Microsurgical vs. Endoscopic Excision of Colloid Cysts: An Analysis of Complications and Costs Using a Longitudinal Administrative Database

ObjectiveOpen microsurgical and endoscopic approaches are the two main surgical options for excision of colloid cysts. Controversy remains as to which is superior. Previous studies consist of small cohort sizes. This topic has not been investigated using national administrative claims data which benefits from larger patient numbers.MethodsCurrent Procedural Terminology (CPT) and International Classification of Disease version 9 (ICD-9) coding at inpatient visit was used to select for index surgical procedures corresponding to microsurgical or endoscopic excision of colloid cysts. Comorbidities, costs, and complications were collected.ResultsWe identified a total of 483 patients. In all, 240 were from the microsurgical cohort and 243 were from the endoscopic cohort. The two groups displayed similar demographic and comorbidity profiles. Thirty-day post-operative complications were also similar between groups with the exception of seizures and thirty-day readmissions, both higher in the open surgical cohort. The seizure rates were 14.7 and 5.4% in the microsurgical and endoscopic cohorts, respectively (p = 0.0011). The thirty-day readmission rates were 17.3 and 9.6% in the microsurgical and endoscopic cohorts, respectively (p = 0.0149). Index admission costs and 90-day post discharge payments were higher in patients receiving microsurgical excision.ConclusionAn analysis of administrative claims data revealed few differences in surgical complications following colloid cyst excision via microsurgical and endoscopic approaches. Post-operative seizures and thirty-day readmissions were seen at higher frequency in patients who underwent microsurgical resection. Despite similar complication profiles, patients undergoing microsurgical excision experienced higher index admission costs and 90-day aggregated costs suggesting that complications may have been more severe in this group

Global adoption of robotic technology into neurosurgical practice and research

Recent technological advancements have led to the development and implementation of robotic surgery in several specialties, including neurosurgery. Our aim was to carry out a worldwide survey among neurosurgeons to assess the adoption of and attitude toward robotic technology in the neurosurgical operating room and to identify factors associated with use of robotic technology. The online survey was made up of nine or ten compulsory questions and was distributed via the European Association of the Neurosurgical Societies (EANS) and the Congress of Neurological Surgeons (CNS) in February and March 2018. From a total of 7280 neurosurgeons who were sent the survey, we received 406 answers, corresponding to a response rate of 5.6%, mostly from Europe and North America. Overall, 197 neurosurgeons (48.5%) reported having used robotic technology in clinical practice. The highest rates of adoption of robotics were observed for Europe (54%) and North America (51%). Apart from geographical region, only age under 30, female gender, and absence of a non-academic setting were significantly associated with clinical use of robotics. The Mazor family (32%) and ROSA (26%) robots were most commonly reported among robot users. Our study provides a worldwide overview of neurosurgical adoption of robotic technology. Almost half of the surveyed neurosurgeons reported having clinical experience with at least one robotic system. Ongoing and future trials should aim to clarify superiority or non-inferiority of neurosurgical robotic applications and balance these potential benefits with considerations on acquisition and maintenance costs

Generative Adversarial Network Based Synthetic Learning and a Novel Domain Relevant Loss Term for Spine Radiographs

Problem: There is a lack of big data for the training of deep learning models in medicine, characterized by the time cost of data collection and privacy concerns. Generative adversarial networks (GANs) offer both the potential to generate new data, as well as to use this newly generated data, without inclusion of patients' real data, for downstream applications. Approach: A series of GANs were trained and applied for a downstream computer vision spine radiograph abnormality classification task. Separate classifiers were trained with either access or no access to the original imaging. Trained GANs included a conditional StyleGAN2 with adaptive discriminator augmentation, a conditional StyleGAN2 with adaptive discriminator augmentation to generate spine radiographs conditional on lesion type, and using a novel clinical loss term for the generator a StyleGAN2 with adaptive discriminator augmentation conditional on abnormality (SpineGAN). Finally, a differential privacy imposed StyleGAN2 with adaptive discriminator augmentation conditional on abnormality was trained and an ablation study was performed on its differential privacy impositions. Key Results: We accomplish GAN generation of synthetic spine radiographs without meaningful input for the first time from a literature review. We further demonstrate the success of synthetic learning for the spine domain with a downstream clinical classification task (AUC of 0.830 using synthetic data compared to AUC of 0.886 using the real data). Importantly, the introduction of a new clinical loss term for the generator was found to increase generation recall as well as accelerate model training. Lastly, we demonstrate that, in a limited size medical dataset, differential privacy impositions severely impede GAN training, finding that this is specifically due to the requirement for gradient perturbation with noise

Robotic and navigated spine surgery surgical techniques and advancements

As the benefits of surgical robotic systems in spine surgery become more widely known, spine procedures that utilize these technologies are expected to greatly increase over the next decade. Robotic and Navigated Spine Surgery: Surgical Techniques and Advancements provides up-to-date, authoritative clinical guidance in this dynamic area for surgeons who are already using these innovative methods, as well as for those exploring the field. In a single, convenient source, this title comprehensively summarizes clinical studies, advancements, and expert recommendations regarding today’s robotic and navigated spine surgery

Brain Tuberculoma in a Non-Endemic Area

Brain tuberculoma has previously accounted for up to a third of new intracranial lesions in areas endemic with tuberculosis, but is unexpected in the United States and other Western countries with improved disease control. Here we show the importance of considering this diagnosis in at-risk patients, even with no definitive pulmonary involvement. We describe a young man who presented with partial seizures and underwent craniotomy for resection of a frontoparietal tuberculoma. He subsequently completed six months of antituberculosis therapy and was doing well without neurological sequelae or evidence of recurrence five months after completion of therapy. With resurgence of tuberculosis cases in the United States and other Western countries, intracerebral tuberculoma should remain a diagnostic consideration in at-risk patients with new space occupying lesions. Mass lesions causing neurological sequelae can be safely addressed surgically and followed with antituberculosis therapy

Brain Tuberculoma in a Non-Endemic Area

Brain tuberculoma has previously accounted for up to a third of new intracranial lesions in areas endemic with tuberculosis, but is unexpected in the United States and other Western countries with improved disease control. Here we show the importance of considering this diagnosis in at-risk patients, even with no definitive pulmonary involvement. We describe a young man who presented with partial seizures and underwent craniotomy for resection of a frontoparietal tuberculoma. He subsequently completed six months of antituberculosis therapy and was doing well without neurological sequelae or evidence of recurrence five months after completion of therapy. With resurgence of tuberculosis cases in the United States and other Western countries, intracerebral tuberculoma should remain a diagnostic consideration in at-risk patients with new space occupying lesions. Mass lesions causing neurological sequelae can be safely addressed surgically and followed with antituberculosis therapy

Trigeminal Neuralgia

Trigeminal Neuralgia (TN) is the most common cranio-facial pain syndrome, with an incidence of up to 5 in 100,000. Long-term medical treatment is commonly required, with up to 10% of cases suffering adverse drug-related events. In 1951, Lars Leksell pioneered the application of stereotactic irradiation for the treatment of TN, which may now achieve up to 90% pain control at 1 year and 60% at 2 years. Pain control can remain excellent in 26% of treated patients at 10 years. Radiosurgical treatment targets either the nerve\u2019s emergence (the root entry zone) or the retrogasserian portion of the nerve. Use of the former has a greater likelihood for long-term pain control, but may lead to higher doses to the brainstem. Targeting the latter may reduce the risk of complications, but requires a higher maximum dose to obtain optimal results. Generally speaking, radiosurgical treatment achieves better results in patients receiving high doses of radiations ranging from 70 to 90 Gy. It is also recommended that the length of nerve treated is between 4 and 6 mm. Hypoesthesia and facial numbness are frequently observed after high-dose trigeminal irradiation. Mild hypoesthesia is acceptable and is considered by many an efficacy endpoint of the procedure. Bothersome facial numbness is relatively rare. Sensitive trigeminal disturbances and paresthesia after treatment have been reported to range 6%\u201354% and 0%\u201317%, respectively. The prescribed dose and brainstem-delivered dose are correlated with the subsequent rate of sensitive trigeminal disturbances. CyberKnife frameless non-isocentric radiosurgery is an emerging and thoroughly non-invasive treatment for TN that can potentially deliver homogeneous irradiation to an extended length of the trigeminal nerve. This feature makes CyberKnife radiosurgery essentially different from isocenter-based Gamma Knife treatment. By contrast, targeting an extended segment of the trigeminal nerve with Gamma Knife requires placement of a second isocenter and generates hot and cold spots along the nerve. Thus, CyberKnife can administer variable doses to discreet lengths of nerve in order to improve pain control and reduce complication rates. Currently, clinical results reported in the literature are comparable to those offered by the Gamma Knife

Intracranial fat migration: A newly described complication of autologous fat repair of a cerebrospinal fluid leak following supracerebellar infratentorial approach

Introduction: Intracranial fat migration following autologous fat graft and placement of a lumbar drain for cerebrospinal fluid leak after pineal cyst resection surgery has not been previously reported. Case presentation: The authors present a case of a 39-year-old male with a history of headaches who presented for removal of a pineal cyst from the pineal region. He subsequently experienced cerebrospinal fluid leak and postoperative Escherichia coli (E. Coli) wound infection, and meningitis, which were treated initially with wound washout and antibiotics in addition to bone removal and primary repair with primary suture-closure of the durotomy. A lumbar drain was left in place. The cerebrospinal fluid leak returned two weeks following removal of the lumbar drain; therefore, autologous fat graft repair and lumbar drain placement were performed. Three days later, the patient began experiencing right homonymous hemianopia and was found via computed tomography and magnetic resonance imaging to have autologous fat in the infra‑ and supratentorial space, including intraparenchymal and subarachnoid spread. Symptoms began to resolve with supportive care over 48 hours and had almost fully resolved within one week. Discussion: This is the first known report of a patient with an autologous fat graft entering the subarachnoid space, intraparenchymal space, and ventricles following fat graft and lumbar drainage. Conclusion: This case highlights the importance of monitoring for complications of lumbar drain placement