Quality of Life in Patients Undergoing Spine Surgery: Systematic Review and Meta-Analysis.

STUDY DESIGN: Meta-analysis. OBJECTIVE: Despite the increasing importance of tracking clinical outcomes using valid patient-reported outcome measures, most providers do not routinely obtain baseline preoperative health-related quality of life (HRQoL) data in patients undergoing spine surgery, precluding objective outcomes analysis in individual practices. We conducted a meta-analysis of pre- and postoperative HRQoL data obtained from the most commonly published instruments to use as reference values. METHODS: We searched PubMed, EMBASE, and an institutional registry for studies reporting EQ-5D, SF-6D, and Short Form-36 Physical Component Summary scores in patients undergoing surgery for degenerative cervical and lumbar spinal conditions published between 2000 and 2014. Observational data was pooled meta-analytically using an inverse variance-weighted, random-effects model, and statistical comparisons were performed. RESULTS: Ninety-nine articles were included in the final analysis. Baseline HRQoL scores varied by diagnosis for each of the 3 instruments. On average, postoperative HRQoL scores significantly improved following surgical intervention for each diagnosis using each instrument. There were statistically significant differences in baseline utility values between the EQ-5D and SF-6D instruments for all lumbar diagnoses. CONCLUSIONS: The pooled HRQoL values presented in this study may be used by practitioners who would otherwise be precluded from quantifying their surgical outcomes due to a lack of baseline data. The results highlight differences in HRQoL between different degenerative spinal diagnoses, as well as the discrepancy between 2 common utility-based instruments. These findings emphasize the need to be cognizant of the specific instruments used when comparing the results of outcome studies.

Surgical Approaches for the Treatment of Multilevel Cervical Ossification of the Posterior Longitudinal Ligament: Results of a Decision Analysis.

BACKGROUND: Ossification of the posterior longitudinal ligament (OPLL) often leads to cervical myelopathy. Although multiple procedures have been shown to be effective in the treatment of OPLL, outcomes are less predictable than in degenerative cervical myelopathy, and surgery is associated with high rates of complications and reoperation, which affect quality of life. In this study, we performed a decision analysis using postoperative complication data and health-related quality of life (HRQoL) utility scores to assess the average expected health utility and 5-year quality-adjusted life years (QALYs) associated with the most common surgical approaches for multilevel cervical OPLL. METHODS: We searched Medline, EMBASE, and the Cochrane Library for relevant articles published between 1990 and October 2017. Meta-analytically pooled complication data and HRQoL utility scores associated with each complication were evaluated in a long-term model. RESULTS: The overall incidence of perioperative complications ranged from 6.2% for laminectomy alone to 11.0% for anterior decompression and fusion. Revision surgery for hardware/fusion failure or progression was highest for laminectomy alone (3.0%) and lowest for laminectomy and fusion (1.6%). Laminoplasty resulted in the highest 5-year QALYs gained, compared with laminectomy and anterior approaches (P < 0.001). There was no significant difference in QALY gained between laminectomy-fusion and laminoplasty. CONCLUSION: The results suggest that owing to the higher rates of complications associated with anterior cervical approaches, laminoplasty may result in improved long-term outcomes from an HRQoL standpoint. These findings may guide surgeons in cases where either procedure is a reasonable option.

A Retrospective Propensity Score-Matched Early Thromboembolic Event Analysis of Prothrombin Complex Concentrate vs Fresh Frozen Plasma for Warfarin Reversal Prior to Emergency Neurosurgical Procedures.

BACKGROUND: Reversal of therapeutic anticoagulation prior to emergency neurosurgical procedures is required in the setting of intracranial hemorrhage. Multifactor prothrombin complex concentrate (PCC) promises rapid efficacy but may increase the probability of thrombotic complications compared to fresh frozen plasma (FFP). OBJECTIVE: To compare the rate of thrombotic complications in patients treated with PCC or FFP to reverse therapeutic anticoagulation prior to emergency neurosurgical procedures in the setting of intracranial hemorrhage at a level I trauma center. METHODS: Sixty-three consecutive patients on warfarin therapy presenting with intracranial hemorrhage who received anticoagulation reversal prior to emergency neurosurgical procedures were retrospectively identified between 2007 and 2016. They were divided into 2 cohorts based on reversal agent, either PCC (n = 28) or FFP (n = 35). The thrombotic complications rates within 72 h of reversal were compared using the χ2 test. A multivariate propensity score matching analysis was used to limit the threat to interval validity from selection bias arising from differences in demographics, laboratory values, history, and clinical status. RESULTS: Thrombotic complications were uncommon in this neurosurgical population, occurring in 1.59% (1/63) of treated patients. There was no significant difference in the thrombotic complication rate between groups, 3.57% (1/28; PCC group) vs 0% (0/35; FFP group). Propensity score matching analysis validated this finding after controlling for any selection bias. CONCLUSION: In this limited sample, thrombotic complication rates were similar between use of PCC and FFP for anticoagulation reversal in the management of intracranial hemorrhage prior to emergency neurosurgical procedures.

Surgical Approaches for the Treatment of Thoracic Disk Herniation: Results of a Decision Analysis.

STUDY DESIGN: A decision analysis. OBJECTIVE: To perform a decision analysis utilizing postoperative complication data, in conjunction with health-related quality of life (HRQoL) utility scores, to rank order the average health utility associated with various surgical approaches used to treat symptomatic thoracic disk herniation (TDH). SUMMARY OF BACKGROUND DATA: Symptomatic TDH is an uncommon entity accounting for <1% of all symptomatic herniated disks. A variety of surgical approaches have been developed for its treatment, which may be classified into 4 major categories: open anterolateral transthoracic, minimally invasive anterolateral thoracoscopic, posterior, and lateral. These treatments have varying risk/benefit profiles, but there is still no set algorithm for choosing an approach in cases with multiple surgical options. METHODS: We searched Medline, EMBASE, and the Cochrane Library for relevant articles on surgical approaches for TDHs published between 1990 and August 2014. Pooled complication data and HRQoL utility scores associated with each complication were evaluated using standard meta-analytic techniques to determine which surgical approach resulted in the highest average HRQoL. RESULTS: Posterior surgical approaches resulted in the highest average HRQoL, followed by thoracoscopic, lateral, and finally open anterolateral transthoracic procedures. The higher average HRQoL associated with posterior approaches over all others was highly significant (P<0.001); conversely, the open anterolateral approach resulted in a lower average postoperative utility compared with all other approaches (P<0.001). CONCLUSIONS: The results of this decision analysis favor posterior over lateral approaches, and thoracoscopic over open anterolateral approaches for the treatment of symptomatic TDHs, which may guide surgeons in cases where multiple surgical options are feasible. Future studies, such as randomized clinical trials, are necessary to ascertain whether novel surgical strategies have risk/benefit profiles that ultimately supersede those of traditional approaches, and whether enough cases are encountered by the average surgeon to justify their adoption.

Long-term utility and complication profile of open craniotomy for biopsy in patients with idiopathic encephalitis.

Neurosurgeons are often asked to perform open biopsy for diagnosis of encephalitis after medical investigations are non-diagnostic. These patients may be critically ill with multiple comorbidities. Patients and their families often request data regarding the success rates and complication profile of biopsy, but minimal literature exists in this area. Retrospective chart review of all patients undergoing open brain biopsy (burr hole or craniotomy) for encephalitis refractory to medical diagnosis between January 2009 and December 2013 was undertaken. Pathology records and outpatient follow-up were reviewed to determine most recent clinical status of each patient. A total of 59 patients were included with mean follow up of 20months. The average age at biopsy was 55years. The most common unconfirmed diagnoses leading to biopsy were vasculitis (44%), neoplasm (27%), infection (12%), autoimmune (12%), amyloidosis (5%). Tissue pathology was diagnostic in 42% of all cases. Overall, biopsy confirmed the preoperative diagnosis in 46% of cases and refuted the preoperative leading diagnosis in 25% of cases. At last follow-up, the tissue pathology resulted in a medical treatment change in 25% of cases. There was a 14% major neurological complication rate (postoperative stroke, hemorrhage, or neurological deficit) and 9% cardiopulmonary complication rate (delayed extubation and re-intubation) attributable to surgical intervention. In this limited series, diagnostic utility of biopsy in patients with idiopathic encephalitis is less than 50% and the major complication rate is 23%. Patients and providers must be counseled accordingly and weigh the risks and benefits of open biopsy for encephalitis cautiously.

Navigated odontoid screw placement using the O-arm: technical note and case series.

OBJECTIVE As odontoid process fractures become increasingly common in the aging population, a technical understanding of treatment approaches is critical. 3D image guidance can improve the safety of posterior cervical hardware placement, but few studies have explored its utility in anterior approaches. The authors present in a stepwise fashion the technique of odontoid screw placement using the Medtronic O-arm navigation system and describe their initial institutional experience with this surgical approach. METHODS The authors retrospectively reviewed all cases of anterior odontoid screw fixation for Type II fractures at an academic medical center between 2006 and 2015. Patients were identified from a prospectively collected institutional database of patients who had suffered spine trauma. A standardized protocol for navigated odontoid screw placement was generated from the collective experience at the authors' institution. Secondarily, the authors compared collected variables, including presenting symptoms, injury mechanism, surgical complications, blood loss, operative time, radiographically demonstrated nonunion rate, and clinical outcome at most recent follow-up, between navigated and nonnavigated cases. RESULTS Ten patients (three female; mean age 61) underwent odontoid screw placement. Most patients presented with neck pain without a neurological deficit after a fall. O-arm navigation was used in 8 patients. An acute neck hematoma and screw retraction, each requiring surgery, occurred in 2 patients in whom navigation was used. Partial vocal cord paralysis occurred after surgery in one patient in whom no navigation was used. There was no difference in blood loss or operative time with or without navigation. One patient from each group had radiographic nonunion. No patient reported a worsening of symptoms at follow-up (mean duration 9 months). CONCLUSIONS The authors provide a detailed step-by-step guide to the navigated placement of an odontoid screw. Their surgical experience suggests that O-arm-assisted odontoid screw fixation is a viable approach. Future studies will be needed to rigorously compare the accuracy and efficiency of navigated versus nonnavigated odontoid screw placement.

Comparing Utility Scores in Common Spinal Radiculopathies: Results of a Prospective Valuation Study.

Study Design Prospective observational study. Objective To determine whether preference-based health utility scores for common spinal radiculopathies vary by specific spinal level. Methods We employed a standard gamble study using the general public to calculate individual preference-based quality of life for four common radiculopathies: C6, C7, L5, and S1. We compared utility scores obtained for each level of radiculopathy with analysis of variance and t test. Multivariable regression was used to test the effects of the covariates age, sex, and years of education. We also reviewed the literature for publications reporting EuroQol-5 Dimensions (EQ-5D) scores for patients with radiculopathy. Results Two hundred participants were included in the study. Average utility for the four spinal levels fell within a narrow range (0.748 to 0.796). There were no statistically significant differences between lumbar and cervical radiculopathies, nor were there significant differences among the different spinal levels (F = 0.0850, p = 0.086). Age and sex had no significant effect on utility scores. There was a significant correlation between years of education and utility values for S1 radiculopathy (p = 0.037). On review of the literature, no study separated utility values by specific spinal level. EQ-5D utilities for both cervical and lumbar radiculopathy were considerably lower than the results of our study. Conclusions Utility values associated with the most common levels of cervical and lumbar radiculopathy do not significantly differ from each other, validating the current practice of grouping utility by spinal segment rather than by specific root levels. The discrepancy in average utility values between our study and the EQ-5D highlights the need to be mindful of the underlying instruments used when assessing outcomes studies from different sources.

Microsurgical treatment of sacral perineural (Tarlov) cysts: case series and review of the literature.

OBJECTIVE Tarlov cysts (TCs) occur most commonly on extradural components of the sacral and coccygeal nerve roots. These lesions are often found incidentally, with an estimated prevalence of 4%-9%. Given the low estimated rates of symptomatic TC and the fact that symptoms can overlap with other common causes of low-back pain, optimal management of this entity is a matter of ongoing debate. Here, the authors investigate the effects of surgical intervention on symptomatic TCs and aim to solidify the surgical criteria for this disease process. METHODS The authors performed a retrospective review of data from consecutive patients who were surgically treated for symptomatic TCs from September 2011 to March 2013. Clinical evaluations and results from surveying pain and overall health were used. Univariate statistical analyses were performed. RESULTS Twenty-three adults (4 males, 19 females) who had been symptomatic for a mean of 47.4 months were treated with laminectomy, microsurgical exposure and/or imbrication, and paraspinous muscle flap closure. Eighteen patients (78.3%) had undergone prior interventions without sustained improvement. Thirteen patients (56.5%) underwent lumbar drainage for an average of 8.7 days following surgery. The mean follow-up was 14.4 months. Univariate analyses demonstrated that an advanced age (p = 0.045), the number of noted perineural cysts on preoperative imaging (p = 0.02), and the duration of preoperative symptoms (p = 0.03) were associated with a poor postoperative outcome. Although 47.8% of the patients were able to return to normal activities, 93.8% of those surveyed reported that they would undergo the operation again if given the choice. CONCLUSIONS This is one of the largest published studies on patients with TCs treated microsurgically. The data suggest that patients with symptomatic TCs may benefit from open microsurgical treatment. Although outcomes seem related to patient age, duration of symptoms, and extent of disease demonstrated on imaging, further study is warranted and underway.

Tracking patient-reported outcomes in spinal disorders.

BACKGROUND: Patient-reported outcome measures (PROMs) quantify health status from the patient's point of view. While the number of published outcomes studies grows each year, so too has the number of instruments being reported, leading to confusion on which instruments are appropriate to use for various spinal conditions. METHODS: A broad search was conducted to identify commonly used PROMs in patients undergoing spinal surgery. We searched PubMed for combinations of terms related to anatomic location and a measure of patient-reported outcome in the title or text. We supplemented the search using the "related articles" feature of PubMed and by manually searching the bibliographies of selected articles. RESULTS: Major categories of PROMs in spine surgery include health-related quality-of-life, pain, and disease-specific disability, for which several different instrument options were identified and detailed. The minimal clinically important difference varies between instruments and differentiates statistical significance from clinical significance. In addition, the accurate estimation of costs has become a challenging but intrinsically linked variable to outcomes as increased attention is paid to the relative value of surgical interventions. CONCLUSION: While a number of PROMs are available for tracking outcomes in spine surgery, only a handful appear to be widely used. At least one instrument from each category should be measured pre- and post-operatively to quantify treatment effect. In addition, while the primary goal is to select the most appropriate instruments for the patient's condition, one should keep in mind sustainability of efforts with regard to patient and administrative burden.

Advanced Multi-Axis Spine Testing: Clinical Relevance and Research Recommendations.

Back pain and spinal degeneration affect a large proportion of the general population. The economic burden of spinal degeneration is significant, and the treatment of spinal degeneration represents a large proportion of healthcare costs. However, spinal surgery does not always provide improved clinical outcomes compared to non-surgical alternatives, and modern interventions, such as total disc replacement, may not offer clinically relevant improvements over more established procedures. Although psychological and socioeconomic factors play an important role in the development and response to back pain, the variation in clinical success is also related to the complexity of the spine, and the multi-faceted manner by which spinal degeneration often occurs. The successful surgical treatment of degenerative spinal conditions requires collaboration between surgeons, engineers, and scientists in order to provide a multi-disciplinary approach to managing the complete condition. In this review, we provide relevant background from both the clinical and the basic research perspectives, which is synthesized into several examples and recommendations for consideration in increasing translational research between communities with the goal of providing improved knowledge and care. Current clinical imaging, and multi-axis testing machines, offer great promise for future research by combining invivo kinematics and loading with in-vitro testing in six degrees of freedom to offer more accurate predictions of the performance of new spinal instrumentation. Upon synthesis of the literature, it is recommended that in-vitro tests strive to recreate as many aspects of the in-vivo environment as possible, and that a physiological preload is a critical factor in assessing spinal biomechanics in the laboratory. A greater link between surgical procedures, and the outcomes in all three anatomical planes should be considered in both the in-vivo and in-vitro settings, to provide data relevant to quality of motion, and stability.

Myofascial Closure of Intradural Inclusion Cysts following in utero Myelomeningocele Repair.

Myelomeningocele is one of the most common congenital malformations. A randomized controlled trial, known as the Management of Myelomeningocele Study (MOMS), demonstrated that closure during the fetal period can be performed relatively safely and be of significant benefit to patients. However, postnatally, patients can develop resultant symptoms from a tethered cord and inclusion cysts; this often requires surgical treatment. Repeat surgery in this population can be challenging due to the age of the patients, the extent of surgical exposure needed and the need for resection of dermal and epidermal tissues in the midline. We describe our approach for closure of these complex defects using lateral fasciocutaneous flaps with relaxing incisions made in the posterior axillary line, in order to minimize tension and maximize soft tissue coverage of the midline.

Minimally Invasive Surgery for Traumatic Fractures in Ankylosing Spinal Diseases.

Study Design Retrospective case series. Objective Ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) are two related diseases that significantly increase the risk of unstable spinal fractures from seemingly trivial trauma. Given the older age and higher surgical risk profile of most of these patients, minimally invasive (MIS) approaches to the treatment of such fractures may reduce operative risk and physiologic stress. Methods Eleven consecutive patients with hyperextension thoracolumbar injuries and a diagnosis of AS or DISH admitted to a single level I trauma center between June 2009 and June 2014 were retrospectively reviewed. All patients were treated with MIS stabilization. In addition, the patients were administered the Oswestry Disability Index and EuroQol-5D surveys to evaluate patient-reported outcomes regarding disability and health-related quality of life, respectively. Results Of the 11 patients, 10 were alive at the time of review. The mean follow-up time was 28 months. The average age was 77 years old with a mean body mass index of 34. All patients had severe systemic disease, American Society of Anesthesiologists grade III, with multiple medical comorbidities. Seven segments on average were included in the operative construct. There were no instrumentation failures or nonunions requiring revision surgery. The average postoperative Oswestry disability index was 21.5% (range: 0 to 34%), corresponding to low to moderate disability, and the average EuroQol-5D utility score was 0.77 (range: 0.60 to 1), a similar average postoperative utility value to those published in the literature on elective surgery for degenerative lumbar conditions. Conclusions MIS stabilization, when used on patients with good preoperative neurologic status, can successfully manage spinal fractures in patients with AS and DISH and preserve a favorable postoperative quality of life with limited disability.

Endoscopic approaches to brainstem cavernous malformations: Case series and review of the literature.

BACKGROUND: Symptomatic cavernous malformations involving the brainstem are frequently difficult to access via traditional methods. Conventional skull-base approaches require significant brain retraction or bone removal to provide an adequate operative corridor. While there has been a trend toward limited employment of the most invasive surgical approaches, recent advances in endoscopic technology may complement existing methods to access these difficult to reach areas. CASE DESCRIPTIONS: Four consecutive patients were treated for symptomatic, hemorrhagic brainstem cavernous malformations via fully endoscopic approaches (endonasal, transclival; retrosigmoid; lateral supracerebellar, infratentorial; endonasal, transclival). Together, these lesions encompassed all three segments of the brainstem. Three of the patients had complete resection of the cavernous malformation, while one patient had stable residual at long-term follow up. Associated developmental venous anomalies were preserved in the two patients where one was identified preoperatively. Three of the four patients maintained stable or improved neurological examinations following surgery, while one patient experienced ipsilateral palsies of cranial nerves VII and VIII. The first transclival approach resulted in a symptomatic cerebrospinal fluid leak requiring re-operation, but the second did not. Although there are challenges associated with endoscopic approaches, relative to our prior microsurgical experience with similar cases, visualization and illumination of the surgical corridors were superior without significant limitations on operative mobility. CONCLUSION: The endoscope is a promising adjunct to the neurosurgeon's ability to approach difficult to access brainstem cavernous malformations. It allows the surgeon to achieve well-illuminated, panoramic views, and by combining approaches, can provide minimally invasive access to most regions of the brainstem.

Aneurysmal vasculopathy in human-acquired immunodeficiency virus-infected adults: Imaging case series and review of the literature.

BACKGROUND: Intracranial vasculopathy in adult patients with human-acquired immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) is a rare but increasingly recognized disease entity. OBJECTIVE: We aimed to contribute to and summarize the adult literature describing patients with HIV/AIDS who have intracranial vasculopathy. METHODS: A retrospective review of adult patients with HIV/AIDS undergoing diagnostic cerebral angiography at our institution from 2007-2013 was performed. A literature review of relevant existing studies was performed. RESULTS: Five adult patients with HIV-related aneurysmal and occlusive vasculopathy were diagnosed and/or treated at our institution. A comprehensive review of the literature yielded data from 17 series describing 28 adult patients with HIV/AIDS and intracranial vasculopathy. Our review suggests that low CD4 count, motor weakness, and meningismus may be associated with the sequelae of intracranial vasculopathy/vasculitis in patients with HIV/AIDS. CONCLUSION: Patients with HIV/AIDS who have aneurysmal and stenotic vascular disease may benefit from earlier surveillance with the onset of neurological symptoms. The roles of medical, open surgical, and endovascular therapy in this unique entity will be further defined as the pathological basis of the disease is better understood.

Genetics of Moyamoya disease.

Moyamoya disease (MMD) is a disease pattern consisting of bilateral stenosis of the intracranial internal carotid arteries (ICA) accompanied by a network of abnormal collateral vessels that bypass the stenosis. Once symptomatic, insufficient cerebral blood flow or rupture of the fragile collaterals may cause stroke or hemorrhage, resulting in severe neurological dysfunction or death. The etiology of MMD is still unknown, although few associations with other diseases and environmental factors have been described. Strong regional differences in epidemiological data, as well as known familial cases, turned the focus to genetics for the insight into the disease's pathogenesis. Thus far, several reports have suggested specific genetic loci and individual genes as predisposing to MMD, but none have demonstrated reproducible results in independent cohorts. Small sample sizes, as well as a likely multifactorial origin, seem to be the most challenging tasks in identifying the disease-causing mechanisms. Once identified, susceptibility genes may allow preventive screening and a possible development of novel therapeutic options.

Prevalence of productivity-enhancing technologies in radiology.

OBJECTIVE: The objective of our study was to describe the prevalence of different operational technologies in radiology practices and to identify which characteristics of radiology practices are plausibly causal factors in a practice's use of a technology. MATERIALS AND METHODS: We analyzed data from the American College of Radiology's 2003 Survey of Radiologists, a stratified random-sample survey that guaranteed respondents' confidentiality and achieved a 63% response rate with a total of 1,924 responses. Responses were weighted to make them representative of all radiologists and radiology practices in the United States. We used univariate analysis and multiple logistic regression. RESULTS: In 2003, PACS, wet-reading telephone lines, film-hanging staff, and templates (standard report language) were each used in practices that encompassed approximately half of U.S. radiologists. In contrast, only 42% of radiologists were in practices that used nurse practitioners or physician assistants for tasks beyond what technologists may do, and only 18% were in practices that used speech recognition software (SRS). Twenty-one percent of radiologists were in practices reported to have neither film-hanging staff nor PACS. The percentage of practices (as opposed to radiologists) that used various technologies ranged from 13% for SRS to 49% for templates. Multiple logistic regression showed that, other factors equal, academic practices were particularly likely to use some of the technologies and solo practices and other small practices were particularly likely not to have some of the technologies. CONCLUSION: Most operational technologies are fairly widely diffused, but a surprising number of radiologists work without some basic supports.