Sudheer Ambekar

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

Spinal aneurysms: clinicoradiological features and management paradigms

45,452.24 in 2003 to

Evolution of management strategies for cavernous carotid aneurysms: A Review

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.

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

OBJECTnSpinal aneurysms (SAs) are rare lesions. The clinicoradiological features and the exact degree of their association with comorbid conditions such as arteriovenous malformations (AVMs) and coarctation of the aorta have not been definitively described. The ideal management paradigm has not been established. The authors reviewed literature to determine the clinical patterns of presentation, management, and outcome of spinal aneurysms.nnnMETHODSnA systematic review of literature was performed using 23 separate strings. A total of 10,190 papers were screened to identify 87 papers that met the inclusion criteria. A total of 123 SAs could be included for analysis.nnnRESULTSnThe mean age of patients at presentation was 38 years; 10% of patients were aged less than 10 years and nearly 50% were greater than 38 years. Spinal aneurysms can be divided into 2 groups: those associated with AVMs (SA-AVMs, or Type 1 SAs) and those with isolated aneurysms (iSAs, or Type 2 SAs). Patients with Type 2 SAs were older and more likely to present with bleeding than those with Type 1 SAs. The acute syndromes can be divided into 3 groups of patients: those with spinal syndrome, those with cranial/craniospinal syndrome, and those with nonspecific presentation. Overall, 32.6% presented with angiography-negative cranial subarachnoid hemorrhage (SAH). Presentation with evidence of cord dysfunction (myelopathy/weakness/sensory loss/bladder involvement) correlated with poor outcome, as did presentation with hemorrhage and association with other comorbid conditions. Surgery and endovascular therapy both led to comparable rates of complete aneurysm obliteration for Type 2 SAs, whereas for the AVM-associated Type 1 SAs, surgery led to better rates of lesion obliteration. The authors propose a classification scheme for spinal aneurysms based on whether the lesion is solitary or is associated with a coexistent spinal AVM; this would also imply that the ideal therapy for the aneurysm would differ based on this association.nnnCONCLUSIONSnThe clinical and radiological patterns that influence outcome are distinct for Type 1 and Type 2 SAs. The ideal treatment for Type 1 SAs appears to be excision, whereas surgery and endovascular therapy were equally effective for Type 2 SAs.

Long-term outcome of gamma knife radiosurgery for vestibular schwannoma.

OBJECTIVEnCavernous carotid aneurysms are considered benign lesions with indolent natural history. Apart from idiopathic aneurysms, traumatic, iatrogenic, and mycotic aneurysms are common in the cavernous segment of the carotid artery. With rapid advances in endovascular therapy, management of cavernous carotid aneurysms has evolved. Our aim was to review the management options available for cavernous carotid aneurysms.nnnMETHODSnThe English literature was searched for various studies describing the management of cavernous carotid aneurysms and the evolution of various treatments was studied.nnnRESULTSnNumerous treatment options are available such as conservative management, Hunterian ligation, surgical clipping, and endovascular therapy. The introduction of flow-diverting stents has revolutionized the management of these lesions. The evolution of various treatment strategies are described.nnnCONCLUSIONSnA thorough knowledge of all the options is paramount to individualize therapy. We discuss the indications of treatment, various management options for cavernous carotid aneurysms and their outcomes.

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

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

Objectiveu2003We evaluated the long-term outcome of vestibular schwannoma (VS) treated with gamma knife radiosurgery (GKRS) as a primary treatment as well as an adjunct therapy. Materials and Methodsu2003We performed a retrospective review (2000-2012) of 82 patients with VS who received GKRS. Of 82 patients, 20 patients with prior resection received GKRS treatment as an adjunct therapy. The remainder of the patients (62) received GKRS as a primary treatment. Resultsu2003GKRS for VS showed significant variations in tumor growth control (decreased in 44 patients [54%], arrested growth in 30 patients [36%], and increased tumor size in 8 patients [10%]). Progression-free survival rates after GKRS at 3, 5, and 10 years were 98%, 95%, and 95%, respectively. Hearing, facial nerve function, and Karnofsky performance scale were significantly improved after GKRS compared with pretreated status (79 versus 90). Two patients (2.5%) required resection again due to tumor progression and worsening of signs and symptoms. Conclusionu2003Long-term follow-up demonstrated that GKRS offers a high rate of tumor control, preservation of multiple nerve functions, and a good quality of life in both new and recurrent patients with VS.

A technique to identify core journals for neurosurgery using citation scatter analysis and the Bradford distribution across neurosurgery journals.

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.

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

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.