Surgical reversal of prolonged blindness from a metastatic neuroblastoma

Reports of tumor-related anterior visual pathway blindness that have resolved after surgical decompression are rare. The longest reported duration of tumor-related blindness completely reversed by optic nerve decompression is 3 days. We describe a pediatric patient with 7 days of no light perception who experienced reversal of blindness following tumor resection and optic nerve decompression.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/47141/1/381_2004_Article_1062.pd

3-Hydroxy-3-methylglutaryl coenzyme A reductase inhibitors reduce the risk of perioperative stroke and mortality after carotid endarterectomy

ObjectiveThere is increasing evidence that 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) reduce cardiovascular and cerebrovascular events through anti-inflammatory, plaque stabilization, and neuroprotective effects independent of lipid lowering. This study was designed to investigate whether statin use reduces the incidence of perioperative stroke and mortality among patients undergoing carotid endarterectomy (CEA).MethodsAll patients undergoing CEA from 1994 to 2004 at a large academic medical center were retrospectively reviewed. The independent association of statin use and perioperative morbidity was assessed via multivariate logistic regression analysis.ResultsCEA was performed by 13 surgeons on 1566 patients (987 men and 579 women; mean age, 72 ± 10 years), including 1440 (92%) isolated and 126 (8%) combined CEA/coronary artery bypass grafting procedures. The indication for CEA was symptomatic disease in 660 (42%) cases. Six hundred fifty-seven (42%) patients received a statin medication for at least 1 week before surgery. Statin use was associated with a reduction in perioperative strokes (1.2% vs 4.5%; P < .01), transient ischemic attacks (1.5% vs 3.6%; P < .01), all-cause mortality (0.3% vs 2.1%; P < .01), and median (interquartile range) length of hospitalization (2 days [2-5 days] vs 3 days [2-7 days]; P < .05). Adjusting for all demographics and comorbidities in multivariate analysis, statin use independently reduced the odds of stroke threefold (odds ratio [95% confidence interval], 0.35 [0.15-0.85]; P < .05) and death fivefold (odds ratio [95% confidence interval], 0.20 [0.04-0.99]; P < .05).ConclusionsThese data suggest that perioperative statin use may reduce the incidence of cerebrovascular events and mortality among patients undergoing CEA

Acute hospital costs after minimally invasive versus open lumbar interbody fusion: data from a US national database with 6106 patients

STUDY DESIGNRetrospective multi-institutional database review.OBJECTIVETo determine if minimally invasive interbody fusion is associated with cost savings when compared with open surgery.SUMMARY OF BACKGROUND DATAMinimally invasive spine (MIS) surgeries are increasingly recognized as equivalent to open procedures. Although these techniques have been advocated for reducing pain, disability, and length of hospitalization, to date there has been little data demonstrating these benefits.METHODSThis study analyzed inpatient hospital records from the Premier Perspective database (2002 to 2009), including patients who underwent a posterior lumbar fusion with interbody cage placement by ICD-9 code, and had implant charge codes that allowed determination if MIS pedicle screws were utilized. Exclusion criteria included a refusion surgery, deformity, >2 levels, and anterior fusion. Total costs were adjusted for covariates (age, sex, race, hospital geography and setting, payor, and comorbidities) using an analysis of covariance model.RESULTSA total of 6106 patients were identified (1667 MIS and 4439 open). Length of stay (LOS) for 1-level MIS surgery averaged of 3.35 days versus 3.6 days for open surgery (P≤0.006). For 2-level MIS surgery LOS averaged of 3.4 days versus 4.03 days for open surgery (P≤0.001). Total inflation-adjusted acute hospitalization cost averaged $29,187 for 1-level MIS procedures versus$29,947 for open surgery, a nonsignificant difference (P=0.55). Total inflation-adjusted acute hospitalization cost averaged $2106 lower for 2-level MIS surgery (total costs of$33,879 for MIS vs. $35,984 for open surgery, P=0.0023). Cost savings were attributable primarily to lower room and board ($857), operating room ($359), pharmacy ($304), and laboratory ($166) costs in the MIS group. High variances in the 2-level open surgery with prolonged hospital stay also accounted for overall cost differences.CONCLUSIONSThis data from a large nationwide sample of hospitalizations demonstrates that MIS lumbar interbody fusion results in a statistically significant reduction in hospital LOS and a reduction in total hospital costs with 2-level surgery after adjusting for significant covariates. The majority of cost savings from MIS surgery were due to more rapid mobilization and discharge, as well as a reduction in outliers with extended hospitalizations

Association of Annular Defect Width After Lumbar Discectomy With Risk of Symptom Recurrence and Reoperation: Systematic Review and Meta-analysis of Comparative Studies.

Study designSystematic review and meta-analysis of comparative studies.ObjectiveTo characterize the association of annular defect width after lumbar discectomy with the risk of symptom recurrence and reoperation.Summary of background dataLarge annular defect width after lumbar discectomy has been reported to increase risk of symptom recurrence. However, this association has not been evaluated in a systematic manner.MethodsA systematic literature search of MEDLINE and EMBASE was performed to identify comparative studies of large versus small annular defects following lumbar discectomy that reported symptom recurrence or reoperation rates. Main outcomes were reported with pooled odds ratios (OR) and 95% confidence intervals (CIs). Sensitivity analyses were performed to assess the robustness of the meta-analysis findings.ResultsAfter screening 696 records, we included data from 7 comparative studies involving 1653 lumbar discectomy patients, of whom 499 (30%) had large annular defects and 1154 (70%) had small annular defects. Methodological quality of studies was good overall. The median follow-up period was 2.9 years. The risk of symptom recurrence (OR = 2.5, 95% CI = 1.3-4.5, P = 0.004) and reoperation (OR = 2.3, 95% CI = 1.5-3.7, P &lt; 0.001) was higher in patients with large versus small annular defects. Publication bias was not evident. The associations between annular defect width and risk of symptom recurrence and reoperation remained statistically significant in all sensitivity analyses.ConclusionAnnular defect width after lumbar discectomy is an under-reported modifier of patient outcome. Risk for symptom recurrence and reoperation is higher in patients with large versus small annular defects following lumbar discectomy.Level of evidence2

Association of Annular Defect Width After Lumbar Discectomy With Risk of Symptom Recurrence and Reoperation: Systematic Review and Meta-analysis of Comparative Studies

Study Design. Systematic review and meta-analysis of comparative studies. Objective. To characterize the association of annular defect width after lumbar discectomy with the risk of symptom recurrence and reoperation. Summary of Background Data. Large annular defect width after lumbar discectomy has been reported to increase risk of symptom recurrence. However, this association has not been evaluated in a systematic manner. Methods. A systematic literature search of MEDLINE and EMBASE was performed to identify comparative studies of large versus small annular defects following lumbar discectomy that reported symptom recurrence or reoperation rates. Main outcomes were reported with pooled odds ratios (OR) and 95% confidence intervals (CIs). Sensitivity analyses were performed to assess the robustness of the meta-analysis findings. Results. After screening 696 records, we included data from 7 comparative studies involving 1653 lumbar discectomy patients, of whom 499 (30%) had large annular defects and 1154 (70%) had small annular defects. Methodological quality of studies was good overall. The median follow-up period was 2.9 years. The risk of symptom recurrence (OR = 2.5, 95% CI = 1.3–4.5, P = 0.004) and reoperation (OR = 2.3, 95% CI = 1.5–3.7, P < 0.001) was higher in patients with large versus small annular defects. Publication bias was not evident. The associations between annular defect width and risk of symptom recurrence and reoperation remained statistically significant in all sensitivity analyses. Conclusion. Annular defect width after lumbar discectomy is an under-reported modifier of patient outcome. Risk for symptom recurrence and reoperation is higher in patients with large versus small annular defects following lumbar discectomy. Level of Evidence:

Cost Savings Associated with Antibiotic-Impregnated Shunt Catheters in the Treatment of Adult and Pediatric Hydrocephalus

BackgroundCerebrospinal fluid (CSF) shunt infection is a major cause of morbidity and mortality in the treatment of hydrocephalus and is associated with significant medical cost. Several studies have demonstrated the efficacy of antibiotic-impregnated (AI) shunt catheters in reducing CSF shunt infection; however, providers remain reluctant to adopt AI catheters into practice because of the increased upfront cost. The objective of this study was to determine if the use of AI catheters provided cost savings in a large nationwide database.MethodsHospital discharge and billing records from the Premier Perspective Database from 2003–2009 were retrospectively reviewed to identify all adult and pediatric patients undergoing de novo ventricular shunt placement. The incidence of shunt infection within 1 year of implantation was determined. Shunt infection–related cost was defined as all inpatient billing costs incurred during hospitalization for treatment of shunt infection.ResultsIn 287 U.S. hospitals, 10,819 adult (AI catheters, 963; standard catheters, 9856) and 1770 pediatric (AI catheters, 229; standard catheters, 1541) patients underwent ventricular shunt placement. AI catheters were associated with significant reduction in infection for both adult (2.2% vs. 3.6%, P = 0.02) and pediatric (2.6% vs. 7.1%, P < 0.01) patients. Total infection-related costs were $17,371,320 ($45,714 ± $49,745 per shunt infection) for adult patients and$6,508,064 ($56,104 ±$65,746 per shunt infection) for pediatric patients. Infection-related cost per 100 de novo shunts placed was $120,534 for AI catheters and$162,659 for standard catheters in adult patients and $165,087 for AI catheters and$395,477 for standard catheters in pediatric patients.ConclusionsIn analysis of this large, nationwide database, AI catheters were found to be associated with a significant reduction in infection incidence, resulting in tremendous cost savings. AI catheters were associated with a cost savings of $42,125 and$230,390 per 100 de novo shunts placed in adult and pediatric patients, respectively