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Ken R. Winston and Marjorie C. Wang

Object. Fixation of cranial bone flaps should be reliable, safe, rapid, esthetically acceptable, and inexpensive. It should require minimal foreign material, and ideally it should produce no artifacts on neuroimaging. The authors describe a new procedure that meets these criteria.

Methods. In this procedure, the cranial bone flap is affixed by tightly packing into the surrounding kerf the shims of bone that are harvested from the under edge of the free bone flap and then securing the flap with absorbable sutures. The result is a keystone arrangement that locks the flap into the craniotomy site.

Conclusions. The bone shim method for cranial bone fixation was used successfully in 386 of 387 consecutive craniotomies in adults. This procedure for cranial flap fixation is reliable, safe, and rapid, and it achieves solid structural stability with excellent esthetic results. No special tools are required, and, because no plates, screws, or wire are used, all problems associated with these materials are avoided, including the artifacts on postoperative neuroimaging. This method is conceptually simple and quite inexpensive.

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Robert E. Breeze and Marjorie C. Wang

Although its roots date back over a century, the field of neurotransplantation has been shaped mostly by advances over the past 30 years. Animal models of nigrostriatal disconnection in the 1970s allowed investigators to explore the feasibility of neural grafting. By the end of that decade, functional and behavioral effects had been demonstrated using fetal tissue grafts. In the 1980s, animal experimentation continued, as did clinical trials involving patients with idiopathic Parkinson's disease. Both autologous adrenal medullary tissue and fetal allografts were tested in the clinical setting, with the latter proving to yield superior results. Animal models of striatal cell loss provided the impetus for limited clinical trials in patients with Huntington's disease by the early 1990s, and work with both diseases continues today. Although much has been learned, neural grafting remains experimental. Broader applications are being explored even now, though, as transplant techniques are applied to animal models of dementia, spinal cord injury, cortical injury, and pain. Some very limited human trials have already begun in some of these areas. In this review some of the advances in the field are highlighted.

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Siddhartha Singh, Rodney Sparapani and Marjorie C. Wang

OBJECTIVE

Pay-for-performance programs are targeting hospital readmissions. These programs have an underlying assumption that readmissions are due to provider practice patterns that can be modified by a reduction in reimbursement. However, there are limited data to support the role of providers in influencing readmissions. To study this, the authors examined variations in readmission rates by spine surgeon within 30 days among Medicare beneficiaries undergoing elective lumbar spine surgery for degenerative conditions.

METHODS

The authors applied validated ICD-9-CM algorithms to 2003–2007 Medicare data to select beneficiaries undergoing elective inpatient lumbar spine surgery for degenerative conditions. Mixed models, adjusting for patient demographics, comorbidities, and surgery type, were used to estimate risk of 30-day readmission by the surgeon. Length of stay (LOS) was also studied using these same models.

RESULTS

A total of 39,884 beneficiaries were operated on by 3987 spine surgeons. The mean readmission rate was 7.2%. The mean LOS was 3.1 days. After adjusting for patient characteristics and surgery type, 1 surgeon had readmission rates significantly below the mean, and only 5 surgeons had readmission rates significantly above the mean. In contrast, for LOS, the patients of 288 surgeons (7.2%) had LOS significantly lower than the mean, and the patients of 397 surgeons (10.0%) had LOS significantly above the mean. These findings were robust to adjustments for surgeon characteristics and clustering by hospital. Similarly, hospital characteristics were not significantly associated with readmission rates, but LOS was associated with hospital for-profit status and size.

CONCLUSIONS

The authors found almost no variations in readmission rates by surgeon. These findings suggest that surgeon practice patterns do not affect the risk of readmission. Likewise, no significant variation in readmission rates by hospital characteristics were found. Strategies to reduce readmissions would be better targeted at factors other than providers.

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Marjorie C. Wang, Ken R. Winston and Robert E. Breeze

✓ The authors report a case of cerebellar mutism arising from a hemorrhagic midbrain cavernous malformation in a 14-year-old boy. No cerebellar lesion was identified; however, edema of the dorsal midbrain was noted on postoperative magnetic resonance images. Dysarthric speech spontaneously returned and then completely resolved to normal speech. This case provides further evidence for the theory that involvement of the dentatothalamic tracts, and not a cerebellar lesion per se, is the underlying cause of “cerebellar” mutism.

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Marjorie C. Wang, David Rubinstein, Glenn W. Kindt and Robert E. Breeze

Object

A familial predisposition toward cerebral aneurysms has been previously described in patients with two or more affected family members. In the present study the familial incidence of unruptured intracranial aneurysms was studied in 96 patients with at least one first-degree relative (parent, sibling, or child) in whom a cerebral aneurysm was diagnosed.

Methods

All patients were between 20 and 70 years of age and underwent three-dimensional fast–spin echo magnetic resonance imaging. Sixty-one patients (63.5%) were women. The majority of patients (84%) were caucasian and the remainder were Hispanic (13%) or African-American (3%). No patient suffered a medical condition (excluding hypertension and smoking) known to be associated with cerebral aneurysm formation.

In four patients at least one aneurysm was found (two harbored multiple aneurysms). Three of the four patients were women. Two of the patients were siblings. The estimated prevalence in first-degree relatives was 4.2% (95% confidence interval 1.2–10.1). Of note, the mean age in the current study population was 39 years. The authors of recent metaanalyses have suggested that the prevalence of nonfamilial aneurysms is approximately 2%, despite earlier reports in which higher figures were cited.

Conclusions

The authors conclude that first-degree relatives of patients with aneurysms are at higher risk for harboring an intracranial aneurysm.

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Marjorie C. Wang, Frank Pintar, Narayan Yoganandan and Dennis J. Maiman

Object

Spine fractures are a significant cause of morbidity and mortality after motor vehicle crashes (MVCs). Public health interventions, such as the National Highway Traffic Safety Administration's Federal Motor Vehicle Safety Standards, have led to an increase in automobiles with air bags and the increased use of seat belts to lessen injuries sustained from MVCs. The purpose of this study was to evaluate secular trends in the occurrence of spine fractures associated with MVCs and evaluate the association between air bag and seat belt use with spine fractures.

Methods

Using the Crash Outcome Data Evaluation System, a database of the police reports of all MVCs in Wisconsin linked to hospital records, the authors studied the occurrence of spine fractures and seat belt and air bag use from 1994 to 2002. Demographic information and crash characteristics were obtained from the police reports. Injury characteristics were determined using International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) hospital discharge codes.

Results

From 1994 to 2002, there were 29,860 hospital admissions associated with automobile or truck crashes. There were 20,276 drivers or front-seat passengers 16 years of age and older who were not missing ICD-9-CM discharge codes, seat belt or air bag data, and who had not been ejected from the vehicle. Of these, 2530 (12.5%) sustained a spine fracture. The occurrence of spine fractures increased over the study period, and the use of a seat belt plus air bag, and of air bags alone also increased during this period. However, the occurrence of severe spine fractures (Abbreviated Injury Scale Score ≥3) did not significantly increase over the study period. The use of both seat belt and air bag was associated with decreased odds of a spine fracture. Use of an air bag alone was associated with increased odds of a severe thoracic, but not cervical spine fracture.

Conclusions

Among drivers and front-seat passengers admitted to the hospital after MVCs, the occurrence of spine fractures increased from 1994 to 2002 despite concomitant increases in seat belt and air bag use. However, the occurrence of severe spine fractures did not increase over the study period. The use of both seat belt and air bag is protective against spine fractures. Although the overall increased occurrence of spine fractures may appear contrary to the increased use of seat belts and air bags in general, it is possible that improved imaging technology may be associated with an increase in the diagnosis of relatively minor fractures. However, given the significant protective effects of both seat belt and air bag use against spine fractures, resources should continue to be dedicated toward increasing their use to mitigate the effects of MVCs.

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Saman Shabani, Mayank Kaushal, Matthew Budde, Brian Schmit, Marjorie C. Wang and Shekar Kurpad

OBJECTIVE

Cervical spondylotic myelopathy (CSM) is a common cause of spinal cord dysfunction. Recently, it has been shown that diffusion tensor imaging (DTI) may be a better biomarker than T2-weighted signal intensity (T2SI) on MRI for CSM. However, there is very little literature on a comparison between the quantitative measurements of DTI and T2SI in the CSM patient population to determine disease severity and recovery.

METHODS

A prospective analysis of 46 patients with both preoperative DTI and T2-weighted MRI was undertaken. Normalized T2SI (NT2SI), regardless of the presence or absence of T2SI at the level of maximum compression (LMC), was determined by calculating the T2SI at the LMC/T2SI at the level of the foramen magnum. Regression analysis was performed to determine the relationship of fractional anisotropy (FA), a quantitative measure derived from DTI, and NT2SI individually as well their combination with baseline preoperative modified Japanese Orthopaedic Association (mJOA) score and ∆mJOA score at the 3-, 6-, 12-, and 24-month follow-ups. Goodness-of-fit analysis was done using residual diagnostics. In addition, mixed-effects regression analysis was used to evaluate the impact of FA and NT2SI individually. A p value < 0.05 was selected to indicate statistical significance.

RESULTS

Regression analysis showed a significant positive correlation between FA at the LMC and preoperative mJOA score (p = 0.041) but a significant negative correlation between FA at the LMC and the ΔmJOA score at the 12-month follow-up (p = 0.010). All other relationships between FA at the LMC and the baseline preoperative mJOA score or ∆mJOA score at the 3-, 6-, and 24-month follow-ups were not statistically significant. For NT2SI and the combination of FA and NT2SI, no significant relationships with preoperative mJOA score or ∆mJOA at 3, 6, and 24 months were seen on regression analysis. However, there was a significant correlation of combined FA and NT2SI with ∆mJOA score at the 12-month follow-up. Mixed-effects regression revealed that FA measured at the LMC was the only significant predictor of ΔmJOA score (p = 0.03), whereas NT2SI and time were not. Goodness-of-fit analysis did not show any evidence of lack of fit.

CONCLUSIONS

In this large prospective study of CSM patients, FA at LMC appears to be a better biomarker for determining long-term outcomes following surgery in CSM patients than NT2SI or the combination values at LMC.