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Cover Journal of Neurosurgery: Spine

Letter to the Editor: Reduction of early postoperative dysphagia via steroid use after anterior cervical surgery

Rodrigo Ramos-Zúñiga and Daniel Alexander Saldaña-Koppel

Open access

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Cover Neurosurgical Focus: Video

Qualitative head-to-head comparison of headlamp and microscope for visualizing 5-ALA fluorescence during resection of glioblastoma

Fraser Henderson Jr., Evgenii Belykh, Alexander D. Ramos, and Theodore H. Schwartz

Fluorescence-guided surgery (FGS) for high-grade gliomas using 5-aminolevulinic acid has become a new standard of care for neurosurgeons in several countries. In this video the authors present the case of a man with glioblastoma who underwent FGS in which similar images of the operative field were acquired alternating between the microscope and a new commercially available headlight, facilitating the comparison of visualization quality between the two devices. The authors also review some of the principles of fluorescence-guidance surgery that may explain the improved brightness and contrast that they observed when using the headlamp versus the microscope.

The video can be found here: https://stream.cadmore.media/r10.3171/2021.10.FOCVID21181

Free access

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Cover Journal of Neurosurgery: Spine

Analysis of reasons for medical malpractice litigation due to laminectomy

Alexander Bouterse, Jacob Razzouk, Daniel Bohen, Omar Ramos, Olumide Danisa, and Wayne K. Cheng

OBJECTIVE

The aim of this study was to identify the incidence and characteristics of malpractice lawsuits pertaining to laminectomy performed either as a stand-alone operation or concurrent with another procedure by querying the Westlaw Edge and VerdictSearch databases. Malpractice claims analysis is performed by several medical specialties to provide insight into patient values, methods to improve quality of care, and risk factors for litigation pertaining to specific procedures or treatments.

METHODS

Westlaw and VerdictSearch were queried using the keywords "laminectomy" and "spine." Claims were reviewed, with the inclusion criteria defined as a case filed between 2000 and 2022 that involved the plaintiff’s basis of litigation resting on a claim of medical malpractice due to laminectomy. Additional collected data included the case date, verdict ruling, state or federal location of the filed claim, sustained injuries, and payment or settlement amount.

RESULTS

After review of 4732 cases, 201 were identified as malpractice claims due to laminectomy. The most common reasons for litigation were delayed or denied treatment (n = 106), procedural errors (n = 38), inadequate management of postlaminectomy syndrome (n = 26), and incorrect procedural selection (n = 14). Regarding the verdict ruling, 47.3% (n = 95) of cases ruled in favor of the defendant, 9.0% (n = 18) resulted in a mixed ruling, 15.9% (n = 32) ruled in favor of the plaintiff, and 9.5% (n = 19) were resolved with an out-of-court settlement. An average payment of $4,530,277 resulted from the cases that ruled in favor of the plaintiff, while out-of-court settlements yielded an average payment of $1,193,146.

CONCLUSIONS

This study suggests that there are several well-documented risk factors for malpractice claims attributed to laminectomy. The study findings suggest that prompt and accurate diagnosis, coordination of care, timely referral for surgical intervention, and understanding of the indications versus limitations of conservative therapy may help to mitigate the risk of litigation associated with laminectomy.

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Cover Journal of Neurosurgery: Spine

Letter to the Editor. Malpractice litigation due to laminectomy: patient viewpoint

Chutzu Chang

Free access

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Cover Journal of Neurosurgery

Perioperative prophylactic middle meningeal artery embolization for chronic subdural hematoma: a series of 44 cases

Justin Schwarz, Joseph A. Carnevale, Jacob L. Goldberg, Alexander D. Ramos, Thomas W. Link, and Jared Knopman

OBJECTIVE

Chronic subdural hematoma (cSDH) is a common and challenging pathology to treat due to both the historically high recurrence rate following surgical evacuation and the medical comorbidities inherent in the aging patient population that it primarily affects. Middle meningeal artery (MMA) embolization has shown promise in the treatment of cSDHs, most convincingly to avoid surgical evacuation in relatively asymptomatic patients. Symptomatic patients requiring surgical evacuation may also benefit from perioperative MMA embolization to prevent cSDH recurrence. The goal of this study was to determine the utility of perioperative MMA embolization for symptomatic cSDH requiring surgical evacuation and to assess if there is a decrease in the cSDH recurrence rate compared to historical recurrence rates following surgical evacuation alone.

METHODS

Symptomatic cSDHs were evacuated using a subdural evacuating port system (SEPS) with 5-mm twist-drill craniostomy in an intensive care unit or by performing a craniotomy in the operating room, using either a small (silver dollar, < 4 cm) or large (≥ 4 cm) craniotomy. MMA embolization was performed perioperatively using angiography, selective catheterization of the MMA, and infusion of polyvinyl particles. Outcomes were assessed clinically and radiographically with interval head CT imaging.

RESULTS

There were 44 symptomatic cSDHs in 41 patients, with 3 patients presenting with bilateral symptomatic cSDH. All cSDHs were evacuated using an SEPS (n = 18), a silver-dollar craniotomy (n = 16), or a large craniotomy (n = 10). Prophylactic MMA embolization was performed successfully in all cSDHs soon after surgical evacuation. There were no deaths and no procedural complications. There was an overall reduction of greater than 50% or resolution of cSDH in 40/44 (90.9%) cases, regardless of the evacuation procedure used. Of the 44 prophylactic cases, there were 2 (4.5%) cases of cSDH recurrence that required repeat surgical evacuation at the 1-year follow-up. These 2 cSDHs were initially evacuated using an SEPS and subsequently required a craniotomy, thereby representing an overall 4.5% recurrence rate of treated cSDH requiring repeat evacuation. Most notably, of the 26 patients who underwent surgical evacuation with a craniotomy followed by MMA embolization, none had cSDH recurrence requiring repeat intervention.

CONCLUSIONS

Perioperative prophylactic MMA embolization in the setting of surgical evacuation, via either craniotomy or SEPS, may help to lower the recurrence rate of cSDH.

Free access

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Cover Journal of Neurosurgery: Pediatrics

Repeat convection-enhanced delivery for diffuse intrinsic pontine glioma

Evan D. Bander, Alexander D. Ramos, Eva Wembacher-Schroeder, Iryna Ivasyk, Rowena Thomson, Peter F. Morgenstern, and Mark M. Souweidane

OBJECTIVE

While the safety and efficacy of convection-enhanced delivery (CED) have been studied in patients receiving single-dose drug infusions, agents for oncological therapy may require repeated or chronic infusions to maintain therapeutic drug concentrations. Repeat and chronic CED infusions have rarely been described for oncological purposes. Currently available CED devices are not approved for extended indwelling use, and the only potential at this time is for sequential treatments through multiple procedures. The authors report on the safety and experience in a group of pediatric patients who received sequential CED into the brainstem for the treatment of diffuse intrinsic pontine glioma.

METHODS

Patients in this study were enrolled in a phase I single-center clinical trial using 124I-8H9 monoclonal antibody (124I-omburtamab) administered by CED (clinicaltrials.gov identifier NCT01502917). A retrospective chart and imaging review were used to assess demographic data, CED infusion data, and postoperative neurological and surgical outcomes. MRI scans were analyzed using iPlan Flow software for volumetric measurements. Target and catheter coordinates as well as radial, depth, and absolute error in MRI space were calculated with the ClearPoint imaging software.

RESULTS

Seven patients underwent 2 or more sequential CED infusions. No patients experienced Clinical Terminology Criteria for Adverse Events grade 3 or greater deficits. One patient had a persistent grade 2 cranial nerve deficit after a second infusion. No patient experienced hemorrhage or stroke postoperatively. There was a statistically significant decrease in radial error (p = 0.005) and absolute tip error (p = 0.008) for the second infusion compared with the initial infusion. Sequential infusions did not result in significantly different distribution capacities between the first and second infusions (volume of distribution determined by the PET signal/volume of infusion ratio [mean ± SD]: 2.66 ± 0.35 vs 2.42 ± 0.75; p = 0.45).

CONCLUSIONS

This series demonstrates the ability to safely perform sequential CED infusions into the pediatric brainstem. Past treatments did not negatively influence the procedural workflow, technical application of the targeting interface, or distribution capacity. This limited experience provides a foundation for using repeat CED for oncological purposes.

Open access

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Cover Neurosurgical Focus: Video

Flow diversion for cerebral aneurysms

Joseph A. Carnevale, Jacob L. Goldberg, Gary Kocharian, Andrew L. A. Garton, Alexander Ramos, Justin Schwarz, Srikanth Reddy Boddu, Y. Pierre Gobin, and Jared Knopman

The treatment of cerebral aneurysms includes open microsurgical options (e.g., clipping, trapping/bypass) and evolving endovascular techniques. Following the landmark trials that propelled endovascular treatment to the forefront, flow diversion has shown high aneurysm cure rates with minimal complications. Flow diversion stents are placed in the parent vessel, redirecting blood flow from the aneurysm, promoting reendothelization across the neck, and resulting in complete occlusion of the aneurysm. As a result, flow diversion has become increasingly used as the primary treatment for unruptured aneurysms; however, its applications are being pushed to new frontiers. Here, the authors present three cases showcasing the treatment of intracranial aneurysms with flow diversion.

The video can be found here: https://stream.cadmore.media/r10.3171/2022.7.FOCVID2253

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Cover Neurosurgical Focus

Impact of preoperative endovascular embolization on immediate meningioma resection outcomes

Michael G. Brandel, Robert C. Rennert, Arvin R. Wali, David R. Santiago-Dieppa, Jeffrey A. Steinberg, Christian Lopez Ramos, Peter Abraham, J. Scott Pannell, and Alexander A. Khalessi

OBJECTIVE

Preoperative embolization of meningiomas can facilitate their resection when they are difficult to remove. The optimal use and timing of such a procedure remains controversial given the risk of embolization-linked morbidity in select clinical settings. In this work, the authors used a large national database to study the impact of immediate preoperative embolization on the immediate outcomes of meningioma resection.

METHODS

Meningioma patients who had undergone elective resection were identified in the National (Nationwide) Inpatient Sample (NIS) for the period 2002–2014. Patients who had undergone preoperative embolization were propensity score matched to those who had not, adjusting for patient and hospital characteristics. Associations between preoperative embolization and morbidity, mortality, and nonroutine discharge were investigated.

RESULTS

Overall, 27,008 admissions met the inclusion criteria, and 633 patients (2.34%) had undergone preoperative embolization and 26,375 (97.66%) had not. The embolization group was younger (55.17 vs 57.69 years, p < 0.001) with a lower proportion of females (63.5% vs 69.1%, p = 0.003), higher Charlson Comorbidity Index (p = 0.002), and higher disease severity (p < 0.001). Propensity score matching retained 413 embolization and 413 nonembolization patients. In the matched cohort, preoperative embolization was associated with increased rates of cerebral edema (25.2% vs 17.7%, p = 0.009), posthemorrhagic anemia or transfusion (21.8% vs 13.8%, p = 0.003), and nonroutine discharge (42.8% vs 35.7%, p = 0.039). There was no difference in mortality (≤ 2.4% vs ≤ 2.4%, p = 0.82). Among the embolization patients, the mean interval from embolization to resection was 1.49 days. On multivariate analysis, a longer interval was significantly associated with nonroutine discharge (OR 1.33, p = 0.004) but not with complications or mortality.

CONCLUSIONS

Relative to meningioma patients who do not undergo preoperative embolization in the same admission, those who do have higher rates of cerebral edema and nonroutine discharge but not higher rates of stroke or death. Thus, meningiomas requiring preoperative embolization represent a distinct clinical entity that requires prolonged, more complex care. Further, among embolization patients, the timing of resection did not affect the risk of in-hospital complications, suggesting that the timing of surgery can be determined according to surgeon discretion.

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Cover Journal of Neurosurgery

The effect of hospital safety-net burden on outcomes, cost, and reportable quality metrics after emergent clipping and coiling of ruptured cerebral aneurysms

Christian Lopez Ramos, Robert C. Rennert, Michael G. Brandel, Peter Abraham, Brian R. Hirshman, Jeffrey A. Steinberg, David R. Santiago-Dieppa, Arvin R. Wali, Kevin Porras, Yazeed Almosa, Jeffrey S. Pannell, and Alexander A. Khalessi

OBJECTIVE

Safety-net hospitals deliver care to a substantial share of vulnerable patient populations and are disproportionately impacted by hospital payment reform policies. Complex elective procedures performed at safety-net facilities are associated with worse outcomes and higher costs. The effects of hospital safety-net burden on highly specialized, emergent, and resource-intensive conditions are poorly understood. The authors examined the effects of hospital safety-net burden on outcomes and costs after emergent neurosurgical intervention for ruptured cerebral aneurysms.

METHODS

The authors conducted a retrospective analysis of the Nationwide Inpatient Sample (NIS) from 2002 to 2011. Patients ≥ 18 years old who underwent emergent surgical clipping and endovascular coiling for aneurysmal subarachnoid hemorrhage (SAH) were included. Safety-net burden was defined as the proportion of Medicaid and uninsured patients treated at each hospital included in the NIS database. Hospitals that performed clipping and coiling were stratified as low-burden (LBH), medium-burden (MBH), and high-burden (HBH) hospitals.

RESULTS

A total of 34,647 patients with ruptured cerebral aneurysms underwent clipping and 23,687 underwent coiling. Compared to LBHs, HBHs were more likely to treat black, Hispanic, Medicaid, and uninsured patients (p < 0.001). HBHs were also more likely to be associated with teaching hospitals (p < 0.001). No significant differences were observed among the burden groups in the severity of subarachnoid hemorrhage. After adjusting for patient demographics and hospital characteristics, treatment at an HBH did not predict in-hospital mortality, poor outcome, length of stay, costs, or likelihood of a hospital-acquired condition.

CONCLUSIONS

Despite their financial burden, safety-net hospitals provide equitable care after surgical clipping and endovascular coiling for ruptured cerebral aneurysms and do not incur higher hospital costs. Safety-net hospitals may have the capacity to provide equitable surgical care for highly specialized emergent neurosurgical conditions.

Free access

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Cover Journal of Neurosurgery

Multidisciplinary management of carotid body tumors: a single-institution case series of 22 patients

Alexander Ramos, Joseph A. Carnevale, Kashif Majeed, Gary Kocharian, Ibrahim Hussain, Jacob L. Goldberg, Justin Schwarz, David I. Kutler, Jared Knopman, and Philip Stieg

OBJECTIVE

Carotid body tumors (CBTs) are rare, slow-growing neoplasms derived from the parasympathetic paraganglia of the carotid bodies. Although inherently vascular lesions, the role of preoperative embolization prior to resection remains controversial. In this report, the authors describe an institutional series of patients with CBT successfully treated via resection following preoperative embolization and compare the results in this series to previously reported outcomes in the treatment of CBT.

METHODS

All CBTs resected between 2013 and 2019 at a single institution were retrospectively identified. All patients had undergone preoperative embolization performed by interventional neuroradiologists, and all had been operated on by a combined team of cerebrovascular neurosurgeons and otolaryngology–head and neck surgeons. The clinical, radiographic, endovascular, and perioperative data were collected. All procedural complications were recorded.

RESULTS

Among 22 patients with CBT, 63.6% were female and the median age was 55.5 years at the time of surgery. The most common presenting symptoms included a palpable neck mass (59.1%) and voice changes (22.7%). The average tumor volume was 15.01 ± 14.41 cm3. Most of the CBTs were Shamblin group 2 (95.5%). Blood was predominantly supplied from branches of the ascending pharyngeal artery, with an average of 2 vascular pedicles (range 1–4). Fifty percent of the tumors were embolized with more than one material: polyvinyl alcohol, 95.5%; Onyx, 50.0%; and N-butyl cyanoacrylate glue, 9.1%. The average reduction in tumor blush following embolization was 83% (range 40%–95%). No embolization procedural complications occurred. All resections were performed within 30 hours of embolization. The average operative time was 173.9 minutes, average estimated blood loss was 151.8 ml, and median length of hospital stay was 4 days. The rate of permanent postoperative complications was 0%; 2 patients experienced transient hoarseness, and 1 patient had medical complications related to alcohol withdrawal.

CONCLUSIONS

This series reveals that endovascular embolization of CBT is a safe and effective technique for tumor devascularization, making preoperative angiography and embolization an important consideration in the management of CBT. Moreover, the successful management of CBT at the authors’ institution rests on a multidisciplinary approach whereby endovascular surgeons, neurosurgeons, and ear, nose, and throat–head and neck surgeons work together to optimally manage each patient with CBT.