1
|
Agarwal N, Johnson SE, Bydon M, Bisson EF, Chan AK, Shabani S, Letchuman V, Michalopoulos GD, Lu DC, Wang MY, Lavadi RS, Haid RW, Knightly JJ, Sherrod BA, Gottfried ON, Shaffrey CI, Goldberg JL, Virk MS, Hussain I, Glassman SD, Shaffrey ME, Park P, Foley KT, Pennicooke B, Coric D, Slotkin JR, Upadhyaya C, Potts EA, Tumialán LM, Chou D, Fu KMG, Asher AL, Mummaneni PV. Cervical spondylotic myelopathy and driving abilities: defining the prevalence and long-term postoperative outcomes using the Quality Outcomes Database. J Neurosurg Spine 2024; 40:630-641. [PMID: 38364219 DOI: 10.3171/2023.11.spine23738] [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: 07/18/2023] [Accepted: 11/28/2023] [Indexed: 02/18/2024]
Abstract
OBJECTIVE Cervical spondylotic myelopathy (CSM) can cause significant difficulty with driving and a subsequent reduction in an individual's quality of life due to neurological deterioration. The positive impact of surgery on postoperative patient-reported driving capabilities has been seldom explored. METHODS The CSM module of the Quality Outcomes Database was utilized. Patient-reported driving ability was assessed via the driving section of the Neck Disability Index (NDI) questionnaire. This is an ordinal scale in which 0 represents the absence of symptoms while driving and 5 represents a complete inability to drive due to symptoms. Patients were considered to have an impairment in their driving ability if they reported an NDI driving score of 3 or higher (signifying impairment in driving duration due to symptoms). Multivariable logistic regression models were fitted to evaluate mediators of baseline impairment and improvement at 24 months after surgery, which was defined as an NDI driving score < 3. RESULTS A total of 1128 patients who underwent surgical intervention for CSM were included, of whom 354 (31.4%) had baseline driving impairment due to CSM. Moderate (OR 2.3) and severe (OR 6.3) neck pain, severe arm pain (OR 1.6), mild-moderate (OR 2.1) and severe (OR 2.5) impairment in hand/arm dexterity, severe impairment in leg use/walking (OR 1.9), and severe impairment of urinary function (OR 1.8) were associated with impaired driving ability at baseline. Of the 291 patients with baseline impairment and available 24-month follow-up data, 209 (71.8%) reported postoperative improvement in their driving ability. This improvement seemed to be mediated particularly through the achievement of the minimal clinically important difference (MCID) in neck pain and improvement in leg function/walking. Patients with improved driving at 24 months noted higher postoperative satisfaction (88.5% vs 62.2%, p < 0.01) and were more likely to achieve a clinically significant improvement in their quality of life (50.7% vs 37.8%, p < 0.01). CONCLUSIONS Nearly one-third of patients with CSM report impaired driving ability at presentation. Seventy-two percent of these patients reported improvements in their driving ability within 24 months of surgery. Surgical management of CSM can significantly improve patients' driving abilities at 24 months and hence patients' quality of life.
Collapse
Affiliation(s)
- Nitin Agarwal
- 1Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- 2Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- 3Neurological Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Sarah E Johnson
- 4Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Mohamad Bydon
- 4Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Erica F Bisson
- 5Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Andrew K Chan
- 6Department of Neurosurgery, Columbia University Irving Medical Center, New York, New York
| | - Saman Shabani
- 7Department of Neurological Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Vijay Letchuman
- 8Department of Neurosurgery, University of California, San Francisco, San Francisco, California
| | | | - Daniel C Lu
- 9Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California
| | - Michael Y Wang
- 10Department of Neurological Surgery, University of Miami, Miami, Florida
| | - Raj Swaroop Lavadi
- 1Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Regis W Haid
- 11Atlanta Brain and Spine Care, Atlanta, Georgia
| | - John J Knightly
- 12Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Brandon A Sherrod
- 5Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Oren N Gottfried
- 13Department of Neurosurgery, Duke University, Durham, North Carolina
| | | | - Jacob L Goldberg
- 14Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | - Michael S Virk
- 14Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | - Ibrahim Hussain
- 14Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | | | - Mark E Shaffrey
- 16Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Paul Park
- 17Department of Neurosurgery, Semmes Murphey Clinic, University of Tennessee, Memphis, Tennessee
| | - Kevin T Foley
- 17Department of Neurosurgery, Semmes Murphey Clinic, University of Tennessee, Memphis, Tennessee
| | - Brenton Pennicooke
- 18Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Domagoj Coric
- 19Neuroscience Institute, Carolina Neurosurgery & Spine Associates, Carolinas Healthcare System, Charlotte, North Carolina
| | | | - Cheerag Upadhyaya
- 21Department of Neurosurgery, University of North Carolina, Chapel Hill, North Carolina
| | - Eric A Potts
- 22Department of Neurological Surgery, Goodman Campbell Brain and Spine, Indianapolis, Indiana; and
| | - Luis M Tumialán
- 23Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Dean Chou
- 6Department of Neurosurgery, Columbia University Irving Medical Center, New York, New York
| | - Kai-Ming G Fu
- 14Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | - Anthony L Asher
- 19Neuroscience Institute, Carolina Neurosurgery & Spine Associates, Carolinas Healthcare System, Charlotte, North Carolina
| | - Praveen V Mummaneni
- 8Department of Neurosurgery, University of California, San Francisco, San Francisco, California
| |
Collapse
|
2
|
Agarwal N, DiGiorgio A, Michalopoulos GD, Letchuman V, Chan AK, Shabani S, Lavadi RS, Lu DC, Wang MY, Haid RW, Knightly JJ, Sherrod BA, Gottfried ON, Shaffrey CI, Goldberg JL, Virk MS, Hussain I, Glassman SD, Shaffrey ME, Park P, Foley KT, Pennicooke B, Coric D, Upadhyaya C, Potts EA, Tumialán LM, Fu KMG, Asher AL, Bisson EF, Chou D, Bydon M, Mummaneni PV. Impact of Educational Background on Preoperative Disease Severity and Postoperative Outcomes Among Patients With Cervical Spondylotic Myelopathy. Clin Spine Surg 2024; 37:E137-E146. [PMID: 38102749 DOI: 10.1097/bsd.0000000000001557] [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: 10/31/2022] [Accepted: 10/03/2023] [Indexed: 12/17/2023]
Abstract
STUDY DESIGN Retrospective review of a prospectively maintained database. OBJECTIVE Assess differences in preoperative status and postoperative outcomes among patients of different educational backgrounds undergoing surgical management of cervical spondylotic myelopathy (CSM). SUMMARY OF BACKGROUND DATA Patient education level (EL) has been suggested to correlate with health literacy, disease perception, socioeconomic status (SES), and access to health care. METHODS The CSM data set of the Quality Outcomes Database (QOD) was queried for patients undergoing surgical management of CSM. EL was grouped as high school or below, graduate-level, and postgraduate level. The association of EL with baseline disease severity (per patient-reported outcome measures), symptoms >3 or ≤3 months, and 24-month patient-reported outcome measures were evaluated. RESULTS Among 1141 patients with CSM, 509 (44.6%) had an EL of high school or below, 471 (41.3%) had a graduate degree, and 161 (14.1%) had obtained postgraduate education. Lower EL was statistically significantly associated with symptom duration of >3 months (odds ratio=1.68), higher arm pain numeric rating scale (NRS) (coefficient=0.5), and higher neck pain NRS (coefficient=0.79). Patients with postgraduate education had statistically significantly lower Neck Disability Index (NDI) scores (coefficient=-7.17), lower arm pain scores (coefficient=-1), and higher quality-adjusted life-years (QALY) scores (coefficient=0.06). Twenty-four months after surgery, patients of lower EL had higher NDI scores, higher pain NRS scores, and lower QALY scores ( P <0.05 in all analyses). CONCLUSIONS Among patients undergoing surgical management for CSM, those reporting a lower educational level tended to present with longer symptom duration, more disease-inflicted disability and pain, and lower QALY scores. As such, patients of a lower EL are a potentially vulnerable subpopulation, and their health literacy and access to care should be prioritized.
Collapse
Affiliation(s)
- Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh School of Medicine
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Anthony DiGiorgio
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA
| | | | - Vijay Letchuman
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA
| | - Andrew K Chan
- Department of Neurosurgery, Columbia University Irving Medical Center, New York City, NY
| | - Saman Shabani
- Department of Neurological Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Raj Swaroop Lavadi
- Department of Neurological Surgery, University of Pittsburgh School of Medicine
| | - Daniel C Lu
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, CA
| | - Michael Y Wang
- Department of Neurological Surgery, University of Miami, Miami, FL
| | | | | | | | | | | | - Jacob L Goldberg
- Department of Neurological Surgery, Weill Cornell Medical Center, New York, NY
| | - Michael S Virk
- Department of Neurological Surgery, Weill Cornell Medical Center, New York, NY
| | - Ibrahim Hussain
- Department of Neurological Surgery, Weill Cornell Medical Center, New York, NY
| | | | - Mark E Shaffrey
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
| | - Paul Park
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, University of Tennessee, Memphis, TN
| | - Kevin T Foley
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, University of Tennessee, Memphis, TN
| | - Brenton Pennicooke
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Domagoj Coric
- Neuroscience Institute, Carolina Neurosurgery & Spine Associates, Carolinas Healthcare System, Charlotte
| | - Cheerag Upadhyaya
- Department of Neurosurgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Eric A Potts
- Department of Neurological Surgery, Goodman Campbell Brain and Spine, Indianapolis, IN
| | - Luis M Tumialán
- Department of Neurosurgery, Barrow Neurologic Institute, Phoenix, AZ
| | - Kai-Ming G Fu
- Department of Neurological Surgery, Weill Cornell Medical Center, New York, NY
| | - Anthony L Asher
- Neuroscience Institute, Carolina Neurosurgery & Spine Associates, Carolinas Healthcare System, Charlotte
| | - Erica F Bisson
- Department of Neurosurgery, University of Utah, Salt Lake City, UT
| | - Dean Chou
- Department of Neurosurgery, Columbia University Irving Medical Center, New York City, NY
| | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Praveen V Mummaneni
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA
| |
Collapse
|
3
|
Florence TJ, Say I, Rivera J, Kim J, Li G, Holly LT, Lu DC. Methylprednisolone Following Minimally Invasive Lumbar Decompression: A Large Prospective Single-Institution Study. Spine (Phila Pa 1976) 2024; 49:506-512. [PMID: 37093030 DOI: 10.1097/brs.0000000000004660] [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: 12/13/2022] [Accepted: 02/18/2023] [Indexed: 04/25/2023]
Abstract
STUDY DESIGN Prospective randomized. OBJECTIVE Intraoperative methylprednisolone is a common adjunct following microscopic laminectomy/microdiscectomy. The goal of epidural instillation is a rapid symptomatic reduction in irritation of neural elements. There is inconsistent data supporting its use intraoperatively. To understand whether this maneuver results in any clinical effect, we performed a multiyear prospective study. SUMMARY OF BACKGROUND DATA Previous work has demonstrated equivocal effects on pain with a suggestion of an increased risk of complication. These studies tend to suffer from small sample sizes and short follow-ups. MATERIALS AND METHODS Study obtained IRB approval. During the study period from 2013 to 2019, nearly equivalent numbers of patients who had received steroids during MIS decompressions were followed. Primary outcomes included pain (visual analog scale) and disability [Oswestry Disability Index (ODI)] at 2 weeks and 4 months. Secondary outcomes included complications, readmissions, and reoperation rates during the study period. RESULTS Four hundred eighty-six patients were followed for a mean follow-up of 5.17 years. The index case was more likely to be a revision surgery in the steroid group. Across all patients, there was no difference in pain at 2 weeks or 4 months. Disability was reduced at 2 weeks in the steroid group (ODI: 16.71 vs . 21.02, P = 0.04) but not at 4 months. By subgroup analysis, this is largely explained by ODI reduction in patients with high preoperative ODI (13.00 vs . 43.43, P = 0.03). Patients in the steroid cohort were more likely to undergo subsequent spinal surgery during the study period. CONCLUSION Methylprednisolone instillation is associated with a large, transient reduction in ODI for patients with high preoperative ODI; there is no measurable effect on pain. There is equivocal effect on risk of subsequent reoperation. This issue was clarified in peer review but changes did not make it to the abstract. Therefore, the technique is likely best reserved for patients with significant preoperative disability.
Collapse
Affiliation(s)
| | | | | | | | - Gang Li
- UCLA Biostatistics, Los Angeles, CA
| | | | | |
Collapse
|
4
|
Mooney J, Nathani KR, Zeitouni D, Michalopoulos GD, Wang MY, Coric D, Chan AK, Lu DC, Sherrod BA, Gottfried ON, Shaffrey CI, Than KD, Goldberg JL, Hussain I, Virk MS, Agarwal N, Glassman SD, Shaffrey ME, Park P, Foley KT, Chou D, Slotkin JR, Tumialán LM, Upadhyaya CD, Potts EA, Fu KMG, Haid RW, Knightly JJ, Mummaneni PV, Bisson EF, Asher AL, Bydon M. Does diabetes affect outcome or reoperation rate after lumbar decompression or arthrodesis? A matched analysis of the Quality Outcomes Database data set. J Neurosurg Spine 2024; 40:331-342. [PMID: 38039534 DOI: 10.3171/2023.9.spine23522] [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: 05/13/2023] [Accepted: 09/25/2023] [Indexed: 12/03/2023]
Abstract
OBJECTIVE Diabetes mellitus (DM) is a known risk factor for postsurgical and systemic complications after lumbar spinal surgery. Smaller studies have also demonstrated diminished improvements in patient-reported outcomes (PROs), with increased reoperation and readmission rates after lumbar surgery in patients with DM. The authors aimed to examine longer-term PROs in patients with DM undergoing lumbar decompression and/or arthrodesis for degenerative pathology. METHODS The Quality Outcomes Database was queried for patients undergoing elective lumbar decompression and/or arthrodesis for degenerative pathology. Patients were grouped into DM and non-DM groups and optimally matched in a 1:1 ratio on 31 baseline variables, including the number of operated levels. Outcomes of interest were readmissions and reoperations at 30 and 90 days after surgery in addition to improvements in Oswestry Disability Index, back pain, and leg pain scores and quality-adjusted life-years at 90 days after surgery. RESULTS The matched decompression cohort comprised 7836 patients (3236 [41.3] females) with a mean age of 63.5 ± 12.6 years, and the matched arthrodesis cohort comprised 7336 patients (3907 [53.3%] females) with a mean age of 64.8 ± 10.3 years. In patients undergoing lumbar decompression, no significant differences in nonroutine discharge, length of stay (LOS), readmissions, reoperations, and PROs were observed. In patients undergoing lumbar arthrodesis, nonroutine discharge (15.7% vs 13.4%, p < 0.01), LOS (3.2 ± 2.0 vs 3.0 ± 3.5 days, p < 0.01), 30-day (6.5% vs 4.4%, p < 0.01) and 90-day (9.1% vs 7.0%, p < 0.01) readmission rates, and the 90-day reoperation rate (4.3% vs 3.2%, p = 0.01) were all significantly higher in the DM group. For DM patients undergoing lumbar arthrodesis, subgroup analyses demonstrated a significantly higher risk of poor surgical outcomes with the open approach. CONCLUSIONS Patients with and without DM undergoing lumbar spinal decompression alone have comparable readmission and reoperation rates, while those undergoing arthrodesis procedures have a higher risk of poor surgical outcomes up to 90 days after surgery. Surgeons should target optimal DM control preoperatively, particularly for patients undergoing elective lumbar arthrodesis.
Collapse
Affiliation(s)
- James Mooney
- 1Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Karim Rizwan Nathani
- 2Department of Neurologic Surgery, Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
- 3Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Daniel Zeitouni
- 4Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina
- 5Department of Neurosurgery, Atrium Health, Charlotte, North Carolina
| | - Giorgos D Michalopoulos
- 2Department of Neurologic Surgery, Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
- 3Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Michael Y Wang
- 6Department of Neurosurgery, University of Miami, Florida
| | - Domagoj Coric
- 7Neuroscience Institute, Carolina Neurosurgery & Spine Associates, Carolinas Healthcare System, Charlotte, North Carolina
| | - Andrew K Chan
- 8Department of Neurological Surgery, Columbia University, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Daniel C Lu
- 9Department of Neurosurgery, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California
| | - Brandon A Sherrod
- 10Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Oren N Gottfried
- 11Department of Neurological Surgery, Duke University Medical Center, Durham, North Carolina
| | - Christopher I Shaffrey
- 11Department of Neurological Surgery, Duke University Medical Center, Durham, North Carolina
| | - Khoi D Than
- 11Department of Neurological Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jacob L Goldberg
- 12Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | - Ibrahim Hussain
- 12Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | - Michael S Virk
- 12Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | - Nitin Agarwal
- 24Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Mark E Shaffrey
- 14Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Paul Park
- 15Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Kevin T Foley
- 16Department of Neurosurgery, University of Tennessee, Memphis, Tennessee
| | - Dean Chou
- 8Department of Neurological Surgery, Columbia University, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | | | - Luis M Tumialán
- 18Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Cheerag D Upadhyaya
- 19Department of Neurosurgery, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Eric A Potts
- 20Department of Neurological Surgery, Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Kai-Ming G Fu
- 12Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | - Regis W Haid
- 22Atlanta Brain and Spine Care, Atlanta, Georgia
| | - John J Knightly
- 23Atlantic Neurosurgical Specialists, Morristown, New Jersey; and
| | - Praveen V Mummaneni
- 21Department of Neurological Surgery, University of California, San Francisco, California
| | - Erica F Bisson
- 10Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Anthony L Asher
- 4Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina
| | - Mohamad Bydon
- 2Department of Neurologic Surgery, Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
5
|
Harary M, Chang D, Say I, Lu DC. Minimally-invasive tubular resection of thoracolumbar intradural schwannoma. Neurosurg Focus Video 2023; 9:V19. [PMID: 37854661 PMCID: PMC10580752 DOI: 10.3171/2023.6.focvid2335] [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] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/21/2023] [Indexed: 10/20/2023]
Abstract
Minimally invasive surgical (MIS) approaches to the spine are increasingly adopted for intradural pathology. In this setting, they may especially be useful to minimize risk of CSF leakage due to the decreased disruption to paraspinal musculature and minimal dead space. Herein, the authors demonstrate their technique for the resection of an intradural thoracolumbar schwannoma in a 30-year-old woman via an MIS approach using a nonexpandable tubular retractor. Salient points include the use of bayonetted instruments and the technique for dural closure in a small corridor. Indications for this technique are discussed in the context of a series of patients with intradural extramedullary lesions.
Collapse
Affiliation(s)
- Maya Harary
- Department of Neurosurgery, University of California, Los Angeles, California; and
| | - Diana Chang
- Department of Neurosurgery, University of California, Los Angeles, California; and
| | - Irene Say
- Department of Neurosurgery, University of California, San Francisco, California
| | - Daniel C. Lu
- Department of Neurosurgery, University of California, Los Angeles, California; and
| |
Collapse
|
6
|
Bisson EF, Mummaneni PV, Michalopoulos GD, El Sammak S, Chan AK, Agarwal N, Wang MY, Knightly JJ, Sherrod BA, Gottfried ON, Than KD, Shaffrey CI, Goldberg JL, Virk MS, Hussain I, Shabani S, Glassman SD, Tumialan LM, Turner JD, Uribe JS, Meyer SA, Lu DC, Buchholz AL, Upadhyaya C, Shaffrey ME, Park P, Foley KT, Coric D, Slotkin JR, Potts EA, Stroink AR, Chou D, Fu KMG, Haid RW, Asher AL, Bydon M. Sleep Disturbances in Cervical Spondylotic Myelopathy: Prevalence and Postoperative Outcomes-an Analysis From the Quality Outcomes Database. Clin Spine Surg 2023; 36:112-119. [PMID: 36920372 DOI: 10.1097/bsd.0000000000001454] [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: 10/16/2022] [Accepted: 01/25/2023] [Indexed: 03/16/2023]
Abstract
STUDY DESIGN Prospective observational study, level of evidence 1 for prognostic investigations. OBJECTIVES To evaluate the prevalence of sleep impairment and predictors of improved sleep quality 24 months postoperatively in cervical spondylotic myelopathy (CSM) using the quality outcomes database. SUMMARY OF BACKGROUND DATA Sleep disturbances are a common yet understudied symptom in CSM. MATERIALS AND METHODS The quality outcomes database was queried for patients with CSM, and sleep quality was assessed through the neck disability index sleep component at baseline and 24 months postoperatively. Multivariable logistic regressions were performed to identify risk factors of failure to improve sleep impairment and symptoms causing lingering sleep dysfunction 24 months after surgery. RESULTS Among 1135 patients with CSM, 904 (79.5%) had some degree of sleep dysfunction at baseline. At 24 months postoperatively, 72.8% of the patients with baseline sleep symptoms experienced improvement, with 42.5% reporting complete resolution. Patients who did not improve were more like to be smokers [adjusted odds ratio (aOR): 1.85], have osteoarthritis (aOR: 1.72), report baseline radicular paresthesia (aOR: 1.51), and have neck pain of ≥4/10 on a numeric rating scale. Patients with improved sleep noted higher satisfaction with surgery (88.8% vs 72.9%, aOR: 1.66) independent of improvement in other functional areas. In a multivariable analysis including pain scores and several myelopathy-related symptoms, lingering sleep dysfunction at 24 months was associated with neck pain (aOR: 1.47) and upper (aOR: 1.45) and lower (aOR: 1.52) extremity paresthesias. CONCLUSION The majority of patients presenting with CSM have associated sleep disturbances. Most patients experience sustained improvement after surgery, with almost half reporting complete resolution. Smoking, osteoarthritis, radicular paresthesia, and neck pain ≥4/10 numeric rating scale score are baseline risk factors of failure to improve sleep dysfunction. Improvement in sleep symptoms is a major driver of patient-reported satisfaction. Incomplete resolution of sleep impairment is likely due to neck pain and extremity paresthesia.
Collapse
Affiliation(s)
- Erica F Bisson
- Department of Neurological Surgery, University of Utah, Salt Lake City, UT
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA
| | - Giorgos D Michalopoulos
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN
| | - Sally El Sammak
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN
| | - Andrew K Chan
- Department of Neurological Surgery, Columbia University, The Och Spine Hospital at NewYork-Presbyterian, New York, NY
| | - Nitin Agarwal
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO
| | - Michael Y Wang
- Department of Neurosurgery, University of Miami, Miami, FL
| | | | - Brandon A Sherrod
- Department of Neurological Surgery, University of Utah, Salt Lake City, UT
| | - Oren N Gottfried
- Department of Neurological Surgery, Duke University Medical Center, Durham, NC
| | - Khoi D Than
- Department of Neurological Surgery, Duke University Medical Center, Durham, NC
| | | | - Jacob L Goldberg
- Department of Neurological Surgery, Weill Cornell Medical Center, New York
| | - Michael S Virk
- Department of Neurological Surgery, Weill Cornell Medical Center, New York
| | - Ibrahim Hussain
- Department of Neurological Surgery, Weill Cornell Medical Center, New York
| | - Saman Shabani
- Department of Neurosurgery, Medical College of Wisconsin, Wauwatosa, WI
| | | | - Louis M Tumialan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Jay D Turner
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Juan S Uribe
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | | | - Daniel C Lu
- Department of Neurosurgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA
| | - Avery L Buchholz
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
| | - Cheerag Upadhyaya
- Department of Neurosurgery, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Mark E Shaffrey
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
| | - Paul Park
- Department of Neurosurgery, University of Tennessee, Memphis, TN
| | - Kevin T Foley
- Department of Neurosurgery, University of Tennessee, Memphis, TN
| | - Domagoj Coric
- Neuroscience Institute, Carolina Neurosurgery and Spine Associates, Carolinas Healthcare System, Charlotte, NC
| | | | - Eric A Potts
- Department of Neurological Surgery, Indiana University, Goodman Campbell Brain and Spine, Indianapolis, IN
| | - Ann R Stroink
- Central Illinois Neuro Health Science, Bloomington, IL
| | - Dean Chou
- Department of Neurological Surgery, Columbia University, The Och Spine Hospital at NewYork-Presbyterian, New York, NY
| | - Kai-Ming G Fu
- Department of Neurological Surgery, Weill Cornell Medical Center, New York
| | | | - Anthony L Asher
- Neuroscience Institute, Carolina Neurosurgery and Spine Associates, Carolinas Healthcare System, Charlotte, NC
| | - Mohamad Bydon
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN
| |
Collapse
|
7
|
|
8
|
Galer EL, Huang R, Madhavan M, Wang E, Zhou Y, Leiter JC, Lu DC. Cervical Epidural Electrical Stimulation Increases Respiratory Activity through Somatostatin-Expressing Neurons in the Dorsal Cervical Spinal Cord in Rats. J Neurosci 2023; 43:419-432. [PMID: 36639888 PMCID: PMC9864577 DOI: 10.1523/jneurosci.1958-21.2022] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 09/21/2022] [Accepted: 09/29/2022] [Indexed: 12/12/2022] Open
Abstract
We tested the hypothesis that dorsal cervical epidural electrical stimulation (CEES) increases respiratory activity in male and female anesthetized rats. Respiratory frequency and minute ventilation were significantly increased when CEES was applied dorsally to the C2-C6 region of the cervical spinal cord. By injecting pseudorabies virus into the diaphragm and using c-Fos activity to identify neurons activated during CEES, we found neurons in the dorsal horn of the cervical spinal cord in which c-Fos and pseudorabies were co-localized, and these neurons expressed somatostatin (SST). Using dual viral infection to express the inhibitory Designer Receptors Exclusively Activated by Designer Drugs (DREADD), hM4D(Gi), selectively in SST-positive cells, we inhibited SST-expressing neurons by administering Clozapine N-oxide (CNO). During CNO-mediated inhibition of SST-expressing cervical spinal neurons, the respiratory excitation elicited by CEES was diminished. Thus, dorsal cervical epidural stimulation activated SST-expressing neurons in the cervical spinal cord, likely interneurons, that communicated with the respiratory pattern generating network to effect changes in ventilation.SIGNIFICANCE STATEMENT A network of pontomedullary neurons within the brainstem generates respiratory behaviors that are susceptible to modulation by a variety of inputs; spinal sensory and motor circuits modulate and adapt this output to meet the demands placed on the respiratory system. We explored dorsal cervical epidural electrical stimulation (CEES) excitation of spinal circuits to increase ventilation in rats. We identified dorsal somatostatin (SST)-expressing neurons in the cervical spinal cord that were activated (c-Fos-positive) by CEES. CEES no longer stimulated ventilation during inhibition of SST-expressing spinal neuronal activity, thereby demonstrating that spinal SST neurons participate in the activation of respiratory circuits affected by CEES. This work establishes a mechanistic foundation to repurpose a clinically accessible neuromodulatory therapy to activate respiratory circuits and stimulate ventilation.
Collapse
Affiliation(s)
- Erika L Galer
- Department of Neurosurgery, University of California Los Angeles, Los Angeles 90095, California
- Department of Molecular Cellular and Integrative Physiology, University of California Los Angeles, Los Angeles 90095, California
| | - Ruyi Huang
- Department of Neurosurgery, University of California Los Angeles, Los Angeles 90095, California
| | - Meghna Madhavan
- Department of Neurosurgery, University of California Los Angeles, Los Angeles 90095, California
| | - Emily Wang
- Department of Neurosurgery, University of California Los Angeles, Los Angeles 90095, California
| | - Yan Zhou
- Department of Neurosurgery, University of California Los Angeles, Los Angeles 90095, California
| | - James C Leiter
- Department of Neurosurgery, University of California Los Angeles, Los Angeles 90095, California
- Research Service, White River Junction VA Medical Center, White River Junction 05009, Vermont
| | - Daniel C Lu
- Department of Neurosurgery, University of California Los Angeles, Los Angeles 90095, California
- Department of Molecular Cellular and Integrative Physiology, University of California Los Angeles, Los Angeles 90095, California
- Brain Research Institute, University of California Los Angeles, Los Angeles 90095, California
| |
Collapse
|
9
|
Zhao Y, Wang B, Tan J, Yin H, Huang R, Zhu J, Lin S, Zhou Y, Jelinek D, Sun Z, Youssef K, Voisin L, Horrillo A, Zhang K, Wu BM, Coller HA, Lu DC, Pei Q, Emaminejad S. Soft strain-insensitive bioelectronics featuring brittle materials. Science 2022; 378:1222-1227. [PMID: 36520906 DOI: 10.1126/science.abn5142] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Advancing electronics to interact with tissue necessitates meeting material constraints in electrochemical, electrical, and mechanical domains simultaneously. Clinical bioelectrodes with established electrochemical functionalities are rigid and mechanically mismatched with tissue. Whereas conductive materials with tissue-like softness and stretchability are demonstrated, when applied to electrochemically probe tissue, their performance is distorted by strain and corrosion. We devise a layered architectural composite design that couples strain-induced cracked films with a strain-isolated out-of-plane conductive pathway and in-plane nanowire networks to eliminate strain effects on device electrochemical performance. Accordingly, we developed a library of stretchable, highly conductive, and strain-insensitive bioelectrodes featuring clinically established brittle interfacial materials (iridium-oxide, gold, platinum, and carbon). We paired these bioelectrodes with different electrochemical probing methods (amperometry, voltammetry, and potentiometry) and demonstrated strain-insensitive sensing of multiple biomarkers and in vivo neuromodulation.
Collapse
Affiliation(s)
- Yichao Zhao
- Interconnected and Integrated Bioelectronics Lab (I²BL), Department of Electrical and Computer Engineering, Samueli School of Engineering, University of California, Los Angeles, CA, USA.,Department of Materials Science and Engineering, Samueli School of Engineering, University of California, Los Angeles, CA, USA
| | - Bo Wang
- Interconnected and Integrated Bioelectronics Lab (IBL), Department of Electrical and Computer Engineering, Samueli School of Engineering, University of California, Los Angeles, CA, USA
| | - Jiawei Tan
- Interconnected and Integrated Bioelectronics Lab (IBL), Department of Electrical and Computer Engineering, Samueli School of Engineering, University of California, Los Angeles, CA, USA.,Department of Materials Science and Engineering, Samueli School of Engineering, University of California, Los Angeles, CA, USA
| | - Hexing Yin
- Department of Materials Science and Engineering, Samueli School of Engineering, University of California, Los Angeles, CA, USA
| | - Ruyi Huang
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,Neuromotor Recovery and Rehabilitation Center, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,Brain Research Institute, University of California, Los Angeles, CA, USA
| | - Jialun Zhu
- Interconnected and Integrated Bioelectronics Lab (IBL), Department of Electrical and Computer Engineering, Samueli School of Engineering, University of California, Los Angeles, CA, USA
| | - Shuyu Lin
- Interconnected and Integrated Bioelectronics Lab (IBL), Department of Electrical and Computer Engineering, Samueli School of Engineering, University of California, Los Angeles, CA, USA
| | - Yan Zhou
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,Neuromotor Recovery and Rehabilitation Center, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - David Jelinek
- Department of Molecular, Cell and Developmental Biology, University of California, Los Angeles, CA, USA.,Department of Biological Chemistry, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Zhengyang Sun
- Department of Molecular, Cell and Developmental Biology, University of California, Los Angeles, CA, USA
| | - Kareem Youssef
- Department of Materials Science and Engineering, Samueli School of Engineering, University of California, Los Angeles, CA, USA
| | - Laurent Voisin
- Department of Molecular, Cell and Developmental Biology, University of California, Los Angeles, CA, USA
| | - Abraham Horrillo
- Department of Molecular, Cell and Developmental Biology, University of California, Los Angeles, CA, USA
| | - Kaiji Zhang
- Interconnected and Integrated Bioelectronics Lab (IBL), Department of Electrical and Computer Engineering, Samueli School of Engineering, University of California, Los Angeles, CA, USA.,Department of Materials Science and Engineering, Samueli School of Engineering, University of California, Los Angeles, CA, USA
| | - Benjamin M Wu
- Department of Materials Science and Engineering, Samueli School of Engineering, University of California, Los Angeles, CA, USA.,Weintraub Center for Reconstructive Biotechnology, School of Dentistry, University of California, Los Angeles, CA, USA.,Division of Advanced Prosthodontics, School of Dentistry, University of California, Los Angeles, CA, USA.,Department of Bioengineering, Samueli School of Engineering, University of California, Los Angeles, CA, USA.,Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Hilary A Coller
- Department of Molecular, Cell and Developmental Biology, University of California, Los Angeles, CA, USA.,Department of Biological Chemistry, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,Molecular Biology Institute, University of California, Los Angeles, CA, USA
| | - Daniel C Lu
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,Neuromotor Recovery and Rehabilitation Center, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,Brain Research Institute, University of California, Los Angeles, CA, USA
| | - Qibing Pei
- Department of Materials Science and Engineering, Samueli School of Engineering, University of California, Los Angeles, CA, USA
| | - Sam Emaminejad
- Interconnected and Integrated Bioelectronics Lab (IBL), Department of Electrical and Computer Engineering, Samueli School of Engineering, University of California, Los Angeles, CA, USA.,Department of Bioengineering, Samueli School of Engineering, University of California, Los Angeles, CA, USA
| |
Collapse
|
10
|
Say I, Chen YE, Sun MZ, Li JJ, Lu DC. Machine learning predicts improvement of functional outcomes in traumatic brain injury patients after inpatient rehabilitation. Front Rehabil Sci 2022; 3:1005168. [PMID: 36211830 PMCID: PMC9535093 DOI: 10.3389/fresc.2022.1005168] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 09/07/2022] [Indexed: 06/16/2023]
Abstract
Survivors of traumatic brain injury (TBI) have an unpredictable clinical course. This unpredictability makes clinical resource allocation for clinicians and anticipatory guidance for patients difficult. Historically, experienced clinicians and traditional statistical models have insufficiently considered all available clinical information to predict functional outcomes for a TBI patient. Here, we harness artificial intelligence and apply machine learning and statistical models to predict the Functional Independence Measure (FIM) scores after rehabilitation for traumatic brain injury (TBI) patients. Tree-based algorithmic analysis of 629 TBI patients admitted to a large acute rehabilitation facility showed statistically significant improvement in motor and cognitive FIM scores at discharge.
Collapse
Affiliation(s)
- Irene Say
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, CA, United States
| | - Yiling Elaine Chen
- Department of Statistics, University of California, Los Angeles, CA, United States
| | - Matthew Z. Sun
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, CA, United States
| | - Jingyi Jessica Li
- Department of Statistics, University of California, Los Angeles, CA, United States
| | - Daniel C. Lu
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, CA, United States
- Neuromotor Recovery and Rehabilitation Center, David Geffen School of Medicine, University of California, Los Angeles, CA, United States
- Brain Research Institute, University of California, Los Angeles, CA, United States
| |
Collapse
|
11
|
Huang R, Worrell J, Garner E, Wang S, Homsey T, Xu B, Galer EL, Zhou Y, Tavakol S, Daneshvar M, Le T, Vinters HV, Salamon N, McArthur DL, Nuwer MR, Wu I, Leiter JC, Lu DC. Epidural electrical stimulation of the cervical spinal cord opposes opioid-induced respiratory depression. J Physiol 2022; 600:2973-2999. [PMID: 35639046 DOI: 10.1113/jp282664] [Citation(s) in RCA: 2] [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] [Received: 12/06/2021] [Accepted: 03/25/2022] [Indexed: 02/02/2023] Open
Abstract
Opioid overdose suppresses brainstem respiratory circuits, causes apnoea and may result in death. Epidural electrical stimulation (EES) at the cervical spinal cord facilitated motor activity in rodents and humans, and we hypothesized that EES of the cervical spinal cord could antagonize opioid-induced respiratory depression in humans. Eighteen patients requiring surgical access to the dorsal surface of the spinal cord between C2 and C7 received EES or sham stimulation for up to 90 s at 5 or 30 Hz during complete (OFF-State) or partial suppression (ON-State) of respiration induced by remifentanil. During the ON-State, 30 Hz EES at C4 and 5 Hz EES at C3/4 increased tidal volume and decreased the end-tidal carbon dioxide level compared to pre-stimulation control levels. EES of 5 Hz at C5 and C7 increased respiratory frequency compared to pre-stimulation control levels. In the OFF-State, 30 Hz cervical EES at C3/4 terminated apnoea and induced rhythmic breathing. In cadaveric tissue obtained from a brain bank, more neurons expressed both the neurokinin 1 receptor (NK1R) and somatostatin (SST) in the cervical spinal levels responsive to EES (C3/4, C6 and C7) compared to a region non-responsive to EES (C2). Thus, the capacity of cervical EES to oppose opioid depression of respiration may be mediated by NK1R+/SST+ neurons in the dorsal cervical spinal cord. This study provides proof of principle that cervical EES may provide a novel therapeutic approach to augment respiratory activity when the neural function of the central respiratory circuits is compromised by opioids or other pathological conditions. KEY POINTS: Epidural electrical stimulation (EES) using an implanted spinal cord stimulator (SCS) is an FDA-approved method to manage chronic pain. We tested the hypothesis that cervical EES facilitates respiration during administration of opioids in 18 human subjects who were treated with low-dose remifentanil that suppressed respiration (ON-State) or high-dose remifentanil that completely inhibited breathing (OFF-State) during the course of cervical surgery. Dorsal cervical EES of the spinal cord augmented the respiratory tidal volume or increased the respiratory frequency, and the response to EES varied as a function of the stimulation frequency (5 or 30 Hz) and the cervical level stimulated (C2-C7). Short, continuous cervical EES restored a cyclic breathing pattern (eupnoea) in the OFF-State, suggesting that cervical EES reversed the opioid-induced respiratory depression. These findings add to our understanding of respiratory pattern modulation and suggest a novel mechanism to oppose the respiratory depression caused by opioids.
Collapse
Affiliation(s)
- Ruyi Huang
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,Neuromotor Recovery and Rehabilitation Center, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,Interdepartmental Program in Neuroscience, University of California, Los Angeles, CA, USA
| | - Jason Worrell
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,Neuromotor Recovery and Rehabilitation Center, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Eric Garner
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Stephanie Wang
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,Neuromotor Recovery and Rehabilitation Center, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Tali Homsey
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,Neuromotor Recovery and Rehabilitation Center, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Bo Xu
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,Neuromotor Recovery and Rehabilitation Center, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Erika L Galer
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,Neuromotor Recovery and Rehabilitation Center, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,Molecular, Cellular, Integrated Physiology Program, University of California, Los Angeles, CA, USA
| | - Yan Zhou
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,Neuromotor Recovery and Rehabilitation Center, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Sherwin Tavakol
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Meelod Daneshvar
- University of California Fresno, Department of Surgery, Fresno, CA, USA
| | - Timothy Le
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,Neuromotor Recovery and Rehabilitation Center, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Harry V Vinters
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,Brain Research Institute, University of California, Los Angeles, CA, USA
| | - Noriko Salamon
- Department of Radiology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - David L McArthur
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Marc R Nuwer
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Irene Wu
- Department of Anesthesiology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - James C Leiter
- Department of Molecular and Systems Biology, Geisel School of Medicine, Lebanon, NH, USA
| | - Daniel C Lu
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,Neuromotor Recovery and Rehabilitation Center, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,Interdepartmental Program in Neuroscience, University of California, Los Angeles, CA, USA.,Brain Research Institute, University of California, Los Angeles, CA, USA
| |
Collapse
|
12
|
Huang R, Nikooyan AA, Moore LD, Zdunowski S, Morikawa E, Sierro T, Sayenko D, Gad P, Homsey T, Le T, Madhavan MA, Abdelshahid M, Abdelshahid M, Zhou Y, Nuwer MR, Sarrafzadeh M, Edgerton VR, Leiter JC, Lu DC. Minimal handgrip force is needed for transcutaneous electrical stimulation to improve hand functions of patients with severe spinal cord injury. Sci Rep 2022; 12:7733. [PMID: 35545644 PMCID: PMC9095635 DOI: 10.1038/s41598-022-11306-5] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 04/14/2022] [Indexed: 11/09/2022] Open
Abstract
Spinal cord stimulation enhanced restoration of motor function following spinal cord injury (SCI) in unblinded studies. To determine whether training combined with transcutaneous electrical spinal cord stimulation (tSCS), with or without systemic serotonergic treatment with buspirone (busp), could improve hand function in individuals with severe hand paralysis following SCI, we assessed ten subjects in a double-blind, sham-controlled, crossover study. All treatments—busp, tSCS, and the busp plus tSCS—reduced muscle tone and spasm frequency. Buspirone did not have any discernible impact on grip force or manual dexterity when administered alone or in combination with tSCS. In contrast, grip force, sinusoidal force generation and grip-release rate improved significantly after 6 weeks of tSCS in 5 out of 10 subjects who had residual grip force within the range of 0.1–1.5 N at the baseline evaluation. Improved hand function was sustained in subjects with residual grip force 2–5 months after the tSCS and buspirone treatment. We conclude that tSCS combined with training improves hand strength and manual dexterity in subjects with SCI who have residual grip strength greater than 0.1 N. Buspirone did not significantly improve the hand function nor add to the effect of stimulation.
Collapse
Affiliation(s)
- Ruyi Huang
- Neurosurgery Department, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, 90095, USA.,Neuroplasticity and Repair Laboratory, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - Ali A Nikooyan
- Neurosurgery Department, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, 90095, USA.,School of Information, University of California, Berkeley, Berkeley, CA, 94720, USA
| | - Lisa D Moore
- Neurosurgery Department, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, 90095, USA.,Neuroplasticity and Repair Laboratory, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - Sharon Zdunowski
- Department of Neurobiology, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - Erika Morikawa
- Neurosurgery Department, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, 90095, USA.,Neuroplasticity and Repair Laboratory, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - Tiffany Sierro
- Neurosurgery Department, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | | | - Parag Gad
- Department of Neurobiology, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - Tali Homsey
- Neurosurgery Department, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, 90095, USA.,Neuroplasticity and Repair Laboratory, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - Timothy Le
- Neurosurgery Department, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, 90095, USA.,Neuroplasticity and Repair Laboratory, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - Meghna A Madhavan
- Neurosurgery Department, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, 90095, USA.,Neuroplasticity and Repair Laboratory, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - Marina Abdelshahid
- Neurosurgery Department, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - Martina Abdelshahid
- Neurosurgery Department, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - Yan Zhou
- Neurosurgery Department, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, 90095, USA.,Neuroplasticity and Repair Laboratory, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - Mark R Nuwer
- Neurosurgery Department, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, 90095, USA.,Brain Research Institute, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - Majid Sarrafzadeh
- Department of Computer Science, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - V Reggie Edgerton
- Brain Research Institute, University of California, Los Angeles, Los Angeles, CA, 90095, USA.,Department of Integrative Biology and Physiology, University of California, Los Angeles, Los Angeles, CA, 90095, USA.,Department of Neurobiology, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - James C Leiter
- White River Junction VA Medical Center, White River Junction, VT, 05009, USA
| | - Daniel C Lu
- Neurosurgery Department, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, 90095, USA. .,Neuroplasticity and Repair Laboratory, University of California, Los Angeles, Los Angeles, CA, 90095, USA. .,Brain Research Institute, University of California, Los Angeles, Los Angeles, CA, 90095, USA. .,Department of Orthopedic Surgery, University of California, Los Angeles, Los Angeles, CA, 90095, USA. .,Neuromotor Recovery and Rehabilitation Center, University of California, Los Angeles, Los Angeles, CA, 90095, USA.
| |
Collapse
|
13
|
Florence TJ, Say I, Patel KS, Unterberger A, Laiwalla A, Vivas AC, Lu DC. Neurosurgical Management of Interspinous Device Complications: A Case Series. Front Surg 2022; 9:841134. [PMID: 35372480 PMCID: PMC8965756 DOI: 10.3389/fsurg.2022.841134] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 01/27/2022] [Indexed: 11/13/2022] Open
Abstract
Background Best practice guidelines for treating lumbar stenosis include a multidisciplinary approach, ranging from conservative management with physical therapy, medication, and epidural steroid injections to surgical decompression with or without instrumentation. Marketed as an outpatient alternative to a traditional lumbar decompression, interspinous process devices (IPDs) have gained popularity as a minimally invasive stabilization procedure. IPDs have been embraced by non-surgical providers, including physiatrists and anesthesia interventional pain specialists. In the interest of patient safety, it is imperative to formally profile its safety and identify its role in the treatment paradigm for lumbar stenosis. Case Description We carried out a retrospective review at our institution of neurosurgical consultations for patients with hardware complications following the interspinous device placement procedure. Eight cases within a 3-year period were identified, and patient characteristics and management are illustrated. The series describes the migration of hardware, spinous process fracture, and worsening post-procedural back pain. Conclusions IPD placement carries procedural risk and requires a careful pre-operative evaluation of patient imaging and surgical candidacy. We recommend neurosurgical consultation and supervision for higher-risk IPD cases.
Collapse
Affiliation(s)
- T. J. Florence
- UCLA Department of Neurosurgery, Los Angeles, CA, United States
| | - Irene Say
- Department of Neurosurgery, University of Massachusetts, Worcester, MA, United States
| | - Kunal S. Patel
- UCLA Department of Neurosurgery, Los Angeles, CA, United States
| | - Ansley Unterberger
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Azim Laiwalla
- UCLA Department of Neurosurgery, Los Angeles, CA, United States
| | - Andrew C. Vivas
- UCLA Department of Neurosurgery, Los Angeles, CA, United States
| | - Daniel C. Lu
- UCLA Department of Neurosurgery, Los Angeles, CA, United States
- *Correspondence: Daniel C. Lu
| |
Collapse
|
14
|
Say I, Niu T, Thum JA, Archie MM, Chen DC, Lu DC. A novel endoscope-assisted technique for lateral lumbar interbody fusion: feasibility study, technical note, and operative video. J Neurosurg Spine 2021:1-7. [PMID: 34171832 DOI: 10.3171/2020.12.spine201326] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 12/07/2020] [Indexed: 11/06/2022]
Abstract
The lateral approach to the spine is generally well tolerated, but reports of debilitating injury to the lumbar plexus, iliac vessels, ureter, and abdominal viscera are increasingly recognized, likely related to the lack of direct visualization of these nearby structures. To minimize this complication profile, the authors describe here a novel, minimally invasive, endoscope-assisted technique for the LLIF and evaluate its clinical feasibility. Seven consecutive endoscope-assisted lateral lumbar interbody fusion (LLIF) procedures by the senior authors were reviewed for the incidence of approach-related complications. One patient had a postoperative approach-related complication. This patient developed transient ipsilateral thigh hip flexion weakness that resolved spontaneously by the 3-month follow-up. No patient experienced visceral, urological, or vascular injury, and no patient sustained a permanent neurological injury related to the procedure. The authors' preliminary experience suggests that this endoscope-assisted LLIF technique may be clinically feasible to mitigate vascular, urological, and visceral injury, especially in patients with previous abdominal surgery, anomalous anatomy, and revision operations. It provides direct visualization of at-risk structures without significant additional operative time. A larger series is needed to determine whether it reduces the incidence of lumbar plexopathy or visceral injury compared with traditional lateral approaches.
Collapse
Affiliation(s)
| | | | | | | | | | - Daniel C Lu
- 1Department of Neurosurgery.,3Neuromotor Recovery and Rehabilitation Center, David Geffen School of Medicine, and.,4Brain Research Institute, University of California, Los Angeles, California
| |
Collapse
|
15
|
Lu DC, Zador Z, Yao J, Fazlollahi F, Manley GT. Aquaporin-4 Reduces Post-Traumatic Seizure Susceptibility by Promoting Astrocytic Glial Scar Formation in Mice. J Neurotrauma 2021; 38:1193-1201. [PMID: 21939392 DOI: 10.1089/neu.2011.2114] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [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: 12/11/2022] Open
Abstract
Seizures are important neurological complications after traumatic brain injury (TBI) and are reported for up to 50% of patients with TBI. Despite several studies, no drug strategy has been able to alter the biological events leading to epileptogenesis. The glial water channel, aquaporin-4 (AQP4), was shown to facilitate cytotoxic cell swelling in ischemia and glial scar formation after stab wound injury. In this study, we examined post-traumatic seizure susceptibility of AQP4-deficient mice (AQP4-/-) after injection of pentylenetetrazole (PTZ) 1 month after controlled cortical impact (CCI) and compared them to wild-type sham injury controls. After PTZ injection, AQP4-/- mice demonstrated dramatically shortened seizure latency (120 ± 40 vs. 300 ± 70 sec; p < 0.001) and increased seizure severity (grade 7.5 ± 0.4 vs. 5.8 ± 0.4; p < 0.001) compared to their wild-type counterparts. Morphometric analysis demonstrated a significant 2-fold reduction in astrocytosis, with a concomitant increase in microgliosis in injured AQP4-null mice compared to their injured wild-type counterparts (44 ± 2 vs. 24 ± 3 cells per high power field [cells/hpf], respectively; p < 0.0001). Minocycline, an inhibitor of microglia, reversed the post-TBI epilepsy phenotype of AQP4-null mice. After minocycline treatment, AQP4-/- mice demonstrated similar latency of seizures evoked by PTZ (723 ± 35 vs. 696 ± 38 sec; p > 0.05) and severity of seizures evoked by PTZ (grade 4.0 ± 0.5 vs. 3.81 ± 0.30; p > 0.05) compared to wild-type counterparts. Immunohistochemical analysis demonstrated decreased immunostaining of microglia to levels comparable to wild-type (12 ± 2 vs. 11 ± 4 cells/hpf, respectively; p > 0.05). Taken together, these results suggest a protective role of AQP4 in post-traumatic seizure susceptibility by promoting astrogliosis, formation of a glial scar, and preventing microgliosis.
Collapse
Affiliation(s)
- Daniel C Lu
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Zsolt Zador
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Jinghua Yao
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Farbod Fazlollahi
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| |
Collapse
|
16
|
Jin B, Alam M, Tierno A, Zhong H, Roy RR, Gerasimenko Y, Lu DC, Edgerton VR. Serotonergic Facilitation of Forelimb Functional Recovery in Rats with Cervical Spinal Cord Injury. Neurotherapeutics 2021; 18:1226-1243. [PMID: 33420588 PMCID: PMC8423890 DOI: 10.1007/s13311-020-00974-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2020] [Indexed: 10/22/2022] Open
Abstract
Serotonergic agents can improve the recovery of motor ability after a spinal cord injury. Herein, we compare the effects of buspirone, a 5-HT1A receptor partial agonist, to fluoxetine, a selective serotonin reuptake inhibitor, on forelimb motor function recovery after a C4 bilateral dorsal funiculi crush in adult female rats. After injury, single pellet reaching performance and forelimb muscle activity decreased in all rats. From 1 to 6 weeks after injury, rats were tested on these tasks with and without buspirone (1-2 mg/kg) or fluoxetine (1-5 mg/kg). Reaching and grasping success rates of buspirone-treated rats improved rapidly within 2 weeks after injury and plateaued over the next 4 weeks of testing. Electromyography (EMG) from selected muscles in the dominant forelimb showed that buspirone-treated animals used new reaching strategies to achieve success after the injury. However, forelimb performance dramatically decreased within 2 weeks of buspirone withdrawal. In contrast, fluoxetine treatment resulted in a more progressive rate of improvement in forelimb performance over 8 weeks after injury. Neither buspirone nor fluoxetine significantly improved quadrupedal locomotion on the horizontal ladder test. The improved accuracy of reaching and grasping, patterns of muscle activity, and increased excitability of spinal motor-evoked potentials after buspirone administration reflect extensive reorganization of connectivity within and between supraspinal and spinal sensory-motor netxcopy works. Thus, both serotonergic drugs, buspirone and fluoxetine, neuromodulated these networks to physiological states that enabled markedly improved forelimb function after cervical spinal cord injury.
Collapse
Affiliation(s)
- Benita Jin
- Department of Integrative Biology and Physiology, University of California, Los Angeles, 610 Charles E. Young Drive, Los Angeles, CA, 90095-1527, USA
| | - Monzurul Alam
- Department of Integrative Biology and Physiology, University of California, Los Angeles, 610 Charles E. Young Drive, Los Angeles, CA, 90095-1527, USA
| | - Alexa Tierno
- Department of Integrative Biology and Physiology, University of California, Los Angeles, 610 Charles E. Young Drive, Los Angeles, CA, 90095-1527, USA
| | - Hui Zhong
- Department of Integrative Biology and Physiology, University of California, Los Angeles, 610 Charles E. Young Drive, Los Angeles, CA, 90095-1527, USA
| | - Roland R Roy
- Department of Integrative Biology and Physiology, University of California, Los Angeles, 610 Charles E. Young Drive, Los Angeles, CA, 90095-1527, USA
- Brain Research Institute, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - Yury Gerasimenko
- Department of Integrative Biology and Physiology, University of California, Los Angeles, 610 Charles E. Young Drive, Los Angeles, CA, 90095-1527, USA
- Pavlov Institute of Physiology, St. Petersburg, 199034, Russia
- Institute of Fundamental Medicine and Biology, Kazan Federal University, Kazan, 420006, Russia
| | - Daniel C Lu
- Department of Neurosurgery, University of California, Los Angeles, CA, 90095, USA
| | - V Reggie Edgerton
- Department of Integrative Biology and Physiology, University of California, Los Angeles, 610 Charles E. Young Drive, Los Angeles, CA, 90095-1527, USA.
- Brain Research Institute, University of California, Los Angeles, Los Angeles, CA, 90095, USA.
- Department of Neurosurgery, University of California, Los Angeles, CA, 90095, USA.
- Department of Neurobiology, University of California, Los Angeles, CA, 90095, USA.
- Faculty of Science, The Centre for Neuroscience and Regenerative Medicine, University of Technology Sydney, Ultimo, NSW, Australia.
- Institut Guttmann, Hospital de Neurorehabilitació, Institut Universitari adscript a la Universitat Autònoma de Barcelona, 08916, Badalona, Spain.
| |
Collapse
|
17
|
Kawabori M, Weintraub AH, Imai H, Zinkevych I, McAllister P, Steinberg GK, Frishberg BM, Yasuhara T, Chen JW, Cramer SC, Achrol AS, Schwartz NE, Suenaga J, Lu DC, Semeniv I, Nakamura H, Kondziolka D, Chida D, Kaneko T, Karasawa Y, Paadre S, Nejadnik B, Bates D, Stonehouse AH, Richardson RM, Okonkwo DO. Cell Therapy for Chronic TBI: Interim Analysis of the Randomized Controlled STEMTRA Trial. Neurology 2021; 96:e1202-e1214. [PMID: 33397772 PMCID: PMC8055341 DOI: 10.1212/wnl.0000000000011450] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 10/20/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To determine whether chronic motor deficits secondary to traumatic brain injury (TBI) can be improved by implantation of allogeneic modified bone marrow-derived mesenchymal stromal/stem cells (SB623). METHODS This 6-month interim analysis of the 1-year double-blind, randomized, surgical sham-controlled, phase 2 Stem Cell Therapy for Traumatic Brain Injury (STEMTRA) trial (NCT02416492) evaluated safety and efficacy of the stereotactic intracranial implantation of SB623 in patients with stable chronic motor deficits secondary to TBI. Patients in this multicenter trial (n = 63) underwent randomization in a 1:1:1:1 ratio to 2.5 × 106, 5.0 × 106, or 10 × 106 SB623 cells or control. Safety was assessed in patients who underwent surgery (n = 61), and efficacy was assessed in the modified intent-to-treat population of randomized patients who underwent surgery (n = 61; SB623 = 46, control = 15). RESULTS The primary efficacy endpoint of significant improvement from baseline of Fugl-Meyer Motor Scale score at 6 months for SB623-treated patients was achieved. SB623-treated patients improved by (least square [LS] mean) 8.3 (standard error 1.4) vs 2.3 (standard error 2.5) for control at 6 months, the LS mean difference was 6.0 (95% confidence interval 0.3-11.8, p = 0.040). Secondary efficacy endpoints improved from baseline but were not statistically significant vs control at 6 months. There were no dose-limiting toxicities or deaths, and 100% of SB623-treated patients experienced treatment-emergent adverse events vs 93.3% of control patients (p = 0.25). CONCLUSIONS SB623 cell implantation appeared to be safe and well tolerated, and patients implanted with SB623 experienced significant improvement from baseline motor status at 6 months compared to controls. CLINICALTRIALSGOV IDENTIFIER NCT02416492. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that implantation of SB623 was well tolerated and associated with improvement in motor status.
Collapse
Affiliation(s)
- Masahito Kawabori
- From the Department of Neurosurgery (M.K.), Hokkaido University Hospital, Sapporo, Japan; Rocky Mountain Regional Brain Injury System and University of Colorado School of Medicine (A.H.W.), Englewood; JCHO Tokyo Shinjuku Medical Center (H.I.), Japan; Ukraine Presidential Hospital (I.Z.), Kiev; New England Institute for Neurology and Headache (P.M.); New England Institute for Clinical Research (P.M.), Stamford; Department of Neurology (P.M.), Yale University, New Haven; Frank Netter School of Medicine (P.M.), Quinnipiac University, Hamden, CT; Department of Neurosurgery (G.K.S.), Department of Neurology and Neurological Sciences (N.E.S.), and Stanford Stroke Center (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; The Neurology Center of Southern California (B.M.F.), Carlsbad; Department of Neurological Surgery (T.Y.), Okayama University Graduate School of Medicine, Okayama University Hospital, Japan; Department of Neurological Surgery (J.W.C.), University of California, Irvine, School of Medicine; Department of Neurology (S.C.C.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.); Los Angeles; Department of Neurosurgery (A.S.A.), Loma Linda University Medical Center; Department of Neurosurgery (J.S.), Yokohama City University School of Medicine, Kanagawa, Japan; Department of Neurosurgery (D.C.L.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; Clinical Hospital Feofaniya (I.S.), Kiev, Ukraine; Department of Neurosurgery (H.N.), Osaka University Graduate School of Medicine, Suita, Japan; Department of Neurosurgery (D.K.), New York University and NYU Langone Medical Center, NY; SanBio, Inc (D.C., T.K., B.N., D.B.), Mountain View, CA; Department of Neurosurgery (Y.K.), University of Tokyo Hospital, Japan; Biostatistical Consulting Inc (S.P.), Lexington, MA; Watson & Stonehouse Enterprises LLC (A.H.S.), Pacific Grove, CA; Massachusetts General Hospital and Harvard Medical School (R.M.R.), Boston; and Department of Neurological Surgery (D.O.O.), University of Pittsburgh Medical Center, PA.
| | - Alan H Weintraub
- From the Department of Neurosurgery (M.K.), Hokkaido University Hospital, Sapporo, Japan; Rocky Mountain Regional Brain Injury System and University of Colorado School of Medicine (A.H.W.), Englewood; JCHO Tokyo Shinjuku Medical Center (H.I.), Japan; Ukraine Presidential Hospital (I.Z.), Kiev; New England Institute for Neurology and Headache (P.M.); New England Institute for Clinical Research (P.M.), Stamford; Department of Neurology (P.M.), Yale University, New Haven; Frank Netter School of Medicine (P.M.), Quinnipiac University, Hamden, CT; Department of Neurosurgery (G.K.S.), Department of Neurology and Neurological Sciences (N.E.S.), and Stanford Stroke Center (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; The Neurology Center of Southern California (B.M.F.), Carlsbad; Department of Neurological Surgery (T.Y.), Okayama University Graduate School of Medicine, Okayama University Hospital, Japan; Department of Neurological Surgery (J.W.C.), University of California, Irvine, School of Medicine; Department of Neurology (S.C.C.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.); Los Angeles; Department of Neurosurgery (A.S.A.), Loma Linda University Medical Center; Department of Neurosurgery (J.S.), Yokohama City University School of Medicine, Kanagawa, Japan; Department of Neurosurgery (D.C.L.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; Clinical Hospital Feofaniya (I.S.), Kiev, Ukraine; Department of Neurosurgery (H.N.), Osaka University Graduate School of Medicine, Suita, Japan; Department of Neurosurgery (D.K.), New York University and NYU Langone Medical Center, NY; SanBio, Inc (D.C., T.K., B.N., D.B.), Mountain View, CA; Department of Neurosurgery (Y.K.), University of Tokyo Hospital, Japan; Biostatistical Consulting Inc (S.P.), Lexington, MA; Watson & Stonehouse Enterprises LLC (A.H.S.), Pacific Grove, CA; Massachusetts General Hospital and Harvard Medical School (R.M.R.), Boston; and Department of Neurological Surgery (D.O.O.), University of Pittsburgh Medical Center, PA
| | - Hideaki Imai
- From the Department of Neurosurgery (M.K.), Hokkaido University Hospital, Sapporo, Japan; Rocky Mountain Regional Brain Injury System and University of Colorado School of Medicine (A.H.W.), Englewood; JCHO Tokyo Shinjuku Medical Center (H.I.), Japan; Ukraine Presidential Hospital (I.Z.), Kiev; New England Institute for Neurology and Headache (P.M.); New England Institute for Clinical Research (P.M.), Stamford; Department of Neurology (P.M.), Yale University, New Haven; Frank Netter School of Medicine (P.M.), Quinnipiac University, Hamden, CT; Department of Neurosurgery (G.K.S.), Department of Neurology and Neurological Sciences (N.E.S.), and Stanford Stroke Center (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; The Neurology Center of Southern California (B.M.F.), Carlsbad; Department of Neurological Surgery (T.Y.), Okayama University Graduate School of Medicine, Okayama University Hospital, Japan; Department of Neurological Surgery (J.W.C.), University of California, Irvine, School of Medicine; Department of Neurology (S.C.C.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.); Los Angeles; Department of Neurosurgery (A.S.A.), Loma Linda University Medical Center; Department of Neurosurgery (J.S.), Yokohama City University School of Medicine, Kanagawa, Japan; Department of Neurosurgery (D.C.L.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; Clinical Hospital Feofaniya (I.S.), Kiev, Ukraine; Department of Neurosurgery (H.N.), Osaka University Graduate School of Medicine, Suita, Japan; Department of Neurosurgery (D.K.), New York University and NYU Langone Medical Center, NY; SanBio, Inc (D.C., T.K., B.N., D.B.), Mountain View, CA; Department of Neurosurgery (Y.K.), University of Tokyo Hospital, Japan; Biostatistical Consulting Inc (S.P.), Lexington, MA; Watson & Stonehouse Enterprises LLC (A.H.S.), Pacific Grove, CA; Massachusetts General Hospital and Harvard Medical School (R.M.R.), Boston; and Department of Neurological Surgery (D.O.O.), University of Pittsburgh Medical Center, PA
| | - Iaroslav Zinkevych
- From the Department of Neurosurgery (M.K.), Hokkaido University Hospital, Sapporo, Japan; Rocky Mountain Regional Brain Injury System and University of Colorado School of Medicine (A.H.W.), Englewood; JCHO Tokyo Shinjuku Medical Center (H.I.), Japan; Ukraine Presidential Hospital (I.Z.), Kiev; New England Institute for Neurology and Headache (P.M.); New England Institute for Clinical Research (P.M.), Stamford; Department of Neurology (P.M.), Yale University, New Haven; Frank Netter School of Medicine (P.M.), Quinnipiac University, Hamden, CT; Department of Neurosurgery (G.K.S.), Department of Neurology and Neurological Sciences (N.E.S.), and Stanford Stroke Center (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; The Neurology Center of Southern California (B.M.F.), Carlsbad; Department of Neurological Surgery (T.Y.), Okayama University Graduate School of Medicine, Okayama University Hospital, Japan; Department of Neurological Surgery (J.W.C.), University of California, Irvine, School of Medicine; Department of Neurology (S.C.C.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.); Los Angeles; Department of Neurosurgery (A.S.A.), Loma Linda University Medical Center; Department of Neurosurgery (J.S.), Yokohama City University School of Medicine, Kanagawa, Japan; Department of Neurosurgery (D.C.L.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; Clinical Hospital Feofaniya (I.S.), Kiev, Ukraine; Department of Neurosurgery (H.N.), Osaka University Graduate School of Medicine, Suita, Japan; Department of Neurosurgery (D.K.), New York University and NYU Langone Medical Center, NY; SanBio, Inc (D.C., T.K., B.N., D.B.), Mountain View, CA; Department of Neurosurgery (Y.K.), University of Tokyo Hospital, Japan; Biostatistical Consulting Inc (S.P.), Lexington, MA; Watson & Stonehouse Enterprises LLC (A.H.S.), Pacific Grove, CA; Massachusetts General Hospital and Harvard Medical School (R.M.R.), Boston; and Department of Neurological Surgery (D.O.O.), University of Pittsburgh Medical Center, PA
| | - Peter McAllister
- From the Department of Neurosurgery (M.K.), Hokkaido University Hospital, Sapporo, Japan; Rocky Mountain Regional Brain Injury System and University of Colorado School of Medicine (A.H.W.), Englewood; JCHO Tokyo Shinjuku Medical Center (H.I.), Japan; Ukraine Presidential Hospital (I.Z.), Kiev; New England Institute for Neurology and Headache (P.M.); New England Institute for Clinical Research (P.M.), Stamford; Department of Neurology (P.M.), Yale University, New Haven; Frank Netter School of Medicine (P.M.), Quinnipiac University, Hamden, CT; Department of Neurosurgery (G.K.S.), Department of Neurology and Neurological Sciences (N.E.S.), and Stanford Stroke Center (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; The Neurology Center of Southern California (B.M.F.), Carlsbad; Department of Neurological Surgery (T.Y.), Okayama University Graduate School of Medicine, Okayama University Hospital, Japan; Department of Neurological Surgery (J.W.C.), University of California, Irvine, School of Medicine; Department of Neurology (S.C.C.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.); Los Angeles; Department of Neurosurgery (A.S.A.), Loma Linda University Medical Center; Department of Neurosurgery (J.S.), Yokohama City University School of Medicine, Kanagawa, Japan; Department of Neurosurgery (D.C.L.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; Clinical Hospital Feofaniya (I.S.), Kiev, Ukraine; Department of Neurosurgery (H.N.), Osaka University Graduate School of Medicine, Suita, Japan; Department of Neurosurgery (D.K.), New York University and NYU Langone Medical Center, NY; SanBio, Inc (D.C., T.K., B.N., D.B.), Mountain View, CA; Department of Neurosurgery (Y.K.), University of Tokyo Hospital, Japan; Biostatistical Consulting Inc (S.P.), Lexington, MA; Watson & Stonehouse Enterprises LLC (A.H.S.), Pacific Grove, CA; Massachusetts General Hospital and Harvard Medical School (R.M.R.), Boston; and Department of Neurological Surgery (D.O.O.), University of Pittsburgh Medical Center, PA
| | - Gary K Steinberg
- From the Department of Neurosurgery (M.K.), Hokkaido University Hospital, Sapporo, Japan; Rocky Mountain Regional Brain Injury System and University of Colorado School of Medicine (A.H.W.), Englewood; JCHO Tokyo Shinjuku Medical Center (H.I.), Japan; Ukraine Presidential Hospital (I.Z.), Kiev; New England Institute for Neurology and Headache (P.M.); New England Institute for Clinical Research (P.M.), Stamford; Department of Neurology (P.M.), Yale University, New Haven; Frank Netter School of Medicine (P.M.), Quinnipiac University, Hamden, CT; Department of Neurosurgery (G.K.S.), Department of Neurology and Neurological Sciences (N.E.S.), and Stanford Stroke Center (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; The Neurology Center of Southern California (B.M.F.), Carlsbad; Department of Neurological Surgery (T.Y.), Okayama University Graduate School of Medicine, Okayama University Hospital, Japan; Department of Neurological Surgery (J.W.C.), University of California, Irvine, School of Medicine; Department of Neurology (S.C.C.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.); Los Angeles; Department of Neurosurgery (A.S.A.), Loma Linda University Medical Center; Department of Neurosurgery (J.S.), Yokohama City University School of Medicine, Kanagawa, Japan; Department of Neurosurgery (D.C.L.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; Clinical Hospital Feofaniya (I.S.), Kiev, Ukraine; Department of Neurosurgery (H.N.), Osaka University Graduate School of Medicine, Suita, Japan; Department of Neurosurgery (D.K.), New York University and NYU Langone Medical Center, NY; SanBio, Inc (D.C., T.K., B.N., D.B.), Mountain View, CA; Department of Neurosurgery (Y.K.), University of Tokyo Hospital, Japan; Biostatistical Consulting Inc (S.P.), Lexington, MA; Watson & Stonehouse Enterprises LLC (A.H.S.), Pacific Grove, CA; Massachusetts General Hospital and Harvard Medical School (R.M.R.), Boston; and Department of Neurological Surgery (D.O.O.), University of Pittsburgh Medical Center, PA
| | - Benjamin M Frishberg
- From the Department of Neurosurgery (M.K.), Hokkaido University Hospital, Sapporo, Japan; Rocky Mountain Regional Brain Injury System and University of Colorado School of Medicine (A.H.W.), Englewood; JCHO Tokyo Shinjuku Medical Center (H.I.), Japan; Ukraine Presidential Hospital (I.Z.), Kiev; New England Institute for Neurology and Headache (P.M.); New England Institute for Clinical Research (P.M.), Stamford; Department of Neurology (P.M.), Yale University, New Haven; Frank Netter School of Medicine (P.M.), Quinnipiac University, Hamden, CT; Department of Neurosurgery (G.K.S.), Department of Neurology and Neurological Sciences (N.E.S.), and Stanford Stroke Center (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; The Neurology Center of Southern California (B.M.F.), Carlsbad; Department of Neurological Surgery (T.Y.), Okayama University Graduate School of Medicine, Okayama University Hospital, Japan; Department of Neurological Surgery (J.W.C.), University of California, Irvine, School of Medicine; Department of Neurology (S.C.C.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.); Los Angeles; Department of Neurosurgery (A.S.A.), Loma Linda University Medical Center; Department of Neurosurgery (J.S.), Yokohama City University School of Medicine, Kanagawa, Japan; Department of Neurosurgery (D.C.L.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; Clinical Hospital Feofaniya (I.S.), Kiev, Ukraine; Department of Neurosurgery (H.N.), Osaka University Graduate School of Medicine, Suita, Japan; Department of Neurosurgery (D.K.), New York University and NYU Langone Medical Center, NY; SanBio, Inc (D.C., T.K., B.N., D.B.), Mountain View, CA; Department of Neurosurgery (Y.K.), University of Tokyo Hospital, Japan; Biostatistical Consulting Inc (S.P.), Lexington, MA; Watson & Stonehouse Enterprises LLC (A.H.S.), Pacific Grove, CA; Massachusetts General Hospital and Harvard Medical School (R.M.R.), Boston; and Department of Neurological Surgery (D.O.O.), University of Pittsburgh Medical Center, PA
| | - Takao Yasuhara
- From the Department of Neurosurgery (M.K.), Hokkaido University Hospital, Sapporo, Japan; Rocky Mountain Regional Brain Injury System and University of Colorado School of Medicine (A.H.W.), Englewood; JCHO Tokyo Shinjuku Medical Center (H.I.), Japan; Ukraine Presidential Hospital (I.Z.), Kiev; New England Institute for Neurology and Headache (P.M.); New England Institute for Clinical Research (P.M.), Stamford; Department of Neurology (P.M.), Yale University, New Haven; Frank Netter School of Medicine (P.M.), Quinnipiac University, Hamden, CT; Department of Neurosurgery (G.K.S.), Department of Neurology and Neurological Sciences (N.E.S.), and Stanford Stroke Center (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; The Neurology Center of Southern California (B.M.F.), Carlsbad; Department of Neurological Surgery (T.Y.), Okayama University Graduate School of Medicine, Okayama University Hospital, Japan; Department of Neurological Surgery (J.W.C.), University of California, Irvine, School of Medicine; Department of Neurology (S.C.C.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.); Los Angeles; Department of Neurosurgery (A.S.A.), Loma Linda University Medical Center; Department of Neurosurgery (J.S.), Yokohama City University School of Medicine, Kanagawa, Japan; Department of Neurosurgery (D.C.L.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; Clinical Hospital Feofaniya (I.S.), Kiev, Ukraine; Department of Neurosurgery (H.N.), Osaka University Graduate School of Medicine, Suita, Japan; Department of Neurosurgery (D.K.), New York University and NYU Langone Medical Center, NY; SanBio, Inc (D.C., T.K., B.N., D.B.), Mountain View, CA; Department of Neurosurgery (Y.K.), University of Tokyo Hospital, Japan; Biostatistical Consulting Inc (S.P.), Lexington, MA; Watson & Stonehouse Enterprises LLC (A.H.S.), Pacific Grove, CA; Massachusetts General Hospital and Harvard Medical School (R.M.R.), Boston; and Department of Neurological Surgery (D.O.O.), University of Pittsburgh Medical Center, PA
| | - Jefferson W Chen
- From the Department of Neurosurgery (M.K.), Hokkaido University Hospital, Sapporo, Japan; Rocky Mountain Regional Brain Injury System and University of Colorado School of Medicine (A.H.W.), Englewood; JCHO Tokyo Shinjuku Medical Center (H.I.), Japan; Ukraine Presidential Hospital (I.Z.), Kiev; New England Institute for Neurology and Headache (P.M.); New England Institute for Clinical Research (P.M.), Stamford; Department of Neurology (P.M.), Yale University, New Haven; Frank Netter School of Medicine (P.M.), Quinnipiac University, Hamden, CT; Department of Neurosurgery (G.K.S.), Department of Neurology and Neurological Sciences (N.E.S.), and Stanford Stroke Center (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; The Neurology Center of Southern California (B.M.F.), Carlsbad; Department of Neurological Surgery (T.Y.), Okayama University Graduate School of Medicine, Okayama University Hospital, Japan; Department of Neurological Surgery (J.W.C.), University of California, Irvine, School of Medicine; Department of Neurology (S.C.C.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.); Los Angeles; Department of Neurosurgery (A.S.A.), Loma Linda University Medical Center; Department of Neurosurgery (J.S.), Yokohama City University School of Medicine, Kanagawa, Japan; Department of Neurosurgery (D.C.L.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; Clinical Hospital Feofaniya (I.S.), Kiev, Ukraine; Department of Neurosurgery (H.N.), Osaka University Graduate School of Medicine, Suita, Japan; Department of Neurosurgery (D.K.), New York University and NYU Langone Medical Center, NY; SanBio, Inc (D.C., T.K., B.N., D.B.), Mountain View, CA; Department of Neurosurgery (Y.K.), University of Tokyo Hospital, Japan; Biostatistical Consulting Inc (S.P.), Lexington, MA; Watson & Stonehouse Enterprises LLC (A.H.S.), Pacific Grove, CA; Massachusetts General Hospital and Harvard Medical School (R.M.R.), Boston; and Department of Neurological Surgery (D.O.O.), University of Pittsburgh Medical Center, PA
| | - Steven C Cramer
- From the Department of Neurosurgery (M.K.), Hokkaido University Hospital, Sapporo, Japan; Rocky Mountain Regional Brain Injury System and University of Colorado School of Medicine (A.H.W.), Englewood; JCHO Tokyo Shinjuku Medical Center (H.I.), Japan; Ukraine Presidential Hospital (I.Z.), Kiev; New England Institute for Neurology and Headache (P.M.); New England Institute for Clinical Research (P.M.), Stamford; Department of Neurology (P.M.), Yale University, New Haven; Frank Netter School of Medicine (P.M.), Quinnipiac University, Hamden, CT; Department of Neurosurgery (G.K.S.), Department of Neurology and Neurological Sciences (N.E.S.), and Stanford Stroke Center (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; The Neurology Center of Southern California (B.M.F.), Carlsbad; Department of Neurological Surgery (T.Y.), Okayama University Graduate School of Medicine, Okayama University Hospital, Japan; Department of Neurological Surgery (J.W.C.), University of California, Irvine, School of Medicine; Department of Neurology (S.C.C.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.); Los Angeles; Department of Neurosurgery (A.S.A.), Loma Linda University Medical Center; Department of Neurosurgery (J.S.), Yokohama City University School of Medicine, Kanagawa, Japan; Department of Neurosurgery (D.C.L.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; Clinical Hospital Feofaniya (I.S.), Kiev, Ukraine; Department of Neurosurgery (H.N.), Osaka University Graduate School of Medicine, Suita, Japan; Department of Neurosurgery (D.K.), New York University and NYU Langone Medical Center, NY; SanBio, Inc (D.C., T.K., B.N., D.B.), Mountain View, CA; Department of Neurosurgery (Y.K.), University of Tokyo Hospital, Japan; Biostatistical Consulting Inc (S.P.), Lexington, MA; Watson & Stonehouse Enterprises LLC (A.H.S.), Pacific Grove, CA; Massachusetts General Hospital and Harvard Medical School (R.M.R.), Boston; and Department of Neurological Surgery (D.O.O.), University of Pittsburgh Medical Center, PA
| | - Achal S Achrol
- From the Department of Neurosurgery (M.K.), Hokkaido University Hospital, Sapporo, Japan; Rocky Mountain Regional Brain Injury System and University of Colorado School of Medicine (A.H.W.), Englewood; JCHO Tokyo Shinjuku Medical Center (H.I.), Japan; Ukraine Presidential Hospital (I.Z.), Kiev; New England Institute for Neurology and Headache (P.M.); New England Institute for Clinical Research (P.M.), Stamford; Department of Neurology (P.M.), Yale University, New Haven; Frank Netter School of Medicine (P.M.), Quinnipiac University, Hamden, CT; Department of Neurosurgery (G.K.S.), Department of Neurology and Neurological Sciences (N.E.S.), and Stanford Stroke Center (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; The Neurology Center of Southern California (B.M.F.), Carlsbad; Department of Neurological Surgery (T.Y.), Okayama University Graduate School of Medicine, Okayama University Hospital, Japan; Department of Neurological Surgery (J.W.C.), University of California, Irvine, School of Medicine; Department of Neurology (S.C.C.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.); Los Angeles; Department of Neurosurgery (A.S.A.), Loma Linda University Medical Center; Department of Neurosurgery (J.S.), Yokohama City University School of Medicine, Kanagawa, Japan; Department of Neurosurgery (D.C.L.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; Clinical Hospital Feofaniya (I.S.), Kiev, Ukraine; Department of Neurosurgery (H.N.), Osaka University Graduate School of Medicine, Suita, Japan; Department of Neurosurgery (D.K.), New York University and NYU Langone Medical Center, NY; SanBio, Inc (D.C., T.K., B.N., D.B.), Mountain View, CA; Department of Neurosurgery (Y.K.), University of Tokyo Hospital, Japan; Biostatistical Consulting Inc (S.P.), Lexington, MA; Watson & Stonehouse Enterprises LLC (A.H.S.), Pacific Grove, CA; Massachusetts General Hospital and Harvard Medical School (R.M.R.), Boston; and Department of Neurological Surgery (D.O.O.), University of Pittsburgh Medical Center, PA
| | - Neil E Schwartz
- From the Department of Neurosurgery (M.K.), Hokkaido University Hospital, Sapporo, Japan; Rocky Mountain Regional Brain Injury System and University of Colorado School of Medicine (A.H.W.), Englewood; JCHO Tokyo Shinjuku Medical Center (H.I.), Japan; Ukraine Presidential Hospital (I.Z.), Kiev; New England Institute for Neurology and Headache (P.M.); New England Institute for Clinical Research (P.M.), Stamford; Department of Neurology (P.M.), Yale University, New Haven; Frank Netter School of Medicine (P.M.), Quinnipiac University, Hamden, CT; Department of Neurosurgery (G.K.S.), Department of Neurology and Neurological Sciences (N.E.S.), and Stanford Stroke Center (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; The Neurology Center of Southern California (B.M.F.), Carlsbad; Department of Neurological Surgery (T.Y.), Okayama University Graduate School of Medicine, Okayama University Hospital, Japan; Department of Neurological Surgery (J.W.C.), University of California, Irvine, School of Medicine; Department of Neurology (S.C.C.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.); Los Angeles; Department of Neurosurgery (A.S.A.), Loma Linda University Medical Center; Department of Neurosurgery (J.S.), Yokohama City University School of Medicine, Kanagawa, Japan; Department of Neurosurgery (D.C.L.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; Clinical Hospital Feofaniya (I.S.), Kiev, Ukraine; Department of Neurosurgery (H.N.), Osaka University Graduate School of Medicine, Suita, Japan; Department of Neurosurgery (D.K.), New York University and NYU Langone Medical Center, NY; SanBio, Inc (D.C., T.K., B.N., D.B.), Mountain View, CA; Department of Neurosurgery (Y.K.), University of Tokyo Hospital, Japan; Biostatistical Consulting Inc (S.P.), Lexington, MA; Watson & Stonehouse Enterprises LLC (A.H.S.), Pacific Grove, CA; Massachusetts General Hospital and Harvard Medical School (R.M.R.), Boston; and Department of Neurological Surgery (D.O.O.), University of Pittsburgh Medical Center, PA
| | - Jun Suenaga
- From the Department of Neurosurgery (M.K.), Hokkaido University Hospital, Sapporo, Japan; Rocky Mountain Regional Brain Injury System and University of Colorado School of Medicine (A.H.W.), Englewood; JCHO Tokyo Shinjuku Medical Center (H.I.), Japan; Ukraine Presidential Hospital (I.Z.), Kiev; New England Institute for Neurology and Headache (P.M.); New England Institute for Clinical Research (P.M.), Stamford; Department of Neurology (P.M.), Yale University, New Haven; Frank Netter School of Medicine (P.M.), Quinnipiac University, Hamden, CT; Department of Neurosurgery (G.K.S.), Department of Neurology and Neurological Sciences (N.E.S.), and Stanford Stroke Center (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; The Neurology Center of Southern California (B.M.F.), Carlsbad; Department of Neurological Surgery (T.Y.), Okayama University Graduate School of Medicine, Okayama University Hospital, Japan; Department of Neurological Surgery (J.W.C.), University of California, Irvine, School of Medicine; Department of Neurology (S.C.C.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.); Los Angeles; Department of Neurosurgery (A.S.A.), Loma Linda University Medical Center; Department of Neurosurgery (J.S.), Yokohama City University School of Medicine, Kanagawa, Japan; Department of Neurosurgery (D.C.L.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; Clinical Hospital Feofaniya (I.S.), Kiev, Ukraine; Department of Neurosurgery (H.N.), Osaka University Graduate School of Medicine, Suita, Japan; Department of Neurosurgery (D.K.), New York University and NYU Langone Medical Center, NY; SanBio, Inc (D.C., T.K., B.N., D.B.), Mountain View, CA; Department of Neurosurgery (Y.K.), University of Tokyo Hospital, Japan; Biostatistical Consulting Inc (S.P.), Lexington, MA; Watson & Stonehouse Enterprises LLC (A.H.S.), Pacific Grove, CA; Massachusetts General Hospital and Harvard Medical School (R.M.R.), Boston; and Department of Neurological Surgery (D.O.O.), University of Pittsburgh Medical Center, PA
| | - Daniel C Lu
- From the Department of Neurosurgery (M.K.), Hokkaido University Hospital, Sapporo, Japan; Rocky Mountain Regional Brain Injury System and University of Colorado School of Medicine (A.H.W.), Englewood; JCHO Tokyo Shinjuku Medical Center (H.I.), Japan; Ukraine Presidential Hospital (I.Z.), Kiev; New England Institute for Neurology and Headache (P.M.); New England Institute for Clinical Research (P.M.), Stamford; Department of Neurology (P.M.), Yale University, New Haven; Frank Netter School of Medicine (P.M.), Quinnipiac University, Hamden, CT; Department of Neurosurgery (G.K.S.), Department of Neurology and Neurological Sciences (N.E.S.), and Stanford Stroke Center (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; The Neurology Center of Southern California (B.M.F.), Carlsbad; Department of Neurological Surgery (T.Y.), Okayama University Graduate School of Medicine, Okayama University Hospital, Japan; Department of Neurological Surgery (J.W.C.), University of California, Irvine, School of Medicine; Department of Neurology (S.C.C.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.); Los Angeles; Department of Neurosurgery (A.S.A.), Loma Linda University Medical Center; Department of Neurosurgery (J.S.), Yokohama City University School of Medicine, Kanagawa, Japan; Department of Neurosurgery (D.C.L.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; Clinical Hospital Feofaniya (I.S.), Kiev, Ukraine; Department of Neurosurgery (H.N.), Osaka University Graduate School of Medicine, Suita, Japan; Department of Neurosurgery (D.K.), New York University and NYU Langone Medical Center, NY; SanBio, Inc (D.C., T.K., B.N., D.B.), Mountain View, CA; Department of Neurosurgery (Y.K.), University of Tokyo Hospital, Japan; Biostatistical Consulting Inc (S.P.), Lexington, MA; Watson & Stonehouse Enterprises LLC (A.H.S.), Pacific Grove, CA; Massachusetts General Hospital and Harvard Medical School (R.M.R.), Boston; and Department of Neurological Surgery (D.O.O.), University of Pittsburgh Medical Center, PA
| | - Ihor Semeniv
- From the Department of Neurosurgery (M.K.), Hokkaido University Hospital, Sapporo, Japan; Rocky Mountain Regional Brain Injury System and University of Colorado School of Medicine (A.H.W.), Englewood; JCHO Tokyo Shinjuku Medical Center (H.I.), Japan; Ukraine Presidential Hospital (I.Z.), Kiev; New England Institute for Neurology and Headache (P.M.); New England Institute for Clinical Research (P.M.), Stamford; Department of Neurology (P.M.), Yale University, New Haven; Frank Netter School of Medicine (P.M.), Quinnipiac University, Hamden, CT; Department of Neurosurgery (G.K.S.), Department of Neurology and Neurological Sciences (N.E.S.), and Stanford Stroke Center (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; The Neurology Center of Southern California (B.M.F.), Carlsbad; Department of Neurological Surgery (T.Y.), Okayama University Graduate School of Medicine, Okayama University Hospital, Japan; Department of Neurological Surgery (J.W.C.), University of California, Irvine, School of Medicine; Department of Neurology (S.C.C.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.); Los Angeles; Department of Neurosurgery (A.S.A.), Loma Linda University Medical Center; Department of Neurosurgery (J.S.), Yokohama City University School of Medicine, Kanagawa, Japan; Department of Neurosurgery (D.C.L.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; Clinical Hospital Feofaniya (I.S.), Kiev, Ukraine; Department of Neurosurgery (H.N.), Osaka University Graduate School of Medicine, Suita, Japan; Department of Neurosurgery (D.K.), New York University and NYU Langone Medical Center, NY; SanBio, Inc (D.C., T.K., B.N., D.B.), Mountain View, CA; Department of Neurosurgery (Y.K.), University of Tokyo Hospital, Japan; Biostatistical Consulting Inc (S.P.), Lexington, MA; Watson & Stonehouse Enterprises LLC (A.H.S.), Pacific Grove, CA; Massachusetts General Hospital and Harvard Medical School (R.M.R.), Boston; and Department of Neurological Surgery (D.O.O.), University of Pittsburgh Medical Center, PA
| | - Hajime Nakamura
- From the Department of Neurosurgery (M.K.), Hokkaido University Hospital, Sapporo, Japan; Rocky Mountain Regional Brain Injury System and University of Colorado School of Medicine (A.H.W.), Englewood; JCHO Tokyo Shinjuku Medical Center (H.I.), Japan; Ukraine Presidential Hospital (I.Z.), Kiev; New England Institute for Neurology and Headache (P.M.); New England Institute for Clinical Research (P.M.), Stamford; Department of Neurology (P.M.), Yale University, New Haven; Frank Netter School of Medicine (P.M.), Quinnipiac University, Hamden, CT; Department of Neurosurgery (G.K.S.), Department of Neurology and Neurological Sciences (N.E.S.), and Stanford Stroke Center (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; The Neurology Center of Southern California (B.M.F.), Carlsbad; Department of Neurological Surgery (T.Y.), Okayama University Graduate School of Medicine, Okayama University Hospital, Japan; Department of Neurological Surgery (J.W.C.), University of California, Irvine, School of Medicine; Department of Neurology (S.C.C.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.); Los Angeles; Department of Neurosurgery (A.S.A.), Loma Linda University Medical Center; Department of Neurosurgery (J.S.), Yokohama City University School of Medicine, Kanagawa, Japan; Department of Neurosurgery (D.C.L.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; Clinical Hospital Feofaniya (I.S.), Kiev, Ukraine; Department of Neurosurgery (H.N.), Osaka University Graduate School of Medicine, Suita, Japan; Department of Neurosurgery (D.K.), New York University and NYU Langone Medical Center, NY; SanBio, Inc (D.C., T.K., B.N., D.B.), Mountain View, CA; Department of Neurosurgery (Y.K.), University of Tokyo Hospital, Japan; Biostatistical Consulting Inc (S.P.), Lexington, MA; Watson & Stonehouse Enterprises LLC (A.H.S.), Pacific Grove, CA; Massachusetts General Hospital and Harvard Medical School (R.M.R.), Boston; and Department of Neurological Surgery (D.O.O.), University of Pittsburgh Medical Center, PA
| | - Douglas Kondziolka
- From the Department of Neurosurgery (M.K.), Hokkaido University Hospital, Sapporo, Japan; Rocky Mountain Regional Brain Injury System and University of Colorado School of Medicine (A.H.W.), Englewood; JCHO Tokyo Shinjuku Medical Center (H.I.), Japan; Ukraine Presidential Hospital (I.Z.), Kiev; New England Institute for Neurology and Headache (P.M.); New England Institute for Clinical Research (P.M.), Stamford; Department of Neurology (P.M.), Yale University, New Haven; Frank Netter School of Medicine (P.M.), Quinnipiac University, Hamden, CT; Department of Neurosurgery (G.K.S.), Department of Neurology and Neurological Sciences (N.E.S.), and Stanford Stroke Center (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; The Neurology Center of Southern California (B.M.F.), Carlsbad; Department of Neurological Surgery (T.Y.), Okayama University Graduate School of Medicine, Okayama University Hospital, Japan; Department of Neurological Surgery (J.W.C.), University of California, Irvine, School of Medicine; Department of Neurology (S.C.C.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.); Los Angeles; Department of Neurosurgery (A.S.A.), Loma Linda University Medical Center; Department of Neurosurgery (J.S.), Yokohama City University School of Medicine, Kanagawa, Japan; Department of Neurosurgery (D.C.L.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; Clinical Hospital Feofaniya (I.S.), Kiev, Ukraine; Department of Neurosurgery (H.N.), Osaka University Graduate School of Medicine, Suita, Japan; Department of Neurosurgery (D.K.), New York University and NYU Langone Medical Center, NY; SanBio, Inc (D.C., T.K., B.N., D.B.), Mountain View, CA; Department of Neurosurgery (Y.K.), University of Tokyo Hospital, Japan; Biostatistical Consulting Inc (S.P.), Lexington, MA; Watson & Stonehouse Enterprises LLC (A.H.S.), Pacific Grove, CA; Massachusetts General Hospital and Harvard Medical School (R.M.R.), Boston; and Department of Neurological Surgery (D.O.O.), University of Pittsburgh Medical Center, PA
| | - Dai Chida
- From the Department of Neurosurgery (M.K.), Hokkaido University Hospital, Sapporo, Japan; Rocky Mountain Regional Brain Injury System and University of Colorado School of Medicine (A.H.W.), Englewood; JCHO Tokyo Shinjuku Medical Center (H.I.), Japan; Ukraine Presidential Hospital (I.Z.), Kiev; New England Institute for Neurology and Headache (P.M.); New England Institute for Clinical Research (P.M.), Stamford; Department of Neurology (P.M.), Yale University, New Haven; Frank Netter School of Medicine (P.M.), Quinnipiac University, Hamden, CT; Department of Neurosurgery (G.K.S.), Department of Neurology and Neurological Sciences (N.E.S.), and Stanford Stroke Center (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; The Neurology Center of Southern California (B.M.F.), Carlsbad; Department of Neurological Surgery (T.Y.), Okayama University Graduate School of Medicine, Okayama University Hospital, Japan; Department of Neurological Surgery (J.W.C.), University of California, Irvine, School of Medicine; Department of Neurology (S.C.C.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.); Los Angeles; Department of Neurosurgery (A.S.A.), Loma Linda University Medical Center; Department of Neurosurgery (J.S.), Yokohama City University School of Medicine, Kanagawa, Japan; Department of Neurosurgery (D.C.L.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; Clinical Hospital Feofaniya (I.S.), Kiev, Ukraine; Department of Neurosurgery (H.N.), Osaka University Graduate School of Medicine, Suita, Japan; Department of Neurosurgery (D.K.), New York University and NYU Langone Medical Center, NY; SanBio, Inc (D.C., T.K., B.N., D.B.), Mountain View, CA; Department of Neurosurgery (Y.K.), University of Tokyo Hospital, Japan; Biostatistical Consulting Inc (S.P.), Lexington, MA; Watson & Stonehouse Enterprises LLC (A.H.S.), Pacific Grove, CA; Massachusetts General Hospital and Harvard Medical School (R.M.R.), Boston; and Department of Neurological Surgery (D.O.O.), University of Pittsburgh Medical Center, PA
| | - Takehiko Kaneko
- From the Department of Neurosurgery (M.K.), Hokkaido University Hospital, Sapporo, Japan; Rocky Mountain Regional Brain Injury System and University of Colorado School of Medicine (A.H.W.), Englewood; JCHO Tokyo Shinjuku Medical Center (H.I.), Japan; Ukraine Presidential Hospital (I.Z.), Kiev; New England Institute for Neurology and Headache (P.M.); New England Institute for Clinical Research (P.M.), Stamford; Department of Neurology (P.M.), Yale University, New Haven; Frank Netter School of Medicine (P.M.), Quinnipiac University, Hamden, CT; Department of Neurosurgery (G.K.S.), Department of Neurology and Neurological Sciences (N.E.S.), and Stanford Stroke Center (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; The Neurology Center of Southern California (B.M.F.), Carlsbad; Department of Neurological Surgery (T.Y.), Okayama University Graduate School of Medicine, Okayama University Hospital, Japan; Department of Neurological Surgery (J.W.C.), University of California, Irvine, School of Medicine; Department of Neurology (S.C.C.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.); Los Angeles; Department of Neurosurgery (A.S.A.), Loma Linda University Medical Center; Department of Neurosurgery (J.S.), Yokohama City University School of Medicine, Kanagawa, Japan; Department of Neurosurgery (D.C.L.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; Clinical Hospital Feofaniya (I.S.), Kiev, Ukraine; Department of Neurosurgery (H.N.), Osaka University Graduate School of Medicine, Suita, Japan; Department of Neurosurgery (D.K.), New York University and NYU Langone Medical Center, NY; SanBio, Inc (D.C., T.K., B.N., D.B.), Mountain View, CA; Department of Neurosurgery (Y.K.), University of Tokyo Hospital, Japan; Biostatistical Consulting Inc (S.P.), Lexington, MA; Watson & Stonehouse Enterprises LLC (A.H.S.), Pacific Grove, CA; Massachusetts General Hospital and Harvard Medical School (R.M.R.), Boston; and Department of Neurological Surgery (D.O.O.), University of Pittsburgh Medical Center, PA
| | - Yasuaki Karasawa
- From the Department of Neurosurgery (M.K.), Hokkaido University Hospital, Sapporo, Japan; Rocky Mountain Regional Brain Injury System and University of Colorado School of Medicine (A.H.W.), Englewood; JCHO Tokyo Shinjuku Medical Center (H.I.), Japan; Ukraine Presidential Hospital (I.Z.), Kiev; New England Institute for Neurology and Headache (P.M.); New England Institute for Clinical Research (P.M.), Stamford; Department of Neurology (P.M.), Yale University, New Haven; Frank Netter School of Medicine (P.M.), Quinnipiac University, Hamden, CT; Department of Neurosurgery (G.K.S.), Department of Neurology and Neurological Sciences (N.E.S.), and Stanford Stroke Center (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; The Neurology Center of Southern California (B.M.F.), Carlsbad; Department of Neurological Surgery (T.Y.), Okayama University Graduate School of Medicine, Okayama University Hospital, Japan; Department of Neurological Surgery (J.W.C.), University of California, Irvine, School of Medicine; Department of Neurology (S.C.C.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.); Los Angeles; Department of Neurosurgery (A.S.A.), Loma Linda University Medical Center; Department of Neurosurgery (J.S.), Yokohama City University School of Medicine, Kanagawa, Japan; Department of Neurosurgery (D.C.L.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; Clinical Hospital Feofaniya (I.S.), Kiev, Ukraine; Department of Neurosurgery (H.N.), Osaka University Graduate School of Medicine, Suita, Japan; Department of Neurosurgery (D.K.), New York University and NYU Langone Medical Center, NY; SanBio, Inc (D.C., T.K., B.N., D.B.), Mountain View, CA; Department of Neurosurgery (Y.K.), University of Tokyo Hospital, Japan; Biostatistical Consulting Inc (S.P.), Lexington, MA; Watson & Stonehouse Enterprises LLC (A.H.S.), Pacific Grove, CA; Massachusetts General Hospital and Harvard Medical School (R.M.R.), Boston; and Department of Neurological Surgery (D.O.O.), University of Pittsburgh Medical Center, PA
| | - Susan Paadre
- From the Department of Neurosurgery (M.K.), Hokkaido University Hospital, Sapporo, Japan; Rocky Mountain Regional Brain Injury System and University of Colorado School of Medicine (A.H.W.), Englewood; JCHO Tokyo Shinjuku Medical Center (H.I.), Japan; Ukraine Presidential Hospital (I.Z.), Kiev; New England Institute for Neurology and Headache (P.M.); New England Institute for Clinical Research (P.M.), Stamford; Department of Neurology (P.M.), Yale University, New Haven; Frank Netter School of Medicine (P.M.), Quinnipiac University, Hamden, CT; Department of Neurosurgery (G.K.S.), Department of Neurology and Neurological Sciences (N.E.S.), and Stanford Stroke Center (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; The Neurology Center of Southern California (B.M.F.), Carlsbad; Department of Neurological Surgery (T.Y.), Okayama University Graduate School of Medicine, Okayama University Hospital, Japan; Department of Neurological Surgery (J.W.C.), University of California, Irvine, School of Medicine; Department of Neurology (S.C.C.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.); Los Angeles; Department of Neurosurgery (A.S.A.), Loma Linda University Medical Center; Department of Neurosurgery (J.S.), Yokohama City University School of Medicine, Kanagawa, Japan; Department of Neurosurgery (D.C.L.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; Clinical Hospital Feofaniya (I.S.), Kiev, Ukraine; Department of Neurosurgery (H.N.), Osaka University Graduate School of Medicine, Suita, Japan; Department of Neurosurgery (D.K.), New York University and NYU Langone Medical Center, NY; SanBio, Inc (D.C., T.K., B.N., D.B.), Mountain View, CA; Department of Neurosurgery (Y.K.), University of Tokyo Hospital, Japan; Biostatistical Consulting Inc (S.P.), Lexington, MA; Watson & Stonehouse Enterprises LLC (A.H.S.), Pacific Grove, CA; Massachusetts General Hospital and Harvard Medical School (R.M.R.), Boston; and Department of Neurological Surgery (D.O.O.), University of Pittsburgh Medical Center, PA
| | - Bijan Nejadnik
- From the Department of Neurosurgery (M.K.), Hokkaido University Hospital, Sapporo, Japan; Rocky Mountain Regional Brain Injury System and University of Colorado School of Medicine (A.H.W.), Englewood; JCHO Tokyo Shinjuku Medical Center (H.I.), Japan; Ukraine Presidential Hospital (I.Z.), Kiev; New England Institute for Neurology and Headache (P.M.); New England Institute for Clinical Research (P.M.), Stamford; Department of Neurology (P.M.), Yale University, New Haven; Frank Netter School of Medicine (P.M.), Quinnipiac University, Hamden, CT; Department of Neurosurgery (G.K.S.), Department of Neurology and Neurological Sciences (N.E.S.), and Stanford Stroke Center (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; The Neurology Center of Southern California (B.M.F.), Carlsbad; Department of Neurological Surgery (T.Y.), Okayama University Graduate School of Medicine, Okayama University Hospital, Japan; Department of Neurological Surgery (J.W.C.), University of California, Irvine, School of Medicine; Department of Neurology (S.C.C.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.); Los Angeles; Department of Neurosurgery (A.S.A.), Loma Linda University Medical Center; Department of Neurosurgery (J.S.), Yokohama City University School of Medicine, Kanagawa, Japan; Department of Neurosurgery (D.C.L.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; Clinical Hospital Feofaniya (I.S.), Kiev, Ukraine; Department of Neurosurgery (H.N.), Osaka University Graduate School of Medicine, Suita, Japan; Department of Neurosurgery (D.K.), New York University and NYU Langone Medical Center, NY; SanBio, Inc (D.C., T.K., B.N., D.B.), Mountain View, CA; Department of Neurosurgery (Y.K.), University of Tokyo Hospital, Japan; Biostatistical Consulting Inc (S.P.), Lexington, MA; Watson & Stonehouse Enterprises LLC (A.H.S.), Pacific Grove, CA; Massachusetts General Hospital and Harvard Medical School (R.M.R.), Boston; and Department of Neurological Surgery (D.O.O.), University of Pittsburgh Medical Center, PA
| | - Damien Bates
- From the Department of Neurosurgery (M.K.), Hokkaido University Hospital, Sapporo, Japan; Rocky Mountain Regional Brain Injury System and University of Colorado School of Medicine (A.H.W.), Englewood; JCHO Tokyo Shinjuku Medical Center (H.I.), Japan; Ukraine Presidential Hospital (I.Z.), Kiev; New England Institute for Neurology and Headache (P.M.); New England Institute for Clinical Research (P.M.), Stamford; Department of Neurology (P.M.), Yale University, New Haven; Frank Netter School of Medicine (P.M.), Quinnipiac University, Hamden, CT; Department of Neurosurgery (G.K.S.), Department of Neurology and Neurological Sciences (N.E.S.), and Stanford Stroke Center (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; The Neurology Center of Southern California (B.M.F.), Carlsbad; Department of Neurological Surgery (T.Y.), Okayama University Graduate School of Medicine, Okayama University Hospital, Japan; Department of Neurological Surgery (J.W.C.), University of California, Irvine, School of Medicine; Department of Neurology (S.C.C.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.); Los Angeles; Department of Neurosurgery (A.S.A.), Loma Linda University Medical Center; Department of Neurosurgery (J.S.), Yokohama City University School of Medicine, Kanagawa, Japan; Department of Neurosurgery (D.C.L.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; Clinical Hospital Feofaniya (I.S.), Kiev, Ukraine; Department of Neurosurgery (H.N.), Osaka University Graduate School of Medicine, Suita, Japan; Department of Neurosurgery (D.K.), New York University and NYU Langone Medical Center, NY; SanBio, Inc (D.C., T.K., B.N., D.B.), Mountain View, CA; Department of Neurosurgery (Y.K.), University of Tokyo Hospital, Japan; Biostatistical Consulting Inc (S.P.), Lexington, MA; Watson & Stonehouse Enterprises LLC (A.H.S.), Pacific Grove, CA; Massachusetts General Hospital and Harvard Medical School (R.M.R.), Boston; and Department of Neurological Surgery (D.O.O.), University of Pittsburgh Medical Center, PA
| | - Anthony H Stonehouse
- From the Department of Neurosurgery (M.K.), Hokkaido University Hospital, Sapporo, Japan; Rocky Mountain Regional Brain Injury System and University of Colorado School of Medicine (A.H.W.), Englewood; JCHO Tokyo Shinjuku Medical Center (H.I.), Japan; Ukraine Presidential Hospital (I.Z.), Kiev; New England Institute for Neurology and Headache (P.M.); New England Institute for Clinical Research (P.M.), Stamford; Department of Neurology (P.M.), Yale University, New Haven; Frank Netter School of Medicine (P.M.), Quinnipiac University, Hamden, CT; Department of Neurosurgery (G.K.S.), Department of Neurology and Neurological Sciences (N.E.S.), and Stanford Stroke Center (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; The Neurology Center of Southern California (B.M.F.), Carlsbad; Department of Neurological Surgery (T.Y.), Okayama University Graduate School of Medicine, Okayama University Hospital, Japan; Department of Neurological Surgery (J.W.C.), University of California, Irvine, School of Medicine; Department of Neurology (S.C.C.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.); Los Angeles; Department of Neurosurgery (A.S.A.), Loma Linda University Medical Center; Department of Neurosurgery (J.S.), Yokohama City University School of Medicine, Kanagawa, Japan; Department of Neurosurgery (D.C.L.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; Clinical Hospital Feofaniya (I.S.), Kiev, Ukraine; Department of Neurosurgery (H.N.), Osaka University Graduate School of Medicine, Suita, Japan; Department of Neurosurgery (D.K.), New York University and NYU Langone Medical Center, NY; SanBio, Inc (D.C., T.K., B.N., D.B.), Mountain View, CA; Department of Neurosurgery (Y.K.), University of Tokyo Hospital, Japan; Biostatistical Consulting Inc (S.P.), Lexington, MA; Watson & Stonehouse Enterprises LLC (A.H.S.), Pacific Grove, CA; Massachusetts General Hospital and Harvard Medical School (R.M.R.), Boston; and Department of Neurological Surgery (D.O.O.), University of Pittsburgh Medical Center, PA
| | - R Mark Richardson
- From the Department of Neurosurgery (M.K.), Hokkaido University Hospital, Sapporo, Japan; Rocky Mountain Regional Brain Injury System and University of Colorado School of Medicine (A.H.W.), Englewood; JCHO Tokyo Shinjuku Medical Center (H.I.), Japan; Ukraine Presidential Hospital (I.Z.), Kiev; New England Institute for Neurology and Headache (P.M.); New England Institute for Clinical Research (P.M.), Stamford; Department of Neurology (P.M.), Yale University, New Haven; Frank Netter School of Medicine (P.M.), Quinnipiac University, Hamden, CT; Department of Neurosurgery (G.K.S.), Department of Neurology and Neurological Sciences (N.E.S.), and Stanford Stroke Center (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; The Neurology Center of Southern California (B.M.F.), Carlsbad; Department of Neurological Surgery (T.Y.), Okayama University Graduate School of Medicine, Okayama University Hospital, Japan; Department of Neurological Surgery (J.W.C.), University of California, Irvine, School of Medicine; Department of Neurology (S.C.C.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.); Los Angeles; Department of Neurosurgery (A.S.A.), Loma Linda University Medical Center; Department of Neurosurgery (J.S.), Yokohama City University School of Medicine, Kanagawa, Japan; Department of Neurosurgery (D.C.L.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; Clinical Hospital Feofaniya (I.S.), Kiev, Ukraine; Department of Neurosurgery (H.N.), Osaka University Graduate School of Medicine, Suita, Japan; Department of Neurosurgery (D.K.), New York University and NYU Langone Medical Center, NY; SanBio, Inc (D.C., T.K., B.N., D.B.), Mountain View, CA; Department of Neurosurgery (Y.K.), University of Tokyo Hospital, Japan; Biostatistical Consulting Inc (S.P.), Lexington, MA; Watson & Stonehouse Enterprises LLC (A.H.S.), Pacific Grove, CA; Massachusetts General Hospital and Harvard Medical School (R.M.R.), Boston; and Department of Neurological Surgery (D.O.O.), University of Pittsburgh Medical Center, PA
| | - David O Okonkwo
- From the Department of Neurosurgery (M.K.), Hokkaido University Hospital, Sapporo, Japan; Rocky Mountain Regional Brain Injury System and University of Colorado School of Medicine (A.H.W.), Englewood; JCHO Tokyo Shinjuku Medical Center (H.I.), Japan; Ukraine Presidential Hospital (I.Z.), Kiev; New England Institute for Neurology and Headache (P.M.); New England Institute for Clinical Research (P.M.), Stamford; Department of Neurology (P.M.), Yale University, New Haven; Frank Netter School of Medicine (P.M.), Quinnipiac University, Hamden, CT; Department of Neurosurgery (G.K.S.), Department of Neurology and Neurological Sciences (N.E.S.), and Stanford Stroke Center (G.K.S., N.E.S.), Stanford University School of Medicine and Stanford Health Care, CA; The Neurology Center of Southern California (B.M.F.), Carlsbad; Department of Neurological Surgery (T.Y.), Okayama University Graduate School of Medicine, Okayama University Hospital, Japan; Department of Neurological Surgery (J.W.C.), University of California, Irvine, School of Medicine; Department of Neurology (S.C.C.), University of California, Los Angeles; California Rehabilitation Institute (S.C.C.); Los Angeles; Department of Neurosurgery (A.S.A.), Loma Linda University Medical Center; Department of Neurosurgery (J.S.), Yokohama City University School of Medicine, Kanagawa, Japan; Department of Neurosurgery (D.C.L.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; Clinical Hospital Feofaniya (I.S.), Kiev, Ukraine; Department of Neurosurgery (H.N.), Osaka University Graduate School of Medicine, Suita, Japan; Department of Neurosurgery (D.K.), New York University and NYU Langone Medical Center, NY; SanBio, Inc (D.C., T.K., B.N., D.B.), Mountain View, CA; Department of Neurosurgery (Y.K.), University of Tokyo Hospital, Japan; Biostatistical Consulting Inc (S.P.), Lexington, MA; Watson & Stonehouse Enterprises LLC (A.H.S.), Pacific Grove, CA; Massachusetts General Hospital and Harvard Medical School (R.M.R.), Boston; and Department of Neurological Surgery (D.O.O.), University of Pittsburgh Medical Center, PA
| |
Collapse
|
18
|
Waheed S, Noreen S, Tripathi D, Lu DC. Electrothermal transport of third-order fluids regulated by peristaltic pumping. J Biol Phys 2020; 46:45-65. [PMID: 32052248 PMCID: PMC7098401 DOI: 10.1007/s10867-020-09540-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 05/29/2019] [Accepted: 01/31/2020] [Indexed: 10/25/2022] Open
Abstract
The study of heat and electroosmotic characteristics in the flow of a third-order fluid regulated by peristaltic pumping is examined by using governing equations, i.e., the continuity equation, momentum equation, energy equation, and concentration equation. The wavelength is considered long compared to its height and a low Reynolds number is assumed. The velocity slip condition is employed. Analytical solutions are performed through the perturbation technique. The expressions for the dimensionless velocity components, temperature, concentration, and heat transfer rate are obtained. Pumping features were computed numerically for discussion of results. Trapping and heat transfer coefficient distributions were also studied graphically. The findings of the present study can be applied to design biomicrofluidic devices like tumor-on-a-chip and organ-on-a-chip.
Collapse
Affiliation(s)
- S Waheed
- Department of Mathematics, COMSATS University Islamabad, Park Road, Tarlai Kalan, Islamabad, 45550, Pakistan
| | - S Noreen
- Department of Mathematics, COMSATS University Islamabad, Park Road, Tarlai Kalan, Islamabad, 45550, Pakistan.
- Department of Mathematics, Faculty of Science, Jiangsu University, Zhenjiang, 212013, China.
| | - D Tripathi
- Department of Mathematics, National Institute of Technology, Srinagar, Uttarakhand, 246174, India
| | - D C Lu
- Department of Mathematics, Faculty of Science, Jiangsu University, Zhenjiang, 212013, China
| |
Collapse
|
19
|
Denis DJ, Champagne PO, Hoffman H, Niu T, Lu DC. Catheter-based Minimally Invasive Evacuation of Extensive Spinal Epidural Abscess: A Technical Report. Cureus 2019; 11:e4649. [PMID: 31312574 PMCID: PMC6624161 DOI: 10.7759/cureus.4649] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Surgical treatment of extensive spinal epidural abscess (SEA) usually involves multilevel exposure of the dural sac with subsequent risk for iatrogenic instability. A minimally invasive technique using an epidural catheter inserted through a limited approach for distant irrigation and drainage of the abscess represents an interesting alternative. Most described techniques involve blind placement of the catheters, with the potential risk of damage to the spinal cord and incomplete abscess drainage. We present and analyze a new technique used in two cases of SEA. Those were successfully treated using a minimally invasive approach supplemented with fluoroscopically-guided catheter drainage. We suggest that fluoroscopic placement of the catheter is a safe and effective method that offers a more focused and potentially safer way to proceed to this technique.
Collapse
|
20
|
Freyvert Y, Yong NA, Morikawa E, Zdunowski S, Sarino ME, Gerasimenko Y, Edgerton VR, Lu DC. Engaging cervical spinal circuitry with non-invasive spinal stimulation and buspirone to restore hand function in chronic motor complete patients. Sci Rep 2018; 8:15546. [PMID: 30341390 PMCID: PMC6195617 DOI: 10.1038/s41598-018-33123-5] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 09/17/2018] [Indexed: 01/01/2023] Open
Abstract
The combined effects of cervical electrical stimulation alone or in combination with the monoaminergic agonist buspirone on upper limb motor function were determined in six subjects with motor complete (AIS B) injury at C5 or above and more than one year from time of injury. Voluntary upper limb function was evaluated through measures of controlled hand contraction, handgrip force production, dexterity measures, and validated clinical assessment batteries. Repeated measure analysis of variance was used to evaluate functional metrics, EMG amplitude, and changes in mean grip strength. In aggregate, mean hand strength increased by greater than 300% with transcutaneous electrical stimulation and buspirone while a corresponding clinically significant improvement was observed in upper extremity motor scores and the action research arm test. Some functional improvements persisted for an extended period after the study interventions were discontinued. We demonstrate that, with these novel interventions, cervical spinal circuitry can be neuromodulated to improve volitional control of hand function in tetraplegic subjects. The potential impact of these findings on individuals with upper limb paralysis could be dramatic functionally, psychologically, and economically.
Collapse
Affiliation(s)
- Yevgeniy Freyvert
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, 90095, USA
- Neuromotor Recovery and Rehabilitation Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, 90095, USA
| | - Nicholas Au Yong
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, 90095, USA
- Neuromotor Recovery and Rehabilitation Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, 90095, USA
| | - Erika Morikawa
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, 90095, USA
- Neuromotor Recovery and Rehabilitation Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, 90095, USA
| | - Sharon Zdunowski
- Departments of Integrative Biology and Physiology, University of California, Los Angeles, Los Angeles, California, 90095, USA
| | - Melanie E Sarino
- Rancho Los Amigos National Rehabilitation Center, Downey, California, 90242, USA
| | - Yury Gerasimenko
- Departments of Integrative Biology and Physiology, University of California, Los Angeles, Los Angeles, California, 90095, USA
- Pavlov Institute of Physiology, St. Petersburg, Russia
| | - V Reggie Edgerton
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, 90095, USA
- Departments of Integrative Biology and Physiology, University of California, Los Angeles, Los Angeles, California, 90095, USA
- Neurobiology, University of California, Los Angeles, Los Angeles, California, 90095, USA
- Brain Research Institute, University of California, Los Angeles, Los Angeles, California, 90095, USA
| | - Daniel C Lu
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, 90095, USA.
- Neuromotor Recovery and Rehabilitation Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, 90095, USA.
- Brain Research Institute, University of California, Los Angeles, Los Angeles, California, 90095, USA.
| |
Collapse
|
21
|
Abstract
Background Lumbar spinal stenosis (LSS) is the most common indication for spine surgery among the geriatric population. Although decompressive surgery is effective, older patients do not benefit as much as younger patients, and they are frequently excluded from studies assessing postoperative physiotherapy. We sought to evaluate the long-term outcomes after surgery when a novel postoperative physiotherapy regimen was included. Methods We performed a retrospective review of patients with LSS greater than 70 years old who underwent lumbar decompressive surgery by the senior author over the past five years. We evaluated patients who participated in a novel postoperative physiotherapy regimen involving four phases of rehabilitation aimed at progressively independent ambulation. The visual analog scale (VAS), lower extremity motor strength, and functional independence measure (FIM) were collected preoperatively and after physiotherapy to measure outcomes. Results Ten consecutive patients with an average age of 83 years (range: 71 - 96) met the inclusion criteria. Nine patients underwent minimally invasive laminotomies at L4-L5 and one underwent a laminotomy at L3-L4. The average follow-up time was 41.9 months. The preoperative mean VAS was 7.35, and at the end of the study, it was 1.7 (p = 0.005). Three of the four patients with preoperative motor deficits improved. The median transfer and locomotion subscores of the FIM were six preoperatively and increased to seven postoperatively. Neither of these improvements was significant. Conclusions Patients older than 70 years undergoing decompressive surgery and a novel postoperative physiotherapy regimen experienced significant reductions in pain. Independence also increased; however, this did not reach statistical significance.
Collapse
Affiliation(s)
- Haydn Hoffman
- Department of Neurosurgery, University of California Los Angeles
| | - Shelley S Bennett
- Department of Physical Therapy, University of California, Los Angeles
| | - Charles H Li
- Department of Neurosurgery, University of California, Los Angeles
| | - Piia Haakana
- Department of Neurosurgery, University of California Los Angeles
| | - Daniel C Lu
- Department of Neurosurgery, University of California Los Angeles
| |
Collapse
|
22
|
Lee SI, Huang A, Mortazavi B, Li C, Hoffman HA, Garst J, Lu DS, Getachew R, Espinal M, Razaghy M, Ghalehsari N, Paak BH, Ghavam AA, Afridi M, Ostowari A, Ghasemzadeh H, Lu DC, Sarrafzadeh M. Quantitative assessment of hand motor function in cervical spinal disorder patients using target tracking tests. ACTA ACUST UNITED AC 2018; 53:1007-1022. [PMID: 28475202 DOI: 10.1682/jrrd.2014.12.0319] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [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: 12/30/2014] [Revised: 12/01/2015] [Indexed: 11/05/2022]
Abstract
Cervical spondylotic myelopathy (CSM) is a chronic spinal disorder in the neck region. Its prevalence is growing rapidly in developed nations, creating a need for an objective assessment tool. This article introduces a system for quantifying hand motor function using a handgrip device and target tracking test. In those with CSM, hand motor impairment often interferes with essential daily activities. The analytic method applied machine learning techniques to investigate the efficacy of the system in (1) detecting the presence of impairments in hand motor function, (2) estimating the perceived motor deficits of CSM patients using the Oswestry Disability Index (ODI), and (3) detecting changes in physical condition after surgery, all of which were performed while ensuring test-retest reliability. The results based on a pilot data set collected from 30 patients with CSM and 30 nondisabled control subjects produced a c-statistic of 0.89 for the detection of impairments, Pearson r of 0.76 with p < 0.001 for the estimation of ODI, and a c-statistic of 0.82 for responsiveness. These results validate the use of the presented system as a means to provide objective and accurate assessment of the level of impairment and surgical outcomes.
Collapse
Affiliation(s)
- Sunghoon I Lee
- Computer Science Department, University of California Los Angeles (UCLA), Los Angeles, CA
| | - Alex Huang
- Department of Neurosurgery, UCLA, Los Angeles, CA
| | | | - Charles Li
- Computer Science Department, University of California Los Angeles (UCLA), Los Angeles, CA
| | | | - Jordan Garst
- Department of Neurosurgery, UCLA, Los Angeles, CA
| | - Derek S Lu
- Department of Neurosurgery, UCLA, Los Angeles, CA
| | | | | | | | | | - Brian H Paak
- Department of Neurosurgery, UCLA, Los Angeles, CA
| | | | - Marwa Afridi
- Department of Neurosurgery, UCLA, Los Angeles, CA
| | | | - Hassan Ghasemzadeh
- Computer Science Department, University of California Los Angeles (UCLA), Los Angeles, CA
| | - Daniel C Lu
- Department of Neurosurgery, UCLA, Los Angeles, CA.,Department of Orthopedic Surgery, UCLA, Los Angeles, CA
| | - Majid Sarrafzadeh
- Computer Science Department, University of California Los Angeles (UCLA), Los Angeles, CA
| |
Collapse
|
23
|
Lee SI, Campion A, Huang A, Park E, Garst JH, Jahanforouz N, Espinal M, Siero T, Pollack S, Afridi M, Daneshvar M, Ghias S, Sarrafzadeh M, Lu DC. Identifying predictors for postoperative clinical outcome in lumbar spinal stenosis patients using smart-shoe technology. J Neuroeng Rehabil 2017; 14:77. [PMID: 28720144 PMCID: PMC5516369 DOI: 10.1186/s12984-017-0288-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 07/06/2017] [Indexed: 11/21/2022] Open
Abstract
Background Approximately 33% of the patients with lumbar spinal stenosis (LSS) who undergo surgery are not satisfied with their postoperative clinical outcomes. Therefore, identifying predictors for postoperative outcome and groups of patients who will benefit from the surgical intervention is of significant clinical benefit. However, many of the studied predictors to date suffer from subjective recall bias, lack fine digital measures, and yield poor correlation to outcomes. Methods This study utilized smart-shoes to capture gait parameters extracted preoperatively during a 10 m self-paced walking test, which was hypothesized to provide objective, digital measurements regarding the level of gait impairment caused by LSS symptoms, with the goal of predicting postoperative outcomes in a cohort of LSS patients who received lumbar decompression and/or fusion surgery. The Oswestry Disability Index (ODI) and predominant pain level measured via the Visual Analogue Scale (VAS) were used as the postoperative clinical outcome variables. Results The gait parameters extracted from the smart-shoes made statistically significant predictions of the postoperative improvement in ODI (RMSE =0.13, r=0.93, and p<3.92×10−7) and predominant pain level (RMSE =0.19, r=0.83, and p<1.28×10−4). Additionally, the gait parameters produced greater prediction accuracy compared to the clinical variables that had been previously investigated. Conclusions The reported results herein support the hypothesis that the measurement of gait characteristics by our smart-shoe system can provide accurate predictions of the surgical outcomes, assisting clinicians in identifying which LSS patient population can benefit from the surgical intervention and optimize treatment strategies. Electronic supplementary material The online version of this article (doi:10.1186/s12984-017-0288-0) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Sunghoon I Lee
- College of Information and Computer Science, UMass Amherst, Amherst, USA
| | - Andrew Campion
- Neuroplasticity and Repair Laboratory, UCLA, Los Angeles, USA.,Neuromotor Recovery and Rehabilitation Center, UCLA, Los Angeles, USA.,Department of Neurosurgery, UCLA, Los Angeles, USA
| | - Alex Huang
- Neuroplasticity and Repair Laboratory, UCLA, Los Angeles, USA.,Neuromotor Recovery and Rehabilitation Center, UCLA, Los Angeles, USA.,Department of Neurosurgery, UCLA, Los Angeles, USA
| | - Eunjeong Park
- Cardiovascular Research Institute, Yonsei University College of Medicine, Los Angeles, USA
| | - Jordan H Garst
- Neuroplasticity and Repair Laboratory, UCLA, Los Angeles, USA.,Neuromotor Recovery and Rehabilitation Center, UCLA, Los Angeles, USA.,Department of Neurosurgery, UCLA, Los Angeles, USA
| | - Nima Jahanforouz
- Neuroplasticity and Repair Laboratory, UCLA, Los Angeles, USA.,Neuromotor Recovery and Rehabilitation Center, UCLA, Los Angeles, USA.,Department of Neurosurgery, UCLA, Los Angeles, USA
| | - Marie Espinal
- Neuroplasticity and Repair Laboratory, UCLA, Los Angeles, USA.,Neuromotor Recovery and Rehabilitation Center, UCLA, Los Angeles, USA.,Department of Neurosurgery, UCLA, Los Angeles, USA
| | - Tiffany Siero
- Neuroplasticity and Repair Laboratory, UCLA, Los Angeles, USA.,Neuromotor Recovery and Rehabilitation Center, UCLA, Los Angeles, USA.,Department of Neurosurgery, UCLA, Los Angeles, USA
| | - Sophie Pollack
- Neuroplasticity and Repair Laboratory, UCLA, Los Angeles, USA.,Neuromotor Recovery and Rehabilitation Center, UCLA, Los Angeles, USA.,Department of Neurosurgery, UCLA, Los Angeles, USA
| | - Marwa Afridi
- Neuroplasticity and Repair Laboratory, UCLA, Los Angeles, USA.,Neuromotor Recovery and Rehabilitation Center, UCLA, Los Angeles, USA.,Department of Neurosurgery, UCLA, Los Angeles, USA
| | - Meelod Daneshvar
- Neuroplasticity and Repair Laboratory, UCLA, Los Angeles, USA.,Neuromotor Recovery and Rehabilitation Center, UCLA, Los Angeles, USA.,Department of Neurosurgery, UCLA, Los Angeles, USA
| | - Saif Ghias
- Neuroplasticity and Repair Laboratory, UCLA, Los Angeles, USA.,Neuromotor Recovery and Rehabilitation Center, UCLA, Los Angeles, USA.,Department of Neurosurgery, UCLA, Los Angeles, USA
| | | | - Daniel C Lu
- Neuroplasticity and Repair Laboratory, UCLA, Los Angeles, USA. .,Neuromotor Recovery and Rehabilitation Center, UCLA, Los Angeles, USA. .,Department of Neurosurgery, UCLA, Los Angeles, USA. .,Department of Orthopaedic Surgery, UCLA, Los Angeles, USA.
| |
Collapse
|
24
|
Abstract
Background: Cervical total disc replacement (TDR) is an established alternative to anterior cervical discectomy and fusion (ACDF) with excellent long-term outcomes and low failure rates. Cases of implant failure and migration are scarce and primarily limited to several years postoperatively. The authors report a case of anterior extrusion of a C4-C5 ProDisc-C (DePuy Synthes, West Chester, PA, USA) cervical artificial disc (CAD) 14 months after placement due to minor trauma. Case Description: A 33-year-old female who had undergone C4-C5 CAD implantation presented with neck pain and spasm after experiencing a paragliding accident. A 4 mm anterior protrusion of the CAD was seen on x-ray. She underwent removal of the CAD followed by anterior fusion. Other cases of CAD extrusion in the literature are discussed and the device's durability and testing are considered. Conclusion: Overall, CAD extrusion is a rare event. This case is likely the result of insufficient osseous integration. Patients undergoing cervical TDR should avoid high-risk activities to prevent trauma that could compromise the disc's placement, and future design/research should focus on how to enhance osseous integration at the interface while minimizing excessive heterotopic ossification.
Collapse
Affiliation(s)
- Tianyi Niu
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Haydn Hoffman
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Daniel C Lu
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, California, USA.,Department of Orthopedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, USA.,Neuromotor Recovery and Rehabilitation Center, David Geffen School of Medicine, University of California, Los Angeles, California, USA.,Brain Research Institute, University of California, Los Angeles, California, USA
| |
Collapse
|
25
|
Gad P, Gerasimenko Y, Zdunowski S, Turner A, Sayenko D, Lu DC, Edgerton VR. Weight Bearing Over-ground Stepping in an Exoskeleton with Non-invasive Spinal Cord Neuromodulation after Motor Complete Paraplegia. Front Neurosci 2017. [PMID: 28642680 PMCID: PMC5462970 DOI: 10.3389/fnins.2017.00333] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
We asked whether coordinated voluntary movement of the lower limbs could be regained in an individual having been completely paralyzed (>4 year) and completely absent of vision (>15 year) using two novel strategies-transcutaneous electrical spinal cord stimulation at selected sites over the spine as well as pharmacological neuromodulation by buspirone. We also asked whether these neuromodulatory strategies could facilitate stepping assisted by an exoskeleton (EKSO, EKSO Bionics, CA) that is designed so that the subject can voluntarily complement the work being performed by the exoskeleton. We found that spinal cord stimulation and drug enhanced the level of effort that the subject could generate while stepping in the exoskeleton. In addition, stimulation improved the coordination patterns of the lower limb muscles resulting in a more continuous, smooth stepping motion in the exoskeleton along with changes in autonomic functions including cardiovascular and thermoregulation. Based on these data from this case study it appears that there is considerable potential for positive synergistic effects after complete paralysis by combining the over-ground step training in an exoskeleton, combined with transcutaneous electrical spinal cord stimulation either without or with pharmacological modulation.
Collapse
Affiliation(s)
- Parag Gad
- Department of Integrative Biology and Physiology, University of California, Los AngelesLos Angeles, CA, United States
| | - Yury Gerasimenko
- Department of Integrative Biology and Physiology, University of California, Los AngelesLos Angeles, CA, United States.,Pavlov Institute of PhysiologySt. Petersburg, Russia
| | - Sharon Zdunowski
- Department of Integrative Biology and Physiology, University of California, Los AngelesLos Angeles, CA, United States
| | - Amanda Turner
- Department of Integrative Biology and Physiology, University of California, Los AngelesLos Angeles, CA, United States
| | - Dimitry Sayenko
- Department of Integrative Biology and Physiology, University of California, Los AngelesLos Angeles, CA, United States
| | - Daniel C Lu
- Department of Neurosurgery, University of California, Los AngelesLos Angeles, CA, United States.,Brain Research Institute, University of California, Los AngelesLos Angeles, CA, United States
| | - V Reggie Edgerton
- Department of Integrative Biology and Physiology, University of California, Los AngelesLos Angeles, CA, United States.,Department of Neurosurgery, University of California, Los AngelesLos Angeles, CA, United States.,Brain Research Institute, University of California, Los AngelesLos Angeles, CA, United States.,Department of Neurobiology, University of California, Los AngelesLos Angeles, CA, United States.,Institut Guttmann, Hospital de Neurorehabilitació, Institut Universitari adscrit a la Universitat Autònoma de BarcelonaBarcelona, Spain
| |
Collapse
|
26
|
Abstract
STUDY DESIGN Case series. OBJECTIVE Intervertebral disc (IVD) degeneration is the cause of spondylosis. The pathogenesis is poorly understood, but disc dehydration often plays a role. In this study, we aim to identify and quantify aquaporin-1 (AQP1) in ex vivo human degenerated IVDs obtained intraoperatively and to investigate the relationship between AQP1 levels and magnetic resonance imaging (MRI) T2 intensity of the disc. METHODS Ex vivo samples of nucleus pulposus (NP) tissue from lumbar IVDs were obtained from 18 consecutive patients who underwent surgery for disc herniation at L4/5 and L5/S1 level. Immunohistochemistry was performed to determine the presence of AQP1 expression, and this was quantified by Western blot analysis. AQP1 expression was compared to preoperative IVD signal intensity on T2-weighted MRI. RESULTS NP tissue was obtained from 18 patients (9 for L4/5 level and 9 for L5/S1 level). AQP1 expression was detected in all samples by Western blot and immunohistochemistry. AQP1 expression had a linear correlation with the preoperative IVD signal intensity on T2-weighted MRI at L4/5 level (R2 = 0.90) and at L5/S1 level (R2 = 0.92). AQP1 expression was 52.2 ± 59.0 at L5/S1 level and 15.9 ± 20.6 at L4/5 (P = .10). CONCLUSIONS Our results show that AQP1 can be detected in IVD obtained from live human subjects. Increased AQP1 expression is associated with greater disc hydration as measured by signal intensity on T2-weighted MRI. AQP1 may have a role in the dehydration associated with disc degeneration.
Collapse
Affiliation(s)
- Haydn Hoffman
- University of California, Los Angeles, CA, USA,University of California, San Francisco, CA, USA
| | - Aaron W. Choi
- University of California, Los Angeles, CA, USA,*Contributed equally to this article
| | | | - Jon Kimball
- University of California, Los Angeles, CA, USA
| | | | | | - Brian Kim
- University of California, Los Angeles, CA, USA
| | - Tianyi Niu
- University of California, Los Angeles, CA, USA
| | - Daniel C. Lu
- University of California, Los Angeles, CA, USA,Daniel C. Lu, Department of Neurosurgery, University of California, Los Angeles, 300 Stein Plaza, Ste 536, Los Angeles, CA 90095-6901, USA.
| |
Collapse
|
27
|
Hoffman HA, Li CH, Everson RG, Strunck JL, Yong WH, Lu DC. Primary lung metastasis of glioblastoma multiforme with epidural spinal metastasis: Case report. J Clin Neurosci 2017; 41:97-99. [PMID: 28343918 DOI: 10.1016/j.jocn.2017.03.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [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: 01/01/2017] [Accepted: 03/06/2017] [Indexed: 11/30/2022]
Abstract
Extracranial metastasis of glioblastoma multiforme (GBM) is rare, but has recently been reported with increasing frequency. GBM metastases typically present after a biopsy or resection of the primary tumor. An otherwise healthy 54year-old woman presented with recurring pleural effusions originally believed to be from a primary lung malignancy. The patient subsequently experienced a generalized tonic clonic seizure and a right temporal brain mass was discovered. The patient later developed weakness and radiculopathy, and an extramedullary extradural mass spreading from C7 to T6 was discovered. She underwent resection of both central nervous system lesions as well as a lung biopsy, and all pathologic specimens were consistent with GBM. The case presented is unique in that the patient's initial symptoms were related to her metastasis. Furthermore, a purely epidural spread of GBM that respects the leptomeninges and intramedullary parenchyma is highly unusual.
Collapse
Affiliation(s)
- Haydn A Hoffman
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Charles H Li
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Richard G Everson
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Jennifer L Strunck
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - William H Yong
- Division of Neuropathology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA; Brain Research Institute, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Daniel C Lu
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA; Brain Research Institute, University of California, Los Angeles, Los Angeles, CA 90095, USA; Department of Orthopedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA; Neuromotor Recovery and Rehabilitation Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA.
| |
Collapse
|
28
|
Hoffman H, Sierro T, Niu T, Sarino ME, Sarrafzadeh M, McArthur D, Edgerton VR, Lu DC. Rehabilitation of hand function after spinal cord injury using a novel handgrip device: a pilot study. J Neuroeng Rehabil 2017; 14:22. [PMID: 28327161 PMCID: PMC5361778 DOI: 10.1186/s12984-017-0234-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Accepted: 03/14/2017] [Indexed: 01/21/2023] Open
Abstract
Background Activity-based therapy (ABT) for patients with spinal cord injury (SCI), which consists of repetitive use of muscles above and below the spinal lesion, improves locomotion and arm strength. Less data has been published regarding its effects on hand function. We sought to evaluate the effects of a weekly hand-focused therapy program using a novel handgrip device on grip strength and hand function in a SCI cohort. Methods Patients with SCI were enrolled in a weekly program that involved activities with the MediSens (Los Angeles, CA) handgrip. These included maximum voluntary contraction (MVC) and a tracking task that required each subject to adjust his/her grip strength according to a pattern displayed on a computer screen. For the latter, performance was measured as mean absolute accuracy (MAA). The Spinal Cord Independence Measure (SCIM) was used to measure each subject’s independence prior to and after therapy. Results Seventeen patients completed the program with average participation duration of 21.3 weeks. The cohort included patients with American Spinal Injury Association (ASIA) Impairment Scale (AIS) A (n = 12), AIS B (n = 1), AIS C (n = 2), and AIS D (n = 2) injuries. The average MVC for the cohort increased from 4.1 N to 21.2 N over 20 weeks, but did not reach statistical significance. The average MAA for the cohort increased from 9.01 to 21.7% at the end of the study (p = .02). The cohort’s average SCIM at the end of the study was unchanged compared to baseline. Conclusions A weekly handgrip-based ABT program is feasible and efficacious at increasing hand task performance in subjects with SCI.
Collapse
Affiliation(s)
- Haydn Hoffman
- Department of Neurosurgery, University of California, Los Angeles, 300 Stein Plaza, Ste. 536, Los Angeles, CA, 90095-6901, USA
| | - Tiffany Sierro
- Department of Neurosurgery, University of California, Los Angeles, 300 Stein Plaza, Ste. 536, Los Angeles, CA, 90095-6901, USA
| | - Tianyi Niu
- Department of Neurosurgery, University of California, Los Angeles, 300 Stein Plaza, Ste. 536, Los Angeles, CA, 90095-6901, USA
| | - Melanie E Sarino
- Rancho Los Amigos National Rehabilitation Center, Downey, CA, 90242, USA
| | - Majid Sarrafzadeh
- Wireless Health Institute, University of California Los Angeles, Los Angeles, CA, USA.,Department of Computer Science, University of California Los Angeles, Los Angeles, CA, USA
| | - David McArthur
- Department of Neurosurgery, University of California, Los Angeles, 300 Stein Plaza, Ste. 536, Los Angeles, CA, 90095-6901, USA
| | - V Reggie Edgerton
- Department of Neurosurgery, University of California, Los Angeles, 300 Stein Plaza, Ste. 536, Los Angeles, CA, 90095-6901, USA.,Brain Research Institute, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - Daniel C Lu
- Department of Neurosurgery, University of California, Los Angeles, 300 Stein Plaza, Ste. 536, Los Angeles, CA, 90095-6901, USA. .,Department of Orthopedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, 90095, USA. .,Neuromotor Recovery and Rehabilitation Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, 90095, USA. .,Brain Research Institute, University of California, Los Angeles, Los Angeles, CA, 90095, USA.
| |
Collapse
|
29
|
Alam M, Garcia-Alias G, Jin B, Keyes J, Zhong H, Roy RR, Gerasimenko Y, Lu DC, Edgerton VR. Electrical neuromodulation of the cervical spinal cord facilitates forelimb skilled function recovery in spinal cord injured rats. Exp Neurol 2017; 291:141-150. [PMID: 28192079 DOI: 10.1016/j.expneurol.2017.02.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 01/21/2017] [Accepted: 02/01/2017] [Indexed: 01/03/2023]
Abstract
Enabling motor control by epidural electrical stimulation of the spinal cord is a promising therapeutic technique for the recovery of motor function after a spinal cord injury (SCI). Although epidural electrical stimulation has resulted in improvement in hindlimb motor function, it is unknown whether it has any therapeutic benefit for improving forelimb fine motor function after a cervical SCI. We tested whether trains of pulses delivered at spinal cord segments C6 and C8 would facilitate the recovery of forelimb fine motor control after a cervical SCI in rats. Rats were trained to reach and grasp sugar pellets. Immediately after a dorsal funiculus crush at C4, the rats showed significant deficits in forelimb fine motor control. The rats were tested to reach and grasp with and without cervical epidural stimulation for 10weeks post-injury. To determine the best stimulation parameters to activate the cervical spinal networks involved in forelimb motor function, monopolar and bipolar currents were delivered at varying frequencies (20, 40, and 60Hz) concomitant with the reaching and grasping task. We found that cervical epidural stimulation increased reaching and grasping success rates compared to the no stimulation condition. Bipolar stimulation (C6- C8+ and C6+ C8-) produced the largest spinal motor-evoked potentials (sMEPs) and resulted in higher reaching and grasping success rates compared with monopolar stimulation (C6- Ref+ and C8- Ref+). Forelimb performance was similar when tested at stimulation frequencies of 20, 40, and 60Hz. We also found that the EMG activity in most forelimb muscles as well as the co-activation between flexor and extensor muscles increased post-injury. With epidural stimulation, however, this trend was reversed indicating that cervical epidural spinal cord stimulation has therapeutic potential for rehabilitation after a cervical SCI.
Collapse
Affiliation(s)
- Monzurul Alam
- Department of Integrative Biology and Physiology, University of California, Los Angeles, CA 90095, United States
| | - Guillermo Garcia-Alias
- Department of Integrative Biology and Physiology, University of California, Los Angeles, CA 90095, United States
| | - Benita Jin
- Department of Integrative Biology and Physiology, University of California, Los Angeles, CA 90095, United States
| | - Jonathan Keyes
- Department of Integrative Biology and Physiology, University of California, Los Angeles, CA 90095, United States
| | - Hui Zhong
- Department of Integrative Biology and Physiology, University of California, Los Angeles, CA 90095, United States
| | - Roland R Roy
- Department of Integrative Biology and Physiology, University of California, Los Angeles, CA 90095, United States; Brain Research Institute, University of California, Los Angeles, CA 90095, United States
| | - Yury Gerasimenko
- Department of Integrative Biology and Physiology, University of California, Los Angeles, CA 90095, United States; Pavlov Institute of Physiology, St. Petersburg 199034, Russia; Institute of Fundamental Medicine and Biology, Kazan Federal University, Kazan 420006, Russia
| | - Daniel C Lu
- Departments of Neurosurgery, University of California, Los Angeles, CA 90095, United States
| | - V Reggie Edgerton
- Department of Integrative Biology and Physiology, University of California, Los Angeles, CA 90095, United States; Brain Research Institute, University of California, Los Angeles, CA 90095, United States; Departments of Neurobiology, University of California, Los Angeles, CA 90095, United States; Departments of Neuroscience, University of California, Los Angeles, CA 90095, United States.
| |
Collapse
|
30
|
Niu T, Lu DS, Yew A, Lau D, Hoffman H, McArthur D, Chou D, Lu DC. Postoperative Cerebrospinal Fluid Leak Rates with Subfascial Epidural Drain Placement after Intentional Durotomy in Spine Surgery. Global Spine J 2016; 6:780-785. [PMID: 27853662 PMCID: PMC5110360 DOI: 10.1055/s-0036-1582392] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 02/25/2016] [Indexed: 02/07/2023] Open
Abstract
Study Design Retrospective chart review. Objective Postoperative cerebrospinal fluid (CSF) leak is a known complication of intraoperative durotomy. Intraoperative placement of subfascial epidural drains following primary dural repair has been proposed as a potential management strategy to prevent formation of CSF cutaneous fistula and symptomatic pseudomeningocele. Here we describe our experience with subfascial drain after intentional durotomy. Methods Medical records of patients who underwent placement of subfascial epidural drains during spinal procedures with intentional intraoperative durotomies over a 4-year period at two institutions were retrospectively reviewed. Primary outcomes of interest were postoperative CSF cutaneous fistula or symptomatic pseudomeningocele formation. Results Twenty-five patients were included. Mean length of follow-up was 9.5 months. Twelve patients (48%) underwent simultaneous arthrodesis. The average duration of the drain was 5.3 days with average daily output of 126.5 mL. Subgroup analyses revealed that average drain duration for the arthrodesis group was 6.33 days, which is significantly greater than that of the nonfused group, which was 3.7 days (p = 0.016). Similarly, the average daily drain output for the arthrodesis subgroup at 153.1 mL was significantly higher than that of the nonfused subgroup (86.8 mL, p = 0.04). No patient developed postoperative CSF cutaneous fistula or symptomatic pseudomeningocele or had negative sequelae associated with overdrainage of CSF. One patient had a delayed wound infection. Conclusions The intraoperative placement of subfascial epidural drains was not associated with postoperative development of CSF cutaneous fistula, symptomatic pseudomeningocele, overdrainage, or subdural hematoma in the cases reviewed. Subfascial closed wound drain placement is a safe and efficacious management method after intentional spinal durotomies. It is particularly helpful in those who undergo simultaneous arthrodesis, as those patients have statistically higher daily drain output and longer drain durations.
Collapse
Affiliation(s)
- Tianyi Niu
- Department of Neurosurgery, University of California, Los Angeles, California, United States
| | - Derek S. Lu
- Department of Neurosurgery, University of California, Los Angeles, California, United States
| | - Andrew Yew
- Department of Neurosurgery, University of California, Los Angeles, California, United States
| | - Darryl Lau
- Department of Neurological Surgery, University of California, San Francisco, California, United States
| | - Haydn Hoffman
- Department of Neurosurgery, University of California, Los Angeles, California, United States
| | - David McArthur
- Department of Neurosurgery, University of California, Los Angeles, California, United States
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, California, United States
| | - Daniel C. Lu
- Department of Neurosurgery, University of California, Los Angeles, California, United States,Brain Research Institute, University of California, Los Angeles, California, United States,Address for correspondence Daniel C. Lu, MD, PhD Department of Neurosurgery, University of California650 Charles E. Young Drive South, Center for Health Sciences 74-129Los Angeles, CA 90095United States
| |
Collapse
|
31
|
Lu DC, Edgerton VR, Modaber M, AuYong N, Morikawa E, Zdunowski S, Sarino ME, Sarrafzadeh M, Nuwer MR, Roy RR, Gerasimenko Y. Engaging Cervical Spinal Cord Networks to Reenable Volitional Control of Hand Function in Tetraplegic Patients. Neurorehabil Neural Repair 2016; 30:951-962. [PMID: 27198185 PMCID: PMC5374120 DOI: 10.1177/1545968316644344] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Paralysis of the upper limbs from spinal cord injury results in an enormous loss of independence in an individual's daily life. Meaningful improvement in hand function is rare after 1 year of tetraparesis. Therapeutic developments that result in even modest gains in hand volitional function will significantly affect the quality of life for patients afflicted with high cervical injury. The ability to neuromodulate the lumbosacral spinal circuitry via epidural stimulation in regaining postural function and volitional control of the legs has been recently shown. A key question is whether a similar neuromodulatory strategy can be used to improve volitional motor control of the upper limbs, that is, performance of motor tasks considered to be less "automatic" than posture and locomotion. In this study, the effects of cervical epidural stimulation on hand function are characterized in subjects with chronic cervical cord injury. OBJECTIVE Herein we show that epidural stimulation can be applied to the chronic injured human cervical spinal cord to promote volitional hand function. METHODS AND RESULTS Two subjects implanted with a cervical epidural electrode array demonstrated improved hand strength (approximately 3-fold) and volitional hand control in the presence of epidural stimulation. CONCLUSIONS The present data are sufficient to suggest that hand motor function in individuals with chronic tetraplegia can be improved with cervical cord neuromodulation and thus should be comprehensively explored as a possible clinical intervention.
Collapse
Affiliation(s)
- Daniel C Lu
- University of California, Los Angeles, Los Angeles, CA, USA
| | | | | | | | - Erika Morikawa
- University of California, Los Angeles, Los Angeles, CA, USA
| | | | - Melanie E Sarino
- Rancho Los Amigos National Rehabilitation Center, Downey, CA, USA
| | | | - Marc R Nuwer
- University of California, Los Angeles, Los Angeles, CA, USA
| | - Roland R Roy
- University of California, Los Angeles, Los Angeles, CA, USA
| | - Yury Gerasimenko
- University of California, Los Angeles, Los Angeles, CA, USA Pavlov Institute of Physiology, St. Petersburg, Russia
| |
Collapse
|
32
|
Park E, Lee SI, Nam HS, Garst JH, Huang A, Campion A, Arnell M, Ghalehsariand N, Park S, Chang HJ, Lu DC, Sarrafzadeh M. Unobtrusive and Continuous Monitoring of Alcohol-impaired Gait Using Smart Shoes. Methods Inf Med 2016; 56:74-82. [PMID: 27782289 DOI: 10.3414/me15-02-0008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [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: 10/26/2015] [Accepted: 07/27/2016] [Indexed: 11/09/2022]
Abstract
BACKGROUND Alcohol ingestion influences sensory-motor function and the overall well-being of individuals. Detecting alcohol-induced impairments in gait in daily life necessitates a continuous and unobtrusive gait monitoring system. OBJECTIVES This paper introduces the development and use of a non-intrusive monitoring system to detect changes in gait induced by alcohol intoxication. METHODS The proposed system employed a pair of sensorized smart shoes that are equipped with pressure sensors on the insole. Gait features were extracted and adjusted based on individual's gait profile. The adjusted gait features were used to train a machine learning classifier to discriminate alcohol-impaired gait from normal walking. In experiment of pilot study, twenty participants completed walking trials on a 12 meter walkway to measure their sober walking and alcohol-impaired walking using smart shoes. RESULTS The proposed system can detect alcohol-impaired gait with an accuracy of 86.2 % when pressure value analysis and person-dependent model for the classifier are applied, while statistical analysis revealed that no single feature was discriminative for the detection of gait impairment. CONCLUSIONS Alcohol-induced gait disturbances can be detected with smart shoe technology for an automated monitoring in ubiquitous environment. We demonstrated that personal monitoring and machine learning-based prediction could be customized to detect individual variation rather than applying uniform boundary parameters of gait.
Collapse
Affiliation(s)
- Eunjeong Park
- Eunjeong Park, PhD, Cardiovascular Research Institute, Yonsei University College of Medicine, 50 -1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea, E-mail:
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Denis DR, Hirt D, Shah S, Lu DC, Holly LT. Minimally invasive surgery for lumbar synovial cysts with coexisting degenerative spondylolisthesis. Int J Spine Surg 2016; 10:37. [PMID: 27909658 DOI: 10.14444/3037] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [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: 01/23/2023] Open
Abstract
BACKGROUND About one third of lumbar synovial cysts are associated with degenerative spondylolisthesis. Segmental instability is thought to contribute to the pathogenesis and recurrence of synovial cysts and lumbar fusion has been advocated as a treatment of choice in the presence of spondylolisthesis. In patients with spondylolisthesis, minimally invasive resection of lumbar synovial cysts, without fusion, could minimize surgically induced segmental instability while providing good pain relief. METHODS Clinical and radiological outcomes of lumbar synovial cyst patients with and without spondylolisthesis were retrospectively compared. Pain outcomes were assessed with modified Macnab criteria. RESULTS Fifty-three patients (18 with grade 1 spondylolisthesis) underwent minimally invasive synovial cyst resection and all had either excellent or good pain outcome at ≤ 8 post- operative weeks (P = 1.000, n = 53). At > 8 post-operative weeks (mean (SD) follow-up of 200 (175) weeks), excellent or good outcomes were noted in 89% of patients without spondylolisthesis and in 75% of patients with spondylolisthesis (P = 0.425, n = 40). Four patients developed a new grade 1 spondylolisthesis at a mean follow-up of 2.6 ± 2.1 years. Nine patients were assessed for spondylolisthesis measurements at 1.2 ± 1.3 years of follow up and no significant difference was observed (5 ± 0 vs 5 ± 1 mm; P = 0.791). Two patients without spondylolisthesis and none of the patients with spondylolisthesis had a synovial cyst recurrence. CONCLUSION Patients with concomitant lumbar degenerative spondylolisthesis and synovial cyst can have good short- and long-term clinical outcomes with minimally invasive surgery without fusion. Post-operative segmental instability does not appear to be significant in patients with spondylolisthesis. All patients included in this article signed an informed consent for the use of their medical information for research.
Collapse
Affiliation(s)
- Daniel R Denis
- Department of Neurosurgery, Ochsner Medical Center, New Orleans, LA, USA
| | - Daniel Hirt
- Department of Neurosurgery, University of California, Los Angeles, CA, USA
| | - Saumya Shah
- Department of Neurosurgery, University of California, Los Angeles, CA, USA
| | - Daniel C Lu
- Department of Neurosurgery, University of California, Los Angeles, CA, USA
| | - Langston T Holly
- Department of Neurosurgery, University of California, Los Angeles, CA, USA
| |
Collapse
|
34
|
Huang R, Baca SM, Worrell JW, Liu X, Seo Y, Leiter JC, Lu DC. Modulation of respiratory output by cervical epidural stimulation in the anesthetized mouse. J Appl Physiol (1985) 2016; 121:1272-1281. [PMID: 27763875 DOI: 10.1152/japplphysiol.00473.2016] [Citation(s) in RCA: 6] [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] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 09/26/2016] [Accepted: 10/03/2016] [Indexed: 11/22/2022] Open
Abstract
Respiration is produced and controlled by well-characterized brain stem nuclei, but the contributions of spinal circuits to respiratory control and modulation remain under investigation. Many respiratory studies are conducted in in vitro preparations (e.g., brain stem slice) obtained from neonatal rodents. While informative, these studies do not fully recapitulate the complex afferent and efferent neural circuits that are likely to be involved in eupnea (i.e., quiet breathing). To begin to investigate spinal contributions to respiration, we electrically stimulated the cervical spinal cord during unassisted respiration in anesthetized, intact mice. Specifically, we used epidermal electrical stimulation at 20 Hz and varied current intensity to map changes in respiration. Stimulating at 1.5 mA at cervical level 3 (C3) consistently caused a significant increase in respiratory frequency compared with prestimulation baseline and when compared with sham stimulations. The increase in respiratory frequency persisted for several minutes after epidural stimulation ceased. There was no change in tidal volume, and the estimated minute ventilation was increased as a consequence of the increase in respiratory frequency. Sigh frequency also increased during epidural stimulation at C3. Neither the increase in respiratory frequency nor the increase in sighing were observed after stimulation at other dorsal cervical levels. These findings suggest that the spinal circuits involved in the modulation of eupnea and sighing may be preferentially activated by specific endogenous inputs. Moreover, the cervical spinal cord may play a role in respiratory modulation that affects both eupneic respiration and sigh production in intact, adult mice.
Collapse
Affiliation(s)
- Ruyi Huang
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California.,Neuromotor Recovery and Rehabilitation Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California.,Interdepartmental Program in Neuroscience, University of California, Los Angeles, Los Angeles, California
| | - Serapio M Baca
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California; and
| | - Jason W Worrell
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California.,Neuromotor Recovery and Rehabilitation Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Xingquan Liu
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California.,Neuromotor Recovery and Rehabilitation Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California.,Interdepartmental Program in Neuroscience, University of California, Los Angeles, Los Angeles, California
| | - Yeji Seo
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California.,Neuromotor Recovery and Rehabilitation Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California.,Interdepartmental Program in Neuroscience, University of California, Los Angeles, Los Angeles, California
| | - James C Leiter
- Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Daniel C Lu
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California; .,Neuromotor Recovery and Rehabilitation Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California.,Interdepartmental Program in Neuroscience, University of California, Los Angeles, Los Angeles, California.,Brain Research Institute, University of California, Los Angeles, Los Angeles, California
| |
Collapse
|
35
|
Lee SI, Park E, Huang A, Mortazavi B, Garst JH, Jahanforouz N, Espinal M, Siero T, Pollack S, Afridi M, Daneshvar M, Ghias S, Lu DC, Sarrafzadeh M. Objectively quantifying walking ability in degenerative spinal disorder patients using sensor equipped smart shoes. Med Eng Phys 2016; 38:442-9. [PMID: 26970892 DOI: 10.1016/j.medengphy.2016.02.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [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: 05/31/2015] [Revised: 11/27/2015] [Accepted: 02/07/2016] [Indexed: 02/04/2023]
Abstract
Lumbar spinal stenosis (LSS) is a condition associated with the degeneration of spinal disks in the lower back. A significant majority of the elderly population experiences LSS, and the number is expected to grow. The primary objective of medical treatment for LSS patients has focused on improving functional outcomes (e.g., walking ability) and thus, an accurate, objective, and inexpensive method to evaluate patients' functional levels is in great need. This paper aims to quantify the functional level of LSS patients by analyzing their clinical information and their walking ability from a 10 m self-paced walking test using a pair of sensorized shoes. Machine learning algorithms were used to estimate the Oswestry Disability Index, a clinically well-established functional outcome, from a total of 29 LSS patients. The estimated ODI scores showed a significant correlation to the reported ODI scores with a Pearson correlation coefficient (r) of 0.81 and p<3.5×10(-11). It was further shown that the data extracted from the sensorized shoes contribute most to the reported estimation results, and that the contribution of the clinical information was minimal. This study enables new research and clinical opportunities for monitoring the functional level of LSS patients in hospital and ambulatory settings.
Collapse
Affiliation(s)
- Sunghoon Ivan Lee
- Department of Physical Medicine & Rehabilitation, Harvard Medical School, Charlestown, MA 02129, USA; Spaulding Rehabilitation Hospital, Charlestown, MA 02129, USA; Computer Science Department, UCLA, Los Angeles, CA 90095, USA; Wireless Health Institute, UCLA, Los Angeles, CA 90095, USA.
| | - Eunjeong Park
- Computer Science Department, UCLA, Los Angeles, CA 90095, USA; Wireless Health Institute, UCLA, Los Angeles, CA 90095, USA.
| | - Alex Huang
- Department of Neurosurgery, UCLA, Los Angeles, CA 90095, USA.
| | - Bobak Mortazavi
- Computer Science Department, UCLA, Los Angeles, CA 90095, USA; Wireless Health Institute, UCLA, Los Angeles, CA 90095, USA; Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, CT 06510, USA.
| | | | | | - Marie Espinal
- Department of Neurosurgery, UCLA, Los Angeles, CA 90095, USA
| | - Tiffany Siero
- Department of Neurosurgery, UCLA, Los Angeles, CA 90095, USA
| | - Sophie Pollack
- Department of Neurosurgery, UCLA, Los Angeles, CA 90095, USA
| | - Marwa Afridi
- Department of Neurosurgery, UCLA, Los Angeles, CA 90095, USA
| | | | - Saif Ghias
- Department of Neurosurgery, UCLA, Los Angeles, CA 90095, USA
| | - Daniel C Lu
- Department of Neurosurgery, UCLA, Los Angeles, CA 90095, USA; Neuroplasticity and Repair Laboratory, UCLA, Los Angeles, CA 90095, USA; Neuromotor Recovery and Rehabilitation Center, UCLA, Los Angeles, CA 90095, USA; Department of Orthopaedic Surgery, UCLA, Los Angeles, CA 90095, USA.
| | - Majid Sarrafzadeh
- Computer Science Department, UCLA, Los Angeles, CA 90095, USA; Wireless Health Institute, UCLA, Los Angeles, CA 90095, USA.
| |
Collapse
|
36
|
Gerasimenko YP, Lu DC, Modaber M, Zdunowski S, Gad P, Sayenko DG, Morikawa E, Haakana P, Ferguson AR, Roy RR, Edgerton VR. Noninvasive Reactivation of Motor Descending Control after Paralysis. J Neurotrauma 2015; 32:1968-80. [PMID: 26077679 DOI: 10.1089/neu.2015.4008] [Citation(s) in RCA: 176] [Impact Index Per Article: 19.6] [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: 12/23/2022] Open
Abstract
The present prognosis for the recovery of voluntary control of movement in patients diagnosed as motor complete is generally poor. Herein we introduce a novel and noninvasive stimulation strategy of painless transcutaneous electrical enabling motor control and a pharmacological enabling motor control strategy to neuromodulate the physiological state of the spinal cord. This neuromodulation enabled the spinal locomotor networks of individuals with motor complete paralysis for 2-6 years American Spinal Cord Injury Association Impairment Scale (AIS) to be re-engaged and trained. We showed that locomotor-like stepping could be induced without voluntary effort within a single test session using electrical stimulation and training. We also observed significant facilitation of voluntary influence on the stepping movements in the presence of stimulation over a 4-week period in each subject. Using these strategies we transformed brain-spinal neuronal networks from a dormant to a functional state sufficiently to enable recovery of voluntary movement in five out of five subjects. Pharmacological intervention combined with stimulation and training resulted in further improvement in voluntary motor control of stepping-like movements in all subjects. We also observed on-command selective activation of the gastrocnemius and soleus muscles when attempting to plantarflex. At the end of 18 weeks of weekly interventions the mean changes in the amplitude of voluntarily controlled movement without stimulation was as high as occurred when combined with electrical stimulation. Additionally, spinally evoked motor potentials were readily modulated in the presence of voluntary effort, providing electrophysiological evidence of the re-establishment of functional connectivity among neural networks between the brain and the spinal cord.
Collapse
Affiliation(s)
- Yury P Gerasimenko
- 1 Department of Integrative Biology and Physiology, University of California , Los Angeles, Los Angeles, California.,2 Pavlov Institute of Physiology , St. Petersburg, Russia .,3 Institute of Fundamental Medicine and Biology, Kazan Federal University , Kazan, Russia
| | - Daniel C Lu
- 4 Department of Neurosurgery, University of California , Los Angeles, Los Angeles, California.,5 Neuromotor Recovery and Rehabilitation Center, David Geffen School of Medicine, University of California , Los Angeles, Los Angeles, California
| | - Morteza Modaber
- 4 Department of Neurosurgery, University of California , Los Angeles, Los Angeles, California.,5 Neuromotor Recovery and Rehabilitation Center, David Geffen School of Medicine, University of California , Los Angeles, Los Angeles, California
| | - Sharon Zdunowski
- 1 Department of Integrative Biology and Physiology, University of California , Los Angeles, Los Angeles, California
| | - Parag Gad
- 1 Department of Integrative Biology and Physiology, University of California , Los Angeles, Los Angeles, California
| | - Dimitry G Sayenko
- 1 Department of Integrative Biology and Physiology, University of California , Los Angeles, Los Angeles, California
| | - Erika Morikawa
- 4 Department of Neurosurgery, University of California , Los Angeles, Los Angeles, California.,5 Neuromotor Recovery and Rehabilitation Center, David Geffen School of Medicine, University of California , Los Angeles, Los Angeles, California
| | - Piia Haakana
- 4 Department of Neurosurgery, University of California , Los Angeles, Los Angeles, California.,5 Neuromotor Recovery and Rehabilitation Center, David Geffen School of Medicine, University of California , Los Angeles, Los Angeles, California
| | - Adam R Ferguson
- 6 Brain and Spinal Injury Center, Department of Neurological Surgery, University of California , San Francisco, San Francisco, California
| | - Roland R Roy
- 1 Department of Integrative Biology and Physiology, University of California , Los Angeles, Los Angeles, California.,7 Brain Research Institute, University of California , Los Angeles, Los Angeles, California
| | - V Reggie Edgerton
- 1 Department of Integrative Biology and Physiology, University of California , Los Angeles, Los Angeles, California.,4 Department of Neurosurgery, University of California , Los Angeles, Los Angeles, California.,7 Brain Research Institute, University of California , Los Angeles, Los Angeles, California
| |
Collapse
|
37
|
Abstract
The spinal cord of vertebrate animals is comprised of intrinsic circuits that are capable of sensing the environment and generating complex motor behaviors. There are two major perspectives for understanding the biology of this complicated structure. The first approaches the spinal cord from the point of view of function and is based on classic and ongoing research in electrophysiology, adult behavior, and spinal cord injury. The second view considers the spinal cord from a developmental perspective and is founded mostly on gene expression and gain-of-function and loss-of-function genetic experiments. Together these studies have uncovered functional classes of neurons and their lineage relationships. In this review, we summarize our knowledge of developmental classes, with an eye toward understanding the functional roles of each group.
Collapse
Affiliation(s)
- Daniel C Lu
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA USA
| | - Tianyi Niu
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA USA
| | - William A Alaynick
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA USA
| |
Collapse
|
38
|
Yew A, Lu D, Lu DC. CT-based morphometric analysis of C1 laminar dimensions: C1 translaminar screw fixation is a feasible technique for salvage of atlantoaxial fusions. Surg Neurol Int 2015; 6:S236-9. [PMID: 26005585 PMCID: PMC4431052 DOI: 10.4103/2152-7806.156603] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 12/20/2014] [Indexed: 11/27/2022] Open
Abstract
Background: Translaminar screw fixation has become an alternative in the fixation of the axial and subaxial cervical spine. We report utilization of this approach in the atlas as a salvage technique for atlantoaxial stabilization when C1 lateral mass screws are precluded. To assess the feasibility of translaminar fixation at the atlas, we have characterized the dimensions of the C1 lamina in the general adult population using computed tomography (CT)-based morphometry. Methods: A 46-year-old male with symptomatic atlantoaxial instability secondary to os odontoideum underwent bilateral C1 and C2 translaminar screw/rod fixation as C1 lateral mass fixation was precluded by an anomalous vertebral artery. The follow-up evaluation 2½ years postoperatively revealed an asymptomatic patient without recurrent neck/shoulder pain or clinical signs of instability. To better assess the feasibility of utilizing this approach in the general population, we retrospectively analyzed 502 consecutive cervical CT scans performed over a 3-month period in patients aged over 18 years at a single institution. Measurements of C1 bicortical diameter, bilateral laminar length, height, and angulation were performed. Laminar and screw dimensions were compared to assess instrumentation feasibility. Results: Review of CT imaging found that 75.9% of C1 lamina had a sufficient bicortical diameter, and 63.7% of C1 lamina had sufficient height to accept bilateral translaminar screw placement. Conclusions: CT-based measurement of atlas morphology in the general population revealed that a majority of C1 lamina had sufficient dimensions to accept translaminar screw placement. Although these screws appear to be a feasible alternative when lateral mass screws are precluded, further research is required to determine if they provide comparable fixation strength versus traditional instrumentation methods.
Collapse
Affiliation(s)
- Andrew Yew
- Department of Neurosurgery, University of California, Los Angeles, CA, USA
| | - Derek Lu
- Department of Neurosurgery, University of California, Los Angeles, CA, USA
| | - Daniel C Lu
- Department of Neurosurgery, University of California, Los Angeles, CA, USA
| |
Collapse
|
39
|
Lee SI, Mortazavi B, Hoffman HA, Lu DS, Li C, Paak BH, Garst JH, Razaghy M, Espinal M, Park E, Lu DC, Sarrafzadeh M. A Prediction Model for Functional Outcomes in Spinal Cord Disorder Patients Using Gaussian Process Regression. IEEE J Biomed Health Inform 2014; 20:91-9. [PMID: 25423659 DOI: 10.1109/jbhi.2014.2372777] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Predicting the functional outcomes of spinal cord disorder patients after medical treatments, such as a surgical operation, has always been of great interest. Accurate posttreatment prediction is especially beneficial for clinicians, patients, care givers, and therapists. This paper introduces a prediction method for postoperative functional outcomes by a novel use of Gaussian process regression. The proposed method specifically considers the restricted value range of the target variables by modeling the Gaussian process based on a truncated Normal distribution, which significantly improves the prediction results. The prediction has been made in assistance with target tracking examinations using a highly portable and inexpensive handgrip device, which greatly contributes to the prediction performance. The proposed method has been validated through a dataset collected from a clinical cohort pilot involving 15 patients with cervical spinal cord disorder. The results show that the proposed method can accurately predict postoperative functional outcomes, Oswestry disability index and target tracking scores, based on the patient's preoperative information with a mean absolute error of 0.079 and 0.014 (out of 1.0), respectively.
Collapse
|
40
|
Gerasimenko Y, Gorodnichev R, Puhov A, Moshonkina T, Savochin A, Selionov V, Roy RR, Lu DC, Edgerton VR. Initiation and modulation of locomotor circuitry output with multisite transcutaneous electrical stimulation of the spinal cord in noninjured humans. J Neurophysiol 2014; 113:834-42. [PMID: 25376784 DOI: 10.1152/jn.00609.2014] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [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: 12/26/2022] Open
Abstract
The mammalian lumbar spinal cord has the capability to generate locomotor activity in the absence of input from the brain. Previously, we reported that transcutaneous electrical stimulation of the spinal cord at vertebral level T11 can activate the locomotor circuitry in noninjured subjects when their legs are placed in a gravity-neutral position (Gorodnichev RM, Pivovarova EA, Pukhov A, Moiseev SA, Savokhin AA, Moshonkina TR, Shcherbakova NA, Kilimnik VA, Selionov VA, Kozlovskaia IB, Edgerton VR, Gerasimenko IU. Fiziol Cheloveka 38: 46-56, 2012). In the present study we hypothesized that stimulating multiple spinal sites and therefore unique combinations of networks converging on postural and locomotor lumbosacral networks would be more effective in inducing more robust locomotor behavior and more selective control than stimulation of more restricted networks. We demonstrate that simultaneous stimulation at the cervical, thoracic, and lumbar levels induced coordinated stepping movements with a greater range of motion at multiple joints in five of six noninjured subjects. We show that the addition of stimulation at L1 and/or at C5 to stimulation at T11 immediately resulted in enhancing the kinematics and interlimb coordination as well as the EMG patterns in proximal and distal leg muscles. Sequential cessation of stimulation at C5 and then at L1 resulted in a progressive degradation of the stepping pattern. The synergistic and interactive effects of transcutaneous stimulation suggest a multisegmental convergence of descending and ascending, and most likely propriospinal, influences on the spinal neuronal circuitries associated with locomotor activity. The potential impact of using multisite spinal cord stimulation as a strategy to neuromodulate the spinal circuitry has significant implications in furthering our understanding of the mechanisms controlling posture and locomotion and for regaining significant sensorimotor function even after a severe spinal cord injury.
Collapse
Affiliation(s)
- Yury Gerasimenko
- Pavlov Institute of Physiology, St. Petersburg, Russia; Integrative Biology and Physiology, University of California, Los Angeles, California; and
| | - Ruslan Gorodnichev
- Velikie Luky State Academy of Physical Education and Sport, Velikie Luky, Russia
| | - Aleksandr Puhov
- Velikie Luky State Academy of Physical Education and Sport, Velikie Luky, Russia
| | | | | | - Victor Selionov
- Institute for Information Transmission Problems, Russian Academy of Science, Moscow, Russia
| | - Roland R Roy
- Integrative Biology and Physiology, University of California, Los Angeles, California; and Brain Research Institute, University of California, Los Angeles, California
| | - Daniel C Lu
- Departments of Neurosurgery University of California, Los Angeles, California
| | - V Reggie Edgerton
- Departments of Neurosurgery University of California, Los Angeles, California; Integrative Biology and Physiology, University of California, Los Angeles, California; and Brain Research Institute, University of California, Los Angeles, California
| |
Collapse
|
41
|
Gad PN, Roy RR, Zhong H, Lu DC, Gerasimenko YP, Edgerton VR. Initiation of bladder voiding with epidural stimulation in paralyzed, step trained rats. PLoS One 2014; 9:e108184. [PMID: 25264607 PMCID: PMC4180450 DOI: 10.1371/journal.pone.0108184] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 08/15/2014] [Indexed: 11/26/2022] Open
Abstract
The inability to control timely bladder emptying is one of the most serious challenges among the several functional deficits that occur after a complete spinal cord injury. Having demonstrated that electrodes placed epidurally on the dorsum of the spinal cord can be used in animals and humans to recover postural and locomotor function after complete paralysis, we hypothesized that a similar approach could be used to recover bladder function after paralysis. Also knowing that posture and locomotion can be initiated immediately with a specific frequency-dependent stimulation pattern and that with repeated stimulation-training sessions these functions can improve even further, we reasoned that the same two strategies could be used to regain bladder function. Recent evidence suggests that rats with severe paralysis can be rehabilitated with a multisystem neuroprosthetic training regime that counteracts the development of neurogenic bladder dysfunction. No data regarding the acute effects of locomotion on bladder function, however, were reported. In this study we show that enabling of locomotor-related spinal neuronal circuits by epidural stimulation also influences neural networks controlling bladder function and can play a vital role in recovering bladder function after complete paralysis. We have identified specific spinal cord stimulation parameters that initiate bladder emptying within seconds of the initiation of epidural stimulation. The clinical implications of these results are substantial in that this strategy could have a major impact in improving the quality of life and longevity of patients while simultaneously dramatically reducing ongoing health maintenance after a spinal cord injury.
Collapse
Affiliation(s)
- Parag N. Gad
- Department of Integrative Biology and Physiology, University of California Los Angeles, Los Angeles, California, United States of America
| | - Roland R. Roy
- Department of Integrative Biology and Physiology, University of California Los Angeles, Los Angeles, California, United States of America
- Brain Research Institute, University of California Los Angeles, Los Angeles, California, United States of America
| | - Hui Zhong
- Department of Integrative Biology and Physiology, University of California Los Angeles, Los Angeles, California, United States of America
| | - Daniel C. Lu
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, United States of America
| | - Yury P. Gerasimenko
- Department of Integrative Biology and Physiology, University of California Los Angeles, Los Angeles, California, United States of America
- Pavlov Institute of Physiology, St. Petersburg, Russia
| | - V. Reggie Edgerton
- Department of Integrative Biology and Physiology, University of California Los Angeles, Los Angeles, California, United States of America
- Department of Neurobiology, University of California Los Angeles, Los Angeles, California, United States of America
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, United States of America
- Brain Research Institute, University of California Los Angeles, Los Angeles, California, United States of America
- * E-mail:
| |
Collapse
|
42
|
Getachew R, Lee SI, Kimball JA, Yew AY, Lu DS, Li CH, Garst JH, Ghalehsari N, Paak BH, Razaghy M, Espinal M, Ostowari A, Ghavamrezaii AA, Pourtaheri S, Wu I, Sarrafzadeh M, Lu DC. Utilization of a novel digital measurement tool for quantitative assessment of upper extremity motor dexterity: a controlled pilot study. J Neuroeng Rehabil 2014; 11:121. [PMID: 25117936 PMCID: PMC4138400 DOI: 10.1186/1743-0003-11-121] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Accepted: 07/10/2014] [Indexed: 11/16/2022] Open
Abstract
Background The current methods of assessing motor function rely primarily on the clinician’s judgment of the patient’s physical examination and the patient’s self-administered surveys. Recently, computerized handgrip tools have been designed as an objective method to quantify upper-extremity motor function. This pilot study explores the use of the MediSens handgrip as a potential clinical tool for objectively assessing the motor function of the hand. Methods Eleven patients with cervical spondylotic myelopathy (CSM) were followed for three months. Eighteen age-matched healthy participants were followed for two months. The neuromotor function and the patient-perceived motor function of these patients were assessed with the MediSens device and the Oswestry Disability Index respectively. The MediSens device utilized a target tracking test to investigate the neuromotor capacity of the participants. The mean absolute error (MAE) between the target curve and the curve tracing achieved by the participants was used as the assessment metric. The patients’ adjusted MediSens MAE scores were then compared to the controls. The CSM patients were further classified as either “functional” or “nonfunctional” in order to validate the system’s responsiveness. Finally, the correlation between the MediSens MAE score and the ODI score was investigated. Results The control participants had lower MediSens MAE scores of 8.09%±1.60%, while the cervical spinal disorder patients had greater MediSens MAE scores of 11.24%±6.29%. Following surgery, the functional CSM patients had an average MediSens MAE score of 7.13%±1.60%, while the nonfunctional CSM patients had an average score of 12.41%±6.32%. The MediSens MAE and the ODI scores showed a statistically significant correlation (r=-0.341, p<1.14×10-5). A Bland-Altman plot was then used to validate the agreement between the two scores. Furthermore, the percentage improvement of the the two scores after receiving the surgical intervention showed a significant correlation (r=-0.723, p<0.04). Conclusions The MediSens handgrip device is capable of identifying patients with impaired motor function of the hand. The MediSens handgrip scores correlate with the ODI scores and may serve as an objective alternative for assessing motor function of the hand. Electronic supplementary material The online version of this article (doi:10.1186/1743-0003-11-121) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Daniel C Lu
- Neuroplasticity and Repair Laboratory, UCLA, Los Angeles, USA.
| |
Collapse
|
43
|
Buchanan CC, McLaughlin N, Lu DC, Martin NA. Rotational vertebral artery occlusion secondary to adjacent-level degeneration following anterior cervical discectomy and fusion. J Neurosurg Spine 2014; 20:714-21. [PMID: 24745352 DOI: 10.3171/2014.3.spine13452] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [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: 12/13/2022]
Abstract
Rotational vertebral artery occlusion (RVAO), or bow hunter's syndrome, most often occurs at the C1-2 level on physiological head rotation. It presents with symptoms of vertebrobasilar insufficiency (VBI). Several previously published studies have reported on subaxial sites of vertebral artery (VA) compression by head rotation. The authors report a case of subaxial spine RVAO due to adjacent-segment degeneration. A 52-year-old man presented with dizziness when rotating his head to the left. Twenty years earlier, he had undergone a C4-5 anterior cervical discectomy and fusion (ACDF) for a herniated disc. Imaging studies including a dynamic CT angiography and dynamic catheter angiography revealed occlusion of the left VA at the C3-4 level when the patient turned his head to the left, in the setting of an aberrant vertebrobasilar system. Successful treatment was achieved by surgical decompression of the left VA and C3-4 ACDF. Expedited diagnosis and treatment are dependent on the recognition of this unusual manifestation of RVAO, especially when patients present with nonspecific symptoms of VBI.
Collapse
Affiliation(s)
- Colin C Buchanan
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | | | | | | |
Collapse
|
44
|
Chang V, Lu DC, Hoffman H, Buchanan C, Holly LT. Clinical results of cervical laminectomy and fusion for the treatment of cervical spondylotic myelopathy in 58 consecutive patients. Surg Neurol Int 2014; 5:S133-7. [PMID: 24843810 PMCID: PMC4023005 DOI: 10.4103/2152-7806.130670] [Citation(s) in RCA: 10] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 02/18/2014] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND There are a number of surgical treatment options for cervical spondylotic myelopathy (CSM). In this study, the authors present their clinical results with cervical laminectomy and fusion for the treatment of patients with CSM. METHODS This retrospective study included 58 consecutive patients who underwent cervical laminectomy and fusion for CSM. There were 38 males and 20 females, with a mean age of 64 (range 42-92) years. The Japanese orthopedic association score (mJOA) scale was used as the functional outcome measurement. Both the absolute increase in mJOA and the neurological recovery rate of mJOA were analyzed. The mean clinical follow-up was 17 months (range 5-52 months). RESULTS There was a statistically significant improvement between mean preoperative (13.2, range 7-17) and postoperative (16.1, range 11-18) mJOA scores following surgery. The average improvement in mJOA score was 2.9 points. The mean neurological recovery rate was 56.6%. Overall 85.5% of patients improved with surgery (n = 51) and the remaining 14.5% of patients had no change in their mJOA score after surgery (n = 7). Fusion was documented in all 58 patients. There was a 10.3% overall complication rate (n = 6). The most common complications were C5 nerve palsies which occurred in 6.9% of the cohort (n = 4); all completely resolved. CONCLUSION Cervical laminectomy and fusion is a safe and efficacious procedure for the treatment of CSM. The clinical outcomes appear to be quite reproducible, and this technique is an important part of a spine surgeon's armamentarium.
Collapse
Affiliation(s)
- Victor Chang
- Department of Neurosurgery, David Geffen UCLA School of Medicine, Los Angeles, USA
| | - Daniel C Lu
- Department of Neurosurgery, David Geffen UCLA School of Medicine, Los Angeles, USA ; Department of Orthopaedics, David Geffen UCLA School of Medicine, Los Angeles, USA
| | - Haydn Hoffman
- Department of Neurosurgery, David Geffen UCLA School of Medicine, Los Angeles, USA
| | - Colin Buchanan
- Department of Neurosurgery, David Geffen UCLA School of Medicine, Los Angeles, USA
| | - Langston T Holly
- Department of Neurosurgery, David Geffen UCLA School of Medicine, Los Angeles, USA ; Department of Orthopaedics, David Geffen UCLA School of Medicine, Los Angeles, USA
| |
Collapse
|
45
|
Abstract
Transforaminal lumbar interbody fusion (TLIF) was originally developed as a method for circumferential fusion via a single posterior approach and is now an extremely common procedure for the treatment of lumbar instability. More recently, minimally invasive techniques have been applied to this procedure with the goal of decreasing tissue disruption, blood loss and postoperative patient discomfort. Here we describe a minimally invasive tubular TLIF on a 60-year-old male with radiculopathy from an unstable L4-5 spondylolisthesis. The video can be found here: http://youtu.be/0BbxQiUmtRc.
Collapse
Affiliation(s)
- Jon Kimball
- Department of Neurosurgery, Ronald Reagan Medical Center, University of California Los Angeles, Los Angeles, California 90095, USA
| | | | | | | |
Collapse
|
46
|
Saigal R, Lu DC, Deng DY, Chou D. Conversion of high sacral to midsacral amputation via S-2 nerve preservation during partial S-2 sacrectomy for chordoma. J Neurosurg Spine 2014; 20:421-9. [PMID: 24527829 DOI: 10.3171/2014.1.spine12652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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
Chordomas of the sacrum require en bloc resection to reduce the risk of recurrence, but this may sacrifice nerves vital to bladder, bowel, and sexual function. High, mid-, and low sacral amputations have been previously classified based on nerve root sacrifice, not bony amputation. Sacrifice of the S-2 nerves or those above results in a high sacral amputation, but preserving the S-2 nerves converts it into a midsacral amputation. Preservation of the S-2 nerves has been shown to improve functional outcome, despite the bony osteotomy being unchanged. Thus, keeping the same bony amputation while preserving the S-2 nerve roots may allow for improved functional outcome while still achieving the same goal of oncological resection. Preservation of the S-2 nerves may be particularly difficult during amputation at the S-2 pedicle or above, and the authors describe their technique for preserving the S-2 nerves during partial sacrectomy at or just above the S-2 pedicle. Four cases of sacral chordoma resections are presented to illustrate the technique.
Collapse
|
47
|
Buchanan CC, Lu DC, Buchanan C, Tran TT. Spontaneous spinal epidural hematoma and spinal cord infarction following orthotopic liver transplantation: Case report and review of the literature. Surg Neurol Int 2013; 4:S359-61. [PMID: 24340232 PMCID: PMC3841936 DOI: 10.4103/2152-7806.120775] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 08/26/2013] [Indexed: 01/30/2023] Open
Abstract
Background: Spinal epidural hematomas are rare conditions. Although the exact cause remains unknown in up to 40% of cases, anticoagulation therapy, neoplasm, thrombolytic therapy, internal jugular vein thrombosis, and prolonged Valsalva maneuvers associated with pregnancy may be contributing factors. The source of bleeding appears to be the dorsal internal vertebral venous plexus (IVVP). Case Description: A 65-year-old female patient with hepatitis C-related cirrhosis underwent orthotopic liver transplantation (OLT). The patient developed SSEH due to congestion of the IVVP in the peri-transplant period. Concurrent spinal cord infarction occurred, likely secondary to hypoperfusion during a cardiac arrest. Conclusion: This case study should increase awareness of SSEH as a complication of OLT.
Collapse
Affiliation(s)
- Colin C Buchanan
- Department of Neurosurgery, Cedars-Sinai Medical Center, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | | | | | | |
Collapse
|
48
|
Abstract
The lumbar spinal cord contains the necessary circuitry to independently drive locomotor behaviors. This function is retained following spinal cord injury (SCI) and is amenable to rehabilitation. Although the effectiveness of task-specific training and pharmacologic modulation has been repeatedly demonstrated in animal studies, results from human studies are less striking. Recently, lumbar epidural stimulation (EDS) along with locomotor training was shown to restore weight-bearing function and lower-extremity voluntary control in a chronic, motor-complete human SCI subject. Related animal studies incorporating EDS as part of the therapeutic regiment are also encouraging. EDS is emerging as a promising neuromodulatory tool for SCI.
Collapse
Affiliation(s)
- Nicholas AuYong
- Department of Neurosurgery, University of California, Los Angeles, 650 Charles E Young Drive South, CHS 74-129, Los Angeles, CA 90095, USA
| | | |
Collapse
|
49
|
Abstract
Seroma formation following posterior cervical laminectomy and fusion is now recognized as a rare but significant risk. Previous reports have attributed the development of postoperative seromas to the use of recombinant bone morphogenetic protein–2 (rhBMP-2). Here the authors present the case of a 78-year-old female with a history of osteoporosis who developed delayed postoperative neck and shoulder pain following posterior cervical laminectomy and fusion utilizing only autograft bone and demineralized bone matrix (DBM) allograft. Postoperative MRI demonstrated normal hardware placement and a large epidural fluid collection that extended from C-4 to C-6. The patient underwent decompression and drainage of her sterile postoperative seroma. To the authors' knowledge, no case of seroma formation with the use of DBM has been previously reported. This case suggests that although rhBMP-2 is involved in the majority of postoperative seroma developments, other osteoinductive agents such as DBM can contribute to the development of a symptomatic seroma. This report presents an illustrative case study and reviews the current understanding of the development of and treatment for cervical seroma following posterior cervical laminectomy and fusion.
Collapse
|
50
|
Yew AY, Hoffman H, Li C, Lu DC. Oral Presentations of the 2013 Annual Meeting of the Congress of Neurological Surgeons. Neurosurgery 2013. [DOI: 10.1227/neu.0000000000000007] [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: 11/19/2022] Open
|