Cytokine Changes in Cerebrospinal Fluid and Plasma Post-Emergency Orthopaedic Surgery

Background: The process of neuroinflammation after surgery and how it may contribute to post-operative neurocognitive disorders (PND) is not well understood. Studying the association between central and peripheral cytokines and neuroinflammation is a prelude to the development of treatments for PND. Here, we investigate the hypotheses that there is a greater cytokine response in cerebrospinal fluid (CSF) than plasma after orthopaedic surgery, and that plasma cytokine levels are directly related to CSF cytokine levels, enabling plasma cytokine levels to be used as markers of neuroinflammation. Methods: Patients admitted with a fractured neck of femur were invited to participate in this study. Participants had a spinal catheter inserted just prior to induction of anaesthesia. Samples of blood and CSF were taken before, immediately after, and on the first day following emergency surgery. The catheter was then removed. Samples were analysed for the presence of ten cytokines by immunoassay. Results: A spinal catheter was successfully inserted in 11 participants during the 18-month study period. Five plasma cytokines (IL-4, IL-6, IL-10, IL-12p70 and IL-13) rose significantly following surgery, whereas all ten CSF cytokines rose significantly (IL-1β, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p70, IL-13, IFN-γ and TNF-α) (adjusted-p <0.05). Central (CSF) cytokine levels were consistently higher than their peripheral (plasma) counterparts after surgery, with some patients having a particularly marked neuroinflammatory response. The greatest increases occurred in IL-8 in CSF and IL-6 in plasma. There were significant, strong positive correlations between several of the measured cytokines in the CSF after surgery, but far fewer in plasma. There was no significant correlation between cytokine levels in the plasma and CSF at each of the three time points.Conclusions: To our knowledge, this is the first study to analyse paired samples of plasma and CSF for cytokine levels before and after emergency orthopaedic surgery. This study demonstrates that following surgery for a fractured neck of femur, there is a far greater rise in cytokines in the CSF compared to plasma. The lack of correlation between peripheral and central cytokines suggests measurement of peripheral cytokines are not necessarily related to which patients may have a large neuroinflammatory response.

Pediatric Intrathecal Baclofen Pumps: A Descriptive Analysis of Hospital Course and Associated Costs

<b><i>Introduction:</i></b> The purpose of this study was to identify predictors of increased cost and postoperative length-of-stay (LOS) following intrathecal baclofen pump (ITBP) placement. <b><i>Methods:</i></b> Patients were derived from the 2009/2012 kids’ inpatient database. Inclusion criteria were selected for patients with ICD-9 codes 343.X (infantile cerebral palsy), 86.06 (infusion pump insertion), 03.90 (spinal catheter insertion), and elective hospitalizations. Nonparametric univariate analysis and subsequent gamma log-link general linear modeling were used to identify significant predictors of cost/LOS (<i>p</i> &#x3c; 0.05). <b><i>Results:</i></b> 529 unweighted patients (787 with survey weights applied) met criteria. Median LOS was 3.00 days, and median cost was USD 23,284. Following multivariate modeling, predictors of increased LOS (in days) included increased hospital ITBP volume (<i>p</i> = 0.027), small hospital size (+0.55, <i>p</i> = 0.004), device complications (+0.95, <i>p</i> &#x3c; 0.001), procedural complications (+1.40, <i>p</i> &#x3c; 0.001), additional procedures (+0.86, <i>p</i> &#x3c; 0.001), electrolyte abnormalities (+3.74, <i>p</i> &#x3c; 0.001), and neurological comorbidities (+1.60, <i>p</i> &#x3c; 0.001). Factors associated with decreased LOS were paralysis (−0.53, <i>p</i> &#x3c; 0.001), Northeastern hospital region (−0.55, <i>p</i> = 0.018), and investor-owned hospital status (−0.75, <i>p</i> = 0.001). Similarly, predictors of increased cost included race of Hispanic (+USD 1,156, <i>p</i> = 0.033) or “other” (+USD 2,158, <i>p</i> = 0.001), Northeast hospital region (+USD 4,120, <i>p</i> &#x3c; 0.001), small (+USD 4,139, <i>p</i> &#x3c; 0.001) or medium (+USD 3,368, <i>p</i> &#x3c; 0.001) hospital sizes, additional procedures (+USD 1,649, <i>p</i> &#x3c; 0.001), neurological comorbidities (+USD 3,222, <i>p</i> = 0.003), and increased LOS (<i>p</i> &#x3c; 0.001). Factors associated with decreased cost included Western hospital region (–USD 1,594, <i>p</i> = 0.001), government hospitals (–USD 1,391, <i>p</i> = 0.019), and investor-owned hospitals (–USD 2,057, <i>p</i> = 0.021). <b><i>Conclusion:</i></b> This study found multiple variables associated with increased cost/LOS following ITBP placement. Broadly, this analysis demonstrates national trends associated with increased cost following ITBP placement.

Vascular imaging of the spine in the US Medicare population: Catheter and MR angiography volumes from 2004 to 2016

Aims The purpose of our study was to analyze utilization trends and physician specialty distribution in spinal catheter angiography and magnetic resonance angiography in the Medicare fee-for-service population. Methods Data from the CMS Physician/Supplier Procedure Summary Master Files for 2004 to 2016 were used for this study. The Current Procedural Terminology version 4 codes for spinal magnetic resonance angiography (72159) and spinal catheter angiography (75705) were used to analyze the volumes of these procedures. Using Medicare’s 108 specialty code, we compared procedure volumes among physician specialties. Data analysis was performed using SAS version 9.3 for Windows. Results The volume of spinal catheter angiography performed was 4758 in 2004, peaked at 6869 in 2012, and dropped to 6656 in 2016. Overall, the volume of spinal catheter angiography increased by 40% from 2004 to 2016. Radiologists performed the majority of these procedures (3736 or 56.1%) in 2016, followed by neurosurgeons (2456 or 36.9%), and neurologists (346 or 5.2%). The spinal magnetic resonance angiography volume fluctuated between 0 and 1 from 2004 to 2009, then precipitously increased to 40 in 2010, peaked at 133 in 2011, and declined to 81 in 2016. The volume of spinal magnetic resonance angiography procedures increased by 8000% from 2004 to 2016, with radiologists performing the majority of them. Conclusion Our results show that spinal catheter angiography volumes continue to rise in the Medicare fee-for-service population, and are largely performed by radiologists, neurosurgeons, and neurologists. Although spinal magnetic resonance angiography volumes have started to increase, they comprise only a small fraction of studies performed for vascular evaluation of the spine.

Combined Extended High Spinal Anesthesia and Endotracheal Narcosis: a Clinical Case

Background. In recent years, various methods of combined anesthesia during abdominal surgery have been introduced into clinical practice.Aim. To demonstrate the possibilities of a combination of high prolonged spinal anesthesia and endotracheal anesthesia during abdominal surgery.Materials and methods. A clinical case of combined use of high prolonged spinal anesthesia and endotracheal anesthesia in a 48-year-old patient with a tumor in the right half of the ascending part of the right half of the colon is presented.Results. The patient received a puncture of the spinal space at a standard point and was installed a spinal catheter in the cranial direction for 3 cm. An isobaric solution of marcaine in the initial dose of 20 mg was injected into the catheter. The regulation of the development of the block was regulated by the inclination of the head end of the table by 60°. After that endotracheal anesthesia was performed on the basis of fentanyl and propofol. This combination allowed to expand the scope of surgical intervention, provided adequate pain relief intraoperatively and in the postoperative period, without the use of narcotic analgesics. With the appearance of signs of recovery of pain sensitivity, intraoperatively or in the postoperative period, re-introduction of the anesthetic into the spinal catheter was performed in half of the initial dose with liquor barbotage. In the early postoperative period, the patient was on strict bed rest with a head end of the bed raised at 30–45°. The method provides complete segmental blockade and muscle relaxation in the area of operation, stability of central hemodynamics during surgery and in the postoperative period.Conclusion. This type of anesthesia is more easily tolerated by patients, accompanied by early awakening and extubation, characterized by stability of central hemodynamics, reduced risk of complications, the possibility of prolonging anesthesia with lower doses of narcotic analgesics in the intraoperative period, providing high-quality anesthesia in the postoperative period without resorting to the use of narcotic analgesics.

Fluoroscopic-Guided Paramedian Approach for Lumbar Catheter Placement in Cerebrospinal Fluid Shunting: Assessment of Safety and Accuracy

BACKGROUND Spinal catheter insertion in lumboperitoneal (LP) shunt surgery for idiopathic normal pressure hydrocephalus (iNPH) is frequently associated with technical difficulties especially in patients with obesity and elderly patients with vertebral deformities. OBJECTIVE To elucidate the accuracy and safety of image-guided spinal catheter placement using a paramedian approach (PMA). METHODS We retrospectively analyzed 39 consecutive iNPH patients treated by LP shunting with spinal catheter insertion via the PMA. The success rate of catheter placement and the number of changes in puncture location were evaluated. Accuracy of catheter insertion was assessed by measuring both vertical and horizontal deviations in the point of catheter dural penetration from the center of the interlaminar space. RESULTS The success rate of catheter placement was 100% (39/39). The difficulty rate for catheter insertion, measured by the number of changes in puncture location, was 2.6% (1/39). No bloody punctures or surgical infections were observed. Accuracy of catheter insertion, measured as the degree of deviation, was 0.5 ± 1.9 mm horizontally and 0.0 ± 2.4 mm vertically. The rates of minor complications, including caudal catheter insertion, transient low-pressure headache, and root pain, were 5.1% (2/39), 10.4% (4/39), and 0% (0/43), respectively. Subdural hematoma requiring surgical intervention occurred in 1 case (2.6%). During the mean follow-up period of 36 mo, spinal catheter rupture at the level of the spinous processes was not observed. CONCLUSION Fluoroscopic-guided spinal catheter placement via the PMA was safe, accurate, and reliable, even for use in geriatric and obese patients.

Novel Dual Lumen Catheter and Filtration Device for Removal of Subarachnoid hemorrhage: First Case Report

BACKGROUND AND IMPORTANCE The amount of subarachnoid blood and the presence of toxic blood breakdown products in the cerebrospinal fluid (CSF) have long been associated with poor outcomes in aneurysmal subarachnoid hemorrhage. The Neurapheresis™ system (Minnetronix Inc, St. Paul, Minnesota) has been developed to filter CSF and remove blood products, and is being investigated for safety and feasibility in the ExtracorPoreal FILtration of subarachnoid hemorrhage via SpinaL CAtheteR (PILLAR) study. We report the first case using this novel device. CLINICAL PRESENTATION A 65-yr-old female presented with a ruptured left posterior communicating artery aneurysm. Following placement of a ventriculostomy and coil embolization of her aneurysm, the patient underwent placement of a lumbar dual lumen catheter for CSF filtration as part of the PILLAR study. In this case, a total of 9 h of filtration during 31 h of catheter indwelling resulted in 309.47 mL of processed CSF without complication. Computed tomography images demonstrated an interval reduction of subarachnoid hemorrhage immediately after filtration. The patient was discharged home on postbleed day 11 and at 30 d showed good recovery. CONCLUSION Safety of the Neurapheresis procedure was confirmed in this first case, and we will continue to evaluate safety of the Neurapheresis system through the PILLAR trial.

Pain control in chronic, refractory CRPS by continuous brachial plexus analgesia

We report on the outcomes of treatment for severe pain associated with long-standing, refractory CRPS in 10 female patients by continuous brachial plexus analgesia. The duration of the disease prior to treatment was 3.5 years on average, and mean baseline pain intensity was 8.3 on a numeric analogue scale (NRS). All patients met the Budapest criteria for the diagnosis of CRPS. A spinal catheter was implanted into the brachial plexus via an open axillary approach. Results: Each patient underwent a mean of 4.4 (range 2–8) spinal catheter implantations. A rapid and strong analgesic effect was observed immediately after the injection of bupivacaine solution was started: Pain decreased from a mean of 8.3 to 1.6. The duration of maintaining the catheter in the brachial plexus and achieving effective analgesia was 5.3 months (range 2–12). After the removal of the catheter, the pain returned to baseline. No patient achieved a permanent, or at least partial, reduction of pain after completing this therapy.