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Factors associated with readmission after minimally invasive transforaminal lumbar interbody fusion

Luis M. Tumialán, Nolan Weinstein, S. Harrison Farber, Shashvat M. Desai, and Frederick F. Marciano

OBJECTIVE

The objective of this study was to identify factors that lead to a prolonged hospital stay or 30-day readmission after minimally invasive surgery (MIS) for transforaminal lumbar interbody fusion (TLIF) at a single institution.

METHODS

Consecutive patients who underwent MIS TLIF from January 1, 2016, to March 31, 2018, were retrospectively analyzed. Demographic data, including age, sex, ethnicity, smoking status, and body mass index, were collected along with operative details, indications, affected spinal levels, estimated blood loss, and operative duration. The effects of these data were evaluated relative to the hospital length of stay (LOS) and 30-day readmission.

RESULTS

The authors identified 174 consecutive patients who underwent MIS TLIF at 1 or 2 levels from a prospectively collected database. The mean (range) patient age was 64.1 (31–81) years, 97 were women (56%), and 77 were men (44%). Of 182 levels fused, 127 were done at L4–5 (70%), 32 at L3–4 (18%), 13 at L5–S1 (7%), and 10 at L2–3 (5%). Patients underwent 166 (95%) single-level procedures and 8 (5%) 2-level procedures. The mean (range) procedural duration, defined as the time from incision to closure, was 164.6 (90–529) minutes. The mean (range) LOS was 1.8 (0–8) days. Eleven patients (6%) were readmitted within 30 days; the most frequent causes were urinary retention, constipation, and persistent or contralateral symptoms. Seventeen patients had LOS greater than 3 days. Six of those patients (35%) were identified as widows, widowers, or divorced, and 5 of them lived alone. Six patients with prolonged LOS (35%) required placement in either skilled nursing or acute inpatient rehabilitation. Regression analyses showed living alone (p = 0.04) and diabetes (p = 0.04) as predictors of readmission. Regression analyses revealed female sex (p = 0.03), diabetes (p = 0.03), and multilevel surgery (p = 0.006) as predictors of LOS > 3 days.

CONCLUSIONS

Urinary retention, constipation, and persistent radicular symptoms were the leading causes of readmission within 30 days of surgery in this series, which is distinct from data from the American College of Surgeons National Surgical Quality Improvement Program. The inability to discharge a patient home for social reasons led to prolonged inpatient hospital stays. Identifying these risk factors and proactively addressing them could lower readmission rates and decrease LOS among patients undergoing MIS TLIF.

In Journal of Neurosurgery: Spine Publish Before Print

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History of neurosurgery at Howard University: the nation’s only historically black academic institution that practices neurological surgery

Deja M. Rush and Damirez T. Fossett

Howard University Hospital has been a pillar for healthcare delivery in the Black community, an underserved sector of Washington, DC, since its founding in 1862. Neurological surgery, one of the many areas of service provided, was established by trailblazer Dr. Clarence Greene Sr., who was appointed the division’s first chief in 1949. Because of the color of his skin, Dr. Greene had to complete his neurosurgical training at the Montreal Neurological Institute, as he was refused the opportunity to train in the United States. He went on to become the first African American to be board certified in neurological surgery in 1953. Drs. Jesse Barber, Gary Dennis, and Damirez Fossett, the subsequent division chiefs, have all continued Dr. Greene’s legacy of providing academic enrichment and subserving a disparate population. Many patients who may not have received treatment otherwise have been able to receive exemplary neurosurgical care from them. Under their tutelage, numerous African American medical students have gone on to train in neurological surgery. Future directions include developing a residency program, collaborating with other neurosurgery programs in continental Africa and the Caribbean, and establishing a fellowship for training international students.

In Journal of Neurosurgery Publish Before Print

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Hydrocephalus and school-age neurodevelopmental outcomes in the management of myelomeningocele prenatal surgery trial: a secondary analysis

Jack M. Fletcher, Amy J. Houtrow, Cora MacPherson, Nina H. Thomas, Nalin Gupta, N. Scott Adzick, and Elizabeth A. Thom

OBJECTIVE

The purpose of this secondary analysis was to assess the role of hydrocephalus on neurodevelopmental outcomes in a cohort of school-age children enrolled in the Management of Myelomeningocele Study (MOMS) clinical trial.

METHODS

The sample analyzed in this report consisted of 150 of 183 children aged 5–10 years (mean ± SD 7 years 8 months ± 1.2) who were randomly assigned between 20 and 26 weeks of gestational age to undergo either prenatal or postnatal surgery and were enrolled in the school-age follow-up study of MOMS. These 150 children (76 prenatal and 74 postnatal) were placed into three groups: no hydrocephalus (n = 22), unshunted hydrocephalus (n = 31), and shunted hydrocephalus (n = 97). Comparisons were made on the basis of measures of adaptive behavior, intelligence, reading and math skills, verbal and nonverbal memory, fine motor dexterity, and sensorimotor skills. Parent ratings of executive functions, inattention, and hyperactivity-impulsivity were also compared.

RESULTS

There were no statistically significant differences in neurodevelopmental outcomes between the groups with no hydrocephalus and unshunted hydrocephalus, or between the prenatal and postnatal groups with shunted hydrocephalus, so these groups were combined (no/unshunted vs shunted hydrocephalus). The no/unshunted group showed significantly better performance (p < 0.05) than the shunted group in terms of adaptive behavior, intelligence, verbal and nonverbal memory, reading skills (but not math), fine motor dexterity, sensorimotor skills (but not visual-motor integration), and inattention (but not hyperactivity-impulsivity or executive function ratings). An assessment of the prenatal surgery group showed that the combined no/unshunted group performed better than the shunted group in terms of adaptive behavior and verbal memory skills. Both the prenatal and postnatal surgery subgroups with unshunted hydrocephalus performed as well as the group with no hydrocephalus despite significantly enlarged ventricles.

CONCLUSIONS

Although the primary assessment of school-age outcomes in the MOMS clinical trial did not show better adaptive behavior and cognitive skills in the prenatal group, hydrocephalus and shunting were associated with poorer neurodevelopmental outcomes (both prenatal and postnatal groups). Disease severity and dynamic changes in hydrocephalus status may be the primary factors in the need for shunting and a major determinant of adaptive behavior and cognitive outcomes after prenatal surgery.

In Journal of Neurosurgery: Pediatrics Publish Before Print

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Incorporating simulation into the neurosurgical residency curriculum: a program director survey

Kent J. Kilbourn, Nathan K. Leclair, Jonathan E. Martin, Markus J. Bookland, Inam U. Kureshi, Ketan R. Bulsara, and David S. Hersh

In Journal of Neurosurgery Publish Before Print

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Letter to the Editor. Acoustic analysis during glioma surgery

Binghao Zhao and Wenbin Ma

In Journal of Neurosurgery Publish Before Print

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Letter to the Editor. Pedicle screw pullout strength, screw diameter, and possible complications

Masanori Hashimoto, Tadatsugu Morimoto, Masatsugu Tsukamoto, Hirohito Hirata, and Masaaki Mawatari

In Journal of Neurosurgery: Spine Publish Before Print

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Magnetic resonance imaging–guided stereotactic laser ablation therapy for the treatment of pediatric epilepsy: a retrospective multiinstitutional study

Elsa V. Arocho-Quinones, Sean M. Lew, Michael H. Handler, Zulma Tovar-Spinoza, Matthew D. Smyth, Robert J. Bollo, David Donahue, M. Scott Perry, Michael Levy, David Gonda, Francesco T. Mangano, Benjamin C. Kennedy, Phillip B. Storm, Angela V. Price, Daniel E. Couture, Chima Oluigbo, Ann-Christine Duhaime, Gene H. Barnett, Carrie R. Muh, Michael D. Sather, Aria Fallah, Anthony C. Wang, Sanjiv Bhatia, Daniel Eastwood, Sergey Tarima, Sarah Graber, Sean Huckins, Daniel Hafez, Kavelin Rumalla, Laurie Bailey, Sabrina Shandley, Ashton Roach, Erin Alexander, Wendy Jenkins, Deki Tsering, George Price, Antonio Meola, Wendi Evanoff, Eric M. Thompson, Nicholas Brandmeir, and

OBJECTIVE

The authors of this study evaluated the safety and efficacy of stereotactic laser ablation (SLA) for the treatment of drug-resistant epilepsy (DRE) in children.

METHODS

Seventeen North American centers were enrolled in the study. Data for pediatric patients with DRE who had been treated with SLA between 2008 and 2018 were retrospectively reviewed.

RESULTS

A total of 225 patients, mean age 12.8 ± 5.8 years, were identified. Target-of-interest (TOI) locations included extratemporal (44.4%), temporal neocortical (8.4%), mesiotemporal (23.1%), hypothalamic (14.2%), and callosal (9.8%). Visualase and NeuroBlate SLA systems were used in 199 and 26 cases, respectively. Procedure goals included ablation (149 cases), disconnection (63), or both (13). The mean follow-up was 27 ± 20.4 months. Improvement in targeted seizure type (TST) was seen in 179 (84.0%) patients. Engel classification was reported for 167 (74.2%) patients; excluding the palliative cases, 74 (49.7%), 35 (23.5%), 10 (6.7%), and 30 (20.1%) patients had Engel class I, II, III, and IV outcomes, respectively. For patients with a follow-up ≥ 12 months, 25 (51.0%), 18 (36.7%), 3 (6.1%), and 3 (6.1%) had Engel class I, II, III, and IV outcomes, respectively. Patients with a history of pre-SLA surgery related to the TOI, a pathology of malformation of cortical development, and 2+ trajectories per TOI were more likely to experience no improvement in seizure frequency and/or to have an unfavorable outcome. A greater number of smaller thermal lesions was associated with greater improvement in TST.

Thirty (13.3%) patients experienced 51 short-term complications including malpositioned catheter (3 cases), intracranial hemorrhage (2), transient neurological deficit (19), permanent neurological deficit (3), symptomatic perilesional edema (6), hydrocephalus (1), CSF leakage (1), wound infection (2), unplanned ICU stay (5), and unplanned 30-day readmission (9). The relative incidence of complications was higher in the hypothalamic target location. Target volume, number of laser trajectories, number or size of thermal lesions, or use of perioperative steroids did not have a significant effect on short-term complications.

CONCLUSIONS

SLA appears to be an effective and well-tolerated treatment option for children with DRE. Large-volume prospective studies are needed to better understand the indications for treatment and demonstrate the long-term efficacy of SLA in this population.

In Journal of Neurosurgery: Pediatrics Publish Before Print

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Opposed evolution of the osseous and soft parts of progestin-associated osteomeningioma after progestin intake discontinuation

Simona M. Florea, Thibault Passeri, Rosaria Abbritti, Anne L. Bernat, Sylvie Fontanel, Isabelle Yoldjian, Thomas Funck-Brentano, Alain Weill, Emmanuel Mandonnet, and Sébastien Froelich

OBJECTIVE

Numerous studies have confirmed a strong association between progestins and meningiomas and the regression and/or stabilization of meningiomas after discontinuation of treatment. Osteomeningiomas represent a small subgroup of meningiomas that appear to be more common among progestin-related meningiomas. However, the specificity of the behavior of this subset of meningiomas after discontinuation of progestin has not yet been assessed.

METHODS

Thirty-six patients (mean age 49.5 years) who presented with at least one progestin-related osteomeningioma (48 tumors total) were identified from a prospectively collected database of patients and had been referred to our department for meningioma and had documented use of cyproterone acetate, nomegestrol acetate, and/or chlormadinone acetate. Hormonal treatment was stopped at the time of diagnosis for all the patients, and the clinical and radiological evolution of this subgroup of tumors was evaluated.

RESULTS

For half of the 36 patients, treatment was prescribed for signs of hyperandrogenism, such as hirsutism, alopecia, or acne. Most lesions were spheno-orbital (35.4%) or frontal (31.2%). Although the tissular part of the meningioma shrank in 77.1% of cases, the osseous part exhibited discordant behavior with 81.3% showing volume progression. The combination of estrogens, as well as the prolonged duration of progestin treatment, seems to increase the risk of progression of the osseous part after treatment discontinuation (p = 0.02 and p = 0.028, respectively). No patient required surgical treatment at diagnosis or during the study.

CONCLUSIONS

These results show that while the soft intracranial part of progestin-related osteomeningioma tumor is the most likely to regress after treatment discontinuation, the bony part is more likely to increase in volume. These findings suggest the need for careful follow-up of these patients, especially those with tumors near the optical apparatus.

In Journal of Neurosurgery Publish Before Print

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Oscillation analysis as a supporting element toward safe and reliable lumbar catheter intracranial pressure monitoring

Anton Früh, Stefan Wolf, Lars Wessels, Peter Vajkoczy, and Nils Hecht

OBJECTIVE

Lumbar drainage of cerebrospinal fluid for treatment of refractory increased intracranial pressure (ICP) is associated with the risk of infratentorial herniation, but real-time biomarkers for signaling herniation at bedside are lacking. Here, the authors tested whether an alteration of pulsatile waveform conduction across the level of the foramen magnum could serve as an indicator of insufficient hydrostatic communication and impending herniation.

METHODS

This prospective observational cohort study included patients with severe acute brain injury who underwent continuous external ventricular drain monitoring of ICP and lumbar drain pressure monitoring. Continuous recordings of ICP, lumbar pressure (LP), and arterial blood pressure (ABP) were screened throughout a recording period of 4–10 days. Pressure differences between ICP and LP > 5 mm Hg for 5 minutes were defined as a Δ-event, implicating nonsufficient hydrostatic communication. During this period, oscillation analysis of the ICP, LP, and ABP waveforms was performed by determining the eigenfrequencies (EFs) and their amplitudes (AEF) via Fourier transformation scripted in Python.

RESULTS

Of 142 patients, 14 exhibited a Δ-event, with a median (range) ICP of 12.2 (10.7–18.8) mm Hg and LP of 5.6 (3.3–9.8) mm Hg during 2993 hours of recording time. The AEF ratio between ICP and LP (p < 0.01) and between ABP and LP (p = 0.032) increased significantly during Δ-events compared with the baseline values determined 3 hours prior to the event. The ratio between ICP and ABP remained unaffected.

CONCLUSIONS

Oscillation behavior analysis of LP and ABP waveforms during controlled lumbar drainage may serve as a personalized, simple, and effective biomarker to signal impending infratentorial herniation in real time without the need for simultaneous ICP monitoring.

In Journal of Neurosurgery Publish Before Print

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Parental sensitivity and specificity to recognize shunt malfunction in their child: a single-center prospective study

Amparo Saenz, Santiago Cicutti, Romina Argañaraz, Beatriz Mantese, and Diego Giunta

OBJECTIVE

The objective of this study was to estimate the diagnostic performance (sensitivity, specificity, positive predictive value, and negative predictive value) for recognizing ventriculoperitoneal shunt (VPS) failure in the parents of patients 0–18 years of age who attended the hospital’s emergency room (ER). The second objective was to identify the factors associated with the parents’ ability to recognize the shunt blockage (true positives).

METHODS

A prospective cohort study was conducted between 2021 and 2022 including all patients 0–18 years of age who had a VPS and attended the hospital’s ER with symptoms that could correspond to VPS blockage. Parents were interviewed on admission and patients were assessed over time to discover potential VPS malfunction by surgery or follow-up. Consent was obtained from all participants.

RESULTS

Ninety-one patients were surveyed, and 59.3% showed evidence of a confirmed VPS blockage. Parental sensitivity was 66.7%, with a specificity of 21.6%. An association was found between parents who could correctly identify their child’s shunt block and the number of symptoms of shunt failure that the parent could name (OR 2.4, p < 0.05) as well as parents who reported vomiting and headache as symptoms of shunt malfunction (OR 6, p < 0.05). Parents who knew the first and last name of their primary neurosurgeon (OR 3.5, p < 0.05) also had better diagnostic sensitivity.

CONCLUSIONS

Parents who are more knowledgeable of their child’s disease, as well as parents who have good communication with their neurosurgeon, were found to have better diagnostic sensitivity.

In Journal of Neurosurgery: Pediatrics Publish Before Print