Traumatic, nonaneurysmal subarachnoid hemorrhage (SAH) is common after closed head injury and most often results from ruptured cortical microvessels. Here, the authors present the case of a 60-year-old woman who fell and struck her head, causing traumatic enucleation and avulsion of both the optic nerve and ophthalmic artery. The arterial avulsion caused a Fisher Grade 3 SAH. During her stay in the intensive care unit, hydrocephalus and vasospasm developed, clinical conditions commonly observed after aneurysmal SAH. Epileptiform activity also developed, although this may have been related to concurrent Pantoea agglomerans ventriculitis. It is reasonable to suggest that intracerebral arterial avulsion with profuse arterial bleeding may be more likely than traditional traumatic SAH to result in clinical events similar to that of aneurysmal SAH. Special consideration should be given to the acute care of patients with intracranial arterial avulsions (conservative management vs surgical exploration or endovascular treatment), as well as long-term follow-up for vascular or other neurosurgical complications.
David D. Limbrick Jr., Amir Behdad, Colin P. Derdeyn, Phillip L. Custer, Gregory J. Zipfel and Paul Santiago
Toru Fukuhara, Guy M. McKhann II, Paul Santiago, Joseph M. Eskridge, John D. Loeser and H. Richard Winn
✓ The authors describe a patient with right-sided central pain resulting from a left parietal arteriovenous malformation (AVM). The AVM was treated with staged embolization and stereotactic radiosurgery, and its obliteration was documented on follow-up angiographic studies. Surprisingly, the patient noted complete resolution of her pain syndrome after embolization, which is an extremely rare result. Central pain and its proposed mechanisms are discussed.
Manish N. Shah, Ivan T. Stoev, Dominic E. Sanford, Feng Gao, Paul Santiago, David P. Jaques and Ralph G. Dacey Jr.
The goal of this study was to examine the reasons for early readmissions within 30 days of discharge to a major academic neurosurgical service.
A database of readmissions within 30 days of discharge between April 2009 and September 2010 was retrospectively reviewed. Clinical and administrative variables associated with readmission were examined, including age, sex, race, days between discharge and readmission, and insurance type. The readmissions were then assigned independently by 2 neurosurgeons into 1 of 3 categories: scheduled, adverse event, and unrelated. The adverse event readmissions were further subcategorized into patients readmitted although best practices were followed, those readmitted due to progression of their underlying disease, and those readmitted for preventable causes. These variables were compared descriptively.
A total of 348 patients with 407 readmissions were identified, comprising 11.5% of the total 3552 admissions. The median age of readmitted patients was 55 years (range 16–96 years) and patients older than 65 years totaled 31%. There were 216 readmissions (53% of 407) for management of an adverse event that was classified as either preventable (149 patients; 37%) or unpreventable (67 patients; 16%). There were 113 patients (28%) who met readmission criteria but who were having an electively scheduled neurosurgical procedure. Progression of disease (48 patients; 12%) and treatment unrelated to primary admission (30 patients; 7%) were additional causes for readmission. There was no significant difference in the proportion of early readmissions by payer status when comparing privately insured patients and those with public or no insurance (p = 0.09).
The majority of early readmissions within 30 days of discharge to the neurosurgical service were not preventable. Many of these readmissions were for adverse events that occurred even though best practices were followed, or for progression of the natural history of the neurosurgical disease requiring expected but unpredictably timed subsequent treatment. Judicious care often requires readmission to prevent further morbidity or death in neurosurgical patients, and penalties for readmission will not change these patient care obligations.
Mohamad Bydon, Risheng Xu, David Santiago-Dieppa, Mohamed Macki, Daniel M. Sciubba, Jean-Paul Wolinsky, Ali Bydon, Ziya L. Gokaslan and Timothy F. Witham
The aim of this study was to study the long-term outcomes of patients undergoing instrumented posterior fusion of the lumbar spine.
The authors present 511 patients who underwent instrumented arthrodesis for lumbar degenerative disease over a 23-year period at a single institution. Patients underwent follow-up for an average of 39.73 ± 46.52 months (± SD) after the index lumbar arthrodesis procedure.
The average patient age was 59.45 ± 13.48 years. Of the 511 patients, 502 (98.24%) presented with back pain, 379 (74.17%) with radiculopathy, 76 (14.87%) with motor weakness, and 32 (6.26%) with preoperative bowel/bladder dysfunction. An average of 2.04 ± 1.03 spinal levels were fused. Postoperatively, patients experienced a significant improvement in back pain (p < 0.0001) and radiculopathy (p < 0.0001). Patients with fusions excluding the sacrum (floating fusions) were statistically more likely to develop adjacent-segment disease (ASD) than those with fusion constructs ending at S-1 distally (p = 0.030) but were less likely to develop postoperative radiculopathy (p = 0.030). In the floating fusion cohort, 31 (12.11%) of 256 patients had cephalad ASD, whereas 39 (15.29%) of 255 patients in the lumbosacral cohort had cephalad ASD development; this was not statistically different (p = 0.295). This suggests that caudad ASD development in the floating fusion cohort is due to the added risk of an unfused L5–S1 vertebral level. Because of the elevated risk of symptomatic radiculopathy but lower risk of ASD, patients in the lumbosacral fusion cohort had a reoperation rate similar to those undergoing floating fusions (p = 0.769).
In this paper, the authors present one of the largest cohorts in the Western literature of patients undergoing instrumented fusion for degenerative lumbar spine disease. Patients who had floating lumbar fusions were statistically more likely to develop ASD over time than those who had lumbosacral fusions incorporating the S-1 spinal segment, but were less likely to experience postoperative radicular symptoms. Additional prospective studies may more clearly delineate the long-term risks of instrumented posterolateral fusions of the lumbar spine.
Kaisorn L. Chaichana, Mohamad Bydon, David R. Santiago-Dieppa, Lee Hwang, Gregory McLoughlin, Daniel M. Sciubba, Jean-Paul Wolinsky, Ali Bydon, Ziya L. Gokaslan and Timothy Witham
Posterior lumbar spinal fusion for degenerative spine disease is a common procedure, and its use is increasing annually. The rate of infection, as well as the factors associated with an increased risk of infection, remains unclear for this patient population. A better understanding of these features may help guide treatment strategies aimed at minimizing infection for this relatively common procedure. The authors' goals were therefore to ascertain the incidence of postoperative spinal infections and identify factors associated with postoperative spinal infections.
Data obtained in adult patients who underwent instrumented posterior lumbar fusion for degenerative spine disease between 1993 and 2010 were retrospectively reviewed. Stepwise multivariate proportional hazards regression analysis was used to identify factors associated with infection. Variables with p < 0.05 were considered statistically significant.
During the study period, 817 consecutive patients underwent lumbar fusion for degenerative spine disease, and 37 patients (4.5%) developed postoperative spine infection at a median of 0.6 months (IQR 0.3–0.9). The factors independently associated with an increased risk of infection were increasing age (RR 1.004 [95% CI 1.001–1.009], p = 0.049), diabetes (RR 5.583 [95% CI 1.322–19.737], p = 0.02), obesity (RR 6.216 [95% CI 1.832–9.338], p = 0.005), previous spine surgery (RR 2.994 [95% CI 1.263–9.346], p = 0.009), and increasing duration of hospital stay (RR 1.155 [95% CI 1.076–1.230], p = 0.003). Of the 37 patients in whom infection developed, 21 (57%) required operative intervention but only 3 (8%) required instrumentation removal as part of their infection management.
This study identifies that several factors—older age, diabetes, obesity, prior spine surgery, and length of hospital stay—were each independently associated with an increased risk of developing infection among patients undergoing instrumented lumbar fusion for degenerative spine disease. The overwhelming majority of these patients were treated effectively without hardware removal.
Robert E. Isaacs, Vinod K. Podichetty, Paul Santiago, Faheem A. Sandhu, John Spears, Kevin Kelly, Laurie Rice and Richard G. Fessler
The authors have developed a novel technique for percutaneous fusion in which standard microendoscopic discectomy is modified. Based on data obtained in their cadaveric studies they considered that this minimally invasive interbody fusion could be safely implemented clinically. The authors describe their initial experience with a microendoscopic transforaminal lumbar interbody fusion (METLIF) technique, with regard to safety in the placement of percutaneous instrumentation, perioperative morbidity, and early postoperative results.
The METLIF procedure was performed unilaterally in 20 patients with single-level lumbar spondylolisthesis or pure mechanical back pain with endoscopic assistance, hemilaminectomy, unilateral facetectomy, and microdiscectomy. Two interbody grafts were placed via the lateral exposure of the disc space. Bilateral percutaneous pedicle screws were then inserted.
Compared with patients who had undergone single-level posterior LIF at the same institutions, intraoperative blood loss, hospital length of stay (LOS), and postoperative narcotic agent use were significantly lower in the METLIF group. The mean LOS for the percutaneous fusion group was 3.4 days (5.1 days in those who underwent PLIF; p < 0.02). There have been no procedure-related complications in this series to date.
The METLIF technique provided an option for percutaneous interbody fusion similar to that in open surgery while minimizing destruction to adjacent tissues. This technique was safe and exhibited a trend toward decreased intraoperative blood loss, postoperative pain, total narcotic use, and the risk of transfusion.
Georgios A. Maragkos, Luis C. Ascanio, Mohamed M. Salem, Sricharan Gopakumar, Santiago Gomez-Paz, Alejandro Enriquez-Marulanda, Abhi Jain, Clemens M. Schirmer, Paul M. Foreman, Christoph J. Griessenauer, Peter Kan, Christopher S. Ogilvy and Ajith J. Thomas
The Pipeline embolization device (PED) is a routine choice for the endovascular treatment of select intracranial aneurysms. Its success is based on the high rates of aneurysm occlusion, followed by near-zero recanalization probability once occlusion has occurred. Therefore, identification of patient factors predictive of incomplete occlusion on the last angiographic follow-up is critical to its success.
A multicenter retrospective cohort analysis was conducted on consecutive patients treated with a PED for unruptured aneurysms in 3 academic institutions in the US. Patients with angiographic follow-up were selected to identify the factors associated with incomplete occlusion.
Among all 3 participating institutions a total of 523 PED placement procedures were identified. There were 284 procedures for 316 aneurysms, which had radiographic follow-up and were included in this analysis (median age 58 years; female-to-male ratio 4.2:1). Complete occlusion (100% occlusion) was noted in 76.6% of aneurysms, whereas incomplete occlusion (≤ 99% occlusion) at last follow-up was identified in 23.4%. After accounting for factor collinearity and confounding, multivariable analysis identified older age (> 70 years; OR 4.46, 95% CI 2.30–8.65, p < 0.001); higher maximal diameter (≥ 15 mm; OR 3.29, 95% CI 1.43–7.55, p = 0.005); and fusiform morphology (OR 2.89, 95% CI 1.06–7.85, p = 0.038) to be independently associated with higher rates of incomplete occlusion at last follow-up. Thromboembolic complications were noted in 1.4% and hemorrhagic complications were found in 0.7% of procedures.
Incomplete aneurysm occlusion following placement of a PED was independently associated with age > 70 years, aneurysm diameter ≥ 15 mm, and fusiform morphology. Such predictive factors can be used to guide individualized treatment selection and counseling in patients undergoing cerebrovascular neurosurgery.