Surgical treatment for chronic subdural hematoma in the elderly: A retrospective analysis.

Background: Chronic subdural hematoma (CSDH) is primarily a disease of the elderly. Less invasive interventions are often offered for elderly (> 80 years) patients due to concerns for elevated surgical risk, although data suggesting a clear outcome benefit is lacking. Methods: All patients aged 65 years or older who underwent surgical treatment for CSDH at a single institution over a 4-year period were evaluated in this retrospective analysis. Surgical options included twist drill craniostomy (TDC), burr hole craniotomy (BHC), or standard craniotomy (SC). Outcomes, demographics, and clinical data were collected. Practice patterns and outcomes for patients older than 80 years old were compared to the age 65-80 cohort. Results: 110 patients received TDC, 35 received BHC, and 54 received SC. There was no significant difference in post-operative complications, outcomes, or late recurrence (30-90 days). Recurrence at 30 days was significantly higher for TDC (37.3% vs. 2.9% vs 16.7%, p 80 group, SC had higher risk of stroke and increased length of stay. Conclusion: Twist drill craniostomy, burr hole craniostomy, and standard craniotomy have similar neurologic outcomes in elderly patients. Presence of thick membranes is a relative contra-indication for TDC due to high 30-day recurrence. Patients > 80 have higher risk of stroke and increased length of stay with SC.

Endoscopic Third Ventriculostomy and Endoscopic Intracranial Cyst Fenestration in an Outpatient Ambulatory Surgery Center Yields Reduced Cost But Equal Efficacy and Safety Compared with Surgery in the Hospital.

BACKGROUND: A transition is underway in neurosurgery to perform relatively safe surgeries outpatient, often at ambulatory surgery centers (ASC). We sought to evaluate whether simple intracranial endoscopic procedures such as third ventriculostomy and cyst fenestration can be safely and effectively performed at an ASC, while comparing costs with the hospital. METHODS: A retrospective chart review was performed for patients who underwent elective intracranial neuroendoscopic (NE) intervention at either a quaternary hospital or an affiliated ASC between August 2014 and September 2017. Groups were compared on length of stay, perioperative and 30-day morbidity, as well as clinical outcome at last follow-up. The total cost for these procedures were compared in relative units between all ASC cases and a small subset of hospital cases. RESULTS: In total, 16 NE operations performed at the ASC (mean patient age 29.8 years) and 37 at the hospital (mean age 15.4 years) with average length of stay of 3.5 hours and 23.1 hours respectively (P < 0.05). There were no acute complications in either cohort or morbid events requiring hospitalization within 30 days. Surgical success was noted for 75% of the ASC patients and 73% of the hospital cohort. The mean cost of 5 randomly selected hospital operations with same-day discharge and 5 with overnight stay was 3.4 and 4.1 times that of the ASC cohort, respectively (P < 0.05). CONCLUSIONS: Elective endoscopic third ventriculostomy and other simple NE procedures can be safely and effectively performed at an ASC for appropriate patients with significantly reduced cost compared with the hospital.

Preoperative Acetazolamide Challenge in Pediatric Chiari I Malformation.

PURPOSE: In patients who present with headaches and Chiari 1 malformation without cranial nerve or brainstem dysfunction or syrinx formation, the decision to decompress can be difficult to make. We present a case series examining the use of acetazolamide as a diagnostic aid to determine candidacy for decompression. METHODS: A single pediatric neurosurgeon's (M.M.H.) experience from 2003 to 2018 was retrospectively reviewed. All cases evaluated in the clinic for CPT code of Chiari 1 malformation were analyzed. Inclusion criteria were patients with diagnosis of Chiari 1 malformation and headache-predominant symptoms who underwent an acetazolamide challenge test. Exclusion criteria included age over 18, syrinx, or significant clinical evidence of brainstem compression or cranial nerve dysfunction. Data were recorded with respect to response to acetazolamide. Surgical outcomes were assessed using the Chicago Chiari Outcome Scale (CCOS) pain category and the improve/same/worse (IWS) scale. Overall satisfaction from surgery was also recorded. RESULTS: Forty-five patients met inclusion criteria and underwent acetazolamide challenge. Thirty-three (73.3%) patients showed improvement of their symptoms with acetazolamide challenge (responders). Of the 33 responders, 25 (75.8%) underwent Chiari decompression. The remaining 8 (24.2%) responders experienced persistent improvement of their symptoms after the acetazolamide trial and did not require intervention. Twelve (26.7%) patients did not improve with acetazolamide (nonresponders) of which 11 (91.7% of nonreponders) never required intervention. One nonresponder eventually underwent Chiari decompression due to progressively worsening and debilitating headaches. All twenty-five (100%) responders improved after surgery and 24 (96%) were satisfied with the outcome of surgery. The average responder CCOS pain score was 3.52 out of 4. The nonresponder who did not improve with acetazolamide had persistent severe headaches after decompression. The CCOS pain score for this nonresponder was 2 out of 4. CONCLUSION: Pediatric headache-predominant Chiari 1 malformation presents a difficult diagnostic dilemma. The authors describe a trial of acetazolamide as a preoperative diagnostic tool to aid the decision to decompress. Further studies will need to be performed to determine the effectiveness of preoperative acetazolamide in identifying which patients may benefit from surgical decompression.

Outpatient anterior cervical discectomy and fusion in the ambulatory surgery center setting: safety assessment for the Medicare population.

OBJECTIVE: Several studies have demonstrated that anterior cervical discectomy and fusion (ACDF) surgery in the outpatient versus hospital setting provides improved efficiency, cost-effectiveness, and patient satisfaction without a compromise in safety or outcome. Recent anecdotal reports, however, have questioned whether outpatient ACDF surgery is safe in the > 65-year-old Medicare population. To date, no clinical study has assessed the safety of outpatient ACDF in an ambulatory surgery center (ASC), specifically in a Medicare population. The authors set out to analyze their 3-year experience with Medicare-enrolled patients undergoing ACDF surgery at a single ASC to determine its safety profile, perioperative care protocol, and associated outcomes. METHODS: A retrospective analysis of 119 consecutive patients > 65 years (Medicare-eligible) who underwent 1-, 2-, or 3-level ACDF at a single ASC from 2015 to 2018 (since Medicare payment approval) was conducted. All patients were in American Society of Anesthesiologists classes I-III. Postoperatively, patients were observed for a minimum of 4 hours in a recovery setting for the following factors: neck swelling, neurological status, ability to swallow solid food, and urination capacity. All patients received a multimodal pain management regimen prior to discharge home. Data were collected on patient demographics, comorbidities, operative details, and all perioperative and 90-day morbidity. RESULTS: Complete data were available for all 119 consecutive Medicare-eligible patients, 97 (81.5%) of whom were actively enrolled in Medicare. One-, 2-, and 3-level ACDFs were performed in 103 (86.6%), 15 (12.6%), and 1 (0.8%) patients, respectively. No patients required return to the operating room for intervention within the 4-hour postanesthesia care unit observation window. No patients required transfer from the ASC to the hospital setting for further observation or intervention. Thirty-day adverse events were reported in 2.4% of cases, all of which resolved by 90 days after surgery. The incidence of 90-day hospital readmission was 1.7% (n = 2), with 1 patient (0.8%) requiring reoperation at the index level for deep infection. All-cause 90-day mortality was 0%. CONCLUSIONS: An analysis of consecutive Medicare patients (American Society of Anesthesiologists classes I-III) who underwent mostly 1-level and some 2-level ACDFs in an ASC setting demonstrates that surgical complications occur at a low rate with a safety profile similar to that reported for both inpatient ACDF and patients younger than 65 years. In an effort to reduce cost and improve efficiency of care, surgeons can safely perform ACDF in the Medicare population in an ASC environment utilizing patient selection criteria and perioperative management similar to those reported here.