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David O. Okonkwo

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David M. Panczykowski and David O. Okonkwo

Object

Acute subdural hematomas (SDHs) impart serious morbidity and mortality on the elderly population, with only 5% of those older than 65 years of age attaining functional independence. Despite its widespread use, oral antithrombotic therapy (OAT) in the context of acute SDH has not been extensively studied. The authors sought to evaluate the impact of premorbid OAT on recurrence of SDH, radiographic outcome, and mortality in patients undergoing surgical evacuation of an acute SDH.

Methods

The authors conducted a retrospective comparative cohort study reviewing all surgically treated cases of acute SDH at their institution between September 2005 and December 2008. They assessed baseline demographics, coagulation parameters, surgical management, and clinical course. Study end points included additional craniotomy for SDH reaccumulation, follow-up Rotterdam score, recurrent SDH volumetric analysis, Glasgow Outcome Score, and death.

Results

A total of 300 patients with acute SDH treated by craniotomy were assessed. Of these patients, 49% (148 patients) were receiving OAT. Of those who were on a regimen of OAT, 49% were taking warfarin (mean international normalized ratio 3.1 ± 1.8), 31% were receiving antiplatelet therapy, and 20% were on a regimen of a combination of agents. On presentation, 72% of those using OAT received reversal agents. Recurrence of SDH necessitating additional evacuation was not significantly different with respect to premorbid OAT status (13% vs 14%). Patients with a history of OAT did not demonstrate a significant difference in Rotterdam score (2 vs 2), recurrent SDH volume (24.1 vs 19.6 cm3), GOS score (4 vs 3), or mortality (21% vs 24%). These findings remained stable after controlling for age, injury mechanism, and injury severity.

Conclusions

Premorbid OAT was not a significant risk factor for recurrence of SDH necessitating additional evacuation following acute SDH. Additionally, postoperative Rotterdam score, volume of SDH reaccumulation, and overall mortality were not predicted by antithrombotic history. While premorbid use may predispose the patient to an SDH, OAT does not increase the risk of morbidity or mortality following surgical intervention.

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David O. Okonkwo and Praveen V. Mummaneni

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David M. Panczykowski, Nestor D. Tomycz and David O. Okonkwo

Object

The current standard of practice for clearance of the cervical spine in obtunded patients suffering blunt trauma is to use CT and an adjuvant imaging modality (such as MR imaging). The objective of this study was to determine the comparative effectiveness of multislice helical CT alone to diagnose acute unstable cervical spine injury following blunt trauma.

Methods

The authors performed a meta-analysis of studies comparing modern CT with adjunctive imaging modalities and required that studies present acute traumatic findings as well as treatment for unstable injuries. Study quality, population characteristics, diagnostic protocols, and outcome data were extracted. Positive disease status included all injuries necessitating surgical or orthotic stabilization identified on imaging and/or clinical follow-up.

Results

Seventeen studies encompassing 14,327 patients met the inclusion criteria. Overall, the sensitivity and specificity for modern CT were both > 99.9% (95% CI 0.99–1.00 and 0.99–1.00, respectively). The negative likelihood ratio of an unstable cervical injury after a CT scan negative for acute injury was < 0.001 (95% CI 0.00–0.01), while the negative predictive value of a normal CT scan was 100% (95% CI 0.96–1.00). Global severity of injury, CT slice thickness, and study quality did not significantly affect accuracy estimates.

Conclusions

Modern CT alone is sufficient to detect unstable cervical spine injuries in trauma patients. Adjuvant imaging is unnecessary when the CT scan is negative for acute injury. Results of this meta-analysis strongly show that the cervical collar may be removed from obtunded or intubated trauma patients if a modern CT scan is negative for acute injury.

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Daniel A. Tonetti, William J. Ares, David O. Okonkwo and Paul A. Gardner

OBJECTIVE

Large interhemispheric subdural hematomas (iSDHs) causing falx syndrome are rare; therefore, a paucity of data exists regarding the outcomes of contemporary management of iSDH. There is a general consensus among neurosurgeons that large iSDHs with neurological deficits represent a particular treatment challenge with generally poor outcomes. Thus, radiological and clinical outcomes of surgical and nonsurgical management for iSDH bear further study, which is the aim of this report.

METHODS

A prospectively collected, single-institution trauma database was searched for patients with isolated traumatic iSDH causing falx syndrome in the period from January 2008 to January 2018. Information on demographic and radiological characteristics, serial neurological examinations, clinical and radiological outcomes, and posttreatment complications was collected and tallied. The authors subsequently dichotomized patients by management strategy to evaluate clinical outcome and 30-day survival.

RESULTS

Twenty-five patients (0.4% of those with intracranial injuries, 0.05% of those with trauma) with iSDH and falx syndrome represented the study cohort. The average age was 73.4 years, and most patients (23 [92%] of 25) were taking anticoagulants or antiplatelet medications. Six patients were managed nonoperatively, and 19 patients underwent craniotomy for iSDH evacuation; of the latter patients, 17 (89.5%) had improvement in or resolution of motor deficits postoperatively. There were no instances of venous infarction, reaccumulation, or infection after evacuation. In total, 9 (36%) of the 25 patients died within 30 days, including 6 (32%) of the 19 who had undergone craniotomy and 3 (50%) of the 6 who had been managed nonoperatively. Patients who died within 30 days were significantly more likely to experience in-hospital neurological deterioration prior to surgery (83% vs 15%, p = 0.0095) and to be comatose prior to surgery (100% vs 23%, p = 0.0031). The median modified Rankin Scale score of surgical patients who survived hospitalization (13 patients) was 1 at a mean follow-up of 22.1 months.

CONCLUSIONS

iSDHs associated with falx syndrome can be evacuated safely and effectively, and prompt surgical evacuation prior to neurological deterioration can improve outcomes. In this study, craniotomy for iSDH evacuation proved to be a low-risk strategy that was associated with generally good outcomes, though appropriately selected patients may fare well without evacuation.

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Editorial

Thoracolumbar spinal deformity

Christopher I. Shaffrey

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Pawel G. Ochalski, David O. Okonkwo, Michael J. Bell and P. David Adelson

The authors report on a case of successful reversal of sedation with flumazenil, a benzodiazepine antagonist, in a child following a moderate traumatic brain injury and demonstrate the utility of flumazenil to reverse benzodiazepine effects in traumatically injured children.

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Gurpreet S. Gandhoke, Christian Ricks, Zachary Tempel, Brian Zuckerbraun, D. Kojo Hamilton, David O. Okonkwo and Adam S. Kanter

In deformity surgery, anterior lumbar interbody fusion provides excellent biomechanical support, creates a broad surface area for arthrodesis, and induces lordosis in the lower lumbar spine. Preoperative MRI, plain radiographs, and, when available, CT scan should be carefully assessed for sacral slope as it relates to pubic symphysis, position of the great vessels (especially at L4/5), disc space height, or contraindication to an anterior approach. This video demonstrates the steps in an anterior surgical procedure with minimal open exposure.

The video can be found here: https://youtu.be/r3bC4_vu1hQ.

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Matthew J. Tormenti, Matthew B. Maserati, Christopher M. Bonfield, David O. Okonkwo and Adam S. Kanter

Object

The authors recently used a combined approach of minimally invasive transpsoas extreme lateral interbody fusion (XLIF) and open posterior segmental pedicle screw instrumentation with transforaminal lumbar interbody fusion (TLIF) for the correction of coronal deformity. The complications and radiographic outcomes were compared with a posterior-only approach for scoliosis correction.

Methods

The authors retrospectively reviewed all deformity cases that were surgically corrected at the University of Pittsburgh Medical Center Presbyterian Hospital between June 2007 and August 2009. Eight patients underwent combined transpsoas and posterior approaches for adult degenerative thoracolumbar scoliosis. The comparison group consisted of 4 adult patients who underwent a posterior-only scoliosis correction. Data on intra- and postoperative complications were collected. The pre- and postoperative posterior-anterior and lateral scoliosis series radiographic films were reviewed, and comparisons were made for coronal deformity, apical vertebral translation (AVT), and lumbar lordosis. Clinical outcomes were evaluated by comparing pre- and postoperative visual analog scale scores.

Results

The median preoperative coronal Cobb angle in the combined approach was 38.5° (range 18–80°). Following surgery, the median Cobb angle was 10° (p < 0.0001). The mean preoperative AVT was 3.6 cm, improving to 1.8 cm postoperatively (p = 0.031). The mean preoperative lumbar lordosis in this group was 47.3°, and the mean postoperative lordosis was 40.4°. Compared with posterior-only deformity corrections, the mean values for curve correction were higher for the combined approach than for the posterior-only approach. Conversely, the mean AVT correction was higher in the posterior-only group. One patient in the posterior-only group required revision of the instrumentation. One patient who underwent the transpsoas XLIF approach suffered an intraoperative bowel injury necessitating laparotomy and segmental bowel resection; this patient later underwent an uneventful posterior-only correction of her scoliotic deformity. Two patients (25%) in the XLIF group sustained motor radiculopathies, and 6 of 8 patients (75%) experienced postoperative thigh paresthesias or dysesthesias. Motor radiculopathy resolved in 1 patient, but persisted 3 months postsurgery in the other. Sensory symptoms persisted in 5 of 6 patients at the most recent follow-up evaluation. The mean clinical follow-up time was 10.5 months for the XLIF group and 11.5 months for the posterior-only group. The mean visual analog scale score decreased from 8.8 to 3.5 in the XLIF group, and it decreased from 9.5 to 4 in the posterior-only group.

Conclusions

Radiographic outcomes such as the Cobb angle and AVT were significantly improved in patients who underwent a combined transpsoas and posterior approach. Lumbar lordosis was maintained in all patients undergoing the combined approach. The combination of XLIF and TLIF/posterior segmental instrumentation techniques may lead to less blood loss and to radiographic outcomes that are comparable to traditional posterior-only approaches. However, the surgical technique carries significant risks that require further evaluation and proper informed consent.