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Mueller KB, Hou Y, Beach K, Griffin LP. Development and validation of a point-of-care clinical risk score to predict surgical site complication-associated readmissions following open spine surgery. J Spine Surg 2024; 10:40-54. [PMID: 38567014 PMCID: PMC10982919 DOI: 10.21037/jss-23-89] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 11/21/2023] [Indexed: 04/04/2024]
Abstract
Background Surgical site complications (SSCs) contribute to increased healthcare costs. Predictive analytics can aid in identifying high-risk patients and implementing optimization strategies. This study aimed to develop and validate a risk-assessment score for SSC-associated readmissions (SSC-ARs) in patients undergoing open spine surgery. Methods The Premier Healthcare Database (PHD) of adult patients (n=157,664; 3,182 SSC-ARs) between January 2019 and September 2020 was used for retrospective data analysis to create an SSC risk score using mixed effects logistic regression modeling. Full and reduced models were developed using patient-, facility-, or procedure-related predictors. The full model used 37 predictors and the reduced used 19. Results The reduced model exhibited fair discriminatory capability (C-statistic =74.12%) and demonstrated better model fit [Pearson chi-square/degrees of freedom (DF) =0.93] compared to the full model (C-statistic =74.56%; Pearson chi-square/DF =0.92). The risk scoring system, based on the reduced model, comprised the following factors: female (1 point), blood disorder [2], congestive heart failure [2], dementia [3], chronic pulmonary disease [2], rheumatic disease [3], hypertension [2], obesity [2], severe comorbidity [2], nicotine dependence [1], liver disease [2], paraplegia and hemiplegia [3], peripheral vascular disease [2], renal disease [2], cancer [1], diabetes [2], revision surgery [2], operative hours ≥5 [4], emergency/urgent surgery [2]. A final risk score (sum of the points for each surgery; range, 0-40) was validated using a 1,000-surgery random hold-out sample (C-statistic =85.16%). Conclusions The resulting SSC-AR risk score, composed of readily obtainable clinical information, could serve as a robust predictive tool for unplanned readmissions related to wound complications in the preoperative setting of open spine surgery.
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Affiliation(s)
- Kyle B. Mueller
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Mueller KB. Reply to the letter to the editor regarding: development and validation of a point-of-care clinical risk score to predict surgical site infection following open spinal fusion by Mueller et al. N Am Spine Soc J 2023; 14:100220. [PMID: 37229210 PMCID: PMC10205479 DOI: 10.1016/j.xnsj.2023.100220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 04/10/2023] [Accepted: 04/11/2023] [Indexed: 05/27/2023]
Affiliation(s)
- Kyle B. Mueller
- Corresponding author at: Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Bldg 421, Philadelphia, PA, 19104, USA. Tel.: +1 713-249-4894
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Borja AJ, Ahmad HS, Ghenbot Y, Na J, McClintock SD, Mueller KB, Burkhardt JK, Yoon JW, Malhotra NR. Resident Assistant Training Level is not Associated with Patient Spinal Fusion Outcomes. Clin Neurol Neurosurg 2022; 221:107388. [DOI: 10.1016/j.clineuro.2022.107388] [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] [Received: 06/13/2022] [Revised: 07/17/2022] [Accepted: 07/23/2022] [Indexed: 11/03/2022]
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Mueller KB, D'Antuono M, Patel N, Pivazyan G, Aulisi EF, Evans KK, Nair MN. In Reply: Effect of Incisional Negative Pressure Wound Therapy vs Standard Wound Dressing on the Development of Surgical Site Infection After Spinal Surgery: A Prospective Observational Study. Neurosurgery 2021; 89:E343. [PMID: 34498690 DOI: 10.1093/neuros/nyab351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Kyle B Mueller
- Department of Neurosurgery University of Pennsylvania Philadelphia, Pennsylvania, USA.,Penn-Virtua Department of Neuroscience Virtua Our Lady of Lourdes Hospital Camden, New Jersey, USA
| | - Matthew D'Antuono
- Georgetown University School of Medicine Washington, District of Columbia, USA
| | - Nirali Patel
- Department of Neurosurgery Georgetown University Medical Center Washington, District of Columbia, USA
| | - Gnel Pivazyan
- Department of Neurosurgery Georgetown University Medical Center Washington, District of Columbia, USA
| | - Edward F Aulisi
- Department of Neurosurgery MedStar Washington Hospital Center Washington, District of Columbia, USA
| | - Karen K Evans
- Department of Plastic Surgery Georgetown University Medical Center Washington, District of Columbia, USA
| | - M Nathan Nair
- Department of Neurosurgery Georgetown University Medical Center Washington, District of Columbia, USA
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Mueller KB, D’Antuono M, Patel N, Pivazyan G, Aulisi EF, Evans KK, Nair MN. Effect of Incisional Negative Pressure Wound Therapy vs Standard Wound Dressing on the Development of Surgical Site Infection after Spinal Surgery: A Prospective Observational Study. Neurosurgery 2021. [DOI: 10.1093/neuros/nyab040_s129] [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: 11/14/2022] Open
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Altshuler M, Mueller KB, MacConnell A, Wirth P, Sandhu FA, Voyadzis JM. Reoperation, Readmission, and Discharge Disposition for Patients With Degenerative Lumbar Pathology Treated With Either Open or Minimally Invasive Techniques: A Single-Center Retrospective Review of 1435 Cases. Neurosurgery 2021. [DOI: 10.1093/neuros/nyaa246_s048] [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: 11/13/2022] Open
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Pivazyan G, Mualem W, D'Antuono MR, Dowlati E, Nair N, Mueller KB. The Utility of Prolonged Prophylactic Systemic Antibiotics (PPSA) for Subfascial Drains After Degenerative Spine Surgery. Spine (Phila Pa 1976) 2021; 46:E1077-E1082. [PMID: 33710111 DOI: 10.1097/brs.0000000000004031] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The aim of the current investigation was to evaluate the impact of prolonged prophylactic systemic antibiotics (PPSA) on the development of surgical site infection rate (SSIR) in degenerative spine surgery. SUMMARY OF BACKGROUND DATA Surgical drains are utilized postoperatively in posterior spine surgery to help minimize the risk of seroma formation. Prophylactic antibiotics while drains are in place are frequently used to reduce SSIR, though the practice remains controversial. METHODS We performed a single center, retrospective review of all patients that underwent posterior spinal surgery for cervical and lumbar degenerative pathology over a 3.5 year period (January 2016-July 2019). Patients underwent a traditional open posterior midline procedure with postoperative placement of a subfascial surgical drain. Antibiotics were administered for the duration of the drain (PPSA group) or for 24 hours postoperatively (non-PPSA group). The number of surgical site infections, organism, and Clostridium difficile infections was recorded. RESULTS Three hundred thirty six patients were identified, 168 patients in the PPSA group and 168 in the non-PPSA groups. The overall SSIR was 5.36% (18/336). The SSIR for the non-PPSA and PPSA groups were 7.14% (12/168) and 3.57% (6/168), respectively (P = 0.146). While difference of SSIR between the groups was two-fold, it was not statistically significant. For the non-PPSA and PPSA groups, the SSIR for cervical (5.95% [5/84] vs. 2.38% [2/84], P = 0.443) and lumbar (8.33% [7/84], vs. 4.76% [4/84], P = 0.535) regions were not significantly different. C. difficile cases in the PPSA and non-PPSA groups were 1/168 and 0/168 respectively (P = 1.00). CONCLUSION Our series demonstrate a two-fold reduction of SSI with implementation of PPSA regimen. This benefit was demonstrated separately for both cervical and lumbar regions. Randomized trials and increase in sample size are warranted to elucidate the significance of PPSA in posterior spinal surgery.Level of Evidence: 3.
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Affiliation(s)
- Gnel Pivazyan
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, DC
| | - William Mualem
- Georgetown University School of Medicine, Washington, DC
| | | | - Ehsan Dowlati
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, DC
| | - Nathan Nair
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, DC
| | - Kyle B Mueller
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, DC
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Mueller KB, Garrett CT, Kane S, Sandhu FA, Voyadzis JM. Incidental Durotomy Following Surgery for Degenerative Lumbar Disease and the Impact of Minimally Invasive Surgical Technique on the Rate and Need for Surgical Revision: A Case Series. Oper Neurosurg (Hagerstown) 2021; 21:351-355. [PMID: 34460926 DOI: 10.1093/ons/opab282] [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: 02/03/2021] [Accepted: 06/14/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Incidental durotomy (ID) is a common complication during lumbar spine surgery. A paucity of literature has studied the impact of minimally invasive surgery (MIS) on durotomy rates and strategies for repair as compared to open surgery. OBJECTIVE To examine the impact that MIS techniques have on the durotomy rate, repair techniques, and need for surgical revision following surgery for degenerative lumbar disease as compared to open technique. METHODS A single-center retrospective review of consecutive cases between 2013 and 2016 was performed. All patients underwent lumbar decompression with or without instrumented fusion for degenerative pathology using either open posterior or MIS techniques. ID rate, closure technique, and need for surgical revision related to the durotomy were recorded. RESULTS A total of 1,196 patients were included with an overall ID rate of 6.8%. There was no difference between open or minimally invasive surgical techniques (P = .14). There was a higher durotomy rate with open technique in patients that underwent decompression with fusion (P = .03) as well as in revision cases (P = .02). Primary repair was feasible more frequently in the open group (P = .001), whereas use of dural substitute (P < .001) was more common in the MIS group. Fibrin sealant was used routinely in both groups (P = .34). There were no failed repairs, regardless of technique used. CONCLUSION MIS techniques may reduce durotomies in cases involving instrumentation or revisions. Use of dural substitute onlay and fibrin sealant was effective at preventing reoperation. Both MIS and open techniques result in a low rate of future surgical revision when a durotomy occurs.
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Affiliation(s)
- Kyle B Mueller
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Coleman T Garrett
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Stephen Kane
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Faheem A Sandhu
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Jean-Marc Voyadzis
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, District of Columbia, USA
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Affiliation(s)
- Kyle B Mueller
- Department of Neurosurgery, Brown University - Rhode Island Hospital, Providence, Rhode Island, USA
| | - Rahul A Sastry
- Department of Neurosurgery, Brown University - Rhode Island Hospital, Providence, Rhode Island, USA
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Carroll AH, Dowlati E, Molina E, Zhao D, Altshuler M, Mueller KB, Sandhu FA, Voyadzis JM. Does minimally invasive spine surgery improve outcomes in the obese population? A retrospective review of 1442 degenerative lumbar spine surgeries. J Neurosurg Spine 2021; 35:460-470. [PMID: 34271544 DOI: 10.3171/2021.1.spine201785] [Citation(s) in RCA: 3] [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: 10/05/2020] [Accepted: 01/08/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The effect of obesity on outcomes in minimally invasive surgery (MIS) approaches to posterior lumbar surgery is not well characterized. The authors aimed to determine if there was a difference in operative variables and complication rates in obese patients who underwent MIS versus open approaches in posterior spinal surgery, as well as between obese and nonobese patients undergoing MIS approaches. METHODS A retrospective review of all consecutive patients who underwent posterior lumbar surgery from 2013 to 2016 at a single institution was performed. The primary outcome measure was postoperative complications. Secondary outcome measures included estimated blood loss (EBL), operative time, the need for revision, and hospital length of stay (LOS); readmission and disposition were also reviewed. Obese patients who underwent MIS were compared with those who underwent an open approach. Additionally, obese patients who underwent an MIS approach were compared with nonobese patients. Bivariate and multivariate analyses were carried out between the groups. RESULTS In total, 423 obese patients (57.0% decompression and 43.0% fusion) underwent posterior lumbar MIS. When compared with 229 obese patients (56.8% decompression and 43.2% fusion) who underwent an open approach, patients in both the obese and nonobese groups who underwent MIS experienced significantly decreased EBL, LOS, operative time, and surgical site infections (SSIs). Of the nonobese patients, 538 (58.4% decompression and 41.6% fusion) underwent MIS procedures. When compared with nonobese patients, obese patients who underwent MIS procedures had significantly increased LOS, EBL, operative time, revision rates, complications, and readmissions in the decompression group. In the fusion group, only LOS and disposition were significantly different. CONCLUSIONS Obese patients have poorer outcomes after posterior lumbar MIS when compared with nonobese patients. The use of an MIS technique can be of benefit, as it decreased EBL, operative time, LOS, and SSIs for posterior decompression with or without instrumented fusion in obese patients.
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Affiliation(s)
| | - Ehsan Dowlati
- 2Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC; and
| | | | - David Zhao
- 2Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC; and
| | - Marcelle Altshuler
- 3Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kyle B Mueller
- 2Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC; and
| | - Faheem A Sandhu
- 2Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC; and
| | - Jean-Marc Voyadzis
- 2Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC; and
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Mueller KB, D'Antuono M, Patel N, Pivazyan G, Aulisi EF, Evans KK, Nair MN. Effect of Incisional Negative Pressure Wound Therapy vs Standard Wound Dressing on the Development of Surgical Site Infection after Spinal Surgery: A Prospective Observational Study. Neurosurgery 2021; 88:E445-E451. [PMID: 33611587 DOI: 10.1093/neuros/nyab040] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [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: 05/15/2020] [Accepted: 12/14/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Use of a closed-incisional negative pressure therapy (ci-NPT) dressing is an emerging strategy to reduce surgical site infections (SSIs) in spine surgery that lacks robust data. OBJECTIVE To determine the impact of a ci-NPT, as compared with a standard dressing, on the development of SSIs after spine surgery. METHODS This was a prospective observational study over a 2-yr period. Indications for surgery included degenerative disease, deformity, malignancy, and trauma. Exclusion criteria included anterior and lateral approaches to the spine, intraoperative durotomy, or use of minimally invasive techniques. SSIs up to 60 d following surgery were recorded. RESULTS A total of 274 patients were included. SSI rate was significantly lower with ci-NPT dressing (n = 118) as compared with the standard dressing (n = 156) (3.4 vs 10.9%, P = .02). There was no statistical difference in infection rate for decompression alone procedures (4.2 vs 9.1%, P = .63), but there was a statistically significant reduction with the use of a negative-pressure dressing in cases that required instrumentation (3.2 vs 11.4%, P = .03). Patients at higher risk (instrumentation, deformity, and malignancy) had less SSIs with the use of ci-NPT, although this did not reach statistical significance. There were no complications in either group. CONCLUSION SSI rates were significantly reduced with a ci-NPT dressing vs a standard dressing in patients who underwent spinal surgery. The higher cost of a ci-NPT dressing might be justified with instrumented cases, as well as with certain high-risk patient populations undergoing spine surgery, given the serious consequences of an infection.
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Affiliation(s)
- Kyle B Mueller
- Department of Neurosurgery, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Matthew D'Antuono
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Nirali Patel
- Department of Neurosurgery, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Gnel Pivazyan
- Department of Neurosurgery, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Edward F Aulisi
- Department of Neurosurgery, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Karen K Evans
- Department of Plastic Surgery, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - M Nathan Nair
- Department of Neurosurgery, Georgetown University Medical Center, Washington, District of Columbia, USA
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Mueller KB, Voyadzis JM. Resection of a Large Thoracic Schwannoma: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 20:E297. [PMID: 33372977 DOI: 10.1093/ons/opaa381] [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: 04/13/2020] [Accepted: 09/13/2020] [Indexed: 11/12/2022] Open
Abstract
Spinal schwannomas most likely occur at the thoracic level and within the intradural extramedullary compartment. They are benign, typically slow-growing, peripheral nerve sheath tumors that produce symptoms by displacing or compressing the nerve roots and spinal cord. There is an association with patients that have neurofibromatosis type 2. Surgical pearls including the utilization of intraoperative ultrasound for localization, D wave monitoring, and microsurgical dissection are demonstrated. Pertinent high-yield radiographic and histological features of schwannomas are reviewed.1-4 We report the case of a 59-yr-old female who presented with progressively worsening gait instability that was associated with lower extremity numbness progressing to weakness. She had myelopathic findings on examination, which included brisk patellar reflexes and persistent clonus with sensory changes to the umbilicus and mild leg weakness. Full body examination revealed no stigmata of neurofibromatosis. Magnetic resonance imaging of the neuroaxis demonstrated a large, intradural extramedullary mass with peripheral enhancement that spanned the T9 to T11 vertebral levels with severe compression of the spinal cord. There were no intracranial, cervical, or lumbar findings. Surgical intervention was planned with the following objectives: decompression of the neural elements, curative resection, and diagnosis. Patient consent for the procedure was obtained. Institutional Review Board approval for solitary case reports are not needed at our institution.
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Affiliation(s)
- Kyle B Mueller
- MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Jean-Marc Voyadzis
- MedStar Georgetown University Hospital, Washington, District of Columbia
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Molina E, Zhao D, Dowlati E, Carroll AH, Mueller KB, Sandhu FA, Voyadzis JM. Minimally invasive posterior lumbar surgery in the morbidly obese, obese and non-obese populations: A single institution retrospective review. Clin Neurol Neurosurg 2021; 207:106746. [PMID: 34144463 DOI: 10.1016/j.clineuro.2021.106746] [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: 02/18/2021] [Revised: 05/20/2021] [Accepted: 06/06/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is a paucity of information regarding outcomes in minimally invasive surgical (MIS) approaches to posterior lumbar surgery in morbidly obese patients. We seek to determine if there are differences in operative variables and early complication rates in morbidly obese patients undergoing MIS posterior lumbar surgery compared to obese and non-obese patients. METHODS A single institution retrospective review of patients undergoing MIS posterior lumbar surgery (decompression and/or fusion) between 2013 and 2016 was performed. Morbidly obese patients (BMI ≥ 40) were compared to obese (BMI 30-39.9) and non-obese (BMI < 30) cohorts. Postoperative complication rates and perioperative variables including estimated blood loss, operative time, and outcome measures including length of stay (LOS), in-hospital complications, readmission, and disposition were assessed. RESULTS 47 morbidly obese, 135 obese and 224 non-obese patients underwent posterior MIS instrumented fusion. 59 morbidly obese, 182 obese and 314 non-obese patients underwent posterior MIS decompression. The morbidly obese group experienced a greater rate of deep vein thrombosis and had an increased hospital LOS (p < 0.05). Morbidly obese patients who underwent MIS decompression experienced increased postoperative complications (p < 0.01), and increased LOS (p < 0.0001) compared to obese and non-obese patients. There were no differences in revision rates, readmissions, and other complications including surgical site infection. Morbid obesity was an independent predictor of overall complications and increased LOS on multivariate analysis. CONCLUSION Morbidly obese patients undergoing posterior MIS fusion had a higher rate of complications and increased LOS. While weight loss should be encouraged, complication rates remains acceptably low in morbidly obese patients and MIS posterior lumbar surgery should still be offered.
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Affiliation(s)
- Esteban Molina
- Georgetown University School of Medicine, Washington, DC, USA
| | - David Zhao
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Ehsan Dowlati
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA.
| | | | - Kyle B Mueller
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Faheem A Sandhu
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Jean-Marc Voyadzis
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA.
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Carroll AH, Ramirez MP, Dowlati E, Mueller KB, Borazjani A, Chang JJ, Felbaum DR. Management of Intracranial Hemorrhage in Patients with a Left Ventricular Assist Device: A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis 2020; 30:105501. [PMID: 33271486 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105501] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/12/2020] [Accepted: 11/21/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Intracranial hemorrhage (ICH) has been reported to occur in up to 23% of patients with left ventricular assist devices (LVADs). Currently, limited data exists to guide neurosurgical management strategies to optimize outcomes in patients with an LVAD who develop ICH. METHODS A systematic review and meta-analysis of the literature was performed to evaluate the mortality rate in these patients following medical and/or surgical management and to evaluate antithrombotic reversal and resumption strategies after hemorrhage. RESULTS 17 studies reporting on 3869 LVAD patients and 545 intracranial hemorrhages spanning investigative periods from 1996 to 2019 were included. The rate of ICH in LVAD patients was 10.6% (411/3869) with 58.6% (231/394) being intraparenchymal hemorrhage (IPH), 23.6% (93/394) subarachnoid hemorrhage (SAH), and 15.5% (61/394) subdural hemorrhage (SDH). Total mortality rates for surgical management 65.6% (40/61) differed from medical management at 45.2% (109/241). There was an increased relative risk of mortality (RR=1.45, 95% CI: 1.10-1.91, p = 0.01) for ICH patients undergoing surgical intervention. The hemorrhage subtype most frequently managed with anticoagulation reversal was IPH 81.8% (63/77), followed by SDH 52.2% (12/23), and SAH 39.1% (18/46). Mean number of days until antithrombotic resumption ranged from 6 to 10.5 days. CONCLUSION Outcomes remain poor, specifically for those undergoing surgery. As experience with this population increases, prospective studies are warranted to contribute to management and prognostication .
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Affiliation(s)
| | | | - Ehsan Dowlati
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, D.C., USA.
| | - Kyle B Mueller
- Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School at Brown University, Providence, R.I., USA
| | - Ali Borazjani
- Georgetown University School of Medicine, Washington, D.C., USA
| | - Jason J Chang
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington D.C., USA
| | - Daniel R Felbaum
- Department of Neurosurgery, MedStar Washington Hospital Center, Washington, D.C., USA; Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, D.C., USA
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Altshuler M, Mueller KB, MacConnell A, Wirth P, Sandhu FA, Voyadzis JM. Reoperation, Readmission, and Discharge Disposition for Patients With Degenerative Lumbar Pathology Treated With Either Open or Minimally Invasive Techniques: A Single-Center Retrospective Review of 1435 Cases. Neurosurgery 2020; 87:1199-1205. [PMID: 32542331 DOI: 10.1093/neuros/nyaa246] [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] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 04/11/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Spine surgery has been transformed by the growth of minimally invasive surgery (MIS) procedures. Previous studies agree that MIS has shorter hospitalization and faster recovery time when compared to conventional open surgery. However, the reoperation and readmission rates between the 2 techniques have yet to be well characterized. OBJECTIVE To evaluate the rate of subsequent revision between MIS and open techniques for degenerative lumbar pathology. METHODS A total of 1435 adult patients who underwent lumbar spine surgery between 2013 and 2016 were included in this retrospective analysis. The rates of need for subsequent reoperation, 30- and 90-d readmission, and discharge to rehabilitation were recorded for both MIS and traditional open techniques. Groups were divided into decompression alone and decompression with fusion. RESULTS The rates of subsequent reoperation following MIS and open surgery were 10.4% and 12.2%, respectively (P = .32), which were maintained when subdivided into decompression and decompression with fusion. MIS and open 30-d readmission rates were 7.9% and 7.2% (P = .67), while 90-d readmission rates were 4.3% and 3.6% (P = .57), respectively. Discharge to rehabilitation was significantly lower for patients under 60 yr of age undergoing MIS (1.64% vs 5.63%, P = .04). CONCLUSION The use of minimally invasive techniques for the treatment of lumbar spine pathology does not result in increased reoperation or 30- and 90-d readmission rates when compared to open approaches. Patients under the age of 60 yr undergoing MIS procedures were less likely to be discharged to rehab.
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Affiliation(s)
- Marcelle Altshuler
- Georgetown University School of Medicine, Washington, District of Columbia
| | - Kyle B Mueller
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, District of Columbia
| | - Ashley MacConnell
- Georgetown University School of Medicine, Washington, District of Columbia
| | - Peter Wirth
- Georgetown University School of Medicine, Washington, District of Columbia
| | - Faheem A Sandhu
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, District of Columbia
| | - Jean-Marc Voyadzis
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, District of Columbia
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Mueller KB, Fayed I, Spitz S, Nair N, Voyadzis JM, Sandhu F. In Reply: Contralateral Minimally Invasive Laminectomy for Resection of a Synovial Cyst: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2020; 18:E260-E261. [PMID: 32147710 DOI: 10.1093/ons/opaa048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Kyle B Mueller
- Department of Neurosurgery Georgetown University Medical Center Washington, District of Columbia
| | - Islam Fayed
- Department of Neurosurgery Georgetown University Medical Center Washington, District of Columbia
| | - Steve Spitz
- Department of Neurosurgery Georgetown University Medical Center Washington, District of Columbia
| | - Nathan Nair
- Department of Neurosurgery Georgetown University Medical Center Washington, District of Columbia
| | - Jean-Marc Voyadzis
- Department of Neurosurgery Georgetown University Medical Center Washington, District of Columbia
| | - Faheem Sandhu
- Department of Neurosurgery Georgetown University Medical Center Washington, District of Columbia
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Cunningham BW, Mueller KB, Mullinix KP, Sun X, Sandhu FA. Biomechanical analysis of occipitocervical stabilization techniques: emphasis on integrity of osseous structures at the occipital implantation sites. J Neurosurg Spine 2020; 33:1-10. [PMID: 32276257 DOI: 10.3171/2020.1.spine191331] [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: 11/06/2019] [Accepted: 01/20/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of the current study was to quantify and compare the multidirectional flexibility properties of occipital anchor fixation with conventional methods of occipitocervical screw fixation using nondestructive and destructive investigative methods. METHODS Fourteen cadaveric occipitocervical specimens (Oc-T2) were randomized to reconstruction with occipital anchors or an occipital plate and screws. Using a 6-degree-of-freedom spine simulator with moments of ± 2.0 Nm, initial multidirectional flexibility analysis of the intact and reconstructed conditions was performed followed by fatigue loading of 25,000 cycles of flexion-extension (x-axis, ± 2.0 Nm), 15,000 cycles of lateral bending (z-axis, ± 2.0 Nm), and 10,000 cycles of axial rotation (y-axis, ± 2.0 Nm). Fluoroscopic images of the implantation sites were obtained before and after fatigue testing and placed on an x-y coordinate system to quantify positional stability of the anchors and screws used for reconstruction and effect, if any, of the fatigue component. Destructive testing included an anterior flexural load to construct failure. Quantification of implant, occipitocervical, and atlantoaxial junction range of motion is reported as absolute values, and peak flexural failure moment in Newton-meters (Nm). RESULTS Absolute value comparisons between the intact condition and 2 reconstruction groups demonstrated significant reductions in segmental flexion-extension, lateral bending, and axial rotation motion at the Oc-C1 and C1-2 junctions (p < 0.05). The average bone mineral density at the midline keel (1.422 g/cm3) was significantly higher compared with the lateral occipital region at 0.671 g/cm3 (p < 0.05). There were no significant differences between the occipital anchor and plate treatments in terms of angular rotation (degrees; p = 0.150) or x-axis displacement (mm; p = 0.572), but there was a statistically significant difference in y-axis displacement (p = 0.031) based on quantitative analysis of the pre- and postfatigue fluoroscopic images (p > 0.05). Under destructive anterior flexural loading, the occipital anchor group failed at 90 ± 31 Nm, and the occipital plate group failed at 79 ± 25 Nm (p > 0.05). CONCLUSIONS Both reconstructions reduced flexion-extension, lateral bending, and axial rotation at the occipitocervical and atlantoaxial junctions, as expected. Flexural load to failure did not differ significantly between the 2 treatment groups despite occipital anchors using a compression-fit mechanism to provide fixation in less dense bone. These data suggest that an occipital anchor technique serves as a biomechanically viable clinical alternative to occipital plate fixation.
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Affiliation(s)
- Bryan W Cunningham
- 1Musculoskeletal Education Center, Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, Maryland
| | - Kyle B Mueller
- 2Department of Neurosurgery, Georgetown University Medical Center, Washington, DC; and
| | - Kenneth P Mullinix
- 1Musculoskeletal Education Center, Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, Maryland
| | - Xiaolei Sun
- 3Department of Orthopaedic Surgery, Tianjin Hospital, Tianjin, China
| | - Faheem A Sandhu
- 2Department of Neurosurgery, Georgetown University Medical Center, Washington, DC; and
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Mueller KB, Zhao D, Dowlati E, D'Antuono M, Felbaum D, Chang J, Hockstein M, Mai J, Mason B, Aulisi E, Armonda R. Intracranial hemorrhage type and same-admission mortality in patients with left ventricular assist devices. Clin Neurol Neurosurg 2020; 193:105790. [PMID: 32200214 DOI: 10.1016/j.clineuro.2020.105790] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 02/22/2020] [Accepted: 03/15/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Left ventricular assist devices (LVAD) provide mechanical circulatory support for patients with advanced heart failure. Intracranial hemorrhage in this population represent a significant management challenge. The objective of this study is to report our initial experience on same-admission outcomes with LVAD patients that presented with various types of intracranial hemorrhage (ICH). PATIENTS AND METHODS A retrospective review of a large volume center over a two-year period was performed. LVAD patients with ICH requiring a neurosurgical consultation were identified. Hemorrhage type, interventions, discharge disposition and cause of death were recorded. RESULTS 27 LVAD patients with ICH received a neurosurgical consultation. The average INR at the time of ICH was 2.7 (1.0-8.8). Hemorrhage types seen were lobar (10/27, 37 %), SAH (5/27, 19 %), SDH (4/27, 15 %), cerebellar ICH (3/27, 11 %), multiple ICH (3/27, 11 %), and hemorrhagic conversion (2/27, 7 %). The overall mortality rate was 48.2 % (13/27), with the highest mortality being in those patients who had multiple ICH at the time of presentation (3/3, 100 %). The majority of patients with ICH (85.2 %) were non-operative. Lobar IPH was <3 cm in 80 % (8/10) of these, and 6/8 (75 %) ultimately died. 11 %(3/27) received surgical intervention. Of these, 67 % ultimately withdrew care. 77 % (10/13) of patients died as a result of the ICH. 80 % of patients with SAH were ultimately discharged home. CONCLUSIONS Patients with a LVAD and ICH have a high rate of same-admission mortality (48 %). Hemorrhage location, intra-axial or extra-axial, resulted in patients being a risk for death secondary to either the hemorrhage itself or pump thrombosis, respectively.
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Affiliation(s)
- Kyle B Mueller
- Georgetown University Medical Center, Department of Neurosurgery, Washington, DC, United States; Medstar Washington Hospital Center, Department of Neurosurgery, Washington, DC, United States.
| | - David Zhao
- Georgetown University Medical Center, Department of Neurosurgery, Washington, DC, United States; Medstar Washington Hospital Center, Department of Neurosurgery, Washington, DC, United States
| | - Ehsan Dowlati
- Georgetown University Medical Center, Department of Neurosurgery, Washington, DC, United States; Medstar Washington Hospital Center, Department of Neurosurgery, Washington, DC, United States
| | - Matthew D'Antuono
- Georgetown University School of Medicine, Washington, DC, United States
| | - Daniel Felbaum
- Georgetown University Medical Center, Department of Neurosurgery, Washington, DC, United States; Medstar Washington Hospital Center, Department of Neurosurgery, Washington, DC, United States
| | - Jason Chang
- Medstar Washington Hospital Center, Department of Critical Care Medicine, Washington, DC, United States
| | - Michael Hockstein
- Medstar Washington Hospital Center, Department of Cardiac Critical Care, Washington, DC, United States
| | - Jeffery Mai
- Georgetown University Medical Center, Department of Neurosurgery, Washington, DC, United States; Medstar Washington Hospital Center, Department of Neurosurgery, Washington, DC, United States
| | - Bryan Mason
- Medstar Washington Hospital Center, Department of Neurosurgery, Washington, DC, United States
| | - Edward Aulisi
- Medstar Washington Hospital Center, Department of Neurosurgery, Washington, DC, United States
| | - Rocco Armonda
- Georgetown University Medical Center, Department of Neurosurgery, Washington, DC, United States; Medstar Washington Hospital Center, Department of Neurosurgery, Washington, DC, United States
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Mueller KB, Mullinix KP, Bermudez HF. How I do it: en-bloc subaxial cervical laminectomy using a high-speed drill with a footplate attachment. Acta Neurochir (Wien) 2020; 162:311-315. [PMID: 31823120 DOI: 10.1007/s00701-019-04158-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 11/25/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Cervical laminectomy is a common strategy to decompress the spinal canal. METHODS The anatomy of the cervical spine and surrounding critical structures as viewed from the posterior approach is described. The use of a high-speed drill with a footplate attachment to make laminar troughs with an en-bloc subaxial cervical laminectomy is described with a discussion on surgical technique and complication avoidance. CONCLUSION This technique allows for a safe, comfortable, and rapid decompression of the cervical spine with minimal risk. For routine cases, this may potentially be more safe and cost-effective than using a cutting bur or bone scalpel attachment.
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Sandhu FA, McGowan JE, Felbaum DR, Syed HR, Mueller KB. S2-AI screw placement with the aide of electronic conductivity device monitoring: a retrospective analysis. Eur Spine J 2017; 26:2941-2950. [PMID: 28766018 DOI: 10.1007/s00586-017-5242-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 01/26/2017] [Accepted: 07/25/2017] [Indexed: 11/24/2022]
Abstract
STUDY DESIGN A retrospective analysis of two consecutive patients who underwent a novel surgical technique. OBJECTIVE A report of a novel surgical technique utilizing an electronic conductivity device guidance to aide placement of S2-Alar-Iliac (S2-AI) instrumentation. Electronic conductivity guidance for instrumentation of the thoracolumbar spine is an accepted means of improving intraoperative accuracy. Although commercially available for percutaneous techniques, there is a paucity of literature regarding its use. Percutaneous implantation of S2-AI screws has been previously described as another technique surgeons can avail, primarily employing fluoroscopy as a means of intraoperative feedback. We describe a novel technique that utilizes electronic conductivity as an added feedback measure to increase accuracy of percutaneous S2-AI fixation. METHODS Two patients were treated by the senior author (FAS) who underwent surgery employing S2-AI fixation utilizing an electronic conductivity device (Pediguard cannulated probe, Spineguard, Paris, France). The surgical technique, case illustrations, and radiographic outcomes are discussed. RESULTS Stable and accurate fixation was attained in both patients. There were no peri-operative complications related to hardware placement. CONCLUSION To the authors' knowledge, this is the first reported literature combining S2-AI screws with electronic conductivity for immediate intraoperative feedback. This technique has the opportunity to provide surgeons with increased accuracy for placement of S2-AI screws while improving overall radiation safety. This feedback can be particularly helpful when surgeons are learning new techniques such as placement of S2AI screws.
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Affiliation(s)
- Faheem A Sandhu
- Department of Neurosurgery, MedStar Georgetown University Hospital, 7 PHC, 3800 Reservoir Rd. NW, Washington, DC, 20057, USA.
| | - Jason E McGowan
- Department of Neurosurgery, MedStar Georgetown University Hospital, 7 PHC, 3800 Reservoir Rd. NW, Washington, DC, 20057, USA
| | - Daniel R Felbaum
- Department of Neurosurgery, MedStar Georgetown University Hospital, 7 PHC, 3800 Reservoir Rd. NW, Washington, DC, 20057, USA
| | - Hasan R Syed
- Department of Neurosurgery, MedStar Georgetown University Hospital, 7 PHC, 3800 Reservoir Rd. NW, Washington, DC, 20057, USA
| | - Kyle B Mueller
- Department of Neurosurgery, MedStar Georgetown University Hospital, 7 PHC, 3800 Reservoir Rd. NW, Washington, DC, 20057, USA
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