✓This is the first report of a cerebellar cryptococcoma in a previously healthy, HIV-negative child. Cryptococcus neoformans is an opportunistic fungus that typically affects patients who are HIV-positive and other patients with compromised immune systems. Isolated cryptococcomas of the central nervous system (CNS) have been previously described in immunocompetent adults; however, this is the first report of a cryptococcoma in a child. The patient presented with progressive headaches and nausea and was found to have a large cerebellar hemispheric mass. The patient underwent excision of the mass, and analysis of frozen sections suggested the presence of an astrocytic tumor with pilocytic features; therefore gross-total resection was performed. Once the definitive diagnosis of a cryptococcal abscess was obtained, medical treatment with antifungal medications led to the resolution of all symptoms and the normalization of serum titers. Cryptococcoma is a rare cause of ring enhancing lesions in the cerebellum, even in apparently immunocompetent patients. The authors' experience with this case and the patient's postoperative care lead them to advocate resection of large isolated cryptococcomas of the CNS, especially those situated in the posterior fossa.
Yakov Gologorsky, Patricia Delamora, Mark M. Souweidane and Jeffrey P. Greenfield
Yakov Gologorsky, Branko Skovrlj, Jeremy Steinberger, Max Moore, Marc Arginteanu, Frank Moore and Alfred Steinberger
Transforaminal lumbar interbody fusion (TLIF) with segmental pedicular instrumentation is a wellestablished procedure used to treat lumbar spondylosis with or without spondylolisthesis. Available biomechanical and clinical studies that compared unilateral and bilateral constructs have produced conflicting data regarding patient outcomes and hardware complications.
A prospective cohort study was undertaken by a group of neurosurgeons. They prospectively enrolled 80 patients into either bilateral or unilateral pedicle screw instrumentation groups (40 patients/group). Demographic data collected for each group included sex, age, body mass index, tobacco use, and Workers' Compensation/litigation status. Operative data included segments operated on, number of levels involved, estimated blood loss, length of hospital stay, and perioperative complications. Long-term outcomes (hardware malfunction, wound dehiscence, and pseudarthrosis) were recorded. For all patients, preoperative baseline and 6-month postoperative scores for Medical Outcomes 36-Item Short Form Health Survey (SF-36) outcomes were recorded.
Patient follow-up times ranged from 37 to 63 months (mean 52 months). No patients were lost to follow-up. The patients who underwent unilateral pedicle screw instrumentation (unilateral cohort) were slightly younger than those who underwent bilateral pedicle screw instrumentation (bilateral cohort) (mean age 42 vs 47 years, respectively; p = 0.02). No other significant differences were detected between cohorts with regard to demographic data, mean number of lumbar levels operated on, or distribution of the levels operated on. Estimated blood loss was higher for patients in the bilateral cohort, but length of stay was similar for patients in both cohorts. The incidence of pseudarthrosis was significantly higher among patients in the unilateral cohort (7 patients [17.5%]) than among those in the bilateral cohort (1 patient [2.5%]) (p = 0.02). Wound dehiscence occurred for 1 patient in the unilateral cohort. Reoperation was offered to 8 patients in the unilateral cohort and 1 patient in the bilateral cohort (p = 0.03). The physical component scores of the Medical Outcomes SF-36 outcomes improved significantly for all patients (p < 0.001).
Transforaminal lumbar interbody fusion with either unilateral or bilateral segmental pedicular instrumentation is an effective treatment for lumbar spondylosis. Because patients with unilateral constructs were 7 times more likely to experience pseudarthrosis and require reoperation, TLIF with bilateral constructs might be the biomechanically superior technique.
Yakov Gologorsky, John J. Knightly, John H. Chi and Michael W. Groff
The rates of lumbar spinal fusion operations have increased dramatically over the past 2 decades, and several studies based on administrative databases such as the Nationwide Inpatient Sample (NIS) have suggested that the greatest rise is in the general categories of degenerative disc disease and disc herniation, neither of which is a well-accepted indication for lumbar fusion. The administrative databases classify cases with the International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM). The ICD-9-CM discharge codes are not generated by surgeons but rather are assigned by trained hospital medical coders. It is unclear how accurately they capture the surgeon's indication for fusion. The authors sought to compare the ICD-9-CM code(s) assigned by the medical coder to the surgeon's indication based on a review of the medical chart.
A retrospective review was undertaken of all lumbar fusions performed at our institution by the department of neurosurgery between 8/1/2011 and 8/31/2013. Based on the authors' review, the indication for fusion for each case was categorized as spondylolisthesis, deformity, tumor, infection, nonpathological fracture, pseudarthrosis, adjacent-level degeneration, stenosis, degenerative disc pathology, or disc herniation. These surgeon diagnoses were compared with the primary ICD-9-CM codes that were submitted to administrative databases.
There were 178 lumbar fusion operations performed for 170 hospital admissions. There were 44 hospitalizations in which fusion was performed for tumor, infection, or nonpathological fracture; the remaining 126 were for degenerative diagnoses. For these degenerative cases, the primary ICD-9-CM diagnosis matched the surgeon's diagnosis in only 61 of 126 degenerative cases (48.4%). When both the primary and all secondary ICD-9-CM diagnoses were considered, the indication for fusion was identified in 100 of 126 cases (79.4%).
Characterizing indications for fusion based solely on primary ICD-9-CM codes extracted from large administrative databases does not accurately reflect the surgeon's indication. While these databases may accurately describe national rates of lumbar fusion surgery, the lack of fidelity in the source codes limits their role in accurately identifying indications for surgery. Studying relationships among indications, complications, and outcomes stratified solely by ICD-9-CM codes is not well founded.
Frank J. Yuk, Jonathan J. Rasouli, Marc S. Arginteanu, Alfred A. Steinberger, Frank M. Moore, Kevin C. Yao, John M. Caridi and Yakov Gologorsky
Rigid cervicothoracic kyphotic deformity (CTKD) remains a difficult pathology to treat, especially in the setting of prior cervical instrumentation and fusion. CTKD may result in chronic neck pain, difficulty maintaining horizontal gaze, and myelopathy. Prior studies have advocated for the use of C7 or T1 pedicle subtraction osteotomies (PSOs). However, these surgeries are fraught with danger and, most significantly, place the C7, C8, and/or T1 nerve roots at risk.
The authors retrospectively reviewed their experience with performing T2 PSO for the correction of rigid CTKD. Demographics collected included age, sex, details of prior cervical surgery, and coexisting conditions. Perioperative variables included levels decompressed, levels instrumented, estimated blood loss, length of surgery, length of stay, complications from surgery, and length of follow-up. Radiographic measurements included C2–7 sagittal vertical axis (SVA) correction, and changes in the cervicothoracic Cobb angle, lumbar lordosis, and C2–S1 SVA.
Four male patients were identified (age range 55–72 years). Three patients had undergone prior posterior cervical laminectomy and instrumented fusion and developed postsurgical kyphosis. All patients underwent T2 PSO: 2 patients received instrumentation at C2–T4, and 2 patients received instrumentation at C2–T5. The median C2–7 SVA correction was 3.85 cm (range 2.9–5.3 cm). The sagittal Cobb angle correction ranged from 27.8° to 37.6°. Notably, there were no neurological complications.
T2 PSO is a powerful correction technique for the treatment of rigid CTKD. Compared with C7 or T1 PSO, there is decreased risk of injury to intrinsic hand muscle innervators, and there is virtually no risk of vertebral artery injury. Laminectomy may also be safer, as there is less (or no) scar tissue from prior surgeries. Correction at this distal level may allow for a greater sagittal correction. The authors are optimistic that these findings will be corroborated in larger cohorts examining this challenging clinical entity.
Jonathan J. Rasouli, Brooke T. Kennamer, Frank M. Moore, Alfred Steinberger, Kevin C. Yao, Omar N. Syed, Marc S. Arginteanu and Yakov Gologorsky
The C7 vertebral body is morphometrically unique; it represents the transition from the subaxial cervical spine to the upper thoracic spine. It has larger pedicles but relatively small lateral masses compared to other levels of the subaxial cervical spine. Although the biomechanical properties of C7 pedicle screws are superior to those of lateral mass screws, they are rarely placed due to increased risk of neurological injury. Although pedicle screw stimulation has been shown to be safe and effective in determining satisfactory screw placement in the thoracolumbar spine, there are few studies determining its utility in the cervical spine. Thus, the purpose of this study was to determine the feasibility, clinical reliability, and threshold characteristics of intraoperative evoked electromyographic (EMG) stimulation in determining satisfactory pedicle screw placement at C7.
The authors retrospectively reviewed a prospectively collected data set. All adult patients who underwent posterior cervical decompression and fusion with placement of C7 pedicle screws at the authors’ institution between January 2015 and March 2019 were identified. Demographic, clinical, neurophysiological, operative, and radiographic data were gathered. All patients underwent postoperative CT scanning, and the position of C7 pedicle screws was compared to intraoperative neurophysiological data.
Fifty-one consecutive C7 pedicle screws were stimulated and recorded intraoperatively in 25 consecutive patients. Based on EMG findings, 1 patient underwent intraoperative repositioning of a C7 pedicle screw, and 1 underwent removal of a C7 pedicle screw. CT scans demonstrated ideal placement of the C7 pedicle screw in 40 of 43 instances in which EMG stimulation thresholds were > 15 mA. In the remaining 3 cases the trajectories were suboptimal but safe. When the screw stimulation thresholds were between 11 and 15 mA, 5 of 6 screws were suboptimal but safe, and in 1 instance was potentially dangerous. In instances in which the screw stimulated at thresholds ≤ 10 mA, all trajectories were potentially dangerous with neural compression.
Ideal C7 pedicle screw position strongly correlated with EMG stimulation thresholds > 15 mA. In instances, in which the screw stimulates at values between 11 and 15 mA, screw trajectory exploration is recommended. Screws with thresholds ≤ 10 mA should always be explored, and possibly repositioned or removed. In conjunction with other techniques, EMG threshold testing is a useful and safe modality in determining appropriate C7 pedicle screw placement.
Yakov Gologorsky, John J. Knightly, Yi Lu, John H. Chi and Michael W. Groff
Large administrative databases have assumed a major role in population-based studies examining health care delivery. Lumbar fusion surgeries specifically have been scrutinized for rising rates coupled with ill-defined indications for fusion such as stenosis and spondylosis. Administrative databases classify cases with the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). The ICD-9-CM discharge codes are not designated by surgeons, but rather are assigned by trained hospital medical coders. It is unclear how accurately they capture the surgeon's indication for fusion. The authors first sought to compare the ICD-9-CM code(s) assigned by the medical coder according to the surgeon's indication based on a review of the medical chart, and then to elucidate barriers to data fidelity.
A retrospective review was undertaken of all lumbar fusions performed in the Department of Neurosurgery at the authors' institution between August 1, 2011, and August 31, 2013. Based on this review, the indication for fusion in each case was categorized as follows: spondylolisthesis, deformity, tumor, infection, nonpathological fracture, pseudarthrosis, adjacent-level degeneration, stenosis, degenerative disc disease, or disc herniation. These surgeon diagnoses were compared with the primary ICD-9-CM codes that were generated by the medical coders and submitted to administrative databases. A follow-up interview with the hospital's coders and coding manager was undertaken to review causes of error and suggestions for future improvement in data fidelity.
There were 178 lumbar fusion operations performed in the course of 170 hospital admissions. There were 44 hospitalizations in which fusion was performed for tumor, infection, or nonpathological fracture. Of these, the primary diagnosis matched the surgical indication for fusion in 98% of cases. The remaining 126 hospitalizations were for degenerative diseases, and of these, the primary ICD-9-CM diagnosis matched the surgeon's diagnosis in only 61 (48%) of 126 cases of degenerative disease. When both the primary and all secondary ICD-9-CM diagnoses were considered, the indication for fusion was identified in 100 (79%) of 126 cases. Still, in 21% of hospitalizations, the coder did not identify the surgical diagnosis, which was in fact present in the chart. There are many different causes of coding inaccuracy and data corruption. They include factors related to the quality of documentation by the physicians, coder training and experience, and ICD code ambiguity.
Researchers, policymakers, payers, and physicians should note these limitations when reviewing studies in which hospital claims data are used. Advanced domain-specific coder training, increased attention to detail and utilization of ICD-9-CM diagnoses by the surgeon, and improved direction from the surgeon to the coder may augment data fidelity and minimize coding errors. By understanding sources of error, users of these large databases can evaluate their limitations and make more useful decisions based on them.