Browse

You are looking at 91 - 100 of 38,045 items for

  • Refine by Access: all x
Clear All
Open access

Georgia Kaidonis, Melike Pekmezci, Jessica Van Ziffle, Kurtis I. Auguste, and Jonathan C. Horton

BACKGROUND

In the past decade, next-generation sequencing has spurred significant progress in the understanding of cytogenetic alterations that occur in meningiomas. Eighty percent of adult meningiomas harbor pathogenic somatic variants involving NF2, TRAF7, SMARCB1, KLF4, PI3K, or POLR2A. Somatic variants in TRAF7 associated with meningiomas usually localize to the gene’s WD40 domains but are mutually exclusive to germline mutations, which cause a distinctive autosomal dominant syndrome.

OBSERVATIONS

This case involved a 15-year-old girl with bilateral optic nerve sheath meningiomas, diffuse meningiomatosis, and syndromic features, including craniosynostosis, brain anomalies, syndactyly, brachydactyly, epicanthus, and patent ductus arteriosus. Genetic testing of the meningioma specimen 7 years after biopsy showed a pathogenic p.R641C variant within the WD40 domain of the TRAF7 gene. Additional testing of unaffected tissues identified the same variant at lower allele frequencies, consistent with postzygotic somatic mosaicism.

LESSONS

The authors report postzygotic somatic mosaicism for a p.R641C variant in the TRAF7 gene in a patient with bilateral optic nerve sheath meningiomas, diffuse meningiomatosis and a constellation of systemic findings previously recognized in patients with germline mutations of this gene. This is the first report of optic nerve sheath meningioma in a patient with mutation in the TRAF7 gene.

Open access

Ghani Haider, Katherine E. Wagner, Venita Chandra, Ivan Cheng, Martin N. Stienen, and Anand Veeravagu

BACKGROUND

The use of the lateral decubitus approach for L5–S1 anterior lumbar interbody fusion (LALIF) is a recent advancement capable of facilitating single-position surgery, revision operations, and anterior column reconstruction. To the authors’ knowledge, this is the first description of the use of LALIF at L5–S1 for failed prior transforaminal lumbar interbody fusion (TLIF) and anterior column reconstruction. Using an illustrative case, the authors discuss their experience using LALIF at L5–S1 for the revision of pseudoarthrosis and TLIF failure.

OBSERVATIONS

The patient had prior attempted L2 to S1 fusion with TLIF but suffered from hardware failure and pseudoarthrosis at the L5–S1 level. LALIF was used to facilitate same-position revision at L5–S1 in addition to further anterior column revision and reconstruction by lateral lumbar interbody fusion at the L1–2 level. Robotic posterior T10–S2 fusion was then added to provide stability to the construct and address the patient’s scoliotic deformity. No complications were noted, and the patient was followed until 1 year after the operation with a favorable clinical and radiological result.

LESSONS

Revision of a prior failed L5–S1 TLIF with an LALIF approach has technical challenges but may be advantageous for single position anterior column reconstruction under certain conditions.

Restricted access

Hani Malone, Gregory M. Mundis Jr., Martin Collier, Reilly L. Kidwell, Fernando Rios, Michael Jelousi, Shae Galli, Bahar Shahidi, Behrooz A. Akbarnia, and Robert K. Eastlack

OBJECTIVE

Intervertebral devices are increasingly utilized for fusion in the lumbar spine, along with a variety of bone graft materials. These various grafting materials often have substantial cost burdens for the surgical procedure, although they are necessary to overcome the limitations in healing capacity for many traditional interbody devices. The use of bioactive interbody fusion devices, which have demonstrable stimulatory capacity for the surrounding osteoblasts and osteoprogenitor cells and allow for osseointegration, may reduce this heavy reliance on osteobiologics for achieving interbody fusion. The objective of this study was to evaluate the rate of successful interbody fusion with a bioactive lateral lumbar interbody titanium implant with limited volume and low-cost graft material.

METHODS

The authors conducted a retrospective study (May 2017 to October 2018) of consecutively performed lateral lumbar interbody fusions with a bioactive 3D-printed porous titanium interbody device. Each interbody device was filled with 2–3 cm3/cage of a commercially available ceramic bone extender (β-tricalcium phosphate-hydroxyapatite) and combined with posterior pedicle screw fixation. No other biological agents or grafts were utilized. Demographic, clinical, and radiographic variables were captured. Fusion success was the primary endpoint of the study, with graft subsidence, fixation failure, and patient-reported outcomes (Oswestry Disability Index [ODI] and visual analog scale [VAS]–back and –leg pain scores) collected as secondary endpoints. The authors utilized a CT-based fusion classification system that accounted for both intervertebral through-growth (bone bridging) and ingrowth (integration of bone at the endplate-implant interface).

RESULTS

In total, 136 lumbar levels were treated in 90 patients. The mean age was 69 years, and 63% of the included patients were female. Half (50.0%) had undergone previous spinal surgery, and a third (33.7%) had undergone prior lumbar fusion. A third (33.7%) were treated at multiple levels (mean levels per patient 1.51). One year after surgery, the mean improvements in patient-reported outcomes (vs preoperative scores) were −17.8 for ODI (p < 0.0001), −3.1 for VAS–back pain (p < 0.0001), and −2.9 for VAS–leg pain (p < 0.0001). Bone bridging and/or appositional integrity was achieved in 99.3% of patients, including 97.8% who had complete bone bridging. No fixation loosening or implant failure was observed at any segment. Low-grade graft subsidence (Marchi grade ≤ I) occurred in 3 levels (2.2%), and intraoperative endplate violation occurred twice (1.5%). High-grade subsidence was not found. No implant failure or revision surgery for pseudarthrosis/subsidence was necessary.

CONCLUSIONS

The use of bioactive titanium interbody devices with a large surface footprint appears to result in a very high rate of effective fusion, despite the use of a small volume of low-cost biological material. This potential change in the osteobiologics required to achieve high fusion rates may have a substantially beneficial impact on the economic burden inherent to spinal fusion.

Restricted access

Edouard Mazerand, Sandro Benichi, Maxime Taverne, Giovanna Paternoster, Alice Rolland, Pierre Antherieu, Julien Todeschi, Lawrence Kamdem Noumoye, Vianney Gilard, Maxime Bretonnier, Luc Le Fournier, Vincent Jecko, Edouard Gimbert, François Proust, Sergio Boetto, Thomas Roujeau, Syril James, Roman H. Khonsari, Laurent Riffaud, Matthieu Delion, Michel Zerah, and Didier Scavarda

OBJECTIVE

Chiari malformation type I (CM-I) is frequent in children and remains a surgical challenge. Several techniques have been described for posterior fossa decompression. No decision algorithm has been validated, and strategies are highly variable between institutions. The goal of this study was to define therapeutic guidelines that take into consideration patient specificities.

METHODS

The authors retrospectively collected data from patients who were < 18 years of age, were diagnosed with CM-I, and were treated surgically between 2008 and 2018 in 8 French pediatric neurosurgical centers. Data on clinical features, morphological parameters, and surgical techniques were collected. Clinical outcomes at 3 and 12 months after surgery were assessed by the Chicago Chiari Outcome Scale. The authors used a hierarchical clustering method to define clusters of patients by considering their anatomical similarities, and then compared outcomes between surgical strategies in each of these clusters.

RESULTS

Data from 255 patients were collected. The mean age at surgery was 9.6 ± 5.0 years, syringomyelia was reported in 60.2% of patients, the dura mater was opened in 65.0% of patients, and 17.3% of patients underwent a redo surgery for additional treatment. The mean Chicago Chiari Outcome Scale score was 14.4 ± 1.5 at 3 months (n = 211) and 14.6 ± 1.9 at 12 months (n = 157). The hierarchical clustering method identified three subgroups with potentially distinct mechanisms underlying tonsillar herniation: bony compression, basilar invagination, and foramen magnum obstruction. Each cluster matched with specific outcomes.

CONCLUSIONS

This French multicenter retrospective cohort study enabled the identification of three subgroups among pediatric patients who underwent surgery for CM-I, each of which was associated with specific outcomes. This morphological classification of patients might help in understanding the underlying mechanisms and providing personalized treatment.

Restricted access

Peixi Liu, Zongze Li, Liuxun Hu, Yingjun Liu, Peiliang Li, Wei Zhu, Yanlong Tian, and Ying Mao

OBJECTIVE

The authors aimed to evaluate the clinical features, endovascular strategy selection, and outcomes of vertebral artery (VA) dissecting aneurysms (VADAs) near the origin of the posterior inferior cerebellar artery (PICA).

METHODS

Clinical data were obtained from 196 patients with 202 VADAs who had been surgically treated at the authors’ hospital between 2005 and 2021. The patients’ medical records, imaging data, and follow-up outcomes were retrospectively analyzed.

RESULTS

All 196 patients (148 male, 48 female; mean age 53 years) underwent endovascular therapy for VADA. The most common chief complaints were headache (56.6%), dizziness (40.8%), and other occasional symptoms (18.4%). Twenty-six patients experienced posterior circulation ischemia, and 25 patients experienced subarachnoid hemorrhage (SAH). On DSA images, 37 aneurysms were found in the dominant VA, and 165 aneurysms were found on the nondominant side. Eighty-eight VADAs had stenosis. Regarding the VADA location, there were 59 distal, 51 proximal, 23 ventral, 64 PICA, and 5 obliteration types. Single-stent implantation (10.9%), overlapping stent implantation (23.8%), flow diverter (FD) implantation (11.9%), single stent-assisted coil (SAC) embolization (31.7%), overlapping SAC embolization (12.9%), parent artery occlusion (PAO) (8.4%), and FD-assisted coil embolization (0.5%) were chosen. The follow-up rate was 82.7%. The modified Rankin Scale (mRS) score was 0.5 ± 1.1. Ninety-six patients underwent DSA. The complete occlusion rates were 100%, 81.4%, 56.7%, and 76.5% in the PAO group, SAC reconstruction group, stent implantation group, and FD implantation group, respectively.

CONCLUSIONS

Young patients showed a higher probability of SAH, and elderly patients showed a higher probability of posterior circulation infarction. The surgical plan selection should be based on the SAH history, VA dominant side, and PICA origin location.

Restricted access

Rajiv K. Sethi, Caroline E. Drolet, Rebecca P. Pumpian, Jesse Shen, Kelsey Hanson, Sofia Guerra, and Philip K. Louie

OBJECTIVE

Measuring costs across entire episodes of care, time-driven activity-based costing (TDABC) has recently been described as a novel cost accounting arm of value-based care organizations. Lean methodology is a system used to understand pathways of care at a granular level, allowing for standardization. The current work presents an attempt at combining the 2 methodologies to detect meaningful variation in a patient’s care following single-level spine fusion. The objective of this study was to evaluate the combination of TDABC and lean methodologies in detecting meaningful variability in time-based care in patients undergoing single-level spine fusion surgery.

METHODS

This study is a consecutive case series of patients who underwent single-level spine fusion performed by 1 of 5 fellowship-trained spine surgeons. Patients were diagnosed with either lumbar stenosis or spondylolisthesis. Additional inclusion criteria included inpatient stays from 1 to 3 days, discharge to home, and no readmission within 30 days of surgery. Patient demographic data were obtained. Time spent on activities for each personnel role was aggregated in 15-minute increments occurring preoperatively, intraoperatively, and postoperatively. Patients were analyzed in 3 groups based on the duration of their in-hospital stay.

RESULTS

Patients discharged on postoperative day (POD) 3 had statistically significantly more total time spent than those discharged on POD 2. Patients discharged on POD 1 had less total time than those in the former 2 groups. The amount of time spent with patients did not differ for personnel in either preoperative or postanesthesia care unit phases of care. There was a statistically significant difference in time spent in surgery for surgeons, anesthesia attendings, circulators, and scrub technicians.

CONCLUSIONS

In a healthcare setting run by lean methodology, TDABC may detect meaningful variability in an episode of care for single-level spine fusion. Clinicians and administrators can use this combination to allocate costs appropriately, optimize value care streams, and help improve patient care.

Restricted access

Ann Mansur, Benjamin Morgan, Alexandre Lavigne, Nicolas Phaneuf-Garand, Jocelyne Diabira, Han Yan, Unni G. Narayanan, Darcy Fehlings, Golda Milo-Manson, Blythe Dalziel, Sara Breitbart, Claude Mercier, Dominic Venne, Pierre Marois, Alexander G. Weil, Jeffrey S. Raskin, Sruthi P. Thomas, and George M. Ibrahim

OBJECTIVE

In nonambulatory children with predominantly spastic cerebral palsy (CP), the authors compared care needs, symptom burden, and complications after surgical treatment with either intrathecal baclofen (ITB) pump insertion or selective dorsal rhizotomy (SDR). The patients were treated at two Canadian centers with variability in practice pertaining to these surgical options.

METHODS

The authors performed a retrospective analysis of nonambulatory children with predominantly spastic quadriplegic or diplegic CP who underwent treatment with ITB or SDR. These two strategies were retrospectively assessed by comparing patient data from the two treatment groups for demographic characteristics, outcomes, and complications. A partial least-squares analysis was performed to identify patient phenotypes associated with outcomes.

RESULTS

Thirty patients who underwent ITB and 30 patients who underwent SDR were included for analysis. Patients in the ITB group were older and had lower baseline functional status, with greater burdens of spasticity, dystonia, pain, deformity, bladder dysfunction, and epilepsy than patients in the SDR group. In addition, children who underwent SDR had lower Gross Motor Function Classification System (GMFCS) levels and were less likely to experience complications than those who underwent ITB. However, children treated with SDR had fewer improvements in pain than children treated with ITB. A single significant latent variable explaining 88% of the variance in the data was identified.

CONCLUSIONS

Considerable baseline differences exist within this pediatric CP patient population. Factors specific to individual children must be taken into account when determining whether ITB or SDR is the appropriate treatment.

Restricted access

Kazuya Kitamura, Eddie de Dios, Gergely Bodon, Laszlo Barany, and Anna MacDowall

OBJECTIVE

Muscle-preserving selective laminectomy (SL) is an alternative to conventional decompression surgery in patients with degenerative cervical myelopathy (DCM). It is less invasive, preserves the extensor musculature, and maintains the range of motion of the cervical spine. Therefore, the preferred treatment for DCM at the authors’ institution has changed from anterior decompression and fusion (ADF), including anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF), toward SL. The aim of this study was to evaluate surgical outcomes before and after this paradigm shift with patient-reported outcome measures (PROMs), complications, reoperations, and cost-effectiveness.

METHODS

This study was a retrospective register-based cohort study. All patients with DCM who underwent ADF or SL at the authors’ institution from 2008 to 2019 were reviewed. Using ANCOVA, changes in PROMs from baseline to the 2-year follow-up were compared between the two groups, adjusting for clinicodemographic parameters, baseline PROMs, number of decompressed levels, and MRI measurements (C2–7 Cobb angle, C2–7 sagittal vertical axis [SVA], and modified K-line interval [mK-line INT]). The PROMs, including the European Myelopathy Score (EMS), the Neck Disability Index (NDI), and the EQ-5D, were collected from the national Swedish Spine Register. Complications, reoperations, and in-hospital treatment costs were also compared between the two groups.

RESULTS

Ninety patients (mean age 60.7 years, 51 men [57%]) were included in the ADF group and 63 patients (mean age 68.8 years, 41 men [65%]) in the SL group. The ADF and SL groups had similar PROMs at baseline. The preoperative MR images showed similar C2–7 Cobb angles (10.7° [ADF] vs 14.1° [SL], p = 0.12) and mK-line INTs (4.08 vs 4.88 mm, p = 0.07), but different C2–7 SVA values (16.2 vs 19.3 mm, p = 0.04). The comparison of ANCOVA-adjusted mean changes in PROMs from baseline to the 2-year follow-up presented no significant differences between the groups (EMS, p = 0.901; NDI, p = 0.639; EQ-5D, p = 0.378; and EQ-5D health, p = 0.418). The overall complication rate was twice as high in the ADF group (22.2% vs 9.5%, p = 0.049), while the reoperation rate was comparable (16.7% vs 7.9%, p = 0.146). The average in-hospital treatment cost per patient was $6617 (USD) for SL, $7046 for ACDF, and $12,000 for ACCF.

CONCLUSIONS

SL provides similar PROMs after 2 years, a significantly lower complication rate, and better cost-effectiveness compared with ADF.

Restricted access

Geraint J. Sunderland, Elizabeth J. Conroy, Alexandra Nelson, Carrol Gamble, Michael D. Jenkinson, Michael J. Griffiths, and Conor L. Mallucci

OBJECTIVE

The British Antibiotic and Silver Impregnated Catheter Shunt (BASICS) trial established level I evidence of the superiority of antibiotic-impregnated catheters in the prevention of infection of newly implanted ventriculoperitoneal shunts (VPSs). A wealth of patient, shunt, and surgery-specific data were collected from trial participants beyond that of the prespecified trial objectives.

METHODS

This post hoc analysis of the BASICS survival data explores the impact of patient age, hydrocephalus etiology, catheter type, valve type, and previous external ventricular drain on the risk of infection or mechanical failure. Time to failure was analyzed using Fine and Gray survival regression models for competing risk.

RESULTS

Among 1594 participants, 75 patients underwent revision for infection and 323 for mechanical failure. Multivariable analysis demonstrated an increased risk of shunt infection associated with patient ages < 1 month (subdistribution hazard ratio [sHR] 4.48, 95% CI 2.06–9.72; p < 0.001) and 1 month to < 1 year (sHR 2.67, 95% CI 1.27–5.59; p = 0.009), as well as for adults with posthemorrhagic hydrocephalus (sHR 2.75, 95% CI 1.21–6.26; p = 0.016). Age ≥ 65 years was found to be independently associated with reduced infection risk (sHR 0.26, 95% CI 0.10–0.69; p = 0.007). Antibiotic-impregnated catheter use was also associated with reduced infection risk (sHR 0.43, 95% CI 0.22–0.84; p = 0.014). Independent risk factors predisposing to mechanical failure were age < 1 month (sHR 1.51, 95% CI 1.03–2.21; p = 0.032) and 1 month to < 1 year (sHR 1.31, 95% CI 0.95–1.81; p = 0.046). Age ≥ 65 years was demonstrated to be the only independent protective factor against mechanical failure risk (sHR 0.64, 95% CI 0.40–0.94; p = 0.024).

CONCLUSIONS

Age is the predominant risk for VPS revision for infection and/or mechanical failure, with neonates and infants being the most vulnerable.

Restricted access

Zong-Yu Yu, Ming-Hsuan Chung, Peng-Wei Wang, Yi-Chieh Wu, Hsiang-Chih Liao, and Dueng-Yuan Hueng