Contralateral psoas hematoma after minimally invasive, lateral retroperitoneal transpsoas lumbar interbody fusion: a multicenter review of 3950 lumbar levels.

OBJECTIVE Minimally invasive lateral lumbar interbody fusion (LLIF) via the retroperitoneal transpsoas approach is a technically demanding procedure with a multitude of potential complications. A relatively unknown complication is the contralateral psoas hematoma. The authors speculate that injury occurs from segmental vessel injury at the time of contralateral annulus release; however, this is not fully understood. In this multicenter retrospective review, the authors report the incidence of this contralateral complication and its neurological sequelae. METHODS This study was a retrospective chart review of all minimally invasive LLIF performed at participating institutions from 2008 to 2014. Exclusion criteria included an underlying diagnosis of trauma or neoplasia as well as lateral corpectomies or anterior column releases. Single-level, multilevel, and stand-alone constructs were included. All patients underwent preoperative MRI. Follow-up was at least 12 months. All complications and clinical outcomes were self-reported by each surgeon. RESULTS There were 3950 lumbar interbody cages placed via the retroperitoneal transpsoas approach, with 7 cases (0.18% incidence) of symptomatic contralateral psoas hematoma, 3 of which required reoperation for hematoma evacuation. Neurological outcome did not improve after reoperation. Reoperation occurred an average of 1 month after the initial operation due to a delay in diagnosis. In 1 case, segmental artery injury was confirmed at the time of surgery; in the others, segmental vessel injury was suspected, although it could not be confirmed. Neurological deficits persisted in 3 patients while the others remained neurologically intact. Two patients were receiving antiplatelet therapy prior to the procedure. CONCLUSIONS The contralateral psoas hematoma is a rare complication suspected to occur from segmental vessel injury during contralateral annulus release. Detailed review of preoperative imaging for aberrant vessel anatomy may prevent injury and subsequent neurological deficit.

Intraoperative Magnetic Resonance Imaging in Skull Base Surgery: A Review of 71 Consecutive Cases.

BACKGROUND: Although intraoperative magnetic resonance imaging (iMRI) increasingly is used during glioma resection, its role in skull base surgery has not been well documented. In this study, we evaluate our experience with iMRI for skull base surgery. METHODS: Medical records were reviewed retrospectively on all neurosurgical cases performed at our institution in the IMRIS iMRI suite between April 2014 and July 2015. RESULTS: During the study period, the iMRI suite was used for 71 skull base tumors. iMRI was performed in 23 of 71 cases. Additional tumor resection was pursued after scanning in 7 of 23 patients. There was a significant difference in procedure length between the scanned versus nonscanned groups, and this was likely attributable to a greater proportion of petroclival meningiomas in the scanned group. Further analyses revealed significant increases in procedure length for the following scanned subgroups: anterolateral approach, anterolateral and petroclival lesion locations, and meningiomas. The rate of non-neurologic complications was significantly greater in the scanned group, particularly for patients with tumors >3 cm. CONCLUSIONS: Despite the unique challenges associated with skull base tumor surgery, iMRI can be safely obtained while adding a modest although not prohibitive amount of time to the procedure. The immediate evidence of residual tumor with a patient still in position to have additional resection may influence the surgeon to alter the surgical plan and attempt further resection in a critical area.

Minimally invasive anterolateral corpectomy for spinal tumors.

Traditional open anterior and posterior approaches for the thoracic and thoracolumbar spine are associated with approach-related morbidity and limited surgical access to the level of abnormality. This article describes the minimally invasive anterolateral corpectomy for the treatment of spinal tumors, and reviews the current literature.

Oral health comparison between children with neutropenia and healthy controls.

The purpose of this cross-sectional study was to assess and compare the oral health of children with neutropenia, who are under the active care of a hematologist in a designated marrow failure and myelodysplasia program, to a healthy control group. Children aged 6-18 with neutropenia attending the Marrow Failure and Myelodysplasia Program at SickKids Hospital and controls attending the Children's Clinic, Faculty of Dentistry, University of Toronto were asked to participate in the study consisting of a patient questionnaire followed by a dental and radiographic examination. Fifteen patients with neutropenia (mean age 12.14 ± 4.04 years) and 26 healthy controls (mean age 11.61 ± 3.82 years) participated in this study. Patients with neutropenia reported significantly increased mouth sores (p < .008) and bleeding gums while brushing (p < .001). The dmft/t score was significantly lower for the neutropenia group (p < .009). The clinical examination also showed that there were no statistically significant differences with respect to ulcerations, gingival recession, tooth mobility, gingival inflammation, periodontal bone loss, DMFT/T scores, plaque, and calculus levels. Preliminary data demonstrates that pediatric patients who are under the active care of a hematologist do not present with an increased risk of oral diseases.

Angiography-negative primary angiitis of the central nervous system in childhood.

Childhood primary angiitis of the CNS is a recently characterized, potentially reversible disease process. A favorable outcome requires early diagnosis and appropriate treatment. The histological findings of childhood primary angiitis of the CNS are characterized by a lymphocytic, nongranulomatous vasculitis. This disorder can lead to neurological deficits, seizures, and strokes. Laboratory and radiographic investigation are part of the evaluation, but are often nonspecific. Conventional angiography can fail to show any abnormality, and biopsy may ultimately be required for diagnosis. Although there can be significant rates of morbidity and mortality if untreated, patients who receive appropriate therapy can experience excellent outcomes, and in many cases will demonstrate near-complete or total clinical and radiographic resolution. The case of a previously healthy 13-year-old girl with new-onset generalized tonic-clonic seizures is presented, with a review of the literature.

Outcome of corpus callosotomy in adults.

We present, to our knowledge, the first published series of corpus callosotomy (CC) in adults with medically intractable symptomatic generalized epilepsy (SGE). Fifteen adults were followed for the outcome measures of seizure and antiepileptic drug (AED) burden and quality of life (QoL). Five (33%) patients reported >60%, one (7%) reported between 30 and 60%, and nine (60%) reported <30% reduction in the total number of seizures after CC. Seven (47%) patients reported >60%, three (20%) experienced between 30 and 60%, and five (33%) reported <30% atonic seizure reduction. Twelve patients had no change in AED burden. Nine (60%) patients had no change in QoL, while six (40%) reported some improvement. Corpus callosotomy should be considered as a safe option for adults with medically intractable SGE with demonstrated reduction in the frequency of atonic seizures, and some patients experience a meaningful improvement in quality of life.

Early versus delayed carotid endarterectomy in symptomatic patients.

BACKGROUND: Delayed carotid endarterectomy (CEA) after a stroke or transient ischemic attack (TIA) is associated with risks of recurrent neurologic symptoms. In an effort to preserve cerebral function, urgent early CEA has been recommended in many circumstances. We analyzed outcomes of different time intervals in early CEA in comparison with delayed treatment. STUDY DESIGN: Retrospective chart review from a single university hospital tertiary care center between April 1999 and November 2010 revealed 312 patients who underwent CEA following stroke or TIA. Of these 312 patients, 69 received their CEA within 30 days of symptom onset and 243 received their CEA after 30 days from symptom onset. The early CEA cohort was further stratified according to the timing of surgery: group A (27 patients), within 7 days; group B (17), between 8 and 14 days; group C (12), between 15 and 21 days; and group D (12), between 22 and 30 days. Demographic data as well as 30-day (mortality, stroke, TIA, and myocardial infarction) and long-term (all-cause mortality and stroke) adverse outcome rates were analyzed for each group. These were also analyzed for the entire early CEA cohort and compared against the delayed CEA group. RESULTS: Demographics and comorbid conditions were similar between groups. For 30-day outcomes, there were no deaths, 1 stroke (1.4%), 0 TIAs, and 0 myocardial infarctions in the early CEA cohort; in the delayed CEA cohort, there were 4 (1.6%), 4 (1.6%), 2 (0.8%), and 2 (0.8%) patients with these outcomes, respectively (P > .05 for all comparisons). Over the long term, the early group had one ipsilateral stroke at 17 months and the delayed group had two ipsilateral strokes at 3 and 12 months. For long-term outcomes, there were 16 deaths in the early CEA cohort (21%) and 74 deaths in the delayed CEA cohort (30%, P > .05). Mean follow-up times were 4.5 years in the early CEA cohort and 5.8 years in the delayed CEA cohort. CONCLUSIONS: There were no differences in 30-day and long-term adverse outcome rates between the early and delayed CEA cohorts. In symptomatic carotid stenosis patients without evidence of intracerebral hemorrhage, carotid occlusion, or permanent neurologic deficits early carotid endarterectomy can be safely performed and is preferred over delaying operative treatment.

Emergent repair of acute thoracic aortic catastrophes: a comparative analysis.

OBJECTIVE: To provide a contemporary institutional comparative analysis of expedient correction of acute catastrophes of the descending thoracic aorta (ACDTA) by traditional direct thoracic aortic repair (DTAR) or thoracic endovascular aortic repair (TEVAR). DESIGN: Single-center retrospective review (April 2001-January 2010). SETTING: Academic medical center. PATIENTS: One hundred patients with ACDTA treated with either TEVAR (n = 76) or DTAR (n = 24). Indications for repair included ruptured degenerative aneurysm (n = 41), traumatic transection (n = 27), complicated acute type B dissection (n = 20), penetrating ulcer (n = 4), intramural hematoma (n = 3), penetrating injury (n = 3), and embolizing lesion (n = 2). MAIN OUTCOME MEASURES: Demographics and 30-day and late outcomes were analyzed using multivariate analysis over a mean follow-up of 33.8 months. RESULTS: Among the 100 patients, mean (SD) age was 58.5 (17.3) years (range, 18-87 years). Demographics and comorbid conditions were similar between the 2 groups, except more patients in the DTAR group had prior aortic surgery (P = .02) and were older (P = .01). Overall 30-day mortality was significantly better among the TEVAR group (8% vs 29%; P = .007). Incidence of postoperative myocardial infarction, acute renal failure, stroke, and paraplegia/paresis was similar between the 2 treatment groups (TEVAR, 5%, 12%, 8%, and 8% vs DTAR, 13%, 13%, 9%, and 13%, respectively). Major respiratory complications were lower in the TEVAR group (16% vs 48%; P < .05). Mean length of hospital stay was also shorter after TEVAR (13.5 vs 16.3 days; P = .30). Independent predictors of patient mortality included age (P = .004) and DTAR (P = .001). CONCLUSION: Patients presenting with ACDTA are best treated with TEVAR whenever feasible.

A comparative study of the bell-bottom technique vs hypogastric exclusion for the treatment of aneurysmal extension to the iliac bifurcation.

INTRODUCTION: A significant proportion of patients undergoing endovascular aneurysm repair (EVAR) have common iliac artery aneurysms (CIAA). Aneurysmal involvement at the iliac bifurcation potentially undermines long-term durability. METHODS: Patients with CIAA who underwent EVAR were identified in two teaching hospitals. Bell-bottom technique (BBT; iliac limb ≥20 mm) or internal iliac artery embolization and limb extension to the external iliac artery (IIE + EE) were used. Outcome between these two approaches was compared. RESULTS: We identified 185 patients. Indication for EVAR included asymptomatic abdominal aortic aneurysm (AAA) in 157, symptomatic or ruptured aneurysm in 19, and CIAA in nine. Mean AAA diameter was 59 mm. Among 260 large CIAAs that were treated, BBT was used to treat 166 CIAA limbs, and 94 limbs underwent IIE + EE. Total reintervention rates were 11% for BBT (n = 19) and 19.1% for IIE + EE (n = 18; P = .149). Rates of reintervention for type Ib or III endoleak were 4% for BBT (n = 7) and 4% for IIE + EE (n = 4; P > .99). The difference in limb patency rates was not significant. The 30-day mortality rate was 1%. Median follow-up was 22 months. Complications did not differ significantly between the two groups; however, the combined incidence of perioperative complications and reinterventions was higher in the IIE + EE group (49% vs 22%; P = .002). CONCLUSIONS: The combined incidence of perioperative complications and reinterventions is significantly higher with IIE + EE than with BBT; therefore, when feasible, BBT is desirable.

Does a contralateral carotid occlusion adversely impact carotid artery stenting outcomes?

BACKGROUND: Carotid artery stenting (CAS) has grown as a possible alternative for the treatment of extracranial cerebrovascular disease in the past decade. A preexisting contralateral carotid artery occlusion has been described as a risk factor for inferior outcomes after carotid endarterectomy, but its impact on CAS outcomes is less understood. METHODS: A retrospective review of 417 CAS procedures performed between May 2001 and July 2010 at a single center using self-expanding nitinol stents and mechanical embolic protection devices was conducted. Patients were divided into two groups, those with a preexisting contralateral carotid occlusion (group A, n = 39) versus those without a contralateral occlusion (group B, n = 378). Patient demographics and comorbidities as well as 30-day and late death, stroke, and myocardial infarction (MI) rates were analyzed. Mean follow-up was 4 years (range: 0-9.4 years). RESULTS: Overall, mean age of the 314 men and 103 women was 70.5 years. In group A, there were two (5.1%) octogenarians and nine patients (23.1%) with symptomatic disease as compared with group B with 53 (14%) octogenarians and 121 (32%) patients with symptomatic disease. The overall 30-day death, stroke, and MI rates were 0.5%, 1.9%, and 0.7%, respectively. When comparing group A with group B, these results were not significantly different: death (0% vs. 0.5%), stroke (2.6% vs. 1.9%), and MI (0% vs. 0.8%). Long-term outcomes for groups A and B were also not significantly different: death (25.6% vs. 22.2%), stroke (5.3% vs. 3.4%), and MI (15.4% vs. 14%) (p = nonsignificant). CONCLUSION: A preexisting contralateral carotid artery occlusion does not seem to adversely impact CAS outcomes.

Obesity paradox in amputation risk among nonelderly diabetic men.

The association between BMI and amputation risk is not currently well known. We used data for a cohort of diabetic patients treated in the US Department of Veterans Affairs Healthcare System in 2003. Men aged <65 years at the end of follow-up were examined for their amputation risk and amputation-free survival during the next 5 years (2004-2008). Compared to overweight individuals (BMI 25-29.9 kg/m(2)), the risks of amputation and treatment failure (amputation or death) were higher for patients with BMI <25 kg/m(2) and were lower for those with BMI ≥30 kg/m(2). Individuals with BMI ≥40 kg/m(2) were only half as likely to experience any (hazard ratios (HR) = 0.49; 95% confidence interval (CI), 0.30-0.80) and major amputations (HR = 0.53; 95% CI, 0.39-0.73) during follow-up as overweight individuals. While the amputation risk continued to decrease for higher BMI, amputation-free survival showed a slight upturn at BMI >40 kg/m(2). The association between obesity and amputation risk in our data shows a pattern consistent with "obesity paradox" observed in many health conditions. More research is needed to better understand pathophysiological mechanisms that may explain the paradoxical association between obesity and lower-extremity amputation (LEA) risk.

The role of hospital-based dentistry in providing treatment for persons with developmental delay.

Hospital dentistry is important to the delivery of oral health care to persons with disabilities. Recent cuts in funding for hospital dentistry in Ontario have placed a great strain on the health care system"s ability to meet the demand for such care. General anesthesia is an accepted treatment option for patients who are uncooperative, but involves inherent risks. In this paper, we present the case of a person with developmental delay who received dental treatment under general anesthesia and subsequently developed complications to support the position that a dental program for persons with special needs should be provided in a hospital setting to minimize their risk of suffering serious complications and to ensure their safety.