Middle Meningeal Artery Embolization in Adjunction to Surgical Evacuation for Treatment of Subdural Hematomas

Neurosurgery 93:1082–1089, 2023

Surgical evacuation is the standard treatment for chronic subdural hematomas (CSDHs) but is associated with a high risk of recurrence and readmission. Middle meningeal artery embolization (MMAE) is a novel treatment approach which could be performed upfront or in adjunction to surgical evacuation. MMAE studies are limited by small sample sizes. This study aimed to describe and compare outcomes of MMAE in adjunction to surgery with those of surgery alone on a national level.

METHODS: The national Vizient Clinical Database was queried by use of a specific validated set of International Classification of Diseases, Tenth Revision codes (October 2018-June 2022). Patients with the diagnosis of nontraumatic CSDH who received MMAE and surgical drainage in the same hospitalization were identified, and their outcomes were compared with isolated surgical drainage.

RESULTS: A total of 606 subjects from 156 institutes and 6340 subjects from 369 institutes were included in the MMAE plus surgery (M&S) and surgery groups, respectively. Average length of stay was significantly longer in the M&S group (9.87 vs 7.53 days; P < .01). There was no significant difference in the in-hospital mortality rate (2.8% vs 2.9%), but the complication rate was significantly higher in the M&S group (8.7% vs 5.5%; P < .01). Complications that were significantly more common in the M&S group included aspiration pneumonia, postoperative sepsis, and anesthesia-related. Mean direct costs were significantly higher in the M&S group (28 834 vs 16 292 US dollars; P < .01). The 30-day readmission rate was significantly lower in the M&S group compared with the surgery group (4.2% vs 8.0%; P < .01).

CONCLUSION: This analysis of large-scale national data indicates that MMAE performed in adjunction to surgery for treatment of CSDH is associated with higher direct costs, higher complication rates, and longer length of stay but lower readmission rates compared with surgical evacuation alone.

Factors associated with readmission after minimally invasive transforaminal lumbar interbody fusion

J Neurosurg Spine 38:681–687, 2023

The objective of this study was to identify factors that lead to a prolonged hospital stay or 30-day readmission after minimally invasive surgery (MIS) for transforaminal lumbar interbody fusion (TLIF) at a single institution.

METHODS Consecutive patients who underwent MIS TLIF from January 1, 2016, to March 31, 2018, were retrospectively analyzed. Demographic data, including age, sex, ethnicity, smoking status, and body mass index, were collected along with operative details, indications, affected spinal levels, estimated blood loss, and operative duration. The effects of these data were evaluated relative to the hospital length of stay (LOS) and 30-day readmission.

RESULTS The authors identified 174 consecutive patients who underwent MIS TLIF at 1 or 2 levels from a prospectively collected database. The mean (range) patient age was 64.1 (31–81) years, 97 were women (56%), and 77 were men (44%). Of 182 levels fused, 127 were done at L4–5 (70%), 32 at L3–4 (18%), 13 at L5–S1 (7%), and 10 at L2–3 (5%). Patients underwent 166 (95%) single-level procedures and 8 (5%) 2-level procedures. The mean (range) procedural duration, defined as the time from incision to closure, was 164.6 (90–529) minutes. The mean (range) LOS was 1.8 (0–8) days. Eleven patients (6%) were readmitted within 30 days; the most frequent causes were urinary retention, constipation, and persistent or contralateral symptoms. Seventeen patients had LOS greater than 3 days. Six of those patients (35%) were identified as widows, widowers, or divorced, and 5 of them lived alone. Six patients with prolonged LOS (35%) required placement in either skilled nursing or acute inpatient rehabilitation. Regression analyses showed living alone (p = 0.04) and diabetes (p = 0.04) as predictors of readmission. Regression analyses revealed female sex (p = 0.03), diabetes (p = 0.03), and multilevel surgery (p = 0.006) as predictors of LOS > 3 days.

CONCLUSIONS Urinary retention, constipation, and persistent radicular symptoms were the leading causes of readmission within 30 days of surgery in this series, which is distinct from data from the American College of Surgeons National Surgical Quality Improvement Program. The inability to discharge a patient home for social reasons led to prolonged inpatient hospital stays. Identifying these risk factors and proactively addressing them could lower readmission rates and decrease LOS among patients undergoing MIS TLIF.

Clinical Outcomes of Liposomal Bupivacaine Erector Spinae Block in Minimally Invasive Transforaminal Lumbar Interbody Fusion Surgery

Neurosurgery 92:590–598, 2023

Postoperative pain is a barrier to early mobility and discharge after lumbar surgery. Liposomal bupivacaine (LB) has been shown to decrease postoperative pain and narcotic consumption after transforaminal lumbar interbody fusions (TLIFs) when injected into the marginal suprafascial/subfascial plane-liposomal bupivacaine (MSSP-LB). Erector spinae plane (ESP) infiltration is a relatively new analgesic technique that may offer additional benefits when performed in addition to MSSP-LB.

OBJECTIVE: To evaluate postoperative outcomes of combining ESP-LB with MSSP-LB compared with MSSP-LB alone after single-level TLIF.

METHODS: A retrospective analysis was performed for patients undergoing single-level TLIFs under spinal anesthesia, 25 receiving combined ESP-LB and MSSP-LB and 25 receiving MSSP-LB alone. The primary outcome was length of hospitalization. Secondary outcomes included postoperative pain score, time to ambulation, and narcotics usage.

RESULTS: Baseline demographics and length of surgery were similar between groups. Hospitalization was significantly decreased in the ESP-LB + MSSP-LB cohort (2.56 days vs 3.36 days, P = .007), as were days to ambulation (0.96 days vs 1.29 days, P = .026). Postoperative pain area under the curve was significantly decreased for ESP-LB + MSSP-LB at 12 to 24 hours (39.37 ± 21.02 vs 53.38 ± 22.11, P = .03) and total (44.46 ± 19.89 vs 50.51 ± 22.15, P = .025). Postoperative narcotic use was significantly less in the ESP-LB + MSSP-LB group at 12 to 24 hours (13.18 ± 4.65 vs 14.78 ± 4.44, P = .03) and for total hospitalization (137.3 ± 96.3 vs 194.7 ± 110.2, P = .04).

CONCLUSION: Combining ESP-LB with MSSP-LB is superior to MSSP-LB alone for single level TLIFs in decreasing length of hospital stay, time to ambulation, postoperative pain, and narcotic use.

Thirty-Day Outcomes After Craniotomy for Primary Malignant Brain Tumors

Neurosurgery 83:1249–1259, 2018

Despite improved perioperative management, the rate of postoperative morbidity and mortality after brain tumor resection remains considerably high.

OBJECTIVE: To assess the rates, causes, timing, and predictors of major complication, extended length of stay (>10 d), reoperation, readmission, and death within 30 d after craniotomy for primary malignant brain tumors.

METHODS: Patients were extracted from the National Surgical Quality Improvement Program registry (2005-2015) and analyzed using multivariable logistic regression.

RESULTS: A total of 7376 patientswere identified, ofwhich 948 (12.9%) experienced a major complication. The most common major complications were reoperation (5.1%), venous thromboembolism (3.5%), and death (2.6%). Furthermore, 15.6% stayed longer than 10 d, and 11.5% were readmitted within 30 d after surgery. The most common reasons for reoperation and readmission were intracranial hemorrhage (18.5%) and wound-related complications (11.9%), respectively. Multivariable analysis identified older age, higher body mass index, higher American Society of Anesthesiologists (ASA) classification, dependent functional status, elevated preoperative white blood cell count (white blood cell count [WBC], >12 000 cells/mm3), and longer operative time as predictors of major complication (all P < .001). Higher ASA classification, dependent functional status, elevated WBC, and ventilator dependence were predictors of extended length of stay (all P < .001). Higher ASA classification and elevatedWBCwere predictors of reoperation (both P<.001). Higher ASA classification and dependent functional status were predictors of readmission (both P < .001). Older age, higher ASA classification, and dependent functional status were predictors of death (all P< .001).

CONCLUSION: This study provides a descriptive analysis and identifies predictors for short term complications, including death, after craniotomy for primary malignant brain tumors.


Predictors for Patient Discharge Destination After Elective Anterior Cervical Discectomy and Fusion

Spine 2017;42:1538–1544

Study Design. Retrospective study of prospectively collected data.

Objective. To identify risk factors for nonhome patient discharge after elective anterior cervical discectomy and fusion (ACDF).

Summary of Background Data. ACDF is one of the most performed spinal procedures and this is expected to increase in the coming years. To effectively deal with an increasing patient volume, identifying variables associated with patient discharge destination can expedite placement applications and subsequently reduce hospital length of stay.

Methods. The 2011 to 2014 ACS-NSQIP database was queried using Current Procedural Terminology (CPT) codes 22551 or 22554. Patients were divided into two cohorts based on discharge destination. Bivariate and multivariate logistic regression analyses were employed to identify predictors for patient discharge destination and extended hospital length of stay.

Results. A total of 14,602 patients met the inclusion criteria for the study of which 498 (3.4%) had nonhome discharge. Multivariate logistic regression found that Hispanic versus Black race/ ethnicity (odds ratio, OR¼0.21, 0.05–0.91, P¼0.037), American Indian or Alaska Native, Asian, Native Hawaiian or Pacific Islander versus Black race/ethnicity (OR¼0.52, 0.34–0.80, p-value¼0.003), White versus Black race/ethnicity (OR¼0.55, 0.42–0.71), elderly age 65 years (OR¼3.32, 2.72–4.06), obesity (OR¼0.77, 0.63–0.93, P¼0.008), diabetes (OR¼1.32, 1.06–1.65, P¼0.013), independent versus partially/totally dependent functional status (OR¼0.11, 0.08–0.15), operation time 4hours (OR¼2.46, 1.87–3.25), cardiac comorbidity (OR ¼1.38, 1.10– 1.72, P ¼0.005), and ASA Class 3 (OR¼2.57, 2.05–3.20) were predictive factors in patient discharge to a facility other than home. In addition, multivariate logistic regression analysis also found nonhome discharge to be the most predictive variable in prolonged hospital length of stay.

Conclusion. Several predictive factors were identified in patient discharge to a facility other than home, many being preoperative variables. Identification of these factors can expedite patient discharge applications and potentially can reduce hospital stay, thereby reducing the risk of hospital acquired conditions and minimizing health care costs.

Level of Evidence: 3

Complications in awake versus asleep DBS

J Neurosurg 127:360–369, 2017

As the number of deep brain stimulation (DBS) procedures performed under general anesthesia (“asleep” DBS) increases, it is more important to assess the rates of adverse events, inpatient lengths of stay (LOS), and 30-day readmission rates in patients undergoing these procedures compared with those in patients undergoing traditional “awake” DBS without general anesthesia.

METHODS All patients in an institutional database who had undergone awake or asleep DBS procedures performed by a single surgeon between August 2011 and August 2014 were reviewed. Adverse events, inpatient LOS, and 30-day readmissions were analyzed.

RESULTS A total of 490 electrodes were placed in 284 patients, of whom 126 (44.4%) underwent awake surgery and 158 (55.6%) underwent asleep surgery. The most frequent overall complication for the cohort was postoperative mental status change (13 patients [4.6%]), followed by hemorrhage (4 patients [1.4%]), seizure (4 patients [1.4%]), and hardwarerelated infection (3 patients [1.1%]). Mean LOS for all 284 patients was 1.19 ± 1.29 days (awake: 1.06 ± 0.46 days; asleep: 1.30 ± 1.67 days; p = 0.08). Overall, the 30-day readmission rate was 1.4% (1 awake patient, 3 asleep patients). There were no significant differences in complications, LOS, and 30-day readmissions between awake and asleep groups.

CONCLUSIONS Both awake and asleep DBS can be performed safely with low complication rates. The authors found no significant differences between the 2 procedure groups in adverse events, inpatient LOS, and 30-day readmission rates.

Minimally invasive microsurgery for anterior circulation aneurysms

MIS for Anterior Circulation Aneurysms

Acta Neurochir (2014) 156:493–503

The aim of our study was to evaluate minimally invasive techniques for the treatment of anterior circulation aneurysms versus standard surgery, and to calculate the impact of these techniques on health resources, length of stay, and treatment costs.

Methods A consecutive series of 24 patients with ruptured and 30 with unruptured anterior circulation aneurysms treated with minimally invasive microsurgery (MIM) by the same surgeon was compared with a matched series of standard microsurgeries (SM) conducted for 23 ruptured and 22 unruptured aneurysms. Complication rates, aneurysm obliteration, modified Rankin Scale (mRS) outcomes, length of stay, and treatment costs were assessed.

Results Surgical complications, aneurysm obliteration rates and mRS outcomes were comparable between MIM and SM groups in ruptured and unruptured aneurysm cohorts. MIM resulted in shorter operative times both in unruptured (102.7±4.35 vs 194.7±10.26 min, p<0.0001) and ruptured aneurysms (124.3±827 vs 209±13.84 min, p<0.0001). Length of stay was reduced in patients with MIM for unruptured aneurysms (1.55±24 vs 4.28±0.71 days, p<0.000,1) but not in those with ruptured aneurysms. MIM reduced treatment costs of unruptured aneurysm patients, mainly through reduced utilization of inpatient resources (non-acute bed costs in CAD: 371.2±80.99 vs 1440±224.1, p<0.0001), whereas costs were comparable in patients with ruptured aneurysms.

Conclusion Minimally invasive surgery is a safe and effective approach for the treatment of ruptured and unruptured aneurysms of the anterior circulation. In patients with unruptured aneurysms, reduced invasiveness and shorter operative times decreased length of stay, which reflects improved patient postoperative recovery. Overall, this translated into bed resource economy and cost reduction.

Postoperative Outcome of Cerebral Amyloid Angiopathy-Related Lobar Intracerebral Hemorrhage: Case Series and Systematic Review

Neurosurgery 70:125–130, 2012 DOI: 10.1227/NEU.0b013e31822ea02a

Despite its accessible superficial location, the indication for surgical evacuation in cases of lobar intracerebral hemorrhage (LICH) suspected to be related to cerebral amyloid angiopathy (CAA) is controversial because of advanced patient age and concerns about postoperative hemostasis.

OBJECTIVE: To examine factors associated with postoperative outcome in CAA-related LICH.

METHODS: Review of consecutive patients with pathologically proven CAA who underwent LICH evacuation at Saint Marys Hospital, Rochester, Minnesota, between 1987 and 2006. End points were length of stay and postoperative outcome at discharge and last follow-up using the Glasgow Outcome Scale. We also performed a systematic review of all published studies evaluating the outcome of surgically treated CCA-related LICH published between 1984 and 2010.

RESULTS: We identified 23 patients with CAA-related LICH treated surgically. Favorable outcome (Glasgow Outcome Scale .3) at discharge was noted in 5 patients (22%), and at 6- to 12-month follow-up (n = 15) in 7 patients (47%). Three (13%) died in the hospital, including 1 of 4 patients with postoperative hemorrhage. Intraventricular hemorrhage (IVH) was associated with poor outcome at discharge. Older age ($75 years), history of hypertension, and degree of preoperative midline shift were associated with more prolonged length of stay. In our systematic review, we identified 14 studies including 278 cases. Overall mortality rate was 25%, and poor postoperative outcome was associated with older age, IVH, and preoperative dementia.

CONCLUSION: Neurosurgical evacuation may be performed with acceptable safety in patients with CAA-related LICH. A systematic literature review indicates that older age, preexistent dementia, and presurgical IVH portend poor postoperative outcome.

The effect of coiling vs clipping of ruptured and unruptured cerebral aneurysms on length of stay, hospital cost, hospital reimbursement, and surgeon reimbursement at the University of Florida

Neurosurgery 64:614–621, 2009 DOI: 10.1227/01.NEU.0000340784.75352.A4

There are few studies comparing the economic costs and reimbursements for aneurysm clipping versus coiling, and none are from the United States. Our hypothesis predicted that coiling would result in shorter lengths of hospitalization than clipping in patients with unruptured aneurysms and would therefore result in lower hospital charges. However, because of the severity of subarachnoid hemorrhage, there would be no difference in length of hospitalization or hospital charges in patients with ruptured aneurysms.

Methods: We compared aneurysm coiling with aneurysm clipping in patients with unruptured and ruptured aneurysms treated at the University of Florida from January 2005 to June 2007 for differences in length of hospitalization, hospital costs, hospital collections, and surgeon collections. Patient demographic and aneurysm characteristic data were obtained from a clinical database. Length of hospitalization, cost, billing, and collection data were obtained from the hospital cost accounting database. Multivariate statistical analyses of length of hospitalization, hospital costs, hospital collections, and surgeon collections were performed using factors including patient age, sex, aneurysm size, aneurysm location, aneurysm treatment, presence of subarachnoid hemorrhage, clinical grade, payor, hospital billing, and surgeon billing.

Results: There were 565 patients with cerebral aneurysms treated either surgically (306 patients, 54%) or endovascularly (259 patients, 46%). In patients without subarachnoid hemorrhage (unruptured aneurysms) (n=367), surgery, compared with endovascular treatment, was associated with longer hospitalization (P<0.001), but lower hospital costs (P<0.001), higher surgeon collections (P<0.003), and similar hospital collections. In patients with subarachnoid hemorrhage (ruptured aneurysms) (n=198), surgery was associated with lower hospital costs (P<0.011), but similar length of stay, surgeon collections, and hospital collections. Larger aneurysm size was significantly associated with longer hospitalization in the patients with unruptured aneurysms (P<0.001) and higher hospital costs for both patients with unruptured (P<0.001) and ruptured (P<0.015) aneurysms. The payor was significantly associated with hospital costs in patients with ruptured aneurysms (P<0.034) and length of stay (unruptured aneurysms, P<0.001; ruptured aneurysms, P<0.001), hospital collections (unruptured aneurysms, P<0.001; ruptured aneurysms, P<0.001), and surgeon collections (unruptured aneurysms, P<0.001; ruptured aneurysms, P<0.001) in both patients with unruptured and ruptured aneurysms. A worse clinical grade was significantly associated with higher hospital costs (P<0.001).

Conclusion: Despite a shorter length of hospitalization in patients with unruptured aneurysms, coiling was associated with higher hospital costs in both patients with unruptured and ruptured aneurysms. This is likely attributable to the higher device cost of coils than clips. The advantages of coiling over clipping would be better realized if the cost of coils could be comparably reduced to that of clips.