David O. Okonkwo
David M. Panczykowski and David O. Okonkwo
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.
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.
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.
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.
David O. Okonkwo and Praveen V. Mummaneni
David M. Panczykowski, Nestor D. Tomycz, and David O. Okonkwo
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.
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.
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.
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.
Daniel A. Tonetti, William J. Ares, David O. Okonkwo, and Paul A. Gardner
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.
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.
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.
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.
Thoracolumbar spinal deformity
Christopher I. Shaffrey
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.
Rob Dickerman, Julie Williamson, and Matthew Bennett
Nitin Agarwal, Phillip A. Choi, David O. Okonkwo, Daniel L. Barrow, and Robert M. Friedlander
Application for a residency position in neurosurgery is a highly competitive process. Visiting subinternships and interviews are integral parts of the application process that provide applicants and programs with important information, often influencing rank list decisions. However, the process is an expensive one that places significant financial burden on applicants. In this study, the authors aimed to quantify expenses incurred by 1st-year neurosurgery residents who matched into a neurosurgery residency program in 2014 and uncover potential trends in expenses.
A 10-question survey was distributed in partnership with the Society of Neurological Surgeons to all 1st-year neurosurgery residents in the United States. The survey asked respondents about the number of subinternships, interviews, and second looks (after the interview) attended and the resultant costs, the type of program match, preferences for subinternship interviews, and suggestions for changes they would like to see in the application process. In addition to compiling overall results, also examined were the data for differences in cost when stratifying for region of the medical school or whether the respondent had contact with the program they matched to prior to the interview process (matched to home or subinternship program).
The survey had a 64.4% response rate. The mean total expenses for all components of the application process were US $10,255, with interview costs comprising the majority of the expenses (69.0%). No difference in number of subinternships, interviews, or second looks attended, or their individual and total costs, was seen for applicants from different regions of the United States. Respondents who matched to their home or subinternship program attended fewer interviews than respondents who had no prior contact with their matched program (13.5 vs 16.4, respectively, p = 0.0023) but incurred the same overall costs (mean $9774 vs $10,566; p = 0.58).
Securing a residency position in neurosurgery is a costly process for applicants. No differences are seen when stratifying by region of medical school attended or contact with a program prior to interviewing. Interview costs comprise the majority of expenses for applicants, and changes to the application process are needed to control costs incurred by applicants.
Michael M. McDowell, Andrew Venteicher, Ezequiel Goldschmidt, Maximiliano Nuñez, David O. Okonkwo, and Paul A. Gardner
Craniocervical instability due to chronic atlantoaxial dissociation presents the challenge of providing adequate decompression, reduction, and fixation to promote long-term stability while avoiding iatrogenic vertebral artery dissection or entrapment. The authors present one patient with chronic atlantoaxial dissociation and basilar invagination treated via Goel’s technique and with bilateral vertebral artery mobilization. There was substantial decompression and reduction postoperatively and the patient was discharged with a stable examination. Vertebral artery mobilization at the C1–2 junction can be safely performed via a standard midline suboccipital incision and dissection without vertebral artery injury.
The video can be found here: https://youtu.be/VS1Mt1dBLO4.