Jason Chu

Complications following cranioplasty and relationship to timing: A systematic review and meta-analysis

The optimal timing of cranioplasty after decompressive craniectomy has not been well established. The purpose of this study was to evaluate the relationship between timing of cranioplasty and related complications. A systematic search of MEDLINE, Scopus, and the Cochrane databases was performed using PRISMA guidelines for English-language articles published between 1990 and 2015. Case series, case-control and cohort studies, and clinical trials reporting timing and complication data for cranioplasty after decompressive craniectomy in adults were included. Extracted data included overall complications, infections, reoperations, intracranial hemorrhage, extra-axial fluid collections, hydrocephalus, seizures, and bone resorption for cranioplasty performed within (early) and beyond (late) 90days. Twenty-five of 321 articles met inclusion criteria for a total of 3126 patients (1421 early vs. 1705 late). All were retrospective observational studies. Early cranioplasty had significantly higher odds of hydrocephalus than late cranioplasty (Odds Ratio [OR] 2.38, 95% Confidence Interval [CI] 1.25-4.52, p=0.008). There was no difference in odds of overall complications, infections, reoperations, intracranial hemorrhage, extra-axial fluid collections, seizures, or bone resorption. Subgroup analysis of trauma patients revealed a decreased odds of extra-axial fluid collection (OR 0.30, p=0.02) and an increased odds of hydrocephalus (OR 4.99, p=0.05). Early cranioplasty within 90days after decompressive craniectomy is associated with an increased odds of hydrocephalus than with later cranioplasty, but no difference in odds of developing other complications. Earlier cranioplasty in the trauma population is associated with fewer extra-axial fluid collections.

Return to system within 30 days of discharge following pediatric shunt surgery

OBJECT The rate of readmission after CSF shunt surgery is significant and has caught the attention of purchasers of health care. However, a detailed description of clinical scenarios that lead to readmissions and reoperations after index shunt surgery is lacking in the medical literature. METHODS This study included 1755 shunt revision and insertion surgeries that were performed at a single institution between May 1, 2009, and April 30, 2013. Demographic, socioeconomic, and clinical characteristics were prospectively collected in the administrative, business, and operating room databases. Clinical events within the 30 days following discharge were reviewed and analyzed. Two events of interest, Emergency Department (ED) utilization and reoperation, were further analyzed for risk factor associations by using multivariate logistic regression. RESULTS There were 290 readmissions within 30 days of discharge (16.5%). Admission sources included ED (n = 216), hospital transfers (n = 23), and others. Of the 290 readmissions, 184 were associated with an operation, but only 165 of these were performed by the neurosurgical service. These included surgeries for shunt occlusion and externalization (n = 150), wound revision (n = 7), and other neurosurgical procedures that were not shunt related (n = 8). The remaining readmissions (n = 106) were not associated with an operation, and only 59 patients were admitted for issues related to the index shunt surgery. When return to the ED was the dependent variable in a multivariate regression model, patients who returned to the ED were more likely to be from the Atlanta metropolitan area and to be either uninsured or insured with public assistance. When reoperation was the dependent variable, patients whose surgery started after 3 p.m. were more likely to undergo subsequent CSF shunt revision surgery on readmission. CONCLUSIONS Of the readmissions within 30 days of shunt surgery, 74.5% were related to the index shunt surgery. Whether and to what extent these readmissions are preventable continues to be controversial. Further study is needed to identify modifiable risk factors that may eventually improve patient care.

Extreme task specificity in writer's cramp

Focal hand dystonia may be task specific, as is the case with writers cramp. In early stages, task specificity can be so specific that it may be mistaken for a psychogenic movement disorder.

Early Cranioplasty is Associated with Greater Neurological Improvement: A Systematic Review and Meta-Analysis

BACKGROUND Cranioplasty after decompressive craniectomy is a common neurosurgical procedure, yet the optimal timing of cranioplasty has not been well established. OBJECTIVE To investigate whether the timing of cranioplasty is associated with differences in neurological outcome. METHODS A systematic literature review and meta-analysis was performed using MEDLINE, Scopus, and the Cochrane databases for studies reporting timing and neurological assessment for cranioplasty after decompressive craniectomy. Pre- and postcranioplasty neurological assessments for cranioplasty performed within (early) and beyond (late) 90 d were extracted. The standard mean difference (SMD) was used to normalize all neurological measures. Available data were pooled to compare pre-cranioplasty, postcranioplasty, and change in neurological status between early and late cranioplasty cohorts, and in the overall population. RESULTS Eight retrospective observational studies were included for a total of 528 patients. Studies reported various outcome measures (eg, Barthel Index, Karnofsky Performance Scale, Functional Independence Measure, Glasgow Coma Scale, and Glasgow Outcome Score). Cranioplasty, regardless of timing, was associated with significant neurological improvement (SMD .56, P = .01). Comparing early and late cohorts, there was no difference in precranioplasty neurological baseline; however, postcranioplasty neurological outcome was significantly improved in the early cohort (SMD .58, P = .04) and showed greater magnitude of change (SMD 2.90, P = .02). CONCLUSION Cranioplasty may improve neurological function, and earlier cranioplasty may enhance this effect. Future prospective studies evaluating long-term, comprehensive neurological outcomes will be required to establish the true effect of cranioplasty on neurological outcome.

Immunoengineering nerve repair

Significance Annually, more than 250,000 Americans suffer from a peripheral nerve injury, which results in a loss of function and a compromised quality of life. The current clinical gold standard to bridge long, nonhealing nerve gaps, the autograft, has several drawbacks. Therefore, there is a clear and urgent unmet clinical need for an alternative approach that can match or exceed autograft performance. Here we investigated the regenerative effect of fractalkine, a chemokine that preferentially recruits reparative monocytes in the synthetic nerve conduit. Our method of bridging gaps enhanced axonal regeneration and muscle reinnervation and showed results comparable to those observed in autografts. Injuries to the peripheral nervous system are major sources of disability and often result in painful neuropathies or the impairment of muscle movement and/or normal sensations. For gaps smaller than 10 mm in rodents, nearly normal functional recovery can be achieved; for longer gaps, however, there are challenges that have remained insurmountable. The current clinical gold standard used to bridge long, nonhealing nerve gaps, the autologous nerve graft (autograft), has several drawbacks. Despite best efforts, engineering an alternative “nerve bridge” for peripheral nerve repair remains elusive; hence, there is a compelling need to design new approaches that match or exceed the performance of autografts across critically sized nerve gaps. Here an immunomodulatory approach to stimulating nerve repair in a nerve-guidance scaffold was used to explore the regenerative effect of reparative monocyte recruitment. Early modulation of the immune environment at the injury site via fractalkine delivery resulted in a dramatic increase in regeneration as evident from histological and electrophysiological analyses. This study suggests that biasing the infiltrating inflammatory/immune cellular milieu after injury toward a proregenerative population creates a permissive environment for repair. This approach is a shift from the current modes of clinical and laboratory methods for nerve repair, which potentially opens an alternative paradigm to stimulate endogenous peripheral nerve repair.

Effects of Cranioplasty on Cerebral Blood Flow Following Decompressive Craniectomy: A Systematic Review of the Literature.

BACKGROUND Cranioplasty after decompressive craniectomy (DC) is routinely performed for reconstructive purposes and has been recently linked to improved cerebral blood flow (CBF) and neurological function. OBJECTIVE To systematically review all available literature to evaluate the effect of cranioplasty on CBF and neurocognitive recovery. METHODS A PubMed, Google Scholar, and MEDLINE search adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines included studies reporting patients who underwent DC and subsequent cranioplasty in whom cerebral hemodynamics were measured before and after cranioplasty. RESULTS The search yielded 21 articles with a total of 205 patients (range 3-76 years) who underwent DC and subsequent cranioplasty. Two studies enrolled 29 control subjects for a total of 234 subjects. Studies used different imaging modalities, including CT perfusion (n = 10), Xenon-CT (n = 3), single-photon emission CT (n = 2), transcranial Doppler (n = 6), MR perfusion (n = 1), and positron emission tomography (n = 2). Precranioplasty CBF evaluation ranged from 2 days to 6 months; postcranioplasty CBF evaluation ranged from 7 days to 6 months. All studies demonstrated an increase in CBF ipsilateral to the side of the cranioplasty. Nine of 21 studies also reported an increase in CBF on the contralateral side. Neurological function improved in an overwhelming majority of patients after cranioplasty. CONCLUSION This systematic review suggests that cranioplasty improves CBF following DC with a concurrent improvement in neurological function. The causative impact of CBF on neurological function, however, requires further study.

Repair of a traumatic subarachnoid-pleural fistula with the percutaneous injection of fibrin glue in a 2-year-old

Subarachnoid-pleural fistulas (SPFs) are rare clinical entities that occur after severe thoracic trauma or iatrogenic injury during anterolateral approaches to the spine. Treatment of these fistulas often entails open repair of the dural defect. The authors present the case of an SPF in a 2-year-old female after a penetrating injury to the chest. The diagnosis of an SPF was suspected given the high chest tube output and was confirmed with a positive β2-transferrin test of the chest tube fluid, as well as visualization of dural defects on MRI. The dural defects were successfully repaired with CT-guided percutaneous epidural injection of fibrin glue alone. This case represents the youngest pediatric patient with a traumatic SPF to be treated percutaneously. This technique can be safely used in pediatric patients, offers several advantages over open surgical repair, and could be considered as an alternative first-line therapy for the obliteration of SPFs.

Endoscopic transsphenoidal pituitary surgery: 4 unique cases of craniopharyngioma: 3-dimensional operative video.

These series of videos demonstrate 4 examples of endoscopic transsphenoidal resection of a craniopharyngioma. Figures and captions for relevant anatomy during tumor resection are depicted at the end of each video. Case 1 (0:06): The patient is a 54-year-old man who was found to have a 2.6 · 2.0 · 3.6-cm cystic sellar mass with suprasellar extension on workup of headaches, fatigue, gynecomastia, and decreased libido. His laboratory studies demonstrated central hypogonadism and central hypothyroidism. Case 2 (2:28): The patient is a 29-year-old man who was found to have a 3.6 · 2.7 · 2.5-cm sellar mass with suprasellar extension on workup of headaches, decreased libido, and visual field deficits. The mass has both a cystic and a solid component. His preoperative endocrine laboratory studies demonstrated adrenal insufficiency, hypogonadism, and hypothyroidism. Case 3 (4:39): The patient is a 61-year-old woman who was found to have a 1.7 · 1.4 · 1.1-cm sellar mass with suprasellar extension on workup of headaches, fatigue, vertigo, and blurry vision. The mass has both a cystic and a solid component. Her preoperative endocrine laboratory studies were unremarkable. Case 4 (5:58): The patient is a 32-year-old woman who was found tohave a1.9· 1.3 · 2.8-cm solid sellar mass with extension into the third ventricle on workup of headaches, horizontal diplopia, and bilateral abducens nerve palsies. Her preoperative endocrine laboratory studies were unremarkable.

Three-Dimensional Endoscopy for Skull Base Surgery

The transsphenoidal approach (TSA) remains the method of choice for resection of pituitary adenomas and the endoscope has advanced pituitary surgery, replacing microscopy as the preferred technique in experienced hands. This approach is associated with a relatively small number of complications, with transient diabetes insipidus being the most common, occurring in less than 5% of patients. Although endoscopic transsphenoidal procedures are most often performed for resection of pituitary adenomas, the indications for transsphenoidal surgery have expanded with the development of extended approaches that involve the anterior skull base (tuberculum sellae and planum sphenoidale), suprasellar area, third ventricle, cavernous sinus, clivus, ventral brainstem, and craniocervical junction.

Percutaneous Instrumentation Without Arthrodesis for Thoracolumbar Flexion-Distraction Injuries: A Review of the Literature

Background Flexion-distraction injuries (FDI) represent 5% to 15% of traumatic thoracolumbar fractures. Treatment depends on the extent of ligamentous involvement: osseous/Magerl type B2 injuries can be managed conservatively, while ligamentous/Magerl type B1 injuries undergo stabilization with arthrodesis. Minimally invasive surgery without arthrodesis can achieve similar outcomes to open procedures. This has been studied for burst fractures; however, its role in FDI is unclear. Objective To conduct a systematic review of the literature that examined minimally invasive surgery instrumentation without arthrodesis for traumatic FDI of the thoracolumbar spine. Methods Four electronic databases were searched, and articles were screened using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines for patients with traumatic FDI of the thoracolumbar spine treated with percutaneous techniques without arthrodesis and had postoperative follow-up. Results Seven studies with 44 patients met inclusion criteria. There were 19 patients with osseous FDI and 25 with ligamentous FDI. When reported, patients (n = 39) were neurologically intact preoperatively and at follow-up. Osseous FDI patients underwent instrumentation at 2 levels, while ligamentous injuries at approximately 4 levels. Complication rate was 2.3%. All patients had at least 6 mo of follow-up and demonstrated healing on follow-up imaging. Conclusion Percutaneous instrumentation without arthrodesis represents a low-risk intermediate between conservative management and open instrumented fusion. This “internal bracing” can be used in osseous and ligamentous FDIs. Neurologically intact patients who do not require decompression and those that may not tolerate or fail conservative management may be candidates. The current level of evidence cannot provide official recommendations and future studies are required to investigate long-term safety and efficacy.