1
|
Liu B, Wang ZJ, Huang XL. The geriatric nutritional risk index predicts blood transfusion risk in elderly patients undergoing posterior lumbar interbody fusion: a retrospective study. J Orthop Surg Res 2024; 19:659. [PMID: 39407316 PMCID: PMC11481367 DOI: 10.1186/s13018-024-05167-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2024] [Accepted: 10/13/2024] [Indexed: 10/19/2024] Open
Abstract
BACKGROUND Malnutrition can lead to an increased risk of blood transfusion in elderly patients. The Geriatric Nutritional Risk Index (GNRI) is a tool used to assess nutritional status, but its predictive value for blood transfusion in elderly patients undergoing posterior lumbar interbody fusion (PLIF) is not well established. This study aimed to investigate the association between GNRI and the risk of perioperative blood transfusion in this population. METHODS A retrospective cohort study was conducted on elderly patients aged 60 and above who underwent PLIF at Qingdao University Affiliated Hospital. Preoperative GNRI was calculated using height, weight, and serum albumin levels. The primary outcome was perioperative blood transfusion. Logistic regression analysis was performed, adjusting for potential confounders such as demographic characteristics, comorbidities, surgical factors, and laboratory tests. RESULTS A total of 1,246 elderly patients were included, with 144 (11.6%) requiring blood transfusion. After adjusting for all confounders, a lower GNRI was associated with a significantly higher risk of blood transfusion (OR = 2.4, 95% CI: 1.9-3.1, p < 0.001). Patients with a GNRI score below 92 had a significantly increased transfusion risk compared to those with normal GNRI scores (OR = 5.8, 95% CI: 3.7-9.1, p < 0.05). RCS analysis revealed a linear negative relationship between GNRI and transfusion risk. CONCLUSION The GNRI is a strong predictor of perioperative blood transfusion risk in elderly patients undergoing PLIF. Preoperative nutritional assessment using GNRI may help identify high-risk patients, enabling tailored interventions to optimize outcomes.
Collapse
Affiliation(s)
- Bo Liu
- Department of Spinal Surgery, the Affiliated Hospital of Qingdao University, No. 1677 Wutaishan Road, Qingdao, 266000, Shandong, China
| | - Zhi-Jie Wang
- Department of Spinal Surgery, the Affiliated Hospital of Qingdao University, No. 1677 Wutaishan Road, Qingdao, 266000, Shandong, China.
| | - Xiu-Ling Huang
- Department of Laboratory Medicine, the Affiliated Hospital of Qingdao University, No. 1677 Wutaishan Road, Qingdao, 266000, Shandong, China.
| |
Collapse
|
2
|
Azam F, Neerukonda SV, Smith P, Anand S, Mittal S, Bah MG, Barrie U, Detchou D, Aoun SG, Braga BP. Red blood cell transfusion threshold guidelines in pediatric neurosurgery. Neurosurg Rev 2024; 47:555. [PMID: 39240361 DOI: 10.1007/s10143-024-02785-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2024] [Revised: 08/19/2024] [Accepted: 08/31/2024] [Indexed: 09/07/2024]
Affiliation(s)
- Faraaz Azam
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sanjay V Neerukonda
- McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Parker Smith
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Soummitra Anand
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sukul Mittal
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Momodou G Bah
- College of Human Medicine, Michigan State University, East Lansing, MI, USA
| | - Umaru Barrie
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Donald Detchou
- School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- University of Pennsylvania School of Medicine, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Salah G Aoun
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Bruno P Braga
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Center for Cerebrovascular Disease in Children, Children's Health, Dallas, TX, USA
| |
Collapse
|
3
|
An S, Kwon WK, Choi I, Lee JB, Kim J, Hur JW. Evaluating the Efficacy and Safety of Hemofence (Thorombin Cross-Linked Sodium Hyaluronate Gel Matrix) in Hemostasis for Intractable Exudative Bleeding in Spinal Surgery: A Multicenter, Randomized, Phase III Clinical Trial. Neurospine 2024; 21:1004-1013. [PMID: 38575113 PMCID: PMC11456942 DOI: 10.14245/ns.2448024.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 02/22/2024] [Indexed: 04/06/2024] Open
Abstract
OBJECTIVE To demonstrate the noninferiority of the novel hemostatic agent, Hemofence (BMI Korea Co., Ltd., thrombin cross-linked sodium hyaluronate gel matrix) compared to the established agent, Floseal Hemostatic Matrix (Baxter, thrombin-gelatin matrix) in achieving hemostasis for spinal surgeries, with secondary objectives to assess additional efficacy and safety. METHODS This clinical trial was a multicenter, randomized, subject-blinded, active-controlled, parallel-group, phase 3 study. Investigational drugs were administered to the first and second bleeding sites of each participant (or only to the first site if a second site was absent), evaluating hemostasis success rate within 10 minutes and the time to achieve hemostasis. Subsequent visits were conducted for safety assessments. For noninferiority test, a 97.5% one-sided confidence interval (CI) was used; the test group was deemed noninferior if the lower limit exceeded -10%. RESULTS This trial showed a 97.10% success rate in the test group and 96.05% in the control group for primary efficacy. The 95% CI (-4.90% to 7.44%) confirmed the test drug's noninferiority. Time to hemostasis showed no significant difference between groups. All adverse events, adverse drug reactions, and serious adverse events were statistically similar between groups (p=1.000, p=0.243, and p=0.966, respectively). CONCLUSION A novel hemostatic agent, Hemofence, demonstrated an efficacy and safety profile comparable to that of Floseal.
Collapse
Affiliation(s)
- Sungjae An
- Department of Neurosurgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Woo-Keun Kwon
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Il Choi
- Department of Neurosurgery, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Jang-Bo Lee
- Department of Neurosurgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
- Department of Neurosurgery, University of Iowa Hospitals & Clinics, Iowa City, IA, USA
| | - Joohyun Kim
- Department of Neurosurgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Junseok W Hur
- Department of Neurosurgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| |
Collapse
|
4
|
Pirot C, Tantrakansakun C, Sirithiantong T. Clinical prediction model for red cell blood transfusion in elective primary posterior lumbar spine fusion. Sci Rep 2024; 14:14339. [PMID: 38906974 PMCID: PMC11192874 DOI: 10.1038/s41598-024-65174-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 06/18/2024] [Indexed: 06/23/2024] Open
Abstract
Overestimated the cross-match of preoperative PRC preparation for elective primary lumbar spinal fusion needs revision for cost-effectiveness. We aimed to develop a novel preoperative predictive model for appropriate PRC preparation. This clinical prediction model in a retrospective cohort was studied between January 2015 and September 2022. Multivariate logistic regression models were used to assess predictive variables. The logistic coefficient of each predictor generated scores to establish a predictive model. The area under the receiver operating characteristic curve (AuROC) was used to evaluate the model. The predictive performance was validated using bootstrapping techniques and externally validated in 102 independent cases. Among 416 patients, 178 (43%) required transfusion. Four final predictors: preoperative hematocrit level, laminectomy level, transforaminal lumbar interbody fusion level, and sacral fusion. When categorized into two risk groups, the positive predictive values for the low-risk score (≤ 4) were 18.4 (95% Cl 13.9, 23.6) and 83.9 (95% CI 77.1, 89.3) for the high-risk score (> 4). AuROC was 0.90. Internal validation (bootstrap shrinkage = 0.993) and external validation (AuROC: 0.91). A new model demonstrated exemplary performance and discrimination in predicting the appropriate preparation for PRC. This study should be corroborated by rigorous external validation in other hospitals and by prospective assessments.
Collapse
Affiliation(s)
- Chatchawan Pirot
- Department of Orthopaedics, Hatyai Hospital, Songkhla, 90110, Thailand
| | | | | |
Collapse
|
5
|
Zou J, Luo G, Zhou L, Wang X, Wang T, Gao Q, Lv T, Xu G, Yao Y, Yan M. Nomogram for predicting postoperative pulmonary complications in spinal tumor patients. BMC Anesthesiol 2024; 24:56. [PMID: 38331767 PMCID: PMC10851528 DOI: 10.1186/s12871-024-02443-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 02/02/2024] [Indexed: 02/10/2024] Open
Abstract
OBJECTIVES Although several independent risk factors for postoperative pulmonary complications (PPCs) after spinal tumor surgery have been studied, a simple and valid predictive model for PPC occurrence after spinal tumor surgery has not been developed. PATIENTS AND METHODS We collected data from patients who underwent elective spine surgery for a spinal tumor between 2013 and 2020 at a tertiary hospital in China. Data on patient characteristics, comorbidities, preoperative examinations, intraoperative variables, and clinical outcomes were collected. We used univariable and multivariable logistic regression models to assess predictors of PPCs and developed and validated a nomogram for PPCs. We evaluated the performance of the nomogram using the area under the receiver operating characteristic curve (ROC), calibration curves, the Brier Score, and the Hosmer-Lemeshow (H-L) goodness-of-fit test. For clinical use, decision curve analysis (DCA) was conducted to identify the model's performance as a tool for supporting decision-making. RESULTS Among the participants, 61 (12.4%) individuals developed PPCs. Clinically significant variables associated with PPCs after spinal tumor surgery included BMI, tumor location, blood transfusion, and the amount of blood lost. The nomogram incorporating these factors showed a concordance index (C-index) of 0.755 (95% CI: 0.688-0.822). On internal validation, bootstrapping with 1000 resamples yielded a bias-corrected area under the receiver operating characteristic curve of 0.733, indicating the satisfactory performance of the nomogram in predicting PPCs. The calibration curve demonstrated accurate predictions of observed values. The decision curve analysis (DCA) indicated a positive net benefit for the nomogram across most predicted threshold probabilities. CONCLUSIONS We have developed a new nomogram for predicting PPCs in patients who undergo spinal tumor surgery.
Collapse
Affiliation(s)
- Jingcheng Zou
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ge Luo
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Liwang Zhou
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xuena Wang
- Department of Anesthesiology, The First People's Hospital of Huzhou, First affiliated Hospital of Huzhou, Huzhou, China
| | - Tingting Wang
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qi Gao
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Tao Lv
- The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, China
| | - Guangxin Xu
- The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, China
| | - Yuanyuan Yao
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Min Yan
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
- Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, China.
| |
Collapse
|
6
|
Bassani R, Galvain T, Battaglia S, Maheswaran H, Wright G, Kambli A, Piemontese A. Budget Impact Analysis of Minimally Invasive versus Open Transforaminal Lumbar Interbody Fusion for Lumbar Degenerative Disease: A European Hospital Perspective. CLINICOECONOMICS AND OUTCOMES RESEARCH 2024; 16:13-24. [PMID: 38259876 PMCID: PMC10802124 DOI: 10.2147/ceor.s445141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 12/29/2023] [Indexed: 01/24/2024] Open
Abstract
Purpose When traditional therapies fail to provide relief from debilitating lower back pain, surgeries such as transforaminal lumbar interbody fusion (TLIF) may be required. This budget impact analysis (BIA) compared minimally-invasive (MI)-TLIF versus open (O)-TLIF for single-level fusion from an Italian hospital perspective. Methods The BIA compared costs of 100 MI-TLIF and 100 O-TLIF procedures from an Italian hospital perspective over a one-year time horizon. The base case included costs for length of hospital stay (LOS), blood loss, and sterilizing surgical trays. The scenario analysis also included operating room (OR) time and complication costs. Base case inputs were from the Miller et al meta-analysis; scenario analysis inputs were from the Hammad et al meta-analysis. The device costs for MI-TLIF and O-TLIF procedures were from Italian tender prices for Viper Prime™ System and Expedium™ Spine System, respectively. Results Base case deterministic analysis results showed cost savings of €207,370 for MI-TLIF compared with O-TLIF. MI-TLIF costs were lower for LOS (€215,277), transfusion for blood loss (€16,881), and surgical tray sterilization (€28,232), whereas device costs were lower for O-TLIF (€53,020). The probabilistic result was similar, with MI-TLIF resulting in savings of €211,026 (95% credible interval [CR]: €208,725 - €213,327). All 1000 base case probabilistic sensitivity analysis runs were cost saving. Deterministic scenario analysis results showed cost savings of €166,719 for MI-TLIF. MI-TLIF costs were lower for LOS (€190,813), transfusion for blood loss (€16,881), surgical tray sterilization (€28,232), and complications (€2076), whereas O-TLIF costs were lower for OR time (€18,263) and devices used (€53,020). Conclusion Despite the increase incremental cost for medical device innovation and OR time, this study demonstrates the economic savings of MI-TLIF compared to O-TLIF from a European hospital perspective. The findings will be useful to policy and hospital decision makers in assessing purchasing, funding and reimbursement decisions.
Collapse
Affiliation(s)
- Roberto Bassani
- II Spinal Surgery Unit, IRCCS Galeazzi-Sant’Ambrogio Hospital, Milano, Italy
| | | | | | | | | | | | | |
Collapse
|
7
|
Hammon DE, Chidambaran V, Templeton TW, Pestieau SR. Error traps and preventative strategies for adolescent idiopathic scoliosis spinal surgery. Paediatr Anaesth 2023; 33:894-904. [PMID: 37528658 DOI: 10.1111/pan.14735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/26/2023] [Accepted: 07/10/2023] [Indexed: 08/03/2023]
Abstract
Anesthesia for posterior spinal fusion for adolescent idiopathic scoliosis remains one of the most common surgeries performed in adolescents. These procedures have the potential for significant intraprocedural and postoperative complications. The potential for pressure injuries related to prone positioning must be understood and addressed. Additionally, neuromonitoring remains a mainstay for patient care in order to adequately assess patient neurologic integrity and alert the providers to a reversible action. As such, causes of neuromonitoring signal loss must be well understood, and the provider should have a systematic approach to signal loss. Further, anesthetic design must facilitate intraoperative wake-up to allow for a definitive assessment of neurologic function. Perioperative bleeding risk is high in posterior spinal fusion due to the extensive surgical exposure and potentially lengthy operative time, so the provider should undertake strategies to reduce blood loss and avoid coagulopathy. Pain management for adolescents undergoing spinal fusion is also challenging, and inadequate analgesia can delay recovery, impede patient/family satisfaction, increase the risk of chronic postsurgical pain/disability, and lead to prolonged opioid use. Many of the significant complications associated with this procedure, however, can be avoided with intentional and evidence-based approaches covered in this review.
Collapse
Affiliation(s)
- Dudley E Hammon
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Vidya Chidambaran
- Department of Anesthesiology, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Thomas W Templeton
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Sophie R Pestieau
- Department of Anesthesiology, Washington National, Washington, DC, USA
| |
Collapse
|
8
|
Liu T, Bai Y, Yin L, Wang JH, Yao N, You LW, Guo JR. Effect of acute normovolemic hemodilution on anesthetic effect, plasma concentration, and recovery quality in elderly patients undergoing spinal surgery. BMC Geriatr 2023; 23:689. [PMID: 37875833 PMCID: PMC10598930 DOI: 10.1186/s12877-023-04397-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 10/09/2023] [Indexed: 10/26/2023] Open
Abstract
OBJECTIVE To explore the effect of acute normovolemic hemodilution (ANH) on the anesthetic effect, plasma concentration, and postoperative recovery quality in elderly patients undergoing spinal surgery. METHODS A total of 60 cases of elderly patients aged 65 to 75 years who underwent elective multilevel spinal surgery were assigned randomly into the ANH group (n = 30) and control group (n = 30). Hemodynamic and blood gas analysis indexes were observed and recorded before ANH (T1), after ANH (T2), immediately after postoperative autologous blood transfusion (T3), 10 min (T4), 20 min (T5), 30 min (T6), 40 min (T7), and 50 min (T8) after the transfusion, and at the end of the transfusion (i.e., 60 min; T9). At T3 ~ 9, bispectral index (BIS) and train-of-four (TOF) stimulation were recorded and the plasma propofol/cisatracurium concentration was determined. The extubation time and recovery quality were recorded. RESULTS The ANH group presented a lower MAP value and a higher SVV value at T2, and shorter extubation and orientation recovery time (P < 0.05) compared with the control group. BIS values at T8 and T9 were lower in the ANH group than those in the control group (P < 0.05). TOF values at T7 ~ 9 were lower in the ANH group than those in the control group (P < 0.05). There were no statistically significant differences in the postoperative plasma concentrations of propofol and cisatracurium between the groups (P > 0.05). CONCLUSION During orthopedic surgery, the plasma concentration of elderly patients is increased after autologous blood transfusion of ANH, and the depth of anesthesia and muscle relaxant effect are strengthened, thus leading to delayed recovery of respiratory function and extubation.
Collapse
Affiliation(s)
- Tong Liu
- Department of Anesthesiology and Perioperative Medicine, Shanghai Gongli Hospital, Naval Military Medical University, No.219 Miaopu Road, Pudong New Area, Shanghai, 200135, China
| | - Yu Bai
- Department of Anesthesiology and Perioperative Medicine, Shanghai Gongli Hospital, Naval Military Medical University, No.219 Miaopu Road, Pudong New Area, Shanghai, 200135, China
| | - Lei Yin
- Department of Anesthesiology and Perioperative Medicine, Shanghai Gongli Hospital, Naval Military Medical University, No.219 Miaopu Road, Pudong New Area, Shanghai, 200135, China
| | - Jin-Huo Wang
- Department of Anesthesiology and Perioperative Medicine, Shanghai Gongli Hospital, Naval Military Medical University, No.219 Miaopu Road, Pudong New Area, Shanghai, 200135, China
| | - Na Yao
- Department of Anesthesiology and Perioperative Medicine, Shanghai Gongli Hospital, Naval Military Medical University, No.219 Miaopu Road, Pudong New Area, Shanghai, 200135, China
| | - Lai-Wei You
- Department of Anesthesiology and Perioperative Medicine, Shanghai Gongli Hospital, Naval Military Medical University, No.219 Miaopu Road, Pudong New Area, Shanghai, 200135, China
| | - Jian-Rong Guo
- Department of Anesthesiology and Perioperative Medicine, Shanghai Gongli Hospital, Naval Military Medical University, No.219 Miaopu Road, Pudong New Area, Shanghai, 200135, China.
| |
Collapse
|
9
|
Issa TZ, Lee Y, Heard JC, Lambrechts MJ, Giakas A, Mazmudar AS, Vaccaro A, Henry TW, Kalra A, Fras S, Canseco JA, Kaye ID, Kurd MF, Hilibrand AS, Vaccaro AR, Schroeder GD, Kepler CK. The severity of preoperative anemia escalates risk of poor short-term outcomes after lumbar spine fusion. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:3192-3199. [PMID: 37253836 DOI: 10.1007/s00586-023-07789-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 05/10/2023] [Accepted: 05/17/2023] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To evaluate how preoperative anemia severity affects 90-day outcomes of spinal fusion surgery. METHODS A retrospective cohort study was conducted on adult lumbar fusion patients at a tertiary medical center. Patients were classified by World Health Organization anemia severity definitions for comparisons. Multivariate regression models were created to control for confounding variables, for all primary outcomes of transfusion requirements, non-home discharge, readmissions, complications, and length of stay. RESULTS A total of 2582 patients were included: 2.7% with moderate-severe anemia, 11.0% with mild anemia, and 86.3% without anemia. Moderate-severe patients had the longest hospital stay (5.03 days vs 4.14 and 3.59 days, p < 0.001) and highest risk of transfusion (52.2% vs 13.0% vs 2.69%, p < 0.001), non-home discharge (39.1% vs 27.8% vs 15.4%, p < 0.001), readmission (7.25% vs 5.99% vs 3.36%, p = 0.023), and complications (13.0% vs 9.51% vs 6.20%, p = 0.012). On multivariable logistic regression, both patients with mild and moderate-severe anemia had an increased risk of transfusion (OR: 37.3, p < 0.001; OR: 5.25, p < 0.001, respectively) and non-home discharge (OR: 2.00, p = 0.021; OR: 1.71, p = 0.001, respectively) compared to patients without anemia. Anemia severity was not independently associated with complications or 90-day readmission. On multivariable linear regression, mild anemia (β: 0.37, p = 0.001) and moderate-severe anemia (β: 1.07, p < 0.001) were independently associated with length of hospital stay. CONCLUSION Patients with moderate-severe preoperative anemia are at increased risk for longer length of stay, transfusions, and non-home discharge. Improved optimization of preoperative anemia may significantly reduce healthcare utilization, and surgeons should consider these risks in preoperative planning. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Tariq Z Issa
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, 125 S 9th St, Suite 1000, Philadelphia, PA, 19107, USA.
- Feinberg School of Medicine, Northwestern University, Chicago, IL, 60611, USA.
| | - Yunsoo Lee
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, 125 S 9th St, Suite 1000, Philadelphia, PA, 19107, USA
| | - Jeremy C Heard
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, 125 S 9th St, Suite 1000, Philadelphia, PA, 19107, USA
| | - Mark J Lambrechts
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, 125 S 9th St, Suite 1000, Philadelphia, PA, 19107, USA
| | - Alec Giakas
- Medical University of South Carolina, Charleston, SC, 29425, USA
| | - Aditya S Mazmudar
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, 125 S 9th St, Suite 1000, Philadelphia, PA, 19107, USA
| | - Alexander Vaccaro
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, 125 S 9th St, Suite 1000, Philadelphia, PA, 19107, USA
| | - Tyler W Henry
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, 125 S 9th St, Suite 1000, Philadelphia, PA, 19107, USA
| | - Andrew Kalra
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, 125 S 9th St, Suite 1000, Philadelphia, PA, 19107, USA
| | - Sebastian Fras
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, 125 S 9th St, Suite 1000, Philadelphia, PA, 19107, USA
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, 125 S 9th St, Suite 1000, Philadelphia, PA, 19107, USA
| | - Ian David Kaye
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, 125 S 9th St, Suite 1000, Philadelphia, PA, 19107, USA
| | - Mark F Kurd
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, 125 S 9th St, Suite 1000, Philadelphia, PA, 19107, USA
| | - Alan S Hilibrand
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, 125 S 9th St, Suite 1000, Philadelphia, PA, 19107, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, 125 S 9th St, Suite 1000, Philadelphia, PA, 19107, USA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, 125 S 9th St, Suite 1000, Philadelphia, PA, 19107, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, 125 S 9th St, Suite 1000, Philadelphia, PA, 19107, USA
| |
Collapse
|
10
|
Heard JC, Siegel N, Yalla GR, Lambrechts MJ, Lee Y, Sherman M, Wang J, Dambly J, Baker S, Bowen G, Mangan JJ, Canseco JA, Kurd MF, Kaye ID, Hilibrand AS, Vaccaro AR, Kepler CK, Schroeder GD. Predictors of Blood Transfusion in Patients Undergoing Lumbar Spinal Fusion. World Neurosurg 2023; 176:e493-e500. [PMID: 37257651 DOI: 10.1016/j.wneu.2023.05.087] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 05/20/2023] [Indexed: 06/02/2023]
Abstract
OBJECTIVE To determine risk factors for perioperative blood transfusion after lumbar fusion surgery. METHODS After institutional review board approval, a retrospective cohort study of adult patients who underwent lumbar fusion at a single, urban tertiary academic center was retrospectively retrieved. Our primary outcome, blood transfusion, was collected via chart query. A receiver operating characteristic curve was used to evaluate the regression model. A P-value < 0.05 was considered statistically significant. RESULTS Of the 3,842 patients, 282 (7.3%) required a blood transfusion. For patients undergoing posterolateral decompression and fusion, predictors of transfusion included age (P < 0.001) and more levels fused (P < 0.001). A higher preoperative hemoglobin level (P < 0.001) and revision surgery (P = 0.005) were protective of blood transfusion. For patients undergoing transforaminal lumbar interbody fusion, greater Elixhauser comorbidity index (P < 0.001), longer operative time (P = 0.040), and more levels fused (P = 0.030) were independent predictors of the need for blood transfusion. Patients with a higher body mass index (P = 0.012) and preoperative hemoglobin level (P < 0.001) had a reduced likelihood of receiving a transfusion. For circumferential fusion, greater age (P = 0.006) and longer operative times (P = 0.015) were independent predictors of blood transfusion, while a higher preoperative hemoglobin level (P < 0.001) and male sex (P = 0.002) were protective. CONCLUSIONS Our analysis identified older age, lower body mass index, greater Elixhauser comorbidity index, longer operative duration, more levels fused, and lower preoperative hemoglobin levels as independent predictors of requiring a blood transfusion following lumbar spinal fusion. Different surgical approaches were not found to be associated with transfusion.
Collapse
Affiliation(s)
- Jeremy C Heard
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nicholas Siegel
- Department of Orthopaedic Surgery, Johns Hopkins University Hospital, Baltimore, Maryland, USA
| | - Goutham R Yalla
- Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Mark J Lambrechts
- Department of Orthopaedic Surgery, Washington University at St. Louis, St. Louis, Missouri, USA
| | - Yunsoo Lee
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.
| | - Matthew Sherman
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Jasmine Wang
- Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Julia Dambly
- Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Sydney Baker
- Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Grace Bowen
- Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - John J Mangan
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Mark F Kurd
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ian D Kaye
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Alan S Hilibrand
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| |
Collapse
|
11
|
Terada R, Stewart K, Hansen S, Shettar SS, Butt A, Vallurupalli S, Martin M, Tanaka K. Temporal changes and predictors of perioperative blood transfusion in elective spine surgery: a retrospective analysis of a large surgical database. Br J Anaesth 2023; 130:421-429. [PMID: 36586804 DOI: 10.1016/j.bja.2022.11.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 11/09/2022] [Accepted: 11/13/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Allogeneic blood transfusion used to be common in spine surgery. Patient blood management has been widely adopted, and it is important to reassess transfusion predictors in contemporary practice. METHODS A retrospective study of inpatient spine surgery was performed using National Surgical Quality Improvement Program (NSQIP) data from 2011 to 2019. The primary outcome was perioperative transfusion within 72 h of surgery. Multivariable logistic regression and recursive partitioning were used to assess up to 15 variables including patient and surgical data, surgical specialty (orthopaedic surgery vs neurosurgery), and year of surgery. RESULTS The study population included 251 971 US surgical patients; 6.9% of these patients received perioperative blood transfusion. Perioperative transfusions declined over time with the steepest decline from 2011 to 2015. The greatest reduction was seen among orthopaedic cases where the transfusion rate declined from 16.0% to 8.7% between 2011 and 2015. Eight variables were predictive factors in a reduced model: operative time, preoperative haemoglobin, vertebral level, number of vertebral levels, older age, surgeon specialty, arthrodesis, and year of surgery (area under the curve [AUC]=0.880; 95% confidence interval [CI], 0.878-0.883). Overall, longer operative time (>144 min) and greater numbers of vertebral levels had greater associations with transfusion than surgical specialty after adjustments. Prevalence of anaemia (15%) has not substantially declined. CONCLUSIONS Perioperative blood transfusion rate in spine surgery has declined over the past decade. The extent and duration of surgery and preoperative haemoglobin level remain important factors associated with increased odds for perioperative blood transfusion.
Collapse
Affiliation(s)
- Rui Terada
- Department of Anaesthesiology, University of Oklahoma Health Science Center, Oklahoma City, OK, USA
| | - Kenneth Stewart
- Department of Anaesthesiology, University of Oklahoma Health Science Center, Oklahoma City, OK, USA; Department of Surgery, University of Oklahoma Health Science Center, Oklahoma City, OK, USA
| | - Sandra Hansen
- Department of Anaesthesiology, University of Oklahoma Health Science Center, Oklahoma City, OK, USA
| | - Shashank S Shettar
- Department of Anaesthesiology, University of Oklahoma Health Science Center, Oklahoma City, OK, USA
| | - Amir Butt
- Department of Anaesthesiology, University of Oklahoma Health Science Center, Oklahoma City, OK, USA
| | - Santaram Vallurupalli
- Department of Orthopedic Surgery, University of Oklahoma Health Science Center, Oklahoma City, OK, USA
| | - Michael Martin
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, OK, USA
| | - Kenichi Tanaka
- Department of Anaesthesiology, University of Oklahoma Health Science Center, Oklahoma City, OK, USA.
| |
Collapse
|
12
|
Transfusion Guidelines in Brain Tumor Surgery: A Systematic Review and Critical Summary of Currently Available Evidence. World Neurosurg 2022; 165:172-179.e2. [PMID: 35752421 DOI: 10.1016/j.wneu.2022.06.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 06/14/2022] [Accepted: 06/15/2022] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Red blood cell (RBC) transfusion is commonly indicated in brain tumor surgery due to risk of blood loss. Current transfusion guidelines are based on evidence derived from critically ill patients and may not be optimal for brain tumor surgeries. Our study is the first to synthesize available evidence to suggest RBC transfusion thresholds in brain tumor patients undergoing surgery. METHODS A systematic review was conducted using PubMed, EMBASE, and Google Scholar databases in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines to critically assess RBC transfusion thresholds in adult patients with brain tumors and complications secondary to transfusion following blood loss in the operating room (OR) or the perioperative period. RESULTS Seven (7) articles meeting our search criteria were reviewed. Brain tumor patients who received blood transfusions were older, had greater rates of ASA class 3 or 4, and presented with increased number of comorbidities including diabetes, hypertension, and cardiovascular diseases. In addition, transfused patients had a prolonged surgical time. Transfusions were associated with multiple postoperative major and minor complications, including longer hospital length of stay (LOS), increased return to the OR, and elevated 30-day mortality. Analysis of transfusion thresholds showed that a restrictive hemoglobin (Hb) threshold of 8 g/dL is safe in patients, as evidenced by a reduction in LOS, mortality, and complications (Level C Class IIa). CONCLUSIONS A restrictive Hb threshold of 8 g/dL appears to be safe and minimizes potential complications of transfusion in brain tumor patients. LEVEL OF EVIDENCE Class C Level IIa.
Collapse
|
13
|
Effectiveness of Oral Antibiotic Therapy in Prevention of Postoperative Wound Infection Requiring Surgical Washout In Spine Surgery. World Neurosurg 2022; 163:e275-e282. [PMID: 35364295 DOI: 10.1016/j.wneu.2022.03.106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 03/23/2022] [Accepted: 03/24/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Surgical site infections (SSIs) after spine surgery are a significant cause of morbidity. Surgeons often prescribe oral antibiotics in the postoperative setting for infected-appearing wounds to prevent reoperation for infection; however, the efficacy of this practice has not been well studied. METHODS Neurosurgical spine patients with clinical concerns for SSI at the University of Pennsylvania were retrospectively studied from 2014 to 2018. Clinical predictors of 90-day reoperation for infection despite antibiotic treatment and variables that influenced antibiotic prescription were analyzed. RESULTS Three hundred and ninety-two patients were included in the study. Preoperative albumin level, days elapsed to antibiotic prescription from index surgery, preoperative hemoglobin level, surgical location, gender, discharge disposition, and level of wound concern were significant predictors of reoperation for infection on bivariate analysis. Days elapsed to antibiotic prescription, surgical location, and level of wound concern remained significant after multivariable logistic regression. Variables that significantly predicted prescription of an antibiotic include length of stay, cerebrospinal fluid leak, race, and level of wound concern. Length of stay, race, and level of wound concern remained significant after multivariable analysis. CONCLUSIONS Wound infection remains a challenging problem in spine surgery and it is reasonable to perform early reoperation in patients with high clinical concerns for infection, because bacterial isolates are often resistant to common oral antibiotics. Patients with wounds with low clinical concerns for infection may undergo a trial of oral antibiotics; however, duration of treatment should not be prolonged.
Collapse
|
14
|
Briguglio M, Perazzo P, Langella F, Crespi T, De Vecchi E, Riso P, Porrini M, Scaramuzzo L, Bassani R, Brayda-Bruno M, Banfi G, Berjano P. Prediction of Long-Term Recovery From Disability Using Hemoglobin-Based Models: Results From a Cohort of 1,392 Patients Undergoing Spine Surgery. Front Surg 2022; 9:850342. [PMID: 35372461 PMCID: PMC8966424 DOI: 10.3389/fsurg.2022.850342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 02/17/2022] [Indexed: 11/13/2022] Open
Abstract
Hemoglobin and its associated blood values are important laboratory biomarkers that mirror the strength of constitution of patients undergoing spine surgery. Along with the clinical determinants available during the preadmission visit, it is important to explore their potential for predicting clinical success from the patient's perspective in order to make the pre-admission visit more patient-centered. We analyzed data from 1,392 patients with spine deformity, disc disease, or spondylolisthesis enrolled between 2016 and 2019 in our institutional Spine Registry. Patient-reported outcome measure at 17 months after surgery was referred to the Oswestry disability index. High preoperative hemoglobin was found to be the strongest biochemical determinant of clinical success along with high red blood cells count, while low baseline disability, prolonged hospitalization, and long surgical times were associated with poor recovery. The neural network model of these predictors showed a fair diagnostic performance, having an area under the curve of 0.726 and a sensitivity of 86.79%. However, the specificity of the model was 15.15%, thus providing to be unreliable in forecasting poor patient-reported outcomes. In conclusion, preoperative hemoglobin may be one of the key biomarkers on which to build appropriate predictive models of long-term recovery after spine surgery, but it is necessary to include multidimensional variables in the models to increase the reliability at the patient's level.
Collapse
Affiliation(s)
- Matteo Briguglio
- IRCCS Orthopedic Institute Galeazzi, Scientific Direction, Milan, Italy
- *Correspondence: Matteo Briguglio
| | - Paolo Perazzo
- IRCCS Orthopedic Institute Galeazzi, Intensive Care Unit, Milan, Italy
| | | | - Tiziano Crespi
- IRCCS Orthopedic Institute Galeazzi, Intensive Care Unit, Milan, Italy
| | - Elena De Vecchi
- IRCCS Orthopedic Institute Galeazzi, Laboratory of Clinical Chemistry and Microbiology, Milan, Italy
| | - Patrizia Riso
- University of Milan, Department of Food, Environmental and Nutritional Sciences, Division of Human Nutrition, Milan, Italy
| | - Marisa Porrini
- University of Milan, Department of Food, Environmental and Nutritional Sciences, Division of Human Nutrition, Milan, Italy
| | | | - Roberto Bassani
- IRCCS Orthopedic Institute Galeazzi, Spine Unit 2, Milan, Italy
| | | | - Giuseppe Banfi
- IRCCS Orthopedic Institute Galeazzi, Scientific Direction, Milan, Italy
- Vita-Salute San Raffaele University, Faculty of Medicine and Surgery, Milan, Italy
| | - Pedro Berjano
- IRCCS Orthopedic Institute Galeazzi, GSpine 4, Milan, Italy
| |
Collapse
|
15
|
Montgomery EY, Barrie U, Kenfack YJ, Edukugho D, Caruso JP, Rail B, Hicks WH, Oduguwa E, Pernik MN, Tao J, Mofor P, Adeyemo E, Ahmadieh TYE, Tamimi MA, Bagley CA, Bedros N, Aoun SG. Transfusion Guidelines in Traumatic Brain Injury: A Systematic Review and Meta-Analysis of the Currently Available Evidence. Neurotrauma Rep 2022; 3:554-568. [PMID: 36636743 PMCID: PMC9811955 DOI: 10.1089/neur.2022.0056] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Our study aims to provide a synthesis of the best available evidence on the hemoglobin (hgb) red blood cell (RBC) transfusion thresholds in adult traumatic brain injury (TBI) patients, as well as describing the risk factors and outcomes associated with RBC transfusion in this population. A systematic review and meta-analysis was conducted using PubMed, Google Scholar, and Web of Science electronic databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to assess articles discussing RBC transfusion thresholds and describe complications secondary to transfusion in adult TBI patients in the perioperative period. Fifteen articles met search criteria and were reviewed for analysis. Compared to non-transfused, TBI patients who received transfusion tended to be primarily male patients with worse Injury Severity Score (ISS) and Glasgow Coma Scale. Further, the meta-analysis corroborated that transfused TBI patients are older (p = 0.04), have worse ISS scores (p = 0.001), receive more units of RBCs (p = 0.02), and have both higher mortality (p < 0.001) and complication rates (p < 0.0001). There were no differences identified in rates of hypertension, diabetes mellitus, and Abbreviated Injury Scale scores. Additionally, whereas many studies support restrictive (hgb <7 g/dL) transfusion thresholds over liberal (hgb <10 g/dL), our meta-analysis revealed no significant difference in mortality between those thresholds (p = 0.79). Current Class B/C level III evidence predominantly recommends against a liberal transfusion threshold of 10 g/dL for TBI patients (Class B/C level III), but our meta-analysis found no difference in survival between groups. There is evidence suggesting that an intermediate threshold between 7 and 9 g/dL, reflecting the physiological oxygen needs of cerebral tissue, may be worth exploring.
Collapse
Affiliation(s)
- Eric Y. Montgomery
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Address correspondence to: Eric Y. Montgomery, BA, Department of Neurosurgery, The University of Texas Southwestern, 5151 Harry Hines Boulevard, Dallas, TX 75235, USA.
| | - Umaru Barrie
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Yves J. Kenfack
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Derrek Edukugho
- Department of Neurological Surgery, Boonshoft School of Medicine, Wright State University, Dayton, Ohio, USA
| | - James P. Caruso
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Benjamin Rail
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - William H. Hicks
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Emmanuella Oduguwa
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mark N. Pernik
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jonathan Tao
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Paula Mofor
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Emmanuel Adeyemo
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Tarek Y. El Ahmadieh
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Mazin Al Tamimi
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Carlos A. Bagley
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Nicole Bedros
- Department of Surgery, Baylor University Medical Center, Dallas, Texas, USA
| | - Salah G. Aoun
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| |
Collapse
|