A Predictive Model of Failure to Rescue After Thoracolumbar Fusion

Objective Although failure to rescue (FTR) has been utilized as a quality-improvement metric in several surgical specialties, its current utilization in spine surgery is limited. Our study aims to identify the patient characteristics that are independent predictors of FTR among thoracolumbar fusion (TLF) patients. Methods Patients who underwent TLF were identified using relevant diagnostic and procedural codes from the National Surgical Quality Improvement Program (NSQIP) database from 2011–2020. Frailty was assessed using the risk analysis index (RAI). FTR was defined as death, within 30 days, following a major complication. Univariate and multivariable analyses were used to compare baseline characteristics and early postoperative sequelae across FTR and non-FTR cohorts. Receiver operating characteristic (ROC) curve analysis was used to assess the discriminatory accuracy of the frailty-driven predictive model for FTR. Results The study cohort (N = 15,749) had a median age of 66 years (interquartile range, 15 years). Increasing frailty, as measured by the RAI, was associated with an increased likelihood of FTR: odds ratio (95% confidence interval [CI]) is RAI 21–25, 1.3 [0.8–2.2]; RAI 26–30, 4.0 [2.4–6.6]; RAI 31–35, 7.0 [3.8–12.7]; RAI 36–40, 10.0 [4.9–20.2]; RAI 41– 45, 21.5 [9.1–50.6]; RAI ≥ 46, 45.8 [14.8–141.5]. The frailty-driven predictive model for FTR demonstrated outstanding discriminatory accuracy (C-statistic = 0.92; CI, 0.89–0.95). Conclusion Baseline frailty, as stratified by type of postoperative complication, predicts FTR with outstanding discriminatory accuracy in TLF patients. This frailty-driven model may inform patients and clinicians of FTR risk following TLF and help guide postoperative care after a major complication

Endoscopic and Nonendoscopic Approaches to Single-Level Lumbar Spine Decompression: Propensity Score-Matched Comparative Analysis and Frailty-Driven Predictive Model

Objective The endoscopic spine surgery (ESS) approach is associated with high levels of patient satisfaction, shorter recovery time, and reduced complications. The present study reports multicenter, international data, comparing ESS and non-ESS approaches for single-level lumbar decompression, and proposes a frailty-driven predictive model for nonhome discharge (NHD) disposition. Methods Cases of ESS and non-ESS lumbar spine decompression were queried from the American College of Surgeons National Surgical Quality Improvement Program database (2017–2020). Propensity score matching was performed on baseline characteristics frailty score (measured by risk analysis index [RAI] and modified frailty index-5 [mFI-5]). The primary outcome of interest was NHD disposition. A predictive model was built using logistic regression with RAI as the primary driver. Results Single-level nonfusion spine lumbar decompression surgery was performed in 38,686 patients. Frailty, as measured by RAI, was a reliable predictor of NHD with excellent discriminatory accuracy in receiver operating characteristic (ROC) curve analysis: C-statistic: 0.80 (95% confidence interval [CI], 0.65–0.94) in ESS cohort, C-statistic: 0.75 (95% CI, 0.73–0.76) overall cohort. After propensity score matching, there was a reduction in total operative time (89 minutes vs. 103 minutes, p = 0.049) and hospital length of stay (LOS) (0.82 days vs. 1.37 days, p < 0.001) in patients treated endoscopically. In ROC curve analysis, the frailty-driven predictive model performed with excellent diagnostic accuracy for the primary outcome of NHD (C-statistic: 0.87; 95% CI, 0.85–0.88). Conclusion After frailty-based propensity matching, ESS is associated with reduced operative time, shorter hospital LOS, and decreased NHD. The RAI frailty-driven model predicts NHD with excellent diagnostic accuracy and may be applied to preoperative decision-making with a user-friendly calculator: nsgyfrailtyoutcomeslab.shinyapps.io/lumbar_decompression_dischargedispo

A new triterpene glycoside from Centella erecta

A new (2α,3β)-23-sulphonyl-2,3-dihydroxyurs-12-en-28-oic acid O-α-l-rhamnopyranosyl-(1→4)-O-β-d-glucopyranosyl-(1→6) -O-β-d-glucopyranosyl ester (1) together with eighteen known compounds were isolated from Centella erecta (L.f.) Fern. Their structures were elucidated mainly by NMR and HRESIMS, as well as on comparison with the reported data. © 2010 Elsevier B.V. All rights reserved

Two new triterpene glycosides from centella asiatica

Phytochemical investigation of the leaves of Centella asiatica resulted in the isolation and characterization of eight triterpenes and/or saponins [which were characterized as 23-O-acetylmadecassoside (1), asiatic acid (2), madecassic acid (3), asiaticoside C (4), asiaticoside F (5), asiaticoside (6), madecassoside (7), and 23-O-acetylasiaticoside B (8)] together with sitosterol 3-O-β-glucoside (9), stigmasterol 3-Oβ-glucoside (10), and querectin-3-O-β-D-glucuronide (11). A new ursane-derived saponin (23-O-acetylmadecassoside) and a new oleanane-derived saponin (23-O-acetylasiaticoside B) were found as well. Structure elucidation was done by using spectroscopic techniques (HRESIMS, 1D and 2DNMR), chemical methods, and comparative literature studies. © Georg Thieme Verlag KG Stuttgart - New York

Comparative study of three Plumbago L. species (Plumbaginaceae) by microscopy, UPLC-UV and HPTLC

This paper presents a comparative study of anatomy of leaves, stems and roots of three species of Plumbago, namely P. auriculata Lam., P. indica L. and P. zeylanica L. by light microscopy. The paper also provides qualitative and quantitative analysis of the naphthoquinone, plumbagin - a major constituent present in these species - using UPLC-UV. Microscopic examinations revealed the presence of distinctive differences in the anatomical features of the leaf, stem and root of the three species, and these can thus be used for identification and authentication of these species. UPLC-UV analysis showed the highest concentration of plumbagin in the roots of P. zeylanica (1.62 % w/w) followed by the roots of P. indica (0.97 % w/w) and then P. auriculata (0.33-0.53 % w/w). In contrast, plumbagin was not detected in the stems and leaves of P. indica and in the leaves of P. auriculata, whereas very low concentrations (\u3c0.02 % w/w) of plumbagin were detected in the stems and leaves of P. zeylanica and in the stems of P. auriculata. HPTLC fingerprints of the leaf and root of the three species exhibited distinguishable profiles, while those of the stems were undifferentiated. © 2012 The Japanese Society of Pharmacognosy and Springer Japan

Prospective application of the risk analysis index to measure preoperative frailty in spinal tumor surgery: A single center outcomes analysis

Introduction: Surgeons are frequently faced with challenging clinical dilemmas evaluating whether the benefits of surgery outweigh the substantial risks routinely encountered with spinal tumor surgery. The Clinical Risk Analysis Index (RAI-C) is a robust frailty tool administered via a patient-friendly questionnaire that strives to augment preoperative risk stratification. The objective of the study was to prospectively measure frailty with RAI-C and track postoperative outcomes after spinal tumor surgery. Methods: Patients surgically treated for spinal tumors were followed prospectively from 7/2020–7/2022 at a single tertiary center. RAI-C was ascertained during preoperative visits and verified by the provider. The RAI-C scores were assessed in relation to postoperative functional status (measured by modified Rankin Scale score [mRS]) at the last follow-up visit. Results: Of 39 patients, 47% were robust (RAI 0–20), 26% normal (21–30), 16% frail (31–40), and 11% severely frail (RAI 41+).). Pathology included primary (59%) and metastatic (41%) tumors with corresponding mRS>2 rates of 17% and 38%, respectively. Tumors were classified as extradural (49%), intradural extramedullary (46%), or intradural intramedullary (5.4%) with mRS>2 rates of 28%, 24%, and 50%, respectively. RAI-C had a positive association with mRS>2 ​at follow-up: 16% for robust, 20% for normal, 43% for frail, and 67% for severely frail. The two deaths in the series had the highest RAI-C scores (45 and 46) and were patients with metastatic cancer. The RAI-C was a robust and diagnostically accurate predictor of mRS>2 in receiver operating characteristic curve analysis (C-statistic: 0.70, 95 CI: 0.49–0.90). Conclusions: The findings exemplify the clinical utility of RAI-C frailty scoring for prediction of outcomes after spinal tumor surgery and it has potential to help in the surgical decision-making process as well as surgical consent. As a preliminary case series, the authors intend to provide additional data with a larger sample size and longer follow-up duration in a future study

A taxonomy for deep cerebral cavernous malformations: subtypes of basal ganglia lesions

OBJECTIVE: Anatomical taxonomy is a practical tool that has successfully guided clinical decision-making for patients with brain arteriovenous malformations and brainstem cavernous malformations (CMs). Deep CMs are similarly complex lesions that are difficult to access and highly variable in size, shape, and position. The authors propose a novel taxonomy for deep CMs in the basal ganglia based on clinical presentation (syndromes) and anatomical location. METHODS: The taxonomy system was developed and applied to an extensive 2-surgeon experience over 19 years (2001-2019). Lesions involving the basal ganglia were identified and subtyped on the basis of the predominant superficial presentation identified on preoperative MRI. Three subtypes of basal ganglia CMs were defined: caudate (31, 57%), putaminal (16, 30%), and pallidal (7, 13%). Neurological outcomes were assessed using the modified Rankin Scale (mRS). Postoperative mRS scores ≤ 2 were defined as a favorable outcome, and scores \u3e 2 were defined as a poor outcome. Clinical and surgical characteristics and neurological outcomes were compared among subtypes. RESULTS: Fifty-four basal ganglia lesions were identified in 54 patients. Each basal ganglia CM subtype was associated with a recognizable constellation of neurological symptoms. The most common symptoms at presentation were severe or worsening headaches (25, 43%), mild hemiparesis (13, 24%), seizures (7, 13%), and dysmetria or ataxia (6, 11%). Patients with caudate CMs were the most likely to present with headaches and constitutional symptoms. Patients with putaminal CMs were the most likely to present with hemibody sensory deficits and dysmetria or ataxia. Patients with pallidal CMs were the most likely to present with mild hemiparesis and visual field deficits. A single surgical approach was preferred (\u3e 80% of cases) for each basal ganglia subtype: caudate (contralateral transcallosal-transventricular, 28/31, 90%), putaminal (transsylvian-anterior transinsular, 13/16, 81%), and pallidal (transsylvian supracarotid-infrafrontal, 7/7, 100%). Most patients with follow-up had stable or improved mRS scores postoperatively (94%, 44/47); mRS scores of \u3e 2 at final follow-up did not differ among the 3 basal ganglia subtypes. CONCLUSIONS: The study confirms the authors\u27 hypothesis that this taxonomy for basal ganglia CMs meaningfully guides the selection of surgical approach and resection strategy. Furthermore, the proposed taxonomy can increase the diagnostic acumen at the patient bedside, help identify optimal surgical approaches, enhance the consistency of clinical communications and publications, and improve patient outcomes

Giant cerebral cavernous malformations: redefinition based on surgical outcomes and systematic review of the literature

OBJECTIVE: Giant cerebral cavernous malformations (GCCMs) are rare vascular malformations. Unlike for tumors and aneurysms, there is no clear definition of a giant cavernous malformation (CM). As a result of variable definitions, working descriptions and outcome data of patients with GCCM are unclear. A new definition of GCCM related to surgical outcomes is needed. METHODS: An institutional database was searched for all patients who underwent resection of CMs \u3e 1 cm in diameter. Patient information, surgical technique, and clinical and radiographic outcomes were assessed. A systematic review was performed to augment an earlier published review. RESULTS: In the authors\u27 institutional cohort of 183 patients with a large CM, 179 with preoperative and postoperative modified Rankin Scale (mRS) scores were analyzed. A maximum CM diameter of ≥ 3 cm was associated with greater risk of severe postoperative decline (≥ 2-point increase in mRS score). After adjustment for age and deep versus superficial location, size ≥ 3 cm was strongly predictive of severe postoperative decline (OR 4.5, 95% CI 1.2-16.9). A model with CM size and deep versus superficial location was developed to predict severe postoperative decline (area under the receiver operating characteristic curve 0.79). Thirteen more patients with GCCMs have been reported in the literature since the most recent systematic review, including some patients who were treated earlier and not discussed in the previous review. CONCLUSIONS: The authors propose that cerebral CMs with a diameter ≥ 3 cm be defined as GCCMs on the basis of the inflection point for functional and neurological outcomes. This definition is in line with the definitions for other giant lesions. It is less exclusive than earlier definitions but captures the rarity of these lesions (approximately 1% incidence) and variation in outcomes. GCCMs remain operable with potentially favorable outcomes. The term giant is not meant to deter or contraindicate surgery

Cost Comparison of Microsurgery vs Endovascular Treatment for Ruptured Intracranial Aneurysms: A Propensity-Adjusted Analysis

BACKGROUND: In specialized neurosurgical centers, open microsurgery is routinely performed for aneurysmal subarachnoid hemorrhage (aSAH). OBJECTIVE: To compare the cost of endovascular vs microsurgical treatment for aSAH at a single quaternary center. METHODS: All patients undergoing aSAH treatment from July 1, 2014, to July 31, 2019, were retrospectively reviewed. Patients were grouped based on primary treatment (microsurgery vs endovascular treatment). The primary outcome was the difference in total cost (including hospital, discharge facility, and all follow-up) using a propensity-adjusted analysis. RESULTS: Of 384 patients treated for an aSAH, 234 (61%) were microsurgically treated and 150 (39%) were endovascularly treated. The mean cost of index hospitalization for these patients was marginally higher ($9504) for endovascularly treated patients ($103 980) than for microsurgically treated patients ($94 476) ( P = .047). For the subset of patients with follow-up data available, the mean total cost was$45 040 higher for endovascularly treated patients ($159 406, n = 59) than that for microsurgically treated patients ($114 366, n = 105) ( P \u3c .001). After propensity scoring (adjusted for age, sex, comorbidities, Glasgow Coma Scale score, Hunt and Hess grade, Fisher grade, aneurysms, and type/size/location), linear regression analysis of patients with follow-up data available revealed that microsurgery was independently associated with healthcare costs that were $37 244 less than endovascular treatment costs ( P \u3c .001). An itemized cost analysis suggested that this discrepancy was due to differences in the rates of aneurysm retreatment and long-term surveillance. CONCLUSION: Microsurgical treatment for aSAH is associated with lower total healthcare costs than endovascular therapy. Aneurysm surveillance after endovascular treatments, retreatment, and device costs warrants attention in future studies