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Baker CM, Joyce E, Gamboa N, Dailey AT. Intramedullary Nocardiosis of the Cervical and Thoracic Spine Presenting With Progressive Upper-Extremity and Lower-Extremity Weakness: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2024; 26:102. [PMID: 37655870 DOI: 10.1227/ons.0000000000000897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 07/06/2023] [Indexed: 09/02/2023] Open
Affiliation(s)
- Cordell M Baker
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
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Sherrod BA, Young JB, Wilkerson CG, Bisson EF, Dailey AT, Mazur MD. Epidemiology of Gunshot-Related Spinal Injuries and Related Risk Factors for In-Hospital Mortality in the United States from 2015-2019: A National Trauma Data Bank Analysis. J Neurotrauma 2023. [PMID: 37694721 DOI: 10.1089/neu.2023.0081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023] Open
Abstract
Firearm injuries in the U.S. pose a significant public health burden, but data on gunshot wounds (GSWs) specifically involving the spine are scarce. We examined epidemiological trends in GSWs to the spine and associated spinal cord injury (SCI) and mortality rates. This was a cross-sectional study of data from level I-III trauma centers in the U.S. participating in the American College of Surgeons National Trauma Data Bank (ACS NTDB) in 2015-2019. We identified adult and pediatric patients presenting with GSW and evaluated those with Abbreviated Injury Scale codes indicating spinal involvement and SCI. We assessed in-hospital mortality and GSW-related SCI. A total of 5,021,316 patients were enrolled in the ACS NTDB. Of the 107,233 patients (2.1% of total) presenting with GSW, 9023 (8.4%) patients had spine involvement. Overall rates of GSW and spinal GSW were similar across years. The most common cause of spinal GSW injury was assault (86.7%). The cervical spine was involved in 24.2% of patients, thoracic spine in 42.8%, and lumbar spine in 39.7%. Cervical SCI was present in 8.7% of all spinal GSW (35.7% of cervical GSW), thoracic SCI in 17.4% (40.6% of thoracic GSW), and lumbar SCI in 8.1% (20.3% of lumbar GSW). The mean patient age was 29.0 ± 12.2 years, 88.5% were male, 62.4% were black, 23.7% were white, and 13.9% were another race. Blood alcohol content was ≥0.08 in 12.1%, and illicit drugs were positive in 24.4%. In-hospital mortality was high in patients with spinal GSWs (8.1%), and mortality was significantly higher with cervical involvement (18.1%), cervical SCI (30.7%), or thoracic incomplete SCI (13.6%) on univariate analysis. On multi-variate analysis of age (excluding patients <16 years of age), sex, Injury Severity Score (ISS), complete SCI, and spinal area of involvement, only greater patient age (age 40-65 years: adjusted odds ratio [aOR] 1.52, 95% confidence interval [CI] 1.09-2.11, p = 0.014; age >65 years: aOR 3.90, 95% CI 2.10-7.27, p < 0.001) and higher ISS (ISS 9-15: aOR 6.65, 95% CI 2.38-18.54, p < 0.001; ISS 16-24: aOR 18.13, 95% CI 6.65-49.44, p < 0.001; ISS >24: aOR 68.44, 95% CI 25.39-184.46, p < 0.001) were independently associated with in-hospital mortality risk after spinal GSW. These results demonstrate that spinal GSW is not uncommon and that older patients with more severe systemic injuries have higher in-hospital mortality risk.
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Affiliation(s)
- Brandon A Sherrod
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Jason B Young
- Department of Surgery, University of Utah, Salt Lake City, Utah, USA
| | | | - Erica F Bisson
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Andrew T Dailey
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Marcus D Mazur
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
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Kim LJY, Mazur MD, Dailey AT. Mid-term and Long-term Outcomes After Total Cervical Disk Arthroplasty Compared With Anterior Cervical Discectomy and Fusion: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Clin Spine Surg 2023; 36:339-355. [PMID: 37735768 DOI: 10.1097/bsd.0000000000001537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 08/15/2023] [Indexed: 09/23/2023]
Abstract
STUDY DESIGN A meta-analysis of randomized controlled trials (RCTs). OBJECTIVE The aim of this study was to compare mid-term to long-term outcomes of cervical disk arthroplasty (CDA) with those of anterior cervical discectomy and fusion (ACDF) for the treatment of symptomatic cervical degenerative disk disease. SUMMARY OF BACKGROUND DATA After ACDF to treat symptomatic cervical degenerative disk disease, the loss of motion at the index level due to fusion may accelerate adjacent-level disk degeneration. CDA was developed to preserve motion and reduce the risk of adjacent segment degeneration. Early-term to mid-term clinical outcomes from RCTs suggest noninferiority of CDA compared with ACDF, but it remains unclear whether CDA yields better mid-term to long-term outcomes than ACDF. MATERIALS AND METHODS Two independent reviewers searched PubMed, Embase, and the Cochrane Library for RCTs with at least 60 months of follow-up. The risk ratio or standardized mean difference (and 95% CIs) were calculated for dichotomous or continuous variables, respectively. RESULTS Eighteen reports of 14 RCTs published in 2014-2023 were included. The pooled analysis demonstrated that the CDA group had a significantly greater improvement in neurological success and Neck Disability Index than the ACDF group. The ACDF group exhibited a significantly better improvement in the Short Form-36 Health Survey Physical Component Summary than the CDA group. Radiographic adjacent segment degeneration was significantly lower in the CDA group at 60- and 84-month follow-ups; at 120-month follow-up, there was no significant difference between the 2 groups. Although the overall rate of secondary surgical procedures was significantly lower in the CDA group, we did not observe any significant difference at 60-month follow-up between the CDA and ACDF group and appreciated statistically significant lower rates of radiographic adjacent segment degeneration, and symptomatic adjacent-level disease requiring surgery at 84-month and 108- to 120-month follow-up. The rate of adverse events and the neck and arm pain scores in the CDA group were not significantly different from those of the ACDF group. CONCLUSIONS In this meta-analysis of 14 RCTs with 5- to 10-year follow-up data, CDA resulted in significantly better neurological success and Neck Disability Index scores and lower rates of radiographic adjacent segment degeneration, secondary surgical procedures, and symptomatic adjacent-level disease requiring surgery than ACDF. ACDF resulted in improved Short Form-36 Health Survey Physical Component Summary scores. However, the CDA and ACDF groups did not exhibit significant differences in overall changes in neck and arm pain scores or rates of adverse events.
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Affiliation(s)
- Leo J Y Kim
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT
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Sherrod BA, Dailey AT, Mazur MD. Closed cervical traction techniques: moving into the 21st century. J Neurosurg Spine 2023; 39:618-627. [PMID: 37548544 DOI: 10.3171/2023.5.spine23344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 05/24/2023] [Indexed: 08/08/2023]
Abstract
Closed cervical traction for reducing dislocating cervical injuries, deformity correction, or discectomy distraction has been implemented in its modern form since the 1930s. Cervical traction state of the art has not changed significantly since the 1960s, with most reductions performed by using Gardner-Wells tongs or halo traction; however, there are many limitations of traditional weight-pulley traction, including limited reduction efficacy and patient safety shortcomings. In this paper, the authors review the history of cervical traction in the 20th century and the limitations of current traction techniques and describe a novel traction device developed at the University of Utah with robotic actuator load or position control and real-time force-sensing capabilities. Preliminary biomechanical testing results using the novel device in an extension spring loading model, with intact cadavers, and in iatrogenic facet injury cadaveric models demonstrated preliminary safety and efficacy of the device. The authors believe this and future research efforts aimed toward improving the efficacy and safety of cervical traction will help advance the field into the 21st century.
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Scoville JP, Joyce E, Dailey AT, Mazur MD. A radiological analysis of pelvic fixation trajectories: patient series. J Neurosurg Case Lessons 2023; 6:CASE23465. [PMID: 37871336 PMCID: PMC10599452 DOI: 10.3171/case23465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 09/14/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND Three well-defined methods for pelvic fixation are used for biomechanical support in spine fusion constructs: iliac, recessed iliac, and S2-alar-iliac (S2AI) screws. The authors compared the maximum screw sizes that could be placed with these techniques by using image-guidance software and high-resolution computed tomography scans from 20 randomly selected patients. Six trajectories were plotted per side, beginning at recognized starting points (standard or recessed posterior superior iliac spine [PSIS] or S2AI screw) and ending at the anterior inferior iliac spine (AIIS) or supra-acetabular notch (SAN). OBSERVATIONS The mean maximum screw length and width ranged from 80.0 ± 32.2 mm to 140.8 ± 22.6 mm and from 8.25 ± 1.2 mm to 13.0 ± 2.7 mm, respectively, depending on the trajectory. Statistically significant differences in length were found between the standard and recessed PSIS trajectories to the AIIS (p < 0.001) and between the standard PSIS-to-AIIS trajectory and the S2AI-to-AIIS (p = 0.007) or S2AI-to-SAN (p < 0.001) trajectories. The most successful trajectory was the PSIS to SAN (95%, 38/40). LESSONS The traditional iliac screw trajectory enabled the longest and widest screw trajectories and highest rate of successful screw placement with the fewest theoretical breaches more reliably than recessed and S2AI trajectories. These findings may help surgeons plan for maximum screw purchase for pelvic fixation.
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Gamblin AS, Awad AW, Karsy M, Guan J, Mazur MD, Bisson EF, Bican O, Dailey AT. Efficacy of Intraoperative Neuromonitoring during the Treatment of Cervical Myelopathy. Indian Journal of Neurosurgery 2023. [DOI: 10.1055/s-0043-1764455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
Abstract
Objective The accuracy of intraoperative neuromonitoring (IONM) during surgery for cervical spondylotic myelopathy (CSM) to detect iatrogenic nervous system injuries while they are reversible remains unknown. We evaluated a cohort of patients who had IONM during surgery to assess accuracy.
Methods Patients who underwent surgical treatment of CSM that included IONM from January 2018 through August 2018 were retrospectively identified. A standardized protocol was used for operative management. Clinical changes and postoperative neurological deficits were evaluated.
Results Among 131 patients in whom IONM was used during their procedure, 42 patients (age 58.2 ± 16.3 years, 54.8% males) showed IONM changes and 89 patients had no change. The reasons for IONM changes varied, and some patients had changes detected via multiple modalities: electromyography (n = 25, 59.5%), somatosensory-evoked potentials (n = 14, 33.3%), motor evoked potentials (n = 13, 31.0%). Three patients, all having baseline deficits before surgery, had postoperative deficits. Among the 89 patients without an IONM change, 4 showed worsened postoperative deficits, which were also seen at last follow-up. The sensitivity of IONM for predicting postoperative neurological change was 42.86% and the specificity was 68.55%. However, most patients (124, 94.7%) in whom IONM was used showed no worsened neurological deficit.
Conclusions IONM shows potential in ensuring stable postoperative neurological outcomes in most patients; however, its clinical use and supportive guidelines remain controversial. In our series, prediction of neurological deficits was poor in contrast to some previous studies. Further refinement of clinical and electrophysiological variables is needed to uniformly predict postoperative neurological outcomes.
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Sherrod BA, Kim R, Hunsaker J, Rada C, Christensen C, Stoddard GJ, Brodke D, Mahan MA, Mazur MD, Bisson EF, Dailey AT. Postoperative ileus risk after posterior thoracolumbar fusion performed with total intravenous anesthesia versus inhaled anesthesia. J Neurosurg Spine 2023; 38:307-312. [PMID: 36308475 DOI: 10.3171/2022.9.spine22520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 09/26/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE There has been an increase in the use of total intravenous anesthesia (TIVA) for intraoperative neuromonitoring during thoracolumbar posterior spinal fusion (PSF). Although prior studies have identified risk factors for postoperative ileus (PI) after PSF, to the authors' knowledge, PI rates in patients receiving inhaled anesthetic versus TIVA have not been evaluated. In this study the authors analyzed whether TIVA is associated with greater risk of PI in PSF patients. METHODS In this retrospective single-institution cohort study, all patients undergoing PSF at the authors' tertiary academic institution from May 2014 to December 2020 were included. Patients undergoing anterior/lateral approaches or who had concurrent abdominal procedures unrelated to ileus in the same admission were excluded. PI was defined using radiographic and/or clinical diagnoses (postoperative radiographs, abdominal CT, and/or ICD-9 or -10 codes) and was confirmed via chart review. The use of TIVA or inhaled anesthetic was captured from the anesthesia record; patients were excluded if they were missing anesthesia technique data. Postoperative occurrence of PI was compared between patients who had TIVA or inhaled anesthetics while controlling for collected demographic, clinical, and surgical variables. RESULTS Of the 2819 patients meeting inclusion criteria, 283 (10.0%) had PI (mean ± SD age 59.3 ± 15.8 years; 155 [54.8%] male). The mean patient length of stay was 7.7 ± 5.0 days, which was significantly longer than that of patients without PI (4.9 ± 3.9 days, p < 0.001). Patients with PI had more levels fused (46% of PI patients with ≥ 5 levels fused vs 25% of non-PI patients, p < 0.001) and longer operations (6.0 ± 2.2 vs 5.4 ± 1.9 hours, p < 0.001). TIVA patients were more likely than inhalation-only patients to experience PI, but this finding did not reach significance on univariate analysis (11.0% PI rate vs 8.9%, p = 0.06). After propensity matching 125 non-PI patients and 50 PI patients by age, sex, operative time, and number of levels fused, there was a significant difference in intraoperative opiate dosing between TIVA and inhalational patients (275.7 ± 187.5 intravenous morphine milligram equivalents vs 120.9 ± 155.5, p < 0.001). On multivariate analysis of PI outcome, TIVA was an independently significant predictor (OR 1.45, p = 0.02), as was anesthesia time (OR per hour increase: 1.09, p = 0.03) and ≥ 8 levels fused (OR 1.86, p = 0.01). CONCLUSIONS In a large cohort of PSF patients, TIVA was associated with a higher rate of PI compared with inhaled anesthetic. This effect is likely due to higher intraoperative opiate use in these patients.
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Affiliation(s)
| | | | | | | | | | | | - Darrel Brodke
- 4Orthopedic Surgery, University of Utah, Salt Lake City, Utah
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Croci DM, Nguyen S, Streitmatter SW, Sherrod BA, Hardy J, Cole KL, Gamblin AS, Bisson EF, Mazur MD, Dailey AT. O-Arm Accuracy and Radiation Exposure in Adult Deformity Surgery. World Neurosurg 2023; 171:e440-e446. [PMID: 36528322 DOI: 10.1016/j.wneu.2022.12.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 12/06/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE In long thoracolumbar deformity surgery, accurate screw positioning is critical for spinal stability. We assessed pedicle and pelvic screw accuracy and radiation exposure in patients undergoing long thoracolumbar deformity fusion surgery (≥4 levels) involving 3-dimensional fluoroscopy (O-Arm/Stealth) navigation. METHODS In this retrospective single-center cohort study, all patients aged >18 years who underwent fusion in 2016-2018 were reviewed. O-Arm images were assessed for screw accuracy. Effective radiation doses were calculated. The primary outcome was pedicle screw accuracy (Heary grade). Secondary outcomes were pelvic fixation screw accuracy, radiation exposure, and screw-related perioperative and postoperative complications or revision surgery within 3 years. RESULTS Of 1477 pedicle screws placed in 91 patients (mean 16.41 ± 5.6 screws/patient), 1208 pedicle screws (81.8%) could be evaluated by 3-dimensional imaging after placement. Heary Grade I placement was achieved in 1150 screws (95.2%), Grade II in 47 (3.9%), Grade III in 10 (0.82%), Grade IV in 1 (0.08%), and Grade V in 0; Grade III-V were replaced intraoperatively. One of 60 (1.6%) sacroiliac screws placed showed medial cortical breach and was replaced. The average O-Arm-related effective dose was 29.54 ± 14.29 mSv and effective dose/spin was 8.25 ± 2.65 mSv. No postoperative neurological worsening, vascular injuries, or revision surgeries for screw misplacement were recorded. CONCLUSIONS With effective radiation doses similar to those in interventional neuroendovascular procedures, the use of O-Arm in multilevel complex deformity surgery resulted in high screw accuracy, no need for surgical revision because of screw malposition, less additional imaging, and no radiation exposure for the surgical team.
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Affiliation(s)
- Davide Marco Croci
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Sarah Nguyen
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Seth W Streitmatter
- Medical Imaging Physics and Radiation Safety, Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Brandon A Sherrod
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Jeremy Hardy
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Kyril L Cole
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Austin S Gamblin
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Erica F Bisson
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Marcus D Mazur
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Andrew T Dailey
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA.
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Gamboa NT, Wilkerson C, Kundu B, Sherrod BA, Dailey AT, Couldwell WT. Natural history of pituitary carcinoma with metastasis to the cervical spine: illustrative case. J Neurosurg Case Lessons 2023; 5:CASE22363. [PMID: 36647250 PMCID: PMC9844525 DOI: 10.3171/case22363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 10/19/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Pituitary carcinoma is a rare tumor of the adenohypophysis with noncontiguous craniospinal dissemination and/or systemic metastases. Given the rarity of this malignancy, there is limited knowledge and consensus regarding its natural history, prognosis, and optimal treatment. OBSERVATIONS The authors present the case of a 46-year-old woman initially treated with invasive prolactin-secreting pituitary macroadenoma who developed metastatic disease of the cervical spine 6 years later. The patient presented with acutely worsening compressive cervical myelopathy and required posterior cervical decompression, tumor resection, and instrumented arthrodesis for posterolateral fusion. LESSONS This case underscores the importance of long-term monitoring of hormone levels and having a high clinical suspicion for metastatic disease to the spine in patients presenting with acute myelopathy or radiculopathy in the setting of previously treated invasive secreting pituitary adenoma.
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Affiliation(s)
- Nicholas T. Gamboa
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Christopher Wilkerson
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Bornali Kundu
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Brandon A. Sherrod
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Andrew T. Dailey
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - William T. Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
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Hamrick FA, Sherrod BA, Cole K, Cox P, Croci DM, Bowers CA, Mazur MD, Dailey AT, Bisson EF. Using Frailty Measures to Predict Functional Outcomes and Mortality After Type II Odontoid Fracture in Elderly Patients: A Retrospective Cohort Study. Global Spine J 2023:21925682221149394. [PMID: 36626221 DOI: 10.1177/21925682221149394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
STUDY DESIGN Single-center retrospective cohort study. OBJECTIVES Type II odontoid fractures occur disproportionately among elderly populations and cause significant morbidity and mortality. It is a matter of debate whether these injuries are best managed surgically or conservatively. Our goal was to identify how treatment modalities and patient characteristics correlated with functional outcome and mortality. METHODS We identified adult patients (>60 years) with traumatic type II odontoid fractures. We used multivariate regression controlling for patient demographics, Glasgow Coma Scale (GCS) score, Charlson Comorbidity Index (CCI), modified Rankin Scale (mRS) score, modified Frailty Index (mFI-5 and mFI-11), fracture displacement, and conservative vs operative treatment. RESULTS Of the 59 patients (mean age 77.9 years), 24 underwent surgical intervention and 35 underwent conservative management. Operatively managed patients were younger (73.4 vs 80.6 years, P < .001) and had higher degree of fracture displacement (3.5 vs 1.0 mm, P = .002) than conservatively managed patients but no other differences in baseline characteristics. Twenty-four patients (40.7%) died within the study period (median time to death: 376 days). There were no differences between treatment groups in functional outcomes (mRS or Frankel Grade) or mortality (33.3% in operative group vs 45.7%, P = .34). There was a statistically significant correlation between higher presentation mRS score and subsequent mortality on multivariate analysis (OR = 2.06, 95% CI 1.04-4.10, P = .039), whereas surgical intervention, age, GCS score, CCI, mFI-5, mFI-11, sex, and fracture displacement were not significantly correlated. CONCLUSIONS Mortality after type II odontoid fractures in elderly patients is common. mRS score at presentation may help predict mortality more accurately than other patient factors.
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Affiliation(s)
| | - Brandon A Sherrod
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Kyril Cole
- School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Parker Cox
- School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Davide M Croci
- Department of Neurosurgery, University of South Florida, Tampa, FL, USA
| | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM, USA
| | - Marcus D Mazur
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Andrew T Dailey
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Erica F Bisson
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
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Croci DM, Cole K, Sherrod B, Yen CP, Dailey AT, Mazur MD. L4 Corpectomy: Surgical Approaches and Mitigating the Risk of Femoral Nerve Injuries. World Neurosurg 2022; 166:e905-e914. [PMID: 35948223 DOI: 10.1016/j.wneu.2022.07.133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/26/2022] [Accepted: 07/27/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Because of the challenging anatomic location, corpectomies are performed less often at the fourth lumbar vertebral body than at other levels. Our objective was to review the literature of L4 corpectomy and anterior column reconstruction. METHODS A literature search in the Medline/PubMed database was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify all relevant cases and cases series describing corpectomies of the L4 vertebral body using "lumbar" AND "corpectomy" as search terms. We present an illustrative case to describe the technique. RESULTS We identified 18 articles with 30 patients who met the search criteria. Including our case illustration, the most common approach used was the lateral retroperitoneal approach (n = 17, 54.8%), of which 8 (26.7%) were performed via a transpsoas approach. Seven (23%) patients underwent corpectomy through a posterior approach, 4 (12.9%) through an anterior retroperitoneal approach, and 3 (10%) through combined anterior and lateral retroperitoneal. The overall complications rate was 19.3% including 1 case each of femoral nerve injury and iatrogenic lumbar nerve root injury. CONCLUSIONS Corpectomies of the L4 vertebral body are challenging. None of the various approaches described clearly demonstrates any superiority in mitigating the risk of neural complications. Decision making about which surgical approach to use should be based on patient-specific characteristics.
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Affiliation(s)
- Davide Marco Croci
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Kyril Cole
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Brandon Sherrod
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Chun Po Yen
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Andrew T Dailey
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Marcus D Mazur
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA.
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Sherrod BA, Wilkerson CG, Rolston JD, Bisson EF, Mazur MD, Couldwell WT, Dailey AT. Neurosurgery at Pearl Harbor: Ralph Cloward’s legacy. Neurosurg Focus 2022; 53:E14. [DOI: 10.3171/2022.6.focus22127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 06/24/2022] [Indexed: 11/06/2022]
Abstract
Ralph B. Cloward (1908–2000) was the sole neurosurgeon present during the Japanese attack on Pearl Harbor on December 7, 1941. Cloward operated on 42 patients in a span of 4 days during the attacks and was awarded a commendation signed by President Franklin D. Roosevelt in 1945 for his wartime efforts. During the attacks, he primarily treated depressed skull fractures and penetrating shrapnel wounds, but he also treated peripheral nerve and spine injuries in the aftermath. His techniques included innovative advancements such as tantalum cranioplasty plates, electromagnets for intracranial metallic fragment removal, and the application of sulfonamide antibiotic powder within cranial wounds, which had been introduced by military medics for gangrene prevention in 1939 and described for penetrating cranial wounds in 1940. Despite the severity of injuries encountered, only 2 soldiers died in the course of Cloward’s interventions. As the sole neurosurgeon in the Pacific Theater until 1944, he remained in Honolulu through World War II’s duration and gained immense operative experience through his wartime service. Here, the authors review the history of Cloward’s remarkable efforts, techniques, injury patterns treated, and legacy.
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Affiliation(s)
- Brandon A. Sherrod
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
| | - Christopher G. Wilkerson
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
| | - John D. Rolston
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
- Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah
| | - Erica F. Bisson
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
| | - Marcus D. Mazur
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
| | - William T. Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
| | - Andrew T. Dailey
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
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13
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Fredrickson VL, Hollon TC, Rennert RC, Mazur MD, Dailey AT, Couldwell WT. Laminectomy at T4 and T5 for Resection of Symptomatic Cavernous Malformation. World Neurosurg 2022; 163:3. [PMID: 35342024 DOI: 10.1016/j.wneu.2022.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/02/2022] [Accepted: 03/03/2022] [Indexed: 11/17/2022]
Abstract
Although rare, intramedullary spinal cavernous malformations have a 1.4%-6.8% annual hemorrhage risk and can cause significant morbidity.1 Prior hemorrhage and size >1 cm are risk factors for future hemorrhage that, in addition to notable or progressive symptoms, may justify early surgical intervention.1,2 In this video, we present key steps in surgical management of a large, symptomatic thoracic cavernous malformation. A 56-year-old woman presented with worsening lower extremity weakness, imbalance, and difficulty ambulating. Strength was 3/5 in her right lower extremity and 4/5 in her left lower extremity. She had an incomplete T4 sensory level and hyperreflexia. Magnetic resonance imaging demonstrated a heterogeneous "popcorn"-appearing expansile intradural intramedullary 2.2- × 1.2-cm lesion at T4-5, consistent with a cavernous malformation. Angiography was deferred given the characteristic magnetic resonance imaging appearance. Given her progressive symptoms (including weakness), lesion size, and good health, resection was recommended. Using neurological monitoring, a T4-5 laminectomy, midline myelotomy, and piecemeal microsurgical resection of the lesion was performed, clearly identifying the cavernoma-spinal cord interface and avoiding spinal cord retraction. Histopathology confirmed a cavernoma. Postoperatively, the patient had improved left lower extremity strength and stable right lower extremity strength but worsened dorsiflexion (1/5), which improved with rehabilitation. At 1-year follow-up, she had full strength in her left lower extremity and 4/5 in her right lower extremity, with mild paresthesias below T10. Consistent with prior series demonstrating low complication rates and good long-term neurological outcomes,2 microsurgical resection of selected symptomatic intramedullary spinal cavernous malformations can halt neurological decline and potentially improve neurological function.
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Affiliation(s)
- Vance L Fredrickson
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Todd C Hollon
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Robert C Rennert
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Marcus D Mazur
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Andrew T Dailey
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA.
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14
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Croci DM, Gamboa NT, Osman AEG, Maese L, Mazur M, Bisson EF, Dailey AT. Solitary manifestations of primary B-lymphoblastic lymphoma of the spine: Systematic literature review with case illustration. Clin Neurol Neurosurg 2021; 212:107064. [PMID: 34871993 DOI: 10.1016/j.clineuro.2021.107064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/13/2021] [Accepted: 11/21/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Given the locally destructive osteolytic nature of primary B-cell lymphoblastic lymphoma (B-LBL) of the spine, careful attention is needed to identify clinical signs and symptoms as well as radiological findings of spinal instability because these lesions may warrant resection, decompression, and instrumentation with posterolateral fusion. Our objective was to summarize the presenting symptoms, clinical features, potential treatment modalities, and clinical outcome of cases described in the literature. METHODS We undertook a systematic literature review to identify all relevant cases and case series describing primary manifestations B-LBL of the spine using Pubmed/Medline. We summarized the findings in accordance with the PRISMA guidelines. We also present a case illustration. RESULTS Together with our case, 9 cases of primary B-LBL of the spine were identified in 6 male and 3 female patients (age 8-58 years, median 31 years). Back pain was the most common symptom, and five patients also had neurological signs of spinal cord compression. T1-weighted MRI contrast enhancement was seen in 5 cases. Surgery was performed in 5 patients with progression of neurological deficits. Steroid treatment was also given in 3 patients preoperatively. Seven patients had chemotherapy after diagnosis. During follow-up of 1 month to 1 year, 2 cases of recurrence and 4 cases of complete remission were noted; however, with the short follow-up time, patient prognosis overall remains unclear. CONCLUSIONS Primary B-LBL of the spine represents a rare clinical entity whose management mandates a multidisciplinary approach. Careful attention must be paid to the neurological status of the patient, as well as to imaging that may highlight potential local instability of the spine.
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Affiliation(s)
- Davide Marco Croci
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175N Medical Drive East, Salt Lake City, UT 84132, USA.
| | - Nicholas T Gamboa
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175N Medical Drive East, Salt Lake City, UT 84132, USA
| | - Afaf E G Osman
- Department of Internal Medicine, Division of Hematology & Hematologic Malignancies, 2000 Circle of Hope, Salt Lake City, UT 84112, USA
| | - Luke Maese
- Department of Pediatric Hematology and Oncology, University of Utah & Huntsman Cancer Institute, Salt Lake City, UT, USA
| | - Marcus Mazur
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175N Medical Drive East, Salt Lake City, UT 84132, USA
| | - Erica F Bisson
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175N Medical Drive East, Salt Lake City, UT 84132, USA
| | - Andrew T Dailey
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175N Medical Drive East, Salt Lake City, UT 84132, USA
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15
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Greenberg JK, Burks SS, Dibble CF, Javeed S, Gupta VP, Yahanda AT, Perez-Roman RJ, Govindarajan V, Dailey AT, Dhall S, Hoh DJ, Gelb DE, Kanter AS, Klineberg EO, Lee MJ, Mummaneni PV, Park P, Sansur CA, Than KD, Yoon JJW, Wang MY, Ray WZ. An updated management algorithm for incorporating minimally invasive techniques to treat thoracolumbar trauma. J Neurosurg Spine 2021:1-10. [PMID: 34715673 DOI: 10.3171/2021.7.spine21790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 07/01/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Minimally invasive surgery (MIS) techniques can effectively stabilize and decompress many thoracolumbar injuries with decreased morbidity and tissue destruction compared with open approaches. Nonetheless, there is limited direction regarding the breadth and limitations of MIS techniques for thoracolumbar injuries. Consequently, the objectives of this study were to 1) identify the range of current practice patterns for thoracolumbar trauma and 2) integrate expert opinion and literature review to develop an updated treatment algorithm. METHODS A survey describing 10 clinical cases with a range of thoracolumbar injuries was sent to 12 surgeons with expertise in spine trauma. The survey results were summarized using descriptive statistics, along with the Fleiss kappa statistic of interrater agreement. To develop an updated treatment algorithm, the authors used a modified Delphi technique that incorporated a literature review, the survey results, and iterative feedback from a group of 14 spine trauma experts. The final algorithm represented the consensus opinion of that expert group. RESULTS Eleven of 12 surgeons contacted completed the case survey, including 8 (73%) neurosurgeons and 3 (27%) orthopedic surgeons. For the 4 cases involving patients with neurological deficits, nearly all respondents recommended decompression and fusion, and the proportion recommending open surgery ranged from 55% to 100% by case. Recommendations for the remaining cases were heterogeneous. Among the neurologically intact patients, MIS techniques were typically recommended more often than open techniques. The overall interrater agreement in recommendations was 0.23, indicating fair agreement. Considering both literature review and expert opinion, the updated algorithm indicated that MIS techniques could be used to treat most thoracolumbar injuries. Among neurologically intact patients, percutaneous instrumentation without arthrodesis was recommended for those with AO Spine Thoracolumbar Classification System subtype A3/A4 (Thoracolumbar Injury Classification and Severity Score [TLICS] 4) injuries, but MIS posterior arthrodesis was recommended for most patients with AO Spine subtype B2/B3 (TLICS > 4) injuries. Depending on vertebral body integrity, anterolateral corpectomy or mini-open decompression could be used for patients with neurological deficits. CONCLUSIONS Spine trauma experts endorsed a range of strategies for treating thoracolumbar injuries but felt that MIS techniques were an option for most patients. The updated treatment algorithm may provide a foundation for surgeons interested in safe approaches for using MIS techniques to treat thoracolumbar trauma.
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Affiliation(s)
- Jacob K Greenberg
- 1Department of Neurological Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Stephen Shelby Burks
- 2Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Christopher F Dibble
- 1Department of Neurological Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Saad Javeed
- 1Department of Neurological Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Vivek P Gupta
- 1Department of Neurological Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Alexander T Yahanda
- 1Department of Neurological Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Roberto J Perez-Roman
- 2Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Vaidya Govindarajan
- 2Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Andrew T Dailey
- 3Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Sanjay Dhall
- 4Department of Neurological Surgery, University of California, San Francisco, California
| | - Daniel J Hoh
- 5Department of Neurosurgery, University of Florida, Gainesville, Florida
| | | | - Adam S Kanter
- 8Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Eric O Klineberg
- 9Department of Orthopedic Surgery, University of California, Davis, Sacramento, California
| | - Michael J Lee
- 10Department of Orthopedic Surgery, University of Chicago, Chicago, Illinois
| | - Praveen V Mummaneni
- 4Department of Neurological Surgery, University of California, San Francisco, California
| | - Paul Park
- 11Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Charles A Sansur
- 7Neurosurgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Khoi D Than
- 12Department of Neurosurgery, Duke University, Durham, North Carolina; and
| | - Jon J W Yoon
- 13Department of Neurosurgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Michael Y Wang
- 2Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Wilson Z Ray
- 1Department of Neurological Surgery, Washington University in St. Louis, St. Louis, Missouri
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16
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Finley SM, Astin JH, Joyce E, Dailey AT, Brockmeyer DL, Ellis BJ. FEBio finite element model of a pediatric cervical spine. J Neurosurg Pediatr 2021:1-7. [PMID: 34678779 DOI: 10.3171/2021.7.peds21276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 07/28/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The underlying biomechanical differences between the pediatric and adult cervical spine are incompletely understood. Computational spine modeling can address that knowledge gap. Using a computational method known as finite element modeling, the authors describe the creation and evaluation of a complete pediatric cervical spine model. METHODS Using a thin-slice CT scan of the cervical spine from a 5-year-old boy, a 3D model was created for finite element analysis. The material properties and boundary and loading conditions were created and model analysis performed using open-source software. Because the precise material properties of the pediatric cervical spine are not known, a published parametric approach of scaling adult properties by 50%, 25%, and 10% was used. Each scaled finite element model (FEM) underwent two types of simulations for pediatric cadaver testing (axial tension and cardinal ranges of motion [ROMs]) to assess axial stiffness, ROM, and facet joint force (FJF). The authors evaluated the axial stiffness and flexion-extension ROM predicted by the model using previously published experimental measurements obtained from pediatric cadaveric tissues. RESULTS In the axial tension simulation, the model with 50% adult ligamentous and annulus material properties predicted an axial stiffness of 49 N/mm, which corresponded with previously published data from similarly aged cadavers (46.1 ± 9.6 N/mm). In the flexion-extension simulation, the same 50% model predicted an ROM that was within the range of the similarly aged cohort of cadavers. The subaxial FJFs predicted by the model in extension, lateral bending, and axial rotation were in the range of 1-4 N and, as expected, tended to increase as the ligament and disc material properties decreased. CONCLUSIONS A pediatric cervical spine FEM was created that accurately predicts axial tension and flexion-extension ROM when ligamentous and annulus material properties are reduced to 50% of published adult properties. This model shows promise for use in surgical simulation procedures and as a normal comparison for disease-specific FEMs.
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Affiliation(s)
- Sean M Finley
- 1Department of Biomedical Engineering and Scientific Computing and Imaging Institute, and
| | - J Harley Astin
- 1Department of Biomedical Engineering and Scientific Computing and Imaging Institute, and
| | - Evan Joyce
- 2Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Andrew T Dailey
- 2Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Douglas L Brockmeyer
- 2Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Benjamin J Ellis
- 1Department of Biomedical Engineering and Scientific Computing and Imaging Institute, and
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17
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Wilkerson C, Dailey AT. Spinal Cord Injury Management on the Front Line: ABCs of Spinal Cord Injury Treatment Based on American Association of Neurological Surgeons/Congress of Neurological Surgeons Guidelines and Common Sense. Neurosurg Clin N Am 2021; 32:341-351. [PMID: 34053722 DOI: 10.1016/j.nec.2021.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Spinal cord injury (SCI) affects approximately 54 per 1 million people annually in the United States. Treatment strategies for this patient population focus on initial stabilization and early intervention. The cornerstones of early management are clinical assessment, characterization of the injury, medical optimization, and definitive surgical treatment, including surgical stabilization and/or decompression. This article discusses the important strategies in caring for patients with SCI that are supported with significant literature.
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Affiliation(s)
- Christopher Wilkerson
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 North Medical Drive East, Salt Lake City, UT 84132, USA
| | - Andrew T Dailey
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 North Medical Drive East, Salt Lake City, UT 84132, USA.
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18
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Croci DM, Fredrickson VL, Hollon TC, Dailey AT, Couldwell WT. Lateral Suboccipital Craniotomy With C1-C2 Hemilaminectomies and C1-C3 Fusion for the Treatment of a C1-C2 Synovial Cyst Causing Spinal Cord Compression: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 21:E248-E249. [PMID: 34161593 DOI: 10.1093/ons/opab197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 04/04/2021] [Indexed: 11/13/2022] Open
Abstract
Atlantoaxial synovial cysts are a rare cause of cervical myelopathy. Here we describe a case of a 26-yr-old woman who presented with progressively decreasing right arm and leg strength and associated gait imbalance. On examination, she had diffuse weakness in the right upper and lower extremities, a positive right-sided Hoffman sign, and clonus in the right lower extremity. Computed tomography demonstrated an os odontoideum and a retro-odontoid cyst. Magnetic resonance imaging demonstrated a T1 hypointense, T2 hyperintense, slightly rim-enhancing retro-odontoid cyst causing a marked narrowing of the spinal canal, with resultant flattening and leftward deviation of the spinal cord. The patient consented to undergo cyst fenestration via a right suboccipital craniotomy and right C1-C2 hemilaminectomies, along with a C1-C3 instrumented posterior spinal fusion. This approach was chosen because it allows for cyst fenestration and instrumentation of the hypermobile cervical spine within the same incision. After the dura was opened and the arachnoid was dissected, the cyst was visualized compressing the spinal cord. The cyst was fenestrated just inferior to the C1 nerve rootlets, resulting in immediate egress of a gelatinous content; thereafter, all accessible cyst wall portions were removed. Fusion was performed with lateral mass screws at C1 and C3 and pars screws at C2. Pathological analysis described the cyst content as reactive fibrovascular tissue with cholesterol deposition. There were no complications associated with the procedure, and the patient's right-sided weakness had nearly resolved by postoperative day 1. Patient consent was granted for publication.
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Affiliation(s)
- Davide Marco Croci
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Vance L Fredrickson
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Todd C Hollon
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Andrew T Dailey
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
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19
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Herron MR, Park J, Dailey AT, Brockmeyer DL, Ellis BJ. Febio finite element models of the human cervical spine. J Biomech 2020; 113:110077. [PMID: 33142209 DOI: 10.1016/j.jbiomech.2020.110077] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 10/05/2020] [Accepted: 10/16/2020] [Indexed: 11/29/2022]
Abstract
Finite element (FE) analysis has proven to be useful when studying the biomechanics of the cervical spine. Although many FE studies of the cervical spine have been published, they typically develop their models using commercial software, making the sharing of models between researchers difficult. They also often model only one part of the cervical spine. The goal of this study was to develop and evaluate three FE models of the adult cervical spine using open-source software and to freely provide these models to the scientific community. The models were created from computed tomography scans of 26-, 59-, and 64-year old female subjects. These models were evaluated against previously published experimental and FE data. Despite the fact that all three models were assigned identical material properties and boundary conditions, there was notable variation in their biomechanical behavior. It was therefore apparent that these differences were the result of morphological differences between the models.
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Affiliation(s)
- Michael R Herron
- Department of Biomedical Engineering, and Scientific Computing and Imaging Institute, University of Utah, 72 S. Central Campus Drive, Salt Lake City, UT 84112, United States
| | - Jeeone Park
- Department of Biomedical Engineering, and Scientific Computing and Imaging Institute, University of Utah, 72 S. Central Campus Drive, Salt Lake City, UT 84112, United States
| | - Andrew T Dailey
- Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Utah, Primary Children's Hospital, 100 N. Mario Capecchi Drive #5, Salt Lake City, UT 84132, United States
| | - Douglas L Brockmeyer
- Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Utah, Primary Children's Hospital, 100 N. Mario Capecchi Drive #5, Salt Lake City, UT 84132, United States
| | - Benjamin J Ellis
- Department of Biomedical Engineering, and Scientific Computing and Imaging Institute, University of Utah, 72 S. Central Campus Drive, Salt Lake City, UT 84112, United States.
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20
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Sherrod B, Nguyen S, Strauss A, Wilkerson CG, Lawrence B, Spiker WR, Spina NT, Brodke DS, Mazur MD, Mahan MA, Dailey AT, Bisson EF. Predictors of Dysphagia Following Anterior Cervical Fusion. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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21
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Astin JH, Wilkerson CG, Dailey AT, Ellis BJ, Brockmeyer DL. Finite element modeling to compare craniocervical motion in two age-matched pediatric patients without or with Down syndrome: implications for the role of bony geometry in craniocervical junction instability. J Neurosurg Pediatr 2020; 27:218-224. [PMID: 33186914 DOI: 10.3171/2020.6.peds20453] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 06/30/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Instability of the craniocervical junction (CCJ) is a well-known finding in patients with Down syndrome (DS); however, the relative contributions of bony morphology versus ligamentous laxity responsible for abnormal CCJ motion are unknown. Using finite element modeling, the authors of this study attempted to quantify those relative differences. METHODS Two CCJ finite element models were created for age-matched pediatric patients, a patient with DS and a control without DS. Soft tissues and ligamentous structures were added based on bony landmarks from the CT scans. Ligament stiffness values were assigned using published adult ligament stiffness properties. Range of motion (ROM) testing determined that model behavior most closely matched pediatric cadaveric data when ligament stiffness values were scaled down to 25% of those found in adults. These values, along with those assigned to the other soft-tissue materials, were identical for each model to ensure that the only variable between the two was the bone morphology. The finite element models were then subjected to three types of simulations to assess ROM, anterior-posterior (AP) translation displacement, and axial tension. RESULTS The DS model exhibited more laxity than the normal model at all levels for all of the cardinal ROMs and AP translation. For the CCJ, the flexion-extension, lateral bending, axial rotation, and AP translation values predicted by the DS model were 40.7%, 52.1%, 26.1%, and 39.8% higher, respectively, than those for the normal model. When simulating axial tension, the soft-tissue structural stiffness values predicted by the DS and normal models were nearly identical. CONCLUSIONS The increased laxity exhibited by the DS model in the cardinal ROMs and AP translation, along with the nearly identical soft-tissue structural stiffness values exhibited in axial tension, calls into question the previously held notion that ligamentous laxity is the sole explanation for craniocervical instability in DS.
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Affiliation(s)
- J Harley Astin
- Departments of1Bioengineering, Scientific Computing and Imaging Institute, and
| | | | - Andrew T Dailey
- 2Neurosurgery, Division of Pediatric Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Benjamin J Ellis
- Departments of1Bioengineering, Scientific Computing and Imaging Institute, and
| | - Douglas L Brockmeyer
- 2Neurosurgery, Division of Pediatric Neurosurgery, University of Utah, Salt Lake City, Utah
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22
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Eli IM, Karsy M, Brodke DS, Bachus KN, Couldwell WT, Dailey AT, Mazur MD. Restabilization of the Occipitocervical Junction After a Complete Unilateral Condylectomy: A Biomechanical Comparison of Unilateral and Bilateral Fixation Techniques. Oper Neurosurg (Hagerstown) 2020; 19:157-164. [PMID: 31768546 DOI: 10.1093/ons/opz341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 09/04/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Occipitocervical instability may result from transcondylar resection of the occipital condyle. Initially, patients may be able to maintain a neutral alignment but severe occipitoatlantal subluxation may subsequently occur, with cranial settling, spinal cord kinking, and neurological injury. OBJECTIVE To evaluate the ability of posterior fixation constructs to prevent progression to severe deformity after radical unilateral condylectomy. METHODS Eight human cadaveric specimens (Oc-C2) underwent biomechanical testing to compare stiffness under physiological loads (1.5 N m). A complete unilateral condylectomy was performed to destabilize one Oc-C1 joint, and the contralateral joint was left intact. Unilateral Oc-C1 or Oc-C2 constructs on the resected side and bilateral Oc-C1 or Oc-C2 constructs were tested. RESULTS The bilateral Oc-C2 construct provided the greatest stiffness, but the difference was only statistically significant in certain planes of motion. The unilateral constructs had similar stiffness in lateral bending, but the unilateral Oc-C1 construct was less stiff in axial rotation and flexion-extension than the unilateral Oc-C2 construct. The bilateral Oc-C2 construct was stiffer than the unilateral Oc-C2 construct in axial rotation and lateral bending, but there was no difference between these constructs in flexion-extension. CONCLUSION Patients who undergo a complete unilateral condylectomy require close surveillance for occipitocervical instability. A bilateral Oc-C2 construct provides suitable biomechanical strength, which is superior to other constructs. A unilateral construct decreases abnormal motion but lacks the stiffness of a bilateral construct. However, given that most patients undergo a partial condylectomy and only a small proportion of patients develop instability, there may be scenarios in which a unilateral construct may be appropriate, such as for temporary internal stabilization.
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Affiliation(s)
- Ilyas M Eli
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Michael Karsy
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Darrel S Brodke
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah
| | - Kent N Bachus
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Andrew T Dailey
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Marcus D Mazur
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
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23
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Chavez JL, Porucznik CA, Gren LH, Guan J, Joyce E, Brodke DS, Dailey AT, Mahan MA, Hood RS, Lawrence BD, Spiker WR, Spina NT, Bisson EF. The Impact of Preoperative Mindfulness-Based Stress Reduction on Postoperative Outcomes in Lumbar Spine Degenerative Disease: 3-Month and 12-Month Results of a Pilot Study. World Neurosurg 2020; 139:e230-e236. [PMID: 32278820 DOI: 10.1016/j.wneu.2020.03.186] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 03/25/2020] [Accepted: 03/26/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND We previously reported inpatient and 30-day postoperative patient-reported outcomes (PROs) of a controlled, noncrossover pilot study using preoperative mindfulness-based stress reduction (MBSR) training for lumbar spine surgery. Our goal here was to assess 3-month and 12-month postoperative PROs of preoperative MBSR in lumbar spine surgery for degenerative disease. METHODS Intervention group participants were prospectively enrolled in a preoperative online MBSR course. A comparison standard care only group was one-to-one matched retrospectively by age, sex, surgery type, and prescription opioid use. Three-month and 12-month postoperative PROs for pain, disability, quality of life, and opioid use were compared within and between groups. Regression models were used to assess whether MBSR use predicted outcomes. RESULTS Twenty-four participants were included in each group. At 3 months, follow-up was 87.5% and 95.8% in the comparison and intervention groups, respectively. In the intervention group, mean Patient-Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF) was significantly higher, whereas mean Patient-Reported Outcomes Measurement Information System-Pain Interference (PROMIS-PI) and Oswestry Disability Index were significantly lower. The change from baseline in mean PROMIS-PF and PROMIS-PI was significantly greater than in the comparison group. At 12 months, follow-up was 58.3% and 83.3% in the comparison and intervention groups, respectively. In the intervention group, mean PROMIS-PI was significantly lower and change in mean PROMIS-PI from baseline was significantly greater. MBSR use was a significant predictor of change in PROMIS-PF at 3 months and in PROMIS-PI at 12 months. No adverse events were reported. CONCLUSIONS Three-month and 12-month results suggest that preoperative MBSR may have pain control benefits in lumbar spine surgery.
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Affiliation(s)
- Juneyoung L Chavez
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah Health Sciences Center, Salt Lake City, Utah, USA.
| | - Christina A Porucznik
- Division of Public Health, Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Lisa H Gren
- Division of Public Health, Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Jian Guan
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Evan Joyce
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Darrel S Brodke
- Department of Orthopaedic Surgery, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Andrew T Dailey
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Mark A Mahan
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Robert S Hood
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Brandon D Lawrence
- Department of Orthopaedic Surgery, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - William R Spiker
- Department of Orthopaedic Surgery, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Nicholas T Spina
- Department of Orthopaedic Surgery, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Erica F Bisson
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
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Wilde H, Gamblin AS, Reese J, Garry JG, Guan J, Mortenson J, Flis A, Rosenbluth JP, Karsy M, Bisson EF, Dailey AT. The Effect of Hospital Transfer on Patient Outcomes After Rehabilitation for Spinal Injury. World Neurosurg 2020; 133:e76-e83. [DOI: 10.1016/j.wneu.2019.08.091] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 08/12/2019] [Accepted: 08/14/2019] [Indexed: 11/26/2022]
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Wilkerson C, Mortimer V, Dailey AT, Mazur MD. Minimally invasive oblique interbody fusion for correction of iatrogenic lumbar deformity. Neurosurgical Focus: Video 2020; 2:V3. [PMID: 36284699 PMCID: PMC9521211 DOI: 10.3171/2020.1.focusvid.19706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 09/18/2019] [Indexed: 11/18/2022]
Abstract
Spinal instability may arise as a consequence of decompressive lumbar surgery. An oblique lumbar interbody fusion combined with pedicle screw fixation can provide indirect decompression on neural elements, stabilization of mobile spondylolisthesis, and restoration of segmental lordosis. Minimally invasive techniques may facilitate a shorter hospitalization and faster recovery than a traditional open revision operation. The authors describe the use of an anterior interbody fusion via an oblique retroperitoneal approach and posterior pedicle screw fixation to treat a 67-year-old woman who developed L3–4 and L4–5 unstable spondylolisthesis after a lumbar laminectomy. The video can be found here: https://youtu.be/KWwGMIoDrmU.
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Anderson PA, Raksin PB, Arnold PM, Chi JH, Dailey AT, Dhall SS, Eichholz KM, Harrop JS, Hoh DJ, Qureshi S, Rabb CH, Kaiser MG, O'Toole JE. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Evaluation and Treatment of Patients with Thoracolumbar Spine Trauma: Surgical Approaches. Neurosurgery 2019; 84:E56-E58. [PMID: 30203100 DOI: 10.1093/neuros/nyy363] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 07/16/2018] [Indexed: 11/13/2022] Open
Abstract
QUESTION Does the choice of surgical approach (anterior, posterior, or combined anterior-posterior) improve clinical outcomes in patients with thoracic and lumbar fractures? RECOMMENDATIONS In the surgical treatment of patients with thoracolumbar burst fractures, physicians may use an anterior, posterior, or a combined approach as the selection of approach does not appear to impact clinical or neurological outcomes. Strength of Recommendation: Grade B With regard to radiologic outcomes in the surgical treatment of patients with thoracolumbar fractures, physicians may utilize an anterior, posterior, or combined approach because there is conflicting evidence in the comparison among approaches. Strength of Recommendation: Grade Insufficient With regard to complications in the surgical treatment of patients with thoracolumbar fractures, physicians may use an anterior, posterior, or combined approach because there is conflicting evidence in the comparison among approaches. Strength of Recommendation: Grade Insufficient The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_11.
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Affiliation(s)
- Paul A Anderson
- Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, Wisconsin
| | - P B Raksin
- Division of Neurosurgery, John H. Stroger, Jr Hospital of Cook County and Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
| | - Paul M Arnold
- Department of Neurosurgery, University of Kansas School of Medicine, Kansas City, Kansas
| | - John H Chi
- Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Andrew T Dailey
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Sanjay S Dhall
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Kurt M Eichholz
- St. Louis Minimally Invasive Spine Center, St. Louis, Missouri
| | - James S Harrop
- Departments of Neurological Surgery and Orthopedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Daniel J Hoh
- Lillian S. Wells Department of Neurological Surgery, University of Florida, Gainesville, Florida
| | - Sheeraz Qureshi
- Department of Orthopaedic Surgery, Weill Cornell Medical College, New York, New York
| | - Craig H Rabb
- Department of Neurosurgery, Columbia University, New York, New York
| | - Michael G Kaiser
- Department of Neurosurgery, Columbia University, New York, New York
| | - John E O'Toole
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
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Raksin PB, Harrop JS, Anderson PA, Arnold PM, Chi JH, Dailey AT, Dhall SS, Eichholz KM, Hoh DJ, Qureshi S, Rabb CH, Kaiser MG, O'Toole JE. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Evaluation and Treatment of Patients With Thoracolumbar Spine Trauma: Prophylaxis and Treatment of Thromboembolic Events. Neurosurgery 2019; 84:E39-E42. [PMID: 30203078 DOI: 10.1093/neuros/nyy367] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 07/12/2018] [Indexed: 01/01/2023] Open
Abstract
QUESTION 1 Does routine screening for deep venous thrombosis prevent pulmonary embolism (or venous thromboembolism (VTE)-associated morbidity and mortality) in patients with thoracic and lumbar fractures? RECOMMENDATION 1 There is insufficient evidence to recommend for or against routine screening for deep venous thrombosis in preventing pulmonary embolism (or VTE-associated morbidity and mortality) in patients with thoracic and lumbar fractures. Strength of Recommendation: Grade Insufficient. QUESTION 2 For patients with thoracic and lumbar fractures, is one regimen of VTE prophylaxis superior to others with respect to prevention of pulmonary embolism (or VTE-associated morbidity and mortality)? RECOMMENDATION 2 There is insufficient evidence to recommend a specific regimen of VTE prophylaxis to prevent pulmonary embolism (or VTE-associated morbidity and mortality) in patients with thoracic and lumbar fractures. Strength of Recommendation: Grade Insufficient. QUESTION 3 Is there a specific treatment regimen for documented VTE that provides fewer complications than other treatments in patients with thoracic and lumbar fractures? RECOMMENDATION 3 There is insufficient evidence to recommend for or against a specific treatment regimen for documented VTE that would provide fewer complications than other treatments in patients with thoracic and lumbar fractures. Strength of Recommendation: Grade Insufficient. RECOMMENDATION 4 Based on published data from pooled (cervical and thoracolumbar) spinal cord injury populations, the use of thromboprophylaxis is recommended to reduce the risk of VTE events in patients with thoracic and lumbar fractures. Consensus Statement by the Workgroup The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_7.
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Affiliation(s)
- P B Raksin
- Division of Neurosurgery, John H. Stroger, Jr Hospital of Cook County and Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
| | - James S Harrop
- Departments of Neurological Surgery and Orthopedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Paul A Anderson
- Department of Orthopedics & Rehabilitation, University of Wisconsin, Madison, Wisconsin
| | - Paul M Arnold
- Department of Neurosurgery, University of Kansas School of Medicine, Kansas City, Kansas
| | - John H Chi
- Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Andrew T Dailey
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Sanjay S Dhall
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Kurt M Eichholz
- St. Louis Minimally Invasive Spine Center, St. Louis, Missouri
| | - Daniel J Hoh
- Lillian S. Wells Department of Neurological Surgery, University of Florida, Gainesville, Florida
| | - Sheeraz Qureshi
- Department of Orthopaedic Surgery, Weill Cornell Medical College, New York, New York
| | - Craig H Rabb
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Michael G Kaiser
- Department of Neurosurgery, Columbia University, New York, New York
| | - John E O'Toole
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
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Phuntsok R, Provost CW, Dailey AT, Brockmeyer DL, Ellis BJ. The atlantoaxial capsular ligaments and transverse ligament are the primary stabilizers of the atlantoaxial joint in the craniocervical junction: a finite element analysis. J Neurosurg Spine 2019. [DOI: 10.3171/2019.4.spine181488] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEPrior studies have provided conflicting evidence regarding the contribution of key ligamentous structures to atlantoaxial (AA) joint stability. Many of these studies employed cadaveric techniques that are hampered by the inherent difficulties of testing isolated-injury scenarios. Analysis with validated finite element (FE) models can overcome some of these limitations. In a previous study, the authors completed an FE analysis of 5 subject-specific craniocervical junction (CCJ) models to investigate the biomechanics of the occipitoatlantal joint and identify the ligamentous structures essential for its stability. Here, the authors use these same CCJ FE models to investigate the biomechanics of the AA joint and to identify the ligamentous structures essential for its stability.METHODSFive validated CCJ FE models were used to simulate isolated- and combined ligamentous–injury scenarios of the transverse ligament (TL), tectorial membrane (TM), alar ligament (AL), occipitoatlantal capsular ligament, and AA capsular ligament (AACL). All models were tested with rotational moments (flexion-extension, axial rotation, and lateral bending) and anterior translational loads (C2 constrained with anterior load applied to the occiput) to simulate physiological loading and to assess changes in the atlantodental interval (ADI), a key radiographic indicator of instability.RESULTSIsolated AACL injury significantly increased range of motion (ROM) under rotational moment at the AA joint for flexion, lateral bending, and axial rotation, which increased by means of 28.0% ± 10.2%, 43.2% ± 15.4%, and 159.1% ± 35.1%, respectively (p ≤ 0.05 for all). TL removal simulated under translational loads resulted in a significant increase in displacement at the AA joint by 89.3% ± 36.6% (p < 0.001), increasing the ADI from 2.7 mm to 4.5 mm. An AACL injury combined with an injury to any other ligament resulted in significant increases in ROM at the AA joint, except when combined with injuries to both the TM and the ALs. Similarly, injury to the TL combined with injury to any other CCJ ligament resulted in a significant increase in displacement at the AA joint (significantly increasing ADI) under translational loads.CONCLUSIONSUsing FE modeling techniques, the authors showed a significant reliance of isolated- and combined ligamentous–injury scenarios on the AACLs and TL to restrain motion at the AA joint. Isolated injuries to other structures alone, including the AL and TM, did not result in significant increases in either AA joint ROM or anterior displacement.
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Affiliation(s)
- Rinchen Phuntsok
- 1Department of Biomedical Engineering and Scientific Computing and Imaging Institute, University of Utah; and
| | - Chase W. Provost
- 1Department of Biomedical Engineering and Scientific Computing and Imaging Institute, University of Utah; and
| | - Andrew T. Dailey
- 2Department of Neurosurgery, Division of Pediatric Neurosurgery, Primary Children’s Hospital, University of Utah, Salt Lake City, Utah
| | - Douglas L. Brockmeyer
- 2Department of Neurosurgery, Division of Pediatric Neurosurgery, Primary Children’s Hospital, University of Utah, Salt Lake City, Utah
| | - Benjamin J. Ellis
- 1Department of Biomedical Engineering and Scientific Computing and Imaging Institute, University of Utah; and
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Chavez JL, Porucznik CA, Gren LH, Guan J, Joyce E, Brodke DS, Dailey AT, Mahan MA, Hood RS, Lawrence B, Spiker WR, Spina NT, Bisson EF. The Impact of Preoperative Mindfulness-Based Stress Reduction on Postoperative Patient-Reported Pain, Disability, Quality of Life, and Prescription Opioid Use in Lumbar Spine Degenerative Disease: Three- and Twelve-Month Results. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Guan J, Karsy M, Brock AA, Couldwell WT, Kestle JRW, Jensen RL, Dailey AT, Bisson EF, Schmidt RH. Analysis of an overlapping surgery policy change on costs in a high-volume neurosurgical department. J Neurosurg 2019; 131:903-910. [DOI: 10.3171/2018.5.jns18569] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 05/02/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEOverlapping surgery remains a controversial topic in the medical community. Although numerous studies have examined the safety profile of overlapping operations, there are few data on its financial impact. The authors assessed direct hospital costs associated with neurosurgical operations during periods before and after a more stringent overlapping surgery policy was implemented.METHODSThe authors retrospectively reviewed the records of nonemergency neurosurgical operations that took place during the periods from June 1, 2014, to October 31, 2014 (pre–policy change), and from June 1, 2016, to October 31, 2016 (post–policy change), by any of the 4 senior neurosurgeons authorized to perform overlapping cases during both periods. Cost data as well as demographic, surgical, and hospitalization-related variables were obtained from an institutional tool, the Value-Driven Outcomes database.RESULTSA total of 625 hospitalizations met inclusion criteria for cost analysis; of these, 362 occurred prior to the policy change and 263 occurred after the change. All costs were reported as a proportion of the average total hospitalization cost for the entire cohort. There was no significant difference in mean total hospital costs between the prechange and postchange period (0.994 ± 1.237 vs 1.009 ± 0.994, p = 0.873). On multivariate linear regression analysis, neither the policy change (p = 0.582) nor the use of overlapping surgery (p = 0.273) was significantly associated with higher total hospital costs.CONCLUSIONSA more restrictive overlapping surgery policy was not associated with a reduction in the direct costs of hospitalization for neurosurgical procedures.
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Sherrod B, Karsy M, Guan J, Brock AA, Eli IM, Bisson EF, Dailey AT. Spine trauma and spinal cord injury in Utah: a geographic cohort study utilizing the National Inpatient Sample. J Neurosurg Spine 2019; 31:93-102. [DOI: 10.3171/2018.12.spine18964] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 12/27/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe objective of this study was to investigate the effect of hospital type and patient transfer during the treatment of patients with vertebral fracture and/or spinal cord injury (SCI).METHODSThe National Inpatient Sample (NIS) database was queried to identify patients treated in Utah from 2001 to 2011 for vertebral column fracture and/or SCI (ICD-9-CM codes 805, 806, and 952). Variables related to patient transfer into and out of the index hospital were evaluated in relation to patient disposition, hospital length of stay, mortality, and cost.RESULTSA total of 53,644 patients were seen (mean [± SEM] age 55.3 ± 0.1 years, 46.0% females, 90.2% white), of which 10,620 patients were transferred from another institution rather than directly admitted. Directly admitted (vs transferred) patients showed a greater likelihood of routine disposition (54.4% vs 26.0%) and a lower likelihood of skilled nursing facility disposition (28.2% vs 49.2%) (p < 0.0001). Directly admitted patients also had a significantly shorter length of stay (5.6 ± 6.7 vs 7.8 ± 9.5 days, p < 0.0001) and lower total charges ($26,882 ± $37,348 vs $42,965 ± $52,118, p < 0.0001). A multivariable analysis showed that major operative procedures (hazard ratio [HR] 1.7, 95% confidence interval [CI] 1.4–2.0, p < 0.0001) and SCI (HR 2.1, 95% CI 1.6–2.8, p < 0.0001) were associated with reduced survival whereas patient transfer was associated with better survival rates (HR 0.4, 95% CI 0.3–0.5, p < 0.0001). A multivariable analysis of cost showed that disposition (β = 0.1), length of stay (β = 0.6), and major operative procedure (β = 0.3) (p < 0.0001) affected cost the most.CONCLUSIONSOverall, transferred patients had lower mortality but greater likelihood for poor outcomes, longer length of stay, and higher cost compared with directly admitted patients. These results suggest some significant benefits to transferring patients with acute injury to facilities capable of providing appropriate treatment, but also support the need to further improve coordinated care of transferred patients, including surgical treatment and rehabilitation.
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Phuntsok R, Ellis BJ, Herron MR, Provost CW, Dailey AT, Brockmeyer DL. The occipitoatlantal capsular ligaments are the primary stabilizers of the occipitoatlantal joint in the craniocervical junction: a finite element analysis. J Neurosurg Spine 2019; 30:1-9. [PMID: 30771758 DOI: 10.3171/2018.10.spine181102] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 10/04/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThere is contradictory evidence regarding the relative contribution of the key stabilizing ligaments of the occipitoatlantal (OA) joint. Cadaveric studies are limited by the nature and the number of injury scenarios that can be tested to identify OA stabilizing ligaments. Finite element (FE) analysis can overcome these limitations and provide valuable data in this area. The authors completed an FE analysis of 5 subject-specific craniocervical junction (CCJ) models to investigate the biomechanics of the OA joint and identify the ligamentous structures essential for stability.METHODSIsolated and combined injury scenarios were simulated under physiological loads for 5 validated CCJ FE models to assess the relative role of key ligamentous structures on OA joint stability. Each model was tested in flexion-extension, axial rotation, and lateral bending in various injury scenarios. Isolated ligamentous injury scenarios consisted of either decreasing the stiffness of the OA capsular ligaments (OACLs) or completely removing the transverse ligament (TL), tectorial membrane (TM), or alar ligaments (ALs). Combination scenarios were also evaluated.RESULTSAn isolated OACL injury resulted in the largest percentage increase in all ranges of motion (ROMs) at the OA joint compared with the other isolated injuries. Flexion, extension, lateral bending, and axial rotation significantly increased by 12.4% ± 7.4%, 11.1% ± 10.3%, 83.6% ± 14.4%, and 81.9% ± 9.4%, respectively (p ≤ 0.05 for all). Among combination injuries, OACL+TM+TL injury resulted in the most consistent significant increases in ROM for both the OA joint and the CCJ during all loading scenarios. OACL+AL injury caused the most significant percentage increase for OA joint axial rotation.CONCLUSIONSThese results demonstrate that the OACLs are the key stabilizing ligamentous structures of the OA joint. Injury of these primary stabilizing ligaments is necessary to cause OA instability. Isolated injuries of TL, TM, or AL are unlikely to result in appreciable instability at the OA joint.
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Affiliation(s)
- Rinchen Phuntsok
- 1Department of Bioengineering, and Scientific Computing and Imaging Institute, University of Utah; and
| | - Benjamin J Ellis
- 1Department of Bioengineering, and Scientific Computing and Imaging Institute, University of Utah; and
| | - Michael R Herron
- 1Department of Bioengineering, and Scientific Computing and Imaging Institute, University of Utah; and
| | - Chase W Provost
- 1Department of Bioengineering, and Scientific Computing and Imaging Institute, University of Utah; and
| | - Andrew T Dailey
- 2Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Utah, Primary Children's Hospital, Salt Lake City, Utah
| | - Douglas L Brockmeyer
- 2Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Utah, Primary Children's Hospital, Salt Lake City, Utah
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Mazur MD, Dailey AT, Shah L, Scoville JP, Couldwell WT. Delayed Occipitocervical Instability With Cranial Settling After Far-Lateral Transcondylar Surgery for Invasive Skull Base Tumor. Oper Neurosurg (Hagerstown) 2019; 16:250-255. [PMID: 29660043 DOI: 10.1093/ons/opy070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 03/12/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Occipitocervical instability is a rare but potentially severe complication of a far-lateral transcondylar surgical approach to the skull base. OBJECTIVE To investigate the incidence of clinically significant occipitocervical instability after transcondylar surgery via a far-lateral approach and to determine whether the extent of occipital condyle resection relative to the hypoglossal canal was associated with the development of occipitocervical instability. METHODS A retrospective review of patients undergoing far-lateral transcondylar surgery was performed at our institution to identify patients who developed postoperative occipitocervical instability. RESULTS Of the 61 far-lateral transcondylar operations performed, the authors identified 2 cases of delayed occipitocervical instability after surgery. In each case, the patient had tumor invading into the occipital condyle and supracondylar region and a resection extending anterior to the hypoglossal canal was performed. Both patients presented with pathological fractures and a severe occipitocervical deformity. CONCLUSION Patients who have tumor involvement of the occipital condyle and supracondylar region and undergo partial unilateral condylar resection are at risk for occipitocervical instability and should be considered for occipitocervical fusion.
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Affiliation(s)
- Marcus D Mazur
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Andrew T Dailey
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Lubdha Shah
- Department of Radiology, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Jonathan P Scoville
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
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Yi JL, Porucznik CA, Gren LH, Guan J, Joyce E, Brodke DS, Dailey AT, Mahan MA, Hood RS, Lawrence BD, Spiker WR, Spina NT, Bisson EF. The Impact of Preoperative Mindfulness-Based Stress Reduction on Postoperative Patient-Reported Pain, Disability, Quality of Life, and Prescription Opioid Use in Lumbar Spine Degenerative Disease: A Pilot Study. World Neurosurg 2019; 121:e786-e791. [DOI: 10.1016/j.wneu.2018.09.223] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 09/27/2018] [Accepted: 09/28/2018] [Indexed: 12/01/2022]
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Dailey AT, Arnold PM, Anderson PA, Chi JH, Dhall SS, Eichholz KM, Harrop JS, Hoh DJ, Qureshi S, Rabb CH, Raksin PB, Kaiser MG, O'Toole JE. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Evaluation and Treatment of Patients With Thoracolumbar Spine Trauma: Classification of Injury. Neurosurgery 2019; 84:E24-E27. [PMID: 30202904 DOI: 10.1093/neuros/nyy372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 07/18/2018] [Indexed: 11/14/2022] Open
Abstract
QUESTION 1 Are there classification systems for fractures of the thoracolumbar spine that have been shown to be internally valid and reliable (ie, do these instruments provide consistent information between different care providers)? RECOMMENDATION 1 A classification scheme that uses readily available clinical data (eg, computed tomography scans with or without magnetic resonance imaging) to convey injury morphology, such as Thoracolumbar Injury Classification and Severity Scale or the AO Spine Thoracolumbar Spine Injury Classification System, should be used to improve characterization of traumatic thoracolumbar injuries and communication among treating physicians. Strength of Recommendation: Grade B. QUESTION 2 In treating patients with thoracolumbar fractures, does employing a formally tested classification system for treatment decision-making affect clinical outcomes? RECOMMENDATION 2 There is insufficient evidence to recommend a universal classification system or severity score that will readily guide treatment of all injury types and thereby affect outcomes. Strength of Recommendation: Grade Insufficient The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_2.
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Affiliation(s)
- Andrew T Dailey
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Paul M Arnold
- Department of Neurosurgery, University of Kansas School of Medicine, Kansas City, Kansas
| | - Paul A Anderson
- Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, Wisconsin
| | - John H Chi
- Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sanjay S Dhall
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Kurt M Eichholz
- St. Louis Minimally Invasive Spine Center, St. Louis, Missouri
| | - James S Harrop
- Departments of Neurological Surgery and Orthopedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Daniel J Hoh
- Lillian S. Wells Department of Neurological Surgery, University of Florida, Gainesville, Florida
| | - Sheeraz Qureshi
- Department of Orthopaedic Surgery, Weill Cornell Medical College, New York, New York
| | - Craig H Rabb
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - P B Raksin
- Division of Neurosurgery, John H. Stroger, Jr Hospital of Cook County and Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
| | - Michael G Kaiser
- Department of Neurosurgery, Columbia University, New York, New York
| | - John E O'Toole
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
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Qureshi S, Dhall SS, Anderson PA, Arnold PM, Chi JH, Dailey AT, Eichholz KM, Harrop JS, Hoh DJ, Rabb CH, Raksin PB, Kaiser MG, O'Toole JE. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Evaluation and Treatment of Patients With Thoracolumbar Spine Trauma: Radiological Evaluation. Neurosurgery 2019; 84:E28-E31. [PMID: 30202989 DOI: 10.1093/neuros/nyy373] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 07/18/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Radiological evaluation of traumatic thoracolumbar fractures is used to classify the injury and determine the optimal treatment plan. Currently, there remains a lack of consensus regarding appropriate radiological protocol. Most clinicians use a combination of plain radiographs, 3-dimensional computed tomography with reconstructions, and magnetic resonance imaging (MRI). OBJECTIVE To determine, through evidence-based guidelines review: (1) whether the use of MRI to identify ligamentous integrity predicted the need for surgical intervention; and (2) if there are any radiological findings that can assist in predicting clinical outcomes. METHODS A systematic review of the literature was performed using the National Library of Medicine/PubMed database and the Cochrane Library for studies relevant to thoracolumbar trauma. Clinical studies specifically addressing the radiological evaluation of thoracolumbar spine trauma were selected for review. RESULTS Two of 2278 studies met inclusion criteria for review. One retrospective review (Level III) and 1 prospective cohort (Level III) provided evidence that the addition of an MRI scan in acute thoracic and thoracolumbar trauma can predict the need for surgical intervention. There was insufficient evidence that MRI can help predict clinical outcomes in patients with acute traumatic thoracic and thoracolumbar spine injuries. CONCLUSION This evidence-based guideline provides a Grade B recommendation that radiological findings in patients with acute thoracic or thoracolumbar spine trauma can predict the need for surgical intervention. This evidence-based guideline provides a grade insufficient recommendation that there is insufficient evidence to determine if radiographic findings can assist in predicting clinical outcomes in patients with acute thoracic and thoracolumbar spine injuries. QUESTION 1 Are there radiographic findings in patients with traumatic thoracolumbar fractures that can predict the need for surgical intervention? RECOMMENDATION 1 Because MRI has been shown to influence the management of up to 25% of patients with thoracolumbar fractures, providers may use MRI to assess posterior ligamentous complex integrity, when determining the need for surgery. Strength of Recommendation: Grade B. QUESTION 2 Are there radiographic findings in patients with traumatic thoracolumbar fractures that can assist in predicting clinical outcomes? RECOMMENDATION 2 Due to a paucity of published studies, there is insufficient evidence that radiographic findings can be used as predictors of clinical outcomes in thoracolumbar fractures. Strength of Recommendation: Grade Insufficient The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_3.
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Affiliation(s)
- Sheeraz Qureshi
- Department of Orthopaedic Surgery, Weill Cornell Medical College, New York, New York
| | - Sanjay S Dhall
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Paul A Anderson
- Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, Wisconsin
| | - Paul M Arnold
- Department of Neurosurgery, University of Kansas School of Medicine, Kansas City, Kansas
| | - John H Chi
- Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Andrew T Dailey
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Kurt M Eichholz
- St. Louis Minimally Invasive Spine Center, St. Louis, Missouri
| | - James S Harrop
- Departments of Neurological Surgery and Orthopedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Daniel J Hoh
- Lillian S. Wells Department of Neurological Surgery, University of Florida, Gainesville, Florida
| | - Craig H Rabb
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - P B Raksin
- Division of Neurosurgery, John H. Stroger, Jr Hospital of Cook County and Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
| | - Michael G Kaiser
- Department of Neurosurgery, Columbia University, New York, New York
| | - John E O'Toole
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
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Hoh DJ, Qureshi S, Anderson PA, Arnold PM, John HC, Dailey AT, Dhall SS, Eichholz KM, Harrop JS, Rabb CH, Raksin PB, Kaiser MG, O'Toole JE. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Evaluation and Treatment of Patients With Thoracolumbar Spine Trauma: Nonoperative Care. Neurosurgery 2019; 84:E46-E49. [PMID: 30203096 DOI: 10.1093/neuros/nyy369] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 07/12/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Thoracic and lumbar burst fractures in neurologically intact patients are considered to be inherently stable, and responsive to nonsurgical management. There is a lack of consensus regarding the optimal conservative treatment modality. The question remains whether external bracing is necessary vs mobilization without a brace after these injuries. OBJECTIVE To determine if the use of external bracing improves outcomes compared to no brace for neurologically intact patients with thoracic or lumbar burst fractures. METHODS A systematic review of the literature was performed using the National Library of Medicine PubMed database and the Cochrane Library for studies relevant to thoracolumbar trauma. Clinical studies specifically comparing external bracing to no brace for neurologically intact patients with thoracic or lumbar burst fractures were selected for review. RESULTS Three studies out of 1137 met inclusion criteria for review. One randomized controlled trial (level I) and an additional randomized controlled pilot study (level II) provided evidence that both external bracing and no brace equally improve pain and disability in neurologically intact patients with burst fractures. There was no difference in final clinical and radiographic outcomes between patients treated with an external brace vs no brace. One additional level IV retrospective study demonstrated equivalent clinical outcomes for external bracing vs no brace. CONCLUSION This evidence-based guideline provides a grade B recommendation that management either with or without an external brace is an option given equivalent improvement in outcomes for neurologically intact patients with thoracic and lumbar burst fractures. The decision to use an external brace is at the discretion of the treating physician, as bracing is not associated with increased adverse events compared to no brace. QUESTION Does the use of external bracing improve outcomes in the nonoperative treatment of neurologically intact patients with thoracic and lumbar burst fractures? RECOMMENDATION The decision to use an external brace is at the discretion of the treating physician, as the nonoperative management of neurologically intact patients with thoracic and lumbar burst fractures either with or without an external brace produces equivalent improvement in outcomes. Bracing is not associated with increased adverse events compared to not bracing. Strength of Recommendation: Grade B The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_8.
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Affiliation(s)
- Daniel J Hoh
- Lillian S. Wells Department of Neurological Surgery, University of Florida, Gainesville, Florida
| | - Sheeraz Qureshi
- Department of Orthopaedic Surgery, Weill Cornell Medical College, New York, New York
| | - Paul A Anderson
- Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, Wisconsin
| | - Paul M Arnold
- Department of Neurosurgery, University of Kansas School of Medicine, Kansas City, Kansas
| | - H Chi John
- Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Andrew T Dailey
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Sanjay S Dhall
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Kurt M Eichholz
- St. Louis Minimally Invasive Spine Center, St. Louis, Missouri
| | - James S Harrop
- Departments of Neurological Surgery and Orthopedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Craig H Rabb
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - P B Raksin
- Division of Neurosurgery, John H. Stroger, Jr Hospital of Cook County and Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
| | - Michael G Kaiser
- Department of Neurosurgery, Columbia University, New York, New York
| | - John E O'Toole
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
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Rabb CH, Hoh DJ, Anderson PA, Arnold PM, Chi JH, Dailey AT, Dhall SS, Eichholz KM, Harrop JS, Qureshi S, Raksin PB, Kaiser MG, O'Toole JE. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Evaluation and Treatment of Patients with Thoracolumbar Spine Trauma: Operative Versus Nonoperative Treatment. Neurosurgery 2019; 84:E50-E52. [PMID: 30203034 DOI: 10.1093/neuros/nyy361] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 07/16/2018] [Indexed: 11/13/2022] Open
Abstract
QUESTION 1 Does the surgical treatment of burst fractures of the thoracic and lumbar spine improve clinical outcomes compared to nonoperative treatment? RECOMMENDATION 1 There is conflicting evidence to recommend for or against the use of surgical intervention to improve clinical outcomes in patients with thoracolumbar burst fracture who are neurologically intact. Therefore, it is recommended that the discretion of the treating provider be used to determine if the presenting thoracic or lumbar burst fracture in the neurologically intact patient warrants surgical intervention. Strength of Recommendation: Grade Insufficient. QUESTION 2 Does the surgical treatment of nonburst fractures of the thoracic and lumbar spine improve clinical outcomes compared to nonoperative treatment? RECOMMENDATION 2 There is insufficient evidence to recommend for or against the use of surgical intervention for nonburst thoracic or lumbar fractures. It is recommended that the decision to pursue surgery for such fractures be at the discretion of the treating physician. Strength of Recommendation: Grade Insufficient The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_1.
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Affiliation(s)
- Craig H Rabb
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Daniel J Hoh
- Lillian S. Wells Department of Neurological Surgery, University of Florida, Gainesville, Florida
| | - Paul A Anderson
- Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, Wisconsin
| | - Paul M Arnold
- Department of Neurosurgery, University of Kansas School of Medicine, Kansas City, Kansas
| | - John H Chi
- Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Andrew T Dailey
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Sanjay S Dhall
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Kurt M Eichholz
- St. Louis Minimally Invasive Spine Center, St. Louis, Missouri
| | - James S Harrop
- Departments of Neurological Surgery and Orthopedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Sheeraz Qureshi
- Department of Orthopaedic Surgery, Weill Cornell Medical College, New York, New York
| | - P B Raksin
- Division of Neurosurgery, John H. Stroger, Jr Hospital of Cook County and Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
| | - Michael G Kaiser
- Department of Neurosurgery, Columbia University, New York, New York
| | - John E O'Toole
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
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Harrop JS, Chi JH, Anderson PA, Arnold PM, Dailey AT, Dhall SS, Eichholz KM, Hoh DJ, Qureshi S, Rabb CH, Raksin PB, Kaiser MG, O'Toole JE. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Evaluation and Treatment of Patients With Thoracolumbar Spine Trauma: Neurological Assessment. Neurosurgery 2019; 84:E32-E35. [PMID: 30203084 DOI: 10.1093/neuros/nyy370] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 07/16/2018] [Indexed: 11/14/2022] Open
Abstract
QUESTION 1 Which neurological assessment tools have demonstrated internal reliability and validity in the management of patients with thoracic and lumbar fractures (ie, do these instruments provide consistent information between different care providers)? RECOMMENDATION 1 Numerous neurologic assessment scales (Functional Independence Measure, Sunnybrook Cord Injury Scale and Frankel Scale for Spinal Cord Injury) have demonstrated internal reliability and validity in the management of patients with thoracic and lumbar fractures. Unfortunately, other contemporaneous measurement scales (ie, American Spinal Cord Injury Association Impairment Scale) have not been specifically studied in patients with thoracic and lumbar fractures. Strength of Recommendation: Grade C. QUESTION 2 Are there any clinical findings (eg, presenting neurological grade/function) in patients with thoracic and lumbar fractures that can assist in predicting clinical outcomes? RECOMMENDATION 2 Entry American Spinal Injury Association Impairment Scale grade, sacral sensation, ankle spasticity, urethral and rectal sphincter function, and AbH motor function can be used to predict neurological function and outcome in patients with thoracic and lumbar fractures (Table I https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_4_table1). Strength of Recommendation: Grade B The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_4.
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Affiliation(s)
- James S Harrop
- Departments of Neurological Surgery and Orthopedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - John H Chi
- Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Paul A Anderson
- Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, Wisconsin
| | - Paul M Arnold
- Department of Neurosurgery, University of Kansas School of Medicine, Kansas City, Kansas
| | - Andrew T Dailey
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Sanjay S Dhall
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Kurt M Eichholz
- St. Louis Minimally Invasive Spine Center, St. Louis, Missouri
| | - Daniel J Hoh
- Lillian S. Wells Department of Neurological Surgery, University of Florida, Gainesville, Florida
| | - Sheeraz Qureshi
- Department of Orthopaedic Surgery, Weill Cornell Medical College, New York, New York
| | - Craig H Rabb
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - P B Raksin
- Division of Neurosurgery, John H. Stroger, Jr Hospital of Cook County and Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
| | - Michael G Kaiser
- Department of Neurosurgery, Columbia University, New York, New York
| | - John E O'Toole
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
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Chi JH, Eichholz KM, Anderson PA, Arnold PM, Dailey AT, Dhall SS, Harrop JS, Hoh DJ, Qureshi S, Rabb CH, Raksin PB, Kaiser MG, O’Toole JE. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Evaluation and Treatment of Patients With Thoracolumbar Spine Trauma: Novel Surgical Strategies. Neurosurgery 2018; 84:E59-E62. [DOI: 10.1093/neuros/nyy364] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 07/16/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- John H Chi
- Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kurt M Eichholz
- St. Louis Minimally Invasive Spine Center, St. Louis, Missouri
| | - Paul A Anderson
- Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, Wisconsin
| | - Paul M Arnold
- Department of Neurosurgery, University of Kansas School of Medicine, Kansas City, Kansas
| | - Andrew T Dailey
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Sanjay S Dhall
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - James S Harrop
- Departments of Neurological Surgery and Orthopedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Daniel J Hoh
- Lillian S. Wells Department of Neurological Surgery, University of Florida, Gainesville, Florida
| | - Sheeraz Qureshi
- Department of Orthopaedic Surgery, Weill Cornell Medical College, New York, New York
| | - Craig H Rabb
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - P B Raksin
- Division of Neurosurgery, John H. Stroger, Jr Hospital of Cook County and Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
| | - Michael G Kaiser
- Department of Neurosurgery, Columbia University, New York, New York
| | - John E O’Toole
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
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Worrell FC, Campbell LF, Dailey AT, Brown RT. Commentary: Consensus findings and future directions. Professional Psychology: Research and Practice 2018. [DOI: 10.1037/pro0000201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Campbell LF, Worrell FC, Dailey AT, Brown RT. Master’s level practice: Introduction, history, and current status. Professional Psychology: Research and Practice 2018. [DOI: 10.1037/pro0000202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Dhall SS, Dailey AT, Anderson PA, Arnold PM, Chi JH, Eichholz KM, Harrop JS, Hoh DJ, Qureshi S, Rabb CH, Raksin PB, Kaiser MG, O’Toole JE. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Evaluation and Treatment of Patients With Thoracolumbar Spine Trauma: Hemodynamic Management. Neurosurgery 2018; 84:E43-E45. [DOI: 10.1093/neuros/nyy368] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 07/12/2018] [Indexed: 11/15/2022] Open
Affiliation(s)
- Sanjay S Dhall
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Andrew T Dailey
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Paul A Anderson
- Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, Wisconsin
| | - Paul M Arnold
- Department of Neurosurgery, University of Kansas School of Medicine, Kansas City, Kansas
| | - John H Chi
- Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kurt M Eichholz
- St. Louis Minimally Invasive Spine Center, St. Louis, Missouri
| | - James S Harrop
- Departments of Neurological Surgery and Orthopedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Daniel J Hoh
- Lillian S. Wells Department of Neurological Surgery, University of Florida, Gainesville, Florida
| | - Sheeraz Qureshi
- Department of Orthopaedic Surgery, Weill Cornell Medical College, New York, New York
| | - Craig H Rabb
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - P B Raksin
- Division of Neurosurgery, John H. Stroger, Jr Hospital of Cook County and Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
| | - Michael G Kaiser
- Department of Neurosurgery, Columbia University, New York, New York
| | - John E O’Toole
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
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45
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Eichholz KM, Rabb CH, Anderson PA, Arnold PM, Chi JH, Dailey AT, Dhall SS, Harrop JS, Hoh DJ, Qureshi S, Raksin PB, Kaiser MG, O’Toole JE. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Evaluation and Treatment of Patients With Thoracolumbar Spine Trauma: Timing of Surgical Intervention. Neurosurgery 2018; 84:E53-E55. [DOI: 10.1093/neuros/nyy362] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 07/16/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kurt M Eichholz
- St. Louis Minimally Invasive Spine Center, St. Louis, Missouri
| | - Craig H Rabb
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Paul A Anderson
- Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, Wisconsin
| | - Paul M Arnold
- Department of Neurosurgery, University of Kansas School of Medicine, Kansas City, Kansas
| | - John H Chi
- Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Andrew T Dailey
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Sanjay S Dhall
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - James S Harrop
- Departments of Neurological Surgery and Orthopedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Daniel J Hoh
- Lillian S. Wells Department of Neurological Surgery, University of Florida, Gainesville, Florida
| | - Sheeraz Qureshi
- Department of Orthopaedic Surgery, Weill Cornell Medical College, New York, New York
| | - P B Raksin
- Division of Neurosurgery, John H. Stroger, Jr Hospital of Cook County and Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
| | - Michael G Kaiser
- Department of Neurosurgery, Columbia University, New York, New York
| | - John E O’Toole
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
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Arnold PM, Anderson PA, Chi JH, Dailey AT, Dhall SS, Eichholz KM, Harrop JS, Hoh DJ, Qureshi S, Rabb CH, Raksin PB, Kaiser MG, O’Toole JE. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Evaluation and Treatment of Patients With Thoracolumbar Spine Trauma: Pharmacological Treatment. Neurosurgery 2018; 84:E36-E38. [DOI: 10.1093/neuros/nyy371] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 07/16/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Paul M Arnold
- Department of Neurosurgery, University of Kansas School of Medicine, Kansas City, Kansas
| | - Paul A Anderson
- Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, Wisconsin
| | - John H Chi
- Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Andrew T Dailey
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Sanjay S Dhall
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Kurt M Eichholz
- St. Louis Minimally Invasive Spine Center, St. Louis, Missouri
| | - James S Harrop
- Departments of Neurological Surgery and Orthopedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Daniel J Hoh
- Lillian S. Wells Department of Neurological Surgery, University of Florida, Gainesville, Florida
| | - Sheeraz Qureshi
- Department of Orthopaedic Surgery, Weill Cornell Medical College, New York, New York
| | - Craig H Rabb
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - P B Raksin
- Division of Neurosurgery, John H. Stroger, Jr Hospital of Cook County and Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
| | - Michael G Kaiser
- Department of Neurosurgery, Columbia University, New York, New York
| | - John E O’Toole
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
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O’Toole JE, Kaiser MG, Anderson PA, Arnold PM, Chi JH, Dailey AT, Dhall SS, Eichholz KM, Harrop JS, Hoh DJ, Qureshi S, Rabb CH, Raksin PB. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Evaluation and Treatment of Patients with Thoracolumbar Spine Trauma: Executive Summary. Neurosurgery 2018; 84:2-6. [DOI: 10.1093/neuros/nyy394] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 07/27/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- John E O’Toole
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
| | - Michael G Kaiser
- Department of Neurosurgery, Columbia University, New York, New York
| | - Paul A Anderson
- Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, Wisconsin
| | - Paul M Arnold
- Department of Neurosurgery, University of Kansas School of Medicine, Kansas City, Kansas
| | - John H Chi
- Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Andrew T Dailey
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Sanjay S Dhall
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Kurt M Eichholz
- St. Louis Minimally Invasive Spine Center, St. Louis, Missouri
| | - James S Harrop
- Departments of Neurological Surgery and Orthopedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Daniel J Hoh
- Lillian S. Wells Department of Neurological Surgery, University of Florida, Gainesville, Florida
| | - Sheeraz Qureshi
- Department of Orthopaedic Surgery, Weill Cornell Medical College, New York, New York
| | - Craig H Rabb
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - P B Raksin
- Division of Neurosurgery, John H. Stroger, Jr Hospital of Cook County and Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
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Guan J, Karsy M, Brock AA, Couldwell WT, Kestle JRW, Jensen RL, Dailey AT, Schmidt RH. Impact of a more restrictive overlapping surgery policy: an analysis of pre- and postimplementation complication rates, resident involvement, and surgical wait times at a high-volume neurosurgical department. J Neurosurg 2018; 129:515-523. [DOI: 10.3171/2017.5.jns17183] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVERecently, overlapping surgery has been a source of controversy both in the popular press and within the academic medical community. There have been no studies examining the possible effects of more stringent overlapping surgery restrictions. At the authors’ institution, a new policy was implemented that restricts attending surgeons from starting a second case until all critical portions of the first case that could require the attending surgeon’s involvement are completed. The authors examined the impact of this policy on complication rates, neurosurgical resident education, and wait times for neurosurgical procedures.METHODSThe authors performed a retrospective chart review of nonemergency neurosurgical procedures performed over two periods—from June 1, 2014, to October 31, 2014 (pre–policy change) and from June 1, 2016, to October 31, 2016 (post–policy change)—by any of 4 senior neurosurgeons at a single institution who were authorized to schedule overlapping cases. Information on preoperative evaluation, patient demographics, premorbid conditions, surgical variables, and postoperative course were collected and analyzed.RESULTSSix hundred fifty-three patients met inclusion criteria for complications analysis. Of these, 378 (57.9%) underwent surgery before the policy change. On multivariable regression analysis, neither overlapping surgery (odds ratio [OR] 1.072, 95% confidence interval [CI] 0.710–1.620) nor the overlapping surgery policy change (OR 1.057, 95% CI 0.700–1.596) was associated with overall complication rates. Similarly, neither overlapping surgery (OR 1.472, 95% CI 0.883–2.454) nor the overlapping surgery policy change (OR 1.251, 95% CI 0.748–2.091) was associated with numbers of serious complications. After the policy change, the percentage of procedures in which the senior assistant was a postresidency fellow increased significantly, from 11.9% to 34.2% (p < 0.001). In a multiple linear regression analysis of surgery wait times, patients undergoing surgery after the policy change had significantly longer delays from the decision to operate until the actual neurosurgical procedure (p < 0.001).CONCLUSIONSAt the authors’ institution, further restriction of overlapping surgery was not associated with a reduction in overall or serious complications. Resident involvement in neurosurgical procedures decreased significantly after the policy change, and this study suggests that wait times for neurosurgical procedures also significantly lengthened.
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Ravindra VM, Onwuzulike K, Heller RS, Quigley R, Smith J, Dailey AT, Brockmeyer DL. Chiari-related scoliosis: a single-center experience with long-term radiographic follow-up and relationship to deformity correction. J Neurosurg Pediatr 2018; 21:185-189. [PMID: 29171800 DOI: 10.3171/2017.8.peds17318] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Previous reports have addressed the short-term response of patients with Chiari-related scoliosis (CRS) to suboccipital decompression and duraplasty (SODD); however, the long-term behavior of the curve has not been well defined. The authors undertook a longitudinal study of a cohort of patients who underwent SODD for CRS to determine whether there are factors related to Chiari malformation (CM) that predict long-term scoliotic curve behavior and need for deformity correction. METHODS The authors retrospectively reviewed cases in which patients underwent SODD for CRS during a 14-year period at a single center. Clinical (age, sex, and associated disorders/syndromes) and radiographic (CM type, tonsillar descent, pBC2 line, clival-axial angle [CXA], syrinx length and level, and initial Cobb angle) information was evaluated to identify associations with the primary outcome: delayed thoracolumbar fusion for progressive scoliosis. RESULTS Twenty-eight patients were identified, but 4 were lost to follow-up and 1 underwent fusion within a year. Among the remaining 23 patients, 11 required fusion surgery at an average of 88.3 ± 15.4 months after SODD, including 7 (30%) who needed fusion more than 5 years after SODD. On univariate analysis, a lower CXA (131.5° ± 4.8° vs 146.5° ± 4.6°, p = 0.034), pBC2 > 9 mm (64% vs 25%, p = 0.06), and higher initial Cobb angle (35.1° ± 3.6° vs 22.8° ± 4.0°, p = 0.035) were associated with the need for thoracolumbar fusion. Multivariable modeling revealed that lower CXA was independently associated with a need for delayed thoracolumbar fusion (OR 1.12, p = 0.0128). CONCLUSIONS This investigation demonstrates the long-term outcome and natural history of CRS after SODD. The durability of the effect of SODD on CRS and curve behavior is poor, with late curve progression occurring in 30% of patients. Factors associated with CRS progression include an initial pBC2 > 9 mm, lower CXA, and higher Cobb angle. Lower CXA was an independent predictor of delayed thoracolumbar fusion. Further study is necessary on a larger cohort of patients to fully elucidate this relationship.
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Affiliation(s)
- Vijay M Ravindra
- 1Department of Neurosurgery, University of Utah, Primary Children's Hospital
| | - Kaine Onwuzulike
- 2Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio; and
| | - Robert S Heller
- 3Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts
| | - Robert Quigley
- 4Department of Orthopedic Surgery, Primary Children's Hospital, Salt Lake City, Utah
| | - John Smith
- 4Department of Orthopedic Surgery, Primary Children's Hospital, Salt Lake City, Utah
| | - Andrew T Dailey
- 1Department of Neurosurgery, University of Utah, Primary Children's Hospital
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50
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Mazur MD, Mahan MA, Shah LM, Dailey AT. Fate of S2-Alar-Iliac Screws After 12-Month Minimum Radiographic Follow-up: Preliminary Results. Neurosurgery 2017; 80:67-72. [PMID: 27341341 DOI: 10.1227/neu.0000000000001322] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 05/08/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND S2-alar-iliac (S2AI) screws are 1 technique for lumbopelvic fixation to improve fusion rates across the lumbosacral junction that has gained wider acceptance. The S2AI screw crosses the cortical surfaces of the sacroiliac joint (SIJ), which may improve the biomechanical strength of the instrumentation. OBJECTIVE To report preliminary radiographic outcomes of patients who underwent lumbopelvic fixation with S2AI screws with a minimum 12-month follow-up. METHODS We retrospectively reviewed adult patients who underwent lumbopelvic fixation with S2AI screws. Patients with computed tomography (CT) scans obtained preoperatively and ≥12 months postoperatively were reviewed to determine whether there was S2AI screw backout or breakage, periscrew lucency, or SIJ degeneration, and to assess L5-S1 fusion status. RESULTS Twenty-six S2AI screws in 13 patients were evaluated (mean follow-up 24.8 months [14-52 months]). Nine patients had L5-S1 interbody grafts. Partial periscrew lucency was identified in 7 S2AI screws (27%) in 5 patients (38%), and L5-S1 fusion occurred in 92% of patients. L5-S1 nonunion was seen in 1 patient (8%), who had evidence of bilateral screw loosening in the sacral portion. Four patients with screw loosening had an osseous L5-S1 fusion. No patients had radiographic evidence of progression of SIJ degeneration, experienced screw backout or breakage, required reoperation for L5-S1 nonunion, or had S2AI screw-related complication. CONCLUSION S2AI screws maintained their integrity without causing SIJ degeneration or major screw-related complications in this small retrospective series with short follow-up. Long-term results are needed to evaluate the durability of S2AI screws over time.
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Affiliation(s)
- Marcus D Mazur
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Mark A Mahan
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Lubdha M Shah
- Department of Radiology, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Andrew T Dailey
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
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