Patrick R. Maloney

Increased Operative Time for Benign Cranial Nerve Tumor Resection Correlates with Increased Morbidity Postoperatively

OBJECTIVES Operative time, previously identified as a risk factor for postoperative morbidity, is examined in patients undergoing benign cranial nerve tumor resection. DESIGN/SETTING/PARTICIPANTS This retrospective cohort analysis included patients enrolled in the ACS-NSQIP registry from 2007 through 2013 with a diagnosis of a benign cranial nerve neoplasm. MAIN OUTCOME MEASURES Primary outcomes included postoperative morbidity and mortality. Readmission and reoperation served as secondary outcomes. RESULTS A total of 565 patients were identified. Mean (median) operative time was 398 (370) minutes. The 30-day complication, readmission, and return to the operating room rates were 9.9%, 9.9%, and 7.3%, respectively, on unadjusted analyses. CSF leak requiring reoperation or readmission occurred at a rate of 3.1%. On multivariable regression analysis, operations greater than 413 minutes were associated with an increased odds of overall complication (OR 4.26, 95% CI 2.08-8.72), return to the operating room (OR 2.65, 95% CI 1.23-5.67), and increased length of stay(1.6 days, 95% CI 0.94-2.23 days). Each additional minute of operative time was associated with an increased odds of overall complication (OR 1.004, 95% CI 1.002-1.006) and increased length of stay (0.006 days, 95% CI 0.004-0.008). CONCLUSION Increased operative time in patients undergoing surgical resection of a benign cranial nerve neoplasm was associated with an increased rate of complications.

Full-endoscopic versus micro-endoscopic and open discectomy: A systematic review and meta-analysis of outcomes and complications

OBJECTIVES The purpose of this study was to systematically compare the effectiveness and safety of full-endoscopic discectomy (FED) and micro-endoscopic discectomy (MED) with open discectomy (OD) for the treatment of symptomatic lumbar disc herniation. METHODS Electronic searches were performed using six databases from their inception to February 2016, identifying all relevant randomized controlled trials and comparative observational studies comparing either FED or MED with OD. Data were extracted and analyzed according to predefined clinical endpoints. RESULTS Twenty three studies were selected for analysis, including 421 FED, 6914 MED, and 21,152 OD cases. No significant difference was found between FED and OD in regards to postoperative visual analog scale (VAS) leg pain scores (WMD 0.03, P=0.93). Similar results were obtained for MED vs OD (WMD 0.09, P=0.18). In terms of postoperative Oswestry disability index (ODI), both FED and MED were similar to OD (WMD -2.60, P=0.32 and WMD -1.00, P=0.21, respectively). FED had a significantly shorter operative duration compared to OD (54.6 vs 102.6min, P=0.0001). MED alone and endoscopic approaches overall (including MED and FED) demonstrated significantly lower estimated blood loss (44.3 vs 194.4mL, P=0.03 and 38.2 vs 203.5mL, respectively, both p<0.05). FED alone demonstrated a trend towards lower estimated blood loss in comparison to OD (3.3 vs 244.9mL, P=0.07). No difference was found in overall complications, recurrence or reoperation rates, dural tears, root injury, wound infections, and spondylodiscitis between FED vs OD, or MED vs OD. CONCLUSIONS Based on this meta-analysis, FED and MED appear to be safe and efficacious alternatives to traditional approaches, but these results require further investigation and validation by prospective randomized studies.

Coma and Stroke Following Surgical Treatment of Unruptured Intracranial Aneurysm: An American College of Surgeons National Surgical Quality Improvement Program Study

OBJECTIVE A large national surgical registry was used to establish national benchmarks and associated predictors of major neurologic complications (i.e., coma and stroke) after surgical clipping of unruptured intracranial aneurysms. METHODS The American College of Surgeons National Surgical Quality Improvement Program data set between 2007 and 2013 was used for this retrospective cohort analysis. Demographic, comorbidity, and operative characteristics associated with the development of a major neurologic complication (i.e., coma or stroke) were elucidated using a backward selection stepwise logistic regression analysis. This model was subsequently used to fit a predictive score for major neurologic complications. RESULTS Inclusion criteria were met by 662 patients. Of these patients, 57 (8.61%) developed a major neurologic complication (i.e., coma or stroke) within the 30-day postoperative period. On multivariable analysis, operative time (log odds 0.004 per minute; 95% confidence interval [CI], 0.002-0.007), age (log odds 0.05 per year; 95% CI, 0.02-0.08), history of chronic obstructive pulmonary disease (log odds 1.26; 95% CI, 0.43-2.08), and diabetes (log odds 1.15; 95% CI, 0.38-1.91) were associated with an increased odds of major neurologic complications. When patients were categorized according to quartile of a predictive score generated from the multivariable analysis, rates of major neurologic complications were 1.8%, 4.3%, 6.7%, and 21.2%. CONCLUSIONS Using a large, national multi-institutional cohort, this study established representative national benchmarks and a predictive scoring system for major neurologic complications following operative management of unruptured intracranial aneurysms. The model may assist with risk stratification and tailoring of decision making in surgical candidates.

341 Diabetes Mellitus and Back Pain: Markers of Diabetes Disease Progression Are Associated With Chronic Back Pain.

INTRODUCTION Recent studies suggest that diabetic patients may be more likely to exhibit back pain. Correlating diabetic disease progression to the presence of back pain could provide insight into the relationship between these conditions. METHODS A total of 67 132 patients within our institutional database were identified as having the diagnosis of either diabetes mellitus type I (DMI) or diabetes mellitus type II (DMII). Within this larger cohort, patients diagnosed with chronic back pain (CBP) were identified. In addition, patients with a history of spinal surgery were also identified. Clinical and laboratory measures of diabetic disease burden were then collected on all patients. Multinomial logistic regression analysis using a backward stepwise selection algorithm was then implemented for multivariable analysis to determine whether patient variables were associated with the diagnosis of CBP or history of spinal surgery among diabetic patients. RESULTS On unadjusted analysis, highest recorded values of hemoglobin A1C (HgbA1C), low-density lipoprotein (LDL), triglycerides, and total cholesterol were significantly greater in diabetic patients with CPB and diabetic patients with CBP that underwent spinal surgery. Highest recorded value of high-density lipoprotein (HDL) was significantly lower in diabetic patients with CPB and diabetic patients with CBP that underwent spinal surgery. Highest recorded body mass index (BMI) was also greater in patients with CBP (36.67) and patients with CBP who underwent surgery (36.63) compared with patients without CBP (34.06, P < .001). On multinomial logistic regression analysis, increased age at time of DM diagnosis, increased duration of time with DM, presence of hypertension, presence of neuropathy, increased BMI, increased levels of HgbA1C, LDL, and triglycerides, and decreased levels of HDL were independently associated with the presence of CBP. CONCLUSION Our results suggest that markers of diabetes disease progression are associated with the presence of back pain, suggesting that uncontrolled DM may be a contributing factor to the development of CBP.INTRODUCTION:Recent studies suggest that diabetic patients may be more likely to exhibit back pain. Correlating diabetic disease progression to the presence of back pain could provide insight into the relationship between these conditions.METHODS:A total of 67 132 patients within our institutional d

199 Multiple Concussions in Young Athletes: Identifying Patients at Risk for Repeat Injury

INTRODUCTION Concussion diagnosis and management is a topic of interest for health care, education, and government professionals. Given the evidence concerning the association of long-term effects and cumulative insult of multiple concussions, we sought to identify risk factors in young athletes for repeat injury. METHODS This study is a retrospective cohort analysis of our institutions series of pediatric sports related concussions. Patient demographics, characteristics, and clinical features of concussion were analyzed in an unadjusted fashion. Bivariate analysis examined these variables in relation to occurrence of subsequent concussion. Multivariable analysis was then used to evaluate for predictors of repeat injury. RESULTS One hundred ninety-one patients with a mean age of 13.5 years were included for analysis. Relative to patients whose injury was associated with football, patients playing soccer (odds ratio [OR], 5.36; 95% confidence interval [CI], 1.18-24.5), ice hockey/skating (OR, 6.97; 95% CI, 1.60-30.37), and basketball (OR, 5.99; 95% CI, 1.23-29.07) were associated with a significant increased odds of having a subsequent concussion. History of prior concussion was also significantly associated with an increased odds of repeat injury following the index concussion, defined as the first concussion evaluated at our institution (OR, 12.54; 95% CI, 3.78-41.62). Relative to a concussion resulting from a mechanism involving blunt force to the head, patients with a concussion in the setting of a fall were significantly less likely to experience a subsequent concussion (OR, 0.19; 95% CI, 0.05-0.71). CONCLUSION Efforts to protect young athletes are of immeasurable value given the potential life years at risk for productivity and quality of life. With the identification of specific sports, prior injury, and mechanism influencing risk of repeat injury, clinicians are more informed to assess and discuss both risk and potential consequences of concussions with young athletes and their families.

Risk factors for dural tears: a study of elective spine surgery*

Abstract Objective: This study moves beyond previous cohort studies and benchmark data by studying a population of elective spine surgery from a multicenter registry in an effort to validate, disprove, and/or identify novel risk factors for dural tears. Methods: A retrospective cohort analysis queried a multicenter registry for patients with degenerative spinal diagnoses undergoing elective spinal surgery from 2010–2014. Multivariable logistic regression analysis interrogated for independent risk factors of dural tears. Results: Of 104,930 patients, a dural tear requiring repair occurred in 0.6% of cases. On adjusted analysis, the following factors were independently associated with increased likelihood of a dural tear: ankylosing spondylitis vs. intervertebral disc disorders, greater than two levels, combined surgical approach and posterior approach vs. anterior approach, decompression only vs. fusion and decompression, age groups 85+, 75–84 and 65–74 vs. <65, obesity (BMI ≥30), corticosteroid use and preoperative platelet count <150,000. Conclusions: This multicenter study identifies novel risk factors for dural tears in the elective spine surgery population, including corticosteroids, thrombocytopenia, and ankylosing spondylitis. The results of this analysis provide further information for surgeons to use both in operative planning and in preoperative counseling when discussing the risk of dural tears.

Postoperative Delayed Cervical Palsies: Understanding the Etiology

Study Design Retrospective study. Objective This study reviews 1,768 consecutive cervical decompressions with or without instrumented fusion to identify patient-specific and procedural risk factors significantly correlated with the development of delayed cervical palsy (DCP). Methods Baseline demographic and procedural information was collected from the electronic medical record. Particular attention was devoted to reviewing each chart for recognized risk factors of postsurgical inflammatory neuropathy: autoimmune disease, blood transfusions, diabetes, and smoking. Results Of 1,669 patients, 56 (3.4%) developed a DCP. Although 71% of the palsies involved C5, 55% of palsies were multimyotomal and 18% were bilateral. Significant risk factors on univariate analysis included age (p = 0.0061, odds ratio [OR] = 1.07, 95% confidence interval [CI] 1.008 to 1.050), posterior instrumented fusion (p < 0.0001, OR = 3.30, 95% CI 1.920 to 5.653), prone versus semisitting/sitting position (p = 0.0036, OR = 3.58, 95% CI 1.451 to 11.881), number of operative levels (p < 0.0001, OR = 1.42, 95% CI 1.247 to 1.605), intraoperative transfusions (p = 0.0231, OR = 2.57, 95% CI 1.152 to 5.132), and nonspecific autoimmune disease (p = 0.0107, OR = 3.83, 95% CI 1.418 to 8.730). On multivariate analysis, number of operative levels (p = 0.0053, OR = 1.27, 95% CI 1.075 to 1.496) and nonspecific autoimmune disease (p = 0.0416, OR 2.95, 95% CI 1.047 to 7.092) remained significant. Conclusions Although this study partially supports a mechanical etiology in the pathogenesis of a DCP, we also describe a notable correlation with autoimmune risk factors. Bilateral and multimyotomal involvement provides additional support that some DCPs may result from an inflammatory response and thus an underlying multifactorial etiology for this complication.

Quantitative analysis of the effect of institutional case volume on complications after surgical clipping of unruptured aneurysms

OBJECTIVE The mechanism by which greater institutional case volume translates into improved outcomes after surgical clipping of unruptured intracranial aneurysms (UIAs) is not well established. The authors thus aimed to assess the effect of case volume on the rate of various types of complications after clipping of UIAs. METHODS Using information on the outcomes of inpatient admissions for surgical clipping of UIAs collected within a national database, the relationship of institutional case volume to the incidence of different types of complications after clipping was investigated. Complications were subdivided into different categories, which included all complications, ischemic stroke, intracerebral hemorrhage, medical complications, infectious complications, complications related to anesthesia, and wound complications. The relationship of case volume to different types of complications was assessed using linear regression analysis. The relationships between case volume and overall complication and stroke rates were fit with both linear and quadratic equations. The numerical cutoff for institutional case volume above and below which the authors found the greatest differences in mean overall complication and stroke rate was determined using classification and regression tree (CART) analysis. RESULTS Between October 2012 and September 2015, 125 health care institutions reported patient outcomes from a total of 6040 cases of clipping of UIAs. On linear regression analysis, increasing case volume was negatively correlated to both overall complications (r2 = 0.046, p = 0.0234) and stroke (r2 = 0.029, p = 0.0557) rate, although the relationship of case volume to the complication (r2 = 0.092) and stroke (r2 = 0.067) rate was better fit with a quadratic equation. On CART analysis, the cutoff for the case number that yielded the greatest difference in overall complications and stroke rate between higher- or lower-volume centers was 6 cases/year and 3 cases/year, respectively. CONCLUSIONS Although the authors confirm that increasing case volume is associated with reduced complications after clipping of UIAs, their results suggest that the relationship between case volume and complications is not necessarily linear. Moreover, these results indicate that the effect of case volume on outcome is most evident between very-low-volume centers relative to centers with a medium-to-high volume.

Predictors of discharge to a nonhome facility in patients undergoing lumbar decompression without fusion for degenerative spine disease

BACKGROUND Patients recovering from decompressive laminectomy without fusion may require assistance with activities of daily living and physical/occupational therapy upon hospital discharge. OBJECTIVE To examine comorbidities and perioperative characteristics of patients undergoing lumbar decompression for associations with discharge status using a multicenter database. METHODS A multicenter database was used for this retrospective cohort analysis. Patients admitted from home with degenerative spine disease for lumbar decompression without fusion were included. Thirty-day outcomes and operative characteristics were compared as a function of patient discharge using chi-square and Wilcoxon Rank Sum tests. Multivariable logistic regression was used to determine factors associated with discharge to a nonhome facility. RESULTS Of the 8627 patients included for analysis, 9.7% were discharged to a nonhome facility. On multivariable analysis, age (85+ vs <65, odds ratio [OR] 13.59), number of levels of decompression (3+ vs 1, OR 1.75), African American race vs Non-Hispanic or Hispanic White (OR 1.87), female vs male gender (OR 1.97), body mass index (BMI) (40+ vs 18.5-24.9, OR 1.74), American Society of Anesthesiologists physical classification status (4 vs 1 or 2, OR 2.35), hypertension (OR 1.29), dependent functional status (OR 3.92), diabetes (OR 1.47), smoking (OR 1.40), hematocrit (<35 vs 35+, OR 1.76), international normalized ratio (≥1.3 vs <1.3, OR 2.32), and operative time (3+ h vs <1 h, OR 5.34) were significantly associated with an increased odds of discharge to nonhome facilities. CONCLUSION Preoperative status and operative course variables can influence discharge disposition in lumbar decompression patients. Identifying specific factors that contribute to a greater likelihood of dismissal to skilled facility or rehabilitation unit can further inform both surgeons and patients during preoperative counseling and disposition planning.

Skull base plasmacytoma: A unique case of POEMS syndrome with a plasmacytoma causing craniocervical instability

INTRODUCTION Plasmacytomas, considered to be the solitary counterparts of multiple myeloma, are neoplastic monoclonal plasma cell proliferations within soft tissue or bone. Plasmacytomas often present as a collection of findings known as POEMS-syndrome (Polyneuropathy, Organomegaly, Endocrinopathy, M-Protein spike, and Skin changes). CASE DESCRIPTION We present a report of a 47 yo male diagnosed with POEMS-syndrome secondary to a skull base plasmacytoma. The mass resulted in marked instability of the cranio-cervical junction due to bony erosion. Following an induction course of chemotherapy, he showed clinical improvement with a marked reduction in tumor size and underwent an autologous peripheral blood stem cell transplant for systemic treatment of his POEMS-syndrome. Following completion of systemic treatment, he then underwent a definitive occipital-cervical fusion without complications. His neurologic exam upon dismissal was stable with subjective improvement in left upper extremity strength. Postoperative radiographs confirmed spinal alignment and pathological examination of a small biopsy from C1 revealed benign fibrous tissue. CONCLUSION To the best of our knowledge, this is the first report of a skull-base plasmacytoma associated with POEMS-syndrome, causing cranio-cervical instability. The approach of systemic therapy combined with temporary external fixation, followed by definitive occipital cervical fusion resulted in a good outcome for this patient.