Mayur Sharma

Surgical Complications of Anterior Cervical Diskectomy and Fusion for Cervical Degenerative Disk Disease: A Single Surgeon's Experience of 1576 Patients

BACKGROUNDnAlthough anterior cervical diskectomy and fusion (ACDF) is a safe and effective procedure, the complications associated with it cannot be underestimated. The aim of this study was to highlight the potential complications associated with ACDF and the strategies to avoid them.nnnMETHODSnA total of 1576 patients was included in this retrospective study from 1995 to 2012. All patients were operated by a single surgeon, who used the standard technique. Data pertaining to the postoperative complications and mortality were collected from the database.nnnRESULTSnThe overall ACDF-related complication rate in our series was 8.4% (n = 133). Dysphagia was the most common complication encountered in 3.3 % (n = 52) of our patients. The inadvertent dural tear was encountered in 1.3% (n = 20) of our patients. Hoarseness was seen in 1.2% (n = 19) of our patients. A total of 0.88% (n = 14) of the patients had worsening of myelopathy/radiculopathy in the immediate postoperative period. Superficial wound infection occurred in 0.2% (n = 3) of our patients. Postoperative neck hematoma was seen in 0.1% (n = 2), recurrent laryngeal nerve palsy in 0.1% (n = 2), esophageal tear in 0.1% (n = 1), and graft extrusion in 0.88% (n = 14) of our cases. There was 0.1% (n = 1) mortality in our series. Of all these complications, only dysphagia was significantly correlated with 3-level ACDF as compared to 1- or 2-level ACDF (H = 12.89, df= 3, P = 0.05).nnnCONCLUSIONnACDF is a relatively safe procedure with very low morbidity and almost no mortality. In this study, the common complications encountered were postoperative dysphagia, dural injury, and hoarseness.

Discharge dispositions, complications, and costs of hospitalization in spinal cord tumor surgery: analysis of data from the United States Nationwide Inpatient Sample, 2003–2010

OBJECTnThe aim of this study was to analyze the incidence of adverse outcomes and inpatient mortality following resection of intramedullary spinal cord tumors by using the US Nationwide Inpatient Sample (NIS) database. The overall complication rate, length of the hospital stay, and the total cost of hospitalization were also analyzed from the database.nnnMETHODSnThis is a retrospective cohort study conducted using the NIS data from 2003 to 2010. Various patient-related (demographic categories, complications, comorbidities, and median household income) and hospital-related variables (number of beds, high/low case volume, rural/urban location, region, ownership, and teaching status) were analyzed from the database. The adverse discharge disposition, in-hospital mortality, and the higher cost of hospitalization were taken as the dependent variables.nnnRESULTSnA total of 15,545 admissions were identified from the NIS database. The mean patient age was 44.84 ± 19.49 years (mean ± SD), and 7938 (52%) of the patients were male. Regarding discharge disposition, 64.1% (n = 9917) of the patients were discharged to home or self-care, and the overall in-hospital mortality rate was 0.46% (n = 71). The mean total charges for hospitalization increased from

Trends in intracranial meningioma surgery and outcome: a Nationwide Inpatient Sample database analysis from 2001 to 2010.

45,452.24 in 2003 to

Complications and outcomes of surgery for spinal meningioma: A Nationwide Inpatient Sample analysis from 2003 to 2010

76,698.96 in 2010. Elderly patients, female sex, black race, and lower income based on ZIP code were the independent predictors of other than routine (OTR) disposition (p < 0.001). Private insurance showed a protective effect against OTR disposition. Patients with a higher comorbidity index (OR 1.908, 95% CI 1.733-2.101; p < 0.001) and with complications (OR 2.214, 95% CI 1.768-2.772; p < 0.001) were more likely to have an adverse discharge disposition. Hospitals with a larger number of beds and those in the Northeast region were independent predictors of the OTR discharge disposition (p < 0.001). Admissions on weekends and nonelective admission had significant influence on the disposition (p < 0.001). Weekend and nonelective admissions were found to be independent predictors of inpatient mortality and the higher cost incurred to the hospitals (p < 0.001). High-volume and large hospitals, West region, and teaching hospitals were also the predictors of higher cost incurred to the hospitals (p < 0.001). The following variables (young patients, higher median household income, nonprivate insurance, presence of complications, and a higher comorbidity index) were significantly correlated with higher hospital charges (p < 0.001), whereas the variables young patients, nonprivate insurance, higher median household income, and higher comorbidity index independently predicted for inpatient mortality (p < 0.001).nnnCONCLUSIONSnThe independent predictors of adverse discharge disposition were as follows: elderly patients, female sex, black race, lower median household income, nonprivate insurance, higher comorbidity index, presence of complications, larger hospital size, Northeast region, and weekend and nonelective admissions. The predictors of higher cost incurred to the hospitals were as follows: young patients, higher median household income, nonprivate insurance, presence of complications, higher comorbidity index, hospitals with high volume and a large number of beds, West region, teaching hospitals, and weekend and nonelective admissions.

The Pterional and Suprabrow Approaches for Aneurysm Surgery: A Systematic Review of Intraoperative Rupture Rates in 9488 Aneurysms

The objective of the present study was to analyze the risk of in-patient mortality, adverse outcome, practice patterns and regional variations in patients who underwent intracranial meningioma surgery in the United States between 2001 and 2010. We performed a retrospective cohort study using the Nationwide Inpatient Sample database. In-patient mortality and adverse outcome at discharge were the outcome predictors. Multivariate analyses were done to analyze the patient, hospital and physician characteristics. The annual case-volume of patients with meningioma increased from 2001 to 2010 by 40xa0%. The in-patient mortality rate remained the same at 1.3xa0% and the rate of adverse discharge disposition remained at 35xa0% between 2001 and 2010. Caucasian female patients in younger age group with private insurance who underwent treatment at a high case-volume center had the best outcomes. In older patients (≥70xa0years), the in-patient mortality rate decreased by 25xa0% whereas the adverse discharge disposition rate increased by 19xa0%. Patients treated at high case-volume centers and by high case-volume physicians had lower rates of in-patient mortality (Pxa0<xa00.05) and adverse outcome at discharge (Pxa0=xa00xa0<xa00.05). There was a 54xa0% decrease in the number of hospitals performing one surgery/year through the decade. A 2xa0% relative decrease in mortality was observed in lowest volume hospitals. Though the highest increase in admission charges through the decade was seen in hospitals located in the north-east (165xa0% relative increase), the highest relative decrease in mortality and morbidity was observed in hospitals located in the mid-west and the south (67.6xa0 and 22xa0% respectively).

The Utility and Limitations of Intraoperative Near-Infrared Indocyanine Green Videoangiography in Aneurysm Surgery

OBJECTIVEnThe aim of the present study was to analyze the practice patterns, complications and outcome following surgery for spinal meningioma in the United States.nnnPATIENTS AND METHODSnWe performed a retrospective cohort study using the Nationwide Inpatient Sample database from 2003 to 2010. In-patient mortality and discharge disposition were the outcome predictors.nnnRESULTSnA total of 13,792 admissions for surgically managed spinal meningioma were identified. The number of admissions increased from 12.6% in 2003 to 14.7% in 2010. 1.2% patients were ≤18 years and 28.4% ≥70 years. 8.3% patients had high co-morbidity score. The total in-hospital complication rate was 6.4%. 42% of the admissions were discharged to facilities other than home or self-care. Patients in the pediatric and adult age groups had a significantly higher rate of adverse outcome. There was no difference in complication rates and adverse discharge disposition between the hospitals with varying case volumes.nnnCONCLUSIONSnCaucasian patients with private insurance without co-morbidity had significantly lower complication rate and good outcome. Occurrence of spinal meningioma in the pediatric and adult age groups does not carry worse prognosis.

Technical nuances in the management of tuberculum sellae and diaphragma sellae meningiomas

OBJECTIVEnTo assess the safety of the suprabrow approach (SBCA) for aneurysm surgery by comparing intraoperative rupture rates with those for the standard pterional approach.nnnMETHODSnA systematic review of all literature published in or after 1997 was performed using specified search words. All articles described aneurysm surgery by one of two approaches--pterional or suprabrow--and mentioned the rate of intraoperative rupture. A total of 41 articles were found fit for inclusion for the final analysis. Articles that focused on giant, bilateral, posterior fossa, or previously coiled aneurysms were not included. The χ(2) test was used to compare the two cohorts and various subgroup analyses were carried out. A P value of <0.05 was considered significant.nnnRESULTSnThe search of literature yielded 9488 aneurysm reports (41 articles), 7535 operated by the pterional approach and 1953 aneurysms by the SBCA. The overall intraoperative rupture (IOR) rate for the entire group was 9.20%. In the pterional craniotomy approach (PtCA) group, the rate of IOR was 10.09% and in the SBCA group, IOR occurred in 5.78%. The IOR rate in the PtCA group was almost double that in the SBCA group and the odds ratio (OR) for this difference was 1.8 (95% confidence interval [CI] 1.49-2.26; P< 0.001). A total of 3039 ruptured aneurysms were analyzed--2848 aneurysms in the PtCA group and 191 in the SBCA group. The rate of IOR was 14.15% for the overall group, 13.8% in the PtCA group, and 19.37% in the SBCA group. The difference in IOR between the PtCA group and the SBCA group for ruptured aneurysms was found to be significant (OR 1.5, 95% CI 1.003-2.119; P< 0.05). The number of unruptured aneurysms in the PtCA group was 862 (39.4%) and in the SBCA group, it was 232 (49.1%). The difference in the number of unruptured aneurysms between the groups was significant (P< 0.001). The rate of IOR was significantly less with the SBCA than with the pterional approach.nnnCONCLUSIONSnThe rate of intraoperative rupture is significantly higher when ruptured aneurysms are operated with the SBCA (in comparison to the pterional approach). However, the SBCA may be safer for unruptured and middle cerebral artery aneurysms with a lower rate of IOR.

A Comparison between the Kawase and Extended Retrosigmoid Approaches (Retrosigmoid Transtentorial and Retrosigmoid Intradural Suprameatal Approaches) for Accessing the Petroclival Tumors. A Cadaveric Study.

OBJECTIVEnTo analyze the clip repositioning rate and the correlation between indocyanine green (ICG) videoangiography and conventional postoperative digital subtraction angiography for completeness of aneurysm occlusion and parent and branching vessel compromise.nnnMETHODSnThis retrospective study included 112 patients with 126 aneurysms who underwent microsurgical clipping and ICG videoangiography during aneurysm surgery at a single center from January 2008 to June 2013. Age, gender, aneurysm size, location, and rupture status were included in the model for analysis.nnnRESULTSnIn 10 patients (8%), ICG videoangiography resulted in clip repositioning during surgery. Discordance between ICG videoangiography and postoperative angiography was observed in 5 patients (4%). There was no significant difference of ICG videoangiography-postoperative angiography discordance between ruptured and unruptured aneurysms (P = 0.56). On multivariate analysis, patient age, gender, aneurysm size, and rupture status did not reach significance. Ophthalmic internal carotid artery aneurysms were more likely to have discordance compared with all other aneurysms (P = 0.04; odds ratio, 10.8; confidence interval, 1.5-75.94).nnnCONCLUSIONSnICG videoangiography is a very useful modality for intraoperative assessment of the adequacy of aneurysmal obliteration and patency of parent and perforating vessels. However, ICG videoangiography is not absolutely reliable as a stand-alone method during clipping of ophthalmic artery aneurysms and can be complemented with intraoperative digital subtraction angiography. ICG videoangiography can be used either as an alternative or as a complementary technique to intraoperative digital subtraction angiography during aneurysm surgery.

Successful Treatment of Iatrogenic Vertebral Pseudoaneurysm Using Pipeline Embolization Device

OBJECTnTuberculum sellae meningiomas (TSMs) and diaphragma sellae meningiomas (DSMs) are challenging lesions to treat due to their proximity to neurovascular structures.nnnMETHODSnThe authors reviewed the medical records of patients who underwent surgical excision of TSMs and DSMs from 1990 to 2013. They also describe the technical strategies used to minimize injury to the optic apparatus, vascular structures, and pituitary stalk.nnnRESULTSnTwenty-four patients with TSM and 6 patients with DSM were included in the study. Seventy percent of the tumors were large (≥ 5 cm). The pterional approach was employed in most cases. Optic canal involvement was observed in 4 patients. Twenty-one patients (70%) had visual dysfunction before surgery. At follow-up (median 18 months), visual improvement was noted in 10 (47.6%) of 21 patients. Gross-total excision was achieved in 22 patients (91.6%) with TSM and 5 (83.3%) with DSM. At last follow-up, 28 patients (93.3%) had a Glasgow Outcome Scale score of 5. There were no deaths in this series.nnnCONCLUSIONSnTuberculum and diaphragma sellae meningiomas present a unique subset of tumors due to their location. They can be safely excised with minimal morbidity and mortality using microsurgical techniques. Attention to technical details during surgery leads to greater respectability and superior visual outcome.

Unruptured intracranial aneurysms: Comparison of perioperative complications, discharge disposition, outcome, and effect of calcification, between clipping and coiling: A single institution experience

Backgroundu2003The aim of our study was to compare the area of exposure at the ventral brainstem and petroclival region offered by the Kawase, retrosigmoid transtentorial (RTT), and the retrosigmoid intradural suprameatal (RISA) approaches in cadaveric models. Methodsu2003We performed 15 approaches (five each of the Kawase, RISA, and RTT approaches) on silicone-injected adult cadaver heads. Ventral brainstem and petroclival areas of exposure were measured and compared. Resultsu2003The mean ventral brainstem area exposed by the Kawase approach was 55.00u2009±u200924.1 mm(2), significantly less than that exposed by RTT (441u2009±u200963.3 mm(2)) and RISA (311u2009±u200961 mm(2)) (pu2009<u20090.05). The area of ventral brainstem exposure was significantly more via RTT than through RISA (pu2009=u20090.01). The mean petroclival area of exposure through the Kawase approach was significantly smaller than that obtained through the RTT and RISA approaches (101.7u2009±u2009545.01 mm(2), 696u2009±u200957.7 mm(2), and 716.7u2009±u200951.4 mm(2), respectively). Conclusionu2003Retrosigmoid approaches provide a greater exposure of the brainstem and petroclival areas. The Kawase approach is ideally suited for lesions around the Meckel cave with an extension into the middle fossa. These approaches can be used in conjunction with one another to access petroclival tumors.