OBJECT The health care landscape is rapidly shifting to incentivize quality of care rather than quantity of care. Quality and outcomes registry platforms lie at the center of all emerging ...evidence-driven reform models and will be used to inform decision makers in health care delivery. Obtaining real-world registry outcomes data from patients 12 months after spine surgery remains a challenge. The authors set out to determine whether 3-month patient-reported outcomes accurately predict 12-month outcomes and, hence, whether 3-month measurement systems suffice to identify effective versus noneffective spine care. METHODS All patients undergoing lumbar spine surgery for degenerative disease at a single medical institution over a 2-year period were enrolled in a prospective longitudinal registry. Patient-reported outcome instruments (numeric rating scale NRS, Oswestry Disability Index ODI, 12-Item Short Form Health Survey SF-12, EQ-5D, and the Zung Self-Rating Depression Scale) were recorded prospectively at baseline and at 3 months and 12 months after surgery. Linear regression was performed to determine the independent association of 3- and 12-month outcome. Receiver operating characteristic (ROC) curve analysis was performed to determine whether improvement in general health state (EQ-5D) and disability (ODI) at 3 months accurately predicted improvement and achievement of minimum clinical important difference (MCID) at 12 months. RESULTS A total of 593 patients undergoing elective lumbar surgery were included in the study. There was a significant correlation between 3-month and 12-month EQ-5D (r = 0.71; p < 0.0001) and ODI (r = 0.70; p < 0.0001); however, the authors observed a sizable discrepancy in achievement of a clinically significant improvement (MCID) threshold at 3 versus 12 months on an individual patient level. For postoperative disability (ODI), 11.5% of patients who achieved an MCID threshold at 3 months dropped below this threshold at 12 months; 10.5% of patients who did not meet the MCID threshold at 3 months continued to improve and ultimately surpassed the MCID threshold at 12 months. For ODI, achieving MCID at 3 months accurately predicted 12-month MCID with only 62.6% specificity and 86.8% sensitivity. For postoperative health utility (EQ-5D), 8.5% of patients lost an MCID threshold improvement from 3 months to 12 months, while 4.0% gained the MCID threshold between 3 and 12 months postoperatively. For EQ-5D (quality-adjusted life years), achieving MCID at 3 months accurately predicted 12-month MCID with only 87.7% specificity and 87.2% sensitivity. CONCLUSIONS In a prospective registry, patient-reported measures of treatment effectiveness obtained at 3 months correlated with 12-month measures overall in aggregate, but did not reliably predict 12-month outcome at the patient level. Many patients who do not benefit from surgery by 3 months do so by 12 months, and, conversely, many patients reporting meaningful improvement by 3 months report loss of benefit at 12 months. Prospective longitudinal spine outcomes registries need to span at least 12 months to identify effective versus noneffective patient care.
Malignant transformation of intracranial epidermoid cysts is a rare occurrence. We present the second case of such an event occurring in the pineal region and the first case sent for detailed genomic ...profiling. MRI demonstrated two lesions: a cyst in a quadrigeminal cistern with restricted diffusion on DWI-weighted images and an adjacent, peripherally enhancing tumor with cerebellar infiltration. Both the lesions were completely resected with a small residual of the epidermoid cyst. The final pathology of both lesions was consistent with epidermoid cyst and squamous cell carcinoma (SCC), respectively. The tumor specimen was sent for comprehensive genomic profiling which revealed stable microsatellite status and loss of CDKN2A/B, MTAP (exons 2–8), and PTEN (exons 6–9). Although reports of primary SCC originating from the epidermoid cyst have been previously described, this is the first description of the genomic profile of such a tumor.
Background The ability to understand factors associated with an increased duration of missed work postoperatively could be used to more effectively select patients with the greatest opportunity for a ...successful outcome. We set out to determine the effect of preoperative depression on postoperative return to work in patients undergoing transforaminal lumbar interbody fusion (TLIF) for degenerative spondylolisthesis. Methods Fifty-eight patients undergoing TLIF for symptomatic grade I degenerative lumbar spondylolisthesis were included in this analysis. Patient demographics, clinical presentation, indications for surgery, radiologic studies, and operative variables were assessed for each case. Patient-assessed outcome measures were obtained prospectively at baseline and 2 years postoperatively. To understand the factors associated with prolonged return to work, univariate linear regression analysis and stepwise multivariate Cox proportional hazards model was used. Results All patient-reported outcomes assessed were significantly improved 2 years after TLIF ( P < 0.001). Of the 32 patients working preoperatively, 26 (81%) returned to work postoperatively. Median time to return to work was 56 days (range, 10–150 days). Independent of patient age; preoperative pain, disability, and quality of life; and extent of postoperative improvement, increased preoperative Zung depression score remained associated with prolonged return to work ( P = 0.02). Conclusions Independent of postoperative improvement in pain, disability, and quality of life, the extent of preoperative depression was an independent predictor of time to return to work in patients undergoing TLIF for spondylolisthesis, suggesting that regardless of how successful TLIF surgery may be at improving a patient's pain, disability, or quality of life, greater depression will delay or prohibit their ability to return to work postoperatively.
BACKGROUND:Sectioning of the C2 nerve root allows for direct visualization of the C1-2 joint and may facilitate arthrodesis.
OBJECTIVE:To determine the clinical and functional consequences of C2 ...nerve root sectioning during placement of C1 lateral mass screws.
METHODS:All patients undergoing C1 lateral mass screw fixation were included in this prospective study. A standard questionnaire was used to determine the severity of occipital numbness/pain and its effect on quality of life (QOL). Domains of the neck disability index were used to assess the disability related to C2 symptoms.
RESULTS:A total of 28 patients were included (C2 transection, 8; C2 preservation, 20). A trend of decreased blood loss and length of surgery was observed in the C2 transection cohort. Occipital numbness was reported by 4 (50.0%) patients after C2 transection. Occipital neuralgia was reported by 7 (35.0%) patients with C2 preservation. None of the patients with numbness after C2 transection reported being “bothered” by it. All patients with occipital neuralgia after C2 sparing reported being “bothered” by it, and 57.1% reported a moderate to severe effect on QOL. The use of medication was reported by 5 (71.4%) patients with neuralgia vs none with numbness. Mean disability was significantly higher with neuralgia vs numbness (P = .016).
CONCLUSION:C2 nerve root transection is associated with increased occipital numbness but this has no effect on patient-reported outcomes and QOL. C2 nerve root preservation can be associated with occipital neuralgia, which has a negative impact on patient disability and QOL. C2 nerve root transection has no negative consequences during C1-2 stabilization.
ABBREVIATIONS:NDI, neck disability indexQOL, quality of life
Abstract
BACKGROUND AND IMPORTANCE
Brainstem lesions are challenging to manage, and surgical options have been controversial. Stereotactic radiosurgery (SRS) has been used for local control, but ...life-threatening toxicities from 0% to 9.5% have been reported. Several microsurgical approaches involving safe entry zones have been developed to optimize the exposure and minimize complications in different portions of the brainstem, but require extensive drilling and manipulation of neurovascular structures. With recent advancements, the endoscopic endonasal approach (EEA) can provide direct visualization of ventral brainstem. No case has been reported of EEA to remove a brainstem metastasis.
CLINICAL PRESENTATION
We present an illustrative case of a 68-yr-old female with metastatic colon cancer who presented with 2.8 × 2.7 × 2.1 cm (7.9 cm3) heterogeneously enhancing, right ventral pontine lesion with extensive edema. She underwent endoscopic endonasal transclival approach, and gross total resection of the lesion was achieved.
CONCLUSION
The endoscopic approach may offer certain advantages for removal of ventral brainstem lesions, as it can provide direct visualization of important neurovascular structures, especially, if the lesion displaces the tracts and comes superficial to the pial surface.
Suboccipital decompression is a common procedure for patients with Chiari malformation Type I (CMI). Published studies have reported complication rates ranging from 3% to 40%, with pseudomeningocele ...being one of the most common complications. To date, there are no studies assessing the effect of this complication on long-term outcome. Therefore, the authors set out to assess the effect of symptomatic pseudomeningocele on patient outcomes following suboccipital decompression for CM-I.
The study comprised 50 adult patients with CM-I who underwent suboccipital craniectomy and C-1 laminectomy with or without duraplasty. Clinical presentation, radiological studies, operative variables, and complications were assessed for each case. Baseline and 1-year postoperative patient-reported outcomes were assessed to determine improvement in pain, disability, and quality of life. The extent of improvement was compared for patients with and without development of a postoperative symptomatic pseudomeningocele.
A symptomatic pseudomeningocele developed postoperatively in 9 patients (18%). There was no difference with regard to clinical, radiological, or operative variables for patients with or without a postoperative pseudomeningocele. Patients without a pseudomeningocele had significant improvement in all 9 patient-reported outcome measures assessed. On the other hand, patients with pseudomeningocele only had significant improvement in headache (as measured on the Numeric Rating Scale) and headache-related disability (as measured on the Headache Disability Index) but no improvement in quality of life. Twenty-nine (71%) of 41 patients without a pseudomeningocele reported improvement in health status postoperatively compared with only 3 (33%) of 9 patients with a postoperative pseudomeningocele (p = 0.05).
Surgical management of CM-I in adults provides significant and sustained improvement in pain, disability, general health, and quality of life. Development of a postoperative symptomatic pseudomeningocele has lingering effects at 1 year, and it significantly diminishes the overall benefit of suboccipital decompression for CM-related symptoms. Further research is needed to accurately predict which patients may benefit from decompression alone without duraplasty.
Silent corticotroph adenomas (SCAs) are the only pituitary adenomas thought to originate from the pars intermedia. This case report presents the rare finding of a multimicrocystic corticotroph ...macroadenoma displacing the anterior and posterior lobes of the pituitary gland on magnetic resonance imaging (MRI). This finding supports the hypothesis that silent corticotroph adenomas may originate from the pars intermedia and should be considered in the differential for tumors arising from this location.
A 55-year-old man presented with an episode of confusion and blurred vision. MRI demonstrated separation of the anterior and posterior glands by a solid-cystic lesion located within the pars intermedia that superiorly displaced the optic chiasm. Endocrinologic evaluation was unremarkable. The differential diagnosis included pituitary adenoma, Rathke cleft cyst, and craniopharyngioma. The tumor was confirmed to be an SCA on pathology and was completely removed through the endoscopic endonasal transsphenoidal approach.
The case highlights the importance of preoperative screening for subclinical hypercortisolism for tumors arising from this location. Knowledge of a patient's preoperative functional status is critical and dictates their postoperative biochemical assessment to determine remission. The case also illustrates surgical strategies for resecting pars intermedia lesions without injuring the gland.
There has been a transition to using patient-reported outcome instruments (PROi) to assess surgical effectiveness. However, none of these instruments have been validated for outcomes of adult Chiari ...I malformation (CMI).
The aim of this study was to determine the relative validity and responsiveness of various PROi in measuring outcomes after surgery for CMI.
Fifty patients undergoing suboccipital craniotomy for adult CMI were prospectively followed for 1 year. Baseline and 1-year patient-reported outcomes (visual analog scale for head pain and visual analog scale for neck pain, Neck Disability Index NDI, Headache Disability Index, SF-12, Zung Self-Rating Depression Scale, and EuroQol-5D EQ-5D) were assessed. A level of improvement in general health after surgery was defined as meaningful improvement. Receiver-operating characteristic curves were generated to assess the validity of PROi to discriminate between meaningful improvement and not. The difference between standardized response means (SRMs) in patients reporting meaningful improvement vs not as calculated to determine the relative responsiveness of each outcome instrument.
For pain and disability, the NDI was the most accurate discriminator of meaningful effectiveness (area under the curve: 0.90) and also most responsive to postoperative improvement (standardized response means difference: 1.87). For general health and quality of life, the SF-12 PCS, EQ-5D, and Zung Self-Rating Depression Scale were all accurate discriminators; however, SF-12 Physical Component Scale (SF-12 PCS) and EQ-5D were most accurate. SF-12 PCS was also most responsive.
For pain and disability, NDI is the most valid and responsive measure of improvement after surgery for CMI. For health-related quality of life, SF-12 PCS and EQ-5D are the most valid and responsive measures. NDI with SF-12 or EQ-5D is the most valid in patients with CMI and should be considered in cost-effectiveness studies.
Abstract
Background
Microvascular decompression (MVD) is a common surgical treatment for cranial nerve compression, though cerebrospinal fluid (CSF) leak is a known complication of this procedure. ...Bone cement cranioplasty may reduce rates of CSF leak.
Objective
To compare rates of CSF leak before and after implementation of bone cement cranioplasty for the reconstruction of cranial defects after MVD.
Methods
Retrospective chart review was performed of patients who underwent MVD through retrosigmoid craniectomy for cranial nerve compression at a single institution from 1998 to 2017. Study variables included patient demographics, medical history, type of closure, and postoperative complications such as CSF leak, meningitis, lumbar drain placement, and ventriculoperitoneal shunt insertion. Cement and noncement closure groups were compared, and predictors of CSF leak were assessed using a multivariate logistic regression model.
Results
A total of 547 patients treated by 10 neurosurgeons were followed up for more than 20 years, of whom 288 (52.7%) received cement cranioplasty and 259 (47.3%) did not. Baseline comorbidities were not significantly different between groups. CSF leak rate was significantly lower in the cement group than in the noncement group (4.5 vs. 14.3%;
p
< 0.001). This was associated with significantly fewer patients developing postoperative meningitis (0.7 vs. 5.2%;
p
= 0.003). Multiple logistic regression model demonstrated noncement closure as the only independent predictor of CSF leak (odds ratio: 3.55; 95% CI: 1.78–7.06;
p
< 0.001).
Conclusion
CSF leak is a well-known complication after MVD. Bone cement cranioplasty significantly reduces the incidence of postoperative CSF leak and other complications. Modifiable risk factors such as body mass index were not associated with the development of CSF leak.
INTRODUCTION:Validated patient reported outcomes (PROs) for spinal disorders may be too lengthy to feasibly apply to large scale registry efforts. We set out to determine which PROs are most valid ...and responsive, and which domains have closest correlation (overlap). Our aim was to introduce a shorter, valid and responsive, and more feasible questionnaire for measuring effectiveness of lumbar surgery.
METHODS:A total of 520 patients undergoing surgery for degenerative lumbar spine disease were enrolled into our prospective registry. Baseline and 1-yr PROs were assessed. In order to assess the validity of PROs and individual items, ROC analysis was performed. In order to assess responsiveness, standardized response means (SRM) was calculated. Correlation was assessed via Spearman rank. For PROs and their items demonstrating high validity (AUC > 0.70), and for individual items with similar dimensions and high correlation, items with maximum validity were included in the final questionnaire, Vanderbilt Back Index (VBI-6).
RESULTS:ODI (AUC0.77;SRM diff0.96) and SF-12 PCS (AUC HTI0.76; SRM diff0.94) were found to be most valid and responsive. For ODI, pain intensity, mobility, social life and travel had highest AUC. For SF-12 PCS, general health, climbing stairs, less accomplishment, limitation from pain, effect on work and social activities had the highest AUC. 6 of these 12 most valid and responsive items were found to have significant correlation (r = 0.48,P < .0001). Thus, 6 items out of 22 (sitting, standing, social function, general health, accomplishment due to pain, effect on usual work) comprised VBI-6. VBI-6 (AUC0.81; SRM diff1.10) demonstrated better validity and responsiveness and strongly correlated with ODI (r = 0.84;P < .0001) and SF-12 PCS (r = 0.81;P < .0001).
CONCLUSION:The 10-item ODI and 12-item SF-12 PCS were the most valid and responsive PROs. However, a more valid and responsive instrument VBI-6 can be constructed using 6 out of 22 items. Large scale registry efforts can utilize this more feasible VBI-6, which has better validity and responsiveness than ODI and SF-12 PCS.
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