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Matthew C. Davis, Elizabeth N. Kuhn, Bonita S. Agee, Robert A. Oster and James M. Markert

OBJECTIVE

Many neurosurgical training programs have moved from a 24-hour resident call system to a night float system, but the impact on outcomes is unclear. Here, the authors compare length of stay (LOS) for neurosurgical patients admitted before and after initiation of a night float system at a tertiary care training hospital.

METHODS

The neurosurgical residency at the University of Alabama at Birmingham transitioned from 24-hour call to a night float resident coverage system in July 2013. In this cohort study, all patients admitted to the neurosurgical service for 1 year before and 1 year after this transition were compared with respect to hospital and ICU LOSs, adjusted for potential confounders.

RESULTS

A total of 4619 patients were included. In the initial bivariate analysis, night float was associated with increased ICU LOS (p = 0.032) and no change in overall LOS (p = 0.65). However, coincident with the transition to a night float system was an increased frequency of resident service transitions, which were highly associated with hospital LOS (p < 0.01) and ICU LOS (p < 0.01). After adjusting for resident service transitions, initiation of the night float system was associated with decreased hospital LOS (p = 0.047) and no change in ICU LOS (p = 0.35).

CONCLUSIONS

This study suggests that a dedicated night float resident may improve night-to-night continuity of care and decrease hospital LOS, but caution must be exercised when initiation of night float results in increased resident service transitions.

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Elizabeth N. Kuhn, Matthew C. Davis, Bonita S. Agee, Robert A. Oster and James M. Markert

OBJECT

Handoffs and services changes are potentially modifiable sources of medical error and delays in transition of care. This cohort study assessed the relationship between resident service handoffs and length of stay for neurosurgical patients.

METHODS

All patients admitted to the University of Alabama at Birmingham neurosurgical service between July 1, 2012, and July 1, 2014, were retrospectively identified. A service handoff was defined as any point when a resident handed off coverage of a service for longer than 1 weekend. A conditional probability distribution was constructed to adjust length of stay for the increasing probability of a random handoff. The Student t-test and ANCOVA were used to assess relationships between resident service handoffs and length of hospital stay, adjusted for potential confounders.

RESULTS

A total of 3038 patients met eligibility criteria and were included in the statistical analyses. Adjusted length of hospital stay (5.32 vs 3.53 adjusted days) and length of ICU stay (4.38 vs 2.96 adjusted days) were both longer for patients who experienced a service handoff, with no difference in mortality. In the ANCOVA model, resident service handoff remained predictive of both length of hospital stay (p < 0.001) and length of ICU stay (p < 0.001).

CONCLUSIONS

Occurrence of a resident service handoff is an independent predictor of length of hospital and ICU stay in neurosurgical patients. This finding is novel in the neurosurgical literature. Future research might identify mechanisms for improving continuity of care and mitigating the effect of resident handoffs on patient outcomes.

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Esther B. Dupépé, Matthew Davis, Galal A. Elsayed, Bonita Agee, Keneshia Kirksey, Amber Gordon and Patrick R. Pritchard

OBJECTIVE

The aim of this study was to determine the inter-rater reliability of the modified Medical Research Council (MRC) scale for grading motor function in patients with chronic incomplete spinal cord injury (SCI).

METHODS

Two neurosurgical residents and 2 faculty members performed motor examinations in 6 chronic incomplete SCI patients for a total of 156 muscle groups. Examinations were performed using the modified MRC grading scale during routine clinic visits for each patient. Informed consent was obtained prior to enrollment. Patients with American Spinal Injury Association (ASIA) Impairment Scale grade A (ASIA A) injuries were excluded. Inter-rater reliability coefficients were calculated using Kendall’s coefficient of concordance (W) and intraclass correlation coefficients (ICCs).

RESULTS

Sixty-four percent of the tested variables demonstrated extremely strong (W 0.71–0.9) or strong (0.51–0.7) inter-rater reliability using Kendall’s coefficient of concordance and an ICC corresponding to excellent (ICC > 0.75) or fair to good (ICC 0.4–0.75) inter-rater reliability. An additional 7% showed poor inter-rater reliability (ICC < 0.4). The remaining variables tested did not reach statistical significance.

CONCLUSIONS

The inter-rater reliability of the modified MRC scale was found to be high in the majority of tested variables, but the results suggest that discrepancy among trained observers does exist. Reliability was greatest in the lower-extremity muscle groups and least in the upper-extremity muscle groups in patients with chronic incomplete SCI.

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Matthew S. Erwood, Mark N. Hadley, Amber S. Gordon, William R. Carroll, Bonita S. Agee and Beverly C. Walters

OBJECTIVE

Recurrent laryngeal nerve (RLN) injury is one of the most frequent complications of anterior cervical discectomy and fusion (ACDF) procedures. The frequency of RLN is reported as 1%–11% in the literature.4,15 The rate of palsy after reoperative ACDF surgery is not well defined. This meta-analysis was performed to review the current medical evidence on RLN injury after ACDF surgery and to determine a relative rate of RLN injury after reoperative ACDF.

METHODS

MEDLINE, PubMed, and Google Scholar searches were performed using several key words and phrases related to ACDF surgery. Included studies were written in English, addressed revisionary ACDF surgery, and studied outcomes of RLN injury. Statistical analysis was then performed using a random-effects model to calculate a pooled rate of RLN injury. The heterogeneity of the studies was assessed using Cochran's Q statistic and I2 statistic, and a funnel plot was constructed to evaluate publication bias.

RESULTS

The search initially identified 345 articles on this topic. Eight clinical articles that met all inclusion criteria were included in the meta-analysis. A total of 238 patients were found to have undergone reoperative ACDF. Thirty-three of those patients experienced an RLN injury. This analysis identified a rate of RLN injury in the literature after reoperative ACDF of 14.1% (95% confidence interval [CI] 9.8%–19.1%).

CONCLUSIONS

The rate of RLN palsy of 14.1% was greater than any published rate of RLN injury after primary ACDF operations, suggesting that there is a greater risk of hoarseness and dysphagia with reoperative ACDF surgeries than with primary procedures as reported in these studies.

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Ross L. Dawkins, Joseph H. Miller, Omar I. Ramadan, Michael C. Lysek, Elizabeth N. Kuhn, Brandon G. Rocque, Michael J. Conklin, R. Shane Tubbs, Beverly C. Walters, Bonita S. Agee and Curtis J. Rozzelle

OBJECTIVE

There are many classification systems for injuries of the thoracolumbar spine. The recent Thoracolumbar Injury Classification and Severity Score (TLICS) has been shown to be a reliable tool for adult patients. The aim of this study was to assess the reliability of the TLICS system in pediatric patients. The validity of the TLICS system is assessed in a companion paper.

METHODS

The medical records of pediatric patients with acute, traumatic thoracolumbar fractures at a single Level 1 trauma center were retrospectively reviewed. A TLICS was calculated for each patient using CT and MRI, along with the neurological examination recorded in the patient’s medical record. TLICSs were compared with the type of treatment received. Five raters scored all patients separately to assess interrater reliability.

RESULTS

TLICS calculations were completed for 81 patients. The mean patient age was 10.9 years. Girls represented 51.8% of the study population, and 80% of the study patients were white. The most common mechanisms of injury were motor vehicle accidents (60.5%), falls (17.3%), and all-terrain vehicle accidents (8.6%). The mean TLICS was 3.7 ± 2.8. Surgery was the treatment of choice for 33.3% of patients. The agreement between the TLICS-suggested treatment and the actual treatment received was statistically significant (p < 0.0001). The interrater reliability of the TLICS system ranged from moderate to very good, with a Fleiss’ generalized kappa (κ) value of 0.69 for the TLICS treatment suggestion among all patients; however, interrater reliability decreased when MRI was used to contribute to the TLICS. The κ value decreased from 0.73 to 0.57 for patients with CT only vs patients with CT/MRI or MRI only, respectively (p < 0.0001). Furthermore, the agreement between suggested treatment and actual treatment was worse when MRI was used as part of injury assessment.

CONCLUSIONS

The TLICS system demonstrates good interrater reliability among physicians assessing thoracolumbar fracture treatment in pediatric patients. Physicians should be cautious when using MRI to aid in the surgical decision-making process.

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Joseph H. Miller, Clarence Gill, Elizabeth N. Kuhn, Brandon G. Rocque, Joshua Y. Menendez, Jilian A. O'Neill, Bonita S. Agee, Steven T. Brown, Marshall Crowther, R. Drew Davis, Drew Ferguson and James M. Johnston

OBJECT

Pediatric sports-related concussions are a growing public health concern. The factors that determine injury severity and time to recovery following these concussions are poorly understood. Previous studies suggest that initial symptom severity and diagnosis of attention deficit hyperactivity disorder (ADHD) are predictors of prolonged recovery (> 28 days) after pediatric sports-related concussions. Further analysis of baseline patient characteristics may allow for a more accurate prediction of which patients are at risk for delayed recovery after a sports-related concussion.

METHODS

The authors performed a single-center retrospective case-control study involving patients cared for at the multidisciplinary Concussion Clinic at Children's of Alabama between August 2011 and January 2013. Patient demographic data, medical history, sport concussion assessment tool 2 (SCAT2) and symptom severity scores, injury characteristics, and patient balance assessments were analyzed for each outcome group. The control group consisted of patients whose symptoms resolved within 28 days. The case group included patients whose symptoms persisted for more than 28 days. The presence or absence of the SCAT2 assessment had a modifying effect on the risk for delayed recovery; therefore, stratum-specific analyses were conducted for patients with recorded SCAT2 scores and for patients without SCAT2 scores. Unadjusted ORs and adjusted ORs (aORs) for an association of delayed recovery outcome with specific risk factors were calculated with logistic regression analysis.

RESULTS

A total of 294 patients met the inclusion criteria of the study. The case and control groups did not statistically significantly differ in age (p = 0.7). For the patients who had received SCAT2 assessments, a previous history of concussion (aOR 3.67, 95% CI 1.51–8.95), presenting SCAT2 score < 80 (aOR 5.58, 95% CI 2.61–11.93), and female sex (aOR 3.48, 95% CI 1.43–8.49) were all associated with a higher risk for postconcussive symptoms lasting more than 28 days. For patients without SCAT2 scores, female sex and reporting a history of ADHD significantly increased the odds of prolonged recovery (aOR 4.41, 95% CI 1.93–10.07 and aOR 3.87, 95% CI 1.13–13.24, respectively). Concussions resulting from playing a nonhelmet sport were also associated with a higher risk for prolonged symptoms in patients with and without SCAT2 scores (OR 2.59, 95% CI 1.28–5.26 and OR 2.17, 95% CI 0.99–7.73, respectively). Amnesia, balance abnormalities, and a history of migraines were not associated with symptoms lasting longer than 28 days.

CONCLUSIONS

This case-control study suggests candidate risk factors for predicting prolonged recovery following sports-related concussion. Large prospective cohort studies of youth athletes examined and treated with standardized protocols will be needed to definitively establish these associations and confirm which children are at highest risk for delayed recovery.

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Matthew S. Erwood, Beverly C. Walters, Timothy M. Connolly, Amber S. Gordon, William R. Carroll, Bonita S. Agee, Bradley R. Carn and Mark N. Hadley

OBJECTIVE

Dysphagia and vocal cord palsy (VCP) are common complications after anterior cervical discectomy and fusion (ACDF). The reported incidence rates for dysphagia and VCP are variable. When videolaryngostroboscopy (VLS) is performed to assess vocal cord function after ACDF procedures, the incidence of VCP is reported to be as high as 22%. The incidence of dysphagia ranges widely, with estimates up to 71%. However, to the authors’ knowledge, there are no prospective studies that demonstrate the rates of VCP and dysphagia for reoperative ACDF. This study aimed to investigate the incidence of voice and swallowing disturbances before and after reoperative ACDF using a 2-team operative approach with comprehensive pre- and postoperative assessment of swallowing, direct vocal cord visualization, and clinical neurosurgical outcomes.

METHODS

A convenience sample of sequential patients who were identified as requiring reoperative ACDF by the senior spinal neurosurgeon at the University of Alabama at Birmingham were enrolled in a prospective, nonrandomized study during the period from May 2010 until July 2014. Sixty-seven patients undergoing revision ACDF were enrolled using a 2-team approach with neurosurgery and otolaryngology. Dysphagia was assessed both preoperatively and postoperatively using the MD Anderson Dysphagia Inventory (MDADI) and fiberoptic endoscopic evaluation of swallowing (FEES), whereas VCP was assessed using direct visualization with VLS.

RESULTS

Five patients (7.5%) developed a new postoperative temporary VCP after reoperative ACDF. All of these cases resolved by 2 months postoperatively. There were no new instances of permanent VCP. Twenty-five patients had a new swallowing disturbance detected on FEES compared with their baseline assessment, with most being mild and requiring no intervention. Nearly 60% of patients showed a decrease in their postoperative MDADI scores, particularly within the physical subset.

CONCLUSIONS

A 2-team approach to reoperative ACDF was safe and effective, with no new cases of VCP on postoperative VLS. Dysphagia rates as assessed through the MDADI scale and FEES were consistent with other published reports.

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Paul Foreman, Samuel McClugage III, Robert Naftel, Christoph J. Griessenauer, Benjamin J. Ditty, Bonita S. Agee, Jay Riva-Cambrin and John Wellons III

Object

Postresection hydrocephalus is observed in approximately 30% of pediatric patients with posterior fossa tumors. However, which patients will develop postresection hydrocephalus is not known. The Canadian Preoperative Prediction Rule for Hydrocephalus (CPPRH) was developed in an attempt to identify this subset of patients, allowing for the optimization of their care. The authors sought to validate and critically appraise the CPPRH.

Methods

The authors conducted a retrospective chart review of 99 consecutive pediatric patients who presented between 2002 and 2010 with posterior fossa tumors and who subsequently underwent resection. The data were then analyzed using bivariate and multivariate analyses, and a modified CPPRH (mCPPRH) was applied.

Results

Seventy-six patients were evaluated. Four variables were found to be significant in predicting postresection hydrocephalus: age younger than 2 years, moderate/severe hydrocephalus, preoperative tumor diagnosis, and transependymal edema. The mCPPRH produced observed likelihood ratios of 0.737 (95% CI 0.526–1.032) and 4.688 (95% CI 1.421–15.463) for low- and high-risk groups, respectively.

Conclusions

The mCPPRH utilizes readily obtainable and reliable preoperative variables that together stratify children with posterior fossa tumors into high- and low-risk categories for the development of postresection hydrocephalus. This new predictive model will aid patient counseling and tailor the intensity of postoperative clinical and radiographic monitoring for hydrocephalus, as well as provide evidence-based guidance for the use of prophylactic CSF diversion.

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Christoph J. Griessenauer, Joseph H. Miller, Bonita S. Agee, Winfield S. Fisher III, Joel K. Curé, Philip R. Chapman, Paul M. Foreman, Wilson A. M. Fisher, Adam C. Witcher and Beverly C. Walters

Object

The aim of this study was to examine observer reliability of frequently used arteriovenous malformation (AVM) grading scales, including the 5-tier Spetzler-Martin scale, the 3-tier Spetzler-Ponce scale, and the Pollock-Flickinger radiosurgery-based scale, using current imaging modalities in a setting closely resembling routine clinical practice.

Methods

Five experienced raters, including 1 vascular neurosurgeon, 2 neuroradiologists, and 2 senior neurosurgical residents independently reviewed 15 MRI studies, 15 CT angiograms, and 15 digital subtraction angiograms obtained at the time of initial diagnosis. Assessments of 5 scans of each imaging modality were repeated for measurement of intrarater reliability. Three months after the initial assessment, raters reassessed those scans where there was disagreement. In this second assessment, raters were asked to justify their rating with comments and illustrations. Generalized kappa (κ) analysis for multiple raters, Kendall's coefficient of concordance (W), and interclass correlation coefficient (ICC) were applied to determine interrater reliability. For intrarater reliability analysis, Cohen's kappa (κ), Kendall's correlation coefficient (tau-b), and ICC were used to assess repeat measurement agreement for each rater.

Results

Interrater reliability for the overall 5-tier Spetzler-Martin scale was fair to good (ICC = 0.69) to extremely strong (Kendall's W = 0.73) on initial assessment and improved on reassessment. Assessment of CT angiograms resulted in the highest agreement, followed by MRI and digital subtraction angiography. Agreement for the overall 3-tier Spetzler-Ponce grade was fair to good (ICC = 0.68) to strong (Kendall's W = 0.70) on initial assessment, improved on reassessment, and was comparable to agreement for the 5-tier Spetzler-Martin scale. Agreement for the overall Pollock-Flickinger radiosurgery-based grade was excellent (ICC = 0.89) to extremely strong (Kendall's W = 0.81). Intrarater reliability for the overall 5-tier Spetzler-Martin grade was excellent (ICC > 0.75) in 3 of the 5 raters and fair to good (ICC > 0.40) in the other 2 raters.

Conclusion

The 5-tier Spetzler-Martin scale, the 3-tier Spetzler-Ponce scale, and the Pollock-Flickinger radiosurgery-based scale all showed a high level of agreement. The improved reliability on reassessment was explained by a training effect from the initial assessment and the requirement to defend the rating, which outlines a potential downside for grades determined as part of routine clinical practice to be used for scientific purposes.

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Brandon G. Rocque, Bonita S. Agee, Eric M. Thompson, Mark Piedra, Lissa C. Baird, Nathan R. Selden, Stephanie Greene, Christopher P. Deibert, Todd C. Hankinson, Sean M. Lew, Bermans J. Iskandar, Taryn M. Bragg, David Frim, Gerald Grant, Nalin Gupta, Kurtis I. Auguste, Dimitrios C. Nikas, Michael Vassilyadi, Carrie R. Muh, Nicholas M. Wetjen and Sandi K. Lam

OBJECTIVE

In children, the repair of skull defects arising from decompressive craniectomy presents a unique set of challenges. Single-center studies have identified different risk factors for the common complications of cranioplasty resorption and infection. The goal of the present study was to determine the risk factors for bone resorption and infection after pediatric cranioplasty.

METHODS

The authors conducted a multicenter retrospective case study that included all patients who underwent cranioplasty to correct a skull defect arising from a decompressive craniectomy at 13 centers between 2000 and 2011 and were less than 19 years old at the time of cranioplasty. Prior systematic review of the literature along with expert opinion guided the selection of variables to be collected. These included: indication for craniectomy; history of abusive head trauma; method of bone storage; method of bone fixation; use of drains; size of bone graft; presence of other implants, including ventriculoperitoneal (VP) shunt; presence of fluid collections; age at craniectomy; and time between craniectomy and cranioplasty.

RESULTS

A total of 359 patients met the inclusion criteria. The patients’ mean age was 8.4 years, and 51.5% were female. Thirty-eight cases (10.5%) were complicated by infection. In multivariate analysis, presence of a cranial implant (primarily VP shunt) (OR 2.41, 95% CI 1.17–4.98), presence of gastrostomy (OR 2.44, 95% CI 1.03–5.79), and ventilator dependence (OR 8.45, 95% CI 1.10–65.08) were significant risk factors for cranioplasty infection. No other variable was associated with infection.

Of the 240 patients who underwent a cranioplasty with bone graft, 21.7% showed bone resorption significant enough to warrant repeat surgical intervention. The most important predictor of cranioplasty bone resorption was age at the time of cranioplasty. For every month of increased age the risk of bone flap resorption decreased by 1% (OR 0.99, 95% CI 0.98–0.99, p < 0.001). Other risk factors for resorption in multivariate models were the use of external ventricular drains and lumbar shunts.

CONCLUSIONS

This is the largest study of pediatric cranioplasty outcomes performed to date. Analysis included variables found to be significant in previous retrospective reports. Presence of a cranial implant such as VP shunt is the most significant risk factor for cranioplasty infection, whereas younger age at cranioplasty is the dominant risk factor for bone resorption.