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Kalil G. Abdullah, Mark A. Attiah, Andrew S. Olsen, Andrew Richardson and Timothy H. Lucas

OBJECT

Although the use of topical vancomycin has been shown to be safe and effective for reducing postoperative infection rates in patients after spine surgery, its use in cranial wounds has not been studied systematically. The authors hypothesized that topical vancomycin, applied in powder form directly to the subgaleal space during closure, would reduce cranial wound infection rates.

METHODS

A cohort of 150 consecutive patients who underwent craniotomy was studied retrospectively. Seventy-five patients received 1 g of vancomycin powder applied in the subgaleal space at the time of closure. This group was compared with 75 matched-control patients who were accrued over the same time interval and did not receive vancomycin. The primary outcome measure was the presence of surgical site infection within 3 months. Secondary outcome measures included tissue pH from a subgaleal drain and vancomycin levels from the subgaleal space and serum.

RESULTS

Vancomycin was associated with significantly fewer surgical site infections (1 of 75) than was standard antibiotic prophylaxis alone (5 of 75; p < 0.05). Cultures were positive for typical skin flora species. As expected, local measured vancomycin concentrations peaked immediately after surgery (mean ± SD 499 ± 37 μg/ml) and gradually decreased over 12 hours. Vancomycin in the circulating serum remained undetectable. Subgaleal topical vancomycin was associated with a lower incidence of surgical site infections after craniotomy. The authors attribute this reduction in the infection rate to local vancomycin concentrations well above the minimum inhibitory concentration for antimicrobial efficacy.

CONCLUSIONS

Topical vancomycin is safe and effective for reducing surgical site infections after craniotomy. These data support the need for a prospective randomized examination of topical vancomycin in the setting of cranial surgery.

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Luke Macyszyn, Mark Attiah, Tracy S. Ma, Zarina Ali, Ryan Faught, Alisha Hossain, Karen Man, Hiren Patel, Rosanna Sobota, Eric L. Zager and Sherman C. Stein

OBJECTIVE

Moyamoya disease (MMD) is a chronic cerebrovascular disease that can lead to devastating neurological outcomes. Surgical intervention is the definitive treatment, with direct, indirect, and combined revascularization procedures currently employed by surgeons. The optimal surgical approach, however, remains unclear. In this decision analysis, the authors compared the effectiveness of revascularization procedures in both adult and pediatric patients with MMD.

METHODS

A comprehensive literature search was performed for studies of MMD. Using complication and success rates from the literature, the authors constructed a decision analysis model for treatment using a direct and indirect revascularization technique. Utility values for the various outcomes and complications were extracted from the literature examining preferences in similar clinical conditions. Sensitivity analysis was performed.

RESULTS

A structured literature search yielded 33 studies involving 4197 cases. Cases were divided into adult and pediatric populations. These were further subdivided into 3 different treatment groups: indirect, direct, and combined revascularization procedures. In the pediatric population at 5- and 10-year follow-up, there was no significant difference between indirect and combination procedures, but both were superior to direct revascularization. In adults at 4-year follow-up, indirect was superior to direct revascularization.

CONCLUSIONS

In the absence of factors that dictate a specific approach, the present decision analysis suggests that direct revascularization procedures are inferior in terms of quality-adjusted life years in both adults at 4 years and children at 5 and 10 years postoperatively, respectively. These findings were statistically significant (p < 0.001 in all cases), suggesting that indirect and combination procedures may offer optimal results at long-term follow-up.

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Raqeeb Haque, Teresa J. Wojtasiewicz, Paul R. Gigante, Mark A. Attiah, Brendan Huang, Steven R. Isaacson and Michael B. Sisti

Object

The goal of this article was to show that a combination of facial nerve–sparing microsurgical resection and Gamma Knife surgery (GKS) for expansion of any residual tumor can preserve good facial nerve function in patients with recurrent vestibular schwannoma (VS).

Methods

Records of individuals treated by a single surgeon with a facial nerve–sparing technique for a VS between 1998 and 2009 were retrospectively analyzed for tumor recurrence. Of the 383 patients treated for VS, 151 underwent microsurgical resection, and 20 (13.2%) of these patients required postoperative retreatment for a significant expansion of residual tumor after microsurgery. These 20 patients were re-treated with GKS.

Results

The rate of preservation of good facial nerve function (Grade I or II on the House-Brackmann scale) in patients treated with microsurgery for VS was 97%. Both subtotal and gross-total resection had excellent facial nerve preservation rates (97% vs 96%), although subtotal resection carried a higher risk that patients would require retreatment. In patients re-treated with GKS after microsurgery, the rate of facial nerve preservation was 95%.

Conclusions

In patients with tumors that cannot be managed with radiosurgery alone, a facial nerve–sparing resection followed by GKS for any significant regrowth provides excellent facial nerve preservation rates.

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Mark Attiah, Bilwaj Gaonkar, Yasmine Alkhalid, Diane Villaroman, Rogelio Medina, Christine Ahn, Tianyi Niu, Joel Beckett, Christopher Ames and Luke Macyszyn

OBJECTIVE

There have been numerous studies demonstrating increased pain and disability when patients’ spinopelvic parameters fall outside of certain accepted ranges. However, these values were established based on patients suffering from spinal deformities. It remains unknown how these parameters change over a lifetime in asymptomatic individuals. The goal of this study was to define a range of spinopelvic parameters from asymptomatic individuals.

METHODS

Sagittal scoliosis radiographs of 210 asymptomatic patients were evaluated. All measurements were reviewed by 2 trained observers, supervised by a trained clinician. The following parameters and relationships were measured or calculated: cervical lordosis (CL), thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), sagittal vertical axis (SVA), cervical SVA (cSVA), and T1 slope, TK/LL, truncal inclination, pelvic tilt (PT), LL−PI, LL/PI, and T1 slope/PI. Patients were stratified by decade of life, and regression analysis was performed to delineate the relationship between each consecutive age group and the aforementioned parameters.

RESULTS

Cervical lordosis (R2 = 0.61), thoracic kyphosis (R2 = 0.84), SVA (R2 = 0.88), cSVA (R2 = 0.51), and T1 slope (R2 = 0.77) all increase with age. Truncal inclination (R2 = 0.36) and T1 slope/CL remain stable over all decades (R2 = 0.01). LL starts greater than PI, but in the 6th decade of life, LL becomes equal to PI and in the 7th decade becomes smaller than PI (R2 = 0.96). The ratio of TK/LL is stable until the 7th decade of life (R2 = 0.81), whereas PT is stable until the 6th decade (R2 = 0.92).

CONCLUSIONS

This study further refines the generally accepted LL = PI + 10° by showing that patients under the age of 50 years should have more LL compared to PI, whereas after the 5th decade the relationship is reversed. SVA was not as sensitive across age groups, exhibiting a marked increase only in the 7th decade of life. Given the reliable increase of CL with age, and the stability of T1 slope/CL, this represents another important relationship that should be maintained when performing cervical deformity/fusion surgery. This study has important implications for evaluating adult patients with spinal deformities and for establishing corrective surgical goals.