Citations

OBJECTIVE Insular lobe epilepsy is a challenging condition to diagnose and treat. Due to anatomical intricacy and proximity to eloquent brain regions, resection of epileptic foci in that region can be associated with significant postoperative morbidity. The aim of this study was to review available evidence on postoperative outcomes following insular epilepsy surgery. METHODS A comprehensive literature search (PubMed/MEDLINE, Scopus, Cochrane) was conducted for studies investigating the postoperative outcomes for seizures originating in the insula. Seizure freedom at last follow-up (at least 12 months) comprised the primary endpoint. The authors also present their institutional experience with 8 patients (4 pediatric, 4 adult). RESULTS A total of 19 studies with 204 cases (90 pediatric, 114 adult) were identified. The median age at surgery was 23 years, and 48% were males. The median epilepsy duration was 8 years, and 17% of patients had undergone prior epilepsy surgery. Epilepsy was lesional in 67%. The most common approach was transsylvian (60%). The most commonly resected area was the anterior insular region (n = 42, 21%), whereas radical insulectomy was performed in 13% of cases (n = 27). The most common pathology was cortical dysplasia (n = 68, 51%), followed by low-grade neoplasm (n = 16, 12%). In the literature, seizure freedom was noted in 60% of pediatric and 69% of adult patients at a median follow-up of 29 months (75% and 50%, respectively, in the current series). A neurological deficit occurred in 43% of cases (10% permanent), with extremity paresis comprising the most common deficit (n = 35, 21%), followed by facial paresis (n = 32, 19%). Language deficits were more common in left-sided approaches (24% vs 2%, p < 0.001). Univariate analysis for seizure freedom revealed a significantly higher proportion of patients with lesional epilepsy among those with at least 12 months of follow-up (77% vs 59%, p = 0.032). CONCLUSIONS These findings may serve as a benchmark when tailoring decision-making for insular epilepsy, and may assist surgeons in their preoperative discussions with patients. Although seizure freedom rates are quite high with insular epilepsy treatment, the associated morbidity needs to be weighed against the potential for seizure freedom.

OBJECTIVE Sustained postoperative opioid use after elective surgery is a matter of growing concern. Herein, the authors investigated incidence and predictors of long-term opioid use among patients undergoing elective lumbar spine surgery, especially as a function of opioid prescribing practices at postoperative discharge (dose in morphine milligram equivalents [MMEs] and type of opioid). METHODS The OptumLabs Data Warehouse (OLDW) was queried for postdischarge opioid prescriptions for patients undergoing elective lumbar decompression and discectomy (LDD) or posterior lumbar fusion (PLF) for degenerative spine disease. Only patients who received an opioid prescription at postoperative discharge and those who had a minimum of 180 days of insurance coverage prior to surgery and 180 days after surgery were included. Opioid-naive patients were defined as those who had no opioid fills in 180 days prior to surgery. The following patterns of long-term postoperative use were investigated: additional fills (at least one opioid fill 90–180 days after surgery), persistent fills (any span of opioid use starting in the 180 days after surgery and lasting at least 90 days), and Consortium to Study Opioid Risks and Trends (CONSORT) criteria for persistent use (episodes of opioid prescribing lasting longer than 90 days and 120 or more total days’ supply or 10 or more prescriptions in 180 days after the index fill). Multivariable logistic regression was performed to identify predictors of long-term use. RESULTS A total of 25,587 patients were included, of whom 52.7% underwent PLF (n = 13,486) and 32.5% (n = 8312) were opioid-naive prior to surgery. The rates of additional fills, persistent fills, and CONSORT use were 47%, 30%, and 23%, respectively, after PLF and 35.4%, 19%, and 14.2%, respectively, after LDD. The rates among opioid-naive patients were 18.9%, 5.6%, and 2.5% respectively, after PLF and 13.3%, 2.0%, and 0.8%, respectively, after LDD. Using multivariable logistic regression, the following were identified to be significantly associated with higher risk of long-term opioid use following PLF: discharge opioid prescription ≥ 500 MMEs, prescription of a long-acting opioid, female sex, multilevel surgery, and comorbidities such as depression and drug abuse (all p < 0.05). Elderly (age ≥ 65 years) and opioid-naive patients were found to be at lower risk (all p < 0.05). Similar results were obtained on analysis for LDD with the following significant additional risk factors identified: discharge opioid prescription ≥ 400 MMEs, prescription of tramadol alone at discharge, and inpatient surgery (all p < 0.05). CONCLUSIONS In an analysis of pharmacy claims from a national insurance database, the authors identified incidence and predictors of long-term opioid use after elective lumbar spine surgery.

OBJECTIVE The objective of this study was to determine the frequency with which brain biopsy for presumed CNS relapse of systemic hematological malignancies yields new, actionable diagnostic information. Hematological malignancies represent a disparate group of genetic and histopathological disorders. Proclivity for brain involvement is dependent on the unique entity and may occur synchronously or metasynchronously with the systemic lesion. Diffuse large B-cell lymphomas (DLBCLs) have a high propensity for brain involvement. Patients in remission from systemic DLBCL may present with a lesion suspicious for brain relapse. These patients often undergo brain biopsy. The authors’ a priori hypothesis was that brain biopsy in patients with a history of systemic DLBCL and a new brain MRI lesion would have lower diagnostic utility compared with patients with non-DLBCL systemic malignancies. METHODS The authors performed a retrospective review of patients who underwent brain biopsy between 2000 and 2019. Inclusion criteria were patients ≥ 18 years of age with a prior systemic hematological malignancy in remission presenting with a new brain MRI lesion concerning for CNS relapse. Patients with a history of any CNS neoplasms, demyelinating disorders, or active systemic disease were excluded. The main outcome was the proportion of patients with a distinct histopathological brain diagnosis compared with the systemic malignancy. The authors secondarily assessed overall survival, procedure-related morbidity, and 30-day mortality. RESULTS Sixty patients met inclusion criteria (40 males and 20 females); the median age at brain biopsy was 67 years (range 23–88 years). The median follow-up was 8.5 months (range 0.1–231 months). Thirty-nine (65.0%) patients had DLBCL and 21 (35%) had non-DLBCL malignancies. Thirty-five of 36 (97.2%) patients with prior systemic DLBCL and a diagnostic biopsy had histopathological confirmation of the original systemic disease versus 0 of 21 patients with non-DLBCL systemic malignancies (p < 0.001). Morbidity and 30-day mortality were 8.3% and 10.0%, respectively; 2 of 6 30-day mortalities were directly attributable to the biopsy. The median overall survival following brain biopsy was 10.8 months. CONCLUSIONS Patients with a history of systemic DLBCL and presumed CNS relapse gained minimal clinical benefit from brain biopsy but were at high risk of morbidity and mortality. In patients with a history of non-DLBCL systemic malignancies, brain biopsy remained critical given the high likelihood for discovery of distinct diagnostic entities. It was determined that patients with a prior systemic DLBCL and presumed brain relapse should likely receive empirical therapy obviating treatment delay and the risks of brain biopsy.

Abstract BACKGROUND With a dramatic rise in prescription opioid use, it is imperative to review postsurgical prescribing patterns given their contributions to the opioid epidemic. OBJECTIVE To evaluate the impact of departmental postoperative prescribing guidelines on opioid prescriptions following elective spine surgery. METHODS Patients undergoing elective cervical or lumbar spine surgery between 2017 and 2018 were identified. Procedure-specific opioid prescribing guidelines to limit postoperative prescribing following neurosurgical procedures were developed in 2017 and implemented in January 2018. Preguideline data were available from July to December 2017, and postguideline data from July to December 2018. Discharge prescriptions in morphine milliequivalents (MMEs), the proportion of patients (i) discharged with an opioid prescription, (ii) needing refills within 30 d, (iii) with guideline compliant prescriptions were compared in the 2 groups. Multivariable (MV) analyses were performed to assess the impact of guideline implementation on refill prescriptions within 30 d. RESULTS A total of 1193 patients were identified (cervical: 308; lumbar: 885) with 569 (47.7%) patients from the preguideline period. Following guideline implementation, fewer patients were discharged with a postoperative opioid prescription (92.5% vs 81.7%, P < .001) and median postoperative opioid prescription decreased significantly (300 MMEs vs 225 MMEs, P < .001). The 30-d refill prescription rate was not significantly different between preguideline and postguideline cohorts (pre: 24.4% vs post: 20.2%, P = .079). MV analyses did not demonstrate any impact of guideline implementation on need for 30-d refill prescriptions for both cervical (odds ratio [OR] = 0.68, confidence interval [CI] = 0.37-1.26, P = .22) and lumbar cohorts (OR = 0.95, CI = 0.66-1.36, P = .78). CONCLUSION Provider-aimed interventions such as implementation of procedure-specific prescribing guidelines can significantly reduce postoperative opioid prescriptions following spine surgery without increasing the need for refill prescriptions for pain control.

OBJECTIVE The ideal surgical management of grade I lumbar spondylolisthesis has not been determined despite extensive prior investigations. In this cohort study, the authors used data from the large, multicenter, prospectively collected Quality Outcomes Database to bridge the gap between the findings in previous randomized trials and those in a more heterogeneous population treated in a typical practice. The objective was to assess the difference in patient-reported outcomes among patients undergoing decompression alone or decompression plus fusion. METHODS The primary outcome measure was change in 24-month Oswestry Disability Index (ODI) scores. The minimal clinically important difference (MCID) in ODI score change and 30% change in ODI score at 24 months were also evaluated. After adjusting for patient-specific and clinical factors, multivariable linear and logistic regressions were employed to evaluate the impact of fusion on outcomes. To account for differences in age, sex, body mass index, and baseline listhesis, a sensitivity analysis was performed using propensity score analysis to match patients undergoing decompression only with those undergoing decompression and fusion. RESULTS In total, 608 patients who had grade I lumbar spondylolisthesis were identified (85.5% with at least 24 months of follow-up); 140 (23.0%) underwent decompression alone and 468 (77.0%) underwent decompression and fusion. The 24-month change in ODI score was significantly greater in the fusion plus decompression group than in the decompression-only group (−25.8 ± 20.0 vs −15.2 ± 19.8, p < 0.001). Fusion remained independently associated with 24-month ODI score change (B = −7.05, 95% CI −10.70 to −3.39, p ≤ 0.001) in multivariable regression analysis, as well as with achieving the MCID for the ODI score (OR 1.767, 95% CI 1.058–2.944, p = 0.029) and 30% change in ODI score (OR 2.371, 95% CI 1.286–4.371, p = 0.005). Propensity score analysis resulted in 94 patients in the decompression-only group matched 1 to 1 with 94 patients in the fusion group. The addition of fusion to decompression remained a significant predictor of 24-month change in the ODI score (B = 2.796, 95% CI 2.228–13.275, p = 0.006) and of achieving the 24-month MCID ODI score (OR 2.898, 95% CI 1.214–6.914, p = 0.016) and 24-month 30% change in ODI score (OR 2.300, 95% CI 1.014–5.216, p = 0.046). CONCLUSIONS These results suggest that decompression plus fusion in patients with grade I lumbar spondylolisthesis may be associated with superior outcomes at 24 months compared with decompression alone, both in reduction of disability and in achieving clinically meaningful improvement. Longer-term follow-up is warranted to assess whether this effect is sustained.

OBJECTIVE Surgical treatment for degenerative spondylolisthesis has been proven to be clinically challenging and cost-effective. However, there is a range of thresholds that surgeons utilize for incorporating fusion in addition to decompressive laminectomy in these cases. This study investigates these surgeon- and site-specific factors by using the Quality Outcomes Database (QOD). METHODS The QOD was queried for all cases that had undergone surgery for grade 1 spondylolisthesis from database inception to February 2019. In addition to patient-specific covariates, surgeon-specific covariates included age, sex, race, years in practice (0–10, 11–20, 21–30, > 30 years), and fellowship training. Site-specific variables included hospital location (rural, suburban, urban), teaching versus nonteaching status, and hospital type (government, nonfederal; private, nonprofit; private, investor owned). Multivariable regression and predictor importance analyses were performed to identify predictors of the treatment performed (decompression alone vs decompression and fusion). The model was clustered by site to account for site-specific heterogeneity in treatment selection. RESULTS A total of 12,322 cases were included with 1988 (16.1%) that had undergone decompression alone. On multivariable regression analysis clustered by site, adjusting for patient-level clinical covariates, no surgeon-specific factors were found to be significantly associated with the odds of selecting decompression alone as the surgery performed. However, sites located in suburban areas (OR 2.32, 95% CI 1.09–4.84, p = 0.03) were more likely to perform decompression alone (reference = urban). Sites located in rural areas had higher odds of performing decompression alone than hospitals located in urban areas, although the results were not statistically significant (OR 1.33, 95% CI 0.59–2.61, p = 0.49). Nonteaching status was independently associated with lower odds of performing decompression alone (OR 0.40, 95% CI 0.19–0.97, p = 0.04). Predictor importance analysis revealed that the most important determinants of treatment selection were dominant symptom (Wald χ2 = 34.7, accounting for 13.6% of total χ2) and concurrent diagnosis of disc herniation (Wald χ2 = 31.7, accounting for 12.4% of total χ2). Hospital teaching status was also found to be relatively important (Wald χ2 = 4.2, accounting for 1.6% of total χ2) but less important than other patient-level predictors. CONCLUSIONS Nonteaching centers were more likely to perform decompressive laminectomy with supplemental fusion for spondylolisthesis. Suburban hospitals were more likely to perform decompression only. Surgeon characteristics were not found to influence treatment selection after adjustment for clinical covariates. Further large database registry experience from surgeons at high-volume academic centers at which surgically and medically complex patients are treated may provide additional insight into factors associated with treatment preference for degenerative spondylolisthesis.

OBJECTIVE Acute traumatic subdural hematoma (atSDH) can be a life-threatening neurosurgical emergency that necessitates immediate evacuation. The elderly population can be particularly vulnerable to tearing bridging veins. The aim of this study was to evaluate inpatient morbidity and mortality, as well as predictors of inpatient mortality, in a national trauma database. METHODS The authors queried the 2016–2017 National Trauma Data Bank registry for patients aged 65 years and older who had undergone evacuation of atSDH. Patients were categorized into three age groups: 65–74, 75–84, and 85+ years. A multivariable logistic regression model was fitted for inpatient mortality adjusting for age group, sex, race, presenting Glasgow Coma Scale (GCS) category (3–8, 9–12, and 13–15), Injury Severity Score, presence of coagulopathy, presence of additional hemorrhages (epidural hematoma [EDH], intraparenchymal hematoma [IPH], and subarachnoid hemorrhage [SAH]), presence of midline shift > 5 mm, and pupillary reactivity (both, one, or none). RESULTS A total of 2508 patients (35% females) were analyzed. Age distribution was as follows: 990 patients at 65–74 years, 1096 at 75–84, and 422 at 85+. Midline shift > 5 mm was present in 72% of cases. With regard to additional hemorrhages, SAH was present in 21%, IPH in 10%, and EDH in 2%. Bilaterally reactive pupils were noted in 90% of patients. A major complication was observed in 14.4% of patients, and the overall mortality rate was 18.3%. In the multivariable analysis, the presenting GCS category was found to be the strongest predictor of postoperative inpatient mortality (3–8 vs 13–15: OR 3.63, 95% CI 2.68–4.92, p < 0.001; 9–12 vs 13–15: OR 2.64, 95% CI 1.79–3.90, p < 0.001; 30% of overall variation), followed by the presence of SAH (OR 2.86, 95% CI 2.21–3.70, p < 0.001; 25% of overall variation) and the presence of midline shift > 5 mm (OR 2.40, 95% CI 1.74–3.32, p < 0.001; 11% of overall variation). Model discrimination was excellent (c-index 0.81). Broken down by age decile group, mortality increased from 8.0% to 15.4% for GCS 13–15 to around 36% for GCS 9–12 to almost as high as 60% for GCS 3–8, particularly in those aged 85 years and older. CONCLUSIONS The present results from a national trauma database will, the authors hope, assist surgeons in preoperative discussions with patients and their families with regard to expected postoperative outcomes following surgical evacuation of an atSDH.

ABSTRACTBACKGROUND AND PURPOSEThere is a relative paucity of radiology literature on spinal cord cavernous malformations (SCMs). We hypothesized that the classic MRI features of cavernous malformations are not highly prevalent. The purpose was to review MR imaging findings of SCMs with a focus on prevalence of hemorrhagic features, including adjacent intramedullary hemorrhage at initial presentation.METHODSIn this single‐institution study, 78 SCMs in 76 patients diagnosed on imaging/pathology were retrospectively evaluated for size, location, cord expansion, exophytic component, popcorn morphology, signal characteristics, including T1 weighted (T1w) and T2w rims, blood‐fluid levels, and adjacent intramedullary hemorrhage. Intramedullary hemorrhage was defined as centrally and/or eccentrically located linear or flame shaped non‐edematous signal abnormality extending longitudinally away from SCMs, distinct from lesional rim.RESULTSSixty‐three percent (49/78) of SCMs measured <1 cm in length, 78% (61/78) extended to the cord surface, 65% (51/78) were expansile, and 32% (25/78) were exophytic. Popcorn morphology was seen in 15% (12/78) on T1w and 22% (17/78) on T2w. Internal blood‐fluid levels were evident in 4% (3/78). Sixty‐nine percent (54/78) showed T2w hypointense rims; the T2w rim was complete/near‐complete in 37% (29/78). A rim on T1w was visible in 49% (38/78); this was hyperintense in 58% (22/38). Adjacent intramedullary hemorrhage was seen in 45/78 (58%), was most commonly bidirectional in 67% (30/45) and eccentric in 68% (30/44). Cord edema was seen in 22% (17/78); 53% (9/17) also demonstrated intramedullary hemorrhage with edema.CONCLUSIONSThe classically described popcorn morphology, internal blood‐fluid levels, and complete/near‐complete T2w hypointense rims are often absent on MRIs in SCMs. Adjacent intramedullary hemorrhage is frequently present, often eccentric and bidirectional.

Abstract BACKGROUND The impact of symptom characteristics on outcomes of spine surgery remains elusive. OBJECTIVE To determine the impact of symptom location, severity, and duration on outcomes following lumbar spine surgery. METHODS We queried the Quality Outcomes Database (QOD) for patients undergoing elective lumbar spine surgery for lumbar degenerative spine disease. Multivariable regression was utilized to determine the impact of preoperative symptom characteristics (location, severity, and duration) on improvement in disability, quality of life, return to work, and patient satisfaction at 1 yr. Relative predictor importance was determined using an importance metric defined as Wald χ 2 penalized by degrees of freedom. RESULTS A total of 22 022 subjects were analyzed. On adjusted analysis, we found patients with predominant leg pain were more likely to be satisfied ( P < .0001), achieve minimum clinically important difference (MCID) in Oswestry Disability Index (ODI) ( P = .002), and return to work ( P = .03) at 1 yr following surgery without significant difference in Euro-QoL-5D (EQ-5D) ( P = .09) [ref = predominant back pain]. Patients with equal leg and back pain were more likely to be satisfied ( P < .0001), but showed no significant difference in achieving MCID ( P = .22) or return to work ( P = .07). Baseline numeric rating scale-leg pain and symptom duration were most important predictors of achieving MCID and change in EQ-5D. Predominant symptom was not found to be an important determinant of return to work. Worker's compensation was found to be most important determinant of satisfaction and return to work. CONCLUSION Predominant symptom location is a significant determinant of functional outcomes following spine surgery. However, pain severity and duration have higher predictive importance. Return to work is more dependent on sociodemographic features as compared to symptom characteristics.