Post‐operative length of stay after elective CSF leak repair: Costs and outcomes

Object Lumbar disc herniation is a rare but significant cause of pain and disability in the pediatric population. Lumbar microdiscectomy, although routinely performed in adults, has not been described in the pediatric population. The objective of this study was to determine the surgical results of lumbar microdiscectomy in the pediatric population by analyzing the experiences at Children's Hospital Boston over the past decade. Methods A series of 87 consecutive cases of lumbar microdiscectomy performed by the senior author (M.R.P.) from 1999 to 2008 were reviewed. Presenting symptoms, physical examination findings, and preoperative MR imaging findings were obtained from medical records. Immediate operative results were assessed including operative duration, blood loss, length of stay, and complications, along with long-term outcome and need for repeat surgery. Results This series represents the first surgical series of pediatric microdiscectomies. The mean patient age was 16.6 years (range 12–18 years) and 60% were female. The preoperative physical examination results were notable for motor deficits in 26% of patients, sensory changes in 41%, loss of deep tendon reflex in 22%, and a positive straight leg raise in 95%. Conservative management was the first line of treatment in all patients and the mean duration of symptoms until surgical treatment was 12.2 months. The mean operative time was 110 minutes and the mean postoperative length of stay was 1.3 days. Complications were rare: postoperative infection occurred in 1%, postoperative CSF leak in 1%, and new postoperative neurological deficits in 1%. Only 6% of patients needed repeat lumbar surgery and 1 patient ultimately required lumbar fusion. Conclusions The treatment of pediatric lumbar disc herniation with microdiscectomy is a safe procedure with low operative complications. Nuances of the presentation, treatment options, and surgery in the pediatric population are discussed.

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Minimally invasive approach for the treatment of intradural spinal pathology

Neurosurgical FOCUS ◽

10.3171/2013.5.focus13163 ◽

2013 ◽

Vol 35 (2) ◽

pp. E5 ◽

Cited By ~ 21

Author(s):

Ravi H. Gandhi ◽

John W. German

Keyword(s):

Postoperative Complications ◽

Length Of Stay ◽

Blood Loss ◽

Minimally Invasive ◽

Csf Leak ◽

Spinal Instability ◽

Average Hospital ◽

Invasive Approach ◽

Initial Surgery ◽

Csf Leakage

Object A wide variety of spinal intradural pathology traditionally has been treated from a midline posterior laminectomy using standard microsurgical techniques. This approach has been successful in treating the pathology; however, it carries a risk of postoperative complications including CSF leakage, wound infection, and spinal instability. The authors describe a minimally invasive surgical (MIS) approach to treating spinal intradural pathology with a low rate of postoperative complications. Methods Through a retrospective review of a prospectively collected surgical database, the authors identified 26 patients who underwent 27 surgeries via an MIS approach for intradural pathology of the spine. Using a tubular retractor system and an operative microscope, the authors were able to treat all patients with a unilateral, paramedian, and muscle-splitting technique. They then collected data regarding operative blood loss, length of stay, imaging characteristics, and outcomes. Results Eight cervical, 8 thoracic, and 11 lumbar intradural pathological entities, which included 14 oncological lesions, 4 Chiari I malformations, 4 arachnoid cysts, 3 tethered cords, 1 syrinx, and 1 chronic visceral pain, were treated via an MIS approach. The average blood loss was 197 ml and the average hospital stay was 3 days. One patient had to return to the operating room for noninfectious wound dehiscence. One patient required reoperation 18 months after the initial surgery for recurrence of the initial pathology. There was no CSF leak, no infection, and no spinal instability associated with the initial surgery on follow-up. Conclusions Intradural spinal pathology can be safely and effectively treated with MIS approaches without an increased risk of neurological injury. This approach may also offer a reduced postoperative length of stay, risk of CSF leak, and risk of future spinal instability.

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Outcome of hospital discharge on postoperative Day 1 following uncomplicated tethered spinal cord release

Journal of Neurosurgery Pediatrics ◽

10.3171/2015.10.peds15318 ◽

2016 ◽

Vol 17 (6) ◽

pp. 651-656 ◽

Cited By ~ 4

Author(s):

Seerat Poonia ◽

Sarah Graber ◽

C. Corbett Wilkinson ◽

Brent R. O'neill ◽

Michael H. Handler ◽

...

Keyword(s):

Spinal Cord ◽

Length Of Stay ◽

Postoperative Management ◽

Leak Rate ◽

Csf Leak ◽

Quality Improvement Initiative ◽

Dural Defect ◽

The Mean ◽

Spinal Cord Tethering ◽

Csf Leaks

OBJECTIVE Postoperative management following the release of simple spinal cord–tethering lesions is highly variable. As a quality improvement initiative, the authors aimed to determine whether an institutional protocol of discharging patients on postoperative day (POD) 1 was associated with a higher rate of postoperative CSF leaks than the prior protocol of discharge on POD 2. METHODS This was a single-center retrospective review of all children who underwent release of a spinal cord–tethering lesion that was not associated with a substantial fascial or dural defect (i.e., simple spinal cord detethering) during 2 epochs: prior to and following the institution of a protocol for discharge on POD 1. Outcomes included the need for and timing of nonroutine care of the surgical site, including return to the operating room, wound suturing, and nonsurgical evaluation and management. RESULTS Of 169 patients identified, none presented with CSF-related complications prior to discharge. In the preintervention group (n = 113), the postoperative CSF leak rate was 4.4% (5/113). The mean length of stay was 2.3 days. In the postintervention group, the postoperative CSF leak rate was 1.9% (1/53) in the patients with postdischarge follow-up. The mean length of stay in that group was 1.3 days. CONCLUSIONS At a single academic children's hospital, a protocol of discharging patients on POD 1 following uncomplicated release of a simple spinal cord–tethering lesion was not associated with an increased rate of postoperative CSF leaks, relative to the previous protocol. The rates identified are consistent with the existing literature. The authors' practice has changed to discharge on POD 1 in most cases.

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Readmission after endoscopic transsphenoidal pituitary surgery: analysis of 584 consecutive cases

Journal of Neurosurgery ◽

10.3171/2019.7.jns191558 ◽

2020 ◽

Vol 133 (4) ◽

pp. 1242-1247 ◽

Cited By ~ 1

Author(s):

Iyan Younus ◽

Mina M. Gerges ◽

Georgiana A. Dobri ◽

Rohan Ramakrishna ◽

Theodore H. Schwartz

Keyword(s):

Pituitary Adenoma ◽

Length Of Stay ◽

Statistical Significance ◽

Csf Leak ◽

Categorical Variables ◽

Control Group ◽

Unplanned Readmission ◽

Continuous Variables ◽

Study Results ◽

Postoperative Length

OBJECTIVEHospital readmission is a key component in value-based healthcare models but there are limited data about the 30-day readmission rate after endonasal endoscopic transsphenoidal surgery (EETS) for pituitary adenoma. The objective of this study was to determine the incidence and identify factors associated with 30-day readmission after EETS for pituitary adenoma.METHODSThe authors analyzed a prospectively acquired database of patients who underwent EETS for pituitary adenoma from 2005 to 2018 at NewYork-Presbyterian Hospital, Weill Cornell Medicine. Clinical, socioeconomic, and radiographic data were reviewed for cases of unplanned readmission within 30 days of surgery and, as a control group, for all other patients in the series who were not readmitted. Statistical significance was determined with an alpha < 0.05 using Pearson’s chi-square and Fisher’s exact tests for categorical variables and the independent-samples t-test for continuous variables.RESULTSOf 584 patients undergoing EETS for pituitary adenoma, 27 (4.6%) had unplanned readmission within 30 days. Most readmissions occurred within the first week after surgery, with a mean time to readmission of 6.6 ± 3.9 days. The majority of readmissions (59%) were for hyponatremia. These patients had a mean sodium level of 120.6 ± 4.6 mEq/L at presentation. Other causes of readmission were epistaxis (11%), spinal headache (11%), sellar hematoma (7.4%), CSF leak (3.7%), nonspecific headache (3.7%), and pulmonary embolism (3.7%). The postoperative length of stay was significantly shorter for patients who were readmitted than for the controls (2.7 ± 1.0 days vs 3.9 ± 3.2 days; p < 0.05). Patients readmitted for hyponatremia had an initial length of stay of 2.6 ± 0.9 days, the shortest of any cause for readmission. The mean BMI was significantly lower for readmitted patients than for the controls (26.4 ± 3.9 kg/m2 vs 29.3 ± 6.1 kg/m2; p < 0.05).CONCLUSIONSReadmission after EETS for pituitary adenoma is a relatively rare phenomenon, with delayed hyponatremia being the primary cause. The study results demonstrate that shorter postoperative length of stay and lower BMI were associated with 30-day readmission.

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Evaluation of early postoperative day 1 discharge after endoscopic endonasal pituitary adenoma resection

Journal of Neurosurgery ◽

10.3171/2021.5.jns2185 ◽

2021 ◽

pp. 1-10

Author(s):

Siyuan Yu ◽

Mohammad Taghvaei ◽

Sarah Collopy ◽

Keenan Piper ◽

Michael Karsy ◽

...

Keyword(s):

Multivariate Analysis ◽

Pituitary Adenoma ◽

Length Of Stay ◽

Tertiary Care ◽

Early Discharge ◽

Csf Leak ◽

Complication Rates ◽

Prolonged Length ◽

Number Of Patients ◽

Increased Risk

OBJECTIVE While multiple studies have evaluated the length of stay after endonasal transsphenoidal surgery (ETS) for pituitary adenoma, the potential for early discharge on postoperative day 1 (POD 1) remains unclear. The authors compared patients discharged on POD 1 with patients discharged on POD > 1 to better characterize factors that facilitate early discharge after ETS. METHODS A retrospective chart review was performed for patients undergoing ETS for pituitary adenoma at a single tertiary care academic center from February 2005 to February 2020. Discharge on POD 1 was defined as a discharge within 24 hours of surgery. RESULTS A total of 726 patients (mean age 55 years, 52% male) were identified, of whom 178 (24.5%) patients were discharged on POD 1. These patients were more likely to have pituitary incidentaloma (p = 0.001), require dural substitutes and DuraSeal (p = 0.0001), have fewer intraoperative CSF leaks (p = 0.02), and have lower postoperative complication rates (p = 0.006) compared with patients discharged on POD > 1. POD 1 patients also showed higher rates of macroadenomas (96.1% vs 91.4%, p = 0.03) and lower rates of functional tumors (p = 0.02). POD > 1 patients were more likely to have readmission within 30 days (p = 0.002), readmission after 30 days (p = 0.0001), nasal synechiae on follow-up (p = 0.003), diabetes insipidus (DI; 1.7% vs 9.8%, p = 0.0001), postoperative hypocortisolism (21.8% vs 12.1%, p = 0.01), and postoperative steroid usage (44.6% vs 59.7%, p = 0.003). The number of patients discharged on POD 1 significantly increased during each subsequent time epoch: 2005–2010, 2011–2015, and 2016–2020 (p = 0.0001). On multivariate analysis, DI (OR 7.02, 95% CI 2.01–24.57; p = 0.002) and intraoperative leak (OR 2.02, 95% CI 1.25–3.28; p = 0.004) were associated with increased risk for POD > 1 discharge, while operation epoch (OR 0.46, 95% CI 0.3–0.71; p = 0.0001) was associated with POD 1 discharge. CONCLUSIONS This study demonstrates that discharge on POD 1 after ETS for pituitary adenomas was safe and feasible and without increased risk of 30-day readmission. On multivariate analysis, surgical epoch was associated with decreased risk of prolonged length of stay, while factors associated with increased risk of prolonged length of stay included DI and intraoperative CSF leak. These findings may help in selecting patients who are deemed reasonable for safe, early discharge after pituitary adenoma resection.

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