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Seba Ramhmdani and Ali Bydon

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Stephan Dützmann, Florian Geßler, Gerhard Marquardt, Volker Seifert and Christian Senft

Object

The authors performed a study to evaluate whether preoperative assessment of prothrombin time (PT) is mandatory in patients undergoing routinely planned neurosurgical procedures.

Methods

The charts of all patients admitted to general wards of the authors' department for routinely planned surgery (excluding trauma and ICU patients) between 2006 and 2010 were retrospectively reviewed. The authors assessed preoperative PT and the clinical courses of all patients, with special consideration for patients receiving coagulation factor substitution. All cases involving hemorrhagic complications were analyzed in detail with regard to pre- and postoperative PT abnormalities. Prothrombin time was expressed as the international normalized ratio, and values greater than 1.28 were regarded as elevated.

Results

Clinical courses and PT values of 4310 patients were reviewed. Of these, 33 patients (0.7%) suffered hemorrhagic complications requiring repeat surgery. Thirty-one patients (94%) had a normal PT before the initial operation, while 2 patients had slightly elevated PT values of 1.33 and 1.65, which were anticipated based on the patient's history. In the latter 2 cases, surgery was performed without prior correction of PT. Preoperatively, PT was elevated in 78 patients (1.8%). In 73 (93.6%) of the 78 patients, the PT elevation was expected and explained by each patient's medical history. In only 5 (0.1%) of 4310 patients did we find an unexpected PT elevation (mean 1.53, range 1.37–1.74). All 5 patients underwent surgery without complications, while 2 had received coagulation factor substitution preoperatively, as requested by the surgeon, because of an estimated risk of bleeding complications. None of the 5 patients received coagulation factor substitution postoperatively, and later detailed laboratory studies ruled out single coagulation factor deficiencies. There was no statistically significant association between preoperatively elevated PT levels and the occurrence of hemorrhagic complications (p = 0.12). Before the second procedure but not before the initial operation, 4 (12%) of the 33 patients had elevated PT.

Conclusions

The findings suggest that the value of preoperative PT testing is limited in patients in whom a normal history can be ascertained. Close postoperative PT control is necessary in every neurosurgical patient, and better tests need to be developed to identify patients who are prone to hemorrhagic complications.

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Markus Bruder, Adriano Cattani, Florian Gessler, Christian Droste, Matthias Setzer, Volker Seifert and Gerhard Marquardt

OBJECTIVE

Synovial cysts of the spine are rare lesions, predominantly arising in the lumbar region. Despite their generally benign behavior, they can cause severe symptoms due to compression of neural structures in the spinal canal. Treatment strategies are still a matter of discussion. The authors performed a single-center survey and literature search focusing on long-term results after minimally invasive surgery.

METHODS

A total of 141 consecutive patients treated for synovial cysts of the lumbar spine between 1997 and 2014 in the authors’ department were analyzed. Medical reports with regard to signs and symptoms, operative findings, complications, and short-term outcome were reviewed. Assessment of long-term outcome was performed with a standardized telephone questionnaire based on the Oswestry Disability Index (ODI). Furthermore, patients were questioned about persisting pain, symptoms, and further operative procedures, if any. Subjective satisfaction was classified as excellent, good, fair, or poor based on the Macnab classification.

RESULTS

The approach most often used for synovial cyst treatment was partial hemilaminectomy in 70%; hemilaminectomy was necessary in 27%. At short-term follow-up, the presence of severe and moderate leg pain had decreased from 93% to 5%. The presence of low-back pain decreased from 90% to 5%. Rates of motor and sensory deficits were reduced from 40% to 14% and from 45% to 6%, respectively. The follow-up rate was 58%, and the mean follow-up period was 9.3 years. Both leg pain and low-back pain were still absent in 78%. Outcome based on the Macnab classification was excellent in 80%, good in 14%, fair in 1%, and poor in 5%. According to the ODI, 78% of patients had no or only minimal disability, 16% had moderate disability, and 6% had severe disability at the time of follow-up. In this cohort, 7% needed surgery due to cyst recurrence, and 9% required a delayed stabilization procedure after the initial operation.

CONCLUSIONS

Surgical treatment with resection of the cyst provides favorable results in outcome. Excellent or good outcome persisting for a long-term follow-up period can be achieved in the vast majority of cases. Complication rates are low despite an increased risk of dural injury. With facet-sparing techniques, the stability of the segment can be preserved, and resection of spinal synovial cysts does not necessarily require segmental fusion.

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Florian Gessler, Haitham Mutlak, Karima Tizi, Christian Senft, Matthias Setzer, Volker Seifert and Lutz Weise

OBJECTIVE

The value of postoperative epidural analgesia after major spinal surgery is well established. Thus far, the use of patient-controlled epidural analgesia (PCEA) has been denied to patients undergoing debridement and instrumentation in spondylodiscitis, with the risk of increased postoperative pain resulting in prolonged recovery. The value of PCEA with special regard to infectious complications remains to be clarified. The present study examined the value of postoperative PCEA in comparison with intravenous analgesia in patients with spondylodiscitis undergoing posterior spinal surgery.

METHODS

Thirty-two patients treated surgically for spondylodiscitis of the thoracic and lumbar spine were prospectively included in a database and retrospectively reviewed for this study. Postoperative antibiotic treatment, functional capacity, pain levels, side effects, and complications were documented. Sixteen patients were given patient-demanded intravenous analgesia (PIA) followed by 16 patients assigned to PCEA. If PCEA was applied, the insertion of an epidural catheter was performed under the direct visual guidance of the surgeon at the end of the surgery.

RESULTS

Three patients intended for PCEA treatment were excluded due to predefined exclusion criteria. Postoperative pain was significantly lower in the PCEA group during the first 48 hours after surgery (p = 0.03). As determined by the trunk control test conducted at 8 (p < 0.001), 24 (p = 0.004), 48 (p = 0.015), 72 (p = 0.0031), and 96 hours (p < 0.001), patients in the PCEA treatment group displayed significantly increased mobilization capacity compared with those of the PIA group. Time until normal accomplishment of all mobilization maneuvers was reduced in the PCEA group compared with that in the PIA group (p = 0.04). No differences in complication rates were observed between the 2 groups (p = 0.52).

CONCLUSIONS

PCEA may reduce postoperative pain and lead to earlier achievement of functional capacity at a low complication rate in patients with surgically treated lumbar and thoracic spondylodiscitis.

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Florian Gessler, Markus Bruder, Stephan Duetzmann, Stephanie Tritt, Joshua D. Bernstock, Volker Seifert and Christian Senft

OBJECTIVE

Neurosurgical intervention may increase the risk of developing cerebral vein and dural sinus thrombosis (CVT). The clinical management of CVT in postoperative patients remains unclear. This retrospective study explores the disease occurrence, associated risk factors, and outcomes in patients with tumors who developed CVT after craniotomy.

METHODS

A retrospective analysis and review of patient records in those who had undergone cranial tumor removal within the authors' neurosurgical department was performed. In so doing, the authors identified a cohort of patients who developed CVT postoperatively. The study included patients who presented to the department between January 2004 and December 2013.

RESULTS

Of 2286 patients with intracranial lesions who underwent craniotomy, 35 (1.5%) went on to develop CVT. The authors identified the semisitting position (OR 7.55, 95% CI 3.73–15.31, p < 0.001); intraoperative sinus injury (OR 1.5, 95% CI 3.57–15.76, p < 0.001); and known CVT risk factors (OR 7.77, 95% CI 2.28–21.39, p < 0.001) as predictors of CVT development. Of note, 19 patients (54.3%) had good outcomes (modified Rankin Scale Score 0–1), whereas 9 patients (25.7%) had suffered dependency or death (modified Rankin Scale Score 4–6) at last follow-up. Intracerebral hemorrhage (OR 21.27, 95% CI 1.59–285.01, p = 0.02) and delayed delivery of an intermediate dose of low-molecular-weight heparin anticoagulation (OR 24.12, 95% CI 2.08–280.13, p = 0.01) were associated with unfavorable outcomes.

CONCLUSIONS

Only a minority of patients undergoing craniotomy for tumor removal develop CVT, and the majority of those who do develop CVT recover well. Early administration of an intermediate dose of low-molecular-weight heparin anticoagulation might be considered once CVT is diagnosed.

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Sae-Yeon Won, Florian Gessler, Daniel Dubinski, Michael Eibach, Bedjan Behmanesh, Eva Herrmann, Volker Seifert, Juergen Konczalla, Stephanie Tritt and Christian Senft

OBJECTIVE

Prophylactic placement of an external ventricular drain (EVD) is often performed prior to resection of a posterior fossa tumor (PFT); however, there is no general consensus regarding the indications. The purpose of this study was to establish a novel grading system for the prediction of required CSF drainage due to symptomatic elevated intracranial pressure (ICP) after resection of a PFT to identify patients who require an EVD.

METHODS

The authors performed a retrospective analysis of data from a prospective database. All patients who had undergone resection of a PFT between 2012 and 2017 at the University Hospital, Goethe University Frankfurt, were identified and data from their cases were analyzed. PFTs were categorized as intraparenchymal (iPFT) or extraparenchymal (ePFT). Prior to resection, patients underwent EVD placement, prophylactic burr hole placement, or neither. The authors assessed the amount of CSF drainage (if applicable), rate of EVD placement at a later time point, and complication rate and screened for factors associated with CSF drainage. By applying those factors, they established a grading system to predict the necessity of CSF drainage for elevated ICP.

RESULTS

A total of 197 patients met the inclusion criteria. Of these 197, 70.6% received an EVD, 15.7% underwent prophylactic burr hole placement, and 29.4% required temporary CSF drainage. In the prophylactic burr hole group, 1 of 32 patients (3.1%) required EVD placement at a later time. Independent predictors for postoperative need for CSF drainage due to symptomatic intracranial hypertension in patients with iPFTs were preoperative hydrocephalus (OR 2.9) and periventricular CSF capping (OR 2.9), whereas semi-sitting surgical position (OR 0.2) and total resection (OR 0.3) were protective factors. For patients with ePFTs, petroclival/midline tumor location (OR 12.2/OR 5.7), perilesional edema (OR 10.0), and preoperative hydrocephalus (OR 4.0) were independent predictors of need for CSF drainage. According to our grading system, CSF drainage after resection of iPFT or ePFT, respectively, was required in 16.7% and 5.1% of patients with a score of 0, in 21.1% and 12.5% of patients with a score of 1, in 47.1% and 26.3% of patients with a score of 2, and in 100% and 76.5% of patients with a score ≥ 3 (p < 0.0001). The rate of relevant EVD complications was 4.3%, and 10.1% of patients were shunt-dependent at 3-month follow-up.

CONCLUSIONS

This novel grading system for the prediction of need for CSF drainage following resection of PFT might be of help in deciding in favor of or against prophylactic EVD placement.

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Bedjan Behmanesh, Florian Gessler, Katrin Schnoes, Daniel Dubinski, Sae-Yeon Won, Jürgen Konczalla, Volker Seifert, Lutz Weise and Matthias Setzer

OBJECTIVE

The incidence of patients with pyogenic spinal infection is increasing. In addition to treatment of the spinal infection, early diagnosis of and therapy for coexisting infections, especially infective endocarditis (IE), is an important issue. The aim of this study was to evaluate the proportion of coexisting IE and the value of routine transesophageal echocardiography (TEE) in the management of these patients.

METHODS

The medical history, laboratory data, radiographic findings, treatment modalities, and results of TEE of patients admitted between 2007 and 2017 were analyzed.

RESULTS

During the abovementioned period, 110 of 255 total patients underwent TEE for detection of IE. The detection rate of IE between those patients undergoing and not undergoing TEE was 33% and 3%, respectively (p < 0.0001). Thirty-six percent of patients with IE needed cardiac surgical intervention because of severe valve destruction. Chronic renal failure, heart failure, septic condition at admission, and preexisting heart condition were significantly associated with coexisting IE. The mortality rate in patients with IE was significantly higher than in patients without IE (22% vs 3%, p = 0.002).

CONCLUSIONS

TEE should be performed routinely in all patients with spondylodiscitis.

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Andrej Paľa, Jan Coburger, Moritz Scherer, Hajrullah Ahmeti, Constantin Roder, Florian Gessler, Christine Jungk, Angelika Scheuerle, Christian Senft, Marcos Tatagiba, Michael Synowitz, Christian Rainer Wirtz, Bernd Schmitz and Andreas W. Unterberg

OBJECTIVE

The level of evidence for adjuvant treatment of diffuse WHO grade II glioma (low-grade glioma, LGG) is low. In so-called “high-risk” patients most centers currently apply an early aggressive adjuvant treatment after surgery. The aim of this assessment was to compare progression-free survival (PFS) and overall survival (OS) in patients receiving radiation therapy (RT) alone, chemotherapy (CT) alone, or a combined/consecutive RT+CT, with patients receiving no primary adjuvant treatment after surgery.

METHODS

Based on a retrospective multicenter cohort of 288 patients (≥ 18 years old) with diffuse WHO grade II gliomas, a subgroup analysis of patients with a confirmed isocitrate dehydrogenase (IDH) mutation was performed. The influence of primary adjuvant treatment after surgery on PFS and OS was assessed using Kaplan-Meier estimates and multivariate Cox regression models, including age (≥ 40 years), complete tumor resection (CTR), recurrent surgery, and astrocytoma versus oligodendroglioma.

RESULTS

One hundred forty-four patients matched the inclusion criteria. Forty patients (27.8%) received adjuvant treatment. The median follow-up duration was 6 years (95% confidence interval 4.8–6.3 years). The median overall PFS was 3.9 years and OS 16.1 years. PFS and OS were significantly longer without adjuvant treatment (p = 0.003). A significant difference in favor of no adjuvant therapy was observed even in high-risk patients (age ≥ 40 years or residual tumor, 3.9 vs 3.1 years, p = 0.025). In the multivariate model (controlled for age, CTR, oligodendroglial diagnosis, and recurrent surgery), patients who received no adjuvant therapy showed a significantly positive influence on PFS (p = 0.030) and OS (p = 0.009) compared to any other adjuvant treatment regimen. This effect was most pronounced if RT+CT was applied (p = 0.004, hazard ratio [HR] 2.7 for PFS, and p = 0.001, HR 20.2 for OS). CTR was independently associated with longer PFS (p = 0.019). Age ≥ 40 years, histopathological diagnosis, and recurrence did not achieve statistical significance.

CONCLUSIONS

In this series of IDH-mutated LGGs, adjuvant treatment with RT, CT with temozolomide (TMZ), or the combination of both showed no significant advantage in terms of PFS and OS. Even in high-risk patients, the authors observed a similar significantly negative impact of adjuvant treatment on PFS and OS. These results underscore the importance of a CTR in LGG. Whether patients ≥ 40 years old should receive adjuvant treatment despite a CTR should be a matter of debate. A potential tumor dedifferentiation by administration of early TMZ, RT, or RT+CT in IDH-mutated LGG should be considered. However, these data are limited by the retrospective study design and the potentially heterogeneous indication for adjuvant treatment.