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Chen Y, Yu P, Li Z, Xu H, Li S, Wang Q, Ji F, Lan Q. Outcomes and adverse events for spinal synovial cysts surgical treatment: a systematic review and meta-analysis. Arch Orthop Trauma Surg 2024; 144:3275-3289. [PMID: 39039314 DOI: 10.1007/s00402-024-05460-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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 07/07/2024] [Indexed: 07/24/2024]
Abstract
BACKGROUND Spinal synovial cysts (SSCs) are a rare cause of nerve root and spinal cord compression. Surgical excision of SSCs remains the mainstay of treatment in the presence of unremitting symptoms or neurological deficits, but the choice of the surgical approach remains controversial. The goal of this study was to compare clinical outcomes and adverse events associated with traditional approaches (interlaminar or laminectomy/hemilaminectomy) and minimally invasive approaches (microsurgical tubular approaches or endoscopic approaches) for SSCs. METHODS Studies reporting surgical management of SSCs were searched in three online databases (PubMed, the Cochrane Library, and Web of Science). This meta-analysis was reported following the PRISMA Statement. It was registered at the International Prospective Register of Systematic Reviews (CRD42021288992). The Cochrane Collaboration's Risk of Bias in Nonrandomised Studies-of Interventions (ROBINS-I) was used to evaluate bias. Extracted research data were statistically analyzed using Stata 16 and SPSS statistics 25. RESULTS A total of 22 related relevant studies were included. Meta-analysis revealed no statistically significant difference in dural tear, residual cyst, recurrence, reoperation, and operation time between minimally invasive approaches and traditional approaches (p > 0.05), but minimally invasive approaches had a good functional improvement (p = 0.004). Postoperative length of hospital stays and intraoperative bleeding in traditional approaches were also higher than in minimally invasive approaches (p < 0.05). CONCLUSION Based on the available evidence, minimally invasive approaches may be better than traditional approaches in the treatment of SSCs. Minimally invasive approaches had the advantages of improving clinical satisfaction, with a similar complication rate to traditional approaches. Moreover, endoscopic and microsurgical tubular approaches had similar outcomes.
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Affiliation(s)
- Ying Chen
- Department of Neurosurgery, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215004, P.R. China
| | - Pei Yu
- Department of Neurosurgery, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215004, P.R. China
| | - Zhaoliang Li
- Department of Neurosurgery, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215004, P.R. China
| | - Hui Xu
- Department of Neurosurgery, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215004, P.R. China
| | - Shenggang Li
- Department of Neurosurgery, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215004, P.R. China
| | - Qing Wang
- Department of Neurosurgery, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215004, P.R. China
| | - Fufu Ji
- Department of Neurosurgery, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215004, P.R. China
| | - Qing Lan
- Department of Neurosurgery, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215004, P.R. China.
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Chen Y, Yu P, Xu H, Li S, Wang Q, Wu C, Wang J, Ji F, Huang Q, Lan Q. Efficacy of minimally invasive tubular approaches for management of the lumbar spinal synovial cysts: a meta-analysis. Eur J Med Res 2023; 28:494. [PMID: 37941083 PMCID: PMC10631136 DOI: 10.1186/s40001-023-01481-0] [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: 07/06/2022] [Accepted: 10/28/2023] [Indexed: 11/10/2023] Open
Abstract
The treatment of lumbar spinal synovial cysts (LSCs) which are relatively rare but can cause neurogenic dysfunction and intractable pain has been a controversial topic for many years. Surgical excision of LSCs is the standard treatment for patients in whom conservative treatment options fail. This meta-analysis was undertaken to compare clinical outcomes between minimally invasive approaches using tubular retractors (microscopic vs. endoscopic) and traditional percutaneous approaches for LSCs. Studies reporting surgical management of LSCs were searched in the Cochrane Library, PubMed and Web of Science database. This meta-analysis was reported following the PRISMA Statement, registered in Prospero (CRD42021288992). A total of 1833 patients were included from both the related relevant studies (41 studies, n = 1831) and the present series (n = 2). Meta-analysis of minimally invasive tubular approaches revealed no statistically significant difference in pain improvement, dural tear, residual cyst, recurrence and operation time between minimal groups with traditional groups (p > 0.05). Minimal groups had better Functional improvement of 100% (95% CI 1.00-1.00; p < 0.001, I2 = 75.3%) and less reoperation rates of 0% (95% CI - 0.00-0.00; p = 0.007, I2 = 47.1%). Postoperative length of hospital stay and intraoperative bleeding in minimal groups were also less than traditional groups (p < 0.05). Subgroup analysis revealed endoscopic groups had less operation time (p = 0.004), and there was no significant difference in the rest. For patients with LSCs but without obvious clinical and imaging evidence of vertebral instability, even when preoperative stable grade 1 spondylolisthesis is present, minimally invasive tubular approaches without fusion may provide the best outcome in surgical management.
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Affiliation(s)
- Ying Chen
- Department of Neurosurgery, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215004, People's Republic of China
| | - Pei Yu
- Department of Neurosurgery, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215004, People's Republic of China
| | - Hui Xu
- Department of Neurosurgery, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215004, People's Republic of China
| | - Shenggang Li
- Department of Neurosurgery, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215004, People's Republic of China
| | - Qing Wang
- Department of Neurosurgery, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215004, People's Republic of China
| | - Chunwang Wu
- Department of Neurosurgery, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215004, People's Republic of China
| | - Ji Wang
- Department of Neurosurgery, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215004, People's Republic of China
| | - Fufu Ji
- Department of Neurosurgery, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215004, People's Republic of China
| | - Qiang Huang
- Department of Neurosurgery, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215004, People's Republic of China
| | - Qing Lan
- Department of Neurosurgery, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215004, People's Republic of China.
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Staszkiewicz R, Sobański D, Ulasavets U, Wieczorek J, Golec E, Marcol W, Grabarek BO. Evaluation of the concentration of selected elements in serum patients with intervertebral disc degeneration. J Trace Elem Med Biol 2023; 77:127145. [PMID: 36921371 DOI: 10.1016/j.jtemb.2023.127145] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 02/10/2023] [Accepted: 02/27/2023] [Indexed: 03/14/2023]
Abstract
Quantitative analysis of the trace element content of human intervertebral discs (IVDs) is essential because it can identify specific enzymes or metabolites that may be related to human intervertebral disc degeneration (IVDD). The goal of this study was to assess the concentrations of copper (Cu), iron (Fe), manganese (Mn), lead (Pb), zinc (Zn), sodium (Na), magnesium (Mg), potassium (K), phosphorus (P), and calcium (Ca) in serum samples obtained from patients with IVDD in comparison to healthy volunteers (a control group). The study group consisted of 113 Caucasian patients qualified by a specialist neurosurgeon for microdiscectomy. The control group consisted of 113 healthy volunteers who met the eligibility criteria for blood donors. The examined clinical material was the serum samples obtained from both groups.Based on the quantitative analysis of selected elements, there were statistically significantly (p 0.05) higher concentrations of Cu (1180 μg/L±800 μg/L vs. 1230 μg/L±750 μg/L), Zn (790 μg/L±300 μg/L vs. 850 μg/L±200 μg/L), and Mg (21730 μg/L±4360 μg/L vs. 23820 μg/L±4990 μg/L) in the serum of healthy volunteers compared to those in the study group. In addition, statistically significant changes were not detected in the concentrations of any elements among either sex in either the study or control group or in their body mass index (BMI) values (p > 0.05). In the serum samples from the study group, the strongest relationships were noted between the concentrations of Zn and Pb (r = 0.61), Zn and P (r = 0.69), Zn and Ca (r = 0.84), Zn and Cu (r = 0.83), Mg and Ca (r = 0.74), and Ca and P (r = 0.98).It has been indicated that, above all, the concentrations of Cu, Zn, Ca, and Mg depend on the advancement of radiological changes, according to the Pfirrmann scale. However, no influence on pain intensity was found, depending on the concentration of the assessed elements.The analysis indicates that the determination of serum Cu, Zn, Ca, and Mg concentrations may have diagnostic significance in predicting the onset of lumbosacral IVDD. The predictive evaluation of changes in the concentrations of selected elements in patients with degenerative lumbar IVD lesions appears to be a promising, cost-effective strategy.
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Affiliation(s)
- Rafał Staszkiewicz
- Department of Neurosurgery, 5th Military Clinical Hospital with the SP ZOZ Polyclinic in Krakow, 30-901 Krakow, Poland; Department of Histology, Cytophysiology and Embryology, Faculty of Medicine in Zabrze, Academy of Silesia in Katowice, 41-800 Zabrze, Poland.
| | - Dawid Sobański
- Department of Neurosurgery, St. Raphael Hospital, 30-693 Krakow, Poland; Department of Neurosurgery, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski University, 30-705 Kraków, Poland
| | - Uladzislau Ulasavets
- Department of Neurosurgery, 5th Military Clinical Hospital with the SP ZOZ Polyclinic in Krakow, 30-901 Krakow, Poland
| | - Jerzy Wieczorek
- Department of Agricultural and Environmental Chemistry, University of Agriculture in Krakow, 31-120 Krakow, Poland
| | - Edward Golec
- Department of Trauma and Orthopedic Surgery, 5th Military Clinical Hospital, Kraków, Poland; Department of Rehabilitation in Orthopedics, Faculty of Motor Rehabilitation Bronisław Czech University of Physical Education in Kraków, Poland
| | - Wiesław Marcol
- Department of Physiology, School of Medicine in Katowice, Medical University of Silesia, 40-752 Katowice, Poland; Department of Neurosurgery, Provincial Specialist Hospital No. 2 in Jastrzębie-Zdrój, 44-300 Jastrzębie-Zdrój, Poland
| | - Beniamin Oskar Grabarek
- Department of Neurosurgery, 5th Military Clinical Hospital with the SP ZOZ Polyclinic in Krakow, 30-901 Krakow, Poland; Department of Histology, Cytophysiology and Embryology, Faculty of Medicine in Zabrze, Academy of Silesia in Katowice, 41-800 Zabrze, Poland
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Gonzalez GA, Corso K, Kothari P, Franco D, Porto G, Miao J, Wainwright JV, O'Leary M, Hines K, Mahtabfar A, Vanderkarr M, Thalheimer S, Sharan A, Jallo J, Harrop J. Lumbar Synovial Cysts-Should You Fuse or Not? Neurosurgery 2022; 92:1013-1020. [PMID: 36700698 DOI: 10.1227/neu.0000000000002314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 10/19/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Spinal synovial cysts are lesions that most commonly occur in the lumbar region. The need for an instrumented spinal fusion in addition to lumbar decompression with removal of the synovial cyst is unknown. OBJECTIVE To test the hypothesis that select patients who underwent decompression with instrumented fusion for lumbar synovial cysts would be less likely to have subsequent surgery (SS) in a 2-year period than patients treated with laminectomy alone. METHODS This retrospective cohort study was performed using IBM MarketScan Commercial Claims and Encounters Database. Patients who had a lumbar synovial cyst diagnosis and laminectomy surgery with or without fusion surgery were included in this study. Patients were tracked for SS 2 years after surgery. Laminectomy patients were propensity score-matched to laminectomy with fusion (LF) patients using a 2:1 ratio. The log-rank test and Cox regression were used to compare the cumulative incidence of SS between groups. RESULTS There were 7664 and 1631 patients treated with laminectomy and LF before matching. After matching, there were 2212 laminectomy and 1631 LF patients and patient characteristics were balanced. The 2-year incidence of recurrent SS was 3.1% ([CI]: 2.2%, 4.0%) and 1.7% (95% CI: 0.9%, 2.5%) laminectomy and LF, respectively. Compared with laminectomy, LF had a statistically significant lower risk of recurrent SS (hazard ratio: 0.56 [95% CI: 0.32-0.97]; P -value: .04). CONCLUSION All patients who had concomitant lumbar fusion showed decreased chance of having a cyst- or noncyst-related recurrence SS when compared with all patients undergoing laminectomy alone, regardless of diagnosis at the time of SS.
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Affiliation(s)
- Glenn A Gonzalez
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Katherine Corso
- Real World Data Sciences, Medical Device Epidemiology, Johnson & Johnson, New Brunswick, New Jersey, USA
| | | | - Daniel Franco
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Guilherme Porto
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Jingya Miao
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - John V Wainwright
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Matthew O'Leary
- Department of Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Kevin Hines
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Aria Mahtabfar
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Mari Vanderkarr
- Real World Data Sciences, Medical Device Epidemiology, Johnson & Johnson, New Brunswick, New Jersey, USA
| | - Sara Thalheimer
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Ashwini Sharan
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Jack Jallo
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - James Harrop
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
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Chesney K, Stylli J, Elsouri M, Phelps E, Fayed I, Anaizi A, Voyadzis JM, Sandhu FA. Minimally Invasive Surgical Decompression without Fusion for the Treatment of Lumbar Synovial Cysts: Feasibility and Long-Term Outcomes. World Neurosurg 2022; 167:e323-e332. [PMID: 35961590 DOI: 10.1016/j.wneu.2022.08.015] [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: 07/20/2022] [Revised: 08/02/2022] [Accepted: 08/03/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND Lumbar synovial cysts (LSCs) can cause painful radiculopathy and sensory and/or motor deficits. Historically, first-line surgical treatment has been decompression with fusion. Recently, minimally invasive laminectomy without fusion has shown equal or superior results to traditional decompression and fusion methods. OBJECTIVE This study investigates the long-term efficacy of minimally invasive laminectomy without fusion in the treatment of LSC as it relates to the rate of subsequent fusion surgery. METHODS A retrospective review was performed over a 10-year period of patients undergoing minimally invasive laminectomy for symptomatic LSCs. The primary end point was the rate of revision surgery requiring fusion. RESULTS Eighty-five patients with symptomatic LSCs underwent minimally invasive laminectomy alone January 2010-August 2020 at our institution. The most common location was L4-5 (72%). Preoperative imaging identified spondylolisthesis (grade 1) in 43 patients (57%), none of which was unstable on available dynamic radiographs. Average procedure duration was 93 minutes, with 78% of patients discharged home on the same day of surgery. Over 46 months of mean follow-up, 17 patients (20%) required 19 revision operations. Of those operations, 16 were spinal fusions (17.6%). Median time to fusion surgery was 36 months. There were no identifiable risk factors on multivariate regression analysis that predicted the need for fusion. CONCLUSIONS Minimally invasive laminectomy is an effective first-line treatment for symptomatic LSCs and avoids the need for fusion in most treated patients. Of our patients, 18% required a fusion over 46 months, suggesting that further studies are required to guide patient selection.
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Affiliation(s)
- Kelsi Chesney
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Jack Stylli
- Georgetown University School of Medicine, Washington, DC, USA
| | - Mohamad Elsouri
- Georgetown University School of Medicine, Washington, DC, USA
| | - Emily Phelps
- Georgetown University School of Medicine, Washington, DC, USA
| | - Islam Fayed
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Amjad Anaizi
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Jean-Marc Voyadzis
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Faheem A Sandhu
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA.
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6
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Page PS, Burkett DJ, Greeneway GP, Resnick DK. Comparison of Decompression versus Decompression and Fusion for Lumbar Synovial Cysts and Predictive Factors for Cyst Recurrence. World Neurosurg 2020; 146:e378-e383. [PMID: 33256941 DOI: 10.1016/j.wneu.2020.10.097] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 10/18/2020] [Accepted: 10/19/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND The management of lumbar synovial cysts (LSC) has been a controversial topic for many years. Whereas many authors label LSC as markers of instability and thus necessitating fusion, others suggest that decompression alone without fusion is a viable initial treatment option. Our objective was to clarify outcomes in patients undergoing decompression alone and decompression with fusion for symptomatic LSC and identify factors for cyst recurrence. METHODS A retrospective case series was performed of all patients undergoing initial treatment for LSC at a single institution ranging from January 1999 to February 2020. Surgical treatment included either decompression with cystectomy or decompression with cystectomy and a fusion procedure. Preoperative symptoms were collected and included radicular pain, motor deficits, sensory deficits, or bowel/bladder changes. Radiographic data were calculated individually and confirmed with radiology reports. Categorical variables were assessed using χ2 analysis and continuous variables were assessed with the 2-sample t test. RESULTS In total, 161 patients were identified as presenting with symptomatic LSC. Of these, 104 patients underwent decompression alone versus 57 who underwent decompression and fusion. In the decompression group 11 patients required reoperation at the level of the cyst compared with none in those undergoing fusion as their initial procedure (10.5% vs. 0%, P = 0.012). On subgroup analysis of those undergoing decompression as their initial procedure, patients with cyst recurrence demonstrated a statistically significant greater coronal facet inclination angle compared with those without cyst recurrence (52.4° vs. 40.6°, P = 0.02). CONCLUSIONS Decompression alone is a reasonable choice for the initial management of LSC, although it does carry a significant risk of same-level reoperation due to cyst recurrence and spondylolisthesis. Preoperative coronal facet inclination angle may be a useful measurement in predicting cyst recurrence following decompression.
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Affiliation(s)
- Paul S Page
- Department of Neurosurgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
| | - Daniel J Burkett
- Department of Neurosurgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
| | - Garret P Greeneway
- Department of Neurosurgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
| | - Daniel K Resnick
- Department of Neurosurgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA.
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Sagoo NS, Bhatti H, Rowe SE, Sharma I, Haider AS. Lumbar Facet Joint Cyst Treated With Decompression and Interlaminar Stabilization. Cureus 2020; 12:e9391. [PMID: 32850257 PMCID: PMC7445097 DOI: 10.7759/cureus.9391] [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] [Indexed: 12/04/2022] Open
Abstract
Spinal facet joint cysts (FJCs) are an increasingly reported cause of lower back pain, radiculopathy, and neurological deficits owing to their proximity to adjacent nerve roots. The etiology of these cysts has not yet been fully elucidated, although they appear to be related to degenerative changes in the facet joints themselves. Conservative management strategies including physical therapy and oral analgesics rarely result in spontaneous regression of an FJC, often providing only short-term relief. The current treatment modalities reported for FJCs generally range from percutaneous cyst aspiration to decompression surgery with or without instrumented spinal fusion. However, instrumented fusion often results in a higher rate of complications such as pseudoarthrosis and adjacent segment disease. The Coflex® (Paradigm Spine, LLC, New York, NY) interlaminar stabilization (ILS) implant is a novel titanium, U-shaped device which acts as a motion-preserving stabilizer and has proven to be a viable alternative to instrumental fusion. Here, we discuss a case of an FJC treated with both decompression and placement of a Coflex ILS device.
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Affiliation(s)
- Navraj S Sagoo
- Orthopedic Surgery, The University of Texas Medical Branch at Galveston, Galveston, USA
| | | | - Scott E Rowe
- Neurosurgery, University of Texas Southwestern, Dallas, USA.,Neurosurgery, Nova Southeastern University College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Ishaan Sharma
- Orthopedic Surgery, Ross University School of Medicine, Bridgetown, USA
| | - Ali S Haider
- Neurosurgery, Texas A&M University College of Medicine, Houston, USA.,Neurosurgery, Baylor Scott & White Medical Center, College Station, USA
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