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Brandon A. Sherrod and Brandon G. Rocque

OBJECTIVE

Morbidity associated with surgical site infection (SSI) following nonshunt pediatric neurosurgical procedures is poorly understood. The purpose of this study was to analyze acute morbidity and mortality associated with SSI after nonshunt pediatric neurosurgery using a nationwide cohort.

METHODS

The authors reviewed data from the American College of Surgeons National Surgical Quality Improvement Program–Pediatric (NSQIP-P) 2012–2014 database, including all neurosurgical procedures performed on pediatric patients. Procedures were categorized by Current Procedural Terminology (CPT) codes. CSF shunts were excluded. Deep and superficial SSIs occurring within 30 days of an index procedure were identified. Deep SSIs included deep wound infections, intracranial abscesses, meningitis, osteomyelitis, and ventriculitis. The following outcomes occurring within 30 days of an index procedure were analyzed, along with postoperative time to complication development: sepsis, wound disruption, length of postoperative stay, readmission, reoperation, and death.

RESULTS

A total of 251 procedures associated with a 30-day SSI were identified (2.7% of 9296 procedures). Superficial SSIs were more common than deep SSIs (57.4% versus 42.6%). Deep SSIs occurred more frequently after epilepsy or intracranial tumor procedures. Superficial SSIs occurred more frequently after skin lesion, spine, Chiari decompression, craniofacial, and myelomeningocele closure procedures. The mean (± SD) postoperative length of stay for patients with any SSI was 9.6 ± 14.8 days (median 4 days). Post-SSI outcomes significantly associated with previous SSI included wound disruption (12.4%), sepsis (15.5%), readmission (36.7%), and reoperation (43.4%) (p < 0.001 for each). Post-SSI sepsis rates (6.3% vs 28.0% for superficial versus deep SSI, respectively; p < 0.001), wound disruption rates (4.9% vs 22.4%, p < 0.001), and reoperation rates (23.6% vs 70.1%, p < 0.001) were significantly greater for patients with deep SSIs. Postoperative length of stay in patients discharged before SSI development was not significantly different for deep versus superficial SSI (4.2 ± 2.7 vs 3.6 ± 2.4 days, p = 0.094). No patient with SSI died within 30 days after surgery.

CONCLUSIONS

Thirty-day SSI is associated with significant 30-day morbidity in pediatric patients undergoing nonshunt neurosurgery. Rates of SSI-associated complications are significantly lower in patients with superficial infection than in those with deep infection. There were no cases of SSI-related mortality within 30 days of the index procedure.

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Brandon A. Sherrod, James M. Johnston and Brandon G. Rocque

OBJECTIVE

Hospital readmission rate is increasingly used as a quality outcome measure after surgery. The purpose of this study was to establish, using a national database, the baseline readmission rates and risk factors for patient readmission after pediatric neurosurgical procedures.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program–Pediatric database was queried for pediatric patients treated by a neurosurgeon between 2012 and 2013. Procedures were categorized by current procedural terminology (CPT) code. Patient demographics, comorbidities, preoperative laboratory values, operative variables, and postoperative complications were analyzed via univariate and multivariate techniques to find associations with unplanned readmissions within 30 days of the primary procedure.

RESULTS

A total of 9799 cases met the inclusion criteria, 1098 (11.2%) of which had an unplanned readmission within 30 days. Readmission occurred 14.0 ± 7.7 days postoperatively (mean ± standard deviation). The 4 procedures with the highest unplanned readmission rates were CSF shunt revision (17.3%; CPT codes 62225 and 62230), repair of myelomeningocele > 5 cm in diameter (15.4%), CSF shunt creation (14.1%), and craniectomy for infratentorial tumor excision (13.9%). The lowest unplanned readmission rates were for spine (6.5%), craniotomy for craniosynostosis (2.1%), and skin lesion (1.0%) procedures. On multivariate regression analysis, the odds of readmission were greatest in patients experiencing postoperative surgical site infection (SSI; deep, organ/space, superficial SSI, and wound disruption: OR > 12 and p < 0.001 for each). Postoperative pneumonia (OR 4.294, p < 0.001), urinary tract infection (OR 4.262, p < 0.001), and sepsis (OR 2.616, p = 0.006) also independently increased the readmission risk. Independent patient risk factors for unplanned readmission included Native American race (OR 2.363, p = 0.019), steroid use > 10 days (OR 1.411, p = 0.010), oxygen supplementation (OR 1.645, p = 0.010), nutritional support (OR 1.403, p = 0.009), seizure disorder (OR 1.250, p = 0.021), and longer operative time (per hour increase, OR 1.059, p = 0.029).

CONCLUSIONS

This study may aid in identifying patients at risk for unplanned readmission following pediatric neurosurgery, potentially helping to focus efforts at lowering readmission rates, minimizing patient risk, and lowering costs for health care systems.

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Brandon G. Rocque, Samir Lapsiwala and Bermans J. Iskandar

Object

The clinical diagnosis of cerebrospinal fluid (CSF) shunt malfunction can be challenging. In this prospective study, the authors evaluated a common method of interrogating shunts: the shunt tap; specifically, its ability to predict proximal malfunction.

Methods

The authors performed standardized shunt taps in a consecutive series of cases involving children with suspected or proven shunt malfunction, assessing flow and, when possible, opening pressure. Data were collected prospectively, and results analyzed in light of surgical findings.

Results

A shunt tap was performed prior to 68 operative explorations in 51 patients. Of the 68 taps, 28 yielded poor or no CSF flow on aspiration. After 26 of these 28 procedures, proximal catheter obstruction was identified. After 28 taps with good CSF return and normal or low opening pressure, 18 shunts were found to have a proximal obstruction, 8 had no obstruction, and 2 had a distal obstruction. Another 12 taps with good CSF flow had high opening pressure; subsequent surgery showed distal obstruction in 11 of the shunts, and proximal obstruction in 1. The positive predictive value of poor flow was 93%, while good flow on shunt tap predicted adequate proximal catheter function in only 55% of cases.

Conclusions

Poor flow of CSF on shunt tap is highly predictive of obstruction of the proximal catheter. Because not all patients with good flow on shunt tap underwent surgical shunt exploration, the specificity of this test cannot be determined. Nonetheless, a shunt tap that reveals good flow with a normal opening pressure can be misleading, and management of such cases should be based on clinical judgment.

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Brandon G. Rocque, Timothy M. George, John Kestle and Bermans J. Iskandar

Object

The purpose of this study was to report the results of a survey of the American Society of Pediatric Neurosurgeons (ASPN) on treatment of Chiari malformation Type I (CM-I) with syringomyelia.

Methods

A questionnaire was circulated during the 2006 meeting of the ASPN, in which surgeons were surveyed on their management of patients with CM-I and syringomyelia. The survey consisted of questions about 4 clinical scenarios, common causes of surgical failures, and complications.

Results

There were 72 respondents, representing more than 90% of attendees at the 2006 ASPN meeting and approximately half of the society's members. The majority of respondents (85%) reported that they perform posterior fossa decompression as first-line treatment for CM-I with syringomyelia. Seven percent perform bony decompression alone, 36% open the dura, and 27% shrink the tonsils. Very few respondents indicated that they offer syrinx drainage as first-line therapy (< 3%). Although all respondents reported that they treat symptomatic CM-I/syringomyelia patients surgically, 15% of respondents indicated that they do not operate on asymptomatic patients. Finally, respondents stated that their most common complications are pseudomeningocele and chemical meningitis.

Conclusions

This survey, given to a representative group of experienced North American pediatric neurosurgeons, confirms that posterior fossa decompression is still the preferred treatment modality in children with CM-I and syringomyelia, regardless of symptoms. Although most surgeons open the dura, preferred techniques for decompression vary. In contrast to the results of past surveys, conservative follow-up is now only used by a minority of respondents and only in the asymptomatic patient, and primary syrinx drainage seems to have lost popularity. A multicenter trial of surgical outcomes has been designed based on the information from this survey.

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Brandon G. Rocque, Kaushik Amancherla, Sean M. Lew and Sandi Lam

Cranioplasty is routinely performed following decompressive craniectomy in both adult and pediatric populations. In adults, this procedure is associated with higher rates of complications than is elective cranial surgery. This study is a review of the literature describing risk factors for complications after cranioplasty surgery in pediatric patients. A systematic search of PubMed, Cochrane, and SCOPUS databases was undertaken. Articles were selected based on their titles and abstracts. Only studies that focused on a pediatric population were included; case reports were excluded. Studies in which the authors assessed bone flap storage method, timing of cranioplasty, material used (synthetic vs autogenous), skull defect size, and/or complication rates (bone resorption and surgical site infection) were selected for further analysis. Eleven studies that included a total of 441 cranioplasties performed in the pediatric population are included in this review.

The findings are as follows: 1) Based on analysis of pooled data, using cryopreserved bone flaps during cranioplasty may lead to a higher rate of bone resorption and lower rate of infection than using bone flaps stored at room temperature. 2) In 3 of 4 articles describing the effect of time between craniectomy and cranioplasty on complication rate, the authors found no significant effect, while in 1 the authors found that the incidence of bone resorption was significantly lower in children who had undergone early cranioplasty. Pooling of data was not possible for this analysis. 3) There are insufficient data to assess the effect of cranioplasty material on complication rate when considering only cranioplasties performed to repair decompressive craniectomy defects. However, when considering cranioplasties performed for any indication, those in which freshly harvested autograft is used may have a lower rate of resorption than those in which stored autograft is used. 4) There is no appreciable effect of craniectomy defect size or patient age on complication rate.

There is a paucity of articles describing outcomes and complications following cranioplasty in children and adolescents. However, based on the studies examined in this systematic review, there are reasons to suspect that method of flap preservation, timing of surgery, and material used may be significant. Larger prospective and retrospective studies are needed to shed more light on this important issue.

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Jonathan Pindrik, Brandon G. Rocque, Anastasia A. Arynchyna, James M. Johnston and Curtis J. Rozzelle

OBJECTIVE

Endoscopic third ventriculostomy (ETV) with choroid plexus (CP) cauterization (CPC) represents a viable treatment option for congenital hydrocephalus in infants younger than 2 years. Imaging studies complement clinical data in the evaluation of treatment success or failure. The objectives of this study were to investigate novel radiographic markers—cerebrospinal fluid (CSF) turbulence and CP visualization—and their ability to reflect or predict clinical outcomes following ETV/CPC.

METHODS

Hydrocephalic patients younger than 2 years who were initially treated by ETV/CPC at the senior authors' institution between March 2013 and February 2014 were retrospectively reviewed. Clinical data, as well as the visualization of CSF turbulence and CP on pre- and postoperative fast-sequence MRI, were recorded. Radiographic images were reviewed by a blinded observer based on specific criteria for the visualization of CSF turbulence and CP. Data were collected and analyzed using descriptive statistics, including Fisher's exact test for comparisons. The research team obtained appropriate institutional review board approval for this study, without the need for informed consent.

RESULTS

Among the 32 patients (53% male and 47% female) studied, 18 of 32 (56%) responded favorably to initial or repeat ETV/CPC, with 13 of 32 (41%) patients requiring 1 surgery. Of the 19 (59%) patients whose initial ETV/CPC failed, 8 of 19 (42%) patients underwent repeat ETV/CPC, with 5 of 8 (63%) patients responding favorably. Radiographic CSF turbulence appeared more frequently following ETV/CPC failure than after ETV/CPC success (55% vs 18%, respectively; p = 0.02). The sensitivity and specificity of CSF turbulence as a radiographic marker for ETV/CPC failure were 80% and 58%, respectively. The radiographic depiction of CP disappearance following ETV/CPC from pre- to postoperative imaging occurred in 20 of 30 patients (67%). Among the patients who responded unsuccessfully to ETV/CPC and ultimately required secondary shunt insertion, 71% (10 of 14 patients) demonstrated CP persistence on postoperative imaging. In contrast, 6% (1 of 18) of patients who were treated successfully by ETV/CPC demonstrated the presence of CP on follow-up imaging. This difference reached statistical significance (p = 0.0001). The visualization of CP persistence despite ETV/CPC reflected treatment failure with 91% sensitivity and 81% specificity. The sensitivity of either or both radiographic markers to suggest ETV/CPC failure was 77%, while their specificity (both markers absent, thereby indicating ETV/CPC success) was 81%.

CONCLUSIONS

Radiographic markers correlate with clinical outcomes following the treatment of infantile hydrocephalus with ETV/CPC. Specifically, CSF turbulence may indicate ongoing pathological CSF flow dynamics, while CP absence following ETV/CPC may predict shunt independence. Future studies that incorporate prospective review and formal intra- and interobserver reliability estimates may help corroborate the utility of these radiographic markers.

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Joyce Koueik, Brandon G. Rocque, Jordan Henry, Taryn Bragg, Jennifer Paul and Bermans J. Iskandar

Continuous irrigation is an important adjunct for successful intraventricular endoscopy, particularly for complex cases. It allows better visualization by washing out blood and debris, improves navigation by expanding the ventricles, and assists with tissue dissection. A method of irrigation delivery using a centrifugal pump designed originally for cardiac surgery is presented.

The BioMedicus centrifugal pump has the desirable ability to deliver a continuous laminar flow of fluid that excludes air from the system. A series of modifications to the pump tubing was performed to adapt it to neuroendoscopy. Equipment testing determined flow and pressure responses at various settings and simulated clinical conditions. The pump was then studied clinically in 11 endoscopy cases and eventually used in 310 surgical cases.

Modifications of the pump tubing allowed for integration with different endoscopy systems. Constant flow rates were achieved with and without surgical instruments through the working ports. Optimal flow rates ranged between 30 and 100 ml/min depending on endoscope size. Intraoperative use was well tolerated with no permanent morbidity and showed consistent flow rates, minimal air accumulation, and seamless irrigation bag replacement during prolonged surgery. Although the pump is equipped with an internal safety mechanism to protect against pressure buildup when outflow obstructions occur, equipment testing revealed that flow cessation is not instantaneous enough to protect against sudden intracranial pressure elevation.

A commonly available cardiac pump system was modified to provide continuous irrigation for intraventricular endoscopy. The system alleviates the problems of inconsistent flow rates, air in the irrigation lines, and delays in changing irrigation bags, thereby optimizing patient safety and surgical efficiency. Safe use of the pump requires good ventricular outflow and, clearly, sound surgical judgment.