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Darryl Lau, Vedat Deviren, Rushikesh S. Joshi, and Christopher P. Ames

OBJECTIVE

The correction of severe cervicothoracic sagittal deformities can be very challenging and can be associated with significant morbidity. Often, soft-tissue releases and osteotomies are warranted to achieve the desired correction. There is a paucity of studies that examine the difference in morbidity and complication profiles for Smith-Petersen osteotomy (SPO) versus 3-column osteotomy (3CO) for cervical deformity correction.

METHODS

A retrospective comparison of complication profiles between posterior-based SPO (Ames grade 2 SPO) and 3CO (Ames grade 5 opening wedge osteotomy and Ames grade 6 closing wedge osteotomy) was performed by examining a single-surgeon experience from 2011 to 2018. Patients of interest were individuals who had a cervical sagittal vertical axis (cSVA) > 4 cm and/or cervical kyphosis > 20° and who underwent corrective surgery for cervical deformity. Multivariate analysis was utilized.

RESULTS

A total of 95 patients were included: 49 who underwent 3CO and 46 who underwent SPO. Twelve of the SPO patients underwent an anterior release procedure. The patients’ mean age was 63.2 years, and 60.0% of the patients were female. All preoperative radiographic parameters showed significant correction postoperatively: cSVA (6.2 cm vs 4.5 cm [preoperative vs postoperative values], p < 0.001), cervical lordosis (6.8° [kyphosis] vs −7.5°, p < 0.001), and T1 slope (40.9° and 35.2°, p = 0.026). The overall complication rate was 37.9%, and postoperative neurological deficits were seen in 16.8% of patients. The surgical and medical complication rates were 17.9% and 23.2%, respectively. Overall, complication rates were higher in patients who underwent 3CO compared to those who underwent SPO, but this was not statistically significant (total complication rate 42.9% vs 32.6%, p = 0.304; surgical complication rate 18.4% vs 10.9%, p = 0.303; and new neurological deficit rate 20.4% vs 13.0%, p = 0.338). Medical complication rates were similar between the two groups (22.4% [3CO] vs 23.9% [SPO], p = 0.866). Independent risk factors for surgical complications included male sex (OR 10.88, p = 0.014), cSVA > 8 cm (OR 10.36, p = 0.037), and kyphosis > 20° (OR 9.48, p = 0.005). Combined anterior-posterior surgery was independently associated with higher odds of medical complications (OR 10.30, p = 0.011), and preoperative kyphosis > 20° was an independent risk factor for neurological deficits (OR 2.08, p = 0.011).

CONCLUSIONS

There was no significant difference in complication rates between 3CO and SPO for cervicothoracic deformity correction, but absolute surgical and neurological complication rates for 3CO were higher. A preoperative cSVA > 8 cm was a risk factor for surgical complications, and kyphosis > 20° was a risk factor for both surgical and neurological complications. Additional studies are warranted on this topic.

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Rushikesh S. Joshi, Darryl Lau, Alexander F. Haddad, Vedat Deviren, and Christopher P. Ames

OBJECTIVE

Correction of rigid cervical deformities can be associated with high complication rates and result in prolonged intensive care unit (ICU) and hospital stays. In this study, the authors aimed to examine the risk factors contributing to length of stay (LOS) in both the hospital and ICU following adult cervical deformity (ACD) surgery and to identify severe adverse events that occurred in this setting.

METHODS

A retrospective review of ACD patients who underwent posterior-based osteotomies for deformity correction from 2010 to 2019 was performed. Inclusion criteria were cervical kyphosis > 20° and/or cervical sagittal vertical axis (cSVA) > 4 cm. Multivariate analysis was used to identify risk factors independently associated with ICU and hospital LOS.

RESULTS

A total of 107 patients were included. The mean age was 63.5 years, and 61.7% were female. Over half (52.3%) underwent 3-column osteotomies, while 47.7% underwent posterior column osteotomies. There was significant correction of all cervical parameters: cSVA (6.0 vs 3.6 cm, p < 0.001), cervical lordosis (8.2° vs −5.3°, p < 0.001), cervical scoliosis (6.5° vs 2.2°, p < 0.001), and T1-slope (40.2° vs 34.5°, p < 0.001). There were also reciprocal changes to the distal spine: thoracic kyphosis (54.4° vs 46.4°, p < 0.001), lumbar lordosis (49.9° vs 45.8°, p = 0.003), and thoracolumbar scoliosis (13.9° vs 11.1°, p = 0.009). Overall, 4 patients (3.7%) suffered aspiration-related complications, 3 patients (2.8%) experienced dysphagia requiring a feeding tube, and 4 patients (3.7%) had compromised airways, with 1 resulting in death. The mean ICU and hospital LOS were 2.8 days and 7.9 days, respectively. Multivariate analysis identified three factors independently associated with longer ICU LOS: female sex (3.0 vs 2.4 days, p = 0.004), ≥ 12 segments fused (3.5 vs 1.9 days, p = 0.002), and postoperative complication (4.0 vs 1.9 days, p = 0.017). These same factors were independently associated with longer hospital LOS as well: female sex (8.3 vs 7.3 days, p = 0.013), ≥ 12 segments fused (9.4 vs 6.2 days, p = 0.001), and complication (9.7 vs 6.7 days, p = 0.026).

CONCLUSIONS

Posterior-based osteotomies are very effective for the correction of ACD, but postoperative hospital stays are relatively longer than those following surgery for degenerative disease. Risk factors for prolonged ICU and hospital LOS consist of both nonmodifiable (female sex) and modifiable (≥ 12 segments fused and presence of complication) risk factors. Additional multicenter prospective studies will be needed to validate these findings.

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Matheus P. Pereira, Taemin Oh, Rushikesh S. Joshi, Alexander F. Haddad, Kaitlyn M. Pereira, Robert C. Osorio, Kevin C. Donohue, Zain Peeran, Sweta Sudhir, Saket Jain, Angad Beniwal, José Gurrola II, Ivan H. El-Sayed, Lewis S. Blevins Jr., Philip V. Theodosopoulos, Sandeep Kunwar, and Manish K. Aghi

OBJECTIVE

Life expectancy has increased over the past century, causing a shift in the demographic distribution toward older age groups. Elderly patients comprise up to 14% of all patients with pituitary tumors, with most lesions being nonfunctioning pituitary adenomas (NFPAs). Here, the authors evaluated demographics, outcomes, and postoperative complications between nonelderly adult and elderly NFPA patients.

METHODS

A retrospective review of 908 patients undergoing transsphenoidal surgery (TSS) for NFPA at a single institution from 2007 to 2019 was conducted. Clinical and surgical outcomes and postoperative complications were compared between nonelderly adult (age ≥ 18 and ≤ 65 years) and elderly patients (age > 65 years).

RESULTS

There were 614 and 294 patients in the nonelderly and elderly groups, respectively. Both groups were similar in sex (57.3% vs 60.5% males; p = 0.4), tumor size (2.56 vs 2.46 cm; p = 0.2), and cavernous sinus invasion (35.8% vs 33.7%; p = 0.6). Regarding postoperative outcomes, length of stay (1 vs 2 days; p = 0.5), extent of resection (59.8% vs 64.8% gross-total resection; p = 0.2), CSF leak requiring surgical revision (4.3% vs 1.4%; p = 0.06), 30-day readmission (8.1% vs 7.3%; p = 0.7), infection (3.1% vs 2.0%; p = 0.5), and new hypopituitarism (13.9% vs 12.0%; p = 0.3) were similar between both groups. Elderly patients were less likely to receive adjuvant radiation (8.7% vs 16.3%; p = 0.009), undergo future reoperation (3.8% vs 9.5%; p = 0.003), and experience postoperative diabetes insipidus (DI) (3.7% vs 9.4%; p = 0.002), and more likely to have postoperative hyponatremia (26.7% vs 16.4%; p < 0.001) and new cranial nerve deficit (1.9% vs 0.0%; p = 0.01). Subanalysis of elderly patients showed that patients with higher Charlson Comorbidity Index scores had comparable outcomes other than higher DI rates (8.1% vs 0.0%; p = 0.006). Elderly patients’ postoperative sodium peaked and troughed on postoperative day 3 (POD3) (mean 138.7 mEq/L) and POD9 (mean 130.8 mEq/L), respectively, compared with nonelderly patients (peak POD2: mean 139.9 mEq/L; trough POD8: mean 131.3 mEq/L).

CONCLUSIONS

The authors’ analysis revealed that TSS for NFPA in elderly patients is safe with low complication rates. In this cohort, more elderly patients experienced postoperative hyponatremia, while more nonelderly patients experienced postoperative DI. These findings, combined with the observation of higher DI in patients with more comorbidities and elderly patients experiencing later peaks and troughs in serum sodium, suggest age-related differences in sodium regulation after NFPA resection. The authors hope that their results will help guide discussions with elderly patients regarding risks and outcomes of TSS.

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Alexander F. Haddad, Jacob S. Young, Taemin Oh, Matheus P. Pereira, Rushikesh S. Joshi, Kaitlyn M. Pereira, Robert C. Osorio, Kevin C. Donohue, Zain Peeran, Sweta Sudhir, Saket Jain, Angad Beniwal, Ashley S. Chopra, Narpal S. Sandhu, Philip V. Theodosopoulos, Sandeep Kunwar, Ivan H. El-Sayed, José Gurrola II, Lewis S. Blevins Jr., and Manish K. Aghi

OBJECTIVE

Nonfunctioning pituitary adenomas present without biochemical or clinical signs of hormone excess and are the second most common type of pituitary adenomas. The 2017 WHO classification scheme of pituitary adenomas differentiates null-cell adenomas (NCAs) and silent gonadotroph adenomas (SGAs). The present study sought to highlight the differences in patient characteristics and clinical outcomes between NCAs and SGAs.

METHODS

The records of 1166 patients who underwent transsphenoidal surgery for pituitary adenoma between 2012 and 2019 at a single institution were retrospectively reviewed. Patient demographics and clinical outcomes were collected.

RESULTS

Of the overall pituitary adenoma cohort, 12.8% (n = 149) were SGAs and 9.2% (n = 107) NCAs. NCAs were significantly more common in female patients than SGAs (61.7% vs 26.8%, p < 0.001). There were no differences in patient demographics, initial tumor size, or perioperative and short-term clinical outcomes. There was no significant difference in the amount of follow-up between patients with NCAs and those with SGAs (33.8 months vs 29.1 months, p = 0.237). Patients with NCAs had significantly higher recurrence (p = 0.021), adjuvant radiation therapy usage (p = 0.002), and postoperative diabetes insipidus (p = 0.028). NCA pathology was independently associated with tumor recurrence (HR 3.64, 95% CI 1.07–12.30; p = 0.038), as were cavernous sinus invasion (HR 3.97, 95% CI 1.04–15.14; p = 0.043) and anteroposterior dimension of the tumor (HR 2.23, 95% CI 1.09–4.59; p = 0.030).

CONCLUSIONS

This study supports the definition of NCAs and SGAs as separate subgroups of nonfunctioning pituitary adenomas, and it highlights significant differences in long-term clinical outcomes, including tumor recurrence and the associated need for adjuvant radiation therapy, as well as postoperative diabetes insipidus. The authors also provide insight into independent risk factors for these outcomes in the adenoma population studied, providing clinicians with additional predictors of patient outcomes. Follow-up studies will hopefully uncover mechanisms of biological aggressiveness in NCAs and associated molecular targets.