Surgery for Metastatic Spinal Disease in Octogenarians and Above: Analysis of 78 Patients.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVE: Octogenarians living with spinal metastases are a challenging population to treat. Our objective was to identify the rate, types, management, and predictors of complications and survival in octogenarians following surgery for spinal metastases. METHODS: A retrospective review of a prospectively collected cohort of patients aged 80 years or older who underwent surgery for metastatic spinal tumor treatment between 2008 and 2019 were included. Demographic, intraoperative, complications, and postoperative follow-up data was collected. Cox proportional hazards regression and logistic regression were used to associate variables with overall survival and postoperative complications, respectively. RESULTS: 78 patients (mean 83.6 years) met inclusion criteria. Average operative time and blood loss were 157 minutes and 615 mL, respectively. The median length of stay was 7 days. The overall complication rate was 31% (N = 24), with 21% considered major and 7% considered life-threatening or fatal. Blood loss was significantly associated with postoperative complications (OR = 1.002; P = 0.02) and mortality (HR = 1.0007; P = 0.04). Significant associations of increased risk of death were also noted with surgeries with decompression, and cervical/cervicothoracic index level of disease. For deceased patients, median time to death was 4.5 months. For living patients, median follow-up was 14.5 months. The Kaplan-Meier based median overall survival for the cohort was 11.6 months (95% CI: 6.2-19.1). CONCLUSIONS: In octogenarians undergoing surgery with instrumentation for spinal metastases, the median overall survival is 11.6 months. There is an increased complication rate, but only 7% are life-threatening or fatal. Patients are at increased risk for complications and mortality particularly when performing decompression with stabilization, with increasing intraoperative blood loss, and with cervical/cervicothoracic tumors.

Cavernous malformation hemorrhage due to trans-mural pressure alterations after cerebrospinal fluid diversion: a case report.

BACKGROUND: Cavernous malformations are rare cerebral pseudo-vascular lesions with annualized bleeding rates of 0.5-3% in most studies. Of the various explored risk factors for bleeding to date, only prior hemorrhage has shown significant correlation. CASE PRESENTATION: In this case, we describe a 65-year old man with a peri-ventricular atrial cavernous malformation that hemorrhaged after CSF diversion via ventriculoperitoneal shunting. Serial imaging showed that bleeding continued until the shunt was revised with a programmable valve set at maximum resistance with the addition of a gravitational unit, thereby lowering the trans-mural pressure differential across the cavernous malformation. CONCLUSIONS: Given that other vascular lesions are subject to hemorrhage from alterations in trans-mural pressure dynamics, we hypothesize that cavernous malformations are similarly affected by trans-mural pressure gradients as they are composed of primitive vascular elements. This hypothesis is corroborated by the temporal correlation of interventions, imaging, and exam findings in the present case, and suggests a potentially important risk factor for hemorrhage in CM patients that affects prognostication and management.

Future Directions in Communication in Neurosurgery.

Modern-day care of the neurosurgery patient has grown increasingly complex and typically involves a variety of medical team members. Proper communication and transmission of clinical data within the neurosurgery team is required for successful outcomes, especially within the operating room. Effective communication is also critical to the patient-physician relationship and can aid in improving rapport and possibly reducing malpractice lawsuit risk. In addition, interactions exist between practicing neurosurgeons and members of the administration, often focusing on reimbursement and quality issues. Although most physicians would agree that communication between all these stakeholders should improve, certain barriers are present, including the adoption of newer technologies and the lack of formal training. In this article, we review current and projected trends relating to the enhancement of neurosurgical communication at all levels.

Communication in Neurosurgery-The Tower of Babel.

Clinical neurosurgery is a complex specialty with multiple participants, including a variety of providers, patients, family members, and administrators, who interact in complex fashions. Modern-day patient care requires near-constant team communication of vital, detailed clinical information; any breakdown in this process can result in patient harm. Medical communication practices with patients impact mutual rapport as well as the overall physician-patient relationship. Enhanced relationship-centered communication techniques have been shown to improve patient compliance and may positively influence malpractice litigation rates. Neurosurgeons frequently interact with other health care providers and members of the hospital administration on matters relating to billing, compliance, and quality. Communication among the stakeholders is complicated, however, by the fact that the participants may be speaking a variety of different, mutually unintelligible "languages." We discuss the details of the various types of information exchanges in neurosurgery, the key players involved, and the vulnerabilities to breakdowns in the system. In addition, we review the multifaceted, systems-level issues in neurosurgical communication and related weaknesses.

Barriers to the Enhancement of Effective Communication in Neurosurgery.

Communication issues play a major role within neurosurgery. There has been a growing awareness of the necessity of enhanced patient-centered communication between the physician and patient to improve patient satisfaction, compliance, and outcomes. In addition, the threat of malpractice litigation within neurosurgery is of particular concern, and improved communication may lead to some degree of risk mitigation. Within the neurosurgical and medical team, effective transmittal of vital clinical data is essential for patient safety. Despite the recent recognition of the critical role that communication plays in all aspects of medical care, multiple impediments hinder the improvement and use of effective techniques. We have identified 8 unique barriers to the advancement of communication practices: lack of recognition of the importance of communication skills; cognitive bias; sense that it "takes too much time"; cultural hierarchy within medicine; lack of formal communication skill training; fear that disclosure of medical errors will lead to malpractice litigation; the electronic medical record; and frequent shift changes and handoffs.