Piyush Kalakoti

Inpatient Outcomes and Postoperative Complications After Primary Versus Revision Lumbar Spinal Fusion Surgeries for Degenerative Lumbar Disc Disease: A National (Nationwide) Inpatient Sample Analysis, 2002–2011

INTRODUCTIONnThe present study investigates outcomes in patients undergoing elective primary versus revision fusion surgery for lumbar degenerative pathologies with the use of a large population based database.nnnMETHODSnA total of 126,044 patients registered in the National Inpatient Sample (NIS) database were identified to have undergone elective fusion of the lumbar spine (primary fusion: 94%; redo fusion: 6%) for degenerative pathologies, between 2002 and 2011. A multivariable logistic regression model was built that adjusted for patient demographics and clinical and hospital characteristics to explore clinical outcomes and postoperative complications.nnnRESULTSnThe mean age of the cohort was 54.91 ± 13.98 years, and 58% were women. Multivariable regression analysis revealed patients undergoing redo lumbar fusion had a greater likelihood for an unfavorable discharge (odds ratio [OR] 1.17; 95% confidence interval [95% CI] 1.08-1.26; P < 0.0001), prolonged length of stay (OR: 1.80; 95% CI 1.68-1.92; P < 0.0001), greater hospital charges (OR 1.60; 95% CI 1.51-1.71; P < 0.0001), neurologic complications including dural tears and nerve root injuries (OR 2.06; 95% CI 1.80-2.37; P < 0.0001), deep venous thrombosis (OR 2.35; 95% CI 1.76-3.14; P < 0.0001), pulmonary embolism (OR 1.72; 95% CI 1.45-2.03; P < 0.0001), would infections (OR 2.40; 95% CI 1.79-3.22; P < 0.0001) and wound complications (OR 1.59; 95% CI 1.32-1.91; P < 0.0001), and gastrointestinal complications (OR 1.23; 95% CI 1.04-1.45; P = 0.016), compared with patients undergoing a primary lumbar fusion procedure.nnnCONCLUSIONSnThe association of a likely postoperative complication in patients undergoing revision lumbar spine fusion compared with those undergoing primary fusion procedures at the same region of the spine is quantified. Our analysis provides baseline estimates that could aid in preoperative risk stratification and as an adjunct in patient education and counseling, and policy makers for higher reimbursements for these sicker patients.

Pattern of injury in fatal road traffic accidents in a rural area of western Maharashtra, India

BACKGROUNDnFatal road traffic accidents (RTA) are a major cause of concern all over the world. The outcome of injuries sustained in an RTA depends on various factors including but not limited to: the location of the event, type of vehicle involved, nature of the roads, the time of accident, etc.nnnAIMSnThis study aims to investigate and evaluate prospectively the socio-demographic profile and pattern of injuries in victims of RTA in the rural area of the Ahmedanagar district of Maharashtra state.nnnMETHODnThis prospective study included all victims of RTA that presented to our emergency room from 1 June 2007 to 31 May 2009 and were either found dead on arrival or died during treatment. All the victims were autopsied at the post-mortem centre of Rural Medical College, Loni.nnnRESULTSnNinety-eight RTA victims were studied during the period. The most commonly affected age group was 20-39 years. Men died in RTA more than women. Fatal RTA were more prevalent on the secondary road system (47.97 per cent) and especially involved pedestrian and two wheeler vehicle users. Large numbers (n=63, 64.28%) of victims either died on the scene or during transportation. Numbers of skeletal injuries (199) and internal organ injuries (202) exceeded the total number of victims (98) clearly indicating the multiplicity of injuries. The majority of RTA victims (n=46, 46.93%) died due to head injury. The study showed that most deaths in RTA, brought to a tertiary care rural hospital, took place either on the spot or within 24 hours of injury which is very alarming and highlights the need to take urgent steps to establish good pre-hospital care and provision of trauma services at site.nnnCONCLUSIONnA computerised trauma registry is urgently needed to highlight risk factors, circumstances and chains of events leading to accidents. This would be extremely helpful in policy making and health management in India.

Endoscopic Endonasal versus Microsurgical Transsphenoidal Approach for Growth Hormone–Secreting Pituitary Adenomas—Systematic Review and Meta-Analysis

BACKGROUNDnThe pituitary adenoma causing acromegaly is typically resected through a transsphenoidal approach and visualized with an operating microscope or endoscope. We undertook a systematic review and meta-analysis examining the clinical efficacy of endoscopic and microsurgical approaches.nnnMETHODSnRelevant studies using either endoscopic or microscopic transsphenoidal approaches for growth hormone pituitary adenomas were identified until February 2016. Data were extracted and analyzed according to predefined clinical end points.nnnRESULTSnWe identified 31 studies, in which 950 patients underwent endoscopic transsphenoidal resection and 2137 patients underwent microsurgical transsphenoidal resection. Patients undergoing microsurgery were less likely to present with hypothyroidism (10.7% vs. 19.1%, Pxa0= 0.033, 462 vs. 156 patients) and less likely to have macroadenomas (66.9% vs. 83.8%, P ≤ 0.001, 1484 vs. 884 patients); adenomas with cavernous sinus invasion (21.3% vs. 44.4%, Pxa0= 0.036, 592 vs. 558 patients); and a lower mean tumor volume (17.84 vs. 20.54 mm3, Pxa0= 0.012, 158 vs. 248 patients). Patients treated via the endoscopic approach were more likely to achieve remission for noninvasive macroadenomas (83.8% vs. 66.9%, P ≤ 0.001, 115 vs. 365 patients). Sinusitis (15.6% vs. 2.6%, P < 0.001, 241 vs. 295 patients) and intraoperative cerebrospinal fluid leak (21.6% vs. 1.0%, Pxa0= 0.022, 697 vs. 127 patients) were more common in patients treated endoscopically, and meningitis (0.7% vs. 1.7%, Pxa0= 0.027, 511 vs. 1513 patients) was more common in patients undergoing a microsurgical approach.nnnCONCLUSIONSnOur study shows the clinical utility of the endoscopic approach and demonstrates potential benefits including increased remission rates with noninvasive macroadenomas and a lower rate of meningitis.

Outcome of resection of WHO Grade II meningioma and correlation of pathological and radiological predictive factors for recurrence

This study investigated whether extent of surgical resection (Simpson and Shinshu grade) along with pathological and radiological factors influence the tumor control and recurrence-free survival (RFS) of patients with World Health Organization (WHO) grade II meningiomas. The clinical, radiological and surgical notes on the 59 patients with WHO grade II meningioma managed at our institution over 20years were retrospectively reviewed. In this study, median survival time was 41months. The overall recurrence rate in Simpson grades I and II resection was 31%. In grades III and IV, the overall recurrence rate was 73%, and this high recurrence rate in these groups was confined within 5years. In Cox regression analysis, combined data of grades (I and II)/complete resection showed a significant difference in RFS compared to grades (III and IV)/subtotal resection (p=0.0001). A similar trend of RFS (p=0.0001) was observed with the Shinshu grading system of resection. In addition, a Ki-67% marker for proliferation less than 15% (p=0.029), absence of certain radiological features including heterogeneous enhancement, cyst formation and peritumoral edema (p=0.006), and repeat surgery for recurrent meningioma was associated with better survival (p=0.014). However, radiosurgery did not have a beneficial role in the treatment of recurrence of atypical meningioma. The Simpson grading system is the primary predictor of recurrence of WHO grade II meningioma after resection. In addition, certain pathological and radiological features need to be considered as possible factors of recurrence after resection. Lastly, depending on the likely risks and surgical morbidity, repeat surgical resection should be performed for recurrent atypical meningioma.

Outcome of ventriculoperitoneal shunt and predictors of shunt revision in infants with posthemorrhagic hydrocephalus.

ObjectVentriculoperitoneal (VP) shunts in infants with posthemorrhagic hydrocephalus (PHH) are prone to failures, with some patients at risk for multiple revisions. The objective of our study is to observe long-term outcomes and identify factors leading to proximal and distal multiple failures.MethodsWe performed a retrospective review of infants with PHH that required VP shunt placement between 1982 and 2014. These patients were monitored clinically and radiographically after VP shunt placement.ResultsA total of 502 surgical procedures (initial shunt insertion and revisions) were performed, with 380 shunt revisions in 102 (84xa0%) patients. Median shunt survival time was 54xa0months (0.03–220xa0months). Shunt survival was significantly affected by the following factors: intraventricular hemorrhage (IVH, grade II–III, 95xa0months vs. grade IV, 28xa0months, pxa0=xa00.022), birth weight (<1.5xa0kg, 59xa0months vs. >1.5xa0kg, 22xa0months, pxa0=xa00.005), gestational age (>27xa0weeks, 90xa0months vs. <27xa0weeks, 20xa0months, pxa0<xa00.0001), distal vs. proximal revision (133xa0months vs. 48xa0months, pxa0=xa00.013), obstruction (yes, 78xa0months vs. no, 28xa0months, pxa0=xa00.007), and infection (no, 75xa0months vs. yes, 39xa0months, pxa0=xa00.045). Regression analysis revealed that multiple gestation, head circumference (>27xa0cm), congenital anomalies, infection, and obstruction increased the proximal and distal shunt malfunction.ConclusionLong-term outcome of VP shunt placement in infants revealed a relatively high rate of complications requiring shunt revision as late as 30xa0years after initial placement. Infants with VP shunts should be monitored lifelong of these patients by neurosurgeons.

Treatment of vertebrobasilar fusiform aneurysms with Pipeline embolization device

Object Treatment of complex intracranial aneurysms with Pipeline embolization device (PED) (ev3/Covidien Vascular Therapies) has gained recent popularity. One application of PEDs that is not well described in the literature is the utility and long-term safety in treatment of vertebrobasilar fusiform (VBF) aneurysms. Despite the advancements in endovascular therapy, VBF aneurysms continue to challenging pathology. The authors provide long-term follow-up of VBF aneurysms treated with PEDs. Methods We retrospectively reviewed four patients that were treated at Louisiana State University Health Sciences Center in Shreveport with PEDs for VBFs from 2012 to 2014. Each patient was discussed in a multidisciplinary setting between neurosurgeons and neurointerventionalists. Each patient underwent platelet function tests to ensure responsiveness to anti-platelet agents and was treated by one neurointerventionalist (HC). All patients were placed on aspirin and Plavix and were confirmed for therapeutic response prior to discharge. Results Follow-up ranged from 12 to 25 months, with a mean of 14.25 months. Two cases presented with a recurrence after the initial treatment, both of which required subsequent treatment. Of the four patients treated, one patient developed hemiparesis and three died. Conclusion Despite reports describing successful treatment of VBF aneurysms with PEDs, delayed complications after obliteration and remodeling can occur. We describe our institutional experience of VBFs treated with PEDs. Treatment of holobasilar fusiform aneurysms may carry a worse prognosis after treatment. Further long-term follow-up will provide a better understanding of this pathology.

Seven Intracranial Aneurysms in One Patient: Treatment and Review of Literature

Before the advent of endovascular coiling, patients with multiple intracranial aneurysms were treated with surgical clipping; however, with the advancements in endovascular technology, intracranial aneurysms can be treated with surgical clipping and/or endovascular coiling. We describe a case of subarachnoid hemorrhage in a patient with 7 intracranial aneurysms. A 45-year-old female developed a sudden headache and left sided hemiparesis. Initial workup showed a subarachnoid hemorrhage in the right Sylvian fissure. Further angiographic workup showed 7 intracranial aneurysms (left and right middle cerebral artery bifurcation, right middle cerebral artery, anterior communicating artery, left posterior communicating artery, right posterior inferior cerebellar artery, and left superior cerebellar artery). The patient underwent two craniotomies for surgical clipping of the anterior circulation aneurysms and endovascular stent-assisted coils for the posterior circulation aneurysms. The need for anti-platelet agents for endovascular treatment of the posterior circulation aneurysms and clinical presentation warranted surgical clipping of the anterior circulation aneurysms prior to endovascular therapy. We describe a case report and decision making for a patient with multiple intracranial aneurysms treated with surgical clipping and endovascular coiling.

Predictors of reoperation-free survival following decompression-alone lumbar spine surgery for on-the-job injuries.

INTRODUCTIONnWorkers compensation patients are known to be associated with inferior outcomes following lumbar surgery. We investigated demographics and clinical characteristics between the reoperative and non-reoperative group of patients undergoing decompression-alone lumbar surgery (discectomy and/or laminectomy) for on-the-job injuries (OJI) at our institute, and evaluated its possible impact on the reoperation-free survival (RFS).nnnMETHODSnA retrospective analysis of patients undergoing lumbar surgery for OJI between 2003 through 2010 by a single surgeon (A.N.) was performed. A comparison of baseline clinical and demographic parameters between the two groups was compared using Fishers exact test for the categorical variables and the independent t-test (2-tailed) for the continuous variables. Overall, RFS was presented in Kaplan-Meier curves and the RFS difference was compared using log-rank (Mantel-Cox) test. Cox proportional hazard model was used for the univariate and multivariate analysis and hazard ratios with 95% confidence intervals were reported.nnnRESULTSnAbout 92 patients with mean age 48.07 ± 10.10 years and mean follow-up of 36.4 (range 24.3-66.0) months were included. About 38 (41.3%) patients underwent reoperation for failed decompression-alone procedures whereas the non-reoperative cohort comprises 54 (58.7%) patients. Female gender (p = 0.015) and history of previous surgery (p = 0.05) were associated with a higher chance of reoperation. Majority of the reoperations (20/38, 52.6%) were performed within the first 2 years, with a RFS at the end of 2 years being 78.3% (n = 72) and 58.9% (n = 53) at 5 years. Cox-regression analysis did not demonstrate any influence of patients and treatment-related factors on the RFS.nnnCONCLUSIONnThere is a substantial risk of redo surgeries following decompression-alone lumbar procedures for OJI. As patient and treatment-related factors did not influence the reoperation rates and RFS in this study, it appears that workman compensation status of patients is inherently associated with poor outcomes following spine surgeries.

High-grade Gliomas Exhibit Higher Peritumoral Fractional Anisotropy and Lower Mean Diffusivity than Intracranial Metastases

Differentiating high-grade gliomas and intracranial metastases through non-invasive imaging has been challenging. Here, we retrospectively compared both intratumoral and peritumoral fractional anisotropy (FA), mean diffusivity (MD), and fluid-attenuated inversion recovery (FLAIR) measurements between high-grade gliomas and metastases. Two methods were utilized to select peritumoral region of interest (ROI). The first method utilized the manual placement of four ROIs adjacent to the lesion. The second method utilized a semiautomated and proprietary MATLAB script to generate an ROI encompassing the entire tumor. The average peritumoral FA, MD, and FLAIR values were determined within the ROIs for both methods. Forty patients with high-grade gliomas and 44 with metastases were enrolled in this study. Thirty-five patients with high-grade glioma and 30 patients with metastases had FLAIR images. There was no significant difference in age, gender, or race between the two patient groups. The high-grade gliomas had a significantly higher tumor-to-brain area ratio compared to the metastases. There were no differences in average intratumoral FA, MD, and FLAIR values between the two groups. Both the manual sample method and the semiautomated peritumoral ring method resulted in significantly higher peritumoral FA and significantly lower peritumoral MD in high-grade gliomas compared to metastases (pu2009<u20090.05). No significant difference was found in FLAIR values between the two groups peritumorally. Receiver operating curve analysis revealed FA to be a more sensitive and specific metric to differentiate high-grade gliomas and metastases than MD. The differences in the peritumoral FA and MD values between high-grade gliomas and metastases seemed due to the infiltration of glioma to the surrounding brain parenchyma.

Reaction to Koppad SN et al. Bilateral spermatocytic seminoma: an update on "synchronous" and "sequential" presentation of this rare variant of testicular tumour.

We read with interest the report of Koppad and colleagues in the Pan African Medical Journal describing a case of bilateral synchronous presentation of spermatocytic seminoma in an elderly Indian male. While we appreciate their efforts in documenting this rare presentation, we disagree with the reported figures as outlined in the report and wish to draw attention of the authors as well as the readers of the journal to the gross inaccuracies in the reported statistics. We present our data, following a comprehensive literature review, to unveil the magnitude of bilateral presentation (synchronous and sequential) of this unique variant of testicular tumor as reported in medical literature to facilitate dissemination of precise information on the topic.