Can Young Vascular Neurosurgeons Become Proficient in Microsurgical Clip Reconstruction in the Endovascular Era? A Rotterdam Cohort Spanning 2 Decades with Propensity Score Matching for Complexity.

BACKGROUND: Little is known about the results of young vascular neurosurgeons who perform only microsurgical clip reconstruction in the era since the International Subarachnoid Aneurysm Trial (ISAT) or about the training and caseload required to equivocate the results of senior, more experienced colleagues. The aim of this study was to compare clinical outcomes of patients treated by young and senior vascular neurosurgeons at Erasmus MC University Medical Center Rotterdam, adjusting for case mix. METHODS: A partially prospective and partially retrospective database was used. Hierarchical mixed models with a random intercept for surgeon were used for confounder adjustment, and propensity score matching for complexity was used to create comparable groups. RESULTS: The study included 609 patients harboring 767 aneurysms. Most (86%) of the aneurysms had at least 1 complexity characteristic, with the majority having 3 characteristics. The most often encountered complexity characteristics were the presence of a broad neck and the presence of branches emerging from the aneurysm. Use of temporary clipping and skull base approaches was significantly higher in the young vascular neurosurgeons group (P < 0.0001). The complexity score differed significantly between senior and young vascular neurosurgeons (P < 0.001). After propensity score matching for complexity, multivariable logistic regression showed young vascular neurosurgeons to be significantly associated with better outcomes for ruptured aneurysms (propensity score weighted odds ratio 0.55 [95% confidence interval 0.35-0.88], P = 0.01). CONCLUSIONS: In a high-volume neurovascular center where both endovascular and microsurgical treatment options are available, young vascular neurosurgeons can be trained to achieve at least the same results as their senior colleagues despite increased complexity.

A novel noninstrumented surgical approach for foramen reconstruction for isthmic spondylolisthesis in patients with radiculopathy: preliminary clinical and radiographic outcomes.

OBJECTIVE The health care costs for instrumented spine surgery have increased dramatically in the last few decades. The authors present a novel noninstrumented surgical approach for patients with isthmic spondylolisthesis, with clinical and radiographic results. METHODS Charts of patients who underwent this technique were reviewed. The procedure consisted of nerve root decompression by reconstruction of the intervertebral foramen. This was achieved by removal of the pedicle followed by noninstrumented posterolateral fusion in which autologous bone graft from the right iliac crest was used. Outcomes regarding radicular complaints, bony fusion, progression of the slip, and complications were evaluated using patient history and radiographs obtained at follow-up intervals of 3-18 months after surgery. RESULTS A total of 58 patients with a mean age of 47 years were treated with this method. Partial removal of the pedicle was performed in 93.1% of the cases, whereas in 6.9% of the cases the entire pedicle was removed. The mean duration of surgery was 216.5 ± 54.5 minutes (range 91-340 minutes). The mean (± SD) duration of hospitalization was 10.1 ± 2.9 days (range 5-18 days). After 3 months of follow-up, 86% of the patients reported no leg pain, and this dropped to 81% at last follow-up. Radiographic follow-up showed bony fusion in 87.7% of the patients. At 1 year, 5 patients showed progression of the slip, which in 1 patient prompted a second operation within 1 year. No major complications occurred. CONCLUSIONS Treatment of isthmic spondylolisthesis by reconstruction of the intervertebral neuroforamen and posterolateral fusion in situ is a safe procedure and has comparable results with the existing techniques. Cost-effectiveness research comparing this technique to conventional instrumented fusion techniques is necessary to evaluate the merits for both patients and society.

Occurrence of malignant vertebral fractures in an emergency room setting.

BACKGROUND: To perform a risk analysis study to determine the probability of a spinal fracture being of malignant origin in patients presenting at a level I trauma centre emergency room after trauma. PATIENTS AND METHODS: Data from 334 consecutive patients were retrospectively obtained from 1993 to 2003. They were divided into two groups: group 1--(benign) traumatic fractures; and group 2--malignant fractures (n = 32). For statistical analysis independent Student t test, chi2 test, and backward-stepwise logistic regression were used. RESULTS: The risk of vertebral fractures appearing to be of malignant origin increased with anatomical location (non-cervical--that is, thoracic or lumbar: odds ratio (OR) 48, 95% confidence interval (CI) 8 to 291), a history of malignancy (OR 72, 95% CI 12 to 422), trauma mechanism (that is, high energy: OR 0.03, 95% CI 0.003 to 0.28), and age >64 years (OR 3, 95% CI 0.9 to 12). Hence, patients over 64 years old attending the emergency room, with a vertebral fracture after a low energy trauma, had an approximately 50% chance of having a malignant fracture. With a non-cervical location and a history of malignancy this increased to 98%. Regardless of the trauma mechanism and age of the patient, a history of a malignancy and a non-cervical fracture posed at least a 36% risk of having a malignant fracture. CONCLUSION: Supported by the present results we feel the probability of malignant fractures, although not frequently encountered, should always be considered in elderly and middle-aged patients with a history of malignancy and a non-cervical traumatic fracture.