Glioblastoma Recurrence Versus Treatment Effect in a Pathology-Documented Series.

OBJECTIVE: Patients diagnosed with glioblastoma (GBM) are treated with surgery followed by fractionated radiotherapy with concurrent and adjuvant temozolomide. Patients are monitored with serial magnetic resonance imaging (MRI). However, treatment-related changes frequently mimic disease progression. We reviewed a series of patients undergoing surgery for presumed first-recurrence GBM, where pathology reports were available for tissue diagnosis, in order to better understand factors associated with a diagnosis of treatment-related changes on final pathology. METHODS: Patient records at a single institution between 2005 and 2015 were retrospectively reviewed. Pathology reports were reviewed to determine diagnosis of recurrent GBM or treatment effect. Survival analysis was performed interrogating overall survival (OS) and progression-free survival (PFS). Correlation with radiation treatment plans was also examined. RESULTS: One-hundred-twenty-three patients were identified. One-hundred-sixteen patients (94%) underwent resection and seven underwent biopsy. Treatment-related changes were reported in 20 cases (16%). These patients had longer median OS and PFS from the time of recurrence than patients with true disease progression. However, there was no significant difference in OS from the time of initial diagnosis. Treatment effect was associated with surgery within 90 days of completing radiation. In patients receiving radiation at our institution (n = 53), larger radiation target volume and a higher maximum dose were associated with treatment effect. CONCLUSION: Treatment effect was associated with surgery nearer to completion of radiation, a larger radiation target volume, and a higher maximum point dose. Treatment effect was associated with longer PFS and OS from the time of recurrence, but not from the time of initial diagnosis.

Does patient selection account for the perceived cost savings in outpatient spine surgery? A meta-analysis of current evidence and analysis from an administrative database.

OBJECTIVEFrom 1994 to 2006 outpatient spinal surgery increased 5-fold. The perceived cost savings with outcomes comparable to or better than those achieved with inpatient admission for the same procedures are desirable in an era where health expenditures are scrutinized. The increase in outpatient spine surgery is also driven by the proliferation of ambulatory surgery centers. In this study, the authors hypothesized that the total savings in outpatient spine surgery is largely driven by patient selection and biases toward healthier patients.METHODSA meta-analysis assessed patient selection factors and outcomes associated with outpatient spine procedures. Pooled odds ratios and mean differences were calculated using a Bayesian random-effects model. The authors extended this analysis in a novel way by using the results of the meta-analysis to examine cost data from an administrative database of academically affiliated hospitals. A Bayesian approach with priors informed by the meta-analysis was used to compare costs for inpatient and outpatient performance of anterior cervical discectomy and fusion (ACDF) and lumbar laminectomy.RESULTSSixteen studies with a total of 370,195 patients met the inclusion criteria. Outpatient procedures were associated with younger patient age (mean difference [MD] -2.34, 95% credible interval [CrI] -4.39 to -0.34) and no diabetes diagnosis (odds ratio [OR] 0.78, 95% CrI 0.54-0.97). Outpatient procedures were associated with a lower likelihood of reoperation (OR 0.42, 95% CrI 0.16-0.80), 30-day readmission (OR 0.39, 95% CrI 0.16-0.74), and complications (OR 0.29, 95% CrI 0.15-0.50) and with lower overall costs (MD -$121,392.72, 95% CrI -$216,824.81 to -$23,632.92). Additional analysis of the national administrative data revealed more modest cost savings than those found in the meta-analysis for outpatient spine surgeries relative to inpatient spine surgeries. Estimated cost savings for both younger patients ($555 for those age 30-35 years [95% CrI -$733 to -$374]) and older patients ($7290 for those age 65-70 years [95% CrI -$7380 to -$7190]) were less than the overall cost savings found in the meta-analysis.CONCLUSIONSCompared to inpatient spine surgery, outpatient spine surgery was associated with better short-term outcomes and an initial reduction in direct costs. A selection bias for outpatient procedures toward younger, healthier patients may confound these results. The additional analysis of the national database suggests that cost savings in the outpatient setting may be less than previously reported and a result of outpatient procedures being offered more frequently to younger and healthier individuals.

Tarlov Cyst Causing Sacral Insufficiency Fracture.

BACKGROUND AND IMPORTANCE: Tarlov cysts, also known as perineural cysts, have been described as meningeal dilations of the spinal nerve root sheath between the peri- and endoneurium at the dorsal root ganglion. Most often they are found in the sacrum involving the nerve roots. Normally asymptomatic, they have been reported to present with radiculopathy, paresthesias, and even urinary or bowel dysfunction. Sacral insufficiency has not been a well-documented presentation. CLINICAL PRESENTATION: The patient is a 38-year-old female who started to develop left low back pain and buttock pain that rapidly progressed into severe pain with some radiation down the posterior aspect of her left leg. There was no recent history of spine or pelvic trauma. These symptoms prompted her initial emergency department evaluation, and imaging demonstrated a large Tarlov cyst with an associated sacral insufficiency fracture. She was noted to have a normal neurological examination notable only for an antalgic gait. She was taken to surgery via a posterior approach and the cyst was identified eccentric to the left. The cyst was fenestrated and the nerve roots identified. Given her large area of bone erosion and insufficiency fractures, fixation of the sacroiliac joints was deemed necessary. Fusion was extended to the L5 vertebral body to buttress the fixation. She tolerated the procedure well and was discharged from the hospital on postoperative day 3. CONCLUSION: Tarlov cysts of the sacrum can lead to significant bone erosion and subsequent insufficiency fractures, requiring fenestration and in some cases, complex sacropelvic fixation.

Mild Carotid Stenosis with Recurrent Symptoms Triggered by Eating.

BACKGROUND: Carotid atherosclerosis is a known risk factor for acute ischemic stroke. Although severe luminal narrowing is a well-established risk factor for future ischemic events, 10% of patients with acute ischemic stroke or transient ischemic attacks are thought to have ischemic events secondary to vulnerable carotid plaques in the setting of mild to moderate carotid artery stenosis. CASE DESCRIPTION: A 78-year-old man presented with multiple recurrent strokes and transient ischemic attacks that consistently occurred with eating. Based on the anatomic relationships of the proximal internal carotid artery harboring the plaque, we hypothesized that multiple recurrent emboli occurred secondary to the mechanical effect of the esophagus "squeezing" the vulnerable plaque against the surrounding fixed tissues despite a mild degree of stenosis (approximately 20% stenosis on magnetic resonance angiography and angiography). Despite the mild stenosis, a carotid endarterectomy was performed, which resulted in immediate resolution of the ischemic events. CONCLUSIONS: We postulate that the likely mechanical "squeeze" of the vulnerable plaque involving the retropharyngeal proximal internal carotid artery was responsible for the multiple recurrent transient ischemic attacks, which characteristically occurred only while eating. Resolution of the episodes after carotid endarterectomy supports this hypothesis.

Understanding the Impact of Obesity on Short-term Outcomes and In-hospital Costs After Instrumented Spinal Fusion.

BACKGROUND: Obesity rates continue to rise along with the number of obese patients undergoing elective spinal fusion. OBJECTIVE: To evaluate the impact of obesity on resource utilization and early complications in patients undergoing surgery for degenerative spine disease. METHODS: A single-institution retrospective analysis was conducted on patients with degenerative spine disease requiring instrumentation between 2008 and 2012. The 801 identified patients were grouped based on a body mass index (BMI) of <30 (nonobese, n = 478), ≥30 and <40 (obese, n = 283), and alternatively BMIs of ≥40 (morbidly obese, n = 40). Baseline characteristics, surgical outcomes and requirements, complications, and cost were compared. Logistic and linear regression analyses were used to determine the strength of association between obesity and outcomes for categorical and continuous data, respectively. RESULTS: Significant differences were found in comorbidities between cohorts. Multivariate analysis revealed significant associations between obesity and longer anesthesia times (30 minutes, P = .008), and surgical times (24 minutes, P = .02). Additionally, there was a 2.8 times higher rate of wound complications in obese patients (4.2% vs 1.5, P = .03), and 2.5 times higher rate of major medical complications (7.8% vs 3.1, P = .01). Morbid obesity resulted in a 10 times higher rate of wound complications (P < .001). Morbid obesity resulted in a $9078 (P = .005) increase in overall cost of care. CONCLUSION: Increased BMI is associated with longer operative times, increased complication rates, and increased cost independent of comorbidities. These effects are more pronounced with morbidly obese patients, further supporting a role for preoperative weight loss.