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Catherine Miller and Daniel Guillaume

OBJECT

External ventricular drains (EVDs) are regularly used in pediatric neurosurgery for diagnostic and therapeutic purposes. Hemorrhage caused by placing an EVD is a common complication noted in the adult literature. In the pediatric literature, on the other hand, only a few articles have assessed the risk of hemorrhage with placement, and none have reported the occurrence of hemorrhage with removal of an EVD. The authors investigated the incidence of hemorrhage with both placement and removal of the EVD in a pediatric population.

METHODS

After obtaining institutional review board approval, a comprehensive database was created to include all pediatric patients who required EVD placement between March 2008 and June 2014 at the authors’ institution. A retrospective chart review was completed, and all imaging was reviewed for evidence of hemorrhage with placement and removal of the EVD.

RESULTS

During the designated time period, 73 EVDs were placed in 63 patients (ages 2 weeks–17 years). Indications for EVD placement were as follows: shunt infection/malfunction (21), tumor (12), hydrocephalus (18), hemorrhage (12), edema (4), trauma (1), and other (5). Hemorrhage with placement was noted in 5 of the 50 patients who underwent imaging, with a volume ranging from 0.48 cm3 to 7.7 cm3. Thirty-two patients had imaging after EVD removal, and 7 of these patients were noted to have hemorrhage (volume range 0.012 cm3 to 81.5 cm3).

CONCLUSIONS

The authors found the incidence of hemorrhage at EVD placement to be 10%, and the incidence of hemorrhage on EVD removal to be 21.9% in those patients who underwent imaging after each event. Although none of the hemorrhages were of obvious clinical significance, these data can be useful in decision making, and in discussing the risks of EVDs with the patient’s family.

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Howard J. Senter and Daniel J. Miller

✓ A ruptured anterior cerebral artery aneurysm is reported in a patient in whom a solitary anterior cerebral artery arose from the proximal carotid artery and ascended between the optic nerves.

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Daniel L. Silbergeld and John W. Miller

✓ Four adults with unilateral (three cases) or bilateral (one case) closed schizencephaly, medically intractable epilepsy, and otherwise normal neurological examinations are presented. Three were examined preoperatively with magnetic resonance imaging and one with computerized tomography. Scalp electroencephalographic (EEG) studies in all four patients and electrocorticography via intracranial electrodes in two showed seizure origin in the cleft regions in two patients and in the ipsilateral temporal lobe in the other two. Temporal lobectomy was performed in the two patients with temporal lobe foci. Resection of superficial pachygyria around the cleft was performed in one patient. The authors conclude that the abnormal cortical mantle lining schizencephalic clefts may be epileptogenic. Alternatively, temporal allocortex may become the source of seizures. Therefore, these patients require careful EEG monitoring of the entire ipsilateral hemisphere as well as the cleft region.

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Catherine Miller, Daniel Guillaume, Kathryn Dusenbery, H. Brent Clark and Christopher Moertel

Brain tumors are the most common solid tumor in childhood, and astrocytomas account for the largest proportion of these tumors. Increasing sophistication in genetic testing has allowed for the detection of specific mutations within tumor subtypes that may represent targets for individualized tumor treatment. The mitogen-activating protein kinase (MAPK) pathway and, more specifically, BRAF mutations have been shown to be prevalent in pediatric pilocytic astrocytomas and may represent one such area to target. Herein, the authors describe 2 cases of inoperable, chemotherapy-resistant pediatric pilocytic astrocytomas with a documented response to trametinib, an MAPK pathway inhibitor. While these cases were not treated in the setting of a clinical trial, their data support further ongoing clinical trial investigation to evaluate the safety and efficacy of this agent in pediatric low-grade gliomas.

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Ryan Snowden, Justin Miller, Tome Saidon, Joseph D. Smucker, K. Daniel Riew and Rick Sasso

OBJECTIVE

The authors sought to compare the effect of index level sagittal alignment on cephalad radiographic adjacent segment pathology (RASP) in patients undergoing cervical total disc arthroplasty (TDA) or anterior cervical discectomy and fusion (ACDF).

METHODS

This was a retrospective study of prospectively collected radiographic data from 79 patients who underwent TDA or ACDF and were enrolled and followed prospectively at two centers in a multicenter FDA investigational device exemption trial of the Bryan cervical disc prosthesis used for arthroplasty. Neutral lateral radiographs were obtained pre- and postoperatively and at 1, 2, 4, and up to 7 years following surgery. The index level Cobb angle was measured both pre- and postoperatively. Cephalad disc degeneration was determined by a previously described measurement of the disc height/anteroposterior (AP) distance ratio.

RESULTS

Sixty-eight patients (n = 33 ACDF; n = 35 TDA) had complete radiographs and were included for analysis. Preoperatively, there was no difference in the index level Cobb angle between the ACDF and TDA patients. Postoperatively, the ACDF patients had a larger segment lordosis compared to the TDA patients (p = 0.002). Patients who had a postoperative kyphotic Cobb angle were more likely to have undergone TDA (p = 0.01). A significant decrease in the disc height/AP distance ratio occurred over time (p = 0.035), by an average of 0.01818 at 84 months. However, this decrease was not influenced by preoperative alignment, postoperative alignment, or type of surgery.

CONCLUSIONS

In this cohort of patients undergoing TDA and ACDF, the authors found that preoperative and postoperative sagittal alignment have no effect on RASP at follow-up of at least 7 years. They identified time as the only significant factor affecting RASP.

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Charles A. Miller, Jason H. Boulter, Daniel J. Coughlin, Michael K. Rosner, Chris J. Neal and Michael S. Dirks

OBJECTIVE

Symptomatic cervical spondylosis with or without radiculopathy can ground an active-duty military pilot if left untreated. Surgically treated cervical spondylosis may be a waiverable condition and allow return to flying status, but a waiver is based on expert opinion and not on recent published data. Previous studies on rates of return to active duty status following anterior cervical spine surgery have not differentiated these rates among military specialty occupations. No studies to date have documented the successful return of US military active-duty pilots who have undergone anterior cervical spine surgery with cervical fusion, disc replacement, or a combination of the two. The aim of this study was to identify the rate of return to an active duty flight status among US military pilots who had undergone anterior cervical discectomy and fusion (ACDF) or total disc replacement (TDR) for symptomatic cervical spondylosis.

METHODS

The authors performed a single-center retrospective review of all active duty pilots who had undergone either ACDF or TDR at a military hospital between January 2010 and June 2017. Descriptive statistics were calculated for both groups to evaluate demographics with specific attention to preoperative flight stats, days to recommended clearance by neurosurgery, and days to return to active duty flight status.

RESULTS

Authors identified a total of 812 cases of anterior cervical surgery performed between January 1, 2010, and June 1, 2017, among active duty, reserves, dependents, and Department of Defense/Veterans Affairs patients. There were 581 ACDFs and 231 TDRs. After screening for military occupation and active duty status, there were a total of 22 active duty pilots, among whom were 4 ACDFs, 17 TDRs, and 2 hybrid constructs. One patient required a second surgery. Six (27.3%) of the 22 pilots were nearing the end of their career and electively retired within a year of surgery. Of the remaining 16 pilots, 11 (68.8%) returned to active duty flying status. The average time to be released by the neurosurgeon was 128 days, and the time to return to flying was 287 days. The average follow-up period was 12.3 months.

CONCLUSIONS

Adhering to military service-specific waiver guidelines, military pilots may return to active duty flight status after undergoing ACDF or TDR for symptomatic cervical spondylosis.

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Daniel J. Miller, Frederick F. Lang, Garrett L. Walsh, Dima Abi-Said, David M. Wildrick and Ziya L. Gokaslan

Object. A unique method of anterior spinal reconstruction after decompressive surgery was used to prevent methylmethacrylate—dural contact in cancer patients who underwent corpectomy. The purpose of this study was to assess the efficacy and stability of polymethylmethacrylate (PMMA) anterior surgical constructs in conjunction with anterior cervical plate stabilization (ACPS) in these patients.

Methods. Approximately 700 patients underwent spinal surgery at The University of Texas M. D. Anderson Cancer Center over a 4-year period. The authors conducted a retrospective outcome study for 29 of these patients who underwent anterior cervical or upper thoracic tumor resections while in the supine position. These patients were all treated using the coaxial, double-lumen, PMMA technique for anterior spinal reconstruction with subsequent ACPS. No postoperative external orthoses were used. Twenty-seven patients (93%) harbored metastatic spinal lesions and two (7%) harbored primary tumors. At 1 month postsurgery, significant improvement was seen in spinal axial pain (p < 0.001), radiculopathy (p < 0.00 1), gait (p = 0.008), and Frankel grade (p = 0.002). A total of nine patients (31%) underwent combined anterior—posterior 360° stabilization. Twenty-one patients (72%) experienced no complications. Complications related to instrumentation failure occurred in only two patients (7%). There were no cases in which the patients' status worsened, and there were no neurological complications or infections. The median Kaplan—Meier survival estimate for patients with spinal metastases was 9.5 months. At the end of the study, 13 patients (45%) had died and 16 (55%) were alive. Postoperative magnetic resonance images consistently demonstrated that the dura and PMMA in all patients remained separated.

Conclusions. The anterior, coaxial, double-lumen, PMMA reconstruction technique provides a simple means of spinal cord protection in patients in the supine position while undergoing surgery and offers excellent results in cancer patients who have undergone cervical vertebrectomy.

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William D. Tobler, Miguel A. Melgar, Thomas J. Raley, W. Daniel Bradley, Larry E. Miller and Richard J. Nasca

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Matthew D. Alvin, Jacob A. Miller, Daniel Lubelski, Benjamin P. Rosenbaum, Kalil G. Abdullah, Robert G. Whitmore, Edward C. Benzel and Thomas E. Mroz

Object

Cost-effectiveness research in spine surgery has been a prominent focus over the last decade. However, there has yet to be a standardized method developed for calculation of costs in such studies. This lack of a standardized costing methodology may lead to conflicting conclusions on the cost-effectiveness of an intervention for a specific diagnosis. The primary objective of this study was to systematically review all cost-effectiveness studies published on spine surgery and compare and contrast various costing methodologies used.

Methods

The authors performed a systematic review of the cost-effectiveness literature related to spine surgery. All cost-effectiveness analyses pertaining to spine surgery were identified using the cost-effectiveness analysis registry database of the Tufts Medical Center Institute for Clinical Research and Health Policy, and the MEDLINE database. Each article was reviewed to determine the study subject, methodology, and results. Data were collected from each study, including costs, interventions, cost calculation method, perspective of cost calculation, and definitions of direct and indirect costs if available.

Results

Thirty-seven cost-effectiveness studies on spine surgery were included in the present study. Twenty-seven (73%) of the studies involved the lumbar spine and the remaining 10 (27%) involved the cervical spine. Of the 37 studies, 13 (35%) used Medicare reimbursements, 12 (32%) used a case-costing database, 3 (8%) used cost-to-charge ratios (CCRs), 2 (5%) used a combination of Medicare reimbursements and CCRs, 3 (8%) used the United Kingdom National Health Service reimbursement system, 2 (5%) used a Dutch reimbursement system, 1 (3%) used the United Kingdom Department of Health data, and 1 (3%) used the Tricare Military Reimbursement system. Nineteen (51%) studies completed their cost analysis from the societal perspective, 11 (30%) from the hospital perspective, and 7 (19%) from the payer perspective. Of those studies with a societal perspective, 14 (38%) reported actual indirect costs.

Conclusions

Changes in cost have a direct impact on the value equation for concluding whether an intervention is cost-effective. It is essential to develop a standardized, accurate means of calculating costs. Comparability and transparency are essential, such that studies can be compared properly and policy makers can be appropriately informed when making decisions for our health care system based on the results of these studies.

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Rafael De la Garza Ramos, C. Rory Goodwin, Nancy Abu-Bonsrah, Amit Jain, Emily K. Miller, Nicole Huang, Khaled M. Kebaish, Paul D. Sponseller and Daniel M. Sciubba

OBJECTIVE

The aim of this study was to investigate the incidence of and factors associated with complications following idiopathic scoliosis surgery in adolescents.

METHODS

The Nationwide Inpatient Sample database was used to identify patients 10–18 years of age who had undergone spinal fusion for adolescent idiopathic scoliosis (AIS) from 2002 to 2011. Twenty-three unique in-hospital postoperative complications, including death, were examined. A series of logistic regressions was used to determine if any demographic, comorbid, or surgical parameter was associated with complication development. Results of multiple logistic regression analyses were reported as odds ratios with 95% confidence intervals. All analyses were performed after the application of discharge weights to produce national estimates.

RESULTS

A total of 36,335 patients met the study inclusion criteria, 7.6% of whom (95% CI 6.3%–8.9%) developed at least one in-hospital complication. The 3 most common complications were respiratory failure (3.47%), reintubation (1.27%), and implant related (1.14%). Major complications such as death, pancreatitis, disseminated intravascular coagulation, visual loss, spinal cord injury, cardiac arrest, sepsis, nerve root injury, deep vein thrombosis, pulmonary embolism, shock, malignant hyperthermia, myocardial infarction, and iatrogenic stroke each had an incidence ≤ 0.2%. On multiple logistic regression analysis, an increasing age (OR 0.80) was associated with significantly lower odds of complication development; patients who were male (OR 1.80) or who had anemia (OR 2.10), hypertension (OR 2.51), or hypothyroidism (OR 2.27) or underwent revision procedures (OR 5.55) were at a significantly increased risk for complication development. The rates of postoperative complications for posterior, anterior, and combined approaches were 6.7%, 10.0%, and 19.8%, respectively (p < 0.001). Length of fusion (< 8 vs ≥ 8 levels) was not associated with complication development (p = 0.311).

CONCLUSIONS

Analysis of 36,335 patients who had undergone surgery for AIS revealed that younger patients, male patients, patients with a history of anemia, hypertension, or hypothyroidism, as well as those undergoing revision or anterior or combined approaches may have higher rates of postoperative complications. However, the overall complication rate was low (7.6%), and major complications had a rate ≤ 0.2% for each event. These findings suggest that surgery for AIS remains relatively safe, and future prospective investigations may further help to decrease the postoperative morbidity rate.