Mitchell Maltenfort

Hypofractionated Stereotactic Radiation Therapy: An Effective Therapy for Recurrent High-Grade Gliomas

PURPOSE Salvage options for recurrent high-grade gliomas (HGGs) are limited by cumulative toxicity and limited efficacy despite advances in chemotherapeutic and radiotherapeutic techniques. Previous studies have reported encouraging survival results and favorable toxicity with fractionated stereotactic radiotherapy, and small studies have shown similar benefit using a shortened course of hypofractionated stereotactic radiation therapy (H-SRT). We sought to determine the efficacy and toxicity profile of H-SRT alone or in addition to repeat craniotomy or concomitant chemotherapy. PATIENTS AND METHODS Between 1994 and 2008, 147 patients with recurrent HGG were treated with H-SRT (median dose, 35 Gy in 3.5-Gy fractions). Cox regression models were used to analyze survival outcomes. Variables included age, surgery before H-SRT, time to first recurrence, reirradiation dose, inclusion of chemotherapy with H-SRT, and gross tumor volume (GTV). RESULTS Younger age (P = .001), smaller GTV (P = .025), and shorter time between diagnosis and recurrence (P = .034) were associated with improvement in survival from H-SRT. Doses of radiation > or = 35 Gy approached significance (P = .07). There was no significant benefit of surgical resection or chemotherapy in this population when analysis was controlled for other prognostic factors. CONCLUSION H-SRT was well tolerated and resulted in a median survival time of 11 months after H-SRT, independent of re-operation or concomitant chemotherapy. Patients who experienced recurrence within 6 months after initial treatment had an excellent response and should not be disqualified from H-SRT. This is the largest series to examine the efficacy and tolerability of H-SRT in recurrent HGG.

Effect of early surgery, material, and method of flap preservation on cranioplasty infections: a systematic review.

BACKGROUND:Infection is a significant cause of morbidity with cranioplasty procedures. However, few studies have investigated the effect of specific surgical practices on cranioplasty infection. OBJECTIVE:To analyze the literature on the effect of early surgery (within 3 months of craniectomy), implant material, and method of flap preservation on cranioplasty infections, and to perform a subanalysis of the effect of early surgery on overall complications associated with cranioplasty. METHODS:A systematic search of the PubMed, Cochrane, SCOPUS, and CINAHL databases was conducted. Comparative studies that reported on timing of surgery, implant material (autograft vs allograft), or method of flap preservation (subcutaneous vs extracorporeal), and infection or complication rates were selected for detailed analysis. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for each analysis. RESULTS:Eighteen articles (2254 data points) met criteria for inclusion. There was no difference in infection rates (OR, 1.35; 95% CI, 0.53-3.41; P = .53) or overall complication rates (OR, 0.57; 95% CI, 0.29-1.11; P = .10) between early or later surgery. Fourteen studies (n = 1582) compared infection rates between autograft and allograft materials; there was no difference in infection rates between the two (OR, 0.81; 95% CI, 0.40-1.66; P = .57). There was no significant difference in infection rates between subcutaneous or extracorporeal preservation (OR, 0.35; 95% CI, 0.09-1.35; P = .13). CONCLUSION:Analysis of the best current evidence suggests that early surgery, implant material, and method of flap preservation have no effect on the rate of cranioplasty infections.

Comparison of ICD-9–based, retrospective, and prospective assessments of perioperative complications: assessment of accuracy in reporting

OBJECT large studies of ICD-9-based complication and hospital-acquired condition (HAC) chart reviews have not been validated through a comparison with prospective assessments of perioperative adverse event occurrence. Retrospective chart review, while generally assumed to underreport complication occurrence, has not been subjected to prospective study. It is unclear whether ICD-9-based population studies are more accurate than retrospective reviews or are perhaps equally susceptible to bias. To determine the validity of an ICD-9-based assessment of perioperative complications, the authors compared a prospective independent evaluation of such complications with ICD-9-based HAC data in a cohort of patients who underwent spine surgery. For further comparison, a separate retrospective review of the same cohort of patients was completed as well. METHODS a prospective assessment of complications in spine surgery over a 6-month period (May to December 2008) was completed using an independent auditor and a validated definition of perioperative complications. The auditor maintained a prospective database, which included complications occurring in the initial 30 days after surgery. All medical adverse events were included in the assessment. All patients undergoing spine surgery during the study period were eligible for inclusion; the only exclusionary criterion used was the availability of the auditor for patient assessment. From the overall patient database, 100 patients were randomly extracted for further review; in these patients ICD-9-based HAC data were obtained from coder data. Separately, a retrospective assessment of complication incidence was completed using chart and electronic medical record review. The same definition of perioperative adverse events and the inclusion of medical adverse events were applied in the prospective, ICD-9-based, and retrospective assessments. RESULTS ninety-two patients had adequate records for the ICD-9 assessment, whereas 98 patients had adequate chart information for retrospective review. The overall complication incidence among the groups was similar (major complications: ICD-9 17.4%, retrospective 19.4%, and prospective 22.4%; minor complications: ICD-9 43.8%, retrospective 31.6%, and prospective 42.9%). However, the ICD-9-based assessment included many minor medical events not deemed complications by the auditor. Rates of specific complications were consistently underreported in both the ICD-9 and the retrospective assessments. The ICD-9 assessment underreported infection, the need for reoperation, deep wound infection, deep venous thrombosis, and new neurological deficits (p = 0.003, p < 0.0001, p < 0.0001, p = 0.0025, and p = 0.04, respectively). The retrospective review underestimated incidences of infection, the need for revision, and deep wound infection (p < 0.0001 for each). Only in the capture of new cardiac events was ICD-9-based reporting more accurate than prospective data accrual (p = 0.04). The most sensitive measure for the appreciation of complication occurrence was the prospective review, followed by the ICD-9-based assessment (p = 0.05). CONCLUSIONS an ICD-9-based coding of perioperative adverse events and major complications in a cohort of spine surgery patients revealed an overall complication incidence similar to that in a prospectively executed measure. In contrast, a retrospective review underestimated complication incidence. The ICD-9-based review captured many medical events of limited clinical import, inflating the overall incidence of adverse events demonstrated by this approach. In multiple categories of major, clinically significant perioperative complications, ICD-9-based and retrospective assessments significantly underestimated complication incidence. These findings illustrate a significant potential weakness and source of inaccuracy in the use of population-based ICD-9 and retrospective complication recording.

Association between hyperoxia and mortality after stroke: a multicenter cohort study.

Objective:To test the hypothesis that hyperoxia was associated with higher in-hospital mortality in ventilated stroke patients admitted to the ICU. Design:Retrospective multicenter cohort study. Setting:Primary admissions of ventilated stroke patients with acute ischemic stroke, subarachnoid hemorrhage, and intracerebral hemorrhage who had arterial blood gases within 24 hours of admission to the ICU at 84 U.S. ICUs between 2003 and 2008. Patients were divided into three exposure groups: hyperoxia was defined as PaO2 ≥300 mm Hg (39.99 kPa), hypoxia as any PaO2<60 mm Hg (7.99 kPa) or PaO2/FiO2 ratio ⩽300, and normoxia, not defined as hyperoxia or hypoxia. The primary outcome was in-hospital mortality. Participants:Two thousand eight hundred ninety-four patients. Methods:Patients were divided into three exposure groups: hyperoxia was defined as PaO2 more than or equal to 300 mm Hg (39.99 kPa), hypoxia as any PaO2 less than 60 mm Hg (7.99 kPa) or PaO2/FIO2 ratio less than or equal to 300, and normoxia, not defined as hyperoxia or hypoxia. The primary outcome was in-hospital mortality. Interventions:Exposure to hyperoxia. Results:Over the 5-year period, we identified 554 ventilated patients with acute ischemic stroke (19%), 936 ventilated patients with subarachnoid hemorrhage (32%), and 1,404 ventilated patients with intracerebral hemorrhage (49%) of whom 1,084 (38%) were normoxic, 1,316 (46%) were hypoxic, and 450 (16%) were hyperoxic. Mortality was higher in the hyperoxia group as compared with normoxia (crude odds ratio 1.7 [95% CI 1.3-2.1]; p < 0.0001) and hypoxia groups (crude odds ratio, 1.3 [95% CI, 1.1–1.7]; p < 0.01). In a multivariable analysis adjusted for admission diagnosis, other potential confounders, the probability of being exposed to hyperoxia, and hospital-specific effects, exposure to hyperoxia was independently associated with in-hospital mortality (adjusted odds ratio, 1.2 [95% CI, 1.04–1.5]). Conclusion:In ventilated stroke patients admitted to the ICU, arterial hyperoxia was independently associated with in-hospital death as compared with either normoxia or hypoxia. These data underscore the need for studies of controlled reoxygenation in ventilated critically ill stroke populations. In the absence of results from clinical trials, unnecessary oxygen delivery should be avoided in ventilated stroke patients.

Early complications of surgical versus conservative treatment of isolated type II odontoid fractures in octogenarians: A retrospective cohort study

Study Design A retrospective cohort study of operative versus nonoperative treatment of isolated type II odontoid fractures in patients aged 80 years and more without neurologic deficit admitted to a level 1 spinal cord injury center between June 1985 and July 2006. Objective To assess the presentation and acute complications of operatively and nonoperatively managed type II odontoid fractures in the octogenarian population. Summary of Background Data Type II odontoid fractures are the most common cervical spine fracture in the elderly. Studies suggest acute in-hospital complication rates in type II odontoid fractures in the elderly exceed 50%. Few studies have examined the acute in-hospital outcomes of isolated type II odontoid fractures in the octogenarian population. Methods The medical records of 223 consecutive C2 fractures from June 1985 to July 2006 over the age of 80 years were reviewed retrospectively. Patients with associated cervical spine fractures were excluded. Eighty neurologically intact patients over age 80 were identified with isolated acute type II odontoid fractures. The charts were reviewed and mechanism of injury, comorbidities, date of injury, date of admission, date of discharge, radiology reports, discharge disposition, associated injuries, fracture management, type of surgical fixation (if any), and documented complications were abstracted. Results Thirty-two patients received operative treatment (10 anterior and 22 posterior) and 40 patients received nonsurgical treatment. Eight patients were excluded because the medical record could not be located. The mean age was 85.5±3.5 years in the surgical and 87.3±4.7 years in the nonsurgical group (P>0.05); mean length of acute hospital stay was 11.2±8.5 days in the nonsurgical and 22.8±28.3 days in the surgical group (P<0.05); mean comorbidity score was 2.3±1.2 in the nonsurgical and 2.0±1.0 in the surgical group (P>0.5); mean fracture displacement was 4.1±3.5 mm in the nonsurgical and 3.9±3.4 mm in the surgical group (P>0.5). Acute in-hospital mortality rate was 15% in the nonsurgical group and 12.5% in the surgical group (P>0.05). The percentage of patients experiencing at least one significant complication was higher in the operative group than the nonoperative group (62% vs. 35%, respectively, P<0.05). Conclusions Type II odontoid fractures in the octogenarian population are associated with substantial morbidity and mortality, irrespective of management method. Prospective studies are needed to better elucidate management strategies for this difficult clinical problem.

Risk factors for surgical site infections following spinal fusion procedures: a case-control study.

BACKGROUND Spinal fusion procedures are associated with a significant rate of surgical site infection (SSI) (1%-12%). The goal of this study was to identify modifiable risk factors for spinal fusion SSIs at a large tertiary care center. METHODS A retrospective, case-control (1:3 ratio) analysis of SSIs following posterior spine fusion procedures was performed over a 1-year period. Clinical and surgical data were collected through electronic database and chart review. Variables were evaluated by univariate analysis and multivariable logistic regression. RESULTS In total, 57 deep SSIs were identified out of 1587 procedures (3.6%). Infections were diagnosed a mean of 13.5 ± 8 days postprocedure. Staphylococcus aureus was the predominant pathogen (63%); 1/3 of these isolates were methicillin resistant. Significant patient risk factors for infection by univariate analysis included ASA score >2 and male gender. Among surgical variables, infected cases had significantly higher proportions of staged procedures and thoracic level surgeries and had a greater number of vertebrae fused. Notably, infected fusion procedures had a longer duration of closed suction drains than controls (5.1 ± 2 days vs 3.4 ± 1 day, respectively; P < .001). Drain duration (unit odds ratio [OR], 1.6 per day drain present; 95% confidence interval [CI], 1.3-1.9), body mass index (OR, 1.1; 95% CI, 1.0-1.1), and male gender (OR, 2.7; 95% CI, 1.4-5.6) were significant risk factors in the multivariate analysis. CONCLUSIONS Prolonged duration of closed suction drains is a strong independent risk factor for SSI following instrumented spinal fusion procedures. Therefore, removing drains as early as possible may lower infection rates.

Mortality rates in geriatric patients with spinal cord injuries

OBJECT The authors undertook this study to evaluate the incidence of spinal cord injury (SCI) in geriatric patients (> or = 70 years of age) and examine the impact of patient age, extent of neurological injury, and spinal level of injury on the mortality rate associated with traumatic SCI. METHODS A prospectively maintained SCI database (3481 patients) at a single institution was retrospectively studied for the period from 1978 through 2005. Parameters analyzed included patient age, admission American Spinal Injury Association (ASIA) motor score, level of SCI, mechanism of injury, and mortality data. The data pertaining to the 412 patients 70 years of age and older were compared with those pertaining to the younger cohort using a chi-square analysis. RESULTS Since 1980, the number of SCI-related hospital admissions per year have increased fivefold in geriatric patients and the percentage of geriatric patients within the SCI population has increased from 4.2 to 15.4%. In comparison with younger patients, geriatric patients were found to be less likely to have severe neurological deficits (greater percentage of ASIA Grades C and D injuries), but the mortality rates were higher in the older age group both for the period of hospitalization (27.7% compared with 3.2%, p < 0.001) and during 1-year follow-up. The mortality rates in this older population directly correlate with the severity of neurological injury (1-year mortality rate, ASIA Grade A 66%, Grade D 23%, p < 0.001). The mortality rate in elderly patients with SCI has not changed significantly over the last two decades, and the 1-year mortality rate was greater than 40% in all periods analyzed. CONCLUSIONS Spinal cord injuries in older patients are becoming more prevalent. The mortality rate in this patient group is much greater than in younger patients and should be taken into account when aggressive interventions are considered and in counseling families regarding prognosis.

Obesity and spine surgery: reassessment based on a prospective evaluation of perioperative complications in elective degenerative thoracolumbar procedures

BACKGROUND CONTEXT The correlation between obesity and incidence of complications in spine surgery is unclear, with some reports suggesting linear relationships between body mass index (BMI) and complication incidence and others noting no relationship. PURPOSE The purpose of this article was to assess the relationship between obesity and occurrence of perioperative complications in an elective thoracolumbar surgery cohort. STUDY DESIGN/SETTING Prospective observational cohort study at a tertiary care facility. PATIENT SAMPLE Cohort of 87 consecutive patients undergoing elective surgery for degenerative thoracolumbar pathologies over a 6-month period (May to December 2008). OUTCOME MEASURES Incidence of perioperative complications (those occurring within 30 days of surgery). METHODS A prospective assessment of perioperative spine surgery complications was completed, and data were prospectively entered into a central database. Two independent auditors assessed for the presence and severity of perioperative complications. Previously validated binary definitions of major and minor complications were used. Patient data and early complications (those occurring within 30 days of index surgery) were analyzed using multivariate regression. RESULTS Mean BMI in this cohort was 31.3; 40.8% of patients were obese (BMI>30) and 10 patients (11.5%) were morbidly obese (BMI>40). The overall complication incidence was 67%. Minor complications occurred in 50% of patients, and major complications occurred in 17.8% of patients. No positioning palsies occurred in this series. Age correlated with an increase in complication risk (p=.006) as did hypertension (p=.004) and performance of a fusion (p<.0001). BMI did not correlate with the incidence of minor, major, or any complications (p=.58). CONCLUSIONS This prospective assessment of perioperative complications in elective degenerative thoracolumbar procedures shows no relationship between patient BMI and the incidence of perioperative minor or major complications. Specific care in perioperative positioning may limit the risk of perioperative positioning palsies in obese patients.

Stent-assisted coiling of wide-necked aneurysms in the setting of acute subarachnoid hemorrhage: experience in 65 patients.

BACKGROUND Stent-assisted coiling in the setting of subarachnoid hemorrhage remains controversial. Currently, there is a paucity of data regarding the utility of this procedure and the risks of hemorrhagic and ischemic complications. OBJECTIVE To assess the utility of stent-assisted coil embolization and pretreatment with antiplatelet agents in the management of ruptured wide-necked aneurysms. METHODS A retrospective study of 65 patients with ruptured wide-necked aneurysms treated with stent-assisted coiling. Patients with hydrocephalus or a Hunt and Hess grade ≥ III received a ventriculostomy before endovascular intervention. Patients were treated intraoperatively with 600 mg of clopidogrel and maintained on daily doses of 75 mg of clopidogrel and 81 mg of aspirin. The Glasgow outcome scale (GOS) score was recorded at the time of discharge. We identified major bleeding complications secondary to antiplatelet therapy and cases of in-stent thrombosis that required periprocedural thrombolysis. RESULTS Of the aneurysms, 66.2% arose within the anterior circulation; 69.2% of patients presented with hydrocephalus or a Hunt and Hess grade ≥ III and required a ventriculostomy. A good outcome (GOS of 4 or 5) was achieved in 63.1% of patients, and the overall mortality rate was 16.9%. There were 10 (15.38%) major complications associated with bleeding secondary to antiplatelet therapy (5 patients, 7.7%) or intraoperative in-stent thrombosis (5 patients, 7.7%). Three (4.6%) patients had a fatal hemorrhage. CONCLUSION Our findings suggest that stent-assisted coiling and routine treatment with antiplatelet agents is a viable option in the management of ruptured wide-necked aneurysms.

Trends in epidemiology and management of type II odontoid fractures: 20-year experience at a model system spine injury tertiary referral center.

Study Design A retrospective cohort study of consecutive type II Odontoid fractures presenting to a Level 1 Regional Model Systems Spinal Cord Injury Center between June 1985 and July 2006. Objective To assess trends in management of type II Odontoid fractures presenting to a Level 1 Model Systems Regional Spinal Cord Injury Center over a 20-year period. Summary of Background Data Type II Odontoid fracture management is controversial, and a majority of studies have had relatively small cohorts. There is no consensus regarding definitive treatment, particularly in older patients. Methods Medical records of 263 consecutive type II Odontoid fractures from June 1985 to July 2006 were retrospectively reviewed. Patients were excluded if they had neurologic deficits, nonacute fracture, or ambiguous fracture classification. A cohort of 192 neurologically intact, acute type II odontoid fractures were identified. Admission records were reviewed for age, date of injury, date of admission, date of discharge, mechanism of injury, associated injuries, medical comorbidities, and radiologic findings. Results There was a statistically significant increase in the rate of presentation of type II odontoid fractures with time. The average age and medical comorbidities of the patient did not change over time. The probability of operative management markedly increased over time, corresponding to a statistically significant increase in length of hospital stay for patients undergoing surgery. The discharge disposition correlated significantly to both age of the patient and associated injuries. Conclusions The number and frequency of type II odontoid fractures compared with other spine injuries seems to be increasing over the last 2 decades, which may be correlated with the increasing number of elderly persons in the population, given that referral patterns have been unchanged at our institution. Prospective outcomes data are needed to better elucidate optimal treatment algorithms from both, an outcomes and cost-efficacy perspective.