Complications and Revision Rates in Minimally Invasive Robotic-Guided Versus Fluoroscopic-Guided Spinal Fusions: The MIS ReFRESH Prospective Comparative Study.

STUDY DESIGN: Prospective, multicenter, partially randomized. OBJECTIVE: Assess rates of complications, revision surgery, and radiation between Mazor robotic-guidance (RG) and fluoro-guidance (FG). SUMMARY OF BACKGROUND DATA: Minimally invasive surgery MIS ReFRESH is the first study designed to compare RG and FG techniques in adult minimally invasive surgery (MIS) lumbar fusions. METHODS: Primary endpoints were analyzed at 1 year follow-up. Analysis of variables through Cox logistic regression and a Kaplan-Meier Survival Curve of surgical complications. RESULTS: Nine sites enrolled 485 patients: 374 (RG arm) and 111 (FG arm). 93.2% of patients had more than 1 year f/u. There were no differences for sex, Charlson Comorbidity Index, diabetes, or tumor. Mean age of RG patients was 59.0 versus 62.5 for FG (P = 0.009) and body mass index (BMI) was 31.2 versus 28.1 (P< 0.001). Percentage of smokers was almost double in the RG (15.2% vs. 7.2%, P = 0.029). Surgical time was similar (skin-to-skin time/no. of screws) at 24.9 minutes RG and 22.9 FG (P = 0.550). Fluoroscopy during surgery/no. of screws was 15.5 seconds RG versus 35.4 seconds FG, (15 seconds average reduction). Fluoroscopy time during instrumentation/no. of screws was 3.6 seconds RG versus 17.8 seconds FG showing an 80% average reduction of fluoro time/screw in RG (P < 0.001). Within 1 year follow-up, there were 39 (10.4%) surgical complications RG versus 39 (35.1%) FG, and 8 (2.1%) revisions RG versus 7 (6.3%) FG. Cox regression analysis including age, sex, BMI, CCI, and no. of screws, demonstrated that the hazard ratio (HR) for complication was 5.8 times higher FG versus RG (95% CI: 3.5-9.6, P < 0.001). HR for revision surgery was 11.0 times higher FG versus RG cases (95% CI 2.9-41.2, P < 0.001). CONCLUSION: Mazor robotic-guidance was found to have a 5.8 times lower risk of a surgical complication and 11.0 times lower risk for revision surgery. Surgical time was similar between groups and robotic-guidance reduced fluoro time per screw by 80% (approximately 1 min/case).Level of Evidence: 2.

Digital images taken with a mobile phone can assist in the triage of neurosurgical patients to a level 1 trauma centre.

We investigated whether head CT images captured using a mobile phone would be of sufficient quality for neurosurgeons at a level 1 trauma centre to make decisions about whether to transfer patients from referring hospitals. All patients who had been transferred from outside facilities with reported intracranial pathology during 2008 were identified. Two emergency medicine physicians selected 1-3 images from the hospital archive that best represented the pathology described by the radiologist and the medical record. The images were photographed in a darkened room using a smart phone. The mobile phone images and clinical history were reviewed by two neurosurgeons independently. The neurosurgeons rated the adequacy and quality of the images, and indicated whether the images would have changed their transfer decision. Based on clinical data alone, neurosurgeon A would have transferred 64 (73%) patients and neurosurgeon B 39 (44%). After images were provided, A would have transferred 67 (76%) and B would have transferred 49 (56%). The availability of the images significantly altered the transfer decision by A in 25 cases (28%) (P = 0.024) and by B in 28 cases (32%) (P < 0.001). The level of agreement between the two neurosurgeons significantly increased from 53% (kappa = 0.11) to 75% (kappa = 0.47) (P < 0.001). Mobile-phone images of CT scans appear to provide adequate images for triaging patients and helping with transfer decisions of neurosurgical cases.

Surgical decompression and coil removal for the recovery of vision after coiling and proximal occlusion of a clinoidal segment aneurysm: technical case report.

OBJECTIVE: We present the case of a patient with continued deterioration of vision after endovascular treatment of an unruptured clinoidal segment aneurysm. In conjunction with a review of the literature, the findings in this case highlight the need for further refinements in our understanding of pathophysiological changes induced by coiling of cerebral aneurysms, especially those in aneurysms producing signs and symptoms relating to mass effect. CLINICAL PRESENTATION: The patient is a 45-year-old man who presented with progressive vision loss. Imaging studies revealed a large, clinoidal segment aneurysm. The patient continued to experience progressive vision loss despite treatment with endovascular coiling, proximal occlusion, and high-dose steroid medication. INTERVENTION: The patient underwent a craniotomy for decompression of the optic nerve and for salvage of vision. Clipping of the distal vessel was performed, and the coil mass was removed. The patient experienced marked improvement of central vision after the surgical procedure. CONCLUSION: Although endovascular treatment of aneurysms protects most patients from aneurysm rupture, this case illustrates the fact that coiling, followed by proximal occlusion, might fail to alleviate symptoms related to mass effect. Our experience in this case suggests that early surgical decompression may be indicated for patients presenting with progressive visual deterioration.

Advancements in carotid stenting leading to reductions in perioperative morbidity among patients 80 years and older.

OBJECTIVE: Patients 80 years and older are generally considered to be at an increased risk for stroke and death from carotid endarterectomy. High-risk status often qualifies them for entry into a carotid angioplasty and stenting (CAS) trial. The aim of this study is to report periprocedure (0-30 d) morbidity and mortality among elderly patients undergoing CAS with and without distal embolic protection in an intention-to-treat analysis. METHODS: A retrospective review was performed to evaluate the medical records and imaging studies of patients 80 years or older who underwent attempted CAS procedures with and without distal embolic protection between June 1996 and February 2004. RESULTS: Ages of the 75 patients identified in our review ranged from 80 to 91 years (average 83.1 yr); 41 were men. Internal carotid artery stenosis ranged from 60 to 95% (mean 78.3%). Forty-two patients had symptoms (transient ischemic attack, 29; stroke, 13), and 33 patients were asymptomatic. Total event rates were major stroke, 4% (3 patients); minor stroke, 6.7% (5 patients); death, 4% (3 patients). Rates in the unprotected group (35 patients) were major stroke, 8.6% (3 patients); minor stroke, 5.7% (2 patients); major stroke/death, 14.3% (5 patients). Rates in the protected group (40 patients) were major stroke, 0; minor stroke, 7.5% (3 patients); major stroke/death, 0; (P < 0.05). CONCLUSION: These results suggest that elderly patients undergoing CAS with adjunctive distal embolic protection are at a lower risk of periprocedure adverse events. Routine clopidogrel use, smaller hardware profile, patient selection, and increased experience likely contributed to these results.