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The birth of modern military neurosurgery through the eyes of Harvey Cushing’s war memoir From a Surgeon’s Journal, 1915-1918

Harjus Birk, Caleb Stewart, and Jennifer A. Kosty

Dr. Harvey Cushing is considered the father of modern neurological surgery, and his role and efforts in World War I continue to have a lasting effect on today’s practice of neurosurgery. During World War I, he embodied the tenets of a neurosurgeon-scientist: he created and implemented novel antiseptic techniques to decrease infection rates after craniotomies, leading him often to be referred to as “originator of brain wound care.” His contributions did not come without struggles, however. He faced criticism for numerous military censorship violations, and he developed a severe peripheral neuropathy during the war. However, he continued to stress the importance of patient care and his surgical prowess was evident. In this paper, the authors summarize Cushing’s notes published in From a Surgeon’s Journal, 1915-1918 and discuss the impact of his experiences on his own practice and the field of neurosurgery.

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Anterior corpectomy via the mini-open, extreme lateral, transpsoas approach combined with short-segment posterior fixation for single-level traumatic lumbar burst fractures: analysis of health-related quality of life outcomes and patient satisfaction

Alexander A. Theologis, Ehsan Tabaraee, Paul Toogood, Abbey Kennedy, Harjus Birk, R. Trigg McClellan, and Murat Pekmezci

OBJECT

The authors present clinical outcome data and satisfaction of patients who underwent minimally invasive vertebral body corpectomy and cage placement via a mini-open, extreme lateral, transpsoas approach and posterior short-segment instrumentation for lumbar burst fractures.

METHODS

Patients with unstable lumbar burst fractures who underwent corpectomy and anterior column reconstruction via a mini-open, extreme lateral, transpsoas approach with short-segment posterior fixation were reviewed retrospectively. Demographic information, operative parameters, perioperative radiographic measurements, and complications were analyzed. Patient-reported outcome instruments (Oswestry Disability Index [ODI], 12-Item Short Form Health Survey [SF-12]) and an anterior scar-specific patient satisfaction questionnaire were recorded at the latest follow-up.

RESULTS

Twelve patients (7 men, 5 women, average age 42 years, range 22–68 years) met the inclusion criteria. Lumbar corpectomies with anterior column support were performed (L-1, n = 8; L-2, n = 2; L-3, n = 2) and supplemented with short-segment posterior instrumentation (4 open, 8 percutaneous). Four patients had preoperative neurological deficits, all of which improved after surgery. No new neurological complications were noted. The anterior incision on average was 6.4 cm (range 5–8 cm) in length, caused mild pain and disability, and was aesthetically acceptable to the large majority of patients. Three patients required chest tube placement for pleural violation, and 1 patient required reoperation for cage subsidence/hardware failure. Average clinical follow-up was 38 months (range 16–68 months), and average radiographic follow-up was 37 months (range 6–68 months). Preoperative lumbar lordosis and focal lordosis were significantly improved/maintained after surgery. Patients were satisfied with their outcomes, had minimal/moderate disability (average ODI score 20, range 0–52), and had good physical (SF-12 physical component score 41.7% ± 10.4%) and mental health outcomes (SF-12 mental component score 50.2% ± 11.6%) after surgery.

CONCLUSIONS

Anterior corpectomy and cage placement via a mini-open, extreme lateral, transpsoas approach supplemented by short-segment posterior instrumentation is a safe, effective alternative to conventional approaches in the treatment of single-level unstable burst fractures and is associated with excellent functional outcomes and patient satisfaction.

Open access

Wound vacuum-assisted closure as a bridge therapy in the treatment of infected cranial gunshot wound in a pediatric patient: illustrative case

Harjus Birk, Audrey Demand, Sandeep Kandregula, Christina Notarianni, Andrew Meram, and Jennifer Kosty

BACKGROUND

The authors reported the first pediatric case of a craniocerebral gunshot injury successfully treated with a wound vacuum-assisted closure (VAC) device after dehiscence and infection of the initial cranial wound.

OBSERVATIONS

A 17-year-old boy suffered several gunshots to the left hemisphere, resulting in significant damage to the scalp, calvaria, and brain. Emergency hemicraniectomy was performed, with reconstruction of a complicated scalp wound performed at the initial surgery. The scalp was devitalized and ultimately dehisced, resulting in a cranial infection. It was treated first with a repeated attempt at primary closure, which failed because of persistent devitalized tissue, and was then treated with aggressive debridement followed by placement of a wound VAC device over the exposed brain as a bridge therapy to reconstruction. This procedure was deemed necessary given the active infection.

LESSONS

The patient received delayed reconstruction with a free split-thickness skin graft and made a remarkable recovery, with cranioplasty performed 6 months later. The authors reviewed the literature on wound VAC use in cranial wound treatment and proposed it as a legitimate bridge therapy to definitive reconstruction in the setting of dirty wounds, active infection, or even hemodynamically unstable patients.

Free access

Improving patient care in neurosurgery through postoperative telephone calls: a systematic review and lessons from all surgical specialties

Dylan Goehner, Sandeep Kandregula, Harjus Birk, Christopher P. Carroll, Bharat Guthikonda, and Jennifer A. Kosty

OBJECTIVE

Postoperative telephone calls are a simple intervention that can be used to improve communication with patients, potentially affecting patient safety and satisfaction. Few studies in the neurosurgical literature have examined the effect of a postoperative telephone call on patient outcomes, although several exist across all surgical specialties. The authors performed a systematic review and analyzed studies published since 2000 to assess the effect of a postoperative telephone call or text message on patient safety and satisfaction across all surgical specialties.

METHODS

A search of PubMed-indexed articles was performed on June 12, 2021, and was narrowed by the inclusion criteria of studies from surgical specialties with > 50 adult patients published after 1999, in which a postoperative telephone call was made and its effects on safety and satisfaction were assessed. Exclusion criteria included dental, medical, and pediatric specialties; systematic reviews; meta-analyses; and non–English-language articles. Dual review was utilized.

RESULTS

Overall, 24 articles met inclusion criteria. The majority reported an increase in patient satisfaction scores after a postoperative telephone call was implemented, and half of the studies demonstrated an improvement in safety or outcomes.

CONCLUSIONS

Taken together, these studies demonstrate that implementation of a postoperative telephone call in a neurosurgical practice is a feasible way to enhance patient care. The major limitations of this study were the heterogeneous group of studies and the limited neurosurgery-specific studies.

Free access

Perioperative morbidity and mortality after lumbar trauma in the elderly

Ethan A. Winkler, John K. Yue, Harjus Birk, Caitlin K. Robinson, Geoffrey T. Manley, Sanjay S. Dhall, and Phiroz E. Tarapore

OBJECT

Traumatic fractures of the thoracolumbar spine are common injuries, accounting for approximately 90% of all spinal trauma. Lumbar spine trauma in the elderly is a growing public health problem with relatively little evidence to guide clinical management. The authors sought to characterize the complications, morbidity, and mortality associated with surgical and nonsurgical management in elderly patients with traumatic fractures of the lumbar spine.

METHODS

Using the National Sample Program of the National Trauma Data Bank, the authors performed a retrospective analysis of patients ≥ 55 years of age who had traumatic fracture to the lumbar spine. This group was divided into middle-aged (55–69 years) and elderly (≥ 70 years) cohorts. Cohorts were subdivided into nonoperative, vertebroplasty or kyphoplasty, noninstrumented surgery, and instrumented surgery. Univariate and multivariable analyses were used to characterize and identify predictors of medical and surgical complications, mortality, hospital length of stay, ICU length of stay, number of days on ventilator, and hospital discharge in each subgroup. Adjusted odds ratios, mean differences, and associated 95% CIs were reported. Statistical significance was assessed at p < 0.05, and the Bonferroni correction for multiple comparisons was applied for each outcome analysis.

RESULTS

Between 2003 and 2012, 22,835 people met the inclusion criteria, which represents 94,103 incidents nationally. Analyses revealed a similar medical and surgical complication profile between age groups. The most prevalent medical complications were pneumonia (7.0%), acute respiratory distress syndrome (3.6%), and deep venous thrombosis (3%). Surgical site infections occurred in 6.3% of cases. Instrumented surgery was associated with the highest odds of each complication (p < 0.001). The inpatient mortality rate was 6.8% for all subjects. Multivariable analyses demonstrated that age ≥ 70 years was an independent predictor of mortality (OR 3.16, 95% CI 2.77–3.60), whereas instrumented surgery (multivariable OR 0.38, 95% CI 0.28–0.52) and vertebroplasty or kyphoplasty (OR 0.27, 95% CI 0.17–0.45) were associated with decreased odds of death. In surviving patients, both older age (OR 0.32, 95% CI 0.30–0.34) and instrumented fusion (OR 0.37, 95% CI 0.33–0.41) were associated with decreased odds of discharge to home.

CONCLUSIONS

The present study confirms that lumbar surgery in the elderly is associated with increased morbidity. In particular, instrumented fusion is associated with periprocedural complications, prolonged hospitalization, and a decreased likelihood of being discharged home. However, fusion surgery is also associated with reduced mortality. Age alone should not be an exclusionary factor in identifying surgical candidates for instrumented lumbar spinal fusion. Future studies are needed to confirm these findings.

Free access

Role of pregnancy and female sex steroids on aneurysm formation, growth, and rupture: a systematic review of the literature

Milli Desai, Arvin R. Wali, Harjus S. Birk, David R. Santiago-Dieppa, and Alexander A. Khalessi

OBJECTIVE

Women have been shown to have a higher risk of cerebral aneurysm formation, growth, and rupture than men. The authors present a review of the recently published neurosurgical literature that studies the role of pregnancy and female sex steroids, to provide a conceptual framework with which to understand the various risk factors associated with cerebral aneurysms in women at different stages in their lives.

METHODS

The PubMed database was searched for “(“intracranial” OR “cerebral”) AND “aneurysm” AND (“pregnancy” OR “estrogen” OR “progesterone”)” between January 1980 and February 2019. A total of 392 articles were initially identified, and after applying inclusion and exclusion criteria, 20 papers were selected for review and analysis. These papers were then divided into two categories: 1) epidemiological studies about the formation, growth, rupture, and management of cerebral aneurysms in pregnancy; and 2) investigations on female sex steroids and cerebral aneurysms (animal studies and epidemiological studies).

RESULTS

The 20 articles presented in this study include 7 epidemiological articles on pregnancy and cerebral aneurysms, 3 articles reporting case series of cerebral aneurysms treated by endovascular therapies in pregnancy, 3 epidemiological articles reporting the relationship between female sex steroids and cerebral aneurysms through retrospective case-control studies, and 7 experimental studies using animal and/or cell models to understand the relationship between female sex steroids and cerebral aneurysms. The studies in this review report similar risk of aneurysm rupture in pregnant women compared to the general population. Most ruptured aneurysms in pregnancy occur during the 3rd trimester, and most pregnant women who present with cerebral aneurysm have caesarean section deliveries. Endovascular treatment of cerebral aneurysms in pregnancy is shown to provide a new and safe form of therapy for these cases. Epidemiological studies of postmenopausal women show that estrogen hormone therapy and later age at menopause are associated with a lower risk of cerebral aneurysm than in matched controls. Experimental studies in animal models corroborate this epidemiological finding; estrogen deficiency causes endothelial dysfunction and inflammation, which may predispose to the formation and rupture of cerebral aneurysms, while exogenous estrogen treatment in this population may lower this risk.

CONCLUSIONS

The aim of this work is to equip the neurosurgical and obstetrical/gynecological readership with the tools to better understand, critique, and apply findings from research on sex differences in cerebral aneurysms.

Full access

Laser ablative therapy of sessile hypothalamic hamartomas in children using interventional MRI: report of 5 cases

Derek G. Southwell, Harjus S. Birk, Paul S. Larson, Philip A. Starr, Leo P. Sugrue, and Kurtis I. Auguste

Hypothalamic hamartomas (HHs) are benign lesions that cause medically refractory seizures, behavioral disturbances, and endocrine dysfunction. Open resection of HHs does not guarantee seizure freedom and carries a relatively high risk of morbidity. Minimally invasive stereotactic laser ablation has recently been described as an effective and safe alternative for HH treatment. Prior studies have not, however, assessed HH lesion size and morphology, 2 factors that may influence treatment results and, ultimately, the generalizability of their findings. In this paper, the authors describe seizure outcomes for 5 pediatric patients who underwent laser ablation of sessile HHs. Lesions were treated using a frameless, interventional MRI-guided approach, which facilitated laser targeting to specific components of these complex lesions. The authors’ experiences in these cases substantiate prior work demonstrating the effectiveness of laser therapy for HHs, while elucidating HH complexity as a potentially important factor in laser treatment planning, and in the interpretation of early studies describing this treatment method.

Restricted access

Resection of gliomas deemed inoperable by neurosurgeons based on preoperative imaging studies

Derek G. Southwell, Harjus S. Birk, Seunggu J. Han, Jing Li, Jeffrey W. Sall, and Mitchel S. Berger

OBJECTIVE

Maximal safe resection is a primary objective in the management of gliomas. Despite this objective, surgeons and referring physicians may, on the basis of radiological studies alone, assume a glioma to be unresectable. Because imaging studies, including functional MRI, may not localize brain functions (such as language) with high fidelity, this simplistic approach may exclude some patients from what could be a safe resection. Intraoperative direct electrical stimulation (DES) allows for the accurate localization of functional areas, thereby enabling maximal resection of tumors, including those that may appear inoperable based solely on radiological studies. In this paper the authors describe the extent of resection (EOR) and functional outcomes following resections of tumors deemed inoperable by referring physicians and neurosurgeons.

METHODS

The authors retrospectively examined the cases of 58 adult patients who underwent glioma resection within 6 months of undergoing a brain biopsy of the same lesion at an outside hospital. All patients exhibited unifocal supratentorial disease and preoperative Karnofsky Performance Scale scores ≥ 70. The EOR and 6-month functional outcomes for this population were characterized.

RESULTS

Intraoperative DES mapping was performed on 96.6% (56 of 58) of patients. Nearly half of the patients (46.6%, 27 of 58) underwent an awake surgical procedure with DES. Overall, the mean EOR was 87.6% ± 13.6% (range 39.0%–100%). Gross-total resection (resection of more than 99% of the preoperative tumor volume) was achieved in 29.3% (17 of 58) of patients. Subtotal resection (95%–99% resection) and partial resection (PR; < 95% resection) were achieved in 12.1% (7 of 58) and 58.6% (34 of 58) of patients, respectively. Of the cases that involved PR, the mean EOR was 79.4% ± 12.2%. Six months after surgery, no patient was found to have a new postoperative neurological deficit. The majority of patients (89.7%, 52 of 58) were free of neurological deficits both pre- and postoperatively. The remainder of patients exhibited either residual but stable deficits (5.2%, 3 of 58) or complete correction of preoperative deficits (5.2%, 3 of 58).

CONCLUSIONS

The use of DES enabled maximal safe resections of gliomas deemed inoperable by referring neurosurgeons. With rare exceptions, tumor resectability cannot be determined solely by radiological studies.

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Metastatic clival chordoma: a case report of multiple extraneural metastases following resection and proton beam radiotherapy in a 5-year old boy

Martin J. Rutkowski, Harjus S. Birk, Matthew D. Wood, Arie Perry, Theodore Nicolaides, Christopher P. Ames, and Nalin Gupta

The authors report the case of a 5-year-old boy in whom extraneural metastases developed 5 years after he underwent an occipitocervical fusion and transoral approach to treat a clival chordoma without local recurrence. Following primary resection, the patient's postoperative course was complicated by recurrent meningitis secondary to CSF leak, which responded to antibiotics, and communicating hydrocephalus, for which a ventriculoperitoneal shunt was placed. The patient then underwent postoperative proton beam radiotherapy. Five years following his initial presentation, surveillance imaging revealed a new asymptomatic lung mass for which the patient underwent thoracotomy and resection of the mass. Histological examination of the lung mass revealed findings consistent with a de-differentiated chordoma, confirming extraneural metastasis from the original tumor without evidence of local recurrence. Chest wall and scalp metastases subsequently developed, and the patient was started on an adjuvant chemotherapy regimen that included imatinib and rapamycin followed by subsequent nivolumab and an EZH2 inhibitor for recurrent, disseminated disease. Despite this patient's remote and distant metastases, primary gross-total resection for chordoma remains a critical treatment objective, followed by proton beam radiotherapy. This case illustrates the importance of interval posttreatment imaging and the emerging potential to treat chordoma with molecularly targeted therapies.

Free access

Visualization of nerve fibers and their relationship to peripheral nerve tumors by diffusion tensor imaging

Tene A. Cage, Esther L. Yuh, Stephanie W. Hou, Harjus Birk, Neil G. Simon, Roger Noss, Anuradha Rao, Cynthia T. Chin, and Michel Kliot

OBJECT

The majority of growing and/or symptomatic peripheral nerve tumors are schwannomas and neurofibromas. They are almost always benign and can usually be resected while minimizing motor and sensory deficits if approached with the proper expertise and techniques. Intraoperative electrophysiological stimulation and recording techniques allow the surgeon to map the surface of the tumor in an effort to identify and thus avoid damaging functioning nerve fibers. Recently, MR diffusion tensor imaging (DTI) techniques have permitted the visualization of axons, because of their anisotropic properties, in peripheral nerves. The object of this study was to compare the distribution of nerve fibers as revealed by direct electrical stimulation with that seen on preoperative MR DTI.

METHODS

The authors conducted a retrospective chart review of patients with a peripheral nerve or nerve root tumor between March 2012 and January 2014. Diffusion tensor imaging and intraoperative data had been prospectively collected for patients with peripheral nerve tumors that were resected. Preoperative identification of the nerve fiber location in relation to the nerve tumor surface as seen on DTI studies was compared with the nerve fiber’s intraoperative localization using electrophysiological stimulation and recordings.

RESULTS

In 23 patients eligible for study there was good correlation between nerve fiber location on DTI and its anatomical location seen intraoperatively. Diffusion tensor imaging demonstrated the relationship of nerve fibers relative to the tumor with 95.7% sensitivity, 66.7% specificity, 75% positive predictive value, and 93.8% negative predictive value.

CONCLUSIONS

Preoperative DTI techniques are useful in helping the peripheral nerve surgeon to both determine the risks involved in resecting a nerve tumor and plan the safest surgical approach.