Faculty Bibliography

BACKGROUND:Patient safety is foundational to neurosurgical care. Postprocedural "debrief" checklists have been proposed to improve patient safety, but data about their use in neurosurgery are limited. Here, we implemented an initiative to routinely perform postoperative debriefs and evaluated the impact of debriefing on operating room (OR) safety culture. METHODS:A 10-question safety attitude questionnaire (SAQ) was sent to neurosurgical OR staff at a major academic medical center before and 18 months after the implementation of a postoperative debriefing initiative. Rates of debrief compliance and changes in attitudes before and after the survey were evaluated. The survey used a Likert scale and analyzed with standard statistical methods. RESULTS:After the debrief initiative, the rate of debriefing increased from 51% to 86% of cases for the neurosurgery service. Baseline SAQ responses found that neurosurgeons had a more favorable perception of OR safety than did anesthesiologists and nurses. After implementation of the postoperative debriefing process, perceptions of OR safety significantly improved for neurosurgeons, anesthesiologists, and nurses. Furthermore, the disparity between nurses and surgeons was no longer significant. After debrief implementation, neurosurgical OR staff had improved perceptions of patient safety compared with surgical services that did not commonly perform debriefing. Debriefing identified OR efficiency concerns in 26.9% of cases, and prevention of potential adverse events/near misses was reported in 8% of cases. CONCLUSIONS:Postoperative debriefing can be effectively introduced into the OR and improves the safety culture after implementation. Debriefing is an effective tool to identify OR inefficiencies and potential adverse events.

Choroid plexus papillomas (CPPs) are typically benign tumors that can occur in any age group but are more commonly found in pediatric patients. Although these tumors are benign, there are several reports in adult patients of distant metastases present either at the time of diagnosis or occurring months to years after initial resection. Here, the authors report the case of a 14-year-old boy who presented with symptoms of elevated intracranial pressure due to obstructive hydrocephalus that was caused by a large fourth ventricular mass. Preoperative imaging included a full MRI of the spine, which revealed an intradural lesion that encased the distal sacral nerve roots at the tip of the thecal sac and was concerning for a drop metastasis. The patient underwent gross-total resection of both the fourth ventricular and sacral tumors with histology of both lesions consistent with benign CPP (WHO Grade I). In addition, the authors review prior reports of both pediatric and adult patients in whom benign CPPs have metastasized with either benign or atypical pathology found at a distant site. Taking into account this unusual case and reports in the literature, patients with even benign CPPs may warrant initial and routine follow-up imaging of the total neural axis in search of the rare, but possible, occurrence of drop metastasis.

OBJECTIVE Cervical curvature is an important factor when deciding between laminoplasty and laminectomy with posterior spinal fusion (LPSF) for cervical spondylotic myelopathy (CSM). This study compares outcomes following laminoplasty and LPSF in patients with matched postoperative cervical lordosis. METHODS Adults undergoing laminoplasty or LPSF for cervical CSM from 2011 to 2014 were identified. Matched cohorts were obtained by excluding LPSF patients with postoperative cervical Cobb angles outside the range of laminoplasty patients. Clinical outcomes and radiographic results were compared. A subgroup analysis of patients with and without preoperative pain was performed, and the effects of cervical curvature on pain outcomes were examined. RESULTS A total of 145 patients were included: 101 who underwent laminoplasty and 44 who underwent LPSF. Preoperative Nurick scale score, pain incidence, and visual analog scale (VAS) neck pain scores were similar between the two groups. Patients who underwent LPSF had significantly less preoperative cervical lordosis (5.8° vs 10.9°, p = 0.018). Preoperative and postoperative C2-7 sagittal vertical axis (SVA) and T-1 slope were similar between the two groups. Laminoplasty cases were associated with less blood loss (196.6 vs 325.0 ml, p < 0.001) and trended toward shorter hospital stays (3.5 vs 4.3 days, p = 0.054). The perioperative complication rate was 8.3%; there was no significant difference between the groups. LPSF was associated with a higher long-term complication rate (11.6% vs 2.2%, p = 0.036), with pseudarthrosis accounting for 3 of 5 complications in the LPSF group. Follow-up cervical Cobb angle was similar between the groups (8.8° vs 7.1°, p = 0.454). At final follow-up, LPSF had a significantly lower mean Nurick score (0.9 vs 1.4, p = 0.014). Among patients with preoperative neck pain, pain incidence (36.4% vs 31.3%, p = 0.629) and VAS neck pain (2.1 vs 1.8, p = 0.731) were similar between the groups. Similarly, in patients without preoperative pain, there was no significant difference in pain incidence (19.4% vs 18.2%, p = 0.926) and VAS neck pain (1.0 vs 1.1, p = 0.908). For laminoplasty, there was a significant trend for lower pain incidence (p = 0.010) and VAS neck pain (p = 0.004) with greater cervical lordosis, especially when greater than 20° (p = 0.011 and p = 0.018). Mean follow-up was 17.3 months. CONCLUSIONS For patients with CSM, LPSF was associated with slightly greater blood loss and a higher long-term complication rate, but offered greater neurological improvement than laminoplasty. In cohorts of matched follow-up cervical sagittal alignment, pain outcomes were similar between laminoplasty and LPSF patients. However, among laminoplasty patients, greater cervical lordosis was associated with better pain outcomes, especially for lordosis greater than 20°. Cervical curvature (lordosis) should be considered as an important factor in pain outcomes following posterior decompression for multilevel CSM.

STUDY DESIGN/METHODS:Retrospective review of patients who underwent surgery for spinal metastasis between 2005 and 2011. OBJECTIVE:To assess the utility of the surgical Apgar score (SAS) in patients who underwent surgery for spinal metastasis. SUMMARY OF BACKGROUND DATA/BACKGROUND:Surgery for spinal metastasis can be associated with relatively high morbidity and mortality. Consequently, identifying patients at risk for major postoperative complications is important. Several studies have validated SAS for predicting 30-day complication risk. METHODS:SASs were calculated and patients stratified into 5 groups: scores 0-2, 3-4, 5-6, 7-8, 9-10 points. Multivariate logistic regression assessed whether SAS was an independent predictor of major complication 30 days after surgery. Multivariate analysis of covariance assessed whether SAS was independently associated with length of stay. RESULTS:Ninety-seven patients with a variety of metastatic tumors were analyzed. There was no obvious trend in complication rates, or significant association between SAS and complication rate (P=0.413). Complication rates were 25.0% for SASs 0-2, 33.3% for 3-4, 18.4% for 5-6, 10.0% for 7-8, and 33.3% for 9-10 points. On multivariate analysis, SAS was not independently associated with complications; age above 65 years (odds ratio 4.19; 95% confidence interval, 1.31-52.27; P=0.028) and preoperative Karnofsky Performance Score of 10-40 (odds ratio 9.13; 95% confidence interval, 1.42-58.63; P=0.020) were associated with higher odds of complication. SASs 0-2 were an independent predictor of longer hospital stay (P=0.004). CONCLUSIONS:Our findings suggest that SAS is not a significant predictor of major perioperative complications after spinal metastasis surgery; preoperative functional status and age are stronger predictors. The need continues for a preoperative scoring system to reliably predict risk for perioperative complications after spinal metastasis surgery.

OBJECTIVE During the mini-open posterior corpectomy, percutaneous instrumentation without fusion is performed above and below the corpectomy level. In this study, the authors' goal was to compare the perioperative and long-term implant failure rates of patients who underwent nonfused percutaneous instrumentation with those of patients who underwent traditional open instrumented fusion. METHODS Adult patients who underwent posterior thoracic corpectomies with cage reconstruction between 2009 and 2014 were identified. Patients who underwent mini-open corpectomy had percutaneous instrumentation without fusion, and patients who underwent open corpectomy had instrumented fusion above and below the corpectomy site. The authors compared perioperative outcomes and rates of implant failure requiring reoperation between the open (fused) and mini-open (unfused) groups. RESULTS A total of 75 patients were identified, and 53 patients (32 open and 21 mini-open) were available for followup. The mean patient age was 52.8 years, and 56.6% of patients were male. There were no significant differences in baseline variables between the 2 groups. The overall perioperative complication rate was 15.1%, and there was no significant difference between the open and mini-open groups (18.8% vs 9.5%; p = 0.359). The mean hospital stay was 10.5 days. The open group required a significantly longer stay than the mini-open group (12.8 vs 7.1 days; p < 0.001). Overall implant failure rates requiring reoperation were 1.9% at 6 months, 9.1% at 1 year, and 14.7% at 2 years. There were no significant differences in reoperation rates between the open and mini-open groups at 6 months (3.1% vs 0.0%, p = 0.413), 1 year (10.7% vs 6.2%, p = 0.620), and 2 years (18.2% vs 8.3%, p = 0.438). The overall mean follow-up was 29.2 months. CONCLUSIONS These findings suggest that percutaneous instrumentation without fusion in mini-open transpedicular corpectomies offers similar implant failure and reoperation rates as open instrumented fusion as far out as 2 years of follow-up.

BACKGROUND:Atypical and malignant meningiomas can recur despite resection and radiation. OBJECTIVE:To determine outcomes of patients with recurrent atypical or malignant meningioma treated with repeat resection and permanent iodine-125 ( 125 I) brachy-therapy. METHODS:Charts of patients who underwent surgical resection and 125 I brachyther-apy implantation for atypical and malignant meningiomas between 1988 and 2013 were retrospectively reviewed. The Kaplan-Meier actuarial method was used to calculate progression-free and overall survival. The log-rank test was used to compare groups. Significance was set at P < .05. RESULTS:Forty-two patients underwent 50 resections with 125 I brachytherapy im-plantations. All patients had undergone previous resections and 85% had previously undergone radiation. Median follow-up was 7.5 years after diagnosis and 2.3 years after brachytherapy. Median time to progression after resection with 125 I brachytherapy was 20.9 months for atypical meningioma, 11.4 months for malignant meningioma, and 11.4 months for the combined groups. Median survival after re-resection and 125 I brachytherapy was 3.5 years for atypical meningioma, 2.3 years for malignant menin-gioma, and 3.3 years for all subjects. Median overall survival after diagnosis was 11.1 years for atypical meningioma, 9.1 years for malignant meningioma, and 9.4 years for all subjects. Complications occurred in 17 patients and included radiation necrosis (n = 8, 16%), wound breakdown (n = 6, 12%), hydrocephalus (n = 4, 8%), infection (n = 3, 6%), and a pseudomeningocele (n = 2, 5%). CONCLUSION:This is the largest experience with adjuvant 125 I brachytherapy for recurrent high-grade meningiomas. The outcomes support the use of adjuvant brachytherapy as an option for these aggressive tumors.

OBJECTIVE Functional mapping using direct cortical stimulation is the gold standard for the prevention of postoperative morbidity during resective surgery in dominant-hemisphere perisylvian regions. Its role is necessitated by the significant interindividual variability that has been observed for essential language sites. The aim in this study was to determine the statistical probability distribution of eliciting aphasic errors for any given stereotactically based cortical position in a patient cohort and to quantify the variability at each cortical site. METHODS Patients undergoing awake craniotomy for dominant-hemisphere primary brain tumor resection between 1999 and 2014 at the authors' institution were included in this study, which included counting and picture-naming tasks during dense speech mapping via cortical stimulation. Positive and negative stimulation sites were collected using an intraoperative frameless stereotactic neuronavigation system and were converted to Montreal Neurological Institute coordinates. Data were iteratively resampled to create mean and standard deviation probability maps for speech arrest and anomia. Patients were divided into groups with a "classic" or an "atypical" location of speech function, based on the resultant probability maps. Patient and clinical factors were then assessed for their association with an atypical location of speech sites by univariate and multivariate analysis. RESULTS Across 102 patients undergoing speech mapping, the overall probabilities of speech arrest and anomia were 0.51 and 0.33, respectively. Speech arrest was most likely to occur with stimulation of the posterior inferior frontal gyrus (maximum probability from individual bin = 0.025), and variance was highest in the dorsal premotor cortex and the posterior superior temporal gyrus. In contrast, stimulation within the posterior perisylvian cortex resulted in the maximum mean probability of anomia (maximum probability = 0.012), with large variance in the regions surrounding the posterior superior temporal gyrus, including the posterior middle temporal, angular, and supramarginal gyri. Patients with atypical speech localization were far more likely to have tumors in canonical Broca's or Wernicke's areas (OR 7.21, 95% CI 1.67-31.09, p < 0.01) or to have multilobar tumors (OR 12.58, 95% CI 2.22-71.42, p < 0.01), than were patients with classic speech localization. CONCLUSIONS This study provides statistical probability distribution maps for aphasic errors during cortical stimulation mapping in a patient cohort. Thus, the authors provide an expected probability of inducing speech arrest and anomia from specific 10-mm² cortical bins in an individual patient. In addition, they highlight key regions of interindividual mapping variability that should be considered preoperatively. They believe these results will aid surgeons in their preoperative planning of eloquent cortex resection.

BACKGROUND:The pedicle subtraction osteotomy (PSO) has been a mainstay treatment for flat-back syndrome. The morbidity of open deformity correction can be high, and minimally invasive applications may reduce such morbidity. OBJECTIVE:To describe an operative technique of the mini-open PSO. METHODS:Two patients underwent percutaneous fixation above and below the PSO, and the PSO was performed in a mini-open fashion. The correction was obtained by cantilever. RESULTS:The patient who underwent the L3 PSO had a prior fusion from T11 to L4 for scoliosis 35 years ago. On presentation at 62 years of age, he had a pelvic incidence of 54°, lumbar lordosis of 23°, sagittal vertical axis of +14 cm, and pelvic tilt of 25°. He underwent an anterior lumbar interbody fusion at L5-S1 followed by a min-open L3 PSO. He had a postoperative lumbar lordosis of 64° (correction of 41°), and his sagittal vertical axis went to +3 cm. His Oswestry Disability Index and visual analog scale scores decreased after surgery. The second patient was 64 years of age and underwent an L1 PSO. He had 43° of kyphosis from T10 to L2. He had a preoperative pelvic incidence of 63°, lumbar lordosis of 35°, pelvic tilt of 24°, and sagittal vertical axis of 3 cm. His postoperative kyphosis improved from 43° to 32°. CONCLUSION:The mini-open PSO can achieve significant lordosis, although it is heavily reliant on anterior arthrodesis. Larger studies are needed to compare this approach with an open PSO.

Study Design Retrospective chart review. Objective Postoperative cerebrospinal fluid (CSF) leak is a known complication of intraoperative durotomy. Intraoperative placement of subfascial epidural drains following primary dural repair has been proposed as a potential management strategy to prevent formation of CSF cutaneous fistula and symptomatic pseudomeningocele. Here we describe our experience with subfascial drain after intentional durotomy. Methods Medical records of patients who underwent placement of subfascial epidural drains during spinal procedures with intentional intraoperative durotomies over a 4-year period at two institutions were retrospectively reviewed. Primary outcomes of interest were postoperative CSF cutaneous fistula or symptomatic pseudomeningocele formation. Results Twenty-five patients were included. Mean length of follow-up was 9.5 months. Twelve patients (48%) underwent simultaneous arthrodesis. The average duration of the drain was 5.3 days with average daily output of 126.5 mL. Subgroup analyses revealed that average drain duration for the arthrodesis group was 6.33 days, which is significantly greater than that of the nonfused group, which was 3.7 days (p = 0.016). Similarly, the average daily drain output for the arthrodesis subgroup at 153.1 mL was significantly higher than that of the nonfused subgroup (86.8 mL, p = 0.04). No patient developed postoperative CSF cutaneous fistula or symptomatic pseudomeningocele or had negative sequelae associated with overdrainage of CSF. One patient had a delayed wound infection. Conclusions The intraoperative placement of subfascial epidural drains was not associated with postoperative development of CSF cutaneous fistula, symptomatic pseudomeningocele, overdrainage, or subdural hematoma in the cases reviewed. Subfascial closed wound drain placement is a safe and efficacious management method after intentional spinal durotomies. It is particularly helpful in those who undergo simultaneous arthrodesis, as those patients have statistically higher daily drain output and longer drain durations.

OBJECTIVE Because the surgical strategies for primary and metastatic spinal tumors are different, the respective associated costs and morbidities associated with those treatments likely vary. This study compares the direct costs and 90-day readmission rates between the resection of extradural metastatic and primary spinal tumors. The factors associated with cost and readmission are identified. METHODS Adults (age 18 years or older) who underwent the resection of spinal tumors between 2008 and 2013 were included in the study. Patients with intradural tumors were excluded. The direct costs of index hospitalization and 90-day readmission hospitalization were evaluated. The direct costs were compared between patients who were treated surgically for primary and metastatic spinal tumors. The independent factors associated with costs and readmissions were identified using multivariate analysis. RESULTS A total of 181 patients with spinal tumors were included (63 primary and 118 metastatic tumors). Overall, the mean index hospital admission cost for the surgical management of spinal tumors was $52,083. There was no significant difference in the cost of hospitalization between primary ($55,801) and metastatic ($50,098) tumors (p = 0.426). The independent factors associated with higher cost were male sex (p = 0.032), preoperative inability to ambulate (p = 0.002), having more than 3 comorbidities (p = 0.037), undergoing corpectomy (p = 0.021), instrumentation greater than 7 levels (p < 0.001), combined anterior-posterior approach (p < 0.001), presence of a perioperative complication (p < 0.001), and longer hospital stay (p < 0.001). The perioperative complication rate was 21.0%. Of this cohort, 11.6% of patients were readmitted within 90 days, and the mean hospitalization cost of that readmission was $20,078. Readmission rates after surgical treatment for primary and metastatic tumors were similar (11.1% vs 11.9%, respectively) (p = 0.880). Prior hospital stay greater than 15 days (OR 6.62, p = 0.016) and diagnosis of lung metastasis (OR 52.99, p = 0.007) were independent predictors of readmission. CONCLUSIONS Primary and metastatic spinal tumors are comparable with regard to the direct costs of the index surgical hospitalization and readmission rate within 90 days. The factors independently associated with costs are related to preoperative health status, type and complexity of surgery, and postoperative course.