- Pre-emptive scalp infiltration with ropivacaine plus methylprednisolone versus ropivacaine alone for relief of postoperative pain after craniotomy in children (RP/MP vs RP): a study protocol for a randomised controlled trial. [Journal Article]
- BOBMJ Open 2019 Jun 22; 9(6):e027864
- Pre-emptive scalp infiltration with local anaesthetics is the simplest and most effective method to prevent postoperative incisional pain. However, local infiltration of an anaesthetic only provides …
Pre-emptive scalp infiltration with local anaesthetics is the simplest and most effective method to prevent postoperative incisional pain. However, local infiltration of an anaesthetic only provides relatively short-term pain relief. Methylprednisolone (MP) treatment, administered as an adjuvant at the wound site, has been shown to provide satisfactory pain management after lumbar laminectomy. However, there is no evidence regarding the efficacy of MP infiltration for the relief of postoperative pain after craniotomy. Currently, postoperative pain after craniotomy in children is undertreated. Therefore, we aim to investigate whether pre-emptive scalp infiltration with ropivacaine (RP) plus MP is superior to RP alone to improve postoperative pain after craniotomy in children.
- Centers for Medicare & Medicaid Services Hierarchical Condition Category score as a predictor of readmission and reoperation following elective inpatient spine surgery. [Journal Article]
- JNJ Neurosurg Spine 2019 Jun 21; :1-7
- CONCLUSIONS: The HCC score may hold value as an objective, automated predictor of postoperative resource utilization and outcomes, including readmission and reoperation. This may have value as a universal, reproducible tool to target clinical interventions for higher-risk patients.
- Refining Risk-Adjustment for Bundled Payment Models in Cervical Fusions - An Analysis of Medicare Beneficiaries. [Journal Article]
- SJSpine J 2019 Jun 18
- CONCLUSIONS: The current cervical fusion bundled payment model fails to employ a robust risk adjustment of prices resulting in the large amount of cost-variation seen within 90-day reimbursements. Under the proposed DRG-based risk-adjustment model, providers would be reimbursed the same amount for cervical fusions regardless of the surgical approach (posterior vs. anterior), the extent of fusion, use of adjunct procedures (decompressions) and cause/indication of surgery (fracture vs. degenerative pathology), despite each of these factors having different resource utilization and associated reimbursements. Our findings suggest that defining payments based on DRG codes only is an imperfect way of employing bundled payments for spinal fusions and will only end up creating major financial disincentives and barriers to access of care in the healthcare system.
- Bow Hunter's Syndrome: Complete Microsurgical Decompression of Vertebral Artery by Far Lateral Retrocondylar Approach: 3-Dimensional Operative Video. [Journal Article]
- ONOper Neurosurg (Hagerstown) 2019 Jun 21
- This 50-yr-old man had a 15-yr history of presyncopal episodes that were precipitated by turning his head to the right, and had worsened recently. Cerebral angiogram demonstrated complete cessation o…
This 50-yr-old man had a 15-yr history of presyncopal episodes that were precipitated by turning his head to the right, and had worsened recently. Cerebral angiogram demonstrated complete cessation of anterograde flow in left vertebral artery (VA) at the level of the C1 sulcus arteriosus while turning head to right, indicating dynamic compression at the C1 level. Patient underwent left extreme lateral retrocondylar approach, partial C1 laminectomy and opening of the C1 foramen with complete microsurgical decompression of the VA. After skin incision, meticulous muscle dissection was performed and superior and inferior oblique muscles were disconnected from the tubercle of C1. The VA was exposed, and three areas of constriction were visible, first at the atlanto-occipital membrane laterally; second, located more medially as the artery curved around the occipital condyle to enter the posterior fossa; and third, located anterior to C2 nerve root. The artery was dissected from all the surrounding tissues, preserving the C2 nerve root, and the Cl foramen was opened completely. The Cl lamina was also partially resected and grooved to allow free placement of the VA. The VA was also decompressed near the C2 foramen. Postoperative computed tomography angiogram of the head and neck showed complete decompression of VA. The patient had no episodes of presyncope or dizziness while turning head to right and his mRs was 0 at 8 mo follow up. This 3D video shows the technical nuances of decompression of V3 segment of VA in bow hunters's syndrome. Informed consent was obtained from the patient prior to the surgery that included videotaping of the procedure and its distribution for educational purposes. All relevant patient identifiers have also been removed from the video and accompanying radiology slides.
- Innovative mouse model mimicking human-like features of spinal cord injury: efficacy of Docosahexaenoic acid on acute and chronic phases. [Journal Article]
- SRSci Rep 2019 Jun 20; 9(1):8883
- Traumatic spinal cord injury has dramatic consequences and a huge social impact. We propose a new mouse model of spinal trauma that induces a complete paralysis of hindlimbs, still observable 30 days…
Traumatic spinal cord injury has dramatic consequences and a huge social impact. We propose a new mouse model of spinal trauma that induces a complete paralysis of hindlimbs, still observable 30 days after injury. The contusion, performed without laminectomy and deriving from the pressure exerted directly on the bone, mimics more closely many features of spinal injury in humans. Spinal cord was injured at thoracic level 10 (T10) in adult anesthetized female CD1 mice, mounted on stereotaxic apparatus and connected to a precision impactor device. Following severe injury, we evaluated motor and sensory functions, and histological/morphological features of spinal tissue at different time points. Moreover, we studied the effects of early and subchronic administration of Docosahexaenoic acid, investigating functional responses, structural changes proximal and distal to the lesion in primary and secondary injury phases, proteome modulation in injured spinal cord. Docosahexaenoic acid was able i) to restore behavioural responses and ii) to induce pro-regenerative effects and neuroprotective action against demyelination, apoptosis and neuroinflammation. Considering the urgent health challenge represented by spinal injury, this new and reliable mouse model together with the positive effects of docosahexaenoic acid provide important translational implications for promising therapeutic approaches for spinal cord injuries.
- Ultrasound-guided Syringosubarachnoid Shunt Insertion for Cervicothoracic Syringomyelia. [Journal Article]
- CSClin Spine Surg 2019 Jun 18
- Syrinx can be secondary to many etiologies, including tumor, Chiari malformation, tethered cord, or sequelae of infection or trauma. Posttraumatic syringomyelia, a potential complication of spinal in…
Syrinx can be secondary to many etiologies, including tumor, Chiari malformation, tethered cord, or sequelae of infection or trauma. Posttraumatic syringomyelia, a potential complication of spinal injury, can insidiously present years after the initial event. Expansion of the cerebrospinal fluid-filled cyst can lead to pain, sensorimotor deficits, and myelopathy. Simple fenestration is often unsuccessful, therefore permanent shunting of cerebrospinal fluid from the syrinx to the subarachnoid, pleura, or peritoneum can prevent recurrence. In this report, we present a patient with a complex L3 burst fracture from a remote trauma s/p stabilization. Thirty-two years later, he developed progressive neck pain, upper extremity radiculopathy, dysesthesias, and clinical myelopathy (dropping objects, gait imbalance). An MRI demonstrated an expansile syrinx from C2-conus medullaris which previously had been unsuccessfully treated by fenestration. We offered a T1-2 laminectomy and placement of synringosubarachnoid shunt. In the associated video (Supplemental Digital Content 1, http://links.lww.com/CLINSPINE/A107), we demonstrate the step-by-step approach for this procedure, including microsurgical intradural intramedullary exploration and insertion of a T-tube shunt catheter. We additionally demonstrate nuances of ultrasonography that guide medullary entry localization and confirmation of successful shunt placement. Finally, we review preoperative planning pearls pertinent to revision surgeries, pitfalls of the operation, and postoperative management strategies germane to successful outcomes.
- An Analysis of the Cost-Effectiveness of Spinal Versus General Anesthesia for Lumbar Spine Surgery in Various Hospital Settings. [Journal Article]
- GSGlobal Spine J 2019; 9(4):368-374
- CONCLUSIONS: We conclude that use of spinal anesthesia for lumbar laminectomy leads to less operating room, postanesthesia care unit, and anesthesia times, lower levels of postoperative pain, and no increased rate of other complications compared with general anesthesia at an academic institution as compared to a private practice setting. Spinal anesthesia is 9.93% less expensive than general anesthesia, indicating substantial cost-saving potential. With no sacrifice of patient outcomes and the added benefit of less pain and recovery time, Spinal anesthesia represents a more cost-effective alternative to general anesthesia in lumbar spine surgery in the academic hospital setting.
- Posterior Inferior Cerebellar Artery Reanastomosis After Excision of a Ruptured p2-PICA Aneurysm: 2-Dimensional Operative Video. [Journal Article]
- ONOper Neurosurg (Hagerstown) 2019 Jun 19
- Posterior inferior cerebellar artery (PICA) aneurysms have an increased tendency towards a fusiform morphology precluding primary clip reconstruction. The management of these complex aneurysms might …
Posterior inferior cerebellar artery (PICA) aneurysms have an increased tendency towards a fusiform morphology precluding primary clip reconstruction. The management of these complex aneurysms might require cerebral revascularization to preserve flow in a distal PICA territory. This video illustrates a case of a ruptured p2-PICA aneurysm excision followed by a PICA reanastomosis. A 54-yr-old male presented with a sudden-onset severe headache, diplopia, and complete left cranial nerve six (CN VI) palsy. Neuroimaging demonstrated diffuse subarachnoid hemorrhage in basal cisterns. A catheter angiogram shows a ruptured small fusiform aneurysm in the p2-PICA segment. After obtaining consent for surgery, the patient was placed in a three-quarter prone position. After a hockey stick skin incision and C1 laminectomy, a lateral suboccipital craniotomy was performed. The aneurysm was identified within the vagoaccessory triangle. Cerebral protection consisted of propofol-induced electroencephalography burst suppression during the clamp time for the bypass, without hypothermia or hypertension. After trapping the aneurysm and excising the diseased arterial segment, the distal end of the p2-PICA was reanastomosed to the proximal parent vessel in an end-to-end fashion. Indocyanine green angiography confirmed patency of the anastomosis. Postoperatively, the patient was neurologically at his baseline. The CN VI palsy had completely resolved at a follow-up visit. Reanastomosis is an effective modality for reconstructing PICA following the excision of the fusiform aneurysm. The redundancy of the tonsillomedullary segment of PICA allows for easier distal segment reapproximation in the inferior hypoglossal triangle. An intracranial-intracranial revascularization technique eliminates the need for harvesting the occipital artery. Additionally, it prevents iatrogenic ischemic injury to contralateral PICA, if used for a PICA-PICA bypass.1 © Barrow Neurological Institute, used with permission.
- Bony decompression vs duraplasty for Chiari I malformation: does the eternal dilemma matter? [Journal Article]
- CNChilds Nerv Syst 2019 Jun 18
- CONCLUSIONS: PFBD and PFBDD are different techniques that are indicated for different types of patients. In children, PFBD has been demonstrated to represent the best choice, although some patients may require a more aggressive treatment. Therefore, the success in the management of CIM, with or without syringomyelia, depends on the correct indication to surgery and on a patient-tailored choice rather than on the surgical technique.
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- Cervical Laminectomy With or Without Lateral Mass Instrumentation: A Comparison of Outcomes. [Journal Article]
- CSClin Spine Surg 2019 Jun 14
- CONCLUSIONS: In carefully selected patients with normal preoperative cervical sagittal alignment, stand-alone cervical laminectomy may offer acceptably low rates of postoperative kyphosis. In patients with preoperative loss of cervical lordosis and/or kyphosis, posterior fusion is recommended to reduce the risk of progression to postoperative kyphotic deformity, bearing in mind that radiologic evidence of kyphosis may not necessarily correlate with poorer clinical outcomes. Furthermore, the specific risks associated with posterior fusion (instrumentation failure, pseudarthrosis, infection, C5 nerve root palsy, and vertebral artery injury) need to be considered and weighed up against potential benefits.