Category Archives: Infection

Neurosurgery and ACS National Surgical Quality Improvement Program (ACS-NSQIP)


VP shunts were placed in 3,984 patients either as an initial placement (n = 1,093) or as a revision (n = 2,891). Compared to the initial-placement group, the revision group was significantly more likely to experience shunt failure (14 vs. 8%, p < 0.0001). In the initial-placement group, congenital hydrocephalus was independently associated with shunt failure (OR 1.83; 95% CI 1.01-3.31, p = 0.047). In the revision group, cardiac risk factors (OR 1.38; 95% CI 1.00-1.90, p = 0.047), a chronic history of seizures (OR 1.33; 95% CI 1.04-1.71, p = 0.022), and a history of neuromuscular disease (OR 0.61; 95% CI 0.41-0.90, p = 0.014) were independently associated with shunt failure.

Identifying the factors associated with VP shunt failure may allow the development of interventions to decrease failures. Further refinement of the collected variables in the ACS National Surgical Quality Improvement Program (NSQIP) Pediatric specific to neurosurgical procedures is necessary to identify modifiable risk factors 1).


Cote et al., performed a search of the ACS National Surgical Quality Improvement Program (ACS-NSQIP) database for all patients undergoing operations with a neurosurgeon from 2006 to 2013. They analyzed demographics, past medical history, and post-operative respiratory failure, defined as unplanned intubation and/or ventilator dependence for more than 48 h post-operatively.

Of 94,621 NSQIP-reported neurosurgical patients from 2006 to 2013, 2325 (2.5 %) developed post-operative respiratory failure. Of these patients, 1270 (54.6 %) were male, with an overall mean age of 60.59 years; 571 (24.56 %) were current smokers and 756 (32.52 %) were ventilator-dependent. Past medical history included dyspnea in 204 patients (8.8 %), COPD in 198 (8.5 %), and congestive heart failure in 66 (2.8 %). The rate of post-operative respiratory failure decreased from 4.1 % in 2006 to 2.1 % in 2013 (p < 0.001). Of the 2325 patients with respiratory failure, 1061 (45.6 %) underwent unplanned intubation post-operatively and 1900 (81.7 %) were ventilator-dependent for more than 48 h. The rate of both unplanned intubation (p < 0.001) and ventilator dependence (p < 0.001) decreased significantly from 2006 to 2013. Multivariate analysis demonstrated that significant risk factors for respiratory failure included inpatient status (p < 0.001, OR = 0.165), age (p < 0.001, OR = 1.014), diabetes (p = 0.001, OR = 1.489), functional dependence prior to surgery (p < 0.001, OR = 2.081), ventilator dependence (p < 0.001, OR = 10.304), hypertension requiring medication (p = 0.005, OR = 1.287), impaired sensorium (p < 0.001, OR = 2.054), CVA/stroke with or without neurological deficit (p < 0.001, OR = 2.662; p = 0.002, OR = 1.816), systemic sepsis (p < 0.001, OR = 1.916), prior operation within 30 days (p = 0.026, OR = 1.439), and operation type (cranial relative to spine, p < 0.001, OR = 4.344).

Based on the NSQIP database, risk factors for respiratory failure after neurosurgery include pre-operative ventilator dependence, alcohol use, functional dependence prior to surgery, stroke, and recent operation. The overall rate of respiratory failure decreased from 4.1 % in 2006 to 2.1 % in 2013 according to these data 2).


Data from adult patients who underwent surgery for spinal tumors (2011-2014) were extracted from the prospective National Surgical Quality Improvement Program (NSQIP) registry. Multivariable logistic regression was used to evaluate predictors of reoperation, readmission, and major complications (death, neurological, cardiopulmonary, venous thromboembolism [VTE], surgical site infection [SSI], and sepsis). Variables screened included patient age, sex, tumor location, American Society of Anesthesiologists (ASA) physical classification, preoperative functional status, comorbidities, preoperative laboratory values, case urgency, and operative time. Additional variables that were evaluated when analyzing readmission included complications during the surgical hospitalization, hospital length of stay (LOS), and discharge disposition.

Among the 2207 patients evaluated, 51.4% had extradural tumors, 36.4% had intradural extramedullary tumors, and 12.3% had intramedullary tumors. By spinal level, 20.7% were cervical lesions, 47.4% were thoracic lesions, 29.1% were lumbar lesions, and 2.8% were sacral lesions. Readmission occurred in 10.2% of patients at a median of 18 days (interquartile range [IQR] 12-23 days); the most common reasons for readmission were SSIs (23.7%), systemic infections (17.8%), VTE (12.7%), and CNS complications (11.9%). Predictors of readmission were comorbidities (dyspnea, hypertension, and anemia), disseminated cancer, preoperative steroid use, and an extended hospitalization. Reoperation occurred in 5.3% of patients at a median of 13 days (IQR 8-20 days) postoperatively and was associated with preoperative steroid use and ASA Class 4-5 designation. Major complications occurred in 14.4% of patients: the most common complications and their median time to occurrence were VTE (4.5%) at 9 days (IQR 4-19 days) postoperatively, SSIs (3.6%) at 18 days (IQR 14-25 days), and sepsis (2.9%) at 13 days (IQR 7-21 days). Predictors of major complications included dependent functional status, emergency case status, male sex, comorbidities (dyspnea, bleeding disorders, preoperative systemic inflammatory response syndrome, preoperative leukocytosis), and ASA Class 3-5 designation (p < 0.05). The median hospital LOS was 5 days (IQR 3-9 days), the 30-day mortality rate was 3.3%, and the median time to death was 20 days (IQR 12.5-26 days).

In a ACS National Surgical Quality Improvement Program analysis, 10.2% of patients undergoing surgery for spinal tumors were readmitted within 30 days, 5.3% underwent a reoperation, and 14.4% experienced a major complication. The most common complications were SSIs, systemic infections, and VTE, which often occurred late (after discharge from the surgical hospitalization). Patients were primarily readmitted for new complications that developed following discharge rather than exacerbation of complications from the surgical hospital stay. The strongest predictors of adverse events were comorbidities, preoperative steroid use, and higher ASA score. These models can be used by surgeons to risk-stratify patients preoperatively and identify those who may benefit from increased surveillance following hospital discharge 3).


Using the American College of Surgeons’ National Surgical Quality Improvement Program (ACS-NSQIP) dataset, a retrospective analysis of the complications experienced by patients that underwent surgical management of a UIA between the years of 2007 and 2013. The primary outcomes of interest were mortality within the 30-day perioperative period and adverse discharge disposition to a location other than home. Predictors of morbidity and mortality were elucidated using multivariable logistic regression analyses controlling for available patient demographic, comorbidity, and operative characteristics.

662 patients were identified in the ACS-NSQIP dataset for operative management of an unruptured aneurysm. The observed rates of 30-day mortality and adverse discharge disposition were 2.27% and 19.47%, respectively. A hundred and eight (16.31%) patients developed at least one major complication. On multivariable analysis, death within 30days was significantly associated with increased operative time (OR 1.005 per minute, 95% CI 1.002-1.008) and chronic preoperative corticosteroid use (OR 28.4, 95% CI 1.68-480.42), whereas major complication development was associated with increased operative time (OR 1.004 per minute, 95% CI 1.002-1.006), age (OR 1.017 per year, 95% CI 1-1.034), preoperative dependency (OR 3.3, 95% CI 1.16-9.40) and diabetes mellitus (OR 2.89, 95% CI 1.45-5.75). Lastly, increasing age (OR 1.017 per year, 95% CI 1-1.034) as well as ASA Class 3 (OR 1.73, 95% CI 1.08-2.77) and 4 (OR 2.28, 95% CI 1.1-4.72) were independent predictors of discharge to a location other than home.

The study yields morbidity and mortality benchmarks for UIA surgery in a representative, national surgical registry. It will hopefully aid in recognizing those patients at greater risk for postoperative complications following surgical management, leading to appropriate changes in treatment strategies for this selected group of patients 4).


2351 patients underwent peripheral nerve surgery, 120 complications were identified in 100 patients (4.25%), and 103 patients (4.38%) received nerve grafting. Thirty-one (1.95%) of the 1593 patients underwent unplanned readmission. Nerve grafting procedures had no association with postoperative complications and unplanned readmission rates. Patients who experienced an inpatient procedure (OR= 2.54, P<0.001), a longer operative time (OR= 1.00, P<0.001) and worse wound classifications (OR= 1.83, P<0.001) all had increased odds of postoperative complications. An inpatient procedure (OR= 2.74, P=0.014) and any complications (OR= 24.43, P<0.001) were significantly associated with unplanned readmission.

The study confirms that peripheral nerve surgery and nerve graft procedures can be safely performed with low complication risks and low unplanned readmission rates. We also identified the risks associated with perioperative adverse outcomes, and these data may be used as an adjunct for risk stratification for patients under consideration for peripheral nerve surgery. This approach may enable the improved targeting of the most costly and harmful complications of preventive measures 5).


1) Gonzalez DO, Mahida JB, Asti L, Ambeba EJ, Kenney B, Governale L, Deans KJ, Minneci PC. Predictors of Ventriculoperitoneal Shunt Failure in Children Undergoing Initial Placement or Revision. Pediatr Neurosurg. 2017;52(1):6-12. PubMed PMID: 27490129.
2) Cote DJ, Karhade AV, Burke WT, Larsen AM, Smith TR. Risk factors for post-operative respiratory failure among 94,621 neurosurgical patients from 2006 to 2013: a NSQIP analysis. Acta Neurochir (Wien). 2016 Sep;158(9):1639-45. doi: 10.1007/s00701-016-2871-8. Epub 2016 Jun 23. PubMed PMID: 27339268.
3) Karhade AV, Vasudeva VS, Dasenbrock HH, Lu Y, Gormley WB, Groff MW, Chi JH, Smith TR. Thirty-day readmission and reoperation after surgery for spinal tumors: a National Surgical Quality Improvement Program analysis. Neurosurg Focus. 2016 Aug;41(2):E5. doi: 10.3171/2016.5.FOCUS16168. PubMed PMID: 27476847.
4) Kerezoudis P, McCutcheon BA, Murphy M, Rayan T, Gilder H, Rinaldo L, Shepherd D, Maloney PR, Hirshman BR, Carter BS, Bydon M, Meyer F, Lanzino G. Predictors of 30-day perioperative morbidity and mortality of unruptured intracranial aneurysm surgery. Clin Neurol Neurosurg. 2016 Oct;149:75-80. doi: 10.1016/j.clineuro.2016.07.027. Epub 2016 Jul 27. PubMed PMID: 27490305.
5) Hu K, Zhang T, Hutter MM, Xu W, Williams ZM. Thirty-Day Perioperative Adverse Outcomes Following Peripheral Nerve Surgery: An Analysis of 2351 Patients in the ACS NSQIP Database. World Neurosurg. 2016 Jul 16. pii: S1878-8750(16)30545-9. doi: 10.1016/j.wneu.2016.07.023. [Epub ahead of print] PubMed PMID: 27436210.

Book: Cranial Osteomyelitis: Diagnosis and Treatment

Cranial Osteomyelitis: Diagnosis and Treatment
By Ali Akhaddar

Cranial Osteomyelitis: Diagnosis and Treatment

Price:$129.00 

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This book is the first reference book covering exclusively all aspects of this challenging disease. It is designed to serve as a succinct appropriate resource for neurosurgeons, otorhinolaryngologists, neuroradiologists, researchers and infectious disease specialists with an interest in cranial infection. Cranial Osteomyelitis provides an in-depth review of knowledge of the management of skull osteomyelitis, with an emphasis on risk factors, causative pathogens, pathophysiology of dissemination, clinical presentations, neuroradiological findings and treatment modalities, medical and surgical. Sections on the prognosis and prevention of this illness are also included. The book will help the reader in choosing the most appropriate way to manage this challenging bone infection. In addition, it supplies clinicians and investigators with both basic and more sophisticated information and procedures relating to the complications associated with skull osteomyelitis. It also considers future areas of investigation and innovative therapeutic philosophies. The book is richly illustrated to provide readers with unparalleled access to a comprehensive collection of cranial osteomyelitis images (biological, clinical, neuroradiological, and surgical) taken directly from the author’s collection and experience in the field.


Product Details

  • Published on: 2016-04-24
  • Original language: English
  • Number of items: 1
  • Dimensions: 9.61″ h x .79″ w x 6.26″ l, .0 pounds
  • Binding: Hardcover
  • 325 pages

Ali AKHADDAR, MD, is Professor of Neurosurgery at the Faculty of Medicine, Mohammed V University in Rabat (Morocco) and Chairman of the Department of Neurosurgery at Avicenne Military Hospital of Marrakech (Morocco). He is an Expert Member of the Scientific Committees of the National Scientific and Technological Research Center of Morocco (CNRST). Dr Akhaddar is a Member of the American Association of Neurological Surgeons (AANS), the Congress of Neurological Surgeons (CNS), the French speaking society of Neurosurgery (SNCLF) and the Military Neurosurgeons Committee in the World Federation of Neurosurgical Societies (WFNS). He has received many awards during his career, including from the Moroccan Society of Neurosurgery, the World Federation of Neurosurgical Societies [Traveling Fellowship Award: Nagoya 2007, Boston 2009 and Seoul 2013], the University of Mohammed V of Rabat and the French Society of Hospitals’ History (SFHH).Dr Akhaddar is a member of the editorial board of the Open Neurosurgery Journal and Médecine du Maghreb and is a reviewing editor for many medical journals. He is the author of three previous books; he has authored and co-authored more than 200 papers published in peer-reviewed journals (140 indexed in PubMed*) and five book chapters.

Una proteína del alzhéimer podría transmitirse por la contaminación del instrumental quirúrgico

Se ha comprobado que miles de personas que fueron inyectadas con hormonas del crecimiento extraídas quirúrgicamente de las glándulas pituitarias de cadáveres, un procedimiento médico que se realizó en el Reino Unido entre 1958 y 1985, han acabado desarrollando ECJ. Se cree que las hormonas transportaban los priones de la ECJ, que se habrían adherido a los instrumentos quirúrgicos durante el proceso de extracción.

Al estudiar esos ocho cerebros, el equipo de Collinge descubrió que en seis de ellos había beta-amiloides, asociados con el alzhéimer. En cuatro casos, los depósitos de amiloides estaban extendidos, apuntan los científicos, que aclaran que ninguno de los pacientes presentaban signos de padecer alzhéimer hereditario de aparición temprana. Los expertos creen que el tratamiento con la hormona del crecimiento que se hizo a todos los pacientes pudo estar en el origen de la aparición del alzhéimer así como de la ECJ, debido a esa transmisión por neurocirugía.

Los fragmentos de la proteína beta-amiloide pueden adherirse también a las superficies de metal y resisten la esterilización convencional, argumentan. “Es posible que haya tres maneras de que se generen las semillas de estas proteínas en el cerebro -explica Collinge-. Pueden aparecer espontáneamente con la edad, que haya un gen defectuoso o que surjan tras haber sido expuesto a un accidente médico”. “Esta es nuestra hipótesis”, afirma el científico.

Los expertos descartan que los rastros de alzhéimer procedieran de la enfermedad de Creutzfeldt-Jakob, pues, en otro estudio, 116 pacientes afectados de este mal que no habían sido tratados con la hormona del crecimiento extraída de cadáveres no presentaban marcadores de alzhéimer. Collinge advierte de que, en el caso de las proteínas del alzhéimer, “potencialmente, las semillas podrían adherirse a la superficie de cualquier instrumento de metal”, lo que incluye los utilizados por el dentista en procedimientos que afectan al tejido nervioso.

El experto subrayó, no obstante, que no hay pruebas de transmisión epidemiológica que sugieran que la enfermedad pueda contagiarse por transfusiones de sangre y señaló que el mal de Alzhéimer “no es una enfermedad contagiosa”. “No puede contraerse por vivir con una persona con alzhéimer o por cuidarla”, aseveró. Otros expertos han advertido de que, aunque interesantes, las conclusiones de este informe son prematuras, pues solo se refieren a ocho pacientes.

Update: Vancomycin powder

Vancomycin powder

Local vancomycin powder appears to lower the risk of wound infection following lumbar laminectomy and fusion, both instrumented and non-instrumented 1).

The interpretation of the available evidence supporting the use of intrasite vancomycin powder in surgical wounds is limited, and its extrapolation should be performed with caution. Despite the lack of significant high-quality evidence available in the literature, many surgeons have adopted this practice; anecdotally it continues to provide protection from infection without apparent significant risk of side effects 2).

Debate on the effectiveness

Effectiveness

The addition of intrawound vancomycin powder in 195 consecutive posterior cervical spine surgical procedures resulted in no infections and no adverse effects 3).

Routine local application of vancomycin powder is a low-cost, effective strategy for preventing wound infection after posterior cervical fusion. 4).

The use of adjuvant vancomycin powder was associated with a significant reduction in the incidence of postoperative infection as well as infection-related medical cost. These findings suggest that use of adjuvant vancomycin powder in high-risk patients undergoing spinal fusion is a cost-saving option for preventing postoperative infections, as it can lead to cost-savings of $438,165 per 100 spinal fusions performed 5).

In the study population of Emohare et al., the cost savings totaled more than half a million dollars 6).

No effectiveness

Martin et al., found no significant difference in the incidence of deep wound infection rates after posterior cervical fusion surgery with routine use of locally applied vancomycin powder 7)

The local application of powdered vancomycin was not associated with a significant difference in the rate of deep SSI after spinal deformity surgery, and other treatment modalities are necessary to limit infection for this high-risk group. This study is in contrary to prior studies, which have reported a decrease in SSI with vancomycin powder.Level of Evidence: 2 8)


1) Strom RG, Pacione D, Kalhorn SP, Frempong-Boadu AK. Lumbar laminectomy and fusion with routine local application of vancomycin powder: decreased infection rate in instrumented and non-instrumented cases. Clin Neurol Neurosurg. 2013 Sep;115(9):1766-9. doi: 10.1016/j.clineuro.2013.04.005. Epub 2013 Apr 23. PubMed PMID: 23622935.

2) Kang DG, Holekamp TF, Wagner SC, Lehman RA Jr. Intrasite Vancomycin Powder for the Prevention of Surgical Site Infection in Spine Surgery: A Systematic Literature Review. Spine J. 2015 Jan 27. pii: S1529-9430(15)00079-0. doi: 10.1016/j.spinee.2015.01.030. [Epub ahead of print] Review. PubMed PMID: 25637469.
3) Pahys JM, Pahys JR, Cho SK, Kang MM, Zebala LP, Hawasli AH, Sweet FA, Lee DH, Riew KD. Methods to decrease postoperative infections following posterior cervical spine surgery. J Bone Joint Surg Am. 2013 Mar 20;95(6):549-54. doi: 10.2106/JBJS.K.00756. PubMed PMID: 23515990.
4) Strom RG, Pacione D, Kalhorn SP, Frempong-Boadu AK. Decreased risk of wound infection after posterior cervical fusion with routine local application of vancomycin powder. Spine (Phila Pa 1976). 2013 Jan 15. [Epub ahead of print] PubMed PMID: 23324930.
5) Godil SS, Parker SL, O’Neill KR, Devin CJ, McGirt MJ. Comparative effectiveness and cost-benefit analysis of local application of vancomycin powder in posterior spinal fusion for spine trauma: clinical article. J Neurosurg Spine. 2013 Sep;19(3):331-5. doi: 10.3171/2013.6.SPINE121105. Epub 2013 Jul 12. PubMed PMID: 23848350.
6) Emohare O, Ledonio CG, Hill BW, Davis R, Polly DW Jr, Kang M. Cost Savings Analysis of Intra-Wound Vancomycin Powder in Posterior Spinal Surgery. Spine J. 2014 Mar 17. pii: S1529-9430(14)00252-6. doi: 10.1016/j.spinee.2014.03.011. [Epub ahead of print] PubMed PMID: 24650851.
7) Martin JR, Adogwa O, Brown CR, Kuchibhatla M, Bagley CA, Lad SP, Gottfried ON. Experience with intrawound vancomycin powder for posterior cervical fusion surgery. J Neurosurg Spine. 2014 Nov 7:1-8. [Epub ahead of print] PubMed PMID: 25380539.
8) Martin JR, Adogwa O, Brown CR, Bagley CA, Richardson WJ, Lad SP, Kuchibhatla M, Gottfried ON. Experience with intrawound vancomycin powder for spinal deformity surgery. Spine (Phila Pa 1976). 2014 Jan 15;39(2):177-84. doi: 10.1097/BRS.0000000000000071. PubMed PMID: 24158179.

Book: Complications of CSF Shunting in Hydrocephalus: Prevention, Identification, and Management

Complications of CSF Shunting in Hydrocephalus: Prevention, Identification, and Management

Complications of CSF Shunting in Hydrocephalus: Prevention, Identification, and Management

List Price: $179.00

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Written and edited by leading international authorities in the field, this book provides an in-depth review of knowledge of complications of CSF shunting,  with emphasis on prevention, identification, and management. It covers the full range of shunt-related complications and the various associated adverse consequences that remain common despite significant improvements in imaging techniques and therapeutic methods. The chapters are organized into two parts: complications of extrathecal CSF shunt devices and complications of endoscopy. In addition to providing clinicians and investigators with the most pertinent current evidence, the book looks forward to future areas of hydrocephalus research and to innovative therapeutic philosophies. This comprehensive reference book will be an ideal source for neurosurgeons seeking both basic and more sophisticated information and procedures relating to the complications associated with CSF shunting.


Product Details

  • Original language: English
  • Dimensions: 10.28″ h x .79″ w x 7.20″ l,
  • Binding: Hardcover
  • 322 pages

Update: Streptococcus pyogenes in neurosurgery

Streptococcus pyogenes is a beta-hemolytic bacterium that belongs to Lancefield serogroup A, also known as group A streptococci (GAS).

Streptococcus pyogenes is rarely seen, and is grown in only 2% of sinusitis and otitis media cultures.

It has rarely been reported as a cause of brain abscess. There have been five reported cases in terms of PubMed-based search but no reported case of brain abscess caused by Streptococcus pyogenes as a result of penetrating skull injury till 2010.

Streptococcus pyogenes is a rare but aggressive cause of streptococcal meningitis, which often evolves in a poor outcome with fatal consequences.

Any penetrating lesion showing a connection between the lamina cribrosa and ethmoid sinus may result in brain abscess caused by Streptococcus pyogenes. These patients should be treated urgently to repair the defect and drain the abscess with appropriate antibiotic therapy started due to the fulminant course of the brain abscess caused by this microorganism 1).

A 36-year-old woman admitted to the emergency department of a hospital three days after the onset of earache and otorrhoea. When the patient developed an emergent refractory status epilepticus, the CT scan of the brain showed an unusual pneumocephalus. However, the MRI study of the brain revealed a pachymeningitis with partial thrombosis of the right transverse sinus and subdural empyema due to a S. pyogenes otitis media. Prompt diagnosis and the specific findings of the MRI allowed rapid correct treatment and thus led to a good outcome for the patient 2).

1) Gulsen S, Aydin G, Cömert S, Altinors N. Rapid Development of Brain Abscess Caused by Streptococcus Pyogenes Following Penetrating Skull Injury via the Ethmoidal Sinus and Lamina Cribrosa. J Korean Neurosurg Soc. 2010 Jul;48(1):73-8. doi: 10.3340/jkns.2010.48.1.73. Epub 2010 Jul 31. PubMed PMID: 20717517; PubMed Central PMCID: PMC2916153.
2) Gritti P, Lanterna AL, Sarnecki T, Brembilla C, Agostinis C, Rizzi M, Lorini FL. What is hiding behind bubbles of air? An unusual Streptococcus pyogenes meningitis. Infez Med. 2014 Dec 1;22(4):317-321. PubMed PMID: 25551849.