Management of symptomatic postoperative epidural hematoma in spine surgery: Medicolegal implications.

INTRODUCTION: Spine surgery is one of the specialties with the highest medicolegal risk, with a legal action initiated every 17 months per practitioner. One of the most dreaded complications is an epidural hematoma with postoperative deficit. The treatment of this complication is still being debated. We therefore conducted a retrospective study of the database of a medical liability insurer to assess perioperative factors determining the liability of the surgeon or paramedical team during an expert review in the event of a postoperative symptomatic epidural hematoma. HYPOTHESIS: To identify the factors determining the liability of the medical team in the event of a postoperative symptomatic epidural hematoma. MATERIALS AND METHODS: We retrospectively analyzed the largest French register of medicolegal expert reviews between 2011 and 2018. We identified 68 cases by entering the following keywords in this database: "spine surgery," "complications," and "epidural hematoma." After a thorough review of each case, only 14 were deemed to be truly relevant to our study. We collected for each patient the perioperative data, complications (including neurologic deficits) and their clinical course. RESULTS: Only one surgeon was accused and found liable for failing to perform a surgical revision within a reasonable timeframe (time to revision of 11 days). In 2 cases, the liability of a nurse working in the surgical department was called into question for failing to contact the surgeon upon the onset of symptoms. In the other cases (11 patients, 79%), the occurrence of a symptomatic epidural hematoma was considered a no-fault medical accident that was not caused by the surgeon. The presence of a drain did not have any medicolegal impact in the cases reviewed. CONCLUSION: The key element in medicolegal decisions is the reaction time of the healthcare teams, in particular the time between the onset of symptoms and surgical revision. According to these expert reviews, the placement of a drain was not taken into consideration during the medicolegal assessment of a postoperative symptomatic epidural hematoma. LEVEL OF EVIDENCE: II; retrospective prognostic study, investigation of patient characteristics and their impact on functional outcome.

Improvement in Sagittal Balance After Decompression Surgery without Fusion in Patients with Degenerative Lumbar Stenosis: Clinical and Radiographic Results at 1 Year.

OBJECTIVE: To evaluate modifications in static spinal status after posterior decompression surgery without fusion in patients with symptomatic central canal stenosis. METHODS: From November 2014 to May 2016, 72 patients who underwent isolated decompression for lumbar spinal stenosis were enrolled prospectively in this single-center study. All of the patients had lateral full-body x-ray scans with the EOS system (EOS Imaging, Paris, France) before surgery and after 12 months of follow-up. Patients were classified into 3 groups according to their preoperative sagittal vertical axis (<50 mm, ≥50 mm, and <100 mm, ≥100 mm). RESULTS: SVA decreased significantly (SVA preoperative: 72.3 ± 43.1; SVA postoperative: 48.3 ± 46.8. P < 0.001). Lumbar lordosis increased significantly from 41.9 ± 13.4 in the preoperative period to 46.5 ± 14.8 at the last follow-up (P < 0.001). In the imbalance groups, the mean postoperative SVA decreased significantly compared with preoperative SVA (P = 0.004). Surgery led to a significant increase in lumbar lordosis in the 3 groups (P < 0.05). Nonetheless, a certain degree of residual imbalance persisted in the major imbalance group. In all of the groups, decompression surgery led to a significant improvement in clinical scores (P < 0.05). CONCLUSIONS: Our study showed an improvement in sagittal balance and lumbar lordosis after decompression surgery without fusion, even in patients with a preoperative SVA >100 mm. However, a certain degree of sagittal imbalance may persist after surgery in patients with major initial imbalance (SVA >100 mm). Nonetheless, after surgery, these patients experienced a clinical benefit comparable with that in the other groups.

Blood baseline neutrophil count predicts bevacizumab efficacy in glioblastoma.

Bevacizumab is used to treat glioblastoma; however, no current biomarker predicts its efficacy. We used an exploratory cohort of patients treated with the radiochemotherapy then bevacizumab or chemotherapy at recurrence (N = 265). Bevacizumab use increased median overall survival (OS) 18.7 vs 11.3 months, p = 0.0014). In multivariate analysis, age, initial surgery, neutrophil count, Karnofsky status >70% and bevacizumab administration were independent prognostic factors of survival. We found an interaction between bevacizumab use and baseline neutrophil count. The cut-off value for the neutrophil count was set at 6000/mm3. Only patients with a high neutrophil count benefited from the bevacizumab treatment (17.3 vs 8.8 months p < 0.0001). We validated this result using data from the TEMAVIR trial, which tested the efficacy of neoadjuvant bevacizumab plus irinotecan versus radiochemotherapy in the first-line treatment of glioblastoma. Transcriptomic data from TCGA underlined that CSF3 expression, the gene encoding G-CSF, the growth factor for neutrophils, correlated with VEGF-A-dependent angiogenesis. In another independent cohort (BELOB trial), which compared lomustine versus lomustine plus bevacizumab at recurrence, bevacizumab only benefited patients with high CSF3 expression in the tumor. These data suggest that only patients with a high peripheral neutrophil count before bevacizumab treatment benefited from this therapy.

Spontaneous resolution of perforator aneurysms of the posterior circulation.

The authors present the cases of 3 patients with ruptured perforator aneurysms of the posterior circulation. Patients were 39, 55, and 59 years old. None of the patients had relevant past medical or family history. All presented with World Federation of Neurosurgical Societies Grade I and Fisher Grade 2 or 3 subarachnoid hemorrhage. Initial angiography results were normal. A second cerebral angiogram in each case revealed a small (< 3 mm) aneurysm of perforator arteries of the posterior circulation. Patients were successfully managed conservatively. None of the patients developed symptomatic vasospasm, rebleeding, or hydrocephaly. Control angiograms at 3 months showed spontaneous resolution of the aneurysm in all cases. Rupture of perforator aneurysms of the posterior circulation is a rare condition and it may be underdiagnosed because of limitations of imaging techniques. Treatments can lead to complications in highly functional territories and should be considered wisely, especially due to the fact that the causes and natural history of such aneurysms are unknown and spontaneous healing remains a possibility.