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Christopher I. Shaffrey and Justin S. Smith

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Owoicho Adogwa, Isaac O. Karikari, Kevin R. Carr, Max Krucoff, Divya Ajay, Parastou Fatemi, Edgar L. Perez, Joseph S. Cheng, Carlos A. Bagley and Robert E. Isaacs

Object

A spinal epidural abscess (SEA) is a rare but severe infection requiring prompt recognition and management. The incidence of SEA has doubled in the past decade, owing to an aging population and to increased use of spinal instrumentation and vascular access. The optimal management of SEAs in patients 50 years of age and older remains a matter of considerable debate. In an older patient population with multiple comorbidities, whether intravenous antibiotics alone or in combination with surgery lead to superior outcomes remains unknown. The present study retrospectively analyzes cases of SEAs, in patients 50 years of age and older, treated at Duke University Medical Center over the past 15 years.

Methods

Eighty-two patients underwent treatment for a spinal epidural abscess between 1999 and 2013. There were 46 men and 36 women, whose overall mean age (± SD) was 65 ± 8.58 years (range 50–82 years). The mean duration of clinical follow-up was 41.38 ± 86.48 weeks. Thirty patients (37%) underwent surgery for removal of the abscess, whereas 52 (63%) were treated more conservatively, undergoing CT-guided aspiration or receiving antibiotics alone based on the results of blood cultures. The correlation between pretreatment variables and outcomes was evaluated in a multivariate regression analysis.

Results

Back pain and severe motor deficits were the most common presenting symptoms. Compared with baseline neurological status, the majority of patients (68%) reported being neurologically “better” or “unchanged.” Twelve patients (15%) had a good outcome (7 [23%] treated operatively vs 5 [10%] treated nonoperatively, p = 0.03), while clinical status in 41 patients (50%) remained unchanged (10 [33%] treated operatively vs 31 [60%] treated nonoperatively, p = 0.01). Overall, 20 patients (25%) died (9 [30%] treated operatively vs 11 [21%] treated nonoperatively, p = 0.43). In a multivariate logistic regression model, an increasing baseline level of pain, the presence of paraplegia or quadriplegia on initial presentation, and a dorsally located SEA were independently associated with poor outcomes.

Conclusions

The results of the study suggest that in patients 50 years of age and older, early surgical decompression combined with intravenous antimicrobial therapy was not associated with superior clinical outcomes when compared with intravenous antimicrobial therapy alone.

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Ankit I. Mehta, Owoicho Adogwa, Isaac O. Karikari, Paul Thompson, Terence Verla, Ulysses T. Null, Allan H. Friedman, Joseph S. Cheng, Carlos A. Bagley and Robert E. Isaacs

Object

Intradural extramedullary (IDEM) neoplasms are uncommon lesions that can pose a challenge for resection. Numerous factors affect the resectability and ultimately the outcome of these lesions. The authors report their 10-year institutional experience with the resection of IDEM neoplasms, focusing on the effect of location on surgical outcomes.

Methods

The authors performed a retrospective review of 96 consecutive patients who presented with a cervical and/or thoracic IDEM tumor that was resected between February 2000 and July 2009. All patients underwent MRI, and the axial location of the tumor was categorized as anterior, posterior, or lateral. Postoperative complications were assessed, as was neurological status at the patient's last follow-up clinic visit. Major complications assessed included CSF leakage requiring lumbar drainage, reexploration for epidural hematoma, and major postoperative neurological deficits.

Results

The mean ± SD age at presentation was 51.16 ± 17.87 years. Major surgical approach–related complications occurred in 15% of patients. Major non–approach related surgical complications occurred in 7.1% of patients, while minor complications occurred in 14.2% of patients. Postoperative neurological deficits occurred most commonly in the thoracic spine between T-1 and T-8. Based on axial spinal cord location, the surgery-related complications rates for all anterior tumors (n = 12) was 41.6%, whereas that for all lateral tumors (n = 69) was 4.4% and that for all posteriorly located tumors (n = 17) was 0%.

Conclusions

Spinal IDEM tumors that are anteriorly located in the upper thoracic spine were found to have the highest rate of surgery-related complications and postoperative neurological deficits. This finding may be associated with the unforgiving anatomy of the upper thoracic spine in which there is a higher cord-to-canal ratio and a tenuous vascular supply.

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Vijay Agarwal, Ranjith Babu, Jordan Grier, Owoicho Adogwa, Adam Back, Allan H. Friedman, Takanori Fukushima and Cory Adamson

Object

Tumors of the cerebellopontine angle (CPA) have always proven difficult for neurosurgeons to optimally manage. Studies investigating the natural history and treatment of vestibular schwannomas have dominated the literature in this regard. Distinguishing meningiomas from schwannomas in this location carries particular importance as each tumor type has certain prognostic and surgical considerations. In this study, the authors have characterized the outcomes of 34 patients surgically treated for CPA meningiomas and have investigated various factors that may affect postoperative neurological function.

Methods

The medical records of patients with CPA meningiomas who underwent surgery from 2005 to 2013 at the Duke University Health System were reviewed. Various patient, clinical, and tumor data were gathered from the medical records including patient demographics, pre- and postoperative neurological examinations, duration of symptoms, procedural details, tumor pathology and size, and treatment characteristics. Differences in continuous variables were then analyzed using the Student t-test while categorical variables were evaluated using the chi-square test.

Results

A total of 34 patients underwent surgical treatment for CPA meningiomas during the 8-year period. Jugular foramen invasion was seen in 17.6% of tumors, with nearly half (41.2%) extending into the internal acoustic canal. The most common presenting symptom was hearing loss (58.8%), followed by headache (52.9%) and facial numbness/pain (50.0%). The most common cranial nerve (CN) affected was CN X (11.8%), followed by CNs VI and VII (5.9%). Postoperatively, no patients experienced a decrease in hearing, with only 5.9% of patients experiencing facial nerve palsies. Patients with tumors larger than 3 cm had a significantly higher incidence of permanent CN deficits than those with smaller tumors (45.5% vs 5.9%, respectively; p = 0.011). Also, tumor extension into the jugular foramen was associated with the occurrence of lower CN deficits, none of which occurred in tumors without jugular foramen invasion. Internal acoustic canal tumor extension was not seen to be associated with postoperative complications or CN deficits.

Conclusions

Meningiomas of the CPA are challenging lesions to treat surgically. However, the risk of facial palsy and hearing loss is significantly lower when compared with vestibular schwannomas. Novel methods for preoperative differentiation are needed to appropriately counsel patients on surgical risks. Also, due to the significant potential for neurological deficits, further studies are needed to investigate the utility of radiotherapy for these lesions.

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Owoicho Adogwa, Ricardo K. Carr, Katherine Kudyba, Isaac Karikari, Carlos A. Bagley, Ziya L. Gokaslan, Nicholas Theodore and Joseph S. Cheng

Object

Same-level recurrent lumbar stenosis, pseudarthrosis, and adjacent-segment disease (ASD) are potential complications that can occur after index lumbar spine surgery, leading to significant discomfort and radicular pain. While numerous studies have demonstrated excellent results following index lumbar spine surgery in elderly patients (age > 65 years), the effectiveness of revision lumbar surgery in this cohort remains unclear. The aim of this study was to assess the long-term effectiveness of revision lumbar decompression and fusion in the treatment of symptomatic pseudarthrosis, ASD, and same-level recurrent stenosis, using validated patient-reported outcomes.

Methods

After a review of the institutional database, 69 patients who had undergone revision neural decompression and instrumented fusion for ASD (28 patients), pseudarthrosis (17 patients), or same-level recurrent stenosis (24 patients) were included in this study. Baseline and 2-year scores on the visual analog scale for leg pain (VAS-LP), VAS for back pain (VAS-BP), Oswestry Disability Index (ODI), and Zung Self-Rating Depression Scale (SDS) as well as the time to narcotic independence, time to return to baseline activity level, health state utility (EQ-5D, the EuroQol-5D health survey), and physical and mental component summary scores of the 12-Item Short-Form Health Survey (SF-12 PCS and MCS) were assessed.

Results

Compared with the preoperative status, VAS-BP was significantly improved 2 years after surgery for ASD (mean ± standard deviation 9 ± 2 vs 4.01 ± 2.56, p = 0.001), pseudarthrosis (7.41 ± 1 vs 5.52 ± 3.08, p = 0.02), and same-level recurrent stenosis (7 ± 2.00 vs 5.00 ± 2.34, p = 0.003). The 2-year ODI was also significantly improved after surgery for ASD (29 ± 9 vs 23.10 ± 10.18, p = 0.001), pseudarthrosis (28.47 ± 5.85 vs 24.41 ± 7.75, p = 0.001), and same-level recurrent stenosis (30.83 ± 5.28 vs 26.29 ± 4.10, p = 0.003). The Zung SDS score and SF-12 MCS did not change appreciably after surgery in any of the cohorts, with an overall mean 2-year change of 1.01 ± 5.32 (p = 0.46) and 2.02 ± 9.25 (p = 0.22), respectively.

Conclusions

Data in this study suggest that revision lumbar decompression and extension of fusion for symptomatic pseudarthrosis, ASD, and same-level recurrent stenosis provides improvement in low-back pain, disability, and quality of life and should be considered a viable treatment option for elderly patients with persistent or recurrent back and radicular pain. Mental health symptoms may be more refractory to revision surgery.

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Owoicho Adogwa, Ryan Owens, Isaac Karikari, Vijay Agarwal, Oren N. Gottfried, Carlos A. Bagley, Robert E. Isaacs and Joseph S. Cheng

Object

Despite advances in technology and understanding in spinal physiology, reoperation for symptomatic adjacent-segment disease (ASD), same-level recurrent stenosis, and pseudarthrosis in elderly patients continues to occur. While revision lumbar surgery is effective, attention has turned to questions on the utility and value of the revision decompression and fusion procedure. To date, an analysis of the cost and health state gain associated with revision lumbar surgery in elderly patients with symptomatic pseudarthrosis, ASD, or same-level recurrent lumbar stenosis has yet to be performed. The aim of this study was to assess the long-term outcomes and cost-effectiveness of revision surgery in elderly patients with recurrent or persistent back and leg pain.

Methods

After reviewing their institutional database, the authors found 69 patients 65 years of age and older who had undergone revision decompression and instrumented fusion for back and leg pain associated with pseudarthrosis (17 patients), same-level recurrent stenosis (24 patients), or ASD (28 patients) and included them in this study. Total 2-year back-related medical resource utilization and health state values (quality-adjusted life years [QALYs], calculated from the EQ-5D, the EuroQol-5D health survey, with US valuation) were assessed. Two-year resource use was multiplied by unit costs based on Medicare national allowable payment amounts. The mean total 2-year cost per QALY gained after revision surgery was assessed.

Results

The mean (± standard deviation) time between the index surgery and revision surgery was 3.51 ± 3.63 years. A mean cumulative 2-year gain of 0.35 QALY was observed after revision surgery. The mean total 2-year cost of revision surgery was $28,256 ± $3000 (ASD: $28,829 ± $3812, pseudarthrosis: $28,069 ± $2508, same-level recurrent stenosis: $27,871 ± $2375). Revision decompression and extension of fusion was associated with a mean 2-year cost of $80,594 per QALY gained.

Conclusions

Revision decompression and fusion provided a significant gain in health state utility for elderly patients with symptomatic pseudarthrosis, same-level recurrent stenosis, or ASD, with a mean 2-year cost of $80,594 per QALY gained. When indicated, revision surgery for symptomatic ASD, same-level recurrent stenosis, and pseudarthrosis is a valuable treatment option for elderly patients experiencing persistent back and leg pain. Findings in this study provided a value measure of surgery that can be compared with future cost-per-QALY-gained studies of medical management or alternative surgical approaches.

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Chetan Bettegowda, Owoicho Adogwa, Vivek Mehta, Kaisorn L. Chaichana, Jon Weingart, Benjamin S. Carson, George I. Jallo and Edward S. Ahn

Object

Choroid plexus tumors (CPTs) are rare intracranial neoplasms that constitute approximately 2%–5% of all pediatric brain tumors. Most of these tumors present with severe hydrocephalus. The optimal perioperative management and oncological care remain a matter of debate. The authors present the epidemiological and clinical features of CPTs from a 20-year single-institutional experience.

Methods

A total of 39 consecutive patients with pathologically proven CPTs (31 choroid plexus papillomas [CPPs] and 8 choroid plexus carcinomas [CPCs]) were included in this series. Patient demographics, clinical presentation, comorbidities, indications for surgery, radiological studies, tumor location, and all operative variables were reviewed for each case. Multivariate regression analysis was performed to identify independent predictors of tumor recurrence and survival.

Results

The overall mean age (± SD) was 13.13 ± 19.59 years (15.27 ± 21.10 years in the CPP group and 3.66 ± 3.59 years in the CPC group). Hydrocephalus was noted at presentation in 34% of patients. The most common presenting symptoms were headache (32%) and nausea/vomiting (26%). Gross-total resection (GTR) was achieved in 86% of CPPs and in 71% of CPCs (p = 0.57). There was 100% survival in patients with CPPs observed at the 5- and 10-year follow-up and 71% survival in patients with CPCs at the 5-year follow-up. In a multivariate regression analysis, a diagnosis of papilloma, preoperative vision changes, or hydrocephalus; right ventricle tumor location; and GTR were all independently associated with a decreased likelihood of tumor recurrence at last follow-up.

Conclusions

The authors' study suggests that patients with CPCs are more likely to experience local recurrence and metastasis; hence, GTR with chemotherapy and radiotherapy, particularly for CPCs, is pivotal in preventing recurrence and prolonging survival. While GTR was important for local control following resection of CPPs, it had a minimal effect on prolonging survival in this patient cohort.

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Scott L. Parker, Stephen K. Mendenhall, David N. Shau, Owoicho Adogwa, William N. Anderson, Clinton J. Devin and Matthew J. McGirt

Object

Spine surgery outcome studies rely on patient-reported outcome (PRO) measurements to assess treatment effect, but the extent of improvement in the numerical scores of these questionnaires lacks a direct clinical meaning. Because of this, the concept of a minimum clinically important difference (MCID) has been used to measure the critical threshold needed to achieve clinically relevant treatment effectiveness. As utilization of spinal fusion has increased over the past decade, so has the incidence of same-level recurrent stenosis following index lumbar fusion, which commonly requires revision decompression and fusion. The MCID remains uninvestigated for any PROs in the setting of revision lumbar surgery for this pathology.

Methods

In 53 consecutive patients undergoing revision surgery for same-level recurrent lumbar stenosis–associated back and leg pain, PRO measures of back and leg pain were assessed preoperatively and 2 years postoperatively, using the visual analog scale for back pain (VAS-BP) and leg pain (VAS-LP), Oswestry Disability Index (ODI), Physical and Mental Component Summary categories of the 12-Item Short Form Health Survey (SF-12 PCS and MCS) for quality of life, Zung Depression Scale (ZDS), and EuroQol-5D health survey (EQ-5D). Four established anchor-based MCID calculation methods were used to calculate MCID (average change; minimum detectable change; change difference; and receiver operating characteristic curve analysis) for 2 separate anchors (health transition index of the SF-36 and the satisfaction index).

Results

All patients were available for 2-year PRO assessment. Two years after surgery, a significant improvement was observed for all PROs assessed. The 4 MCID calculation methods generated a range of MCID values for each of the PROs (VAS-BP 2.2–6.0, VAS-LP 3.9–7.5, ODI 8.2–19.9, SF-12 PCS 2.5–12.1, SF-12 MCS 7.0–15.9, ZDS 3.0–18.6, and EQ-5D 0.29–0.52). Each patient answered synchronously for the 2 anchors, suggesting both of these anchors are equally appropriate and valid for this patient population.

Conclusions

The same-level recurrent stenosis surgery-specific MCID is highly variable based on calculation technique. The “minimum detectable change” approach is the most appropriate method for calculation of MCIDs in this population because it was the only method to reliably provide a threshold above the 95% confidence interval of the unimproved cohort (greater than the measurement error). Based on this method, the MCID thresholds following neural decompression and fusion for symptomatic same-level recurrent stenosis are 2.2 points for VAS-BP, 5.0 points for VAS-LP, 8.2 points for ODI, 2.5 points for SF-12 PCS, 10.1 points for SF-12 MCS, 4.9 points for ZDS, and 0.39 QALYs for EQ-5D.

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Owoicho Adogwa, Scott L. Parker, David N. Shau, Stephen K. Mendenhall, Clinton J. Devin, Joseph S. Cheng and Matthew J. McGirt

Object

Over the past decade, there has been a dramatic increase in the number of spinal fusions performed in the US and a corresponding increase in the incidence of adjacent-segment disease (ASD). Surgical management of symptomatic ASD consists of decompression of neural elements and extension of fusion. It has been shown to have favorable long-term outcomes, but the cost-effectiveness remains unclear. In this study, the authors set out to assess the cost-effectiveness of revision surgery in the treatment of ASD over a 2-year period.

Methods

Fifty patients undergoing neural decompression and extension of fusion construct for ASD-associated back and leg pain were included in the study. Two-year total back-related medical resource utilization, missed work, and health state values (quality-adjusted life years [QALYs], calculated from the EQ-5D with US valuation) were assessed. Two-year resource use was multiplied by unit costs based on Medicare national allowable payment amounts (direct cost), and patient and caregiver workday losses were multiplied by the self-reported gross-of-tax wage rate (indirect cost). Mean total 2-year cost per QALY gained after revision surgery was assessed.

Results

The mean (± SD) interval between prior fusion and revision surgery for ASD was 3.07 ± 2.02 years. A mean cumulative 2-year gain of 0.76 QALYs was observed after revision surgery. The mean total 2-year cost of extension of fusion constructs was $47,846 ± $32,712 (surgery cost: $24,063 ± $300; outpatient resource utilization cost: $4175 ± $3368; indirect cost: $19,607 ± $32,187). Revision decompression and extension of fusion was associated with a mean 2-year cost per QALY gained of $62,955.

Conclusions

In the authors' practice, revision decompression and extension of fusion provided a significant gain in health state utility for patients with symptomatic ASD, with a 2-year cost per QALY gained of $62,995. When indicated, revision surgery for ASD is a valuable treatment option for patients experiencing back and leg pain secondary to ASD. The findings provide a value measure of surgery that can be compared with future cost-per-QALY-gained studies of medical management or alternative surgical approaches.