Journal club: role of endoscopic third ventriculostomy and ventriculoperitoneal shunt in idiopathic normal pressure hydrocephalus: preliminary results of a randomized clinical trial.

1. Significance/Context and Importance of the Study: Idiopathic normal pressure hydrocephalus (INPH) was first defined by Hakim and colleagues in 19651, and its symptoms later classified by the clinical triad of gait dysfunction, urinary incontinence, and dementia. The exact pathophysiology of this disease is not well understood.2 Surgical options for the treatment of INPH are ventriculoperitoneal shunt (VPS) placement (most commonly with a programmable valve), and endoscopic third ventriculostomy (ETV). VPS is by far the most common method used to treat INPH worldwide. Debate exists as to the superiority between the two management options. Historically, VPS placement with a programmable valve has led to improved outcomes with INPH.3 More recent use of ETV has been reported in the form of retrospective data, demonstrating neurological improvement in up to 69% of patients.4 However, a cited limitation of this study is the less stringent diagnostic criteria that fails to discriminate secondary NPH from INPH. This is important because of the higher success rates of treatment in secondary NPH.2 This study by Pinto et al should be commended for its attempt to compare ETV to VPS with a nonprogrammable valve for patients with the diagnosis of INPH prospectively. Given that the natural history of VPS carries a significant rate of shunt revision, there have been no prior attempts to provide level I evidence demonstrating equivalence or superiority of ETV to VPS placement

Thoracolumbar spine trauma: review of the evidence.

AIM: The aim of this paper was to provide a comprehensive review of literature regarding the classification systems and surgical management of thoracolumbar spine trauma. METHODS: A Pubmed search of thoracolumbar , spine , fracture was used on January 05, 2013. Exclusionary criteria included non-Human studies, case reports, and non-clinical papers. RESULTS. One thousand five hundred twenty manuscripts were initially returned for the combined search string; 150 were carefully reviewed, and 48 manuscripts were included in the review. DISCUSSION: Traumatic spinal cord injury (SCI) has a high prevalence in North America. The thoracolumbar junction is a point of high kinetic energy transfer and often results in thoracolumbar fractures. New classification systems for thoracolumbar spine fractures are being developed in an attempt to standardize evaluation, diagnosis, and treatment as well as reporting in the literature. Earlier classifications such as the Denis 3-column model emphasized anatomic divisions to guide surgical planning. More modern classification systems such as the Thoracolumbar injury classification system (TLICS) emphasize initial neurologic status and structural integrity of the posterior ligamentous complex as a guide for surgical decision making and have demonstrated a high intra- and interobserver reliability. Other systems such as the Load-Sharing Classification aid as a useful tool in planning the extent of instrumentation and fusion. CONCLUSION: There is still much controversy over the surgical management of various thoracolumbar fractures. Level I data exists supporting the nonsurgical management of thoracolumbar burst fractures without neurologic compromise. However, for the majority of fracture types in this region, more randomized controlled trials are necessary to establish standards of care

Nitrous oxide myelopathy posing as spinal cord injury.

The authors describe a patient who presented with acute tetraparesis and a proposed acute traumatic spinal cord injury that was the result of nitrous oxide myelopathy. This 19-year-old man sustained a traumatic fall off a 6-ft high wall. His examination was consistent with a central cord syndrome with the addition of dorsal column impairment. Cervical MRI demonstrated an isolated dorsal column signal that was suggestive of a nontraumatic etiology. The patient\u27s symptoms resolved entirely over the course of 48 hours. Nitrous oxide abuse is increasing in prevalence. Its toxic side effects can mask vitamin B12 and folate deficiency and central cord syndrome. The patient\u27s history and radiographic presentation are key to establishing a diagnosis

Variability of patient spine education by Internet search engine.

BACKGROUND: Patients are increasingly reliant upon the Internet as a primary source of medical information. The educational experience varies by search engine, search term, and changes daily. There are no tools for critical evaluation of spinal surgery websites. PURPOSE: To highlight the variability between common search engines for the same search terms. To detect bias, by prevalence of specific kinds of websites for certain spinal disorders. Demonstrate a simple scoring system of spinal disorder website for patient use, to maximize the quality of information exposed to the patient. STUDY DESIGN: Ten common search terms were used to query three of the most common search engines. The top fifty results of each query were tabulated. A negative binomial regression was performed to highlight the variation across each search engine. RESULTS: Google was more likely than Bing and Yahoo search engines to return hospital ads (P=0.002) and more likely to return scholarly sites of peer-reviewed lite (P=0.003). Educational web sites, surgical group sites, and online web communities had a significantly higher likelihood of returning on any search, regardless of search engine, or search string (P=0.007). Likewise, professional websites, including hospital run, industry sponsored, legal, and peer-reviewed web pages were less likely to be found on a search overall, regardless of engine and search string (P=0.078). CONCLUSION: The Internet is a rapidly growing body of medical information which can serve as a useful tool for patient education. High quality information is readily available, provided that the patient uses a consistent, focused metric for evaluating online spine surgery information, as there is a clear variability in the way search engines present information to the patient

Cervical spondylotic myelopathy in the young adult: A review of the literature and clinical diagnostic criteria in an uncommon demographic

Background: Cervical spondylotic myelopathy (CSM) is typically encountered in the elderly population. Significant inconsistencies currently exist regarding the definition of the disorder, the true incidence of CSM in younger populations, and the established diagnostic criteria. Objective: To highlight the lack of standardization in the definition and diagnosis of CSM. Methods: A PubMed literature search was conducted spanning the years 2001 to 2011. The search was limited by the following terms: 1) English language, 2) Adults (19-44 years old), and 3) “cervical spondylotic myelopathy.” Each article was reviewed to determine if the presence of the definition of CSM existed in the article. The clinical characteristics used to make the diagnosis of CSM were recorded for each article. Cochran’s Q statistic was used to determine whether some clinical characteristics were more frequently used than others. Results: 93 papers were reviewed in detail and 16 case reports, reviews, and articles concerning less than three patients were excluded, resulting in 77 articles in the final analysis. The most common clinical definitions were gait disturbance (22/77 articles (28.6%)), upper limb paresthesias or sensory disturbance (21/77 (27.3%)), and clumsy hands (15/77 (19.5%)). Hyperreflexia, spasticity, and pathologically increased reflexes were identified as diagnostic criteria in a minority of patients. Conclusion: The literature employs a wide range of neurologic signs and symptoms to make the diagnosis of CSM, with a majority of studies failing to rely on strict diagnostic criteria. The clinician should not discount CSM as an explanation for the aforementioned findings, as it is well-reported in the literature among the ages 18-44

Technology and Simulation to Improve Patient Safety.

Improving the quality and efficiency of surgical techniques, reducing technical errors in the operating suite, and ultimately improving patient safety and outcomes through education are common goals in all surgical specialties. Current surgical simulation programs represent an effort to enhance and optimize the training experience, to overcome the training limitations of a mandated 80-hour work week, and have the overall goal of providing a well-balanced resident education in a society with a decreasing level of tolerance for medical errors

Simulated spinal cerebrospinal fluid leak repair: an educational model with didactic and technical components.

BACKGROUND: In the era of surgical resident work hour restrictions, the traditional apprenticeship model may provide fewer hours for neurosurgical residents to hone technical skills. Spinal dura mater closure or repair is 1 skill that is infrequently encountered, and persistent cerebrospinal fluid leaks are a potential morbidity. OBJECTIVE: To establish an educational curriculum to train residents in spinal dura mater closure with a novel durotomy repair model. METHODS: The Congress of Neurological Surgeons has developed a simulation-based model for durotomy closure with the ongoing efforts of their simulation educational committee. The core curriculum consists of didactic training materials and a technical simulation model of dural repair for the lumbar spine. RESULTS: Didactic pretest scores ranged from 4/11 (36%) to 10/11 (91%). Posttest scores ranged from 8/11 (73%) to 11/11 (100%). Overall, didactic improvements were demonstrated by all participants, with a mean improvement between pre- and posttest scores of 1.17 (18.5%; P = .02). The technical component consisted of 11 durotomy closures by 6 participants, where 4 participants performed multiple durotomies. Mean time to closure of the durotomy ranged from 490 to 546 seconds in the first and second closures, respectively (P = .66), whereby the median leak rate improved from 14 to 7 (P = .34). There were also demonstrative technical improvements by all. CONCLUSION: Simulated spinal dura mater repair appears to be a potentially valuable tool in the education of neurosurgery residents. The combination of a didactic and technical assessment appears to be synergistic in terms of educational development

Evaluating initial spine trauma response: injury time to trauma center in PA, USA.

Historical perceptions regarding the severity of traumatic spinal cord injury has led to considerable disparity in triage to tertiary care centers. This article retrospectively reviews a large regional trauma database to analyze whether the diagnosis of spinal trauma affected patient transfer timing and patterns. The Pennsylvania Trauma database was retrospectively reviewed. All acute trauma patient entries for level I and II centers were categorized for diagnosis, mechanism, and location of injury, analyzing transportation modality and its influence on time of arrival. A total of 1162 trauma patients were identified (1014 blunt injuries, 135 penetrating injuries and 12 other) with a mean transport time of 3.9 hours and a majority of patients arriving within 7 hours (\u3e75%). Spine trauma patients had the longest mean arrival time (5.2 hours) compared to blunt trauma (4.2 hours), cranial neurologic injuries (4.35 hours), and penetrating injuries (2.13 hours,

Intraoperative Vancomycin Use in Spinal Surgery: Single Institution Experience and Microbial Trends.

Study Design. Retrospective Case Series.Objective. To demonstrate the microbial trends of spinal surgical site infections(SSI) in patients who had previously received crystallized vancomycin in the operative bed.Summary of Background Data. Prior large, case control series demonstrate the significant decrease in SSI with the administration of vancomycin in the wound bed.Methods. A single institution, electronic database search was conducted for all spinal surgery patients who had received prophylactic crystalline vancomycin powder in the wound bed. Patient\u27s with a prior history of wound infection, intrathecal pumps, or spinal stimulators were excludedResults. 981 consecutive patients (494 male, 487 female, mean age 59.4 years, range 16-95 years) were identified from January 2011 to June 2013. The average dose of vancomycin powder was 1.13 grams(range: 1-6 grams). 66 patients (6.71%) were diagnosed with a SSI of which 51 patients had positive wound cultures (5.2%). Of the 51 positive cultures the most common organism was Staphylococcus aureus. The average dose of vancomycin was 1.3 grams in the 38 cases where a gram-positive organism was cultured. A number of gram-negative infections were encountered such as Serratia marcescens, Enterobacter aerogenes, Bacteroides fragilis, Enterobacter cloacae, Citrobacter koseri and Pseudomonas aeruginosa. The average dose of vancomycin was 1.2 grams in 23 cases where a gram negative infection was cultured. 15 of the 51 (29.4%) positive-cultures were polymicrobial. 8 (53%) of these 15 polymicrobial cultures contained three or more distinct organisms.Conclusion. Prophylactic intraoperative vancomycin use in the wound bed in spinal surgery may increase the incidence of gram-negative or polymicrobial spinal infections. The use of intraoperative vancomycin may correlate with postoperative seromas, due to the high incidence of non-positive cultures. Large, randomized, prospective trials are needed to demonstrate causation and dose-response relationship

Intraperitoneal drain placement and outcomes after elective colorectal surgery: international matched, prospective, cohort study

Despite current guidelines, intraperitoneal drain placement after elective colorectal surgery remains widespread. Drains were not associated with earlier detection of intraperitoneal collections, but were associated with prolonged hospital stay and increased risk of surgical-site infections.Background Many surgeons routinely place intraperitoneal drains after elective colorectal surgery. However, enhanced recovery after surgery guidelines recommend against their routine use owing to a lack of clear clinical benefit. This study aimed to describe international variation in intraperitoneal drain placement and the safety of this practice. Methods COMPASS (COMPlicAted intra-abdominal collectionS after colorectal Surgery) was a prospective, international, cohort study which enrolled consecutive adults undergoing elective colorectal surgery (February to March 2020). The primary outcome was the rate of intraperitoneal drain placement. Secondary outcomes included: rate and time to diagnosis of postoperative intraperitoneal collections; rate of surgical site infections (SSIs); time to discharge; and 30-day major postoperative complications (Clavien-Dindo grade at least III). After propensity score matching, multivariable logistic regression and Cox proportional hazards regression were used to estimate the independent association of the secondary outcomes with drain placement. Results Overall, 1805 patients from 22 countries were included (798 women, 44.2 per cent; median age 67.0 years). The drain insertion rate was 51.9 per cent (937 patients). After matching, drains were not associated with reduced rates (odds ratio (OR) 1.33, 95 per cent c.i. 0.79 to 2.23; P = 0.287) or earlier detection (hazard ratio (HR) 0.87, 0.33 to 2.31; P = 0.780) of collections. Although not associated with worse major postoperative complications (OR 1.09, 0.68 to 1.75; P = 0.709), drains were associated with delayed hospital discharge (HR 0.58, 0.52 to 0.66; P < 0.001) and an increased risk of SSIs (OR 2.47, 1.50 to 4.05; P < 0.001). Conclusion Intraperitoneal drain placement after elective colorectal surgery is not associated with earlier detection of postoperative collections, but prolongs hospital stay and increases SSI risk