Object The goal of this study was to examine the reasons for early readmissions within 30 days of discharge to a major academic neurosurgical service. Methods A database of readmissions within 30 days of discharge between April 2009 and September 2010 was retrospectively reviewed. Clinical and administrative variables associated with readmission were examined, including age, sex, race, days between discharge and readmission, and insurance type. The readmissions were then assigned independently by 2 neurosurgeons into 1 of 3 categories: scheduled, adverse event, and unrelated. The adverse event readmissions were further subcategorized into patients readmitted although best practices were followed, those readmitted due to progression of their underlying disease, and those readmitted for preventable causes. These variables were compared descriptively. Results A total of 348 patients with 407 readmissions were identified, comprising 11.5% of the total 3552 admissions. The median age of readmitted patients was 55 years (range 16–96 years) and patients older than 65 years totaled 31%. There were 216 readmissions (53% of 407) for management of an adverse event that was classified as either preventable (149 patients; 37%) or unpreventable (67 patients; 16%). There were 113 patients (28%) who met readmission criteria but who were having an electively scheduled neurosurgical procedure. Progression of disease (48 patients; 12%) and treatment unrelated to primary admission (30 patients; 7%) were additional causes for readmission. There was no significant difference in the proportion of early readmissions by payer privately insured patients and those with public or no insurance (p = 0.09). Conclusions The majority of early readmissions within 30 days of discharge to the neurosurgical service were not preventable. Many of these readmissions were for adverse events that occurred even though best practices were followed, or for progression of the natural history of the neurosurgical disease requiring expected but unpredictably timed subsequent treatment. Judicious care often requires readmission to prevent further morbidity or death in neurosurgical patients, and penalties for readmission will not change these patient care obligations.

BACKGROUND Traumatic brain injury (TBI) is a significant public health problem affecting tens of thousands of children each year, and an important subset of these patients sustains intracranial hemorrhage (ICH). The purpose of this study was to test the hypothesis that we could identify a subset of children with traumatic ICH who could be monitored on a general neurosurgery ward with a low risk of clinical deterioration. METHODS We performed a retrospective review of pediatric patients ≤18 years of age with mild TBI (Glasgow Coma Scale score 14–15) and traumatic ICH admitted to Saint Louis Children’s Hospital between 2006 and 2011. We excluded patients with injuries unrelated to the TBI that would require ICU admission and those with penetrating intracranial injuries. RESULTS We identified 118 patients meeting inclusion criteria. Repeat neuroimaging was obtained in 69/118 patients (58%). Radiologic progression was noted in 6/69 (8.7%) patients, with a trend toward more frequent progression in patients with epidural hematoma (EDH) versus other ICH (3/15 (20%) vs. 3/54 (5.6%); p=0.11). Eight of 118 patients (6.8%) experienced clinically important neurological decline (CIND), and 6/118 (5.1%) required neurosurgical intervention. Both CIND and need for neurosurgical intervention were significantly higher in patients with EDH (21% each) compared to those with other types of ICH (4% and 2% respectively) (P=0.02; P<0.01). Based on these results, we developed a preliminary management framework to assist in determining which patients can be safely observed on a neurosurgery ward without an intensive care unit (ICU) admission. Specifically, those patients without EDH, intraventricular hemorrhage, coagulopathy, or concern for a high-risk neurosurgical lesion (e.g. arteriovenous malformation) may be safely observed on the ward. CONCLUSIONS These results demonstrate that few children with mild TBI and ICH experience CIND, and the preliminary framework we developed assists in identifying which patients can safely avoid ICU admission. This framework should be validated prospectively and externally. LEVEL OF EVIDENCE Therapeutic/care management, level IV.

Object The sacroiliac (SI) joint can be a pain generator in 13%–27% of cases of back pain in adults. These numbers are largely unknown for the pediatric population. In children and especially girls, development of the pelvic girdle makes the SI joint prone to misalignment. Young athletes sustain repeated stress on their SI joints, and sometimes even minor trauma can result in lasting pain that mimics radiculopathy. The authors present a series of 48 pediatric patients who were evaluated for low-back pain and were found to have SI joint misalignment as the cause of their symptoms. They were treated with a simple maneuver described in this paper that realigned their SI joint and provided significant improvement of symptoms. Methods A retrospective review of the electronic records identified 48 patients who were referred with primary complaints of low-back pain and were determined to have SI joint misalignment during bedside examination maneuvers described here. Three patients did not have a record of their response to treatment and were excluded. Patients were evaluated by a physical therapist and had the realignment procedure performed on the day of initial consultation. The authors collected data regarding the immediate effect of the procedure, as well as the duration of pain relief at follow-up visits. Results Eighty percent of patients experienced dramatic improvement in symptoms that had a lasting effect after the initial treatment. The majority of them were given a home exercise program, and only 2 of the 36 patients who experienced significant relief had to be treated again. Fifty-three percent of all patients had immediate and complete resolution of symptoms. Three of the 48 patients had missing data from the medical records and were excluded from computations. Conclusions Back pain is multifactorial, and the authors' data demonstrate the potential importance of SI joint pathology. Although the technique described here for treatment of misaligned SI joints in the pediatric patients is not effective in all, the authors have observed significant improvement in 80% of cases. Often it is difficult to determine the exact cause of back pain, but when the SI joint is suspected as the primary pathology, the authors have described a simple and effective bedside treatment that should be attempted prior to the initiation of further testing and surgery.