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  • Author or Editor: Thomas C. Origitano x
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Kevin Yoo and Thomas C. Origitano

✓ Cervical spondylosis is a disease that is often attributed to aging and considered the result of degenerative changes in the spine. The idea that there is a genetic predisposition to develop diseases of the skeletal elements of the spine has been discussed previously, but has never been proven conclusively. The authors report three cases of severe cervical spondylosis in patients who are first-degree relatives: a mother and her two sons. All three individuals had cervical disc herniations and stenosis at C3–4, C4–5, C5–6, and C6–7, and all three required decompressive procedures. The location and degree of cervical spondylosis were as similar among these three patients as they have been in identical twins reported in other studies. Such familial inheritance of cervical spondylosis has been reported only once. The existence of familial cervical spondylosis is not an unrealistic proposal because other studies have shown that genetics determines the shape of one's spine and that similar spines tend to degenerate in similar ways. Therefore, genetic counseling for a family such as the one reported here may prove to be of great benefit to warn siblings that they are at high risk for cervical spine injury. However rare it might be, familial cervical spondylosis may be a phenomenon that any spine surgeon should suspect in a family with cervical spine abnormalities found in several members.

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Editorial

The value of a postoperative computed tomography scan

Douglas Kondziolka

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Ahmad Khaldi, Vikram C. Prabhu, Douglas E. Anderson and Thomas C. Origitano

Object

This study was conducted to evaluate the value of postoperative CT scans in determining the probability of return to the operating room (OR) and the optimal time to obtain such scans to determine the effects of surgery.

Methods

Between January and December 2006 (12 months), all postoperative head CT scans obtained for 3 individual surgeons were reviewed. Scans were divided into 3 groups, which were determined by the preference of each surgeon: Group A (early scans—scheduled between 0 and 7 hours); Group B (delayed scans—scheduled between 8 and 24 hours); and Group C (urgent scans—ordered because of a new neurological deficit). The initial scans were reviewed and analyzed in 2 different fashions. The first was to analyze the efficacy of the scans in predicting return to the OR. The second was to determine the optimal time for obtaining a scan. The second analysis was a review of serial postoperative scans for expected versus unexpected findings and changes in the acuity of these findings over time.

Results

In 251 (74%) of 338 cases, the patients had postoperative head CT scans within 24 hours of surgery. Analysis 1 determined the percent of patients returning to the OR for emergency treatment based on postoperative scans: Group A (early)—133 patients, with 0% returning to the OR; Group B (delayed)—108 patients, with 0% returning to the OR; and Group C (urgent)—10 patients, with 30% returning to the OR (p < 0.05). Analysis 2 determined the optimal timing of postoperative scans and changes in scan acuity: Group A (early scan) had an 11% incidence of change in acuity on subsequent scans. Group B (delayed scan) had a 3% incidence of change in acuity on follow-up scans (p < 0.05).

Conclusions

Routine postoperative scans at 0–7 hours or at 8–24 hours are not predictive of return to the OR, whereas patients with a new neurological deficit in the postoperative period have a 30% chance of emergency reoperation based on CT scans. In addition, early postoperative scans (0–7 hours) fail to predict CT changes, which might evolve over time and may influence postoperative medical management.

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Ahmad Khaldi, Naseem Helo, Michael J. Schneck and Thomas C. Origitano

Object

Venous thromboembolism (VTE), a combination of deep venous thrombosis (DVT) and pulmonary embolism (PE), is a major cause of morbidity and death in neurosurgical patients. This study evaluates 1) the risk of developing lower-extremity DVT following a neurosurgical procedure; 2) the timing of initiation of pharmacological DVT prophylaxis upon the occurrence of VTE; and 3) the relationship between DVT and PE as related to VTE prophylaxis in neurosurgical patients.

Methods

The records of all neurosurgical patients between January 2006 and December 2008 (2638 total) were reviewed for clinical documentation of VTE. As part of a quality improvement initiative, a subgroup of 1638 patients was studied during the implementation of pharmacological prophylaxis. A high-risk group of 555 neurosurgical patients in the intensive care unit underwent surveillance venous lower-extremity duplex ultrasonography studies twice weekly. All patients throughout the review received mechanical DVT prophylaxis. Pharmacological DVT prophylaxis, consisting of 5000 U of subcutaneous heparin twice daily (initially started within 48 hours of a neurosurgical procedure and subsequently within 24 hours of a procedure) was implemented in combination with mechanical prophylaxis. The DVT and PE rates were calculated for each group.

Results

In the surveillance group (555 patients), 84% of the DVTs occurred within 1 week and 92% within 2 weeks of a neurosurgical procedure. There was a linear correlation between the duration of surgery and DVT development. The use of subcutaneous heparin reduced the rate of DVT from 16% to 9% when medication was given at either 24 or 48 hours postoperatively, without any increase in hemorrhagic complications. In the overall group (2638 patients), there were 94 patients who exhibited clinical signs of a possible PE and therefore underwent spiral CT; 22 of these patients (0.8%) had radiological confirmation of PE. There was no correlation between the use of pharmacological prophylaxis at either time point and the occurrence of PE, despite a 43% reduction in the lower-extremity DVT rate with pharmacological intervention.

Conclusions

The majority of DVTs occurred within the first week after a neurosurgical procedure. There was a linear correlation between the duration of surgery and DVT occurrence. Use of early subcutaneous heparin (at either 24 or 48 hours) was associated with a 43% reduction of developing a lower-extremity DVT, without an increase in surgical site hemorrhage. There was no association of pharmacological prophylaxis with overall PE occurrence.

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O. Howard Reichman, Edward A. M. Duckworth, Douglas E. Anderson and Thomas C. Origitano

✓The conventional wisdom resulting from the international, multicenter, trial of extracranial–intracranial bypass surgery is that this procedure offers no benefit. Because of the complex and unique circumstances of some, clinical experience and judgment must sometimes overrule some statistical conclusions.

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Debraj Mukherjee and Chirag G. Patil

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Ronald Hammers, Susan Anzalone, James Sinacore and Thomas C. Origitano

Object

Mortality rate is a common outcome measure used by patients, families, physicians, insurers, and health care policy makers to evaluate and measure the quality of health care. The mortality index is a heavily used metric to measure survival, and is a key indicator in hospital report cards and national rankings. The significance of this metric is belied by the literature, which fails to accurately detail the overall mortality rate within the neurosurgical population. Given that there is no gold standard that can be used as a baseline, it is difficult to make durable interinstitutional comparisons concerning performance. In Part I of this paper, the authors examined an academic neurosurgical program's mortality rate and the effect of certain variables on this rate. In Part II, they assumed a broader perspective, examining a group of institutions, the University HealthSystem Consortium (UHC) Clinical Database/Resource Manager, and identifying factors that may be responsible for variability in the mortality index between hospitals.

Methods

Over a 36-month period, the authors' neurosurgical service performed 3650 procedures. Monthly “mortality and morbidity” conference logs were reviewed to collect information on the number of deaths. Deaths were classified according to elective or nonelective admission status. Additionally, the authors reviewed the UHC Clinical Database/Resource Manager for information regarding mortality rates in various other neurosurgical programs. These data reflected a 12-month period. Comparisons of hospital mortality indices were based on the percentage of transferred patients (both emergency department [ED] and inpatient), whether a hospital was a designated Level 1 trauma center, whether a hospital was designated a certified stroke center, and also based on the number of Medicaid patients treated.

Results

Sixty-two patients met the criteria to be considered neurosurgery-related deaths at the authors' institution (1.7% of all cases): 9 elective admissions (15%), 3 nonelective direct admissions (5%), 24 transfer patients (39%), and 26 ED admissions (42%). Causes of death included trauma (40%), stroke (33%), tumor (14%), spinal disease (8%), and infection (6%). Evaluation of the UHC data revealed that a mortality index of ≥ 1.00 was seen in the following hospital types: trauma centers, hospitals with 11–20% Medicaid patients, and those with > 50,000 ED admissions. A nonstatistically significant trend toward increasing mortality rates was seen in hospitals with a lower percentage of elective neurosurgical cases, in Level 1 trauma centers, and in hospitals that were not certified stroke centers. Significance was seen in comparisons of hospitals with the highest and lowest mortality index quartiles in the following groups: trauma centers, hospitals with > 10% Medicaid patients, and hospitals with a high number of ED visits.

Conclusions

Many variables appear to impact the mortality rate within the neurosurgical population. The authors' observations have illuminated some of the reasons why: the data are elusive, documentation is variable, and the modes of statistical analysis are questionable. The first step in addressing this issue is to identify that there is a problem. The authors believe that this study has done so. Presently there is no definitive or reliable source for rating the quality of overall neurosurgical care, nor is there a good and complete source for understanding the quality of neurosurgical care in the US. It is important to view these results as the initial steps to a better understanding of patient outcomes, their measures, and their impact on neurosurgical practice.

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Thomas C. Origitano, Guy J. Petruzzelli, Darl Vandevender and Bahman Emami

Object

Malignant tumors of the skull base represent a group of diverse and infrequent lesions. Comprehensive oncological management requires a multidisciplinary team of neurological surgeons, otolaryngologists, radiation oncologists, plastic surgeons, and medical oncologists. The authors describe an institutional experience in performing 54 combined anterior–anterolateral cranial base resections for malignant disease.

Methods

The technical considerations for preoperative workup, surgical approach, resection, and reconstruction are outlined and illustrated. Considerations for complication management and avoidance are detailed.

Conclusions

Overall mortality (0%) and morbidity rates (18%) are acceptable. The influence on the natural history of the disease process is an ongoing study.

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Nathan R. Selden, Valerie C. Anderson, Shirley McCartney, Thomas C. Origitano, Kim J. Burchiel and Nicholas M. Barbaro

Object

In July 2010, the Society of Neurological Surgeons (SNS) introduced regional courses to promote patient safety and teach fundamental skills and knowledge to all postgraduate Year 1 (PGY1) trainees entering Accreditation Council for Graduate Medical Education (ACGME)–accredited US neurosurgery residency programs. Data from these courses demonstrated significant didactic learning and high faculty and resident satisfaction with hands-on training. Here, the authors evaluated the durability of learning from and the relevance of participation in SNS PGY1 courses as measured midway through PGY1 training.

Methods

Resident participants were resurveyed 6 months after boot camp course attendance to assess knowledge retention and course effectiveness. Exposure to relevant hands-on experiences during PGY1 training and the subjective value of pre-residency simulated training in the courses were assessed.

Results

Ninety-four percent of all residents entering US PGY1 neurosurgical training participated in the 2010 SNS boot camp courses. One hundred sixty-four (88%) of these resident participants responded to the survey. Six months after course completion, 99% of respondents believed the boot camp courses benefited beginning neurosurgery residents and imparted skills and knowledge that would improve patient care. The PGY1 residents' knowledge of information taught in the courses was retained 6 months after initial testing (p < 0.0001).

Conclusions

The learning and other benefits of participation in a national curriculum for residents entering PGY1 neurosurgical training were maintained 6 months after the courses, halfway through the initial training year.

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Brian P. Walcott, Ganesh Sivarajan, Bronislava Bashinskaya, Douglas E. Anderson, John P. Leonetti and Thomas C. Origitano

Object

Vestibular schwannomas (VSs) are rare in the pediatric population. Most often, these lesions manifest as a bilateral disease process in the setting of neurofibromatosis Type 2. Even in the absence of additional clinical diagnostic criteria, the presentation of a unilateral VS in a young patient may be a harbinger of future penetrance for this hereditary tumor syndrome.

Methods

The authors retrospectively reviewed the charts of a cohort of 7 patients who presented with apparently sporadic, unilateral VSs. These patients had previously undergone surgery via translabyrinthine, retrosigmoid, or combined approaches. Clinical outcomes were reviewed with emphasis on facial nerve function and follow-up for signs and symptoms of a heritable disorder.

Results

All patients underwent microsurgical resection in a multidisciplinary effort by the senior authors. The average tumor size was 4.57 cm, with an average duration of symptoms prior to definitive diagnosis of 31.2 months. The tumor size at the time of presentation followed a trend different from reports in adults, while the duration of symptoms did not. At a follow-up average of 6.3 years (range 1–12 years), 100% of patients demonstrated good facial function (House-Brackmann Grade I or II). No patient in this cohort demonstrated symptoms, objective signs, or genetic analysis indicating the presence of neurofibromatosis Type 2.

Conclusions

Diagnosis and management of sporadic, unilateral VSs in children is complicated by clinical presentations and surgical challenges unique from their adult counterparts. Careful consideration should be given to a heritable genetic basis for sporadic unilateral VS in the pediatric population. Results of genetic testing do not preclude the necessity for long-term follow-up and systemic investigation. In patients who present with large tumors, preliminary experience leads the authors to suggest that a combined retrosigmoid-translabyrinthine approach offers the greatest opportunity for preservation of facial nerve function.