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Ryan Hirschi, Gregory W. J. Hawryluk, Jessica L. Nielson, J. Russell Huie, Lara L. Zimmermann, Rajiv Saigal, Quan Ding, Adam R. Ferguson and Geoffrey Manley

OBJECTIVE

Brain tissue hypoxia is common after traumatic brain injury (TBI). Technology now exists that can detect brain hypoxia and guide corrective therapy. Current guidelines for the management of severe TBI recommend maintaining partial pressure of brain tissue oxygen (PbtO2) > 15–20 mm Hg; however, uncertainty persists as to the optimal treatment threshold. The object of this study was to better inform the relationship between PbtO2 values and outcome for patients with TBI.

METHODS

PbtO2 measurements were prospectively and automatically collected every minute from consecutive patients admitted to the San Francisco General Hospital neurological ICU during a 6-year period. Mean PbtO2 values in TBI patients as well as the proportion of PbtO2 values below each of 75 thresholds between 0 mm Hg and 75 mm Hg over various epochs up to 30 days from the time of admission were analyzed. Patient outcomes were determined using the Glasgow Outcome Scale. The authors explored putative treatment thresholds by generating 675 separate receiver operating characteristic curves and 675 generalized linear models to examine each 1–mm Hg threshold for various epochs.

RESULTS

A total of 1,380,841 PbtO2 values were recorded in 190 TBI patients. A high proportion of PbtO2 measures were below 20 mm Hg irrespective of the examined epoch. Time below treatment thresholds was more strongly associated with outcome than mean PbtO2. A treatment window was suggested: a threshold of 19 mm Hg most robustly distinguished patients by outcome, especially from days 3–5; however, benefit was suggested from maintaining values at least as high as 33 mm Hg.

CONCLUSIONS

This analysis of high-frequency physiological data substantially informs the relationship between PbtO2 values and outcome. The results suggest a therapeutic window for PbtO2 in TBI patients along with minimum and preferred PbtO2 treatment thresholds, which may be examined in future studies. Traditional treatment thresholds that have the strongest association with outcome may not be optimal.

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Hussam Abou-Al-Shaar, Mohammed A. Azab, Michael Karsy, Jian Guan, Gmaan Alzhrani, Yair M. Gozal, Randy L. Jensen and William T. Couldwell

OBJECTIVE

Microsurgical resection and radiosurgery remain the most widely used interventions in the treatment of vestibular schwannomas. There is a growing demand for cost-effectiveness analyses to evaluate these two treatment modalities and delineate the factors that drive their total costs. Here, the authors evaluated specific cost drivers for microsurgical and radiosurgical management of vestibular schwannoma by using the Value Driven Outcomes system available at the University of Utah.

METHODS

The authors retrospectively reviewed all cases involving microsurgical and radiosurgical treatment of vestibular schwannomas at their institution between November 2011 and September 2017. Patient and tumor characteristics, subcategory costs, and potential cost drivers were analyzed.

RESULTS

The authors identified 163 vestibular schwannoma cases, including 116 managed microsurgically and 47 addressed with stereotactic radiosurgery (SRS). There were significant differences between the two groups in age, tumor size, and preoperative Koos grade (p < 0.05), suggesting that indications for treatment were markedly different. Length of stay (LOS) and length of follow-up were also significantly different. Facility costs were the most significant contributor to both microsurgical and SRS groups (58.3% and 99.4%, respectively); however, physician professional fees were not specifically analyzed. As expected, microsurgical treatment resulted in an average 4-fold greater overall cost of treatment than for SRS cases (p < 0.05), and there was a greater variation in costs for open cases as well. Costs remained stable over time for both open resection and SRS. Multivariable analysis showed that LOS (β = 0.7, p = 0.0001), discharge disposition (β = 0.2, p = 0.004), nonserviceable hearing (β = 0.1, p = 0.02), and complications (β = 0.2, p = 0.005) affected cost for open surgery, whereas no specifically examined factor could be identified as driving costs for SRS.

CONCLUSIONS

This analysis identified the fact that facility utilization constitutes the majority of total costs for both microsurgery and SRS treatment modalities of vestibular schwannomas. LOS, discharge disposition, nonserviceable hearing, and complications contributed significantly to the total costs for the microsurgical group, whereas none of the factors could be identified as driving total costs for the SRS group. This information may be used to establish policies and protocols to reduce facility costs, with the goal of decreasing the total costs without jeopardizing patient care.

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Galal Elsayed, Matthew S. Erwood, Matthew C. Davis, Esther C. Dupépé, Samuel G. McClugage III, Paul Szerlip, Beverly C. Walters and Mark N. Hadley

OBJECTIVE

This study defines the association of preoperative physical activity level with functional outcomes at 3 and 12 months following surgical decompression for lumbar spinal stenosis.

METHODS

Data were collected as a prospective observational registry at a single institution from 2012 through 2015, and then analyzed with a retrospective cohort design. Patients who were able to participate in activities outside the home preoperatively were compared to patients who did not participate in such activities, with respect to 3-month and 12-month functional outcomes postintervention, adjusted for relevant confounders.

RESULTS

Ninety-nine patients were included. At baseline, sedentary/inactive patients (n = 55) reported greater back pain, lower quality of life, and higher disability than similarly treated patients who were active preoperatively. Both cohorts experienced significant improvement from baseline in back pain, leg pain, disability, and quality of life at both 3 and 12 months after lumbar decompression surgery. At 3 months postintervention, sedentary/inactive patients reported more leg pain and worse disability than patients who performed activities outside the home preoperatively. However, at 12 months postintervention, there were no statistically significant differences between the two cohorts in back pain, leg pain, quality of life, or disability. Multivariate analysis revealed that sedentary/inactive patients had improved disability and higher quality of life after surgery compared to baseline. Active patients experienced greater overall improvement in disability compared to inactive patients.

CONCLUSIONS

Sedentary/inactive patients have a more protracted recovery after lumbar decompression surgery for spinal stenosis, but at 12 months postintervention can expect to reach similar long-term outcomes as patients who are active/perform activities outside the home preoperatively.

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Lucas Alverne F. Albuquerque, Fátima C. Pessoa, Gabryella S. Diógenes, Felipe S. Borges and Stélio C. Araújo Filho

Cavernous angiomas constitute 5%–10% of cerebrovascular malformations and may cause seizure and neurological deficits from bleeding.4 The authors present a case of a 44-year-old man with a 3.5-year history of epilepsy without complete seizure control despite anticonvulsants. Brain MRI showed a 2.8 cm cavernous angioma at the left pars opercularis, also known as the Broca’s area.3 The patient underwent an awake craniotomy for intraoperative cortical–subcortical language and sensory-motor mapping for a complete resection of the cavernous angioma and the hemosiderin rim.1–6 The procedure was uneventful, and the patient evolved seizure free and with no deficits.

The video can be found here: https://youtu.be/QajbLIsr_vg.

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Eva Pamias-Portalatin, Ivan Segura Duran, James Ebot, Elird Bojaxhi, William Tatum and Alfredo Quiñones-Hinojosa

Cavernomas make up approximately 8%–15% of all intracranial vascular malformations, and the most common presenting symptom is seizures. Complete resection of the cavernoma and removal of the surrounding gliotic core presents a cure but poses a challenge if an eloquent brain is involved or with incomplete resection of the epileptogenic foci. The authors present the case of a 53-year-old man with intractable seizures from a left posterior temporal lobe cavernoma who underwent an awake craniotomy with intraoperative seizure monitoring via electrocorticography.

The video can be found here: https://youtu.be/vxaikozg2g4.

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Rafael T. M. Leal and Jose A. Landeiro

Awake craniotomy is a method usually used for brain tumors near or within language and/or sensorimotor areas. Preservation of these important neurological functions, however, may not be enough for a normal life. The authors present a case of a 45-year-old woman with an inferior parietal lobule low-grade glioma who underwent an awake craniotomy with sensorimotor and spatial cognition mapping.

The video can be found here: https://youtu.be/HMA_pZYg3Ms.

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Thiébaud Picart and Hugues Duffau

A 30-year-old right-handed female medical doctor experienced generalized seizures. MRI showed a left operculo-insular low-grade glioma. Awake resection was proposed. During the cortical mapping, counting and naming task combined with right upper limb movement enabled the identification of the ventral premotor cortex and negative motors areas. The so-called Broca’s area was not eloquent. Subpial dissection was performed by avoiding coagulation until the inferior fronto-occipital fasciculus and the junction between the output projection fibers and the anterior part of the superior longitudinal fasciculus III were reached. The patient resumed a normal familial and socio-professional life despite the resection of Broca’s area.

The video can be found here: https://youtu.be/OALk0tvctQw.

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Ashish H. Shah, Ernest Barthélemy, Yudy Lafortune, Joanna Gernsback, Ariel Henry, Barth Green and John Ragheb

Given Haiti’s longstanding socioeconomic burden and recent environmental and epidemiological catastrophes, the capacity for neurosurgery within Haiti has been limited, and outcomes for patients with neurosurgical conditions have remained poor. With few formally trained neurosurgeons (4) in a country of 10.5 million inhabitants, there is a significant need for the development of formal structured neurosurgical training. To mitigate the lack of neurosurgical care within Haiti, the authors established the first neurosurgical residency program within the country by creating an integrated model that uniquely fortifies existing Haitian neurosurgery with government sponsorship (Haitian Ministry of Health and National Medical School) and continual foreign support. By incorporating web-based learning modules, online assessments, teleconferences, and visiting professorships, the residency aims to train neurosurgeons over the course of 3–5 years to meet the healthcare needs of the nation. Although in its infancy, this model aims to facilitate neurosurgical capacity building by ultimately creating a self-sustaining residency program.

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Liang Xu, Zhonghui Chen, Yong Qiu, Xi Chen, Song Li, Changzhi Du, Qingshuang Zhou and Xu Sun

OBJECTIVE

As scoliosis in arthrogryposis multiplex congenita (AMC) is unusual and the number of cases reviewed in previous studies is also relatively small, no previous study exists that has directly compared the results of spinal deformity correction between AMC and adolescent idiopathic scoliosis (AIS) patients. The aim of this study was to compare the radiographic and clinical outcomes of surgical correction of spinal deformity associated with AMC versus AIS.

METHODS

Twenty-four adolescents with AMC were matched with 48 AIS patients in terms of Cobb angle of main curve, curve pattern, sex, age at surgery, Risser grade, and length of follow-up. Patients in both groups underwent posterior-only spinal correction and fusion procedures. The surgical outcomes and complications were analyzed and compared between the 2 groups.

RESULTS

In comparison to the AIS group, the AMC group had a significantly longer mean operation time (5.6 vs 4.4 hours, p = 0.002), more blood loss (1620 ± 250 ml vs 840 ± 260 ml, p < 0.001), and more fusion levels (14.1 ± 2.3 levels vs 12.4 ± 2.5 levels, p = 0.007) as well as a lower correction rate (44.3% ± 11.1% vs 70.8% ± 12.4%, p < 0.001) and a higher rate of loss of correction (5.0% ± 3.1% vs 2.1% ± 1.9%, p < 0.001). Nine patients in the AMC group had preoperative pelvic obliquity, which was corrected from a mean of 14.2° ± 8.4° to a mean of 4.3° ± 3.2° (p < 0.001) after the surgery. The thoracic lordosis and sagittal vertical axis were significantly improved in the AMC group. Notably, however, the AMC group was found to have higher rates of screw malpositioning (15.9% vs 9.5%, p = 0.002) and complications (8/24 [33.3%] vs 4/48 [8.3%], p = 0.016) as compared to the AIS group.

CONCLUSIONS

Correction of AMC-associated scoliosis tends to require a longer operating time and involve more fusion levels but results in less correction, more blood loss, and more complications, in comparison with AIS. In addition, more attention should be paid to pelvic obliquity and sagittal hyperlordosis in AMC patients.

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David Kitya, Maria Punchak, Jihad Abdelgadir, Oscar Obiga, Derek Harborne and Michael M. Haglund

OBJECTIVE

Causes, clinical presentation, management, and outcomes of chronic subdural hematoma (CSDH) in low- and middle-income countries are not well characterized in the literature. Knowledge regarding these factors would be beneficial in the development and implementation of effective preventive and management measures for affected patients. The authors conducted a study to gain a better understanding of these factors in a low-income setting.

METHODS

This prospective study was performed at Mbarara Regional Referral Hospital (MRRH) in Uganda between January 2014 and June 2017. Patients of any age who presented and were diagnosed with CSDH during the aforementioned time period were included in the study. Variables were collected from patients’ files at discharge and follow-up clinic visits. The primary outcome of interest was death. Secondary outcomes of interest included discharge Glasgow Coma Scale (GCS) score, ICU admission, wound infection, and CSDH recurrence.

RESULTS

Two hundred five patients, the majority of whom were male (147 [72.8%]), were enrolled in the study. The mean patient age was 60.2 years (SD 17.7). Most CSDHs occurred as a result of motor vehicle collisions (MVCs) and falls, 35.6% (73/205) and 24.9% (51/205), respectively. The sex ratio and mean age varied depending on the mechanism of injury. Headache was the most common presenting symptom (89.6%, 173/193), whereas seizures were uncommon (11.5%, 23/200). Presenting symptoms differed by age. A total of 202 patients underwent surgical intervention with burr holes and drainage, and 22.8% (46) were admitted to the ICU. Two patients suffered a recurrence, 5 developed a postoperative wound infection, and 18 died. Admission GCS score was a significant predictor of the discharge GCS score (p = 0.004), ICU admission (p < 0.001), and death (p < 0.001).

CONCLUSIONS

Trauma from an MVC is the commonest cause of CSDH among the young. For the elderly, falling is common, but the majority have CSDH with no known cause. Although the clinical presentation is broad, there are several pronounced differences based on age. Burr hole surgery plus drainage is a safe and reliable intervention. A low preoperative GCS score is a risk factor for ICU admission and death.