1
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Yahanda AT, Koueik J, Ackerman LL, Adelson PD, Albert GW, Aldana PR, Alden TD, Anderson RCE, Bauer DF, Bethel-Anderson T, Bierbrauer K, Brockmeyer DL, Chern JJ, Couture DE, Daniels DJ, Dlouhy BJ, Durham SR, Ellenbogen RG, Eskandari R, Fuchs HE, Grant GA, Graupman PC, Greene S, Greenfield JP, Gross NL, Guillaume DJ, Hankinson TC, Heuer GG, Iantosca M, Iskandar BJ, Jackson EM, Jallo GI, Johnston JM, Kaufman BA, Keating RF, Khan NR, Krieger MD, Leonard JR, Maher CO, Mangano FT, Martin J, McComb JG, McEvoy SD, Meehan T, Menezes AH, Muhlbauer MS, O'Neill BR, Olavarria G, Ragheb J, Selden NR, Shah MN, Shannon CN, Shimony JS, Smyth MD, Stone SSD, Strahle JM, Tamber MS, Torner JC, Tuite GF, Tyler-Kabara EC, Wait SD, Wellons JC, Whitehead WE, Park TS, Limbrick DD, Ahmed R. The role of occipital condyle and atlas anomalies on occipital cervical fusion outcomes in Chiari malformation type I with syringomyelia: a study from the Park-Reeves Syringomyelia Research Consortium. J Neurosurg Pediatr 2024:1-9. [PMID: 38579359 DOI: 10.3171/2024.1.peds23229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 01/30/2024] [Indexed: 04/07/2024]
Abstract
OBJECTIVE Congenital anomalies of the atlanto-occipital articulation may be present in patients with Chiari malformation type I (CM-I). However, it is unclear how these anomalies affect the biomechanical stability of the craniovertebral junction (CVJ) and whether they are associated with an increased incidence of occipitocervical fusion (OCF) following posterior fossa decompression (PFD). The objective of this study was to determine the prevalence of condylar hypoplasia and atlas anomalies in children with CM-I and syringomyelia. The authors also investigated the predictive contribution of these anomalies to the occurrence of OCF following PFD (PFD+OCF). METHODS The authors analyzed the prevalence of condylar hypoplasia and atlas arch anomalies for patients in the Park-Reeves Syringomyelia Research Consortium database who underwent PFD+OCF. Condylar hypoplasia was defined by an atlanto-occipital joint axis angle (AOJAA) ≥ 130°. Atlas assimilation and arch anomalies were identified on presurgical radiographic imaging. This PFD+OCF cohort was compared with a control cohort of patients who underwent PFD alone. The control group was matched to the PFD+OCF cohort according to age, sex, and duration of symptoms at a 2:1 ratio. RESULTS Clinical features and radiographic atlanto-occipital joint parameters were compared between 19 patients in the PFD+OCF cohort and 38 patients in the PFD-only cohort. Demographic data were not significantly different between cohorts (p > 0.05). The mean AOJAA was significantly higher in the PFD+OCF group than in the PFD group (144° ± 12° vs 127° ± 6°, p < 0.0001). In the PFD+OCF group, atlas assimilation and atlas arch anomalies were identified in 10 (53%) and 5 (26%) patients, respectively. These anomalies were absent (n = 0) in the PFD group (p < 0.001). Multivariate regression analysis identified the following 3 CVJ radiographic variables that were predictive of OCF occurrence after PFD: AOJAA ≥ 130° (p = 0.01), clivoaxial angle < 125° (p = 0.02), and occipital condyle-C2 sagittal vertical alignment (C-C2SVA) ≥ 5 mm (p = 0.01). A predictive model based on these 3 factors accurately predicted OCF following PFD (C-statistic 0.95). CONCLUSIONS The authors' results indicate that the occipital condyle-atlas joint complex might affect the biomechanical integrity of the CVJ in children with CM-I and syringomyelia. They describe the role of the AOJAA metric as an independent predictive factor for occurrence of OCF following PFD. Preoperative identification of these skeletal abnormalities may be used to guide surgical planning and treatment of patients with complex CM-I and coexistent osseous pathology.
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Affiliation(s)
| | - Joyce Koueik
- 2Department of Neurological Surgery, University of Wisconsin at Madison, Wisconsin
| | - Laurie L Ackerman
- 3Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - P David Adelson
- 4Department of Neurosurgery, West Virginia University School, Morgantown, West Virginia
| | - Gregory W Albert
- 5Division of Neurosurgery, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Philipp R Aldana
- 6Division of Pediatric Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida
| | - Tord D Alden
- 7Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Illinois
| | | | - David F Bauer
- 9Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, Texas
| | | | - Karin Bierbrauer
- 10Division of Pediatric Neurosurgery, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Douglas L Brockmeyer
- 11Division of Pediatric Neurosurgery, Primary Children's Hospital, Salt Lake City, Utah
| | - Joshua J Chern
- 12Division of Pediatric Neurosurgery, Children's Healthcare of Atlanta University, Atlanta, Georgia
| | - Daniel E Couture
- 13Department of Neurological Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - David J Daniels
- 14Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Brian J Dlouhy
- 15Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Susan R Durham
- 16Division of Pediatric Neurosurgery, Children's Hospital of Los Angeles, USC Keck School of Medicine, Los Angeles, California
| | - Richard G Ellenbogen
- 17Division of Pediatric Neurosurgery, Seattle Children's Hospital, Seattle, Washington
| | - Ramin Eskandari
- 18Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Herbert E Fuchs
- 19Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina
| | - Gerald A Grant
- 19Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina
| | - Patrick C Graupman
- 20Division of Pediatric Neurosurgery, Gillette Children's Hospital, St. Paul, Minnesota
| | - Stephanie Greene
- 21Divsion of Pediatric Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jeffrey P Greenfield
- 22Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
| | - Naina L Gross
- 23Warren Clinic Pediatric Neurosurgery, Saint Francis Health System, Tulsa, Oklahoma
| | - Daniel J Guillaume
- 24Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Todd C Hankinson
- 25Department of Neurosurgery, Penn State College of Medicine, Hershey, Pennsylvania
| | - Gregory G Heuer
- 26Division of Pediatric Neurosurgery, Children's Hospital of Philadelphia, Pennsylvania
| | - Mark Iantosca
- 27Division of Pediatric Neurosurgery, Penn State Health Children's Hospital, Hershey, Pennsylvania
| | - Bermans J Iskandar
- 2Department of Neurological Surgery, University of Wisconsin at Madison, Wisconsin
| | - Eric M Jackson
- 28Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - George I Jallo
- 29Division of Neurosurgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - James M Johnston
- 30Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Bruce A Kaufman
- 31Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Robert F Keating
- 32Department of Neurosurgery, Children's National Medical Center, Washington, DC
| | - Nickalus R Khan
- 33Department of Neurosurgery, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Mark D Krieger
- 16Division of Pediatric Neurosurgery, Children's Hospital of Los Angeles, USC Keck School of Medicine, Los Angeles, California
| | - Jeffrey R Leonard
- 34Division of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Cormac O Maher
- 35Department of Neurosurgery, Stanford University, Palo Alto, California
| | - Francesco T Mangano
- 10Division of Pediatric Neurosurgery, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Jonathan Martin
- 36Department of Neurosurgery, Connecticut Children's Hospital, Hartford, Connecticut
| | - J Gordon McComb
- 16Division of Pediatric Neurosurgery, Children's Hospital of Los Angeles, USC Keck School of Medicine, Los Angeles, California
| | | | | | - Arnold H Menezes
- 15Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Michael S Muhlbauer
- 33Department of Neurosurgery, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Brent R O'Neill
- 25Department of Neurosurgery, Penn State College of Medicine, Hershey, Pennsylvania
| | - Greg Olavarria
- 37Division of Pediatric Neurosurgery, Arnold Palmer Hospital for Children, Orlando, Florida
| | - John Ragheb
- 38Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida
| | - Nathan R Selden
- 39Department of Neurological Surgery and Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Manish N Shah
- 40Division of Pediatric Neurosurgery, McGovern Medical School, Houston, Texas
| | - Chevis N Shannon
- 41American Society for Reproductive Medicine, Birmingham, Alabama
| | - Joshua S Shimony
- 42Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Matthew D Smyth
- 29Division of Neurosurgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Scellig S D Stone
- 43Division of Pediatric Neurosurgery, Boston Children's Hospital, Boston, Massachusetts
| | | | - Mandeep S Tamber
- 44Division of Neurosurgery, The University of British Columbia, Vancouver, British Columbia, Canada
| | - James C Torner
- 15Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Gerald F Tuite
- 29Division of Neurosurgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | | | - Scott D Wait
- 46Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - John C Wellons
- 40Division of Pediatric Neurosurgery, McGovern Medical School, Houston, Texas
| | - William E Whitehead
- 9Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, Texas
| | | | | | - Raheel Ahmed
- 2Department of Neurological Surgery, University of Wisconsin at Madison, Wisconsin
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2
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Kelly KA, Guidry BS, Wong GW, Thomas HC, Girgis M, Shannon CN, Wellons JC, Cools MJ. The role of traditional social determinants of health in referral patterns, timing of surgery, and Chiari Health Index for Pediatrics-determined quality of life in children with symptomatic Chiari type I malformation. J Neurosurg Pediatr 2023; 32:686-691. [PMID: 37877946 DOI: 10.3171/2023.7.peds22114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 07/20/2023] [Indexed: 10/26/2023]
Abstract
OBJECTIVE Understanding the impact of the social determinants of health on the utilization of healthcare resources is an important step in eliminating inequalities. The goal of this study was to determine the role of social determinants of health in referral patterns, timing of consultation/intervention, and quality of life in children with Chiari malformation type I (CM-I). METHODS A retrospective study was conducted of children aged 0 to 18 years who underwent surgical treatment for CM-I at a single pediatric facility from 2015 to 2019. The variables included demographic and socioeconomic characteristics, referral patterns, timing, and quality of life data based on the Chiari Health Index for Pediatrics (CHIP). RESULTS The cohort consisted of 103 surgically treated CM-I patients. No differences were seen in race, sex, insurance, or household income when evaluating referral source (community, specialist, or emergency department) or when comparing patients with incidental versus symptomatic findings. In the evaluation of timing from initial evaluation to surgery, no statistical differences were seen between racial, sex, insurance status, or income groups. Children from households of lower median family income were significantly more likely to report pain at the time of consultation (pain group median [interquartile range] $46,660 [$41,004-$50,367] vs nonpain group $53,604 [$41,427-$59,828], p = 0.004). Those in the lower-income group also reported lower CHIP scores corresponding to increased symptomatology in the nonpain physical symptoms (p = 0.004) and psychosocial domains (p = 0.018). CONCLUSIONS There was no evidence of a difference in referral patterns or a delay in time from clinic presentation to surgery based on the traditional social determinants of health categories. Children from households in the lower-income group were associated with increased severity of pain and nonpain symptoms.
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Affiliation(s)
- Katherine A Kelly
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
- 2Vanderbilt University School of Medicine, Nashville, Tennessee
- 3Department of Neurological Surgery, University of Washington, Seattle, Washington; and
| | - Bradley S Guidry
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
- 2Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Gunther W Wong
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
- 2Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Harrison C Thomas
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
- 2Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Mariam Girgis
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Chevis N Shannon
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
- 2Vanderbilt University School of Medicine, Nashville, Tennessee
- 4Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John C Wellons
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
- 2Vanderbilt University School of Medicine, Nashville, Tennessee
- 4Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael J Cools
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
- 2Vanderbilt University School of Medicine, Nashville, Tennessee
- 4Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Johnson GW, Greenberg JK, Hale AT, Ahluwalia R, Hill M, Belal A, Baygani S, Foraker RE, Carpenter CR, Yan Y, Ackerman LL, Noje C, Jackson E, Burns EC, Sayama CM, Selden NR, Vachhrajani S, Shannon CN, Kuppermann N, Limbrick DD. Toward rational use of repeat imaging in children with mild traumatic brain injuries and intracranial injuries. J Neurosurg Pediatr 2023; 32:26-34. [PMID: 37021760 DOI: 10.3171/2023.2.peds22393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 02/22/2023] [Indexed: 04/07/2023]
Abstract
OBJECTIVE Limited evidence exists on the utility of repeat neuroimaging in children with mild traumatic brain injuries (mTBIs) and intracranial injuries (ICIs). Here, the authors identified factors associated with repeat neuroimaging and predictors of hemorrhage progression and/or neurosurgical intervention. METHODS The authors performed a multicenter, retrospective cohort study of children at four centers of the Pediatric TBI Research Consortium. All patients were ≤ 18 years and presented within 24 hours of injury with a Glasgow Coma Scale score of 13-15 and evidence of ICI on neuroimaging. The outcomes of interest were 1) whether patients underwent repeat neuroimaging during index admission, and 2) a composite outcome of progression of previously identified hemorrhage ≥ 25% and/or repeat imaging as an indication for subsequent neurosurgical intervention. The authors performed multivariable logistic regression and report odds ratios and 95% confidence intervals. RESULTS A total of 1324 patients met inclusion criteria; 41.3% of patients underwent repeat imaging. Repeat imaging was associated with clinical change in 4.8% of patients; the remainder of the imaging tests were for routine surveillance (90.9%) or of unclear prompting (4.4%). In 2.6% of patients, repeat imaging findings were reported as an indication for neurosurgical intervention. While many factors were associated with repeat neuroimaging, only epidural hematoma (OR 3.99, 95% CI 2.22-7.15), posttraumatic seizures (OR 2.95, 95% CI 1.22-7.41), and age ≥ 2 years (OR 2.25, 95% CI 1.16-4.36) were significant predictors of hemorrhage progression and/or neurosurgery. Of patients without any of these risk factors, none underwent neurosurgical intervention. CONCLUSIONS Repeat neuroimaging was commonly used but uncommonly associated with clinical deterioration. Although several factors were associated with repeat neuroimaging, only posttraumatic seizures, age ≥ 2 years, and epidural hematoma were significant predictors of hemorrhage progression and/or neurosurgery. These results provide the foundation for evidence-based repeat neuroimaging practices in children with mTBI and ICI.
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Affiliation(s)
| | | | - Andrew T Hale
- 2Department of Neurological Surgery, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama
| | - Ranbir Ahluwalia
- 3Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Madelyn Hill
- 4Department of Neurological Surgery, Dayton Children's Hospital, Dayton, Ohio
| | - Ahmed Belal
- 5Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Shawyon Baygani
- 5Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | | | | | - Yan Yan
- 8Surgery, Washington University School of Medicine in St. Louis, Missouri
| | - Laurie L Ackerman
- 5Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | | | - Eric Jackson
- 10Neurological Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | | | - Christina M Sayama
- 12Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
| | - Nathan R Selden
- 12Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
| | - Shobhan Vachhrajani
- 4Department of Neurological Surgery, Dayton Children's Hospital, Dayton, Ohio
| | - Chevis N Shannon
- 2Department of Neurological Surgery, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama
| | - Nathan Kuppermann
- Departments of13Emergency Medicine and
- 14Pediatrics, University of California, Davis, School of Medicine, Sacramento, California
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4
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Chen JW, Shlobin NA, Bhebhe A, Zhao S, Shannon CN, Sichizya K, Bonfield CM, Reynolds RA. Local conceptions of the role of folate in neural tube defects in Zambia. J Neurosurg Pediatr 2023; 31:268-274. [PMID: 36681960 DOI: 10.3171/2022.11.peds22217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 11/11/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE In sub-Saharan Africa, neural tube defects (NTDs) are the second most common birth defect, occurring eight times more frequently than in the US. The objective of this study was to assess baseline Zambian caregiver understanding of folate and NTDs and the effectiveness of an NTD prevention educational program. METHODS This prospective survey-based study included Zambian caregivers of children born with NTDs who completed pre- and post-educational program surveys between January 2020 and January 2021. The verbal survey was administered in English or local Zambian dialects. The 1-hour educational program administered by local Zambian research nurses sought to facilitate understanding of the direct relationship between prenatal folate supplementation and NTDs. RESULTS Sixty-one eligible caregivers with a median age of 20 (IQR 24-29) years completed the survey. Participants were predominantly from regions outside of Lusaka Province (68%, 41/60) rather than the capital city, Lusaka (32%, 19/60). Most had received prenatal care (91%, 57/61), and 80% (47/59) reported folate use in pregnancy. Of the mothers who took folate during pregnancy, 24% (11/45) reported use within the first 4 weeks after conception, while 76% (34/45) started thereafter. Myelomeningocele was the most common NTD (74%, 32/43), followed by meningocele (14%, 6/43). Prior to the educational program, 52% (29/56) of caregivers reported that NTDs were caused by a vitamin deficiency, which improved to 98% (55/56) after the program (p < 0.001). Furthermore, only 54% (33/61) of caregivers believed that folate should be taken before conception on the baseline survey evaluation, which improved to 95% (58/61, p < 0.001) after the program. All survey participants (58/58) found the educational session helpful. CONCLUSIONS This study found that a high proportion of Zambian caregivers had received prenatal care and even had taken folate during pregnancy, but none had taken it prior to pregnancy. An educational program effectively improved understanding about the role and timing of perinatal folate administration in NTD prevention. This result also emphasizes the need for folate fortification and folate education for not only mothers but also primary care providers.
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Affiliation(s)
- Jeffrey W Chen
- 1Vanderbilt University School of Medicine, Nashville, Tennessee
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital, Nashville, Tennessee
| | - Nathan A Shlobin
- 3Northwestern University School of Medicine, Northwestern University, Chicago, Illinois
| | - Arnold Bhebhe
- 4Department of Neurosurgery, University Teaching Hospital, Lusaka, Zambia
| | - Shilin Zhao
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital, Nashville, Tennessee
- 5Vanderbilt Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chevis N Shannon
- 6Department of Neurological Surgery, University of Alabama, Birmingham, Alabama
| | | | - Christopher M Bonfield
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital, Nashville, Tennessee
- Departments of8Neurological Surgery and
- 9Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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5
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Mooney J, Laskay NMB, Salehani A, Shannon CN, Rozzelle C. Postgraduate Year 6 Versus Postgraduate Year 7 Neurosurgical Chief Year: A Survey of Residents and Program Directors. World Neurosurg 2023; 171:e679-e685. [PMID: 36563850 DOI: 10.1016/j.wneu.2022.12.084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 12/17/2022] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Recently, more neurosurgical residency programs have transitioned from a postgraduate year (PGY)-7 to a PGY-6 chief year. There has not been a national analysis of resident and program director perceptions regarding the timing of chief year conductance and its influence on overall program satisfaction. METHODS An online survey was distributed to all North American PGY 4-7 residents and program directors. Data regarding program size, protected research timing, chief year timing (PGY-6 vs. PGY-7), and resident and program director perceptions of the influence of neurosurgical chief year timing on program satisfaction and ability of residents to practice were recorded. Survey results were summarized descriptively. RESULTS A total of 134 respondents completed the survey. Thirty-five percent of respondents reported a recent program transition from a PGY-7 to PGY-6 chief year while 44% of respondents at programs conducting a PGY-7 chief year reported they were interested in transitioning to a PGY-6 chief year. The large majority (76%) of respondents at PGY-6 chief year programs stated they were overall satisfied with this. A large percentage of all respondents reported that a PGY-6 chief year provided increased opportunity for subspecialty focus, enfolded fellowships and career planning. CONCLUSIONS Program directors and residents at PGY-6 chief year programs report a high level of satisfaction with close to half of those at PGY-7 programs desiring to make this transition. Most PGY-6 chief year respondents report that this model allows for greater subspecialty focus and career planning during the PGY-7 year.
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Affiliation(s)
- James Mooney
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA.
| | - Nicholas M B Laskay
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Arsalaan Salehani
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Chevis N Shannon
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Curtis Rozzelle
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Jakopin NE, Myong E, Bogucki T, Gray D, Gross P, McComb JG, Shannon CN, Tamber MS, Toyama M, van der Willigen T, Yazdani A, Hamilton MG, Koschnitzky JE. Establishing ranked priorities for future hydrocephalus research. J Neurosurg 2022:1-10. [PMID: 36681979 DOI: 10.3171/2022.10.jns22753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 10/25/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE The aim of this initiative was to develop a ranked list of hydrocephalus research priorities as determined by the hydrocephalus patient community in conjunction with the healthcare and scientific community. METHODS Using the validated methodology published by the James Lind Alliance (JLA), the Hydrocephalus Association (HA) administered two surveys and hosted a final prioritization workshop. Survey One solicited open-ended responses from the community. From these responses, a long list of priority statements was developed. This list was then consolidated into a short list of research priority statements, which, after a nonsystematic literature review, were verified as being research uncertainties. Survey Two asked the community members to select their top 10 priorities from the short list. The final prioritization leading to a final ranked top 20 list of hydrocephalus research priorities took place at a virtual workshop led by a team of trained facilitators, by means of an iterative process of consensus building. RESULTS From Survey One, 3703 responses from 890 respondents were collected, leading to a long list of 146 priority statements. The consolidated short list contained 49 research priority statements, all of which were verified as uncertainties in hydrocephalus research. From an analysis of Survey Two responses, the top 21 research priority statements were determined. A consensus on these statements was reached at the virtual workshop, leading to a final ranked top 20 list of hydrocephalus research priorities, within which needs were apparent in several areas: development of noninvasive and/or one-time therapies, reduction of the burden of current treatments, improvement of the screening and diagnosis of hydrocephalus, improved quality of life, and improved access to care. CONCLUSIONS By gathering extensive input from the hydrocephalus community and using an iterative process of consensus building, a ranked list of the top 20 hydrocephalus research priorities was developed. The HA will use this ranked list to guide future research programs and encourages the healthcare and scientific community to do the same.
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Affiliation(s)
- Noriana E Jakopin
- 1Hydrocephalus Association, Bethesda, Maryland.,2University of Maryland, College Park, Maryland
| | - Elliot Myong
- 1Hydrocephalus Association, Bethesda, Maryland.,3University of Southern California, Los Angeles, California
| | | | - Diana Gray
- 1Hydrocephalus Association, Bethesda, Maryland
| | - Paul Gross
- 1Hydrocephalus Association, Bethesda, Maryland.,4Cerebral Palsy Research Network, Greenville, South Carolina
| | | | - Chevis N Shannon
- 5Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Mandeep S Tamber
- 6Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | - Mark G Hamilton
- 8Department of Clinical Neurosciences, Division of Neurosurgery, Cumming School of Medicine, University of Calgary, Alberta, Canada
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7
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Kaur K, Acharya G, Chen H, Shannon CN, Lipscomb BE, Newman R, Zuckerwise LC. Impact of fetal trisomy 21 on umbilical artery Doppler indices. J Matern Fetal Neonatal Med 2022; 35:8364-8371. [PMID: 34570672 PMCID: PMC10346994 DOI: 10.1080/14767058.2021.1974388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/16/2021] [Accepted: 08/26/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Umbilical artery (UA) Doppler indices are surrogate measures of placental function, most commonly used to assess fetal wellbeing in pregnancies with fetal growth restriction. Fetuses with trisomy 21 (t21) are reported to have elevated UA Doppler indices, but reference percentiles are currently lacking for this population. We hypothesized that gestational age-specific values of UA Doppler indices in pregnancies complicated by t21 will be elevated compared to established percentiles based on euploid pregnancies. We aimed to assess UA Doppler indices longitudinally in fetuses with t21 in order to demonstrate Doppler patterns across gestation in this population, compare them with euploid fetuses, and investigate their association with pregnancy outcomes. METHODS We conducted a retrospective cohort study of singleton pregnancies with confirmed fetal t21 who underwent UA Doppler surveillance antenatally from January 2012 to August 2019. UA Doppler indices, including systolic/diastolic (S/D) ratio, pulsatility index (PI), and resistance index (RI) were extracted from ultrasound reports or directly from ultrasound images. UA S/D, PI, and RI percentiles by gestational week were created from available observations from our cohort via a data-driven approach using a generalized additive model. A secondary analysis was run to statistically compare t21 values to established percentiles based on observations from a historical population of euploid fetuses. RESULTS UA Doppler measurements from 86 t21 fetuses and 130 euploid fetuses were included in our analysis. Median (IQR) maternal age in t21 pregnancies and euploid pregnancies were 35 years (29-38) and 30 years (27-33), respectively. As in euploid fetuses, we found a negative association between Doppler indices and gestational age in the t21 fetuses. Maternal tobacco use, obesity, or chronic hypertension had no significant effect on UA Doppler indices. As hypothesized, values for UA S/D ratio, PI, and RI at the 2.5th, 5th, 10th, 25th, 50th, 75th, 90th, 95th, and 97.5th percentiles by gestational week were significantly higher in t21 fetuses compared to euploid fetuses (p<.001). Overall, 55.8% (48/86) of the t21 fetuses demonstrated at least one Doppler value above the 95th percentile for gestational age based on euploid reference standard. At birth, eight (9.3%) of the t21 fetuses were small for gestational age. When these pregnancies were removed from analysis, UA Doppler indices remained significantly higher than established percentiles at each week of gestation (p < .001). Only three pregnancies ended in fetal demise in the t21 population, two of which had persistently elevated Dopplers above the 95th percentile per established reference percentiles. CONCLUSIONS At each week of gestation, UA Doppler indices in t21 fetuses were significantly higher than established percentiles from a euploid population. Reference intervals based on euploid fetuses may therefore not be appropriate for antenatal surveillance of fetuses with t21. Prospective studies are needed to investigate the role and impact of serial UA Doppler velocimetry in the surveillance of pregnancies complicated by fetal t21.
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Affiliation(s)
- Karampreet Kaur
- Vanderbilt University School of Medicine, Vanderbilt Surgical Outcomes Center for Kids, Nashville, TN, USA
| | - Ganesh Acharya
- Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway
- Department of Clinical Science, Intervention and Technology, Division of Obstetrics and Gynecology, Karolinska Institute, Stockholm, Sweden
| | - Heidi Chen
- Department of Biostatistics, Vanderbilt University Medical Center, Vanderbilt Surgical Outcomes Center for Kids, Nashville, TN, USA
| | - Chevis N Shannon
- Department of Neurosurgery, Vanderbilt University Medical Center, Vanderbilt Surgical Outcomes Center for Kids, Nashville, TN, USA
| | | | - Randa Newman
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lisa C Zuckerwise
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Vanderbilt University Medical Center, Vanderbilt Surgical Outcomes Center for Kids, Nashville, TN, USA
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8
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Reynolds RA, Kelly KA, Ahluwalia R, Zhao S, Vance EH, Lovvorn HN, Hanson H, Shannon CN, Bonfield CM. Protocolized management of isolated linear skull fractures at a level 1 pediatric trauma center. J Neurosurg Pediatr 2022; 30:1-8. [PMID: 35901741 DOI: 10.3171/2022.6.peds227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 06/01/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Isolated linear skull fractures without intracranial findings rarely require urgent neurosurgical intervention. A multidisciplinary fracture management protocol based on antiemetic usage was implemented at our American College of Surgeons-verified level 1 pediatric trauma center on July 1, 2019. This study evaluated protocol safety and efficacy. METHODS Children younger than 18 years with an ICD-10 code for linear skull fracture without acute intracranial abnormality on head CT were compared before and after protocol implementation. The preprotocol cohort was defined as children who presented between July 1, 2015, and December 31, 2017; the postprotocol cohort was defined as those who presented between July 1, 2019, and July 1, 2020. RESULTS The preprotocol and postprotocol cohorts included 162 and 82 children, respectively. Overall, 57% were male, and the median (interquartile range) age was 9.1 (4.8-25.0) months. The cohorts did not differ significantly in terms of sex (p = 0.1) or age (p = 0.8). Falls were the most common mechanism of injury (193 patients [79%]). After protocol implementation, there was a relative increase in patients who fell from a height > 3 feet (10% to 29%, p < 0.001) and those with no reported injury mechanism (12% to 16%, p < 0.001). The neurosurgery department was consulted for 86% and 44% of preprotocol and postprotocol cases, respectively (p < 0.001). Trauma consultations and consultations for abusive head trauma did not significantly change (p = 0.2 and p = 0.1, respectively). Admission rate significantly decreased (52% to 38%, p = 0.04), and the 72-hour emergency department revisit rate trended down but was not statistically significant (2.8/year to 1/year, p = 0.2). No deaths occurred, and no inpatient neurosurgical procedures were performed. CONCLUSIONS Protocolization of isolated linear skull fracture management is safe and feasible at a high-volume level 1 pediatric trauma center. Neurosurgical consultation can be prioritized for select patients. Further investigation into criteria for admission, need for interfacility transfers, and healthcare costs is warranted.
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Affiliation(s)
- Rebecca A Reynolds
- 1Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Katherine A Kelly
- 3Department of Neurosurgery, University of Washington, Seattle, Washington
| | - Ranbir Ahluwalia
- 1Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Shilin Zhao
- 4Department of Biostatistics, Vanderbilt University Medical Center, Nashville
| | - E Haley Vance
- 1Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Harold N Lovvorn
- 5Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville; and
| | - Holly Hanson
- 6Department of Pediatrics, Division of Emergency Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Chevis N Shannon
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Christopher M Bonfield
- 1Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
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9
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Greenberg JK, Olsen MA, Johnson GW, Ahluwalia R, Hill M, Hale AT, Belal A, Baygani S, Foraker RE, Carpenter CR, Ackerman LL, Noje C, Jackson EM, Burns E, Sayama CM, Selden NR, Vachhrajani S, Shannon CN, Kuppermann N, Limbrick DD. Measures of Intracranial Injury Size Do Not Improve Clinical Decision Making for Children With Mild Traumatic Brain Injuries and Intracranial Injuries. Neurosurgery 2022; 90:691-699. [PMID: 35285454 PMCID: PMC9117421 DOI: 10.1227/neu.0000000000001895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 12/05/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND When evaluating children with mild traumatic brain injuries (mTBIs) and intracranial injuries (ICIs), neurosurgeons intuitively consider injury size. However, the extent to which such measures (eg, hematoma size) improve risk prediction compared with the kids intracranial injury decision support tool for traumatic brain injury (KIIDS-TBI) model, which only includes the presence/absence of imaging findings, remains unknown. OBJECTIVE To determine the extent to which measures of injury size improve risk prediction for children with mild traumatic brain injuries and ICIs. METHODS We included children ≤18 years who presented to 1 of the 5 centers within 24 hours of TBI, had Glasgow Coma Scale scores of 13 to 15, and had ICI on neuroimaging. The data set was split into training (n = 1126) and testing (n = 374) cohorts. We used generalized linear modeling (GLM) and recursive partitioning (RP) to predict the composite of neurosurgery, intubation >24 hours, or death because of TBI. Each model's sensitivity/specificity was compared with the validated KIIDS-TBI model across 3 decision-making risk cutoffs (<1%, <3%, and <5% predicted risk). RESULTS The GLM and RP models included similar imaging variables (eg, epidural hematoma size) while the GLM model incorporated additional clinical predictors (eg, Glasgow Coma Scale score). The GLM (76%-90%) and RP (79%-87%) models showed similar specificity across all risk cutoffs, but the GLM model had higher sensitivity (89%-96% for GLM; 89% for RP). By comparison, the KIIDS-TBI model had slightly higher sensitivity (93%-100%) but lower specificity (27%-82%). CONCLUSION Although measures of ICI size have clear intuitive value, the tradeoff between higher specificity and lower sensitivity does not support the addition of such information to the KIIDS-TBI model.
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Affiliation(s)
- Jacob K. Greenberg
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA;
| | - Margaret A. Olsen
- Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA;
| | - Gabrielle W. Johnson
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA;
| | - Ranbir Ahluwalia
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA;
| | - Madelyn Hill
- Division of Neurosurgery, Dayton Children's Hospital, Dayton, Ohio, USA;
| | - Andrew T. Hale
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA;
| | - Ahmed Belal
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA;
| | - Shawyon Baygani
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA;
| | - Randi E. Foraker
- Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA;
| | - Christopher R. Carpenter
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA;
| | - Laurie L. Ackerman
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA;
| | - Corina Noje
- Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Critical Care Medicine, The Charlotte R. Bloomberg Children's Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA;
| | - Eric M. Jackson
- Neurological Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA;
| | - Erin Burns
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon, USA;
| | - Christina M. Sayama
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon, USA;
- Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon, USA;
| | - Nathan R. Selden
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon, USA;
- Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon, USA;
| | - Shobhan Vachhrajani
- Division of Neurosurgery, Dayton Children's Hospital, Dayton, Ohio, USA;
- Department of Pediatrics, Wright State University, Dayton, Ohio, USA;
| | - Chevis N. Shannon
- Division of Neurosurgery, Dayton Children's Hospital, Dayton, Ohio, USA;
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California Davis, School of Medicine, Sacramento, California, USA;
- Department of Pediatrics, University of California Davis, School of Medicine, Sacramento, California, USA
| | - David D. Limbrick
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA;
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10
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Tang AR, Chen JW, Sellyn GE, Chen H, Zhao S, Gannon SR, Shannon CN, Bonfield CM. Evaluating caregiver stress in craniosynostosis patients. J Neurosurg Pediatr 2022; 30:1-8. [PMID: 35561696 DOI: 10.3171/2022.4.peds21596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 04/06/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Caregiver stress from a child's diagnosis can impact a caregiver's ability to participate in treatment decisions, comply, and manage long-term illness. The aim of this study was to compare caregiver stress in children with craniosynostosis at diagnosis and postoperatively. METHODS This prospective study included caregivers of pediatric patients with craniosynostosis receiving operative intervention. Demographics and Parenting Stress Index, Short Form (PSI-SF) and Pediatric Inventory for Parents (PIP) surveys at baseline (preoperatively) and 3 and 6 months postoperatively were completed. PSI-SF scores between 15 and 80 are considered normal, with > 85 being clinically significant and requiring follow-up. Higher PIP scores represent increased frequency and difficulty of stressful events due to the child's illness. Pairwise comparisons were performed using the Wilcoxon signed-rank test. Multivariate analysis was performed to assess for PSI-SF and PIP predictors. RESULTS Of 106 caregivers (84% Caucasian), there were 62 mothers and 40 fathers. There were 68 and 45 responses at 3 and 6 months postoperatively, respectively. Regarding the baseline group, more than 80% were between 20 and 40 years of age and 58% had less than 2 years of college education. The median household income fell in the $45,001-$60,000 bracket. There was no significant difference between median baseline PSI-SF score (65, IQR 51-80) and those at 3 months (p = 0.45) and 6 months (p = 0.82) postoperatively. Both median PIP frequency (89 vs 74, p < 0.01) and difficulty (79 vs 71, p < 0.01) scores were lower at 3 months, although no significant difference was observed at 6 months (frequency: 95 vs 91, p = 0.67; difficulty: 82 vs 80, p = 0.34). Female sex, uninsured status, and open surgery type were all risk factors for higher parental stress. CONCLUSIONS Stress levels ranged from normal to clinically significant in the caregivers, with sex, uninsured status, and open repair predicting higher stress. Stress decreased at 3 months postoperatively before increasing at 6 months. Intervention targeting caregiver stress should be explored to maintain lower stress observed at 3 months after surgery.
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Affiliation(s)
- Alan R Tang
- 1Vanderbilt University School of Medicine, Nashville
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville
| | - Jeffrey W Chen
- 1Vanderbilt University School of Medicine, Nashville
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville
| | - Georgina E Sellyn
- 1Vanderbilt University School of Medicine, Nashville
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville
| | - Heidi Chen
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville
- 3Department of Biostatistics, Vanderbilt University, Nashville; and
| | - Shilin Zhao
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville
- 3Department of Biostatistics, Vanderbilt University, Nashville; and
| | - Stephen R Gannon
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville
| | - Chevis N Shannon
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville
- 4Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christopher M Bonfield
- 4Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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11
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Akbari SHA, Yahanda AT, Ackerman LL, Adelson PD, Ahmed R, Albert GW, Aldana PR, Alden TD, Anderson RCE, Bauer DF, Bethel-Anderson T, Bierbrauer K, Brockmeyer DL, Chern JJ, Couture DE, Daniels DJ, Dlouhy BJ, Durham SR, Ellenbogen RG, Eskandari R, Fuchs HE, Grant GA, Graupman PC, Greene S, Greenfield JP, Gross NL, Guillaume DJ, Hankinson TC, Heuer GG, Iantosca M, Iskandar BJ, Jackson EM, Jallo GI, Johnston JM, Kaufman BA, Keating RF, Khan NR, Krieger MD, Leonard JR, Maher CO, Mangano FT, McComb JG, McEvoy SD, Meehan T, Menezes AH, Muhlbauer MS, O'Neill BR, Olavarria G, Ragheb J, Selden NR, Shah MN, Shannon CN, Shimony JS, Smyth MD, Stone SSD, Strahle JM, Tamber MS, Torner JC, Tuite GF, Tyler-Kabara EC, Wait SD, Wellons JC, Whitehead WE, Park TS, Limbrick DD. Complications and outcomes of posterior fossa decompression with duraplasty versus without duraplasty for pediatric patients with Chiari malformation type I and syringomyelia: a study from the Park-Reeves Syringomyelia Research Consortium. J Neurosurg Pediatr 2022; 30:1-13. [PMID: 35426814 DOI: 10.3171/2022.2.peds21446] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 02/28/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to determine differences in complications and outcomes between posterior fossa decompression with duraplasty (PFDD) and without duraplasty (PFD) for the treatment of pediatric Chiari malformation type I (CM1) and syringomyelia (SM). METHODS The authors used retrospective and prospective components of the Park-Reeves Syringomyelia Research Consortium database to identify pediatric patients with CM1-SM who received PFD or PFDD and had at least 1 year of follow-up data. Preoperative, treatment, and postoperative characteristics were recorded and compared between groups. RESULTS A total of 692 patients met the inclusion criteria for this database study. PFD was performed in 117 (16.9%) and PFDD in 575 (83.1%) patients. The mean age at surgery was 9.86 years, and the mean follow-up time was 2.73 years. There were no significant differences in presenting signs or symptoms between groups, although the preoperative syrinx size was smaller in the PFD group. The PFD group had a shorter mean operating room time (p < 0.0001), fewer patients with > 50 mL of blood loss (p = 0.04), and shorter hospital stays (p = 0.0001). There were 4 intraoperative complications, all within the PFDD group (0.7%, p > 0.99). Patients undergoing PFDD had a 6-month complication rate of 24.3%, compared with 13.7% in the PFD group (p = 0.01). There were no differences between groups for postoperative complications beyond 6 months (p = 0.33). PFD patients were more likely to require revision surgery (17.9% vs 8.3%, p = 0.002). PFDD was associated with greater improvements in headaches (89.6% vs 80.8%, p = 0.04) and back pain (86.5% vs 59.1%, p = 0.01). There were no differences between groups for improvement in neurological examination findings. PFDD was associated with greater reduction in anteroposterior syrinx size (43.7% vs 26.9%, p = 0.0001) and syrinx length (18.9% vs 5.6%, p = 0.04) compared with PFD. CONCLUSIONS PFD was associated with reduced operative time and blood loss, shorter hospital stays, and fewer postoperative complications within 6 months. However, PFDD was associated with better symptom improvement and reduction in syrinx size and lower rates of revision decompression. The two surgeries have low intraoperative complication rates and comparable complication rates beyond 6 months.
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Affiliation(s)
- S Hassan A Akbari
- 1Division of Pediatric Neurosurgery, Penn State Health Children's Hospital, Hershey, PA
| | - Alexander T Yahanda
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Laurie L Ackerman
- 3Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - P David Adelson
- 4Division of Pediatric Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ
| | - Raheel Ahmed
- 5Department of Neurological Surgery, University of Wisconsin at Madison, Madison, WI
| | - Gregory W Albert
- 6Division of Neurosurgery, Arkansas Children's Hospital, Little Rock, AR
| | - Philipp R Aldana
- 7Division of Pediatric Neurosurgery, University of Florida College of Medicine, Jacksonville, FL
| | - Tord D Alden
- 8Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Richard C E Anderson
- 9Division of Pediatric Neurosurgery, Department of Neurological Surgery, Children's Hospital of New York, Columbia-Presbyterian, New York, NY
| | - David F Bauer
- 10Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, TX
| | - Tammy Bethel-Anderson
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Karin Bierbrauer
- 36Division of Pediatric Neurosurgery, Cincinnati Children's Medical Center, Cincinnati, OH
| | - Douglas L Brockmeyer
- 11Division of Pediatric Neurosurgery, Primary Children's Hospital, Salt Lake City, UT
| | - Joshua J Chern
- 12Division of Pediatric Neurosurgery, Children's Healthcare of Atlanta University, Atlanta, GA
| | - Daniel E Couture
- 13Department of Neurological Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | | | - Brian J Dlouhy
- 15Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Susan R Durham
- 16Division of Pediatric Neurosurgery, Children's Hospital of Los Angeles, Los Angeles, CA
| | | | - Ramin Eskandari
- 18Department of Neurosurgery, Medical University of South Carolina, Charleston, SC
| | - Herbert E Fuchs
- 19Department of Neurosurgery, Duke University School of Medicine, Durham, NC
| | - Gerald A Grant
- 20Division of Pediatric Neurosurgery, Lucile Packard Children's Hospital, Palo Alto, CA
| | - Patrick C Graupman
- 21Division of Pediatric Neurosurgery, Gillette Children's Hospital, St. Paul, MN
| | - Stephanie Greene
- 22Division of Pediatric Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jeffrey P Greenfield
- 23Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, NY
| | - Naina L Gross
- 24Department of Neurosurgery, University of Oklahoma, Oklahoma City, OK
| | - Daniel J Guillaume
- 25Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, MN
| | - Todd C Hankinson
- 26Department of Neurosurgery, Children's Hospital Colorado, Aurora, CO
| | - Gregory G Heuer
- 27Division of Pediatric Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Mark Iantosca
- 1Division of Pediatric Neurosurgery, Penn State Health Children's Hospital, Hershey, PA
| | - Bermans J Iskandar
- 5Department of Neurological Surgery, University of Wisconsin at Madison, Madison, WI
| | - Eric M Jackson
- 28Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - George I Jallo
- 29Division of Neurosurgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - James M Johnston
- 30Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL
| | - Bruce A Kaufman
- 31Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI
| | - Robert F Keating
- 32Department of Neurosurgery, Children's National Medical Center, Washington, DC
| | - Nicklaus R Khan
- 33Department of Neurosurgery, The University of Tennessee Health Science Center, Memphis, TN
| | - Mark D Krieger
- 16Division of Pediatric Neurosurgery, Children's Hospital of Los Angeles, Los Angeles, CA
| | - Jeffrey R Leonard
- 34Division of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, OH
| | - Cormac O Maher
- 35Department of Neurosurgery, University of Michigan, Ann Arbor, MI
| | - Francesco T Mangano
- 36Division of Pediatric Neurosurgery, Cincinnati Children's Medical Center, Cincinnati, OH
| | - J Gordon McComb
- 16Division of Pediatric Neurosurgery, Children's Hospital of Los Angeles, Los Angeles, CA
| | - Sean D McEvoy
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Thanda Meehan
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Arnold H Menezes
- 15Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Michael S Muhlbauer
- 33Department of Neurosurgery, The University of Tennessee Health Science Center, Memphis, TN
| | - Brent R O'Neill
- 26Department of Neurosurgery, Children's Hospital Colorado, Aurora, CO
| | - Greg Olavarria
- 37Division of Pediatric Neurosurgery, Arnold Palmer Hospital for Children, Orlando, FL
| | - John Ragheb
- 38Department of Neurological Surgery, University of Miami School of Medicine, Miami, FL
| | - Nathan R Selden
- 39Department of Neurological Surgery and Doernbecher Children's Hospital, Oregon Health & Science University, Portland, OR
| | - Manish N Shah
- 40Division of Pediatric Neurosurgery, McGovern Medical School, Houston, TX
| | - Chevis N Shannon
- 41Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital at Vanderbilt University, Nashville, TN
| | - Joshua S Shimony
- 42Department of Radiology, Washington University School of Medicine, St. Louis, MO
| | - Matthew D Smyth
- 29Division of Neurosurgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Scellig S D Stone
- 43Division of Pediatric Neurosurgery, Boston Children's Hospital, Boston, MA
| | - Jennifer M Strahle
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Mandeep S Tamber
- 44Division of Neurosurgery, The University of British Columbia, Vancouver, BC, Canada
| | - James C Torner
- 15Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Gerald F Tuite
- 29Division of Neurosurgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | | | - Scott D Wait
- 46Carolina Neurosurgery & Spine Associates, Charlotte, NC
| | - John C Wellons
- 41Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital at Vanderbilt University, Nashville, TN
| | - William E Whitehead
- 10Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, TX
| | - Tae Sung Park
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - David D Limbrick
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
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12
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Patel PD, Niu X, Shannon CN, Denny JC, Peterson JF, Fusco MR, Chitale RV. CYP2C19 Loss-of-Function Associated with First-Time Ischemic Stroke in Non-surgical Asymptomatic Carotid Artery Stenosis During Clopidogrel Therapy. Transl Stroke Res 2022; 13:46-55. [PMID: 33611730 PMCID: PMC9722320 DOI: 10.1007/s12975-021-00896-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 10/29/2020] [Accepted: 02/09/2021] [Indexed: 02/03/2023]
Abstract
This study measures effect of CYP2C19 genotype on ischemic stroke risk during clopidogrel therapy for asymptomatic, extracranial carotid stenosis patients. Using deidentified electronic health records, patients were selected for retrospective cohort using administrative code for carotid stenosis, availability of CYP2C19 genotype result, clopidogrel exposure, and established patient care. Patients with intracranial atherosclerosis, aneurysm, arteriovenous malformation, prior ischemic stroke, or observation time <1 month were excluded. Dual antiplatelet therapy patients were included. Patients with carotid endarterectomy or stenting were analyzed in a separate subgroup. Time-to-event analysis using Cox regression was conducted to model ischemic stroke events based on CYP2C19 loss-of-function allele and adjusted with the most predictive covariates from univariate analysis. Covariates included age, gender, race, length of aspirin, length of concurrent antiplatelet/anticoagulant treatment, diabetes, coagulopathy, hypertension, heart disease, atrial fibrillation, and lipid disorder. A total of 1110 patients met selection criteria for medical therapy cohort (median age 68 [interquartile range (IQR) 60-75] years, 64.9% male, 91.9% Caucasian). Median study period was 2.8 [0.8-5.3] years. A total of 47 patients (4.2%) had an ischemic stroke event during study period. CYP2C19 loss-of-function allele was strongly associated with ischemic stroke events (one allele: HR 2.3, 95% CI 1.1-4.7, p=0.020; two alleles: HR 10.2, 95% CI 2.8-36.8, p<0.001) after adjustment. For asymptomatic carotid stenosis patients receiving clopidogrel to prevent ischemic stroke, CYP2C19 loss-of-function allele is associated with 2- to 10-fold increased risk of ischemic stroke. CYP2C19 genotype may be considered when selecting antiplatelet therapy for stroke prophylaxis in non-procedural, asymptomatic carotid stenosis.
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Affiliation(s)
- Pious D Patel
- Vanderbilt University School of Medicine, 1161 21st Ave S # D3300, Nashville, TN, 37232, USA.
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA.
| | - Xinnan Niu
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chevis N Shannon
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joshua C Denny
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Josh F Peterson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew R Fusco
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Rohan V Chitale
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
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13
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Akbari SHA, Rizvi AA, CreveCoeur TS, Han RH, Greenberg JK, Torner J, Brockmeyer DL, Wellons JC, Leonard JR, Mangano FT, Johnston JM, Shah MN, Iskandar BJ, Ahmed R, Tuite GF, Kaufman BA, Daniels DJ, Jackson EM, Grant GA, Powers AK, Couture DE, Adelson PD, Alden TD, Aldana PR, Anderson RCE, Selden NR, Bierbrauer K, Boydston W, Chern JJ, Whitehead WE, Dauser RC, Ellenbogen RG, Ojemann JG, Fuchs HE, Guillaume DJ, Hankinson TC, O'Neill BR, Iantosca M, Oakes WJ, Keating RF, Klimo P, Muhlbauer MS, McComb JG, Menezes AH, Khan NR, Niazi TN, Ragheb J, Shannon CN, Smith JL, Ackerman LL, Jea AH, Maher CO, Narayan P, Albert GW, Stone SSD, Baird LC, Gross NL, Durham SR, Greene S, McKinstry RC, Shimony JS, Strahle JM, Smyth MD, Dacey RG, Park TS, Limbrick DD. Socioeconomic and demographic factors in the diagnosis and treatment of Chiari malformation type I and syringomyelia. J Neurosurg Pediatr 2021:1-10. [PMID: 34861643 DOI: 10.3171/2021.9.peds2185] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 09/16/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The goal of this study was to assess the social determinants that influence access and outcomes for pediatric neurosurgical care for patients with Chiari malformation type I (CM-I) and syringomyelia (SM). METHODS The authors used retro- and prospective components of the Park-Reeves Syringomyelia Research Consortium database to identify pediatric patients with CM-I and SM who received surgical treatment and had at least 1 year of follow-up data. Race, ethnicity, and insurance status were used as comparators for preoperative, treatment, and postoperative characteristics and outcomes. RESULTS A total of 637 patients met inclusion criteria, and race or ethnicity data were available for 603 (94.7%) patients. A total of 463 (76.8%) were non-Hispanic White (NHW) and 140 (23.2%) were non-White. The non-White patients were older at diagnosis (p = 0.002) and were more likely to have an individualized education plan (p < 0.01). More non-White than NHW patients presented with cerebellar and cranial nerve deficits (i.e., gait ataxia [p = 0.028], nystagmus [p = 0.002], dysconjugate gaze [p = 0.03], hearing loss [p = 0.003], gait instability [p = 0.003], tremor [p = 0.021], or dysmetria [p < 0.001]). Non-White patients had higher rates of skull malformation (p = 0.004), platybasia (p = 0.002), and basilar invagination (p = 0.036). Non-White patients were more likely to be treated at low-volume centers than at high-volume centers (38.7% vs 15.2%; p < 0.01). Non-White patients were older at the time of surgery (p = 0.001) and had longer operative times (p < 0.001), higher estimated blood loss (p < 0.001), and a longer hospital stay (p = 0.04). There were no major group differences in terms of treatments performed or complications. The majority of subjects used private insurance (440, 71.5%), whereas 175 (28.5%) were using Medicaid or self-pay. Private insurance was used in 42.2% of non-White patients compared to 79.8% of NHW patients (p < 0.01). There were no major differences in presentation, treatment, or outcome between insurance groups. In multivariate modeling, non-White patients were more likely to present at an older age after controlling for sex and insurance status (p < 0.01). Non-White and male patients had a longer duration of symptoms before reaching diagnosis (p = 0.033 and 0.004, respectively). CONCLUSIONS Socioeconomic and demographic factors appear to influence the presentation and management of patients with CM-I and SM. Race is associated with age and timing of diagnosis as well as operating room time, estimated blood loss, and length of hospital stay. This exploration of socioeconomic and demographic barriers to care will be useful in understanding how to improve access to pediatric neurosurgical care for patients with CM-I and SM.
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Affiliation(s)
- Syed Hassan A Akbari
- 1Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | | | | | | | | | - James Torner
- 4Department of Epidemiology, University of Iowa, Iowa City, Iowa
| | - Douglas L Brockmeyer
- 5Department of Pediatric Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - John C Wellons
- 6Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jeffrey R Leonard
- 7Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, Ohio
| | - Francesco T Mangano
- 8Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - James M Johnston
- 9Division of Neurosurgery, University of Alabama School of Medicine, Birmingham, Alabama
| | - Manish N Shah
- 10Department of Pediatric Surgery and Neurosurgery, The University of Texas McGovern Medical School, Houston, Texas
| | - Bermans J Iskandar
- 11Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Raheel Ahmed
- 11Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Gerald F Tuite
- 12Department of Neurosurgery, Neuroscience Institute, All Children's Hospital, St. Petersburg, Florida
| | - Bruce A Kaufman
- 13Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David J Daniels
- 14Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Eric M Jackson
- 15Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Gerald A Grant
- 16Department of Neurosurgery, Stanford Child Health Research Institute, Stanford, California
| | - Alexander K Powers
- 17Department of Neurosurgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Daniel E Couture
- 17Department of Neurosurgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - P David Adelson
- 18Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Tord D Alden
- 19Department of Pediatric Neurosurgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Illinois
| | - Philipp R Aldana
- 20Department of Pediatric Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida
| | - Richard C E Anderson
- 21Department of Neurological Surgery, Columbia University College of Physicians and Surgeons, New York, New York
| | - Nathan R Selden
- 22Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Karin Bierbrauer
- 8Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - William Boydston
- 23Department of Neurosurgery, Children's Healthcare of Atlanta, Georgia
| | - Joshua J Chern
- 23Department of Neurosurgery, Children's Healthcare of Atlanta, Georgia
| | | | - Robert C Dauser
- 24Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Richard G Ellenbogen
- 25Department of Neurosurgery, University of Washington Medicine, Seattle, Washington
| | - Jeffrey G Ojemann
- 25Department of Neurosurgery, University of Washington Medicine, Seattle, Washington
| | - Herbert E Fuchs
- 26Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina
| | - Daniel J Guillaume
- 27Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Todd C Hankinson
- 28Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado
| | - Brent R O'Neill
- 28Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado
| | - Mark Iantosca
- 1Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - W Jerry Oakes
- 9Division of Neurosurgery, University of Alabama School of Medicine, Birmingham, Alabama
| | - Robert F Keating
- 29Department of Neurosurgery, Children's National Medical Center, Washington, DC
| | - Paul Klimo
- 30Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Michael S Muhlbauer
- 30Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - J Gordon McComb
- 31Division of Neurosurgery, Children's Hospital Los Angeles, California
| | - Arnold H Menezes
- 32Department of Neurosurgery, University of Iowa Hospitals, Iowa City, Iowa
| | - Nickalus R Khan
- 33Department of Pediatric Neurosurgery, Miami Children's Hospital and University of Miami Miller School of Medicine, Miami, Florida
| | - Toba N Niazi
- 33Department of Pediatric Neurosurgery, Miami Children's Hospital and University of Miami Miller School of Medicine, Miami, Florida
| | - John Ragheb
- 33Department of Pediatric Neurosurgery, Miami Children's Hospital and University of Miami Miller School of Medicine, Miami, Florida
| | - Chevis N Shannon
- 6Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jodi L Smith
- 34Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Laurie L Ackerman
- 34Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Andrew H Jea
- 34Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Cormac O Maher
- 35Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Prithvi Narayan
- 36Department of Neurological Surgery, St. Christopher's Hospital, Philadelphia, Pennsylvania
| | - Gregory W Albert
- 37Department of Neurosurgery, University of Arkansas College of Medicine, Little Rock, Arkansas
| | - Scellig S D Stone
- 38Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts
| | - Lissa C Baird
- 38Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts
| | - Naina L Gross
- 39Department of Neurosurgery, University of Oklahoma, Oklahoma City, Oklahoma
| | - Susan R Durham
- 40Division of Neurosurgery, University of Vermont Medical Center, Burlington, Vermont; and
| | - Stephanie Greene
- 41Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Robert C McKinstry
- 3Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Joshua S Shimony
- 3Radiology, Washington University School of Medicine, St. Louis, Missouri
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14
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Greenberg JK, Ahluwalia R, Hill M, Johnson G, Hale AT, Belal A, Baygani S, Olsen MA, Foraker RE, Carpenter CR, Yan Y, Ackerman L, Noje C, Jackson E, Burns E, Sayama CM, Selden NR, Vachhrajani S, Shannon CN, Kuppermann N, Limbrick DD. Development and external validation of the KIIDS-TBI tool for managing children with mild traumatic brain injury and intracranial injuries. Acad Emerg Med 2021; 28:1409-1420. [PMID: 34245632 DOI: 10.1111/acem.14333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 05/06/2021] [Accepted: 06/24/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Clinical decision support (CDS) may improve the postneuroimaging management of children with mild traumatic brain injuries (mTBI) and intracranial injuries. While the CHIIDA score has been proposed for this purpose, a more sensitive risk model may have broader use. Consequently, this study's objectives were to: (1) develop a new risk model with improved sensitivity compared to the CHIIDA model and (2) externally validate the new model and CHIIDA model in a multicenter data set. METHODS We analyzed children ≤18 years old with mTBI and intracranial injuries included in the PECARN head injury data set (2004-2006). We used binary recursive partitioning to predict the composite outcome of neurosurgical intervention, intubation for > 24 h due to TBI, or death due to TBI. The new model was externally validated in a separate data set that included children treated at any one of six centers from 2006 to 2019. RESULTS Based on 839 patients from the PECARN data set, a new risk model, the KIIDS-TBI model, was developed that incorporated imaging (e.g., midline shift) and clinical (e.g., Glasgow Coma Scale score) findings. Based on the model-predicted probability of the composite outcome, three cutoffs were evaluated to classify patients as "high risk" for level of care decisions. In the external validation data set consisting of 1,630 patients, the most conservative cutoff (i.e., any predictor present) identified 119 of 119 children with the composite outcome (sensitivity = 100%), but had the lowest specificity (26.3%). The other two decision-making cutoffs had worse sensitivity (94.1%-96.6%) but improved specificity (67.4%-81.3%). The CHIIDA model lacked the most conservative cutoff and otherwise showed the same or slightly worse performance compared to the other two cutoffs. CONCLUSIONS The KIIDS-TBI model has high sensitivity and moderate specificity for risk stratifying children with mTBI and intracranial injuries. Use of this CDS tool may help improve the safe, resource-efficient management of this important patient population.
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Affiliation(s)
- Jacob K. Greenberg
- Department of Neurological Surgery Washington University School of Medicine in St. Louis St. Louis MO USA
| | - Ranbir Ahluwalia
- Department of Neurological Surgery Vanderbilt University Medical Center Nashville TN USA
| | - Madelyn Hill
- Department of Neurological Surgery Dayton Children’s Hospital Dayton OH USA
| | - Gabbie Johnson
- Department of Neurological Surgery Washington University School of Medicine in St. Louis St. Louis MO USA
| | - Andrew T. Hale
- Department of Neurological Surgery Vanderbilt University Medical Center Nashville TN USA
| | - Ahmed Belal
- Department of Neurological Surgery Indiana University School of Medicine Indianapolis IN USA
| | - Shawyon Baygani
- Department of Neurological Surgery Indiana University School of Medicine Indianapolis IN USA
| | - Margaret A. Olsen
- Department of Medicine Washington University School of Medicine in St. Louis St. Louis MO USA
| | - Randi E. Foraker
- Department of Medicine Washington University School of Medicine in St. Louis St. Louis MO USA
| | - Christopher R. Carpenter
- Department of Emergency Medicine Washington University School of Medicine in St. Louis St. Louis MO USA
| | - Yan Yan
- Department of Surgery Washington University School of Medicine in St. Louis St. Louis MO USA
| | - Laurie Ackerman
- Department of Neurological Surgery Indiana University School of Medicine Indianapolis IN USA
| | - Corina Noje
- Department of Anesthesiology Johns Hopkins School of Medicine Baltimore MD USA
| | - Eric Jackson
- Department of Neurological Surgery Johns Hopkins School of Medicine Baltimore MD USA
| | - Erin Burns
- Department of Pediatrics Oregon Health and Science University Portland OR USA
| | - Christina M. Sayama
- Department of Neurological Surgery Oregon Health and Science University Portland OR USA
| | - Nathan R. Selden
- Department of Neurological Surgery Oregon Health and Science University Portland OR USA
| | | | - Chevis N. Shannon
- Department of Neurological Surgery Vanderbilt University Medical Center Nashville TN USA
- American Society for Reproductive Medicine University of California Davis Davis CA USA
| | - Nathan Kuppermann
- Department of Emergency Medicine University of California–Davis Davis CA USA
| | - David D. Limbrick
- Department of Neurological Surgery Washington University School of Medicine in St. Louis St. Louis MO USA
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15
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Whitehead WE, Riva-Cambrin J, Wellons JC, Kulkarni AV, Limbrick DD, Wall VL, Rozzelle CJ, Hankinson TC, McDonald PJ, Krieger MD, Pollack IF, Tamber MS, Pindrik J, Hauptman JS, Naftel RP, Shannon CN, Chu J, Jackson EM, Browd SR, Simon TD, Holubkov R, Reeder RW, Jensen H, Koschnitzky JE, Gross P, Drake JM, Kestle JRW. Anterior versus posterior entry site for ventriculoperitoneal shunt insertion: a randomized controlled trial by the Hydrocephalus Clinical Research Network. J Neurosurg Pediatr 2021:1-11. [PMID: 34798600 DOI: 10.3171/2021.9.peds21391] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 09/02/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The primary objective of this trial was to determine if shunt entry site affects the risk of shunt failure. METHODS The authors performed a parallel-design randomized controlled trial with an equal allocation of patients who received shunt placement via the anterior entry site and patients who received shunt placement via the posterior entry site. All patients were children with symptoms or signs of hydrocephalus and ventriculomegaly. Patients were ineligible if they had a prior history of shunt insertion. Patients received a ventriculoperitoneal shunt after randomization; randomization was stratified by surgeon. The primary outcome was shunt failure. The planned minimum follow-up was 18 months. The trial was designed to achieve high power to detect a 10% or greater absolute difference in the shunt failure rate at 1 year. An independent, blinded adjudication committee determined eligibility and the primary outcome. The study was conducted by the Hydrocephalus Clinical Research Network. RESULTS The study randomized 467 pediatric patients at 14 tertiary care pediatric hospitals in North America from April 2015 to January 2019. The adjudication committee, blinded to intervention, excluded 7 patients in each group for not meeting the study inclusion criteria. For the primary analysis, there were 229 patients in the posterior group and 224 patients in the anterior group. The median patient age was 1.3 months, and the most common etiologies of hydrocephalus were postintraventricular hemorrhage secondary to prematurity (32.7%), myelomeningocele (16.8%), and aqueductal stenosis (10.8%). There was no significant difference in the time to shunt failure between the entry sites (log-rank test, stratified by age < 6 months and ≥ 6 months; p = 0.061). The hazard ratio (HR) of a posterior shunt relative to an anterior shunt was calculated using a univariable Cox regression model and was nonsignificant (HR 1.35, 95% CI, 0.98-1.85; p = 0.062). No significant difference was found between entry sites for the surgery duration, number of ventricular catheter passes, ventricular catheter location, and hospital length of stay. There were no significant differences between entry sites for intraoperative complications, postoperative CSF leaks, pseudomeningoceles, shunt infections, skull fractures, postoperative seizures, new-onset epilepsy, or intracranial hemorrhages. CONCLUSIONS This randomized controlled trial comparing the anterior and posterior shunt entry sites has demonstrated no significant difference in the time to shunt failure. Anterior and posterior entry site surgeries were found to have similar outcomes and similar complication rates.
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Affiliation(s)
| | - Jay Riva-Cambrin
- 2Department of Neurosurgery, University of Calgary, Calgary, Alberta, Canada
| | - John C Wellons
- 3Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee
| | - Abhaya V Kulkarni
- 4Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - David D Limbrick
- 5Department of Neurosurgery, Washington University, St. Louis, Missouri
| | - Vanessa L Wall
- 6Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Curtis J Rozzelle
- 7Department of Neurosurgery, University of Alabama, Birmingham, Alabama
| | - Todd C Hankinson
- 8Department of Neurosurgery, University of Colorado, Aurora, Colorado
| | - Patrick J McDonald
- 9Department of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mark D Krieger
- 10Department of Neurosurgery, University of Southern California, Los Angeles, California
| | - Ian F Pollack
- 11Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mandeep S Tamber
- 9Department of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jonathan Pindrik
- 12Department of Neurosurgery, Ohio State University, Columbus, Ohio
| | - Jason S Hauptman
- 13Department of Neurosurgery, University of Washington, Seattle, Washington
| | - Robert P Naftel
- 3Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee
| | - Chevis N Shannon
- 3Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee
| | - Jason Chu
- 10Department of Neurosurgery, University of Southern California, Los Angeles, California
| | - Eric M Jackson
- 14Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland
| | - Samuel R Browd
- 13Department of Neurosurgery, University of Washington, Seattle, Washington
| | - Tamara D Simon
- 15Department of Pediatrics, Keck School of Medicine at the University of Southern California, Los Angeles, California
| | - Richard Holubkov
- 6Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Ron W Reeder
- 6Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Hailey Jensen
- 6Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | | | - Paul Gross
- 16Hydrocephalus Association, Washington, DC; and
| | - James M Drake
- 4Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - John R W Kestle
- 17Department of Neurosurgery, University of Utah, Salt Lake City, Utah
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16
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Riva-Cambrin J, Kulkarni AV, Burr R, Rozzelle CJ, Oakes WJ, Drake JM, Alvey JS, Reeder RW, Holubkov R, Browd SR, Cochrane DD, Limbrick DD, Naftel R, Shannon CN, Simon TD, Tamber MS, McDonald PJ, Wellons JC, Luerssen TG, Whitehead WE, Kestle JRW. Impact of ventricle size on neuropsychological outcomes in treated pediatric hydrocephalus: an HCRN prospective cohort study. J Neurosurg Pediatr 2021:1-12. [PMID: 34767531 DOI: 10.3171/2021.8.peds21146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 08/19/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In pediatric hydrocephalus, shunts tend to result in smaller postoperative ventricles compared with those following an endoscopic third ventriculostomy (ETV). The impact of the final treated ventricle size on neuropsychological and quality-of-life outcomes is currently undetermined. Therefore, the authors sought to ascertain whether treated ventricle size is associated with neurocognitive and academic outcomes postoperatively. METHODS This prospective cohort study included children aged 5 years and older at the first diagnosis of hydrocephalus at 8 Hydrocephalus Clinical Research Network sites from 2011 to 2015. The treated ventricle size, as measured by the frontal and occipital horn ratio (FOR), was compared with 25 neuropsychological tests 6 months postoperatively after adjusting for age, hydrocephalus etiology, and treatment type (ETV vs shunt). Pre- and posttreatment grade point average (GPA), quality-of-life measures (Hydrocephalus Outcome Questionnaire [HOQ]), and a truncated preoperative neuropsychological battery were also compared with the FOR. RESULTS Overall, 60 children were included with a mean age of 10.8 years; 17% had ≥ 1 comorbidity. Etiologies for hydrocephalus were midbrain lesions (37%), aqueductal stenosis (22%), posterior fossa tumors (13%), and supratentorial tumors (12%). ETV (78%) was more commonly used than shunting (22%). Of the 25 neuropsychological tests, including full-scale IQ (q = 0.77), 23 tests showed no univariable association with postoperative ventricle size. Verbal learning delayed recall (p = 0.006, q = 0.118) and visual spatial judgment (p = 0.006, q = 0.118) were negatively associated with larger ventricles and remained significant after multivariate adjustment for age, etiology, and procedure type. However, neither delayed verbal learning (p = 0.40) nor visual spatial judgment (p = 0.22) was associated with ventricle size change with surgery. No associations were found between postoperative ventricle size and either GPA or the HOQ. CONCLUSIONS Minimal associations were found between the treated ventricle size and neuropsychological, academic, or quality-of-life outcomes for pediatric patients in this comprehensive, multicenter study that encompassed heterogeneous hydrocephalus etiologies.
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Affiliation(s)
- Jay Riva-Cambrin
- 1Department of Clinical Neurosciences, Alberta Children's Hospital, University of Calgary, Alberta, Canada
| | - Abhaya V Kulkarni
- 2Department of Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Robert Burr
- 4Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Curtis J Rozzelle
- 3Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, Alabama
| | - W Jerry Oakes
- 3Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, Alabama
| | - James M Drake
- 2Department of Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Jessica S Alvey
- 4Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Ron W Reeder
- 4Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Richard Holubkov
- 4Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Samuel R Browd
- 5Department of Neurological Surgery, Seattle Children's Hospital, Seattle, Washington
| | - D Douglas Cochrane
- 6Division of Pediatric Neurosurgery, BC Children's Hospital, University of British Columbia, Vancouver, Canada
| | - David D Limbrick
- 7Department of Neurosurgery, St. Louis Children's Hospital, St. Louis, Missouri
| | - Robert Naftel
- 8Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chevis N Shannon
- 8Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tamara D Simon
- 9Department of Pediatrics, University of Southern California, Los Angeles, California; and
| | - Mandeep S Tamber
- 6Division of Pediatric Neurosurgery, BC Children's Hospital, University of British Columbia, Vancouver, Canada
| | - Patrick J McDonald
- 6Division of Pediatric Neurosurgery, BC Children's Hospital, University of British Columbia, Vancouver, Canada
| | - John C Wellons
- 8Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Thomas G Luerssen
- 10Department of Pediatric Neurosurgery, Texas Children's Hospital, Houston, Texas
| | - William E Whitehead
- 10Department of Pediatric Neurosurgery, Texas Children's Hospital, Houston, Texas
| | - John R W Kestle
- 4Department of Neurosurgery, University of Utah, Salt Lake City, Utah
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Patel PD, Kelly KA, Chen H, Greeno A, Shannon CN, Naftel RP. Measuring the effects of institutional pediatric traumatic brain injury volume on outcomes for rural-dwelling children. J Neurosurg Pediatr 2021:1-9. [PMID: 34598145 DOI: 10.3171/2021.7.peds21159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 07/06/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Rural-dwelling children may suffer worse pediatric traumatic brain injury (TBI) outcomes due to distance from and accessibility to high-volume trauma centers. This study aimed to compare the impacts of institutional TBI volume and sociodemographics on outcomes between rural- and urban-dwelling children. METHODS This retrospective study identified patients 0-19 years of age with ICD-9 codes for TBI in the 2012-2015 National Inpatient Sample database. Patients were characterized as rural- or urban-dwelling using United States Census classification. Logistic and linear (in log scale) regressions were performed to measure the effects of institutional characteristics, patient sociodemographics, and mechanism/severity of injury on occurrence of medical complications, mortality, length of stay (LOS), and costs. Separate models were built for rural- and urban-dwelling patients. RESULTS A total of 19,736 patients were identified (median age 11 years, interquartile range [IQR] 2-16 years, 66% male, 55% Caucasian). Overall, rural-dwelling patients had higher All Patient Refined Diagnosis Related Groups injury severity (median 2 [IQR 1-3] vs 1 [IQR 1-2], p < 0.001) and more intracranial monitoring (6% vs 4%, p < 0.001). Univariate analysis showed that overall, rural-dwelling patients suffered increased medical complications (6% vs 4%, p < 0.001), mortality (6% vs 4%, p < 0.001), and LOS (median 2 days [IQR 1-4 days ] vs 2 days [IQR 1-3 days], p < 0.001), but multivariate analysis showed rural-dwelling status was not associated with these outcomes after adjusting for injury severity, mechanism, and hospital characteristics. Institutional TBI volume was not associated with medical complications, disposition, or mortality for either population but was associated with LOS for urban-dwelling patients (nonlinear beta, p = 0.008) and cost for both rural-dwelling (nonlinear beta, p < 0.001) and urban-dwelling (nonlinear beta, p < 0.001) patients. CONCLUSIONS Overall, rural-dwelling pediatric patients with TBI have worsened injury severity, mortality, and in-hospital complications, but these disparities disappear after adjusting for injury severity and mechanism. Institutional TBI volume does not impact clinical outcomes for rural- or urban-dwelling children after adjusting for these covariates. Addressing the root causes of the increased injury severity at hospital arrival may be a useful path to improve TBI outcomes for rural-dwelling children.
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Affiliation(s)
- Pious D Patel
- 1Vanderbilt University School of Medicine.,2Surgical Outcomes Center for Kids, Vanderbilt Monroe Carell Jr. Children's Hospital; and
| | - Katherine A Kelly
- 1Vanderbilt University School of Medicine.,2Surgical Outcomes Center for Kids, Vanderbilt Monroe Carell Jr. Children's Hospital; and
| | | | - Amber Greeno
- 2Surgical Outcomes Center for Kids, Vanderbilt Monroe Carell Jr. Children's Hospital; and
| | - Chevis N Shannon
- 2Surgical Outcomes Center for Kids, Vanderbilt Monroe Carell Jr. Children's Hospital; and.,4Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert P Naftel
- 4Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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18
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Reynolds RA, Ahluwalia R, Krishnan V, Kelly KA, Lee J, Waldrop RP, Guidry B, Hengartner AC, McCroskey J, Arynchyna A, Staulcup S, Chen H, Hankinson TC, Rocque BG, Shannon CN, Naftel R. Risk factors for unchanged ventricles during pediatric shunt malfunction. J Neurosurg Pediatr 2021:1-7. [PMID: 34560626 DOI: 10.3171/2021.6.peds2125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 06/15/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Children whose ventricles do not change during shunt malfunction present a diagnostic dilemma. This study was performed to identify risk factors for unchanged ventricular size at shunt malfunction. METHODS This retrospective 1:1 age-matched case-control study identified children with shunted hydrocephalus who underwent shunt revision with intraoperative evidence of malfunction at one of the three participating institutions from 1997 to 2019. Cases were defined as patients with a change of < 0.05 in the frontal-occipital horn ratio (FOR) between malfunction and baseline, and controls included patients with FOR changes ≥ 0.05. The presence of infection, abdominal pseudocyst, pseudomeningocele, or wound drainage and lack of baseline cranial imaging at the time of malfunction warranted exclusion. RESULTS Of 450 included patients, 60% were male, 73% were Caucasian, and 67% had an occipital shunt. The median age was 4.3 (IQR 0.97-9.21) years at malfunction. On univariable analysis, unchanged ventricles at malfunction were associated with a frontal shunt (41% vs 28%, p < 0.001), programmable valve (17% vs 9%, p = 0.011), nonsiphoning shunt (85% vs 66%, p < 0.001), larger baseline FOR (0.44 ± 0.12 vs 0.38 ± 0.11, p < 0.001), no prior shunt infection (87% vs 76%, p = 0.003), and no prior shunt revisions (68% vs 52%, p < 0.001). On multivariable analysis with collinear variables removed, patients with a frontal shunt (OR 1.67, 95% CI 1.08-2.70, p = 0.037), programmable valve (OR 2.63, 95% CI 1.32-5.26, p = 0.007), nonsiphoning shunt at malfunction (OR 2.76, 95% CI 1.63-4.67, p < 0.001), larger baseline FOR (OR 3.13, 95% CI 2.21-4.43, p < 0.001), and no prior shunt infection (OR 2.34, 95% CI 1.27-4.30, p = 0.007) were more likely to have unchanged ventricles at malfunction. CONCLUSIONS In a multicenter cohort of children with shunt malfunction, those with a frontal shunt, programmable valve, nonsiphoning shunt, baseline large ventricles, and no prior shunt infection were more likely than others to have unchanged ventricles at shunt failure.
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Affiliation(s)
- Rebecca A Reynolds
- 1Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville.,2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Ranbir Ahluwalia
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Vishal Krishnan
- 3University of Colorado School of Medicine, Aurora, Colorado
| | | | - Jaclyn Lee
- 4Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Raymond P Waldrop
- 5University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Bradley Guidry
- 4Vanderbilt University School of Medicine, Nashville, Tennessee
| | | | - Justin McCroskey
- 8Department of Neurological Surgery, University of Alabama at Birmingham, Alabama
| | - Anastasia Arynchyna
- 8Department of Neurological Surgery, University of Alabama at Birmingham, Alabama
| | - Susan Staulcup
- 7Department of Neurological Surgery, Children's Hospital Colorado, Aurora, Colorado; and
| | - Heidi Chen
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee.,6Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Todd C Hankinson
- 3University of Colorado School of Medicine, Aurora, Colorado.,7Department of Neurological Surgery, Children's Hospital Colorado, Aurora, Colorado; and
| | - Brandon G Rocque
- 8Department of Neurological Surgery, University of Alabama at Birmingham, Alabama
| | - Chevis N Shannon
- 1Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville.,2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Robert Naftel
- 1Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville.,2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
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19
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Li B, Dudley AG, Lauderdale CJ, Shannon CN, Pope JC. Hidden consequences of patient satisfaction: A survey of pediatric surgeons. J Pediatr Surg 2021; 56:1524-1527. [PMID: 33773798 DOI: 10.1016/j.jpedsurg.2021.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 03/07/2021] [Accepted: 03/12/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patient satisfaction surveys are increasingly utilized to assess patients' perceptions of their health care. Recently, these scores have been linked to payment, potentially incentivizing practices to meet certain metrics. We hypothesize that increasing pressures to receive positive reviews have led physicians to alter the delivery of their care to accommodate patient expectations over standards of care. METHODS An 11-question REDCap™ survey was developed and emailed anonymously to all sixty-two surgeons across all surgical subspecialties at our children's hospital. Multiple-choice and open-ended questions were included. A modified Delphi method was used to acquire general consensus. RESULTS Survey response rate for analysis was 41/62 (66%). 23 (56%) stated that they have changed their clinical practice patterns due to concerns regarding patient dissatisfaction. Examples of such changes included: requesting imaging tests or laboratory studies, performing invasive procedures, referring for second opinions, and prescribing medications. Only 2% felt that these interventions led to any significant change in outcome of a patient's condition. Several respondents expressed concerns that factors outside their control (scheduling, parking, wait times) contributed to patient dissatisfaction and affected providers' ratings, while others expressed concerns about inherent biases driving survey participants. CONCLUSIONS As a result of patient satisfaction surveys, a significant number of surgeons reported altering their clinical practice beyond standard care to meet patient expectations. Some of these modifications included performing unnecessary interventions. Reliance on these surveys may be at odds with reducing health care costs and avoiding physician burnout. These and other unintended consequences of patient satisfaction surveys warrant further study before they are widely accepted as appropriate quality metrics. LEVEL OF EVIDENCE Level IV, questionnaire.
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Affiliation(s)
- Belinda Li
- Division of Pediatric Urology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA.
| | - Anne G Dudley
- Division of Pediatric Urology, Connecticut Children's Medical Center, University of Connecticut School of Medicine, Hartford, CT, USA
| | - Chelsea J Lauderdale
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Chevis N Shannon
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - John C Pope
- Division of Pediatric Urology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
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20
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Hale AT, Akinnusotu O, He J, Wang J, Hibshman N, Shannon CN, Naftel RP. Genome-Wide Association Study Identifies Genetic Risk Factors for Spastic Cerebral Palsy. Neurosurgery 2021; 89:435-442. [PMID: 34098570 PMCID: PMC8364821 DOI: 10.1093/neuros/nyab184] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 03/31/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Although many clinical risk factors of spastic cerebral palsy (CP) have been identified, the genetic basis of spastic CP is largely unknown. Here, using whole-genome genetic information linked to a deidentified electronic health record (BioVU) with replication in the UK Biobank and FinnGen, we perform the first genome-wide association study (GWAS) for spastic CP. OBJECTIVE To define the genetic basis of spastic CP. METHODS Whole-genome data were obtained using the multi-ethnic genotyping array (MEGA) genotyping array capturing single-nucleotide polymorphisms (SNPs), minor allele frequency (MAF) > 0.01, and imputation quality score (r2) > 0.3, imputed based on the 1000 genomes phase 3 reference panel. Threshold for genome-wide significance was defined after Bonferroni correction for the total number of SNPs tested (P < 5.0 × 10-8). Replication analysis (defined as P < .05) was performed in the UK Biobank and FinnGen. RESULTS We identify 1 SNP (rs78686911) reaching genome-wide significance with spastic CP. Expression quantitative trait loci (eQTL) analysis suggests that rs78686911 decreases expression of GRIK4, a gene that encodes a high-affinity kainate glutamatergic receptor of largely unknown function. Replication analysis in the UK Biobank and FinnGen reveals additional SNPs in the GRIK4 loci associated with CP. CONCLUSION To our knowledge, we perform the first GWAS of spastic CP. Our study indicates that genetic variation contributes to CP risk.
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Affiliation(s)
- Andrew T Hale
- Vanderbilt University School of Medicine, Medical Scientist Training Program, Nashville, Tennessee, USA
- Surgical Outcomes Center for Kids, Monroe Carell Jr Children's Hospital of Vanderbilt University, Nashville, Tennessee, USA
- Division of Genetic Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Oluwatoyin Akinnusotu
- Surgical Outcomes Center for Kids, Monroe Carell Jr Children's Hospital of Vanderbilt University, Nashville, Tennessee, USA
| | - Jing He
- Department of Bioinformatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Janey Wang
- Department of Bioinformatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Natalie Hibshman
- Surgical Outcomes Center for Kids, Monroe Carell Jr Children's Hospital of Vanderbilt University, Nashville, Tennessee, USA
| | - Chevis N Shannon
- Surgical Outcomes Center for Kids, Monroe Carell Jr Children's Hospital of Vanderbilt University, Nashville, Tennessee, USA
- Division of Pediatric Neurosurgery, Monroe Carell Jr Children's Hospital of Vanderbilt University, Nashville, Tennessee, USA
| | - Robert P Naftel
- Surgical Outcomes Center for Kids, Monroe Carell Jr Children's Hospital of Vanderbilt University, Nashville, Tennessee, USA
- Division of Pediatric Neurosurgery, Monroe Carell Jr Children's Hospital of Vanderbilt University, Nashville, Tennessee, USA
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21
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Strahle JM, Mahaney KB, Morales DM, Buddhala C, Shannon CN, Wellons JC, Kulkarni AV, Jensen H, Reeder RW, Holubkov R, Riva-Cambrin JK, Whitehead WE, Rozzelle CJ, Tamber M, Pollack IF, Naftel RP, Kestle JRW, Limbrick DD. Longitudinal CSF Iron Pathway Proteins in Posthemorrhagic Hydrocephalus: Associations with Ventricle Size and Neurodevelopmental Outcomes. Ann Neurol 2021; 90:217-226. [PMID: 34080727 DOI: 10.1002/ana.26133] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/27/2021] [Accepted: 05/15/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Iron has been implicated in the pathogenesis of brain injury and hydrocephalus after preterm germinal matrix hemorrhage-intraventricular hemorrhage, however, it is unknown how external or endogenous intraventricular clearance of iron pathway proteins affect the outcome in this group. METHODS This prospective multicenter cohort included patients with posthemorrhagic hydrocephalus (PHH) who underwent (1) temporary and permanent cerebrospinal fluid (CSF) diversion and (2) Bayley Scales of Infant Development-III testing around 2 years of age. CSF proteins in the iron handling pathway were analyzed longitudinally and compared to ventricle size and neurodevelopmental outcomes. RESULTS Thirty-seven patients met inclusion criteria with a median estimated gestational age at birth of 25 weeks; 65% were boys. Ventricular CSF levels of hemoglobin, iron, total bilirubin, and ferritin decreased between temporary and permanent CSF diversion with no change in CSF levels of ceruloplasmin, transferrin, haptoglobin, and hepcidin. There was an increase in CSF hemopexin during this interval. Larger ventricle size at permanent CSF diversion was associated with elevated CSF ferritin (p = 0.015) and decreased CSF hemopexin (p = 0.007). CSF levels of proteins at temporary CSF diversion were not associated with outcome, however, higher CSF transferrin at permanent CSF diversion was associated with improved cognitive outcome (p = 0.015). Importantly, longitudinal change in CSF iron pathway proteins, ferritin (decrease), and transferrin (increase) were associated with improved cognitive (p = 0.04) and motor (p = 0.03) scores and improved cognitive (p = 0.04), language (p = 0.035), and motor (p = 0.008) scores, respectively. INTERPRETATION Longitudinal changes in CSF transferrin (increase) and ferritin (decrease) are associated with improved neurodevelopmental outcomes in neonatal PHH, with implications for understanding the pathogenesis of poor outcomes in PHH. ANN NEUROL 2021;90:217-226.
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Affiliation(s)
- Jennifer M Strahle
- Department of Neurosurgery, Washington University St. Louis, St. Louis, MO, USA
| | - Kelly B Mahaney
- Department of Neurosurgery, Stanford University, Palo Alto, CA, USA
| | - Diego M Morales
- Department of Neurosurgery, Washington University St. Louis, St. Louis, MO, USA
| | - Chandana Buddhala
- Department of Neurosurgery, Washington University St. Louis, St. Louis, MO, USA
| | - Chevis N Shannon
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - John C Wellons
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Abhaya V Kulkarni
- Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Hailey Jensen
- Data Coordinating Center, University of Utah, Salt Lake City, UT, USA
| | - Ron W Reeder
- Data Coordinating Center, University of Utah, Salt Lake City, UT, USA
| | - Richard Holubkov
- Data Coordinating Center, University of Utah, Salt Lake City, UT, USA
| | - Jay K Riva-Cambrin
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Curtis J Rozzelle
- Department of Neurosurgery, University of Alabama - Birmingham, Birmingham, AL, USA
| | - Mandeep Tamber
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ian F Pollack
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Robert P Naftel
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - John R W Kestle
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA
| | - David D Limbrick
- Department of Neurosurgery, Washington University St. Louis, St. Louis, MO, USA
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22
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Sadler B, Skidmore A, Gewirtz J, Anderson RCE, Haller G, Ackerman LL, Adelson PD, Ahmed R, Albert GW, Aldana PR, Alden TD, Averill C, Baird LC, Bauer DF, Bethel-Anderson T, Bierbrauer KS, Bonfield CM, Brockmeyer DL, Chern JJ, Couture DE, Daniels DJ, Dlouhy BJ, Durham SR, Ellenbogen RG, Eskandari R, Fuchs HE, George TM, Grant GA, Graupman PC, Greene S, Greenfield JP, Gross NL, Guillaume DJ, Hankinson TC, Heuer GG, Iantosca M, Iskandar BJ, Jackson EM, Jea AH, Johnston JM, Keating RF, Khan N, Krieger MD, Leonard JR, Maher CO, Mangano FT, Mapstone TB, McComb JG, McEvoy SD, Meehan T, Menezes AH, Muhlbauer M, Oakes WJ, Olavarria G, O'Neill BR, Ragheb J, Selden NR, Shah MN, Shannon CN, Smith J, Smyth MD, Stone SSD, Tuite GF, Wait SD, Wellons JC, Whitehead WE, Park TS, Limbrick DD, Strahle JM. Extradural decompression versus duraplasty in Chiari malformation type I with syrinx: outcomes on scoliosis from the Park-Reeves Syringomyelia Research Consortium. J Neurosurg Pediatr 2021:1-9. [PMID: 34144521 DOI: 10.3171/2020.12.peds20552] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 12/03/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Scoliosis is common in patients with Chiari malformation type I (CM-I)-associated syringomyelia. While it is known that treatment with posterior fossa decompression (PFD) may reduce the progression of scoliosis, it is unknown if decompression with duraplasty is superior to extradural decompression. METHODS A large multicenter retrospective and prospective registry of 1257 pediatric patients with CM-I (tonsils ≥ 5 mm below the foramen magnum) and syrinx (≥ 3 mm in axial width) was reviewed for patients with scoliosis who underwent PFD with or without duraplasty. RESULTS In total, 422 patients who underwent PFD had a clinical diagnosis of scoliosis. Of these patients, 346 underwent duraplasty, 51 received extradural decompression alone, and 25 were excluded because no data were available on the type of PFD. The mean clinical follow-up was 2.6 years. Overall, there was no difference in subsequent occurrence of fusion or proportion of patients with curve progression between those with and those without a duraplasty. However, after controlling for age, sex, preoperative curve magnitude, syrinx length, syrinx width, and holocord syrinx, extradural decompression was associated with curve progression > 10°, but not increased occurrence of fusion. Older age at PFD and larger preoperative curve magnitude were independently associated with subsequent occurrence of fusion. Greater syrinx reduction after PFD of either type was associated with decreased occurrence of fusion. CONCLUSIONS In patients with CM-I, syrinx, and scoliosis undergoing PFD, there was no difference in subsequent occurrence of surgical correction of scoliosis between those receiving a duraplasty and those with an extradural decompression. However, after controlling for preoperative factors including age, syrinx characteristics, and curve magnitude, patients treated with duraplasty were less likely to have curve progression than patients treated with extradural decompression. Further study is needed to evaluate the role of duraplasty in curve stabilization after PFD.
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Affiliation(s)
- Brooke Sadler
- 1Department of Pediatrics, Washington University in St. Louis, MO
| | - Alex Skidmore
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Jordan Gewirtz
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | | | - Gabe Haller
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Laurie L Ackerman
- 4Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - P David Adelson
- 5Division of Pediatric Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ
| | - Raheel Ahmed
- 6Department of Neurological Surgery, University of Wisconsin at Madison, WI
| | - Gregory W Albert
- 7Division of Neurosurgery, Arkansas Children's Hospital, Little Rock, AR
| | - Philipp R Aldana
- 8Division of Pediatric Neurosurgery, University of Florida College of Medicine, Jacksonville, FL
| | - Tord D Alden
- 9Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital of Chicago, IL
| | - Christine Averill
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Lissa C Baird
- 10Department of Neurological Surgery and Doernbecher Children's Hospital, Oregon Health & Science University, Portland, OR
| | - David F Bauer
- 11Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, TX
| | - Tammy Bethel-Anderson
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Karin S Bierbrauer
- 12Division of Pediatric Neurosurgery, Cincinnati Children's Medical Center, Cincinnati, OH
| | - Christopher M Bonfield
- 43Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN
| | - Douglas L Brockmeyer
- 13Division of Pediatric Neurosurgery, Primary Children's Hospital, Salt Lake City, UT
| | - Joshua J Chern
- 14Division of Pediatric Neurosurgery, Children's Healthcare of Atlanta, GA
| | - Daniel E Couture
- 15Department of Neurological Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | | | - Brian J Dlouhy
- 39Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Susan R Durham
- 18Department of Neurosurgery, University of Vermont, Burlington, VT
| | | | - Ramin Eskandari
- 20Department of Neurosurgery, Medical University of South Carolina, Charleston, SC
| | | | - Timothy M George
- 22Division of Pediatric Neurosurgery, Dell Children's Medical Center, Austin, TX
| | - Gerald A Grant
- 23Division of Pediatric Neurosurgery, Lucile Packard Children's Hospital and Stanford University School of Medicine, Palo Alto, CA
| | - Patrick C Graupman
- 24Division of Pediatric Neurosurgery, Gillette Children's Hospital, St. Paul, MN
| | - Stephanie Greene
- 25Division of Pediatric Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jeffrey P Greenfield
- 26Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, NY
| | - Naina L Gross
- 27Department of Neurosurgery, University of Oklahoma, Oklahoma City, OK
| | - Daniel J Guillaume
- 28Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, MN
| | - Todd C Hankinson
- 29Department of Neurosurgery, Children's Hospital Colorado, Aurora, CO
| | - Gregory G Heuer
- 30Division of Pediatric Neurosurgery, Children's Hospital of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mark Iantosca
- 31Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, PA
| | - Bermans J Iskandar
- 6Department of Neurological Surgery, University of Wisconsin at Madison, WI
| | - Eric M Jackson
- 32Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew H Jea
- 4Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - James M Johnston
- 33Division of Pediatric Neurosurgery, University of Alabama at Birmingham, AL
| | - Robert F Keating
- 34Department of Neurosurgery, Children's National Medical Center, Washington, DC
| | - Nickalus Khan
- 36Department of Neurosurgery, Le Bonheur Children's Hospital, Memphis, TN
| | - Mark D Krieger
- 37Department of Neurosurgery, Children's Hospital Los Angeles, CA
| | - Jeffrey R Leonard
- 38Division of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, OH
| | - Cormac O Maher
- 3Department of Neurosurgery, University of Michigan School of Medicine, Ann Arbor, MI
| | - Francesco T Mangano
- 12Division of Pediatric Neurosurgery, Cincinnati Children's Medical Center, Cincinnati, OH
| | | | - J Gordon McComb
- 37Department of Neurosurgery, Children's Hospital Los Angeles, CA
| | - Sean D McEvoy
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Thanda Meehan
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Arnold H Menezes
- 39Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Michael Muhlbauer
- 36Department of Neurosurgery, Le Bonheur Children's Hospital, Memphis, TN
| | - W Jerry Oakes
- 33Division of Pediatric Neurosurgery, University of Alabama at Birmingham, AL
| | - Greg Olavarria
- 40Division of Pediatric Neurosurgery, Arnold Palmer Hospital for Children, Orlando, FL
| | - Brent R O'Neill
- 29Department of Neurosurgery, Children's Hospital Colorado, Aurora, CO
| | - John Ragheb
- 41Department of Neurological Surgery, University of Miami School of Medicine, Miami, FL
| | - Nathan R Selden
- 10Department of Neurological Surgery and Doernbecher Children's Hospital, Oregon Health & Science University, Portland, OR
| | - Manish N Shah
- 42Division of Pediatric Neurosurgery, McGovern Medical School, Houston, TX
| | - Chevis N Shannon
- 43Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN
- 47Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN
| | - Jodi Smith
- 4Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Matthew D Smyth
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Scellig S D Stone
- 44Division of Pediatric Neurosurgery, Boston Children's Hospital, Boston, MA
| | - Gerald F Tuite
- 45Department of Neurosurgery, Neuroscience Institute, All Children's Hospital, St. Petersburg, FL
| | - Scott D Wait
- 46Carolina Neurosurgery & Spine Associates, Charlotte, NC; and
| | - John C Wellons
- 43Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN
- 47Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN
| | - William E Whitehead
- 11Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, TX
| | - Tae Sung Park
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - David D Limbrick
- 1Department of Pediatrics, Washington University in St. Louis, MO
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Jennifer M Strahle
- 1Department of Pediatrics, Washington University in St. Louis, MO
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
- 35Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO
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Tang AR, Reynolds RA, Dallas J, Chen H, Vance EH, Bonfield CM, Shannon CN. Admission trends in pediatric isolated linear skull fracture across the United States. J Neurosurg Pediatr 2021:1-13. [PMID: 34087799 DOI: 10.3171/2020.12.peds20659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 12/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Pediatric isolated linear skull fractures commonly result from head trauma and rarely require surgery, yet patients are often admitted to the hospital-a costly care plan. In this study, the authors utilized a national database to investigate trends in admission for skull fractures across the United States. METHODS Children younger than 18 years with isolated linear skull fracture, according to ICD-9 diagnosis codes in the Kids' Inpatient Database of the Healthcare and Utilization Project (HCUP), who presented between 2003 and 2016 were included. HCUP collected data in 2003, 2006, 2009, 2012, and 2016. Children with a depressed skull fracture, multiple traumatic injuries, and acute intracranial findings were excluded. Sample-level data were translated into population-level data by using an HCUP-specific discharge weight. RESULTS Overall, 11,355 patients (64% males) were admitted to 1605 hospitals. National admissions decreased from 3053 patients in 2003 to 1203 in 2016. The mean ± SD age at admission also decreased from 6.3 ± 5.9 years to 1.2 ± 3.0 years (p < 0.001). The proportion of patients in the lowest quartile of median household income increased by 9%, while that in the highest income quartile decreased by 7% (p < 0.001). Admission was generally more common in the summer months (June, July, and August) and on weekdays (68%). The mean ± SD hospital length of stay decreased from 2.0 ± 3.1 days to 1.4 ± 1.4 days between 2003 and 2012, and then increased to 2.1 ± 6.8 days in 2016 (p < 0.001). When adjusted for inflation, the mean total hospital charges increased from $13,099 to $21,204 (p < 0.001). The greatest proportion of admissions was in the South (35%), and the lowest was in the Northeast (17%). The proportion of patients admitted to large hospitals increased (59% to 72%, p < 0.001), which corresponded to a decrease in patients admitted to small hospitals (16% to 9%, p < 0.001). Overall, the total proportion of admissions to rural hospitals decreased by 6%, and that to urban teaching centers increased by 15% (p < 0.001). Since 2003, no child has undergone a neurosurgical procedure or died as an inpatient. CONCLUSIONS This study identified a general nationwide decrease in admissions for pediatric linear isolated skull fracture, but associated costs increased. Admissions became less common at smaller rural hospitals and more common at larger urban teaching hospitals. This patient population required no inpatient neurosurgical intervention after 2003.
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Affiliation(s)
- Alan R Tang
- 1Vanderbilt University School of Medicine, Nashville
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville
| | - Rebecca A Reynolds
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville
- 3Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan Dallas
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville
- 4Department of Neurological Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California; and
| | - Heidi Chen
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville
- 5Department of Biostatistics, Vanderbilt University, Nashville, Tennessee
| | - E Haley Vance
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville
- 3Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christopher M Bonfield
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville
- 3Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chevis N Shannon
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville
- 3Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Kelly KA, Monk S, Koschnitzky JE, Chen H, Shannon CN, Bey A. Differences in health-seeking behaviors by socioeconomic groups among the pediatric hydrocephalus patient population. Interdisciplinary Neurosurgery 2021. [DOI: 10.1016/j.inat.2020.101074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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25
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Hale AT, Riva-Cambrin J, Wellons JC, Jackson EM, Kestle JRW, Naftel RP, Hankinson TC, Shannon CN. Machine learning predicts risk of cerebrospinal fluid shunt failure in children: a study from the hydrocephalus clinical research network. Childs Nerv Syst 2021; 37:1485-1494. [PMID: 33515058 DOI: 10.1007/s00381-021-05061-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 01/22/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE While conventional statistical approaches have been used to identify risk factors for cerebrospinal fluid (CSF) shunt failure, these methods may not fully capture the complex contribution of clinical, radiologic, surgical, and shunt-specific variables influencing this outcome. Using prospectively collected data from the Hydrocephalus Clinical Research Network (HCRN) patient registry, we applied machine learning (ML) approaches to create a predictive model of CSF shunt failure. METHODS Pediatric patients (age < 19 years) undergoing first-time CSF shunt placement at six HCRN centers were included. CSF shunt failure was defined as a composite outcome including requirement for shunt revision, endoscopic third ventriculostomy, or shunt infection within 5 years of initial surgery. Performance of conventional statistical and 4 ML models were compared. RESULTS Our cohort consisted of 1036 children undergoing CSF shunt placement, of whom 344 (33.2%) experienced shunt failure. Thirty-eight clinical, radiologic, surgical, and shunt-design variables were included in the ML analyses. Of all ML algorithms tested, the artificial neural network (ANN) had the strongest performance with an area under the receiver operator curve (AUC) of 0.71. The ANN had a specificity of 90% and a sensitivity of 68%, meaning that the ANN can effectively rule-in patients most likely to experience CSF shunt failure (i.e., high specificity) and moderately effective as a tool to rule-out patients at high risk of CSF shunt failure (i.e., moderately sensitive). The ANN was independently validated in 155 patients (prospectively collected, retrospectively analyzed). CONCLUSION These data suggest that the ANN, or future iterations thereof, can provide an evidence-based tool to assist in prognostication and patient-counseling immediately after CSF shunt placement.
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Affiliation(s)
- Andrew T Hale
- Medical Scientist Training Program, Vanderbilt University School of Medicine, 2200 Pierce Ave., Light Hall 514, Nashville, TN, 37232, USA. .,Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN, USA.
| | - Jay Riva-Cambrin
- Department of Clinical Neurosciences, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - John C Wellons
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN, USA.,Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN, USA
| | - Eric M Jackson
- Department of Neurosurgery, Johns Hopkins Children's Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John R W Kestle
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA
| | - Robert P Naftel
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN, USA.,Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN, USA
| | - Todd C Hankinson
- Division of Pediatric Neurosurgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Chevis N Shannon
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN, USA.,Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN, USA
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Bonfield CM, Shannon CN, Reeder RW, Browd S, Drake J, Hauptman JS, Kulkarni AV, Limbrick DD, McDonald PJ, Naftel R, Pollack IF, Riva-Cambrin J, Rozzelle C, Tamber MS, Whitehead WE, Kestle JRW, Wellons JC. Hydrocephalus treatment in patients with craniosynostosis: an analysis from the Hydrocephalus Clinical Research Network prospective registry. Neurosurg Focus 2021; 50:E11. [PMID: 33794488 DOI: 10.3171/2021.1.focus20979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/06/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Hydrocephalus may be seen in patients with multisuture craniosynostosis and, less commonly, single-suture craniosynostosis. The optimal treatment for hydrocephalus in this population is unknown. In this study, the authors aimed to evaluate the success rate of ventriculoperitoneal shunt (VPS) treatment and endoscopic third ventriculostomy (ETV) both with and without choroid plexus cauterization (CPC) in patients with craniosynostosis. METHODS Utilizing the Hydrocephalus Clinical Research Network (HCRN) Core Data Project (Registry), the authors identified all patients who underwent treatment for hydrocephalus associated with craniosynostosis. Descriptive statistics, demographics, and surgical outcomes were evaluated. RESULTS In total, 42 patients underwent treatment for hydrocephalus associated with craniosynostosis. The median gestational age at birth was 39.0 weeks (IQR 38.0, 40.0); 55% were female and 60% were White. The median age at first craniosynostosis surgery was 0.6 years (IQR 0.3, 1.7), and at the first permanent hydrocephalus surgery it was 1.2 years (IQR 0.5, 2.5). Thirty-three patients (79%) had multiple different sutures fused, and 9 had a single suture: 3 unicoronal (7%), 3 sagittal (7%), 2 lambdoidal (5%), and 1 unknown (2%). Syndromes were identified in 38 patients (90%), with Crouzon syndrome being the most common (n = 16, 42%). Ten patients (28%) received permanent hydrocephalus surgery before the first craniosynostosis surgery. Twenty-eight patients (67%) underwent VPS treatment, with the remaining 14 (33%) undergoing ETV with or without CPC (ETV ± CPC). Within 12 months after initial hydrocephalus intervention, 14 patients (34%) required revision (8 VPS and 6 ETV ± CPC). At the most recent follow-up, 21 patients (50%) required a revision. The revision rate decreased as age increased. The overall infection rate was 5% (VPS 7%, 0% ETV ± CPC). CONCLUSIONS This is the largest prospective study reported on children with craniosynostosis and hydrocephalus. Hydrocephalus in children with craniosynostosis most commonly occurs in syndromic patients and multisuture fusion. It is treated at varying ages; however, most patients undergo surgery for craniosynostosis prior to hydrocephalus treatment. While VPS treatment is performed more frequently, VPS and ETV are both reasonable options, with decreasing revision rates with increasing age, for the treatment of hydrocephalus associated with craniosynostosis.
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Affiliation(s)
| | - Chevis N Shannon
- 1Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Samuel Browd
- 3Department of Neurosurgery, University of Washington, Seattle, Washington
| | - James Drake
- 4Division of Neurosurgery, University of Toronto, Ontario, Canada
| | - Jason S Hauptman
- 3Department of Neurosurgery, University of Washington, Seattle, Washington
| | | | - David D Limbrick
- 5Department of Neurosurgery, Washington University School of Medicine in St. Louis, Missouri
| | - Patrick J McDonald
- 6Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert Naftel
- 1Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ian F Pollack
- 7Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jay Riva-Cambrin
- 8Division of Neurosurgery, University of Calgary, Alberta, Canada
| | - Curtis Rozzelle
- 9Department of Neurosurgery, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama; and
| | - Mandeep S Tamber
- 6Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | - John C Wellons
- 1Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Yengo-Kahn AM, Akinnusotu O, Wiseman AL, Owais Abdul Ghani M, Shannon CN, Golinko MS, Bonfield CM. Sport participation and related head injuries following craniosynostosis correction: a survey study. Neurosurg Focus 2021; 50:E15. [PMID: 33794495 DOI: 10.3171/2021.1.focus20970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 01/14/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Craniosynostosis (CS) affects about 1 in 2500 infants and is predominantly treated by surgical intervention in infancy. Later in childhood, many of these children wish to participate in sports. However, the safety of participation is largely anecdotal and based on surgeon experience. The objective of this survey study was to describe sport participation and sport-related head injury in CS patients. METHODS A 16-question survey related to child/parent demographics, CS surgery history, sport history, and sport-induced head injury history was made available to patients/parents in the United States through a series of synostosis organization listservs, as well as synostosis-focused Facebook groups, between October 2019 and June 2020. Sports were categorized based on the American Academy of Pediatrics groupings. Pearson's chi-square test, Fisher's exact test, and the independent-samples t-test were used in the analysis. RESULTS Overall, 187 CS patients were described as 63% male, 89% White, and 88% non-Hispanic, and 89% underwent surgery at 1 year or younger. The majority (74%) had participated in sports starting at an average age of 5 years (SD 2.2). Of those participating in sports, contact/collision sport participation was most common (77%), and 71% participated in multiple sports. Those that played sports were less frequently Hispanic (2.2% vs 22.9%, p < 0.001) and more frequently had undergone a second surgery (44% vs 25%, p = 0.021). Only 9 of 139 (6.5%) sport-participating CS patients suffered head injuries; 6 (67%) were concussions and the remaining 3 were nondescript but did not mention any surgical needs. CONCLUSIONS In this nationwide survey of postsurgical CS patients and parents, sport participation was exceedingly common, with contact sports being the most common sport category. Few head injuries (mostly concussions) were reported as related to sport participation. Although this is a selective sample of CS patients, the initial data suggest that sport participation, even in contact sports, and typically beginning a few years after CS correction, is safe and commonplace.
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Affiliation(s)
- Aaron M Yengo-Kahn
- Departments of1Neurological Surgery and.,2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt University; and
| | - Oluwatoyin Akinnusotu
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt University; and.,3Meharry Medical College School of Medicine, Nashville, Tennessee
| | - Alyssa L Wiseman
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt University; and
| | - Muhammad Owais Abdul Ghani
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt University; and.,4Plastic Surgery, Vanderbilt University Medical Center
| | - Chevis N Shannon
- Departments of1Neurological Surgery and.,2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt University; and
| | | | - Christopher M Bonfield
- Departments of1Neurological Surgery and.,2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt University; and
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Sadler B, Wilborn J, Antunes L, Kuensting T, Hale AT, Gannon SR, McCall K, Cruchaga C, Harms M, Voisin N, Reymond A, Cappuccio G, Brunetti-Pierri N, Tartaglia M, Niceta M, Leoni C, Zampino G, Ashley-Koch A, Urbizu A, Garrett ME, Soldano K, Macaya A, Conrad D, Strahle J, Dobbs MB, Turner TN, Shannon CN, Brockmeyer D, Limbrick DD, Gurnett CA, Haller G. Rare and de novo coding variants in chromodomain genes in Chiari I malformation. Am J Hum Genet 2021; 108:530-531. [PMID: 33667397 DOI: 10.1016/j.ajhg.2021.01.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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29
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Yahanda AT, Adelson PD, Akbari SHA, Albert GW, Aldana PR, Alden TD, Anderson RCE, Bauer DF, Bethel-Anderson T, Brockmeyer DL, Chern JJ, Couture DE, Daniels DJ, Dlouhy BJ, Durham SR, Ellenbogen RG, Eskandari R, George TM, Grant GA, Graupman PC, Greene S, Greenfield JP, Gross NL, Guillaume DJ, Hankinson TC, Heuer GG, Iantosca M, Iskandar BJ, Jackson EM, Johnston JM, Keating RF, Krieger MD, Leonard JR, Maher CO, Mangano FT, McComb JG, McEvoy SD, Meehan T, Menezes AH, O'Neill BR, Olavarria G, Ragheb J, Selden NR, Shah MN, Shannon CN, Shimony JS, Smyth MD, Stone SSD, Strahle JM, Torner JC, Tuite GF, Wait SD, Wellons JC, Whitehead WE, Park TS, Limbrick DD. Dural augmentation approaches and complication rates after posterior fossa decompression for Chiari I malformation and syringomyelia: a Park-Reeves Syringomyelia Research Consortium study. J Neurosurg Pediatr 2021; 27:459-468. [PMID: 33578390 DOI: 10.3171/2020.8.peds2087] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 08/24/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Posterior fossa decompression with duraplasty (PFDD) is commonly performed for Chiari I malformation (CM-I) with syringomyelia (SM). However, complication rates associated with various dural graft types are not well established. The objective of this study was to elucidate complication rates within 6 months of surgery among autograft and commonly used nonautologous grafts for pediatric patients who underwent PFDD for CM-I/SM. METHODS The Park-Reeves Syringomyelia Research Consortium database was queried for pediatric patients who had undergone PFDD for CM-I with SM. All patients had tonsillar ectopia ≥ 5 mm, syrinx diameter ≥ 3 mm, and ≥ 6 months of postoperative follow-up after PFDD. Complications (e.g., pseudomeningocele, CSF leak, meningitis, and hydrocephalus) and postoperative changes in syrinx size, headaches, and neck pain were compared for autograft versus nonautologous graft. RESULTS A total of 781 PFDD cases were analyzed (359 autograft, 422 nonautologous graft). Nonautologous grafts included bovine pericardium (n = 63), bovine collagen (n = 225), synthetic (n = 99), and human cadaveric allograft (n = 35). Autograft (103/359, 28.7%) had a similar overall complication rate compared to nonautologous graft (143/422, 33.9%) (p = 0.12). However, nonautologous graft was associated with significantly higher rates of pseudomeningocele (p = 0.04) and meningitis (p < 0.001). The higher rate of meningitis was influenced particularly by the higher rate of chemical meningitis (p = 0.002) versus infectious meningitis (p = 0.132). Among 4 types of nonautologous grafts, there were differences in complication rates (p = 0.02), including chemical meningitis (p = 0.01) and postoperative nausea/vomiting (p = 0.03). Allograft demonstrated the lowest complication rates overall (14.3%) and yielded significantly fewer complications compared to bovine collagen (p = 0.02) and synthetic (p = 0.003) grafts. Synthetic graft yielded higher complication rates than autograft (p = 0.01). Autograft and nonautologous graft resulted in equal improvements in syrinx size (p < 0.0001). No differences were found for postoperative changes in headaches or neck pain. CONCLUSIONS In the largest multicenter cohort to date, complication rates for dural autograft and nonautologous graft are similar after PFDD for CM-I/SM, although nonautologous graft results in higher rates of pseudomeningocele and meningitis. Rates of meningitis differ among nonautologous graft types. Autograft and nonautologous graft are equivalent for reducing syrinx size, headaches, and neck pain.
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Affiliation(s)
- Alexander T Yahanda
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - P David Adelson
- 2Division of Pediatric Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ
| | - S Hassan A Akbari
- 3Division of Pediatric Neurosurgery, University of Alabama at Birmingham, AL
| | - Gregory W Albert
- 4Division of Neurosurgery, Arkansas Children's Hospital, Little Rock, AR
| | - Philipp R Aldana
- 5Division of Pediatric Neurosurgery, University of Florida College of Medicine, Jacksonville, FL
| | - Tord D Alden
- 6Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital of Chicago, IL
| | - Richard C E Anderson
- 7Division of Pediatric Neurosurgery, Department of Neurological Surgery, Children's Hospital of New York, Columbia-Presbyterian, New York, NY
| | - David F Bauer
- 8Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Tammy Bethel-Anderson
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Douglas L Brockmeyer
- 9Division of Pediatric Neurosurgery, Primary Children's Hospital, Salt Lake City, UT
| | - Joshua J Chern
- 10Division of Pediatric Neurosurgery, Children's Healthcare of Atlanta, GA
| | - Daniel E Couture
- 11Department of Neurological Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | | | - Brian J Dlouhy
- 13Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Susan R Durham
- 14Department of Neurosurgery, University of Vermont, Burlington, VT
| | | | - Ramin Eskandari
- 16Department of Neurosurgery, Medical University of South Carolina, Charleston, SC
| | - Timothy M George
- 17Division of Pediatric Neurosurgery, Dell Children's Medical Center, Austin, TX
| | - Gerald A Grant
- 18Division of Pediatric Neurosurgery, Lucile Packard Children's Hospital, Palo Alto, CA
| | - Patrick C Graupman
- 19Division of Pediatric Neurosurgery, Gillette Children's Hospital, St. Paul, MN
| | - Stephanie Greene
- 20Division of Pediatric Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jeffrey P Greenfield
- 21Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, NY
| | - Naina L Gross
- 22Department of Neurosurgery, University of Oklahoma, Oklahoma City, OK
| | - Daniel J Guillaume
- 23Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, MN
| | - Todd C Hankinson
- 24Department of Neurosurgery, Children's Hospital Colorado, Aurora, CO
| | - Gregory G Heuer
- 25Division of Pediatric Neurosurgery, Children's Hospital of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mark Iantosca
- 26Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, PA
| | - Bermans J Iskandar
- 27Department of Neurological Surgery, University of Wisconsin at Madison, WI
| | - Eric M Jackson
- 28Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - James M Johnston
- 3Division of Pediatric Neurosurgery, University of Alabama at Birmingham, AL
| | - Robert F Keating
- 29Department of Neurosurgery, Children's National Medical Center, Washington, DC
| | - Mark D Krieger
- 30Division of Pediatric Neurosurgery, Children's Hospital of Los Angeles, CA
| | - Jeffrey R Leonard
- 31Division of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, OH
| | - Cormac O Maher
- 32Department of Neurosurgery, University of Michigan, Ann Arbor, MI
| | - Francesco T Mangano
- 33Division of Pediatric Neurosurgery, Cincinnati Children's Medical Center, Cincinnati, OH
| | - J Gordon McComb
- 30Division of Pediatric Neurosurgery, Children's Hospital of Los Angeles, CA
| | - Sean D McEvoy
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Thanda Meehan
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Arnold H Menezes
- 13Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Brent R O'Neill
- 24Department of Neurosurgery, Children's Hospital Colorado, Aurora, CO
| | - Greg Olavarria
- 34Division of Pediatric Neurosurgery, Arnold Palmer Hospital for Children, Orlando, FL
| | - John Ragheb
- 35Department of Neurological Surgery, University of Miami School of Medicine, Miami, FL
| | - Nathan R Selden
- 36Department of Neurological Surgery and Doernbecher Children's Hospital, Oregon Health & Science University, Portland, OR
| | - Manish N Shah
- 37Division of Pediatric Neurosurgery, McGovern Medical School, Houston, TX
| | - Chevis N Shannon
- 38Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN
| | - Joshua S Shimony
- 39Department of Radiology, Washington University School of Medicine, St. Louis, MO
| | - Matthew D Smyth
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Scellig S D Stone
- 40Division of Pediatric Neurosurgery, Boston Children's Hospital, Boston, MA
| | - Jennifer M Strahle
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - James C Torner
- 13Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Gerald F Tuite
- 41Department of Neurosurgery, Neuroscience Institute, All Children's Hospital, St. Petersburg, FL
| | - Scott D Wait
- 42Carolina Neurosurgery & Spine Associates, Charlotte, NC; and
| | - John C Wellons
- 38Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN
| | - William E Whitehead
- 43Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, TX
| | - Tae Sung Park
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - David D Limbrick
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
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Patel PD, Salwi S, Liles C, Mistry AM, Mistry EA, Fusco MR, Chitale RV, Shannon CN. Creation and Validation of a Stroke Scale to Increase Utility of National Inpatient Sample Administrative Data for Clinical Stroke Research. J Stroke Cerebrovasc Dis 2021; 30:105658. [PMID: 33588186 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105658] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 01/22/2021] [Accepted: 01/30/2021] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION The National Inpatient Sample (NIS) has led to several breakthroughs via large sample size. However, utility of NIS is limited by the lack of admission NIHSS and 90-day modified Rankin score (mRS). This study creates estimates for stroke severity at admission and 90-day mRS using NIS data for acute ischemic stroke (AIS) patients treated with mechanical thrombectomy (MT). METHODS Three patient cohorts undergoing MT for AIS were utilized: Cohort 1 (N = 3729) and Cohort 3 (N = 1642) were derived from NIS data. Cohort 2 (N=293) was derived from a prospectively-maintained clinical registry. Using Cohort 1, Administrative Stroke Outcome Variable (ASOV) was created using disposition and mortality. Factors reflective of stroke severity were entered into a stepwise logistic regression predicting poor ASOV. Odds ratios were used to create the Administrative Data Stroke Scale (ADSS). Performances of ADSS and ASOV were tested using Cohort 2 and compared with admission NIHSS and 90-day mRS, respectively. ADSS performance was compared with All Patient Refined-Diagnosis Related Group (APR-DRG) severity score using Cohort 3. RESULTS Agreement of ASOV with 90-day mRS > 2 was fair (κ = 0.473). Agreement with 90-day mRS > 3 was substantial (κ = 0.687). ADSS significantly correlated (p < 0.001) with clinically-significant admission NIHSS > 15. ADSS performed comparably (AUC = 0.749) to admission NIHSS (AUC = 0.697) in predicting 90-day mRS > 2 and mRS > 3 (AUC = 0.767, 0.685, respectively). ADSS outperformed APR-DRG severity score in predicting poor ASOV (AUC = 0.698, 0.682, respectively). CONCLUSION We developed and validated measures of stroke severity at admission (ADSS) and outcome (ASOV, estimate for 90-day mRS > 3) to increase utility of NIS data in stroke research.
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Affiliation(s)
- Pious D Patel
- Vanderbilt University School of Medicine, Nashville, TN, USA; Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA.
| | - Sanjana Salwi
- Vanderbilt University School of Medicine, Nashville, TN, USA; Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA.
| | - Campbell Liles
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA; Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA.
| | - Akshitkumar M Mistry
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Eva A Mistry
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Matthew R Fusco
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Rohan V Chitale
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Chevis N Shannon
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA; Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA.
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Sadler B, Wilborn J, Antunes L, Kuensting T, Hale AT, Gannon SR, McCall K, Cruchaga C, Harms M, Voisin N, Reymond A, Cappuccio G, Brunetti-Pierri N, Tartaglia M, Niceta M, Leoni C, Zampino G, Ashley-Koch A, Urbizu A, Garrett ME, Soldano K, Macaya A, Conrad D, Strahle J, Dobbs MB, Turner TN, Shannon CN, Brockmeyer D, Limbrick DD, Gurnett CA, Haller G. Rare and de novo coding variants in chromodomain genes in Chiari I malformation. Am J Hum Genet 2021; 108:100-114. [PMID: 33352116 DOI: 10.1016/j.ajhg.2020.12.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 11/24/2020] [Indexed: 12/16/2022] Open
Abstract
Chiari I malformation (CM1), the displacement of the cerebellum through the foramen magnum into the spinal canal, is one of the most common pediatric neurological conditions. Individuals with CM1 can present with neurological symptoms, including severe headaches and sensory or motor deficits, often as a consequence of brainstem compression or syringomyelia (SM). We conducted whole-exome sequencing (WES) on 668 CM1 probands and 232 family members and performed gene-burden and de novo enrichment analyses. A significant enrichment of rare and de novo non-synonymous variants in chromodomain (CHD) genes was observed among individuals with CM1 (combined p = 2.4 × 10-10), including 3 de novo loss-of-function variants in CHD8 (LOF enrichment p = 1.9 × 10-10) and a significant burden of rare transmitted variants in CHD3 (p = 1.8 × 10-6). Overall, individuals with CM1 were found to have significantly increased head circumference (p = 2.6 × 10-9), with many harboring CHD rare variants having macrocephaly. Finally, haploinsufficiency for chd8 in zebrafish led to macrocephaly and posterior hindbrain displacement reminiscent of CM1. These results implicate chromodomain genes and excessive brain growth in CM1 pathogenesis.
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Dallas J, Naftel RP, Shannon CN. Pediatric Intrathecal Baclofen Pumps: A Descriptive Analysis of Hospital Course and Associated Costs. Pediatr Neurosurg 2021; 56:334-344. [PMID: 33965955 DOI: 10.1159/000515988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 03/18/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The purpose of this study was to identify predictors of increased cost and postoperative length-of-stay (LOS) following intrathecal baclofen pump (ITBP) placement. METHODS Patients were derived from the 2009/2012 kids' inpatient database. Inclusion criteria were selected for patients with ICD-9 codes 343.X (infantile cerebral palsy), 86.06 (infusion pump insertion), 03.90 (spinal catheter insertion), and elective hospitalizations. Nonparametric univariate analysis and subsequent gamma log-link general linear modeling were used to identify significant predictors of cost/LOS (p < 0.05). RESULTS 529 unweighted patients (787 with survey weights applied) met criteria. Median LOS was 3.00 days, and median cost was USD 23,284. Following multivariate modeling, predictors of increased LOS (in days) included increased hospital ITBP volume (p = 0.027), small hospital size (+0.55, p = 0.004), device complications (+0.95, p < 0.001), procedural complications (+1.40, p < 0.001), additional procedures (+0.86, p < 0.001), electrolyte abnormalities (+3.74, p < 0.001), and neurological comorbidities (+1.60, p < 0.001). Factors associated with decreased LOS were paralysis (-0.53, p < 0.001), Northeastern hospital region (-0.55, p = 0.018), and investor-owned hospital status (-0.75, p = 0.001). Similarly, predictors of increased cost included race of Hispanic (+USD 1,156, p = 0.033) or "other" (+USD 2,158, p = 0.001), Northeast hospital region (+USD 4,120, p < 0.001), small (+USD 4,139, p < 0.001) or medium (+USD 3,368, p < 0.001) hospital sizes, additional procedures (+USD 1,649, p < 0.001), neurological comorbidities (+USD 3,222, p = 0.003), and increased LOS (p < 0.001). Factors associated with decreased cost included Western hospital region (-USD 1,594, p = 0.001), government hospitals (-USD 1,391, p = 0.019), and investor-owned hospitals (-USD 2,057, p = 0.021). CONCLUSION This study found multiple variables associated with increased cost/LOS following ITBP placement. Broadly, this analysis demonstrates national trends associated with increased cost following ITBP placement.
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Affiliation(s)
- Jonathan Dallas
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.,Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Robert P Naftel
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA.,Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Chevis N Shannon
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA.,Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Hauptman JS, Kestle J, Riva-Cambrin J, Kulkarni AV, Browd SR, Rozzelle CJ, Whitehead WE, Naftel RP, Pindrik J, Limbrick DD, Drake J, Wellons JC, Tamber MS, Shannon CN, Simon TD, Pollack IF, McDonald PJ, Krieger MD, Chu J, Hankinson TC, Jackson EM, Alvey JS, Reeder RW, Holubkov R. Predictors of fast and ultrafast shunt failure in pediatric hydrocephalus: a Hydrocephalus Clinical Research Network study. J Neurosurg Pediatr 2020; 27:277-286. [PMID: 33338993 DOI: 10.3171/2020.7.peds20111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 07/16/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The primary objective of this study was to use the prospective Hydrocephalus Clinical Research Network (HCRN) registry to determine clinical predictors of fast time to shunt failure (≤ 30 days from last revision) and ultrafast time to failure (≤ 7 days from last revision). METHODS Revisions (including those due to infection) to permanent shunt placements that occurred between April 2008 and November 2017 for patients whose entire shunt experience was recorded in the registry were analyzed. All registry data provided at the time of initial shunt placement and subsequent revision were reviewed. Key variables analyzed included etiology of hydrocephalus, age at time of initial shunt placement, presence of slit ventricles on imaging at revision, whether the ventricles were enlarged at the time of revision, and presence of prior fast failure events. Univariable and multivariable analyses were performed to find key predictors of fast and ultrafast failure events. RESULTS A cohort of 1030 patients with initial shunt insertions experienced a total of 1995 revisions. Of the 1978 revision events with complete records, 1216 (61.5%) shunts remained functional for more than 1 year, and 762 (38.5%) failed within 1 year of the procedure date. Of those that failed within 1 year, 423 (55.5%) failed slowly (31-365 days) and 339 (44.5%) failed fast (≤ 30 days). Of the fast failures, 131 (38.6%) were ultrafast (≤ 7 days). In the multivariable analysis specified a priori, etiology of hydrocephalus (p = 0.005) and previous failure history (p = 0.011) were independently associated with fast failure. Age at time of procedure (p = 0.042) and etiology of hydrocephalus (p = 0.004) were independently associated with ultrafast failure. These relationships in both a priori models were supported by the data-driven multivariable models as well. CONCLUSIONS Neither the presence of slit ventricle syndrome nor ventricular enlargement at the time of shunt failure appears to be a significant predictor of repeated, rapid shunt revisions. Age at the time of procedure, etiology of hydrocephalus, and the history of previous failure events seem to be important predictors of fast and ultrafast shunt failure. Further work is required to understand the mechanisms of these risk factors as well as mitigation strategies.
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Affiliation(s)
- Jason S Hauptman
- 1Department of Neurosurgery, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - John Kestle
- 2Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Medical Center, University of Utah, Salt Lake City, Utah
| | - Jay Riva-Cambrin
- 3Department of Neurosurgery, University of Calgary, Alberta, Canada
| | - Abhaya V Kulkarni
- 4Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Samuel R Browd
- 1Department of Neurosurgery, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Curtis J Rozzelle
- 5Section of Pediatric Neurosurgery, Division of Neurosurgery, Children's Hospital of Alabama, University of Alabama-Birmingham, Alabama
| | - William E Whitehead
- 6Division of Pediatric Neurosurgery, Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Robert P Naftel
- 7Division of Pediatric Neurosurgery, Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan Pindrik
- 8Department of Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio
| | - David D Limbrick
- 9Department of Neurosurgery, St. Louis Children's Hospital, Washington University in St. Louis, Missouri
| | - James Drake
- 4Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - John C Wellons
- 7Division of Pediatric Neurosurgery, Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mandeep S Tamber
- 10University of British Columbia Department of Surgery, Division of Neurosurgery, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Chevis N Shannon
- 7Division of Pediatric Neurosurgery, Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tamara D Simon
- 11Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Ian F Pollack
- 12Division of Neurosurgery, Children's Hospital of Pittsburgh, Pennsylvania
| | - Patrick J McDonald
- 10University of British Columbia Department of Surgery, Division of Neurosurgery, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Mark D Krieger
- 13Division of Neurosurgery, Children's Hospital Los Angeles, California
| | - Jason Chu
- 13Division of Neurosurgery, Children's Hospital Los Angeles, California
| | - Todd C Hankinson
- 14Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Colorado School of Medicine, Aurora, Colorado; and
| | - Eric M Jackson
- 15Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jessica S Alvey
- 2Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Medical Center, University of Utah, Salt Lake City, Utah
| | - Ron W Reeder
- 2Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Medical Center, University of Utah, Salt Lake City, Utah
| | - Richard Holubkov
- 2Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Medical Center, University of Utah, Salt Lake City, Utah
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Tamber MS, Kestle JRW, Reeder RW, Holubkov R, Alvey J, Browd SR, Drake JM, Kulkarni AV, Limbrick DD, McDonald PJ, Rozzelle CJ, Simon TD, Naftel R, Shannon CN, Wellons JC, Whitehead WE, Riva-Cambrin J. Temporal trends in surgical procedures for pediatric hydrocephalus: an analysis of the Hydrocephalus Clinical Research Network Core Data Project. J Neurosurg Pediatr 2020; 27:269-276. [PMID: 33338996 DOI: 10.3171/2020.7.peds20142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 07/16/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Analysis of temporal trends in patient populations and procedure types may provide important information regarding the evolution of hydrocephalus treatment. The purpose of this study was to use the Hydrocephalus Clinical Research Network's Core Data Project to identify meaningful trends in patient characteristics and the surgical management of pediatric hydrocephalus over a 9-year period. METHODS The Core Data Project prospectively collected patient and procedural data on the study cohort from 9 centers between 2008 and 2016. Logistic and Poisson regression were used to test for significant temporal trends in patient characteristics and new and revision hydrocephalus procedures. RESULTS The authors analyzed 10,149 procedures in 5541 patients. New procedures for hydrocephalus (shunt or endoscopic third ventriculostomy [ETV]) decreased by 1.5%/year (95% CI -3.1%, +0.1%). During the study period, new shunt insertions decreased by 6.5%/year (95% CI -8.3%, -4.6%), whereas new ETV procedures increased by 12.5%/year (95% CI 9.3%, 15.7%). Revision procedures for hydrocephalus (shunt or ETV) decreased by 4.2%/year (95% CI -5.2%, -3.1%), driven largely by a decrease of 5.7%/year in shunt revisions (95% CI -6.8%, -4.6%). Concomitant with the observed increase in new ETV procedures was an increase in ETV revisions (13.4%/year, 95% CI 9.6%, 17.2%). Because revisions decreased at a faster rate than new procedures, the Revision Quotient (ratio of revisions to new procedures) for the Network decreased significantly over the study period (p = 0.0363). No temporal change was observed in the age or etiology characteristics of the cohort, although the proportion of patients with one or more complex chronic conditions significantly increased over time (p = 0.0007). CONCLUSIONS Over a relatively short period, important changes in hydrocephalus care have been observed. A significant temporal decrease in revision procedures amid the backdrop of a more modest change in new procedures appears to be the most notable finding and may be indicative of an improvement in the quality of surgical care for pediatric hydrocephalus. Further studies will be directed at elucidation of the possible drivers of the observed trends.
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Affiliation(s)
- Mandeep S Tamber
- 1Division of Neurosurgery, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - John R W Kestle
- 2Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Ron W Reeder
- 2Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Richard Holubkov
- 2Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Jessica Alvey
- 2Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Samuel R Browd
- 3Department of Neurological Surgery, Seattle Children's Hospital, Seattle, Washington
| | - James M Drake
- 4Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Abhaya V Kulkarni
- 4Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - David D Limbrick
- 5Department of Neurosurgery, St. Louis Children's Hospital, St. Louis, Missouri
| | - Patrick J McDonald
- 1Division of Neurosurgery, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Curtis J Rozzelle
- 6Department of Neurosurgery, Children's Hospital of Alabama, Birmingham, Alabama
| | - Tamara D Simon
- 3Department of Neurological Surgery, Seattle Children's Hospital, Seattle, Washington
| | - Robert Naftel
- 7Department of Neurological Surgery, Vanderbilt University, Nashville, Tennessee
| | - Chevis N Shannon
- 7Department of Neurological Surgery, Vanderbilt University, Nashville, Tennessee
| | - John C Wellons
- 7Department of Neurological Surgery, Vanderbilt University, Nashville, Tennessee
| | | | - Jay Riva-Cambrin
- 9Department of Clinical Neurosciences, Alberta Children's Hospital, University of Calgary, Alberta, Canada
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Sellyn GE, Tang AR, Zhao S, Sherburn M, Pellegrino R, Gannon SR, Guidry BS, Ladner TR, Wellons JC, Shannon CN. Effectiveness of the Chiari Health Index for Pediatrics instrument in measuring postoperative health-related quality of life in pediatric patients with Chiari malformation type I. J Neurosurg Pediatr 2020; 27:139-144. [PMID: 33276337 DOI: 10.3171/2020.7.peds20250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 07/09/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors' previously published work validated the Chiari Health Index for Pediatrics (CHIP), a new instrument for measuring health-related quality of life (HRQOL) for pediatric Chiari malformation type I (CM-I) patients. In this study, the authors further evaluated the CHIP to assess HRQOL changes over time and correlate changes in HRQOL to changes in symptomatology and radiological factors in CM-I patients who undergo surgical intervention. Strong HRQOL evaluation instruments are currently lacking for pediatric CM-I patients, creating the need for a standardized HRQOL instrument for this patient population. This study serves as the first analysis of the CHIP instrument's effectiveness in measuring short-term HRQOL changes in pediatric CM-I patients and can be a useful tool in future CM-I HRQOL studies. METHODS The authors evaluated prospectively collected CHIP scores and clinical factors of surgical intervention in patients younger than 18 years. To be included, patients completed a baseline CHIP captured during the preoperative visit, and at least 1 follow-up CHIP administered postoperatively. CHIP has 2 domains (physical and psychosocial) comprising 4 components, the 3 physical components of pain frequency, pain severity, and nonpain symptoms, and a single psychosocial component. Each CHIP category is scored on a scale, with 0 indicating absent and 1 indicating present, with higher scores indicating better HRQOL. Wilcoxon paired tests, Spearman correlations, and linear regression models were used to evaluate and correlate HRQOL, symptomatology, and radiographic factors. RESULTS Sixty-three patients made up the analysis cohort (92% Caucasian, 52% female, mean age 11.8 years, average follow-up time 15.4 months). Dural augmentation was performed in 92% of patients. Of the 63 patients, 48 reported preoperative symptoms and 42 had a preoperative syrinx. From baseline, overall CHIP scores significantly improved over time (from 0.71 to 0.78, p < 0.001). Significant improvement in CHIP scores was seen in patients presenting at baseline with neck/back pain (p = 0.015) and headaches (p < 0.001) and in patients with extremity numbness trending at p = 0.064. Patients with syringomyelia were found to have improvement in CHIP scores over time (0.75 to 0.82, p < 0.001), as well as significant improvement in all 4 components. Additionally, improved CHIP scores were found to be significantly associated with age in patients with cervical (p = 0.009) or thoracic (p = 0.011) syrinxes. CONCLUSIONS The study data show that the CHIP is an effective instrument for measuring HRQOL over time. Additionally, the CHIP was found to be significantly correlated to changes in symptomatology, a finding indicating that this instrument is a clinically valuable tool for the management of CM-I.
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Affiliation(s)
- Georgina E Sellyn
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt.,2Vanderbilt University School of Medicine; and.,5Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alan R Tang
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt.,2Vanderbilt University School of Medicine; and
| | - Shilin Zhao
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt.,3Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Madeleine Sherburn
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt.,5Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rachel Pellegrino
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt
| | - Stephen R Gannon
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt.,5Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Bradley S Guidry
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt.,2Vanderbilt University School of Medicine; and
| | - Travis R Ladner
- 4Department of Neurological Surgery, Mt. Sinai Hospital, New York, New York; and
| | - John C Wellons
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt.,5Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chevis N Shannon
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt.,5Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Penzias A, Azziz R, Bendikson K, Falcone T, Hansen K, Hill M, Hurd W, Jindal S, Kalra S, Mersereau J, Racowsky C, Rebar R, Reindollar R, Shannon CN, Steiner A, Stovall D, Tanrikut C, Taylor H, Yauger B. Testing and interpreting measures of ovarian reserve: a committee opinion. Fertil Steril 2020; 114:1151-1157. [DOI: 10.1016/j.fertnstert.2020.09.134] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 09/11/2020] [Indexed: 11/26/2022]
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Patel PD, Vimalathas P, Niu X, Shannon CN, Denny JC, Peterson JF, Chitale RV, Fusco MR. CYP2C19 Loss-of-Function is Associated with Increased Risk of Ischemic Stroke after Transient Ischemic Attack in Intracranial Atherosclerotic Disease. J Stroke Cerebrovasc Dis 2020; 30:105464. [PMID: 33246208 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 10/29/2020] [Accepted: 11/05/2020] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES Intracranial atherosclerotic disease (ICAD) is responsible for 8-10% of acute ischemic strokes, and resistance to antiplatelet therapy is prevalent. CYP2C19 gene loss-of-function (up to 45% of patients) causes clopidogrel resistance. For patients with asymptomatic ICAD and ICAD characterized by transient ischemic attack (TIA), this study measures the effect of CYP2C19 loss-of-function on ischemic stroke risk during clopidogrel therapy. MATERIALS AND METHODS From a deidentified database of medical records, patients were selected with ICD-9/10 code for ICAD, availability of CYP2C19 genotype, clopidogrel exposure, and established patient care. Dual-antiplatelet therapy patients were included. Patients with prior ischemic stroke, other neurovascular condition, intracranial angioplasty/stenting, or observation time <1 month were excluded. Time-to-event analysis using Cox regression was conducted to model first-time ischemic stroke events based on CYP2C19 loss-of-function allele and adjusted for age, gender, race, length of aspirin, length of concurrent antiplatelet/anticoagulant treatment, diabetes, coagulopathy, hypertension, heart disease, atrial fibrillation, and lipid disorder. Subset analyses were performed for asymptomatic and post-TIA subtypes of ICAD. RESULTS A total of 337 patients were included (median age 68, 58% male, 88% Caucasian, 26% CYP2C19 loss-of-function). A total of 161 (47.8%) patients had TIA at time of ICAD diagnosis, while 176 (52.2%) were asymptomatic. First-time ischemic stroke was observed among 20 (12.4%) post-TIA ICAD patients and 17 (9.7%) asymptomatic ICAD patients. Median observation time was 2.82 [IQR 1.13-5.17] years. CYP2C19 loss-of-function allele was associated with ischemic stroke event (HR 2.2, 95% CI 1.1-4.3, p=0.020) after adjustment. Post-TIA ICAD patients had a higher risk of ischemic stroke from CYP2C19 loss-of-function (HR 3.4, 95% CI 1.4-8.2, p=0.006). CONCLUSIONS CYP2C19 loss-of-function was associated with 3-fold increased risk of first-time ischemic stroke for ICAD patients treated with clopidogrel after TIA. This effect was not observed for asymptomatic ICAD. CYP2C19-guided antiplatelet selection may improve stroke prevention in ICAD after TIA.
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Affiliation(s)
- Pious D Patel
- Vanderbilt University School of Medicine, 1161 21st Ave S # D3300, Nashville, TN 37232, United States; Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, United States.
| | - Praveen Vimalathas
- Vanderbilt University School of Medicine, 1161 21st Ave S # D3300, Nashville, TN 37232, United States
| | - Xinnan Niu
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Chevis N Shannon
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, United States; Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Joshua C Denny
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Josh F Peterson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Rohan V Chitale
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Matthew R Fusco
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, United States
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Patel PD, Chotai S, Liles C, Chen H, Shannon CN, Froehler MT, Fusco MR, Chitale RV. Impact of Neurovascular Comorbidities and Complications on Outcomes After Procedural Management of Intracranial Aneurysm: Part 1, Unruptured Intracranial Aneurysm. World Neurosurg 2020; 146:e233-e269. [PMID: 33122142 DOI: 10.1016/j.wneu.2020.10.092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/14/2020] [Accepted: 10/15/2020] [Indexed: 12/01/2022]
Abstract
OBJECTIVE This study investigates the relationship between neurovascular comorbidities and in-hospital complications in determining functional outcome, mortality, length of stay (LOS), and cost of stay. METHODS Patients were identified from the 2012-2015 National Inpatient Sample (NIS) using International Classification of Diseases, Ninth Revision codes for unruptured intracranial aneurysm (UIA) treatment in patients without subarachnoid hemorrhage. In-hospital complications were divided into medical complications, surgical complications, and seizures. Primary outcomes were functional outcome measured by modified Rankin Scale (mRS)-equivalent measure, in-hospital mortality, LOS, and cost. Multivariable logistic regression models were built for mRS-equivalent and in-hospital mortality. Multivariable linear regression models in log scale were built for LOS and cost. RESULTS A total of 7398 procedurally managed patients with UIA were included (median age, 58 years; 75% female; 66% white; 43% private insurance). Higher Neurovascular Comorbidities Index (NCI) was associated with seizure (odds ratio [OR], 1.11 if NCI = 1; OR, 2.49 if NCI = 7; P < 0.001), medical complication (OR, 1.21, NCI = 1; OR, 3.46, NCI = 7; P < 0.001), and surgical complication (OR, 1.25, NCI = 1; OR, 3.47, NCI = 7; P < 0.001). NCI remained significantly predictive of poor mRS-equivalent outcome (OR, 1.20, NCI = 1; OR, 5.79, NCI = 7; P < 0.001), in-hospital mortality (OR, 1.98, NCI = 1; OR, 10.9, NCI = 7; P < 0.001), LOS (coefficient dependent on multiple variables, P < 0.001), and cost (coefficient dependent on multiple variables, P < 0.001) after adjustment. CONCLUSIONS Neurovascular comorbidities are the primary driver of poor mRS-equivalent outcome, in-hospital mortality, higher LOS, and higher cost after procedural treatment of UIA. The conditional event of complication influences patients with fewer comorbidities more so than those with no comorbidities or high comorbidities. It is imperative to precisely account for these factors to optimize targeted resource allocation and increase the value of care for patients with UIA.
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Affiliation(s)
- Pious D Patel
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA; Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA.
| | - Silky Chotai
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Campbell Liles
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Heidi Chen
- Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Chevis N Shannon
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Michael T Froehler
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Matthew R Fusco
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Rohan V Chitale
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
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Chotai S, Patel PD, Liles C, Chen H, Shannon CN, Froehler MT, Chitale RV, Fusco MR. Impact of Neurovascular Comorbidities and Complications on Outcomes After Procedural Management of Intracranial Aneurysm: Part 2, Ruptured Intracranial Aneurysm. World Neurosurg 2020; 146:e270-e312. [PMID: 33470214 DOI: 10.1016/j.wneu.2020.10.091] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/14/2020] [Accepted: 10/15/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE We aim to define the dynamic interplay between neurovascular-specific comorbidities and in-hospital complications on outcomes (functional outcome and mortality), length of stay (LOS), and cost of hospital stay. METHODS The 2012-2015 National Inpatient Sample (NIS) was queried for intracranial aneurysm treatment after subarachnoid hemorrhage using International Classification of Diseases, Ninth Revision codes. Neurovascular comorbidity index (NCI) was aggregated. NIS-Subarachnoid Hemorrhage Severity Score (NIS-SSS) was used as a Hunt-Hess grade proxy. In-hospital complications were medical complications, surgical complications, seizures, and cerebral vasospasm. Outcomes were functional outcome (modified Rankin Scale [mRS]-equivalent measure), in-hospital mortality, LOS, and cost. Multivariable logistic regression models were built for mRS equivalent and in-hospital mortality. Multivariable linear regression models in log scale were built for LOS and cost. RESULTS A total of 5353 patients were included. The median NCI was 4.00 (interquartile range [IQR], 0.00-7.00) and 2882 patients (54%) had in-hospital complication. Higher NCI (odds ratio [OR], 1.13 if NCI = 1; OR, 2.05 if NCI = 7; P < 0.001) was associated with any complication, seizure (OR, 1.11, NCI = 1; OR, 1.60, NCI = 7; P < 0.001), medical complication (OR, 1.18, NCI = 1; OR, 2.50, NCI = 7; P < 0.001), surgical complication (OR, 1.13, NCI = 1; OR, 1.91, NCI = 7; P < 0.001), and cerebral vasospasm (OR, 1.09, NCI = 1; OR, 1.49, NCI = 7; P < 0.001). Patients with higher NCI (OR, 1.06, NCI = 1; OR, 1.95, NCI = 7; P < 0.001) or with in-hospital complication (P < 0.001) had poorer mRS equivalent outcome. Similar trends were observed for other outcomes including in-hospital mortality, LOS, and cost. CONCLUSIONS Neurovascular comorbidities are the primary driver of poor mRS equivalent outcome, in-hospital mortality, higher LOS, and higher cost after ruptured intracranial aneurysm procedural treatment. The conditional event of complication influences patients with moderate comorbidities more so than those with low or high comorbidities.
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Affiliation(s)
- Silky Chotai
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital, Vanderbilt, Nashville, Tennessee, USA
| | - Pious D Patel
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA; Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital, Vanderbilt, Nashville, Tennessee, USA.
| | - Campbell Liles
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital, Vanderbilt, Nashville, Tennessee, USA
| | - Heidi Chen
- Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital, Vanderbilt, Nashville, Tennessee, USA
| | - Chevis N Shannon
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital, Vanderbilt, Nashville, Tennessee, USA
| | - Michael T Froehler
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital, Vanderbilt, Nashville, Tennessee, USA
| | - Rohan V Chitale
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital, Vanderbilt, Nashville, Tennessee, USA
| | - Matthew R Fusco
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital, Vanderbilt, Nashville, Tennessee, USA
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Reynolds RA, Dixon M, Gannon S, Zhao S, Bonfield CM, Naftel RP, Wellons JC, Shannon CN. The interaction between parental concern and socioeconomic status in pediatric hydrocephalus management. J Neurosurg Pediatr 2020; 27:16-22. [PMID: 33035994 DOI: 10.3171/2020.6.peds20191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 06/08/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Parent or guardian involvement is implicit in the care of pediatric patients with hydrocephalus. Some parents and guardians are more engaged than others. The relationship between socioeconomic status (SES), the level of parental concern about their child's hydrocephalus management and future, and overall health status has not been clearly delineated. In this study, the authors sought to clarify this connection using hydrocephalus patient-reported health outcomes. METHODS This cross-sectional study included children with surgically managed hydrocephalus whose parent or guardian completed the validated Hydrocephalus Outcome Questionnaire (HOQ) and Hydrocephalus Concern Questionnaire for parents (HCQ-P) on a return visit to the pediatric neurosurgery clinic at Vanderbilt University Medical Center between 2016 and 2018. Patients were excluded if the questionnaires were not completed in full. The calculated Overall Health Score (OHS) was used to represent the child's global physical, emotional, cognitive, and social health. The HCQ-P was used to assess parental concern about their child. Type of insurance was a proxy for SES. RESULTS The HOQ and HCQ-P were administered and completed in full by 170 patient families. In the cohort, 91% of patients (n = 155) had shunt-treated hydrocephalus, and the remaining patients had undergone endoscopic third ventriculostomy. The mean (± SD) patient age was 12 ± 4 years. Half of the patients were male (n = 90, 53%), and most were Caucasian (n = 134, 79%). One in four patients lived in single-parent homes or with a designated guardian (n = 45, 26%). Public insurance and self-pay accounted for 38% of patients (n = 64), while the remaining 62% had private or military insurance. In general, parents with higher concern about their child's medical condition indicated that their son or daughter had a higher OHS (χ2 = 17.07, p < 0.001). Patients in families with a lower SES did not have different OHSs from those with a higher SES (χ2 = 3.53, p = 0.06). However, parents with a lower SES were more worried about management of their child's hydrocephalus and their child's future success (χ2 = 11.49, p < 0.001). In general, parents were not preoccupied with one particular aspect of their child's hydrocephalus management. CONCLUSIONS More engaged parents, regardless of their family's SES, reported a better OHS for their child. Parents with public or self-paid insurance were more likely to report higher concern about their child's hydrocephalus and future, but this was not associated with a difference in their child's current health status.
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Affiliation(s)
- Rebecca A Reynolds
- 1Department of Neurological Surgery, Division of Pediatric Neurosurgery, and.,2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Makayla Dixon
- 2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
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- 2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shilin Zhao
- 3Department of Biostatistics, Vanderbilt University Medical Center; and
| | - Christopher M Bonfield
- 1Department of Neurological Surgery, Division of Pediatric Neurosurgery, and.,2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert P Naftel
- 1Department of Neurological Surgery, Division of Pediatric Neurosurgery, and.,2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John C Wellons
- 1Department of Neurological Surgery, Division of Pediatric Neurosurgery, and.,2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chevis N Shannon
- 1Department of Neurological Surgery, Division of Pediatric Neurosurgery, and.,2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
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Reynolds RA, Bhebhe A, Garcia RM, Zhao S, Lam S, Sichizya K, Shannon CN. Pediatric hydrocephalus outcomes in Lusaka, Zambia. J Neurosurg Pediatr 2020; 26:624-635. [PMID: 32916646 PMCID: PMC7947024 DOI: 10.3171/2020.5.peds20193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 05/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Hydrocephalus is a global disease that disproportionally impacts low- and middle-income countries. Limited data are available from sub-Saharan Africa. This study aims to be the first to describe pediatric hydrocephalus epidemiology and outcomes in Lusaka, Zambia. METHODS This retrospective cohort study included patients < 18 years of age who underwent surgical treatment for hydrocephalus at Beit-CURE Hospital and the University Teaching Hospital in Lusaka, Zambia, from August 2017 to May 2019. Surgeries included ventriculoperitoneal shunt insertions, revisions, and endoscopic third ventriculostomies (ETVs) with or without choroid plexus cauterization (CPC). A descriptive analysis of patient demographics, clinical presentation, and etiologies was summarized, followed by a multivariable analysis of mortality and 90-day complications. RESULTS A total of 378 patients met the inclusion criteria. The median age at first surgery was 5.5 (IQR 3.1, 12.7) months, and 51% of patients were female (n = 193). The most common presenting symptom was irritability (65%, n = 247), followed by oculomotor abnormalities (54%, n = 204). Postinfectious hydrocephalus was the predominant etiology (65%, n = 226/347), and 9% had a myelomeningocele (n = 32/347). It was the first hydrocephalus surgery for 87% (n = 309) and, of that group, 15% underwent ETV/CPC (n = 45). Severe hydrocephalus was common, with 42% of head circumferences more than 6 cm above the 97th percentile (n = 111). The median follow-up duration was 33 (IQR 4, 117) days. The complication rate was 20% (n = 76), with infection being most common (n = 29). Overall, 7% of the patients died (n = 26). Postoperative complication was significantly associated with mortality (χ2 = 81.2, p < 0.001) with infections and CSF leaks showing the strongest association (χ2 = 14.6 and 15.2, respectively, p < 0.001). On adjusted multivariable analysis, shunt revisions were more likely to have a complication than ETV/CPC or primary shunt insertions (OR 2.45 [95% CI 1.26-4.76], p = 0.008), and the presence of any postoperative complication was the only significant predictor of mortality (OR 42.9 [95% CI 12.3-149.1], p < 0.001). CONCLUSIONS Pediatric postinfectious hydrocephalus is the most common etiology of hydrocephalus in Lusaka, Zambia, which is similar to other countries in sub-Saharan Africa. Most children present late with neglected hydrocephalus. Shunt revision procedures are more prone to complication than ETV/CPC or primary shunt insertion, and postoperative complications represent a significant predictor of mortality in this population.
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Affiliation(s)
- Rebecca A. Reynolds
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Neurological Surgery, University Teaching Hospital, Lusaka, Zambia
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children’s Hospital, Nashville, Tennessee
| | - Arnold Bhebhe
- Department of Neurological Surgery, University Teaching Hospital, Lusaka, Zambia
| | - Roxanna M. Garcia
- Department of Neurological Surgery, Northwestern University, Chicago, Illinois
| | - Shilin Zhao
- Vanderbilt Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sandi Lam
- Department of Neurological Surgery, Northwestern University, Chicago, Illinois
| | - Kachinga Sichizya
- Department of Neurological Surgery, University Teaching Hospital, Lusaka, Zambia
| | - Chevis N. Shannon
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children’s Hospital, Nashville, Tennessee
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Ghani MOA, Foster J, Shannon CN, Bichell DP. Association of chest tube position with phrenic nerve palsy after neonatal and infant cardiac surgery. J Thorac Cardiovasc Surg 2020; 161:1618-1622.e1. [PMID: 32807556 DOI: 10.1016/j.jtcvs.2020.05.121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 05/23/2020] [Accepted: 05/26/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Diaphragm paralysis (DP) complicates the postoperative course of neonates and infants undergoing cardiac surgery. Events causing DP remain poorly understood, and preventive strategies remain elusive. This retrospective cohort analysis aims to test the hypothesis that chest tubes in contact with the phrenic nerve in the pleural apex may cause pressure palsy. METHODS In late 2018, the chest tube positioning strategy was changed so as to avoid a putative "danger zone" configuration, defined as (1) the chest tube looping apicomedially at the level of the second right intercostal space, and (2) wedging of chest tube tip against pericardium. A preintervention and postintervention analysis of 531 patients from 2012 to 2019 was performed to evaluate any association of chest tube position or duration in place with DP. Univariable and multivariable analyses were carried out, with significance set a priori at P < .05. RESULTS The preintervention group comprised 488 patients, of whom 32 (6.6%) had RDP. The postintervention group comprised 43 patients, none of whom had DP. Multivariable analysis of the entire cohort revealed chest tube positioning in the danger zone as the only significant association with RDP (odds ratio, 4.22; 95% confidence interval, 1.57-11.33; P < .05). CONCLUSIONS Chest tubes that occupy the right superior pleural space are associated with increased risk of DP.
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Affiliation(s)
- Muhammad Owais Abdul Ghani
- Division of Pediatric Cardiac Surgery, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tenn; Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tenn
| | - Jarrett Foster
- Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tenn
| | - Chevis N Shannon
- Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tenn
| | - David P Bichell
- Division of Pediatric Cardiac Surgery, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tenn; Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tenn.
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Ghani MOA, Raees MA, Harris GR, Shannon CN, Nicholson GT, Bichell DP. Reintervention After Infant Aortic Arch Repair Using a Tailored Autologous Pericardial Patch. Ann Thorac Surg 2020; 111:973-979. [PMID: 32512001 DOI: 10.1016/j.athoracsur.2020.04.091] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/10/2020] [Accepted: 04/16/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Aortic arch reobstruction is a common complication after aortic repair, with rates of reintervention varying from 0% to 40%, depending on the disease and the institution. This study aimed to determine the reintervention rate in children undergoing aortic arch repair using a tailored autologous pericardial patch at our center (Monroe Carell, Jr Children's Hospital at Vanderbilt, Nashville, TN). METHODS This retrospective study examined all patients operated on by a single surgeon for aortic arch reconstruction through sternotomy, from 2011 to 2018, with 1 year of follow-up. Our data set was analyzed for normality by using the Shapiro-Wilk test, and nonparametric statistical methods were used. Kaplan-Meier survival analysis was performed, IBM SPSS software version 23 was used to perform all statistical analysis. RESULTS A total of 171 patients met inclusion criteria. Twenty-three (13.5%) patients underwent aortic arch reinterventions during the study period, 17 (9.9%) catheter based and 3 (1.8%) surgical. Three patients (1.8%) had both. Freedom from reintervention at 1-year follow-up for the univentricular and biventricular patients was 82.1% and 89.4% (P = .174), respectively. To assess the growth of the aortic arch over time, cardiac catheterization measurements were used to index different parts of the aortic arch against the descending aorta. Ascending-to-descending aortic arch measurements revealed that the pre-Glenn median was 2.0 (interquartile range, 1.8 to 2.2), whereas the pre-Fontan median was 2.5 (interquartile range, 2.2 to 2.7) (P < .05). CONCLUSIONS There was no significant difference in reintervention rates between biventricular and univentricular arches, and catheterization measurements showed significant growth of the arch over time. The use of a tailored autologous pericardial patch for aortic arch repair is comparable to other reported methods of arch repair.
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Affiliation(s)
- Muhammad Owais Abdul Ghani
- Division of Pediatric Cardiac Surgery, Monroe Carell, Jr Children's Hospital at Vanderbilt, Nashville, Tennessee; Surgical Outcomes Center for Kids, Monroe Carell, Jr Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Muhammad Aanish Raees
- Division of Pediatric Cardiac Surgery, Monroe Carell, Jr Children's Hospital at Vanderbilt, Nashville, Tennessee; Surgical Outcomes Center for Kids, Monroe Carell, Jr Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Glenn R Harris
- Surgical Outcomes Center for Kids, Monroe Carell, Jr Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Chevis N Shannon
- Surgical Outcomes Center for Kids, Monroe Carell, Jr Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - George T Nicholson
- Division of Pediatric Cardiology, Monroe Carell, Jr Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - David P Bichell
- Division of Pediatric Cardiac Surgery, Monroe Carell, Jr Children's Hospital at Vanderbilt, Nashville, Tennessee.
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Foster J, Ahluwalia R, Sherburn M, Kelly K, Sellyn GE, Kiely C, Wiseman AL, Gannon S, Shannon CN, Bonfield CM. Pediatric cranial deformations: demographic associations. J Neurosurg Pediatr 2020; 26:415-420. [PMID: 32470930 DOI: 10.3171/2020.3.peds2085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 03/31/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE No study has established a relationship between cranial deformations and demographic factors. While the connection between the Back to Sleep campaign and cranial deformation has been outlined, considerations toward cultural or anthropological differences should also be investigated. METHODS The authors conducted a retrospective review of 1499 patients (age range 2 months to less than 19 years) who presented for possible trauma in 2018 and had a negative CT scan. The cranial vault asymmetry index (CVAI) and cranial index (CI) were used to evaluate potential cranial deformations. The cohort was evaluated for differences between sex, race, and ethnicity among 1) all patients and 2) patients within the clinical treatment window (2-24 months of age). Patients categorized as "other" and those for whom data were missing were excluded from analysis. RESULTS In the CVAI cohort with available data (n = 1499, although data were missing for each variable), 800 (56.7%) of 1411 patients were male, 1024 (79%) of 1304 patients were Caucasian, 253 (19.4%) of 1304 patients were African American, and 127 (10.3%) of 1236 patients were of Hispanic/Latin American descent. The mean CVAI values were significantly different between sex (p < 0.001) and race (p < 0.001). However, only race was associated with differences in positional posterior plagiocephaly (PPP) diagnosis (p < 0.001). There was no significant difference in CVAI measurements for ethnicity (p = 0.968). Of the 520 patients in the treatment window cohort, 307 (59%) were male. Of the 421 patients with data for race, 334 were Caucasian and 80 were African American; 47 of the 483 patients with ethnicity data were of Hispanic/Latin American descent. There were no differences between mean CVAI values for sex (p = 0.404) or ethnicity (p = 0.600). There were significant differences between the mean CVAI values for Caucasian and African American patients (p < 0.001) and rate of PPP diagnosis (p = 0.02). In the CI cohort with available data (n = 1429, although data were missing for each variable), 849 (56.8%) of 1494 patients were male, 1007 (67.4%) of 1283 were Caucasian, 248 (16.6%) of 1283 were African American, and 138 patients with ethnicity data (n = 1320) of Hispanic/Latin American descent. Within the clinical treatment window cohort with available data, 373 (59.2%) of 630 patients were male, 403 were Caucasian (81.9%), 84 were African American (17.1%), and 55 (10.5%) of 528 patients were of Hispanic/Latin American descent. The mean CI values were not significantly different between sexes (p = 0.450) in either cohort. However, there were significant differences between CI measurements for Caucasian and African American patients (p < 0.001) as well as patients of Hispanic/Latin American descent (p < 0.001) in both cohorts. CONCLUSIONS The authors found no significant associations between cranial deformations and sex. However, significant differences exist between Caucasian and African American patients as well as patients with Hispanic/Latin American heritage. These findings suggest cultural or anthropological influences on defining skull deformations. Further investigation into the factors contributing to these differences should be undertaken.
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Affiliation(s)
- Jarrett Foster
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee.,2University of South Carolina School of Medicine, Columbia, South Carolina
| | - Ranbir Ahluwalia
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee.,3Florida State University College of Medicine, Tallahassee, Florida
| | - Madeleine Sherburn
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Katherine Kelly
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee.,6Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Georgina E Sellyn
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Chelsea Kiely
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee.,4Department of Neurobiology, Cornell University, Ithaca, New York
| | - Alyssa L Wiseman
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Stephen Gannon
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Chevis N Shannon
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee.,5Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | - Christopher M Bonfield
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee.,5Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; and
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Ahluwalia R, Foster J, Brooks E, Lim J, Zhao S, Gannon SR, Guidry B, Wellons J, Shannon CN. Chiari type I malformation: role of the Chiari Severity Index and Chicago Chiari Outcome Scale. J Neurosurg Pediatr 2020; 26:262-268. [PMID: 32442974 DOI: 10.3171/2020.2.peds19770] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 02/25/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors aimed to determine whether the Chiari Severity Index (CSI), and other clinical variables, can be used as a predictor of postoperative outcomes for Chiari type I malformation (CM-I) using the modified Chicago Chiari Outcome Scale (mCCOS) as the postoperative measure. METHODS The cohort included patients 18 years of age and younger who were treated for CM-I between 2010 and 2015 who had at least 12 months of clinical and radiographic follow-up. CSI grades were assigned using preoperative clinical and neuroimaging data. Clinical, radiographic, and operative data were obtained from medical records. Kruskal-Wallis tests and Spearman correlations were conducted to assess for differences among CSI grades. Linear and ordinal regressions were conducted to evaluate predictors of the mCCOS and its components. Statistical significance was set a priori at p < 0.05. RESULTS A total of 65 patients were included in the final cohort. The average age at the time of surgery and the mean mCCOS score were 9.8 ± 4.9 years and 10.4 ± 1.4, respectively. There were no significant differences in the mean mCCOS scores or CSI grades. Pre- and postoperative syrinx sizes were similar across the total patient cohort with median sizes of 7.4 and 3.7 mm, respectively. After controlling for age at the time of surgery, whether duraplasty and/or arachnoid dissection was performed, CSI preoperative score did not predict postoperative mCCOS score. No clinical variable could predict total mCCOS score. When the mCCOS was broken down into 3 subcomponents (pain, non-pain, and complications), only one relationship was identified. Those patients who presented with no headache had a statistically significant decrease in their pain (neck pain, shoulder pain, or dysesthesia in the upper extremities) as measured by the pain component of the mCCOS (χ2 [2, n = 20] = 6.43, p = 0.04). All other preclinical predictors, including CSI grades, were nonsignificant in demonstrating correlations to the mCCOS subcomponents. CONCLUSIONS CSI grade was not found to be a marker of surgical outcome as measured by the mCCOS in this study. There were no correlations between the clinical variables and covariates investigated with the mCCOS. The lack of variation in mCCOS scores across this cohort may suggest that the mCCOS is not adequate for detecting differences in postsurgical outcomes. Further investigation is warranted to make this determination.
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Affiliation(s)
- Ranbir Ahluwalia
- 1Surgical Outcome Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee.,2Florida State University College of Medicine, Tallahassee, Florida
| | - Jarrett Foster
- 1Surgical Outcome Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee.,3University of South Carolina School of Medicine, Columbia, South Carolina
| | - Earllondra Brooks
- 1Surgical Outcome Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee.,4Department of Neurology, Harvard Brigham and Women's Hospital/Massachusetts General Hospital, Boston, Massachusetts
| | - Jaims Lim
- 1Surgical Outcome Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee.,5Department of Neurological Surgery, University at Buffalo, New York
| | - Shilin Zhao
- 1Surgical Outcome Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Stephen R Gannon
- 1Surgical Outcome Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Bradley Guidry
- 6Vanderbilt University School of Medicine, Nashville, Tennessee; and
| | - John Wellons
- 1Surgical Outcome Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee.,7Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chevis N Shannon
- 1Surgical Outcome Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee.,7Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Kelly KA, Sherburn MM, Sellyn GE, Ahluwalia R, Foster J, Shannon CN, Bonfield CM. Management of Suprasellar Arachnoid Cysts in Children: A Systematic Literature Review Highlighting Modern Endoscopic Approaches. World Neurosurg 2020; 141:e316-e323. [PMID: 32445899 DOI: 10.1016/j.wneu.2020.05.122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/12/2020] [Accepted: 05/13/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Suprasellar arachnoid cysts are a rare but important pediatric neurosurgical pathology with unknown ideal management. They have been previously managed with techniques including open craniotomy with microsurgical fenestration, cystoperitoneal shunting, endoscopic ventriculocystostomy, and endoscopic ventriculocystocisternostomy (VCC), without a consistent consensus on the best surgical approach. We present an overview of the literature on surgical management of suprasellar arachnoid cysts. METHODS A literature search following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted for all articles evaluating treatment modalities for suprasellar arachnoid cysts, using PubMed, OVID, and Web of Science. RESULTS Twenty-five articles on management of suprasellar arachnoid cysts in children were identified. Few published studies exist that examine different types of surgical management across a single institution. The majority of studies reported best clinical outcomes in patients treated with endoscopic approaches when compared with microsurgical fenestration or cystoperitoneal shunting, reporting lower rates of infection, shunt dependence, and need for revision in addition to better resolution of clinical symptoms. Furthermore, most studies argue that VCC is superior to ventriculocystostomy, offering better long-term improvement of clinical symptoms and lower rates of failure. CONCLUSIONS This study examines the current literature on suprasellar arachnoid cyst surgical management to conclude that an endoscopic approach in comparison with other approaches has the best outcomes. Of the endoscopic options available, VCC provides patients with the best long-term resolution of symptoms and the lowest need for revision. These findings should be further investigated with larger multicenter studies to further compare different surgical techniques and outcomes.
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Affiliation(s)
- Katherine A Kelly
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA; Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
| | - Madeleine M Sherburn
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Georgina E Sellyn
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Ranbir Ahluwalia
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA; Florida State University College of Medicine, Tallahassee, Florida, USA
| | - Jarrett Foster
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA; University of South Carolina School of Medicine, Columbia, South Carolina, USA
| | - Chevis N Shannon
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA; Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christopher M Bonfield
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA; Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Dewan MC, Dallas J, Zhao S, Smith BP, Gannon S, Dawoud F, Chen H, Shannon CN, Rocque BG, Naftel RP. Cerebrospinal fluid alterations following endoscopic third ventriculostomy with choroid plexus cauterization: a retrospective laboratory analysis of two tertiary care centers. Childs Nerv Syst 2020; 36:1017-1024. [PMID: 31781913 DOI: 10.1007/s00381-019-04415-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 10/10/2019] [Indexed: 11/28/2022]
Abstract
PURPOSE This study sought to determine the previously undescribed cytologic and metabolic alterations that accompany endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC). METHODS Cerebrospinal fluid (CSF) samples were collected from infant patients with hydrocephalus at the time of index ETV/CPC and again at each reintervention for persistent hydrocephalus. Basic CSF parameters, including glucose, protein, and cell counts, were documented. A multivariable regression model, incorporating known predictors of ETV/CPC outcome, was constructed for each parameter to inform time-dependent normative values. RESULTS A total of 187 infants were treated via ETV/CPC for hydrocephalus; initial laboratory values were available for 164 patients. Etiology of hydrocephalus included myelomeningocele (53, 32%), intraventricular hemorrhage of prematurity (43, 26%), aqueductal stenosis (24, 15%), and others (44, 27%). CSF parameters did not differ significantly with age or etiology. Glucose levels initially drop below population average (36 to 32 mg/dL) post-operatively before slowly rising to normal levels (42 mg/dL) by 3 months. Dramatically elevated protein levels post-ETV/CPC (baseline of 59 mg/dL up to roughly 200 mg/dL at 1 month) also normalized over 3 months. No significant changes were appreciated in WBC. RBC counts were very elevated following ETV/CPC and quickly declined over the subsequent month. CONCLUSION CSF glucose and protein deviate significantly from normal ranges following ETV/CPC before normalizing over 3 months. High RBC values immediately post-ETV/CPC decline rapidly. Age at time of procedure and etiology have little influence on common clinical CSF laboratory parameters. Of note, the retrospective study design necessitates ETV/CPC failure, which could introduce bias in the results.
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Affiliation(s)
- Michael C Dewan
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan Dallas
- School of Medicine, Vanderbilt University, 2209 Garland Avenue, Nashville, TN, 37240, USA.
| | - Shilin Zhao
- Department of Biostatistics, Vanderbilt University, Nashville, TN, USA
| | - Burkely P Smith
- Department of General Surgery, University of Alabama-Birmingham, Birmingham, AL, USA
| | - Stephen Gannon
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Fakhry Dawoud
- Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Heidi Chen
- Department of Biostatistics, Vanderbilt University, Nashville, TN, USA
| | - Chevis N Shannon
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Brandon G Rocque
- Department of Neurosurgery, University of Alabama-Birmingham, Birmingham, AL, USA
| | - Robert P Naftel
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
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Ahluwalia R, Foster J, Sherburn MM, Sellyn GE, Kelly KA, Abdul Ghani MO, Wiseman AL, Shannon CN, Bonfield CM. Deformational brachycephaly: the clinical utility of the cranial index. J Neurosurg Pediatr 2020; 26:122-126. [PMID: 32357338 DOI: 10.3171/2020.2.peds19767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 02/18/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The incidence of deformational brachycephaly has risen since the "Back to Sleep" movement in 1992 by the American Academy of Pediatrics. Brachycephaly prevalence and understanding the dynamic nature of the pediatric skull have not been explored in relation to the cranial index (CI). The objective of the study was to determine the prevalence of brachycephaly, via the CI, with respect to time. METHODS The authors conducted a retrospective review of 1499 patients ≤ 19 years of age who presented for trauma evaluation with a negative CT scan for trauma (absence of bleed) in 2018. The CI was calculated using CT at the lateral-most point of the parietal bone (cephalic width), and the distance from the glabella to the opisthocranion (cephalic length). Brachycephaly was defined as a CI ≥ 90%. RESULTS The mean CI was 82.6, with an average patient age of 6.8 years. The prevalence of deformational brachycephaly steadily decreased from 27% to 4% from birth to > 2 years of life. The mean CI was statistically different between ages < 12 months, 12-24 months, and > 24 months (F[2,1496] = 124.058, p < 0.0005). A simple linear regression was calculated to predict the CI based on age; the CI was found to decrease by 0.038 each month. A significant regression equation was found (F[1,1497] = 296.846, p < 0.0005), with an R2 of 0.140. CONCLUSIONS The incidence of deformational brachycephaly is common in infants but decreases as the child progresses through early childhood. Clinicians can expect a significant decrease in mean CI at 12 and 24 months. Additionally, these regression models show that clinicians can expect continued improvement throughout childhood.
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Affiliation(s)
- Ranbir Ahluwalia
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee.,2Florida State University College of Medicine, Tallahassee, Florida
| | - Jarrett Foster
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee.,3University of South Carolina School of Medicine, Columbia, South Carolina; and
| | - Madeleine M Sherburn
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Georgina E Sellyn
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Katherine A Kelly
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee.,4Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Muhammad Owais Abdul Ghani
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Alyssa L Wiseman
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Chevis N Shannon
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee.,4Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christopher M Bonfield
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee.,4Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Chotai S, Chan EW, Ladner TR, Hale AT, Gannon SR, Shannon CN, Bonfield CM, Naftel RP, Wellons JC. Timing of syrinx reduction and stabilization after posterior fossa decompression for pediatric Chiari malformation type I. J Neurosurg Pediatr 2020; 26:193-199. [PMID: 32330878 DOI: 10.3171/2020.2.peds19366] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 02/18/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to determine the timeline of syrinx regression and to identify factors mitigating syrinx resolution in pediatric patients with Chiari malformation type I (CM-I) undergoing posterior fossa decompression (PFD). METHODS The authors conducted a retrospective review of records from pediatric patients (< 18 years old) undergoing PFD for the treatment of CM-I/syringomyelia (SM) between 1998 and 2015. Patient demographic, clinical, radiological, and surgical variables were collected and analyzed. Radiological information was reviewed at 4 time points: 1) pre-PFD, 2) within 6 months post-PFD, 3) within 12 months post-PFD, and 4) at maximum available follow-up. Syrinx regression was defined as ≥ 50% decrease in the maximal anteroposterior syrinx diameter (MSD). The time to syrinx regression was determined using Kaplan-Meier analysis. Multivariate analysis was conducted using a Cox proportional hazards model to determine the association between preoperative, clinical, and surgery-related factors and syrinx regression. RESULTS The authors identified 85 patients with CM-I/SM who underwent PFD. Within 3 months post-PFD, the mean MSD regressed from 8.1 ± 3.4 mm (preoperatively) to 5.6 ± 2.9 mm within 3 months post-PFD. Seventy patients (82.4%) achieved ≥ 50% regression in MSD. The median time to ≥ 50% regression in MSD was 8 months (95% CI 4.2-11.8 months). Using a risk-adjusted multivariable Cox proportional hazards model, the patients who underwent tonsil coagulation (n = 20) had a higher likelihood of achieving ≥ 50% syrinx regression in a shorter time (HR 2.86, 95% CI 1.2-6.9; p = 0.02). Thirty-six (75%) of 45 patients had improvement in headache at 2.9 months (IQR 1.5-4.4 months). CONCLUSIONS The maximum reduction in syrinx size can be expected within 3 months after PFD for patients with CM-I and a syrinx; however, the syringes continue to regress over time. Tonsil coagulation was associated with early syrinx regression in this cohort. However, the role of surgical maneuvers such as tonsil coagulation and arachnoid veil identification and sectioning in the overall role of CM-I surgery remains unclear.
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Affiliation(s)
- Silky Chotai
- 1Department of Neurosurgery, Vanderbilt University Medical Center.,2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Emily W Chan
- 2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Travis R Ladner
- 2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee.,3Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Andrew T Hale
- 2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stephen R Gannon
- 2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chevis N Shannon
- 1Department of Neurosurgery, Vanderbilt University Medical Center.,2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee.,4Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christopher M Bonfield
- 1Department of Neurosurgery, Vanderbilt University Medical Center.,2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee.,4Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert P Naftel
- 1Department of Neurosurgery, Vanderbilt University Medical Center.,2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee.,4Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John C Wellons
- 1Department of Neurosurgery, Vanderbilt University Medical Center.,2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee.,4Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
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Strahle JM, Taiwo R, Averill C, Torner J, Gewirtz JI, Shannon CN, Bonfield CM, Tuite GF, Bethel-Anderson T, Anderson RCE, Kelly MP, Shimony JS, Dacey RG, Smyth MD, Park TS, Limbrick DD. Radiological and clinical associations with scoliosis outcomes after posterior fossa decompression in patients with Chiari malformation and syrinx from the Park-Reeves Syringomyelia Research Consortium. J Neurosurg Pediatr 2020; 26:53-59. [PMID: 32276246 DOI: 10.3171/2020.1.peds18755] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 01/07/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In patients with Chiari malformation type I (CM-I) and a syrinx who also have scoliosis, clinical and radiological predictors of curve regression after posterior fossa decompression are not well known. Prior reports indicate that age younger than 10 years and a curve magnitude < 35° are favorable predictors of curve regression following surgery. The aim of this study was to determine baseline radiological factors, including craniocervical junction alignment, that might predict curve stability or improvement after posterior fossa decompression. METHODS A large multicenter retrospective and prospective registry of pediatric patients with CM-I (tonsils ≥ 5 mm below the foramen magnum) and a syrinx (≥ 3 mm in width) was reviewed for clinical and radiological characteristics of CM-I, syrinx, and scoliosis (coronal curve ≥ 10°) in patients who underwent posterior fossa decompression and who also had follow-up imaging. RESULTS Of 825 patients with CM-I and a syrinx, 251 (30.4%) were noted to have scoliosis present at the time of diagnosis. Forty-one (16.3%) of these patients underwent posterior fossa decompression and had follow-up imaging to assess for scoliosis. Twenty-three patients (56%) were female, the mean age at time of CM-I decompression was 10.0 years, and the mean follow-up duration was 1.3 years. Nine patients (22%) had stable curves, 16 (39%) showed improvement (> 5°), and 16 (39%) displayed curve progression (> 5°) during the follow-up period. Younger age at the time of decompression was associated with improvement in curve magnitude; for those with curves of ≤ 35°, 17% of patients younger than 10 years of age had curve progression compared with 64% of those 10 years of age or older (p = 0.008). There was no difference by age for those with curves > 35°. Tonsil position, baseline syrinx dimensions, and change in syrinx size were not associated with the change in curve magnitude. There was no difference in progression after surgery in patients who were also treated with a brace compared to those who were not treated with a brace for scoliosis. CONCLUSIONS In this cohort of patients with CM-I, a syrinx, and scoliosis, younger age at the time of decompression was associated with improvement in curve magnitude following surgery, especially in patients younger than 10 years of age with curves of ≤ 35°. Baseline tonsil position, syrinx dimensions, frontooccipital horn ratio, and craniocervical junction morphology were not associated with changes in curve magnitude after surgery.
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Affiliation(s)
- Jennifer M Strahle
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Rukayat Taiwo
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Christine Averill
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - James Torner
- 2Department of Epidemiology, University of Iowa, Iowa City, Iowa
| | - Jordan I Gewirtz
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Chevis N Shannon
- 3Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christopher M Bonfield
- 3Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gerald F Tuite
- 4Department of Neurosurgery, Neuroscience Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Tammy Bethel-Anderson
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Richard C E Anderson
- 6Department of Neurological Surgery, Columbia University College of Physicians and Surgeons, New York, New York; and
| | - Michael P Kelly
- 7Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Joshua S Shimony
- 5Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Ralph G Dacey
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Matthew D Smyth
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Tae Sung Park
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - David D Limbrick
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
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