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Joshua M. Beckman, Ernest K. Amankwah, Lisa L. Tetreault and Gerald F. Tuite

OBJECT

The application of concentrated topical antibiotic powder directly to surgical wounds has been associated with a reduction in wound infection in cardiac, spinal, and deep brain stimulator surgery. As a result of these findings, the corresponding author began systematically applying concentrated bacitracin powder directly to wounds during shunt surgery more than 5 years ago. The object of this study was to evaluate the effectiveness of concentrated bacitracin powder applied directly to wounds prior to closure during cranial shunt surgery and to evaluate the association between shunt infection and other risk factors. A single surgeon’s cranial shunt surgery experience, equally divided between periods during which antibiotic powder was and was not applied, was studied to assess the effect of concentrated bacitracin powder application on shunt infection rates.

METHODS

This retrospective cohort study included all patients who underwent a cranial shunting procedure at All Children’s Hospital performed by a single surgeon (G.F.T.) from 2001 to 2013. The surgeon applied bacitracin powder to all shunt wounds prior to closure between 2008 and 2013, whereas no antibiotic powder was applied to wounds prior to 2008. Both initial and revision shunting procedures were included, and all procedures were performed at a large children’s hospital (All Children’s Hospital). The primary outcome measure was shunt infection, which was defined using clinical criteria previously used by the Hydrocephalus Clinical Research Network. The association between bacitracin powder use and shunt infection was estimated using hazard ratios (HRs) and 95% CIs from Cox proportional hazard regression models.

RESULTS

A total of 47 infections out of 539 shunt operations occurred during the study period, resulting in an overall infection rate of 8.7%. Procedures performed before the use of concentrated bacitracin powder was instituted resulted in a 13% infection rate, whereas procedures performed after systematic use of bacitracin powder had been adopted experienced a 1% infection rate. Bacitracin powder use was associated with a reduced risk of shunt infection in univariate analysis (HR 0.11, 95% CI 0.03–0.34, p = 0.0002) and also in multivariate analysis (HR 0.12, 95% CI 0.04–0.41, p = 0.0006) when controlling for covariates that were associated with infection from the univariate analysis. The presence of a tracheostomy or a gastrostomy tube was also found to be independently associated with shunt infection in multivariate analysis (HR 3.15, 95% CI 1.05–9.50, p = 0.04, and HR 2.82, 95% CI 1.33–5.96, p = 0.007, respectively).

CONCLUSIONS

This study suggests, for the first time, that the systematic application of concentrated bacitracin powder to surgical wounds prior to closure during shunt surgery may be associated with a reduction in cranial shunt infection. This initial finding requires validation in a large prospective study before widespread application can be advocated.

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Chun-Po Yen, Joshua M. Beckman, Andrew C. Vivas, Konrad Bach and Juan S. Uribe

OBJECTIVE

The authors investigated whether the presence of intradiscal vacuum phenomenon (IVP) results in greater correction of disc height and restoration of segmental lordosis (SL).

METHODS

A retrospective chart review was performed on every patient at the University of South Florida's Department of Neurosurgery treated with lateral lumbar interbody fusion between 2011 and 2015. From these charts, preoperative plain radiographs and CT images were reviewed for the presence of IVP. Preoperative and postoperative posterior disc height (PDH), anterior disc height (ADH), and SL were measured at disc levels with IVP and compared with those at disc levels without IVP using the t-test. Linear regression was used to evaluate the factors that predict changes in PDH, ADH, and SL.

RESULTS

One hundred forty patients with 247 disc levels between L-1 and L-5 were treated with lateral lumbar interbody fusion. Among all disc levels treated, the mean PDH increased from 3.69 to 6.66 mm (p = 0.011), the mean ADH increased from 5.45 to 11.53 mm (p < 0.001), and the mean SL increased from 9.59° to 14.55° (p < 0.001). Significantly increased PDH was associated with the presence of IVP, addition of pedicle screws, and lack of cage subsidence; significantly increased ADH was associated with the presence of IVP, anterior longitudinal ligament (ALL) release, addition of pedicle screws, and lack of subsidence; and significantly increased SL was associated with the presence of IVP and ALL release.

CONCLUSIONS

IVP in patients with degenerative spinal disease remains grossly underreported. The data from the present study suggest that the presence of IVP results in increased restoration of disc height and SL.

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R. Shane Tubbs, Joshua M. Beckman, Marios Loukas, Mohammadali M. Shoja and Aaron A. Cohen-Gadol

Object

Various donor nerves have been used for brachial plexus neurotization procedures. To the authors' knowledge, neurotization of median nerve branches to the pronator teres to the radial nerve at the elbow have not been explored.

Methods

In an attempt to identify an additional nerve donor candidate for neurotization procedures of the upper limb, 20 cadaveric upper limbs underwent dissection of the cubital fossa and identification of branches of the median nerve to the pronator teres. Measurements were made of such branches, and distal transection was then performed to determine the appropriate length so that the structure could be brought to the laterally positioned radial nerve via tunneling deep to the biceps brachii muscle.

Results

All specimens were found to have a median nerve branch to the pronator teres that was long enough to reach the radial nerve in the cubital fossa. Neural connections remained tension free with full pronation and supination. The mean length of these branches to the pronator teres was 3.6 cm. The overall mean diameter of these nerves was 1.5 mm. The mean proximal, midpoint, and distal diameters were 2.0, 1.8, and 1.5 mm, respectively. The mean distance between the origin of these branches to the pronator teres and the medial epicondyle of the humerus was 4.1 cm.

Conclusions

Based on the results of our cadaveric study, the use of the branch of the median nerve to the pronator teres muscle may be considered for neurotization of the radial nerve in the cubital fossa.

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Angela E. Downes, William A. Vandergrift, Joshua M. Beckman, Devon Truong and Gerald F. Tuite

Placement of a ventriculoperitoneal shunt (VPS) is a procedure comprising many small steps. Difficulties and delays can arise when passing the distal shunt tubing down the distal tunneling sheath during surgery. The authors of this report describe a simple technique for quickly passing the distal catheter of a VPS through the tunneler sheath, whereby the sheath is used as a fluid tube to allow the distal catheter to be drawn through the fluid tube under suction pressure. The plastic sheath that surrounds the shunt tunneler device is used as a fluid tube, or “straw,” with the proximal aperture submerged into a bucket of sterile irrigation liquid containing the distal catheter. Suction pressure is placed against the distal aperture of the tunneler, and the shunt catheter is quickly drawn through the sheath. No special equipment is required. In time trials, the bucket and straw technique took an average of 0.43 seconds, whereas traditional passage methods took 32.3 seconds.

The “bucket and straw” method for passing distal shunt tubing through the tunneler sheath is a technique that increases surgical efficiency and reduces manual contact with shunt hardware.

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R. Shane Tubbs, Joshua Beckman, Robert P. Naftel, Joshua J. Chern, John C. Wellons III, Curtis J. Rozzelle, Jeffrey P. Blount and W. Jerry Oakes

Object

The diagnosis and treatment of Chiari malformation Type I (CM-I) has evolved over the last few decades. The authors present their surgical experience of over 2 decades of treating children with this form of hindbrain herniation.

Methods

The authors conducted a retrospective review of their institutional experience with the surgical treatment of the pediatric CM-I from 1989 to 2010.

Results

The 2 most common presentations were headache/neck pain (40%) and scoliosis (18%). Common associated diagnoses included neurofibromatosis Type 1 (5%) and idiopathic growth hormone deficiency (4.2%). Spine anomalies included scoliosis (18%), retroversion of the odontoid process (24%), Klippel-Feil anomaly (3%), and atlantooccipital fusion (8%). Approximately 3% of patients had a known family member with CM-I. Hydrocephalus was present in 48 patients (9.6%). Syringomyelia was present in 285 patients (57%), and at operation, 12% of patients with syringomyelia were found to have an arachnoid veil occluding the fourth ventricular outlet. Fifteen patients (3%) have undergone reoperation for continued symptoms or persistent large syringomyelia. The most likely symptoms and signs to resolve following surgery were Valsalva-induced headache and syringomyelia. The average hospital stay and “return to school” time were 3 and 12 days, respectively. The follow-up for this group ranged from 2 months to 15 years (mean 5 years). Complications occurred in 2.4% of cases; there was no mortality. No patient required acute return to the operating room, and no blood transfusions were performed.

Conclusions

The authors believe this to be the largest reported series of surgically treated pediatric CM-I patients and hope that their experience will be of use to others who treat this surgical entity.

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Joshua M. Beckman, Berney Vincent, Michael S. Park, James B. Billys, Robert E. Isaacs, Luiz Pimenta and Juan S. Uribe

OBJECTIVE

Minimally invasive lateral lumbar interbody fusion (LLIF) via the retroperitoneal transpsoas approach is a technically demanding procedure with a multitude of potential complications. A relatively unknown complication is the contralateral psoas hematoma. The authors speculate that injury occurs from segmental vessel injury at the time of contralateral annulus release; however, this is not fully understood. In this multicenter retrospective review, the authors report the incidence of this contralateral complication and its neurological sequelae.

METHODS

This study was a retrospective chart review of all minimally invasive LLIF performed at participating institutions from 2008 to 2014. Exclusion criteria included an underlying diagnosis of trauma or neoplasia as well as lateral corpectomies or anterior column releases. Single-level, multilevel, and stand-alone constructs were included. All patients underwent preoperative MRI. Follow-up was at least 12 months. All complications and clinical outcomes were self-reported by each surgeon.

RESULTS

There were 3950 lumbar interbody cages placed via the retroperitoneal transpsoas approach, with 7 cases (0.18% incidence) of symptomatic contralateral psoas hematoma, 3 of which required reoperation for hematoma evacuation. Neurological outcome did not improve after reoperation. Reoperation occurred an average of 1 month after the initial operation due to a delay in diagnosis. In 1 case, segmental artery injury was confirmed at the time of surgery; in the others, segmental vessel injury was suspected, although it could not be confirmed. Neurological deficits persisted in 3 patients while the others remained neurologically intact. Two patients were receiving antiplatelet therapy prior to the procedure.

CONCLUSIONS

The contralateral psoas hematoma is a rare complication suspected to occur from segmental vessel injury during contralateral annulus release. Detailed review of preoperative imaging for aberrant vessel anatomy may prevent injury and subsequent neurological deficit.

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Joshua M. Beckman, Ernest K. Amankwah, Lisa L. Tetreault, Sharon A. Perlman and Gerald F. Tuite

OBJECT

There has been renewed interest in the application of concentrated antibiotic powder to surgical wounds as a method to decrease infection rates. While there is substantial medical literature describing the effectiveness and complications associated with vancomycin and gentamycin powders, very little has been reported regarding the safety and effectiveness of bacitracin powder in surgical wounds. In this paper the authors report their detailed analysis of potential bacitracin powder-related complications in a population of pediatric patients who underwent shunt surgery.

METHODS

A detailed retrospective analysis was completed of all CSF shunt surgeries performed by the corresponding author at a large children’s hospital between 2001 and 2013. This cohort consisted of many patients who were the subject of a previous report that showed the use of bacitracin powder in shunt wounds potentially decreased infection rates. Data were collected regarding the most common known complications of bacitracin, i.e., anaphylaxis, wound healing difficulties, and renal dysfunction. Data were stratified by typical demographic, medical, and surgical variables, including whether bacitracin powder was applied to wounds prior to closure.

RESULTS

A total of 597 patients were reviewed in the analysis: 389 underwent surgery without bacitracin powder and 208 had concentrated bacitracin powder applied to the wounds prior to closure. The application of bacitracin powder was not associated with anaphylaxis (n = 0 both groups) or with an increase in wound breakdown (n = 5 in the control group, n = 0 in the bacitracin powder group) or renal dysfunction (creatinine/estimated glomerular filtration rate) using both comparative and multivariate analyses between the 2 groups. The sample size evaluating renal function was significantly lower (range 6–320) than that of anaphylaxis and wound breakdown analysis because only clinical values acquired during the routine care of these patients were available for analysis. The only significant difference in demographics was the more frequent use of intrathecal vancomycin and gentamycin in patients who received bacitracin powder (n = 1 for controls, n = 21 for bacitracin powder). In the multivariate analysis, only 1 factor, surgery performed on a premature infant within the first 3 months of life, was independently associated with a change in creatinine at 3 months (creatinine decreased by 0.18) compared with the level before surgery (p < 0.0001). Bacitracin powder was not a significant factor.

CONCLUSIONS

To the authors’ knowledge, this is the first study to systematically analyze the potential complications of concentrated bacitracin powder applied to surgical wounds. The use of topical bacitracin powder in CSF shunt wounds was not associated with anaphylaxis, wound breakdown, or renal dysfunction. Further study using standardized protocols is necessary before widespread use can be recommended.