Which Objective Nutritional Index Is Better for the Prediction of Adverse Medical Events in Elderly Patients Undergoing Spinal Surgery?

OBJECTIVE: The relationship of preoperative malnutrition with perioperative adverse medical events (PAMEs) has not been well studied in elderly patients undergoing spinal surgery (SS). We aimed to compare the Prognostic Nutritional Index (PNI), Controlling Nutritional Status (CONUT) score, and Geriatric Nutritional Risk Index (GNRI) for prediction of PAMEs in elderly patients undergoing SS. METHODS: Data of 454 patients ≥65 years old undergoing SS were reviewed. PAMEs were defined as death, cardiopulmonary complications, respiratory failure, acute kidney injury, pneumonia, delirium, cerebrovascular events, and sepsis. The area under the receiver operating characteristic curve was used to compare the predictive value of each nutritional index for PAMEs. RESULTS: Incidence of PAMEs was 15.3%. Patients who had PAMEs had significantly lower GNRI and PNI but higher CONUT score before surgery compared with patients without PAMEs. Multivariate analysis showed that age (odds ratio [OR] 1.55, 95% confidence interval [CI] 1.01-4.75, P = 0.014), chronic renal failure (OR 1.34, 95% CI 1.03-3.82, P = 0.002), coronary artery disease (OR 1.12, 95% CI 1.11-3.54, P = 0.028), PNI <45.4 (OR 2.12, 95% CI 1.16-4.80, P = 0.011), CONUT score >5 (OR 2.17, 95% CI 1.03-3.76, P = 0.001), and GNRI <92 (OR 2.68, 95% CI 1.20-6.45, P < 0.001) were significant predictors of PAMEs. The receiver operating characteristic curve showed that GNRI had much greater discriminatory ability regarding PAMEs than PNI and CONUT score. CONCLUSIONS: Preoperative malnutrition is associated with PAMEs in elderly patients undergoing SS. GNRI had the highest accuracy for predicting PAMEs among the nutritional indices studied.

The Necessity of Upper Extremity Neurologic Examination while Evaluating Breast Pain.

INTRODUCTION: Breast pain is one of the most frequent complaints and occurs in 45-69% of all women. Cervical disc herniation is a common cause of cervical radiculopathy with an incidence rate of 18.6 per 100,000, and it should be considered as a cause of breast pain. OBJECTIVE: To identify the extent to which upper extremity neurologic findings and cervical root disorders accompany breast pain. METHODS: We prospectively collected clinical features of patients with breast pain. An upper extremity neurologic examination was performed in patients and controls. Patients who had neurologic findings underwent cervical spine magnetic resonance imaging (MRI) to identify cervical root disorders. RESULTS: Out of the 554 participants, 233 had breast pain, and 321 were controls. Women with breast pain had more numbness (116 [49.8%] vs. 104 [32.4%], p < 0.001) and more dysesthesia (36 [15.5%] vs. 17 [5.3%], p < 0.001) than the controls, but they had similar upper extremity weakness (10 [4.3%] vs. 14 [4.4%], p > 0.05). The number of women with one neurologic finding was significantly greater in the group with breast pain (119 [51.1%] vs. 111 [34.6%], p < 0.001). Ninety (16.2%) patients underwent a cervical vertebra MRI, which showed that 86 (95.6%) patients had cervical root disorders including 21 (23.3%) cases of bulging, 9 (10%) of annular tear, and 56 (62.2%) of central disc protrusion; 4 (4.4%) patients had normal findings. The multivariate logistic regression analysis revealed that age was the only significant predictor of neurologic findings in patients with breast pain (p < 0.05, OR: 1.02, CI: 1.002-1.053). CONCLUSIONS: Cervical root disorders should be considered as a cause of extramammary breast pain.

Inflammatory Events in Patients with Sagittal Imbalance through Platelet-Associated Inflammation.

AIM: To determine whether platelet-associated inflammation parameters (PAIP) could be useful for evaluating inflammation in sagittal imbalance (SI) by investigating its relationship with pelvic tilt (PT), sacral slope (SS), pelvic incidence (PI), lumbar lordosis (LL) and thoracic kyphosis (TK). MATERIAL AND METHODS: The study included 57 patients (19 males, 38 females) who were diagnosed with SI and 44 healthy control subjects. Spinal sagittal balance was evaluated using digitalized-standing lumbar lateral radiographs of the patients. All parameters including SS, PI, LL and PT were evaluated through from the lateral radiographs. RESULTS: In the analysis, Mean Platelet Volume (MPV) (10.6 ± 0.9; p < 0.0001), Platelet Distribution Width (PDW) (12.7 ± 2.2; p < 0.001) and Platelet Distribution Width (RDW) (41.9 ± 4.4; p < 0.0001) were observed to be much higher in the SI than in the control. The neutrophil-lymphocyte ratio (NLR) was higher in the SI group (p=0.033), and no difference was determined in respect of the platelet-lymphocyte ratio (PLR) (p > 0.05). The PT had a positive correlation with hospital length of stay in SI patients (r=0.655; p=0.008). MPV showed a strong positive correlation with comorbidity (r=0.715; p=0.001). A positive correlation was determined between NLR and PLR (r=0.692; p=0.002), and between MPV and RDW (r=0.788; p=0.001). No correlation was determined between the PAIP and radiological measurements (PI, PT, SS) that were used for SI. CONCLUSION: The results suggest that the neurosurgical approach should cover not only the sagittal parameters and their angles but also PAIP showing inflammatory events originating from platelets.

Value of N-Terminal Pro-Brain Natriuretic Peptide in Predicting Perioperative Complications Following Spine Surgery.

OBJECTIVE: The utility of preoperative biomarkers for assessing perioperative complications in patients undergoing spine surgery (SS) is unclear, and no study has assessed the ability of preoperative natriuretic peptides to predict adverse events following SS. This study aimed to evaluate the prognostic importance of N-terminal pro-brain natriuretic peptide (NT-proBNP) in patients undergoing SS. METHODS: We prospectively followed 154 consecutive adult patients ≥50 years old hospitalized for elective SS. The outcomes of interest were length of stay in hospital and perioperative medical complications during hospitalization, defined as pneumonia, deep or organ space surgical site infection, bacteremia, prolonged mechanical ventilation >48 hours, unplanned reintubation, acute renal failure, sepsis or septic shock, venous thromboembolism (deep vein thrombosis or pulmonary embolism), cardiac arrest, stroke, myocardial infarction, return to operating room, and in-hospital mortality. RESULTS: In 21 (13.6%) patients, 32 episodes of medical adverse events occurred. Older patients and patients with more comorbid conditions, such as heart failure, diabetes, cerebrovascular disease, coronary artery disease, and chronic obstructive pulmonary disease, tended to have a higher rate of adverse events. Patients with adverse events had higher NT-proBNP and troponin levels on admission compared with patients without adverse events. Multivariate analysis showed that NT-proBNP >242 pg/ml (odds ratio 2.374; 95% confidence interval, 1.000-2.958; P = 0.001) and presence of diabetes (odds ratio 2.16; 95% confidence interval, 1.86-7.89; P = 0.008) were significant and independent predictors of perioperative adverse events. CONCLUSIONS: This study demonstrates that preoperative NT-proBNP level in patients undergoing SS could be a valuable prognostic marker for several postoperative complications.

A Novel Prognostic Marker in Patients Undergoing Spinal Surgery: Prognostic Nutritional Index.

OBJECTIVE: The relationship of a preoperative Prognostic Nutritional Index (PNI) with perioperative adverse events (PAEs) other than delirium has never been described in patients undergoing spinal surgery. We aimed to evaluate the impact of admission PNI on the outcome of patients undergoing spinal surgery. METHODS: Medical records of 408 consecutive patients 50 years or older undergoing spinal surgery were reviewed. Patients' information including demographic data, routine preoperative laboratory tests, and PNI were collected to assess the association between these factors and PAEs. The PNI was calculated from this formula: 10 × serum albumin (g/dL) + 0.005 × total lymphocyte count/mm3. Receiver operating characteristic curve analysis was performed to determine the cutoff value of the PNI. RESULTS: PAEs occurred in 61 (14.9%) of the patients. Older patients and those with more comorbid conditions such as atrial fibrillation, chronic renal failure, history of malignancy, and diabetes mellitus tended to have a higher rate of PAEs. Patients with PAEs had higher C-reactive protein (4.4 ± 5.4 vs 2.2 ± 3.0 mg/dL; p < 0.001) but had lower hemoglobin levels (12.2 ± 1.57 vs 13.1 ± 1.84 g/dL; p < 0.001) on admission. Patients who had PAEs had a significantly lower preoperative PNI (46.1 ± 4.4 vs 51.9 ± 5.8; p < 0.001) compared with patients without a PAE. Multivariate analysis showed that age (odds ratio [OR]: 1.23; 95% confidence interval [CI] 0.76-1.35; p < 0.04), PNI < 47.7 (OR: 2.51; 95% CI, 1.188-5.477; p = 0.008) and the presence of diabetes (OR: 3.23; 95% CI, 11.326-7.474; p = 0.004) were significant and independent predictors of PAEs. CONCLUSION: This study is the first to demonstrate that a lower preoperative PNI is associated with PAEs in patients undergoing spinal surgery.

The outcome of epiduroscopy treatment in patients with chronic low back pain and radicular pain, operated or non-operated for lumbar disc herniation: a retrospective study in 88 patients.

BACKGROUND: Patients with lumbar disc herniation are treated with physiotherapy/medication and some with surgery. However, even after technically successful surgery some develop a failed back syndrome with persistent pain. Our aim was to evaluate the efficacy of epiduroscopy in patients who suffer chronic low back pain and/or radicular pain with or without surgery and the gender difference in outcome. METHODS: A total of 88 patients were included with a mean age of 52 years (27-82), 54 women and 34 men. 66 of them were operated previously and 22 were non-operated. They all had persistent chronic back pain and radicular pain despite of medication and physical rehabilitation. Visual Analog Scale (VAS) for pain and Oswestry Disability Index (ODI) were evaluated preoperatively, after one month, six months and one-year after the epiduroscopy. RESULTS: All patients, and also the subgroups (gender and operated/non-operated) improved significantly in pain (VAS) and disability (ODI) at one month. A significant improvement was also seen at one year. No differences were found between men and woman at the different follow-up times. A slight worsening in VAS and ODI was noticed over time except for the non-operated group. CONCLUSIONS: Epiduroscopy helps to improve the back and leg pain due to lumbar disc herniation in the early stage. At one year an improvement still exists, and the non-operated group seems to benefit most of the procedure.

Clear cell ependymoma of the temporal lobe in a child: a case report.

A 12-year-old boy with a left temporal tumor diagnosed as clear cell ependymoma (CCE) was reported. CCE is an uncommon central variant of ependymomas with a predilection for the supratentorial region in children. Brain tumors with a honeycomb pattern with clear cells having round nuclei and perinuclear halos could pose a problem in the differential diagnosis with the other tumors with clear cells. There were 41 reported cases of CCE in the literature. In 61% of these cases, tumors were located in the supratentorial region, and in the others in the posterior fossa and spinal cord. However, there was none located in the temporal lobe except in the case presented here.