reoperation were rare at 1%, with no postoperative infections. CONCLUSIONS: These results suggest that iMRI is a safe and effective method of increasing the extent of resection for pituitary adenomas while preserving hormone function. When paired with the endoscope, iMRI may offer the ability to tailor more aggressive removal of tumors while optimizing pituitary function, resulting in high rates of secretory hormone remission. Secretory tumors and adenomas with Knosp grade < 3 cavernous sinus invasion may benefit most from the use of iMRI.

Preoperative Versus Extended Postoperative Antimicrobial Prophylaxis of Surgical Site Infection During Spinal Surgery: A Comprehensive Systematic Review and Meta-Analysis.

INTRODUCTION: Surgical site infection (SSI) following spinal surgery is a major source of postoperative morbidity. Although studies have demonstrated perioperative antimicrobial prophylaxis (AMP) to be beneficial in the prevention of SSI among spinal surgery patients, consensus is lacking over whether preoperative or extended postoperative AMP is most efficacious. To date, no meta-analysis has investigated the comparative efficacy of these two temporally variable AMP protocols in spinal surgery. We undertook a systemic review and meta-analysis to determine whether extended postoperative AMP is associated with a difference in the rate of SSI occurrence among adult patients undergoing spinal surgery. METHODS: Embase and MEDLINE databases were systematically searched for clinical trials and cohort studies directly comparing SSI rates among adult spinal surgery patients receiving either preoperative or extended postoperative AMP. Quality of evidence of the overall study population was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group approach. Random effects meta-analyses were performed utilizing both pooled and stratified data based on instrumentation use. RESULTS: Five studies met inclusion criteria. No individual study demonstrated a significant difference in the rate of SSI occurrence between preoperative and extended postoperative AMP protocols. The GRADE quality of evidence was low. Among the overall cohort of 2824 patients, 96% underwent lumbar spinal surgery. Pooled SSI rates were 1.38% (26/1887) for patients receiving extended postoperative AMP and 1.28% (12/937) for patients only receiving preoperative AMP. The risk of SSI development among patients receiving extended postoperative AMP was not significantly different from the risk of SSI development among patients only receiving preoperative AMP [RR (risk ratio), 1.11; 95% CI (confidence interval) 0.53-2.36; p = 0.78]. The difference in risk of SSI development when comparing extended postoperative AMP to preoperative AMP was also not significant for both instrumented (RR, 0.92; 95% CI 0.15-5.75; p = 0.93) and non-instrumented spinal surgery (RR, 1.25; 95% CI 0.49-3.17; p = 0.65). There was no evidence of heterogeneity of treatment effects for all meta-analyses. CONCLUSION: Preoperative AMP appears to provide equivalent protection against SSI development when compared to extended postoperative AMP. Prudent antibiotic use is also known to decrease hospital length of stay, healthcare expenditure, and risk of complications. However, until higher-quality evidence becomes available regarding AMP in spinal surgery, surgeons should continue to exercise discretion and clinical judgment when weighing the effects of patient comorbidities and complications before determining the optimal duration of perioperative AMP.

The relationship between surgical site drains and reoperation for wound-related complications following posterior cervical spine surgery: a multicenter retrospective study.

OBJECTIVEUse of surgical site drains following posterior cervical spine surgery is variable, and its impact on outcomes remains controversial. Studies of drain use in the lumbar spine have suggested that drains are not associated with reduction of reoperations for wound infection or hematoma. There is a paucity of studies examining this relationship in the cervical spine, where hematomas and infections can have severe consequences. This study aims to examine the relationship between surgical site drains and reoperation for wound-related complications following posterior cervical spine surgery.METHODSThis study is a multicenter retrospective review of 1799 consecutive patients who underwent posterior cervical decompression with instrumentation at 4 tertiary care centers between 2004 and 2016. Demographic and perioperative data were analyzed for associations with drain placement and return to the operating room.RESULTSOf 1799 patients, 1180 (65.6%) had a drain placed. Multivariate logistic regression analysis identified history of diabetes (OR 1.37, p = 0.03) and total number of levels operated (OR 1.32, p < 0.001) as independent predictors of drain placement. Rates of reoperation for any surgical site complication were not different between the drain and no-drain groups (4.07% vs 3.88%, p = 0.85). Similarly, rates of reoperation for surgical site infection (1.61% vs 2.58%, p = 0.16) and hematoma (0.68% vs 0.48%, p = 0.62) were not different between the drain and no-drain groups. However, after adjusting for history of diabetes and the number of operative levels, patients with drains had significantly lower odds of returning to the operating room for surgical site infection (OR 0.48, p = 0.04) but not for hematoma (OR 1.22, p = 0.77).CONCLUSIONSThis large study characterizes current practice patterns in the utilization of surgical site drains during posterior cervical decompression and instrumentation. Patients with drains placed did not have lower odds of returning to the operating room for postoperative hematoma. However, the authors' data suggest that patients with drains may be less likely to return to the operating room for surgical site infection, although the absolute number of infections in the entire population was small, limiting the analysis.

Factors associated with spinal fusion after posterior fossa decompression in pediatric patients with Chiari I malformation and scoliosis.

OBJECTIVE The authors performed a study to identify clinical characteristics of pediatric patients diagnosed with Chiari I malformation and scoliosis associated with a need for spinal fusion after posterior fossa decompression when managing the scoliotic curve. METHODS The authors conducted a multicenter retrospective review of 44 patients, aged 18 years or younger, diagnosed with Chiari I malformation and scoliosis who underwent posterior fossa decompression from 2000 to 2010. The outcome of interest was the need for spinal fusion after decompression. RESULTS Overall, 18 patients (40%) underwent posterior fossa decompression alone, and 26 patients (60%) required a spinal fusion after the decompression. The mean Cobb angle at presentation and the proportion of patients with curves > 35° differed between the decompression-only and fusion cohorts (30.7° ± 11.8° vs 52.1° ± 26.3°, p = 0.002; 5 of 18 vs 17 of 26, p = 0.031). An odds ratio of 1.0625 favoring a need for fusion was established for each 1° of increase in Cobb angle (p = 0.012, OR 1.0625, 95% CI 1.0135-1.1138). Among the 14 patients older than 10 years of age with a primary Cobb angle exceeding 35°, 13 (93%) ultimately required fusion. Patients with at least 1 year of follow-up whose curves progressed more 10° after decompression were younger than those without curve progression (6.1 ± 3.0 years vs 13.7 ± 3.2 years, p = 0.001, Mann-Whitney U-test). Left apical thoracic curves constituted a higher proportion of curves in the decompression-only group (8 of 16 vs 1 of 21, p = 0.002). CONCLUSIONS The need for fusion after posterior fossa decompression reflected the curve severity at clinical presentation. Patients presenting with curves measuring > 35°, as well as those greater than 10 years of age, may be at greater risk for requiring fusion after posterior fossa decompression, while patients less than 10 years of age may require routine monitoring for curve progression. Left apical thoracic curves may have a better response to Chiari malformation decompression.

The Role of Liposomal Bupivacaine in Reduction of Postoperative Pain After Transforaminal Lumbar Interbody Fusion: A Clinical Study.

BACKGROUND: Postoperative pain after transforaminal lumbar interbody fusion (TLIF) is a barrier to early mobility. Intraoperative local infiltration of anesthetic agents is standard practice to alleviate postoperative pain. Liposomal formulations may prolong the action of these anesthetic agents. The purpose of this study was to investigate the role of liposomal bupivacaine in postoperative pain control in patients undergoing unilateral, single-level TLIF. METHODS: From a cohort of 74 patients, half received nonliposomal local anesthetic and half received liposomal bupivacaine (LB) (LB group) via local infiltration. Both groups received a standard postoperative analgesia regimen. Demographic information, postoperative pain scores (visual analog scale), analgesic consumption, length of stay, and complications were retrospectively collected. RESULTS: The area under the curve of cumulative pain scores was significantly lower in the LB group between 0 and 12 hours (15.0 ± 15.6 vs. 45.6 ± 21.1, P = 0.003) and between 12 and 24 hours (37.6 ± 20.6 vs. 48.4 ± 24.9, P = 0.05) after surgery. Significantly fewer narcotic equivalents were consumed in the LB group between 12 and 24 hours (16.0 ± 13.4 mg vs. 24.1 ± 19.7 mg intravenous morphine equivalents, P = 0.04). Length of stay was significantly shorter in the LB group than in the control group (3.1 ± 0.9 days vs. 4.3 ± 1.3 days, P < .001). CONCLUSIONS: LB may be a useful adjunct during unilateral TLIF for decreasing pain and narcotic consumption in the first 24 hours after surgery and may also decrease overall length of stay.

Flow Diverter Therapy With the Pipeline Embolization Device Is Associated With an Elevated Rate of Delayed Fluid-Attenuated Inversion Recovery Lesions.

BACKGROUND AND PURPOSE: Flow diversion using the Pipeline Embolization Device is reported as a safe treatment of aneurysms. Complete aneurysm occlusion, however, occurs in a delayed fashion with initial persistent filling of the aneurysm dome. We hypothesized that this transflow across metallic struts may be associated with thromboembolic events. METHODS: Forty-one consecutive patients undergoing aneurysm treatment with the Pipeline Embolization Device and a comparison group of 78 Neuroform stent-mediated embolizations were studied. Patients' charts, procedure notes, platelet function, and anticoagulation state were analyzed. Serial magnetic resonance images were assessed for the presence of newly occurring diffusion-weighted imaging and fluid-attenuated inversion recovery (FLAIR) lesions at multiple postprocedure time ranges (average days post procedure [Pipeline Embolization Device/Neuroform]: T1=1, T2=73/107, T3=174, T4=277/335, and T5=409). In addition, diffusion-weighted imaging or FLAIR burden was estimated by lesional diameter summation. RESULTS: Pipeline patients were more likely to have new ipsilateral FLAIR lesions at all time points studied (30.6% versus 7.2% of patients at T=2 and 34.5% versus 6.2% at T=4). The mean FLAIR burden was significantly increased for Pipeline patients (10.1 versus 0.7 mm at T=2 and 8.8 versus 1.9 mm at T=4). Overall 34% (14/41) of Pipeline patients experienced a new FLAIR lesion at anytime when compared with 10% (8/78) of Neuroform stent-coil patients. Postprocedural diffusion-weighted imaging did not predict future FLAIR lesions suggesting a nonprocedural cause. CONCLUSIONS: The Pipeline Embolization Device is associated with increased rate of de novo FLAIR lesions occurring in a delayed fashion and distinct from perioperative diffusion-weighted imaging lesions. The cause and clinical effect of these lesions are unknown and suggest the need for prudent follow-up and evaluation.

Survival following Ommaya reservoir placement for neoplastic meningitis.

The objective of this study was to evaluate the outcomes of patients with neoplastic meningitis (NM) following Ommaya reservoir placement in order to determine whether any patient factors are associated with longer survival. NM is a devastating late manifestation of cancer, and given its dismal prognosis, identifying appropriate patients for Ommaya reservoir placement is difficult. The authors performed a retrospective review of 80 patients who underwent Ommaya reservoir placement at three medical centers from September 2001 through September 2012. The primary outcome was death. Differences in survival were assessed with Kaplan-Meier survival analyses. The Cox proportional hazards and logistic regression modeling were performed to identify factors associated with survival. The primary diagnoses were solid organ, hematologic, and primary central nervous system tumors in 53.8%, 41.3%, and 5%, respectively. The median overall survival was 72.5 days (95% confidence interval 36-122) with 30% expiring within 30 days and only 13.8% surviving more than 1 year. There were no differences in median overall survival between sites (p=0.37) despite differences in time from diagnosis of NM to Ommaya reservoir placement (p<0.001). Diagnosis of hematologic malignancy was inversely associated with death within 90 days (p=0.04; odds ratio 0.34), older age was associated with death within 90 days (p=0.05; odds ratio 1.5, per 10 year increase in age). The prognosis of NM remains poor despite the available treatment with intraventricular chemotherapy. There exists significant variability in treatment algorithms among medical centers and consideration of this variability is crucial when interpreting existing series of Ommaya reservoir use in the treatment of patients with NM.

Magnetic resonance imaging as an alternative to computed tomography in select patients with traumatic brain injury: a retrospective comparison.

OBJECT: Traumatic head injury (THI) is a highly prevalent condition in the United States, and concern regarding excess radiation-related cancer mortality has placed focus on limiting the use of CT in the evaluation of pediatric patients with THI. Given the success of rapid-acquisition MRI in the evaluation of ventriculoperitoneal shunt malfunction in pediatric patient populations, this study sought to evaluate the sensitivity of MRI in the setting of acute THI. METHODS: Medical records of 574 pediatric admissions for THI to a Level 1 trauma center over a 10-year period were retrospectively reviewed to identify patients who underwent both CT and MRI examinations of the head within a 5-day period. Thirty-five patients were found, and diagnostic images were available for 30 patients. De-identified images were reviewed by a neuroradiologist for presence of any injury, intracranial hemorrhage, diffuse axonal injury (DAI), and skull fracture. Radiology reports were used to calculate interrater reliability scores. Baseline demographics and concordance analysis was performed with Stata version 13. RESULTS: The mean age of the 30-patient cohort was 8.5 ± 6.7 years, and 63.3% were male. The mean Injury Severity Score was 13.7 ± 9.2, and the mean Glasgow Coma Scale score was 9 ± 5.7. Radiology reports noted 150 abnormal findings. CT scanning missed findings in 12 patients; the missed findings included DAI (n = 5), subarachnoid hemorrhage (n = 6), small subdural hematomas (n = 6), cerebral contusions (n = 3), and an encephalocele. The CT scan was negative in 3 patients whose subsequent MRI revealed findings. MRI missed findings in 13 patients; missed findings included skull fracture (n = 5), small subdural hematomas (n = 4), cerebral contusions (n = 3), subarachnoid hemorrhage (n = 3), and DAI (n = 1). MRI was negative in 1 patient whose preceding CT scan was read as positive for injury. Although MRI more frequently reported intracranial findings than CT scanning, there was no statistically significant difference between CT and MRI in the detection of any intracranial injury (p = 0.63), DAI (p = 0.22), or intracranial hemorrhage (p = 0.25). CT scanning tended to more frequently identify skull fractures than MRI (p = 0.06). CONCLUSIONS: MRI may be as sensitive as CT scanning in the detection of THI, DAI, and intracranial hemorrhage, but missed skull fractures in 5 of 13 patients. MRI may be a useful alternative to CT scanning in select stable patients with mild THI who warrant neuroimaging by clinical decision rules.

Morphometric analysis of lumbar pedicles in patients with spinal dysraphism.

BACKGROUND: In patients with open neural tube defects, the incidence of scoliosis and requirement for spinal fusions are increased. Historically, there has been no standardized measurement of vertebral morphometry in these patients. However, anecdotally, patients with open neural tube defects have a more medially oriented lumbar pedicle trajectory than the average population. METHODS: A single-institution retrospective review of patients with open neural tube defects was conducted. The demographic parameters and functional and anatomical levels of the defects were noted. CT and MRI scans of the lumbar spine were analyzed; the pedicles from L 1 to S 1 were measured for width (W), length (L) and midline angle (α). The measurements were compared bilaterally, at each level, and with data from previously published reports. RESULTS: 16 scans of pediatric patients (mean = 3.0 ・} 4.3; age range = 7 days to 14.4 years; 7 males, 9 females) with a diagnosis of either myelomeningocele or lipomyelomeningocele were assessed. Most defects occurred in the lumbar region, with L 2 and L 5 accounting for 37.5% each. All angles demonstrated a quadratic increase from L 1 to S 1 (means: L 1 = 28.3 ・} 5.24° ; L 2 = 29.1 ・} 6.2°; L 3 = 33.2 ・} 6.0°; L 4 = 36.8 ・} 5.6°; L 5 = 43.8 ・} 5.9°; S 1 = 52.0 ・} 3.6°) and were more medially angulated than those reported previously; no significant difference existed between right and left measurements (W = 0.65 ≤ p ≤ 0.94; L = 0.91 ≤ p ≤ 1; α = 0.24 ≤p ≤0.86). CONCLUSIONS: Patients with open neural tube defects had more medially angled pedicle trajectories in the lumbar spine when compared to previously reported values.

Non-operative outcomes in Chiari I malformation patients.

While postoperative outcomes of Chiari I malformation patients have been well-reported, there is a paucity of literature concerning non-operative management in these patients. We retrospectively identified patients with Chiari I malformation who were not recommended for surgery based on lack of clinical objective findings or inconsistent cough headaches and conducted patient follow-up with a prospective telephone survey. Of the 68 patients (mean age at diagnosis 30.1 ± 17.4 years), 72% were female and 31% were pediatric patients (age at diagnosis ⩽ 18 years). Average follow up was 4.9 ± 2.9 years. Typical presenting symptoms included cough headache, non-specific headache, nausea, ataxia, dysphagia and paresthesias. Overall, 40% of patients who had cough headaches and 61.5% of patients with non-specific headaches reported improvement. The presence of subjective sensory symptoms was significantly associated with less likelihood of cough headache improvement while the presence of a cough headache was also associated with a lower likelihood of improvement in all non-cough symptoms. The pediatric subgroup had a greater rate of improvement with all cases of nausea/emesis and paresthesias improved or resolved at follow-up. Overall 67% of pediatric patients had improved cough headache and 71% had improvement of migraines/diffuse headaches. We found that many symptoms of Chiari I patients from our conservatively managed cohort either improved or remained unchanged over time. However, the presence of cough headaches was a significant negative predictor of concomitant symptom improvement. This further validates the view that patients with cough headaches should be considered for surgical intervention and provides useful information to counsel patients.

A review of the combined medical and surgical management in patients with herpes simplex encephalitis.

BACKGROUND: Herpes simplex encephalitis (HSE) is a devastating and severe viral infection of the human central nervous system. This viral encephalitis is well known to cause severe cerebral edema and hemorrhagic necrosis with resultant increases in intracranial pressure (ICP). While medical management has been standardized in the treatment of this disease, the role of aggressive combined medical and surgical management including decompressive craniectomy and/or temporal lobectomy has not been fully evaluated. In addition, while barbiturate coma has been studied for treatment of status epilepticus associated with infectious encephalitis, its use for treatment of encephalitis associated intractable intracranial hypertension has not been fully reported. CASE DESCRIPTION: We report the case of a 22 year old female with severe herpetic encephalitis requiring aggressive ICP management utilizing all modalities (both medical and surgical) known to control ICP. She continues to have memory deficits but has made a good recovery with a Glasgow Outcome Scale score of 5. CONCLUSION: We provide evidence that aggressive combined medical and surgical therapy is warranted even in cases of severe HSE with transtentorial herniation, as there is evidence for the potential of good recovery. A detailed literature review of the medical and surgical management strategies in this disease is presented.

Postoperative cervical sagittal imbalance negatively affects outcomes after surgery for cervical spondylotic myelopathy.

STUDY DESIGN: Prospective observational cohort study. OBJECTIVE: To determine if postoperative cervical sagittal balance is an independent predictor of health-related quality of life outcome after surgery for cervical spondylotic myelopathy. SUMMARY OF BACKGROUND DATA: Both ventral and dorsal fusion procedures for CSM are effective at reducing the symptoms of myelopathy. The importance of cervical sagittal balance in predicting overall health-related quality of life outcome after ventral versus dorsal surgery for CSM has not been previously explored. METHODS: A prospective, nonrandomized cohort of 49 patients undergoing dorsal and ventral fusion surgery for CSM was examined. Preoperative and postoperative C2-C7 sagittal vertical axis was measured on standing lateral cervical spine radiographs. Outcome was assessed with 2 disease-specific measures-the modified Japanese Orthopedic Association scale and the Oswestry Neck Disability Index and 2 generalized outcome measures-the Short-Form 36 physical component summary (SF-36 PCS) and Euro-QOL-5D. Assessments were performed preoperatively, and at 3 months, 6 months, and 1 year postoperatively. Statistical analyses were performed using SAS version 9.3 (SAS Institute). RESULTS: Most patients experienced improvement in all outcome measures regardless of approach. Both preoperative and postoperative C2-C7 sagittal vertical axis measurements were independent predictors of clinically significant improvement in SF-36 PCS scores (P = 0.03 and P = 0.02). The majority of patients with C2-C7 sagittal vertical axis values greater than 40 mm did not improve from an overall health-related quality of life perspective (SF-36 PCS) despite improvement in myelopathy. The postoperative sagittal balance value was inversely correlated with a clinically significant improvement of SF-36 PCS scores in patients undergoing dorsal surgery but not ventral surgery (P = 0.03 vs. P = 0.93). CONCLUSION: Preoperative and postoperative sagittal balance measurements independently predict clinical outcomes after surgery for CSM. LEVEL OF EVIDENCE: 2.

Comparison of operative and non-operative outcomes based on surgical selection criteria for patients with Chiari I malformations.

Few studies have directly compared operative and non-operative outcomes in Chiari I patients. We evaluated risk factors for clinical improvement in 177 patients in order to help determine the optimal treatment of these often difficult to treat patients. The mean age at surgery for the operative treatment group was 29.9 years. The most common presenting signs and symptoms included cough headache (63.0%), migraine and non-cough type headaches (23.9%), paresthesias (32.1%), and abnormal reflexes or clonus (27.5%). The mean age of diagnosis for the non-operative treatment group was 30.2 years. The most common presenting signs or symptoms included migraine and other types of non-cough-associated headache (57.4%), paresthesias (45.6%), cough headache (44.1%), cerebellar signs or symptoms (41.2%), and dysphagia or apnea (15.7%). A propensity score was generated using cough headache, any headache, other headache, syrinx, abnormal reflexes or clonus, cerebellar symptoms, and miscellaneous symptoms as independent predictors of selection for surgery. The propensity score-adjusted odds of overall improvement for patients treated with surgery were 16.5 times the odds of overall improvement for patients treated conservatively (95% confidence interval 5.5-57.1, p<0.0001). Overall 94.5% and 47.1% of operative and conservatively treated patients reported improvement, respectively. Only 26.5% of conservatively treated patients reported worsening of any of their symptoms. In conclusion, we provided further evidence for the use of cough headache as surgical indication for suboccipital decompression in patients with Chiari I malformation.

Pigmented villonodular synovitis of the thoracic spine.

Pigmented villonodular synovitis (PVNS) is a proliferative lesion of the synovial membranes. Knees, hips, and other large weight-bearing joints are most commonly affected. PVNS rarely presents in the spine, in particular the thoracic segments. We present a patient with PVNS in the thoracic spine and describe its clinical presentation, radiographic findings, pathologic features, and treatment as well as providing the first comprehensive meta-analysis and review of the literature on this topic, to our knowledge. A total of 28 publications reporting 56 patients were found. The lumbar and cervical spine were most frequently involved (40% and 36% of patients, respectively) with infrequent involvement of the thoracic spine (24% of patients). PVNS affects a wide range of ages, but has a particular predilection for the thoracic spine in younger patients. The mean age in the thoracic group was 22.8 years and was significantly lower than the cervical and lumbar groups (42.4 and 48.6 years, respectively; p=0.0001). PVNS should be included in the differential diagnosis of osteodestructive lesions of the spine, especially because of its potential for local recurrence. The goal of treatment should be complete surgical excision. Although the pathogenesis is not clear, mechanical strain may play an important role, especially in cervical and lumbar PVNS. The association of thoracic lesions and younger age suggests that other factors, such as neoplasia, derangement of lipid metabolism, perturbations of humoral and cellular immunity, and other undefined patient factors, play a role in the development of thoracic PVNS.

Postpartum internal carotid and vertebral arterial dissections.

OBJECTIVE: Headache and neck pain are common postpartum symptoms. However, these symptoms can rarely be associated with internal carotid artery and vertebral artery dissections. We aimed to review five cases of postpartum cervical artery dissection and to review the clinical course of previously reported cases. METHODS: Patients with postpartum dissections diagnosed at our institution since 2005 were identified through a database maintained by the senior author, and their clinical data were reviewed. Additionally, a literature search for previously reported cases was performed, and the clinical data in those reports were reviewed. RESULTS: Five patients presented with cervical artery dissections within 6 weeks postpartum. Four patients had delivered vaginally and one delivered by emergent cesarean. Headache and neck pain were the primary presenting symptoms of all five patients. Four patients demonstrated neurologic symptoms, and one had development of stroke. Two patients had single internal carotid artery dissections, one patient had bilateral dissections of the vertebral artery, and two patients had dissections in the internal carotid artery and vertebral artery. All patients were treated with either anticoagulation therapy or antiplatelet therapy. Two patients required endovascular stenting. Four of five patients returned to neurologic baseline after treatment. A literature search yielded 27 previously reported cases, with similar clinical characteristics of older reproductive age, presentation days to weeks from delivery, and recovery to neurologic baseline in the majority of patients. CONCLUSION: Postpartum cervical dissections are rare occurrences that require prompt diagnosis to prevent long-term neurologic deficits. Individualized management strategies include medical treatment (anticoagulation therapy, antiplatelet therapy, or anticoagulation and antiplatelet therapy) and endovascular recanalization.

Surgeons' perspectives on optimal patient positioning during simultaneous cranial procedures and exploratory laparotomy.

OBJECTIVES: Patients presenting with traumatic intracranial and intraabdominal injuries often require emergent care. Triage of injuries is based on severity of the individual injuries, but treatment occasionally must proceed simultaneously. Determining an optimal patient position at the time of surgery often produces unnecessary delays and this delay may negatively affect patient outcome. This study aimed to determine an operative patient position that simultaneously optimizes access to neurosurgical and general surgical teams without compromising sterility or severely affecting surgeon and anesthesia comfort. METHODS: Photographs of traditional exploratory laparotomy patient positioning (position A), traditional supine craniotomy patient positioning (position B), and a hybrid patient position (position C) were presented to 29 general surgeons and 12 neurosurgeons at a single institution. Surgeons were asked to rate the positions on acceptability and to rank the three positions according to preference when simultaneous exploratory laparotomy and craniotomy were necessary. RESULTS: Position C was rated as an acceptable option by 82.8% of general surgeons and 100% of neurosurgeons. In addition, 51.9% of general surgeons and 81.8% of neurosurgeons preferred position C to their respective specialty's traditional patient positioning in situations that required simultaneous exploratory laparotomy and craniotomy. CONCLUSIONS: We present a novel hybrid operative patient position for use during simultaneous exploratory laparotomy and craniotomy. In doing so, we emphasize the importance of constructive dialogue among trauma surgeons and neurosurgeons in optimizing the care of acutely ill trauma patients with multisystem injuries.

Risk to the vertebral artery during C-2 translaminar screw placement: a thin-cut computerized tomography angiogram-based morphometric analysis: clinical article.

OBJECT: The goal of this study was to characterize the anatomy relevant to placement of crossing C-2 translaminar screws, including morphometric data, and to evaluate the risk of violating the vertebral artery (VA) during the screw placement. Placement of bilateral crossing C-2 translaminar screws has become an increasingly popular method for dorsal C-2 instrumentation as it is felt to avoid the known risk of VA injury associated with C1-2 transarticular screw fixation and C-1 lateral mass-C-2 pars screw fixation. METHODS: The source images from 50 CT angiograms of the neck obtained from October to November 2007 were studied. Digital imaging software was used to measure lamina thickness and maximum screw length, perform angulation of screw trajectories in the axial plane, and evaluate the potential for VA injury. In cases where the VA could be injured, the distance between the maximal screw length and artery was measured. Logistic regression was performed to evaluate lamina width, axial angle, and screw length for predicting the potential for VA injury. RESULTS: Mean lamina thickness, axial angle, and maximal screw length were determined for 100 laminae, and a potential for VA injury was noted in 55 laminae. The anatomically defined ideal screw length was longer in laminae with potential for VA injury than in laminae with no apparent risk (35.2 vs 33.6 mm, p = 0.0131). Only increasing optimal screw length was noted to be a statistically significant predictor of potential VA injury (p = 0.0159). The "buffer zone" (the distance between an optimally placed screw and the VA) was 5.6 ± 1.9 mm (mean ± SD, range 1.8-11.4 mm). A screw limited to 28 mm in length appeared to be safe in all laminae studied. CONCLUSIONS: Crossing C-2 translaminar screws have been reported to be safe and effective. In addition to morphometric characteristics, the authors have found that screws placed in this trajectory could jeopardize the vertebral arteries in the foramen transversarium or the C1-2 interval. A C-2 translaminar screw limited to 28 mm in length appeared to be safe in all 100 screw trajectories studied in this series.

Mild elevations of international normalized ratio at hospital Day 1 and risk of expansion in warfarin-associated subdural hematomas.

OBJECT: A primary goal in the treatment of patients with warfarin-associated subdural hematoma (SDH) is reversal of coagulopathy with fresh-frozen plasma. Achieving the traditional target international normalized ratio (INR) of 1.3 is often difficult and may expose patients to risks of volume overload and of thromboembolic complications. This retrospective study evaluates the risk of mild elevations of INR from 1.31 to 1.69 at 24 hours after admission in patients presenting with warfarin-associated SDH. METHODS: Sixty-nine patients with warfarin-associated SDH and 197 patients with non-warfarin-associated SDH treated at a single institution between January 2005 and January 2012 were retrospectively identified. Charts were reviewed for patient age, history of trauma, associated injuries, neurological status at presentation, size and chronicity of SDH, associated midline shift, INR at admission and at hospital Day 1 (HD1), concomitant aspirin or Plavix use, platelet count, and medical comorbidities. Patients were stratified according to use of warfarin and by INR at HD1 (INR 0.8-1.3, 1.31-1.69, 1.7-1.99, and ≥ 2). The groups were evaluated for differences the in rate of radiographic expansion of SDH and in the rate of clinically significant SDH expansion resulting in death, unplanned procedure, and/or readmission. RESULTS: There was no difference in the rate of radiographic versus clinically significant expansion of SDH between patients not on warfarin and those on warfarin (no warfarin: 22.3% vs 20.3%, p = 0.866; warfarin: 10.7% vs 11.6%, p = 0.825), but the rate of medical complications was significantly higher in the warfarin subgroup (13.3% for patients who did not receive warfarin vs 26.1% for those who did; p = 0.023). For warfarin-associated SDH, there was no difference in the rate of radiographic versus clinically significant expansion between patients reversed to HD1 INRs of 0.8-1.3 and 1.31-1.69 (HD1 INR 0.8-1.3: 22.5% vs 20%, p = 1; HD1 INR 1.31-1.69: 15% vs 10%, p = 0.71). CONCLUSIONS: Mild INR elevations of 1.31-1.69 in warfarin-associated SDH are not associated with a markedly increased risk of radiographic or clinically significant expansion of SDH. Larger prospective studies are needed to determine if subtherapeutic INR elevations at HD1 are associated with smaller increases in risk of SDH expansion.

Successful management of an acute subdural hematoma in a patient dependent on continuous treprostinil infusion therapy.

Treprostinil is a synthetic analog of prostacyclin, which is used for treatment of pulmonary arterial hypertension (PAH). Continuous subcutaneous administration of treprostinil has been proven in randomized controlled trials to improve quality of life, hemodynamics, and 5-year survival in patients with PAH. The efficacy of treprostinil has been attributed to its vasodilatory and antiplatelet effects. Unfortunately, the efficacy of treprostinil in the treatment of PAH is rapidly reversed upon cessation of the continuous infusion. Furthermore, cases of patients rapidly declining or succumbing to disease progression upon cessation of treprostinil have raised significant concern regarding discontinuation of this medication. To date, there are no reports of emergency craniotomies performed in the setting of continuous subcutaneous infusion of treprostinil. The authors report a case of a patient with PAH, treated with continuous administration of subcutaneous treprostinil as well as warfarin, who developed an acute subdural hematoma (SDH). Despite adequate INR (international normalized ratio) correction, the patient eventually underwent an emergency craniotomy for evacuation of the SDH while on continuous treprostinil administration. This case highlights the neurosurgical dilemma regarding the appropriate management of acute SDHs in patients receiving continuous treprostinil infusion.