Tag: Postoperative complications

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Postoperative complications after surgery for lumbar spinal stenosis, assessment using two different data sources

Acta Neurochirurgica (2024) 166:189

Lumbar spinal stenosis (LSS) is a prevalent disorder, and surgery for LSS is a common procedure. Postoperative complications occur after any surgery and impose costs for society and costs and additional morbidity for patients. Since complications are relatively rare, medical registries of large populations may provide valuable knowledge. However, recording of complications in registries can be incomplete. To better estimate the true prevalence of complications after LSS surgery, we reviewed two different sources of data and recorded complications for a sample of Norwegian LSS patients.

Methods 474 patients treated surgically for LSS during 2015 and 2016 at four hospitals reported to a national spine registry (NORspine). Postoperative complications were recorded by patients in NORspine, and we cross-referenced complications documented in NORspine with the patients´ electronic patient records (EPR) to re-test the complication rates. We performed descriptive statistics of complication rates using the two different data sources above, and analyzed the association between postoperative complications and clinical outcome with logistic regression.

Results The mean (95%CI) patient age was 66.3 (65.3–67.2) years, and 254 (53.6%) were females. All patients were treated with decompression, and 51 (10.7%) received an additional fusion during the index surgery. Combining the two data sources, we found a total rate for postoperative complications of 22.4%, the NORspine registry reported a complication rate of 15.6%, and the EPR review resulted in a complication rate of 16.0%. However, the types of complications were inconsistent across the two data sources. According to NORspine, the frequency of reoperation within 90 days was 0.9% and according to EPR 3.4%. The rates of wound infection were for NORspine 3.1% and EPR review 2.1%. There was no association between postoperative complication and patient reported outcome.

Conclusion Postoperative complications occurred in 22% of LSS patients. The frequency of different postoperative complications differed between the two data sources.

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The Role of Prolonged Bed Rest in Postoperative Cerebrospinal Fluid Leakage After Surgery of Intradural Pathology

Neurosurgery 93:563–575, 2023

Postoperative cerebrospinal fluid leakage (CSFL) is a feared complication after surgery on intradural pathologies and may cause postoperative complications and subsequently higher treatment costs.

OBJECTIVE: To assess whether prolonged bed rest may lower the risk of CSFL.

METHODS: We performed a retrospective cohort study including patients with intradural pathologies who underwent surgery at our department between 2013 and 2021. Cohorts included patients who completed 3 days of postoperative bed rest and patients who were mobilized earlier. The primary end point was the occurrence of clinically proven CSFL.

RESULTS: Four hundred and thirty-three patients were included (female [51.7%], male [48.3%]) with a mean age of 48 years (SD ±20). Bed rest was ordered in 315 cases (72.7%). In 7 cases (N = 7/433, 1.6%), we identified a postoperative CSFL. Four of them (N = 4/118) did not preserve bed rest, showing no significant difference to the bed rest cohort (N = 3/315; P = .091). In univariate analysis, laminectomy (N = 4/61; odds ratio [OR] 8.632, 95% CI 1.883-39.573), expansion duraplasty (N = 6/70; OR 33.938, 95% CI 4.019-286.615), and recurrent surgery (N = 5/66; OR 14.959, 95% CI 2.838-78.838) were significant risk factors for developing CSFL. In multivariate analysis, expansion duraplasty was confirmed as independent risk factor (OR 33.937, 95% CI 4.018-286.615, P = .001). In addition, patients with CSFL had significan’t higher risk for meningitis (N = 3/7; 42.8%, P = .001).

CONCLUSION: Prolonged bed rest did not protect patients from developing CSFL after surgery on intradural pathologies. Avoiding laminectomy, large voids, and minimal invasive approaches may play a role in preventing CSFL. Furthermore, special caution is indicated if expansion duraplasty was done.

 

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How safe are elective craniotomies in elderly patients in neurosurgery today?

J Neurosurg 134:1113–1121, 2021

With global aging, elective craniotomies are increasingly being performed in elderly patients. There is a paucity of prospective studies evaluating the impact of these procedures on the geriatric population. The goal of this study was to assess the safety of elective craniotomies for elderly patients in modern neurosurgery.

METHODS For this cohort study, adult patients, who underwent elective craniotomies between November 1, 2011, and October 31, 2018, were allocated to 3 age groups (group 1, < 65 years [n = 1008], group 2, ≥ 65 to < 75 [n = 315], and group 3, ≥ 75 [n = 129]). Primary outcome was the 30-day mortality after craniotomy. Secondary outcomes included rate of delayed extubation (> 1 hour), need for emergency head CT scan and reoperation within 48 hours after surgery, length of postoperative intensive or intermediate care unit stay, hospital length of stay (LOS), and rate of discharge to home. Adjustment for American Society of Anesthesiologists Physical Status (ASA PS) class, estimated blood loss, and duration of surgery were analyzed as a comparison using multiple logistic regression. For significant differences a post hoc analysis was performed.

RESULTS In total, 1452 patients (mean age 55.4 ± 14.7 years) were included. The overall mortality rate was 0.55% (n = 8), with no significant differences between groups (group 1: 0.5% [95% binominal CI 0.2%, 1.2%]; group 2: 0.3% [95% binominal CI 0.0%, 1.7%]; group 3: 1.6% [95% binominal CI 0.2%, 5.5%]). Deceased patients had a significantly higher ASA PS class (2.88 ± 0.35 vs 2.42 ± 0.62; difference 0.46 [95% CI 0.03, 0.89]; p = 0.036) and increased estimated blood loss (1444 ± 1973 ml vs 436 ± 545 ml [95% CI 618, 1398]; p <0.001). Significant differences were found in the rate of postoperative head CT scans (group 1: 6.65% [n = 67], group 2: 7.30% [n = 23], group 3: 15.50% [n = 20]; p = 0.006), LOS (group 1: median 5 days [IQR 4; 7 days], group 2: 5 days [IQR 4; 7 days], and group 3: 7 days [5; 9 days]; p = 0.001), and rate of discharge to home (group 1: 79.0% [n = 796], group 2: 72.0% [n = 227], and group 3: 44.2% [n = 57]; p < 0.001).

CONCLUSIONS Mortality following elective craniotomy was low in all age groups. Today, elective craniotomy for well selected patients is safe, and for elderly patients, too. Elderly patients are more dependent on discharge to other hospitals and postacute care facilities after elective craniotomy. Clinical trial registration no.: NCT01987648 (clinicaltrials.gov).

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Impact of Extent of Resection on Incidence of Postoperative Complications in PatientsWith Glioblastoma

Neurosurgery 86:625–630, 2020

Extent of resection (EOR) is well established as correlating with overall survival in patients with glioblastoma (GBM). The impact of EOR on reported quality metrics such as patient safety indicators (PSIs) and hospital-acquired conditions (HACs) is unknown.

OBJECTIVE: To perform a retrospective study to evaluate possible associations between EOR and the incidence of PSIs and HACs.

METHODS: We queried all patients diagnosed with GBM who underwent surgical resection at our institution between January 2011 and May 2017. Pre- and postoperative magnetic resonance imageswere analyzed for EOR. Each chart was reviewed to determine the incidence of PSIs and HACs.

RESULTS: A total of 284 patients met the inclusion criteria. EOR ranged from 39.00 to 100%, with a median of 99.84% and a mean of 95.7%. There were 16 PSI, and 13 HAC, events. There were no significant differences in the rates of PSIs or HACs when compared between patients stratified by gross total resection (EOR ≥ 95%) and subtotal resection (EOR < 95%). The odds of encountering a PSI or HAC were 2.5 times more likely in the subtotal resection group compared to the gross total resection group (P = .58). After adjusting for confounders, the odds of encountering a PSI or HAC in the subtotal resection group were 3.9 times greater than for the gross total resection group (P < .05).

CONCLUSION: Gross total resection of GBM is associated with a decreased incidence of PSIs and HACs, as compared to subtotal resection.

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Epilepsy, headache, and abdominal pain after shunt surgery for idiopathic normal pressure hydrocephalus: the INPH-CRasH study

J Neurosurg 128:1674–1683, 2018

Adverse events related to shunt surgery are common and might have a negative effect on outcome in patients with idiopathic normal pressure hydrocephalus (INPH). The authors’ objectives were to establish the frequencies of epilepsy, headache, and abdominal pain and determine their impact on patient quality of life (QOL), in long-term follow-up after shunt surgery for INPH.

METHODS One hundred seventy-six shunt-treated patients with INPH (mean age 74 years) and 368 age- and sexmatched controls from the population were included. The mean follow-up time after surgery was 21 months (range 6–45 months). Each participant answered a questionnaire regarding present frequency and severity of headache and abdominal pain. Confirmed diagnoses of epilepsy and all prescriptions for antiepileptic drugs (AEDs) before and after shunt surgery for INPH were gathered from national registries. Equivalent presurgical and postsurgical time periods were constructed for the controls based on the date of surgery (the division date for controls is referred to as virtual surgery). All registry data covered a mean period of 6 years (range 3–8 years) before surgery/virtual surgery and 4 years (range 2–6 years) after surgery/virtual surgery. Provoked epileptic seizures were excluded. Patient QOL was assessed with the EuroQoL 5-dimension 5-level instrument.

RESULTS Epilepsy was more common in shunt-treated patients with INPH than in controls (4.5% vs 1.1%, respectively; p = 0.023), as was treatment with AEDs (14.8% vs 7.3%, respectively; p = 0.010). No difference was found between the populations before surgery/virtual surgery (epilepsy, 2.3% [INPH] vs 1.1% [control], p = 0.280; AED treatment, 8.5% [INPH] vs 5.4% [control], p = 0.235). New-onset epilepsy and new AED treatment after surgery/virtual surgery were more common in INPH (epilepsy, 2.3% [INPH] vs 0.0% [control], p = 0.011; AED, 8.5% [INPH] vs 3.3% [control], p = 0.015). At follow-up, more patients with INPH than controls experienced headache several times per month or more often (36.1% vs 11.6%, respectively; p < 0.001). Patients with INPH and unilateral headache had more right-sided headaches than controls (p = 0.038). Postural headache was experienced by 16% (n = 27 of 169) of the patients with INPH. Twenty percent (n = 35) of the patients with INPH had persistent abdominal pain. Headache was not correlated to lower QOL. The study was underpowered to draw conclusions regarding QOL in patients with INPH who had epilepsy and abdominal pain, but the finding of no net difference in mean QOL indicates that no correlation between them existed.

CONCLUSIONS Epilepsy, headache, and abdominal pain are common in long-term follow-up in patients after shunt surgery for INPH and are more common among patients with INPH than in the general population. All adverse events, including mild and moderate ones, should be considered during postoperative follow-ups and in the development of new methods for shunt placement.

 

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Early Postoperative Complications for Elderly Patients Undergoing Single-Level Decompression for Lumbar Disc Herniation, Ligamentous Hypertrophy, or Neuroforaminal Stenosis

Neurosurgery 81:1005–1010, 2017

Lumbar decompression for disc herniation is frequently performed on elderly patients, and this trend will continue as the population ages. Clinical reports on the complications of lumbar discectomy show good results and cost effectiveness in young or middle-aged patients.

OBJECTIVE: To assess and compare the morbidity of single-level lumbar disc surgery for radicular pain in a cohort of patients greater than 80 yr of age to that of a middle-aged cohort.

METHODS: A total of 9451 patients who received a single-level lumbar decompression procedure for disc displacement without myelopathy were retrospectively selected from a multicenter validated surgical database from the American College of Surgeons National Surgical Quality Improvement Program. A cohort with 485 patients greater than 80 yr of age (80+) was compared with a middle-aged cohort with 8966 patients between 45 and 65 yr. Preoperative comorbidity and postoperative outcome variables observed included mortality, myocardial infarction, return to the operating room, sepsis, deep vein thrombosis, transfusions, cardiac arrest necessitating cardiopulmonary resuscitation, coma greater than 24 h, urinary tract infection, acute renal failure, use of ventilator greater than 24 h, pulmonary embolism, pneumonia, wound dehiscence, and postoperative infection.

RESULTS: The preoperative comorbidities and characteristics were significantly different between the middle-aged and the 80+ cohorts, with the older cohort having many more preoperative comorbidities. There was statistically significantly greater postoperative morbidity among the 80+ cohort regarding pulmonary embolism (0.8% vs 0.2%, P = .037), intra/postoperative transfusion requirement (1.9% vs 0.7%, P = .01), urinary tract infection (1.2% vs 0.3%, P = .011), and 30-d mortality (0.4% vs 0.1%, P = .046).

CONCLUSION: In this large sample of patients who received a single-level lumbar decompression procedure for disc displacement without myelopathy, elderly patients, particularly with American Society of Anesthesiologists class 3 and 4, had a statistically significant increase in morbidity and mortality, but the overall risk of complications remains low.

 

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Complications and Resource Use Associated With Surgery for Chiari Malformation Type 1 in Adults

Dura_Splitting_Decompression_for_Chiari_I

Neurosurgery 77:261–268, 2015

Outcomes research on Chiari malformation type 1 (CM-1) is impeded by a reliance on small, single-center cohorts.

OBJECTIVE: To study the complications and resource use associated with adult CM-1 surgery using administrative data.

METHODS: We used a recently validated International Classification of Diseases, Ninth Revision, Clinical Modification code algorithm to retrospectively study adult CM-1 surgeries from 2004 to 2010 in California, Florida, and New York using State Inpatient Databases. Outcomes included complications and resource use within 30 and 90 days of treatment. We used multivariable logistic regression to identify risk factors for morbidity and negative binomial models to determine risk-adjusted costs.

RESULTS: We identified 1947 CM-1 operations. Surgical complications were more common than medical complications at both 30 days (14.3% vs 4.4%) and 90 days (18.7% vs 5.0%) postoperatively. Certain comorbidities were associated with increased morbidity; for example, hydrocephalus increased the risk for surgical (odds ratio [OR] = 4.51) and medical (OR = 3.98) complications. Medical but not surgical complications were also more common in older patients (OR = 5.57 for oldest vs youngest age category) and male patients (OR = 3.19). Risk-adjusted hospital costs were $22530 at 30 days and $24852 at 90 days postoperatively. Risk-adjusted 90-day costs were more than twice as high for patients experiencing surgical ($46264) or medical ($65679) complications than for patients without complications ($18880).

CONCLUSION: Complications after CM-1 surgery are common, and surgical complications are more frequent than medical complications. Certain comorbidities and demographic characteristics are associated with increased risk for complications. Beyond harming patients, complications are also associated with substantially higher hospital costs. These results may help guide patient management and inform decision making for patients considering surgery.

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Contemporary Surgical Management of Vestibular Schwannomas

Vestibular-schwannoma

Neurosurgery 72[ONS Suppl 2]:ons103–ons115, 2013 

Despite advanced microsurgical techniques, more refined instrumentation, and expert team management, there is still a significant incidence of complications in vestibular schwannoma surgery.

OBJECTIVE: To analyze complications from the microsurgical treatment of vestibular schwannoma by an expert surgical team and to propose strategies for minimizing such complications.

METHODS: Surgical outcomes and complications were evaluated in a consecutive series of 410 unilateral vestibular schwannomas treated from 2000 to 2009. Clinical status and complications were assessed postoperatively (within 7 days) and at the time of follow-up (range, 1-116 months; mean, 32.7 months).

RESULTS: Follow-up data were available for 357 of the 410 patients (87.1%). Microsurgical tumor resection was performed through a retrosigmoid approach in 70.7% of cases. Thirty-three patients (8%) had intrameatal tumors and 204 (49.8%) had tumors that were ,20 mm. Gross total resection was performed in 306 patients (74.6%). Hearing preservation surgery was attempted in 170 patients with tumors ,20 mm, and good hearing was preserved in 74.1%. The main neurological complication was facial palsy (House-Brackmann grade III-VI), observed in 14% of patients (56 cases) postoperatively; however, 59% of them improved during the follow-up period. Other neurological complications were disequilibrium in 6.3%, facial numbness in 2.2%, and lower cranial nerve deficit in 0.5%. Nonneurological complications included cerebrospinal fluid leaks in 7.6%, wound infection in 2.2%, and meningitis in 1.7%.

CONCLUSION: Many of these complications are avoidable through further refinement of operative technique, and strategies for avoiding complications are proposed.

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Morbidity of Transcallosal and Transcortical Approaches to Lesions in and Around the Lateral and Third Ventricles: A Single-Institution Experience

Neurosurgery 67:1483–1496, 2010 DOI: 10.1227/NEU.0b013e3181f7eb68

Resection of an intraventricular mass can result in life-altering complications. Many advocate transcallosal rather than transcortical approaches to these lesions, citing differential postoperative seizure risk.

OBJECTIVE: To test the hypothesis that the complication rates and patient outcomes are no different between these ventricular approaches.

METHODS: The medical records of 127 patients (93 adults and 34 children) operated on for intraventricular lesions between 1996 and 2007 were retrospectively analyzed. Risk factors for specific postoperative complications and outcome were assessed by multivariate analysis.

RESULTS: The transcallosal (59%) or transcortical (41%) approach was used. Gross or nearly total resection was achieved in 87% of cases. The permanent neurological complication rate determined by a staff neurologist was 23.6%. Seizure attributable to surgery occurred after 8% of transcortical and 25% of transcallosal operations (P = .01). After controlling for a variety of factors, the transcallosal approach carried a 4.4-fold increased risk of seizure (95% confidence interval, 1.3-18.9). The operative approach was not a risk factor for any other postoperative complication. One year after surgery, 72% of patients had excellent functional outcome (Karnofsky Performance Score $ 70 and Glasgow Outcome Score = 5). High tumor grade and impaired preoperative Karnofsky Performance Score predicted poor outcome. More than 90% of patients operated on for symptomatic colloid cysts (n = 34) had an excellent outcome.

CONCLUSION: Although the 2 traditional approaches to the ventricular system had similar major complication rates, the transcallosal approach was associated with significantly increased seizure risk. Accordingly, the chosen operative corridor should optimize tumor access and the protection of vulnerable neurovascular structures.

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Functional Magnetic Resonance Imaging and Diffusion Tensor Tractography Incorporated Into an Intraoperative 3-Dimensional Ultrasound-Based Neuronavigation System: Impact on Therapeutic Strategies, Extent of Resection, and Clinical Outcome

Neurosurgery 67:251-264, 2010 DOI: 10.1227/01.NEU.0000371731.20246.AC

Functional neuronavigation with intraoperative 3-dimensional (3D) ultrasound may facilitate safer brain lesion resections than conventional neuronavigation.

OBJECTIVE: In this study, functional magnetic resonance imaging (fMRI) and diffusion tensor tractography (DTT) were used to map eloquent areas. We assessed the use of fMRI and DTT for preoperative assessments and determined whether using these data together with 3D ultrasound during surgery enabled safer lesion resection.

METHODS:We reviewed 51 consecutive patients with intracranial lesions in whom fMRI with or without DTT was used to map eloquent areas. To assess a possible impact of fMRI/DTT, we reviewed and analyzed the quality of the fMRI/DTT data, any change in therapeutic strategies, lesion to eloquent area distance (LEAD), extent of resection, and clinical outcome.

RESULTS: As a result of the fMRI/DTT mapping, the therapeutic strategies were changed in 4 patients. The median tumor residue for glioma patients was 11% (n = 33) and 0% for nonglioma lesions (n = 12). For gliomas, there was a significant correlation between decreasing LEAD and increasing tumor residue. Of the glioma patients, 42% underwent gross total resection (≥ 95%) and 12% suffered neurological worsening after surgery as a result of complications. Of glioma patients with an LEAD of ≤ 5 mm, 24% underwent gross total resection and 10% experienced neurological deterioration.

CONCLUSION: This study demonstrates that preoperative fMRI and DTT had direct consequences for therapeutic strategies and indicates their impact on intraoperative strategies to spare eloquent cortex and tracts. Functional neuronavigation combined with intraoperative 3D ultrasound can, in most patients, enable resection of brain lesions with general anesthesia without jeopardizing neurological function.

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