Patrick W. Hitchon, Mario Zanaty, Logan Helland, Kingsley Abode-Iyamah and Nader S. Dahdaleh
Timothy W. Vogel, Calvin S. Carter, Kingsley Abode-Iyamah, Qihong Zhang and Shenandoah Robinson
Neural tube defects (NTDs) are a set of disorders that occur from perturbation of normal neural development. They occur in open or closed forms anywhere along the craniospinal axis and often result from a complex interaction between environmental and genetic factors. One burgeoning area of genetics research is the effect of cilia signaling on the developing neural tube and how the disruption of primary cilia leads to the development of NTDs. Recent progress has implicated the hedgehog (Hh), wingless-type integration site family (Wnt), and planar cell polarity (PCP) pathways in primary cilia as involved in normal neural tube patterning. A set of disorders involving cilia function, known as ciliopathies, offers insight into abnormal neural development. In this article, the authors discuss the common ciliopathies, such as Meckel-Gruber and Joubert syndromes, that are associated with NTDs, and review cilia-related signaling cascades responsible for mammalian neural tube development. Understanding the contribution of cilia in the formation of NTDs may provide greater insight into this common set of pediatric neurological disorders.
Timothy E. Lindley, Nader S. Dahdaleh, Arnold H. Menezes and Kingsley O. Abode-Iyamah
Management of pediatric occipitocervical instability remains especially challenging. The off-label use of recombinant human bone morphogenetic protein (rhBMP)-2 for spinal fusion has increased with a well-documented increase in fusion rate in many case series. Unfortunately, recent reports have documented complications associated with rhBMP use in adult spinal fusions. Complications associated with the use of rhBMP in pediatric spinal surgery is less well understood. In this study the authors report on the fusion rate and complications associated with rhBMP in pediatric occipitocervical arthrodesis.
The authors reviewed the medical records of those patients 18 years old and younger who underwent dorsal occipitocervical fusion from January 2004 to December 2007 at the University of Iowa Hospitals and Clinics. Forty-eight patients were identified who received rhBMP-augmented fusion. The clinical outcome and complications of these fusions were analyzed.
All 48 patients had fusion confirmed on lateral radiographs within 4–14 months with an average fusion time of 6.7 months. There were 6 complications, 5 of which included seroma formation. Two of 5 patients who developed postoperative seroma presented with symptoms suggesting brainstem compression and obstructive hydrocephalus requiring emergency reoperation. One patient developed heterotopic bone formation causing cervicomedullary compression requiring reoperation.
The use of rhBMP to augment autograft in occipitocervical fusion allows for a high rate of successful arthrodesis, but is associated with potentially life-threatening complications in pediatric patients.
Vincent C. Traynelis, Kingsley O. Abode-Iyamah, Katie M. Leick, Sarah M. Bender and Jeremy D. W. Greenlee
The primary goal of this study was to review the immediate postoperative neurological function in patients surgically treated for symptomatic cervical spine disease without intraoperative neurophysiological monitoring. The secondary goal was to assess the economic impact of intraoperative monitoring (IOM) in this patient population.
This study is a retrospective review of 720 consecutively treated patients who underwent cervical spine procedures. The patients were identified and the data were collected by individuals who were not involved in their care.
A total of 1534 cervical spine levels were treated in 720 patients using anterior, posterior, and combined (360°) approaches. Myelopathy was present preoperatively in 308 patients. There were 185 patients with increased signal intensity within the spinal cord on preoperative T2-weighted MR images, of whom 43 patients had no clinical evidence of myelopathy. Three patients (0.4%) exhibited a new neurological deficit postoperatively. Of these patients, 1 had a preoperative diagnosis of radiculopathy, while the other 2 were treated for myelopathy. The new postoperative deficits completely resolved in all 3 patients and did not require additional treatment. The Current Procedural Terminology (CPT) codes for IOM during cervical decompression include 95925 and 95926 for somatosensory evoked potential monitoring of the upper and lower extremities, respectively, as well as 95928 and 95929 for motor evoked potential monitoring of the upper and lower extremities. In addition to the charge for the baseline [monitoring] study, patients are charged hourly for ongoing electrophysiology testing and monitoring using the CPT code 95920. Based on these codes and assuming an average of 4 hours of monitoring time per surgical case, the savings realized in this group of patients was estimated to be $1,024,754.
With the continuing increase in health care costs, it is our responsibility as providers to minimize expenses when possible. This should be accomplished without compromising the quality of care to patients. This study demonstrates that decompression and reconstruction for symptomatic cervical spine disease without IOM may reduce the cost of treatment without adversely impacting patient safety.
Arnold H. Menezes, Jeremy D. W. Greenlee, Reid A. Longmuir, Daniel R. Hansen and Kingsley Abode-Iyamah
The authors present the case of a 14-year-old boy with holocord syringohydromyelia extending into the brainstem, cerebral peduncle, internal capsule, and cerebral cortex. At the posterior fossa exploration, an opaque thickened arachnoid with occlusion of the foramen of Magendie was encountered. Careful documentation of postoperative regression of the syringocephaly, syringobulbia, and syringohydromyelia was made. The pathophysiology is discussed.
Kirsten E. Stoner, Kingsley O. Abode-Iyamah, Vincent A. Magnotta, Matthew A. Howard III and Nicole M. Grosland
Cervical myelopathy (CM) is a common and debilitating form of spinal cord injury caused by chronic compression; however, little is known about the in vivo mechanics of the healthy spinal cord during motion and how these mechanics are altered in CM. The authors sought to measure 3D in vivo spinal cord displacement and strain fields from MR images obtained during physiological motion of healthy individuals and cervical myelopathic patients.
Nineteen study participants, 9 healthy controls and 10 CM patients, were enrolled in the study. All study participants had 3T MR images acquired of the cervical spine in neutral, flexed, and extended positions. Displacement and strain fields and corresponding principal strain were obtained from the MR images using image registration.
The healthy spinal cord displaces superiorly in flexion and inferiorly in extension. Principal strain is evenly distributed along the spinal cord. The CM spinal cord displaces less than the healthy cord and the magnitude of principal strain is higher, at the midcervical levels.
Increased spinal cord compression during cervical myelopathy limits motion of the spinal cord and increases spinal cord strain during physiological motion. Future studies are needed to investigate how treatment, such as surgical intervention, affects spinal cord mechanics.
Ravi Sharma, Manoj Phalak and Varidh Katiyar
Beejal Y. Amin and Praveen V. Mummaneni
Kingsley O. Abode-Iyamah, Hsiu-Yin Chiang, Royce W. Woodroffe, Brian Park, Francis J. Jareczek, Yasunori Nagahama, Nolan Winslow, Loreen A. Herwaldt and Jeremy D. W. Greenlee
Deep brain stimulation is an effective surgical treatment for managing some neurological and psychiatric disorders. Infection related to the deep brain stimulator (DBS) hardware causes significant morbidity: hardware explantation may be required; initial disease symptoms such as tremor, rigidity, and bradykinesia may recur; and the medication requirements for adequate disease management may increase. These morbidities are of particular concern given that published DBS-related infection rates have been as high as 23%. To date, however, the key risk factors for and the potential preventive measures against these infections remain largely uncharacterized. In this study, the authors endeavored to identify possible risk factors for DBS-related infection and analyze the efficacy of prophylactic intrawound vancomycin powder (VP).
The authors performed a retrospective cohort study of patients who had undergone primary DBS implantation at a single institution in the period from December 2005 through September 2015 to identify possible risk factors for surgical site infection (SSI) and to assess the impact of perioperative (before, during, and after surgery) prophylactic antibiotics on the SSI rate. They also evaluated the effect of a change in the National Healthcare Safety Network’s definition of SSI on the number of infections detected. Statistical analyses were performed using the 2-sample t-test, the Wilcoxon rank-sum test, the chi-square test, Fisher’s exact test, or logistic regression, as appropriate for the variables examined.
Four hundred sixty-four electrodes were placed in 242 adults during 245 primary procedures over approximately 10.5 years; most patients underwent bilateral electrode implantation. Among the 245 procedures, 9 SSIs (3.7%) occurred within 90 days and 16 (6.5%) occurred within 1 year of DBS placement. Gram-positive bacteria were the most common etiological agents. Most patient- and procedure-related characteristics did not differ between those who had acquired an SSI and those who had not. The rate of SSIs among patients who had received intrawound VP was only 3.3% compared with 9.7% among those who had not received topical VP (OR 0.32, 95% CI 0.10–1.02, p = 0.04). After controlling for patient sex, the association between VP and decreased SSI risk did not reach the predetermined level of significance (adjusted OR 0.32, 95% CI 0.10–1.03, p = 0.06). The SSI rates were similar after staged and unstaged implantations.
While most patient-related and procedure-related factors assessed in this study were not associated with the risk for an SSI, the data did suggest that intrawound VP may help to reduce the SSI risk after DBS implantation. Furthermore, given the implications of SSI after DBS surgery and the frequency of infections occurring more than 90 days after implantation, continued follow-up for at least 1 year after such a procedure is prudent to establish the true burden of these infections and to properly treat them when they do occur.
Kingsley O. Abode-Iyamah, Hsiu-Yin Chiang, Nolan Winslow, Brian Park, Mario Zanaty, Brian J. Dlouhy, Oliver E. Flouty, Zachary D. Rasmussen, Loreen A. Herwaldt and Jeremy D. Greenlee
Craniectomy is often performed to decrease intracranial pressure following trauma and vascular injuries. The subsequent cranioplasty procedures may be complicated by surgical site infections (SSIs) due to prior trauma, foreign implants, and multiple surgeries through a common incision. Several studies have found that intrawound vancomycin powder (VP) is associated with decreased risk of SSIs after spine operations. However, no previously published study has evaluated the effectiveness of VP in cranioplasty procedures. The purpose of this study was to determine whether intrawound VP is associated with decreased risk of SSIs, to evaluate VP’s safety, and to identify risk factors for SSIs after cranioplasty among patients undergoing first-time cranioplasty.
The authors conducted a retrospective cohort study of adult patients undergoing first-time cranioplasty for indications other than infections from January 1, 2008, to July 31, 2014, at an academic health center. Data on demographics, possible risk factors for SSIs, and treatment with VP were collected from the patients’ electronic health records.
During the study period, 258 patients underwent first-time cranioplasties, and 15 (5.8%) of these patients acquired SSIs. Ninety-two patients (35.7%) received intrawound VP (VP group) and 166 (64.3%) did not (no-VP group). Patients in the VP group and the no-VP group were similar with respect to age, sex, smoking history, body mass index, and SSI rates (VP group 6.5%, no-VP group 5.4%, p = 0.72). Patients in the VP group were less likely than those in the no-VP group to have undergone craniectomy for tumors and were more likely to have an American Society of Anesthesiologists physical status score > 2. Intrawound VP was not associated with other postoperative complications. Risk factors for SSI from the bivariable analyses were diabetes (odds ratio [OR] 3.65, 95% CI 1.07–12.44), multiple craniotomy procedures before the cranioplasty (OR 4.39, 95% CI 1.47–13.18), prior same-side craniotomy (OR 4.73, 95% CI 1.57–14.24), and prosthetic implants (OR 4.51, 95% CI 1.40–14.59). The multivariable analysis identified prior same-side craniotomy (OR 3.37, 95% CI 1.06–10.79) and prosthetic implants (OR 3.93, 95% CI 1.15–13.40) as significant risk factors for SSIs. After adjusting for potential confounders, patients with SSIs were more likely than those without SSIs to be readmitted (OR 7.28, 95% CI 2.07–25.60).
In this study, intrawound VP was not associated with a decreased risk of SSIs or with an increased risk of complications. Prior same-side craniotomy and prosthetic implants were risk factors for SSI after first-time cranioplasty.