- [Show abstract] [Hide abstract] ABSTRACT: OBJECTIVE The aim in this paper was to evaluate the efficacy of long-acting liposomal bupivacaine in comparison with bupivacaine hydrochloride for lowering postoperative analgesic usage in the management of posterior cervical and lumbar decompression and fusion. METHODS A retrospective cohort-matched chart review of 531 consecutive cases over 17 months (October 2013 to February 2015) for posterior cervical and lumbar spinal surgery procedures performed by a single surgeon (J.J.) was performed. Inclusion criteria for the analysis were limited to those patients who received posterior approach decompression and fusion for cervical or lumbar spondylolisthesis and/or stenosis. Patients from October 1, 2013, through December 31, 2013, received periincisional injections of bupivacaine hydrochloride, whereas after January 1, 2014, liposomal bupivacaine was solely administered to all patients undergoing posterior approach cervical and lumbar spinal surgery through the duration of treatment. Patients were separated into 2 groups for further analysis: posterior cervical and posterior lumbar spinal surgery. RESULTS One hundred sixteen patients were identified: 52 in the cervical cohort and 64 in the lumbar cohort. For both cervical and lumbar cases, patients who received bupivacaine hydrochloride required approximately twice the adjusted morphine milligram equivalent (MME) per day in comparison with the liposomal bupivacaine groups (5.7 vs 2.7 MME, p = 0.27 [cervical] and 17.3 vs 7.1 MME, p = 0.30 [lumbar]). The amounts of intravenous rescue analgesic requirements were greater for bupivacaine hydrochloride in comparison with liposomal bupivacaine in both the cervical (1.0 vs 0.39 MME, p = 0.31) and lumbar (1.0 vs 0.37 MME, p = 0.08) cohorts as well. None of these differences was found to be statistically significant. There were also no significant differences in lengths of stay, complication rates, or infection rates. A subgroup analysis of both cohorts of opiate-naive versus opiate-dependent patients found that those patients who were naive had no difference in opiate requirements. In chronic opiate users, there was a trend toward higher opiate requirements for the bupivacaine hydrochloride group than for the liposomal bupivacaine group; however, this trend did not achieve statistical significance. CONCLUSIONS Liposomal bupivacaine did not appear to significantly decrease perioperative narcotic use or length of hospitalization, although there was a trend toward decreased narcotic use in comparison with bupivacaine hydrochloride. While the results of this study do not support the routine use of liposomal bupivacaine, there may be a benefit in the subgroup of patients who are chronic opiate users. Future prospective randomized controlled trials, ideally with dose-response parameters, must be performed to fully explore the efficacy of liposomal bupivacaine, as the prior literature suggests that clinically relevant effects require a minimum tissue concentration.
- [Show abstract] [Hide abstract] ABSTRACT: Background context: The North American Spine Society's (NASS) Evidence-Based Clinical Guideline for the Diagnosis and Treatment of Degenerative Lumbar Spondylolisthesis features evidence-based recommendations for diagnosing and treating degenerative lumbar spondylolisthesis. The guideline updates the 2008 guideline on this topic and is intended to reflect contemporary treatment concepts for symptomatic degenerative lumbar spondylolisthesis as reflected in the highest quality clinical literature available on this subject as of May 2013. NASS' guideline on this topic is the only guideline on degenerative lumbar spondylolisthesis included in the Agency for Healthcare Research and Quality's National Guideline Clearinghouse (NGC). Purpose: The purpose of this guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for patients with degenerative lumbar spondylolisthesis. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition. Study design: Guideline summary review METHODS: This guideline is the product of the Degenerative Lumbar Spondylolisthesis Work Group of NASS' Evidence-Based Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multi-disciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guidelines were submitted to an internal peer review process and ultimately approved by the NASS Board of Directors. Upon publication, the Degenerative Lumbar Spondylolisthesis guideline was accepted into the NGC and will be updated approximately every 5 years. Results: Twenty-seven clinical questions were addressed in this guideline update, including 15 clinical questions from the original guideline and 12 new clinical questions. The respective recommendations were graded by strength of the supporting literature, which was stratified by levels of evidence. Twenty-one new or updated recommendations or consensus statements were issued and 13 recommendations or consensus statements were maintained from the original guideline. Conclusions: The clinical guideline was created using the techniques of evidence-based medicine and best available evidence to aid practitioners in the care of patients with degenerative lumbar spondylolisthesis. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flow chart, suggestions for future research and all of the references, is available electronically on the NASS website at https://www.spine.org/Pages/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx and will remain updated on a timely schedule.
- [Show abstract] [Hide abstract] ABSTRACT: Approximately one-third of patients with isolated traumatic brain injury (iTBI) present with acute traumatic coagulopathy (ATC). ATC is associated with increased morbidity and mortality. Its effects on long-term functional and cognitive outcomes are not as well characterized. Data from the Citicoline Brain Injury Treatment Trial (COBRIT) were analyzed retrospectively. Exclusion criteria were renal failure or malignancy, and any extracranial injury severity score >3. ATC was defined as INR > 1.3, PTT > 38 s, or platelets < 100 K, determined at baseline, and during the first 7 days of hospitalization. Six hundred forty-seven patients were included; 21 % were found to have ATC. Highest incidence occurred at baseline, and Day Two. Forty-two percent of ATC patients had a GCS < 8, compared with 11.3 % of non-ATC patients (p < 0.001). A significantly higher proportion of ATC patients was transfused blood products, required greater than 4L of fluids, demonstrated hyperthermia and hypothermia, were hypotensive and demonstrated elevated lactate when compared to non-ATC patients. In-hospital mortality, mean hospital length of stay, incidence of DVT and seizures were also significantly higher in ATC patients. A significantly lower portion of ATC patients had good outcomes on the GOS-E (i.e., score > 6), and the DRS (i.e., score < 2) at 180 days, for which ATC was found to be an independent predictor with binary logistic regression. ATC patients also performed significantly worse on several components of the CVLT-II at 180 days. ATC accompanying iTBI is associated with worse functional and cognitive outcomes at 180 days.
- [Show abstract] [Hide abstract] ABSTRACT: Syringomyelia is a potentially debilitating disease that involves abnormal CSF flow mechanics; its incidence after traumatic spinal cord injury (SCI) is approximately 15%. Treatment consists of restoration of CSF flow, typically via arachnoidolysis and syrinx decompression. The authors present a case of pronounced syringomyelia in a patient with concomitant severe cervical myelomalacia to demonstrate unilateral C-5 palsy as a potential complication of aggressive syrinx decompression at a remote level. A 56-year-old man with a remote history of SCI at T-11 (ASIA [American Spinal Injury Association] Grade A) presented with complaints of ascending motor and sensory weakness into the bilateral upper extremities that had progressed over 1 year. MRI demonstrated severe distortion of the spinal cord at the prior injury level of T10-11, where an old anterior column injury and prior hook-rod construct was visualized. Of note, the patient had a holocord syrinx with demonstrable myelomalacia. To restore CSF flow and decompress the spinal cord, T-2 and T-3 laminectomies, followed by arachnoidolysis and syringopleural shunt placement, were performed. Postoperatively on Day 1, with the exception of a unilateral deltoid palsy, the patient had immediate improvement in upper-extremity strength and myelopathy. He was discharged from the hospital on postoperative Day 5; however, at his 2-week follow-up visit, a persistent unilateral deltoid palsy was noted. MRI demonstrated a significant reduction in the holocord syrinx, no neural foraminal stenosis, and a significant positional shift of the ventral spinal cord. Further motor recovery was noted at the 8-month follow-up. Syringomyelia is a debilitating disease arising most often as a result of traumatic SCI. In the setting of myelomalacia with a pronounced syrinx, C-5 palsy is a potential complication of syrinx decompression.
- [Show abstract] [Hide abstract] ABSTRACT: Retrospective series report varied rates of bleeding and infection with external ventricular drainage (EVD). There have been no prospective studies of these risks with systematic surveillance, threshold definitions, or independent adjudication. To analyze the rate of complications in the ongoing Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage Phase III (CLEAR III) trial, providing a comparison with a systematic review of complications of EVD in the literature. Patients were prospectively enrolled in the CLEAR III trial after placement of an EVD for obstructive intraventricular hemorrhage and randomized to receive recombinant tissue-type plasminogen activator or placebo. We counted any detected new hemorrhage (catheter tract hemorrhage or any other distant hemorrhage) on computed tomography scan within 30 days from the randomization. Meta-analysis of published series of EVD placement was compiled with STATA software. Growing or unstable hemorrhage was reported as a cause of exclusion from the trial in 74 of 5707 cases (1.3%) screened for CLEAR III. The first 250 patients enrolled have completed adjudication of adverse events. Forty-two subjects (16.8%) experienced ≥1 new bleeds or expansions, and 6 of 250 subjects (2.4%) suffered symptomatic hemorrhages. Eleven cases (4.4%) had culture-proven bacterial meningitis or ventriculitis. Risks of bleeding and infection in the ongoing CLEAR III trial are comparable to those previously reported in EVD case series. In the present study, rates of new bleeds and bacterial meningitis/ventriculitis are very low despite multiple daily injections, blood in the ventricles, the use of thrombolysis in half the cases, and generalization to >60 trial sites. CI, confidence intervalCLEAR, Clot Lysis: Evaluating Accelerated Resolution of Intraventricular HemorrhageEVD, external ventricular drainageICH, intracranial hemorrhageIVH, intraventricular hemorrhagertPA, recombinant tissue-type plasminogen activator.
- [Show abstract] [Hide abstract] ABSTRACT: Objectives: Examine the effects of posttraumatic amnesia (PTA) duration on neuropsychological and global recovery from 1 to 6 months after complicated mild traumatic brain injury (cmTBI). Participants: A total of 330 persons with cmTBI defined as Glasgow Coma Scale score of 13 to 15 in emergency department, with well-defined abnormalities on neuroimaging. Methods: Enrollment within 24 hours of injury with follow-up at 1, 3, and 6 months. Measures: Glasgow Outcome Scale-Extended, California Verbal Learning Test II, and Controlled Oral Word Association Test. Duration of PTA was retrospectively measured with structured interview at 30 days postinjury. Results: Despite all having a Glasgow Coma Scale Score of 13 to 15, a quarter of the sample had a PTA duration of greater than 7 days; half had PTA duration of 1 of 7 days. Both cognitive performance and Extended Glasgow Outcome Scale outcomes were strongly associated with time since injury and PTA duration, with those with PTA duration of greater than 1 week showing residual moderate disability at 6-month assessment. Conclusions: Findings reinforce importance of careful measurement of duration of PTA to refine outcome prediction and allocation of resources to those with cmTBI. Future research would benefit from standardization in computed tomographic criteria and use of severity indices beyond Glasgow Coma Scale to characterize cmTBI.
- [Show abstract] [Hide abstract] ABSTRACT: Objectives: To test the hypothesis that hyperoxia was associated with higher in-hospital case-fatality in ventilated patients with ICH admitted to the Intensive Care Unit (ICU). Methods: Admissions of ventilated ICH patients within 24 hours of admission to the ICU at 77 United States hospitals between 2003-2008. Patients were divided into three exposure groups: hyperoxia (PaO2≥300 mmHg), hypoxia (PaO2<60 mmHg or PaO2/FiO2 ratio ≤300), and normoxia, not defined as hyperoxia or hypoxia. The primary outcome was in-hospital case-fatality. Results: 1,388 ventilated ICH patients. Mean age 63 years (SD 15), 47% (653/1388) female, and median GCS 5 (IQR 3-8). The overall case-fatality was 59% (812/1388). Upon admission to the ICU, 36% (492/1388) were normoxic, 47% (641/1388) were hypoxic, and 17% (238/1388) were hyperoxic on ABGt1. ABGt2 was accomplished in 780 patients, of whom 46% (352/780) were normoxic, 45% (352/780) were hypoxic, and 9% (67/780) were hyperoxic. Of the initially admitted hyperoxic patients, 15% (21/138) remained hyperoxic and had a case-fatality of 82% (18/21) as compared to 49% (67/138) who became normoxic and had a case-fatality of 46% (32/67) (crude OR 6.6, 95%CI:1.8-25, χ2=9.4, p=0.002). In a multivariable analysis controlling for other predictors of poor outcome and hospital specific characteristics, and a propensity-score, failure to correct hyperoxia was associated with higher case-fatality (adjusted OR 2.5, 95%CI:1.1-6.1, p=0.04). Conclusion: In ventilated ICH patients, failure to normalize hyperoxia was associated with higher case-fatality. These data underscore the need for studies of controlled re-oxygenation in ventilated ICH patients. © 2015, Indonesian Society of Critical Care Medicine. All rights reserved.
- [Show abstract] [Hide abstract] ABSTRACT: Objective: The epidemiology of circulatory shock after spontaneous intracerebral hemorrhage (ICH) is unknown. We sought to determine its incidence, risk factors, and effect on case-fatality. Design: Retrospective multi-center cohort study.Setting: 83 ICUs in the United States from 2003- 2008. Patients: Subjects with ICH >17 years of age admitted to an ICU. Shock was defined as sustained systolic blood pressure <90 mmHg for ≥1 hour despite vasopressors. Interventions: None. Measurements and results: A total of 4,192 ICH patients. Median age was 67 yrs (IQR 54-77), 2221 (53%) were male, and 3030 (75%) were white. Median APACHE-II score was 15 (interquartile-range [IQR] 11-21) and Glasgow Coma Scale (GCS) was 11 (IQR 6-14). Incidence of shock after ICH was 5% (212/4192). Case-fatality was 72% among shock vs. 30% without shock (p<0.0001). In multi-variable analysis the following were associated with increased case-fatality: age (OR 1.01, 95%CI:1.01-1.02), DNR status (OR 1.8, 95%CI:1.3-2.6), GCS<8 (OR 11.4, 95%CI:8.4- 15.4), GCS 8-12 (OR 2.1, 95%CI:1.5-2.9), mechanical ventilation (OR 2.0, 95%CI:1.6-2.5), organ dysfunction (OR 1.7, 95%CI:1.4-2.0), spontaneous hypothermia (OR 7.3, 95%CI:2.8-19.3), APACHE ≥15 (OR 2.9, 95%CI:2.2-3.7), and shock (OR 1.9, 95%CI:1.2-3.0). EVD placement was associated with survival (OR 0.8, 95%CI:0.6-0.9). Conclusion: Circulatory shock after ICH is rare and associated with increased case-fatality. © 2015, Indonesian Society of Critical Care Medicine. All rights reserved.
Chapter: Traumatic Brain Injury[Show abstract] [Hide abstract] ABSTRACT: The ongoing maturation in the understanding of the pathophysiology of traumatic brain injury has led to an evolution in the management of this patient population. Segregation of patients into operative and nonoperative categories has been replaced by a multidisciplinary approach in which medical and surgical interventions represent tools in a broader arsenal of critical care. As a result, an understanding of surgical options is important not only to the neurosurgeon but also to the intensivist and neurologist. The Guidelines for the Surgical Management of Traumatic Brain Injury represents the most extensive review of the literature to date, yet it is mostly limited to class III evidence that provides a basis upon which to build clinical decision making. The information presented in the following highlights neurosurgical intervention within the broader context of a multidisciplinary approach, but it is intended to be of use to all practitioners involved in the care of the traumatic brain injury patient.
- [Show abstract] [Hide abstract] ABSTRACT: Open-label Laboratory Investigational Study; Non-animal Surgical Simulation OBJECTIVES:: The authors perform a comparison of dural closure strength in a durotomy simulator across two different suture materials.
- [Show abstract] [Hide abstract] ABSTRACT: Object: One often overlooked aspect of spinal epidural abscesses (SEAs) is the timing of surgical management. Limited evidence is available correlating earlier intervention with outcomes. Spinal epidural abscesses, once a rare diagnosis carrying a poor prognosis, are steadily becoming more common, with one recent inpatient meta-analysis citing an approximate incidence of 1 in 10,000 admissions with a mortality approaching 16%. One key issue of contention is the benefit of rapid surgical management of SEA to maximize outcomes. Timing of surgical management is definitely one overlooked aspect of care in spinal infections. Therefore, the authors performed a retrospective analysis in which they evaluated patients who underwent early (evacuation within 24 hours) versus delayed surgical intervention (> 24 hours) from the point of diagnosis, in an attempt to test the hypothesis that earlier surgery results in improved outcomes. Methods: A retrospective review of a prospectively maintained adult neurosurgical database from 2009 to 2011 was conducted for patients with the diagnostic heading: epidural abscess, infection, osteomyelitis, osteodiscitis, spondylodiscitis, and abscess. The primary end point for each patient was neurological grade, measured as an American Spinal Injury Association Impairment Scale grade using hospital inpatient records on admission and discharge. Patients were divided into early surgical (< 24 hours) and delayed surgical cohorts. Results: Eighty-seven consecutive patients were identified (25 females; mean age 55.5 years, age range 18-87 years). Fifty-four patients received surgery within 24 hours of admission (mean time from admission to incision, 11.2 hours), and 33 underwent surgery longer than 24 hours (mean 59 hours) after admission. Of the 54 patients undergoing early surgery 45 (85%) had a neurological deficit, whereas in the delayed surgical group 21 (64%) of 33 patients presented with a neurological deficit (p = 0.09). Patients in the delayed surgery cohort were significantly older by 10 years (59.6 vs 51.8 years, p = 0.01). With regard to history of prior revision, body mass index, intravenous drug abuse, tobacco use, prior radiation therapy, diabetes, chronic systemic infection, and prior osteomyelitis, there were no significant differences. There was no significant difference between early and delayed surgery groups in neurological grade on presentation, discharge, or location of epidural abscess. The most common organism isolated was Staphylococcus aureus (n = 51, 59.3%). The incidence of methicillin-resistant S. aureus was 21% (18 of 87). Conclusions: Evacuation within 24 hours appeared to have a relative advantage over delayed surgery with regard to discharge neurological grade. However, due to a limited, variable sample size, a significant benefit could not be shown. Further subgroup analyses with larger populations are required.
- [Show abstract] [Hide abstract] ABSTRACT: Background: Prior studies published in the cardiothoracic, orthopedic and gastrointestinal surgery have identified the importance of nasal (methicillin-resistant Staphylococcus aureus) MRSA screening and subsequent decolonization to reduce MRSA surgical site infection (SSI). This is the first study to date correlating nasal MRSA colonization with postoperative spinal MRSA SSI. Objective: To assess the significance of nasal MRSA colonization in the setting of MRSA SSI. Methods: A retrospective electronic chart review of patients from year 2011 to June 2013 was conducted for patients with both nasal MRSA colonization within 30 days prior to spinal surgery. Patients who tested positive for MRSA were put on contact isolation protocol. None of these patients received topical antibiotics for decolonization of nasal MRSA. Results: A total of 519 patients were identified; 384 negative (74%), 110 MSSA-positive (21.2%), and 25 (4.8%) MRSA-positive. Culture positive surgical site infection (SSI) was identified in 27 (5.2%) cases and was higher in MRSA-positive group than in MRSA-negative and MSSA-positive groups (12% vs. 5.73% vs. 1.82%; p = 0.01). The MRSA SSI rate was 0.96% (n = 5). MRSA SSI developed in 8% of the MRSA-positive group as compared to only in 0.61% of MRSA-negative group, with a calculated odds ratio of 14.23 (p = 0.02). In the presence of SSI, nasal MRSA colonization was associated with MRSA-positive wound culture (66.67 vs. 12.5%; p < 0.0001). Conclusion: Preoperative nasal MRSA colonization is associated with postoperative spinal MRSA SSI. Preoperative screening and subsequent decolonization using topical antibiotics may help in decreasing the incidence of MRSA SSI after spine surgery. Nasal MRSA+ patients undergoing spinal surgery should be informed regarding their increased risk of developing surgical site infection.
- [Show abstract] [Hide abstract] ABSTRACT: Objective Subarachnoid hemorrhage (SAH) causes significant morbidity and mortality. Pulmonary complications may be particularly frequent, but national data is lacking on the outcomes associated with acute respiratory distress syndrome (ARDS) in SAH patients. The aim of this study is to determine national trends for SAH patients with ARDS. Methods The Nationwide Inpatient Sample Database (NIS) was utilized to sample 193,209 admissions for SAH with and without ARDS from 1993 to 2008 using ICD-9-CM coding. A multivariate stepwise regression analysis was performed. Results The incidence of ARDS in SAH has increased from 35.51% in 1993 to 37.60% in 2008. However, the overall mortality in SAH patients and in SAH patients with ARDS has decreased in the same period, from 42.30% to 31.99% and from 75.13% to 60.76% respectively. Multivariate analysis showed that the predictors of developing ARDS in SAH patients include older age, larger hospital size, and comorbidities such as epilepsy, cardiac arrest, sepsis, congestive heart failure, hypertension, chronic obstructive pulmonary disease, and hematologic, renal, or neurological dysfunction. Predictors of mortality in SAH patients include age and hospital complications such as coronary artery disease, ARDS, cancer, and hematologic, or renal dysfunction. Conclusion SAH patients are at increased risk of developing ARDS and the identification of certain risk factors may alert and aid the practitioner in preventing worsening disease.
- [Show abstract] [Hide abstract] ABSTRACT: We aimed to assess the efficacy of intraoperative vancomycin powder in intrathecal baclofen pump placement patients, a high risk population. A retrospective review was conducted using prospectively collected data at an academic tertiary care unit. The neurosurgical adult patient population was queried for all intrathecal baclofen pump implantation procedures. Patients were then reviewed for the use of intraoperative crystalline vancomycin powder. Those with a history of prior surgical site infection, chronic systemic infections or osteomyelitis were excluded. Anhydrous, crystalline vancomycin was utilized in the wound bed after completion of implantation, distributed evenly in the case of multiple incisions. Patients received 500mg or 1000mg of crystallized vancomycin, evenly distributed through the wound layers based on a 70 kg weight cutoff. Intraoperative institutional standards of infection prophylaxis were unchanged throughout the study period. Infection rate of baclofen pump placement prior to the use of vancomycin powder from 2001-2009 at the same institution was monitored. Wound infection rate was tracked for a 12month postoperative period. Six patients out of 26 baclofen pump implantations (23%) in this cohort were identified to have seven infections despite vancomycin powder placement in the lumbar and catheter wounds. Prior infection rates have been investigated for intrathecal drug delivery systems from 2001 to 2009 at the same institution with an overall infection rate of 3% (8/274). The use of vancomycin powder in patients with implants in this series did not reduce infection rates compared to published historical controls, and was elevated compared to institutional controls. Further prospective study of this high risk patient population is warranted.
- [Show abstract] [Hide abstract] ABSTRACT: To describe national trends in prevalence, demographics, hospital length of stay (LOS), hospital charges, and mortality for burn patients with and without inhalational injury and to compare to the National Burn Repository. Burns and inhalation injury cause considerable mortality and morbidity in the United States. There remains insufficient reporting of the demographics and outcomes surrounding such injuries. The National Inpatient Sample database, the nation's largest all-payer inpatient care data repository, was utilized to select 506,628 admissions for burns from 1988 to 2008 based on ICD-9-CM recording. The data were stratified based on the extent of injury (%TBSA) and presence or absence of inhalational injury. Inhalation injury was observed in only 2.2% of burns with <20% TBSA but 14% of burns with 80 to 99% TBSA. Burn patients with inhalation injury were more likely to expire in-hospital compared to those without (odds ratio, 3.6; 95% confidence interval, 2.7-5.0; P < .001). Other factors associated with higher mortality were African-American race, female sex, and urban practice setting. Patients treated at rural facilities and patients with hyperglycemia had lower mortality rates. Each increase in percent of TBSA of burns increased LOS by 2.5%. Patients with burns covering 50 to 59% of TBSA had the longest hospital stay at a median of 24 days (range, 17-55). The median in-hospital charge for a burn patient with inhalation injury was US$32,070, compared to US$17,600 for those without. Overall, patients who expired from burn injury accrued higher in-hospital charges (median, US$50,690 vs US$17,510). Geographically, California and New Jersey were the states with the highest charges whereas Vermont and Maryland were states with the lowest charges. The study analysis provides a broad sampling of nationwide demographics, LOS, and in-hospital charges for patients with burns and inhalation injury.
- [Show abstract] [Hide abstract] ABSTRACT: Background: The reported incidence of concurrent traumatic brain (TBI) and spine or spinal cord injuries (SCI) is poorly defined, with widely variable literature rates from 16 to 74%. Objectives: To define the incidence of concurrent TB! and SCI, and compare the incidence over a twenty-year time period. Methods: To define the longitudinal incidence and concurrent rate of TBI and SCI via a retrospective review of the Nationwide Inpatient Sample (NIS) database over a twenty year period. Results: Over the study period, the incidence of TBI declined from 143 patients/100k admissions to 95 patients/100k. However, there was a concurrent increase in SCI from 61 patients/100k admissions to 75 patients/100k admissions (P <0.0001). Regional variations in SCI trends were noted, with specific regions demonstrating an increasing trend. Cervical fractures had the greatest increase by nearly a three-fold rise (1988: 4562-2008: 12,418). There was an increase in the incidence of TBI among SCI admission from 3.7% (1988) to 12.5% (2008) (OR = 1.067 per year; 95% Cl = 1.065-1.069 per year; P <0.0001). Concurrently, SCI patients had an increase in TBI (9.1% (1988)-15.9% (2008) (OR = 1.038 per year (95% Cl 1.036-1.040; P < 0.001))). Conclusion: A retrospective review of the NIS demonstrates a rising trend in the incidence of concurrent TBI and SCI. More investigative work is necessary to examine causative factors for this trend.
- [Show abstract] [Hide abstract] ABSTRACT: Study Design. Retrospective Case Series.Objective. To demonstrate the microbial trends of spinal surgical site infections(SSI) in patients who had previously received crystallized vancomycin in the operative bed.Summary of Background Data. Prior large, case control series demonstrate the significant decrease in SSI with the administration of vancomycin in the wound bed.Methods. A single institution, electronic database search was conducted for all spinal surgery patients who had received prophylactic crystalline vancomycin powder in the wound bed. Patient's with a prior history of wound infection, intrathecal pumps, or spinal stimulators were excludedResults. 981 consecutive patients (494 male, 487 female, mean age 59.4 years, range 16-95 years) were identified from January 2011 to June 2013. The average dose of vancomycin powder was 1.13 grams(range: 1-6 grams). 66 patients (6.71%) were diagnosed with a SSI of which 51 patients had positive wound cultures (5.2%). Of the 51 positive cultures the most common organism was Staphylococcus aureus. The average dose of vancomycin was 1.3 grams in the 38 cases where a gram-positive organism was cultured. A number of gram-negative infections were encountered such as Serratia marcescens, Enterobacter aerogenes, Bacteroides fragilis, Enterobacter cloacae, Citrobacter koseri and Pseudomonas aeruginosa. The average dose of vancomycin was 1.2 grams in 23 cases where a gram negative infection was cultured. 15 of the 51 (29.4%) positive-cultures were polymicrobial. 8 (53%) of these 15 polymicrobial cultures contained three or more distinct organisms.Conclusion. Prophylactic intraoperative vancomycin use in the wound bed in spinal surgery may increase the incidence of gram-negative or polymicrobial spinal infections. The use of intraoperative vancomycin may correlate with postoperative seromas, due to the high incidence of non-positive cultures. Large, randomized, prospective trials are needed to demonstrate causation and dose-response relationship.
- [Show abstract] [Hide abstract] ABSTRACT: Background The reported incidence of concurrent traumatic brain (TBI) and spine or spinal cord injuries (SCI) is poorly defined, with widely variable literature rates from 16 to 74%. Objectives To define the incidence of concurrent TBI and SCI, and compare the incidence over a twenty-year time period. Methods To define the longitudinal incidence and concurrent rate of TBI and SCI via a retrospective review of the Nationwide Inpatient Sample (NIS) database over a twenty year period. Results Over the study period, the incidence of TBI declined from 143 patients/100k admissions to 95 patients/100k. However, there was a concurrent increase in SCI from 61 patients/100k admissions to 75 patients/100k admissions (P < 0.0001). Regional variations in SCI trends were noted, with specific regions demonstrating an increasing trend. Cervical fractures had the greatest increase by nearly a three-fold rise (1988: 4562–2008: 12,418). There was an increase in the incidence of TBI among SCI admission from 3.7% (1988) to 12.5% (2008) (OR = 1.067 per year; 95% CI = 1.065–1.069 per year; P < 0.0001). Concurrently, SCI patients had an increase in TBI (9.1% (1988)–15.9% (2008) (OR = 1.038 per year (95% CI 1.036–1.040; P < 0.001))). Conclusion A retrospective review of the NIS demonstrates a rising trend in the incidence of concurrent TBI and SCI. More investigative work is necessary to examine causative factors for this trend.
Thomas Jefferson UniversityFiladelfia, Pennsylvania, United States
University of New OrleansNew Orleans, Louisiana, United States
Temple UniversityFiladelfia, Pennsylvania, United States