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Andrew T. Hale, Amanda N. Stanton, Shilin Zhao, Faizal Haji, Stephen R. Gannon, Anastasia Arynchyna, John C. Wellons, Brandon G. Rocque and Robert P. Naftel

OBJECTIVE

At failure of endoscopic third ventriculostomy (ETV) with choroid plexus cauterization (CPC), the ETV ostomy may be found to be closed or open. Failure with a closed ostomy may indicate a population that could benefit from evolving techniques to keep the ostomy open and may be candidates for repeat ETV, whereas failure with an open ostomy may be due to persistently abnormal CSF dynamics. This study seeks to identify clinical and radiographic predictors of ostomy status at the time of ETV/CPC failure.

METHODS

The authors conducted a multicenter, retrospective cohort study on all pediatric patients with hydrocephalus who failed initial ETV/CPC treatment between January 2013 and October 2016. Failure was defined as the need for repeat ETV or ventriculoperitoneal (VP) shunt placement. Clinical and radiographic data were collected, and ETV ostomy status was determined endoscopically at the subsequent hydrocephalus procedure. Statistical analysis included the Mann-Whitney U-test, Wilcoxon rank-sum test, t-test, and Pearson chi-square test where appropriate, as well as multivariate logistic regression.

RESULTS

Of 72 ETV/CPC failures, 28 patients (39%) had open-ostomy failure and 44 (61%) had closed-ostomy failure. Patients with open-ostomy failure were older (median 5.1 weeks corrected age for gestation [interquartile range (IQR) 0.9–15.9 weeks]) than patients with closed-ostomy failure (median 0.2 weeks [IQR −1.3 to 4.5 weeks]), a significant difference by univariate and multivariate regression. Etiologies of hydrocephalus included intraventricular hemorrhage of prematurity (32%), myelomeningocele (29%), congenital communicating (11%), aqueductal stenosis (11%), cyst/tumor (4%), and other causes (12%). A wider baseline third ventricle was associated with open-ostomy failure (median 15.0 mm [IQR 10.3–18.5 mm]) compared to closed-ostomy failure (median 11.7 mm [IQR 8.9–16.5 mm], p = 0.048). Finally, at the time of failure, patients with closed-ostomy failure had enlargement of their ventricles (frontal and occipital horn ratio [FOHR], failure vs baseline, median 0.06 [IQR 0.00–0.11]), while patients with open-ostomy failure had no change in ventricle size (median 0.01 [IQR −0.04 to 0.05], p = 0.018). Previous CSF temporizing procedures, intraoperative bleeding, and time to failure were not associated with ostomy status at ETV/CPC failure.

CONCLUSIONS

Older corrected age for gestation, larger baseline third ventricle width, and no change in FOHR were associated with open-ostomy ETV/CPC failure. Future studies are warranted to further define and confirm features that may be predictive of ostomy status at the time of ETV/CPC failure.

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Tim Adamson, Saniya S. Godil, Melissa Mehrlich, Stephen Mendenhall, Anthony L. Asher and Matthew J. McGirt

OBJECTIVE

In an era of escalating health care costs and pressure to improve efficiency and cost of care, ambulatory surgery centers (ASCs) have emerged as lower-cost options for many surgical therapies. Anterior cervical discectomy and fusion (ACDF) is one of the most prevalent spine surgeries performed, and the frequency of its performance is rapidly increasing as the aging population grows. Although ASCs offer significant cost advantages over hospital-based surgical centers, concern over the safety of outpatient ACDF has slowed its adoption. The authors intended to 1) determine the safety of the first 1000 consecutive ACDF surgeries performed in their outpatient ASC, and 2) compare the safety of these outpatient ACDFs with that of consecutive ACDFs performed during the same time period in the hospital setting.

METHODS

A total of 1000 consecutive patients who underwent ACDF in an ACS (outpatient ACDF) and 484 consecutive patients who underwent ACDF at Vanderbilt University Hospital (inpatient ACDF) from 2006 to 2013 were included in this retrospective study of patients' medical records. Data were collected on patient demographics, comorbidities, operative details, and perioperative and 90-day morbidity. Perioperative morbidity and hospital readmission were compared between the outpatient and inpatient ACDF groups.

RESULTS

Of the first 1000 outpatient ACDF cases performed in the authors' ASC, 629 (62.9%) were 1-level and 365 (36.5%) were 2-level ACDFs. Mean patient age was 49.5 ± 8.6, and 484 (48.4%) were males. All patients were observed postoperatively at the ASC postanesthesia care unit (PACU) for 4 hours before being discharged home. Eight patients (0.8%) were transferred from the surgery center to the hospital postoperatively (for pain control [n = 3], chest pain and electrocardiogram changes [n = 2], intraoperative CSF leak [n = 1], postoperative hematoma [n = 1], and profound postoperative weakness and surgical reexploration [n = 1]). No perioperative deaths occurred. The 30-day hospital readmission rate was 2.2%. All 90-day surgical morbidity was similar between outpatient and inpatient cohorts for both 1-level and 2-level ACDFs.

CONCLUSIONS

An analysis of 1000 consecutive patients who underwent ACDF in an outpatient setting demonstrates that surgical complications occur at a low rate (1%) and can be appropriately diagnosed and managed in a 4-hour ASC PACU window. Comparison with an inpatient ACDF surgery cohort demonstrated similar results, highlighting that ACDF can be safely performed in the outpatient ambulatory surgery setting without compromising surgical safety. In an effort to decrease costs of care, surgeons can safely perform 1- and 2-level ACDFs in an ASC environment.

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Emily W. Chan, Stephen R. Gannon, Chevis N. Shannon, Jeffrey E. Martus, Gregory A. Mencio and Christopher M. Bonfield

OBJECTIVE

Adolescent idiopathic scoliosis (AIS), the most common type of scoliosis, often presents immediately prior to a woman’s childbearing years; however, research investigating the impact of AIS on women’s health, particularly pregnancy delivery outcomes, is sparse, with existing literature reporting mixed findings. Similarly limited are studies examining the change in scoliotic curve during or after pregnancy. Therefore, this study aims to determine 1) the impact of scoliotic curvature on obstetric complications (preterm births, induction of labor, and urgent/emergency caesarean section delivery), 2) regional anesthetic decision making and success during delivery for these patients, and 3) the effect of pregnancy on curve progression.

METHODS

Records of all pregnant patients diagnosed with AIS at the authors’ institution who delivered between January 2002 and September 2016 were retrospectively reviewed. Demographic information, pre- and postpartum radiographic Cobb angles, and clinical data for each pregnancy and delivery were recorded and analyzed. The Wilcoxon rank-sum test and the Wilcoxon signed-rank test were used for statistical analyses.

RESULTS

Fifty-nine patients (84 deliveries) were included; 14 patients had undergone prior posterior spinal fusion. The median age at AIS diagnosis was 15.2 years, and the median age at delivery was 21.8 years. Overall, the median major Cobb angle prior to the first pregnancy was 25° (IQR 15°–40°). Most births were by spontaneous vaginal delivery (n = 45; 54%); elective caesarean section was performed in 17 deliveries (20%). Obstetric complications included preterm birth (n = 18; 21.4%), induction of labor (n = 20; 23.8%), and urgent/emergency caesarean section (n = 12; 14.0%); none were associated with severity of scoliosis curve or prior spinal fusion. Attempts at spinal anesthesia were successful 99% of the time (70/71 deliveries), even among the patients who had undergone prior spinal fusion (n = 13). There were only 3 instances of provider refusal to administer spinal anesthesia. In the subset of 11 patients who underwent postpartum scoliosis radiography, there was no statistically significant change in curve magnitude either during or immediately after pregnancy.

CONCLUSIONS

The results of this study suggest that there was no effect of the severity of scoliosis on delivery complications or regional anesthetic decision making in pregnant patients with AIS. Moreover, scoliosis was not observed to progress significantly during or immediately after pregnancy. Larger prospective studies are needed to further investigate these outcomes, the findings of which can guide the prenatal education and counseling of pregnant patients with AIS.

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Ranbir Ahluwalia, Chelsea Kiely, Jarrett Foster, Stephen Gannon, Alyssa L. Wiseman, Chevis N. Shannon and Christopher M. Bonfield

OBJECTIVE

The authors sought to assess the prevalence and severity of positional posterior plagiocephaly (PPP) in the pediatric population at a tertiary care center.

METHODS

The authors conducted a retrospective review of 1429 consecutive patients aged 2 months to 18 years who presented with head trauma and a negative CT scan in 2018. The cohort was stratified by age. The cranial vault asymmetry index (CVAI) was calculated at the superior orbital rim. Asymmetry was categorized according to the following CVAI scores: mild (3.5%–7%), moderate (7%–12%), and severe (> 12%). Patients were grouped by age to assess PPP at different stages of head development: group 1, 2–5 months; group 2, 6–11 months; group 3, 12–23 months; group 4: 2–4 years; group 5, 5–8 years; group 6, 9–12 years; and group 7, 13–18 years. Patients with a history of shunted hydrocephalus, craniosynostosis, skull surgery, or radiographic evidence of intracranial trauma were excluded.

RESULTS

The overall cohort prevalence of PPP was 24.8% (354 patients). PPP prevalence was higher among younger patients from groups 1–3 (40.4%, 33.5%, and 0.8%, respectively). There was a continued decline in PPP by age in groups 4–7 (26.4%, 20%, 20%, and 10.8%, respectively). Mild cranial vault asymmetry was noted most often (78.0%, 276 patients), followed by moderate (19.5%, 69 patients) and severe (2.5%, 9 patients). There were no patients in group 6 or 7 with severe PPP.

CONCLUSIONS

PPP is prevalent in pediatric populations and most commonly presents as a case of mild asymmetry. Although there was an overall decline of PPP prevalence with increasing age, moderate asymmetry was seen in all age groups. No patients in the cohort had severe asymmetry that persisted into adolescence.

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Rajiv R. Iyer, Carolyn M. Carey, S. Alex Rottgers, Lisa Tetreault, Nir Shimony, Jennifer Katzenstein, Ernesto Ruas and Gerald F. Tuite

OBJECTIVE

Infants with severe hydrocephalus and extreme macrocephaly typically undergo CSF diversion early in life, which can result in significant cranial deformity due to CSF overdrainage. In this scenario, overlap of the cranial plates can precede the development of secondary synostosis and/or severe, permanent cranial deformity. As a result, extensive cranial vault remodeling is sometimes undertaken later in life, which is often challenging and has been associated with mortality and a high morbidity rate. The authors have previously described a technique for early postnatal cranial vault reduction and fixation (CVRF), in which the calvarial bones are stabilized using absorbable fixation plates in the neonatal period, in an attempt to facilitate patient positioning, simplify hydrocephalus management, and improve cosmesis. Here, the authors describe their institutional experience managing patients with extreme neonatal hydrocephalus with CSF diversion, with and without CVRF, over the past 12 years.

METHODS

The authors retrospectively reviewed the charts of infants with extreme hydrocephalus (head circumference > 49 cm) treated at their children’s hospital with ventriculoperitoneal shunting, with or without CVRF, between 2005 and 2017. Data collected included age, sex, etiology of hydrocephalus, type of CVRF performed (anterior, posterior, or combined), follow-up duration, orbitofrontal circumference, craniometric measurements, intraoperative blood loss, operative duration, and postoperative complications. Developmental data were collected using the third edition of the Ages and Stages Questionnaire. Photographic imaging was used to demonstrate esthetic outcomes, and family questionnaires were used to evaluate satisfaction with the esthetic outcome.

RESULTS

Eleven patients with extreme neonatal hydrocephalus underwent CSF shunting; 5 underwent shunting alone and 6 patients underwent shunting and CVRF. For patients who underwent shunting and CVRF, the median age at CVRF was 6 days and the median interval between shunt placement and CVRF was 2.5 days. The mean extent of calvarial vault volume reduction was 44.5% (± 3.9%). The mean duration of the CVRF procedure was 108 minutes, and 5 of 6 patients required intraoperative transfusion. Of the 5 patients who underwent shunting alone, 3 developed severe cranial deformities. Of 6 patients who underwent shunting and CVRF, 1 had a poor cosmetic outcome. In the shunting-alone group, 2 patients died and 1 required extensive cranial vault correction at 10 years of age. One patient in the shunting and CVRF group also died.

CONCLUSIONS

CVRF in combination with CSF shunting in the neonatal period can simplify the treatment of the rare case of severe hydrocephalic macrocephaly and leads to cosmetic outcomes that are considered good by their families.

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Leah Y. Carreon, Kelly R. Bratcher, Nandita Das, Jacob B. Nienhuis and Steven D. Glassman

Object

The Neck Disability Index (NDI) and numeric rating scales (0 to 10) for neck pain and arm pain are widely used cervical spine disease–specific measures. Recent studies have shown that there is a strong relationship between the SF-6D and the NDI such that using a simple linear regression allows for the estimation of an SF-6D value from the NDI alone. Due to ease of administration and scoring, the EQ-5D is increasingly being used as a measure of utility in the clinical setting. The purpose of this study is to determine if the EQ-5D values can be estimated from commonly available cervical spine disease–specific health-related quality of life measures, much like the SF-6D.

Methods

The EQ-5D, NDI, neck pain score, and arm pain score were prospectively collected in 3732 patients who presented to the authors' clinic with degenerative cervical spine disorders. Correlation coefficients for paired observations from multiple time points between the NDI, neck pain and arm pain scores, and EQ-5D were determined. Regression models were built to estimate the EQ-5D values from the NDI, neck pain, and arm pain scores.

Results

The mean age of the 3732 patients was 53.3 ± 12.2 years, and 43% were male. Correlations between the EQ-5D and the NDI, neck pain score, and arm pain score were statistically significant (p < 0.0001), with correlation coefficients of −0.77, −0.62, and −0.50, respectively. The regression equation 0.98947 + (−0.00705 × NDI) + (−0.00875 × arm pain score) + (−0.00877 × neck pain score) to predict EQ-5D had an R-square of 0.62 and a root mean square error (RMSE) of 0.146. The model using NDI alone had an R-square of 0.59 and a RMSE of 0.150. The model using the individual NDI items had an R-square of 0.46 and an RMSE of 0.172. The correlation coefficient between the observed and estimated EQ-5D scores was 0.79. There was no statistically significant difference between the actual EQ-5D score (0.603 ± 0.235) and the estimated EQ-5D score (0.603 ± 0.185) using the NDI, neck pain score, and arm pain score regression model. However, rounding off the coefficients to fewer than 5 decimal places produced less accurate results.

Conclusions

The regression model estimating the EQ-5D from the NDI, neck pain score, and arm pain score accounted for 60% of the variability of the EQ-5D with a relatively large RMSE. This regression model may not be sufficient to accurately or reliably estimate actual EQ-5D values.

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Leah Y. Carreon, Kelly R. Bratcher, Chelsea E. Canan, Lauren O. Burke, Mladen Djurasovic and Steven D. Glassman

Object

Previous studies have reported on the minimum clinically important difference (MCID), a threshold of improvement that is clinically relevant for lumbar degenerative disorders. Recent studies have shown that pre- and postoperative health-related quality of life (HRQOL) measures vary among patients with different diagnostic etiologies. There is also concern that a patient's previous care experience may affect his or her perception of clinical improvement. This study determined if MCID values for the Oswestry Disability Index (ODI), 36-Item Short-Form Health Survey (SF-36), and back and leg pain are different between patients undergoing primary or revision lumbar fusion.

Methods

Prospectively collected preoperative and 1-year postoperative patient-reported HRQOLs, including the ODI, SF-36 physical component summary (PCS), and numeric rating scales (0–10) for back and leg pain, in patients undergoing lumbar spine fusion were analyzed. Patients were grouped into either the primary surgery or revision group. As the most widely accepted MCID values were calculated from the minimum detectable change, this method was used to determine the MCID.

Results

A total of 722 patients underwent primary procedures and 333 patients underwent revisions. There was no statistically significant difference in demographics between the groups. Each group had a statistically significant improvement at 1 year postoperatively compared with baseline. The minimum detectable change–derived MCID values for the primary group were 1.16 for back pain, 1.36 for leg pain, 12.40 for ODI, and 5.21 for SF-36 PCS. The MCID values for the revision group were 1.21 for back pain, 1.28 for leg pain, 11.79 for ODI, and 4.90 for SF-36 PCS. These values are very similar to those previously reported in the literature.

Conclusions

The MCID values were similar for the revision and primary lumbar fusion groups, even when subgroup analysis was done for different diagnostic etiologies, simplifying interpretation of clinical improvement. The results of this study further validate the use of patient-reported HRQOLs to measure clinical effectiveness, as a patient's previous experience with care does not seem to substantially alter an individual's perception of clinical improvement.

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Mladen Djurasovic, Katlyn E. McGraw, Kelly Bratcher, Charles H. Crawford III, John R. Dimar II, Rolando M. Puno, Steven D. Glassman, R. Kirk Owens II and Leah Y. Carreon

OBJECTIVE

The goal of this study was to determine efficacy and cost-effectiveness of Cell Saver in 2- and 3-level lumbar decompression and fusion.

METHODS

Patients seen at a tertiary care spine center who were undergoing a posterior 2- or 3-level lumbar decompression and fusion were randomized to have Cell Saver used during their surgery (CS group, n = 48) or not used (No Cell Saver [NCS] group, n = 47). Data regarding preoperative and postoperative hemoglobin and hematocrit, estimated blood loss, volume of Cell Saver blood reinfused, number of units and volume of allogeneic blood transfused intraoperatively and postoperatively, complications, and costs were collected. Costs associated with Cell Saver use were calculated based on units of allogeneic blood transfusions averted.

RESULTS

Demographics and surgical parameters were similar in both groups. The mean estimated blood loss was similar in both groups: 612 ml in the CS group and 742 ml in the NCS group. There were 53 U of allogeneic blood transfused in 29 patients in the NCS group at a total blood product cost of $67,688; and 38 U of allogeneic blood transfused in 16 patients in the CS group at a total blood cost of $113,162, resulting in a cost of $3031 per allogeneic blood transfusion averted using Cell Saver.

CONCLUSIONS

Cell Saver use produced lower rates of allogeneic transfusion but was found to be more expensive than using only allogeneic blood for 2- and 3-level lumbar degenerative fusions. This increased cost may be reasonable to patients who perceive that the risks associated with allogeneic transfusions are unacceptable.

CLASSIFICATION OF EVIDENCE Type of question: therapeutic; study design: randomized controlled trial; evidence: class III.

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Mladen Djurasovic, Steven D. Glassman, John R. Dimar II, Charles H. Crawford III, Kelly R. Bratcher and Leah Y. Carreon

Object

Clinical studies use both disease-specific and generic health outcomes measures. Disease-specific measures focus on health domains most relevant to the clinical population, while generic measures assess overall health-related quality of life. There is little information about which domains of the Oswestry Disability Index (ODI) are most important in determining improvement in overall health-related quality of life, as measured by the 36-Item Short Form Health Survey (SF-36), after lumbar spinal fusion. The objective of the study is to determine which clinical elements assessed by the ODI most influence improvement of overall health-related quality of life.

Methods

A single tertiary spine center database was used to identify patients undergoing lumbar fusion for standard degenerative indications. Patients with complete preoperative and 2-year outcomes measures were included. Pearson correlation was used to assess the relationship between improvement in each item of the ODI with improvement in the SF-36 physical component summary (PCS) score, as well as achievement of the SF-36 PCS minimum clinically important difference (MCID). Multivariate regression modeling was used to examine which items of the ODI best predicted achievement for the SF-36 PCS MCID. The effect size and standardized response mean were calculated for each of the items of the ODI.

Results

A total of 1104 patients met inclusion criteria (674 female and 430 male patients). The mean age at surgery was 57 years. All items of the ODI showed significant correlations with the change in SF-36 PCS score and achievement of MCID for the SF-36 PCS, but only pain intensity, walking, and social life had r values > 0.4 reflecting moderate correlation. These 3 variables were also the dimensions that were independent predictors of the SF-36 PCS, and they were the only dimensions that had effect sizes and standardized response means that were moderate to large.

Conclusions

Of the health dimensions measured by the ODI, pain intensity, walking, and social life best predicted improvement in overall health-related quality of life, as measured using the SF-36 PCS.

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Luis M. Tumialán, Ryan P. Ponton, Angelina Garvin and Wayne M. Gluf

Object

The introduction of cervical and lumbar arthroplasty has allowed for management of cervical radiculopathy and lumbar degenerative disease in patients with the preservation of motion at the affected segment. While the early clinical outcomes of this technology appear promising, it remains unclear what activity limitations should be imposed after surgery in patients with these implants. This is of particular interest in military personnel, who may be required to return to a rigorous level of activity after surgery. The goals of the FDA trials evaluating various disc arthroplasty devices were to establish safety, efficacy, and equivalency to arthrodesis. Information regarding the level of physical performance attained and restrictions or limitations is lacking, as these were outside the objectives of these trials. Nevertheless, there data are essential for the military surgeon, who is tasked with guiding the postoperative management of patients treated with arthroplasty and returning them to full duty. While there is a single report of clinical results of lumbar arthroplasty in athletes, at this writing, there are no reports of either cervical or lumbar arthroplasty in active duty military personnel.

Methods

The surgical database at a single, tertiary care military treatment facility was queried for all activeduty patients who underwent placement of either a cervical or lumbar arthroplasty device over a 3-year period. The authors performed a retrospective chart review to collect patient and procedural data including blood loss, length of hospital stay, tobacco use, age, rank, complications, and ability to return to full unrestricted active duty. Arthroplasty cohorts were then compared to historical controls of arthrodesis to ascertain differences in the time required to return to full duty.

Results

Twelve patients were identified who underwent cervical arthroplasty. All patients returned to unrestricted full duty. This cohort was then compared with 12 patients who had undergone a single-level anterior cervical discectomy and fusion. The average time to return to unrestricted full duty for the arthroplasty group was 10.3 weeks (range 7–13 weeks), whereas that in the fusion group was 16.5 weeks. This difference between these 2 groups was statistically significant (p = 0.008). Twelve patients were identified who underwent lumbar arthroplasty. Ten (83%) of 12 patients in this group returned to unrestricted full duty. In patients who returned to full duty, it took an average of 22.6 weeks (range 12–29 weeks). This cohort was then compared with one in which patients had undergone anterior lumbar interbody fusion. Eight (67%) of 12 patients in the lumbar arthrodesis group returned to unrestricted full duty. In patients who returned to full duty, it took an average of 32.4 weeks (range 25–41 weeks). This difference was not statistically significant (p = 0.156).

Conclusions

The preliminary experience with cervical and lumbar arthroplasty at the authors' institution indicates that arthroplasty is comparable with arthrodesis and may actually expedite return to active duty. Patients are capable of returning to a high level of rigorous training and physical performance. There are no apparent restrictions or limitations that are required after 3 months in the cervical patient and after 6 months in the lumbar patient. Further prospective studies with long-term follow-up are indicated and will be of value when determining the role of arthroplasty compared to arthrodesis in the active-duty population.