Triage of spine surgery referrals through a multidisciplinary care pathway: a value-based comparison with conventional referral processes.

STUDY DESIGN: Retrospective medical record review. OBJECTIVE: To (1) determine if outpatient referrals for low back pain (LBP) and leg pain triaged through a multidisciplinary spine care pathway (group A) were more likely to be candidates for surgery than conventional physician referrals (group B); (2) compare relevant clinical differences in the 2 groups (e.g., diagnosis, pain scores, level of disability); and (3) compare wait times for magnetic resonance imaging and surgical assessment. SUMMARY OF BACKGROUND DATA: The Saskatchewan Spine Pathway was introduced on the basis of evidence that a co-ordinated, multidisciplinary, and stratified approach to the assessment and management of LBP may improve quality. During early implementation, some physicians began to refer patients to Saskatchewan Spine Pathway clinics, whereas others continued to refer patients directly to the surgeon through the conventional process. METHODS: We retrospectively analyzed consecutive new outpatient referrals for LBP and leg pain, June 1, 2011 through May 30, 2012 for 2 surgeons. RESULTS: We identified 215 referrals, including 66 (30.7%) in group A and 149 (69.3%) in group B. There was no difference in overall health (mean EuroQol Group 5-Dimension Self-Report Questionnaire visual analogue scale) or lower back-related disability score (Oswestry Disability Index). Group A patients were significantly more likely to be candidates for surgery (59.1% vs. 37.6% for group B; P = 0.0034, χ test), had significantly poorer scores for EuroQol Group 5-Dimension Self-Report Questionnaire mobility, a higher proportion of leg dominant pain, and a lower proportion of back dominant pain. Group A patients also had significantly shorter wait times for magnetic resonance imaging and surgical assessment. CONCLUSION: A co-ordinated multidisciplinary pathway with a stratified approach to LBP assessment and care provided a greater proportion of surgery candidates than the conventional referral process. The implementation of such processes may allow surgeons to restrict their practices to patients who are more likely to benefit from their services, thereby reducing wait times and potentially reducing costs. LEVEL OF EVIDENCE: 3.

A prospective randomized trial of perioperative seizure prophylaxis in patients with intraparenchymal brain tumors.

OBJECT: Seizures are a potentially devastating complication of resection of brain tumors. Consequently, many neurosurgeons administer prophylactic antiepileptic drugs (AEDs) in the perioperative period. However, it is currently unclear whether perioperative AEDs should be routinely administered to patients with brain tumors who have never had a seizure. Therefore, the authors conducted a prospective, randomized trial examining the use of phenytoin for postoperative seizure prophylaxis in patients undergoing resection for supratentorial brain metastases or gliomas. METHODS: Patients with brain tumors (metastases or gliomas) who did not have seizures and who were undergoing craniotomy for tumor resection were randomized to receive either phenytoin for 7 days after tumor resection (prophylaxis group) or no seizure prophylaxis (observation group). Phenytoin levels were monitored daily. Primary outcomes were seizures and adverse events. Using an estimated seizure incidence of 30% in the observation arm and 10% in the prophylaxis arm, a Type I error of 0.05 and a Type II error of 0.20, a target accrual of 142 patients (71 per arm) was planned. RESULTS: The trial was closed before completion of accrual because Bayesian predictive probability analyses performed by an independent data monitoring committee indicated a probability of 0.003 that at the end of the study prophylaxis would prove superior to observation and a probability of 0.997 that there would be insufficient evidence at the end of the trial to choose either arm as superior. At the time of trial closure, 123 patients (77 metastases and 46 gliomas) were randomized, with 62 receiving 7-day phenytoin (prophylaxis group) and 61 receiving no prophylaxis (observation group). The incidence of all seizures was 18% in the observation group and 24% in the prophylaxis group (p = 0.51). Importantly, the incidence of early seizures (< 30 days after surgery) was 8% in the observation group compared with 10% in the prophylaxis group (p = 1.0). Likewise, the incidence of clinically significant early seizures was 3% in the observation group and 2% in the prophylaxis group (p = 0.62). The prophylaxis group experienced significantly more adverse events (18% vs 0%, p < 0.01). Therapeutic phenytoin levels were maintained in 80% of patients. CONCLUSIONS: The incidence of seizures after surgery for brain tumors is low (8% [95% CI 3%-18%]) even without prophylactic AEDs, and the incidence of clinically significant seizures is even lower (3%). In contrast, routine phenytoin administration is associated with significant drug-related morbidity. Although the lower-than-anticipated incidence of seizures in the control group significantly limited the power of the study, the low baseline rate of perioperative seizures in patients with brain tumors raises concerns about the routine use of prophylactic phenytoin in this patient population.

Neurocognitive function before and after surgery for insular gliomas.

OBJECT: Insular gliomas can be resected with acceptable rates of neurological morbidity, but little is known with regard to impairment of higher-order neurocognitive functions. The frequency and functional impact of neurocognitive deficits in patients with gliomas has until recently been underappreciated. The authors therefore examined neurocognitive function in patients with insular gliomas and compared the findings in this group to those in a matched control group of patients with gliomas in nearby brain regions. METHODS: Thirty-three patients with WHO Grade II or III insular gliomas participated in neuropsychological evaluations before and after resection. To establish whether the pattern of neurocognitive performance was different from that of other patients with tumors in neighboring areas, patients with insular tumors were matched with control patients for age, educational level, preoperative Karnofsky Performance Scale score, tumor side, grade, and volume. The control group comprised patients in whom gliomas had been resected from frontal, temporal, and parietal areas near the insula. Baseline pre- and postoperative neurocognitive test results were compared between and within groups. RESULTS: Preoperative neurocognitive impairment was common in both insular and control groups. Patients with insular tumors had significantly worse preoperative performance on naming tests. In both groups, postoperative decline occurred in most neurocognitive domains. There were no statistically significant differences between patients in the insular and control groups with regard to rates of postoperative decline on any test. However, there were trends suggesting differential cognitive performance postoperatively, because patients with insular tumors were more likely to experience greater decline in learning and memory. Neurological morbidity was similar to prior rates reported in the literature. CONCLUSIONS: Few statistically significant differences in cognitive function were observed between patients in the insular and control groups at either the pre- or postoperative evaluation, although there was a trend for patients with insular tumors to exhibit greater postoperative decline in learning and memory. Although technically more challenging, surgery for insular region glioma appears feasible without profound neurological or cognitive morbidity for many patients.

Intratumoral mediated immunosuppression is prognostic in genetically engineered murine models of glioma and correlates to immunotherapeutic responses.

PURPOSE: Preclinical murine model systems used for the assessment of therapeutics have not been predictive of human clinical responses, primarily because their clonotypic nature does not recapitulate the heterogeneous biology and immunosuppressive mechanisms of humans. Relevant model systems with mice that are immunologically competent are needed to evaluate the efficacy of therapeutic agents, especially immunotherapeutics. EXPERIMENTAL DESIGN: Using the RCAS/Ntv-a system, mice were engineered to coexpress platelet-derived growth factor B (PDGF-B) receptor + B-cell lymphoma 2 (Bcl-2) under the control of the glioneuronal specific Nestin promoter. The degree and type of tumor-mediated immunosuppression were determined in these endogenously arising gliomas on the basis of the presence of macrophages and regulatory T cells. The immunotherapeutic agent WP1066 was tested in vivo to assess therapeutic efficacy and immunomodulation. RESULTS: Ntv-a mice were injected with RCAS vectors to express PDGF-B + Bcl-2, resulting in both low- and high-grade gliomas. Consistent with observations in human high-grade gliomas, mice with high-grade gliomas also developed a marked intratumoral influx of macrophages that was influenced by tumor signal transducer and activator of transduction 3 (STAT3) expression. The presence of intratumoral F4/80 macrophages was a negative prognosticator for long-term survival. In mice coexpressing PDGF-B + Bcl-2that were treated with WP1066, there was 55.5% increase in median survival time (P < 0.01), with an associated inhibition of intratumoral STAT3 and macrophages. CONCLUSIONS: Although randomization is necessary for including mice in a therapeutic trial, these murine model systems are more suitable for testing therapeutics, especially immunotherapeutics, in the context of translational studies.

Histopathological examination of intervertebral disc specimens: a cost-benefit analysis.

OBJECT: Routine histopathological examination of intervertebral disc specimens is commonly performed in North American hospitals, but recent studies have questioned the utility of this practice in cases where the indication for surgery is a benign process such as degenerative disc disease. In this study, we have performed a cost-benefit analysis of this practice. METHODS: We performed a cost-benefit analysis of routine histopathological examination of 1775 routine (non-neoplastic and non-infectious indications for surgery) and 70 non-routine (suspected neoplastic or infectious indications for surgery) discectomy specimens obtained over an eight-year period (1996 and 2004). Chart reviews were used to determine if any histopathology findings were clinically significant (i.e., affected subsequent patient care). Total costs were calculated. A literature review was conducted to compare our results with other published series. RESULTS: We found four unexpected histopathology results among 1775 specimens obtained from routine cases, one of which was clinically significant. We calculated costs of $42,165.25 per unexpected histopathological finding and $168,625 per clinically significant histopathological finding. For non-routine surgeries, the cost per abnormal pathological finding was $116.67. CONCLUSIONS: In routine cases, histopathological examination of disc specimens is not justified. The decision to send specimens for pathological examination should be based on the surgeon's judgment.

Incidence of unusual and clinically significant histopathological findings in routine discectomy.

OBJECT: Routine histopathological examination of discectomy specimens remains common practice in many hospitals, although it rarely detects unsuspected clinically significant disease. Controversy exists as to the effectiveness of this practice. The objectives of this study were to compare the authors' experience with a review of the literature. METHODS: In a retrospective database analysis the authors identified all intervertebral disc specimens obtained during spinal procedures over an 8-year period (1996-2004). Cases of benign (nonneoplastic and noninfectious) indications for surgery were included in the study, whereas cases of nonbenign indications were excluded. The final pathological diagnoses were reviewed, and a chart review was performed to determine whether any unexpected findings affected subsequent patient care. A total of 1858 discectomy specimens were identified: 1775 of these were obtained in 1719 routine discectomy procedures. Unexpected histopathological findings were identified in four cases, and none was clinically significant. CONCLUSIONS: Routine histopathological examination of disc specimens is not justified. The decision to send specimens for pathological examination should be determined on a case-by-case basis after consideration of the clinical presentation, results of laboratory and imaging studies, and intraoperative findings.

Supportive care aspects of vertebroplasty in patients with cancer.

Minimally invasive vertebroplasty involves the percutaneous injection of polymethylmethacrylate bone cement into a fractured vertebral body. Although most frequently performed for osteoporotic compression fractures, vertebroplasty has also been very effective in the palliation of back pain secondary to osteolytic metastases and myeloma bone disease. The mechanism of pain relief is unclear; however, stabilization of microfractures and restoration of vertebral body strength is the leading theory. The decision to perform vertebroplasty is made after multiple factors are considered, including clinical presentation, medical fitness, functional capacity, tumor type, location and extent of disease, anticipated radiation sensitivity, and quality of life. Cement extravasation beyond the vertebral body is the most frequent complication; however, it is asymptomatic in the vast majority of patients. In the cancer setting, vertebroplasty is used as an adjunct to other standard treatments, including medical therapy, radiation therapy, chemotherapy, and surgery. In well-selected patients, vertebroplasty offers rapid relief of axial back pain and the potential for improved function.

Evolution of treatment for metastatic spine disease.

The management of patients with metastatic disease of the spine should be highly individualized and depends on several factors, including the clinical presentation, duration of symptoms, tu-mor type, anticipated radiosensitivity, tumor lo-cation, extent of extraspinal disease, integrity of the spinal column, and medical fitness and life expectancy of the patient. Early diagnosis and intervention are of paramount importance in improving the likelihood of functional neurologic recovery, with the maintenance of ambulation as the primary goal. Effective management of axial spinal pain involves reconstruction and stabilization of the spinal column. Although the ideal therapy has not been established, a wide range of management options is currently available.

Spinal subdural empyema after a dural tear. Case report.

Spinal subdural empyema is an exceptionally rare and serious condition. Immediate surgery with complete exposure and drainage of the abscess is generally recommended. The authors present a patient in whom a Staphylococcus aureus septicemia related to nosocomial pneumonia developed after a thoracic laminectomy. The surgery was further complicated by an unintended durotomy (dural tear). Ten days postoperatively, the patient experienced back pain and lower-extremity symptoms caused by a subdural empyema. Cultures from the wound also grew S. aureus. This represents the first case of spinal subdural empyema in which the spread of infection into the subdural space is believed to have been facilitated by a dural tear. The patient had a favorable outcome despite an initial delay in surgical intervention because of a pulmonary embolus.

Acceptability and impact of pet visitation on a pediatric cardiology inpatient unit.

We evaluated the effectiveness of a pet visitation program in helping children and their families adjust to hospitalization on a pediatric cardiology ward. Thirty-one pet visits were observed and followed by interviews with patients and parents. Analysis of data suggested that pet visits relieved stress, normalized the hospital milieu, and improved patient and parent morale. The benefit received by the subjects correlated with the amount of physical contact and rapport developed with the visiting animal.