Shearwood McClelland

Postoperative Central Nervous System Infection: Incidence and Associated Factors in 2111 Neurosurgical Procedures

BACKGROUND Postoperative central nervous system infection (PCNSI) in patients undergoing neurosurgical procedures represents a serious problem that requires immediate attention. PCNSI most commonly manifests as meningitis, subdural empyema, and/or brain abscess. Recent studies (which have included a minimum of 1000 operations) have reported that the incidence of PCNSI after neurosurgical procedures is 5%-7%, and many physicians believe that the true incidence is even higher. To address this issue, we examined the incidence of PCNSI in a sizeable patient population. METHODS The medical records and postoperative courses for patients involved in 2111 neurosurgical procedures at our institution during 1991-2005 were reviewed retrospectively to determine the incidence of PCNSI, the identity of offending organisms, and the factors associated with infection. RESULTS The median age of patients at the time of surgery was 45 years. Of the 1587 cranial operations, 14 (0.8%) were complicated by PCNSI, whereas none of the 32 peripheral nerve operations resulted in PCNSI. The remaining 492 operative cases involved spinal surgery, of which 2 (0.4%) were complicated by PCNSI. The overall incidence of PCNSI was 0.8% (occurring after 16 of 2111 operations); the incidence of bacterial meningitis was 0.3% (occurring after 4 of 1587 operations), and the incidence of brain abscess was 0.2% (occurring after 3 of 1587 operations). The most common offending organism was Staphylococcus aureus (8 cases; 50% of infections), followed by Propionibacterium acnes (4 cases; 25% of infections). Cerebrospinal fluid leakage, diabetes mellitus, and male sex were not associated with PCNSI (P>.05). CONCLUSIONS In one of the largest neurosurgical studies to have investigated PCNSI, the incidence of infection after neurosurgical procedures was <1%--more than 6 times lower than that reported in recent series of comparable numerical size. Cerebrospinal fluid leak, diabetes mellitus, and male sex were not associated with an increased incidence of PCNSI. The results from this study indicate that the true incidence of PCNSI after neurosurgical procedures may be greatly overestimated in the literature and that, in surgical procedures associated with a high risk of infection, prophylaxis for S. aureus and/or P. acnes infection should be of primary concern.

Population-Based Analysis of Morbidity and Mortality Following Surgery for Intractable Temporal Lobe Epilepsy in the United States

OBJECTIVE To assess the morbidity of temporal lobe epilepsy (TLE) surgery on a nationwide level in order to address reservations regarding the morbidity of anterior temporal lobectomy (ATL) for TLE despite class I evidence demonstrating the superiority of ATL over continued medical therapy. DESIGN Retrospective cohort study. SETTING The Nationwide Inpatient Sample from 1988 to 2003 was used for analysis. PATIENTS Only patients who were admitted for ATL for TLE (International Classification of Diseases, Ninth Revision, Clinical Modification codes 345.41 and 345.51; primary procedure code, 01.53) were included. MAIN OUTCOME MEASURES Morbidity and mortality. Analysis was adjusted for several variables including patient age, race, sex, admission type, primary payer for care, income in zip code of residence, and hospital volume of care. RESULTS Multivariate analyses revealed that the overall morbidity (postoperative morbidity and/or adverse discharge disposition) following ATL for TLE was 10.8%, with no mortality. Private insurance decreased postoperative morbidity (odds ratio [OR] = 0.52; 95% confidence interval [CI] = 0.28-0.98; P = .04) and adverse discharge disposition (OR = 0.31; 95% CI = 0.12-0.81; P = .02). Increased patient age increased postoperative morbidity (OR = 1.04; 95% CI = 1.01-1.07; P = .03) and adverse discharge disposition (OR = 1.08; 95% CI = 1.02-1.13; P = .004). Neither sex, income, race, nor hospital volume was predictive of postoperative morbidity. The degree of medical comorbidity directly correlated with the incidence of postoperative morbidity. CONCLUSIONS Morbidity following ATL for TLE is low throughout the United States regardless of sex, race, insurance status, or income. Younger age and private insurance status are independently predictive of reduced postoperative morbidity. In patients with low medical comorbidity, ATL for TLE is safe, with low morbidity and no mortality.

Facial Emotion Recognition after Curative Nondominant Temporal Lobectomy in Patients with Mesial Temporal Sclerosis

Summary:  Purpose: The right (nondominant) amygdala is crucial for processing facial emotion recognition (FER). Patients with temporal lobe epilepsy (TLE) associated with mesial temporal sclerosis (MTS) often incur right amygdalar damage, resulting in impaired FER if TLE onset occurred before age 6 years. Consequently, early right mesiotemporal insult has been hypothesized to impair plasticity, resulting in FER deficits, whereas damage after age 5 years results in no deficit. The authors performed this study to test this hypothesis in a uniformly seizure‐free postsurgical population.

Racial Disparities in the Surgical Management of Intractable Temporal Lobe Epilepsy in the United States: A Population-Based Analysis

OBJECTIVE To determine whether, over a long time span, race and/or other predictive factors for patients with intractable temporal lobe epilepsy (TLE) who receive anterior temporal lobectomy (ATL) exist on a national level. DESIGN Retrospective cohort study. PATIENTS Adult patients with TLE admitted for ATL (International Classification of Diseases, Ninth Revision, Clinical Modification, 345.41, 345.51; primary procedure code, 01.53). INTERVENTIONS A population-based analysis was performed using the Nationwide Inpatient Sample from 1988 through 2003. Variables besides race that were examined included patient age, sex, and insurance status. RESULTS Of the 5779 adults admitted with TLE from 1988 through 2003, 562 (9.7%) received ATL. Multivariate analyses revealed that African American race (odds ratio [OR], 0.56; 95% confidence interval [CI], 0.38-0.84; P = .005) and increased age (OR, 0.98; 95% CI, 0.97-0.99; P < .001 per 1-year increase in age) independently predicted decreased likelihood of receiving ATL for TLE, while private insurance increased the odds of ATL receipt (OR, 1.85; 95% CI, 1.39-2.46; P < .001). These findings remained stable over time. CONCLUSIONS Fewer than 10% of the TLE patient population receives ATL. Younger age and private insurance are independent predictors of receiving ATL, and African American race independently predicts decreased likelihood of receiving ATL. Despite recent attempts to bridge racial health disparities, the gap between African American and other races in optimal TLE management has remained relatively unchanged on a nationwide level.

Distribution of Auditory and Visual Naming Sites in Nonlesional Temporal Lobe Epilepsy Patients and Patients with Space-Occupying Temporal Lobe Lesions

Summary:  Purpose: Current knowledge regarding the topography of essential language cortex is based primarily on stimulation mapping studies of nonlesional epilepsy patients. We sought to determine whether space‐occupying temporal lobe lesions are associated with a similar topography of language sites, as this information would be useful in surgical planning.

Morbidity and mortality following acoustic neuroma excision in the United States: analysis of racial disparities during a decade in the radiosurgery era.

Acoustic neuromas present a challenging problem, with the major treatment modalities involving operative excision, stereotactic radiosurgery, observation, and fractionated stereotactic radiotherapy. The morbidity/mortality following excision may differ by patient race. To address this concern, the morbidity of acoustic neuroma excision was assessed on a nationwide level. The Nationwide Inpatient Sample from 1994-2003 was used for analysis. Only patients admitted for acoustic neuroma excision were included (International Classification of Diseases, 9th edition, Clinical Modification = 225.1; primary procedure code = 04.01). Analysis was adjusted for several variables, including patient age, race, sex, primary payer for care, income in ZIP code of residence, surgeon caseload, and hospital caseload. Multivariate analyses revealed that postoperative mortality following acoustic neuroma excision was 0.5%, with adverse discharge disposition of 6.1%. The odds ratio for mortality in African Americans compared with Caucasians was 8.82 (95% confidence interval = 1.85-41.9, P = .006). Patients with high-caseload surgeons (more than 2 excisions/year), private insurance, and younger age had decreased mortality, better discharge disposition, and lower overall morbidity (P < .04). Neither hospital caseload nor median income were predictive factors. African Americans were 9 times more likely to die following surgery than Caucasians over a decade-long analysis. Given the relatively benign natural history of acoustic neuroma and the alarmingly increased mortality rate following surgical excision among older patients, African Americans, and patients receiving care from low-caseload surgeons, acoustic neuromas in these patient populations may be best managed by a more minimally invasive modality such as observation, fractionated stereotactic radiotherapy, or stereotactic radiosurgery.

A cost analysis of intraoperative microelectrode recording during subthalamic stimulation for Parkinson's disease.

Deep brain stimulation of the subthalamic nucleus is the standard of care for treating medically intractable Parkinsons disease. Although the adjunct of microelectrode recording improves the targeting accuracy of subthalamic nucleus deep brain stimulation in comparison with image guidance alone, there has been no investigation of the financial cost of intraoperative microelectrode recording. This study was performed to address this issue. A comprehensive literature search of large subthalamic nucleus deep brain stimulation series (minimum, 75 patients) was performed, revealing a mean operating room time of 223.83 minutes for unilateral and 279.79 minutes for simultaneous bilateral implantation. The baseline operating room time was derived from the published operating room time for subthalamic nucleus deep brain stimulation without microelectrode recording. The total cost (operating room, anesthesia, neurosurgery) was then calculated based on hospitals geographically representative of the entire United States. The average cost for subthalamic nucleus deep brain stimulation implantation with microelectrode recording per patient is

Intrathecal baclofen for spasticity-related pain in amyotrophic lateral sclerosis: Efficacy and factors associated with pain relief

26,764.79 for unilateral,

Hemispherectomy for intractable epilepsy in adults: The first reported series

33,481.43 for simultaneous bilateral, and

Long-term results of radiosurgery for refractory cluster headache.

53,529.58 for staged bilateral. For unilateral implantation, the cost of microelectrode recording is