Cost-Effectiveness of Postoperative Ketamine in Chiari Decompression.

INTRODUCTION: In Chiari I patients, postoperative pain and discomfort frequently slow the transition back to the home setting. OBJECTIVE: We sought to determine the effect of standardized ketamine infusion protocols on hospital length of stay (LOS). METHODS: This retrospective cohort study reviewed 100 consecutive adult patients undergoing Chiari I decompression. Fifty-nine patients were placed on a 2-3 mg/hr ketamine drip until postoperative day 1. This group was compared with a group who received 2-3 mg/hr of ketamine until postoperative day 2 (19 patients) and patients who did not receive ketamine at all (22 patients). Clinical characteristics, opioid use, LOS, and relative hospitalization costs were assessed. All narcotic amounts were converted into milligram equivalents of morphine. RESULTS: LOS of the short-ketamine group was 46.5 hours when compared with the long-ketamine group (66.8 hours) and no-ketamine group (56.9 hours). There was a statistically significant difference when comparing the short-ketamine group with the long-ketamine group and no-ketamine group together (P < 0.001), as well as when compared individually (P = 0.001 and 0.004). The mean cost of hospitalization was 20% less when a short-ketamine protocol was used (P < 0.001). Mean morphine milligram equivalents used postoperatively were 148 mg in the short-ketamine group, 196 mg in the long-ketamine group, and 187 mg in the no-ketamine group (P = 0.65). No adverse events from ketamine were noted. CONCLUSIONS: Ketamine at subanesthetic levels may be an effective tool to facilitate early return home postoperatively and may significantly reduce medical costs.

A minimally invasive technique for decompression of Chiari malformation type I (DECMI study): study protocol for a randomised controlled trial.

INTRODUCTION: Chiari malformation type I (CM-I) is a congenital hindbrain anomaly that requires surgical decompression in symptomatic patients. Posterior fossa decompression with duraplasty (PFDD) has been widely practiced in Chiari decompression, but dural opening carries a high risk of surgical complications. A minimally invasive technique, dural splitting decompression (DSD), preserves the inner layer of the dura without dural opening and duraplasty, potentially reducing surgical complications, length of operative time and hospital stay, and cost. If DSD is non-inferior to PFDD in terms of clinical improvement, DSD could be an alternative treatment modality for CM-I. So far, no randomised study of surgical treatment of CM-I has been reported. This study aims to evaluate if DSD is an effective, safe and cost-saving treatment modality for adult CM-I patients, and may provide evidence for using the minimally invasive procedure extensively. METHODS AND ANALYSIS: DECMI is a randomised controlled, single-masked, non-inferiority, single centre clinical trial. Participants meeting the criteria will be randomised to the DSD group and the PFDD group in a 1:1 ratio. The primary outcome is the rate of clinical improvement, which is defined as the complete resolution or partial improvement of the presenting symptoms/signs. The secondary outcomes consist of the incidence of syrinx reduction, postoperative morbidity rates, reoperation rate, quality of life (QoL) and healthcare resource utilisation. A total of 160 patients will be included and followed up at 3 and 12 months postoperatively. ETHICS AND DISSEMINATION: The study protocol was approved by the Biological and Medical Ethics Committee of West China Hospital. The findings of this trial will be published in a peer-reviewed scientific journal and presented at scientific conferences. TRIAL REGISTRATION NUMBER: ChiCTR-TRC-14004099.

Complications and Resource Use Associated With Surgery for Chiari Malformation Type 1 in Adults: A Population Perspective.

BACKGROUND: Outcomes research on Chiari malformation type 1 (CM-1) is impeded by a reliance on small, single-center cohorts. OBJECTIVE: To study the complications and resource use associated with adult CM-1 surgery using administrative data. METHODS: We used a recently validated International Classification of Diseases, Ninth Revision, Clinical Modification code algorithm to retrospectively study adult CM-1 surgeries from 2004 to 2010 in California, Florida, and New York using State Inpatient Databases. Outcomes included complications and resource use within 30 and 90 days of treatment. We used multivariable logistic regression to identify risk factors for morbidity and negative binomial models to determine risk-adjusted costs. RESULTS: We identified 1947 CM-1 operations. Surgical complications were more common than medical complications at both 30 days (14.3% vs 4.4%) and 90 days (18.7% vs 5.0%) postoperatively. Certain comorbidities were associated with increased morbidity; for example, hydrocephalus increased the risk for surgical (odds ratio [OR] = 4.51) and medical (OR = 3.98) complications. Medical but not surgical complications were also more common in older patients (OR = 5.57 for oldest vs youngest age category) and male patients (OR = 3.19). Risk-adjusted hospital costs were $22530 at 30 days and $24852 at 90 days postoperatively. Risk-adjusted 90-day costs were more than twice as high for patients experiencing surgical ($46264) or medical ($65679) complications than for patients without complications ($18880). CONCLUSION: Complications after CM-1 surgery are common, and surgical complications are more frequent than medical complications. Certain comorbidities and demographic characteristics are associated with increased risk for complications. Beyond harming patients, complications are also associated with substantially higher hospital costs. These results may help guide patient management and inform decision making for patients considering surgery.

Dura-splitting decompression of the craniocervical junction: reduced operative time, hospital stay, and cost with equivalent early outcome.

OBJECT: The choice of surgical technique for decompressive surgery in patients with Chiari I malformation is controversial. Good preliminary postoperative outcomes have been achieved in patients with Chiari I malformation (without syringomyelia) after using a dura-splitting technique. The authors evaluated safety, resource use, and early outcome after this surgery in patients without syringomyelia and compared the findings associated with duraplasty in patients with syringomyelia. METHODS: A prospective series of 24 patients with Chiari I malformation (12 with a syrinx) underwent decompression of the craniocervical junction (CCJ). An allograft-augmented duraplasty was performed in patients with syringomyelia. Intraoperative ultrasonography confirmed adequate tonsillar decompression after lysis of the periosteal bands at the foramen magnum and C-1 arch as well as partial resection of the outer leaf of the dura in patients without syringomyelia. Patients in each group were of similar mean age (syringomyelia 10.8 years and no syringomyelia 7.6 years old; p = 0.07) and functional status. The mean follow-up period was 15.3 months (range 3-30 months). Dura-splitting decompression required significantly less mean operative time (99 minutes compared with 169 minutes, respectively; p < 0.001), total operating room time (166 minutes compared with 249 minutes, respectively; p < 0.001), duration of hospitalization (3 days compared with 3.75 days, respectively; p < 0.05), perioperative charges ($3615 compared with $5538, respectively; p < 0.001), and overall hospital charges ($7705 compared with $9759, respectively; p < 0.001) than the duraplasty. Mean clinical outcome scores were similar (syringomyelia 1.53 of 2; no syringomyelia 1.67 of 2; not statistically significant). CONCLUSIONS: Dura-splitting CCJ decompression in pediatric patients with Chiari I malformation and without syringomyelia is safe, provides good early clinical results, and significantly reduces resource use. A randomized controlled trial of dura-splitting decompression in a uniform population of patients with Chiari I malformation is indicated.