Anterior Lumbar Corpectomy with Expandable Titanium Cage Reconstruction: A Case Series of 42 Patients.

BACKGROUND: Burst fractures involve the anterior and middle columns with an intact posterior column. Deforming forces are magnified at areas of transition, making the thoracolumbar junction highly susceptible to injury. METHODS: This is a retrospective review of 42 consecutive patients who underwent single-level anterior lumbar corpectomy using an obelisc expandable titanium cage and lateral fixation for traumatic lumbar burst fractures. RESULTS: Myelopathy and sensory dysfunction were the most frequent neurologic deficits initially, occurring in 16 (38%) and 15 (36%) patients, respectively, which both decreased to 5 (13%). At follow-up, 26 patients (68%) were able to ambulate independently. No patient had significant cage displacement or needed cage replacement. Subsidence was minimal in 32 of 39 patients (82%). There were no hardware infections or surgical site infections. Options for stabilization include posterior instrumentation and fusion, anterior corpectomy with interbody fusion, and combination procedures. We believe anterior stabilization is superior because the aim is structural restoration of anterior and middle columns. The aim of posterior fixation is to replace the posterior tension band, which is not affected. There are 3 major surgical components to consider. First is anterior versus posterior decompression of the spinal canal. Second is the choice of autograft or titanium graft. Third is whether to stabilize posteriorly or anterolateral. CONCLUSIONS: Anterior corpectomy with an expandable titanium cage and lateral rod fixation is safe and effective with minimal complications. It is a viable alternative to posterior decompression and instrumentation.

Neuroanatomical Interpretation of the Painting Starry Night by Vincent van Gogh.

Gogh, Vincent Van (1853-1890). The Starry Night. Saint Rémy, June 1889. Oil on canvas, 29 × 36 1/4″ (73.7 × 92.1 cm). Acquired through the Lillie P. Bliss Bequest. The Museum of Modern Art. Digital Image © The Museum of Modern Art/Licensed by SCALA/Art Resource, NY.

The effect of multidisciplinary teams for rectal cancer on delivery of care and patient outcome: has the use of multidisciplinary teams for rectal cancer affected the utilization of available resources, proportion of patients meeting the standard of care, and does this translate into changes in patient outcome?

BACKGROUND: We hypothesized that mandatory multidisciplinary team (MDT) participation improves process evaluation, outcomes, and technical aspects of surgery for rectal cancer in a stable practice of colorectal surgery. METHODS: A retrospective review of MDT data was conducted of all patients with colorectal cancer since 2010. Demographic, clinical stage, process evaluation, quality of surgery, and outcome data were collected. Total mesorectal excision and MDT required participation started 2013. RESULTS: One hundred thirty patients were included in this study: 47 patients in 2014; 41 patients in 2013; and 42 patients pre-MDT. Improvements were seen in 12 of the 14 preoperative process variables, 6 significantly. Improvement in the completeness of total mesorectal excision (0% to 76%) was significant. Local recurrence occurred in 10% of the pre-MDT group, and follow-up is ongoing in the MDT groups. CONCLUSIONS: MDT participation improves care of patients with rectal cancer. Preoperative clinical staging, multimodality treatment, pathologic staging, and technical aspects of surgery have improved.

Trauma patient readmissions: Why do they come back for more?

BACKGROUND: Hospital readmissions are a frequent challenge. Speculation exists that rates of readmission following traumatic injury will be publicly disclosed. The primary aim of this study was to characterize and model 1-year readmission patterns to multiple institutions among patients originally admitted to a single, urban Level I trauma center. Additional analyses within the superutilizers subgroup identified predictors of 30-day readmissions as well as patient loyalty for readmission to their index hospital. We hypothesized that hospital readmission among trauma patients would be associated with socioeconomic, demographic, and clinical features and superutilizers would be identifiable during initial hospitalization. METHODS: Data were retrospectively gathered for 2,411 unique trauma patients admitted to a Level I American College of Surgeons-certified trauma center over 1 year, with readmissions identified 1 year after index admission. A regional hospital database was queried for readmissions. Outcomes of all readmission encounters were analyzed using a binary logistic regression model including demographic, diagnoses, Injury Severity Score (ISS), procedures, Elixhauser comorbidities, insurance, and disposition data. Subset analysis of superutilizers was also performed to examine patterns among superutilizers. RESULTS: A total of 434 patients (21%) were readmitted during the study period, accounting for 720 readmission encounters. Sixty-three patients accounting for 269 encounters were identified as superutilizers (3+ readmissions). A total of 136 patients (6%) were readmitted within 30 days of initial discharge. Fifty-seven percent of readmissions returned to the originating hospital. CONCLUSION: Complications including comorbid disease (diabetes and congestive heart failure), septicemia, weight loss, and trauma recidivism distinguish the superutilizer trauma patient. Having Medicaid funding increased the odds of readmission by 274%. It is imperative that interventions be developed and targeted toward those at high risk of superutilization of health care resources to curb spending. These results strongly support continuation of longitudinal readmission research in trauma patients conducted in multicenter settings. LEVEL OF EVIDENCE: Epidemiologic study, level III.