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Sandi Lam and Larry T. Khoo

Object

Vertebroplasty and kyphoplasty are minimally invasive procedures used to treat persistently symptomatic vertebral compression fractures (VCFs). Both interventions usually involve injection of polymethyl methacrylate (PMMA). The purpose of this technical note was to review the theory and surgical technique for a novel percutaneous system for fracture reduction and stabilization of VCFs by using bone graft.

Methods

This technical note highlights the Optimesh system as an alternative method of minimally invasive VCF reduction and stabilization with the delivery of a bone graft containment device. Instead of using PMMA as in vertebroplasty or kyphoplasty, this system allows the delivery of allograft and/or autograft bone, with its osteoinductive, osteoconductive, and osteogenic properties.

Conclusions

This system allows for restoration of sagittal alignment of the spine with direct control of bone graft delivery by using a mesh graft containment device that allows for ingrowth of new bone and vascular tissue.

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Nathan A. Shlobin, Mark Sheldon, and Sandi Lam

OBJECTIVE

Informed consent has served as a main principle of medical ethics and laws in the United States. The 1986 American Association of Neurological Surgeons Code of Ethics implied medicolegal liability for the failure to obtain informed consent without providing practical guidance regarding the application of informed consent to individual patient encounters in a medicolegal environment. Here, the authors aimed to identify baseline patient recall after discussions with neurosurgeons and their capacity to provide informed consent, describe the effects of interventions to improve patient comprehension, and elucidate the role of informed consent in malpractice litigation in neurosurgery. Their findings may guide neurosurgeons in discussions to properly inform patients and reduce the risk of litigation.

METHODS

A systematic review was conducted to explore informed consent within neurosurgery and its application to medicolegal liability using the PubMed, Embase, and Scopus databases. Titles and abstracts from articles identified in the search were read and selected for full-text review. Studies meeting prespecified inclusion criteria were reviewed in full and analyzed for study design, aim, population, interventions, and outcomes.

RESULTS

Of 1428 resultant articles, 21 were included in the review. Baseline patient recall was low, particularly for risks and alternatives of treatments, and even decreased over time. Cognitive impairment was noted as a factor limiting the ability to provide informed consent. Interventions incorporating a combination of modalities in informed consent discussions, a specialized consent form with points for neurosurgeons to check off upon discussion, interactive websites, question prompt lists, and illustrations were found to be effective in improving patient knowledge. Lack of informed consent was a common factor for malpractice litigation. Spine surgery was particularly prone to costly lawsuits. Payments were generally greater for plaintiff verdicts than for settlements.

CONCLUSIONS

The application of informed consent to patient encounters is an important facet of clinical practice. Neurosurgeons have a duty to provide patients with all pertinent information to allow them to make decisions about their care. The authors examined baseline patient comprehension and capacity, interventions to improve informed consent, and malpractice litigation; it appears that determining the proper capacity to provide informed consent and considering informed consent as a process that depends on the setting are important. There is room to improve the informed consent process centered on baseline patient health literacy and understanding as well as clear communication using multiple modalities.

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Melissa A. LoPresti, Kathryn Wagner, and Sandi Lam

Intractable epilepsy impacts many children. Surgically resective and palliative treatments have developed to increase seizure freedom or palliate the seizure burden in those with medically refractory epilepsy. However, surgical epilepsy treatment can confer significant morbidity and death. Endoscope-assisted surgical approaches may be helpful in reducing the morbidity related to traditional open surgical approaches while allowing for good visualization of surgical targets. Here, the authors report a case utilizing an endoscope-assisted keyhole approach to perform a posterior quadrantectomy and corpus callosotomy, achieving the surgical goals of disconnection and reducing the need for large craniotomy exposure. They present the case of a 17-year-old male with medically refractory epilepsy treated with endoscope-assisted posterior quadrantectomy and corpus callosotomy through two mini-craniotomies to achieve a functional disconnection. To the authors’ knowledge, this is the first reported case of an endoscope-assisted approach for a posterior quadrantectomy for surgical epilepsy treatment in an adult or a pediatric patient. The case is reported to highlight the technical nuances and benefits of this approach in select patients as well as the expansion of applications of endoscope-assisted epilepsy surgery.

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Sandi Lam, Ramesh Grandhi, and Stephanie Greene

Meconium staining of open myelomeningoceles has been reported to occur both prenatally and postnatally, but meconium staining of the brainstem has not been previously documented. The authors present a case of meconium staining of the brainstem in an infant with a meconium-stained myelomeningocele, Chiari malformation Type II, and hydrocephalus and discuss possible implications for prenatal and perinatal care.

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Sandi Lam, Ulrich Batzdorf, and Marvin Bergsneider

Object

The most commonly reported treatment of primary syringomyelia has been laminectomy with duraplasty or direct shunting from the syrinx cavity. Diversion of cerebrospinal fluid (CSF) from the spinal subarachnoid space to peritoneal, atrial, or pleural cavities has been described previously in only a few case reports. Shunting of the CSF from the subarachnoid space rostral to the level of myelographic blockage may reduce the filling force of the syrinx cavity and avoids myelotomy and manipulation of the spinal cord parenchyma. The authors report on 7 patients who underwent thecal shunt placement for primary spinal syringomyelia.

Methods

This study is a retrospective review of a consecutive series. The authors reviewed the medical records and neuroimaging studies of 7 adult patients with posttraumatic, postsurgical, or postinflammatory syringomyelia treated with thecoperitoneal, thecopleural, or thecoatrial shunt placement at the University of California Los Angeles Medical Center. Myelographic evidence of partial or complete CSF flow obstruction was confirmed in the majority of patients. The mean duration of follow-up was 33 months (range 6–104 months).

Results

Six (86%) of 7 patients showed signs of clinical improvement, whereas 1 remained with stable clinical symptoms. Of the 6 patients with available postoperative imaging, each demonstrated a reduction in syrinx size. Three patients (43%) had ≥ 1 complication, including shunt-induced cerebellar tonsillar descent in 1 patient and infections in 2.

Conclusions

If laminectomy with duraplasty is not possible for the treatment of primary syringomyelia, placement of a thecoperitoneal shunt (or thecal shunt to another extrathecal cavity) should be considered. Although complications occurred in 3 of 7 patients, the complication rate was outweighed by a relatively high symptomatic and imaging improvement rate.

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Dominic A. Harris and Sandi Lam

Object

The risk of venous thromboembolism (VTE) in children with traumatic brain injury (TBI) has not been well characterized given its rarity in the pediatric population. Investigation of risk factors for VTE in this group requires the use of a large sample size. Using nationally representative hospital discharge data for 2009, the authors of this study characterize the incidence and risk factors for VTE in children hospitalized for TBI.

Methods

The authors conducted a cross-sectional study using data from the Healthcare Cost and Utilization Project Kids' Inpatient Database to examine VTE in TBI-associated hospitalizations for patients 20 years of age or younger during the year 2009.

Results

There were 58,529 children with TBI-related admissions, including 267 with VTE diagnoses. Venous thromboembolisms occurred in 4.6 per 1000 TBI-associated hospitalizations compared with 1.2 per 1000 pediatric hospitalizations overall. By adjusted logistic regression, patients significantly more likely to be diagnosed with VTE had the following: older age of 15–20 years (adjusted odds ratio [aOR] 3.7, 95% CI 1.8–8.0), venous catheterization (aOR 3.0, 95% CI 2.0–4.6), mechanical ventilation (aOR 1.9, 95% CI 1.2–2.9), tracheostomy (aOR 2.3, 95% CI 1.3–4.0), nonaccidental trauma (aOR 2.8, 95% CI 1.1–6.9), increased length of stay (aOR 1.02, 95% CI 1.01–1.03), orthopedic surgery (aOR 2.4, 95% CI 1.8–3.4), and cranial surgery (aOR 1.8, 95% CI 1.1–2.8).

Conclusions

Using the Kids' Inpatient Database, the authors found that risk factors for VTE in the setting of TBI in the pediatric population include older age, venous catheterization, nonaccidental trauma, increased length of hospital stay, orthopedic surgery, and cranial surgery.

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Christopher M. Bonfield, Sandi Lam, Yimo Lin, and Stephanie Greene

Object

Attention deficit hyperactivity disorder (ADHD) and traumatic brain injury (TBI) are significant independent public health concerns in the pediatric population. This study explores the impact of a premorbid diagnosis of ADHD on outcome following mild TBI.

Methods

The charts of all patients with a diagnosis of mild closed head injury (CHI) and ADHD who were admitted to Children's Hospital of Pittsburgh between January 2003 and December 2010 were retrospectively reviewed after institutional review board approval was granted. Patient demographics, initial Glasgow Coma Scale (GCS) score, hospital course, and King's Outcome Scale for Childhood Head Injury (KOSCHI) score were recorded. The results were compared with a sample of age-matched controls admitted with a diagnosis of CHI without ADHD.

Results

Forty-eight patients with mild CHI and ADHD, and 45 patients with mild CHI without ADHD were included in the statistical analysis. Mild TBI due to CHI was defined as an initial GCS score of 13–15. The ADHD group had a mean age of 12.2 years (range 6–17 years), and the control group had a mean age of 11.14 years (range 5–16 years). For patients with mild TBI who had ADHD, 25% were moderately disabled (KOSCHI Score 4b), and 56% had completely recovered (KOSCHI Score 5b) at follow-up. For patients with mild TBI without ADHD, 2% were moderately disabled and 84% had completely recovered at follow-up (p < 0.01). Patients with ADHD were statistically significantly more disabled after mild TBI than were control patients without ADHD, even when controlling for age, sex, initial GCS score, hospital length of stay, length of follow-up, mechanism of injury, and presence of other (extracranial) injury.

Conclusions

Patients who sustain mild TBIs in the setting of a premorbid diagnosis of ADHD are more likely to be moderately disabled by the injury than are patients without ADHD.

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Yimo Lin, I-Wen Pan, Rory R. Mayer, and Sandi Lam

OBJECT

Research conducted using large administrative data sets has increased in recent decades, but reports on the fidelity and reliability of such data have been mixed. The goal of this project was to compare data from a large, administrative claims data set with a quality improvement registry in order to ascertain similarities and differences in content.

METHODS

Data on children younger than 12 months with nonsyndromic craniosynostosis who underwent surgery in 2012 were queried in both the Kids’ Inpatient Database (KID) and the American College of Surgeons Pediatric National Surgical Quality Improvement Program (Peds NSQIP). Data from published clinical craniosynostosis surgery series are reported for comparison.

RESULTS

Among patients younger than 12 months of age, a total of 1765 admissions were identified in KID and 391 in Peds NSQIP in 2012. Only nonsyndromic patients were included. The mean length of stay was 3.2 days in KID and 4 days in Peds NSQIP. The rates of cardiac events (0.5% in KID, 0.3% in Peds NSQIP, and 0.4%-2.2% in the literature), stroke/intracranial bleeds (0.4% in KID, 0.5% in Peds NSQIP, and 0.3%-1.2% in the literature), infection (0.2% in KID, 0.8% in Peds NSQIP, and 0%-8% in the literature), wound disruption (0.2% in KID, 0.5% in Peds NSQIP, 0%-4% in the literature), and seizures (0.7% in KID, 0.8% in Peds NSQIP, 0%-0.8% in the literature) were low and similar between the 2 data sets. The reported rates of blood transfusion (36% in KID, 64% in Peds NSQIP, and 1.7%-100% in the literature) varied between the 2 data sets.

CONCLUSIONS

Both the KID and Peds NSQIP databases provide large samples of surgical patients, with more cases reported in KID. The rates of complications studied were similar between the 2 data sets, with the exception of blood transfusion events where the retrospective chart review process of Peds NSQIP captured almost double the rate reported in KID.

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Ricky H. Wong, Fabrice Smieliauskas, I-Wen Pan, and Sandi K. Lam

OBJECT

Neurosurgery studies traditionally have evaluated the effects of interventions on health care outcomes by studying overall changes in measured outcomes over time. Yet, this type of linear analysis is limited due to lack of consideration of the trend’s effects both pre- and postintervention and the potential for confounding influences. The aim of this study was to illustrate interrupted time-series analysis (ITSA) as applied to an example in the neurosurgical literature and highlight ITSA’s potential for future applications.

METHODS

The methods used in previous neurosurgical studies were analyzed and then compared with the methodology of ITSA.

RESULTS

The ITSA method was identified in the neurosurgical literature as an important technique for isolating the effect of an intervention (such as a policy change or a quality and safety initiative) on a health outcome independent of other factors driving trends in the outcome. The authors determined that ITSA allows for analysis of the intervention’s immediate impact on outcome level and on subsequent trends and enables a more careful measure of the causal effects of interventions on health care outcomes.

CONCLUSIONS

ITSA represents a significant improvement over traditional observational study designs in quantifying the impact of an intervention. ITSA is a useful statistical procedure to understand, consider, and implement as the field of neurosurgery evolves in sophistication in big-data analytics, economics, and health services research.